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Smoking in the Home: Changing Attitudes and Current Practices Marxy Jane Ashley, MD, Joanna Cohen, MHSc, Roberta Ferrence, PhD, Shelley Bull, PhD, Susan Bondy, PhD, Blake Poland, PhD, and Linda Pederson, PhD Introduction Attitudes toward the control of environmental tobacco smoke in public places and workplaces have changed markedly in North America over the past decade.'"2 Much less infonrnation is available on attitudes toward environmental tobacco smoke exposure in the home, although the home is a major source of exposure, especially for children.3- It is now clear that exposure to environmental tobacco smoke is a cause of lower respiratory tract infections (such as bronchitis and pneumonia), fluid in the middle ear, symptoms of upper respiratory tract irritation, and a small but significant reduction in lung function, as well as new cases and additional episodes of asthma and increased severity of asthma symptoms.)36 Since these effects in children have significant public health3 7 and economic"9 impacts, environmental tobacco smoke exposure in the home can no longer be ignored. Information on public attitudes toward smoking in the home and on smoking-related practices in homes can help detennine the need for programs. We report recent population-based data on attitudes and practices concerning smoking in the home in Ontario, Canada (1995 postcensal population estimate 11 100 300"') and discuss their implications.

Methods The data were taken from provincewide telephone surveys conducted in 1992 (n= 1058),'' 1993 (n= 1034), 2 1995 (n = 994), 3 and 1996 (n = 1764).'4 In all instances, 2-stage sampling was carried out to yield population-based estimates. The first stage of sampling involved selection of

a household by random-digit dialing. The second stage involved random selection of an adult respondent (1 8 years of age or older) for a computer-assisted interview. Response rates, estimated conservatively, ranged from 63% to 65%. Responses were tabulated as percentages, weighted according to the sample design. Epi Info's or PC-CARP'6 was used to detennmine the effective cell counts for the attitude variable from the weighted proportions and design effects estimated in each survey. The statistical significance of changes in individual attitudes from 1992 to 1996 was tested for all respondents and for nonsmokers and smokers separately by logistic regression, with year as the covariate and cell frequencies adjusted for the effective sample size. The proportions of households that were smoke-free (either smoking was not allowed or no one in the home smoked) were compared according to the smoking status of the respondent for the household, the presence and number of daily smokers in the household, and the presence

The authors are with the Ontario Tobacco Research Unit, Centre for Health Promotion, University of Toronto, Toronto, Ontario. In addition. Dr Ashley, Dr Bull, and Dr Poland are with the Department of Public Health Sciences. University of Toronto: Dr Ferrence and Dr Bondy are with tlle Addiction Research Foundation, Toronto; and Dr Pederson is with the Department of Communitv Health and Preventive Medicine and the Drew-MeharrvMorehouse Consortiumii Cancer Center, Morehouse School of Medicine, Atlanta, Ga. Dr Bull is also with the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto. Requests for reprints should be sent to Mary Jane Ashley, MD, Department of Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S IAS. Canada (e-mail: maryjane.ashley(a utoronto.ca). This paper was accepted October 3. 1997.

Americanl Jouimal of Public Health 797


of children (younger, older, or both) in the home. A chi-square test, adjusted for the design effect with PC-CARP, was used to test differences in proportions.

Results One question, common to all the surveys, concemed attitudes of the adult population toward parental smoking in the home when children are present (Table 1). Between 1992 and 1996, there were major changes in the attitudes of both smokers and nonsmokers. The percentage of nonsmokers who agreed that parents spending time with young children should not smoke at all inside the house increased steadily from 62.6% (95% confidence interval [CI] = 58.9, 66.3) in 1992 to 78.0% (95% CI = 75.5, 80.5) in 1996. The corresponding change in this percentage for smokers was even more marked, increasing from 16.7% (95% CI = 11.8, 21.5) to 42.6% (95% CI = 37.1, 48.0). Furthermore, the proportion of smokers unopposed to parental smoking in front of children declined from 22.4% (95% CI = 17.0, 27.8) in 1992 to 13.8% (95% CI = 10.0, 17.6) in 1996. Data from the 1996 survey suggest that in more than half the homes in Ontario there were no rules conceming smoking for people who lived in the home, while just over one third of homes were smoke-free (smoking was not allowed or no one smoked in the home) (Table 2). Included in the "other rules" category are respondents who reported that smoking was allowed only in certain areas (8.5%; 95% CI = 7.2, 9.8) and not when children were present (2.4%; 95% CI = 1.7, 3.1). Smoke-free homes were reported much less often by current smokers than by never and former smokers, whose percentages were similar. Smoke-free homes were also less likely to be reported when there were daily smokers in the home, especially when these were two or more, and were more likely to be reported when there were children in the home, regardless of their ages. Nonetheless, further analyses indicated that only 19.8% (95% CI = 15.0, 25.6) of homes with at least one daily smoker and with children younger than 18 years (n = 255) were smoke-free, whereas 50.3% (95% CI = 44.0, 56.6) had no rules about smoking in the home and 29.8% (95%, CI = 24.0, 35.6) reported "other rules." These estimates are similar to findings from a 1993 survey of adolescents conducted in Massachustetts.5 Among adolescents who lived with smokers, 25% reported smoking bans, while 53% reported no smoking restricfions for family members and 22% reported that there were designated smoking areas in the home.

