Work-related exposure to tobacco smoke and support for workers’ smoking cessation at the workplace
Kari E. Reijula, Jere P. Reijula, Finnish Institute of Occupational Health, Finland
- 1 Introduction
- 2 Tobacco smoke – toxic and carcinogen
- 3 Health effects of environmental tobacco smoke (ETS)
- 4 Global and EU actions against tobacco epidemics
- 5 Assessing tobacco smoke exposure in OSH
- 6 Smoking cessation in occupational health
- 7 Conclusions
- 8 References
- 9 Links for further reading
Tobacco use in EU has claimed over 10 million lives during the previous century and will lead to another 100 million deaths during the 21st century. Over 50% of smokers die due to tobacco-related diseases and on average smokers die 14 years earlier than non-smokers. Smoking tobacco is the largest avoidable health risk in the EU causing annually to 700 000 premature deaths. There is potential for workplaces and occupational health programmes to play a more active role in helping smokers to quit. Altogether 79 000 adults, including 19 000 non-smokers, die in EU countries annually due to tobacco smoke exposure at home (72 000) and at their workplace (7 300). With some exceptions, for example in the hospitality sector in some Member states, employers have to ensure that no one is exposed to environmental tobacco smoke in workplaces. Eliminating exposure leads to better health condition among both workers and employers, as well as improvements in work productivity.
Tobacco smoke – toxic and carcinogen
Environmental tobacco smoke (ETS) is the combination of the smoke from the burning tobacco emitted between the puffs of the smoker (“side stream smoke”), and “the exhaled smoke by the smoker” (“mainstream smoke”). Table 1 lists the compounds of tobacco smoke with adverse health effects .
Source: Modified from Hoffmann and Hoffmann (1998) 
Tobacco smoke consists of numerous chemicals that act as toxic irritants ,  . Examples of these include ammonia, nitrogen oxides, organic acids, sulphur dioxide and various aldehydes which can irritate the eyes and respiratory tract. Some of these decrease the cleansing of the respiratory tract.
In the late 1990s, the exposure to ETS was listed as the second most common exposure to occupational carcinogens after solar radiation in the European Union . In tobacco smoke, there are nine chemical agents classified as Group 1 carcinogen , namely: benzene, cadmium, arsenic, nickel, chromium, 2-naphthylamine, vinyl chloride, 4-aminobiphenyl and beryllium. Tobacco-specific nitrosamines are formed in processing cigarettes and while smoking. Most of them have been detected as carcinogens in experimental animals. More than 35 PAHs (polycyclic aromatic hydrocarbons) have been found in tobacco smoke, many with carcinogenic potential.
Tobacco smoke contains carcinogenic heavy metals, such as arsenic, cadmium and hexavalent chromium as well as a number of naturally occurring radionuclides, of which the most important is the alpha-emitter polonium-210.
Tobacco smoke contains several known reproductive toxicants such as carbon monoxide, carbon disulphide, nicotine, cadmium and lead. PAHs can cause developmental and reproductive effects . Tobacco smoke consists of nicotine which is a strongly addictive substance. Nicotine, carbon monoxide, and nitrogen monoxide have cardiovascular effects. Carbon monoxide forms carboxyhaemoglobin in the blood decreasing its oxygen-carrying capacity.
Health effects of environmental tobacco smoke (ETS)
Exposure to ETS or “second hand smoke” increases significantly the risk of developing cardiovascular diseases(25-35% increase) , lung cancer (20-40%), asthma (40-60%), pulmonary irritation (15%-2.5 times) and chronic obstructive pulmonary disease (COPD) (20%-2.5 times) ; , , , , . It is also associated with lowered birth weight and premature death . Furthermore, particulate materials (PM) of ETS lead to adverse health effects in eyes and respiratory tract, as for instance irritation.
A statistically significant association has been found between lung cancer risk in spouses of smokers and exposure to ETS from the smoking spouse. The excess risk is approximately 20% for women and 30% for men . Meta-analyses of lung cancer in never smokers exposed to ETS at the workplace have shown a statistically significant increased risk of 16 to 19 per cent . Therefore, it is possible to conclude that exposure to ETS is a cause of lung cancer in never smokers . Although the excess risk related to ETS exposure is small, tobacco smoke is an important environmental carcinogen because the number of exposed individuals is high. The number of lung cancer cases attributable annually to the exposure of tobacco smoke (assuming a RR in the order of 1.2-1.3) is approximately 1100 in the EU .
