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Should smoking in outside public spaces be banned? No



After success in stopping smoking in public buildings, campaigns are turning outdoors. George Thomson and colleagues (doi:10.1136/bmj.a2806) argue that a ban will help to stop children becoming smokers but Simon Chapman believes that it infringes personal freedom
76 BMJ | 10 JANUARY 2009 | VOLUME 338
Should smoking in outside public
spaces be banned?
cies. California has banned smoking within
25 feet (7.6 metres) of outdoor playgrounds.
United Kingdom, Australian, and New Zea-
land authorities have been explicit about
the need to reduce the modelling of smok-
ing to children as a justification for this type
of outdoor smoking restrictions.9-12 Policies
encouraging or requiring
other outdoor smoke-
free areas have been
introduced in the past 10
years in North America,
Australasia, Hong Kong,
Singapore, and elsewhere.
Reducing the
modelling of smoking to children has often
been given as a justification for introducing
these restrictions.
Are outdoor smoke-free policies practical?
How best to reduce the visibility of smok-
ing? Media campaigns can promote not
smoking in the presence of children as a
social norm.
Legislation and other uses
of law can expand smoke-free policies to
ensure the inclusion of all public areas
where children predominate. These areas
include schools, parks and playgrounds,
swimming pool complexes, sports grounds,
and parts of beaches. The success of out-
door bans depends on the size of the areas
covered, the ways the policy is communi-
cated (for example, signage), and the extent
of public support.15
Reports from Britain, New Zealand, and
parts of Australia and the United States
indicate majority support for restricting or
banning smoking in outdoor areas where
there are children.
We are aware of no
evidence that outdoor smoke-free policies
have resulted in a public backlash against
other advances in tobacco control.
Ethical and international treaty
Children are a highly vulnerable population,
susceptible to the influences of adult behav-
iours. Protection from addiction can be con-
sidered to enhance overall freedom, given
that most smokers regret ever starting.21
We may not yet be certain that outdoor
smoke-free areas reduce smoking uptake;
the necessary studies have not been carried
out. However, where there is uncertainty in
policy making, any assessment of the balance
of benefit and harm should put the protec-
tion of children first.
This is because of the
extent and severity of the hazard that taking
up smoking poses to children and the theo-
retical and empirical evidence for a role mod-
elling effect on smoking uptake. The principle
of giving primacy to the
protection of children is
also underpinned by inter-
national treaty obligations.
The United Nations Con-
vention on the Rights of
the Child requires that in making policy,
children’s rights must be put first, and govern-
ments “shall undertake all appropriate legisla-
tive, administrative, and other measures for
the implementation of the rights.”23
Adverse effects from outdoor smoke-free
areas are largely restricted to the possible loss
of amenities for some smokers.
We argue that society has an ethical duty
to minimise the risk of children becoming
nicotine dependent smokers. A reasonable
step is banning smoking in selected outdoor
areas frequented by children. Children need
smoke-free outdoor places now, to help nor-
malise a smoke-free society.
Competing interests: All authors have done contract work
for health non-governmental organisations, the New Zealand
Ministry of Health, or WHO on tobacco control research.
Cite this as: BMJ 2008;337:a2806
Legislation to ban smoking
indoors in public places is
now commonplace, driven
mainly by the need to protect non-smokers
from exposure to secondhand smoke. A
new domain for tobacco control policy is
outdoor settings, where secondhand smoke
is usually less of a problem. However, the
ethical justification for outdoor smoking
bans is compelling and is supported by
international law. The central argument is
that outdoor bans will reduce smoking being
modelled to children as normal behaviour
and thus cut the uptake of smoking. Out-
door smoke-free policies may in some cir-
cumstances (such as crowded locations like
sports stadiums) reduce the health effects
of secondhand smoke
; will reduce fires
and litter
; and are likely to help smokers’
attempts at quitting.
Need to reduce modelling
There is no simple answer to the question of
what causes children to take up smoking.
3 4
We know, however, that children tend to copy
what they observe and are influenced by the
normality and extent of smoking around
Many smokers recognise that their
smoking affects children’s behaviour.8
The primary strategy for tobacco con-
trol is reducing the prevalence of smoking,
and such reduction will in itself mean that
smoking is less visible in society. But the
modelling of smoking can also be reduced
by policies to restrict smoking in the pres-
ence of children. The entrenched nature of
tobacco use in most societies, and its highly
addictive qualities, require that such policies
are far reaching. Smoking bans in many out-
door public areas are therefore an important
additional approach to tobacco control.
