ORIGINAL ARTICLE
Clothing Flammability and Burn Injuries: Public Opinion Concerning an Overlooked, Preventable Public Health Problem Shannon Frattaroli, PhD, MPH,* Steven M. Spivak, PhD, FTI, FSFPE,† Keshia M. Pollack, PhD, MPH,* Andrea C. Gielen, ScD, ScM,* Michele Salomon, JD,‡ Gordon H. Damant, BSc§
The objective of this study was to describe knowledge of clothing flammability risk, public support for clothing flammability warning labels, and stronger regulation to reduce the risk. As part of a national survey of homeowners about residential sprinkler systems, the authors included questions about clothing flammability. The authors used an online web panel to sample homeowners and descriptive methods to analyze the resulting data. The sample included 2333 homeowners. Knowledge of clothing flammability and government oversight of clothing flammability risk was low. Homeowners were evenly split about the effectiveness of current standards; however, when presented with clothing-related burn injury and death data, a majority (53%) supported stricter standards. Most homeowners (64%) supported warning labels and indicated that such labels would either have no effect on their purchasing decisions (64%) or be an incentive (24%) to purchase an item. Owners of sprinkler-equipped homes were more likely to support these interventions than owners of homes without sprinkler systems. Public knowledge about clothing flammability risks is low. Most homeowners supported clothing labels to inform consumers of this risk and increased government intervention to reduce the risk. (J Burn Care Res 2016;37:e196–e204)
Fire and burn-related injuries are a leading cause of morbidity and mortality worldwide, and result from a variety of mechanisms involving heat and chemical energy transfers. In the United States, house fires are the leading cause of fire-related death,1 and systematic efforts to address residential fire risks have been underway for decades. Burns that occur when clothing catches fire From the *The Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, Baltimore, Maryland; †Department of Fire Protection Engineering, University of Maryland, College Park; ‡Harris Interactive, Inc., New York, New York; and §Damant and Associates, Sacramento, California. This work was supported by the Fire Prevention and Safety grant program of the Federal Emergency Management Agency (Grant EMW-2010-FP-00471). Address correspondence to Shannon Frattaroli, PhD, MPH, The Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, 624 North Broadway #545, Baltimore, Maryland 21205. E-mail: [email protected] Reprint address: Shannon Frattaroli, PhD, MPH, The Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, 624 North Broadway #545, Baltimore, Maryland 21205. E-mail: [email protected] Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000213
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are also a significant source of fire- and burn-related injuries, resulting in 102 deaths2 and about 4500 injuries treated in emergency rooms in the United States in 2009.3,4 However, unlike improvements to the building code and efforts to increase the prevalence of smoke alarms, clothing-related fire risks have received relatively little investment in prevention.5,6 One effort to address clothing-related burn risks occurred in 1971 with the flammability standard for children’s sleepwear, which requires that fabrics used to make sleepwear sizes 0 to 6× “self extinguish after exposure to a small open flame.”7 This requirement can be accomplished through fabric choice (different fabrics burn differently, and some are more resistant to ignition than others)8 or through the addition of fire retardant treatments. In 1974, a second standard expanded the original sleepwear rule to include sizes 7 to 14, but the Consumer Product Safety Commission (CPSC) relaxed that standard in 1996 by exempting infant sleepwear (up to 9 months) and snug-fitting pajamas.9 Proponents of the amendments argued that before 9 months infants are not mobile and therefore are at lower risk of coming into contact with a heat source. They also reasoned that
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tight fitting sleepwear presented a lower flammability risk than the loose fitting cotton garments (such as t-shirts) that consumers were reportedly favoring over regulated sleepwear, perhaps to avoid clothing treated with flame retardants.10 Garments that fit close to the body are less likely to come into contact with a heat source than clothing that is loose and flowing, and tight fitting clothing prevents ignition-related gases from accumulating between the fabric and skin which can further elevate burn risk.8 The amendments require exempt sleepwear to display hangtags indicating a snug-fit is safer and warning that the fabric is not flame resistant, and specifies marketing practices for those who sell children’s sleepwear.9 Despite the 1996 exemptions, and early evidence that the marketing regulations were not being implemented,11 the incidence of children treated in emergency rooms for sleepwear-related burns remains relatively low.4,10 CPSC regulates clothing flammability based on authority granted under the Federal Flammability Act of 1953.12 The Act is the foundation for regulatory authority concerning the flammability of all clothing manufactured and/or sold in the United States. While this authority exists and has been applied successfully to children’s sleepwear, greater attention to clothing-related burn risks is needed. During the 10 years from 2000 to 2009, 1,131 people died2 and more than 43,000 sought treatment in emergency rooms when their clothing caught fire.3,4 Most (75%) of the people who died were 65 years and older, even though this group comprised only 14% of the population.2 By contrast, non-fatal clothing burns disproportionately affect children, teens, and young adults ages 5 to 24 who comprise only 28% of the population but constitute 42% of people with clothing burn injuries treated in emergency rooms.4 Clothing that burns quickly when exposed to a flame is often implicated,13 and the type of clothing involved differs across age groups. “Nightwear” was worn by an estimated 3% of children under 5 years treated in emergency rooms for clothing-related burns, but was involved in 27% of those injuries to people 65 years and older. Eighty-two percentage of nightwear burn-related deaths occurred among those 65 years and older.4 Both biological and environmental risk factors associated with these injuries are documented in the literature where older burn victims are described as “sicker” patients who are admitted with more extensive burns than their younger counterparts.14 Differences in severity are explained by “slower reaction times, reduced mobility, impaired smell, vision, or hearing”14 that may result from “prior stroke, dementia, alcohol, and
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prescription drug use,”15 and are exacerbated by clothing characteristics. While individual circumstances of these burns vary, a common scenario involves an older woman cooking in a loose fitting, full cover robe designed to be donned or removed over the head. In wearing apparel made mostly of flammable fabric, once that garment catches fire, prompt removal is difficult or impossible without the wearer sustaining serious burn injury. The risk associated with cooking-related clothing fires has been documented15–18 and has prompted clothing product recalls.19 With the continued death and disability because of clothing-related burns, there are questions about whether the current federal standards are sufficient, and discussion of more rigorous standards and better use of clothing labels is occurring among some clothing flammability specialists.4,5 The appropriate roles for government and manufacturers in protecting the public from clothing-related burns is an important public health matter, and one that should be informed by evidence. One source of data for such a discussion is the public. Public knowledge of clothing flammability risks, perceptions of current government regulation of those risks, and support for additional protections by the government and/or industry are all important considerations in assessing different intervention options for the continuing problem of clothing-related burns. Such insight from the public, however, is limited. In the 1980s, two surveys assessed knowledge of flammability risk among Rhode Island residents (Helms P, unpublished manuscript, 1990) and residents in a western Canadian province.20 While the two surveys explored different aspects of the flammability issue (clothing [Helms P, unpublished manuscript, 1990] and clothing as part of a broader examination of home textiles),20 both sets of respondents reported general awareness of government standards, although in Rhode Island the knowledge tended to be specific to children’s sleepwear (Helms P, unpublished manuscript, 1990). The Rhode Island results also highlighted respondents’ lack of knowledge about the relative flammability of different fabrics and the injury risks associated with clothing fires (Helms P, unpublished manuscript, 1990). Both articles concluded that efforts to inform consumers of clothing flammability and burn risks were needed and cited labeling as one strategy with strong public support. Brown and Crown,20 coauthors of the Canadian study, further emphasized the need for stricter government standards to reduce flammability risks in part because their respondents conveyed a belief that the Canadian government was providing more oversight than was
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the case. This confidence, from the authors’ perspective, translated into a lower perception of risk than the current policies warranted.20 Given the burden of clothing-related burn injuries and the lack of data regarding public awareness about current flammability standards and public support for interventions to reduce this risk, we included questions about clothing flammability as part of a national survey about residential sprinkler systems. We fielded the survey among U.S. homeowners living in one- and two-family homes with and without residential sprinklers. By exploring clothing flammability knowledge and support for fire prevention interventions with these two populations, we were able to assess whether those living in sprinklerequipped homes view clothing flammability risk and interventions differently from those in homes without residential sprinkler systems. We hypothesized that those living in sprinkler-equipped homes would be more aware of current flammability standards and more supportive of interventions to reduce clothing flammability risk because their decision to live in a sprinkler-equipped home may reflect a higher level of attention to safety. Here, we report the findings and discuss the implications for policy and practice.
