State-Specific Prevalence of Smoke-Free Home Rules --- United States, 1992--2003

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Secondhand smoke (SHS) causes premature death and disease in children and nonsmoking adults (1). The home is the primary source of exposure to SHS for infants and children and a major source of SHS exposure for nonsmoking adults (1). To assess trends in national and state-specific prevalence of home "no smoking" rules (i.e., smoke-free home rules), CDC analyzed data from the Tobacco Use Supplement to the Current Population Survey for 1992--1993, 1998--1999, and 2003. This report summarizes the results of that analysis, which indicated that the national prevalence of households with smoke-free home rules in the United States increased significantly, from 43.2% during 1992--1993 to 72.2% in 2003. During this period, the national prevalence of such rules increased from 9.6% to 31.8% among households with at least one smoker and from 56.8% to 83.5% among households with no smoker. A regression analysis of the rate of change over time indicated that the increase in smoke-free homes during this period was not significantly different for households with at least one smoker compared with households with no smoker. Statistically significant increases in the prevalence of smoke-free home rules were also observed in all states, although variation was observed among states. Comprehensive tobacco-control measures, including 1) evidence-based interventions to help smokers quit, 2) policies making workplaces and public places smoke-free, 3) voluntary rules making homes smoke-free, and 4) initiatives to educate the public regarding the health effects of SHS, are needed to further reduce exposure of nonsmokers to SHS.

The Current Population Survey (CPS) is a continuous monthly household survey administered by the U.S. Census Bureau for the Bureau of Labor Statistics that examines labor-force indicators for the U.S. civilian, noninstitutionalized population aged >15 years (2). Since 1992--1993, the National Cancer Institute has sponsored a Tobacco Use Supplement (TUS) to this survey with questions on tobacco use and related topics, including voluntary home smoking rules. CDC has cosponsored the supplement since 2001. The TUS-CPS was conducted in selected months during 1992--1993, 1995--1996, 1998--1999, 2000, 2001--2002, and 2003. Approximately 75% of respondents were contacted by telephone, and 25% of respondents were contacted by personal home visit. The supplement self-response rates for the TUS-CPS ranged from 65% in 2003 to 72% during 1992--1993 (2).* Data were adjusted for nonresponse and weighted using the household supplement self-response weight. This weight was calculated by summing the self-response weights for all respondents aged >15 years and dividing by the rostered number of persons aged >15 years to provide national and state prevalences of smoke-free home rules.

Each household member aged >15 years was asked, "Which statement best describes the rules about smoking inside your home?" The response options were 1) "No one is allowed to smoke anywhere inside your home," 2) "Smoking is allowed in some places or at some times inside your home," or 3) "Smoking is permitted anywhere inside your home." Excluded from the analysis were households with discrepancies in household members' responses (e.g., when one respondent reported a smoke-free home rule and another respondent from the same household reported that smoking is allowed inside the home).

From 1992--1993 to 2003, increases occurred nationally and in every state in the percentage of households with complete smoke-free home rules (i.e., no one is allowed to smoke anywhere inside the home) (Table). During 1992--1993, the percentage of households with smoke-free home rules ranged from 25.7% in Kentucky to 69.6% in Utah. In 2003, the percentage ranged from 53.4% in Kentucky to 88.8% in Utah. The state with the smallest increase during this period was Utah, which had the highest prevalence of smoke-free home rules during 1992--1993. Kentucky, the state with the lowest prevalence of smoke-free home rules during 1992--1993, had the largest increase during this period.

Reported by: A Trosclair, MS, S Babb, MPH, R Murphy-Hoefer, PhD, K Asman, MSPH, C Husten, MD, A Malarcher, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

Revised Healthy People 2010 objectives call for reducing the proportion of children aged <6 years who are exposed regularly (>4 days per week) to SHS in the home to 6% (objective 27-9) and reducing to 63% the proportion of nonsmokers aged >4 years who are exposed to SHS, as measured by having detectable levels of cotinine (a metabolite of nicotine used as a biologic marker for SHS exposure in nonsmokers) in their blood (objective 27-10) (3). The second objective has already been met: approximately 47% of U.S. nonsmokers were exposed to SHS during 1999--2002; in addition, the prevalence of regular exposure of children aged <6 years to SHS in the home has declined, from 27% in 1994 to 8% in 2005. The progress made toward realizing these objectives reflects recent decreases in SHS exposure in workplaces, public places, homes, and other settings.

