LETTER FROM
HONG KONG
Environmental Tobacco Smoke Exposure
Among Police Officers in Hong Kong
Tai Hing Lam, MD
Lai Ming Ho, PhD
Anthony J. Hedley, MD
Peymane Adab, MBChB
Richard Fielding, PhD
Sarah M. McGhee, PhD
L. Aharonson-Daniel, PhD
T
HE 1992 US ENVIRONMENTAL PRO-
tection Agency (EPA) review1 on
passive smoking contains strong
and sufficient evidence confirming that
exposure to environmental tobacco
smoke (ETS), ie, passive smoking, can
cause respiratory illnesses in children.
However, other than lung cancer, evi-
dence on the relationship between ETS
and respiratory ill health in adults is
scarce. Three epidemiological stud-
ies2-4 of this relationship were included
in the EPA report. One of them studied
women,2 another studied both men and
women,3 and the third4 did not explic-
itly state the sex of the subjects who were
student nurses and so were mostly
women. Furthermore, apart from the
study by Schwartz and Zeger,4 which in-
vestigated ETS exposure among nurs-
ing school students with smoking room-
mates living in a residential hall, the
other 2 studies2,3 investigated only ETS
at home. So far no clear conclusion has
been reached about the association be-
tween ETS exposure, particularly at
work, and chronic respiratory symp-
toms in adults.1
We conducted a literature search us-
ing the same strategy as in the Report
of the UK Scientific Committee on To-
bacco and Health5 to identify all ETS
references related to respiratory symp-
toms. Because a comprehensive re-
756 JAMA, August 9, 2000—Vol 284, No. 6 (Reprinted)
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Context Few epidemiological studies have examined the relationship between chronic
respiratory symptoms and exposure to environmental tobacco smoke (ETS) at work in
adults, and none have shown clear dose-response relationships.
Objective To examine the respiratory effects of ETS exposure at home and at work
among never-smoking adults.
Design, Setting, and Participants Cross-sectional, self-administered question-
naire survey conducted in December 1995 and January 1996 among 4468 male and
728 female police officers in Hong Kong who were never-smokers.
Main Outcome Measures Respiratory symptoms and physician consultation in the
previous 14 days for such symptoms by presence and amount of ETS exposure at work.
Results Eighty percent of both men and women reported ETS exposure at work. Sig-
nificant odds ratios (ORs) for respiratory symptoms were found among men with ETS
exposure at work (for any respiratory symptoms, difference in absolute rate, 20.4%;
OR, 2.33; 95% confidence interval [CI], 1.97-2.75; attributable risk, 57%) and phy-
sician consultation (difference in absolute rate, 4.5%; OR, 1.30; 95% CI, 1.05-1.61;
attributable risk, 23%). Trends were similar among women for any respiratory symp-
toms (difference in absolute rate, 15.4%; OR, 1.63; 95% CI, 1.04-2.56; attributable
risk, 39%) and for physician consultation (difference in absolute rates, 2.8%; OR, 1.45;
95% CI, 0.87-2.41; attributable risk, 31%). Positive dose-response relationships with
number of coworkers smoking nearby and amount of ETS exposure in the work place
were found.
Conclusions This study provides further evidence of the serious health hazards as-
sociated with ETS exposure at work. The findings support a ban on smoking in the
workplace to protect all workers in both developed and developing countries.
JAMA. 2000;284:756-763 www.jama.com
view on ETS before 1990 has been re- those with ETS exposure at work.
ported in the US EPA report, we Leuenberger et al9 reported a signifi-
searched the MEDLINE and EMBASE cant trend of increasing risk with total
databases from January 1991 to Octo- ETS at home and at work, but there was
ber 1998 using the criteria passive or no separate analysis for exposure ei-
second-hand or second hand or involun- ther at home or work since the expo-
tary; smok$ or tobacco$ or cigarette$; sure data on ETS were not collected
and cough or wheeze or breathless or separately for home and workplace. Al-
phlegm or mucous where “$” indicates though Jaakkola et al10 measured ETS
a wild character. Five epidemiological exposure both at home and at work
studies of chronic respiratory disease
and ETS were found.6-10 Two of them7,8 Author Affiliations: Department of Community
Medicine and Behavioural Sciences Unit, University
studied only ETS exposure at home in of Hong Kong, Hong Kong.
women. The other 3 articles6,9,10 stud- Corresponding Author and Reprints: Tai Hing Lam,
MD, Department of Community Medicine, Univer-
ied ETS exposure at home and/or at sity of Hong Kong, Patrick Manson Building South
work in men and women. White et al6 Wing, 7 Sassoon Rd, Hong Kong, China (e-mail:
hrmrlth@hkucc.hku.hk).
reported that respiratory symptoms Section Editor: Annette Flanagin, RN, MA, Manag-
were more likely to be found among ing Senior Editor.
©2000 American Medical Association. All rights reserved.
 LETTER FROM HONG KONG

