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Table 1. Surveys With Information on Beliefs, Attitudes, and Exposures to Environmental Tobacco Smoke Survey YLLL Suonsor 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 6b. If People Want to Smoke, They Should Not Do So Inside Public Places Where it Might Disturb Others. (1987) Aaree Dise¢ree No Oninion Current Smokers 67 22 9 Former Smokers 80 10 8 Never Smokers 89 5 5 All Respondents 81 11 7 Source: NHIS-CEC 1987

prohibition policy in a halth maintainance organization. American J. Publ. Health 76(8):1014-1015, 1986. Support for smoking ban. New York Times, July 5, 1988:B2. i 20

Table 8. Restrictions on Smoking in Public Places (% of respondents favoring increase) by Smoking Status, 1964, 1966, 1970, 1975, and 1986 Smokina Status 1964 1966 1970 1975 1986* Current Smokers 34 35 42 51 23 Former Smokers 56 58 61 77 53 Never Smokers 68 67 68 82 63 All Respondents 52 52 57 70 50 *The question for the first four surveys read "The smoking of cigarettes should be allowed in fewer places than it is now." The question in 1986 read "There are already enough restrictions on where people can amoke." Source: Adult Use of Tobacco Surveys 1964, 1966, 1970, 1975, and 1986.

Table 4. Public Opinion (X of Respondents) on Separation of Smokers and Nonsmokers in Selected Public Places, 1978 Smokina In separate should be permitted sections Anywhere S_ 7 In trains, airplanes and buses 91 7 In theaters 83 11 In eating places 73 25 At indoor sporting events 73 22 At public meetings 67 28 In train, plane, bus stations 62 34 In work places or offices 61 34 In barber or beauty shops 53 42 Source: Roper Organization 1978

Table 5.a Public Opinion (% of Respondents) on Banning Smoking in Selected Public Places, 1978 Should smokina be Banned b Not banned i In elevators 86 12 In doctors' or dentists' waiting rooms 69 27 In retail stores 55 41 In theaters 44 47 At indoor sporting events 34 57 At public meetings 32 58 In city, state or federal buildings 32 63 In taxis 32 64 In trains, planes, buses 26 65 In eating places 23 68 In barber or beauty shops 21 70 In work places or offices 17 73 In train, plane, bus stations 16 75 Source: Roper Organization 1978

TABLES AND FIGIIREB. CHAPTER 1 21

Table 5.b Public Opinion (% of Respondents) on Prohibiting Smoking or Retaining Current Policies in Selected Public Places, 1988 C~rr r yt Policy Prohibit all Smokinc No Restriction _, In Restaurants 74 24 2 In Worksites 76 20 3 Source: Hamilton, Frederick, and Schneidera 1988

Table 3.b Reactions to Secondhand Smoke in Public Places, 1987* Former Never Total e s Smokers Ask Person Not to Smoke 4 5 4 Move Away 52 46 52 Do Nothing 40 47 40 Something else 3 3 3 *Not asked of current smokers Source: 1987 HHIS-CEC

Table 6.a Should Smokers Refrain from Smoking in the Presence of Nonsmokers? (% of Respondents) by Cigarette Smoking Status, 1983, 1985, 1987, and 1989 Smokins Status Agree Disearee Don't K^-ow $urvevYear M = _§.Zi$ i3LU M _@,Q M _!65.M LU Current Smokers 55 62 64 39 37 31 6 1 5 Former Smokers 70 78 76 22 22 19 8 0 5 Nonsmokers 82 85 86 14 15 10 4 * 4 All Respondents 69 75 77 82 25 24 19 15 6 1 4 2 Less than 0.5% Source: Gallup Surveys 1983, 1985, 1987, 1989

Table 2. Beliefs About Harwfulness Caused by Envirm.untal Tobacco Smoke (% of Respondents) by Smoking Status ETS Harnful to Non-snokers Smoking Status rv rr n Former Nonsmokers Never Ta Smokers k r m ke3 Roper 1974 30 57 46 Roper 1976 38 61 52 Roper 1978 40 69 58 Gallup 1983 64 80 84 Research and Forecasts 1985 AVTS 1986 69 82 85 87 77 (Physicians-87) 81 NHIS-CEC 1987 67 84 89 82 Gallup 1988 64 86 89 81 Gallup 1989 86X (To Adults) 88% (To Pregnant Woawn) 89% (To Children) $7808189 Source: Roper Organiaation 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 Survey Current Smokinx Former Status 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, NBIS-CEC 1987.

