CDC Publicizes the Dangers of Secondhand Smoke

The trend toward the banning of smoking in public places gained momentum when the Centers for Disease Control published a report that indicated a strong correlation between secondhand cigarette smoke and lung cancer.

Summary of Event

In June of 1991, the National Institute for Occupational Safety and Health, National Institute for Occupational Safety and Health part of the Centers for Disease Control Centers for Disease Control (CDC), issued a report titled “Environmental Tobacco Smoke in the Workplace” that reiterated what had long been recognized by other agencies concerned with health matters: Tobacco smoke is a major cause of mortality and morbidity. Tobacco use was known to cause cancer at various sites in the human organism, in particular the lungs; this was established by the U.S. Department of Health and Human Services in 1982 and by the International Agency for Research on Cancer International Agency for Research on Cancer (IARC) in 1986. There was also growing concern that nonsmokers exposed to “passive smoking” Passive smoking might be at risk for some of the same negative health effects as smokers. Antismoking movement
Secondhand smoke
“Environmental Tobacco Smoke in the Workplace” (National Institute for Occupational Safety and Health)[Environmental Tobacco Smoke in the Workplace]
Cancer;tobacco use
[kw]CDC Publicizes the Dangers of Secondhand Smoke (June, 1991)
[kw]Publicizes the Dangers of Secondhand Smoke, CDC (June, 1991)
[kw]Secondhand Smoke, CDC Publicizes the Dangers of (June, 1991)
[kw]Smoke, CDC Publicizes the Dangers of Secondhand (June, 1991)
Antismoking movement
Secondhand smoke
“Environmental Tobacco Smoke in the Workplace” (National Institute for Occupational Safety and Health)[Environmental Tobacco Smoke in the Workplace]
Cancer;tobacco use
[g]North America;June, 1991: CDC Publicizes the Dangers of Secondhand Smoke[08080]
[g]United States;June, 1991: CDC Publicizes the Dangers of Secondhand Smoke[08080]
[c]Health and medicine;June, 1991: CDC Publicizes the Dangers of Secondhand Smoke[08080]
[c]Environmental issues;June, 1991: CDC Publicizes the Dangers of Secondhand Smoke[08080]
Hirayama, T.
Trichopoulos, Dimitrios

Ample evidence had shown that nonsmokers are exposed to elements of tobacco smoke when they are near people who are smoking, through sidestream smoke (smoke that escapes from the nonburning end of a cigarette, cigar, or pipe) and mainstream smoke (smoke that has been inhaled by a smoker and then exhaled). Both types of smoke mix with the air in enclosed spaces to form environmental tobacco smoke (ETS). The terms “passive smoking,” “involuntary smoking,” “exposure to environmental tobacco smoke,” and “exposure to secondhand smoke” have been used interchangeably in various studies of the effects of tobacco smoke on nonsmokers.

Although ETS is diluted in comparison with the mainstream smoke inhaled by active smokers, it is chemically similar and contains many of the same carcinogenic and toxic agents. Nonsmokers exposed to ETS absorb tar, nicotine, carbon monoxide, and other constituents of tobacco smoke, although in smaller amounts than do smokers. Tar, the material that remains after cigarette smoke has been passed through a filter, contains most of the cancer-causing substances in the smoke; carbon monoxide is a gas found in cigarette smoke, and nicotine is a drug unique to tobacco. How much of these elements an individual absorbs depends on the smoke concentration, the quality of ventilation, and the time spent in the area. Nonsmokers heavily exposed to other people’s smoke may inhale the equivalent of one or two cigarettes a day.

Ample evidence was found to support the contention that cigarette smoking in the workplace caused more disease and death than all other occupational illnesses combined. Sidestream smoke was found to contain comparatively higher levels of some toxic substances than the smoke inhaled during active smoking.

Epidemiologic evidence of an association between passive smoking and lung cancer first appeared in a 1981 study by T. Hirayama in Japan and then in a 1983 study by Dimitrios Trichopoulos in Greece. Both researchers found that the incidence and mortality of lung cancer in nonsmoking women was higher for women married to smokers than for those married to nonsmokers. Although there are other sources of exposure to ETS, particularly outside the home, the assumption was that women married to smokers are exposed to more tobacco smoke than are women married to nonsmokers. These studies aroused the interest of public health epidemiologists, who initiated other studies of various designs and in different parts of the world. The study populations were mainly, although not exclusively, women. Studies that focused on passive smoking and lung cancer were conducted in Hong Kong, Germany, and different parts of the United States.