separately, only the relationship be- pants to complete under classroom con-
Table 1. Demographic Characteristics and
tween total exposure level at home and ditions. The participants were asked to Environmental Tobacco Smoke (ETS) Pattern
at work and respiratory symptoms was provide their unique police identity in the Hong Kong Police
reported with an increasing, but insig- numbers but not their names. The ques- No. (%)
nificant, trend for some symptoms. tionnaire was presented in both Chi-
Men Women
None of these studies have demon- nese and English and covered demo- Characteristics (n = 4468) (n = 728)
strated a clear dose-response relation- graphic characteristics, working history, Age, y
ship, which is an important criterion for smoking habit, exposure to ETS at #24 738 (16.6) 269 (37.2)
a causal association,11 between ETS ex- home and at work, utilization of health 25-29 821 (18.4) 179 (24.8)
posure at work and respiratory symp- care services, and respiratory health 30-34 879 (19.7) 45 (6.2)
toms in those who have never smoked. (TABLE 1). 35-39 881 (19.8) 57 (7.9)
In November 1999, the US National Respiratory symptoms were elicited $40 1136 (25.5) 173 (23.9)
Cancer Institute announced the avail- using the British Medical Research Marital status
Single 1605 (36.2) 413 (56.9)
ability of the most comprehensive re- Council Respiratory Health Question- Married 2754 (62.2) 280 (38.6)
port12 on the health risks of ETS expo- naire.13 Completed questionnaires were Other 72 (1.6) 33 (4.6)
sure ever conducted. However, no placed into envelopes, sealed, and re- Education
definite conclusion of the association turned to the research team. The par- ,Grade II 908 (21.2) 108 (15.4)
between ETS and chronic respiratory ticipants were reassured that no one (in- Grade II 3034 (70.7) 497 (70.8)
symptoms in adults was reached. cluding their seniors and peers) other Matriculation 227 (5.3) 67 (9.5)
The dearth of research on ETS in the than designated researchers in the uni- Tertiary education 123 (2.9) 30 (4.3)
Police rank
workplace and chronic respiratory versity department of community medi- Police-constables 3152 (71.0) 584 (81.3)
symptoms prompted this study, which cine would be permitted to gain ac- Sergeants or senior 1048 (23.6) 88 (12.3)
examined the effects of ETS exposure cess to the identity of any participant, sergeants
at home and at work among adults in and confidentiality was guaranteed. Inspectors or above 240 (5.4) 46 (6.4)
Hong Kong who have never smoked. Type of police duties
Outcome and ETS Traffic police 621 (20.6) 150 (14.0)
METHODS Foot patrol 2696 (72.8) 530 (60.6)
Exposure Measures
Marine police 1132 (6.6) 48 (25.4)
Participants and Survey The following definitions of the depen- Worked in dusty
This study was conducted within the dent variables for respiratory symp- environment before
police force for the personnel depart- toms were used: throat problems, usu- No 3913 (89.2) 676 (94.2)
Yes 473 (10.8) 42 (5.9)
ment and traffic division of the Hong ally having a sore or itchy throat or
ETS
Kong Police Department following a re- other throat discomfort; cough or Nil 719 (16.8) 103 (14.5)
quest from officers for an inquiry into phlegm in the morning, usually having At home only 148 (3.5) 36 (5.1)
the potential risks of exposure to am- cough or bringing up phlegm first thing At work only 2717 (63.5) 332 (46.8)
bient air pollution. The officers were in the morning; cough or phlegm dur- At home and at work 695 (16.2) 238 (33.6)
told that the purpose of the study was ing day or night, usually having cough Total No. of smokers at
to measure aspects of their general or bringing up phlegm either during the home and at work
0 719 (16.9) 103 (14.7)
health, and this is written in the intro- day or at night; chronic cough or phlegm, 1 474 (11.2) 77 (11.0)
ductory remark of the questionnaire. All usually having cough or bringing up 2-3 1490 (35.1) 198 (28.3)
uniformed officers in the traffic, foot pa- phlegm on most days for as much as 3 4-5 727 (17.1) 143 (20.4)
trol, and marine formations of the Hong months each year; any cough or phlegm, $6 839 (19.8) 180 (25.7)
Kong Police department were eligible usually having cough and/or bringing No. of coworkers
for inclusion in the respiratory health up phlegm first thing in the morning, smoking nearby
at work
survey. The survey was carried out over or during the day or at night; in- 0 884 (20.4) 142 (20.0)
a 2-month period, among all regional creased cough and phlegm, usually hav- 1 466 (10.8) 75 (10.6)
and district traffic teams and foot pa- ing a period of increased cough and 2 758 (17.5) 121 (17.4)
trol officers in December 1995 and phlegm lasting 3 weeks or more in the 3 861 (19.9) 117 (16.5)
among Marine police officers in Janu- past 3 years; ever wheezing, ever expe- $4 1355 (31.3) 255 (35.9)
ary 1996. Participation was voluntary, rienced wheezing or whistling in the Daily amount of
ETS exposure,
there was no requirement for officers chest; blocked or running nose, usually cigarette-hours
to attend the questionnaire sessions or having a blocked or running nose; any 0 884 (20.3) 142 (19.8)
to reveal their identity, and there were symptoms, having any of the symp- #4 982 (22.5) 133 (18.5)
no sanctions for nonattendance. toms defined above. .4-16 877 (20.1) 144 (20.0)
A self-administered structured ques- Utilization of health services was as- .16-48 758 (17.4) 124 (17.3)
tionnaire was distributed to partici- sessed by whether the subject had con- .48 856 (19.7) 176 (24.5)

