Peer Reviewed: Using Indoor Air Quality Monitoring in 6 Counties to Change Policy in North Carolina

Introduction

Indoor air quality monitoring has become a valuable tool for states wanting to assess levels of particulate matter before and after smoke-free policies are implemented. However, many states face barriers in passing comprehensive smoke-free legislation, making such study comparisons unlikely. We used indoor air monitoring data to educate decision makers about the value of comprehensive smoke-free laws in a state with strong historical ties to tobacco.

Methods

We trained teams in 6 counties in North Carolina to monitor air quality in hospitality venues with 1 of 3 possible smoking policy designations: 1) smoke-free, 2) separate smoking and nonsmoking sections (mixed), or 3) smoking allowed in all areas. Teams monitored 152 venues for respirable suspended particles that were less than 2.5 μm in diameter and collected information on venue characteristics. The data were combined and analyzed by venue policy and by county. Our findings were presented to key decision makers, and we then collected information on media publicity about these analyses.

Results

Overall, smoke-free venues had the lowest particulate matter levels (15 µg/m³), well below established Environmental Protection Agency standards. Venues with mixed policies and venues that permitted smoking in all areas had particulate matter levels that are considered unhealthy by Environmental Protection Agency standards. The media coverage of our findings included newspaper, radio, and television reports. Findings were also discussed with local health directors, state legislators, and public health advocates.

Conclusion

Study data have been used to quantify particulate matter levels, raise awareness about the dangers of secondhand smoke, build support for evidence-based policies, and promote smoke-free policies among policy makers. The next task is to turn this effort into meaningful policy change that will protect everyone from the harms of secondhand smoke.     

Vital Signs: Disparities in Nonsmokers’ Exposure to Secondhand Smoke — United States, 1999–2012

Background

Exposure to secondhand smoke (SHS) from burning tobacco causes disease and death in nonsmoking children and adults. No risk-free level of SHS exposure exists.

Methods

National Health and Nutrition Examination Survey (NHANES) data from 1999–2012 were used to examine SHS exposure among the nonsmoking population aged ≥3 years. SHS exposure among nonsmokers was defined as a serum cotinine level (a metabolite of nicotine) of 0.05–10 ng/mL. SHS exposure was assessed overall and by age, sex, race/ethnicity, poverty level, education, and whether the respondent owned or rented their housing.

Results

Prevalence of SHS exposure in nonsmokers declined from 52.5% during 1999–2000 to 25.3% during 2011–2012. During this period, declines were observed for all population subgroups, but disparities exist. During 2011–2012, SHS was highest among: children aged 3–11 years (40.6%), non-Hispanic blacks (46.8%), persons living below the poverty level (43.2%), and persons living in rental housing (36.8%). Among children aged 3–11 years, 67.9% of non-Hispanic blacks were exposed to SHS compared with 37.2% of non-Hispanic whites and 29.9% of Mexican Americans.

Conclusion

Overall, SHS exposure in the United States has been reduced by half since 1999–2000. However, 58 million persons were still exposed to SHS during 2011–2012, and exposure remains higher among children, non-Hispanic blacks, those living in poverty, and those who rent their housing.

Implications for Public Health Practice

Eliminating smoking in indoor spaces fully protects nonsmokers from SHS exposure; separating smokers from nonsmokers, cleaning the air and ventilating buildings cannot completely eliminate exposure. Continued efforts to promote implementation of comprehensive statewide laws prohibiting smoking in workplaces and public places, smoke-free policies in multiunit housing, and voluntary smoke-free home and vehicle rules are critical to protect nonsmokers from this preventable health hazard in the places they live, work, and gather.     

