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Home My WebLink AboutCOM 0746.043 2000-2002n Ll Editorial Smoke-Free,OrdinancesDo Not Affe RestaurantBusiness./> >j/ HE STORY has become tediously familiar: a concerned legislator or group of citizens decides that it is time to pass a local clean indoor air ordi- nance to protect the public and workers from the toxins in secondhand tobacco smoke.'-" After mustering the scientific evidence that secondhand smoke causes heart disease, cancer, sudden infant death, asthma, and a variety of other problems, public health advocates ap- proach the city council or other legisla- tive body to act. Shortly thereafter, a con- cerned restaurant association sidesteps the issue that secondhand smoke is dan- gerous and produces a "study" claiming that the result will be economic chaos, with 20-40 percent drops in restaurant business. As time passes, local tobacco control advocates or the media force the restaurant association to admit that it "re- quested and received some support." Often, it ultimately comes out that the tobacco industry or one of its public rela- tions firms-' organized the "restaurant as- sociation." (Figure 1). After a long debate, the ordinance passes.-' After Glantz and Smith1 ," published their study demonstrating that smoke- free restaurant ordinances have no effect on restaurant revenues in the first 15 cit - This work was supported in part by Na- tional Cancer Institute grant CA -61021 and a gift from Edith and Henry Everett. Address for correspondence: Stanton A. Glantz, PhD Professor of Medicine Box 0130 University of California San Francisco, CA 94143-0130 Telephone: 415-476-3893 Fax: 415-476-0424 E-mail: glantz@medicine.ucsf.edu Stanton A. Glantz, PhD ies to pass such ordinances, the tobacco industry's claims of economic chaos lost credibility, particularly in California and Colorado, where the cities were located. While this study was also useful to advo- cates in other states (including those in New York and Massachusetts), the indus- try started to argue that there was some- thing unique about California or Colo- rado and, while there might not have been economic chaos there, it would happen elsewhere. The articles in this is- sue of the journal of Public Health Man- agement and Practice (JPHMP) show that, in contrast to claims by the tobacco industry, smoke-free restaurant ordi- nances have had no impact on revenues after New York City and several commu- nities in Massachusetts passed such ordi- nances. With the addition of the articles in this issue of JPHMP, there are now published data', 10,11,12-18 on the economic impact of smoking restrictions on restaurant sales for 81 localities in six states, 67 of which are 100 percent smoke-free in restaurants (Appendix 1). While there are some dif- ferences in the ordinances and the meth- ods used to study them across localities, all have relied on objective sales tax data to assess economic impact. The sales tax data from these 81 localities are consis- tent in demonstrating that ordinances re- stricting smoking in restaurants have no effect on revenues. Studies of economic impact based on sales tax revenues have several advan- tages. First, and most important, the data are objective. They are collected by tax authorities with no interest in the impact of a clean indoor air ordinance. Second, they are complete; they include all res- taurants. Third, they are available over time, so it is possible to adjust for under- [r9 lying economic trends or seasonal vari- ability. The problem with studies of the impact of clean indoor air ordinances based on sales tax data is that they are not available until well after an ordinance passes. Thus, when confronted with pre- dictions of disaster based on industry -in- spired surveys of the city in question, ad- vocates can only point to evidence from other cities. The appropriate response to such pre- dictions from the tobacco industry and its allies and front groups is to point out that these claims have been made every- where else and, when the objective data became available a year or two later, they turned out to be wrong. Faced with the growing evidence that restaurant ordinances do not affect rev- enues, the tobacco industry has fallen back on a series of secondary claims, that the public will not comply with the ordi- nance or that it will somehow hurt em- ployment or tourism (even though rev- enues are not affected). Other articles in this issue of JPHMP also debunk these claims. Indeed, New York City added restaurant jobs faster than the rest of the state after the ordinance went into effect. As already demonstrated in other places,19-21 the public supports and com- plies with these ordinances. These results are not surprising, given growing public awareness of the dangers of secondhand smoke. indeed, despite a major public relations campaign de- signed to undermine it, the public sup - Stanton A. Glantz, PhD, is a Profes- sor of Medicine at the Institute for Health Policy Studies and Depart- ment of Medicine, University of Cali- fornia, San Francisco, California. CONFIDENTIAL: (MINNESOTA TOBACCO LITIGATION PHILIP MORRIS, INC. Dolphin Group, Inc. Calif, susina" PAA Direct San Diego Northam Calif. and Restaurant Communication Tavern and Tavern and Alhar�ce Restaurant Restaurant Assoc. Assoc. California Action Plan Element 1 Element 2 Element 3 Point of Sale AB 13 Restaurant California Tavern Protection Program Accommodation Association Figure 1. Organization chart prepared by the Dolphin Media Groups a California Public Relations firm, probably for Philip Morris Tobacco, describing planned efforts to fight implementation of California's smoke-free workplace law, AB13, which also includes restaurants and bars. This chart clearly shows that "organizations" such as the California Business and Restaurant Alliance, San Diego Tavern and Restaurant Association, and Northern California Tavern and Restaurant Association are creations of the tobacco industry. Such organizations seek to appear to be legitimate representatives of the business community (as opposed to the tobacco industry) when dealing with the public, the press, and legislators. ports and complies with California's smoke-free bar law, which went into ef- fect on January 1, 1998. A June 1998 statewide poll conducted by the nonpar- tisan Field Institute showed that 85 per- cent of bar patrons go to bars as much or more than they did before the ordinance. At the same time, local health depart- ments reported that compliance is good (90% in restaurant -bar combinations and 70% in stand-alone bars), and is improv- ing over time 22 The tobacco industry has created "res- taurant associations" since the early 1980s, when it created the Beverly Hills Restaurant Association for purposes of seeking a repeal of Beverly Hills' clean indoor air ordinance.6 As documented in the history of how the New York ordi- nance passed, the industry is continuing this strategy. Public health advocates should investigate carefully the bona fides of "restaurant" or "business" groups that suddenly appear willing to spend large amounts of money opposing to- bacco control ordinances, with reason- able sounding names like the California Business and Restaurant Alliance or the Vii San Diego Tavern and Restaurant Asso- ciation (Figure 1). 6,7,9,23.24 In addition, since the industry now knows that public health advocates are looking for this tac- tic, it may be moving to work through legitimate restaurant organizations, per- haps by funding their efforts or directly or indirectly underwriting their lobbying expenses. Public health advocates should demand that any organization that opposes a local clean indoor air ordi- nance disclose fully its involvement with the tobacco industry or its public rela- tions apparatus. v The articles in this issue of JPHMP con- Surgeon General. Washington, D.C.: Control Ordinances on Restaurant Rev- firm that continuing local activity to pass U.S. Department of Health and Human enues in California. Claremont, CA: The clean indoor air ordinances tailored to Services, Public Health Service, Centers Claremont Institute for Economic Policy meet local conditions is the best way to for Disease Control; 1986. Studies; The Claremont Graduate School; protect nonsmokers from secondhand 2. National Research Council Committee 1994. tobacco smoke Aware of this fact, it is on Passive Smoking. Environmental To- 15. Bartosch, W., and Pope, G. The Eco- .21 particularly important that public health bacco Smoke: Measuring Exposures and nomic Impact of Brookline's Restaurant advocates defeat efforts by the tobacco Assessing Health Effects. Washington, D.C.: National Academy Press; 1986. Smoking Ban, Waltham, MA: Health Eco- nomics Research, Inc.; 1995. industry to enact weak state legislation 3. U.S. Environmental Protection Agency. 16. Sciacca, J., and Ratliff, M. Prohibiting preemptingthe ability of local communi- Respiratory Health Effects of Passive Smoking in Restaurants: Effects on Res- ties to enact tobacco control ordi- Smoking: Lung Cancer and Other Disor- tau rant Sales. Americanlourna/ofHealth nances.18•26.27 ders. St. Paul, MN: U.S. Environmental Promotion. 1998;12, no. 3:176-184. The real reason that the tobacco indus- Protection Agency; 1992. 17. Hwang, P., et al. Assessment of the Im- try opposes these ordinances is that the 4. Office of Environmental Health Hazard pact of a 100% Smoke-Free Ordinance creation of smoke-free restaurants repre- Assessment. Health Effects of Exposure to on Restaurant Sales-West Lake Hill, sentEnvironmental a strong message that smoking Tobacco Smoke. Berke- Texas, 1992-1994. Morbidity and Mor- around other people is no longer socially around ley, CA: California Environmental Protec- tality Weekly Report. 1995;44: 3 70-3 72. acceptable. Creating smoke-free work- tion Agency (http://www.caiepa.cahw net.gov/oehha/docs/finalets.htm); 1997. 18. Goldstein, A., and Sobel, R. Environmen- tal Tobacco Smoke Regulations Have Not places reduces cigarette consump- 5. Philip Morris Tobacco. California Action Hurt Restaurant Sales in North Carolina. tion .20,28-11 This changing social environ- Plan (Philip Morris Bates numbers North Carolina Medical Journal. 1998; ment will help people quit smoking and 2044325927-36 in the Minnesota To- 59:284-288. reduce tobacco industry sales and prof- bacco Document Depository). 19. Biener, L., and Siegel, M. Behavior Inten- i;s.2o,2s For example, Glasgow et a1.30 esti- 6. Samuels, B., and Glantz, S. The Politics of tions of the Public after Bans on Smoking mate that if all workplaces in the United Local Tobacco Control. /AMA. 1991; in Restaurants and Bars. American lour- States were smoke-free, an additional 266: 2110-2117. 7. Traynor, M., and Glantz S. New Tobacco nal of Public Health. 1997;87: 2042- 2044. 178,000 smokers would stop smoking, and, among those who continued to Industry Strategy To Prevent Local To- 20. Pierce,J.P.,etaLTobacco.UseinCalifor- smoke, they would consume 10 billion bacco Control. JAMA. 1993;270. 8. Bialous, S.A., and Glantz, S. Tobacco nia: An Evaluation of the Tobacco Con- trol Program, 1989-1993. University of fewer cigarettes per year. There is simply Control in Arizona, 1973-1997. San California, San Diego; 1994. no other tobacco control intervention Francisco, CA: UCSF Institute for Health 21. Corsun, D., et al. Should NYC's Restaura- that can contribute this much to public Policy Studies (http://www.library.ucsf. teurs Lighten Up? Cornell Hotel and Res- health this quickly-for both nonsmok- edu/tobacco/azo; 1997. taurant Administration Quarterly. 1996; ers and people who would like to quit-® 9. Smith, L. Big Apple Breathes Easy. To- 37: 26. as creating smoke-free environments. bacco Control. 1995;4: 15-17. 22. Rankin, T., et al. Letter to California Leg- The battle over clean indoor air in restau- 10. Glantz, S., and Smith, L.R.A. The Effect of islature. Sacramento, CA: BREATH, A rants has become symbolic for the whole Ordinances Requiring Smoke-Free Res- Project of the American Lung Associa- battle over clean indoor air. taurants on Restaurant Sales. American Journal of Public Health. 1994;84, no. 7: 23. tion; 1998. Samuels, B., et al. Philip Morris' Failed in any event, there is now evidence 1081-1085. Experiment in Pittsburgh. Journal of from so many cities of varying location, 11. Glantz, S., and Smith, L. Erratum for "The Health Politics, Policy, and Law. 1992; size, and demographics that the question Effect of Ordinances Requiring Smoke- 17:329-351. of whether clean indoor air ordinances Free Restaurants on Restaurant Sales. 24. Smoke-Free Educational Services. Philip affect restaurant revenues--adversely or American lournalofPublicHealth. 1997; Morris Front Groups. New York, NY; otherwise-should be considered closed. (in press). 1995. Local officials can now go about their 12. Glantz, S., and Smith, L. The Effect of 25. Glantz, S. Back to Basics: Getting Smoke- business of protecting the public from the Ordinances Requiring Smoke-Free Res- Free Workplaces Back on Track (edito- toxins in secondhand smoke without taurants and Bars on Revenues: A Fol low- rial). Tobacco Control. 1997;6:164-166. about this issue. Up. American Journal of Public Health. 26. Conlisk, E., et al. The Status of Local worrying phony 1997;87:1687-1693. Smoking Regulations in North Carolina 13. Glantz, S., and Smith, L. Erratum for "The Following a State Preemption Bill. JAMA. REFERENCES Effect of Ordinances Requiring Smoke- 1995;273: 805-807. Free Restaurants and Bars on Revenues: A 27. Siegel, M., et al. Preemption in Tobacco 1. U.S. Department of Health and Human Follow-Up". American Journal of Public Control. Review of an Emerging Public Services. The Health Consequences of involuntary Smoking. A Report of the Health. 