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Item 6L
City of Southlake, Texas April 11, 2007 TO: Shana Yelverton, City Manager FROM: Ken Baker, Planning and Development Services Director SUBJECT: Ordinance No. 907, 2nd Reading, Amending Chapter 10, Article V, "Public Smoking," of the Southlake City Code Action Requested: Consider approving Ordinance No. 907, 2nd 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 June, 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 smolcing 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 -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 workplaces, Here in the Metroplex there are several cities that have either adopted or are considering changes to their smoking policies including Plano, Irving, Port 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). The following changes have been made to the ordinance since the first reading. • Page 3, Revised the revised the next to the last "Whereas" clause by changing "within 12 feet of buildings" to "within 12 feet of the entrances or exits of buildings", • Page 4, Inserted a definition of "person" in Section 10-151. Person will mean any individual. • Page 5, removed "food" from Section 10-152 (b). The sentence now reads "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", • Page 5, revised Section 3 to make the repeal of Sections 10-154 through 10-158 effective as of .Tune 1, 2007„ • Page 5, revised section 10-153 to make the maximum fine for an individual $500 for each offense and the maximum fine for an association, partnership, or corporation $2,000 for each offense. • Page 6, revised Section 6 to provide that the ordinance take effect ,Tune 1, 2007. Financial Considerations: None. Financial Impact: None. Citizen Input/ Board Review: City-wide SPIN meeting held March 12, 2007, City Council approved this item (7-0) on first reading at its April 3, 2007 meeting. Legal Review: The City Attorney has reviewed the proposed ordinance. 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) RenYarks at press conference to launch Health Consequences of Involuntary Exposure to Tobacco Smoke:..,. Page 1 of 7 Remarks as prepared; not a transcript. Surgeon General News Home About the Office of the Vice Admiral Richard H. Carmona, M.D., • March 19, 2007 Surgeon General M.P.H, FACS Statement by Rear Admiral Public Health Priorities United States Surgeon General Kenneth Moritsugu Acting Surgeon General Regarding U.S. Department of Health and Human the Death of Peter Van Reports and Publications Services Vechten Hamill, medical director for the 1964 U,S, Newsroom Remarks at press conference to launch Surgeon General's smoking report Contact Us Health Consequences of Involuntary fu113_toa Exposure to Tobacco Smoke: A Report of • March 6, 2007 the Surgeon General Acting surgeon General Issues National Call to Tuesday, June 27, 2006 Action on Underage Drinking 10:00 a.m. f !!l s ev Washington, D.C. • February 14, 2007 "The Health Effects of Secondhand Smoke"' Statement by Rear Admiral Kenneth Moritsugu Acting Surgeon General Regarding National Donor Day Thank you, Rear Admiral Moritsugu for your kind fvit5toly introduction. Features I am grateful to be here today and to be able to say unequivocally that the debate Is over. The The summon General's ea to Actlon to Prevent and science 15 Clear: secondhand smoke i5 not a Re uce tJndera a Drinkl mere annoyance, but a serious health hazard U.S. sur�egn Genera's that causes premature death and disease in Family hiist0_ Initiative Health children and nonsmoking adults. • The Cose-quegces ot_Invalunta_ry Exposule to Tobacco. Smoke Updating the Evidence Related Wei3sites Twenty years ago, the 1986 Surgeon General's . once of Public i�ealth anri Report on The Health Consequences of Involuntary Smoking concluded that secondhand . u.s,_�ubliG iieaith Se vr�ce smoke exposure was a cause of disease in �sslaned Corp •Medical Rve corps nonsmokers. That Report, which was one of the 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 http://www.surgeongencral.gov/news/speeches/06272006a.html 3/28/2007 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 littp://www.surgeongencral,gov/news/speeches/06272006a.html 3/28/2007 Remarks at press conference to launch. Health Consequences of Involuntary Exposure to Tobacco Smoke:... Page 3 of 7 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. 