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10
Sensory Reactions to and Irritation Effects of Environmental Tobacco Smoke

In this chapter, the acute sensory reactions from exposure to ETS are discussed. These reactions include perception of odor and irritation of eyes and upper airways. Methods for evaluating these psychosensory phenomena include controlled chamber studies, where ventilation and smoking rates are manipulated and evaluated in terms of reported perception by a small number of subjects.

ODOR

The perception of odor is often the earliest indicator of exposure to many airborne contaminants, but not for all. For some individuals, odor may merely be a nuisance. For others, odor is an early indicator of a complex reaction to exposure to ETS involving allergic and other physiologic responses.

Considerations of sensory reactions have a central role in the development of guidelines for ventilation requirements for occupied spaces. The amount of ventilation, or number of air exchanges, needed to eliminate unacceptable odors and irritation commonly exceeds that required to meet any other needs, such as control of carbon dioxide. For a number of years, quite apart from concerns about possible adverse health from exposure to ETS, ventilation engineers have viewed ETS as the most problematic common indoor contaminant (Leonardos and Kendall, 1971).

Efforts to derive functional relationships between the amount of a contaminant generated in a space and the amount of outdoor air, i.e., ventilation, necessary to control its odor began in the



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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects 10 Sensory Reactions to and Irritation Effects of Environmental Tobacco Smoke In this chapter, the acute sensory reactions from exposure to ETS are discussed. These reactions include perception of odor and irritation of eyes and upper airways. Methods for evaluating these psychosensory phenomena include controlled chamber studies, where ventilation and smoking rates are manipulated and evaluated in terms of reported perception by a small number of subjects. ODOR The perception of odor is often the earliest indicator of exposure to many airborne contaminants, but not for all. For some individuals, odor may merely be a nuisance. For others, odor is an early indicator of a complex reaction to exposure to ETS involving allergic and other physiologic responses. Considerations of sensory reactions have a central role in the development of guidelines for ventilation requirements for occupied spaces. The amount of ventilation, or number of air exchanges, needed to eliminate unacceptable odors and irritation commonly exceeds that required to meet any other needs, such as control of carbon dioxide. For a number of years, quite apart from concerns about possible adverse health from exposure to ETS, ventilation engineers have viewed ETS as the most problematic common indoor contaminant (Leonardos and Kendall, 1971). Efforts to derive functional relationships between the amount of a contaminant generated in a space and the amount of outdoor air, i.e., ventilation, necessary to control its odor began in the

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects FIGURE 10–1 Relationships between ventilation rate and air space per person in an environmental chamber according to three criteria: (A) maintenance of oxygen concentration; (B) control of carbon dioxide to a level of 0.6% (2.5 cubic feet per minute); and (C) control of body odor at a moderate level under sedentary conditions of occupancy, no smoking. 1930s (Yaglou et al., 1936). Function C in Figure 10–1 is derived from experiments of Yaglou et al. (1936), where judges assessed the odor generated by occupants sitting quietly in an environmental chamber. The function depicts the combination of air space per person and ventilation rate of the air space (outdoor air) per person necessary to maintain odor at a moderate, acceptable level under steady-state conditions. Theoretical functions A and B, which fall below C, implying less need for ventilation, represent the outdoor air needed to maintain oxygen at a minimum of 20% and the air necessary to hold carbon dioxide at a maximum 0.6%, respectively. The decrease in curve C at low occupancy density (large air space per person) resulted most likely from the instability of occupancy body odor in Yaglou’s chamber. That is, occupancy odor decays relatively rapidly on its own (Yaglou and Witheridge, 1937; Clausen et al., 1984). Tobacco smoke odor, on the other hand, exhibits relative stability. When smoking has ceased in an unventilated room, the odor will remain at the about same level over many hours (Yaglou and Witheridge, 1937; Clausen et al., 1985). In a diagram such as Figure 10–1, a function for tobacco

