UNIVERSITY OF CINCINNATI

Transcription

1 UNIVERSITY OF CINCINNATI Date: I,, hereby submit this work as part of the requirements for the degree of: in: It is entitled: This work and its defense approved by: Chair:

2 University Students Perceptions and Behaviors Regarding Secondhand Smoke, Smoking Bans and Spending in Smoke-Free Establishments A thesis submitted to Division of Graduate Studies and Research of the University of Cincinnati In partial fulfillment of the requirements for the degree of MASTER OF EDUCATION In the Division of Human Services of the College of Education, Criminal Justice, and Human Services 2005 by Brigid Molloy B.S., Xavier University Committee Chair: Keith A. King, PhD, CHES

3 Abstract AN ABSTRACT OF THE THESIS FOR THE MASTER OF EDUCATION DEGREE IN HEALTH PROMOTION AND EDUCATION, PRESENTED ON JULY 19, 2005, AT THE UNIVERSITY OF CINCINNATI, OHIO TITLE:University Students Perceptions and Behaviors Regarding Secondhand Smoke, Smoking Bans and Spending in Smoke-Free Establishments MASTERS COMMITTEE MEMBERS: Dr. Keith King (chair) and Dr. Amy Bernard The present study assessed students perceptions, attitudes, and knowledge of the effects of secondhand smoke and their willingness to patronize smoke free establishments at one public and one private university in the same Midwest city. A total of 1232 university students enrolled in courses at one public and one private university in the same Midwest city were surveyed regarding their support for smoking bans, preferences regarding smoking policy, and projected relative time and money spent in restaurants and bars/nightclubs if there was a smoking ban in effect (participation rate = 98.%). Results indicated that most university students believed that secondhand smoke is unhealthy and most supported a law banning smoke in restaurants and a law banning smoke in bars/nightclubs. Most students also reported preferring stricter smoking restrictions (M=3.59, SD=.599) compared to their impression of their friends preferences (M=3.16, SD=.880). The same was true for their preferences for smoking restrictions in bars/nightclubs (M=3.04, SD=1.018 and M=2.57, SD=1.126). On average, students predicted that their money and time expenditures in restaurants would not change if there were a law banning smoke ii

4 in restaurants. On average, the same was also true for the university students money and time expenditures in bars/nightclubs. T-tests were conducted on twelve hypotheses. Results indicated that smoking status significantly affected support for restaurant smoking bans, bar smoking bans, projected change in money and time expenditures in bars, and projected change in money and time expenditures in restaurants. Restaurant patronage had no significant relationship with students support for laws banning smoking in restaurants and students projected changes in money and time expenditures in restaurants. However, bar patronage did have a significant relationship with students support for laws banning smoking in restaurants, and projected changes in time and money expenditures in bars/nightclubs if there was a law banning smoking in bars/nightclubs. iii

5 Table of Contents List of Tables vi Chapter 1: The Problem 1 Statement of the Problem. 3 Research Questions and Hypotheses. 4 Delimitations 12 Limitations 12 Assumptions 12 Operational Definitions.. 13 Chapter 2: Review of Literature 14 Leading Causes of Death.. 16 Secondhand Smoke Exposure. 19 Barriers Affecting Laws Banning Smoking in Public Places 21 Economic Impact of Smoking Bans. 22 Public Opinion of Smoking Bans.. 22 Successes of Smoking Bans. 24 Summary.. 26 Chapter 3: Methods 27 Participants.. 28 Instrumentation 29 Procedures Data Analysis Chapter 4: Results and Discussion. 32 Participants.. 33 Demographic and Background Characteristics.. 34 Support for Smoking Bans 35 Restaurant and Bar Preferences.. 37 Perceived Effect of Smoking Bans.. 37 Hypothesis Testing. 39 Discussion 46 Chapter 5: Conclusions and Recommendations Conclusions. 49 Discussion 51 Recommendations for Practice 53 Recommendations to Improve this Research 54 Recommendations for Future Research. 55 References.. 57 Appendices.. 62 iv

6 Appendix A: Survey Instrument 62 v

7 List of Tables Table 4.1 Demographic and Background Characteristics Table 4.2 Support for Smoking Bans.. 36 Table 4.3 Restaurant and Bar Preferences Table 4.4 Effect of Smoking Ban on Time/Money Spending.. 39 Table 4.5 Support for Smoking Bans and Effects of Smoking Bans on Time and Money Spent in Bars and Restaurants Based on Smoking Status.. 41 Table 4.6 Support for Smoking Bans and Effects of Smoking Bans on Time and Money Spent in Bars Based on Recent Patronage Table 4.7 Support for Smoking Bans and Effects of Smoking Bans on Time and Money Spent in Restaurants Based on Recent Patronage vi

