Key Results: Clean Indoor Air
Citations Listed in Key Results
- Consensus exists that secondhand smoke causes coronary heart disease, lung cancer, and adverse respiratory ailments in children and adults (CDC 2006 SGR Report). Some regulatory agencies have also concluded that secondhand smoke causes breast cancer in younger, primarily pre-menopausal women (Cal-EPA 2005).
The most recent review of research on the adverse health effects of secondhand smoke was published by the U.S. Surgeon General in 2006. Besides cancer, heart disease, and major lung diseases in children and adults, conditions causally associated with exposure to secondhand smoke include:
- low birth weight
- sudden infant death syndrome
- pre-term delivery
- acute lower respiratory tract infections in children, including bronchitis and pneumonia, asthma induction, and exacerbation of asthma in children and adults
- chronic respiratory symptoms in children
- eye and nasal irritation in adults
- middle ear infections in children
Even brief exposures ranging from a few minutes to a few hours can cause heart problems. The conclusions in the California EPA report are very similar to other reviews, including those done by the U.S. EPA, the National Toxicology Program, and the International Agency for Research on Cancer. However, the more recent California EPA report also adds the breast cancer finding.
- Compliance with smoke-free regulations is usually high. Launching a comprehensive and carefully planned educational effort well in advance of the implementation date facilitates compliance by providing both the public and business owners with information on the purpose of the law and how to avoid violations (Sorensen 1991; Hyland et al. 1999b; Weber et al. 2003; Skeer et al. 2004; Howell 2005).
Actual implementation of smoke-free regulations is often accompanied by a period of anxiety. Some business owners are concerned that they will be required to spend a lot of money to comply with the law and that many will ignore the regulations. Some enforcement agencies are concerned that they will be unable to adequately enforce the regulations and/or that enforcement will divert funding and staff from other areas.
However, the literature indicates that most establishments and individuals willingly obey the new regulations, meaning that compliance is usually widespread and enforcement is neither costly nor a drain on human resources.
The best smoke-free policies, those that pose the least burden on business and offer the greatest public health benefits, are comprehensive (Sorensen 1991). Policies that create variances for some establishments make both compliance and enforcement more difficult and undermine the rationale for adopting smoke-free regulations. Businesses may have a hard time understanding the exemptions. Meanwhile, there is no health basis for the variances because secondhand smoke is dangerous regardless of whether the exposure occurs in a bar or in a hospital. Examples of variances include the following:
- exempting certain types of establishments such as bars
- allowing businesses that suffer financial hardship to apply for a waiver
- allowing establishments to permit smoking if they install a special smoking room or ventilation equipment
- allowing establishments to permit smoking if minors are not allowed on premises
- allowing establishments to permit smoking if they pay an extra fee
The research shows that businesses typically comply with simple, comprehensive smoke-free regulations with relative ease, although there is an adjustment period. When restaurants first went smoke-free in New York City in 1995, for example, there was a surge in complaints to the Health Department about the regulations in the first two months after they took effect. Protests then leveled off, though they increased again following the one-year anniversary. However, after two years the level of complaints dropped below what it had been when the law was merely under consideration. In other words, despite initial opposition, the regulations eventually were accepted.
Few business owners built special smoking rooms, the majority complied without spending any money, and the vast majority of restaurant owners reported their dining rooms were smoke-free (Hyland et al. 1999b).
In Los Angeles, compliance inspections were done after bars were required to become smoke-free by state law in 1998. The percentage of bars that were observed to be smoke-free increased from 46% in 1998 to 76% in 2002, while in restaurants the compliance rate increased from 92% to 99% over the same period (Weber et al. 2003).
In Boston, a pre-implementation outreach and educational campaign was implemented before bars and restaurants were required to go smoke-free. Unlike the results from Los Angeles, the rate of compliance increased much more quickly. In the three months after the law took effect, the percentage of bars observed with smoking patrons decreased from 100% before the law to 2.5% (Skeer et al. 2004).
