The Effectiveness of Cigarette Price and Smoke-Free Homes on Low-Income Smokers in the United States

Objectives. We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.Methods. We used the 2006–2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.Results. High state cigarette price (pack price ≥ $4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.Conclusions. High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.High state cigarette prices1–3 and clean indoor air laws4–8 are 2 of the most effective tobacco control policies for decreasing tobacco use5 and increasing cessation on a population level.4–6 These policies have been included in national surveillance surveys of tobacco use.9 Whether these policies are effective among lower-income as well as higher-income smokers is unclear. Some studies, including an econometric analysis,10 have suggested that price and clean air laws have a similar effect in reducing smoking behavior among lower- and higher-income smokers.2,10,11 Others have suggested that such policies may be less effective for lower-income smokers12–14 as they have a higher smoking prevalence,15 higher consumption rate per smoker,16 and lower rates of successful quitting17–19 compared with higher-income smokers. Indeed, the prevalence of smoking among adults living below the federal poverty level (FPL) is almost 50% higher than the prevalence in the general population.15Economic theory suggests that rising cigarette prices should reduce cigarette consumption more in low-income smokers compared with those with higher incomes.2,12,13,20–23 However, studies have shown that low-income smokers vary in their response to rising cigarette prices. Some individuals may compensate for higher prices by relying on lower-priced cigarette products (e.g., generic vs premium brands, discount vs convenience stores, or non–state-taxed products [e.g., from Indian reservations] vs taxed products).23–29 Others who are motivated to quit may react to a price increase as an opportunity to quit smoking or reduce cigarette consumption.3,21 One concern is that the higher prevalence of heavy smoking among low-income smokers may be evidence of impaired personal autonomy such that fewer are able to quit even with a price increase.30 This in combination with the stress of coping with material or environmental constraints may pose significant challenges to smoking cessation.31 Another concern is that high cigarette prices can result in a significant financial burden for low-income smokers.32Social cognitive theory predicts that a person’s motivation to change behavior varies with the social norms of his or her environment.33 Variability in smoking behaviors between low- and high-income smokers may result from different social norms related to smoking.34 The passage of smoke-free policies in communities is one indicator of social norms related to smoking35; a stronger marker is the prevalence of households with smokers who have voluntarily established a smoke-free home.6 Strong clean indoor air laws are associated with increased adoption of smoke-free homes among smokers and nonsmokers.36,37 Smoke-free homes have been associated with reduced exposure to second-hand smoke among nonsmokers, and reduced smoking behaviors among smokers.5,6,38 Lower-income adults are less likely than higher-income adults to adopt smoke-free homes,39,40 reflecting differential smoking norms in the respective communities.To determine whether cigarette prices and smoke-free home policies are effective among smokers of different income levels, we used the 2006–2007 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), a nationally representative cross-sectional survey, to explore the association of these policies with smoking behaviors by income categories indexed on poverty status. The level of excise tax on tobacco products has differed considerably across states.41 Thus, we aggregated self-reported purchase price of cigarettes and compared across states. We examined whether average daily consumption and successful quitting differed by income levels among adults living in states with higher average cigarette prices compared with those with lower prices. We similarly assessed whether an income gradient existed in cigarette consumption and successful quitting among adults living in smoke-free homes relative to non–smoke-free homes. We examined the independent association of state cigarette price and smoke-free homes on smoking behaviors. We hypothesized that smoke-free homes would be a stronger predictor than price in reducing smoking behaviors because smokers may have access to a number of price-minimizing strategies23,26 but lack similar strategies to minimize the effects of smoking restrictions.     

Fewer Hospitalizations for Chronic Obstructive Pulmonary Disease in Communities With Smoke-Free Public Policies

Objectives. We determined the impact of smoke-free municipal public policies on hospitalizations for chronic obstructive pulmonary disease (COPD).Methods. We conducted a secondary analysis of hospital discharges with a primary diagnosis of COPD in Kentucky between July 1, 2003, and June 30, 2011 using Poisson regression. We compared the hospitalization rates of regions with and without smoke-free laws, adjusting for personal and population covariates, seasonality, secular trends over time, and geographic region.Results. Controlling for covariates such as sex, age, length of stay, race/ethnicity, education, income, and urban–rural status, among others, we found that those living in a community with a comprehensive smoke-free law or regulation were 22% less likely to experience hospitalizations for COPD than those living in a community with a moderate–weak law or no law. Those living in a community with an established law were 21% less likely to be hospitalized for COPD than those with newer laws or no laws.Conclusions. Strong smoke-free public policies may provide protection against COPD hospitalizations, particularly after 12 months, with the potential to save lives and decrease health care costs.Chronic obstructive pulmonary disease (COPD) is a serious, chronic, progressive lower respiratory disorder characterized by airflow limitation with varying degrees of chronic bronchitis and emphysema. The primary risk factor for COPD is cigarette smoke, with either direct exposure (firsthand smoking) or indirect exposure through secondhand smoke.1–3 COPD is a leading cause of physician office visits4 and emergency department visits,5 and it is a primary cause of hospitalization in older adults.4 COPD is also associated with more comorbidities,6 reduced quality of life,7 decreased functional status,8 depression,7 and cognitive deficits.9 In 2010, the economic burden associated with COPD was approximately $50 billion, including $29.5 billion for direct care, $8 billion in indirect morbidity costs, and $12.4 billion for indirect mortality costs.10 The health care costs associated with COPD for the next 2 decades are projected to be $800 billion.11 Although many states and local US communities have enacted comprehensive smoke-free workplace laws, southern, rural tobacco-growing states and locales lag behind in smoking cessation rates and protection of workers from exposure to secondhand smoke.The worldwide prevalence of COPD is estimated at 10.1%.12 By comparison, the prevalence of COPD in southeastern Kentucky, a rural tobacco-growing state, is nearly double at 19.6%.13 COPD is currently the third leading cause of death in Kentucky and the United States,14,15 and 9.3% of Kentucky adults have been told by a provider that they have COPD.16 Kentucky is a national leader in smoking prevalence, with 29% of adults reporting current tobacco use.17 One fourth (25%) of Kentucky high school students and 12% of middle school students are current cigarette smokers.18 As of December 1, 2013, 66% of Kentuckians were regularly exposed to secondhand smoke in workplaces and public places.19Previous studies have shown a decrease in hospitalization20–22 and mortality rates23 for respiratory diseases after smoke-free legislation. As of June 30, 2011, communities in 28 Kentucky counties had enacted smoke-free laws or adopted Board of Health regulations limiting exposure to some degree. The first ordinance was implemented in Lexington-Fayette County in April 2004,24 with the majority of public policies taking effect in 2008–2011. The most comprehensive ordinances and regulations, 100% smoke-free workplace and 100% smoke-free enclosed public place laws, were implemented in communities in 16 counties, covering more than 30% of the state’s population. Moderate smoke-free ordinances and 100% smoke-free enclosed public place laws including restaurants and bars, but not all workplaces, were in effect in 3 counties. Communities in 9 counties had enacted weak smoke-free laws or regulations, protecting workers and patrons in some public and workplace venues with significant exemptions (e.g., age restrictions, enclosed smoking rooms, restaurants only). Laws or regulations in 11 of the 28 counties covered the entire county. Although some additional counties had very limited smoking restrictions that applied only to municipal buildings (not 100% public policies), we did not include these laws in the study. Given the prevalence of smoking and COPD in Kentucky, and the presence of local smoke-free public policies in some counties, we aimed to determine the impact of smoke-free laws in Kentucky on hospitalizations for COPD exacerbation. We hypothesized that areas with comprehensive smoke-free laws would have lower COPD-related hospitalizations than those with moderate–weak laws and those without laws, controlling for sex, age, length of stay, race/ethnicity, education, income, urban–rural status, primary care physician supply, heart disease, diabetes, smoking rate, quit attempt rate, seasonality, and region of residence. A secondary aim was to determine whether duration of law influenced COPD hospitalizations, controlling for these covariates. We hypothesized that communities with established laws would exhibit lower rates of COPD hospitalization than those with newer or no laws.     

