State Smoke-Free Laws for Worksites, Restaurants, and Bars --- United States, 2000--2010

State Smoke-Free Laws for Worksites, Restaurants, and Bars --- United States, 2000--2010
Weekly
April 22, 2011 / 60(15);472-475




Secondhand smoke (SHS) exposure causes lung cancer and cardiovascular and respiratory diseases in nonsmoking adults and children, resulting in an estimated 46,000 heart disease deaths and 3,400 lung cancer deaths among U.S. nonsmoking adults each year (1). Smoke-free laws that prohibit smoking in all indoor areas of a venue fully protect nonsmokers from involuntary exposure to SHS indoors (1). A Healthy People 2010 objective (27-13) called for enacting laws eliminating smoking in public places and worksites in all 50 states and the District of Columbia (DC); because this objective was not met by 2010, it was retained for Healthy People 2020 (renumbered as TU-13). To assess progress toward meeting this objective, CDC reviewed state laws restricting smoking in effect as of December 31, 2010. This report summarizes the changes in state smoking restrictions for private-sector worksites, restaurants, and bars that occurred from December 31, 2000 to December 31, 2010. The number of states (including DC) with laws that prohibit smoking in indoor areas of worksites, restaurants, and bars increased from zero in 2000 to 26 in 2010. However, regional disparities remain in policy adoption, with no southern state having adopted a smoke-free law that prohibits smoking in all three venues. The Healthy People 2020 target on this topic is achievable if current activity in smoke-free policy adoption is sustained nationally and intensified in certain regions, particularly the South.

This report focuses on laws that completely prohibit smoking in private-sector worksites, restaurants, and bars. These three venues were selected because they are a major source of SHS exposure for nonsmoking employees and the public (1). CDC considers a state smoke-free law to be comprehensive if it prohibits smoking in these three venues. Some states have enacted laws with less stringent smoking restrictions (e.g., provisions restricting smoking to designated areas or to separately ventilated areas); however, these laws are not effective in eliminating SHS exposure. The Surgeon General has concluded that the only way to fully protect nonsmokers from SHS exposure is to prohibit smoking in all indoor areas, and that separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate SHS exposure (1).

Data on state smoking restrictions for this report were obtained from CDC's State Tobacco Activities Tracking and Evaluation (STATE) System database, which contains tobacco-related epidemiologic and economic data and information on state tobacco-related legislation.* State legislation is collected quarterly from an online legal research database of state laws and is analyzed, coded, and entered into the STATE System. The STATE System contains information on state tobacco-related laws, including smoke-free policies, in effect since the fourth quarter of 1995. In addition to information on state smoking restrictions in worksites, restaurants, and bars, the STATE System contains information on state smoking restrictions in other venues, including government worksites, commercial and home-based child care centers, multiunit housing, vehicles, hospitals, prisons, and hotels and motels.

The number of states with comprehensive smoke-free laws in effect increased from zero on December 31, 2000, to 26 states on December 31, 2010 (Table 1). In 2002, Delaware became the first state to implement a comprehensive smoke-free law, followed by New York in 2003, Massachusetts in 2004, and Rhode Island and Washington in 2005. In 2006, comprehensive smoke-free laws went into effect in Colorado, Hawaii, New Jersey, and Ohio, followed by Arizona, DC, Minnesota, and New Mexico in 2007; Illinois, Iowa, and Maryland in 2008; Maine, Montana, Nebraska, Oregon, Utah, and Vermont in 2009; and Kansas, Michigan, South Dakota, and Wisconsin in 2010. The years listed are the years in which the laws took effect; in some cases the laws were enacted in a preceding year. Some state laws were expanded gradually or phased in; in these cases, the year provided is the year when the law first applied to all three of the settings considered in this study. Additionally, while most of these laws were enacted through the state legislative process, Arizona, Ohio, South Dakota, and Washington enacted their laws through ballot measures.

As of December 31, 2010, in addition to the 26 states with comprehensive smoke-free laws, 10 states had enacted laws that prohibit smoking in one or two, but not all three, of the venues included in this study (Table 2). Additionally, eight states had passed less restrictive laws (e.g., laws allowing smoking in designated areas or areas with separate ventilation). Finally, seven states have no statewide smoking restrictions in place for private worksites, restaurants, or bars (Table 2). Of note, only three southern states (Florida, Louisiana, and North Carolina) have laws that prohibit smoking in any two of the three venues examined in this report, and no southern state has a comprehensive state smoke-free law in effect (Figure).

Reported by
M Tynan,* S Babb, MPH, A MacNeil, MPH, M Griffin, MPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. *Corresponding contributor: Michael Tynan, CDC, 770-488-5286 begin_of_the_skype_highlighting 770-488-5286 end_of_the_skype_highlighting, mtynan@cdc.gov.

Editorial Note
A Healthy People 2020† objective (TU-13) calls for all states to enact laws on smoke-free indoor air that prohibit smoking in public places and worksites. Smoke-free laws substantially improve indoor air quality, reduce SHS exposure and related health problems among nonsmokers, help smokers quit, change social norms regarding the acceptability of smoking, and reduce heart attack and asthma hospitalizations (1--5). The findings in this analysis indicate that the United States made considerable progress during the past decade in increasing the number of states with comprehensive smoke-free laws that prohibit smoking in all indoor areas of worksites, restaurants, and bars, and increasing the number of U.S. residents protected by such laws. As of December 31, 2010, 26 states have implemented comprehensive smoke-free laws, and almost half (47.8%) of U.S. residents are covered by comprehensive state or local smoke-free laws.§ Despite this progress, approximately 88 million nonsmokers aged ≥3 years in the United States are exposed to SHS, as determined from levels of serum cotinine (a biological marker for SHS exposure) measured as part of the 2007--2008 National Health and Nutrition Examination Survey (6).