1998;88:1122. 14. Maroney, N. et al. The Impact ofTobacco Health Problem. JAMA. 1997;278: 858- 863. 28. Woodruff, T., et al. Lower Levels of Ciga- rette Consumption Found in Smoke -Free Workplaces in California. Archives of In- ternal Medicine 1993;153: 1485-1493. 29. Stillman, F., et al. Ending Smoking at the Johns Hopkins Medical Institutions: An Evaluation of Smoking Prevalence and Indoor Pollution. JAMA. 1990;264: 1565-1569. 30. Glasgow, R., et al. A. Relationship of Worksite Smoking Policy to Changes in Employee Tobacco Use: Findings from Appendix 1 COMMIT. Tobacco Control. 1997;6 (suppl 2): S44—S48. 31. Patten, C., et al. Workplace Smoking Policy and Changes in Smoking Behavior in California: A Suggested Association. Tobacco Control. 1995;4: 36111. 32. Taylor Consulting Group. The San Luis Obispo Smoking Ordinance: A Study of the Economic Impacts of San Luis Obispo Restaurants and Bars. San Luis Obispo, CA: Taylor Consulting Group (under con- tract to the City of San Luis Obispo); 1993. 33. Bartosch, W., and Pope, G. The Eco- nomic Effect of Smoke -Free Restaurant Policies on Restaurant Business in Massa- chusetts. journal of Public Health Man- agement and Practice. 1999;5, no. 1:53- 62. 34. Hyland, A., Cummings, K.M., and Nauenberg, E. Analysis of Taxable Sales Receipts: Was New York City's Smoke - Free Air Act Bad for Restaurant Business? Journal of Public Health Management and Practice. 1999;5, no. 1: 14-21. . Cities and Counties with Ordinances Restricting Smoking in Restaurants or Bars that Have Been Studied Based on Sales Tax Data Amherst, MA33 Halifax County, NC78 *t Roseville, CA 10.11.12-14 Anderson, CA` -`Holden, MA33 Ross, CAM11.12.13 Andover, MA" Holyoke, MA 13 Sacramento, CA10.11.12.13 Arlington, MA33 Indian Wells, CA14 ' San Luis Obispo, CA`-1',1'-'4,32Aspen, C010.11.12.13 Lanesborough, MA33 San Joaquin County, CA14 Attleboro,MA33 Lee, MA 33 San Mateo County, CA 14 * Auburn, CA10.11.12-14 Lenox, MA 33 Santa Clara County, CA 12.13 Bedford, MA 31 Lexington, MA 33 Saratoga, CA14 Bellflower, CA11M.12-14 Lodi, CA10.11.12-14 Sharon, MA 33 Belmont,,33 MA Long Beach, CA11 * Shasta County, CA1a-14 Beverly Hills, CA70.11.12-14 Longmeadow, MA 33 Snowmass, C030.11.12.13 Brookline, MA11.33 Los Gatos, CA14 South Hadley, MA" Buncombe County, NCIe t Martinez, CAa.10.12.13.33 Southampton, MA 31 Chicopee, MA 31t Medfield, MA 31 Stockbridge, MA 31 Colfax, CA14 Mesa, AZe Stockton, CA 14 * Contra Costa County, CA14 Montague, MA 31 Sunderland, MA 33 Craven County, NC1B *t New York, NY314,� Sunnyvale, CA14 * Culver City, CA1' * A Northampton, MA33 Telluride, C010.11.12.13 Davis, CA72.13 Norwell, MA 33t Tewksbury, MA 33 East Longmeadow, MA33 Orange County, NC11 t Tiburon, CA 12.13 Easthampton, MA33 Palo Alto, CA" -11.12-14 Tracey, CA14 * El Cerrito, CA 10.11.12-14 Paradise, CA70.11.12-14 Wake County, NC38 *t Flagstaff, AV' Plainville, MA33 Wakefield, MA33 Foxborough, MA33 Plymouth, MA 13 Walnut Creek, CA14 Framingham, MA33 Rancho Mirage, CA11 * West Springfield, MA 13 Grass valley, CA14 Reading, MA 33 West Lake Hills, TX` Greenfield MA 33 Redding, CA 11.13 Yountville, CA" * , *Less than 100% smoke-free restaurants. tRepealed or overturned in court after a period of time in force. ix 11 11 Reprinted tram JAMA ® The Journal of the American Medical Association May 26, 1999 Volume 281 Copyright 1999, American Medical Association MW ORIGINAL CONTRIBUTION AfterTourisill and Hotel Revenues s:.>-. �. ands of Smoke—Free ..: inances Stanton A. Glantz, PhD Annemarie Charlesworth, MA S THE EVIDENCE THAT SECOND - hand tobacco smoke endan- gers nonsmokers has accu- mulated,',' more and more communities have eliminated smok- ing in public places and workplaces. As of September 1998, 212 communities and 3 states had enacted laws mandat- ing smoke-free restaurants' and 1 state ( California') and 31 communities' had enacted local ordinances requiring smoke-free bars. These ordinances not only protect nonsmokers from the tox- ins in secondhand smoke, they also cre- ate an environment that encourages smokers to quit.' The tobacco industry vigorously op- poses these public health measures to protect its sales. During the debates over these laws, it is common for the to- bacco industry (acting directly or through front groups") to claim that these ordinances create severe eco- nomic problems for the restaurants and bars. After Glantz and Smith"' pub- lished their study demonstrating that smoke-free restaurant ordinances have had no effect on restaurant revenues in the first 15 cities to pass such ordi- nances, the tobacco industry's claims of economic chaos lost credibility, particu- larly in California and Colorado, where the cities were located. Glantz and Smith"-" -" later updated this study and ex- tended it to include smoke-free bars. Sub- sequent work by other researchers Context Claims that ordinances requiring smoke-free restaurants will adversely af- fect tourism have been used to argue against passing such ordinances. Data exist re- garding the validity of these claims. Objective To determine the changes in hotel revenues and international tourism af- ter passage of smoke-free restaurant ordinances in locales where the effect has been debated. Design Comparison of hotel revenues and tourism rates before and after passage of 100% smoke-free restaurant ordinances and comparison with US hotel revenue overall. Setting Three states (California, Utah, and Vermont) and 6 cities (Boulder, Colo; Flag- staff, Ariz; Los Angeles, Calif; Mesa, Ariz; New York, NY; and San Francisco, Calif) in which the effect on tourism of smoke-free restaurant ordinances had been debated. Main Outcome Measures Hotel room revenues and hotel revenues as a fraction of total retail sales compared with preordinance revenues and overall US revenues. Results In constant 1997 dollars, passage of the smoke-free restaurant ordinance was associated with a statistically significant increase in the rate of change of hotel revenues in 4 localities, no significant change in 4 localities, and a significant slowing in the rate of increase (but not a decrease) in 1 locality. There was no significant change in the rate of change of hotel revenues as a fraction of total retail sales (P =.1 6) or total US hotel revenues associated with the ordinances when pooled across all locali- ties (P =.93). International tourism was either unaffected or increased following imple- mentation of the smoke-free ordinances. Conclusion Smoke-free ordinances do not appear to adversely affect, and may in- crease, tourist business. JAMA. 1999;289:1911-1918 yielded similar findings for smoke-free restaurant ordinances in 89 cities in 6 states. 13-19 Despite tobacco industry pro- testations to the contrary, all the empiri- cal evidence supports the proposition that smoke-free restaurant ordinances do not hurt the restaurant business.20 As the tobacco industry's claims of adverse effects on the restaurant and bar business have lost credibility, it has ad- vanced a new economic argument against passing smoke-free restaurant ordinances: these ordinances will ad- www.jama.com versely affect tourism. In some places, the industry has claimed that tourism from countries such as Japan and Ger- many will be particularly affected. There is only 1 study of 1 city on the effects of a smoke-free ordinance on tour- ism." We identified 3 states and 6 cit - Author Affiliations: Institute for Health Policy Stud- ies, Department of Medicine, University of Califor- nia; San Francisco. Corresponding Author and Reprints: Stanton A. Glantz, PhD, Division of Cardiology, University of Cali- fornia, San Francisco, San Francisco, CA 94143- 0124 (e-mail: glantz®medicine.ucsf.edu). JAMA, May 26, 1999—Vol 281, No. 20 1911 SMOKE-FREE RESTAURANTS AND TOURISM ies in which opponents of clean in- trary to industry claims, these ordi- METHODS door air ordinances specifically nances were not associated with sig- We searched newspaper databases and advanced claims that the ordinance nificant drops in tourism. Quite the publications by tobacco industry groups would adversely affect tourism contrary, in several locales the ordi- (such as the National Smokers' Alli - (TABLE 12135) and obtained data on nances were associated with signifi- ante that was created for Philip Mor - tourism from the local authorities. Con- cant increases in tourism. ris Incorporated 36) and contacted Table 1. Predicted Effects of Smoke -Free Restaurant Ordinance on Tourism Made by the Tobacco Industry and Related Groups' Location On a larger scale, New York Stands to lose millions of dollars as the meetings and conventions that bring visitors Effective Date of Law Population-" (1989) Predicted Effect California Revenues of hotels and other lodging places create a significant number of jobs in California. If the proposed January 1, 1995 smoking ban is adopted by the state of California, some tourists, visitors, and convention delegates may travel . 29.760021 to other states or forgo traveling altogether. In particular, a smoking ban in California could reduce expenditures in the following way: • Reduced Domestic Out -of -State Tourism—Many travelers, visitors, vacationers, and businesspeople may choose not to travel to California San Francisco, Calif • Reduced Foreign Tounsm— Some foreign tourists, visitors, and business people may choose not to visit January 1, 1995 California. 723 959 • Reduced Conventions—Some groups may decide not to hold conventions in California. The expenditures of these consumers significantly contribute to California's economy: Potentia! Losses for Each 1 Percent Reduction in Foreign Visitor Expenditures, $31 017 51822 Utah Richard Davis, Salt Lake Convention& Visitors Bureau president, said his agency supported the concept of January 1, 1995 protecting nonsmokers from dangerous second-hand smoke in restaurants. But he said making Utah the first 1 722 850 state to enact such a ban would result in tourism losses, "Utah already is a leader in liquor control and abortion," Mr Davis said. Leading in restricting smokers would "have a negative effect on our tourism marketing efforts." Mr Davis warned passage of the bill could cost Utah $50 million in lost conventions right off the bat .23 Opponents—including the Tobacco Institute—say Utah's measure will burden public establishments by separating smokers and could damage Utah's tourism industry.24 Vermont Since the Vermont Clean Indoor Act took effect on July 1, 1995, owners have claimed sales losses between 3% July 1, 1995 562 758 and 30%. Members of the Vermont Business and Restaurant Coalition and the Vermont Lodging and Restaurant Association said the ban would reduce tourism, average restaurant tabs, and sales overall23 Boulder, Colo After a ferocious campaign to defeat the measure, some bar and restaurant owners said the ban would slash their November 14, 1995 business and drive smoking customers out of town. Some said they likely would go out of business., 83 312 Flagstaff, Ariz Vote Yes on Proposition 310 ... to protect tourism revenues (estimated $150 million annual economic impact to June 18, 1993 45 857 Flagstaff from tourism!)?' This could be a great loss for Flagstaff. Tour groups won't return, guests will never come to Flagstaff again.28 Los Angeles, Calif "Forget about loss of local business: that's bad enough," Richard Schilling, general manager of Hotel Sofitel Los July 26, 1993 Angeles, says. "What about tourism receipts?" The throngs of European visitors who flock to LA annually will 3 485 398 instead fly south to Florida if they can't smoke while they dine, he says. "And were not the only ones who are going to get.hurt: These tourists take cabs, rent cars, and shop in local boutiques," 11e adds?` "Since implementation of the ban in January 1995, 46.2% of the California restaurants surveyed reported lower gross sales receipts while only 15.5% reported higher gross sales receipts," states Barbara Boultinghouse, a KPMG Peat Marwick LLP manager who coordinated the survey. "The reported losses of this magnitude are devastating to California's hospitality industry."30 Mesa. Ariz Tom Lauria, spokesman for the Tobacco Institute, a tobacco manufacturing industry trade association, said he December 20, 1996 expects local hospitality and restaurant associations to mount the defense against the initiative. "If they're not 288 091 already well organized, they will be once they gauge the economic impact."3' Chaos is the only word to describe what is happening in Mesa, Ariz. Business owners felt the economic blow immediately. Restaurant and bar owners are losing customers to nearby communities where smoking is still allowed, and one restaurateur cited the ban as the reason he went cut of business. A convention has changed its meetinq site from Mesa.w New York, NY On a larger scale, New York Stands to lose millions of dollars as the meetings and conventions that bring visitors April 10. 