Perceptions of harm from secondhand smoke exposure among US adults,

Transcription

1 Perceptions of harm from seconhan smoke exposure among US aults, Juy Kruger, Emory University Roshni Patel, Centers for Disease Control an Prevention Michelle Kegler, Emory University Steven D. Babb, Centers for Disease Control an Prevention Brian A. King, Centers for Disease Control an Prevention Journal Title: Tobacco Inuce Diseases Volume: Volume 14 Publisher: BioMe Central , Pages 3-3 Type of Work: Article Final Publisher PDF Publisher DOI: /s Permanent URL: Final publishe version: Copyright information: Kruger et al The Creative Commons Public Domain Deication waiver ( applies to the ata mae available in this article, unless otherwise state. This is an Open Access work istribute uner the terms of the Creative Commons Attribution 4.0 International License ( Accesse January 24, :22 PM EST

2 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 DOI /s RESEARCH Open Access Perceptions of harm from seconhan smoke exposure among U.S. aults, Juy Kruger 1*, Roshni Patel 2, Michelle Kegler 3, Steven D. Babb 1 an Brian A. King 1 Abstract Backgroun: Exposure to seconhan smoke (SHS) causes significant isease an eath. We assesse the prevalence an correlates of perceptions about the health harm of SHS among U.S. aults at the national an state level. Methos: Data came from the National Ault Tobacco Survey, a national lanline an cellular telephone survey. Perceptions about the health harms of SHS were assesse as follows: not at all harmful, somewhat harmful, an very harmful. Descriptive statistics were use to assess the prevalence of SHS harm perceptions by tobacco use an socioemographic factors, incluing sex, age, race/ethnicity, eucation, marital status, annual househol income, region, sexual orientation, chilren in the househol, an smoke-free law coverage. Logistic regression was use to assess os of perceiving SHS to be very harmful (vs. not at all harmful or somewhat harmful ), ajusting for the aforementione factors. Results: Nationally, 64.5 % of aults perceive SHS as very harmful (state range: 73.5 % [Utah] to 53.7 % [Kentucky]). By tobacco use, the perception that SHS is very harmful was: 76.5 % among nonusers of tobacco; 62.1 % among noncombustible only users; 47.9 % among combustible only users; an 40.8 % among ual combustible an noncombustible users. Following ajustment, the perception that SHS was very harmful was higher among females, non-hispanic minorities an Hispanics, responents living with chilren, an states with 100 % smoke-free law coverage. Among current tobacco users the os of perceiving SHS to be very harmful was lower in the Miwest than the West. Conclusions: Almost two-thirs of American aults perceive SHS as very harmful ; however, currently only half of all Americans are protecte by comprehensive state or local smoke-free laws. These finings unerscore the importance of public eucation campaigns to increase awareness of SHS exposure harm an the benefits of smoke-free environments. Expaning comprehensive smoke-free laws coul protect all Americans from SHS. Keywors: Tobacco, Smoking, Policy, Seconhan smoke Backgroun Seconhan smoke (SHS) exposure causes heart isease, stroke, an lung cancer in nonsmoking aults, an suen infant eath synrome, acute respiratory infections, mile ear infections, an more severe asthma in chilren [1]. SHS exposure causes more than 41,000 eaths among U.S. nonsmokers each year, costing the country an estimate $5.6 billion annually [2]. The U.S. Surgeon * Corresponence: ezk0@cc.gov 1 Office on Smoking an Health, National Center for Chronic Disease Prevention an Health Promotion, Centers for Disease Control an Prevention, Atlanta, GA, USA Full list of author information is available at the en of the article General has conclue that there is no risk-free level of SHS exposure, an that eliminating smoking in inoor spaces is the only way to fully protect nonsmokers from SHS exposure [1]. Over the past two ecaes, substantial progress has been achieve in implementing comprehensive smoke-free laws prohibiting smoking in all inoor workplaces an public places, incluing restaurants an bars, at both the local an state levels. Across the U.S., the number of local level comprehensive smokefree laws increase from two in 1993 to more than 600 in 2014, while the number of statewie laws increase from one in 2002 to 26 an the District of Columbia in 2016 Kruger et al. Open Access This article is istribute uner the terms of the Creative Commons Attribution 4.0 International License ( which permits unrestricte use, istribution, an reprouction in any meium, provie you give appropriate creit to the original author(s) an the source, provie a link to the Creative Commons license, an inicate if changes were mae. The Creative Commons Public Domain Deication waiver ( applies to the ata mae available in this article, unless otherwise state.

