Environmental tobacco smoke

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A study published in January 1998 in the Journal of the American Medical Association examined the impact of exposure to ETS on the progression of atherosclerosis and concluded that the arteries of non-smokers exposed to ETS thickened 25% faster than non-smokers with no second-hand exposure [1]. Another study published in the British Medical Journal in June 2003 concluded that "nicotine concentration in the 5 B's were 2.4 to 18.5 times higher than in offices or residences" [2]. At that level of exposure, the study estimated that lifetime excess lung cancer risk to be between 1.09 - 4.1/1000. It is clear that smoking in public areas, such as the 5 B's: bars, bowling alleys, billiards hall, betting establishments, and bingo parlors, can be harmful to the health of not only the smoker himself, but everybody around him. These recent studies, including a plethora of other studies on the harmful effect of environmental tobacco smoke (ETS), prompted New York City to ban tobacco smoke in bars and clubs.

In December 2002, newly elected Mayor Michael Bloomberg, mayor of New York City, passed Local Law 47, which amended Smoke-Free Air Act of New York City. Local Law 47 expanded coverage on its' processor by banning tobacco smoke in all bars and clubs in the city. Those in support of the policy, including the mayor, argued that Local Law 47 would prevent disease and death among bar and club employees caused by tobacco smoke. However, opponents of the policy cite that the law would hurt the economy by preventing patrons to smoke freely, which subsequently influences tips, wages, and business. In addition, those against the policy claim that bar and club owners will lose money, resulting in closure of bar and club establishments. However, supporters believe the opposite will occur. They claim a ban on tobacco smoke would actually promote economic growth by increasing new patronship. New customers would be encouraged to go to establishments that ban tobacco smoke, instead of establishments that allow tobacco smoke.

As a non-smoker, and a frequent patron to the nightlife scene in Chicago, I support the tobacco smoke ban in New York City bars and clubs. Not only does the ban promote economic growth, it prevents adverse health outcomes due to passive smoking, improved quality of life in bars, promotes smokers to quit, and reduce societal and health care costs.

Environmental Tobacco Smoke (ETS)

There is a plethora of support for the New York City policy that bans tobacco smoke in bars. A recent study conducted in Ireland comparing the before and after of smoke-free legislation of bars, found that smoke-free laws protect non-smokers from exposure to secondhand smoke [3]. The prospective cohort study enrolled staff workers in a baseline survey in the six months leading up to the ban and followed them up one year later to assess changes in exposure to secondhand smoke (cotinine concentrations) and symptoms. It was shown that after adjustment for confounding factors, respiratory symptoms declined significantly (-16.7%, P = .001), and thus, protecting non-smoking bar workers from exposure to second-hand smoke.

Many opponents of the ban claim that secondhand smoke is not a contributing factor to adverse health outcomes such as lung cancer and heart disease. However, in a study conducted in five metropolitan areas in the United States and 11 areas in Germany, Italy, Sweden, United Kingdom, France, Spain and Portugal found that there is an increased risk of lung cancer from passive smoking [4]. A case-control study design was used to investigate pooled analysis data from two previously reported large case-control studies. Subjects included 1,263 never smoked lung cancer patients and 2,740 population and hospital controls recruited during 1985 - 1994. Odds ratios of lung cancer were calculated for ever exposure and duration of exposure to second hand smoke from spouse, workplace and social sources. The OR for ever exposure to all 3 sources were all greater than 1 and were all significant. In addition, a dose response relationship was present with increasing duration of exposure to secondhand smoke for all 3 sources, with an OR of 1.32 (95% CI = 1.10 - 1.79) for the long-term exposure from all sources.

While there are many studies that show an increased risk of lung cancer caused by secondhand smoke, there is a substantial amount of evidence showing the opposite. Lee, Chamberlain et al showed in a case-controlled study that amongst lifelong non-smokers, passive smoking was not associated with any significant increase in risk of lung cancer, chronic bronchitis, ischaemic heart disease, or stroke [5]. While every calculated relative risk was above or near 1.0, the 95% confidence interval was inclusive of both greater and less than 1.0 relative risk. Thus, there is no significant correlation between secondhand smoke and lung cancer. In further support, Brownson, Alavanja et al showed relatively similar results. In a case-control study evaluating the relation between passive smoke exposure and lung cancer in nonsmoking women showed minimal correlation between the two, by odds ratio analysis [6]. Case patients were identified through a cancer registry and were interviewed on their passive smoking exposure and history. Controls were provided by Missouri Department of Revenue and were asked similar questions as the case patients were. Results showed no increased risk of lung cancer with childhood passive smoking. However, adulthood passive smoking analyses showed a slight increase in cancer risk. While the 95% percent confidence interval showed significant results, conclusions must be made cautiously. The confidence interval included the odds ratio of 1.0, which corresponds to no correlation.

