Ashes to ashes

With an increasing number of countries promising to ban smoking in public places,

Thomas Mac Mahon weighs up the evidence about the effects of passive smoking

With much fanfare, on 29 March 2004, Ireland became the first country in the European Union (EU) to ban smoking in bars and restaurants. Billed primarily as a measure to protect workers from passive smoking and environmental tobacco smoke, the ban extended existing restrictions by outlawing smoking in almost all enclosed workplaces. A year later it has proved to be a popular piece of legislation - 93% of the Irish public think its introduction was a good idea, including 80% of smokers.¹

What is environmental tobacco smoke?

Environmental tobacco smoke refers to the ambient smoke present when someone is smoking. It contains more than 4000 substances, including strong irritants and more than 50 known or suspected carcinogens (such as nitrosamines, polycyclic aromatic hydrocarbons, and nickel). Environmental tobacco smoke has two components - mainstream smoke, which is inhaled and exhaled directly by the smoker, and sidestream smoke, which is composed mainly of the smoke emitted from the tip of a smouldering cigarette.² This latter component, which is responsible for up to 85% of the smoke in a room, is more hazardous since it contains higher concentrations of a variety of harmful chemicals.³ Non-smokers exposed to environmental tobacco smoke are estimated to absorb the equivalent of 0.1 to 1.0 cigarettes per day.⁴

Evidence behind the ban

In 1964, the US Surgeon General released a report on smoking and health that bluntly stated that smoking causes cancer in smokers: "Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking far outweighs all other factors. The data for women, though less extensive, point in the same direction."⁵

HAYDN WEST/PA/EMPICS

Many large studies have since confirmed this, but it was not until 1986 that two studies were published that showed an association between adverse health effects in non-smokers and exposure to environmental tobacco smoke.^6,7 This work was followed up in 1992 by a study analysing the effects on the respiratory system, which found a strong association between exposure to environmental tobacco smoke and lung cancer.⁸ That year also saw the US Environmental Protection Agency classify it as a group A carcinogen. The World Health Organization confirmed the carcinogenic potential of environmental tobacco smoke in 2002.⁹ A fuller analysis of the range of associated conditions has been done in the intervening period (see table 1).^10-12

People who have never smoked but are exposed to environmental tobacco smoke at work are conservatively estimated to have a significantly increased risk of developing lung cancer of 16%-19%; the increased risk for coronary heart disease is 25%-35%.⁹ In the United States, this translates into 3000 lung cancer deaths and up to 35000 deaths a year from ischaemic heart disease in adult non-smokers.¹³ Rough estimates for the former European Union group of 15 countries were that exposure caused 50000-100000 deaths a year in the region.¹⁴

The results of a recent study, however, although not disputing its carcinogenic potential, did not support a direct causal relationship between environmental tobacco smoke and tobacco related death.¹⁵ The analysis of the data could not show any significant association between environmental tobacco smoke and disease. So although they did not rule out a small effect, the authors concluded that the association between exposure and coronary heart disease and lung cancer may be weaker than previously supposed. This controversial result provoked fierce criticism, mainly of the researchers' integrity and independence (a proportion of the study's funding came from the tobacco industry, but was fully declared) but also of the study design centring on the fact that most people, whether they smoked or not, were exposed to tobacco smoke at work in the 1950s, and also that many quitters are misclassified as smokers.

Nonetheless, the existence of any association between exposure to environmental tobacco smoke and adverse health effects is clearly an occupational health issue, since workers have the right not to be exposed to any harmful substance while carrying out their duties. The WHO Framework Convention on Tobacco Control obliges governments to implement effective measures that provide protection from exposure to tobacco smoke in indoor workplaces and other locations.¹⁶

 Reports of individuals successfully suing for damages due to harm from environmental tobacco smoke reflect the onus on employers to tackle this problem as well.

The Irish experience

This issue came on to the political agenda in 1999 when the Parliamentary Joint Committee on Health and Children recommended restrictions on workplace smoking. In a debate fuelled by estimates that 150 Irish bar workers die from illnesses related to environmental tobacco smoke a year,¹⁷ agreement was reached in 2002 on a tobacco control bill empowering the minister for health and children to create smoke-free workplaces. After a protracted period of consultation on the scope of the restrictions and extensive lobbying by vested interests and legal delays, the ban came into effect three months later than planned in March 2004. Publicans' attempts to broker a compromise deal by installing ventilation systems in smoking areas were rejected as being insufficient to guarantee air quality.

Since then the focus has shifted to compliance and enforcement. Concerns that implementing the law would add to the workload of the Irish police force were unfounded, as the responsibility falls instead to 40 dedicated tobacco control officers, 100 health and safety inspectors, and 400 environmental health officers. Despite high profile cases of individuals breaking the law, including the opposition's justice spokesman and Simon Cowell, pop impresario, there was 97% compliance during the first month of the ban's existence.

