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i ENVIRONMENTAL TOBACCO SMOKE Measuring Exposures and Assessing Health Effects Committee on Passive Smoking Board on Environmental Studies and Toxicology National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1986
ii National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose mem- bers are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee con- sisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of sci- ence and technology with the Academy's purposes of furthering knowledge and of advising the federal government. The Council operates in accordance with general policies determined by the Academy under the authority of its congressional charter of 1863, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the Institute of Medicine. The National Academy of Engineering and the Institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. This study was prepared under EPA Contract #68â02â4073 and Department of Health and Human Services, Public Health Services Grant #ASU000001â06-S1. The content of this publication does not necessarily reflect the views or policies of the U.S. Environmental Pro- tection Agency or the Department of Health and Human Services, and an official endorsement should not be inferred. INTERNATIONAL STANDARD BOOK NUMBER 0-309-03730-1 LIBRARY OF CONGRESS CATALOG CARD NUMBER 86â28622 Copyright Â© 1986 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the pub- lisher, except for the purposes of official use by the United States Government. Printed in the United States of America
iii BOARD ON ENVIRONMENTAL STUDIES AND TOXICOLOGY DONALD HORNIG, Harvard University, Boston, Massachusetts, Chairman ALVIN L.ALM, Thermal Analytical, Inc., Waltham, Massachusetts RICHARD N.L.ANDREWS, University of North Carolina, Chapel Hill, North Carolina WILLIAM E.COOPER, Michigan State University, East Lansing, Michigan JOHN DOULL , University of Kansas Medical Center, Kansas City, Kansas EMMANUEL FARBER , University of Toronto, Toronto, Ontario, Canada BENJAMIN G.FERRIS, Harvard School of Public Health, Boston, Massachusetts PHILIP LANDRIGAN, Mt. Sinai Medical Center, New York, New York RAYMOND C.LOEHR, University of Texas, Austin, Texas ROGER MINEAR, University of Illinois, Urbana, Illinois PHILIP A.PALMER , E.I. DuPont de Nemours & Co., Wilmington, Delaware EMIL PFITZER, Hoffman-La Roche, Inc., Nutley, New Jersey PAUL PORTNEY, Resources for the Future, Washington, D.C. PAUL RISSER , Illinois Natural History Survey, Champaign, Illinois WILLIAM H.RODGERS, University of Washington, Seattle, Washington F.SHERWOOD ROWLAND, University of California, Irvine, California LIANE B.RUSSELL , Oak Ridge National Laboratory, Oak Ridge, Tennessee ELLEN SILBERGELD, Environmental Defense Fund, Washington, D.C. PETER SPENCER , Albert Einstein College of Medicine, Bronx, New York National Research Council Staff DEVRA LEE DAVIS, Acting Director, BEST JACQUELINE PRINCE, Staff Associate
iv COMMITTEE ON PASSIVE SMOKING BARBARA S.HULKA , University of North Carolina, Chapel Hill, North Carolina, Chairman OLAV AXELSON , University Hospital, Linkoping, Sweden JOSEPH BRAIN , Harvard School of Public Health, Boston, Massachusetts PATRICIA BUFFLER , University of Texas at Houston, Houston, Texas A.SONIA BUIST, Oregon Health Sciences University, Portland, Oregon DIETRICH HOFFMANN, American Health Foundation, Valhalla, New York BRIAN LEADERER, Yale University, New Haven, Connecticut GENEVIEVE MATANOSKI, Johns Hopkins University, Baltimore, Maryland JAMES ROBINS, Harvard School of Public Health, Boston, Massachusetts JOHN SPENGLER, Harvard School of Public Health, Boston, Massachusetts NICHOLAS WALD, Medical College of St. Bartholomew's Hospital, London, England National Research Council Staff DEVRA LEE DAVIS, Acting Director, BEST DIANE K.WAGENER, Project Director MARVIN SCHNEIDERMAN , Senior Staff Officer RICHARD E.MORRIS, Editor EDNA W.PAULSON , Information Specialist MARY ELLEN SCHENKENBACH, Staff Assistant JULIETTE L.WALKER, Senior Secretary
