James A. Bergman, J.D. and Judith L. Falit, M.S.
The Center for Social Gerontology, Inc.
2307 Shelby Avenue
Ann Arbor, Michigan, U.S.A. 48103
Phone: (734) 665-1126
Fax: (734) 665-2071
Keywords: Smoking Policy; Elderly; Cessation Programs; Tobacco Education.
Published in: Tobacco Control - An International Journal. Autumn, 1997, Vol. 6, No. 3, pages 194-198.
Non-Smoking Policies, Tobacco Education and Smoking Cessation Programs in Facilities Serving the Elderly in Michigan, USA
James A. Bergman, J.D. and Judith L. Falit, M.S.
Objective - To determine the extent of and impetus for smoke-free policies in facilities serving Michigan's elderly, and the extent of tobacco education and smoking cessation programs for elders and staff of these facilities.
Design - Telephone survey in February 1997 of three types of facilities serving Michigan's elderly population.
Subjects - Area Agencies on Aging (n=12), Councils and Commissions on Aging (n=31) and Senior Centers (n=98) located in Michigan, USA.
Main outcome measures - Prevalence of smoke-free policies, tobacco education and smoking cessation programs in facilities serving the elderly.
Results - Ninety-nine percent (95% CI 97 to 100%) of 141 facilities surveyed have an indoor smoke-free policy. Eighty-five percent (95% CI 79 to 91%) of these policies prohibit all smoking inside the facility. Forty-five percent (95% CI 37 to 54%) cited a law as requiring the smoke-free policy, while 38% (95% CI 30 to 46%) indicated the policy was voluntarily adopted for health reasons. Forty-two percent (95% CI 34 to 50%) of the facilities provided some education on the dangers of tobacco, while eleven percent (95% CI 6 to 16%) arranged smoking cessation programs for staff or elders.
Conclusions - In Michigan, which has clean indoor air laws, a very high percentage of non-institutional facilities serving the elderly have smoke-free policies, which appear to increase participation at these facilities. Tobacco education programs are provided in less than half the facilities, and very few arrange smoking cessation programs for elders or staff.
Keywords: smoking policy; elderly; cessation programs; tobacco education.
Tobacco use is a geriatric disease in the United States. Of almost 416,000 deaths annually in the U.S. due to smoking, over 70% occurred in persons aged 65 and over, and over 94% to persons aged 50 and over.
Thus, while smoking rates among persons aged 65 and over are the lowest of all adult cohorts -- 12% among persons aged 65 and over as of 1994, versus approximately 27% for all adults aged 18 to 64 -- the disease, suffering and death caused by smoking overwhelmingly occurs among older persons, and this will continue well into the 21st century based on current smoking and mortality rates.
Over 53,000 Americans -- mainly middle-aged and older persons -- who never smoked die each year of tobacco-related diseases due to environmental tobacco smoke (ETS), largely of heart, lung and cancer diseases. Millions of other non-smoking older Americans suffer from ETS, particularly those with pre-existing heart or respiratory diseases. Recent studies have shown that some of the health benefits of quitting smoking are almost immediate for older, as well as younger, persons. Even for those people over 50, quitting smoking can avoid or delay illnesses that could drastically affect the length and quality of life.,,,,
These data clearly demonstrate the need for smoke-free policies in facilities frequented by older persons, and the need for tobacco education and smoking cessation programs targeted to the elderly. However, there have been few studies on the prevalence of smoke-free policies in facilities specifically serving the elderly, nor on the extent of tobacco education or smoking cessation programs implemented when smoke-free policies were adopted in facilities serving the elderly. ,,, This study provides a preliminary assessment of the nature and scope of smoke-free policies and related tobacco education and smoking cessation programs in non-institutional facilities serving older persons.
Survey data was collected from the three major non-institutional types of facilities serving Michigan's elders: Area Agencies on Aging (AAAs), Michigan Councils and Commissions on Aging (MCCAs) and Senior Centers. All three types of facilities are also worksites for staff serving elders. AAAs are public or private non-profit agencies which are focal points for elder rights advocacy, provide information and casework services for elders, and fund other local aging services programs in their geographic area. MCCAs and Senior Centers are the primary community facilities providing meals, social and recreational programs for the elderly. MCCAs are public agencies of county governments, whereas Senior Centers are local public or private facilities which provide social and recreational activities and also serve as nutrition sites, generally serving one meal a day to their clientele. For the purposes of this survey, stand-alone nutrition sites, stand-alone Senior Centers, and combined nutrition sites and Senior Centers are all categorized as Senior Centers.