3 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 2 of [3, 4]. However, while aoption of local level comprehensive smoke-free laws continues, the aoption of statewie laws has stalle in recent years an resients of 24 states remain unprotecte by such laws an, thus, are susceptible to SHS exposure in many inoor public spaces [5]. Approximately 58 million Americans, incluing 15 million chilren, continue to be expose to SHS [6]. Research on public perception towar the harmful effects of SHS is growing [7, 8] an stuies have reveale that socioemographic correlates may contribute to harm perception [2] an the use of noncombustible tobacco proucts [9 11]. Levels of support for smoke-free public places have been shown to vary by cigarette smoking status, experience with smoke-free environments, knowlege about the harmfulness of SHS exposure, an other factors [12 18]. Changes in attitues about the acceptability of SHS exposure an the benefits of smoke-free environments both contribute to, an are further accelerate by, the publicity, eucation, ebate, an experiences that generally accompany the aoption of smoke-free laws [1, 19]. State an local smoke-free laws typically receive high levels of public support, with this support increasing over time as people become accustome to the protections affore by these laws [20]. Awareness of the averse health effects of SHS exposure is an especially important factor shaping public attitues towars smoke-free policies [21]. Research inicates that increase knowlege about the harmfulness of SHS is associate with greater efforts to minimize exposure [22, 23], reuce SHS exposure among both smokers an nonsmokers [22 24], an aoption of smoke-free home rules [25, 26]. Increase awareness of the averse health effects of SHS exposure is also associate with lower smoking initiation among youth [27] an more favorable attitues towar smokefree environments [1, 19, 28]. Past research suggests that many U.S. aults recognize the angers of SHS exposure. For example, using ata from 2001, McMillen an colleagues reporte that 95.1 % of U.S. aults believe that inhaling smoke from a parent s cigarette cause any level of harm to infants an chilren, with lower prevalence among smokers (89.5 %) than nonsmokers (96.7 %) [13]. These finings were consistent with stuies showing smokers are less likely to perceive that SHS exposure is harmful [3, 24]. Similarly, a Gallup poll conucte uring July 2014 foun that 57 % of U.S. aults viewe SHS as very harmful [29]. However, to ate, no publishe stuies have assesse potential variations in perceive harm from SHS exposure comprehensively across states, tobacco use status, smoke-free law coverage, an certain socioemographic factors. Thus, we assesse the prevalence an socioemographic correlates of perceptions that exposure to SHS is very harmful both overall an by state an tobacco use status among a nationally representative sample of U.S. aults. Methos Sample Data came from the National Ault Tobacco Survey (NATS), a national lanline an cellular telephone survey of noninstitutionalize civilian aults age 18 years or oler resiing in the 50 U.S. states an District of Columbia [30]. The stuy esign has been escribe in etail elsewhere, incluing cognitive testing of the employe measures [31]. In brief, the NATS use a stratifie, multistage probability esign to yiel ata representative at both the national an state levels. For the lanline component, each state was allocate an equal target sample size (n = 1863) to ensure aequate precision for state estimates. For the cellular telephone component, each state was allocate a sample size in proportion to its population (range: ,100). Louisiana, New Jersey, an Oklahoma ae to their lanline an cellular telephone target sample size; Delaware, Georgia, Iowa, North Dakota, Pennsylvania, South Carolina, an Virginia ae to their lanline target sample size. The sample esign consists of a ual frame Ranom Digit Diale sample, with inepenent samples rawn from lanline an cell phone fames [31]. Responent selection varie by telephone type. For the lanline numbers, one ault was ranomly selecte from each eligible househol. For cellular telephone numbers, the ault reache was selecte if a cellular telephone was the only way they coul be reache at home. Interviews were aministere from October 20, 2009 to February 28, 2010, an were conucte in both English an Spanish. In total, 118,581 interviews were conucte (lanline = 110,634 an cellular = 7947). The Council of American Survey an Research Organizations (CASRO) overall response rate, efine as the number of complete interviews ivie by the number of eligible responents in the sample, was 37.6 % (lanline = 40.4 % an cellular = 24.9 %) [32]. The overall cooperation rate, efine as the number of complete interviews ivie by the number of eligible responents who were successfully reache by an interviewer, was 62.3 % (lanline = 61.9 % an cellular = 68.7 %) [32]. State-specific CASRO response rates range from 28.2 % in New Jersey to 49.3 % in Vermont, while cooperation rates range from 52.9 % in Louisiana to 72.4 % in Vermont. Measures Harm perceptions Perceptions about the harm of SHS exposure were assesse by the question, Do you think that breathing