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 LETTER FROM HONG KONG

sulted a Western-trained physician or
Chinese traditional physician during the
past 14 days for respiratory illness.
A full lifetime smoking history was
obtained. A never-smoker was defined
as someone who had never smoked any
more than 1 cigarette a day or 1 cigar a
week or chewed an ounce of tobacco a
month for a total accumulation of no
more than 6 months. Exposure to ETS
at home was defined as the presence of
1 or more smokers who lived in the
same household as the study partici-
pant. Exposure to ETS at work was de-
fined as the presence of 1 or more co-
workers who smoked nearby each day,
the number of cigarettes smoked by co-
workers nearby per day, the number of
hours of exposure per day, and an in-
dex of the daily amount of ETS expo-
sure at work, which is defined as the
number of cigarettes smoked nearby
multiplied by the number of hours ex-
posed to ETS per day, expressed as the
number of cigarette-hours. Total ex-
posure to ETS at home and at work is
the total number of smokers at home
and coworkers smoking nearby.
Data Analysis
The analysis was based on those par-
ticipants who had never smoked and
was performed separately for women
and men. In comparing the effects of
ETS exposure at work on respiratory
symptoms, multiple logistic regres-
sion was used to calculate odds ratios
(ORs) with 95% confidence intervals
(CIs), adjusted for age, marital status,
educational attainment, police rank,
type of police duties (traffic police, foot
patrol, or marine police), time on the
force, any exposure to a dusty environ-
ment in previous jobs, and ETS expo-
sure at home. The analysis was per-
formed using STATA.14
RESULTS
Of the 11038 police officers eligible to
join the survey, 9923 (90%) com-
pleted the questionnaire. Of the re-
spondents, 416 subjects were ex-
cluded because of missing entries for
sex or smoking status. After exclusion
of the missing data, 46.1% of men and
12.3% of women were current smok-
ers, and 2.4% of men and 0.6% of

Table 2. Adjusted Odds Ratio for Respiratory Symptoms and Physician Consultation by Total Number of Smokers at Home and at Work
in the Hong Kong Police*
Odds Ratio (95% Confidence Interval)
P for
Symptoms Sex 1 Smoker 2-3 Smokers 4-5 Smokers $6 Smokers Trend
Throat problems Men 1.49 (1.11-1.99)† 1.95 (1.55-2.45)‡ 2.30 (1.79-2.97)‡ 2.83 (2.22-3.63)‡ ,.001
Women 1.36 (0.64-2.91) 1.57 (0.84-2.91) 1.73 (0.90-3.34) 2.47 (1.31-4.66)† .003
Cough, morning Men 1.27 (0.87-1.86) 1.62 (1.20-2.17)‡ 1.63 (1.17-2.27)† 1.88 (1.37-2.58)‡ ,.001
Women 1.14 (0.32-4.01) 2.04 (0.76-5.49) 3.58 (1.32-9.74)§ 3.50 (1.30-9.44)§ .002
Cough, day or night Men 1.18 (0.80-1.75) 1.57 (1.16-2.11)† 1.76 (1.26-2.45)‡ 2.08 (1.52-2.87)‡ ,.001
Women 0.89 (0.31-2.54) 1.03 (0.44-2.40) 1.74 (0.74-4.09) 1.80 (0.78-4.14) .04
Cough, chronic Men 1.82 (0.84-3.94) 2.07 (1.09-3.90)§ 3.06 (1.58-5.95)‡ 2.89 (1.50-5.57)† ,.001
Women 0.29 (0.03-2.85) 0.54 (0.12-2.31) 0.80 (0.17-3.67) 0.74 (0.17-3.21) .95
Phlegm, morning Men 1.22 (0.86-1.73) 1.79 (1.37-2.33)‡ 2.04 (1.52-2.75)‡ 2.12 (1.59-2.83)‡ ,.001
Women 0.48 (0.14-1.65) 1.57 (0.68-3.61) 2.32 (0.98-5.48) 2.37 (1.02-5.50)§ .004
Phlegm, day or night Men 1.11 (0.73-1.71) 1.70 (1.24-2.33)‡ 2.20 (1.56-3.10)‡ 2.42 (1.73-3.38)‡ ,.001
Women 0.42 (0.07-2.32) 0.98 (0.31-3.11) 2.06 (0.67-6.36) 2.19 (0.72-6.67) .02
Phlegm, chronic Men 0.83 (0.41-1.65) 1.40 (0.87-2.26) 2.67 (1.63-4.37)‡ 2.74 (1.69-4.44)‡ ,.001
Women 0.86 (0.12-6.16) 1.42 (0.31-6.62) 1.86 (0.39-8.77) 2.09 (0.44-9.82) .23
Any cough or phlegm Men 1.15 (0.86-1.55) 1.71 (1.37-2.15)‡ 1.93 (1.50-2.49)‡ 2.15 (1.68-2.74)‡ ,.001
Women 1.01 (0.43-2.37) 1.72 (0.88-3.37) 2.00 (0.98-4.07) 2.04 (1.02-4.07)§ .02
Increased cough and phlegm Men 1.83 (1.27-2.63)‡ 1.78 (1.32-2.41)‡ 2.43 (1.76-3.36)‡ 2.33 (1.69-3.20)‡ ,.001
Women 1.77 (0.56-5.61) 2.90 (1.14-7.37)§ 3.70 (1.42-9.63)† 3.84 (1.49-9.89)† .002
Ever wheezing Men 1.42 (0.86-2.34) 1.77 (1.19-2.62)† 1.57 (1.01-2.44)§ 2.02 (1.33-3.06)‡ .002
Women 1.51 (0.46-5.00) 0.64 (0.23-1.73) 0.50 (0.16-1.57) 0.73 (0.27-2.00) .37
Blocked or running nose Men 1.31 (0.99-1.74) 1.75 (1.41-2.18)‡ 1.78 (1.39-2.28)‡ 2.40 (1.89-3.04)‡ ,.001
Women 0.93 (0.43-2.00) 1.50 (0.84-2.68) 1.64 (0.88-3.05) 1.68 (0.92-3.06) .05
Any symptoms Men 1.60 (1.24-2.08)‡ 2.16 (1.77-2.64)‡ 2.36 (1.87-2.98)‡ 3.12 (2.48-3.93)‡ ,.001
Women 0.92 (0.46-1.84) 1.72 (0.97-3.04) 2.01 (1.08-3.73)§ 1.70 (0.93-3.08) .03
Physician consultation, past 14 days Men 1.04 (0.75-1.45) 1.18 (0.92-1.52) 1.13 (0.84-1.51) 1.68 (1.28-2.21)‡ ,.001
for respiratory symptoms Women 1.91 (0.90-4.04) 1.64 (0.86-3.09) 1.17 (0.58-2.35) 1.35 (0.69-2.64) .96
*Odds ratios are adjusted for age, marital status, educational attainment, police rank, type of police duties, duration of time in the force, and any exposure to dusty environment in
previous jobs. P values for odds ratios were calculated by comparing with no smokers at home and at work. P for trend indicates any significant linear dose-response relationship
between odds ratios and total number of smokers at home and at work.
†P,.01.
‡P,.001
§P,.05.

