Smokefree Policy Research: Translating Outcomes Research into Practice

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Smoke-free Policy Research Translating Outcomes
Research into Practice

• Ellen J. Hahn, DNS, RN
• Professor, University of Kentucky
• College of Nursing and College of Public Health
• Director, Kentucky Center for Smoke-free Policy
• www.mc.uky.edu/tobaccopolicy

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From the Womb to the Tomb
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Nothing Kills Like Tobacco
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What are the Costs of Exposure toSecondhand
Smoke?

• Over 5 billion in direct medical costs per year
  in the U.S.
• Over 5 billion in indirect costs per year in the
  U.S.

Kentucky spends 1.17 Billion to treat sick
smokers every year!
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Tobacco The 1 Cause of Preventable Death

• By 2025, 19 years from now, 500 million people
  worldwide will die of tobacco-related
  diseasethat is 9/11 every two hours for 21
  years,
• C. Everett Koop, March 2004

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Kentucky Continues to Lead the Nation in Adult
Cigarette Smoking
2004 estimates, Centers for Disease Control and
Prevention, 2005
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Most Adults in Kentucky Do NOT Smoke Cigarettes

• Most Kentuckians ARE exposed to secondhand smoke.

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Lexingtons Smoke-free Law

• ON JULY 1, 2003, LEXINGTON-FAYETTE URBAN COUNTY
  COUNCIL VOTED 11-3 TO BAN SMOKING IN MOST PUBLIC
  BUILDINGS
• THE LAW WENT INTO EFFECT ON APRIL 27, 2004

By LFUCG Ordinance 171-2003
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Kentucky Supreme Court Decision, April 2004

• Among the police powers of the government, the
  power to promote and safeguard public health
  ranks at the top.. The real issue is whether
  the public health regulation Lexingtons
  smoke-free law is reasonable.. In this case we
  must conclude that it is.

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Why is SecondhandTobacco Smoke so Toxic?
SHS contains at least 250 toxic chemicals

• Methanol
• Carbon Monoxide
• Hydrogen Cyanide
• Acetone
• Tar
• DDT
• Naphthalene
• Vinyl Chloride
• Benzene

• Formaldehyde
• Mercury
• Lead
• Arsenic
• Toluene
• Cadmium
• Ammonia
• Butane
• Ethanol

There is no risk-free level of exposure to
firsthand tobacco smoke or secondhand tobacco
smoke
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What Does the Tobacco Industry Say About the
Health Effects?

• It is our view that, the scientific evidence is
  not sufficient to establish that environmental
  tobacco smoke is a cause of lung cancer, heart
  disease or other chronic diseases. Brown
  Williamson Tobacco, 2003

There is no longer any doubt in the scientific or
medical community that secondhand smoke is a
CAUSE of disease and premature death! U.S.
Surgeon General, 2006
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• Sign in Chicago where they have a weak ordinance

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Why Does the Tobacco Industry Fight Smoke-free
Laws?

• Financial impact of smoking bans will be
  tremendous 3 to 5 fewer cigarettes per day per
  smoker will reduce annual manufacturer profits a
  billion dollars plus per year. (A
  Smokers Alliance, Phillip Morris, 8/1/93)

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Smoke-free Laws and Indoor Air Quality in
Lexington and Louisville

• Ellen J. Hahn, DNS, RN
• Professor
• University of Kentucky, Colleges of Nursing and
  Public Health
• Kiyoung Lee, ScD, CIH
• Assistant Professor
• University of Kentucky College of Public Health
• Department of Preventive Medicine and
  Environmental Health
• Chizimuzo T.C. Okoli, MSN, RN
• Research Assistant and Doctoral Candidate
• University of Kentucky College of Nursing
• Adewale Troutman, MD, MA, MPH
• Associate Professor, School of Public Health and
  Information Sciences
• University of Louisville
• Director, Louisville Metro Health Department
• Robert W. Powell, MD
• Chair, Jefferson County Smoke-Free Coalition
• James L. Repace, MSc
• Tufts University School of Medicine

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Secondhand Smoke is an Air Pollutant

• Exposure to the fine particles from the burning
  end of a cigarette is inhaled deep into the lungs
  and increases the risk of heart disease, stroke,
  cancer, and respiratory disease.
• Secondhand tobacco smoke contributes to indoor
  fine particle air concentrations up to 10-fold
  those emitted from a new model idling car engine.
  

