1. Secondhand Smoke Exposure Reduction Strategy for 21-29 Year-Olds in Bars Paul Hunting, MPH Joanne Wellman-Benson, RDH, MPH Hao Tang, MD, PhD California Department of Health Services/ Tobacco Control Section (CDHS/TCS) Friday, 12 December 2003 - 8:30 AM Boston Marriott Copley Place Salon C This Presentation is part of POLI-186

2. “The bars in California have been raped and stripped of what they do well, and that’s hospitality” “Boycott California!” “This thing is scary to us … It could go national” National Licensed Beverage Association, April 29, 1998 “California bars are experiencing an average sales decline of 26.2%” “first definitive proof that the bar smoking ban has had severe negative impacts” “This is conclusive evidence that the California smoking ban is an experiment that has failed” The American Beverage Institute, April 29, 1998

3. Secondhand Smoke (SHS) Exposure Reduction Strategy for 21-29 Year-Olds in Bars Brief History of Tobacco Control in California Restaurants and Workplaces 1995 -1998 21-29 Year-Old Patronization Practices Exposure Data/Effects of the Law Among 21-29 year- olds In the Face of Industry Targeting “The Science” of Economics (not even Econ. 101) –Tourism –Businesses –Employment Lessons Learned and Future Directions

4. Effects Causally Associated with SHS Exposure Low Birth Weight SIDS Respiratory Infections in Children Asthma: Induction and Exacerbation Eye and Nasal Irritation Ear Infections in Children Cancer: Lung and Nasal Sinus Heart Disease Morbidity & Mortality Source: Health Effects of Exposure to ETS, California EPA, September 1997

5. Estimated Annual Morbidity & Mortality in Non-Smokers from SHS Exposure in California 147,660 - 351,820 Illnesses & Hospitalizations 4,696 - 7,945 Deaths Source: Health Effects of Exposure to ETS, California EPA, September 1997

6. TCS Priority Areas Counter Pro-Tobacco Influences Reduce Access to Tobacco Products Reduce Exposure to Secondhand Smoke Increase Access to Culturally Appropriate Cessation Services

7. The California Smoke-free Workplace Law (Labor Code 6404.5) Regulates smoking by employees and patrons in most “enclosed” workplaces in California. Adopted as part of the Labor Code to protect workers from involuntary exposure to SHS. Both business owners and patrons may be issued a citation. Is enforced at the lowest jurisdictional level. Does not apply to owner operated establishments or Native American (sovereign) lands, among other exemptions.

8. Primary “On-Sale” Alcohol License Types Type 40: On-Sale Beer (Beer Bar) - 1,350 Type 41: On-Sale Beer and Wine Eating Place (Pizza Place) - 20,587 Type 42: On-Sale Beer and Wine Public Premises (Beer and Wine Bar) - 1,157 Type 47: On-Sale General Eating Place (Full-Service Restaurant) - 11,445 Type 48: On-Sale General Public Premises (Stand-Alone Bar) - 3,140 These numbers are from June 30, 2003 and these five types constitute 94-96% of all On-Sale licenses in California annually.

9. Smoke-free Workplace Timeline Highlights June, 1994: Assembly Bill 13 Signed by Governor and becomes Labor Code Section 6404.5; November 1994: Proposition 188 (Philip Morris Initiative) defeated (71% to 29%) guaranteeing LC 6404.5 stays in place; January 1, 1995: Nearly all enclosed workplaces go smoke-free; October 1996: AB 3037 passes postponing Bar/Gaming Club implementation by one year; January 1, 1998: All bars, gaming clubs and bingo halls go smoke-free: #1 Media Story in the Country!

