Passive smoking in New Zealand: health risks and control measures

Alistair Woodward, Professor of Public Health, Wellington School of medicine; Trish Fraser, Director, Action on Smoking and Health

The New Zealand Health Report, May 1997

Passive smoking is common in New Zealand. There is evidence linking exposure to environmental tobacco smoke (ETS) with a range of health problems, including chest illnesses in children, asthma, sudden infant death syndrome, glue ear, upper respiratory tract irritation, lung cancer, and ischaemic heart disease. We estimate that annually in New Zealand passive smoking leads to at least 20 deaths and 1000 admissions to hospitals. Part 1 of the Smoke-free Environments Act 1990 was introduced to prevent the detrimental effects of smoking on the health of any nonsmoker. Since 1989, the proportion of workers exposed to tobacco smoke during working hours has reduced by almost half, but there is very little protection in private homes, restaurants, licensed premises, and workplaces other than offices. The Accident Rehabilitation and Compensation Insurance Corporation (ACC) excludes compensation for illness caused by passive smoking, which raises the potential for litigation. Ventilation measures may reduce levels of ETS indoors, but cannot provide complete protection and may be prohibitively expensive. Passive smoking means breathing tobacco smoke produced by someone else cigarette, cigar, or pipe. So-called ‘environmental tobacco smoke’ (ETS) is made up mainly of the Fumes emitted from the lit end of a cigarette, cigar, or pipe. This smoke is known as ‘sidestream smoke’, as distinct from the ‘mainstream smoke’ that is inhaled directly from a cigarette by an active smoker. Passive smoking is a health issue for several reasons. The health risks of active smoking are well known and there is no evidence of a safe lower threshold of exposure. There is now strong epidemiological and clinical evidence that passive smoking causes disease. Moreover, passive smoking is common. The purpose of this article is to summarise what is known about the risks to health from passive smoking, to describe the prevalence of exposure to ETS in New Zealand, and to review the steps that are being taken in this country to extend smokefree environments at work and in enclosed public places.

The public health problem The major public health problems linked to passive smoking are shown in Table 1. A subjective rating of the strength of the evidence is included also. This assessment is made on the basis of recent reviews of the health effects of passive smoking by agencies such as the United States Environmental Protection Agency 1 the United States Surgeon General 2 and the Australian National Health and Medical Research Council. 3 Other diseases and conditions that are associated with passive smoking, but not so strongly, include stroke, low birthweight, and respiratory tract cancers other than lung cancer. Are these associations causal? The weight of the evidence suggests strongly that passive smoking is a cause of illness. For example, of the 35 studies of childhood lower respiratory illness published up to the end of 1995, after controlling for a wide range of confounding factors, 31 reported higher rates of illness among children exposed to ETS. lt is known that ETS contains many of the same toxic agents that are

inhaled directly by active smokers. There are data from clinical studies (showing, for example, that children with asthma experience less severe symptoms when their parents reduce smoking),4 and a convincing piece of evidence for pet lovers: dogs are 60% more likely to suffer lung cancer if they come from a household that contains smokers. 5 How big is the public health problem due to passive smoking? The burden of illness maybe substantial because exposure to ETS is common and levels of exposure are frequently high. In a national New Zealand telephone survey carried out in June 1996, 57% of non-smoking adults (15 years and over) reported that they had been exposed to ETS in the previous two days. Of those in paid employment, 14% reported that smoking was permitted in their workplace, and over a third of workers said they were exposed to ETS in lunch or tea breaks (Figure 1) 6 The National Health and Medical Research Council has estimated that in Australia passive smoking causes about 9% of childhood asthma and 13% of lower respiratory tract illness in children under 18 months. 3 Passive smoking was estimated to cause more than 90 deaths each year (including 78 deaths due to ischaemic heart disease and 12 due to lung cancer), as well as 5000 admissions to hospital and direct costs of about $14 million. This estimate was a conservative one, based on ETS exposures at home only, excluding effects of passive smoking on ex-smokers, and including only illnesses where the evidence for an effect of passive smoking was regarded as very strong. If these figures are translated to New Zealand on a per capita basis, as seems reasonable since smoking rates and disease patterns are similar in the two countries, passive smoking would lead to at least 20 deaths per year, 1000 admissions to hospital, and millions of dollars of healthcare costs. An earlier New Zealand analysis, using a different approach, gave an estimate of 273 deaths per year due to passive smoking. 7 The true size of the problem is likely to fall somewhere between these figures.

