Adult Attitudes and Practices Regarding Smoking Restrictions and Child Tobacco Smoke Exposure: 2000 to 2015

The annual cross-sectional Social Climate Survey of Tobacco Control is a national survey that contains items pertaining to normative beliefs, practices and/or policies, and knowledge regarding tobacco control. We have administered this survey to representative samples of US adults since 2000. From 2000 to 2009, these data were collected via automated, random-digit-dialing (RDD) telephone surveys. We added an additional probability-based Internet panel frame in 2010 to address noncoverage issues arising from wireless substitution. Respondents were recruited from nationally representative dual-frame samples in 2010 through 2015.³⁷ The RDD frame included households with listed and unlisted landline telephones; 5 attempts were made to contact those selected adults who were not home. The Survey Research Laboratory at Mississippi State University’s Social Science Research Center administered the surveys via computer-assisted telephone interviews to respondents in this frame. The probability-based panel frame included an online survey administered to a randomly selected sample from a nationally representative research panel.^38,39 This panel is based on a sampling frame that includes both listed and unlisted numbers not associated with landlines, does not accept self-selected volunteers,^38,39 and provides sample coverage for 99% of US households.⁴⁰ The institutional review board at Mississippi State University approved this study, informed verbal consent was obtained, and the institutional review board provided a waiver of documentation of the written consent process.

In Table 1, we describe the 8 items that measured the prevalence of smoking bans in private and public places. Each respondent reported the degree of smoking restrictions in the home and provided an assessment of smoking restrictions in public places within his or her community.

We examined support for restricting smoking in private and public places with the variables described in Table 2. These variables included attitudes about smoking bans in public places and normative beliefs about exposing children to secondhand smoke in private places.

Respondents who had a child under the age of 18 in the home were asked the following questions: “In the past 12 months, did your child’s doctor ask if anyone in the household smokes?”; “In the past 12 months, did your child’s doctor ask if you have a smoke-free home?”; and “In the past 12 months, did your child’s doctor ask if you have a smoke-free car?”

The samples were weighted to be representative of the US population. Data from all years were weighted to adjust for age, race, sex, and region. Data from the 2015 frame were also weighted to account for the frame overlap among Internet panel respondents who also had a landline telephone and were therefore also eligible for the RDD frame.

Cross-sectional data from the annual Social Climate Survey of Tobacco Control were analyzed for changes in knowledge, attitudes, and practices regarding tobacco by using bivariate χ² procedures.

Sample sizes in 2000 and 2009 were ∼1500. More funds were available in 2015 and the sample size was 3070. Unweighted and weighted sample characteristics demonstrate the representativeness of each sample (see Table 3).

The majority of adults reported household smoking restrictions in 2000, and these restrictions increased through 2015. Households prohibiting indoor smoking increased from 69.1% in 2000 to 79.5% in 2015, whereas car smoking prohibitions increased from 68.3% to 81.8% (P < .05). Support for smoke-free public places and implementation of smoke-free policies also increased. Most US adults supported smoke-free policies for indoor public places in 2000, yet there was a clear disconnect between public support and actual policies for these venues (see Table 4). By 2009, both support and implementation of smoke-free policies had increased, and the disconnect between public support and actual policy was greatly reduced.

In 2009, public support was associated with local and statewide smoke-free legislation. Although the strong majority of adults believed that these public venues should be smoke-free, support for smoke-free malls, convenience stores, fast food establishments, and restaurants was stronger among adults who live in places that had already implemented smoke-free policies than among those who did not (84.5% vs 76.8%, 94.6% vs 81.2%, 92.2% vs 71.5%, and 81.6% vs 66.0%, respectively, P < .05). We changed to a global measure in 2010 (“Would you favor or oppose a law that would prohibit smoking in all indoor workplaces, including offices, restaurants, and bars?”) to better assess support for comprehensive smoke-free policies.