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Air Pollution Before and After Lexingtons
Smoke-free Law

• Indoor air pollution in restaurants, bars, and
  other entertainment venues was 3 times the
  outdoor air pollution standard, but dropped 91
  after Lexingtons smoke-free law took effect.

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Enclosed Smoking Rooms Do Not Work
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• The Truth About Indoor Smoking Areas

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Note Attendance reflects the number of people
who were present during the air quality
monitoring period.
Source UK College of Nursing, UK College of
Public Health, WEDCO Health Department
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Daviess County Smoking and Nonsmoking Venues
After Passage of a Partial Smoke-free Law
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Air Pollution in a Rural Kentucky High School
Student Restroom is 10 Times the Federal Outdoor
Air Quality Standard and Over 2 Times Higher than
Lexingtons Bars, Pre-Law
PM2.5 (microgram per cubic meter)
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Secondhand Smoke Exposure in Restaurant and Bar
Workers Before and After Lexingtons Smoke-free
Ordinance

• Ellen J. Hahn, DNS, RN, UK College of Nursing
• Mary Kay Rayens, PhD, UK College of Nursing
• Nancy York, PhD Student, UK College of Nursing
• Mark Dignan, PhD, UK Prevention Research Center
• Wael K. Al-Delaimy, MD, PhD, UCSD

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Hospitality Workers are Disproportionately
Affected

• Levels of secondhand tobacco smoke in restaurants
  and bars is 1.6 to 6 times higher than in office
  workplaces.
• Servers have the greatest risk of developing lung
  cancer and heart disease compared to other
  occupations.

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After Lexingtons Smoke-free Law, Hair Nicotine
Dropped by 56
Hahn, E.J., Rayens, M.K., York, N., Okoli,
C.T.C., Zhang, M., Dignan, M., Al-Delaimy, W.K.
(2006). Effects of a smoke-free law on hair
nicotine and respiratory symptoms of restaurant
and bar workers. Journal of Occupational and
Environmental Medicine, 48(9), 906-913.
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The Average Decrease in Hair Nicotine Was Greater
in Bar Workers
Geometric means for hair nicotine (ng/mg)
Figure 2. Geometric means by establishment type
and time, adjusted for cigarettes per day
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Ive been a waitress for 40 years to earn a
decent living for my daughter and myself. The
air where I worked was blue from the smoke. My
doctor told me I have a smokers tumor and Im
dying. I never smoked a day in my life.
Heather C
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Smoke-free Laws and Asthma Outcomes

• Ellen J. Hahn, DNS, RN
• Patricia V. Burkhart, PhD, RN
• Mary Kay Rayens, PhD
• Seongjik Lee, EdS
• Debra K. Moser, DNSc, RN

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Secondhand Smoke and the Heart

• In Helena, Montana, the number of admissions for
  heart attacks fell by 40 in just six months
  after implementation of the smoke-free law.
• Secondhand smoke exposure increases the risk of
  heart disease by 50-60, twice the previous
  estimated risk. Small does rapidly increase the
  risk
• Secondhand smoke exposure leads to inflammation
  which is linked to heart disease. These effects
  are similar to the effects of active smoking.
• In April 2004, the Centers for Disease Control
  and Prevention issued a warning that all patients
  with heart disease should avoid exposure to
  secondhand smoke.

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Secondhand Smoke and Asthma

• Contributes to the development and exacerbation
  of asthma among adults, and decreased lung
  functioning and increased asthma severity in
  children.
• Reducing exposure to SHS improves asthma severity
  and decreases the risk of ED visits and
  hospitalizations.

