WHO Library Cataloguing-in-Publication Data:Protection from exposure t - PDF document

WHO Library Cataloguing-in-Publication Data:Protection from exposure to second-hand tobacco smoke.Policy recommendations.1.Tobacco smoke pollution - adverse effects.2.Tobacco smoke pollution - legislation.3.Smoking - legislation.4.Legislation,Health.5.Health policy.6.Occupational exposure - legislation.I.World Health Organization.ISBN 978 92 4 156341 3(LC/NLM classification:HD 9130.6)World Health Organization 2007All rights reserved.Publications of the World Health Organization can be obtained from WHO Press,World Health Organization,20 Avenue Appia,1211 Geneva 27,Switzerland (tel.:+41 22 791 3264;fax:+41 22 791 4857;e-mail:bookorders@who.int).Requests for permission to reproduce or translate WHO publications Ð whether for sale or for noncommercial distribution Ð shoulbe addressed to WHO Press,at the above address (fax:+41 22 791 4806;e-mail:permissions@who.int).The designations employed and the presentation of the material in this publication do not imply the expression of any opinionwhatsoever on the part of the World Health Organization concerning the legal status of any country,territory,city or area or ofits authorities,or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate borderThe mention of specific companies or of certain manufacturersÕ products does not imply that they are endorsed or recommended bythe World Health Organization in preference to others of a similar nature that are not mentioned.Errors and omissions excepted,the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publicaHowever,the published material is being distributed without warranty of any kind,either expressed or implied.The responsibilitythe interpretation and use of the material lies with the reader.In no event shall the World Health Organization be liableages arising from its use.Design and layout by EKZE (www.ekze.ch)Printed in France OMS Protecting Exposure 25/06/07 15:54 Page II OMS Protecting Exposure 25/06/07 15:54 Page B Protection from exposure to second-hand tobacco smoke. Policy recommendations. Scientific evidence has firmly established thatthere is no safe level of exposure to second-hand tobacco smoke (SHS), a pollutant thatcauses serious illnesses in adults and children.There is also indisputable evidence that imple-menting 100% smoke-free environments is theonly effective way to protect the population fromthe harmful effects of exposure to SHS.Moreover, several countries and hundreds ofsubnational and local jurisdictions have suc-cessfully implemented laws requiring indoorworkplaces and public places to be 100%smoke-free without encountering significantchallenges in enforcement. The evidence fromthese jurisdictions consistently demonstratesnot only that smoke-free environments areenforceable, but that they are popular andbecome more so following implementation.These laws have no negative impact … and oftenhave a positive one … on businesses in the hos-pitality sector and elsewhere. Their outcomes… an immediate reduction in heart attacks andrespiratory problems … also have a positiveThese experiences offer numerous, consistentlessons learnt, which policy-makers shouldconsider to ensure the successful implemen-tation of public policies that effectively protectthe population from SHS exposure. These les-sons include the following:1.Legislation that mandates smoke-freeenvironments … not voluntary policies … isnecessary to protectpublic health;2.Legislation should be simple, clear andenforceable, and comprehensive; 3.Anticipating and responding to the tobaccoindustrys opposition, often mobilizedthrough third parties, is crucial;4.Involving civil society is central to achievingeffective legislation;5.Education and consultation are necessaryto ensure smooth implementation; 6.An implementation and enforcement plan aswell as an infrastructure for enforcement areessential;and7.Implementation of smoke-free environmentsmust be monitored and, ideally, their impactmeasured and experiences documented.In light of the above experience, the WorldHealth Organization (WHO) makes the follow-ing recommendations to protect workers andthe public from exposure to SHS:1.Remove the pollutant … tobacco smoke … byimplementing 100% smoke-free environ-ments. This is the only effective strategy toreduce exposure to tobacco smoke to safelevels in indoor environments and to providean acceptable level of protection from thedangers of SHS exposure. Ventilation andsmoking areas, whether separately ventilatedfrom non-smoking areas or not, do notreduce exposure to a safe level of risk andare not recommended;2.Enact legislation requiring all indoor work-places and public places to be 100% smoke-free environments. Laws should ensure uni-versal and equal protection for all. Voluntarypolicies are not an acceptable response toprotection. Under some circumstances, theprinciple of universal, effective protection mayrequire specific quasi-outdoor and outdoorworkplaces to be smoke-free; 3.Implement and enforce the law. Passing smoke-free legislation is not enough. Its proper imple-mentation and adequate enforcement requirerelatively small but critical efforts and means.4.Implement educational strategies to reduceSHS exposure in the home, recognizing thatsmoke-free workplace legislation increasesthe likelihood that people (both smokers andnon-smokers) will voluntarily make theirhomes smoke-free.WHO encourages Member States to follow theserecommendations and apply lessons learnt toadvance the goals of public health through leg-islated implementation of 100% smoke-freeenvironments in workplaces and public places. OMS Protecting Exposure 25/06/07 15:55 Page 2 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Finally, the obligations under WHOs FrameworkConvention on Tobacco Control (WHO FCTC),to which more than 140 WHO Member Statesand the European Community are Parties, arefurther driving the need for clearer guidancefrom WHO on protection from SHS. Article 8 ofthe WHO FCTC, , requires Parties to:from exposure to At its first session in February 2006, theConference of the Parties to the WHO FCTCdecided to accord the highest priority to devel-guidelines on Article 8, and to request theConvention Secretariat to initiate work on theseguidelines. In the same decision, the Conferenceof the Parties also adopted a template for theelaboration of Article 8, which lists severalresources for the guideline development, ofwhich the present recommendations are one.In summary, these recommendations are aresponse to the unquestionable dangers ofexposure to SHS, as well as to the opportunityto assist the WHO FCTC implementationprocess and provide guidance to the growingnumber of jurisdictions interested in becomingsmoke-free. recommendations With the support of the WHO Collaborating Centreon Tobacco Control Surveillance and Evaluationat the Institute for Global Tobacco Control, JohnsHopkins Bloomberg School of Public Health, WHO convened a consultation in Montevideo,Uruguay in November 2005. Its purpose wasto gather experts to discuss the many aspectsof SHS and smoke-free environments. The con-sultation addressed the health effects of SHSexposure and the toxic properties of SHS; SHSexposures economic costs; the