The need for outdoor smoking restric-
tions is increasingly recognised. Finland,
five Canadian provinces, two US states, and
New Zealand use law to require smoke-free
school grounds. Other jurisdictions (such as
Australian states) use administrative poli-
“Children tend to copy
what they observe and are
influenced by the normality of
smoking around them”
George Thomson senior research fellow, Nick Wilson senior
lecturer, Richard Edwards associate professor, University of
Otago, Wellington, Box 7343, Wellington, New Zealand
Alistair Woodward professor, University of Auckland, Private Bag
92019, Auckland, New Zealand
BMJ | 10 JANUARY 2009 | VOLUME 338 77
All references are in the version on
Indoor smoking bans draw their
ethical authority from extensive
research showing harm from
prolonged and repeated exposures in homes
and workplaces, over many years. By contrast,
recent agitation to extend bans to outdoor set-
tings like parks, car parks, beaches, and streets
is supported by flimsy evidence. Brief expo-
sures to others’ smoke can produce measur-
able physiological changes.1 2 However, acute
exposure studies typically define brief as 15
to 30 minutes—considerably more than usual
smoky encounters outdoors.3
A recent paper concluded that outdoor
smoke is rapidly attenuated but for those within
half a metre of multiple smokers “between 8
and 20 cigarettes smoked sequentially could
cause an incremental 24-hour particle exposure
greater than . . . the 24-hour EPA [US Environ-
mental Protection Agency] health-based stand-
ard for fine particles.”
The authors referred
to bar patios as where this might happen but
state that “sitting next to a smoker on a park
bench” might produce such exposure, despite
also stating that multiple smokers are required
to get to levels that challenge the EPA stand-
ard. “Multiple smokers” are rarely seated on
park benches next to non-smokers for the time
it would take to smoke 8-20 cigarettes.
the toxiogenic hypothesis (that intolerance
of low levels of any environmental agent
explains symptoms either through toxicody-
namic pathways or by sensitising neural path-
ways) and the psychogenic hypothesis (that
idiopathic environmental intolerance is a cul-
turally learnt phenomenon characterised by
an overvalued idea of toxic harm explained
by psychological or psychosocial processes).8 9
The reviews concluded that none of the Brad-
ford-Hill criteria for causation
were satisfied
by the toxiogenic theory, but that all of the
criteria were met for the psychogenic theory.
Governments often regulate citizens’ con-
duct to reduce nuisance, regardless of whether
it affects health. Public health research is
debased when it lends bogus credibility to
what are essentially matters of community
preference. If authorities wish to stop smoking
on beaches to reduce litter, they should frame
their actions in terms of litter reduction, not
public health. Landlords wanting to prevent
smokers from renting apartments because
of complaints about smoke drift from other
residents, should be at lib-
erty to do so, but need not
invoke public health justi-
In most of the world
smoking remains a normal, unremarkable,
and unregulated activity. Health workers in
those nations are desperate to convince gov-
ernments of how reasonable it should be to
remove involuntary tobacco smoke expo-
sure in occupational and indoor public set-
tings. They marshal evidence about disease
caused by long term exposure and staunchly
defend the credibility of that evidence from
the predations of the tobacco and hospital-
ity industries, intent on exposing those risks
as trivial. Opponents of clean indoor air will
point to campaigns against outdoor smoking
and argue that advocates actually want to ban
smoking everywhere. Such views are likely to
undermine the credibility of advocacy for evi-
dence based smoke-free policies to the great
detriment of hundreds of millions of citizens.
This article is adapted from Chapman S. Going too far?
Exploring the limits of smoking regulations.
William Mitchell
Law Review
Competing interests: None declared.
Cite this as: BMJ 2008;337:a2804
After success in stopping smoking in public buildings, campaigns are turning outdoors.
George Thomson and colleagues argue that a ban will help to stop children becoming smokers
but Simon Chapman believes that it infringes personal freedom
Some are affronted by the mere sight of smok-
ing. Others have an evangelical mission to use
paternalistic “tough love” to help others quit.
Prohibitions on personal behaviours can be
justified by the right to interfere with the lib-
erty of people to harm to others. But paternal-
ism is most odious when used as a justification
for limiting the choices that adults make when
they put only themselves at risk.
