Environmental and 

Biological Assessment of 

Environmental Tobacco 

Smoke Exposure Among 

Casino Dealers

Chandran Achutan, PhD

Christine West, RN, MSN, MPH

Charles Mueller, MS

Yvonne Boudreau, MD, MSPH

Kenneth Mead, PhD, PE

Health Hazard Evaluation Report

HETA 2005-0076; 2005-0201-3080

Bally’s, Paris, and Caesars Palace Casinos

Las Vegas, Nevada

May 2009

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page i

Appendix A

Report Abbreviations.......................................................................i

Highlights of the NIOSH Health Hazard Evaluation............iv

Summary .............................................................................v

Introduction..........................................................................1

Assessment.........................................................................2

Results.................................................................................8

Discussion .........................................................................16

Conclusions.......................................................................21

Recommendations.............................................................21

References ........................................................................22

Contents

Methodology......................................................................31

Preliminary Assessment....................................................28

Ventilation Overview ..........................................................29

Acknowledgment

Appendix B

Appendix C

Appendix Occupational Exposure Limits & Health Effects ...............3

Acknowledgments and Availability of Report.....................38
Page ii Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

4-VP 4-vinyl pyridine

ACGIH® American Conference of Governmental Industrial Hygienists

ACTLD Acetaldehyde

ALD Aldehyde

ANSI American National Standards Institute

API Atmospheric-pressure ionization

ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers

ASTM American Society for Testing and Materials

cfm Cubic feet per minute

CO Carbon monoxide

CO2 Carbon dioxide

COT Cotinine

oF Degrees Fahrenheit

EPA Environmental Protection Agency

ETS Environmental tobacco smoke

FLD Formaldehyde

fpm Feet per minute

GC Gas chromatography

GM Geometric mean

HHE Health hazard evaluation

HPLC High performance liquid chromatography

HVAC Heating, ventilation, and air conditioning

IEQ Indoor environmental quality

LOD Limit of detection

LOQ Limit of quantitation

Lpm Liters per minute

MDC Minimum detectable concentration

MERV Minimum efficiency reporting value

min Minute(s)

mg/m3 Milligrams per cubic meter

mL Milliliter

mm Millimeter

MS Mass spectrometry

n Sample size

ng Nanogram

Abbreviat
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page iii

Abbreviat

(continued

NIC Nicotine

NIOSH National Institute for Occupational Safety and Health

nmol/mgcr Nanomoles per milligrams of creatinine

NNAL 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol

NNK 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone

NP Nonpoker

NRT Nicotine replacement therapy

OEL Occupational exposure limit

OSHA Occupational Safety and Health Administration

OVS OSHA versatile sampler

PAH Polynuclear aromatic hydrocarbon

PBZ Personal breathing zone

PEL Permissible exposure limit

PFTE Polytetrafluoroethylene

pg Picogram

pmol/mgcr Picomoles per milligrams of creatinine

ppb Parts per billion

ppm Parts per million

r Pearson’s correlation coefficient

REL Recommended exposure limit

RH Relative humidity

RSP Respirable suspended particulates

SOL Solanesol

STEL Short-term exposure limit

THC Total hydrocarbon (as toluene)

TLV® Threshold limit value

TOL Toluene

TWA Time-weighted average

UV Ultraviolet

VOC Volatile organic compound

μL Microliter

μg/m3 Micrograms per cubic meter

μm Micrometer

WEEL Workplace environmental exposure limit
Page iv Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Highlights of 

NIOSH 

Hazard Eval

National Institute for 

Occupational Safety 

and Health (NIOSH) 

investigators evaluated 

environmental tobacco 

smoke (ETS) exposure 

at Bally’s, Paris, and 

Caesars Palace casinos 

in Las Vegas, Nevada, 

at the request of casino 

employees. They 

measured exposures 

and surveyed employees 

about health symptoms. 

They found evidence 

of workplace exposure 

to a tobacco-specific 

carcinogen among nonpoker casino dealers. 

Based on the known 

link between ETS and 

health effects, NIOSH 

investigators recommend 

establishing casino-wide 

no smoking policies and 

developing smoking 

cessation programs for 

casino employees.

What NIOSH Did

● We talked to nonpoker (NP) casino dealers about symptoms 

that may have been related to ETS exposure.

● We took personal breathing zone and area air samples to 

measure ETS.

● We took urine samples to see if components of ETS were 

absorbed into NP casino dealers’ bodies.

● We surveyed NP casino dealers and casino office staff about 

their work, medical problems, and symptoms.

What NIOSH Found

● NP casino dealers reported having respiratory symptoms. 

They thought these symptoms were related to ETS.

● We found ETS components in the air. These components 

include nicotine, 4-vinyl pyridine, respirable dust, solanesol, 

benzene, toluene, p-dichloromethane, naphthalene, 

formaldehyde, and acetaldehyde.

● We found increased urinary levels of one ETS component 

during the work shift. This finding shows that these 

components were absorbed in NP casino dealers’ bodies.

● More NP casino reported respiratory symptoms than 

administrative and engineering employees, but the 

differences between the groups were not statistically 

significant.

What Casino Managers Can Do

● Ban smoking in the casinos.

● Offer smoking cessation classes for employees.

● Make sure that ventilation systems are working properly.

● Form health and safety committees with employees and 

managers. These committees should meet regularly to address 

employee health concerns.

What Casino Employees Can Do

● Stop smoking.

● See a doctor for any health concerns or symptoms.

● Take part in casino health and safety committees.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page v

Summ

Evidence of workplace 

exposure to ETS was 

demonstrated by a 

measurable increase of a 

biological marker (NNAL), 

a known lung carcinogen, 

over a work shift in 

NP casino dealers. NP 

casino dealers reported 

higher prevalence of 

respiratory symptoms 

than administrative and 

engineering workers 

unexposed to ETS at work, 

but these differences 

were not statistically 

significant. The casinos 

should institute casinowide no smoking policies 

and develop smoking 

cessation programs for 

their employees.

Between January and April 2005, NIOSH received confidential 

requests for HHEs from NP casino dealers at Bally’s, Paris, and 

Caesars Palace casinos in Las Vegas, Nevada. These casino dealers 

were concerned that exposure to ETS in their workplace was 

causing a variety of acute and long-term health effects.

In response to these requests, NIOSH investigators conducted 

three onsite evaluations at Bally’s, Paris, and Caesars Palace 

casinos. The first onsite evaluation was conducted July 22–24, 

2005, during which we interviewed employees, reviewed OSHA 

Forms 200 and 300 (Log of Work Related Injuries and Illnesses), 

and administered a screening questionnaire. The screening 

questionnaire was used to select potential participants to take 

a subsequent health symptom questionnaire and undergo 

environmental and biological monitoring. During the second 

site visit, from August 21–24, 2005, additional screening 

questionnaires were distributed to NP casino dealers. A health 

symptom questionnaire was mailed January 6, 2006, and we 

conducted biological and environmental monitoring on our final 

site visit from January 19–22, 2006.

During the confidential medical interviews and the open 

discussions, NP casino dealers reported that they were most 

concerned about respiratory health effects related to ETS. NP 

casino dealers who worked in areas where smoking was permitted 

made up our study sample. Casino employees in administrative 

and engineering jobs who worked in areas where smoking was 

not permitted made up the comparison group. Of the responses 

from the health symptom questionnaire, the three most common 

symptoms reported by NP casino dealers were red or irritated 

eyes, cough, and stuffy nose. The prevalence of upper and lower 

respiratory symptoms, eye symptoms, headache, nausea, and 

dizziness was higher among the NP casino dealers than among the 

administrative and engineering employees, but these differences 

were not statistically significant. The low participation rate of the 

NP casino dealers and the small number of administrative and 

engineering casino employees may limit our ability to provide a 

confident estimate of symptom prevalence among these groups.

Of the 1,188 total poker and NP casino dealers working in Bally’s, 

Paris, and Caesars Palace, 124 NP casino dealers participated in the 

environmental and/or biological exposure assessment. Full-shift 

PBZ and area air sampling for NIC, RSP, VOCs, PAHs, and ALD, 

were conducted in the casino gaming areas on Thursday, Friday, 
Page vi Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Summary (contin

and Saturday during the swing shift and on Sunday during the 

day shift at all three casinos. We also monitored CO in the area 

samples.

NIC PBZ concentrations were similar to ranges found in a 

previous study of ETS in a casino. Of the 16 PAHs monitored, 

only naphthalene was present in quantifiable amounts. The 

VOCs identified included benzene, TOL, total hydrocarbons, 

p-dichlorobenzene, and limonene. The overall geometric means 

of the area samples were similar to those of the PBZ samples. Area 

CO concentrations were very low, with maximum values for each 

day measured ranging from 0.8–5.3 ppm in the three casinos.

We collected preshift and postshift urine samples on 114 NP casino 

dealers to determine whether levels of ETS biomarkers (COT and 

NNAL) in their urine would increase over an 8-hour work shift. 

Levels of NNAL in urine increased significantly during an 8-hour 

work shift both adjusting for, and not adjusting for, creatinine 

clearance. Creatinine-unadjusted COT increased during the 8-hour 

shift, but creatinine-adjusted COT decreased.

The NP casino dealers at Bally’s, Paris, and Caesars Palace casinos 

had measurable airborne levels of ETS in their personal breathing 

zone and were found to absorb an ETS component into their 

bodies, as evidenced by measureable levels in the urine. The 

presence of NNAL in the urine demonstrates that casino dealers 

are exposed to a known carcinogen from the tobacco smoke. NP 

casino dealers reported higher prevalence of respiratory symptoms 

compared to administrative and engineering employees, but 

the differences in the prevalence between the groups were not 

statistically significant. 

Keywords: NAICS 721120 (Casino Hotels), environmental tobacco 

smoke, ETS, nicotine, markers, respirable suspended particulates, 

formaldehyde, acetaldehyde, benzene, volatile organic compounds, 

naphthalene, cotinine, 4-(Methylnitrosoamino)-1-(3-pyridyl)-1-butanol, 

NNAL
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 1

Introduct

Between January and April 2005, NIOSH received confidential 

requests for HHEs from casino dealers at Bally’s, Paris, and Caesars 

Palace casinos in Las Vegas, Nevada. NP casino dealers were 

concerned that exposure to ETS at work was causing a variety of 

health problems such as asthma, headaches, and eye irritation. NP 

casino dealers were also concerned about long-term health effects 

from ETS exposure such as cancer and heart disease. They also 

requested that the casino management provide gaming tables with 

built-in ventilation systems.