In the United States, an estimated nine to eleven thousand nonsmokers died of lung cancer each year out of a total of about one hundred thousand lung cancer deaths. About one-third of the nonsmokers who died of lung cancer were men, and two-thirds were women. The precise type of cancer tended to differ between smokers and nonsmokers, suggesting at least some different causes in nonsmokers. Passive smoking might have accounted for a portion of the deaths among nonsmokers, but there could also have been other causes.

Most of the studies found that there was approximately a doubling in the risk of lung cancer among nonsmokers heavily exposed to ETS compared with nonsmokers who were not exposed. Some studies reported larger increased risks and some smaller; two studies found no increase. Because passive smoking exposure varied considerably around the world as a result of differences in social customs and living conditions, the different results were not unexpected. Statistically significant increased risks were reported in five studies.

The IARC, a unit of the World Health Organization, reviewed some of the published studies as part of a monograph about the carcinogenic effects of smoking published in 1988. The IARC noted that the risk estimates could actually be somewhat higher or lower than calculated because of the uncertainties in measurements of passive exposure to cigarette smoke as well as to other elements that might have contributed to the development of lung cancer. Because of these uncertainties, the IARC concluded that each study was compatible with either an increase or an absence of excess risk of lung cancer from passive exposure to tobacco smoke, even though statistically significant results were reported.

A study published in 1985 reported the passive smoking histories of 124 nonsmoking women with lung cancer compared with the passive smoking histories of 402 nonsmoking women with colorectal cancer, a cancer not known to be associated with smoking. Information was collected about several different aspects of passive exposure to cigarette smoke: the current smoking habits of husbands or other cohabitants, the number of cigarettes smoked per day at home by the cohabitant smokers, the number of years the cohabitant smoked, and the average number of hours per day the women had been exposed to the smoke of others during the previous five years at home, at work, or elsewhere, as well as during childhood. The data were analyzed using a variety of standard statistical methods. In almost all cases, the women with lung cancer had been somewhat more exposed to cigarette smoke than had been the controls, the women with colorectal cancers.

This study’s strongest evidence for the effect of passive smoking was a comparison of the total number of cigarettes smoked by the cohabitant per day and the number smoked at home. The risks for women whose cohabitants smoked a total of more than forty cigarettes per day, or more than twenty cigarettes per day at home, were significantly higher than the risks for women whose cohabitants did not smoke. More important, the risk increased significantly with increased daily cigarette consumption by the cohabitant.

Lifetime smokers were on the order of ten to fifteen times more likely to develop lung cancer than were lifetime nonsmokers. The data indicated that the risk of lung cancer among nonsmoking women passively exposed to the smoke of twenty cigarettes per day, smoked at home by cohabitants, was more than two times the risk of nonsmoking women not passively exposed to cigarette smoke.

The 1984 report of the U.S. surgeon general included a review of the studies of the relationship between passive smoking and chronic lung disease. The pertinent questions regarding passive smoking were whether passive smoking contributed to the development of chronic lung disease and whether passive smoking exacerbated the symptoms of, or had long-term adverse effects on, people with preexisting chronic lung disease. The studies in this area were laboratory-based experiments of short-term changes in lung function and epidemiologic studies of the relationship between passive exposure to cigarette smoke and measurement of lung function or morbidity. Most of the epidemiologic studies focused on children, classified according to parental smoking. Investigators studied the exposure of healthy people to find out whether those passively exposed to tobacco smoke were more likely to develop respiratory problems than those not exposed and to see whether exposure worsened the condition of those with respiratory conditions, particularly asthma.

In 1986, the National Research Council (NRC) and the U.S. Public Health Service Public Health Service, U.S. independently assessed the health effects of exposure to ETS. Both concluded that ETS can cause lung cancer in adult nonsmokers and that children of parents who smoke have increased frequency of respiratory symptoms and infections of the lower respiratory tract. Epidemiologic studies of the associations between ETS and lung cancer in nonsmoking adults, and between ETS and noncancer respiratory effects, indicated that the simple separation of smokers and nonsmokers within the same air space could reduce but not eliminate the exposure of nonsmokers to environmental tobacco smoke.


The 1991 CDC report on active and passive smoking had many ramifications for the use of tobacco products in public and private places across the United States. In many states, workplace restrictions on smoking became more stringent, and various regulations were established at state and federal levels. All of the legislation and policies at federal, state, and local levels were influenced by the public’s demands for a reduction in the risk of developing lung cancer as a result of breathing secondhand smoke.

