To our knowledge, this is the first longitudinal study to assess the effect of restaurant smoking regulations on smoking‐related attitudes and quitting behaviours among smokers. It provides new evidence that restaurant smoking regulations (1) encourage new quit attempts among smokers who have previously tried to quit and (2) seem to reinforce anti‐smoking social norms among smokers who already view smoking as socially unacceptable in bars. However, during this short period of time, there was no effect of a strong smoking regulation on smokers' actual likelihood of quitting over 2 years.
Completely smoke‐free restaurant regulations seemed to have an effect on perceived social unacceptability of smoking in bars over the 2‐year follow‐up only among smokers who reported it was socially unacceptable to smoke in bars at baseline. This finding was consistent with the overall adult sample (analyses not shown), which suggests that smokers are not impervious to larger trends in social norms related to smoking in restaurants and bars. More time may be needed to assess whether restaurant smoking bans discourage smoking—particularly among the subset of smokers who already view smoking as socially unacceptable in bars—by strengthening anti‐smoking community norms and, in turn, influencing quitting behaviours.
Because we did not find an effect of strong smoking restaurant regulations on perceptions of social acceptability of smoking in restaurants either among those who reported smoking as socially unacceptable or among those who reported it as acceptable at baseline, this effect may be seen as backsliding or no movement, in which clean indoor air laws seem to have reached their maximum potential in altering views on smoking in public places. From this perspective, we found less backsliding at follow‐up among those who live in towns with strong restaurant regulations. This finding is of critical importance because it shows the great need for strong smoking restaurant regulations to be in place to maintain and continually reinforce social norms around smoking in public places. Progress in this tobacco control measure may be accompanied by periods of no movement and backsliding, but without strong regulations in place, rapid erosion of their positive effects on anti‐smoking attitudes would probably follow.
Our findings also suggest that restaurant and bar smoking bans promote further cessation efforts among adult smokers who were already engaged in the process of quitting. These regulations may not affect smokers who are not already motivated to quit, or more time may be necessary to observe an effect of moving smokers along the continuum of stages of change towards smoking cessation. Given that there was a relatively short period of time between baseline and follow‐up, and particularly because quitting smoking is a lengthy process in which relapse is common, it is not surprising that strong restaurant regulations did not produce more smoking cessation over a 2‐year period. Again, it is likely that more time is needed between baseline and follow‐up to observe an effect on successful quitting.
We believe that these findings represent a true effect of restaurant smoking regulations, rather than an effect of bias or confounding. The observed associations are not explained by a wide range of potential individual‐, household‐, and town‐level confounding factors, including age, education, household income, workplace smoking bans, the percentage of town voters who voted for a 1992 cigarette tax initiative, a measure that controls for the baseline anti‐smoking sentiment in a town, and likely reflects baseline levels of education and smoking prevalence as well.19
This analysis also involves some important limitations. One limitation is that these smoking regulations were in effect for a short period of time; the majority were in effect for <2 years. A related limitation is the length of follow‐up and, as noted, more time may be needed to observe an effect on these outcomes, particularly with respect to quitting behaviours.
These findings have important public health implications. They suggest that adoption of local smoke‐free regulations, while primarily intended to protect non‐smokers from secondhand smoke exposure, may have the potential to encourage anti‐smoking social norms and adult cessation efforts, particularly among a subset of smokers who already view smoking as socially unacceptable in public places and among smokers who are engaged in the process of quitting smoking. This study provides further justification for state and local efforts to enact clean indoor air policies, and for state tobacco control programmes to include a substantial focus on supporting local secondhand smoke policy efforts.
What this paper adds
- 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 influence quitting behaviours.
- 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.
- As the study controlled for a wide range of potential individual‐and town level confounding factors, we believe it provides new evidence that restaurant smoking regulations encourage new quit attempts among smokers who have previously tried to quit, and reinforce anti‐smoking social norms among smokers who already view smoking as socially unacceptable in bars.
- It suggests that adoption of local smoke‐free regulations may have the potential to encourage anti‐smoking social norms and adult cessation efforts, particularly among a subset of smokers who already view smoking as socially unacceptable in public places and among smokers who are engaged in the process of quitting smoking.
- To protect patrons and employees from the health consequences of exposure to secondhand smoke, including cancer, heart disease and respiratory illness, many communities have adopted local regulations that require restaurants and bars to be completely smoke‐free.1,2,3
- Currently, more than 200 cities and 11 states have adopted laws that specifically prohibit smoking in restaurants.4,5