Workplace Compliance with a No-Smoking Law: A Randomized Community Intervention Trial
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Nancy A. Rigotti, MD, David Boumne, MD, SM, Amy Rosen, PhD, John A. Locke, MPH, and Thomas C. Schelling, PhD
Introduction Over the past two decades, states and communities have enacted laws restricting smoking in public places and workplaces at a rapid pace.' By 1988, 43 states and over 300 cities and counties had adopted a law limiting smoking in one or more public places.2 The strictest laws require smoking restrictions at the workplace. As of 1989, laws in 14 states and 297 communities required workplaces to limit smoking.3-4 The intent of these laws, often termed clean indoor air laws, is to protect individuals from the discomfort and health hazards of involuntary smoke exposure. The laws may also decrease smoking prevalence by encouraging smokers to quit and discouraging nonsmokers from starting. Whether no-smoking laws will have these effects is not known because they have not been systematically assessed.2'5 However, laws can be expected to have little impact on air quality or smoking behavior if individuals and businesses do not comply with them. To date, compliance has not been formally evaluated, and implementation has received little attention. Most laws delegate implementation to public health departments but do not fund this activity.4 Health departments appear to regard the laws as selfenforcing, implying little need for surveillance because high compliance is expected.2 Enforcement occurs in response to complaints, and a lack of complaints is considered evidence of good compliance and, presumably, reduced involuntary smoke exposure.2'6 This assumption has not been tested, however. The passage of a comprehensive nosmoking ordinance in Brookline, Mass, in 1987 provided the opportunity to evaluate
workplace compliance with a community clean indoor air law and to test whether employers' awareness and compliance could be improved with intervention. We targeted businesses because the workplace is the primary site outside the home for passive smoke exposure.7 Surveys indicate that 27% of US businesses and over one third of large corporations have smoking policies, but little is known about how smoking is handled in small businesses, which constitute the majority of American businesses.128-"II Furthermore, little is known about how the business community responds to legislation requiring it to adopt smoking policies. The potential for a negative reaction has concemed some policymakers considering no-smoking laws. We assessed workplace compliance with the Brookline no-smoking ordinance and conducted a randomized controlled trial of town businesses to determine whether a low-cost mailed program of education and surveillance could increase employers' awareness of and compliance with the law. The town's health department, which is responsible for implementing the law, conducted the intervention. At the time of the study Nancy A. Rigotti was with the Department of Medicine, Massachusetts General Hospital, Harvard Medical School. David Bourne is with the Arkansas Health Department. Amy Rosen is with the Section of General Internal Medicine, Boston University Medical School. John A. Locke, is Director of Public Health, Brookline, MA. Thomas C. Schelling is with the Department of Economics, University of Maryland. Requests for reprints should be sent to Nancy A. Rigotti, MD, General Internal Medicine Unit, Massachusetts General Hospital, Fruit St., Boston, MA 02114. This paper was submitted to the journal February 12, 1991, and accepted with revisions June 24, 1991.
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We hypothesized that employers sent information would be more aware of what the law required and, consequently, more likely to comply with it.
Methods Brookline Bylaw Brookline is a town of 55 062 residents in the Boston metropolitan area.'2 In 1982, there were 1455 businesses and government agencies in Brookline employing a total of 16 758 workers.13 That year, Brookline became the third Massachusetts community to restrict smoking when the 250-member Town Meeting adopted a bylaw requiring restaurants with 40 seats or more to reserve 25% of those seats for nonsmokers (Bylaw XLI). Five years later, on June 1, 1987, the town meeting passed Bylaw XLII, which restricted or banned smoking in work sites and public places and enlarged restaurant nonsmoking sections to 50% of seats. The worksite provisions of Bylaw XLII apply to businesses with three or more employees. The law requires employers to establish and post a work-site smoking policy. Employers must provide a nonsmoking working area for all employees. They are allowed, but not required, to designate smoking areas so long as the area does not expose nonsmoking employees or the public to smoke. Nosmoking signs must be "conspicuously" displayed in nonsmoking areas. Upon request, a written copy of the policy must be provided to employees or to the director of public health.14 Workplace provisions of the bylaw became effective on March 1, 1988. Implementation and enforcement were the responsibility of the health department. The health director used local media, primarily the weekly town newspaper, to inform the public. Food service establishments were formally notified in January 1988 in a license renewal mailing. Inspectors subsequently checked for compliance during routine restaurant inspections. The health department sent no other information to citizens or businesses, except in response to complaints or questions. During the first year, the health department received 11 complaints about work-site smoking and informed those employers about the law. Work-site surveillance to monitor compliance was not done.
Inteivention We obtained a comprehensive mailing list of Brookline businesses from the
230 American Journal of Public Health
Massachusetts Department of Employment and Training. The list included all companies using a Brookline address for payment of unemployment compensation taxes. All businesses with five or more employees (n = 535) were included in the trial. Businesses in the smallest category (less than five employees) were excluded because the bylaw applies only to work sites with three or more employees. The 535 eligible businesses were randomly assigned to one of three groups. The health department mailed an information packet to companies in the two intervention groups in January 1989, 10 months after the law went into effect. No mailing was sent to controls. The packet sent to both intervention groups included (1) a copy of the bylaw, (2) a cover letter from the health director summarizing what the bylaw required of employers, and (3) a sample smoking policy. One intervention group also received a request from the health commissioner to return a written copy of its smoking policy. The estimated cost of preparing and mailing the information packet was $800.
