The most c=monly employd my for mu~ ectivity is done with various strains of &l~~~~ e whole irmdta 8% well as CSC from four types of bh - fauad ;O be mutageaic in S. typhrimurium TA1533 (Basrur et d 1~8). - gmo)reWarr also found to be mutagenic in a w hy- wLLB - directly on the bacterial plates (w et d 193~. b etudies lend support to the extensive assays performed a a w eehaMiah that tobacco smoke has significant mutagepic *w Several of the studies with Csc fm em haW besu aimed at comparing the effects of &ous tobaocas, w - strains, and various systems selected far m w lost of the mutagenic activity was m &tb & bagic fnrtion a CSC (DeMarini 1983). For the CSC! from w e mpta genie activity was primarily detected with &e m T- and TA98, thus indicating the presence of &e u - tJped mutagens. Except for studies on the e&&s af m cigarettes, metabolic activation was required t.4) demoaastra&e m* genie activity for most of the CZC studied. Several short-term tests have been performed in s systems. A solution of the gas phase of e mm dissolved in a phosphate buffer induced reciprocal u&c& e nation in Swcharcmzpc?s ~e~~isiae D3 snd petite mm io m i&ate of strain D3 (Izard et al. 1980). Whole mainetwam c&are&e smoke induced mitotic gene conversion, reverse mu&&m, and reciprocal mitotic recombination in strain M ofS. cenx&& @air&a 1982). Transformation of mammalian cells was also induced in several cell systems using the CSC from mainstream . &g&t&i 1968; Inui and Takayama 1971; Rhim auE?m &n&ct et al. 1975; Takayama et al. 1978; Ridal and ti 1980). Transplacental exposure t0 n CSC was WJorted b trasfom Syrian hamster foeti cells (Raamuseen et ~ ml). Transforming activity was reported in the acidic and basic fra&~~ I as well as the neutral fractions of C&L S~dies on v of csc have shown that the basic fraction and some of the a&c& fractions are the most active in Cd tran%formation (Bened& ~4 d 1975). The neutral fraction OfCSCwaS*~ported~~*DNA repair h normal human lymphocytes (Gadin et al- 197% Transfer mation of mammalian cells with SS or m has not been repOti Summary of Carcinogenicity At present, the scientific literature offers some information on the physicochernical nature of the sidestream smoke from tobacco products and of environmental tobacco smoke. Chemical analytical studies have already demonstrated that SS and FYI'S contain a wfde spectrum of carcinogens such as polynuclear aromatic hydrocarbons, 261 volatile and tobacco-specific N-nitrosamines, and polonium-210. To date, only one study has demonstrated the carcinogenic activity of the particulate matter of sidestream smoke and a few isolated reports have dealt with the genotoxicity of SS and EX'S. Therefore, bioassay studies with the mainstream smoke and the environmental tobacco smoke of cigarettes are needed. Although the resulting bioassay data will derive from tests of concentrations of environmen- tal smoke that do not realistically occur in the human setting, these results will provide information about the relative carcinogenic potential of sidestream smoke in comparison with the mainstream smoke of the same cigarettes. In a comprehensive analytical approach, data should be generated to systematically determine the concentrations of toxic and tumorigenic agents in the ETS samples and to simultaneously measure the uptake of tobacco-specific agents by the body fluids of nonsmokers exposed to ETS. Conclusions 1. The main effects of the irritants present in EZS occur in the conjunctiva of the eyes and the mucous membranes of the nose, throat, and lower respiratory tract. These irritant effects are a frequent cause of complaints about poor air quality due to environmental tobacco smoke. 2. 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New York, Academic Press, 1967. 