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HomeMy WebLinkAboutCOM 0942.107 2006-2008 Mar ll 08 10:26p John Harrison (808}5955143 p.1 A~'AIJ For the Protection e3 Hawon's Native Wt)dML- IIAWAH AUDUBON SOCIETY ffiO Richards Smet, Suite 505. Hono4du, H7 968134709 4 Pboneft -(8061528-1432; himWd Qpixis .v www1womiatdahon. $ ~o s°° v~ 00 z. P7 Date: March 10, 2008 To: Hawaii County Council 3 01 Re: Council Hearing, March 12, 2008, Bill 224 - Y c.a TESTIMONY IN STRONG SUPPORT Chair Hoffinann, Vice Chair Pilago, and members of the Hawaii County Council. The Hawaii Audubon Society would like to once again offer testimony in strong support of Bill 224. Founded in 1939, the Hawaii Audubon Society is Hawai`i's oldest conservation organization, with a membership of over 1,500 dedicated individuals statewide, including the island of Hawaii. The Society's primary mission is the protection of Hawai`i's endemic birds, wildlife and their habitats. The Society supports efforts that improve habitat resources and the environment It is well known that our ecosystems are under attadu Hawaii is the endangered species capitol of the world with the highest comber of listed threatened and endangered species in the nation. There are 294 threatened and endangered bird, animal and plant species in KawaPi, many of which can only be found on the Big Island. We know that cigarette butt litter, which includes packaging and plastic lighters, is a major problem at our beaches, in the ocean, and our watersheds, all of which are critical habitats for our various bird species. Cigarette butts discarded in parking lots, along sidewalks and in street gutters miles from the coast inevitably make their way through storm drains, creeks and rivers. eventually collecting in our costa ecosystem and ocean. Cigarette bulls discarded onto beaches add to the problem, it isn't just a matter of unsightly trash. Toxins Balm cigarettes collect on the filter and are then leach out into the beach sands and aquatic coastal waters_ Comm. No. Ref. To: Ref. Dote rend Mar 11 08 1026p John Harrison (808)595.5143 p.2 Birds and sea mammals ingest the butts and brightly colored lighters thinking that ifs food. Plastic pieces have been found in the stomachs of fish. birds, whales, and other marine creatures. Ingestion of plastic lighters and cigarette filters is a known threat to island wildlife. Passage of Bill 244, will go a long way in eventually improving the costal ecosystems on the Big Island. The reduction of smoking related litter, cigarette butts, cigar tips, lighters, and the wrappers on cigarette packs, will eliminate cigarette litter throughout our watershed and ensure the survival or many of our State's endemic and indigenous birds, sea hwdes, and costal fishes- Let's put an end to the worlds greatest environmental titter problem, at least on the Big Island. I strongly urge you to pass Bill 224 as is un-amended. R y. John arrison Went World Health Organization - - PROTECTION FROM EXPOSURE i 1 1 TOBACCO SMOKE Policy recommencJc~tions r e s r w it ~C WHO Library Cataloguing-in-Publication Data: Protection from exposure to second-hand tobacco smoke. Policy recommendations. 1.Tobacco smoke pollution - adverse effects. 2.Tobacco smoke pollution - legislation. 3.Smoking - legislation. 4.1-egislation, Health. S.Health policy. 6.0ccupational exposure - legislation. I.World Health Organization. P` ISBN 978 92 4 156341 3 (LC/NLM classification: HD 9130.6) "World Health Organization 2007 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 7913264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications -whether for sale or for noncommercial distribution -should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion r whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by r. the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. M PM All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility r for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable ¦ for damages arising from its use. r Design and layout by EKZE (www.ekze.ch) r Printed in France r r R r w r Protection from exposure to second-hand tobacco smoke. Policy recommendations. r a r a - r s ¦ 0 World Health Organization Table of contents it Table of contents 1 Executive summary 2 r SectionI - Introduction 3 Background and rationale 3 r Development of the recommendations 4 Section 11- The problem 4 as Health effects of SHS exposure 4 Magnitude of exposure to SHS 6 1 Economic costs of SHS exposure 7 r Section III- The solution 7 Effective protection strategies 7 Effects of smoke-free environments on health and tobacco use 10 Economic impact of smoke-free environments 12 r Section IV - Experiences and best practices. 13 Smoke-free environments should be mandated by law, not byvoluntary policies 14 Legislation should be simple, clear and enforceable, and comprehensive 15 Consider which jurisdictional level(s) will afford the most progress........... 16 Anticipate the opposition 17 ¦d Involve civil society 18 Educate and consult to ensure smooth implementation 18 qW Develop an implementation and enforcement plan and ensure infrastructure for enforcement 19 Monitor implementation and, ideally, measure impact and document experiences 19 Section V - Recommendations 20 Recommendation 1: 100% smoke-free environments, not ventilation 20 Recommendation 2: Universal protection by law 20 Recommendation 3: Proper implementation and adequate enforcement of the law 20 Recommendation 4: Public education to reduce SHS exposure in the home.... 21 Section VI- Appendices 22 Section VII- References 40 0 ¦ Protection from exposure to second-hand tobacco smoke. Policy recommendations. r Executive summary 6. An implementation and enforcement plan as PIP Scientific evidence has firmly established that `Nell as an infrastructure for enforcement are essential; and 6. there is no safe level of exposure to second- hand tobacco smoke [SHSI, a pollutant that 7. Implementation of smoke-free environments p causes serious illnesses in adults and children. must be monitored and, ideally, their impact V There is also indisputable evidence that imple- measured and experiences documented. menting 100% smoke-free environments is the F" only effective way to protect the population from In light of the above experience, the World the harmful effects of exposure to SHS Health Organization [WHO) makes the follow- I. . ng recommendations to protect workers and Moreover, several countries and hundreds of the public from exposure to SHS: 1P subnational and local jurisdictions have suc- IN cessfully implemented laws requiring indoor 1. Remove the pollutant - tobacco smoke - by workplaces and public places to be 100% implementing 100% smoke-free environ- op smoke-free without encountering significant ments. This is the only effective strategy to challenges in enforcement. The evidence from reduce exposure to tobacco smoke to safe these jurisdictions consistently demonstrates levels in indoor environments and to provide not only that smoke-free environments are an acceptable level of protection from the i enforceable, but that they are popular and dangers of SHS exposure. Ventilation and become more so following implementation. smoking areas, whether separately ventilated These laws have no negative impact - and often from non-smoking areas or not, do not have a positive one - on businesses in the hos- reduce exposure to a safe level of risk and pitatity sector and elsewhere. Their outcomes are not recommended; - an immediate reduction in heart attacks and p Enact legislation requiring all indoor work- respiratory problems - also have a positive places and public places to be 100% smoke- impact on health. free environments. Laws should ensure uni- These experiences offer numerous, consistent versal and equal protection for all. Voluntary r lessons learnt, which policy-makers should policies are not an acceptable response to 1P consider to ensure the successful implemen- protection. Under some circumstances, the tation of public policies that effectively protect principle of universal, effective protection may the population from SHS exposure. These les- require specific quasi-outdoor and outdoor sons include the following: workplaces to be smoke-free; r 1. Legislation that mandates smoke-free 3. Implement and enforcethe law. Passing smoke- environments- not voluntary policies - Is free legislation is not enough. Its proper imple- n. necessary to protect public health; mentation and adequate enforcement require relatively small but critical efforts and means. r 2. Legislation should be simple, clear and enforceable, and comprehensive; 4. Implement educational strategies to reduce SHS exposure in the home, recognizing that 3. Anticipating and responding to the tobacco smoke-free workplace legislation increases industry's opposition, often mobilized the likelihood that people [both smokers and through third parties, is crucial; non-smokers) will voluntarily make their r 4. Involving civil society is central to achieving homes smoke-free. effective legislation; WHO encourages Member States to follow these 5. Education and consultation are necessary recommendations and apply lessons learnt to to ensure smooth implementation; advance the goals of public health through leg- islated implementation of 100% smoke-free r © environments in workplaces and public places. r~ Protection from exposure to second-hand tobacco smoke. Policy recommendations. p SECTION I - INTRODUCTION health improvements in workers previously a exposed to SHS. Background and rationale The last several years have seen a wealth of At the same time, smoke-free environments new evidence on the health effects of expo- have been found to be very effective as a sure to second-hand tobacco smoke (SHSI, the tobacco control policy by making it easier for benefits of smoke-free environments and best smokers to cut down or quit and by reducing practice in implementing smoke-free policies. smoking initiation. Furthermore, smoke-free Compiling and disseminating this evidence is laws enjoy popular support and high levels of critical to raising awareness among decision- compliance when properly implemented; they makers and public health advocates about the forcefully deliver the message that smoking necessity for smoke-free environments to pro- is not socially acceptable. ' tect health and their broad acceptance and endorsement. It is for this reason that the Recent progress has highlighted the feasibility World Health Organization (WHO) is now pub- of achieving smoke-free environments and - lishing policy recommendations on protection heightened worldwide interest in promoting from SHS exposure. them. Developed and developing countries like Ireland, New Zealand, Scotland and Uruguay, A clear scientific consensus on SHS exposure's as well as territoriesd such as Bermuda, have dangerous health effects has developed, based built on the implementation of smoke-free laws on accumulated evidence and copious new atthe localand subnational levelthat began in data, which show that SHS causes serious and North America in the late 1970s. With almost fatal diseases in adults and children. Several universal success, they have since enacted and current reports, including the 2004 monograph implemented laws to protect workers and the from the International Agency for Research on public from SHS in almost all indoor work- Cancer (IARC), the 2005 report from the places and public places (including bars and California Environmental Protection Agency casinos), achieving strong popular support. (Cal/EPA) in the United States of America and Other countries are interested in learning from the 2006 report of the United States Surgeon their experiences. General, have synthesized this evidence and reached unambiguous and solid conclusions on Since the 1970s, tobacco companies have con- SHS exposure's adverse consequences. These sidered smoke-free laws to be the "most dan- conclusions provide a strong imperative for gerous development to the viability of the tobac- eliminating indoor SHS exposure. co industry that has yet occurred."' The tobacco industry - usuallyworking through front groups In light of the accumulated evidence, local, operating with its support- vigorously opposes subnationala and national governments world- the passage and implementation of smoke-free wide are increasingly imptementing smoke- laws, whether at local, subnational or national free policies in workplaces and public places level. Tobacco companies continue to misrep- to protect people from the dangers of SHS. resent the evidence on the health effects of Jurisdictions that have implemented smoke- SHS exposure and even claim that WHO has free workplaces and public places have concluded that SHS is not dangerous. In fact, observed an immediate drop in levels of SHS, WHO has consistently concluded the opposite: a decline in levels of SHS components in the SHS kills. population aswell as significant and immediate a Subnational Level refers to all jurisdictions other than the Local, municipal Loveland the national or federal level of a country. It may include states, provinces, cantons, departments or similar jurisdictions. Protection from exposure to second-hand tobacco smoke. Policy recommendations. M Finally, the obligations under WHO's Framework WHO convened a consultation in Montevideo, Convention on Tobacco Control (WHO FCTC), Uruguay in November 2005. Its purpose was to which more than 140 WHO Member States to gather experts to discuss the many aspects and the European Community are Parties', are of SHS and smoke-free environments. The con- further driving the need for clearer guidance sultation addressed the health effects of SHS from WHO on protection from SHS. Article 8 of exposure and the toxic properties of SHS; SHS the WHO FCTC, Protection from exposure to exposure's economic costs; the impact of tobacco smoke, requires Parties to: smoke-free environments on tobacco consump- Adopt and implement in areas of existing tion as well as business; policy development nationaljurisdiction as determined by national and implementation; and needs and available law and actively promote at otherjurisdictional resources for making progress towards smoke- levels the adoption and implementation of free environments. effective legislative, executive, administrative and/or other measures, providing forprotection These policy recommendations are based in from exposure to tobacco smoke in indoor work- part on the deliberations of the Uruguay con- places, public transport, indoorpublic places sultationd and have been amplified and M and, as appropriate, other public places.2 reviewed by a broader group of experts from all of the WHO regions and within a variety of dis- At its first session in February 2006, the ciplines (Appendix 1 - List of participants and Conference of the Parties to the WHO FCTC observers at the expert consultation on policy decided to accord the highest priority to devel- recommendations on second-hand tobacco " oping guidelines on Article 8, and to request the smoke in Montevideo, Uruguay), including the Convention Secretariat to initiate work on these WHO Collaborating Centre on Tobacco Control guidelines. In the same decision, the Conference Policy at the University of California, San of the Parties also adopted a template for the Francisco. elaboration of Article 8, which lists several resources for the guideline development, of The recommendations aim to elucidate for WHO which the present recommendations are one.3 Member States the science on SHS exposure as well as the health and economic benefits of In summary, these recommendations are a smoke-free laws and to guide decision-makers response to the unquestionable dangers of in developing and implementing evidence-based M, exposure to SHS, as well as to the opportunity and enforceable smoke-free policies. to assist the WHO FCTC implementation process and provide guidance to the growing SECTION II - THE PROBLEM number ofjurisdictions interested in becoming smoke-free. Health effects of SHS exposure Second-hand tobacco smoke isthe combination ^ Development of the of smoke emitted from the burning end of a recommendations cigarette or other tobacco products and smoke With the support of the WHO Collaborating Centre exhaled by the smoker. SHS contains thou- " on Tobacco Control Surveillance and Evaluation sands of known chemicals, at least 250 of at the Institute for Global Tobacco Control, Johns which are known to be carcinogenic or other- Hopkins Bloomberg School of Public Health, wise toxic.4 b A territoryis a geographical area distinct from a WHO Member State forwhich the United Nations makes no assumption regarding its politicat or administrative affiliation. c 147 parties as of 1 June 2007. d Participation in the Uruguay meeting does not necessarily imply endorsement of the recommendations. r w r Protection from exiaosure to second-hand tobacco smoke. Policy recommendations. " Evidence on the adverse health effects of expo- Tobacco and Health 18 is that SHS exposure sure to SHS has been accumulating for nearly causes heart disease and increases the risk 50 years. The first studies to appear in the of death from heart disease by about 30%; 1950s and 1960s focused on the effects of SHS recent evidence suggests that the effect could on children and on the impact of smoking by be more than twice as large." the motheron the fetus.5,1'As more and more studies in the ensuing decades have linked Lung cancer. SHS exposure has been linked to SHS exposure to a variety of serious diseases lung cancer in dozens of studies from around the in children and adults, a solid scientific consen- world, beginning with studies in 1981 showing sus has developed on the effects of SHS expo- an increased risk of lung cancer in non-smok- sure. WHO, IARC, the United States Surgeon ing women married to cigarette smokers. 20, 21 General, the United States Environmental The IARC, the United States Surgeon General Protection Agency [EPA). CaVEPA, and numer- and the United States EPA, among numerous ous expert scientific and medical bodies world- other scientific bodies worldwide, have all con- wide have documented the adverse effects of cluded that SHS causes lung cancer in non- SHS on the respiratory and circulatory systems, smokers. 9- 10, 11, 12, 13, 14, 15 its role as a carcinogen in adults, and its impact on children's health and development.',',10, n. Breast cancer. The 2005 CaVEPA report, pre- 12. 