Restrictions on smoking for fire and safety reasons have existed for much of this century, but restrictions based on health and annoyance have been implemented largely over the last two decades (US DHHS, 1986). The major motivations for this new wave of restrictions have been the irritation and annoyance of the nonsmoker caused by environmental tobacco smoke and the evolving understanding of the decease risks associated with exposure to environmental tobacco smoke. Now these motivations are blending to produce a social climate in which cigarette smoking is increasingly unacceptable.

Much of the credit for changes in the social acceptability of smoking has focused on recent events such as the call for a smoke-free society by the year 2000 as well as reports on the scientific evidence by the Surgeon General (US DHHS, 1986), the National Academy of Sciences (1986), and most recently the U.S. Environmental Protection Agency (in press). However, this kind of social shift occurs slowly, gathering momentum with time. The understanding of the risks associated with environmental tobacco smoke began in 1970 when the Surgeon General at that time, Jesse L. Steinfeld, M.D., recognized the clear biological plausibility of a significant public health risk from environmental tobacco smoke. Addressing the National Interagency Council on Smoking and Health, he state, "Evidence is accumulating that the nonsmoker may have untoward effects from the pollution his smoking neighbor forces upon him." Dr. Steinfeld called for a bill or rights for the nonsmoker (Steinfeld, 1972), and he directed the National Clearinghouse for Smoking and Health to conduct a complete assessment of scientific evidence on the topic for inclusion in the next Surgeon General's Report (US DHEW, 1972).

225 (con't)

Those documented concerns, coupled with nonsmokers' annoyance at being exposed to tobacco smoke, ignited the nonsmokers' rights movement. By the mid-1970's, the change in social acceptability of smoking was well under way and has been credited with the downturn in per capita cigarette consumption that began in 1974 (Warner, 1981).

Federal Actions

Federal Government efforts to restrict smoking have not been as extensive as those of state and local governments. Outside the tobacco belt, state and local governments are less subject to lobbying efforts by the tobacco industry and therefore have passed more laws restricting smoking.

the only area in which Congress has acted to restrict smoking has been aboard commercial airline flights. Until recently, most of the regulation of smoking on airlines was the responsibility of the Civil Aeronautics Board (CAB). In 1971, the CAB mandated that all commercial airline flights provide nonsmoking sections large enough to accommodate every passenger who desired to sit in them, and in 1983 it issued new regulations that banned smoking on flights of 2 hours or less. However, within hours of its announcement, the ban was reversed at the insistence of lobbyists and powerful members of Congress (Walsh and Gorden, 1986).

Nevertheless, public pressure for a smoking ban continued to mount, and as a result, Congress passed legislation in 1987 doing exactly what the Cab had tried to do in 1983-ban smoking on all commercial airline flights of 2 hours or less. This included about 80 percent of all flights within the continental United States (US DHHS, 1989a). In spite of concerns to the contrary, the airlines have found the law to be an easy on to enforce. Flight crews found it necessary to initiate enforcement actions against only 1 out of approximately every 4 million airline passengers in 1988 (Hensley, 1989).

In 1989, Congress again considered the issue of smoking on commercial airflights because the law dictating the 2-hour smoking ban was about to expire. The Senate wanted a total ban on all flights, whereas the House voted only to continue the 2-hour ban. A compromise was reached, whereby the ban on smoking was increased to 6 hours, effectively eliminating smoking on all flights except those to Alaska, Hawaii, and foreign locates, as well as on charger flights (Phillips, 1990).

Most other Federal action regulating smoking has been by agencies restricting smoking at Government worksites. The General Services Administration, which is responsible for one-third of all Federal buildings, prohibits smoking except in designated areas. The Department of Health and Human Services completely bans all smoking in its buildings. In 1986,

226

the Department of Defense established a new policy to curtail smoking among Armed Forces personnel. As part of the policy, smoking is permitted only in designated areas (US DHHS, 1989a).