260 CHAPTER 6 POLICIES RESTRICTING SMOKING IN PUBLIC PLACES AND THE WORKPLACE CONTENTS Introduction Current Status of Restrictions on Smoking in Public Places Legislative Approaches Federal Legislation State, Legislation Local Legislation Regulatory Approaches Smoking Regulation in Specific Public Places Public Transportation Retail Stores Restaurants Hotels and Motels Schools Health Care Facilities Current Status of Smoking Regulations in the Workplace Smoking Policies Prevalence of Smoking Policies Reasons for Adopting Smoking Policies Barriers to Adopting Smoking Policies Types of Smoking Policies The "Individual Solution" Approach Environmental Alterations Restrictions on Employee Smoking Banning Smoking at the. Workplace Preferential Hiring of Nonsmokers Implementation of Smoking Policies Impact of Policies Restricting Smoking in Public Places and in the Workplace Potential Impacts of Smoking Policies Policy Implementation and Approval Direct Effects: Air Quality and Smoking Behav- ior Indirect Effects: Knowledge, Attitudes, Social Norms, and Smoking Behatior Methodologic Considerations in Policy Evaluation Study Design Assessing the Effects of Smoking Policies Review of Current Eviderice on Impact Workplace Smoking Policies Policy Implementation Air Quality Policy Approval Smoking Behavior Attitudes About Smoking Management Issues Legislation Restricting Smoking in Public Places Policy Implementation and Enforcement Policy Approval Attitudes tid Social Norms Smoking Behavior Recommendations for Future Research Conclusions Appendix: `I'he Comprehensiveness Index of State Laws References 264 Introduction Since the 197% the accumulating evidence on the health risks of involuntary smoking has been accompanied by a wave of social action regulating tobacco smoking in public places. hntiatives in the public sector and in the private sector have aimed at protecting individuals from exposure tc side&ream smoke by regulating the circumstances in which smoking is permitted. Smoking h public places has been regulated ~rhmily by government action at the local level and at the Federal level. Legislation has been the most common vehicle at the local and State level; agency regulations have predominated in the Federal Government. There has been relatively little judicial action to restrict smoking in public places; most cases have focused on nonsmoking employees' right to a smokefree workplace (Feldman et al. 1978; Eriksen, in press; Walsh and Gordon 1986). Private sector initiatives have gained momentum in the 1980s. Businesses in a ,wide variety of industries have adopted smoking policies to protect employee health. Other private initiatives include no-smoking sections in restaurants, no-smoking rooms in hotels and motels, and smoking restrictions in hospitals. Though this trend was fueled by growing evidence about the health effects of involuntary smoking, it also reflects the changing public attitudes about smoking since 1964, when public attention was focused on the health hazards of cigarette smoking by the Report of the Advisory Committee to the Surgeon General (US PEIS 1964). The acceptability and desirability of tobacco smoking in public places has fallen dramatically over time, as reflected in public opinion surveys. A majority now support the right of nonsmokers to breathe smoke-free air and favor policies that ensure that right (ALA 198!jb; Hanauer et al. 1986; BNA 1966; US DHEW 1969). This chapter addresses the scope and impact of these diverse pohcies. It begins with a review of the current status of policies restficting smoking. Issues specific to smoking regulation in trans- portation vehicles and motels, restaurants, stores, schools, health care facilities, and the workplace are addressed. The effects of smoking policies on air quality, attitudes, and smoking behavior are considered. Current Status of Restrictions on Smoking in Public Places Smoking regulations in public places represent a mix of public and private actions. A public place may be defined as any enclosed area in which the public is permitted or to which the public is invited. Smoking restrictions are generally limited to indoor enclosed spaces (Hanauer et al. 1986). This broad definition of a public place encompasses a diverse group of facilities that differ in the degree to which smoking is restricted, the ease of introducing new regulations, and the methods by which new smoking restrictions have been proposed and adopted. Smoking in Federal, State, and local government facilities has been addressed by legislative and regulatory action. These facilities include government offices, public schools and libraries, and publicly owned transport&ion, health care, cultural, and sports facilities. In public facili&s under private ownership, smoking restrictions are a mixture of government-sponsored regulation and private initiative. These facilities include