Smoke-free laws and adult smoking prevalence

Navigating grey areas in HIV and mental health implementation science

INTRODUCTION

Implementation science (IS) offers methods to systematically achieve the Ending the HIV Epidemic goals in the United States, as well as the global UNAIDS targets. Federal funders such as the National Institutes of Mental Health (NIMH) have invested in implementation research to achieve these goals, including supporting the AIDS Research Centres (ARCs), which focus on high-impact science in HIV and mental health (MH). To facilitate capacity building for the HIV/MH research workforce in IS, "grey areas," or areas of IS that are confusing, particularly for new investigators, should be addressed in the context of HIV/MH research.

DISCUSSION

A group of IS experts affiliated with NIMH-funded ARCs convened to identify common and challenging grey areas. The group generated a preliminary list of 19 grey areas in HIV/MH-related IS. From the list, the authors developed a survey which was distributed to all ARCs to prioritize grey areas to address in this paper. ARC members across the United States (N = 60) identified priority grey areas requiring clarification. This commentary discusses topics with 40% or more endorsement. The top grey areas that ARC members identified were: (1) Differentiating implementation strategies from interventions; (2) Determining when an intervention has sufficient evidence for adaptation; (3) Integrating recipient perspectives into HIV/MH implementation research; (4) Evaluating whether an implementation strategy is evidence-based; (5) Identifying rigorous approaches for evaluating the impact of implementation strategies in the absence of a control group or randomization; and (6) Addressing innovation in HIV/MH IS grants. The commentary addresses each grey area by drawing from the existing literature (when available), providing expert guidance on addressing each in the context of HIV/MH research, and providing domestic and global HIV and HIV/MH case examples that address these grey areas.

CONCLUSIONS

HIV/MH IS is key to achieving domestic and international goals for ending HIV transmission and mitigating its impact. Guidance offered in this paper can help to overcome challenges to rigorous and high-impact HIV/MH implementation research.

Association of cigarette excise taxes and clean indoor air laws with change in smoking behavior in the United States: a Markov modeling analysis

The rates of cigarette smoking in the United States have declined over the past few decades in parallel with increases in cigarette taxes and introduction of more stringent clean indoor air laws. Few longitudinal studies have examined association of taxes and clean indoor air policies with change in smoking nationally. This study examined the association of state and local cigarette taxes and clean indoor laws with change in smoking status of 18,499 adult participants of the longitudinal 2010-2011 Tobacco Use Supplement of the Current Population Survey over a period of 1 year. Every $1 increase in cigarette excise taxes was associated with 36% higher likelihood of stopping smoking among regular smokers. We found no association between clean indoor air laws and smoking cessation nor between taxes and clean indoor air laws with lower risk of smoking initiation. Cigarette taxes appear to be effective anti-smoking policies. Some state and local governments do not take full advantage of this effective policy measure.

Defining indicators for the scoping stage of health impact assessment to evaluate tobacco control policy in the city of Beijing

INTRODUCTION

Beijing initiated the nation's most comprehensive tobacco control program that adheres to the WHO Framework Convention on Tobacco Control. This study aimed to identify a set of indicators for the scoping of an Health Impact Assessment (HIA) to assess this policy.

METHODS

This study used a modified Delphi process. It proposed a tobacco control health impact framework based on the Driving forces- Pressure- State- Exposure- Effect- Action model and the Determinants of Health Theory. After a review of current surveillance system and literature, a working group of 13 experts with multidisciplinary background was established to formulate indicator evaluation criteria and conduct indicator scoring. Each indicator was scored by experts according to four evaluation criteria chosen. Indicators that obtained a total score above 80% and with standard error less than 5 were selected as the final set of indicators. Kendall's coefficient of concordance was calculated.

RESULTS

Twenty-three out of 36 indicators were selected. Smoking prevalence, mortality rate, hospital admission rate, tobacco consumption and hospital admission fees of smoking related diseases achieved more than 90% of total scores and ranked as the top five. Kendall's concordance coefficient was 0.218 for all indicators. For all model composition, Kendall's concordance coefficients were statistically significant.

CONCLUSION

This study identified a set of twenty-three indicators for scoping of HIA of a comprehensive tobacco control policy in Beijing based on a tobacco control health impact conceptual framework. The set of indicators achieved high scores and statistically significant consistency and has great potential to promote the evaluation of tobacco control policy in a global city. Further study might use the set of indicators for HIA on tobacco control policy to analyze empirical data.

Municipal smoke-free laws and preterm birth

BACKGROUND

Smoking during pregnancy and prenatal secondhand smoke exposure increase the risk of preterm birth. As Kentucky has the second highest rate of smoking in the United States and no statewide smoke-free law, an examination of the effect of municipal smoke-free legislation on preterm birth is warranted.

OBJECTIVE

This study used state-level live birth data and county-level municipal smoke-free legislation status to assess the association between the presence and strength of smoke-free laws and the likelihood of preterm birth. Moreover, this study hypothesized that pregnant persons living in counties with comprehensive municipal smoke-free laws prohibiting smoking inside all workplaces and enclosed public places would exhibit a lower likelihood of preterm birth than those living in counties with weak or moderate laws (ie, smoke-free laws with exemptions that do not cover all workplaces and enclosed public places) or no smoke-free law.

STUDY DESIGN

Using live birth data from the Kentucky Office of Vital Statistics with birth years ranging from 2004 to 2020, a total of 894,372 live births were recorded that indicated that a childbearing person was between the ages of 18 and 49 years and a resident of Kentucky; these live births formed the sample for the study. Municipal ordinances implemented during a given calendar year were coded in the model as present starting with the following calendar year, as the birth records were time deidentified except for the year of birth. This lagged law convention maximized the likelihood that pregnant persons included in the study were exposed to the smoke-free policy for at least a portion of their pregnancy. Multilevel logistic regression was used to assess the effect of smoke-free ordinances on the likelihood of preterm birth, with personal- and county-level variables included as potential covariates and pregnant persons nested within the county of residence. Data analysis was conducted using SAS (version 9.4; SAS Institute, Cary, NC), with an alpha level of .05.

RESULTS

Nearly all personal-level variables were associated with preterm birth status. Personal factors associated with an increased likelihood of preterm birth included being older (relative to 18-24 years old; odds ratios [95% confidence intervals]: 1.02 [1.01-1.04] and 1.27 [1.24-1.31] for ages 25-34 and 35-49 years, respectively); having a history of preterm birth (odds ratio, 4.65; 95% confidence interval, 4.53-4.78); and smoking before pregnancy (odds ratio, 1.14; 95% confidence interval, 1.12-1.16). Pregnant persons living in counties with comprehensive laws were 9% less likely to have a preterm birth than those living in counties without a smoke-free ordinance (odds ratio, 0.91; 95% confidence interval, 0.89-0.94; P<.001). There was no difference in the likelihood of preterm birth between those living in counties with moderate or weak laws and those unprotected by any smoke-free ordinance in their county of residence.