8

9 Chapter One The Problem Secondhand smoke has been linked to several of the leading causes of death, including lung cancer, respiratory illnesses and problems, and heart disease (Hackshaw, Law, & Wald, 1997; Kawachi, Colditz, Speizer, Manson, et. al., 1997; Law, Morris, & Wald, 1997; Pitsavos, et. al., 2002; Sigel & Skeer, 2003; Woodward & Langesen, 2001). Women who reported occasional exposure to secondhand smoke had a relative risk of coronary artery disease of 1.58 compared to those who were not exposed. There was an increased risk, 1.91, for women with regular exposure (Kawachi, et. al., 1997). Nonsmokers who live with smokers have a 24% risk of lung cancer (Hackshaw, et al., 1997; Law, et al., 1997). Infants who were exposed to smoke in utero visited the doctor 26% more than unexposed infants and were hospitalized 18% more, costing about $2.1 million (Leung, Ho, & Lam, 2003). Worldwide, tobacco related deaths are projected to increase from 3 million in 1990 to 8.4 million in By this time, tobacco is projected to cause more deaths than any single disease (Murray & Lopez, 1997). Currently, 39.2% of the US population reports secondhand smoke exposure (Nebot, Lopez, Tomas, Ariza, Borrell, & Villalbi, 2004). People are exposed to secondhand smoke in a variety of places. Public smoking is commonly allowed in restaurants, bars/nightclubs, bowling alleys, and smoking lounges in predominantly smoke free sites, such as airports. The concentrations of nicotine in the air of bars and bowling alleys were times higher than in offices or residence and times higher than in restaurants (Sigel & Skeer, 2003). In aircraft flights were smoking was allowed, 95% of the harmful respirable particles in the 1

10 smoking section and 85% in the nonsmoking section were a result of tobacco smoke (Repace, 2004a). The goal of Healthy People 2010 objective is to reduce the proportion of nonsmokers exposed to environmental tobacco smoke to 45%. This would be a 20% reduction (United States Department of Health & Human Services [USDHHS], 2000). In regards to airplanes, non-smoking sections were established in 1977 and most major airlines ban smoking altogether, although this is not mandated by law in many countries (Repace, 2004a). Another possible way to reduce secondhand smoke exposure is through a total ban on public smoking. This policy has been implemented in Boston, California, Miami, Louisville, and New York City, in addition to many other locations. An assessment of air quality in a casino showed that 90-95% of the respirable particles (known to cause cancer, heart disease, and stroke) were contributed by secondhand smoke (Repace, 2004b). There are several barriers to smoke free legislation. Often, the owners of establishments that have allowed smoking in the past are hesitant to support such a ban because they are afraid of the economic impact on their business. Also, the tobacco industry raises large concerns because bars are a major avenue for marketing (Goold, 2003). Also, social cues, like bars, are a common reason for people who are trying to quit smoking to relapse. About 70% of smokers reported smoking more in bars. About 25% of smokers said that they would be likely to quit if smoking were banned in bars and restaurants (Trotter, Wakefield & Borland, 2002). While these barriers seem very real to those who would be affected by the ban, there is actually a lot of evidence showing that smoking bans do not negatively affect 2

11 the economic success of a restaurant or bar. In some cases, the establishments actually improved economically after the smoking ban went into effect (Lam, Janghorbani, Hedley, et. al., 2002; Scollo, Lal, Hyland, & Glantz, 2003). Regardless of the hesitation of restaurant and bar owners and the objections of the tobacco industry, this does not usually affect legislators. The most common dimensions underlying legislator support for tobacco control policies were: believing that the government has a role in health promotion, being a non-smoker, and knowledge of health risks and mortality related to tobacco smoke (De Guia, Cohen, & Ashley, et. al., 2003). Throughout all of the debate, 68.9% of the US public support a total ban on smoking (Lam, Janghorbani, Hedley, et.al., 2002). Statement of the Problem Given that secondhand smoke is a major health problem (Hackshaw, Law, & Wald, 1997; Kawachi, Colditz, Speizer, Manson, et. al., 1997; Law, Morris, & Wald, 1997; Pitsavos, et. al., 2002; Sigel & Skeer, 2003; Woodward & Langesen, 2001) and one way to reduce secondhand smoke exposure is to place bans on public smoking (Repace, 2004b), the goal of this study was to determine the current attitudes and behaviors of university students with regards to secondhand smoke and to determine their willingness to support smoke-free legislation and patronize smoke-free establishments. The goal of Healthy People 2010 objective is to reduce the proportion of nonsmokers exposed to environmental tobacco smoke to 45%. The baseline data for this recommendation showed that about 65% of nonsmokers are exposed to environmental tobacco smoke. Therefore, this would be a 20% reduction (USDHHS, 3

12 2000). Studies have shown that 90-95% of the respirable air pollutants in public facilities, such as casinos, come from tobacco smoke (Repace, 2004b). Thus, smokefree policies for such facilities would dramatically decrease the public s exposure environmental tobacco smoke. While public opinion greatly supports smoking bans in public places (Lam, Janghorbani, Hedley, et. al., 2002) cities and states have been hesitant to create laws banning smoking in public places. The tobacco industry fears a decrease in revenues, as do business owners (Goold, 2003; Trotter, Wakefield & Borland, 2002). While the tobacco industry may loose revenues as a portion of smokers quit smoking (Trotter, Wakefield & Borland, 2002) much of the data on smoke-free regions show that local business are either not impacted by the smoking ban or, in some cases, they are positively impacted by the smoking ban (Lam, Janghorbani, Hedley, et. al., 2002; Scollo, Lal, Hyland, & Glantz, 2003). Research Questions and Hypothesis The following were the research questions explored in this study. 1. Do university students have knowledge about the effects of secondhand smoke? 2. What are the attitudes of university students in regards to secondhand smoke? 3. Are university students willing to support a legislative smoking ban? 4. Do university students prefer a smoke free environment? 5. Would a smoking ban affect the time and money university students spend in restaurants or bars/nightclubs? 4

