Statement of Alfred Munzer, MD
Past President, American Lung Association
to the Senate Environment and Public Works Committee
"Environmental Tobacco Smoke"
April 1, 1998

Mr. Chairman, and members of the Committee on The Environment and Public Works, I am Dr. Alfred Munzer, Past President of the American Lung Association (ALA). I am also Director of Critical Care and Pulmonary Medicine at Washington Adventist Hospital in Takoma Park, MD, where I specialize in the treatment of diseases of the Lung.

The ALA is the nation's oldest voluntary health organization and is dedicated to the prevention and control of lung disease. This organization and its medical section, the American Thoracic Society, has long recognized the contribution of indoor and outdoor air pollution to the development and exacerbation of lung disease. The ALA has devoted over three decades to the implementation of programs aimed at improving air quality in our homes and in our communities.

As a pulmonary physician, I all too often see first hand the devastation caused by tobacco use. I see the men and women who come to me with end-stage lung cancer or emphysema, seeking a medical miracle to cure their disease. I see the children who cough and wheeze as their asthma is made worse by exposure to smoke exhaled by smokers and that comes from the burning end of a cigarette, pipe, or cigar. Smoke of this nature has been commonly called involuntary, passive, or secondhand smoke. Today, it is generally referred to as environmental tobacco smoke, or "ETS".

Mr. Chairman, the American Lung Association believes that all workers and the entire public must be protected from ETS. Further, it is our strong belief that state and local governments must retain the right to enact stronger tobacco control laws.

These principles are one important factor in our opposition to the "Sweetheart Deal" negotiated by the Attorneys General with the Tobacco Industry last June. We also oppose the "Deal", and will oppose any legislation that grants special protection, such as immunity or caps on liability, to the industry. We have testified several times recently before committees of this Congress, and our views are well known.

Today, I want to re-state the opinion of the American Lung Association and its medical section, the American Thoracic Society, that Environmental Tobacco Smoke is a threat to the health, and the lives, of all Americans. Much progress has been made on the local and state level since the publication of the EPA's 1992 risk assessment "Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders". A good example is the recent California action to protect patrons and employees of bars by making them entirely smoke free, along with restaurants and other public places.

But once again, the scientific foundation for elimination of the ETS threat has come under attack, just as it did immediately following publication of the EPA document. I think it is important to understand the facts before anyone leaps to any conclusion based on unpublished research that is still undergoing peer review. On March 19, 1998, the Wall Street Journal printed an article titled "Smoking Out Bad Science" authored by Ms. Lorraine Mooney, a medical demographer for the Cambridge, Great Britain based European Science and Environment Forum. In her article, Ms. Mooney attacks a study of ETS conducted by the International Agency for Research on Cancer on statistical grounds. Several British newspapers also attacked the study. The tobacco industry is attempting to use these reports to further its agenda by issuing press releases and writing opinion editorial articles that tout "no risk". The press reports and opinion editorials accuse the World Health Organization of suppressing this study. That assertion is false.

The World Health Organization issued a statement on March 9, 1998. WHO states that the study did in fact find an increase of 16% in the risk of lung cancer for non-smoking spouses of smokers, and a 17% increase for exposure to passive smoking at the workplace. The study was conducted in 12 centers from seven European countries including 650 cases of lung cancer and 1,542 controls and is the largest study carried out in European populations to date. However, it is the small sample size used in the study that led to the finding that neither increased risk was statistically significant.

WHO concludes "The results of this study, which have been completely misrepresented in recent news reports, are very much in line with the results in the similar studies in Europe and elsewhere: passive smoking causes lung cancer in non-smokers."

Mr. Chairman, there is no need to be confused. The evidence is there and it is overwhelming. So let us look back at how the scientific body of evidence has been accumulated and also at attempts to discredit that evidence.

ETS has been the topic of discussion for more than 25 years. Its health effects were first reviewed in 1972 in the U.S. Surgeon General's report on smoking and health. That report was devoted, in part, to public exposure to air pollution caused by tobacco smoke. It concluded that "an atmosphere contaminated with tobacco smoke can contribute to the discomfort of many individuals."

In 1982, the U.S. Surgeon General again examined the issue of passive smoking but this time in the context of smoking and the development of cancer. At that time there were only three epidemiological studies linking passive smoking and lung cancer. Even with this limited amount of evidence, the Surgeon General concluded that the evidence in these studies is the cause for grave concern regarding the possible serious public health problem associated with passive smoke and lung cancer.

By 1986, federal interest in the health effects of ETS had grown to the extent that the U.S. Surgeon General released a report devoted entirely to the issue of passive smoking. By that time, the number of epidemiological studies had increased to 13, 11 of which showed a positive correlation between passive smoking and lung cancer in healthy nonsmokers. Based upon these findings, the Surgeon General concluded that exposure to secondhand smoke is a cause of lung cancer in healthy nonsmokers. He also concluded that children whose parents smoked had an increased frequency of respiratory symptoms and infections, compared to children whose parents were nonsmokers.

