Orac is the nom de blog of a humble pseudonymous surgeon/scientist with an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his miscellaneous verbal meanderings, but just barely small enough to admit to himself that few will. (Continued 
"What do you think about second hand smoke?" he asked me. I sensed ulterior motives behind the question, but I wasn't sure. I suspected that he was just looking for an argument.
"It's bad," I joked.
"Some have told me that the studies don't show any health problems from second hand smoke," he replied.
"I'm sure 'some' have," I retorted somewhat sarcastically.
"No, really, is there any evidence," he replied. "I'm open-minded about this topic."
Somehow I doubted this, but I figured, what the heck, and did a little reviewing. It makes for some interesting reading.
The question of whether second hand smoke (SHS) causes lung cancer or other health problems in people exposed to it on a chronic basis is a tough one to examine epidemiologically because, as with most studies of exposures, it's difficult to control for other factors. It's not like studying smoking as a cause for cancer, where it's relatively easy to examine the exposure. More importantly, whatever the effect of SHS may be, we can, based on the simple principle of dose-response, expect that it would produce considerably less profund of an effect than smoking itself, given the obvious difference between inhaling someone else's smoke at a bar and inhaling 10-30 cigarettes a day over the course of many years. Moreover, it should be remembered that the science behind whether SHS is a health risk is a distinct from the policy question of what we should do about it as far as indoor smoking bans go. Finally, when millions of people are exposed, small increased risks can lead to many, many additional cases of smoking-caused disease.
Before I get into the studies, as a background, I'd point out that the tobacco industry managed to try to deny and obfuscate for decades over the very real and now indisputable risk of health problems from smoking. How on earth did they manage to do this? One has to remember that most people who smoke will not get cancer. As hard as it is for many lay people to believe, it's true. A person who smokes two packs a day smoker for 40-50 years will have approximately a 20% chance of dying of lung cancer. True to a dose-response curve, that means people who smoke less (which is most smokers these days) will have even less of a chance of dying of cancer. That means that there are a lot of smokers who never develop lung cancer and a lot of smokers who never develop cardiovascular disease. Indeed, I once said that it's impossible to tell whether any individual smoker will or won't get lung cancer; I can only quote the odds. In any case, if it was possible for tobacco companies to obfuscate such a powerful and now indisputable epidemiological risk for so long, imagine how much easier it is to sow doubt over the considerably smaller elevation in risk due to SHS.
I realize that "skeptics" of the health dangers of SHS will immediately start spinning conspiracy theories, but an excellent source of information on the topic is the most recent Surgeon General's report, released about a year ago, entitled The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. I had thought of plowing through the literature myself without a guide until the hundreds of studies out there convinced me that it was such a massive undertaking that it would be hard to justify it for just one blog article. The report lists many, many studies that support the contention that SHS causes health problems and critically compares them to the fewer studies that don't support such a link. I realize that to those who don't accept the science indicating an increased health risk from passive smoke, invoking any government document will be viewed in much the same way as HIV/AIDS denialists view the NIH statement on the link between HIV and AIDS, but keep in mind that this document was a product of the Bush administration, hardly a champion of regulating human exposure to environmental toxins.
Also, such "skeptics" often forget or ignore a key element in making a connection, namely biological plausibility. We already know that smoking causes cancer and heart disease; it is thus plausible that exposure to secondhand smoke would be likely to cause cancer as well, just at a decreased rate because of its much lower dose. This is not like the arguments over mercury in thimerosal in vaccines, where not only is it not biologically plausible that mercury causes autism but the epidemiological evidence does not support such a link. Moreover, "skeptics" also often will point to single studies as "proof" that there is no connection between SHS and human disease. The problem is, for a complex epidemiological problem like whether SHS causes cancer or heart disease, no single study will ever definitively prove or disprove a link. The totality of evidence has to be examined critically. Many "skeptics" that SHS is a danger will cherry pick studies that didn't find a link, but usually those studies fail to find a link because of inadequate sample size or statistical power.
Because the issue at hand is smoke exposure in the workplace and in indoor spaces, I'm not going to focus so much on the well-known and well-documented harmful effects of smoking on children's respiratory health. The evidence for this is well-documented in Chapter 6 of the Surgeon General's report. Suffice it to say that children exposed to secondhand smoke are at increased risk for acute respiratory infections, more severe asthma, and a variety of other health conditions.
In adults, numerous studies support the existence of approximately a 25% elevated risk of lung cancer from those exposed to secondhand smoke chronically. The types of epidemiologic studies generally include studies of secondhand smoke exposure in the home, which usually take the form of studies looking at cancer rates in nonsmoking spouses of smokers. Criticisms of these studies generally takes the form of criticizing how well they control for other factors, given that spouses living together generally share more than just exposure to smoke. Even so, the better-controlled studies here consistently show elevated risk of lung cancer in nonsmoking spouses of smokers. There are at least 52 spousal smoking studies, and meta-analysis produces estimates of relative risk ranging from 1.15 to 1.43; i.e., a 15-43% elevation in lung cancer risk. These are summarized in Chapter 7 of the Surgeon General's report.
The second type fo study tends to look at smoking in the workplace. As of the Surgeon General's report, there were at least 25 such studies, of which seven were from the U.S., one from Canada, seven from Europe, and ten from Asia. The studies are fairly heterogeneous, but their conclusions are remarkably consistent for such a diverse bunch of epidemiological studies. Not all studies reached statistical significance, namely because of small numbers and inadequate statistical power, but they still came to similar estimates, with relative risks ranging from 1.12 to 1.32, with a pooled estimate of 1.22, or a 22% increased risk of lung cancer. More interestingly, there are studies that support not just a correlation between exposure to SHS and lung cancer but a dose-response effect (Hackshaw et al, 1997; Lubin 1999; Zhong et al, 2000; Brennan et al, 2004). When these studies are looked at, neither confounding factors, publication bias, nor misclassification errors account for the observed increased relative risk.
A number of studies have also looked at the risk of cardiovascular disease due to SHS. As summarized in Chapter 8 of the Surgeon General's report, they consistently show a roughly 30% increase in risk of cardiovascular events. This data is summarized well in Chapter 8 of the Surgeon General's report. Epidemiological links are supported also by a wealth of preclinical evidence showing the effect of SHS on vascular tone, endothelial cell function, platelet aggregation, and a number of other markers of vascular injury.
