ATTITUDES TOWARDS A SMOKING BAN IN RESTAURANTS OF MANAGERS, EMPLOYEES AND CUSTOMERS IN KUNMING CITY, CHINA
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SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH
ATTITUDES TOWARDS A SMOKING BAN IN
RESTAURANTS OF MANAGERS, EMPLOYEES AND
CUSTOMERS IN KUNMING CITY, CHINA
Li Jiang1, Hutcha Sriplung2, Virasakdi Chongsuvivatwong2, Tao Li3 and Yize Xiao1
1
Yunnan Provincial Centers for Disease Control and Prevention, China;
2
Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Thailand;
3
Health Inspection Bureau of Xishan District, Kunming, China
Abstract. The objective of this study was to investigate the attitudes of restaurant
managers, employees and customers towards a total smoking ban policy in restau-
rants. A restaurant based survey in an urban area of Kunming City, China, was
carried out from May to August 2009. One hundred managers, 1,055 employees and
5,213 customers aged 15 years or above were interviewed using a structured ques-
tionnaire. The percentage of respondents supporting a total smoking ban in restau-
rants was 17% among managers, 13.4% among employees, and 16.6% among cus-
tomers. Multilevel analysis confirmed respondents who did not smoke, who were
educated, and who worked or dined at a restaurant with fewer than 200 seats were
more likely to support a total smoking ban. A total smoking ban in restaurants is
unlikely to be supported by people involved in the restaurant business in the study
area. This coincides with poor awareness of the harms of smoking.
Key words: smoking ban, restaurant, attitude, China
INTRODUCTION use (31.4%)(Yang et al, 2005), China does
not have a comprehensive smoke free law
Smoking in China has been estimated at the national level. National regulations
to cause about one million deaths a year for sanitary administration of public places
(Liu et al, 1998; Peto et al, 2009) and a huge stipulate smoking is banned in thirteen
economic burden (Sung et al, 2006). The types of public places. Restaurants, a pub-
Chinese government is aware of the nega- lic place where both workers and custom-
tive impact of smoking, and recently ers are most exposed to second hand
adopted a partial smoking ban and rati- smoke [National Cancer Institute (US),
fied the World Health Organization’s 1993], are not included in the regulation.
Framework Convention on Tobacco Con-
Studies in the USA and Australia on
trol (FCTC) (WHO, 2008).
the implementation of legislative bans on
Amidst the high prevalence of tobacco smoking in restaurants have found the
Correspondence: Li Jiang, Yunnan Provincial bans were accepted to the public (Miller
Centers for Disease Control and Prevention, et al, 2002; Gilpin et al, 2004), without any
158 Dongsi Street, Kunming, Yunnan 650022, loss of sales (Scollo et al, 2003). A smoke-
PR China. free policy in restaurants drastically im-
Tel: 86 871 3632033; Fax: 86 871 3632033 proves air quality, reduces exposure to sec-
E-mail: gzynjl@hotmail.com ond hand smoke (Fernando et al, 2007) and
1258 Vol 41 No. 5 September 2010SMOKING BAN IN RESTAURANTS OF CHINA
improves the health of workers (Allwright lation consisted of the managers and the
et al, 2005). A smoke-free policy for restau- employees who were currently working in
rants may help improve social norms re- those restaurants, and their customers,
garding the unacceptability of tobacco use, aged 15 and above.
and reduce the prevalence of tobacco use Interview method
among the general people (Alamar and
Data on demographic characteristics,
Glantz, 2006).
personal smoking status, personal percep-
The above findings in a context of low tions about the effects of smoking in res-
smoking prevalence may not be general- taurants, and preference about proposed
ized to China where the smoking preva- tobacco control policies, were collected by
lence is high. Studies are needed to assist face-to-face interviews with managers and
policy makers before any new policies can employees, and by self-completion of
be implemented. The objective of the cur- forms by customers.
rent study was to assess attitudes toward The demographic factors recorded for
a smoking ban among managers, employ- all subjects were gender, age, education,
ees and customers in urban restaurants of and length of time worked in the restau-
Kunming City, China. rant for employees, and frequency of res-
taurant visits per week for customers.
MATERIALS AND METHODS For current smoking status, the re-
spondents was classified into daily smok-
Study setting ers, non-daily smokers and non-smokers.