Asthma is a major area of priority for the American Lung Association. Asthma is the leading serious chronic illness among children and the major cause of school absenteeism. Asthma deaths from 1979 to 1993 increased almost 99%. ETS exposure is also associated with additional attacks and increased severity of symptoms in children with asthma. The EPA estimates that 200,000 to 1 million asthmatic children have their condition worsened by ETS, and that ETS is a risk factor for new cases of asthma in children without a history of symptoms.

Several organizations -- the National Academy of Science and the International Agency for Research on Cancer-- published reports which drew conclusions similar to those of the EPA. The International Agency for Research on Cancer, for example, released a report on cancer which concluded that "knowledge of the nature of sidestream and mainstream smoke, of materials absorbed during passive smoking, and of the quantitative relationships between dose and effect that are commonly observed from exposure to carcinogens leads to the conclusion that passive smoking gives rise to some risk of cancer."

In December 1992, the EPA released its report assessing current scientific evidence on the risks of exposure to ETS "Health Effects of Passive Smoking: Assessment of Lung Cancer in Adults and Respiratory Disorders in Children." The risk assessment focused on the potential correlation between ETS and lung cancer in nonsmoking adults and respiratory disease and pulmonary effects in children. Based on the total weight of evidence in the scientific literature, the EPA designated ETS as a Group A carcinogen, a rating used only for extremely hazardous substances known to cause cancer in humans. It ranked ETS in a class of carcinogens which includes asbestos, benzene, and radon.

After evaluating 30 epidemiological studies on lung cancer in nonsmoking adults, the EPA determined that ETS is responsible for approximately 3,000 lung cancer deaths each year. The agency also added that ETS accounts for the development of 20 percent of all lung cancers caused by factors other than smoking. For the average adult, ETS increases their risk of cancer to approximately 2 per 1,000. From these conclusions, it is clear that ETS is a serious hazard to the health of nonsmoking adults.

After evaluating more than 100 studies on respiratory health in children, the EPA concluded that ETS exposure increases their risk of lower respiratory infections, like bronchitis and pneumonia. ETS is known to cause an estimated 150,000 to 300,000 cases of respiratory illnesses in children up to 18 months each year. Of these cases, 7,500 to 15,000 result in hospitalization.

Also of concern are the risks for children whose mothers smoked during and after pregnancy. The U.S. Department of Health and Human Services has reported that, under these circumstances, children are three times more likely to die of Sudden Infant Death Syndrome (SIDS) than children of nonsmoking mothers. The risks of SIDS double for children whose mothers smoked after birth and not during pregnancy than for children reared in nonsmoking environments.

The evidence presented represents very sound science and more than adequately supports the conclusions by the EPA regarding exposure to ETS. Uniquely, each of the studies and reports used to reach this conclusion were developed and edited by different processes. In contrast to assertions made of opponents of the EPA's findings, such as those offered by the tobacco industry, it is this diverse methodology which only strengthens the validity of the conclusion of this research combined.

Without spending too much time on the tobacco industry criticisms of the risk assessment, let me first remind the committee that after 60,000 studies linking smoking with disease and death, this industry still fails to acknowledge that it produces a lethal product. This year, in the Minnesota Tobacco Trial, Walker Merryman, chief spokesman for the Tobacco Institute was quoted as saying: "We don't believe it's ever been established that smoking is the cause of disease". This is clearly the same old tobacco industry, denying, offering excuses, and challenging any science that links smoking with illness and death.

This is an industry which has criticized each Surgeon General's report since 1964. Among the industry criticisms is the failure of the EPA to include studies which show no relationship between ETS and lung cancer. Among the studies cited by the industry as examples are several funded by the National Cancer Institute:

Brownson, Ph.D., et.al. Passive Smoking and Lung Cancer in Nonsmoking Women. - Am J Public Health 82:1525-1530,1992.

This study was published in November 1992, too late for inclusion in the risk assessment. The industry contends that the risk assessment would change if the study was included. However, the author's of the study conclude: "Ours and other recent studies suggest a small but consistent increased risk of lung cancer from passive smoking. Comprehensive actions to limit smoking in public places and worksites are well-advised."

Stockwell, Sc.D., et.al. Environmental Tobacco Smoke and Lung Cancer in Nonsmoking Women. J Natl Cancer Inst 84:1417-1422, 1992.

This study was not included in the final risk assessment and again the industry claims it is a negative study therefore left out purposefully. However, the author's conclude: "These findings suggest that long-term exposure to environmental tobacco smoke increases the risk of lung cancer in women who have never smoked."