TABLE 1 -Attitudes toward Parental Smoking in the Home When Children Are Present: Ontario, 1992 through 1996 Year of Survey

%

Nonsmokers 95% Cl

Smokers %

95% Cl

Parents spending time with small children should ... . Not smoke at all inside the housea 11.8, 21.5 16.7 58.9, 66.3 62.6 1992 15.3, 26.9 21.1 61.7, 69.0 65.3 1993 29.8, 42.1 35.9 63.8, 71.4 67.6 1995 37.1, 48.0 42.6 75.5, 80.5 78.0 1996 .0001 .0001 P (trend) Smoke only in another part of the house 53.1, 65.9 59.5 25.0, 31.9 28.5 1992 50.4, 64.5 57.4 26.8, 33.8 30.3 1993 42.2, 55.0 48.6 21.9, 29.0 25.4 1995 35.1, 45.9 40.5 14.5, 19.0 16.8 1996 .0001 .0001 P (trend) Feel free to smoke in front of children 17.0, 27.8 22.4 4.7, 8.5 6.6 1992 11.6, 22.3 17.0 1.6, 4.2 2.9 1993 8.7,17.3 13.0 3.7, 7.4 5.5 1995 10.0,17.6 13.8 2.2, 4.3 3.2 1996 .005 .04 P (trend)

All Respondents 95% Cl %

47.3, 53.9 52.0, 58.4 55.2, 61.9 67.0, 71.9

50.6 55.2 58.5 69.5

.0001 33.5, 39.8 33.2, 39.6 28.8, 35.2 20.3, 24.7

36.6 36.4 32.0 22.5

.0001

8.6,12.7 4.6, 7.8 5.8, 9.5 4.5, 7.0

10.7 6.2 7.7 5.8

.001

Note. The effective sample sizes for each year for all respondents, nonsmokers, and smokers, respectively, were as follows: 1992: n = 888, n = 656, n = 227; 1993: n= = 875, n = 658, n = 190; 1995: n = 819, n = 582, n = 234; 1996: n = 1362, n = 1035, n 316. Confidence intervals (Cls) were constructed with design-adjusted variances. at aln 1995 the first response category was changed from "not smoke at all" to "not smoke 4 the of in each the same were categories response other The house." all inside the years. Not shown in the table are the percentages of responses that were categorized as "don't know/refused to answer." These ranged from 1.8% to 2.3%.

The prevalence of smoke-free homes in 1996 among respondents from homes with both daily smokers and children varied markedly, according to the respondents' attitudes toward parental smoking in the home when small children are present. When the respondent's attitude failed to support no smoking by parents in the home in the presence of small children, only 6.3% (95% CI = 2.6, 13.6) of homes (n = 120) were smokefree, compared with 31.8% (95% CI = 23.9, 40.8) of homes (n = 135) when the respondent's attitude was supportive.

Discussion Although the attitudes of both smokers and nonsmokers are more favorable toward smoke-free homes for children than they were just 4 years ago, and differences between smokers and nonsmokers are narrowing, most homes in Ontario with daily smokers and children are not smoke-free. Recent reports of the provincial Chief Medical Officer of Health'7 and the Ontario Medical Association'8 highlight the importance of smoke-free homes, indicating that the control of environmental tobacco smoke in homes now has a prominent place on the

public health program and professional practice agendas in Ontario. However, the emergence of environmental tobacco smoke control in home environments as a public health priority raises a host of social, legal, and political issues.19 The potential for change rests not only on supportive public, professional, and political attitudes with regard to the protection of children from harm, but also on the realities of housing, income, education, and child care.19'20 Efforts should be made to assist parents in reducing the exposure of children to environmental tobacco smoke in the home. Evaluations of community-based programs with this objective21-23 indicate variable success. Some clinical interventions among pediatric patients and children with asthma or allergies have been successful,2426 while

others have not had much impact,27'28 especially in the long term.29 Barriers to clinical interventions, such as lack of time,30 unease about giving advice,30 deficiencies in professional training,3' and difficulties in involving parents who smoke,32 have been

identified. The attitude trends reported here, particularly those in smokers, and the finding that there is sufficient concern in half the homes with smokers and children that some measures have been taken to restrict May 1998, Vol. 88, No. 5