13 6. Do recent restaurant or bar/nightclub patronage and smoking status have an effect on a university student s support of a legislative smoking ban in restaurants and bars/nightclubs, and do they have an effect on the time or the money university students would spend in restaurants or bars/nightclubs if there was a smoking ban? Hypothesis 1 Predictive hypothesis 1. University students who have patronized a restaurant in the past 30 days will be more likely to support a law making restaurants smoke-free than university students who have not patronized a restaurant in the past 30 days. Alternative hypothesis 1. University students who have patronized a restaurant in the past 30 days will be less likely to support a law making restaurants smoke-free than university students who have not patronized a restaurant in the past 30 days. Null hypothesis 1. There will be no difference between university students that have patronized a restaurant in the past 30 days and university students that have not patronized a restaurant in the past 30 days related to support for a law making restaurants smoke-free. Hypothesis 2 Predictive hypothesis 2. University students who have patronized a bar/nightclub in the past 30 days will be more likely than university students who have not patronized a bar/nightclub in the past 30 days to support a law making bars/nightclubs smoke-free. 5

14 Alternative hypothesis 2. University students who have patronized a bar/nightclub in the past 30 days will be less likely than university students who have not patronized a bar/nightclub in the past 30 days to support a law making bars/nightclubs smoke-free. Null hypothesis 2. There will be no difference between university students that have patronized a bar/nightclub in the past 30 days and university students that have not patronized a bar/nightclub in the past 30 days related to support for a law making bars/nightclubs smoke-free. Hypothesis 3 Predictive hypothesis 3. University students who have smoked in the past 30 days will be less likely than university students who have not smoked in the past 30 days to support a law making restaurants smoke-free. Alternative hypothesis 3. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to support a law making restaurants smoke-free. Null hypothesis 3. There will be no difference between university students that have smoked in the past 30 days and university students that have not smoked in the past 30 days related to support for a law making restaurants smoke-free. Hypothesis 4 Predictive hypothesis 4. University students who have smoked in the past 30 days will be less likely than university students who have not smoked in the past 30 days to support a law making bars/nightclubs smoke-free. 6

15 Alternative hypothesis 4. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to support a law making bars/nightclubs smoke-free. Null hypothesis 4. There will be no difference between university students that have smoked in the past 30 days and university students that have not smoked in the past 30 days related to support for a law making bars/nightclubs smoke-free. Hypothesis 5 Predictive hypothesis 5. University students who have patronized a restaurant in the past 30 days will be more likely than university students who have not patronized a restaurant in the past 30 days to spend more time in a restaurant if there was a law making restaurants smoke-free. Alternative hypothesis 5. University students who have patronized a restaurant in the past 30 days will be less likely than university students who have not patronized a restaurant in the past 30 days to spend more time in a restaurant if there was a law making restaurants smoke-free. Null hypothesis 5. There will be no difference between university students that have patronized a restaurant in the past 30 days and university students that have not patronized a restaurant in the past 30 days related to the amount of time spent in a restaurant if there was a law making restaurants smoke-free. Hypothesis 6 7

16 Predictive hypothesis 6. University students who have patronized a bar/nightclub in the past 30 days will be more likely than university students who have not patronized a bar/nightclub in the past 30 days to spend more time in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Alternative hypothesis 6. University students who have patronized a bar/nightclub in the past 30 days will be less likely than university students who have not patronized a bar/nightclub in the past 30 days to spend more time in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Null hypothesis 6. There will be no difference between university students that have patronized a bar/nightclub in the past 30 days and university students that have not patronized a bar/nightclub in the past 30 days related to the amount of time spent in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Hypothesis 7 Predictive hypothesis 7. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to spend more time in a restaurant if there was a law making restaurants smokefree. Alternative hypothesis 7. University students who have smoked in the past 30 days will be less likely than university students who have not smoked in the past 30 days to spend more time in a restaurant if there was a law making restaurants smokefree. 8

17 Null hypothesis 7. There will be no difference between university students that have smoked in the past 30 days and university students that have not smoked in the past 30 days related to the amount of time spent in a restaurant if there was a law making restaurants smoke-free. Hypothesis 8 Predictive hypothesis 8. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to spend more time in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Alternative hypothesis 8. University students who have smoked in the past 30 days will be less likely than university students who have not smoked in the past 30 days to spend more time in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Null hypothesis 8. There will be no difference between university students that have smoked in the past 30 days and university students that have not smoked in the past 30 days related to the amount of time spent in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Hypothesis 9 Predictive hypothesis 9. University students who have patronized a restaurant in the past 30 days will be more likely than university students who have not patronized a 9

