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MEMORANDUM
March 28, 2007
TO: Shana Yelverton, City Manager
FROM: Ken Baker, Planning and Development Services Director
SUBJECT: Ordinance No. 907, 1s` Reading, Amending Chapter 10, Article V, "Public
Smoking," of the Southlake City Code
Action Requested: Consider approving Ordinance No. 907, 1" Reading, Amending Chapter 10,
Article V, "Public Smoking" of the Southlake City Code.
Background
Information: The basis for the City of Southlake reviewing its smoking ordinance is the US
Surgeon General report "The Health Consequences of Involuntary Exposure to
Tobacco Smoke" (See Attachment A). This report was released in .Tune, 2006.
At the press conference to launch the report, the US Surgeon General stated
that based on overwhelming scientific evidence a number of new conclusions
regarding the effects of smoking have been reached. These conclusions
include:
• Secondhand smoke exposure causes heart disease and lung cancer in
adults and sudden infant death syndrome and respiratory problems in
children.
There is no risk-ffree level of secondhand smoke exposure, with even
brief exposure adversely affecting the cardiovascular and respiratory
system.
Only smoke -free environments effectively protect nonsmokers from
secondhand smoke exposure in indoor spaces.
Finally, the Report concludes that, while great strides have been made in recent
years in reducing nonsmoking Americans' secondhand smoke exposure,
millions of Americans continue to be exposed to secondhand smoke in their
workplaces..
Here in the Metroplex there are several cities that have either adopted or are
considering changes to their smoking policies including Irving and Fort Worth,
Arlington and Dallas. The Smoking Ordinance in Southlake was last revised
in 1998.
The staff presented a draft of the proposed smoking ordinance to City Council
on January 16, 2006, The new ordinance proposes prohibiting smoking in all
public buildings (i.e. stores, restaurants, taverns, schools, offices, warehouses),
outdoor dining areas, and within 12 feet of a public building entrance. A
comparison of the 1998 ordinance and the proposed new ordinance is provided
in Attachment B. There have been no changes to the proposed smoking
ordinance since staff s presentation in January,
On March 12, 2007, a City-wide SPIN meeting was held regarding the new
ordinance. Approximately 15 people were in attendance. A summary of this
SPIN meeting is included in the staff report (See Attachment C).
Finally, the City has received correspondence regarding the proposed
ordinance. Those e-mails have been provided (See Attachment D),
Financial
Considerations: None.
Financial Impact: None.
Citizen Input/
Board Review: City-wide SPIN meeting held March 12, 2007.
Legal Review: The City Attorney has reviewed the proposed ordinance.
Supporting
Documents: Attachment A - Summary of the press conference launching the Surgeon
General's report "The Health Consequences of Involuntary Exposure to
Tobacco Smoke" and Chapter I of this report (Introduction, Summary and
Conclusion).
Attachment B — Smoking Ordinance Comparison (1998 versus 2007
proposed)
Attachment C — SPIN report
Attachment D -.. Correspondence
Attachment E — Proposed Ordinance No, 907
Attachment A
Summary of the press conference launching the Surgeon General's
report "The Health Consequences of Involuntary Exposure to
Tobacco Smoke" and Chapter 1 of this report (Introduction,
Summary and Conclusion).
(See following page)
Remarks at press conference to launch Health Consequences of Involuntary Exposure to Tobacco Smoke:.. Page 1 of 7
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Newsroom Remarks at press conference to launch Surgeon
General's smoking
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Contact us Health Consequences of Involuntary full_story
Exposure to Tobacco Smoke: A Report of • March 6, 2007
the Surgeon General Acting Surgeon General
Issues National Call to
Tuesday, .tune 27, 2006 Action on underage
Drinking
10:00 a.m. full -story
Washington, D.C.
• February 14, 2007
"The Health Effects of Secondhand Smoke" statement by Rear Admiral
Kenneth Morltsugu Acting
Surgeon General Regarding
you, Rear Admiral Moritsu a for our kind National Donor nay
Thank
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Introduction.
Features
I am grateful to be here today and to be able to
say unequivocally that the debate is over. The
• The-Sur_gecsn_General's Call
science is clear: Secondhand smoke Is not a
to Action to Prevent_a.fld.
Reduce underage Drinking
mere annoyance, but a serious health hazard
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that causes premature death and disease In
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children and nonsmokingadults.
• The �lealth_Consequence
t of Involuntary -Exposure to
Tobacco. Smoke
Updating the Evidence
Related Websites
Twenty years ago, the 1986 Surgeon General's
Report on The Health Consequences of
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Involuntary Smoking concluded that secondhand
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Smoke exposure was a cause of disease in
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nonsmokers, That Report, which was one of the
• NledlcalReseLve Corps
first major reports to investigate this topic,
concluded that secondhand smoke caused lung
cancer among nonsmoking adults and several
respiratory problems among children,
Since that Report was published, hundreds of
peer -reviewed studies and several additional
major reports on the health effects of
secondhand smoke have been published, and
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Remarks at press conference to launch Health (consequences of Involuntary Exposure to Tobacco Smoke:... Page 2 of 7
the evidence on these health effects has become
even stronger,
The Surgeon General's Report that we are
releasing today, The Health Consequences of
.involuntary Exposure to Tobacco Smoke,
documents beyond any doubt that secondhand
smoke harms people's health. In the course of
the past 20 years, the scientific community has
reached consensus on this point,
Main Messages
I would like to draw your attention to several
new conclusions that I have reached due to
overwhelming scientific evidence,
• Secondhand smoke exposure causes heart
disease and lung cancer in adults and sudden
infant death syndrome and respiratory problems
in children.
• There is NO risk -free level of secondhand smoke
exposure, with even brief exposure adversely
affecting the cardiovascular and respiratory
system.
• Only smoke -free environments effectively
protect nonsmokers from secondhand smoke
exposure in indoor spaces.
• Finally, the Report concludes that, while great
strides have been made in recent years in
reducing nonsmoking Americans' secondhand
smoke exposure, millions of Americans continue
to be exposed to secondhand smoke in their
homes and workplaces,
Secondhand Smoke is Harmful to All People
Allow me to expand on the first major
conclusion. Secondhand smoke Is a health
hazard for all people: it is harmful to both
children and adults, and to both women and
men. It is harmful to nonsmokers whether they
are exposed in their homes, their vehicles, their
workplaces, or in enclosedpublic places. We
have found that certain populations are
especially susceptible to the health effects of
secondhand smoke, including infants and
children, pregnant women, older persons, and
persons with pre-existing respiratory conditions
and heart disease,
It Is not surprising that secondhand smoke is so
harmful, Nonsmokers who are exposed to
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secondhand smoke inhale the same toxins and
cancer -causing substances as smokers.
Secondhand smoke has been found to contain
more than 50 carcinogens and at least 250
chemicals that are known to be toxic or
carcinogenic. This helps explain why
nonsmokers who are exposed to secondhand
smoke develop some of the same diseases that
smokers do.
Health Effects of Exposure to Secondhand Smoke
in Adults
Let's look first at the health effects that
secondhand smoke causes in adults.
Lung Cancer
The Report confirms that secondhand smoke is a
known human carcinogen that causes lung
cancer in nonsmoking adults. Nonsmokers who
are exposed to secondhand smoke, at home or
at work, increase their risk of developing lung
cancer by 20 percent to 30 percent, Secondhand
smoke causes approximately 3,000 lung cancer
deaths among U.S. nonsmokers each year.
Heart Disease
The Report released today also concludes that
secondhand smoke causes heart disease.
Nonsmoking adults who are exposed to
secondhand smoke at home or at work increase
their risk of developing heart disease by 25 to
30 percent. The evidence indicates that even
brief secondhand smoke exposures can have
Immediate adverse effects on the cardiovascular
system. This is especially true for persons who
already have heart disease, or who are at
special risk of heart disease. Secondhand smoke
causes tens of thousands of heart disease
deaths each year among U.S. nonsmokers.
Health Effects of Secondhand Smoke Exposure in
Children
Now let's turn to the special health risks that
secondhand smoke poses to children. Because
their bodies are still developing, infants and
children are especially vulnerable to the poisons
in secondhand smoke,
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Respiratory Infections
Secondhand smoke is a cause of respiratory
conditions in children —we've known that since
our study of second hand smoke effects began
in 1986, however, after further research and
analysis, we have found that the consequences
of smoke on a child's respiratory system are
more severe than originally thought. Acute
respiratory infections such as bronchitis and
pneumonia, respiratory symptoms such as
cough, phlegm, wheezing, and breathlessness,
more frequent and severe asthma attacks,
slowing of lung growth, and ear infections have
all been proven to be results of exposure to
secondhand smoke in children,
SIDS
In an important new finding, we have
determined that secondhand smoke is a cause
of sudden infant death syndrome (SIDS).
Infants who die from SIDS tend to have higher
concentration of nicotine In their lungs and
higher levels of cotinine (a biological marker for
secondhand smoke exposure) than Infants who
die from other causes. We have also found that
Infants who are exposed to secondhand smoke
after birth are also at increased risk of dying of
SIDS,
In addition, babies of nonsmoking women who
are exposed to secondhand smoke during
pregnancy are at risk for a small reduction in
birth weight Chemicals in secondhand smoke
appear to affect the brain in ways that interfere
with its regulation of infants' breathing.
There is No Risk -Free Level of Exposure to
Secondhand Smoke
We know that secondhand smoke harms
people's health, but many people assume that
exposure to secondhand smoke in small doses
does not do any significant damage to one's
health. However, science has proven that there
is NO risk -free level of exposure to secondhand
smoke. Let me say that again: there is no safe
level of exposure to secondhand smoke.
Breathing secondhand smoke for even a short
time can damage cells and set the cancer
process in motion. Brief exposure can have
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Immediate harmful effects on blood and blood
vessels, potentially increasing the risk of a heart
attack. Secondhand smoke exposure can quickly
irritate the lungs, or trigger an asthma attack,
For some people, these rapid effects can be life -
threatening, People who already have heart
disease or respiratory conditions are at
especially high risk,
Establishing Smoke -free Environments is the
only Proven Way to Prevent Exposure
The good news is that, unlike some public health
hazards, secondhand smoke exposure is
preventable, A proven method exists for
protecting nonsmokers from the health risks
associated with secondhand smoke exposure:
avoiding places where secondhand smoke is
present.
An important new conclusion of this Report is
that smoke -free environments are the ONLY
approach that effectively protects nonsmokers
from the dangers of secondhand smoke. The
1986 Surgeon General's Report concluded that
the simple separation of smokers and
nonsmokers within the same air space may
reduce, but does not eliminate, secondhand
smoke exposure among nonsmokers. The
current Report expands on that finding by
concluding that even sophisticated ventilation
approaches cannot completely remove
secondhand smoke from an indoor space.
Because there is no risk -free level of
secondhand smoke exposure, anything less
cannot ensure that nonsmokers are fully
protected from the dangers of exposure to
secondhand smoke,
Yet, Many Americans Remain at Risk
The good news is that we are making progress,
Secondhand smoke exposure among U.S.
nonsmokers has declined since the publication of
the 1986 Surgeon General's Report, Levels of
cotinine, the blomarker of secondhand smoke
exposure, fell by 70 percent from 1988-91 to
2001-02, The proportion of nonsmokers with
detectable cotinine levels has been halved from
88 percent to 43 percent.
However, while we have made great strides over
the years to reduce smoking in America, the
success story is not complete, More than 126
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million nonsmoking Americans, Including both
children and adults, are still exposed to
secondhand smoke in their homes and
workplaces.
Given the extensive evidence on the serious
health risks posed by secondhand smoke
exposure that is reviewed in the Report we are
releasing today, the involuntary nature of this
exposure, and the availability of a proven
method for eliminating these risks, we cannot be
satisfied until all Americans are aware of the
health hazards caused by secondhand smoke on
their families and loved ones.
companion Piece
As many of you are aware, I have made it my
goal as US Surgeon General to increase the
overall health literacy of my fellow Americans.
Health literacy is the ability of an Individual to
access, understand, and use health -related
information and services to make appropriate
health decisions.
More than 90 million Americans cannot
adequately understand basic health information.
People of all ages, races, incomes, and
education levels are challenged by low health
literacy,
By making health information easier to
understand, we allow people to actively take
steps to increase their health and wellness and
to actually prevent disease as a result of healthy
choices.
Because of this, all communications issued by
the Office of the Surgeon General for the
general public are now tested to be sure that
they are on a reading level where people can
understand and use the Information. In addition
to this report, I am also releasing a magazine -
style, full -color "Consumer Guide or People's
Piece" with the science presented in a way that
every American can understand and apply to
their individual circumstances.
By placing the conclusions of the Report into the
hands of Americans, we ensure that the Report
has an impact that extends beyond the scientific
community into people's daily lives. I am
confident that the information in this Report,
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Remarks at press conference to launch Health Consequences of Involuntary Exposure to Tobacco Smoke:.., Page 7 of 7
when broadly disseminated, will literally save
lives. Copies of the Report and the People's
Piece are available on my website;
www...surgeongeneral.gov.
Thank you for being here today. Car, 5amet, will
you please join me on stage for questions, We
will now answer questions that you may have.
Last revised: January 8, 2007
HHS_Home I Questions.?, I Con.tact_HH5 I Site -Feedback I Accessibility. I P-rJvacy-Ea.11.cy I EOIA I Disclaimers
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U,S. Department of Health & Human services • 200 Independence Avenue, SM. - Washington, D,C. 20201
http://www.surgeongeneral.gov/news/speeches/06272006a,html 3/28/2007
Chapter 1
Introduction, Summary, and Conclusions
Introduction 3
Organization of the Report 8
Preparation of the Report 9
Definitions and Terminology 9
Evidence Evaluation 10
Major Conclusions 11
Chapter Conclusions 12
Chapter 2 Toxicology of Secondhand Smoke 12
Evidence of Carcinogenic Effects from Secondhand Smoke Exposure 12
Mechanisms of Respiratory Tract injury and Disease Caused by Secondhand Smoke Exposure 12
Mechanisms of Secondhand Smoke Exposure and Heart Disease 12
Chapter 3. Assessment of Exposure to Secondhand Smoke 12
Building Designs and Operations 12
Exposure Models 12
Biomarkers of Exposure to Secondhand Smoke 12
Chapter 4, Prevalence of Exposure to Secondhand Smoke 13
Chapter 5 Reproductive and Developmental Effects from Exposure to Secondhand Smoke 13
Fertility 13
Pregnancy (Spontaneous Abortion and Perinatal Death) 13
Infant Deaths 13
Sudden Infant Death Syndrome 13
Preterm Delivery 1.3
Low Birth Weight 13
Congenital Malformations 13
Cognitive Development 1.3
Behavioral Development 13
Height/Growth 13
Childhood Cancer 13
Chapter 5. Respiratory Effects in Children from Exposure to Secondhand Smoke 14
Lower Respiratory Illnesses in Infancy and Early Childhood 14
Middle Ear Disease and Adenotonsillectomy 14
Respiratory Symptoms and Prevalent Asthma in School -Age Children 14
Childhood Asthma Onset 14
Atopy 14
Lung Growth and Pulmonary Function 14
Chapter 7 Cancer Among Adults from Exposure to Secondhand Smoke 14
Lung Cancer 14
Breast Cancer 15
Nasal Sinus Cavity and Nasopharyngeal Carcinoma 15
Cervical Cancer 15
Surgem Gerieral's Report
Chapter 8 Cardiovascular Diseases from Exposure to Secondhand Smoke 15
Chapter 9. Respiratory Effects in Adults from Exposure to Secondhand Smoke 15
Odor and Irritation 15
Respiratory Symptoms 15
Lung Function 15
Asthma 16
Chronic Obstructive Pulmonary Disease 16
Chapter 10. Control of Secondhand Smoke Exposure 16
Methodologic Issues 17
Classification of Secondhand Smoke Exposure 17
Misclassification of Secondhand Smoke Exposure 19
Use of Meta -Analysis 21
Confounding 22
Tobacco Industry Activities 23
References 24
Introduction
The topic of passive or involuntary smoking
was first addressed in the 1972 U.S Surgeon Gen-
eral's report (Tlre Health Consequences of Smoking,
U.S. Department of Health, Education, and Welfare
)USDHEW) 1972), only eight years after the first Sur-
geon General's report on the health consequences of
active smoking (USDHEW 1964). Surgeon General
Dr. Jesse Steinfeld had raised concerns about this
topic, leading to its inclusion in that report. Accord-
ing to the 1972 report, nonsmokers inhale the mixture
of sidestream smoke given off by a smoldering ciga-
rette and mainstream smoke exhaled by a smoker, a
mixture now referred to as "secondhand smoke" or
"environmental tobacco smoke." Cited experimental
studies showed thatsmoking in enclosed spaces could
lead to high levels of cigarette smoke components in
the air. For carbon monoxide (CO) specifically, levels
in enclosed spaces could exceed levels then permitted
in outdoor air_ The studies supported a conclusion that
"an atmosphere contaminated with tobacco smoke
can contribute to the discomfort of many individuals"
(USDHEW 1972, p. 7). The possibility that CO emitted
from cigarettes could harm persons with chronic heart
or lung disease was also mentioned.
