Philippe Boucher's Rendez-vous with . . . Elizabeth Gilpin
about Clean Indoor Air: Advances in California, 1990-1999
Rendez-vous with . . . Elizabeth Gilpin
Clinical Professor of Biostatistics
Department of Family and Preventive Medicine University of California, San Diego
La Jolla, California, USA
By Philippe Boucher
Monday, May 20 2002
PB : Thank you Elizabeth for accepting our rendez-vous.
May I ask you to introduce yourself ?
Elizabeth Gilpin: I have worked as a statistician in medical research since 1974, and in other areas before then. My interest in tobacco control dates from my participation in the baseline California Tobacco Survey (CTS) in 1990. In 1996, I was co-principal investigator, and in 1999 and 2002 Principal Investigator for the CTS. Besides the contracts to conduct these surveys, I have several other grants for data analysis of results from the CTS and from other public-use, tobacco-related data sources. These will be my primary focus in the next few years.
Q1. The article you published in the May 2002 issue of the American Journal of Public Health documents advances in California from 1990 to 1999 as far as clean indoor air is concerned. What do you see as the main milestones of this period?
Elizabeth Gilpin: The first milestone was the voter-approved $.25/pack cigarette excise tax increase in 1989 which funded the California Tobacco Control Program. Some of the early efforts of this program involved supporting activists and local health departments with efforts to gain local ordinances promoting clean air in public and work places. Some of the early media sponsored by the Program also was devoted to the dangers of secondhand smoke. These efforts rallied public support for clean air, resulting in the passage of AB13 in 1994, which prohibits smoking in indoor work areas. I think that the success of this initiative encouraged voter approval of a further $.50/pack excise tax increase which took place in January 1999.
Q2. To evaluate advances you rely on surveys that include relevant questions. What are those basic questions? When did they start being asked? Are they now systematically asked in evaluation surveys or do they remain a Californian specialty?
Elizabeth Gilpin: When workplace smoking restrictions were up to the company or required by local ordinance, the 1990 and 1992 CTS asked smokers three questions:
1) Do you/does your employer have an official policy that restricts smoking in any way?These questions were adopted by other surveys of smoking behavior, such as the tobacco-use supplement to the Current Population Survey. After the passage of AB13, all California indoor work areas (with few exceptions, bars, restaurant bars, game rooms) should have been smoke-free, so in 1996 the question was changed to: Is your place of work completely smoke-free indoors? AB13 does allow for some exceptions, such as specially-ventilated smoking rooms. Thus, if workers answered no to the above questions, there were follow-up questions to determine whether the workplace had special smoking rooms, or where the respondent perceived that smoking was allowed.
If affirmative, respondents were asked:
2) Which of the following best describes (your/your employer's) smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?
3) Which of the following best describes (your/your employer's) smoking policy for areas in which employees work? Response choices were: not allowed in any, allowed in some, and allowed in all.
In all survey years, all nonsmoking indoor workers were asked: During the past 2 weeks, has anyone smoked in the area in which you work?
This is the main question used to evaluate compliance with AB13, and it is also now used in other population surveys.
Because of the recognition of the dangers of secondhand smoke to children, and the potential of smoking restrictions in the workplace to foster decreased consumption and even quitting among smokers, the 1992 CTS began asking a question about home smoking restrictions: What are the smoking rules or restrictions in your household, if any? Would you say ... smoking is completely banned, smoking is generally banned with few exceptions, smoking is allowed in some rooms only, or there are no restrictions on smoking.
This question is also now being asked in other surveys nationwide.
Q3. Can you summarize how much the situation changed in California in 10 years? For the workplace and for the home?