CONCLUSION

This study demonstrated that comprehensive municipal smoke-free laws are associated with reduced risk of preterm birth and that moderate or weak smoke-free laws are not. The findings have major implications for public health policy and underscore the potential influence of healthcare providers' advocacy for strong smoke-free policies, prohibiting smoking in all workplaces (including restaurants, bars, and casinos), to support healthy pregnancies.

Changes in smoking prevalence and perception of smoking on campus before and after a smoke-free university campus policy

ObjectiveTo examine whether policies prohibiting smoking on college campuses contribute to greater decreases in smoking. Participants: This study compares smoking prevalence and perceptions of prevalence pre/post a smoking ban enacted in 2015 by using repeated cross-sectional surveys administered at a university in 2011 (n = 1.548), 2013 (n = 3.657), 2015 (n = 3.456), 2016 (n = 2.575), and 2018 (n = 4.600). Methods: Regression models evaluated trends in prevalence with a spline term to evaluate differences after the smoking ban. Results: Before the ban, the prevalence of any past 30-day smoking decreased each survey period (AOR = 0.89, 95%CI: 0.85, 0.97); after the ban, a significantly greater decrease was observed (AOR = 0.78, 95%CI: 0.74, 0.83). Similar patterns were observed specifically for cigarette use as well as students' perceptions of the proportion of the student body who use tobacco and nicotine products. Stratified analysis identified that pre/post declines were largest in the youngest age category. Conclusions: Results support the effectiveness of campus-based antismoking policies.

Implementation of the Smoke-Free Policy in Medan City, Indonesia: Compliance and Challenges

Background:

Indonesia has an estimated 61.4 million current smokers, and the smoking prevalence among adults is persistently high while that among youth is increasing. In 2014, Medan city enacted the smoke-free policy (SFP) to protect community members against the adverse effects of smoking. Our study examines the implementation of SFP in terms of compliance and challenges.

Methods:

We conducted a mixed-methods study. Quantitative analyses examined the compliance with six criteria including having signage, no active smoking, no selling, no advertisement, no smoke, and no ashtray at SFP facilities. They included health facilities, educational facilities, places of worship, workplaces, and indoor/outdoor public facilities. The qualitative analysis examined the challenges through in-depth interviews of six key informants.

Results:

We found the overall compliance of 44%, ranging from 0% at outdoor public facilities to 83% at health facilities. We found relatively higher compliance among facilities within 1-km from the provincial and city health offices compared to those outside of the buffer (but not significant at 5% level, P = 0.070). The challenges identified were lack of budget, monitoring, enforcement, and sensitization.

Conclusions:

The implementation of SFP in Medan city still has lower compliance and faces many challenges.

Smoke-Free Policy Disparities in Long-Term Care Facilities

Older adults in long-term care (LTC) facilities suffer disproportionately from health conditions caused or worsened by secondhand smoke. Long-term care facilities in many states and municipalities permit smoking. Americans for Nonsmokers’ Rights compiles data on smoke-free policies only in institutional facilities (e.g., nursing homes), but not in transitional (e.g., independent living) or community-based settings (e.g., adult day). A cross-sectional, observational study was conducted of smoke-free policies using cluster random sampling in Kentucky to compare differences in policy location of coverage and strength of smoke-free policies in institutional, transitional, and community-based LTC facilities by rural/urban status. Online or phone surveys of LTC administrators representing 306 facilities were conducted. Of the facilities sampled, 35.5% were institutional, 33.4% transitional, 25.1% community-based, and 6.0% multi-type. Only one in five (19.6%) facilities restricted smoking indoors and outdoors. Only 17.3% of the policies were comprehensive (i.e., prohibiting use of all tobacco products by all persons living, frequenting, or working in LTC facilities). Compared to transitional facilities, institutional and community-based facilities were more likely to have comprehensive policies and restrict smoking indoors and outdoors. Facilities located in rural communities were less likely to restrict smoking indoors or outdoors and less likely to have comprehensive smoke-free policies, reflecting a disparity in policy protections. Strong, consistent smoke-free policies and policy enforcement are needed to reduce the disparity in smoke-free protections for older adults, LTC employees, and visitors. More research is needed to investigate the best strategies for implementing and enforcing policies that completely restrict smoking in all LTC facilities.

State Tobacco Excise Taxation, Comprehensive Smoke-free Air Laws, and Tobacco Control Appropriations as Predictors of Smoking Cessation Success in the United States

The purpose of the present study was (1) to examine demographic differences between smokers who successfully quit (n = 1809), who relapsed (n = 6548), and who did not attempt to quit (n = 11 102) within the last year, and (2) to examine state-level tobacco policies/programs as predictors of quit success. Data were utilized from the 2014-2015 Tobacco Use Supplement to the Current Population Survey, which were paired with 2014 data on taxation, appropriations, and smoke-free air laws. As compared with smokers who relapsed, those who successfully quit were more likely to be white, married, more highly educated, of higher income, and heavier smokers. Compared with those who did not attempt to quit, those who attempted to quit, regardless of success, were younger and more likely to be Hispanic. State comprehensive smoke-free air laws and tobacco excise taxation significantly predicted quit success. Thus, expansions of these policies should be considered to promote successful quitting.

Associations of tobacco use and consumption with rurality among patients with psychiatric disorders: Does smoke-free policy matter?

PURPOSE

People with psychiatric disorders (PDs) have high risks for tobacco use and associated health effects; however, little is known about differences in tobacco use status and consumption by urban or rural residence. Among patients with PDs, we examined the association of smoke-free policy on tobacco use by rural/urban residence METHOD: A cross-sectional retrospective study (N = 2060) among patients in a psychiatric facility was conducted. Multi-logistic and multilinear regression analyses assessed differences in outcomes stratified by rural/urban status.

RESULTS

Among rural residents, a substance use history (odds ratios [ORs[ = 2.82, 95% CI: 2.01-3.96), high school education (OR = 0.71, 95% CI: 0.51-0.98), older age (OR = 0.99, 95% CI: 0.98-1.00), and longer length of hospital stay (OR = 0.99, 95% CI: 0.98-1.00) were associated with tobacco use. Among urban residents, male sex (OR = 1.38, 95% CI: 1.02-1.86), a substance use history (OR = 2.61, 95% CI: 1.86-3.66), and externalizing disorder diagnosis (OR = 2.72, 95% CI: 1.35-5.48) correlated with tobacco use. Increased tobacco consumption among rural residents was associated with being male (β = 0.12, p = 0.007) and having less than a high school education (β = 0.14, P = 0.001). Whereas, White ethnicity (β = 0.14, p = 0.006), having less than a high school education (β = 0.11, p = 0.022), and a psychotic disorder diagnosis (β = 0.25, p = 0.038) were associated with greater tobacco consumption in urban residents. Smoke-free policy was not associated with tobacco use (OR = 1.08, 95% CI: 0.87-1.34) and consumption (β = 0.05, p = 0.134).

CONCLUSIONS

Despite higher rates of tobacco use among rural patients with PDs, they have similar risk factors as their urban counterparts. However, residing in a location with a smoke-free policy may not contribute to tobacco use behaviors among those with PDs.

Impact of smoke-free ordinance strength on smoking prevalence and lung cancer incidence

Background

Smoke-free ordinances (SFO) have been shown to be effective public health interventions, but there is limited data on the impact SFO on lung cancer outcomes. We explored the effect of county-level SFO strength with smoking prevalence and lung cancer incidence in Indiana.