4 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 3 of 13 smoke from other people s cigarettes or from other tobacco proucts is?, with the following response options: not at all harmful to one s health, somewhat harmful to one s health, an very harmful to one s health. In this analysis, responents who answere very harmful to one s health were consiere to perceive SHS as very harmful. Current tobacco prouct use Tobacco prouct use was etermine by responents answers to questions on use of six proucts (cigarettes, cigars/cigarillos/little cigars, water pipes, pipes, chew/ snuff/ip, an snus); responents were classifie into four categories: 1) combustible only use; 2) noncombustible only use; 3) combustible an noncombustible use; 4) an no tobacco use. Combustible only use was efine as a responent who reporte smoking at least 100 cigarettes uring their lifetime, an now smoke every ay or some ays an/or use cigars/cigarillos/little cigars, water pipes, or pipes on 1 ay uring the past 30 ays, but i not use a noncombustible prouct. Noncombustible only use was efine as a responent who reporte using chewing tobacco/snuff/ip or snus on 1 ay uring the past 30 ays, but i not use a combustible prouct. Combustible an noncombustible use was efine as a responent who reporte smoking at least 100 cigarettes uring their lifetime an now smoke every ay or some ays an/or use cigars/cigarillos/little cigars, water pipes, pipes, chewing tobacco/ snuff/ip, or snus on 1 ay uring the past 30 ays. No tobacco use was efine as a responent who i not currently use combustible or noncombustible tobacco. Comprehensive smoke-free law coverage Comprehensive smoke-free law coverage was etermine using the American Nonsmokers Rights Founation (ANRF) U.S. Tobacco Control Laws Database, which tracks U.S. municipal, county, an state laws relating to tobacco [33]. Laws inclue in this atabase are ientifie through systematic scanning of tobacco control publications, Web sites an iscussion lists, biannual solicitation of information from tobacco control professionals, an partnerships. Ientifie tobacco control laws are coe by senior staff members at ANRF; the online legal research atabase of state an/or local comprehensive smoke-free laws are regularly upate quarterly. For the purposes of this stuy, responents were categorize accoring to the proportion of iniviuals in their state covere by a state an/or local comprehensive smoke-free law as of July 1, 2010 [33]. A comprehensive smoke-free law was efine as an orinance or regulation that prohibits smoking in all inoor areas of non-hospitality workplaces, restaurants, an freestaning bars, incluing attache bars or separately ventilate rooms with no size exemptions. For the purposes of analysis, comprehensive smoke-free laws were categorize as follows: 100 % (statewie law); %; 1 19 %; 0 % (no local or statewie laws). These categories were selecte base on the population istribution of coverage across states so as to ensure that statistically reliable comparisons coul be mae across categories. Socioemographic characteristics Socioemographic characteristics of responents that were assesse inclue: sex (male or female); age group (18 24, 25 44, 45 64, or 65 years); race/ethnicity (non-hispanic white, non-hispanic black, non-hispanic Asian, non-hispanic American Inian/Alaska native, non-hispanic Native Hawaiian/Pacific Islaner, non- Hispanic multirace, non-hispanic other, or Hispanic); eucational attainment (0 12 years [no iploma], Grauate Equivalency Degree (GED), high school grauate, some college [no egree], associate egree, unergrauate egree, or grauate egree); marital status (single/separate/ivorce/wiowe or marrie/living with a partner); annual househol income (<$20,000, $20,000 $49,999, $50,000 $99,999, $100,000, or unspecifie); U.S. Census region (Northeast, Miwest, South, or West); sexual orientation (heterosexual/ straight, lesbian/gay/bisexual/transgener [LGBT], or unspecifie); an whether the responent live in a househol with chilren 17 years ol (yes or no). Analyses Data were analyze using SAS-Callable SUDAAN 10 (SAS Institute Inc., Research Triangle Park, NC) an weighte to ajust for the ifferential probabilities of selection an response [31]. The lanline ata were first weighte by the inverse of the probability of selection of the telephone number, a nonresponse ajustment, an ajustments for the number of lanlines an the number of eligible subjects in the househol. The cellular telephone ata were first weighte by the inverse of the probability of selection of the telephone number an a nonresponse ajustment. Next, the ata were poststratifie by state accoring to the istribution of emographic variables (sex, age, race/ethnicity, marital status, an eucational attainment) an telephone type. For states with a small number of cellular telephone responents, the use of both lanline an cellular telephone ata resulte in a large unequal weighting effect an, therefore, large estimate variances of survey estimates an small effective sample sizes. As a result, the national an state estimates were calculate ifferently. For national estimates, we inclue both cellular telephone an lanline responents. For state estimates, cellular telephone responents were inclue only for the 12