retail stores, restaurants and bars, hotels and motels, and privately owned transportation, health care, cultural, and sports facilities. The extent and ac&ptability of smoking restrictions in public places is influenced by (1) whether ownership is public or private; (2) the historical acceptance of smoking in the facility; (3) the degree to which nonsmokers are exposed to involuntary smoking, determined by the facility's size, degree of ventilation, and ease of separating smokers and nonsmokers; and (4) the degree of inconvenience that smoking restrictions pose to smokers. Smoking restrictions are still most widespread and least controversial in facilities where smoking has traditionally been prohibited by fire codes, such as theaters or libraries, or where smoking is negatively associated with the activity taking play, such as gyms or health care facilities (Feldman et al. 1978). Small crowded areas with poor ventilation, such as elevators and public transit vehicles, are also frequently regulated. On the other hand, the strong association of smoking with eating and drinking contributes to the controversial nature of smoking re&ic- Cons in restaurants and bars. Legislative Approaches Fe&r-d Legislation Congress has enacted no Federal legislation restricting smoking in public places, although bills have been introduced in Congress several times since 1973 (Feldman et al. 1978). State Legislation Most legislation restricting smoking has been enacted at the State level. Although legislation regulating smoking for health reasons is largely a phenomenon of the past decade, cigarette smoking has been the subject of restrictive legislation for nearly a century. Early legislation had two different rationales. The first, a relatively noncontroversial rationale, was the protection of the public from fire or other safety hazards, largely in the workplace (Warner 1981b). The second, more controversial motivation for early legislative action was a moral crusade against cigarettes similar in tone and coincident with the moral crusade against alcohol that emerged at the tux-n ofthe century Wlow 1981; Nobel 1978). INS goal w~ a total ban On Cigarettes, which were blamed for social e* and physical % based 1arge~Y on unfounded claims. By 1887, three States (North Dakota, Iowa, and Te==ee) had completely banned the de and use of cig=ett-. At the peak of the movement, cigarettes were b-cd h a dozen Stat.e~ RJuhing and Markle 1974; sobe 1978). Most were in the Midwest where cigarette consumption was low and a~~ticigarette feeling high. The movement lost momentum when enforcing the regulations proved controversial. AS part of the strong reaction to alcohol prohibition, ah State laws banmng smoking were repealed by 1927. During the 196Os, as the health risks of smoking became widely `recogn&d, public POLICY on smoking began tc focus on encow the smoker to quit. However, the few existing State laws regulating smoking in public places were old and limited in scope. Even newly enacted laws-in Delaware (1960) and in Michigan (1967, 1968& restricted smoking in limited areas: public buses and trolleys, elevators, and retail food establishments (VS DHHS 1985b). Protec- ting the health or comfort of nonsmokers was not cited as a rationale of these laws. As Of 1970,~tatuteS restricting smoking were in force in 14 states (US DHHS 1985b). In the early 19709, a new wave of smoking legislation emerged. It covered smoking in a larger number of places and extended for the first time to privately owned facilities. The language became more restrictive, moving from permitting a no-smoking section to requir- ing one and making nonsmoking the principal or assumed condition. me language also changed to make it clear that the specific intent was the safety and comfort of nonsmokers. me pace of new legislation increased in the mid-1970s. Between 1976 and 1974, 9 laws were enacted in 8 States, between 1975 and 1979, 29 new laws were passed and 15 additional States adopted smoking regulations. Minnesota passed its landmark Clean Indoor fi Act in 1975 "to protect the public health, comfort, and environment by prohibiting smoking in public places and at public meet-s except in designated smoking areas" (M~IUESO~~ Stthte~ Annual 1985). It covered restaurants, private worksites, and a large number of public places, and soon became the model for other State legislation. Within the next 5 years, Utah, Montana, and Nebraska enacted similar comprehensive legislation (US DHHS 1985b). The language of statutes passed by 11 States during the 1970s made it clear that the specific purpose was to protect nonsmokers from involuntary smoking (US DHHS 198523). Model legislation and advice about the successful enactment of State laws can be found in several sources (Hanauer et al. 1986; Feldman et al. 1978; Walsh and Gordon 1986). 