One study that is frequently cited by "skeptics" who don't accept that SHS can cause health problems is J. E. Enstrom and G. C. Kabat Br. Med. J. 326, 1057; 2003. This study failed to find a causal relation between SHS and tobacco-related mortality. There's just one problem. The study was crap, and the BMJ was forced to reveal that the authors had accepted money from tobacco companies and that the study had several fatal flaws. In an editorial in Nature recently, this fiasco was recounted:
But top scientists at the cancer society say they repeatedly warned Enstrom of possible deficiencies in his analysis -- particularly a 25-year gap in which exposure to second-hand smoke could not be verified. The society also says that when it gave Enstrom computerized records of study subjects, it was not aware that he was receiving funding from the tobacco industry. Later tobacco-related lawsuits revealed he had received money from industry funneled through an organization called the Center for Indoor Air Research. And court records show Enstrom previously did consulting and research for attorneys defending the tobacco companies R. J. Reynolds and Philip Morris.
Perhaps my favorite paper of all is one that I'm saving for last because if I started with it I might have been accused of "poisoning the well." This one, which appeared in JAMA in 1998, is revealing. It examined review articles, and, well, here's the abstract:
Why Review Articles on the Health Effects of Passive Smoking Reach Different Conclusions Deborah E. Barnes, MPH; Lisa A. Bero, PhDJAMA. 1998;279:1566-1570.
Objective.-- To determine whether the conclusions of review articles on the health effects of passive smoking are associated with article quality, the affiliations of their authors, or other article characteristics.
Data Sources.-- Review articles published from 1980 to 1995 were identified through electronic searches of MEDLINE and EMBASE and from a database of symposium proceedings on passive smoking.
Article Selection.-- An article was included if its stated or implied purpose was to review the scientific evidence that passive smoking is associated with 1 or more health outcomes. Articles were excluded if they did not focus specifically on the health effects of passive smoking or if they were not written in English.
Data Extraction.-- Review article quality was evaluated by 2 independent assessors who were trained, followed a written protocol, had no disclosed conflicts of interest, and were blinded to all study hypotheses and identifying characteristics of articles. Article conclusions were categorized by the 2 assessors and by one of the authors. Author affiliation was classified as either tobacco industry affiliated or not, based on whether the authors were known to have received funding from or participated in activities sponsored by the tobacco industry. Other article characteristics were classified by one of the authors using predefined criteria.
Data Synthesis.-- A total of 106 reviews were identified. Overall, 37% (39/106) of reviews concluded that passive smoking is not harmful to health; 74% (29/39) of these were written by authors with tobacco industry affiliations. In multiple logistic regression analyses controlling for article quality, peer review status, article topic, and year of publication, the only factor associated with concluding that passive smoking is not harmful was whether an author was affiliated with the tobacco industry (odds ratio, 88.4; 95% confidence interval, 16.4-476.5; P<.001).
Conclusions.-- The conclusions of review articles are strongly associated with the affiliations of their authors. Authors of review articles should disclose potential financial conflicts of interest, and readers of review articles should consider authors' affiliations when deciding how to judge an article's conclusions.
Indeed. Lest you think that this isn't still going on, it's instructive to take a look at a couple of more recent articles that demonstrate the tobacco industry's favored techniques for denying a link between SHS and health problems: namely, challenging causation of adverse health effects of passive smoking by citing limitations of epidemiologic research, raising methodological and statistical issues, and disputing biological plausibility.
The bottom line is that, although the effect of SHS is relatively small in epidemiological terms because it is a relative risk that is well under 2, namely a roughly 25% increased risk of lung cancer and heart disease, plus lower and less clear associations to a number of other cancers and diseases, it is real. It consistently shows up in multiple studies done using multiple different methods in many different countries. Moreover, even though it is relatively small, because of the sheer numbers of people exposed to SHS, it is most definitely significant. Indeed, in the case of heart disease, which is the most common cause of death, even an increase of risk due to SHS of only a few percent would be significant, although such a small increase would be almost impossible to detect in epidemiological studies. Consequently, a strong argument can be made for indoor smoking bans in the workplace. We may not be able to do much aside from education and the encouragement of smoking cessation to prevent the exposure of children and nonsmoking spouses to the dangers of SHS. Arguments on a public policy basis and a cost-benefit basis about whether banning indoor smoking makes sense, but arguments that the science doesn't show that SHS can cause lung cancer and cardiovascular disease and adults and a variety of health problems in children are nonstarters. The science doesn't support them (although ideologues will try to take advantage of controversies over the exact magnitude of the health risks posed by SHS). Indeed, even Penn Jillette has admitted that he was wrong about SHS in an episode of Bullsh*t! in which it was claimed that SHS was not a danger, although he was full of, well, Bullsh*t! when he stated that a "lot of this was very new."
No, it wasn't. The data at the time that original episode aired was quite strong. The newer data only confirm the older data available then.
That being said, there is a risk of going too far in legislating smoking bans. Certainly indoor smoking bans at workplaces and in restaurants and bars are defensible on a scientific and public health basis. However, outdoor smoking bans, such as I've heard about on many California beaches and a recent law passed by the Beverly Hills City Council to ban smoking in all outdoor eating areas, are just plain stupid and wrong-headed, at least if the rationale is to prevent SHS-caused health problems in the population. This is particularly true since such bans apply to sidewalk cafes, where, in my experience, the exhaust fumes from passing traffic tend to overwhelm any smoke that comes from cigarettes. It doesn't help the reasonable and scientifically supported cause of indoor workplace smoking bans to overstep and impose bans in cases where the science doesn't support it.
And here are some studies that I picked almost at random. If anyone doesn't think they're enough, you can review the Surgeon General's report for literally hundreds more, and I could post many more as well.
- de Waard F, Kemmeren JM, van Ginkel LA, Stolker AAM. Urinary cotinine and lung cancer risk in a female cohort. British Journal of Cancer 1995; 72(3):784-7.
- Johnson KC, Hu J, Mao Y, the Canadian Cancer Registries Epidemiology Research Group. Lifetime residential and workplace exposure to environmental tobacco smoke and lung cancer in never-smoking women, Canada 1994-97. International Journal of Cancer 2001;93(6):902-6.