Attitudes,Experiences, and Acceptance of Smoke-Free Policies Among US Multiunit Housing Residents

We assessed factors related to smoke-free policies among a cross-sectional, nationally representative, random-digit-dial sample (landline and cell phone) of US multiunit housing residents (n = 418). Overall, 29% reported living in smoke-free buildings, while 79% reported voluntary smoke-free home rules. Among those with smoke-free home rules, 44% reported secondhand smoke incursions in their unit. Among all respondents, 56% supported smoke-free building policy implementation. These findings suggest that smoke-free building policies are needed to protect multiunit housing residents from secondhand smoke in their homes.Secondhand smoke (SHS) contains hundreds of toxic or carcinogenic compounds and can cause significant morbidity and mortality among nonsmoking children and adults.1–3 Currently, there is a growing interest in adopting smoke-free policies in private settings, including multiunit housing (MUH). The home represents a major source of SHS exposure for many individuals,2,4–6 and MUH residents are particularly susceptible to SHS incursions from nearby units and shared areas.6–8 This cross-sectional study evaluated attitudes, experiences, and acceptance of smoke-free home rules and building policies among a nationally representative sample of US MUH residents.     

Strategies implemented by 20 local tobacco control agencies to promote smoke-free recreation areas, California, 2004-2007

Introduction

Since 2000, local jurisdictions in California have enacted hundreds of policies and ordinances in an effort to protect their citizens from the harmful effects of secondhand smoke. We evaluated strategies used by state-funded local tobacco control programs to enact local smoke-free policies involving outdoor recreational spaces.

Methods

The Tobacco Control Evaluation Center analyzed 23 final evaluation reports that discussed adopting local smoke-free policies in outdoor recreational facilities in California. These reports were submitted for the 2004 through 2007 funding period by local tobacco control organizations to the California Department of Public Health, Tobacco Control Program. We used a comparative technique whereby we coded passages and compared them by locale and case, focusing on strategies that led to the enactment of smoke-free policies.

Results

Our analysis found the following 6 strategies to be the most effective: 1) having a "champion" who helps to carry an objective forward, 2) tapping into a pool of potential youth volunteers, 3) collecting and using local data as a persuasive tool, 4) educating the community in smoke-free policy efforts, 5) working strategically in the local political climate, and 6) framing the policy appropriately.

Conclusion

These strategies proved effective regardless of whether policies were voluntary, administrative, or legislative. Successful policy enactment required a strong foundation of agency funding and an experienced and committed staff. These results should be relevant to other tobacco control organizations that are attempting to secure local smoke-free policy.     

Peer Reviewed: Changes in Exposure to Secondhand Smoke Among Youth in Nebraska, 2002–2006

Introduction

Secondhand smoke is a major cause of morbidity and mortality. It has been associated with serious health problems in both children and adults. Efforts to reduce exposure to secondhand smoke in Nebraska have included programs to prevent tobacco use among young people and campaigns for smoke-free workplaces and homes. Despite these interventions, young people continue to be exposed to secondhand smoke at an unacceptably high rate. The objective of this study was to examine the extent to which Nebraska public middle and high school students were exposed to secondhand smoke in 2002 and 2006, to evaluate factors associated with this exposure, and to propose interventions.

Methods

The Nebraska Youth Tobacco Survey was administered in 2002 and 2006 to a representative sample of students from public middle and high schools. All students who chose to participate completed an anonymous, self-administered survey that included questions on demographics, tobacco use, tobacco-related knowledge and attitudes, and exposure to secondhand smoke. Data were weighted to account for nonresponses at both student and school levels and to ensure generalizability of the estimates for public school students in Nebraska according to their grade, sex, and race/ethnicity. This study analyzed a subset of responses on secondhand smoke exposure, which was defined as being in a room or vehicle during the previous 7 days with someone who was smoking cigarettes.