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects smoke odor, like functions A and B, would be independent of the size of the space or of air space per occupant. In this respect, tobacco smoke odor behaves as a simple contaminant and ventilation requirements for reducing tobacco smoke odor should depend strictly on rate of smoking. Twenty years after his study on occupancy odor, Yaglou (1955) reported a small experiment on tobacco smoke odor. Studying the very high smoking rate of 24 cigarettes per hour generated by six of nine occupants in his 1,410-cubic-foot chamber, he reported the need for 40 cfm (cubic feet per minute) per smoker, or 600 cubic feet per cigarette, in order to achieve moderate, acceptable odor. At about the same time, Kerka and Humphreys (1956), using similar psychophysical techniques, estimated the requirement at 2,250 cubic feet per cigarette, or 300 cfm per smoker smoking 8 cigarettes per hour. At a smoking rate of 2 cigarettes per hour, this would be 75 cfm per smoker. Recent results have estimated ventilation needs closer to those of Kerka and Humphreys (1956) than those of Yaglou (1955), but have also uncovered limitations on ventilation as a solution to the odor problems produced by ETS. Figure 10–2 shows how tobacco smoke odor varied over time for three smoking rates and various ventilation rates (Cain et al., 1983). The line connecting the open squares in the left panel depicts the level of odor generated by nonsmoking occupancy with low ventilation. It shows that even in the presence of higher ventilation rates, smoking generated more odor than simple occupancy. The psychophysical judges in the experiment, a mixed group of smokers and nonsmokers, assessed acceptability in addition to perceived intensity. Figure 10–3 shows the percent of dissatisfaction as a function of ventilation rate per cigarette. The ventilation rate that would lead to 20% of judges dissatisfied is 4,240 cubic feet per cigarette (shown by the vertical dashed line). Twenty percent dissatisfied is the maximum level allowed by recommendation of the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE, 1981). On the realistic assumption that the percentage of people actually smoking in a space at any given time will equal about 10%, ventilation rate per person (smokers and nonsmokers) would need to be 53 cfm (see Figure 10–3) to reduce odors to a level that would satisfy 80% of the judges. Despite ASHRAE’s goal of satisfying at least 80% of visitors to a space, none of its recommendations for ventilation are as high

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects FIGURE 10–2 Intensity of odor during and after smoking in an environmental chamber for three different rates of cigarettes smoked per hour. Measurement of odor intensity was parts per million butanol matched to the test odor according to ASTM standard E544–75. Each point represents judgments taken over a 15-minute period. From Cain et al. (1983).

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects FIGURE 10–3 Percent of judgments of unacceptable odor quality of air versus ventilation per cigarette and ventilation per occupant, assuming that 10% of occupants in a space will be smoking at any time. Data from Cain et al. (1983). as 53 cfm per occupant. For offices where smoking is allowed, the ASHRAE recommendation is 20 cfm per occupant. For many other smoking areas, however, the ASHRAE recommendation is 35 cfm per occupant. Such recommendations did not result from experiment, but rather from a consensus procedure of expert heating and refrigerating engineers that weighed available information. The bulk of the data on the acceptability of odor and irritation from ETS was not available at the time ASHRAE prepared its standard in 1981. The standard was, however, the first to specify the need for 4 to 5 times greater ventilation rates during smoking occupancy as compared with nonsmoking occupancy. The most common rate specified for smoking occupancy is 35 cfm per occupant, whereas 7 cfm per occupant is the most common rate specified for nonsmoking occupancy. This means that in a space where smoking is allowed, the pollution generated by smoking creates the greatest need for ventilation. According to the data of Cain et al. (1983) (Figure 10–3), ASHRAE’s proposed ventilation rate of 35 cfm per occupant during smoking will lead to 25% of visitors being dissatisfied (75%