impact ofsmoke-free environments on tobacco consump-tion as well as business; policy developmentand implementation; and needs and availableresources for making progress towards smoke-free environments.These policy recommendations are based inpart on the deliberations of the Uruguay con-sultationand have been amplified andreviewed by a broader group of experts from allof the WHO regions and within a variety of dis-ciplines (Appendix 1 … List of participants andobservers at the expert consultation on policyrecommendations on second-hand tobaccosmoke in Montevideo, Uruguay), including theWHO Collaborating Centre on Tobacco ControlPolicy at the University of California, SanFrancisco. The recommendations aim to elucidate for WHOMember States the science on SHS exposure aswell as the health and economic benefits ofsmoke-free laws and to guide decision-makersin developing and implementing evidence-basedand enforceable smoke-free policies.SECTION II Ð THE PROBLEMHealth effects of SHS exposureSecond-hand tobacco smoke is the combinationof smoke emitted from the burning end of acigarette or other tobacco products and smokeexhaled by the smoker. SHS contains thou-sands of known chemicals, at least 250 ofwhich are known to be carcinogenic or other-wise toxic.bA territory is a geographical area distinct from a WHO Member State for which the United Nations makes no assumption regardingits political or administrative affiliation.dParticipation in the Uruguay meeting does not necessarily imply endorsement of the recommendations. OMS Protecting Exposure 25/06/07 15:55 Page 4 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Impact on childrenmaternal and paternal smoking cause lowerrespiratory tract illnesses such as bronchitisand pneumonia, particularly during the firstyear of life.Numerous surveys also showa greater frequency of the most common res-piratory symptoms … cough, phlegm andwheeze … in the children of smokers.highest levels of risk have been found in house-holds where both parents smoke.. Exposure to SHS exacerbates pre-existing asthma and causes new-onset asthmaamong children (as well as adults, as discussedabove).Exposure to SHS in the homeincreases emergency room visits and medicationuse by asthmatic children.. Since the UnitedStates Surgeon General concluded in 1986 thatSHS reduces the rate of lung function growthduring childhood, evidence has continued toaccumulate to support this conclusion.An effect has been associated both withmaternal smoking during pregnancy and withexposure to SHS after birth..SHS exposurecauses otitis media, or middle ear disease, acommon childhood illness that accounts for alarge number of visits to physicians and, ifuntreated, can lead to hearing impairment.Pre and postnatal effectsExposure of non-smoking women to SHS duringpregnancy causes low birth weight and pretermdelivery.SHS exposure also causesSudden Infant Death Syndrome (SIDS or cotOther perinatal health effects wherethere may be a link with SHS exposure areintrauterine growth retardation and sponta-abortion (miscarriage).Magnitude of exposure to SHSExposure to SHS is widespread in most coun-tries, even in health-care settings and amonghealth professionals. Data from the GlobalYouth Tobacco Survey (GYTS) indicate that SHSexposure is common among youth. Surveys ofchildren in school, aged 13 … 15 years, conductedbetween 1999 and 2006 in 132 countriesfoundthat 44% had been exposed at home and 56%in public places during the 7 days prior to thesurvey.A study of workers at Mexicos NationalInstitute of Health showed that 91% wereexposed to some degree to tobacco smoke.survey of third-year students in health profes-sional schools in 10 countries found exposureto SHS at home ranging from 30% in Ugandato 87% in Albania, and exposure in public placesfrom 53% in Uganda to 98% in Serbia.While exposure to tobacco smoke in the UnitedStates has declined substantially over the pastseveral years, studies of cotinine (a by-productof nicotine) reviewed in the 2006 United StatesSurgeon Generals Report show that more than40% of non-smoking adults and almost 60%of children aged 3 through 11 years are stillexposed to SHS.Two recent studies of a variety of settings in 39developed and developing countries found SHSin the great majority of the locations surveyed.In seven Latin American countries SHS(measured by ambient nicotine levels) wasdetected in 94% of the locations surveyed,including hospitals, schools and governmentA study comparing levels of fineparticulate matter in indoor environments,where smoking was or was not observed, con-cluded that among the 32 countries studied,only the two countries with national compre-hensive smoke-free air policies … Ireland andNew Zealand … had acceptable levels of indoorair quality.Widespread exposure translates into significanthealth consequences at the population level.For example, Cal/EPA estimates that in theUnited States SHS causes 3 400 lung cancerdisease deaths annually. In children, SHS is OMS Protecting Exposure 25/06/07 15:55 Page 6 Protection from exposure to second-hand tobacco smoke. Policy recommendations. control odour,which per se is not an indicatorof the level of toxins in the air because theselevels may be high even without a strong odourof tobacco smoke. Even higher ventilation rateswould be required to eliminate toxins, which isthe only safe option for health. These ventila-tion levels are neither physically practical noreconomically feasible. In order to eliminate thetoxins in SHS from the air, so many air exchangeswould be required that it would be impractical,uncomfortable and unaffordable.Similarly, neither central nor local air cleaningdevices can reduce the levels of toxins from SHSin indoor air to safe levels. The performance ofthese devices also usually declinesover because they require high and expensive levelsof maintenance, and they may even becomesources of indoor air pollution. The one passŽsystems advocated by the tobacco industry andits allies do not re-circulate air and thereforeare much more expensive to operate becauseoutdoor air has to be continuously heated orcooled. In any case, these systems do not reducetobaccosmoke to safe levels.Despite decades of pressure from the tobaccoindustry,the American Society of Heating,Refrigerating, and Air Conditioning Engineers(ASHRAE), the leading professional standards-setting organization in the United States onventilation, no longer provides recommendedstandards for ventilation when tobacco smokingis present. In its 2005 (ETS) position document, ASHRAE con-cludes, At present, the only means of effective-ly eliminating [the] health risk associated withindoor exposure is to ban smoking activity.ŽThe position document also states, Because ofASHRAEs mission to act for the benefit of thepublic, it encourages elimination of smokingin the indoor environment as the optimal wayto minimize ETS exposure.