Results

Secondhand smoke exposure in a room, a vehicle, or both declined significantly among all students from 2002 (69.0%) to 2006 (61.3%). In both 2002 and 2006, students were significantly more likely to be exposed to secondhand smoke in a room than in a vehicle (64.4% vs 48.2% in 2002 and 56.9% vs 40.2% in 2006). Among racial and ethnic groups, only white students experienced a significant decline in exposure from 2002 (70.0%) to 2006 (61.4%). Girls were significantly more likely to be exposed to secondhand smoke in 2006 than were boys, and only boys experienced a significant overall decline in exposure from 2002 (69.3%) to 2006 (57.7%). Smoking behaviors and attitudes continued to influence secondhand smoke exposure from 2002 to 2006, although students experienced significant declines whether they were smokers or nonsmokers, and whether they lived with a smoker or not. Those with close friends who smoked and those who did not perceive secondhand smoke as harmful, however, did not benefit.

Conclusion

These data indicate reductions in exposure to secondhand smoke among Nebraska''s middle and high school students, but exposure remains a problem, particularly in rooms. Adoption of a comprehensive statewide smoke-free policy will contribute to significantly reduced exposure to secondhand smoke among young people in public places, but other measures to address exposure in the home and private vehicles are needed or should be strengthened. These include physician counseling based on behavioral change theory to encourage cessation and home-based no-smoking rules, in addition to interventions that target minorities, who are disproportionately affected by secondhand smoke exposure. Evaluation of existing measures, such as programs to prevent tobacco use among young people and campaigns to collect pledges for smoke-free homes, will be required to determine their effectiveness in reducing exposure to secondhand smoke among youth in Nebraska.     

Refining compliance surveys to measure the smokefree status of jurisdictions using the Delphi method

Setting:

Compliance assessment surveys are cost-effective means of assessing smokefree status in a jurisdiction. Assigning weights to assessment criteria (indicators) can also inform law implementers and policy makers about the effectiveness of the enforcement of smokefree rules.

Objective:

To develop a standardised measure for compliance surveys using the Delphi method in India.

Design:

Tobacco control experts from India comprising different constituencies and jurisdictions met for a half-day workshop in August 2012 to deliberate on how weights can be assigned to criteria for smokefree status. Using the Delphi method, the relevance and ranking of criteria from an existing protocol for measuring compliance was evaluated.

Results:

Consensus was reached on all five compliance survey indicators through three rigorous rounds of discussion. The highest priority was assigned to the absence of the act of smoking in public places (33%), followed by the display of no-smoking signage in public places (32%), absence of cigarette butts or bidi stubs (15%), absence of smoking aids (10%) and absence of tobacco smoke and ash (10%).

Conclusion:

Tobacco control advocates can effectively inform local policy makers using weights that prioritise directed enforcement and targeted interventions, which in turn will ensure stronger compliance and sustainable smokefree settings.     

Changing Policy Framing as a Deliberate Strategy for Public Health Advocacy: A Qualitative Policy Case Study of Minimum Unit Pricing of Alcohol

Context

Scotland is the first country in the world to pass legislation introducing a minimum unit price (MUP) for alcohol in an attempt to reduce consumption and associated harms by increasing the price of the cheapest alcohol. We investigated the competing ways in which policy stakeholders presented the debate. We then established whether a change in framing helped explain the policy''s emergence.

Methods

We conducted a detailed policy case study through analysis of evidence submitted to the Scottish parliament, and in-depth, one-to-one interviews (n = 36) with politicians, civil servants, advocates, researchers, and industry representatives.

Findings

Public- and voluntary-sector stakeholders tended to support MUP, while industry representatives were more divided. Two markedly different ways of presenting alcohol as a policy problem were evident. Critics of MUP (all of whom were related to industry) emphasized social disorder issues, particularly among young people, and hence argued for targeted approaches. In contrast, advocates for MUP (with the exception of those in industry) focused on alcohol as a health issue arising from overconsumption at a population level, thus suggesting that population-based interventions were necessary. Industry stakeholders favoring MUP adopted a hybrid framing, maintaining several aspects of the critical framing. Our interview data showed that public health advocates worked hard to redefine the policy issue by deliberately presenting a consistent alternative framing.

