Snuffing out cigarettes in the workplace is first step in curbing smoking
Snuffing out cigarettes in the workplace is first step in curbing smoking
Eliminate practice entirely — don’t accommodate
The American College of Occupational and Environmental Medicine (ACOEM) in Arling-ton Heights, IL, is taking a hard line on smoking in the workplace, urging employers and occupational health providers to eliminate it entirely instead of trying to accommodate smokers with rules limiting the use of tobacco and with engineering controls. The group’s president says the new position statement could be influential in formulating worldwide policies to curb smoking.
The position statement released recently by ACOEM notes that environmental tobacco smoke (ETS) contains numerous toxins. "Robust epidemiologic evidence implicates ETS as a cause of lung cancer and as a primary cause and a source of exacerbation of excess respiratory disease," the statement says. "There is also increasing evidence that ETS may be associated with other outcomes, including heart disease. There is currently little doubt that ETS is an important and avoidable health hazard. Unfortunately, ETS is frequently encountered in the workplace — where it is no safer than in other environments and where it presents hazards to exposed workers and others."
The statement goes on to say that employers and occupational health providers should work to eliminate smoking from the workplace completely. That is a change from the trend of recent years to discourage smoking while still trying to accommodate smokers in some way.
The group has been working to reduce ETS exposure for years, but Robert Goldberg, MD, FACOEM, a physician in San Francisco who is president of ACOEM, says the position statement is intended as a "forceful but scientifically justified" step forward.
"The goal is to eliminate workplace smoking as completely as possible," he says. "That protects nonsmokers but also acts as a spur to [people] to seek smoking cessation if they are still smoking."
While some smokers will resist such an effort to eliminate workplace smoking entirely, he says employers already were headed in that direction.
"Smokers have accepted or at least grudgingly learned to accept smaller and smaller areas where they can smoke," he says. "They’ve had to move outside the factory walls, then to only certain areas outdoors, and now more employers are saying they don’t want smoking on their property at all. We endorse that approach."
Damage from ETS entirely preventable
ACOEM submitted the position statement to the World Health Organization (WHO) in Geneva, which will be formulating an international standard on ETS. Goldberg says he’s hopeful that WHO will use the ACOEM position statement prominently. Also, ACOEM is continuing to press the Occupational Safety and Health Administration to adopt indoor air standards that would include ETS. The ACOEM position paper may be an impetus in that direction, he says.
Goldberg says ACOEM is aggressively fighting workplace ETS because it’s rarely an outcome of essential manufacturing, extraction, or service-delivery process. Unlike some other workplace hazards, ETS exposure is entirely preventable by engineering or policy means, he says.
The ACOEM position statement notes that "implementation of policies to prevent workplace ETS can be highly effective, entailing low costs and yielding primary and secondary benefits to employers and employees. ACOEM strongly supports an increase in the scope and effectiveness of policies and efforts that protect against exposure to ETS in the workplace and elsewhere. To that end, ACOEM supports voluntary, regulatory, and legislative initiatives to eliminate ETS from the workplace, including public spaces such as bars, casinos, restaurants, schools, day-care centers, and public transportation. ACOEM also encourages employers to provide employee training concerning the health hazards of ETS and offer voluntary personal smoking-cessation programs."
Goldberg says it is important for occupational health professionals to offer smoking cessation in conjunction with any smoking ban. It is not acceptable to just eliminate ETS and ignore the difficulty that smokers will experience, he says.
The U.S. surgeon general linked public smoking practices to involuntary exposure and to disease outcomes more than a decade ago. The Centers for Disease Control and Prevention (CDC) in Atlanta reported employee discomfort where smoking is permitted in workplaces and recommended a policy approach to reducing discomfort and exposure.
Some occupations are at particular risk from ETS. ACOEM cites flight attendants; food-service and hospitality workers, including restaurant and bar employees; and casino workers. Specific research shows an elevated risk in those professions, but Goldberg says many more workers are exposed in other job categories. Of indoor workers, 58 million are not protected by a smoke-free workplace policy; most (40 million) are nonsmokers.
Although the number of employees at a work site is not directly related to the difficulty of implementing a protective policy, workers in small workplaces are generally less sheltered by policy, Goldberg says.
The primary purpose of policies forbidding or restricting smoking in workplaces and other public venues is protection of nonsmokers, but Goldberg says opponents of workplace tobacco control policies spread the notion, often effectively, that workplace tobacco control advocates seek to outlaw smoking, including smoking in private homes.
"This assertion lacks both logic and supporting evidence. From a public health standpoint, workplace smoking protection policies are justified by the common good and the reduction of unnecessary involuntary exposure," the ACOEM statement says. "There is formal knowledge of risk, a population with involuntary risk in the absence of protection, and a means to prevent risk."
