CONTENTS

2 Introduction

2 Secondhand Smoke Causes Death and Disease

3 Nine Out of Ten Minnesotans Agree: Secondhand Smoke Harms Adults

3 Nearly All Minnesotans Agree: Secondhand Smoke Harms Children

4 Secondhand Smoke is Annoying—Even to Many Smokers

4 Smoking Restrictions Help Many Smokers Cut Down

5 Not All Minnesotans Are Protected from Secondhand Smoke at Work

6 Two-Thirds of Minnesota Households Have a Smoking Ban

6 Many Children Are at Risk at Home

7 Nearly All Young People Agree: Secondhand Smoke is Harmful

7 Most Youth are Exposed to Secondhand Smoke—Many Repeatedly

7 Youth Living with Smokers Are at Greater Risk

8 Appendix A: Methods

9 Appendix B: Who Was Surveyed

11 Acknowledgements/For Further Information

12 Collaborating Organizations/References

Secondhand SmokeKnowledge, Att i tudes , and Behaviors of Minnesotans

November 2000

2

Secondhand Smoke: Knowledge, Attitudes, andBehaviors of Minnesotans is the first in a series ofcollaborative research reports from the MinnesotaPartnership for Action Against Tobacco (MPAAT),Blue Cross and Blue Shield of Minnesota, and theMinnesota Department of Health. These threeorganizations conducted surveys of youth and adultsin Minnesota, the results of which are reported here.The Minnesota Smoke-Free Coalition also con-tributed significantly to this report.

Our objective is to provide scientifically valid,Minnesota-specific data on knowledge, attitudes,and behaviors to support policy development, advo-cacy, and program planning. Our overarching goalsare to help current smokers quit, to prevent newsmokers from starting, and to protect all peoplefrom secondhand smoke.

This report provides information on secondhandsmoke for four groups of Minnesotans: the generalpopulation of adults, adult members of the BlueCross MinnesotaCare program, adult membersunder age 65 of the Blue Cross Prepaid Medical

Assistance Program (PMAP), and 6th-12th grade pub-lic school students. MinnesotaCare is a uniquehealth insurance program subsidized by the stategovernment for low-income employed persons.PMAP is a Medicaid managed care program paid forby the state and federal governments. (See AppendixB for more information about the groups surveyed.)

Blue Cross PMAP and Blue Cross MinnesotaCareresults will be of special interest because low-incomepopulations have a high smoking rate and face dis-proportionate damage from tobacco use. Theseresults are also of interest to stakeholders involved inthese programs, including: the MinnesotaDepartment of Human Services, state legislators,health plans, county contractors, providers, and pro-gram members. Although these populations aresmall compared to the state’s population, findingsshow that these groups have higher smoking rates,are less often protected by smoke-free policies, andmore often have children exposed to tobacco smokein their homes.

Secondhand smoke, also referred to as environ-mental tobacco smoke, is a complex mixture ofchemicals from smoke exhaled by a smoker andfrom a lit tobacco product (cigarette, cigar, orpipe). Secondhand smoke contains thousands ofchemicals, including more than 50 known cancer-causing agents and 200 known poisons.

Numerous studies have confirmed that expo-sure to secondhand smoke causes many seriousillnesses in nonsmokers, including heart disease,respiratory problems, low birth weight, and suddeninfant death. Secondhand smoke is estimated to beresponsible for 3,000 deaths from lung cancer peryear among nonsmokers in the United States.

Secondhand smoke accounts for up to 62,000heart disease deaths annually in the U.S.

U.S. Surgeon General David Satcher, M.D.,Ph.D., states that the public health burden causedby secondhand smoke “more than justifies publicpolicies creating smoke-free workplaces and publicareas.” The latest report from the U.S. SurgeonGeneral on reducing tobacco use states that “moststate and local laws for clean indoor air reduce butdo not eliminate nonsmokers’ exposure to ETS;smoking bans are the most effective method forreducing ETS exposure . . . Optimal protection ofnonsmokers and smokers requires a smoke-freeenvironment.” (See page 12 for references.)

SECONDHAND SMOKE CAUSES DEATH AND DISEASE

INTRODUCTION

3

NINE OUT OF TEN MINNESOTANS AGREE: SECONDHAND SMOKE HARMS ADULTS

Three million Minnesotans—89% of the adult pop-ulation—believed that secondhand smoke is harmfulto adults. Even three-quarters of current smokersagreed.