In response to these requests, NIOSH investigators conducted 

three onsite evaluations at Bally’s, Paris, and Caesars Palace 

casinos. The first onsite evaluation was conducted July 22–24, 

2005, during which we interviewed employees, reviewed OSHA 

Forms 200 and 300 (Log of Work Related Injuries and Illnesses) 

("OSHA Logs") and administered a screening questionnaire to 

select potential participants for the health symptom questionnaire 

and environmental and biological monitoring. During the 

second site visit, from August 21–24, 2005, additional screening 

questionnaires were distributed to NP casino dealers. A health 

symptom questionnaire was mailed on January 6, 2006, to 

NP casino dealers and administrative staff, and we conducted 

biological and environmental monitoring on our final site visit 

January 19–22, 2006. At the start of the evaluation, Caesars 

Entertainment owned the casinos; by the January 2006 visit, 

Harrah’s Entertainment owned them.

Of the three casinos, Caesars Palace is the largest (129,000 square 

feet), followed by Paris (83,000 square feet), and Bally’s (67,000 

square feet). Each of the casinos offers table gaming such as 

blackjack, poker, roulette, and craps. Gaming tables are usually 

arranged to form an oval, called a “pit.” At the time of our first 

site visit, smoking was permitted for patrons throughout the 

gaming area of the three casinos except for poker tables in Bally’s 

casino. By our third visit, Caesars Palace had established a smokefree poker room. Employees on the gaming floors include casino 

dealers, pit supervisors, cocktail servers, security officers, and 

managers. Most of the Bally’s, Paris, and Caesars Palace casino 

dealers worked throughout the gaming areas where smoking was 

permitted, but at the time of our site visits, a small percentage of 

casino dealers worked only at the poker tables where smoking was 

not permitted. Work schedules are similar at the three casinos. The 

casinos are open 24 hours a day, and casino dealers primarily work 

one of several 8-hour shifts.
Page 2 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Introducti

(continued

Assessment

Our comparison group included casino employees assigned to 

administrative and engineering job duties who worked in areas 

of the casinos where smoking was not permitted, adjacent to the 

casino gaming areas and with separate ventilation. Administrative 

and engineering employees worked 8-hour daytime shifts, 5 days a 

week. We included the comparison group to provide a background 

prevalence of symptoms to which the prevalence of symptoms 

among the exposed group (NP casino dealers) could be compared.

The principal objectives of these HHEs were to quantify NP 

casino dealers’ exposure to ETS and to determine the prevalence 

of respiratory symptoms among NP casino dealers. To achieve 

these objectives, the evaluation was conducted in three phases. 

During the preliminary assessment phase, July 22–24 and August 

21–24, 2005, we interviewed employees, reviewed OSHA Logs, 

and administered a screening questionnaire to select potential 

participants for the subsequent phases of the study. In the second 

phase, January 6, 2006, we mailed a health symptom questionnaire 

to NP casino dealers and casino employees in administrative 

and engineering jobs. In the third phase, January 19–22, 2006, 

we assessed levels of NIC, 4-VP, RSP/SOL, TOL, THC, PAHs, 

VOCs, and ALDs (FLD and ACLTD) in the air, and levels of COT, 

NNAL, and creatinine in the urine of NP casino dealers over an 

8-hour shift.

Preliminary Assessment

Employee Interviews and Review of OSHA Logs

During the initial site visit (July 2005), casino dealers at Bally’s, 

Paris, and Caesars Palace casinos were invited to discuss their 

health concerns in a private room with one of three NIOSH 

medical officers. These interviews were scheduled so that 

employees working any shift had an opportunity to speak with the 

medical officers. Many of the dealers also openly discussed their 

health concerns in the dealer break rooms where medical officers 

were available.

The OSHA Logs were reviewed for the years 2003–2005 for Bally’s 

and Paris casinos. For Caesars Palace, the OSHA Logs from 1999, 

2000, 2001, 2003, and 2004 were reviewed; OSHA Logs for 2002 

were not available. Information from the employee interviews 

and the OSHA Logs was used in designing the health symptom 
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 3

Assessment (continued) questionnaire. A summary of the employee interviews and review

of OSHA Logs appears in Appendix A.

Selection of Potential Study Participants

Based on employee records provided by casino management, 

1,188 poker and NP casino dealers were working at the time of 

our evaluation. This number included 211 dealers at Bally’s, 319 

dealers at Paris, 545 dealers at Caesars Palace, and 113 dealers 

who worked on an as-needed basis (extra board dealers) for Bally’s 

and Paris casinos. No information was available on the number of 

workers unexposed to ETS at the three casinos.

During the July and August 2005 site visits, NIOSH investigators 

used a screening questionnaire to identify potential study 

participants for the health symptom questionnaire and biological 

and environmental monitoring. Participation in the screening 

questionnaire was open to all casino employees who worked in 

the gaming areas of the casinos, as well as administrative and 

engineering employees who worked in locations adjacent to the 

casino gaming areas that had separate ventilation. We distributed 

screening questionnaires in gaming employees’ break rooms where 

casino dealers and other casino gaming employees began their work 

shift and took breaks. Although other casino employees from the 

gaming floor used the break rooms, we narrowed our selection and 

targeted only NP casino dealers for participation in the subsequent 

phases of the study. We distributed the screening questionnaire to 

administrative and engineering employees at their workstations. 

After completing the questionnaires, employees returned them 

to locked boxes, directly to NIOSH investigators, or by mail in 

NIOSH-provided, addressed, stamped envelopes. Of the 467 casino 

employees who returned screening questionnaires, 412 were from 

employees working in smoking permitted areas, and 55 were from 

employees in the areas of the casinos that do not permit smoking.

The screening questionnaire asked employees for contact 

information, sex, date of birth, job title, name of casino they 

worked in, and work shift. It also asked whether they currently 

smoke or use tobacco products and whether they live with 

someone who smokes inside the home. Employees were selected as 

potential study participants for the health symptom questionnaire 

and the biological and environmental monitoring if they reported 

they did not use any tobacco products and were not living with 

someone who smokes inside the home. We found 365 employees 
Page 4 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Assessment (continued) who met these initial inclusion criteria for the health symptom

questionnaire and biological and environmental monitoring.

Air Sampling (July 2005)

Full-shift area air sampling for NIC, RSP, VOCs, CO, and PAHs 

was conducted in the casino gaming areas during the swing shifts 

at all three casinos. These samples were used to work out logistical 

issues pertaining to sample collection and to develop analytical 

methods for SOL (extracted from the RSP sample filters) and 4-VP 

(extracted from the XAD-4TM sorbent tubes used to collect NIC). 

Because the samples were not collected to provide information on 

human exposure to ETS and were not part of the HHE requests, 

this report does not discuss these results.

Ventilation Overview

NIOSH investigators reviewed casino ventilation diagrams and 

discussed them with the casinos’ facility engineers. These findings 

are available in Appendix B. No ventilation measurements were 

taken by NIOSH investigators at any of the casinos.

Health Symptom Questionnaire

Health symptom questionnaires and stamped return envelopes 

were mailed to 365 casino employees who met our initial inclusion 

criteria from the screening questionnaire. The questionnaire was 

mailed January 6, 2006, prior to our on-site exposure assessment 

January 19–22, 2006.

Employees were asked if they have ever smoked or currently smoke 

tobacco products, lived with someone who smokes inside the 

home, or were exposed more than 5 days per week to tobacco 

smoke in other settings, such as in bars, restaurants, or other 

places. Employees were also asked for job type, number of hours 

they worked in a week, and name of the casino where they worked. 

Only NP casino dealers and administrative and engineering casino 

employees were included in the analysis of the questionnaire data. 

Additionally, employees were included in the analyses for the 

health symptom questionnaire if they reported no current use of 

tobacco products, did not live with someone who smokes inside 

the home, and had no exposure to tobacco smoke more than 5 

days per week in other settings such as bars, restaurants, or other 

places.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 5

Assessment (continued) Participants were asked if they had experienced respiratory

symptoms, eye symptoms, dizziness, headache, or nausea in the last 

4 weeks while working in the casino(s). A participant’s symptom 

was defined as work-related if it improved on days away from work. 

Participants were determined to have current asthma if a physician 

had diagnosed them with asthma and they indicated in the 

questionnaire that they still had asthma. Symptoms consistent with 

work-related asthma were defined as the presence of work-related 

wheeze, or two or more of the following symptoms: work-related 

cough, chest tightness, or shortness of breath. 

Exposure Assessment

Additional inclusion criteria for participants in the biological 

monitoring and environmental assessment phases were as follows: 

(1) participants had to be NP casino dealers and (2) they had to 

work either the swing shift (starts between 6 p.m. and 9 p.m.) 

from Thursday through Saturday, or the day shift (starts between 

9 a.m. and 12 p.m.) on Sunday. These shift/time combinations 

were identified by NP casino dealers as the busiest times of the 

week, possibly when ETS levels were highest. We identified 213 

NP casino dealers as potential participants for the biological and 

environmental monitoring using these additional criteria.

Biological Monitoring

On the days of the exposure assessment, we verbally administered 

an acute exposure questionnaire. We asked the NP casino dealers 

about their use of tobacco products, how long ago they used 

tobacco products, whether they use NRT, exposure to ETS in 

the 4 days prior to sampling, the casino they worked in, and the 

shift they worked. As an additional step, we verbally verified that 

participants were nonsmokers. To participate in the biological 

monitoring, NP casino dealers had to report no current use of 

tobacco products and no ETS exposure outside of work. For 

NP casino dealers who reported NRT use, analysis of biological 

monitoring was restricted to NNAL.

From among the 213 NP casino dealers who were potential 

participants, we chose a convenience sample of 124 participants 

for biological monitoring. This number of participants was chosen 

to match the limited number of PBZ air sampling pumps available 

for these participants to wear during the evaluation. We targeted 

10 NP casino dealers at each casino on each day that we conducted 
Page 6 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Assessment (continued) biological monitoring. NP casino dealers provided a urine sample

before the start of their work shift and at the end of the work 

shift. NIOSH investigators provided them with urine cups to 

collect their samples. The samples were analyzed for urinary COT, 

total NNAL, and creatinine (used to adjust for urinary dilution). 

Individual results for the biological monitoring component were 

mailed to participants.

COT is the major metabolite of NIC with a biological half-life 

of approximately 16–20 hours. The biological half-life is the time 

required for a substance within a biological system to decrease by 

one half. The rate of removal is often approximately exponential. 

