Do work-place smoking bans cause smokers to smoke ^'harder"? Results from a naturalistic observational study

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1 Addiction (1997) 92(5), RESEARCH REPORT Do work-place smoking bans cause smokers to smoke ^'harder"? Results from a naturalistic observational study SIMON CHAPMAN, SUZY HADDAD & DOUNGKAMOL SINDHUSAKE Department of Public Health and Community Medicine, University of Sydney, New South Wales, Australia Abstract The purpose of this study was to investigate whether smokers outside buildings with work-place smoking bans smoke "harder" than those smoking in social settings. An unobtrusive random observational study of smokers followed by structured interview was used, with 143 smokers taking smoking breaks outside their office buildings and 113 smokers in social settings. The main outcome measurements were number of puffs per cigarette and cigarette smoking duration. The mean number of puffs per cigarette for the office building group was 18.7% greater than that for the social settings group (10.7±3.2 vs. 8.7±2.7, t = 5.58, df= 253, p< 0.001); 74.8% of smokers outside offices took more than the mean number of puffs for the group compared to 42.5% of smokers in social settings (x^ df 1 = 26.31, p < ). Mean cigarette smoking duration was 30.4% shorter for the work-place group than the social settings group (3.9 ± 1.2 minutes vs. 5.6 ±2.6 minutes). Of smokers outside offices, 55.2% had a cigarette smoking duration between 3 and 4.59 minutes, while 53.1% of smokers in social settings took s= 5 minutes to smoke the observed cigarette (y^ df 2 = 31.55, p < ). Smokers who scored at the 75th percentile on the Fagerstrom Tolerance Scale took a mean 9.5 ±2.6 puffs per cigarette compared to 9.3 ± 2.7 puffs by those who scored in the 25th percentile on the scale (t = 0.34, df= 145, p = 0.73). Regardless of degree of nicotine dependency, smokers leaving work-stations to smoke outside buildings smoked their cigarettes nearly 19% "harder" than cigarettes smoked in social settings. The individual and public health benefits of reduced smoking frequency engendered by work-place smoking bans may be lessened by policies which allow smokers to take smoking breaks. Introduction A latent effect of work-place smoking bans (WSBs) is that 24-hour smoking frequency can fall substantially.'"^ This "Trojan horse" smoking reduction benefit from WSBs may be of far greater public health significance than the net health benefits to non-smokers resulting from reduced exposure to ETS. The resulting reduced cigarette sales are likely to explain much of the tobacco industry's vehement opposition to moves to restrict smoking in public areas.^ All studies examining the impact of WSBs on smok- Correspondence: Simon Chapman PhD, Associate Professor, Department of Public Health and Community Medicine, University of Sydney, New South Wales 2006, Australia. Submitted 18th April 1996; initial review completed 6th August 1996; finalversion accepted 17th September /97/ $9.50 Society for the Study of Addiction to Alcohol and Other Drugs Carfax Publishing Company

2 608 Simon Chapman et al. ersj however, have not considered if smokers smoke "harder" than normal during their smoking breaks. If this were found to be the case, such compensatory 'harder' smoking would need to be balanced against reduced 24-hour smoking frequency in any estimation of net individual and population-wide public health benefits. Researched components of cigarette puff topography include the number of puffs per cigarette, single and aggregate puff duration and volume, interpuff interval, cigarette duration, inter-cigarette interval and filter vent blocking.* Many studies have attempted to determine which component correlates best with total smoke,'"'' nicotine''^'* and CO" exposure. The results of this research have been generally confiicting and it remains doubtful that any single pufif parameter is the best indicator of smoke exposure. ing areas, shopping malls, pool rooms and pubs) where we would expect smokers to be unconstrained by time or any preceding smoking deprivation. Using a stopwatch, subjects outside offices were observed unobtrusively after they exited buildings, with the observer at a distance of approximately metres firom the subjects. Subjects in social settings were observed firom distances ranging from 4-20 metres. The observer recorded only the first cigarette smoked by each observed subject. Timing commenced the moment the first cigarette was lit and ceased when the cigarette was discarded. Each puff (defined by the smoker returning and then withdrawing the cigarette from the lips) was tallied. Each smoker was subsequently approached and invited to answer brief questions, including their nicotine dependence as assessed via the Fagerstrom Tolerance Questionnaire.^'' Studying puff topography Nearly all research on puff topography involves subjects smoking in artificial settings with cigarettes connected to recording equipment. Recognizing that these arrangements may infiuence subjects' normal manner of smoking, some researchers have attempted to create more relaxed atmospheres and allowing subjects to carry portable devices attached to cigarette holders so that they might move freely while smoking.'^'"''^"^^ One stud/^ videorecorded through one-way glass and did not inform subjects' that their smoking was being observed. This present study appears to be the first to report the unobtrusive observation of smokers in naturalistic settings. With the intention of being as unobtrusive as possible in making observations, recording of many of the puff parameters that can be successfully measured in a laboratory settings must be forgone. In this study, we sought to observe two easily observable puff parameters: puff frequency and time taken to smoke a cigarette. Both components are amenable to naturalistic observation and recording using tally sheets and stopwatches. Methods Randomly selected subjects were observed in two settings by the second author: people smoking outside central Sydney office buildings in which smoking was barmed, and those smoking in social settings (outside cinemas, outdoor eat- Results One hundred and forty-three smokers outside office blocks were observed, 99 (69.2%) of whom agreed to be interviewed. One hundred and thirteen smokers were observed in social settings, 101 (89.4%) of whom were interviewed. As a group subjects were similar in terms of gender, age, years smoking and mean Fagerstrom Tolerance Score (Table 1). Smokers smoking outside their work-places had statistically significant (18.7%) higher mean number of puffs per cigarette (r=5.58, df 253, p< 0.001) and a 30.4% shorter mean cigarette duration compared to smokers in social settings. On average, those smoking outside buildings took a puff every 21.8 seconds, compared to a puff every 38.6 seconds taken by social setting smokers (Table 2). The only significant relationship (p< ) that existed between the number of puffs per cigarette and any variable was that between puff firequency and setting (outside work-site vs. social). A greater percentage (74.8%) of smokers who were smoking outside the work-place took more than the median number of puffs calculated for the group compared to smokers in social settings (42.5%). Similarly, the only significant relationship (p< ) for cigarette duration was that with the setting. The greatest percentage (53.1%) of smokers smoking in social settings had a smoking duration of more than 5 minutes, while the greatest percentage in the

