In the debate over the health effects of smoking in restaurants and bars, one group has been largely ignored: restaurant and bar employees.
A new study reported today in the Journal of the American Medical Association suggests that such employees have a 50 percent to 90 percent higher risk of developing lung cancer because of the unusually high levels of tobacco smoke in the air of such establishments.
"The thing that is really important is that the study establishes that restaurants aren't just public places, they are workplaces," said Dr. Stanton A. Glantz, a cardiologist at the University of California, San Francisco. "This suggests strongly that high levels of smoke are a real threat to the employees there."
The author of the study is Dr. Michael Siegel, an epidemiologist who was at the University of California, Berkeley when he carried out his research but is now at the federal Centers for Disease Control and Prevention in Atlanta. Dr. Siegel drew together information from previous studies that analyzed the amount of tobacco smoke in bars and restaurants and from other studies about the health of workers in various industries.
"Public health efforts to regulate smoking in bars and restaurants can no longer focus only on protecting the patron," Dr. Siegel wrote.
"That's a worthwhile thing to do because nobody ever looked at it in the way he did," Dr. Glantz said. "Nobody had ever put together the exposure data and the cancer rates before."
Compiling results from previous studies, Dr. Siegel found that the levels of environmental tobacco smoke, commonly known as ETS, in restaurants averages 1.6 to 2 times higher than levels in workplaces of other businesses and 1.5 times higher than in residences of smokers.
The air was worse in bars. There, levels of ETS were 3.9 to 6.1 times higher than in other workplaces and 4.4 to 4.5 times as high as in smokers' homes.
Overall, the epidemiological evidence from six prior studies showed that the workers were at a 50 percent to 90 percent increased risk of developing lung cancer.
"It appears clear that ETS is increasing lung cancer risk," Dr. Siegel said. "To protect these workers, smoking in bars and restaurants should be prohibited."
His study of cancer is "only the tip of the iceberg," Dr. Siegel added.
Previous studies have shown that ETS is also a major contributor to heart disease, which has not been studied among food-service workers.
Although the contribution of ETS to heart disease is smaller than its contribution to lung cancer, the number of people with heart disease is much larger than the number with lung cancer and ETS will thus have a larger impact.
The issue also has direct impact on the pocketbooks of the public, added Dr. Raymond Melrose, an oral pathologist at the University of Southern California who serves as a spokesman for the local American Cancer Society on the issue.
"Many times these workers are not highly paid, not unionized and may not have access to health benefits," he said.
"When they become ill, they often delay seeking medical care because of their lack of access. They end up in county health facilities with prolonged stays and irreversible damage. All of this costs all of us a lot of money."