Unwilling Fighter in War on Secondhand Smoke : Health: Rosita Garcia says she got cancer as waitress in a bar. But ex-employer has fought off workers’ comp claim.

Rosita Garcia never wanted to be a poster girl for the fight against tobacco. But here she is, living testimony in the debate over the dangers of secondhand smoke: the cocktail waitress who never touched a cigarette but got lung cancer after 11 years of serving drinks in the blue haze of a smoky airport bar.

This is not how she wants to be remembered. At 39, she is a very private woman, a former fitness buff (she quit exercising when the cancer was discovered) who hates to be thought of as being sick. She does not look sick; there is color in her cheeks, her dark eyes are bright, her waistline is full--a sign that she is again eating well.

Yet the evidence is there, if one looks close enough. She wears her reddish-brown hair in a pixie cut, not by design but by necessity--it is just growing back after chemotherapy and radiation. With every few sentences, she lets out a sputtering cough. Lately, she says, her chest has been hurting. Sometimes, she must excuse herself to vomit.

The coldest proof of all sits in the medical file that Garcia keeps in the closet of her tiny government-subsidized apartment in Daly City, a working-class suburb just south of San Francisco. Although her disease, diagnosed nearly three years ago, is confined to a single lung and is not getting worse, neither is it getting better. Her tumors, reduced to scar tissue by radiation, may recur. Her oncologist says she is lucky to have survived. Her prognosis: Fair.

Garcia rarely looks in the file. She does not want to think about what it says. “I don’t believe that,” she says optimistically. “I think I’m getting better.”

Garcia’s plight provides a snapshot of the human side of the emotional secondhand smoke debate. Last year, the U.S. Environmental Protection Agency declared secondhand smoke a human carcinogen, saying that it causes 3,000 lung cancer deaths a year. Health advocacy groups put the annual total death toll at 53,000 from secondhand smoke, including deaths from various forms of cancer as well as heart disease.

Despite these figures and several hundred scientific studies documenting the ill effects of secondhand smoke, the tobacco industry counters with research showing that it is little more than a nuisance. As a consequence, Garcia and others who count themselves as its victims must battle not only disease, but also skeptics.

For Garcia, the fight comes with a price tag: $26,889. That is the cost of her medical care. She is seeking this amount, plus her weekly wages, in a workers’ compensation suit that is languishing in the bureaucracy while she lives on disability checks of $600 a month. Her former employer, Host Marriott, which operates the bars where Garcia worked for more than a decade, thus far has successfully fought the claim, saying Garcia did not get sick at work.

At the San Francisco airport, a handful of Garcia’s former colleagues have waged a losing battle to clean the barroom air. Ironically, the airport has won plaudits for its aggressive anti-smoking policy; in 1991, it became the first airport in the nation to ban tobacco in all public places--with one notable exception: bars.

For the next two years there was nowhere else for smokers to go. Then in 1993, the airport began installing ventilated smoking rooms. Although airport officials could have banned tobacco in the bars, they left that decision to Host Marriott, which after a trial ban chose to permit it.

The reason? Economics. Bars lose money when patrons cannot smoke. Customers complained. Tips got so low that even the bartenders--many of whom say the smoke makes them sick--asked to have smoking back.

“No smoking did not go over well,” said Nancy Wood, a Host Marriott official. “We had a very hard time explaining to our client base, which is largely international travelers, why they couldn’t smoke in the bar.”

“It was a total fight in anger and futility,” said Elizabeth Voigt, a friend of Garcia and former airport bartender. Voigt says she also is a victim of secondhand smoke, but unlike Garcia, she does not trace her illness solely to tobacco. Like many victims, she has an underlying medical disorder--a heart condition--that is exacerbated by secondhand smoke. She has developed a phrase for herself: “I am,” she says, “a disabled American who cannot be around secondhand smoke.”

Voigt is recovering from heart surgery at Stanford University Hospital. Although Host Marriott officials say they went to great lengths to accommodate her--installing ventilation and a separate time clock in a smoke-free area--Voigt complains that passengers and airline employees are protected while she and other bartenders are not.

“I am not a human being?” she asks, her voice laced with sarcasm. “I don’t have a heart? I don’t have lungs?”

*

The struggle at the San Francisco airport typifies a nationwide wrestling match over the issue of secondhand smoke. While more workplaces are banning tobacco use, in restaurants, bars and other quarters, matters of health collide with matters of money.

Money often wins.