1995 from all over the world take their business and vacations elsewhere. New York today has over 25 million visitors 7 322 564 every year. Tourism is a $14 billion industry. This helps support our city. it means jobs. Other big cities that compete for this business will be very giad<to see this smoking ban pass.3" New York has over 25 million visitors ayear. Tourism is a $14 billion industry. But if this bill passes in its present form, tourists will steer clear of a city so harshly intolerant of smokers. The bill would encourage many smokers, tourists and residents aiike, to abandon restaurants altogether in favor of bars and cabarets, where smoking would not be restricted.34 San Francisco, Calif The hospitality industry as a group is and has long been one of the largest employers in San Francisco. However, January 1, 1995 the current recession, combined with the aftereffects of the 1989 earthquake, has caused nearly every restaurant and hotel to cut their staffing drastically. The jobs are scarce; t!1e job/labor peol ratio have reduced 723 959 some wages to the lowest levels in 4 years. Any attempt to restrict activities of our patrons wculd reduce the traffic in our restaurants. Not only do the hardworking operators lose but their employees lose as well (Golden Gate Restaurant Association, written communication, February 13. 1992). -All data are direct quotes from.resl3ec:irve Sour=. 1912 )AMA, May 26, 1999—Vol 281, No. 20 SMOKE-FREE RESTAURANTS AND TOURISM Table 2. Data Sources' Location hotel Revenuefrotai Retail Data International Tourism Consumer Price Index Califomia California Travel Impacts by County, prepared for the A Market Profile of Overseas West urban Division of Tourism, Cafrforria Trade and Commerce Visitors to California (1996), Agency, California Travel Spending and Related Division of Tourism, Calitomia Impacts, Travel Spending by Type of Business, Trade and Commerce Agency, Accommodations (CY 1987-1997)36 March 199837 Taxable Sales in California (Sales & Use Tax), statewide the 240 largest cities, by type of business, retail stores taxable sales, by type of business, retail stores totals, prepared by the California State Board of Equalization (CY 1986-1997, second quarter) 38t* Equalization (CY 1986-1997, second quarter)38# Utah Gross Taxable Retail Sales, Services & (Use Tax) Purchases "International Visitation to Utah, US city average in Utah, prepared by State of Utah Tax Commission, 1990-97," provided by Division OBS 19, Services, Hotels & Lodging (7011-7041) of Travel Development, US (CY 1990-1997) Department of Commerce, (CY 1989-1997)"§ Tourism tndusthe09 Gross Taxable Retail Sales, Services & (Use Tax) Purchases in Utah, prepared by State of Utah Tax Commission, Gross Retail Sales and Purchases Total (CY 1990-1997) Vermont State of Vermont, Department of Taxes, M&R Statistics, Northeast urban gross (taxable) rents, grand total, prepared by State of Vermont Department of Taxes (FY 1988-1997) State of Vermont, Department of Taxes Sales Statistics, gross sales, grand total, prepared by State of Vermont Department of Taxes (FY 1988-1997) Boulder, Colo Accommodations Tax Revenue, prepared by City of Denver, Boulder, and Boulder, Finance Division (CY 1990-1998)§ Greenley, Cob Sales and Use Tax Revenue Report, retail sales tax, pr eP arad by City of Boulder finance director, revenue collection supervisor, and budget director for acting city manager, May 1998 (CY 1990-1998)40§ Flagstaff, Ariz City of Flagstaff BBB Sales History, hotels/campgrounds, West urban sk prepared by City of Flaostaff (CY 1988-1998) IP Retail Sales Report, prepared by City of Flagstaff (CY 1988-1998) Los Angeles, Transient Occupancy Tax Revenue, prepared by City of Los Los Angeles, Riverside, Calif Angeles, Office of the City Clerk, Tax and Permit Division and Orange County, (FY 1988-1997)§ California Taxeb:e Sales in California (Sales & Use Tax), taxable sales in the 240 largest cities, by type of business, retail stores totals, prepared by the California State Board of Equalization (CY 1986-1997, second quarter)38# Mesa, Ariz Summary of ,Total Transient Occupancy Tax Revenue, West urban prepared by City of Me€u Tax & Licensing Administrator (CY 1989-1997)"§ Sales Tax Revenue Information, prepared by City of Mesa Tax & Licensing (FY 1990-1998)§ New York, NY NYC Hotel Tax Collections by Quarter, prepared by New New York City Visitor Statistics, New York, northern New York City Department of Finance, Office of Tax Policy prepared by New York City Jersey, Long Island, (FY 1989-1998)§ Convention & Visitor's Bureau12 Connecticut, and Pennsylvania NYC Sales Tax Collections by Quarter, prepared by New York. City Department of Finance, Office of Tax Policy (FY 1989-1998)§ San Francisco, Annual Report, business tax section, statistical activity, hotel San Francisco, Oakland, Calif tax collection, prepared by San Francisco Treasurer/Tax and San Jose, Calif Collector (FY 1989-1997)43.44§ Taxable Sales in California (Sales & Use Tax), taxable sales in the 240 largest cities, by type of business, retail stores totals, prepared by the California State Board of Equalization (CY 1986-1997, second quarter)t United States National Accounts Data, Gross Domestic Product by industry in Current Dollars, 1987-1991 and 1992-1997, line 62: Hotels and other lodging places, US Department of Commerce Bureau of Economic Anatysis451 "CY indicates calendar year FY, fis al year. tAdded quarterly figures to obtain annual results. $Added quarterly figures to obtain FY rssults. §Revenues caicu'Xed based on tax receipts and tax rate. ¶Fiscal -year results by averaging 2 relevant CYs. JAMA. May 26, 1999—Vol 281. No. 20 1913 SMOKE-FREE RESTAURANTS AND TOURISM tobacco control advocates in volun- tary health agencies, nonsmokers' rights groups, and health departments to iden- tify localities in which the issue of effect on tourism was raised in the debate over clean indoor air ordi- nances. We then identified those local ordi- nances and state laws that required 100% smoke-free restaurants. (An ex- emption for the bar area of a restau- rant did not disqualify a smoke-free res- taurant ordinance from our study, so long as the eating areas were smoke- --------------- Table 3. Change in Hotel Revenues After Passage of Smoke -Free Restaurant Ordinances' - Slope Change, y-' Mean Location Value Slopes SE 95% Cl P R� 1997 Dollars, Millions California 7386 291 t 145 -43 to 625 .08 0.78 Utah 369 12.75 t 4.85 0.28 to 25.22 .05 0.99 Vermont 200 7.18 t 4.76 -4.08 to 18.44 .18 0.48 Boulder, Colo 3 -0.107 t 0.067 -0.240 to 0.026 .12 0.89 Flagstaff, Ariz 4 -0.286 t 0.038 -0.361 to -0.211 .001 0.97 Los Angeles, Calif 549 47.2 t 14.6 12.7 to 81.7 .01 0.77 Mesa. Ariz 8 2.07 t 0.65 0.78 to 3.36 .002 0.81 New York. NY 488 85.5 t 15.3 54.4 to 116.6 .001 0.71 San Francisco, Calif 797 49.9 t 26.0 -13.7 to 113.5 .10 0.83 California 6437 Current Dollars, Millions 252 t 129 -45 to 549 .09 0.96 Utah 307 16.23 t 4.69 4.17 to 28.29 .02 0.995 Vermont 207 3.43 t 3.52 -4.90 to 11.76 .36 0.94 Boulder 3 -0.060 t 0.066 -0.191 to 0.071 .36 0.90 Flagstaff 4 -0.285 t 0.042 -0.368 to -0.202 .001 0.96 Los Angeles 483 28.2 t 14.8 -6.8 to 63.2 .10 0.42 Mesa 8 2.27 t 0.69 0.90 to 3.64 .001 0.82 New York 440 77.4 t 12.3 52.4 to 102.4 .00 0.86 San Francisco 724 42.6 t 23.7 -15.4 to 100.6 .12 0.94 California Fraction of Hotel Sales to Total Retail Sales, % 3.45 -0.080 t 0.057 -0.211 to 0.051 .21 0.92 Utah 1.97 -0.058 t 0.039 -0.158 to 0.042 .20 0.50 Vermont 1.49 -0.034 t 0.031 -0.107 to 0.039 .31 0.68 Boulder 2.28 0.037 t 0.069 -0.100 to 0.174 .60 0.78 Flagstaff 3.99 -0.389 t 0.038 -0.464 to -0.314 .001 0.96 Los Angeles 2.83 0.122 t 0.049 0.006 to 0.238 .04 0.55 Mesa 1.90 0.262 t 0.114 0.036 to 0.488 .02 0.79 New York 2.75 0.264 t 0.069 0.124 to 0.404 .001 0.73 San Francisco 12.89 -0.589:t 0.506 -1.827 to 0.649 .29 0.59 Pooled Califomia 2.43 0.054 t 0.038 -0.128 to 0.020 .16 Hotel Revenues Divided by National Hotel Revenues (Normalized) 1.037 0.150 t 0.020 0.104 to 0.196 .47 0.997 0.32 Utah 1.080 0.005 ±.016 -0.036 to 0.046 .75 0.90 Vermont 1.786 0.026 t 0.031 -0.047 to 0.099 .43 0.95 Boulder 1.656 -0.119 t 0.016 -0.160 to -0.078 .001 0.99 Flagstaff 4.595 -0.479 t 0.061 -0.628 to -0.330 .001 0.91 Los Angeles 0.663 0.057 t 0.015 0.020 to 0.094 .01 0.94 Mesa 1.322 0.311 t 0.047 0.190 to 0.432 .001 0.98 New York 1.058 0.140 t 0.067 -0.024 to 0.304 Ub U.40 San Francisco 4.638 0.122 t 0.151 -0.247 to 0.491 .45 0.13 Pooled 1.979 0.011 t 0.012 -0.013 to 0.035 .93 0.99 •C1 indicates oonwence interval 1914 JAMA, May 26,1999 -Vol 281, No. 20 free.) Smoke-free restaurant ordi- nances and their effective dates were confirmed with local health depart- ment officials. This process yielded the 3 states and 6 cities that met the crite- ria for 'inclusion in the study outlined earlier. Because hotel revenue data for Aspen, Colo, were not available pre- dating passage of its ordinance in 1985, we could not include it, leaving 6 cit- ies for analysis (Table 1). We used revenues from hotel rooms as our measure of tourism. Data on ho- tel revenues were obtained from the ap- propriate authorities (TABLE 237"6). We analyzed the hotel revenues directly and in constant 1997 dollars using the ap- propriate seasonally unadjusted all - items consumer price index. We also analyzed hotel revenues as a fraction of total retail sales, similar to the analysis we did in our studies of res- taurant revenues .1-12 Analyzing hotel revenues as a fraction of total retail sales accounts for underlying economic con- ditions and inflation. In our earlier studies,"-" we com- pared restaurant revenues in similar control cities that did not have 100% smoke-free restaurant ordinances. Rather than doing a locality -by - locality matching, in this study our comparisons against control are done by comparing hotel revenues in the study localities with hotel revenues for the entire United States. We followed this approach because, unlike our ear- lier study, there was often not a natu- ral match to the study cities and states or, when there may have been a logi- cal match, the "control" locality did not have available data or had a smoking - restriction ordinance in place that pre- vented it from qualifying as a control locality. Comparing revenues in the study localities with the United States as a whole controlled for the overall health of the tourist industry. The issue of impact of smoke-free or- dinances on international tourism was raised in California, Utah, and New York City (Table 1). We obtained data on the numbers of international tour- ists for California, Utah, and New York City (Table 2) and analyzed the ef- 11 SMOKE-FREE RESTAURANTS AND TOURISM fects of the ordinance on the number the law went into force. The dummy cording to L = 0 if no ordinance and of tourists over time. The dependent variable L quantifies the presence of a L =1 if an ordinance is in effect. For the variable was the hotel revenues in the smoke-free restaurant ordinance ac- period in which the ordinance goes into study locality divided by total US ho- tel revenues for the same year. To fa- cilitate comparisons between locali- Table 4. Number of International Tourists in Thousands` m ties, this ratio was normalized by 1989 Slope Change, y-' population for each locality (Table 1) Tourist Home Mean No. Slope: SE 95% Cl P R' divided by the US population California (248 709 873) from the 1990 cen- Germany 481 -32 f 25 -89 to 25 .23 0.79 sus. ' Data were analyzed with linear Japan 929 117:t 45 14 to 220 .03 0.51 regression: y = ba+ b,t + bL(t - tlaw) Utah L + 1b;Si where y indicates the depen- Germany 115 -25 s 13 -59 to 8 .11 0.48 dent variables in TABLE 3 and TABLE 4; Japan 19.8 7 t 3 -1 to 16 .07 0.65 t, time to represent the underlying secu- New York City lar trend; L, a dummy variable that in- Europe 2248.6 230± 41 116 to 345 .005 0.95 dicates whether a smoke-free restau- Asia 766.1 37 :t 55 -117 to 191 .54 0.75 rant law is in force; and ti.., the time 'CI indicates confidence interval. Figure 1. Hotel Revenues Before and After Implementation of the Ordinance • 10096 Smoke -Free Ordinance in Effect 9000 California B00 Los Angeles, Calif 800 Utah o Smci<e-Free Ordinance Not in Effect • 750 — Prediction of Reg, --cion Mode! 8500 700 700 8000 650 0 600 ° ° 600 ° 7500 0 0 550 o • c o ° 500 • • 5lp 7000 450 • 6500 400 400 c 350 60o0 350 300 1986 1988 1990 1992 1994 1996 1998 1986 ?988 1990 1992 1994 1996 1998 19M 1%8 1990 1992 1994 1996 1998 10 0 25 Mesa, Ariz 220 Vermont 800 New York, NY n � ° 20 210 ° 700 • `o • 15 600 ° o r c l o� i h 200 0 o .•. 10 1k 500 ° • iAw c�� 190�Q5 ° 400 °• o» °oo 7 V o ° a 0 180 3o0 B 1986 1968 1990 1992 1994 1996 1998 1986 1988 1990 1992 1994 1996 1998 1986 1988 1990 1992 1994 19% 1998 8 Boulder, Colo 1000 San Francisco, CaW • 8 Flagstaff, Ariz ` • 7 9 / 7 6 900 / 6 q¢ i }• f�` 5 ° • 5 850I •'i Il �li ° ° �• f # 1 4 � ; a 3 �� IF% 800 3 2 c JJ • • 750 ° ° 2 • • • d o 1 700 ° 1- 0- 650 0- 1986 1988 1990 199.2 1994 1996 1998 1986 1988 1990 1992 1994 1996 1998 1986 1988 1990 1492 1994 1996 1998 Year Year Year Hotel revenues in constant 1997 dollars for the 3 states and 6 cities with smoke-free restaurants included in this study. Significant changes in slope (P<.05) occurred for Utah, Los Angeles, Mesa, New York City, and Flagstaff. JAMA, May 26, 1999—Vol 281, No. 20 1915 SMOKE-FREE RESTAURANTS AND TOURISM Figure 2. Annual International Tourists and Effect of Smoke -Free Ordinances 7400 California 3000 New York City 160 Utah '00 1200 C• • 2500 140 120 0 • • n 1000 ° 0 Japan• °o---�� 2000 • Europe* 700 ° Gennarry 800 0 ° 1500 80 . 