A Minimal Intervention to Promote Smoke-Free Homes Among 2-1-1 Callers: A Randomized Controlled Trial

Objectives. We tested the efficacy of a minimal intervention to create smoke-free homes in low-income households recruited through the United Way of Greater Atlanta 2-1-1, an information and referral system that connects callers to local social services.Methods. We conducted a randomized controlled trial (n = 498) from June 2012 through June 2013, with follow-up at 3 and 6 months. The intervention consisted of 3 mailings and 1 coaching call.Results. Participants were mostly smokers (79.7%), women (82.7%), African American (83.3%), and not employed (76.5%), with an annual household income of $10 000 or less (55.6%). At 6-months postbaseline, significantly more intervention participants reported a full ban on smoking in the home than did control participants (40.0% vs 25.4%; P = .002). The intervention worked for smokers and nonsmokers, as well as those with or without children.Conclusions. Minimal intervention was effective in promoting smoke-free homes in low income households and offers a potentially scalable model for protecting children and adult nonsmokers from secondhand smoke exposure in their homes.Despite declines in exposure to secondhand smoke (SHS) over the last 2 decades, children and nonsmoking adults who live with a person who smokes still experience significant exposure to SHS.1–3 SHS exposure causes lung cancer, coronary heart disease, and stroke in nonsmoking adults, aexacerbates asthma, and causes impaired lung function, middle ear disease, respiratory illness, and sudden infant death syndrome in children.3–5Exposure differs markedly between those who live with someone who smokes in the home and those who do not. In 2007 and 2008, 93.4% of nonsmoking adults who lived with someone who smoked inside the home had elevated serum cotinine levels compared with 33.4% of those who did not live with someone who smoked inside the home.6 This pattern was similar, but more striking, for children and youths.6 Certain subgroups of the US population are less likely to have household smoking restrictions and are disproportionately affected by SHS exposure in the home. For instance, African American nonsmokers have an increased prevalence of detectable serum cotinine compared with other major racial/ethnic groups and are less likely to report home smoking bans.6–8 Low income families and those with less education are less likely to have full smoking bans.6,8–11 Other predictors of household smoking bans include the presence of children, the presence of a nonsmoking adult in the home, and fewer friends and family members who smoke.9,10,12–17Home smoking bans can lead to lower levels of SHS exposure, less smoking, and increased attempts to quit.7,13,18–22 The prevalence of smoke-free homes has increased as states and communities have legislated smoke-free public places.23,24 Intervention studies have typically examined the effects of counseling parents of children with asthma, infants, or medically compromised children on exposure levels.25–29 Effective interventions involve multiple counseling sessions and often combine smoking cessation and smoke-free home messages.30–32 Much of the existing intervention research has taken place or recruited participants through clinical settings.30–33 Minimal interventions to create smoke-free homes in community-based settings have not been adequately studied.31,33,34Minimal interventions have the potential for greater reach than more intensive interventions, and thus, have the potential for a greater impact at the population level.35–38 Similarly, interventions that target general populations, including households with no young children, can help to achieve population-level reductions in SHS exposure. We tested the efficacy of a minimal intervention with callers to the United Way of Greater Atlanta, Georgia, 2-1-1 number. The 2-1-1 information and referral system consists of more than 200 nonprofit state and local call centers operating in all 50 states and connects more than 16 million callers per year to local health and social services.39 Callers to 2-1-1 are disproportionately low-income, unemployed, uninsured, and have fewer years of education relative to the general population.40 2-1-1 callers have a higher rate of smoking and lower likelihood of a home smoking ban than the general population.41,42 Because 2-1-1 provides extensive reach to vulnerable populations, they are strategic partners for testing, delivering, and ultimately sustaining interventions to reduce risk and improve the lives of low-income persons in the United States.40We tested the efficacy of a minimal intervention to create smoke-free homes among 2-1-1 callers. Our study builds on formative research on family dynamics related to establishing household smoking bans,43,44 a pilot study to test a brief intervention,45 and a cross-site survey of 2-1-1 callers that showed a relatively low prevalence of smoke-free homes.41 This randomized controlled trial is the first in a series of studies that will move from testing efficacy to effectiveness to dissemination of the intervention through 2-1-1 centers nationally.     

Policy Support, Norms, and Secondhand Smoke Exposure Before and After Implementation of a Comprehensive Smoke-Free Law in Mexico City

Objectives. We assessed attitudes and beliefs about smoke-free laws, compliance, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico City.Methods. Trends and odds of change in attitudes and beliefs were analyzed across 3 representative surveys of Mexico City inhabitants: before implementation of the policy (n = 800), 4 months after implementation (n = 961), and 8 months after implementation (n = 761).Results. Results indicated high and increasing support for 100% smoke-free policies, although support did not increase for smoke-free bars. Agreement that such policies improved health and reinforced rights was high before policy implementation and increased thereafter. Social unacceptability of smoking increased substantially, although 25% of nonsmokers and 50% of smokers agreed with smokers'' rights to smoke in public places at the final survey wave. Secondhand smoke exposure declined generally as well as in venues covered by the law, although compliance was incomplete, especially in bars.Conclusions. Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions.Smoke-free policies can reduce involuntary exposure to toxic secondhand tobacco smoke (SHS), reduce tobacco consumption and promote quitting,^1,2 and shift social norms against smoking.^3–5 These policies are fundamental to the World Health Organization''s Framework Convention on Tobacco Control, an international treaty that promotes best-practices tobacco control policies across the world.⁶Evidence of successful implementation of smoke-free policies generally comes from high-income countries. Low- and middle-income countries increasingly bear the burden of tobacco use,⁷ however, and these countries may face particular challenges in implementing smoke-free policies, including greater social acceptability of tobacco use, shorter histories of programs and policies to combat tobacco-related dangers, and greater tolerance of law breaking.^8–10 There is a need for research that will help identify effective strategies for promoting and implementing smoke-free policies in low- and middle-income countries.Studies in high-income countries generally indicate that popular support for laws that ban smoking in public places and workplaces is strong and increases after such laws are passed.^11–15 Weaker laws that allow smoking in some workplaces can leave policy support unchanged.¹⁶ Policy-associated increases in support have been shown across populations that include smokers^{11,13,14,17,18} and bar owners and staff.^19,20 Beliefs about rights to work in smoke-free environments¹¹ and the health benefits of these environments²¹ have also been shown to increase with policy implementation. Support for banning smoking in all workplaces appears high in Latin American countries,²² but responses to smoke-free policies are less well known. In Uruguay, the first country in the Americas to prohibit smoking in all workplaces, including restaurants and bars,²³ support before the law was unknown. However, the level of support was high among both the general population²² and smokers²⁴ after the law''s implementation.Compliance with smoke-free laws in high-income countries has been good, particularly when laws apply across all workplaces, including restaurants and bars, and involve media campaigns. Self-reported declines in exposure in regulated venues^11,17,25 are consistent with findings from observational studies,^11,26 biomarkers of exposure,^11,25,27 and air quality assessments.^11,12Approximately 26% of Mexican adults residing in urban areas smoke.⁸ Most Mexicans recognize the harms of SHS and support smoke-free policies.^9,24,28,29 According to an opinion poll conducted before the August 2007 passage of a smoke-free law in Mexico City, about 80% of both Mexico City inhabitants and Mexicans in general supported prohibiting smoking in enclosed public places and workplaces.²⁸ In 2006, 60% of smokers reported that their workplace had a smoking ban, with Mexico City smokers reporting the lowest percentage of workplace bans at 37%.²⁴Mexico City''s smoke-free workplace law^30–32 initially allowed for designated smoking areas that were ventilated and physically separate.^22,33 Concerns about the inequity of this law for small business owners who could not afford to build designated smoking areas led the hospitality industry to support a comprehensive smoke-free law^31,32 that prohibited smoking inside all enclosed public places and workplaces, including public transport, restaurants, and bars. This law entered into force on April 3, 2008.Media coverage of the law was similar to that in high-income countries, pitting arguments about the government''s obligation to protect citizens from SHS dangers against arguments about discrimination toward smokers and the “slippery slope” of regulating behavior^4,32,34 (J. F. Thrasher et al., unpublished data, 2010). Most print media coverage was either positive or neutral, with much less coverage pitched against tobacco control policies.³⁴In the month before and after the law came into effect, the Mexico City Ministry of Health and nongovernmental organizations disseminated print materials and aired radio spots describing the dangers of SHS and the benefits of the law.³⁰ Community health promoters informed businesses about the law. From September through December 2008, a television, radio, print, and billboard campaign emphasized the law''s benefits.³⁵ We assessed, among Mexico City inhabitants, the prevalence of and increases in support, beliefs, norms, and compliance around the smoke-free law, as well as decreases in SHS exposure.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.     