1 f 30- .s e $ 25- 5 f z20 b P 15 - 2 1960 1964 1970 1975 1880 1885 Year FIGURE l.-Prevalence and restrictiveness of State laws regulating smoking in public places, 19604986 NOTE See appendix for definitions of mtrictivenem of laws. S4WRCE: ASH (1SW; OTA (1986); Tri-Agency Tobacco Free Project MSSk US DHHS WS6b). The rate of enactment of State legislation increased throughout the seventies (Figure 1, Table 1). The pace of new legislation continues in the 1980s with 23 new laws enacted by 16 States between 1980 and 1985 (Table 1). As of 1986, 41 States and the District of Columbia have enacted laws regulating smoking in at least one public place (Figure 1). Eighty percent of the U.S. population currently resides in States with some smoking restric- tion, compared with 8 percent in 1971 Warner 1981b). Most of the nine States with no smoking legislation are concentrated in the southeast United States and include three of the six major tobacco- producing States (North Carolina, Virginia, and Tennessee) (Figure a. Current State legislation varies in comprehensiveness and lan- guage. The number of public places in which smoking is regulated by State law ranges from 1 (Delaware, Mississippi, and South Carolina regulate smoking on public transportation only) to 16 (Minnesota and Florida) (US DHHS 198513, Tri-Agency Tobacco Free Project 268 1986). State laws most often restrict smoking in public transporta- tion (35 States), hospitals (33 States), elevator (31 States), indoor cultural or recreational facilities (29 States), schools (27 Stat.@, public meeting rooms (21 States), and libraries (19 States) (Table 2). Other public places specifically mentioned in State smoking legisla- tion are public restrooms and waiting rooms, jury rooms, polling places, prisons, hallways, stairwells, and stables. Most laws restriqt smoking in these places to designated areas, thereby making nonsmoking the norm; in a few States smoking is banned entirely in these places. For example, smoking on pqblic transportation is banned entirely in four States (Florida, Georgia, Massachusetts, and W&&t& ad one (Washington) bans smoking in theaters, m-e-, au&t()dm, and indoor sports arenas. Smoking restric- 269 m Nominal 0 No-ns FIGURE 2.-Geographic variability of State laws regulating smoking in public places, 1996 tions extend to restaurants and retail stores, which are largely privately owned, in 18 States. Smoking at the workplace is restricted for public sector employees in 22 States and for private sector employees in 9 States. The provisions of worksite smoking legislation vary widely, making direct comparisons of their comprehensiveness difficult. Currently enacted workplace smoking laws contain provisions to (1) require a written policy (5 States); (2) limit smoking to designated areas (8 States); (3) require the posting of signs (10 States); and (4) give preference to nonsmokers in resolving conflicts over the designation of a work area (2 States) (OTA 1986). Public or private worksites are included in the definition of public places in some States where worksites are subject to the general provisions for public places. Other States have written separate guidelines for the worksite, which are usually more stringent. Laws in four States apply only to State and local government employees; restrictions apply to the private worksite in an additional nine States. 