18 restaurant in the past 30 days to spend more money in a restaurant if there was a law making restaurants smoke-free. Alternative hypothesis 9. University students who have patronized a restaurant in the past 30 days will be less likely than university students who have not patronized a restaurant in the past 30 days to spend more money in a restaurant if there was a law making restaurants smoke-free. Null hypothesis 9. There will be no difference between university students that have patronized a restaurant in the past 30 days and university students that have not patronized a restaurant in the past 30 days related to the amount of money spent in a restaurant if there was a law making restaurants smoke-free. Hypothesis 10 Predictive hypothesis 10. University students who have patronized a bar/nightclub in the past 30 days will be more likely than university students who have not patronized a bar/nightclub in the past 30 days to spend more money in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Alternative hypothesis 10. University students who have patronized a bar/nightclub in the past 30 days will be more likely than university students who have not patronized a bar/nightclub in the past 30 days to spend more money in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Null hypothesis 10. There will be no difference between university students that have patronized a bar/nightclub in the past 30 days and university students that have 10

19 not patronized a bar/nightclub in the past 30 days related to the amount of money spent in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Hypothesis 11 Predictive hypothesis 11. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to spend more money in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Alternative hypothesis 11. University students who have smoked in the past 30 days will be less likely than university students who have not smoked in the past 30 days to spend more money in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Null hypothesis 11. There will be no difference between university students that have smoked in the past 30 days and university students that have not smoked in the past 30 days related to the amount of money spent in a restaurant if there was a law making restaurants smoke-free. Hypothesis 12 Predictive hypothesis 12. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to spend more money in a bar/nightclub if there was a law making bars/nightclubs smoke-free. 11

20 Alternative hypothesis 12. University students who have smoked in the past 30 days will be more likely than university students who have not smoked in the past 30 days to spend more money in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Null hypothesis 12. There will be no difference between university students that have smoked in the past 30 days and university students that have not smoked in the past 30 days related to the amount of money spent in a bar/nightclub if there was a law making bars/nightclubs smoke-free. Delimitations This study was delimited to year old university students attending classes at one private university or at one public university in the same Midwest city. Further, these students must also have been enrolled in a class that was participating in the survey. Limitations This study was limited by the following: 1. the honesty of the participants 2. the memory of the participants. Assumptions It was assumed that all participants could read and understand the survey instrument and that they responded in an open, honest manner. 12

21 Operational Definitions 1. Secondhand smoke- For the purpose of this study, secondhand smoke will be tobacco smoke inhaled from the environment and not from a tobacco product the person is smoking. 2. Smoke free- Any complete ban on smoking in a public place, including restaurants, bars/nightclubs, bowling alleys, etc. 13

22 Chapter Two Review of Literature Each year 4 million people die due to tobacco-related diseases (Murray & Lopez, 1997). By 2020, this number is expected to increase to 8.4 million (World Health Organization, 2002). Based on current smoking trends, by the year 2030 tobacco will cause 1 in 8 deaths, become the leading cause of morbidity and mortality throughout the world, and result in more deaths than HIV, tuberculosis, maternal mortality, automobile accidents, homicide, and suicide combined (Bamum, 1994). Secondhand smoke exposure annually kills 60,000 nonsmoking Americans and has become the third most preventable cause of death in the United States (Kurtz, et al., 2001; Napier, et al., 2000). Such exposure places nonsmokers at elevated risk for heart disease, cancer, respiratory disorders, and middle ear disease (Laughlin, 2000). Smoke-free ordinances in cities have been proposed as a means of limiting secondhand smoke exposure, but have been met with a lot of objections from restaurant and bar owners who are concerned with a possible drop in revenues. A comparative study of cities with and without ordinances found that ordinances had no significant effect on the fraction of total retail sales that went to eating and drinking places or on the ratio between sales in communities with ordinances and sales in comparison communities. Ordinances requiring smoke-free bars had no significant effect on the fraction of revenues going to eating and drinking places that serve all types of liquor (Glantz & Smith, 1997). 14

23 The purpose of this study is to assess students perceptions, attitudes, and knowledge of the effects of secondhand smoke and their willingness to patronize smoke free establishments at one public and one private university in the same Midwest city. Chapter one addressed the problem. This chapter provides a review of the literature regarding secondhand smoke, smoking ban support, and barriers to smoking bans. Given that secondhand smoke is a major health problem (Hackshaw, et al., 1997; Kawachi, et. al., 1997; Law, et al., 1997; Pitsavos, et al., 2002; Sigel & Skeer, 2003; Woodward & Langesen, 2001) and one way to reduce secondhand smoke exposure is to place bans on public smoking (Repace, 2004b), the goal of this study was to determine the current attitudes and behaviors of university students with regards to secondhand smoke and to determine their willingness to support smoke-free legislation and patronize smoke-free establishments. The goal of Healthy People 2010 objective is to reduce the proportion of nonsmokers exposed to environmental tobacco smoke to 45%. The baseline data for this recommendation showed that about 65% of nonsmokers are exposed to environmental tobacco smoke. Therefore, this would be a 20% reduction (Department of Health & Human Services, 2000). Studies have shown that 90-95% of the respirable air pollutants in public facilities, such as casinos, come from tobacco smoke (Repace, 2004a). Thus, smoke-free policies for such facilities would dramatically decrease the public s exposure environmental tobacco smoke. While public opinion greatly supports smoking bans in public places (Lam, Janghorbani, Hedley, et. al., 2002) cities and states have been hesitant to create laws banning smoking in public places. The tobacco industry fears a decrease in revenues, 15