Secondhand tobacco smoke was then addressed
in greater depth in Chapter 4 (Involuntary Smoking)
of the 1975 Surgeon General's report, The Health Conse-
quences of Smoking (USDHEW 1975) , The chapter noted
that involuntary smoking takes place when nonsmok-
ers inhale both sidestream and exhaled mainstream
smoke and that this "smoking" is "involuntary" when
"the exposure occurs as an unavoidable consequence
ofbreathinginasmoke-filledenvironment" (p 87).The
report covered exposures and potential health conse-
quences of involuntary smoking, and the researchers
concluded that smoking on buses and airplanes was
annoying to nonsmokers and that involuntary smok-
ing had potentially adverse consequences for persons
with heart and lung diseases Two studies on nicotine
concentrations in nonsmokers raised concerns about
nicotine as a contributing factor to atherosclerotic
cardiovascular disease in nonsmokers.
The 1979 Surgeon General's report, Smoking
and Health: A Report of the Surgeon General (USDHEW
1979), also contained a chapter entitled "Involuntary
Smoking" The chapter stressed that "attention to
involuntary smoking is of recent vintage, and only
The Health Coirsequerrces of Involuntary Eiposure to Tobacco Siwk-e
limited information regarding the health effects of
such exposure upon the nonsmoker is available"
(p. 11--35). The chapter concluded with recommen-
dations for research including epidemiologic and
clinical studies The 1982 Surgeon General's
report specifically addressed smoking and cancer
(U.S. Department of Health and Human Services
)USDHHS] 1982) By 1982, there were three published
epidemiologic studies on involuntary smoking and
lung cancer, and the 1982 Surgeon General's report
included a brief chapter on this topic. That chapter
commented on the methodologic difficulties inherent
in such studies, including exposure assessment, the
lengthy interval during which exposures are likely
to be relevant, and accounting for exposures to other
carcinogens. Nonetheless, the report concluded that
"Although the currently available evidence is not suf-
ficient to conclude thatpassive or involuntary smoking
causes lung cancer in nonsmokers, the evidence does
raise concern about a possible serious public health
problem" (p. 251)..
Involuntary smoking was also reviewed in the
1984 report, which focused on chronic obstructive
pulmonary disease and smoking (USDHHS 1984).
Chapter 7 (Passive Smoking) of that report included
a comprehensive review of the mounting information
on smoking by parents and the effects on respiratory
health of their children, data on irritation of the eye,
and the more limited evidence on pulmonary effects
of involuntary smoking on adults, The chapter began
with a compilation of measurements of tobacco smoke
components in various indoor environments The
extent of the data had increased substantially since
1972. By 1984, the data included measurements of
more specific indicators such as acrolein and nicotine,
and less specific indicators such as particulate matter
(PM), nitrogen oxides, and CO The report reviewed
new evidence on exposures of nonsmokers using bio-
markers, with substantial information on levels of
cotinine, a major nicotine metabolite The report antic-
ipated future conclusions with regard to respiratory
effects of parental smoking on child respiratory health
(Table 1,1)-
Involuntary smoking was the topic for the entire
1986 Surgeon General's report, The Health Conse-
quences of Involuntany Smoking (USDHHS 1986) In its
359 pages, the report covered the full breadth of the
hitrodrrctiatr, Sunrrrrary, mid Coiidusioiis
Surgeon General's report
Table 1.1 Conclusions from previous Surgeon General's reports on the health effects of secondhand
smoke exposure
............................
Surgeon General's
Disease and statement report
Coronary heart disease: "The presence of such levels" as found in cigarettes "indicates that 1972
the effect of exposure to carbon monoxide may on occasion, depending upon the length
of exposure, be sufficient to be harmful to the health of an exposed person This would be
particularly significant for people who are already suffering from coronary heart disease "
(p 7)
Chronic respiratory symptoms (adults): "The presence of such levels" as found in cigarettes 1972
"indicates that the effect of exposure to carbon monoxide may on occasion, depending
upon the length of exposure, be sufficient to be harmful to the health of an exposed person
This would be particularly significant for people who are already suffering fromchronic
bronchopulmonary disease .. (p. 7)
Pulmonary function: "Other components of tobacco smoke, such as particulate matter and 1972
the oxides of nitrogen, have been shown in various concentrations to affect adversely animal
pulmonary. €unction. The extent of the contributions of these substances to illness in humans
exposed to the concentrations present in an atmosphere contaminated with tobacco smoke is
not presently known." (pp.. 7--8)
Asthma: 'The limited existing data yield conflicting results concerning the relationship 1984
between passive smoke exposure and pulmonary function changes in patients with asthma "
(p, 13)
Bronchitis and pneumonia: "The children of smoking parents have an 'increased prevalence of 1984
reported respiratory symptoms, and have an increased frequency of bronchitis and pneumonia
early in life " (p. 13)
Pulmonary function (children): 'The children of smoking parents appear to have measurable 1984
but small differences in tests of pulmonary function when compared with children of
nonsmoking parents.. The significance of this finding; to the future development of lung disease
is unknown." (p, 13)
Pulmonary function (adults): some studies suggest that high levels of involuntary 1984
[tobacco) smoke exposure might produce small changes in pulmonary function in normal
subjects Two studies have reported differences in measures of lung function in older
populations between subjects chronically exposed to involuntary smoking and those who were
not. This difference was not found in a younger and possibly less exposed population " (p. 13)
Acute respiratory infections: 'The children of parents who smoke have an increased 1986
frequency of a variety of acute respiratory illnesses and infections, including chest illnesses
before 2 years of age and physician -diagnosed bronchitis, tracheitis, and laryngitis, when
compared with the children of nonsmokers" (p. 13)
Bronchitis and pneumonia: "The children of parents who smoke have an increased frequency 1986
of hospitalization for bronchitis and pneumonia during the first year of life when compared
with the children of nonsmokers " (p 13)
Cancers other than lung: "The associations between cancers, other than cancer of the lung, 1986
and involuntary smoking require further investigation before a determination can be made
about the relationship of involuntary smoking to these cancers." (p 14)
Cardiovascular disease: "Further studies on the relationship behveen involuntary smoking 1986
and cardiovascular disease are needed in order to determine whether involuntary smoking
increases the risk of cardiovascular disease." (p. 14)
Chapter T
Tire Health Comegucnces of Involuntary Exposure to Tobacco Smoke
Table 1,1 Continued
Surgeon General's
Disease and statement report
Chronic cough and phlegm (children): "Chronic cough and phlegm are more frequent in 1986
children whose parents smoke compared with children of nonsmokers " (p 13)
Chronic obstructive pulmonary disease (COPD): "Healthy adults exposed to environmental 1986
tobacco smoke may have small changes on pulmonary function testing, but are unlikely
to experience clinically significant deficits in pulmonary function as a result of exposure to
environmental tobacco smoke alone " (pp. 13-14)
"The implications of chronic respiratory symptoms for respiratory health as an adult are
unknown and deserve further study.." (p. 13)
Lung cancer: "Involuntary smoking can cause lung cancer in nonsmokers " (p. 13) 1986
Middle ear effusions: 'A number of studies report that chronic middle car effusions are more 1986
common in young children whose parents smoke than in children of nonsmoking parents "
(p. 14)
Pulmonary function (children): -rhe children of parents who smoke have small differences in 1986
tests of pulmonary function when compared with the children of nonsmokers Although this
decrement is insufficient to cause symptoms, the possibility that it may increase susceptibility
to chronic obstructive pulmonary disease with exposure to other agents in adult life, a g, [sic]
active smoking or occupational exposures, needs investigation." (p 1.3)
Other.
"An atmosphere contaminated with tobacco smoke can contribute to the discomfort of many
1972
individuals" (p 7)
"Cigarette smoke can make a significant, measurable contribution to the level of indoor air
1984
pollution at levels of smoking and ventilation that are common in the indoor environment "
(p.13)
"Cigarette smoke in the air can produce an increase in both subjective and objective measures
1984
of eye irritation " (p. 13)
"Nonsmokers who report exposure to environmental tobacco smoke have higher levels of
1984
urinary cotinine, a metabolite of nicotine, than those who do not report such exposure," (p. 13)
"rhe simple separation of smokers and nonsmokers within the same air space may reduce, but
1986
does not eliminate, the exposure of nonsmokers to environmental tobacco smoke " (p 13)
"Validated questionnaires are needed for the assessment of recent and remote exposure to
1986
environmental tobacco smoke in the home, workplace, and other environments " (p. 14)
Sources: U S. Department of Health, Education, and Welfare 1972; U S Department of health and Human Services 1984,
1986.
Introduction, Surnmaty, and Conclusions
Sit rgeon General's Report
topic, addressing toxicology and dosimetry of tobacco
smoke; the relevant evidence on active smoking; pat-
terns of exposure of nonsmokers to tobacco smoke;
the epidemiologic evidence on involuntary smoking
and disease risks for infants, children, and adults; and
policies to control involuntary exposure to tobacco
smoke. That report concluded that involuntary smok-
ing caused lung cancer in lifetime nonsmoking adults
and was associated with adverse effects on respiratory
health in children. The report also stated that simply
separating smokers and nonsmokers within the same
airspace reduced but did not eliminate exposure to
secondhand smoke. All of these findings are relevant
to public health and public policy ('Table 1.1) The lung
cancer conclusion was based on extensive informa-
tion already available on the carcinogenicity of active
smoking, the qualitative similarities between second-
hand and mainstream smoke, the uptake of tobacco
smoke components by nonsmokers, and the epidemi-
ologic data on involuntary smoking The three major
conclusions of the report (Table 1.2), led Dr C_ Ever-
ett Koop, Surgeon General at the time, to comment in
his preface that "the right of smokers to smoke ends
where their behavior affects the health and well-being
of others; furthermore, it is the smokers' responsibil-
ity to ensure that they do not expose nonsmoker's to
the potential [sic] harmful effects of tobacco smoke"
(USDHHS 1986, p xii)
Two other reports published in 1986 also reached
the conclusion that involuntary smoking increased
the risk for lung cancer. The International Agency
for Research on Cancer (IARC) of the World Health
Organization concluded that "passive smoking gives
rise to some risk of cancer" (IARC 1986, p. 314).
In its monograph on tobacco smoking, the agency
supported this conclusion on the basis of the char-
acteristics of sidestream and mainstream smoke, the
absorption of tobacco smoke materials during an
involuntary exposure, and the nature of dose -response
relationships for carcinogenesis In the same year, the
National Research Council (NRC) also concluded
that involuntary smoking increases the incidence of
lung cancer in nonsmokers (NRC 1986). In reaching
this conclusion, the NRC report cited the biologic
plausibility of the association between exposure to
secondhand smoke and lung cancer and the supporting
epidemiologic evidence. On the basis of a pooled
analysis of the epidemiologic data adjusted for bias,
the report concluded that the best estimate for the
excess risk of lung cancer in nonsmokers married to
smokers was 25 percent, compared with nonsmok-
ers married to nonsmokers. With regard to the effects
of involuntary smoking on children, the NRC report
commented on the literature linking secondhand
smoke exposures from parental smoking to increased
risks for respiratory symptoms and infections and to a
slightly diminished rate of lung growth.
Since 1986, the conclusions withregard toboth the
carcinogenicity of secondhand smoke and the adverse
effects of parental smoking on the health of children
have been echoed and expanded (Table 1.3). In 1992,
the U S. Environmental Protection Agency (EPA) pub-
lished its risk assessment of secondhand smoke as a car-
cinogen (USEPA 1992). The agency's evaluation drew
on toxicologic information on secondhand smoke and
the extensive literature on active smoking A compre-
hensive meta -analysis of the 31 epidemiologic stud-
ies of secondhand smoke and lung cancer published
up to that time was central to the decision to classify
secondhand smoke as a group A carcinogen —namely,
a knotnrn human carcinogen. Estimates of approxi-
mately 3,000 U S. lung cancer deaths per year in non-
smokers were attributed to secondhand smoke. The
report also covered other respiratory health effects in
Table'1.2 Major conclusions of the 1986 Surgeon General's report, 77te Health Consequences of Involuntary
Smoking
1 Involuntary smoking is a cause of disease, including lung cancer, in healthy nonsmokers.
2 The children of parents who smoke compared with the children of nonsmoking; parents have an increased frequency
of respiratory infections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the
lung matures
3 The simple separation of smokers and nonsmokers within the same airspace may reduce, but does not eliminate, the
exposure of nonsmokers to environmental tobacco smoke.
Source: U.S. Department of Health and Human Services 1986, p. 7.
Chapter 1
The Health Consequences of Involrnrtanj Exposure to Tobacco Smoke
Table 13 Selected major reports, other than those of the U.S. Surgeon General, addressing adverse effects
from exposure to tobacco smoke
Place and date of
Agency
Publication
publication
National Research Council
Environmental Tobacco Smoke: Measuring Exposures and
Washington, D.0
.Assessing Health Effects
United States
1986
International Agency for Research on
Monographs on the Euaivation of the Carcinogenic
Lyon, France
Cancer (IARC)
Risk of Chemicals to Humans: Tobacco Smoking
1986
(IARC Monograph 38)
U S. Environmental Protection Agency
Respiratonj Health Effects of Passive Smoking: Laing
Washington, D C
(EPA)
Cancer and Other Disorders
United States
1992
National Health and Medical Research
Tire Health Effects of Passive Smoking
Canberra, Australia
Council
1997
California EPA (Cal /EPA), Office
Health Effects of Exposure to Environmental Tobacco
Sacramento, California
of Environmental Health Hazard
Smoke
United States
Assessment
1997
Scientific Committee on Tobacco and
Report of the Scientific Committee on Tobacco
London, United
Health
and Health
Kingdom
1998
World Health Organization
International Consultation on Environmental Tobacco
Geneva, Switzerland
Srnoke (ETS) and Child Health. Consultation Report
1999
IARC
Tobacco Snake and Involuntary Smoking
Lyon, France
(IARC Monograph 83)
2004
Cal/EPA, Office of Environmental
Proposed Identification of Environmental Tobacco Smoke
Sacramento, California
Health Hazard Assessment
as a Toxic Air Confatninant
United States
2005
children and adults and concluded that involuntary
smoking is causally associated with several adverse
respiratory effects in children. There was also a quan-
titative risk assessment for the impact of involuntary
smoking on childhood asthma and lower respiratory
tract infections in young children.
In the decade since the 1992 EPA report, scientific
panels continued to evaluate the mounting evidence
linking involuntary smoking to adverse health effects
(Table 1.3). The most recent was the 2005 report of the
California EPA (Cal/EPA 2005). Over time, research
has repeatedly affirmed the conclusions of the 1986
Surgeon General's reports and studies have further
identified causal associations of involuntary smok-
ing with diseases and other health disorders The
epidemiologic evidence on involuntary smoking has
markedly expanded since 1986, as have the data on
exposure to tobacco smoke in the many environments
where people spend time. An understanding of the
mechanisms by which involuntary smoking causes
disease has also deepened.
