Environmental tobacco smoke.

Smoking
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Environmental tobacco smoke
P R Edwards, M van Tongeren, A Watson, I Gee, R E Edwards
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
UK workplace regulations leave hospitality trade workforce
unprotected
B
ans on smoking in public places
and workplaces, including bars and
restaurants, have recently been
introduced in California and New York
City and have been announced in
Ireland. In addition, the UK Chief
Medical Officer1 and the EU Health
Commissioner have recently called for
a ban on smoking in public places.
Despite clear evidence that environmen-
tal tobacco smoke (ETS) adversely
affects health and is an important
occupational health hazard, the current
UK policy response and regulatory fra-
mework for occupational ETS exposure
remains inadequate with no discernable
scientific rationale.
ETS is a complex mixture of over 3800
gaseous and particulate components,
including more than 50 known or
suspected human carcinogens and 100
toxic chemicals. Exposure to ETS
through passive smoking has been
associated with many diseases including
lung cancer, and cardiovascular and
respiratory diseases.2 3 The impact on
cardiovascular disease is particularly
important from an occupational and
public health perspective. Steenland
et al recently estimated that in the USA
there are 2000–3000 deaths annually
among non-smokers from cardiovascu-
lar related disease due to occupational
exposure to ETS.4
Occupational exposure to ETS is wide-
spread, with an estimated 7.5 million
workers in the EU and 1.3 million
workers in the UK exposed to ETS for
at least 75% of their working time.5
Many are employed in the hospitality
industry on a casual basis in bars, pubs,
restaurants, hotels, and nightclubs.
Studies have shown high ETS marker
concentrations levels in a range of
hospitality settings.6 7
‘‘Control measures should be imple-
mented to reduce occupational
exposure’’
The UK has no specific regulatory
framework for occupational ETS expo-
sure. The Health and Safety at Work Act
(1974) requires employers ‘‘to provide
and maintain a safe working environ-
ment which is so far as reasonably
practicable, safe, without risks to health
…’’. Each year, The Health and Safety
Commission (HSC) publishes occupa-
tional exposure standards (OESs) and
maximum exposure limits (MELs) for
pollutants.8 The Control of Substances
Hazardous to Health (COSHH)
Regulations, 20029 state that employers
should prevent exposure of their
employees to substances hazardous to
health or, where this is not reasonably
practicable, ensure that exposures are
adequately controlled. If substances
cannot be eliminated, then control
measures should be implemented to
reduce occupational exposure, for exam-
ple by enclosure of the source, localised
ventilation, or as a last resort, by using
respiratory protection. However, there is
no occupational exposure standard for
ETS, although many constituents of ETS
have OESs or MELs (for example,
benzene). The recent classification of
involuntary tobacco smoke exposure as
a class I carcinogen by the International
Agency for Research in Cancer (IARC),10
should increase pressure on the HSC to
set a standard for ETS.
In 1998, the UK Government
announced in the white paper
‘‘Smoking kills’’ that it would consult
about the introduction of an Approved
Code of Practice (ACoP) on workplace
passive smoking.11 The ACoP consulta-
tion document12 set out a hierarchy of
measures with the preferred option
being a complete ban on smoking
‘‘where it was reasonable and practical’’
to do so. Other possibilities included
physical separation of smoking and
non-smoking employees, and not
restricting smoking but ‘‘adequately’’
ventilating the workplace. The HSC
recommended immediate implementa-
tion of the ACoP in October 2000,
arguing that it would have significant
health benefits, but the government has
taken no action to do so.
The other main component of the UK
Government’s policy on passive smok-
ing is the Public Places Charter,11 which
is a voluntary, self-regulatory, charter
supported by the main hospitality
industry organisations. Compliance
with this charter includes provision of
no-smoking areas with or without
mechanical ventilation, and even allow-
ing smoking throughout the premises,
provided that this is clearly indicated
using visible signs and supported by a
written smoking policy. The latter
option was adopted by 49% of Charter
compliant pubs in 2003. The Charter
does not address (nor was it designed to
address) occupational exposure to pas-
sive smoking. This voluntary Charter is
monitored and promoted in the hospi-
tality industry by Atmosphere Improves
Results (AIR),13 which is a lobby group
funded by the Tobacco Manufacturers
Association.