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects satisfied) with the odor. Data suggest that the difference in satisfaction between smoking and nonsmoking occupancy, and hence the difference in recommended ventilation rates, arises largely because of the intensity of the odors (Figure 10–4), rather than the quality of the odors. At equal odor intensity, the occupancy odor and tobacco smoke odor are disliked about equally. An additional factor affecting annoyance with odor is that nonsmokers are much more likely than smokers to object to tobacco smoke odor. Figure 10–5 depicts relative dissatisfaction with tobacco smoke odor at various intensities, expressed in terms of equivalent levels of butanol. At 32 ppm (butanol level 2), 1% of smokers found the odor unacceptable, while 20% of nonsmokers found it so. The odor had to rise to 256 ppm (level 5) before as FIGURE 10–4 Percent of judgments of unacceptable odor quality of air versus odor intensity assessed by means of a graphic rating procedure during various conditions of smoking and nonsmoking occupancy. Each point represents the outcome from a particular combination of contaminant generation (number of occupants or rate of smoking) and ventilation rate. Data from Cain et al. (1983).

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects FIGURE 10–5 Percent of judgments of unacceptable odor quality of air derived from tobacco smoke odor related to equivalent level of butanol (parts per million at top; log2 at bottom). Judgments accumulated across all conditions of smoking (2,357 judgments). Left: Data from all visitors. Right: Data from smokers and nonsmokers plotted separately. Data from Cain et al. (1983). many as 20% of smokers found the odor unacceptable. In terms of practical solutions to the odor problem caused by tobacco smoke, the difference between smokers and nonsmokers may prove insurmountable. Under usual levels of smoking, no realistic level of ventilation will drive tobacco smoke odor as low as the equivalent of 32 ppm butanol (butanol level 2). IRRITATION Ventilating and air-conditioning engineers have typically concerned themselves with the reactions of visitors to enclosed spaces on the assumption that visitors will exhibit more sensitivity than occupants. As society has become more concerned with the health risks of smoking in the recent past, research on consequences of ETS exposure has focused on the occupant. Included within this concern have been the sensory reactions of occupants. Figure 10–6 illustrates changes in tobacco smoke odor and irritation over time for occupants. Whereas perceived odor magnitude may fade due to olfactory adaptation, irritation may increase. Also apparent in this figure is a relationship between relative humidity and odor or irritation perception. In the low relative humidity conditions, both odor and irritation were exacerbated.

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects Receptors for irritation exist throughout the nasal, pharyngeal, and laryngeal areas and on the surface of the eyes. The receptors comprise free nerve endings of the fifth, ninth, and tenth cranial nerves and form the mediating elements of what is known as the common chemical sense. Although particularly sensitive to corrosive stimuli, the common chemical sense responds to almost any airborne organic material at high concentration (Cain, 1981). The common chemical sense (or irritation perception) is characterized by a tendency to respond more vigorously over time (Cometto-Muniz and Cain, 1984). A person in an environment with a low-level irritant may even fail to notice any irritation at first. Once irritation has begun, however, it may persist even after removal of the stimulus. FIGURE 10–6 Changes in odor and irritation during continuous, short-term exposure to cigarette smoke generated in a chamber. Ventilation equalled 14 cfm per cigarette and ambient temperature equalled 25°C. Relative humidity (RH) was 30% in one condition and 65% in the other. Adapted from Kerka and Humphreys (1956).