There was no difference in this belief betweenpeople who live in the seven-county metropolitanarea and Greater Minnesota, and there was no consis-tent difference by age. Women (93%) were morelikely than men (85%) to state that secondhandsmoke is harmful to adults. College graduates (93%)were more likely than people with fewer years of for-mal education to believe that secondhand smokeharms adults (for example, 85% of those who havenot completed high school agreed).

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACAREFindings for the Blue Cross PMAP and Blue CrossMinnesotaCare samples were approximately thesame as the statewide sample.

Even more Minnesotans—95% of the state’s adultpopulation (3.2 million people)—believed that sec-ondhand smoke is harmful to children. Almost allMinnesotans believed this, regardless of whether ornot they smoke. This awareness did not substantiallyvary by region of the state, gender, level of educa-tion, or age.

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACAREThis high level of awareness also existed among theBlue Cross PMAP and Blue Cross MinnesotaCarepopulations.

NEARLY ALL MINNESOTANS AGREE: SECONDHAND SMOKE HARMS CHILDREN

Figure 1—Minnesotans who agree thatsecondhand smoke is harmful to adults

Figure 2—Minnesotans who agree thatsecondhand smoke is harmful to children

CurrentSmokers

NeverSmokers

FormerSmokers

93% 96% 96%

0%

20%

40%

60%

80%95%

AllMinnesotans

100%

CurrentSmokers

NeverSmokers

FormerSmokers

78%

89%94%

0%

20%

40%

60%

80% 89%

AllMinnesotans

100%

4

In addition to understanding that secondhandsmoke harms the health of adults and children,overall, eight of ten Minnesotans—nearly 2.8 mil-lion adults—stated that smoke from other people’scigarettes annoys them. Just over half of currentsmokers (52%) found secondhand smoke annoying.

Annoyance with secondhand smoke did not dif-fer between people who live in the seven-countymetro area and those who live in Greater Minnesota.A greater percentage of women (85%) than men(77%) said that secondhand smoke annoys them.Almost 90% of college graduates, as compared toabout 70% of those with less than a high schooleducation, expressed annoyance with secondhandsmoke. Twenty-five to thirty-four-year-olds were themost likely of any age group to find secondhandsmoke annoying (85%).

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACARE

Findings for the Blue Cross PMAP and Blue CrossMinnesotaCare samples were similar to the statewidesample.

Figure 3—Minnesotans who agree thatsecondhand smoke is annoying

SECONDHAND SMOKE IS ANNOYING—EVEN TO MANY SMOKERS

Restrictions in public settings, school settings, andthe workplace have helped an estimated 310,000adult Minnesotans to reduce their smoking.

Public SettingsAlmost 40% of adult Minnesotans who currentlysmoke (250,000 people) reported having reducedtheir smoking due to restrictions in public settings,such as indoor shopping malls and restaurants.

School Settings (Including Training Facilities)Statewide, one-third of adults who currentlysmoke said that they reduced their smoking dueto restrictions at educational settings.

WorkplaceOne-quarter of Minnesotans who currentlysmoke and work outside their homes reportedhaving reduced smoking due to restrictions in theworkplace.

In addition, 20% of Minnesota adults who currentlysmoke reported that smoking bans inside the homehave encouraged them to smoke less.

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACAREBlue Cross PMAP and Blue Cross MinnesotaCaremembers were as motivated as Minnesotans overallto cut back on smoking due to restrictions in publicsettings. Compared to Minnesotans overall, about halfof Blue Cross PMAP (49%) and Blue CrossMinnesotaCare (51%) members reduced smokingdue to restrictions in school settings. In the work-place, approximately one-third of Blue Cross PMAP(31%) and Blue Cross MinnesotaCare (20%) mem-bers reduced due to smoking restrictions.

SMOKING RESTRICTIONS HELP MANY SMOKERS CUT DOWN

Figure 4—Minnesotans who smoked lessdue to smoking restrictions

CurrentSmokers

NeverSmokers

FormerSmokers

52%

81%

93%

0%

20%

40%

60%

80%81%

AllMinnesotans

100%

In School At HomeAt Work

35%27%

20%

0%

20%

40%

60%

80%

38%

In PublicSettings

100%

5

Smoke-free Policy ProtectionApproximately two-thirds (64%) of the state’semployed population reported that their workplacehas a policy that does not allow smoking at all in thebuilding. The remaining one-third, or approximately800,000 Minnesotans, indicated that they either donot have an official workplace policy or have a policythat does not completely eliminate exposure to sec-ondhand smoke.