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 LETTER FROM HONG KONG

women were former smokers. Only the
5196 (4468 men and 728 women)
never-smokers were included in this
study. The majority were police con-
stables (72.4%), the lowest rank of of-
ficers, followed by sergeants or senior
sergeants (22.0%), and inspectors or
above (5.5%). Their age ranged from 18
to 58 years.
The demographic characteristics and
exposure to ETS at home or work of the
never-smoking men and women are
shown in Table 1. More women
(38.7%) than men (19.7%) were ex-
posed to ETS at home. The same pro-
portion of men and women (80%) re-
ported exposure to ETS at work. More
than 70% of both men and women had
2 or more smokers at home and at work,
and about half had 3 or more cowork-
ers who smoked nearby.
For total exposure to ETS at home
and at work, positive and significant
dose-response relationships were found
in men between the total number of
smokers at home and at work and the
risks of respiratory symptoms for all res-
piratory categories and physician con-
sultation (TABLE 2). In women the pat-
tern of trends, except for chronic cough,
chronic phlegm, ever wheezing, and
physician consultation, was similar to
that in men.
For ETS at home, the presence of a
significant excess of wheezing, nasal
problems, and any symptoms was found
in men and a significant excess of throat
problems was found in women
(TABLE 3). Men exposed at work had a
significantly higher prevalence of res-
piratory symptoms and physician con-
sultation. In women exposed at work,
throat problems, morning cough, morn-
ing phlegm, nasal problems, and the
presence of any symptoms all showed a
significant excess compared with women
who were not exposed. After adjusting
for age, marital status, educational attain-
ment, police rank, type of police officer,
time on the force, previous job expo-
sure to dusty environment, and other
ETS exposure, the ORs for exposure to
ETS at home were significant for wheez-
ing in men and for throat problems in

Table 3. Prevalence of and Adjusted Odds Ratios (ORs) for Respiratory Symptoms and Physician Consultation by Sources of Environmental
Tobacco Smoke (ETS) in the Hong Kong Police*
Prevalence

ETS at Home ETS at Work Odds Ratio (95% Confidence Interval)

Symptoms Sex No Yes P Value No Yes P Value ETS at Home ETS at Work
Throat problems Men 32.4 31.6 .62 20.6 35.4 ,.001 0.99 (0.82-1.18) 2.15 (1.77-2.61)†
Women 28.3 37.2 .01 24.4 33.9 .04 1.66 (1.17-2.35)‡ 1.41 (0.87-2.30)
Cough, morning Men 14.7 16.5 .20 10.4 16.6 ,.001 1.15 (0.92-1.45) 1.72 (1.33-2.21)†
Women 12.3 14.0 .51 4.4 14.9 ,.001 1.07 (0.66-1.73) 3.98 (1.61-9.82)‡
Cough, day or night Men 14.4 15.9 .26 9.6 16.2 ,.001 1.16 (0.92-1.46) 1.81 (1.39-2.34)†
Women 12.5 15.4 .26 10.1 14.4 .18 1.18 (0.74-1.89) 1.70 (0.85-3.41)
Cough, chronic Men 4.0 4.1 .94 2.0 4.7 ,.001 1.03 (0.68-1.56) 2.61 (1.50-4.55)‡
Women 3.9 2.2 .21 2.9 3.3 .79 0.52 (0.18-1.48) 1.00 (0.29-3.47)
Phlegm, morning Men 20.2 19.7 .73 12.8 22.3 ,.001 1.08 (0.88-1.34) 1.92 (1.52-2.42)†
Women 15.1 16.0 .73 9.4 16.8 .03 1.20 (0.76-1.91) 2.06 (1.03-4.11)§
Phlegm, day or night Men 14.1 14.2 .94 8.3 15.8 ,.001 1.07 (0.84-1.37) 2.03 (1.53-2.67)†
Women 8.3 7.7 .75 4.3 9.0 .07 0.97 (0.52-1.81) 2.07 (0.79-5.43)
Phlegm, chronic Men 5.9 6.7 .42 3.5 6.8 ,.001 1.29 (0.91-1.82) 2.05 (1.35-3.11)‡
Women 5.3 3.6 .30 2.1 5.1 .13 0.62 (0.25-1.51) 2.57 (0.67-9.90)
Any cough or phlegm Men 30.1 30.7 .74 20.6 33.0 ,.001 1.10 (0.92-1.32) 1.87 (1.54-2.26)†
Women 25.3 26.8 .66 16.9 28.0 .008 1.12 (0.77-1.65) 2.06 (1.18-3.61)§
Increased cough and phlegm Men 16.0 18.2 .11 10.1 18.1 ,.001 1.12 (0.90-1.39) 1.88 (1.47-2.41)†
Women 15.4 19.9 .12 8.5 19.3 .002 1.23 (0.79-1.90) 2.44 (1.19-4.98)§
Ever wheezing Men 7.8 11.7 ,.001 5.5 9.4 ,.001 1.41 (1.08-1.85)† 1.76 (1.26-2.45)‡
Women 6.9 7.0 .96 7.9 6.7 .61 1.07 (0.57-2.03) 0.55 (0.26-1.19)
Blocked or running nose Men 32.1 38.1 .001 23.1 36.1 ,.001 1.15 (0.97-1.37) 1.85 (1.54-2.23)†
Women 34.9 34.3 .88 24.3 37.5 .003 0.85 (0.60-1.20) 1.59 (0.99-2.55)
Any symptoms Men 57.0 62.2 .007 42.1 62.5 ,.001 1.15 (0.96-1.37) 2.33 (1.97-2.75)†
Women 55.1 61.4 .11 45.2 60.6 .002 1.23 (0.86-1.76) 1.63 (1.04-2.56)§
Physician consultation, past 14 days Men 19.2 17.8 .34 15.6 20.1 .003 1.13 (0.91-1.40) 1.30 (1.05-1.61)§
for respiratory symptoms Women 24.4 24.0 .89 21.8 24.6 .48 1.04 (0.71-1.53) 1.45 (0.87-2.41)
*Odds ratios are adjusted for age, marital status, educational attainment, police rank, type of police duties, duration of time in the force, any exposure to dusty environment in
previous jobs, and the other ETS.
†P,.001.
‡P,.01.
§P,.05.