The evidence on breast cancer risk associated with ETS exposure of never smokers has been inconsistent . Four of the 10 case-control studies found statistically significant increased risks. For associations between exposure to tobacco smoke and cancers of the nasopharynx, nasal cavity, paranasal sinuses, cervix, gastrointestinal tract and cancers at all sites combined, the data has been conflicting and sparse.
Exposure to other carcinogens simultaneously with ETS at work should be taken into consideration. Smokers who are also exposed to asbestos have a risk of developing lung cancer that is greater than the individual risks from asbestos and smoking added together ). Furthermore, the responsibility of the employer is important if a non-smoking worker develops lung cancer while exposed to ETS at work but not at home.
Exposure to tobacco smoke related to spousal smoking has been associated with an increased risk of heart disease , , . In previous studies, overall risk of coronary heart disease (CHD) in eight workplaces increased 18%, while the risk of acute myocardial infarction associated with work-related exposure to ETS increased 21% , , .
Non-smokers exposed to ETS have had an increased risk of CHD compared to non-smokers without any exposure . Exposure to tobacco smoke increases the risk of an acute coronary heart disease event by 25-30% .
Non-smokers exposed to tobacco smoke both at work and at home had an increased risk (25%) of CHD compared with non-exposed non-smokers . The increase of risk has varied between cohort studies (21%) and in case-control study (51%). A significant dose-response relationship was demonstrated between the intensity of the exposure and the size of relative risk.
In a case-control study among 521 stroke patients, men who were exposed to tobacco smoke had 2.1 times higher risk for stroke than the non-exposed ones. Among women the risk increased 66% .
Exposure to tobacco smoke increases susceptibility to respiratory infections in children . Invasive pneumococcal infection is 2.5 times more likely among adult non-smokers who had been exposed to tobacco smoke than non-exposed non-smoking controls. A dose-response relationship has been observed between duration of daily tobacco smoke exposure and the risk of invasive pneumococcal disease. Tobacco smoke exposure has an association with the risk of meningococcal disease in adults.
Asthma and COPD
Exposure to ETS causes inflammatory and irritative reactions in the airways, leading to respiratory symptoms and to lung function impairment ,  . Defects in mucociliary clearance of the airways and impairment of immunological defense mechanisms increase susceptibility to respiratory infections. Repeated infections, on the other hand, may predispose a person to the development of COPD. In addition, lung function deficits due to tobacco smoke exposure in early ages may increase the risk to develop lung diseases in adult life , .
An association and dose-response relationship between occupational tobacco smoke exposure and respiratory symptoms such as, cough, phlegm production, shortness of breath, eye irritation and common cold symptoms have been demonstrated , , .
Tobacco smoke exposure in non-smoking women during pregnancy causes a reduction in birth weight, which is closely related to adverse health outcomes , . Based on literature reviews, ,  the weight decrements have varied between 25g and 100g. Low birth weight is strongly associated with perinatal mortality. Pregnant women who are exposed to second hand smoke are estimated to be 23% more likely to experience stillbirth and 13% more likely give birth to a child with a congenital malformation . According to recent meta-analysis, women exposed to environmental tobacco smoke have increased risks of infants with lower birth weight, congenital anomalies, longer lengths, and trends towards smaller head circumferences and low birth weight , .
Global and EU actions against tobacco epidemics
Strict tobacco legislation is an important measure in reducing harms of smoking and exposure to tobacco smoke , . Legislation concerning all workplaces, including restaurants and bars, has been the main instrument to protect employees against occupational exposure to ETS , , . Furthermore, strict tobacco legislation concerning public places also has significant benefits to the general population.
The hospitality industry has been concerned about the strict tobacco legislation due to the fear of losing clients. Recent studies have shown, however, that smoke-free legislation did not have an adverse economic impact on restaurants or bars in Ireland or in any of the states in the US which were studied , .
Smoke-free legislation has been effective in several countries in reducing exposure to tobacco smoke. After launching smoke-free legislation, the exposure to ETS at work decreased 80% in the Republic of Ireland, as measured by using saliva cotinine concentrations . In New York, it declined on average from 12.1 hours to 0.2 hours, as assessed by using an estimated exposure time . It decreased 89% in Scotland as measured by saliva cotinine levels , and reduced from 17.8 to 5.5 ng/ml in Italy, measured by using non-smokers urinary cotinine levels .
WHO Framework Convention on Tobacco Control
The WHO Framework Convention on Tobacco Control (WHO FCTC) was adopted in 2003 and came into force in 2005 . So far it had been signed by 168 countries and is legally binding in 177 ratifying countries. The FCTC has recently been widely referred to in reforms of tobacco legislation in EU Member States. Worldwide tobacco control has set a precedent for EU Commission participation and negotiation in multilateral treaties.
