Secondhand smoke at indoor workplaces and public places : results from the Oklahoma adult tobacco survey, 2004 and 2008.

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Executive Summary
The Adult Tobacco Survey, conducted by the Oklahoma State Department of Health in
cooperation with the U.S. Centers for Disease Control and Prevention in 2004 and 2008, shows
strong and increasing support for entirely smokefree policies so that all workers and the public
will be protected from secondhand tobacco smoke exposure inside all public places and indoor
workplaces, including all restaurants and bars.
Smokers demonstrated the greatest increases in support over this four-year span, which
included the transition in 2006 from unprotected smoking areas in restaurants, showing more
widespread change of social norms concerning smokefree policies and broadened acceptance
of entirely smokefree indoor environments.
Key findings include the following:
• There is very strong support for entirely smokefree indoor workspaces.
o 79.5% of indoor workers believe smoking should not be allowed at all inside
indoor work areas (2008).
• Support for entirely smokefree workplaces increased significantly between 2004 and
2008, especially among smokers.
o 61.0% of smokers employed indoors support entirely smokefree indoor work
areas (2008), an increase of almost one third from 47.2% support among these
smokers four years earlier (2004).
o Regarding restaurants specifically, support among all smokers for totally
smokefree restaurants more than doubled between 2004 and 2008, from 21.8%
to 45.7%.
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Secondhand Smoke at Indoor Workplaces and Public Places in
Oklahoma: Results from the Adult Tobacco Survey, 2004 and 2008
INTRODUCTION
Secondhand smoke (SHS) is a mixture of the smoke given off by the burning end of a
cigarette, pipe, or cigar, and the smoke exhaled from the lungs of smokers. There are 4000
chemicals released into the air when tobacco is burned, many of which are harmful to human
health and more than 50 are carcinogenic.1,2 In 1981 the first reports of non-smoking spouses
of heavy smokers being diagnosed with lung cancer emerged.3 Since then, many investigations
have linked secondhand smoke to heart disease, stroke, asthma, SIDS, and other cancers,
including bladder and kidney cancers. In 2000, the National Toxicology Program officially
classified secondhand smoke as a known human carcinogen.2
Significant scientific evidence has amassed in recent years documenting the adverse effects
of secondhand smoke on children and adults, including cancer and cardiovascular diseases
in adults, and adverse respiratory effects in both children and adults. The 2006 report of
the Surgeon General, The Health Consequences of Involuntary Smoking, provided a detailed
review of the epidemiologic evidence on the health effects of secondhand smoke, concluding
that SHS causes premature death and disease in children and in adults who do not smoke, and
that there is no risk-free level of exposure to secondhand smoke.4
A recent report of the Institute of Medicine further established that exposure to SHS
increases the risk of coronary heart disease and heart attacks.5 In addition, the immediate
benefits of smokefree policies were highlighted. The IOM report reviewed evidence from 11
different studies demonstrating a decrease in the incidence of heart attacks after smokefree
public policies were implemented. Decreases in the incidence of heart attacks ranged from 6%
to 47%, and the committee concluded a causal association between smokefree laws and
decreases in heart attacks.
The goal of this report is to provide current data on SHS attitudes among both smokers and
nonsmokers in Oklahoma, in hopes that policymakers and others will use the evidence in their
decision-making process to advance protections from the harmful components of secondhand
smoke.
METHODS
The data analyzed in this report come from the Adult Tobacco Survey (ATS) conducted in
Oklahoma in 2004 and 2008 using telephone survey methodology. Sample sizes for the 2004
and 2008 Adult Tobacco Surveys were 1530 and 3000, respectively. The analyses were
performed using Proc Survey freq in SAS version 9.1. Percents and 95% confidence intervals
are presented in table format. The data were weighted to represent the population of Oklahoma
with weights created by CDC. Additional information was obtained from previously published
reports and research on secondhand smoke and health.