24 as do business owners (Goold, 2003; Trotter, Wakefield & Borland, 2002). While the tobacco industry may loose revenues as a portion of smokers quit smoking (Trotter, Wakefield & Borland, 2002) much of the data on smoke-free regions show that local business are either not impacted by the smoking ban or, in some cases, they are positively impacted by the smoking ban (Lam, Janghorbani, Hedley, et. al., 2002; Scollo, Lal, Hyland, & Glantz, 2003). Leading Causes of Death A recent study has shown that those women who are exposed to secondhand smoke are at an increased risk of heart attack (Kawachi, et. al., 1997). In this study a sample of 32,046 women were followed for 10 years. Every two years they would supply detailed health information for a variety of purposes. All of the women involved in the study were part of the Nurses Health Study cohort. The study went on to find that those who were occasionally exposed had a 1.58 relative risk for coronary artery disease compared with those who were not exposed. The relative risk for those who were regularly exposed was These statistics did take into account other cardiovascular risk factors. The researchers stated that these findings, in conjunction with other evidence, suggest a cause and effect relationship between secondhand smoke exposure and cardiovascular disease. Two meta-analyses (Hackshaw, et al., 1997; Law, et al., 1997) published the same year as the Kawachi, et. al. (1997) study, showed an increased risk of heart disease and lung cancer in those exposed to secondhand smoke. These studies indicated that secondhand smoke increased the risk for heart disease by 23%. These 16

25 studies suggested that exposure to tobacco smoke led to platelet aggregation. This was consistent with the evidence of high risk despite low exposure. A more recent study by Pitsavos, Panagiotakos, Chrysohoou, et. al. (2002) also showed an increased risk of developing acute coronary syndromes (ACS). This was a case-control study. 847 individuals with a first event of ACS were frequency matched by age, sex, and region with 1078 cardiovascular disease-free controls. The cases and controls were asked to self report whether or not they were currently exposed to tobacco smoke for 30 minutes or more per day and how long they had been regularly exposed to tobacco smoke. Relatives and friends of the cases and controls were also asked to report on the participant and a Kendal s coefficient was used to show high agreement. The study found that cases were 47% more likely to report regular exposure to environmental tobacco smoke (ETS) than controls. ETS exposure at work was associated with a greater risk of ACS compared to home exposure. Also, smokers who reported ETS exposure were also at a higher risk of ACS than those smokers who were not exposed. These researchers also suggested that the consistency of these findings with previous data supports a causal relationship between secondhand smoke exposure and heart disease. Furthering the relationship, Panagiotakos, et. al. (2004) published a study evaluating the effect of secondhand smoke on inflammatory markers related to heart disease. A randomly selected adult sample of 1,128 men and 1,154 women was first surveyed to determine exposure to secondhand smoke in the workplace and at home. Dietary and physical activity information was also collected. Blood pressure, height, and weight were measured. Blood was drawn to determine LDL, homocysteine, blood 17

26 glucose levels, fibrinogen, and C-reactive protein measurements. Of the participants, 38% of men and 33% of women nonsmokers reported current exposure to secondhand smoke. Compared to those who reported no exposure, this group had significantly higher white blood cell counts and C-reactive protein levels. After adjusting for confounding factors, it was determined that persons with regular secondhand smoke exposure had significantly higher levels of all inflammatory markers. The authors conclusions were that exposure to secondhand smoke leads to inflammation. This may be another mechanism for the development of atherosclerosis and recommended that efforts to reduce secondhand smoke exposure be implemented. This same meta-analysis (Law, et al., 1997.) also showed that the increased risk for lung cancer as a result of secondhand smoke exposure is about 24%. The amount of exposure was directly correlated with the increased amount of risk. A more recent study by Sigel and Skeer (2003) showed that workers in bars, bowling alleys, billiard halls, betting establishments, and bingo parlours were at and increased risk for dying from lung cancer. This study calculated an average of nicotine concentrations in these facilities. The researchers then estimated the working lifetime excess lung cancer mortality risk associated with such levels of exposure. They determined that nicotine concentrations in these facilities were times higher than in homes or offices and times greater than in restaurants. The estimated lifetime risk from these levels was /1000. The typical risk level of people not working in these facilities is about 0.3/1000. The researchers recommended that workplace smoking regulations be put in place at these facilities to decrease the worker s high levels of exposure. 18