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 N$IS-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 5. 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 iti 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 00 ~ ~ O OD N

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 17

Table 9. Reported Worksite Smoking Policies and Worksite Exposure to Environmental Tobacco Smoke (% of Respondents), 1986 Worksite Policv %&evorting Policv %&eoortina Exnoaure to ETS Not Restricted 55.4 64.8 Restrictive 42.1 53.2 Total Ban 2.5 21.1 Source: Adult Use of Tobacco Survey 1986

racial, and age distribution of the U.S. population based on the 1986 Current Population Survey of the U.S. Bureau of the Census. More detailed information on attitudes, beliefs, and exposure regarding ETS was collected in this survey. National Health Interview Survey The National Health Interview Survey of Cancer Epidemiology and Control (NHIS-CEC) collected data in-person from 22,000 adults >_18 years of age in households throughout the United States. The data are weighted to reflect the entire U.S. population, and the overall response rate for NHIS-CEC was 82%. Respondents were asked about the harmfulness of ETS and about attitudes toward passive smoking. These included perceived annoyance and whether smoking should occur inside public places. Nonsmokers were asked about their actions in response to smokers' lighting up in their presence. Other Surveys Worksite Surveys Several surveys of worksites and businesses have been carried out in the last several years. These are described in detail in The 1986 and 1989 Surgeon General's Reports (U.S. DHHS 1987, 1989). The Bureau of National Affairs and the American Society for Personnel Administration (ASPA) conducted a mail-in questionnaire survey of ASPA members. Six hundred twenty-three respondents reported on activities related to smoking in the workplace. The response rate was 54%. A similar survey had been carried out in 1986 on 662 businesses, and results on the presence or absence of restrictions were comparable. In 1988, the Office of Health Promotion and Disease Prevention (OHPDP) of the United States Public Health Service reported on worksite health promotion activities, including smoking control. The survey was carried out in 1985 on a sample drawn from the Dun and Bradstreet list of businesses. Using a telephone interview, 320 worksites with 50-90 employees and 1,038 worksites with 100 or more employees, drawn from a probability sample based on geographic region, size of firm, and industry type, were surveyed. Questions about smoking restrictions were included. In December 1984, the American Board of Family Practice (ABFP) sponsored a National telephone survey of 1007 adults >_18 years of age and of 303 Family Physicians conducted by Research and Forecasts, Incorporated. The results were published in a report entitled, Riohts and ResDonsibilities: Healthcare Octions. Questions were asked regarding beliefs about the harmfulness of ETS, the rights of smokers and non-smokers, and whether smoking restrictions are effective in stopping or discouraging smoking. The final sample response rates were 41% for the general public 9

telephone survey of 1500 persons which was conducted by Hamilton, Frederick, and Schneiders (Hamilton, Frederick and Schneiders, 1989). This survey asked about various public policy issues and was to measure levels of support on governmental policy on smoking. The respondents were asked what they thought about restrictions on smoking in restaurants and worksites. The results were not reported by smoking status of the respondents, but 401 (27%) of the respondents were smokers. The response rates were not reported. Other Public Ooinion Surveys Gallup Surveys Gallup Poll results have been- published monthly by the Gallup organization since 1965. Surveys are either personal interviews or by telephone, with a population-based sample of at least 1000 adults, >_ 18 years of age. The sampling error for overall responses is reported to be no more than ±ZA (Gallup Report 1987). In addition, Gallup surveys may be commissioned by a variety of organizations. The surveys reported here were commissioned by the American Lung Association (1983, 1985, 1987, and 1989) and The American Cancer Society (1988) to study both the prevalence of smoking and public opinions regarding smoking issues. An additional Gallup Survey was commissioned by the National Restaurant Association (1987) to obtain public opinion on smoking in restaurants. The 1989 Gallup Survey sponsored by the American Lung Association did not ask respondents about their smoking status. Harris Poll Louis Harris and Associates have performed eight national surveys between 1974 and 1987 using probability samples of adults aged 18 and older. These surveys were conducted on behalf of various organizations, including Prevention magazine and Pacific Mutual Life Insurance Co., to ascertain health practices in Americans. In 1987, 1250 persons were also asked about regulating smoking in public places. Government Soonsored Surveys Adult Use of Tobacco Surveys (AUTS) The Office on Smoking and Health (formerly, National Clearing House on Smoking and Health) commissioned surveys of adult smoking behavior, attitudes, and beliefs beginning in 1964. These surveys oversampled smokers, but final results were weighted to represent the United States resident population aged 21 years and older (1964, 1966, 1970, 1975). The 1986 AUS oversampled smokers and also collected data from persons aged 17 and older. The final data in this survey were weighted to reflect the educational, regional, 8