The fact is that everyone has the right to smoke; but there is no way that a non-smoker should be forced to inhale smoke that is not his or hers. There is outstanding evidence that link secondhand smoke to various respiratory conditions and symptoms; however, its association with health-related quality of life is not well understood. In a recent study aimed at understanding health-related quality of life (HRQOL) found that secondhand smoke is associated with lower HRQOL [7]. This cross-sectional study gave 2500 non-smokers a 36-Item Short Form Health Survey (SF-36). Of 2500, 388 subjects were placed in the SHS exposure group, which was defined by having regular exposure to SHS during the 12-month period prior to the survey. After adjusting for confounding variables, the study found that SHS was associated with reduced scores in all SF-36 items.

It was been shown by several studies that there are substantial risks involved with passive smoke. However, conclusions regarding those studies must be taken with a grain of salt. As shown above, there are equally as many studies showing little to no significant correlation between passive smoke and lung cancer. However, when considering whether the New York City tobacco smoke ban is justified, other factors such as reduced societal and health care costs and affects on the economy must be taken under consideration.

Financial Reasons

Each year, approximately 440,000 Americans die from tobacco smoke - that is one out of five deaths in the US. In addition, more than 43,000 people die annually due to smoking related causes [8]. There is unanimous agreement that disease burden has many direct and indirect impacts on local, state, federal economies. In a study looking at the economic burden of smoking in California, researchers calculated that the total cost of smoking was $15.9 billion [8]. This amount included direct costs due to lost productivity from illnesses and indirect costs due to premature death. However, when determining the justification for New York City's tobacco smoking policy, measures of direct economic impact due to the policy must be evaluated.

In March 2002, Bowling Green, Ohio implemented a ban on tobacco smoke in workplaces and public places. A quasi-experimental design was used, which included a matched control city of Kent, Ohio with no ordinance of a smoking ban and similar demographics, to investigate hospital admissions rates for smoking-related diseases from 1999 to 2005. The study showed that Bowling Green, with a implemented tobacco smoking ban, achieved a reduction in admissions rates for smoking-related disease compared to the control city, particularly a reductions of coronary heart disease problems [9]. In addition, there was an 8.9% reduction in cigarette sales; a 2.3% decrease in overall smoking prevalence; an increase in smoking cessation, and a decrease in hospital costs; thus, reducing health care costs.

In addition to reduced health care burden, New York City's bar and restaurant industry has thrived. According to the New York City Department of Health and Mental Hygiene's one -year review, bar and restaurant employment have risen, new liquor licenses issued have increased, and the majority of New Yorkers support the law and say that they are more likely to patronize bars and restaurants because of the smoke-free law [10]. The report claimed that business tax receipts increased by 8.7%, employment increased by 10,600 jobs, and cotinine levels decreased by 85% in nonsmoking bar and restaurant workers.


  1. Howard, G., et al., Cigarette smoking and progression of atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Jama, 1998. 279(2): p. 119.
  2. Siegel, M. and M. Skeer, Exposure to secondhand smoke and excess lung cancer mortality risk among workers in the" 5 B's": bars, bowling alleys, billiard halls, betting establishments, and bingo parlours. British Medical Journal, 2003. 12(3): p. 333.
  3. Allwright, S., et al., Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study. British Medical Journal, 2005. 331(7525): p. 1117.
  4. Brennan, P., et al., Secondhand smoke exposure in adulthood and risk of lung cancer among never smokers: a pooled analysis of two large studies. International Journal of Cancer, 2004. 109(1): p. 125-131.
  5. Lee, P.N., J. Chamberlain, and M.R. Alderson, Relationship of passive smoking to risk of lung cancer and other smoking-associated diseases. British Journal of Cancer, 1986. 54(1): p. 97.
  6. Brownson, R.C., et al., Passive smoking and lung cancer in nonsmoking women. American Journal of Public Health, 1992. 82(11): p. 1525.
  7. Bridevaux, P.O., et al., Secondhand smoke and health-related quality of life in never smokers: Results from the SAPALDIA cohort study 2. Archives of Internal Medicine, 2007. 167(22): p. 2516.
  8. Max, W., et al., The economic burden of smoking in California. British Medical Journal, 2004. 13(3): p. 264.
  9. Khuder, S.A., et al., The impact of a smoking ban on hospital admissions for coronary heart disease. Preventive Medicine, 2007. 45(1): p. 3-8.
  10. Finance, N.D.o. and N.D.o.H.a.M. Hygiene, The State of Smoke-Free New York City: A One-Year Review. 2004: New York City.