As there are only sixteen AAAs and 56 MCCAs in Michigan, all Michigan AAAs and MCCAs were included in the phone survey. In contrast, there are 459 Senior Centers in Michigan. The costs and time required to survey by phone all 459 Senior Centers would have been prohibitive; therefore, random sampling was used to obtain a representative group of 161 Michigan Senior Centers for this phone survey. A listing of the 459 Senior Centers in Michigan, arranged by zip-code, was obtained from the Michigan Senior Resource Directory, 1995. Every third Senior Center from this listing was included in the survey; the starting point was randomly selected.
Interviewers telephoned sixteen AAAs, 52 MCCAs and 161 Senior Centers and requested to speak with the director or manager of the organization; if this person was unavailable, interviewers called again at a different time. In all, six AAAs, fifteen MCCAs, and 27 Senior Centers were called back at least once. Respondents were limited to directors and managers as they were assumed to have the most knowledge of smoke-free policies implemented in their organizations.
Data in this survey was collected through an 8-12 question phone survey conducted by staff from The Center for Social Gerontology during the first three weeks of February, 1997 . On average, the phone survey lasted 2-3 minutes. Respondents were informed that this was a survey regarding smoke-free policies in organizations serving the elderly in Michigan and that their individual responses would remain confidential.
The questions in the phone survey were based on those in a mail-survey on smoking policies included in the Summer, 1996 issue of Tobacco & the Elderly Notes, which was sent to all 459 Senior Centers in Michigan and all 56 MCCAs. The questions were adapted only to facilitate the survey being conducted by phone; efforts were made to ensure that differences in wording were minor and did not affect the meaning or interpretation of the questions.
Respondents were first asked if their facility had an indoor smoke-free policy; those that answered in the affirmative (n=139) continued with the survey reported in this article. Those respondents who indicated that their organization did not have an indoor smoke-free policy (n=2) were asked a different set of questions; discussion of this survey is beyond the scope of this article.
In addition to discussing the extent of their facility's indoor smoke-free policy, respondents were asked to identify the impetus for their smoke-free policy as well as indicate whether they provided education on the effects of tobacco or arranged for a smoking cessation program. Respondents were asked to discuss any opposition they faced when implementing the smoke-free policy and to assess the consequences of the policy on elders' utilization of the facility.
Of the 229 organizations selected for the phone survey, 34 had disconnected phone numbers. From the remaining 195 eligible organizations, a total of 141 responded to the survey -- twelve AAAs (75%), 31 MCCAs (72%) and 98 Senior Centers (72%). Of the remaining 54 organizations, interviewers were unable to reach them; there were no refusals to participate. Although this non-response affected the final sample size, there was no known opportunity for self-selection.
Twenty-seven organizations which had responded to the earlier mail-survey were among the 229 randomly selected for the phone survey. Follow-up calls were made to 21 of these organizations to clarify ambiguous or incomplete responses; the remaining six organizations had completed the mail-survey in full. As the mail-survey data was received in Fall, 1996, and the questions were identical to those in the phone survey, these respondents were not surveyed again. Differences between mail and phone survey respondents were insignificant (p > 0.05) for all questions except for two addressing changes in attendance as a result of the smoke-free policy (p < .032).
Of the 141 AAAs, MCCAs and Senior Centers who responded to the survey, 99% (95% CI 97 to 100%) had some form of indoor smoke-free policy. Further, of the 139 organizations with smoke-free policies, 85% (95% CI 79 to 91%) required that the facility be completely smoke-free. In only 5% (95% CI 2 to 9%) of the facilities with smoke-free policies was smoking permitted in areas which were not physically separated from smoke-free areas. (Table I) Tables are not available for preview here
There was no significant relationship between the type of facility and whether a smoke-free policy had been implemented (p > 0.05). Of the 141 facilities interviewed, only 2 of 98 Senior Centers lacked a smoke-free policy of some type, while all AAAs and MCCAs interviewed had some smoke-free policy.
IMPETUS FOR SMOKE-FREE POLICIES
Of the 139 respondents with some form of smoke-free policy, 45% (95% CI 37 to 54%) stated that their facility had an indoor smoke-free policy due to state, city or county law. Although responses varied by organizational type, the differences were not statistically significant (p > 0.05). Thirty-eight percent (95% CI 30 to 46%) of respondents that have smoke-free policies said their policy was implemented voluntarily, generally due to health concerns. The remaining 17% (95% CI 10 to 23%) of respondents stated they did not know why the smoke-free policy had been implemented or indicated "other" reasons for their smoke-free policy.
OPPOSITION TO SMOKE-FREE POLICIES
Of the 139 respondents with smoke-free policies, 62% (95% CI 54 to 70%) reported no opposition to the smoke-free policies. Of the 38% (95% CI 30 to 46%) of respondents who reported opposition to the smoke-free policies, an overwhelming majority of the respondents stated that the number of elders, staff or public who opposed the policy was insignificant, i.e., generally just one or two persons objected, and the objection had virtually no affect on these individuals' participation in the facilities' activities.
