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.     

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.     

Evaluating Local Policy Adoption Campaigns in California: Tobacco Retail License (TRL) Adoption

As part of its state-wide “denormalization” campaign, the California Tobacco Control Program has funded local tobacco control projects to secure tobacco retail licenses (TRLs) in their communities. TRL policies generate funding by requiring tobacco retailers within a jurisdiction to obtain a license, which is in addition to the state license that tobacco retailers are legally required to purchase to sell tobacco products. The funding provided by TRLs enables local law enforcement to carry out inspection and enforcement operations. This paper examines the unique processes by which local project campaigns attempt to get TRL policies adopted in communities across the State of California. Twenty-two local projects submitted final evaluation reports pertaining to the adoption of TRLs, and the reports from these projects form the basis of the analysis. Successful campaigns tended to include the following strategies: (1) determining policy readiness; (2) gathering local data; (3) identifying and working with a “champion”; (4) building relationships with local law enforcement agencies and decision makers; and (5) educating community and decision makers. The major challenges faced by local projects included budget cuts and staffing issues, concern about creating an unfavorable environment for business by imposing more regulations and fees, and complaints about using law enforcement resources for tobacco control in light of more “pressing” public safety issues. These challenges proved difficult for local projects to overcome, and also highlight the need for projects to create and carry out strong but flexible tactical plans that incorporate the aforementioned strategies.     

Promoting the effective translation of the framework convention on tobacco control: a case study of challenges and opportunities for strategic communications in Mexico

The World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) promotes the implementation of best-practices tobacco control policies at a global scale. This article describes features of the sociocultural and political-economic context of Mexico that pose challenges and opportunities to the effective translation of WHO-FCTC policies there. It also considers how strategic communication efforts may advance these policies by framing their arguments in ways that resonate with prevalent values, understandings, and concerns. A focus on a smoke-free policy illustrates barriers to policy compliance, including how similar issues have been overcome among Latino populations in California. Overall, this article aims to lay the foundation for comparative research from policy uptake to impact so that the scientific evidence base on tobacco control policies includes examination of how context moderates this process.     

Smoking Policy Change Within Permanent Supportive Housing

Smoke-free policies effectively reduce secondhand smoke (SHS) exposure among non-smokers, and reduce consumption, encourage quit attempts, and minimize relapse to smoking among smokers. Such policies are uncommon in permanent supportive housing (PSH) for formerly homeless individuals. In this study, we collaborated with a PSH provider in San Diego, California to assess a smoke-free policy that restricted indoor smoking. Between August and November 2015, residents completed a pre-policy questionnaire on attitudes toward smoke-free policies and exposure to secondhand smoke, and then 7–9 months after policy implementation residents were re-surveyed. At follow-up, there was a 59.7% reduction in indoor smoking. The proportion of residents who identified as current smokers reduced by 13% (95% CI: ?38, 10.2). The proportion of residents who reported never smelling SHS indoors (apartment 24.2%, 95% CI: 4.2, 44.1; shared areas 17.2%, 95% CI: 1.7, 32.7); in outdoor areas next to the living unit (porches or patio 56.7%, 95% CI: 40.7, 72.8); and in other outdoor areas (parking lot 28.6%, 95% CI: 8.3, 48.9) was lower post-policy compared with pre-policy. Overall, resident support increased by 18.7%; however, the greatest increase in support occurred among current smokers (from 14.8 to 37.5%). Fewer current smokers reported that the policy would enable cessation at post-policy compared to pre-policy. Our findings demonstrate the feasibility of implementing smoke-free policies in PSH for formerly homeless adults. However, policy alone appears insufficient to trigger change in smoking behavior, highlighting the need for additional cessation resources to facilitate quitting.     

Local Smoke-Free Policy Experiences in Appalachian Communities

In Appalachian areas, strong tobacco control policies are not in place, so residents are not adequately protected from secondhand smoke exposure. This area is predominantly rural, and residents experience a high burden of tobacco-related illnesses. There has been limited examination of elements that hinder smoke-free policy adoption in these vulnerable communities. Key informant interviews were conducted with individuals identified as being knowledgeable about local tobacco control policy activities within a random selection of Appalachian communities within 6 states with (n = 15) and without (n = 12) local smoke-free policies. Five key themes emerged from the qualitative interviews: (1) opposition to tobacco control, (2) need for local involvement, (3) role of community coalitions, (4) leveraging outside advocates, and (5) working with decision makers. In Appalachian communities, the local context and locally-based coalitions were critical to promote the adoption of smoke-free policies.     

