Effect of smoking regulations in local restaurants on smokers' anti-smoking attitudes and quitting behaviours

Objective

To examine the effect of smoking regulations in local restaurants on anti‐smoking attitudes and quitting behaviours among adult smokers.

Design

Hierarchical linear modelling (HLM) was used to assess the relationship between baseline strength of town‐level restaurant smoking regulation and follow‐up (1) perceptions of the social acceptability of smoking and (2) quitting behaviours.

Setting

Each of the 351 Massachusetts towns was classified as having strong (complete smoking ban) or weak (all other and no smoking restrictions) restaurant smoking regulations.

Subjects

1712 adult smokers of Massachusetts aged ⩾18 years at baseline who were interviewed via random‐digit‐dial telephone survey in 2001–2 and followed up 2 years later.

Main outcome measures

Perceived social acceptability of smoking in restaurants and bars, and making a quit attempt and quitting smoking.

Results

Among adult smokers who had made a quit attempt at baseline, living in a town with a strong regulation was associated with a threefold increase in the odds of making a quit attempt at follow‐up (OR = 3.12; 95% CI 1.51 to 6.44). Regulation was found to have no effect on cessation at follow‐up. A notable, although marginal, effect of regulation was observed for perceiving smoking in bars as socially unacceptable only among smokers who reported at baseline that smoking in bars was socially unacceptable.

Conclusions

Although local restaurant smoking regulations did not increase smoking cessation rates, they did increase the likelihood of making a quit attempt among smokers who had previously tried to quit, and seem to reinforce anti‐social smoking norms among smokers who already viewed smoking in bars as socially unacceptable.Despite the proliferation of restaurant and bar smoking ordinances, very little is known about their specific effects on smokers'' attitudes towards smoking in public places and actual quitting behaviours. The effect of clean indoor air ordinances on smokers is of particular interest given that these types of bans may discourage smoking by strengthening anti‐smoking community norms and in turn influencing quitting behaviours. That is, the social unacceptability of smoking in restaurants and bars may be a potential mechanism in reducing smoking behaviours. Glantz has argued that the tobacco industry''s opposition to restaurant and bar smoking bans is primarily due to the strong message that smoking is no longer socially acceptable.⁶ A recent cross‐sectional study showed that strong local restaurant and bar regulations are associated with more negative attitudes towards the social acceptability of smoking in restaurants and bars among adults who eat out or go out primarily in their towns.⁷ It is known that public smoking restrictions limit smokers'' opportunities to smoke, thus raising the costs of smoking (eg, having to go outside to smoke), which may reduce the perceived benefits of this behaviour (eg, social camaraderie and “pleasure” of smoking a cigarette after a meal).Several studies have shown that smoking restrictions in the workplace encourage smokers to quit or cut back on cigarette consumption.^8,9 According to a recent review of 26 studies on the effects of smoke‐free workplaces across the US, Australia, Canada and Germany, completely smoke‐free workplaces are associated with reductions in prevalence of smoking and fewer cigarettes smoked per continuing smoker.⁹ One study reported that strong local clean indoor air ordinances in California during 1990–1 were associated with an absolute quit rate (over the previous 6 months) 7.6% higher than in areas with no workplace laws.¹⁰ Another study conducted in Canada during the same time period found a 21% reduction in the odds of being a smoker in areas with high coverage versus those with low coverage of smoking bylaws.¹¹ These worksite studies have generally found that completely smoke‐free workplaces are associated with smoking cessation and reduction in cigarette consumption.However, of the 26 studies reviewed by Fichtenberg and Glantz, only two employed longitudinal data and none were specific to restaurants and bar regulations.⁹ The use of cross‐sectional data prevents determination of whether the regulations caused the reduced smoking or whether states and towns with lower smoking rates are more likely to adopt such regulations. These studies are also limited by their failure to control for town‐level factors that may confound the relationship between the presence of regulations and the observed levels of smoking. Furthermore, the few studies reviewed grouped together different smoking restriction sites (eg, worksites, schools, restaurants, public places), and assessed only state‐level rather than local laws.Another limitation of current research is that none has investigated how restaurant smoking regulations influence smokers'' attitudes and behaviours by existing attitudes towards smoking and smokers'' quitting behaviour. Smoking regulations in restaurants may have a stronger effect on smokers who have begun to change their perception of the social unacceptability of smoking in public places and on smokers who are already motivated to quit. Most research efforts have assumed homogeneity in attitudes and behaviours by examining the effect of bans on all adults and all smokers. Prochaska et al^12,13, for example, have characterised quitting as a process, with smokers classified according to their stage of change from precontemplation (earliest stage) to maintenance (last stage). A large variation exists in the quitting process—smokers often do not exhibit a steady progression through this change sequence¹⁴ and achievement of successful cessation often includes regression to a previous stage.¹⁵ Additionally, two obvious reasons for the limited research are the small samples used in many studies and the lack of longitudinal data to support stratified analyses. These data allowed us to investigate in detail heterogeneity in smoking regulation effects across attitudes and quitting behaviours among a smoker cohort.To help address the weaknesses of previous research, our study focused on the effect of smoking regulations over the 2‐year follow‐up period on two outcomes: (1) anti‐smoking attitudes among smokers who did or did not report anti‐smoking attitudes at baseline and (2) quitting behaviours among smokers who had or had not made a past year quit attempt at baseline. To our knowledge, this is the first longitudinal study to assess the effect of restaurant smoking restrictions on smokers'' attitudes towards smoking in restaurants and bars, quit attempts and actual quitting behaviour.