Evaluation We conducted a telephone survey of Brookline businesses in April 1989, 3 months after the mailing and 13 months after the law became effective. Firms were randomly selected from the 535 businesses in the trial. Of 459 firms telephoned, 53 (11%) could not be reached after four calls and 61 (13%) were not eligible. Interviews were completed in 299 of 345 eligible businesses, a response rate of 87%. Trained interviewers asked to speak to the owner, manager, or employee most familiarwith the company's smoking rules. Respondentswere informed that the survey was conducted for Harvard University and that data on individual firms were confidential. The survey instrument, adapted from one we previously developed for a survey of Cambridge, Mass, businesses, contained 34 brief, closed-ended items and required 8 minutes to administer. Respondents were asked about their awareness and opinion of the law, their company's compliance, and their perception of the law's effect on employees, air quality, and costs. To understand how Brookline businesses handled smoking, we asked separate sets of questions about the company's smoking policy for employees, overall rules about smoking, smoking rules in six areas (private offices, shared work areas, public areas, conference rooms, hallways, cafeterias, and employee lounges), and
posting of no-smoking signs. Type of business, work-force size, estimated employee smoking prevalence, and respondent's job title and smoking status were also recorded. To confirm the validity of telephone self-reports, an observer made unannounced visits to all work sites reporting the presence of any one of the three observable outcome measures: a written smoking policy, posted smoking policy, or posted no-smoking sign. Additionally, the observer noted whether no-smoking signs were "conspicuously displayed" as required by law and whether employees or customers were smoking. Direct observations were made in 142 worksites, 48% of our sample. Smoking policies returned to the health department in response to the commissioner's request were reviewed by one rater, who judged whether each complied with the law. This data collection permitted several separate assessments of compliance with the law: (1) respondents' self-rating; (2) respondents' reports of smoking rules, policies, and signs that constituted an operational definition of compliance; (3) direct observation of policies, signs, and smoking; and (4) analysis of written policies returned to the health department. For the purposes of the study, a business was in full compliance if it posted a written smoking policy at the work site, prohibited smoking in shared work areas and public areas, and posted signs in no-smoking areas.
Data Analysis We compared the three groups on all endpoints, using chi-square and t tests to analyze the significance of differences in proportions and means.15 Because the information sent to both intervention groups was very similar, we repeated the analysis, comparing a combined intervention group with controls to investigate the effect of a mailing. There were no major differences between the two intervention groups, and we report results using the combined intervention group. Multiple logistic regression was used to identify factors associated with awareness of the law, opinion of the law, and rules about smoking.'6
Results Charactenstics of the Sample Table 1 describes the 299 Brookline businesses surveyed. The average company was small; 73% had less than 20 employees. Nearly half were in service in-
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Workplace Compliance dustries, and employee unions were rare. Employee smoking prevalence, estimated by respondents, was low, as was respondents' own smoking status. There were no significant differences between groups on any descriptive variable. The distribution of business size and type in the sample closely resembles the distribution for all Brookline businesses.13
Awareness of the Law Overall, 36% of businesses were aware of the town's no-smoking law. Companies sent the mailing were more likely to know about the law than were controls, suggesting that the mailing informed businesses (46% vs 18%,P < .0001; odds ratio [OR] = 3.88; Table 2). After adjusting, with multiple logistic regression, for potential confounders (business size and type, respondent job category and smoking status), the effect of group designation on awareness was unchanged (OR = 3.82; 95% confidence interval [CI] = 2.11, 6.93). No factor in Table 1 was independently related to awareness. The 109 businesses aware of the Brookline bylaw were tested on their specific knowledge of six provisions highlighted in the mailing. Businesses correctly answered 64% of the questions, but the proportion of correct responses varied by question (Table 2). Businesses were best informed about the need to post nosmoking signs and ban smoking in public areas. They were least likely to know that providing a smoking area for employees was not required.
Opinion of the Law One year after it took effect, the law was popular with businesses: 65% of respondents favored the law, 23% were neutral, and only 12% opposed it (Table 2). These proportions did not change when the analysis was limited to respondents aware of the law. The mailing did not influence attitudes about the law. On multivariate analysis, approval of the law was significantly higher in firms with nonsmoking respondents (OR = 4.22; 95% CI = 2.20, 8.17), work-site smoking restrictions (OR = 3.23; 95% CI = 2.23, 6.68), and fewer smoking employees (OR = 1.58; 95% CI = 1.12, 2.23). Approvalwasunrelated to company size or type.
Compliance and Effects of the Law: Managers 'Assessment The 109 businesses aware of the law reported a high level of compliance and few problems. Ninety-five respondents (87%) considered their firm to be in com-
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pliance. Only three reported problems in complying; two problems involved employee opposition to smoking restrictions and one involved separating smokers and nonsmokers. Most companies reported that the law did not affect costs (n = 95, 87%) or air quality (n = 78, 72%); the remainder thought air quality had improved. Control and intervention groups did not differ on these questions. The law also stimulated businesses to take action on smoking. According to respondents, the law prompted 39 firms aware of the law (36%) to adopt or revise a smoking policy. Forty (23%) of 177 companies with smoking policies cited the Brookline law as one reason their policy was adopted, and businesses sent the
mailing cited the law more often than did controls (30% vs 10%, P = .005). Figure 1 illustrates the number of smoking policies adopted or revised each year among businesses whose managers recalled the date of policy adoption; 114 (64%) of 177 firms with policies could do so. Peaks of activity followed the adoption and implementation of no-smoking laws and the health department mailing. Two thirds (25/38) of firms implementing a policy after the law was adopted (1988 and 1989) were aware of the law.
Compliance: Self-Reports of Smoking Rules, Policies, and Signs Table 3 displays measures of compliance with the law in all work sites and
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m
employee observed in 14% (Table 3). Firms that banned smoking had significantly fewer smoking customers (15% vs 51%, P < .0001) and employees (6% vs 19%, P = .037). Table 4 demonstrates that businesses aware of the law were more likely to comply with it.
m
20
Smoking Policies Returned to the Health Department
15
Adopt new policy Revise policy
| A B C D
-
A
Restaurant law takes effect Workplace law passed Workplace law takes effect Mailing sent
5
70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 + + 4 + Year B C D A *1st 3 months only
Bars repreenthe number of smoking policies newly adopted (black bars) or revisd (shaded bars) in each year, 1970-1989, among businesses who could recall the date of policy adoped. tion. Arrows indicate when local smoking legislation was passed or im FIGURE I-Smdldng polkles adoped or revised by Brooldine businesses 1970-1989.
