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Breathing Easier in the Bluegrass
UK College of Nursing Plays Major Role in Smoke-free Lexington

by Jeff Worley

Here’s Ellen Hahn, talking about an encounter that dramatically changed the focus of her professional life:

Illustration of man and woman seated at a restaurant and a waiter serving them“I had just come to UK—this was 1993—and was driving near downtown Lexington. I looked over and saw a woman walking with her four- or five-year-old son. She was smoking. She’d take a puff, bend down, and give him a puff. I stopped my car and said out loud, ‘Surely not.’ But then they walked past me, and she continued to share her cigarette with her child. She was teaching him how to smoke.”

When Hahn saw this, she realized that in Kentucky there were larger issues than drunk driving, her primary research focus when she got her doctorate in health policy and community health at the Indiana University School of Nursing just a few months earlier. So she began a full-court press to educate Kentuckians about the dangers of smoking to their health and to the health of those around them. In the Lexington area, Hahn, a professor in UK’s College of Nursing, has become known as a crusader for smoke-free public places.

“Secondhand smoke, also known as environmental tobacco smoke, is a mixture of the smoke given off by the burning end of a cigarette, pipe or cigar, and the smoke exhaled from the lungs of smokers,” explains Hahn, who, when she talks about the smoking issue, manages to be intense and affable at the same time. “It’s involuntarily inhaled by nonsmokers, lingers in the air hours after cigarettes have been extinguished, and can cause or worsen a wide range of health problems, including cancer, respiratory infections and asthma.”

The EPA has classified secondhand smoke as a known cause of cancer in humans. It causes approximately 3,000 lung cancer deaths and 35,000 heart disease deaths in adult nonsmokers in the United States each year. A study published in The New England Journal of Medicine in 1999 found that nonsmokers exposed to environmental smoke were 25 percent more likely to have coronary heart diseases compared to nonsmokers not exposed to smoke. And a 2002 U.S. Department of Health and Human Services report on carcinogens found that nonsmokers exposed to secondhand smoke at work are at elevated risk for adverse health effects.

Almost everyone believes that secondhand smoke is bad for us. But how bad? And what can be done about it? These were the key questions Hahn set out to answer in four recent studies, all of which are now completed. And the early data she and her colleagues collected set the stage for a once-unimaginable policy shift in Lexington. In the heart of tobacco country, a smoke-free law went into effect in April 2004 in all public establishments in Lexington-Fayette County, including restaurants and bars.

Building the Research Base

In September 2003 Hahn and several of her staff, backed in part by a $75,000 Robert Wood Foundation grant, did some field research, measuring the air quality in 10 Lexington businesses—restaurants, bars, night clubs, and bowling alleys—where smoking was common. The researchers, wearing backpacks, went into these establishments during three Friday and Saturday evenings. In each backpack was a MetOne photometer, which can detect and measure the level of fine-particle air pollution.

“We measured the room, counted the number of people who were smoking at the beginning, middle and end of the evening, and collected all sorts of data,” Hahn explains. Specifically, her group wanted to measure particulate matter, very fine particles you can’t see with the naked eye. After their visits, the researchers downloaded the information for computer analysis.

“We found that all venues tested were heavily polluted and dangerously above the federal standards for outdoor air quality,” Hahn says. Then, exactly one year later, after Lexington’s smoke-free law went into effect, this study was repeated.

Photo of Ellen HahnEllen Hahn, a professor in UK’s College of Nursing, has become known in Kentucky as a crusader for smoke-free public places.

“We went into the same places at the same times of night and took readings,” says Kiyoung Lee, UK College of Public Health assistant professor and co-principal investigator in the study. “Fine particle air pollution was 11 times lower after the smoke-free law was enforced.” Hahn adds that during this second visit, one of the sites wasn’t enforcing the new law, and the readings were “enlightening.”

“In that bar, we saw particulate matter that was sky high. What’s interesting about this kind of monitoring is, some people think that if you don’t smell the secondhand smoke, it’s not there; in actuality those toxins are still in the air. Ventilation systems can reduce the smell and the odor, but they don’t take the toxins away.”