Local control measures The control of passive smoking in New Zealand has been largely undertaken through the Smokefree Envimnments Act and Regulations 1990, and health promotion activities related to the Act. Part 1 of the Act, Smokefree Indoor Environments, was developed “to prevent, so far as is reasonably practicable, the detrimental effects of smoking on the health of any person who does not smoke, or who does not wish to smoke, inside any workplace or in certain public enclosed areas”.8

The Act does not cover private homes and vehicles, which are where many children and non-smoking adults are exposed to ETS. For these settings, education is the principal control measure. Public health units in Crown health enterprises, nongovenmental agencies, and primary health providers have undertaken promotion projects to encourage smoke-free homes, marae, kohanga reo, and vehicles. The message of ‘if you must smoke, smoke outside’ has also been promoted. According to Areta Koopu, then President of the Maori Women’s Welfare League, many Maori women are declaring their homes smoke-free and many rnarae are now smokefree.9 Smokefree officers are appointed by the Director-General of Health to enforce the provisions of Part I of the Act. A major component of a smokefree officer’s work is to follow up complaints relating to workplaces and certain public enclosed areas, and assist the non-compliers to comply with the Act. If there is a lack of compliance then prosecution may be undertaken by the Crown health enterprises or the Ministry of Health. In 1996, the Ministry of Health implemented a Regional Smokefree Enforcement Service for New Zealand. The Service emphasises that employers and other parties must meet their legal obligations under Part 1 of the Act.10 Since the Act was implemented in 1990, there have been no prosecutions taken against workplaces. Auckland Healthcare has taken a successful prosecution against a restaurant in 1994 for refusing to designate a smoke-free area for diners. A research report undertaken by Auckland Healthcare stated that “due to resource constraints, most activity has centred on the provision of advisory services in response to approaches from employees and employers” Results from a survey undertaken for the report indicated most offices in Auckland were smoke-free but ‘community, social and personal services’ and ‘trade, wholesale and retail’ workplaces were not.11

Discussion The Smoke-free Environments Act 1990 was associated with a fall of almost 50% in the proportion of workers exposed to tobacco smoke during working hours between 1989 and 1991, but there has been little change in the subsequent five years (Figure

1). The Act does not cover ‘workplaces’ to the same extent as ‘offices’. Offices that are shared are required to be totally smoke-free, as are all workplace areas that the public has access to, apart from the cafeteria or lunchroom, which must be at least 50% smoke-free. In contrast, employees in a non-office workplace may request only a two metre smoke-free workspace where they usually work.8 Research undertaken lay Auckland Healthcare revealed only one factory’ was actually using the two metre rule, reflecting the limitations of this part of the Act, and in particular the difficulty of implementation and enforcement.11 Enclosed public places include certain institutions, aircraft, passenger service vehicles, ships, trains, passenger lounges, waiting lounges, restaurants, and licensed premises. The Act provides a minimum cover in these areas which is generally not monitored by the employers and only comes to the attention of the authorities if there is a complaint from a member of the public oran employee. Where legislation has limited effects, other approaches may be needed, The Accident Rehabilitation and Compensation Insurance Corporation (ACC) excludes compensation for illness caused by passive smoking and the public are not prevented from taking legal action against employers and hospitality managers. Overseas, the risk of litigation has encouraged employers and hospitality managers to introduce smoke-free workplaces.12 Ventilation together with modern air-cleaning systems can reduce levels of ETS indoors, but these systems are expensive and unlikely to prevent pockets of high concentrations of ETS in areas of heavy smoking, such as bars and casinos. 13 Medical practitioners and public health workers play very important roles in prevention of illness due to passive smoking. It is important that patients with respiratory disease are given accurate information about the risks associated with exposure to ETS. It is vital that parents with young children are informed about the effects of passive smoking, and are encouraged and assisted to provide smoke-free environments for their children, Employers should be reminded about their responsibilities to meet the minimum requirements of the smoke-free legislation and encouraged to provide an entirely smoke-free environment for their workers. Health professionals can also play an important advocacy role to support successful legislation such as the Smokefree Environments Act, to point out areas where the law requires strengthening (such as non-office workplaces), and to support more comprehensive monitoring and implementation of the legislation. Table 1: Diseases and conditions most strongly associated with passive smoking and the nature and strength of the evidence (based on refgerence 1 and 3) Group