Tobacco counseling by child’s health care provider also increased. Pediatrician and family practitioner screening and counseling for both parental smoking (50.6%–64.0%) and rules prohibiting smoking in the house (34.6%–57.1%) and car (21.7%–33.6%) increased from 2001 to 2015 (P < .05). In 2009, counseling by the child’s health care provider did not relate to parent’s support for smoke-free policies in malls, convenience stores, or fast food establishments. Moreover, the existence of smoke-free public policies for these venues did not increase parental reports of screening and counseling. However, parents who had been asked about household policies (89.7% vs 80.1%), vehicle policies (90.5% vs 80.3%), and smoking parents who were advised to quit (78.3% vs 43.9%) were more supportive of smoke-free policies for restaurants than those who had not received screening and counseling (P < .05 for all comparisons). Also, parents who lived in communities with smoke-free policies were less likely to be screened for household (24.8% vs 41.7%) and vehicle smoking rules (20.5% vs 31.9%) (P < .05). There were no differences in cessation counseling to parental smokers.

We also examined these changes in beliefs, practices, and knowledge across demographic categories. The observed changes occurred across sex, age, education, race, regional, and smoking status subsets.

Modest improvements in smoke-free protection for children in the home and family vehicles occurred from 2000 to 2015. Moreover, a growing majority of adults supports smoke-free policies in public settings, and many states and communities have implemented comprehensive smoking restrictions.

However, members of 1 in 5 households still permit smoking inside the home and family vehicle, and a third of the US population is not protected by state or local laws prohibiting smoking inside of restaurants. Clinical and advocacy-driven tobacco control efforts continue to push for increased restrictions on where tobacco can be smoked. Pediatricians can help to prevent children’s tobacco smoke exposure through patient and family education. Screening smokers and then advising them to quit has been shown to be an effective intervention in a variety of clinical settings and screening forms first step of the effective 5 A’s (ask, advise, assess, assist, arrange) treatment strategy for adult tobacco dependence.⁴¹ Counseling to parents increased substantially over the past 16 years, yet there is room for improvement. A third of parents have reported that their child’s pediatrician did not screen for household tobacco use, and fewer parents have reported screening for household rules about smoking in the home and vehicle. Clinical screening and counseling for tobacco use and exposure did have a potentially important relationship with smoke-free policies in restaurants. Reports of screening and counseling in the past year appears to have increased parents’ support for smoke-free restaurants, but parents who live in communities with smoke-free restaurants are less likely to report receiving screening and counseling. Child health care providers in these communities may be underestimating tobacco smoke exposure, possibly because it is no longer an issue in their local public venues.

This study has at least 2 limitations. First, we designed our dual-frame methodology to reduce the potential for sample bias associated with either RDD or Internet panel samples alone, but we still cannot eliminate the potential for noncoverage bias. Also, the use of the Internet panel raises some concern about the representativeness of the sample. However, the authors of several studies have demonstrated that this probability-based panel can produce results similar to those of well-designed RDD surveys,^42,43 and our use of this dual-frame methodology produced estimates for current smoking that did not differ from those of several large, government surveys of US adults.³⁷ We examined the validity of this dual-frame approach to reduce noncoverage bias in tobacco surveys in a previous study.³⁷ We assessed the comparability of self-reported smoking prevalence estimates from our 2010 dual-frame survey with those from the 2010 National Health Interview Survey and the 2009–2010 NHANES. These are both large-scale national surveys and serve as the principal sources of information about tobacco use in the US population. We found that our estimates of self-reported smoking were within the confidence intervals of those from both the National Health Interview Survey and the NHANES. This finding applied to overall estimates and those for sex, race, and age. Second, these data are self-reported, and we could not verify that responses concerning smoke-free practices and/or policies and physician counseling were not misrepresented.

The percentage of families who were screened and counseled for tobacco use and exposure has improved from 2000 to 2015. The percentage of children enjoying smoke-free homes, cars, and public indoor places has also increased. Additional counseling and treatment opportunities remain to help parents protect children from tobacco smoke exposure in homes and cars and to move local smoke-free policies forward at the community level.

 
• AAP

  American Academy of Pediatrics

 
• RDD

  random-digit-dialing