Nine months and almost 35000 inspections later, the rate had dropped to 94%, but this was attributed to a concentration of inspections on non-compliant premises, 12 of which had been prosecuted in that period.¹⁸ Such high compliance reflects overwhelming public support, with 96% of Irish people believing the initiative to be successful and 98% agreeing that the legislation is a positive health measure.¹ For the remainder, the threat of a €3000 (£2100; $3800) fine if convicted of breaking the law is a strong incentive to comply.

Although it is too early to assess the health benefits of the ban, research from US states with smoke-free workplace legislation indicates that there is an immediate impact on respiratory health and levels of heart attacks and heart disease. In a very small study in Montana, there was a 40% decline in the number of hospital admissions for myocardial infarction during the first six months of a ban.¹⁹ Similarly, after only one month of smoke-free measures in California, a 5%-7% improvement in pulmonary function tests was seen in both smokers and non-smokers.²⁰ It is anticipated that comparable effects will be seen in Ireland and research is ongoing to determine this.

As smoking at work or while socialising has become inconvenient, many smokers have taken advantage of the new law to cut down or quit; one fifth of smokers now choose not to smoke at all when out socialising.¹⁸ The ban is only an element of a broader anti-smoking strategy, however. Hard hitting advertisements showing graphic images of the damage done to the brain and heart by smoking (achieving unprecedented 89% recognition levels) as well as a telephone helpline also play a significant role. Of almost 20000 callers to the helpline in the six months since its launch, about one third quit, and 39% of them credited the legislation with influencing their decision.²¹

This change in society's acceptance of cigarettes has played a role in the slump in sales reported in 2004. The Gallaher Group, which controls about 50% of the Irish cigarette market, noted a 10.7% fall in sales during the first ten months of last year. Overall, tobacco sales shrank by 17.6%, cutting the government's revenue from excise duty by almost €128m.

Predictably, the licensed trade has been quick to blame a drop in sales of stout, ale, and lager on the smoking ban. 23 million fewer pints were sold in the first six months of the ban (a fall of 6.4% on 2003). The fall in the volume of bar sales for the whole year, was 4.4%, however, mirroring 2003's fall of 4.2% and extending a decline that began back in 2001. The fact that you can expect to pay on average €3.73 for a pint of Guinness in a Dublin pub may have contributed to the fall, since off-licence sales rose by 7% in those first six months.

Looking at the employment statistics is more complicated, as figures fluctuate notoriously. The most recent survey shows that the number of people employed in the hospitality sector declined by 2.4% during 2004, yet by December that total still exceeded the number employed in 2002 by 0.6%. Loudly articulated fears of an industry meltdown have thus far not materialised.

JOHN COGILL/PA/EMPICS

Smoking at work or while socialising has become inconvenient

International attention

Governments around the world are showing interest in adopting more extensive workplace restrictions, having monitored Ireland's experience closely. Already Norway and New Zealand have enacted similarly tough laws, with other countries about to follow suit (see table 3). Many US, Canadian, and Australian states have also implemented smoke-free legislation at a local level.

Future trends

The Health Committee of the European Parliament recently stated that Italy's smoking ban should become an example for the entire EU. Although variants of the smoking ban look certain to spread, no country has yet gone as far as the tiny Himalayan kingdom of Bhutan, which is banning all tobacco sales as part of a bid to increase its population's gross national happiness. Recently, though, there have been a growing number of calls to do just that. The US surgeon general, Richard Carmona, provoked controversy in June 2003 when he supported calls for all tobacco products to be banned across the US, a position echoed in the UK by the Lancet.²² However, given the difficulties encountered with introducing a relatively straightforward workplace ban and regardless of how beneficial it would be, governments are unlikely to experiment with a fully tobacco-free society in the near future.

Thomas Mac Mahon, third year medical student, University College Dublin, Ireland
Email: tomacmahon@hotmail.com

I thank Valerie Robinson, Office of Tobacco Control, and Shane Allwright, senior lecturer in Epidemiology, department of public health and primary care, Trinity College Dublin, for their help.

