Effects of a Restricted Work-Site Smoking Policy on Employees Who Smoke Janet Brigham, PhD, Janet Gross, PhD, Maxine L. Stitzer, PhD, and Linda J. Felch, M4 Introduction example, in the study by Hatsukami et al.,6 smokers who reduced the number of Many institutions throughout the cigarettes smoked by 50% or reduced the United States have moved toward restrict- nicotine yield of their cigarettes by about ing smoking in public places, particularly 50% experienced some craving and with- since the Surgeon General's 1986 report drawal discomfort but reported signifi- on involuntary smoking.1 Several studies cantly less discomfort than total abstain- have indicated that the incidence of ers. On the other hand, West et al.7 found public smoking changes when restricted- that switching to an ultra-low-yield ciga- smoking policies are implemented. Still- rette did not result in any appreciable man et al.2 reviewed empirical evidence of reporting of withdrawal distress, except reduction in smoking at the Johns Hop- for increased hunger. The mechanisms kins medical institutions and concluded thought to cause low-level withdrawal that implementing a smoke-free policy in symptoms under conditions of restricted a large medical center can decrease visible smoking are reduction in blood nicotine smoking and passive exposure to tobacco levels and habit change. smoke. A previous report by Becker et al.3 In a related vein, research on re- indicated that public smoking at the Johns stricted smoking in habitual smokers has Hopkins Children's Center was virtually suggested that smokers may adjust their eliminated in 1987 by implementation of a smoking behavior to offset effects of smoke-free policy. Recently, Borland et restricted access or reduced cigarette al.4 reported that Australian smokers yield.8'9 Benowitz et al.10 found that when exposed to a mandatory work-site smok- smokers reduced their consumption from ing ban reduced their smoking by about an average of 37 to 5 cigarettes per day seven cigarettes per day while working (i.e., a sixfold reduction), the toxicity per inside and by about five cigarettes per day cigarette increased threefold because of overall with very little compensatory, or more puffs per cigarette, longer breath increased, smoking observed outside of holding, and deeper inhalation, whereas work after enforced reduction at work. the cumulative daily exposure to tar and Of interest to policymakers and carbon monoxide dropped by only about work-site managers are the potential one half. This tendency for smokers to negative side effects of daytime absti- alter their smoking style (e.g., by increas- nence, which may affect the smoker's ing inhalation or taking more frequent behavior (e.g., symptoms of the tobacco withdrawal syndrome), as well as the Janet Gross, Maxine L. Stitzer, and Linda J. overall impact on smoking exposure (e.g., Felch are with the Johns Hopkins University compensatory changes in rates ofsmoking School of Medicine, Baltimore, Md. At the time of this study, Janet Brigham was with the outside the work place). Researchers on Johns Hopkins University School of Medicine; smoking cessation have found that some currently she is with the Western Psychiatric of the symptoms of the tobacco with- Institute, University of Pittsburgh, Pitts- drawal syndrome that typically accom- burgh, Pa. are to a Requests for reprints should be sent to pany tobacco abstinence5 present Maxine L. Stitzer, PhD, Behavioral Pharmacol- lesser extent in individuals who reduce ogy Research Unit, 5510 Nathan Shock Dr, cigarette consumption or switch to a Baltimore, MD 21224. lower-nicotine-yielding cigarette.6'7 For This paper was accepted August 3, 1993. American Journal of Public Health 773 Brigham et al. tional status. The self-reported amount of TABLE 1 -Baseline Characteristics of Groups (n = 67) smoking was significantly higher in the control group (t (60) = 2.02, P < .05). Group However, the groups did not differ on the biological indices of tobacco exposure, Restricted (n = 34) Control (n = 33) which included expired-breath carbon monoxide and saliva cotinine and nico- Mean age, y (SD) 38 (9.5) 37 (10.4) tine. The groups also differed with respect Mean weight, lb (SD) 176 (43) 173 (48) to the total withdrawal score and the score Occupational status,a % on the Depression-Dejection subscale of 1 12 10 the Profile of Mood States. In both cases, 2 30 29 the control subjects had higher scores, 3 42 26 4 15 35 indicative of greater distress. Gender, % male 27 30 Procedures Mean scores on self-report (SD) Tension-Anxiety 7 (6.2) 10 (8.0) All subjects participated in data Depression-Dejection* 5 (6.6) 10 (11.0) collection sessions at the research labora- Anxiety-Hostility 7 (8.6) 7 (7.7) Vigor 17 (5.4) 16 (7.8) tory after their work shifts. Experimental Fatigue 8 (6.6) 8 (6.7) (restricted smoking) subjects attended a Confusion-Bewilderment 4 (4.4) 5 (4.8) laboratory data collection session once Friendliness 19 (3.7) 19 (4.7) per week for 4 weeks before and 4 weeks Total Mood Disturbance 13 (31.8) 25 (39.3) after implementation of the smoking ban. Total withdrawal score 11 (7.1) 15 (9.6) Control subjects attended sessions at their Smoking characteristics, mean (SD) work site once weekly for 8 consecutive Years smoked 19 (8.6) 18 (10.4) weeks. Informed consent, which had been No. of cigarettes/day* 22 (10.7) 27 (10.0) approved by the Francis Scott Key Medi- Carbon monoxide, ppm 26 (14.0) 29 (12.6) Saliva nicotine, ng/mL 566 (764) 595 (640) cal Center Institutional Review Board, Saliva cotinine, ng/mL 232 (136) 282 (121) was obtained from all subjects after the study was explained at the first session. al = low status and 4 = high status. Subjects were paid $100 for successfully *P < .05. completing the study. Measures puffs) could offset the potential health pants were between 18 and 65 years old At each study contact, behavioral, advantages of reducing the number of and were not seeking treatment to quit biological, and subjective report data were cigarettes smoked at work. The extent to smoking. Forty-one smokers were re- collected. engage in compensatory which smokers cruited from the Francis Scott Key Medi- Smokng amount. Smoking amount smoking behavior and increase their expo- cal Center, the site of the smoking ban, was assessed via self-report and by collec- sure to toxic constituents of tobacco as a through advertisements, flyers, and refer- tion of cigarette butts for designated time result of restrictions on workplace smok- rals. Before analysis, four dropped out of periods. To determine the pattern of ing is unknown. the study, and three were omitted from smoking during the work shift, subjects the the Among hospitals joining the analysis because ofincomplete compli- were asked at each lab visit to recollect smoke-free movement recently was Fran- ance with the study procedures. The and report the number of cigarettes cis Scott Key Medical Center, part of the comparison control group was composed smoked at their workstation, at other sites institutions in Johns Hopkins medical of 51 individuals recruited through news- inside the building, and at any sites Baltimore, Md. This institution imple- paper advertisements at several nearby outside the building for the time period of mented a hospital-wide smoking ban on hospitals that had no restricted smoking the most recent work shift. To estimate event as an July 1, 1989. We used this policy. Of those initially enrolled, 10 24-hour smoking amount and toxic expo- to examine the opportunity biological, failed to complete the study, 1 quit sure to tobacco constituents, subjects subjective, and behavioral impact of a smoking during the study, and 7 were collected their cigarette butts for the smoking policy restriction on individual excluded from analyses because their 24-hour period before the lab session. smokers, including objective measures of mean number of cigarettes per day before Three separate plastic collection bags tobacco smoke exposure. We compared the smoking ban exceeded the maximum reflected three intervals of the day: (1) these effects with those in a control group number observed in the restricted-smok- between the end of work and bedtime the of smokers whose work-site smoking ing group. Consequently, 67 participants previous day, (2) between arising and policy remained unrestricted. were included in the final analysis of the going to work the day of the lab session, data. and (3) during work the day of the lab Methods Table 1 shows the demographic, session. The number of cigarette butts per smoking, and psychological characteris- interval and the weight of the butts from Subjects tics of the two groups at baseline. The each interval were assessed. Thus, for the Ninety-two smokers were recruited groups were similar with respect to mean period of the work shift, both self-report for the present study. All study partici- age, distribution of gender, and occupa- and butt count data were available. Butt 774 American Journal of Public Health May 1994, Vol. 84, No. 5 Work-Site Smoldng weight was used as an indirect measure of comparisons ofpreban and postban inter- behavior outside the building. Before the smoking intensity.9 Like butt length, butt actions were conducted by using Tukey's ban, the restricted group smoked an weight indicates the amount ofmaterial in Honestly Significant Difference (HSD) average of 0.83 (SD = 1.0) cigarettes per the cigarette left unsmoked. Butt length test. day outside the building compared with provides an indirect measure of smoking 2.51 (SD = 1.7) cigarettes after the ban intensity and relative toxicity because tar Results (q = 6.7, P < .01). The ban on smoking and carbon monoxide delivery increase had no effect on behavior at other logarithmically as cigarettes are smoked Work-Site Smoking locations within the building.