13 The IARC review of the relationship pared as part of the process that led SHS to be between SHS exposure and cancer published listed by the state as a "toxic air contaminant," in its 2004 monograph has been followed by indicates that 13 out of 14 studies reviewed, updated comprehensive reviews of the health which contained data on pre- versus post- effects of SHS exposure released by CaVEPA in menopausal status found an elevated risk of 200514 and the United States Surgeon General breast cancer in younger, primarily pre- in 2006.15The chronology of the accumulation menopausal women, leading to an overall esti- of evidence and the summary of conclusions mate that SHS exposure was associated with by the recent Cal/EPA and the United States a nearly 70% increased risk of breast cancer in Surgeon General's reports are found in Appendix this group. The Cal/EPA concluded that SHS 2 and Appendix 3. causes breast cancer in younger, primarily pre- Impact on adults menopausal women based on this observed risk as well as the current state of knowledge Coronary heart disease ICHO/. There is con- . vincing evidence from studies on a wide geo- that the biology of breast cancer and the fact that there are 20 known mammary carcino- graphical and racial range of populations that gens in SHS, which have caused detectable SHS causes both fatal and non-fatal heart dis- genetic damage in women's breasts.14, e The ease. Exposure to SHS causes acute adverse United States Surgeon General's Report found effects on the blood tipids, clotting systems the evidence to be suggestive of a causal rela- (platelets) and arterial wall function within tionship between SHS and breast cancer.15 minutes, and many of these effects are nearly as targe as those seen in active smokers. 14.15, 16 Respiratory symptoms and illnesses. Data indicate that SHS exposure plays a role in the The current consensus from agencies, including development of chronic respiratory symptoms the American Heart Association, 17 the United and produces measurable decreases in put- States Surgeon General, 15 CaVEPAl4and the monaryfunction.l4SHSalso inducesandexacer- United Kingdom Scientific Committee on bates asthma inadults.l4 a e Cal/EPA concluded that evidence for an effect of SHS on breast cancer in postmenopausat women remains inconclusive. i tW Impact on children health professionals. Data from the Global Respiratory illnesses and symptoms. Both Youth Tobacco Survey (GYTSI indicate that SHS maternal and paternal smoking cause lower exposure is common among youth. Surveys of respiratory tract illnesses such as bronchitis children in school, aged 13 -15 years, conducted and pneumonia, particularly during the first between 1999 and 2006 in 132 countries found year of life.15,22,23 Numerous surveys also show that 44% had been exposed at home and 56% a greater frequency of the most common res- in public places during the 7 days prior to the piratory symptoms - cough, phlegm and survey.38AstudyofworkersatMexico'sNational wheeze - in the children of smokers.24.25 The Institute of Health showed that 91% were ` highest levels of risk have been found in house- exposed to some degree to tobacco smoke.39A s holds where both parents smoke. survey of third-year students in health profes- sional schools in 10 countries found exposure ` Asthma. Exposure to SHS exacerbates pre- to SHS at home ranging from 30% in Uganda existing asthma and causes new-onset asthma to 87% in Albania, and exposure in public places among children (as well as adults, as discussed from 53% in Uganda to 98% in Serbia.40 ` above). 11, 2e, 27 Exposure to SHS in the home increases emergency room visits and medication While exposure to tobacco smoke in the United use by asthmatic children. 28.21 States has declined substantially over the past ` several years, studies of cotinine (a by-product Lung growth and development. Since the United of nicotine) reviewed in the 2006 United States States Surgeon General concluded in 1986 that Surgeon General's Report show that more than ` SHS reduces the rate of lung function growth 40% of non-smoking adults and almost 60% during childhood, evidence has continued to of children aged 3 through 11 years are still accumulate to support this conclusion. iL15,30, exposed to SHS.15 ` 31 An effect has been associated both with e, maternal smoking during pregnancy and with Two recent studies of a variety of settings in 39 exposure to SHS after birth. developed and developing countries found SHS ` in the great majority of the locations surveyed.41, Middle-eardisease/otitismedial.SHS exposure 42 In seven Latin American countries SHS causes otitis media, or middle ear disease, a (measured by ambient nicotine levels) was common childhood illness that accounts for a detected in 94% of the locations surveyed, large number of visits to physicians and, if including hospitals, schools and government untreated, can lead to hearing impairment. 13.15.31 buildings.41 A study comparing levels of fine particulate matter in indoor environments, Pre and postnatal effects where smoking was or was not observed, con- Exposure of non-smoking women to SHS during duded that among the 32 countries studied, ` pregnancy causes low birth weight and preterm only the two countries with national compre- delivery.14, 33, 34.35 SHS exposure also causes hensive smoke-free air policies - Ireland and Sudden Infant Death Syndrome (SIDS or cot New Zealand - had acceptable levels of indoor death).15,"Other perinatalhealth effects where airquality.42,43 there may be a link with SHS exposure are intrauterine growth retardation and sponta- Widespread exposure translates into significant neous abortion (miscarriagel.14,31 health consequences at the population level. For example, Cal/EPA estimates that in the Magnitude of exposure to SHS United States SHS causes 3 400 lung cancer Exposure to SHS is widespread in most coun- deaths and between 23 000 and 70 000 heart tries, even in health-care settings and among disease deaths annually. In children, SHS is estimated to be responsible for the country's health from the dangerous effects of SHS. annual 430 cases of SIDS, 24500 low-birth Smoke-free policies protect health; where they weight babies, 71 900 pre-term deliveries, are introduced, exposure to SHS falls and health 200 000 episodes of asthma and 790 000 improves. They are also extremely cost-effective, medical visits due to middle-ear infection. 13.44 especially compared with the ineffective "alter- Estimates of deaths attributable to exposure to natives" promoted by the tobacco industry, SHS are available for at least 27 other coun- generally through third parties, namely: 55 t rles,45, 46, 47, 48, 49 • separation of smokers and non-smokers within the same airspace; and Economic costs of SHS exposure • increased ventilation and air filtration com- Exposure to SHS imposes economic costs on bined with "designated smoking areas". individuals, businesses and society as a whole. Economic costs include primarily direct and Ineffective "alternatives" indirect medical costs and productivity losses. Separation of smokers and non-smokers within In addition, workplaces where smoking is per- the same airspace. Simply separating smokers mitted incur higher renovation and cleaning and non-smokers within the same air space, costs, an increased risk of fire and may expe- absent any floor-to-ceiling barriers, does not rience higher insurance premiums. 50 eliminate - and in many cases does not even reduce - non-smokers' exposure to SHS.16, 57, The costs of SHS exposure have been evaluated sa,s9, 60 Exposure of non-smokers to SHS in such in Australia, Canada, Hong Kong Special open air spaces is highlyvariable depending on Administrative Region (Hong Kong SAR), Ireland, local airflow patterns, dilution volume, dis- the United Kingdom and the United States. 51 tance between smokers and non-smokers and Specific estimates of cost vary, depending on amount of smoking, among other elements. the factors included in the study. However, in Heating, ventilating, and air conditioning (HVAC) all cases these costs are significant. systems, depending on their design, almost e always re-circulate air from smoke-contami- A recent study bythe Society of Actuaries in the nated areas to non-smoking areas. One study United States estimates that SHS exposure of ambient nicotine levels (a marker for SHS) in ti results in over US$ 5 billion in direct medical Latin America showed higher levels of nicotine costs and in over US$ 5 billion in indirect medical in non-smoking than the adjacent smoking sec- costs (such as disability, lost wages and related tions in some settings.41 Moreover, studies of benefits) annually in the United States.52 In workers in non-smoking areas have shown that Hong Kong SAR, the annual value of direct their exposure to SHS can be as high as that of medical costs, long-term care and productivity workers in areaswhere smoking is permitted 61,62 loss due to SHS exposure is estimated to be US$ 156 million. 53 Increased ventilation and filtration combined • with "designated smoking areas'". Neither.ven- tilation nor filtration, alone or in combination, SECTION III -THE SOLUTION can reduce exposure levels of tobacco smoke from indoor spaces to levels that are considered ¦ Effective protection strategies acceptable, even in terms of odour, much less 100% indoor smoke-free environments health effects.6a, 64 While increasing the ven- ' There is no safe level of exposure to SHS.14,15, 54 tilation rate does reduce the concentration of a Therefore, the elimination of smoking from indoor pollutants, including tobacco smoke, indoor environments is the only science-based ventilation rates more than 100 times above measure that adequately protects a population's common standards would be required just to ¦ i Protection from exposure to second-hand tobacco smoke. Policy recommendations. control odour,63which per se is not an indicator The International Standards Organization (ISO) of the level of toxins in the air because these is drafting a recommended standard ISO 16814 w levels may be high even without a strong odour on ventilation and tobacco smoke prepared by of tobacco smoke. Even higher ventilation rates Technical Committee ISOM 205 on building would be required to eliminate toxins, which is environment design. However, policy-makers the only safe option for health. These ventila- need to be aware that the ISO standards have r tion levels are neither physically practical nor been heavily influenced bytobacco industry lob- economically feasible. In order to eliminate the bying in the past.6 In addition, the present draft toxins in SHS from the air, so many air exchanges of ISO 16814, while recognizing that "no realistic would be required that it would be impractical, combination of ventilation and filtration will uncomfortable and unaffordable. 65 provide a reasonably safe environment where w smoking is permitted ,,70 creates the illusion Similarly, neither central nor local aircleaning that ventilation may prevent recirculation or devices can reduce the levels of toxins from SHS movement of air from designated smoking areas w in indoor air to safe levels. The performance of into non-smoking areas. The 2005ASHRAE posi- _ these devices also usually declines over time tion statement, not the present draft of the ISO because they require high and expensive levels 16814 standard, reflects the best available cur- of maintenance, and they may even become rent scientific evidence on ventilation and SHS. ¦ sources of indoor air pollution. The "one pass" systems advocated by the tobacco industry and One particular ventilation-based approach pro- its allies do not re-circulate air and therefore moted by tobacco companies, and which some are much more expensive to operate because jurisdictions have accepted in specific settings, outdoor air has to be continuously heated or particularly bars and restaurants, is the impte- cooled. In any case, these systems do not reduce mentation of smoking areas separated from tobacco smoke to safe levels.66,67 non-smoking areas by physical barriers and with separate ventilation systems. These so- Despite decades of pressure from the tobacco called "designated smoking rooms," (DSRs), industry, 68 the American Society of Heating, with exhaust of air to the outside, isolated return Refrigerating, and Air Conditioning Engineers air, and negative pressurization in relation to (ASHRAE), the leading professional standards- adjoining spaces, have been designed and test- setting organization in the United States on ed for the degree of protection provided. Based ventilation, no longer provides recommended on existing literature, such rooms may reduce standards forventilation when tobacco smoking but not eliminate the exposure to SHS inside is present. In its 2005 environmental tobacco the DSR. In addition, DSRs do not eliminate smoke' (ETSI position document, ASHRAE con- non-smokers' exposure to second-hand smoke cludes, "At present, the only means of effective- in adjacent spaces, 71, 72 offer no protection to ly eliminating [the] health risk associated with workers required to work in them, and may also indoor exposure is to ban smoking activity."59 Intensify exposure of smokers to SHS, thus The position document also states, "Because of increasing risks to their health.73 For example, ASHRAE's mission to act for the benefit of the the door to the designated smoking room can public, it encourages elimination of smoking act as a pump moving smoke out of the room in the indoor environment as the optimal way when people enter and leave the room. to minimize ETS exposure." f The Cat/EPA used the term 'environmental tobacco smoke IETSI in its report. WHO prefers the terms second-hand tobacco smoke" or "involuntary smoking." ALL three terms are synonymous. r e Protection from eXDOSUFe to second-hand tobacco smoke. Policy recommeri DSRs are also difficult and costly to implement [Box 1). The problems encountered in imple- Box 1. Why not separately ventilate menting them have led some jurisdictions that designated smokingcooms(DSRs)? - had permitted DSRs to later change the law to Smoking moms are very difficult to insulate, eliminate them completely " The tendency to expensive toinstattandmaintain,areoften not M built create DSRs in the hospitality industry is par- : or operated according to specifications and can expose smokers and workers to con- ticularly troubling from a worker's health per- centrated SHS. spective, because doing so leads to exception- Air filtration and ventilation systems, even if ally high SHS exposure levels for employees. independent from ventilation systems in non- In addition, allowing - or even more problem- smoking areas. can only be designed for com- atic - mandating DSRswitl encourage or require - fort and are not effective_ in protecting.health businesses to invest in expensive and ineffective and'removfng t9kins ventilation systems, thus compromising future In theory, the law may statethatworkersmust 100% smoke-free legislation because of the not be required to work in, DSRsbut,in-prac- large investments that many institutions will tice, managers may pressure employees to - have made in these systems. 9 serve these areas in orderto please customers. Doors of DSRs-are opened constantly to pro- Outdoor and quasi-outdoor environments. vide service to this area and .ma even be left Research conducted and reviewed b the Y open use rooms become too smoky some Cal/EPA in consideration of its decision to smokers refuse to use them). The amount of - declare tobacco smoke a toxic air contaminant SHS polluting; non-smoking areas through shows that outdoor SHS concentrations can doors to DSRs is significant. be significant - sometimes reaching levels They add considerable costs and create enforce- observed indoors - depending on the number ment difficulties for enforcement agencies. of cigarettes smoked, location of adjacent walls, Source: Adapted from Ontario Campaign for Action on and meteorological conditions, such as wind tobacco speed and direction. la However, levels of SHS are, on average, lower than in indoor environ- semi-enclosed patios, where smoking is per- " ents where smoking is permitted. milted as well as security and door staff. m Certain localities75 76 and institutions do not For example, mean ambient concentrations of " nicotine adjacent to an outdoor smoking area allow smoking in outdoor areas such as on at an amusement park (2.4 pg/m3) were com- beaches,77,7e in outdoor stadiums,79 on patios parable to concentrations found indoors in the (covered or outdoor) 80 or within a certain dis- homes of smokers where 50 or fewer cigarettes once of building entrances.a Often, these deci- q were smoked per week (<3 pg/m3). Therefore, sions are made in response to public demand exposure to tobacco smoke outdoors can be once the indoor spaces are made smoke-free. significant for those who spend a considerable r amount of time in outdoor environments with Problems can arise when smoking is permitted tobacco smoke, such as wait staff on covered or at outdoor areas immediately adjacent to attached to indoor areas (e.g. patios) and where re +r 9 New York City Mayor Michael Bloomberg referred to the problems created by legislation mandating ventilation systems in his testimony before the New York City Council Committee on Health, "The experience other cities and states have had with mandating such ventilation systems also is instructive. When legislators in those jurisdictions have realized that ventilation systems haven't solved the problem of eliminating second-hand smoke, and have proposed new action, what has been the result? Business owners protest -with some justification - that the money that government has encouraged them to invest in ventilation systems has been wasted." Testimony of Michael R Bloomberg, Mayorof Newyork City, before the Newyork City Council Committee on Health on Iint. 256 in Relation to the Prohibition of Smoking in Public Places and Places of Employment. Thursday, 10 October 2002 City Hall, New York New York. lhttp://www.nyc.govlhtm(ldoh/htm(/testiltesti1010-bloomberg.shtmi, accessed 26 February 2007). a 0 ar w Protection from exposure to second-hand tobacco smoke. Poticy recommendations. r w there are open doors and windows or intake vents. Smoking can also be problematic in"quasi-outdoor" environments, which are common in warm-climate countries and which are much less likely to have solid structures clearly delimiting indoor and outdoor space. Common problems include: s Fig. 1 The "outdoor" addition to a club in New South Wales, • Smoke drifting into indoor areas from out- Australiawhere the law currently allows smoking in this door smoking areas that lead directly into type of outdoor area. (Photo courtesy of ASH Australia/ indoor spaces with open doors and windows. considerations. At the very least, these areas A study in Ireland that found that exposure to should not be specifically designated as smok- tobacco smoke had decreased significantly ing areas, which will make it simpler to deal among hospitality sector workers following with them when, after indoor areas have been