Smoking behavior of US youths: a comparison between child welfare system and community populations

Objectives. We compared rates of smoking for 2 groups of youths aged 12 to 14 years: those involved in the child welfare system (CW) and their counterparts in the community population. We then investigated factors associated with smoking for each group.Methods. We drew data from 2 national-level US sources: the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health. We estimated logistic regression models for 3 binary outcome measures of smoking behavior: lifetime, current, and regular smoking.Results. CW-involved youths had significantly higher rates of lifetime smoking (43% vs 32%) and current smoking (23% vs 18%) than did youths in the community population. For CW-involved youths, delinquency and smoking were strongly linked. Among youths in the community population, multiple factors, including youth demographics and emotional and behavioral health, affected smoking behavior.Conclusions. Smoking prevalence was notably higher among CW-involved youths than among the community population. In light of the persistent public health impact of smoking, more attention should be focused on identification of risk factors for prevention and early intervention efforts among the CW-involved population.Cigarette smoking among US youths persists as a critical public health problem. Notably, 80% to 90% of adult smokers initiate smoking by age 18 years.^1–3 Trends in smoking behavior among youths have not paralleled the steady decline evident among adult smokers.² Tobacco use is related to more than 400 000 US deaths per year, and direct medical costs attributable to smoking total more than $50 billion in the United States annually.^1,4 The public health importance of tobacco use is underscored by the Obama administration''s prioritization of smoking prevention and cessation.⁵Youths involved with the child welfare system (CW) face unique experiences that may put them at elevated risk for smoking compared with youths without similar experiences.^6,7 Youths enter the CW system as a result of case investigations conducted by local child protective services agencies. This population includes both youths receiving services in their homes and those in out-of-home care. The lives of CW-involved youths are characterized by problems such as child abuse, neglect, poverty, domestic violence, and parental substance abuse.⁸ Although CW cases are typically referred on the basis of parent behavior, these youths are also at high risk for mental health disorders, substance use, and other psychosocial problems.^6,8–10 However, we are unaware of any studies examining cigarette smoking among CW youths in comparison with community samples to determine whether a difference in smoking-prevalence risk exists for these youths. It is important to determine whether CW-involved youths are at higher risk for smoking so that targeted prevention and intervention strategies can be developed.Among community youths, studies have demonstrated that some subgroups (e.g., age, gender, race/ethnicity, region) are at higher risk for both lifetime and current smoking.² Boys are more likely to initiate smoking, but they smoke more infrequently than girls do.^2,11,12 Racial/ethnic minority youths smoke less than do their White peers.^11–13 Parent education and family structure are associated with lifetime, current, and regular smoking, with youths from households of lower socioeconomic status smoking at higher rates.^14–17Smoking is also linked to emotional well-being, including internalizing and externalizing behaviors and parent–child closeness. Depression is related to increased smoking behavior.^18–23 Engaging in delinquent acts is associated with increased youth smoking.^11,15,24 Youths who report having a close relationship with their parents are less likely to be regular smokers.²⁵Several longitudinal studies have connected youth smoking with behavioral outcomes in adolescence and adulthood. Early-onset smokers are 3 times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and engage in stealing and other delinquent behaviors.²⁶ In addition, long-term emotional and physical health—such as reduced adult life satisfaction, more severe nicotine dependence, and higher smoking quantities—are associated with youth smoking.^27,28Our purpose in the current study was to investigate whether CW-involved youths were at greater risk for smoking than were community youths and to determine whether factors associated with smoking behavior were similar among both populations. We focused explicitly on early adolescence because smoking initiation occurs most often between the ages of 12 and 14 years,^29,30 and early smokers face greater risk of later negative outcomes. We examined 3 distinct measures of smoking behavior: lifetime, current, and regular smoking. Each of these outcomes has a unique public health impact, and investigating them together provides a comprehensive picture of smoking across the 2 youth populations. We expected smoking rates to be higher for CW-involved youths than for community youths. Although there is a dearth of previous research on factors related to smoking behavior in the CW population, we expected some similarities between the groups, with demographic characteristics, family structure, and emotional and behavioral health being associated with smoking among CW-involved youths.     

Tobacco Smoke Incursions in Multiunit Housing

Objectives. We sought to describe the prevalence of secondhand tobacco smoke incursions reported by multiunit housing (MUH) residents, pinpoint factors associated with exposure, and determine whether smoke-free building policy was associated with prevalence of reported tobacco smoke incursions.Methods. Data are from a 2011 nationally representative dual-frame survey (random-digit-dial and Internet panels) of US adults aged 18 years and older. Individuals who lived in MUH and who reported no smoking in their homes for the past 3 months, whether or not they reported being smokers themselves, were included in this study. Incursions were defined as smelling tobacco smoke in their building or unit.Results. Of 562 respondents, 29.5% reported smoke incursions in their buildings. Of these, 16% reported incursions in their own unit, 36.2% of which occurred at least weekly. Government-subsidized housing and partial smoke-free policies were associated with a higher likelihood of reporting smoke incursions.Conclusions. Many residents of multiunit housing are exposed to tobacco smoke in their units and buildings. Partial smoke-free policies do not appear to protect residents and might increase the likelihood of incursions in residents’ individual units.The United States Surgeon General has extensively documented the harmful effects of smoking tobacco among adults1 and the negative effects of secondhand tobacco smoke (SHS) on both adults and children.2 Even brief exposures to SHS can result in sustained vascular injury3 and changes in endothelial function.4 In addition, studies have shown that very low levels of SHS exposure are associated with cognitive deficits5 and decreased antioxidant levels6 in children. Young children breathe faster than adults,7 have a tendency to mouth surfaces and objects,8 and may spend more of their time in the home,9 especially in places where outdoor activities might be perceived as unsafe.10 These all may increase their potential for tobacco smoke inhalation and ingestion.11 In a recent US Centers for Disease Control and Prevention study, 54% of children aged 3 to 11 years had biological evidence of SHS exposure; however, only 18% had a household member who smoked in the home,12 suggesting the significant contribution of other sources of tobacco smoke.Approximately 25% of US residents live in multiunit housing,13 where air circulation patterns facilitate the spread of tobacco smoke from unit to unit.14 Tobacco smoke permeates housing complexes through air ducts, cracks in the floor and walls, stairwells, hallways, elevator shafts, electrical lines, and open windows.15 US residents spend about 69% of their time in private residences16; thus, drifting smoke from other residences may provide a significant source of exposure for those in nonsmoking homes. A study of real-time SHS transfer in multiunit housing (MUH) between smoke-free and smoke-permitting units demonstrated incursions into both smoke-free units and adjacent hallways15; another study of low-income MUH in Boston, Massachusetts, demonstrated SHS contamination in homes where residents reported that neither household members nor visitors smoked.17 In an analysis of national data, cotinine levels for children living in apartments were 45% higher than for those living in detached homes.18 These studies suggest a significant role for SHS exposure in MUH. Recently, studies have begun to examine the prevalence of incursions in MUH. The first major national study discovered that 29% of US multiunit housing residents lived in a smoke-free building, and of those who did not but had voluntary smoke-free home rules, 44% reported incursions in their unit.19 In New York State, 46.2% of residents of MUH reported experiencing an incursion in their home, and more than 9% experienced incursions daily.20 Other local studies have shown similar rates of SHS incursions in MUH.21,22In 2012, the US Department of Housing and Urban Development (HUD) reissued recommendations that strongly encouraged all of their housing units go smoke-free23; however, this is not yet a requirement, and policies regulating SHS exposure in personal living spaces remain limited.22 Estimates show that although most residents of MUH would prefer to live in a smoke-free environment,20,22 most MUH developments do not have comprehensive smoke-free policies.22 We reported on a national survey of MUH residents to examine factors associated with tobacco smoke incursions. We hypothesized that type of smoke-free building policy (comprehensive, partial, or none) would be associated with prevalence of reported SHS incursions.     