When detected in the urine, COT provides a valuable indicator 

of tobacco smoke exposure, including secondary smoke exposure 

from the previous 1–2 days [Pirkle et al. 1996]. The tobacco-specific 

nitrosamine NNAL is a urinary metabolite of NNK, which is a 

potent pulmonary carcinogen in humans. NNK is not found in 

materials other than tobacco, so the presence of NNAL provides 

a direct association between tobacco exposure and body burden 

of a tobacco-related carcinogen [Benowitz 1999]. In one study that 

quantified urinary levels of NNK and NNAL in cigarette smokers 

after smoking cessation, the researchers estimated that NNAL 

had an elimination half- life of 45.2 days and that NNK had an 

elimination half-life of 39.6 days [Hecht et al. 1999]. No research is 

available describing the elimination of NNK and its metabolites as 

a result of exposure to ETS. The methods used for these analyses 

are available in Appendix C.

Environmental Monitoring

Full-shift area and PBZ air samples for NIC, 4-VP, RSP/SOL, TOL, 

THC, PAHs, VOCs, and ALDs (FLD and ACTLD) were collected 

at each casino. The specific sampling and analytical methods for 

these analytes are available in Appendix C. We collected two sets of 

area samples daily at each casino. The purpose of the area samples 

was to continuously monitor the ambient concentrations in the 

gaming areas for worst-case exposure scenarios, and to see how 

they compared with PBZ sample measures. Area samplers were 

placed within the center of the pit and at the same height as the 

PBZ of the dealers. Ambient parameters, such as temperature, RH, 

and CO2

 concentration, as well as CO concentration (found in 

ETS from tobacco combustion), were measured using a QTRAK 

Plus®, a direct reading instrument (TSI, St. Paul, Minnesota). 

Background information on ETS, such as health effects, as well as 

OELs on environmental measures that were collected, are available 

in Appendix D.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 7

Assessment (continued) PBZ air samples were collected on 10 NP casino dealers at each

casino who provided urine samples each day. If these dealers opted 

not to wear the sampling equipment, we attempted to recruit 

new nonsmoking NP casino dealers to replace them. Because the 

NIOSH staging areas were where NP casino dealers reported to 

work, we were able to efficiently recruit new participants, verify 

that they met the inclusion criteria to participate, and enroll 

them into the environmental and biological monitoring. We then 

collected their preshift urine sample and provided them with 

environmental samplers prior to the start of their work shift. All 

NP casino dealers who contributed a urine sample were asked 

to wear samplers for NIC and 4-VP; eight of the ten NP casino 

dealers were also asked to wear an additional sampler that would 

sample for one of the following: RSP/SOL, PAH, and VOCs. The 

remaining two NP casino dealers were asked to wear a badge that 

passively measured ALD in the air. In a few instances, volunteers 

wearing the samplers for RSP/SOL, PAH, and VOCs requested 

passive badges to measure their ALD exposures. Whenever possible 

we provided them with these badges. Specific analytical methods 

for each of these analytes are available in Appendix C.

Statistical Analysis

We used SAS version 9.1 (SAS Institute, Cary, North Carolina) 

for all statistical analyses. Using chi-square tests and Fisher’s exact 

tests at a significance level of 0.05, we compared the prevalence 

of symptoms between NP casino dealers and casino workers 

in administrative and engineering jobs. Symptoms considered 

included respiratory symptoms, eye irritation, sore throat, 

headache, nausea, and dizziness. We also examined the differences 

between preshift and postshift NNAL, NNAL adjusted for 

creatinine, COT, and COT adjusted for creatinine using paired 

t-tests or paired signed tests, depending on the distributions of 

the differences. Pearson’s or Spearman’s correlation coefficients 

were calculated among and between environmental and biological 

sampling results.

For environmental and NNAL samples with mass below the 

LOD, an estimate of the mass was obtained by dividing the LOD 

(obtained from the laboratory) by √2. Hornung and Reed [1990] 

have described this method of handling censored data. For the 

environmental samples, this estimate was divided by the maximum 

sample volume to obtain the estimated sample concentration. The 

MDCs were determined by dividing the LOD by the maximum 
Page 8 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Assessment (continued) sample volume. Similarly, where the lab did not report COT

measures below the LOQ, the LOQ divided by √2 was used.

Health Symptom Questionnaire

NIOSH investigators mailed 365 health symptom questionnaires 

to participants who met inclusion criteria based on responses to 

the screening questionnaire; of these, 195 (53%) completed and 

returned the questionnaire. After reviewing the responses, we 

determined that 36 participants did not meet our inclusion criteria 

for the health symptom questionnaire; they were removed from the 

analysis. This resulted in 159 participants who met the inclusion 

criteria for the health symptom questionnaire, 147 NP casino 

dealers and 12 administrative or engineering casino employees. 

The mean age of the NP casino dealers was 48 years (range: 24–73); 

79 (54%) were women. The mean age of the administrative and 

engineering casino employees was 48 years (range: 27–67); 8 (67%) 

were women. Table 1 shows the number of participants in the 

health symptom questionnaire by casino and job group. The mean 

number of hours worked across all three casinos was 41 hours 

(range: 5–80) for NP casino dealers and 43 hours (range: 40–55) 

for administrative and engineering casino employees.

Results

Table 1. Number of participants by casino for health 

symptom questionnaire

Casino NP casino 

dealers

n

Administrative

and engineering 

casino

employees

n

Bally’s only 23 2

Paris only 48 5

Caesars Palace only 62 0

Multiple casinos* 14 5

Total 147 12

*Fourteen dealers and five administrative and engineering 

employees reported working at two or more casinos.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 9

Results (continued

Table 3 presents the prevalence of current physician-diagnosed 

asthma and symptoms that suggest work-related asthma in 

NP casino dealers and administrative and engineering casino 

employees. The prevalences of symptoms that suggest work-related 

asthma were higher among the NP casino dealers than among 

the administrative and engineering casino employees, but the 

differences were not statistically significant. Of the 11 NP casino 

dealers who reported they had current physician-diagnosed asthma, 

seven reported their asthma was worse when they were at work.

Table 2 presents the prevalences of work-related symptoms for 

the NP casino dealers and the administrative and engineering 

casino employees. The three most common health symptoms 

reported by the NP casino dealers were red or irritated eyes 

(49%), cough (48%), and stuffy nose (43%). The prevalences 

of respiratory symptoms, eye symptoms, headache, nausea, and 

dizziness were higher among the NP casino dealers than among 

the administrative and engineering casino employees, but these 

differences were not statistically significant.

Table 2. Prevalences of work-related health symptoms* in participants 

Health Symptom 

NP casino NP

NP casino

dealers 

n(%)†

Administrative and 

engineering casino 

employees 

n (%)‡

p value 

Red or irritated eyes 68 (49) 4 (33) 0.31

Cough 68 (48) 3 (25) 0.13

Stuffy nose 60 (43) 3 (25) 0.36

Sneezing 59 (42) 2 (17) 0.13

Runny nose 57 (40) 2 (17) 0.13

Itching eyes 54 (39) 2 (17) 0.21

Headache 51 (37) 2 (17) 0.22

Watery eyes 47 (33) 2 (17) 0.34

Sore or scratchy throat 43 (31) 1 (8) 0.18

Shortness of breath 25 (17) 1 (8) 0.69

Dizziness 23 (16) 0 0.22

Wheezing or whistling in chest 21 (14) 0 0.37

Tightness in chest 

Nausea 

18 (13) 

11 (8) 

0

0

0.36

1.00

*Report of symptom in the last 4 weeks while working in a casino and positive response to “Does this 

symptom improve on your days off?”

†

Denominators vary from 139–145.

‡

Denominator is 12.
Page 10 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

RESULTS

(C ONTINUED )

 

Exposure Assessment

Environmental Monitoring

Tables 4 and 5 present the geometric means, sample sizes, 

and ranges for the PBZ and area air samples by casino and for 

all casinos combined. The GMs of the area and PBZ sample 

concentrations were comparable within casinos for a particular 

analyte.

Table 4. Geometric means (sample sizes) and ranges of ETS components (μg/m3) in PBZ air samples 

Bally’s Paris Caesars Palace Combined 

GM (n) Range GM (n) Range GM (n) Range GM (n) Range

ACTLD 9.30 (11) 6.2–15 9.16 (12) 4.8–16 15.1 (6) 14–17 10.2 (29) 4.8–17 

4-VP 0.867 (34) 0.18–2.8 0.852 (35) 0.18–1.7 1.33 (38) 0.57–2.5 1.00 (107) 0.18–2.8 

FLD 7.46 (11) 2.3–22 7.75 (12) 2.3–29 16.8 (6) 14–23 8.96 (29) 2.3–29 

NIC 4.60 (34) 1.6–12 4.03 (35) 0.58–10 7.80 (38) 3.9–17 5.32 (107) 0.58–17

PAH* 0.652 (12) 0.21–1.2 0.753 (11) 0.25–1.2 1.02 (11) 0.72–1.4 0.790 (34) 0.21–1.4 

RSP 43.0 (11) 22–78 31.6 (10) 13–56 52.5 (12) 13–140 42.1 (33) 13–140 

SOL 0.208 (11) 0.07–0.82 0.145 (10) 0.07–0.55 0.352 (12) 0.07–1.1 0.226 (33) 0.07–1.1 

THC 208 (6) 56–390 425 (7) 130–1200 735 (9) 230–3100 438 (22) 56–3100

TOL 23.1 (6) 5.6–290 6.29 (7) 5.6–13 18.5 (9) 5.6–180 13.9 (22) 5.6–290

*The concentrations reflect the levels of naphthalene, the only PAH detected in the samples. 

Table 5. Geometric means (sample sizes), and ranges of ETS components (μg/m3) in area air samples 

Bally’s Paris Caesars Palace Combined 

GM (n) Range GM (n) Range GM (n) Range GM (n) Range

ACTLD 8.55 (5) 2.3–19 9.30 (8) 6.9–14 15.4 (6) 7.6–20 11.0 (19) 2.3–20 

4-VP 0.831 (8) 0.18–1.8 1.10 (8) 0.72–1.6 1.76 (8) 0.97–3.4 1.20 (24) 0.18–3.4 

FLD 7.19 (5) 2.3–36 6.70 (8) 2.3–14 15.6 (6) 7.6–34 8.91 (19) 2.3–36 

NIC 5.31 (8) 1.0–14 5.31 (8) 2.6–7.2 10.7 (8) 4.5–23 6.69 (24) 1.0–23 

PAH* 0.607 (7) 0.31–1.2 0.617 (8) 0.19–1.3 1.01 (8) 0.55–1.6 0.729 (23) 0.19–1.6 

RSP 38.1 (6) 23–77 32.6 (8) 25–44 56.1 (8) 40–86 41.4 (22) 23–86

SOL 0.300 (6) 0.07–0.89 0.141 (8) 0.07–0.36 0.359 (8) 0.10–0.99 0.242 (22) 0.07–0.99

THC 320 (8) 142–470 251 (8) 130–420 553 (8) 200–960 354 (24) 130–960

TOL 18.7 (8) 5.6–500 6.61 (8) 5.6–12 9.56 (8) 5.6–19 10.6 (24) 5.6–500

*The concentrations reflect the levels of naphthalene, the only PAH detected in the samples. 