implementation of Ireland's smoke-free law smoke-free for long enough, the public also discovered that bars with designated out- demands that the adjacent outdoor areas be door smoking areas had significantly higher smoke-free. concentrations of ambient nicotine than those without outdoor smoking areas.82 Effects of smoke-free environments on health and tobacco use • Difficulty in distinguishing between indoor and Smoke-free environments drastically reduce outdoor spaces for purposes ofimplementa- toxins in the air and are associated with tion and enforcement,83,84,85,e6 For example, measurable rapid increases in health among business owners may build covered patios, workers previously exposed to SHS. partially enclosed tents or similar spaces to circumvent indoor smoking restrictions. Immediate drops in pollution levels In Irish bars, levels of fine particles in the air • Allowing smoking in quasi-outdoor areas (PM2.51, which reach deep into the lung and where people have to work may expose them damage the lung and heart, dropped by 83% to significant levels of SHS and unaccept- following the implementation of the smoke-free able risks to health. Under some conditions, law. Nicotine in the air also fell by 83% and the levels of exposure may be comparable to median time per week of exposure to SHS those indoors.14 reported by workers fell from 30 hours to 0 hours.87 Experience in New South Wales, Australia, " demonstrates the types of difficulties that may This reduced exposure to SHS led to lower be encountered with "quasi-outdoor" areas. Its amounts of the toxins in the smoke appearing current law allows smoking in outdoor areas, in the bodies of non-smoking hospitality work- which are defined as "maximum 75% enclosed." ers. Carbon monoxide in the breath of bar As a result, many businesses are building "out- workers was also measured and was found to door" seating areas, such asthe one illustrated have decreased by 45% among non-smokers in Fig. 1, that meet this definition. and by 36% among ex-smokers.87 Cotinine concentrations in saliva, which indicate the Universal effective protection from SHS may level of smoke toxins people absorb into their therefore require making certain outdoor or bodies from the SHS exposure, felt by 69% in quasi-outdoor areas smoke-free, with workers non-smoking hospitality sector workers fol- health, equity and enforceability being the key lowing implementation of the law. M M Protection from exposure to second-hand tobacco smoke. PoLicy recommendations. Better worker health Smoke-free environments are a highly Self-reported respiratory symptoms among effective smoking cessation intervention Irish barworkers decreased by 16.7% one year Smoke-free environments not only protect the after implementation of its smoke-free law.88 health of non-smokers, they also have a bene- ficial impact on reducing smoking. The World A study in California, United States showed a Bank has concluded that smoking restrictions reduction of 59% in negative respiratory symp- can reduce overall tobacco consumption by 4- toms and a reduction of 78% in sensory irritation 10%.95 A more recent review of studies in symptoms in bartenders within eight weeks Australia, Canada, Germany and the United after the implementation of the law requiring States concluded that smoke-free workplaces bars to be smoke-free, compared with symp- result in a reduction in consumption of 29% by toms reported prior to the smoke-free law.89 smokers.96 The review estimated that, on aver- age, smoke-free workplaces reduce consump- In New Zealand, a 2002 studyfound that people tion by 3.1 cigarettes per day per smoker and " working in smoke-free office environments reduce smoking prevalenceby3.8%. This impact were less likely to report respiratory and irri- is greatly attenuated when smoking is allowed tation symptoms than hospitality workers in designated rooms or areas. exposed to SHS in the workplace [smoke-free bars were not implemented until December White not required by any of the taws creating 20041.90 smoke-free environments, more people volun- tary make their homes smoke-free when work- In Scotland, within three months of implement- place and public place laws are imptemented.97 ing smoke-free legislation in 2006, barworkers Smoke-free homes protect workers' children " showed significant early improvements in res- and other family members from SHS and fur- piratory symptoms, objective measures of lung ther increase the likelihood that the smokers y function and systemic inflammation. Asthmatic will successfully quit smoking. bar workers also demonstrated reduced air- way inflammation and improved quality of life. 91 In fact, smoke-free environments can be more cost-effective than programmes targeted specifi- In the United States, in the communities of cally at smoking cessation. One study showed Helena, Montana and Pueblo, Colorado as well that smoke-free environments are nine times as in the Piedmont region of Italy, the number more cost-effective per new non-smoker than w of hospital admissions for heart attacks (acute providing smokers with free nicotine replace- myocardial infarction) dropped by an average ment therapy.9 Indeed, several countries that of 20%h following implementation of strong have recently implemented comprehensive smoke-free workplace and public place tegis- smoke-free laws report declines in tobacco con- tation. There was no decline in admissions in sumption (as measured by tobacco sales data similar communities used as controls. However, or by surveys of smoking prevalence) and/or a r when the smoke-free law in Helena was switch to smokeless tobacco following the repealed under tobacco industry pressure, hos- implementation of the laws.", m0 Some have pital admissions rose to levels seen prior to also reported increases in call volume to r implementation of the law.93, 94 national "quit lines" immediately after imple- mentation, although call volume tends to return to normal after a few months.101 nl h Stan A Glantz, personal communication of the result of a meta-analysis of the three studies. M Protection from exposure to second-hand tobacco smoke. Policy recommendations. Smoke-free workplaces tobacco smoke while simultaneously having a r reduce youth smoking initiation positive impact on two other major tobacco There is some evidence that smoke-free policies control goals established by public health lessen the likelihood that youth will become organizations: reducing smoking initiation and addicted to tobacco. Several studies have shown increasing smoking cessation. that smoke-free workplaces and community- wide, smoke-free by-laws are associated with Economic impact of e' a decreased likelihood of ever-smoking among smoke-free environments teenagers. One study found that teenagers who worked in completely smoke-free work sites It follows from the finding that SHS exposure were, on average, 6810 o as likely to be ever- carries economic costs that smoke-free poli- smokers compared to teenagers who worked cies carry economic benefits. These include: W in establishments with fewer smoking restric s condi- tions.lOS Studies that have examined smoking bons r direct attribmediutable cal to costs SHS care for prevalence and tobacco consumption among exposure e and nd re enagers in communities with extensive educed insurance costs [the higher insur- tesmoke-free laws versus no laws show absolute ance cost for smokers includes health, fire, 1111110 reductions in prevalence of 2.3% to 46.0%, a accident and life insurancel, + relative reduction in prevalence of 17.2%, and a relative reduction in per capita cigarette con- increased productivity among those who quit sumption of 50.4%,103 smoking and among workers no longer r exposed to second-hand smoke [time saved on smoking breaks and absenteeism due to Smoke-free homes are also associated with reduced tobacco use among teenagers. illness); r Teenagers living in a smoke-free home were, on average, 74% as likely to be ever-smokers • reduced hiring costs less labour is lost y; a compared with those living in homes with no tobacco-related morbidity and mortality; smoking restrictions, even after adjusting for lower building maintenance costs; and • demographics and smoking status of other household members.98 • reduced employer liability for SHS exposure's effect on workers and for SHS's compounding Taken together, the evidence suggests that smoke-free environments play a powerful role effects on workers exposed to other toxins in in reducing the social acceptability of smok- the workplace. ing, leading to decreased smoking initiation. Given that smoking has long been promoted These economic benefits can be substantial. It by tobacco companies as an "adult choice", it s estimated that smoke-free environments is logical to predict that the elimination of would save employers the equivalent of 0.515% smoking in those establishments into which too.77%oftheGDPinScotland104andbetween adolescents aspire to enter, such as bars and 1.1%and 1.7% of GDP in Ireland. 10'The United nightclubs, will lead to reducing the status of States Occupational Safety and Health smoking as a rite of passage into adulthood. Administration (OSHA) has estimated that clean air increases productivity by 3%.106 In summary Smoke-free environments achieve the goal of There are some modest costs associated with the protecting non-smokers from exposure to administrative capacity ofgovernments toimple- ment and enforce smoke-free laws (primarily r. r. Protection from exposure to second-hand tobacco smoke. Policy recommenclati n uM Box 2.Thz-iFr~pactafsmcike-fdirect contradiction to tobacco industry environments-in thetibbietri claims, 108 worldwide studies of sales and indostrys;aao tniords employment data before and after smoke-free " • ecorlarmc:arguments often used,by the policies are implemented have found either no [tobaccolindustryto56,reoffsmokjngban impact or a positive impact within the hospi- actiwt weTg no to 'er aurkm a~rdeeQl: tahty sector. 109• "0 Smoke-free policies do not y ~ g aSr* tk~ey ever"21rt1.~~hase argutnenls~s 4hax3 drive away existing clientele in this sector; they, no credibilttyvrfls he,pvbfic whicf~ls~stifr in fact, attract new clientele. They also appear p.F7 slPfg W,he'niyEftl.=fO'(^>sTf~LT "I Ydld'2 t0 result in reduced maintenance 111.112 and tionsin epastrare,ca efrue-' lip" Morris, 1994, Cite: insurance costs as well as decreased employee hap:11lega'cy.tibraryliscEeiJ nf79eo0 absenteeism both for this sectorlla, 114 and • "Ifourc ! f others.ns,n'Thus, the tobacco industry hasa on mershavefeweroppo[unitfies ' powerful incentive to oppose robust smoke-free - to enloy otirprodlscts, Sfiey w1l`use them p less frequently and theresuttLLwidbg.an laws since their impact on the workplace results adverseiriipact orrourbottom hqe'`'- PtSilip,< in a major reduction in cigarette consumption Morris, 1994 Cite: -c [Box 21. h ttp://legacy.l ibrary.uscf. edutidlvnf77e00 • "Those.wbosaytheyworkunderre92:nctions SECTION IV -EXPERIENCES smoiFe2f aliauf 1ne- nd"`one gv~}Fer""°' cigarettes each day than those wfia dont,;. AND BEST PRACTICES That one-and-one-qua rter pbr dayxtgiil'6'[35e reduction then, fseansnearty 7tsltttofr eviler Several countries and hundreds of subnational cigarette's smol ed eac} ydar aassa of and local jurisdictions have successfully imple- wJorkplade s'nokrlag;restinotto mented laws that require almost all' indoor x mit{ion pacfks of cigaoeites l4t_doli"a. k workplaces and public places to be 100% pack; even the tightes~q#wdorkp'ta,~esir~gk ng restrictions is costing this ii.i-6, ty 233 smoke-free without significant difficulties in million dollars a year, in revenue'. =United'. implementation and enforcement.88, 101, 117 State sTabeco fT541,t2 1985 Ci}e _ These jurisdictions report immediate and 3tip./%tegoyhtarary.vc fedu/ifxldlvoOflA` considerable health benefits, 87. 118 smoke-free environments are feasible and realistic in a variety of contexts. Their experience signs as well as educational and enforcement also offers a number of consistent lessons learnt efforts during the initial implementation stage). to facilitate passage and successful implemen- However, these costs tend to decrease overtime tation and enforcement of smoke-free laws. as public acceptance of the law grows and com- pliance increases (as it usually does). In any case, Smoke-free environments the World Bank notes that the benefits of mak- should be mandated by law, ing workplaces smoke-free far outweigh the not by voluntary policies costs. 107 i It is often argued that smoke-free environ- Two main approaches have been used to create ments impose costs on businesses, especially n smoke-free environments: legislation and those in the hospitality sector. In fact, evidence vootuluntary policies or agreements. shows the opposite, including for this sector. In i For example, most taws passed to date do not require hotel rooms to be smoke-free, even though cleaners and other staff are required to work in them. In addition, smoking rooms often feed into the same ventilation system as the rest of the hotel, meaning that workers in the hotel lobby, restaurants and other facilities will be exposed to SHS even if smoking is not permitted in their work areas. Even when legislation requires a specific percentage of hotel rooms to be smoke-free and for smoking rooms to have a separate ventilation system, all of the problems associated with designated smoking areas apply. This is an issue that legislation ® must eventually address. r 1 Protection from exposure to second-hand tobacco smoke. Policy recommendations. M Voluntary policiesi United Kingdom, less than 1 % of pubs were Voluntary policies, where an establishment or smoke-free under a voluntary approach. 113.124 a group of establishments willingly commits In Spain, a 2006 law gave bars and restaurants to implementing 100% smoke-free environ- whose premises were less than 100 m2 the ments through an internal policy or through a option to decide whether to become smoke- written agreement with the government, can be free or not. Only around 10% of eligible estab- useful as part of an initial public education lishments opted to become smoke-free.125 R programme to build public support for smoke- free environments before legislation is imple- As awareness of SHS exposure's health effects mented. Argentina, Chile and Costa Rica, for has increased, fear of worker litigation under example, have used this approach among com- occupational safety and health or related R munlty and business leaders to build aware- domestic taw has compelled workplaces to ness of the need for action, and institutions become smoke-free in certain jurisdictions. 126, that voluntarily go smoke-free have been vital 127 Although in some countries a number of and credible advocates in campaigns for workplaces such as shopping malls, cinemas smoke-free laws. and public transport have become smoke-free under a voluntary approach, this approach does However, even strong voluntary policies have not provide comprehensive and universal pro- major limitations that make them much less tection and leaves the majority of workers - preferable to legislation. They are, by defini- particularly those in the hospitality sector - R tion, legally non-binding, lack a mechanism of unprotected. r enforcement, and have weak penalties or no penalties at all for violations. In addition, vol- Legislation R untary agreements leave to the individual busi- Smoke-free workplace laws are far more effec- ness owners and operators the decision to tive than voluntary agreements in providing become smoke-free. adequate and extensive protection from SHS exposure. Indeed, laws are the only acceptable Since many businesses (typically in the hospi- public health and human rights approach for talitysectorlfearthattheywilllose clients to a ensuring protection from exposure to SHS's competitor that permits smoking, only a small lethal toxins because they: minority will go smoke-free voluntarily, even • are binding; in the face of a strong clientele preference for ' establish enforcement mechanisms; smoke-free environments. As what is best for - imposepenaltiesforinfringements;and a business isalso generallyseen aswhat is best • level the playing field for business. for its competitor, the self-regulatory approach usually is a recipe for inertia. 120 For instance, following a period of voluntary agreements, Finland introduced a law requiring In Australia, a voluntary code of practice in the that most workplaces be smoke-free. One year hospitality sector had no significant impact on later, data clearly showed a remarkable the adoption of smoke-free policies, and com- decrease in employee exposure to SHS at work ptiance with the code was poor, 121 with only 2% and an increase in the number of smoke-free of restaurants in New South Wales, Australia workplaces. 