1-ittp://www.surgeongener-al,gov/news/speeches/06272006a,html 3/28/2007 Remarks at press conference to launch Health Consequences of involuntary Exposure to Tobacco Smoke:... Page 4 of 7 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 llttp://www.surgeongeneral.gov/news/speeches/06272006a�html 3/28/2007 Remarks at press conference to launch Health Consequences of Involuntary Exposure to Tobacco Smoke: — Wage S of 7 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 biomarker 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 littp://www.surgeongeneral.gov/news/speeches/06272006a,htmi 3/28/2007 Remarks at press conference to launch Health (consequences of Involuntary Exposure to Tobacco Smoke:... Page 6 of 7 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, http://www.surgeongeneral.gov/news/speeches/06272006a,htrnl 3/28/2007 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,surgeon.generai gav, Thank you for being here today. Dr. Samet, will you please join me on stage for questions. We will now answer questions that you may have. Last revised: January B, 2007 The White Mouse I VA goy I H.d{2 g Amedo S Youth U.S, Department of health & human Services , 200 independence Avenue, S.W. , Washington, D,C. 20201 h4://www.surgeongeneral.gov/news/speeches/06272006a.himl 3/28/2007 Chapter 1 Introduction, Summary, and Conclusions Introduction 3 Organization of the Report Preparation of the Report 9 Definitions and Terminology 9 Evidence Evaluation IQ 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 Preten Delivery 1.3 Low Birth Weight 1.3 Congenital Malformations 1.3 Cognitive Development 13 Behavioral Development 13 Height/Growth 13 Childhood Cancer 13 Chapter 6, 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 Surgeon General's Repart Chapter S. Cardiovascular Diseases from Exposure to Secondhand Smoke 15 Chapter 9, Respiratory Effects in Adults from Exposure to Secondhand Smoke 1.5 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 Meihodologic 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 (Tire Health Consequences of Srnok`mg, 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 sidestxeam 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 that smoking in enclosed spaces could lead to nigh 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, I1ze Health Conse- quences of Smoking (USDHEW 1975), The chapter noted that involuntary smoking takes place when nonsmok- ers inhale both sidestrearn and exhaled mainstream smoke and that this "smoking" is "involuntary„ when "the exposure occurs as an unavoidable consequence of breathing in a smoke -filled environment" (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 Consequences of Inaolunfaiy Ex7iosicre to Tobacco Srrroke 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 that passive 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 1971. 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 Involuntary Smoking (USDHHS 1986). In its 359 pages, the report covered the full breadth of the Introduction, Summary, and Conclusions 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 from chronic 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.. ,function 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 1994 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 1994 but small differences in tests of pulmonary function urhen 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 between involuntary smoking 1986 and cardiovascular disease are needed in order to determine whether involuntary smoking increases the risk of cardiovascular disease." (p. 14) Chapter 1 The Health Consequences of Involuntary Exposure to Tobacco Suroke 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., i 3--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: 'Anumber of studies report that chronic middle ear effusions are more 1986 common in young children whose parents smoke than in children of nonsmoking parents (p..14) Pulmonary function (children): - the 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, e.g., [sic] active smoking or occupational exposures, needs investigation." (p 13) Other: An atmosphere contaminated with tobacco smoke can contribute to the discomfort of many 1972 individuals " (p. 7) "C igarette 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) "The 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, .Sumnranj, and Conclusions Surgeon 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 nonsmokers to the potential [sic] harmful effects of tobacco smoke" (USDHIS 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" (1ARC 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. Can 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 infecti ons and to a slightly diminished rate of lung growth. Since 1986, the conclusions with regard to boththe 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 known human carcinogen„ Estimates of approxi- mately .3,000 US_ 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, 77re Dealt] 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 air space 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 Table 1.3 The Health Consequences of Involuntary Exposure to Tobacco Snioke 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 C. Assessing Health Effects United States 1986 International Agency for Research on Monographs on the Evaluation of the Carcinogenic Lyon, France Cancer (IARC) Risk of Chemicals to Humans: Tobacco Smoking 1986 (IARC Monograph 38) U S. Environmental Protection Agency Respiratory Health Effects of Passive Smoking: Lung Washington, D C. (EPA) Cancer and Other Disorders United States 1992 National Health and Medical Research The 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 InfernationaI Consultation on Ennronnrenfal Tobacco Geneva, Switzerland