The recently published Surgeon General's report The Health Consequences of Involuntary Exposure to Tobacco Smoke notes that SHS exposure declined during the past decade as a result of the implementation of smoke-free policies in workplaces and public places (1). However, approximately 126 million children and nonsmoking adults were still exposed to SHS in the United States as of 1999--2002. Because children spend so much time in the home, it remains the primary setting where they are exposed to SHS (1). Adults also spend much of their time in the home, and the home is a major source of exposure for nonsmoking adults. Substantial sociodemographic disparities exist with regard to SHS exposure in the home. For example, evidence suggests that blacks and persons with low incomes are more likely to be exposed to SHS in the home than other groups (1).

The Surgeon General's report states that complete elimination of smoking in indoor spaces is the only measure that fully protects nonsmokers from SHS exposure; other approaches, such as separation of smokers from nonsmokers and ventilation, are not effective (1). Making homes completely smoke-free substantially reduces SHS exposure among nonsmoking residents; the evidence also suggests that smoke-free home rules help smokers quit and reduce smoking initiation among youth (1,4).

The increase in smoke-free homes described in this report might have been driven by two factors: 1) an underlying decrease in smoking rates among adults and youths, and 2) changes in knowledge and attitudes regarding the adverse health effects of SHS (1). Because smoke-free home rules are voluntary, they are important indicators of changes in public awareness of the health effects of SHS and in public attitudes regarding the social acceptability of smoking. They also reflect personal concerns about protecting family members (1). In particular, the large increase in smoke-free home rules that has occurred in households with smokers during the past 10 years suggests a considerable shift in social norms.

Findings from a recent international prospective study suggest that the presence of smoke-free policies in public places is associated with increased voluntary adoption of smoke-free home rules (5). Other factors, including the absence of smokers and the presence of children and nonsmoking adults in a household, also are consistent predictors of smoke-free home rules (1,5).

The public health community promotes smoke-free homes by educating smokers about the dangers SHS exposure poses to the health of their families (1). The U.S. Environmental Protection Agency carries out a national educational program that encourages parents to make their homes smoke-free to protect their children's health (6). Educational campaigns also can raise public awareness about the health risks that SHS exposure in the home poses to nonsmoking adults. Further research, including evaluation of ongoing initiatives, is needed to determine which approaches are most effective in promoting smoke-free homes.

The findings in this report are subject to at least three limitations. First, estimates for homes with smoke-free rules are based on self-report and are not validated by an objective measure (7). However, data from a study conducted during 1998--1999 indicate that parental reporting of extent of smoke-free home rules correlated with child cotinine levels, suggesting that self-reports of home rules are accurate (8). Second, because responses from members of certain households were discrepant regarding the level of smoking restrictions, these households were excluded from the analysis. However, the percentage of households with such discrepancies was small and declined over time, from 6.6% of households during 1992--1993 to 2.3% in 2003. Finally, response rates for TUS-CPS have declined over time (from 72% during 1992--1993 to 65% in 2003). However, the national estimates of smoke-free home rules described in this report are not significantly different from estimates reported in other studies (1,5).

The single best step that persons who smoke can take to protect both the health of family members and their own health is to quit smoking. Effective smoking-cessation interventions are available, including clinical counseling, medications approved by the Food and Drug Administration, and state telephone quitlines (available by dialing 1-800-QUIT NOW) (9). In addition to advising patients to quit smoking, health-care providers can discuss the health effects of SHS exposure with patients and recommend that they adopt smoke-free home rules (1).

Comprehensive tobacco-control programs that include effective interventions to decrease smoking initiation, increase smoking cessation, and eliminate nonsmokers' exposure to SHS need to be implemented fully to accelerate progress in reducing the health burden from tobacco use and SHS exposure (10). Although SHS exposure has decreased substantially among U.S. nonsmokers during the past 10 years, the findings of this report indicate that millions of children and nonsmoking adults remain at risk for SHS exposure because their homes are not smoke-free. Continued increases in the number of smoke-free workplaces, smoke-free public places, and smoke-free homes are needed to protect nonsmokers from this widespread and preventable health hazard (1).

This report is based, in part, on contributions by AM Hartman, National Cancer Institute; A Freeman, US Environmental Protection Agency; JT Gibson, Information Management Services, Inc., Silver Spring, Maryland; and AP Meier, US Census Bureau.

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