Health facili-
ties banning smoking outdoors often justify
this as normative role modelling. This is ethi-
cally unproblematic for staff who are contrac-
tually obligated to observe employers’ policies
but represents ethically muddled thinking
when it comes to patients and visitors, who
are not somehow “owned and controlled” by
health authorities. If they harm no one else by
smoking outdoors, they ought not be coerced
into signing up to the health promotion values
of a hospital when visiting.
Many smokers support paternalistic policies
designed to discourage their smoking. But we
do not evaluate the ethics of public health by
the willingness of people
to give up their autonomy,
nor with the success of
commandments to obey
laws. The ethics here is
about respect for the autonomy of individu-
als to act freely, providing their actions do not
harm others.
There are few differences between the
chemistry of tobacco smoke and that gener-
ated by incomplete combustion of any bio-
mass: leaves, campfires, petrol, or barbecued
Secondhand smoke is not so uniquely
noxious that it justifies extraordinary controls
of such stringency that zero tolerance outdoors
is the only acceptable policy. Park barbecues
aren’t banned for the obvious reason that the
amount of smoke involved is trivial. Zero tol-
erance of tobacco smoke in outdoor public
settings is nakedly paternalistic.
Problems of health argument
Advocates for smoke-free outdoor areas
include those who passionately attest to being
severely affected by even the tiniest exposure
to smoke. If public health policy is to be evi-
dence based, such claims need to be subjected
to scientific assessment.
Two reviews examined evidence for both
“Zero tolerance of tobacco smoke
in outdoor public settings is
nakedly paternalistic”
Simon Chapman profe sso r of pub lic hea lth ,
Un iver sit y of Sydn ey, S ydn ey, A ust ral ia
These two articles were posted on
on 11 December 2008. In the accompanying
online poll, 416 readers (57.66%) voted yes
and 307 (42.34%) voted no.
Tell us on
... Time activity studies previously conducted by Klepis et al. and Yang et al. indicated that people spent 5% of their time outdoors, which is approximately 1 to 2 h per day [39][40][41]. As the time spent outdoors was relatively short, the effectiveness of the outdoor smoking ban has been widely debated [42,43]. However, Lopez et al. reported that the concentration of nicotine and other substances from SHS in the air can be higher in terraces or corridors of buildings with a smoking ban, as compared to their concentrations outdoors. ...
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Since the global enforcement of smoke-free policies, indoor smoking has decreased significantly, and the characteristics of non-smokers’ exposure to secondhand smoke (SHS) has changed. The purpose of this study was to assess the temporal and spatial characteristics of SHS exposure in non-smokers by combining questionnaires and biomarkers with time activity patterns. To assess SHS exposure, biomarkers such as cotinine and 4-(methylnitrosamino)-1-3-(pyridyl)-1-butanol (NNAL) in urine and nicotine in hair were collected from 100 non-smokers in Seoul. Questionnaires about SHS exposure and time activity patterns were also obtained from the participants. The analysis of biomarker samples indicated that about 10% of participants were exposed to SHS when compared with the criteria from previous studies. However, 97% of the participants reported that they were exposed to SHS at least once weekly. The participants were most exposed to SHS in the outdoor microenvironment, where they spent approximately 1.2 h daily. There was a significant correlation between the participants’ time spent outdoors and self-reported SHS exposure time (r2 = 0.935). In this study, a methodology using time activity patterns to assess temporal and spatial characteristics of SHS exposure was suggested. The results of this study may help develop policies for managing SHS exposure, considering the time activity patterns.
... Policymakers and scholars have debated the effectiveness of banning smoking in outdoor public places and raised ethical questions in relation to individual liberty. Opponents of these bans assert that the negative health effects of outdoor smoking have not been demonstrated and that such policies go too far ("paternalism";Chapman, 2008). Supporters argue that there are sufficient ethical and practical justifications for the policy, because it is expected to reduce secondhand smoke, reduce the likelihood of children to follow unhealthy behavior, and help smokers to quit (Thomson, Edwards, & Woodward, 2008). ...