600 0 0 �,--�v'—° 60 o 400 0 1000 • • 40 m p 0 Germany 500 ._ ° Asia ° Japan 200 20 0 0 0 p 1986 0 p 1988 1990 1992 1994 1996 1998 1986 7988 1990 1992 1994 1996 1998 1986 1988 1990 1992 1994 1996 1996 Year Year Ye r Annual visitors from Japan (or Asia) and Germany (or Europe) to 3 locales where the effects of smoke-free restaurant ordinances on international tourism were an issue. The years in which 100 % smoke-free bar ordinances were in effect are shown as solid points. Asterisks indicate significant changes in slope. Figure 3. Reactions of European and American Smokers to Smoke -Free Ordinances in Restaurants 100 L2 Continue to Eat Co.1 just as Frequently 2 Eat Out L1.83 Frequently 0 Stop Eating Out A survey done by Philip Morris Incorporated in 1989 demonstrated that European smokers were more accept- ing of smoke-free regulations than were Americans. Source of the data was the Minnesota Tobacco Litigation Depository (Bates No. 2500147496).' effect, L is set to a value between 0 and 1 that corresponds to the fraction of the period that the ordinance was in force. The term bL (t - tla,,.)L models the ef- fect of the smoke-free law as a change in the slope of tourism revenues or vol- ume over time. This approach differs from our earlier work, which modeled the effect of the ordinance as a simple intercept change. We found that mod- eling it as a slope change consistently gave better fits to the data than an in- tercept change model; the results ob- tained with an intercept change model were qualitatively similar to those pre - 1916 JAMA. May 26. 1999 --Vol 281. No. 20 sented in this article using the model above. For locations where data were available more frequently than annu- ally (ie, quarterly or monthly), we also included a dummy variable, Si, to al- low for seasonal variability. The esti- mate of the coefficient b, quantifies the annual rate of increase (or decrease) in the dependent variable y each year. The coefficient b,. quantifies the magni- tude of the effect of the ordinance on the rate of change over time of the de- pendent variable. For hotel revenues as a fraction of re- tail sales and normalized locality hotel revenues divided by total US rev- enues, we also conducted a pooled analysis with the equation above by adding effects -coded dummy vari- ables to code for between -locality ef- fects. The pooled analysis was done us- ing annual data for all localities. A change is considered statistically sig- nificant when PG.05. RESULTS Table 3 and FIGURE 1 present the results for total hotel revenues over time before and after implementation of the law. In terms of constant 1997 dollars, the smoke-free law was associated with a significant increase in the rate of growth of hotel revenues in 4 localities, no sig- nificant change in 4 localities, and a sig- nificant slowing in the rate of increase of hotel revenues in 1 city (Flagstaff) where revenues tended to flatten out. Analysis of hotel revenues in current dollars or as a fraction of total retail sales (Table 3) yielded similar results. Pooled across all localities, there was no sig- nificant change in the fraction of hotel revenues as total retail sales (P = .16). The smoke-free law was associated with no significant change in the rate of growth of hotel revenues compared with the United States as a whole in 5 locali- ties, a significant speeding in 2, and a sig- nificant slowing in 2 localities (Table 3). Pooled across all localities, there was no significant change in the rate of change of hotel revenues compared with the United States as a whole (P=.93). FIGURE 2 and Table 4 show the changes in the number of tourists from 2 11 Japan (or Asia) and Germany (or Eu- rope) associated with implementation of the California, Utah, and New York City smoke-free restaurant ordi- nances. The implementation of the or- dinances was associated with a signifi- cant increase in the rate of change of tourists from Japan to California and from Europe to New York City. The other trends were not significantly af- fected by the ordinances. The regressions for Flagstaff and Mesa, Ariz, exhibited significant Durbin -Watson statistics, indicating the presence of serial correlations in the re- siduals. We attempted a variety of al- ternate models using functions of time, changes in the intercept term associ- ated with the ordinance, or interac- tions between the seasonal variables and the presence of the ordinance. None of these approaches substantially changed the value of the Durbin -Watson statis- tics. Figure 1 suggests that the signifi- cant Durbin -Watson statistic for Flag- staff is due to a period of rapid hotel building between 1989 and 1993; the rate of change in hotel revenues be- fore and after this period (which in- cludes the time covered by the smoke- free ordinance) were similar. For Mesa, the significant Durbin -Watson statis- tic is due to the disproportionate sea- sonal increase in business following implementation of the smoke-free or- dinance. COMMENT This study debunks the tobacco indus- try allegation that smoke-free restau- rant laws adversely affect tourism, in- cluding international tourism. Quite the contrary, implementation of these laws is often associated with an increase in the rate of growth of tourism rev- enues. In the pooled analysis, the or- dinances had no significant effect, one way or the other, on tourist revenues as a fraction of total retail sales or com- pared with the rate of change in the United States as a whole. The cities and states included in this study represent a wide.range of geographic locations and types of tourist destinations, a fact that increases the confidence one can SMOKE-FREE RESTAURANTS AND TOURISM have in the generality of the results. The result that smoke-free restau- rant ordinances did not hurt, and may have helped, international tourism was surprising because of the commonly held belief that Europeans are more willing to tolerate secondhand smoke and less supportive of clean indoor air regula- tions than are Americans. Secret re- search conducted for Philip Morris In- corporated in 1989, however, shows that this belief is incorrect.' Philip Morris polled 1000 people in each of 10 Euro- pean countries and found that smokers were more accepting of smoke-free res- taurant ordinances than were Ameri- cans (FIGURE 3). In our analysis of smoke-free restau- rant ordinances, we include Boulder, Colo, which permits the construction of a separately ventilated smoking room. While the Boulder Environmen- tal Enforcement Office has not done a formal survey, they reported that "ac- tual use" of such separate smoking rooms is rare. We also included Flag- staff and Mesa, cities that allowed for the application of hardship exemp- tions or exceptions. The Flagstaff County Health Department reported that no such hardship exemptions have been granted. As of August 1998, the City of Mesa Code Compliance Office cited 73 (3.5%) of 2080 businesses (in- cluding smoke shops) that were granted such exceptions. Our results are based on aggregate data, not results from in- dividual businesses. As a result, we can- not exclude the possibility that some es- tablishments experienced gains in business that exactly offset losses in other businesses. At the same time, no data have ever been published to sup- port this possibility. In any event, it is the aggregate data that are necessary to test the tobacco industry's hypothesis that business is severely depressed by these laws. Food -service workers enjoy the least protection from secondhand tobacco smoke of any employee group." Leg- islators and government officials can enact such health and safety require- ments to protect patrons and employ- ees48 in restaurants from the toxins in secondhand tobacco smoke without the fear of adverse effects on tourism. Indeed, these ordinances may even be beneficial for business. Funding/Support: This work was supported by Na- tional Cancer Institute grant CA -61021 and a gift from Edith and Henry Everett. Acknowledgment: We thank Jeremiah Paknawin- Moch, MS, for,his comments on the manuscript. REFERENCES I. US Environmental Protection Agency. Respira- tory Health -Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: US Environ- mental Protection Agency; 1992. Document EPA/ 600/6-90/006F. 2. Office of Environmental Health Hazard Assess- ment Health Effects of Exposure to Environmental To- bacco Smoke. Berkeiey: California Environmental Pro- tection Agency; 1997. Available at: http:// www.oehha.org/scientific/ets/finalets.htm. 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Tob Control. 1997;6:199-206. n n A simoaLIJ v a 3 _ �.;? :; • X �>:?. °mss° 18 O all 3a Q 00 � OBJ Mon sm mm '4 Z 4 �8t E vl ism M�m mmm sy A simoaLIJ _ X A L* n C� so r is a. 00 1. k: a: CIo a ft 6 r r frr► i:: a;: pgeo CD CD CD r pgeo CD CD CD is a. 1. k: a: a r r frr► i:: a;: I g 2 � I California State Board of Equalization Report comparing taxable sales for 6,211 of the smallest bars and bar/restaurants in the state for 1999, compared to 1998, and 1998 compared to 1997. On January 1, 1995, California's Smokefree Workplace law (A.B. 13) took effect. The law delayed the startup of smokefree bars and nightclubs until January 1, 1997. (Historical note: Bars and nightclubs were included in the law at the insistence of the California Restaurant Association, which opposed any restaurant law that did not include bars and nightclubs.) Eighty-five percent of the bars covered are those in restaurants, with only 15% being "stand-alone" bars (i.e., those that do not serve meals). After A.B. 13 passed, the tobacco industry successfully promoted an amendment which delayed implementation of the bar/restaurant and nightclub provisions until January 1, 1998. They tried to delay implementation again, but were defeated. TABLE 1. STATEWIDE TAXABLE SALES, BY TYPE OF BUSINESS, 1999 TABLE 1. STATEWIDE TAXABLE SALES, BY TYPE OF BUSINESS, 1998 Taxable transactions Per capita - Number of I !Percent change !taxable transactions a/ Type of business I permits on Amount Percent ! from I July 1. 1999 [(in thousands) Iofr total year to year 19981999 ;Eating places: no alcoholic beverages i 42,744 j - 13,352,181 3.72 I 7.31 377.46! 398.64 Eating places: beer and wine i �i i i Eating places: no alcoholic beverages F 43,796 14,358,620 FF3.64 7.5 398.64 j^j 421. !Eating places: beer and wine F 19,212 FF -8,273,362F 2.16 i 8.81 i 227.07 243.08 ;Eating and drinking: all types of liquor 10,84i[ 9,8r 24,624 2.49 ! j 8.1 271.34-i 288.65 j Eatingand drinkin group gg p 73,850 32,456,606 8.22 j 8 0 jv-- ��F: 897.06 ! 953.60 TABLE 1. STATEWIDE TAXABLE SALES, BY TYPE OF BUSINESS, 1998 Taxable transactions Per capita ;Number of j ---� Percent change itaxable transactions a/ ^i - Type of business permits on i Amount !Percent! from �!July 1 1998 (in thousands) i of total year to year 1997 ; 1998 ;Eating places: no alcoholic beverages i 42,744 j - 13,352,181 3.72 I 7.31 377.46! 398.64 Eating places: beer and wine I 19,385 j 7,605 613 I Ir2.12 6.1 j I 217.50 1 227.07 !Eating and drinking: all types of liquor __ ,-_ F2.53 10,780 9,688,234F2.53 5.1 262.34 271.34' ::Eating and drinking group i ��^i ; 72,90_971730,46,028 ; 6.3 857.29 ; 897.06 . Jan -21-02 02:39pm From -OOH ENVIROMENTAL HEALTH ME CLINICAL INVESTIGATION 8085864368 T-548 P.03/10 F-311 Ryo Otsuka, MD ffirovuki Watanabe, 2)1D Kumiko klirsta, MD Kotaro `I'oktai, MD Takashi Xuro, MD 1'Iinoru XoshiXama, MD Kx pthide Takeuchi, MD Juniohl Yoshikawa, MD ,Dw- ASSB1r; SMOKING MAS BEEN EDEN- tified as an important risk fac- tor for cardiovascular dis- eme." In 1992, site American bleart Association concluded that the risk of death due w heart disease is increased by about 30% among those exposed to environmental tobacco smoke at hoarse, Context Recent studies have shown that passive smoking is a risk factor for ische- mic heart disease and may be associated with vascular endothelial dysfunction. The acute effects of passive smoking on coronary circulation in nonsmokers are not known. Objective To determine the acute effects of passive smoking on coronary circula- tion using coronary flow velocity reserve (CFVR), assessed by noninvasive transtho- racic floppier echocardiography. Ves*n, Setting, and Par#icipantsii Cross-sectional study conducted from Sep- tember 2Q00 to.November 2000 among 30 <apariese men (mean age, 27 years; 15 healthy nonsmokers and 15 asymptomatic active smokers) without. history of hyper- tension, diabetes mellitus, or hyperiipiderna- Alllaiio Outcome Measurw Coronary flow velocity reserve, calculated as the ratio of hyperemic to basal coronary flow velocity induced by intravenous infusion of aden- osine triphosphate and measured In each participant before and after a30 -minute ex- posure to environmental tobacco smoke. Resvlta Heart rate and blood pressure responses to adenosine triphosphate infusion were not affected by passive smoking exposure in either group. Passive smoking ex- posure had no effect on basal coronary flow velocity in either group, Mean (SD) CFVR in nonsmokers was significantly higher than that in active smokers before passive smok- ing exposure (4,4 {0:91 } vs 3.6 [0, 1313}, respectively; P.42), while CF1/Ed after passive and could be much higher in those smoking exposure did not differ between groups (Pm,83). Passive smoking exposure exposed at the workplace, where higher significantly reduced mean (SD) CFVR in nonsmokers (4.4 [0,91} vs 3.4 {0.731, re - levels of environmental tobacco smoke ihis pectively, P<.001). may be present.' Thera: is evidence thatonegaeslons Passive smoking substantially reduced CFVR in healthy nonsmokers. exposure of nonsmokers to environ- finding provides direct evidence that passive smoking may cause endothelial dys- mental tobacco smoke breaks down the serum antioxidant defenses' and is asso- ciated with imvainnent of endothelium - dependent function of arterial wells.' However, the acute effects of passive smolcing on the coronary circulation fn nonsmokers have not been evaluated. Coronary flow velocity reserve (CFVR), a measure of endothelial func- tion in the coronary circulation, can be noninvasively measured in the left an- terior descending coronary artery (LAD) using tmnsthoracic Doppler ech- For editorial comment see p 862:, 436 JAMA, July 25. 