Methods

We obtained county-level lung cancer incidence from the Indiana State Cancer Registry and county-level characteristics from the Indiana Tobacco Prevention and Cessation Commission’s policy database between 1995 and 2016. Using generalized estimating equations, we performed multivariable analyses of smoking prevalence and age-adjusted lung cancer rates with respect to the strength of smoke-free ordinances at the county level over time.

Results

Of Indiana’s 92 counties, 24 had a SFO by 2011. In 2012, Indiana enacted a state-wide SFO enforcing at least moderate level SFO protection. Mean age-adjusted lung cancer incidence per year was 76.8 per 100,000 population and mean smoking prevalence per year was 25% during the study period. Counties with comprehensive or moderate SFO had a smoking prevalence 1.2% (95% CI [-1.88, -0.52]) lower compared with counties with weak or no SFO. Counties that had comprehensive or moderate SFO also had an 8.4 (95% CI [-11.5, -5.3]) decrease in new lung cancer diagnosis per 100,000 population per year compared with counties that had weak or no SFO.

Conclusion

Counties with stronger smoke-free air ordinances were associated with decreased smoking prevalence and fewer new lung cancer cases per year. Strengthening SFO is paramount to decreasing lung cancer incidence.

Testing effects of awareness of statewide smoke-free air law and risk perception on smoking behaviors

Purpose

To reduce the smoking rates and alleviate societal problems associated with smoking, health administrators and policy makers have attempted to promote and implement statewide smoking free policy. The present study examined how adults' awareness of and attitude toward the smoke-free air law, their perceived risks of secondhand smoke and current smoking status were associated with smoking attitude and behaviors.

Design/methodology/approach

As part of the Indiana Adult Tobacco Survey, 2,027 respondents participated in cross-sectional telephone surveys. A series of independent sample t-test and binary logistic regression analyses were performed.

Findings

Awareness of the state law was inversely related to negative attitude toward smoking behaviors. Individuals who reported favorable attitude toward the state smoke-free air law and higher risk perceptions of secondhand smoke showed negative attitude toward smoking behaviors. Non-smokers and former smokers were significantly different from current smokers with regard to attitude toward smoking. Negative attitude was significantly related to intention to quit smoking. Awareness of the state law, perceived risk and current smoking status were key determinants for anti-smoking attitude and behavior.

Originality/value

Findings highlight the importance of effective dissemination of the state law and recommend a strategic intervention design that invokes risk perceptions of secondhand smoke.

Compliance with Smoke-Free Policy and Challenges in Implementation: Evidence from Bengkulu, Indonesia

Background:

Smoking is among the top contributors to deaths and disability-adjusted life years in Indonesia, particularly among males. In 2012, a presidential decree encouraged provinces and districts to implement a smoke-free policy (SFP). This study aims to evaluate compliance and explore the challenges in the implementation.

Methods:

Through a mixed-methods design, we used quantitative methods to examine the compliance with six criteria including signage, no active smoking, no selling, no advertisement, no smoke, and no ashtray at SFP facilities in Bengkulu city. We observed SFP compliance at 105 facilities, including health/educational facilities, places of worship, workplaces, and indoor/outdoor public facilities. We also used a qualitative method to explore challenges in the implementation through interviews with the government and legislators.

Results:

The compliance rate to all six criteria was 38% overall, ranging from 17% at outdoor public facilities to 67% at health facilities. We found no spatial patterning, as shown by non-significant differences in compliance rates between SFP facilities inside and outside of 1-kilometer around the provincial and city health offices. Implementation challenges included lack of sensitization, lack of coordination, and limited budget.

Conclusion:

The compliance was relatively low due to several challenges, which could serve as a tobacco control policy lesson in a lower-middle-income country.

County Smoke-Free Laws and Cigarette Smoking Among U.S. Adults, 1995-2015

INTRODUCTION

Tobacco use remains the leading cause of preventable death worldwide. Though research on smoke-free policies in the U.S. exists at the state or national level, there is limited evidence on such policies at the county level. This study examined the association between changes in county-level comprehensive smoke-free laws and smoking behavior among U.S. adults.

METHODS

Data were used from the 1995/1996 to the 2014/2015 Tobacco Use Supplement to the Current Population Survey, analyzed in 2019. Changes in county smoke-free law population coverage over time were used as a natural experiment. Quasi-experimental analyses were performed to examine the association between changes in county-level comprehensive smoke-free laws and smoking behavior (smoking status and number of cigarettes smoked).

RESULTS

During the study period, current smoking prevalence decreased from 21.6% to 11.9%. Specifically, the prevalence of every day smoking decreased from 17.1% to 9.1% and some days smoking decreased from 4.4% to 2.9%. The number of cigarettes smoked per day for every day smokers decreased from 18.5 to 13.6, and from 5.9 to 4.1 for those who smoked some days. Comprehensive smoke-free legislation was associated with lower odds of cigarette smoking (AOR=0.76, 95% CI=0.74, 0.79). Adults living in counties with comprehensive smoke-free policies smoked fewer cigarettes per day both for every day smokers (β= -1.55, p<0.0001) and some days smokers (β= -0.79, p<0.0001).

CONCLUSIONS

County smoke-free policies in the U.S. may have contributed significantly to the reduction in smoking prevalence as well as the reduction in the number of cigarettes smoked among continuing cigarette smokers.

Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.

The association of county-level socioeconomic factors with individual tobacco and alcohol use: a longitudinal study of U.S. adults

Background

Place-based factors have been implicated as root causes of socioeconomic disparities in risky health behaviors such as tobacco and alcohol use. Yet few studies examine the effects of county-level socioeconomic characteristics, despite the fact that social and public health policies are often implemented at the county level. In this study, we tested the hypothesis that county-level socioeconomic disadvantage was associated with individual tobacco and alcohol use.

Methods

The sample included a panel of participants from the National Longitudinal Survey of Youth (N = 9302). The primary predictors were three time-varying measures of socioeconomic disadvantage in an individual’s county of residence: educational attainment, percent unemployment, and per capita income. We first conducted traditional ordinary least squares (OLS) models, both unadjusted and adjusted for individual-level covariates. We then conducted fixed effects (FE) models to adjust for confounding by unmeasured time-invariant individual-level factors.

Results

OLS and FE models yielded contrasting results: higher county-level per capita income was associated with decreased drinking in OLS models and increased drinking in FE models, while decreased county-level educational attainment was associated with decreased smoking in OLS models and more cigarettes per day in FE models. The findings from FE models suggest that OLS models were confounded by unobserved time-invariant characteristics. Notably, the point estimates for the county-level measures were small, and in many cases they may not represent a clinically meaningful effect except at the population level.

Conclusions

These results suggest that county-level socioeconomic characteristics may modestly influence tobacco and alcohol use. Future work should examine the effects of specific county policies that might explain these findings.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6700-x) contains supplementary material, which is available to authorized users.