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To address exposure to secondhand smoke, which is highly prevalent in Korea, local governments have implemented smoking bans at open public places (parks, bus stops, and school zones) since 2011. Exploiting temporal and spatial variation in the implementation dates of these bans, this study estimates their causal effects on individual smoking behavior. The individual‐level longitudinal data from the 2009–2017 Korean Labor and Income Panel Study are linked to the smoking ban legislation information from the National Law Information Center. I find robust evidence that outdoor smoking bans increased the probability of making a quit attempt by 16%. This effect appears immediately after a ban goes into effect and lasts for three or more years. People who spend more time outdoors are more likely to change smoking behavior. I also find heterogeneity in effects across the amount of monetary penalty. Whereas the policy change did not affect the prevalence of smoking overall, higher penalties had stronger impacts on reducing the intensity of smoking and increasing the propensity to try to quit.
... Commercial marketing's approach to ethics provides rather a narrow view of social problems as it is driven by consumer orientation (Witkowski 2007), making ethical and moral problems a consumer concern (Peattie and Peattie 2003), which does not necessarily lead to consumer welfare in a social marketing sense. For example, for individuals who are informed about the consequences of smoking, maintaining the habit may be an expression of civil liberty (Chapman 2008;Crotty and Malhotra 2015); yet, in social marketing smoking and its social costs need to be considered in a broader public heath context (Jha and Peto 2014). Thus, the dangers of overrelying on commercial marketing principles and practices in social marketing are particularly conspicuous in the area of public health, where social marketing faces ethical challenges that are far more complex than those of commercial marketing (Peattie and Peattie 2003). ...
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Social marketing has been established with the purpose of effecting change or maintaining people’s behaviour for the welfare of individuals and society (Kotler and Zaltman in J Market 35:3–12, 1971; MacFadyen et al. in The marketing book, Butterworth Heinemann, Oxford, 2003; French et al. in Social marketing and public health: Theory and practice, Oxford University Press, Oxford, UK, 2010), which is also what differentiates it from other types of marketing. However, social marketing scholars have struggled with guiding social marketers in conceptualising the social good and with defining who decides what is socially beneficial in different contexts. In this paper, we suggest that many dilemmas in identifying the social good in social marketing could be addressed by turning to human rights principles, and, in particular, by following a human rights-based approach. We examine a number of cross-cutting human rights principles—namely, transparency and accountability, equality and non-discrimination, and participation and inclusion—that are capable, in a practical way, of guiding the work of social marketers. Through an illustrative case study of the anti-obesity discourse, we present how these principles might help to address some of the challenges facing social marketing, both as a theory and practice, in meeting its definitional characteristic.
... Similarly, university and educational institutions in the US and in Australia are increasingly implementing smoke-free policies that extend to the whole campus (Lee et al., 2010). These policies arguably go beyond second-hand smoke protection to justify maximum smoke-free space and potentially implicate smokers' access to higher education facilities (Chapman, 2008). ...
Scholarship on stigma, originally theorised as a ‘mark’ of social disgrace or difference, has since moved away from individual-level analyses to consider the socio-cultural context in the ‘marking’ of groups of people. In response to this theoretical shift, scholars have demonstrated how extensive tobacco denormalisation policies have contributed to the stigmatisation of smokers, documenting smokers’ experiences of stigma across a number of developed countries. We extend this analysis to the Australian context, examining smokers’ constructions of stigma and their reactions to policies that would give smokers differential access to healthcare. Based on 29 interviews with Australian smokers, we focus on what constitutes evidence of stigma and how participants use social comparisons to respond to stigma. We then explore an assumption underpinning participants’ accounts of stigma: that only smokers committed to cessation are ‘deserving’ of treatment. We close by discussing theoretical perspectives and opportunities in stigma research and the need to extend a stigma lens to study emerging public health issues, such as electronic cigarettes.
... Besides health concerns, there are other reasons to support the prohibition of outdoor smoking such as reducing the litter, decreasing fire risks, and, most importantly, establishing a positive smoke-free model for youth in order to reduce imitative behavior. 11 In Spain, 28.6% of young adults aged 18 to 24 years old are enrolled in university-level degree programs. 12 Universities, especially those that offer degree programs in health-related disciplines, can contribute to the health of the wider community by setting an example of good practice and banning smoking from their premises. ...