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 LETTER FROM HONG KONG

women (Table 3). The adverse effects of
ETS exposure at work were more promi-
nent in men than in women; all adjusted
ORs were significantly greater than 1 in
men. In women, except for ever wheez-
ing, all ORs were greater than 1. How-
ever, 5 categories of symptoms were not
significantly associated, probably due to
the smaller sample size. Of those respi-
ratory symptoms with insignificant ORs,
the estimated sample size required for
the logistic regression analysis, with a 5%
2-sided significance level and 80%
power, ranges from 699 (for nasal prob-
lems) to 106734 (for chronic cough)
with a median of 2381 women.15
Significant trends for all respiratory
categories and physician consultation
were found in men with smoking co-
workers together with positive dose-
response relationships between the num-
ber of coworkers smoking nearby and
the risks of respiratory symptoms
(TABLE 4). The same pattern was ob-
served among all respiratory categories
and physician consultation and the num-
ber of cigarettes smoked by coworkers
nearby per day (results are available on
request), the number of hours exposed
per day (results are available on re-
quest), and the exposure index in terms
of cigarette-hours (TABLE 5).
In women, generally positive trends
with the number of smoking cowork-
ers (Table 4) and the exposure index
(Table 5) were found. However, a nega-
tive but insignificant trend was ob-
served between the number of smok-
ing coworkers and ever wheezing
categories, suggesting that women who
had a history of wheezing may tend to
avoid excessive ETS exposure at work.
COMMENT
This study showed clear associations
and dose-response relationships be-
tween ETS exposure at work and res-
piratory symptoms in men and women,
with the associations being highly sig-
nificant in men. Although some sig-
nificant excess risks were observed for
ETS exposure at home, stronger ef-
fects were observed at work where the
risk of ETS exposure was much greater
because subjects spent more time
among a larger number of smoking co-
workers at work than at home.