ŽThe International Standards Organization (ISO)is drafting a recommended standard ISO 16814on ventilation and tobacco smoke prepared byTechnical Committee ISO/TC 205 on buildingenvironment design. However, policy-makersneed to be aware that the ISO standards havebeen heavily influenced by tobacco industry lob-bying in the past.In addition, the present draftof ISO 16814, while recognizing that no realisticcombination of ventilation and filtration willprovide a reasonably safe environment wheresmoking is permitted,Žcreates the illusionthat ventilation may prevent recirculation ormovement of air from designated smoking areasinto non-smoking areas. The 2005 ASHRAE posi-tion statement, not the present draft of the ISO16814 standard, reflects the best available cur-rent scientific evidence on ventilation and SHS.One particular ventilation-based approach pro-moted by tobacco companies, and which somejurisdictions have accepted in specific settings,particularly bars and restaurants, is the imple-mentation of smoking areas separated fromnon-smoking areas by physical barriers andwith separate ventilation systems. These so-called designated smoking rooms,Ž (DSRs),with exhaust of air to the outside, isolated returnair, and negative pressurization in relation toadjoining spaces, have been designed and test-ed for the degree of protection provided. Basedon existing literature, such rooms may reducebut not eliminate the exposure to SHS insidethe DSR. In addition, DSRs do not eliminatenon-smokers exposure to second-hand smokein adjacent spaces,offer no protection toworkers required to work in them, and may alsointensify exposure of smokers to SHS, thusincreasing risks to their health.For example,the door to the designated smoking room canact as a pump moving smoke out of the roomwhen people enter and leave the room.fThe Cal/EPA used the term environmental tobacco smokeŽ (ETS) in its report. WHO prefers the terms second-hand tobacco smokeŽor involuntary smoking.Ž All three terms are synonymous. OMS Protecting Exposure 25/06/07 15:55 Page 8 Protection from exposure to second-hand tobacco smoke. Policy recommendations. there are open doors and windows or intakevents. Smoking can also be problematicinquasi-outdoorŽ environments, which arecommon in warm-climate countries and whichare much less likely to have solid structuresclearly delimiting indoor and outdoor space.Common problems include:€Smoke drifting into indoor areas from out-door smoking areas that lead directly intoindoor spaces with open doors and windows.A study in Ireland that found that exposure totobacco smoke had decreased significantlyamong hospitality sector workers followingimplementation of Irelands smoke-free lawalso discovered that bars with designated out-door smoking areas had significantly higherconcentrations of ambient nicotine than thosewithout outdoor smoking areas.€Difficulty in distinguishing between indoor andoutdoor spaces for purposes of implementa-tion and enforcement.For example,business owners may build covered patios,partially enclosed tents or similar spaces tocircumvent indoor smoking restrictions.€Allowing smoking in quasi-outdoor areaswhere people have to work may expose themto significant levels of SHS and unaccept-able risks to health. Under some conditions,levels of exposure may be comparable tothose indoors.Experience in New South Wales, Australia,demonstrates the types of difficulties that maybe encountered with quasi-outdoorŽ areas. Itscurrent law allows smoking in outdoor areas,which are defined as maximum 75% enclosed.ŽAs a result, many businesses are building out-doorŽ seating areas, such as the one illustratedUniversal effective protection from SHS maytherefore require making certain outdoor orquasi-outdoor areas smoke-free, with workershealth, equity and enforceability being the key considerations. At the very least, these areasshould not be specifically designated as smok-ing areas, which will make it simpler to dealwith them when, after indoor areas have been smoke-free for long enough, the publicdemands that the adjacent outdoor areas besmoke-free.Effects of smoke-free environmentsSmoke-free environments drastically reducetoxins in the air and are associated withmeasurablerapid increases in health amongworkers previously exposed to SHS.Immediate drops in pollution levels In Irish bars, levels of fine particles in the air), which reach deep into the lung anddamage the lung and heart, dropped by 83%following the implementation of the smoke-freelaw. Nicotine in the air also fell by 83% and themedian time per week of exposure to SHSreported by workers fell from 30 hours to 0hours.This reduced exposure to SHS led to loweramounts of the toxins in the smoke appearingin the bodies of non-smoking hospitality work-ers. Carbon monoxide in the breath of barworkers was also measured and was found tohave decreased by 45% among non-smokersand by 36% among ex-smokers.concentrations in saliva, which indicate thelevel of smoke toxins people absorb into theirbodies from the SHS exposure, fell by 69% innon-smoking hospitality sector workers fol-lowing implementation of the law. Fig. 1 The outdoorŽ addition to a club in New South Wales, courtesyof OMS Protecting Exposure 25/06/07 15:55 Page 10 Protection from exposure to second-hand tobacco smoke. Policy recommendations. 11 Better worker healthSelf-reported respiratory symptoms amongIrish bar workers decreased by 16.7% one yearafter implementation of its smoke-free law.A study in California, United States showed areduction of 59% in negative respiratory symp-toms and a reduction of 78% in sensory irritationsymptoms in bartenders within eight weeksafter the implementation of the law requiringbars to be smoke-free, compared with symp-toms reported prior to the smoke-free law.In New Zealand, a 2002 study found that peopleworking in smoke-free office environmentswere less likely to report respiratory and irri-tation symptoms than hospitality workersexposed to SHS in the workplace (smoke-freebars were not implemented until DecemberIn Scotland, within three months of implement-ing smoke-free legislation in 2006, bar workersshowed significant early improvements in res-piratory symptoms, objective measures of lungfunction and systemic inflammation. Asthmaticbar workers also demonstrated reduced air-way inflammation and improved quality of life.In the United States, in the communities ofHelena, Montana and Pueblo, Colorado as wellas in the Piedmont region of Italy, the numberof hospital admissions for heart attacks (acutemyocardial infarction) dropped by an averagefollowing implementation of strongsmoke-free workplace and public place legis-lation. There was no decline in admissions insimilar communities used as controls. However,when the smoke-free law in Helena wasrepealed under tobacco industry pressure, hos-pital admissions rose to levels seen prior toimplementation of the law.Smoke-free environments are a highlyeffective smoking cessation interventionSmoke-free environments not only protect thehealth of non-smokers, they also have a bene-ficial impact on reducing smoking. The WorldBank has concluded that smoking restrictionscan reduce overall tobacco consumption by 4 …A more recent review of studies inAustralia, Canada, Germany and the UnitedStates concluded that smoke-free workplacesresult in a reduction in consumption of 29% bysmokers.The review estimated that, on aver-age, smoke-free workplaces reduce consump-tion by 3.1 cigarettes per day per smoker andreduce smoking prevalence by 3.8%. This impactis greatly attenuated when smoking is allowedin designated rooms or areas.While not