Smoke (ETS) and Child Health. Consultation Report 1999 IARC Tobacco Smoke and Involuntary Srtiaking 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 Contarninant 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 infant death syndrome (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, Sunnnary, and Conclusions Surgeon 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 430 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 remains 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, the relevant literature is substantial.. Consequently, this report uses meta -analysis to quantitatively summarize evidence as appropriate. Following the approach used in the 2004 report (77ze 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 I 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 (CHD), stroke, and subdinical 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, Centers 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, Sidestxeam 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 Consequences of Inuoluutanj Exposure to Tobacco .Stwke 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://wu-A,.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 Introduction, Suarmanf, and Conclusions Surgeon General's Repoi f 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 (USDHEW 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 an 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 Smoking, the framework for interpreting evidence on smoking and health was revisited in depth for the first time since the 1964 report (USDH.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 (USDHEW 1964), but they were not intended to be applied strictly or as a "checklist" that needed to be met before the designation of "causal" couldbe applied toan 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 1 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, I0 Chapfer I example of spousal smoking and lung cancer riskin 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, Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SDDS), acute respiratory infections, ear problems, The Health Consequences of lnvoluittany Exposure to Tobacco Smoke 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. introduction, Sumrnaiy, and Cmdusi0ns 12 Sirrgeorr General's Report Chapter Conclusions Chapter 2. Toxicology of Secondhand Smoke Evidence of Carcinogenic Effects fi-orrr Secondhand Smoke Exposure 1. More than 50 carcinogens have been identified in sidestream and secondhand smoke. 2. The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and its condensates and tumors in laboratory animals. 1 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-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (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.. Mechanistrrs of Respiratory Tract injury and Disease Caused by Secondhand Snoke Exposure 5: The evidence indicates multiple mechanisms by which secondhand smoke exposure causes injury to the respiratory tract The evidence indicates mechanisms by which secondhand smoke exposure could increase the risk for sudden infant death syndrome. Mechanisms of Secondhand Srnoke Exposure and Heart Disease 7. The evidence is sufficient to infer that exposure to secondhand smoke has a prothrombotic effect, 12 Chapter I 8.. The evidence is sufficient to infer that exposure to secondhand smoke causes endothelial cell dysfunctions. 9. 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. Biornarkers of Exposure to Secondhand Srnoke 5. Biomarkers suitable for assessing recent exposures to secondhand smoke are available. T 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 Chapter 4. Prevalence of Exposure to Secondhand Smoke 1. The evidence is sufficient to infer that large numbers of nonsmokers are still exposed to secondhand smoke. The Health CorEsequences of Involurstanj Exposure to Tobacco Smoke Sudden Infant Death Syndrome 4. The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and sudden infant death syndrome. Preterin Delivery/ 2. Exposure of nonsmokers to secondhand smoke S. 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 Innvoluntanlj Strokingand 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, gaining halls, and vehicles. Chapter 5. Reproductive and Developmental Effects from Exposure to Secondhand Smoke Fertility 1. The evidence is inadequate to infer the presence or absence of a causal relationship between 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 Po inatal 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 stroke 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 Developrneynt 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.. Heiglyt/Growth 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. Childhood 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, Summary, and Conclusions 13 5rirgeon General's Report 12. The evidence is inadequate to infer the presence or absence of a causal relationship between maternal exposure to secondhand smoke during pregnancy and childhood cancer. The evidence is suggestive but not sufficient to infer a causal relationship between parental smoking and the natural history of middle ear effusion. 