‘‘The level of ETS exposure at which
risk becomes acceptable is unde-
fined’’
The Public Places Charter and the
draft ACoP both promote ventilation as
a method for addressing ETS exposure
in public places and workplaces.
However, the benefits are described
with reference to improved comfort
rather than reduction in risk. There is
little research on the effectiveness of
general ventilation in removing ETS or
in estimating associated reductions in
risk. Indeed, the level of ETS exposure at
which risk becomes acceptable is unde-
fined. A recent UK study14 found that
the concentrations of a range of ETS
markers, though still high, were signifi-
cantly lower (p , 0.05) in non-smoking
compared to smoking areas of pubs.
However, ventilation systems (sophisti-
cated HVAC systems and extractor fans
in either the on or off mode) did not
significantly reduce ETS marker con-
centrations in either smoking or non-
smoking areas. This suggests that exist-
ing ventilation systems may be ineffec-
tive in reducing ETS exposure and hence
have little effect in reducing health risk
for staff and public in hospitality envir-
onments.
The ventilation systems currently
used in pubs and bars have generally
not been installed to control ETS expo-
sure of employees but rather to improve
physical comfort for customers.
Alternative ventilation approaches may
be effective but these will require
objective assessment before the indus-
try’s claims for ventilation solutions can
be accepted. An essential requirement
for assessing ventilation solutions will
be the development of a consensus ETS
guideline or standard value that the
ventilation system must achieve, as
called for in the ASHRAE 62 ventilation
standard for acceptable air quality.15
On current evidence, the only mea-
sure guaranteed to protect employees
from health risks associated with occu-
pational ETS exposure is removal of the
EDITORIAL 385
www.occenvmed.com

source of exposure—that is, by provid-
ing smoke free hospitality environ-
ments. Support for this approach
comes from a study in San Francisco
which showed that the introduction of
smoke-free bars was associated with a
rapid improvement of respiratory health
among bartenders.16
‘‘Smoke-free policies do not have a
negative impact on revenue or jobs’’
The main objection raised to provid-
ing smoke-free environments in the
hospitality industry is that it will result
in ruinous economic consequences due
to loss of revenue from smoking custo-
mers. This is not supported by evidence.
A recent systematic review found that of
21 well designed studies on the impact
of smoke-free policies in the hospitality
trade, none showed a negative impact
on revenue or jobs.17 Furthermore, there
is clear evidence of public support in the
UK for restrictions on smoking in the
workplace and public places.18
It is clear that for informed policy
decisions about involuntary occupa-
tional ETS exposure to be made, a
health based review of safe exposure
levels for workers and the public, and
subsequent development of health
based exposure limits is urgently
required. More research is needed to
determine whether sophisticated venti-
lation systems or other available engi-
neering solutions are effective in
reducing exposure to ETS and minimis-
ing adverse heath effects.
Until there is clear evidence that
ventilation systems can reduce personal
ETS exposures of employees to a level
at which there is no significant health
risk, the most rational regulatory solu-
tion is to require that workplaces are
smoke-free, including in the hospitality
sector. In the absence of effective
ventilation control measures and the
continued (but disputed) argument
made by the hospitality industry that
banning smoking is not reasonably
practicable on economic grounds, the
remaining alternative according to the
COSHH hierarchy of control measures
would be to provide and enforce the use
of personal protective equipment, a
measure that would probably be unac-
ceptable to staff, customers, and the
industry. If, despite increasing scientific
evidence about the dangers of occupa-
tional exposure to ETS, the hospitality
industry does not act and is hence is not
seen to exercise its duty of care towards
its employees, it is potentially opening
itself up to future, costly litigation. Does
the hospitality industry really want to
take that risk?
Occup Environ Med 2004;61:385–386.
doi: 10.1136/oem.2003.011692
Authors’ affiliations
. . . . . . . . . . . . . . . . . . . . . .