Instrument Development Our survey included six clothing flammability questions. The process of developing these survey questions began with a review of the literature. The two surveys previously described20 (Helms P, unpublished manuscript, 1990) provided limited guidance since they included questions that were more detailed than was needed to accomplish our study aims and was feasible given resource constraints. As a result, our questions were driven primarily by our study aims and the expertise of our co-authors (S.S. and G.D.) who have decades of experience in the field of materials and fire science. We assessed public awareness by self-reported knowledge of federal standards and a response to a question about fabric flammability. Opinions about new potential interventions to reduce risk were measured through questions about support for stricter federal standards and clothing flammability labels. We assessed satisfaction with current standards and then provided a statement about clothing-related burn injuries before asking about support for stricter standards. We pilot tested the survey with fire safety experts and members of the research team (including administrative staff with no content area expertise) and incorporated their feedback into the fielded version. Pilot testing the survey with these experts and lay people helped assess the questions’ face validity.
METHODS We conducted a cross-sectional survey of owners of one- and two-family homes in the United States. The primary aims of the survey were to assess homeowners’ experiences with and attitudes about residential sprinkler systems as well as other strategies for preventing fire- and burn-related injuries. Because of our interest in residential sprinkler systems, we sought to obtain a nationally representative sample of homeowners living in sprinkler-equipped one- and two-family homes (an estimated 2% of one- and twofamily homes in the United States). For comparison purposes, we sampled a second group of homeowners without sprinkler systems. Since the prevalence of sprinkler systems in one- and two-family homes is low, we sought a mechanism that would provide us access to a large, diverse sample. Harris Interactive maintains the Harris Poll Online, an extensive worldwide panel of respondents who enroll to participate in survey research. The web panel provides an efficient means of accessing low prevalence populations that cannot be readily identified and has been used to field surveys on several public health topics to date.21–23
Data Collection Screening questions identified people living in the United States who were 18 years and older in a oneor two-family home they owned. An additional question determined whether the respondent owned a sprinkler-equipped home. Based on these screening questions, a set of members who owned sprinklerequipped homes and a second set who owned homes without residential sprinkler systems were invited to participate in the full survey for sprinkler-equipped homeowners and an abbreviated survey for those living in homes without sprinklers. The clothing flammability questions on the two versions of the survey were identical. Data collection took place from August 16 to September 24, 2012. During this time, approximately 385,000 members received an invitation to respond to the survey. Those who did not respond received one follow-up invitation. We oversampled Blacks or African-Americans, and Hispanics in order to assure sufficient participation from these groups to allow for comparisons by race and ethnicity. Oversamples can compensate for possible lower response rates and, in the case of this study allowed for each race
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and ethnic group to be demographically representative of the population. The three racial and ethnic groups (White, Black or African-American, and Hispanic) were weighted separately and then postweighted into a representative total. To access the survey, invited panel members logged onto the Harris site using their user identification and password. This system assures that only invited members have access to the survey and prevents any one person completing the survey more than once. Homeowners recorded their answers online, using a computer of their choosing and at a time and location convenient for them. Members who completed the survey received points in the Harris loyalty program that can be redeemed for products and services. On average, homeowners completed the survey in 14 minutes.
Data Analysis The data were weighted to be representative of the U.S. population of homeowners 18 years and older. Each category of the sample (general population, Black or African-American oversample, Hispanic oversample) was weighted using the 2011 Current Population Survey by the following key demographic variables: household income, education, age, gender, and region of residence. The general population category was also weighted by race and ethnicity, in addition to the other demographic variables previously listed. Descriptive statistics of respondent characteristics are presented as weighted proportions. Bivariate comparisons of responses between homeowners with and without residential sprinkler systems were analyzed using t-tests of proportions and means with software designed for market research analysis.24 Data are presented for all homeowners, and separately for homeowners with and without residential sprinkler systems. Statistical significance was established at P < .05.
RESULTS The final sample for the online survey included 2,333 homeowners identified from among 46,901 homeowners who responded to the screening questions. The large number of people who were screened, but ineligible was driven by the low prevalence of residential sprinkler systems in one- and two-family homes. Homeowners in the two groups were significantly different: those in the sprinkler sample were younger (45 vs 54 median years), reported higher incomes (35% vs 26% with household incomes of $100,000 and higher), and were more educated
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(80% vs 67% earned a college or graduate degree). A detailed demographic table is available elsewhere (data available with the author).
Knowledge of Fabric Flammability and Current Standards Knowledge questions revealed low-levels of understanding about fabric flammability. For example, 15% of homeowners correctly identified that a cotton shirt is more likely to catch fire compared to a polyester shirt. Regarding familiarity with the federal standards governing clothing flammability, only 7% of all homeowners self-identified as “extremely familiar” (1%) or “very familiar” (6%) with current policy compared to 93% who responded they were “somewhat” (55%) or “not familiar at all” (38%). Homeowners living in sprinkler-equipped homes were significantly more likely to respond correctly to the question about fabric flammability (21% vs 14% of homeowners without sprinklers), and much more likely to self-report high levels of familiarity (extremely or very familiar) with the federal flammability standards (26% vs 6% of homeowners without sprinklers). Responses regarding familiarity with current federal standards resulted in a significantly higher mean score for owners of sprinkler-equipped homes (2.1 on a 4-point scale) compared to owners of homes without sprinklers (mean score = 1.7). The full text of these questions and responses are included in Table 1.
Support for Stricter Standards Overall, homeowners were evenly divided when asked if current safety standards are effective in preventing clothes from catching fire when exposed to a flame (34% agreed, 33% were neutral, and 34% disagreed). However, homeowners with sprinkler systems reported significantly higher agreement that federal standards provide effective protection compared to homeowners without sprinkler systems (mean score = 3.2 vs 2.9). While homeowners overall were evenly split in their views about the effectiveness of current standards, when provided information about the number of people who die and are treated in emergency rooms every year when their clothing catches fire, a majority of homeowners (53%) supported stricter federal standards compared to 31% who neither supported nor opposed, and 17% who opposed. Homeowners with sprinkler systems expressed significantly higher levels of support compared to homeowners without them (mean score = 3.7 vs 3.5; Table 2).