PREFACE v Preface The Office of Air and Radiation of the Environmental Protection Agency and the Office on Smoking and Health of the Department of Health and Human Services asked the National Research Council to evaluate methods for assessing exposure to environmental tobacco smoke and to review the literature on the health consequences from such exposures. The National Research Council responded to this request by appointing 11 scientists to serve on the Committee on Passive Smoking, in the Board on Environmental Studies and Toxicology, under the Commission on Life Sciences. The committee membership represented the disciplines of toxicology, biochemistry, atmospheric science, epidemiology, biostatistics, and pulmonary physiology. The committee's charge was to review the existing scientific literature and to identify the current state of knowledge with respect to known facts and areas of uncertainty. Many more of the latter were found than the former. To the extent that they could be justified scientifically, conclusions have been stated and recommendations proposed. Many of the recommendations are for future research, rather than for public policy. The latter were for the most part avoided on two grounds: the data were frequently not sufficiently secure and the charge to the committee was primarily for scientific review. The committee conducted a public hearing on scientific studies relevant to its charge on January 29, 1986. Furthermore, it reviewed the published scientific literature and received testimony from professional societies; medical, industry, consumer, and public interest groups; academic scientists; and others involved in the generation and interpretation of scientific evidence on the health
PREFACE vi consequences of exposure to cigarette smoking. Pursuance of these activities was followed by the preparation of individual chapters by committee members and consultants. Thereafter, chapters were discussed, revised, and integrated with each other for the full report. In producing this report, the committee confronted a complex charge under severe time constraints. That it completed its task well and on time is a credit both to its members and the scientific staff of the National Research Council. I would like to express my personal appreciation to every one of the committee members, all of whom donated their time, intellect, and knowledge to the substance of this report. Dr. Diane Wagener of the National Research Council assumed the difficult task of coordinating, translating, and negotiating ideas and insights among committee members, consultants, and reviewers. Drs. Devra Davis and Marvin Schneiderman worked with Dr. Wagener in ensuring the thoughtful and timely completion of this report. While the committee restricted itself to analysis of the scientific data, it was not unmindful of the fact of modern life that smokers and nonsmokers have taken strong positions regarding the right to smoke on the one hand and a rejection of being exposed to other people's smoke on the other. Persons on each side of the issue may wish to infer information from this report that the committee did not intend. Our strategy has been to synthesize information, present judgments and conclusions wherever possible, and to recognize inadequacies in existing data in order to provide a focus for future research. We have not taken the stance of a public policy board that necessarily has to make decisions on less-than-adequate information. Rather, we have chosen to prepare a scientifically responsible report that will be intelligible to a lay audience and useful to a scientific one. BARBARA S.HULKA, Chairman Committee on Passive Smoking
ACKNOWLEDGMENTS vii Acknowledgments The preparation of this report by the Committee on Passive Smoking would not have been possible without assistance from a large number of people. The committee consulted with a number of experts about various topics. We would like to thank the Office on Smoking and Health, particularly Clarisse Brown, who provided us with the many statistics and data that were requested by various members of the committee. We would also like to thank William Cain and Edward LaVoie for their contributions. Other individuals who gave special assistance in the preparation of the report include Leslie Waters Barger, Kiran Nanchahal, Simon Thompson, Christopher Frost, and Don Blevins. The committee thanks all the peer reviewers of the report. Their constructive remarks contributed to the improvement of presentations of technical information and its readability. We would like to express our thanks to the NRC staff for their work in supporting the committee. We would especially like to thank Edna W.Paulson and the staff of the Toxicology Information Center, who were of great assistance.
CONTENTS ix Contents EXECUTIVE SUMMARY 1 Introduction 1 Environmental Tobacco Smoke 2 Measures of Exposure 3 In Vivo and In Vitro Studies 7 Health Effects 7 1 INTRODUCTION 13 Definitions 14 Trends in Cigarette Usage 15 Organization 20 References 21 Part I PHYSICOCHEMICAL AND TOXICOLOGICAL STUDIES OF ENVIRONMENTAL TOBACCO SMOKE 2 THE PHYSICOCHEMICAL NATURE OF SIDESTREAM SMOKE AND ENVIRON- 25 MENTAL TOBACCO SMOKE Introduction 25 Sidestream Smoke 28 Principal Chemical Constituents of Environmental Tobacco Smoke 36 Radioactivity of Environmental Tobacco Smoke 37 Toxic and Carcinogenic Agents in Tobacco Smoke 44 Summary and Recommendations 45 References 48