P R Edwards, Evidence for Population Health
Unit, School of Epidemiology and Health
Sciences, University of Manchester, UK
M van Tongeren, Centre for Occupational
and Environmental Health, School of
Epidemiology and Health Sciences, University
of Manchester, UK
A Watson, I Gee, ARIC, Department of
Environmental & Geographical Sciences,
Manchester Metropolitan University, UK
R E Edwards, The Manchester Centre for Civil
and Construction Engineering, UMIST,
Manchester, UK
Correspondence to: Dr P Richard Edwards,
Evidence for Population Health Unit, School of
Epidemiology and Health Sciences, Stopford
University of Manchester, Stopford Building,
Oxford Rd, Manchester MP13 9PT, UK;
richard.edwards@man.ac.uk
Competing interests: Richard Edwards is unpaid
Chair of North West Action on Smoking and
Health and a member of the Royal College of
Physicians Tobacco Control Group
REFERENCES
1 Donaldson L. Health check on the state of the
public health: the annual report of the Chief
Medical Officer 2002. London: Department of
Health, 2003.
2 Scientific Committee on Tobacco and Health.
Report of the Scientific Committee on Tobacco
and Health. London: The Stationery Office, 1998.
3 WHO Regional Office for Europe. Environmental
tobacco smoke. World Health Organisation,
2000.
4 Steenland K, Burnett C, Lalich N, et al. Dying for
work: the magnitude of US mortality from selected
causes of death associated with occupation.
Am J Ind Med 2003;43:461–82.
5 Kauppinen T, Toikkanen J, Pedersen D, et al.
Occupational exposure to carcinogens in the
European Union. Occup Environ Med
2000;57:10–18.
6 Jarvis M. Quantitative survey of exposures to
other people’s smoke in London bar staff. London:
Department of Epidemiology and Public Health,
University College London, 2001.
7 Siegel M. Involuntary smoking in the restaurant
workplace. A review of employee exposure and
health effects. JAMA 1993;270:490–3.
8 Health and Safety Executive. EH40/2002.
Occupational exposure limits 2002. London: HSE
Books, 2002.
9 Health and Safety Executive. Control of
substances hazardous to health regulations 2002.
Approved code of practice and guidance. L5.
London: HSE Books, 2002.
10 International Agency on Research on Cancer.
Tobacco smoke and involuntary smoking (June
2002). http://monographs.iarc.fr/htdocs/
monographs/vol83/02-involuntary.html
(accessed 29 August 2003). IARC Monographs
(Vol. 83). Lyon: International Agency on Research
on Cancer, Lyon, 2003.
11 Secretary of State for Health. Smoking
kills: a White Paper on tobacco. London: The
Stationery Office, 1998.
12 Health and Safety Commission. Proposal for an
Approved Code of Practice on passive smoking at
work: consultative document. London: Health and
Safety Executive, 1999.
13 Atmosphere Improves Results. Atmosphere
Improves Results. http://www.airinitiative.com/
(accessed 29 October 2003). London:
Atmosphere Improves Results, 2003.
14 Carrington J, Watson AFR, Gee IL. The effects of
smoking status and ventilation on environmental
tobacco smoke concentrations in public areas of
UK pubs and bars. Atmospheric Environment
2003;37:3255–66.
15 ASHRAE. Addendum 62 to ASHRAE Standard
62-2001: Ventilation for Acceptable Air Quality,
2002. Atlanta: American Society of Heating,
Refrigerating and Air-Conditioning Engineers,
2002.
16 Eisner MD, Smith AK, Blanc PD. Bartenders’
respiratory health after establishment of smoke-
free bars and taverns. JAMA
1998;280:1909–14.
17 Scollo M, Lal A, Hyland A, et al. Review of the
quality of studies on the economic effects of
smoke-free policies on the hospitality industry.
Tobacco Control 2003;12:13–20.
18 Office for National Statistics. Smoking related
behaviour and attitudes 2002. London: The
Stationery Office, 2003.
386 EDITORIAL
www.occenvmed.com