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Editorial
REVISTA PAULISTA DE MEDICIN AEnvironme ntal tobacco smoke e xposure
among non-smoking waite rs: me asure me nt of
e xpire d carbon monoxide le ve ls
• Vera Luiz a da Co sta e Silva
Despite the fact that to b acco use co ntinues to b e a pub lic health pro b lem in develo ped co untries, there has b een gro wth in its impact o n mo rtality pro -files in develo ping co untries. So me natio ns o f Latin Am e ric a are am o ng the se c o untrie s, highlighting Chile, Uruguay, Argentina and Brazil.1
Ho wever, it is no t o nly the smo kers who are respo nsib le fo r this situatio n, b ut also the passive smo kers, tho se who do no t smo ke b ut b re athe and live with cigare tte smo ke in clo sed spaces.
The lo ng-term effect o f expo sure to ETS - Envi-ro nmental To b aco Smo ke - has b een the target o f innumerab le studies o ver the last 20 years. Co nsis-tent epidemio lo gical evidence has been accumulated fo r an asso ciatio n b etween such expo sure and lung cancer and athero sclero tic cardio vascular disease, as well as respirato ry signs and sympto ms, amo ng o ther effects.2,3,4
This evidence has been co ntested by the to bacco industry, bo th in relatio n to its scientific co ntent,5and the actio ns that so ciety has been ado pting fo r its co n-tro l.6 Such co ntestatio n has created o bstacles to bet-ter so cial appro aches to the pro blem.
Nevertheless, the impact o f passive smo king o n the health o f the general po pulatio n has repercussio ns that require immediate actio n, because despite the lo wer relative risk o f to bacco -related diseases fo r pas-sive smo kers in relatio n to smo kers, it can be pre-sumed that the po pulatio n expo sed to ETS is greater than that directly expo sed to to bacco abuse. This im-plies a greater abso lute number o f passive smo kers, thus increasing the po pulatio n at risk o f suffering the ill effects caused by this expo sure.
Two gro ups o f passive smo kers in particular de-serve special attentio n: children, firstly, because they do no t cho o se the air they breathe, and wo rkers who are o bliged to live to gether in clo sed spaces with their smo king co lleagues and clients. A segment o f this gro up, that o f wo rkers in transpo rtatio n co mpanies, was benefited by the pro hibitio n o f smo king in Brazil-ian buses and planes, within and o utside o f Brazil (Law 9294/96 and Decrete 3157/99).
No netheless, fo r emplo yees o f bars and restau-rants, the expo sure to ETS has o nly been dealt with by making it o bligato ry to divide the space into smo k-ing and no n-smo kk-ing sectio ns. This do es no t reso lve the pro blem, especially because this divisio n is gen-erally within the same enviro nment and because res-taurants are the greatest so urce o f expo sure to envi-ro nmental po llutio n fenvi-ro m to bacco penvi-ro ducts.7 Studies made amo ng waiters and bar staff have indicated the po tential risks to their health, as well as the effective-ness o f co ntro l measures fo r ETS in these enviro n-ments.8,9
Eisner et al.,10
1998 sho wed that 74% and 77% o f the wo rkers in taverns and bars repo rted respira-to ry symprespira-to ms and muco sa irritatio n symprespira-to ms, re-spectively. These disappeared in 59% and 78% o f the cases after the pro hibitio n o f smo king in these estab-lishments, with significant impro vements in respira-to ry functio n tests. Other studies have sho wn that the frequently raised argument that such measures influ-ence the pro fitability o f bars, restaurants and even ho tels do no t appear to be co nsistent.11 Fro m co m-pariso ns o f to urist rates and ho tel receipts befo re and after measures restricting smo king in restaurants in so me American cities, there appeared no t to have been
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any negative effect o n the pro fits o f these establish-ments, with there even being an increase in to urist business.6 Finally, there is evidence that the simple separatio n into smo king and no n-smo king areas do es no t really appear to reso lve the pro blem: Brauer et al.,12 1998, using cadmium markers to evaluate the co ncentratio n o f suspended particles in restaurants, co ncluded that the average co ncentratio n o f particles in restaurants witho ut restrictio ns o n the use o f to -bacco was 70% greater than in restaurants with par-tial restrictio ns, sho wing the need fo r mo re restrictive measures. These measures, ho wever, appear to have little effect when they are the result o f vo luntary agree-ments with establishagree-ments in the secto r. Evidence fo r this was bro ught o ut in a study do ne in Australia,13 which sho wed the lo w adherence o f Australian res-taurateurs to the agreement, leading the autho rs to give co nsiderable suppo rt to the reco mmendatio n fo r a to tal pro hibitio n o f the use o f to bacco in restaurants. The result o f the Brazilian study b y Laranjeira et al.,14 pub lished in this issue o f São Paulo Medical
Jo urnal/Revista Paulista de Medicina, co rro b o rates the e vid e nc e that has b e e n ac c um ulating in the wo rld’s literature o n the sub ject. It sho ws that the average levels o f carb o n mo no xide in the air exhaled b y no n-smo king waiters after a day o f wo rk in restau-rants witho ut restrictio ns o n the use o f to b acco are 2.5 times higher than the pre-expo sure levels. This makes it clear that studies like this need to b e stimu-lated in Brazil, to evaluate the expo sure to and the magnitude o f the ill-effects o f passive smo king, and the pro b lem represented b y o ccupatio nal expo sure to ETS, thereb y giving suppo rt to pub lic po licies fo r co ntro l o f to b acco ab use. It also sho ws that o ur wait-ers and restaurant wo rkwait-ers, like tho se all o ver the wo rld, must b e pro tected b y mo re efficacio us mea-sures fo r restricting the ETS, which will o nly really b e so lved b y the to tal restrictio n o f the use o f to -b acco in clo sed enviro nments.