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Preliminary Asthma Findings
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Smoke-free laws associated with decline in ED
visits for asthma

• ED discharges for asthma declined 33 from pre-
  and post-law (plt.0001 95 CI from 16-31).
• The rate of decline was similar among children
  aged 19 or younger and in the adult population
  aged 20 and older (28 and 37 decline,
  respectively).
• Hospitalizations for asthma remained stable
  during this time period.

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Public Opinion and Lexingtons Smoke-free Law

• Ellen J. Hahn, DNS, RN
• University of Kentucky Colleges of Nursing and
  Public Health
• Mary Kay Rayens, PhD
• University of Kentucky College of Nursing
• Ronald E. Langley, PhD
• University of Kentucky Survey Research Center

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Lexingtons Public Support and Knowledge of
Health Risks Before and After the Law
Public support for the law increased significantly
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Economic Impact of Lexingtons Smoke-free Law

• Ellen J. Hahn, DNS, RN
• University of Kentucky
• Colleges of Nursing and Public Health
• Donald J. Mullineaux, PhD
• University of Kentucky
• Director, School of Management
• Gatton College of Business and Economics
• Eric Thompson, PhD, Associate Professor
• University of Nebraska-Lincoln
• Director, Business Research, Department of
  Economics
• Mark Pyles, MS, Research Assistant
• University of Kentucky
• Gatton College of Business and Economics
• Chizimuzo T.C. Okoli, MSN, RN, Research Assistant
• University of Kentucky College of Nursing

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Lexingtons Smoke-free Law Did Not Harm Business

• An average of 400 additional restaurant employees
  per month (3 of total restaurant employment)
• Bar employment remained stable
• No change in business openings or closings

Pyles, M, Mullineaux, DJ, Okoli, CTC, Hahn, EJ.
(2006). Economic impact of a smoke-free law in a
tobacco-growing community. Tobacco Control. in
press.
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Smoke-free Laws and Employee Turnover

• Ellen J. Hahn, DNS, RN
• Eric Thompson, PhD
• Mary Kay Rayens, PhD
• Glenn Blomquist, PhD
• John Garen, PhD
• Donald J. Mullineaux, PhD
• Nola Ogunro

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Sample

• N 39,270
• 54 female
• Mean age 27 years (SD 7.09)
• 80.6 Caucasian, 8.1 Black, 7.7 Hispanic
• Average hours worked 52.5 hours bimonthly
• Average wage 545 bimonthly
• Average tenure 60.1 weeks (if end date)
• 33.2 had no end date

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Effect of Local SmokeFree Ordinance on
Likelihood of Turnover By Occupation Category
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Kentucky Center for Smoke-free Policy (KCSP)

• Provides rural and urban communities across
  Kentucky with science-based strategies for
  advancing smoke-free policies on the local level
  and educating citizens and policymakers about the
  importance of smoke-free environments.
• Funded by initial seed money from The Robert Wood
  Johnson Foundation to the UK College of Nursing
  Tobacco Policy Research Program
• www.kcsp.uky.edu

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Kentucky Communities with 100 Smoke-free
Workplace and/or Public Place Ordinances

• Implementation Date
• 4/27/04
• 10/1/05
• 7/1/06
• 8/1/06
• 8/22/06
• 10/1/06
• 4/1/07
• 12/1/06

• Community
• Lexington
• Georgetown
• Letcher County
• Morehead
• Frankfort
• Ashland
• Paducah
• Elizabethtown

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Proposed Dissemination and Implementation Project
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Are We Making Progress?

• There has been a 70 reduction in secondhand
  smoke exposure in nonsmokers since 1988, due in
  large part to smoke-free laws.
• Unfortunately, more than 3.6 million Kentuckians
  (91) are still exposed to secondhand smoke in
  public places and workplaces.
• Source U.S. Surgeon General, 2006