Among the 53 organizations that did report opposition, 80% (95% CI 68 to 90%) indicated that elders who used the facility were the source of opposition, while objections from staff were reported by respondents in 40% (95% CI 26 to 53%) of the facilities. (Note that some respondents reported opposition to the policies from both elders and staff.)
AFFECTS ON ATTENDANCE ATTRIBUTED TO SMOKE-FREE POLICIES
Respondents in 72% (95% CI 64 to 79%) of the facilities surveyed stated that no elders stopped using the facility as a result of the smoke-free policy. Twelve percent (95% CI 7 to 18%) stated that "a few" elders, meaning one or two persons, stopped using the facility. Only 1% (95% CI 0 to 3%) reported "some" elders (3 or 4) stopped using the facilities; and just one facility reported "a lot" of elders (more than 5) stopped attending.
Six percent (95% CI 2 to 10%) of the respondents said that "a lot" of elders started attending; 7% (95% CI 3 to 12%) stated that "some" new elders began participating due to the smoke-free policies. In addition, 12% (95% CI 6 to 17%) reported that the smoke-free policies resulted in "a few" new elders attending facility activities. Fifty-six percent (95% CI 48 to 64%) of respondents reported no changes in attendance due to the smoke-free policies; and about 14% (95% CI 8 to 19%) were not certain of the effects.
EDUCATION ON EFFECTS OF TOBACCO
Although an overwhelming number of facilities for the elderly have implemented smoke-free policies, only 42% (95% CI 34 to 50%) of the organizations indicated that they provided some type of education on the effects of tobacco and smoking. (See Table II). Differences in the provision of tobacco education among the three types of elderly facilities surveyed was significant (c2 = 6.685, df = 2, p = 0.0354).
Tables are not available for preview here
SMOKING CESSATION PROGRAMS
Just 11% (95% CI 6 to 16%) of the elderly facilities with smoke-free policies provided or arranged for smoking cessation programs for their staff or elderly clientele. Although differences between organizations were not significant (p > 0.05), none of the twelve AAAs surveyed had arranged a smoking cessation program for their employees.
This study of smoking and the elderly sought to obtain preliminary data, and as such, relied upon self-reported perceptions of the respondents, not upon data such as program or attendance records or actual copies of smoke-free policies. The survey also did not address the issues of enforcement; it is possible that, although smoke-free policies are in place, staff and elders do not comply with the regulations. Similarly, the survey sought to determine the extent of smoking cessation programs; it did not seek to determine successful cessation rates for staff and elders participating in the programs. The study obtained information only from facilities in Michigan; surveying another state(s) for control group purposes was beyond the scope of this study.
This study recognized that the Michigan Clean Indoor Air Act and local clean indoor air laws set the state apart from some others in terms of smoke-free policies. The study, therefore, sought to make a threshold assessment of the impact of these laws on the adoption of smoke-free policies in elderly facilities, albeit without conducting a study of smoke-free policies before and after the adoption of the statewide law in 1986 and subsequent local laws. The statewide law prohibits smoking in certain facilities -- including facilities owned by state or local governments and various health care facilities -- except in designated areas. The designated areas for smoking in these facilities may be adjacent to non-smoking areas and are not required to be separately enclosed and ventilated. Thus, the state law does not require completely smoke-free facilities, except in certain areas of health care or child care facilities.
Many cities/towns and counties in Michigan have enacted their own clean indoor air laws covering county or municipal buildings and other public places. Some of these local laws require completely smoke-free buildings, and a number of the Senior Centers and MCCAs in the state are located in such buildings. Therefore, some of the facilities surveyed were covered by both local and state clean indoor air laws. However, since Michigan's clean indoor air laws do not cover most private sector worksites and office buildings -- where many AAAs and some Senior Centers are located -- facilities for the elderly located therein are not required by law to be smoke-free.
Within these parameters, one of the key findings of this study is that most of the surveyed non-institutional facilities serving the elderly in Michigan had some type of smoke-free policies (over 98%), and 84% had policies which prohibited all smoking in the facility.
The Michigan Clean Indoor Air Act and local clean indoor air laws appear to have been a significant impetus for this high percentage of smoke-free policies, with 45% of the respondents citing these laws as the basis for their policies. Another 38% of respondents stated that their smoke-free policies were voluntarily adopted due to health concerns; responses to open-ended survey questions indicated that these voluntarily enacted policies were in reaction to the health risks posed by smoking and environmental tobacco smoke (ETS), including fire hazards. While the survey did not seek to determine any correlation between the existence of the clean indoor air laws and the voluntary adoption of smoke-free policies by facilities which were not covered by these laws, such a side-effect is plausible.
Additional research is needed in other states to determine the prevalence of and impetus for the adoption of smoke-free policies by non-institutional elderly facilities, particularly in states which lack clean indoor air laws or which have a tradition of opposing smoke-free policies.