distinguishes between smoking policies and smoking restrictions. Smoking restrictions were reported by 80% of work sites; 34% banned smoking and 46% restricted it to designated areas. Figure 2 presents the smoking rules for six specific areas. Over 65% of businesses banned smoking in shared work areas, public areas, conference rooms, and hallways. Smoking rules did not differ significantly between companies sent the mailing and controls, although those sent the mailing were more likely to ban smoking in shared work areas (70% vs 58%, P = .068). Respondents were asked separately about their company's smoking policy. Fifty-nine percent replied that their company had a smoking policy for employees at that work site, but only half of these policies were written and only one third were posted at the workplace, as stipulated by law. Forty percent posted nosmoking signs. By our definition, 34 businesses (11%) reported full compliance with the law (Table 3). Companies sent the mailing were more likely than controls to report full compliance, a written smoking policy, and no-smoking signs, although the last difference was not statistically significant. On multivariate analysis, smoking restrictions were more common in service businesses (OR = 3.48; 95% CI = 1.14, 6.13) and in firms whose top manager did
232 American Journal of Public Health
= 4.74; 95% CI = 2.09, 10.71). Smoking bans were more common in companies with a non-smoking manager (OR = 19.31; 95% CI = 2.56, 145.53) and fewer smoking employees (OR = 1.60; 95% CI = 1.12, 2.29). Restrictions were not independently associated with work-force size.
not smoke (OR
Compliance: Direct Observations Direct observations in Brookline businesses confirmed self-reports of nosmoking signs in 98% of firms (119/121), although only 60% of signs were "conspicuously displayed" as required by law. In contrast, we validated few reports of written or posted smoking policies. We observed written policies in 6 of 89 companies reporting them (7%) and posted policies in 5 of 60 companies (8%). Employees often responded to a request for a written or posted smoking policyby pointing to a no-smoking sign. Table 3 compares control and intervention groups on the validated endpoints of signs and policies. All written and posted policies were observed in businesses sent the mailing, but the number was so small that group differences were not statistically significant. By direct observation, only three Brookline companies (1%) fully complied with the law. Furthermore, a customer was seen smoking in 36% ofbusinessesvisited and a smoking
Half (n = 50) of businesses in the group asked to submit a written smoking policy did so. Nearly all used the demonstration policy provided by the health department. Twenty-nine policies (58%) were in compliance, indicating that smokingwas restricted or banned and no-smoking signs were posted. The major reason for noncompliance was the misconception that firms without smoking employees need not have a smoldng policy or post signs.
Disussion This study assessed workplace compliance with a community clean indoor air law 1 year after the law's implementation. It also evaluated a low-cost intervention designed to increase employers' awareness and compliance with the law. Our discussion addresses these questions in order: (1) What was the prevalence of work-site smoking restrictions in Brookline 1 year after the law became effective? (2) Was the law responsible for these restrictions? (3) Did the intervention increase employers' awareness and compliance with the law? (4) What did town businesses think of the law? 1. One year after the law went into effect, the prevalence of work-site smoking restrictions in town businesses was high. Eight of ten firms had some smoking restrictions, one third banned smoking altogether, and two thirds banned smoking in shared work areas, where passive smoke exposure is likely to be highest. Two observations suggest that the situation was more complex, however. First, there was considerable discrepancy among estimates of smoking policy prevalence. The prevalence ofrules about smoking (80%o) exceeded that of smoking policies (59%o), and self-reported prevalence of smoking policies greatly exceeded that directlyobserved. Second, we observed customers and employees smoking in some businesses that reported not permitting it. These discrepancies could reflect employers' misrepresentation of their policy, failure to enforce their
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Wodpm Complac policy, or misconception of what is a smoking policy and what the law requires businesses to do. The last two explanations are most likely. Smoking rules were probably not always enforced, and many businesses considered a no-smoking sign to be their written policy or felt no policy was needed because no employee smoked. Misrepresentation is less likely, given good agreement between self-reported and observed estimates of nosmoking-sign prevalence, a more concrete endpoint. It appears that the law was understood differently by policymakers who drafted it and businesses to whom it applied. Because "smoking policy" was variously interpreted, we consider respondents' reports of "smoking rules" to be a better reflection of the actual prevalence of smoking restrictions in Brookline businesses. We conclude that the prevalence of smoking restrictions is high. Despite this, few Brookline firms complied fully with the law as written. Lack of awareness of the law and misinterpretation of the ordinance probably account for this finding. Nonetheless, it appears that the law achieved much of its intentreducing exposure to passive smoke. The scarcity of complaints to the health department supports this interpretation but demonstrates that a lack of complaints does not guarantee compliance with a law. The frequency with which smoking was observed in businesses further indicates the limits of complaints as a measure of compliance. We suggest that differences in practice between large and small businesses account for some of employers' nmisconceptions about what the law required. While large businesses typically write formal policies to define acceptable employee behavior, small companies (as are most Brookline businesses) appear to make and enforce rules about smoldng more informally and communicate them orally to employees, and they may not consider the rules to be policies.17 PoliCymakers need to be aware of the practices of small businesses, which constitute the bulk of US companies, in order to draft work-site no-
prompted to adopt smoking restrictions; however, without observations from a comparison community, we cannot exclude the possibility that smoking restrictions resulted from concurrent social change. Estimates of work-site smoking policy prevalence in other communities, with which to compare our data, are few. A 4% prevalence of written policies was found in New York City businesses in 1986, prior to a no-smoking ordinance.18
In contrast, the prevalence of smoking policies and restrictions in Seattle manufacturing companies in 1988 was similar to Brookline, despite Seattle's lack of a work-site no-smoking law. However, Seattle bans smoking in public places and government work sites, and "public acceptance of smoking restrictions is widespread."19 Although comparisons between surveys require caution, these data suggest that smoking policies may be less
smoldng laws that can be readily implemented by small and large firms. 2. To what extent was the Brookline law responsible for work-site smoking restrictions present 1 year later? The law was followed by a dramatic increase in the number of firms adopting smoking policies, and businesses aware of the law had more smoking policies. Companies aware of the law appeared to have been February 1992, Vol. 82, No. 2
Bars representthe percentage of Brooldine businessesthat ban or restictsmofxng overall and in six sp fi areas at work. The figure compares the responses of companies sent Fe mailing (intervention group [11) with conts (C). FIGURE 2-Ruls about smoldng In Brookdine businesses.