State Legislation

In 1973, Arizona became the first state to restrict smoking in a number of public places because environmental tobacco smoke is a public health hazard. This was done in response to the 1972 Surgeon General's Report, which for the first time identified involuntary smoking as a health risk. The passage of the Arizona law marked a shift in the content of laws regulating smoking. Instead of restricting smoking because it is a fire hazard, likely to contaminate food, or morally wrong, legislatures started restricting smoking because it endangers the health of nonsmokers (US DHHS, 1989a).

throughout the 1970's, the regulation of smoking in public places became a major issue for state legislatures. In 1974, Connecticut became the first state to pass a law restricting smoking in restaurants, and in 1975, Minnesota passed its Clean Indoor Air Act. This was the first law to use the approach that smoking would be prohibited everywhere except where specifically permitted, thereby making nonsmoking the norm. It was also the first law to extend smoking restrictions to worksites, both public and private. Continuing until today, this law has served as a model for other state legislatures seeking to pass comprehensive smoking legislation (US DHHS, 1989a; Kahn, 1983).

the growth of state smoking legislation was rapid throughout the 1970's and 1980's. Two years that particularly stand out are 1975, in which 13 states enacted smoking laws, and 1987, in which a record 20 states passed such laws. The flurry of activity in 1987 reflected the 1986 publication of reports from the Surgeon General and the National Academy of Sciences, both of which documented the health risks of involuntary smoking (Rigotti, 1989; us DHHS, 1989a). As of August 1, 1990, 45 states and the District of Columbia had passed laws restricting smoking in public places in some manner (Tobacco-Free America, 1990).

the laws that were passed were also more restrictive. Previously, laws restricted smoking only in public places such as elevators or buses, but the new laws began increasingly to regulate smoking in restaurants and private worksite (Rigotti, 1989; US DHHS, 1989a; Warner, 1981). As of August 1, 1990, 27 states regulated smoking in restaurants and 18 restricted smoking at private worksites (Tobacco-Free America, 1990).

227

The restrictiveness of state smoking laws varies in different regions of the country. In particular, southern states have fewer smoking laws, and they are less comprehensive. Of the five states that have no laws whatsoever to restrict smoking public places, two-Tennessee and North Carolina-are major tobacco produces (Rigotti, 1989; Tobacco-Free America, 1990; US DHHS, 1989a).

No-smoking laws passed by the states are generally implemented by the state health departments with minimal burden (US DHHS, 1989a). For example, for the 3 years after the passage of the Minnesota Clean Indoor Air Act, the costs to the Minnesota Department of Health was only about $4,600 per year (Kahn, 1983).

Local Legislation

During the 1980's, efforts to control cigarette use spread to the local level-towns, cities, and counties (US DHHS, 1989a). During the period between 1986 and 1990, a more than fourfold increase occurred in the number of communities with smoking ordinances, from 89 in 1986 (US DHHS, 1989a) to 468 in 1990 (Tobacco-Free America, 1990).

although state smoking laws are generally called clean indoor air acts, smoking laws at the local level are usually referred to as smoking ordinances (Pertschuk and Shopland, 1989). With few exceptions, these local ordinances are stronger and more comprehensive than corresponding state laws and are often enacted because of difficulties in passing stronger state laws (Rigotti, 1989). A legislative response by the tobacco industry has been to promote state legislation that preempts the right of local communities to pass laws restricting tobacco use. As a result, seven states have passed laws preventing the passage of more stringent ordinances at the local level. In Florida, the law not only prevents the passage of future local smoking ordinances but also preempts all existing ones (Tobacco-Free America, 1990).

the most complete records on local smoking ordinances have been kept for California, which has been a leader in the passage of these laws. The first were passed in 1970, and in 1982, San Diego became the first large California city to enact an ordinance regulating smoking in the workplace (US DHHS, 1989a). In 1983, the San Francisco Board of Supervisors passed an ordinance regulating smoking in private worksites, which later was brought before the voters in the form of a proposition. In spite of heavy opposition from tobacco interests, it passed, and the publicity generated by the campaign stimulated other communities around the country to pass similar ordinances (Martin and Silverman, 1986).

Laws restricting smoking are often called "self-enforcing" because few complaints of violations are filed, and so it is

228

assumed that most people are obeying the law (Rigotti, 1989). In San Francisco, only 1 out of approximately 60 department of Public Health inspectors was assigned to enforce that city's Smoking Pollution Control Ordinance. Three percentage of time he spent doing that job declined during the first year until, during the last 4 months, only 21 percent of his time was spent on the program. No additional funds were needed to enforce the law (Martin and Silverman, 1986). Similarly, New York's Health Department reported receiving only a few complaints after the city's no-smoking law restricted smoking in restaurants (US DHHS, 1989a).

an effort to actively measure compliance with laws restricting smoking, rather than just counting the number of complaints received by a health department, was made in Cambridge, Massachusetts. Researchers asked city residents whether they had recently noticed smoking in places where it was not permitted 3 months after the passage of a city smoking ordinance. One-third,it turned out, had noticed illegal smoking. Asked what their response was most people said that they had ignored the violation (US DHHS, 1989a).