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Objective: To assess attitudes towards the extension of outdoor smoke-free areas on university campuses. Methods: Cross-sectional study (n = 384) conducted using a questionnaire administered to medical and nursing students in Barcelona in 2014. Information was obtained pertaining to support for indoor and outdoor smoking bans on university campuses, and the importance of acting as role models. Logistic regression analyses were performed to examine agreement. Results: Most of the students agreed on the importance of health professionals and students as role models (74.9% and 64.1%, respectively) although there were statistically significant differences by smoking status and age. 90% of students reported exposure to smoke on campus. Students expressed strong support for indoor smoke-free policies (97.9%). However, only 39.3% of participants supported regulation of outdoor smoking for university campuses. Non-smokers (OR = 12.315; 95% CI: 5.377-28.204) and students ≥22 years old (OR = 3.001; 95% CI: 1.439-6.257) were the strongest supporters. Conclusions: The students supported indoor smoke-free policies for universities. However, support for extending smoke-free regulations to outdoor areas of university campuses was limited. It is necessary to educate students about tobacco control and emphasise their importance as role models before extending outdoor smoke-free legislation at university campuses.
Background: Community participation in health programme planning has gained traction in public health in recent decades. When an idea enters the mainstream, it becomes vulnerable to overuse and dilution, and public health professionals claiming "community participation" may intentionally or unintentionally prevent more meaningful participatory action. The principle of community-centred planning is seldom integrated into programme evaluation. We have previously argued that, to prevent ambiguity and abuse, a stronger and more explicit idea of community ownership is useful. Un-like "participation", "ownership" leaves little room for dilution. Method: This perspective piece explores a framework to support evaluating community ownership in planning, by emphasising decision-making power in health planning and management as a necessary element for evaluation alongside other outcomes. After defining the concept of community ownership, we identify and discuss challenges and research gaps related to implementing community ownership in health programme planning, management, and evaluation. Such issues include considering which communities have claims to programme ownership, alternative approaches to representation and participation that support ownership, gathering community values and preferences, and incorporating them into ongoing programme planning, management and evaluation. We consider methodological issues likely to arise when transitioning from gathering community voices - which is valuable but incomplete work - towards community decision making power in planning and evaluation. Results: We use cases from recent policy and research in Chile as examples to consider through the lens of this framework. Finally, we discuss some current constraints in implementing community ownership in healthcare planning and evaluation. Conclusion: We encourage exploring how to practice evaluation in ways that will further our ability to be helpful professional supporters of community self-determination in finding their paths to health.
Issue addressed Smoking near hospital entrances occurs frequently despite smoke-free policies, resulting in multiple issues including second-hand smoke exposure (SHS) to vulnerable populations. Primary school children were engaged through their health curriculum to produce antismoking audio recordings for broadcast over a hospital entrance loudspeaker system to determine if this reduced smoking. Method Students produced original recordings against hospital grounds smoking during class workshops, from which a collection (n = 16) was selected. Episodes of entrance smoking and total entrance traffic were recorded using security camera infrastructure over a 5-week period. A computer-controlled entrance loudspeaker played a message which was followed by silence until a new (different) message was played. Intensity of messaging was moderate in week 3 (every 5 minutes), increasing to high in week 4 (3 minutely) and compared to no messages (weeks 1-2 preintervention) and week 5 (postintervention). Results Smokers presented 316 times, smoking 523 cigarettes over 155 hours of observation (patients 70.6%, visitors 29.4%). SHS exposure was high given 172 others used the entrance/hour. Smoking was highest in the preintervention period (weeks 1-2), median five cigarettes/hr [IQR,3-7 (min = 0, max = 12)], falling to four cigarettes/hr during 5-minutely broadcasts [IQR,2-5 (min = 1, max = 14)] (P = .06), but zero cigarettes/hr during 3-minutely broadcasts [IQR,0-1(min = 0, max = 7)] (P < .0001). Postintervention (no broadcasts), smoking increased from zero to 1 cigarette/hr [IQR,0-3 (min = 0, max = 5)]; (P = .052). Nonsmoker movements did not change significantly between each period. Conclusion Intensive (3 minutely) broadcasting of short antismoking messages significantly reduced hospital entrance smoking. So what? Health services can positively interact with the health curriculum of primary schools against tobacco use while developing low-cost strategies to effectively deter entrance smoking.