Ireland became the first nation to adopt a comprehensive national policy that requires all indoor public places, including bars and restaurants, to become smoke-free. This policy captured a tremendous amount of media attention in the months leading up to the implementation date, offering a long, sustained opportunity to educate the public about the dangers of secondhand smoke and the issues involved in the debate. As a result, the Irish public became more knowledgeable about secondhand smoke. The implementation of the Irish smoke-free law was a tremendous success with a 94% compliance rate. Complaints peaked one month after the law went into effect but quickly subsided (Howell 2005).
In summary, comprehensive smoke-free policies are simplest to implement and they are largely self-enforcing, which means that relatively few resources are needed to assure compliance. Communities that have made strong efforts to educate the public and business communities about the purpose of the smoke-free regulations have experienced the easiest and shortest transition periods.
- Once comprehensive smoke-free policies are adopted, the health benefits are immediate, both among workers and the general population. Levels of indoor air pollution decrease by about 90%, providing significant benefits to respiratory and cardiac health. Ventilation and filtration systems do not eliminate disease risk (Repace 2004, 2005; Travers 2004; Eisner et al. 1998; Farrelly et al. 2005; Allwright et al. 2005; ASHRAE 2005; Americans for Nonsmokers Rights Foundation 2005; Stark et al. 2007; Pell et al. 2008; Hyland et al. 2008; Arheart et al. 2008; Glantz 2008).
Comprehensive smoke-free policies are highly effective in reducing exposure to secondhand smoke and result in improved short-term health outcomes. The particles found in secondhand smoke are very small and are easily inhaled into the lungs. Studies have documented levels of fine particles in bars and restaurants that are about 90% lower in jurisdictions with smoke-free policies compared to those where smoking is permitted (Repace 2004; Travers 2004; Hyland et al. 2008) and a 90% drop in carcinogenic polycyclic aromatic hydrocarbons (Repace 2004). These air quality improvements have health benefits for bar and restaurant staff.
Bartenders in California experienced improvements in lung function and decreases in the frequency of adverse respiratory symptoms shortly after their statewide law took effect in January 1998 (Eisner et al. 1998). A 2007 study found that levels of NNK, a potent cancer-causing chemical that is a by-product of tobacco smoke, in the urine of nonsmoking hospitality staff working in smoky workplaces increased with as little as one hour of exposure to secondhand smoke (Stark et al. 2007). In the months after New York States smoke-free law took effect, hospitality workers experienced large decreases in cotinine, which is a marker for exposure to nicotine, and were less likely to report adverse symptoms such as wheezing, cough, and shortness of breath (Farrelly et al. 2005). In a nationally representative study cotinine levels have decreased from 1988 to 2002 in all worker groups, with the largest reductions in blue collar and service occupations (Arheart et al. 2008). Similar health improvements following Irelands smoke-free law were observed, while the negative health effects of secondhand smoke remained constant in Northern Ireland, which did not implement a smoke-free policy (Allwright et al. 2005). Ten months after Scotlands smoke-free law took effect, admissions for acute coronary syndrome decreased by 17% compared to a 4% decrease in neighboring England that did not have a smoke-free law in effect at the time (Pell et al. 2008). A 2008 review by Glantz estimates that comprehensive smoke-free legislation reduces rates of myocardial infarction in the general population by 19% from his review of the eight studies done to date (Glantz 2008).
Some policymakers have proposed addressing the problem of secondhand smoke in the workplace by requiring businesses to install special ventilation or filtration equipment. ASHRAE, the leading professional society for heating and air conditioning professions, concluded in a 2005 report that at present, the only means of effectively eliminating health risk associated with indoor exposure is to ban smoking activity (ASHRAE 2005). Given the amount of air exchanges required to remove the smoke, there is no practical ventilation method available to render smoke-filled air as safe as fresh outdoor air (Repace 2005).
