NC Med J May/June 2005, Volume 66, Number 3
Background: Exposure to job-related secondhand smoke represents a significant, but entirely preventable occupational health risk to
non-smoking workers. This article examines trends in smoke-free workplace policies in North Carolina. We also examine whether workers
comply with such policies.
Methods: Data from the Census Bureau’s Current Population Survey were analyzed from 1992 through 2002. Trends for North
Carolina workers are compared with workers nationally, and trends are presented by age, race, gender, and type of worker.
Results: North Carolina ranks 35th in the proportion of its workforce reporting a smoke-free place of employment. The proportion of
workers reporting such a policy doubled between 1992 and 2002. Females were more likely to report a smoke-free work environment (72.0%,
CI +/-2.6) than males (61.2%, CI +/-4.6%). Blue-collar (55.6%, CI +/-5.5) and service workers (61.2%, CI +/-8.4), especially males,
were less likely to report a smoke-free worksite than white-collar workers (73.4%, CI +/-2.6). Compliance with a smoke-free policy does not
appear to be an issue, only 3.2% of workers statewide reported someone had violated their company’s nonsmoking policy.
Conclusion: While some progress has been made in North Carolina to protect workers from secondhand smoke, significant disparities
exist. Smoke-free policies can make a significant difference in reducing exposure to airborne toxins and their associated diseases, and these
protective public health policies have not been shown to reduce business revenues. Much has been done to assure the health and safety of
workers through public health policy. However, opportunities to protect North Carolina workers from the health effects of secondhand
smoke are limited by a preemptive state law.
Key Words: Secondhand smoke, environmental tobacco smoke, occupational status, public health policy, CPS, NCI.
series of authoritative reports have conclusively demonstrated
that exposure to secondhand smoke is a significant health
threat to non-smokers, increasing the risk for lung cancer, coronary
artery disease, asthma and other lung diseases, and Sudden Infant
Death Syndrome.1-5New evidence indicates there are health risks
for even a brief exposure to secondhand smoke for individuals with
preexisting heart disease. In Helena, Montana, a comprehensive
local ordinance that banned smoking in all indoor public places,
including worksites, was associated with a 40% decline in hospital
admissions for acute myocardial infarction during the six months
the ordinance was in effect, only to rebound after the ordinance
was suspended following a legal challenge.6The Helena study
prompted the Centers for Disease Control and Prevention to
review the literature and to issue a commentary on the public
health risks of secondhand smoke, stating, “All patients at risk
of coronary heart disease or with known coronary artery disease
should be advised to avoid all indoor environments that permit
Protecting Workers from Secondhand Smoke
in North Carolina
Marcus Plescia,MD,MPH,Sally Herndon Malek,MPH,Donald R.Shopland,Christy M.Anderson,and
Marcus Plescia, MD, MPH, is Chief of the Chronic Disease and Injury section in the Division of Public Health, North Carolina
Department of Health and Human Services.He can be reached at email@example.com or 1915 Mail Service Center,Raleigh,NC
Sally Herndon Malek,MPH,is the head of the Tobacco Prevention and Control Branch in the Division of Public Health,North Carolina
Department of Health and Human Services.She can be reached at firstname.lastname@example.org or 1932 Mail Service Center,Raleigh,NC
Donald R.Shopland,is retired from the United State Public Health Service,Ringgold,GA.
Christy M.Anderson,BS,works with the University of California at San Diego,San Diego,CA.
David M.Burns,MD,works with the University of California at San Diego,San Diego,CA.
NC Med J May/June 2005, Volume 66, Number 3
The United States workforce has undergone fundamental
change in workplace smoking restrictions. Fifteen years ago the
United States Congress banned smoking aboard all commercial
airlines8out of concern for the health of flight attendants who
were routinely required to work in the smoking section of the
aircraft. At least 11 states* have now enacted comprehensive
legislation mandating that most places of employment, including
restaurants and/or bars, be smoke-free. These states join hundreds
of local communities that have passed totally smoke-free work-
In this important area of occupational health protection,
states with historical, economic, and political ties to tobacco,
like North Carolina, have traditionally lagged behind other
states and the nation.10The purpose of this article is to examine
trends in smoke-free workplace policies in North Carolina. The
data presented are from the Census Bureau’s Current
Population Survey (CPS).** Trends in the state are compared
with trends nationally and among select surrounding states. We
also examine the degree to which workers in the state comply
with rules that prohibit smoking at their place of employment.
