Northwest Ohio Environmental Tobacco Smoke Study Results

1. Northwest Ohio Environmental Tobacco Smoke Study Results Findings Relative to Economic Impact, ETS Related Contaminants, and Morbidity

2. Introductions • Welcome – Mike Renner, TUPCF executive director • Findings - Dr. James H. Price, Lead researcher for Toledo economic and scientific studies • Dr. Farhang Akbar-Khanzadeh, ETS Exposure Principle Investigator • Dr. Sadik Khuder, Morbidity Principle Investigator

3. Background – Toledo • Toledo CIA ordinance effective 8/24/03 • Prohibits smoking in any public indoor place • Exemptions include: • Entire rooms/halls rented for private functions • Retail tobacco stores • Bars with serving areas smaller than 245 sq. ft • Membership associations • Smoking lounges

4. Background – Bowling Green • Bowling Green CIA ordinance effective 2/4/02 • Prohibits smoking in any public indoor place • Exemptions include: • Restaurants w/ bars where smoking contained w/in separate room • Bars can permit/prohibit smoking at their discretion • Bowling alleys can permit/prohibit smoking at their discretion

5. Research Goals • Develop test methods to measure the impact of CIA ordinances on health and the economy of Toledo and Bowling Green • Benefit other Ohio communities in their efforts towards the passage of a comprehensive CIA ordinance

6. Research Parameters • Significant sample size for each study • Economic impact – studied about 700 bars, restaurants and bowling alleys • Morbidity study – referenced hospital admissions/discharge data over 4.5 years • Acknowledge limitations for each of the studies

7. Post-Ordinance Findings Revealed • Economic impact of smoke-free public places • ETS exposure post ordinance • Impact on local morbidity rates

8. Key Findings • Economic Impact: • There appears to be no statistically significant difference in the economic stress indicator of bars, restaurants and bowling alleys in these communities following the establishment of their clean indoor air ordinances when compared to control cities. • ETS Related Contaminants: • Designs of separate smoking lounges in the establishments included in this research were not completely effective in containing all environmental tobacco smoke related containments. (Smoking lounges were established to allow smoking within designated enclosed rooms within businesses.) • Morbidity: • Study results showed a 54% reduction in the rate of acute heart attack admissions in Bowling Green, compared to Kent which showed a 34% reduction in the same post ordinance period.

9. Economic Impact James H. Price, PhD, MPH Professor of Public Health, University of Toledo Joseph A. Dake, PhD, MPHWayne State University Jan Ruma, MEd, CFRE Hospital Council of Northwest Ohio Pam Butler, MPHHospital Council of Northwest Ohio

10. Economic Impact Study – Purpose • Compare short-term financial effects of two communities with clean indoor air ordinances versus two control communities • Clean indoor air ordinance – Toledo and Bowling Green • Control communities – Youngstown and Kent • Determine whether the economic stress indicators of businesses in suburban communities’ have been reduced since the urban ordinance • Pre and post implementation assessment of Toledo CIA ordinance compared to Maumee, Perrysburg & Sylvania

11. Economic Impact Study – Methods • Composition of Economic Stress Indicator • Available data on • payment performance information • Type of industry • Size (number of employees) • Corporate structure • Public records • Time in business under the same management • Net profit after taxes • Financial ratios (liquidity ratios, efficiency ratios, and profitability ratios) • Utilizing Financial data to categorize businesses into one of five groups: • Group one = lowest probability of economic stress • Group five = highest probability of economic stress

12. Economic Impact Study – Results • No statistically significant impact on the economic stress indicators of bars, bowling alleys, and restaurants in Toledo or restaurants in Bowling Green were found for cities with CIA ordinances when compared to their control cities

13. Bowling Alleys Restaurants Bars 3.0 3.0 3.0 2.5 2.5 2.5 2.0 2.0 2.0 1.5 1.5 1.5 1.0 1.0 1.0 0.5 0.5 0.5 First Half 2003 First Half 2003 First Half 2004 First Half 2004 First Half 2003 First Half 2004 Economic Impact Study – Results:Toledo and Youngstown 1.68 1.59 1.62 1.63 1.61 1.55 1.25 1.44 1.65 1.25 Toledo 1.23 Youngstown 1.00

14. Toledo Maumee Perrysburg Sylvania Economic Impact Study – Results:Toledo and Suburbs Restaurants Bars 3.0 3.0 2.5 2.50 2.50 2.5 2.0 2.0 1.76 1.72 1.68 1.59 1.5 1.33 1.5 1.58 1.45 1.44 1.25 1.53 1.0 1.37 1.33 1.0 1.00 1.00 0.5 0.5 First Half 2003 First Half 2004 First Half 2003 First Half 2004

15. 3 2.5 2 1.5 1 0.5 Q2_04 Q1_03 Q2_03 Q3_03 Q4_03 Q1_04 Bowling Green Kent Economic Impact Study – Results:Bowling Green and Kent Restaurants

16. Potential Limitations of the Economic Stress Study • Lack of long-term historical economic stress indicators for the cities • It may be that the economic stress levels of the businesses may have changed, but the measurement used was not sensitive enough to detect the changes • The financial stress of clean indoor air ordinances may be cumulative over years and this effect may be delayed • This study did not investigate the historical trend of new businesses opening and existing businesses closing (concurrent validity) • Only group data is reported; individual establishments may have been affected

17. Impact of Post-Ordinance ETS Exposure Farhang Akbar-Khanzadeh, PhD Professor of Public Health, Medical College of Ohio Sheryl Milz, PhD Assistant Professor of Public Health, Medical College of Ohio April Ames, MS Student, Medical College of Ohio Sara Spino, MS Student, Medical College of Ohio Christopher Tex, MPH Student, Medical College of Ohio