10. Study Populations October 2002 Field Poll –Total Respondents: 1,000 –Smokers: 190 (19%) –Non Smokers: 810 (81%) –Age 21-29 Smoking Rate (25%) –Total 21-29 in Survey 269 March 1998 Field Poll –Total Respondents 1,001 –Smokers: 255 (25%) –Non Smokers: 745 (75%) –Age 21-29 Smoking Rate (27%) –Total 21-29 in Survey: 274 August 1998 Field Poll – Total Respondents 1,020 – Smokers: 255 (25%) – Non Smokers: 765 (75%) – Age 21-29 Smoking Rate (26.4%) – Total 21-29 in Survey: 288 June 2000 Field Poll – Total Respondents 1,000 – Smokers: 255 (25%) – Non Smokers: 765 (75%) – Age 21-29 Smoking Rate (28%) – Total 21-29 in Survey: 261

11. Smoking in Bars & Compliance 86% of all Bar Patrons REPORT COMPLIANCE WITH THE LAW (2000) 77% of Bar Owners/Employees says it’s EASY or FAIRLY EASY to COMPLY WITH THE LAW (2002) June 2000 study of bar patrons and the October 2002 study of bar owners and employees were conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section.

12. Why do we care about 21-29 year-old bar patrons? 21-29 year olds had the greatest frequency of response to the survey; 21-29 year-old bar patrons stay in bars for the longest periods of time 48.2% stay 2+ hours per visit and nearly 87% stay 1 hour or more; and Over 75% of 21-29 year-old bar patrons go to bars at least once a month with 22% going at least once a week! 44% of 21-29 years old drank 3 or more drinks during their stays, comparing to 29%, 23%, 18%, and 11% for other age groups. (March 1998 survey only) March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section.

13. And Where do They (21-29) Go? March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. Year Clubs Casino RestaurantsBar 3/9847.5% 6.9% 40.5%19.7% 8/9844.1% 6.6% 40.3%20.1% 6/0041.8% 8.4% 39.5%19.9% 10/0250.6% 8.2%32.3%24.9%

14. And How Often? March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. Year 1/Week 3/9824.8% 51.9% 15.0%8.4% 8/9826.4% 47.9% 15.3%10.4% 6/0031.8% 44.0% 15.3%8.8% 10/0224.8% 52.9%11.1%11.1%

15. Approval of Smoke-free Bar Environment by 21-29 Year-old Bar Patrons March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. Percent Change from 1998 to 2002 is significant. OR 1.9 (p=.004)

16. Approve of Smoke-Free Bar Law General and 21-29 Year-Old Specific March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. Increase in 2002 over March 98 is significant for 21-29 OR 1.7 (p=.001)

17. 21-29 Year-Old Bar Patrons More Likely to Visit Smoke-Free Bars Now that smoking is prohibited in bars, are you more likely, …, to visit them? March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. Percent Changes from 1998 to 2002 are not significant.

18. Smoking in Bars & Compliance of 21-29 Year-Olds March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. YearDo You Smoke?Do You Comply With the Law? 3/9827.0%65.6% 8/9826.4%54.1% 6/0028.0%80.3% 10/0219%83.6% October 2002 compliance has significantly increased in this population since March 1998 OR 0.3 (p=.01)

19. Perceived Non-Compliance with Smoke-free Bars by 21-29 Year-old Bar Patrons March 1998, August 1998, June 2000 and October 2002 studies conducted by the Field Poll Corporation for the California Department of Health Services, Tobacco Control Section. Percent Change from 1998 to 2002 is significant. OR 0.5 (p=.001)

20. What Additional Data or Evidence Do We Have?

21. Bar Sponsorships In California Who is Being Targeted Here???

22. Vodka Shots off a Camel Ice Sculpture Anyone? Rock the Casbah!

23. “I thought Parliament was just a bunch of stuffy Brits.”

24. California must also be Marlboro Country!

25. Who Goes to Bar Nights? 76% are 18-35 years old (most 21-25) 58% Male 80% Caucasian What’s In it for the Bar? (Marlboro Example) 8 Events a year Neon Signs, Napkins, Pool Cues, Bar lights, etc. Wall mural with Marlboro theme - Not the name. Bi-Monthly ad space in appropriate papers This amounts to about $80,000 per year to the bar - AND IT’S LEGAL! We observed 22 bars in 2000, randomly selected from 3 different time periods, from San Diego, San Francisco, and LA. The bars were sponsored by either Marlboro, Camel, or Lucky Strike.

26. Eating establishment’s taxable annual sales in California by liquor license type, 1992-2001 Billion Dollars Smoke-free Restaurants Smoke-free Bars Source: California State Board of Equalization. Prepared by: California Department of Health Services, Tobacco Control Section, November 2002.