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Table 1. Knowledge about clothing flammability standards and fabric flammability Homeowners With RSS* N = 976
Homeowners Without RSS N = 1357
All Homeowners N = 2333
Question: “How familiar are you with the safety standards for clothing flammability?” Extremely familiar 9% 1% 1% Very familiar 17% 5% 6% Somewhat familiar 47% 55% 55% Not familiar at all 27% 39% 38% Mean score, with 1 = extremely familiar and 4 = not familiar 2.1 1.7 1.7 at all Question: “Is a shirt made from 100% cotton or a shirt made from 100% polyester more or less likely to catch fire if exposed to a flame?” The polyester shirt is more likely to catch fire 41% 44% 44% They are equally likely to catch fire 25% 30% 30% The cotton shirt is more likely to catch fire† 21% 14% 15% Not sure 13% 11% 11% RSS, Residential Sprinkler System. Statistical significance is reported at 95% confidence level. Bold font indicates percentages that are significantly higher; RSS homeowners are tested against nonRSS homeowners. Neither of those groups is tested against the total. † Correct response.
Table 2. Effectiveness of federal clothing flammability standards Homeowners With RSS* N = 976
Homeowners Without RSS N = 1357
All Homeowners N = 2333
Question: “Clothing available for sale in the United States is subject to safety standards that effectively prevent clothes from catching on fire when exposed to flames.” Agree 42% 33% 34% Strongly agree 13% 6% 6% Somewhat agree 29% 27% 27% Neither agree nor disagree 33% 33% 33% Disagree 25% 34% 34% Somewhat disagree 17% 24% 24% Strongly disagree 8% 10% 10% Mean score, with 1 = strongly disagree and 5 = strongly agree 3.2 2.9 3.0 Question: “Despite current safety standards, every year more than 4000 people in the United States are treated in emergency rooms for clothingrelated burns; more than 100 people die every year from these burns. Knowing this, would you oppose or support stricter clothing safety standards for clothing sold in the United States?” Support 59% 52% 53% Very much support 28% 18% 19% Somewhat support 31% 34% 34% Neither support nor oppose 27% 31% 31% Oppose 14% 17% 17% Somewhat oppose 9% 10% 10% Very much oppose 5% 7% 7% Mean score, with 1 = very much oppose and 5 = very much 3.7 3.5 3.5 support RSS, Residential Sprinkler System. Statistical significance is reported at 95% confidence level. Bold font indicates percentages that are significantly higher; RSS homeowners are tested against nonRSS homeowners. Neither of those groups is tested against the total.
Support for Clothing Labels Warning labels are one strategy for informing consumers about the flammability risk of clothing
available for sale. A majority of homeowners indicated they either very much supported (30%) or somewhat supported (34%) requiring clothing
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manufacturers to include labels explaining fire risk. Support among those living in sprinkler-equipped homes was significantly higher (mean score = 3.9 vs 3.8; Table 3). We further explored whether the presence of warning labels would influence homeowners’ clothing buying decisions. When asked about their purchasing preference for clothing with a warning label, they read as part of the question (text included in Table 3), most (64%) homeowners responded that such warnings would not affect their purchasing decisions. Almost one-quarter (24%) of all homeowners responded that they would be more likely to buy clothing with such a label, with owners of sprinkler-equipped homes expressing in significantly greater numbers than homeowners without sprinkler systems that they would be more likely buy clothing labeled with the sample warning text (mean score = 3.4 vs 3.1). A minority of homeowners (12%) indicated they
would be less likely to purchase clothing with the sample label language (Table 3).
DISCUSSION Thousands are injured every year in the United States when their clothing catches fire. Whether people are aware of clothing flammability risks is a question we sought to inform after realizing the dearth of literature on this topic. Findings from our survey reveal that U.S. homeowners are not well informed about clothing flammability risks or the government’s role in mitigating those risks. We explored homeowners’ support for two strategies to reduce this risk: including warning labels on clothing and strengthening federal flammability standards to reduce clothing flammability risk. The homeowners in our sample indicated support for both strategies. We discuss the implications of these findings for education and policy strategies to reduce this risk.
Table 3. Clothing flammability warning labels Homeowners With RSS* N = 976
Homeowners Without RSS* N = 1357
All Homeowners N = 2333
Question: “Do you support or oppose requirements for clothing manufacturers to include warning labels explaining flammability and burn risks of the clothing they produce?” Support 67% 64% 65% Very much support 36% 30% 30% Somewhat support 31% 34% 34% Neither support nor oppose 22% 23% 23% Oppose 10% 13% 12% Somewhat oppose 6% 7% 7% Very much oppose 4% 5% 5% Mean score, with 1 = very much oppose 3.9 3.8 3.8 and 5 = very much support Question: “Would you be more or less likely to buy clothing with a warning label with the following language explaining flammability and burn risk of clothing?” CAUTION: ALL CLOTHING CAN BURN. DO NOT EXPOSE TO FLAME OR INTENSE HEAT. All of our fabrics meet or exceed the requirements of the Flammable Fabrics Act. However, please avoid exposing fabrics and clothing to open flames or other sources of intense heat such a candles, stoves and ranges, fireplaces, wood stoves, matches, or lighters. This is especially important if you have used excess liquid fabric softener during laundering.† More likely to purchase 42% 23% 24% Much more likely 19% 7% 8% Somewhat more likely 23% 16% 16% Neither more nor less likely 42% 65% 64% Less likely to purchase 16% 12% 12% Somewhat less likely 8% 6% 6% Much less likely 7% 6% 6% Mean score, with 1 = much less likely and 3.4 3.1 3.1 5 = much more likely RSS, Residential Sprinkler System. Statistical significance is reported at 95% confidence level. Bold font indicates percentages that are significantly higher; RSS homeowners are tested against nonRSS homeowners. Neither of those groups is tested against the total. †Tested language is a composite of several warning labels used by manufacturers.
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Education Given the low level of knowledge about the relative flammability risk of cotton compared to polyester, efforts to raise awareness about this risk are worth pursuing. Manufacturer warning labels are one way to increase knowledge about this injury risk. Labeling is a strategy that manufacturers can adopt voluntarily and one with the potential to yield a competitive advantage with a segment of the buying public who indicated they would be more inclined to purchase clothing with a flammability warning label. Our data revealed that 74% of all homeowners either very much support or somewhat support requiring clothing manufacturers to include labels explaining fire risk. Furthermore, the disproportionate risk of death to older people associated with nightwear ignitions is both longstanding and documented in the literature.14–16 Assuring that policymakers and the public are aware of this disproportionate risk and the role of certain garments in explaining this increased risk can inform decisions about clothing regulations and which nightwear to buy.
