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Fewer current smokers reported annoyance than on the 1986 AUTS (34% vs 42%), but this difference may be in part due to the different methodologies and sampling frames used in these two surveys. A greater percentage of never smokers reported annoyance in 1987 than in 1986 (88% vs 83%), but the overall response was exactly the same (69% annoyed) on the two surveys. The NHIS-CEC also collected information about what non-smokers did in response to exposure to ETS. About half of respondents moved away from the exposure source, 40% did nothing, 3% did something else, and only 4% asked the person not to smoke. Despite high positive responses to perceived harm caused by and annoyance to ETS, most non-smokers remain rather passive in their behavior toward exposure sources (Davis, in press). Limiting or Banning Smoking in Public Places Roper Surveys The Roper Surveys began questioning the public about laws to prohibit smoking or to segregate smokers in 1974. The percentage of respondents favoring segregation in a variety of public places is shown in Table 4. The majority of respondents felt that smokers should at least be segregated in all the public places cited. After asking about segregation of smokers and nonsmokers, respondents were asked if amoking should be banned outright in selected public places. The percentage of respondents favoring bans is shown in Table 6L The majority of respondents favored smoking bans in retail stores, physicians' or dentists' waiting rooms, and elevators. The Roper Survey was careful to ask about segregating smokers before asking about entirely banning smoking in public places. The narrative pointed out that after recognizing the option to segregate smokers, respondents were probably less likely to be in favor of a total ban (Roper 1978). The two most important reasons given by Roper Survey respondents prior to 1978 as to why smoking should be restricted always had to do with dangers to others, specifically, cigarette smoking as a fire hazard and ETS as a health hazard to nonsmokers. In 1978, the "health of non-smokers is harmed by other people smoking in their presence" became the chief reason given by respondents (33%) in favor of public laws against smoking. Gallup Surveys and Polls In 1983, 1985, 1987, and 1989, the Gallup Poll telephone surveys conducted on behalf of the American Lung Association (ALA) asked if smokers should refrain from smoking in the presence of nonsmokers. Table 6 shows the results of these surveys. Overall, 11 Lb .l m O m N m M~

the percentage of respondents to these surveys agreeing that smokers should not smoke in the presence of nonsmokers has increased between 1983 and 1989. This trend holds true for both smokers and nonsmokers in 1987 more than three-quarters of adults, including 64% of current smokers, 76% of former smokers, and 86% of nonsmokers, held this opinion. The 1989 survey did not differentiate between smokers and nonsmokers. The Gallup Organization also surveyed U.S. residents as to their opinion regarding where smoking should be restricted or banned. With regard to smoking in certain hotels, motels, and restaurants, the majority of respondents in both 1983, 1987, and 1989 felt that certain areas should be set aside for smoking (Table 7a). Bans were less favored, especially by current smokers. In addition to the 1983 and 1987 surveys, Gallup respondents were asked if companies should have a policy on smoking at work in 1985. The results of these surveys are also shown in Table 7. By 1985, almost 90% of all respondents, including 80% of smokers and 89% of nonsmokers, felt that smoking should be assigned to certain areas of the worksite or that it should be totally banned at work. In 1987, the monthly Gallup Polls (not commissioned by the ALA) asked if respondents favored or opposed a complete ban on smoking in all public places. The results of this poll are much more strongly in favor of total bans on smoking in public places. Overall, 55% of Americans favor a ban (43% oppose and 2% have no opinion). Stratified by smoking status, 69% of nonsmokers and 25% of smokers favor such a ban. These results contrast sharply with the Roper results of almost a decade ago and are even more impressive than the ALA sponsored surveys in the same year. In the Gallup Survey conducted for the National Restaurant Association in 1987, 61% of adults reported that they preferred to sit in non-smoking sections in restaurants. These included 20% of smokers, 65% of former smokers, and 83% of never smokers. (Mills 1987) These results are similar to the AUTS results on non-smoking section preferences described below. However, an increasing trend toward favoring the prohibition of smoking in public places is evident. By 1989, the percentage of respondents favoring prohibition of smoking was 12% for hotels and motels, 23 % for restaurants, and 21% for worksites. NHIS-CEC The 1987 NHIS-CEC asked a slightly different question, which restricted the respondent to consider indoor public places. The percentage of all respondents, especially former smokers, agreeing that smoking should not be done inside public places, was higher on this survey than on the 1987 Gallup survey (Table 6b). The Gallup question applied to a general statement about refraining from smoking in the presence of nonsmokers. 12