Rating the Effectiveness of Local Tobacco Policies for Reducing Youth Smoking

Important questions remain regarding the effectiveness of local tobacco policies for preventing and reducing youth tobacco use and the relative importance of these policies. The aims of this paper are to: (1) compare policy effectiveness ratings provided by researchers and tobacco prevention specialists for individual local tobacco policies, and (2) develop and describe a systematic approach to score communities for locally-implemented tobacco policies. We reviewed municipal codes of 50 California communities to identify local tobacco regulations in five sub-domains. We then developed an instrument to rate the effectiveness of these policies and administered it to an expert panel of 40 tobacco researchers and specialists. We compared mean policy effectiveness ratings obtained from researchers and prevention specialists and used it to score the 50 communities. High inter-rater reliabilities obtained for each sub-domain indicated substantial agreement among the raters about relative policy effectiveness. Results showed that, although researchers and prevention specialists differed on the mean levels of policy ratings, their relative rank ordering of the effectiveness of policy sub-domains were very similar. While both researchers and prevention specialists viewed local outdoor clean air policies as least effective in preventing and reducing youth cigarette smoking, they rated tobacco sales policies and advertising and promotion as more effective than the other policies. Moreover, we found high correlations between community scores generated from researchers’ and prevention specialists’ ratings. This approach can be used to inform research on local policies and prevention efforts and help bridge the gap between research and practice.     

The economic effect of smoke-free restaurant policies on restaurant business in Massachusetts.

The objective of the study was to determine if local smoke-free restaurant policies in Massachusetts affected restaurant sales. The authors used a pre-/post-quasi-experimental design to compare town-level meals tax data before and after the imposition of local smoke-free restaurant policies. Data for 235 towns (including 32 adopting communities) were entered into a fixed effects regression model to estimate changes in restaurant sales over time. The study failed to find a statistically significant effect of local smoke-free policies on restaurant business. It provides evidence that local smoke-free policies do not cause a large decline in communities' restaurant industries.     

Recall of tobacco pack health warnings by the population in Ukraine and its association with the perceived tobacco health hazard

Objectives  

After years of prevalence of smoking increase, Ukraine observes its decline. Recent tobacco control measures included smoke-free policies, new textual health warnings (THW) since late 2006, ban of outdoor tobacco advertising since January 2009 and tobacco tax increase since late 2008. The objective was to estimate potential contribution of THW to smoking decline process in Ukraine.     

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.     

Smoke-Free Coalition Cohesiveness in Rural Tobacco-Growing Communities

Promoting tobacco control policies in rural tobacco-growing communities presents unique challenges. The purpose of this study was to assess smoke-free coalition cohesiveness in rural communities and identify coalition members’ perceived barriers or divisive issues that impede the development of smoke-free policies. A secondary aim was to evaluate differences in coalition cohesiveness between advocates in communities receiving stage-based, tailored policy advocacy assistance versus those without assistance. Tobacco control advocates from 40 rural Kentucky communities were interviewed by telephone during the final wave of a 5-year longitudinal study of community readiness for smoke-free policy. On average, five health advocates per county participated in the 45-min interview. Participants rated coalition cohesiveness as not at all cohesive, somewhat cohesive, or very cohesive, and answered one open-ended question about potentially divisive issues within their coalitions. The mean age of the 186 participants was 48.1 years (SD = 13.3). The sample was predominantly female (83.6 %) and Caucasian (99.5 %). Divisive concerns ranged from rights issues, member characteristics, type of law, and whether or not to allow certain exemptions. Three of the divisive concerns were significantly associated with their rankings of coalition cohesiveness: raising tobacco in the community, the belief that smoke-free would adversely affect the economy, and government control. Educating coalition members on the economics of smoke-free laws and the actual economic impact on tobacco-growing may promote smoke-free coalition cohesiveness. More resources are needed to support policy advocacy in rural tobacco-growing communities as well as efforts to reduce the divisive concerns reported in this study.     

Correlates of Smoke-Free Housing Policies and Interest in Implementing Policies among Multiunit Housing Owners in New York City

Secondhand smoke exposure is a concern in multiunit housing, where smoke can migrate between apartments. In 2012, the New York City (NYC) Department of Health and Mental Hygiene conducted a cross-sectional mail and phone survey among a random sample of low-income and market-rate multiunit housing owners and managers in NYC. The study compared experiences and attitudes regarding smoke-free policies between owners/managers (owners) with and without low-income units. Logistic regression analysis was used to assess the correlates of smoke-free residential unit rules and interest in adopting new smoke-free rules. Perceived benefits and challenges of implementing smoke-free rules were also examined. Overall, one-third of owners prohibited smoking in individual units. Among owners, nearly one-third owned or managed buildings with designated certified low-income units. Owners with low-income units were less likely than those without to have a smoke-free unit policy (26 vs. 36 %, p < 0.01) or be aware that owners can legally adopt smoke-free building policies (60 vs. 70 %, p < 0.01). In the final model, owners who believed that owners could legally adopt smoke-free policies were more likely to have a smoke-free unit policy, while current smokers and owners of larger buildings were less likely to have a policy. Nearly three quarters of owners without smoke-free units were interested in prohibiting smoking in all of their building/units (73 %). Among owners, correlates of interest in prohibiting smoking included awareness that secondhand smoke is a health issue and knowledge of their legal rights to prohibit smoking in their buildings. Current smokers were less likely to be interested in future smoke-free policies. Educational programs promoting awareness of owners’ legal right to adopt smoke-free policies in residential buildings may improve the availability of smoke-free multiunit housing.     