Policies Protect Workers from SecondhandSmoke ExposureOnly one in ten Minnesotans protected by a smoke-free worksite policy reported that smoking occurs inthe building. In contrast, of workers employed inworkplaces without a smoke-free policy, eight of tenreported that smoking occurs in their building, result-ing in a much greater chance for exposure to second-hand smoke.

Men, cigarette smokers, and those who have notgraduated from college were more likely to work inplaces without smoke-free policies.

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACARESeventy-one percent of Blue Cross PMAP membersand 82% of Blue Cross MinnesotaCare memberswere employed. Compared to the state overall, amuch higher proportion of Blue Cross PMAP andBlue Cross MinnesotaCare workers reported risk ofexposure to secondhand smoke in the workplace.Only 49% of Blue Cross PMAP and 39% of BlueCross MinnesotaCare wage-earners indicated havingsmoke-free policies restricting all indoor smoking.Similar to the state overall, Blue Cross PMAP andBlue Cross MinnesotaCare workers who are men,cigarette smokers, and who have not graduated fromcollege, were more likely to work in places withoutsmoke-free policies.

NOT ALL MINNESOTANS ARE PROTECTED FROM SECONDHAND SMOKE AT WORK

Figure 5—Worksite smokingpolicies in Minnesota

Figure 6—Worksite smoking policiesfor Blue Cross PMAP members

Figure 7—Worksite smoking policiesfor Blue Cross MinnesotaCare members

No Smoke-freePolicy 36%

Smoke-freePolicy 64%

No Smoke-freePolicy 51%

Smoke-freePolicy 49%

No Smoke-freePolicy 61%

Smoke-freePolicy 39%

6

Note: This section describes any type of smoking inMinnesota households—cigarette, pipe, or cigar smok-ing by any household member. The survey found thata smoker lives in approximately one-third ofMinnesota households.

Two-thirds of all Minnesota households havebanned indoor smoking, regardless of whether ornot a smoker lives there. Even 40% of householdswith a smoker have limited their exposure tosecondhand smoke by banning indoor smoking.

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACARE

Note: A smoker lives in almost half (48%) of BlueCross MinnesotaCare households and almost two-thirds (61%) of PMAP households.

Approximately half of Blue Cross MinnesotaCare(53%) and Blue Cross PMAP (48%) householdsstated that they did not allow smoking inside thehome.

Note: The survey found that 40% of all Minnesotahouseholds have at least one child under age 18 livingat home.

Seventy percent of households with children havebanned smoking in the home, although in house-holds where both children and a smoker reside, only47% have banned smoking. This leaves children atrisk for secondhand smoke exposure at home in53% of households with both smokers and children.

BLUE CROSS PMAP AND BLUE CROSS MINNESOTACARE

Note: Sixty-nine percent of Blue Cross MinnesotaCareand 80% of Blue Cross PMAP households reportedhaving at least one child under age 18 living in thehousehold.

In each of the Blue Cross publicly insured popula-tions, less members’ homes have banned indoorsmoking when both a tobacco smoker and a childlive there.

TWO-THIRDS OF MINNESOTA HOUSEHOLDS HAVE A SMOKING BAN

Figure 9—Smoking bans inhouseholds with smokers and children

Households with smokersand children under 18

47%

29% 30%

Minnesota

Blue Cross MinnesotaCare

Blue Cross PMAP

0%

20%

40%

60%

80%

100%

Figure 8—Smoking bansin households

All Households

66%

53%48%

Minnesota

Blue Cross MinnesotaCare

Blue Cross PMAP

0%

20%

40%

60%

80%

100%

MANY CHILDREN ARE AT RISK AT HOME

7

The Minnesota Youth Tobacco Survey (MYTS),conducted by the Minnesota Department of Health,found that Minnesota’s youth share the same beliefsas adults about secondhand smoke—93% of 6th-12th

grade students agreed that “smoke from other peo-ple’s cigarettes is harmful to you.” Current smokerswere almost as likely as nonsmokers to agree withthis statement.

