Current Trends Attitudes Toward Smoking Policies in Eight States -- United States, 1993

Legislation regulating smoking has at least two functions: to protect nonsmokers from the adverse health effects of environmental tobacco smoke and to prevent young persons from smoking (1). To characterize public attitudes toward such legislation, the National Cancer Institute (NCI) and the American Cancer Society used the Behavioral Risk Factor Surveillance System (BRFSS) to survey persons in eight states * during July-August 1993 as part of the American Stop Smoking Intervention Study for Cancer Prevention (2). This report summarizes the survey findings.

BRFSS provides state-specific estimates of the prevalence of selected risk behaviors to be used for planning, implementing, and evaluating public health programs. Each month, state health departments use survey sampling and random-digit-dialing techniques (3) to conduct telephone interviews with adults aged greater than or equal to 18 years. During July-August 1993, a total of 20 questions were added to BRFSS in the eight states to assess support for policies related to cigarette smoking (4). To estimate the state population prevalences (5), data were weighted to the age-, race-, and sex-specific population counts from the most current census (or intercensal estimate) in each state and for the respondent's probability of selection. SUDAAN (6) was used to calculate the 95% confidence intervals for the prevalence estimates. For this study, sample sizes ranged from 252 to 431 per state; state-specific response rates for completed interviews ranged from 63.6% to 93.3%. Current smokers were defined as persons who had smoked at least 100 cigarettes and who reported being a smoker at the time of the interview. Environmental Tobacco Smoke

Respondents were given a list of public locations and asked whether, for each setting, smoking should be allowed in all areas (do not restrict), allowed in some areas (restrict), or not allowed at all (ban). Public opinion about whether to restrict or ban smoking varied across settings Table_1: support was greater for banning smoking in fast-food restaurants (range: 42.5%-63.0%) and at indoor sporting events (55.4%-66.9%) than in sit-down restaurants (39.5%-50.6%) and indoor malls (33.4%-56.5%). Overall, smokers were less likely than nonsmokers to support banning smoking in the different locations. Preventing Teenagers from Smoking

Respondents were given a list of five strategies that might prevent teenagers from smoking and asked whether they believed the strategies were not at all effective, somewhat effective, or very effective. Each of the strategies was believed to be effective (i.e., somewhat or very) by most respondents Table_2: in particular, 65.3%-77.8% of respondents believed that banning all smoking inside and outside school property would be an effective strategy. Most respondents (79.1%-89.6%) favored a ban on smoking inside school buildings that applies to students, visitors, and teachers; 66.2%-85.1% of respondents favored a ban on the use of any tobacco product (including cigarettes, cigars, pipes, and chewing tobacco) at school-sponsored events (e.g., football games and field trips).

Banning all cigarette advertising was considered to be an effective strategy in reducing smoking among teenagers by 54.3%- 71.9% of respondents Table_2. In addition, 49.8%-66.5% of respondents believed that tobacco advertising influences persons to buy tobacco products. The proportion of respondents who supported a ban on advertising tobacco products at sports stadiums and arenas ranged from 67.7% to 78.2%, and the proportion who supported a ban on advertising tobacco products on billboards ranged from 62.6% to 77.2%.

High proportions of respondents believed in the effectiveness of selected measures to limit teenager's access to tobacco products, including stronger enforcement of laws prohibiting the sale of cigarettes to minors (77.1% to 85.5%), banning all cigarette vending machines (69.3% to 79.3%), and increasing the price of a pack of cigarettes (55.4% to 67.7%) Table_2. Most respondents (54.1% to 68.8%) favored increasing the tax on a pack of cigarettes $1 per pack; however, many (47.9% to 66.1%) believed that such an increase would be unfair to cigarette smokers. Belief in the effectiveness of teenage access restrictions was high among both smokers (41.8% to 79.3%) and nonsmokers (60.2% to 88.4%).