Secondhand Smoke Exposure Among Young Adult Sexual Minority Bar and Nightclub Patrons

Objectives. We compared exposure to secondhand smoke (SHS) and attitudes toward smoke-free bar and nightclub policies among patrons of lesbian, gay, bisexual, and transgender (LGBT) and non-LGBT bars and nightclubs.Methods. We conducted randomized time–location sampling surveys of young adults (aged 21–30 years) in 7 LGBT (n = 1113 patrons) and 12 non-LGBT (n = 1068 patrons) venues in Las Vegas, Nevada, in 2011, as part of a cross-sectional study of a social branding intervention to promote a tobacco-free lifestyle and environment in bars and nightclubs.Results. Compared with non-LGBT bars and nightclubs, patrons of LGBT venues had 38% higher adjusted odds of having been exposed to SHS in a bar or nightclub in the past 7 days but were no less likely to support smoke-free policies and intended to go out at least as frequently if a smoke-free bar and nightclub law was passed.Conclusions. The policy environment in LGBT bars and nightclubs appears favorable for the enactment of smoke-free policies, which would protect patrons from SHS and promote a smoke-free social norm.Secondhand smoke (SHS) exposure increases the risk of cardiovascular disease, respiratory conditions, and cancer.1 Bars and nightclubs are tobacco-friendly environments that the tobacco industry uses as marketing and promotional venues.2–4 In the absence of a smoke-free law that covers bars and nightclubs, these venues can also have particularly high levels of SHS.5,6Bars and nightclubs have played an important role historically in the lesbian, gay, bisexual, and transgender (LGBT) rights movement, and they serve as a welcoming social venue.7,8 However, compared with non-LGBT venues, LGBT bars and nightclubs may be particularly tobacco friendly, because smoking rates are higher among LGBT than heterosexual individuals.9,10 According to the 2009 to 2010 National Adult Tobacco Use Survey, prevalence of tobacco use was significantly higher among LGBT than heterosexual participants (38.5% vs 25.3%).10 Also, the tobacco industry has targeted LGBT individuals and young adults with bar and nightclub advertisements and promotions.2,11,12 Previous studies with men who have sex with men conducted in Tucson, Arizona; Portland, Oregon; and Los Angeles, California, indicated an association between frequency of LGBT bar attendance and smoking.13,14 Although it is well established that LGBT individuals have high smoking rates,9,15 less is known about exposure to SHS in LGBT bars and nightclubs.Smoke-free laws, which restrict smoking in certain areas, are an important intervention to reduce or eliminate SHS exposure.5,6,16 Smoke-free policies have been shown to reduce asthma exacerbations and heart attacks17,18 and to contribute to smoking reduction or cessation.19 Smoke-free bar and nightclub environments might contribute to lowering rates of smoking among the LGBT population.Pizacani et al. examined attitudes about SHS in Oregon and Washington among heterosexual and LGB individuals and found no significant differences by sexual orientation among individuals living in Washington.20 However, among Oregon residents, gay smokers were more likely than heterosexual male smokers to support banning smoking in bars. In addition, lesbian nonsmokers living in Oregon were more likely than heterosexual female nonsmokers to support such a ban. McElroy et al. found that a lower percentage of LGBT than non-LGBT individuals in Missouri supported smoke-free bar policies; however, this difference was not significant after adjustment for other demographic factors.21 Kelly et al. found no difference in support for the New York state smoke-free law between LGBT and heterosexual individuals in New York City nightclubs.22 However, in a nationwide study, King et al. found significantly higher prevalence of support for smoke-free bars, casinos, and clubs among heterosexual than LGBT participants. (49.5% vs 43.0%)23Nevada has historically lagged behind the nation in enacting smoke-free policies.24 In 2001, Nevada ranked last in percentage of employees covered by a smoke-free policy. Between 1993 and 1999, the percentage of employees covered ranged from 33.3% to 48.7%. By 1999, Nevada was the only state with fewer than half of employees covered by a smoke-free policy.24 In 2006, Nevada passed a state smoke-free law that exempted bars, nightclubs, and gaming areas. This law also removed preemption, allowing local communities to pass stronger smoke-free policies.25 As of January 2013, bars and nightclubs in Nevada were still exempt from the smoke-free law.26We compared SHS exposure and attitudes toward smoke-free bars and nightclubs among patrons of LGBT and non-LGBT bars and nightclubs in Las Vegas, Nevada, in 2011. We assessed (1) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of past-7-day exposure to SHS in a bar or nightclub, (2) whether frequently going out to LGBT venues was an independent predictor of 7-day exposure to SHS in a bar or nightclub, (3) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of intention to continue to go out as frequently as before if a smoke-free law was enacted, and (4) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of opposition to smoke-free bar and nightclub policies.     

Impact of State Cigarette Taxes on Disparities in Maternal Smoking During Pregnancy

Objectives. We evaluated the impact of state tobacco control policies on disparities in maternal smoking during pregnancy.Methods. We analyzed 2000–2010 National Vital Statistics System natality files with 17 699 534 births from 28 states and the District of Columbia that used the 1989 revision of the birth certificate. We conducted differences-in-differences regression models to assess whether changes in cigarette taxes and smoke-free legislation were associated with changes in maternal smoking during pregnancy and number of cigarettes smoked. To evaluate disparities, we included interaction terms between maternal race/ethnicity, education, and cigarette taxes.Results. Although maternal smoking decreased from 11.6% to 8.9%, White and Black women without a high school degree had some of the highest rates of smoking (39.7% and 16.4%, respectively). These same women were the most responsive to cigarette tax increases, but not to smoke-free legislation. For every $1.00 cigarette tax increase, low-educated White and Black mothers decreased smoking by nearly 2 percentage points and smoked between 14 and 22 fewer cigarettes per month.Conclusions. State cigarette taxes may be an effective population-level intervention to decrease racial/ethnic and socioeconomic disparities in maternal smoking during pregnancy.A substantial literature has demonstrated the success of cigarette taxes on decreasing adult smoking.1–3 State taxes in 2013 ranged from $0.17 in Missouri to $4.35 in New York,4 and 2010 smoking levels in women were at 17%.5 Low-income adults, a group with the highest levels of smoking,5 have been shown to be more sensitive to tax increases.2,6 Despite racial/ethnic differences in smoking rates,5 less is known about whether responsiveness to taxes also varies.7 Over the past decade, many US states have enacted smoke-free legislation in the workplace, restaurants, or both in addition to increasing cigarette taxes. Although the aim of smoke-free policies is to protect nonsmokers from secondhand smoke, for which they have been very effective,8,9 the evidence for their impact on smoking rates is limited.1,9,10Despite these achievements, a population that has received little attention is pregnant women. The detrimental effects of smoking on maternal and fetal health11 and other household members through secondhand smoke exposure are well known.12 Although pregnancy is often a time of positive behavioral change, as of 2008, 10% to 15% of women smoked during pregnancy.13–15 However, these overall estimates masked racial/ethnic and socioeconomic gradients, such that 16% of White, 9% to 10% of Black, and 2% to 4% of Hispanic mothers smoked during pregnancy,14,15 and women with 12 or less years of education were more than 3 times (19.4%–22.3%) as likely to smoke during pregnancy as women with more than 12 years of education (6.5%).15Previous studies using data from the 1990s have found that pregnant women are responsive to cigarette tax increases.16–19 Ringel and Evans16 used population-level data from 1989 through 1995 and found that every $1.00 increase in cigarette taxes decreased smoking by 6.6 percentage points but had no effect on the number of cigarettes smoked daily. Specifically, they found that women who were White, older, and higher educated were the most responsive to tax changes.16 However, smoking patterns, social norms, and the politics related to tobacco control have changed over the past 20 years. A more recent study by Adams et al.20 used state-representative data from 2000 through 2005 to assess both tax changes and smoke-free policies on quitting during pregnancy. They found that a $1.00 cigarette tax increase was associated with a 4.8 percentage point increase in quitting smoking, and a full smoking ban at private worksites increased quit rates by 5.1 percentage points.20 However, they were unable to examine racial/ethnic or socioeconomic differences because of small sample sizes.A substantial gap in the literature remains, specifically, the effect of recent tobacco control policies on smoking levels among those mothers at the highest risk for smoking. We were able to use population-level data to exploit the natural experiment created through cigarette tax increases and the enactment of smoke-free legislation across and within US states over the past decade. Our first aim was to examine disparities in maternal smoking during pregnancy across and within racial/ethnic groups and, second, to evaluate the impact of state tobacco control policies on disparities in maternal smoking.     