Conclusions

Framing alcohol policy as a broad, multisectoral, public health issue that requires a whole-population approach has been crucial to enabling policymakers to seriously consider MUP, and public health advocates intentionally presented alcohol policy in this way. This reframing helped prioritize public health considerations in the policy debate and represents a deliberate strategy for consideration by those advocating for policy change around the world and in other public health areas.     

Tobacco‐Control Policies in Tobacco‐Growing States: Where Tobacco Was King

Context

The 5 major tobacco-growing states (Kentucky, North Carolina, South Carolina, Tennessee, and Virginia) are disproportionately affected by the tobacco epidemic, with higher rates of smoking and smoking-induced disease. These states also have fewer smoke-free laws and lower tobacco taxes, 2 evidence-based policies that reduce tobacco use. Historically, the tobacco farmers and hospitality associations allied with the tobacco companies to oppose these policies.

Methods

This research is based on 5 detailed case studies of these states, which included key informant interviews, previously secret tobacco industry documents (available at http://legacy.library.ucsf.edu), and media articles. This was supplemented with additional tobacco document and media searches specifically for this article.

Findings

The tobacco companies were particularly concerned about blocking tobacco-control policies in the tobacco-growing states by promoting a pro-tobacco culture, beginning in the late 1960s. Nevertheless, since 2003, there has been rapid progress in the tobacco-growing states’ passage of smoke-free laws. This progress came after the alliance between the tobacco companies and the tobacco farmers fractured and hospitality organizations stopped opposing smoke-free laws. In addition, infrastructure built by National Cancer Institute research projects (COMMIT and ASSIST) led to long-standing tobacco-control coalitions that capitalized on these changes. Although tobacco production has dramatically fallen in these states, pro-tobacco sentiment still hinders tobacco-control policies in the major tobacco-growing states.

Conclusions

The environment has changed in the tobacco-growing states, following a fracture of the alliance between the tobacco companies and their former allies (tobacco growers and hospitality organizations). To continue this progress, health advocates should educate the public and policymakers on the changing reality in the tobacco-growing states, notably the great reduction in the number of tobacco farmers as well as in the volume of tobacco produced.     

Evaluating the Implementation Process of a Citywide Smoke-Free Multiunit Housing Ordinance: Insights from Community Stakeholders

We evaluated the implementation process of Richmond, California’s citywide smoke-free multiunit housing ordinance. We conducted semistructured focus groups with multiunit housing tenants, owners, and managers. Residents understood the harms of secondhand smoke but lacked accurate information about the ordinance and questioned its enforceability. They shared concerns that the city lacked cessation resources for smokers wishing to quit because of the ordinance. To increase compliance with the ordinance, tenants, owners, and managers need accurate information.Implementing smoke-free multiunit housing (MUH) policies is the most effective way to protect MUH residents from secondhand smoke exposure.1,2 We have discussed how MUH tenants, owners, and managers view the implementation of Richmond, California’s citywide smoke-free MUH ordinance and potential barriers to its equitable implementation across the city’s diverse neighborhoods.The majority (78%) of Richmond’s 106 516 residents are ethnic minorities; 38% of Richmond’s population live in MUH residences.3,4 In 2009, Richmond passed an ordinance to prohibit the smoking of any tobacco product or marijuana in residential dwellings containing 2 or more units; it was fully implemented in 2011.5     

Peer Reviewed: Smoke-Free Law Associated With Higher-Than-Expected Taxable Retail Sales for Bars and Taverns in Washington State

Introduction

Continued progress in implementing smoke-free laws throughout the United States would benefit from documenting positive economic effects, particularly for the hospitality industry. This study describes changes in sales revenue in bars and taverns since December 2005, when a statewide smoke-free law in Washington State went into effect.

Methods

Using 24 quarters of inflation-adjusted taxable retail sales data from 2002 through 2007, we fitted a regression model to estimate the effect of the smoke-free law on sales revenue, controlling for seasonality and other economic factors.

