The Impact of Wisconsin s Statewide Smoke-Free Law on Bartender Health and Attitudes

Transcription

1 Center for Urban Initiatives and Research The Impact of Wisconsin s Statewide Smoke-Free Law on Bartender Health and Attitudes Karen A. Palmersheim, PhD, MS a Kyle P. Pfister, B.S. b Randall L. Glysch, M.S. c Abstract Introduction: This report presents the findings from a longitudinal study of bartenders in Wisconsin, designed to assess change in their health and attitudes after the implementation of a statewide smoke-free workplace law in July Methods: Surveys conducted before and after the law was implemented collected information on the number of hours exposed to secondhand smoke, prevalence of upper respiratory tract symptoms, attitudes towards smoking in bars and restaurants, and perceptions of risk related to secondhand smoke exposure. Information on bartender cigarette smoking was also collected. Results: Exposure to secondhand smoke during an average week decreased from 17.0 hours to 1.7 hours in the workplace and from 6.5 hours to 2.2 hours in other places. Among non-smokers, the prevalence of all eight upper respiratory symptoms decreased significantly (wheezing or whistling in chest, shortness of breath, cough first thing in the morning, cough during the rest of the day and night, cough up any phlegm, red or irritated eyes, runny nose, nose irritation, or sneezing, and sore or scratchy throat). Support for not allowing smoking in bars that are also restaurants increased significantly among all bartenders. Support for smoke-free bars/taverns did not change significantly for the overall sample. However, a statistically significant increase in support for smoke-free bars/taverns was noted for bartenders that were current smokers. Perceived level of health risk associated with exposure to secondhand smoke increased among the sample as a whole, and among non-smokers and bartenders working in rural counties. a Dr. Palmersheim is an epidemiologist and researcher with the Center for Urban Initiatives and Research at the University of Wisconsin-Milwaukee. At the time this study was conducted, she was a researcher with the University of Wisconsin Carbone Cancer Center, Tobacco Surveillance and Evaluation Program. b Mr. Pfister is a policy coordinator with the Wisconsin Tobacco Prevention and Control Program at the Bureau of Community Health Promotion, WI Division of Public Health. c Mr. Glysch is a research scientist with the Wisconsin Tobacco Prevention and Control Program at the Bureau of Community Health Promotion, WI Division of Public Health. 1

2 Conclusion: This study demonstrates a significant reduction in upper respiratory symptoms among non-smoking bartenders following the establishment of a smoke-free workplace law in the state of Wisconsin. These results suggest that this policy will help reduce the future risk of disease related to secondhand smoke among employees and patrons of bars and restaurants throughout the state. Introduction Secondhand smoke (SHS) is classified as carcinogenic to humans. 1 Exposure is associated with an increased risk for lung cancer and coronary heart disease in non-smoking adults. 1,2,3,4 Common upper respiratory symptoms of secondhand smoke exposure include chronic coughing, phlegm, wheezing, chest discomfort, eye and nose irritation. 4,5 Young children exposed to secondhand smoke are at increased risk of sudden infant death syndrome (SIDS), asthma, bronchitis, and pneumonia. 3,4,6 Accordingly, SHS has been recognized as a health hazard by all U.S. occupational, health and environmental regulatory authorities. 1,4,6,7,8 Of all occupations, non-smoking adults employed in the hospitality industry have the highest levels of SHS exposure, as measured by mean serum cotinine levels. 9 A long duration of exposure puts hospitality workers at increased risk for developing conditions associated with SHS. Further, bartenders often encounter significantly higher levels of SHS than restaurant wait staff. 10 Thus, they have the most to benefit from smoke-free workplace protections. At the time of this study, a total of 29 states, along with Puerto Rico and Washington DC, had passed laws that require restaurants and bars to be 100% smoke-free. 11 In addition, a number of countries had passed smoke-free laws. Accordingly, a fair amount of interest in studying health improvements among restaurant and bar staff relative to the implementation of smoke-free laws followed. For example, a 2007 study of the effects of two municipal level smoke-free ordinances indicated that significantly fewer bartenders reported having upper respiratory symptoms one year after the establishment of the policies in two Wisconsin cities. 12 Similar results have been observed following the implementation of smoke-free laws in California, 5 Norway, 13 Spain, 14 and Scotland. 15 Some studies have revealed drops in cotinine concentrations among bar staff following the establishment of smoke-free laws, including in Ireland, 16 and Minnesota. 17 A dose response relationship has been shown between SHS exposure, as measured by cotinine, and county smoke-free laws. 18 A 2006 study of the Spanish smoke-free law further distinguished between the protection of full and partial smoke-free laws by observing significantly smaller decreases in cotinine levels among bar staff still exposed to designated smoking areas. 14 Prior to implementation of the Smoke-Free Wisconsin Act on July 5, 2010, approximately 500,000 of Wisconsin s 2.7 million workers were regularly exposed to secondhand smoke during their workday. 19 Of those, 250,000 were employed in hospitality establishments where the public was also exposed. 20 Every year in Wisconsin, SHS is estimated to cause approximately 57 lung cancer deaths, 674 deaths from ischemic heart disease, and 7 infant deaths from sudden infant death syndrome (SIDS). 21 2

