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Chapter 6

ENVIRONMENTAL TOBACCO SMOKE

INTRODUCTION

Passive smoking has been the subject of intense scientific scrutiny for more than a decade. The aim of hundreds of medical studies has been to determine what, if any, adverse health effects can be attributed to inhaling the tobacco smoke given off by the burning ends of cigarettes, pipes, and cigars, or exhaled by smokers. Of particular concern to some researchers has been the one-half to two-thirds of all American children under five years of age who are exposed to cigarette smoke in the home.[1] A recent national survey indicated that 43 percent of children two months to eleven years of age live in homes with at least one smoker.[2]

These studies typically test the assumption that when nonsmokers inhale environmental tobacco smoke they are subject to the same chemicals inhaled by the 26 percent of the adult U.S. population that smokes.[3] Research has linked the habits of smokers -- who consume approximately one-half trillion cigarettes per year[4] -- to higher incidences of lung cancer, a host of cardiac problems, and myriad other health problems that cause some 434,000 deaths per year (roughly one in six American deaths).[5] The Congressional Office of Technology Assessment has estimated that the costs of smoking in 1990 were upward of $68 billion -- and this figure does not take into account the potential costs of passive smoking.[6]

In light of the sobering research results on active smoking, the findings of studies on passive smoking are of grave importance. While legislatures and the courts debate whether active smokers are personally responsible for the ill effects of their habit or if tobacco companies ought to share in the blame, few people would argue that passive smokers are responsible for the exposure they suffer involuntarily. This is particularly true for children, who are typically less able than adults to control their exposure to environmental tobacco smoke.

In 1992, the EPA conducted a comprehensive review of the scientific evidence collected over the past decade on passive smoking. Entitled Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders, this study concluded that environmental tobacco smoke (ETS) is a known cause of lung cancer in humans, a so-called Group A carcinogen.[7] The EPA report estimates that passive smoking causes approximately 3,000 lung cancer deaths among nonsmokers each year,[8] and that children exposed to environmental tobacco smoke are more likely to suffer an increased prevalence of respiratory symptoms such as coughing, sputum, and wheezing; an increased prevalence of middle ear effusions, or presence of excess fluid in the middle ear; a small but statistically significant reduction in lung function; exacerbation of asthma and long-term lung deficiencies (e.g., cystic fibrosis); and increased prevalence of lower respiratory infections including pneumonia, bronchitis, and bronchiolitis.[9] Preliminary evidence from other studies has linked smoking by mothers to the heightened presence of carcinogens in the blood of their children[10] and an increased incidence of sudden infant death syndrome (SIDS).[11] A more recent assessment of the health effects of environmental tobacco smoke by CalEPA in 1997 confirmed the findings of the EPA's earlier report and, based on new studies, found that ETS increases the risk of SIDS and induces asthma in children.[12]

Despite this flood of data, a number of crucial questions remain unanswered, chief of which is the precise nature of the long-term health effects of juvenile passive smoking as these children grow to be adults, and whether these effects include the kind of cancer and cardiopulmonary risks associated with active smoking. What remains clear, however, is this: cigarette smoking is the leading known cause of avoidable death in the United States.

Citizens need to seek remedies to safeguard the health of their families in the face of the threat of environmental tobacco smoke at home and in public. Toward that end, this chapter describes scientific research on the health effects of passive smoking on children, suggests measures that concerned parents and others can take, and identifies model programs and local solutions that have worked throughout the nation.

Hazards Of Environmental Tobacco Smoke

Active Smoking

Nearly 180,000 deaths from cardiovascular disease were caused by active smoking in 1990.[13] Such deaths come about because constituents of cigarette smoke damage the inner lining of blood vessels, leading to the development of arteriosclerosis. The smoking of a single cigarette can profoundly disturb blood flow to the heart in patients with existing coronary artery disease.[14] Cigarette smoking is the leading cause of pulmonary illness and death in the United States; in 1990 alone, smoking caused more than 84,000 deaths from lung disease, mainly resulting from such problems as pneumonia, emphysema, and bronchitis.[15]