5 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 4 of 13 states that ha a cellular telephone sample of 200 or more responents (California, Floria, Georgia, Illinois, Louisiana, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, an Texas). Descriptive analyses, incluing point estimates an 95 % confience intervals (CI), were calculate for each responent characteristic overall, by state, an by tobacco use status. Differences between estimates were consiere statistically significant if 95 % CIs i not overlap. Aitionally, a binary logistic regression moel was constructe with perceptions about SHS exposure being very harmful as the epenent variable; inepenent variables inclue: sex, age group, race/ethnicity, eucational attainment, marital status, annual househol income, U.S. region, sexual orientation, whether responents ha chilren 17 years ol living in the househol, comprehensive smoke-free law coverage, an current tobacco use. Separate logistic regression moels were constructe to preict perceive harm from SHS exposure among each respective category of tobacco users (i.e., combustible only use, noncombustible only use, combustible an noncombustible use, no tobacco use), each of which ajuste for the same covariates as the overall moel (excluing tobacco use). Results Perception of harm from seconhan smoke exposure, overall Nationally, 64.5 % of aults reporte that SHS exposure was very harmful, 31.5 % reporte it was somewhat harmful, an 4.0 % of reporte it was not at all harmful (Table 1). The unajuste prevalence of perceiving that SHS exposure was very harmful was higher among females (72.5 %) compare to males (56.3 %); among responents with an unspecifie sexual orientation (79.2 %) compare to heterosexual/straight iniviuals (64.5 %) an LGBT iniviuals (59.5 %); an among responents with chilren living in the househol (68.2 %) compare to those without chilren living in the househol (62.0 %) (p < 0.05). The prevalence of perceiving that SHS exposure was very harmful was lower among resients of states in the Miwest (60.5 %) compare to those in other regions (South = 64.5 %; Northeast = 66.0 %; West = 67.5 %) (p < 0.05). Perception of harm from seconhan smoke exposure, by state Table 2 shows the prevalence of harm perceptions towar SHS among aults by state. The prevalence of those who perceive SHS exposure to be very harmful to health range from 73.5 % in Utah to 53.7 % in Kentucky; the prevalence of those who consiere exposure to be somewhat harmful range from 39.5 % in Kentucky to 25.3 % in Floria; an the prevalence of those who consiere exposure to be not at all harmful range from 6.8 % in Kentucky to 2.4 % in Delaware. Ajuste os of perceive harm, overall Overall, the ajuste os of perceiving SHS to be very harmful were higher among females (ajuste os ratio [AOR] = 1.6, 95 % CI = ) compare to men; among non-hispanic Blacks (AOR = 2.0, 95 % CI = ), non-hispanic Asians (AOR = 1.7, 95 % CI = ), non-hispanic American Inian/Alaska Natives (AOR = 1.5, 95 % CI = ), non-hispanic others (AOR=2.1, 95 % CI= ), an Hispanics (AOR=1.8, 95 % CI= ) compare to non- Hispanic whites; among responents with chilren living in the househol (AOR = 1.3, 95 % CI = ) compare to responents without chilren living in the househol; an responents covere by a 100 % smoke-free law (AOR = 1.1, 95 % CI = ) compare to those living in states with less coverage (Table 3). The os of perceiving SHS to be very harmful were lower among responents age (AOR = 0.8, 95 % CI = ) compare to responents years of age; those with an annual househol incomes >$20,000 compare to responents with an annual income of <$20,000; an those living in the Miwest (AOR = 0.8, 95 % CI = ) compare to those in the West. Ajuste os of perceive harm, by tobacco use status Perceptions that SHS was very harmful were highest among those who i not use tobacco (76.5 %), followe by noncombustible only users (62.1 %), combustible only users (47.9 %), an combustible an noncombustible users (40.7 %) (Table 3). By tobacco use, the os of perceiving SHS to be very harmful were lower among noncombustible only users (AOR =0.7, 95 % CI= ), combustible only users (AOR=0.3, 95 % CI= ), an combustible an noncombustible users (AOR = 0.3, 95 % CI = ) compare to those who i not use tobacco. Among combustible only users, os of perceiving SHS to be very harmful were higher among females compare to males, non-hispanic Blacks, non- Hispanic American Inian/Alaska Natives compare to non-hispanic whites, an among responents with chilren 17 years ol living in the househol compare to responents without chilren living in the househol; the os were lower among responents 45 years of age compare to those years of age, high school grauates, those with some college or an unergrauate or grauate egree compare to those with 0 12 years of eucation, an responents

6 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 5 of 13 Table 1 Percentage of U.S. aults who think breathing smoke from other people s cigarettes or tobacco proucts causes harm, by selecte characteristics National Ault Tobacco Survey (NATS) Unweighte frequency Not at all harmful to one s health Somewhat harmful Very harmful Characteristics n % (95 % CI) % (95 % CI) % (95 % CI) Overall 97, ( ) 31.5 ( ) 64.5 ( ) Sex Male 38, ( ) 38.4 ( ) 56.3 ( ) Female 59, ( ) 24.8 ( ) 72.5 ( ) Age (years) ( ) 32.4 ( ) 64.9 ( ) , ( ) 30.9 ( ) 66.0 ( ) , ( ) 33.6 ( ) 61.5 ( ) 65 25, ( ) 27.2 ( ) 67.0 ( ) Race/ethnicity White, non-hispanic 81, ( ) 35.7 ( ) 60.1 ( ) Black, non-hispanic ( ) 21.5 ( ) 75.5 ( ) Asian, non-hispanic 1645 a 21.0 ( ) 75.9 ( ) AI/AN, non-hispanic ( ) 28.4 ( ) 64.1 ( ) NH/PI, non-hispanic 399 a 28.0 ( ) 66.5 ( ) Non-Hispanic, multirace ( ) 28.4 ( ) 67.9 ( ) Non-Hispanic, other 481 a 23.0 ( ) 69.8 ( ) Hispanic ( ) 20.9 ( ) 75.3 ( ) Eucation 0 12 years (no iploma) ( ) 27.2 ( ) 67.4 ( ) GED ( ) 33.8 ( ) 60.1 ( ) High school grauate 21, ( ) 32.5 ( ) 62.6 ( ) Some college (no egree) 15, ( ) 32.5 ( ) 63.6 ( ) Associate egree 14, ( ) 31.1 ( ) 65.5 ( ) Unergrauate egree 23, ( ) 33.2 ( ) 64.6 ( ) Grauate egree 15, ( ) 30.8 ( ) 66.9 ( ) Marital status Marrie/partnere 59, ( ) 30.9 ( ) 65.4 ( ) Single/separate/ivorce or wiowe 38, ( ) 32.3 ( ) 63.3 ( ) Annual househol income <$20,000 11, ( ) 25.9 ( ) 68.1 ( ) $20,000 $49,999 31, ( ) 31.4 ( ) 64.6 ( ) $50,000 $99,999 33, ( ) 33.0 ( ) 63.1 ( ) $100,000 18, ( ) 34.2 ( ) 62.8 ( ) Unspecifie ( ) 27.8 ( ) 69.1 ( ) U.S. region Northeast 17, ( ) 30.7 ( ) 66.0 ( ) Miwest 20, ( ) 35.1 ( ) 60.5 ( ) South 38, ( ) 31.3 ( ) 64.4 ( ) West 21, ( ) 28.8 ( ) 67.5 ( )