- Zhong L, Goldberg MS, Gao YT, Jin F. A case-control study of lung cancer and environmental tobacco smoke among nonsmoking women living in Shanghai, China. Cancer Causes Control. 1999 Dec;10(6):607-16.
- Eisner MD, Wang Y, Haight TJ, Balmes J, Hammond SK, Tager IB. Secondhand smoke exposure, pulmonary function, and cardiovascular mortality. Ann Epidemiol. 2007 May;17(5):364-73.
- Venn A, Britton J. Exposure to secondhand smoke and biomarkers of cardiovascular disease risk in never-smoking adults. Circulation. 2007 Feb 27;115(8):990-5.
- Hill SE, Blakely T, Kawachi I, Woodward A. Mortality among lifelong nonsmokers exposed to secondhand smoke at home: cohort data and sensitivity analyses. Am J Epidemiol. 2007 Mar 1;165(5):530-40.
- Barnoya J, Glantz SA. Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation. 2005 May 24;111(20):2684-98.
- Raupach T, Schafer K, Konstantinides S, Andreas S. Secondhand smoke as an acute threat for the cardiovascular system: a change in paradigm. Eur Heart J. 2006 Feb;27(4):386-92.
- Brennan P, Buffler PA, Reynolds P, Wu AH, Wichmann HE, Agudo A, Pershagen G, Jockel KH, Benhamou S, Greenberg RS, Merletti F, Winck C, Fontham ET, Kreuzer M, Darby SC, Forastiere F, Simonato L, Boffetta P. Secondhand smoke exposure in adulthood and risk of lung cancer among never smokers: a pooled analysis of two large studies. Int J Cancer. 2004 Mar;109(1):125-31.
Medicine & Health
Comments
That was very interesting. I live in the UK where we've recently had a smoking ban introduced, and I have to say that I was one of those "in denial" (I smoke) about the scientific evidence for any actual harm caused by second-hand smoke; partly having seen the Penn and Teller Bullsh*t episode you mention. However, it would appear that I was wrong, and there is a link. Thank you.
Having said that, your comments regarding the distinction between health effect and policy decisions has shown itself to be true here in the UK. Whilst our country has only banned smoking in "enclosed or partially enclosed" areas, some companies and councils appear to be ignoring this. My local bus company has banned - under the auspices of the ban - smoking in, of all places, an open-air bus station. Your comment on car fumes sprung to my mind too.
Posted by: JohnW | July 16, 2007 9:35 AM
I saw that P&T as well. While I enjoy the show, unfortunately they seem to be spreading as much BS as anyone else. They tend to bring on one expert, whom they agree with, to debunk another expert, who they don't agree with, rather than using evidence.
That being said, that P&T claims that the primary piece of evidence that SHS advocates use is an EPA study that actually claims there is no correlation, do you know which one this is and is that actually what it says?
Posted by: apy | July 16, 2007 10:10 AM
I believe it was an old EPA report from 1993 (which is out of date now), but I may have to go back and look it up.
Posted by: Orac | July 16, 2007 10:14 AM
Did it claim no correlation due to poor methods?
Posted by: apy | July 16, 2007 10:36 AM
I live in the first town in the US that implemented a ban on smoking in public buildings. Even though there isn't a ban on outdoor smoking, smokers here have caught on to the fact that it is not socially acceptable. I can go for weeks without some moron blowing smoke in my face. Even if there were no health benefits to banning smoking, the improvement in air quality inside and outside is remarkable. On the rare occasions that I travel to the midwest or east I am struck by how bad it is there.
We don't tolerate industry spewing fumes into the air anymore, so why should we tolerate it when individuals do it? One individual doesn't have the right to ruin the air quality for dozens of people around them. A ban on smoking at beaches and in town makes perfect sense to me.
Posted by: JScarry | July 16, 2007 10:50 AM
A ban on smoking at beaches and in town makes perfect sense to me.
JScarry, there are a couple of problems with such widespread smoking bans. First, it is politically difficult to pass such a measure (let alone enforce it). Forcing the matter could generate a backlash against all anti-smoking measures as well.
The second problem I see is that forcing smokers into their homes will increase the exposure of some others (notably children) to SHS. Daddy might want to go outside to smoke, but if he is not allowed to he'll just end up smoking inside with the kids. (Sure, he could quit, but most people will take the path of least resistance and continue the habit.)
Posted by: Dan | July 16, 2007 11:16 AM
Where do you live that your bus company banned smoking at bus stops? I would like to move there. Or to where JScarry lives. I absolutely agree that I am thrilled with every new restriction on smoking totally irrespective of what its long-term health effects on non-smokers are. Frankly, I don't *care* if it will increase my risk of lung cancer in forty years (well, I do, but it doesn't actually change my position). It makes me sick *now*. Any exposure at all (yes, this includes when I'm stuck in a place outside, like a bus stop or outdoor cafe, and it's blowing in my face) and it hurts to breathe, I can't take a full breath, I have to either breathe through a sleeve over my nose and mouth or just flee. Enough exposure and I'll be coughing, sick, chest sore, for the rest of the day. That's a really unpleasant experience just so that the small minority who have chosen this vile habit aren't inconvenienced in their freedom to indulge it whenever and wherever they please.
I guess I'm just counting on the trend towards increasing social unacceptability continuing, as it's probably too much to hope for outdoor bans, even though I think they're perfectly justified irrespective of any health considerations. Also, I honestly think that if I were offered a job in a state without an indoor smoking ban, barring extraordinary circumstances, I would turn it down for that reason alone. If smoking is allowed in restaurants, I simply can't eat in restaurants. Why should I have to take that kind of restriction, versus the smokers just having to go without for an hour or so? I don't get it.
Posted by: Katie | July 16, 2007 11:28 AM
Regarding the tobacco industry's obfuscation of smoking's health issues, I wonder if there was probably too much focus on cancer, which is scary but doesn't get that many smokers, as you say.
I've known a lot more smokers with COPD than cancer, and its a nasty debilitating disease. I wonder what the incidence of COPD is, both severe and mild, and whether it also shows up in 2nd hand cases.
Posted by: Zombie | July 16, 2007 11:45 AM
There are at least 52 spousal smoking studies, and meta-analysis produces estimates of relative risk ranging from 1.15 to 1.43; i.e., a 15-43% elevation in lung cancer risk
Is this meaningful epidemiologically? If it were not SHS then would these figures warrant futher investigation?