4
Data were examined by smoking status. Smokers were defined as respondents who had
smoked 100 cigarettes in their lifetimes and who currently smoke some days or all days. In the
tables, nonsmokers include never smokers as well as former smokers. When cell sizes
contained five or fewer responses, data were not shown. When appropriate, data are presented
overall, and for nonsmokers and smokers separately.
RESULTS
Attitudes about Secondhand Smoke Policies
Attitudes were examined among Oklahomans regarding smokefree policies in indoor work
areas, restaurants, and bars. As might be expected, attitudes toward smokefree policies were
different among smokers and nonsmokers; thus, this section summarizes these attitudes
overall, and for these two groups separately.
Indoor work areas
Attitudes about smokefree policies in indoor workplaces are reported in Table 1 for
employed Oklahomans in 2004 and 2008. Only ATS respondents who indicated they worked
indoors were included in this analysis. Overall in 2004, nearly 78% of Oklahoma indoor workers
supported entirely smokefree indoor workplaces. Support was strongest among nonsmokers
(86.7%) as compared to smokers (47.2%). Support for totally smokefree indoor workplaces
increased somewhat in 2008, with 79.5% of Oklahoma indoor workers responding that smoking
should not be allowed at all in indoor workplaces. Notably, support for entirely smokefree indoor
workplaces increased dramatically among smokers from 2004 (47.2%) to 2008 (61.0%).
Table 1. Support for smokefree policies in indoor workplaces among indoor workers in Oklahoma,
overall and by smoking status, ATS 2004 and 2008
Year
2004 2008
Response°
Smoking
StatusΩ N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper
Allowed in all areas Overall 9 15802 1.4 0.2 2.6 19 49546 4.6 1.3 8.0
Smoker * * * * * 13 42165 15.6 3.7 27.5
Nonsmoker 6 8929 1.1 0.0 2.3 6 7381 0.9 0.0 2.2
Allowed in some areas Overall 121 227234 20.8 16.4 25.1 112 169536 15.9 11.3 20.5
Smoker 62 123688 50.0 38.8 61.1 48 63181 23.4 12.7 34.1
Nonsmoker 59 103546 12.2 8.4 16.1 63 98233 12.4 7.5 17.4
Not allowed at all Overall 460 851818 77.8 73.4 82.2 754 848539 79.5 74.2 84.8
Smoker 66 116897 47.2 36.2 58.3 106 164767 61.0 46.3 75.7
Nonsmoker 393 733549 86.7 82.7 90.7 647 683555 86.6 81.6 91.7
° Question asked was “In indoor work areas, do you think smoking should be allowed in all areas, some areas, or not at all?”
CI = Confidence Interval.
* Indicates the cell had less than six responses.
2004 Sample size=596 indoor worker respondents; Missing/don’t know/not sure = 6
2008 Sample size=899 indoor worker respondents; Missing/don’t know/not sure = 14
Smoker plus Nonsmoker totals may not equal Overall sample size because of missing smoking status.
5
Indoor dining areas of restaurants
In 2006 all restaurants in Oklahoma became smokefree, except for those that built specially
ventilated smoke rooms. Consistent with what other states have shown,6 support among
Oklahomans for entirely smokefree indoor dining areas increased among all groups following
the 2006 law (Table 2). Interestingly, support among smokers doubled from 21.8% in 2004 to
45.7% in 2008. Among nonsmokers, support also increased from 68.2% in 2004 to 75.1% in
2008. Overall, support for a totally smokefree indoor dining areas in restaurants increased from
58.0% in 2004 to 67.2% in 2008. All of these increases in the support for smokefree policies in
indoor dining areas are meaningful and statistically significant, as indicated by the non-overlapping
confidence intervals.