Hamilton, Frederick, and Schneiders Survey Interestingly, the Tobacco Institute-sponsored survey (Table 5b) showed even stronger responses for restaurant and worksite restrictions in 1988. For each of these sites, the question referred to the "current policy" as a choice; for restaurants, the choice was up to customers to select smoking vs. nonsmoking sections, and for worksites, the choice was up to employers and employees to decide on worksite policies. Fewer respondents in this survey favored no restrictions on smoking than in the American Lung Association survey (restaurants 2% vs 8%, worksites 3% vs 10%). Adult Use of Tobacco Surveys Between 1964 and 1975, the percentage of respondents favorinq restrictions on smoking in public places increased from 52% to 70% (Strongly agree and mildly agree) (Table 8). The question asked in 1986 was quite different from the questions asked in the earlier surveys, but the 1986 responses are also shown in Table 8. Between 1964 and 1975, AUTS respondents favoring increased restrictions increased 18 percentage points, from 52% to 70% overall. About half of respondents in 1986 felt that restrictions against smoking were adequate, perhaps because many more restrictions were in place by 1986. In 1966 and 1975, respondents were also asked if employers have a right to regulate smoking in their places of business. In 1966, 92% felt that the "employer has a right to tell a person when or where he can smoke while on the job," whereas in 1975, 78% felt that "management should have the right to prohibit smoking in their places of business." These are somewhat different questions; the first has to do with management's right to regulate employees, and the second has to do with management's right to regulate customers, visitors, and employees. Harris Poll In 1987, respondents to the Harris Poll, performed on behalf of Prevention magazine, were asked if they think that laws should prohibit smoking in public places, should these laws require. separate smoking and nonsmoking sections, or should smoking in public places not be regulated by law. Among all respondents, 23% felt that laws should prohibit smoking in public places, 61% felt that laws should require separate smoking and nonsmoking sections, and only 13% felt that laws should not regulate smoking in public places at all (3% were unsure). Again, more than 80% of respondents, smoking and nonsmoking, favorea restrictions against smoking in public places. 13

t Public Opinion on Restrictions After Enactment Few evaluations of the acceptability of laws banning smoking in public places have been performed. New York City enacted a ban on smoking in most public places, including restaurants, in April, 1988. Three months after the ban took effect, a telephone poll of 676 randomly sampled New Yorkers (New York Times/WCBS-TV poll) revealed that 73% of respondents overall approved of the law, including 844 of nonsmokers and 43% of smokers (New York Times, 7/5/88). The 1986 AUTS asked respondents if they would select nonsmoking sections if given a choice. Overall, 61% choose nonsmoking seating in airplanes, restaurants, and other public places. This includes 82% of never smokers, 69% of former smokers, and even 14% of current smokers. These data suggest a high degree of acceptability for smoking restrictions (CDC 1988). Finally, A Clean-Air Ordinance took effect in March 1987 in Cambridge, Massachusetts, and was evaluated after three months. This evaluation revealed that 78% of Cambridge residents favored the restriction, including 41% of smokers and 90% of nonsmokers (Rigotti 1988). Exposure to ETS Many studies have been performed demonstrating the biochemically measurable exposure of nonsmokers to ETS (US DHHS 1987). However, only the 1986 AUTS has asked a nationally representative sample of residents about exposure to ETS. A subsample of 8,600 working respondents from the AUS was analyzed as to reported exposure at the worksite and as to reported policies that restrict smoking at their worksites. Table 9 shows the percentage of working respondents reporting exposure to ETS according to reported worksite smoking restrictions in place. Fifty-three percent of respondents who worked in environments with restrictive smoking policies still reported exposure to ETS. Of these, 11% reported that their worksite is "very smoky." Even among the 2.5% of respondents reporting a total ban on smoking in the workplace, 21% still reported being at least somewhat exposed to ETS at work. These data suggest that worksite restrictions decrease but do not eliminate reported exposure to ETS at the worksite. Worksite Surveys In 1987, a random sample of the members of the American Society for Personnel Administration (ASPA) reported that their worksites had restrictive smoking policies. In 1986, a similar survey showed that 14

