Reductions in exposure to second hand smoke in workplaces and public places have been accomplished largely through provincial or federal legislation, municipal bylaws or workplace policies. Controls on second-hand smoke-exposure in home environments, on the other hand, have been left entirely to persuasive messaging for voluntary changes -- urging smokers to "take it outside."
Why the difference in approach? And what about smoking restrictions in home environments when the home is also a workplace? Should we pursue a legislative agenda? Should we treat these spaces like a home or like a workplace? This paper explores these questions.
This paper also highlights discussion, issues and ideas raised on this topic at a workshop held in Sault Ste Marie earlier this year. Forty-three people attended, most of whom were health and social service providers who conduct home visits as part of their jobs. Many of these homes are smoky. These homes are of course workplace environments for staff during the time they are conducting these visits.
II No Public Health Rationale for Differential Treatment
There is no public health rationale for providing less protection from second-hand smoke in the home than in public places and workplaces. On the contrary, the public health rationale for the complete elimination of second-hand smoke in all environments is compelling:
1. Second-hand smoke causes health effects in those exposed -- the greater the exposure, the higher the risk. (i) This is regardless of whether the exposure is at home, at work or in public places. In fact, children, whose exposure is primarily in home environments, are more susceptible than adults to the negative effects of second-hand smoke. (ii) By this rationale, home environments should be more, not less, tightly controlled than workplaces and public places when it comes to second-hand smoke exposure.
2. Smoking restrictions in workplaces, public places and homes are all associated with higher rates of quitting among smokers, and reduced consumption. (iii)
3. There is no ventilation solution (short of separately enclosed, separately ventilated rooms, which are very expensive and not practical for many workplaces, let alone homes). (iv) There is only one effective way to eliminate risk associated with second hand smoke exposure and that is to eliminate smoking inside.
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III Patchwork of Existing Legislation for Workplaces, None for Homes
Smoking is subject to a patchwork of federal and provincial legislation, municipal bylaws and individual workplace policies. (v) Federal legislation bans smoking in most federally regulated workplaces. In Ontario, the Smoking in the Workplace Act restricts smoking in workplaces to 25% or less of the total floor area of a workplace (however, the fact that no requirements are specified for separation of smoking and non-smoking areas renders this legislation ineffective). The Tobacco Control Act restricts or prohibits smoking in a number of indoor places where members of the public might go. However, restaurants, bars, bingo halls, bowling alleys, billiard halls and a number of other workplaces are not included. To address these gaps, a number of municipalities have passed bylaws. These bylaws vary on the level of restriction and on the locations to which the restrictions apply. In 1994, an estimated 67% of Ontario's population was covered by smoke-free bylaws, with 20% of Ontario's population covered by "strong" or "very strong" bylaws. By 1998, these numbers had increased to 80% and 28% respectively. (vi)
None of these laws cover homes.
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IV Expansion of Home-Based Workplaces
Home-based businesses have increased in recent years. Higher demands for specialized services and corporate downsizing have led to an increased demand for freelance consulting. (vii) With vastly improved communications technology has come a trend for employees to work some or all of their time out of their homes. Home-based work is also popular with parents of small children and an increasingly available option to many.
As more and more people work out of their homes, what impact will that have on the level of second-hand smoke in the home, and consequently the health of those who live under the same roof? Should this impel us to move towards legislated restrictions on home-based workplaces? One municipality has recently included home-based workplaces in its smoke-free workplaces bylaw: Brandon, Manitoba is the first Canadian municipality to take this bold step.
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V The Home as a Workplace During a Home Visit
Many social service and public health staff go into the home as part of community outreach programs. Some examples are Healthy Babies programs, home care, Family and Children's Services/Children's Aid Society, postnatal visits to high risk families, and staff who work in group homes. In some cases, clients and workers have a choice regarding whether or not to accept the visit. In others, they do not.
Forty-three people involved in home visit programs attended a meeting in Sault Ste. Marie January 29, 2002. In these discussions, some dynamic tensions between client and worker rights and preferences became evident, particularly the follwing:
* Workers fear lost opportunities if they are too dogmatic about insisting on smoke-free environments during their visits. They worry that such demands will compromise the client-patient relationship, or that they may be refused entry into a home in need of home care or counselling services. This often leads to the worker deciding to put up with their own health risk or personal discomfort "for the sake of the client."
* On the other hand, the group agreed that workers have the right to request a smoke-free environment when conducting home visits. They have a right to health and safety in their workplace and, during the time of the visit, the client's home is their workplace. For some workers, the right extends further to a professional responsibility to educate the family about the effects of second-hand smoke on themselves and their children.
By the end of the day, a consensus emerged that the concern about "lost intervention opportunities" was probably overstated. In the words of one of the participants, "it is possible to establish a therapeutic relationship on the first visit at the same time as you request smoke-free during visits. Most will comply with this request."
One of the important outcomes of the day was that several participants reported that the discussion motivated and empowered them to be more assertive regarding their own rights.
This meeting was co-hosted by the Algoma Health Unit and the Program Training and Consultation Centre. If you are interested in hosting a similar meeting in your community, contact the author.