Impact of US Smoke-free Air Laws on Restaurant and Bar Employment, 1990-2015

INTRODUCTION

Secondhand smoke exposure is responsible for an estimated 50000 deaths per year among nonsmokers in the United States. Smoke-free air laws reduce secondhand smoke exposure but often encounter opposition over concerns about their economic impact. Expansion of these laws has stagnated and efforts to weaken existing laws may exacerbate existing disparities in exposure. Studies at the state and local levels have found that smoke-free air laws do not generally have an adverse effect, but there are no recent estimates of the impact of these laws nationally.

METHODS

Employment and sales are two measures commonly used to estimate the economic impact of smoke-free air laws. Sales data are gathered by state and local taxing authorities but not uniformly across jurisdictions. Dynamic panel models are used to estimate a population-weighted national average treatment effect of smoke-free air laws on restaurant and bar employment using data from the Quarterly Census of Employment and Wages for 1990 to 2015.

RESULTS

A one-percentage point increase in population covered by a restaurant smoke-free air law is associated with a small increase (approximately 0.01%) in restaurant employment (b = .0001, p < .001). The percentage of state population covered by a bar smoke-free air law was not associated with bar employment.

DISCUSSION

Smoke-free air laws are a powerful tool for protecting hospitality workers and patrons from the dangers of secondhand smoke. Using data from over more than two decades, these results suggest that smoke-free air laws in the United States do not generally have any meaningful effect on restaurant and bar employment.

IMPLICATIONS

Smoke-free air laws are associated with reductions in negative health outcomes and decreased smoking prevalence. Despite this clear public health argument and strong public support, passage of new laws has stagnated and exemptions are being used to weaken existing laws. The ability to make both a health and business case in support of existing laws may also bolster the case for expansion. This study provides an updated look at the economic impact of smoke-free air laws nationally through 2015. The lack of adverse findings provides additional support for these laws as public health win-win.

Effect of the comprehensive smoke-free law on time trends in smoking behaviour in primary healthcare patients in Spain: a longitudinal observational study

OBJECTIVE

This study aimed to analyse the impact of comprehensive smoke-free legislation (SFL) on the prevalence and incidence of adult smoking in primary healthcare (PHC) patients from three Spanish regions, overall and stratified by sex.

DESIGN

Longitudinal observational study conducted between 2008 and 2013.

SETTING

66 PHC teams in Catalonia, Navarre and the Balearic Islands (Spain).

PARTICIPANTS

Population over 15 years of age assigned to PHC teams.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Quarterly age-standardised prevalence of non-smoker, smoker and ex-smoker and incidence of new smoker, new ex-smoker and ex-smoker relapse rates were estimated with data retrieved from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardised prevalence and incidence rates. Trends were expressed as annual percentage change and average annual percent change.

RESULTS

The overall standardised smoker prevalence rate showed a significant downward trend (higher in men than women) and the overall standardised ex-smoker prevalence rate showed a significant increased trend (higher in women than men) in the three regions. Standardised smoker and ex-smoker prevalence rates were higher for men than women in all regions. With regard to overall trends of incidence rates, new smokers decreased significantly in Catalonia and Navarre and similarly in men and women, new ex-smokers decreased significantly and more in men in Catalonia and the Balearic Islands, and ex-smoker relapse increased in Catalonia (particularly in women) and decreased in Navarre.

CONCLUSIONS

Trends in smoking behaviour in PHC patients remain unchanged after the implementation of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the preceding partial SFL.

Socioeconomic status and cigarette expenditure among US households: results from 2010 to 2015 Consumer Expenditure Survey

OBJECTIVES

To examine (1) the association between household socioeconomic status (SES) and whether a household spends money on cigarettes and (2) socioeconomic variations in proportion of total household expenditure spent on cigarettes among smoking households.

METHODS

We pooled data from six consecutive years, 2010-2015, of the Consumer Expenditure Interview Survey. The interviews involved a structured questionnaire about household income, demographics and expenditures including expenditure on cigarettes. Households that reported cigarette expenditure in the previous 3 months were distinguished as smoking households. SES indicators were household poverty status, education and occupation of the head of household. Logistic regression was used to assess the association of household smoking status with SES. Fractional logistic regression was used to assess the association of cigarette expenditure as a proportion of total household expenditure with SES. The analysis sample size was 39 218.

RESULTS

The probability of spending money on cigarettes was higher among lower SES households. Households in poverty compared with those above 300% of poverty threshold had 1.86 (95% CI 1.61 to 2.16), households headed by a person with less than high school education compared with those headed by a person with at least a bachelor's degree had 3.37 (95% CI 2.92 to 3.89) and households headed by a blue-collar work compared with those headed by a person in a managerial occupation had 1.45 (95% CI 1.26 to 1.66) higher odds of spending money on cigarettes. Similarly, the proportion of total household expenditure spent on cigarettes was higher among lower SES smoking households.

CONCLUSION

Lower SES households are more likely to spend money on cigarettes and spend a larger proportion of their total expenditure on cigarettes. We recommend strategies effective in reducing smoking among low SES smokers.

Longitudinal Associations of Local Cigarette Prices and Smoking Bans with Smoking Behavior in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Few studies have examined associations of geographically proximal cigarette prices with within-person changes in smoking outcomes or assessed interactions between cigarette prices and smoking bans.

METHODS

We linked neighborhood cigarette prices (inflation-adjusted) at chain supermarkets and drug stores and bar/restaurant smoking ban policies to cohort participants (632 smokers from the Multi-Ethnic Study of Atherosclerosis, 2001-2012, baseline mean age 58 years) using geocoded retailer and participant addresses. We used fixed-effects models to investigate associations of within-person changes in price and ban exposures with within-person changes in five smoking outcomes: current smoking, heavy (≥10 cigarettes) smoking, cessation, relapse, and intensity (average number of cigarettes smoked per day, natural log transformed). We assessed intensity associations among all smokers, and heavy (≥10 cigarettes per day) and light (<10) baseline smokers. Finally, we tested interactions between cigarette price and bans.

RESULTS

A $1 increase in price was associated with a 3% reduction in risk of current smoking (adjusted risk ratio [aRR]: 0.97; 95% confidence interval [CI] = 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93; CI = 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR: 1.2; CI = 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65; CI = 0.45, 0.93). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans.

CONCLUSIONS

Results underscore the importance of local prices, but not hospitality smoking bans, in influencing older adults' smoking behaviors.

Changes in smoking prevalence after the enforcement of smoking control regulations in urban Shanghai, China: Findings from two cross-sectional surveys

INTRODUCTION

The Smoking Control Regulation in Public Places (hereafter, the ‘regulations’) has been implemented in Shanghai since 2010. This study explores the changes in smoking prevalence and its influencing factors among urban Shanghai residents.

METHODS

Two rounds of household investigations (the Health Status and Health Service Utilization Survey) were carried out using a multistage probability proportionate-to-size sampling method in an urbanized district in 2010 and 2015. Descriptive and logistic regression analyses were applied to the statistics.