2001—vol Z66, No. 4 function of the coronary circulation in nonsmokers. JAMA, 21107;286:436-447 ocardiography (TTM."" The pur- pose of this study was to determine the acute effects of passive smoking on coronary circulation using measure - anent of CFVR by TTDF. METHODS Subjeds We studied 30 healthy Japanese men (mean (SD} age, 27 (41 years) includ- ing 15 nonsmokers and 15 asyrnptorn- atic active smokers from September 2000 wavw.iama MM to November 2000. These subjects were recruited from the students of Osaka City Uniwmty Medical School. All were clhd- eally well and had no history of hyper- tension, -diabetes mellitus, hyperlipid- Author Affiliations. Department of Internal Medi- cine and Cardiology, Osaka City University Medical Scheol, Osaka, Japan. Con,aspanding Author circ@ Repdtntr: Hiroyuki Wa- tanabe. MD, Depamneotaf Imarrial Medkine and Car- (1l0logy, Osaka City Uri"emity Medical School, 1-4-3 ASahimatri Abeno-kv, Osaka City, Japan 545.8585 Wmad: watanabeGmed.asaka-cu.ac jp). Jan -21-02 02:39pm From -00H ENVIR0MENTAL HEALTH 8085864368 T-548 P.04/10 F-311 emia, or left ventricular hypertrophy (septal or posterior wall thickness at di- astole >12 mm). Nonsmokers lived in smoke-free homes, worked in smoke- free environments, and had no expo- snre to env rorunental tobacco smoke for more than 12 hours. Subjects were con- sidered active smokers if they regularly smoked at least 20 cigarettes per day; the average (SD) duration of smoking `vas 6.8 (2,T) years. Active smokers had re- frained from smoking formorethan 12 hours before this study in order to mini- mize effects of actate smoking on study measurements_ All subjects gave in- formed consent to the protocol, which was approved by the Committee for the Protection of Human Subjects in lie - search at Osaka City University Medi- cal School. Mead Sampling From all subjects, blood samples were taken into a hepatinizedsyringebyveni- puncturefor de p1mmacar- boxyhemoglobinoglobin level (fibco), total cho- lesterol, triglycerides, and high-density lipoprotein (HDL) cholesterol levels. Plasma Hbco level was determined by spectrophotoretetry as a parameter of exposure to passive smoking. PassWe Sertoklag After baseline hemodynamic and echo- cardiographic recording, all subjects spent 30 minutes in the smoking room (450 cm X 300 cm with a 250 -cm ceil- ing) in our hospital, When this room was used for the study, some individu- als who were not among the study par- ticipants visited to smoke on their own accord. The air concentrations of car- bon monoxide in the echocardio- graphic laboratory and smoking room were determined by averaging values measured every 5 minutes in each room using Indoor pollution Evaluating System Model IES -1000 (constant - potential electrolysis, Sibata Scientific Technology, Ltd, Tokyo, japan). Hemody namic AReasurements All subjects underwent heart rate and electrocardiographic monitoring con- tinuously and blood pressure measure- ment every 1 minute during echocar- diographic exata mations. we calculated mean arterial pressure and heart rate— blood pressure product as indices of car- diac ardiac work."" Comnatyy Fkm Veiaidty Reserve Measurements by TrDE Before and after passive stroking, we measured echocardiographic param- eters with a digital ultrasound system (Acuson Sequoia 512, Acuson Corpo- ration, Mountain View, Calif) using a frequency of 5 to 12 MHz (Doppler frequency, 3.5 MHz). For color Dop- pler flow mapping, the velocity range was set at=12 to* 25 cm/s. The color gain was adjusted to provide optimal imaging. The acoustic window was around the midclavicular litre in the fourth and fifth intercostal spaces in the left lateral decubitus position. The left ventricle was imaged in the long axis cross-section and the ultrasound beam was inclined laterally. Next, coronary blood flow in the distal por- tion of the LAIC was searched for under color Doppler flow mapping guidance. With a sample volume (1.5 or 2.0 mm wide) positioned on the color signal in the LAD, we recorded Doppler spectral tracings of the flow velocity by fast Fourier transformation analysis. Adenosine triphosphate16 was administered (140 pg/kg per minute) for 2 minutes to record spectral Dop- pler signals during hyperemic condi- tions_ All studies were continuously recorded on videotape and clips of stopped frames were also stored digt- tally on magneto -optical disks (230 MB) for subsequent off-line analysis. Coronary flow velocity was measured at baseline and at peak hyperemic con- ditions by tracing contours of spectral Doppler signals using the software incorporated m the ultrasound system. These measurements were made by the investigators who were blinded to the subjects' smoking status. Each parameter was averaged over 3 con- secutive cycles. Coronary flow velocity reserve was calculated as the ratio of hyperemic to basal coronary flow Velocity— S FASSWE SMOKING AND CIRCUI ATION Anaiy% Baseline characteristics including age, total cholesterol, triglycerides, and HDL cholesterol in the 2 groups at baseline were compared with the unpaired t test; P<.05 -was considered significant. To compare effects of adenosine rriphosphate administration and passive smoking, we used re- peated measures analysis of variance (ANOVA) for hernodya mic param- eters, the air concentration of carbon monoxide, Hbco level, coronary flow velocity, and CFVR over asfeaaosine tri - phosphate adminismatiorl before and after passive smoking. Where appro- priate, directed pairstise comparisons of individual groups were conducted using the unpaired t test. We used a paired r test for directed comparisons of passive smoking effect in each group. For all analyses, we used SAS software version 6.12 (SAS Institute, Cary, NO. lipid values are reported In conventional units, To convert total and HDL cholesterol from mg/dL to mmollL, multiply by 0.0259. To con- vert triglycerides from mg/dL to ramoi/i, multiple 0.0113. RESULTS sasefine chain docs Patient age did not significantly differ in nonsmokers and active smokers (mean [SDI, 27 [4j years for both groups; P=.82). Other baseline char- acteristics including heart rate, blood pressure, mean arterial pressure, and heart ram—blood pressure productwere also similar in nonsmoker` and active smokers (TASK I). Total cholesterol, triglycerides, artd HVL levels did not significantly differ in nonsmokers and active smokers (167 f 33 mg/dL vs 163 1431 mg/dl., ?=.78,,102 [351 mg/dL vs 90 (301 mg/dl., P=.53; and 56.1 (7.81 tng/dL vs 35.0 (13.51 mg/dL, P=.19, respectively). ilea wdynamics None of the subjects experienced any symptoms or had any electrocardio- gram change during either passive stroking or adenosine triphosphate administration. Possive smoking had JAMA, July 25,2001—Vol 286, No, 4 437 Jan-Z]-aZ oZ:39pm From -00H ENVIROMENTAL HEALTH 8085864368 T-548 P.05/10 F-311 PASSIVE SMOKING AND CIRCULATION Table 1. Hemodynamic Change Due to Passive Smoking' HR. beats/min SOP, mm Hg Dip, rum Ha MAP, mm Hg RPP Nonsmokers ®e?ore passive smoking 613?ethe 61-1 (8.3) 108.8 (10.6) 64.3 (7.3) 86-5(6.6) .... 5264.4 (7972) HyPerarnh 64.2 (9.6) 104.9 (10.2) 592 (8.7) 82.1 (8.7) 6267.9 (922.2) After PaWvo slttoldng �latara sea. PAS& fm�king Anter Passive Smoklrtg mine 61.8 (8.5) 110.2 (11.1) 62,3(5-9) 36.2 (8.1) 59280 (912,1) HWemmh- 64.2(9,S) 106.9 (12:0) 60.6 (6-0) 83.8 (8.5) 5380.2 ($90.6) F Value Smokers 9efam ria amoking nyperamr, 84,7 (10.6) 102.8 (11,41 58.8 00.3) 80,700A) 5251.1 (1271 After Passive smoklno 64.1 (10.5) 85.6 01.0) 5359,4 Hyperemia 5519 (11 2) 104-6 (10.5) 59.8 (8,8) 821 (9.4) - 5429,8 (1222.9) Rapearted til wunes ANCYVAt Group 197 ,46 87 Aamiva smoking ,20 .24 .78 .36 .13 Group x Pmm m smoking .34 >.90 .53 79 39 A�i3t>sklss .01 001 . <_001 <.001 .26 Group X adenosine A4 .tib ,fib ,32 Passive a,'t;e€:m X sderlosi * 21 .81 .24 .37 .36 T'wei°d£ arr*Km x y x adwtl t v 52 .91 .27 .43 .20 M- aft" pry WP, isle PMM" PmduCt (bats PW mhkfio x mm HA and Stood' 37.9 for vaeh s w, ars 1, 213_ CO M -Y.. as woon of Yom. no effect on hemodymmic parr meters including heart rate, blood pressure, mean arterial pressure, and heart rate - blood pressure product in each group (Table 1). 438 JAMA, July 25.2001 -Vol 286, No. 4 ,001 e,001 x.001 H®ca. CWbo w*mo-- Carbon MonoWde and Hbco Level The results of repeated measures ANOVA, analysis for carbon monoxide level in air and Hbco level in blood axe presented in TABLE 2. Carbon morox- idelevelinthe oldhgroom was higher don that in the echocardiographic labo- ratory for both non rokets axed active smokers. Them were sigeriflcant group, passive smoldng,'and interaction ef- fects on Nbco level over passive smok- ing between both ,groups. Before pas - Ave stnokasag the- Hboo 1cvd in the blood was siMni£ac t1y lower in nonsmokers than in active smok . Passive sraok- ing sigrdficandyincrtx Hbco level in nonmokers but did not significantly in- crease Hbco level in active smokers. Coronary flow Vel Coronary flow velociry could be ob- served at baseline and during hyper- emia in all subjects, dere was a signifi- cant interaction effect between the 2 Maps over adenosine tricphosphate ad- ministration before and after passive smolrang l`TABIE 3 omdFIGURz 1). Coro- nary flow velocity during hyperemia ire nonsmokers was significantly higher than that in active smokers before pas- sive smoking. This parameter was quite similar in the 2 groups after passive smoking,. Thus. CFVR in nonsmokers was sil nif candy higher than that in ac - atocaV-0X! 1- t,-bo-lorg Smoking Rooth. Cn, PPM Noes wkws 0,40 (0.21 6.02 (0188) 0,52 (0.1Ti �latara sea. PAS& fm�king Anter Passive Smoklrtg Nonvmci 0.24 (0.18) 1.67 (0.32) Smokers 2.49 (1.78) 2.67 (1.79) Repeated Meesums ANOVA F Value P Value 37.9 for vaeh s w, ars 1, 213_ CO M -Y.. as woon of Yom. no effect on hemodymmic parr meters including heart rate, blood pressure, mean arterial pressure, and heart rate - blood pressure product in each group (Table 1). 438 JAMA, July 25.2001 -Vol 286, No. 4 ,001 e,001 x.001 H®ca. CWbo w*mo-- Carbon MonoWde and Hbco Level The results of repeated measures ANOVA, analysis for carbon monoxide level in air and Hbco level in blood axe presented in TABLE 2. Carbon morox- idelevelinthe oldhgroom was higher don that in the echocardiographic labo- ratory for both non rokets axed active smokers. Them were sigeriflcant group, passive smoldng,'and interaction ef- fects on Nbco level over passive smok- ing between both ,groups. Before pas - Ave stnokasag the- Hboo 1cvd in the blood was siMni£ac t1y lower in nonsmokers than in active smok . Passive sraok- ing sigrdficandyincrtx Hbco level in nonmokers but did not significantly in- crease Hbco level in active smokers. Coronary flow Vel Coronary flow velociry could be ob- served at baseline and during hyper- emia in all subjects, dere was a signifi- cant interaction effect between the 2 Maps over adenosine tricphosphate ad- ministration before and after passive smolrang l`TABIE 3 omdFIGURz 1). Coro- nary flow velocity during hyperemia ire nonsmokers was significantly higher than that in active smokers before pas- sive smoking. This parameter was quite similar in the 2 groups after passive smoking,. Thus. CFVR in nonsmokers was sil nif candy higher than that in ac - Jan-ZI-OZ OZ:40pm From -00H ENV IROVENTAL HEALTH tive smokers before passive smoking (P=.02). whereas CFVR did not differ be- tween the 2 ,groups aft passive smok- ing (P=.83). Coronary flow velocity re- serve in nonsmokers was significantly reduced by pamive smoking (P<OM) (TABU 4 and. Fwum 2). � Our data revealed that temporary pw- sive smoking abruptly reduced CFVR in nonsmokers but did not affect CM in active smokers. This provides di- rect evidence of a harmful effect of pas- sive smoking on the coronary cimula- tion in nonsmokers. Cav9eg 8650st With Previous Studies Cigarette stroking is one of the major risk factors for cardiovascular dis- ease.",18'This may be the result of struc- tural19 or functional changes -'8-20 in the coronary artery produced by smok- ing. Some epidemiological studies have linked passive smoking to excess risk for atherosclerotic heart disease.' -I140 It is thought that some premature deaths of nonanaok,ers may be related to pas- sive stroking, with the majority of such dealt due to eff&4C ischmnizl '-;s Cel- ermajer et vF have shown that passive smoking is associated with dose- related im Nirment of endothelium - dependent dilatanon. of the brachial ar- tery in healthy young adults, Dilatation mediated by'brachW artery flow is en- dothelium -dependent, mediated by the release of niatc oxide. Although endo- thelial dysfunction in the brachial ar- tery appears to be well correlated with both coronary endothelial physiologi- cal function and the degree of coro- naryatherosclerosts, flow -mediated di- latation of brachial artery does not evaluate response of the coronary cir- culation directly. Rerun of CFVR by Passive Smaking in Nowmakers The predictive association of coro- nary endothelial function with clini- cal outcome of patients with coronary artery dim supports the concept that mdothclia3 function may serve as au in- tegrating index of overall coronary risk 8085864368 T-548 P.06/10 F-311 PASSIVE SMOKING AND CIRCULATION Table 3. Flow Velocity Data - Before Passive Smoking After Passive Smoking Nonsmokers, anis ft, 2p.2 (B 8' 20.7 L5.gl ! i pq em!e 88.6 (27.4) A-6.8 Ten smot<em, cm/s t�£QE+!inR 19 2 ($ O) 205 L4.6 Fiyperemse 87.1 (15.0) 0,7 04.61 Repeated Mo=ures ANOVA %,ma m mea as n10t n 1 -ti Vi• vor m anehaes..C/ = 1. ZB. ANOVA irKkcu_-,Ss ana� of vsA8slas, Figure 1. Doppler Trading of Left Anterior Descending Coronary Artery Fiona in 2 Subjects A] None A, it the rimsmoker. cosraseary flow velocity at breis+ did not ehanZo atwr pamve smoking, but coronary flora V91My during hypeseMa was reduced after.p ae smoking, S. In the srtx XW, cow.ary flow velocity at basdsw and during hyps-ma did not Change after p ire smoking.