Secondhand smoke is a mixture of gases and fine particles that includes smoke from a burning cigarette, cigar, or pipe tip, and smoke that has been exhaled or breathed out by the person or people smoking. Secondhand smoke causes heart disease and lung cancer in nonsmoking adults and several serious health conditions in children, and has immediate adverse effects on the cardiovascular system. Children who are exposed to secondhand smoke are at an increased risk for sudden infant death syndrome, acute respiratory infections such as pneumonia and bronchitis, middle ear disease, more severe asthma, respiratory symptoms, and slowed lung growth.
The 2006 Surgeon General’s Report on “The Health Consequences of Involuntary Exposure to Tobacco Smoke” systematically reviewed the scientific evidence on the health effects of secondhand smoke. The Report concluded that there is no risk-free level of secondhand smoke exposure and that eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from secondhand smoke. The recent 2010 Surgeon General’s Report on “How Tobacco Smoke Causes Disease” reaffirmed the conclusion that there is no risk-free level of exposure to tobacco smoke, and found that cigarette smoke contains at least 69 substances that cause cancer.
In December 2010, the Centers for Disease Control and Prevention, Office on Smoking and Health conducted an air quality monitoring study in CNMI to evaluate the impact of the Smoke-Free Air Act of 2008. The study measured fine particle air pollution levels from secondhand smoke in venues in which smoking is either permitted or prohibited. The study found that the average level of fine particle air pollution in venues where smoking was completely permitted at all times was considered “hazardous” by U.S. Environmental Protection Agency standards and was over 44 times higher than the level in venues where smoking was completely prohibited at all times. In venues where smoking was only permitted after 10 p.m., the average level before 10 p.m. was still considered “unhealthy for sensitive groups” by EPA standards.
These findings in CNMI reflect the 2006 Surgeon General’s Report’s conclusion that eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from secondhand smoke. Other approaches are not effective. The Report finds that separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate secondhand smoke exposure.
Comprehensive smoke-free laws have broad effects on population health. Research has shown that jurisdictions that have implemented smoke-free laws have experienced a reduction in heart attack hospitalizations ranging from 8 to 17 percent on average. In October 2009, the Institute of Medicine issued an independent report on secondhand smoke exposure, smoke-free policies, and their relationship to acute coronary events. The report, titled “Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence,” concluded that:
• The evidence is consistent with a casual relationship between secondhand smoke exposure and acute coronary events, including heart attacks.
• It is biologically plausible that a relatively brief exposure to secondhand smoke could trigger an acute coronary event.
• There is a casual relationship between smoke-free laws and decreases in heart attacks.
The World Health Organization 2008 “Report on the Global Tobacco Epidemic” lays out a framework called MPOWER for eliminating tobacco use and protecting people from tobacco-related disease and death. “Protecting people from tobacco smoke” is one of the six evidence-based tobacco control interventions that the WHO calls for implementing worldwide. The report concludes that “Once enacted and enforced, smoke-free laws are widely popular, even among smokers, and do not harm business. Only a total ban on smoking in public places and workplaces protects people from secondhand smoke and helps smokers quit.”
The 2006 Surgeon General’s Report also concludes, based on the findings of numerous peer-reviewed studies that have examined objective economic indicators such as employment levels and taxable sales revenues for restaurants and bars, that smoke-free policies, laws, and regulations do not have an adverse economic impact on the hospitality industry.
Today, the home and the workplace are the main settings where nonsmokers are exposed to secondhand smoke, and hospitality workers are especially likely to be exposed to high levels of secondhand smoke on the job. Smoke-free policies in hospitality venues such as restaurants, bars and casinos protect employees and patrons from the health effects of secondhand smoke. These policies are associated with improved indoor air quality and with reduced secondhand smoke exposure, reduced sensory and respiratory symptoms, and improved lung function in nonsmoking employees. These improvements occur within months after smoke-free policies are implemented.
In addition to protecting nonsmokers from secondhand smoke exposure, the 2006 Surgeon General’s Report finds that smoke-free workplace policies help employees who smoke successfully quit smoking. This would be expected to save employers money by reducing health care and disability costs, by increasing employee productivity through fewer breaks and sick days, and by reducing workers’ compensation, life insurance, and maintenance costs. The Guide to Community Services also concluded recently that policies and laws making workplaces smoke-free help smokers quit and reduce tobacco use. In addition, smoke-free policies promote health by contributing to changes in community attitudes regarding smoking and by setting a positive example for youth.
Over the past 20 years, in large part due to the widespread adoption of smoke-free policies, secondhand smoke exposure among U.S. nonsmokers has declined sharply.
As of January 1, 2011, 25 states and the District of Columbia have comprehensive laws in effect that prohibit smoking in most workplaces and public places, including restaurants and bars. Additionally, a number of U.S. territories, including CNMI and Puerto Rico, have adopted smoke-free policies that provide protections in workplaces, restaurants, and bars.
Secondhand smoke exposure poses serious health risks to residents and visitors in CNMI. And, unlike many other health hazards, secondhand smoke exposure is completely preventable. Substantial reductions in tobacco use and tobacco-related disease and death can be achieved by sustaining support for comprehensive, evidence-based tobacco control programs over time [16-21]. In combination with other evidence-based tobacco control interventions — including enacting 100 percent smoke-free laws, increasing the price of tobacco products, implementing media campaigns, and making cessation services available to all populations — adequately funded comprehensive state tobacco control can bring an end to the tobacco use epidemic.
TIM A. McAFEE, M.D., M.P.H.
Director, Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
Atlanta, Georgia
