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.     

Arguing for Rural Health in Medicare: A Progressive Rhetoric for Rural America

Rural health policy is the laws, regulations, rules, and interpretations that benefit or affect health and health care for rural populations. This paper examines how rural health policy is viewed in the broader field of public policy, discusses the role of advocacy in developing rural health policy, and suggests ways to make that advocacy more effective. This paper critically reviews policy statements and policy positions taken by key opinion leaders and the leading stakeholders in rural health policy to determine how advocacy for rural communities is expressed. It is not clear how the rural health advocacy coalition is viewed by the professional policy world or the public: as an issues network pressing for fair and equal treatment or as an interest group seeking special advantages. This paper also explores the types of claims that rural advocates make in the specific context of Medicare policy to determine to what extent those claims reflect a central theme of fairness and inclusiveness in national policies versus claims that benefit special interests. The paper suggests that the rhetoric of rural advocates can be better structured to advocate for policies on the basis of a progressive sense of fairness.     

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.     

Rural print media portrayal of secondhand smoke and smoke-free policy

The purpose of this article is to describe how the print media portrays secondhand smoke and smoke-free policy in rural communities. Baseline print media clips from an ongoing 5-year study of smoke-free policy development in 40 rural communities were analyzed. The authors hypothesized that community population size would be positively associated with media favorability toward smoke-free policy. Conversely, pounds of tobacco produced and adult smoking prevalence would be negatively associated with media favorability. There was a positive correlation between population size and percentage of articles favorable toward smoke-free policy. The authors did not find a correlation between adult smoking or tobacco produced and media favorability toward smoke-free policy, but we did find a positive relationship between tobacco produced and percentage of pro-tobacco articles and a negative relationship between adult smoking prevalence and percentage of articles about health/comfort. Implications for targeting pro-health media in rural communities as well as policy-based initiatives for tobacco control are discussed.     

A decade of work on organized labor and tobacco control: reflections on research and coalition building in the United States

Labor unions can and should make strong allies in tobacco control efforts. Through much of the 1980s and 1990s, however, the organized labor and tobacco control communities rarely formed coalitions to achieve mutual gains. Recently, labor unions and tobacco control organizations have begun to work together on smoking cessation programs, smoke-free worksite policies, and increased insurance coverage for cessation treatments. This paper explores the historic and present-day intersections among organized labor and tobacco control advocates. We summarize research in this area and report on our recent programmatic efforts to promote collaboration between the labor and tobacco control communities. We discuss lessons learned with the aims of promoting deeper understanding among tobacco control and labor advocates of how each views tobacco control issues, and most importantly, stimulating further collaboration toward mutual gains in protecting workers' health.     

Secondhand Smoke Exposure and Smoke-Free Policy Support Among Public Housing Authority Residents in Rural and Tribal Settings

Previous research has shown that multi-unit housing (MUH) residents are at risk of secondhand smoke (SHS) exposure, which can transfer between units. The purpose of this study was to determine SHS exposure and examine attitudes towards smoking policies among public housing authority (PHA) residents in rural and tribal settings. A self-administered questionnaire was completed by 895 adult tenants (41 % response rate) living in PHA multiunit buildings in Montana in 2013. Our primary outcome was tenant support of smoke-free policies; our secondary outcome was exacerbation of child asthma symptoms due to SHS exposure. In 2014, we used multiple logistic regression models to test associations between independent variables and outcomes of interest. The majority (80.6 %) of respondents supported having a smoke-free policy in their building, with support being significantly higher among nonsmokers [adjusted odds ratio (aOR) 4.2, 95 % confidence interval (CI) 1.5–11.6] and among residents living with children (aOR 2.9, 95 % CI 1.3–6.2). Tribal residents were as likely to support smoke-free policies as non-tribal residents (aOR 1.4; 95 % CI 0.5–4.0). Over half (56.5 %) of respondents reported SHS exposure in their home; residents in a building with no smoke-free policy in place were significantly more likely to report exposure (aOR 3.5, 95 % CI 2.2–5.5). SHS exposure was not significantly associated with asthma symptoms. There is a significant reduction in exposure to SHS in facilities with smoke-free policies and there is strong support for such policies by both tribal and non-tribal MUH residents. Opportunities exist for smoke-free policy initiatives in rural and tribal settings.     

Tobacco control advocacy in Australia: reflections on 30 years of progress.

