Significant medical evidence supports the upcoming smoking ban, argues Dr Muiris Houston in the first of a two-part series
Eleven months after the Minister for Health, Micheál Martin first announced a workplace ban on smoking, his initial deadline of January 1st 2004 will not now be met. But this is merely a blip; he has prevailed in a series of high-profile political battles. The reason for the delay in implementing the ban (until early March) is a combination of EU bureaucracy and a tactical decision not to finalise exemption criteria until last November. By common consent nothing will stop the ban now. The Minister has seen off the hospitality industry and some resistance from within the Fianna Fáil Party. Whatever else happens in Micheál Martin's political career, he is destined to go down in history as the politician who introduced the first national ban on smoking indoors in public places within the EU.
The publication on January 30th last of the Report on the Health Effects of Environmental Tobacco Smoke (ETS) in the Workplace gave the Minister of Health the authority with which to proceed with a ban. Put together by a range of specialists from Trinity College Dublin and University College Dublin and the Health and Safety Authority (HSA), it declared unequivocally that exposure to second-hand smoke in the environment caused cancer. It also found a link with heart disease and concluded that for pregnant women, inhaling passive smoke could result in a low-birth-weight baby.
Significantly, the expert report said: "Current ventilation technology is ineffective at removing the risk of environmental tobacco smoke to health." The experts added that future technology, in the form of displacement ventilation, would still leave exposure levels 1,500 to 2,500 times the acceptable level for hazardous health pollution.
The report also highlighted the legal implications of allowing smoke exposure among non-smoking employees. In 1997, flight attendants in the US won a $300 million settlement in a class action against airlines. A non-smoking barmaid in Australia was awarded $235,000 in 2001 for cancer caused by working for 11 years in smoky bars.
Although the ban, which will be introduced by ministerial directive, rather than by further legislation, will affect all places of employment, it was not until last summer that hoteliers and vintners mounted a campaign against it. This included a high-profile visit to New York, (where a similar ban was introduced earlier this year), in an attempt to highlight what the Irish Hospitality Industry Alliance saw as a major threat to its members' livelihoods.
However, according to Dr Fenton Howell, spokesperson for ASH Ireland, "practically every well-conducted study looking at the economic impact of such a ban shows no negative impact on business. Similar doomsday scenarios were predicted for theatres, cinemas, airlines, duty-free and newspaper advertising when smoking bans were implemented and absolutely none came to pass." An initial prevarication by the Minister for State responsible for the Health and Safety Authority, Frank Fahy, disappeared following the Taoiseach's intervention. At a regional level, the chairman of the Western Health Board, prominent publican Val Hanley, resigned in the autumn, when he felt his position as health-board leader became incompatible with his personal beliefs about the futility of a ban on smoking in pubs and restaurants. By the time Micheál Martin published a final list of exemptions in November, the hospitality supporters knew their race was run.
The places where the smoking ban exemption will now apply are: prisons, outdoor workplaces, psychiatric hospitals, hospices, nursing homes and the bedrooms of hotels and B & Bs.
The genesis of the ban on passive smoking here can be traced back five years or more when a group of Irish non-governmental organisations (NGOs) got together to lobby for legislative intervention. The Irish Cancer Society, the Irish Heart Foundation and ASH Ireland were responding to scientific research indicating that passive smoke damaged people's health. For many years, doctors had strong anecdotal evidence that people with respiratory problems such as asthma, who lived with a smoker, had more attacks than those who were not exposed to passive smoke. Now the solid evidence was there, as was a reliable method of measuring exposure to second-hand smoke.
NGOs here aligned themselves with the powerful international anti-smoking lobby. A key forum was the triennial World Conference on Tobacco or Health, a World Health Organisation-sponsored meeting of healthcare professionals and patient advocates determined to take on the tobacco industry.
By the time of the 12th World Conference on Tobacco or Health, held last August in the Finnish capital, Helsinki, the Republic was leading the race to introduce a national ban on smoking in the workplace. Although it had passed the necessary legislation, the Norwegian government has elected to wait until June 1st 2004 before implementing the total ban on smoking in pubs and restaurants.
As well as the international research and national political impetus, studies in the Republic were instrumental in reinforcing the case for a workplace ban.
For example, Maurice Mulcahy, senior environmental health officer with the Western Health Board (WHB) and Dr David Evans of the Department of Public Health, WHB, examined 123 children from three schools in the Galway area.
They took saliva samples from the children in order to measure the level of cotinine - a breakdown product of nicotine - and a widely accepted method of assessing exposure to passive smoking. The researchers assessed the level of home smoking by parents by means of a questionnaire.
Mulcahy told the Helsinki conference that children from smoking households had more than three times the cotinine concentration level than children from "smoke-free homes". Households where only a mother smoked accounted for twice the levels of those in children where only the father smoked.
"The most common location for exposure to environmental tobacco smoke were children's homes (27 per cent) and other people's homes at 13 per cent. Ten per cent of children were exposed to smoke in restaurants and 9 per cent in cars," he says.