128 opting to become totally smoke-free.122 In the w r j In this section we only consider voluntary policies that propose 100% smoke-free environments. However, policy-makers should be aware that voluntary agreements often do not propose 100% smoke-free environments, but merely restrict smoking in some . areas to create the illusion that something is being done and to avoid strong legislation (Saloojee V, Dagli E. Tobacco industry tactics for resisting public policy on health. Bulletin of the World Health Organization, 2000, 78: 902-9101 r m R r Protection from exposure to second-hand tobacco smoke. Policy recommendations. Jurisdictions that have carried out public infor- Specific signage mation campaigns preparing the public for The law should require strong and clear "No implementation and that have demonstrated smoking" signs that feature the universal symbol their intent to enforce the law fairly but strictly (Fig. 2) at every building entrance and through- have found that the laws quickly become self- out smoke-free buildings. These signs are inex- enforcing, that compliance rates are high pensive and key to effective implementation within a very short time period and that they because they empower non-smokers to urge grow overtime. A recent review of compliance compliance with the law and inform smokers with 100% smoke-free laws found typical com- what areas are smoke-free. The signs should ptiance rates of 94% - 99%.129 also contain information on how to report vio- + lotions of the law. These simple signs can be Legislation should be simple, supplemented or combined with more cre- clear and enforceable, ative educational signs that reinforce the mes- and comprehensive sage (Fig. 2). Legislation will be more successfully imple- mented and enforced if it is: Simple The law should avoid complicated tests for determine when orwhere smoke-free settings are required (e.g. time of day or surface of the premise or designated smoking rooms), which m will involve extensive and expensive enforce- ment efforts to determine compliance. It should simply require all indoor workplaces, public places and public transportation to be 100% smoke-free, all of the time. Clear and enforceable Fig. 2 The universal "No smoking" symbol as well as more navel The law should provide clear definitions of set- smoke-free signs from tings covered by the law (such as a workplace Spain /Madrid), Uruguay, Sweden and Canada (Toronto) r or "enclosed" spaces); make clear who is responsible for enforcing and ensuring compli- ance (e.g. designation of inspectors as well as Comprehensive and provides universal e building owners and managers to ensure the protection The law should avoid exempting certain classes law is obeyed on their premises); and plainly state other requirements that smoke-free of premises. If some areas (such as bars) can- premises are obligated to implement, including not be included because of inadequate political the removal of ashtrays from those facilities and public support, simply leave them out of + required to be smoke-free. The law should also the law; do not provide for specific exemptions establish a clear and simple ticketing system that could be interpreted as sanctioning or 'r [or spot fines) for violations, similar to parking requiring smoking areas. Reasonable phase-in tickets in many countries, to avoid more periods [ideally no longer than one year) for administratively burdensome procedures like bars and similar settings may be acceptable arrest and trial. and can even facilitate implementation. In juris- dictions where implementing smoke-free poli- cies may need to proceed incrementally forthe respective settings, this intervening time period should be used to build political and public sup- local level and, more recently, at the state/provin- port to achieve a comprehensive smoke-free law cial level. Initially, public health advocates did that includes all workplaces and public places not have the resources and political power to in the shortest time period possible. defeat the tobacco industry and secure passage of strong national - or even state - legislation The law should afford protection to all. A focus in the United States. In these countries, it has on protecting "vulnerable" or other specific been easierto enact and enforce strong smoke- populations and settings wrongly implies that free legislation at the local level fortwo reasons: other populations and settings are not vulner- able and therefore do not need protection. The Political leaders at the local level tend to be tobacco industry has successfully used laws more sensitive to the wishes of the people designed to "protect children" to secure pas- who live in their jurisdictions than to tobacco sage of ineffective legislation. 730 company lobbyists (who are almost always s from out of town]. In Canada, local medical Consider which jurisdictional level(s) officers have proven to be effective advocates, will afford the most progress enjoying strong credibilitywith the public and The question of what level ofjurisdiction should municipal councils. W be used to implement smoke-free legislation public health advocates often have limited is an important one, and the answer will resources (especially compared to the tobac- depend on local factors such as a country's co industry]: focusing these limited resources legal framework and traditions as well as the sf one at a time increases country's size. Action should be taken at any thone chances lanceces o of success. and all levels where effective legislation can hbe achieved. If strong national legislation that The possibility that local laws will be pre- meets the standards described in these WHO recommendations is politically feasible and can empted is of concern. For example, in the United provide an effective implementation framework, States, the tobacco industry has worked con- e- it is preferable to local laws that may only build able state to or natiofor ineffective legislatineffectiveoan and that at includes able up protection of the entire population over a long period of time. National legislation has language prohibiting local jurisdictions from been an effective route to achieving protection enacting stronger legislation. As the move- for the greatest number of people in several ment to implement strong smoke-free laws countries. Ireland, Scotland and Uruguay, for spreads worldwide, the tobacco industry can be - example, achieved national legislation with expected to aggressively promote weak pre- minimal municipal restrictions in place. emptive laws (represented as "a step forward" or"'reasonable compromise") in other countries. If legislation that meets the standards described in these WHO recommendations cannot be aTo protect tahigher jurisdictional Level al Level must not weakatiustnotweaken en advanced at the national level, then efforts can at a be focused on smaller jurisdictions where effec- allowshe contrary, where contain jurisprudence tive action may be possible. Precedents set at allow, all t Legislation should uld contain a provision explicitly giving authority to lowerjurisdictions to W the local level consistently stimulate similar pass laws and granting precedence to any law laws elsewhere, resulting in the synergistic or for comprehensive domino" effect that the tobacco industry fears. containing more cose or requirements. This s is is the e case provin- Smoke-free legislation in Australia, Canada and cial laws in Canada that explicitly give prece- dence to stronger laws in the case of overlapping the United States has advanced the most at the or conflicting obligations.132,133 M s r Protection from exposure to second-hand tobacco smoke. Policy recommendations. :V Where federal authorities have limited jurisdic- some cases, these parties may have previ- tion to restrict smoking, national governments ously existed and the industry will provide should provide technical, financial and adminis- them with funding or strategic support; in trative support to state/provincial and munici- other cases the tobacco industry may create pal jurisdictions to pass smoke-free legislation, the organizations solely to oppose a smoke- as provided for in Article 8.2 of the WHO FCTC. free law. For this reason, it is critical that public policy-makers and health advocates Anticipate the opposition investigate the sources of support of opposi- Successful campaigns to implement smoke- tion groups and expose those that are indus- • free laws must anticipate the industry 's argu- try-affiliated to the media and the public. A ments and tactics along with those of its allies great deal of research has been done on and be prepared to counterthem. Most opposi- industry front groups showing howthe indus- tion tactics and arguments are predictable: try uses third parties and describing the chain of connections between various international • The tobacco industry will claim that smoke- front organizations. 108 This research is a valu- free laws are not necessary, not feasible, able tool to help policy-makers and public will have a negative impact on business health advocates distinguish between legit- imate opposition and industry-created (particularly restaurants, bars and case- ri and that ventilation is an acceptable opposition. alternative. These claims are unproven and pposi- should not be factored into policy-making • co iAlthonduughstry most soosturces, opposition legitimate comes local from - decisions. The evidence, based on the expe- tern to laws g quar rience of hundreds of jurisdictions, shows may arise from surprising ther ' exactly the opposite: smoke-free laws are ters. For example, nursing homes and other popular, enforceable and have no effect or residences for older people have opposed have a positive impact on business (except, smoke-free Because la ecause with the tobacco indpublic of course, the tobacco business, which loses sympathy. industry has sales because smoke-free environments try for for so so long, it is alstong, it is also common t for restau- si- make it easier for smokers who wish to cut rateurs and other people with abo tyut bu the down or quit to do so). Policy-makers and nesse to be e genuinely concerned about the should familiarize themselveswith impact to of the law on their businesses. It is this evidence and promote it to counter the impact opposition's arguments, examples of which important that legitimate opposition views are found throughout this publication and in are heard so that opponents cannot claim Appendix 4 in Section VI. that a law was rushed through without con- sultation. When possible, work to provide • The tobacco industry will often use a third these people with the evidence, which demon- party, such as hotel and restaurant associa- strates that their fears are unfounded. Among tions or gambling interests, to promote its the most effective advocates are those in the _ arguments, with the tobacco industry doing business sector, especially those who may its best to stay out of the public debate. In have initially opposed smoke-free laws but ¦ k Tim Zagat, founder of the world-renowned Zagat Survey guides, recently wrote an invaluable advocacy piece in the lead trade journat for the United States restaurant industry: Opponents of smoke-free laws argue that these laws would hurt small busi- nesses. The opposite is true. I spent three years as the chairman of NYC & Company, the official marketing, pro motion and tourism arm of Newyork City. In that capacity I watched Newyork transition into a smoke-free city and witnessed the positive impact the law had on our restaurants and nightlife. After the law took effect, our 2004 Newyork City survey found that 96% of New Yorkers were eating out as much, or more, than before. Moreover, business receipts and employment increased for restaurants and bars, the number of liquor licenses increased and virtually all establishments were complying with the law. Nation's Restaurant News, 7 August 2006. m a• became convinced of their popularity [Fig. 3, members would substantially weaken the Appendix 4, statement by Barry Vogel, the message and political will for insisting on " nominal head of the Beverly Hills Restaurant strong, enforceable legislation. Organizations Association). k It is also important for policy- should not be pressured to join the effort if makers to keep in mind the cost of exemp- the cost is substantial weakening of the tions to the law as these relate to public coalition. Some campaigns have ended in health, public perception of SHS exposure's failure due to insistence that all the major harm, the ease of enforcement and potential health groups participate. This means that legal actions against the law that could focus the effort goes at the speed of the slowest ¦ on inconsistency of application. and strength of the weakest organization. The effort needs leadership from credible Involve civil society public voices but does not need to include Civil society involvement is critical to creating a all public voices. W political climate in which to successfully imple- ment 100% smoke-free laws. Civil society has Educate and consult to ensure smooth ¦ access to networks to which governments may implementation not and may have greater freedom of commu- One of government's critical tasks, in partner- nication, making it better positioned to debate ship with civil society, is to raise awareness ` opposition. Governments should support and among the public and opinion leaders on the w facilitate civil society's participation in develop- risks of SHS through ongoing information Gam- ing and implementing smoke-free laws. To paigns to ensure that the public understands maximize effectiveness, the following elements and supports legislative action. Broad consul- a should be considered: tation with stakeholders is essential to further educate the community and facilitate support • The public health community must present for implementation of legislation. Public edu- a strong, consistent message, in partnership cation campaigns can also target settings for with a broad coalition of organizations from all which legislation is neither feasible nor advis- sectors, in support of smoke-free legislation. able, such as the home. • The campaign should engage one or more Key messages should focus on the harm caused ` committed political or civil society champions by SHS exposure in the home and in the work- i willing to promote and engage in the issue on place and public places, the fact that elimina- a long-term basis. tion of smoke indoors is the only science-based solution, the right of all workers to be equally • Governments and civil society should develop protected by law, and the fact that there is no a plan to facilitate support for smoke-free trade-off between health and economics laws and their implementation. However, in because smoke-free environments benefit both. many jurisdictions political opportunities arise that greatly accelerate implementation735 This educational effort should begin well before Therefore, governments and civil society introducing the legislation. An education cam- should prepare for the opportunity to "seize paign leading up to implementation of the law the moment" and capitalize on it. and information packages delivered in advance to business owners and building managers • White broader coalitions can be desirable, it outlining the law and their responsibilities will is not required that all public-health organi- increase compliance and ensure that govern- zations participate, particularly if some ments can counter arguments that a law was Protection from exposure to second-hand tobacco smoke. Policy recommendations. "rushed through" or that insufficient prepara- fair and that policy-makers are serious about A tion was provided. it. Following the grace period, firm and well- publicized enforcement actions should be Develop an implementation and taken, particularly with establishments that .a enforcement plan and ensure repeatedly violate the law. This effort is par- infrastructure for enforcement titularly important because the tobacco industry implementation and enforcement plan and sometimes encourages and publi- organized strategy for enforcement are critical cites violations as part its effort create for successful implementation. the impression the e law is not being respected. • Information packages for business as men- tioned above can assist greatly with imple- Monitor implementation and, mentation and enforcement. In addition to ideally, measure impact clear information outlining the business and document experiences owner's responsibilities under the law, signs While no further research and evaluation is required by law should be included. needed to justify smoke-free policy implemen- tation, an evaluation strategy is very useful to • It is critical to designate one or more groups monitor the success of implementation, public as inspectors (e.g. public health inspectors support for the laws as well as the health and backed up by other authorities, if necessary) economic impacts. In this way, ongoing public who are well-trained and supported, particu- and political support for the legislation can be larly during the first weeks and months after sustained. Local pre- and post-implementation the law goes into force. data are usually more effective than statistics from other countries in convincing politicians • There should be a reasonable "grace period" to act. This information should be a critical com- Inot more than a few months) during which ponent of a communication's strategy and violators are warned and provided an oppor- should also be made available to otherjurisdic- tunity to comply with the law voluntarily tions to support their efforts to introduce and before formal enforcement actions are taken. implement effective legislation successfully. This grace period is important because expe- Documenting experiences is important for the rience has shown that most "violations" are success of others; precedent-setting laws and due to lack of knowledge of the law, not wil- experiences should be recorded, studied and ful violation. promoted to show that the achievement of smoke-free policies can be generalized and to 41 • There should be a procedure forthe public to learn from successful experiences. The simi- report violations, such as a toll-free telephone larities in these laws - and how they are com- line. This information should be promoted bated by the tobacco industry - are much a widely and should appear on all no-smoking greater than the differences between different signs. countries. The most successful efforts, such as those of Ireland, were based on careful con- - Enforcement of the law should communi- sideration by Irish authorities of experiences in cate to the public that enforcement will be California and elsewhere. Smoke-free taws enloYstrop9 Public support and are raretY opposed by anyone other than groups funded by or misinformed by the ~ tobacco industry. Public polls demonstrating this have been useful in countering opposition claiming that laws wi0. not be obeyed and in isolating the tobacco industry. M M Protection from exposure to second-hand tobacco smoke. Policy recommendations. M' SECTION V - free environments. Laws should ensure equal M, RECOMMENDATIONS protection for all. Voluntary policies are not an acceptable response to protection. Under In light of the deleterious health effects and some circumstances, the principle ofuniver- the frequency of exposure to SHS (an exposure sal, effective protection may require specific that carries significant social and economic quasi-outdoor and outdoor workplaces to be ` costs); the cost-effectiveness, feasibility and smoke-free. popularity of smoke-free policies; and the suc- cessful experience of a rapidly growing number There is no scientific basis for exempting par- ` of jurisdictions worldwide, WHO makes the fol- ticular types of spaces or categories of the lowin recommendations to protect workers • 9 population from protection; all individuals are and the public from exposure to SHS, vulnerable to the harm caused by SHS expo- sure. The critical principle bearing on universal Recommendation 1: application of smoke-free legislation is the pro- 100% smoke-free environments, tection of human rights. The right to the highest ` not ventilation attainable standard of health, the right to life Remove the pollutant - tobacco smoke - and the right to a healthy environment are found through implementation of 100% smoke-free within international human rights laws and r environments. This is the only effective strate- many national constitutions. Exposure to SHS gy to reduce exposure to tobacco smoke in clearly hinders the exercise of these and other indoor environments to safe levels and to pro- fundamental rights and freedoms found within ` vide an acceptable level of protection from the human rights law. 138 dangers of SHS exposure. Ventilation and smoking areas, whether separately ventilated Legislation protecting all workers is necessary from non-smoking areas or not, do not reduce to safeguard these rights. Voluntary policies are exposure to a safe level of risk and are not incompatible with the responsibility of govern- recommended. ments to protect public health and are not effec- tive. Just three months after Ireland imple- Second-hand tobacco smoke causes serious o mented its smoke-free legislation, 97% of pubs and fatal diseases in adults and children. There were smoke-free. Five years into a voluntary is no safe level of exposure to SHS. Ventilation agreement in the United Kingdom, less than and health experts agree that ventilation is not 1 % of pubs were smoke-free. a solution to this significant health issue. In 2006, the United States Surgeon General's Recommendation 3: report concluded (Conclusions 3 and 10 on proper implementation and page 6491, "Establishing smoke-free work- adequate enforcement of the law places is the only effective way to ensure that Passing smoke-free legislation is not enough. second-hand smoke exposure does not occur in the workplace. Exposure of non-smokers to Its proper implementation and adequate second-hand smoke cannot be controlled byair enforcement require relatively small but criti- cleaning or mechanical air exchange." cal efforts and means. Alt governments - whether in high- or low- W Recommendation 2: income jurisdictions - must be prepared to Universal protection by law invest reasonable resources in achieving and Enact legislation requiring all indoor work- enforcing smoke-free laws. Investment in places and public places to be 100% smoke- tobacco control is an explicit obligation under m Protection from exposure to second-hand tobacco smoke. Policy recommendations. Article 26 of the WHO FCTC.