Yunnan is one of the poorest provinces The respondents were requested to choose
in southwestern China. More than 1/3 of the smoking ban policy they approve of:
tobacco leaves in China are produced there no ban (smoking is allowed anywhere),
annually. All production of tobacco is un- partial ban (designate a no smoking area)
der government monopoly. Around seven and total ban (smoking is not allowed any-
million Yunnanese are directly involved in where). For analysis, this was divided as
this industry. support for a total ban or less than a total
Kuming is the capital of Yunnan Prov- ban.
ince, well known for its mild temperate Perceptions regarding the effects of
climate and relatively low level of air pol- smoking in restaurants were measured on
lution from industries. In 2008 the reported a 5-point scale: “strongly agree”, “agree”,
smoking rate was nearly 30% among city “neutral”, “disagree” and “strongly dis-
residents, similar to the national adult av- agree”. To improve paticipation the num-
erage of 31.4%. Xishan District, where this ber of items in this part were kept to a
study was conducted, is one of four cen- minimum. Data regarding restaurant char-
tral districts of Kunming City. There are acteristics were obtained from the manag-
approximately 4,080 restaurants registered ers’ questionnaire. Variables included res-
and regularly inspected by the district taurant size (number of seats), average
health bureau. spending per customer, tobacco selling
Restaurants and respondents selection and availability of private compartments.
Of the 246 restaurants scheduled for Statistic analysis
inspection during May to August 2009, 104 Descriptive statistics were used. Cross
were randomly selected. The study popu- tabulation was made between respondent
Vol 41 No. 5 September 2010 1259SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH
characteristics and support for a total all three groups were interviewed. Of the
smoking ban. Significance of associations 1,055 approached employees, the response
was initially assessed with the χ2 test. rate was 100%. The response rate of the
As gender, smoking status and edu- customers could not be assessed. The to-
cation were potentially confounding, lo- tal number of customers who responded
gistic regression was applied to identify was 5,213.
independent predictors for support of to- Characteristics of restaurants and respon-
tal smoking ban. Since groups of employ- dents
ees and customers working or eating in the The size of the 100 investigated res-
same restaurant environment might tend taurants ranged from 50 to 1,000 seats with
to give similar responses to the question- a median of 200 seats. The average spend-
naire, a multilevel mixed effects logistic ing per customer was from 10 to 300 Chi-
regression model was used. In this mod- nese Yuan (CNY) with a median of 30 CNY.
elling process, independent variables have Forty restaurants sold tobacco, and 82 res-
fixed effects for all subjects, whereas sub- taurants had private compartments.
jects from the same restaurant shared res-
Table 1 summarizes the characteristics
taurant specific variables. For example,
of the respondents. Most respondents
employees of the same restaurant share the
were young adults. While the managers
same base line odds of preferring smok-
were balanced in gender, females pre-
ing ban. The same assumption was also
dominated among employees and males
applied to the customer group. All inde-
among customers. A higher smoking rate
pendent variables were first included in
was seen among the men in all three
the model with subsequent backward
groups.
elimination. Those having a p-value >0.05
were removed one-by-one by descending Individual characteristics and a total
order of their p-values until the models smoking ban policy
consisted of only a significant covariate. Table 2 shows the relationship be-
As we had a only few items on perception, tween characteristics of the respondents
and they were also outcome variables, and support for a total smoking ban.
these variables were not included in the Among managers, smoking status was the
models. only significant factor. This factor was also
Epidata (Lauritsen and Bruus, 2003- consistently significant in the other two
2004) was used for data entry, and R soft- groups. University graduates had a high
ware (R Development Core Team, 2009) rate of supporting a total smoking ban
was used for all statistical analysis. The among employees and customers. The
package lme4 (Douglas and Martin, 2009) same was true among customers. Females
was used for mixed effects models. had more support for a smoking ban than
males. Those who visited the restaurant
less than twice per week were also more
RESULTS
supportive of a total smoking ban.
Among the 104 restaurants selected Table 3 shows the result of fitting the
for the study, 4 refused to participate. Of logistic regression model to the data. For
the remaining 100 restaurants, data were employees and customers, random effects
collected only from the managers in 11 res- (intercepts) were also added. Since the in-
taurants. In the remaining 89 restaurants teractions among the covariates were not
1260 Vol 41 No. 5 September 2010SMOKING BAN IN RESTAURANTS OF CHINA
Table 1
Characteristics of restaurants and subjects.