The WHO FCTC consists of guidelines focusing on the protection against exposure to tobacco smoke (Article 8 ). According to the guidelines, all people should be protected against tobacco smoke, all indoor spaces should be smoke free and legislation is necessary to achieve the goal of totally smoke-free indoor environments.
EU – state of art in 2013
EU Council adopted a Recommendation (2009) on Smoke-Free Environments which calls on Member States to provide effective protection from exposure to ETS in indoor workplace, indoor public places, public transport and other public places . The recommendation is closely related to the Article 8 of the WHO FCTC .
Although significant improvements have been performed concerning work-related exposure to tobacco smoke, overall 28% of the EU citizens reported that they were exposed to tobacco smoke in their workplace at least occasionally . For 7% of the population this is the case for one or more hours a day. In 2012, altogether 23% of EU citizens reported that there were people smoking inside drinking establishments while they visited the premises during last 6 months. 
All EU Member States have reported that they have legislation in place with the aim to protect their citizens from exposure to tobacco smoke at indoor workplaces, indoor public premises, public transport and other public places . However, the scope of this legislation varies considerably from one Member State to another. Smoking bans are the most comprehensive in educational establishments, facilities providing services for children, public transport and in healthcare sector.
The vast majority of Member States have banned smoking in educational establishments. In some Member States smoking is completely banned in institutions of lower education while smoking is allowed or restricted to smoking rooms in the higher education institutions. A large majority of Member States report a total smoking ban in public transport. Some countries have limited exemptions and allow smoking in areas or designated rooms on long distance passenger trains and ships (46).
Half of the Member States have banned smoking completely in health care facilities. A large majority of Member States allow smoking in some hotel rooms or smoking is allowed in the rooms at the owners’ discretion. Some member states allow that a certain percentage of hotel rooms are reserved for smokers.
The most far reaching legislation is provided in Hungary, Bulgaria, Spain, Ireland, the UK, Malta, Greece, the Former Yugoslav Republic of Macedonia and Turkey where smoking is completely banned in enclosed workplaces and public places, including bars and restaurants. The rest of the EU countries have a general ban on smoking in workplaces and enclosed public places but allow separate, enclosed smoking rooms under specific conditions. Legislation in several countries is less strict in the hospitality industry.
Altogether ten EU Member States provide comprehensive protection from exposure to tobacco smoke (46). Total bans on smoking in all enclosed public places and workplaces, including bars and restaurants, are in place in Ireland and in the UK. Italy, Malta, Sweden, Latvia, Finland, Slovenia, France and the Netherlands have introduced smoke-free legislation allowing for special enclosed smoking rooms.
However, in more than half of the Member States, citizens and workers are still not fully protected from exposure to tobacco smoke in indoor workplaces and public places (46). Bars and restaurants are a particularly difficult area to regulate. Partial smoking bans in hospitality venues are in place in Austria, Bulgaria, Denmark, Portugal, Romania, Spain and most of Germany (exemptions for smaller establishments); Belgium, Luxembourg and Slovakia (exemptions for non-food and snack establishments) and Lithuania (exemption for special cigars and pipe clubs) while in the Czech Republic, Cyprus and Greece there are at the moment virtually no restrictions on smoking in bars and restaurants.
Furthermore, the enforcement of the existing laws and consequent penalties may be lax or non-existent. In some Member States, smoke-free laws are rather comprehensive on paper, but exposure to tobacco smoke in workplaces and public places continues to be very high .
Assessing tobacco smoke exposure in OSH
Exposure assessments can be carried out by measuring suitable tobacco smoke indicator components in the air, by biomarkers of exposure and in epidemiological studies by surveys and questionnaires , .
The most widely used marker compounds for assessing the presence and concentration of tobacco smoke in indoor air have been vapour-phase nicotine and respirable suspended particle (RSP) mass , . Some researchers have used 3-ethenylpyridine (3-EP), solanesol, and ultraviolet particulate matter as markers of ETS. Airborne nicotine as well as 3-EP are specific to tobacco combustion. Nicotine is present both in aerosol and vapour phase, and subsequently cannot be reliably sampled with passive personal monitors (diffusive samplers). 3-EP is in the ETS vapour phase and so suitable for easy and cheap passive sampling .
Respirable suspended particles are present in large quantities but are not unique to tobacco smoke . When respirable suspended particles are used as a marker for tobacco smoke, background levels from other sources must be accounted for. Carbon monoxide may also be used as a marker for tobacco smoke.