`° Costs for imple- how to protect their families from SHS harm. 138 menting smoke-free laws may include promo- Since the home is often the highest source of tional campaigns to build support for the taw, SHS exposure for children and for adults who " commissioning public opinion polls, educa- do not work outside the home, policies need to M tional materials on implementation, compli- be developed to address this setting if public ance monitoring systems, staffing a phone num- health is to be adequately protected. Education ber to respond to public complaints and a tem- can be an effective strategy in promoting pro- . porary increase in the number of inspectors tection from SHS in the home. 140, 141 assigned to monitor initial implementation. Smoke-free workplaces result in lower levels Governments should also be prepared to face of tobacco consumption among smokers and challenges to the law even after successful are associated with a greater likelihood of implementation. These may include lobbying workers implementing smoke-free policies in campaigns by tobacco industry front groups to their homes. 142, 143. 144 Therefore, smoke-free roll back the law or a legal challenge in the workplace legislation should be a primary courts. While legal challenges to smoke-free strategy in protecting individuals from SHS in laws have been upheld only in rare circum- the home. stances (usually based on inadequate consul- tation prior to implementation of a law or pre- Education to promote smoke-free homes can emption of a taw bya superseding jurisdiction), be part of campaigns implemented to build governments should take actions before and public support for smoke-free legislation, after implementation of the law to ensure the which have included messages informing sustainability of the law.13' These actions smokers, particularlyas parents, of the impact include a comprehensive public education cam- of SHS exposure in the home and have urged paign, consultation with stakeholders, assur- them to make their homes smoke-free.14s, 146, ante that the law is consistent in protecting 141,141 public health, and providing data showing that the law is being enforced fairly. To complement mass media campaigns, health warnings on tobacco packages are a very cost- Recommendation 4: effective public education medium that are Public education to reduce SHS guaranteed to reach all smokers. Most coun- exposure in the home tries with picture-based warnings include warnings related to SHS. In Canada, more than Implement educational strategies to reduce SHS exposure in the home, recognizing that one fourth of smokers reported that picture smoke-free workplace legislation increases warnings implemented in 2000 motivated them to smoke less inside the home. 149 the likelihood that people /both smokers and non-smokers/ will voluntarily make their homes smoke-free All individuals have the right to be informed 'r about the risks of SHS exposure, how to exer- cise their right to a healthy environment and A M Article 26 provides that each Party shalt provide financial support in respect of its national activities intended to achieve the objective of the Convention" and that Parties shalt promote "the utilization of bilateral, regional, subregional and other multilateral ¦ channels to provide funding for the development and strengthening of multisectoral comprehensive tobacco control programmes of developing country Parties and Parties with economies in transition." do R Protection from exposure to second-hand tobacco smoke. Policy recommendations. ff SECTION VI - APPENDICES Appendix 1 Af' List of participants and observers at the Expert Consultation on Policy Recommendations on Second-hand Tobacco Smoke in Montevideo, Uruguay, 1-3 November 2005 and additional reviewers of policy recommendations R Leon Alevantis, MS, PE Julio Gonzalez Molina Senior Mechanical Engineer International Adviser Health Promotion Administration - Program Support Branch PAHO/WHO Representation in Uruguay Facilities Management Section Avda. Brazil 2697 2nd Floor +e California Department of Health Services Montevideo, Uruguay MS 1401 P.O. Box 997413 Sacramento, CA 95899-7413 USA Cynthia Hallett Executive Director, Americans for Non- Matthew Allen smokers Rights Allen & Clarke Policy and Regulatory 2530 San Pablo Ave, Suite J Specialists Limited Berkeley, CA 94702, USA PO Box 54 180, Mana Wellington, New Zealand Fenton Howell Carmen Audera Lopez Director of Public Health Health Service Executive - NE Tobacco Free Initiative Railway World Health Organization Street Avenue Appia, 1211 Geneva, Switzerland Navan Meath, Ireland Ron Borland PhD, Sin6ad Jones Nigel Gray Distinguisted Fellow in Cancer Head, Tobacco Control Prevention, VicHealth Center for Tobacco UICC Control, Cancer Control Research Institute, 187 Granton Road The Cancer Council Victoria, EH5 3RQ Edinburgh SC 1 Rathdowne St United Kingdom Carlton Vic 3053, Australia Ph: 61-3-9635 5185, Fax: 61-3-9635 5440 TH Lam Mobite: 61-409 979 269 Professor and Head e-mail Ron.Bortandfdcancervic org.au Department of Community Medicine Professorial Fellow, School of Population Faculty of Medicine Building Health and Department of Information The University of Hong Kong Systems, The University of Melbourne 21 Sassoon Road, Pokfulam, Hong Kong, SAR China Tania Cavalcante National Tobacco Control Mark Miller MD, MPH Programme Coordinator Office of Environmental Health Hazard National Cancer Institute of Brazil (INCA) Assessment Ministry of Health 1515 Clay St, 16th Floor Rua dos Invahdos 212- 2nd floor Oakland, CA. 94612, USA 20231-020-Rio de Janeiro, RJ, Brazil Yumiko Mochizuki-Kobayashi Carolyn Dresler Director, Tobacco Free Initiative Head, Tobacco Control World Health Organization International Agency Against Cancer (IARC) 20, Avenue Appia CH-1211 Geneva, 150 Cours Albert-Thomas Switzerland 69008 Lyon Cedex 08, France P Protection from exposure to second-hand tobacco smoke, PoLicv recommendations.! „ Michael Ong Richard Stanwick Asst.Professor Chief Medical Health Officer A' UCLA Med-GIM & HSR Vancouver Island Health Authority University of California at Los Angeles V8R4R2 430 - 1900 Richmond Avenue 911 Broxton Ave, 1st. Floor Victoria, British Columbia, Canada r Los Angeles, CA 90024, USA Martina Poetschke-Langer Frances Stillman Head of Unit Cancer Prevention and Associate Professor of WHO Collaborative Centre for Tobacco Co-director, Institute for Global Tobacco Control 615 N. German Cancer Research Centre Baltimore, Street Im Neuenheimer Feld 280 Bal, MD 21205, USA 69120 Heidelberg, Germany Elizabeth Tamang Armando Peruga Director Coordinator Tobacco Control Team Centro Regionale di Riferimento per la Pan American Health Organization (PAHO) Prevenzione SDE-RA Rm 525 Dorsoduro, 3494/a 30123 525 23rd St NW Venezia, Italy Washington DC 20037, USA Peter Ucko Cornet Radu Director President National Council Against Smoking Aer Pur Romania / Romanian Network for 3rd Floor, NIOH Building, Smoking Prevention IRNSP) 106 Joubert Street Extension, Braamfontein, " Str. Argentina 35 Sector 1 2001 Johannesburg, South Africa 011753 Bucharest, Romania Srinath Reddy Heather Wipfli Professor & Head Project Director, Institute for Global Tobacco Department of Cardiology Control All India Institute of Medical Sciences Johns Hopkins Bloomberg New Delhi - 110 029 School of Public Health Ansari Nagar, India 615 N. Wolfe Street Hana Ross Baltimore, MD 21205, USA Health Economist Ayda Yurekli Research Triangle Institute Senior Health Economist WHO/TFI 3040 Cornwallis Road 145 Snyder Hill Rd. Research Triangle Park Ithaca, NY 14850, USA NC 27709-2194, USA 'r Jonathan Samet Observers Professor and Chair, Department of Winston Abascal Epidemiology Director Nacional de Control de Tabaco Director, Institute for Global Tobacco Control Ministerio de Salud Publica 615 N. Wolfe Street, Suite W604 18 de Julio 1892 Baltimore, MD 21205, USA Montevideo, Uruguay Heather Selin Adviser, Tobacco Control Miguel Asqueta Pan American Health Organization/World Diputado Nacional t Health Organization (PAHO/WHO) Presidente Comisi6n de Salud 525 23rd St NW Av. De Las Leyes s/n Washington DC 20037, USA Montevideo, Uruguay r Protection from exposure to second-hand tobacco smoke. Poticy recommendations. Adriana Blanco Adriana Menendez Medica, Representante Intendencia Medica Comisi6n para Controt de Municipal de Montevideo en Tabaquismo Alianza Nacional contra el Tabaco Sindicato Medico del Uruguay 18 de Julio 1360, 3er piso [Divisi6n Salud] Bvar. Artigas 1515 Montevideo, Uruguay Montevideo, Uruguay Xavier Camps Alejandro Santini w Medico Cardi6logo Medico Asesor Coordinador Programa de Cesaci6n en Area de Educaci6n Poblacional de la CAMDEL y Hospital Vidal y Fuentes Comisi6n de Lucha contra el Cancer IF C. Williman 529 Minas Brandzen 1961, Of. 1104/05 Lavalleja, Uruguay Montevideo, Uruguay Osvaldo Davyt Mirta A Molinari Medico Cardi6logo Abogada Consultora en Control de Tabaco Federaci6n Medica del Interior Ministerio de Salud yAmbiente Alianza Nacional para el Control del Tabaco Avda. 9 de Julio 1925 P. 9 12 de Febrero 365, Buenos Aires, Argentina Carmelo, Uruguay Additional Reviewers of the Elba Esteves Policy Recommendations Medica Internista Jean-Pierre Baptiste Integrante Policlinica Cesaci6n de Tabaco / Hospital de Clinicas Regional Adviser Avda. Italia s/n / P. 1 Bureau regional de CAfrique Montevideo, Uruguay Cite du Djoue PO Box 06 Araceli Ferrari Brazzaville, Congo we Medico Asesor Douglas Bettcher Area de Educaci6n Poblacional de to Coordinator Comisi6n de Lucha contra el Cancer World Health Organization Brandzen 1961, Of. 1104/05 Tobacco Free Initiative Montevideo, Uruguay 20 Avenue Appia Beatriz Goja Geneva 27, Switzerland W Medico Facultad de Medicina Annemieke Brands Alianza Nacional para el Control del Tabaco / Policlinica Cesaci6n Tabaquismo Technical Officer _ Avda. Italia 3499/1006 World Health Organization Montevideo, Uruguay Tobacco Free Initiative National Capacity-building Ana Lorenzo 20 Avenue Appia Medico Programa Control de Tabaco Geneva 27, Switzerland Ministerio de Salud Pubtica Poonam Dhavan 18 de Julio 1892 Technical Officer Montevideo, Uruguay World Health Organization Tobacco Free Initiative National Capacity-building 20 Avenue Appia a Geneva 27, Switzerland M R' s Protection from exposure to second-hand tobacco smoke. Policy recommendations. Fatimah M S El-Awa Khalitur Rahman Regional Adviser Regional Adviser Tobacco Free Initiative Tobacco Free Initiative Abdul Razzak at Sanhouri Street World Health House, Indraprastha Estate Nasr City Mahatma Gandhi Road Cairo 11371, Egypt New Delhi 110002, India Burke Fishburn Bung-On Ritthiphakdee Regional Adviser Southeast Asia Tobacco Control Alliance Tobacco Free Initiative ISEATCAI United Nations Avenue, corner Taft Avenue 36/2 Pradipat 10 Ermita, Manila, 1000, Philippines Phayathai Bangkok, 10400, Thaitand Stanton Glantz Head, WHO Collaborating Centre on Tobacco Yussuf Saloojee Control Policy Development Executive Director, National Council against Center for Tobacco Control, Research and Smoking ^ Education & Professor of Medicine 106 Joubert St Ext University of California, San Francisco Braamfontein Department of Cardiology 2042 Johannesburg, South Africa 530 Parnassus Avenue. Suite 366 Library P.O Box 1390 Stafford Sanders San Francisco, CA 94143-1390, USA Communications Officer (ASH Australia); Coordinator [Smoke Free Australia Coalition) Katharine Hammond 153 Dowling Street Professor of Environmental Health Sciences 2011 Woolloomootoo NSW, Australia University of California 140 Warren Hall Marta Seoane MC 7360 Communications Officer r Berkeley, CA 94720-7360, USA World Health Organization Tobacco Free Initiative Phillip Karugaba 20 Avenue Appia The Environmental Action Network (TEANI Geneva 27, Switzerland P.O. Box 7166 Kampala, Uganda Tomotaka Sobue Head, WHO Collaborating Centre for Haik Nikogosian Reference on Smoking and Health Deputy Director Chief, Statistics and Cancer Control Division Division of Technical Support National Cancer Centre Research Institute a Scherfigsvej 8 - 2100 5-1-1 Tsukiji Chuo-ku Copenhagen, Denmark Tokyo 104-0045, Japan Patrick Petit Judith Watt Project Officer Director, Protocol Management World Health Organization 36 Thorne Street Tobacco Free Initiative Edgecliff w 20 Ave. Appia Sydney, New South Wales 2027, Australia Geneva 27, Switzerland ¦ Protection from exposure to second-hand tobacco smoke. Poticv recommendations. Appendix 2 Twenty years of scientific consensus Major consensus reports on health consequences of exposure to second-hand tobacco smoke (2006) The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, The United States Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health r Promotion, National Center for Chronic Disease Prevention and Health Promotion, w. Office on Smoking and Health. l http://www. surgeongeneral.gov/library/secon d-handsmoke/reportlful treport. pdf, R accessed 27 March 20071 W 120051 Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant. Tobacco Control. Surveys and Program Evaluations from Outside UCSF Paper CALEPA2005. I h ttp://repositories. cdtib. org/tc/surveys/CAL EPA2005, accessed 27 March 20071 (2004) Tobacco Smoke and Involuntary Smoking. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 83. Geneva, World Health Organization and r Lyon, International Agency for Research on Cancer (IARC). (http://m onographs. iarc. frIENGIMon ographslvoIB31volume83. pdf, accessed 27 March 20071 r (2004) Scientific Committee on Tobacco and Health. Secondhand Smoke: Reviewof evidence since 1998. Update of evidence on health effects of second-hand smoke. London, Department of Health. lwww.advisorybodies.doh.gov.uk/Scoth/PDF`S/Scothnov2OO4.pdf, accessed 27 March 2007) (2000), 120021, (2005) United States National Toxicology Program, ninth, tenth and eleventh Reports on r Carcinogens. Atlanta, United States Department of Health and Human Services. (http://n tp. niehs. nih.gov/n tplroc%leven t h/profiles/s l76toba. pdf, accessed 27 March 20071 (1998) Scientific Committee on Tobacco and Health. Report of the Scientific Committee on Tobacco and Health. London, Department of Health, Department of Health And Social Services, Northern Ireland, The Scottish Office Department of Health Welsh Office. (h ttp://www. archive. official-docum en ts. co. uk/document/doh/tobacco%on ten ts. h tm, accessed 27 March 2007) m Protection from exposure to second-hand tobacco smoke. Poticv recommendatonE (7997) Health effects of exposure to environmental tobacco smoke. Sacramento, California Environmental Protection Agency. (h ttp://www. oehha. ca. gov/airlenvironmen tal_ tobaccolfinalets. h tm l #down l oad, accessed 27 March 2007) Published in 1999 as National Cancer Institute Smoking and Health Monograph 10: Health Effects of Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monographs. Ihttp://cancercontrot. cancer.gov/tcrb/monographs/70/m 10_complete.pdf, accessed 27 March 20071 (1997) The health effects of passive smoking. Canberra, Australia, National Health and Medical Research Council. (7992) Respiratory health effects of passive smoking: Lung cancer and other disorders. Washington, DC, Office of Health and Environmental Assessment. Office of Research and Development, United States Environmental Protection Agency (http://cfpub.epa.govlncealcfmletsletsindex.cfm, accessed 27 March 20071 (7991) Environmental Tobacco Smoke in the Workplace: Lung Cancer and Other Health Effects. Current Intelligence Bulletin 54. Attanta, United States National Institute for Occupational Safety and Health (http://www.cdc.govlniosh/91108 54.html, accessed 27 March 20071 (1986) United States Surgeon General Report: The Health Consequences of Involuntary Smoking. Atlanta, United States Department of Health and Human Services. Public Health Service. Centers for Disease Control. Office on Smoking and Health. r (http://profiles.nim.nih.gov/NN/B/C/P/M/, accessed 27 March 20071 (1986) National Research Council. Board on Environmental Studies and Toxicology. Committee on Passive Smoking. Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects. Washington, DC, National Academy Press. (http://www.nap.edu/books103090373O1/htmU, accessed 27 March 20071 r r 1 r w i Appendix 3 Health effects associated with exposure to Second-hand Tobacco Smoke Summary of findings of the California Environmental Protection Agency, 2005 Effects causally associated with SHS exposure Developmental effects • Fetal growth: Low birth weight and decrease in birth weight • Sudden Infant Death Syndrome (SIDS) • Pre-term delivery Respiratory effects • Acute lower respiratory tract infections in children (e.g. bronchitis and pneumonia) • Asthma induction and exacerbation in children and adults s • Chronic respiratory symptoms in children • Eye and nasal irritation in adults • Middle-ear infections in children sr Carcinogenic effects • Lung cancer • Nasal sinus cancer ~r • Breast cancer in younger, primarily premenopausal women Cardiovascular effects • Heart disease mortality • Acute and chronic coronary heart disease morbidity r • Altered vascular properties ¦r Effects with suggestive evidence of a causal association with SHS exposure Reproductive and developmental effects • Spontaneous abortion, intrauterine growth retardation • Adverse impact on cognition and behaviour • Allergic sensitization • Decreased pulmonary function growth • Adverse effects on fertility or fecundability - Cardiovascular and haematological effects • Elevated risk of stroke in adults Respiratory effects • Exacerbation of cystic fibrosis • Chronic respiratory symptoms in adults Carcinogenic effects • Cervical cancer • Brain cancer and lymphomas in children • Nasopharyngeal cancer • All cancers - adult and child r m s¦ Protection from exposure to second-hand tobacco smoke. Policy reco mmendation~ Summary of findings of the United States Surgeon General, 2006 Reproductive and developmeniat effects from exposure to SHS Sudden Infant Death Syndrome The evidence is sufficient to infer a causal relationship between exposure to SHS and sudden infant death syndrome. Preterm delivery The evidence is suggestive but not sufficient to infer a causal relationship between maternal exposure to SHS during pregnancy and preterm delivery. Low birth weight „ The evidence is sufficient to infer a causal relationship between maternal exposure to SHS during pregnancy and a small reduction in birth weight. Childhood cancer The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to SHS and childhood cancer. The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to SHS and childhood leukaemias. The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to SHS and childhood lymphomas. ^ The evidence is suggestive but not sufficient to infer a causal relationship between prenatal and postnatal exposure to SHS and childhood brain tumours. " Respiratory effects in children from exposure to SHS' Lower respiratory illnesses in infancy and early childhood r The evidence is sufficient to infer a causal relationship between SHS exposure from parental smoking and lower respiratory illnesses in infants and children. The increased risk for lower respiratory illnesses is greatest from smoking by the mother. Middle-ear disease and Adenotons illectomy The evidence is sufficient to infer a causal relationship between parental smoking and middle-ear disease in children, including acute and recurrent otitis media and chronic middle-ear effusion. The evidence is suggestive but not sufficient to infer a causal relationship between parental ¦ smoking and the natural history of middle-ear effusion. Respiratory symptoms and prevalent asthma in school-age children The evidence is sufficient to infer a causal relationship between parental smoking and cough, phlegm, wheeze and breathlessness among school-age children. The evidence is sufficient to infer a causal relationship between parental smoking and ever having asthma among school-age children. Childhood Asthma Onset The evidence is sufficient to infer a causal relationship between SHS exposure from parental smoking and the onset of wheeze illnesses in early childhood. r a M Protection from exposure to second-hand tobacco smoke. Poticy recommendations. The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure from parental smoking and the onset of childhood asthma. Lung growth and pulmonary function The evidence is sufficient to infer a causal relationship between maternal smoking during pregnancy and persistent adverse effects on lung function across childhood. The evidence is sufficient to infer a causal relationship between exposure to SHS after birth and a lower level of lung function during childhood. w Cancer among adults from exposure to 5H5 Lung cancer W The evidence is sufficient to infer a causal relationship between SHS exposure and lung ¦ cancer among lifetime non-smokers. This conclusion extends to all SHS exposure, regardless of location. The pooled evidence indicates a 20% to 30% increase in the risk of lung cancer from SHS exposure associated with living with a smoker. s Breast cancer The evidence is suggestive but not sufficient to infer a causal relationship between SHS ° and breast cancer. Nasal sinus cavity and nasopharyngeat carcinoma r The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and a risk of nasal sinus cancer among non-smokers. s Cardiovascular diseases foam exposure to sffs The evidence is sufficient to infer a causal relationship between exposure to SHS and increased risks of coronary heart disease morbidity and mortality among both men and women. Pooled relative risks from meta-analyses indicate a 25 to 30% increase in the risk of coronary heart disease from SHS exposure. The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and an increased risk of stroke. Studies of SHS and subclinical vascular disease, particularly carotid arterial wall thickening, are suggestive but not sufficient to infer a causal relationship between SHS exposure and atherosclerosis. Respiratory effects in adults from SHS exposure Odour and irritation The evidence is sufficient to infer a causal relationship between SHS exposure and odour annoyance. The evidence is sufficient to infer a causal relationship between SHS exposure and nasal irritation. The evidence is suggestive but not sufficient to conclude that people with nasal allergies or a history of respiratory illnesses are more susceptible to developing nasal irritation from SHS exposure. s r ,m Respiratory symptoms The evidence is suggestive but not sufficient to infer a causal relationship between SHS " exposure and acute respiratory symptoms, including cough, wheeze, chest tightness and difficulty breathing among people with asthma. The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and acute respiratory symptoms including cough, wheeze, chest tightness, and difficulty breathing among healthy people. The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and chronic respiratory symptoms. Lung function The evidence is suggestive but not sufficient to infer a causal relationship between short-term SHS exposure and an acute decline in lung function in people with asthma. The evidence is suggestive but not sufficient to infer a causal relationship between chronic second-hand smoke exposure and a small decrement in lung function in the general population. Asthma The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and adult-onset asthma. The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and a worsening of asthma control. Chronic obstructive pulmonary disease m The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and risk for chronic obstructive pulmonary disease. A r l1 7 ¦ r Protection from exposure to second-hand tobacco smoke . PoLicy recommend Appendix 4 compared to 36pg1m3 in premises where smoking was not observed during the moni- toring period. 42 This level is more than 12-fold While effective smoke-free laws are popular, the WHO general air quality guidelines that policy-makers must be prepared to respond recommend maximum 24-hour mean expo- to many, often-made arguments aimed at dis- sures of 25 pg/m3. 151 In fact, workers in the suading their passage and implementation. United States exposed to tobacco smoke on a These arguments generally involve ideological regular basis during their working life have a issues; challenges to science on the health risk of cancer that is between 7 and 700 times r effects of SHS exposure; proposals for alter- higher than levels established as de minimus natives to smoke-free laws; the economic and for exposures to contaminants other than other negative effects of smoke-free laws as SHS. 138 well as the feasibility of implementation and enforcement. Epidemiology, the basis for risk estimates of exposure to SHS, is "junk science" Previous sections provide background infor- Use of the pejorative term "junk science" to mation that can be used to refute many of these describe the scientific method of epidemiology arguments. Below are other common argu- can be traced back to the tobacco industry and other industries, which are fearful of the impli- ments not found in these sections with their responses. cations that epidemiological research may have for their products. Tobacco industry documents s The risks of involuntaryn smoking are trivial, have left an extensive trail showing an organized particularly compared to other health issues effort to discredit it. A well-established, funda- s This claim has often been made respecting lung mental science of public health, epidemiology cancer. The increase in risk for a never smoker is the scientific method for directly gathering married to a smoker is about 20% compared to information on the health effects of exposures that for a never smoker married to a never as received in natural settings. The same smoker. As many scientific publications have approaches employed successfully for studying shown, a 20% increase in risk is substantial, both SHS have been used over decades for infec- at the individual and population levels for an tious diseases and for major acute and chron- exposure that is so widespread. Highly exposed is diseases. Epidemiological evidence is the individuals, such as bar and restaurant work- foundation for public policy in many areas, such ers, may have far higher risks than the popula- as infection control and management of airand tion average. The risks associated with heart water pollution. 4 disease are even larger and more immediate than for lung cancer. Smoke-free laws are unconstitutional and violate the personal rights and liberties of , The levels of toxic emissions from cigarettes smokers. are low compared to other air contaminants This argument states that smoking is a person- On the contrary, they are exceptionally high al choice for adults and that legislation requiring compared with most other environmental and smoke-free environments victimizes and stigma- workplace toxins.14 The air pollution emitted tizes smokers and sets a dangerous precedent by cigarettes is 10 times greater than diesel about the reach of the state. However, smoke- car exhaust. 150 Moreover, a recent study of fine free legislation does not say that smokers can- particulate matter PM25° exposure in indoor not smoke; it only limits where smoking ispermis-+. smoking and smoke-free settings in 24 countries Bible to prevent smokers from harming others. found an average level of PM25 of 317 pg/m3 in locations were there was tobacco smoking Protection from exposure to second-hand tobacco smoke. Policy recommendations. In addition, there is no "right to smoke" in any Universal application can only be achieved national constitution or international human gradually rights law.75' Conversely, the right to life, the When smoke-free environments became right to the "enjoyment of the highest attainable increasingly widespread in North America and standard of health," the right to a healthy envi- other developed countries throughout the 1980s °i ronment and other rights relevant to protection and 1990s, the pace was incremental, with from exposure to tobacco smoke are found in smoke-free environments being introduced numerous international human rights laws. 138 gradually on a sector-by-sector basis. This was -cn usually necessary because the public was less Universal application of smoke-free laws is aware of the damage caused by SHS exposure not realistic or appropriate for developing and because smoke-free environments were countries. not a familiar part of the public consciousness. The goal of universal protection is also equally An incremental approach may be the only prac- valid in high- and low-income jurisdictions, tical initial option for some countries, but it although the means for achieving it may differ. may not be required in others. The benchmark There may be a perception that developing for smoke-free environments is now far higher countries cannot afford to implement smoke- than when policies first began to be imple- r free taws, but in reality modest resources are mented, and this has made rapid change far needed to implement these laws; costs go down more feasible. The many case studies now dramatically following implementation of the available show that jurisdictions can go and All laws and improved public health will reduce have gone from virtually no smoke-free legisla- health-care costs. tion to comprehensive 100% smoke-free legisla- Comprehensive smoke-free laws are tion in a single step. Scotland and Uruguay are r culturally inappropriate in many places just two significant examples of this. National, provincial and local governments in varied cultural and ethnic settings and in devel- mentaed unless a environments cannot to help ~ entcombined with support to help oped and developing countries have shown that smokers quit comprehensive smoke-free laws are feasible The success of smoke-free laws is not dependent and successful regardless of a country's income upon providing cessation programmes in smoke- level, language or ethnic background. In Ireland free settings. Programmes to help smokers quit it was argued that smoking was an essential in settings that become smoke-free can send a component of the pub atmosphere, yet Ireland supportive message to smokers reminding them has been smoke-free for more than two years that smoke-free policies are not meant to isolate with overwhelming public support. Spanish- them but to protect everyone's health. However, and French-speaking countries are often cited experience shows that they are not necessary for r as laces that could never become smoke-free places smooth implementation of smoke-free laws. R because smoking is such an integral part of While smoking cessation programmes can bea their culture. Yet Uruguay is smoke-free, a useful ancillary intervention to smoke-free envi- r majority of the French population supports ronments if resources are available, lack of smoke-free bars and restaurants, and the resources for smoking cessation programmes French-speaking province of Quebec in Canada should not delay implementation of smoke-free r became smoke-free (including in bars and environments. Protection of public health is the restaurants) on 31 May 2006, primary goal of smoke-free environments. r n Atso known as passive smoking 1 o PM25 are harmful fine particles that are easily inhaled deep into the lungs and are emitted in large quantities from burning cigarettes r a Protection from exposure to second-hand tobacco smoke. Policy recommendations. ~t Studies quoted by opposition groups indicating What 9 they dire economic effects from smoke-free laws 4 normally rely on subjective data or do not eval- pGll~,f~rr~~~~±~~~rred a law mate objective data with acceptable scientific methods. Data may also be reported out of con- that took away text. For example, opponents of Ireland's smoke- free law noted that receipts for beer and spirits your in pubs declined following implementation of _ 311/6 of you the taw. What they failed to mention is that this trend began before the law came into effect, and b tC Riess? did not worsen as a result of the law. 154 Jlirr7111~+~7~7 Tobacco industry front groups have released many studies presenting as data the predictions .rr+r .,.,,,..,,R or opinions of a select group of bar owners. W:~n.r~r.L°.'.swiKr a.~„weer~,a+wWrr~e These unrrr+wa.-...~ vrtrsrwrsry~+ Predictions always turn out to be wrong, reep~rr1ffraWrarMK nYerwa+awrr~® wrv......rwwa ..r+wwwvr as the tobacco industry itself has admitted ~~+Rb+a~Mr~ err•ensM~awKrrw rwKWrwyW rb.wy ..~.I.rzw~pl.sMK.~..•. (Figs. 3, 41. w 1NatiwiY~aeee~~rsesr~~rbs pw.tr`ow.r~wr aulMeiSaaW rlMrra~W~. Y~Wr n~al Well, SO Pm[I4lae+piY 111! ~ :,ti Nraewnir+Wry 1YerY~~rtlrt+1 IIYYYiii s.Zi' Je~we. Restaurant Revenues (Milllons of Dollars) $30 Fig. 3 The Tobacco Institute ran this ad in California in the late Actual Revenues ew 1980s. The president the Beverly hatRestaurant $25 Association, Barry Fogel, f, later testified that, "There was no Beverly Hills Restaurant Association before the smoke free ordinance. We were organized by the tobacco Indus ?r!