____ JAW, July 21, 2001—Vol Z86, No. 4 439 Jan -21-02 02:40pm From -DOH ENVIROMENTAL HEALTH 8085864368 PASSIVE SMOIGNG AND CIRCULATION Tablo 4- Coronary Flow Velocity Reserve' 906% arolwho as MM €star VM •Mothods" Wen Mr car tzr4Y.xr of oaronery kw veko rem. For et snaly- sm, dr = ,, 28, &NOVA irl' oe t?a ansrp*of voiatm �. Coronary Flown Velocity Reserve Values 044 • woresrts g{� 5.0 � SmeitaQ 3333¢5555 s,0 3.5 3.0 &M ;tip Data are mem (M). Qwary flow velocity MgMe (CFVw berg � srr v+as,artraAca?saiyiiigrier In rsonvroc 4as this h mercers, mcvt'Ydr, CWR af- terpar^, smoking-,Nwredidsigrrslreantiyinnon- smasts,but only !�; t4yamongsmokers. factor stress. Thus, assessment of coro- nary endothelial vasoreactivity may be an important diagnostic and prognos- tic tooi.26 Coronary flow reserve has been proposed as a parameter of physi- ological changes in the coronary cir- culation reflecting the function of large epicardial arteries and microcircula- tion.Y'i Impaired coronary flow re- serve has been suggested as a surro- gate measure of subclinical coronary atherosclerosis, providing an inte- grated measure of both vascular endo- thelial function and smooth muscle re- laxation." Recent studies have found a good agreement between CFVR as as- sessed with Doppler guide wire and the results of perfusion scintigraphy and positron emission tomography?0s1 Tanaka et a131 found that smoking a cigarette with a high nicotine content abruptly reduced CFVR. Sumidat et al" found that long-term exposure to envi- 44o )AMA, July zs, 2001—vol 286, No. a ronmental tobacco smokeimpaised ace- tylcholine -induced coronary artery di- latation, indicating coronary endothelial dysfunction. However, CXW has pre- viously been treasured only by invasive or semi. -invasive proceduresW7.28-W36 md few findings have been reported on the direct impact of passive smoking on coronary circulation in healthy non- smokers. CFVR can now be gneasured nownvasiveiy by TTDE,o-=" and good agreement has been found between CFVRas assessedwithTT'DiE and there - sults of Doppler guide wire ommina- tion jt Thus, CFVR measurement by TrDE has become a dh*ml tool for non - b vaslve and physiologicalassessment of coronary circulation. In this study, CFVR before passive smoking was lower in active smokers than in nommokers. This difference was also found in recent studies of CFVR in active smokers."-" Vauimann et al3s found that mean (SD) CFVR values in nonsmokers and active smokers were 4,55 (0.84) and 3.79 (0,60), respec- tively (P<.05). In. the present article, C in nonsmoketswas reduced to the same level as in active smokers after pas- sive -smoking. On the other hand, CFVR in active smokers was not significantly reduced by passive smoking The pres ent study is the first to demonstrate that passive smoking may have a stronger ad- verse effect on CFVR in nonsmokers than i active smokers. Environmental tobacco smoke in- cludes many toxic constituents, such as carbon monoxide, benzopyrene, and more than 4000 chemicals.' -9 One or some of these toxic constituents Wray in- jure njure the arterial wall."` Allred et al' T-548 PAT/10 F-311 fe nd that increased ! and �onwdde ie�-eT M U 5 Ort Terru exposure to pct: spa„, -refit ,. in more ��fs angina in - d!;5ease r n. In the present article, short -terns exposure to environmental tobacco smoke in- creased the level of HbCo in nonsmok- ers, but in active smokers no difference in libco was found before and after passive smoking. This may be one of the renons why passive smoking had a stronger adverse effect on CFVR in non- .9mokers than in active smokeas. We measured changes in coronary flow velocity, not rhariges in coronary blood flow. However, it has been re- ported that changes in coronary flow ve- locities itaduced by coronary vasodilata- tion closely reflect changes in coronary blood flow," Furiiieratom we c mmt ex- ;lude the possibility that some of the voi- unteersi31 thisswdyhad.epicardialcoro- nary artery disease, This may have been ruled out only with coronary angiogra- phy, the performance of which seemed ux:tjttstified in these as�vmptomaac vol- unweas. However, new of the subjects had hypertension, diabetes, hyperlipid- a, or a history of coronary cartery dis- ease. Thus, their clinical risk for coro- noy artery disease was considered low. A limitation in our study was that our design did not allow us to comment on long-term effects of passive smoking or the durationof the CFVR reduction af- ter passive smoking; thm effects may be worth testing in a large-scale trial, in healthy individuals without coro- y artery disease, reduction of CFVR can result from dysfunction of the coro- nary tnlcrocirculadom"-2' The present findings suggest that reduction of CFVR after passive smoking way be caused by endothelial dysfunction of the coro- nary circulation, an early process of ath- erosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbid- ity and mortality in nonsmokers. Author Contributions; Srudy concept 4041 design: Otsuka. Watanabe, Muro, Yoshiyama, Takewthl, Yo.hftwa. Acgpisi6on of darn: Otsuka, Watanabe, Hirata. Tokai. Coronary Flour Vokwity Reserve Moro Psvmsve Smoking After Passive Smoking Nons.nowrs 4-4(0.91) 3,4. (4.73) Smokers 3.6 (0,68), Repeated Memures ANOVA F Va)usr 3.3 (4:74) P Value Group 2.4 .14 Passive smotdng 69.7 <.001 Group x pmt,* snsolorQ 24,9 _ <.001 -- 906% arolwho as MM €star VM •Mothods" Wen Mr car tzr4Y.xr of oaronery kw veko rem. For et snaly- sm, dr = ,, 28, &NOVA irl' oe t?a ansrp*of voiatm �. Coronary Flown Velocity Reserve Values 044 • woresrts g{� 5.0 � SmeitaQ 3333¢5555 s,0 3.5 3.0 &M ;tip Data are mem (M). Qwary flow velocity MgMe (CFVw berg � srr v+as,artraAca?saiyiiigrier In rsonvroc 4as this h mercers, mcvt'Ydr, CWR af- terpar^, smoking-,Nwredidsigrrslreantiyinnon- smasts,but only !�; t4yamongsmokers. factor stress. Thus, assessment of coro- nary endothelial vasoreactivity may be an important diagnostic and prognos- tic tooi.26 Coronary flow reserve has been proposed as a parameter of physi- ological changes in the coronary cir- culation reflecting the function of large epicardial arteries and microcircula- tion.Y'i Impaired coronary flow re- serve has been suggested as a surro- gate measure of subclinical coronary atherosclerosis, providing an inte- grated measure of both vascular endo- thelial function and smooth muscle re- laxation." Recent studies have found a good agreement between CFVR as as- sessed with Doppler guide wire and the results of perfusion scintigraphy and positron emission tomography?0s1 Tanaka et a131 found that smoking a cigarette with a high nicotine content abruptly reduced CFVR. Sumidat et al" found that long-term exposure to envi- 44o )AMA, July zs, 2001—vol 286, No. a ronmental tobacco smokeimpaised ace- tylcholine -induced coronary artery di- latation, indicating coronary endothelial dysfunction. However, CXW has pre- viously been treasured only by invasive or semi. -invasive proceduresW7.28-W36 md few findings have been reported on the direct impact of passive smoking on coronary circulation in healthy non- smokers. CFVR can now be gneasured nownvasiveiy by TTDE,o-=" and good agreement has been found between CFVRas assessedwithTT'DiE and there - sults of Doppler guide wire ommina- tion jt Thus, CFVR measurement by TrDE has become a dh*ml tool for non - b vaslve and physiologicalassessment of coronary circulation. In this study, CFVR before passive smoking was lower in active smokers than in nommokers. This difference was also found in recent studies of CFVR in active smokers."-" Vauimann et al3s found that mean (SD) CFVR values in nonsmokers and active smokers were 4,55 (0.84) and 3.79 (0,60), respec- tively (P<.05). In. the present article, C in nonsmoketswas reduced to the same level as in active smokers after pas- sive -smoking. On the other hand, CFVR in active smokers was not significantly reduced by passive smoking The pres ent study is the first to demonstrate that passive smoking may have a stronger ad- verse effect on CFVR in nonsmokers than i active smokers. Environmental tobacco smoke in- cludes many toxic constituents, such as carbon monoxide, benzopyrene, and more than 4000 chemicals.' -9 One or some of these toxic constituents Wray in- jure njure the arterial wall."` Allred et al' T-548 PAT/10 F-311 fe nd that increased ! and �onwdde ie�-eT M U 5 Ort Terru exposure to pct: spa„, -refit ,. in more ��fs angina in - d!;5ease r n. In the present article, short -terns exposure to environmental tobacco smoke in- creased the level of HbCo in nonsmok- ers, but in active smokers no difference in libco was found before and after passive smoking. This may be one of the renons why passive smoking had a stronger adverse effect on CFVR in non- .9mokers than in active smokeas. We measured changes in coronary flow velocity, not rhariges in coronary blood flow. However, it has been re- ported that changes in coronary flow ve- locities itaduced by coronary vasodilata- tion closely reflect changes in coronary blood flow," Furiiieratom we c mmt ex- ;lude the possibility that some of the voi- unteersi31 thisswdyhad.epicardialcoro- nary artery disease, This may have been ruled out only with coronary angiogra- phy, the performance of which seemed ux:tjttstified in these as�vmptomaac vol- unweas. However, new of the subjects had hypertension, diabetes, hyperlipid- a, or a history of coronary cartery dis- ease. Thus, their clinical risk for coro- noy artery disease was considered low. A limitation in our study was that our design did not allow us to comment on long-term effects of passive smoking or the durationof the CFVR reduction af- ter passive smoking; thm effects may be worth testing in a large-scale trial, in healthy individuals without coro- y artery disease, reduction of CFVR can result from dysfunction of the coro- nary tnlcrocirculadom"-2' The present findings suggest that reduction of CFVR after passive smoking way be caused by endothelial dysfunction of the coro- nary circulation, an early process of ath- erosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbid- ity and mortality in nonsmokers. Author Contributions; Srudy concept 4041 design: Otsuka. Watanabe, Muro, Yoshiyama, Takewthl, Yo.hftwa. Acgpisi6on of darn: Otsuka, Watanabe, Hirata. Tokai. Jan -21-02 02:41 pm From -DOH ENVIR0MENTAL HEALTH 8085864368 T-548 P.08/10 F-311 Analysis and interpretation of data: Otsuka, Watanabe Drafting of the manuscript Otsuka, Watanabe, Hbafa. Tokai, Mauro. Critical swolon of the manuscript for important in- ze*ctvar contz-t Qtst:(9a, Watanabe, Hirata, Yoshi- yama, Talo" ch;,- Ywh*mwa. St WsticaJ taper Otsuka: Watanabs. Hirata. Adminlsf tve, .1t&=d, d,- ormatenallopport ot€ul a, Watana!aC, Hiram, Tokas, Mum - Steady supervision: Watanabe, Yoshiyama, Takeuchi, Yoshikawa. REFERENCES 1. Taylor AE, Johnson DC, Kaaemi H. Environmental tobacco srrokR wid rwdiovascular disaase: a post - Ion papa from the Count on Cardtaoimonary and Critical Care, Ar^ed%n beast Association. Circula- tion. 199 3E:E-70% 2. Wells AJ. Pam Wokog W a eatise of heart dis- tumn. I Am Coll Catdfa 1994 4;546.554. 3. Krfft H, Ser M_ f, Slrftger H. Passive smoking and a7dloYmmi!arftd Arch IrstemMer1.199St155:1942- 1948. 4. Glantz aA, Pan191ey W W. 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Trans- thoraew tivo- fimensionw high 3rquency (7.5 MHz) ultrasonic wsu4iaa9 on of the 2lstal left anterior coronary artery, J Am Coll Cartrol. 19$0:15=373- 3". 11. Kenny A, Shapiro I.M. Transthoracic high- fso uencyitvra-dirzraalienalcchowdia-raphy,Dop- pler and calor flair mappmg to determine anatomy ane# blood flow pattems M the distal (eft anterior de-, Eng coronary rarw y, Am I C'andtcl. 1993,5¢: 1265-120, 12. Kenny A. Wlsbey CR, Shapira LM. Measure- ment ofleft arttes{grdast lt(bigesto9laryawyflow veloades by transthoracic Doppler ultrasound. Am J Cardiol. 1994:73;1021-1022, 317t`-* . t'.enrty A, WJsbeyCR,Shaiairo uw, Proflies otooro- nary blood f9oW velaCtty in pntienfswith aorticstxnosis arxJ the efifect of vaMe rcWa�terte a transtt9orndc eefso- cardiographic study. 8r Hea.-f 1.'199'4:71:57-62. 14.: amid P, ManauiM P, Marzilli M, et ai. Coro- mary hamodynamics and myocardial metabolism dur- Aand after Pacing 9tr£'34 in rtOrMal humans. Am I pJrysial_ 19e^9.:257:E309-817. 15. Nagamand S, Cternin J, Kamm AS, ct at. Repro- 2utlbility of measurements of regtooai restktgand hy- peremic myocardial blood flow assessed with PET. J Nucl Med 1996;37:1626.1631 1i. SonodaS,Takeuchi M,NakashimaY,KurohvaA. Safety and optimal dose of Intracoronary adenosine 51-iriphosphats for the meawramcmtof coronary flow re•.*", Am J Heart- 1998,139:621.627, 17, Holbrook 1H, Grundy SM, Hen6ekens CH, Kan - net W8, Strong JP. Qgww1ssmoking and eardcovas- WW!laea es: a statement for health profmionals by a task force appointed by the steering committee of the Amerman Heart Association, Clradation. 13&4: 70:1114A -1117A, 15. Zeiher AM, Schachinger V, Minners I. Long- term cigarette smoking impairs endothellum- dependentcoronary arterial vasodriatorfunction. Cir- culation, 1995,92:1044-1100. 19. Folkov B. "Structural f=tar" in primary and sec- ondary hypertension. hypertension. 1990;16:89- 101. 21L RaJj L, Nagy), Jaimes E, Shultz P, DeMaster EG. Mv,72mnisms of cigamtbesmoke ladueed impairment of todotl3eiium dependeritmodulation of vaseulartone 4abSirecta. Clreulatton, 1"4:90(9"10:575. "10:575. 