27 As a result of the risks for heart disease and lung cancer as a result of secondhand smoke, a study examining the number of deaths related to secondhand smoke was conducted (Woodward & Laugesen, 2001). The researchers used a case study approach by examining the exposure and mortality data for New Zealand. The number of deaths caused by past exposures to secondhand smoke averaged 347 per year. Based on this information, the researchers estimated that there were about 325 avoidable deaths each year. The researchers suggested that policy makers and health educators should use these results as an indication of the magnitude of this health problem. To put these numbers of deaths into perspective, the researchers also listed the numbers of deaths for skin melanomas (200) and road crashes (500). Secondhand Smoke Exposure A study published this year (Nebot, Lopez, Tomas, et. al., 2004). surveyed a cross-sectional sample of adults in Barcelona, Spain regarding secondhand smoke exposure. The sample was surveyed on this topic along with other health topics through the Barcelona Health Interview Survey. The survey looked at sources of exposure, but focused mainly on home and work exposure. The researchers found that 69.7% reported being exposed to secondhand smoke. Of those reporting exposure, 22.6% reported being exposed at work and home, and 29.7% reported only being exposed at work and 17.5% reported only being exposed at home. The researchers mentioned that these rates are higher than the U.S. rates, which report 39.2% of the population is exposed to tobacco smoke. The researchers did admit that questionnaires usually lead to underreporting. 19

28 There is a slight discrepancy in the amount of exposure that is reported in the U. S. In the previous study, a 39.2% exposure rate was reported. However, according to Healthy People 2010 objective 27-10, about 65% of the population is exposed to secondhand smoke. The goal is to reduce the amount of exposure to 45%, which was lower than any U. S. population reported being exposed to. A study by James Repace (2004b) states that not all exposure is equal. When commissioned to study the air quality in a casino, six bars, and a pool hall in Delaware, the levels of pollutants in these venues were far higher than the pollution found on major truck highways and polluted city streets. During the study, Repace measured respirable particle (RSP) air pollution and particulate polycyclic aromatic hydrocarbons (PPAH). Both of these pollutants are known to increase risk of respiratory disease, cancer, heart disease, and stroke. The study found that 90-95% of the RSP air pollution resulted from secondhand smoke and 85-90% of PPAH pollutants resulted from secondhand smoke. Repace reported that hospitality workers and patrons health is endangered by tobacco smoke pollution. An earlier study rated state indoor air laws (Chriqui, Frosh, Brownson, et. al., 2002). This study looked at each state s laws yearly from 1993 to The committee rated each state on laws regarding 7 venues and 2 enforcement components. A high score in these 9 areas resulted in a score of 36, but up to 6 extra points could be earned by exceeding recommendations and scores were adjusted if the state enacted preemptive measures. The researchers found that summary scores ranged from 0-20 in 1993 and 0-31 in By 1999, scores increased for 22 states, however, there were no changes made between 1995 and Three states also scored 0 20

29 across all years. There was a 41% increase in states that had preemption measures. The researchers concluded that progress toward state laws to meet specified public health targets was low. They also noted that preemption laws increasingly undermine laws passed in localities. Barriers Affecting Laws Banning Smoking in Public Places An analysis of print media (Magzamen, Charlesworth, & Glantz, 2001) in California prior to and immediately following the implementation the smoke-free bar law found that the contributions from the tobacco industry dominated the print media, especially opinion items. The study analyzed 446 news articles, 31 opinion editorials, 104 editorials, 240 letters to the editor, and 10 cartoons. The articles were rated by the number and timing of publication items, the presence of tobacco industry perspectives, the presence of public health perspectives, and positive, negative, and neutral views of opinion items. The tobacco industry dominated most categories, however, the public health groups obtained adequate attention to keep the law in effect. An alternative to smoking bans is smoking lounges. This alternative was mandated in Toledo, OH restaurants and bars in Indoor Environmental Quality Strategies (2004) reported the success of this regulation. The article mentioned that while these lounges still pose risks to non-smokers, they greatly decrease the risk from previous regulations. One major drawback mentioned was the expense of the mandated systems. The regulations require fans and must maintain negative pressure. The ventilation systems must expel air at least 10 feet from windows, doors, and any other ventilation intake. The layout of the lounges cannot block restrooms, entrances, 21

30 or exits used by non-smokers. These accommodations can be difficult to make and the ventilation systems can be expensive to run, especially in the winter. Economic Impact of Smoking Bans The Substance Abuse Policy Research Program conducted research regarding the economic impact of smoking bans on restaurants in New York City and in Massachusetts (1999). In New York City, which had stricter smoke-free policies in restaurants, showed a 2% increase in restaurant sales in 1999, while the rest of the state decreased sales by 4%. The city gained 18% more restaurant jobs while the rest of the state gained only 5%. The Massachusetts study yielded similar results and found that almost half of non-smokers resisted going somewhere specifically to avoid smoke. A study was conducted to determine the quality of studies regarding the economic effects of smoke-free policies (Scollo, Lal, Hyland, et. al., 2003). There were 97 studies included in this review. In this review, the findings and characteristics of studies were determined by two reviewers and then by a reviewer blind to study objectives and funding source. Studies yielding a negative economic impact were 4 times more likely to utilize only subjective measures and were 20 times more likely to not be peer reviewed than studies concluding no negative impact. All studies concluding a negative impact were funded by the tobacco industry. The results stated that 94% of tobacco industry funded studies found a negative impact, while none of the non-industry funded studies found a negative impact. The reviewers concluded that all of the best designed studies reported no impact or positive impact. Public Opinion of Smoking Bans 22