3 Improvement in Wisconsin workers health was cited as rationale for the statewide smoke-free workplace law, but has this improvement been realized? The purpose of this study is to assess change in the health and attitudes of Wisconsin bartenders upon decreased workplace exposure to SHS following the statewide smoke-free workplace law. Methods The University of Wisconsin Tobacco Surveillance and Evaluation Program contracted the University of Wisconsin Survey Research Shared Service to administer the baseline and followup surveys, and conduct data entry. Baseline data were collected during the 2 months prior to the law, which went into effect July 5, The follow-up survey was conducted 3-6 months after the establishment of the law. Study Population: The sampling frame for the baseline survey included all individuals licensed to sell alcoholic beverages in one large urban city and 10 randomly selected small to mid-sized cities located in rural counties. Milwaukee was selected for the urban population. Based on previous experience, 12 it was determined that 10 cities, each with a general population ranging between 7,000 and 15,000, would be required to obtain an adequate sample size to represent the more rural areas. In effort to be representative of the overall state, two cities were randomly selected from each of the state s five geographic regions. The cities selected for inclusion were: Antigo, Fort Atkinson, Lake Geneva, Menomonie, Monroe, Platteville, Rhinelander, Sturgeon Bay, Tomah, and Two Rivers. In the final stage of sample selection, a random sample of 3,000 licensees was selected from more than 8,000 licensees in Milwaukee, and all 2,222 licensees were selected from the 10 smaller cities. It is difficult to calculate a response rate for this population because not all persons licensed to sell alcoholic beverages are working as bartenders. Some licensed individuals may be working in liquor stores, gas stations/convenience stores, or liquor departments in grocery stores. Of the 5,222 persons that were sent a baseline survey, 355 were unreachable due to bad addresses, had moved to non-qualifying locations, or were deceased. 2,446 individuals returned the survey, and of these, 1,197 persons indicated they were working as bartenders. The sampling frame for the follow-up survey included all individuals that participated in the baseline survey who were working as bartenders in the selected cities (N=1,197). At the time of follow-up, 34 of these persons were unreachable, had moved away, or were deceased; 857 of them returned a survey. Using the number of licensees with valid addresses as a denominator, the final overall adjusted response rate for the follow-up survey was 74%. Of the 857 returned surveys, 730 respondents indicated they were still working as bartenders at follow-up. Data Collection: Information was collected using a 4-page, self-administered mail questionnaire that assessed the number of hours exposed to secondhand smoke while at home, at work, and in other places, the prevalence of eight upper respiratory tract symptoms, attitudes towards smoking in bars and restaurants, and perceptions of the health risk associated with secondhand smoke exposure. Information on past and current use of cigarettes was also assessed. 3