270 state AL AK AZ AR CA CO (;T DE DC FL GA HI ID IL IN IA KS KY 1971.76 1973 1925 Year(s) legislation 1975 1973 1977 1960.61 1977 1974 1963 1975 enacted - 1964 1981 1963 1962 1985' 1963 1960 1979 1965 1975 1976 1965 - 1978 1975 1972 PUBLIC PLACES WHERE SMOKING IS PROHIBITED (EXCEPT IN DESIGNATED AREAS) Public transportation x x (X)' X3.4 X X8 x X x3.5 X' X X X X Elevators X' x X X' X x1 X' x X X X Indoor recreational or cultural facilities' x x X X X X X X X Retail stores (X)' (X)' x X X X X Restaurants X' X0 X X'O X' X Schools X X X X X X X X X Health care facilities Hospitals X X X X X X x x X X X X Nursing homes X X X X X X X X X Public meeting rooms X X X X X X X X X Libraries X X X X X Restrmns X' x X X X Waiting rooms X X X X X X Other p.27 xn X262-7.30 WORKSITE SMOKING RESTRICITONS " Public worksites D" B D' B B B,D I11 B' B D Private worksites A B BD IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes X No discrimination against nonsmokers ENFORCEMENT Penalties for violations X X X X X X X X X X X X x x Smoking Xm pa x23. XS xm X" x= X21' x23. X" X2&i x- 2P x- Y Failure to post signs X@h XUh c Overall State law restrictiveness:" 0 3 2 1 3 3 4 1 2 4 1 2 3 0 0 2 2 1 ii TABLE 2.-Cantinued St& LAME MDMAMIMN IbiB MO MT NE NV NH NJ Nbf NY NC ND OH 1954 1924 1967 1955 1921 Year@) legislation 1961,63 1957 1947 1966 1971 1911 1979 1975 1961 enacted 1965 1975 1975 1976 1975 1942 - 1979 1979 1976 1961 1965 16% 1976 - 1977 lsec PUBLIC PLACES WHERE SMOKING I8 PROHIBITED (EXCEPT IN DEslGNATBD AREAS) Public transportation X X X' 00' x x X x x x x x x x x ElW&XI X X' x x x x x x x x x x Indoor recreational or cultural facilities* X X x x x x x x x x x Retail stores X cm' x x x x X X Restaurants X X" x x X" X" X Schools X x x x x x x x x Health care facilities Hospitals X x x x x x x x x x x x x Nursing homea X x x x x x x x x x x x x Public meeting rooms X x x x x x x x x Libra+ X X x x x x x X Rentmoms x X X x x waiting rooms X X x x x X X Other X'" X" Xmm X" X" X" WORKSITE SMOKING RE!i%`RICl'IONS" Public worksites BP D" D " D" D'O B,C" B$F C C Private worksites 4D Dl7.21 D" D17P A" B,C " Aal IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes X X No discrimination against nonsmokers X ENFURCEMENT state OK OR PA I.. SC SD TN TX UT VT VA WA WV WI WY 1973.76 1927 1913 w Year(s) legislation 1977 1947 1976 1976 1919 N CC) enacted 1975 1961 1977 1977 1937 1974 - 1975 1979 1692 - 1963 1965 1964 - 51 wo) PUBLIC PLACES WHER?- SMOKING IS PROHIBITED (EXCEPT IN DESIGNATED AREAS) Public transportation X X (x)* x X Elevators X X X X X Indoor recreational or cultural facilities0 X X x x X X Retail stores X X X Restaurants X X Schools X X X X Health care facilities Hospitals X X X X X Nursing homes X X X X Public meeting rooms X Libraries X X X X Restrooms Waiting rooms X Other XS" X" X X X X X' XL X' X' X X' X X X' X X X X" X X X X X X X X X X X 36 (66.6) 31 (60.8) 29 (59.6) 16 (35.3) 16 (35.3) n (52.9) 33 (64.7) 29 (56.9) 21 (41.2) 19 (37.2) 11 (21.6) 16 (31.4) 12 (23.5) WORKSITE SMOKING RESTRICI'IONS" Public worksites D Private worksites D" D D" 22 (43.1) D17.22 A" D A" 9 (17.6) IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers X 4 (7.6) X 2 (3.9) ENFORCEMENT Penalties for violations X X X X X X X X x x X 40 (78.4) Smoking XW XWb X2" x= X2.% X2" x= X23. XZJ' psa X= 39 (76.5) Failure to post signs X2& XW pe 9 (17.6) Overall State law restrictivenewzS 2 3 2 3 1 2 0 2 4 1 0 4 1 3 0 Y TABLE 2.-C!ontinued (Footnotes) ' Executive order. `School buses only. a Including school buses. `California stipulates that at least 50 percent of all passenger seats must be in nonsmoking areas on trains, airplanes. and street railroad cam departing from the State. `Smoking never permitted in this area. `Indoor recreational and cultural facilities: museums, auditoriums, theaters, and sports arenas. `Grocery storea only. ' Beatauranta seating 50 or more persons must have a no-smoking section. eBestauranta seating 50 or more persons must have e no+moking eection if the restaurant ia in a publicly owned building. `OBestauranta seating 15 or more persons must have a nwmoking section. " Restaurants must designate at least 30 percent of their mata aa a no+moking area. " Reatauranta are encouraged to establish noamoking areas. `I Ftentauranta must designate at least 50 percent of their seats 88 a no.emoking area. "Kkleted). I' No place other than a bar may be designated B smoking area in its entirety. `* Worksite (only 8, C. and D munt aa having a worksite policy in maculation of totals): A - Employer must post a sign prohibiting smoking at the work&q B - Employer mu& have a (wit&n) smoking policy; C - Employer must have policy that provides a nonsmoking area; D - No smoking except in designated .wcas. " Employer must post signs designating smoking and nwmoking arena. `*Employer mu& vt signs in smoking area.