From the late 1960’s onward, evidence on the health risks of involuntary smoking was increasingly accompanied by social action designed to protect individuals from exposure to sidestream smoke by regulating the circumstances in which smoking was permitted. Initially, state and local governments took legislative action that dealt with nonsmokers’ rights to smoke-free workplaces. In the late 1970’s, the private sector began to adopt policies aimed at protecting the health of nonsmokers: Restaurants adopted nonsmoking areas, hospitals restricted smoking, and hotels and motels offered nonsmoking rooms. This trend was the result of growing evidence about the health effects of both voluntary and involuntary smoking, but it also reflected changing public attitudes toward smoking. Since 1964, when the U.S. surgeon general’s report on cigarette smoking first called widespread attention to health hazards, public smoking has declined and public support has increased for the right of nonsmokers to breathe smoke-free air.

Most legislation restricting smoking has been enacted at the state level. Cigarette smoking, for nearly a century, had been the subject of restrictive legislation intended to protect the public from fire and other safety hazards. The early legislation also stemmed from a moral crusade against cigarettes similar to the one against alcohol; this movement lost momentum when the enforcement of regulations proved controversial and difficult.

During the 1960’s, as the health risks of smoking became more recognized, public policy on smoking began to focus on encouraging smokers to quit. Legislation began to employ more restrictive language to promote the safety and comfort of nonsmokers. Three federal agencies—the General Services Administration, the Department of Defense, and the Postal Service—administered 90 percent of federal office space. More than two million civilian and federal workers and two million military personnel were affected by the policies of these agencies, which drastically revised their policies on smoking to provide more protection to nonsmokers by prohibiting smoking in all federal buildings.

After the mid-1980’s, many states and communities also passed laws regulating smoking in workplaces. Two provisions were common to many of the state laws: restricting smoking to designated areas and requiring signs to define smoking and nonsmoking areas. After 1991, smoking was banned on state-owned premises. Smoking policies in the private sector were revised in accordance with the federal and state policies. Many companies had banned smoking in their workplaces, whereas others allowed smoking but only in specially designated areas. Smoking on interstate transport vehicles such as buses, trains, and airplanes was regulated by federal agencies and often banned completely.

State and local legislation prohibited smoking in retail and department stores, and proprietors and trade associations supported these restrictions because of the cost of damage to facilities and merchandise from cigarette burns. Smoking regulations in restaurants developed through both private initiatives and public mandate. In 1974, the state of Connecticut was the first to require restaurants to have nonsmoking sections. Soon, the other states followed suit. Smoking restrictions in hotels and motels came mainly in response to customer demands, although later state and local regulations were put in place.

State legislation, state and local school board regulations, and individual school policies initially regulated smoking by students in schools, but eventually smoking was banned within school buildings and allowed only in designated areas outside the school building. Restrictions on smoking in health care facilities were considered particularly important, because many patients in those facilities have conditions that could be worsened by exposure to tobacco smoke. Smoking was eventually banned completely in all health care facilities across the United States. Antismoking movement
Secondhand smoke
“Environmental Tobacco Smoke in the Workplace” (National Institute for Occupational Safety and Health)[Environmental Tobacco Smoke in the Workplace]
Cancer;tobacco use

Further Reading

  • Douville, Judith A. Active and Passive Smoking Hazards in the Workplace. New York: Van Nostrand Reinhold, 1990. Presents excellent discussion of the dangers posed by smoking in the workplace for both smokers and nonsmokers. Somewhat technical, but accessible to general readers.
  • Jenkins, R. A., M. R. Guerin, and B. A. Tomkins. The Chemistry of Environmental Tobacco Smoke: Composition and Measurement. 2d ed. Boca Raton, Fla.: Lewis, 2000. Technical study provides ample data and references useful for the consideration of ETS as a public health issue.
  • Lee, P. N. Environmental Tobacco Smoke and Mortality. Basel, Switzerland: Karger, 1992. Gives a detailed review of epidemiological evidence for environmental tobacco smoke as a cause of cancer, heart disease, and other illnesses in nonsmoking adults. Intended for scientists, but includes several sections accessible to nonscientists.
  • U.S. Department of Health and Human Services. Smoking, Tobacco, and Health: A Fact Book. Atlanta, Ga.: Author, 1987. Presents a discussion of smoking and its health effects in lay terms.
  • U.S. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, D.C.: Author, 1992. Discusses the respiratory health effects of passive smoking, with particular focus on lung cancer. Scientific in presentation, but each chapter is summarized, and many sections are accessible to nonscientists.
  • Watson, Ronald R., and Mark Witten, eds. Environmental Tobacco Smoke. Boca Raton, Fla.: CRC Press, 2001. Collection of technical essays describes the health effects of exposure to ETS among pregnant women, young people, the elderly, and other groups.

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