Before Delaware passed its smoke-free law in 2002, no state had adopted a comprehensive law making private workplaces, restaurants, and bars smoke-free. California's state smoking restrictions were enacted in 1994, but the law allows exemptions for smoking in ventilated employee smoking rooms, an exemption that remains in effect. Although a Utah law prohibiting smoking in restaurants took effect in 1995, smoking was still allowed in worksites and bars in that state until 2009. Comprehensive smoke-free laws were rare even at the local level until the 2000s. In 1990, the community of San Luis Obispo, California, adopted the first law in the United States eliminating smoking in bars. During the 1990s, smoke-free bar laws were largely limited to communities in California and Massachusetts.

The progress made during the past decade in enacting comprehensive state smoke-free laws is an extraordinary public health achievement. In the span of 10 years, smoke-free workplaces, restaurants, and bars went from being relatively rare to being the norm in half of the states and DC. Several factors appear to have contributed to this outcome. First, smoke-free laws increasingly were viewed as a worker protection measure that should apply to all employees, including those in restaurants and bars (1). Second, as state and local smoke-free laws were enacted across the country, other states and communities learned from the experiences of similar jurisdictions and were able to adapt and implement such laws (1,7). For example, New York City's adoption of a comprehensive smoke-free law in 2002 drew substantial news media coverage and established that a smoke-free law could be implemented successfully in a large, diverse, metropolitan setting (1). Finally, the Surgeon General's 2006 report, The Health Consequences of Involuntary Exposure to Tobacco Smoke (1), presented several important conclusions about the health risks associated with SHS exposure and effective protection approaches, generated extensive news media coverage, and was cited by a number of state and local policymakers as influencing their decisions on this topic. Of the 26 states that adopted comprehensive smoke-free laws, 16 did so after this report was released.

Even among the 26 states that have comprehensive smoke-free laws in effect, protections could be extended to locations that are typically exempted from state laws. For example, casino workers are heavily exposed to SHS on the job and could benefit from smoke-free policies that protect them (8). In addition, policies that prohibit smoking in the common areas and individual units (i.e., living areas) of apartments could protect nonsmoking residents, including children, from SHS infiltration from adjoining units (9,10). This is because SHS from apartment units where smoking occurs can penetrate into units in the same building that are occupied by nonsmokers (9,10).

The findings in this report are subject to at least two limitations. First, the STATE System only captures information on certain types of state smoking restrictions, primarily statutory laws and executive orders, and does not include information on state administrative laws, regulations, or implementation guidelines. As a result, the manner in which a state smoking restriction is implemented or enforced in practice might differ from how it is coded in the STATE System. Finally, the STATE System only collects state-level data; it does not capture information on local smoking restrictions.

Despite the substantial progress made nationally in the past decade, southern states lack statewide laws that prohibit smoking in worksites, restaurants, and bars. However, while no southern states have a comprehensive smoke-free law in effect, many communities in these states have adopted comprehensive local smoke-free laws.¶ All states that have not done so already could protect the health of their residents by adopting laws that prohibit smoking in workplaces, restaurants, and bars. The Healthy People 2020 target of enacting smoke-free indoor air laws that prohibit smoking in public places and worksites in all 50 states and DC can be achieved if such laws continue to be adopted at the current pace, and activities are intensified in southern states.

Acknowledgments
This report is based, in part, on contributions by R Patrick, JD, and B Ketterer, MayaTech Corporation, Silver Spring, Maryland.

References
1.US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at http://www.surgeongeneral.gov/library/secondhandsmoke/report. Accessed April 14, 2011.
2.International Agency for Research on Cancer. Evaluating the effectiveness of smoke-free policies. Lyon, France: International Agency for Research on Cancer; 2009.
3.Institute of Medicine. Secondhand smoke exposure and cardiovascular effects: making sense of the evidence. Washington, DC: The National Academies Press; 2010.
4.Mackay D, Haw S, Ayres JG, Fischbacher C, Pell JP. Smoke-free legislation and hospitalizations for childhood asthma. N Engl J Med 2010;363:1139--45.
5.Herman PM, Walsh ME. Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona's comprehensive statewide smoking ban. Am J Public Health 2011;101:491--6.
6.CDC. Vital Signs: Current cigarette smoking among adults aged ≥18 years---United States, 2009. MMWR 2010;59:1135--40.
7.Rogers EM, Peterson JC. Diffusion of clean indoor air ordinances in the southwestern United States. Health Educ Behav 2008;35:683.
8.CDC. Health hazard evaluation report: environmental and biological assessment of environmental tobacco smoke exposure among casino dealers, Las Vegas, Nevada. Cincinnati, OH: US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2009. Available at
http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0201-3080.pdf . Accessed April 14, 2011.
9.King BA, Travers MJ, Cummings KM, Mahoney MC, Hyland AJ. Secondhand smoke transfer in multiunit housing. Nicotine Tob Res 2010;12:1133--41.
10.Wilson KM, Klein JD, Blumkin AK, Gottlieb M, Winickoff JP. Tobacco-smoke exposure in children who live in multiunit housing. Pediatrics 2011;127:85--92.


* Additional information on the STATE System is available at http://www.cdc.gov/tobacco/statesystem.

† Additional information on Healthy People 2010 and Healthy People 2020 is available at http://www.healthypeople.gov.

§ Additional information is available at http://www.no-smoke.org/pdf/SummaryUSPopList.pdf .

¶ Additional information is available at http://www.no-smoke.org/pdf/percentstatepops.pdf .

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State Smoke-Free Laws for Worksites, Restaurants, and Bars --- United States, 2000--2010