Australia has one of the world's most successful records on tobacco control. The role of public health advocacy in securing public and political support for tobacco control legislation and policy and program support is widely acknowledged and enshrined in World Health Organization policy documents yet is seldom the subject of analysis in the public health policy research literature. Australian public health advocates tend to not work in settings where evaluation and systematic planning are valued. However, their day-to-day strategies reveal considerable method and grounding in framing theory. The nature of media advocacy is explored, with differences between the conceptualization of routine "programmatic" public health interventions and the modus operandi of media advocacy highlighted. Two case studies on securing smoke-free indoor air and banning all tobacco advertising are used to illustrate advocacy strategies that have been used in Australia. Finally, the argument that advocacy should emanate from communities and be driven by them is considered.     

Unhealthy Partnerships: The Tobacco Industry and African American and Latino Labor Organizations

The tobacco industry in the 1980s began to form relationships with outside groups for assistance on key policy issues due to its own poor credibility in the policy arena. This strategy allowed the industry to advance its own interests while seeming to match the agendas of very different organizations. Between 1988 and 1998, the tobacco industry developed coalitions with the A. Philip Randolph Institute (APRI), representing African American trade unionists, and the Labor Coalition on Latin American Advancement (LCLAA), representing Latino trade unionists. APRI and LCLAA each adopted resolutions supporting industry positions on smokefree worksites and excise taxes, issues on which they had not previously taken positions, and promoted these positions to their members, political leaders and the public. They also supported the industry’s youth programs. This research relied upon a review of background literature and document searches through the Legacy Tobacco Documents Library and Tobacco Documents Online to examine the development of the excise tax coalition. The tobacco industry built support with APRI and LCLAA by framing policy positions in line with the organizations’ interests, creating institutional arrangements that circumvented direct funding from the industry, and enhancing the industry’s ability to influence excise tax debates indirectly. Although tobacco control advocates do not have the financial resources of the tobacco industry at their disposal, they can learn from tobacco industry techniques as they seek to build coalitions with people of color in the labor movement. Tobacco control advocates can both counter tobacco industry issue frames and also align their interests with those of working people of color by working on other issues of interest to this population, including health care and worker health and safety.     

Limited state progress in regulating secondhand tobacco smoke.

From 1990 to 2005, U.S. state legislation on secondhand tobacco smoke significantly increased in eight put c areas: general public areas, government buildings, private workplaces, schools, child care facilities, health care facilities, restaurants, and bars. Despite the U.S. Surgeon General's proclaiming in 2006 that "rapid progress" is being made in state legislation on clean indoor air, vigorous state smoke-free secondhand tobacco smoke legislation in six public area categories was minimal, which has favored the policy agenda of the corporate tobacco lobby. Two exceptions include smoke-free legislation for child care facilities and schools. While public interest group health advocates have traditionally used insider lobbying of public officials in the "halls of power" to pass smoke-free legislation, this should be supplemented with astute outsider advocacy tactics such as public demonstrations or issue advertisements to increase the likelihood of passage of more state-level smoke-free legislation.     

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.     

Circus monkeys or change agents? Civil society advocacy for HIV/AIDS in adverse policy environments

This paper explores the factors enabling and undermining civil society efforts to advocate for policy reforms relating to HIV/AIDS and illicit drugs in three countries in Eastern Europe and Central Asia: Georgia, Kyrgyzstan and Ukraine. It examines how political contexts and civil society actors’ strengths and weaknesses inhibit or enable advocacy for policy change – issues that are not well understood in relation to specific policy areas such as HIV/AIDS, or particular regions of the world where national policies are believed to be major drivers of the HIV/AIDS epidemic. The study is based on in-depth interviews with representatives of civil society organizations (CSOs) (n = 49) and national level informants including government and development partners (n = 22). Our policy analysis identified a culture of fear derived from concerns for personal safety but also risk of losing donor largesse. Relations between CSOs and government were often acrimonious rather than synergistic, and while we found some evidence of CSO collective action, competition for external funding – in particular for HIV/AIDS grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria was often divisive. Development partners and government tend to construct CSOs as service providers rather than advocates. While some advocacy was tolerated by governments, CSO participation in the policy process was, ultimately, perceived to be tokenistic. This was because there are financial interests in maintaining prohibitionist legislation: efforts to change punitive laws directed at the behaviors of minority groups such as injecting drug users have had limited impact.     

