February 2008

Grant Results

National Program

Substance Abuse Policy Research Program

SUMMARY

Researchers at the Multnomah County Health Department in Portland, Ore., examined the prevalence of NNK, a known carcinogen associated solely with tobacco, among nonsmoking Oregon bar and restaurant workers in establishments where smoking was permitted and in those where it was prohibited.

The project was part of the Robert Wood Johnson Foundation's (RWJF) Substance Abuse Policy Research Program (SAPRP) (for more information see Grant Results).

Key Findings

  • People exposed to workplace secondhand smoke had almost six times the odds of having NNK in their urine than unexposed workers.
  • Exposure to workplace secondhand smoke was associated with nearly three times greater increase in the level of NNK in urine.
  • Each hour of exposure to secondhand smoke at work was associated with about a six percent increase in the level of urinary NNK.

Funding
RWJF supported the project with a solicited grant of $99,996 between August 2004 and April 2006.

 See Grant Detail & Contact Information
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THE PROBLEM

Nonsmokers exposed to secondhand smoke at work have a 25 to 30 percent higher risk of heart disease and a 20 to 30 percent higher risk of lung cancer than nonsmokers who are not exposed to secondhand smoke at work, according to data from the Centers for Disease Control and Prevention.

During the 1990s and early 2000s, states passed laws banning smoking in most indoor work environments. Yet, as of 2004, some 39 states exempted bars and restaurants from these laws, according to the American Lung Association. These exemptions left food service workers exposed to health risks associated with secondhand smoke.

In 2001, the state of Oregon passed a law prohibiting smoking in most indoor establishments except bars and restaurants with lounges that serve alcohol. The law included two additional provisions:

  • One provision prohibited localities from passing more stringent local laws that would ban smoking in bars and restaurants.
  • One provision grandfathered laws passed in Corvallis, Eugene and Philomath that had banned smoking in bars and restaurants prior to passage of the state law.

Some nonsmoking food service workers in Oregon were protected from secondhand smoke by local ordinance while others were not protected because of exemptions. This provided an opportunity for researchers to assess the extent to which smoking policies create health problems among nonsmoking restaurant workers.

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THE PROJECT

The goal of this study was to assess the effects of exemptions to clean indoor air laws on the prevalence of NNK, a tobacco-specific lung carcinogen, among bar and restaurant workers in Oregon.

From August 2004 to April 2006, Michael J. Stark, Ph.D., and colleagues at the Multnomah County Health Department in Oregon examined the prevalence of NNK among two groups of nonsmoking Oregon bar and restaurant workers:

  • Those who worked in establishments where smoking was permitted.
  • Those who worked in establishments where smoking was prohibited.

Workers in good health were eligible to participate in the study if they:

  • Had never smoked or had not smoked or used tobacco products in the prior six months.
  • Had not been exposed to secondhand smoke in non-work settings for more than two hours during the prior seven days.
  • Worked at least four hours during the targeted workshift for which exposure would be measured.

Funding

A grant from RWJF's Substance Abuse Policy Research Program provided funding for the project. The program funds research that can help reduce the harm caused by the use of alcohol, tobacco and drugs in the United States.

Methodology

Researchers recruited workers through newspapers, flyers and word-of-mouth and offered $50 as an incentive to participate. They telephoned potential participants to gather demographic information (age, gender, income) and ask about smoking history and worksite smoking practices.

Two-thirds of participants were women. Some 63.1 percent came from households with annual incomes under $25,000 and 35.7 percent did not have health insurance.

Researchers visited participants' worksites to determine whether smoking did or did not take place and they used breathalyzers to verify that participants were truly nonsmokers. They measured the level and length of workplace exposure based on hours worked during the targeted shifts.

Each participant provided a urine sample within one hour before and within one hour after the targeted workshift. Researchers collected samples from 32 nonsmoking bar and restaurant workers employed in smoke-free establishments and from 52 nonsmoking workers in establishments where smoking was allowed. Urine samples were tested for the presence of NNK, nicotine and cotinine (a metabolic by-product of nicotine).

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FINDINGS

Stark and colleagues presented the following findings in an article published in 2007 in the American Journal of Public Health:

  • People exposed to workplace secondhand smoke had almost six times the odds of having NNK in their urine than unexposed workers.
  • Exposure to workplace secondhand smoke was associated with nearly three times greater increase in the level of NNK in urine.
  • Exposure to workplace secondhand smoke was significantly associated with large increases in total nicotine and cotinine levels in urine.
  • Duration of exposure to secondhand smoke in a single work shift was significantly associated with the level of total urinary NNK, nicotine and cotinine. Each hour of exposure was associated with about a 6 percent increase in NNK, a 33 percent increase in the level of nicotine and a 12 percent increase in cotinine.