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects FIGURE 10–7 Eye irritation related to duration of exposure and concentration (parts per million carbon monoxide) of ETS. Left: Eye irritation index. Right: Eye blink rate. From Weber (1984). Chamber Studies A number of chamber studies have examined irritation and odor from tobacco smoke (Weber et al., 1976a,b; Weber et al., 1979a,b; Weber and Fischer, 1980; Muramatsu et al., 1983; Weber, 1984). The major findings include: Irritation from ETS varies with both concentration (measured as an increment in carbon monoxide as a surrogate for ETS) and time over long durations, as shown in Figure 10–7. The eyes are the most readily affected site for irritation, with the nose second. Rate of eye blinking correlates well with estimates of eye and nose irritation when the level of ETS is high (i.e., level of ETS such that the carbon monoxide concentration is at least 5 ppm), though eye blinking seems a less sensitive index than psychophysical judgments (Figure 10–7). Degree of annoyance (a composite index of impressions as defined by Weber) reaches a steady state much more rapidly than irritation, presumably because odor contributes to annoyance. Degree of annoyance depend almost entirely on the gas phase of ETS. Filtration of the particles is followed by only a small, though relatively constant, reduction in annoyance.

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects Eye irritation and increased eye blink rate depend almost entirely on the particulate phase of ETS. Particle filtration diminishes the sense of irritation greatly. Weber (1984) suggested that ETS corresponding to CO concentrations of 1.5 to 2.0 ppm should form the maximum permissible level of exposure in environmentally realistic circumstances. At about 2 ppm of CO, almost 20% of occupants report “strong” or “very strong” eye irritation. Cain et al. (1983) and Clausen et al. (1985) found that incremental CO concentrations of 1 to 2 ppm led to 20% of visitors becoming dissatisfied with the air. One of the more important issues with respect to control of ETS is whether filtration of the particles will reduce discomfort. As indicated above, Weber and colleagues found only a small reduction of annoyance when they filtered the particles with Cambridge pads. Since their criteria for annoyance largely assessed odor, their data largely agree with those of Clausen et al. (1985), who found that electrostatic precipitation of the particles caused no significant reduction in odor perceived by visitors to a chamber. Nevertheless, Weber and associates did find that filtration reduced reported eye irritation considerably. This led them to draw the conclusion that eye irritation derived largely from the particulate phase of ETS. Cain et al. (in press), on the other hand, found only a slight reduction of irritation following electrostatic precipitation of the particles. This disparity suggests the need for a more direct comparison of the sensory effects of the two filtration methods and for chemical analysis in order to determine whether Cambridge pads remove a vapor-phase constitutent of ETS that is left airborne by electrostatic precipitation. Field Studies Winnecke et al. (1984) argued that when people engage in social activities (e.g., playing cards or games) they become somewhat less critical of the environment and will tolerate a level corresponding to more than a 5-ppm increment in CO. It is suggested that when undistracted, occupants of chambers in experimental studies might complain about circumstances that would go unnoticed in life situations. On the other hand, irritation may prove relatively resistant to distraction. Restaurants would seem to offer a realistic proving ground for the interpretation of the chamber studies.

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects Weber et al. (1979a) found that more than 20% of occupants in restaurants included in a Zurich study reported eye irritation when CO, used as a surrogate for tobacco smoke levels, increased by 2 ppm above background. There was a direct relationship between reported irritation and CO concentration in four restaurants surveyed. In a study of more than 40 workrooms, Weber and Fischer (1980) also found a similar association between the concentration of CO and reported eye irritation. Judgments of dissatisfaction, whether taken inside a chamber or in the field, may well vary as the social acceptance of certain odors, including ETS, changes with time. For this reason, judgments of some attribute, such as eye irritation, or judgments of odor intensity, particularly those that entail a reference such as butanol, should form the information of interest for long-term considerations. Dissatisfaction measures may be more variable. HYPERSENSITIVE INDIVIDUALS Individuals with chronic lung diseases, such as asthma and vasomotor rhinitis, may be more sensitive to the acute irritating effects of exposure to ETS (see Chapter 11). In addition, many people without active diseases report allergic or allergic-like symptoms as a result of exposure to ETS (e.g., Speer, 1968; Zussman, 1974). Reported symptoms include eye irritation, nasal symptoms, headache, cough, wheezing, sore throat, and nausea. The percent of people who report these responses varies with the nature of the exposure. These reports have led to the belief that a tobacco smoke allergy may exist. Several investigators have studied immediate cutaneous hyper sensitivity to extracts of tobacco leaves. Zussman (1974) found that 16% of 200 atopic patients reported that they were clinically sensitive to ETS exposure. All of them did develop erythema during the intradermal tests. Becker et al. (1976) found that one-third (11 out of 31) of human volunteers, including smokers, exhibit hypersensitivity to a glycoprotein purified from cured tobacco leaves (TGP-L) and from cigarette smoke condensate (TGP-CSC). Reports of immediate skin reactivity suggest an immunological basis for clinical sensitivity to tobacco smoke. Tobacco smoke has been shown to contain immunogens that can stimulate immune responses to tobacco leaf extract in experimental animals (Lehrer et al., 1978; Becker et al., 1979; Gleich and