Passive Smoking

Passive smoking -- sometimes called involuntary smoking -- happens when one breathes the mixture of smoke given off by the burning end of tobacco products (sidestream smoke) and smoke exhaled by smokers (secondhand smoke). This mixture, a Group A carcinogen, is what comprises environmental tobacco smoke. Environmental tobacco smoke contains some 4,000 substances, more than 40 of which are known to cause cancer in humans or animals , such as benzene, nickel, polonium-210, 2-napthylamine, 4-aminobiphenyl, formaldehyde, various N-nitrosamines, benz[a]anthracene, and benzo[a]pyrene. Other chemicals present in tobacco smoke -- such as carbon monoxide, nitrogen oxides, ammonia, and hydrogen cyanide -- are strong irritants that can cause a variety of serious cardiac and pulmonary diseases.[16]

Although environmental tobacco smoke is dilute compared with the mainstream smoke inhaled by active smokers, it is chemically similar, containing many of the same carcinogenic and toxic agents.[17] What's more, no safe threshold level of exposure to the toxicants in tobacco smoke has been found.[18]

The first major report on the health effects of passive smoking came out in 1986, when the National Research Council and the Surgeon General concluded that environmental tobacco smoke could cause lung cancer in nonsmokers, as well as increased respiratory problems and decreased lung function in children of parents who smoke.[19] Using sets of data approximately twice as large as what was available in 1986, the EPA released a report in late 1992 which concluded, among other things, that environmental tobacco smoke was carcinogenic and otherwise harmful to the lung function of nonsmokers.[20]

Special Vulnerability of Children

To understand the special risks associated with passive smoking, particularly for children, it is necessary to understand how the lungs work. Infants and children are generally more susceptible to disease brought on by exposure to air pollutants than all otherwise healthy groups in the population, with the possible exception of elderly people, and this susceptibility is well supported by scientific research. A detailed discussion of this greater susceptibility can be found in the Chapter 4.

According to the National Research Council and the Surgeon General, infants and young children whose parents smoke are among the most seriously affected by exposure to environmental tobacco smoke, being at increased risk of lower respiratory tract infections such as pneumonia and bronchitis.[21] The EPA estimates that environmental tobacco smoke is responsible for between 150,000 and 300,000 lower respiratory tract infections in infants and children under eighteen months of age annually, resulting in between 7,500 and 15,000 hospitalizations each year. Children exposed to secondhand smoke are also more likely to have reduced lung function and symptoms of respiratory irritation such as coughing, excess phlegm, and wheezing.[22] There is also evidence that upper respiratory illnesses and acute middle ear effusions may have long-term consequences on linguistic and cognitive development.[23] In April 1997, the Committee on Environmental Health of the American Academy of Pediatrics concluded that children's exposure to environmental tobacco smoke is associated with increased rates of lower respiratory illness, middle ear effusion, asthma, and SIDS, and may be associated with the development of cancer during adulthood.[24]

Impairment of Lung Development

Evidence suggests that children exposed to environmental tobacco smoke both prenatally and postnatally may suffer a slower rate of increase in lung function as they grow up.[25] The EPA states that prenatal and early postnatal passive smoking alters the structural and functional properties of the lung, thereby increasing the likelihood of severe complications to viral respiratory infections contracted early in life.[26] The most recent review of scientific studies reports that while the studies are not wholly consistent, childhood exposure to ETS affects lung growth and development as measured by small but statistically significant decrements in pulmonary function tests. These reductions may persist into adulthood.[27]

Respiratory Tract Infections

Passive smoking causes from between 150,000 to 300,000 lower respiratory tract infections annually, including cases of bronchitis and pneumonia in small children and infants under eighteen months of age.[28] Some 7,500 to 15,000 of these cases require hospitalization.[29] A 1996 study attributed 136 to 212 deaths nationwide from acute lower respiratory illness in children under eighteen months each year to ETS.[30] Exposure to environmental tobacco smoke at home has been causally linked to coughing, excess phlegm, and wheezing as well as more serious lower respiratory tract infections such as bronchitis and pneumonia.[31] In the case of pneumonia, the Surgeon General concluded that children whose parents smoke had between 20 and 40 percent greater risk of hospitalization for severe bronchitis and pneumonia during their first year of life.[32] There is also solid evidence suggesting that passive smoking exacerbates respiratory symptoms in older children who are already predisposed to such symptoms.[33] A new study demonstrates that older children exposed to ETS in their homes are more susceptible to acute respiratory infections than unexposed children.[34] ETS can also increase the risk of acute and chronic middle ear infections. One study estimated that 700,000 to 1.6 million physician office visits for middle ear infections each year were associated with ETS exposure.[35]

Childhood Cancer

While the 1992 EPA report concludes that environmental tobacco smoke is a Group A carcinogen, causing 3,000 annual cases of lung cancer in adults, the EPA makes no conclusion about the cancer risks to children who are exposed to environmental tobacco smoke. This is not because the scientific evidence disproves the potential cancer risk, but rather that insufficient evidence has been collected. There are other reports, however, suggesting that prenatal exposure to cigarette smoking may be a risk factor for cancer in children. In one study, published in the American Journal of Epidemiology, parents' tobacco smoking prior to birth was associated with an increased risk of all childhood cancers.[36] The epidemiological data are not sufficient at this time to make conclusions regarding the role of ETS in childhood cancer.

