Assessment of local health department smoking policies—North Carolina, July-August 2003

Morbidity and Mortality Weekly Report, July 8, 2005 by A.O. Goldstein, C. Gray, A.Y. Butzen, K.M. Ribisl

Secondhand smoke is a cause of disease in healthy nonsmokers (1-6), and an increasing number of states have adopted laws prohibiting smoking in private-sector worksites, restaurants, and bars (7). However, certain state governments have provisions in their state smoking restrictions that preempt more stringent local laws (8). North Carolina has such a preemptive state smoking law, * passed in 1993, which mandates that 20% of the space within state-controlled buildings be designated as smoking areas. Exemptions from the law included local health departments (LHDs), providing an opportunity for public health practitioners to enact more stringent policies, To assess smoking policy gains from this exemption, a research team from the University of North Carolina at Chapel Hill (UNC) surveyed LHD directors. Results of the survey indicated uncertainty regarding the state law, with 37% of LHD directors believing they were prohibited from enacting a 100% tobacco-free policy on LHD grounds ([dagger]) and 20% not knowing whether they were prohibited. The North Carolina Association of Local Health Directors used these findings to work with legislators in the North Carolina General Assembly to amend the state smoking law in 2005, specifying that the exemption applies to both LHD buildings and grounds.

North Carolina has 85 county or multicounty LHD directors, representing all 100 counties in the state. Of the 85 directors, a total of 76 (89.4%) agreed to participate in the study. During July August 2003, the LHD directors responded to a telephone survey that included questions related to their knowledge and opinions regarding 1) the effects of exposure to secondhand smoke; 2) state legislation on smoking in public spaces; 3) tobacco-use policies, enforcement provisions, and availability of smoking-cessation support services at their LHDs; and 4) perceived LHD employee support for a 100% tobacco-free policy. LHD directors also were asked whether smoking was permitted in 13 traditional smoking sites ([section]) in the buildings or on the grounds of their LHDs. To assess the accuracy of such self-reported data on tobacco-use policies, 15 written policies were obtained at random from the LHDs and compared with the responses of their 15 respective directors. The responses were determined to be 86% in agreement with the written policies. The survey received approval by the Biomedical Institutional Review Board of the UNC School of Medicine.

Among the 76 county or multicounty LHDs represented, the median number of employees was 85 (range: 15 600), the average number of buildings occupied was 3.2, and the median number of patients or visitors annually was 20,000 (range: 3,000-400,000). Among the 76 LHD directors, 53 (69.7%) were nonsmokers, 20 (26.3%) were former smokers, and three (3.9%) were current smokers. ([paragraph]) According to LHD director estimates, the mean percentage of current smokers among employees at the 76 LH Ds was 10% (range: 1%-42%). Approximately 60% of LHD directors reported their departments did not routinely offer cessation services for employees who smoked.

High percentages of LHD directors agreed or strongly agreed that exposure to secondhand smoke can trigger asthma attacks (98.7%), cause lung cancer (97.4%) and lead to adverse short-term cardiovascular effects (84.3%). Official, written tobacco-use policies were in effect at 89.5% of the LHDs, whereas 10.5% operated with unofficial tobacco-use policies. Among 75 of the 76 LHDs, 33 (44.0%) had tobacco-use policies specific to the LHD, 33 (44.0%) operated under countywide policies, four (5.3%) operated under both LHD and countywide policies, and five (6.7%) operated tinder the federal Pro-Children Act of 1994. **

At 100% of the LHDs, smoking was prohibited in indoor hallways and corridors, waiting areas and lobbies, administrative and private offices, clinics and doctors' offices, cafeterias, locker rooms, and restrooms. One LHD reported having a 100% tobacco-free policy. However, among those LHD directors who answered the questions, 38 of 66 (57.6%) said smoking was permitted at LHD events and functions, 29 of 39 (74.4%) said smoking was permitted on outdoor walkways and loading docks, 60 of 76 (78.9%) said smoking was permitted outside all entrances and exits, and 74 of76 (97.4%) said smoking was permitted in parking lots (Figure).

Among the LHD directors, 57 of 75 (76.0%) said they were very familiar or somewhat familiar with the preemptive provisions of North Carolina's state law on smoking in public places (9). However, 28 of 75 (37.3%) incorrectly believed the law prevented enactment and enforcement of a 100% tobacco-free policy on LHD grounds, and 15 (20.0%) said they did not know whether the law prohibited such a policy. Sixty-six of the 76 LHD directors (86.8%) believed the majority of their employees would support a 100% tobacco-free policy at their LHDs. Fifty-eight (76.3%) reported that no single person was officially responsible for enforcing their tobacco-use policy.