Numerous studies indicate that hospitality workers, particularly bar and tavern workers, are exposed to SHS in the workplace. Moreover, laws that prohibit smoking in hospitality workplaces are highly effective in reducing exposure. After the California workplace smoking ban went into effect, self-reported workplace exposure to SHS decreased from a median of 28 to 2 hours per week [2]. Total SHS exposure decreased from a median of 40 to 10 hours per week. Other studies have confirmed that hospitality workers experience markedly decreased SHS exposure after smoke-free workplaces are mandated, including self-reported exposure, measurement of cotinine (in saliva, urine or serum) and hair nicotine.

Other studies have investigated the impact of smoke-free workplace laws on direct measurement of SHS constituents in the indoor environment. Investigators measured indoor PM_2.5 levels in Irish pubs before and after the national smoking ban [3]. Before the ban, the average indoor level of PM_2.5 was 35.5 μg/m³; after the ban the average level declined by 84% to 5.8 μg/m³. Of note, the post-ban PM_2.5 level was the same as that in outdoor air, which is expected if there is no indoor point source of exposure (such as SHS). Indoor air levels of benzene, which is an established carcinogen, also decreased by 80%. Other studies have also shown that workplace smoking bans result in marked reduction in fine particles and carcinogens in the indoor air.

In sum, when smoking is permitted, hospitality workers are exposed to high levels of SHS, which includes potent respiratory irritants and carcinogens. Laws that ban workplace smoking are rapidly effective in reducing exposure of hospitality workers to these dangerous substances.

In the state of California, smoking was banned in most workplaces effective 1 January 1996 and in all bars and taverns effective 1 January 1998. Using a case-crossover design, we studied the effects of the law, which prohibited tobacco smoking in bars and taverns, on the respiratory health of bartenders [2]. Based on a random sample of all bars and taverns in San Francisco, we interviewed and performed spirometry on 53 bartenders before and after the smoking ban. After prohibition of smoking, self-reported workplace SHS exposure sharply declined from a median of 28 to 2 hours per week. Thirty-nine (74%) of the 53 bartenders reported at least one respiratory symptom at baseline (including cough, dyspnea and wheezing), while only 17 (32%) were still symptomatic at follow-up. Of the 39 bartenders reporting baseline symptoms, 23 subjects (59%) no longer indicated any respiratory symptoms after prohibition of smoking (p < 0.001). In conditional logistic regression analysis, a 5 hours reduction of workplace ETS exposure was associated with a lower risk of respiratory symptoms at follow-up (OR 0.7; 95% CI 0.5-0.9), after controlling for upper respiratory infections and reduced personal cigarette smoking. The majority also reported sensory irritation symptoms (77%), which largely resolved after the smoke-free workplace law went into effect (19% at follow-up, reflecting a 78% reduction).

After prohibition of workplace smoking, pulmonary function also rapidly improved. We observed an improvement in mean FVC (189 ml; 95% CI 82-296 ml) and mean FEV₁ (39 ml; 95% CI 30-107 ml). Complete cessation of workplace SHS exposure was associated with an even greater pulmonary function improvement.

Other studies from Scotland, Ireland, Norway and the USA, using a similar design, have shown a substantial decline in respiratory and sensory irritation symptoms among hospitality workers after their workplaces became smoke-free [2, 4]. In addition, pulmonary function has improved quickly after the smoking ban; this benefit has been observed up to 6 months after the smoking ban went into effect. It is important to note that both smokers and nonsmokers benefit from smoke-free workplace legislation; both experienced reduction in respiratory and sensory irritation symptoms.

Other studies show that hospitality workers can experience a substantive decrement in pulmonary function after a single work shift in a smoky environment, suggesting that SHS has acute negative effects on airway tone and pulmonary function [4, 5]. In other studies, this cross-shift reduction of pulmonary function improved after a workplace smoking ban reduced SHS exposure.

Studies demonstrating that smoke-free workplace legislation leads to rapid improvement in pulmonary function add to the general epidemiologic literature on the effects of SHS on lung function. These observations help clarify the previously published mixed results that are based mostly on cross-sectional or small studies that have lacked the prospective design, control for confounding or statistical power to definitively link SHS exposure to impaired pulmonary function. Taken together with a recent large prospective study, these hospitality worker studies strongly suggest a negative effect of SHS exposure on pulmonary function.