Elizabeth Gilpin: Indoor workers reporting smoke-free workplaces (not allowed in any work areas or common areas [1990, 1992], or completely smoke-free indoors [1996, 1999] increased from 35.0% in 1990, to 48.3% in 1992, to 90.5% in 1996, and to 93.4% in 1999. Exposure of indoor workers to secondhand smoke in the past 2 weeks, decreased from 29.0% in 1990 to 22.2% in 1992, to 11.8% in 1993, and was up slightly to 15.6% in 1999.
In 1992, only 15.8% of smokers reported smoke-free homes. This increased to 20.1% in 1993, to 31.9% in 1996 and to 48.6% by 1999. In 1999, 79.5% of all California homes were smoke-free, up from 37.6% in 1992. With the increase in smoke-free homes there were gains in the percentage of children and adolescents protected from secondhand smoke in the home, from 38.0% in 1992 to 82.2% in 1999.
Q4. You are mentioning inequities in exposure that are still persisting. Can you tell us what they are? How do you explain them?
Elizabeth Gilpin: Tabulating the exposed-in-the-past-2-weeks question according to the type of workplace revealed that in 1999 offices, schools and hospitals had lower rates of exposure than factories, warehouses, or restaurants/bars. A tabulation by demographics in all years showed that males, younger workers, minorities and less educated workers suffered greater exposure. These demographic groups may be more likely to work in workplaces where compliance with AB13 is not as high as it should be.
Q5. You seem to credit mass media campaigns about the dangers of ETS as a key factor. Can you give us more details about those campaigns? How frequent were/are they? What public do they target? Did the themes evolve along the years? Are they still going on?
Elizabeth Gilpin: Most of the ads featuring the issue of second-hand smoke were aired between 1990 and 1992. They typically showed children or a pregnant woman being distressed by the smoke from an adult's (parent's) cigarette.
Some of the ads featured minority actors, and versions of them ran on Asian and Hispanic TV stations. The ads were tagged with the telephone number for the California Smoker's Helpline, but the real value of the ads wasn't necessarily in promoting quitting, but rather in raising public awareness about the second-hand smoke problem.
I think we are ready for a new round of these ads. The public needs to be made aware of some of the more recently recognized dangers of secondhand smoke to children, such as ear infections, worsening of asthma and the dangers to the fetus.
Another theme might be the right of the nonsmoker to breathe clean air at work and in indoor public places. These ads might be tagged with a phone number to call to report violations of AB13. This might be an effective way to address the slight increase in exposure of nonsmoking indoor workers between 1996 and 1999. We cannot rest on our laurels.
Q6. Is there anything else you would like to add?
Elizabeth Gilpin: Compared to other states, California is not highest in the strength of its clean indoor air legislation. States with comprehensive laws that ban special smoking rooms rank higher. However, very few employers (~1.5%) in California provide such facilities. It is expensive and a total indoor smoking ban (no ambiguity) is much easier to enforce.
In 1999, 37% of California's nonsmokers reported no recent exposure to secondhand smoke in any setting. Visitors to our state can breathe easy, and likely take home with them a desire for more smoke-free venues in their own states. It is through a desire on the part of the nonsmoking public to protect itself that change will come. Tobacco control programs in other states would do well to foster this desire and emulate the successes achieved in California.
Smoke-free workplaces and homes appear to decrease smoking among smokers and prevent relapse in former smokers. So besides protection of nonsmokers, they have important health benefits to smokers as well. Public acceptance of such restrictions signals a higher degree of societal norms against smoking. As smoking becomes less of an acceptable adult activity, adolescents may be less likely to adopt smoking as a way of proclaiming they are grown up.
PB: Thank you Elizabeth for taking the time to be with us today.
P.S: the abstract for the article Clean Indoor Air: Advances in California, 1990-1999 by Elizabeth A. Gilpin, MS, Arthur J. Farkas, PhD, Sherry L. Emery, PhD, Christopher F. Ake, PhD and John P. Pierce, PhD is available at: http://www.ajph.org/cgi/content/abstract/92/5/785
Rendez-vous is supported by a contract from the Robert Wood Johnson Foundation
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