Should all activities or substances that produce risks at these levels be banned?
Even if there were no health benefits to banning smoking, the improvement in air quality inside and outside is remarkable
How is the air quality outside improved? Does industry continue to spew out toxins, traffic spew out exhaust?
Enough exposure and I'll be coughing, sick, chest sore, for the rest of the day
This seems an extreme reaction.
west
----
Posted by: west2 | July 16, 2007 12:18 PM
Banning smoking at bus stops??????
Well its a start I guess. However what are the long range effects of exposure to diesel hydrocarbon exhaust on human lung tissue?
I don't smoke, never have, but I have what I believe to be a reasonable perspective on second hand smoke from cigarettes. Its a matter of dosage. At least in California which appears to be more anti smoke or at least more proactive say versus the midwest is or was. As I have stated in a previous post, my involuntary exposure to secondhand cigarette smoke in my childhood was what I would call severe as compared to the second hand smoke issues of today (my employer has banned smoking while on company property altogether). It's been almost never since I have been exposed to the dosages I saw as a kid.
Zombie makes a very good point as well with COPD. My mother has just been diagnosed with Emphysema. She was a long term smoker. My grandfather died due to complications from emphysema (basically died of exhaustion in an attempt to continue to get enough volume of air- not a pretty sight). Grandfather may have had other issues with industrial fume exposure as well however. People need to look at the other serious emplications of long term smoking and second hand exposure (at least the second hand exposure most 45-65 year old non smokers were exposed to when they were children - which is more severe than that of today). I am more concerned with emphysema and other pulmonary health problems associated with exposures to more than just cigarette smoke (people working in garages, at airports, sitting at buss stops etc). Seems like emhysema and other lung problems causing tissue damage
for some are almost a promise rather than a risk.
Posted by: Uncle Dave | July 16, 2007 12:43 PM
Lisa Bero also co-authored an interesting study showing that in its quest to discredit the science linking SHS and disease, Philip Morris successfully pushed for legislation that's proving useful to several different industries opposing regulation of their products.
The study authors found that Philip Morris sought the raw data from one of the researchers whose studies demonstrated that SHS exposure increases risk of lung cancer in nonsmokers; their plan was to reanalyze it and "prove it does not show any association between ETS and disease." When the researcher, Elizabeth Fontham, refused to give Philip Morris her data, the company successfully pushed for passage of the Data Access Act, which makes all data produced under federally funded research studies available by FOIA request.
While this kind of access seems reasonable, the effect has been that companies whose products are subject to regulation are able to obtain and re-analyze the data from studies used in setting regulations or guidelines (often yielding reanalyses that contradict the original studies' findings). Meanwhile, corporations and trade associations are under no obligation to release data from studies they've funded, so the playing field is tilted in their favor.
After the Data Access Act passed, Philip Morris successfully pushed for the Data Quality Act (or Information Quality Act), which allows companies and trade associations to challenge the information behind regulations and guidelines issued by federal agencies. So, the American Chemistry Council has challenged a Consumer Products Safety Council ban on arsenic-treated wood; the Salt Institute and Chamber of Commerce have challenged the NIH's recommendations on cutting salt consumption; logging groups have challenged Forest Service calculations justifying timber harvest restrictions, etc.
Posted by: Liz Borkowski | July 16, 2007 12:45 PM
National Cancer Institute - "In epidemiologic research, relative risks of less than 2 are considered small and usually difficult to interpret. Such increases may be due to chance, statistical bias or effects of confounding factors that are sometimes not evident." - National Cancer Institute, "Abortion and possible risk for breast cancer: analysis and inconsistencies," October 26, 1994.
Sir Richard Doll - " ... when relative risk lies between 1 and 2 ... problems of interpretation may become acute, and it may be extremely difficult to disentangle the various contributions of biased information, confounding of two or more factors, and cause and effect."
"The Causes of Cancer," by Richard Doll, F.R.S. and Richard Peto. Oxford-New York, Oxford University Press, 1981, p. 1219.
WHO/IARC - "Relative risks of less than 2.0 may readily reflect some unperceived bias or confounding factor, those over 5.0 are unlikely to do so." - Breslow and Day, 1980, Statistical methods in cancer research, Vol. 1, The analysis of case control studies. Published by the World Health Organization, International Agency for Research on Cancer, Sci. Pub. No. 32, Lyon, p. 36
FDA - "Relative risks of 2 have a history of unreliability" - Robert Temple, M.D. Food and Drug Administration Journal of the American Medical Association (JAMA), Letters, September 8, 1999
FDA - "My basic rule is if the relative risk isn't at least 3 or 4, forget it." - Robert Temple, director of drug evaluation at the Food and Drug Administration.
Average cancer risk elevation for exposure to passive smoke: about 20% (relative risk=1.2)
Average cardiovascular disease risk elevation for exposure to passive smoke: about 30% (relative risk=1.3)
This is a contrived issue to force a specific behavior on a segment of the population. Why is using spit tobacco or spitless tobacco banned? Last I checked there was no SHS from it? It should concern all Americans when a group can massage data to prosecute an agenda that they believe is better for all. What's next? Privacy and freedom are American values, the SHS issue was invented to organize non-smokers against smokers and it has worked.
The diesel issue is real. Check the asthma rates in the Bronx NY.
Posted by: rrgabe23 | July 16, 2007 1:02 PM
Well I guess I'll expose my libertarian side (scary, who knew I had one?). I fully accept that SHS is probably dangerous in the way that Orac describes above. However, I have a problem legislating smoking in bars. I really don't see why when people make a choice to go to a bar and know it has smoking or chose to work at a bar and know it has smoking that there is a problem. I think that a business owner should be allowed to offer their bar as a smoking bar. If they chose to ban it in their bar then they have that choice as well. Are they going to stop allowing people to smoke in Pipe or cigar stores? Where I live the widespread banning of smoking is currently being implemented. One bar that I have frequented lost serious business because of the ban. There were reports that their business was down as much as 50% over certain times in the spring and summer (this is a beach bar) that are their most busy (no I can't supply numbers or a source even, just knowing the bartenders there so the estimate is likely to be at least somewhat high but a loss none the less).
Just so you know, I don't smoke I've had family members die directly as a result of their smoking habit. I'd be perfectly happy if no one ever smoked in my presence again but I also know I am making a choice when I go into a bar where people smoke. And some nights out I avoid the bars I know are more smoky than others.