~~ \ - try. The tobacco industry repeatedly claimed that Beverly Hills restaurants suffered a 30% decline in revenues dur- $15 TOUaooa nduft Claim ing the five months that the [original] smoke-free ordi- nance was in effect. Figures from the State Board of $18 Equalization using sales tax data, however, showed a - - slight increase in restaurant sales. "Vogel went on to say - that he regretted his participation in opposing the law $5 The chart below shows the industry's claim versus actual sales in Beverly Hills. $D 1889 1987 1988 1989 Smoke-free laws will reduce business in the Fig. 4 Actual revenues vs tobacco industry claim hospitality sector and harm tourism. The impact of smoke-free legislation on employ- Some places have promoted smoke-free envi- e ronments and business has been studied in dozens ing that their tourism campaigns, o - r of jurisdictions. Not a single study using objec- tunny t to hat enjoy oy entertainment mainmwent with nt withthe oppor- uitout tobacco tive data and sound research methodology has found an overall negative impact of smoke-free smoke [Fig. 5). w legistation association.45, i53 The effects are uni- formty neutral or positive, with little short-term effect on the hospitality business and some pos- itive effects in the long-term as non-smokers start going to bars and other venues that they once avoided because of second-hand smoke. M 4 Protection from exposure to second-hand tobacco smoke. Poticv recommendation Smoke-free workplaces will cause smokers to smoke more in the home, thus increasing • children's exposure to SHS. There is no evidence that smoke-free work- places will increase children's exposure to A tobacco smoke at home. Indeed, a growing body of evidence suggests that legislation ban- ning smoking in public places and workplaces A leads to a reduction in smoking in the home. Smoke-free workplaces encourage smokers to quit. The reduction in smoking among adults w means that fewer children are likely to be NORWAy exposed to smoke at home. Smoke-free work- places are associated with a greater likelihood of workers implementing smoke-free policies in their homes.tss r Fig. 5 Norway"s tourist promotions highlight its smoke-free policies. r 100% smoke-free environments are not enforceable: people will not obey the laws. The reality is just the opposite. Unclear laws that designate square footage or percentages for non-smoking and smoking sections; prohibit • smoking only during certain hours in specific establishments; or set requirements for DSRs create confusion for institutions implementing the law, and for employees and customers and inspectors enforcing the law. + y On the other hand, if the law simply requires a certain type of institution [such as schools + or retail establishments) to be 100% smoke- free, building managers and owners know that they cannot permit any smoking in their build- ing, employees and customers know that they cannot smoke in the establishment, and inspectors know immediately if an institution is complying with the law: either someone is a smoking inside or no one is smoking inside. + it Will iiiii III III Appendix 5 Resources Smoke-free experiences • Multiple case studies Global Smokefree Partnership (http://www.globalsmokefreepartnership.org/evidence.php, accessed 27 March 20071 • Bermuda Tobacco Products (Public Health) Amendment Act 2005 (h ttp://www. fortknox. bm/NXT/gateway. dli?f=templates& fn=default. h tm, accessed 27 March 20071 or search under http://www.bermudalaws.bmA • California State, USA r Eliminating Smoking in Bars, Taverns, and Gaming Clubs: The California Smoke-free Workplace Act Ile I http://www. smokefreeengland. co. uk/files/smokefreeworkplacecasestudy_califonia. pdf accessed 27 March 2007). it • Ireland Office of Tobacco Control - Smoke-free workplaces (http://www.otc.ie%ommunication_smoke-free.asp, accessed 27 March 2007) Research and publications describing and evaluating the law r Ihttp://www.otc.ielcomm_pub.asp#annuat.asp, accessed 27 March 20071 R • Italy „ Ministry of Health Ihttp://www ministerosalute.it/dettaglic/phPrimoPiano.jsp?id=247, accessed 27 March 2007) • New Zealand Ministry of Health - Smoke-free Law home page R (http://www.moh.govt.nz/smoke-freelaw, accessed 27 March 2007) Going Smoke free in New Zealand, Lessons from the Battlefield. ASH New Zealand. (http://www.ash.org.nz accessed 27 March 2007) Research and publications describing and evaluating the law I http://www. moh.govt. nz/moh. nsf/wpg_ Index/Abou t-smoke-freelaw-research, accessed 27 March 20071 • Norway 4 The introduction of smoke-free hospitality venues in Norway. Impact on revenues, frequency R of patronage, satisfaction and compliance. The Norwegian Institute for Alcohol and Drug Research (SIRUS) (http://www.sirus.no%wobjekterISIRUSskrifter0206eng.pdf, accessed 27 March 2007) M Protection from e Scotland Scottish Executive I http://www.clearingtheairscottand.com/index.htmi, accessed 27 March 2007) a a ASH Scotland: The Unwelcome Guest [case study) (h ttp://www. ashscottand. org. uklashlash_disptay. jsp?p Con ten tl D=4366& p_applic =CCC&pE1ement1D=462&pMenu1D=11&p service=Content.show&, e accessed 27 March 2007) • Sweden r Government of Sweden (http://www.5weden.gov.se/sb/dl5625,-jsessionid=azTLvs7yg3b8, accessed 27 March 2007) ,a Swedish National Institute of Public Health (http://www.fhi.se/templatesIPage 5623.aspx, accessed 27 March 20071 i Uruguay Ministry of Public Health Tobacco Control Programme (http://www.msp.gub.uylcategoria_46_1_1.htmi, accessed 27 March 20071 ,r Ministry of Public Health - link to campaign materials Ihttp://www.msp.gub.uylnoticia_546_l.html, accessed 27 March 2007) • New York State, USA (h ttp://www. hea l th. s tate. ny. uslnysdoh/tobacco/reportsldocslnytcp_ eval_ report_final 11-19-04.pdf, accessed 27 March 2007) • Victoria, Canada British Columbia capital regional district 100°/% smoke-free bylaw: a successful public health campaign despite industry opposition thttp://tc.bmjjoumals.com/cgi/content/abstract/12/3/264, accessed 27 March 2007) Smoke-Free: How One City Successfully Banned Smoking in All Indoor Public Places. Contact Or Richard Stanwick, Chief Medical Officer of Health, Capital Regional District at: rstanwick0caphealth.org or order from: (h ttp://www. amazon. com/gp/product/18 94 6 943 1 7/002-4 80343 1- - 6852064?v=glance&n=283155, accessed 27 March 20071 a • El Paso, USA PowerPoint presentation: El Paso, Star of Texas: Mobilizing a community of color; r the passage of a smoke-free ordinance (h ttp://www. smoke-freeamericas. org/ppt/El %20Paso %2OSmoke-Free %2OExperience. PPT, accessed 27 March 20071 r Clean Indoor Air in El Paso, Texas: A case study I http://www.cdc.govlpcd/issues/2005ljanIO4_0065.htm, accessed 27 March 20071 a r k'I • Countering the opposition Americans for Non-smokers' Rights (ANR) What to expect from the tobacco industry, November 2004. I http://www..no-smoke.org/document.php?id=271, accessed 27 March 20071 Tobacco Scam (focus on restaurants and bars) Iwww.tobaccoscam.ucsfedu, accessed 27 March 20071 Lifting the smokescreen: Tobacco industry strategy to defeat smoke-free policies and - legislation (companion to the smoke-free Europe report, cited below) (http://www.ersnet.orglers/showldefault.aspx?id_attach=13552, accessed 27 March 2007) • Ventilation American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc. Environmental Tobacco Smoke. Position Paper. Approved by ASHRAE Board of Directors 30 June 2005. Available at: (http://www.ashrae.orglcontent/ASHRAEIASHRAElArticleAltFormat/20058211239 347.pdf. accessed 27 March 2007) Ontario Coalition for Action on Tobacco (OCAT) - facts on designated smoking rooms (http://www.ocat.orglonlegistationldesignated.html, accessed 27 March 20071 • Package warnings Pan American Health Organization (WHO Regional Office of the Americas) http://www.paho.org/English/ADISDEIRAITob_pack_warnings.htm [English) http://www.paho.orglspanishladlsdelra/tab-paq_advertencias.htm (espanol) • General Tobacco Control Legal Symposium (TCLS), Legal Authority to Regulate Smoking and Common Threats and Challenges (http://www.wmitchell.edu/tobaccolaw/resources/Sbarra.pdf, accessed 27 March 20071 r Lifting the smokescreen: 10 reasons for a smoke-free Europe (http://www.ersnet.org/ers/show/default.aspx?id_attach=13509, accessed 27 March 20071 ! Smoke free Europe makes economic sense: A report on the economic aspects of Smoke free policies by the Smoke Free Europe partnership. May 2005. (http://www.smokefreeeurope. com/assets/downloads/smoke %20free %20europe % 20-%20economic%20report.pdf, accessed 27 March 2007) Enacting strong smoke-free laws. The advocate's guide to legislative strategies 2006. American Cancer Society/UICC Tobacco Control Strategy Planning Guide #3 2006. (http://www.globalsmokefreepartnership.org/files1129.pdf?PHPSESSID=0319ee 133dffcdc 25cb84f9c5fcebcce #search= %22Enacting %20strong %20sm oke-free %201aws % 20advocate's%20guide%201egislative%20UICC%20%22, accessed 27 March 20071 M ! Protection from exposure to second-hand tobacco smoke. Policy recommendati ons. Enforcing Strong Smoke-free Laws. The advocate's guide to enforcement strategies. American Cancer Society/UICC Tobacco Control Strategy Planning Guide #4 2006. M (h t tp://www.globaismokefreepartnership. org/files/143. pdf?PHPSESSI D=de8533cfd 74e60f lO34O 183a4 9e29548#search= %22Enacting %2Ostrong %20smoke- free%20laws%20advocate's%20guide%2OUICC%20%22, accessed 27 March 2007) • Additional resource organizations Numerous case studies, research investigations, guidelines, capacity-building tools, and ~e organizations are available to assist WHO Member States in implementation of smoke-free M environments. Here are some key organizations to consult about available resources. A • Government and intergovernmental World Health Organization I http://www.who.int/tobacco, accessed 27 March 2007) • Smoke Free Americas (http://www.srnokefreeamericas.org, accessed 27 March 2007) Centers for Disease Control and Prevention Media Campaign Resource Center (http://www.cdc.gov/tobaccolmcrclindex.htm, accessed 27 March 2007) Health Canada (http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/second/index e.html, accessed 27 March 2007) • Nongovernmental Global Smoke free Partnership a (http://www.g(obalsmokefreepartnership. org) Americans for Nonsmokers' Rights i [http://www.no-smoke.org/, accessed 27 March 20071 7 Physicians for a Smoke-Free Canada I http://www.smoke-free. ca/, accessed 27 March 2007) Smoke-free Thailand Ihttp://www.smokefreezone.or.th, accessed 27 March 20071 A Smoke-free Europe (http.llwww.smoke-freeeurope.com/date-and-venue.htrn, accessed 27 March 2007) r w a ED it Protection from exposure to second-hand tobacco smoke. Poticy recommendation6~ SECTION VII - REFERENCES A study of public attitudes toward cigarette smoking and the tobacco industry in 1978. Roper Organization, Volume 1. Prepared for the Tobacco Institute, 1978. (http://legacy. library. ucsfedu/tid/yuf92f00, accessed 4 January 2007). s WHO Framework Convention on Tobacco Control, Article 8.2. Geneva, World Health Organization, 2003. w. 3 Conference of the Parties to the WHO Framework Convention on Tobacco Control. Decision A/FCTC/COP1(15). Documents A/FCTC/COP/1/DIV/8, pp. 45-48 and W A/FCTC/COP/l/DIV/8/Corr1, pp. 2-4. 4 Report on Carcinogens, Eleventh Edition. Washington DC, United States Department of Health and Human Services, National Institutes of Health, National Institute of Environmental Health Sciences, National Toxicology Program, 2005 (http://ntp.niehs.nih.gov/ntplroc%leventh/profileslsl76toba.pdf, accessed 4 January 2007). e Simpson WJ. A preliminary report on cigarette smoking and the incidence of prematurity. American Journal of Obstetrics & Gynecology, 1957, 73:808-815. e 6 Cameron P. The presence of pets and smoking as correlates of perceived disease. The Journal of Allergy and Clinical Immunology, 1967, 40:12-15. Cameron et at. The health of smokers' and non-smokers' children. The Journal of Allergy and Clinical Immunology, June 1969, 4316):336-41. 0 International Consultation on Environmental Tobacco Smoke JETS/ and Child Health. Consultation Report. Geneva, World Health Organization, 1999. v Tobacco smoke and involuntary smoking: summary of data reported and evaluation. Lyon, International Agency for Research on Cancer, 2004 (IARC Monographs, Vol. 83). 10 The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 11 Health effects of exposure to environmental tobacco smoke. The report of the California Environmental Protection Agency. Bethesda, United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Smoking and Tobacco Control, 1999 (Monograph 10, NIH Pub. No. 99-46451. 11 UK Scientific Committee on Tobacco and Health, HSMO. Report of the Scientific Committee on Tobacco and Health. The Stationary Office, 1998. 13 Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington DC, United States Environmental Protection Agency, Office of Research and Development, Office of Health and Environmental Assessment. December 1992 (EPA/600/6-90/006F) [http://www.epa.gov/smoke-freelhealtheffects.htm1, accessed 4 January 2007). r M r, Protection from exposure to second-hand tobacco smoke. Poticy recommendations. 14 Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant, SRPApproved Version. Part B: Health Effects. California Environmental Protection Agency, 24 June 2005 thttp://www.arb.ca.gov/toxicslets/finalreportlfinalreport.htm, accessed 4 January 2007). ax 15 The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the 114 Surgeon General. Atlanta, United States Department of Health and Human Services, 1111 Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006 lhttp://www.cdc.gov/tobaccolsgrlsgr2OO6lindex.htm, uw accessed 4 January 2007). n 11 Barnoya J, Glantz SA. Cardiovascular Effects of Second-hand Smoke: Nearly as Large as Smoking. Circulation, 2005, 111:2684-2698. 17 Taylor AE, Johnson DC, Kazemi H. Environmental tobacco smoke and cardiovascular disease. A position paper from the Council on Cardiopulmonary and Critical Care, American Heart Association. Circulation, 1992, Vol. 86, 699-702. 1E Secondhand Smoke: Review of evidence since 1998. Update of evidence on health effects W of secondhand smoke. London, Scientific Committee on Tobacco and Health. (SCOTH), United Kingdom Department of Health, 2004. 19 Whincup PH et at. Passive smoking and risk of coronary heart disease and stroke: prospective r study with cotinine measurement. British Medical Journal, 2004, 329(74591:200-5. 2° Hirayama T. Non-smoking wives of heavy smokers have a higher risk of lung cancer: a 'r study from Japan. British Medical Journal, (Clin Res Ed), 1981, 282(6259):183-5. 21 Trichopoulos D et aL Lung cancer and passive smoking. International Journal of Cancer, 1981, 27:1-4. 22 Yue Chen BM, Wan-Xian LI, Shunzhang Y. Influence of passive smoking on admissions for respiratory illness in early childhood. British Medical Journal, 1986, 293:303-6. r 23 Strachan D, Cook D. Health effects of passive smoking. Parental smoking and lower respiratory illness in infancy and early childhood. Thorax, 1997, 52:905-914. r 24 Samet JM, Wang SS. Environmental tobacco smoke. In: Lippmann M, ed. Environmental toxicants: human exposures and their health effects. New York, Van Nostrand Reinhold Co, r Inc, 2000:319-75. ' 25 Strachan D, Cook D. Health effects of passive smoking. Parental smoking childhood asthma: longitudinal and case-control studies. Thorax, 1998, 53:204-212. r „ 26 Samet JM, Tager IB, Speizer FE. The relationship between respiratory illness in childhood r and chronic airflow obstruction in adulthood. American Review of Respiratory Disease, 1983,127:508-23. 27 Tager IB. Passive smoking-bronchial responsiveness and atopy. American Review of r Respiratory Disease, 1988, 138:507-9. r Protection from exposure to second-hand tobacco smoke. Policy recommendations. 28 Evans D et at. The impact of passive smoking on emergency room visits of urban children with asthma. American Review of Respiratory Disease, 1987, 135 (31:567-72. 29 Weitzman M et al. Maternal smoking and childhood asthma. Pediatrics, 1990, 85141:505-11. 30 The Health Consequences of Involuntary Smoking: A Report of the Surgeon General. Rockville, United States Department of Health and Human Services, Centers for Disease R! Control and Prevention, 1986. 31 Samet JM, Lange P. Longitudinal studies of active and passive smoking. American Journal of Respiratory and Critical Care Medicine, 1996, 154:5257-65. 32 California Environmental Protection Agency, Office of Environmental Hazard Assessment. Health Effects of Exposure to Environmental Tobacco Smoke. Final Report, September 1997. I http://www,oehha.org/air/environmentaltobacco/finalets.htmt, accessed 15 March 20071 33 Martin and Bracken. Association of low birth weight with passive smoke exposure in pregnancy. American Journal of Epidemiology, 1986, 124:633-42. 34 Rubin D et at. Effect of passive smoking on birth-weight. Lancet, 1986, 2:415-417. s 35 Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General. Washington, DC, United States Department of Health and Human a Services, Centers for Disease Control and Prevention, 1989. 34 Smoking and reproductive life: the impact of smoking on sexual, reproductive and child health. London, Board of Science and Education and Tobacco Control Resource Centre, February 2004. 39 Smoking and Women's Health: A Report of the Surgeon General. Atlanta, United States Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. 39 The GTSS collaborative group. A cross-country comparison of exposure to second-hand smoke among youth. Tobacco Control, 2006, 15(Suppl. 1lhi4-0. 39 Sansores RH et at. Exposici6n pasiva at humo de tabaco en los Institutos Nacionales de Salud en M6xico. Revista del Instituto Nacional de Enfermedades Respiratorias, 2000, 13(21:96-100 I h ttp://www. imbiomed. com. mx/l NERlI n v l3n2lespanoVWinOO2-03. h tmi, accessed 4 January 20071. 40 Warren CW et at. Tobacco use and cessation counseling: Cross-country data from the Global Health Professionals Survey (GHPS). Atlanta, Centers for Disease Control internal report, 2006. 4t Navas-Acien A et at. Secondhand Tobacco Smoke in Public Places in Latin America, 2002- 2003. Journal of the American Medical Association, 2004, 291: 2741-2745. M Protection from exposure to second-hand tobacco smoke. Policy recommendationM 42 Hyland A et at. A 24-Country Comparison of Levels of Indoor Air Pollution in Different Workplaces. September 2006. (http://wwwtobaccofreeair.org/downloads/GAMS%20report.v7Sept O6.pdf, accessed 26 March 2007). .w 43 Travers MJ et at. A 32-Country Comparison of Workplace Tobacco Smoke Exposure. Abstract presented to the SRNT's 13th Annual Meeting 21-24 February 2007. Austin Texas. California Environmental Protection Agency. Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant, SRPApproved Version. Executive Summary. Appendix 1/l, 24 June 2005 (http://www.arb.ca.govltoxics/id/summary/ETS execsum.pdf, accessed 15 March 2007). 45 The Smoke Free Partnership. Lifting the smokescreen: 10 reasons for a smoke-free Europe. February 2006 (http://www.ersnet.orglers/showldefault.aspx?id attach=13509, accessed 4 January 2007) 44 Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs - United States, 1995-1999. Morbidity Mortality Weekly Report, 12 April 2002, 51(14):300-3. 47 Jamrozik K. Estimate of deaths attributable to passive smoking among UK adults: data- base analysis. British Medical Journat, 2 March 2005. - 48 Woodward A, Hill S, Blakely T. Deaths caused by second-hand smoke: estimates are r consistent. Tobacco Control, 2004, 13:319-320. 49 Wigle DT et al. Deaths in Canada from lung cancer due to involuntary smoking. Canadian y Medical Association Journal, 1987, 13619):945-951. r 50 Ross H. Economics of smoke-free policies. In: The Smoke Free Europe partnership. Smoke free Europe makes economic sense: A report on the economic aspects of Smoke free policies, May 2005. (http://www.ehnheart.orglfiles/SmokefreeEurope-102853A.pdf, accessed 26 Feb 2007). u 51 Adams K. Magnitude of Smoking Attributable Costs. Rollins School of Public Health, Emory University, Atlanta, Ga. Background Paper to the International Consultation on Environmental Tobacco Smoke PETS/ and Child Health 11-14 January 1999 Geneva, Switzerland [WHO Technical Document WHO/NCD/TFI/99.11). 51 Behan D, Eriksen M, Yijia Lin. Economic effects of environmental tobacco smoke. Society of Actuaries, 31 March 2005. (h ttp://www. soa. org/ccm/con tent/areas-of-practice/life-insurance/research/econ omic- effects-of-environmental-tobacco-smoke-SOA/, accessed 24 November 2006). 53 McGhee SM et at. Cost of tobacco-related diseases, including passive smoking, in Hong Kong. Tobacco Control, 2006, 15:125-130. 54 Report on Carcinogens, Eleventh Edition. Washington, DC, Department of Health and Human Services, 2005 (http://ntp.nichs.nih.govlntplroc%leventh/profileslsl76toba.pdf, accessed 24 November 2006). r 55 Drope J, Aguinaga-Bialous S, Glantz S. Tobacco industry efforts to present ventilation as an alternative to smoke-free environments. Tobacco Control, 2004, 13 ISuppl ):i41-i47. 56 Alevantis L et at. Effectiveness of Ventilation in 23 Designated Smoking Areas in California Office Buildings. Proceedings: IAQ 94 - Engineering Indoor Environments, American Society of Heating, Refrigerating and Air-Conditioning Engineers, 30 October-2 November 1994. 