Referring to the fact that less than half of those questioned could recall a specific exposure to smoke, even though every child showed some level of cotinine in their bodies, Mulcahy says the research indicated that passive smoking is widespread among children. "Not only is their exposure involuntary but it often goes unnoticed by them," he told the conference.
American second-hand smoke expert, Jim Repace, told a conference organised by the Office for Tobacco Control in October, of research showing that ventilation is not a solution to the problem of passive smoking in the hospitality industry. Describing research carried out by him and Maurice Mulcahy, Repace said it showed that bar staff here suffered a level of premature death equivalent to 150 deaths per year as a result of exposure to second-hand smoke. Their findings are based on a measurement of cotinine levels among bar workers in Galway, extrapolated to take account of the 26,000 full-time bar staff in the Republic. Repace said that, based on US and Irish figures, there are 840 deaths here every year attributable to the harmful effects of passive smoke.
Looking ahead, the scientific and medical community are by no means set to rest on their laurels. Earlier this month, the Office for Tobacco Control and the NGOs announced the appointment of Prof Luke Clancy as the first director general of the new Research Institute for a Tobacco-Free Society. Prof Clancy, a consultant physician at St James's Hospital and a long time anti-tobacco campaigner, says this is an opportunity for the Republic to continue tolead international smoking research. "The institute is uniquely comprehensive - covering such areas as health promotion, legislation and marketing - that it has the potential and freedom to develop a position of EU leadership."
Tomorrow, part 2: Kicking the habit
Passive or second-hand smoke - also known as Environmental Tobacco Smoke (ETS) - is made up of exhaled mainstream smoke as well as sidestream smoke emitted by the smouldering cigarette. Sidestream smoke is the principal component of ETS; it consists of both vapour and particles.
Second-hand smoke is a complex mixture of more than 4,000 compounds. Of these, 60, including arsenic, chromium and nickel, are proven or suspected carcinogens (cancer-causing agents).
ETS also contains a number of irritants that affect the upper- and lower-respiratory tracts as well as the eyes.
Carbon monoxide and nicotine are known to damage the heart and vascular system.
A number of scientific studies have suggested that sidestream smoke from the smouldering cigarette is more damaging than mainstream smoke.
The best way to measure ETS is by analysing body fluids, such as saliva, blood or urine, for the constituents of tobacco smoke. Cotinine, a breakdown product of nicotine, is the most widely-used and most reliable estimate of recent exposure to passive smoke. The method is sensitive enough to pick up differences between pre-shift and post-shift levels of smoke exposure. A 2002 New Zealand study on the exposure of hospitality workers to ETS showed that non-smoking workers in premises that allowed smoking had a greater increase in cotinine in their saliva over the course of a work shift compared with workers in smoke-free premises.
How passive smoke harms health
It causes lung cancer
It causes heart disease
It contributes to Sudden Infant Death Syndrome
It causes breathing problems in adults and children
It is associated with low-birth-weight babies
Components of ETS irritate the eyes, nose and lungs
The pet effect
Even the family pet may be harmed by second-hand smoke, according to American research.
Lung cancer is rare in dogs, with an incidence of 1 in 25,000. A 1992 study, published in the American Journal of Epidemiology, found that dogs living in smoking households had a 60 per cent increased risk of lung cancer. According to the authors, the risk was highest for dogs with short noses.
But even long-nosed dogs, such as collies and wolfhounds, are twice as likely to get nasal cancer if they live with smokers. This is thought to be because carcinogens in the smoke become trapped in their nasal passages.
Cats may be victims also. Veterinary researchers from Tufts University found a threefold increase in the risk of lymphoma cancer among cats whose owners smoked.
Lymphoma is a common cat cancer; nonetheless, the research suggests that if a cat has lived in a smoking household for five years or more, its risk of lymphoma was increased.
Pat O'Connor is 56 and has worked in the bar trade for 38 years. He joined his brother in running a bar in Co Kildare in 1961.
O'Connor has never smoked. Over six years ago, however, he noticed that every time he entered a smoky atmosphere at work, his eyes became sore and his nose began to run. He became concerned when he developed a short cough. His symptoms progressed to the point where he is now short of breath and has chest soreness, as well as eye and nasal symptoms. He left the hospitality industry three years ago.
"I try to avoid going into pubs," he says, "but recently had to, as part of attending a funeral. During that night I woke up suddenly; I felt I was going to smother. Even after taking my inhaler I could not sleep because of chest tightness."
O'Connor's voice sounds noticeably "hollow". He says this is a recent development. His quality of life is suffering: "I get very tired going to football matches and when I do the garden." He takes two inhalers, a "preventer" and a "reliever", as well as tablets to help him breath.
He is currently being investigated by a consultant respiratory physician to establish the exact trigger for his symptoms. But O'Connor himself is in no doubt: "I honestly believe 100 per cent that passive smoke is the cause of this."