Public Opinion

Rigotti (1989) makes the point that public support for smoking restrictions was present long before either the passage of no-smoking laws or the publication of most of the evidence that passive smoke could be damaging to one's health. As early as 1964, most nonsmokers felt that smoking should be allowed in fewer places, and by 1975, a majority of both nonsmokers and smokers felt that way. In 1987, a Gallup poll found, for the first time, that a majority of all adults (55 percent) favored a complete ban on smoking in all public places (US DHHS, 1989a).

Effects of Restrictions on Smoking Prevalence

In 1982, the government of Hong Kong began making a concerted effort to reduce smoking in that city. Smoking was restricted in public places, a fourfold increase in the duty paid on tobacco was instituted, public health education was increased, and an antismoking publicity campaign launched. As a result, 16 percent of the population quit smoking between 1982 and 1984, and the number regular smokers between the ages of 15 and 19 was cut in half. When ex-smokers were asked in surveys, which factors were influential in causing them to quit, respondents identified two main ones-cost and health concerns (Mackay and Barnes, 1986).

A similar effort to decrease smoking was instituted by the U.S. Department of Defense starting in 1986. Between 1985 and 1987, smoking prevalence decreased in all branches of the Armed Forces, particularly in the Army, which was the branch most active in getting its personnel to eliminate smoking (Hagey, 1989; Rigotti, 1989; US DHHS, 1989a).

229

Data collected by the Wisconsin Department of Health and Social Services show the effects of the antismoking campaign in that state. Per capita sales of cigarettes in Wisconsin started dropping off sharply from a peak in 1981. Coincident with this dropoff were two cigarette tax increases, one state and one Federal, and the 1983 passage of Wisconsin's Clean Indoor air Act (Centers for Disease Control, 1989).

Employee Attitudes

Worksite smoking restrictions are gaining acceptance among workers, including smokers (Becker et al., 1989; Biener et al., 1989a; Sorensen and Pechacek, 1989). Sorensen and Pechacek found support for no-smoking policies among smokers who were interested in quitting, those who were concerned about the health effects of smoking, those who indicated a high level of support from coworkers for previous quit attempts, and those who had a high number of nonsmoking coworkers. this may help to allay the fears of employers who believe that smoking restrictions will lead to dissension or low morale among employees, In most situations, smoking restrictions can be implemented without significant conflict.

a study that included a survey of smokers outside office buildings in Pasadena showed similar support from smokers for smoking restrictions. Pasadena citywide smoking regulations require restrictions in all indoor places, including worksites. In the study by Sussman et al. (in press), a majority of smokers interviewed thought it was important to stop smoking and had positive feelings about the nonsmokers' rights movement. In addition, about three-quarters of the smokers had made a least one quit attempt, with those subject to no-smoking policy reportedly putting more effort into quitting smoking. The researchers caution that "little is known about attitude-behavior relationships and smoking policy effects" (Sussman et al, in press).

Impact of Worksite Restrictions

Millar (1988), in a government work setting, found a continuous quit rate of 3.5 percent at 1 year after smoking restrictions went into effect. Two hundred registrants for a smoking cessation course were surveyed at 6 weeks, 6 months, and 1 year after smoking restrictions began. The overall smoking prevalence in the year after restrictions declined 29 to 24 percent.

A recent study analyzed the impact of a strict smoking policy at the Texas Department of Human Services (Gottlieb et al., 1990). The policy limited smoking to break rooms or lunges and cafeteria smoking sections. regional administrators were given the authority to declare a worksite smoke-free if no appropriate room was available, and smoking was banned outright in 4 or the 12 regions. Again, most of the departments studied had some restrictive policy in effect prior to implementation of the new policy and before the study began.

230

The Texas study showed that the reduction in smoking prevalence at 6 months after policy implementation was greater in the work areas with smoking bans than in those with smoking restrictions. Consumption of cigarettes at work decreased in work areas with both types of policies. However, the authors concluded that although daily consumption of cigarettes at work decreased significantly, "no significant change was detected in smoking prevalence."

The authors of the Texas study summed up in this way: the "failure to find changes in smoking rates may also have been due to an insufficient follow-up period. Quitting smoking has been conceptualized as a process of change, with smokers moving through the stages of precontemplation, contemplation, action, and maintenance. It is possible that the smokers had increased their readiness to quit but not yet taken action" (Gottlieb et al., 1990).