7 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 6 of 13 Table 1 Percentage of U.S. aults who think breathing smoke from other people s cigarettes or tobacco proucts causes harm, by selecte characteristics National Ault Tobacco Survey (NATS) (Continue) Sexual orientation Heterosexual/straight 94, ( ) 31.5 ( ) 64.5 ( ) LGBT ( ) 36.9 ( ) 59.5 ( ) Unspecifie ( ) 13.9 ( ) 79.2 ( ) Chilren 17 years ol living in househol Yes 30, ( ) 28.8 ( ) 68.2 ( ) No 67, ( ) 33.4 ( ) 62.0 ( ) Tobacco use c Combustible only 13, ( ) 43.5 ( ) 47.9 ( ) Noncombustible only ( ) 32.6 ( ) 62.1 ( ) Combustible & Noncombustible ( ) 50.1 ( ) 40.7 ( ) No tobacco use 49, ( ) 21.5 ( ) 76.5 ( ) Population coverage of smoke-free laws b 100 % state laws 46, ( ) 31.1 ( ) 64.9 ( ) % state laws 15, ( ) 33.6 ( ) 62.1 ( ) 1 19 % state laws 16, ( ) 29.1 ( ) 67.2 ( ) 0 % state or local laws 17, ( ) 33.8 ( ) 62.0 ( ) Note: Bol values inicate statistical significance (p < 0.05) when compare to all other categories for the respective characteristic Abbreviations: AI/AN American Inian/Alaska Native, NH/PI Native Hawaiian/Pacific Islaner, GED Grauate Equivalency Degree, LGBT Lesbian, Gay, Bisexual, or Transgener a Estimate exclue ue to relative stanar error >30 % b Population coverage of smoke-free laws was base on the American Nonsmokers Rights Founation U.S. Tobacco Control Laws Database an represent the percent of the population covere by state an/or local comprehensive smoke-free laws as of July 1, 2010 c Combustible only use is efine as those who currently smoke cigarettes, pipes, hookah, or cigars an o not use snus or chew/snuff/ip. Noncombustible only use is efine as those who use snus or chew/snuff/ip an o not currently smoke cigarettes, pipes, hookah or cigars. Combustible an noncombustible users are those who use both combustible an noncombustible tobacco proucts with an annual househol income of $50,000 $99,000 compare to those with a househol income <$20,000. Among noncombustible only users, the os were higher among responents with chilren 17 years ol living in the househol compare to responents without chilren living in the househol an those living in a state with 100 % or % population coverage of state an/or local smoke-free laws compare to those living in states with less coverage; the os were lower among responents with an associates an grauate egree compare to those with 0 12 years of eucation, responents with an income of $50,000 $99,000 compare to those with a househol income <$20,000. Among combustible an noncombustible users, the os were lower among responents resiing in locations with 100 % smoke-free laws compare to those without any 100 % state/local smoke-free law coverage. Among those who i not use tobacco, the os were higher among females, non-hispanic Blacks, non-hispanic Asians an Hispanics, responents with chilren 17 years ol living in the househol, an those covere by 100 % smoke-free laws; the os were lower among responents with an annual househol income of $20,000 an those in the Miwest. Discussion The finings from this stuy reveal that 96 % of U.S. aults perceive SHS exposure as harmful, with nearly two-thirs (64.5 %) perceiving it to be very harmful. The prevalence of perceiving that SHS exposure was very harmful was significantly higher among females, racial/ethnic minorities, responents with chilren 17 years ol living in the househol, an those covere by 100 % smoke-free laws. Population-level perception of SHS harm ata can be an important component in unerstaning societal contexts for eveloping eucational campaigns [27]. Such efforts coul inclue public health eucational initiatives an meia campaigns, such as CDC s Tips from Former Smokers, which inclue as relate to the averse health effects of SHS exposure [34]. The present stuy expans upon a previous stuy that examine perceptions of harm from SHS exposure among youth [8]. However, in this stuy, we assesse the proportion of aults who perceive that SHS exposure

8 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 7 of 13 Table 2 Percentage of U.S. aults who think breathing smoke from other people s cigarettes or other tobacco proucts causes harm, by state National Ault Tobacco Survey (NATS) State Unweighte frequency Not at all harmful to one s health Somewhat harmful Very harmful n % (95 % CI) % (95 % CI) % (95 % CI) 100 % of population covere by a comprehensive smoke-free law a Arizona ( ) 28.2 ( ) 66.1 ( ) Colorao ( ) 35.7 ( ) 60.9 ( ) Delaware ( ) 32.0 ( ) 65.6 ( ) District of Columbia 1427 b 30.0 ( ) 67.1 ( ) Floria c ( ) 25.3 ( ) 69.1 ( ) Hawaii ( ) 29.5 ( ) 66.3 ( ) Illinois c ( ) 33.3 ( ) 62.7 ( ) Iowa ( ) 36.0 ( ) 61.2 ( ) Louisiana c ( ) 27.3 ( ) 67.9 ( ) Maine ( ) 31.4 ( ) 64.9 ( ) Marylan ( ) 34.3 ( ) 63.3 ( ) Massachusetts c ( ) 33.1 ( ) 63.2 ( ) Minnesota ( ) 38.4 ( ) 56.4 ( ) Montana ( ) 31.7 ( ) 63.1 ( ) Nebraska ( ) 37.4 ( ) 57.4 ( ) Nevaa ( ) 34.8 ( ) 59.8 ( ) New Jersey c ( ) 32.1 ( ) 64.5 ( ) New Mexico ( ) 27.6 ( ) 68.5 ( ) New York c ( ) 27.1 ( ) 70.4 ( ) Ohio c ( ) 35.3 ( ) 59.9 ( ) Oregon ( ) 33.9 ( ) 62.7 ( ) Rhoe Islan 1566 b 30.1 ( ) 65.4 ( ) Utah ( ) 23.9 ( ) 73.5 ( ) Vermont ( ) 32.0 ( ) 65.9 ( ) % of population covere by comprehensive smoke-free law Washington ( ) 33.3 ( ) 63.3 ( ) Alaska ( ) 28.5 ( ) 68.9 ( ) Iniana ( ) 35.0 ( ) 60.2 ( ) Kansas ( ) 35.2 ( ) 60.2 ( ) Kentucky ( ) 39.5 ( ) 53.7 ( ) North Dakota 1850 b 30.5 ( ) 65.6 ( ) South Carolina ( ) 31.8 ( ) 63.9 ( ) Texas c ( ) 32.7 ( ) 63.7 ( ) West Virginia ( ) 30.3 ( ) 65.1 ( ) 1 19 % of population covere by a comprehensive smoke-free laws Alabama ( ) 29.4 ( ) 66.8 ( ) Arkansas 2384 b 35.0 ( ) 56.9 ( ) California c ( ) 26.1 ( ) 70.5 ( ) Georgia c ( ) 29.0 ( ) 67.6 ( ) Mississippi ( ) 27.0 ( ) 70.1 ( )

