Secondhand smoke is a scientifically proven health risk to nonsmokers.

• To educate the public about the health dangers of passive smoking, we need to properly convey the concrete scientific evidence proving the severity of its risks. It is also important for the public to know that "studies" showing that passive smoking is not harmful are generally funded by the tobacco industry and sometimes are not even conducted by scientists.

Messages that engage and empower

Messages not only convey information, but they also engage and empower citizens to actively resist passive smoking. Our message must be crafted to convey the vital information in ways that engage the target audience emotionally and that empower them to take action.

Some messages will resonate more strongly with some audiences than with others. For example, employees are most likely to be receptive to the direct effects of passive smoking on their own health, while parents are more likely to respond to messages about the harm passive smoking causes their children.

It is also important to focus on smoke and its effects on nonsmokers. This issue is not about smokers versus nonsmokers. It is about getting rid of the smoke, not the smoker, and it is about helping smokers quit for their own health and the health of those around them. The message we are trying to convey is that secondhand smoke is harmful and that no one should be exposed to increased health risk because someone else chooses to smoke.

This message is effective because it provokes an emotional response in almost any listener. Effective messages are characterized by this combination of sound science and emotive language. An effective message has several key components:

• It equates the damage from passively breathing smoke to the damage from direct smoking. We know that the public is more aware of the dangers of smoking than of dangers from secondhand smoke.
• It conveys the fact that even short periods of exposure are harmful.
• It evokes an emotional reaction from the use of scientific terms.
• It utilizes startling and memorable imagery.
• It clearly states the risk of grave health conditions such as heart attacks and strokes.

Another message that may encourage the public to take action concerns a 2002 case study conducted in Helena, Montana (USA). Researchers found that, in the six months following the enactment of a new smoke-free workplace law, heart attack frequency declined significantly. This message is effective for several reasons.

• It offers a positive indication of what can happen to public health when people stop smoking and breathing secondhand smoke in public places.
• It indicates that a ban on smoking in public places can reduce the incidence of heart attacks for smokers and nonsmokers alike.
• It demonstrates that the health benefits of clean indoor air ordinances are virtually immediate.
• It provides more scientific evidence that smoke-free workplace policies improve health and save lives, which should encourage communities around the world to take action to protect the health of their citizens.

Social math

Statistics can convey powerful messages without distorting the science on which they are based.

According to a 1997 report by the California Environmental Protection Agency (USA), the estimated annual tobacco-induced death rate among nonsmokers in California ranges from 147 to 251 per million. If the rate applied in the European Union, the annual toll would be 55,000 to 94,000 victims of passive smoking. In China, the same rate would result in a death toll of 185,000 to 317,000 per year. In the Americas, 122,000 to 209,000 nonsmokers die as a result of tobacco annually.#3 ASH-UK estimates that about 600 annual lung cancer deaths and up to 12,000 cases of heart disease in nonsmokers in the United Kingdom can be attributed to passive smoking. ⁴

This is a strong message that can be applied anywhere. It might be even more effective to phrase the message this way:

Another effective "social math" strategy is to estimate the annual health care and other costs attributed to passive smoking in your country or city. For example, researchers and advocates in Indiana (USA) published such an estimate in the Indianapolis Star newspaper to illustrate for the public the health hazards of passive smoking. According to the article:

• "The cost of disease and deaths related to passive smoking was estimated at $56 million in Marion County in 2000, according to a report being released today by the county Health Department."
• "It is estimated that $25 million was spent for adults suffering from ailments related to passive smoking, such as lung cancer and heart disease, and $31 million was spent for treating children for diseases, such as asthma and other respiratory conditions, caused by secondhand smoke."
• "The issue has mobilized health officials and researchers across the country to decry tobacco's effects on nonsmokers who are exposed to tobacco byproducts. Health officials say the smoke contains at least 250 chemicals known to be toxic or carcinogenic."
• "Passive smoking is a significant contributor to adult and childhood morbidity and mortality in the United States according to the study."
• "Sudden infant death syndrome, prenatal deaths, and low birth weights related to passive smoking cost the county more than $20 million in 2000, while the biggest smoking killer, lung cancer, cost $7.9 million."

General information on the dangers of passive smoking

While some information about the health risks of passive smoking is quite technical, and may not be useful in all messages, or for all audiences, it is important that advocates understand the science behind their position.

• A nonsmoker in the presence of a smoker, especially in enclosed spaces, is forced to breathe "sidestream" smoke from the burning tip of the smoker's cigarette and "mainstream" smoke that has been inhaled and then exhaled by the smoker.
• Tobacco smoke contains more than 4,000 chemicals in the form of particles and gases. ⁵
• Many potentially toxic gases are present in higher concentrations in sidestream smoke than in mainstream smoke, and nearly 85 percent of the smoke in a room results from sidestream smoke. ⁶
• The particulate phase includes tar (itself composed of many chemicals), nicotine, benzene, and benzo(a)pyrene. The gas phase includes carbon monoxide, ammonia, dimethylnitrosamine, formaldehyde, hydrogen cyanide, and acrolein. ⁷
• Some of these have strong irritant properties and at least 60 of them are known or suspected carcinogens (cancer-causing substances). The United States Environmental Protection Agency has classified environmental tobacco smoke as a "Class A" (known human) carcinogen along with asbestos, arsenic, benzene, and radon gas. ⁸

Health messages for the general public on the toxic chemicals in secondhand smoke

Generally, public opinion polls in the U.S. show that the public fears toxic chemicals in the air and the water. Therefore, messages that highlight the presence of hazardous chemicals in passive smoke can be effective.