4 Analytical Samples: In order to be included in the current analysis, subjects had to be licensed to sell alcoholic beverages by one or more of the selected cities for study, and working as a bartender, during both baseline and follow-up. In addition, they had to be working in an establishment that allowed smoking during the baseline survey, and that was smoke-free during the follow-up phase. Further, bartender smoking status needed to be known in order to control for this factor in analyses. There were 531 participants meeting these criteria. Paired t-tests were employed to compare baseline scores to follow-up scores on measures of upper respiratory symptoms, attitudes towards smoking in bars, and level of perceived risk associated with exposure to secondhand smoke. Data analyses were conducted using SPSS, version Results Sample characteristics of bartenders who participated in both the baseline and follow-up studies are presented in Table 1. The final sample ranged from 19 to 84 years of age (mean = 43, median = 42), was 57% female, 91 % White, 8% Black, and 6% Hispanic. About 3% of the participants had less than a high school education, 27% had a high school diploma or GED, 34% had completed some college while 11% had an associate s degree, 19% had a bachelor s degree, and 6% had obtained a professional or graduate level of education. The number of months working at the current bar ranged from 1 to 516 (mean = 87, median = 60), and bartenders reported working from 1 to 60 hours per week (mean = 21, median = 20). At follow-up, 42% of the sample were current smokers, with level of consumption ranging from less than 1 to 50 cigarettes per day (mean = 13, median = 10). Table 2 displays the ranges and mean estimates of exposure to secondhand smoke in the home, at work, and other places, during baseline and at follow-up. Exposure was self-reported as the number of hours exposed during the past 7 days. Outliers were truncated at the sample 99 th percentile (those subjects that reported an extra-ordinarily high number of hours were assigned the value at which 99% of the sample fell at or below). Exposure to secondhand smoke in the home ranged from 0 to 30 hours at both baseline and follow-up. Mean exposure was 2.9 hours at baseline and 2.6 hours at follow-up. Exposure to secondhand smoke at work ranged from 0 to 41 hours at baseline, and from 0 to 41 hours at follow-up. Mean exposure at work decreased from 17.0 hours at baseline to 1.7 hours during follow-up. Exposure to smoke in other places ranged from 0 to 25 during both time periods. Similar to workplace exposure, mean exposure in other places decreased from 6.5 hours at baseline to 2.2 hours during the follow-up phase. The last column displays the p-value for the t-test analyses. The observed decrease in exposure was statistically significant at both work and in other places. Respondents were also asked to report how often they experienced a number of upper respiratory symptoms over the past 4 weeks. Data were dichotomized (collapsed into yes/no categories) for the current analyses. In order to control for the effects of smoking status, the sample was stratified by bartender smoking status at follow-up. Table 3 presents the findings for those participants who reported being non-smokers. A statistically significant decrease was observed for all eight upper respiratory symptoms. For example, an absolute percent change of 9% was revealed for wheezing or whistling in chest (37% to 28%; p=.003). Cough first thing in the 4