RESULTS

From 2010 to 2015, the standardized current smoking rate fell from 24.8% to 19.1% (38.3% to 32.0% among men, and 1.9% to 1.4% among women). Meanwhile, the standardized smoking cessation rate increased from 18.1% to 23.3%. Smoking prevalence in respondents aged 45 to 59 years was still higher than that of other age groups. Changes in smoking prevalence and cessation rates were more obvious in respondents aged 30–44 and over 75 years. Sex, age, education, marital status, and alcohol use were influencing factors of current smoking, while sex, age and alcohol use were influencing factors of smoking cessation.

CONCLUSIONS

The implementation of smoking control regulations may be beneficial for reducing smoking and increasing smoking cessation, especially among middle-aged and older men. Nevertheless, tobacco control in urban Shanghai still faces huge challenges. Therefore, more targeted and comprehensive measures should be taken.

Associations of Bar and Restaurant Smoking Bans With Smoking Behavior in the CARDIA Study: A 25-Year Study

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.

Impact of US smoke-free air laws on restaurants and bars by employer size: a panel study

OBJECTIVES

Thirty states have smoke-free air laws that ban smoking in restaurants and bars, covering nearly two-thirds of the US population. It is well established that these laws generally have a null or positive economic impact on restaurants and bars. However, all establishments in a geographic area are usually treated as a homogeneous group without considering the potential for differential effects by establishment characteristics. This study uses variation in smoke-free air laws over time to estimate their impact on employment in restaurants and bars with a focus on potential differences by employer size (number of employees). A two-pronged approach with a national-level and state-level analysis is used to take advantage of more granular data availability for a single state (North Carolina).

DESIGN

Observational study using panel data.

SETTING

1) US, 2) North Carolina INTERVENTIONS: Smoke-free air laws.

OUTCOME MEASURES

State-level accommodation and food services employment for all 50 states and District of Columbia from 1990 through 2014 (Quarterly Census of Employment and Wages); county-level restaurant and bar employment in North Carolina from 2001 through 2014 (North Carolina Department of Commerce).

RESULTS

There is no evidence of a redistributive effect of smoke-free air laws on restaurant and bar employment by employer size.

CONCLUSION

The lack of a redistributive effect is an important finding for policy-makers considering implementation or expansion of a smoke-free air law to protect employees and patrons from the dangers of exposure to secondhand smoke.

Prohibition of e-cigarettes in the US: Are prohibitions where alcohol is consumed related to lower alcohol consumption?

Recently, research has suggested negative consequences related to electronic cigarette (e-cig) use, including the increased risk for alcohol use and abuse. Previous work found that cigarette smoking ban legislation lowered overall smoking and alcohol use rates; however, researchers have not yet examined the potential effects of prohibiting e-cig use. The present study surveyed 617 individuals from a community-based online sample in the US (mean age = 33.33, SD = 10.50, 54.7 per cent female) who reported their smoking/e-cig use status, alcohol consumption, and the presence of e-cig prohibitions where they consume alcohol. E-cig prohibition was associated with a lower likelihood of being an e-cig user (OR = 0.12, p < 0.001) or dual user (use both cigarettes and e-cigs) (OR = 0.07, p < 0.001). Alcohol Use Disorder Identification Test scores (b = -1.92, p < 0.001), total drinks consumed over 14 days (b = -4.58, p = 0.002), and average drinks per drinking day (b = -0.71, p < 0.001) were all lower when e-cigs were prohibited. Findings are an initial step in this line of research and suggest important future work examining implications of e-cig prohibition recommendations and policy.

An Overview of Research and Evaluation Designs for Dissemination and Implementation

The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. This article is one product of a design workgroup that was formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. This article emphasizes randomized and nonrandomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.

Exploring Impacts of Taxes and Hospitality Bans on Cigarette Prices and Smoking Prevalence Using a Large Dataset of Cigarette Prices at Stores 2001-2011, USA

In the USA, little is known about local variation in retail cigarette prices; price variation explained by taxes, bans, and area-level socio-demographics, and whether taxes and hospitality bans have synergistic effects on smoking prevalence. Cigarette prices 2001–2011 from chain supermarkets and drug stores (n = 2973) were linked to state taxes (n = 41), state and county bar/restaurant smoking bans, and census block group socio-demographics. Hierarchical models explored effects of taxes and bans on retail cigarette prices as well as county smoking prevalence (daily, non-daily). There was wide variation in store-level cigarette prices in part due to differences in state excise taxes. Excise taxes were only partially passed onto consumers (after adjustment, $1 tax associated with $0.90 increase in price, p < 0.0001) and the pass-through was slightly higher in areas that had bans but did not differ by area-level socio-demographics. Bans were associated with a slight increase in cigarette price (after adjustment, $0.09 per-pack, p < 0.0001). Taxes and bans were associated with reduction in smoking prevalence and taxes had a stronger association when combined with bans, suggesting a synergistic effect. Given wide variation in store-level prices, and uneven state/county implementation of taxes and bans, more federal policies should be considered.

A Policy Analysis of Smoke-Free Legislation in Kentucky

This article presents a policy analysis of proposed smoke-free legislation in Kentucky during the 2015 General Assembly. Kingdon's three streams model of agenda setting is used to analyze the failure to pass HB145. Secondhand smoke exposure and related deaths are a significant public health problem in Kentucky, a state with one of the highest smoking rates in the U.S. HB145, a comprehensive smoke-free bill, was designed to protect workers and the general public from secondhand smoke and e-cigarette aerosol in enclosed workplaces and public places, with few exemptions. The bill faced intense criticism from opponents who were concerned about violation of personal and business rights and the belief that the decision should be addressed on a local level. HB145 passed the House with amendments but failed to receive a hearing in the Senate. Failure of the smoke-free legislation was due to partisanship, fragmentation of advocacy groups, lack of political bargaining, and conflict of values. As in past years, the policy window did not open for state smoke-free legislation in 2015.

Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans affecting populations. The minimum standard was having an indoor smoking ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. Our search included a broad range of research designs including: randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before-and-after studies, interrupted time series as defined by the Cochrane Effective Practice and Organisation of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

Effect of smoke-free patio policy of restaurants and bars on exposure to second-hand smoke

OBJECTIVE

While there is increasing support for restricting smoking in restaurant and bar patios, there is limited evidence on the effectiveness of this policy. This study examined the effect of smoke-free patio policy of restaurants and bars on adult second-hand smoke (SHS) exposure.

METHODS

Data were drawn from the 2005-2012 Canadian Tobacco Use Monitoring Survey (n=89,743), a repeated cross-sectional survey of youth and adult. Regression analysis, a quasi-experimental design was used to examine the effect of provincial smoke-free patio policy on self-reported exposure to SHS.

RESULTS

Analyses suggest that exposure to SHS on patios of bars and restaurants declined following the adoption of provincial smoke-free patio policy. Relative to pre-policy SHS exposure, regression results showed a reduction in the probability of SHS exposure of up to 25% in Alberta. Similarly, in Nova Scotia, the probability of SHS exposure declined by up to 21%. Analyses stratified by smoking status found similar significant effect on both smokers and non-smokers.

CONCLUSIONS

Findings suggest that provincial patio smoking ban on bars and restaurants had the intended effect of protecting non-smokers from SHS exposure. This study is consistent with a large body of evidence showing that a strong smoke-free legislation is an effective public health measure.