21. Zhu 84, Sun Y -P, Slavers RE, (serrberg WM, Cl&nsx SA, Parm(ey WW, PaMve smoking inure av9renmental atherowier is in cholesterokfed rab- bft J Am ColfCardioL 4393;21:225-232. 22. Penn A,SnyderCA.IMaiaponofsldestreamdgrs- rct4>; smoke accelerates deveiopnt(33tt of artenoos. rotico?aques,-CirartaVCA -1993;83$:1520.1825, 23. Penn A, Chen L-4,-nyderCA.,Inhalation at Ay -state sidestneam sm0kefrotn one cigarette pro- motes arteriomlerotic plaque development Clrcula- ttoM 1994:9071363-1347. X ;WeRS AJ, Art estimate of adu)tlnortality from pas- sive smoking. Environ tnt 1988;14:2+99.265_ 25, VarlMd K;Pasavesnl*ng and the risk of heart dif= e. /AMA,1992:267t94 "_ 26. Schiichinger V, Britten MO.7 iherAM. Pmgnos- 9e impact ofcoronaryvasodilatordysNrictlon on ad- verSe long-terht ou4Gomeof Coronary heart disam. 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Functional aw�emmentofCoronary arerys??n *byDopplerde- rived absolute a i¢ We." corrmy blood flow ve- bcItyresa-ve in o2mez arra v (9 3m) Tc M191 sPECr. 1.3eart 14;82:50:514. 82- Tanaka T. Oka Y, TaWAM 1, Sada T, Kira Y. Acute WNm" 0 nicotine cormrsra In rs.4dr ves on coronary flow velocity and coronary flow reserve in men. Am J Cardiol_ 1996;82;1275.1278. 33. Sumidt H, Watar;abe H, ttuglyama K, oligushl M, Matsumura T. Yasue H. Dolle pwsive smoking Im- pWr endodrellumAependent coronary artery cFbation In womeO J Am Coll Cardial. 1999;31;811.81 S. 34. Seller C, Hess OM, 8ucdh M, art al. influence of serum cholesterol and other coronary risk factors on asomodon of a, igiographk;My normal coronary ar- teries. Circulations, 1553;88 2139-2148. 35- NitiaribergA,VahnnslF,S8d%R,etal,impairment of Coronary vasa W ressrm acrd ACh -Induced com- rsery VaWd1!allon in d!at eWps#iq* w fth angtographi- n-malooronary artenirarldnomwleftventricu- Wilstofactunction.Dla$ 51933;42:1097-1025, 34. FrielleWorf J, S61er C. Y3trfmann P, et al. Nor- m*iraiion of abnayrlttaf coronary vasomotion by cal- dw AMAW..AS its patients with hypertension. Cir- +arla�Jo 3T. 6it5t tai T.,°lsya`r3c4SS.C:g.Y,etal. Noninvasive amwft- ofligrftaltW. rwlordesm4mgmro- n3ryMMYstamsiste _-v1Myftvvelocity reserve m#t2r3trocasdiography. Cir. ovlativrmt 1998I97:1n7-1%2. 31L KattfP_Wn PA, Gnus, -Paas xw T. DI Ter gW M, Scirdfets KP, LbscherTF, Caarici PG. Coron.-uyheartdis- q= in smo§x rs; vitamin C :mwt's coronary microcir- ulatory fUnctksrt. CirculaVm 2940;102:1233.1238. W. GJarr+_ SA. Parmley S° IN. P='ve smoking and slea:t disease; epidema ogg, pbys'sology, and bio- cherr9tstty. Circulation. 1991:93:1-12, 80. Allard EN, weim-ker=_R. cast fan OR, et al, Short- tm- sonthe ex- performa.ce of f' { With coronary artery d`ftt . N 6ngl J hied 1"P.321.1 426-1432, 41. Wilson ltf, s a<lg(;9tr DE, fes , PH, chillan WM, es all. TramisrminaIsL?R 3aEtsl8M,remorrtotcoro- nary artery blood flow v*'oc iy and vasoddator re- serve in amara_ GrruW44n, I M,,72 182 -92. JAMA, July 25, 2001 Vo( 286, No. 4 441 Environmental Tobacco Smoke Exposure Among Police Officers in Hong Kong I d3 Sx IDIIEIAAES OL7�EA�$fl iE>LE Eft.E R SITE !MAP Return to Context Few epidemiological studies have examined the Table of Contents relationship between chronic respiratory symptoms and exposure to environmental tobacco smoke (ETS) at work in adults, and none have shown clear dose -response relationships. Author/Article Information Objective To examine the respiratory effects of ETS exposure at home and at work among never -smoking adults. Design, Setting, and Participants Cross-sectional, self- administered questionnaire survey conducted in December 1995 and January 1996 among 4468 male and 728 female police officers in Hong Kong who were never -smokers. Main Outcome Measures Respiratory symptoms and physician consultation in the previous 14 days for such symptoms by presence and amount of ETS exposure at work. Results Eighty percent of both men and women reported ETS exposure at work. Significant odds ratios (ORs) for respiratory symptoms were found among men with ETS exposure at work (for any respiratory symptoms, difference in absolute rate, 20.4%; OR, 2.33; 95% confidence interval [Cl], 1.97-2.75; attributable risk, 57%) and physician consultation (difference in absolute rate, 4.5%; OR, 1.30; 95% Cl, 1.05-1.61; attributable risk, 23%). Trends were similar among women for any respiratory symptoms (difference in absolute rate, 15.4%; OR, 1.63; 95% Cl, 1.04-2.56; attributable risk, 39%) and for physician consultation (difference in absolute rates, 2.8%; OR, 1.45; 95% Cl, 0.87-2.41; attributable risk, 31 %). Positive dose - response relationships with number of coworkers smoking nearby and amount of ETS exposure in the work place were found. Conclusions This study provides further evidence of the serious health hazards associated with ETS exposure at work. The findings support a ban on smoking in the workplace to protect all workers in both developed and developing countries. I n AAA nnnn.no A.7CC 7c7 Page 1 of 2 http://jarna.arna-assn-org/issues/v284n6/abs/jlf9OOl3.html 1/20/2002 ,..r.! Y Vol. 284 No. 6, (UPREHT15SUE INDEXES PAS'kMIA ' ISSUES August 9, 2000 Lotter From Hong Kong PDF t?E THIS ARTICLE Environmental Tobacco Smoke Exposure Among Police Officers in Hong Kong See Related: A_u_thors' Articles J Tai Hing Lam, MD; Lai Ming Ho, PhD; Anthony J. Hedley, MD; Peymane Adab, MBChB; Richard Fielding, PhD; Sarah M. McGhee, PhD; L. Aharonson-Daniel, PhD Return to Context Few epidemiological studies have examined the Table of Contents relationship between chronic respiratory symptoms and exposure to environmental tobacco smoke (ETS) at work in adults, and none have shown clear dose -response relationships. Author/Article Information Objective To examine the respiratory effects of ETS exposure at home and at work among never -smoking adults. Design, Setting, and Participants Cross-sectional, self- administered questionnaire survey conducted in December 1995 and January 1996 among 4468 male and 728 female police officers in Hong Kong who were never -smokers. Main Outcome Measures Respiratory symptoms and physician consultation in the previous 14 days for such symptoms by presence and amount of ETS exposure at work. Results Eighty percent of both men and women reported ETS exposure at work. Significant odds ratios (ORs) for respiratory symptoms were found among men with ETS exposure at work (for any respiratory symptoms, difference in absolute rate, 20.4%; OR, 2.33; 95% confidence interval [Cl], 1.97-2.75; attributable risk, 57%) and physician consultation (difference in absolute rate, 4.5%; OR, 1.30; 95% Cl, 1.05-1.61; attributable risk, 23%). Trends were similar among women for any respiratory symptoms (difference in absolute rate, 15.4%; OR, 1.63; 95% Cl, 1.04-2.56; attributable risk, 39%) and for physician consultation (difference in absolute rates, 2.8%; OR, 1.45; 95% Cl, 0.87-2.41; attributable risk, 31 %). Positive dose - response relationships with number of coworkers smoking nearby and amount of ETS exposure in the work place were found. Conclusions This study provides further evidence of the serious health hazards associated with ETS exposure at work. The findings support a ban on smoking in the workplace to protect all workers in both developed and developing countries. I n AAA nnnn.no A.7CC 7c7 Page 1 of 2 http://jarna.arna-assn-org/issues/v284n6/abs/jlf9OOl3.html 1/20/2002 Environmental Tobacco Smoke Exposure Among Police Officers in Hong Kong A. Author/Article View _Full .._Text Information Author/Article Information Author Affiliations: Department of Community Medicine and Behavioural Sciences Unit, University of Hong Kong, Hong Kong. Corresponding Author and Reprints: Tai Hing Lam, MD, Department of Community Medicine, University of Hong Kong, Patrick Manson Building South Wing, 7 Sassoon Rd, Hong Kong, China (e-mail: hrmrlth.@hkucc.hku hk). Funding/Support: This study was supported by grants from the Hong Kong Police Department and the Hong Kong Police Training School, Hong Kong Government. Acknowledgment: We thank C. M. Wong, PhD, for research advice and assistance; A. S. M. Abdullah, PhD, J. Cheang, M. Chi, D. Ho, PhD, D. Kwan, K. W. Lee, and S. Ma for data processing and field work. Section Editor: Annette Flanagin, RN, MA, Managing Senior Editor. C 2000 American Medical Association. All rights reserved. SHORTCUT: Choose a Journal o� Page 2of2 http://jama.ama-assn.org/issues/v284n6/abs/jlf9OOl3.html 1/20/2002 .............................................................................. . ................................................................................... Waitress with lung cancer seeks to protect others by Elaine O'Connor / The Ottawa Citizen Ottawa (Ont) Citizen (2002-08-22) For 40 years, Ottawa waitress Heather Cross served her customers the daily special with a smile and a laugh. In return, her customers gave her generous tips, good conversation -- and lung cancer. Ms. Cross, a life-long non-smoker, worked 12 -hour days over four decades in hazy smoke-filled restaurants in Ottawa and Toronto, long before those cities' enacted smokefree workplace laws. The 57 -year-old has run plates back and forth in Moe's World Famous Newport Restaurant on Richmond Road for almost 15 years without a second thought. Until, on Aug. 1, she was diagnosed with advanced, inoperable lung cancer. A checkup in March led to the discovery that a large, deadly tumour had lodged in her left lung. Shortly afterwards, Ms. Cross launched a case to get workers compensation for what her doctors say is clearly a work-related injury. She hopes her claim, now with the Ontario Workplace Safety and Insurance Board, will lead to a provincial re-evaluation of workplace safety regulations to grant others in the restaurant industry greater protection. "I just want people to become a little more aware of what secondhand smoke can do," said the career waitress, who served her first table at Fran's Restaurant in Toronto when she was 17 years old. Her lawyer, Phillip Hunt, acknowledged the case might be an uphill battle, but feels the issues are clear-cut. "She never smoked a cigarette in her life," said Mr. Hunt. "That makes her a model example of exposure to secondhand smoke in a very smoky industry. When it comes to smoke of any consequence, the work environment was the source." Ms. Cross just started her first chemotherapy at the Ottawa General Hospital last week. It left her dehydrated from vomiting for more than 24 hours. Still, she isn't resentful. "I've come to terms with it," said the soft-spoken woman, touching a scar on her neck left by recent exploratory surgery. "I've done nothing to hurt anyone in my life, so I'm not worried about afterwards." Ms. Cross has been told she has 10 months to a year to live. In her will, she has authorized her lawyer to continue the case if she dies before it's completed. "You would think that someone at that point would go and spend their last few months in the happiest way," said Cynthia Callard, executive director of Physicians for a Smoke -Free Canada. "But she's really interested in having people understand how wrong what's happened to her is." The organization plans to support her by fundraising to cover lawyer's fees. The group hopes the Ministry of Labour will re -interpret labour codes to cover workers who are exposed to second-hand smoke. Currently, the province's Smoking in the Workplace Act protects workers by limiting smoking areas to less than 25 per cent of total floor space. The anti-smoking group argues the law offers little protection as smoke can infiltrate the entire area. Although the Ontario Occupational Health and Safety Act regulates workers' levels of chemical exposure, banning exposure to 26 "toxic agents" -- 17 of which are found in cigarette smoke -- the law does not apply to smoking. To date, no -smoking laws have been administered municipally, and then only recently, and not without a fight. Ottawa's no -smoking bylaw came too late for Ms. Cross. "When we brought in the bylaw, we were always very clear that the issue was public safety, but also workers' safety," said Dr. Geoff Dunkley, the city's assistant medical officer of health. "Her case is certainly an argument for the bylaw." Ms. Cross's daughter, siblings and co-workers are struggling to deal with their emotions. "I was devastated when she told me. She's a great lady and we love her like a sister," said Newport owner Moe Atallah. "She worked so hard for all those years for her retirement and now this. I hope to God she'll be okay." Robert Levy, one of the authors mentioned in the article below, has attempted to censor this article by making a veiled threat of legal action against the original author. While we have acceded to the author's request to have his name removed from the article, ANR stands by the full content of this article, which remains as originally written. We have the utmost respect for the truth and no respect for bullies, and will not stop speaking one to appease the other. Responding to Tobacco Industry Attacks on the Scientific'Evidence Linking Secondhand Smoke to Disease and Death July 19, 1999 THE SCIENTIFIC EVIDENCE OF SECONDHAND SMOKE AS A HEALTH HAZARD Contrary to what many people believe, and to what the tobacco industry would like people to believe, the scientific evidence regarding the health effects of environmental tobacco smoke (ETS) did not begin with the release of the Environmental Protection Agency (EPA) report in 1992. As early as 1975, there was evidence in the scientific literature that ETS was a cause of cardiac