As part of the environmental health hazard
assessment, Cal/EPA identified specific health effects
causally associated with exposure to secondhand
smoke. The agency estimated the annual excess deaths
in the United States that are attributable to second-
hand smoke exposure for specific disorders: sudden
infantdeathsyndroe (SIDS), cardiac -related illnesses
(ischemic heart disease), and lung cancer (Cal/EPA
2005). For the excess incidence of other health out-
comes, either new estimates were provided or esti-
mates from the 1997 health hazard assessment were
Introduction, Siunmanj, and Conclusions
Srirgeorr General's Report
used without any revisions (Cal/EPA 1997) Overall,
Cal/EPA estimated that about 50,000 excess deaths
result annually from exposure to secondhand smoke
(Cal/EPA 2005) Estimated annual excess deaths for
the total U.S. population are about .3,400 (a range of
3,423 to 8,866) from lung cancer, 46,000 (a range of
22,700 to 69,600) from cardiac -related illnesses, and
4.30 from SIDS. The agency also estimated that be-
tween 24,300 and 71,900 low birth weight or pre -
term deliveries, about 202,300 episodes of childhood
asthma (new cases and exacerbations), between
150,000 and 300,000 cases of lower respiratory illness
in children, and about 789,700 cases of middle ear
infections in children occur each year in the United
States as a result of exposure to secondhand smoke.
This new 2006 Surgeon General's report returns
to the topic of involuntary smoking. The health effects
of involuntary smoking have not received compre-
hensive coverage in this series of reports since 1986.
Reports since then have touched on selected aspects
of the topic: the 1994 report on tobacco use among
young people (USDHHS 1994), the 1998 report on
tobacco use among U.S. racial and ethnic minorities
(USDHHS 1998), and the 2001 report on women and
smoking (USDHHS 2001). As involuntary smoking
retrains widespread in the United States and else-
where, the preparation of this report was motivated
by the persistence of involuntary smoking as a public
health problem and the need to evaluate the substan-
tial new evidence reported since 1986 This report sub-
stantially expands the list of topics that were included
in the 1986 report. Additional topics include SIDS,
developmental effects, and other reproductive effects;
heart disease in adults; and cancer sites beyond the
lung. For some associations of involuntary smoking
with adverse health effects, only a few studies were
reviewed in 1986 (e.g., ear disease in children); now,
therelevantliter'atureissubstantial. Consequently, this
reportuses meta -analysis to quantitatively summarize
evidence as appropriate. Following the approach used
in the 2004 report (7he Health Consequences of Smoking,
USDHHS 2004), this 2006 report also systematically
evaluates the evidence for causality, judging the
extent of the evidence available and then making an
inference as to the nature of the association.
Organization of the Report
This twenty-ninth report of the Surgeon Gen-
eral examines the topics of toxicology of secondhand
smoke, assessment and prevalence of exposure to
Chapter 1
secondhand smoke, reproductive and developmen-
tal health effects, respiratory effects of exposure to
secondhand smoke in children and adults, cancer
among adults, cardiovascular diseases, and the con-
trol of secondhand smoke exposure
This introductory chapter (Chapter 1) includes a
discussion of the concept of causation and introduces
concepts of causality that are used throughout this
report; this chapter also summarizes the major conclu-
sions of the report. Chapter 2 (Toxicology of Second-
hand Smoke) sets out a foundation for interpreting
the observational evidence that is the focus of most
of the following chapters The discussion details the
mechanisms that enable tobacco smoke components
to injure the respiratory tract and cause nonmalignant
and malignant diseases and other adverse effects
Chapter 3 (Assessment of Exposure to Secondhand
Smoke) provides a perspective on key factors that
determine exposures of people to secondhand smoke
in indoor environments, including building designs
and operations, atmospheric markers of secondhand
smoke, exposure models, and biomarkers of exposure
to secondhand smoke, Chapter 4 (Prevalence of Expo-
sure to Secondhand Smoke) summarizes findings that
focus on nicotine measurements in the air and coti-
nine measurements in biologic materials. The chapter
includes exposures in the home, workplace, public
places, and special populations Chapter 5 (Repro-
ductive and Developmental Effects from Exposure
to Secondhand Smoke) reviews the health effects on
reproduction, on infants, and on child development.
Chapter 6 (Respiratory Effects in Children from Expo-
sure to Secondhand Smoke) examines the effects of
parental smoking on the respiratory health of children.
Chapter 7 (Cancer Among Adults from Exposure to
Secondhand Smoke) summarizes the evidence on can-
cer of the lung, breast, nasal sinuses, and the cervix
Chapter 8 (Cardiovascular Diseases from Exposure to
Secondhand Smoke) discusses coronary heart disease
(CI-11)), stroke, and subclinical vascular disease. Chap-
ter 9 (Respiratory Effects in Adults from Exposure to
Secondhand Smoke) examines odor and irritation,
respiratory symptoms, lung function, and respiratory
diseases such as asthma and chronic obstructive pul-
monary disease. Chapter 10 (Control of Secondhand
Smoke Exposure) considers measures used to con-
trol exposure to secondhand smoke in public places,
including legislation, education, and approaches
based on building designs and operations The report
concludes with "A Vision for the Future." Major con-
clusions of the report were distilled from the chapter
conclusions and appear later in this chapter.
Preparation of the Report
This report of the Surgeon General was prepared
by the Office on Smoking and Health, National Cen-
ter for Chronic Disease Prevention and Health Pro-
motion, Coordinating Center for Health Promotion,
Center's for Disease Control and Prevention (CDC),
and U.S. DHHS, Initial chapters were written by
22 experts who were selected because of their knowl-
edge of a particular topic., The contributions of the
initial experts were consolidated into 10 major chap-
ters that were then reviewed by more than 40 peer
reviewers.. The entire manuscript was then sent to
more than 30 scientists and experts who reviewed
it for its scientific integrity. After each review cycle,
the drafts were revised by the scientific editors on
the basis of the experts' comments Subsequently, the
report was reviewed by various institutes and agencies
Definitions and Terminology
The inhalation of tobacco smoke by nonsmokers
has been variably referred to as "passive smoking"
or "involuntary smoking" Smokers, of course, also
inhale secondhand smoke Cigarette smoke contains
both particles and gases generated by the combustion
at high temperatures of tobacco, paper, and additives.
The smoke inhaled by nonsmokers that contaminates
indoor spaces and outdoor environments has often
been referred to as "secondhand smoke" or "envi-
ronmental tobacco smoke." This inhaled smoke is the
mixture of sidestream smoke released by the smol-
dering cigarette and the mainstream smoke that is
exhaled by a smoker, Sidestream smoke, generated
at lower temperatures and under somewhat different
combustion conditions than mainstream smoke, tends
to have higher concentrations of many of the toxins
found in cigarette smoke (USDHHS 1986). However,
it is rapidly diluted as it travels away from the burn-
ing cigarette.
Secondhand smoke is an inherently dynamic
mixture that changes in characteristics and concen-
tration with the time since it was formed and the
The Health Cortsrquences of hivohrntary Exposrire to Tobacco Srnokc
within U..S DHHS Publication lags, even short ones,
prevent an up-to-the-minute inclusion of all recently
published articles and data Therefore, by the time
the public reads this report, there may be additional
published studies or data To provide published infor-
mation as current as possible, this report includes an
Appendix of more recent studies that represent major
additions to the literature.
This report is also accompanied by a companion
database of key evidence that is accessible through
the Internet (http://www cdc.gov/tobacco). The data-
base includes a uniform description of the stud-
ies and results on the health effects of exposure to
secondhand smoke that were presented in a format
compatible with abstraction into standardized tables.
Readers of the report may access these data for addi-
tional analyses, tables, or figures..
distance it has traveled. The smoke particles change
in size and composition as gaseous components are
volatilized and moisture content changes; gaseous
elements of secondhand smoke maybe adsorbed onto
materials, and particle concentrations drop with both
dilution in the air or environment and impaction on
surfaces, including the lungs or on the body. Because
of its dynamic nature, a specific quantitative defini-
tion of secondhand smoke cannot be offered
This report uses the term secondhand smoke
in preference to environmental tobacco smoke, even
though the latter may have been used more frequently
in previous reports. The descriptor "secondhand" cap-
tures the involuntary nature of the exposure, while
"environmental" does not: This report also refers to
the inhalation of secondhand smoke as involuntary
smoking, acknowledging that most nonsmokers do
not want to inhale tobacco smoke. The exposure of the
fetus to tobacco smoke, whether from active smoking
by the mother or from her exposure to secondhand
smoke, also constitutes involuntary smoking.
hitroductim, Suniniary, and Couclnsiom
SuTgeari General's Report
Evidence Evaluation
Following the model of the 1964 report, the
Surgeon General's reports on smoking have included
comprehensive compilations of the evidence on the
health effects of smoking. The evidence is analyzed
to identify causal associations between smoking and
disease according to enunciated principles, some-
times referred to as the "Surgeon General's criteria" or
the "Hill" criteria (after Sir Austin Bradford Hill) for
causality (USDH1 W 1964; USDHHS 2004) Applica-
tion of these criteria involves covering all relevant
observational and experimental evidence. The criteria,
offered in a brief chapter of the 1964 report entitled
"Criteria for Judgment," included (1) the consistency
of the association, (2) the strength of the association,
(3) the specificity of the association, (4) the temporal
relationship of the association, and (5) the coherence
of the association. Although these criteria have been
criticized (e.g., Rothman and Greenland 1998), they
have proved useful as a framework for interpreting
evidence on smoking and other postulated causes
of disease, and for judging whether causality can be
inferred.
In the 2004 report of the Surgeon General, The
Health Consequences of Sinoking, the framework for
interpreting evidence on smoking and health was
revisited in depth for the first time since the 1964
report (USDI-1.HS 2004). The 2004 report provided
a four -level hierarchy for interpreting evidence
(Table 1-4). The categories acknowledge that evidence
can be "suggestive" but not adequate to infer a causal
relationship, and also allows for evidence that is "sug-
gestive of no causal relationship." Since the 2004
report, the individual chapter conclusions have con-
sistently used this four -level hierarchy (Table 1.4), but
evidence syntheses and other summary statements
may use either the term "increased risk" or "cause"
to describe instances in which there is sufficient evi-
dence to conclude that active or involuntary smoking
causes a disease or condition This four -level frame-
work also sharply and completely separates conclu-
sions regarding causality from the implications of
such conclusions.
That same framework was used in this report
on involuntary smoking and health. The criteria
dating back to the 1964 Surgeon General's report
remain useful as guidelines for evaluating evidence
(USDHFW 1964.), but they were not intended to be
applied strictly or as a "checklist" that needed to be met
beforethedesignationo€"causal" could be applied to an
association. In fact, for involuntary smoking and
health, several of the criteria will not be met for
some associations. Specificity, referring to a unique
exposure -disease relationship (e g.., the association
between thalidomide use during pregnancy and
unusual birth defects), can be set aside as not relevant,
as all of the health effects considered in this report
have causes other than involuntary smoking..
Associations are considered more likely to be causal as
the strength of an association increases because com-
peting explanations become less plausible alterna-
tives. However, based on knowledge of dosimetry and
mechanisms of injury and disease causation, the risk
is anticipated to be only slightly or modestly increased
for some associations of involuntary smoking with
disease, such as lung cancer, particularly when the
very strong relative risks found for active smokers are
compared with those for lifetime nonsmokers,. The
finding of only a small elevation in risk, as in the
Table 1.4 Four -Level hierarchy for classifying the strength of causal inferences based on available
evidence
Level I Evidence is sufficient to infer a causal relationship..
Level 2 Evidence is suggestive but not sufficient to infer a causal relationship
Level 3 Evidence is inadequate to infer the presence or absence of a causal relationship (which encompasses
evidence that is sparse, of poor quality, or conflicting)
Level 4 Evidence is suggestive of no causal relationship.
Source: U S Department of Health and Human Services 2004.
10 Chapfer 1
example of spousal smoking and lung cancer risk in
lifetime nonsmokers, does not weigh against a causal
association; however, alternative explanations for a
risk of a small magnitude need full exploration and
cannot be so easily set aside as alternative explana-
tions for a stronger association. Consistency, coher-
ence, and the temporal relationship of involuntary
smoking with disease are central to the interpretations
in this report. To address coherence, the report draws
not only on the evidence for involuntary smoking, but
on the even more extensive literature on active smok-
ing and disease..
Although the evidence reviewed in this report
comes largely from investigations of secondhand
smoke specifically, the larger body of evidence
on active smoking is also relevant to many of the
associations that were evaluated. The 1986 report
found secondhand smoke to be qualitatively similar
to mainstream smoke inhaled by the smoker and con-
cluded that secondhand smoke would be expected to
have "a toxic and carcinogenic potential that would
Major Conclusions
This report returns to involuntary smoking, the
topic of the 1986 Surgeon General's report. Since then,
there have been many advances in the research on
secondhand smoke, and substantial evidence has been
reported over the ensuing 20 years This report uses
the revised language for causal conclusions that was
implemented in the 2004 Surgeon General's report
(USDHHS 2004) Each chapter provides a compre-
hensive review of the evidence, a quantitative syn-
thesis of the evidence if appropriate, and a rigorous
assessment of sources of bias that may affect inter-
pretations of the findings The reviews in this report
reaffirm and strengthen the findings of the 1986 report.
With regard to the involuntary exposure of nonsmok-
ers to tobacco smoke, the scientific evidence now sup-
ports the following major conclusions:
1. Secondhand smoke causes premature death and
disease in children and in adults who do not
smoke
2. C,:lvldren exposed to secondhand smoke are at an
increased risk for sudden infant death syndrome
(SIDS), acute respiratory infections, ear problems,
The Health Cotrserlucuces of luvolrurtary Exposure to Tobacco Sitioke
not be expected to be qualitatively different from that
of MS [mainstream smoke]" (USDHHS 1986, p. 23).
The 2004 report of the Surgeon General revisited the
health consequences of active smoking (USDHHS
2004), and the conclusions substantially expanded
the list of diseases and conditions caused by smoking.
Chapters in the present report consider the evidence on
active smoking that is relevant to biologic plausibility
for causal associations between involuntary smoking
and disease. The reviews included in this report cover
evidence identified through search strategies set out
in each chapter. Of necessity, the evidence on mecha-
nisms was selectively reviewed. However, an attempt
was made to cover all health studies through speci-
fied target dates. Because of the substantial amount
of time involved in preparing this report, lists of new
key references published after these cut-off dates are
included in an Appendix.. literature reviews were
extended when new evidence was sufficient to pos-
sibly change the level of a causal conclusion.
and more severe asthma.. Smoking by parents
causes respiratory symptoms and slows lung
growth in their children.
3 Exposure of adults to secondhand smoke has
immediate adverse effects on the cardiovascular
system and causes coronary heart disease and
lung cancer.
4 The scientific evidence indicates that there is no
risk -free level of exposure to secondhand smoke.
5 Many millions of Americans, both children and
adults, are still exposed to secondhand smoke in
their homes and workplaces despite substantial
progress in tobacco control.
6. Eliminating smoking in indoor spaces fully pro-
tects nonsmokers from exposure to secondhand
smoke. Separating smokers from nonsmokers,
cleaning the air, and ventilating buildings cannot
eliminate exposures of nonsmokers to second-
hand smoke.
Irzlrodrtctim, Stutrrnary, arid Cotrchisiow 11
SIIIgem General's Report
Chapter Conclusions
Chapter 2. Toxicology of Secondhand
Smoke
Evidence of Carcinogenic Effects
fi•oin Secondliand Smoke Exposure
1. More than 50 carcinogens have been identified in
sidestream and secondhand smoke.