/tucks his minor libertarian views back under the bed
Posted by: Rev. BigDumbChimp | July 16, 2007 2:03 PM
Katie -
Portland, for one, has smoking bans inside bus shelters and on the light rail platforms. For those who want to argue that this is a ridiculous notion, keep in mind that first, these locations are not public property and that people who do not smoke, including children, have to use these facilities, if they wish to ride public trans. Quite honestly, health concerns aside, there is still no reason that they should have to be subjected to the stench of other people's smoke.
Smokers (such as myself) can thank rude, obnoxious smokers, who insist they should be able to smoke wherever, whenever they please. Instead of politely stepping away, or saving the rest of their cigarette for later, when someone politely asks them not to smoke around them, I have often seen them instead, blow smoke in someone's face or pretend they didn't here them. It is this stupid sense of selfish entitlement that has led to smoking bans in so many places. Yeah, it annoys me sometimes, especially when I am on an empty or sparse rail platform and really want to smoke. I am more than happy to stand way off, where my smoke won't bother anyone, putting it out if more people arrive, but alas, I could be ticketed for it now.
On the other hand, I was on a platform the other day with my son. Someone decided they should light up, right there next to my son and another family with an infant in tow, along with a couple other children. Did the jerk step to the side, or walk across the lot, where we're allowed to smoke, of course not. Instead he bristled at the very notion that we might not want him smoking around our kids. Even with the law to stop it, the a-holes just can't stand the idea that there are other people in the world, besides them, people who have no desire to partake of their nasty habits.
That said, some bans are getting way out of hand. The statewide ban in WA, is a great example. There it is now illegal to smoke within 25' of the door or windows that could be open, anywhere in public. In downtown Vancouver, I have seen people literally standing in the middle of the road to smoke, indeed I've done it myself. There comes a point where the bans become a more than acceptable infringement of rights. Unfortunately, it's hard to find a happy medium, with so many rude smokers out there.
Posted by: DuWayne | July 16, 2007 2:04 PM
"Author affiliation was classified as either tobacco industry affiliated or not, based on whether the authors were known to have received funding from or participated in activities sponsored by the tobacco industry."
Seems rather naive to assume that there are no other competing interest author affiliations on this topic. How about affiliations with major funders like pharmaceutical companies -- producers of Nicotine Replacement Therapies. Might they not have a financial stake in 'positive' SHS study outcomes?
Perhaps your "favorite" paper shows nothing more than that SHS is more about opinion than science?
Posted by: GDF | July 16, 2007 2:05 PM
GDF -
Which might be a reasonable argument, were that one paper, the only evidence offered. Alas it is not. Hell, short of any papers or studies supporting the dangers of second hand smoke, it just takes common sense to realize that, while the danger is obviously less to those inhaling SHS, the smoke doesn't magically become completely safe, after being filtered through the smoker.
Rev. BigDumbChimp -
I agree with you there. Several bars in WA have closed since the ban went into effect there.
Posted by: DuWayne | July 16, 2007 2:28 PM
Good point GDF. The Johnson and Johnson company makers of Nicorette and others makes millions from this. I believe the Robert Wood Johnson foundation is the main funder of most of this disinformation.
Posted by: rrgabe23 | July 16, 2007 2:35 PM
Those exposed to secondhand smoke chronically are indoors all the time, and therefore don't get enough sun and so are deficient in vitamin D. This lack of sun would be particularly acute in bar staff who work nights and sleep during the day, and the elderly who tend to be homebodies.
Since financial conflicts of interest were brought up, I can't help but note there are enormous financialconflicts of interest on the anti-Tobacco side.
Posted by: Carter | July 16, 2007 3:09 PM
I find it far more interesting the cases of long term smokers that live to the median age and never develop lung cancer or pulmonary disease.
Are there detailed studies of long term smoking test subjects with no incidence of lung cancer or emphysema? What studies have been done to evaluate thier ability to beat the odds? Granted it may be a tiny group, but it seems that we now know that cultures that routinely consume food high in Omega 3 fatty acids seem to have a lower HDL, LDL and incidence of heart disease. Seems statistically more interesting at this point to focus on the test cases that do not develop lung cancer. Do they may have a genetic disposition or other factor (vitamin D from solar radiation)that works to thier advantage.
I beleive the genetic marker for breast cancer was identified based in part on research of detailed family records within the Morman church (forgive me if I have mis-stated). Damn them Mormans for not smoking!
Seems like we have enough data supporting most of what we already know - smoking, as well as second hand smoke (I won't go into industrial byproduct exposure) increases your risk of heart disease and cancer (to name a few).
Why do we bother given this cultures significant downward swing in smoking proliferation anyway? It is now pretty much viewed in the western world as a universal taboo. Now you routinely see people snear when someone lights up. Is there interesting data that approaches identification of test subjects that beat the statistical probability.
Posted by: Uncle Dave | July 16, 2007 5:32 PM
DuWayne -- I might agree with you if that one paper was just any one study. But the paper discussed was claiming to demonstrate bias in the review articles that were assessing all (or many) of the other primary studies. I was suggesting that there may be sources of bias (other than from the tobacco indusrty) in those review articles that assess the findings of the other studies. Heck, the fact that only the tobacco industry (and no other competing interest) was even considered as a source of bias in a paper about bias is... I won't say biased, how about... ironic?
So, we fall back on common sense. And what you say DOES make sense at first read. Except that there are lots of things that are harmful in large doses and harmless in large doses. Common sense tells us that. That's why we ask science to evaluate the SHS question. And then round and round we go again.
Posted by: GDF | July 16, 2007 5:50 PM
I have to say you can count me in with the BigDumbChimp. I'm a non-smoker but I've always accepted that if I go to a club or a bar, there's going to be smoke. I might not take a job in one for that reason. I would prefer some fairly stringent requirements for active ventillation (has anyone ever done a study on the effects of ventillation on SHS), esp if there were fat tax breaks to pay the bar/clubowner back. Basically I am more in favor of cool, fun nightspots being able to open than I am against SHS. I also have a JH Mill-style dislike of 'social disapproval' being codified into law. I'd even allow smoking in restaurants if they met very stringent ventillation requirements.
Posted by: Antiquated Tory | July 16, 2007 5:53 PM
"Except that there are lots of things that are harmful in large doses and harmless in large doses"
should have read:
"Except that there are lots of things that are harmful in large doses and harmless in small doses."