and respiratory disease. As early as 1986, the Surgeon General and the National Academy of Sciences concluded that secondhand smoke causes lung cancer. In fact, the entire 1986 Surgeon General's report was devoted to the harmful health effects of secondhand smoke. Thus, secondhand smoke has been known to be a health hazard for at least 24 years, and has been recognized as a carcinogen for at least 13 years. Based on recently uncovered industry documents, the tobacco industry had solid evidence of the carcinogenic nature of tobacco smoke as early as 1953, but failed to share this evidence with the scientific community or its customers. The EPA is not the only government body to declare secondhand smoke as a toxic and carcinogenic health hazard. Many other government agencies have concluded that secondhand smoke is a significant health hazard. These agencies include the Surgeon General, Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), Occupational Safety and Health Administration (OSHA), National Academy of Sciences, International Agency for Research on Cancer (IARC), and the National Toxicology Program. Thus, even if the EPA report had never been written, the scientific evidence that secondhand smoke is a deadly toxin and carcinogen would still have been overwhelming. In fact, the EPA report is basically inconsequential from a scientific standpoint. Without it, the scientific evidence for ETS being a deadly chemical is overwhelming. The report itself should have made little difference. It was clear in the scientific literature at least six years earlier that ETS caused lung cancer and 18 years earlier that ETS was a health hazard. The adverse health effects of ETS are not limited to lung cancer. It also causes asthma, respiratory infections, and heart disease. In fact, the annual number of lung cancer deaths caused by ETS is only 3,000, while the number of heart disease deaths each year in the U.S. is about 40,000 and the number of asthma attacks caused by ETS is between 200,000 and 1 million. Thus, in terms of the number of people affected, heart disease and asthma are more important consequences of ETS exposure than lung cancer. In summary, there are three things that must be understood about the science of the health effects of ETS: We have known for at least 24 years that secondhand smoke is harmful. The evidence for secondhand smoke being a severe health hazard goes back to the 1970s, and secondhand smoke was implicated as a cause of lung cancer as early as 1986 by both the National Academy of Sciences and the Surgeon General. 2. At least eight reputable government bodies, outside of the EPA, have concluded that secondhand smoke is a severe health hazard. 3. The health effects of secondhand smoke are not limited to lung cancer, but also include heart disease, nasal sinus cancer, asthma, and respiratory infections. THE TOBACCO INDUSTRY'S APPROACH TO ATTACKING THE SCIENCE In general, the tobacco industry's approach has been similar to the approach of a defense team in a criminal trial. With overwhelming scientific evidence against their client, the defense attorneys try to cast doubt in the minds of the jury by concocting all sorts of conspiracy theories to explain the evidence. Oftentimes, such attorneys are successful in putting enough doubt in the minds of the jurors to gain an acquittal. The tobacco industry has taken a similar approach. Its goal has been to pick out little pieces of the scientific evidence and attack them, trying to invoke some sort of conspiracy theory to put doubt in the minds of policy makers and the public. Most recently, the industry has focused on the EPA report, attacking it for being an example of corrupt science. In some cases, the industry's approach has been successful. Specific examples of the tobacco industry's approach include: • Filing a lawsuit against the EPA in the most favorable court it could find (in North Carolina) and convincing a judge (William Osteen) to rule that the EPA's finding that ETS causes lung cancer was invalid. Supporting the work of scientists who receive tobacco industry funding in return for writing critiques of the EPA and other scientific bodies that have found ETS to be harmful. Recently, Gio Gori and John Luik released a report (issued by the Fraser Institute in British Columbia) attacking the EPA and its report on ETS. Robert Levy and Rosalind Marimont released a report (issued by the CATO Institute) attacking the CDC and its estimate that smoking causes 400,000 deaths each year. All of these authors have strong connections to the tobacco industry. Gio Gori was paid more than $20,000 for writing letters to scientific journals and newspapers criticizing the EPA report. John Luik corresponded closely with the Confederation of European Community Cigarette Manufacturers in writine his critioues of the EPA. and went so far as to ask the industry for its advice as to how to properly frame his articles so as to best advance the tobacco industry's interests. Robert Levy works for the Cato Institute, which receives financial support from the tobacco industry and Rosalind Marimont is with the National Smokers Alliance which also receives tobacco industry financial support. (Note: Americans for Nonsmokers' Rights can provide copies of tobacco industry documents which reveal the details of these authors' ties to the tobacco industry.) EFFECTIVE RESPONSES TO THE TOBACCO INDUSTRY'S ATTACKS First, it is most important to know how not to respond. Do not get into arguments with the industry about the scientific evidence. This is exactly what the industry wants. It wants to draw public health practitioners into a debate. The industry does not have to win the debate; in fact, it knows it cannot win. But all the industry needs to do to succeed is to create a debate. This will cast doubt in people's minds and convince the public and policy makers that there is some sort of controversy or debate out there over the health effects of secondhand smoke. This is, of course, not at all true. There is no debate in the scientific community. But the perception of a debate or controversy may be all that is needed to sway policy makers against voting for clean indoor air legislation. Instead, the best approach is to expose the tobacco industry ties of the so-called scientists making the arguments. In almost every case, scientists who have challenged the finding that ETS is a significant health hazard have turned out to be allied with the tobacco industry. Most have received direct funding from the industry. With the help of the tobacco industry documents, databases like ANR's Tobacco Industry Tracking Database, and other sources, document and expose the connections between these "scientists" and the tobacco industry. Then go on the offensive. Point out how inappropriate it is to accept tobacco industry money for writing articles attacking the EPA. Point out how inappropriate it is for a scientist to ask the tobacco industry to help him write his scientific research to be sure that it properly promotes the industry's position. Point out how inappropriate it is for an industry to mislead and deceive the American public about the hazards of smoking and secondhand smoke. In other words, re -frame the issue. Instead of this being an attack on "corrupt science" by the EPA, turn the issue around into what it is really about: "corrupt science" by persons who have been paid to write articles attacking the EPA by an industry trying desperately to protect its deadly profits. Governing Board: American Cancer Society Hawaii Pacific, Inc. American Heart Association of Hawaii American Lung Association of Hawai 'i Cancer Research Center of Hawai 'i Hawaii State Department of Education Hawaii State Department of Health Hawaii Medical Association Hawaii Medical Services Association Wai'anae Coast Comprehensive Health Center Ko'olauloa Tobacco Free Coalition East Hawai'i Tobacco Free Coalition Kauai Tobacco Free Community Coalition .Woui Tobacco Free Partnership West Hawaii Tobacco Free Coalition Members -at -large: Fred Holsehuh, MD Mark Levin, JD Matt Matsunaga, JD Anthony Saguibo, JD Elizabeth Tam, MD Sandra McGuinness,Chair Coordinator, Maui Tobacco Free Partnership Kim Ku'ulei Bimie, Vice Chair Hawaii Primary Care Association Clifford Chang, MPH, CHES, Project Director Toni Ann S, 4_m xrN Grass Root., advocacy Coordinate> Beth Kuch Communications Coordinator Funded in part by the Robert Wood Johnson Foundation FREE HAwAili 245 N. Kukui Street, Suite 201 Honolulu, HI 96817 Tel: (808) 432-9117 Fax: (808) 524-9072 For More Info... Websites State of Hawaii Department of Health — www.state.hi.us/doh/index.htm] Centers for Disease Control and Prevention — www.cdc.gov World Health Organization — www.who.ch American Cancer Society — www.cancer.org American Heart Association — www.americanheart.org American Lung Association — www.lungusa.org Campaign for Tobacco -Free Kids — www.tobaccofreekids.org American Nonsmokers' Rights — www.no-smoke.org National Cancer Institute Tobacco Control Research Branch - dccps.nci.nih.gov/tcrb Foundation for a Smokefree America — www.tobaccofree.org -75 COALITION FOR ® TOBACco FREE HAWAVI NAVA I'I UEFAA TVEN OF June 7, 2002 Dear Restaurant Owner/Manager, Earlier this year, the Honolulu City Council, backed by overwhelming public support, passed a law to help protect restaurant patrons and workers from exposure to secondhand smoke. On July 1, 2002 all indoor restaurants on Oahu will become smoke-free, affording restaurant workers the same protection provided in other workplaces on Oahu since 1997 (nightclubs and stand-alone bars remain exempt). This law, which addresses a serious public health issue, directly results from growing scientific evidence about the dangers of tobacco smoke to non-smokers. The Coalition for a Tobacco Free Hawaii and the Hawaii State Department of Health are committed to helping restaurants in making the transition to smoke-free environments as smooth as possible. Enclosed are some materials that may help you implement the new law in your restaurant: • An overview and guide for restaurant owners/managers that answers some general questions about the new law and what it means for you. • A guide for restaurant patrons (in English and Japanese) designed to help educate your patrons on the new law. • A suggestion sheet with tips to help you successfully implement the new smoke-free restaurant law. • Table tents (in English and Japanese). One side is for display prior to the July 151 implementation, to help prepare your customers for the change. These tents are most effective when placed in areas of your restaurant where smoking is currently allowed --for example the bar areas and smoking sections. The other side of the table tent is for use once the law goes into effect on July 1, to designate your restaurant as smoke-free, and can be placed throughout your restaurant. • Smoke-free signs, which indicate your restaurant is smoke-free and in compliance with the City and County law. The new law requires restaurant managers and owners to place signs which meet specific design requirements. To help you comply, we have enclosed two signs to place in your restaurant, that meet these requirements. These signs should be placed in highly visible areas, such as the entrance or hostess area, to advise patrons that your restaurant is smoke-free. Additional copies of these materials are available by downloading them from <www.tobaccofreehawaii.org> or by calling 432-9150. We believe a smoke-free environment is a positive change your patrons and employees will appreciate. If you have any questions regarding the implementation of the new law, please feel free to contact us at any time. We look forward to working with you and are committed to helping you establish healthy, smoke-free environments for Oahu's restaurant patrons and employees. Sincerely, *Mlkl219P,12 I tI Sandra McGuinness Chair Coalition for a Tobacco Free Hawaii Tel: 432-9150 <www.tobaccofreehawaii.org> Bruce S. Anderson, Ph.D., M.P.H. Director of Health Hawaii State Department of Health Tel: 586-4613 <www.hawaii.gov/doh> 0 m � U W O O � O N U N � -0 O R1 O C � 3. _ U i �Wcolme to S",mokefree Dg ........................ ............................................................... ................................. ................................ ............................................................. . ............................................................................ ................................................................. . .................................................................................. Six1-5 Sug g9ge tions to Successfully One Month Betm Implementafmn, M - Talk with your �,,-t,,.-,"..,nmers a ,,oul'-- t -Ne law, �`Tcpal I - • Show clear suppW-br tf-ee_ Ia,,,iw- - Post signs. tomt.P" ........... - Train and inform your employees. • Use information about the r nQQ in tN- I • Make sure each employee - Employees sh- • hosts/Hostc5se_ If necessary, Niml terr2< • Waiters/Waltrc.vM{16 f -Have your employees V,5<tl{ t; <07' • What to say to custom�,.M-!�OM • "I'm sorry, butrcsla- nt*-,' But W -C 1.10 M 1 4 01 ;U:y M, M, • "In order to Protta'thM ht'alti of joining other Oahu restaurant, I� • "Can I bring you some coftz or ....... ................... ........................ ................. •What to do when the customzr IS !PM5,tCnt: ............. ............ -Stay calm. Be po€it • Call your supervi.50r. • Staff are not rcquinz-ad to risk M,# to take After Implementation, on 3. my lk - Remove all ashtrays. 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