required by any of the laws creatingsmoke-free environments, more people volun-tarily make their homes smoke-free when work-place and public place laws are implemented.Smoke-free homes protect workerschildrenand other family members from SHS and fur-ther increase the likelihood that the smokerswill successfully quit smoking.In fact, smoke-free environments can be morecost-effective than programmes targeted specifi-cally at smoking cessation. One study showedthat smoke-free environments are nine timesmore cost-effective per new non-smoker thanproviding smokers with free nicotine replace-ment therapy.Indeed, several countries thathave recently implemented comprehensivesmoke-free laws report declines in tobacco con-sumption (as measured by tobacco sales dataor by surveys of smoking prevalence) and/or aswitch to smokeless tobacco following theimplementation of the laws.Some havealso reported increases in call volume toquit linesŽ immediately after imple-mentation, although call volume tends to returnto normal after a few months.hStan A Glantz, personal communication of the result of a meta-analysis of the three studies. OMS Protecting Exposure 25/06/07 15:55 Page 11 Protection from exposure to second-hand tobacco smoke. Policy recommendations. 13 signs as well as educational and enforcementefforts during the initial implementation stage).However, these costs tend to decrease over timeas public acceptance of the law grows and com-pliance increases (as it usually does). In any case,the World Bank notes that the benefits of mak-ing workplaces smoke-free far outweigh thecosts.It is often argued that smoke-free environ-ments impose costs on businesses, especiallythose in the hospitality sector. In fact, evidenceshows the opposite, including for this sector. Indirect contradiction to tobacco industryworldwide studies of sales andemployment data before and after smoke-freepolicies are implemented have found either noimpact or a positive impact within the hospi-talitysector.Smoke-free policies do notdrive away existing clientele in this sector; they,in fact, attract new clientele. They also appearto result in reduced maintenanceinsurance costs as well as decreased employeeabsenteeism both for this sectorothers.Thus, the tobacco industry has apowerful incentive to oppose robust smoke-freelaws since their impact on the workplace resultsin a major reduction in cigarette consumption(Box 2).AND BEST PRACTICESSeveral countries and hundreds of subnationaland local jurisdictions have successfully imple-mented laws that require almost allworkplaces and public places to be 100%smoke-free without significant difficulties inimplementation and enforcement.These jurisdictions report immediate andconsiderable health benefits,smoke-free environments are feasible andrealistic in a variety of contexts. Their experiencealso offers a number of consistent lessons learntto facilitate passage and successful implemen-tation and enforcement of smoke-free laws.Smoke-free environments should be mandated by law,Two main approaches have been used to create100% smoke-free environments: legislation andvoluntary policies or agreements. Box 2. €...economic arguments often used by the[tobacco] industry to scare off smoking banactivity were no longer working, if indeedthey ever did. These arguments simply hadno credibility with the public, which isnt sur-prising when you consider our dire predic-tions in the past rarely came true.Ž … PhilipMorris, 1994, Cite: €If our consumers have fewer opportunitiesto enjoy our products, they will use themless frequently and the result will be anadverse impact on our bottom line.Ž … PhilipMorris, 1994 Cite:€Those who say they work under restrictionssmoked about one-and-one-quarter fewercigarettes each day than those who dont.That one-and-one-quarter per day cigarettereduction then, means nearly 7 billion fewercigarettes smoked each year because ofworkplace smoking restrictions. Thats 350million packs of cigarettes. At a dollar apack, even the lightest of workplace smok-ing restrictions is costing this industry 233million dollars a year in revenueŽ. … UnitedStates Tobacco Institute 1985, Cite: iFor example, most laws passed to date do not require hotel rooms to be smoke-free, even though cleaners and other staff arerequired to work in them. In addition, smoking rooms often feed into the same ventilation system as the rest of the hotel, meanthat workers in the hotel lobby, restaurants and other facilities will be exposed to SHS even if smoking is not permitted in thwork areas. Even when legislation requires a specific percentage of hotel rooms to be smoke-free and for smoking rooms to havea separate ventilation system, all of the problems associated with designated smoking areas apply. This is an issue that legislmust eventually address. OMS Protecting Exposure 25/06/07 15:55 Page 13 Protection from exposure to second-hand tobacco smoke. Policy recommendations. 15 Jurisdictions that have carried out public infor-mation campaigns preparing the public forimplementation and that have demonstratedtheir intent to enforce the law fairly but strictlyhave found that the laws quickly become self-enforcing, that compliance rates are highwithina very short time period and that theygrow over time. A recent review of compliancewith 100% smoke-free laws found typical com-pliance rates of 94% … 99%.Legislation should be simple,clear and enforceable,and comprehensive Legislation will be more successfully imple-mented and enforced if it is:SimpleThe law should avoid complicated tests todetermine when or where smoke-free settingsare required (e.g. time of day or surface of thepremise or designated smoking rooms), whichwill involve extensive and expensive enforce-ment efforts to determine compliance. It shouldsimply require all indoor workplaces, publicplaces and public transportation to be 100%smoke-free, all of the time.Clear and enforceable The law should provide clear definitions of set-tings covered by the law (such as a workplaceor enclosedŽ spaces); make clear who isresponsible for enforcing and ensuring compli-ance (e.g. designation of inspectors as well asbuilding owners and managers to ensure thelaw is obeyed on their premises); and plainlystate other requirements that smoke-freepremises are obligated to implement, includingthe removal of ashtrays from those facilitiesrequired to be smoke-free. The law should alsoestablish a clear and simple ticketing system(or spot fines) for violations, similar to parkingtickets in many countries, to avoid moreadministratively burdensome procedures likearrest and trial.The law should require strong and clear NosmokingŽ signs that feature the universal symbol(Fig. 2) at every building entrance and through-out smoke-free buildings. These signs are inex-pensive and key to effective implementationbecause they empower non-smokers to urgecompliance with the law and inform smokerswhat areas are smoke-free. The signs shouldalso contain information on how to report vio-lationsof the law. These simple signs can besupplemented or combined with more cre-ative educational signs that reinforce the mes-Comprehensive and provides universalprotectionThe law should avoid exempting certain classesof premises. If some areas (such as