American Journal of Public Health 233
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common in communities without laws, but considerable local variability exists. We conclude that smoking restrictions are more common in Brookline businesses than in many communities, due in part to the law. 3. What was the effect of the health departnent's mailing to businesses? The mailing increased awareness but not com-
234 American Journal of Public Health
pliance with the law. It doubled the number of businesses aware of the law, but it informed fewer than half of town businesses about the law. Awareness is an important endpoint because compliance with a self-enforcing law can be expected only if those subject to it know about it. By itself, the mailing did not clearly increase compliance with the law, and the effect of
the mailing was not enhanced by surveillance (e.g., requiring businesses to return a smoking policy to the health department). Surveillance might have been effective had the health department contacted noncompliant businesses it identified. Furthermore, analysis of returned policies provided information valuable for planning subsequent implementation programs. For the health department, major advantages of the intervention were its simplicity and low cost, but these factors also limited its effectiveness. Even with its modest effect, the mailing might be regarded as cost-effective; it cost $14.73 per business informed: $800/[(.46 - .18) x 194 businesses]. 4. The law's popularity with employers 1 year after its adoption is an important additional finding. Employers aware of the law reported no adverse effects and did not perceive compliance to be burdensome. Not surprisingly, the law was more popular among respondents who did not smoke and in companies with smoking restrictions and few smoking employees. Managers' strong endorsement of the strictly worded Brookline statute is good news for policymakers in other communities considering no-smoking laws. Methodologic strengths of this study include the following: we tested the intervention in a randomized controlled trial, assessed outcomes in a large random sample of town businesses, achieved a high response rate to a telephone survey, and validated self-reports by direct observation. Interpretation of study results must consider that this was a study of a single community. The Brookline sample resembles statewide and national distributions of business size, but it has significantly more service and fewer manufacturing businesses than comparison state and national samples. 1020 In summary, the Brookline no-smoking bylaw was popular with businesses, increased the adoption ofwork-site smoking policies, and contributed to a high prevalence of smoking restrictions in town businesses. Although full compliance with the law was low, largely because of misunderstandings inwhat the law required of businesses, the town's modest implementation effort achieved a good measure of the intent of the legislation. The health department's mailing increased companies' awareness but not compliance with the law. Further implementation efforts could improve awareness, compliance, and enforcement of the law. Nonetheless, the study demonstrates that a local health de-
February 1992, Vol. 82, No. 2
Workplace Compliance
partment can disseminate information to employers concerning a new requirement with a modest effort. El
Aclmowledgments This studywas funded in part by Grant 88-6169 from the Henmy J. Kaiser Family Foundation and a teaching and research schloarship awarded by the American College of Physicians to Dr. Rigotti. This work was presented at the annual meeting of the American Public Health Association, October 1989. We are indebted to Eva Jackson for assistance in data collection and analysis, to Pat Camey for manuscript preparation, and to David Hemenway, PhD, and Kenneth Warner, PhD, for reviewing the manuscript.
References 1. US Department ofHealth and Human Services. The Health Consequences ofInvoluntary Smoking. A Report of the Surgeon GeneraL Washington, DC: US Departnent of Health and Human Services; 1986; DHHS publication no. (CDC) 87-8398. 2. US Department of Health and Human Services. Reducing the Health Consequences ofSmoking: 25 Years ofBPrognss. A Report of the Surgeon GeneraL Wash-
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ington, DC: US Department of Health and Human Services; 1989; DHHS publication no. (CDC) 89-8411. 3. Tobacco-Free America. State Legislated Actions on Tobacco Issues. Washington, DC: Tobacco-Free America Legislative Clearinghouse; 1989. 4. Pertschuk M, Shopland DR. Major Local Smokdng Ordinances in the United States. Washington, DC: Americans for Nonsmokers Rights and US Department of Health and Human Services; 1989; NIH publication no. 90-479. 5. Rigotti NA. Trends in the adoption of smoking restrictions in public places and worksites. New York State J Med. 1989;89:19-26. 6. Martin MJ. The San Francisco experience with regulation of smoking in the workplace: the first twelve months.AmJPublic Health. 1986;76:585-586. 7. RepaceJL, LowreyAH. A quantitative estimate of nonsmokers' lung cancer risk from passive smoking. Environment Int.
1985;11:3-22. 8. Bureau of National Affairs. Where There's Smoke: Problem and Policies Concening Smokingin the Woriplace. A BNA Special Report. 2nd ed. Rockville, Md: Bureau of National Affairs; 1987. 9. Gottlieb NH, Hedl JJ, Eriksen MP, Chan F. Smoking policies among private employers and public agencies in Texas: a statewide
analysis. JNCI. 1989;81:200-204.
10. Fielding JE, Piserchia PV. Frequency of worksite health promotion activities. Am J Public Health. 1989;79:16-20. 11. Dun & Bradstreet Corp. Dun's Census of American Businesses 1989. Parsippany, NY: Dun's Marketing Services Inc; 1989. 12. US Department of Commerce. State and MetropolitanArea Data Book 1986. Washington, DC: US Department of Commerce; Bureau of the Census; 1986. 13. Gibney FJ. Brookline. Boston, Mass: Massachusetts Department of Commerce, October 1984. Unpublished monograph. 14. Brookline, Mass, Bylaw Article XLII (November 16, 1988). 15. Willinson L. Systat: the System for Statistics. Evanston, Ill; Systat Inc; 1986. 16. SAS Institute. SAS-PC Release 6.a Cary, NC; SAS Institute Inc; 1987. 17. SorensenG, RosenA, PinneyJ, RudolphJ, Doyle N. Worksite smoking policies in small businesses. J Occup MeL In press. 18. Centers for Disease Control. Survey of worksite smoking policies-New York City. MMWR 1987;36:177-179. 19. Kinne S. Prevalence and restrictiveness of smoking policies in King County, Washington, manufacturing worksites. Am J Public Health. 1990;80:1498-1500. 20. Homer ER, ed. Massachusetts Municpal Profiles, 1988-89. Palo Alto, Calif: Information Publications; 1989.