CHAPTER 1 PASSIVE SMOEING--BELIEFB, ATTITUDEB, AND EXPOSURES IN TBB UNITED STATES Thomas E. Novotny, MD Chief, Program Services Activity office on smoking and Health Centers for Disease Control Introduction The relationship between public attitudes, policies, and exposure to certain health hazards is complex. with the release of the *18th Surgeon General's report on smoking and health, "The Health consequences of Involuntary Smoking," (US DHHS 1987) public attention on the issue of Environmental Tobacco Smoke (ETS) was more strongly focused than ever before. For many years, however, pollsters, the tobacco industry, and the health promotion community have surveyed the public concerning attitudes toward ETS and toward restrictions against exposure to ETS. The Surgeon General's Report described data from several of these surveys as well as results from evaluations of worksite and local policy changes. Additional detailed data on public beliefs and attitudes toward smoking in general are found in the 1989 Surgeon General's Report: Reducina the Health Conseauences of Smokina -- 25 vears of Proaress. Recently, surveys have also included both questions on beliefs about the harmfulness of ETS to the nonsmoker and on respondents' reported exposure to ETS. In addition to such individual exposure data, surveys of worksites and of personnel managers have provided information about restrictions on ETS exposure to workers. Because changes in public attitudes toward ETS usually precede laws or policies regarding ETS exposure (US DHHS 1987), an examination of trends in these data over time is useful. This section will consider several different nationally-based data sets andsummarize the most important findings from them. e5 The surveys reported in this section are summarized in Table 1. 6

Table 7.a Opinions Regarding Smoking In Selected Public Places and Worksites, (% of respondents) by Smoking Status, 1983, 1985, 1987, 1989 Hotels and Motels Set Aside Totally Ban Certain Areas Snokina No Restrictions Don't Know. !3 JI In jU flZ M M AZ .'94 -M M '94 8'780819'7 Current Smokers 49 61 7 6 42 30 2 3 Former Ssokers 54 72 13 9 27 16 6 3 Nonswokers 60 68 15 14 20 15 5 3 All Respondents 54 67 63 12 10 12 30 20 18 4 3 6 Restaurants Set Aside Totally Ban Swokina Certain Areas No Restrictions Don't Know _ M 3? _82 !N ~ $1 Current Smokers 74 79 12 7 13 13 1 1 Forwr Smokers 71 74 19 19 9 6 1 1 Nonsmokers 65 71 26 23 7 5 2 1 A11 Respondents 69 74 66 19 17 23 10 8 B 2 1 3 Worksites Set Aside Certain Areas Totally Ba Smoking n No Restrictions Don 't K now !3 M '9Z M _g3 M ~07 94 M In _5i 18 .Z M Current Snokers 64 76 72 11 4 8 21 19 1B 4 1 2 For.er Sewkers 68 80 73 14 12 16 14 6 8 4 2 3 Nonsmokers 63 80 67 24 9 23 9 10 8 4 1 2 All Respondents 64 79 70 65 17 8 17 21 15 12 11 10 4 1 2 4 Source: Gallup Surveys 1983, 1985, 1987. 1989

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 104). Adult Use of Tobacco Surveys Between 1964 and 1975, the percentage of respondents favoring 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 e. 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 801 of respondents, smoking and nonsmoking, favored restrictions against smoking in public places. 13

