UNIVERSITY OF CINCINNATI

12/10/04 Date: ______I, Dwan C. Marshall ______, hereby submit this work as part of the requirements for the degree of: Master of Science in: Health Administration ______It is entitled: Progression of Local Tobacco Ordinances affecting Restaurants in Ohio 1992-2003 ______

This work and its defense approved by:

Chair: ______Jan M. Fritz, PhD.

______Christopher Auffrey, PhD. ______

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Progression of Local Tobacco Ordinances affecting Restaurants in Ohio 1992-2003

A thesis submitted to the Division of Research and Advanced Studies of the University of Cincinnati

in partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE

in the School of Planning of the College of Design, Art, Architecture and Planning

2004

by

Dwan C. Marshall B.A., University Of Akron 1978 A.D., Tennessee State University 1983

Committee Chair: Jan M. Fritz, PhD.

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Abstract

This study examines local tobacco-control legislation which was enacted or amended between January 1985 and August 2003 and affects restaurants in Ohio. This study follows the work of Paula Bistak who examined the same topic from 1985 through 1992 by extending the period covered from July 1992 – August 2003. Both studies examine the regulations of 19 cities and one county in Ohio and analyze the tobacco-control regulations for comprehensiveness and strength. A content analysis of the regulations and amendments has been conducted to determine the comprehensiveness and strength of the regulations as of August 2003.

The scientific evidence confirming that environmental tobacco smoke (ETS) is harmful to nonsmokers has increased and in recent years has been driving the argument for a smokefree environment in the workplace, specifically restaurants and bars. The Office of the Surgeon

General in 2000 concluded that the most effective method for reducing or eliminating environmental tobacco smoke (ETS) exposure is to establish smoke free environments (U.S.

Public Health Service, 2000). A local tobacco control ordinance that restricts or eliminates smoking is a positive step towards a healthy, smoke-free environment (Bistak, 1995; U.S. Public

Health Service, 1999). This study found that since the late 1990s there has been very little general progress in tobacco control in Ohio. The exceptions would be the cities of Bowling

Green and Toledo.

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Acknowledgement

I have been given this opportunity to complete this journey and to be surrounded by many supportive, loving and positive individuals who gave their time, efforts and assistance in helping me reach this goal.

I appreciate this experience and recognize those who contributed to my success with this thesis:

My husband, Kelvin, who loves and supports me unconditionally;

My parents, Elizabeth and Jason Mills, and my other family members who daily

reminded me that I can do all things and gave me endless encouragement to

complete this project;

Professor Jan Fritz who demonstrated tremendous patience and believed in my

abilities to complete this project. She gave me support through this entire project

by lending her expertise and academic guidance;

Professor Christopher Auffrey for his support and serving on my committee;

LifeShpere and the Maple Knoll Village family for their support and

consideration.

.

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TABLE OF CONTENTS

LIST OF TABLES AND FIGURES 2

Chapter

1. INTRODUCTION 3

2. PROBLEM 6

Ohio and Local Tobacco Control 6

Differences between State and Local Laws 11

Effects of Environmental Tobacco Smoke 12

Trend Towards Smokefree Restaurants 18

Debate against Tobacco Control 21

3. METHODOLOGY 24

4. DATA 27

5. ANALYSIS 39

6. CONCLUSION 52

7. REFERENCES 56

Appendix

A. Citations of Local Regulations 2

LIST OF TABLES AND FIGURES

Table Page

1. Cities Populations 29 2. Legislative Body and Enforcement Agent 31 3. Non-smoking Section Size Provisions 32 4. Smoke Barrier and Ventilation Requirements 33 5. Signage 34 6. Proprietor Responsibilities if Patron in Violation of Regulation 35

7. Complaint Provisions 36 8. Compliance Provisions 37 9. Smoking Prohibited and Separately Ventilated Dining Provision 38 10. Regulation Comprehensiveness 41 11. Non-Smoking Section Provision Strength 43 12. Smoke Barrier and Ventilation Requirements Strengths 44 13. Signage Strength 45 14. Proprietor Responsibility Provision Strength 46 15. Complaint Provision Strength 47 16. Compliance Provision Strength 48 17. Smoking Prohibited and Separately Ventilated Dining Strength 49 18. Regulation Strength Summary 50 19. Comprehensiveness and Strength 51

Figure

1. Ohio Map 30

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CHAPTER 1

INTRODUCTION

This study examines local tobacco-control legislation which was enacted or amended between January 1985 and August 2003 and affects restaurants in Ohio. The term “restaurant” usually has been defined by the regulations (see Appendix A) as any coffee shop, cafeteria, luncheonette, sandwich stand, soda fountain or any other establishment (excluding bars) where cooked or otherwise prepared food is sold to members of the general public for consumption on the premises (see appendix A).

This study is based on the work of Paula Bistak who examined the same topic from 1985 through 1992 and extends the study period from July 1992 to August 2003. Both studies examine the regulations of 19 cities and one county in Ohio and analyze the tobacco-control regulations for comprehensiveness and strength.

The regulations of the 19 cities and one county are cited in the Americans for

Nonsmokers Rights Foundation (ANR) database (February 24, 2004). These regulations, with two exceptions, are from the same communities that were analyzed by Bistak in 1995. Bistak’s list included Cincinnati (which is no longer on the ANR list) and did not include Bowling Green.

Since Bistak’s study, Bowling Green developed a regulation and four communities have amended their regulations.

The Office of the Surgeon General in 2000 concluded that the most effective method for reducing or eliminating environmental tobacco smoke (ETS) exposure is to establish smokefree 4 environments (U.S. Public Health Service, 2000). Environmental tobacco smoke is the complex mixture formed from the escaping smoke of a burning tobacco product and smoke exhaled by the smoker (National Cancer Institute, 1999:ES-1). A local tobacco control ordinance that restricts or eliminates smoking is a positive step towards a healthy, smokefree environment (Bistak, 1995;

U.S. Public Health Service, 1999).

A great deal has been written about tobacco control (e.g., National Cancer Institute, 2000;

Muggli, Hurt and Repace, 2004)) but there is little written about the situation in Ohio. The best sources of information for Ohio are the thesis by Paula Bistak (1995), an article by Paul Monardi and Stanton Glantz (1998) on tobacco control activity from 1981-1998, an article on one Ohio community by Jan Fritz, Paula Bistak and Christopher Auffrey (2000) and the Ohio entry in the

Americans for Nonsmokers Rights database (2004). According to Stanton A. Glantz (1998),

Ohio had made little progress in the area of ordinances that promote a smoke-free environment over the 17-year period ending in 1998.

A content analysis of the regulations and amendments has been conducted to determine the comprehensiveness and strength of the regulations as of August 2003. Bistak used a two- stage content analysis methodology. She first did an emergent qualitative examination of the regulations to determine comprehensiveness. Then she examined each provision category to determine strength. The same approach is used in this study. As recent amendments are being reviewed as part of the study, it is possible to see if the regulations in the communities are now stronger or weaker.

This study is significant for several reasons. First, this study provides a great deal of information for communities that want to enact tobacco-control policies for restaurants. Second, it allows communities with tobacco-control policies for restaurants to compare their situations 5 with other communities. Third, it allows communities and researchers to see the degree of progress in Ohio regarding tobacco-control regulations. In addition, this study adds to the body of research literature about state and local tobacco-control efforts. As such, the information will be useful to researchers as well as practitioners.

This chapter is followed by a problem statement that includes a detailed literature review.

Chapter 3 discusses the methodology used in this study, Chapter 4 presents the data and Chapter

5 provides the analysis. Chapter 5 is followed by a conclusion, references and an appendix.

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CHAPTER 2

STATEMENT OF THE PROBLEM

This study examines local tobacco-control regulations, enacted or amended, between January

1985 and August 2003 that affected restaurants in Ohio. In order to discuss this topic, the following issues will be covered in this chapter: Ohio and local tobacco control, differences between state and local laws, effects of environmental tobacco smoke and trends towards smokefree restaurants.

Ohio and Local Tobacco Control

Ohio has a population of over 11 million and is a state where tobacco is grown.

According to Monardi and Glantz (1998:7), “Ohio is one of the leading states as far as tobacco consumption.” Monardi and Glantz (1998:7) further contend:

One reason that may partially explain the high smoking

rates in Ohio is that it has a large blue collar, less educated

population, and smoking rates increased in lower socioeconomic

strata. Another reason may be that local tobacco control activity

slowed down since the late 1980s, when several cities or counties 7

passed local ordinances restricting but not ending in public places

or the workplaces.

In the last few years, Ohio has been ranked either fourth or eighth for adult smoking prevalence (Ohio Tobacco Use Prevention and Control Foundation, 2004). According to the

Center for Disease Control (CDC), nearly 19,000 Ohioans a year, or 52 a day, die from tobacco related illness and disease. The economic costs of smoking for Ohioans is over $7 billion which includes $3.41 billion a year in direct healthcare costs (American Lung Association, State of

Tobacco Control: 2003; Ohio Tobacco Use Prevention and Control Foundation, 2004).

Local tobacco control efforts in Ohio began to take shape in the late 1980s when many cities and counties passed ordinances requiring entire workplaces or certain areas of workplaces to be smokefree (Monardi and Glantz, 1998). Frustrated by slow state and federal government action, those seeking to reduce tobacco use centered their efforts at the local level (Jouzaitis, 1994:1,

Bistak, 1995:4) During this time, local tobacco control ordinance development was mainly a grassroots effort by local and state nonsmokers’ rights groups in partnership with local health departments or local voluntary health associations such as the American Lung Association,

American Cancer Society, or American Heart Association ( NCI, 2000).

According to Monardi and Glantz (1998), the Ohio legislature, historically, has rarely considered tobacco control legislation for the following reasons: (1) there was no legislator or group of legislators in the Ohio legislature that had made tobacco control a major part of the agenda, (2) since the governor and the House and Senate leaders had not stated clear positions on tobacco control legislation, the voluntary associations did not want to promote legislation that may be amended into non-desirable bills and (3) tobacco control advocates spent most of their time and resources in preventing pro-tobacco preemptive legislation from passing in the Ohio 8

state legislature. Fritz, et.al (2000) states in the study, The Bumpy Road to a Tobacco-Free

Community, that as the local health departments in Ohio were taking on tobacco control issues in the 1990s, a new opponent strategy, preemption, was emerging. Bills had been introduced at the

state level in Ohio that would preempt local tobacco regulations, setting a standard and removing

the right of local government to adopt stronger tobacco-control measures (Fritz, et al, 2000). The

Americans for Nonsmokers Rights (1998) identified that while the national health community

has strongly opposed preemption, preemption initiatives have been a real problem and have been

identified as “tobacco control’s #1 enemy.”

Since the late 1990s, there has been an increased level of activity and interest related to

tobacco control in Ohio. In an effort to reduce tobacco use among Ohioans, the Ohio General

Assembly in 2000 created The Ohio Tobacco Use Prevention and Control Foundation (TUPCF)

(TUPCF, 2004). TUPCF is charged with reducing tobacco use among Ohioans, with an

emphasis on youth, minority and regional populations, pregnant women and others who may be

disproportionately affected by the use of tobacco (TUPCF, 20003).

The American Lung Association’s State of Tobacco Control report for 2003 stated that tobacco control in Ohio was reaching new heights. This is in part due to scientific research concluding that environmental tobacco smoke or secondhand smoke is linked to a variety of adverse health outcomes including cancer, heart disease, asthma and death. (U.S. Environmental protection Agency, 1993, 1999). However, despite the strides Ohio is making in tobacco control efforts, the state received a failing grade on its report card in the area of smoke free air, which is the same grade it received in 2002. The American Lung Association’s State of Tobacco Control

2003 report analyzed each state’s action five years after the 1998 Master Settlement Agreement, through which the tobacco industry agreed to pay 46 states approximately $206 billion over 25 9 years, in recovery of the states tobacco related health care cost (American Lung Association,

2004). The 2003 report analyzed and evaluated state tobacco control laws in the area of

(1) smokefree air, (2) youth access to tobacco, (3) prevention and control spending and (4) cigarette taxes.

In 1998, Monardi and Glantz contended that the tobacco industry was a major political and legal force in Ohio through campaign contributions, lobbying and litigation. There was a pattern whereby lobbyists represented both the tobacco industry and health groups raising the possibility of conflict of interest. Also, there were one or more members of the Ohio legislature who were tobacco farmers and were recipients of tobacco industry money (Monardi and Glantz,1998).

This may suggest that the tobacco industry had the potential to influence a legislator’s behavior on tobacco control issues. However, Monardi and Glantz’s 1998 study on Tobacco Control

Policy Making in Ohio: 1981-1998 found no statistically significant relationship between tobacco industry campaign contributions and legislative behavior in Ohio.

According to Sabetta (2004), in Ohio there have been several county boards of health and health departments that have had their smoking regulations challenged in court. In one instance, the Columbus City and Franklin County Boards of Health introduced a countywide regulation banning smoking in all public buildings except bars. A group of restaurant and bar owners filed suit against the health departments. The court ruled that boards of health do have the power to enact smoking restrictions. However, the regulation was struck down because it was found to be discriminatory in its exemptions. In another example, the Delaware City-County Health

Department was sued by a group of bar owners regarding its regulation restricting smoking in businesses. The court concluded that the Ohio Revised Code did not give boards of health the legislative authority to enact smoking restrictions. 10

The Ohio General Assembly in recent years has attempted but was defeated to introduce preemption legislation that would strip the authority of local and county boards of health to enact regulations (seen as necessary to protect the public health) (Sabetta, 2004).

In another instance (Sabetta, 2004), bar and restaurant owners filed a law suit against the

Toledo-Lucas County Board of Health claiming the Board of Health did not have the authority under Ohio Revised Code to regulate the sale or use of tobacco products. This occurred following the passage of the Toledo-Lucas County Clean Indoor Air Regulation in May of 2001.

The Ohio Supreme Court ruled that the Ohio General Assembly had not indicated through the

Ohio Revised Code to vest local boards of health with unlimited authority to adopt regulations addressing all public-health concerns and therefore the Toledo-Lucas County Board of Health did not have the authority to establish the 100% Clean Indoor Air Regulation (Sabetta, 2004).

Fritz, Bistak and Auffrey (2000) point out that in the state of Ohio, public health districts are politically independent in terms of their rule-making abilities. The boards’ state defined powers enable them to enact health regulations without outside approval from groups like a city council or a state health department and seeks to protect public health by keeping health issues somewhat separate from politics (Fritz et al., 2000).

According to Monardi and Glantz (1998:23), judicial decisions such as the ones discussed above left tobacco control advocates and health officials wondering what they can and cannot do.

Monardi and Glantz (1998) further concluded that health commissioners and the legal community in Ohio need to clearly define what constitutes rulemaking.

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Differences between State and Local Laws

Statewide laws restricting smoking typically are adopted by the state legislature and are collectively referred to as a clean indoor air act (Bistak, 1995:10). Local laws are adopted by city council or county boards of supervisors and are normally referred to as smoking ordinances

(American for Nonsmokers Rights, 1989:2, Bistak, P 1995:10). Laws restricting smoking that are enacted by health departments are called regulations. The Ohio revised Code (Section

3709.36) empowers the board of health of a city or general health district to enact rules and regulations to protect the public’s health (Bistak, 1995). In this study the terms regulation and/or law will be used when local tobacco legislation is discussed and the more specific term of ordinance will be used when appropriate.

Local legislation remains far easier to pass than state or federal tobacco control legislation (Moore et al, 1994, Siegel et al 1997). According to Samuels and Glantz, (1991) and

Bistak (1995), smoking regulations at the local level is where the strongest and most comprehensive tobacco control policies have been enacted and have been the most effective compared to state laws. Meaningful smokefree air legislation is much easier to enact at the local level where policymakers are most responsive to the concerns of constituents and less influenced by tobacco industry lobbyists and campaign contributions (ANR, 2004). Americans for

Nonsmokers’ Rights (2004) states:

The tobacco companies are forced to work at the local level

through fake front groups and allies, whereas they are able to

directly engage policymakers at the state and federal level without 12

as much of a credibility gap. Big Tobacco would much rather

bottle up or weaken one bill at the state house rather than try to

track and fight hundreds of local policy efforts throughout a state.

More than 110 local smokefree ordinances had been passed in the United States before the first state law with smokefree provisions was passed in Vermont in 1993 (NCI, 2000).

Other advantages of local tobacco control ordinances over state legislation include (1) local agencies are more accessible and likely to enforce a law (NCI, 2000), (2) local laws tend to gain higher levels of compliance since they normally mandate local enforcement mechanisms while state laws do not usually contain this provision (Bistak, 1995) and (3) community education where the development of local ordinances puts in motion an educational process of letters to the editor, press coverage, town hall meetings and public hearings ( Jacobson and Wasserman, 1997).

Effects of Environmental Tobacco Smoke

In the past 20 years, there has been mounting scientific evidence that environmental tobacco smoke (ETS) or secondhand smoke (SHS)-exposure to ETS is referred to as passive or involuntary smoking(U.S. Environmental Protection Agency(EPA), 2004)-is associated with a number of adverse health outcomes and consequences not only for the smoker but for the nonsmoker as well. Smoking remains the leading preventable cause of disease and death in the

United States, resulting in more than 440,000 premature deaths each year (CDC, 2002a; U.S.

DHHS, 2004). More recently, the effects of the inhalation of environmental tobacco smoke by nonsmokers have become a pressing public health concern (U.S DHHS, 2004). Secondhand smoke is the third leading preventable cause of disability and early death (after active smoking 13

and alcohol) in the United States (Repace, Kawachi and Glantz, 1999). Repace, Kawachi and

Glantz (1999) further explain that between 70% and 90% of non-smokers in the American

population, children and adults, are regularly exposed to ETS or secondhand smoke. In the

Surgeon General's report of 2004: The Health Consequences of Smoking, concludes that

smoking harms nearly every organ of the body and causes generally poorer health. According to

this 2004 report, the number of diseases caused by smoking has continued to increase. This is in

comparison to the 1964 Surgeon General’s reporting of a short list of diseases known to be

caused by smoking namely chronic bronchitis and cancers of the lung and larynx (USDHEW

1964).

The scientific evidence linking nonsmoker exposure to environmental tobacco smoke with

lung cancer and other diseases has had a major influence on the decline of societal acceptance of

smoking (Kagan and Skoinick, 1993:79, Bistak,1995). The Surgeon General (2004) states,

“Since 1964, there has been a broad societal shift in the acceptability of tobacco use and in the

public’s knowledge about the accompanying health risks.”

In recent years this increased awareness of risk factors associated with environmental

tobacco smoke has stimulated public policy (i.e., clean in-door air legislation, tobacco control

ordinances) aimed at protecting the rights of nonsmoker. Although the level of secondhand tobacco smoke that nonsmokers are exposed to has declined significantly in the last decade, the decline has been greater among adults than among children, who are largely exposed at home

(U.S. DHHS, 2004). Currently, levels of exposure to this known human carcinogen are more than twice as high among nonsmoking children than among nonsmoking adults (CDC, 2003a).

The following discussion will define ETS and review several studies that have had an impact on this issue. 14

ETS is formed from the smoldering or burning end of a cigarette, pipe, or cigar (NRC, 1986,

U.S. EPA, 2004). It is composed of exhaled mainstream smoke from the smoker, sidestream smoke emitted from the smoldering tobacco between puffs, contaminants emitted into the air during the puff, and contaminants that diffuse through the cigarette paper and mouth end between puffs (U.S.DHHS and U.S. EPA, 1993; NCI, 1999). This mixture contains more than

4,000 substances (U.S. EPA, 2004). More than 40 of these substances or chemicals are cancer causing agents and 200 known poisons (Repace et al., 1999).

ETS chemicals include irritants and systemic toxicants such as hydrogen cyanide, mutagens and carcinogens such as formaldehyde, and reproductive and developmental toxicants such as nicotine and carbon monoxide (CalEPA, 1997, Americans for NonSmokers’ Rights, 2004). The literature reviewed concluded that ETS exposure causes lung and nasal sinus cancer, heart disease, and Sudden Infant Death Syndrome. Serious impacts of ETS on children include asthma induction and exacerbation, bronchitis and pneumonia, middle ear infection, chronic respiratory symptoms, and low birth weight (EPA, 1993, 1999, ANR,2004). The U.S. Environmental

Agency (EPA) in its 1992 report concluded that ETS was a group A carcinogen causing 3,000 lung cancer deaths a year among American nonsmokers.

There have been several significant reports and research studies conducted in recent years that have made an impact on the issue of the effects of nonsmoker’s exposure to environmental tobacco smoke and the trend towards a smokefree society. In 1986, the Surgeon General’s report entitled “The Health Consequences of Involuntary Smoking (U.S. DHHS, 1986) concluded that:

1. Involuntary smoking is a cause of disease, including lung cancer, in healthy nonsmokers.

2. The children of parents who smoke compared with the children of nonsmoking parents have an increased frequency of respiratory infections, increased respiratory 15

symptoms, and slightly smaller rates of increase in lung function as the lung matures.

3. The simple separation of smokers and nonsmokers within the same air space may reduce, but does not eliminate, the exposure of nonsmokers to environmental tobacco smoke.

This 1986 report also explored the health effects of environmental tobacco smoke exposure and summarized the following:

1. Involuntary smoking can cause lung cancer in nonsmokers.

2. Although a substantial number of the lung cancers that occur in nonsmokers can be attributed to involuntary smoking, more data on the dose and distribution of ETS exposure in the population are needed in order to accurately estimate the magnitude of risk in the U.S. population.

3. The children of parents who smoke have an increased frequency of hospitalization for bronchitis and pneumonia during the first year of life when compared with the children of nonsmokers.

4. The children of parents who smoke have an increased frequency of a variety of acute respiratory illnesses and infections, including chest illnesses before 2 years of age and physician diagnosed bronchitis, tracheitis, and laryngitis, when compared with the children of nonsmokers.

5. Chronic cough and phlegm are more frequent in children whose parents smoke compared with children of nonsmokers. The implications of chronic respiratory symptoms for respiratory health as an adult are unknown and deserve further study.

6. The children of parents who smoke have small differences in tests of pulmonary function when compared with the children of nonsmokers. Although this decrement is insufficient to cause symptoms, the possibility that it may increase susceptibility to chronic obstructive pulmonary disease with exposure to other agents in adult life, e.g., active smoking or occupational exposures, needs investigation.

7. Healthy adults exposed to environmental tobacco smoke may have small changes on pulmonary function testing, but are 16

unlikely to experience clinically significant deficits in pulmo- nary function as a result of exposure to environmental tobacco smoke alone.

8. A number of studies report that chronic middle ear effusions are more common in young children whose parents smoke than in children of nonsmoking parents.

9. Validated questionnaires are needed for the assessment of recent and remote exposure to environmental tobacco smoke in the home, workplace, and other environments.

10. The associations between cancers, other than cancer of the lung, and involuntary smoking require further investigation before a determination can be made about the relationship of involuntary smoking to these cancers.

11. Further studies on the relationship between involuntary smoking and cardiovascular disease are needed in order to determine whether involuntary smoking increases the risk of cardiovascular disease.

Research and scientific investigations continued to evolve in this area resulting in studies that

found a casual relationship between environmental tobacco smoke and diseases that pose a

health hazards to nonsmokers. One of the more significant studies was conducted by the U.S.

Environmental Protection Agency (EPA) in 1992 to determine whether ETS met the Carcinogen

Risk Assessment guidelines for classifying a compound carcinogenic (NCI, 1993). This risk

assessment entitled, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other

Disorders, reached the following major conclusions:

In adults:

ETS is a human lung carcinogen, responsible for approximately 3,000 lung cancer deaths annually in U.S. nonsmokers.

In children:

ETS exposure is causally associated with an increased risk of lower respiratory tract infections such as bronchitis and pneumonia; an estimated 150,000 to 300,000 cases annually in children up to 18 months of age are attributed to ETS. 17

ETS exposure is causally associated with increase prevalence of fluid in the middle ear, symptoms of upper respiratory tract irritation, and a small but significant reduction in lung function.

ETS exposure is causally associated with additional episodes and increase severity of symptoms in children with asthma; it is estimated that up to 1 million asthmatic children have their condition worsened by exposure to ETS.

ETS exposure is a risk factor for new cases of asthma in children who have not previously displayed symptoms.

ETS is the ONLY agent ever classified as a human carcinogen by the U.S. Environmental Protection Agency where the risk is based on actual ambient levels of exposure.

The release of this report helped to accelerate the passage of local clean indoor air ordinances

(Glantz, 1997) and also helped to expand the understanding and magnitude of the health consequences for the nonsmoker (U.SHHS, 2004).

Another study that appears to have had an impact on the ETS issue was the study conducted by the California Environmental Protection Agency (Cal/EPA): Health Effects of Exposure to

Environmental Tobacco Smoke (NCI, 1999). This agency undertook a comprehensive assessment of the total range of health effects correlated with exposure to ETS (NCI, 1999). The

Cal/EPA found that ETS is an important source of exposures to toxic air contamination indoors and is associated with and causes a number of fatal and non-fatal health effects such as lung cancer, asthma, low birth weights, sudden infant death, coronary heart disease, and nasal sinus cancer (NCI, 1999, ANR, 2004).

The scientific research of the health hazards associated with environmental tobacco smoke has continued to expand on both a national and global level. The information gained from this research will be useful in the planning of tobacco control efforts around the world. According to the Surgeon General (2000) “Globally, smoking related deaths will rise to 10 million per year by

2030, and 7 million of these deaths will occur in developing countries.” 18

Trend Towards Smokefree Restaurants

The scientific evidence confirming that ETS is harmful to nonsmokers has increased and in recent years has been driving the argument for a smokefree environment in the workplace, specifically restaurants and bars. The Surgeon General’s 2000 report Reducing Tobacco Use states “Environmental tobacco smoke exposure remains a common public health hazard that is entirely preventable.” In 1999, Dr. David Satcher, U.S. Surgeon General, called on the nation to commit to public health by encouraging communities to enact clean indoor air ordinances requiring 100 percent smoke free environment in all public areas and workplaces, including all restaurants and bars (NCI, 1999).

This trend towards a smokefree environment was initially born out of a need to protect the rights of nonsmokers to breathe clean air over the rights of smokers to pollute the air (Doyle,

1987:7; Bistak, 1995:7). Over the last decade this movement has accelerated - a record 180 new local clean indoor air ordinances were adopted in 1993 (NCI ,2000) - in part due to the EPA’s

1993 landmark report documenting the link between secondhand smoke, cancer, and other chronic diseases (American Cancer Society, 2004).

The first modern tobacco control laws designed with the purpose of protecting nonsmokers from secondhand smoke appeared in the early 1970s (U.S. DHHS,1986, NCI, 2000). For example, in 1972, Arizona passed a law protecting nonsmokers from second-hand smoke

(Apfel, 2002) and in 1977, Berkeley, California enacted the first modern local tobacco control ordinance limiting smoking in restaurants and other public places (NCI,2000). A quarter-century later, state attorneys general successfully sued tobacco companies, and public-smoking bans have been enacted or proposed in numerous municipalities and communities around the nation (Apfel, 2002). 19

Local communities armed with scientific evidence that confirmed that ETS is a serious

health hazard, have leaned towards more restrictive clean indoor ordinances. According to

the NCI (2000) in its monograph State and Local Legislative Action to Reduce Tobacco

Use, in 1984 there were no local ordinances completely eliminating smoking in restaurants

or workplaces and by 1987 there was only one ordinance that banned smoking in

restaurants. However, in contrast, by December of 1998, 227 ordinances completely

eliminated smoking in restaurants. Ohio communities, through the efforts of community

city councils and health departments (Bistak, 1995), also responded to the issue of the

effects of ETS and protection of the nonsmoker and began to implement tobacco use

restrictions in restaurants in the mid 1980s. While more and more restaurants and public

places are discovering the joys of smokefree air, there are still many places in the U.S. where

secondhand tobacco smoke threatens the health of workers and the public ( Americans for

Nonsmokers’ Rights, 2004).

Restaurant workers are exposed to levels of secondhand smoke that are approximately 1.6 to

2.0 times higher than those to which office workers are exposed on the job and secondhand

smoke levels in restaurants are about 160-200% higher than in smoking offices (Siegel, 1993

ANR, 2004). This creates an environment that makes service industry workers, such as restaurant servers and bartenders extremely susceptible to the harmful effect of second-hand smoke (Cleveland Clinic, 2004). Shopland et. al (2004) in their study, “Disparities in Smokefree

Workplace Policies among Food Service Workers” found that workers in food preparation and

service occupations are less protected by smokefree laws or policies than other occupations.

Siegel (1993) also reported that these workplaces have the highest rate of lung cancer among

nonsmokers (Glantz, 1997). Bistak (1995) noted in the study of local tobacco control regulations 20 affecting restaurants in Ohio that the regulations failed to recognize that restaurants were also places of employment.

Enacting smoke free or clean indoor air ordinances would provide protection for nonsmokers against exposure to ETS. With the passage of clean indoor air ordinances, the general health of the community improves and social norms about tobacco change (NCI, 2000). A study of San

Francisco bar employees found improvements in their lung function after that state’s smokefree bar law went into effect (Eisner et al, 1998).

Venzer and Shockman (2004) reviewed findings of a study released by the Northwest Ohio

Strategic Alliance for Tobacco Control, an anti-smoking group, on the effects of smoking bans in two Ohio cities, Toledo and Bowling Green. This study showed a sharp drop in heart attacks in

Bowling Green following implementation of its smoking ban. The Bowling Green heart-attack study found that heart attacks in the Wood County city fell by 45 percent in the first half of 2003 from the second half of 2002, after the city’s smoking ban was fully implemented. Bowling

Green voters passed a ban on smoking in most bars and restaurants in November, 2002. Dr.

David Grossman, health commissioner for the Toledo-Lucas County health department and an early supporter of Toledo’s smoking ban states, “The decrease doesn’t surprise me. I have little doubt, there’s a relationship between the ban and reduced heart attack cases.”

Hobart (2002) contends that clean indoor air policies are a “two-for-the-price-of-one” public health bargain; they reduce exposure to secondhand smoke, and reduce tobacco consumption by encouraging smokers to quit or at least cut back their consumption. Ordinances with strong workplace smoking restrictions reduced workers’ reported exposure to secondhand smoke

(Pierce et al., 1994). Fithchenberg and Glantz, (2002) reviewed 26 studies on the effect of smokefree workplaces and found that the combined effects of workers quitting or cutting back 21 reduces total consumption by 29%.

Bistak (1995) contends that restricting smoking in restaurants has proven to be a controversial component for many cities attempting regulation. The following discussion will highlight some of the arguments against local tobacco control issues.

Debate Against Tobacco Control

The tobacco and hospitality industry have been the leading opponents of local tobacco control efforts. The common themes that emerged from the literature reviewed were (1) a negative economic impact on both the tobacco and hospitality industry would occur with smoking bans;

(2) the issues of freedom of choice and accommodation for the smokers and private businesses and (3) local and state preemptive measures. Historically, the tobacco companies and their public relations firms have been the only voices heard by the hospitality industry regarding the issue of smoking in restaurants, hotels, bars and other place (ANR, 2004).

The National Restaurant Association (NRA) (Apfel, 1998) and the state restaurant associations continue to fight for the freedom of restaurateurs to decide whether or not to allow smoking in their establishments. The Association supports giving operators the chance to set smoking policies according to customers’ preferences and local customs.

The hospitality industry is very sensitive about the need to accommodate all potential customers, and so making the switch to be smokefree requires a careful and thoughtful decision (ANR,2004).

According to the NRA (1998), many operators fear that when the smoke clears there will be a universal ban on smoking in restaurants. The NRA (Apfel, 1998) further states:

It is increasingly difficult for restaurants to serve smoking customers and it will be even harder to do so in the future. The only relief for restaurants is bittersweet statewide or federal smoking ban 22

that would "level the playing field," as one operator put it, by preventing smoking in any restaurant.

The loss of revenue, customers and employees have been the main concerns for restaurant owners. However, a number of studies have concluded that smokefree restaurants ordinances do not harm restaurants’ sales (American Cancer Society, 2004) or decrease employment (Hyland and Tuk, 2001). For example, data from the New York State Department of Finance showed that tax receipts increased by 8.7%, or approximately $1.4 million after a smokefree ordinance had been implemented (American Cancer Society, 2004).

The tobacco industry has been the lead opponent in the tobacco control issue. Americans

for Nonsmokers’ Rights (2004) states: “Philip Morris and other tobacco companies are the only

losers when businesses go smokefree, as sales of tobacco products decrease, and tobacco profits

go down.” That's why according to the ANR (2004) the tobacco companies have put

considerable time and effort into campaigns to spread false and misleading data on the economic

impact of smokefree policies, junk science about secondhand smoke, and offer expensive and

ineffective solutions (such as ventilation systems) as an alternative to going smokefree.

According to the Hospitality Coalition on Indoor Air Quality (HCIAQ)(2002) creating a

comfortable environment for everyone is important. This organization contends that improved

ventilation is a way to improve indoor air quality (HCIAQ, 2002). Ventilation helps freshen the

air and reduce the concentration of smoke and odors in the indoor space (HCIAQ, 2002).

The tobacco industry has expressed concern over the negative impacts of tobacco control

regulations on other businesses and on specifically the restaurant industry (NCI, 2000).

Hospitality business owners and workers have been lead to believe their livelihood will end if

their businesses go smoke free (American Cancer Society, 2004). Repace, Kawachi and Glantz 23

(1999) concluded that there is no objective evidence to support the claim that smokefree restaurants impose economic penalties on owners. The tobacco industry has challenged science based evidence on the health hazards of ETS and has lobbied against legislation to restrict smoking by supporting state laws that preempt stronger local ordinances (U.S. DHHS, 2000).

Another preemption strategy successfully enacted in Ohio—and attempted in West

Virginia and Massachusetts—prohibits local boards of health from enacting regulations. This bill would have overturned 37 clean indoor air regulations enacted in West Virginia by county boards of health (ANR, 2004). Americans for Nonsmokers’ Rights (2004) suggest that while the tobacco industry’s preemption strategies may not technically deny municipal governments the authority to enact tobacco control laws, they do have the desired effect of eliminating local control.

The debate over accommodation , exposure to the hazard of second hand smoke and personal freedom of choice are challenges for pro and anti tobacco supporter in developing tobacco control legislation.

24

CHAPTER 3

METHODOLOGY

This study examines local tobacco-control legislation which was enacted or amended between January 1985 and August 2003 and affects restaurants in Ohio. This study extends the work of Paula Bistak who examined the same topic from 1985 through 1992. Both studies examine the regulations of 19 cities and one county in Ohio and analyze the tobacco-control regulations for comprehensiveness and strength using a matrix and content analysis methodology.

Paula Bistak’s 1995 analysis of the strength and comprehensiveness of local tobacco control ordinances was summarized to illustrate the progress of the enactment of local tobacco ordinances in Ohio communities. The ordinances included in this study are for those Ohio cities cited in the 2004 American Nonsmokers’ Right Foundation’s Local Tobacco Control Ordinance

Database. A copy of each ordinance was obtained from each city, accessed by either the internet

(ie., Municcode.com), or by contacting a community’s city hall or law department.

A content analysis of the data to determine comprehensiveness of the individual ordinance was conducted using a matrix system to categorize the following areas: signage or posting of non-smoking signs, barrier and ventilation requirements, allows separate ventilation dining, percentage or minimum size of non-smoking area, proprietor responsibilities, complaint procedure, enforcement and penalties for non-compliance. Also, any emergent categories were identified for ordinances that have been amended. Each ordinance will receive one point for each provision provided. To determine the strength of an ordinance each category within the provision was analyzed and given one point for the amount of protection added to each ordinance. 25

Overview of Content Analysis

Content analysis is a systematic research technique for making replicable and valid inferences from large amounts of data or text to their context and its purpose is to provide knowledge, new insights, a representation of “facts,” and a practical guide to action

(Krippendorff, 1980:21; GAO, 1996). This method is an unobtrusive research technique that examines artifacts of social communication (Bistak, 1995:18; Berg, 1995:174).

Text or artifacts can be defined as but not limited to books, newspaper headlines and articles, historical documents (Colorado State University, 2004), magazines, speeches, poems, letters, constitutions, laws ( Bistak,1995:18, Babbie,1992:313), government documents, party platforms and professional publications(Janda, 2004). Budd, Thorp and Donohew (1967:2) contends that content analysis is a tool for observing and analyzing the overt communication behavior of selected communicators and takes the communication that people have produced and asks questions of the communication. In this study, the textual communication of each ordinance for each city will be examined and inferences will be made regarding comprehensiveness and strength of each provision.

Krippendorff (1980) suggests that there are six questions to be addressed in every content analysis: (1) Which data are analyzed?, (2) How are they defined?, (3) What is the population from which they are drawn?, (4) What is the concept relative to which they are drawn?,(5) What are the boundaries of the analysis? and (6) What is the target of the inferences?

According to Stemler (2001), content analysis is also useful for examining trends and patterns in documents and additionally can provide an empirical basis for monitoring shifts in public opinion. Sometimes trends have to be examined over time, across different situations, or 26 among different groups (GAO, 1989). This is the case with the trend towards smokefree restaurants and secondhand smoke hazards which has prompted policy makers to make amendments to current tobacco control ordinances.

The advantage of using a content analysis approach was that it revealed differences among regulations. However, according to Bistak (1995) this approach did not address any intent behind the communities’ choices or their methods at arriving at these final statements.

The matrix method is a structure and a process for systematically reviewing the literature and a system for bringing order out of the chaos of too much information spread across too many sources in too many places (Goldman, Schmalz, 2004:6). The matrix used in this study assisted in organizing the data.

This researcher was introduced to the local tobacco control issues as a graduate student in the health administration program. Also, this researcher has been a registered nurse for twenty- two years and has seen, first hand, the devastating effects of tobacco use and its exposure on the community. The movement towards a smoke-free environment to help maintain the public’s health has generated discussions both locally as well as nationally to enact clean indoor air initiatives. This study was not funded by any source. This researcher has no prior or current connection with the tobacco industry and is not involved in any tobacco control organization or advocacy group.

27

CHAPTER 4

DATA

The individual regulations and their amendments were the sources for the information included here (see Appendix A). As Bistak (1995) noted:

Tobacco-control regulations usually cover many areas –

(e.g., vending machines, youth access) – including

restaurants. Therefore, the smoking restrictions,

proprietor responsibilities and compliance enforcement

provisions for restaurants noted in the legislation are

usually found in various sections throughout the text

of the regulations rather than all being contained in

one section alone.

Bistak presented information in tabular form to condense a lot of information and make the analysis easier. This approach also has been used here. Nine tables and one map are included in this chapter. The tables provide information about the following topics: population, non-smoking section size provisions, smoke barrier and ventilation requirements, signage strength, proprietor responsibility provision strength, complaint provisions, compliance provisions and smoking prohibition. The map of the state of Ohio gives the location of all the communities.

28

Table 1 identifies the Ohio communities included in this study:

Akron, Athens, Beachwood, Bowling Green, Cleveland, Cleveland Heights, Eastlake, Euclid, ,

Lakewood, Maple Heights, Mayfield Village, Medina, Parma, Parma Heights, Shaker Heights,

Summit County, Toledo, University Heights , Warren City, and Xenia

Table 1 also identifies the date each community enacted or amended its regulation. A total of nineteen communities enacted laws from the mid to late 1980s. This surge appears to coincide with the Surgeon General’s report in 1986 regarding the risk for nonsmokers’ exposure to secondhand smoke. There was a twelve year span, from 1989 to 2001, before the next enactment occurred in Bowling Green.

These Ohio communities vary in size ranging from a small population of 3,435 from

Mayfield Village to Summit County with a population of 54,683. Some communities have experienced growth and some population has reduced in size. For example, since Bistak’s study in 1995, Summit County have grown by 442,381 residents. 29

Table 1. Population

Most Enactment Community Recent Population Date Amendment

1.Akron 3/24/1988 10/24/1996 217,074 2. Athens 4/4/1988 21,342

3.Beachwood 7/3/1989 12,186, 4.Bowling Green 11/6/2001 2/4/2002 29,636 5.Cleveland 12/4/1986 7/1/1998 478,403 6.Cleveland Heights 12/7/1987 49,958 7. Eastlake 2/9/1988 20,255 8. Euclid 6/19/1989 52,717 9.Lakewood 9/9/1987 56,646 10. Maple Heights 12/21/1988 26,156 11. Mayfield Village 10/20/1986 3,435 12. Medina 6/8.1987 25,139 13. Parma 7/25/1988 85,655 14. Parma Heights 8/10/1987 21,659 15. Shaker Heights 11/29/1988 29,405 16. Summit County 9/23/2987 5/18/1988 546,381 17. Toledo 9/15/1987 7/10/2003 313,619

18. University Heights 11/2/1987 14146 19.Warren City 12/21/1987 6/24/1992 46,832

20. Xenia 10/24/1985 24,164

30

Figure 1 shows where the Ohio communities are located and illustrates the distribution of the cities with regulations. Sixteen communities are located in the northeastern part of Ohio. Toledo and Bowling Green are in the northwest. Xenia is in the southwest and Athens is in the southeast.

Figure 1-Ohio Map: Distribution of Ohio communities included in this study

31

City councils or public health departments can enact regulations. Table 2 describes which legislative body and enforcement agent is responsible for enacting the legislation and enforcement of the regulation.

Table 2.Legislative Body and Enforcement Agent

Community Enacting Body Enforcement Agt. Variances granted Akron City Council Health Dept. Athens City Council Health Dept. Beachwood City Council Health Dept. Board of Zoning Bowling Green Health Dept. Health Dept Cleveland City Council Health Dept. Cleveland Heights City Council Health Dept. Eastlake City Council Health Dept Euclid City Council Not Specified Lakewood City Council Police Dept. Maple Heights Health Dept. Fire Dept. Mayfield Village City Council Fire Dept. Medina City Council Health Dept Parma City Council Dept Public Parma Heights City Council Fire Dept. Shaker Heights Health Dept. Health Dept. Summit County Health Dept. Health Dept. H. Commissioner Toledo City Council Environ Serv. University Heights City Council Fire Dept. Warren City City Council Health Dept. Xenia City Council Police Dept.

Table 3 presents the nonsmoking section size that is provided in a restaurant. This table describes the minimum size in terms of floor space of the nonsmoking section in comparison to the smoking section. It also covers if a nonsmoking seat is provided for all requesting one and it also lists the number needed to exempt a restaurant from having a non- smoking area. Communities requiring a minimum size for a nonsmoking section ranged from 10% for Mayfield Village to

100% for Toledo and Bowling Green. 32

Table 3. Non-smoking Section Size Provisions

Restaurants seating less Non-smoking seat Min. size of non- Community than this number are provided for all smoking section exempt requesting one Akron 50 Athens 50% 30 X Beachwood 50% 50 X Bowling Green 100% X Cleveland 40% 29 X Cleveland Heights 30% 30 X Eastlake 0% 50 X Euclid 0% Lakewood 0% 29 X Maple Heights 50% 29 X Mayfield Village 10% 30 X Medina 50% 29 Parma 50% 29 X Parma Heights 0% X Shaker Heights 50% 30 X Summit County 0% 49 Toledo 100% X University Heights 50% 29 X Warren City 0% 29 Xenia 0% 49

33

Table 4 is about smoke barriers and ventilation requirements. Bowling Green and Toledo provide provision in all areas. There are a range of responses noted in this section but Xenia and

Eastlake had the least comprehensive provisions.

Table 4. Smoke Barrier and Ventilation Requirements

Seating Ventilation Ventilation or Smoke free arranged to to minimize barrier to Community access to service provide a smoke smoke prevent smoke lines free area migration migration Akron Athens X X X Beachwood X X X Bowling Green X X X X Cleveland X Cleveland Heights X X Eastlake Euclid X Lakewood X X Maple Heights X X Mayfield Village X X Medina X X X Parma X X Parma Heights X X X Shaker Heights Only for Summit County X X Construction Toledo X X X X University Heights X X X Warren City X X Xenia

34

Table 5. Signage

Sign indicating that a seat in a Sign posted in No smoking no-smoking every room where No smoking sign Community sign posted at area must be smoking is entrance provide for all posted on tables regulated persons requesting it Akron X Athens X X Beachwood X Bowling Green X X X X Cleveland X X X Cleveland Heights X Eastlake X Euclid X X Lakewood X Maple Heights X X Mayfield Village X X Medina X Parma X X Parma Heights X X Shaker Heights X X Summit County X X Toledo X X X X University Heights X X Warren City X X Xenia X

Table 5 show the signage requirements for each regulation.

Table 6 is about proprietor responsibilities when a patron is in violation of the regulations.

Thirteen of the 21 communities cover all three areas. These communities were: Athens, Bowling

Green, Cleveland, Cleveland Heights, Eastlake, Lakewood, Mayfield Village, Medina, Parma,

Parma Heights, Toledo, University Heights and Warren City.

Euclid and Xenia were the only communities to not specify proprietor responsibilities.

35

Table 6. Proprietor Responsibilities if Patron in Violation of Regulation

Direct smokers In disputes: Rights of Request Community to designated nonsmoker given smoker to stop area preference Akron X X Athens X X X Beachwood X X Bowling Green X X X Cleveland X X X Cleveland Heights X X X Eastlake X X X Euclid Lakewood X X X Maple Heights X X Mayfield Village X X X Medina X X X Parma X X X Parma Heights X X X Shaker Heights X Summit County X Toledo X X X University Heights X X X Warren City X X X Xenia

36

Table 7. Complaint Provisions

Complaint Respond to Maintain Verify Eligible Community phone written complaint complaints complainants number complaints record Akron X X X Citizens Athens X Citizens Beachwood Citizens Bowling Green X X Citizens Cleveland X X X Citizens Cleveland Heights X Citizens Eastlake X Any Person Euclid Lakewood X Maple Heights X Citizens Mayfield Village X Medina X Resident Parma X Citizens Parma Heights X Resident Shaker Heights Any Person Summit County X X X Citizens Toledo X X Resident University Heights Citizens Warren City X X X Citizens Xenia X Any Person 37

Table 8. Compliance Provisions

Civil/criminal Self Provide copy of Provide Seek proceeding if Community certification provisions and written voluntary violations do not requirement advisory assistance directive compliance cease Akron Athens X X thirty days Beachwood X X X Bowling Green immediate Cleveland X X X reasonable time Cleveland X X X thirty days Heights Eastlake Euclid .Lakewood X X X reasonable time Maple Heights X X X reasonable time Mayfield Village X X X reasonable time Medina X X X reasonable time Parma X X X reasonable time Parma Heights X X X thirty days Shaker Heights X Summit County X X X thirty days Toledo X X X immediate University X X Heights Warren City X X X thirty days Xenia thirty days

38

Table 9. Smoking Prohibited and Separately Ventilated Dining Provision

Allows 100% Separately Attached Community Smoke free Ventilated Bar Dining Akron NO No No restriction Athens NO NO No restriction Beachwood NO NO No restriction Bowling Qualified YES Sep Ventilate Green Cleveland NO NO No restriction Cleveland NO NO No restriction Heights Eastlake NO NO No restriction Euclid NO NO No restriction .Lakewood NO NO No restriction Maple No NO No restriction Heights Mayfield NO NO No restriction Village Medina NO NO No restriction Parma NO Parma NO NO No restriction Heights Shaker NO NO No restriction Heights Summit NO NO No restriction County Toledo Qualified YES 100%S/F University NO NO No restriction Heights Warren City NO NO No restriction Xenia NO NO No restriction 39

CHAPTER 5

ANALYSIS

This chapter reviews and analyzes the comprehensiveness and strength of the regulations.

The basic information was obtained from the tables provided in the data section. Nine tables are presented here: regulation comprehensiveness, non-smoking section provision strength, smoke barrier and ventilation requirements strength, signage strength, proprietor responsibilities if patron is in violation of regulation strength, compliance provision strength, smoking prohibited and separately ventilated dinning provision strength, and regulation strength summary. Each tobacco control regulation affecting restaurants was assessed for (1) comprehensiveness or what the provision covered and (2) strength or stringency of each provision. To determine comprehensiveness of a regulation, one point was given for each provision included in the regulation.

This section contains 10 tables that provide a summary of a regulations’ comprehensiveness

(table 10) and strengths (tables 11-18). Table 19 looks at overall comprehension and strength by combining selected information from tables 10 and 18 and highlights those communities that scored the highest scores, either 6 or 7, on the comprehensiveness summary.

Comprehensiveness

The seven categories examined were non-smoking section size, compliance enforcement,

smoke barrier and ventilation requirements, signage requirements, proprietor responsibility if

person violates the regulations, complaint opportunity and smoking prohibited. Each regulation

had to contain at least six provisions to be considered comprehensive or inclusive. 40

Unique to this study is an emergent category derived from cities that have had an amendment to a current regulation. The category is “smoking prohibited and provides separate smoking lounge.” This provision addresses a 100% smokefree environment and also requires a separate enclosed room in a restaurant. Two cities, Bowling Green and Toledo, provided this provision in their regulations.

Bistak (1995) found in her study that comprehensiveness varied widely among each community’s laws. Table 1 identifies the comprehensives of the regulations. This study found that 11 of 20 communities have regulations with high level of comprehensiveness. The 11 communities were Athens, Beachwood, Cleveland, Cleveland Heights, Lakewood, Maple

Heights, Mayfield Village, Medina, Parma, Parma Heights, and Warren City. They all received scores of six. Bowling Green and Toledo each received a score of seven giving them the most comprehensive regulations. These communities have passed clean indoor air ordinances that prohibit smoking in all public places including restaurants. Two cities, Euclid and Xenia, received the lowest scores – two points each. This is the same total as noted in Bistak’s study for these two cities. These communities have not progressed in the area of local tobacco control.

41

Table 10. Regulation Comprehensiveness

Smoking Non- Smoke Proprietor prohibited smoking barrier and responsibility Complaint Compliance and Community section Signage Total ventilation if patron provision provisions separately size requirements violates ventilate provisions dining Akron 1 1 1 3 Athens 1 1 1 1 1 1 6 Beachwood 1 1 1 1 1 1 6 Bowling 1 1 1 1 1 1 1 7 Green Cleveland 1 1 1 1 1 1 6 Cleveland 1 1 1 1 1 1 6 Heights Eastlake 1 1 1 1 4 Euclid 1 1 2 Lakewood 1 1 1 1 1 1 6 Maple 1 1 1 1 1 1 6 Heights Mayfield 1 1 1 1 1 1 6 Village Medina 1 1 1 1 1 1 6 Parma 1 1 1 1 1 1 6 Parma 1 1 1 1 1 1 6 Heights Shaker 1 1 1 3 Heights Summit 1 1 1 1 1 5 County Toledo 1 1 1 1 1 1 1 7 University 1 1 1 1 1 5 Heights Warren 1 1 1 1 1 1 6 City Xenia 1 1 2

42

Strength

Each provision was reviewed to determine the stringency of a regulation and if it offered more or less protection from the harmful effects of secondhand smoke exposure. One point was given for each section that added strength and a point was subtracted if it weakened the regulation (e.g., one point is subtracted if a regulation offered exemptions to the non-smoking section).

. Tables 11-17 present the total strength for each provision that is provided in the regulation.

Table18 is an overview of the total strength of each regulation.

The non smoking section provision allows communities to offer nonsmokers seating options in restaurants. Table 11 provides information regarding the strength of the provision regarding non-smoking sections. Bowling Green, Mayfield Village and Toledo received the highest rating.

However, this point system does not reveal the depth of the regulations. Toledo and Bowling

Green for example, ban smoking in all restaurants. Mayfield Village provides non-smoking sections. Each community received one point even though providing a 100% smokefree restaurant is the more stringent regulation. Twelve communities offered exemptions and therefore a point was subtracted weakening the regulation. Bistak (1995) contends that

“assigning a quantifiable value to the importance of each component within a provision is beyond the scope of this study,” and her approach was adopted in this study.

43

Table 11. Non-Smoking Section Provision Strength

Min. size of Non-smoking seat Offer Community non-smoking provided for all Total exemptions section requesting one Akron -1 1 Athens 1 -1 1 1 Beachwood 1 -1 1 1 Bowling Green 1 -1 1 2 Cleveland 1 -1 1 1 Cleveland Heights 1 -1 1 1 Eastlake 1 -1 1 1 Euclid 0 Lakewood -1 1 0 Maple Heights 1 0 Mayfield Village 1 1 2 Medina 1 -1 1 1 Parma -1 1 0 Parma Heights 1 1 Shaker Heights 1 -1 1 1 Summit County 0 Toledo 1 -1 1 2 University Heights 1 -1 1 1 Warren City -1 1 0 Xenia 0 44

Table 12. Smoke Barrier and Ventilation Requirements Strengths

Seating Ventilation Ventilation or arranged to to Smoke free barrier to Community provide a minimize access to Total prevent smoke smoke free smoke service lines migration area migration Akron Athens X X X 3 Beachwood X X X 3 Bowling Green X X X X 4 Cleveland X 1 Cleveland Heights X X 2 Eastlake 0 Euclid X 1 Lakewood X X 2 Maple Heights X X 2 Mayfield Village X X 2 Medina X X X 3 Parma X X 2 Parma Heights X X X 3 Shaker Heights New 3 Summit County X X Construction Toledo X X X X 4 University Heights X X X 3 Warren City X X 2 Xenia 0

Table 12 covers smoke barriers and ventilation requirements. These provisions aid restaurants in decreasing smoke migration. Bowling Green and Toledo continue to emerge as leaders, each with the highest possible point total of 4. There are a range of totals in this section but it should be noted that Xenia and Eastlake each received a zero, the lowest score.

45

Table 13. Signage Strength

Sign in every No smoking No smoking room where Community sign posted at sign posted Total smoking is entrance on tables regulated Akron 1 1 Athens 1 1 2 Beachwood 1 1 2

Bowling Green 1 1 1 3 Cleveland 1 1 1 3 Cleveland Heights 1 1 1 3 Eastlake 1 1 Euclid 1 1 .Lakewood 1 1 Maple Heights 1 1 2 Mayfield Village 1 1 2 Medina 1 1 Parma 1 1 2 Parma Heights 1 1 2 Shaker Heights 1 1 2 Summit County 1 1 2 Toledo 1 1 1 3 University Heights 1 1 2

Warren City 1 1 2 Xenia 1 1

Table 13 shows signage provisions for restaurants. Signage keeps customers informed and helps them make choices. Bowling Green, Cleveland, Cleveland Heights and Toledo all post no smoking signs, place signs in every regulated room and post signs on tables. These communities have the strongest provisions and each received the highest rating of 4 points. 46

Table 14. Proprietor Responsibility Provision Strength

Direct Rights of smokers to Request Community nonsmokers Total designated smoker to stop given preference area Akron 1 1 2 Athens 1 1 1 3 Beachwood 1 1 2 Bowling Green 1 1 1 3 Cleveland 1 1 1 3 Cleveland Heights 1 1 1 3 Eastlake 1 1 1 3 Euclid 0 Lakewood 1 1 1 3 Maple Heights 1 1 2 Mayfield Village 1 1 1 3 Medina 1 1 1 3 Parma 1 1 1 3 Parma Heights 1 1 1 3 Shaker Heights 1 1 Summit County 1 1 Toledo 1 1 1 3 University Heights 1 1 1 3 Warren City 1 1 1 3 Xenia 0 .

Table 14 indicates the proprietor responsibilities if a patron is in violation of regulations.

Thirteen of the 20 communities cover all three areas and each received the highest total. .These communities were: Athens, Bowling Green, Cleveland, Cleveland Heights, Eastlake, Lakewood,

Mayfield Village, Medina, Parma, Parma Heights, Toledo, University Heights and Warren City.

Euclid and Xenia were the only communities to earn no points in this category. It would be interesting to learn more about these communities. They had enough interest to begin tobacco control work in this area but what they are doing is very weak. 47

Table 15. Complaint Provision Strength

Complaint Maintain Community Total phone number complaint record Akron 1 2 Athens 1 1 Beachwood 0 Bowling Green 1 1 2 Cleveland 1 1 Cleveland Heights 1 1 Eastlake 0 Euclid 0 Lakewood 1 1 Maple Heights 1 1 Mayfield Village 1 1 Medina 1 1 Parma 1 1 Parma Heights 1 1 Shaker Heights 0 Summit County 1 1 2 Toledo 1 1 2 University Heights 0 Warren City 1 1 2 Xenia 0

Communities (14) that provide a means for voicing complaints and documented their complaints received 2 points as seen in Table 15. Six communities have regulations that made no provisions for lodging complaints. This could be a barrier to and does not help enforcement keeping proprietors accountable.

Table 16 addresses the issue of compliance. Twelve communities required self certification to indicate they are in compliance

48

. Table 16. Compliance Provision Strength

Provide copy Civil/crimina Self Provide of provisions l proceeding Community certification written Total and advisory if violations required directive assistance do not cease Akron 0 Athens 1 1 1 3 Beachwood 1 1 2 Bowling Green 1 1 Cleveland 1 1 1 3 Cleveland Heights 1 1 1 1 4 Eastlake 0 Euclid 0 Lakewood 1 1 1 3 Maple Heights 1 1 1 3 Mayfield Village 1 1 1 3 Medina 1 1 1 3 Parma 1 1 1 3 Parma Heights 1 1 1 1 4 Shaker Heights 0 Summit County 1 1 1 1 4 Toledo 1 1 1 1 4 University Heights 1 1 1 3 Warren City 1 1 1 1 4 Xenia

Table 17 shows which communities that are 100% smokefree and/or allow separately ventilated dining. This provision has been the only new category to emerge since Bistak’s study in 1995.

Bowling Green and Toledo received three points each, the maximum points allowed. This provision is the most stringent regulation. This enables restaurants to be 100% smoke free.

49

Table 17. Smoking Prohibited and Separately Ventilated Dining Strength

Allows 100% Separately Attached Community Total Smoke free Ventilated Bar Dining Akron NO NO No restriction 0 Athens NO NO No restriction 0 Beachwood NO NO No restriction 0 Bowling Qualified YES Sep Ventilate 2 Green Cleveland NO NO No restriction 0 Cleveland NO NO No restriction 0 Heights Eastlake NO NO No restriction 0 Euclid NO NO No restriction 0 Lakewood NO NO No restriction 0 Maple No NO No restriction 0 Heights Mayfield NO NO No restriction 0 Village Medina NO NO No restriction 0 Parma NO 0 Parma NO NO No restriction 0 Heights Shaker NO NO No restriction 0 Heights Summit NO NO No restriction 0 County Toledo Qualified YES 100%S/F 3 University NO NO No restriction 0 Heights Warren City NO NO No restriction 0 Xenia NO NO No restriction 0 50

Table 18. Regulation Strength Summary

Smoking Non- Smoke Proprietor prohibited smoking barrier and responsibility Complaint Compliance and Community section Signage Total ventilation if patron provision provisions separately size requirements violates ventilate provisions dining Akron 0 0 1 2 2 0 0 5 Athens 1 3 2 3 1 3 0 13 Beachwood 0 3 1 2 1 3 0 10 Bowling 2 4 3 3 2 1 2 17 Green Cleveland 1 1 3 3 1 3 0 12 Cleveland 1 2 3 3 1 4 0 14 Heights Eastlake 0 0 0 0 2 0 0 2 Euclid 0 1 1 0 0 1 0 2 Lakewood 0 2 2 3 1 3 0 11 Maple 1 2 2 2 1 3 0 11 Heights Mayfield 2 2 2 3 1 3 0 13 Village Medina 1 3 1 3 1 3 0 12 Parma 0 2 2 3 1 3 0 11 Parma 1 3 2 3 1 4 0 14 Heights Shaker 1 0 2 1 0 0 0 4 Heights Summit 0 3 2 3 2 4 0 14 County Toledo 2 4 3 3 2 4 3 21 University 1 3 2 3 0 3 0 12 Heights Warren 0 0 2 2 3 2 4 13 City Xenia 0 0 1 0 0 3 0 4 51

Table 19. Comprehensiveness and Strength

Community Comprehensive Strength Akron Athens X 13

Beachwood X 10 Bowling Green X 17

Cleveland X 12 Cleveland Heights 14 X Eastlake Euclid Lakewood X 11 Maple Heights X 11 Mayfield Village X 13 Medina X 12 Parma X 11 Parma Heights X 14 Shaker Heights Summit County Toledo X 21 University Heights Warren City X 13 Xenia

Table 19 looks at overall comprehension and strength by combing selected information from tables 10 and 18 and highlights the communities which scored 6 or 7 in the area of comprehensiveness. In general, the picture in Ohio is much the same as it was in 1995 when

Paula Bistak completed her study. There are two significant differences, however, Bowling

Green and Toledo amended their regulations and significantly strengthened them in the process.

Bowling Green, however, has not received high points in the area of compliance provision (e.g., does not require self certification of a proprietor if found to be non-compliant with the regulation). Both communities qualified for the category of 100% smokefree communities according to Americans for Nonsmokers Rights (ANR, 2004). 52

CHAPTER 6

CONCLUSION

This study examined local tobacco control legislation enacted between January 1985 and

August 2003 that affected restaurants in Ohio. Regulations from 20 communities including one county were examined for comprehensiveness and strength of each provision. This study follows the work completed by Paula Bistak in 1995 on this same issue. This study found that

Ohio communities have made minimal progress in enacting or amending local tobacco control legislation since Bistak’s study in 1995. Only one Ohio community, Bowling Green, has enacted tobacco control legislation and four communities, Akron, Cleveland, Toledo, and Bowling Green have amended legislation.

The regulations examined continue to show a wide variety of provision. The assessment tool or matrix was found to be very good but could be improved. For instance, the point system could have been refined, as noted in the analysis section. A more in depth approach would have resulted in a more accurate assessment.

Two Ohio communities, Bowling Green and Toledo were found to have the most comprehensive and stringent tobacco control regulations in the state. Both communities have tobacco control regulations that require no smoking in all public places including restaurants and bars. Smoking can only occur in a separately enclosed and ventilated room. These communities are located in the northwestern part of the state and are located in close proximity to one another.

They share the same international airport located in Toledo and Toledo is 30 minutes driving time from Bowling Green. Each community has (1) a diverse mix of residents, (2) a major university and (3) both are pioneers in the glass industry. Each city views itself as an innovator and is dedicated to an outstanding quality of life (wikipedia.org; bowlinggreen-oh.com, 2004). 53

Enacting their tobacco control legislation was not without challenges. Those in opposition, restaurant and bar owner to name a few, ensued court battles to get the legislation overturned.

In recent years, scientific evidence has confirmed that secondhand smoke causes diseases and death. Bistak asked the question in her 1995 study, “How many communities respond by amending their legislation in light of new scientific data?” Tobacco control intervention such as smokefree restaurant ordinances can provide the public as well as employees protection from secondhand smoke. However, despite having this information, Ohio communities’ response has continued to be disappointingly slow considering this not only is a local but also a national public health issue.

The tobacco and hospitality industries along with state political and legal communities continue to create roadblocks such as opposing smoking bans, supporting preemptive legislation or filing legal challenges with the courts. This is in an effort to dissuade local official and communities from enacting polices that they view would have a negative impact both economically and politically on their industry.

In Ohio, the debate continues over which legislative body (i.e., state or local, city hall or health department) should take the lead in tobacco control initiatives. The communities in this study involved various government and health agencies on the local level which appears to have been effective in getting the legislation enacted. However, when there is no clearly defined legislative body to address tobacco control, communities can become confused about what direction to take and who should take the lead in these matters. Toledo’s quest for a smoking ban was initially started by the health department but ended up in city council and then was put on the ballot for voters after a court ruled that a Board of Health in Ohio lacks the authority to adopt a clean indoor air regulation (Kerr, 2004). 54

Ohio communities’ slow progress in enacting or amending local tobacco control legislation opens the door for future research in this area. The data collected for this study brought to light a concern about the lack of a database that tracks local tobacco control regulation in Ohio. Every agency at both the local and state level referred to the same data source obtained from the

American Nonsmokers’ Rights Foundation. Paula Bistak’s 1995 study and now this study can serve as a baseline to aid other communities or legislators in tracking not only comprehensiveness and strength of a regulation but also a community’s progress in enacting or amending regulations.

Research is needed to examine the differences between communities. This could assist communities in developing regulations from information gained from similar communities and experiences in tobacco control efforts. The Toledo and Bowling Green communities could be paired with other Ohio communities that have not progressed with local tobacco control legislation. By doing this, we might develop a better understanding of why one community moves ahead while another does not.

Opinion polls about local tobacco control issues could be conducted by the public health community. This information could be valuable input for policy makers, local leaders, health organizations and advocacy groups at the local and state level. This kind of research would assist communities in making decisions that affect their future. The needs of the community and what they desire are often the motivation for change.

Exposure to secondhand smoke is preventable especially in restaurants. Establishing local tobacco control regulations is one effort aimed at reducing a health risk for Ohio communities.

Increasing the rate of enacting or amending these regulations remains a challenge for local leaders. Comparing the strengths and comprehensiveness of local tobacco control regulations 55 will allow communities and legislators to measure their progress and stimulate them to move forward by initiating policies that protect the health of the community.

56

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65

APPENDIX A 66

Ohio Communities with Local Laws that Affect Smoking in Restaurants

Most Enactment Recent Community State Type of law Number Date Amendm ent OH 3/24/1988 10/24/199 Ordinance 716-1996 1.Akron 6 2.Athens OH 4/4/1988 Municipal Code 3.Beachwood OH 7/3/1989 Ordinance 1988-155 4.Bowling OH 11/6/2001 2/4/2002 Ordinance 6912 Green 5.Cleveland OH 12/4/19501 7/1/1998 Policy N/S 6.Cleveland OH 12/7/1987 Ordinance 1113-1987 Heights (PSH) 7.Eastlake OH 2/9/1988 Ordinance 1988-028 8.Euclid OH 6/19/1989 Ordinance 131-1989 9.Lakewood OH 9/9/1987 Ordinance 57-87 10. Maple OH 12/21/1988 Ordinance 1988-130 Heights 11. Mayfield OH 10/20/1986 Ordinance 86-7 Village 12. Medina OH 6/8.1987 Ordinance 54-87 13. Parma OH 7/25/1988 Ordinance 212-87 14. Parma OH 8/10/1987 Ordinance 1987-28 Heights 15. Shaker OH 11/29/1988 Ordinance 88-89 Heights 16. Summit OH 9/23/2987 5/18/1988 Ordinance 88-280 County 17. Toledo OH 9/15/1987 7/10/2003 Ordinance 509-03 18. University OH 11/2/1987 Ordinance 87-48 Heights 19.Warren OH 12/21/1987 6/24/1992 Municipal Code Ch 1755 City 20. Xenia OH 10/24/1985 Ordinance 85-75