13. The evidence is inadequate to infer, the presence 5 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 . Respiratory Syznptolrzs and Prevalent Astlzzna in SGlzool-Age Clzildrerl 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 Asthma Onset 17„ 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. 9. Chapter G. Respiratory Effects in Children from Exposure to Secondhand Smoke Lower Respiratory Illnesses in InfMICII and Early Childhood 1. The evidence is sufficient to infer a causal relationshipbetween 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 Adenotonsillectotlz y 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 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. 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 Pulmonary 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, Chapter 7. Cancer Among Adults from Exposure to Secondhand Smoke Lung Cancer 1, 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 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 cancen The Health Corsequerices ofInvolutitan,/ Exposrarc to Tobacco Smoke heart disease from exposure to secondhand smoke, 3 The evidence is suggestive but not sufficient to infer a causal relationship between exposure to secondhand smoke and an increased risk of stroke. 4.. Studies of secondhand smoke and subdinical 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 The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and odor annoyance. Nasal Sinus Cavity arid Nasopharyngeal Carcinoma 4. The evidence is suggestive but not sufficient to 2. The evidence is sufficient to infer a causal infer a causal relationship between secondhand relationship between secondhand smoke exposure smoke exposure and a risk of nasal sinus cancer and nasal irritation., among nonsmokers. 3. The evidence is suggestive but not sufficient 5 The evidence is inadequate to infer the presence to conclude that persons with nasal allergies or absence of a causal relationship between or a history of respiratory illnesses are more secondhand smoke exposure and a risk of susceptible to developing nasal irritation from nasopharyngeal carcinoma among nonsmokers. secondhand smoke exposure. Cervical Cancer Respiratory Syuiptonis 6.. The evidence is inadequate to infer the presence or absence of a causal relationship between secondhand smoke exposure and the risk of cervical cancer among lifetime nonsmokers.. Chapter 8. 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 bath men and women. 2. Pooled relative risks from meta -analyses indicate a 25 to 30 percent increase in the risk of coronary 4. 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 persons with asthma. 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. 6, The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and chronic respiratory symptoms. hitroduction, Srunttraty, arid Conclusions 75 Stirgem 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. 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. I. The majority of workers in the United States are now covered by smoke -free policies. 5.. The extent to which workplaces are covered by 10, The evidence is inadequate to infer the presence or smoke -free policies varies among worker groups, absence of a causal relationship between chronic across states, and by sociodemographic factors. secondhand smoke exposure and an accelerated Workplaces related to the entertainment and decline in lung functionhospitality industries have notably high potential for secondhand stroke exposure.. ,,4.sthma 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 Pulnionar y 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 chronic obstructive pulmonary disease.. 26 Chapter 2 6. Evidence from peer -reviewed studies shows that smoke -free policies and regulations do not have an adverse economic impact on the hospitality industry,. T 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 stroke. 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- logic 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 Gaakkola and Jaakkola 1997; Jaakkola and Samet 1999) . For example, exposures to secondhand smoke across the full life The Health Consequences of Involuntary Exposure to Tobacco Stttoke span may be of interest for lung cancer, while only more recent exposures may be relevant to the exacer- bation of asthma. For CHD, both temporally remote and current exposures may affect risk Assessments of exposures are further cornplicated 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, Summary, and Conchisions 17 Surgeon General's Report Figure 11 The determinants of exposure, dose, and biologically effective dose that underlie the development of health effects from smoking Environment Human body 1 i i Dispersion Individual time (t.) i Type and rate Metabolic present in 1 of breathing elimination location (m,) 1 i i i Microenvironmental (m ) Outdoor i Susceptible body surface concentrations over time (y sources to t1 tx t3 my C10 C11 C17 C13 Concentration = Exposure Biologically mz C20 C21 Cu Cz; Dose effective Indoor m3 C30 C31 C33 C-M E _ c„' t.. dose sources M4 C40 C41 Caz Ca3 =°� fi v Ventilation removal Source: Samet and jaakkola 1999. Reprinted with permission, on the znicroenvironmental 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 microenvironment 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 this 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 28 Chapter 2 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 tool 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 Oaakkola and Jaakkola 1997). Two studies evaluated the reliability of questionnaires on lifetime exposures (Pron 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 child 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 (K.awachi and Colditz 1996; Cal/EPA 1997; Jaakkola and Jaakkola 1997) However, cotinine levels reflect not only exposure but metabolism and excretion (BenoiAdtz 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 (44amino- biphenyl—hemoglobin adducts, benzo[a]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 Conserluences ajlnvolurataTy Exposure to Tobacco Smoke 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 Gaakkola 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 it maybe 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 not been a substantial issue in this research, The consequences for epidemiologic stud- ies of misclassification in general are well established (Rothman and Greenland 1998).. lrilroduction, Swiwiary, and Cmtclusions 79 Surgeon Gewral'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 misrlassified 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 1 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 the association of active smoking with CHI] is not as strong as with lung cancer.. There have been a number of publications on Us 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; Hackshaw 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 (Wu 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). This 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 farther 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 Ir:volurrtary Erasure to Tobacco Srnoke 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 (Flue -Cured Tobacco Cooperative Stabilization Corp v. United States Envir-orrrrrerrtal Protec- tion Agerrey, 857 F. Supp 1137 [M.D N.0 199.31). 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 (Flue -Cured Tobacco Cooperative Stabilization Corp, v. The United States Environmental Protection Agerrcry, No. 98-2407 [4th Crr, December 11, 20021, 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 13 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 Introduction, Surrrniary, and Conclusions ?I Surgeon General'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 SN (2000) assessed the 37 studies consid- ered in the meta -analysis by Hackshaw and colleagues (1997) for publication bias. Copas 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 heteragenous designs can strengthen the meta - analytic findings by making it unlikely that a common bias could persist across different study designs and populations. 22 chapter 2 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 Risk sk For adverse effect Causal path Low Smokin SHS SES e—► active 0"1 ex Qsu"""rid Risk. for adverse effect P Confounding ISKS 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 Involuntary Exposure 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 al 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 thathas 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 (Game 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, Introduction, Sionrrrary, and Conclusions 23 Surgeon General's Report References Armstrong BK, White E, 5aracci R, editors. Principles of Exposure Measurement in Epidemiology. Mono- graphs in Epidemiology and Biostatistics. Vol.. 21.. 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A Report of the .Surgeon General, 1975. Washington: U.S. Depart- ment of Health, Education, and Welfare, Public Health Service, Center for Disease Control, 1975 DHEW Publication No. (CDC) 77-8704. U.S. Department of Health, Education, and Welfare. Smoking and Health. A Report of the Surgeon General Washington: U.S. Department of Health, Educa- tion, and Welfare, Public Health Service, Office of the Assistant Secretary for Health, Office of Smok- ing and Health,1979, DHEW Publication No. (PHS) 79-50066, U.S.. Environmental Protection Agency.. RespiratonJ Health Effects of Passive Smoking: Lung Cancer and Other DiSor'ders, Washington: U.S. Environmental Protection Agency, Office of Research and Devel- opment, Office of Air Radiation, 1992 Report No EPA / 600 / 6-90 / 0006F. Vandenbroucke JP.. Passive smoking and lung cancer: a publication bias? British Medical Journal (CIinicaI Research Edition) 1988;296(6619):391-2.. Wald NJ, Nanchahal K, Thompson SG, Cuckle HS. Does breathing other people's tobacco smoke cause lung cancer? Bi itish Medical Journal (Clinical Research Edition) 1986;293(6556):1217-22, World Health