* * *

A second study, conducted by UK’s Survey Research Center during the same time as the air-quality study, sought out public opinion about a smoke-free law in Lexington. Over 1,000 Fayette County adults (Lexington is in Fayette County), selected randomly, were asked how a smoke-free law would alter their various social practices.

Almost seven of 10 said they would go to restaurants and other public places either more often or about as often when the smoke-free law went into effect; and overall, 57 percent of those surveyed expressed support for the new smoke-free law.

“The results were similar to what we find in other smoke-free communities around the country, that these laws are a ‘win’ for public health and a ‘win’ for business,” says Hahn.

Two-thirds of those surveyed believed their risk of a heart attack or developing cancer would be higher if they lived or worked in a place that allowed smoking. This finding didn’t surprise Hahn at all: “Smoke-free laws act as a vaccine to protect workers and the public from heart disease, cancer and other respiratory diseases caused or worsened by secondhand tobacco smoke.”

After Lexington’s smoke-free law was in effect for about six months, this survey was repeated. “We found a significant jump in support of the new law—64 percent were in favor compared to 57 percent support prior to the law going into effect,” says Hahn.

An additional benefit of the ordinance is that it helps smokers who want to quit. “Smokers who work and live in smoke-free environments are more likely to quit compared to those who are permitted to smoke indoors,” says Hahn. “Our survey showed that of the people who were already trying to quit before the law took effect, 44 percent quit smoking altogether since its implementation.”

* * *

In this smoke-free process, Hahn did encounter some detractors. A major contention of those in the business community who opposed smoke-free laws was that such laws would hurt business.

It’s a common argument, Hahn says, but findings from other cities where restaurants and bars have gone smoke-free don’t support the contention. New York City’s 1995 Smoke-free Air Act had no adverse effects on restaurant employment, and restaurant employment growth was three times higher than in the rest of the state from 1993 to 1997. Gross restaurant sales in Flagstaff, Arizona, increased 16 percent one year after a smoke-free ordinance.

But what about Lexington? To find out whether Lexington’s bars and restaurants had been hit in the wallet by the city’s smoke-free ordinance, Hahn brought in two economic experts and pulled in data from July 2000 through February 2005 from the Kentucky Workforce Cabinet, the Lexington-Fayette Urban County Government Department of Revenue, and the Lexington-Fayette County Health Department.

One top economist who joined the study was Donald Mullineaux, a professor in UK’s Gatton College of Business and Economics. “We used separate econometric models that included data over time on restaurant and bar employment, wages and business closures,” says Mullineaux, who also serves as the duPont Endowed Chair in Banking. “We controlled for population size, seasonality, tourism, and local labor market conditions.” Working with him in this statistical analysis was Eric Thompson, an economist from the University of Nebraska-Lincoln.

They found that restaurant employment increased since the law went into effect, while the average number of bar workers remained stable. “We found that Lexington’s smoke-free law has not had a significant impact on overall employment, business closures or openings, or payroll withholding taxes in the restaurant or bar industries,” says Thompson.

* * *

Illustration of waiter holding serving trayA fourth study, which was reported last July, segued from the economic health impact to the personal health of restaurant and bar workers. The UK College of Nursing collaborated with the UK Prevention Research Center to examine nicotine deposits in the hair of 106 employees at nearly 50 randomly selected Lexington bars and restaurants.

“We went to the owners in person and asked if we could recruit workers. Everybody we asked was helpful,” Hahn explains. Her team asked the employees some questions about their smoking history, their health status, and their daily exposure to secondhand smoke.

Hair samples were analyzed four months before the ordinance took effect and then three months after it became law. Lower nicotine levels in the hair samples were found after the law took effect even among workers who smoked. Also, workers got fewer colds and sinus infections after the law went into effect (84 percent pre-law; 49 percent at three months; and 50 percent at six months).

“Food service workers are disproportionately affected by secondhand smoke when compared to white collar workers, and Lexington’s law is helping to change that,” Hahn says emphatically.