Attitudes of Students and Employees Towards the Implementation of a Totally Smoke Free University Campus Policy at King Saud University in Saudi Arabia: A Cross Sectional Baseline Study on Smoking Behavior Following the Implementation of Policy

Tobacco smoking is the preventable health issue worldwide. The harmful consequences of tobacco smoking and exposure to second-hand tobacco smoke are well documented. The aim of this study is to compares the prevalence of smoking among students, faculty and staff and examines their interest to quit. Study also determines the difference on perceptions of smoking and non-smoking students, faculty and staff with regard to implementation of a smoke-free policy. A cross-sectional survey was administered to one of the largest universities in Riyadh, Saudi Arabia during the academic year of 2013. A Likert scale was used on questionnaires towards attitude to smoking and smoking free policy. The Chi squared test was used to determine the difference of support on completely smoke free campus for smokers and non-smokers. Smoking rates were highest among staff members (36.8 %) followed by students (11.2 %) and faculty (6.4 %). About half of the smokers (53.7 %) within the university attempted to quit smoking. Students (OR 3.10, 95 % CI 1.00–9.60) and faculty (OR 4.06, 95 % CI 1.16–14.18) were more likely to make quit smoking than staff members. Majority of the respondents (89.6 %) were supportive of a smoking—free policy and indicated that should be strictly enforced especially into public places. Results also showed that smokers were more likely to support a smoke-free policy if there are no fines or penalties. These baseline findings will provide information among administrators in formulating and carrying out a total smoke free policy. Although the majority of people within the King Saud University demonstrate a high support for a smoke–free policy, administrators should consider difference between smokers and non-smokers attitudes when implementing such a policy.     

Smoke-free airlines and the role of organized labor: a case study

Labor unions play an important role in debates about smoke-free worksites. We investigated the role of flight attendants and their unions in creating smoke-free air travel. We used case study methodology to search tobacco industry documents and labor union periodicals and to interview key informants (i.e., people identified as having first-hand information and experience in the campaign to make airlines smoke free). We then compared findings across these data sources. Tobacco industry strategies against the establishment of smoke-free worksites failed in the case of airlines, largely because of the efforts of flight attendants and their unions. Other factors contributed to the failure but likely would have been insufficient to derail industry efforts without strong stands by the flight attendants. This case illustrates the potential for successful partnerships between unions and tobacco control policy advocates when developing smoke-free worksite policies.     

Tabakprävention in Deutschland und international

In Germany, several tobacco control policies have been implemented since 2002. These include tobacco tax increases, restrictions on sale and advertising, smoke-free legislation, and health warnings on tobacco products. All of those contributed to the emerging trend towards nonsmoking – especially among youth and young adults – as well as to the impressive decline of cigarette sales from 145.1 billion cigarettes in 2002 to 75.8 billion in 2017. Despite this, still 13% of all deaths are attributable to smoking in Germany.Other countries are acting in a more committed manner and are implementing much stronger tobacco control policies than Germany. Germany is the only EU country that doesn’t yet have a billboard ban on tobacco advertising, the smoke-free legislation is weak due to exceptions, and for more than ten years the tobacco tax has not been markedly increased. Globally, more than 30 countries have implemented at the highest possible level four of the six most important tobacco control policies as defined by the World Health Organization – Germany has implemented only two policies. Therefore, on an international scale, Germany is clearly lagging behind in tobacco control and on the European Tobacco Control Scale it is ranked second last. A more committed and compelling approach towards tobacco control is required in Germany to reach a position in terms of protecting the population from the devastating health hazards of smoking, which would be appropriate for a leading industrial nation.     

“Anti-Smoking Data Are Exaggerated” Versus “The Data Are Clear and Indisputable”: Examining Letters to the Editor About Tobacco

Media advocacy plays a unique role in tobacco control policy development. Letters to the editor in particular are an interesting form of media advocacy because they reflect community sentiment regarding the policy agenda and provide insight into the public debate. The authors used ethnographic context analysis to examine the techniques used by writers of 262 tobacco-related letters to the editor published in 61 newspapers across Missouri over a 2-year period when tobacco tax and smoke-free indoor air initiatives were occurring across the state. The authors found that pro–tobacco control letter writers often used didactic strategies, citing numbers and reports, to convey information and presented their training or experience as a health professional (e.g., M.D., Ph.D.) to add legitimacy to their arguments. Anti–tobacco control letter writers, in contrast, used narrative strategies to support their stance, claimed authority as a smoker or small business owner to legitimize their claims by relating to the audience, and used collectivity to capture the attention of policymakers. These results present the importance of strategic media advocacy in tobacco control. Tobacco control advocates should increase their use of narrative strategies and collectivity in order to better connect with the public and policymakers.     