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects Welsh, 1979). However, the extracts differ and there is controversy concerning the purity of tobacco glycoprotein isolates (Becker et al., 1981; Bick et al., 1981). In a recent study of Lehrer et al. (1984), skin prick tests of 93 subjects were done, including 60 of whom claimed clinical sensitivity to tobacco smoke. The group included atopic and nonatopic individuals. Approximately 50% of the atopic subjects had positive skin tests to leaf extracts or cigarette smoke condensate (CSC). Fewer than 5% of nonatopic individuals had a positive reaction, independent of whether they claimed to be sensitive to ETS exposure. Radioallergosorbent tests (RAST) were also conducted. Forty-five percent of atopic individuals and 6% of nonatopic individuals were positive for leaf extracts. There were no significant differences in specific serum IgE antibodies among smokers, exsmokers, or nonsmokers. Fewer than 6% of either group responded to CSC. Because there was no relationship between subjective tobacco smoke sensitivity and reaction to the various tests, the authors concluded that the reported subjective sensitivity is probably not related to hypersensitivity to tobacco leaf or smoke antigens. In summary, experimental and clinical studies have indicated that there are immunogens in ETS and that a portion of the population is sensitive as shown by dermatological tests. However, the specific agent responsible for this reactivity has not been conclusively identified. Furthermore, there is some question as to whether reactions to skin tests are correlated with subjective complaints. It is clear, however, that a substantial number of atopic individuals will have positive skin tests to tobacco smoke or tobacco leaf extracts. More research needs to be done to characterize the immunogens and explain the relationship between subjective symptoms and skin tests. SUMMARY AND RECOMMENDATIONS There are a number of acute, noxious effects of exposure to ETS by nonsmokers that may occur. These include annoyance with odor, eye irritation, throat irritation, and immunological responses. The specific constituents that elicit these responses are not known.

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects What Is Known Odor ETS arouses odor responses. The objectionable odor generated by ETS greatly exceeds that generated by simple occupancy under comparable conditions of occupancy, density, temperature, and relative humidity, and is more persistent. Tobacco smoke odor is stable over time. Ventilation requirements for tobacco smoke odor will therefore vary in strict proportion to the number of cigarettes smoked. Rooms (and other spaces) where there is smoking require much more ventilation than spaces with nonsmoking occupancy. During smoking, ventilation requirements that satisfy at least 80% of visitors to a room exceed 50 cfm per occupant. Nonsmokers and visitors to rooms appear to set a more stringent criterion than smokers for acceptability of tobacco smoke odor. Current ventilation guidelines for smoking occupancy will apparently fail to satisfy a criterion level of 80% of visitors (mixed group). It is not clear that any practical ventilation rate could satisfy 80% or more nonsmokers under typical conditions of smoking occupancy. Irritation Low humidity may exacerbate odor and irritation responses to ETS. Whereas odor will govern the reactions of visitors to a smoking space, irritation will largely govern the reactions of occupants. Over time, eye irritation grows to become the most important negative response of the occupant. Dissatisfaction observed in chamber studies is commensurate with that found in field studies. Eye blink offers a reasonable correlate of sensory irritation at high levels of smoke (i.e., levels of ETS such that the concentration of CO is at least 5 ppm), but not at low levels. Filtration of particles from ETS via an electrostatic precipitator causes no decline in odor to visitors and no meaningful decline in odor or irritation to occupants. This suggests that irritation and odor derive primarily from gas- or vapor-phase constituents. Filtration of particles via a Cambridge pad reduced irritation, but not odor, to occupants. Perhaps the Cambridge pad