Ve ra Luiza da Costa e Silva, MD. PhD. Natio nal Pro grams Co o rdinato r fo r To bacco Abuse Co ntro l and Preventio n and Vigilance o f Cancer at the Instituto Nacio nal do Câncer, Ministério da Saúde, Rio de Janeiro , Brazil.
1. Co sta e Silva VL, Ko ifman S. Smo king in Latin America: a majo r public health pro blem. Rio de Janeiro : Caderno s de Saúde Pública da Esco la Nacio nal de Saúde Pública/Fio cruz 1998;14(Suppl 3):7-18.
2. Califo rnia Enviro nm e ntal Pro te c tio n Age nc y. He alth Effe c ts o f Expo sure to Enviro nmental To bacco Smo ke. Sacramento : Califo rnia Enviro nmental Pro tectio n Agency, Office o f Enviro nmental Health Hazard Assessment; 1997.
3. Law MR, Mo rris JK, Wald NJ. Enviro nmental to bacco smo ke expo sure and ischaemic heart disease: an evaluatio n o f the evidence. BMJ 1997;315:973-80.
4. Natio nal Health and Medical Research Co uncil - NHMRC. The health effects o f passive smo ke, Co mmo nwealth o f Australia. ISBN: 0 642 272700; 1997.
5. So uza Cruz. Fum o e So c ie d ad e : p e rg untas e re s p o s tas . 36p . Departamento de Co municação Empresarial; 1996.
6. Glantz SA, Charleswo rth A. To urism and Ho tel Revenues Befo re and Afte r Pas s ag e o f Sm o ke - Fre e Re s tau ran t O rd in an c e s . JAMA 1999;281(20):1911-7.
7. Scho field MJ. Smo king bans in restaurants: who is respo nsible and who needs pro tectio n? To bacco Co ntro l 1995;4:113-4.
References
8. Siegel M. Invo luntary Smo king in the Restaurant Wo rkplace: a review o f emplo yee expo sure and health effects. JAMA 1993;270(4):490-3.
9. Jarvis MJ, Fo ulds J, Feyerabend C. Sho rt Repo rt: Expo sure to passive smo king amo ng bar staff. British Jo urnal o f Addictio n 1992;87:111-3.
10. Eisner MD, Smith AK, Blanc PD. Bartenders’ Respirato ry Health After Es tab lis h m e n t o f Sm o ke - Fre e Bars an d Tave rn s . JAMA 1998;280(22):1909-14.
11. Glantz SA, Smith BA. The Effect o f Ordinances Requiring Smo ke-Free Restaurants o n Restaurants Sales. American Jo urnal o f Public Health 1994;84(7):1081-5.
12. Braue r M, Manne tje A. Re s taurant Sm o king Re s tric tio ns and Enviro nmental To bacco Smo ke Expo sure. Jo urnal o f Public Health 1998;88(12):1834-6.
13. Jo nes K, Wakefield M, Turnb ull DA. Attitudes and experiences o f restaurateurs regarding smo king b ans in Adelaide, So uth Australia. To b acco Co ntro l 1999;8:62-6.
14. Laranjeira R, Pillo n S, Dunn J. Enviro nmental to bacco smo ke expo sure am o ng no n- s m o king waite rs : m e as ure m e nt o f e xp ire d c arb o n mo no xide levels. São Paulo Med J/Rev Paul Med 2000;118(4)89-92.
