James L. Repace, MSc
Visiting Assistant Clinical Professor
Department of Family and Community Medicine
Tufts University School of Medicine
The problem: The tobacco industry had asserted that restaurants could install modern ventilation systems and therefore safely provide no-smoking sections to patrons. Tobacco industry advocates and restaurant associations argued that new ventilation systems removed smoke from the smoking sections of bars and restaurants before it reached patrons in non-smoking sections.
Programee background: While working as a senior policy analyst at the Environmental Protection Agency in 1984, James Repace, MSc, estimated that secondhand smoke caused 5,000 U.S. lung cancer deaths each year. This estimate received widespread publicity, and generated significant interest among environmental health, public health and occupational health authorities.
The award: The Robert Wood Johnson Foundation (RWJF) created the Innovators Combating Substance Abuse award program to nurture and promote innovation in combating substance abuse. Between 2000 and 2003, some 20 senior researchers, practitioners and policy-makers received Innovators awards. See Program Results Report for more information on the program. In 2002, Repace received an Innovators award that enabled him to scientifically test the validity of the tobacco industry's ventilation argument. At the time, Repace was a visiting assistant clinical professor in the Department of Family and Community Medicine at Tufts University Medical School and a consultant based in Bowie, Md.
In 2002, only California required restaurants to be smoke-free. In the rest of the country, the tobacco industry had persuaded lawmakers that nonsmoking sections and ventilation systems could protect nonsmoking patrons from inhaling second-hand smoke, while glossing over the risks to nonsmoking workers.
Repace realized on theoretical grounds that the ventilation argument was bogus, but he needed scientifically gathered experimental data on tobacco smoke concentrations and ventilation to prove it.
With his Innovators award, Repace purchased about $40,000 worth of state-of-the-art real-time air quality monitoring equipment. He secretly deployed the equipment in restaurants and bars to measure the respirable particulate air pollution and particulate polycyclic aromatic hydrocarbons—pollutants proven to increase risk of respiratory disease, cancer, heart disease and stroke.
Test case in Delaware. In 2002, the state of Delaware was about to impose smoke-free workplace law in restaurants, bars and other public establishments. Public health advocates desired evidence of the improvement in restaurant and bar air quality following the implementation of the smoking ban. They wanted the evidence to be accurate and credible enough to withstand anticipated legal challenges from the hospitality and tobacco industries.
Repace and volunteers from the American Lung Association of Delaware packed high-tech air monitoring equipment in carry-on luggage and secretly took air quality measurements in Wilmington, Del., at a casino, five restaurant/bars, a stand-alone bar and a pool hall. They measured air quality in November 2002 before the ban went into place and again in January 2003, two months after the state-imposed smoking ban. All of the venues had mechanical ventilation systems.
Results: What the researchers found was devastating to the tobacco industry's ventilation argument. Among the study's startling results: smoky bars have up to 50 times more cancer-causing particles in the air than truck-choked highways and polluted city streets, and ventilation does not control secondhand smoke to safe levels.
Repace's study "Respirable Particles and Carcinogens in the Air of Delaware Hospitality Venues Before and After a Smoking Ban," was published in the September 2004 issue of the Journal of Occupational and Environmental Medicine.
It received wide international media coverage, reaching more than half a billion people through more than 530 media stories worldwide. M Booth and Associates, a New York City-based communications firm retained by the Innovators program, guided the media strategy.
Repace's research was leveraged by the New Jersey Breathes tobacco-control coalition to influence the reintroduction of a smoke-free air law in New Jersey in 2004. That law passed in 2006.
State-of-the-art ventilation systems debunked. In a second seminal study, Repace and his colleague, Ken Johnson, PhD, an authority on secondhand smoke epidemiology, published research about new high-tech "displacement" ventilation systems promoted by restaurant and bar industry representatives as an alternative to smoke-free establishments. The hospitality industry had convinced some city councils to allow smoking in dining establishments that had installed these new systems.
Repace and Johnson compared the level of smoking-related cancer-causing chemicals and toxic particles in the air of nonsmoking and smoking sections of two dining/drinking establishments in Mesa, Ariz., and in a restaurant/bar in Toronto. All three establishments used high-tech ventilation systems for smoke control, and all three made extravagant claims about pristine air quality in the nonsmoking areas, which were not physically separated from the smoking areas.
Repace and Johnson found that these high-tech systems are no match for secondhand smoke and may, in fact, perform worse than standard "dilution" ventilation, which had already been demonstrated to be totally inadequate to control secondhand smoke.
This study was published in a indoor air quality and ventilation engineering specialty journal, but in 2006, the Innovators national program office and M. Booth & Associates again guided widespread dissemination of the results, generating more than 60 million media impressions.
That year, voters in Arizona, Ohio and Nevada had to vote on smoke-free ballot initiatives. The R.J. Reynolds tobacco company invested $40 million in each of these states to roll back smoke-free workplace legislation and defeat cigarette tax increases. However, the smoke-free initiatives were passed in all three states.
Importance of the award: "I believe that the paper that was published in 2004 had a tremendous impact on secondhand smoke research in many other countries, with similar results," Repace said. "When hospitality workplaces go smoke-free, both workers and the public are protected from the diseases of secondhand smoke. And as a side-benefit, when smoke-free air in restaurants and bars becomes the norm, this decreases the social acceptability of smoking."
RWJF perspective: "The Innovators Combating Substance Abuse program recognized the innovation and creativity of researchers, advocates and providers who have dedicated their professional careers to reducing the toll of substance use and abuse," said Michelle A. Larkin, JD, RN, MS, RWJF senior program officer. "These individuals have had an extraordinary impact on the prevention and treatment of substance abuse, promoting the science and advocating for positive and lasting change."