April 1, 1998

Thank you for the opportunity to discuss the health hazards of exposure to environmental tobacco smoke and efforts to reduce exposure. I am Dr. Michael P. Eriksen, director of the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.

Over the past decade, knowledge of the hazards of exposure to environmental tobacco smoke (also known as ETS, passive smoke, or secondhand smoke) has expanded considerably.

In 1986, the U.S. Surgeon General and the National Academy of Sciences formally recognized that ETS is a significant public health threat. In 1991, the Centers for Disease Control and Prevention's (CDC) National Institute for Occupational Safety and Health concluded that ETS is a potential occupational carcinogen, and recommended that exposures be reduced to the lowest feasible concentration. In 1993, the Environmental Protection Agency (EPA) issued a report providing additional information on the hazards of exposure, including an estimated 3,000 lung cancer deaths per year among nonsmoking adults and 150,000-300,000 cases of lower respiratory tract infections among children. ETS exposure causes increased episodes and increased severity of symptoms in children with asthma. Exposure also has been linked with sudden infant death syndrome (SIDS). Furthermore, in recent years, research has emerged on the impact of ETS exposure on the development of heart disease among nonsmokers. There is mounting data that the overall burden of ETS-related heart disease is considerably higher than that for ETS-related lung cancer. In addition, data continue to emerge on the link between ETS and heart disease; for example, in a study reported earlier this year in the Journal of the American Medical Association, ETS exposure was associated with atherosclerosis which is not reversible.

Data from a 1996 CDC study found that among non-tobacco users, 87.9% had detectable levels of serum cotinine, a biological marker for exposure to environmental tobacco smoke, yet only 37% of adult non-tobacco users were aware enough of their exposure to report having been exposed to ETS either at home or at work. Both home and workplace environments were found in this study to significantly contribute to the widespread exposure to environmental tobacco smoke in the United States. In addition, a recent study by CDC found an alarming level of ETS exposure of children in their homes. Exposure ranged from 11.7% of children between the ages of 0 and 17 in Utah to 34.2% of children in Kentucky.

Although a 1992-1993 National Cancer Institute survey found that almost half of all workers had a smoke-free policy in their workplace, significant numbers of workers, especially those in blue-collar and service occupations, reported smoke-free policy rates considerably lower than the overall rate of 46%. The occupational group least likely to have a smoke-free policy was food service workers--waiters, waitresses, cooks, bartenders, and counter help. Of these 5.5 million workers, 22% are teenagers. In a 1993 CDC study, food service workers were found to have a 50% increased risk of dying from lung cancer as compared to the general population, and this increase was attributed to their workplace exposure to ETS. Although potential business losses are usually cited as the reason for excluding these establishments from smoking prohibitions, several studies across the country have shown no adverse impact on sales in these establishments after smoking is eliminated.

In recognition of the health consequences of exposure to ETS, the public health community has adopted several national health objectives related to ETS as part of or in conjunction with Healthy People 2000. These objectives include increasing the proportion of worksites that have adopted smoke-free policies and reducing the proportion of children regularly exposed to ETS in the home. Another Healthy People 2000 objective is to increase the number of states with comprehensive clean indoor air laws in workplaces, restaurants, and public places that prohibit smoking or limit it to separately ventilated areas only. An additional objective addresses reductions in the number of states with preemptive laws limiting more restrictive action at the local level. Recent data indicate that 21 states have enacted laws restricting smoking in private worksites but only one of these states meets the Healthy People 2000 State objective. Thirty-one states have enacted laws restricting smoking in restaurants; only three meet the objective. Although significant actions have been taken by states and localities to limit ETS exposure, much work remains to provide adequate protection to all Americans.

There are a variety of actions that Federal agencies are taking to reduce ETS exposure among the population. These actions fit within an overall framework to prevent and reduce tobacco use which includes data collection, research, state and community programs, school programs, media campaigns, and program evaluation.

Public education is an important component of efforts to reduce ETS exposure. CDC has conducted media and educational campaigns addressing ETS exposure in the home, restaurant, and workplace settings. CDC also has published a publication called "Making Your Workplace Smokefree: A Decision Maker's Guide," which can assist employers who are considering a smoke-free workplace in implementing this decision. In the area of prevention research, CDC is engaged in ongoing efforts to examine the impact of ETS on health. Specifically, CDC's National Center for Environmental Health is supporting laboratory-based prevention research to assess the exposure of the United States population to both active smoking and ETS by measuring serum cotinine in the National Health and Nutrition Examination Surveys. Efforts such as these are critical to our understanding of the extent of ETS exposure in the population. CDC also is working to better our understanding of the relationship of ETS exposure in nonsmokers to adverse health outcomes such as sudden infant death (SIDS), low birth weight, cardiovascular disease and lung cancer. An example of this effort is the growing evidence of ETS as a risk factor for SIDS. Preliminary analysis of data from CDC's Chicago Infant Mortality Study indicate that two of the significant risk factors for SIDS in an urban, largely African-American population were maternal smoking during pregnancy and infant exposure to passive smoking. These results were presented at the fourth SIDS International Conference and the Annual Meeting of the Society for Pediatric Research in June 1996.

In the area of worker safety, CDC's National Institute for Occupational Safety and Health (NIOSH) conducted an Indoor Air Quality Health Hazard Evaluation at Bally's Park Casino Hotel in Atlantic City, New Jersey. The evaluation, completed in 1996, demonstrated that non-smoking employees working in the gaming areas of a large casino demonstrated pre-workshift exposure to ETS at levels 50% higher than those observed in a representative sample of U.S. workers exposed to ETS at home and work. The evaluation also demonstrated that the serum and urine cotinine of these employees increases during the workshift, such that levels of exposure were twice as high after working a shift in the casino than the representative sample of U.S. workers mentioned above. As a result of this analysis, NIOSH presented recommendations that would protect casino workers from ETS exposure. These recommendations included: eliminating tobacco use from the workplace and implementing a smoking cessation program for employees; isolating areas where smoking is permitted; establishing separate smoking areas with dedicated ventilation; and restricting smoking to the outdoors (away from building entrances and air intakes).

State prevention efforts also are critical; survey data indicate that public education campaigns and local community efforts to limit smoking in public places in California and Massachusetts have been associated with reported reductions in ETS exposure of both adults and children. Finally, clinicians, particularly pediatricians, also have an important role to play in educating parents about the impact of ETS exposure on their children. Interest in ETS is not only confined to the United States. Most notably, there is the work of the EPA to bring the ETS and children issue to the attention of the G8. The administration is planning an international conference to address these concerns.

Last summer, President Clinton announced an Executive Order requiring Federal buildings to be smoke-free or have separately ventilated smoking areas. Furthermore, in the five principles contained in his September statement on components for comprehensive tobacco legislation, the President included limiting exposure to ETS in worksites and public places. The proposed settlement language of June 20th provides a starting point for efforts to address this issue. There appears to be consensus that national legislation should serve as a "floor" rather than a "ceiling" and not preempt stronger state and local action, as is suggested by the Healthy People 2000 objective relating to preemption. Involvement of local communities in education regarding enforcement of restrictions will help to ensure adequate implementation. Furthermore, smoking should be prohibited on all international flights that land, stop, or take off in the U.S., given that the tobacco industry has stated that it would support such Federal legislation in the recent Broin flight attendant class action settlement.

In conclusion, in your deliberations on this issue, please remember that harm caused by passive smoke is inflicted on those who have decided not to smoke, or, in the case of young children, cannot make an informed choice. Even one preventable death among Americans who have decided not to smoke should be considered unacceptable.