NEARLY ALL YOUNG PEOPLE AGREE: SECONDHAND SMOKE IS HARMFUL

MOST YOUTH ARE EXPOSED TO SECONDHAND SMOKE—MANY REPEATEDLY

More than half of middle school students (58%) andthree-fourths of high school students (76%) reportedthat they were exposed to secondhand smoke on oneor more days in the past week, either in a room or ina car. Most of these young people were exposed fre-quently, rather than just once or twice. Overall,one-third of middle school students (34%) and halfof high school students (49%) indicated that they

faced repeated exposure to secondhand smoke (threeor more days) during the past week.

Even nonsmoking students report breathing inother people’s smoke. Among high school students,66% of nonsmokers reported that they were exposedto secondhand smoke in the past week, and one-third nonsmokers (34%) were exposed on three ormore days in the past week.

Living with someone who smokes (a parent, sibling,or someone else) was a very important factor indetermining exposure to secondhand smoke amongyouth, especially for younger middle school students

and nonsmokers. Middle school students living withat least one smoker were nearly six times more likelythan students living without any smokers to face re-peated exposure to secondhand smoke (67% to 12%).

YOUTH LIVING WITH SMOKERS ARE AT GREATER RISK

Figure 10—Middle school studentsrepeatedly exposed to secondhand smoke

Lives withSmoker

Does Not Livewith Smoker

0%

20%

40%

60%

80%

100%

67%

12%

8

APPENDIX A: METHODS

ADULT TOBACCO SURVEY

The data in this collaborative report were gatheredfrom adults age 18 and older from three differentsamples using the same survey instrument. Phoneinterviews were conducted during the spring andsummer of 1999. All respondents were assured of theconfidentiality of their individual responses. Responseswere weighted to represent adults in the populationfrom which the sample was selected. Demographiccharacteristics vary among the three adult studypopulations, in part reflecting the eligibility require-ments for participation in the publicly insuredprograms.

• Minnesota SampleMPAAT sampled Minnesotans living in sixgeographic regions in the state. Residentialtelephone numbers were randomly selectedwithin each region, and an adult householdmember living at each residence was randomlyselected to respond to the survey. Approximately1,000 telephone surveys were completed in eachregion for a total statewide sample of 6,000 surveys.

• Blue Cross SamplesFrom a larger survey of approximately 10,000members, the Blue Cross samples described inthis report were selected randomly from itsmembers enrolled in Blue Cross MinnesotaCareor Blue Cross PMAP. This report includesinformation only from the 18- to 65-year-oldmembers of Blue Cross PMAP (689 completedsurveys) and Blue Cross MinnesotaCare (994completed surveys) samples. Blue Cross mem-bers were alerted to the survey by letter prior tobeing called and were offered the opportunity todecline participation.

Comparison with the entire state’s PMAPand MinnesotaCare eligible populations demon-strated that the Blue Cross samples closely mir-ror their respective statewide populations on age,gender, and proportion of households with chil-dren under age 18. However, the Blue Crosssamples substantially underrepresented PMAPand MinnesotaCare membership in the TwinCities seven-county metropolitan area.

• Data LimitationsAs with any telephone survey, these samplesunder-represent households that do not have atelephone (2% of Minnesota’s households).Minority ethnic populations and populationsof color in Minnesota are likely to be under-represented in these surveys for other reasons aswell, including cultural or language barriers tothe survey. All of the results in this report wereself-reported, and may be subject to biases intro-duced in the interview process. However, mostmeasures used in these surveys have been exten-sively tested and are believed to be highly reliable.

YOUTH TOBACCO SURVEY

The Minnesota Department of Health conductedthe MYTS to obtain information on the prevalenceof tobacco use, attitudes and beliefs about tobaccouse, and other topics of interest to tobacco preven-tion efforts. The U.S. Centers for Disease Controland Prevention contributed most of the questionsused in the survey instrument. The survey wasadministered in January, February, and March, 2000.Careful measures were taken to protect the anony-mity and confidentiality of students’ responses.Individual responses were weighted to represent thepublic school 6th-12th grade population in Minnesota.

• MYTS SampleParticipants were selected from 46 middleschools and 57 high schools that were randomlyselected and agreed to participate. Five or sixclassrooms within each school were randomlyselected, and all students in these classroomswere asked to participate. Survey responses werereceived from 12,376 students.