Results

We found no immediate change in bar revenues in the first quarter of 2006, but taxable retail sales grew significantly through the fourth quarter of 2007. In the 2 years after the smoke-free law was implemented, sales revenues were $105.5 million higher than expected for bars and taverns in Washington State.

Conclusion

The higher-than-expected revenue from taxable sales in bars and taverns after the implementation of smoke-free laws in Washington State provided extra funds to the state general fund. Potential increases in revenue in other jurisdictions that implement smoke-free indoor air policies could provide funds to benefit residents of those jurisdictions.     

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.     

Peer Reviewed: An Observational Study of the Secondary Effects of a Local Smoke-Free Ordinance

Introduction

The secondary, sometimes unintended effects of smoke-free ordinances have not been thoroughly evaluated. In this observational study, we evaluated the association of a local ordinance implemented in Madison, Wisconsin, with changes in public disturbances; smoking, drinking, and bar-going behaviors in the general population; and smoking and drinking behaviors among university students.

Methods

We obtained data from 4 sources: police records, key informant interviews, a community survey, and an undergraduate survey. Except for interviews, which we conducted postenactment only, we compared measures before and after the ordinance was put into effect.

Results

We found no evidence of association of the ordinance with public disturbances. We found that the ordinance was not associated with changes in smoking rates, drinking rates, or bar-going in the general population, although bar-going decreased among the 16% of the general adult population who smokes (from 84% in 2005 to 70% in 2007, P < .001). Student smoking rates also decreased (from 23% in 2005 to 16% in 2007, P < .001), but student binge drinking did not change.

Conclusion

The study adds unique information to the evidence base on the effect of smoke-free policies, finding little evidence of their secondary, unintended effects. With the addition of these results to existing evidence, we conclude that the potential health benefits of smoke-free ordinances outweigh the potential harms from unintended effects.     

Compliance with smoke-free legislation within public buildings: a cross-sectional study in Turkey

Objective

To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey.

Methods

Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts.

Findings

Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9–570.8 and aOR: 165.4; 95% CI: 98.0–279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3–0.8.

Conclusion

Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs.     

Smoke-Free Laws in Bars and Restaurants: Does Support Among Teens and Young Adults Change After a Statewide Smoke-Free Law?

Objective

We assessed changes in levels of support for smoke-free bars and restaurants among teens and young adults before and after implementation of a statewide smoke-free law.

Methods

We measured support for smoke-free bars and restaurants among teens and young adults aged 16–24 years living in Minnesota (n=2,785) and five comparison states (n=404), up to 12 months before and up to six months after Minnesota''s smoke-free law went into effect in October 2007. We compared changes in support among three subgroups—Minnesota participants who lived with a previous local smoke-free law, Minnesota participants who did not live with a previous local smoke-free law, and participants from the comparison states—before and after Minnesota''s statewide smoke-free law went into effect.

Results

Support for smoke-free restaurants and bars among participants in Minnesota and comparison states increased after Minnesota''s smoke-free law went into effect. Minnesotans, both those living with and without a previous local smoke-free law, showed similar increases in support for smoke-free restaurants as participants in comparison states. However, Minnesotans living without a previous local law showed larger increases in support for smoke-free bars than both those in comparison states and those living in Minnesota with a previous local smoke-free law.

