Collectively, these results give solid confirmation for the role of second-hand cigarette smoke in the causation of COPD,

as well as for the significant protective effect of vitamin D. These results have significant implications for medical and public health policy. MEDICAL: Due to severe and irreversible nature of COPD, and the subtlety of initial symptoms, doctors should be made aware of the importance of screening patients for exposure to SHS. This especially true in patients with whom COPD would be a significant co-morbid factor, such as those with, or at risks for, bronchitis, asthma, pneumonia, sarcoidosis, lung cancer, heart disease, and any disease involving systemic inflammation. This also applies to all elderly patients, as well as to infants. As COPD, even in its early stages, has been

shown to be associated with emotional disturbances such as anxiety and depression, these patients too should be screened for exposure to SHS. Even though COPD per se is irreversible, due to the complexity of the disease and the frequent occurrence of do-morbid conditions which are reversible, early identification of COPD can lead to interventions such as exercise, respiratory training, and mindbody interventions such as Qigong, all of which are known to be of benefit to he progression and exacerbation of COPD, and which are of greater therapeutic efficacy when implemented early in the course of the disease. By screening regularly for exposure to SHS, doctors will be able to detect subtle symptoms of COPD earlier, and will be able to treat the patient more effectively. Given the debilitating effects of this condition, early treatment will significantly reduce patient suffering and the load on society from increased medical costs, lost work

hours, and need for social services. PUBliC HEALTH POLICY These findings strongly reinforce the arguments for the continuing enforcement, and the extension, of laws, regulations and policies forbidding smoking in various contexts. All the points made above, about COPD and its co-morbidities and their impact on society, apply equally at the level of public policy. These findings should be brought to the attention of those responsible for 'no smoking' laws and regulations. This includes a very wide range of people, including officials in Federal, State and local government, managers of public spaces such as restaurants, movie theaters, shops, malls, etc., as well as business owners and homeowners.

These findings should be brought clearly to the public's attention. If smokers realize they are not just harming themselves by smoking, but also those around them, this might bring more compliance with 'no smoking' laws and regulations, and might be more of a motivation to change behavior than if they believe they are harming only themselves. If non-smokers exposed to SHS realize how much danger they are exposing themselves to, they hopefully will be more likely to take steps, either to remove themselves from the situation or to request the smoker to withdraw or to stop smoking. With the solid findings from this study, people will hopefully feel more empowered, motivated, and justified in taking action to protect themselves and those they care for. Vitamin D These findings add to the already

considerable body of evidence for the beneficial and protective effects of vitamin D. This information should be made available to doctors and to the general public. A more widespread appreciation by doctors of these effects could lead to more medical screening for vitamin D deficiency, and the prescription of appropriate levels of supplementation especially in cases where a person is necessarily or involuntarily exposed to SHS or other forms of lung irritant which might have similar modes of action; when a person is at risk for, or chronically suffers from, an illness which can be exacerbated by COPD (lung disease, heart disease, depression, anxiety, inflammatory conditions); and in populations at risk for vitamin D deficiency such as African-Americans, those living in northern sections of the country, the house-bound, and the elderly. If the public is made more aware of these protective effects of vitamin D, those at risk

will be more likely to ask their doctors about the advisability of supplementing their diet with vitamin D or increasing their consumption of foods containing it.