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Nancy A. Rigotti, MD, David Boumne, MD, SM, Amy Rosen, PhD, John A. Locke, MPH, and Thomas C. Schelling, PhD
Introduction Over the past two decades, states and communities have enacted laws restricting smoking in public places and workplaces at a rapid pace.' By 1988, 43 states and over 300 cities and counties had adopted a law limiting smoking in one or more public places.2 The strictest laws require smoking restrictions at the workplace. As of 1989, laws in 14 states and 297 communities required workplaces to limit smoking.3-4 The intent of these laws, often termed clean indoor air laws, is to protect individuals from the discomfort and health hazards of involuntary smoke exposure. The laws may also decrease smoking prevalence by encouraging smokers to quit and discouraging nonsmokers from starting. Whether no-smoking laws will have these effects is not known because they have not been systematically assessed.2'5 However, laws can be expected to have little impact on air quality or smoking behavior if individuals and businesses do not comply with them. To date, compliance has not been formally evaluated, and implementation has received little attention. Most laws delegate implementation to public health departments but do not fund this activity.4 Health departments appear to regard the laws as selfenforcing, implying little need for surveillance because high compliance is expected.2 Enforcement occurs in response to complaints, and a lack of complaints is considered evidence of good compliance and, presumably, reduced involuntary smoke exposure.2'6 This assumption has not been tested, however. The passage of a comprehensive nosmoking ordinance in Brookline, Mass, in 1987 provided the opportunity to evaluate
workplace compliance with a community clean indoor air law and to test whether employers' awareness and compliance could be improved with intervention. We targeted businesses because the workplace is the primary site outside the home for passive smoke exposure.7 Surveys indicate that 27% of US businesses and over one third of large corporations have smoking policies, but little is known about how smoking is handled in small businesses, which constitute the majority of American businesses.128-"II Furthermore, little is known about how the business community responds to legislation requiring it to adopt smoking policies. The potential for a negative reaction has concemed some policymakers considering no-smoking laws. We assessed workplace compliance with the Brookline no-smoking ordinance and conducted a randomized controlled trial of town businesses to determine whether a low-cost mailed program of education and surveillance could increase employers' awareness of and compliance with the law. The town's health department, which is responsible for implementing the law, conducted the intervention. At the time of the study Nancy A. Rigotti was with the Department of Medicine, Massachusetts General Hospital, Harvard Medical School. David Bourne is with the Arkansas Health Department. Amy Rosen is with the Section of General Internal Medicine, Boston University Medical School. John A. Locke, is Director of Public Health, Brookline, MA. Thomas C. Schelling is with the Department of Economics, University of Maryland. Requests for reprints should be sent to Nancy A. Rigotti, MD, General Internal Medicine Unit, Massachusetts General Hospital, Fruit St., Boston, MA 02114. This paper was submitted to the journal February 12, 1991, and accepted with revisions June 24, 1991.
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We hypothesized that employers sent information would be more aware of what the law required and, consequently, more likely to comply with it.
Methods Brookline Bylaw Brookline is a town of 55 062 residents in the Boston metropolitan area.'2 In 1982, there were 1455 businesses and government agencies in Brookline employing a total of 16 758 workers.13 That year, Brookline became the third Massachusetts community to restrict smoking when the 250-member Town Meeting adopted a bylaw requiring restaurants with 40 seats or more to reserve 25% of those seats for nonsmokers (Bylaw XLI). Five years later, on June 1, 1987, the town meeting passed Bylaw XLII, which restricted or banned smoking in work sites and public places and enlarged restaurant nonsmoking sections to 50% of seats. The worksite provisions of Bylaw XLII apply to businesses with three or more employees. The law requires employers to establish and post a work-site smoking policy. Employers must provide a nonsmoking working area for all employees. They are allowed, but not required, to designate smoking areas so long as the area does not expose nonsmoking employees or the public to smoke. Nosmoking signs must be "conspicuously" displayed in nonsmoking areas. Upon request, a written copy of the policy must be provided to employees or to the director of public health.14 Workplace provisions of the bylaw became effective on March 1, 1988. Implementation and enforcement were the responsibility of the health department. The health director used local media, primarily the weekly town newspaper, to inform the public. Food service establishments were formally notified in January 1988 in a license renewal mailing. Inspectors subsequently checked for compliance during routine restaurant inspections. The health department sent no other information to citizens or businesses, except in response to complaints or questions. During the first year, the health department received 11 complaints about work-site smoking and informed those employers about the law. Work-site surveillance to monitor compliance was not done.
Inteivention We obtained a comprehensive mailing list of Brookline businesses from the
230 American Journal of Public Health
Massachusetts Department of Employment and Training. The list included all companies using a Brookline address for payment of unemployment compensation taxes. All businesses with five or more employees (n = 535) were included in the trial. Businesses in the smallest category (less than five employees) were excluded because the bylaw applies only to work sites with three or more employees. The 535 eligible businesses were randomly assigned to one of three groups. The health department mailed an information packet to companies in the two intervention groups in January 1989, 10 months after the law went into effect. No mailing was sent to controls. The packet sent to both intervention groups included (1) a copy of the bylaw, (2) a cover letter from the health director summarizing what the bylaw required of employers, and (3) a sample smoking policy. One intervention group also received a request from the health commissioner to return a written copy of its smoking policy. The estimated cost of preparing and mailing the information packet was $800.