bars) can-not be included because of inadequate politicaland public support, simply leave them out ofthe law; do not provide for specific exemptionsthat could be interpreted as sanctioning orrequiring smoking areas. Reasonable phase-inperiods (ideally no longer than one year) forbars and similar settings may be acceptableand can even facilitate implementation. In juris-dictions where implementing smoke-free poli-cies may need to proceed incrementally for therespective settings, this intervening time period Fig. 2 The universal No smokingŽ OMS Protecting Exposure 25/06/07 15:55 Page 15 Protection from exposure to second-hand tobacco smoke. Policy recommendations. should be used to build political and public sup-port to achieve a comprehensive smoke-free lawthat includes all workplaces and publicplacesin the shortest time period possible.The law should afford protection to all. A focuson protecting vulnerableŽ or other specificpopulations and settings wrongly implies thatother populations and settings are not vulner-able and therefore do not need protection. Thetobacco industry has successfully used lawsdesigned to protect childrenŽ to secure pas-sage of ineffective legislation.will afford the most progress The question of what level of jurisdiction shouldbe used to implement smoke-free legislationis an important one, and the answer willdepend on local factors such as a countryslegal framework and traditions as well as thecountrys size. Action should be taken at anyand all levels where effective legislation canbe achieved. If strong national legislation thatmeets the standards described in these WHOrecommendations is politically feasible and canprovide an effective implementation framework,it is preferable to local laws that may only buildup protection of the entire population over along period of time. National legislation hasbeen an effective route to achieving protectionfor the greatest number of people in severalcountries. Ireland, Scotland and Uruguay, forexample, achieved national legislation withminimal municipal restrictions in place.If legislation that meets the standards describedin these WHO recommendations cannot beadvanced at the national level, then efforts canbe focused on smaller jurisdictions where effec-tive action may be possible. Precedents set atthe local level consistently stimulate similarlaws elsewhere, resulting in the synergistic ordominoŽ effect that the tobacco industry fears.Smoke-free legislation in Australia, Canada andthe United States has advanced the most at thelocal level and, more recently, at the state/provin-cial level. Initially, public health advocates didnot have the resources and political power todefeat the tobacco industry and secure passageof strong national … or even state … legislationin the United States. In these countries, it hasbeen easier to enact and enforce strong smoke-free legislation at the local level for two reasons: €Political leaders at the local level tend to bemore sensitive to the wishes of the peoplewho live in their jurisdictions than to tobaccocompany lobbyists (who are almost alwaysfrom out of town). In Canada, local medicalofficers have proven to be effective advocates,enjoying strong credibility with the public andmunicipal councils.€Public health advocates often have limitedresources (especially compared to the tobac-co industry); focusing these limited resourceson local jurisdictions one at a time increasesthe chances of success.The possibility that local laws will be pre-empted is of concern. For example, in the UnitedStates, the tobacco industry has worked con-sistently to push for ineffective and unenforce-able state or national legislation that includeslanguage prohibiting local jurisdictions fromenacting stronger legislation.As the move-ment to implement strong smoke-free lawsspreads worldwide, the tobacco industry can beexpected to aggressively promote weak pre-emptive laws (represented as a step forwardŽor reasonable compromiseŽ) in other countries.To protect strong local legislation, laws approvedat a higher jurisdictional level must not weakenit. On the contrary, where national jurisprudenceallows, all legislation should contain a provisionexplicitly giving authority to lower jurisdictions topass laws and granting precedence to any lawcontaining more restrictive or comprehensiverequirements. This is the case for some provin-cial laws in Canada that explicitly give prece-dence to stronger laws in the case of overlappingor conflicting obligations. OMS Protecting Exposure 25/06/07 15:55 Page 16 Protection from exposure to second-hand tobacco smoke. Policy recommendations. became convincedof their popularity (Fig. 3,Appendix 4, statement by Barry Vogel, thenominal head of the Beverly Hills RestaurantAssociation).It is also important for policy-makers to keep in mind the cost of exemp-tions to the law as these relate to publichealth, public perception of SHS exposuresharm, the ease of enforcement and potentiallegal actions against the law that could focuson inconsistency of application.Civil society involvement is critical to creating apolitical climate in which to successfully imple-ment 100% smoke-free laws. Civil society hasaccess to networks to which governments maynot and may have greater freedom of commu-nication, making it better positioned to debateopposition. Governments should support andfacilitate civil societys participation in develop-ing and implementing smoke-free laws. Tomaximize effectiveness, the following elementsshould be considered:€The public health community must presenta strong, consistent message, in partnershipwith a broad coalition of organizations from allsectors, in support of smoke-free legislation.€The campaign should engage one or morecommitted political or civil society championswilling to promote and engage in the issue ona long-term basis.€Governments and civil society should developa plan to facilitate support for smoke-freelaws and their implementation. However, inmany jurisdictions political opportunities arisethat greatly accelerate implementation.Therefore, governments and civil societyshould prepare for the opportunity to seizethe momentŽ and capitalize on it.