Conclusions

Our study employed a more robust design than similar studies and focused on the teen and young adult population. Our results will help advocates and policy makers demonstrate how public support for smoke-free laws increases following smoke-free legislation, particularly among those who were not previously living with a local smoke-free law.Policies that create smoke-free worksites and other public places have been identified as effective measures for reducing environmental tobacco smoke (ETS) exposure¹ and smoking rates.^2,3 An increasing number of communities and states in the U.S. have enacted laws restricting smoking in public places, including restaurants and bars.⁴ ETS exposure in restaurant and bar settings is of particular concern because these settings have often been exempt from smoke-free laws in workplaces.⁵ Efforts to enact smoking restrictions in restaurants, and especially bars, often face strong opposition from the tobacco and hospitality industries;⁶ however, demonstrating strong public support for these laws can help counter this opposition. As more communities and states enact or consider enacting smoke-free laws in restaurants and bars, measuring levels of public support for these laws will be of increasing importance.Numerous cross-sectional studies have been conducted to examine public support for smoke-free laws in bars and restaurants among the general adult population. Support varies considerably depending on jurisdiction, year of study, and type of establishment (e.g., restaurant vs. bar). Support for smoke-free laws in bars and restaurants is often greater among older adults, nonsmokers, and adults living in areas with smoke-free laws.^7–10Only a few studies have examined support for smoke-free laws at bars and/or restaurants among young adults specifically, all of which have used a cross-sectional design.^11–15 It is particularly important to understand levels of support among the young adult population, not only because some studies have shown their support to be lower than older adults, but also because young adults are often employed in bars and restaurants¹⁶ and tend to frequent bars.¹⁷ Most previous studies have been limited to college students and only inquired about smoke-free laws on campus.^12–15 One study, which used data from the same project as the current study, included a community sample of young adults and found that overall support for smoke-free laws in restaurants was 66% and in bars was 40%. The study also found that, as with the adult population, factors associated with increased support included being a nonsmoker and living with a local smoke-free law.¹¹Several studies have also assessed the relationship between implementation of smoke-free laws and support for the laws. Two studies conducted in California measured support for smoke-free bars among the general adult population at several time points after a statewide smoke-free law took effect.^18,19 Both found that overall support for the law increased over time; however, neither study included a comparison group nor a measure of support prior to the legislation being implemented. In addition, Friis and Safer did not provide a statistical test of change in support across time points.¹⁸ The five other longitudinal studies were conducted outside the U.S., including the United Kingdom (UK),^20–22 Australia,²³ and New Zealand.²⁴ All studies measured support among the general adult population both before and after smoke-free legislation was implemented; however, only the UK studies used comparison groups. All studies concluded that support for a smoke-free law increased after a law was implemented, and the studies that included comparison groups found that support increased more among people living with a law than among those living without a law.We assessed changes in support for smoke-free laws in restaurants and bars before and after implementation of Minnesota''s statewide smoke-free law in all workplaces, including bars and restaurants (effective October 1, 2007). For comparison, we included teens and young adults aged 16–24 years from Minnesota and from several other upper Midwest states that did not have statewide or local smoke-free laws. Additionally, we examined differences and changes in support by sociodemographic and personal characteristics. We hypothesized that (1) public support for both smoke-free bars and restaurants would increase following the Minnesota smoke-free law, mainly for those who lived without local smoke-free legislation; (2) support for smoke-free laws would remain stable across the study period in the comparison states; and (3) those who did not smoke would be more supportive of smoke-free laws, before and after the statewide law was implemented. Our results will help advocates and policy makers demonstrate how public support changes following smoke-free legislation.     

Air Nicotine Monitoring for Second Hand Smoke Exposure in Public Places in India

Background:

Air nicotine monitoring is an established method of measuring exposure to second hand smoke (SHS). Not much research has been done in India to measure air nicotine for the purpose of studying exposure to SHS. It is a risk factor and many diseases are known to occur among non smokers if they are exposed to second hand smoke.

Objective:

To conduct monitoring of air nicotine for second hand smoke exposure in public places across major cities in India.

Materials and Methods:

A cross sectional survey was conducted across four cities across the country, using passive air monitoring. The buildings included hospitals, secondary schools, Governmental offices, bars and restaurants. The buildings were selected through convenience sampling method keeping in view specific sentinel locations of interest.

Result:

The presence of air nicotine was recorded in most of the buildings under the study, which included government buildings, hospitals, schools, restaurants and entertainment venues (bars) in all four cities under the study. The highest median levels of air nicotine were found in entertainment venues and restaurants in cities.