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Smoke-free legislations aim to protect non-smokers from second-hand smoke (SHS) exposure and improve population health outcomes. The aim of this study was to explore residents’ perceptions to understand how people living in distinctive SES neighborhoods are differently affected by comprehensive smoke-free laws in a large city like Madrid, Spain. We conducted a qualitative project with 37 semi-structured interviews and 29 focus group discussions in three different SES neighborhoods within the city of Madrid. Constructivist grounded theory was used to analyze the transcripts. One core category arose in our analyses: Neighborhood inequalities in second-hand smoke (SHS) exposure in outdoor places. The enactment of the comprehensive smoke-free law resulted in unintended consequences that affected neighborhoods differently: relocation of smokers to outdoor setting, SHS exposure, noise disturbance and cigarette butt littering. Changes in the urban environment in the three neighborhoods resulted in the denormalization of smoking in outdoor public places, which was more clearly perceived in the high SES neighborhood. Changes in the built environment in outdoor areas of hospitality venues were reported to actually facilitate smoking. Comprehensive smoke-free laws resulted in denormalization of smoking, which might be effective in reducing SHS exposure. Extending smoking bans to outdoor areas like bus stops and hospitality venues is warranted and should include a public health inequalities perspective.
As resident physicians practicing Internal Medicine in hospitals within the USA, we are confronted on a daily basis with patients who wish to leave the hospital floor to smoke a cigarette. While many physicians argue that hospitals should do everything in their power to prevent patients from smoking, we argue that a more comprehensive and nuanced approach is needed. In part 1 of this perspective piece, we outline the various forms of smoking bans in hospital settings, applauding the development of indoor smoking bans while questioning the move towards stricter, campus-wide smoking bans. In part 2, we turn to traditional biomedical ethics to guide our approach to the hospitalised patient who smokes. This approach, which is informed by our backgrounds in harm reduction and medical anthropology, takes into account the lived realities of patients and acknowledges the complicated sociohistorical contexts of tobacco use.
71 selected essays on public health published between 1982-2016 in journals, newspaper opinion pages and blogs by Simon Chapman, professor of public health at the University of Sydney Full text (pdf) available here
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Passive smoking has been linked to an increased risk of dying from atherosclerotic heart disease. Since endothelial dysfunction is an early feature of atherogenesis and occurs in young adults who actively smoke cigarettes, we hypothesized that passive smoking might also be associated with endothelial damage in healthy young-adult nonsmokers. We studied 78 healthy subjects (39 men and 39 women) 15 to 30 years of age (mean +/- SD, 22 +/- 4): 26 control subjects who had never smoked or had regular exposure to environmental tobacco smoke, 26 who had never smoked but had been exposed to environmental tobacco smoke for at least one hour daily for three or more years, and 26 active smokers. Using ultrasonography, we measured the brachial-artery diameter under base-line conditions, during reactive hyperemia (with flow increase causing endothelium-dependent dilatation), and after sublingual administration of nitroglycerin (an endothelium-independent dilator). Flow-mediated dilatation was observed in all control subjects (8.2 +/- 3.1 percent; range, 2.1 to 16.7) but was significantly impaired in the passive smokers (3.1 +/- 2.7 percent; range, 0 to 9; P < 0.001 for the comparison with the controls) and in the active smokers (4.4 +/- 3.1 percent; range, 0 to 10; P < 0.001 for the comparison with the controls; P = 0.48 for the comparison with the passive smokers). In the passive smokers, there was an inverse relation between the intensity of exposure to tobacco smoke and flow-mediated dilatation (r = -0.67, P < 0.001). In contrast, dilatation induced by nitroglycerin was similar in all groups. Passive smoking is associated with dose-related impairment of endothelium-dependent dilatation in healthy young adults, suggesting early arterial damage.