Adults with asthma, because they have chronic airway inflammation, may be particularly susceptible to the respiratory health effects of SHS exposure. The Scottish smoking ban study showed that bar workers with asthma had a markedly greater improvement in pulmonary function than those without asthma after the smoking ban [4]. Bar workers with asthma enjoyed an average 10.1% predicted improvement in FEV₁, compared with a 3.4% predicted increase among those without asthma. This was accompanied by a reduction in exhaled nitric oxide, a biomarker of airway inflammation and improved health-related quality of life. Consequently, hospitality workers with asthma have a substantially greater improvement in respiratory health after their workplaces become smoke-free.

In a population-based study of US adults, we examined the impact of cumulative lifetime SHS exposure and the risk of having chronic obstructive pulmonary disease (COPD). Higher lifetime SHS exposure, both at home and work, was associated with a greater risk of COPD, even after taking personal smoking history into account. On a population level, approximately 1 in 11 cases of COPD may be attributed, at least in part, to home SHS exposure; 1 in 15 cases may be attributable to workplace SHS exposure [6].

Other epidemiologic literature, albeit limited, also supports an association between SHS exposure and chronic bronchitis or obstructive pulmonary disease (which includes asthma) [7]. A study from Denmark found that hotel-restaurant workers were at elevated risk of COPD, although there was no direct control for personal smoking as a confounding factor [8]. In sum, hospitality workers, who are exposed to a high level of SHS at work and have a high lifetime smoking prevalence, are likely to be at increased risk of COPD.

Because adults with asthma have chronic airway inflammation, they may be particularly susceptible to the effects of SHS exposure. Surprisingly, adults with asthma do not appear to selectively avoid SHS exposure. Studies show that SHS exposure is associated with increased asthma symptoms, rescue bronchodilator use, asthma severity and emergency department use and hospitalization for asthma exacerbation [9]. In addition, SHS exposure has been associated with decreased physical health status and health-related quality of life. In its recent review of the health effects of SHS exposure, the California Environmental Protection Agency concluded that SHS exposure is causally related to increased asthma severity among adults with asthma [9].

There is much less information about the effects of SHS exposure on persons with established COPD who no longer smoke. In a prospective population-based cohort study of adults with COPD, we previously studied the impact of directly measured SHS exposure on health outcomes [10]. The highest tertile of urine cotinine was longitudinally associated with greater dyspnea, worse COPD severity and poorer health status among adults with COPD. Although more work is needed, it appears that SHS exposure may indeed negatively affect the health of patients with COPD.

Extensive evidence now indicates that banning smoking in the indoor work environment eliminates SHS exposure. Creating nonsmoking areas, installing ventilation systems or using air cleaners does not protect workers from SHS exposure [11]. A smoke-free workplace policy is the only effective method for eliminating SHS exposure. Because there is no known safe threshold for SHS exposure, complete elimination of workplace exposure must be achieved to prevent serious health consequences.

Creation of smoke-free workplaces has another important public health benefit: a higher rate of smoking cessation among active smokers. Those who continue to smoke reduce their daily cigarette consumption. Shortly after the Irish smoke-free workplace legislation went into effect, a substantial proportion of smokers quit (15%) and many attributed their smoking cessation to the law. Smoke-free workplace laws, by reducing passive and active smoking, will lead to substantive health benefits for the population.

Mandating smoke-free workplaces will decrease secondhand smoke exposure and will improve respiratory health, prevent chronic disease and extend life span. Important salutary health effects occur in as little as 1 month after cessation of SHS exposure. The comprehensive body of research documenting the serious adverse health effects of passive smoking provides a powerful rationale for prohibiting smoking in all workplaces.

Smoke-free workplace laws are effective in reducing exposure only if compliance with the law is achieved. Potentially, achieving compliance could be particularly difficult in the hospitality industry. In fact, smoke-free workplace laws are effective in achieving compliance. Four years after the California ban on smoking in bars, compliance with the law was high: 99% of bars in restaurants and 76% of freestanding bars were smoke-free [13]. Near-perfect compliance has been reported in Boston, Ireland and New Zealand.

A concern is often expressed that the general public will not accept smoke-free bars and restaurants. A series of international studies shows that most people do support smoke-free bars and restaurants. Moreover, opinions become increasingly positive following smoke-free legislation. Many bar and restaurant workers enjoy the benefits of working in a smoke-free environment.