The CPS is a continuous monthly survey that has been
conducted by the Census Bureau for the Bureau of Labor
Statistics since 1940, focusing on labor force indicators for the
civilian non-institutionalized population of the United States
ages 15 and older. In 1992, the National Cancer Institute
(NCI) sponsored a 40-item Tobacco Use Supplement to the CPS,
which included, among other items, questions about official
workplace smoking policies and the nature and characteristics of
those policies. The Supplement was conducted over four time
periods, 1992-1993, 1995-1996, 1998-1999, 2001-2002. The
monthly CPS sample consists of approximately 56,000 eligible
housing units in 792 sampling areas. All strata are defined within
state boundaries, and the sample is allocated among the states to
produce state, Census region and division, and national labor
force estimates, keeping the total sample size to a minimum.
Response rates to the CPS labor force core questionnaire is
about 95% and between 85-89% for the NCI Tobacco Use
Worker Eligibility Criteria
Routine labor force questions from the CPS core were used
to determine each respondent’s employment status and to cat-
egorize each worker into a standard occupational group.
Because the primary area of interest for this report was the
extent of official workplace smoking policies for indoor working
environments in North Carolina, additional questions were
used to identify eligible respondents. To be included in the
analysis, individuals must have been 15 years of age or older and
(1) employed either full- or part-time at the time of interview,
(2) employed outside the home but not self-employed, (3) not
working outdoors or in a motor vehicle, (4) not traveling to
different buildings or sites, and (5) not working in someone
else’s home. Applying these criteria produces 10,773 eligible
indoor workers for further analysis.
Definition of Smoke-Free
All eligible respondents were queried, “Does your place of
work have an official policy that restricts smoking in any way?”
(note: about 2% of subjects responded “don’t know” and were
excluded from the analyses). Those who responded “yes” were
also asked: “Which of these best describes your place of work’s
smoking policy for indoor public or common areas, such as
lobbies, restrooms, and lunch rooms?” and “Which of these best
describes your place of work’s smoking policy for work areas?”
Response choices for each were: “Not allowed in any …”
“Allowed in some …” or “Allowed in all …”
Workers who reported that their employer had an official
policy that restricted smoking and did not permit smoking in
any public or common areas or in the work area, were considered
to be working in a smoke-free environment. This definition is
identical to that used in other national and state-based reports.9-13
For compliance, only workers with smoke-free policies were
included in the analysis.
Statistical analyses were performed using Statistical Analysis
Systems software, version 8.02.14Supplement weights, adjusted
for overall Supplement non-response and Supplement self-
response only, were produced using a special algorithm developed
by the Bureau of Labor Statistics.15Sudaan was used to com-
pute standard errors and 95% confidence intervals (or margin
of error) using the replicate weights that the Census Bureau
constructed using Fay’s methods.16
The percentage of the North Carolina indoor workforce
covered by a smoke-free workplace policy has increased over
the ten-year period 1992 through 2002 (see Table 1). Less than
a third of the state’s workforce was smoke-free in 1992-1993,
but by 2001-2002, slightly more than two thirds were reporting
this level of protection. The trend toward smoke-free worksites
* States that have enacted comprehensive laws, the date of passage and setting affected: California (restaurants 1995, bars 1998), Maryland
(workplaces and restaurants 1995), Delaware (workplaces, restaurants and bars 2002), New York (workplaces, restaurants and bars 2003),
Massachusetts (workplaces, restaurants and bars 2004), Utah (restaurants 2005), Florida (restaurants 2003), Connecticut (restaurants
2003, bars 2004), Idaho (restaurants 2004), South Dakota (workplaces 2002) and Maine (restaurants and bars 2004).
** The federal government’s primary data source for labor force statistics. These data cover the ten-year period 1992 through 2002.
NC Med J May/June 2005, Volume 66, Number 3
increased substantially during the initial three-year survey period,
increasing 77% between 1992-1993 and 1995-1996, but just 24%
over the next six years. As of 2001-2002, North Carolina ranks
35th among all the states in the proportion of its workforce
reporting a smoke-free place of employment.