€While broader coalitions can be desirable, itis not required that all public-health organi-participate, particularly if somemembers would substantially weaken themessage and political will for insisting onstrong, enforceable legislation. Organizationsshould not be pressured to join the effort ifthe cost is substantial weakening of thecoalition. Some campaigns have ended infailure due to insistence that all the majorhealth groups participate. This means thatthe effort goes at the speed of the slowestand strength of the weakest organization.The effort needs from crediblepublic voices but does not need to includeall public voices.Educate and consult to ensure smoothOne of governments critical tasks, in partner-shipwith civil society, is to raise awarenessamong the public and opinion leaders on therisks of SHS through ongoing information cam-paigns to ensure that and supportslegislative action. Broad consul-tation with stakeholders is essential to furthereducate the community and facilitate supportfor implementation of legislation. Public edu-cation campaigns can also target settings forwhich legislation is neitherfeasible nor advis-able, such as the home. Key messages should focus on the harm causedby SHS exposure in the home and in the work-place and public places, the fact that elimina-tion of smoke indoors is the only science-basedsolution, the right of all workers to be equallyprotected by law, and the fact that there is notrade-off between health and economicsbecause smoke-free environments benefit both. This educational effort should begin well beforeintroducing the legislation. An education cam-paign leading up to implementation of the lawand information packages delivered in advanceto business owners and building managersoutlining the law and their responsibilities willincrease compliance and ensure that govern-ments can counter arguments that a law was OMS Protecting Exposure 25/06/07 15:55 Page 18 Protection from exposure to second-hand tobacco smoke. Policy recommendations. SECTION V ÐRECOMMENDATIONSIn light of the deleterious health effects andthe frequency of exposure to SHS (an exposurethat carries significant social and economiccosts); the cost-effectiveness, feasibility andpopularity of smoke-free policies; and the suc-cessful experience of a rapidly growing numberof jurisdictions worldwide, WHO makes the fol-lowing recommendations to protect workersand the public from exposure to SHS.100% smoke-free environments,Second-hand tobacco smoke causes seriousand fatal diseases in adults and children. Thereis no safe level of exposure to SHS. Ventilationand health experts agree that ventilation is nota solution to this significant health issue. In2006, the United States Surgeon Generalsreport concluded (Conclusions 3 and 10 onpage 649), Establishing smoke-free work-places is the only effective way to ensure thatsecond-hand smoke exposure does not occurin the workplace. Exposure of non-smokers tosecond-hand smoke cannot be controlled by aircleaning or mechanicalair exchange.ŽUniversal protection by lawThere is no scientific basis for exempting par-ticular types of spaces or categories of thepopulation from protection; all individuals arevulnerable to the harm caused by SHS expo-sure. The critical principle bearing on universalapplication of smoke-free legislation is the pro-tection of human rights. The right to the highestattainable standard of health, the right to lifeand the right to a healthy environment are foundwithin international human rights laws andmany national constitutions. Exposure to SHSclearly hinders the exercise of these and otherfundamental rights and freedoms found withinhuman rights law.Legislation protecting all workers is necessaryto safeguard these rights. Voluntary policies areincompatible with the responsibility of govern-mentsto protect public health and are not effec-tive.Just three months after Ireland imple-mented its smoke-free legislation, 97% of pubswere smoke-free. Five years into a voluntaryagreement in the United Kingdom, less than1% of pubs were smoke-free.Proper implementation and adequate enforcement of the lawAll governments … whether in high- or low-income jurisdictions … must be prepared toinvest reasonable resources in achieving andenforcing smoke-free laws. Investment intobacco control is an explicit obligation under OMS Protecting Exposure 25/06/07 15:55 Page 20 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Leon Alevantis, MS, PE Senior Mechanical Engineer Administration - Program Support Branch Facilities Management Section California Department of Health Services MS 1401 P.O. Box 997413 Sacramento, CA 95899-7413 USAMatthew Allen Allen & Clarke Policy and RegulatorySpecialists LimitedPO Box 54 180, Mana Wellington, New ZealandCarmen Audera LópezTobacco Free InitiativeWorld Health OrganizationAvenue Appia, 1211 Geneva, SwitzerlandNigel Gray Distinguisted Fellow in CancerPrevention, VicHealth Center for TobaccoControl, Cancer Control Research Institute, The Cancer Council Victoria, Carlton Vic 3053, AustraliaPh: 61-3-9635 5185, Fax: 61-3-9635 5440Mobile: 61-409 979 269e-mail: Ron.Borland@cancervic.org.auProfessorial Fellow, School of PopulationHealth and Department of InformationSystems, The University of MelbourneTania Cavalcante National Tobacco ControlProgramme CoordinatorNational Cancer Institute of Brazil (INCA)Ministry of HealthRua dos Invalidos 212- 2nd floor20231-020-Rio de Janeiro, RJ, BrazilCarolyn DreslerHead, Tobacco ControlInternational Agency Against Cancer (IARC) 150 Cours Albert-Thomas69008 Lyon Cedex 08, FranceJulio González MolinaInternational Adviser Health PromotionPAHO/WHO Representation in UruguayAvda. Brazil 2697 2nd FloorMontevideo, UruguayCynthia HallettExecutive Director, Americans for Non-smokers Rights 2530 San Pablo Ave, Suite JBerkeley, CA 94702, USAFenton HowellDirector of Public Health Health Service Executive - NE Railway StreetNavan Meath, IrelandHead, Tobacco Control187 Granton RoadEH5 3RQ Edinburgh SCUnited KingdomProfessor and HeadFaculty of Medicine BuildingThe University of Hong Kong 21 Sassoon Road, Pokfulam, Hong Kong, SAR ChinaMark MillerOffice of Environmental Health HazardAssessment1515 Clay St, 16th FloorOakland, CA. 94612, USAYumiko Mochizuki-KobayashiDirector, Tobacco Free Initiative World Health Organization20, Avenue Appia CH-1211 Geneva,SECTION VI Ð APPENDICESList of participants and observers at the Expert Consultation on PolicyRecommendations on Second-hand Tobacco Smoke in Montevideo,Uruguay,1-3 November 2005 and additional reviewers of policy recommendations OMS Protecting Exposure 25/06/07 15:55 Page 22 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Adriana BlancoMédica, Representante IntendenciaMunicipal de Montevideo enAlianza Nacional contra el TabacoMontevideo, UruguayMédico Cardiólogo Coordinador Programa de Cesación enCAMDEL y Hospital Vidal y Fuentes Lavalleja, UruguayOsvaldo DavytMédico CardiólogoFederación Médica del InteriorAlianza Nacional para el Control del Tabaco 12 de Febrero 365, Carmelo, UruguayElba EstevesMédica Internista Integrante Policlínica Cesación de Tabaco /Hospital de ClínicasAvda. Italia s/n / P. 1Montevideo, UruguayAraceli FerrariMédico AsesorArea de Educación Poblacional de la Comisión de Lucha contra el CáncerBrandzen 1961, Of. 1104/05Montevideo, UruguayMédico Facultad de MedicinaAlianza Nacional para el Control del Tabaco /Policlínica Cesación TabaquismoAvda. Italia 3499/1006Montevideo, UruguayAna LorenzoMédico Programa Control de TabacoMinisterio de Salud PúblicaMontevideo, UruguayMédica Comisión para Control deTabaquismoSindicato Médico del UruguayBvar. Artigas 1515Montevideo, UruguayAlejandro SantiniMédico AsesorArea de Educación Poblacional de la Comisión de Lucha contra el CáncerBrandzen 1961, Of. 1104/05 Montevideo, UruguayAbogada Consultora en Control de TabacoMinisterio de Salud y AmbienteAvda. 