Public Health Feature - May 2008
By Crystal Conde
Since Abilene enacted a citywide comprehensive smoking ordinance in 2006, Ralph McCleskey, MD, a cardiovascular disease specialist there, isn't quite sure what to expect when he receives a personal letter. He's gotten his fair share of "hate mail" from angry smokers who feel the ordinance infringes on their personal choice to smoke in public.
In one letter, a woman insisted she should be allowed to smoke in public places even though her husband, a smoker, died after cancer forced removal of his larynx.
Dr. McCleskey was a member of Smoke Free Abilene, a coalition formed two years ago to educate residents about smoking's impact on the public's health and to bolster support for the ban. Before the ordinance's passage, Abilene's restaurants had designated smoking and nonsmoking areas that the coalition argued were ineffective in preventing nonsmokers from breathing cigarette smoke.
"Our point was that no one has the right to harm someone else with their activity. If they want to sit at home in their own house and smoke, that's fine. But they don't have the right to blow the smoke on anyone else," said Dr. McCleskey, a member and former chair of the Texas Medical Association Council on Scientific Affairs.
The public health implications of smoking are dire. The U.S. Centers for Disease Control and Prevention (CDC) says cigarettes kill 438,000 Americans each year. The Campaign for Tobacco-Free Kids adds that 24,200 adult Texans die every year from smoking. Secondhand smoke and smoking during pregnancy account for 2,420 to 4,300 deaths annually. The organization projects that 503,000 children living in Texas today will ultimately die from smoking-related diseases.
Dr. McCleskey and other physicians around the state are working to reverse smoking's devastation. And, it turns out, a large percentage of residents favor a statewide law to prohibit smoking in all indoor workplaces and public facilities. In fact, a 2007 survey by Baselice & Associates Inc. shows that 66 percent of Texas voters want no-smoking designations in public buildings, offices, restaurants, and bars. Thirty percent of those polled oppose such a statewide law.
During last year's legislative session, TMA backed antismoking bills. House Bill 9 by Rep. Myra Crownover (R-Denton) and Senate Bill 368 by Sen. Rodney Ellis (D-Houston), as filed, would have eliminated smoking in all public and workplace settings, as well as seating areas of outdoor venues. They also would have prohibited smoking within 15 feet of an entrance, an operable window, or a ventilation system of an enclosed nonsmoking area.
The original bills exempted private residences unless used for child care, adult day care, or health care; designated motel or hotel rooms; designated private or semiprivate rooms in nursing homes or long-term care facilities; and private clubs that don't employ anyone. To win support, amendments exempted cigar bars and tobacco shops and reduced certain penalties within the bill.
But the effort failed. The bills died on the Senate floor.
The Texas Restaurant Association, the Texas Public Health Coalition, the American Cancer Society, the Smoke-Free Texas coalition, and many others joined TMA's support of the bills as filed. Given the broad support, the groups will attempt to push the legislation through the next session in 2009.
To achieve success at the state level, Smoke-Free Texas, of which TMA is a member, and other advocacy groups are working to lay a strong foundation of support at the local level. Grassroots efforts, with physicians at the heart of the cause, are making a difference in one city at a time, as voters and city councils support comprehensive smoking ordinances that protect the public health of residents and level the playing field for business owners.
Making Ordinances Stick
The state of New York is a case study in immediate positive health outcomes from a statewide ban on smoking. Researchers in a November article in the American Journal of Public Health report that admissions for acute myocardial infarction (AMI) at New York hospitals declined after the state passed a comprehensive smoking ban in 2003.
AMI admissions decreased 8 percent, with 3,813 fewer hospital admissions in 2004. Direct cost savings totaled $56 million the same year.
According to the 2006 report The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General , secondhand smoke is a major cause of disease, including lung cancer and coronary heart disease, in healthy nonsmokers. The report's research indicates smoke-free policies are the most economic and effective approach to protect nonsmokers from exposure to secondhand smoke.
Currently, 26 percent of incorporated Texas cities have comprehensive smoking ordinances. (See " Comprehensive Smoke-Free Ordinances in Texas .") Smoke-Free Texas, which supports cities in passing smoke-free ordinances, considers ordinances comprehensive if they cover worksites, including restaurants and bars. Ordinances with weaker provisions such as opt-out clauses, separate rooms, and ventilation allowances are not considered comprehensive.
For example, Addison's municipal worksites, private worksites, and restaurants have designated smoking areas, but bars do not. Galveston permits designated smoking areas in worksites, restaurants, and bars.
Besides TMA, Smoke-Free Texas members include the American Cancer Society (ACS), the American Heart Association, the American Lung Association, the Campaign for Tobacco-Free Kids, and Texas PTA. The group's Web site allows physicians and interested residents to get involved in smoke-free ordinance efforts and to learn how local coalitions can be effective.
Before Smoke-Free Texas will help a city enact a smoke-free ordinance, says James Gray, vice president for health initiatives at ACS, local coalitions must:
- Be committed to a comprehensive plan that stipulates all employees will be protected;
- Develop community support for an extended period of voter education and city council debate; and
- Remain engaged during the implementation phase of the ordinance.
"The coalitions need to be fully prepared for a lengthy campaign and be willing to walk away from an ordinance that doesn't protect all employees," Mr. Gray said. "That can become a big obstacle, if they haven't agreed to those terms yet. During any campaign, there's always a window where somebody wants to try to amend the ordinance and provide exemptions, which can be very alluring if you're faced with losing an ordinance completely."