27. Bar/All Retail Results No change in intercept and slope after implementation of smoke-free bar component Change in intercept and slope after implementation of smoke-free restaurant component

28. Percentage of quarterly bar revenues as a total of all eating and drinking revenues, 1990-2000 Percentage Source: California State Board of Equalization. Prepared by: California Department of Health Services, Tobacco Control Section, November 2001. Smoke-free restaurant law Smoke-free bar law

29. Percentage of quarterly bar revenues as a total of all eating and drinking revenues, 1990-2000 Percentage Source: California State Board of Equalization. Prepared by: California Department of Health Services, Tobacco Control Section, November 2001. Smoke-free restaurant law Smoke-free bar law

30. Bar/All E&D Results Change in intercept and slope after implementation of smoke-free bar component Change in intercept and slope after implementation of smoke-free restaurant component

31. Number of Individuals Employed in Eating and Drinking Places in California: 1992-2000 Annual Average Labor Force Source: State of California, Employment Development Department, Labor Force Statistics (11/03) Year Number of Employees Smoke-free Restaurants Smoke-free Bars Increase of 28.5% in 11 years as compared to a 14.2% increase for all employment statewide over the same period.

32. Tourism in California California Travel Spending and Related Impacts: 1995-2002 Source: California Trade and Commerce Agency, Division of Tourism, September, 2003 “Total Payroll” definition changed in 1999 to include sole proprietors such as owners of Bed & Breakfasts and their family members instead of just the hired staff of such establishments. Destination Spending includes spending on accommodations, eating and drinking, groceries, ground transportation, recreation and retail sales. Total spending also includes air transportation and travel arrangement services. Billions of Dollars

33. Tourism and Employment California Travel Spending and Related Impacts: 1995- 2002 Source: California Trade and Commerce Agency, Division of Tourism, November, 2003

34. So how do you make this work for you? Surprisingly, it’s not all that hard … First step is to develop and gain institutional commitment to do the study. This is key as you may be asking questions you don’t already know the answers to; and Institution must be prepared to defend results. Additionally, this prevents your administration from looking...

35. really ridiculous...

36. forcing you to do some fancy footwork...

37. to avoid being beaten up by the opposition...

38. possibly sacked...

39. so you can celebrate instead!

40. More Steps to Success Select a reputable and independent survey company to collect data. This will add credibility to the results and help deflect the opposition’s arguments of biased data collection Utilize or customize existing data collection tools and methodology. Reduces up-front expense on your end and you know questions are valid

41. More Steps to Success Collect data over time and consider what you want to do with the data before you collect it. This helps you think through the questions and deflects attacks of selective data release or intentional withholding of sub-optimal results. Strategically release data to key audiences for maximum effect. Projects Key opinion Leaders MediaLaw Enforcement General Public

42. Who gets it and how can they use it? Your Projects: Interventions (Bar nights) Local voices for media activity Direct owner education General Public: Perception of normative behavior can be swayed (Everyone smokes in bars is a myth)

43. Who gets it and how can they use it? The Media: They get your message out - stories or ads. Develop talking points and press releases Get to them first. Pitch stories with well-trained spokespeople They can be your best friend or worst enemy - it is up to you. Key Opinion Leaders: Influence change and compliance for the inside.

44. Who gets it and what do they do with it? Law Enforcement: Remind them that the public wants the law They can “influence compliance” as well as enforce They may not want to enforce the “law” But they will acknowledge the will of the people to influence compliance Convey information to owners Training of law enforcement is essential to stimulating action

45. Paul Hunting, MPH California Department of Health Services Tobacco Control Section P.O. Box 942732, MS 7206 Sacramento, CA 94234-7320 (916) 449-5482 phunting@dhs.ca.gov For more information... Joanne Wellman-Benson, RDH, MPH California Department of Health Services Tobacco Control Section P.O. Box 942732, MS 7206 Sacramento, CA 94234-7320 (916) 449-5514 jwellman@dhs.ca.gov Hao Tang, MD, PhD California Department of Health Services Tobacco Control Section P.O. Box 942732, MS 7206 Sacramento, CA 94234-7320 (916) 449-5512 htang@dhs.ca.gov