Reported by the following BRFSS coordinators: D Hargrove-Roberson, MSW, Louisiana; J Jackson-Thompson, PhD, Missouri; G Boeselager, MS, New Jersey; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; M Lane, MPH, South Carolina; R Diamond, MPH, Texas; K Holm, MPH, Washington. Surveillance Program, National Cancer Institute, National Institutes of Health. Div of Chronic Disease Control and Community Intervention, Office of Surveillance and Analysis, and Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report are consistent with previous studies that have documented public support for regulating tobacco use in public places (2). For example, in 1987, 72% of adults in seven Minnesota communities favored prohibiting smoking in public buildings (7). In 1989, findings from a survey conducted for the NCI Community Intervention Trial for Smoking Cessation (COMMIT) (8) indicated that among persons in 10 communities, 62%- 100% supported restricting or banning smoking in selected locations. Most favored restricting smoking in five locations (bars, restaurants, bowling alleys, private worksites, and government buildings) and banning it in three other locations (indoor sports arenas, hospitals, and doctors' offices).

These findings also confirm increasing support for banning smoking in restaurants (9). For example, 16.2% to 32.3% of respondents in the COMMIT study (8) favored banning smoking in restaurants, compared with 39.5% to 63.0% of BRFSS respondents. In addition, the BRFSS findings distinguish between fast-food and sit-down restaurants. Support for banning smoking in fast-food restaurants was stronger than support for banning smoking in sit-down restaurants, possibly because of the perception that fast-food restaurants tend to cater to and be frequented by children and adolescents (2).

Previous studies (2) have documented high levels of support for measures to prevent teenagers from smoking (7,10). The BRFSS findings indicate widespread belief in the effectiveness of such measures and suggest broad support for banning the use of any tobacco product at school-sponsored events. Finally, the BRFSS findings indicate support for recommendations issued by the Institute of Medicine (2), which include the need to 1) adopt and enforce tobacco-free policies in all public locations, especially those that cater to and are frequented by children and youths; 2) adopt tobacco-free policies that apply to persons attending events sponsored by organizations involved with youths; 3) restrict the advertising and promotion of tobacco products; and 4) increase the excise tax on cigarettes.

References

1. Pederson LL, Bull SB, Ashley MJ, Lefcoe NM. A population survey on legislative measures to restrict smoking in Ontario: 3 variables related to attitudes of smokers and nonsmokers. Am J Prev Med 1989;5:313-22.

2. Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, 1994.

3. Waksburg J. Sampling methods for random digit dialing. J Am Stat Assoc 1978;73:40-6.

4. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance, 1981-1987. Pub Health Rep 1988;103:366-75.

5. Siegel PZ, Brackbill RM, Frazier EL, et al. Behavioral risk factor surveillance, 1986-1990. In: CDC surveillance summaries (December). MMWR 1991;40(no. SS-4):1-23.

6. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.5 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

7. Forster JL, McBride C, Jeffery R, Schmid TL, Pirie PL. Support for restrictive tobacco policies among residents of selected Minnesota communities. Am J Health Promot 1991;6:99-104.

8. CDC. Public attitudes regarding limits on public smoking and regulation of tobacco sales and advertising -- 10 U.S. communities, 1989. MMWR 1991;40:344-5,351-3.

9. CDC. Preventing tobacco use among young people -- a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

10. Marcus SE, Emont SL, Corcoran RD, et al. Public attitudes about cigarette smoking: results from the 1990 Smoking Activity Volunteer Executed Survey. Pub Health Rep 1994;109:125-34.

* Louisiana, Missouri, New Jersey, Ohio, Oklahoma, South Carolina, Texas, and Washington.

Table 1. Percentage of persons * who favored restricting or banning + smoking in selected locations -- eight states, United States, 1993
================================================================================================================================================================
                           Fast-food restaurant                Sit-down restaurant                  Indoor malls                   Indoor sporting events
                       --------------------------------   -------------------------------   --------------------------------   ---------------------------------
                          Restrict            Ban            Restrict            Ban           Restrict           Ban             Restrict          Ban
               Sample  ----------------  --------------   --------------   --------------   --------------    --------------   --------------  -----------------
State           size     %   (95% CI &)    %   (95% CI)     %   (95% CI)     %   (95% CI)     %   (95% CI)      %   (95% CI)     %   (95% CI)     %   (95% CI)
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Louisiana       275    47.9  (+/-6.3)    46.8  (+/-6.2)   49.1  (+/-6.3)   44.3  (+/-6.4)   47.2  (+/-6.3)    44.0  (+/-6.1)   34.3  (+/-5.3)   58.2  (+/-5.4)

Missouri        254    46.4  (+/-7.0)    49.0  (+/-6.9)   55.5  (+/-6.9)   39.5  (+/-6.8)   52.0  (+/-7.5)    39.4  (+/-7.2)   35.6  (+/-6.8)   57.8  (+/-6.6)