Moreover, what is sufficient proof for the medical Establishment may not be good enough in a courtroom, as Garcia’s faltering workplace injury claim reveals. The case, which is hung up on a technicality, pits the word of a noted researcher--who says Garcia’s lung cancer was caused by secondhand smoke--against the word of a Host Marriott doctor, who says it was not.

Nationwide, there have been dozens of lawsuits and workers’ compensation cases filed by victims of secondhand smoke, including a recent $650-million wrongful death suit filed against tobacco manufacturers by the heirs of a Mississippi barber. Although no one is tracking the results, there have been some victories, particularly in California, which has long been considered a leader in the anti-smoking movement.

Esther Schiller, a former Los Angeles teacher whose lungs were so damaged by secondhand smoke that she has difficulty talking, won $29,999 after a workers’ compensation judge found that smoke from a teachers lounge had drifted into her classroom and left her disabled. She now coordinates a statewide network of secondhand smoke victims.

Avatar Ubhi is a 58-year-old San Francisco Bay Area waiter who had a heart attack after years of working in a smoky restaurant. He won a $90,000 settlement shortly after the U.S. Environmental Protection Agency released preliminary data deeming secondhand smoke a human carcinogen. He now owns a smoke-free restaurant in Sausalito.

But for every Schiller and Ubhi, anti-smoking advocates say, there is a Garcia--a victim who fights and gets nowhere, or worse, one who is afraid to fight at all.

“There are many, many more (victims),” said Juliette Linzer, project director at one of the Bay Area affiliates of the American Lung Assn. After learning of Garcia’s case, Linzer won a $40,000 state grant last year to create a group called BREATH--Bar and Restaurant Employees Against Tobacco Hazards. But the group, which hoped to change smoking policies, met with little success; bartenders and waiters are often afraid that if they speak out, they will be fired.

“I just got a call from somebody at a casino in Nevada who told me that she’s the only one who is willing to speak up and say anything, and she’s scared for her job,” Linzer said. “She told me that all of her co-workers face what she does--they have trouble breathing, they have shortness of breath, sinus problems, headaches and dizziness, and on days when they don’t work, they don’t experience these symptoms.”

*

To Rosita Garcia, this is a familiar, painful tale.

Her father always warned her about cigarettes. She came to San Francisco from the Philippines to live with him when she was 16. He was a smoker, but never around his children. Although smoking never made him sick--and there is no history of cancer in the Garcia family--David Garcia begged his children not to pick up his unhealthful habit. Often, he would show them pictures of lungs blackened by years of smoke. Young Rosita got the message.

She left home at 18. After a series of jobs--waitressing at Woolworth’s, assembling yo-yos, working as a nurse’s aide--she was hired by Host Marriott.

This was 1980, and nobody was thinking much about secondhand smoke. Garcia was 24. She was jogging and doing aerobics. She thought she was in great health, despite the incessant headaches that came on at work. Anyway, the money was too good to leave--about $100 a day including tips. Often, she would joke with her smoking customers.

“I’ll probably catch cancer,” she would say.

The first sign that something was wrong came in the summer of 1991. The airport had gone smoke-free a few months earlier. For the 31,000 workers and 88,000 travelers who pass through each day--the majority of them nonsmokers--the policy made San Francisco International a much nicer place. For cocktail waitresses, the new rule created an ironic backlash; it made dirty air even dirtier by driving smokers into the bars.

At night, a hacking, dry cough kept her awake. The first attack came on the afternoon of Aug. 8, as she was working her regular 4 p.m. to midnight shift at the Hub Bar, one of the airport’s busiest. “It felt like there was a bubble inside my right chest and it just burst.”

The doctor said it was pneumonia. After two weeks of antibiotics and coughing up sputum streaked with blood, she went back to the hospital. As she was waiting for an X-ray, it happened again. Her chest hurt so much that she thought it was a heart attack. There were more tests--X-rays, bronchoscopy (in which the doctors threaded a tube through her nose to examine her lungs), and then a biopsy. Chemotherapy and 37 consecutive days of radiation treatment lay ahead.

On Sept. 24, 1991, the doctor called. She talked medical talk: squamous cell carcinoma, a right hilar mass extending into the mediastinum. Garcia’s head was swirling. “The only words I understood were: ‘So we will call it cancer. You have cancer.’ ”

*

In a bare-walled government office in the San Francisco Civic Center, the details of Garcia’s disease and treatment are revealed in a three-inch-thick sheaf of paperwork, Workers’ Compensation Case SFU O360532. Here, dueling medical reports--each buttressed by scientific research--debate the cause of Garcia’s lung cancer.