9 de Julio 1925 P. 9Buenos Aires, ArgentinaAdditional Reviewers of the Policy RecommendationsJean-Pierre Baptiste Bureau régional de lAfriquePO Box 06Brazzaville, CongoCoordinatorWorld Health OrganizationTobacco Free Initiative20 Avenue AppiaGeneva 27, SwitzerlandAnnemieke BrandsTechnical OfficerWorld Health OrganizationTobacco Free Initiative20 Avenue AppiaGeneva 27, SwitzerlandPoonam Dhavan Technical OfficerWorld Health OrganizationTobacco Free Initiative20 Avenue AppiaGeneva 27, Switzerland OMS Protecting Exposure 25/06/07 15:55 Page 24 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Twenty years of scientific consensusMajor consensus reports on health consequences of exposure to second-hand tobacco smoke. Atlanta, The United States Department of Health and HumanServices, Centers for Disease Control and Prevention, Coordinating Center for HealthPromotion, National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health. accessed 27 March 2007). PaperCALEPA2005. (accessed 27 March 2007)Tobacco Smoke and Involuntary Smoking. IARC . Volume 83. Geneva, World Health Organization andLyon, International Agency for Research on Cancer (IARC).accessed 27 March 2007)Scientific Committee on Tobacco and Health. Secondhand Smoke:accessed 27 March 2007). Atlanta, United States Department of Health and Human Services. accessed 27 March 2007) Scientific Committee on Tobacco and Health. Services, Northern Ireland, The Scottish Office Department of Health Welsh Office. accessed 27 March 2007) OMS Protecting Exposure 25/06/07 15:55 Page 26 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Health effects associated with exposure to Second-hand Tobacco SmokeEffects causally associated with SHS exposure €Fetal growth: Low birth weight and decrease in birth weight€Sudden Infant Death Syndrome (SIDS)€Pre-term delivery €Acute lower respiratory tract infections in children (e.g. bronchitis and pneumonia)€Asthma induction and exacerbation in children and adults€Chronic respiratory symptoms in children€Eye and nasal irritation in adults€Middle-ear infections in children€Lung cancer€Nasal sinus cancer€Breast cancer in younger, primarily premenopausal women€Heart disease mortality€Acute and chronic coronary heart disease morbidity€Altered vascular propertiesEffects with suggestive evidence of a causal association with SHS exposure €Spontaneous abortion, intrauterine growth retardation€Adverse impact on cognition and behaviour€Allergic sensitization€Decreased pulmonary function growth€Adverse effects on fertility or fecundability€Elevated risk of stroke in adults€Exacerbation of cystic fibrosis€Chronic respiratory symptoms in adults€Cervical cancer€Brain cancer and lymphomas in children€Nasopharyngeal cancer€All cancers … adult and child OMS Protecting Exposure 25/06/07 15:55 Page 28 Protection from exposure to second-hand tobacco smoke. Policy recommendations. The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure from parental smoking and the onset of childhood asthma.The evidence is sufficient to infer a causal relationship between maternal smoking during pregnancy and persistent adverse effects on lung function across childhood.The evidence is sufficient to infer a causal relationship between exposure to SHS after birth and a lower level of lung function during childhood.Cancer among adults from exposure to SHSThe evidence is sufficient to infer a causal relationship between SHS exposure and lung cancer among lifetime non-smokers. This conclusion extends to all SHS exposure, regardless of location.The pooled evidence indicates a 20% to 30% increase in the risk of lung cancer from SHSexposure associated with living with a smoker.The evidence is suggestive but not sufficient to infer a causal relationship between SHS and breast cancer.The evidence is suggestive but not sufficient to infer a causal relationship between SHSexposure and a risk of nasal sinus cancer among non-smokers.Cardiovascular diseases from exposure to SHSThe evidence is sufficient to infer a causal relationship between exposure to SHS and increased risks of coronary heart disease morbidity and mortality among both Pooled relative risks from meta-analyses indicate a 25 to 30% increase in the risk of coronary heart disease from SHS exposure.The evidence is suggestive but not sufficient to infer a causal relationship between SHS exposure and an increased risk of stroke.Studies of SHS and subclinical vascular disease, particularly carotid arterial wall thickening, are suggestive but not sufficient to infer a causal relationship between SHS exposure and atherosclerosis.Respiratory effects in adults from SHS exposureThe evidence is sufficient to infer a causal relationship between SHS exposure and odour annoyance.The evidence is sufficient to infer a causal relationship between SHS exposure and nasal irritation.The evidence is suggestive but not sufficient to conclude that people with nasal allergies or a history of respiratory illnesses are more susceptible to developing nasal irritation from SHS exposure. OMS Protecting Exposure 25/06/07 15:55 Page 30 Protection from exposure to second-hand tobacco smoke. Policy recommendations. While effective smoke-free laws are popular,policy-makers must be prepared to respondto many, often-made arguments aimed at dis-their passage and implementation.These arguments generally involve ideologicalissues; challenges to science on the healtheffects of SHS exposure; proposals for alter-natives to smoke-free laws; the economic andother negative effects of smoke-free laws aswell as the feasibility of implementation andenforcement.Previous sections provide background infor-mation that can be used to refute many of thesearguments. Below are other common argu-ments not found in these sections with theirresponses.The risks of involuntarysmoking are trivial,particularly compared to other health issuesThis claim has often been made respecting lungcancer. The increase in risk for a never smokermarried to a smoker is about 20%compared tothat for a never smoker married to a neversmoker.As many scientific publications haveshown, a 20% increase in risk is substantial, bothat the individual and population levels for anexposure that is so widespread. Highly exposedindividuals, such as bar and restaurant work-ers, may have far higher risks than the popula-tion average. The risks associated with heartdisease are even larger and more immediatethan for lung cancer.The levels of toxic emissions from cigarettesare low compared to other air contaminantsOn the contrary, they are exceptionally highcompared with most other environmental andworkplace toxins.The air pollution emittedby cigarettes is 10 times greater than dieselcar exhaust.Moreover, a recent study of fineparticulate matter PMexposure in indoorsmoking and smoke-free settings in 24 countriesfound an average level of PMin locations were there was tobacco smokingcompared to 36µg/min premises wheresmoking was not observed during the moni-toring period. This level is more than 12-foldthe WHO general air quality guidelines thatrecommend maximum 24-hour mean expo-sures of 25 µg/mIn fact, workers in theUnited States exposed to tobacco smoke on aregular basis during their working life have arisk of cancer that is between 7 and 700 timeshigher than levels established as de for exposures to contaminants other thanEpidemiology, the basis for risk estimates ofexposure to SHS, is junk scienceŽUse of the pejorative term junk scienceŽ todescribe the scientific method of epidemiologycan be traced back to the tobacco industry andother industries, which are fearful of the impli-cations that epidemiological research may havefor their products. Tobacco industry documentshave left an