Environmental tobacco smoke (ETS)

“the most dangerous development to the long-term viability of the tobacco industry
that has yet occurred."

Most smoke from a cigarette goes into the air.   Women and children may face greatest risk from this, which is both a civil rights and public health issue.  Public support for control of ETS is high, perhaps especially among women.  Many buildings are now covered by policy, but regulations are often ignored.  And for many women most exposure occurs at home. 

Composition of ETS
Environmental tobacco smoke accounts for about 85% of the smoke from a cigarette. Compared with mainstream smoke inhaled directly by smokers, it contains higher levels of a range of carcinogens, and more carbon monoxide, nicotine and ammonia.  Particles are smaller and can be inhaled more deeply.

Tobacco is almost the only natural source of nicotine.   But nicotine is quickly broken down, so the metabolite cotinine is usually measured.  Cotinine in blood, saliva or urine shows that non-smokers absorb other people’s smoke, and is a sensitive indicator of ETS exposure. Tobacco specific carcinogens are also found in non-smokers’ urine.

Health risks

Cardiovascular disease
An official UK review concluded that risk of heart disease is increased by around a quarter (23%) by living with a smoker,  with similar findings for women separately.  This is surprisingly large, given that exposure is only 1% of that for smokers.  But ETS has higher level of toxins than mainstream smoke, and biological mechanisms may be different.  For example, ETS may have more impact on platelet aggregation, which thickens the blood.

Research in New Zealand also suggests increased risk of stroke, up by two-thirds for women (RR 1.66). Links with common circulatory diseases make ETS a major health issue.  For example, a US study suggests that ETS may be their third major cause of death, after smoking and alcohol. However, early arterial damage linked to ETS may reverse
within a year or so.

Lung and other cancer
All available evidence confirms that ETS causes lung cancer. The UK review gives best estimate of around 20-30% extra risk. In the UK alone this represents several hundred deaths a year.   A review of 37 studies on women estimated that risk is increased by a quarter (26%) by living with a smoker, for women who never smoked.  Risk increases with length of exposure, and the number of cigarettes the smoker uses.  Recent research suggests increased risk for women lacking a certain enzyme, which detoxifies tobacco carcinogens (glutathione S-transferase M1).

 The US ranks ETS as a Class A carcinogen, together with radon, asbestos, and benzene.
A major report from the Californian Environmental Protection Agency also links ETS to nasal and cervical cancers, and a link with breast cancer is suspected.

Other risks
Those exposed to ETS show small reduction in lung function, increased cough and phlegm. Risk of pneumonia is more than doubled. Angina and symptoms of lung disease may increase with even short-term exposure.  Women are at particular risk of asthma symptoms. Many women also suffer other discomfort, including headache, sore throat, and sore eyes, the last particularly among contact lens users.

Pregnancy
Exposure to ETS during pregnancy affects foetal growth.   More than 30 studies have found lower birth weights for babies born to these mothers.  Generally, the higher the exposure, the lower the birth weight.  ETS has also been linked to risk of spontaneous abortion, particularly in mid-term pregnancy. Finland proposes that women working in smoky areas should have maternity leave soon after pregnancy is confirmed.

Child health

ETS has a huge impact on the health of millions of European children living with smokers. For example, in the UK almost half of all children live with one or more smokers.   Data below are taken from a major UK review. Mothers usually spend more time with infants, so their smoking has greater effect.  This can lead to guilt, but women may have little control over smoking by other people in the house. In poor households damp and overcrowding may add to risk. 

However in Sweden timely information on the effects of ETS has helped prevent relapse to smoking after pregnancy.   Child-health nurses visit within four weeks of the birth, to talk over the benefits of staying stopped.   Relapse then falls to 20% at 8 months, and fathers are also less likely to smoke.

Sudden infant death syndrome  - SIDS
Risk of SIDS has been reduced by advice to put babies on their backs to sleep.  But smoking seems to be an independent risk factor.  The UK review estimates that risk is doubled if the mother smokes (RR 2.08) and increased by over half if the father smokes (RR 1.63).  Another study found nearly four-fold increase if both smoke (RR  3.79).

Respiratory problems
Living in a smoky home increases risk of infections, including croup, bronchitis, bronchiolitis and pneumonia.  Risk is increased by nearly two-thirds when mothers smoke, and by half for fathers (RR 1.64, 1.48).   Children exposed to ETS may also have more risk of meningitis.

Asthma and respiratory symptoms such as wheeze and cough are more common too, with mothers’ smoking increasing risk by around a third (RR 1.38 for cough, 1.61 if both smoke). Tobacco smoke probably does not cause asthma, but symptoms are more common, especially in infants.   Asthma is the most common chronic disease of childhood.