Nicotine and cotinine have a high specificity and sensitivity for tobacco smoke exposure. Cotinine seems to be the best biological indicator of exposure to tobacco smoke in adults and children. Smokers show levels of nicotine and cotinine several hundred times higher than those detected in non-smokers. On the other hand, non-smokers reporting regular exposure to tobacco smoke show significantly elevated levels compared to non-smokers reporting no tobacco smoke exposure ; .
Smoking cessation in occupational health
Although the health risks of ETS exposure (“passive smoking”) are evident, the risk of active smoking is significantly higher , . Tobacco smoking has claimed over 100 million lives globally during the previous century and will lead to one billion deaths during the 21st century. In EU countries this means that smoking caused 10 million deaths during the previous century and will lead to another 100 million deaths during the 21st century. Over 50% of smokers die due to tobacco-related diseases and on average 14 years earlier than non-smokers.
As Dr Margaret Chan Director-General of the WHO recently stated, the “Endgame for Tobacco” has been launched. Endgame means that global actions will be taken to get rid of tobacco products and prohibit smoking everywhere. Thus, all efforts have to be taken also in occupational health to help smokers to quit .
Today 29% of Europeans smoke, and smoking continues to be the largest single cause of preventable death and disease in the EU. According to the Eurobarometer 285 (2012), the highest proportion of smokers is observed in Greece (40%), Bulgaria (36%) and Latvia (36%). The fewest smokers were detected in Sweden (13%), Portugal (23%) and Slovakia (23%) .
Overall 31% of smokers have tried to give up smoking within the last 12 months. Two out of three smokers are willing to quit but unfortunately only 3-5% remain smoke-free 12 months after quitting smoking without any help from health care. By attending smoking cessation groups or using professional help accompanied by nicotine replacement therapy or specific medication (e.g., with varenicline or buprobion), even 20-25% remain smoke-free 12 months after the quitting.
The Council Recommendation on Smoke-Free Environments (2009) calls on Member States to introduce tobacco cessation policies . This is in line with WHO FCTC Article 14 and the implementation guidelines adopted in 2010 . The EU-wide campaign “Ex-smokers are unstoppable” (2011-13) focuses on encouraging Europeans to stop smoking. It shifts the focus from the dangers of smoking to the positive benefits of quitting, highlighting the inspirational achievements of ex-smokers and offering practical tips on quitting .
Approximately 80% of smokers are concerned about their health related to smoking and 38% told that they had tried to give up smoking during the past one-year period. However, only 30-40% of smokers had received a recommendation while seeing their physician or nurse. There seems to be a significant need to encourage personnel in health care to carry out at least a short intervention and raising up a question concerning the wiliness to quit smoking .
The large majority of Member States have developed comprehensive cessation guidelines based on scientific evidence and best practice, media campaigns to promote cessation, cessation programmes for certain target groups, telephone assisted support to quit smoking (“quitlines”) and local events (e.g., No Tobacco Day)). Almost all Member States report about cessation programmes in educational institutions, health care facilities or workplaces. Other activities consist of the diagnosis and treatment of tobacco dependence and counselling services for cessation. Overall 21 states have specialised centers for cessation and treatment of tobacco dependence. Seven states have low cost dispensal of nicotine replacement therapy (NRT) or reimbursement schemes for NRT.
The first experience of smoking leads usually to unpleasant effects in both respiratory tract and central nervous system . This is due to the irritating and toxic smoke with numerous chemical compounds which irritate mucosal membranes and eyes. In addition, after a few seconds, inhalation affects the brains. Nicotine is one of the main substances in inhaled tobacco smoke which after an unexpectedly short time can lead to severe addiction especially among children.
Nicotine is toxic and its LD 50 (content where 50% of those who have consumed the poison have died) is 1 mg per kilogram . Thus, for a child, eating one cigarette can lead to death.
Nicotine is rapidly absorbed through the lungs and it mainly affects the nicotinic receptors, particularly those located in the brain. Repeated consumption of nicotine unfortunately leads to permanent changes called neuro-adaptation. When smoker stops smoking, the nervous system is forced to adapt to a nicotine deprivation condition which leads to physical symptoms of withdrawal from nicotine.
Within a few weeks, daily smoking can lead to nicotine addiction which can be encountered by a weakened ability to control the commencement or cessation of smoking or other types of tobacco use. (After this, the number of cigarettes smoked daily is increased, there is constant craving for smoking and/or all attempts to decrease or control smoking usually fail. If the smoker tries to give up or reduces smoking, typical physiological withdrawal symptoms ensue . The smoker often begins to use the same or closely related substance in order to relieve or avoid the withdrawal symptoms.
