Alice Trillin was 38 years old and in excellent health, she thought. Then "this completely crazy thing" happened.
"I coughed and a tiny, tiny blood clot took me to get a chest X-ray. Ten days later I had my lung removed."
Trillin had lung cancer, the kind smokers get.
But she had never smoked a cigarette.
The cause of her cancer remained a mystery until a doctor friend asked if her parents had smoked. Yes, Trillin told him, they smoked heavily.
"Nobody had ever said anything about passive smoking. I hadn't worried about the question much," she said.
Most scientists hadn't worried about the question much either, until studies in recent years showed that passive smoking was causing 3,000 to 5,000 lung cancer deaths a year in nonsmokers. Now a study estimates that the toll from passive smoking, including deaths from heart disease and other cancers, may be 10 times that.
Toll Could Be 46,000
Tobacco smoke in the home and workplace could be killing 46,000 nonsmokers each year in the United States, the study concludes. That's 3,000 lung cancer deaths, 11,000 from other cancers and 32,000 heart disease deaths.
That would make passive smoking the leading preventable cause of death after alcohol and smoking itself, said Dr. Ronald M. Davis, director of the U.S. Office on Smoking and Health. Smoking kills 390,000; alcohol, 120,000.
"No longer are we talking about runny nose or watery eyes or headache or nausea, but a fatal disease," said Davis. "Which ups the ante, so to speak, for passive smoking."
Passive smoking has become the principal battleground for the tobacco industry and its opponents in the 1980s. It is no longer merely a health issue, but political and environmental. Cigarette pollution is fouling the air.
"We know that the indoor environment is far more polluted than the outdoor environment," said James Repace of the Environmental Protection Agency indoor-air program. "We've seen that again and again wherever we've looked all over the United States."
Innocent Shouldn't Pay
Many people believe smokers have the right to smoke. But they also believe that others shouldn't have to pay a price.
"When you talk about an involuntary risk, the society becomes much more cautious," said University of California-San Francisco biomedical engineer Stanton Glantz, an environmentalist and anti-smoking activist.
The new estimate is controversial. Researchers agree it is preliminary and needs to be confirmed.
A tobacco industry consultant said the emphasis on passive smoking is misplaced. "Environmental tobacco smoke is a smoke screen that is keeping us from looking at the total problem, which is the quality of indoor air," said Dr. David Weeks, president of Per-Med Corp., a health consulting firm in Boise, Ida. "You take the tobacco smoke out of the air and you've still got the problem."
Many public health officials disagree.
The risk of tobacco smoke "is greater than the risk of radon gas is to nonsmokers," said Repace. "We're talking maybe 40% greater. And if you're talking about all the carcinogenic air pollutants that EPA regulates, it's 100 times greater."
EPA researchers in North Carolina say in a new internal report that environmental tobacco smoke "is a major source of indoor air pollution and is also the major combustion source contributing to total human exposure to mutagens and carcinogens."
Threat to Industry
The passive smoking issue poses a serious threat to the tobacco industry. A confidential opinion poll done for the industry in 1978, and leaked to anti-smoking activists, showed passive smoking was "the most dangerous development to the viability of the tobacco industry that has yet occurred."
"What the smoker does to himself may be his business, but what the smoker does to the nonsmoker is quite a different matter," the pollsters concluded.
Concern about passive smoking escalated in 1986 with two reports: The U.S. Surgeon General concluded that passive smoking doesn't merely raise the risk of lung cancer--it causes it. And the National Academy of Sciences said exposure to tobacco smoke may raise the risk of lung cancer in nonsmokers 34%.
Difficult to Treat
Alice Trillin was lucky; she was cured. But lung cancer remains one of the most difficult cancers to treat. Few others will have her luck.
The link between passive smoking and lung cancer is based on four lines of evidence, said Davis, whose Office on Smoking and Health prepares the Surgeon General's reports on smoking.
First, tobacco smoke contains known cancer-causing agents. Second, nonsmokers absorb smoke from the air; by-products can be measured in their blood. Third, there's no safe level of exposure to smoke. Fourth, many studies show that nonsmokers whose spouses smoke have a higher risk of lung cancer than nonsmokers whose spouses don't.
42 States Have Restrictions
At the end of 1987, 42 states had imposed some restrictions on smoking in public, more than double the number in the early 1970s, said Davis. Thirty-two states restrict smoking in the workplace.
The nation's two largest air-quality agencies, the EPA and the California Air Resources Board, are preparing assessments of the danger of passive smoking. Both have included the new estimate in their calculations.
The estimate comes from a study published in the December issue of Environment International by A. Judson Wells, a researcher in Wilmington, Del., and a volunteer with the American Lung Assn.
"In general, we don't think Dr. Wells is going to be off base at all," said Margaret Jenkins, coordinator of the indoor air quality program for the California Air Resources Board.
Heart Disease Worst
The paper's findings on lung cancer agree with other studies; its findings on heart disease and other cancers are more speculative, but plausible, Repace said. "The largest source of death from active smoking is, of course, heart disease. We know the arteries of smokers get plugged up very rapidly, and it is very possible that these same effects could occur in passive smokers."
Wells said he himself was surprised by his estimate. "When I first calculated these numbers, they scared the hell out of me. I'd be the first to admit they're wrong, if we can find out why they're wrong."
So far, no one has, although not everyone accepts Wells' estimate.
Weeks, the industry consultant, dismissed Wells' study, as he does concern about passive smoking altogether. He believes passive smoking causes no risk, but he doesn't think any of the data on the subject are very good.
Many researchers would agree that current estimates are imprecise.
But Repace answers Weeks this way: "Environmental tobacco smoke is tobacco smoke. And tobacco smoke is known to cause 400,000 deaths a year. Here is a known carcinogen to human beings. Are we to assume that low levels are innocuous? The question is, what standard of proof you require before you take public action?"
The risk to a nonsmoker in a typical office is about the same as the risk for a nonsmoker whose spouse smokes, he said. "In a typical office with good ventilation, you're running about 250 times the maximum acceptable cancer risk for environmental carcinogens in air or water or food."
Office Risk High
That is, among 100,000 workers, you'd expect 250 of them to die from lung cancer caused by passive smoking. "And in the poorly ventilated office, it would be four times as high," Repace said.
Occasional exposure in a bar, restaurant or car probably is not nearly as great a risk as exposure in the home or the office, he said.
Most of the regulatory emphasis now is on curbing smoke in the workplace. "It's one of the two most important places of exposure to tobacco smoke, the other being the home," Davis said. "For somebody who doesn't have any smokers in the home, the work site would be the most important place."
Even many smokers favor policies that curb the passive smoking risk.
Smokers Aware of Problem
According to the 1989 Surgeon General's report on smoking, 64% of smokers believe their habit is hazardous to nonsmokers' health. Thirty-four percent of smokers were bothered by other people's smoking.
The question for nonsmokers is how aggressively to avoid tobacco smoke.
"I'm sure one day's exposure isn't going to do you any harm," said Wells. "But every little bit adds to what you've accumulated heretofore.
"Only the most sensitive individuals are going to die of passive smoking. The problem is, we don't know who they are. It could be you. It could be me."