Table 3. Prevalence of physician-diagnosed asthma and symptoms that suggest asthma in 

participants

NP casino

dealers

n (%)* 

Administrative and engineering 

casino employees 

n (%)†

p value 

Current physician-diagnosed asthma‡ 11 (8) 2 (20) 0.22

Symptoms suggestive of work-related 

asthma§

35 (24) 0 0.07

*Denominators range from 122–143. 

†

Denominators range from 8–12. 

‡

Asthma was reported as being diagnosed by a physician and a positive response to “Do you still have 

asthma?” 

§

Reported the presence of work-related wheeze, or two of the following three symptoms: work-related cough, 

work-related chest tightness, or work-related shortness of breath. 
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 11

Results (continued) Nicotine and 4-Vinyl Pyridin

The MDCs for NIC and 4-VP, based on a sample volume of 

765 liters, were 0.26 μg/m3

. None of the PBZ NIC measures 

and three of the PBZ 4-VP measures were below the MDC. PBZ 

concentrations ranged from 0.58 to 17 μg/m for NIC and from 

below the MDC to 2.8 μg/m3 for 4-VP. For all three casinos

combined, the geometric mean for PBZ NIC was 5.32 μg/m3 and

1.00 μg/m3 for 4-VP

None of the NIC area measures and only one 4-VP measure was 

below the MDC. Area measures for NIC ranged from 1.0 to 23 

μg/m; the 4-VP concentrations ranged from below the MDC to 

3.4 μg/m. For all three casinos combined, the geometric mean for 

area NIC was 6.69 μg/m3 and 1.20 μg/m3 for 4-V

Polynuclear Aromatic Hydrocarbons

Of the 16 PAHs analyzed, only naphthalene was detected in 

quantifiable concentrations. All naphthalene PBZ measures were 

above the MDC. PBZ concentrations of naphthalene ranged 

from 0.21 to 1.4 μg/m. The geometric mean for all three casinos 

combined for PBZ naphthalene was 0.790 μg/m. Of the 24 area 

measures taken, one was not analyzed because of pump failure. The 

remaining 23 area measures ranged from 0.19 to 1.6 μg/m. The 

geometric mean for area naphthalene samples for all three casinos 

combined was 0.729 μg/m.

Respirable Suspended Particulates and Solanesol

Based on a sample volume of 1056 liters, the MDC for RSP was 

19 μg/m and 0.09 μg/m3 for SOL. Three PBZ measures for RSP

and eleven PBZ measures for SOL were below the MDC. PBZ 

concentrations ranged from below the MDC to 140 μg/m for 

RSP and from below the MDC to 1.1 μg/m3 for SOL. For all three

casinos combined, the geometric mean for RSP was 42.1 μg/m

and 0.226 μg/m3 for SOL

None of the area RSP measures and six SOL measures was below 

the MDC. Two RSP/SOL area samples were damaged during 

shipping and were not analyzed. Area measures for RSP ranged 

from 23 to 86 μg/m; area SOL measures ranged from below the 

MDC to 0.99 μg/m. For all three casinos combined, the geometric 

mean for area RSP was 41.4 μg/m3 and 0.242 μg/m3 for SO

Volatile Organic Compounds

 A VOC screen using thermal desorption tubes indicated the 

presence of approximately 98 chemicals per sample in the air; 
Page 12 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Results (continued

Only compounds with an abundance above the threshold limit 

of the analytical instrument were included in this figure. Based 

on this profile, benzene, TOL, p-dichlorobenzene, limonene, and 

THC were chosen for quantitative analysis based on the relative 

amount present in the environment, their relative toxicities 

compared to other VOCs, and ability to separate them from the 

mixture. A trace concentration of p-dichlorobenzene was found in 

one PBZ sample at Bally’s. Quantifiable concentrations of benzene 

were found in two PBZ samples, both at Caesars Palace. The fullshift concentrations for both samples were 12 ppb and 13 ppb. 

Quantifiable concentrations of limonene were found in two PBZ 

samples at Bally’s (0.6 mg/m3

 and 1.3 mg/m3) and in four PBZ 

samples at Caesars Palace (0.1 mg/m3

, 0.1 mg/m3, 0.9 mg/m3, and 

1.0 mg/m3

).

Based on a sample volume of 51 liters, the MDC for TOL was 

8 μg/m3 and 79 μg/m3 for THC. Thirteen TOL PBZ measure

approximately 20 of these chemicals are commonly found in 

indoor environments. The chemicals were analyzed using gas 

chromatography with mass spectrometry detection. Figure 1 shows 

a typical profile of the VOCs present in the casinos. The x-axis 

denotes the retention time of a compound, i.e., the time taken 

to separate from a mixture of chemicals. The y-axis is a measure 

of total ion abundances at the retention times. Each scan per 

second made by the analytical instrument is plotted as a point 

(time, abundance) forming the ion chromatogram. Abundance is 

a measure of concentration, i.e., the higher the ion abundance, 

the higher the amount of analyte present. The actual abundance 

“numbers” are relative to what scale is chosen for the plot.

Figure 1. Profile of chemicals inside casinos 

50000

20050000

40050000

60050000

80050000

100050000

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28

Time (minutes)

Abundance

Toluene Nicotine

Benzene Vinylpyridin

C7 C13

C11

Siloxane

Limonene

Hexane/Ethylacetate

Naphthalene
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 13

Results (continued) and one THC PBZ measure were below the MDC. The PBZ

concentrations of TOL ranged from below the MDC to 290 μg/

m3

, and the PBZ concentrations of THC ranged from below the 

MDC to 3100 μg/m3

. The geometric mean in the PBZ measures at 

all three casinos combined was 13.9 μg/m3 for TOL and 438 μg/

m3 for THC. Fourteen of the 24 area measures for TOL and none 

of the THC measures were below the MDC. Area TOL measures 

ranged from below the MDC to 500 μg/m3

, and area THC 

measures ranged from 130 to 960 μg/m3

. The geometric mean in 

the area measures for all three casinos combined was 10.6 μg/m3

for TOL and 354 μg/m3

 for THC.

Formaldehyde and Acetaldehyde

The MDCs for FLD and ACTLD based on a sample volume of 16 

liters were 3.2 μg/m3

. Five of the FLD measures and none of the 

ACTLD PBZ measures were below the MDC. PBZ concentrations 

ranged from below the MDC to 29 μg/m3

 for formaldehyde, and 

from 4.8 to 17 μg/m3

 for ACTLD. For all three casinos combined, 

the geometric mean for PBZ FLD was 8.96 μg/m3 and 10.2 μg/m3 

for ACTLD. Five ALD area samples were damaged during shipping 

and were not analyzed. Of the 19 samples that were analyzed, three 

FLD and one ACTLD area measures were below the MDC. The 

area concentrations of FLD ranged from below the MDC to 36 μg/

m3

, and the area concentrations for ACTLD ranged from below 

the MDC to 20 μg/m3

. The highest area concentrations of FLD 

(36 μg/m3

) and ACTLD (20 μg/m3) were collected on the same 

sample. For all three casinos, the geometric mean for area FLD was 

8.91 μg/m3 and 11.0 μg/m3 for ACTLD.

Carbon Monoxide

CO measures collected at 1-minute intervals were mostly below the 

instrument’s detection limit of 0.1 ppm. The maximum readings 

at the three casinos for each of the 4 days measured ranged from 

0.8–5.3 ppm.

Temperature, Relative Humidity, and Carbon 

Dioxide

Temperature and RH values were within the ASHRAE ranges 

for acceptable human comfort, except on one instance in the 

Paris casino, where the temperature was below the ASHRAE 

indoor design guidance of 68.5oF for winter temperatures [ANSI/

ASHRAE 2004]. At each casino, maximum CO2

 concentrations 

were more than 700 ppm above the outdoor CO2

 concentrations 

suggesting that not enough outdoor air may have been provided 

for acceptable odor control (body odor) and indicating the need 
Page 14 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Results (continued

Biological Monitoring

Of 213 NP casino dealers, 124 (58%) participated in the biological 

monitoring portion of the evaluation. All verbally reported they 

were nonsmokers, and 107 (86%) participants reported they 

had been exposed to ETS at work in the last 4 days. Of the 483 

urine samples (123 COT and 122 NNAL preshift and 119 COT 

and 119 NNAL postshift), some measures from four participants 

were excluded from the analysis. Two participants were removed 

because they reported on the exposure questionnaire that they 

were exposed to tobacco smoke in a bar or other setting in the 

past 4 days. One participant was removed because of a COT 

value inconsistent with being a nonsmoker. One participant was 

not included in the COT analysis because of reported use of 

NRT. Other sampling issues included a lack of both a preshift 

and postshift sample and insufficient sample volume for COT, 

NNAL, and creatinine. For the purposes of the comparative 

analysis, this resulted in 114 preshift and postshift (paired) 

samples for unadjusted COT and NNAL, and 112 preshift and 

postshift (paired) samples for creatinine-adjusted COT. A sample 

size of 113 preshift and postshift (paired) samples of creatinineadjusted NNAL was used for the comparative analysis. Fourteen 

COT measures were below the LOQ of 10 ng/mL and 93 NNAL 

measures were below the LOD of 0.0030 ng/mL. Of the 93 NNAL 

measures, 63 (68%) below the LOD were in the preshift samples, 

and 30 of the 93 (32%) NNAL measures below the LOD were in 

the postshift samples.

Table 7 presents the geometric mean levels of preshift and postshift 

COT and NNAL for each casino and for all casinos combined 

unadjusted for creatinine. Table 8 presents the geometric mean 

levels of preshift and postshift COT and NNAL adjusted for 

creatinine.

for further evaluation of the ventilation systems, as discussed 

in Appendix D. The outdoor CO2

 concentrations ranged from 

250–300 ppm. Table 6 summarizes these results.