Table 4. Adjusted Odds Ratios for Respiratory Symptoms and Physician Consultation by Number of Coworkers Smoking Nearby in
the Hong Kong Police*
Odds Ratio (95% Confidence Interval)
P for
Symptoms Sex 1 Smoker 2 Smokers 3 Smokers $4 Smokers Trend
Throat problems Men 1.48 (1.12-1.96)† 1.98 (1.56-2.51)‡ 2.08 (1.64-2.62)‡ 2.62 (2.12-3.24)‡ ,.001
Women 1.42 (0.72-2.83) 1.23 (0.67-2.28) 1.42 (0.77-2.61) 1.57 (0.92-2.69) .12
Cough, morning Men 1.55 (1.08-2.22)§ 1.78 (1.31-2.43)‡ 1.69 (1.24-2.29)† 1.76 (1.32-2.33)‡ ,.001
Women 3.60 (1.18-10.99)§ 2.05 (0.68-6.20) 5.19 (1.88-14.31)† 4.96 (1.91-12.88)† ,.001
Cough, day or night Men 1.46 (1.01-2.11)§ 1.77 (1.29-2.43)‡ 1.74 (1.27-2.37)‡ 1.99 (1.50-2.65)‡ ,.001
Women 1.46 (0.55-3.89) 1.04 (0.41-2.61) 2.19 (0.96-5.01) 1.98 (0.93-4.22) .04
Cough, chronic Men 2.10 (1.01-4.37)§ 2.22 (1.16-4.27)§ 2.62 (1.40-4.92)† 3.02 (1.68-5.44)‡ ,.001
Women 0.48 (0.05-4.81) 0.56 (0.09-3.50) 1.84 (0.44-7.67) 1.06 (0.26-4.28) .55
Phlegm, morning Men 1.36 (0.97-1.91) 1.91 (1.44-2.53)‡ 1.94 (1.47-2.55)‡ 2.15 (1.67-2.77)‡ ,.001
Women 1.01 (0.35-2.93) 1.47 (0.60-3.56) 2.73 (1.18-6.30) 2.68 (1.26-5.70)§ .002
Phlegm, day or night Men 1.25 (0.83-1.89) 1.93 (1.38-2.69)‡ 1.93 (1.39-2.68)‡ 2.47 (1.83-3.34)‡ ,.001
Women 0.62 (0.11-3.48) 1.45 (0.41-5.19) 1.77 (0.52-6.04) 3.51 (1.23-10.01)§ .003
Phlegm, chronic Men 0.89 (0.45-1.75) 2.01 (1.23-3.29)† 1.60 (0.97-2.65) 2.83 (1.82-4.40)‡ ,.001
Women 1.19 (0.16-9.02) 0.90 (0.12-6.59) 5.72 (1.25-26.15)§ 2.74 (0.62-12.09) .06
Any cough or phlegm Men 1.34 (1.01-1.77)§ 1.92 (1.51-2.43)‡ 1.80 (1.43-2.28)‡ 2.09 (1.69-2.59)‡ ,.001
Women 1.85 (0.85-3.99) 1.53 (0.76-3.09) 2.70 (1.37-5.32)† 2.21 (1.20-4.08)§ .01
Increased cough and phlegm Men 1.56 (1.10-2.21)§ 1.57 (1.15-2.13)† 1.95 (1.45-2.62)‡ 2.18 (1.67-2.85)‡ ,.001
Women 0.99 (0.32-3.10) 2.47 (1.07-5.70)§ 2.61 (1.13-6.02)§ 3.12 (1.46-6.69)† ,.001
Ever wheezing Men 1.58 (0.99-2.51) 1.66 (1.10-2.50)§ 1.97 (1.33-2.91)† 1.74 (1.21-2.51)† .003
Women 1.05 (0.35-3.17) 0.68 (0.26-1.80) 0.13 (0.03-0.64)§ 0.62 (0.26-1.46) .10
Blocked or running nose Men 1.51 (1.15-1.98)† 1.75 (1.39-2.21)‡ 1.82 (1.45-2.29)‡ 2.07 (1.69-2.55)‡ ,.001
Women 1.27 (0.63-2.54) 1.25 (0.68-2.27) 2.25 (1.25-4.04)† 1.66 (0.98-2.80) .03
Any symptoms Men 1.79 (1.39-2.30)‡ 2.17 (1.75-2.70)‡ 2.28 (1.84-2.82)‡ 2.73 (2.25-3.31)‡ ,.001
Women 1.26 (0.65-2.42) 1.81 (1.00-3.28) 1.84 (1.03-3.32)§ 1.69 (1.02-2.82)§ .04
Physician consultation, past 14 days Men 1.13 (0.82-1.56) 1.17 (0.89-1.53) 1.32 (1.01-1.72)§ 1.41 (1.11-1.80)† .002
for respiratory symptoms Women 1.76 (0.87-3.58) 1.83 (0.97-3.45) 1.27 (0.66-2.45) 1.26 (0.71-2.24) .92
*Odds ratios are adjusted for age, marital status, educational attainment, police rank, type of police duties, duration of time in the force, any exposure to dusty environment in
previous jobs, and Environmental Tobacco Smoke at home. P values for odds ratios were calculated by comparing with no coworkers smoking nearby. P for trend indicates any
significant linear dose-response relationship between odds ratios and number of coworkers smoking nearby.
†P,.01.
‡P,.001.
§P,.05.

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 LETTER FROM HONG KONG

A potential weakness of this study is
the lack of validation of smoking status
and ETS exposure level. Since smoking
status was self-reported by the partici-
pants, it is possible that smokers might
have been misclassified as nonsmokers
and included in the analysis. However
a meta-analysis of the validity of self-
reported smoking suggests generally
high levels of sensitivity (87%) and
specificity (89%) for self-report.16 In our
study, we compared the declared smok-
ing histories and expired air carbon
monoxide levels of a random sample of
110 male officers and found that none
of the declared nonsmokers had car-
bon monoxide levels exceeding 10 ppm,
whereas 50 of 55 of the smokers had val-
ues greater than 10 ppm. This showed
that misclassification was unlikely. For
women, Riboli et al17 estimated that the
proportion of women misreporting their
active smoking habit was between 1.9%
to 3.4% in 13 centers from 10 coun-
tries. If we assume a 3.5% misclassifi-
cation in this study, such misclassifica-
tion could not explain all the excess risks
associated with ETS. In addition, the
similarity in the proportion of men and
women (80%) in this study reporting ex-
posure to ETS at work further supports
reliability of the reporting. Hence, mis-
classification, if any, would be minimal
and cannot account for the strong
ETS effects observed in both men and
women.
On the other hand, the ORs re-
ported herein may be underestimated
due to background exposure. It is likely
that some nonsmokers may report no
exposure to any form of ETS, even if
they are exposed and hence are mis-
classified as unexposed nonsmokers.
Although no explicit validation of
outcome measures for respiratory
symptoms and physician consultation
was performed, these measures have
been commonly used elsewhere13,18 and
have been found to achieve a high level
of reliability and validity.
Levels of ETS exposure were not di-
rectly measured. Because smoking
among police officers in their offices was
permitted, the number of smokers was

Table 5. Adjusted Odds Ratios for Respiratory Symptoms and Physician Consultation by Daily Amount of Environmental Tobacco Smoke
Exposure (Cigarette-Hours) at Work in the Hong Kong Police*
Odds Ratio (95% Confidence Interval)