In addition, nicotine addiction is associated with increased tolerance level. This means that larger dosages are needed to reach the state of the desired effect. In daily smoking, nicotine may also have a weaker effect when the same dosages are being used continuously, leading to an increase in the number of cigarettes per day. Nicotine addiction leads the smoker to continue smoking although he/she is aware of the harmful effects of smoking.
Encouraging smoking workers to quit
As a part of their strategic planning, occupational health service providers, including physicians, accident insurances and other stakeholders, should build up models of action and tools for practice concerning smoking cessation . Without having them available, providing high quality services for potential patients is not possible. This also includes special training for the occupational safety and health (OSH) professionals, as basic training of OSH professionals does not provide proper training for smoking cessation.
Smoking cessation is cost effective if those who provide occupational health services have well organised action models and trained personnel. Moreover, employers can be motivated to take preventive actions by providing data showing the higher cost of smoking workers to companies compared to non-smoking employees. According to a recent study from the US, the annual excess cost of employing a smoker is 5816 US dollars.
Counselling of smoking cessation should take into account individual physical, psychological and social needs as well as the environmental factors of each potential smoker to quit , . Firstly, it is important to examine the smoker’s dependence on tobacco products and smoking, especially nicotine addiction. Short-term counselling should focus on the assessment of nicotine addiction, expressions of concern on patient’s smoking and health, and explaining the support options for quitting smoking. On the other hand, long-term counselling contains a more thorough and studious examination of the patient.
Depending on the action models, tools and personnel resources of the OSH service provider concerning smoking cessation, the provider may use individual or group counselling. To adequately support smokers in the cessation process, OSH service providers should provide other means such as written information, handbooks and leaflets. Links to further information obtained via internet networks are very helpful. Contacts by telephone or email are important especially in follow-up which should be long enough to ensure the best outcome of smoking cessation. Social media should be used to build up networks between the patients and the OSH service providers. 
Assessing nicotine dependence
In individual contacts with the patients, the severity of nicotine addiction should be assessed. The easiest way of doing this is to ask two questions: How many cigarettes do you smoke daily? And, how soon after you wake up do you light up your first cigarette? Severity of nicotine addiction helps assess the need for nicotine replacement therapy or medical treatment prescribed by the OH physician .
Other tobacco products
Smokeless tobacco products such as Swedish snuss contains carcinogens and the use of it is a significant health risk, even though snuss is often falsely considered to be less dangerous than tobacco . Moreover, there is no evidence that smokeless tobacco products (e.g., snuss and electronic cigarettes) could help people to quit smoking. Thus, avoiding use of all types of tobacco products and quitting the use of them significantly decreases the risk of developing adverse health effects related to the use of smokeless tobacco. Health promotion efforts with warnings concerning the use of smokeless tobacco products, are of utmost importance especially among young people while marketing of these products has recently mainly been focused on them.
Water pipes and electronic cigarettes have also become popular alternatives to smoking cigarettes. However, the health effects of their inhaled vapors consisting nicotine and several other hazardous chemical substances have not been investigated to ensure the security of these products . It is important to emphasise that intermittent smoking, smoking only a few cigarettes per day or using pipes and cigars instead of cigarettes are not safe alternatives either.
ETS in workplaces is a real health hazard in the indoor environment, fully comparable with asbestos, arsenic and benzene. Because of the harmful health effects, the active health protection is necessary and should be ranked among the highest priorities in the OSH in all EU member states. The maximal protection of people against the exposure to ETS is required and can only be achieved effectively by prohibiting smoking totally in all indoor premises.
OSH providers should build up a strategy on how to help smokers to quit. This consists of active counselling, interventions in the companies rising the importance of quitting smoking, providing therapy to nicotine addiction and careful follow-up to ensure the success in smoke-free life.
- Hoffmann, D. Hoffmann, I., Chemistry and toxicology; Smoking and Tobacco Control, Monograph 9, 1998, pp. 55-104.
- IARC - International Agency for Research on Cancer, Tobacco smoking, IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans, Lyons, France, 2004.
- Finnish Institute of Occupational Health (21.06.2010). Description of CAREX. Retrieved on 21 November 2013, from: 
- Dejmek, J., Solanský, I., Benes, I., Lenícek, J., Srám, R.J., ‘The impact of polycyclic aromatic hydrocarbons and fine particles on pregnancy outcome’, Environ Health Perspect, no. 108(12), 2000, pp. 1159–1164.
- Surgeon General, The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General, U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Ga., 2006.