Public responses to a comprehensive smoking ban

Purpose

– The purpose of this paper is to report public reactions to a total workplace smoking ban, including smoking behavior, attendance at bars and clubs, and attitudes toward a broader ban.

Design/methodology/approach

– Surveys were conducted in two adjacent jurisdictions, one of which instituted a total workplace smoking ban. Surveys took place before (n=1,609) and after (n=1,600) enactment of the ban in the relevant jurisdiction.

Findings

– No change in smoking prevalence occurred in the jurisdiction enacting the ban. Strong majorities of non-smokers supported the ban, while strong majorities of smokers expressed opposition. In the jurisdiction that enacted the ban, smokers who appeared to be high-volume consumers at bars and clubs were most likely to report reducing attendance at these establishments and to oppose the ban.

Research limitations/implications

– Surveys depend on accurate self-reporting of behavior and attitudes.

Practical implications

– Some bars and clubs may incur financial losses due to smoking bans. A core of strong opponents can undermine public consensus regarding smoking bans. Licensing a limited number of bars and clubs to allow smoking can safeguard this consensus.

Social implications

– Limited smoking bans can serve as a means of harm reduction, as non-smokers are protected from environmental tobacco smoke, and accommodation of smokers reduces their motivation to oppose bans.

Originality/value

– This investigation makes use of detailed data on the public’s thinking and reactions to a comprehensive smoking ban and is a before-after study with controls.

Creating Effective Media Messaging for Rural Smoke-free Policy

OBJECTIVES

Objectives were to (1) explore perceived effectiveness of existing smoke-free print advertisements in rural communities and (2) generate message content, characteristics, and media delivery channels that resonate with residents.

DESIGN AND SAMPLE

Qualitative methods design. Thirty-nine rural adults recruited by community partners.

MEASURES

Content analysis of findings from individuals in four focus groups who participated in general discussion and reviewed eight print ads related to secondhand smoke (SHS) and smoke-free policy.

RESULTS

Six content themes were identified: smoking/SHS dangers, worker health, analogies, economic impact, rights, and nostalgia. Seven message characteristics were recognized: short/to the point, large enough to read, graphic images, poignant stories, statistics/charts/graphs, message sender, and messages targeting different groups. Four media delivery channels were considered most effective: local media, technology, billboard messages, and print materials.

CONCLUSIONS

Seeking input from key informants is essential to reaching rural residents. Use of analogies in media messaging is a distinct contribution to the literature on effective smoke-free campaigns. Other findings support previous studies of effective messaging and delivery channels. Further research is needed to examine effectiveness of themes related to message content in smoke-free ads and delivery strategies. Effective media messaging can lead to policy change in rural communities to reduce exposure to SHS.

Smoke-free policy implementation: theoretical and practical considerations

Secondhand smoke exposure is a major public health issue, increasing the risk of cardiovascular and respiratory diseases and cancer. Although best practices for adopting smoke-free policy are well understood, there is limited research on the effective implementation of smoke-free policy. This article presents theoretical and practical considerations for smoke-free policy implementation in three Kentucky communities guided by the Institutional Analysis and Development (IAD) Framework. Although both Danville and Lexington-Fayette County, Kentucky have comprehensive smoke-free policies, Danville had more effective implementation, as well as better outcomes. Further study is needed to understand the critical elements of smoke-free policy implementation and their association with population outcomes. The IAD is a promising model to guide the study of both policy adoption and implementation.

Correlates of smokeless tobacco use among first year college students

OBJECTIVE

Smokeless tobacco (SLT) use is associated with specific adverse health effects. Knowledge of student tobacco use, including SLT, may guide inquiry into other risky health behaviors, and provide opportunities for health education of students.

DESIGN

An incentivized email invitation to complete a web-based survey was sent to students at 11 colleges and universities in North Carolina and Virginia.

METHODS

In autumn 2010, emails were sent to all first-year students (n=29,536) at 11 colleges and universities in North Carolina and Virginia, inviting them to participate in a brief web-based survey to be used to establish a cohort for the parent study evaluating tobacco use over 4 years. Survey items elicited demographic characteristics, tobacco use and other health behaviors.

RESULTS

A total of 10,520 (36%) students responded. Past 30 day smoking and SLT use were 12% and 3%, respectively. Logistic regression analysis revealed that male gender (Adjusted Odds Ratio [AOR] = 11.6, 95% Confidence Interval [CI] = 8.16-16.59); current smoking (AOR = 5.5, 95% CI = 4.21-7.10), ever use of alcoholic energy drinks (AOR = 4.8, 95% CI = 3.63-6.43), and ≥ 5 days vs. < 3 days of physical activity a week (AOR = 1.5, 95% CI = 1.07-2.01) predicted risk of past 30 day SLT use.

CONCLUSION

While SLT use is relatively uncommon, knowledge of significant correlations between student tobacco use, including SLT and other risky health behaviors, might guide clinicians' inquiry and provide opportunities for health education of students.

A controlled community-based trial to promote smoke-free policy in rural communities

PURPOSE

Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak tobacco control policies. The purpose was to test the effects of a stage-specific, tailored policy-focused intervention on readiness for smoke-free policy, and policy outcomes in rural underserved communities.

METHODS

A controlled community-based trial including 37 rural counties. Data were collected annually with community advocates (n = 330) and elected officials (n = 158) in 19 intervention counties and 18 comparison counties over 5 years (average response rate = 68%). Intervention communities received policy development strategies from community advisors tailored to their stage of readiness and designed to build capacity, build demand, and translate and disseminate science. Policy outcomes were tracked over 5 years.

FINDINGS

Communities receiving the stage-specific, tailored intervention had higher overall community readiness scores and better policy outcomes than the comparison counties, controlling for county-level smoking rate, population size, and education. Nearly one-third of the intervention counties adopted smoke-free laws covering restaurants, bars, and all workplaces compared to none of the comparison counties.

CONCLUSIONS

The stage-specific, tailored policy-focused intervention acted as a value-added resource to local smoke-free campaigns by promoting readiness for policy, as well as actual policy change in rural communities. Although actual policy change and percent covered by the policies were modest, these areas need additional resources and efforts to build capacity, build demand, and translate and disseminate science in order to accelerate smoke-free policy change and reduce the enormous toll from tobacco in these high-risk communities.

5-Year trends in the intention to quit smoking amidst the economic crisis and after recently implemented tobacco control measures in Greece

OBJECTIVES

The objective of the present study was to explore the trends in the intention to quit smoking among adults in Greece between 2006 and 2011, a period characterized by financial instability and newly endorsed tobacco control initiatives.

METHODS

Trend analysis of 3 representative national and cross-sectional surveys, 'Hellas Health I' (2006), "Hellas Health III" (2010) and Hellas Health IV (2011).