Limitations

Stark reported limitations to the study in the American Journal of Public Health article:

  • Workers in nonsmoking workplaces may be exposed to non-workplace secondhand smoke if they spend leisure time in local bars or lounges where smoking is allowed.
  • The measure of exposure to secondhand smoke outside the workplace was based on self-report, which might not be accurate.
  • Despite little recent reported exposure to secondhand smoke, a fairly large proportion (45 percent) of people working in smoke-free establishments had a detectable level of NNK, likely a result of the long life of NNK after exposure.
  • Workplaces and participants were not selected at random, and it is possible that those who volunteered for the study differed from those who did not.
  • Findings with regard to the estimate of hourly increases in NNK, nicotine and cotinine are valid only for four or more hours of exposure to secondhand smoke because researchers limited the study to people who worked at least four hours.

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CONCLUSIONS

Stark noted the following conclusions in the American Journal of Public Health article:

  • "Policies that establish smoke-free environments effectively reduce exposure to secondhand smoke and its deleterious health effects among bar and restaurant employees.…There is no justification for policymakers and the public to continue to allow clean indoor air exemptions. All nonsmoking workers deserve protection from lung cancer and other cancers, heart disease and the host of other adverse health effects that result from workplace secondhand smoke exposure."

Additional Publication

In December 2005 the Substance Abuse Policy Research Program national program office commissioned researchers at the Public Health Institute (PHI) in Oakland, Calif., to prepare an analysis of risks to employers who allow smoking in workplaces. The Public Health Institute is a nonprofit organization that provides research, evaluation, training and technical assistance. The paper, "Legal Risks to Employers Who Allow Smoking in the Workplace," was published in the August 2007 issue of the American Journal of Public Health (abstract available online).

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LESSONS LEARNED

  1. Set realistic recruitment goals and pay attention to recruitment catchment areas. Researchers originally planned to enroll 180 workers in Washington and Oregon, but this proved to be overly ambitious. Interest among nonsmoking workers in Oregon was high while in Washington it was low. The project director noted "perhaps this happened because our recruitment advertisements mentioned that the study was being conducted by the Multnomah County Health Department, which is well-known and has a good reputation in Oregon, but may be mainly unknown in Washington." (Project Director)
  2. When studies involve meeting with participants across large geographic areas, hire staff for each locale. Staff based in and around Portland, Ore., often traveled hundreds of miles within a single day to inspect worksites and meet with participants. (Project Director)
  3. Use alternative newspapers as a strategy to recruit bar and restaurant workers into studies. Researchers found that responses to advertisements in free weekly newspapers outweighed responses to posted flyers or advertisements in college newspapers and mainstream daily newspapers. (Project Director)
  4. Provide feedback about research findings to participants affected by the situation studied. Exposure to secondhand smoke by workers in bars and lounges is a health disparity concern as well as a health concern. Many study participants were low-income women who lacked health care coverage and had few options for alternative employment. Participants were concerned about their exposure to secondhand smoke at work and wanted feedback regarding the study results. (Project Director)

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AFTER THE GRANT

The research ended with the end of this grant. As of November 2007, project director Stark continues to make presentations about the study and its findings.

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GRANT DETAILS & CONTACT INFORMATION

Project

Studying the Impact of Clean Indoor Air Law Exemptions on Nonsmoking Workers

Grantee

Multnomah County Health Department (Portland,  OR)

  • Amount: $ 99,996
    Dates: August 2004 to April 2006
    ID#:  051714

Contact

Michael J. Stark, Ph.D.
(503) 731-4291
mike.j.stark@state.or.us

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Stark MJ, Rohde K, Maher JE, Pizacani BA, Dent CW, Bard R, Carmelia SG, Benoit AR, Thomson NM and Hecht SS. "The Impact of Clean Indoor Air Exemptions and Preemption Policies on the Prevalence of a Tobacco-Specific Lung Carcinogen Among Nonsmoking Bar and Restaurant Workers." American Journal of Public Health, 97(8): 1457–1463, 2007. Available online.

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Report prepared by: Mary Nakashian
Reviewed by: Mary B. Geisz
Reviewed by: Molly McKaughan
Program Officer: Elaine F. Cassidy

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