Smoke-free policies vary considerably by age and gender of
the worker, with younger workers, particularly males ages 15-24,
reporting lower rates of smoke-free policies (40.7% CI +/-12)
than middle age male workers age 40-54 (62.0% CI +/-7.4) and
older male workers age 55-64 (72.5% CI +/-10.7). Thus, less
than 50% of male workers ages 15-24 are likely to be currently
covered by a smoke-free policy, the lowest rate of any age group
in the state, and this low rate of coverage has not changed in
absolute terms since 1995-96. Overall, females are currently
more likely to report a smoke-free work environment (72.0%
CI +/-2.6) than males (61.2% CI +/-4.6). Rates are similar
among blacks and whites throughout the 1992-2002 time period.
The rates are slightly lower for Hispanic workers but these
differences are not statistically significant.
While consistent progress has been observed in the effort to
protect workers from job-related secondhand smoke in the
state, some workers are less pro-
tected than others (see Table 2).
Blue-collar and service workers
are considerably less protected
than white-collar workers. In
2001-2002, 52.4% (CI +/-5.8)
of male blue-collar workers and
47.5% (CI +/-14.2) of male
service workers were smoke-free,
compared to 73.4% (CI +/-14.2)
of all white-collar workers. This
difference persisted across all
four time periods. Females,
regardless of occupational cate-
gory, reported higher rates of
smoke-free policies than males.
Table 3 provides estimates
for smoke-free workers in the
state who reported someone had violated their company’s smoke-
free policy in the two weeks prior to interview by smoking in
their work area. Only a small percentage of the state’s workforce
reported a violation of a smoke-free policy over the six-year
time period examined. Furthermore, compliance with such
policies appears to be improving, with noncompliance decreasing
from less than 5% in 1995-1996 to just 3.2% in 2001-2002, a
level of compliance equal to that seen among workers nationally.
Blue-collar and service workers report slightly higher rates of
noncompliance than white-collar workers, a trend also observed
nationally, although none of these differences are statistically
significant. Despite the rapid increase in smoke-free workplace
policies among workers in the state, in 2001-2002, 96.8% of all
workers with such a policy indicated their place of employment
was in compliance with that policy.
The importance of secondhand smoke as a significant
health risk to workers cannot be overstated. Finnish researchers
calculated mortality among workers for several major diseases
Trends in Smoke-Free Policies in North Carolina by Type of Worker
Type of 1992-1993
White-collar 38.3 (+/-2.1)
Service 29.5 (+/-4.8)
(CI) (CI) (CI)
CI = 95% confidence interval or margin of error.
Note:Throughout the manuscript we refer to three major occupational groups,white-collar,blue-collar
and service workers.While no official definition exists for these workers,on the CPS public use data
file,the Census Bureau “recodes”some 500 individual occupations into 14 major groups.Examples of
white-collar occupations include people employed as managers,accountants,clerical workers,
engineers,teachers,physicians,etc.,blue-collar workers include carpenters,mechanics,assembly line
workers,bus and truck drivers,tailors,etc;and examples of service workers are,food service workers,
health technicians,personal and protective services (firefighters,guards,police),etc.