The Effect of Household Smoking Bans on Household Smoking

Objectives. Because household smoking levels and adoption of domestic smoking rules may be endogenously related, we estimated a nonrecursive regression model to determine the simultaneous relationship between home smoking restrictions and household smoking.Methods. We used data from a May–June 2012 survey of Philadelphia, Pennsylvania, households with smokers (n = 456) to determine the simultaneous association between smoking levels in the home and the presence of home restrictions on smoking.Results. We found that home smoking rules predicted smoking in the home but smoking in the home had no effect on home smoking restrictions.Conclusions. Absent in-home randomized experiments, a quasi-experimental causal inference suggesting that home smoking rules result in lower home smoking levels may be plausible.Secondhand smoke (also known as “passive smoking” or “environmental tobacco smoke”) is a health hazard for children and adults.1–5 Institutional, city, or national smoking restrictions reduce smoking prevalence and the average consumption of smokers while naturally limiting exposure to secondhand smoke.6–11 At the household level, the research focus has been on the efficacy of household bans on indoor smoking to reduce nonsmokers’ and children’s exposure.12–18 Many studies have found that smokers in households with smoking bans or restrictive smoking rules smoke fewer cigarettes than smokers in households with no bans or rules.19–23 This relationship appears to suggest that household smoking restrictions are effective in reducing household smoking. But do household bans really reduce household smoking? Unfortunately, this situation is not the same as when smoking bans are implemented in bars,24,25 hospitals,26 prisons,27 schools,28 or countries.29,30 In all of these examples, the bans are introduced independently of the prevalent smoking levels of the institution, city, or country because passive smoking exposure is seen as an important health hazard that requires an administrative or legislative response.In households, this analogy does not necessarily hold. Household smoking could be negatively related to household smoking bans because smokers who smoke fewer cigarettes or households with little smoking may implement a household smoking ban whereas heavier smokers or households with multiple smokers could not do so.23,31 In this situation, household smoking bans are endogenous32 relative to household smoking, which implies that household smoking levels cause the smoking ban, not the reverse. To determine which explanation is correct, an experiment that implemented a household ban randomly in regard to household smoking levels would be appropriate.14,33,34 Under experimental conditions, the ban would be independent of household smoking levels and the effect of implementing a household smoking ban on smoking could be unambiguously estimated.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

Factors Influencing Adoption of and Adherence to Indoor Smoking Bans Among Health Disparity Communities

Objectives. We assessed current home smoking behaviors and secondhand smoke (SHS) levels among parents of children in low-income, racial/ethnic minority communities in Massachusetts.Methods. We used a cross-sectional design to assess home smoking rules, smoking status, cigarettes smoked in the home, and barriers and benefits to attaining a smoke-free home among 138 caregivers (mean age = 30.0 years; 92% women) of children aged 0 to 6 years, between April 2010 and September 2012. Indoor SHS was assessed using a nicotine dosimeter.Results. Households with no ban reported a higher weekly mean number of cigarettes smoked in the home (114 cigarettes/week) than homes with partial (71 cigarettes/week) or complete (30 cigarettes/week) bans (P < .01). Smoking occurred outside more than inside homes with partial or complete bans. Air nicotine levels were positively associated with no household smoking ban, current smoking by the caregiver, and smoking indoors.Conclusions. Strategies to reduce home SHS should focus on a “complete” home smoking ban and smoking cessation. SHS mitigation strategies such as smoking outside were associated with lower SHS among participants unable to maintain a complete ban, and might enhance the likelihood of longer term success while immediately reducing home SHS.Secondhand smoke (SHS) exposure is associated with serious pediatric illnesses, yet is entirely preventable.1 Children’s exposure to SHS occurs chiefly in domestic environments, including the home and car.2,3 SHS exposure varies by income, race, and parental education,4 and the likelihood of exposure to SHS tends to be higher among African American and low socioeconomic status (SES) groups.5 Children from low-income backgrounds are at greater risk for SHS exposure and share a disproportionate burden of disease.6–8 Young children (aged 6 years and younger) from lower SES communities are 3 times more likely to be exposed to the highest levels of SHS in the home (≥ 4 days/week) as children from middle- and high-income groups.9 Recent data indicate that the percentage of households with a voluntary smoke-free rule has risen nationwide.3,10 In 1995, approximately 58% of homes in the United States were reportedly smoke-free, whereas more recent data suggest that this percentage now approaches 84%.11 This figure may be higher in homes in which children are present.10 Despite the increase in smoke-free homes, children’s cotinine levels (an index of SHS exposure) have remained steady since 2000.12 This may be explained, in part, by incomplete or diminishing adherence to self-imposed home smoking bans. However, little research has been conducted to understand the factors associated with implementation and adherence to home smoking bans, including facilitators and barriers to the maintenance of a smoke-free home.Although efficacious interventions to help families establish smoke-free home rules have been widely reported,13 strategies to tailor those interventions to the needs of low-income and minority race/ethnicity communities have so far been limited.14,15 Complete home smoking bans are associated with lower SHS16,17; however, a better understanding is needed of current home smoking behaviors and attitudes among parents of young children in low-income minority communities. Such questions might appropriately be posed in Massachusetts—a state in which the prevalence of children’s exposure to SHS in the home ranks well below the median of US states,4 yet where public health efforts have so far failed to provide protection from SHS exposure for 4.3% (an estimated 61 000) of Massachusetts children.4,18 Nevertheless, it is possible that microlevel changes directed at mitigating SHS exposure have occurred within homes that have not become completely smoke-free. Limiting the number of cigarettes smoked inside a home may directly reduce SHS,17 which, in turn, may influence children’s exposure to SHS.8 Behavioral strategies intended to mitigate SHS exposure, such as smoking outdoors, may be an underinvestigated (albeit suboptimal)19 strategy used in households where a ban has either not been implemented or successfully maintained.To more fully understand home smoking practices among communities of low income and racial and ethnic diversity, we sought to identify who adopted and who adhered to a voluntary home smoking ban, the barriers and perceived benefits to adherence, and the impact of those bans on home smoking behaviors (including mitigation strategies), using a cross-sectional study design. In addition, the number of smokers in the household, their age, race and ethnicity, the number and location (within the home or attached external structure) of cigarettes smoked, and strategies employed to reduce SHS exposure were documented. Finally, indoor air quality was measured by nicotine levels to characterize factors associated with home SHS levels.     

Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

Objectives. We examined loose cigarette (loosie) purchasing behavior among young adult (aged 18–26 years) smokers at bars in New York City and factors associated with purchase and use.Methods. Between June and December 2013, we conducted cross-sectional surveys (n = 1916) in randomly selected bars and nightclubs. Using multivariable logistic regression models, we examined associations of loose cigarette purchasing and use with smoking frequency, price, social norms, cessation behaviors, and demographics.Results. Forty-five percent (n = 621) of nondaily smokers and 57% (n = 133) of daily smokers had ever purchased a loosie; 15% of nondaily smokers and 4% of daily smokers reported that their last cigarette was a loosie. Nondaily smokers who never smoked daily were more likely than were daily smokers to have last smoked a loosie (odds ratio = 7.27; 95% confidence interval = 2.35, 22.48). Quitting behaviors and perceived approval of smoking were associated with ever purchasing and recently smoking loosies.Conclusions. Loosie purchase and use is common among young adults, especially nondaily smokers. Smoking patterns and attitudes should be considered to reduce loose cigarette purchasing among young adults in New York City.Widespread adoption of clean indoor air laws and cigarette tax increases denormalize smoking behavior1 and decrease smoking rates.2,3 Although increasing taxes is one of the most effective means of smoking prevention and reduction,3 the increased price of cigarettes can also lead to tax-avoidant behaviors, such as buying untaxed packs smuggled from states with lower cigarette taxes and purchasing loose cigarettes, or “loosies.”4–6 In New York City (NYC), where a cigarette pack costs about $11.50, it has become common for smokers to purchase discounted packs and individual cigarettes from street peddlers and friends.7,8Much of the research exploring loosie purchasing in the United States has focused on underage or low-income minority populations, often in urban areas.7,9,10 One study found that in early 1993, 70% of stores in central Harlem sold loosies to minors.7 Another study conducted with a 2005–2006 convenience sample in inner-city Baltimore found that 77% of African American smokers aged 18 to 24 years had purchased loosies in the past month.11 Similarly, loosie purchasing in Mexico was more common among younger smokers with lower incomes.12Availability and visibility of loosies can promote smoking and encourage relapse.13 We defined nondaily smokers as those who smoked on 1 to 29 of the past 30 days.14,15 Shiffman et al. found that nondaily smokers were more likely than daily smokers to report that social and environmental stimuli motivated their smoking behavior.16 More specifically, cues such as taste, smell, social goading to smoke, and specific situations (e.g., smoking after meals) are more likely to be reported as motivators to smoke by nondaily smokers than by daily smokers.16 Because social–environmental cues have substantial impact on nondaily smokers’ motivation to smoke, it is likely that the cue of seeing loosies in one’s environment also motivates nondaily smokers to smoke.16Previous research substantiates this claim, with 1 study showing that people who regularly saw loosies available for purchase were more likely to be current smokers.17 Therefore, the widespread availability of loosies may have a greater impact on nondaily smokers. Nondaily smokers make up a third of US smokers,18,19 and nondaily smoking is increasingly common among young adults.20 Many young adults who smoke on only some days do not self-identify as smokers,21 and nondaily smoking is frequently paired with alcohol consumption.22–24 Nondaily and light smoking carry a lower, but substantial, risk for lung cancer and a similar risk as does daily smoking for cardiovascular disease.25–27 Occasional smokers also have higher smoking-related morbidity and mortality than do people who have never smoked.26,28–30Nondaily smoking can be a long-term behavior pattern31,32 or a transition to or from daily smoking.31 Nondaily smokers include different subgroups that may have very different smoking patterns or motivations to quit.33,34 Nondaily smokers who previously smoked daily have been defined in previous research as converted nondaily smokers. Nondaily smokers who have never smoked daily are defined as native nondaily smokers.18,19 Important differences exist between these subgroups of smokers: converted nondaily smokers are more likely to quit smoking than are native nondaily smokers and daily smokers,18,19 although most converted and native nondaily smokers were unable to remain abstinent for more than 90 days.19Loosie purchasing and use may play an important role in promoting continued tobacco use among nondaily smokers. The 2010 NYC Community Health Survey35 found that more than one third (34%) of young adult nondaily smokers (aged 18–26 years) reported that their last cigarette smoked was a loosie, compared with 14% of young adult daily smokers. Another study of NYC adults demonstrated that nondaily smokers were more likely to purchase loose cigarettes than were light and heavy smokers.36 To the best of our knowledge, little is known about the factors associated with loosie purchasing among nondaily smokers in the United States.We sought to better understand the factors associated with loosie purchasing among NYC young adults, specifically to determine (1) loosie purchase and use rates among converted nondaily, native nondaily, and daily smokers; (2) whether loosie purchase or use are associated with perceived social norms of smoking behavior; and (3) whether loosie purchasing is associated with smoking cessation intention or behavior.     

Transitions in Smoking Behavior During Emerging Adulthood: A Longitudinal Analysis of the Effect of Home Smoking Bans

Objectives. We studied the effect of home smoking bans on transitions in smoking behavior during emerging adulthood.Methods. We used latent transition analysis to examine movement between stages of smoking from late adolescence (ages 16–18 years) to young adulthood (ages 18–20 years) and the effect of a home smoking ban on these transitions. We used data from the Minnesota Adolescent Community Cohort study collected in 2004 to 2006.Results. Overall, we identified 4 stages of smoking: (1) never smokers, (2) experimental smokers, (3) light smokers, and (4) daily smokers. Transition probabilities varied by stage. Young adults with a home ban during late adolescence were less likely to be smokers and less likely to progress to higher use later. Furthermore, the protective effect of a home smoking ban on the prevalence of smoking behavior was evident even in the presence of parental smoking. However, this effect was less clear on transitions over time.Conclusions. In addition to protecting family members from exposure to secondhand smoke, home smoking bans appear to have the additional benefit of reducing initiation and escalation of smoking behavior among young adults.Cigarette smoking, particularly among young people, continues to be a major public health concern. Although initiation rates have declined for adolescents, initiation rates among young adults have risen.1 Also, of all age groups, young adults have the highest prevalence of current cigarette smoking.2 Therefore, developing effective interventions for this population is a public health priority.Young or emerging adulthood is typically defined as 18 to 25 years of age and is marked by important transitions such as increased autonomy in decision-making and fewer social constraints than during adolescence.3 It also represents a time for increased vulnerability for both the initiation of smoking and nicotine addiction.4 This period of emerging adulthood may be an important, yet often overlooked, age for formation of long-term health behaviors such as smoking.Relatively little research has examined transitions and trajectories of smoking behaviors among young adults.5 Most researchers have used person-centered techniques such as growth curve and growth mixture modeling to explicitly model the heterogeneity in developmental processes and, in the process, have identified several distinct patterns of smoking trajectories from adolescence to young adulthood.6–9 These approaches assume progression to be continuous instead of incremental (i.e., stage sequential); therefore, smoking must be modeled as a continuous function of time. Growth curves and growth mixture modeling are not as appropriate in situations characterized by a high degree of movement into and out of stages over time, which may be especially relevant to the onset and progression of smoking during emerging adulthood.10 An alternative approach is to take a person-centered approach such as Markov models10,11 and latent transition analysis2 to examine person-specific patterns of developmental stages. This approach has been applied to the study of smoking behavior2,11 but not extensively to the study of smoking behaviors in emerging adulthood.Multiple social, psychological, and environmental factors have been found to influence smoking progression and have been extensively studied as antecedents or correlates of trajectories of smoking.6,8 Among these, home smoking bans have emerged as an important yet understudied protective factor. Although the primary goal of a home ban is to protect children and adult nonsmokers from secondhand smoke,12 recent evidence suggests that home smoking restrictions promote antismoking attitudes and reduce initiation and progression of smoking behavior among adolescents by changing norms about the prevalence and social acceptability of smoking.13–15 Additionally, adult smokers with a home ban are more likely to quit and remain nonsmokers.16 As noted by Albers et al.,17 youths with a smoking ban in their parental homes are more likely to prefer smoke-free housing as independently living young adults. In essence, establishing a home ban has a long-term and even intergenerational effect on promoting nonsmoking attitudes and norms among young adults.17 Individuals with home bans also are more likely to support clean indoor air laws, crucial to tobacco prevention efforts.18A recent literature review on the association between home bans and youth smoking reported reduced smoking among adolescents with a home ban.19 As noted by Emory et al.,19 a few studies also investigated the moderating effect of parental smoking, and most studies found either an association or a stronger association between home smoking restrictions and reduced smoking in homes without parental smoking or an adult smoker. However, 2 studies found that home bans significantly lowered smoking rates, regardless of parental smoking, underscoring the salience of a home ban.14,20 All but 2 of the studies in this review were cross-sectional, and more important, none of the studies examined the effect of a home ban on stage-sequential transitions or the effect on smoking behaviors in emerging adulthood. Therefore, despite previous important findings, relatively little is known about the prospective effect of home smoking restrictions on smoking behavior during emerging adulthood, especially in the presence of parental smoking.19The main goals of this study were to (1) identify distinct stages of smoking behavior and examine within-individual transitions in smoking from late adolescence (ages 16–18 years) to young adulthood (ages 18–20 years) in a population-based cohort sample and (2) evaluate whether a home smoking ban during late adolescence influences the prevalence of smoking and transitions into and out of smoking stages in young adulthood and whether the effect of a home ban differs by parental smoking status.     