5 morning decreased from 54% to 38% (absolute change = -16%; p=.000). For red or irritated eyes, an absolute percent change of 28% was noted (77% to 49%; p=.000). Table 4 presents the prevalence of upper respiratory symptoms at baseline and follow-up for those participants who reported being current smokers. Fewer bartenders experienced five of the eight symptoms at follow-up, compared to baseline. This decrease was statistically significant for one symptom, red or irritated eyes. Forty-nine percent of the participants reported experiencing this symptom at baseline compared to 39% at follow-up (p=.005). Respondents were asked whether they thought smoking should be allowed in bars that are also restaurants (restaurant/bars), and in bars that are not restaurants (bars/taverns). Overall, there was a statistically significant increase in support for smoke-free restaurant/bars from baseline to follow-up (64% to 72%; p=.000) (see Table 5). The sample was further stratified by smoking status in analyzing these data. Non-smokers were generally more supportive of smoke-free restaurant/bars at both baseline and follow-up. However, a significant increase in support was observed among smokers, but not among non-smokers (46% to 60%; p=.000 vs. 77% to 81%; p=.059, respectively). To investigate potential urban versus rural differences in attitudes, the sample was stratified accordingly. Rural bartenders were slightly more likely to express support for smoke-free restaurant/bars compared to urban bartenders. However, among both groups, support significantly increased from baseline to follow-up (67% to 73%; p=.023, and 63% to 71%; p=.000, respectively). A parallel question examined whether participants thought smoking should be allowed in bars that are not restaurants (bars/taverns). Table 6 displays the percentage of bartenders that felt smoking should not be allowed in bars/taverns at baseline and follow-up, respectively. Overall, there was a slight increase in support for smoke-free bars/taverns from baseline to follow-up, though this change was not statistically significant (38% to 40%; p=.393). While non-smokers were considerably more supportive of smoke-free bars/taverns than smokers, a very slight nonsignificant decrease in support was observed among this group (58% to 57%; p=.648). A statistically significant increase in support for smoke-free bars/taverns was observed among smokers (12% to 16%; p=.041). Support for smoke-free bars/taverns among bartenders from the urban area did not change appreciably from baseline to follow-up (40% to 39%; p=.613). Support among rural bartenders increased from 37% at baseline to 41% at follow-up, though the change was not statistically significant (p=.077). Finally, respondents indicated on a scale from 1 to 5, how great of a health risk they think secondhand smoke presents, with 1 representing no risk at all and 5 indicating extremely serious risk (Table 7). Overall, bartenders perceptions of the health risk associated with exposure to secondhand smoke increased from 3.37 at baseline to 3.44 at follow-up (p=.049). Non-smokers were more likely to think secondhand smoke is harmful than smokers at both baseline and follow-up, and the scores for this group increased significantly (3.76 to 3.87; p=.008). Smokers perception of risk did not change appreciably from baseline to follow-up (2.84 to 2.85; p=.878). Urban bartenders perceived risk was greater than that of rural bartenders at baseline. However, their perception did not change from pre- to post-law (3.42 and 3.43, respectively). In contrast, the perception of risk associated with secondhand smoke exposure 5

6 increased significantly among bartenders from rural counties from baseline to follow-up (3.29 to 3.45; p=.006). Discussion This study demonstrates that establishment of a statewide smoke-free law was associated with a significant reduction in workplace secondhand smoke exposure among bartenders in Wisconsin. The new smoke-free law was also associated with significant reductions in exposure in other places. This suggests that when bartenders are not at work, they may be spending some of their time in establishments that have also become smoke-free. In addition, analyses suggest that the reduced level of exposure to secondhand smoke corresponded with a reduction in the prevalence of upper respiratory symptoms among these workers after the implementation of the smoke-free law. In particular, among non-smokers, the prevalence of eight upper respiratory symptoms was significantly lower after the establishment of the smoke-free law compared to that observed prior to the law. Though the change in symptoms was not as great among smokers, even this group reported a significant reduction in the prevalence of one of the eight symptoms. These findings are similar to those reported by Palmersheim et al. 12 in a previous study of bartenders in two Wisconsin cities, as well as studies conducted in other U.S. cities and countries. The current study also revealed a majority of bartenders support smoke-free restaurant/bars, and their support increased significantly from baseline to follow-up, 64% to 72%. Further, increases in this attitude were seen among bartenders who were smokers (46% to 60%), as well as those who were non-smokers (77% to 81%). In terms of geographic location, support for smoke-free restaurant/bars increased among both urban bartenders (63% to 71%) and rural bartenders (67% to 73%). Though support for smoke-free bar/taverns increased slightly for the overall sample, the change was not significant. Interestingly, this attitude did significantly increase among bartenders who were smokers. In addition, bartenders from rural areas of the state reported somewhat stronger support for smoke-free bar/taverns than their urban counterparts after the smoke-free law was implemented. Perceptions of the health risk associated with exposure to secondhand smoke increased from baseline to follow-up for the overall sample of bartenders, and this change was also significant for non-smokers and rural bartenders when analyzed as individual groups. As found at baseline and follow-up, non-smokers perceived it as a greater risk than smokers. While urban bartenders perceived secondhand smoke as a greater health risk than rural bartenders prior to the establishment of the law, the two groups had similar perceptions of the level of associated risk after the law was established. Limitations 6