Sorry!
Posted by: GDF | July 16, 2007 5:53 PM
Orac,
What do you make of the studies claiming increases in cardiovascular problems from acute rather than chronic SHS exposure? I noticed a couple of them in your citations but that you didn't cover it much in the post.
Posted by: MattXIV | July 16, 2007 6:43 PM
> acute
You have to read at least the abstract to understand how they are using the word 'acute' in the study:
"... relatively low doses of toxins inhaled by passive smoking are sufficient to elicit acute endothelial dysfunction ..."
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16230308&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Posted by: Hank Roberts | July 16, 2007 8:19 PM
Antiquated Tory, most of the antismoking guns have pooh-poohed ventilation and all other reasonable measures. In fact, I once wrote a letter to the editor in my hometown suggesting that they require beefed-up ventilation/filtration as a way to calm people who wanted cleaner air and still allow for smoking venues. The editor changed what I wrote to apply *only* to bars that allow smoking. (ASHRAE recently came out with similar recommendations for buildings that allow smoking--but not for nonsmoking buldings!) Thanks to antismoking hype, society now believes that only people who smoke have the right to cleaner air. How's that for irony? By the way, you really should hear Norm Kjono's interview on "The Dangerous Doug Kendall Show". He actually cleaned the air to the point of being better than outdoor air even with people who smoke in the office--and he was accused of being a tobacco shill for his efforts! LOL!
In my lifetime, most of the people I've met who smoked were very considerate, but too many have become tired of derisive comments by antismokers--"filthy", "stinking", "stupid", "moron" are just a few that I've heard. Frankly, I can't blame such people for no longer caring and behaving as described by DuWayne.
;-(
Hopefully, drug companies will be held accountable and this hysteria will come to an end. I do believe that most people wish to be considerate and have consideration shown toward them--and I *know* that most people share my belief.
Concerning the original blog, the Enstrom/Kabat paper was primarily funded by the American Cancer Society until the results "went the wrong way". Enstrom found funding for the tail end of the 30 year study in an organization setup by a tobacco company. His methodology was better than the methodology in most antismoking/pharmaceutical studies. Even the WHO had two large, long-term studies showing either no-correlation or statistically significant negative correlation. (Same for Wu-Williams in 1990--a statistically significant negative correlation on the largest study to date and, like the WHO studies, not exactly done by tobacco shills.) The "cherry-picking" in meta-analysis was first noted in a decision by Judge Osteen about one of the flaws of the EPA report. (That EPA report had already been panned by three federal agencies on methodological grounds.) The Surgeon General has already admitted to making statements on public health just to satisfy "ideological" pressures. In fact, the Surgeon General pushed all forms of NRT and medication; see #4 on http://www.surgeongeneral.gov/tobacco/consquits.htm Persoanlly, I wouldn't recommend things like Chantix, which has been known to cause diabetes, or Zyban, which has had serious side effects.
Posted by: DTB | July 16, 2007 9:13 PM
I am quite amazed there is a dialog still going on as far as second hand smoke is concerned, the Surgeon General among many other nicotine industry promoters declared the matter settled despite the controversy, which will only grow with the suspicion created when propaganda replaces real science as a foundation for health related information.
The foundation of human rights and civil law rests in the precedent of a basic human right to factual information of the highest quality available. Those in the Health care community seem to have found a way of cherry picking what is relevant in those areas, and what is not, which leaves them as a collaborating collective, independently liable when reliable facts are eventually established.
I found the author although apparently well read on the subject, a little confused on the perceptions presented. Although fewer studies refute the level of harm those few are the largest ones which carry much more weight in statistical studies. I could cite the World Health Organization's own research or that of Enstrom and Kabat along with the 50 year research of Sir Doll evaluating doctors who smoked which all are significant, all involve substantial research groups and all seem to deny the ad agency spin promoted by some of the largest health organizations on the planet. It should be noted no research studies of any equal size have provided anything but a proof of the insignificance of ETS exposure. The Surgeon General's report was at the time it was released an embarasement to all the mentioned groups who found it entirely difficult to cozy up to a lot of the unsubstantiated rhetoric particularly in association with the pre release press statements.
Epidemiology is a calculation of a single dimensional phenomenon. It unfortunately has defined limitations particularly in respect to size of population group studied. The larger studies have to carry the final say a collective of cherry picked studies all agreeing to desired opinions by excluding the peer reviewed studies which do not agree with formed opinions in what is known as meta analysis promotes only politics and fraud. The odds tell us some research will not agree the non existence of those studies, is actually proof all are wrong and a result of bias in the model.
As with all things taking short cuts to find sucess will eventually find a higher cost unfortunately in this case we are toying with politics and only the children will suffer despite a truck load of good intentions.
By taking the low road of double talk and deceit encompassed in propaganda terms such as tough love and for the greater good we yield the high road to the Tobacco industry who is not being punished as generally believed, but growing profits by the actions to date. Where is the hurt and hate directed most predominantly, is among the most vulnerable in society the poor and the children. It is too bad when cults and fanatics rule, how much we all suffer as a result. After the last time they hung doctors at the Nuremberg trials apparently the lesson was lost.
When science has to resort to proclamations such as "hurricane force winds" and "outdoor smoke plumes raining down on unsuspecting victims" to sell broad opinions, the future of science is heading into a dark period where snake oil and blood letting become popular once more.
Posted by: kevin | July 16, 2007 9:18 PM
I find this a very interesting topic, but only for historical reasons.
I'm 36, and I've never had a workplace of any sort where smoking was allowed. Frankly, I find the idea of smoking in a workplace a bit old-fashioned - I think many people of my generation associate it with clerks working with green visors on their heads and other 19th century ideas :)
All restaurants and clubs, pubs etc. have had non-smoking areas as long as I can remember, and recently have banned all smoking inside altogether (at the behest of the owners who are worried about SHS effects on staff).
I can remember public transport having smoking carriages on long-distance trains, but that was at least 15 years ago.
Many people seem to not care about primarily about health effects - the general opinions seem to be that smoking is smelly and dirty, and why should the (rapidly shrinking - about 18%, IIRC) small minority who smoke stink the place up for the rest of us?
Oh, I'm Australian, from Sydney.