• Data LimitationsAs with most school-based surveys, the sampleunder-represents school dropouts, students whofrequently miss school, and students in juvenileinstitutions, treatment centers, and some alter-native schools.

9

Minnesota AdultsWhen surveyed, just under half (46%) of theMinnesota population lived outside the seven-countymetropolitan area, half (51%) were women, andone-third had graduated from college. The averageage of the Minnesota adult population was 44.7years.

Blue Cross MinnesotaCare MembersAt the time of the survey, almost all (98%) of BlueCross MinnesotaCare members lived outside theseven-county metropolitan area. Over half (58%) ofthe Blue Cross MinnesotaCare population werewomen, and 8% had graduated from college. Theaverage age of the adult MinnesotaCare member inthis sample was 37.5. Because so few people in theBlue Cross MinnesotaCare sample lived in theseven-county metropolitan area, this report does notpresent information based on residence in the seven-county area as compared to Greater Minnesota.

Blue Cross PMAP MembersAt the time of the survey, 81% of the Blue CrossPMAP population lived outside the seven-countymetropolitan area, three-quarters (74%) werewomen, and one in ten (11%) had graduated fromcollege. The average age of the adult Blue CrossPMAP member in this sample was 32.0 years.

The Minnesota Youth PopulationYouth who participated in the Youth Tobacco Surveyare representative of 6th-12th grade public schoolstudents in Minnesota.

APPENDIX B: WHO WAS SURVEYED

Table 1—Adult Population Demographics

Geographic Area

Gender

Age

Education

Employed for wages(of only those younger than 65)

Children under 18 yearsof age at home

Greater MinnesotaSeven-county metro area

MenWomen

Average age

Less than high schoolHigh school graduate/GEDSome college or technical schoolCollege graduate and above

NoneAt least one

MinnesotaBlue Cross

MinnesotaCareBlue Cross

PMAP

46%54%

49%51%

44.7

7%29%28%36%

86%

60%40%

98%2%

42%58%

37.5

13%49%30%8%

71%

31%69%

81%19%

26%74%

32.0

19%44%27%11%

82%

21%80%

10

Figure 11Statewide smoking rates

Figure 13Blue Cross PMAP smoking rates

Figure 12Blue Cross MinnesotaCare smoking rates

Current Smokers 20%

Former Smokers 26%Never Smokers 54%

Current Smokers 48%

Former Smokers 17%

Never Smokers 35%

Current Smokers 31%

Former Smokers 23%

Never Smokers 46%

SMOKING STATUS

By definition, an adult current smoker is someone who has smoked at least 100 cigarettes in his or her life-time and now smokes every day or some days.

At the time of the survey, 20% of adult Minnesotans were current smokers. Approximately one-quarter(26%) of Minnesotans had quit smoking and over half (54%) of Minnesotans had never smoked.

Almost one-third (31%) of Blue Cross MinnesotaCare members were current smokers, 23% were formersmokers, and nearly half (46%) had never smoked.

Almost half (48%) of Blue Cross PMAP members were current smokers, 17% were former smokers, and35% had never smoked.

11

THIS REPORT WAS PREPARED BY:Blue Cross and Blue Shield of MinnesotaNina L. Alesci, M.P.H.Carolyn Link Carlson, R.N., M.P.H.Steven Foldes, Ph.D.

Minnesota Department of HealthJohn Oswald, Ph.D.Pete Rode, M.A.

Minnesota Partnership for Action Against TobaccoHoward Epstein, M.A.Gayle Geber, M.P.H.

Minnesota Smoke-Free CoalitionJudy Knapp, M.P.H.

ADDITIONAL CONTRIBUTIONS TO THIS REPORTWERE MADE BY:Blue Cross and Blue Shield of MinnesotaNancy Garrett, Ph.D.Carol Walters, M.B.A.

Data IntelligenceGlenn Trystad

Minnesota Department of Human ServicesPaul Farseth

CONTRIBUTIONS TO THE DESIGN OF THE ADULTTOBACCO SURVEY INSTRUMENT WERE MADE BY:Blue Cross and Blue Shield of MinnesotaSteven Foldes, Ph.D.