Table 2. Support for smokefree policies in indoor dining areas of restaurants in Oklahoma, overall
and by smoking status, ATS 2004 and 2008
Year
2004 2008
Response°
Smoking
Status N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper
Allowed in all areas Overall 35 52580 2.0 1.2 2.8 49 62789 2.3 1.1 3.5
Smoker 9 11772 2.1 0.5 3.7 28 44953 6.3 2.4 10.3
Nonsmoker 26 40808 2.0 1.1 3.0 21 17836 0.9 0.1 1.7
Allowed in some areas Overall 558 1036524 39.9 36.5 43.3 909 824552 30.5 27.1 33.9
Smoker 213 431714 76.1 70.2 82.1 315 340084 48.0 39.5 56.4
Nonsmoker 342 599213 29.8 26.3 33.3 589 474819 24.0 20.5 27.4
Not allowed at all Overall 911 1506247 58.0 54.6 61.4 2010 1814419 67.2 63.7 70.6
Smoker 74 123469 21.8 15.9 27.6 227 323857 45.7 37.1 54.2
Nonsmoker 833 1373145 68.2 64.6 71.8 1773 1487528 75.1 71.6 78.6
° Question asked was “In the indoor dining area of restaurants, do you think that smoking should be allowed in all areas, some
areas, or not allowed at all?”
CI=Confidence interval
2004 Sample size = 1530; Missing/don’t know/not sure = 26
2008 Sample size = 3000; Missing/don’t know/not sure = 32
Smoker plus Nonsmoker totals may not equal Overall sample size because of missing smoking status.
Bars
Table 3 shows the level of support for different approaches to limiting secondhand smoke
exposure in bars among Oklahomans in 2008. (These questions were not asked on the 2004
ATS.) Nearly three-quarters of Oklahomans (74.7%) responded that bars should be either totally
smokefree or smokefree except for specially ventilated smoking rooms. Only about one-quarter
(25.3%) of Oklahomans support allowing smoking throughout in bars. Even among smokers,
more than half (53.1%) support totally smokefree bars or smokefree except for specially
ventilated rooms.
6
Table 3. Support for laws making bars smokefree in Oklahoma, ATS 2008
Year
2008
Response°
Smoking
Status N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper
Allow smoking in all areas Overall 484 585706 25.3 21.3 29.3
Smoker 218 292587 47.0 37.6 56.3
Nonsmoker 265 292719 17.4 13.7 21.2
Smokefree except for separately ventilated smoking rooms Overall 672 648279 28.0 24.5 31.5
Smoker 178 222125 35.7 27.1 44.2
Nonsmoker 488 416074 24.8 21.3 28.3
Totally smokefree Overall 1299 1079413 46.7 42.8 50.5
Smoker 95 108098 17.4 12.0 22.7
Nonsmoker 1200 970253 57.8 53.6 62.0
° Question asked was “Do you support a law that would make bars smokefree; that is eliminating all tobacco smoke from bars?”
CI=Confidence interval
Sample size = 3000; Missing/don’t know/not sure = 545
Smoker plus Nonsmoker totals may not equal Overall sample size because of missing smoking status.
Anticipated bar and casino visits
Oklahomans were also asked about their anticipated change in frequency of bar and casino
visits if smoking was not allowed inside these locations (Tables 4 and 5). As expected, smokers
and nonsmokers responded differently to these questions. Among smokers who ever go to
bars, 24.5% reported they would visit bars less frequently if smoking was not allowed inside
these locations (Table 4). However, 18.5% of nonsmokers who ever go to bars reported that
they would visit bars more frequently if smoking was not allowed inside these locations. It is
important to remember that nonsmokers comprise nearly 75% of the adult population.
7
Table 4. Anticipated frequency of bar attendance if smoking was not allowed inside these
locations in Oklahoma (among those who ever go to bars), ATS 2008
Year
2008
Response°
Smoking
status N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper
Less Overall 66 98989 10.1 6.1 14.1
Smoker 57 84778 24.5 13.7 35.4
Nonsmoker 9 14211 2.3 0.2 4.4
More Overall 106 125951 12.9 9.0 16.8
Smoker 6 10776 3.1 0.0 6.3
Nonsmoker 100 115175 18.5 12.9 24.0
No Difference Overall 495 753890 77.0 71.6 82.4
Smoker 122 249950 72.3 61.0 83.7
Nonsmoker 370 494694 79.3 73.4 85.1
° Question asked was “If there were a total ban on smoking in bars, would you go out more, less, or would it make no difference?”