57 Liu K, Alevantis L, Offermann F. A Survey of Environmental Tobacco Smoke Controls in California Office Buildings. Indoor Air, 2001, 11:26-34. 5e Alevantis L et al. 2003. Designing for Smoking Rooms. ASHRAEJournal, 2003, 45(7): 26-32. 59 Wagner J et al. Environmental Tobacco Smoke Leakage from Smoking Rooms. Journal of Occupational and Environmental Hygiene, 2004, 1(2): 110-118. Repace J, Kawachi I, Glantz S. Fact Sheet on Secondhand Smoke. Second European and First Iberoamerican Conference on Tobacco or Health. Canary Islands, 23-27 February 1999. lhttp://www.repace.comlfactsheet.htmt, accessed 20 November 2006). 61 Nebot M et at. Environmental tobacco smoke exposure in public places of European cities. Tobacco Control, 2005:14:60-63. r 62 Fong GT et at. The impact of the Smoke-Free Ontario Act on air quality and biomarkers of R exposure in casinos: A quasi-experimental study. Oral presentation given at the Ontario Tobacco Control Conference, Niagara Falls, Ontario. December 2006 (h ttp://www. arts. uwa terloo. ca/-gfong/smokefree/Fong-Casino-OTCC-Dec2OO6-R. pdf, accessed 26 February 2007. 61 Glantz S, Schick S. Implications of ASHRAE's guidelines for ventilation in smoking-permitted areas. ASHRAEJournal, 2004,46[31:54-61. 64 Junker MH et al. Acute Sensory Responses of Nonsmokers at Very Low Environmental Tobacco Smoke Concentrations in Controlled Laboratory Settings. Environmental Health Perspectives, 2001, 109:1045-1052. 65 Repace J. Controlling tobacco smoke pollution. IAQ Applications, 2005, 60:11-15 (http://www.repace.com/pdf/iagashrae.pdf, accessed 20 November 2006). 66 Jenkins R et al. Environmental tobacco smoke in the nonsmoking section of a restaurant: a case study. Regulatory Toxicology and Pharmacology, 2001, 34:313-20. 67 Repace J. Can Ventilation Control Second-hand Smoke in the Hospitality Industry?An Analysis of the Document "Proceedings of the Workshop on Ventilation Engineering Controls for Environmental Tobacco Smoke in the Hospitality Industry", sponsored by the Federal Occupational Safety and Health Administration and the American Conference of Governmental Industrial Hygienists. Repace Associates, Inc. Second-hand Smoke Consultants, June 2000. 68 Bialous SA, Glantz SA. ASHRAE Standard 62: tobacco industry's influence over national ventilation standards. Tobacco Control, 2002, 11:315-328. M R Protection from exposure to second-hand tobacco smoke. Policv recommendations. 69 ASHRAE. Environmental Tobacco Smoke, Position Document, June 2005. r (http://www.ashrae.org, accessed 20 November 2006). 70 ISO/DIS 16814 draft reviewed by ISO/TC 205/WG 4 N175 rev2 of 18 October 2006. am Wagner J et al. Environmental Tobacco Smoke Leakage from Smoking Rooms. Journal of Occupational and Environmental Hygiene. Vol. 1, No. 2, February 2004, 1:110-118. 72 Pion, M, Give[ MS. Airport smoking rooms don't work. Tobacco Control, 2004, 13:137. (http://tobaccocontrol.bmj.com/cgi/content/abstract/13/suppl 037, accessed 27 March 20071 73 Lam T-H et at. Secondhand smoke and respiratory it[ health in current smokers. Tobacco Control, 2005, 14:307-314; doi:10.1136/tc.2005.011775. 74 Toronto Staff Report. Toronto's No Smoking By-law (Municipal Code Chapter r 709-Smoking) - Final Phase Implementation Update. Memorandum from Or David McKeown, Medical Officer of Health to Board of Health, 14 November 2005. Ihttp://www.toronto.ca/legdocs/2005/agendas/committees/h(/h1051128/it003.pdf, accessed a 20 November 2006). 95 Ordinance no. 2006-217 an ordinance of the city of Calabasas regulating second-hand smoke and amending the Calabasas municipal code. ar (http://www. cityofcalabasas. ccm/pdf/agendas/counciV2006/021506/item2-02006-217. pdf, accessed 27 March 2007). 76 Nakahara S. Smoking brings another danger to children in Japan. Injury Prevention, 2005, 11:318; doi:10.1136/ip.2005.009613. 77 Queensland Government Health tobacco taws: Outdoor public areas (http://www.health.gld.gov.au/a tods/tobaccolaws/outdoor/default. asp, accessed 26 February 2007). r 78 Anon. Goa to ban smoking in public from Oct 2. Deccan Herald (Indial, 12 September 1999. 79 Stadia Football fans facing smoking ban. BBC News. r (http://news.bbc.co.uk/l/hi/england/derbyshirel4512829.stm, accessed 26 March 2007). 80 The Tobacco Control Environment: Ontario and Beyond. Ontario Tobacco Research Unit. November 2006. (http://www.otru.org/pdf/12mr/12mr no1_final.pdf, accessed 26 March 2007). 81 For example, Saskatoon, Canada (http://www.saskatoon.calorglclerks_office/bylaws/8286.pdf, accessed 20 November 2006) and Hawaii beginning in November 2006. Bz Mulcahy M et at. Second-hand smoke exposure and risk following the Irish smoking ban: an assessment of salivary cotinine concentrations in hotel workers and air nicotine levels in bars. Tobacco Control, 2005, 14(61:384-8. a 83 Clarification - Outdoor dining and drinking areas. Issues relating to outdoor dining and drinking areas and enclosed (sections 5A and 5C of the Tobacco Act 1987 from 1 July 2007). State Government of Victoria, Australia, Department of Human Services. May 2006 (http://www.health.vic.gov.au/tobaccoreforms/outdoor.htm, accessed 24 March 20071. M a -Protection from exposure to second-hand tobacco smoke. Policy recommendations. R +n 84 Clean air on patios in the capital region. Part A: an overview of the proposed amendment to the CRD clean air bylaw requiring all patio spaces of businesses where food and bever- ages are served to be smoke free. Capital Regional District of British Columbia, Canada, 7 March 2007 I http://www.crd.bc.calcleanairldocumentslbackground.pdf#view=Fit, accessed 24 March 20071. 95 One-Year Review of the Massachusetts Smoke-Free Workplace Law. M.G.L. Chapter 270, Section 22. July 5, 2004 - June 30, 2005. Massachusetts Tobacco Control Program, Massachusetts Department of Public Health (http://www.mas.5.govldphlmtcpliegaV workplacelaw review 20042005.pdfaccessed 24 March 2007). es Pollard R. Pubs and clubs see loophole in smoking rules. Health Reporter, 25 February 2005. (http://www.smh.com.aulnewsINationaVPubs-and-clubs-see-loophole-in-smoking- rules/2005/02/24/1109180044015.html,accessed 24 March 2007) R" 87 Smoke-free workplaces in Ireland: A one-year review. Ctane, Ireland, Office of Tobacco Control, March 2005. 88 Allwright S at at. Legislation for smoke-free workplaces and health of barworkers in Ireland: before and after study. British Medical Journal, 2005, 33117525):1117. 69 Eisner M, Smith A, Blanc P. Bartenders' respiratory health after establishment of smoke- free bars and taverns. Journal of The American Medical Association, 1998, 280:1909-1914. 91 Bates M et aL Exposure of hospitality workers to environmental tobacco smoke. Tobacco Control, 2002, 11:125-129. w 91 Menzies D et al. Respiratory Symptoms, Pulmonary Function, and Markers of Inflammation Among Bar Workers Before and After a Legislative Ban on Smoking in Public Places. Journal of the American Medical Association, 2006, 296114)1742-48. 92 Barone-Adesi F et al. Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. European Heart Journal, 2006, [Epub ahead of print] doi:10.1093/eurheartj/eh1201. 93 Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. British Medical Journal, 2004, 328(7446):977-80. 94 Bartecchi C et aL Reduction in the Incidence of Acute Myocardial Infarction Associated with a Citywide Smoking Ordinance. Circulation, 2006, 114:1490-1496. 95 Jha P. Curbing the epidemic: governments and the economics of tobacco control: development in practice. Washington, DC, The World Bank, 1999. ` 96 Fichtenberg C, Glantz S. Effect of smoke-free workplaces on smoking behaviour: systematic review. British Medical Journal, 2002, 325:188. 99 Borland R et at. Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia. Tobacco Control, 1999, 8: 266-271. Fi Protection from exposure to second-hand tobacco smoke. Policy recommendations. 98 Ong M, Glantz S. Free nicotine replacement therapy programmes vs implementing smoke- free workplaces: a cost-effectiveness comparison. American Journal of Public Health, 2005, June 9516):969-75. 99 Gallus S et at. Effects of new smoking regulations in Italy. Annals of Oncology, Advance w Access published online on 7 November 2005, doi:10.1093/annonc/mdj070. "'National Institute for Alcohol and Drug Research, Research Centre for Health Promotion. a Smoke-free bars and restaurants in Norway. Oslo, National Institute for Alcohol and Drug Research (SIRUSI and Research Centre for Health Promotion (HEMIL), 2005. 101 The smoke is clearing: Anniversary Report 2005. Wellington, New Zealand Ministry of Health, 2005. 102Farkas AJ et al. Association between household and workplace smoking restrictions and adolescent smoking. Journal of the American Medical Association, 2000, 284717-722. "'Wakefield MA et al. Effect of restrictions on smoking at home, at school and in public places on teenage smoking: cross sectional study. British Medical Journal, 2000, 321:333-337. ,m 104Parrott S, Godfrey C, Raw M. Costs of employee smoking in the workplace in Scotland. Tobacco Control, 2000, 9:187-192. ~ 105Madden D. Setting the appropriate tax on cigarettes in Ireland. Working paper series, Wp02/05, Centre for Economic Research, October 2002. 106United States Occupational Safety and Health Administration. Indoor Air Quality, 1994, 59:15968-16039. "'Smoke-free workplaces ata glance. Washington DC, World Bank lhttp://wwwl.worldbank.orgltobacco/AAG%20SmokeFree%2OWorkplaces.pdf, accessed 24 March 20071. 1oeDearlove A Bialous SA, Glantz SA. Tobacco industry manipulation of the hospitality industry to maintain smoking in public places. Tobacco Control, 2002, June, 11(2):94-104. 109Scollo M et al. Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control, 2003, 12:13-20. a 110Alamar BC, Glantz SA. Smoke-free ordinances increase restaurant profit and value. Contemporary Economic Policy, 2004, 22:520-525. a "'Swart JC. An Overlooked Cost of Employee Smoking. Personnel, August 1990. 112 The Costs and Benefits of Smoking Restrictions: An Assessment of the Smoke-Free r Environmental Act of 1993(H.R. 3434). Washington, DC, Environmental Protection Agency, Office of Air and Radiation, April 1994. 11sDurkan J, Macdowell M. Smoke-free Policies: Market Research and Literature Review On Economic Effects On The Hospitality Sector. The impact of smoke-free policies on the hospitality sector. A review of the literature. Clare, Office of Tobacco Control, 2003. a m a hand tobacco smoke. Policy recommendations. R 114Lopez-Nicol6s A, Pinilla-Dominguez J. Evaluacion del impacto de la ley de medidas sanitarias contra el tabaquismo en el sector hostelero: bares y restaurants. A report of the National Committee for the prevention of tobacco use. Spain, January 2006 (http://www.cnpt.esldocu_pdfllnformeimpacto2 final.pdf, accessed 24 March 2007). 115Ludbrook A et at. International Review of the Health and Economic Impact of the - Regulation of Smoking in Public Places. NHS, Scotland, January 2005 http://www.cymru.gov.uk/keypubassemsmoking/content/0105-paper1-w.pdf, accessed 24 March 2007. 11e1-6pez-Nicot6s A, Pinilta-Dominguez J. Evaluation del impacto de la leyde medidas • sanitarias contra el tabaquismo sobre los costes emrpesariales y los costes sanitarios. A report of the National Committee for the prevention of tobacco use. Spain, December 2005 (http://www.cnpt.esldocu_pdfllnforme_fiscalidad 01.pdf, accessed 24 March 2007). "'First annual independent evaluation of New York State's tobacco control program. Final report. Research Triangle Park, RTI International, November 2004. W 11aRepace J. An Air Quality Survey of Respirable Particles and Particulate Carcinogens in ¦ Delaware Hospitality Venues Before and After a Smoking Ban. Bowie, Maryland, Repace Associates, Inc, 7 February 2003 (http://www.tobaccoscam.ucsf.edu/pdf/RepaceDelaware.pdf, accessed 4 January 20071. ` ...Cr6mieux PY, Ouellette P. Actual and perceived impacts of tobacco regulation on restaurants r and firms. Tobacco Control, 2001, 10:33-37. 121Shiett A, Chapman S. The inertia of self- regulation: a game-theoretic approach to reducing passive smoking in restaurants. Social Science and Medicine, 2000, 51, 7:1111-1119(9). 121 Jones M, Wakefield M, Turnbull DA. Attitudes and experiences of restaurateurs regarding smoking bans in Adelaide, South Australia. Tobacco Control, 1999, 8:62-66. 122Schofiled MJ et at. Smoking control in restaurants: the effectiveness of self-regulation in Australia. American Journal of Public Health, 1993, 83:9:1284-1288. 121Smoke-free world: doctors' notes on clean air laws. London, British Medical Association, 2005 (http://www.kup.nolassetl2494812124948 - 2.pdf?PHPSESSID=3197blO9ebfafO83add 160587917b9fO, accessed 4 January 2007). 121Smoking in public places. An evidence report. Edinburgh, Scottish Executive Social R Research, 2004. 125Un ano de Ley del Tabaco. Sociedad Espanola de Medicina Familiar y comunitaria, W 7 February 2007 (http://www.semfyc.eslwwwlsemfyc%s/noticiaslnormativalnoticia.htmt? title= %20- %20Un %20a %C3 %B 1 o %20de %20Ley%20del %20Tabaco&param 10=6 99, w accessed 27 March 20071. R 126Sweda EL. Lawsuits and secondhand smoke. Tobacco Control, 2004, 13:i61 (http://tc.bmjjoumals.comlcgi/content/abstractll3lsuppL 061, accessed 4 January 2007). M M "'Legislating forsmoke-free workplaces. Copenhagen, WHO Regional Office for Europe, 2006. 12'Heloma A et al. The Short-Term Impact of National Smoke-Free Workplace Legislation on Passive Smoking and Tobacco Use. American Journal of Public Health, 2001, 91:9:1416-1418. 129Weber MD et al. Long-term compliance with California's smoke-free workplace law among bars and restaurants in Los Angeles County. Tobacco Control, 2003, 12:269-273. 130Tsoukalas T, Glantz SA. The Duluth clean indoor air ordinance: Problems and success in fighting the tobacco industry at the local level in the 21 st century. American Journal of Public Health, 2003, 93:1214-1221. 131 Siegel M et al. Pre-emption in tobacco control. Review of an emerging public health r problem. Journal of the American Medical Association, 1447, 278(10J:858-63. 132Tobacco Control Act, 1994 (Ontario), Art. 12. - a 133The Non-Smokers Health Protection Act (Manitoba), Art. 6. 134McLintock B. Smoke-free: how one city successfully banned smoking in all indoor public places. Vancouver, British Columbia, Granville Island Publishing, 2004. "'Reynolds J et at. Clean Indoor Air in El Paso, Texas: A Case Study. Preventing Chronic Disease: Public Health Research, Practice and Policy. 2:1, January 2005. 136Drope J, Glantz SA. British Columbia Capital Regional District 100% smoke-free bylaw: A successful public health campaign despite industry opposition. Tobacco Control, 2003, W 12:264-268. 131Magzamen S, Charlesworth A, Glantz SA. Print media coverage of California's smoke-free • bar law. Tobacco Control, 2001, 10(2):154-60. "'Selin H, Vasquez J. Exposure to second-hand smoke in the Americas: A human rights perspective. Washington, DC, Pan American Health Organization, May 2006. "'Nixon M, Mahmoud L, Glantz SA. Tobacco industry litigation to deter local public health ordinances: The industry usually loses in court. Tobacco Control, 2004, 13:65-73. 141 International consultation on environmental tobacco smoke and child health, 11-14 January 1999. Geneva, World Health Organization, 1999 (WHO/NCD/TFI/99.10). 141 Thompson G, Wilson N, Howden-Chapman P. Population level policy options for increasing the prevalence of smokefree homes. Journal of Epidemiology and Community Health, 2006, 60:298-304. 142Borland R et al. Determinants and consequences of smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006, 151Suppt. 31:iii50; doi: 10.1136/tc.2005.012492. a Protection from exoosure to second-hand tobacco smoke. Pokicy recommendations. 143Merom D, Rissel C. Factors associated with smoke-free homes in NSW: results from the 1998 NSW health survey. Australian And New Zealand Journal of Public Health, Aug. 2001, „ 25(4):339-45. M "'Borland R et at. Trends in environmental tobacco smoke restrictions in the home in u,. Victoria, Australia. Tobacco Control, 1999, 8:226-271. 145Health Canada. Health Canada National Campaigns: Second-hand Smoke. Ottawa, Ontario, 2006. (http://www.hc-sc.gc.ca/hl-vsltobac-tabaclres/media/camp/index e.htmi, accessed 27 March 20071 '"Program Training and Consultation Centre. Smoke-free Homes and Asthma Pilot Sites: w Media Campaigns. Ontario, Canada, 2002. ^ (http://www. ptcc-cfc.on.ca/bpdintervention-de tails. cfm ?IntlD=3 1, accessed 27 March 2007). 147 Take the Smoke-free Home Pledge. Washington, DC, United States Environmental r Protection Agency, 2006 (May 2006 last update). Ihttp://www.epa.govlsmokefree/pledgelindex.htmi, accessed 27 March 2007). 141New South Wales Cancer Council. Car and Home Smoke Free Zone - give your child a healthy future. New South Wates, Australia, 2003. Ihttp://www.smokefreezone.orglindex.cfmlpag(Z_id/1118, accessed 27 March 2007). ~r 149Environics Research Group. Evaluation of the new warnings on cigarette packs. Toronto, Y„ Ontario, January 2002. .e 150invernizzi G et al. Particulate matter from tobacco versus diesel car exhaust: an educational perspective. Tobacco Control, September 2004, 13:219 - 221. 151 WHO Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide. Global update 2005. Summary of risk assessment. Geneva, World Health Organization, 2006 (WH 0/SDE/PH E/O EH/06.02). 152Graff SK. There is no constitutional right to smoke. Tobacco Control Legal Consortium Law ? Synopsis. Tobacco Control Legal Consortium, July 2005. (http://www. tobaccolawcen ter. org/resources/No+Constitutional+Right+to+Smoke, pdf, ¦ accessed 24 March 2007). Mb 153Joossens L. Economic impact of a smoking ban in bars and restaurants. In: Lifting the Smokescreen: 10 reasons fora smoke-free Europe. European Respiratory Society, 2006. I http://www.ersnet.orglersldefault.aspx?id=4524, accessed 4 January 2007). 154Jones S, Muller T. Public attitudes to smoke-free policies in Europe. In: Lifting the Smokescreen: 10 reasons fora smoke-free Europe. European Respiratory Society, 2006. (http://www.ersnet.org/ersldefault.aspx?id=4524, accessed 4 January 2007). F 155Use Borland et at. Decrease in the prevalence of environmental tobacco smoke exposure in the home during the 1990s in families with children. American Journal of Public Health, 2004,94(2):314-320. r s. r y W 1 r 1 r +1 r 1 r r a r 'A Mill 19 At For further information, kindly contact TFI as follows: Tobacco Free Initiative (TFI) World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel. + 41 22 791 21 26 Fax: + 41 22 791 48 32 http://www.who.int/tobacco/en/ ¦ 2's tK M3 ~ r r n'Yx, S 3" w, N ag x~p~ F `e 4 F y., = 4,. b } } 4 ~ ~ Ftn A1 ~ Mil "Md.`aY,.S N H F t~ ealth I gan'ization } igbacco Fieeinitiative (TFI) AvenueAf'is X11 Genea~a7~' ( itzerla d, Jephone 1 22 791 2126 ax: + 41Z~1 4832 j ail: tfi@a hq+~pt Stp://vvvulr¢lrvuho int/tobacco/en/