© Oxford University Press 2006.
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Surgeon General's Report Heralds Turning Tide Against Tobacco, Smoking
The recent report on secondhand smoke from the U.S. Surgeon General has already been the impetus for several new smoking bans and may be the starting point for a national movement, according to smoke-free advocates.
"The scientific evidence is now indisputable: Secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults," then–Surgeon General Richard Carmona, M.D., said at a press briefing to release the report in June.
The report reviews 20 years of literature since the Surgeon General's last report on the dangers of secondhand smoke and concludes that secondhand smoke is so hazardous that no level of exposure can be considered safe. Antitobacco advocates say the new report will accelerate an already heavy downpour of state and local government regulations that are banning smoking in workplaces, restaurants, and bars.
"It is not surprising that secondhand smoke is so harmful. Nonsmokers who are exposed to secondhand smoke inhale the same toxins and cancer-causing substances as smokers. ... This helps explain why nonsmokers who are exposed to secondhand smoke develop some of the same diseases that smokers do," said Carmona, whose 4-year term expired at the end of July. "Breathing secondhand smoke for even a short time can damage cells and set the cancer process in motion."
According to the report, nonsmokers exposed to secondhand smoke have as much as a 20%–30% increased risk of developing lung cancer. Secondhand smoke is responsible for approximately 3,000 lung cancer deaths a year, from the findings of 50 epidemiologic studies collated by the Surgeon General's office.
The report also concludes that secondhand smoke creates other health hazards such as cardiovascular disease and an increased incidence of respiratory infections, especially in children. However, there was inadequate evidence to determine whether secondhand smoke increases the risk of other forms of cancer, such as breast and cervical cancer. But the evidence of the dangers of secondhand smoke continues to build.
At the World Conference on Tobacco OR Health held last month in Washington, investigators presented studies further strengthening the link between occupational exposure to secondhand smoke and an increased risk of developing not only lung cancer but also other common tumors, such as breast cancer.
An analysis by Canadian researchers that looked at data from 19 studies concluded that the risk of developing breast cancer among women who have never smoked but were regularly exposed to secondhand tobacco smoke may be as high as twice that of other women and is comparable to that of women who smoked.
In a speech a day before the release of the Surgeon General's report, American Cancer Society CEO John Seffrin, Ph.D., called for the global cancer community to come together to combat the "scourge of tobacco."
"In the last century, tobacco use killed 100 million smokers. If left unchecked, tobacco use will kill more than one billion people in this century, the worst case of avoidable loss of life in world history. Yet, with comprehensive, concerted action, we can eliminate the global scourge of tobacco and save hundreds of millions of lives within the next few decades," he said.
Seffrin called on the White House to ratify the World Health Organization Framework Convention on Tobacco Control, which has already been signed by 133 of the 140 countries needed for it to go into effect.
"The treaty hits the tobacco companies where they live by restricting their insidious and immoral marketing tactics. It gives nations—particularly the low-income nations the tobacco companies have targeted as their most promising markets—powerful new tools to protect their citizens from the tobacco industry's deception," he said.
Other members of the medical community also took the Surgeon General's report as an opportunity to voice their support for legislative efforts to reduce environmental exposure to tobacco smoke.
Secondhand smoke contains more than 50 chemicals that cause cancer. "The dangers of secondhand smoke are evident. No one should be exposed to secondhand smoke's harmful effects," said Ron Davis, M.D., president-elect of the American Medical Association.
The AMA recently called for more funding for smoking cessation programs and advocacy efforts to eliminate smoking in public places and workplaces at the national, state, and local levels.
Carmona said that he hoped the report's release would mark the beginning of a movement to reduce public exposure to secondhand smoke. Although he stopped short of advocating a federal ban on smoking in public places, he said that his office can support such efforts.
"My goal is to make sure that Congress and the American public and anybody who needs this scientific information gets it in order that they can make informed decisions. I have been elated by all the advocacy I have seen from individuals to families to small communities to big cities who have taken charge to create smoke-free environments in the work place and recreation areas. The issue of legislation, bans, and those things, that's really up to Congress whether they think that is necessary. My job is to make sure and, I hope, to empower the American public to take charge of this situation," he said in response to questions at the press briefing.
"At the federal government level, we have stepped up. We have created smoke-free environments in our own buildings. We have encouraged people not to smoke. We have given them access to quit hotlines. ... We are trying to lead by example," he continued.
The Surgeon General's report concludes that "smoke-free environments are the only approach that effectively protects nonsmokers from the dangers of secondhand smoke."
A few days after the release of the report, the National Cancer Institute announced a new policy that its meetings and conferences would be held only in jurisdictions that have adopted comprehensive smoke-free regulations.
"NCI seeks to recognize the contribution of states, counties, cities, and towns that have chosen to protect the public, including employees, from secondhand smoke exposure," said Robert Croyle, Ph.D., director of NCI's Division of Cancer Control and Population Sciences. "We hope this policy will encourage other states and cities to do likewise."
As of September, all Marriott-owned facilities in both the United States and Canada are smoke free. "Demand for nonsmoking rooms continues to rise with new information from the Surgeon General on the hazards of secondary smoke," according to statement from the hotel chain. Smoking was already prohibited in many of the hotels' public spaces by local laws.
Currently, 33 states and the District of Columbia have local smoke-free laws that prohibit smoking in workplaces, restaurants, bars, or any combination. Those laws cover 44.5% of the U.S. population.
"There has been this incredible norm change over the past 30 years," said Cynthia Hallet, executive director of Americans for Nonsmokers' Rights. "It starts at the local level, but once it reaches a threshold at the community level, it eventually moves up to the state level."
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It has reached that level in 17 states (Hawaii will become the 18th in November) that currently prohibit smoking in workplaces, restaurants, bars, or all three. Another three states have enacted smoke-free laws that have not yet gone into effect.
The trend began on the coasts and has slowly moved toward the middle of the country, even making inroads in the deep South and other tobacco strongholds, Hallet said.
Over the last few years, cities like Lexington and Louisville, Ky., and Hilton Head, N.C., have defied vested state interests to pass their own smoke-free ordinances, she said.
The current political environment may not be ripe for a federal ban, but as public-health advocates push for smoke-free areas in more and more states, eventually the country will reach a threshold where a national movement does make sense, Hallet said. Studies in other countries have shown that government bans on smoking in restaurants are effective in substantially lowering occupational exposure. A Finnish study examining the impact of national tobacco reform legislation found that extended exposure to secondhand smoke among restaurant workers went from 45% to 29% among women and from 49% to 35% among men. The study also found that a larger percentage of restaurant employees reported no exposure after passage of the law.
The Surgeon General's report shows that exposure to secondhand smoke, as gauged by the biomarker cotinine, has declined by 70% over the past decade. But more than 126 million nonsmoking Americans are still exposed to it at home or work. "We have had tremendous incremental improvement over the last couple of decades, since the report in ’86, but none of us on our team are complacent about that. We know that there is a lot more to do," Carmona said.
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