Adverse economic consequences are often cited: will smoke-free laws cause the hospitality industry to lose money? Fortunately, the answer is no. Using sales tax and other objective financial data, studies now conclusively demonstrate that bars, restaurants and hotels do not lose revenue after becoming smoke-free. In fact, some of these studies actually show a growth in income. In sum, smoke-free legislation is effective, accepted by the public and has no negative economic impact. It would appear to be a win-win situation for both health and business.

The practicing clinician may be faced with symptoms referable to the eyes (conjunctival injection, conjunctival pruritis or eye tearing), upper respiratory tract (rhinorrhea, nasal burning, nasal stuffiness or sore throat) or lower respiratory tract (cough, sputum production, dyspnea or wheezing). If the occupational history reveals a job in the hospitality sector, then SHS exposure must be suspected as a cause of these symptoms. A detailed history should be taken to assess for SHS exposure and its avoidance should be counseled. Even among active smokers, SHS exposure may have additional deleterious effects on the respiratory tract.

In addition, any patient with obstructive lung disease, including asthma or COPD, should be assessed for SHS exposure. Because SHS exacerbates asthma, and may make COPD worse, counseling patients to avoid SHS exposure is an important part of clinical management. In particular, excessive use of short-acting bronchodilators may be a clue to ongoing SHS exposure. Although the most effective strategy for reducing SHS exposure is creating a smoke-free work environment, a change in job or job duties may be the only practical approach for an individual patient who works in the hospitality industry in the short term.

Besides health conditions related to SHS exposure, hospitality workers may also be prone to health effects from other exposures. These may include alcohol dependence from alcohol consumption, hearing loss from excessive noise exposure, sleep disturbance from night-time shift work and violence. A careful occupational history should also elicit these and other potential exposures. A program of prevention can then be orchestrated with the patient and his or her employer.

Hospitality workers are often exposed to very high levels of SHS over a long time period. Consequently, they are at risk of serious health consequences, ranging from chronic respiratory symptoms to lung cancer. Studies of smoke-free workplace legislation clearly document the rapid benefit of improved respiratory health. Long-term benefits are likely to include a lower risk of coronary heart disease, other cancers and obstructive lung disease burden. Smoke-free workplaces are effective, accepted and good for business. To improve the health of hospitality workers, and all exposed workers, a total global ban on smoking in workplaces and all public places is mandatory.

Clinicians may be faced with respiratory and nonrespiratory health conditions that are caused or exacerbated by SHS exposure in the workplace. Consideration of SHS exposure in the differential diagnosis of upper and lower respiratory tract conditions is particularly important. Measures to reduce exposure, such as a change in job or job duties, may be an important step in the management of these patients. The ultimate solution, of course, is to create smoke-free workplaces to protect all workers from the health effects of SHS exposure.

References

1. Siegel, M. (1993) Involuntary smoking in the restaurant workplace. A review of employee exposure and health effects. JAMA 270(4): 490-493.

2. Eisner, M.D., Smith, A.K., Blanc, P.D. (1998) Bartenders’ respiratory health after establishment of smoke-free bars and taverns. JAMA 280(22): 1909-1914.

3. Goodman, P., Agnew, M., McCaffrey, M., Paul, G., Clancy, L. (2007) Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs. Am. J. Respir. Crit. Care Med. 175(8): 840-845.

4. Menzies, D., Nair, A., Williamson, P.A. et al. (2006) Respiratory symptoms, pulmonary function, and markers of inflammation among bar workers before and after a legislative ban on smoking in public places. JAMA 296(14): 1742-1748.

5. Dimich-Ward, H., Lawason, J., Chan-Yeung, M. (1998) Work shift changes in lung function in bar workers exposed to environmental tobacco smoke. Am. J. Respir. Crit. Care Med. 157: A505.

6. Eisner, M.D., Balmes, J., Katz, P.P., Trupin, L., Yelin, E.H., Blanc, P.D. (2005) Lifetime environmental tobacco smoke exposure and the risk of chronic obstructive pulmonary disease. Environ. Health 4(1): 7.

7. Yin, P., Jiang, C.Q., Cheng, K.K. et al. (2007) Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study. Lancet 370(9589): 751-757.

8. Tuchsen, F., Hannerz, H. (2000) Social and occupational differences in chronic obstructive lung disease in Denmark 1981-1993. Am. J. Ind. Med. 37(3): 300-306.