Asthma

Tobacco company advertising and information campaigns have often attacked the 1992 EPA report, claiming that concern over the agency's claim that passive smoking causes lung cancer is overblown. But, as Harvard Medical School epidemiologist Julie Buring has stated, the tobacco companies rarely address the most obvious effects of ETS, which, she says, are on asthmatics.[37] The data collected by the EPA about the ways in which passive smoking affects asthma sufferers are alarming. An estimated two to five million children under eighteen years of age are afflicted with asthma, and acute respiratory illnesses in general are among the leading causes of morbidity, or disease, and mortality during infancy and early childhood. Therefore, even small increases in the individual risk for these illnesses -- such as the risk posed by passive smoking -- can have a substantial impact upon public health.[38] The EPA estimates that passive smoking worsens the asthma cases of 200,000 to 1,000,000 children.[39] The EPA has estimated that 8,000 to 26,000 new cases of childhood asthma each year are attributable to ETS exposure from mothers who smoke ten or more cigarettes per day.[40] In addition, there is conclusive evidence that children of smoking mothers require more frequent emergency room visits and need more medication for their asthma than do children of nonsmoking mothers.[41]

Women and Smoking

There are two ways in which the children of mothers who smoke can become passive smokers: during pregnancy, as tobacco's chemicals are absorbed in the womb, and after delivery, when children can inhale their mothers' secondhand smoke. These facts are noteworthy because, as a group, women younger than twenty-three years of age comprise the fastest-growing segment of smokers in the United States. Smoking reduces fertility and has been linked to excessive bleeding during pregnancy and lower birth weights in infants.[42]

Some 5,000 infants die of sudden infant death syndrome (SIDS) annually in the United States; it is the major cause of death in infants ages one month to one year. The exact causes of SIDS are still unknown, but it is thought to be a result of respiratory malfunction. Currently, there is strong evidence that infants whose mothers smoke are at increased risk of SIDS. This relationship is independent of all other known risk factors for SIDS, including low birthweight and low gestational age. However, until recently, studies did not allow differentiation as to whether this increase is a function of in utero versus postnatal exposure to tobacco smoke. Several new epidemiological studies have demonstrated that postnatal environmental tobacco smoke exposure is an independent risk factor for SIDS.[43] Women who smoke during pregnancy are at greater risk of spontaneous abortion, premature birth, and SIDS in their infants.[44] A case-control study (200 SIDS cases and 200 controls) found that every measure of both prenatal and postnatal ETS exposure was associated with increased risk of SIDS.[45] The researchers estimated that 1,900 to 2,700 deaths from SIDS in the United States each year are associated with ETS.

Children of Color

While active, daily smoking has remained high among non-Hispanic white youths (22 percent in 1980 and 21 percent in 1991), information on long-term smoking trends among Hispanic and Asian youths is sparse.[46] In 1991, 12 percent of high school seniors who were Hispanic smoked daily. Small increases and decreases in smoking rates have occurred among all teens as a group over the years, but the prevalence of smoking among the young has remained basically unchanged since 1980. Furthermore, a statistically significant increase of 1.8 percent in daily smoking from 1992 to 1993 has concerned public health officials. A bright spot in this otherwise dim picture is that daily smoking among African-American teenagers has declined dramatically from 16 percent in 1980 to 4.4 percent in 1993, according to surveys of high school seniors.[47] The reasons for this decline are unclear.