Variable Manager Employee Customer
(100) (1,055) (5,213)
Age
Min-max (Median) 19-65 (29) 16-53 (20) 15-78 (29)
Sex
Male (%) 50 (50) 330 (31.3) 3,134 (60.1)
Female (%) 50 (50) 725 (68.7) 2,079 (39.9)
Education
Secondary or lower (%) 30 (30) 714 (67.7) 951 (18.2)
High school (%) 53 (53) 280 (26.5) 2,196 (42.1)
University (%) 17 (17) 55 (5.2) 2,029 (38.9)
Smoking status
Daily smoker (%) 19 (19) 112 (10.6) 1,399 (26.8)
Non-daily smoker (%) 17 (17) 193 (18.3) 1,392 (26.7)
Non-smoker (%) 64 (64) 750 (71.1) 2,422 (46.5)
Length of time employed in restaurant (years)
Min-max (median) -SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH
Table 2
Individual characteristics in relation to a total smoking ban policy.
Variable Manager Employee Customer
Support/total χ2 Support/total χ2 Support/total χ2
(%) test p (%) test p (%) test p
All subjects 17/100(17) 141/1,055(13.4) 865/5,213(16.6)
Sex 0.29 0.02SMOKING BAN IN RESTAURANTS OF CHINA
Table 3
Predictors for support of a total smoking ban policy in restaurants.
Variable Manager Employee Customer
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Individual level variables
Sex
Male 1
Female NS NS 0.56(0.45-0.69)
AgeSOUTHEAST ASIAN J TROP MED PUBLIC HEALTH
Mean (SD)
The sex effect in this study is interest-
5,212 2.81 (1.22)
5,212 2.40 (1.13)
5,213 2.44 (1.17)
ing. Other strong predictors, such as smok-
Customer
-
-
-
ing status and education, confounded the
effect of sex. Crude cross tabulation made
N it appear that females were likely to sup-
-
-
-
port a smoking ban because of the con-
founding effects of these two variables.
Mean (SD)
After adjustment, the independent effect
2.87 (1.03)
2.22 (1.06)
2.53 (1.18)
2.27 (1.11)
- of females was not supportive of a ban. In
-
Employee
western countries (Borland et al, 2006) and
Hong Kong (Lam et al, 2002) research
showed a non-significant effect of female
1,053
1,051
1,049
1,055
sex on support for a total smoking ban. In
N
-
-
Perceptions regarding effect of smoking in a restaurant.
these areas, the prevalence of tobacco use
was relatively low, and smoking is unac-
Mean (SD)
2.55 (0.88)
1.76 (0.90)
1.88 (0.96)
2.40 (1.41)
1.80 (0.93)
1.82 (1.02)
5 = strong disagree
ceptable behavior in the society. In China,
smoking is a usual behavior, and is ac-
Manager
cepted. A recent study from China (Ho
et al, 2009) showed ever-smoking rate
among young Chinese women has in-
100
100
100
100
100
100
N
creased in the last decade, and respon-
A customer smoking in a restaurant affects the health of other customers
dents are less aware of the harm caused
Table 4
A customer smoking in a restaurant affects the health of the employees
4 = disagree
by smoking. In our study, most of the sub-
Totally banning smoking may reduce the income of the restaurant
jects were young. The negative impact
among females reflects inadequate tobacco
Smoking in a restaurant is the personal right of the customer
control interventions.
We found restaurant characteristics
3 = neutral
had an effect on the subjects’ support. Din-
ers who eat at small restaurants prefered
a total ban. This may be linked with poor
air quality in enclosed public places where
2 = agree
unacceptably high levels of nicotine have
been found (Valente et al, 2007). People
Smoking makes a restaurant unclean
Smoking makes a restaurant unsafe
who have experiences of discomfort or
dissatisfaction from exposure to passive
Rating score: 1 = strongly agree
smoking in restaurants are more likely to
support a total smoke-free policy (Lam et
al, 2002). Some studies have found sepa-
rating smokers from non-smokers within
the same air space does not eliminate ex-
posure to second-hand smoke. The only
effective protection strategy is a 100% in-
door smoke-free policy.
Item
As expected, smoking status was
among the strongest predictors for support
1264 Vol 41 No. 5 September 2010SMOKING BAN IN RESTAURANTS OF CHINA
of a total smoking ban. Non-smokers were trict, Kunming, China.
more likely to favor a total ban. The pub-
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