Policy While warning labels could be implemented voluntarily and are used by some clothing manufacturers, we also note the potential for government to mandate such labels. Such a requirement could be based on fabric flammability risk, or high risk applications, and could specify how such products should be marketed in order to clearly distinguish between products subject to the higher standards and those which are exempt as was done with children’s sleepwear decades ago.7 Attention to the implementation and enforcement of such policies would be needed given past evidence that sellers are not always in compliance with the marketing requirements.11 National injury surveillance data have established that a large percentage of clothing-related burn victims who die are people 65 years and older dressed in nightwear.4 Additional documentation of the nightwear involved in these incidents (eg, fabrics used, designs) could inform a new labeling standard. Warning labels may yield some benefit, particularly in addressing the need to inform consumers of flammability risk. Government authority to “prohibit the introduction or movement in interstate commerce of articles of wearing apparel and fabrics which are so highly flammable as to be dangerous when worn by individuals” extends beyond requiring labels.12 Regulatory authority under the Flammable Fabrics Act includes the ability to set flammability performance
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standards for fabrics and apparel. This authority is particularly relevant given that the children’s sleepwear standards are associated with declines in nightwear burn deaths among children,10 and other standards promulgated under the Act are dated and do not reflect the state of the art in testing research,4 a shortcoming noted several decades ago.6 When asked about their knowledge of existing federal standards, the vast majority of homeowners reported a limited understanding. This lack of awareness may help explain the finding that onethird of the sample neither agreed nor disagreed about whether clothing safety standards are effective. This suggests that the public health, injury prevention, and fire prevention communities have not adequately communicated its successes in using regulatory strategies to protect the public, a finding that is consistent with an earlier national survey of effective alcohol-related policies to reduce alcohol-related motor vehicle deaths.25 Efforts to enhance the public’s understanding of effective policy interventions may ultimately increase their support for addressing a wide range of injury problems that could benefit from policy solutions. Although our survey did not specify the content of stricter standards, the low level (17% among all homeowners) of opposition to the general idea may bode well for future efforts in this area. One place to start is with the risk associated with nightwear among women 65 years and older. It is a common and foreseeable scenario for older women to cook in a robe, housecoat, or nightgown. As far back as the 1970s, this fire risk was reported to Congress.17,18 More recently, CPSC recalls of more than 160,000 cotton chenille robes demonstrate the continuing risk.19 While recalls can be effective in removing some dangerous products from commerce, preventing highly flammable fabrics from entering the marketplace is preferable. Importantly, this pre-market intervention strategy does not rely on consumer caution, correction for biological risks associated with age, or informed purchasing because under an improved regulatory system every clothing choice would be a safer choice. Passive protection has long been recognized within the field of injury prevention as a desirable (although sometimes elusive) intervention approach.
Homeowners and Residential Sprinkler Systems In general, owners of sprinkler-equipped homes were more likely to report being knowledgeable about flammability standards; demonstrate their knowledge
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of flammability risk; and support policy and labeling strategies to inform consumers about clothing burn risks, and improved standards to reduce those risks. They also reported being more likely to buy clothing with a flammability warning label than those in homes without sprinklers. Clustering of prevention behaviors has been noted in the literature across distinct health and injury behaviors26 as well as across prevention behaviors that relate to the same injury.27 This observation suggests that support for preventive interventions may be most readily obtained in populations already predisposed to health prevention behaviors. These behaviors may also be related to socioeconomic status, as measured here by income and education, as prevention behaviors often require an investment in time and/or resources. Additional research to understand the role socioeconomic factors in the differences between these groups given that owners of sprinkler-equipped homes reported higher incomes and higher education than their counterparts in homes without sprinklers, and the dynamics of public opinion on this issue beyond owners of one- and two-family homes will be important to developing public interest in realizing change on this issue.
Study Limitations While the online panel from which this sample was drawn was carefully constructed and weighted to approximate the population of U.S. homeowners, with any online survey there is a segment of the population that is not captured. Given that one of our main study aims was to sample owners of one- and two-family sprinkler-equipped homes, this method offered an efficient way to access a large number of this low prevalence group. Accordingly, we decided that any un- or under-represented population groups were an acceptable trade-off in exchange for the information that could be gained about this undersurveyed population. The small number of questions (six) we were able to devote to clothing flammability is also a limitation, as is the fact that the questions were assessed for face validity, but not other measures of validity. Resource constraints were the main limiting factor. Our findings provide a foundation for future research to understand in greater detail the public’s awareness of clothing flammability risk and how to effectively reduce that risk. There is also a need for more detail about the public’s understanding of current federal standards and the specific changes they would support. Despite
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these shortcomings, our data offer an important step toward understanding public opinion and translating those findings to inform a national dialogue about clothing flammability risks and interventions.
CONCLUSION Every year thousands of people are injured when their clothing catches fire. This is a public health problem that requires attention. The findings reported herein document that public knowledge about clothingrelated fire risks is lacking, yet when informed about the magnitude of the problem, a majority indicates their support for labeling about the risks and stronger government oversight to minimize these risks. REFERENCES 1. Karter MJ Jr. Fire loss in the United States during 2012. Quincy: National Fire Protection Association Fire Analysis and Research Division; 2013. 2. Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999–2010 on CDC WONDER Online Database, released January 2013. Data are compiled from Compressed Mortality File 1999–2010 Series 20 No. 2P, 2013; available from http:// wonder.cdc.gov/cmf-icd10.html; accessed 28 Apr. 2013. 3. United States Consumer Product Safety Commission, National Electronic Injury Surveillance System. NEISS Estimates Query Builder. Available from https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx; accessed 28 Apr. 2013. 4. Damant G. Injuries and Deaths Related to the Flammability of Clothing—An Unresolved Problem. Fire and Materials 2011 12th International Conference and Exhibition, January 31, 2011, San Francisco. 5. Hoebel JF, Damant GF, Spivak SM, Berlin GN. Clothingrelated burn casualties: an overlooked problem? Fire Technol 2010;46:629–49. 6. Oglesbay FB. The flammable fabrics problem. Pediatrics 1969;44(Suppl):827–32. 7. CPSC Flammable Fabrics Act Regulations, 16 CFR § 1615; 1971. 8. Backer S, Tesoro GC, Toong TY, Mousa NA. Textile fabric flammability. Cambridge: MIT Press; 1976. 9. CPSC Flammable Fabrics Act Regulations, 16 CFR § 1616; 1996. 10. Adair PK, Rodgers DB. An evaluation of the impact of exemptions to the children’s sleepwear flammability standards on burn injuries to children. Fire Mater 2011;35(2):71–81. 11. United States General Accounting Office. Consumer product safety commission consumer education efforts for revised children’s sleepwear safety standard. Washington, DC: United States General Accounting Office; 1999. 12. Flammable Fabrics Act, 15 U.S.C. §§ 1191–1204; 1953. 13. Buchbinder LB. Relationship of Garment Characteristics and Other Variables to Fire Injury Severity. National Bureau of Standards Technical Note 867. Washington, DC: U.S. Government Printing Office; 1975. 14. Manktelow A, Meyer AA, Herzog SR, Peterson HD. Analysis of life expectancy and living status of elderly patients surviving a burn injury. J Trauma 1989;29:203–7. 15. Turner DG, Leman CJ, Jordan MH. Cooking-related burn injuries in the elderly preventing the “granny gown” burn. J Burn Care Rehabil 1989;10:356–9.
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16. Ryan CM, Thorpe W, Mullin P, et al. A persistent fire hazard for older adults: cooking-related clothing ignition. J Am Geriatr Soc 1997;45:1283–5. 17. Secretary of Health, Education, and Welfare. Third Annual Report to the President and the Congress on the Studies of Deaths, Injuries and Economic Losses Resulting from Accidental Burning of Products, Fabrics, or Related Materials Fiscal Year 1971. Washington, DC: U.S. Government Printing Office; 1972. 18. Secretary of Health, Education, and Welfare. Fourth Annual Report to the President and the Congress on the Studies of Deaths, Injuries and Economic Losses Resulting from Accidental Burning of Products, Fabrics, or Related Materials Fiscal Year 1972. Washington, DC: U.S. Government Printing Office; 1973. 19. Consumer Product Safety Commission. Six Reported Deaths Prompt Urgent Re-announcement of Blair Recall of Women’s Chenille Robes, Consumers Urged to Check for Flammable Robes. Release #09-241, June 11, 2009; available from http://www.cpsc.gov/en/Recalls/2009/ Six-Reported-Deaths-Prompt-Urgent-Re-announcementof-Blair-Recall-of-Womens-Chenille-Robes/; accessed 30 Dec. 2013.