Evaluation We conducted a telephone survey of Brookline businesses in April 1989, 3 months after the mailing and 13 months after the law became effective. Firms were randomly selected from the 535 businesses in the trial. Of 459 firms telephoned, 53 (11%) could not be reached after four calls and 61 (13%) were not eligible. Interviews were completed in 299 of 345 eligible businesses, a response rate of 87%. Trained interviewers asked to speak to the owner, manager, or employee most familiarwith the company's smoking rules. Respondentswere informed that the survey was conducted for Harvard University and that data on individual firms were confidential. The survey instrument, adapted from one we previously developed for a survey of Cambridge, Mass, businesses, contained 34 brief, closed-ended items and required 8 minutes to administer. Respondents were asked about their awareness and opinion of the law, their company's compliance, and their perception of the law's effect on employees, air quality, and costs. To understand how Brookline businesses handled smoking, we asked separate sets of questions about the company's smoking policy for employees, overall rules about smoking, smoking rules in six areas (private offices, shared work areas, public areas, conference rooms, hallways, cafeterias, and employee lounges), and
posting of no-smoking signs. Type of business, work-force size, estimated employee smoking prevalence, and respondent's job title and smoking status were also recorded. To confirm the validity of telephone self-reports, an observer made unannounced visits to all work sites reporting the presence of any one of the three observable outcome measures: a written smoking policy, posted smoking policy, or posted no-smoking sign. Additionally, the observer noted whether no-smoking signs were "conspicuously displayed" as required by law and whether employees or customers were smoking. Direct observations were made in 142 worksites, 48% of our sample. Smoking policies returned to the health department in response to the commissioner's request were reviewed by one rater, who judged whether each complied with the law. This data collection permitted several separate assessments of compliance with the law: (1) respondents' self-rating; (2) respondents' reports of smoking rules, policies, and signs that constituted an operational definition of compliance; (3) direct observation of policies, signs, and smoking; and (4) analysis of written policies returned to the health department. For the purposes of the study, a business was in full compliance if it posted a written smoking policy at the work site, prohibited smoking in shared work areas and public areas, and posted signs in no-smoking areas.
Data Analysis We compared the three groups on all endpoints, using chi-square and t tests to analyze the significance of differences in proportions and means.15 Because the information sent to both intervention groups was very similar, we repeated the analysis, comparing a combined intervention group with controls to investigate the effect of a mailing. There were no major differences between the two intervention groups, and we report results using the combined intervention group. Multiple logistic regression was used to identify factors associated with awareness of the law, opinion of the law, and rules about smoking.'6
Results Charactenstics of the Sample Table 1 describes the 299 Brookline businesses surveyed. The average company was small; 73% had less than 20 employees. Nearly half were in service in-
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Workplace Compliance dustries, and employee unions were rare. Employee smoking prevalence, estimated by respondents, was low, as was respondents' own smoking status. There were no significant differences between groups on any descriptive variable. The distribution of business size and type in the sample closely resembles the distribution for all Brookline businesses.13
Awareness of the Law Overall, 36% of businesses were aware of the town's no-smoking law. Companies sent the mailing were more likely to know about the law than were controls, suggesting that the mailing informed businesses (46% vs 18%,P < .0001; odds ratio [OR] = 3.88; Table 2). After adjusting, with multiple logistic regression, for potential confounders (business size and type, respondent job category and smoking status), the effect of group designation on awareness was unchanged (OR = 3.82; 95% confidence interval [CI] = 2.11, 6.93). No factor in Table 1 was independently related to awareness. The 109 businesses aware of the Brookline bylaw were tested on their specific knowledge of six provisions highlighted in the mailing. Businesses correctly answered 64% of the questions, but the proportion of correct responses varied by question (Table 2). Businesses were best informed about the need to post nosmoking signs and ban smoking in public areas. They were least likely to know that providing a smoking area for employees was not required.
Opinion of the Law One year after it took effect, the law was popular with businesses: 65% of respondents favored the law, 23% were neutral, and only 12% opposed it (Table 2). These proportions did not change when the analysis was limited to respondents aware of the law. The mailing did not influence attitudes about the law. On multivariate analysis, approval of the law was significantly higher in firms with nonsmoking respondents (OR = 4.22; 95% CI = 2.20, 8.17), work-site smoking restrictions (OR = 3.23; 95% CI = 2.23, 6.68), and fewer smoking employees (OR = 1.58; 95% CI = 1.12, 2.23). Approvalwasunrelated to company size or type.
Compliance and Effects of the Law: Managers 'Assessment The 109 businesses aware of the law reported a high level of compliance and few problems. Ninety-five respondents (87%) considered their firm to be in com-
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pliance. Only three reported problems in complying; two problems involved employee opposition to smoking restrictions and one involved separating smokers and nonsmokers. Most companies reported that the law did not affect costs (n = 95, 87%) or air quality (n = 78, 72%); the remainder thought air quality had improved. Control and intervention groups did not differ on these questions. The law also stimulated businesses to take action on smoking. According to respondents, the law prompted 39 firms aware of the law (36%) to adopt or revise a smoking policy. Forty (23%) of 177 companies with smoking policies cited the Brookline law as one reason their policy was adopted, and businesses sent the
mailing cited the law more often than did controls (30% vs 10%, P = .005). Figure 1 illustrates the number of smoking policies adopted or revised each year among businesses whose managers recalled the date of policy adoption; 114 (64%) of 177 firms with policies could do so. Peaks of activity followed the adoption and implementation of no-smoking laws and the health department mailing. Two thirds (25/38) of firms implementing a policy after the law was adopted (1988 and 1989) were aware of the law.
Compliance: Self-Reports of Smoking Rules, Policies, and Signs Table 3 displays measures of compliance with the law in all work sites and
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m
employee observed in 14% (Table 3). Firms that banned smoking had significantly fewer smoking customers (15% vs 51%, P < .0001) and employees (6% vs 19%, P = .037). Table 4 demonstrates that businesses aware of the law were more likely to comply with it.
m
20
Smoking Policies Returned to the Health Department
15
Adopt new policy Revise policy
| A B C D
-
A
Restaurant law takes effect Workplace law passed Workplace law takes effect Mailing sent
5
70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 + + 4 + Year B C D A *1st 3 months only
Bars repreenthe number of smoking policies newly adopted (black bars) or revisd (shaded bars) in each year, 1970-1989, among businesses who could recall the date of policy adoped. tion. Arrows indicate when local smoking legislation was passed or im FIGURE I-Smdldng polkles adoped or revised by Brooldine businesses 1970-1989.