Table 6. Ranges of indoor environmental quality parameters 

Casino Temperature (°F) RH (%) CO2 (ppm) 

Bally’s 69.4–74.3 12.4–18.7 450–1311 

Paris 60.5–74.7 8.3–18.9 286–1220 

Caesars Palace 69.3–77.0 9.6–23.1 583–1244 
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 15

Results (continued

Because the pattern of biological monitoring results was similar 

across casinos, our analysis focused on the combined results. 

Urinary COT and NNAL levels unadjusted for creatinine for all 

three casinos combined increased significantly during an 8-hour 

shift (p<0.01). The levels of urinary NNAL adjusted for creatinine 

for all three casinos combined increased significantly over an 

8-hour shift (p=0.03). However, urinary COT levels adjusted for 

creatinine for all three casinos combined decreased over an 8-hour 

shift. The preshift urinary COT was positively correlated with 

preshift urinary NNAL (r=0.55, p<0.01) and postshift urinary 

COT was positively correlated with postshift urinary NNAL 

levels (r=0.55, p<0.01). The net urinary NNAL correlated with 

the net COT (r=0.49; p<0.01). The net levels of NNAL and COT 

correspond to their preshift level subtracted from their postshift 

level. All correlations were calculated using NNAL and COT levels 

that were unadjusted for creatinine.

Relationship between Biological and 

Environmental Measures of ETS Exposure

No statistically significant positive correlations were found 

between the concentrations of unadjusted and adjusted NNAL 

and environmental measures (NIC, 4-VP, RSP/SOL, PAHs, TOL, 

THC, FLD, ACTLD) during the 4-day evaluation. No statistically 

significant positive correlation was found between unadjusted 

COT and environmental measures (NIC, 4-VP, RSP/SOL, 

Table 7. Geometric means (and sample size) of creatinine-unadjusted ETS components in urine

COT (ng/mL) NNAL (ng/mL) 

Casino Preshift

GM (n) 

Postshift 

GM (n) 

Preshift

GM (n) 

Postshift 

GM (n) 

Bally’s 27.55 (34) 34.18 (34) 0.0053 (35) 0.0089 (35) 

Paris 19.30 (35) 25.92 (35) 0.0042 (35) 0.0079 (35) 

Caesars Palace 21.15 (45) 31.41 (45) 0.0029 (44) 0.0050 (44) 

Combined 22.25 (114) 30.37 (114) 0.0039 (114) 0.0069 (114) 

Table 8. Geometric means (and sample size) of creatinine-adjusted ETS components in urine

COT (nmol/mgcr) NNAL (pmol/mgcr) 

Casino Preshift

GM (n) 

Postshift 

GM (n) 

Preshift

GM (n) 

Postshift 

GM (n) 

Bally’s 0.1706 (34) 0.1640 (34) 0.0270 (35) 0.0353 (35) 

Paris 0.1302 (34) 0.1192 (34) 0.0236 (35) 0.0297 (35) 

Caesars Palace 0.1947 (44) 0.1778 (44) 0.0226 (43) 0.0242 (43) 

Combined 0.1655 (112) 0.1536 (112) 0.0242 (113) 0.0290 (113) 
Page 16 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Results (continued) PAHs, TOL, THC, FLD, ACTLD) over the 4-day evaluation. No

statistically significant positive correlation was found between 

adjusted COT and most of the environmental measures (NIC, 

4-VP, TOL, THC, FLD, ACTLD) except for the following 

environmental measures: PAH (0.40), RSP (0.58), and SOL (0.42) 

where we found a statistically significant positive correlation.

In this evaluation we found that NP casino dealers were exposed 

to workplace ETS, and that they absorbed detectable ETS-specific 

components, including a tobacco-specific carcinogen, into their 

bodies. The 2006 U.S. Surgeon General’s Report concluded 

that the presence of NNAL in urine links ETS exposure with an 

increased risk of lung cancer in nonsmokers, and that exposure to 

ETS causes lung cancer. The report further concludes that no riskfree level of exposure to ETS exists and that eliminating smoking 

in indoor spaces fully protects nonsmokers from exposure to ETS. 

Other methods to reduce exposure, such as separating smokers 

from nonsmokers, cleaning the air, and ventilating buildings, 

cannot eliminate exposures of nonsmokers to ETS [DHHS 2006]. 

Although past research has demonstrated that ETS is harmful 

to those who are occupationally exposed, we chose to conduct 

a comprehensive evaluation because of the lack of biological 

monitoring and health effect data specifically on casino dealers 

who are exposed to ETS in the workplace.

Environmental Monitoring

The findings from this evaluation are consistent with those found 

in other ETS exposure assessment studies. The range of PBZ 

NIC air sample concentrations (0.58–17 μg/m3

) is comparable to 

past studies of workers in smoking environments [Phillips et al. 

1998; Jenkins and Counts 1999], including one study of casino 

dealers [Trout et al. 1998]. Likewise, the range of area air sample 

concentrations of NIC was comparable to data reported by Trout 

et al. [1998], who reported PBZ NIC concentrations between 6 and 

15 μg/m3

 for casino dealers. The area air concentrations in this 

study were similar to the PBZ sample concentrations, indicating 

that they were representative of the overall atmosphere in the 

casino pits.

Discussi
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 17

Discussio  (continued) Historically, RSP has been used as a surrogate for the particula

phase of ETS. RSP is easy to quantify in the environment. A 

drawback is that it is not specific to ETS, thus possibly leading 

to an overestimation of ETS levels. The maximum area RSP 

level in this evaluation was 86 μg/m3

, which is similar to the 

90 μg/m3

 reported by Trout et al. [1998]. The highest PBZ RSP 

concentration in this evaluation was 140 μg/m3

; Trout et al. [1998] 

did not measure PBZ RSP levels. In addition to RSP, SOL, a 

trisesquiterpenoid alcohol found in tobacco leaves, has been used 

as a surrogate for ETS components in the particulate phase [Ogden 

and Maiolo 1989; Tang et al. 1990]. However, recent research 

suggests that SOL is degraded in indoor environments with ozone 

concentrations of 40 ppb [Tucker and Pretty 2005]. Ozone levels 

were not measured as part of this evaluation.

A surprising finding from this evaluation was that common PAHs, 

such as benzo-a-pyrene, anthracene, or pyrene, were not found in 

the PBZ and area air samples. These compounds, some of which 

are known lung carcinogens, have been found in previous studies 

of ETS in homes and restaurants [Husgafvel-Pursiainen et al. 1986; 

Grimmer and Naujack 1987]. Of the 16 PAHs evaluated, only 

naphthalene was found in quantifiable concentrations in both 

PBZ and area air samples. The EPA has classified naphthalene 

as a possible human carcinogen [EPA 2008]. Overall, the 

concentrations of TOL, FLD, and ACTLD were lower than those 

reported in the scientific literature, although past ETS studies 

of these compounds were conducted in smaller spaces such as 

restaurants, automobiles, and residences.

Although the airborne components were below applicable 

regulatory and recommended OELs for these components 

individually, studies have shown that simultaneous exposure to 

multiple components (mixed exposures), even at low levels, can 

cause respiratory health effects, such as acute bronchitis and 

asthma [Burnett et al. 1994; Sheppard et al. 1999; Pope 2000]. 

These studies focused on health effects from air pollution from 

non-ETS fine particulates, but the mixed-exposure effects seen in 

these studies are still relevant to ETS exposure because many air 

pollutants (RSP, PAHs, VOCs, and ALDs) are also found in ETS. 

The regulatory and recommended OELs for these components 

are based on the individual component; the synergistic or additive 

properties are not considered [Lippy and Turner 1991]. OELs 

for some chemicals found in ETS (such as NIC) were developed 

to protect workers whose exposure (route and quantity) to these 
Page 18 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Discussio  (continued) chemicals are different from the ETS exposure route, as discuss

in Appendix D.

Most of the temperature and RH values measured during this 

evaluation fell within the acceptable ranges of thermal comfort 

recommended by ASHRAE. Each ventilation system reportedly was 

designed to comply with the relevant outdoor air recommendations 

in effect at the time of their installation. However, our limited 

area air monitoring data showed indoor concentrations of CO2

 to 

be more than 700 ppm relative to outdoors, suggesting the need 

to further evaluate the effectiveness of the ventilation systems in 

maintaining acceptable odor control. [It should be noted that 

this guideline refers to the control of body odor from sedentary 

people and not odor from tobacco smoke.] As discussed in 

Appendix B, two of the casinos (Paris and Caesars Palace) had CO2

sensors in the ductwork, but we do not know if the relationships 

between duct concentrations and breathing zone concentrations 

have been evaluated or if these sensors have been calibrated or 

maintained properly. The concentrations of ETS compounds 

could be expected to be higher when less outdoor air is brought 

into the casinos, and lower with more outdoor air to dilute these 

contaminants. ASHRAE has a position document stating that, 

although implementing engineering controls, such as current and 

advanced dilution ventilation, can reduce odors and some forms of 

irritation from ETS, it should not be relied upon to control health 

risks from ETS exposure in public spaces. ASHRAE concludes 

that the only means of eliminating the health risks associated with 

indoor ETS exposure is to ban all smoking [ASHRAE 2005].

Biological Monitoring

The biological monitoring portion of the evaluation was designed 

to evaluate body burden of ETS metabolites; that is, whether the 

ETS components were absorbed in the body, metabolized, and 

detectable in the urine. Biological monitoring has been commonly 

used to assess ETS exposure by measuring COT in the serum or 

urine of exposed persons. Because COT is the major metabolite 

of NIC, it has been extensively used in large epidemiological 

studies to measure exposure to ETS. However, COT is potentially 

problematic in that levels can be affected by the ingestion of NICcontaining foods and beverages, and it is not a specific indicator 

relevant to potential carcinogenicity [Benowitz 1999; Hecht 2002]. 

The tobacco-specific nitrosamine, NNK, along with its urinary 

metabolite NNAL, are known pulmonary carcinogens [Hecht 
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 19

Discussio  (continued) 2002], and the presence of NNAL in urine links ETS exposu

with an increased risk of lung cancer, a long-term outcome of ETS 

exposure [DHHS 2006]. NNAL is a tobacco-specific compound, 

so its detection specifically indicates ETS exposure [Hecht 2002]. 

The differences in NNAL and COT may help to explain the low 

correlation between NNAL and COT seen in this evaluation.