Hospital efforts in smoking control: remaining barriers and challenges.

BACKGROUND. This study reports the barriers and challenges for hospital tobacco control efforts after the institution of smoke-free policies. METHODS. Surveys of employees and inpatients of five hospitals in Augusta, Georgia, were conducted and evaluated 4 months after joint hospital implementation of smoke-free policies. A random sample of 1997 employees and a convenience sample of 517 inpatients returned usable surveys. RESULTS. Although attitudes to the hospital bans on smoking reflected strong support for smoke-free policies, four out of five hospitals reported significant implementation problems. Despite the bans, 49% of patients who were smokers continued to smoke while hospitalized, and almost one half of all hospitalized smokers had received no advice to quit smoking from a physician or a nurse since admission. Employees and patients both agreed that the smoke-free policies had benefited employees more than patients. CONCLUSIONS. Despite achieving a smoke-free status, there are many challenges that remain for comprehensive hospital tobacco-control efforts. Hospitals and health care professionals must remain particularly alert and attentive to the needs of patients and employees still addicted to tobacco.     

Workplace Tobacco Policy: Progress on a Winding Road

This is a report of a pre- and post-intervention telephone survey to track changes in workplace tobacco policy in Pima County, Arizona, from 1997 to 1999. During this period, an extensive effort was made to assist workplaces to establish and enforce formal tobacco use policies. A random sample of 1134 workplaces, stratified by workforce size, was surveyed in 1997. Complete interviews were conducted with 934 (82.4%) workplaces. All 934 workplaces were contacted for the follow-up survey that was conducted in 1999. Of these, 824 (88.2%) completed follow-up surveys. The analyses presented were conducted on businesses that were included in both the baseline and follow-up surveys, and that reported having at least one employee on-site (n = 813). Tobacco policies and smoke-free policies were more likely to be found in larger businesses and businesses with a predominantly female workforce. There was no clear policy progression from having no policy, to having a policy, to becoming smoke-free. There was a small but significant overall decrease (4.8%) in the proportion of businesses having policies in the last two years. We found that 10.3% (75) of businesses that had policies in 1997 had dropped their policies by 1999, and that 13.4% (73) of worksites that were smoke-free in 1997 retained tobacco policies but were not smoke-free in 1999. However, formalization of policy in writing and the number of enforcement strategies utilized increased. These findings suggest that efforts to encourage businesses to establish workplace tobacco policies must be sustained even after policies have been established.     

Translation of tobacco policy into practice in disadvantaged and marginalized subpopulations: a study of challenges and opportunities in remote Australian Indigenous communities

Background

In Australia generally, smoking prevalence more than halved after 1980 and recently commenced to decline among Australia's disadvantaged Indigenous peoples. However, in some remote Indigenous Australian communities in the Northern Territory (NT), extremely high rates of up to 83% have not changed over the past 25?years. The World Health Organisation has called for public health and political leadership to address a global tobacco epidemic. For Indigenous Australians, unprecedented policies aim to overcome disadvantage and close the 'health gap' with reducing tobacco use the top priority. This study identifies challenges and opportunities to implementing these important new tobacco initiatives in remote Indigenous communities. Methods: With little empirical evidence available, we interviewed 82 key stakeholders across the NT representing operational- and management-level service providers, local Indigenous and non-Indigenous participants to identify challenges and opportunities for translating new policies into successful tobacco interventions. Data were analysed using qualitative approaches to identify emergent themes.

Results

The 20 emergent themes were classified using counts of occasions each theme occurred in the transcribed data as challenge or opportunity. The 'smoke-free policies' theme occurred most frequently as opportunity but infrequently as challenge while 'health workforce capacity' occurred most frequently as challenge but less frequently as opportunity, suggesting that policy implementation is constrained by lack of a skilled workforce. 'Smoking cessation support' occurred frequently as opportunity but also frequently as challenge suggesting that support for individuals requires additional input and attention.

Conclusions

These results from interviews with local and operational-level participants indicate that current tobacco policies in Australia targeting Indigenous smoking are sound and comprehensive. However, for remote Indigenous Australian communities, local and operational-level participants' views point to an 'implementation gap'. Their views should be heard because they are in a position to provide practical recommendations for effective policy implementation faithful to its design, thereby translating sound policy into meaningful action. Some recommendations may also find a place in culturally diverse low- and middle-income countries. Key words: tobacco policy implementation, challenges, opportunities, remote Indigenous Australian communities.     