Comparison of Workplace Policy Trends in North Carolina with Neighboring States and the Nation and
State Rank in 2001-2002
Percent of indoor workers 15 years of age and older reporting a smoke-free workplace
(rank in 2001-02)%
North Carolina (35)30.8(± 2.1)
Tennessee (39)36.0 (± 2.1)
South Carolina (43)37.7 (± 3.2)
Georgia (47) 46.7 (± 3.5)
Virginia (24) 43.7 (± 2.6)
All United States workers 46.3(± 0.4)
54.4 (± 2.3)
53.0 (± 2.8)
58.3 (± 4.5)
56.7 (± 4.7)
62.2 (± 3.3)
63.4 (± 0.4)
61.0 (± 2.6)
63.0 (± 4.2)
63.8 (± 2.6)
66.1 (± 2.8)
70.6 (± 2.3)
69.0 (± 0.4)
66.1 (± 3.6)
63.3 (± 3.3)
71.2 (± 2.3)
(CI) (CI) (CI)
CI = 95% confidence interval or margin of error
NC Med J May/June 2005, Volume 66, Number 3
related to secondhand smoke and estimated that such exposures
were responsible for 2.8% of all lung cancer deaths, 4.5% of
deaths from asthma, and 3.4% of all coronary heart disease
deaths.17Other investigators have demonstrated that food
service workers experience a lung cancer death rate that is 50
percent higher than the general population even after controlling
for active smoking.18More recently, the Centers for Disease
Control and Prevention has estimated that secondhand smoke
is a cause of 38,000 premature deaths annually in the United
States, the majority from cancer and heart disease,19although
millions more are made ill and lose work from asthma, pneu-
monia, bronchitis and other respiratory problems.4
When smoking is permitted in indoor environments, the
quality of the indoor air quickly becomes unhealthy, not only
for workers, but patrons and visitors alike. When smoking is
eliminated, improvements in air quality are almost immediate,
even in heavily polluted bars and restaurants. Air quality
researcher James Repace recently measured the levels of
particle-bound polycyclic aromatic hydrocarbons (PPAH) and
fine particle respirable suspended air pollutants (RSP) in eight
hospitality venues in Delaware just prior to and several weeks
after a statewide clean indoor air law was implemented.20
PPAH levels in the eight venues prior to implementation of the
statewide ban averaged five times the level found in outdoor air,
while the average level of RSP was 15 times the level allowed in
outdoor air under the United States National Ambient Air
Quality Standards (NAAQS). Implementation of the law was
associated with a 90-95% reduction in both RSP and PPAH
levels. Similar results have been observed elsewhere.21,22Repace
calculated that to bring a typical bar with average smoking
prevalence into compliance with the NAAQS for fine particle
air pollutants would require more than 80 air changes per
In North Carolina, opportunities to protect workers from
the health effects of secondhand smoke through public health
policy are limited by a preemptive law. In 1993, the state legis-
lature passed a law that required state-controlled buildings to
set aside 20% of their space for smoking and prohibited local
regulatory boards from enacting stronger provisions unless the
legislation was enacted before the state law would take effect in
October of that year.23A total of 105 local ordinances were in
effect by the October date, 89 of which had been fast tracked
to beat the deadline. A legal challenge to one ordinance,
contending that boards of health are not elected officials and do
not have the authority to rule on this particular issue, was
eventually appealed to the North Carolina District Court. The
subsequent ruling invalidated almost all of the 89 newly enacted
ordinances,24forcing most communities to suspend legal
enforcement of their ordinances.
Some progress has been made within the state to protect
workers from the health effects of secondhand smoke through
voluntary efforts, but such efforts have created significant
differences in coverage between different categories of workers.
The local Health Directors Association initiated an aggressive
statewide education campaign encouraging local governments
and others to adopt smoke-free policies in 1993,25and North
Carolina Project ASSIST began educational campaigns to
encourage businesses to adopt voluntary policies.26As a result,
the proportion of the state’s workforce reporting a smoke-free
place of employment increased from three-in-ten workers in
1992-1993 to nearly seven-in-ten workers by 2001-2002, with
most of the increase occurring during the time of the state-
sponsored educational campaign.
However, significant disparities exist. While more than
seven-in-ten white-collar workers in the state work in smoke-
free settings, blue-collar and service workers lag significantly
behind, and blue-collar workers are more likely than other
workers to be exposed to other hazardous agents in the work-
place. The smoke-free rate among service workers in North
Carolina is similar to the rate reported by service workers
nationally in 2001-2002, although male service workers in the
state report significantly lower rates of smoke-free policies than
other workers (less than 50% are smoke-free). Many of these
workers are employed in the food service sector of the economy.
A recent study of 38 major occupations showed food service
workers were the least protected from job-related secondhand
smoke. Just 28% of waiters/waitresses and 13% of bartenders
report working under a smoke-free workplace policy.27According
Compliance with Smoke-Free Workplace Policies among North Carolina Workers Compared to Workers Nationally
by Type of Worker and Gender and % of Workers Reporting Someone Violated Workplace Policy in Past Two Weeks.
NCUSNCUS NC US
CI = 95% confidence interval or margin of error.
NC Med J May/June 2005, Volume 66, Number 3
to the Bureau of Labor Statistics, 275,000 North Carolinians
were employed in restaurants and bars in August 2004 compared
to 160,000 at the beginning of 1990, an increase of 70%, making
it one of the more significant and fastest growing segments of the
state’s workforce.28More than 50% of these workers are women.