We have documented an increase in urinary levels of NNAL over 

a work shift in casino dealers, which provides strong evidence 

that the increase is due to workplace ETS exposure. Our results 

are consistent with other studies that have shown an increase in 

levels of NNAL in bar and restaurant workers exposed to ETS 

over a work shift and casino patrons exposed over a 4-hour period 

[Parsons et al. 1998; Anderson et al. 2003; Stark et al. 2007].

We have reported COT and NNAL levels with and without 

creatinine adjustment. This approach was recommended by 

several experts in tobacco biomarker research [Benowitz 2008; 

Bernert 2008; Hecht 2008]. In recently published ETS studies, 

researchers have chosen different approaches regarding creatinine 

adjustment [Parsons et al. 1998; Trout et al. 1998; Carrer et al. 

2000; Anderson et al. 2003; Tulunay et al. 2005; Stark et al. 2007]. 

Creatinine adjustment can account for potential dilutional effects 

when measuring biomarkers in spot urine samples. However, 

according to Barr et al. [2005] and Boeniger et al. [1993], creatinine 

adjustment of biomarkers in populations that vary by age, sex, and 

race may yield inaccurate results. Because these factors may have 

affected our results, we presented both methods. We found that 

the results, with or without adjustment for creatinine, were similar 

for NNAL but different for COT.

The GM values that we reported for unadjusted urinary COT are 

similar to those measured in other indoor environments, such as 

bars, casinos, and restaurants [Trout et al. 1998; Lindgren et al. 

1999; Benowitz and Jacob 2001; Johnsson et al. 2003]. Trout et al. 

[1998] found a GM preshift level of 23.0 ng/mL and postshift level 

of 33.3 ng/mL with a significant increase in urinary levels of COT 

(p<0.01) over the shift.

Health Symptom Questionnaire

NP casino dealers reported higher prevalence of respiratory 

symptoms than the ETS nonexposed group, but none were 

statistically significant. The 2006 U.S. Surgeon General’s Report 
Page 20 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Discussio  (continued) on ETS found a suggestive causal relationship between E

exposure and acute and chronic respiratory symptoms as well as 

adult-onset asthma [DHHS 2006]. Of the 11 NP casino dealers 

reporting existing asthma, seven reported exacerbations at work. 

Although limited studies compare workplace ETS exposure and 

new-onset asthma, studies have shown an association between 

exposures to ETS at work and increased risk of asthma and asthmarelated symptoms [Greer et al. 1993; Flodin et al. 1995; Blanc et 

al. 1999, Jaakkola et al. 2003]. Workplace ETS exposure has been 

shown to contribute more to respiratory symptoms than ETS 

exposure in the home [Larsson et al. 2003; Dhala et al. 2004]. Two 

studies among bar workers reported that, when ETS exposure was 

eliminated from the workplace, improvement in respiratory health, 

including asthma and asthma-related symptoms, was documented 

[Eisner et al. 1998, Menzies et al. 2006].

The low participation rate of the NP casino dealers (53%) and 

the small number of participating administrative and engineering 

casino employees (n=12) may limit our ability to provide a 

confident estimate of symptom prevalence among these groups. 

Because we had no administrative or engineering participants 

from Caesars Palace, the symptom prevalence does not provide 

information concerning the administrative and engineering 

workforce at that casino. However, our findings were comparable to 

several other studies in which ETS-exposed populations had more 

respiratory symptoms than those in unexposed groups [White et al. 

1991; Eisner et al. 1998; Bates et al. 2002; Wakefield et al. 2003; 

Fidan 2004; Menzies et al. 2006]. Also, although participation 

was low among the administrative and engineering employees, 

health symptom prevalence reported among this group also were 

comparable to those reported in other ETS unexposed work 

groups. [White et al. 1991; Nelson et al. 1995; Malkin et al. 1996; 

Bates et al. 2002; Whelan et al. 2003].

Nonrespiratory symptoms, such as eye irritation, nausea, headache, 

and dizziness, were included in the health symptom questionnaire 

based on the health concerns reported by casino dealers. NP casino 

dealers reported a higher prevalence of nausea, headache, and 

dizziness than administrative and engineering casino employees 

did, although these differences were not statistically significant. In 

addition to eye irritation, past studies have examined the role of 

nonrespiratory health effects, such as nausea and headache, related 

to ETS exposure in indoor building environments with conflicting 

results [Norbäck and Edling 1991; Menzies and Bourbeau 1997; 

Iribarren et al. 2001].
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 21

Recommendatio

Conclusion

NP casino dealers at Bally’s, Paris, and Caesars Palace casinos 

are exposed to ETS in the workplace air, and have absorbed an 

ETS-specific component into their bodies, as demonstrated by 

detectable levels of urinary NNAL. The increase in NNAL in the 

urine of most NP casino dealers at the end of their work shift 

demonstrates that NP casino dealers are exposed to a known 

carcinogen in the tobacco smoke at the casinos. NP casino dealers 

reported a higher prevalence of respiratory symptoms than to 

unexposed workers, but the results were not statistically significant. 

The best means of eliminating workplace exposure to ETS is to ban 

all smoking in the casinos.

We recommend eliminating tobacco from the casinos and 

implementing a smoking cessation program. The casinos should 

also eliminate smoking near building entrances and air intakes to 

protect employees from involuntary exposure to ETS. A physician 

should evaluate employees with respiratory symptoms, especially 

symptoms related to asthma that are associated with workplace 

exposures.

We recommend that if any modifications are made to the 

ventilation systems, they should be done in adherence with current 

ASHRAE-recommended guidelines [ANSI/ASHRAE 2007]. In 

addition, a preventive maintenance plan should be developed for 

the ventilation systems. This should include testing and balancing 

the systems and regular calibration of the CO2 sensors in the return 

air ducts.

We also recommend better communication between employees 

and management about occupational health and safety issues. 

One way to achieve this would be for employee and management 

representatives to form joint health and safety committees to 

address workplace health and safety concerns. These committees 

should meet regularly and be given needed resources to address 

ongoing health and safety issues.
Page 22 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Anderson KE, Kliris J, Murphy L, Carmella SG, Han S, Link C, 

Bliss RL, Puumala S, Murphy SE, Hecht SS [2003]. Metabolites of 

a tobacco-specific lung carcinogen in nonsmoking casino patrons. 

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ANSI/ASHRAE [2004]. Thermal environmental conditions for 

human occupancy, standard 55-2004: thermal environmental 

conditions for human occupancy. Atlanta, GA: American Society 

of Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [2007]. Ventilation for acceptable indoor air 

quality, standard 62-2007. Atlanta, GA: American Society of 

Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ASHRAE [2005]. Environmental tobacco smoke. Position 

document. Atlanta, GA: American Society of Heating, 

Refrigerating and Air-Conditioning Engineers, Inc.

Barr DB, Wilder LC, Caudill SP, Gonzalez AJ, Needham LL, 

Pirkle JL [2005]. Urinary creatinine concentrations in the 

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Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 23

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Page 28 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Employee Interviews (July 2005)

During private medical interviews and in open discussions, employees reported a range of health 

symptoms and conditions they believed were related to exposure to ETS during their work in the casino. 

These included four types of cancer (types not reported here for reasons of confidentiality), respiratory 

symptoms and illnesses (asthma, emphysema), mucous membrane irritation, dizziness, nausea, headaches, 

and cardiovascular problems, such as heart attacks and strokes.

Summary of OSHA Logs

Bally’s and Paris Casinos 

No respiratory-related symptoms or illnesses were recorded for Bally’s or Paris casino dealers in 2003, 

2004, or 2005.

Caesars Palace Casino 

No respiratory symptoms or illnesses were recorded for Caesars Palace casino dealers in 1999, 2000, 2001, 

and 2003. Two Caesars Palace casino dealers reported eye irritation in 2000 and 2001, and one dealer 

reported “disease of respiratory system” in 2004. None of these resulted in any lost work days. OSHA Logs 

were not available for 2002 and 2005 from Caesars Palace.

Appendix A: Preliminary Assess
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 29

Bally’s Casino 

The HVAC system originally began operating in 1974 and was updated in 1981. Bally’s HVAC filtration 

design was reported as a single bank of pleated filters with an estimated filtration efficiency rating of 

MERV 8 [ANSI/ASHRAE 1999]. We discussed the design and retrofit of Bally’s HVAC system with 

the ventilation engineer. This engineer described Bally’s as an older facility that has many generations 

of HVAC equipment serving the gaming area. He estimated that outdoor air set points and equipment 

selection were likely determined using the 1973 and 1981 editions of ASHRAE Standard 62 [ASHRAE 

1973, 1981]. The actual supply rates of outdoor air delivered to the occupied zones were not evaluated by 

NIOSH and were unknown.

Paris Casino

The current HVAC system, designed by JBA Consulting Engineers (Las Vegas, Nevada), began operating 

in 1999. According to the ventilation engineers, several factors govern the outdoor air delivery for Paris:

1. The building is designed with variable air volume HVAC systems that are intended to maintain the 

building at a positive pressure.

2. The maximum amount of outdoor air designated for normal operation of each air handler is 

determined by its cooling capacity and the outdoor design temperatures.

3. Minimum outdoor air set points are established for each air handler to meet the JBA engineer’s 

outdoor air supply objectives. Based on conversations with JBA’s engineer, the Paris set points 

would have been selected using the Ventilation Rate Table procedure specified in the 1989 edition 

of ASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality [ANSI/ASHRAE 1989]. This 

procedure prescribes the minimum supply rate of outdoor air (30 cfm/person) based upon the 

number of people and an assumed population density within the gaming areas. The actual supply 

rate of outdoor air delivered to the occupied zone at these supply rates was not evaluated by NIOSH 

and was unknown.

4. The Paris HVAC system monitors concentrations of CO2 in the return air ducts. If the CO2

concentration exceeds 800 ppm, the HVAC system reportedly switches to 100% outdoor air supply.

5. The Paris HVAC systems use an economizer cycle based on the outdoor dry bulb temperature. 

Whenever this temperature falls below 72oF, the economizer switches to 100% outdoor air supply. 

The ventilation engineers estimated this condition occurs approximately 8 months of the year.

6. The Paris HVAC filtration systems were reported to be two-bank systems comprised of a 2” pleated 

prefilter followed by a bag filter with an estimated 80%–95% dust spot efficiency [ANSI/ASHRAE 

1992].