Sources of Exposure

Because of the large number of smokers and the subsequent widespread presence of environmental tobacco smoke, the risk of contracting a tobacco-related illness is a significant threat to the entire population.[48] Since smokers comprise approximately 26 percent of the U.S. adult population, and these people consume an average of about one and a half packs per day, nonsmokers are subject to nearly universal exposure from environmental tobacco smoke.[49]

The health threat of passive smoking is suggested by the presence of tobacco-related chemicals in the bloodstreams of a large percentage of nonsmokers, according to the EPA. Cotinine, a metabolite of the tobacco-specific compound nicotine, acts as a biomarker of tobacco smoke uptake. This substance has been detected in 50 to 75 percent of reported adult nonsmokers. Fifty percent equates to 63 million U.S. nonsmokers, age 18 or older.[50]

This figure does not take into account the large number of U.S. children who also are passive smokers. Several studies have confirmed the exposure and uptake of environmental tobacco smoke in children by assaying saliva, blood serum (fluid that separates from clotted blood), or urine for cotinine. These cotinine concentrations were highly correlated with smoking (especially by the mother) in the child's presence.

Relatively light exposure to environmental tobacco smoke still raises grave health concerns. According to a study published in the Journal of the National Cancer Institute, mothers who smoke only ten cigarettes a day cause their children under five years of age to test positive for biological markers of cancer-causing compounds such as nicotine and polyaromatic hydrocarbons.[51] For instance, blood levels of the nicotine marker cotinine ranged from a mean of 0.25 nanograms per milliliter for children in homes where there was no smoking, to 0.87 nanograms per milliliter in homes with other smokers, to a mean of 4.14 nanograms per milliliter for children whose mothers smoked. While the children in the study are healthy now, these markers can be used for future long-term studies to determine the dose of environmental tobacco smoke that might cause cancer later in life.

Tobacco Smoking by Adolescents

Any evaluation of the effects of passive smoking must take into account the large number of minors who are active smokers. These children not only affect their own health, but also the health of the children around them who then become passive smokers. According to a report by the Institute of Medicine's Committee on Preventing Nicotine Addiction in Children and Youths, more than one million youths become regular smokers each year, and that these new smokers take an average of fifteen years off their lives, committing the nation's health care system to at least $8.2 billion in extra medical costs over their lifetimes.[52]

The 1994 report also found that most smoking begins during childhood and adolescence, and that nicotine addiction begins during the first few years of tobacco use.[53] Decades of research show that if people do not begin to use tobacco as youngsters, they are unlikely to pick up the habit as adults, making a youth-centered prevention policy central to any effective strategy for eliminating tobacco-related deaths and disease.[54]

In June 1997, forty states, public health groups, and tobacco companies reached a proposed agreement that called for the industry to pay $368.5 billion over twenty-five years to states for public health programs, to limit tobacco advertising and marketing, to set targets for sharp reductions in teen smoking, and to face penalties if those targets are not met. In return, the tobacco companies received broad protection from future lawsuits. Three months later, President Clinton called on Congress to rewrite the agreement with harsher penalties if teen smoking is not dramatically reduced and with unlimited regulation of nicotine by FDA. Congress must approve the agreement in order for it to take effect.

Children's Ingestion of Cigarettes and Cigarette Butts

Another source of exposure to tobacco is ingestion of cigarettes or cigarette butts by children. Most cases of nicotine poisoning in children result from ingestion of cigarettes. Each year, poison control centers in the United States receive thousands of reports of children ingesting tobacco products. Researchers at the Rhode Island Department of Health recently analyzed reported ingestions of cigarettes among children under the age of six in their state. For the cases where adequate follow-up information was available, the mean age of the child involved was twelve months, and 77 percent of the children were between the ages of six and twelve months. Ninety-eight percent of the exposures occurred in the child's home.[55] In Rhode Island, ingestion was associated with smoking in the presence of children and easy accessibility to tobacco products. This report provides additional evidence as to why parents should not smoke in the presence of children.

What you can do

The bad news is also the good news: cigarette smoking is the leading cause of avoidable death in the United States. What this means is that even though the ill effects of active and passive smoking are staggering, they can be reduced and even eliminated. The following are suggestions for what parents and others concerned with the health of children can do:

  • Don't smoke in your house or permit others to do so. Don't allow baby-sitters or others who work in your home to smoke in the house or near your children.
  • If an adult insists on smoking indoors, increase ventilation in that area: open windows or use exhaust fans. Adults should not smoke in automobiles with the windows closed if passengers are present. The high concentration of smoke in a small, closed compartment substantially increases the exposure of other passengers.[56]
  • Don't smoke if children are present, particularly infants and toddlers. They are particularly susceptible to the effects of passive smoking.[57] Adults should store cigarettes and other tobacco-related products out of the reach of children.
  • Every organization dealing with children should establish a smoking policy that effectively protects children from exposure to environmental tobacco smoke.
  • Find out about the smoking policies of daycare providers, preschools, schools, and other caregivers.
  • Help other parents understand the serious health risks to children from environmental tobacco smoke. Work with parent/teacher associations, your school board, school administrators, community leaders, and other concerned citizens to make your child's environment smoke-free.
  • Women should refrain from smoking during pregnancy, and if possible avoid smoke-filled areas.
  • Parents should clearly and unequivocally express disapproval of tobacco use by their children. Although the degree of parental influence on tobacco use by youths is not clear, the lack of parents' general concern about children's use of tobacco seems to increase a child's risk of using tobacco.[58]
  • Test your home for radon. Radon contamination in combination with smoking is a much greater health risk than either one individually.[59]

Model Programs and Local Solutions

By 1994, more than 600 ordinances were in place throughout the country restricting smoking. In fact, local action has been the single greatest weapon in the battle against passive smoking. According to the American Heart Association, forty-five states and the District of Columbia restrict smoking in public places in some manner.[60] These laws range from simple prohibitions such as those in West Virginia that cover public transportation and schools to laws in Minnesota that limit or ban smoking in virtually all public places, including elevators, public buildings, health facilities, public conveyances, gymnasiums and arenas, retail stores, and educational facilities. The most far-ranging clean indoor air laws include restaurants and private workplaces, such as in the State of New York. Of the states that limit or prohibit smoking in public places, forty-one restrict smoking in the public workplace and nineteen have extended those limitations to private sector workplaces.[61]

Local communities have also taken the lead in restricting the distribution of tobacco product samples. At least twenty-eight cities now prohibit the distribution of free tobacco product samples, for instance. Nineteen states and the District of Columbia, meanwhile, restrict the sale of tobacco products in vending machines.

Current Regulatory Framework

Since the Surgeon General first called the nation's attention to the health hazards of smoking in 1964, the prevalence of smoking among adults has declined from 40.4 percent in 1965 to 25.7 percent in 1991.

In 1971 the Surgeon General raised the possibility that secondhand smoke may cause disease in nonsmokers. That year, United Airlines became the first major air carrier to voluntarily separate passengers into smoking and nonsmoking sections. In 1972 the Surgeon General released a report stating that smoke can contribute to the discomfort of others, which spurred advocates to press for smoking restrictions on planes, trains, and buses. The following year, Arizona became the first state to pass a law prohibiting smoking in select public places, and the Civil Aeronautics Board ordered all domestic airlines to separate smokers and nonsmokers. In 1975 Alaska, Kansas, Minnesota, Texas, and New York enacted legislation restricting smoking. The Surgeon General then reported that the children of smokers are more likely to have bronchitis and pneumonia during their first year of life.

In 1976 California and Utah passed laws restricting smoking, as did the National Park Service, in the case of federally owned caves. Soon after, Health, Education, and Welfare Secretary Joseph Califano announced an antismoking campaign to restrict smoking to designated areas in all HEW buildings. In 1980 the General Accounting Office deemed smoking "a major indoor source of air pollution and potential cause of lung cancer," and called for the EPA to regulate smoking indoors. In 1985 the EPA and the U.S. Public Health Service asked the National Academy of Sciences to assess the risk of secondhand smoke. Congress asked the NAS to determine whether air quality on commercial planes is adequate. Florida, New Jersey, New Mexico, and Washington enacted smoking restrictions in 1985.

In 1986 the Surgeon General issued a major report concluding that secondhand smoke caused disease, including lung cancer, in healthy nonsmokers. The Surgeon General concluded that separating smokers and nonsmokers was not enough to eliminate the danger. The next year, Congress banned smoking on all airplane flights shorter than two hours; in 1989 it banned smoking on all domestic flights.

In December 1992 the EPA classified passive tobacco smoke as a human carcinogen.[62]

In 1994 Congress considered a bill to ban smoking in nearly all buildings except private clubs and restaurants; the bill failed. The Occupational Safety and Health Administration (OSHA) considered banning smoking in all workplaces that year, but no final rule has been released. In 1994 the tobacco industry also pushed a California ballot initiative that would repeal all local tobacco laws and replace them with a weaker statewide standard, but voters rejected it.[63] Pending Congressional approval, a 1997 historic agreement between tobacco companies and 40 states will reimburse states for tobacco-related health care costs and set goals to reduce teen smoking.