- Steenland, K., ‘Risk assessment for heart disease and workplace ETS exposure among nonsmokers’, Environ Health Perspect, 107 Suppl 6, 1999, pp. 859-63.
- IOM - Institute of Medicine, Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence, The National Academies Press, Washington, DC, 2009.
- Oberg, M., Jaakkola, M.S., Woodward, A, Peruga A, Prüss-Ustün A., ’Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries’, Lancet, 377(9760), 2011 Jan 8, pp. 139-46.
- Thun, M.J., Carter, B.D., Feskanich, D., Freedman, N.D., Prentice, R., Lopez, A.D., Hartge, P., Gapstur, S.M.,‘50-year trend in smoking-related mortality in the US’, N Engl J Med, no. 368(4), 2013 Jan 24, pp. 351-64.
- Windham, G.C., Eaton, A., Hopkins, B., ‘Evidence for an association between environmental tobacco smoke exposure and birthweight: a meta-analysis and new data’,Paediatr Perinat Epidemiol, no.13, 1999, pp. 35-57
- Trédaniel, J., Boffetta, P., Saracci, R., Hirsch, A., ‘Non-smoker lung cancer deaths attributable to exposure to spouse's environmental tobacco smoke’, Int J Epidemiol, 26,1997, pp. 939–944
- Frost, G., Darnton, A., Harding, A.H. ‘The effect of of smoking on the risk of lung cancer mortality for asbestos workers in Great Britain (1971-2005)’, Ann Occup Hyg, 55(3), 2011, pp. 239-47
- Law, M.R., Morris, J.K., Wald, N.J., ‘Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence’, BMJ, 315(7114), 1997, pp. 973-80.
- He, J., Vupputuri, S., Allen, K., Prerost, M.R., Hughes, J., Whelton, P.K., ‘Passive smoking and the risk of coronary heart disease a meta-analysis of epidemiologic studies’, N Engl J Med, 340(12), 1999, pp. 920-6.
- Wells, A.J., ‘Heart disease from passive smoking in the workplace’, J Am Coll Cardiol., no 31(1), 1998 Jan, pp. 1-9.
- Lightwood, J.M., Glantz, S.A.,‘Declines in acute myocardial infarction after smoke-free laws and individual risk attributable to secondhand smoke, Circulation, no. 120(14), 2009 Oct 6; pp. 1373-9.
- Tunstall-Pedoe, H., Brown, C.A., Woodward, M., Tavendale, R,. ‘Passive smoking by self report and serum cotinine and the prevalence of respiratory and coronary heart disease in the Scottish heart health study’, J Epidemiol Community Health, 49(2), 1995, pp. 139-43.
- EPA - U.S. Environmental Protection Agency, America’s Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses, Second Edition, February 2003.
- Janson, C., Chinn, S., Jarvis, D., Zock, J. P., Toren, K., Burney, P. ‘Effect of passive smoking on respiratory symptoms, bronchial responsiveness, lung function, and total serum IgE in the European Community Respiratory Health Survey: a cross-sectional study’, Lancet, no. 358(9299), 2001 Dec 22-29, pp. 2103-9.
- Lam, T.H., Ho, L.M., Hedley, A.J., Adab, P., Fielding, R., McGhee, S.M., Aharonson-Daniel, L.. ‘Environmental tobacco smoke exposure among police officers in Hong Kong’, JAMA, 284, 2000, pp. 756-763.
- Leuenberger, P., Schwartz, J., Ackermann-Liebrich, U., Blaser, K., Bolognini, G., Bongard, J.P., Brandi, O., Braun, P., Bron, C., Brutsche, M., Domenighetti, G., Elsasser, S., Guldimann, P., Hollenstein, C., Hufschmid, P., Keller, R., Keller-Wossidlo, H., Künzli, N., Lüthi, J.C., Martin, B.W., Medici, T., Perruchoud, A.P., Radaelli, A., Schindler, C., Schöni, M.H., Solari, G., Tschopp, J.M., Villiger, B., Wüthrich, B., Zellweger, J.P., Zemp Stutz, E., ’Passive smoking exposure in adults and chronic respiratory symptoms (SAPALDIA Study). Swiss Study on Air Pollution and Lung Diseases in Adults, SAPALDIA Team.”, A m J Respir Crit Care Med, 150, 1994, pp. 1222–1228. Available at: 
- Larsson, M., Boethius, G., Axelsson, S., Montgomery, S.M., ‘Exposure to environmental tobacco smoke and health effects among hospitality workers in Sweden – before and after the implementation of a smoke-free law’, Scand J Work Environ Health, 34 (4), 2008, pp. 267-277.