3 Work-place smoking bans 609 Table 1. Characteristics of observed smokers (per cent or standard deviations in brackets) Male Female Mean age Mean years smoking Mean Fagerstrom score Outside buildings 71 (49.7) 72 (50.3) 31.6 (±8.9) 13.5 (±8.1) 3.9 (±1.7) In social settings (n=113) 59 (52.2) NS 54 (47.8) NS 29.2 (±9.4) NS 11.7 (±8.8)NS 4.0 (±1.6)NS NS = no significant differences. Table 2. Puffs per cigarette and cigarette duration (per cent or standard deviations in brackets) Mean number of puffs* Smokers taking fewer puffs/ cigarette than media** Smokers taking more puffs/ cigarette than median** Mean cigarette duration Cigarette duration minutes*** Cigarette duration minutes*** Cigarette duration > 5 minutes*** *^<0.05; **p<0.01; ***p< Outside buildings 10.7 (±3.2) 36 (25.2) 107 (74.8) 3.9 (±1.2 minutes) 35 (24.5) 79 (55.2) 29 (20.3) In social settings 8.7 (±2.7) 65 (57.5) 48 (42.5) 5.6 (±2.6 minutes) 11 (9.7) 42 (37.2) 60 (53.1) work-place group took between 3 and 4.59 minutes (55.2%). Smokers outside buildings who refused to answer questions after being observed (n = 44) took a shorter mean time to smoke their cigarette (3.5 minutes compared to 4.1 minutes by those who agreed to be interviewed, p < 0.01) but took the same number of puffs (10.7 compared to 10.8), suggesting that refusals may have been pressed for time to get back to their workstations. Discussion The limitations of this study include the limited puff topography measures available and the difficulty of undertaking truly unobtrusive observations while being potentially sighted by the subjects. Also, an assumption was made that in each instance where a cigarette was placed in a smoker's mouth, a puff was being taken. Caution must be exercised when drawing conclusions about total smoke inhaled on the basis of any given puff parameter. The effect of the two parameters we observed on smoke exposure both during these smoking break episodes and over a 24-hour period is therefore unknown and requires further research. However, it would seem reasonable to assume that a cigarette being inhaled every 21.8 seconds (the mean interpuff interval in the work-place group) for 18.7% more puffs per cigarette will deliver more smoke to a smoker than one being inhaled every 38.6 seconds (as per the social smokers). On the assumption that significantly increased puffing frequency per cigarette does increase exposure to smoke constituents for that cigarette, questions arise about whether such "harder" smoking may have negative health consequences, particularly when repeated several times each day throughout each working week. If this were the case, the health detriments of such harder smoking would need to be balanced against any reduced 24-hour smoking frequency engendered by WSBs in a calculation of net benefit or harm to smokers caused by such policies. While many work-places in Australia now require their smoking workers to clock off if they leave the building to smoke, many still regard short smoking breaks as a form of quasi "compassionate leave". Employees with other