RESULTS

Since 2006, the intention to quit smoking has significantly increased among both genders (33.3% [in 2006] to 42.4% [in 2011], p=0.002), among respondents aged >54years (26.9% [in 2006] to 45.1% [in 2011], p=0.019) and among residents of rural areas (26.4% [in 2006] to 46.7% [in 2011], p=0.001). Both highest (32.1% [in 2006] to 49.4% [in 2011], p=0.036) and lowest (31.7% to 46.0%, p=0.021) socioeconomic (SE) strata showed an increase in the proportion of smokers who intend to quit. However, in 2011, quit attempts were more frequent (35.3%, p=0.009) in smokers of high socioeconomic status. Moreover, smoking prevalence has significantly decreased (43.1% [in 2006] to 38.1% [in 2011], p=0.023), mainly among men (52.4% to 45.7%, p=0.037), respondents of low socioeconomic status (38.9% to 29.4%, p=0.008) and residents of urban areas (45.2% to 37.9%, p=0.005).

CONCLUSIONS

Over the past 5years and possibly as a combined result of the implemented tobacco control policies and austerity measures, the intention to quit smoking has increased among all SE strata, however actual quit attempts were higher among those less disadvantaged. Further effort should be made to support quit attempts, especially among vulnerable populations.

Smoke-free homes, strength of smoke-free law, and children in the home

INTRODUCTION

Secondhand smoke (SHS) is a leading cause of childhood illness and premature death, especially in rural areas. The study examined the relationship of having a smoke-free home, strength of smoke-free law (SFL) in the county of residence, having one or more minor children in the home, rural/urban location, and demographics.

METHODS

An Internet-based panel survey was administered to Kentucky residents from 2007 to 2012. Sample size ranged from 400 to 513 per year; N = 2,653 total. Most were female, aged 35-54, had at least some college education, and lived in a smoke-free home. Almost half lived in a county with a comprehensive SFL; 14% lived in a county with a moderate or weak law.

RESULTS

Multivariate logistic regression revealed that the significant predictors of a smoke-free home included having education beyond high school, being a nonsmoker, living in an urban county, and having a year of participation in the survey. Controlling for smoking status and other personal characteristics, those who responded to the survey in the last 2 years of administration were more likely to have a smoke-free home compared to the reference year of 2007. Respondents living in urban counties were nearly 2 times more likely to report a smoke-free home than rural dwellers.

CONCLUSIONS

Smoke-free homes in urban areas, where SFLs may be the norm, may be more typical than in rural communities. Public awareness campaigns and education about the benefits of smoke-free homes is needed, especially in rural areas, targeting smokers, those with less education, and those with children living in the home.

The association between smoking bans and nicotine dependence: a longitudinal analysis of current smokers in Canada

BACKGROUND

While a substantial body of research has examined the effects of smoking bans on smoking behavior, little is known about the relationship between smoking bans and nicotine dependence. The objective of this study was to examine whether home and workplace smoking bans are associated with reduced nicotine dependence among continuing smokers.

METHODS

We used longitudinal data of 1073 adult daily smokers from the Canadian National Population Health Survey (2004-2010). Generalized estimating equations were used to examine the association between smoking bans and nicotine dependence.

RESULTS

Smokers living in homes where smoking is restricted were less likely to be nicotine dependent (OR=0.40, 95% CI=0.32-0.50) than smokers living in homes with no such smoking restriction. Workplace smoking policies had no significant association with nicotine dependence (complete ban: OR=0.79, 95% CI=0.56-1.11; partial ban: OR=0.82, 95% CI=0.57-1.16). There was some evidence that workplace smoking bans were significantly associated with nicotine dependence when single items of the Fagerstrom test were considered.

CONCLUSIONS

This paper demonstrates that the presence of a home smoking ban was associated with lower nicotine dependence among continuing smokers. The relationship of workplace bans with nicotine dependence was less clear and was contingent on the measure of nicotine dependence employed. These findings further confirm the importance of bans on smoking in the home, workplace, and other public places on reducing tobacco-related harms.

Environmental determinants of smoking behaviors: The role of policy and environmental interventions in preventing smoking initiation and supporting cessation

Tobacco control strategies have contributed to substantial declines in smoking in the United States. However, smoking still remains the single largest preventable cause of disease and premature deaths in the country. Despite the continuing challenges of implementing tobacco control strategies and the pervasive influence of the tobacco industry to undermine such strategies, there are now unprecedented opportunities to prevent smoking initiation, facilitate cessation, and protect nonsmokers from secondhand smoke. In this paper, we briefly review the most recent literature discussing key strategies that have proven effective in tobacco control including regulations on sales and marketing of tobacco products, taxation, and smoke-free legislation. We focused on these three tobacco control strategies because of their potential to positively influence the environment of both minors and adults regardless of their smoking status. Although research has identified significant individual and social predictors of tobacco use, environmental influences are also important risk factors for tobacco use.

Assessing secondhand smoke using biological markers

Secondhand smoke exposure (SHSe) is a known cause of many adverse health effects in adults and children. Increasingly, SHSe assessment is an element of tobacco control research and implementation worldwide. In spite of decades of development of approaches to assess SHSe, there are still unresolved methodological issues; therefore, a multidisciplinary expert meeting was held to catalogue the approaches to assess SHSe and with the goal of providing a set of uniform methods for future use by investigators and thereby facilitate comparisons of findings across studies. The meeting, held at Johns Hopkins, in Baltimore, Maryland, USA, was supported by the Flight Attendant Medical Research Institute (FAMRI). A series of articles were developed to summarise what is known about self-reported, environmental and biological SHSe measurements. Non-smokers inhale toxicants in SHS, which are mainly products of combustion of organic materials and are not specific to tobacco smoke exposure. Biomarkers specific to SHSe are nicotine and its metabolites (e.g., cotinine), and metabolites of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). Cotinine is the preferred blood, saliva and urine biomarker for SHSe. Cotinine and nicotine can also be measured in hair and toenails. NNAL (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol), a metabolite of NNK, can be determined in the urine of SHS-exposed non-smokers. The selection of a particular biomarker of SHSe and the analytic biological medium depends on the scientific or public health question of interest, study design and setting, subjects, and funding. This manuscript summarises the scientific evidence on the use of biomarkers to measure SHSe, analytical methods, biological matrices and their interpretation.

Effects of smoke-free laws on alcohol-related car crashes in California and New York: time series analyses from 1982 to 2008

We examined effects of New York and California's statewide smoke-free restaurant and bar policies on alcohol-related car crash fatalities. We used an interrupted time-series design from 1982 to 2008, with 312 monthly observations, to examine the effect of each state's law on single-vehicle-nighttime crashes and crashes involving a driver with a blood alcohol concentration of 0.08 grams per deciliter or greater. Implementation of New York and California's statewide smoke-free policies was not associated with alcohol-related car crash fatalities. Additionally, analyses showed no effect of New York's smoke-free policy on alcohol-related car crash fatalities in communities along the Pennsylvania-New York border. Statewide smoke-free restaurant and bar laws do not appear to affect rates of alcohol-related car crashes.

Minnesota's comprehensive statewide smokefree law: short-term effects on young adults

BACKGROUND

Young adults have the highest rate of smoking among any age group.

PURPOSE

The purpose of this study is to assess the short-term effects of Minnesota's comprehensive statewide smokefree law on young adult smoking perceptions and behavior.