9 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 8 of 13 Table 2 Percentage of U.S. aults who think breathing smoke from other people s cigarettes or other tobacco proucts causes harm, by state National Ault Tobacco Survey (NATS) (Continue) Missouri ( ) 38.2 ( ) 58.0 ( ) Wisconsin ( ) 35.4 ( ) 60.4 ( ) Wyoming 1452 b 37.4 ( ) 58.2 ( ) 0 % of population covere by comprehensive smoke-free law Connecticut ( ) 30.3 ( ) 66.6 ( ) Iaho ( ) 31.5 ( ) 65.2 ( ) Michigan ( ) 33.4 ( ) 61.9 ( ) New Hampshire 1638 b 32.0 ( ) 64.2 ( ) North Carolina c ( ) 36.5 ( ) 58.7 ( ) Oklahoma c ( ) 30.7 ( ) 65.4 ( ) Pennsylvania c ( ) 33.9 ( ) 62.0 ( ) South Dakota ( ) 30.4 ( ) 66.4 ( ) Tennessee ( ) 33.4 ( ) 62.0 ( ) Virginia ( ) 33.7 ( ) 62.7 ( ) National 97, ( ) 31.5 ( ) 64.5 ( ) a Population coverage of smoke-free laws was base on the American Nonsmokers Rights Founation U.S. Tobacco Control Laws Database an represent the percent of the population covere by state an/or local comprehensive smoke-free laws as of July 1, 2010 b Relative SE >30 % c Estimates calculate among both lanline an cellular telephone responents. All other state estimates were calculate among lanline responents only was very harmful. The rationale for assessing high levels of perceptions towar SHS was base on the finings of the 2006 Surgeon General s report, which conclue that there is no safe level of exposure to SHS an that the only way to fully protect the public from SHS exposure is to completely eliminate smoking in inoor public places an worksites [1]. This is the first stuy to examine perceptions of harm by subgroupings of tobacco use status. The finings reveal that nearly two-thirs of noncombustible only tobacco users perceive SHS as very harmful compare to approximately half of combustible only users an two-fifths of ual users of both combustible an noncombustible tobacco. The lower levels of perceptions among ual users may be attributable to multiple factors, incluing greater levels of tobacco epenence among these iniviuals [9], lower levels of unerstaning of the health hazars of tobacco use [11], an increase receptivity to protobacco messaging. These finings unerscore the importance of continue efforts to eucate all tobacco users about the benefits of smoke-free environments as part of a comprehensive approach to reuce tobacco use an SHS exposure, particularly among combustible tobacco users an ual users of both combustible an noncombustible tobacco. These finings also unerscore the importance of eucating smokers on the importance of quitting smoking completely as no level of exposure to SHS is risk-free. Variations in perceptions about the harms of SHS were also observe by socioemographic groups. More specifically, the perception that SHS was very harmful was higher in females, non-hispanic racial/ethnic minorities an Hispanics, an responents with chilren 17 years ol living in the househol. These finings are generally consistent with those from other stuies [8, 35 37]. Of note, estimates of harm perceptions by age iffere by current smoking status. For example, among combustible only users, the os of perceiving SHS to be very harmful were lower for those 45 years of age compare to responents years of age. These variations in perceptions by age coul be ue, in part, to varying tobacco use rates among age groups [8] or factors relate to the social isapproval of tobacco use [9, 38]. Consistent with past stuies, responents who reporte living with chilren in the househol ha higher os of perceiving that SHS was harmful [2], suggesting greater receptivity towar tobacco-relate health messages an unerstaning of the angers of SHS among iniviuals with chilren. A stuy by Tan an colleagues [7] suggeste that raising public awareness to information about the harmfulness of SHS influence public perceptions. More research into the influence of public eucation campaigns on the health effects of SHS coul further increase awareness of the harms of SHS. Variations in perceptions about the harm of SHS were also observe across states. For example, Kentucky ha the lowest prevalence of aults who believe that SHS was very harmful, while Utah, California, an New York ha the highest. The higher prevalence in these states may be attributable to lower smoking rates an/or longstaning comprehensive tobacco control programs in