A Framework for Mobilizing Communities to Advance Local Tobacco Control Policy: The Los Angeles County Experience

The Los Angeles County Tobacco Control and Prevention Program was significantly restructured in 2004 to improve capacity for local policy adoption. Restructuring included creating a fully staffed and trained policy unit; partnering with state-funded tobacco control organizations to provide high-quality, continuous technical assistance and training; implementing a highly structured policy adoption approach; expanding community capacity building; and establishing local coalitions to mobilize communities. Over the ensuing 6 years (2004–2010), 97 tobacco control policies were enacted in the county’s 88 cities and unincorporated area, including 79 that were attributable to the program. By comparison, only 15 policies were enacted from 1998 to 2003. Expanding policy adoption capacity through program restructuring may be achievable in other local jurisdictions.

KEY FINDINGS

• ▪From 2004 to 2010, 97 tobacco control policies were enacted in Los Angeles County’s 88 cities and unincorporated area, including 79 attributable to the program (only 15 policies were enacted from 1998 to 2003).
• ▪Increases in tobacco policy adoptions were attributed to the comprehensive restructuring efforts, including creating a Policy and Planning Unit, establishing key partnerships to provide technical assistance and training, extensive capacity building, use of policy organizing tools, and forming coalitions to mobilize communities.

Municipal-level tobacco control policies, such as indoor and outdoor smoking restrictions, play a vital role in local tobacco prevention and control efforts as well as in building grass roots support for state legislation.1 In 2004, the Los Angeles County Department of Public Health''s Tobacco Control and Prevention Program (TCPP) embarked on a comprehensive restructuring to focus its tobacco control efforts on local policy adoption in the county, a jurisdiction that has 88 cities and a large unincorporated area. We describe the elements of this transformation process and the lessons learned.     

Tobacco policy regression in Arizona worksites

PURPOSE: To learn how worksite tobacco policies in Arizona changed between 1998 and 2001. DESIGN: Telephone survey panel design. SETTING: Arizona. SUBJECTS: Private workplaces with at least five employees (N = 1008). MEASURES: Workplace policies were rated as "smoke free" (no smoking by employees in any indoor areas or in company vehicles except for designated smoking areas enclosed by physical barriers and having separate ventilation systems), "partial" policies (restrictive tobacco policies that did not meet the "smoke-free" standard), or no tobacco policy. ANALYSIS: Bivariate statistical tests included chi2 and analysis of variance. Logistic regression was performed to identify the variables that best predicted the workplaces that weakened or eliminated their policies. RESULTS:. Tobacco policy in Arizona worksites improved overall, but 10.8% of worksites had weakened or eliminated tobacco policies present at baseline. Among worksites that were smoke free at baseline, 15.5% were no longer smoke free at follow-up. CONCLUSION:. Policy regression is a disturbing finding that should be further explored. Our findings suggest that efforts to promote workplace tobacco policies should not end when policies are in place.     

Secondhand Tobacco Smoke Exposure in Open and Semi-Open Settings: A Systematic Review

Background: Some countries have recently extended smoke-free policies to particular outdoor settings; however, there is controversy regarding whether this is scientifically and ethically justifiable.Objectives: The objective of the present study was to review research on secondhand smoke (SHS) exposure in outdoor settings.Data sources: We conducted different searches in PubMed for the period prior to September 2012. We checked the references of the identified papers, and conducted a similar search in Google Scholar.Study selection: Our search terms included combinations of “secondhand smoke,” “environmental tobacco smoke,” “passive smoking” OR “tobacco smoke pollution” AND “outdoors” AND “PM” (particulate matter), “PM_2.5” (PM with diameter ≤ 2.5 µm), “respirable suspended particles,” “particulate matter,” “nicotine,” “CO” (carbon monoxide), “cotinine,” “marker,” “biomarker” OR “airborne marker.” In total, 18 articles and reports met the inclusion criteria.Results: Almost all studies used PM_2.5 concentration as an SHS marker. Mean PM_2.5 concentrations reported for outdoor smoking areas when smokers were present ranged from 8.32 to 124 µg/m³ at hospitality venues, and 4.60 to 17.80 µg/m³ at other locations. Mean PM_2.5 concentrations in smoke-free indoor settings near outdoor smoking areas ranged from 4 to 120.51 µg/m³. SHS levels increased when smokers were present, and outdoor and indoor SHS levels were related. Most studies reported a positive association between SHS measures and smoker density, enclosure of outdoor locations, wind conditions, and proximity to smokers.Conclusions: The available evidence indicates high SHS levels at some outdoor smoking areas and at adjacent smoke-free indoor areas. Further research and standardization of methodology is needed to determine whether smoke-free legislation should be extended to outdoor settings.