% `*Employer must post either smoking or nwemoking sign& depending upon their policy. `"Employer must post Ggna in no-smoking areas. " State doea not restrict smoking in factories. warehouses. and similar placea of work not usually frequented by the general public. " Prohibita smoking in any mill or factory in which a no-emoking sign is pasted. "Pereons who smoke in a prohibited area are subject to a tine or a penalty. Maximum fina or penalties, where applicable, are listed below: a = $5; b = $10, c = 1%; d = $& e = $100, f = $loO/day; g = $200; h = *urn; i = $5CO; j = $50 or up to 10 days in jail or both; k = $60 or SO daya imprisonment; 1 = civil action; m = minor misdemeanor; n = petty mi&mwnor; o = misdemefmor; p = petty offense. " Persona who are required to and fail to pcet smoking and/or no+moking sigma are subjected b a penalty. Maximum finea. where applicable. are listed in footnote 23. I6 Restrictivenea key: 0 = None, no statewide restrictions; 1 = Nominal, State ragul&en smoking in one to three public placm, excluding restaurants and private vorknita; 2 = B&c, State regulatea smoking in four or more public places, excluding restaurants and private workaita; 3 = Moderate. State regulatea smoking in restaurants but not private workaitcs; 1 = ENnaive. State regulates smoking in private work&es. *`Jury moms. " Halb and stain. `*stables. "Polling plaan. *`Prisons, at ptin offL%& diiretion. The least restrictive workplace laws simply empower the employer to restrict smoking in factories by posting signs. These statutes were enacted in the early 1900s. The weakest recent laws simply require an employer to issue a written smoking policy and to post signs. More restrictive laws require that employers designate no-smoking areas at work, implying that smoking is the norm. The most comprehensive laws prohibit smoking except in designated areas, making nonsmoking the norm. Seven States (Florida, Maine, Minne- sota, Montana, Nebraska, Utah, and Washington) have this type of law. In several States, some worksites or some parts of a worksite (usually private offices) are exempted from the regulations. To prevent employers from complying with the letter but not the intent of the law, some States prohibit a workplace from being designated as entirely smoking. State laws vary in their provisions for implementation and enforcement. In most States, the State health department is responsible for policy enforcement. Nearly all (39 of 42) States with laws provide penalties for smokers who violate restrictions; the maximum penalty is $500. In two States violators can be jailed. Employers or others who fail to designate smoking areas can be fined in nine States. The comprehensiveness of State laws, as defined by the number and nature of places where smoking is restricted or prohibited, has increased since 1970. In 1981, Warner (1981b) classified State laws according to their comprehensiveness (restrictiveness) and docu- mented an increase in the average restrictiveness from 1971 to 1978. An updated and modified index of the comprehensiveness of State laws (described in the appendix) demonstrates that the phenomenon reported by Warner has continued into the mid-eighties. The comprehensiveness of newly enacted laws increased markedly dur- ing the mid-seventies, and the average restrictiveness of State laws in effect has increased more than twofold between 1972 and 1985 (Table 1, Figure 3). As shown in Figure 1 and Table 1, the increase in comprehensiveness of State laws occurred in two ways. The average comprehensiveness of first laws in additional States increased, and existing State smoking laws were replaced with more comprehensive legislation. Warner also documented that both the prevalence and comprehen- siveness of State laws enacted through 1978 varied by geographic region (Warner 1982). This has not changed (Table 3, Figure 2). Over 90 percent of the States in the Northeast and West have enacted at least one law regulating smoking, as have three-fourths of the North Central States. Southern States have fewer laws than other regions, and the laws they have are less comprehensive than laws in other regions. The six major tobacco-producing States, all located in the South, have less restrictive laws than do the other six Southern