NEWS

Where There's No Smoke: Popular Smoke-Free Laws Curbing Active, Passive Smoking

Renee Twombly

Of all of the efforts to control smoking in the United States that were launched after the release of the Surgeon General's Report on Smoking 40 years ago, many experts agree that the grassroots movement to limit the public's exposure to secondhand smoke has been the most successful.

That initiative is celebrating its own 30th anniversary this year with a string of very recent successes that highlight a growing trend in passage of smoke-free policies by small towns, large cities, states, and even nations.

In June, the Norwegian government distributed posters nationwide that read, "Welcome to Norway. The only thing we smoke here is salmon," announcing its new ban on smoking in all work-places, including bars and restaurants. Smoking is not allowed in Ireland's pubs as of March 29, nor is it permitted in public spaces in The Netherlands. Similar measures have also been adopted in New Zealand, India, Uganda, and Bhutan, and more nations are expected to quickly follow suit.

Also in June, Massachusetts became the sixth state in the United States to pass a comprehensive smoke-free bill, prohibiting smoking in all workplaces— defined as including restaurants and bars. It joined California, Connecticut, Delaware, Maine, and New York with comparable no-smoking policies.

But those successes seem to pale next to the achievements seen at the local levels. By June, 1,726 towns and cities had passed local clean indoor air laws, and 307 of these municipalities provide for 100% smoke free protection for private workplaces, government buildings, restaurants, and/or bars, according to the national lobbying organization, Americans for Nonsmokers' Rights. The group estimates that to date, more than 35% of the U.S. population is now subject to a local or state 100% smoke-free indoor air law. (See Stat Bite, p. 1059.)

Although that fact prompts celebration among clean indoor air advocates, it also pleases public health officials who foresee future declines in lung cancer and heart disease because of reduced smoking, passive or not.

"There is clear data that smoking bans both reduce the number of cigarettes smokers use and increase the number of people who actually quit," said Thomas Glynn, Ph.D., director of International Tobacco Programs at the American Cancer Society. "No-smoking policies are absolutely a key element in an overall tobacco control program."

Although the effort at passing nosmoking policies is snowballing, it is not rolling as fast it could if the tobacco companies were not "fighting it tooth and nail," said Stanton Glantz, Ph.D., of the University of California at San Francisco. "This issue would have been settled 30 years ago if the tobacco industry had not been trying to stop it any way they can."

Citing tobacco industry documents now publicly available—including a 1992 Philip Morris internal memo that states that smokers facing workplace restrictions quit smoking at a rate that is 84% higher than average—Glantz said, "This is the one battle they have said they must win, but it is the one they are losing. This is an issue that has really, finally, gotten past the tipping point."

Evidence of Health Burden

Although passage of the first local ordinance to create nonsmoking sections in restaurants occurred in 1977, the clean indoor air movement did not really gain a focus until the 1986 Surgeon General's report, "The Health Consequences of Involuntary Smoking." Its conclusions, that exposure to environmental tobacco smoke can cause disease, including lung cancer in smokers, and that separation of smokers and nonsmokers in the same public air space does not eliminate public exposure to carcinogens, changed the argument, said Michele Bloch, M.D., Ph.D., of the National Cancer Institute's Tobacco Control Research Branch.

"It became an issue of protecting nonsmokers," she said. "There is now broad agreement in the scientific community that secondhand smoke has a significant effect on lung cancer and heart disease."

The Centers for Disease Control and Prevention (CDC) now estimates that secondhand tobacco smoke contains at least 250 chemicals that are known to be toxic or carcinogenic, and is responsible for a minimum of 35,000 heart disease deaths in the United States each year, as well as 3,000 lung cancer deaths. One study concluded that for every eight smokers that die from diseases associated with tobacco, one similarly afflicted nonsmoker also dies.

Because lung cancer takes decades to develop, the studies that have most alarmed the public, and fed the non-smokers' rights movement, have focused on the more easily measured association between passive smoking and heart disease.

Findings in the late 1980s revealed that 30 minutes of exposure to tobacco smoke activates blood platelets, resulting in "sticky blood," which leads to heart attacks. Secondhand smoke does the same thing, according to a 2001 study, which concludes that even a half-hour of secondhand smoke exposure causes heart damage similar to that of habitual smokers.

An April study by Glantz, published by the British Medical Journal, led to a first-time warning by the CDC that people at risk of heart disease should avoid all buildings and gathering places that allow indoor smoking.

The advisory, disclosed in a commentary in the same issue of BMJ, stressed that researchers now believe that even a brief exposure to environmental smoke increases the tendency of blood to clot, which restricts flow to the heart, producing a serious and even lethal effect on patients with heart disease.