“They’re Going to Die Anyway”: Smoking Shelters at Veterans’ Facilities

Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities.Despite strong VA support, the tobacco industry created a public relations–focused grassroots veterans’ opposition group, eventually pushing the US Congress to pass a law requiring smoking areas in every VA health facility. Arguing that it would be unpatriotic to deny veterans this “freedom” they had ostensibly fought for and that banning smoking could even harm veterans’ health, industry consultants exploited veterans’ organizations to protect tobacco industry profits.Civilian public health advocates should collaborate with veterans to expose the industry’s manipulation, reframe the debate, and repeal the law.THE US MILITARY, COMPOSED primarily of working-class young people, has long been an important source of new smokers for the tobacco industry.1 Although approaching civilian prevalence in recent years,2 tobacco use among military personnel has historically been much higher than that among civilian populations, resulting in greater morbidity and mortality among veterans.3 The tobacco industry has repeatedly interfered with the military’s attempts to discourage smoking.4–6 The tobacco industry exerts influence on civilian overseers of the military through campaign contributions to Congress members, especially those from tobacco-growing states.7 Congress has berated and intimidated military leaders who promote tobacco control4,6 and has written industry-favored policies into law.5,6On discharge from service, the interests of the 24 million veterans of the US armed services are overseen by the Department of Veterans Affairs (VA).3 In 2007, one third of veterans were enrolled in the VA’s health care system, which includes 171 hospitals throughout the United States.8 Veterans smoke at higher rates than do nonveterans,9 are more likely to die prematurely,10 and incur high costs for treating tobacco-caused illnesses.3 For example, each year the VA spends $5 billion to treat chronic obstructive pulmonary disease, 80% of which is attributable to smoking.3 Whether veterans or governments bear the costs, many veterans experience shortened lifespans, physical suffering, and financial hardship because of tobacco use.By the late 1980s, nearly all civilian hospitals prohibited indoor smoking.11,12 In March 1991, the Joint Commission on the Accreditation of Healthcare Organizations, now the Joint Commission, declared that “Accredited hospitals will have to disseminate and enforce a hospitalwide no-smoking policy.”11 Since that time, many hospitals have established not only smoke-free buildings but also smoke-free grounds, partly as a result of concerns about risks of exposure to outdoor secondhand smoke.13 Knowledge about the benefits of cessation, even late in life, has expanded,14 and studies now show that quitting smoking before surgery can lead to better outcomes.15 Denormalizing smoking16,17 and reducing its visibility18 may improve cessation rates, and cessation tends to spread through social networks.19 Smoke-free health facilities, thus, have the potential to improve the health of patients with direct cessation support and by establishing and promoting tobacco-free norms.Although, like many civilian hospital systems, the VA took steps to restrict smoking and tobacco sales at its health care facilities, the tobacco industry, acting through a front group, persuaded Congress to require smoking areas in all VA hospitals. In this archival case study, we explored the enduring legacy of this action and drew lessons for addressing tobacco’s contributions to veterans’ disease burden.     

Measuring Indoor Air Quality of Hookah Lounges

Many states have implemented smoke-free workplace laws to protect employees and customers from exposure to secondhand smoke. However, exemptions in these laws have allowed indoor tobacco smoking in hookah lounges to proliferate in recent years. To describe the amount of secondhand smoke in hookah lounges, we measured the indoor air quality of 10 hookah lounges in Oregon. Air quality measurements ranged from “unhealthy” to “hazardous” according to Environmental Protection Agency standards, indicating a potential health risk for patrons and employees.Hookahs are pipes used to smoke flavored, sweetened tobacco. Hookah tobacco smoke contains tar, carbon monoxide and other toxins found in cigarette smoke, and in a typical hookah session, smokers inhale more than 40 times the volume of smoke produced by a cigarette.1–3 Hookah lounges are businesses that provide an indoor environment for hookah smoking and sell hookah tobacco in dozens of candy and fruit flavors.4 Indoor smoking in hookah lounges can expose employees and customers to secondhand smoke. Many states have implemented comprehensive smoke-free workplace laws that protect employees and patrons from exposure to secondhand smoke.5 Whereas some laws ban all tobacco use, others include exemptions which have allowed hookah lounges to proliferate.6,7Tobacco smoke is a mixture of chemical compounds that are bound to aerosol particles or are free in the gas phase.8 The concentration of particulate matter in the air is a strong indicator of pollution from tobacco smoke. Studies have measured particulate matter from cigarette smoke in bars and restaurants that allow indoor smoking, revealing employees and customers were exposed to hazardous levels of air pollution.9–11 Hookah smoke contains many of the same toxins as cigarette smoke2,3 and has been associated with lung cancer, respiratory illness, low birth weight, and periodontal disease.12 Laboratory studies have measured the chemical components of hookah smoke, and carbon monoxide levels have been measured in patrons exiting a hookah lounge.1–3,13 However, no study to date has described the concentration of particulate matter in the air inside hookah lounges. This study fills a research gap by analyzing the air quality inside hookah lounges in Oregon.     

Prevalence,Harm Perceptions,and Reasons for Using Noncombustible Tobacco Products Among Current and Former Smokers

Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.The use of noncombustible tobacco products has increased rapidly in recent years1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes.4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette,9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption.10 These products are marketed to appeal to unique target audiences,9,11–13 such as smokers and young adults, and vary in levels of harmful constituents.9Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris14,15 and RJ Reynolds16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products.17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product.18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 201219,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes21,22 and Altria’s MarkTen e-cigarettes.23Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes,24,25 rising to nearly 60% in 201125; awareness approached 75% among current and former smokers in 2010 to 2011.26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette,24,25,27,28 including up to 21.2% of current smokers.25,26 More than 40% of adults have heard of snus,29 5% have tried the product,29 and 1.4% are current users.30 Awareness of dissolvables is low (10%), and use is even lower (0.5%).29 Noncombustible tobacco product use is highest among young adults26,31 and smokers.24,27,28Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes,32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation.12,34–37 For example, a study by Wetter et al.38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product.31 Dual use is more prevalent among men,39,40 those of lower socioeconomic status,39,41 and youths and young adults.35,41,42Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes,24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes.29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money.43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco,34,44 express skepticism that the products are safer than cigarettes,34 do not view them as substitutes for cigarettes,34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes.44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors.45With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.     

Association of Campus Tobacco Policies With Secondhand Smoke Exposure,Intention to Smoke on Campus,and Attitudes About Outdoor Smoking Restrictions

College campus tobacco-free policies are an emerging trend. Between September 2013 and May 2014, we surveyed 1309 college students at 8 public 4-year institutions across California with a range of policies (smoke-free indoors only, designated outdoor smoking areas, smoke-free, and tobacco-free).Stronger policies were associated with fewer students reporting exposure to secondhand smoke or seeing someone smoke on campus. On tobacco-free college campuses, fewer students smoked and reported intention to smoke on campus. Strong majorities of students supported outdoor smoking restrictions across all policy types.Comprehensive tobacco-free policies are effective in reducing exposure to smoking and intention to smoke on campus.Exposure to tobacco smoke harms nearly every organ of the body.1 Young adults smoke at rates higher than any other age group,2 likely in part because the tobacco industry aggressively markets to young adults3 as the youngest age group that they can legally target. Between 2001 and 2011, undergraduate enrollment increased 32% from 13.7 million to 18.1 million, with 42% of young adults (aged 18–24 years) attending a 2- or 4-year college or university. The National Center for Educational Statistics projects that this trend will continue, with a 13% increase in enrollment of students aged 24 years and younger from 2011 to 2021.4 Colleges are rapidly adopting a range of policies on tobacco, including tobacco-free policies that prohibit tobacco use on the entire grounds for students, faculty, staff, and visitors.Smoke-free college campus policies have been associated with a drop in student smoking rates.5 On North Carolina college campuses, as tobacco policy strength increased (none, designated areas, or tobacco-free), less cigarette butt litter was found on the ground outside building entrances.6 As tobacco control advocates shift focus to promoting comprehensive tobacco-free policies, a more nuanced understanding of the benefits of these policies is necessary.Previous research has indicated that college smoke-free policies lead to a reduction in student smoking rates,5 and strength of policy is linked to cigarette butt litter on college campuses.6 The purpose of this study was to examine the relationship between the strength of the tobacco policy and exposure to secondhand smoke, seeing someone smoking, and intention to smoke on campus. We studied a range of policies on 8 public 4-year colleges and universities in California and found that the stronger the policy provisions, the lower the reported exposure to secondhand smoke, and seeing someone smoking. In addition, students on the tobacco-free campuses reported the lowest intention to smoke on campus in the next 6 months.     