CONTENTS x 3 IN VIVO AND IN VITRO ASSAYS TO ASSESS THE HEALTH EFFECTS OF ENVI- 54 RONMENTAL TOBACCO SMOKE Introduction 54 In Vivo Assays on Environmental Tobacco Smoke 55 In Vitro Assays on Environmental Tobacco Smoke 58 Summary and Recommendations 59 References 61 Part II ASSESSING EXPOSURES TO ENVIRONMENTAL TOBACCO SMOKE 4 INTRODUCTION 65 5 ASSESSING EXPOSURES TO ENVIRONMENTAL TOBACCO SMOKE IN THE 69 EXTERNAL ENVIRONMENT Tracers for Environmental Tobacco Smoke 70 Personal Monitoring 76 Concentrations of Environmental Tobacco Smoke in Indoor Environments 79 Modeling 81 Summary and Recommendations 94 References 97 6 ASSESSING EXPOSURES TO ENVIRONMENTAL TOBACCO SMOKE USING 101 QUESTIONNAIRES Exposure Histories Derived from Questionnaires 102 Environmental Tobacco Smoke Exposure Data for Studies of Acute and Chronic Health 107 Effects Data Quality 108 Other Variables 115 Summary and Recommendations 116 References 118
CONTENTS xi 7 EXPOSURE-DOSE RELATIONSHIPS FOR ENVIRONMENTAL TOBACCO SMOKE 120 Estimating Dose 120 Particle Size 121 Breathing Pattern 122 Deposition of Cigarette Smoke Particles 123 Particle Retention in the Lungs 126 Gases in Environmental Tobacco Smoke 127 Summary and Recommendations 129 References 131 8 ASSESSING EXPOSURES TO ENVIRONMENTAL TOBACCO SMOKE USING BIO- 133 LOGICAL MARKERS Biological Markers in Physiological Fluids 134 Genotoxicity of the Urine 148 Future Needs 152 Summary and Recommendations 152 References 154 Part III HEALTH EFFECTS POSSIBLY ASSOCIATED WITH EXPOSURE TO ENVIRON- MENTAL TOBACCO SMOKE BY NONSMOKERS 9 INTRODUCTION 163 10 SENSORY REACTIONS TO AND IRRITATION EFFECTS OF ENVIRONMENTAL 166 TOBACCO SMOKE Odor 166 Irritation 172 Hypersensitive Individuals 176 Summary and Recommendations 177 References 179
CONTENTS xii 11 EFFECTS OF EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE ON LUNG 182 FUNCTION AND RESPIRATORY SYMPTOMS Lung Function and Symptoms in Active Smokers 182 Plausibility for an Effect Due to Passive Smoking 184 Methodologic Considerations for Epidemiologic Studies 185 Cross-sectional Studies 188 Longitudinal Studies of Lung Function in Children and Adults 200 The Effect of Passive Smoking on Respiratory Infections 202 When Do Pulmonary Effects of Passive Smoking Occur? 209 Studies of Acute Pulmonary Effects 212 Summary and Recommendations 216 References 218 12 EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE AND LUNG CANCER 223 Using Biological Markers to Estimate Risk 224 Assessing the Risk From Epidemiologic Studies of Lung Cancer and Exposure to ETS 227 Corrections to Estimates for Systematic Errors 231 Other Considerations 242 Summary and Recommendations 245 References 246 13 CANCERS OTHER THAN LUNG CANCER 250 Smoking-Related Cancers 250 Cancers Not Related to Smoking 252 Interpretation 254 Summary and Recommendations 255 References 255 14 CARDIOVASCULAR SYSTEM 257 Acute Cardiovascular Effects of Environmental Tobacco Smoke Exposure 257 Cardiovascular Disease Morbidity and Mortality 262 Summary and Recommendations 265 References 266
CONTENTS xiii 15 OTHER HEALTH CONSIDERATIONS IN CHILDREN 269 Environmental Tobacco Smoke Exposure by Nonsmoking Pregnant Women 269 Growth in Children 271 Chronic Ear Infections 272 Summary and Recommendations 273 References 274 APPENDIXES A. Guidelines for Public and Occupational Chemical Exposures to Materials That Are Also 279 Found in Environmental Tobacco Smoke B. Method of Combining Data From Studies of Environmental Tobacco Smoke Exposure and 284 Lung Cancer Case-Control Studies 284 Prospective (or Cohort) Studies 286 Summing Over Studies 287 References 288 C. Adjustments to Epidemiologic Estimates of Excess Lung Cancer in Persons Exposed to 289 Environmental Tobacco Smoke Using Cotinine Measurements to Correct Misreporting 290 References 293 D. Risk AssessmentâExposure to Environmental Tobacco Smoke and Lung Cancer 294 James Robins Introduction 294 D-1 Estimation of the True Relative Risk 297 D-2 The Carcinogen-Equivalent Number of Actively Smoked Cigarettes Inhaled Daily by 301 Passive Smokers: Comparisons of Epidemiologic with Dosimetric Estimates D-3 Estimating the Number of Lung Cancer Deaths in Nonsmokers in 1985 Attributable to 304 ETS D-4 Lifetime Risk of Death From Lung Cancer Attributable to ETS 306 Discussion 311 Technical Discussions 313 References 336