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20. Brown SA, Crown EM. Consumer attitudes to flammability in household textiles. Home Econ Res J 1985;13(4):373–82. 21. Pollack KM, McKay T, Cumminskey C, et al. Employee assistance program services for intimate partner violence and client satisfaction with these services. J Occup Environ Med 2010;52:819–26. 22. Pignone M, Anderson GK, Binns K, Tilson HH, Weisman SM. Aspirin use among adults aged 40 and older in the United States: results of a national survey. Am J Prev Med 2007;32:403–7. 23. Klein JD, Thomas RK, Sutter EJ. Self-reported smoking in online surveys: prevalence estimate validity and item format effects. Med Care 2007;45:691–5. 24. Quantum User’s Quide. London, United Kingdom: SPSS Limited; 2000. 25. Girasek DC, Gielen AC, Smith GS. Alcohol’s contribution to fatal injuries: a report on public perceptions. Ann Emerg Med 2002;39:622–30. 26. Langlie JK. Interrelationships among preventive health behaviors: a test of competing hypotheses. Public Health Rep 1979;94:216–25. 27. Webman R, Dultz LA, Simon RJ, et al. Helmet use is associated with safer bicycling behaviors and reduced hospital resource use following injury. J Trauma Acute Care Surg 2013;75:877–81.
Clothing Flammability and Burn Injuries: Public Opinion Concerning an Overlooked, Preventable Public Health Problem Shannon Frattaroli, PhD, MPH,* Steven M. Spivak, PhD, FTI, FSFPE,† Keshia M. Pollack, PhD, MPH,* Andrea C. Gielen, ScD, ScM,* Michele Salomon, JD,‡ Gordon H. Damant, BSc§
The objective of this study was to describe knowledge of clothing flammability risk, public support for clothing flammability warning labels, and stronger regulation to reduce the risk. As part of a national survey of homeowners about residential sprinkler systems, the authors included questions about clothing flammability. The authors used an online web panel to sample homeowners and descriptive methods to analyze the resulting data. The sample included 2333 homeowners. Knowledge of clothing flammability and government oversight of clothing flammability risk was low. Homeowners were evenly split about the effectiveness of current standards; however, when presented with clothing-related burn injury and death data, a majority (53%) supported stricter standards. Most homeowners (64%) supported warning labels and indicated that such labels would either have no effect on their purchasing decisions (64%) or be an incentive (24%) to purchase an item. Owners of sprinkler-equipped homes were more likely to support these interventions than owners of homes without sprinkler systems. Public knowledge about clothing flammability risks is low. Most homeowners supported clothing labels to inform consumers of this risk and increased government intervention to reduce the risk. (J Burn Care Res 2016;37:e196–e204)
Fire and burn-related injuries are a leading cause of morbidity and mortality worldwide, and result from a variety of mechanisms involving heat and chemical energy transfers. In the United States, house fires are the leading cause of fire-related death,1 and systematic efforts to address residential fire risks have been underway for decades. Burns that occur when clothing catches fire From the *The Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, Baltimore, Maryland; †Department of Fire Protection Engineering, University of Maryland, College Park; ‡Harris Interactive, Inc., New York, New York; and §Damant and Associates, Sacramento, California. This work was supported by the Fire Prevention and Safety grant program of the Federal Emergency Management Agency (Grant EMW-2010-FP-00471). Address correspondence to Shannon Frattaroli, PhD, MPH, The Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, 624 North Broadway #545, Baltimore, Maryland 21205. E-mail: [email protected] Reprint address: Shannon Frattaroli, PhD, MPH, The Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, 624 North Broadway #545, Baltimore, Maryland 21205. E-mail: [email protected] Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000213
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are also a significant source of fire- and burn-related injuries, resulting in 102 deaths2 and about 4500 injuries treated in emergency rooms in the United States in 2009.3,4 However, unlike improvements to the building code and efforts to increase the prevalence of smoke alarms, clothing-related fire risks have received relatively little investment in prevention.5,6 One effort to address clothing-related burn risks occurred in 1971 with the flammability standard for children’s sleepwear, which requires that fabrics used to make sleepwear sizes 0 to 6× “self extinguish after exposure to a small open flame.”7 This requirement can be accomplished through fabric choice (different fabrics burn differently, and some are more resistant to ignition than others)8 or through the addition of fire retardant treatments. In 1974, a second standard expanded the original sleepwear rule to include sizes 7 to 14, but the Consumer Product Safety Commission (CPSC) relaxed that standard in 1996 by exempting infant sleepwear (up to 9 months) and snug-fitting pajamas.9 Proponents of the amendments argued that before 9 months infants are not mobile and therefore are at lower risk of coming into contact with a heat source. They also reasoned that
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tight fitting sleepwear presented a lower flammability risk than the loose fitting cotton garments (such as t-shirts) that consumers were reportedly favoring over regulated sleepwear, perhaps to avoid clothing treated with flame retardants.10 Garments that fit close to the body are less likely to come into contact with a heat source than clothing that is loose and flowing, and tight fitting clothing prevents ignition-related gases from accumulating between the fabric and skin which can further elevate burn risk.8 The amendments require exempt sleepwear to display hangtags indicating a snug-fit is safer and warning that the fabric is not flame resistant, and specifies marketing practices for those who sell children’s sleepwear.9 Despite the 1996 exemptions, and early evidence that the marketing regulations were not being implemented,11 the incidence of children treated in emergency rooms for sleepwear-related burns remains relatively low.4,10 CPSC regulates clothing flammability based on authority granted under the Federal Flammability Act of 1953.12 The Act is the foundation for regulatory authority concerning the flammability of all clothing manufactured and/or sold in the United States. While this authority exists and has been applied successfully to children’s sleepwear, greater attention to clothing-related burn risks is needed. During the 10 years from 2000 to 2009, 1,131 people died2 and more than 43,000 sought treatment in emergency rooms when their clothing caught fire.3,4 Most (75%) of the people who died were 65 years and older, even though this group comprised only 14% of the population.2 By contrast, non-fatal clothing burns disproportionately affect children, teens, and young adults ages 5 to 24 who comprise only 28% of the population but constitute 42% of people with clothing burn injuries treated in emergency rooms.4 Clothing that burns quickly when exposed to a flame is often implicated,13 and the type of clothing involved differs across age groups. “Nightwear” was worn by an estimated 3% of children under 5 years treated in emergency rooms for clothing-related burns, but was involved in 27% of those injuries to people 65 years and older. Eighty-two percentage of nightwear burn-related deaths occurred among those 65 years and older.4 Both biological and environmental risk factors associated with these injuries are documented in the literature where older burn victims are described as “sicker” patients who are admitted with more extensive burns than their younger counterparts.14 Differences in severity are explained by “slower reaction times, reduced mobility, impaired smell, vision, or hearing”14 that may result from “prior stroke, dementia, alcohol, and
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prescription drug use,”15 and are exacerbated by clothing characteristics. While individual circumstances of these burns vary, a common scenario involves an older woman cooking in a loose fitting, full cover robe designed to be donned or removed over the head. In wearing apparel made mostly of flammable fabric, once that garment catches fire, prompt removal is difficult or impossible without the wearer sustaining serious burn injury. The risk associated with cooking-related clothing fires has been documented15–18 and has prompted clothing product recalls.19 With the continued death and disability because of clothing-related burns, there are questions about whether the current federal standards are sufficient, and discussion of more rigorous standards and better use of clothing labels is occurring among some clothing flammability specialists.4,5 The appropriate roles for government and manufacturers in protecting the public from clothing-related burns is an important public health matter, and one that should be informed by evidence. One source of data for such a discussion is the public. Public knowledge of clothing flammability risks, perceptions of current government regulation of those risks, and support for additional protections by the government and/or industry are all important considerations in assessing different intervention options for the continuing problem of clothing-related burns. Such insight from the public, however, is limited. In the 1980s, two surveys assessed knowledge of flammability risk among Rhode Island residents (Helms P, unpublished manuscript, 1990) and residents in a western Canadian province.20 While the two surveys explored different aspects of the flammability issue (clothing [Helms P, unpublished manuscript, 1990] and clothing as part of a broader examination of home textiles),20 both sets of respondents reported general awareness of government standards, although in Rhode Island the knowledge tended to be specific to children’s sleepwear (Helms P, unpublished manuscript, 1990). The Rhode Island results also highlighted respondents’ lack of knowledge about the relative flammability of different fabrics and the injury risks associated with clothing fires (Helms P, unpublished manuscript, 1990). Both articles concluded that efforts to inform consumers of clothing flammability and burn risks were needed and cited labeling as one strategy with strong public support. Brown and Crown,20 coauthors of the Canadian study, further emphasized the need for stricter government standards to reduce flammability risks in part because their respondents conveyed a belief that the Canadian government was providing more oversight than was
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the case. This confidence, from the authors’ perspective, translated into a lower perception of risk than the current policies warranted.20 Given the burden of clothing-related burn injuries and the lack of data regarding public awareness about current flammability standards and public support for interventions to reduce this risk, we included questions about clothing flammability as part of a national survey about residential sprinkler systems. We fielded the survey among U.S. homeowners living in one- and two-family homes with and without residential sprinklers. By exploring clothing flammability knowledge and support for fire prevention interventions with these two populations, we were able to assess whether those living in sprinklerequipped homes view clothing flammability risk and interventions differently from those in homes without residential sprinkler systems. We hypothesized that those living in sprinkler-equipped homes would be more aware of current flammability standards and more supportive of interventions to reduce clothing flammability risk because their decision to live in a sprinkler-equipped home may reflect a higher level of attention to safety. Here, we report the findings and discuss the implications for policy and practice.