The real issue here is statistical significance and how it is used. In defining the true meaning of statistical significance, I'd like to defer to the description used by a well-known environmental epidemiologist, Dr. Douglas Dockery, an Associate Professor at the Harvard School of Public Health. Dr. Dockery suggests:

"A naive critique would say that those studies which are not statistically significant' do not show an effect. However, statistical significance is not a measure of association of environmental tobacco smoke with lung cancer, but rather a measure of the stability of the association. It measures the statistical power of the study. In a crude sense it is a measure of study size, and studies that do not achieve statistical significance are simply too small. This does not mean that they do not provide important information on risks.

It is not appropriate to discard studies which do not achieve statistical significance, but rather they should be included giving them a weight which reflects the stability, that is the uncertainty, of their effect estimate. This is exactly what the meta-analysis of these studies provides."

Mr. Chairman, we at the American Lung Association believe the EPA's findings are clear, objective, and complete in regard to ETS. The evidence used to show the relative risks associated with exposure to ETS, and its linkage to the development of lung cancer, are more compelling than similar correlations drawn for other environmental carcinogens.

The California Environmental Protection Agency is the latest to concur. In its September 1997, report "Health Effects of Exposure to Environmental Tobacco Smoke" it states: "ETS exposure is causally associated with a number of health effects." Those listed are:

--Developmental Effects - Low birthweight; Sudden Infant Death Syndrome (SIDS)

--Respiratory Effects - Acute lower respiratory tract infections in children (bronchitis and pneumonia); Asthma induction and exacerbation in children; Chronic respiratory symptoms in children; Eye and nasal irritation in adults; Middle ear infections in children

--Carcinogenic Effects - Lung Cancer; Nasal Sinus Cancer

--Cardiovascular Effects - Heart disease mortality; Acute and chronic coronary heart disease morbidity.

Mr. Chairman, all of these effects caused by ETS are carefully and scientifically documented in the California study - - additional, compelling evidence for strong measures to control this threat to the public health.

The California report states; "With respect to lung cancer, three large U.S. population-based studies and a smaller hospital based case-control study have been published since the most recent comprehensive review (U.S.EPA,1992); the three population based studies were designed to and have successfully addressed many of the weaknesses for which the previous studies on ETS and lung cancer have been criticized. Results from these studies and the smaller case-control study are compatible with the causal association between ETS exposure and risk of lung cancer in nonsmokers already reported by the U.S EPA (1992), Surgeon general (U.S. DHHS, 1986) and NRC (1986)".

The Scientific Review Panel to the California Air Resources Board said; "Based on the available evidence, we conclude ETS is a toxic air contaminant".

A toxic air contaminant - how can we continue to expose our citizens to a toxic air contaminant indoors?

The California report also notes annual mortality estimates associated with ETS exposure in California, including approximately 120 deaths from SIDS (Sudden Infant Death Syndrome), 16 - 25 deaths in infants and toddlers from bronchitis and pneumonia, approximately 360 deaths from lung cancer and 4,220 - 7,440 deaths from heart disease. Thus, ETS has a major public health impact.

That same California report quantifies the effects of ETS as causing between 8,000 and 26,000 new cases of asthma in children yearly in the United States as well as exacerbating asthma in between 400,000 and one million children. And a report by the Australian National Health and Medical Research Council (Nov. 28, 1997), after reviewing over 400 individual medical studies, concluded that passive smoking contributes to the symptoms of asthma in 46,500 Australian children each year. Finally, pediatrician Peter Gergen of the Agency for Health Care Policy and Research reports on a study of 7,680 childre . Compared with children in nonsmoking homes, those in homes where adults smoked a total of at least a pack of cigarettes a day were twice as likely to have asthma between 2 months and 5 years old. This translates, according to Gergen, to about 147,000 cases of smoking-induced asthma in kids 2 months to five years old. (Reported in USA Today, Feb. 3, 1998)

Nationwide, ETS is responsible for 53,000 deaths every year, according to Professors Stanton Glantz, Ph.D. and William Parmley, M.D., School of Medicine, University of California, San Francisco. Their two studies, "Passive Smoking and Heart Disease: Epidemiology, Physiology and Biochemistry" (Circulation 1991; 1-8) in 1991 and a follow up study, titled "Passive Smoking and Heart Disease: Mechanisms and Risk "(Journal of the American Medical Association 1995; 273:1047-1053) in 1995 attribute 37,000 deaths to heart disease, 4,000 deaths to lung cancer and 12,000 deaths to other cancers.

The risk for lung cancer due to exposure from ETS rises considerably for food-service workers. Waiters and waitresses have a 50-90% increased risk of lung cancer that is most likely caused by restaurant tobacco smoke according to a study, titled "Involuntary Smoking in the Restaurant Workplace" (Journal of the American Medical Association 1993;270:490-493).