Glantz's study suggested that a comprehensive clean indoor air policy can result in an almost immediate drop in heart attacks. He and physicians from the single hospital that treats patients in Helena, Mont., collected information that compared the number of heart attacks before, during, and after a 2002 indoor smoking ban that lasted for just 6 months before it was overturned.

When the ban was in effect, 24 Helena residents suffered acute heart attacks, but for the 5 years before and after, the average number of heart attacks reported for Helena residents during the same 6 months was 40. The authors also found through hospital records that the number of heart attacks suffered by people living in the area outside Helena—where there was no smoking ban— did not experience the same 2002 dip as was seen in Helena. Of the patients monitored in the study, 38% were current smokers, 29% were former smokers, and 33% had never smoked.

Glantz also co-authored a study, with Michael Ong, M.D., Ph.D., of Stanford University, that demonstrates the profound cardiovascular health and economic benefits that would result if the entire country instituted smoke-free workplace policies.

According to their findings, published July 1 in the American Journal of Medicine, the first-year effect of such a policy would produce about 1.3 million new quitters and prevent more than 950 million cigarette packs from being smoked annually, worth about $2.3 billion in pretax sales to the tobacco industry.

Making all workplaces smoke free would prevent, in 1 year, about 1,500 heart attacks and 350 strokes and result in nearly $49 million in savings in direct medical costs, they concluded. At "steady state," 6,250 heart attacks and 1,270 strokes would be prevented, and $224 million would be saved in direct medical costs annually.

About half the benefit is from reduced secondhand smoke exposure, and about half is due to making it easier for people to stop smoking, the researchers said.

"No one now questions whether secondhand smoke can cause lung cancer, but it is a lot faster and easier to cast an argument about protection in terms of heart disease," Glantz said.

Results in New York City

Approximately one in five New Yorkers smoke, so the New York City Health Commission expected a fight from the tobacco industry, including Philip Morris, which had headquarters in Manhattan, when Mayor Michael Bloomberg proposed a no-smoking policy soon after he took office in January 2002.

But by August of that year, Bloomberg and his new health commissioner, Thomas Frieden, M.D., introduced a bill to the city council that would prevent smoking in all work-places, including bars and restaurants. It was signed that December and went in effect March 30, 2003.

Exactly 1 year later, the city released a report that concluded the policy had not hurt the city's 30,000 restaurants and bars, as the tobacco industry had alleged, and in fact showed that restaurant and bar tax receipts were up more than 8%, as was employment in these establishments. And one unforeseen consequence of the policy was the exodus of Philip Morris to Virginia, after the city turned down the company's petition to be exempt from the law, said Nancy Miller, Ph.D., assistant commissioner for tobacco control for the New York City Department of Health and Mental Hygiene.

"The law is an overwhelming success," she said. "Air quality in public buildings has increased dramatically, and the reality is that New Yorkers love this bill. Compliance is more than 97%."

As a result of the bill and of a more than doubling in the cigarette package excise tax—a pack now costs $7— overall adult smoking has dropped 11% in the city, Miller said.

She added that the health department is tracking how the policy is affecting health outcomes. The city had estimated that exposure to secondhand smoke killed 1,000 New Yorkers each year through heart disease and lung cancer and caused such illnesses as emphysema, asthma, and other respiratory diseases in an additional 40,000 nonsmoking New Yorkers.

Based on the example of New York City, New York State passed a similar no-smoking policy in July 2003, but a battle continues in the state legislature about proposals to permit smoking in bars and restaurants that use air filtration systems. "The tobacco industry is fronting hospitality associations to continue the fight," said Miller. "They will never give up."

Cynthia Hallett agrees. As executive director of Americans for Nonsmokers' Rights, the advocacy organization that began in a Berkeley, Calif., living room in 1976, Hallett observed that the industry continually changes its tactics. "The battleground has shifted from denying any health consequences of secondhand smoke, to pushing for smoking sections, to arguing that superduper ventilation systems will remove carcinogens, or that past a certain time at night, patrons at bars can start smoking."

The newest strategy is to push states to adopt no-smoking policies that are weaker than many of the local ordinances within those states. Such "preemptive" state laws, which have already passed in 22 states, "puts a pair of handcuffs on local jurisdiction," Hallett said.

She and other experts say there is much work still to be done because 65% of Americans remain exposed to secondhand smoke. "But it also clear that the social norm has been changed, that people now believe they have a right to demand clean indoor air," Hallett said. "On this front, the tobacco industry has lost."


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