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To provide a hazard prioritisation for reported chemical constituents of cigarette smoke using toxicological risk assessment principles and assumptions. The purpose is to inform prevention efforts using harm reduction. International Agency for Research on Cancer Monographs; California and US Environmental Protection Agency cancer potency factors (CPFs) and reference exposure levels; scientific journals and government reports from the USA, Canada, and New Zealand. This was an inclusive review of studies reporting yields of cigarette smoke constituents using standard ISO methods. Where possible, the midpoint of reported ranges of yields was used. Data on 158 compounds in cigarette smoke were found. Of these, 45 were known or suspected human carcinogens. Cancer potency factors were available for 40 of these compounds and reference exposure levels (RELs) for non-cancer effects were found for 17. A cancer risk index (CRI) was calculated by multiplying yield levels with CPFs. A non-cancer risk index (NCRI) was calculated by dividing yield levels with RELs. Gas phase constituents dominate both CRI and NCRI for cigarette smoke. The contribution of 1,3-butadiene (BDE) to CRI was more than twice that of the next highest contributing carcinogen (acrylonitrile) using potencies from the State of California EPA. Using those potencies from the USEPA, BDE ranked third behind arsenic and acetaldehyde. A comparison of CRI estimates with estimates of smoking related cancer deaths in the USA showed that the CRI underestimates the observed cancer rates by about fivefold using ISO yields in the exposure estimate. The application of toxicological risk assessment methods to cigarette smoke provides a plausible and objective framework for the prioritisation of carcinogens and other toxicant hazards in cigarette smoke. However, this framework does not enable the prediction of actual cancer risk for a number of reasons that are discussed. Further, the lack of toxicology data on cardiovascular end points for specific chemicals makes the use of this framework less useful for cardiovascular toxicity. The bases for these priorities need to be constantly re-evaluated as new toxicology information emerges.
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The sentiment that woodsmoke, being a natural substance, must be benign to humans is still sometimes heard. It is now well established, however, that wood-burning stoves and fireplaces as well as wildland and agricultural fires emit significant quantities of known health-damaging pollutants, including several carcinogenic compounds. Two of the principal gaseous pollutants in woodsmoke, CO and NOx, add to the atmospheric levels of these regulated gases emitted by other combustion sources. Health impacts of exposures to these gases and some of the other woodsmoke constituents (e.g., benzene) are well characterized in thousands of publications. As these gases are indistinguishable no matter where they come from, there is no urgent need to examine their particular health implications in woodsmoke. With this as the backdrop, this review approaches the issue of why woodsmoke may be a special case requiring separate health evaluation through two questions. The first question we address is whether woodsmoke should be regulated and/or managed separately, even though some of its separate constituents are already regulated in many jurisdictions. The second question we address is whether woodsmoke particles pose different levels of risk than other ambient particles of similar size. To address these two key questions, we examine several topics: the chemical and physical nature of woodsmoke; the exposures and epidemiology of smoke from wildland fires and agricultural burning, and related controlled human laboratory exposures to biomass smoke; the epidemiology of outdoor and indoor woodsmoke exposures from residential woodburning in developed countries; and the toxicology of woodsmoke, based on animal exposures and laboratory tests. In addition, a short summary of the exposures and health effects of biomass smoke in developing countries is provided as an additional line of evidence. In the concluding section, we return to the two key issues above to summarize (1) what is currently known about the health effects of inhaled woodsmoke at exposure levels experienced in developed countries, and (2) whether there exists sufficient reason to believe that woodsmoke particles are sufficiently different to warrant separate treatment from other regulated particles. In addition, we provide recommendations for additional woodsmoke research.
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The current lack of empirical data on outdoor tobacco smoke (OTS) levels impedes OTS exposure and risk assessments. We sought to measure peak and time-averaged OTS concentrations in common outdoor settings near smokers and to explore the determinants of time-varying OTS levels, including the effects of source proximity and wind. Using five types of real-time airborne particle monitoring devices, we obtained more than 8000 min worth of continuous monitoring data, during which there were measurable OTS levels. Measurement intervals ranged from 2 sec to 1 min for the different instruments. We monitored OTS levels during 15 on-site visits to 10 outdoor public places where active cigar and cigarette smokers were present, including parks, sidewalk cafés, and restaurant and pub patios. For three of the visits and during 4 additional days of monitoring outdoors and indoors at a private residence, we controlled smoking activity at precise distances from monitored positions. The overall average OTS respirable particle concentration for the surveys of public places during smoking was approximately 30 microg m(-3). OTS exhibited sharp spikes in particle mass concentration during smoking that sometimes exceeded 1000 microg m(-3) at distances within 0.5 m of the source. Some average concentrations over the duration of a cigarette and within 0.5 m exceeded 200 microg m(-3), with some average downwind levels exceeding 500 microg m(-3). OTS levels in a constant upwind direction from an active cigarette source were nearly zero. OTS levels also approached zero at distances greater than approximately 2 m from a single cigarette. During periods of active smoking, peak and average OTS levels near smokers rivaled indoor tobacco smoke concentrations. However, OTS levels dropped almost instantly after smoking activity ceased. Based on our results, it is possible for OTS to present a nuisance or hazard under certain conditions of wind and smoker proximity.