Smoking at work poses serious risks to others
The American Lung Association (ALA) calls cigarette smoking "the leading cause of preventable disease and death in the United States." It is a major cause of emphysema, chronic bronchitis, lung cancer, and heart disease. Cigarette smoking also increases the total exposure to harmful chemicals that workers receive, says Judith Jones, an education specialist with the ALA.
Smoking can act in combination with workplace chemicals to raise the level of damaging health effects. In addition, harmful health effects can occur from smoking a cigarette contaminated with chemicals or other substances used or produced on the job. Nonsmokers also may develop health problems from breathing in smoke from co-workers’ cigarettes.
The most dramatic example of greater health damage resulting from "combined" exposures involves smoking and asbestos, Jones says. ALA research indicates that asbestos workers who smoke more than a pack a day have up to 90 times the chance of dying of lung cancer compared with workers who neither smoke nor work with asbestos. Another substance that appears to act in combination with tobacco smoke is chloromethyl ether.
Workplace chemicals and cigarettes
In addition, workplace chemicals can enter the body when contaminated cigarettes are smoked. As a person holds and smokes a cigarette, toxic substances may enter the body when he or she inhales through the mouth or may be absorbed by the skin. Examples include dusts, lead, mercury, and formaldehyde. Additionally, pesticides used to treat tobacco plants can enter the body and become absorbed when smoked. The National Institute for Occupational Safety and Health recommends that cigarettes not be kept on a person in the work area and that if employees must smoke, they should wash their hands before smoking.
In addition, burning tobacco can transform workplace chemicals into more toxic substances, according to the ALA. Polymer fume fever, for example, is caused by breathing fumes generated from heated teflon. The fumes can lead to permanent lung damage. Polymer fumes can enter the lungs as a worker smokes cigarettes contaminated by the work process or by contact with the worker’s hands. Another example of "heat-generated" transformation is the conversion of chlorinated hydrocarbons, such as trichloroethylene, into highly toxic phosgene gas.
The ALA also says workers who smoke have twice the accident rate of nonsmokers on the job. Possible reasons include loss of attention, hands busy with the activity of smoking, irritation of the eyes, and coughing. Higher carbon monoxide levels caused by smoking may lower alertness and reflex speed. Smoking can contribute to fires and explosions in occupational settings where flammable and explosive chemicals are used.
Goldberg says representatives of organized labor do not oppose workplace policies preventing exposure to ETS, since the workers they represent are the primary beneficiaries of such policies. He suggests that occupational health providers engage labor representatives to help in formulating a smoking policy.
Work-site smoking cessation policies can be very effective in reducing or preventing ETS exposure, Goldberg says. One major bonus is that an effective policy leads to the perception that smoking is socially inappropriate in workplaces.
Goldberg says that when California prohibited smoking in restaurants and bars in 1998, there was a marked decrease in ETS exposure from a median of 25 hours per week before legislation to 2 hours per week after legislation. With the decrease in exposure came substantial concomitant decreases in a number of respiratory symptoms and improved pulmonary function.
It’s not enough, however, to put a policy in place if the employer does not enforce it. Some workers report exposure to ETS even where policies exist, suggesting that the nature of policies and their enforcement are as important as their mere presence, Goldberg says. Some policies are simply ineffective, he adds.
Simple separation of smoking and nonsmoking indoor workers fails to prevent involuntary exposure to ETS, he says. Nonsmokers working in a workplace with a "work-area only" smoking restriction are more likely to be exposed to ETS than those working in a completely smoke-free workplace.
"Designated smoking areas do not work well to protect nonsmokers; total bans work more effectively by increasing awareness of policy," the ACOEM position statement says. "In work areas where no policy prohibited work-area smoking, nonsmokers were more than eight times more likely to be exposed to ETS than those who worked in smoke-free work sites. Among variables measured, only increasingly strict policies correlate meaningfully with prevention of exposure to ETS at work and decreased smoking at work."
In contrast to the voluntary actions of some private employers, most state governments take minimal steps to protect workers from ETS, ACOEM reports. While 46 states and the District of Columbia have restricted smoking at work to some extent, only 20 restrict smoking in private work sites, and 30 restrict smoking in restaurants. In many cases, the smoking restrictions are partial, permitting smoking in designated areas or exempting work sites with a minimum number of employees. In general, federal employees are better protected than private-sector employees or consumers who visit workplaces.
The ACOEM position statement also points out that employers have strong economic incentives for rapid adoption of smoke-free workplaces. The costs associated with the development and implementation of policies preventing work site and public exposure to ETS are far less than the resulting economic gains, ACOEM says. Economic benefits include increased productivity and decreased time invested in smoking behaviors.
"An additional economic incentive may be the wish to avoid the costs of litigation based on claims of employer liability for occupational exposures to ETS, an area of case law that has been accumulating since the 1970s," the statement says. "Workplace-smoking bans limit that risk."
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