Smoking Initiation Associated With Specific Periods in the Life Course From Birth to Young Adulthood: Data From the National Longitudinal Survey of Youth 1997

Objectives. Guided by the life-course perspective, we examined whether there were subgroups with different likelihood curves of smoking onset associated with specific developmental periods.Methods. Using 12 waves of panel data from 4088 participants in the National Longitudinal Survey of Youth 1997, we detected subgroups with distinctive risk patterns by employing developmental trajectory modeling analysis.Results. From birth to age 29 years, 72% of female and 74% of US males initiated smoking. We detected 4 exclusive groups with distinctive risk patterns for both genders: the Pre-Teen Risk Group initiated smoking by age 12 years, the Teenage Risk Group initiated smoking by age 18 years, the Young Adult Risk Group initiated smoking by age 25 years, and the Low Risk Group experienced little or no risk over time. Groups differed on several etiological and outcome variables.Conclusions. The process of smoking initiation from birth to young adulthood is nonhomogeneous, with distinct subgroups whose risk of smoking onset is linked to specific stages in the life course.Studies suggest that there have been recent increases in adolescent smoking in the United States.1,2 More effective prevention requires further understanding of tobacco use etiology. Numerous researchers have documented the timing and risk of early onset of tobacco use.3–8 Although children as young as 4 to 5 years have reported smoking,3,4 the hazard of smoking onset (defined as the probability for a never-smoker to initiate smoking during a 1-year period) is relatively low (0%–3%) before age 10 years.3–6 The risk then increases rapidly to peak at around age 14 to 16 years, with initiation rates ranging from 5% to 15%, depending on study population and time of measurement, before it declines.3–6 The risk of smoking initiation in later adolescence and early adulthood remains at less than 10%.9–13Despite this general age pattern of the risk of smoking onset, it remains unclear whether there are actual subgroups with unique risk curves associated with different developmental periods. Most studies of smoking risk trajectories are based, either implicitly or explicitly, on the assumption that 1 probability curve quantifies the risk of smoking onset for all individuals across ages and developmental periods, which may not be the case. An additional limitation of the current literature is that much of the previous research has relied on cross-sectional or brief longitudinal samples of adolescents rather following adolescents through young adulthood.According to the life-course perspective,14–16 the interplay of intrapersonal factors and environmental factors determines who is at risk for smoking initiation at what time periods (i.e., ages). Such influential factors may include age- and development-related differences in individual vulnerability to tobacco use17 and external influences such as peer pressure, parental monitoring, and social support.11,18–20 Therefore, the process of smoking onset may not be homogeneous but diverse, involving subgroups of individuals with unique time patterns corresponding to different developmental periods in the life span.In general, very young children and adolescents are less likely than older adolescents to be self-motivated to smoke.21 Rather, children are likely to be influenced by external factors, such as parents and peers.22–24 For example, some young adolescents may be left home alone around friends who smoke; they may mimic others and simply pick up a cigarette. Those who pass through preadolescence without smoking may face new risks in high school. Most youths have more freedom from their parents in high school than they did previously. The increased unsupervised time allows adolescents more opportunities to start smoking when they feel the need, such as being with other smokers or feeling stressed or depressed.25,26 Research among young adults (primarily college students) indicates that lack of self-efficacy, being more rebellious, and previous use of other substances are among the most influential factors for smoking onset in this period.10,11,18Further support for the existence of subgroups for smoking initiation is the research finding of subgroups with different trajectories in frequency and amount of tobacco use.27–38 Labels vary, but typical subgroups reported by these studies include nonsmokers, occasional smokers, early and late stable smokers, escalators, and quitters. Although not linked to specific developmental periods, each subgroup has its own risk curve across the age span from adolescence to young adulthood. Additionally, researchers have found significant differences in a variety of factors among trajectory subgroups, including gender, race/ethnicity, mental health, and parental monitoring.27–38 A landmark longitudinal study found that early stable smokers had more smoking friends than experimenters, abstainers, late stable smokers, and quitters; abstainers were more likely than early and late stable smokers to have enrolled in college; and late stable smokers were least likely to be married.31We are not aware of other research examining subgroups with time patterns of smoking onset risk that are directly linked to specific periods in the life span, which has direct implications for smoking prevention. Guided by the life-course perspective, we used 12 rounds of panel data from a nationally representative sample. Our goals were to detect subgroups with distinctive time patterns regarding likelihood of smoking initiation and then to determine whether the detected subgroups varied systematically by established risk factors in adolescence and outcome measures in young adulthood.     

Household smoking bans and adolescent antismoking attitudes and smoking initiation: findings from a longitudinal study of a Massachusetts youth cohort

Objectives. We sought to determine whether adolescents living in households in which smoking was banned were more likely to develop antismoking attitudes and less likely to progress to smoking compared with those living in households in which smoking was not banned.Methods. We completed a longitudinal 4-year, 3-wave study of a representative sample of 3834 Massachusetts youths aged 12 to 17 years at baseline; 2791 (72.8%) were reinterviewed after 2 years, and 2217 (57.8%) were reinterviewed after 4 years. We used a 3-level hierarchical linear model to analyze the effect of a household ban on antismoking attitudes and smoking behaviors.Results. The absence of a household smoking ban increased the odds that youths perceived a high prevalence of adult smoking, among both youths living with a smoker (odds ratio [OR] = 1.56; 95% confidence interval [CI] = 1.15, 2.13) and those living with nonsmokers (OR = 1.75; 95% CI = 1.29, 2.37). Among youths who lived with nonsmokers, those with no home ban were more likely to transition from nonsmoking to early experimentation (OR = 1.89; 95% CI = 1.30, 2.74) than were those with a ban.Conclusions. Home smoking bans may promote antismoking attitudes among youths and reduce progression to smoking experimentation among youths who live with nonsmokers.The proliferation of US smoke-free workplace policies and laws over the past decade has been accompanied by increased attention to private household smoking restrictions. The number of US households with comprehensive rules that make homes smoke free in all areas at all times has increased substantially.¹ The proportion of US households with smoke-free home rules increased from 43% in 1992 to 1993 to 72% in 2003.² Even smokers appear to be increasingly adopting such rules, particularly in homes in which they live with a nonsmoking adult.Although smoke-free home bans are typically implemented to reduce or eliminate environmental tobacco smoke exposure in the household, these bans may have the additional benefit of reducing the initiation of smoking among youths by changing norms about the prevalence and social acceptability of smoking. Very little is known about the specific effect of a household smoking ban on youth smoking behavior or on smoking-related attitudes and norms that may mediate an effect on smoking behavior. In particular, few studies have addressed the independent effect of bans on youths who live with smokers—those who are at the greatest risk for becoming smokers themselves.Recent studies showed that strong smoking regulations in local restaurants and bars were associated with more negative attitudes among youths toward the social acceptability of smoking in restaurants and bars.^3–6 Establishing household smoking bans conveys to youths living within these smoke-free home environments the message that smoking is unacceptable. Some supportive evidence, derived from cross-sectional data, indicates that a household smoking ban is associated with antismoking attitudes and norms. A recent cross-sectional study found that a household ban was associated with a lower perceived prevalence of adult smoking and more-negative attitudes about the social acceptability of smoking, 2 factors that affect the likelihood of smoking initiation.⁷Several cross-sectional studies have reported that a smoking ban in the household was associated with a lower likelihood of being in an earlier stage of smoking and a lower current smoking prevalence among adolescents.^8–11 Conversely, other studies found no statistically significant association between a household smoking ban and reduced adolescent smoking.^12–14 Several factors may account for these conflicting results, including varying sample sizes, age groups, and smoking measures used in these cross-sectional studies.A critical question is whether antismoking socialization occurs when parents themselves smoke. One study found that a household smoking ban was related to lower levels of smoking onset for children with nonsmoking parents but not for children with 1 or more parent who smoked.¹⁵ Another study reported that a household smoking ban was not associated with trying smoking among high school students who had 1 or more parents who were current or former smokers.¹⁶ Only 1 study reported an association between a household smoking ban and a reduced likelihood of smoking among 12th graders whose parents were smokers but not among those whose parents were nonsmokers.¹⁷ In summary, more evidence supports an association between home smoking bans and lower levels of smoking behaviors among youths who live with nonsmokers.Current research on household smoking bans has significant limitations. First, these studies rely on cross-sectional data that limit the ability to indicate causality in the relation between home smoking bans and trajectories of attitudes and smoking. Second, most studies have focused on individual-level predictors of attitudes and smoking behaviors, despite evidence that part of the explanation lies within the community context.¹⁸ Third, few studies have investigated the unique effects of a household smoking ban among adolescents living in home environments with parental smokers compared with those living with nonsmokers.In this study, our goal was to improve existing research by (1) using longitudinal data that followed up a cohort of youths and young adults who lived in parental homes over a 4-year period, with a total of 3 repeated observations for each participant; (2) using a multilevel model that simultaneously examined the effects of individual-level and town-level factors; and (3) investigating separately the effects of a household ban on youths who live with at least 1 smoker and youths who live with nonsmokers.