31 A study of the attitudes of residents in a tobacco producing county regarding smoking bans was conducted by Wilson, Duncan, & Nicholson (2004). A sample of 374 people was selected by a recent birthday method. The sample included 130 males and 240 females, and missing data on 4 subjects. Within the study, 70.7% of the subjects were non-smokers, 7.2% smoked less than one pack per day, and 21.8% smoked more than one pack per day. Of the participants, 22.1% reported owning tobacco allotments. The subjects were contacted by phone and reported information through an interview. Of the participants, 26.3% supported banning all smoking in restaurants. Of the participants, 64.6% supported setting aside smoking areas in restaurants. Only 6.1% reported opposing smoking restrictions in restaurants. While smokers were more likely to oppose restrictions, there was no association between support of restrictions and ownership of tobacco allotments. A more wide-scale study of U. S. adults was conducted by McMillen, Winickoff, Klein, et. al. (2003). Cross-sectional data was collected through the Social Climate Survey of Tobacco Control. The data were collected through phone interviews via an automated random-digit-dialing telephone surveys in 2000 and A total of 1501 adults participated in 2000 and 3002 participated in A majority of adults supported smoking bans in a variety of venues, including shopping malls, fast-food restaurants, in the home, in the presence of children, and at indoor sporting events. The researchers noted that while support for smoking bans was gaining, there were still a large number of adults who reported ignorance of the harmful effects of secondhand smoke on children. 23

32 A study of California residents (Gilpin, Lee, Pierce, et. al., 2002) regarding their opinions about smoking bans was conducted. The state of California regulated smoking in workplaces in 1995 and extended the ban to bars and gaming rooms in The sample, consisting of 20,525 residents, was randomly selected through a random digitdialled survey. The phone interviews conducted lasted about 25 minutes and had a response rate of 63%. The interview asked where, if anywhere, the residents would like to extend the smoking ban. Of the participants, 90.5% recommended extending the ban to kids play yards and fields, 88.8% selected common hotel/motel areas, and 87.1% selected common apartment/condo areas. While these three venues garnered the highest response, a majority of participants favored extending the smoking ban to 6 other venues including university residence halls, hotel rooms, outdoor restaurants and outdoor bars, and outdoor worksites. A study was conducted of students opinions regarding tobacco control policies at US colleges (Rigotti, Regan, Moran, & Wechsler, 2003). A mailed survey of 10,904 students at 119 participating four year colleges in the US revealed that more than 75% favored smoke-free policies for all college buildings, residences, and dining areas. Approximately 71% of students favored prohibiting tobacco advertising on campus, 59% favored prohibiting tobacco sales on campus, and 51% supported smoke-free campus bars. All policies had more support from non-smokers than from smokers. It was noted that tobacco control policies were strong among students, including smokers. Successes of Smoking Bans The CDC (2004) completed a study of the impact of smoking bans on reducing respirable suspended particles (RSPs) by collecting baseline data in Western New York 24

33 before a state law banning public smoking went into effect and after the law went into effect. The sample of venues included 6 bars, 6 bar/restaurants, 5 restaurants, 2 bowling alleys, a pool hall, and a bingo parlour. The average decrease in RSPs was 90% in the 14 bars and restaurants that allowed smoking before the bans were put in place. In two bar/restaurants that only allowed smoking in the bars, the decrease was an average of 58%. This study concludes that smoking bans significantly reduce the amount of exposure of workers and patrons to disease causing agents. A study on smoking behaviors related to smoking bans (Trotter, Wakefield, & Borland, 2002) was conducted previous to the above study. This study followed a sample of 409 smokers who reported patronizing bars, nightclubs, or gaming venues at least monthly. The participants were surveyed regarding their behavior in those venues and their perceptions of the potential influence a smoking ban would have on their behaviors. Of the participants, 70% of the smokers reported smoking in those venues. Of those smokers, 25% reported that they would be likely to quit smoking if there was a ban on smoking in those venues. This indicates that smoking bans could decrease cigarette consumption and increase quitting among patrons of those venues. A compliance study of a smoke-free workplace law in California in restaurants and bars was conducted from (Weber, Bagwell, Fielding, & Glantz, 2003). A random sample of bars and bar/restaurants were evaluated for compliance with smoking bans. The study primarily focused on employee and patron smoking and the presence of ashtrays and designated outdoor smoking areas. The study found that compliance increased between 1998 and In freestanding bars, compliance 25

34 increased from 45.7% to 75.8%. In bar/restaurants, compliance increased from 92.2% to 98.5%. Increases in employee non-smoking also increased over the period. Summary Secondhand smoke has been linked to many deadly diseases, such as heart disease and lung cancer. Not only do these diseases have high mortality rates, but they cost the public large amounts of money to treat. It is highly advantages to the public to limit the amount of secondhand smoke all people are exposed to. Laws mandating smoke-free restaurants, bars, casinos, bowling alleys, pool halls, and other betting establishments are an effective and low cost way of limiting secondhand smoke exposure. Not only do these laws protect the health of the public, but also do not cost the establishments money to implement and in some cases increase revenues. Large populations of Americans support such acts. University students have been shown to support on campus tobacco control policies. However, there is a gap in the literature as to the extent of support that university students have for laws mandating smoke-free restaurants and bars. 26