The Impact of Tobacco Control Policies on Disparities in Children’s Secondhand Smoke Exposure: A Comparison of Methods

To examine the impact of cigarette excise taxes and smoke-free legislation on tobacco use among households with school-age children and adolescents as well as disparities in children’s secondhand smoke exposure. We compare the results from models using causal inference techniques to those from cross-sectional models. We linked families of 6–17-year-olds from the 2003 (N = 67,607) and 2007 (N = 62,768) contacts of the National Survey of Children’s Health with state-level cigarette excise taxes and smoke-free legislation total score (0 [none]–32 [very strong]) in 2001 and 2005. Parents reported whether anyone in the household used tobacco products. In adjusted causal inference models every $1.00 increase in cigarette excise tax between 2001 and 2005 was associated with a 4 percentage point decrease in household tobacco use between 2003 and 2007 (p = 0.008); however, there was no effect of smoke-free legislation on household tobacco use. Significant interactions revealed that cigarette tax increases were only associated with reductions in household tobacco use for parents of white children and, separately, lower income households. In contrast, in adjusted cross-sectional models, a higher smoke-free legislation total score was associated with a lower prevalence of household tobacco use. Stronger cigarette excise taxes decrease tobacco use among households with school-age children and adolescents, but smoke-free legislation at the state level does not change parental smoking. Since cross-sectional models cannot assess the direction of causality, evaluations should employ causal inference methods to help inform policy decisions to reduce disparities in adult smoking and, ultimately, protect children from secondhand smoke.     

Still a burning issue: trends in the volume,content and population reach of newspaper coverage about tobacco issues

Tobacco control advocates expend considerable effort in generating news stories on tobacco issues to assist progress in tobacco control, and the news coverage itself may have important policy and behavioral influences. Yet, studies of trends in such news coverage are uncommon. Between 2001 and 2006, we conducted a content analysis of tobacco-related newspaper articles in the 12 major daily Australian newspapers and coded them for type of article, topic, and tone. Overall, 6483 tobacco-focused articles were published, representing an average of one article every 4 days for each newspaper. There was variability in volume between years but no decline over time. Overall, 67% of articles reported on events that represented progress for tobacco control, 21% on setbacks, and 7% on events that were of mixed impact. Newspaper coverage of tobacco issues was dominated by articles on smoke-free issues (32% of articles), health effects of smoking (12%), education, prevention and cessation programs and services (12%), and the tobacco industry (9%). During the 6-year period, on average, Australian adults were potentially exposed to around one article on tobacco issues every week, or using a more stringent prominence-adjusted measure, one article every 2 to 3 weeks, a level comparable to paid media campaigns in some jurisdictions. Temporal variation in population exposure to news coverage about tobacco issues may reflect variability in newsworthiness of tobacco control issues, media advocacy resources and success, and/or preparedness of editors and journalists to entertain news stories on tobacco.     

"Anti-smoking data are exaggerated" versus "the data are clear and indisputable": examining letters to the editor about tobacco

Media advocacy plays a unique role in tobacco control policy development. Letters to the editor in particular are an interesting form of media advocacy because they reflect community sentiment regarding the policy agenda and provide insight into the public debate. The authors used ethnographic context analysis to examine the techniques used by writers of 262 tobacco-related letters to the editor published in 61 newspapers across Missouri over a 2-year period when tobacco tax and smoke-free indoor air initiatives were occurring across the state. The authors found that pro-tobacco control letter writers often used didactic strategies, citing numbers and reports, to convey information and presented their training or experience as a health professional (e.g., M.D., Ph.D.) to add legitimacy to their arguments. Anti-tobacco control letter writers, in contrast, used narrative strategies to support their stance, claimed authority as a smoker or small business owner to legitimize their claims by relating to the audience, and used collectivity to capture the attention of policymakers. These results present the importance of strategic media advocacy in tobacco control. Tobacco control advocates should increase their use of narrative strategies and collectivity in order to better connect with the public and policymakers.     

Tobacco cessation in adolescent females in Appalachian communities

Adolescents who live in tobacco-growing areas use tobacco at earlier ages and more frequently than other youth. These adolescents, like all tobacco users, have many health risks. To be successful, cessation efforts targeting these youth must reflect the cultural, social, and economic import of tobacco in their communities. Six focus groups with girls aged 12 to 14 who lived in tobacco-growing communities in Appalachian Ohio, Tennessee, and Virginia and 20 interviews with key informants were conducted. Barriers identified by informants included community norms around tobacco use, family use of tobacco, school practices and policies, peer influences, youth attitudes, and logistical difficulties with cessation program efforts. Key findings indicated: (1) the social community in tobacco-growing communities is a significant influence in tobacco use; (2) family is important among young people in tobacco-growing communities and influences cessation positively and negatively; (3) parental smoking was an influence to smoke (4) some parents condone and even facilitate tobacco use by their children, but others actively discourage use; and (5) concern for the health of younger brothers and sisters elicits a strongly protective reaction from youth in discussions of health risks related to secondhand smoke. Youth in tobacco-growing regions have many similarities to others, but they also have unique cultural characteristics pertinent in the development and delivery of tobacco cessation programs.