the percentage reporting restrictive policies was only 36% (BNA 1987). The 1986 figure was nearly the same as the percentage of individual workers reporting such policies in the 1986 AUTS. Among respondents to the 1985 ODPHP Worksite Survey, 35.6% of worksites reported offering amoking control activities, including classes, information, special events, or contests. Of these companies, 76.5% also had formal smoking policies (not separated by restriction or prohibition). In addition to frequently cited benefits such as improved employee morale, improved employee health, etc., respondents reported cleaner air and work environments, fewer smokers in the workforce, and fewer complaints from nonsmokers (USPHS1988). Perceived Future Effect of Restrictive Smoking Policies Research and Forecasts, Incorporated Many of the surveys on public opinion cited above asked respondents about their beliefs and attitudes toward passive smoke. Others asked about whether the respondents favored restrictions on smoking in public places. The National Survey of Healthcare Opinions sponsored by the American Board of Family Practice (ABFP) in 1985 asked adults and Family Physicians if restrictions on smoking in medical facilities or on the job would be effective in stopping or discouraging smoking. The survey also asked if legally banning all tobacco use everywhere would be effective. Among the general public, 57% felt that restrictions in medical facilities would be effective, 40% felt that restrictions by employers against smoking on the job would be effective, and 21% felt that legally banning the use of all tobacco would be effective. Among physicians, 83% felt that such restrictions would be effective in health care facilities, 67%. felt that restrictions would be effective on the job, and 17% felt that totally banning the use of all tobacco products would be effective. These responses should be differentiated from those in other surveys that ask about support for restrictive smoking policies. The ABFP survey tried to ascertain if policies were an effective intervention for smokers to refrain from using tobacco, whereas the Gallup surveys tried to ascertain what people want in terms of protecting the nonsmoker from exposure to ETS. Few studies have actually been able to assess the effect of restrictive smoking policies on smokers' behavior, but studies from individual worksites show decreased numbers of cigarettes smoked per day without a change in the prevalence of smoking (Peterson et al., 1987, Rosenstock et al., 1986). Summary and Conclusions QO ~ 15 p aD N ~ G'1

F These data indicate an important shift in public beliefs and attitudes toward ETS over the last decade or more. While the vast majority of U.S. citizens have recognized over the years that cigarette smoking is directly harmful to the health of smokers (89% of males and 90.9% of females in 1975 [AUTS 1975]: 92% of males and 91.8% of females in 1986 [AUTS 1986), the percentage of survey respondents who believe that ETS is also harmful to the health of nonsmokers has increased dramatically (46% overall in 1974 [Roper 1978] to 81% overall in 1986 (AUTS 1986, Gallup 1988]). Even more Americans agree that ETS is harmful to vulnerable populations such as pregnant women and children. Many laws and local ordinances were put into place during the last decade, also, and the procesa of these legislative activities undoubtedly increased public awareness of ETS issues. The National Academy of Sciences Report and the Surgeon General's Report on Involuntary Smoking were released in late 1986. However, very little of the change in belief about ETS harmfulness can be attributed to the publication of these reports, even though they received enormous media attention; most of the 1986 AUS had been completed by late 1986. Therefore, the increase in reported beliefs about ETS likely reflects a growing and sustained awareness among U.S. residents about ETS as a health hazard rather than merely a public response to the highly visible Surgeon General's Report. This report may have convinced more persons abut the harmful effects of ETS, as evidenced by the results of the 1989 Gallup Survey. The somewhat discrepant results on attitudes toward laws regarding restricting smoking in public places found in the 1986 AUTS and the 1988 Harris Poll may be explained by the differences in the way the question was asked in this survey. Many laws were put into place by 1986, and respondents may have felt less concerned about increasing regulations than they did in earlier surveys, before these laws were in effect. Where these laws have been evaluated, there appears to be widespread acceptance of them. Some studies have implied that such laws have a beneficial effect on smoking behavior. (Lewit,1988) There appears to be a trend towards limiting smoking in workplaces. It is unclear as to whether workplace laws and regulations against ETS or simply the *concern for the health of nonsmokers is the stimulus for this trend. The 1986 AUTS results, which show that even with a total ban on smoking in the workplace some workers are exposed to ETS, suggests that there may be incomplete enforcement of restrictions. In worksites with segregation of smokers and nonsmokers, exposure to ETS may result from the lack of efficacy of separating smokers and nonsmokers within the same airspace. The 1986 Surgeon General's Report concluded that this level of restriction was inadequate to protect the nonsmoker from ETS (US DHHS *1987). The 1990 Health Objectives for the Nation, which were 16