35 Chapter Three Methods Each year 4 million people die due to tobacco-related diseases (Murray & Lopez, 1997). By 2020, this number is expected to increase to 8.4 million (World Health Organization, 2002). Based on current smoking trends, by the year 2030 tobacco will cause 1 in 8 deaths, become the leading cause of morbidity and mortality throughout the world, and result in more deaths than HIV, tuberculosis, maternal mortality, automobile accidents, homicide, and suicide combined (Bamum, 1994). Secondhand smoke exposure annually kills 60,000 nonsmoking Americans and has become the third most preventable cause of death in the United States (Kurtz, et al., 2001; Napier, et al., 2000). Such exposure places nonsmokers at elevated risk for heart disease, cancer, respiratory disorders, and middle ear disease (Laughlin, 2000). Smoke-free ordinances in cities have been proposed as a means of limiting secondhand smoke exposure, but have been met with a lot of objections from restaurant and bar owners who are concerned with a possible drop in revenues. A comparative study of cities with and without ordinances found that ordinances had no significant effect on the fraction of total retail sales that went to eating and drinking places or on the ratio between sales in communities with ordinances and sales in comparison communities. Ordinances requiring smoke-free bars had no significant effect on the fraction of revenues going to eating and drinking places that serve all types of liquor (Glantz & Smith, 1997). A comprehensive review of the literature revealed no published study examining Cincinnati area university students perception, attitudes, and knowledge about 27

36 secondhand smoke. Nor did it reveal a published study of Cincinnati area university students willingness to patronize smoke free establishments. Information gained from this population could be helpful in directing further legislation in Hamilton County in regards to smoking policy. Also, the literature review did not reveal a published study comparing multiple university populations on perceptions, attitudes, and knowledge about secondhand smoke. This study could act as a pilot study for further multiple institution studies on secondhand smoke. Therefore, the purpose of this study is to assess students perceptions, attitudes, and knowledge of the effects of secondhand smoke and their willingness to patronize smoke free establishments at one public and one private university in the same Midwest city. Chapter one addressed the problem, purpose, research questions, hypotheses, delimitations, limitations, assumptions, and operational definitions. Chapter two reviewed the professional literature exploring smoking bans, barriers to smoking bans, and the harmful effects of secondhand smoke. This chapter discusses the participants, instrumentation, procedures, and data analysis in the present study. Participants Participants in this study were university students enrolled in courses at one public and one private university in the same Midwest city. The sample was a convenience sample of students enrolled in one of 50 sections of communications (4), general health (First Aid and CPR, Weight Management, and Stress Management) (21), physical activity (24), and psychology (1) courses at the public university. Students at the private university were enrolled in one of 21 sections of philosophy (3), biology (4), chemistry (2), physics (2), business (9), and communications (1) courses. A sample of 28

37 approximately 600 students was surveyed from each university. The sample included students of all class levels, both genders, and a variety of majors and concentrations. Classes were deliberately chosen to include a variety of subjects and class levels. The instructors were ed regarding the survey. Those who were interested in participating made an appointment with the researcher, who came into the class and administered the survey. All participants were assured of the voluntary and confidential nature of the study. All students included fell into the year age range. Instrumentation The survey instrument used in this study (see Appendix A) was created specifically for this study. The questions were compiled from instruments used in similar studies on secondhand smoke and the perceptions and attitudes of other populations regarding public smoking. The survey contains 37 items and utilizes a variety of question types, including modified Likert-type scales, dichotomous questions, and open-ended, quantitative questions. The reliability of the instrument was determined through a test-retest of a public Midwest university class. The face validity was determined by a review of the literature and previous surveys. A panel of three experts in survey instrumentation determined the content validity of the instrument. The first section of the instrument contained 8 items. These items were all Likerttype scales, where the five responses ranged from strongly disagree to neutral to strongly agree. The items examined the participant s knowledge and attitudes regarding secondhand smoke, and their level of support in regard to smoking bans. 29

38 The second section contained 6 items. This section asked respondents to provide a number of days or choose yes or no responses. This section examined recent secondhand smoke behaviors and recent smoking behaviors. The third section contained only two items. Both were open ended questions regarding the number of days the respondents recently patronized bars/nightclubs and restaurants. The fourth section also contained only two items. These items measured the respondents perceived willingness to patronize smoke-free bars/nightclubs and restaurants. These were Likert-type questions with five choices ranging from extremely unwilling to neutral to extremely willing. The next section contains four items. These items assess the respondents preference of smoking policy in a bar/nightclub and restaurant, as well as, their perception of their friends preferences of smoking policy. The respondents chose from one that was entirely smoke-free, one that had smoking sections in separate rooms, one that had smoking sections without barriers, and one that allowed smoking throughout. The sixth section examined consumer spending. Six of the items were openended questions where the respondents filled in dollar amounts regarding average spending. Four of the items asked about the time and money that respondents expected to spend in a bar/nightclub or restaurant, in comparison to their current spending, if a smoke-free ordinance were in place. The respondents chose from more, less, or same for these items. The final section contained demographic information. There were five items. Four of the items required the respondent to mark one of the possible choices. One 30