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects removes some critical vapors from the smoke along with the particles. A substantial portion of atopic individuals are sensitive to tobacco leaf or tobacco smoke extracts as shown by skin tests. However, cutaneous sensitivity appears not to correlate with subjective symptoms. What Scientific Information Is Missing The outcomes obtained in chambers regarding dissatisfaction created by the odor and irritation of ETS should be further verified in field situations. The chamber studies imply that there must be considerably more than 20% dissatisfaction in places where smoking occurs even when current ventilation standards are met. Prospects for abatement of discomfort through filtration of the vapor or particulate phases of ETS should receive attention. Objective physiological or biochemical indices should be sought to validate reports of chronic irritation of the eyes, nose, and throat. Research is needed to determine specific constituents that are the irritants in ETS. Information is needed on the prevalence and severity of allergic and hypersensitive responses to tobacco smoke in the general population and in atopic individuals. Further research needs to be done to determine the specific elements that are immunogenic in extracts of tobacco smoke and to relate immune response on skin tests to subjective complaints of sensitivity to tobacco smoke. Research is needed to evaluate the medical importance of positive reactions to RAST tests of tobacco leaf products for atopics. REFERENCES ASHRAE Standard 62–81. Ventilation for Acceptable Indoor Air Quality. Atlanta: ASHRAE, 1981. 19 pp. Becker, C.G., T.Dubin, and H.P.Wiedemann. Hypersensitivity to tobacco antigen. Proc. Natl. Acad. Sci. USA 73:1712–1716, 1976. Becker, C.G., R.Levi, and J.Zavecz. Induction of IgE antibodies to antigen isolated from tobacco leaves and from cigarette smoke condensate. Am. J. Pathol 96:249–254, 1979.