extensive trail showing an organizedeffort to discredit it. A well-established, funda-mental science of public health, epidemiologyis the scientific method for directly gatheringinformation on the health effects of exposuresas received in natural settings. The sameapproaches employed successfully for studyingSHS have been used over decades for infec-tious diseases and for major acute and chron-ic diseases. Epidemiological evidence is thefoundation for public policy in many areas, suchas infection control and management of air andwater pollution.Smoke-free laws are unconstitutional andviolate the personal rights and liberties ofsmokers. This argument states that smoking is a person-al choice for adults and that legislation requiringsmoke-free environments victimizes and stigma-tizes smokers and sets a dangerous precedentabout the reach of the state. However, smoke-free legislation does not say that smokers can-not smoke; it only limits where smoking is permis-sible to prevent smokers from harming others. OMS Protecting Exposure 25/06/07 15:55 Page 32 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Smoke-free laws will reduce business in theThe impact of smoke-free legislation on employ-ment and business has been studied in dozensof jurisdictions. Not a single study using objec-tive data and sound research methodology hasfound an overall negative impact of smoke-freelegislation association.The effects are uni-formly neutral or positive, with little short-termeffect on the hospitality business and some pos-itive effects in the long-term as non-smokers start going to bars and other venues that theyonce avoided because of second-hand smoke. Studies quoted by opposition groups indicatingdire economic effects from smoke-free lawsnormally rely on subjective data or do not eval-uateobjective data with acceptable scientificmethods. Data may also be reported out of con-text. For example, opponents of Irelands smoke-free law noted that receipts for beer and spiritsin pubs declined following implementation ofthe law. What they failed to mention is that thistrend began before the law came into effect, anddid not worsen as a result of the law.Tobacco industry front groups have releasedmany studies presenting as data the predictionsor opinions of a select group of bar owners.These predictions always turn out to be wrong,as the tobacco industry itself has admitted(Figs. 3, 4).Some places have promoted smoke-free envi-ronments in their tourism campaigns, recog-nizing that many visitors will value the oppor-tunity to enjoy entertainment without tobaccosmoke (Fig. 5).Fig. 4Actual revenues vs tobacco industry claim Fig. 3 The Tobacco Institute ran this ad in California in the latetry. The tobacco industry repeatedly claimed that Beverlytry. The tobacco industry repeatedly claimed that Beverlynance was in effect. Figures from the State Board of OMS Protecting Exposure 25/06/07 15:55 Page 34 Protection from exposure to second-hand tobacco smoke. Policy recommendations. 35 100% smoke-free environments are notenforceable: people will not obey the laws.The reality is just the opposite. Unclear laws thatdesignate square footage or percentages fornon-smoking and smoking sections; prohibitsmoking only during certain hours in specificestablishments; or set requirements for DSRscreate confusion for institutions implementingthe law, and for employees and customers andinspectors enforcing the law.On the other hand, if the law simply requiresa certain type of institution (such as schoolsor retail establishments) to be 100% smoke-free, building managers and owners know thatthey cannot permit any smoking in their build-ing,employees and customers know that theycannot smoke in the establishment, andinspectors know immediately if an institutionis complying with the law: either someone isSmoke-free workplaces will cause smokersto smoke more in the home, thus increasingchildrens exposure to SHS.There is no evidence that smoke-free work-places will increase childrens exposure totobacco smoke at home. Indeed, a growingbody of evidence suggests that legislation ban-ning smoking in public places and workplacesleads to a reduction in smoking in the home.Smoke-free workplaces encourage smokersto quit. The reduction in smoking among adultsmeans that fewer children are likely to beexposed to smoke at home. Smoke-free work-places are associated with a greater likelihoodof workers implementing smoke-free policies Fig. 5 OMS Protecting Exposure 25/06/07 15:55 Page 35 Protection from exposure to second-hand tobacco smoke. Policy recommendations. Resources€Multiple case studiesGlobal Smokefree Partnership, accessed 27 March 2007)€BermudaTobacco Products (Public Health) Amendment Act 2005accessed 27 March 2007) or search under €California State, USA Eliminating Smoking in Bars, Taverns, and Gaming Clubs: The California Smoke-freeWorkplace Act accessed 27 March 2007).€IrelandOffice of Tobacco Control … Smoke-free workplacesaccessed 27 March 2007)Research and publications describing and evaluating the law, accessed 27 March 2007)€ItalyMinistry of Health, accessed 27 March 2007)€New ZealandMinistry of Health … Smoke-free Law home page, accessed 27 March 2007), accessed 27 March 2007)Research and publications describing and evaluating the lawaccessed 27 March 2007) €NorwayThe introduction of smoke-free hospitality venues in Norway. Impact on revenues, frequencyof patronage, satisfaction and compliance. The Norwegian Institute for Alcohol and DrugResearch (SIRUS) (accessed 27 March 2007) OMS Protecting Exposure 25/06/07 15:55 Page 36 Protection from exposure to second-hand tobacco smoke. Policy recommendations. €Countering the oppositionAmericans for Non-smokers Rights (ANR) What to expect from the tobacco industry,November 2004. (accessed 27 March 2007)Tobacco Scam (focus on restaurants and bars), accessed 27 March 2007)Lifting the smokescreen: Tobacco industry strategy to defeat smoke-free policies and legislation (companion to the smoke-free Europe report, cited below), accessed 27 March 2007)€VentilationAmerican Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc.Environmental Tobacco Smoke. Position Paper. Approved by ASHRAE Board of Directors 30June 2005. Available at:accessed 27 March 2007)Ontario Coalition for Action on Tobacco (OCAT) … facts on designated smoking rooms, accessed 27 March 2007)€Package warningsPan American Health Organization (WHO Regional Office of the Americas)€GeneralTobacco Control Legal Symposium (TCLS), Legal Authority to Regulate Smoking andCommon Threats and Challenges, accessed 27 March 2007)Lifting the smokescreen: 10 reasons for a smoke-free Europe, accessed 27 March 2007)Smoke free Europe makes economic sense: A report on the economic aspects of Smokefree policies by the Smoke Free Europe partnership. May 2005., accessed 27 March 2007)Enacting strong smoke-free laws. The advocates guide to legislative strategies 2006. American Cancer Society/UICC Tobacco Control Strategy Planning Guide #3 2006., accessed 27 March 2007) OMS Protecting Exposure 25/06/07 15:55 Page 38 Protection from exposure to second-hand tobacco smoke. Policy recommendations. SECTION VII Ð REFERENCESRoper Organization, Volume 1. 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