Organization, International Consulta- tion on Environmental Tobacco Smoke (ETS) and Child Health, Consultation Report, Geneva: World Health Organization,1999, Wu AH. Exposure misclassification bias in studies of environmental tobacco smoke and lung cancer. Environmental Health Perspectives 1999;107(Suppl 6):873-7. Yach D, Bialous SA. Junking science to pro- mote tobacco. American Journal of Public Health 2001;91(11)J745--8. Attachment B — Smoking Ordinance Comparison (1 998 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 smokin seating areas in that is clearly visible to the person restaurants. entering restaurants, bars or tavern establishment. Smoking permittedsigns are prohibijed within 12' of any public building Ash Trays @ Must be placed on the perimeter + Unlawful to place within 12' of a of non-smoking areas in public building. restaurants. Smoking in Food 0 Allowed if the business utilizes a m Prohibited Product ventilation system designed by a Establishment professional engineer that provides an air change every 15 minutes; or Y an alternative system is approved by the building official that achieves similar results. City Parks 6 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 o Seek advice of the city attorney designated public ROW areas (i.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, SOUTHLAKE, TEXAS MEETING ROOMS .3A & 3B TOTAL ATTENDANCE: Approximately Fifteen (15) • STAFF PRESENT: Planning & Development Services Director Ken Baker, Chief Plattner .Iayashree Narayana, Planner Jennifer Crosby, and Planner Clayton Comstock STAFF CONTACT: Ken Baker, (817)748-8067; kbaker@ci..southlake.tx.us PRESENTATION SUMMARY See attached Power Point Presentation 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 Southlake? 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 based on property and civil rights and the potential loss to business. SPIN Meeting Reports are general observations of SPIN Meetings by City staff and SPIN Representatives The report is neither verbatim nor official meeting minutes; rather, it serves to inform elected and appointed officials, City staff, and the public of the issues and questions raised by residents and the general responses made Responses as summarized in this report should not be taken as guarantees by the applicant Interested parties are strongly encouraged to follow the case through the Planning and Zoning Commission and final action by City Council. Second -Hand Smoke Study Information No risk -free, expasure. 'a �ratinR,smokers'--. eant g:aIr 7 _40 Businesses & Lawmakers Are Also Concerned Westin Hotels and. Resprls Discussion Purpose R a evieW ub,fic health impact of Public Health Concerns Have Prompted Some Cities To Update Their. Regulations. Current Smoking Ordinance rqv sfdW_ Current Smoking Ordinance s ,.,Per M itssrneking areas if Potential Changes to Southlake Regulations Smoking prohibited in .„ -^ Potential Changes to Southlake's Regulations . NIgHry - " -- �,� No 5rokmg signs postedvlll .. Southlake Potential Changes to Southlake's Regulations , ^ "• . : :.: Becomes unlawtuf .to. pla " . Potential Changes to Southlake Regulations i Smokiermitted In: H►M EMAIL (OPTIONAL) COMMENT CARD SPIN FORUM SMOKING ORDINANCE & SIDEWALK PLAN sr- �-1 G ,A--i Circle One: �BesidentBusiness �Vair IZO.Non'P-T SMOKING ORDINANCE — QUESTIONS I COMMENTS �1e_- SIDEWALK PLAN - QUESTIONS I COMMENTS Ws-- w o wt _ i 4, z CL Cl LU Z Uo - LU Z< z Off© CC 0 0 z �e 0 (n Lu z LLI 2 (n z 0 ul LU 0 z z B cc 0 (5 z 52 0 :5 cn W a z RV EA �J 9 J Q 0 p. 0 W H W 15 0 z 0 P in W v W U z Q z 0 Ir z Y m U) t-- zLU 0 U d z 0 w D �6 N `J zz--:� W ©j .A►.ttachment D - Correspondence (See following page) Clayton Comstock From: Ken Baker Sent: Wednesday, March 28, 2007 10:28 AM To: Clayton Comstock Subject: FW: smoking ordinance email Ken Baker, AICP Planning Director City of Southlake 3 17-748-8067 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 Marne: Brett Flory Phone: 817 421 0282 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 make 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 norr- 3mokers. As they have for over a hundred years. Should not the health of the public ultimately be the guiding light in this Debate? 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 fact 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 persons will blame their inability to run a successful business on the smoking ban.. Don't buy it. There are dozens of' atudics 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 ]mown for- years.. Second hand smoke kills. Of course it does. Who really does not know this? Please use a drop of common sense, -.Ilininate this highly addictive, disgusting, and and dangerous chemical from the lives of those that don't want to breath it, if someone wants to inject their body with a legal drug, let them do it in their own ]ionic, please. It is so unfair to force -veryone that wants to be healthy away from virtually all public places so 20% of the population can poison themselves and all the other's innocent people around them.. 5. Personally, my wife and I enjoy going to bars from► tirne 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 unfair 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 Supposed to go. At least a smoker can go outside, inject their drug into their lungs and come back inside. We non-smokers Don't even have that option in a restaurant or bar. We must stay away from all tables and chairs and never come in, or just :lon't patronize the business at all. It's an odd situation that needs to be remedied. 