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects Becker, C.G., N.Van Hamont, and M.Wagner. Tobacco, cocoa, coffee, and ragweed: Cross-reacting allergens that activate factor-XXI-dependent pathways. Blood 58:861–867, 1981. Bick, R.L., R.L.Stedman, P.L.Kronick, E.Hillman, and J.Fareed. Studies related to tobacco glycoprotein: A claimed activator of coagulation fibrolysis, complement, kinin and a claimed allergen. Thromb. Haemostasis 46:231, 1981. Cain, W.S. Olfaction and the common chemical sense: Similarities, differences, and interactions, pp. 109–121. In H.R.Moskowitz and B. Warren, Eds. Order Quality and Intensity as a Function of Chemical Structure. American Chemical Society Symposium 148. Washington, D.C.: American Chemical Society, 1981. Cain, W.S., B.P.Leaderer, R.Isseroff, L.G.Berglund, R.J.Huey, E.D. Lipsitt, and D.Perlman. Ventilation requirements in buildings. I. Control of occupancy odor and tobacco smoke odor. Atmos. Environ. 17:1183–1197, 1983. Cain, W.S., T.Tosun, L.C.See, and B.P.Leaderer. Environmental tobacco smoke: Sensory reactions of occupants. Atmos. Environ., in press. Clausen, G. P.O.Fanger, W.S.Cain, and B.P.Leaderer. Stability of tobacco smoke odor in enclosed spaces, pp. 437–441. In B.Berglund, T.Lindvall, and J.Sundell, Eds. Indoor Air, Vol. 3. Sensory and Hyperreactivity Reactions to Sick Buildings. Stockholm, Sweden: Swedish Council for Building Research, 1984. Clausen, G., P.O.Fanger, W.S.Cain, and B.P.Leaderer. The influence of aging, particle filtration and humidity on tobacco smoke odor, pp. 345–350. In P.O.Fanger, Ed. Clima 2000, Vol. 4. Indoor Climate. Copenhagen, Denmark: VVS Kongress-VVS Messe, 1985. Cometto-Muniz, J.E., and W.S.Cain. Temporal integration of pungency. Chem. Senses 8:315–327, 1984. Gleich, G.J., and P.W.Welsh. Immunochemical and physicochemical properties of tobacco extract. Am. Rev. Respir. Dis. 120:995–1001, 1979. Kerka, W.F., and C.M.Humphreys. Temperature and humidity effect on odor perception. ASHRAE Trans. 61:531–552, 1956. Lawther, P.J., and B.T.Commins. Cigarette smoking and exposure to carbon monoxide. Ann. N.Y. Acad. Sci. 174:135–147, 1970. Leonardos, G., and D.A.Kendall. Questionnaire study on odor problems of enclosed space. ASHRAE Trans. 77, 101–112, 1971. Lehrer, S.B., M.R.Wilson, and J.E.Salvaggio. Immunogenic properties of tobacco smoke. J. Allergy Clin. Immunol. 62:368–370, 1978. Lehrer, S.B., F.Barbandi, J.P.Taylor, and J.E.Salvaggio. Tobacco smoke “sensitivity”—Is there an immunological basis? J. Allergy Clin. Immunol. 73:240–245, 1984. Muramatsu, T., A.Weber, S.Muramatsu, and F.Akermann. An experimental study on irritation and annoyance due to passive smoking. Int. Arch. Occup. Environ. Health 51:305–317, 1983. Speer, F. Tobacco and the nonsmoker. Arch. Environ. Health 16:443–446, 1968. Viessman, W. Ventilation control of odor. Ann. N.Y. Acad. Sci. 116:630–637, 1964. Weber, A. Acute effects of environmental tobacco smoke. Eur. J. Respir. Dis. 68(Suppl. 133):98–108, 1984.

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Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects Weber, A., and T.Fischer. Passive smoking at work. Int. Arch. Occup. Environ. Health 47:209–221, 1980. Weber, A., T.Fischer, and E.Grandjean. Passive smoking in experimental and field conditions. Environ. Res. 20:205–216, 1979a. Weber, A., T.Fischer, and E.Grandjean. Passive smoking: Irritating effects of the total smoke and the gas phase. Int. Arch. Occup. Environ. Health 43:183–193, 1979b. Weber, A., C.Jermini, and E.Grandjean. Irritating effects on man of air pollution due to cigarette smoke. Am. J. Public Health 66:672–676, 1976a. Weber, A., T.Fischer, and E.Grandjean. Objektive und subjektive physiologische Wirkungen des Passivrauchens. Int. Arch. Occup. Environ. Health 37:277–288, 1976b. Winnecke, G., K.Plischke, A.Roscovanu, and H.W.Schlipkoeter. Patterns and determinants of reaction to tobacco smoke in an experimental exposure setting, pp. 351–356. In B.Berglund, T.Lindvall, and J. Sundell, Eds. Indoor Air, Vol. 2. Radon, Passive Smoking, Particulates, and Housing Epidemiology. Stockholm, Sweden: Swedish Council for Building Research, 1984. Yaglou, C.P. Ventilation requirements for cigarette smoke. ASHRAE Trans. 61:25–32, 1955. Yaglou, C.P., and W.N.Witheridge. Ventilation requirements, Part 2. ASHRAE Trans. 43:423–436, 1937. Yaglou, C.P., E.C.Riley, and D.I.Coggins. Ventilation requirements. ASHRAE Trans. 42:133–162, 1936. Zussman, B.M. Tobacco sensitivity in the allergic population. J. Asthma Res. 11:159–167, 1974.