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VI Towards a Solution
Opinions on how to address the need for protection from second-hand smoke in home environments are widely divergent and passionate. One school of thought holds that smoking in the home cannot and should not be regulated. Legislators are reticent to intrude into private homes and enforcement is very difficult. Another school of thought argues that second-hand smoke in the home can and should be dealt with through legal means, as are other important issues related to children's safety and welfare. (viii)
Public attitudes toward legislated restrictions in the workplace and in the home differ widely. Eight in 10 Ontario adults support workplace restrictions. (ix) In contrast, less than 4 in 10 support legislated restrictions in the home. (x)
We are a long way from coming together on this debate of protection versus civil liberties. Meanwhile, we can take some concrete steps to increase protection of workers in the home from second hand smoke.
1. We can advocate for broadening the definition of workplace in existing legislation to protect all workers. A major weakness in existing legislation is the lack of a consistent and comprehensive definition of workplace. For example, restaurants and bars, though they are workplaces for many people, are typically considered a "public place" in local bylaws. Workplaces are generally defined as indoor spaces, excluding work done in outdoor workplaces. Private homes are rarely if ever included in the definition of workplace in existing legislation.
2. Many health and social service workers must enter smoky environments on home visits with clients. These workers can be agents for social change. They can
* request that there be no smoking in the home prior to and during home visits;
* collect data regarding their client opinions by asking all clients "how would you feel about a home visitor asking you not to smoke in your own home while the visit was going on?" Such client opinions and reactions could be compiled and shared with colleagues at professional conferences as a way to profile concerns about smoke-free visit requests compromising the therapeutic relationship, to promote awareness and to stimulate discussion about ways to manage this issue;
* educate clients about the effects of second-hand smoke and assist in strategies to make their homes (and cars) smoke-free;
* offer incentives to clients to keep their home smoke-free during the visit;
* be explicit that they are not asking clients to quit, just to take it outside. At the same time, be open to discussing smoking cessation if the client expresses interest; and
* do visits at a smoke-free coffee shop or other location, if possible.
3. Managers of health and social service workers can support their workers in becoming more assertive about their right to smoke-free work environments by:
* including a standard clause in the consent form that all clients sign to receive home services that their visits will take place in a smoke-free environment.
* including a section in procedures manuals or in formal written policies that it is a worker's right to request smoke-free environments during home visits, and outlining worker responsibilities regarding client education about the effects of second-hand smoke; and
* providing educational materials and information on second-hand smoke and on smoking cessation, for workers to share with clients.
4. Education remains an important if imperfect strategy. For example, myths still prevail among segments of the population that turning on the stove fan or opening a window will remove the smoke. Ventilation can dilute the smoke but it will not make it safe. Similarly, air filters will not remove the contaminants in second-hand smoke completely. These contaminants linger long after the smoke in a room is no longer apparent to the eye or nose.
i National Institutes of Health, National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph #10. Washington DC: NIH Publication #99-4645, August 1999.
ii Ontario Tobacco Research Unit. Protection from Second Hand Tobacco Smoke in Ontario: A Review of the Evidence Regarding Best Practices. Toronto, Ontario: OTRU, May 2001.
iii Chaloupka, F. "Clean indoor air laws, addiction and cigarette smoking." Applied Economics, 24:193-205. 1992.
Farkas, A.J., Gilpin, E.A., Distefan, J.M., and Pierce, J.P. "The effects of household and workplace smoking restrictions on quitting behaviours." Tobacco Control, 8: 261-265. 1999.
Gilpin, E.A., White, M.M., Farkas, A.J. and Pierce J.P. "Home smoking restrictions: which smokers have them and how they are associated with smoking behavior." Nicotine and Tobacco Research, 1: 153-162. 1999.
iv Repace, J. Can ventilation control second hand smoke in the hospitality industry? June 2000. Available from http://www.dhs.cahwnet.gov/tobacco/documents/FedOHSHAets.pdf
v Physicians for a Smoke Free Canada. Second Hand Smoke and Ontario Labour Laws. April 2001. Physicians for a Smoke-free Canada . Available from http://www.smoke-free.ca/factsheets/pdf/Q&A-labourlawontario.PDF.
vi Lacchetti, C., and Abernathy, T. "Analysis of factors related to development, regulatory level and change in municipal no-smoking bylaws in Ontario." Canadian Journal of Public Health, 92(6): 412-416. 2001.
vii Health Canada. Workplace Smoking: Trends, Issues and Strategies. December 2000. Available from http://www.hc-sc.gc.ca/hppb/cessation/air/workplace_smoking.
viii Ontario Medical Association. Second Hand Smoke and Indoor Air Quality, OMA Position Paper on Second Hand Smoke. 1996. Available from http://www.oma.org/phealth/2ndsmoke.htm.
ix Ontario Tobacco Research Unit (2001) Monitoring the Ontario Tobacco Strategy; Progress Toward our Goals 2000/2001, Seventh Annual Monitoring Report. Toronto, Ontario: Ontario Tobacco Research Unit.
x 1995 Ontario Alcohol and Other Drug Opinion Survey, as cited in Ashley, M.J. and Ferrence, R. Environmental Tobacco Smoke in Home Environments. Toronto: Ontario Tobacco Research Unit Special Reports, 1996.