The evidence is sufficient to infer a causal
relationship between exposure to secondhand
smoke and its condensates and tumors in
laboratory animals
The evidence is sufficient to infer that exposure
of nonsmokers to secondhand smoke causes a
significant increase in urinary levels of meta-
bolites of the tobacco -specific lung carcinogen
4-(methyl nitrosamino) -1-(3-pyri dyl) -1-buta none
(NNK). The presence of these metabolites links
exposure to secondhand smoke with an increased
risk for lung cancer.
4. The mechanisms by which secondhand smoke
causes lung cancer are probably similar to
those observed in smokers. The overall risk of
secondhand smoke exposure, compared with
active smoking, is diminished by a substantially
lower carcinogenic dose.
Mechanisms of Respiratory Tract htjury and Disease
Caused by Secondhand Slnoke Exposure
5, The evidence indicates multiple mechanisms by
which secondhand smoke exposure causes injury
to the respiratory tract.
6. The evidence indicates mechanisms by which
secondhand smoke exposure could increase the
risk for sudden infant death syndrome..
Mechanisms of Secondhand Slnoke Exposure
and Heart Disease
7. The evidence is sufficient to infer that exposure to
secondhand smoke has a prothrombotic effect.
12 Chapter 1
8 The evidence is sufficient to infer that exposure
to secondhand smoke causes endothelial cell
dysfunctions
4. The evidence is sufficient to infer that exposure
to secondhand smoke causes atherosclerosis in
animal models.
Chapter 3. Assessment of Exposure
to Secondhand Smoke
Building Designs and Operations
1. Current heating, ventilating, and air conditioning
systems alone cannot control exposure to
secondhand smoke.
2 The operation of a heating, ventilating, and air
conditioning system can distribute secondhand
smoke throughout a building
Exposure Models
3. Atmospheric concentration of nicotine is a
sensitive and specific indicator for secondhand
smoke..
4 Smoking increases indoor particle concentrations
5. Models can be used to estimate concentrations of
secondhand smoke.
Bioniarkers of Exposure to Secondhand Slnoke
6 Siomarkerssuitable for assessing recent exposures
to secondhand smoke are available.
At this time, cotinine, the primary proximate
metabolite of nicotine, remains the biomarker of
choice for assessing secondhand smoke exposure
8 Individual biomarkers of exposure to second-
hand smoke represent only one component of
a complex mixture, and measurements of one
marker may not wholly reflect an exposure to
other components of concern as a result of
involuntary Smoking,
The Health Consequences of hraolurrtanj Exposure to Tobacco Srrroke
Chapter 4. Prevalence of Exposure Sadden Infant Death Syndrome
to Secondhand Smoke 4 The evidence is sufficient to infer a causal
1. The evidence is sufficient to infer that large relationship between exposure to secondhand
numbers of nonsmokers are still exposed to smoke and sudden infant death syndrome
secondhand smoke.
Preterur Delivery
2 Exposure of nonsmokers to secondhand smoke 5, The evidence is suggestive but not sufficient to
has declined in the United States since the 1986 infer a causal relationship between maternal
Surgeon General's report, The Health Consequences exposure to secondhand smoke during pregnancy
of Involuntaiy Sruoking. and preterm delivery.
.3. The evidence indicates that the extent of
secondhand smoke exposure varies across the
country.
4 Homes and workplaces are the predominant
locations for exposure to secondhand smoke.
5 )exposure to secondhand smoke tends to be greater
for persons with lower incomes
6. Exposure to secondhand smoke continues in
restaurants, bars, casinos, gaming halls, and
vehicles
Chapter 5. Reproductive and
Developmental Effects from
Exposure to Secondhand Smoke
FertiIi j
1. The evidence is inadequate to infer the presence or
absence of a causal relationship behveen maternal
exposure to secondhand smoke and female
fertility or fecundability_ No data were found on
paternal exposure to secondhand smoke and male
fertility or fecundability.
Pregnancy (Spontaneous Abortion and Perinatal Death)
2. The evidence is inadequate to infer the presence or
absence of a causal relationship between maternal
exposure to secondhand smoke during pregnancy
and spontaneous abortion.
Infant Deaths
3 The evidence is inadequate to infer the presence
or absence of a causal relationship between
exposure to secondhand smoke and neonatal
mortality..
Low Birth Weight
6 The evidence is sufficient to infer a causal
relationship between maternal exposure to
secondhand smoke during pregnancy and a small
reduction in birth weight.
Congenital Malformations
7. The evidence is inadequate to infer the presence
or absence of a causal relationship between
exposure to secondhand smoke and congenital
malformations.
Cognitive Development
8 The evidence is inadequate to infer the presence
or absence of a causal relationship between
exposure to secondhand smoke and cognitive
functioning among children.
Behavioral Development
9- The evidence is inadequate to infer the presence
or absence of a causal relationship between
exposure to secondhand smoke and behavioral
problems among children.
Heightlrrowth
10 The evidence is inadequate to infer the presence
or absence of a causal relationship between
exposure to secondhand smoke and children's
height/growth..
Child}rood Cancer
11 The evidence is suggestive but not sufficient to
infer a causal relationship between prenatal and
postnatal exposure to secondhand smoke and
childhood cancer.
Introduction, Sumwary, and Conclusions 13
Surgeon General's Reporf
12. The evidence is inadequate to infer the presence 4 The evidence is suggestive but not sufficient
or absence of a causal relationship between to infer a causal relationship between parental
maternal exposure to secondhand smoke during smoking and the natural history of middle ear
pregnancy and childhood cancer effusion
1.3 The evidence is inadequate to infer the presence S The evidence is inadequate to infer the presence
or absence of a causal relationship between or absence of a causal relationship between
exposure to secondhand smoke during infancy parental smoking and an increase in the risk of
and childhood cancer adenoidectomy or tonsillectomy among children
14 The evidence is suggestive but not sufficient to
infer a causal relationship between prenatal and
postnatal exposure to secondhand smoke and
childhood leukemias.
15. The evidence is suggestive but not sufficient to
infer a causal relationship between prenatal and
postnatal exposure to secondhand smoke and
childhood lymphomas,
16. The evidence is suggestive but not sufficient to
infer a causal relationship between prenatal and
postnatal exposure to secondhand smoke and
childhood brain tumors
1T The evidence is inadequate to infer the presence or
absence of a causal relationship between prenatal
and postnatal exposure to secondhand smoke and
other childhood cancer types.
Chapter G. Respiratory Effects
in Children from Exposure
to Secondhand Smoke
Lower Respiratory Illnesses in Infancy
and Early Childhood
1. The evidence is sufficient to infer a causal
relationship between secondhand smoke exposure
from parental smoking and lower respiratory
illnesses in infants and children.
2. The increased risk for lower respiratory illnesses
is greatest from smoking by the mother.
Middle Ear Disease and Adenotonsillectonry
3 The evidence is sufficient to infer a causal
relationship between parental smoking and
middle ear disease in children, including acute
and recurrent otitis media and chronic middle ear
effusion.
14 Chapter I
Respiratonj Synrptorns and Prevalent Asthma
ill School -Age Children
6 The evidence is sufficient to infer a causal rela-
tionship between parental smoking and cough,
phlegm, wheeze, and breathlessness among
children of school age.
7 The evidence is sufficient to infer a causal
relationship between parental smoking and ever
having asthma among children of school age.
Childhood .Asthrrra Onset
B. The evidence is sufficient to infer a causal
relationship between secondhand smoke exposure
from parental smoking and the onset of wheeze
illnesses in early childhood.
9 The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure from parental smoking and the
onset of childhood asthma.
Atopy
10 The evidence is inadequate to infer the presence
or absence of a causal relationship between
parental smoking and the risk of immunoglobulin
E-mediated allergy in their children
Lung Growth and Puhuonary .Function
11. The evidence is sufficient to infer a causal
relationship between maternal smoking during
pregnancy and persistent adverse effects on lung
function across childhood.
12. The evidence is sufficient to infer a causal
relationship between exposure to secondhand
smoke after birth and a lower level of lung
function during childhood.
The Health Consequences of Involuntary Exposure to Tobacco Smoke
Chapter 7. Cancer Among Adults from
Exposure to Secondhand Smoke
Lung Cancer
The evidence is sufficient to infer a causal
relationship between secondhand smoke
exposure and lung cancer among lifetime
nonsmokers. This conclusion extends to all
secondhand smoke exposure, regardless of 4'
location.
2. The pooled evidence indicates a 20 to 30 percent
increase in the risk of lung cancer from secondhand
smoke exposure associated with living with a
smoker.
Breast Cancer
3 The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke and breast cancer
Nasal .sinus Cauihj and Nasopharjngeal Carcinana
4. The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure and a risk of nasal sinus cancer
among nonsmokers.
5. The evidence is inadequate to infer the presence
or absence of a causal relationship between
secondhand smoke exposure and a risk of
nasopharyngeal carcinoma among nonsmokers.
Cervical Cancer
heart disease from exposure to secondhand
smoke..
The evidence is suggestive but not sufficient to
infer a causal relationship between exposure
to secondhand smoke and an increased risk of
stroke.
Studies of secondhand smoke and subrlinical
vascular disease, particularly carotid arterial wall
thickening, are suggestive but not sufficient to
infer a causal relationship between exposure to
secondhand smoke and atherosclerosis.
Chapter 9. Respiratory Effects in Adults
from Exposure to Secondhand Smoke
Odor and Irritation
1 The evidence is sufficient to infer a causal
relationship between secondhand smoke exposure
and odor annoyance.
I The evidence is sufficient to infer a causal
relationship between secondhand smoke exposure
and nasal irritation.
3 The evidence is suggestive but not sufficient
to conclude that persons with nasal allergies
or a history of respiratory illnesses are more
susceptible to developing nasal irritation from
secondhand smoke exposure
Respiratorij Sy? nptoins
6 The evidence is inadequate to infer the presence 4. The evidence is suggestive but not sufficient to
or absence of a causal relationship between infer a causal relationship between secondhand
secondhand smoke exposure and the risk of smoke exposure and acute respiratory symptoms
cervical cancer among lifetime nonsmokers, including cough, wheeze, chest tightness, and
difficulty breathing among persons with asthma.
Chapter S. Cardiovascular Diseases from
Exposure to Secondhand Smoke
1 The evidence is sufficient to infer a causal
relationship between exposure to secondhand
smoke and increased risks of coronary heart
disease morbidity and mortality among both men
and women.
2 Pooled relative risks from meta -analyses indicate
a 25 to 30 percent increase in the risk of coronary
5 The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure and acute respiratory symptoms
including cough, wheeze, chest tightness, and
difficulty breathing among healthy persons
The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure and chronic respiratory
symptoms
Introduchm, Sn innary, and ConchrsioUs 15
Surgeon General's Report
Lung Function
7. The evidence is suggestive but not sufficient to
infer a causal relationship between short-term
secondhand smoke exposure and an acute decline
in lung function in persons with asthma.
8. The evidence is inadequate to infer the presence
or absence of a causal relationship between short-
term secondhand smoke exposure and an acute
decline in lung function in healthy persons.
9. The evidence is suggestive but not sufficient to in-
fer a causal relationship between chronic second-
hand smoke exposure and a small decrement in
lung function in the general population.
10, The evidence is inadequate to infer the presence or
absence of a causal relationship between chronic
secondhand smoke exposure and an accelerated
decline in lung function,
Asthma
11. The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure and adult -onset asthma.
12 The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure and a worsening of asthma
control .
Chronic Obstructive Pulmonary Disease
13. The evidence is suggestive but not sufficient to
infer a causal relationship between secondhand
smoke exposure and risk for chronic obstructive
pulmonary disease.
14. The evidence is inadequate to infer the presence
or absence of a causal relationship between
secondhand smoke exposure and morbidity in
persons with clu°onic obstructive pulmonary
disease.
16 Ghapfer• I
Chapter 10. Control of Secondhand Smoke
Exposure
1 Workplace smoking restrictions are effective in
reducing secondhand smoke exposure.
2. Workplace smoking restrictions lead to less
smoking among covered workers
3. Establishing smoke -free workplaces is the only
effective way to ensure that secondhand smoke
exposure does not occur in the workplace.
4 The majority of workers in the United States are
now covered by smoke -free policies
5. The extent to which workplaces are covered by
smoke -free policies varies among worker groups,
across states, and by sociodemographic factors.
Workplaces related to the entertainment and
hospitality industries have notably high potential
for secondhand smoke exposure.
6 Evidence from peer -reviewed studies shows that
smoke -free policies and regulations do not have
an adverse economic impact on the hospitality
industry,
7. Evidence suggests that exposure to secondhand
smoke varies by ethnicity and gender
8 In the United States, the home is now becoming
the predominant location for exposure of children
and adults to secondhand smoke.
9 Total bans on indoor smoking in hospitals,
restaurants, bars, and offices substantially reduce
secondhand smoke exposure, up to several orders
of magnitude with incomplete compliance, and
with full compliance, exposures are eliminated,
10. Exposures of nonsmokers to secondhand smoke
cannot be controlled by air cleaning or mechanical
air exchange..
Methodologic Issues
Much of the evidence on the health effects of
involuntary smoking comes from observational epide-
miologic studies that were carried out to test hypothe-
ses related to secondhand smoke and risk for diseases
and other adverse health effects. The challenges faced
in carrying out these studies reflect those of observa-
tional research generally: assessment of the relevant
exposures and outcomes with sufficient validity and
precision, selection of an appropriate study design,
identification of an appropriate and sufficiently large
study population, and collection of 'information on
other relevant factors that may confound or modify
the association being studied. The challenge of accu-
rately classifying secondhand smoke exposures con-
fronts all studies of such exposures, and consequently
the literature on approaches to and limitations of
exposure classification is substantial. Sources of bias
that can affect the findings of epidemiologic studies
have been widely discussed (Rothman and Green-
land 1998), both in general and in relation to studies
of involuntary smoking. Concerns about bias apply to
any study of an environmental agent and disease risk:
misclassification of exposures or outcomes, confound-
ing effect modification, and proper selection of study
participants_ In addition, the generalizability of find-
ings from one population to another (external valid-
ity) further determines the value of evidence from
a study. Another methodologic concern affecting
secondhand smoke literature comes from the use of
meta -analysis to combine the findings of epidemio-
log-ic studies; general concerns related to the use of
meta -analysis for observational data and more spe-
cific concerns related to involuntary smoking have
also been raised This chapter considers these meth-
odologic issues in anticipation of more specific treat-
ment in the following chapters.