Caesars Palace Casino

The HVAC system was renovated in 1996 with the design assistance of JBA Consulting Engineers (Las 

Vegas, Nevada). The following HVAC concept of operation was reported by the Caesars Palace facility 

engineering representatives:

Appendix B: Ventilation Over
Page 30 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Appendix B: Ventilation Overv    (conti

1. The building is designed with variable air volume HVAC systems that are intended to maintain the 

building at a positive pressure.

2. The minimum outdoor air set point is 40%. The actual supply rate of outdoor air delivered to 

the occupied zone at this set point was not evaluated by NIOSH and was unknown. However, in 

subsequent telephone conversations with JBA’s engineer, we learned that the Caesars Palace 

outdoor air supply rates would have been selected using the Ventilation Rate Table procedure 

specified in the 1989 edition of ASHRAE Standard 62 for the newer (1996) equipment. Older 

HVAC equipment could be up to 30 years old and would use different outdoor air supply rates 

based upon the applicable version of ASHRAE Standard 62 in effect at that time.

3. The Caesars Palace HVAC system also monitors concentrations of CO2 in the return air ducts. If 

the CO2 levels exceed 600 ppm, the HVAC system is designed to switch to 100% outdoor 

air supply. The Caesars Palace representatives did not know when the last time this monitor had 

been calibrated, replaced, or otherwise maintained. The engineer stated that these are generally 

solid-state units that require replacement approximately every 2 years.

4. The Caesars Palace HVAC system uses an economizer cycle based on the outdoor temperature. 

Whenever this temperature falls below 68oF, the economizer switches to 100% outdoor air 

supply. The Caesars Palace engineers estimated that this condition occurs 4 months of the year.

5. The Caesars Palace HVAC filtration system was described as a single-bank pleated filter with a 

MERV 8 filtration efficiency rating.

References

ASHRAE [1973]. Standards for natural and mechanical ventilation, standard 62. Atlanta, GA: American 

Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ASHRAE [1981]. Ventilation for acceptable indoor air quality, standard 62. Atlanta, GA: American 

Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [1989]. Ventilation for acceptable indoor air quality, standard 62. Atlanta, GA: American 

Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [1992]. Gravimetric and dust-spot procedures for testing air-cleaning devices used in 

general ventilation for removing particulate matter standard 52.1. Atlanta, GA: American Society of 

Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [1999]. Method of testing general ventilation air-cleaning devices for removal efficiency 

by particle size, standard 52.2. Atlanta, GA: American Society of Heating, Refrigerating, and AirConditioning Engineers, Inc.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 31

Cotinine

Urinary COT was analyzed using a solid-phase competitive chemiluminescent immunoassay. Beads coated 

with polyclonal rabbit anti-COT antibody, 20 μL of sample, and alkaline phosphatase conjugated COT

were incubated for 30 minutes. The beads were then washed, and chemiluminescent substrate was added. 

Detection of COT is reflected by the amount of light output measured by a photometer. The assay LOD 

was 5 ng/mL, and the LOQ was 10 ng/mL. Assay adjustors and controls were used as recommended by 

the manufacturer.

4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanol and Creatinine

Analysis of total NNAL in urine samples was performed by using an HPLC/API-MS combined with a 

novel sample clean-up using solid-phase extraction based on a molecularly imprinted polymer column 

developed specifically for this assay. Urine creatinine levels were measured enzymatically by the Roche 

CREA Plus procedure using a Hitachi analyzer [Xia et al. 2005]. The LOD for this analysis is 0.0030 ng/

mL (3 pg/mL ).

Nicotine and 4-Vinyl Pyridine

NIC and 4-VP were simultaneously sampled and analyzed per NIOSH Method 2551 [NIOSH 2008]. 

NIC was collected on XAD-4TM tubes at a flow rate of 1.5 Lpm and analyzed using a GC equipped with a 

nitrogen phosphorous detector.

Polynuclear Aromatic Hydrocarbons

The particulate and vapor phases of PAHs were sampled simultaneously using glass fiber filters for the 

particulate phase and OVS tubes with XAD-7TM sorbent for the vapor phase. Samples were collected at a 

flow rate of 2.0 Lpm and analyzed for 16 individual PAHs using a GC equipped with a flame ionization 

detector. The sampling and analysis method for PAHs is a modification of NIOSH Method 5515 [NIOSH 

2008].

Respirable Suspended Particulates

RSP was sampled and gravimetrically analyzed per a modification of NIOSH Method 0600 [NIOSH 

2008]. Samples were collected using a BGI4L cyclone (BGI Incorporated, Waltham, Massachusetts) on 37-

mm, 1.0 μm pore size, PTFE filters housed in black, opaque polypropylene 3-piece cassettes at a flow rate

of 2.2 Lpm.

Appendix C: Methodolo
Page 32 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Appendix C: Methodolog  (continu

Solanesol

SOL was extracted from the RSP PTFE filters using methanol and analyzed using an HPLC equipped with 

a UV detector according to a modification of ASTM method D-6271-04. The ASTM method was modified 

to use a C 8 column for HPLC separation and analysis [ASTM 2004].

Volatile Organic Compounds

VOCs were collected on charcoal tubes at a flow rate of 100 mL/min and analyzed per NIOSH Method 

2501 [NIOSH 2008].

Aldehydes

FLD and ACTLD air samples were collected on passive badges (UMEXTM, SKC Inc., Eighty-Four, 

Pennsylvania) impregnated with 2,4-dinitrophenylhydrazine, and analyzed using an HPLC per NIOSH 

Method 2016 [NIOSH 2008].

Carbon Monoxide

Area samples for CO were collected using a QTRAK Plus® (TSI, St. Paul, Minnesota) equipped with an 

electrochemical sensor. Data was logged at one-minute intervals and downloaded onto a laptop computer. 

The instruments were calibrated daily using calibration gas.

References

ASTM [2004]. ASTM D6271 - 04 Standard test method for estimating contribution of environmental 

tobacco smoke to respirable suspended particles based on solanesol. ASTM International, 100 Barr 

Harbor Drive, PO Box C700, West Conshohocken, PA, 19428-2959 USA.

NIOSH [2008]. NIOSH manual of analytical methods (NMAM®). 4th ed. Schlecht PC, O’Connor PF, 

eds. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 94-113 

(August, 1994); 1st Supplement Publication 96-135, 2nd Supplement Publication 98-119; 3rd Supplement 

2003-154. [www.cdc.gov/niosh/nmam/].

Xia Y, McGuffey JE, Bhattacharyya S, Sellergren B, Yilmaz E, Wang L, Bernert JT [2005]. Analysis of 

the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol in urine by extraction on 

a molecularly imprinted polymer column and liquid chromatography/atmospheric pressure ionization 

tandem mass spectrometry. Anal Chem 77(23):7639–7645.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 33

In evaluating the hazards posed by workplace exposures, NIOSH investigators use both mandatory (legally 

enforceable) and recommended OELs for chemical, physical, and biological agents as a guide for making 

recommendations. OELs have been developed by Federal agencies and safety and health organizations 

to prevent the occurrence of adverse health effects from workplace exposures. Generally, OELs suggest 

levels of exposure to which most workers may be exposed up to 10 hours per day, 40 hours per week for 

a working lifetime without experiencing adverse health effects. However, not all workers will be protected 

from adverse health effects even if their exposures are maintained below these levels. A small percentage 

may experience adverse health effects because of individual susceptibility, a pre-existing medical condition, 

and/or a hypersensitivity (allergy). In addition, some hazardous substances may act in combination with 

other workplace exposures, the general environment, or with medications or personal habits of the worker 

to produce health effects even if the occupational exposures are controlled at the level set by the exposure 

limit. Also, some substances can be absorbed by direct contact with the skin and mucous membranes in 

addition to being inhaled, which contributes to the individual’s overall exposure.

Most OELs are expressed as a TWA exposure. A TWA refers to the average exposure during a normal 8- 

to 10-hour workday. Some chemical substances and physical agents have recommended STEL or ceiling 

values where health effects are caused by exposures over a short period. Unless otherwise noted, the STEL 

is a 15-minute TWA exposure that should not be exceeded at any time during a workday, and the ceiling 

limit is an exposure that should not be exceeded at any time.

In the United States, OELs have been established by Federal agencies, professional organizations, state 

and local governments, and other entities. Some OELs are legally enforceable limits, while others are 

recommendations. The U.S. Department of Labor OSHA PELs (29 CFR 1910 [general industry]; 29 

CFR 1926 [construction industry]; and 29 CFR 1917 [maritime industry]) are legal limits enforceable in 

workplaces covered under the Occupational Safety and Health Act. NIOSH RELs are recommendations 

based on a critical review of the scientific and technical information available on a given hazard and the 

adequacy of methods to identify and control the hazard. NIOSH RELs can be found in the NIOSH Pocket 

Guide to Chemical Hazards [NIOSH 2005]. NIOSH also recommends different types of risk management 

practices (e.g., engineering controls, safe work practices, worker education/training, personal protective 

equipment, and exposure and medical monitoring) to minimize the risk of exposure and adverse health 

effects from these hazards. Other OELs that are commonly used and cited in the United States include 

the TLVs recommended by ACGIH, a professional organization, and the WEELs recommended by the 

American Industrial Hygiene Association, another professional organization. The TLVs and WEELs are 

developed by committee members of these associations from a review of the published, peer-reviewed 

literature. They are not consensus standards. ACGIH TLVs are considered voluntary exposure guidelines 

for use by industrial hygienists and others trained in this discipline “to assist in the control of health 

hazards” [ACGIH 2007]. WEELs have been established for some chemicals “when no other legal or 

authoritative limits exist” [AIHA 2007].

Outside the United States, OELs have been established by various agencies and organizations and include 

both legal and recommended limits. Since 2006, the Berufsgenossenschaftliches Institut für Arbeitsschutz 

(German Institute for Occupational Safety and Health) has maintained a database of international OELs 

Appendix D: Occupational Exposure Limits & H
Page 34 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Appendix D: Occupational Exposure Limits & HeEffects   

from European Union member states, Canada (Québec), Japan, Switzerland, and the United States 

available at www.hvbg.de/e/bia/gestis/limit_values/index.html. The database contains international 

limits for over 1250 hazardous substances and is updated annually.

Employers should understand that not all hazardous chemicals have specific OSHA PELs, and for some 

agents the legally enforceable and recommended limits may not reflect current health-based information. 