The risk of a nonsmoker getting lung cancer is 1 in 250, far lower than the 1-in-8 risk for a smoker, according to Lawrence Garfinkel, a consultant to the American Cancer Society. And of all diseases that may be caused by secondhand smoke, the link to lung cancer is most firmly established. But, Garfinkel notes, “any one case is hard to prove.”

The key question for Garcia, in the cumbersome language of state bureaucrats, is whether her disability is “the result of occupation, either as an industrial accident or as an occupational disease.”

The answer?

Yes, said Dr. Christine Angeles, the Kaiser Permanente physician who first treated Garcia. Angeles based her conclusion on Garcia’s account that she had been exposed to excessive secondhand smoke at work.

No, said Dr. Irene Danse, who was hired by Host Marriott lawyers to examine Garcia. Noting that Garcia is Filipino, Danse wrote in her report that Asian women, “for some reason that has not been defined,” seem prone to lung cancer. Citing a study that found Garcia’s workplace exposure to be equivalent to smoking one cigarette per day, Danse concluded: “I cannot link her lung cancer to her job.”

To counter that assertion, Garcia’s lawyer hired Stanton A. Glantz, professor of medicine at UC San Francisco and one of the nation’s most respected researchers on the issue of secondhand smoke.

Glantz reviewed Garcia’s medical records. He found that she had only incidental exposure to secondhand smoke at home, that she had no exposure to other toxic agents--such as asbestos or radon--that might have caused her cancer. He dismissed the study Danse cited as flawed and said she had ignored “large and compelling scientific literature.” Garcia’s cancer, he concluded, was caused “in major part, by her exposure to environmental tobacco smoke at her place of employment.”

But there was a problem with Glantz’s report. He is a Ph.D., not a medical doctor, and he never examined Garcia. So Host Marriott persuaded a workers’ compensation judge to strike his testimony. The judge also ruled that it was too late for Garcia to be examined by a medical doctor. That was in March, 1993, and the question of whether Glantz will be permitted to testify has lingered on appeal. Without Glantz, Garcia’s lawyer says, he has no case.

Tom McBirnie, a staff attorney for the Workers’ Compensation Board, suspects that Garcia’s claim has been delayed in part because workers’ compensation law is not equipped to deal with the emerging science of secondhand smoke.

“What we basically see,” McBirnie said, “are bad backs and stress claims.”

In his small, cluttered office at Moffitt Hospital, Glantz grows furious when he talks about the judge’s ruling. Leaning back in his chair, he shakes his curly mop of gray hair, says he does not understand how any doctor can be allowed to examine Garcia and render an “expert opinion,” while his words, based on a career of research, do not count.

“It’s outrageous!” he thunders. “A cheap procedural trick.”

*

Not much has changed at the San Francisco airport since Garcia served her last drink nearly three years ago. The fight over secondhand smoke in the bars is pretty much over. One bar went smoke-free after airline employees complained, and the bartenders who work there say they are losing money.

If anyone is carrying on Garcia’s legacy, it is Michelle Barron. She is the sole bartender in a tiny cocktail lounge, a peach-and-burgundy place where double screwdrivers can be had for a dollar extra, and she is surreptitiously waging her own war on smokers. Although smoking is permitted in her bar, she has plastered it with no smoking signs. Her bosses have made peace with her by looking the other way.

On a recent Wednesday morning, a passenger in khakis and a golf cap came into her bar and ordered a gin and tonic. “There’s no smoking anywhere around here, is there?” he asked.

“No,” Barron said simply, and that was that.

In fact, there is smoking down the hall, in one of four new glass-enclosed smoking rooms that resemble smoky fishbowls. One airport official said he spent 30 minutes inside one “and my throat was scratchy for the next three days.”

The rooms are not a big hit with smokers. “This,” said one, “is exactly like people felt when they were forced to sit in the back of the bus.”

But this is the balance the San Francisco airport has struck--a balance that tips largely in favor of nonsmokers, yet still fails to protect everyone. Other airports, including Memphis, Tenn., and Dallas-Ft. Worth, have gone completely smoke-free, and Los Angeles International Airport is planning to do the same. But from his corner office, with a sweeping view of the runways, the airport’s general manager, a frenetic engineer named Louis Turpen, says more restrictions in San Francisco are not likely anytime soon.

“Is it perfect?” he asks. “No, it is not perfect. But I think we have done it as well as it can be done.”

As for Garcia, she spends her days visiting with friends and family, reading her collection of medical texts and investigating various alternative remedies to improve her health. She has tried tree bark juice and herbal treatments, even capsules containing ground-up shark cartilage, which is being hawked by a doctor on the theory that “sharks don’t get cancer.”