- U.S. Department of Health and Human Services, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.
- Leonardi-Bee, J., Smyth, A., Britton, J., Coleman, T.. ‘Environmental tobacco smoke and fetal health: systematic review and meta-analysis’, Arch Dis Child Fetal Neonatal Ed., no. 93(5), 2008 Sep, pp. F351-61.
- Leonardi-Bee, J., Britton, J., Venn, A., ’Secondhand smoke and adverse fetal outcomes in nonsmoking pregnant women: a meta-analysis’, Pediatrics, 127(4), 2011 Apr, pp. 734-41.
- Lindbohm, M.-L-, Sallmen, M., Taskinen, H., ‘Effects of exposure to environmental tobacco smoke on reproductive health’, Scand J Work Environ Health, 28 suppl 2, 2002, pp. 84-96.
- Salmasi, G., Grady, R., Jones, J., McDonald, S.D., ‘Environmental tobacco smoke exposure and perinatal outcomes: a systematic review and meta-analyses’, Acta Obstet Gynecol Scand., 89(4), 2010, pp. 423-41).
- Fichtenberg, C.M., Glantz, S.A., ‘Effect of smoke-free workplaces on smoking behaviour: systematic review’, BMJ, 325, 2002, pp.188.
- Blackburn, C., Spencer, N., Bonas, S., Coe, C., Dolan, A., Moy, R., ‘Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey’, BMJ, 327(7409), 2003, pp. 257.
- Bates, M.N., Fawcett, J., Dickson, S., Berezowski, R., Garrett, N., ‘Exposure of hospitality workers to environmental tobacco smoke’, Tob Control, 11(2), 2002, pp. 125-9.
- Jaakkola, M.S., Jaakkola, J.J.K.. ’Impact of smoke-free workplace legislation on exposures and health: possibilities for prevention’, Eur Respir J, 28, 2006, pp. 397–408.
- Connolly, G.N., Carpenter, C.M., Travers, M.J., Cummings, K.M., Hyland, A., Mulcahy, M., Clancy, L., ‘How smoke-free laws improve air quality: A global study of Irish pubs’, Nicot Tob Research, 11, 2009, pp. 600-5.
- Cornelsen, L., Normand, C., ‘Impact of the Irish smoking ban on sales in bars using a large business-level data set from 1999 to 2007’, Tob Control., 8 Oct 2013
- Loomis, B.R., Shafer, P.R,, van Hasselt, M., ‘The Economic Impact of Smoke-Free Laws on Restaurants and Bars in 9 States’, Prev Chronic Dis, 10, 2013, p. 120327.
- Allwright, S., Paul, G. Greiner, B., Mullally, B.J., Pursell, L., Kelly, A., Bonner, B., D'Eath, M., McConnell, B., McLaughlin, J.P., O'Donovan, D., O'Kane, E., Perry, I.J., ‘Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study’, BMJ, Nov 12, 2005, pp. 331:1117.
- Farrelly, M.C., Nonnemaker, J.M., Chou, R., Hyland, A., Peterson, K.K., Bauer, U.E., ‘Changes in hospitality workers’ exposure to secondhand smoke following the implementation of New York’s smoke-free law’, Tob Control., 14, 2005, pp. 236–41
- Semple, S., Maccalman, L., Naji, A.A., Dempsey, D., Hilton, S., Miller, B.G., Ayres, J.G., ‘Bar workers' exposure to second-hand smoke: the effect of Scottish smoke-free legislation on occupational exposure’, Ann Occup Hyg, 51, 2007, pp. 571-80.
- Valente, P., Forastiere, F., Bacosi, A., Cattani, G., Di Carlo, S., Ferri, M., Figà-Talamanca, I., Marconi, A., Paoletti, L., Perucci, C., Zuccaro, P., ’Exposure to fine and ultrafine particles from secondhand smoke in public places before and after the smoking ban, Italy 2005’, Tob Control, no. 16(5),2007, pp.312-7. Available at: 
- WHO (2013). Policy recommendations for smoking cessation and treatment of tobacco dependence. Retrieved on 21 November 2013, from: 
- Council Recommendation of 30 November 2009 on smoke-free environments, OJ C 296, 5.12.2009, p. 4–14, Available at: 
- EC – European Commission, Staff Working Document 2013 on the Implementation of the Council Recommendation of 30 November 2009 on smoke-free environments , SWD(2013), 56 final/2, Brussels, 14.3.2013. Available at: 
- European Commission, Attitudes of Europeans towards tobacco, Special Eurobarometer 385, May 2012. Available at: 
- Johnsson, T., Tuomi, T., Riuttala, H., Hyvärinen, M., Rothberg, M., Reijula, K., ‘Environmental tobacco smoke in Finnish restaurants and bars before and after smoking restrictions were introduced’, Ann Occup Hyg, 50, 2006, pp. 331-341.