However, an employer is still required by OSHA to protect its employees from hazards even in the absence 

of a specific OSHA PEL. OSHA requires an employer to furnish employees a place of employment free 

from recognized hazards that cause or are likely to cause death or serious physical harm [Occupational 

Safety and Health Act of 1970 (Public Law 91–596, sec. 5(a)(1))]. Thus, NIOSH investigators encourage 

employers to make use of other OELs when making risk assessment and risk management decisions to 

best protect the health of their employees. NIOSH investigators also encourage the use of the traditional 

hierarchy of controls approach to eliminate or minimize identified workplace hazards. This includes, in 

order of preference, the use of: (1) substitution or elimination of the hazardous agent, (2) engineering 

controls (e.g., local exhaust ventilation, process enclosure, dilution ventilation), (3) administrative controls 

(e.g., limiting time of exposure, employee training, work practice changes, medical surveillance), and (4) 

personal protective equipment (e.g., respiratory protection, gloves, eye protection, hearing protection). 

Control banding, a qualitative risk assessment and risk management tool, is a complementary approach to 

protecting worker health that focuses resources on exposure controls by describing how a risk needs to be 

managed. Information regarding control banding is available at www.cdc.gov/niosh/topics/ctrlbanding/. 

This approach can be applied in situations where OELs have not been established or can be used to 

supplement the OELs, when available.

Environmental Tobacco Smoke

Exposure criteria for ETS have not been established, although NIOSH and others have determined that 

ETS is associated with an increased risk of lung cancer, other lung disease, and possibly heart disease. 

More than 4,000 compounds have been identified in ETS, many of which exert their biologic properties 

through different mechanisms. A common strategy for assessing exposure to ETS is to monitor one or 

more “marker” substances and use these as an index of exposure. Selection of these compounds is based 

on their ease of measurement and specificity to ETS, and not necessarily because they are the most toxic 

components of ETS.

In this survey, vapor-phase NIC, RSP, VOCs, PAHs, and ALD were monitored as marker substances. 

The concentrations of these markers in ETS are consistently lower than their respective OELs, which are 

based primarily on acute effects. The NIOSH REL and the ACGIH TLV for NIC, used in the agricultural 

industry, are 500 μg/m3

 [NIOSH 1992; ACGIH 2007]. OSHA has no corresponding PEL. In contrast, the 

mean area air NIC concentrations reported in ETS studies of public buildings have ranged from 0.7–37 

μg/m3

; concentrations in restaurants and bars have ranged from 2.3–65.5 μg/m3; and concentrations 

in gaming parlors and betting shops have ranged from 11–19 μg/m3

. Full-shift respirable particulate 

measurements using gravimetric analysis have ranged up to 80 μg/m3

 in office buildings [Miesner et al. 
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 35

Appendix D: Occupational Exposure Limits & Heects      

1998] and up to 253 μg/m3 in restaurants [Brauer and Mannetje 1989]. The NIOSH and OSHA criteria 

for NIC and RSP are not applicable to ETS exposures, particularly because these contaminants are 

measured only as markers of ETS exposure [NIOSH 2005; 29 CFR 1910].

Temperature and Relative Humidity

Temperature and RH measurements are often collected as part of an IEQ investigation because these 

parameters affect the perception of comfort in an indoor environment. The perception of thermal 

comfort is related to an individual’s metabolic heat production, the transfer of heat to the environment, 

physiological adjustments, and body temperature [NIOSH 1986]. Heat transfer from the body to the 

environment is influenced by factors such as temperature, humidity, air movement, personal activities, and 

clothing. The ANSI/ASHRAE Standard 55-2004, Thermal Environmental Conditions for Human Occupancy, 

specifies conditions in which 80% or more of the occupants would be expected to find the environment 

thermally acceptable [ANSI/ASHRAE 2004]. Assuming slow air movement (under 40 fpm) and 50% RH, 

the operative temperatures recommended by ASHRAE range from 68.5oF to 76oF in the winter, and from 

75oF to 80.5oF in the summer. The difference between the two is largely due to seasonal clothing selection. 

ASHRAE also recommends maintaining RH at or below 65% [ANSI/ASHRAE 2007]. Excessive humidity 

can promote the excessive growth of microorganisms and dust mites.

Carbon Dioxide

CO2 is a normal constituent of exhaled breath and is not considered a building air pollutant. It can be 

used as an indicator of whether sufficient quantities of outdoor air are being introduced into an occupied 

space for acceptable odor control. However, CO2

 is not an effective indicator of ventilation adequacy if the 

ventilated area is not occupied at its usual occupant density at the time the CO2 is measured. ASHRAE 

notes in an informative appendix to standard 62.1 that indoor CO2

 concentrations no greater than 700 

ppm above outdoor CO2

 concentrations will satisfy a substantial majority (about 80%) of visitors with 

regard to odor from sedentary building occupants (body odor) [ANSI/ASHRAE 2007]. Elevated CO2

concentrations suggest that other indoor contaminants may also be increased. If CO2

 concentrations 

are elevated, the amount of outdoor air introduced into the ventilated space may need to be increased. 

When CO2

 concentrations are used as an indicator to determine outdoor air requirements, ventilation 

system designs that rely on duct-mounted CO2

 sensors should have some form of ventilation efficiency 

documentation that relates concentration values observed at the duct location with those observed within 

the breathing zone of the occupied space.

Carbon Monoxide

CO is a colorless, odorless, tasteless gas that can be a product of the incomplete combustion of organic 

compounds. CO combines with hemoglobin and interferes with the oxygen-carrying capacity of blood. 
Page 36 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

Appendix D: Occupational Exposure Limits & HeEffects   

Symptoms include headache, drowsiness, dizziness, nausea, vomiting, collapse, myocardial ischemia, and 

death [Hathaway et al. 1991]. The NIOSH REL for CO is 35 ppm for up to a 10-hour TWA. NIOSH also 

recommends a ceiling limit of 200 ppm, which should not be exceeded at any time during the workday. 

The ACGIH TLV for an 8-hour TWA is 25 ppm; the OSHA PEL for an 8-hour TWA is 50 ppm.

References

ACGIH® [2007]. 2007 TLVs® and BEIs®: threshold limit values for chemical substances and physical 

agents. Cincinnati, OH: American Conference of Governmental Industrial Hygienists.

AIHA [2007]. 2007 Emergency response planning guidelines (ERPG) & workplace environmental 

exposure levels (WEEL) handbook. Fairfax, VA: American Industrial Hygiene Association.

ANSI/ASHRAE [2004]. Thermal environmental conditions for human occupancy, standard 55-2004. 

Atlanta, GA: American Society for Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [2007]. Ventilation for acceptable indoor air quality, standard 62.1-2007. Atlanta, GA: 

American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

Brauer M, Mannetje A [1998]. Restaurant smoking restrictions and environmental tobacco smoke 

exposure. Am J Public Health 88(12):1834–1836.

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the 

Federal Register.

Hathaway GJ, Proctor NH, Hughes JP, Fischman ML [1991]. Chemical hazards of the workplace. 3rd ed. 

New York, NY: Van Nostrand Reinhold.

Miesner EA, Rudnick SN, Hu FC, Spengler JD, Preller L, Özkaynak H, Nelson W [1989]. Particulate and 

nicotine sampling in public facilities and offices. JAPCA 39(12):1577–1582.

NIOSH [1986]. Criteria for a recommended standard: occupational exposure to hot environments, revised 

criteria. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control, 

National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 86-13.

NIOSH [1992]. Recommendations for occupational safety and health: compendium of policy documents 

and statements. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) 

Publication No. 92-100.
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 37

Appendix D: Occupational Exposure Limits & Heects      

NIOSH [2005]. NIOSH pocket guide to chemical hazards. Cincinnati, OH: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational 

Safety and Health, DHHS (NIOSH) Publication No. 2005-149. [www.cdc.gov/niosh/npg/]. Date accessed: 

January 15, 2009.
Page 38 Health Hazard Evaluation Report 2005-0076; 2005-0201-3080

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health (OSHA) Act of 1970, 29 U.S.C. 669(a)(6), which 

authorizes the Secretary of Health and Human Services, following 

a written request from any employer or authorized representative 

of employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by Chandran Achutan, Christine West, 

Charles Mueller, and Yvonne Boudreau of HETAB, Division of 

Surveillance, Hazard Evaluations and Field Studies (DSHEFS), 

and Kenneth Mead of the Engineering and Physical Hazards 

Branch, Division of Applied Research and Technology (DART). 

Field assistance was provided by Ayodele Adebayo, Donnie 

Booher, Greg Burr, Lisa Delaney, Judith Eisenberg, Lynda Ewers, 

Brad King, Manny Rodriguez, Dave Sylvain, Sangwoo Tak, and 

Loren Tapp of HETAB; Kevin L. Dunn from the Industrywide 

Studies Branch in DSHEFS; Stewart Curtis from Loma Linda 

University; and Shirley Robertson and Debbie Sammons from the 

Biomonitoring and Health Assessment Branch, DART. Analytical 

support was provided by Tom Bernert and Charles Dodson 

in the Tobacco Exposure Biomarkers Section of the National 

Center for Environmental Health (Atlanta, Georgia), DataChem 

Laboratories (Salt Lake City, Utah), and by Ardith Grote of DART. 

Acknowledgments a

Availability of Re
Health Hazard Evaluation Report 2005-0076; 2005-0201-3080 Page 39

Acknowledgments a

 Availability of Rep    (continued) Health communication assistance was provided by Stefanie Ev

Editorial assistance was provided by Ellen Galloway. Desktop 

publishing was performed by Robin Smith.

Copies of this report have been sent to employee and management 

representatives at Bally’s, Paris, and Caesars Palace Casinos in 

Las Vegas, Nevada; and the OSHA Regional Office. This report 

is not copyrighted and may be freely reproduced. The report may 

be viewed and printed at www.cdc.gov/niosh/hhe. Copies may 

be purchased from the National Technical Information Service at 

5825 Port Royal Road, Springfield, Virginia 22161.
Below is a recommended citation for this report:

NIOSH [2009]. Health hazard evaluation report: environmental and biological 

assessment of environmental tobacco smoke exposure among casino dealers, Las 

Vegas, NV. By Achutan C, West C, Mueller C, Boudreau Y, Mead K. Cincinnati, OH: 

U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, NIOSH HETA 

No. 2005-0076 and 2005-0201-3080.

To receive NIOSH documents or information about 

occupational safety and health topics, contact NIOSH at:

1-800-CDC-INFO (1-800-232-4636)

TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov

or visit the NIOSH web site at: www.cdc.gov/niosh.

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NIOSH eNews by visiting www.cdc.gov/niosh/eNews.

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