6. 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 win .3/28/2007 [heir first case of negligence or failure to act? They have no choice. They must make money to feed their families and have no choice but to be infiltrated with these chemicals day in and day out. You can see why a jury would award thorn payment. 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. I chose to speak up.. Freedom is a two way street.. You aren't taking freedom away, you're giving freedom to the majority. Remember, the majority do not smoke, And for those that love their drug, they still have the aption 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 3/28/2007 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 To: 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: Siri Smith Phone: 817 488-0042 Email: Comments: City of Southlake Council Members: As a ten year, resident of Southlake (residing at 901 Nottingham), I atrongly object 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 ban smoking in City parks, feel free to do so. However legal activity should be permitted on one's private property I 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 strops, dines and generally hangs out. The more cities and Dther governments legislate on personal responsibility issues, the more that individuals will rely on government to handle personal responsibilities. That is the true health issue! Siri Smith 3/28/2007 Page 1 of 1 Ken Baker From: Greg Last Sent: Friday, February 09, 2007 1:46 PM To: Ken Baker Subject: FW: Email seat from City of Southlake Web Site Greg Last, CED Director of Economic Development City of Southake, 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: 817-283-3.3.33 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 week. 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 Yelverton; Ken Baker Subject: smoking ordinance From: Sent: Friday, February 09, 2007 12:26 PM To: citycouncil Subject: Email sent from City of Southlake Web Site Name: Betty Springer Phone: 817-481-7082 Email: arks, etc in the City. I Comments: I absolutely totally 10010 support a smoking ban in all restaurants, bars, stores, p ty 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. Second hand 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: Seat: 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 1 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: ;olyn potenza Sent: Tuesday, March 13, 2007 8:22 AM To: Pilar Schank Subject: Against the smoking ordinance vlr. Schank, ?lease do not allow a new smoking ordinance in Southiake, It's unfair and restricts the freedom this country was founded )n. '5incerely, lolyn Potenza 1000 Independence Court 5outhlake TX 76092 M.32M550 ?la Flexicon. the crossword ame that feeds our brain. PLAY now for PREE. 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[ Sent: Monday, March 12, 2007 5:32 PM ro: Pilar 5chank Subject: In Favor of the ordinance to Prohibit Smoking in Southiake ?ilar, 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 uea. 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. thank you again for your help on this, 'odd A. Schneider ?resident VATIONAL INSURANCE NETWORK & BUSINESS SERVICES 817) 329-1855 (metro) satin anvedzon.net rodd A. Schneider 1418 Monarch Way 3outhlake, TX 76092 817) 8754052 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: lilto: rent: Thursday, March 15, 2007 3:19 PM ro: Pilar Schank ,ubject: no smoking Aello- rhis is Debbie Pino, from 1535 Bent Creek Drive, Southlake, TX 76092 at 817-442-8391. 1 was unable to attend the SPIN meeting ?arlier this week but wanted to send you my opinion l am in favor of the ordinance for NO smoking in Southlake. thank you, )ebbie Pino ant. now offers free email to everyone. Find out more about what's free from AOL at A.M.—corn. 3 /27/2007 Clayton Comstock From: Pilar Schank Seat: Tuesday, March 13, 2007 4:41 PM To: Clayton Comstock Subject: FW: Smoking ordinance -rom: Pita Mayle ;e€tt: Tuesday, March 13, 2007 4:39 PM ro: Pilar Schank "subject: Smoking ordinance Ne would simply like to voice our support of the ordinance banning smoking in Southlake. We feel that clean air in -estaurants, 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, Zita and Ron Mayle youthlake Residents [417 Monarch Way ;outhlake TX 76092 �17-488-9689 Fhe most successfull people are those who are good at plan B. iarnes Yorke 3/27/2007 Clayton Comstock From: Sarah Jenkins. Sent: Monday, March 12, 2007 10:11 PM To: Pilar Schank Subject: in favor of the ordinance for NO smoking in 5outhiake ro whom it may concern: ks a mother, I would like to voice my support for this NO smoking in Southlake ordinance. Fhank you- '5arah Jenkins 108 Caroline Lane 3outhlake, TX i l 7-310-6328 3/27/2007 Clayton Comstock From: Tara Efiason 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 � 17-488-0227 rind what ou need at prices ou'll love. Compare products and save at MSN® Slaoppin. 