10 Table 3 Percent an ajuste os ratios of U.S. aults who think breathing smoke from other people s cigarettes or other tobacco proucts was very harmful overall by tobacco use status a an selecte characteristics National Ault Tobacco Survey (NATS) % AOR % AOR % AOR % AOR Combustible only Noncombustible only Combustible & No tobacco use Overall Noncombustible (n = 5648) (n =297) (n = 441) (n = 38,074) (n = 44,460) Characteristics % AOR (95 % CI) b (95 % CI) b (95 % CI) b (95 % CI) b (95 % CI) b Overall 47.9 ( ) 0.3 ( ) 62.1 ( ) 0.7 ( ) 40.7 ( ) 0.3 ( ) 76.5 ( ) ( ) e Sex Male 45.1 ( ) ( ) ( ) ( ) ( ) 1.00 Female 50.8 ( ) 1.3 ( ) 77.3 ( ) 1.6 ( ) 42.1 ( ) 1.0 ( ) 79.2 ( ) 1.7 ( ) 72.8 ( ) 1.6 ( ) Age (years) ( ) ( ) ( ) ( ) ( ) ( ) 0.9 ( ) 59.3 ( ) 0.4 ( ) 37.9 ( ) 0.6 ( ) 78.0 ( ) 1.0 ( ) 68.8 ( ) 1.0 ( ) ( ) 0.6 ( ) 59.9 ( ) 0.6 ( ) 39.0 ( ) 0.7 ( ) 75.8 ( ) 1.0 ( ) 64.6 ( ) 0.8 ( ) ( ) 0.5 ( ) 65.1 ( ) 0.4 ( ) 55.9 ( ) 1.7 ( ) 76.0 ( ) 1.1 ( ) 70.0 ( ) 0.9 ( ) Race/ethnicity White, non-hispanic 41.8 ( ) ( ) ( ) ( ) ( ) 1.00 Black, non-hispanic 60.4 ( ) 2.1 ( ) 64.1 ( ) 1.1 ( ) 69.4 ( ) 6.3 ( ) 83.1 ( ) 1.9 ( ) 76.3 ( ) 2.0 ( ) Asian, non-hispanic 48.0 ( ) 1.2 ( ) e e 12.6 ( ) 0.2 ( ) 82.7 ( ) 1.8 ( ) 78.3 ( ) 1.7 ( ) AI/AN, non-hispanic 53.9 ( ) 1.6 ( ) 0.2 ( ) 1.33 ( ) 81.1 ( ) 1.6 ( ) 65.0 ( ) 1.5 ( ) NH/PI, non-hispanic 58.2 ( ) 1.7 ( ) e e 65.1 ( ) 2.9 ( ) 76.2 ( ) 1.1 ( ) 70.4 ( ) 1.4 ( ) Non-Hispanic, multirace 47.5 ( ) 1.1 ( ) 0.6 ( ) 2.9 ( ) 80.4 ( ) 1.5 ( ) 66.5 ( ) 1.3 ( ) Non-Hispanic, other 57.9 ( ) 1.7 ( ) 96.5 ( ) 50.9 ( ) 78.5 ( ) 8.2 ( ) 86.7 ( ) 2.3 ( ) 74.8 ( ) 2.1 ( ) Hispanic 63.8 ( ) 1.9 ( ) 86.3 ( ) 7.8 ( ) 96.7 ( ) 3.3 ( ) 82.7 ( ) 1.8 ( ) 77.3 ( ) 1.8 ( ) Eucation 0 12 years (no iploma) 56.5 ( ) ( ) ( ) ( ) ( ) 1.00 GED 50.4 ( ) 0.8 ( ) 0.6 ( ) 49.3 ( ) 1.8 ( ) 73.7 ( ) 0.8 ( ) 59.2 ( ) 0.9 ( ) High school grauate 44.7 ( ) 0.7 ( ) 68.3 ( ) 0.7 ( ) 36.9 ( ) 0.9 ( ) 75.3 ( ) 1.0 ( ) 64.7 ( ) 0.9 ( ) Some college (no egree) 45.3 ( ) 0.7 ( ) 48.3 ( ) 0.4 ( ) 41.9 ( ) 1.1 ( ) 75.7 ( ) 1.0 ( ) 66.0 ( ) 0.9 ( ) Associate egree 49.3 ( ) 0.9 ( ) 39.7 ( ) 0.1 ( ) 34.4 ( ) 1.0 ( ) 79.1 ( ) 1.3 ( ) 69.5 ( ) 1.0 ( ) Unergrauate egree 41.0 ( ) 0.7 ( ) 58.6 ( ) 0.5 ( ) 40.7 ( ) 1.4 ( ) 75.7 ( ) 1.1 ( ) 68.9 ( ) 0.9 ( ) Grauate egree 40.4 ( ) 0.7 ( ) 0.1 ( ) 1.0 ( ) 76.6 ( ) 1.1 ( ) 71.6 ( ) 1.0 ( ) Marital status Marrie/partnere 48.4 ( ) 1.1 ( ) 95.4 ( ) 2.0 ( ) 41.2 ( ) 1.0 ( ) 76.7 ( ) 1.1 ( ) 68.6 ( ) 1.1 ( ) Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 9 of 13

11 Table 3 Percent an ajuste os ratios of U.S. aults who think breathing smoke from other people s cigarettes or other tobacco proucts was very harmful overall by tobacco use status a an selecte characteristics National Ault Tobacco Survey (NATS) (Continue) Single/separate/ ivorce or 47.4 ( ) ( ) ( ) ( ) ( ) 1.00 wiowe Annual househol income <$20, ( ) ( ) ( ) ( ) ( ) 1.00 $20,000 $49, ( ) 0.8 ( ) 60.1 ( ) 0.5 ( ) 37.4 ( ) 1.0 ( ) 76.4 ( ) 0.8 ( ) 66.2 ( ) 0.8 ( ) $50,000 $99, ( ) 0.7 ( ) 62.1 ( ) 0.3 ( ) 47.7 ( ) 1.8 ( ) 75.7 ( ) 0.8 ( ) ) 0.8 ( ) $100, ( ) 0.8 ( ) 77.5 ( ) 0.3 ( ) 30.9 ( ) 0.7 ( ) 74.8 ( ) 0.8 ( ) 67.4 ( ) 0.9 ( ) Unspecifie 58.2 ( ) 1.1 ( ) 0.2 ( ) 60.6 ( ) 2.6 ( ) 75.3 ( ) 0.8 ( ) 70.8 ( ) 0.9 ( ) U.S. region inicator Northeast 49.2 ( ) 1.1 ( ) 68.6 ( ) 3.2 ( ) 45.1 ( ) 1.0 ( ) 76.2 ( ) 0.9 ( ) 68.4 ( ) 1.0 ( ) Miwest ) 0.8 ( ) 56.1 ( ) 1.1 ( ) 32.6 ( ) 0.6 ( ) 73.3 ( ) 0.8 ( ) 63.1 ( ) 0.8 ( ) South ) 1.0 ( ) 64.8 ( ) 2.2 ( ) 42.0 ( ) 0.7 ( ) 76.9 ( ) 1.0 ( ) 67.2 ( ) 1.0 ( ) West ) ( ) ( ) ( ) ( ) 1.00 Sexual orientation Heterosexual/straight ) ( ) ( ) ( ) ( ) 1.00 LGBT 47.3 ( ) 0.9 ( ) 80.4 ( ) 1.5 ( ) 0.2 ( ) ) 1.0 ( ) 60.7 ( ) 0.9 ( ) Unspecifie 63.7 ( ) 1.5 ( ) 0.0 ( ) 81.9 ( ) 8.1 ( ) 83.3 ( ) 1.3 ( ) 80.2 ( ) 1.3 ( ) Chilren 17 years ol living in househol Yes 56.7 ( ) 1.4 ( ) 66.1 ( ) 2.0 ( ) 42.8 ( ) 1.4 ( ) 79.1 ( ) 1.2 ( ) 71.5 ( ) 1.3 ( ) No 41.4 ( ) ( ) ( ) ( ) ( ) 1.00 Population coverage of smoke-free laws c 100 % state laws 48.7 ( ) 1.2 ( ) 65.3 ( ) 2.9 ( ) 37.3 ( ) 0.5 ( ) 77.0 ( ) 1.2 ( ) 68.1 ( ) 1.1 ( ) % state laws 48.4 ( ) 1.1 ( ) 69.3 ( ) 3.2 ( ) 39.0 ( ) 0.6 ( ) 78.5 ( ) 1.2 ( ) 69.2 ( ) 1.1 ( ) 1 19 % state laws 47.5 ( ) 1.1 ( ) 51.8 ( ) 1.3 ( ) 40.2 ( ) 0.7 ( ) 75.0 ( ) 1.0 ( ) 65.4 ( ) 1.0 ( ) 0 % state or local laws 45.2 ( ) ( ) ( ) ( ) ( ) 1.00 Abbreviation: AOR ajuste os ratio, CI confience interval, AI/AN American Inian/Alaska Native, NH/PI Native Hawaiian/Pacific Islaner, GED Grauate Equivalency Degree, LGBT Lesbian, Gay, Bisexual, or Transgener a Combustible only was efine as those who reporte smoking at least 100 cigarettes uring their lifetime an who currently smoke cigarettes, an/or use cigars/cigarillos/little cigars, pipes, water pipe/hookah, an o not use chewing tobacco/snuff/ip or snus. Noncombustible only was efine as those who reporte using chewing tobacco/snuff/ip or snus on 1 ay uring the past 30 ays an o not currently smoke cigarettes, an/or use cigars/cigarillos/little cigars, pipes, water pipe/hookah. Combustible an noncombustible users are those who use both combustible an noncombustible tobacco proucts. No tobacco users are those who o not currently use any combustible or noncombustible proucts b Ajuste os ratios were compute using a binary logistic regression moel ajuste for all covariates liste in the table; aitionally, tobacco use was inclue in the overall moel. Statistically significant os ratios are note in bol. For tobacco use status in the overall moel, the overall prevalence an ajuste OR for combustible only users was 47.9 ( ) AOR = 0.3 ( ); noncombustible only users was 62.1 ( ), AOR = 0.7 ( ); combustible an noncombustible users was 40.7 ( ), AOR = 0.3 ( ); an no tobacco users was 76.5 ( ), AOR = 1.00 (referent) c Population coverage of smoke-free laws was base on the ANRF s U.S. Tobacco Control Laws Database an represents the percent of the population covere by state an/or local comprehensive smoke-free laws as of July 1, 2010 Relative SE >30 % e Point estimate was 100 % an ajuste os ratio coul not be calculate ue to zero cell count in nontobacco users Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 10 of 13