Reforms Needed

To date, passive tobacco smoke has been addressed primarily through local ordinances that ban smoking in public places. Nearly all the groundbreaking action on the dangers of tobacco smoke has come from federal government agencies, state legislatures, and local governments. Until recently, Congress has remained all but silent on the subject of the ill effects of tobacco smoke, secondhand or otherwise, and has in fact continually voted to support price supports for the production of tobacco. Congress should act rapidly to improve the pending June 1997 agreement between tobacco companies and states.

A committee of the Institute of Medicine has called for more aggressive measures to counteract the social forces that induce children and others to smoke. Its 1994 report recommended that Congress enact legislation that allows the Public Health Service to regulate the packaging and makeup of all tobacco products and to prescribe ceilings on tar and nicotine content. This committee also recommended a large increase in the federal excise tax on tobacco products and tougher regulation of tobacco advertising, sales, and promotion.[64]

Promotion of a tobacco-free social norm is critical to discouraging both adults and youths from using tobacco. Pro-tobacco messages, however, are particularly difficult to combat among children and youths. Even children ages six to ten can identify the images and slogans of popular brands of cigarettes.[65] The Institute of Medicine has spelled out actions that can be taken to foster a tobacco-free social norm throughout U.S. society:[66]

  • Congress should repeal the federal law that prevents state and local governments from regulating tobacco promotion, advertising, and labeling requirements within state borders.
  • Congress and state legislatures should eliminate all features of advertising and promotion of tobacco products that tend to encourage initiation of tobacco use among the young.
  • Merchants should be required to obtain a state license to sell tobacco products; this license could be suspended or revoked if the merchant sells tobacco to minors or violates other state and local laws designed to reduce access.
  • Mass media campaigns, including paid anti-tobacco advertisements, should be intensified to reverse the appeal of pro-tobacco messages, particularly to juveniles.
  • Tobacco-free policies should be adopted and enforced in all public locations, especially those that cater to or are frequented by children and youths, including all educational institutions, sports arenas, cultural facilities, shopping malls, fast-food restaurants, and transit systems.
  • Tobacco vending machines and self-service displays should be banned.
  • The distribution of free tobacco products in public places or through the mail should be banned.


Notes

1. U. S. EPA, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders, December 1992 , p. 1-13. R. Etzel, "Environmental Tobacco Smoke," Indoor Air Pollution, Vol. 14, August 1994, pp. 621-633.

2. Pirkle, J. et al., "Exposure of the US Population to Environmental Tobacco Smoke: The Third National Health and Nutrition Examination Survey, 1988 to 1991," JAMA, vol. 275, April 24, 1996, pp.1233-1240.

3. U.S. EPA, Respiratory Health Effects of Passive Smoking, pp. 1-11.

4. U.S. EPA, ibid.

5. U.S. EPA, ibid.

6. Lynch, B. and R. Bonnie, eds., Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, D.C.: National Academy Press, 1994.

7. U.S. EPA, Respiratory Health Effects of Passive Smoking, pp. 5-68

8. U.S. EPA, ibid, p. 1-1.

9. U.S. EPA, ibid., p. 1-5.

10. Perera, F. et al., "Biomarkers of Environmental Tobacco Smoke in Preschool Children and Their Mothers," JNCI, vol. 86, no. 18, September 21, 1994, pp. 1398-1402.

11. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 7-56.

12. CalEPA, "Health Effects Assessment of Environmental Tobacco Smoke - Final Draft for Scientific, Public and SRP Review," February 1997.

13. "The Medical Effects of Tobacco Consumption," Scientific American, May 1995, p. 49.

14. "The Medical Effects of Tobacco Consumption," ibid.

15. "The Medical Effects of Tobacco Consumption," ibid.

16. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 2-1.

17. U.S. EPA, ibid, p. 1-2.

18. "The Medical Effects of Tobacco Consumption."

19. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 1-2.

20. U.S. EPA, ibid. p. 2-2.

21. U.S. EPA, ibid. p. 1-13.

22. U.S. EPA, Secondhand Smoke: What You Can Do About Secondhand Smoke As Parents, Decisionmakers, and Building Occupants, Doc. 402-F-93-004, July 1993.