Conclusion:

The presence of air nicotine in indoor public places indicates weak implementation of existing smoke free law in India. The findings of this study provide a baseline characterization of exposure to SHS in public places in India, which could be used to promote clean indoor air policies and programs and monitor and evaluate the progress and future smoke-free initiatives in India.     

Factors Associated with Active Smoking,Quitting, and Secondhand Smoke Exposure among Pregnant Women in Greece

Background

Pregnant women are exposed to tobacco smoke through active smoking and contact with secondhand smoke (SHS), and these exposures have a significant impact on public health. We investigated the factors that mediate active smoking, successful quitting, and SHS exposure among pregnant women in Crete, Greece.

Methods

Using a cotinine-validated questionnaire, data were collected on active smoking and exposure to secondhand smoke from 1291 women who had successfully completed the first contact questionnaire of the prospective mother-child cohort (Rhea) in Crete during the 12th week of pregnancy.

Results

Active smoking at some time during pregnancy was reported by 36% of respondents, and 17% were current smokers at week 12 of gestation. Those less likely to quit smoking during pregnancy were those married to a smoker (OR, 1.76; P = 0.008), those who were multiparous (1.72; P = 0.011), and those with young husbands. Of the 832 (64%) nonsmokers, almost all (94%, n = 780) were exposed to SHS, with the majority exposed at home (72%) or in a public place (64%). Less educated women and younger women were exposed more often than their better educated and older peers (P < 0.001). Adjusting for potential confounders, parental level of education, age, and ethnicity were the main mediators of exposure to SHS during pregnancy.

Conclusions

Active smoking and exposure to SHS are very prevalent among pregnant women in Greece. The above findings indicate the need for support of population-based educational interventions aimed at smoking cessation in both parents, as well as of the importance of establishing smoke-free environments in both private and public places.Key words: smoking, cessation, pregnancy, fetal health, passive smoking, SHS     

Peer Reviewed: The GirlStars Program: Challenges to Recruitment and Retention in a Physical Activity and Health Education Program for Adolescent Girls Living in Public Housing

Background

Although physical inactivity is a concern for all adolescents, physical activity levels are especially low among minority adolescents and minimal among girls from low-income families. After-school programs can reduce high-risk behaviors and strengthen schools, families, and communities.

Context

We conducted an operational research project that provided free access to a program of regular, organized physical activity combined with health education sessions for adolescent girls in 2 public housing developments in Boston, Massachusetts.

Methods

From July 2002 through October 2005, at each of 2 public housing sites, the GirlStars program participants met each week for two 2-hour sessions, 1 dedicated to physical activity and 1 dedicated to health education. Sessions were led by the project coordinator and a resident assistant at each development.

Outcome

Participants in the GirlStars program increased their health knowledge, self-confidence, and decision-making skills, but rates of participation were low. Factors that affected participation included safety concerns, lack of community support for the program, interpersonal conflicts, attrition in staff, and conflicts with other activities.

Interpretation

Programs in public housing developments that address these barriers to recruitment and retention may be more successful and reach more girls.     

Noise nuisance and health inequalities in Belgium: a population study

Context

Lower socioeconomic groups are more likely to live in contaminated environments. This may partly explain socioeconomic health inequalities.

Aims

Does noise nuisance contribute to socio-economic inequalities in subjective health?

Method

This research is based on the last Belgian census data carried out in 2001. We work on a 10% sample of the Belgian population. The data are processed through bivariate and multivariate analyses. We model poor subjective health in relation to exposure to noise nuisance and several socio-economic variables.

Results

The risk of poor subjective health increases with noise nuisance and is higher in lower socio-economic groups. Noise nuisance does contribute to health inequalities, particularly regarding type of housing and activity. These relations are stronger in urban areas.

Conclusions

Noise nuisance affects the subjective health status and contributes to health inequalities, particularly in urban areas. This suggests that public policies, particularly those related to environmental planning, should be driven also by environmental equity considerations.