12 Kruger et al. Tobacco Inuce Diseases (2016) 14:3 Page 11 of 13 these states [3, 39]. Conversely, the relatively lower coverage in some states coul be attributable to higher smoking rates or varying norms relate to the social acceptability of tobacco use [40, 41]. Improving public awareness about the harms of SHS coul help inform pathways to smoke-free policy implementation. The implementation of such policies coul also further enhance public knowlege of the angers of SHS an favorable attitues towars smoke-free environments. The aoption of smoke-free policies have been shown to increase public favorability towar smoke-free environments in public an private settings [15, 42 45]. For example, Tang an colleagues foun favorability towar smokefree bar law implantation among bar patrons an bar owners an staff [46]. Similarly, Fong an colleagues ocumente increase support for smoke-free environments following Irelan s implementation of comprehensive smoke-free legislation [15]. In the U.S., Cheng an colleagues ocumente positive associations between comprehensive smoke-free law aoption an voluntary smoke-free home rules [43]. Thus, opportunities exist for leveraging public attitues towar SHS to promote smoke-free environments in states not protecte by statewie comprehensive smoke-free policies. Variations in harm perception were also observe by comprehensive smoke-free law coverage. A significant association was observe between perceptions about the harm of SHS exposure an population level coverage of state an/or local smoke-free laws, overall an by noncombustible only users, combustible an noncombustible users, an no tobacco users. In general, given that perceptions about the harm of SHS exposure were higher among responents covere by a 100 % smokefree law compare to those not covere by such a law, it is possible this result coul be attributable to the changing social norms relate to the social acceptability of tobacco use an the increase prevalence of smoke-free environments [47]. These finings unerscore the importance of efforts to further increase public awareness of the health effects of SHS through eucation campaigns, which can contribute to changes in social norms regaring the acceptability of smoking aroun others. The major strength of this stuy is that it utilize a large, nationally representative atabase an assesse factors associate with perceptions of harm across tobacco use categories an levels of smoke-free law coverage. However, the stuy is subject to at least eight limitations. First, these ata are self-reporte an may be subject to recall bias. Secon, these ata are crosssectional an, thus, it was not possible to assess causal relationships between harm perceptions an smoke-free law aoption. Thir, the overall NATS response rate was 37.6 % an state response rates range from 28.2 to 49.3 %; low response rates increase the potential for bias. Fourth, in orer to prevent large variances in survey estimates an small sample sizes, cellular telephone responents were exclue from estimates for states that ha fewer than 200 cellular telephone responents. However, we inclue cellular telephone responents in all national estimates an in estimates for the 12 states that ha a sufficient sample size. Given that cellular phone only users are more likely to be current cigarette smokers, the omission of cellular phone only users coul lea to overestimation of perceive harm from SHS for the remaining 38 states [48]. Fifth, the operational efinition of perceive harm use in this stuy i not fully align with measures use elsewhere in the literature [49]. Moreover, the employe question aske about responents beliefs about breathing smoke from other people s cigarettes or from other tobacco proucts, an thus, it is not possible to etermine if perception from cigarette smoke may have iffere from other tobacco proucts. Sixth, these ata are from 2009 to 2010, an thus, may not reflect more recent harm perceptions towar SHS. However, although some progress has been mae in reucing seconhan smoke exposure since that perio at the state an local levels, it is not expecte that population-level perceptions woul change consierably over this five year perio. Seventh, it is possible that perceptions of harm from SHS were unerestimate in states with a statewie smoke-free policy that was not classifie as 100 % smoke-free ue to certain exemptions, but which still protect a large proportion of the state s population from SHS exposure; for example California has an exemption for enclose public places an places of employment, an therefore is not categorize as have a comprehensive law. However, a supplementary analysis that treate California as having 100 % coverage i not significantly impact the currently presente estimates. Finally, it was not possible to assess perceptions of harm by frequency of tobacco prouct use given the manner in which current use was assesse for most proucts in the survey; future research is critical to further explore potential associations between harm perceptions an frequency of use of all forms of tobacco use by U.S. aults. Conclusion This is the first stuy to assess levels of perceive harm from SHS exposure by tobacco use status an comprehensive smoke-free law coverage among a nationally representative sample of U.S. aults. The finings reveal that nearly two-thirs of all U.S. aults perceive SHS exposure to be very harmful. Efforts to increase awareness about the harms of SHS exposure an the benefits of smoke-free environments may help inform efforts to protect all Americans from SHS exposure, particularly tobacco users. Variability in perceptions about the harm