4 610 Simon Chapman et al. forms of dependency (e.g. alcohol, narcotics, gambling) do not have work-place policies that permit them to leave their work-stations for brief periods to satisfy their desires. Our study suggests that it is possible that such well-intentioned compassion by employers may be misguided. References 1, WOODRUFF, T, J., ROSBROOK, B,, PIERCE, J, & GLANTZ, S, A, (1993) Lower levels of cigarette consumption found in smoke-free workplaces in California, Archives of International Medicine, 153, , 2, BORLAND, R,, CHAPMAN, S., OWEN, N. & Hnx, D, (1990) Effects of workplace smoking bans on cigarette consumption, American Journal of Public Health, 80, , CHAPMAN, S., BORLAND, R,, HILL, D,, OWEN, N. & WOODWARD, S, (1990) Why the tobacco industry fears the passive smoking issue. International Journal of Health Services, 20, , ZACNY, J, P,, STTTZER, M, L, & YINGUNG, J. E, (1986) Cigarette filter vent blocking: effects on smoking topography and carbon monoxide exposure, Pharmacologicy, Biochemistry and Behaviour, 25, , HATSUKAMI, D., MORGAN, S. F, & PICKENS R. W. (1987) Smoking topography in a nonlaboratory environment. International Journal of Addiction, 22, , GUYATT, A. R., KiRKHAM, A. J. T,, MARINER, D. C, BALDRY, A. G, & CuMMUNG, G, (1989) Long-term effects of switching to cigarettes with lower tar and nicotine yields, Psychopharmacology, 99, , KOLONEN, S., TUOMISTO, J., PUUSTINEN, P. & AiRAKSiNEN, M. M, (1992) Puffing behaviour during the smoking of a single cigarette in a naturalistic environment. Pharmacology, Biochemistry and Behaviour, 41, , 8, ZACNY, J. P. & STTTZER, M, L, (1985) Effects of smoke deprivation interval on puff topography. Clinical Pharmacology Therapeutics, 38, , BRIDGES, R, B,, COMBS, J, G., HUMBLE, J, W,, TuRBEK, J. A,, REHM, S, R. & HALEY, N, J. (1990) Puffing topography as a determinant of smoke exposure. Pharmacology, Biochemistry and Behaviour, 37, 29-39, 10, WEINHOLD, L, L, & STTTZER, M. L, (1989) Effects of puff number and puff spacing on carbon monoxide from commercial brand cigarettes. Pharmacology, Biochemistry and Behaviour, 33, , 11, BURLING, T, A,, STTTZER, M, L,, BIGELOW, G. E, & MEAD, A, M. (1985) Smoking topography and carbon monoxide levels in smokers. Addiction Behaviour, 10, , 12, HATSUKAMI, D, K., MORGAN, S, F,, PICKENS, R, W, & CHAMPAGNE, S, E, (1990) Situational factors in cigarette smoking. Addiction Behaviour, 15, 1-12, 13, KOLONEN, S., TUOMISTO, J,, PUUSTINEN, P, & AiRAKSiNEN, M, M. (1992) Effects of smoking abstinence and chain-smoking on puffing topography and diurnal nicotine exposure. Pharmacology, Biochemistry and Behaviour, 42, , 14, GUYATT, A, R., KiRKHAM, A. J, T,, MARINER, D, C BALDRY, A, G. & CUMMING, G. (1989) Longterm effects of switching to cigarettes with lower tar and nicotine yields, Pychopharmacohgy, 99, , KOLONEN, S,, TUOMISTO, J,, PinJSTINEN, P, & AIRAKSINEN, M. M, (1992) Puffing behaviour during the smoking of a single cigarette in a naturalistic environment. Pharmacology, Biochemistry and Behaviour, 41, , KOLONEN, S,, TUOMISTO, J,, PUUSTINEN, P. & AIRAKSINEN, M. M. (1991) Smoking behaviour in low-yield cigarette smokers and switchers in the natural environment. Pharmacology, Biochemistry and Behaviour, 40, , 17, HATSUKAMI, D, K,, MORGAN, S, F,, PICKENS, R, W, & CHAMPAGNE, S. E. (1990) Situational factors in cigarette smoking. Addiction Behaviour, 15, 1-12, 18, KOLONEN, S,, TUOMISTO, J,, PUUSTINEN, P, & AIRAKSINEN, M. M. (1992) Effects of smoking abstinence and chain-smoking on puffing topography and diurnal nicotine exposure. Pharmacology, Biochemistry and Behaviour, 42, , KOLONEN, S,, TUOMISTO, J,, PUUSTINEN, P. & AIRAKSINEN, M, M, (1991) Smoking behaviour in low-yield cigarette smokers and switchers in the natural environment. Pharmacology, Biochemistry and Behaviour, 40, , MORGAN, S, F,, GUST, S, W,, PICKENS, R, Y,, CHAMPAGNE, S, E, & HUGHES, J, R, (1985) Temporal patterns of smoking topography in the natural environment. International Journal of the Addictions, 24, , 21, HATSLIKAMI, D. K,, PICKENS, R. Y., SVIKIS, D, S, & HUGHES, J, R, (1988) Smoking topography and nicotine blood levels. Addiction Behaviour, 13, 91-95, 22, KARANCI, N, (1985) Individual nicotine requirements: the relationship between differences in nicotine intake and physiological response. Biological Psychology, 2 1, 27-42, 23, PAYNE, T, J,, SCHARE, M, L,, LEVIS, D, J, & Coi^ LETTI, G, (1991) Exposure to smoking-relevant cues: effects on desire to smoke and topographical components of smoking behaviour. Addiction Behaviour, 16, , 24, FAGERSTROM, K. O, (1978) Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addiction Behaviour, 3, ,

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