Condition

Effect

Strength of evidence 1

Children

Lower respiratory evidence

50-100% increase in children of smoking parents, most marked in children under 2 years

••••

Adults

Asthma

50% increase in young people exposed to ETS at home; severity of asthma events also increased

••••

Sudden infant death syndrome

more cot deaths in households with with ETS, especially when other risk factors present

•••

Glue ear

more common when parents smoke

••

Respiratory irritation

occurs at low levels of ETS, more marked on smokers than non-smokers, more severe effects in persons with chronic respiratory disease

•••••

Lung cancer

20-30% greater occurrence in nonsmokers married to smokers

••••

Ischaemic heart disease

people living with a smoker experience approximately 30% more major coronary events

•••

1

subjective rating, ranging from • = 'association present but causality uncertain' to • • • • • = 'overwhelming evidence, including experimental studies'

References 1. Respiratory health effects of passive smoking lung cancer and other disorders. Washington (DC); Office of Health and Environmental Assessment, Office of Research and Development, Environmental Protection Agency: 1992 Dec. EPA/600/6-90/006F 2. Surgeon General. The health consequences of involuntary smoking. Rockville (MD): Department of Health and Human Services: 1986 3. The health effects of passive smoking. The draft report of the NHMRC Working Party: November l995. Canberra: National Health and Medical Research Council; 1995.&nb/LI; 4. Murray AB, Morrison BJ. The decrease in severity of asthma in children of parents who smoke since the parents have been exposing them to less cigarette smoke. J Allergy Clin Immunol 1993; 91: 102-10. 5. Reif JS, Dunn K, Ogilvie GK, et al. Passive smoking and canine lung cancer risk. Am J Epidenriol 1992: 135: 234-9. 6. Environmental tobacco smoke study 1996. Wellington: Ministry of Health; 1996. 7. Kawachi I, Pearce N, Jackson R. Deaths from lung caucer and ischaernic heart disease due to passive smoking in New Zealand. NZ Med J 1989; 102: 33740. 8. Smokefree Environments Act 1990. Wellington. New Zealand Government.

9. Koopu A. From the community Papers of the 1994 Conference of the Healh Promotion Forum of New Zealand; 1994 Sep 21-23: Rotorua. Auckland: Health Promotion Forum of New Zealand; 1994. 10. A regional smokefree enforcement service for New Zealand. 1996/97 public health service specifications. Technical performance standard for smoke-free environments. Wellington: Mintstry of Health: 1997. 11. Keogh L Hosking J, Blewden M. The Smokefree Environments Act and the workplace; a research report for the regional public health service. Auckland: Auckland Healthcare; 1996. 12. Palm M, Young M. The impact of litigation on the proportion of Australian workplaces with smokefree policies. Tobacco Control 1991: 3: 78. 13. Jarvis M, Foulds J. Feyerabend C. Exposure to passive smoking among bar staff. Br J Addict 1992; 87: 111-3.