Classification of Secondhand
Smoke Exposure
For secondhand smoke, as for, any environmen-
tal factor that may be a cause of disease, the exposure
assessment might encompass the time and place of
the exposure, cumulative exposures, exposure during
a particular time, or a recent exposure Qaakkola and
Jaakkola 1997; Jaakkola and Sarnet 1999) For example,
exposures to secondhand smoke across the full life
The Health Corrsequeuces of hrvoluutanf Eaposurr to Tobacco Snwke
span may be of interest for lung cancer, while only
more recent exposures may be relevant to the exacer-
bation of asthma. For CHID, both temporally remote
and current exposures may affect risk. Assessments
of exposures are further complicated by the multiplic-
ity of environments where exposures take place and
the difficulty of characterizing the exposure in some
locations, such as public places or workplaces. Addi-
tionally, exposures probably vary qualitatively and
quantitatively over time and across locations because
of temporal changes and geographic differences in
smoking patterns
Nonetheless, researchers have used a variety of
approaches for exposure assessments in epidemio-
logic studies of adverse health effects from involun-
tary smoking, Several core concepts that are
fundamental to these approaches are illustrated in
Figure 1.1 (Samet and Jaakkola 1999) Cigarette smok-
ing is, of course, the source of most secondhand
smoke in the United States, followed by pipes, cigars,
and other products. Epidemiologic studies generally
focus on assessing the exposure, which is the con-
tact with secondhand smoke. The concentrations of
secondhand smoke components in a space depend on
the number of smokers and the rate at which they are
smoking, the volume into which the smoke is distrib-
uted, the rate at which the air in the space exchanges
with uncontaminated air, and the rate at which the
secondhand smoke is removed from the air. Concen-
tration, exposure, and dose differ in their definitions,
although the terms are sometimes used without sharp
distinctions. However, surrogate indicators that gen-
erally describe a source of exposure may also be used
to assess the exposure, such as marriage to a smoker
or the number of cigarettes smoked in the home. Bio-
markers can provide an indication of an exposure or
possibly the dose, but for secondhand smoke they are
used for recent exposure only
People are exposed to secondhand smoke in a
number of different places, often referred to as "micro -
environments" (NRC 1991). A microenvironment is
a definable location that has a constant concentra-
tion of the contaminant of interest, such as second-
hand smoke, during the time that a person is there
Some key microenvironments for secondhand smoke
include the home, the workplace, public places, and
transportation environments (Klepeis 1999) Based
Introduction, Sunnnary, and Conchrsims 17
Surgeon Ganciaf's Report
Figure 1.1 The determinants of exposure, dose, and biologically effective dose that underlie the
development of health effects from smoking
Environment Human body
,
,
,
Dispersion Individual time (Y i Type and rate Metabolic
present in 1 of breathing elimination
location (m�)
,
I
Outdoor Microenvironmental (m,)
concentrations over time (t�)
sources
\
In
C10
C„
C:2
C13
z
C20
C21
C22
C23
Indoor
m3
Can
C31
C32
C33
sources
m4
C411
C41
C42
C43
Ventilation
removal
Susceptible body surface
roncentratron Exposure
Source: Samet and Jaakkola 1999. Reprinted with permission
on the microenvironmental model, total exposure
can be estimated as the weighted average of the con-
centrations of secondhand smoke or indicator com-
pounds, such as nicotine, in the microenvironments
where time is spent; the weights are the time spent in
each microenvironrnent. Klepeis (1999) illustrates the
application of the microenvironmental model with
national data from the National Human Activity Pat-
tern Survey conducted by the EPA. His calculations
yield an overall estimate of exposure to airborne par-
ticles from smoking and of the contributions to Ellis
exposure from various microenvironments.
Much of the epidemiologic evidence addresses
the consequences of an exposure in a particular micro -
environment, such as the home (spousal smoking and
lung cancer risk or maternal smoking and risk for
asthma exacerbation), or the workplace (exacerbation
of asthma by the presence of smokers). Some studies
have attempted to cover multiple microenvironments
18 Chapter I
El,,[ - Z c,, * tij
Biologically
Dose effective
dose
and to characterize exposures over time For, example,
in the multicenter study of secondhand smoke expo-
sure and lung cancer carried out in the United States,
Fontham and colleagues (1994) assessed exposures
during childhood, in workplaces, and at home dur-
ing adulthood. Questionnaires that assess exposures
have been the primary too] used in epidemiologic
studies of secondhand smoke and disease. Measure-
ment of biomarkers has been added in some studies,
either as an additional and complementary exposure
assessment approach or for validating questionnaire
responses. Some studies have also measured compo-
nents of secondhand smoke in the air.
Questionnaires generally address sources of
exposure in microenvironments and can be tailored
to address the time period of interest. Question-
naires represent the only approach that can be used
to assess exposures retrospectively over a life span,
because available biomarkers only reflect exposures
over recent days or, at most, weeks. Questionnaires
on secondhand smoke exposure have been assessed
for their reliability and validity, generally based on
comparisons with either biomarker or air moni-
toring data as the "gold" standard (Jaakkola and
Jaakkola 1997) Two studies evaluated the reliability
of questionnaires on lifetime exposures (Prop et al
1988; Coultas et al. 1989) Both showed a high degree
of repeatability for questions concerning whether
a spouse had smoked, but a lower reliability for
responses concerning the quantitative aspects of an
exposure Emerson and colleagues (1995) evaluated
the repeatability of information from parents of chil-
dren with asthma. They found a high reliability for
parent -reported tobacco use and for the number of
cigarettes to which the clvld was exposed in the home
during the past week.
To assess validity, questionnaire reports of cur-
rent or recent exposures have been compared with
levels of cotinine and other biomarkers.. These studies
tend to show a moderate correlation between levels
of cotinine and questionnaire indicators of exposures
(Kawaclu and Colditz 1996; Cal/EPA 1997; Jaakkola
and Jaakkola 1997) However, cotinine levels reflect
not only exposure but metabolism and excretion
(Benowitz 1999). Consequently, exposure is only one
determinant of variation in cotinine levels among per-
sons; there also are individual variations in metabo-
lism and excretion rates. In spite of these sources of
variability, mean levels of cotinine vary as anticipated
across categories of self -reported exposures (Cal/EPA
1997; Jaakkola and Jaakkola 1997), and self -reported
exposures are moderately associated with measured
levels of markers (Cal/EPA 1997; Jaakkola and
Jaakkola 1997).
Biomarkers are also used for assessing expo-
sures to secondhand smoke. A number of biomark-
ers are available, but they vary in their specificity
and in the dynamics of the temporal relationship
between the exposure and the marker level (Cal/EPA
1997; Benowitz 1999). These markers include specific
tobacco smoke components (nicotine) or metabolites
(cotinine and tobacco -specific nitrosamines), nonspe-
cific biomarkers (thiocyanate and CO), adducts with
tobacco smoke components or metabolites (4-amino-
biphenyl—hemoglobin adducts, benzo[n)pyrene—DNA
adducts, and polycyclic aromatic hydrocarbon —
albumin adducts), and nonspecific assays (urinary
mutagenicity) Cotinine has been the most widely
used biomarker, primarily because of its specificity,
half-life, and ease of measurement in body fluids (e.g..,
urine, blood, and saliva) Biomarkers are discussed
The Health Comeparces of Involrnttan) Exposure to Tobacco 5trroh
in detail in Chapter :3 (Assessment of Exposure to
Secondhand Smoke):
Some epidemiologic studies have also incorpo-
rated air monitoring, either direct personal sampling
or the indirect approach based on the microenviron-
mental model Nicotine, present in the gas phase of
secondhand smoke, can be monitored passively with
a special filter or actively using a pump and a sorbent,
Hammond and Leaderer (1987) first described a dif-
fusion monitor for the passive sampling of nicotine in
1987; this device has now been widely used to assess
concentrations in different environments and to study
health effects_ Airborne particles have also been mea-
sured using active monitoring devices
Each of these approaches for assessing expo-
sures has strengths and limitations, and preference for
one over another will depend on the research ques-
tion and its context (Jaakkola and Jaakkola 1997; Jaak-
kola and Samet 1999) Questionnaires can be used to
characterize sources of exposures, such as smoking by
parents. With air concentrations of markers and time -
activity information, estimates of secondhand smoke
exposures can be made with the microenvironmental
model. Biomarkers provide exposure measures that
reflect the patterns of exposure and the kinetics of the
marker; the cotinine level in body fluids, for example,
reflects an exposure during several days, Air moni-
toring may be useful for validating measurements of
exposure. Exposure assessment strategies are matched
to the research question and often employ a mixture
of approaches determined by feasibility and cost
constraints.
Misclassification of Secondhand
Smoke Exposure
Misclassification may occur when classifying
exposures, outcomes, confounding factors, or modi-
fying factors. Misclassification may be differential on
either exposure or outcome, or itmaybe random (Arm-
strong et al. 1992). Differential or nonrandom misclas-
sification may either increase or decrease estimates of
effect, while random misclassification tends to reduce
the apparent effect and weaken the relationship of
exposure with disease risk In studies of secondhand
smoke and disease risk, exposure misclassification
has been a major consideration in the interpretation of
the evidence, although misclassification of health out-
come measures has notbeen a substantial issue in this
research.. The consequences for epidemiologic stud-
ies of misclassification in general are well established
(Rothman and Greenland 1998).
Itthndtictiott, Srtntrttnri1, arrd CoticItisions 79
Srrrgeorr Gcrier•al's Report
An extensive body of literature on the classifica-
tion of exposures to secondhand smoke is reviewed
in this and other chapters, as well as in some pub-
lications on the consequences of misclassification
(Wu 1999). Two general patterns of exposure mis-
classification are of concern to secondhand smoke:
(1) random misclassification that is not differential
by the presence or absence of the health outcome and
(2) systematic misclassification that is differential by
the health outcome. In studying the health effects of
secondhand smoke in adults, there is a further con-
cern as to the classification of the active smoking sta-
tus (never, current, or former smoking); in studies of
children, the accuracy of secondhand smoke expo-
sure classification is the primary methodologic issue
around exposure assessment, but unreported active
smoking by adolescents is also a concern,
With regard to random misclassification of
secondhand smoke exposures, there is an inher-
ent degree of unavoidable measurement error in the
exposure measures used in epidemiologic studies.
Questionnaires generally assess contact with sources
of an exposure (e g., smoking in the home or work-
place) and cannot capture all exposures nor the inten-
sity of exposures; biomarkers provide an exposure
index for a particular time window and have intrinsic
variability. Some building -related factors that deter-
mine an exposure cannot be assessed accurately by a
questionnaire, such as the rate of air exchange and the
size of the microenvironment where time is spent, nor
can concentrations be assessed accurately by subjec-
tive reports of the perceived level of tobacco smoke.
In general, random misclassification of exposures
tends to reduce the likelihood that studies of second-
hand smoke exposure will find an effect. This type of
misclassification lessens the contrast between expo-
sure groups, because some truly exposed persons are
placed in the unexposed group and some truly unex-
posed persons are placed in the exposed group. Differ-
ential misclassification, also a concern, may increase
or decrease associations, depending on the pattern of
misreporting.
One particular form of misclassification has been
raised with regard to secondhand smoke exposure
and lung cancer: the classification of some current or
former smokers as lifetime nonsmokers (USEPA 1992;
Lee and Forey 1995; Hackshaw et al 1997; Wu 1999)
The resulting bias would tend to increase the appar-
ent association of secondhand smoke with lung can-
cer, if the misclassified active smokers are also more
likely to be classified as involuntary smokers. Most
studies of lung cancer and secondhand smoke have
used spousal smoking as a main exposure variable. As
20 Chapter I
smoking tends to aggregate between spouses (smok-
ers are more likely to marry smokers), misclassifica-
tion of active smoking would tend to be differential
on the basis of spousal smoking (the exposure under
investigation). Because active smoking is strongly
associated with increased disease risk, greater mis-
classification of an actively smoking spouse as a non-
smoker among spouses of smokers compared with
spouses of nonsmokers would lead to risk estimates
for spousal smoking that are biased upward by the
effect of active smoking. This type of misclassifica-
tion is also relevant to studies of spousal exposure
and CHD risk or other diseases also caused by active
smoking, although the potential forbias is less because
(lie association of active smoking with CHD is not as
strong as with lung cancer.
There have been a number of publications on
this form of misclassification. Wu (1999) provides a
review, and Lee and colleagues (2001) offer an assess-
ment of potential consequences A number of mod-
els have been developed to assess the extent of bias
resulting from the misclassification of active smok-
ers as lifetime nonsmokers (USEPA 1992; Ilackshaw
et al. 1997) These models incorporate estimates of the
rate of misclassification, the degree of aggregation of
smokers by marriage, the prevalence of smoking in
the population, and the risk of lung cancer in mis-
classified smokers (1Nu 1999) Although debate about
this issue continues, analyses show that estimates of
upward bias from misclassifying active smokers as
lifetime nonsmokers cannot fully explain the observed
increase in risk for lung cancer among lifetime non-
smokers married to smokers (Hackshaw et al. 1997;
Wu 1999)
There is one additional issue related to exposure
misclassification During the time the epidemiologic
studies of secondhand smoke have been carried out,
exposure has been widespread and almost unavoid-
able. Therefore, the risk estimates may be biased
downward because there are no truly unexposed
persons The 1986 Surgeon General's report recog-
nized this methodologic issue and noted the need for
further data on population exposures to secondhand
smoke (USDHHS 1986). TNs bias was also recognized
in the 1986 report of the NRC, and an adjustment for
this misclassification was made to the lung cancer
estimate (NRC 1986). Similarly, the 1992.report of the
EPA commented on background exposure and made
an adjustment (USEPA 1992). Some later studies have
attempted to address this issue; for example, in a case -
control study of active and involuntary smoking and
breast cancer in Switzerland, Morabia and colleagues
(2000) used a questionnaire to assess exposure and
identified a small group of lifetime nonsmokers who
also reported no exposure to secondhand smoke. With
this subgroup of controls as the reference population,
the risks of secondhand smoke exposure were sub-
stantially greater for active smoking than when the
full control population was used.
This Surgeon General's report further addresses
specific issues of exposure misclassification when
they are relevant to the health outcome under
consideration..
Use of Meta -Analysis
Meta -analysis refers to the process of evaluat-
ing and combining a body of research literature that
addresses a common question. Meta -analysis is com-
posed of qualitative and quantitative components.
The qualitative component involves the systematic
identification of all relevant investigations, a sys-
tematic assessment of their characteristics and qual-
ity, and the decision to include or exclude studies
based on predetermined criteria_ Consideration can
be directed toward sources of bias that might affect
the findings. The quantitative component involves the
calculation and display of study results on common
scales and, if appropriate, the statistical combination
of these results across studies and an exploration of
the reasons for any heterogeneity of findings. View-
ing the findings of all studies as a single plot provides
insights into the consistency of results and the preci-
sion of the studies considered. Most meta -analyses are
based on published summary results, although they
are most powerful when applied to data at the level of
individual participants.. Meta -analysis is most widely
used to synthesize evidence from randomized clini-
cal trials, sometimes yielding findings that were not
evident from the results of individual studies Meta -
analysis also has been used extensively to examine
bodies of observational evidence.
Beginning with the 1986 NRC report, meta -
analysis has been used to summarize the evidence on
involuntary smoking and health. Meta -analysis was
central to the 1992 EPA risk assessment of secondhand
smoke, and a series of meta -analyses supported the
conclusions of the 1998 report of the Scientific Com-
mittee on Tobacco and Health in the United Kingdom
The central role of meta -analysis in interpreting and
applying the evidence related to involuntary smok-
ing and disease has led to focused criticisms of the
use of meta -analysis in this context Several papers
that acknowledged support from the tobacco indus-
try have addressed the epidemiologic findings for
lung cancer, including the selection and quality of the
The Health Consequences of hivobiwanj Exposure Io Tobacco .Srrroke
studies, the methods for meta -analysis, and dose -
response associations (Fleiss and Gross 1991; Tweedie
and Mengersen 1995; Lee 1998, 1999). In a lawsuit
brought by the tobacco industry against the EPA,
the 1998 decision handed down by Judge William
L. Osteen, Sr., in the North Carolina Federal District
Court criticized the approach EPA had used to select
studies for its meta -analysis and criticized the use of 90
percent rather than 95 percent confidence intervals for
the summary estimates (FIue-Cured Tobacco Cooperative
Stabilization Corp v. United States Environmental Protec-
tion Agency, 857 F Supp 1137 [M.D.N C. 19931). In
December 2002, the 4th U.S Circuit Court of Appeals
threw out the lawsuit on the basis that tobacco com-
panies cannot sue the EPA over its secondhand smoke
report because the report was not a final agency action
and therefore not subject to court review (FIue-Cured
Tobacco Cooperative Stabilization Corp. v The United
States Environutetttal Protection Agency, No. 98-2407
[4th Cir_, December 11, 2002], cited in 17 7 TPLR 2..472
[20031),
Recognizing that there is still an active discus-
sion around the use of meta -analysis to pool data
from observational studies (versus clinical trials),
the authors of this Surgeon General's report used
this methodology to summarize the available data
when deemed appropriate and useful, even while
recognizing that the uncertainty around the meta -
analytic estimates may exceed the uncertainty indi-
cated by conventional statistical indices, because of
biases either within the observational studies or pro-
duced by the manner of their selection. However, a
decision to not combine estimates might have pro-
duced conclusions that are far more uncertain than
the data warrant because the review would have
focused on individual study results without consid-
ering their overall pattern, and without allowing for
a full accounting of different sample sizes and effect
estimates
The possibility of publication bias has been
raised as a potential limitation to the interpretation of
evidence on involuntary smoking and disease in gen-
eral, and on lung cancer and secondhand smoke expo-
sure specifically. A 1988 paper by Vandenbroucke
used a descriptive approach, called a "funnel plot,"
to assess the possibility that publication bias affected
the 1.3 studies considered in a review by Wald and col-
leagues (1986). This type of plot characterizes the rela-
tionship between the magnitude of estimates and their
precision. Vandenbroucke suggested the possibility
of publication bias only in reference to the studies of
men. Bero and colleagues (1994) concluded that there
haroduction, Snlrrnrary, and Conclusions 21
Surgeon Gencral s Report
had not been a publication bias against studies with
statistically significant findings, nor against the publi-
cation of studies with nonsignificant or mixed findings
in the research literature. The researchers were able to
identify only five unpublished "negative" studies, of
which two were dissertations that tend to be delayed
in publication A subsequent study by Misakian and
Bero (1998) did find a delay in the publication of stud-
ies with nonsignificant results in comparison with
studies having significant results; whether this pat-
tern has varied over the several decades of research on
secondhand smoke was not addressed. More recently,
Copas and Shi (2000) assessed the 37 studies consid-
ered in the meta -analysis by Hackshaw and colleagues
(1997) for publication bias. C-'opas and Shi (2000) found
a significant correlation between the estimated risk of
exposure and sample size, such that smaller studies
tended to have higher values. This pattern suggests
the possibility of publication bias However, using a
funnel plot of the same studies, Lubin (1999) found
little evidence for publication bias
On this issue of publication bias, it is critical to
distinguish between indirect statistical arguments and
arguments based on actual identification of previously
unidentified research. The strongest case against sub-
stantive publication bias has been made by research-
ers who mounted intensive efforts to find the possibly
missing studies; these efforts have yielded little —
nothing that would alter published conclusions
(Bero et al 1994; Glantz 2000) Presumably because
this exposure is a great public health concern, the
findings of studies that do not have statistically sig-
nificant outcomes continue to be published (Kawachi
and Colditz 1996)..