#4 .4 to 16 .16 to 48 .62; 48 P for

Symptoms Sex Cigarette-Hours Cigarette-Hours Cigarette-Hours Cigarette-Hours Trend
Throat problems Men 1.53 (1.21-1.92)† 2.04 (1.62-2.57)† 2.62 (2.07-3.32)† 2.79 (2.21-3.53)† ,.001
Women 0.97 (0.53-1.79) 1.37 (0.76-2.47) 1.65 (0.90-3.03) 1.78 (1.01-3.11)‡ .01
Cough, morning Men 1.17 (0.85-1.59) 1.72 (1.27-2.33)† 2.12 (1.56-2.87)† 2.10 (1.55-2.85)† ,.001
Women 2.98 (1.07-8.32)‡ 4.25 (1.57-11.52)§ 4.89 (1.77-13.54)§ 4.30 (1.61-11.48)§ .005
Cough, day or night Men 1.21 (0.88-1.67) 1.84 (1.35-2.49)† 2.20 (1.61-2.99)† 2.24 (1.65-3.04)† ,.001
Women 1.14 (0.48-2.73) 2.22 (0.99-4.96) 2.09 (0.90-4.83) 1.68 (0.76-3.72) .14
Cough, chronic Men 1.45 (0.74-2.83) 2.76 (1.48-5.13)† 3.06 (1.63-5.74)† 3.58 (1.93-6.61)† ,.001
Women 0.55 (0.09-3.25) 1.04 (0.21-5.01) 1.01 (0.20-5.04) 1.52 (0.37-6.31) .38
Phlegm, morning Men 1.27 (0.95-1.68) 1.73 (1.31-2.28)† 2.23 (1.69-2.95)† 2.83 (2.16-3.71)† ,.001
Women 1.19 (0.50-2.84) 2.11 (0.93-4.80) 2.18 (0.94-5.07) 3.04 (1.40-6.60)§ ,.001
Phlegm, day or night Men 1.42 (1.02-1.98)‡ 1.83 (1.32-2.54)† 2.38 (1.71-3.30)† 2.77 (2.01-3.82)† ,.001
Women 0.87 (0.24-3.13) 2.15 (0.68-6.77) 2.06 (0.64-6.66) 3.75 (1.30-10.83)‡ .002
Phlegm, chronic Men 1.09 (0.65-1.85) 1.58 (0.96-2.60) 2.64 (1.63-4.26)† 3.38 (2.13-5.38)† ,.001
Women 3.18 (0.69-14.62) 1.65 (0.32-8.56) 2.16 (0.42-10.98) 3.34 (0.75-14.94) .24
Any cough or phlegm Men 1.24 (0.98-1.56) 1.77 (1.40-2.23)† 2.35 (1.85-2.98)† 2.52 (1.99-3.18)† ,.001
Women 1.50 (0.76-2.95) 2.42 (1.25-4.69)§ 2.30 (1.16-4.55)‡ 2.25 (1.19-4.25)‡ .01
Increased cough and phlegm Men 1.34 (0.99-1.80) 1.92 (1.44-2.57)† 2.35 (1.75-3.15)† 2.17 (1.62-2.92)† ,.001
Women 1.61 (0.68-3.83) 2.64 (1.17-5.97)‡ 3.17 (1.39-7.22)§ 2.66 (1.20-5.88)‡ .008
Ever wheezing Men 1.28 (0.85-1.91) 1.62 (1.09-2.41)‡ 2.33 (1.58-3.43)† 1.98 (1.34-2.93)† ,.001
Women 0.39 (0.12-1.20) 0.69 (0.27-1.76) 0.72 (0.27-1.89) 0.47 (0.18-1.21) .33
Blocked or running nose Men 1.53 (1.23-1.91)† 1.81 (1.44-2.26)† 1.92 (1.53-2.42)† 2.30 (1.83-2.89)† ,.001
Women 1.02 (0.56-1.86) 1.73 (0.98-3.06) 1.95 (1.08-3.52)‡ 1.82 (1.06-3.15)‡ .006
Any symptoms Men 1.68 (1.37-2.06)† 2.25 (1.82-2.78)† 2.74 (2.19-3.42)† 3.16 (2.53-3.95)† ,.001
Women 0.97 (0.55-1.70) 1.61 (0.92-2.81) 2.66 (1.45-4.90)§ 1.95 (1.13-3.36)‡ ,.001
Physician consultation, past 14 days Men 1.08 (0.83-1.41) 1.21 (0.93-1.58) 1.43 (1.09-1.87)§ 1.55 (1.19-2.01)† ,.001
for respiratory symptoms Women 1.55 (0.84-2.89) 1.18 (0.62-2.22) 1.54 (0.81-2.94) 1.54 (0.85-2.82) .23
*Odds ratios adjusted for age, marital status, educational attainment, police rank, type of police duties, duration of time in the force, any exposure to dusty environment in pre-
vious jobs, and environmental tobacco smoke at home. P values for odds ratios were calculated by comparing with no environmental tobacco smoke at work. P for trend
indicates any significant linear dose-relationship between odds ratios and daily amount of environmental tobacco smoke at work. Cigarette-hours are defined in the “Methods”
section.
†P,.001.
‡P,.05.
§P,.01.