Instrument Development Our survey included six clothing flammability questions. The process of developing these survey questions began with a review of the literature. The two surveys previously described20 (Helms P, unpublished manuscript, 1990) provided limited guidance since they included questions that were more detailed than was needed to accomplish our study aims and was feasible given resource constraints. As a result, our questions were driven primarily by our study aims and the expertise of our co-authors (S.S. and G.D.) who have decades of experience in the field of materials and fire science. We assessed public awareness by self-reported knowledge of federal standards and a response to a question about fabric flammability. Opinions about new potential interventions to reduce risk were measured through questions about support for stricter federal standards and clothing flammability labels. We assessed satisfaction with current standards and then provided a statement about clothing-related burn injuries before asking about support for stricter standards. We pilot tested the survey with fire safety experts and members of the research team (including administrative staff with no content area expertise) and incorporated their feedback into the fielded version. Pilot testing the survey with these experts and lay people helped assess the questions’ face validity.
METHODS We conducted a cross-sectional survey of owners of one- and two-family homes in the United States. The primary aims of the survey were to assess homeowners’ experiences with and attitudes about residential sprinkler systems as well as other strategies for preventing fire- and burn-related injuries. Because of our interest in residential sprinkler systems, we sought to obtain a nationally representative sample of homeowners living in sprinkler-equipped one- and two-family homes (an estimated 2% of one- and twofamily homes in the United States). For comparison purposes, we sampled a second group of homeowners without sprinkler systems. Since the prevalence of sprinkler systems in one- and two-family homes is low, we sought a mechanism that would provide us access to a large, diverse sample. Harris Interactive maintains the Harris Poll Online, an extensive worldwide panel of respondents who enroll to participate in survey research. The web panel provides an efficient means of accessing low prevalence populations that cannot be readily identified and has been used to field surveys on several public health topics to date.21–23
Data Collection Screening questions identified people living in the United States who were 18 years and older in a oneor two-family home they owned. An additional question determined whether the respondent owned a sprinkler-equipped home. Based on these screening questions, a set of members who owned sprinklerequipped homes and a second set who owned homes without residential sprinkler systems were invited to participate in the full survey for sprinkler-equipped homeowners and an abbreviated survey for those living in homes without sprinklers. The clothing flammability questions on the two versions of the survey were identical. Data collection took place from August 16 to September 24, 2012. During this time, approximately 385,000 members received an invitation to respond to the survey. Those who did not respond received one follow-up invitation. We oversampled Blacks or African-Americans, and Hispanics in order to assure sufficient participation from these groups to allow for comparisons by race and ethnicity. Oversamples can compensate for possible lower response rates and, in the case of this study allowed for each race
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and ethnic group to be demographically representative of the population. The three racial and ethnic groups (White, Black or African-American, and Hispanic) were weighted separately and then postweighted into a representative total. To access the survey, invited panel members logged onto the Harris site using their user identification and password. This system assures that only invited members have access to the survey and prevents any one person completing the survey more than once. Homeowners recorded their answers online, using a computer of their choosing and at a time and location convenient for them. Members who completed the survey received points in the Harris loyalty program that can be redeemed for products and services. On average, homeowners completed the survey in 14 minutes.
Data Analysis The data were weighted to be representative of the U.S. population of homeowners 18 years and older. Each category of the sample (general population, Black or African-American oversample, Hispanic oversample) was weighted using the 2011 Current Population Survey by the following key demographic variables: household income, education, age, gender, and region of residence. The general population category was also weighted by race and ethnicity, in addition to the other demographic variables previously listed. Descriptive statistics of respondent characteristics are presented as weighted proportions. Bivariate comparisons of responses between homeowners with and without residential sprinkler systems were analyzed using t-tests of proportions and means with software designed for market research analysis.24 Data are presented for all homeowners, and separately for homeowners with and without residential sprinkler systems. Statistical significance was established at P < .05.
RESULTS The final sample for the online survey included 2,333 homeowners identified from among 46,901 homeowners who responded to the screening questions. The large number of people who were screened, but ineligible was driven by the low prevalence of residential sprinkler systems in one- and two-family homes. Homeowners in the two groups were significantly different: those in the sprinkler sample were younger (45 vs 54 median years), reported higher incomes (35% vs 26% with household incomes of $100,000 and higher), and were more educated
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(80% vs 67% earned a college or graduate degree). A detailed demographic table is available elsewhere (data available with the author).
Knowledge of Fabric Flammability and Current Standards Knowledge questions revealed low-levels of understanding about fabric flammability. For example, 15% of homeowners correctly identified that a cotton shirt is more likely to catch fire compared to a polyester shirt. Regarding familiarity with the federal standards governing clothing flammability, only 7% of all homeowners self-identified as “extremely familiar” (1%) or “very familiar” (6%) with current policy compared to 93% who responded they were “somewhat” (55%) or “not familiar at all” (38%). Homeowners living in sprinkler-equipped homes were significantly more likely to respond correctly to the question about fabric flammability (21% vs 14% of homeowners without sprinklers), and much more likely to self-report high levels of familiarity (extremely or very familiar) with the federal flammability standards (26% vs 6% of homeowners without sprinklers). Responses regarding familiarity with current federal standards resulted in a significantly higher mean score for owners of sprinkler-equipped homes (2.1 on a 4-point scale) compared to owners of homes without sprinklers (mean score = 1.7). The full text of these questions and responses are included in Table 1.