Impact of Smoking Bans

the Australian Public Service used a sample of 2,113 employees who were surveyed 2 to 4 weeks before a complete workplace smoking ban was implemented and again 5 to 6 months later (Borland et al., 1990). Fifty-seven employees who were smoking at the time of the initial survey were not smoking at the time of the followup surveys. However, 36 previous nonsmokers reported starting smoking; it was not noted whether the 36 were relapsing ex-smokers or new smokers. Including the 36 employees who took up smoking brought the reduction findings to a 1 percent reduction in prevalence over the 6-month period, which was no considered significant by the study authors. However, because it is unlikely that these employees took up smoking as a result of the workplace smoking ban, including them in the equation reduced the drop of prevalence that might have been found.

An additional indicator that the reported drop in prevalence might be low is that the work settings in which this study was conducted had various levels of restrictions on smoking prior to the mandated ban. It is therefore possible that some smokers had already quit as a result of a smoking control policy prior to the ban and that this reduction in prevalence was not captured in the study.

the study reached its conclusions on smoking prevalence by conduction pre- and postpolicy surveys on workplace smoking consumption. The smokers were asked to estimate the number of cigarettes they usually smoked on both workdays and nonworkdays and to recall the number of cigarettes they smoked in the previous 24 hours, divided into seven time periods. The showed that moderate and heavy smokers

231

had fewer cigarettes during the day, with the greatest change among heavy smokers. Small increases in smoking rates outside the work environment did not compensate for the enforced reduction at work.

In a more recent study at the Johns Hopkins University however, a significant reduction in smoking prevalence was found to result form implementation of a total ban on smoking (Stillman et al, 1990). As of July 1, 1988, smoking was banned in all areas of Johns Hopkins Hospital complex involving 24 buildings in an area covering 12 square blocks. The previous policy had allowed smoking in designated areas of cafeterias, waiting areas, and lunges. The new policy was announced on January 1, 1988, and the announcement was followed by an extensive internal media campaign. A health-oriented campaign that emphasized the effects of passive smoking and included free screening for exhaled carbon monoxide was launched. Education programs to ensure policy enforcement were offered to the staff, and four smoking cessation options were offered free to all employees. In addition to these efforts, discreet observations of visitor and employee smoking were performed monthly beginning 8 months prior to the ban and at 1 month and 6 months after the ban started.

The initial survey of 8,742 full- and part-time employees was distributed 6 months prior to the ban, thereby allowing for inclusion of smokers who ceased in anticipation of the ban. One year after the initial survey and 6 months after the ban, respondents who were still actively employed (4,480) were mailed a followup survey. A significant decrease in employee smoking prevalence was found (21.7 percent before the ban to 16.2 percent after the ban).

Effect on Continuing Smokers

There is no consensus whether smoking restrictions encourage smokers to quit or the extent to which restrictions later behavior. Some researchers have suggested the, over time, smokers may adapt smoking behavior to smoking restrictions, rather than using the restrictions as an incentive to quit (Biener et al., 1989b). Others suggest that worksite no-smoking policies encourage smokers to put more effort into quitting (Sussman et al., in press). Although restriction the areas in which smoking may occur might reduce the cues that encourage smoking, it is also suggested that the smoking area itself could become a cue to smoke (Glasgow, 1989). Additional research may provide more insight about this area.

Elements Needed For Worksite Restrictions

a number of investigators have made suggestions for the important elements to successfully introduce worksite smoking restrictions and make them as effective as possible. Announcing the restriction or ban well in advance is essential. This will

232

allow time for smokers to prepare for quitting or to make adjustments. Rosenstock and colleagues (1986) recommended introducing new policies gradually, offering smokers an opportunity to express their dissatisfaction, and making clear the limitations of employee influence over the new policy. Millar (1988) suggested that, in designated smoking areas, smokers be separated from nonsmokers and that smoke be vented to the outside and not through the building's ventilation system. Finally, smokers' efforts to quit should be aided by available cessation classes, coworker support, publicity regarding adverse health effects, and ex-smoker support groups.

In conclusion there is some evidence that worksites that eliminate smoking completely, offer cessation clinics and other incentives to encourage smoke-free lifestyles, and implements comprehensive health promotion measures will experience a measurable drop in smoking prevalence.

233