©2000 American Medical Association. All rights reserved. (Reprinted) JAMA, August 9, 2000—Vol 284, No. 6 761

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 LETTER FROM HONG KONG
used as the main indicator of ETS ex-
posure. It is likely to be a valid mea-
sure of ETS exposure for 2 reasons.
First, Cummings et al19 found that the
number of smoking friends and fam-
ily members seen regularly by their sub-
jects was the single best predictor of co-
tinine levels, which is a commonly
accepted biochemical measure for
home, workplace, and social exposure
to ETS. Second, a clear dose-response
relationship was observed between re-
ports of levels of ETS exposure and res-
piratory symptoms in our study. The
participants reported respiratory symp-
toms first and ETS exposure much later
in the questionnaire. It was unlikely that
their reported exposure to ETS was bi-
ased by their symptom reporting.
Although ETS has been extensively
studied in relationship to lung cancer
and coronary heart disease in adults and
respiratory illnesses in children, there
are few reports from the West and none
identified from Asia on the relation-
ship between ETS exposure at work and
respiratory symptoms in adults, par-
ticularly in never-smoking men. In the
West, this may be due to the greater
awareness of the problem of ETS and
more restrictions on smoking in the
workplace. In 1991, 80% of Canadian
workers had smoking restrictions in
their workplace.20 A 1991 survey of
company smoking policies in the
United States showed that 85% of firms
had smoking policies, and of these, 34%
had complete bans and another 34%
prohibited smoking in all open work ar-
eas.21 The Occupational Safety and
Health Administration proposed in
April 1994 that buildings that allow
smoking should provide designated
smoking areas in separated and en-
closed rooms wherein the air would be
exhausted directly to the outside.22 Un-
fortunately, such legislation is not yet
enacted,23 and the tobacco industry will
continue to fight against it by arguing
that there is a lack of strong evidence
of adverse effects due to ETS at work.
However the lack of evidence is prob-
ably due to the greater number of smok-
ing restrictions at work in the West than
in Asia and hence a lower level of ETS,
762 JAMA, August 9, 2000—Vol 284, No. 6 (Reprinted)
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and so the adverse effects of ETS ex-
posure at work are more difficult to
measure.
In Asia, the level of awareness is low
and few workplaces have smoking bans
or restrictions. For example, in main-
land China, 41.5% of men and 19.3%
of women were exposed to ETS at work
and the prevalence of ETS among gov-
ernment employees was 70.8%,24 which
was the highest among all occupa-
tions studied.
In the Hong Kong general popula-
tion aged 15 years and older, 26.7% of
men and 3.1% of women were esti-
mated to be smokers in 1996,25 and a
telephone survey in 1994 through 1996
found that among the adult working
population aged 25 through 74 years,
47.3% (95% CI, 45.6%-49.1%) of men
and 26.5% (95% CI, 25.2%-27.7%) of
women were exposed to ETS at work.26
Compared with these figures, the preva-
lence of ETS at work in the sample of
police officers participating in our study
was much higher, about 80% in women
and men, and more than 30% were ex-
posed to more than 3 smoking cowork-
ers nearby. This was a result of both the
higher smoking prevalence (46.1% of
men; 12.3% of women) in the police
force and the lack of restrictions on
smoking in the workplace.
The difference in absolute rates of
physician consultation for respiratory
illnesses in the past 14 days in non-
smoking men between those exposed
and not exposed to ETS at work was
4.5% (20.1-15.6), and the attributable
risk of ETS exposure at work was 23%
([1.30-1]/1.30). The attributable risk for
any respiratory symptoms was 57%
([2.33-1]/2.33) in the nonsmoking men
exposed to ETS at work. Nonsmokers
exposed to ETS may not realize that
their health is affected by their cowork-
ers who smoke nearby. They may ac-
cept that smoking at work is the norm
and do not attempt to protect them-
selves from exposure to ETS. In addi-
tion to the burden of respiratory ill-
nesses and loss of productivity, public
sector health care resources are also
consumed, leading to economic losses
to the community.
©2000 American Medical Association. All rights reserved.
After an internal report was made to
the personnel and traffic departments
of the force, police administration sup-
ported measures promoting a health-
ful lifestyle within the force aimed at
controlling smoking at work and re-
ducing smoking overall. These mea-
sures included initiating a trial smok-
ing intervention program for both
prevention and cessation in the police
training school, offering smoking ces-
sation programs for members of the
force, re-enforcing the existing no-
smoking policy for officers on duty, and
review of the adequacy of regular health
assessments for training and occupa-
tional health surveillance in the force.
During the past 18 months the se-
nior management has taken steps to cre-
ate a new nonsmoking culture in the po-
lice force. A smoke-free workplace
campaign was launched, which in-
cluded the circulation of documents to
all commanders of major regional for-
mations for their views on the develop-
ment of new regulations and a code of
practice on smoking in the workplace.
In particular the current regulation that
forbids uniformed officers from smok-
ing anywhere in the view of the public
was extended to all members of the force,
including plainclothes officers. In addi-
tion, smoking has been banned in all po-
lice buildings and is only permitted in
specially designated areas.
Although exposure to ETS at work
is involuntary, it is easily preventable.
The prevention of smoking in the
workplace can significantly and rap-
idly improve the respiratory health of
workers.27 There is a need for a total
ban on smoking in the workplace to
protect all workers in both developed
and developing countries. This study
provides evidence of the serious
health hazards due to ETS exposure at
work to support tobacco control and
smoking prevention measures. Delays
in the implementation of stronger
legislation in the United States and
other Western countries can have
adverse implications for tobacco con-
trol in developing countries in which
smoking is still permitted in most
workplaces.

Funding/Support: This study was supported by grants
from the Hong Kong Police Department and the Hong
Kong Police Training School, Hong Kong Govern-
ment.
Acknowledgment: We thank C. M. Wong, PhD, for
research advice and assistance; A. S. M. Abdullah, PhD,
J. Cheang, M. Chi, D. Ho, PhD, D. Kwan, K. W. Lee, and
S. Ma for data processing and field work.
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