798 American Journal of Public Health


TABLE 2-Reported Rules about Smoking in the Home for People Who Live in the Home: Ontario, 1996 No Rules in Home % 95% Cl

n All

Smoking status of respondent* Never Former Current No. of daily smokers in the home* 0 1 2+

Presence of youngerb and/or olderc children in the home** Younger Both younger and older Older None

Smoke-Free Homea 95% Cl %

Other Rules in Home 95% Cl %

1764

54.1

51.7, 56.5

34.6

32.3, 36.9

10.8

9.3, 12.3

869 452 443

50.4 51.7 63.8

47.0, 53.8 47.0, 56.4 59.3, 68.3

42.9 38.4 14.4

39.6, 46.2 33.9, 42.9 11.1, 17.7

6.3 9.0 21.8

4.7, 7.9 6.3, 11.7 17.9, 25.7

1191 375 193

49.2 65.1 63.0

46.4, 52.0 60.3, 69.9 56.2, 69.8

44.3 17.5 7.4

41.5, 47.1 13.7, 21.3 3.7,11.1

6.0 17.2 29.6

4.7, 7.3 13.4, 21.0 23.2, 36.0

187 125

33.6 39.5

26.1, 41.1 30.0, 49.0

47.3 42.5

39.4, 55.2 32.9, 52.1

17.7 18.1

11.6, 23.8 10.6, 25.6

415 1037

46.8 62.5

41.5, 52.1 59.2, 65.8

41.9 28.4

36.6, 47.2 25.4, 31.4

11.0 8.7

7.7,14.3 6.8,10.6

Note. Confidence intervals (Cis) were constructed with design-adjusted variables. Response categories were derived from 2 questions. If "Are there rules in your home about smoking?" was answered affirmatively, the respondent was asked, "Which of the following best describes the rules about smoking in your home for people who live there? Is smoking not allowed in your home, is smoking confined to certain areas of your home, or is smoking not allowed when children are present?" Response categories permitted recording of "No one at home smokes," as well as the specifics of other rules. aSmoke-free homes were defined as homes where either smoking was not allowed or there were no smokers in the home. bAged 0 through 5 years. cAged 6 through 17 years. *Differences in proportions of smoke-free homes across the variable categories were statistically significant at P< .001. **Differences in proportions of smoke-free homes across the variable categories were statistically significant at P< .01.

smoking, suggest that interventions in Ontario aimed at reducing the exposure of children to environmental tobacco smoke may be more successful in the future. D

Acknowledgments Funding for the surveys was provided by the Addiction Research Foundation and Health Canada (1996 survey). The Institute for Social Research, York University, conducted the telephone interviews and provided data files for analysis. Dr Bull is a National Health Research Scholar. Dr Joseph Gao assisted in the data analysis.

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the Third National Health and Nutrition Examination Survey, 1988 to 1991. JAMA. 1996;275: 1233-1240. Biener L, Cullen D, Zhu XD, Hammond SK. Household smoking restrictions and adolescents' exposure to environmental tobacco smoke. Prev Med. 1997;26:358-363. Health Effects of Exposure to Environmental Tobacco Smoke. Sacramento: California Environmental Protection Agency, Office of Environmental Health Hazard Assessment; 1997. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics. 1996;97:560-568. Stoddard JJ, Gray B. Maternal smoking and medical expenditures for childhood respiratory illness. Am JPublic Health. 1997;87:205-209. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:648-653. Statistics Canada. Revised postcensal population estimates, by sex and age group, Canada, provinces and territories, July 1, 1995. Health Rep. 1996;8:51. Ferris J, Templeton L, Wong S. Alcohol, Tobacco and Marijuana: Use, Norms, Problems and Policy Attitudes among Ontario Adults. A Report of the Ontario Alcohol and Other Drug Opinion Survey, 1992. Toronto, Ontario: Addiction Research Foundation; September 1994. Internal Document No. 188. Bondy SJ, Ferrence RG. Smoking Behaviour and Attitudes in Ontario, 1993. A Report of the 1993 Ontario Alcohol and Other Drugs