The quantitative results of the meta -analyses,
however, were not determinate in making causal
inferences in this Surgeon General's report. In par-
ticular, the level of statistical significance of estimates
from the meta -analyses was not a predominant fac-
tor in making a causal conclusion. For that purpose,
this report relied on the approach and criteria set
out in the 1964 and 2004 reports of the Surgeon Gen-
eral, which involved judgments based on an array
of quantitative and qualitative considerations that
included the degree of heterogeneity in the designs of
the studies that were examined. Sometimes this het-
erogeneity limits the inference from meta -analysis by
weakening the rationale for pooling the study results.
However, the availability of consistent evidence
from heterogenous designs can strengthen the meta -
analytic findings by making it unlikely that a common
bias could persist across different study designs and
populations.
72 chaptcr 1
Confounding
Confounding, which refers in this context to
the mixing of the effect of another factor with that of
secondhand smoke, has been proposed as an expla-
nation for associations of secondhand smoke with
adverse health consequences. Confounding occurs
when the factor of interest (secondhand smoke) is
associated in the data under consideration with
another factor (the confounder) that, by itself, increases
the risk for the disease (Rothman and Greenland 1998).
Correlates of secondhand smoke exposures are not
confounding factors unless an exposure to them
increases the risk of disease A factor proposed as
a potential confounder is not necessarily an actual
confounder unless it fulfills the two elements of the
definition. Although lengthy lists of potential con-
founding factors have been offered as alternatives to
direct associations of secondhand smoke exposures
with the risk for disease, the factors on these lists gen-
erally have not been shown to be confounding in the
particular data of interest
The term confounding also conveys an implicit
conceptualization as to the causal pathways that link.
secondhand smoke and the confounding factor to
Figure 1.2 Model for socioeconomic status
(SES) and secondhand smoke (SHS)
exposure
Direct path
Lower
SES -- - Risk for adverse effect
Causal path
Lower t smoking SHS
SES —► active exposur Risk for adverse effect
Confounding
/IfISHS
exposure
Lower
SES • Risk for adverse effect
Arrows indicate directionality of association.
disease risk. Confounding implies that the confound-
ing factor has an effect on risk that is independent of
secondhand smoke exposure. Some factors considered
as potential confounders may, however, be in the same
causal pathway as a secondhand smoke exposure
Although socioeconomic status (SES) is often cited
as a potential confounding factor, it may not have an
independent effect but can affect disease risk through
its association with secondhand smoke exposure
(Figure 1.2).. This figure shows general alternative rela-
tionships among SES, secondhand smoke exposure,
and risk for an adverse effect. SES may have a direct
effect, or it may indirectly exert its effect through an
association with secondhand smoke exposure, or it
may confound the relationship between secondhand
smoke exposure and disease risk. To control for SES
as a potential confounding factor without considering
underlying relationships may lead to incorrect risk
estimates. For example, controlling for SES would not
be appropriate if it is a determinant of secondhand
smoke exposure but has no direct effect.
Nonetheless, because the health effects of invol-
untary smoking have other causes, the possibility of
confounding needs careful exploration when assess-
ing associations of secondhand smoke exposure with
adverse health effects. In addition, survey data from
Tobacco Industry Activities
The evidence on secondhand smoke and disease
risk, given the public health and public policy impli-
cations, has been reviewed extensively in the pub-
lished peer -reviewed literature and in evaluations by
a number of expert panels.. In addition, the evidence
has been criticized repeatedly by the tobacco industry
and its consultants in venues that have included the
peer -reviewed literature, public meetings and hear-
ings, and scientific symposia that included symposia
sponsored by the industry Open criticism in the peer -
reviewed literature can strengthen the credibility of
scientific evidence by challenging researchers to con-
sider the arguments proposed by critics and to rebut
them
Industry documents indicate that the tobacco
industry has engaged in widespread activities, how-
ever, that have gone beyond the bounds of accepted
scientific practice (Glantz 1996; Ong and Glantz 2000,
2001; Rampton and Stauber 2000; Yach and Bialous
The Health Consequences of Jnoolurrfary F_xposnre to Tobacco Smoke
the last several decades show that secondhand smoke
exposure is associated with correlates of lifestyle that
may influence the risk for some health effects, thus
increasing concerns for the possibility of confound-
ing (Kawachi and Colditz 1996). Survey data from the
United States (Matanoski et al. 1995) and the United
Kingdom (Thornton et a].1994) show that adults with
secondhand smoke exposures generally tend to have
less healthful lifestyles_ However, the extent to which
these patterns of association can be generalized, either
to other countries or to the past, is uncertain.
The potential bias from confounding varies with
the association of the confounder to secondhand smoke
exposures in a particular study and to the strength of
the confounder as a risk factor The importance of con-
founding to the interpretation of evidence depends
further' on the magnitude of the effect of secondhand
smoke on disease. As the strength of an association
lessens, confounding as an alternative explanation
for an association becomes an increasing concern. In
prior reviews, confounding has been addressed either
quantitatively (Hackshaw et al. 1997) or qualitatively
(Cal/EPA 1997; Thun et al. 1999). In the chapters in
this report that focus on specific diseases, confound-
ing is specifically addressed in the context of potential
confounding factors for the particular' diseases.
2001; Hong and Bero 2002; Diethelm et al 2004).
Through a variety of organized tactics, the industry
has attempted to undermine the credibility of the sci-
entific evidence on secondhand smoke. The industry
has funded or carried outresearch that has been judged
to be biased, supported scientists to generate letters to
editors that criticized research publications, attempted
to undermine the findings of key studies, assisted in
establishing a scientific society with a journal, and
attempted to sustain controversy even as the scientific
community reached consensus (Larne et al. 2005).
These tactics are not a topic of this report, but to the
extent that the scientific literature has been distorted,
they are addressed as the evidence is reviewed. This
report does not specifically identify tobacco industry
sponsorship of publications unless that information
is relevant to the interpretation of the findings and
conclusions
Introdtictiori, Sumnrary, and Conclusions 23
Surgeon General's Reporf
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Attachment B Smoking Ordinance Comparison (1998 versus
2007 proposed)
(See following page)
SMOKING ORDINANCE COMPARISION
City Council Staff Report 3/27/07
Topic
1998 Ordinance
Proposed 2007 Ordinance
Smoking Prohibited
• Public elevators
• All buildings except private
• city facilities
residences and hotel rooms
• indoor retail or service
designated for smoking;
establishment,
• Outdoor dining areas; and
• theaters, auditoriums, public
• 12' feet from any public building
places within financial
as defined in the ordinance.
institutions,
• schools (indoor)
• personal care facilities (however,
some rooms may be designated
for smoking);
• designated non-smoking areas in
restaurants
• indoor recreational areas; and
• designated non-smoking areas in
the workplace.
Smoking Allowed
• Private offices & workplace (if
• Public ROW unless located within
not specifically designated for
12' of an entrance to a public
non-smoking)
building;
• stadiums (where designated);
• private residences; and
• hospital or personal care rooms
• hotel rooms designated for such,
(where designated);
• businesses engaged in selling
tobacco products;
• restaurants (where proper
ventilation is provided);
• bars and taverns (must provide
non-smoking areas)
• public ROW;
• hotels;
• residences; and
• In certain areas (i.e, employee
break area) explicitly designated
as non-smoking areas in the
ordinance (retail, theaters,
auditoriums, etc).
Signage
• Must clearly designate non-
• Must post "No Smoking" signage
smoking seating areas in
that is clearly visible to the person
restaurants„
entering restaurants, bars or
tavern establishment. Smoking
permitted signs are prohibited
within 12' of any public building
Ash Trays
O Must be placed on the perimeter
o Unlawful to place within 12' of a
of non-smoking areas in
public building.
restaurants.
Smoking in Food
® Allowed if the business utilizes a
O Prohibited
Product
ventilation system designed by a
Establishment
professional engineer that
provides an air change every 15
minutes; or
• an alternative system is approved
by the building official that
achieves similar results.
City Parks
a Prohibited except in designated
No change but will ask City
areas_ Smoking prohibited in
Council to provide a directive.
dugouts, bleachers or other
congested areas in the park (This
regulation is in section 12 of
the city code under parks and
recreation).
Smoking in
! Allowed
Seek advice of the city attorney
designated public
ROW areas O.e.>
Town Square)
Fine
• $2,000 per violation
• $2,000 per violation
Attachment C — SPIN report
(See following page)
SPIN MEETING REPORT
PROJECT NAME: Smoking Ordinance
SPIN DISTRICT: City-wide
MEETING DATE: 6:30PM, March 12, 2007
MEETING LOCATION: 1400 MAIN STREET, SOUTHI_AKE, TEXAS
MEETING ROOMS .3A & 3I3
TOTAL ATTENDANCE: Approximately Fifteen (15)
• STAFF PRESENT: Planning & Development Scrvices Director Ken Baker-, Chief Planner
Jayashree Narayana, Planner Jennifer Crosby, and Planner Clayton Comstock
STAFF CONTACT: Ken Baker, (817)748-8067; kbaker@ci.southlake fx.us
PRESENTATION SUMMARY
See allached Poiver•Poinf Presenlation handout
QUESTIONS & DISCUSSION
• How soon after adoption will it be effective?
• What is the definition of"designated areas„ or "congested areas" in City Parks
• Will this include public events? (Congested Area)
• What is the reality of enforcement?
• What are the driving factors of the ordinance change?
• Concerns for lost business
• Concern that businesses and/or consumers are losing their right to decide which
establishment they'd like to support
• Keeping smoking away from building entrances is a must
• What is the percentage breakdown of smoke -free v. smoking allowed in Southlake9
Which businesses will this affect the most?
• Southlake should be a leader on the subject. Don't wait until everyone else has a
strict ordinance before we pass one.
SUMMARY
The majority of attendees were pleased with the proposed Smoking Ordinance and
correspondence received after the SPIN meeting (attached) confirms that initial response.
Objections to the Ordinance were few and were rased on property and civil rights and the
potential loss to business.
SPIN Meeting Reports are general observations of'SPtN Meetings by City staff and SPIN Representatives. The
report is neither verbatim nor official Erecting minutes; rather it serves to inform elected and appointee! officials. City
staff, and the public of the issues and questions raised by residents and the general €esponses made Responses as
summarized in this report should not betaken as guarantees by the applicant. Interested pai ties are strongly
encouraged to follow the case through the Planning and Zoning Commission and final action by City Council.
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Attachment D - Coffespondence
(See following page)
Clayton Comstock
From: Ken Baker
Sent: Wednesday, March 28, 2007 10:28 AM
To: Clayton Comstock
Subject: FW: smoking ordinance email
Kcn Baker, AICP
Planning Director
City of SOuthlake
317-748-8067
From, Lori Farwell
Sent: Tuesday, January 23, 2007 8:52 AM
To: Mayor - Ext; Place 1; Place 3; Place 4; Place 2; Place 5; Place 6; 'Carolyn Morris'
Cc: Shana Yelverton; Ken Baker
Subject: smoking ordinance email
From:
Sent: Monday, January 22, 2007 10:48 PM
To: citycouncil
Subject: Email sent from City of Southlake Web Site
Name: Brett Flory
Phone: 817 421 028.2
Email:
Comments: Dear City Council, I recently read the article regarding consideration for a smoking ban in Southlake and
wanted to relate my undying support as well as snake a few points to the rhetoric that will undoubtedly be cast against the
initiative. 1, Smokers are very quick to talk about their "rights" but continually and completely ignore the rights of non-
3mokers. As they have for over a hundred years. Should not the health of the public ultimately be the guiding light in this
:Iebate? .2 Bars and restaurants will complain it will hurt their business. This is bull. These same bars and restaurants have
trained non-smokers to stay away from their establishments for years. It may, in tact take some time to 'retrain' customers
that they can actually come eat and enjoy themselves in a restaurant or bar. But, the business will return, 3. Poor business
poisons will blame their inability to run a successful business on the smoking ban, Don't buy it. There are dozens of
studies showing that making non-smoking bars and restaurants does not harm the economy at all. I lived in California
where it has been banned for years:. Even the smokers raved about how much better it was after the law took effect,
Despite their- loud objections prior. 4. The surgeon general has finally published the facts we have all known for ,years.
Second band smoke kills. Of course it does. Who really does not know this? please use a drop of common sense,
diininate this highly addictive, disgusting, and and dangerous chemical frorn the lives ofthose that don't want to breath it.
If someone wants to inject their, body with a legal drug, let theirs do it in their own home, please. It is so unfair to force
everyone that wants to be healthy away from virtually all public places so 20% of the population can poison theniselvcs
and all the others innocent people around there. 5. Personally, my wife and I enjoy going to bars from time to time, but the
reality is, we don't do it. The impact to our health because of second hand smoke is too great. Consider how ullfair it is to
People that actually want to avoid tobacco output_ What is the answer? Non-smoking sections? Be serious, non-smoking
Sections are just as bad as the smoking sections. Smoke and the associated carcinogens do not know where they're
aupposed to go. At least a smoker can go outside, in their drug into their lungs and come back inside, We non-smokers
ion't even have that option in a restaurant or bar. We must stay away frorn all tables and chairs and never come in, or .just
ion't patronize the business at all, It's an odd situation that needs to be remedied. G. Finally, the reality is it your duty to
not only protect your citizens healthwise, but look to the future to protect your constituents financially. Can you not see
that the city's deep pockets will be the first to be cleaned out as soon as the avalanche of dying employees begin to will
3/28/2007
their first case of negligence or failure to act? They have no choice. They must snake money to feed their' families and
Dave no choice but to be infiltrated with these chernicals day in and day out. You can see why a.jury would award then?
I)ayment, We need to protect our financial future. Be leaders, do the right thing. You have many, many supporters in this.