Clearwater Research, Inc.Craig King, M.A.Kara Sumner, M.A.Michael Willmorth, Ph.D.

Minnesota Department of HealthJennifer Ellsworth, M.P.H.Laura Hutton, M.A.Ann Kinney, Ph.D.Laura Oatman, M.S.John Oswald, Ph.D.Pam Van Zyl York, M.P.H., Ph.D., R.D.

Minnesota Department of Human ServicesJayne Fulkerson, Ph.D. (currently with U of M)

Minnesota Partnership for Action Against TobaccoLuanne Nyberg, M.P.A. (currently with Hennepin County)Terry Sluss, M.A. Laura Waterman Wittstock

University of Minnesota, School of MedicineLarry An, M.D.

University of Minnesota, School of Public HealthHarry Lando, Ph.D. Phyllis Pirie, Ph.D.

ACKNOWLEDGMENTS

FOR FURTHER INFORMATION

FOR MORE INFORMATION OR ADDITIONAL COPIES CONTACT:Gayle GeberMinnesota Partnership for Action Against Tobacco651-312-3911ggeber@MPAAT.org

Nina L. AlesciBlue Cross and Blue Shield of Minnesota65l-662-6593Nina_Alesci@bluecrossmn.com

For information about the youth survey contact:Pete RodeMinnesota Department65l-296-6036peter.rode@health.state.mn.us

12

THE MINNESOTA PARTNERSHIP FOR ACTION AGAINSTTOBACCO (MPAAT) is an independent, nonprofitfoundation dedicated to reducing the harm causedby tobacco. MPAAT's goal is to transform the socialenvironment through intervention and research toreduce tobacco use in Minnesota to less than 10%by the year 2023. To achieve this goal, MPAAT willserve Minnesota over a 25-year period throughgrants to health, community and academic organiza-tions throughout the state in support of research,intervention, and related program activities. MPAATis funded by proceeds from the Minnesota tobaccosettlement through payments ordered by the courtsfor the harm tobacco caused Minnesotans.

BLUE CROSS AND BLUE SHIELD OF MINNESOTA is thefirst health care plan to date to win a legal battleagainst the tobacco industry. Blue Cross’ 1994 law-suit against Big Tobacco resulted in unprecedentedpublic gains, open access to secret tobacco industrydocuments and a settlement that will reduce tobaccouse and improve the health of Minnesotans formany years to come. Blue Cross, with headquartersin the St. Paul suburb of Eagan, covers more thantwo million members through its health plans orplans administered by its affiliated companies. BlueCross is Minnesota's oldest health plan and beganoperations in 1933. Blue Cross and Blue Shield ofMinnesota is an independent licensee of the BlueCross and Blue Shield Association.

THE MINNESOTA DEPARTMENT OF HEALTH works toprotect, improve, and maintain the health of allMinnesotans. The Department has launched anenergetic campaign of youth-inspired marketing,youth organizing activities, and statewide and localprograms to significantly reduce youth tobacco useover the next five years.

THE MINNESOTA SMOKE-FREE COALITION is astatewide organization dedicated exclusively toreducing tobacco use in Minnesota. Representinghealth, business, and community organizations, theCoalition supports measures to reduce tobacco useby preventing children from beginning a lifelongaddiction to tobacco, helping those who want toquit smoking and protecting nonsmokers fromexposure to secondhand smoke. The Coalitionincludes Allina Health System, American CancerSociety Midwest Division, the American HeartAssociation Northland Affiliate, the American LungAssociation of Minnesota, Blue Cross and BlueShield of Minnesota, Fairview Health Services,Hazelden Foundation, HealthPartners, MinnesotaMedical Association, Park Nicollet Foundation, theUniversity of Minnesota Cancer Center, and others.

COLLABORATING ORGANIZATIONS

REFERENCESNational Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental

Protection Agency. Smoking and Tobacco Control Monograph No. 10. (NIH Pub. No. 99-4645, 1999).U.S. Department of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of the

U.S. Surgeon General, 1986. (DHHS publication no. (CDC) 87-8398).U.S. Department of Health and Human Services. Reducing Tobacco Use: a Report of the Surgeon General, 2000. U.S. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders.

The Report of the Environmental Protection Agency. U.S. Environmental Protection Agency, Office of Research andDevelopment, 1993. (EPA/600/6-90/006F.)