studentBMJ 2005;13:221-264 June ISSN 0966-6494

1. Office of Tobacco Control. Poll shows 98% of us believe Irish workplaces are healthier as a result of the smoke-free law. Dublin: OoTC, 2005. www.otc.ie/article.asp?article=267 (accessed 18 Apr 2005).
2. World Health Organization. Environmental tobacco smoke. In: Air quality guidelines for Europe. ch 8.1. Geneva: WHO, 2000. www.euro.who.int/document/aiq/8_1ets.pdf (accessed 18 Apr 2005).
3. Fielding JE, Phenow KJ. Health effects of involuntary smoking. N Engl J Med 1988;319:1452-60.
4. Centers for Disease Control and Prevention. Environmental tobacco smoke in the workplace. Atlanta: CDC, 1991. (Current intelligence bulletin 54.) www.cdc.gov/niosh/91108_54.html#NRC%201986 (accessed 18 Apr 2005).
5. US Department of Health. Smoking and health: report of the advisory committee to the surgeon general of the public health service. Washington DC: USDH, 1964 www.cdc.gov/tobacco/sgr/sgr_1964/sgr64.htm (accessed 18 Apr 2005).
6. US Department of Health and Human Services, Public Health Service, Centers for Disease Control. The health consequences of involuntary smoking: a report of the surgeon general. Rockville: USDHHS, PHS, CDC, 1986. www.cdc.gov/tobacco/sgr/sgr_1986/index.htm (accessed 18 Apr 2005).
7. National Academy of Sciences. Environmental tobacco smoke: measuring exposures and assessing health effects. Washington, DC: NAoS, 1986.
8. US Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancers and other disorders. Washington, DC: USEPA, 1992.
9. World Health Organization, International Agency for Research on Cancer. Tobacco smoke and involuntary smoking (summary). Lyons: WHO, IARC, 2002. (Volume 83.) www-cie.iarc.fr/htdocs/monographs/vol83/02-involuntary.html (accessed 18 Apr 2005).
10. European Commission, Office for Official Publications of the European Communities. Tobacco or health in the European Union: past, present and future. Luxembourg: EC, 2004. http://europa.eu.int/comm/health/ph_determinants/life_style/Tobacco/Documents/tobacco_fr_en.pdf (accessed 18 Apr 2005).
11. Allwright S, McLaughlin JP, Murphy D, Pratt I, Ryan MP, Smith A. Report on the health effects of environmental tobacco smoke (ETS) in the workplace. Dublin: Health and Safety Authority, Office of Tobacco Control, 2003. www.otc.ie/article.asp?article=29 (accessed 18 Apr 2005).
12. National Cancer Institute. Environmental tobacco smoke. Washington, DC: NCI. (Cancer facts sheet 10.18). http://cis.nci.nih.gov/fact/10_18.htm (accessed 18 Apr 2005).
13. Centers for Disease Control. Exposure to environmental tobacco smoke and cotinine levels: fact sheet. Atlanta: CDC. www.cdc.gov/tobacco/research_data/environmental/factsheet_ets.htm (accessed April 18, 2005)
14. von Eyben, F.E. Health risks from active and passive smoking, In: Smoke Free Workplaces: Improving the health and well-being of people at work. European Status Report. European Network for Smoking Prevention, 2001 http://www.ensp.org/files/ACF3526.doc (accessed April 18, 2005)
15. Enstrom JE, Kabat GC. Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98. BMJ 2003;326:1057-67.
16. www.who.int/tobacco/framework/en (accessed April 18, 2005)
17. Repace, J. Right to live overrides right to smoke. Irish Times 2002 Feb 11.
18. Office of Tobacco Control. Smoke-free workplace legislation implementation progress report, 2004. Dublin: OTC, 2005 www.otc.ie/article.asp?article=200 (accessed 18 Apr 2005).
19. Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004;328:977-80.
20. Eisner MD, Smith AK, Blanc PD. Bartenders’ respiratory health after establishment of smoke-free bars and taverns. JAMA 1998;280:1909-14.
21. Smoke-free at Work. 7000 fewer smokers in Ireland. Dublin, Department of Health and Children, 2004. www.smokefreeatwork.ie/news/detail.asp?id=22 (accessed 18 Apr 2005). How do you sleep at night, Mr Blair? Lancet 2003;362:1865.

       

           

	LIFE Ashes to ashes       Thomas Mac Mahon (June 2005)
	Taiyyab Mehmood (August 23rd, 2005)       Medical Student/Medicine/3rd year, England/Latvia mrt1066@yahoo.com
	Too little, too late to try to ban smoking at places. Its total hypocritical of governments to allow smoking at home and so to kill all around them and themselves (manslaughter?) but to ban outright cannabis which is as damaging as tobacco. But the huge revenues of making money from tax and not needing to give pension to those who smoke and die at young age, makes our greedy governments continue tobacco. Then you may ask why don’t they allow cannabis become legalised? Well you need less cannabis to become high and so lower volume of sales and so less revenue from tax to the government and a double blow that more will move from tobacco which governments have huge shares in and lose tax from loss of revenue from this also. Its very admirable that the Irish have put in good measures to to a sincere effort to stop smoking. Small countries generally have a more caring government for the welfare of their people. Its better late than never i suppose, but a total outright ban of tobacco sales is the only way. Bad news for pulmonaologists though ;) Peace to you all! :))