CI=Confidence interval
Sample size=674; Missing/don’t know/not sure = 7
Smoker plus Nonsmoker totals may not equal Overall sample size because of missing smoking status.
A similar trend was seen with anticipated casino visits (Table 5). Among smokers who ever
go to casinos, 20.0% reported they would visit casinos less frequently if smoking was not
allowed inside these locations. However, among nonsmokers who ever go to casinos, nearly
one-quarter (23.9%) reported they would visit casinos more frequently if smoking was not
allowed inside. Again, it is important to note that nonsmokers outnumber smokers in Oklahoma
three to one.
Table 5. Anticipated frequency of casino attendance if smoking was not allowed inside these
locations in Oklahoma (among those who ever go to casinos), ATS 2008
Year
2008
Response°
Smoking
status N
Weighted
N Percent
95%
CI
Lower
95%
CI
Upper
Less Overall 68 75610 7.7 4.4 11.1
Smoker 63 71278 20.0 10.9 29.0
Nonsmoker * * * * *
More Overall 162 159253 16.2 12.0 20.5
Smoker 6 10459 2.9 0.0 7.4
Nonsmoker 156 148793 23.9 18.1 29.7
No Difference Overall 664 745616 76.0 70.9 81.2
Smoker 181 275083 77.1 67.2 87.0
Nonsmoker 479 468857 75.4 69.5 81.2
° Question asked was “If there were a total ban on smoking in casinos, would you go to casinos more, less, or would it make no
difference?”
CI=Confidence interval
* Indicates the cell had less than six responses.
Sample size=903; Missing/don’t know/not sure = 9
Smoker plus Nonsmoker totals may not equal Overall sample size because of missing smoking status.
8
SUMMARY
From 2004 to 2008, attitudes toward smokefree policies changed among Oklahomans, with
trends toward increasing support for policies to reduce exposure to secondhand smoke in
indoor worksites and public places. Studies have demonstrated that as stronger smokefree
policies are enacted, attitudes and compliance in support of such policies increase over time,
especially among smokers.6 Data from the ATS in Oklahoma show that following the statewide
law ending smoking in restaurants in 2006 except in special smoking rooms, attitudes in favor of
entirely smokefree restaurants without the possibility of smoking rooms increased significantly
among both smokers and nonsmokers. The implications of these findings, and those from other
states,7-9 support the hypothesis that the policy process itself can contribute to changing social
norms and attitudes to be more accepting of secondhand smoke regulations. Furthermore,
smokefree policies have also been shown to motivate smokers to quit or cut back on the
number of cigarettes smoked, with entirely smokefree policies more effective in this regard than
policies with exemptions such as those allowed under Oklahoma’s laws.10
Data from the ATS not only demonstrate high levels of support for current smokefree
policies in this state, but they also indicate that Oklahomans would be supportive of stronger
policies to further reduce exposure to secondhand smoke. Only about one-quarter (25.3%) of
Oklahomans support allowing smoking throughout bars, which is the current policy for stand-alone
bars.
It is also important to note that among nonsmoking Oklahomans who frequent bars and
casinos, nearly all report that their frequency of visits to bars and casinos would either not
change or would increase, if smoking were not allowed at all inside these locations.
These results highlight some of the positive changes in attitudes among Oklahomans from
2004 to 2008. Policy changes should continue to protect the public and all workers from
secondhand smoke by implementing entirely smokefree laws for all public places and indoor
workplaces. In doing so, increased public support and continued changes in social norms will
likely follow.
9
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