7 It is difficult to know how potential differences between this sample and the entire population of bartenders in Wisconsin may limit the generalizability of these findings. In addition, the current analytical approach did not control for sociodemographic factors, or other factors that may affect upper respiratory symptoms (i.e., asthma or chronic obstructive pulmonary disease). Analyses revealed that 14% of the bartenders reported having asthma and 7% reported having chronic obstructive pulmonary disease. More sophisticated analytical approaches can control for these factors. The study did not control for the prevalence of allergies in the sample. Approximately 36% of the bartenders reported having allergies. Though, specifics regarding type and timing of allergies were not assessed in the current survey. Further, it is likely that some of the individuals in the study may have allergies, but do not know it. Findings based on data from the third National Health and Nutrition Examination Survey showed that 54.3% of individuals aged 6-59 years old had a positive skin test response to at least one of the 10 allergens tested. 22 Given the high prevalence of allergies in the general population, it is likely that a comparable prevalence would be randomly distributed throughout the study population. An additional limitation to the present study is the use of a self-administered questionnaire. A number of studies demonstrate a modest correlation between self-reported levels of secondhand smoke exposure and biomarkers (i.e., serum cotinine). 23,24,25 However, it is difficult to exclude potential misclassification of exposure. Bartenders experiencing respiratory symptoms may be more likely to report secondhand smoke exposure, whereas those without symptoms may underreport exposure. There may be differential reporting depending upon whether the bartender agrees with the establishment of the smoke-free law. Conclusions This study demonstrates a significant reduction in upper respiratory symptoms among nonsmoking bartenders following the establishment of a smoke-free workplace law a result associated with a significant reduction in exposure to secondhand smoke. These findings suggest that this law is reducing the future risk of diseases associated with secondhand smoke exposure among employees of bars and restaurants throughout Wisconsin. Moreover, these health benefits will also be realized by the patrons of bars and restaurants throughout the state. Acknowledgements The authors of this report would like to thank Dr. Nathan R. Jones for his support and oversight as principal investigator of the University of Wisconsin Tobacco Surveillance and Evaluation Program grant, under which this study was conducted. Dr. Jones is also director of the University of Wisconsin Survey Research Shared Service, which administered the survey. This study was supported by the Wisconsin Department of Health Services, Division of Public Health, Bureau of Community Health Promotion, Wisconsin Tobacco Prevention and Control Program. Support for the University of Wisconsin Tobacco Surveillance and Evaluation Program was also 7

8 provided by the University of Wisconsin Carbone Cancer Center (core grant P30 CA ). 8

9 References 1. U.S. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: U.S. Environmental Protection Agency; Pub. No. EPA/600/6-90/006F. 2. National Toxicology Program. 10th Report on Carcinogens. Research Triangle Park, NC: U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program; December, National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke. Smoking and Tobacco Control Monograph No. 10. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; NIH Pub. No U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; Eisner MD, Smith AK, Blanc PD. Bartenders respiratory health after establishment of smoke-free bars and taverns. JAMA. 1998; 280: U.S. Department of Health and Human Services. The Health Consequences of Involuntary Smoking. A Report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking; DHHS Publication No. (CDC) National Institute for Occupational Safety and Health [NIOSH]. Current Intelligence Bulletin 54. Environmental Tobacco Smoke in the Workplace Lung Cancer and Other Health Effects. Cincinnati, OH: U.S. Department of Health and Human Services, NIOSH; NIOSH Pub. No Occupational and Safety Health Administration, U.S. Department of Labor. Indoor Air Quality. 29 CFR Parts 1910, 1915, 1926, Federal Register Vol. 59, No. 65. April 5, Wortley PM, Caraballo RS, Pederson LL, Pechacek TF. Exposure to secondhand smoke in the workplace: serum cotinine by occupation. Journal of Occupational & Environmental Medicine. 2002; 44(6): Jenkins RA, Counts RW. Occupational exposure to environmental tobacco smoke: results of two personal exposure studies. Environmental Health Perspectives. 1999: 107(2):