She would like someday to return to work--not as a cocktail waitress, but perhaps in health care. Her dream of becoming a nurse seems beyond reach--she does not have the money for school--but she has enrolled in an eight-month course to become a medical technician. She starts June 13, and is hoping that school will mark a new beginning.

She misses her aerobics, and being able to go out dancing and partying with friends, but she sounds upbeat. “I’m a very happy person, very happy,” she says. “Right now, I live every day and I don’t have to worry that I have to go to work and face the smoking world.”

Deadly Consequences

Epidemiologists--people who study patterns of disease--estimate that secondhand smoke claims 53,000 lives each year, including 3,000 from lung cancer and as many as 40,000 from heart disease. Here are the leading causes of death in the United States, using the most recently available statistics for each.

Cause (Year) Deaths (in thousands) Smoking (1993) 434 Alcohol (1988) 107.8 Secondhand smoke (1993) 53.0 Vehicle accidents (1991) 43.5 AIDS (1992) 33.5 Suicide (1991) 30.8 Homicide (1992) 26.5

Sources: U.S. Centers for Center Disease Control, Coalition on Smoking OR Health, National Institute on Alcohol Abuse and Alcoholism. Motor vehicle accident, suicide and homicide figures actual; all others estimated.

Secondhand Smoke: A Chronology

* 1971: Surgeon General Jesse Steinfeld first raises possibility that secondhand smoke may cause disease in nonsmokers. United Airlines becomes first major carrier to separate passengers into smoking and nonsmoking sections.

* 1972: Surgeon general reports secondhand smoke can “contribute to discomfort of others.” Anti-smoking advocates press for restrictions on planes, trains and buses.

* 1973: Arizona becomes first state to pass law prohibiting smoking in select public places. Civil Aeronautics Board orders all domestic airlines to separate smokers and nonsmokers.

* 1975: More states--including Alaska, Kansas, Minnesota, Texas and New York--enact legislation restricting smoking. Surgeon general reports that children of smokers are more likely to have bronchitis and pneumonia during first year of life.

* 1976: California and Utah pass laws restricting smoking. National Park Service bans smoking in federally owned caves.

* 1977: Cigar and pipe smoking banned on planes.

* 1978: Health, Education and Welfare Secretary Joseph Califano announces anti-smoking campaign and restricts smoking to designated areas in all HEW buildings. House Committee on Agriculture hears testimony that smoking is not hazardous to nonsmokers.

* 1980: General Accounting Office deems smoking “a major indoor source of (air pollution) and potential cause of lung cancer,” calls for Environmental Protection Agency to regulate smoking indoors.

* 1981: First studies are published connecting secondhand smoke to lung cancer. Tobacco Institute unleashes counterattack with full-page newspaper ads. American Cancer Society publishes study showing only weak link between secondhand smoke and lung cancer.

* 1983: Two more studies connect secondhand smoke to lung cancer, bringing total to six.

* 1985: EPA and U.S. Public Health Service ask National Academy of Sciences to assess risk of secondhand smoke. Congress asks academy to determine whether air quality on commercial planes is adequate. Florida, New Jersey, New Mexico and Washington enact smoking restrictions.

* 1986: Surgeon general issues major report concluding secondhand smoke causes disease, including lung cancer, in healthy nonsmokers. Says simply separating smokers and nonsmokers does not eliminate the danger.

* 1987: Congress bans smoking on all airplane flights shorter than two hours.

* 1989: Smoking banned on all domestic flights.

* 1991: EPA, in draft report, says secondhand smoke should be classified as a human carcinogen. White House bans smoking in its kitchen, locker rooms and maintenance areas.

* 1992: UC San Francisco researchers estimate that 53,000 nonsmokers each year die of exposure to secondhand smoke, including 37,000 to 40,000 heart disease deaths.

* 1993: EPA releases final report, declares secondhand smoke a carcinogen responsible for 3,000 lung cancer deaths in nonsmokers. First Lady Hillary Rodham Clinton bans smoking in White House.

* 1994: More than 600 state and local ordinances restrict smoking. Congress considers a bill to ban smoking in nearly all buildings except private clubs and restaurants. OSHA considers banning smoking in all workplaces. Tobacco industry fights back, pushes California ballot initiative that would repeal all local tobacco laws and replace them with a weaker statewide standard. Cigarette maker RJ Reynolds launches public information campaign designed to prove secondhand smoke is less dangerous than most people think.

Source: Donald Shopland, National Cancer Institute