Posted by: Stephen | July 16, 2007 9:30 PM
Well, Stephen from Sydney, your comments indicate that you've been living in a fantasy world for 36 years as demonstrated by this article from The Sydney Morning Herald on February 25, 2005: "Fags: It Ain't so Black and White" at http://blogs.smh.com.au/radar/archives/2005/02/fags_it_aint_so.html
Posted by: DTB | July 16, 2007 9:35 PM
Well, Stephen from Sydney, your comments indicate that you've been living in a fantasy world for 36 years as demonstrated by this article from The Sydney Morning Herald on February 25, 2005: "Fags: It Ain't so Black and White" at http://blogs.smh.com.au/radar/archives/2005/02/fags_it_aint_so.html
Posted by: DTB | July 16, 2007 9:35 PM
I've come to the conclusion that my problem with SHS isn't the tobacco itself, but additives to the cigarettes.
I can handle being around pipe smoke OK. I like being around pipe smokers, just so long as I don't have to kiss them.
I can handle being around people smoking American Spirit cigarettes just fine.
I can handle being within 3' of a lit Camel outdoors, or within 10' indoors, without too much distress.
But if anyone lights up a Marlboro within 50' of me indoors, or within 15' of me outdoors, I have a problem.
Posted by: Julia | July 16, 2007 9:38 PM
Remember the purpose of bar and restaurant cessation movements are not as much for the patrons, they are for the employees who are facing daily exposure. Businesses being businesses will likely do everything they can to accomodate a paying customer.
Most every work place that I know of has banned smoking indoors at a minimum these days. My employer doesn't allow it anywhere on property (about 30 acres of it). People have to much to go outside the gates of the plant.
I am fairly confident that if I as a non-smoker go about my normal lifestyle, I will have little threat in my life of second hand smoke, as opposed to say 15-20 years ago and beyond. I have a far greater danger of respitory illness from prolonged exhaust exposure from sitting in LA traffic for hours in a day.
Sheeessh! I gotta find another subject this ones giving me second hand information.
Posted by: Uncle Dave | July 16, 2007 9:56 PM
Ah, so people who are mistreated have the right to mistreat others. Gotcha.
Anyway, I enjoy inhaling the fumes of burning human hair. I'm tired of people calling this dirty or disgusting and asking me to extinguish my haircigs. I have a right to my hobby/addiction/fetish. I am a victim!
Posted by: Boris | July 16, 2007 10:45 PM
No, Boris, I never said anything about people having the right to mistreat others. In fact, I said, "most people wish to be considerate and have consideration shown toward them." You have demonstrated the reason that I said "most".
You haven't "got" anything. I feel sorry for you.
Posted by: DTB | July 16, 2007 10:53 PM
DTB...
Not sure what you're talking about, to be honest.
I've never worked in a place (or even visited when consulting) which allowed smoking.
The blog you link to from 2.5 years or so ago is arguing against the ban that just came in at the start of this month on smoking in pubs/clubs etc.
I've never worked in such a place... I fail to see how it in any way relates to my statement.
Posted by: Stephen | July 16, 2007 11:56 PM
First of all, excellent article even though I disagree with your conclusions: at least you've done some research beyond reading press releases.
My main criticisms are that you rely so much on the Surgeon General's Report as an unimpeachable resource and that you have accepted, seemingly without much research, the criticisms of the Enstrom/Kabat study.
Remember how important it is to the antismoking cause to support smoking bans. Realize how difficult these bans would be to achieve without widespread fear of secondary smoke. There's a lot of manipulation of facts and figures going on out there by the antismoking industry today: at least as much and maybe even more than was done by Big Tobacco in the 1950s and 60s. There's also coverup involved, from sources you might not normally think would engage in such things.
See: http://www.acsh.org/factsfears/newsID.990/news_detail.asp for an example of such "passive fraud".
Obviously the full argument is way too involved for a posting like this. But, to get a good solid taste of the kind of distortion and lies that are out there, go to my website at http://pasan.TheTruthIsALie.com and scroll down to the first "boxed" item, titled "Day of Defiance". It's a short and very easy to read document that includes a complete trashing of the health and economics arguments behind smoking bans: you'll be amazed at how some of these "studies" are distorted by the time they hit the evening news.
Smoking bans are bad laws based on lies, and a law based on lies is no law at all. I fully support the growing British defiance of their smoking ban: Free and concerned citizens should feel proud to stand up for freedom and defy the encroachments that lead to ever-more powerful and dictatorial government interference in private lives and businesses.
Michael J. McFadden
Author of Dissecting Antismokers' Brains
Posted by: Michael J. McFadden | July 17, 2007 12:29 AM
The primary message is found here;
"" In philosophy generally, empiricism is a theory of knowledge emphasizing the role of experience in the formation of ideas, while discounting the notion of innate ideas.
In the philosophy of science, empiricism is a theory of knowledge which emphasizes those aspects of scientific knowledge that are closely related to experience, especially as formed through deliberate experimental arrangements. It is a fundamental requirement of scientific method that all hypotheses and theories must be tested against observations of the natural world, rather than resting solely on "a priori" reasoning, intuition, or revelation."
Consistent positive correlations can only be recognized if we can absolutely assure the possibility of bias is less than the predicted result.
In ETS calculations it would be a real stretch of the imagination to presume confounding effect and linear regression is defined so precisely without defining the variations of the suspect cause, or the exposure levels?
The sheer arrogance of anyone in the profession to dispense frauds declaring the precision of the method has been honed to accuracy within a .3 increase which can only truly demonstrate dedication much more than accuracy or expertise,
The confounding base is the same so how can we test the accuracy of the theory when the confounders are all of common design.
The randomness of the modeling process as well as the data has all but been eliminated is it any surprise the results find similar numbers?
More incredible is the formation of conclusion which agrees the level of increased risk with the complexity of a single life's experience can be defined to a level E&K numbers are insignificant yet the .3 level is judged as significant proof?
The precision suggests impropriety and that impropriety is found in the collusion within the major group who demand recognition because of their station alone.
One cannot believe empirical proof can be demonstrated without confounding for the bias of education and collusive need. The unknowns exceed the level of accuracy yet to be discovered. Consensus discoveries among a dedicated group who can not determine which harm will result from exposures and seeks to combine all possible harms in one disease perspective, with an identical model utilized to detect them all. The results are reviewed separately despite the reality many times alternate diseases are found among the same observed individuals.