* * *

In becoming the first municipality in Kentucky to enact a comprehensive smoke-free law, Lexington joins a long list of cities to do so. “Over 1,900 municipalities in the United States have some sort of smoke-free laws,” Hahn says. “And about 400 communities have what are called 100 percent comprehensive smoke-free laws. We can be proud to say we’re one of them.”

At the time Lexington’s law went into effect, Kentucky’s largest metropolitan area, Louisville, and one of its rural towns, Georgetown, were involved in smoke-free debates. Using resources at the UK College of Nursing’s Center for Smoke-free Policy, which Hahn directs, she sent up-to-the-minute data on the effects of secondhand smoke on restaurant and bar employees to proponents of the smoke-free ordinance in both Louisville and Georgetown.

“I provided testimony, at the request of the city councils, about Lexington’s experience, and I helped the people leading the smoke-free ordinance to strategize, based on our experience here,” says Hahn. Louisville and Georgetown followed Lexington’s lead. Georgetown passed a more comprehensive ordinance than Lexington’s (it covers all workplaces as well as buildings open to the public), and it took effect October 1, 2005. Though not as strong as Lexington’s, Louisville’s ordinance (smoking in bars is permitted), was voted in, and it took effect last November.

How do you go smoke-free in the heart of tobacco country?

In the spring of 2001, Ellen Hahn was invited to talk to a group called Lexington Health United. This group included Emery Wilson, former UK dean of the medical school, and Douglas Scutchfield, the former head of the university’s School of Public Health. Representatives from Lexington hospitals and health insurers were also there.

“Todd Warnick, the former tobacco use prevention coordinator from the Lexington-Fayette County Health Department, and I were asked to suggest the most effective way to fight smoking in the Bluegrass,” says Hahn. “Todd and I agreed that the most effective policy would be to pass a smoke-free law in Lexington, so this was our message to the group.”

Given that the city is in the heart of tobacco country, that Kentucky has three times the number of tobacco farms of any other state, and that Kentucky leads the country in adult smoking, Hahn wasn’t optimistic about this suggestion taking root. “But they liked idea and asked us to put together a strategic plan on how to do this. So we did.”

Hahn says the next two and a half years were the “education phase” of the smoke-free initiative. The work she and her colleagues did was made easier by the fact that the Health Department had already distributed pamphlets about the benefits of smoke-free environments to area restaurants. “Half of the food establishments in Lexington were already voluntarily smoke-free when we started, though there were no smoke-free bars.”

In 2001, Hahn helped organize a two-day clean-air forum at the University of Kentucky. Experts on smoking cessation came from around the country. “Also, Dr. [David] Stevens was there the whole time, and he became a champion for this initiative,” she says. Stevens, a retired orthopedic surgeon and former chief of staff at Shriners Hospital for Children, serves as an at-large member of the Lexington-Fayette Urban County Council and asked then Vice Mayor Isabel Yates to appoint a task force to study the smoke-free issue.

“To get input, Isabel assembled a huge group from the community—bar and restaurant owners, burley coop folks, health professionals, farmers, police, fire, and council members. Everyone agreed that secondhand smoke harmed people. There was also consensus that a smoke-free law wouldn’t hurt the farmers financially.”

In November 2002, the council members began to discuss and debate the issue. Hahn made frequent appearances on radio talk shows during this time and wrote op-ed pieces for the Lexington Herald-Leader to try to keep the issue on the front burner. Finally, on July 1, 2003, the city council passed the law.

“It was just a couple days before July 4, and I was quoted in the Herald-Leader as saying, ‘What a great way to celebrate our Independence Day,’” Hahn recalls. The new ordinance, which was supposed to take effect in late September, didn’t sail easily into the law books, however. The Lexington Food and Beverage Association filed a suit to block the law. The suit failed; in April 2004 the Kentucky Supreme Court ruled in favor of the law, and it went into effect that month.

“If somebody had asked me when I first came to UK in ’93 what the odds were of Lexington passing such a law a little over a decade later, I would have said zero,” she says. “But the time was right for this. It was all about getting the facts, educating people, and about political will.”

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