adopted by the Public Health Service, recommend that all 50 states have laws by 1990 that both prohibit smoking in enclosed public places and require separate smoking areas in the workplace and in dining establishments (Public Health Service 1980). As of the publication date of the 1989 Report of the Surgeon General (January, 1989), 31 State had laws restricting smoking in public worksites, 13 had laws restricting smoking in private worksites, and 26 had laws restricting smoking in restaurants (US DHHS 1989). It is important to continue to assess public knowledge and beliefs regarding tobacco use as new information becomes available. These survey results assist public health providers in measuring the success of policies to control health hazards such as ETS. In addition, these data.emphasize the change in the social milieu surrounding tobacco use. As public attitudes shift away from the social acceptability of smoking, it may be more and more important both for smokers to quit and for potential smokers to avoid smoking. It may also be easier for policy-makers to address tobacco issues more directly if they understand the nature of and the changes in public opinions expressed through these surveys. I m ~ GA 17 ~ N GD Q

Table 1. Surveys With Information on Beliefs, Attitudes, and Exposures to Environmental Tobacco Smoke Survey Y= Sponsor Adult Use of Tobacco 1964,1966,1970 1975,1986 Office on Smoking and Health Research and Forecasts 1985 American Academy of Family Physicians Gallup Survey 1983,1985,1987 American Lung Association Gallup Survey Gallup Survey Harris Poll Roper Organization Hamilton, Frederick and Schneiders 1987 1988 1987 1974,1976,1978 1988 National Restaurant Association American Cancer Society Prevention Magazine Tobacco Institute Tobacco Institute

Table 2. Beliefs About Harmfulness Caused by Environmental Tobacco Smoke (% of Respondents) by Smoking Status ETS Harmful to Non-smokers Smoking Status rv rr n Former Nonsmokers Never Total m k r Smokers Smokers Roper 1974 30 57 46 Roper 1976 38 61 52 Roper 1978 40 69 58 Gallup 1983 64 80 84 Research and Forecasts 1985 AUTS 1986 69 82 85 87 77 (Physicians-87) 81 NHIS-CEC 1987 67 84 89 82 Gallup 1988 64 86 89 81 Gallup 1989 86% (To Adults) 88% (To Pregnant Women) 89% (To Children) g'78081199 Source: Roper Organization 1978; Gallup Surveys 1983, 1988; Adult Use of Tobacco Survey 1986, Research and Forecasts 1985

Table 3.a Annoyance Caused by Environmental Tobacco Smoke (% of Respondents) by Smoking Status Annoyed by ETS Smoking Status Survey Current Former Nonsmokers Never Total Smokers Smokers Smokers Roper 1978 5 60 AUTS 1964 20 49 64 69 46 AUTS 1966 26 52 70 48 AUTS 1970 34 63 73 78 59 AUTS 1975 35 72 79 79 63 ROPER 1978 5 60 AUTS 1986 42 73 80 83 69 NHIS-CEC 1987 34 75 88 69 Source: Adult Use of Tobacco Surveys 1964, 1966, 1970, 1975, 1986; Roper Organization 1978, NHIS-CEC 1987.