Most of us are very quiet, l chose to speak up. Freedom is a two way street:. You aren't taking freedom away, you've gr-Iiving
Freedom to the majority, Remember, the majority do not smoke. And for those that love their- drug, they still have the
.)ption to do it, but don't have the right to force it on others that don't want to take it in. Sincerely, Brett Flory
.3/Z8/2007
Clayton Comstock
From: Ken Baker
Sent: Wednesday, March 28, 2007 10:28 AM
To: Clayton Comstock
Subject: FW: smoking ordinance
Ken Baker, AICP
Planning Director
City of Southlake
317-748-8067
From: Lori Farwell
Sent: Friday, February 09, 2007 9:17 AM
ro: Mayor - Ext; Place 5; Place 1; Place 3; Place 4; Place 2; Place 6; 'Carolyn Morris'
Cc: Shana Yelverton; Ken Baker
Subject: smoking ordinance
From:
Sent: Friday, February 09, 2007 9:12 AM
To; citycouncil
Subject: Email sent from City of Southlake Web Site
Name: Sid Smith
Phone: 817 488-0042
Email:
Comments: City of Southlake Council Members: As a ten year resident of Southlake (residing at 901 Nottingham), 1
atrongly o%ject to the City passing an ordinance prohibiting smoking. Although I sincerely detest smoking, I do not
believe a City should prohibit any private property owner from using his or her property as desired.. If you would like to
3arn smoking in City parks, feel tree to do so. However legal activity should be pennitted on one's private property. 1
realize it is tempting to consider health issues of the public at large as a motivating factor on this issue. However, the
public, has a responsibility to make wise choices about where it shops, dines and generally hangs out. The more cities and
7ther governments legislate on personal responsibility issues, the more that individuals will rely on government to I1a11dle
personal responsibilities, That is the true health issue! Sid Smith
3/.28/2007
Page I of I
Ken Baker
From: Greg Last
Sent: Friday, February 09, 2007 1:46 PM
To: Ken Baker
Subject: 1=W: Email sent from City of Southlake Web Site
Greg Last, CED
Director of Economic Development
City of 5outhake, Texas
From:
Sent: Friday, February 09, 2007 9:21 AM
To: Greg last
Subject: Email sent from City of Southlake Web Site
Name: Byron melius
Phone: 817-2 8 3 -3 3.3 3
Email:
Comments: Please pass this on to the City Council. While I live in Colleyville, I spend money in Southlake, so you may
still be interested in my opinion. I encourage your consideration to ban smoking in Southlake restuarants. The opponents
say they will lose business, but I can assure you they will gain business also. Since 2003, when Dallas banned smoking, I
have driven to Dallas restuarants to dine. It always disappoints me to pass all the mid -city restuarants (Colleyville,
Grapevine, Southlake) on my way to Dallas. I can assure you, Southlake, as my closest neighbor, will become my dining
destination several times a weep.
3/28/2007
Page 1 of 1
Ken Baker
From: Lori Farwell
Sent: Friday, February 09, 2007 12:40 PM
To: Mayor - Ext; Place 5; Place 1; Place 3; Place 4; Place 6; 'Carolyn Morris'; Place 2
Cc: Shana Yeiverton; Ken Baker
Subject: smoking ordinance
From:
Sent: Friday, February 09, 2007 12:26 PM
To: c4council
Subject: Email sent from City of Southlake Web Site
Name: Betty Springer
Phone: 817-481-7082
Email:
Comments: I absolutely totally 100% support a smoking ban in all restaurants, bars, stores, parks, etc. in the City. I
would, however, extend that "12 ft. from the entrance" section to more like 20 ft� The Honolulu airport had a short "from
the entrance" designation and the smokers all huddled right outside the doors. It was horrible walking in & out of doors
near the terminals. They recently admended their ordinance to ban all smoking in the airport facility, and what an
improvement!! I noticed in today's FWST newspaper story that Gene Street from Snookies said no smoking would
reduce his customer base & hurt his business. We USED to eat at least once a week at Snookies. Gene might be
interested to know that we quit going to Snookies simply because OF the smoke. If his place wasn't impossible to breath
in at night, we would probably return-- so he might be surprised at what happens to his customer base when non-smokers
can eat there without gagging from the smoke.
3/28/2007
Clayton Comstock
From:
Pilar Schank
Sent:
Thursday, March 15, 2007 10:11 AM
To:
Clayton Comstock; Ken Baker; Jayashree Narayana
Subject:
FW: In Favor
-----Original Message ----
From: The Murphy's [mailto
Sent: Thursday, March 15, 2007 10:10 AM
To: Pilar Schank
Subject: In Favor
We are in favor of the ordiance for No Smoking in Southlake. Secondhand smoke is lethal and we don't want to be
exposed or have our children exposed when we go out as a family We should not have to be subject to suffer from
someone else's dangerous free will choice
Arra & Greg Murphy
1410 Monarch Way
Southlake TX 76092
817-421-7755
Thank you for your support
The Murphy's
1410 Monarch Way
Southlake, Texas 76092
(817) 421-7755
gregandarra@verizon.net
Clayton Comstock
From: Pilar Schank
Sent: Thursday, March 15, 2007 9:32 AM
To: Clayton Comstock; Ken Baker; Jayashree Narayana
Subject: FW: NO Smoking in Southlake
-----Original Message ----
From: Nancy Anderson [mailto
Sent: Wednesday, March 14, 2007 5:30 PM
To: Pilar Schank
Subject: NO Smoking in Southlake
I am writing to let you know that we are very much in favor of the ordinance for NO smoking in Southlake. As Southlake
residents and parents to 3 small children, we would love to see an increase in the number of places smoking is prohibited.
While pregnant and dining at the Southlake Tavern recently, I was surprised, not only that smoking was allowed in the bar
area but that it smelled like smoke throughout the restaurant. Thank you
Nancy & Todd Anderson
733 Ashleigh Lane
Southlake, Texas 76092
817-488-8188
Clayton Comstock
From:
Sent: Tuesday, March 13, 2007 10:26 AM
To: Pilar Schank
Subject: "in favor of the ordinance for NO smoking in Southlake "
Jessica Heintz
1433 Sandstone Court
Southlake, TX 76092
817,421,1438
Clayton Comstock
From: Lou Ann Kleiman i
Sent: Monday, March 12, 2007 11:28 PM
To: Pilar Schank
Subject: NO smoking in Southlake
Pilar Schank,
We are very much in favor of the ordinance for NO smoking in Southlake
We believe that second hand smoke is a very real and serious issue
Thanks,
Lou Ann & Charles Kleiman
1422 Monarch Way
Southlake, TX 76092
817-421-3629
Clayton Comstock
From: jolyn potenza
Sent: Tuesday, March 13, 2007 8:22 AM
To: Pilar Schank
Subject: Against the smoking ordinance
v1r. Schank,
'lease do not allow a new smoking ordinance in Southlake. It's unfair and restricts the freedom this country was founded
)n.
sincerely,
folyn Potenza
1000 Independence Court
3outhlake TX 76092
� 17.329.0550
?lay Flexicon: the crossword game that feeds_y.our brain. FLAY now for FREE.
3/27/2007
Clayton Comstock
From: Pilar Schank
Sent: Tuesday, March 13, 2007 3:07 PM
To: Clayton Comstock
Subject: FW: In Favor of the ordinance to Prohibit Smoking in Southlake
=rom: National Insurance Network I
lent: Monday, March 1.2, 2007 5:32 PM
ro: Pilar Schank
iubject: In Favor of the ordinance to Prohibit Smoking in Southlake
'filar,
appreciate everything you and SPIN do for the community of Southlake. Please record that I am IN FAVOR of the
)rdinance to Prohibit Smoking in Southlake. I am tired of walking through a cloud of smoke in different places -
;specially in front of buildings. Who knows what the second hand smoking problems will be later. I am sure they will
ust get worse, if not bad enough yet. I would also like to see if smoking could also be prohibited in all of town center,
.hopping areas and within 50 feet of a building. Possibly have smoking areas away from the building entrance if people
lave to smoke,
am glad Southlake is doing something about this nasty and unhealthy habit. I feel it will bring more health conscious
)eople to the area and make Southlake an even better place to live. It will also set a lot better example for the youth in the
Lrea. I see a lot of high school age kids smoking. The ordinance may help reduce these numbers. Further reducing health
)roblems and 'increasing the overall quality of the air.
["hank you again for your help on this,
'odd A. Schneider
?resident
VATIONAL INSURANCE NETWORK & BUSINESS SERVICES
817) 329-1855 (metro)
latin@verizon.net
Todd A. Schneider
141 B Monarch Way
Southlake, TX 76092
817) 875-4052
3/27/2007
Clayton Comstock
From: Pilar Schank
Sent: Friday, March 16, 2007 7:51 AM
To: Clayton Comstock; Ken Baker; Jayashree Narayana
Subject: FW: no smoking
-rom: iilto:
'sent: Thursday, March 15, 2007 3:19 PM
ro: Pilar Schank
"subject: no smoking
-lello-
rhis is Debbie Pino, from 1535 Bent Creek Drive, Southlake, TX 76092 at 817-•442-8391. 1 was unable to attend the SPIN meeting
)artier this week but wanted to send you my opinion. I am in favor of the ordinance for NO smoking in Southlake,
(hank you,
)ebbie Pino
\OL now offers free email to everyone Find out more about what's free from AOL at AOL.com.
3/27/2007
Clayton Comstock
From: Pilar Schank
Sent: Tuesday, March 13, 2007 4:41 PM
To: Clayton Comstock
Subject: FW: Smoking ordinance
=rom: Rita Mayle
"seat: Tuesday, March 1.3, 2007 4:39 PM
ro: Pilar Schank
iubject: Smoking ordinance
Ne would simply like to voice our support of the ordinance banning smoking in Southlake. We feel that clean air in
restaurants, offices and shops is everyone's right in a day when second hand smoke is shown to have negative
•epercussions on those of us who choose not to partake.
Sincerely,
vita and Ron Mayle
Southlake Residents
1417 Monarch Way
Southlake TX 76092
H 7-488-9689
Fhe most successful people are those who are good at plan B.
lames Yorke
3/27/2007
Clayton Comstock
Prom:
Sarah Jenkins,
Sent:
Monday, March 12, 2007 10:11 PM
To:
Piiar Schank
Subject: in favor of the ordinance for NO smoking in Southiake
Co whom it may concern:
ks a mother, I would like to voice my support for this NO smoking in Southlake ordinance.
Chank you-
iarah Jenkins
W8 Caroline Lane
5outhlake, TX
� 17-310-b328
3/27/2007
Clayton Comstock
From: Tara Eliason
Sent: Monday, March 12, 2007 9:48 PM
To: Pilar Schank
Subject: In favor of the ordinance for NO smoking in Southlake
Cara and John Eliason
717 Manchester Ct. Southlake
317-488-0227
nd what youu geed at prices y_ou'll love. Copare products and._save at MSN® Slloppin.
3/27/2007
Clayton Comstock
From: Laurie Schneider
Sent: Monday, March 12, 2007 9:09 PM
To: Pilar Schenk
Subject: "In favor of the ordinance for NO smoking in Southlake "
,aurie Schneider
1418 Monarch Way
3outhlake, TX 76092
317-488-2641
'In favor of the ordinance for NO smoking in Southlake," -- Please stop smokers from infringing upon my right to good
iealth. 2nd band smoke is more deadly than actually smoking, so why should my health be put at risk for another's
'habit".
(hank you. Laurie Schneider
3/27/2007
Clayton Comstock
From:
Judith Ursitti ,
Sent:
Monday, March 12, 2007 10:46 PM
To:
Pilar Schank
Subject: No Smoking Ordinance
fully support banning smoking in public areas here in Southlake. Second-hand smoke is a proven carcinogen and just a plain -old
rritant to boot People should be free to smoke in their own homes, but I should not be subject to their second-hand smoke when I
im out in our wonderful community.
Mth all sincerity,
Judith Ursitti
1434 Waltham Drive
3outhlake, Texas
ti=. teas j acCatack.cam
"lick here to ,join our Walk Now for Autism team May 19th at Ameriquest Field.
-ley, Jude, don't make it bad . Take a sad song and make it better
-Lennon-McCartney
Jo virus found in this outgoing message.
'hecked by AVG Free Edition.
Jersion: 7.5.446 / Virus Database: 268.18.9/719 - Release mate: 3/12/2007 8:41 AM
3/27/2007
Clayton Comstock
From: Fullmer's
Sent: Monday, March 12, 2007 9:37 PM
To: Pilar Schank
Subject: No smoking ordinance
Jeff and Allison Fullmer
1424 Sandstone Court Southlake, TX 76092
117-424-4252
Me moved from California 2 years ago and didn't realize at the time how wonderful and enjoyable it was to be in smoke free
=nvironments. We love Texas, especially Southlake, but our family outings have been cut short and even canceled at times because
3f the free range smoking. Our quality of life would change drastically if this ordinance was passed.
Ne are in favor of the ordinance for NO smoking in Southlake,
shank you,
Leff and Allison Fullmer
3/27/2007
Proposed smoking ban in Southlake
am Greg Billingsly, a longtime resident of Southlake and am very
concerned about the recent issue of a city wide smoking ban. The science
regarding the hazards of second hand smoke, do not appear to stack up.
But even if it did,.1 do not believe it warrants a citywide ban n smoking., o,.,..._
I believe that smoking bans are just one more instance of the slippery
slope toward government regulation of all aspects of our personal lives, as
well as, the trampling of property rights.
America was founded on the ideas of personal property rights and
tolerance of others. We tolerate alternative lifestyles, religious and racial
differences, and all sorts of behavior that is not in step with the majority. It
is these things that make America the land of the free and not a fascist
country.
We should not consider banning smoking if we're saying "You shouldn't
smoke" or "Smoking is bad for you" because that is the definition of
intolerance. And it certainly is not the role of the City Council to tell the
private sector what to do. We should also not consider banning smoking if
it is for "protection of our citizens" because that subrogates all individuals
right to choose.
It is true that there have been a wave of anti smoker vigilante groups and
smoking bans implemented across this country in recent years. However
these dogmatic protesters are trying to enforce a universal ban on smoking
in public and are forgetting two key concepts - freedom of choice and
property rights.
Since when, in this country, does the will of the "many" trample on the
rights of the "few"?
SMOKING BANS ARE A THREAT TO PRIVATE PROPERTY RIGHTS
These bans prevent private property owners from allowing a LEGAL
activity in their establishment. It takes away their free choice to pursue a
market force in a free market system. Therefore, it is an infringement on the
right to trade. Private property is sacred! It is sacred by law! We must
remember that a place of business does not become public property just
because the public is invited in.
NO ONE IS FORCED TO BE AROUND SMOKE
No one is forced to work, eat, or visit any establishment that allows
smoking. We have the free choice to use our own intelligence to decide
where to go and where to work. Where is individual responsibility these
days? Banning private business owners from wanting to allow a legal
activity on their property just because some don't like that activity, is the
ultimate form of selfishness. I think a much better solution is that if people
don't like the smoking policy of each establishment., they can vote with
their pocketbooks.
An effective and inexpensive way for people to know each businesses
policies in advance, are the adoption of posting either of these two signs at
the front door of each establishment. These are simple in design and
easily readable from the street. (attached)
THE SCIENCE BEHIND SECONDHAND SMOKE IS FLIMSY
The 1992 EPA ETS Secondhand smoke study was thrown out by known
anti -tobacco federal judge William Osteen for biased science and
manipulated statistics and research. The American Lung/Heart Association,
as well as the U.S. Surgeon General in his 2006 pro -smoking ban speech,
all use this thrown out study as their pretext for supporting bans today.
Even more studies have proven the actual risk of secondhand smoke is
inconclusive. If secondhand smoke is really dangerous, why does it have a
Risk Ratio Value lower than cell phones, computers, electric blankets, hair
dryers and municipal water supplies, which aren't considered dangerous?