A finding of especial interest to elderly service providers is that smoke-free policies engendered minimal opposition by elders or staff and had a positive effect on attendance by elders at activities in these facilities. Both the data and anecdotal comments indicated that the increased participation due to the smoke-free policies more than offset any loss of attendance. These findings suggest that smoke-free policies are good health policy and also good outreach strategy.
A somewhat disturbing finding was the low level of preventive health education on the dangers of tobacco use and ETS. Just forty percent of the facilities surveyed stated that they provided some type of education on the effects of tobacco and/or ETS, and half of these utilized handout materials and/or pamphlets or brochures, which are the most passive form of health education. Less than a third of the facilities that provided education on the risks of tobacco utilized speakers or more interactive methods. Reflecting the data findings, several respondents said "there is no need for education on the effects of tobacco since, by the time you are an elder, you already know that it is bad for you."
An even more disturbing finding was the low level of availability of smoking cessation programs in the facilities surveyed. Only 11% reported that they provided or arranged for smoking cessation programs for either elders or staff using their facility. Few respondents addressed the issue of providing smoking cessation programs for staff, suggesting that such worksite cessation programs were rarely considered.
Several respondents from all three types of the surveyed facilities stated that "there is no need for smoking cessation programs for the elders since there are not that many left smoking, just a few 'die-hards' who are already 90 years old and will never quit." Most respondents claimed that older smokers were not interested in cessation programs. However, this view is contradicted by a 1994 Cancer Supplement paper stating: "Results from the Clear Horizons trial show that older smokers are interested in quitting and will respond positively to a program tailored to their needs." And, a recent JAMA article emphasized that: "Age was also a significant independent predictor of success -- older persons were more likely than younger persons to quit successfully." Recent research suggests that implementation of smoke-free policies in worksites can itself be an event which triggers smokers to try to quit, and therefore is an excellent time for facilities to arrange for smoking cessation programs., Thus, elderly facilities implementing smoke-free policies are currently missing a significant opportunity to offer smoking cessation programs for both elders and staff.
As former Secretary of Health, Education and Welfare Joseph Califano has pointed out, the current crisis in the funding of the Medicare program could have largely been avoided if substance abuse prevention programs, particularly on the dangers of tobacco, had been implemented. Ignoring the elderly population in these efforts ignores the realities that the fastest growing segment of American society is the 65+ population, and that tobacco prevention efforts can succeed with older persons as much as with younger persons.
Footnotes: US Department of Health and Human Services. SAMMEC 3.0 Smoking-Attributable Mortality, Morbidity, and Economic Costs. Rockville, Maryland: Centers for Disease Control and Prevention, Office on Smoking and Health, 1996.
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US Department of Health and Human Services. Long-Term Psychological and Behavioral Consequences and Correlates of Smoking Cessation. In. US Department of Health and Human Services. The Health Benefits of Smoking Cessation, 1990. Rockville, Maryland: Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990:13.(DHHS Publication No.(CDC)90-8416).
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US Department of Health and Human Services. The Health Benefits of Smoking Cessation, 1990. Rockville, Maryland: Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990.(DHHS Publication No.(CDC)90-8416).
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 The Center for Social Gerontology (TCSG) publishes a quarterly newsletter Tobacco & the Elderly Notes which is distributed to over 1300 Senior Centers, AAAs, MCCAs, health care facilities, other organizations serving the elderly and tobacco control organizations in Michigan and throughout the U.S. A written survey on smoke-free policies and programs was sent with the Summer, 1996 issue to assess what types of smoke-free policies and related tobacco education and smoking cessation programs existed in facilities serving the elderly in Michigan. From the 1000 surveys initially mailed, TCSG received 99 responses. The data from this mail survey largely concurred with the data discussed in this article; 95% (94) indicated that they had an indoor smoke-free policy; of those with smoke-free policies, 84 % (79) did not permit smoking in any area of their facilities.
 Respondents were asked to distinguish whether state/federal law or city/town/county law required the smoke-free policy. 22 of the 139 respondents (15.8%) indicated the policy was implemented to be in compliance with a state law; 40 (28.8%) indicated the policy was in compliance with a city, town or county law; 1 (0.7%) indicated that the smoke-free policy was due to both state and city laws. However, since the respondents in a number of cases seemed unclear whether the smoke-free policy was due to state or local law, for purposes of this analysis, we have grouped together those respondents who indicated the impetus as a federal, state, county or city/town law.
 Mich. Comp. Laws Ann. ¤¤ 333.12601-.12617 (West 1992) enacted in 1986 and amended subsequently.
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 Hudzinski LG, Sirois PA. Changes in Smoking Behavior and Body Weight After Implementation of a No-Smoking Policy in the Workplace. Southern Medical Journal 1994;87:322-7.
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