23. U.S. EPA, Respiratory Health Effects of Passive Smoking, pp. 7-28, 7-29.

24. American Academy of Pediatrics, Committee on Environmental Health, "Environmental Tobacco Smoke: A Hazard to Children," Pediatrics, vol. 99, April 1997, pp.639-642.

25. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 7-63.

26. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 7-6.

27. CalEPA, "Health Effects Assessment of Environmental Tobacco Smoke - Final Draft for Scientific, Public and SRP Review," February 1997.

28. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 1-1.

29. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 1-16.

30. DiFranza, J. and R. Lew, "Morbidity and Mortality in Children Associated with the Use of Tobacco Products by Other People," Pediatrics, vol. 97, no. 4, April, 1996, pp. 560-568.

31. U.S. EPA, Respiratory Health Effects of Passive Smoking, pp. 7-41, 7-43.

32. U.S. EPA, ibid, p. 7-10.

33. U.S. EPA, ibid. pp. 7-41, 7-43.

34. Jedrychowski, W. and E. Flak, "Maternal Smoking During Pregnancy and Postnatal Exposure to Environmental Tobacco Smoke as Predisposition Factors to Acute Respiratory Infections," Env. Health Perspectives, vol. 105, no. 3, March 1997, pp. 302-306.

35. Etzel, R. et al., "Passive Smoking and Middle Ear Effusion Among Children in Daycare," Pediatrics, vol. 90, no. 2, August 1992, pp. 228-232.

36. Esther, M. et al., "Prenatal Exposure to Parents' Smoking and Childhood Cancer," American Journal of Epidemiology, vol. 133, no. 2, 1991, pp. 123-132.

37. "Second-Hand Smoke: Med Community Backs EPA Data On Risks," Greenwire, July 18, 1994.

38. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 2-11.

39. U.S. EPA, ibid. , p. 1-1.

40. U.S. EPA, ibid, p. 1-15. CalEPA, "Health Effects Assessment of Environmental Tobacco Smoke."

41. U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 7-50.

42. Upton, A. and E. Graber, Staying Healthy in a Risky Environment, Simon and Schuster. 1993.

43. CalEPA, "Health Effects Assessment of Environmental Tobacco Smoke."

44. Needleman, H. and P. Landrigan, Raising Children Toxic Free. New York: Farrar, Strauss, and Giroux, , 1994.

45. Klonoff-Cohen, H. et al., "The Effect of Passive Smoking and Tobacco Exposure Through Breast Milk on Sudden Infant Death Syndrome," JAMA, vol. 273, no. 10, March 8, 1995, pp. 795-798.

46. Lynch and Bonnie, eds., Growing Up Tobacco Free.

47. Lynch and Bonnie, eds., ibid.

48 U.S. EPA, Respiratory Health Effects of Passive Smoking, p. 1-11.

49. U.S. EPA, ibid., p. 1-11.

50. U.S. EPA, ibid.

51. Perera et al., "Biomarkers of Environmental Tobacco Smoke in Preschool Children and Their Mothers."

52. Lynch and Bonnie, eds., Growing Up Tobacco Free.

53. Lynch and Bonnie, eds., ibid.

54. Lynch and Bonnie, eds., ibid.

55. Lewander, W. et al., "Ingestion of Cigarettes and Cigarette Butts by Children - Rhode Island, January 1994-July 1996," CDC, Morbidity and Mortality Weekly Report, February 14, 1997.

56. U.S. EPA, Secondhand Smoke.

57. U.S. EPA, ibid.

58. Lynch and Bonnie, eds., Growing Up Tobacco Free.

59. U.S. EPA, Secondhand Smoke.

60. O'Connor, C., ed., State Legislated Actions on Tobacco Issues, The Coalition on Smoking OR Health/American Heart Association/American Lung Association, 1992, pp. i-iv.

61. O'Connor, ibid.

62. At virtually the same time, the agency stated that it lacked the authority to regulate indoor air quality generally, and passive tobacco smoke in particular. The EPA's primary approach to reducing the hazard of environment tobacco smoke has been public education. In 1993, the tobacco industry sued the EPA to challenge its classification of environmental tobacco smoke as a human carcinogen.

63. "Secondhand Smoke: A Chronology," Los Angeles Times, May 27, 1994, (Source: Donald Shopland, National Cancer Institute.)

64. Lynch and Bonnie, eds., Growing Up Tobacco Free.

65. Lynch and Bonnie, eds., ibid.

66. Lynch and Bonnie, eds., ibid.

last revised 11/25/1997

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