distinguishes between smoking policies and smoking restrictions. Smoking restrictions were reported by 80% of work sites; 34% banned smoking and 46% restricted it to designated areas. Figure 2 presents the smoking rules for six specific areas. Over 65% of businesses banned smoking in shared work areas, public areas, conference rooms, and hallways. Smoking rules did not differ significantly between companies sent the mailing and controls, although those sent the mailing were more likely to ban smoking in shared work areas (70% vs 58%, P = .068). Respondents were asked separately about their company's smoking policy. Fifty-nine percent replied that their company had a smoking policy for employees at that work site, but only half of these policies were written and only one third were posted at the workplace, as stipulated by law. Forty percent posted nosmoking signs. By our definition, 34 businesses (11%) reported full compliance with the law (Table 3). Companies sent the mailing were more likely than controls to report full compliance, a written smoking policy, and no-smoking signs, although the last difference was not statistically significant. On multivariate analysis, smoking restrictions were more common in service businesses (OR = 3.48; 95% CI = 1.14, 6.13) and in firms whose top manager did
232 American Journal of Public Health
= 4.74; 95% CI = 2.09, 10.71). Smoking bans were more common in companies with a non-smoking manager (OR = 19.31; 95% CI = 2.56, 145.53) and fewer smoking employees (OR = 1.60; 95% CI = 1.12, 2.29). Restrictions were not independently associated with work-force size.
not smoke (OR
Compliance: Direct Observations Direct observations in Brookline businesses confirmed self-reports of nosmoking signs in 98% of firms (119/121), although only 60% of signs were "conspicuously displayed" as required by law. In contrast, we validated few reports of written or posted smoking policies. We observed written policies in 6 of 89 companies reporting them (7%) and posted policies in 5 of 60 companies (8%). Employees often responded to a request for a written or posted smoking policyby pointing to a no-smoking sign. Table 3 compares control and intervention groups on the validated endpoints of signs and policies. All written and posted policies were observed in businesses sent the mailing, but the number was so small that group differences were not statistically significant. By direct observation, only three Brookline companies (1%) fully complied with the law. Furthermore, a customer was seen smoking in 36% ofbusinessesvisited and a smoking
Half (n = 50) of businesses in the group asked to submit a written smoking policy did so. Nearly all used the demonstration policy provided by the health department. Twenty-nine policies (58%) were in compliance, indicating that smokingwas restricted or banned and no-smoking signs were posted. The major reason for noncompliance was the misconception that firms without smoking employees need not have a smoldng policy or post signs.
Disussion This study assessed workplace compliance with a community clean indoor air law 1 year after the law's implementation. It also evaluated a low-cost intervention designed to increase employers' awareness and compliance with the law. Our discussion addresses these questions in order: (1) What was the prevalence of work-site smoking restrictions in Brookline 1 year after the law became effective? (2) Was the law responsible for these restrictions? (3) Did the intervention increase employers' awareness and compliance with the law? (4) What did town businesses think of the law? 1. One year after the law went into effect, the prevalence of work-site smoking restrictions in town businesses was high. Eight of ten firms had some smoking restrictions, one third banned smoking altogether, and two thirds banned smoking in shared work areas, where passive smoke exposure is likely to be highest. Two observations suggest that the situation was more complex, however. First, there was considerable discrepancy among estimates of smoking policy prevalence. The prevalence ofrules about smoking (80%o) exceeded that of smoking policies (59%o), and self-reported prevalence of smoking policies greatly exceeded that directlyobserved. Second, we observed customers and employees smoking in some businesses that reported not permitting it. These discrepancies could reflect employers' misrepresentation of their policy, failure to enforce their
Febnaiy 1992, Vol. 82, No. 2
Wodpm Complac policy, or misconception of what is a smoking policy and what the law requires businesses to do. The last two explanations are most likely. Smoking rules were probably not always enforced, and many businesses considered a no-smoking sign to be their written policy or felt no policy was needed because no employee smoked. Misrepresentation is less likely, given good agreement between self-reported and observed estimates of nosmoking-sign prevalence, a more concrete endpoint. It appears that the law was understood differently by policymakers who drafted it and businesses to whom it applied. Because "smoking policy" was variously interpreted, we consider respondents' reports of "smoking rules" to be a better reflection of the actual prevalence of smoking restrictions in Brookline businesses. We conclude that the prevalence of smoking restrictions is high. Despite this, few Brookline firms complied fully with the law as written. Lack of awareness of the law and misinterpretation of the ordinance probably account for this finding. Nonetheless, it appears that the law achieved much of its intentreducing exposure to passive smoke. The scarcity of complaints to the health department supports this interpretation but demonstrates that a lack of complaints does not guarantee compliance with a law. The frequency with which smoking was observed in businesses further indicates the limits of complaints as a measure of compliance. We suggest that differences in practice between large and small businesses account for some of employers' nmisconceptions about what the law required. While large businesses typically write formal policies to define acceptable employee behavior, small companies (as are most Brookline businesses) appear to make and enforce rules about smoldng more informally and communicate them orally to employees, and they may not consider the rules to be policies.17 PoliCymakers need to be aware of the practices of small businesses, which constitute the bulk of US companies, in order to draft work-site no-
prompted to adopt smoking restrictions; however, without observations from a comparison community, we cannot exclude the possibility that smoking restrictions resulted from concurrent social change. Estimates of work-site smoking policy prevalence in other communities, with which to compare our data, are few. A 4% prevalence of written policies was found in New York City businesses in 1986, prior to a no-smoking ordinance.18
In contrast, the prevalence of smoking policies and restrictions in Seattle manufacturing companies in 1988 was similar to Brookline, despite Seattle's lack of a work-site no-smoking law. However, Seattle bans smoking in public places and government work sites, and "public acceptance of smoking restrictions is widespread."19 Although comparisons between surveys require caution, these data suggest that smoking policies may be less
smoldng laws that can be readily implemented by small and large firms. 2. To what extent was the Brookline law responsible for work-site smoking restrictions present 1 year later? The law was followed by a dramatic increase in the number of firms adopting smoking policies, and businesses aware of the law had more smoking policies. Companies aware of the law appeared to have been February 1992, Vol. 82, No. 2
Bars representthe percentage of Brooldine businessesthat ban or restictsmofxng overall and in six sp fi areas at work. The figure compares the responses of companies sent Fe mailing (intervention group [11) with conts (C). FIGURE 2-Ruls about smoldng In Brookdine businesses.
American Journal of Public Health 233
RigoW et a.
common in communities without laws, but considerable local variability exists. We conclude that smoking restrictions are more common in Brookline businesses than in many communities, due in part to the law. 3. What was the effect of the health departnent's mailing to businesses? The mailing increased awareness but not com-
234 American Journal of Public Health
pliance with the law. It doubled the number of businesses aware of the law, but it informed fewer than half of town businesses about the law. Awareness is an important endpoint because compliance with a self-enforcing law can be expected only if those subject to it know about it. By itself, the mailing did not clearly increase compliance with the law, and the effect of
the mailing was not enhanced by surveillance (e.g., requiring businesses to return a smoking policy to the health department). Surveillance might have been effective had the health department contacted noncompliant businesses it identified. Furthermore, analysis of returned policies provided information valuable for planning subsequent implementation programs. For the health department, major advantages of the intervention were its simplicity and low cost, but these factors also limited its effectiveness. Even with its modest effect, the mailing might be regarded as cost-effective; it cost $14.73 per business informed: $800/[(.46 - .18) x 194 businesses]. 4. The law's popularity with employers 1 year after its adoption is an important additional finding. Employers aware of the law reported no adverse effects and did not perceive compliance to be burdensome. Not surprisingly, the law was more popular among respondents who did not smoke and in companies with smoking restrictions and few smoking employees. Managers' strong endorsement of the strictly worded Brookline statute is good news for policymakers in other communities considering no-smoking laws. Methodologic strengths of this study include the following: we tested the intervention in a randomized controlled trial, assessed outcomes in a large random sample of town businesses, achieved a high response rate to a telephone survey, and validated self-reports by direct observation. Interpretation of study results must consider that this was a study of a single community. The Brookline sample resembles statewide and national distributions of business size, but it has significantly more service and fewer manufacturing businesses than comparison state and national samples. 1020 In summary, the Brookline no-smoking bylaw was popular with businesses, increased the adoption ofwork-site smoking policies, and contributed to a high prevalence of smoking restrictions in town businesses. Although full compliance with the law was low, largely because of misunderstandings inwhat the law required of businesses, the town's modest implementation effort achieved a good measure of the intent of the legislation. The health department's mailing increased companies' awareness but not compliance with the law. Further implementation efforts could improve awareness, compliance, and enforcement of the law. Nonetheless, the study demonstrates that a local health de-
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Workplace Compliance
partment can disseminate information to employers concerning a new requirement with a modest effort. El
Aclmowledgments This studywas funded in part by Grant 88-6169 from the Henmy J. Kaiser Family Foundation and a teaching and research schloarship awarded by the American College of Physicians to Dr. Rigotti. This work was presented at the annual meeting of the American Public Health Association, October 1989. We are indebted to Eva Jackson for assistance in data collection and analysis, to Pat Camey for manuscript preparation, and to David Hemenway, PhD, and Kenneth Warner, PhD, for reviewing the manuscript.
References 1. US Department ofHealth and Human Services. The Health Consequences ofInvoluntary Smoking. A Report of the Surgeon GeneraL Washington, DC: US Departnent of Health and Human Services; 1986; DHHS publication no. (CDC) 87-8398. 2. US Department of Health and Human Services. Reducing the Health Consequences ofSmoking: 25 Years ofBPrognss. A Report of the Surgeon GeneraL Wash-
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ington, DC: US Department of Health and Human Services; 1989; DHHS publication no. (CDC) 89-8411. 3. Tobacco-Free America. State Legislated Actions on Tobacco Issues. Washington, DC: Tobacco-Free America Legislative Clearinghouse; 1989. 4. Pertschuk M, Shopland DR. Major Local Smokdng Ordinances in the United States. Washington, DC: Americans for Nonsmokers Rights and US Department of Health and Human Services; 1989; NIH publication no. 90-479. 5. Rigotti NA. Trends in the adoption of smoking restrictions in public places and worksites. New York State J Med. 1989;89:19-26. 6. Martin MJ. The San Francisco experience with regulation of smoking in the workplace: the first twelve months.AmJPublic Health. 1986;76:585-586. 7. RepaceJL, LowreyAH. A quantitative estimate of nonsmokers' lung cancer risk from passive smoking. Environment Int.
1985;11:3-22. 8. Bureau of National Affairs. Where There's Smoke: Problem and Policies Concening Smokingin the Woriplace. A BNA Special Report. 2nd ed. Rockville, Md: Bureau of National Affairs; 1987. 9. Gottlieb NH, Hedl JJ, Eriksen MP, Chan F. Smoking policies among private employers and public agencies in Texas: a statewide
analysis. JNCI. 1989;81:200-204.
10. Fielding JE, Piserchia PV. Frequency of worksite health promotion activities. Am J Public Health. 1989;79:16-20. 11. Dun & Bradstreet Corp. Dun's Census of American Businesses 1989. Parsippany, NY: Dun's Marketing Services Inc; 1989. 12. US Department of Commerce. State and MetropolitanArea Data Book 1986. Washington, DC: US Department of Commerce; Bureau of the Census; 1986. 13. Gibney FJ. Brookline. Boston, Mass: Massachusetts Department of Commerce, October 1984. Unpublished monograph. 14. Brookline, Mass, Bylaw Article XLII (November 16, 1988). 15. Willinson L. Systat: the System for Statistics. Evanston, Ill; Systat Inc; 1986. 16. SAS Institute. SAS-PC Release 6.a Cary, NC; SAS Institute Inc; 1987. 17. SorensenG, RosenA, PinneyJ, RudolphJ, Doyle N. Worksite smoking policies in small businesses. J Occup MeL In press. 18. Centers for Disease Control. Survey of worksite smoking policies-New York City. MMWR 1987;36:177-179. 19. Kinne S. Prevalence and restrictiveness of smoking policies in King County, Washington, manufacturing worksites. Am J Public Health. 1990;80:1498-1500. 20. Homer ER, ed. Massachusetts Municpal Profiles, 1988-89. Palo Alto, Calif: Information Publications; 1989.
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