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Public Health Briefs 20. Marsh A, McKay S. Poor Smokers. London, England: Policy Studies Institute; 1994. 21. Bondy SJ, Connop H, Pope M, Ferrence RG. Promoting Smoke Free Families. Report of a Pilot Intervention Trial to Reduce Environmental Tobacco Smoke in Family Homes. Toronto, Ontario: Ontario Tobacco Research Unit; August 1995. Working Papers Series No. 3. 22. Vineis P, Ronco G, Ciccone G, et al. Prevention of exposure of young children to parental tobacco smoke: effectiveness of an educational program. Tumori. 1993;79:183-186. 23. Greenberg RA, Strecher VJ, Bauman KE, et al. Evaluation of a home-based intervention program to reduce infant passive smoking and lower respiratory illness. J Behav Med. 1994; 1 7:273-290. 24. Murray AB, Morrison BJ. The decrease in severity of asthma in children of parents who

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smoke since the parents have been exposing them to less cigarette smoke. J Allergy Clin Immunol. 1993;91:102-1 10. McIntosh NA, Clark NM, Howatt WF. Reducing tobacco smoke in the environment of the child with asthma: a cotinine-assisted, minimal contact intervention. J Asthma. 1994;31:453-462. Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction in environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest. 1994;106:440-446. Chilmonczyk BA, Palomaki GE, Knight GJ, Williams J, Haddow JE. An unsuccessful cotinine-assisted intervention strategy to reduce environmental tobacco smoke exposure during infancy. Am JDis Child. 1992; 146:357-360. Eriksen W, Sorum K, Bruusgaard D. Effects of information on smoking behaviour in fami-

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lies with preschool children. Acta Pediatr. 1996;85:209-212. Severson HH, Andrews JA, Lichtenstein E, Wall M, Akers L. Reducing maternal smoking and relapse: long-term evaluation of a pediatric intervention. Prev Med. 1997;26:120-130. Frankowski BL, Weaver SO, Secker-Walker RH. Advising parents to stop smoking: pediatricians' and parents' attitudes. Pediatrics. 1993;91 :296-300. Klein JD, Portilla M, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use. Pediatrics. 1995;96:326-330. Fish L, Wilson SR, Latini DM, Starr NJ. An education program for parents of children with asthma: difference in attendance between smoking and nonsmoking parents. Am J Public Health. 1996;86:246-248.

Socioeconomic Differences in the Use of Physician Services in Nova Scotia George Kephart, PhD, Vince Salazar Thomas, PhD, and David R. MacLean, MD

Introduction

Given the ongoing debate in the United States surrounding the costs of insuring the uninisured population and reducing direct health care costs for consumers,14 studies of socioeconomic differences in the use of Methods health services in Canada are of considerable interest. Several Canadian studies have This study was based on the linkage of examined the socioeconomic differences in individual data from the 1990 Nova Scotia use of physician services, yielding mixed Nutrition Survey, a sample survey of 2198 results. However, the results have generally adult Nova Scotians that includes indicators shown that the introduction of universal of socioeconomic status,16 to the Nova Scomedicare resulted in increased use of health tia Medical Services Insurance Physicians' services by persons in lower-income houseServices database.'5 The Nova Scotia Nutriholds and that there is now an inverse assotion of health and .use-.. ciation between income''' ........... Survey was a 2-stage cluster sample of ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5-14 services. We examined socioeconomic differThe authors are with the Population Health ences in the use of physician services in the Research Unit, Department of Community Health Canadian province of Nova Scotia. Nova and Epidemiology, Dalhousie University, Halifax, health Scotia (population 900 000) has a Nova Scotia. Dr Thomas is also with the Division care system that provides universal coverof Geriatric Medicine, Faculty of Medicine, Dalage for nearly all physician services, with housie University, and the Manitoba Centre for no copayments. Unlike most previous Health Policy and Evaluation, Faculty of Mediresearchers, we used administrative claims cine, University of Manitoba, Winnipeg. Requests for reprints should be sent to data to measure use of physician services. George Kephart, PhD, Department of Community As we have discussed in detail elsewhere,'5 Health and Epidemiology, Faculty of Medicine, this procedure has several advantages over Dalhousie University, Halifax, Nova Scotia B3H the survey-based, self-report measures used 4H7, Canada. in most previous studies. First, administraThis paper was accepted November 21, 1997. tive claims data are not subject to recall Note. Although the data analyzed herein are from the Nova Scotia Department of Health, the error. Second, they permit an examination conclusions are solely those of the authors. of use over a longer time interval, thus pro-

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viding a more robust measure of an individual's "typical" level of use. Finally, they permit the examination of the value of services used, rather than simply the number of physician contacts.

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May 1998, Vol. 88, No. 5