Given the low level of smoke-free policy coverage among service
workers in the state and nationally, it is likely that a large
proportion of the quarter-million bar and restaurant workers in
North Carolina are also at risk from job-related secondhand
There is evidence that suggests immediate improvements in the
health status of bar and restaurant workers after implementation of
a smoke-free law. Eisener et al.29in a study of 53 California
bartenders, documented improvements in pulmonary function
and respiratory symptoms one month after a statewide smoke-free
law went into effect. Sargent et al. observed a 40% reduction in
hospital admissions for acute myocardial infarctions in Helena,
Montana following implementation of a smoke-free ordinance
that included bars and restaurants.6The elimination of secondhand
smoke from all hospitality venues, such as bars and restaurants,
could have a significant impact on the health of this large and
growing segment of the state’s workforce.
Smoke-free policies do not hurt business revenue, even in
restaurants and other hospitality venues. Recently published
economic analyses in California, New York, and elsewhere have
clearly demonstrated that smoke-free laws are essentially revenue
neutral, that is, they neither increase nor decrease revenue when
implemented.30-35In 2003, Scollo and colleagues36reviewed 97
studies on the economic impact of smoke-free policies, including
studies funded by the tobacco industry. None of the 60
independently funded studies found any significant, long-term
economic effects associated with smoking bans in restaurants
and bars. Of the 27 studies that controlled for other economic
factors and used objective measures to assess impact, none
showed a negative effect. Zagat, the world’s leading provider of
survey-based consumer dining behavior, found that 72% of
110,000 American restaurant-goers surveyed for its 2005 poll
indicated their eating-out habits would not change if smoke-
free policies were put into effect in restaurants, while 26% said
they would eat out more often, versus only 3% who said they
would eat out less often.37
The findings of this study are based on a series of cross
sectional surveys conducted by the US Census Bureau for its
Current Population Survey (CPS) and covering the period
1992 through 2002. Information on official worksite smoking
policies is based on responses obtained from employees and not
worksite managers or business owners. Data derived from
workers are likely more accurate than a survey consisting of
responses from workplace managers or owners for several reasons.
First, almost all surveys of worksites published to date,11exclude
small businesses from their sampling frame, yet, according to
the Census Bureau, small companies (<50 employees) employ
42% of all workers and make up more than 95% of all busi-
nesses in the US. Thus, worksite surveys provide an incomplete
picture of worksite smoking policies. Second, worksite surveys
typically rely on a response from a single individual, usually a
company official, who responds for the entire company. In the
COMMIT trial consisting of 11 communities of varying size
in North America, Glasgow et al,38reported that individual
workers reported rates of smoke-free policies that were lower
than those reported by management-level representatives.
Finally, the CPS has an excellent track record for obtaining
accurate worksite and employment data. Since 1940 the CPS
has been the federal government’s main data source for monthly
labor force statistics.
The primary purpose of this paper was to focus on differences
in smoke-free policies by examining a number of demographic
and employment variables as a means of highlighting which
workers are currently not protected from the dangers of second-
hand smoke in North Carolina. Multivariate analysis could
provide some insight regarding which factors are independently
associated with workplace smoking policy but such analysis is
beyond the scope of this report. Variables such as age, gender,
type of worker, work site and smoking status could serve as
confounders of specific trends reported in this study. Previously
published data demonstrate that smokers report significantly
lower rates of smoke-free policies than nonsmokers.11Smokers
tend to be younger and less educated than nonsmokers and
blue-collar and service workers report significantly higher cigarette
use rates than white-collar workers.
Second hand smoke is a well-established health hazard.
While some progress has been made in North Carolina to protect
workers from secondhand smoke, significant disparities exist.
Smoke-free policies can make a significant difference in reducing
exposure to airborne toxins and their associated diseases and
these protective public health policies have not been shown to
reduce business revenues. Much has been done to assure the
health and safety of workers through public health policy.
However, opportunities to protect North Carolina workers
from the health effects of secondhand smoke are limited by a
preemptive state law. NCMedJ
Acknowledgement: Financial support was provided by the
American Legacy Foundation, Washington, D.C. and the William
Kahan Distinguished Professorship from the Flight Attendant
Medical Research Foundation, Miami, Florida.
NC Med J May/June 2005, Volume 66, Number 3
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