18. ETS Exposure Study – Background • Both ordinances in Toledo and Bowling Green provide allowances for separate smoking dining lounges in certain restaurant/bar establishments

19. ETS Exposure Study – Purpose • Examine whether the allowance of separate smoking lounges fully protects the public and employees in these establishments

20. ETS Exposure Study – MethodsStudy Size • Four bars and restaurants in Toledo and Bowling Green • One in each city that allowed smoking • One in each city that did not allow smoking • Note: a sample of 9 bars and restaurants in Toledo and Bowling Green indicated that the sites sampled were representative of settings in these two cities • Control environments included a non-smoking office building and outdoors

21. ETS Exposure Study – MethodsMonitoring • ETS indicators monitored included: • Nicotine • 3-ethenylpyridine (3-EP) • Respirable suspended particles based on Solanesol (Sol-PM) • Ultraviolet particulate matter (UVPM) • Fluorescent particulate matter (FPM) • Total respirable suspended particulate matter (RSP)

22. ETS Exposure Study – MethodsSample Size • A total of 98 integrated active air samples were collected • 49 samples for nicotine and 3-EP • 49 samples for ETS-related particulate matters • In each of the above category: • 14 personal samples inside restaurants • 28 replicate area samples inside restaurants • 2 area samples within office building • 5 area samples collected outdoors

23. ETS Exposure Study – Results • Results suggested that designs of smoking lounges of those restaurants studied were not effective in containing all environmental tobacco smoke within their walls • Nine out of eleven smoking restaurant/bar establishments examined, including the two used in this study, were in violation of one or more provisions of clean indoor air ordinances

24. ETS Exposure Study – Results • In smoking restaurants ETS-related contaminants were: • Significantly higher in the smoking dining rooms than in the non-smoking dining rooms • Significantly higher in the non-smoking dining rooms than in the control environment • Not significantly different from those found in the corresponding non-smoking and smoking dining rooms of the smoking restaurant/bar settings investigated pre-CIA ordinance

25. ETS Exposure Study – Results • In non-smoking restaurants/bars ETS contaminants were: • Comparable to those determined in the control (outdoors and non-smoking office) environment • Significantly lower than those found in both the smoking dining rooms and non-smoking dining rooms of the two smoking restaurant/bar establishments

26. Control Control Control Control NS Restaurant NS Restaurant NS Restaurant NS Restaurant NS in S Restaurant NS in S Restaurant NS in S Restaurant NS in S Restaurant S in S Restaurant S in S Restaurant S in S Restaurant S in S Restaurant ETS Exposure Study – Results 70 25 60 20 50 15 40 Nicotine Concentration Ug/m3 Sol-PM Concentration Ug/m3 30 10 20 5 10 0 0 120 100 100 80 80 60 60 UVPM Concentration Ug/m3 FPM Concentration Ug/m3 40 40 20 20 0 0

27. ETS Exposure Study – Limitations • Whether the air handlers were being used appropriately • Whether the establishments were in compliance at all times with the clean indoor air ordinances • This study did not compare separate smoking rooms to smoking areas within the same rooms as non-smoking sections

28. ETS Exposure Study – Conclusions • The results of this study suggest that the exemptions in the CIA Ordinances in the two cities of Toledo and Bowling Green have still left some unhealthy working and dining environments • To fully protect employees or patrons 100% smoke-free policies should be established and enforced

29. Impact on Morbidity Relative to ETS Sadik Khuder, PhDProfessor of Public Health, The Medical College of Ohio Sheryl Milz, PhDAssistant Professor of Public Health, The Medical College of Ohio Timothy Jordan, PhDAssistant Professor of Public Health, The University of Toledo Kathy Silvestri, MPHThe Hospital Council of NW Ohio Pam Butler, MPHThe Hospital Council of NW Ohio

30. Morbidity Impact Study – Purpose • Develop method for data collection and analysis to measure health effects of clean indoor air ordinances • Obtain and establish baseline ETS-related morbidity statistics for Toledo and Bowling Green

31. Morbidity Impact Study –Methods • Obtained hospital discharge data from January 1999 –June 2003 • Selection Criteria: • Cities with clean indoor air ordinances • Bowling Green and Toledo • Analysis included: • Separate analysis for youth <18 and adults 18-93 • Specific focus on acute heart attacks in adults

32. 1.8 1.6 1.4 1.2 1.0 Morbidity Rate Per 1,000 Population .8 .6 .4 .2 Bowling Green Kent Decrease in Morbidity Due to AMI in BG Morbidity Impact Study – Results 1/99 –6/99 7/99 – 12/99 1/00 –6/00 7/00 – 12/00 1/01 – 6/01 7/01 – 12/01 1/02 – 6/02 7/02 – 12/02 1/03 – 6/03

33. Limitations • May not necessarily be a sustainable change over time • Small number of admissions for diseases potentially related to ETS exposure • Prevented stratified analysis by age, gender, race and other variables • Unable to account for multiple admissions for the same condition • Greater than one-year delay in reporting morbidity through hospital discharge data

34. Recap of Key Findings • Economic Impact: • There appears to be no statistically significant difference in the economic indicator data of bars, restaurants and bowling alleys in Toledo and restaurants in Bowling Green following the establishment of their clean indoor air ordinances when compared to control cities. • ETS Related Contaminants: • Designs of separate smoking lounges in the establishments included in this research were not completely effective in containing all environmental tobacco smoke related containments. (Smoking lounges were established to allow smoking within designated enclosed rooms within businesses.) • Morbidity: • Study results showed a 54% reduction in the rate of acute heart attack admissions in Bowling Green, compared to Kent which showed a 34% reduction in the same post ordinance period.

35. Q&A