These effects have substantial population impact.  For example, it’s estimated that nearly half the children in Madrid (42%) have respiratory problems linked to ETS. An American survey suggests that ETS accounts for around a fifth of the budget for child respiratory care.

Early childhood exposure to ETS also causes acute and chronic middle ear disease, including “glue ear”. This is the most common cause of child deafness, and the most usual reason for child operations.

Other serious illness  
There is some evidence that childhood exposure to ETS promotes development of arterial disease.   More work needs to be done, but some studies also link tobacco smoke to risk of childhood cancers including leukaemia, brain tumours and lymphomas.  The Californian EPA report also suggests that cystic fibrosis may be made worse.

Child development
Children of smokers are slightly shorter than children of non-smokers, though this may reflect the 6-8 cm difference at birth.  These children also do less well at school.  They process information less easily, and have more behavioural problems, including hyperactivity and short attention span.  Most of these studies take social and demographic factors into account.

Action on ETS

Every two years the European Commission reviews laws or guidelines on smoking at work, or in public places, which are often workplaces too.  It also reviews the status of ETS as a workplace carcinogen.  Nordic states generally have well-developed policies, though restrictions are often ignored.  Some central and eastern states such as Hungary and Croatia have new laws, and the Russian parliament has approved a widespread ban in public buildings.  But for many women most exposure to ETS occurs at home, where they may feel unable to control smoking by other household members.

ETS at home

The best way to protect others is to limit areas where people smoke.  Parents who smoke can protect children by not smoking in the house or in a car.  Or they may choose to smoke in one room, away from children, with doors closed and good ventilation.  Some health projects, particularly in poorer areas, have aimed to help women reduce risk in this way.   

ETS in public places
The last two decades have seen great progress in smokefree provision across Europe.   Since the 1970s official buildings, shops, banks, and leisure facilities are much less likely to allow smoking everywhere. 

However, legislation is still patchy.  Effective control appears to depend partly on public acceptance of the dangers, and countries with a high awareness generally have more effective policies.  Reviews in the US suggest that restrictions reduce total tobacco consumption by 4-10%. But these restrictions may also limit public access for some women, especially those from poorer social groups.

ETS at work

Public opinion
In 1992 a Europe Against Cancer survey found strong support across the EU for formal restriction on smoking at work:

Smokers are almost as likely to be in favour as non-smokers.  Workplaces which employ more women are more likely to have restrictions. It is suggested that women are more likely to request or accept restrictions, or that management are more willing to respond.

Ireland 90%   Luxembourg 84%
Portugal        88%   Denmark    83%
UK  87% Belgium 82%

France

 87% Germany    82%
Greece 87% Spain   82%
Netherlands 84%    

Smokers are almost as likely to be in favour as non-smokers.  Workplaces which employ more women are more likely to have restrictions. It is suggested that women are more likely to request or accept restrictions, or that management are more willing to respond.

Smoking policies
The potential benefits of an effective policy include reduced costs for insurance, furniture, cleaning and redecorating.  Productivity may also benefit and there is less risk of legal action. Current smokefree provision varies by business sector as well as by country.  Some European industries, mainly computer and linked products, have long had effective policies.   But these are usually to protect the environment, rather than workers.  (Smoky air is bad for microchips as well as lungs.)  The schools, shops, banks and official buildings where many women work are increasingly covered by a policy. 

However, many European women work in ‘hospitality’ jobs.  Smoking in restaurants and bars is seen as normal, and rooms may be poorly ventilated.  Women work long hours, as pay is low, and are likely be exposed to large doses of ETS.  These facilities are often exempt from regulation.  But in Finland, where ETS is classified as a carcinogen, restaurant workers must be registered and health monitored.

In general women may find it more difficult to complain about ETS, particularly if they have poor job security, and their bosses smoke.  Yet premises which do introduce smokefree areas find no loss of custom, or even improved trade.

Using the law on ETS

More workplaces are becoming smoke-free, though present EU law only requires employers to provide a smoke-free rest area.   But women may also use ‘health and safety’ laws.  For example, a secretary with a shipping company used the UK Health and Safety at Work Act (1974).  She claimed she’d been forced out of a job (‘constructive dismissal’) as her employers refused to provide a smoke-free workplace. The judge said employers must offer a ”working environment which is reasonably suitable for the performance by them of their contractual duties”. The Dutch Asthma Fund is also taking a case to court, claiming that Dutch workers have a right to smoke-free workstations, corridors, lavatories and restaurants. 

An EC guide gives further information on current restrictions on smoking in EU countries.
Or see the ASH European Bulletin for updates on legal cases, and progress on smokefree areas across Europe.

Action points

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