Abilene's nonbinding referendum on a smoke-free ordinance passed with more than 69 percent of registered voters' support. The city council met and unanimously approved passage of the ordinance. An opposition group failed to get enough signatures on a petition to recall the ordinance.
Currently, Amarillo is preparing to seek voter approval of a comprehensive smoke-free ordinance. It will be on the ballot May 10. (See "Amarillo Works to Pass Ordinance.")
Collaboration Key to Success
Tyler is the first city to adopt a comprehensive smoking ordinance this year. Bruce Carter, MD, a diagnostic radiologist in Tyler, was a member of the Smoking Task Force, a coalition appointed by Mayor Joey Seeber to solicit public input and information from the medical community, examine secondhand smoke reports from the U.S. Surgeon General, and talk to other cities that had adopted smoking ordinances.
The group reviewed medical literature, heard testimony on the medical impact of secondhand smoke, and examined the public health concerns of physicians and local public health officials. Dr. Carter took the mayor and individual members of Tyler's City Council on hospital tours to show them firsthand examples of lung cancer and other diseases caused by smoking.
"After meeting with all those groups, it was a pretty easy lobbying effort because once they saw the medical impact in the local hospital setting, there's no disputing it," Dr. Carter said. "All of them became advocates of a smoking ban. Then it was a matter of looking at other smoking bans and fashioning one that fit our community."
Antismoking ordinances in Abilene, El Paso, Houston, and Dallas were models for the task force. The Tyler City Council approved the no-smoking ordinance at a special meeting in February. The stringent regulations ban smoking in public places, places of employment, restaurants, and bars. The new ordinance prohibits smoking within 20 feet of outside entrances, operable windows, and ventilation systems of any public place or worksite. The ordinance takes effect June 1.
While the medical evidence of the need for a smoke-free ordinance wasn't disputed, economic concerns generated considerable debate. Owners of businesses that serve food and alcohol feared a decline in business after the implementation of an ordinance.
But a one-year assessment of the impact of a smoking ban on restaurant and bar revenues in El Paso indicates gross restaurant and bar, restaurant-only, and bar-only revenues continued to increase after that city's 2002 smoking ban.
Dr. Carter and the task force found a strong business ally in Bob Westbrook, president of the East Texas Restaurant Association. Mr. Westbrook is familiar with public health issues. He chaired the Northeast Texas Public Health District Board of Health for three of his five years on the board. He and the restaurant association supported Tyler's proposed ordinance and liked that it didn't exempt bars, pool halls, or bowling alleys.
"Our association took that stance due to the different ordinances that had been passed. If the municipalities allowed any exclusion at all, number one, they weren't fair to small businesses, but they really weren't good for public health," he said.
Mr. Westbrook will become president of the Texas Restaurant Association in 2010. He says he will champion the passage of a statewide smoking ban during the 2009 legislative session.
Dr. Carter says collaboration between business and health care was pivotal to the success of Tyler's smoke-free ordinance. He encourages other physicians to team up with members of the business community to present a unified front to their city councils.
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at Crystal Conde .
Comprehensive Smoke-Free Ordinances in Texas
*"Dry" cities with smoke-free ordinances that do not address bars
Source: Smoke-Free Texas
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Amarillo Works to Pass Ordinance
In February, the Amarillo City Commission opted to let city residents decide whether a citywide smoking ban should be enacted. Supporters of the ordinance formed Breathe Easy Amarillo to educate the city's residents and garner support for the measure.
The community coalition is composed of residents, businesses, the American Cancer Society, the American Heart Association, the American Lung Association, the Campaign for Tobacco-Free Kids, and the March of Dimes. Smoke-Free Texas is assisting the city with its efforts, as well.
Breathe Easy Amarillo petitioned the city commission to put the fate of the smoking ordinance in the hands of voters after the commission declined to approve it. A group called Speak Out Amarillo, which vows to inform voters on the drawbacks of the smoking ban, is fueling opposition to the proposed ordinance.
Brian Eades, MD, an obstetrician-gynecologist in Amarillo, is a city commissioner and is familiar with Amarillo's failed attempt to pass a smoke-free ordinance three years ago.
"On this occasion, what Breathe Easy Amarillo has tried to do is focus on the people who turned out on behalf of the ordinance previously and try not to stir the pot with people who might be opposed," he said.
The proposed smoking ordinance prohibits smoking in all enclosed public places within the city; all enclosed areas of workplaces; and the seating areas of all outdoor arenas, stadiums, and amphitheaters, and in enclosed areas of such facilities. In addition, it outlaws smoking within 10 feet outside entrances and operable windows of an enclosed area.
James Gray, vice president for health initiatives at the American Cancer Society and a member of Smoke-Free Texas, says framing the need for a smoke-free ordinance as a workplace safety issue helps communities like Amarillo succeed.
"When you can get a community and elected officials to look at this as a workplace safety issue - which is what it is - they understand the need to pass a comprehensive ordinance. Every employee needs to be protected, and every employee in Texas has the same value. When you get folks there, that's when you typically see these ordinances pass without much consternation," he said.
Amarillo's previous smoking provisions limited smoke-free protections to city-owned facilities and vehicles and didn't require no-smoking designations in municipal worksites, private worksites, and bars. Voters will go to the polls to weigh in on the comprehensive smoking ordinance May 10.
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