The right of smokers to smoke ends where their behaviour affects the health and well-being of others.
C. Everett Koop, Surgeon General, 1982-1989
The discussion above has looked at the risk of smoking to smokers but arguably the greatest success that the anti-tobacco industry has secured has been in making the risk of smoking at least as important to non-smokers as it is to smokers. The point at which this happened is perhaps easiest to link to the third “World Conference on Tobacco and Health”, held in New York in 1975 where among the conclusions of the conference was one which stated “Passive smokers should be investigated in a large scale study to determine if excess morbidity and/or mortality occur”.
The first paper to suggest an increased risk to non-smokers from smokers was published in 1981, Hirayama’s “Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan”. The research suggested that wives of heavy smokers had a higher risk of developing lung cancer, and that the risk was dose-responsive. The relative risk of lung cancer was 1.61 for wives whose husbands were ex-smokers or smoked less than 20 cigarettes a day and 2.1 where husbands smoked more than 20 a day. Although there was statistical significance to the result, it is also the case that the spouses were self-certified as non-smokers. Given the societal views of female smoking in Japan, this was not necessarily the case.
Further papers followed over the years and by 1986 the Surgeon General’s specific report on the risks of passive smoking stated that
- Involuntary smoking is a cause of disease, including lung cancer, in healthy non-smokers.
- The children of parents who smoke compared with the children of non-smoking parents have an increased frequency of respiratory infections, increased respiratory symptoms, and slightly smaller rates in increase in lung function as the lung matures.
- The simple separation of smokers and nonsmokers within the same air space may reduce, but does not eliminate, the exposure of nonsmokers to environmental tobacco smoke.
The risks of second hand smoke increased greatly over the following 20 years as by the 2006 report the Surgeon General included as a major conclusion “There is no risk-free level of exposure to secondhand smoke”.
In the intervening period WHO had conducted a study of Environmental Tobacco Smoke and lung cancer in Europe. It was a case control study with a large sample size (650 patients with lung cancer and 1,542 controls) conducted over 12 centres in seven European countries over a period of seven years. The study was one of the largest ever undertaken and, unlike many before and since, well designed. Unfortunately for the anti-smoking campaign it concluded that
- ETS exposure during childhood was not associated with an increased risk of lung cancer (odds ratio for ever exposure 0.78; 95% confidence interval 0.64-0.96)
- The odds ratio for spousal exposure to ETS was 1.16, with a 95% confidence interval of 0.93-1.44. There was no clear dose-response relationship for cumulative exposure.
- The odds ratio for workplace ETS was 1.17, with a 95% confidence interval of 0.94-1.45, with weak evidence of increasing risk for increasing duration of exposure but no detectable risk after cessation of exposure.
Even a basic knowledge of statistics (or vague memories of undergraduate degrees) will allow the reader to understand that a confidence interval which includes 1.0, as the spousal and workplace exposures did, suggests no statistically significant increase in risk. Moreover the generally accepted measure of relative risk being established starts at 2.0x (and often 3.0x). Despite this ASH still cites this study as evidence that passive smoking is a risk to non-smokers. And of course we should stress again that these are relative risks, i.e. an increase over the very, very small (but not zero) risk that a non-smoker faces of ever developing lung cancer in the first place.
As an aside, on Desert Island Discs in 2001 Richard Doll, otherwise the doyen of the anti-smoking movement, raised the ire of his supporters by stating “The effects of other people smoking in my presence is so small it doesn’t worry me”. Given he had dedicated much of his research career to the study of risks associated with smoking, that seems a fairly clear message.
The widespread introduction of restrictions on smoking in “public places” has been based on the argument that second-hand smoke was a risk to non-smokers, and in particular to workers in the hospitality industry. ASH has written at length about how it sought to “lever political action by Government” when the Government was committed to an alternative approach. In its own words the review of the levering by ASH highlights:
- that its key message was “everyone has a right to a smokefree workplace”
- it designed its public polling to show public support for the answer it was seeking
- it sought to circumvent Government opposition to its proposal
- once draft legislation was introduced which would have provided an exemption for wet-led pubs and private members’ clubs it sought to undermine the Government’s proposals and then provided detailed briefing to the media on disagreements between ministers
- it lauds the fact that the debate was “won” through use of “evidence” which proved that the argument that making pubs and bars smokefree “would damage the hospitality trade economically” was false
- its key lesson for others in Tobacco Control is the need “to create the impression of inevitable success”.
It is a remarkable document to behold. It is has also been proven woeful in its suggestion that there would be no impact on the hospitality industry. Pub closures accelerated sharply post 2007’s introduction of smoke-free legislation, before the impact of recession started to be felt. Bingo halls were devastated. The idea that there were hordes of people not using pubs because of smoking who would suddenly start using pubs has been shown to be a straw man.
Of course there is also the issue of what a ban on smoking in “public places” actually means in practice. Pubs, clubs and restaurants are not “public places” they are private enterprises which can (and do) set their own restrictions on entry. They do not employ forced labour, and employees have always had the choice not to work in the hospitality trade. This was, therefore, not about public places but private property.
Once this Rubicon has been crossed, then the next logical step is to seek to control smoking in other private places, for example in cars and then homes. Stated objectives of ASH include a desire to see smoking banned in all cars whether children are present or not; to require any film or programme which includes smoking to be preceded by an anti-smoking film whether in a cinema, on TV or on pay-to-view internet; that theatrical performances should no longer have an exemption for actors smoking in character; and to have your smoking history recorded on your death certificate. ASH explicitly states “the ban on smoking in cars carrying children provides a platform for considering a wider ban on smoking in all motor vehicles” (p44). This piecemeal approach to ever tightening regulation is invidious while the idea that to watch Casablanca I would need to sit through a state-sponsored anti-smoking message is positively Orwellian.
One final word on the role of second-hand smoke should go to Stanton Glantz, who summed up his view at the 1990 Seventh World Conference on Tobacco and Health: “the main thing the science has done on the issue of ETS, in addition to help people like me pay mortgages, is it has legitimised the concerns that people have that they don’t like cigarette smoke. And that needs to be harnessed and used … we are all on a roll and the bastards are on the run and I urge you to keep chasing them”.