Filtration technologies do not remove the exposure between the source of the pollutant and the filtration device and, consequently, there is no empirical evidence that they reduce disease risk. Several manufacturers of air handling and filtration equipment have been quoted as saying that filtration technologies will not eliminate the risk of secondhand smoke (Americans for Nonsmokers Rights Foundation 2005).
- Smoke-free regulations can encourage people to quit smoking because they provide a social environment where there are fewer inducements to smoke (Fichtenberg and Glantz 2002; Bauer et al. 2005; Tauras 2004; Longo et al. 1996, 2001; Evans et al. 1999; Farrelly et al. 1999; Bayer and Colgrove 2002; CDC 1999; Levy et al. 2004).
Studies show that smoking bans increase the chance that a smoker will successfully quit and prompt those who continue to smoke to smoke less. Fichtenberg and Glantz reviewed the literature in this area in 2002, and they concluded that totally smoke-free workplaces reduce overall smoking prevalence by 3.8% and people who continue to smoke consume an average of 3.1 fewer cigarettes per day (Fichtenberg and Glantz 2002). Bauer et al. report even larger benefits for cessation and consumption with nearly a doubling in cessation rates for those with smoke-free workplaces over an eight-year period compared to those who could smoke at work without restriction during the same period, suggesting that the effects may grow over time (Bauer et al. 2005). Other studies have reached similar conclusions (Tauras 2004; Longo et al. 1996, 2001; Evans et al. 1999; Farrelly et al. 1999). Smoke-free policies also change societal views on smoking (Hyland et al. 2009), which indirectly reduces smoking prevalence (Bayer and Colgrove 2002). The federal Centers for Disease Control and Prevention report that smoke-free worksite regulations are an integral component of a comprehensive approach to reducing tobacco use (CDC 1999) and other reviews have reached similar conclusions (Levy et al. 2004).
- Studies show that businesses in the hospitality industry do not lose jobs or taxable revenue when smoke-free policies are implemented (Scollo et al. 2003; Hyland and Cummings 1999a, 1999b; Hyland et al. 1999a, 2003; Bartosch and Pope 1999, 2002; Frieden et al. 2005; Cowling and Bond 2005; Biener and Fitzgerald 1999).
In 2003, a review by Scollo et al. found 97 studies that have explored the economic impact of smoke-free regulations on bars, restaurants, and other "hospitality venues." These studies were conducted in communities, states and countries around the world and have considered a wide range of community characteristics.
When the most scientifically rigorous studies were considered, all 21 of these reports concluded that smoke-free regulations do not cause adverse economic outcomes to the hospitality industry. In contrast, every single report that concluded smoke-free regulations were bad for business was funded by the tobacco industry or an agency with ties to the tobacco industry. No study sponsored by the tobacco industry met all of the standards for scientific rigor (Scollo et al. 2003). The Scollo et al. paper remains the most comprehensive review of economic impact studies, although this analysis is being updated (as of July 2009), and updated results should be available in the future.
Studies of taxable sales and employment show business remains unchanged in restaurants (Hyland and Cummings 1999a; Hyland et al. 1999a, 2000, 2003; Bartosch and Pope 1999, 2002). More recent articles exploring bars have replicated the finding of Scollo et al. that bars do not suffer significant losses in business after the adoption of smoke-free environments (Frieden et al. 2005; Cowling and Bond 2005; Alamar and Glantz 2007). Less is known about the potential economic impact of smoke-free policies in gaming establishments due to their limited and only recent inclusion in some smoke-free policies.
Consumer studies provide a possible explanation for the findings. Smokers still patronize the same bars and restaurants after smoke-free rules are implemented. Although some smokers report going out to eat less frequently or spending less money per visit, this change is offset by the fact that some nonsmokers report going out more frequently or spending more money per visit (Hyland and Cummings 1999a; Biener and Fitzgerald 1999). The overwhelming weight of the scientific evidence in this area shows clearly that the hospitality economy has not suffered adverse economic consequences in the wake of regulations.