10 11. American Nonsmokers Rights Foundation. Chronological Table of U.S. Population Protected by 100% Smokefree State or Local Laws; January 2, Available at Palmersheim KA, Remington PL, Wegner MV. The Impact of a Smoke-free Ordinance on the Health and Attitudes of Bartenders, One Year Later. Madison, Wisconsin: University of Wisconsin Paul P. Carbone Comprehensive Center, Tobacco Surveillance and Evaluation Program; March, Available at Eagan TML, Hetland J, Aaro LE. Decline in respiratory symptoms in service workers five months after a public smoking ban. Tobacco Control. 2006;15: Fernendez E, Fu M, Pascual JA, Lopez MJ, Perez-Rios M, et al. Impact of the Spanish smoking law on exposure to second-hand smoke and respiratory health in hospitality workers: a cohort study. PLoS ONE 4(1): e4244. doi: /journal.pone Menzies D, Nair A,Williamson PA, et al. Respiratory symptoms, pulmonary function, and markers of inflammation among bar workers before and after a legislative ban on smoking in public places. JAMA. 2006;296(14): Allwright S, Paul G, Greiner B, Mullally BJ, Pursell L, et al. Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study. BMJ, doi: /bmj (published 17 October 2005). 17. Jensen JA, Schillo BA, Moilanen MM, Lindgren BR, Murphy S, et al. Tobacco smoke exposure in nonsmoking hospitality workers before and after a state smoking ban; Cancer Epidemiology, Biomarkers & Prevention. 2010;19(4): Pickett MS, Schober SE, Brody DJ, Curtin LR, Giovino GA. Smokefree laws and secondhand smoke exposure in U.S. non-smoking adults, Tobacco Control. 2006;15: Hinterthuer CR, Palmersheim KA, Anderson KG, Glysch RL, Remington PL. Smoking Allowed - Trends in Policies that Allow Smoking in the Workplace: Wisconsin and the United States. Madison, Wisconsin: University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Tobacco Surveillance and Evaluation Program; Available at Renfro-Sargent M, Riemer A, Christiansen A. Results of 2002 Wisconsin Restaurant and Bar Smoking Policy Survey. Madison, Wisconsin: University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Tobacco Surveillance and Evaluation Program; Available at Voskuil KR, Palmersheim KA, Glysch RL, Jones NR. Burden of Tobacco in Wisconsin: 2010 Edition. Madison, Wisconsin: University of Wisconsin Carbone Cancer Center; Available at 10

11 22. Arbes SJ Jr, Gergen PJ, Elliott L, Zeldin DC. Prevalences of positive skin test responses to 10 common allergens in the U.S. population: Results from the Third National Health and Nutrition Examination Survey. Journal of Allergy and Clinical Immunology. 2005; 116: Pirkle JL, Flegal KM, Bernert JT, et al. Exposure of the U.S. population to environmental tobacco smoke. JAMA. 1996; 275: Emmons KM, Abrams DB, Marshall R, et al. An evaluation of the relationship between selfreport and biochemical measures of environmental tobacco smoke exposure. Preventive Medicine. 1994; 23: Delfino RJ, Ernst P, Jaakkola MS, et al. Questionnaire assessments of recent exposure to environmental tobacco smoke in relation to salivary cotinine. European Respiratory Journal. 1993; 6:

12 Table 1. Characteristics of Sample at Follow-Up (N=531) Age (years) Range Mean 43 Median 42 Gender (%) Female 57 Race/Ethnicity (%) White 91 Black 8 Other 2 Hispanic 6 Education (%) Less than high school 3 High school diploma/ GED 27 Some college (no degree yet) 34 Associate s degree 11 Bachelor s degree 19 Graduate or professional degree 6 Months work as a bartender (#) Range Mean 156 Median 120 Months bartending at current bar (#) Range Mean 87 Median 60 Hours work at current bar (# per week) Range 1-60 Mean 21 Median 20 Smoking Status Current smoker (%) 42 Cigarettes smoked per day (#) Range <1-50 Mean 13 Median 10 12

13 Table 2. Level of Exposure to Secondhand Smoke at Home, Work, and Other Places at Baseline and Follow-up, and Results of Paired T-Test Analyses* (All; N=531) Place of Exposure Home Work Baseline (# of hours/past 7 days) Follow-up (# of hours/past 7 days) Range p-value Mean Range Mean Other Places Range Mean * 2-tailed test 13

14 Table 3. Percent Reporting Upper Respiratory Symptoms at Baseline and Follow-up, and Results of Paired T-Test Analyses* (Non-Smokers; N=307) Percent Reporting Symptom Paired t-tests Upper Respiratory Symptoms (past 4 weeks) Baseline Follow-up p-value Wheezing or whistling in chest 37% 28%.003 Shortness of breath 46% 30%.000 Cough first thing in the morning 54% 38%.000 Cough during the rest of the day/night 52% 38%.000 Cough up any phlegm 52% 40%.000 Red or irritated eyes 77% 49%.000 Runny nose/irritation, sneezing 75% 60%.000 Sore or scratchy throat 63% 45%.000 * 2-tailed test 14

15 Table 4. Percent Reporting Upper Respiratory Symptoms at Baseline and Follow-up, and Results of Paired T-Test Analyses* (Smokers; N=224) Percent Reporting Symptom Paired t-tests Upper Respiratory Symptoms (past 4 weeks) Baseline Follow-up p-value Wheezing or whistling in chest 40% 41%.786 Shortness of breath 47% 49%.476 Cough first thing in the morning 61% 58%.197 Cough during the rest of the day/night 59% 58%.485 Cough up any phlegm 53% 55%.669 Red or irritated eyes 49% 39%.005 Runny nose/irritation, sneezing 61% 57%.159 Sore or scratchy throat 53% 50%.394 * 2-tailed test 15

16 Table 5. Bartenders Opinions on Whether Smoking Should Be Allowed in Restaurant/Bars at Baseline and Follow-up, and Results of Paired T-Test Analyses* (All; N=531) Baseline (% No ) Follow-up (% No ) p-value All Respondents 64% 72%.000 Smokers 46% 60%.000 Non-smokers 77% 81%.059 Urban 63% 71%.000 Rural 67% 73%.023 * 2-tailed test comparing baseline data to follow-up data, within each respective group 16

17 Table 6. Bartenders Opinions on Whether Smoking Should Be Allowed in Bars/Taverns at Baseline and Follow-up, and Results of Paired T-Test Analyses* (All; N=531) Baseline (% No ) Follow-up (% No ) p-value All Respondents 38% 40%.393 Smokers 12% 16%.041 Non-smokers 58% 57%.648 Urban 40% 39%.613 Rural 37% 41%.077 * 2-tailed test comparing baseline data to follow-up data, within each respective group 17

18 Table 7. Bartenders Perceived Health Risk of Exposure to Secondhand Smoke at Baseline and Follow-up, and Results of Paired T-Test Analyses* (All; N=531) Perceived health risk of secondhand smoke (1 = no risk, 5 = extremely serious risk) Baseline (mean) Follow-up (mean) p-value All Respondents Smokers Non-smokers Urban Rural * 2-tailed test comparing baseline data to follow-up data, within each respective group 18