For example:

• Secondhand smoke is a complex mix of thousands of chemicals. At least 40 substances in secondhand smoke are known to cause cancer. Tobacco smoke also contains large quantities of carbon monoxide, a gas that inhibits the blood's ability to carry oxygen to body tissues including vital organs such as the heart and brain, as well as other substances that contribute to heart disease and stroke. ⁹
• Humans are allergic to more than 4,000 toxic chemicals in smoke, including hydrogen cyanide. ¹⁰

Health messages illustrating the immediate effects of secondhand smoke

It is important that the public understand that not all ill effects of passive smoking take a long time to take effect. Many are virtually instant, and these messages convey the issue's urgency.

• Immediate effects of secondhand smoke include cardiovascular problems such as damage to cell walls in the circulatory system, thickening of the blood and arteries, and arteriosclerosis (hardening of the arteries) or heart disease, increasing the chance of heart attack or stroke. ¹¹
• Short-term exposure to tobacco smoke has a measurable effect on the heart in nonsmokers. Just 30 minutes of exposure is enough to reduce blood flow to the heart. ¹²
• Nonsmokers who are exposed to secondhand smoke in the home have a 25 percent increased risk of heart disease. As is the case with active smoking, much of the cardiovascular effect is due to acute poisoning. 13
• For asthma sufferers, tobacco smoke can cause immediate danger by triggering attacks. The majority of asthma sufferers report symptoms ranging from discomfort to acute attacks from exposure to secondhand smoke, and exposure to smoke can even cause new cases of asthma. ¹⁴

Health messages demonstrating the long-term effects of secondhand smoke

It is equally important that people understand that passive smoking causes serious long-term health problems for nonsmokers.

• In the longer term, individuals who are regularly exposed to secondhand smoke have an increased risk of suffering from a range of smoking-related diseases.
• A major review in the United Kingdom by the government-appointed Scientific Committee on Tobacco and Health (SCOTH) concluded that passive smoking is a cause of lung cancer and ischemic heart disease in adult nonsmokers and a cause of respiratory disease, cot death (also known as crib death or sudden infant death syndrome), middle ear infections, and asthmatic attacks in children. ¹⁵
• Individuals who are HIV positive may develop full-blown AIDS four times as quickly when regularly exposed to secondhand smoke. ¹⁶
• At home, at work, at school, in restaurants, in theatres, or in bars, secondhand smoke is a proven health threat to all people, in all countries.

Health messages about passive smoking in the workplace

Workers are most likely to respond to messages that stress the real health dangers they face from secondhand smoke. For most adults, the workplace is a greater source of exposure to secondhand smoke than the home.

• Secondhand smoke poses a serious health threat in the workplace because it contains toxic chemicals that can poison the heart and blood vessels and cause cancer and respiratory problems. Unfortunately, most workers are not in a position to change their work environment or to leave their jobs to protect their health. In many cases, where smoke-free workplaces are not guaranteed, employees find themselves forced to spend the majority of their waking hours in a health-threatening situation. ¹⁷
• People who are routinely exposed to secondhand smoke, such as workers in restaurants and bars, can expect their risk of lung cancer to triple. ¹⁸
• A 1994 study published in the British Medical Journal found that nonsmoking women in the Xi'an province of China had a 24 percent increased incidence of coronary disease if their husbands smoked and an 85 percent increased incidence if they were exposed to passive smoke at work. ¹⁹
• Finland, Germany, and the U.S. Public Health Service's National Toxicology Program have listed environmental tobacco smoke as a workplace carcinogen. ²⁰
• Levels of secondhand smoke in restaurants were approximately 1.6 to 2.0 times higher than in office workplaces or other businesses. Levels in bars are 3.9 to 6.1 times higher than in offices. The epidemiological evidence suggested that there may be a 50 percent increase in lung cancer risk among food service workers that is in part attributable to tobacco smoke exposure in the workplace. ²¹

Health messages about passive smoking for parents

Parents are most likely to respond to messages that stress the risks forced passive smoking poses to their children.

For example:

• The World Health Organization currently estimates that nearly 700 million, or almost half of the world's children, breathe air polluted by tobacco smoke, particularly at home. Infants and young children subjected to forced passive smoking experience:
  • Increased rates of lower respiratory tract infections, such as bronchitis and pneumonia.
  • Increased rates of ear infections.
  • Exacerbated chronic respiratory symptoms (such as asthma).
  • A four-fold increase in the risk of death from sudden infant death syndrome (SIDS). ²²
• Childhood exposure to secondhand smoke may also contribute to heart disease in adulthood and to behavioral problems. ²³
• Nonsmoking women who are exposed to secondhand smoke during pregnancy may impair fetal growth. ²⁴
• A British study indicates that in households where both parents smoke, young children have a 72 percent increased risk of respiratory illnesses. ²⁵
• A recent study shows that the higher levels of cotinine children have in their bodies, the lower, on average, their reading, math, and reasoning test scores, even after accounting for the education and income levels of their parents. Cotinine is a biomarker for exposure to secondhand smoke. ²⁶