Support for Stricter Standards Overall, homeowners were evenly divided when asked if current safety standards are effective in preventing clothes from catching fire when exposed to a flame (34% agreed, 33% were neutral, and 34% disagreed). However, homeowners with sprinkler systems reported significantly higher agreement that federal standards provide effective protection compared to homeowners without sprinkler systems (mean score = 3.2 vs 2.9). While homeowners overall were evenly split in their views about the effectiveness of current standards, when provided information about the number of people who die and are treated in emergency rooms every year when their clothing catches fire, a majority of homeowners (53%) supported stricter federal standards compared to 31% who neither supported nor opposed, and 17% who opposed. Homeowners with sprinkler systems expressed significantly higher levels of support compared to homeowners without them (mean score = 3.7 vs 3.5; Table 2).
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Table 1. Knowledge about clothing flammability standards and fabric flammability Homeowners With RSS* N = 976
Homeowners Without RSS N = 1357
All Homeowners N = 2333
Question: “How familiar are you with the safety standards for clothing flammability?” Extremely familiar 9% 1% 1% Very familiar 17% 5% 6% Somewhat familiar 47% 55% 55% Not familiar at all 27% 39% 38% Mean score, with 1 = extremely familiar and 4 = not familiar 2.1 1.7 1.7 at all Question: “Is a shirt made from 100% cotton or a shirt made from 100% polyester more or less likely to catch fire if exposed to a flame?” The polyester shirt is more likely to catch fire 41% 44% 44% They are equally likely to catch fire 25% 30% 30% The cotton shirt is more likely to catch fire† 21% 14% 15% Not sure 13% 11% 11% RSS, Residential Sprinkler System. Statistical significance is reported at 95% confidence level. Bold font indicates percentages that are significantly higher; RSS homeowners are tested against nonRSS homeowners. Neither of those groups is tested against the total. † Correct response.
Table 2. Effectiveness of federal clothing flammability standards Homeowners With RSS* N = 976
Homeowners Without RSS N = 1357
All Homeowners N = 2333
Question: “Clothing available for sale in the United States is subject to safety standards that effectively prevent clothes from catching on fire when exposed to flames.” Agree 42% 33% 34% Strongly agree 13% 6% 6% Somewhat agree 29% 27% 27% Neither agree nor disagree 33% 33% 33% Disagree 25% 34% 34% Somewhat disagree 17% 24% 24% Strongly disagree 8% 10% 10% Mean score, with 1 = strongly disagree and 5 = strongly agree 3.2 2.9 3.0 Question: “Despite current safety standards, every year more than 4000 people in the United States are treated in emergency rooms for clothingrelated burns; more than 100 people die every year from these burns. Knowing this, would you oppose or support stricter clothing safety standards for clothing sold in the United States?” Support 59% 52% 53% Very much support 28% 18% 19% Somewhat support 31% 34% 34% Neither support nor oppose 27% 31% 31% Oppose 14% 17% 17% Somewhat oppose 9% 10% 10% Very much oppose 5% 7% 7% Mean score, with 1 = very much oppose and 5 = very much 3.7 3.5 3.5 support RSS, Residential Sprinkler System. Statistical significance is reported at 95% confidence level. Bold font indicates percentages that are significantly higher; RSS homeowners are tested against nonRSS homeowners. Neither of those groups is tested against the total.
Support for Clothing Labels Warning labels are one strategy for informing consumers about the flammability risk of clothing
available for sale. A majority of homeowners indicated they either very much supported (30%) or somewhat supported (34%) requiring clothing
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manufacturers to include labels explaining fire risk. Support among those living in sprinkler-equipped homes was significantly higher (mean score = 3.9 vs 3.8; Table 3). We further explored whether the presence of warning labels would influence homeowners’ clothing buying decisions. When asked about their purchasing preference for clothing with a warning label, they read as part of the question (text included in Table 3), most (64%) homeowners responded that such warnings would not affect their purchasing decisions. Almost one-quarter (24%) of all homeowners responded that they would be more likely to buy clothing with such a label, with owners of sprinkler-equipped homes expressing in significantly greater numbers than homeowners without sprinkler systems that they would be more likely buy clothing labeled with the sample warning text (mean score = 3.4 vs 3.1). A minority of homeowners (12%) indicated they
would be less likely to purchase clothing with the sample label language (Table 3).
DISCUSSION Thousands are injured every year in the United States when their clothing catches fire. Whether people are aware of clothing flammability risks is a question we sought to inform after realizing the dearth of literature on this topic. Findings from our survey reveal that U.S. homeowners are not well informed about clothing flammability risks or the government’s role in mitigating those risks. We explored homeowners’ support for two strategies to reduce this risk: including warning labels on clothing and strengthening federal flammability standards to reduce clothing flammability risk. The homeowners in our sample indicated support for both strategies. We discuss the implications of these findings for education and policy strategies to reduce this risk.
Table 3. Clothing flammability warning labels Homeowners With RSS* N = 976
Homeowners Without RSS* N = 1357
All Homeowners N = 2333
Question: “Do you support or oppose requirements for clothing manufacturers to include warning labels explaining flammability and burn risks of the clothing they produce?” Support 67% 64% 65% Very much support 36% 30% 30% Somewhat support 31% 34% 34% Neither support nor oppose 22% 23% 23% Oppose 10% 13% 12% Somewhat oppose 6% 7% 7% Very much oppose 4% 5% 5% Mean score, with 1 = very much oppose 3.9 3.8 3.8 and 5 = very much support Question: “Would you be more or less likely to buy clothing with a warning label with the following language explaining flammability and burn risk of clothing?” CAUTION: ALL CLOTHING CAN BURN. DO NOT EXPOSE TO FLAME OR INTENSE HEAT. All of our fabrics meet or exceed the requirements of the Flammable Fabrics Act. However, please avoid exposing fabrics and clothing to open flames or other sources of intense heat such a candles, stoves and ranges, fireplaces, wood stoves, matches, or lighters. This is especially important if you have used excess liquid fabric softener during laundering.† More likely to purchase 42% 23% 24% Much more likely 19% 7% 8% Somewhat more likely 23% 16% 16% Neither more nor less likely 42% 65% 64% Less likely to purchase 16% 12% 12% Somewhat less likely 8% 6% 6% Much less likely 7% 6% 6% Mean score, with 1 = much less likely and 3.4 3.1 3.1 5 = much more likely RSS, Residential Sprinkler System. Statistical significance is reported at 95% confidence level. Bold font indicates percentages that are significantly higher; RSS homeowners are tested against nonRSS homeowners. Neither of those groups is tested against the total. †Tested language is a composite of several warning labels used by manufacturers.
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Education Given the low level of knowledge about the relative flammability risk of cotton compared to polyester, efforts to raise awareness about this risk are worth pursuing. Manufacturer warning labels are one way to increase knowledge about this injury risk. Labeling is a strategy that manufacturers can adopt voluntarily and one with the potential to yield a competitive advantage with a segment of the buying public who indicated they would be more inclined to purchase clothing with a flammability warning label. Our data revealed that 74% of all homeowners either very much support or somewhat support requiring clothing manufacturers to include labels explaining fire risk. Furthermore, the disproportionate risk of death to older people associated with nightwear ignitions is both longstanding and documented in the literature.14–16 Assuring that policymakers and the public are aware of this disproportionate risk and the role of certain garments in explaining this increased risk can inform decisions about clothing regulations and which nightwear to buy.