The WHO call for evidence produces only what is requested, and in the absence of studies demonstrating non-proof results. The process is known to be corrupt and that corruption is worn on the sleeves of those who support it.
Most damning of all; the modelers them selves unanimously agree the funding source could somehow produce results with predictable bias.
Who pays hundreds of millions of dollars for the promotion of smoking bans and creating fat pandemics, is the topic which needs evaluation in observing billions in profits earned enjoying apparent immunity of the same discretion as other funders. The public purse is largely augmenting the direct promotion of those same products and services openly.
Antagonists declare all the time no conflicts of interest despite the obvious fallacy in those declarations, yet no one seems to mind???
Posted by: kevin | July 17, 2007 12:41 AM
Antiquated Tory, DTB - When smoking bans were first suggested in New Zeland, the first thing that occured to me was ventilation. After all, the problem is the smoke, not the smokers.
I would attribute the tendency to overlook this solution less to a moral crusade (though for a minority that may be an explanation) but rather to a natural human tendency to examine only the alternatives that are placed in front of one, rather than seriously examining how to correct the root cause of a problem with the minimum fuss to everyone.
Posted by: James | July 17, 2007 1:09 AM
"The Bogus 'Science' of Secondhand Smoke", a recent Washington Post op-ed by cancer epidemiologist and toxicologist Gio Batta Gori, former deputy director of the National Cancer Institute's Division of Cancer Cause and Prevention, calls smoking bans "odious and socially unfair" prohibitions based on "bogus" science and "dangerous, wanton conjectures." Gori says that many of the secondhand smoke studies the Surgeon General uses to claim secondhand smoke life risk fail to control for important confounding variables, are based merely on "brief phone interviews", and assume that people always tell the truth about their smoking histories. Gori further warns that the results of these secondhand smoke studies are inconsistent:
"In addition, results are not consistently reproducible. The majority of studies do not report a statistically significant change in risk from secondhand smoke exposure, some studies show an increase in risk, and ¿ astoundingly ¿ some show a reduction of risk."
http://www.washingtonpost.com/wp-dyn/content/article/2007/01/29/AR2007012901158_pf.html
As a bar patron who very much enjoys a smoke with his beer, Gori makes my loss of freedom due to smoking bans feel unnecessary.
Dr. James Enstrom has very ably defended his ETS research against the attacks of Stanton Glanz and the American Cancer Society. His big ETS cohort study certainly deserves a closer look than most journalists and public health officials have given it.
http://www.scientificintegrityinstitute.org/defense.html
Posted by: Bill Hannegan | July 17, 2007 1:48 AM
Julia -
I used to smoke hand-rolled - and if people smoked normal cigarettes in my college room, I'd know about it for the next couple of days, despite the fact that I was smoking.
Although I can understand workplace/office smoking bans, my main problem with banning smoking in pubs (and, amazingly, private members clubs) is that in many pubs, the majority will be smokers; there is a big correlation between 'people who smoke' and 'people who go to pubs a lot'. I get the impression that the kind of people pushing for bans are the ones who go to bars and pubs only occasionally. After all, if the majority of bar patrons were annoyed by smoking, there would already have been a lot of non-smoking bars.. or much better ventilation.
Posted by: Andrew Dodds | July 17, 2007 3:43 AM
Speaking as someone who has never smoked, I agree that the push for smoking bans oft has gone past the point of keeping the air clean for us non-smokers, becoming instead a moral crusade. I'm glad the inside dining area of restaurants are now smoke-free. But smokers are people, too. They should be free to light up in outside areas and tobacco stores.
Posted by: Russell | July 17, 2007 10:57 AM
Just to throw a wrench in things:
"Although I can understand workplace/office smoking bans"
then
"my main problem with banning smoking in pubs (and, amazingly, private members clubs) is that in many pubs"
Pubs/clubs are workplaces for the people that work there.
"A ban on smoking at beaches and in town makes perfect sense to me."
This is rather silly. Gas's dissipate so quickly I can't imagine that, unless someone is right next to you blowing smoke in your direction, that smoking in a large open area is any sport of problem.
Banning smoking due to health effects is a relatively good idea depending on the circumstances. However banning smoking because you find it unagreeable is simply unacceptable. If everyone could restrict another person from doing things that they found bothersome, nobody would be able to do anything.
Obnoxious , self-righteous, whining little fucks. My biggest fear is that if I quit smoking, I'll become on of you...Don't take that wrong. I have something to tell you non-smokers that I know for a fact that you don't know, and I feel it's my duty to pass on information at all times. Ready?.......Non-smokers die every day...Enjoy your evening. See, I know that you entertain this eternal life fantasy because you've chosen not to smoke, but let me be the 1st to POP that bubble and bring you hurtling back to reality....You're dead too.
- Bill Hicks
Posted by: apy | July 17, 2007 11:21 AM
I still think it kind of disgusting that people believe that the owners of private businesses should be forced to ban smoking, when no one is similarly forced to go to a resturant that allows smoking. The argument that "well, I don't have enough non-smoking choices" is just pathetic. No one OWES you the choices you like. If you really want something, go out and start it yourself.
The job aspect is equally pathetic. No one is owed a job by a particular resturant either. If no one wants to work in a place that allows smoking, that's tough luck for the resturant owner: he'll have to raise his wages above those that don't allow it in order to attract workers. Or, more likely, we won't, because most people DON'T GIVE A SHIT.
And that's the real issue with these sorts of things, isn't it? It can't be about giving crusaders a choice, because they no one owes them the choice of their preference. And it can't be about saving employees from hazards, because they can save themselves/choose the level of risk they desire for the pay. The issue is rather that some people don't like the choices that OTHER people make: they have it in their heads that if someone exposes themselves to a risk, they must be stopped. Not merely educated about the risk so that they can make their own choices: they must be STOPPED. That's the sort of busybody crusading I just can't stomach.
Of course, somehow that idea has never caught on in a sensible way: there are all sorts of huge risks in modern life that get virtually no attention, perhaps because they aren't flashy enough.
Posted by: plunge | July 17, 2007 11:37 AM
Before I go on, I must say I totally support the UK ban on smoking in enclosed public places, mainly for the benefit of bar staff.
However, I do think a lot of the ad-hominems aimed at smokers are extremely similar to anti-gay-rights arguments m