These surveys may report discrepant results. Most discrepancies can be explained by the differences in methodology, especially in the ways that questions are worded. Nonetheless, comparisons between surveys are useful. The only Roper Survey commissioned by the Tobacco institute available to the public was done in 1978. The narrative from this study included data from 1974 and 1976 also. Additional surveys on public attitudes have been performed by Roper or other agencies for the industry, but many of these are not available. A recent Tobacco Institute-sponsored survey of attitudes toward government policies conducted by Hamilton, Frederick, and Schneider has been made available and is reported..The 1974-1978 Roper surveys permit comparisons of data collected for the tobacco industry with similar data collected in the 1970s by the Offiee on Smoking and Health (formerly known as the National Clearinghouse on Smoking and Health). Additional national surveys of public attitudes and beliefs were performed in the 1980's by the Gallup Organization and the Louis Harris Co. National surveys of worksites were also carried out in the 1980's in conjunction with increasing restrictions and laws against smoking in public places throughout the United States (US DHHS 1987). These surveys, which indicate the degree to which workers may be protected from ETS exposure, permit comparisons with exposures reported by individual respondents in the 1986 Adult Use of Tobacco Survey (AUTS) of the Office on Smoking and Health. In addition, the 1987 Gallup survey of attitudes toward smoking in restaurants described public opinion about exposure in an additional, policy-relevant, nonworksite setting. The 1987 National Health Interview Survey of Cancer Epidemiology and Control collected information about respondents' actions in response to ETS exposure. Data sources and Methodology Tobacco Industry Surveys Roper Surveys The Roper organization conducted six biennial national opinion surveys for The Tobacco Institute between 1966 and 1978. The *1974, 1976, and 1978 surveys focused on the passive smoking/non-smoker's rights issue (Roper 1978), whereas all six surveys dealt with public attitudes towards the smoking and health issue, towards the tobacco industry itself, and towards *goverriment regulation of tobacco. The surveys were telephone-based, but information about the exact methodology, sample sizes, and response rates is unavailable. In December 1988, the Tobacco Institute sponsored a National adult 7

and 37% for physicians. Data for the general public portion of this survey were weighted to reflect the 1985 U.S. Census for 1985. The physicians surveyed represented a random sample of U.S. Family Physicians. Results of Surveys Perceived Harmfulness of Environmental Tobacco Smoke Although the questions asked on the various surveys regarding ETS may differ somewhat, comparisons between surveys are still useful. The Roper Surveys asked questions regarding harm and annoyance caused by ETS. All AUTS surveys asked about annoyance caused by ETS, but only the 1986 AUTS asked if respondents believed that ETS was harmful to the nonsmoker. The 1983 and 1988 Gallup Surveys asked if respondents believed that smoking is hazardous to the health of nonsmokers. The 1978 Roper Survey and both the 1986 AUTS and 1988 Gallup surveys provide interesting information on the change in public beliefs about the harmfulness of ETS to the nonsmoker over the last several years. The 1985 ABFP Survey asked both adults and physicians if they believed nonsmokers are harmed by breathing in the smoke of others in the same room. Table 3 shows the responses to survey questions regarding harmfulness caused by ETS. Between 1974 and 1986, the percentage of smokers who believed that ETS is harmful to the health of the nonsmoker more than doubled. In 1974, most nonsmokers believed that ETS is harmful to health in general, and the percentage of those who held this belief increased substantially to almost 90% in 1989 and 1988. Overall, the percentage of persons who believe ETS is harmful to health increased from 46% in 1974 to 81% in 1988. In an additional question on the 1986 AUS, 69% of non-smokers (62% of former smokers and 74% of never smokers) felt that ETS is harmful to their own personal health. The resluts of the 1989 Gallup poll suggest that there is even stronger belief in the harm of ETS to pregnant women and children. These data suggest that there has been a major change in the perception of ETS as a health hazard over the last decade. Annoyance Caused by Environmental Tobacco Smoke The AUTS surveys show an increasing trend in the percentage of respondents who are annoyed by ETS, (from 46% to 69% of all respondents between 1964 and 1987) (Table 3a). Data regarding annoyance to ETS from Roper Surveys other than the 1978 survey are not available. However, the results of the 1978 Roper Survey report that 60% of nonsmokers and 5% of smokers were annoyed by the smoke of others. These data suggest that increasingly fewer Americans are tolerant of ETS exposure The results of the 1987 . m NHIS-CEC indicate increased annoyance to ETS as well (Table 3a). -1 m 10 O OD YA GC O.