Policy While warning labels could be implemented voluntarily and are used by some clothing manufacturers, we also note the potential for government to mandate such labels. Such a requirement could be based on fabric flammability risk, or high risk applications, and could specify how such products should be marketed in order to clearly distinguish between products subject to the higher standards and those which are exempt as was done with children’s sleepwear decades ago.7 Attention to the implementation and enforcement of such policies would be needed given past evidence that sellers are not always in compliance with the marketing requirements.11 National injury surveillance data have established that a large percentage of clothing-related burn victims who die are people 65 years and older dressed in nightwear.4 Additional documentation of the nightwear involved in these incidents (eg, fabrics used, designs) could inform a new labeling standard. Warning labels may yield some benefit, particularly in addressing the need to inform consumers of flammability risk. Government authority to “prohibit the introduction or movement in interstate commerce of articles of wearing apparel and fabrics which are so highly flammable as to be dangerous when worn by individuals” extends beyond requiring labels.12 Regulatory authority under the Flammable Fabrics Act includes the ability to set flammability performance
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standards for fabrics and apparel. This authority is particularly relevant given that the children’s sleepwear standards are associated with declines in nightwear burn deaths among children,10 and other standards promulgated under the Act are dated and do not reflect the state of the art in testing research,4 a shortcoming noted several decades ago.6 When asked about their knowledge of existing federal standards, the vast majority of homeowners reported a limited understanding. This lack of awareness may help explain the finding that onethird of the sample neither agreed nor disagreed about whether clothing safety standards are effective. This suggests that the public health, injury prevention, and fire prevention communities have not adequately communicated its successes in using regulatory strategies to protect the public, a finding that is consistent with an earlier national survey of effective alcohol-related policies to reduce alcohol-related motor vehicle deaths.25 Efforts to enhance the public’s understanding of effective policy interventions may ultimately increase their support for addressing a wide range of injury problems that could benefit from policy solutions. Although our survey did not specify the content of stricter standards, the low level (17% among all homeowners) of opposition to the general idea may bode well for future efforts in this area. One place to start is with the risk associated with nightwear among women 65 years and older. It is a common and foreseeable scenario for older women to cook in a robe, housecoat, or nightgown. As far back as the 1970s, this fire risk was reported to Congress.17,18 More recently, CPSC recalls of more than 160,000 cotton chenille robes demonstrate the continuing risk.19 While recalls can be effective in removing some dangerous products from commerce, preventing highly flammable fabrics from entering the marketplace is preferable. Importantly, this pre-market intervention strategy does not rely on consumer caution, correction for biological risks associated with age, or informed purchasing because under an improved regulatory system every clothing choice would be a safer choice. Passive protection has long been recognized within the field of injury prevention as a desirable (although sometimes elusive) intervention approach.
Homeowners and Residential Sprinkler Systems In general, owners of sprinkler-equipped homes were more likely to report being knowledgeable about flammability standards; demonstrate their knowledge
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of flammability risk; and support policy and labeling strategies to inform consumers about clothing burn risks, and improved standards to reduce those risks. They also reported being more likely to buy clothing with a flammability warning label than those in homes without sprinklers. Clustering of prevention behaviors has been noted in the literature across distinct health and injury behaviors26 as well as across prevention behaviors that relate to the same injury.27 This observation suggests that support for preventive interventions may be most readily obtained in populations already predisposed to health prevention behaviors. These behaviors may also be related to socioeconomic status, as measured here by income and education, as prevention behaviors often require an investment in time and/or resources. Additional research to understand the role socioeconomic factors in the differences between these groups given that owners of sprinkler-equipped homes reported higher incomes and higher education than their counterparts in homes without sprinklers, and the dynamics of public opinion on this issue beyond owners of one- and two-family homes will be important to developing public interest in realizing change on this issue.
Study Limitations While the online panel from which this sample was drawn was carefully constructed and weighted to approximate the population of U.S. homeowners, with any online survey there is a segment of the population that is not captured. Given that one of our main study aims was to sample owners of one- and two-family sprinkler-equipped homes, this method offered an efficient way to access a large number of this low prevalence group. Accordingly, we decided that any un- or under-represented population groups were an acceptable trade-off in exchange for the information that could be gained about this undersurveyed population. The small number of questions (six) we were able to devote to clothing flammability is also a limitation, as is the fact that the questions were assessed for face validity, but not other measures of validity. Resource constraints were the main limiting factor. Our findings provide a foundation for future research to understand in greater detail the public’s awareness of clothing flammability risk and how to effectively reduce that risk. There is also a need for more detail about the public’s understanding of current federal standards and the specific changes they would support. Despite
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these shortcomings, our data offer an important step toward understanding public opinion and translating those findings to inform a national dialogue about clothing flammability risks and interventions.
CONCLUSION Every year thousands of people are injured when their clothing catches fire. This is a public health problem that requires attention. The findings reported herein document that public knowledge about clothingrelated fire risks is lacking, yet when informed about the magnitude of the problem, a majority indicates their support for labeling about the risks and stronger government oversight to minimize these risks. REFERENCES 1. Karter MJ Jr. Fire loss in the United States during 2012. Quincy: National Fire Protection Association Fire Analysis and Research Division; 2013. 2. Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999–2010 on CDC WONDER Online Database, released January 2013. Data are compiled from Compressed Mortality File 1999–2010 Series 20 No. 2P, 2013; available from http:// wonder.cdc.gov/cmf-icd10.html; accessed 28 Apr. 2013. 3. United States Consumer Product Safety Commission, National Electronic Injury Surveillance System. NEISS Estimates Query Builder. Available from https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx; accessed 28 Apr. 2013. 4. Damant G. Injuries and Deaths Related to the Flammability of Clothing—An Unresolved Problem. Fire and Materials 2011 12th International Conference and Exhibition, January 31, 2011, San Francisco. 5. Hoebel JF, Damant GF, Spivak SM, Berlin GN. Clothingrelated burn casualties: an overlooked problem? Fire Technol 2010;46:629–49. 6. Oglesbay FB. The flammable fabrics problem. Pediatrics 1969;44(Suppl):827–32. 7. CPSC Flammable Fabrics Act Regulations, 16 CFR § 1615; 1971. 8. Backer S, Tesoro GC, Toong TY, Mousa NA. Textile fabric flammability. Cambridge: MIT Press; 1976. 9. CPSC Flammable Fabrics Act Regulations, 16 CFR § 1616; 1996. 10. Adair PK, Rodgers DB. An evaluation of the impact of exemptions to the children’s sleepwear flammability standards on burn injuries to children. Fire Mater 2011;35(2):71–81. 11. United States General Accounting Office. Consumer product safety commission consumer education efforts for revised children’s sleepwear safety standard. Washington, DC: United States General Accounting Office; 1999. 12. Flammable Fabrics Act, 15 U.S.C. §§ 1191–1204; 1953. 13. Buchbinder LB. Relationship of Garment Characteristics and Other Variables to Fire Injury Severity. National Bureau of Standards Technical Note 867. Washington, DC: U.S. Government Printing Office; 1975. 14. Manktelow A, Meyer AA, Herzog SR, Peterson HD. Analysis of life expectancy and living status of elderly patients surviving a burn injury. J Trauma 1989;29:203–7. 15. Turner DG, Leman CJ, Jordan MH. Cooking-related burn injuries in the elderly preventing the “granny gown” burn. J Burn Care Rehabil 1989;10:356–9.
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