Mr. Chairman, I hope all of this body of evidence I have presented to the committee today will enable you to step beyond the criticisms offered regarding the validity of the EPA risk assessment and other studies, and encourage you to move forward in your efforts to address the real issue on the table -- adequately responding to the public health issue associated with exposure to ETS.

I urge this committee to take into consideration the growing support for smoke-free public places. Each year, the American Lung Association publishes "State Legislated Actions on Tobacco Issues" (SLATI), a complete survey of state tobacco laws. In our 1997 edition, we report on restrictions on smoking in public places:

"Forty-eight states and the District of Columbia have some restriction on smoking in public places. These laws range from simple, limited restrictions, such as designated areas in schools, to laws that limit or ban smoking in virtually all public places, including elevators, public buildings, retail stores, restaurants, health facilities, public conveyances, museums, shopping malls, retail stores and educational facilities (Vermont). California and Washington require enclosed separately ventilated smoking areas in private workplaces, or smoking must be banned entirely. Of the states that limit or prohibit smoking in public places, 43 restrict smoking in government workplaces and 23 restrict smoking in private sector workplaces".

It is clear that most significant progress has occurred at the local and state level to protect citizens from ETS. Over two hundred and fifty-five communities across the country have enacted ordinances that restrict smoking in the workplace. The enormous success of local ordinances has resulted in battles with the tobacco industry over local control. The tobacco industry has recognized the effectiveness of these local clean indoor air ordinances and has spent millions of dollars in efforts to defeat them. Their favorite tactic is to support passage of weak state laws that preempt the authority of state and local governments to enact more stringent regulations. So far, the tobacco industry has been successful stripping localities in 13 states of their power to pass clean indoor air ordinances. Communities are beginning to fight back and in 1997 Maine became the first state to repeal of a preemptive clean indoor air law.

It is imperative, as I indicated earlier, that Congress not limit the authority of state and local governments to enact legislation and regulations which they believe are necessary to protect their citizens from ETS in their jurisdictions. Communities deserve the right to pass laws that protect their citizens from breathing secondhand smoke.

Does the public support smoke-free facilities? The answer is an emphatic yes! A majority of Californians believe it is important to have smoke-free restaurants and smoke-free bars and nightclubs, although to varying degrees. A very large majority (85%) believe it is important to have smoke-free restaurants. When asked how important it is to have smoke-free bars and nightclubs, 55% feel it is important, with 35% saying it is very important and 20% feeling it is somewhat important. There is widespread agreement among the public that smoking ordinances are an effective way to reduce the number of people who smoke in public places. Eight in ten Californians (80%) agree with this contention. ( Field Research Corporation )

The tobacco industry and their front groups have claimed that smoking restrictions in bars and restaurants would devastate the hospitality industry. These claims are false. A report by Stanton A. Glantz, PhD and Lisa R. A. Smith studied the effect of ordinances in 15 cities that require smoke-free restaurants and bars. The report, published in the American Journal of Public Health, found that smoke-free ordinances do not adversely affect either restaurants or bars. (Am J Public Health 1997;87:1687-1693)

We believe the 1986 report of the Surgeon General has the best recommendation for us to consider. In its conclusion, the report clearly states, ASimple separation of smokers-and nonsmokers within the same air space may reduce, but does not eliminate, exposure of nonsmokers to ETS." Therefore, it is the responsibility of employers and employees to "ensure that the act of smoking does not expose the nonsmoker to tobacco smoke and for smokers to "assure that their behavior does not jeopardize the health of other workers.

In addition, the Surgeon General stated that smokers have the "responsibility to provide a supportive environment for smokers who are attempting to stop."

The American Lung Association urges you to look to the report of the Koop-Kessler Commission for guidance in setting policy on ETS and on development of a national tobacco control policy. The Koop-Kessler report made a number of specific recommendations regarding ETS:

Smoking should be banned in all work sites and in all places of public assembly, especially those in places where children are present.

Smoking should be banned in outdoor areas where people assemble, such as service lines, seating areas of sports stadiums and arenas, etc.

Schools should be required to be 100% smoke-free in all areas of their campuses.

Smoking should be banned on all forms of transportation, including bus, train, commuter services, and flights originating in or arriving at the U.S.

Smoking should be banned at all Federal workplaces, including branches of the military and the Department of Veterans- Affairs and its hospitals.

The report goes on to recommend that a comprehensive education and public awareness program be developed and that economic incentives for smoke-free workplaces be established.

Mr. Chairman, the American Lung Association urges Congress to follow these ETS recommendations as well as all of the recommendations in the Koop-Kessler report. Then, and only then, can I anticipate being slowly put out of a job as the devastation from smoking on our lungs and our bodies is diminished and ultimately ended.