New Jersey      261    41.0  (+/-6.8)    51.0  (+/-7.0)   49.0  (+/-7.0)   44.8  (+/-7.0)   34.1  (+/-6.3)    46.9  (+/-7.1)   29.7  (+/-6.1)   56.4  (+/-6.9)

Ohio            258    46.8  (+/-6.9)    50.2  (+/-6.9)   55.1  (+/-6.9)   41.2  (+/-6.8)   56.2  (+/-6.8)    33.4  (+/-6.5)   33.6  (+/-6.4)   55.4  (+/-6.8)

Oklahoma        252    52.6  (+/-6.9)    42.5  (+/-7.0)   54.3  (+/-6.8)   42.3  (+/-6.8)   57.5  (+/-6.8)    35.5  (+/-7.1)   35.2  (+/-7.5)   60.8  (+/-7.7)

South Carolina  371    36.8  (+/-5.5)    56.8  (+/-5.6)   46.0  (+/-5.9)   50.0  (+/-5.8)   48.4  (+/-6.2)    45.6  (+/-6.3)   25.1  (+/-5.1)   66.9  (+/-5.2)

Texas           405    41.4  (+/-5.4)    50.5  (+/-6.0)   50.0  (+/-6.2)   45.8  (+/-5.8)   46.9  (+/-6.1)    45.3  (+/-6.0)   34.1  (+/-5.6)   57.0  (+/-6.3)

Washington      431    33.1  (+/-4.9)    63.0  (+/-5.0)   45.4  (+/-5.1)   50.6  (+/-5.1)   39.0  (+/-5.0)    56.5  (+/-5.1)   29.1  (+/-4.6)   66.8  (+/-4.8)
----------------------------------------------------------------------------------------------------------------------------------------------------------------
* Aged >=18 years.
+ Response categories included: allowed in all areas (do not restrict), allowed in some areas (restrict), not allowed at all (ban), don't know, and
  refused to answer.
& Confidence interval.
================================================================================================================================================================

Table 2. Percentage of persons * who believed that selected strategies would be somewhat or very effective + in
keeping teenagers from smoking cigarettes -- eight states, United States, 1993
================================================================================================================
                          Ban smoking       Ban all          Ban all          Strongly         Increase
                          on school         cigarette        vending          enforce          price of
                          property +        advertising      machines         laws             cigarettes
                        ----------------  --------------   --------------   --------------   --------------
State       Sample size   %   (95% CI &)    %   (95% CI)     %   (95% CI)     %   (95% CI)     %   (95% CI)
----------------------------------------------------------------------------------------------------------------
Louisiana       275     75.8  (+/-5.2)    71.9  (+/-6.1)   76.0  (+/-5.6)   85.5  (+/-4.3)   67.0  (+/-6.4)

Missouri        254     65.3  (+/-6.2)    54.3  (+/-7.0)   69.3  (+/-6.2)   77.6  (+/-5.7)   62.0  (+/-6.5)

New Jersey      261     76.4  (+/-6.2)    70.2  (+/-6.4)   75.6  (+/-5.7)   77.1  (+/-5.8)   62.5  (+/-6.6)

Ohio            258     72.1  (+/-6.2)    58.0  (+/-6.8)   75.7  (+/-5.8)   78.8  (+/-5.9)   59.0  (+/-6.8)

Oklahoma        252     77.8  (+/-6.2)    70.2  (+/-6.1)   79.3  (+/-5.5)   80.9  (+/-5.4)   55.4  (+/-6.7)

South Carolina  371     75.8  (+/-5.1)    60.6  (+/-5.4)   72.9  (+/-5.4)   78.8  (+/-4.9)   58.3  (+/-5.6)

Texas           405     73.6  (+/-4.8)    64.9  (+/-5.9)   73.3  (+/-5.5)   77.4  (+/-4.9)   63.0  (+/-5.8)

Washington      431     72.0  (+/-4.6)    71.0  (+/-4.8)   78.7  (+/-4.4)   84.3  (+/-3.7)   67.7  (+/-4.8)
----------------------------------------------------------------------------------------------------------------
* Aged >=18 years.
+ Response categories included: not at all effective, somewhat effective, very effective, don't know, and
  refused to answer.
& Confidence interval.
================================================================================================================

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