If we are outlawing smoking, does that mean we should also ban
restaurants with indoor grills and hickory and mesquite smoke? What
about other airborne smells that people are sensitive to? Such as,
flatulence, perfumes, chemical odors on workers clothes like gasoline or
toner ink, whiteout in the workplace, etc.
THE COST OF HEALTHCARE ARGUMENT FAILS
No one in their right mind can use the 'cost to state healthcare' argument
to push a ban on smoking. if we buy into that argument can we also expect
regulation of what we eat? Cholesterol is the number one killer and cost to
healthcare, so, under this argument the state would have to regulate what
we eat and drink as well. I wonder what the fine would be for chocolate
cake? What about the death toll from our highways?
JUST BECAUSE A MAJORITY WANTS IT DOESN'T MEAN THEY GET IT
We are a constitutional republic, not a mob rule democracy. There was a
healthy fear of `the angry mob' in the Founding Fathers thinking. The very
fact that we have a representative republic and not a mob rule democracy
is a testament to the Founding Fathers realistic world view. In our
republican form of government the will of the angry mob is BALANCED
against individual/private property rights. And in our form of government
the rights of the majority are considered but not set into stone.
A problem of modern politics today is self-righteousness. Tyranny is the
result of the self-righteous via their new tool in the form of "big brother"
government. The anti -smoking activists want a government effort to stamp
out a habit they don't like. There was once a nation that did this. It was
Adolf Hitler's Nazi Germany that banned smoking in public, restricted
tobacco advertising, restricted and regulated tobacco farmers growing
abilities, and engaged in a sophisticated anti -smoking public relations
campaigns.
In summation, I believe that people in Southlake should be able to retain
their individual freedoms and that business owners have a property right
that government should not take away lightly.
An 8xl0 sign is easily legible from drivers passing by.
Clayton Comstock
From: Greg Rogers 1
Sent: Monday, March 12, 2007 5:48 PM
To: Piler Schank
Subject: Southlake Smoking Ordinance
)ear Pilar
Ny name is C. Gregory Rogers. I live with my wife Karil S, Rogers at 1370 Bent Trail Circle in Southlake. My
tome phone is 817.416.1720. We are both in favor of the ordinance for NO smoking in Southlake, Thanks for
four help on this initiative.
Jest regards,
Greg
3reg Rogers
ouida, Slavich & Flores, P.C.
750 N. St. Paul St., Suite 200
Dallas, Texas 75201
>14.692,8385 - phone
?14,69Z6610 - fax
tigers@gsfpc,cam
MW,_gsfpc,com
FHIS COMMUNICATION AND ANY ATTACHMENTS ARE PRIVILEGED AND CONFIDENTIAL ANY UNAUTHORIZED RECEIPT,
JSE, OR DISSEMINATION IS STRICTLY PROHIBITED IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE
40TIFY THE SENDER IMMEDIATELY BY RETURN E-MAIL, AND DELETE THIS COMMUNICATION FROM ALL AFFECTED
7ATABASES THANK YOU FOR YOUR COOPERATION
3/27/2007
Attachment E — Proposed Ordinance No, 907
(See following page)
ORDINANCE NO.907
AN ORDINANCE AMENDING CHAPTER 10, ARTICLE V, "PUBLIC
SMOKING", OF THE SOUTHLAKE CITY CODE TO PROHIBIT
SMOKING IN ALL PUBLIC BUILDINGS OR RESTAURANTS, AND
WITHIN 12 FEET OF THE ENTRANCE TO A PUBLIC BUILDING OR
RESTAURANT, REQUIRING SIGNS AND PROHIBITING CERTAIN
ACTS; PROVIDING FOR SEVERABILITY; PROVIDING FOR SAVINGS
AND CODIFICATION; PROVIDING FOR A PENALTY AND
PUBLICATION; AND DECLARING AN EFFECTIVE DATE.
WHEREAS, the City Council of the City of Southlake, Texas, finds that secondhand
tobacco smoke is a major contributor to indoor air pollution and that breathing secondhand
smoke (also known as environmental tobacco smoke) is a cause of disease in healthy
nonsmokers, including heart disease, stroke, respiratory disease, and lung cancer, and further
finds as follows:
WHEREAS, the National Cancer Institute in 1999 found that secondhand smoke is
responsible for the early deaths of approximately 53,000 Americans annually. (National Cancer
Institute (NCI), "Health effects of exposure to environmental tobacco smoke: the report of the
California Environmental Protection Agency. Smoking and Tobacco Control Monograph 10,"
Bethesda, MD,, National Institutes of Health, National Cancer .Institute (NCI), August 1999);
WHEREAS, the Public Health Service's National Toxicology Program (NTP) has listed
secondhand smoke as a known carcinogen. (See Environmental Health Information Service
(EHIS), "Environmental tobacco smoke: first listed in the Ninth Report on Carcinogens," LIS.
Department of Health and Human Services (DHHS), Public Health Service, NTP, 2000;
reaffirmed by the NTP in subsequent reports on carcinogens, 2003, 2005);
WHEREAS, based on a finding by the California Environmental Protection Agency in
2005, the California Air Resources Board has determined that secondhand smoke is a toxic air
contaminant, finding that exposure to secondhand smoke has serious health effects, including
low birth -weight babies; sudden infant death syndrome (SIDS); increased respiratory infections
in children; asthma in children and adults; lung cancer, sinus cancer, and breast cancer in
younger, premenopausal women; heart disease; and death. (Appendix II Findings of the
Scientific Review Panel: Findings of the Scientific Review Panel on Proposed Identification of
Environmental Tobacco Smoke as a Toxic Air Contaminant as adopted at the Panel's .Tune 24,
2005 Meeting," California Air Resources Board (ARB), September 12, 2005);
WHEREAS, there is no safe level of exposure to secondhand smoke, (Environmental
Protection Agency (EPA), "Respiratory health effects of passive smoking: lung cancer and other
disorders, the report of the U.S. Environmental Protection Agency, Smoking and Tobacco
Control Monograph 4," Bethesda, MD, National Institutes of Health. National Cancer Institute, -
Environmental Protection Agency (EPA), August 1993; California. Environmental Protection
Agency, "Health Effects of Exposure to Environmental Tobacco Smoke," 1997; California Air
Resources Board, "Proposed identification of environmental tobacco smoke as a toxic air
contaminant," Sacramento: California Environmental Protection Agency (Cal -EPA). Air
Resources Board, Stationary Source Division, Air Quality Measures Branch, Office of
Environmental Health Hazard Assessment (OEHHA), September 29, 2005);
WHEREAS, a study of hospital admissions for acute myocardial infarction in Helena,
Montana before, during, and after a local law eliminating smoking in workplaces and public
places was in effect, has determined that laws to enforce smokefree workplaces and public places
may be associated with a reduction in morbidity from heart disease. (Sargent, Richard P.;
Shepard, Robert M.; Glantz, Stanton A., "Reduced incidence of admissions of myocardial
infarction associated with public smoking ban: before and after study," British Medical Journal
328:977-980, April 24, 2004);
WHEREAS, secondhand smoke is particularly hazardous to elderly people, individuals
with cardiovascular disease, and individuals with impaired respiratory function, including
asthmatics and those with obstructive airway disease. {California Environmental Protection
Agency (Cal EPA), "Health effects of exposure to environmental tobacco smoke," Tobacco
Control 6(4):346-353, Winter, 1997);
WHEREAS, the Americans with Disabilities Act, which requires that disabled persons
have access to public places and workplaces, deems impaired respiratory function to be a
disability, (Daynard, R,A., "Environmental tobacco smoke and the Americans with Disabilities
Act," Nonsmokers' Voice 15(1):8-9.);
WHEREAS, the U.S. Surgeon General has determined that the simple separation of
smokers and nonsmokers within the same air space may reduce, but does not eliminate, the
exposure of nonsmokers to secondhand smoke, (Department of Health and Human Services,
The Heath Consequences of Involuntary Smoking.- A Report of the Surgeon General, Public
Health Service, Centers for Disease Control, 1986);
WHEREAS, the U.S. Centers for Disease Control and Prevention have determined that
the risk of acute myocardial infarction and coronary heart disease associated with exposure to
tobacco smoke is non -linear at low doses, increasing rapidly with relatively small doses such as
those received from secondhand smoke or actively smoking one or two cigarettes a day, and has
warned that all patients at increased risk of coronary heart disease or with known coronary artery
disease should avoid all indoor environments that permit smoking, (Pechacek, Terry P,; Babb,
Stephen, "Commentary: How acute and reversible are the cardiovascular risks of secondhand
smoke?" British Medical Journal 328: 980-983, April 24, 2004);
WHEREAS, given the fact that there is no safe level of exposure to secondhand smoke,
the American Society of Heating, Refrigerating and Air Conditioning Engineers (AHRAE) bases
its ventilation standards on totally smokefree environments. ASHRAE has determined that there
is currently no air filtration or other ventilation technology that can completely eliminate all the
carcinogenic components in secondhand smoke and the health risks caused by secondhand
smoke exposure, and recommends that indoor environments be smokefree in their entirety,
(Samet, J,; Bohanon, Jr., H.R.; Coultas, D,B.; Houston, T.P.; Persily, A.K,; Schoen, L.J.;
Spengler, L; Callway, C,A., "ASHRAE position document on environmental tobacco smoke and
2
the development of acute coronary syndromes: the CARDIO2000 case -control study," Tobacco
Control 11(3):220-225, September 2005);
WHEREAS, the Society of Actuaries has determined that secondhand smoke costs the
U.S. economy roughly $10 billion a year: $5 billion in estimated medical costs associated with
secondhand smoke exposure, and $4,6 billion in lost productivity. (Behan, D,F.; Eriksen, M.P.;
Lin, Y., "Economic Effects of Environmental Tobacco Smoke," Society of Actuaries, March 31,
2005);
WHEREAS, numerous economic analyses examining restaurant and hotel receipts and
controlling for economic variables have shown either no difference or a positive economic
impact after enactment of laws requiring workplaces to be smokefree. Creation of smokefree
workplaces is sound economic policy and provides the maximum level of employee health and
safety. (Glantz, S.A. & Smith, L. The effect of ordinances requiring smokefree restaurants on
restaurant sales in the United States. American Journal of Public Health, 87:1687-1693, 1997;
Colman, R,; Urbonas, C.M., "The economic impact of smoke -free workplaces: an assessment for
Nova Scotia, prepared for Tobacco Control Unit, Nova Scotia Department of Health," CJPI
Atlantic, September 2001);
WHEREAS, hundreds of communities in the U.S., plus numerous states, including
Texas, California, Delaware, Florida, Massachusetts, Montana, New Jersey, New York, and
Washington, have enacted laws requiring workplaces, restaurants, bars, and other public places
to be smokefree, as have numerous countries, including Ireland, New Zealand, Norway,
Scotland, Sweden, Uganda, and Uruguay;
WHEREAS, smoking is a potential cause of fires, cigarette and cigar burns and ash
stains on merchandise and fixtures, and other economic damage to businesses. ("The high price
of cigarette smoking, " Business ci Health 15(8), Supplement A: 6-9, August 1997);
WHEREAS, the City Council finds there is no legal or constitutional "right to smoke"
Business owners have no legal or constitutional right to expose their employees and customers to
the toxic chemicals in secondhand smoke. On the contrary, employers have a common law duty
to provide their workers with a workplace that is not unreasonably dangerous;
WHEREAS, the City Council finds the congregation of smokers within 12 feet of
buildings in which smoking is prohibited can impair entry into and exit from these buildings,
create noxious clouds of concentrated nuisance smoke that harm the rights of nonsmoking
patrons and passersby, and create a hazard of such concentrated smoke drifting into the indoor
environment; and
WHEREAS, the City Council also finds the smoking of tobacco is a form of air
pollution, a positive danger to health, and a material public nuisance. Accordingly, the City
Council finds and declares that the purposes of this ordinance are (1) to protect the public health
and welfare by prohibiting smoking in public places and places of employment, (2) to guarantee
the right of nonsmokers to breathe smoke -free air, and (3) to recognize that the need to breathe
smoke -free air shall have priority over the desire to smoke.
NOW, THEREFORE, BE IT ORDAINED BY THE CITY COUNCIL OF THE
CITY OF SOUTHLAKE, TEXAS:
SECTION 1.
The declarations, determinations and findings made in the preamble of this ordinance are
hereby adopted and made a part of the operative provisions hereof,
SECTION 2.
The Article V, Chapter 10 of the Southlake City Code is hereby amended to read as
follows:
ARTICLE V.
PUBLIC SMOKING
Sec. 10-151. Definitions.
The following definitions shall apply to this article:
"Smoke" or "Smoking" means inhaling, exhaling, or burning a lighted cigar, cigarette,
pipe or other lighted tobacco product in any manner or form.
"Public building" means any building other than a building used as a private residence or
hotel/motel room. If portions of a building are used as a private residence or hotel room and
another portion of the building is used for business purposes or commercial activities, then
"public building" as used herein shall apply to the portions of the building used for business
purposes or commercial purposes, but not the portion used solely as a residence or hotel room.
"Restaurant" means an establishment that primarily serves food prepared in the kitchen of
the same establishment for patrons and may serve alcohol with a valid Texas Alcoholic Beverage
Commission License as long as the establishment derives less than 75% of its gross revenues
from alcohol sales and includes all indoor and outdoor seating areas, kitchen, bar area, restrooms
and lobby
"Bar" or "Tavern" means an establishment that derives 75% or more of the
establishment's gross revenue from the on -premise sale of alcoholic beverages.
Sec. 10-152. Smoking prohibited in public buildings or restaurants, or within 12
feet of an entrance to a public building or restaurant; signs required; and prohibited acts.
(a) It shall be unlawful for any person to perform the following acts in any public
building or restaurant in the City of Southlake or within 12 feet of any entrance to any public
building or restaurant:
(1) smoke,
M
(2) carry a lighted cigarette, cigar, or tobacco -containing pipe, or
(3) light a cigarette, cigar or tobacco -containing pipe.
(b) It shall be unlawful for any owner of any restaurant, bar and tavern to allow the
operation of the establishment unless one or more of the following signs have been posted at a
location clearly visible to a person entering the food establishment:
(1) a "No Smoking" sign, or
(2) the international "No Smoking" symbol (depiction of a burning cigarette enclosed
in a red circle with a red bar across it).
(c) It shall be unlawful for any owner or operator of any public building to place or
allow to be placed any of the following items in any public building or within 12 feet from an
entrance to any public building:
(1) ashtrays,
(2) smoking paraphernalia, or
(3) signs that indicate that smoking is permitted.
Sec. 10-153. Penalty.
Any person who violates this article shall be guilty of a health and sanitation
misdemeanor violation and subject to a fine of not more than $2,000.00. Each day that a
violation is permitted to exist shall constitute a separate offense.
SECTION .3.
Sections 10-154 through 10-158 of the Southlake City Code are hereby repealed,
SECTION 4.
If' any provision of this ordinance, or the application thereof to any person or
circumstances, shall be held invalid or unconstitutional by a Court of competent .jurisdiction,
such invalidity shall not affect the other provisions, or application thereof, of this ordinance
which can be given effect without the invalid provision or application, and to this end the
provisions of this ordinance are declared to be severable.
SECTION 5.
It is the intention of the City Council that this ordinance shall become a part of the Code
of the City of Southlake, Texas, and it may be renumbered and codified therein accordingly, in
5
the manner approved by the City Attorney, The Code of the City of Southlake, Texas, as
amended, shall remain in full force and effect, save and except as amended by this ordinance.
SECTION 6.
This ordinance shall become effective immediately upon publication that meets the
requirements of the Charter of the City of Southlake after final passage and approval by the City
Council.
PASSED AND APPROVED ON FIRST READING THIS DAY OF
, 2007.
MAYOR
ATTEST:
CITY SECRETARY
PASSED AND APPROVED ON SECOND READING THIS DAY OF
, 2007.
MAYOR
ATTEST:
CITY SECRETARY
EFFECTIVE:
APPROVED AS TO FORM AND LEGALITY:
City Attorney