- Reijula, J., Johnsson, T., Kaleva, S., Reijula, K., ‘Exposure to tobacco smoke and prevalence of symptoms decreased among Finnish restaurant workers after the smoke-free law’, Am J Ind Med, 55, 2012, pp. 37–43.
- Repace, J., ‘Respirable particles and carcinogens in the air of delaware hospitality venues before and after a smoking ban’, J Occup Environ Med., 46(9), 2004 Sep, pp. 887-905.
- Jenkins, R., Guerin, M., Tomkins, B.A., The Chemistry of Environmental Tobacco Smoke: Composition and Measurement, Lewis Publishers Boca Raton, 2000
- EPA - US Environmental Protection Agency, Respiratory health effects of passive smoking: lung cancer and other disorders, NIH Publication, no 93-3605, EPA, Washington DC, 1993.
- Jha, P., Ramasundarahettige, C., Landsman, V., Rostron, B., Thun, M., Anderson, R.N., McAfee, T., Peto, R.,‘21-century hazards of smoking and benefits of cessation in the US’, N Engl J Med, no.368(4), 2013 Jan 24, pp. 341-50.
- European Commission (no date). Ex-smokers are unstoppable. Retrieved on 23 January 2014, from: 
- Fishwick, D., McGregor, M., Drury, M., Webster, J., Rick, J., Carroll, C., BOHRF smoking cessation review, HuSU/12/17, Health & Safety Laboratory, 27.04.2012. Available at: 
- Balfour, D.J.K.,’ The neurobiology of nicotine addiction: a brief overview’, CVD Prevention, no. 2,1999, pp. 140-4.
- Watkins, S.S., Koob, G.F., Markov, A., ‘Neural mechanisms underlying nicotine addiction: Acute positive reinforcement and withdrawal’, Nicotine Tob Res, 2, 2002, pp. 19-37.
- Fishwick, D., McGregor, M., Drury, M., Webster, J., Rich, J., Carroll, C., BOHRF smoking cessation review, HuSU/12/17, Health and Safety Executive, 2012. Available at: 
- Tob Control (3 June 2013). Berman, M., Crane, R., Seiber, E., Munur, M., ‘Estimating the cost of a smoking employee. Retrieved on 21 November 2013, from: 
- Fisher, E.B., Haire-Joshu, D., Morgan, G.D., Rehberg, H., Rost, K., ‘Smoking and Smoking Cessation’, American Review of Respiratory Disease, Vol. 142, No. 3, 1990, pp. 702-720.
- WHO – World Health Organization, Policy recommendations for smoking cessation and treatment of tobacco dependence, 2013. Available at: 
- Bofetta, P., Aagnes, B., Weiderpass, E., Andersen, A., ‘Smokeless tobacco products and risk of cancer of the pancreas and other organs’, Int J Cancer, no. 114, 2005, pp. 992-995.
- FDA – U.S. Food and Drug Administration (08/30/2013). Electronic cigarettes. Retrieved on 23 January 2014, from: 
Links for further reading
ASH – Action on Smoking and Health (no date). ASH Research Reports. Retrieved on 23 January 2014, from: 
European Commission (no date). Tobacco, Smoke free environments. Retrieved on 4 November 2013, from: 
EU-OSHA – European Agency for Safety and Health at Work (no date). Smoke at work. Retrieved on 23 January 2014, from: .
EU-OSHA – European Agency for Safety and Health at Work, Smoke-free workplaces – Advice for employers to create a healthy working environment, no date. Available at: .
EU-OSHA – European Agency for Safety and Health at Work, Smoke-free workplaces – Advice for non-smokers, no date. Available at: 
EU-OSHA – European Agency for Safety and Health at Work, Smoke-free workplaces – Advice for smokers, no date. Available at: 
Hang, B., Sarker, A.H., Havel, C., Saha, S., Hazra, T.K., Schick, S., Jacob. P., Rehan, V.K., Chenna, A., Sharan, D., Sleiman, M., Destaillats, H., Gundel, L.A., ‘Thirdhand smoke causes DNA damage in human cells’, Mutagenesis, no. 4, 28 Jul 2013, pp. 381-91. Available at: 
WHO – World Health Organization (2013). Tobacco control database for the WHO European Region. Retrieved on 4 November 2013, from: