result in less attentive driving; (2) smokers may engage in more risk-taking behavior in operating their vehicles; (3) smokers use alcohol and illegal drugs more frequently than nonsmokers; and (4) nicotine or some other constituent of cigarette smoke may impair complex behaviors such as driving (DiFranza et al. 1986). In the industry's view, whether there is a causal link between smoking and motor vehicle accidents is irrelevant; the better safety record of nonsmokers has been shown repeatedly and is the basis for the discounts. Periodic reviews by Farmers' have been kept proprietary but support continuing discounts for nonsmokers (Clemans 1988). Similarly, Hanover In- surance Group's experience-that smokers have a 24percent higher rate of claims than do nonsmokers-demonstrates that actuarial differences support premium differentials (DiFranza et al. 1986). The first property and casualty insurer to offer premium discounts to nonsmokers, the Farmers' Insurance Group of Companies, includes the third largest private pas- senger auto insurer and the third largest homeowner insurer in the United States. Non- smoking discounts were offered on auto policies beginning in 197 1 and on homeowner policies in 1974 (Clemans 1988). This company remains the only 1 of the 10 leading writers of homeowner and private passenger auto insurance to offer discounts to non- smokers on both types of policies (Wasilewski 1987a,b). Currently Farmers' offers nonsmokers and former smokers who have not smoked for at least 24 months discounts of 3 to 7 percent on homeowner policy base rates and discounts of 10 to 25 percent on auto policies, depending on State of residence. Other insurers that offer nonsmoker discounts on auto policies include Preferred Risk Group and Hanover Insurance Company (NAIC 1987e). On the basis of its own claims experience, Hanover increased discounts from the original 5 percent, instituted between 1974 and 1978, to the current 10 percent. The company provides the discounts on both auto and homeowner policies nationwide, except in States where regulatory bodies prohibit them. Fifty-two percent of its policyholders have nonsmoker discounts (Wein- man 1988). Factors that have prevented the more widespread industry adoption of nonsmoker discounts on auto and homeowner policies include difficulties in the verification of smoking status and regulations in some States that prohibit nonsmoking discounts or prohibit rescission of benefits in cases of misrepresentation. Effects of Insurance Premium Differentials on Smoking Behavior Insurers' use of smoking behavior as a factor in setting premiums may have both economic and educational effects that discourage smoking. Premium differentials may serve as economic disincentives for smoking because they effectively, if indirectly, in- crease the cost of smoking cigarettes. This may reduce tobacco consumption and en- courage cessation. In addition, payment of a higher premium may reinforce smokers' knowledge of the harm caused by smoking and serve as another social message to smokers about the disadvantages of smoking and desirability of cessation. It is less likely that insurance premium differentials will have a strong role in discouraging smok- ing initiation, because most individuals make decisions about smoking during adoles- cence, before many purchase insurance. 551 Empirical studies, reviewed in the previous section, have demonstrated that changes in cigarette prices affect tobacco consumption. Elasticities have been calculated for the effect on demand of changes in the price of cigarettes at the point of purchase, but not for economic policies that indirectly alter a smoker's costs. No empirical studies have examined the effect on smoking prevalence or cigarette consumption of higher in- surance premiums for smokers or of reimbursement for the cost of smoking cessation programs. The potential educational effects of premium differentials on public knowledge or attitudes have not been studied; effects will be difficult to distinguish from other social influences discouraging smoking. The expected effects of excise taxes and premium differentials are not identical, be- cause of inherent differences between buying cigarettes and purchasing insurance. A smoker can respond to higher excise taxes by reducing consumption without giving up smoking, but a smoker can reduce insurance premiums only by stopping smoking al- together. Insurance premium differentials may be less powerful economic incentives than are changes in actual cigarette prices, because higher insurance premiums do not translate directly into an increase in the price of cigarettes at the point of sale. Further- more, a smoker buys cigarettes far more often then he or she pays insurance premiums. On the other hand, the magnitude of an insurance premium differential is greater than a tax-induced change in the price of a pack of cigarettes. Other factors may blunt the impact of insurance premium differentials based on smok- ing behavior. First, smokers may forget or not even know that they are being penal- ized if there is no reminder of that fact on their insurance bill or payroll receipt. Some life and health insurers may not inform smoking policyholders that they use control- lable risk factors when setting premiums. The educational value of the premium dif- ferential is largely lost after the policy is issued if periodic reminders of the basis of premium are not sent with the insurance bill. Furthermore, part of the economic incen- tive is lost if no mechanism exists for smokers who quit smoking after the policy is is- sued to become eligible for a lower premium. Second, the individual may not pay the full cost of insurance premiums. Health and life insurance is often included in employee benefit packages, with the employee paying only a portion of the total premium. The employee's contributions to the insurance premiums may be small or nonexistent. Third, most health insurance policies are group policies that do not include smoker- nonsmoker differentials. Those that do set premiums based on the smoking prevalence of the group, so that a smoker's higher premium cost is partly borne by nonsmoking members of the group. Finally. because not all insurers offer nonsmoking discounts, even smokers purchasing individual insurance have the option of purchasing insurance from companies that do not tie premiums to smoking behavior. Health Insurance Coverage for Smoking Cessation Treatment Insurers who reimburse for the costs of attending a smoking cessation program or of purchasing a cessation aid effectively reduce the cost of quitting smoking, thereby removing a financial disincentive to quit. This reimbursement may also serve as an economic incentive to the provider of the treatment to offer more services, thereby in- creasing availability of cessation treatment. 552 Currently, few health insurance carriers cover the costs of smoking cessation programs. Only I I percent of 263 health insurance carriers surveyed in 1985 included smoking cessation treatment as a covered benefit. Insurers that reimbursed for smok- ing cessation programs did so only to treat established smoking-related diseases, not to prevent these diseases (Gelb 1985). Among BC/BS plans, smoking cessation is usual- ly not an approved benefit for groups unless it is included as part of a wellness pack- age purchased by the employer (Moore 1988). A similar situation holds for the reim- bursement of pharmacologic treatment to promote smoking cessation. Health insurers usually limit reimbursement of drug treatment to drugs that are approved by the Food and Drug Administration (FDA) and are prescribed for treatment of a diagnosed medi- cal illness in a patient who has prescription drug coverage. Currently, nicotine polacrilex gum is the only drug approved by the FDA to aid in smoking cessation. Nevertheless, its prescription is usually not reimbursable for smokers who do not al- ready carry a diagnosis of a smoking-related disease (Moore 1988). Several barriers impede greater coverage of smoking cessation treatment by health insurers. Traditionally, health insurance has covered the cost of treating, not prevent- ing, illness. A major reason for this was that insurers' were not convinced of the finan- cial feasibility of covering preventive services. however socially desirable such a policy might be. Similarly, insurers have only gradually come to cover the costs of drug and alcohol treatment (American Hospital Association 1987). Smoking cessation programs might be classified as either preventive care or as treatment of substance abuse. Regard- less of how it is classified, it appears that insurers are not convinced of the financial feasibility of covering smoking cessation treatment. In part, this stems from a lack of data with which to make appropriate calculations. To be in the health insurers' economic interests, the cost of a treated smoker (the cost of cessation treatment in addition to other health claims) must be less than the claims paid to a smoker who does not attend a cessation program. This calculation requires the estimation of several factors that have not been well studied, including the difference in annual health care costs of current and former smokers, the costs and success rates of different smoking treatments, the likelihood that a smoker will quit without a program, the length of time that the smoker remains insured by the same insurer, and the discount rate at which future costs are evaluated. Furthermore, because health in- surance is usually provided by employers, and employees change jobs, it is possible that the health insurer who pays for a policyholder's smoking cessation may not reap the benefits of any reduced health care costs that individual experiences. Even if reimbursement for smoking cessation treatment were shown to be financial- ly advantageous for insurers, practical problems would remain to slow the implemen- tation of reimbursement. For example, insurers would have to define which programs, drugs, or other aids would be covered and which providers would be reimbursed. Summary The Public Health Service's 1990 Health Objectives for the Nation include twogoals for smoking and insurance: 553 1. By 1985. the collection and publication by insurers of actuarial experience on differential life experience and hospital utilization by specific cause among smokers and nonsmokers, by sex; 2. By 1990, differential insurance premiums for smokers and nonsmokers by major life and health insurers (US DHHS 1981 b. 1986d). Progress has been made toward meeting both of these goals. The actuarial basis for life insurance premium differentials has been established, and data are beginning to be collected on hospitalization rates (US DHHS 1986d). However, more information on the total health care costs of smokers and nonsmokers, including ambulatory care, would help to establish a firmer rationale for offering premium discounts for health and disability insurance and for covering the costs of smoking cessation treatment. The second objective has been partially met. Although nearly all life insurers offer non- smoker discounts, only a minority of health insurers do. This is partly because, unlike life insurance, most health insurance is sold to groups, which, as discussed above, presents greater operational obstacles to the development and implementation of non- smoker discounts. Much of the accomplishment to date is a result of the insurance industry's voluntary initiatives, which seem likely to continue (Walsh and Gordon 1986). Collection and publication of claims experience by industry groups such as the Society of Actuaries are steps that could be taken to increase the use of smoker-nonsmoker premium dif- ferentials in health and disability insurance. State and Federal governments have the opportunity to act as facilitators and educators to encourage insurers-aspecially health insurers-to offer premium discounts to nonsmokers and to reimburse for smoking ces- sation treatment. Government officials at both levels could act to remove those legal barriers that prevent insurers from adopting nonsmoker discounts and to disseminate research findings that support these discounts and coverage for smoking cessation. HMOs may be more likely to use smoking status as a factor in setting premiums if cur- rent Federal restrictions preventing it, except on a case-by-case basis, are removed. Although the insurance industry is State regulated, regulation has generally been limited to ensuring the financial integrity of insurers. Some have suggested that aState- regulated industry could be subject to other controls in the public interest (Hiam 1987/88). Since the 1960s. all States have mandated certain types of coverage that in- surers must provide as a condition of doing business in the State (Glantz 1985). State health insurance commissioners or legislatures could require smoker-nonsmoker premium differentials as a condition for writing policies within their States. In several States, bills have been filed that would mandate insurance premium differentials, al- though none have been enacted (CDC 1980, 1981). The few remaining life insurers without premium differentials might be encouraged to adopt them if the NAIC model rule regarding smoker-nonsmoker mortality tables were adopted by legislatures and insurance commissioners in the States that have not yet done so (NAIC 1985b). Publicly funded health insurance such as medicare and medicaid is more directly amenable to government action. Measures have been introduced into Congress that would restructure medicare premiums to offer discounts to nonsmokers and to cover preventive care, including smoking cessation treatments (past bills include S. 357 and S. 358 in 1985). In the preface to the 1988 Surgeon General's Report (US DHHS 1988). 554 the Surgeon General stated, "Treatment of tobacco addiction should be more widely available and should be considered at least as favorably by third-party payors as treat- ment of alcoholism and illicit drug addiction." Research to establish the cost-effective- ness of preventive care coverage by insurers, especially for smoking cessation, would be useful in reaching that goal. PART III. DIRECT RESTRICTIONS ON SMOKING The policies discussed so far discourage tobacco use indirectly, either by educating the public about the health hazards or by creating economic disincentives to smoke. A third category of public policies acts more directly; their aim is to reduce smoking by limiting either public access to tobacco products or the opportunity to use them. The most extreme potential policy in this category would be a total ban on the sale, posses- sion, or use of tobacco products, analogous to current statutes on such other addictive drugs as heroin or cocaine. Short of that are policies that restrict or ban smoking in specific places, such as indoor public places and workplaces, prohibit the sale of tobac- co products in particular places, or prohibit the use of tobacco by a particular group of individuals, namely minors. Tobacco occupies a position unlike that of any other consumer product (or phar- maceutical agent) in the United States; it was widely used, socially accepted, and economically vital to strong agricultural and manufacturing interests long before its ad- verse health effects and addictive potential were appreciated. These facts have made the most stringent regulatory option-total ban on sale or use-impractical and un- desirable, Such a policy did exist in some States in the early part of this century, when a moral crusade against cigarettes like that against alcohol led to the passage of laws in a dozen States banning the sale of tobacco products (Walsh and Gordon 1986). These laws proved difficult to enforce and were all repealed by 1927. Although a total prohibition on tobacco is unlikely, there is a long tradition of restrict- ing children's and adolescents' access to tobacco. According to established social con- vention, the rational use of certain products, like tobacco, alcohol, or the material sold in adult bookstores, requires an informed decision that minors are deemed to be too young to make. The growing awareness of the addictive nature of nicotine (US DHHS 1988) strengthens that convention in the case of tobacco products. Policies limiting smoking in public places or workplaces have a different rationale; they restrict the smoker's behavior for the sake of the nonsmoker. Although the primary aim of these policies is to protect the nonsmoker from the health consequences of involuntary tobac- co smoke exposure, they may have the side effect of discouraging tobacco use by reduc- ing opportunities to smoke and changing public attitudes about the social acceptability of smoking. The direct restrictions discussed so far address the consumer (smoker or potential smoker). Policies directed at tobacco manufacturers include regulations on the con- tents of tobacco products to reduce their harmfulness. Such policies have the inherent difficulty of defining an acceptable level of tobacco or smoke exposure because, as documented in Chapter 2, there is no known safe level of tobacco use. 555 This Section considers three types of policies that put direct restrictions on smoking or tobacco products. First, it examines policies that restrict smoking in public places and workplaces, including both government actions and policies initiated in the private sector. Second, policies that would restrict minors' access to tobacco products are dis- cussed. Finally, the Section considers the treatment of tobacco products by Federal regulatory agencies. Government Actions to Restrict Smoking in Public Places and Workplaces In 1986. the Surgeon General's Report documented "a wave of social action regulat- ing tobacco smoking in public places" (US DHHS 1986b) that was then occurring. It reviewed public and private policies designed to protect individuals from environmen- tal tobacco smoke (ETS) exposure by regulating the circumstances in which smoking is permitted. Since the 1986 Report, the pace of action appears to have increased in both the public and private sectors. Restrictions on smoking in public places are the result of government actions at the Federal, State, and local levels, particularly State and local legislation. The Federal Government has largely acted via regulatory mechanisms and has addressed smoking in Federal facilities and in public transporta- tion. The major exception is recent congressional legislation restricting smoking on commercial airliners. Accompanying government actions are a wide range of private initiatives; these have become widespread in this decade. Smoking restrictions in the workplace are the most common private sector action, but hospitals, schools, hotels and motels, and other institutions are also adopting no-smoking policies. This trend reflects two forces: a growing scientific consensus about the health risks of involuntary smok- ing (US DHHS 1986b; NAS 1986b) and changing public attitudes about the social ac- ceptability of smoking. As documented in Chapter 4, a growing majority of Americans now supports the right of nonsmokers to breathe smoke-free air and favors restricting smoking in public places and the workplace. This Section addresses the scope and impact of government actions to restrict smok- ing in public places and workplaces. Private initiatives to regulate smoking are dis- cussed in the subsequent section. Both sections summarize and update the findings of Chapter 6 of the 1986 Surgeon General's Report. Smoking Restrictions in Public Places A public place has usually been defined as any enclosed area to which the public is invited or in which the public is permitted (Americans for Nonsmokers' Rights (ANR) 1987a. b). This broad definition encompasses a diverse range of facilities that share the characteristic of being indoor enclosed spaces that permit the general public rela- tively free access. Beyond this general agreement, laws and regulations differ in their operational definition of public place. They even differ in the degree to which the con- cept is specified. Public place is commonly interpreted to include government build- ings, banks, schools, health care facilities, public transportation vehicles and terminals, retail stores and service establishments, theaters, auditoriums, sports arenas, reception areas, and waiting rooms. Although they fit the definition, restaurants are usually 556 treated separately in these laws. Private businesses are also separately addressed, and private homes specifically excluded. As noted in the 1986 Surgeon General's Report, the degree to which smoking is restricted in public places also depends on history or tradition, the level of involuntary smoke exposure that is likely (determined by size, ventilation, and amount of smok- ing), the ease with which smokers and nonsmokers can be separated, and the degree of inconvenience that smoking restrictions pose to smokers. Public places may be owned by government or private interests. As a consequence of these factors and others, there is considerable variability in the methods by which new regulations have been proposed and the ease with which they have been adopted. Smoking restrictions have been most easily adopted in public facilities, especially facilities where smoking has traditionally been prohibited for safety reasons, where smoking is not associated with the activity taking place, and where the public spends limited time. Such considerations explain the relatively slower acceptance of smoking restrictions in restaurants. bars, and private businesses (US DHHS 1986b). Federal Actions Until recently, actions at the State and local Government level- primarily legisla- tion-accounted for the bulk of smoking regulations in public places. Since 1986, the Federal Government has taken new steps, including the first congressional actions (covered below), to restrict smoking in two categories of public places: transportation facilities and Government worksites. The Federal Government has enacted no restric- tions on smoking that apply to a broad range of nongovernmental public places. State Legislation Although the health hazards of smoking were not widely appreciated until the 1960s the fire hazard was recognized much earlier, giving rise to the first State laws regulat- ing smoking. For nearly a century cigarette smoking has been regulated by State law to prevent fires and prevent the contamination of food being prepared or packaged for public consumption. This was the extent of State law in 1964, when the first Surgeon General's Report was issued. At that time, 19 States prohibited smoking near ex- plosives or fireworks, in or near mines, or near hazardous fire areas. Five States banned smoking in food processing factories or restaurant preparation areas (US DHHS 1986e; BNA 1987). These laws affected only a small proportion of the population and did not alter smoking in public places. In addition, by 1964, 13 States had adopted some restrictions on smoking in specific public places. This legislation, also enacted to prevent fires, had some potential to reduce smoking in public places, even though that was not its primary intent. Six States permitted employers to ban smoking in mills and factories as long as signs were posted, and six States restricted smoking in public transportation vehicles or terminals or in auditoriums and theaters. The remaining laws sought to discourage smoking by children: three States prohibited smoking (at least by minors) on school grounds, build- ings, or buses (US DHHS 1986b: BNA 1987). This remained the basic extent of smok- ing restrictions through the 1960s as the health hazards of smoking became widely known. In the 197Os, a new form of smoking legislation emerged, differing in both intent and content. The specific rationale behind this legislation was the safety and comfort of nonsmokers, reflecting growing interest and, later, scientific evidence of the health hazards of passive smoke exposure (US DHHS 1986b; BNA 1987). These Clean In- door Air Acts regulated smoking in a larger number of places and for the first time man- dated smoking restrictions in private facilities. Over time, the language of the laws be- came more restrictive, first permitting, then requiring nonsmoking sections, then making nonsmoking the principal condition, with an option for smoking areas. The legislation was developed and promoted by the growing nonsmokers' rights movement, for the most part a grassroots movement consisting of Californians for Nonsmokers' Rights (later changed to Americans for Nonsmokers' Rights) and a number of other State and local groups, many using the name Group Against Smoking Pollution (GASP). These organizations focused their attention on achieving legislative goals at the State and local levels (see Chapter 6). In doing so, they sometimes worked in con- junction with the voluntary health organizations. The prevalence and content of State legislation on smoking changed dramatically over the ensuing two decades (Figure 6). Current smoking restrictions in public places are largely the product of legislation enacted at the State level beginning in the early 1970s (Tables 18 and 19). Between 1970 and 1979, smoking restrictions were enacted by legislatures in 24 additional States; in 7 others, existing restrictions were extended. In 1975 alone, 13 States enacted laws, more than double the number that had done so in the previous decade (1964-74). Not only the quantity but also the content of these laws was different. In 1973. Arizona became the first State to restrict smoking in a number of public places, and the first to do so explicitly because smoking was a public health hazard. Although not com- prehensive by current standards, the law was regarded as comprehensive when passed. The first State law to include smoking restrictions in restaurants was passed in Connect- icut in 1974. Coverage of worksite smoking also began at this time with the landmark Minnesota Clean Indoor Air Act. Passed in 1975, it extended smoking restrictions to many public places, restaurants, and both public and private worksites. It became the model for other comprehensive State legislation that began to be passed in the mid- 1970s. After a relative lull in the early 198Os, there was another notable increase in passage of State laws in the middle of the decade, probably reflecting greater scientific consen- sus about the health consequences of involuntary smoking. By the end of 1985,41 States and the District of Columbia had passed laws regulating smoking in at least one public place (US DHHS 1986b). In 1987, the year after two national groups separate- ly reviewed the evidence on passive smoking and reached similar conclusions about its health effects (US DHHS 1986b: NRC 1986b), 20 States passed legislation regulating smoking, more than ever before in a single year. Moreover. the legislation being passed grew more comprehensive in its coverage. From the start of 1985 to the end of the 1987 legislative sessions, there was a doubling in the number of States restricting smoking 558 Numkrot States with bwsinsfk~ct j- I- i- I- i- 41 4( 3: 3( 2: 2( 1: I( 5 0 l- j- 1960 1964 1970 1975 1980 1985 1987 Year 45 40 35 30 25 20 15 10 / 5 0 FIGURE &-Prevalence and restrictiveness of State laws regulating smoking in public places, 1960-1987 NOTE: Index of restricrweness: 0 = none. no \tatewde re~tnctions: 0 25 = nommal. State regulates smoking m one to three pubhc places, excluding restaurants and private workutes: 0.50 = barlc. State regulates vnoking m four or more pubhc places. excluding restaurants and private worksttes: 0.75 = moderate. State regulates vnoking m restaurants but not pnvate worksltes: I SKI = extensive. State regulate\ smoking m private work~e\. SOURCE: US DHHS (1986b); unpublished data. OSH. 559 TABLE M.-State laws restricting smoking, 1964-87 Year Number of States Number of States Number of States Number Cumulative restricting restricting restricting of States number of smoking in smoking in smoking in enacting States with restaurants private worksites public worksites laws laws Enacting/cumulative Enacting/cumulative Enacting/cumulative 1964 196.5-56 1967-68 1969-70 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 0 0 2 0 2 1 3 3 13 5 6 2 6 I 7 1 4 3 9 6 20 13 13 14 14 16 17 20 22 1 1 29 2 3 1 32 3 6 I 35 2 7 0 36 1 8 0 38 2 10 2 38 0 10 0 39 I II 0 39 0 11 0 40 1 12 1 41 1 12 0 42 4 16 4 42 1 16 3 43 (84%") 10 23 (45%) 4 4 4 I 5 3 8 1 9 2 11 0 II 3 13 0 13 2 15 2 15 5 20 4 22 15 31 (61%) NOTE: Includes the Dwnct of Columbia. aPercentage of total States. SOURCE. BNA (19X71: US DHHS l1986b): indwdual State law. in private workplaces (from 4 to 13), public workplaces (15 to 3 l), and restaurants (10 to 23) (Table 18). Recently adopted laws are more likely to include three provisions that strengthen the position of nonsmokers: ( 1) protection against discrimination for supporters of worksite smoking policies, (2) priority to the wishes of nonsmokers in any disagreement about the designation of an area as smoking or nonsmoking, and (3) permission for cities and counties to enact more stringent ordinances. In 1985, Maine was the first of five States to adopt a nondiscrimination provision, which makes it illegal for employers to dis- cipline, discharge, or otherwise discriminate against employees who assist in the im- plementation of nonsmoking policies (BNA 1987). The second provision first appeared 560 TABLE 19.Ctate laws regulating smoking in public places and worksites, through October 1,1988 AL AK AZ AR CA CO CT YEAR(S) 1975 1973.81 1977 1971.76 1977 1973.74 LEGISLATION I984 1986.87 1985. x7 19x0. Xl 1985" 1983.87 ENACTED 19x2. x7" PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationh Elevators Indoor cultural or recreational facrlitieh Retail storesd Restaurantse Schools Hospitals Nursing homes Government buildings Public meeting rooms Libraries Other' X X' x X X X X X X X X X X X X X X X X X X XL X X X X X X X X x x X X X x X' x X X X x X X X X X x X WORKSITE SMOKING RESTRICTIONSg ' Public worksites D B.D ED l3 C,D" C Private worksites A C IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers X X ENFORCEMENT (PENALTIES) Against smokers' For failure to post signs' X X X X X X X LOCAL ORDINANCES Specifically allowed Specifically preempted X X OVERALL RESTRICTIVENESS OF STATE LAWk 0 3 2 2 3 2 4 561 TABLE 19.-Continued DE DC FL GA HI ID IL YEAR(S) 1960 1975.79 1974,83 1975 1976,87 1975,85 LEGISLATION 1988 198.5 ENACTED PL'BLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationb X Elevators lndoor cultural or recreational facilities Retail storesd Restaurantse Schools Hospitals Nursing homes Government buildings Public meeting rooms Libraries Other' X X 2: XC XC X X X X X X X X X X X X X X X WORKSITE SMOKING RESTRICTION@ h Public worksites B.D B.D D Private worksites B.D IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers ENFORCEMENT (PENALTIES) Against smokers' X X X X X X For failure to post stgns' X X X LOCAL ORDINANCES Spectfically allowed Specifically preempted X X OVERALL RESTRICTIVENESS OF STATE LAW' I 3 4 I 3 3 0 562 TABLE 19.-Continued IN IA KS KY LA ME MD YEAR(S) 1987 1978.87 1975.87 1972 1954.81 1957,75 LEGISLATION 1988 1983.85 1987a ENACTED 1987.88 1988 PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationb Elevators Indoor cultural or recreational facilities Retail storesd Restaurantse Schools Hospitals Nursing homes Government buildings Public meeting rooms Libraries Other' X X X X X X X X X X X X X X X X X X' XC X X X X X X X X X X X X X X X X X X X X X X Xa X X WORKSITE SMOKING RESTRICTIONSg h Public worksites C.D D CD B.D B" Private worksites D BD IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers X X ENFORCEMENT (PENALTIES) Against smokers' X X X X X X For failure to post signs' X X X LOCAL ORDINANCES Specifically allowed X X Specifically preempted OVERALL RESTRICTIVENESS OF STATE LAWk 2 4 3 I 0 4 2 563 TABLE 19.-Continued MA MI MN MS MO MT NE YEAR(S) 1947,75 1967.68 1971.75 1942 1979 1979 LEGISLATION 1987,88 197% XI 1987 1986 ENACTED I986,87 1988 PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationh xc x X X X X Elevators XC X X XC X Indoor cultural or recreational facilities X X X X X Retail storesd X X X X X Restaurantse X X X X X Schools X X X X Hospitals X X X X X Nursing homes X X X X X Government buildings X X X X X Public meeting rooms X X X X X Libraries X X Other' X X X X WORKSITE SMOKING RESTRICTIONS' h Public worksites C.Da D CD D D Private worksites C.D D D IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimmation agamst nonsmokers X X ENFORCEMENT (PENALTIES) Against smokers' X X X X X For failure to post signs' X X LOCAL ORDINANCES Specifically allowed Spectfically preempted OVERALL RESTRICTIVENESS OF STATE LAW' 3 3 4 I 0 4 4 564 TABLE 19.-Continued NV NH NJ NM NY NC ND YEAR(S) 1911.75 1981 1953 1985 1921.53 1977 LEGISLATION 1979 1986 1979 1975 1987 ENACTED 1987 1987 1985 1976 PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationh X X X Elevators X X X X Indoor cultural or recreational facilities X X X Retail storesd X X X Restaurantse X X X Schools X X X Hospitals X X X Nursing homes X X X Government buildings X X X X Public meeting rooms X X X X Libraries X X X Other' X X X X X X X X X X X X X X X X X WORKSITE SMOKING RESTRICTIONS" h Public worksites D B,C CD CD Private worksites A B B.C A IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers X ENFORCEMENT (PENALTIES) Against smokers' X X X X X X For failure to post signs' X X X LOCAL ORDINANCES Specifically allowed Specifically preempted X OVERALL RESTRICTIVENESS OF STATE LAWk 3 4 4 2 2 0 3 565 TABLE 19.-Continued OH OK OR PA RI SC SD YEAR(S) 1953,81 1975 1973,75 1927 1976 1937 1974 LEGISLATION l981,84 1987 1977 1947 1977 1987 ENACTED 1988 1981 1977 1986 PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationb X X X= Elevators X X X Indoor cultural or recreational facilities X X X X Retail storesd X X Restaurantse X X Schools X X X Hospitals X X X X Nursing homes X X X X Government buildings X X X Public meeting rooms X X X Libraries X Other' X X X X X X X X X X X X X X X X X X X X X X WORKSITE SMOKING RESTRICTIONSB h Public worksites D C.D D B Private worksites B IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers X X X ENFORCEMENT (PENALTIES) Against smokers' X X X X X X For failure to post signs' X X LOCAL ORDINANCES Specifically allowed Specifically preempted X OVERALL RESTRICTIVENESS OF STATE LAWk 2 3 3 2 4 1 2 566 TABLE 19.-Continued TN TX UT VT VA WA WV YEAR(S) 1975 1976 I892 1984 1913 LEGISLATION 1987 1979 1987 1985 1919 ENACTED 1986 1985 PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationb Elevators Indoor cultural or recreational facilities Retail storesd Restaurar& Schools Hospitals Nursing homes Government buildings Public meeting rooms Libraries Othef X X X X X X X X X X X X X X X X X X XC X XC X' XC XC X XC X X X X X X' XC X X X WORKSITE SMOKING RESTRICTIONSg h Public worksites D B.D D Private worksites D BD D A IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers X X X ENFORCEMENT (PENALTIES) Against smokers' For failure to post signs' X X X X X X X LOCAL ORDINANCES Specifically allowed Specifically preempted X OVERALL RESTRICTIVENESS OF STATE LAWk 0 2 4 4 0 4 1 TABLE 19.-Continued TOTAL STATES WI WY N % YEAR(S) 1983 LEGISLATION ENACTED PUBLIC PLACES WHERE SMOKING IS RESTRICTED Public transportationb X Elevators X Indoorcultural or recreational facilities X Retail storesd X RestaurantC' X Schools X Hospitals X Nursing homes X Government buildings X Public meeting rooms Libraries Other' 36 32 30 25 24 32 34 32 31 27 21 70.6 62.7 58.8 49.0 47.1 62.7 66.7 62.7 60.8 52.9 41.1 WORKSITE SMOKING RESTRICTIONS" h Public worksites D 31 60.8 Private worksites 13 25.5 IMPLEMENTATION PROVISIONS Nonsmokers prevail in disputes No discrimination against nonsmokers 8 15.7 5 9.8 ENFORCEMENT (PENALTIES) Against smokers' X 40 78.4 For failure to post signs' 17 33.3 TOTAL 41 80.4 LOCAL ORDINANCES Specifically allowed X 7 13.7 Specifically preempted 3 5.9 OVERALL RESTRICTIVENESS OF STATE LAW' 3 0 568 TABLE 19.-Continued NOTE: Laws clted do not include restrtctions on unokmg near explos~vea. firework?. or hazardow areas: in or near mmes; or m food preparation or handling areas of restaurants or food procewng factones. aExecutwe order. % school buses only m AR, FL, and SC. Smokmg IS prohtbtted on all forms of mtrastate transponat~on m CA. `Smoking iy never permitted m this area. %opnetorr of retad stores m CO are encouraged to establich no-smoking areas Smoking I\ prohIbIted only m grocery stores in AK, CA. CT, MA, NV, and RI. ?`ropnetors of restaurants m NJ and CO are encouraged 10 establnh no-smokmg areas. In AK, FL, HI. MI. NH. OK. RI. and WI. restaurants seating 50 or more persons must have a no-smokmg section In CA, restaurant\ in a publicly owned buildmg seating 50 or more must have a no-smokmg cectmn. In CT and MA, restaurants seatmg 75 or more must have a no-smokmg salon. `Smokmg I\ restricted mJur) rooms m AK, FL. ME, MA. MI. MN. OR. and SD: m day-care centers m .AK. AZ. AR. MA, and MN: in mdls, factones. barns. or stables m ME. MA, NV. RI. VT, and WV: m pollmg placer m NH and NY: in pnsons. at the prison offiaals dncretron. m FL and PA: and m the asbestos hazard abatement proJect m OH. `A. employer must post a stgn where smokmg is prohibtted: B. employer must have a written smoking pohcy; C. employer must have a pohcy that provtdes for a nonsmoking area: D, no cmokmg except m derignated area. Only B. C. and D count as having a worksite policy m calculation of totals. %nployers must pat sagm designatmg smoking and no-smokmg area\ m AK. MI. MN. NE. NJ. and UT public worksites. and in MN, NE, NJ, and UT pnvate worksites: in smokmg areas only in FL, ND. and WI pubhc worksltes: and in nosmokmg areas in NH and NM publtc worksites. Depending upon then pohcy. employers mu\1 post either smoking or no-smoking signs m MT public and private worksltes. Smoking 1s not re,tncted m factones, warehouse\. and similar worksites not usually frequented by the public in MN and NE. Smokmg i\ prohIbIted m any mdl or factory m which a no-smoking sign is posted in NV. NY, VT, and WV. `Persons who smoke m a prohibited area are subject to the followmg maxlmbm finer: $5, AK, KY, VT: $10, IA, OR. PA: $2@-25,CT. DE, HI, KS. NM, WI; $50. ID. ME. NH; $100. AR, CA. DC,GA. NE. NV. NY. ND. OK, RI. WV: $100 per day, WA: $200. NJ: $300, MD: $500. FL, MI; $50 or up to IO days ~a11 OT bath. MA. minor rmsdemeanor. OH; petty misdemeanor, MN; misdemeanor, MS, TX: petty offense, AZ, SD: mfractton, IN, UT. `Persons who are required IO and fall to post smoking and/or no-tmokmg signs are subject to the following maxmwn fines: $10, IA; $2&25. MT; $50, KS. NH; $100. ME, ND. OR. VT: $200. NJ; 5300. AK. DC: $500. FL. MI: $500 per day, HI, RI; ciwl actIon, WA; infraction. CT `Restnctiveness key: 0. none (no statewide restnctions); I, nommal (State regulates smokmg m l-3 pubhc places, ex- cluding restaurants and pnvate worksites): 2. basic (State regulates smokmg m 4 or more public places. excluding res- taurants and private worksites); 3. moderate (State regulates smokmg in restaurants but not pnvate worksites): 4. exten- sive (State regulates smoking in private worksites). SOURCE: BNA (1987): Tobacco-Free America Project 1987. 1988a. b: US DHHS (1986b): individual State laws. in the Minnesota Clean Indoor Act (1975) and is incorporated into statutory language in six other States. Seven States include the third provision, which specifically permits local governments to enact ordinances more stringent than the State law (BNA 1987). Conversely, following intense legislative debate that included heavy lobbying by the tobacco industry, Florida (1985) enacted a State law that preempted more stringent local laws, as have Oklahoma (1987) and New Jersey (BNA 1987). Similar legislation has been proposed in other States. By the end of 1987, smoking was restricted in at least 1 public place in 42 States and the District of Columbia. Table 19 summarizes the provisions of these laws, which most often restrict smoking in public transportation facilities (36 States), hospitals (34 States), schools (32 States), elevators (32 States), government buildings (3 1 States), and recreational facilities (30 States). As of January 1988, over 82 percent of the United States population resided in States that restricted smoking in at least one public place; this compares with a previous estimate of 8 percent in 197 I (US DHHS 1986b). Over 569 17 percent of Americans lived in States with laws requiring smoking restrictions at the worksite for nongovernment workers, whereas over half lived in States with such restrictions for State government employees. More than 40 percent of Americans live in States requiring no-smoking areas in restaurants, and two-thirds live in States that limit smoking in health care facilities. The 1986 Surgeon General's Report documented geographical variation in State smoking laws. Southern States had fewer and less comprehensive laws. This remains true (Table 20). Excluding the major tobacco-producing States (North Carolina, Ken- tucky, South Carolina, Virginia, Tennessee, and Georgia), over 80 percent of States in each region, including the South, have enacted smoking restrictions. Of the major tobacco-growing States, only Georgia, which ranked sixth in production, had enacted restrictions on smoking in any public places other than school facilities or vehicles. State laws also vary in their implementation and enforcement provisions. Health departments are responsible for policy implementation in most States (US DHHS 1986b). Nearly all States with laws (40 of 43) provide penalties for smokers who vio- late restrictions (Table 19). Seventeen States also have penalties for employers and proprietors who do not establish nonsmoking policies or post signs as required (BNA 1987). It is not known how often these penalties are actually imposed. Local Legislation As noted in the 1986 Report, efforts to pass Clean Indoor Air Laws spread from the State to the local level in the 1980s spearheaded by actions in California (US DHHS 1986b). Local ordinances generally extend the scope of smoking restrictions beyond that provided for in corresponding State laws. Usually they include provisions to restrict or ban smoking in restaurants and public and private worksites, in addition to a broad range of public places. An accurate record of local ordinances nationwide is dif- ficult to obtain because there is no single reference library for local legislation. Recent- ly, two organizations have monitored local no-smoking ordinances on a nationwide basis. Their data indicate that local ordinances are being enacted at a rapid pace. As of August 1988, ANR (1988b) identified 321 local ordinances with provisions for sig- nificant nonsmoker protection. The Tobacco-Free America Project (1988~) reported in October 1988 that 380 local communities had passed laws restricting smoking in public places. These numbers represent a nearly fourfold increase in the estimate of 89 communities with smoking ordinances in 1986 (US DHHS 1986b). The most complete information on the prevalence and content of local ordinances is available for California, where ANR has kept an ongoing compilation of laws (ANR 1988a). According to their records, the first local ordinances were passed in 1979. In 1982, San Diego became the first large California city to enact a workplace ordinance. Although not the first local action to include the private workplace, the passage of San Francisco's worksite smoking ordinance in 1983, in the face of heavily subsidized tobacco industry opposition, attracted widespread publicity and stimulated further ac- tion (US DHHS 1986b). The following year, Los Angeles passed a law requiring smok- ing policies in workplaces with five or more employees (ANR 1988a). 570 TABLE 20.-Regional variation in restrictiveness of State laws limiting smoking Mean States Mean rcstrictivenessb States with different degrees Total restrictivenessb with lawsC of laws in effect of restrictivenessb Regiona States in October 1988 N (la) October 1988 1.00 0.75 0.50 0.25 0.00 Northeast 9 .861 9 (1W .861 6 I 2 0 0 Midwest 12 .625 10 (83 ,750 3 4 3 0 2 West 13 .692 12 (92) .750 3 6 3 0 I South 17 ,324 12 (71) ,458 I 2 3 6 5 Major tobacco producer 6 ,125 3 (50) ,250 0003 3 Other I1 ,432 9 (82) .528 1 2 3 3 2 Total 51 ,583 43 (84) ,692 13 13 11 6 8 `Regions are defined by the Bureau of the Census Northeast: Cf, MA, ME, NH. NJ, NY, PA, RI. VT Midwest: IA, IL. IN, KS, MI, MN, MO. ND. NE.OH, SD, WI West: AK, AZ. CA, CO. HI, ID, MT. NM. NV, OR, UT. WA, WY South: AL, AR, DC, DE, FL, GA. KY, LA, MD, MS. NC, OK. SC, TN, TX, VA, WV Major tobacco producers: GA, KY. NC, SC. TN, VA ?ndex of restrictiveness (from US DHHS 1986b): 0.00 = None; no statewide restrictions. 0.25 = Nominal; State regulates smoking in one to three public places, excluding restaurants and private worksites 0.50 = Basic; State regulates smoking in four or more public places, excluding restaurants and private worksites. 0.75 = Moderate; State regulates smoking in restaurants, but not private worksites. I .@I = Extensive; State regulates smoking in private worksites. CDifference in prevalence of laws, South versus all other: chi square (using Yates correction)=1 3.40, p