References f American Lung Association. on-the-Go Americans Prefer Smoke-Free Air (Press-Release). December 4, 1987. Bureau of National Affairs. Where there's smoke: problems and policies concerning smoking in the workplace. A BNA special report, 2nd ed, Rockville, Maryland: Bureau of National Affairs, 1987. CDC. Cigarette smoking in the United States, 1986. MMWR 36(35):581-585, 1987. CDC. Passive smoking: Beliefs, attitudes, and exposures--United States, 1986. MMWR 37(15):239-241, 1988. Davis, RM. Passive smoking: Beliefs, attitudes, and exposures - - United States, in press. Gallup Organization. Cigarette Smoking. The Gallup Report March 258:2-6, 1987. Research and Forecasts, Inc. Rights and responsibilities -- a national survey of health care opinions sponsored by the Amerian Board of Family Practice (ABFP). ABFP, Lexington, KY, 1985. Gallup organization. Survey of attitudes toward smoking. Conducted for: the American Lung Association. The Gallup Organization, Inc. Princeton, New Jersey. July 1985. Gallup Organization. A telephone survey of 1549 adults conducted in 1988 for the American Cancer Society. The Gallup Report 1988 (NO.268): _ . Gallup Organization. Survey of attitudestoward smoking. 1 Conducted for the American Lung Association. The Gallup Organization, Inc., Princeton, NJ August, 1989. Harris, Louis and Associates. Prevention in America V: Steps people take or fail to take for better health, 1987. Survey performed for Prevention Magazine. May 13, 1988. Appendix B:page 8. Lewit, EM. Clean indoor air lws and male/female smoking differences. Final report of program activities. Grant # DAO 3641-02. Newark, NJ, Univ. of Medicine & Dentistry. Mills, I.Attitudes toward smoking in restaurants (Gallup Survey). Restaurants USA. May 1987. 18

National Center for Health Statistics. Smoking and other tobacco use: United States, 1987. NCHS Series 10, N 169, DHHS PUbl. #1. CPHS 89-1597. National Clearinghouse for Smoking and Health. Adult use of tobacco 1970. US Department of Health, Education, and Welfare. Public Health Service. June 1973. National Clearinghouse for Smoking and Health. Adult use of tobacco 1975. US Department of Health, Education, and Welfare. Public Health Service. Center for Disease Control, June 1977. National Clearinghouse for Smoking and Health. Use of tobacco: practices, attitudes, knowledge, and beliefs, United States-Fall 1964 and Spring 1966. U.S. Department of Health, Education, and Welfare. Public Health Service July 1969. Office on Smoking and Health. The health conseguqnces of involuntary smoking: a reoort of the Suraeon Ge eral. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1987; DHHS publication no. (CDC) 87-8398. Office of Health Promotion and Disease Prevention. National Survey of Worksite Health Promotion Activities. U.S. Department of Health and Human Services. Public Health Service. Summer 1987. Office on Smoking and Health. Reducing the Health Consequences of Smoking -- 25 Years of Progress. A Report of the Surgeon General. U.S. DHHS, Public Health Service, CDC, 1989. Peterson, LR, Helgerson, SD, Gibbons, CM, Calhoun, CR, Ciacco, KH, and Pitchford, KC. Employees smoking behavior changes and attitudes following a restrictive policy on worksite smoking in a large company. PUblic Health Persp. 103(2):115-120, 1988. Public Health Service. Promoting health/preventing disease: objectives for the nation. US Department of Health and Human Services, Public Health Service, 1980. Rigotti NA, Stoto MA, Kleiman M, Schelling TC. Implementation and impact of a Cambridge, Massachusetts ordinance restricting smoking in public places and the workplace. In Smoking and Health 1987. Proceedings of the 6th World Conference on Smoking and Health, Tokyo, 9-12 November 1987.Excerpta Medica, Amsterdam, 1988. Roper Organization. A study of public attitudes toward cigarette smoking and the tobacco industry in 1978. New York: Roper Organization, May 1978. Rosenstock IM, Stergachis A, Heaney C. Evaluation of smoking 19

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-smokinq 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

the percentage reporting restrictive policies was only 36% (BHA 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 47 ~1 15 p W N OD G1

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 (464 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 procese 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

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 84% 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