3/27/2007 Clayton Comstock From: Laurie Schneider Sent: Monday, March 12, 2007 9:09 PM To: Pilar Schank Subject: "In favor of the ordinance for NO smoking in Southlake " .autie Schneider 1418 Monarch Way 3outhlake, TX 76092 H 7-488-2641 '1n favor of the ordinance for NO stroking in Southlake." -- Please stop smokers from infringing upon my right to good wealth. 2nd hand 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 l should not be subject to their second-hand smoke when I im out in our wonderful community. Illith all sincerity, ludith Ursitti 1434 Waltham Drive ;outhlake, Texas vww.team_ jacicattacic.com -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 4o virus found in this outgoing message.. :hecked by AVG Free Edition, Tersion: 7.5A46 / Viius Database: 268.18,9/719 - Release Date: 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 leff and Allison Fullmer 1424 Sandstone Court Southlake, TX 76092 317-424-4252 Ne 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 >f 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. Fhank you, leff and Allison Fullmer 3/27/2007 Proposed smoking ban in Southlake I 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 l do not believe it warrants a citywide -ban on smoking. 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 f'rfestyles, 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 Policyofeach 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 toil 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 8x10 sign is easily legible from drivers passing by. Clayton Comstock From: Greg Rogers i Sent: Monday, March 12, 2007 5:48 PM To: Pilar Schank Subject: Southlake Smoking Ordinance )ear Pilar Oy name is C. Gregory Rogers. I live with my wife Karil S. Rogers at 1370 Bent Trail Circle in Southlake. My come phone is 817,416,1720. We are both in favor of the ordinance for NO smoking in Southlake. Thanks for (our help on this initiative. 3est regards, Greg 3reg Rogers auida, Slavich & Flores, P.C. 750 N. St. Paul St., Suite 200 Dallas, Texas 75201 ?14,692.8385 - phone 14,692,6610 W fax oaers- a�g sfpc. Com nW. aSfpc.cam 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 JOTIFY THE SENDER IMMEDIATELY BY RETURN E-MAIL., AND DELETE THIS COMMUNICATION FROM ALL AFFECTED )ATABASES, 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 Iisted in the Ninth Report on Carcinogens," US 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 June 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). d it Resources Board, Stationary Source Division, Air Quality Measures Branch, Office of Environmental Health Hazard Assessment (DEHHA), 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 deterrrrined 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 F.; 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, AK.; Schoen, L.J.; Spengler, J.; Callway, C,A., "ASHRAE position document on environmental tobacco smoke and 2 the development of acute coronary syndromes: the CARD102000 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," GPI 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 & Health 15(8), Supplement A: 6-9, August 1997); WHEREAS, the City Council finds there is no legal or constitutional "Tight 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 the entrances or exits 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. 3 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 See. 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, "Person" means any individual. "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 unlawfE.2l 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: 0 (1) smoke, (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 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 personn who violates this article shall be guilty of a health and sanitation misdemeanor violation and subject to a fine of not more than $500.00, Each day that a violation is permitted to exist shall constitute a separate offense. Any association, partnership or cooperation that violates this article shall be guilty of a health and sanitation misdemeanor violation and subject to a fine of not more than $2000.00. 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 effective on June 1, 2007, 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 5 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 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 take effect on .Tune 1, 2007, following final passage by the City Council and publication in accordance with the Charter of the City of Southlake. PASSED AND APPROVED ON FIRST READING THIS DAY OF , 2007. MAYOR ATTEST: CITY SECRETARY PASSED AND APPROVED ON SECOND READING THIS DAY OF , 2007. U f _► ATTEST: CITY SECRETARY EFFECTIVE: APPROVED AS TO FORM AND LEGALITY: City Attorney Gol