METHODS

Telephone surveys were conducted before and up to 18 months after Minnesota's statewide smokefree law went into effect on October 1, 2007 (data analyzed 2010-2011). Participants included young adults from a population-based cohort in Minnesota (n=1458) and from five other upper Midwest states that serve as a comparison (n=248). Differences in perceptions and smoking behavior were examined between Minnesota participants who lived with and without a local smokefree law prior to Minnesota's statewide law, and participants who lived in the comparison states.

RESULTS

The majority of youth in Minnesota were aware of the smoking restrictions in restaurants and bars following the law. After implementation of the law, Minnesota participants who previously lived without a local law (versus comparison) were more likely to perceive fewer adult and peer smokers and less likely to report leaving social events early because it was too smoky. No changes in smoking behaviors were observed before and after the law. Minnesota participants, however, who lived without a prior law (versus participants with a prior law) were more likely to attribute a quit attempt after the law to smoking restrictions in restaurant and bars.

CONCLUSIONS

Results suggest that Minnesota's law has changed perceptions of the tobacco environment. Longer-term follow-up may be needed to observe changes in smoking behavior.

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

Background. Policymakers need estimates of the impact of tobacco control (TC) policies to set priorities and targets for reducing tobacco use. We systematically reviewed the independent effects of TC policies on smoking behavior. Methods. We searched MEDLINE (through January 2012) and EMBASE and other databases through February 2009, looking for studies published after 1989 in any language that assessed the effects of each TC intervention on smoking prevalence, initiation, cessation, or price participation elasticity. Paired reviewers extracted data from studies that isolated the impact of a single TC intervention. Findings. We included 84 studies. The strength of evidence quantifying the independent effect on smoking prevalence was high for increasing tobacco prices and moderate for smoking bans in public places and antitobacco mass media campaigns. Limited direct evidence was available to quantify the effects of health warning labels and bans on advertising and sponsorship. Studies were too heterogeneous to pool effect estimates. Interpretations. We found evidence of an independent effect for several TC policies on smoking prevalence. However, we could not derive precise estimates of the effects across different settings because of variability in the characteristics of the intervention, level of policy enforcement, and underlying tobacco control environment.

A novel evaluation of World No Tobacco day in Latin America

BACKGROUND

World No Tobacco Day (WNTD), commemorated annually on May 31, aims to inform the public about tobacco harms. Because tobacco control surveillance is usually annualized, the effectiveness of WNTD remains unexplored into its 25th year.

OBJECTIVE

To explore the potential of digital surveillance (infoveillance) to evaluate the impacts of WNTD on population awareness of and interest in cessation.

METHODS

Health-related news stories and Internet search queries were aggregated to form a continuous and real-time data stream. We monitored daily news coverage of and Internet search queries for cessation in seven Latin American nations from 2006 to 2011.

RESULTS

Cessation news coverage peaked around WNTD, typically increasing 71% (95% confidence interval [CI] 61-81), ranging from 61% in Mexico to 83% in Venezuela. Queries indicative of cessation interest peaked on WNTD, increasing 40% (95% CI 32-48), ranging from 24% in Colombia to 84% in Venezuela. A doubling in cessation news coverage was associated with approximately a 50% increase in cessation queries. To gain a practical perspective, we compared WNTD-related activity with New Year's Day and several cigarette excise tax increases in Mexico. Cessation queries around WNTD were typically greater than New Year's Day and approximated a 2.8% (95% CI -0.8 to 6.3) increase in cigarette excise taxes.

CONCLUSIONS

This novel evaluation suggests WNTD had a significant impact on popular awareness (media trends) and individual interest (query trends) in smoking cessation. Because WNTD is constantly evolving, our work is also a model for real-time surveillance and potential improvement in WNTD and similar initiatives.

The association between implicit and explicit attitudes toward smoking and support for tobacco control measures

INTRODUCTION

This study examined the association between implicit and explicit attitudes toward smoking and support for tobacco control policies.

METHODS

Participants were from an ongoing longitudinal study of the natural history of smoking who also completed a web-based assessment of implicit attitudes toward smoking (N = 1,337). Multiple regression was used to test the association between covariates (sex, age, educational attainment, parent status, and smoking status), implicit attitude toward smoking, and explicit attitude toward smoking and support for tobacco control policies. The moderating effect of the covariates on the relation between attitudes and support for policies was also tested.

RESULTS

Females, those with higher educational attainment, parents, and nonsmokers expressed more support for tobacco control policy measures. For nonsmokers, only explicit attitude was significantly associated with support for policies. For smokers, both explicit and implicit attitudes were significantly associated with support. The effect of explicit attitude was stronger for those with lower educational attainment.

CONCLUSIONS

Both explicit and implicit smoking attitudes are important for building support for tobacco control policies, particularly among smokers. More research is needed on how to influence explicit and implicit attitudes to inform policy advocacy campaigns.

Risk factors for smoking in rural women

BACKGROUND

This study examined the association between social, demographic, and psychologic factors and smoking status among Appalachian Ohio women. A secondary aim examined whether specific factors could be identified and segmented for future tailored treatment of tobacco dependence.

METHODS

A cross-sectional survey (n=570) obtained information about social, demographic, and psychologic factors and smoking. Logistic regression described associations between these characteristics and smoking status. Chi-square automatic interaction detection (CHAID) analyses identified subgroups at risk for smoking.

RESULTS

Fifty-two percent never smoked, with 20.5% and 27.5% categorized as former and current smokers, respectively. Women with low adult socioeconomic position (SEP) were more likely to smoke (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.74-5.34) compared to high SEP women. Other factors associated with current smoking included age 31-50 (OR 2.30, 95% CI 1.22-4.33), age 18-30 (OR 3.29, 95% CI 1.72-5.34), Center for Epidemiologic Studies Depression scale (CES-D) score≥16 (OR 1.99, 95% CI 1.31-3.05), and first pregnancy at age<20 (OR 1.74, 95% CI 1.14-2.66). The prevalence of smoking was 50% among those with four or more risk factors compared to 10% for those reporting no risk factors. CHAID analyses identified low adult SEP and depressive symptoms as the combination of risk factors most strongly associated with smoking; 49.3% of women in this subgroup currently smoked.

CONCLUSIONS

Low SEP in adulthood, maternal circumstances, and depressive symptoms are associated with current smoking. Tailored cessation interventions that address these risk factors should be developed and further evaluated in an attempt to reduce disparities in smoking prevalence among this vulnerable group of women.

Perceptions of smoking cessation programs in rural Appalachia

OBJECTIVES

To identify perspectives on smoking cessation programs in Appalachian Kentucky, a region with particularly high smoking rates and poor health outcomes.

METHODS

Insufficient existing research led us to conduct 12 focus groups (smokers and nonsmokers) and 23 key informant interviews.

RESULTS

Several findings previously not described in this high-risk population include (1) transition from pro-tobacco culture toward advocacy for tobacco cessation approaches, (2) region-specific challenges to program access, and (3) strong and diverse social influences on cessation.

CONCLUSIONS

To capitalize on changes from resistance to support for smoking cessation, leaders should incorporate culturally appropriate programs and characteristics identified here.

Smoke-free laws, gender, and reduction in hospitalizations for acute myocardial infarction

OBJECTIVE

We examined gender differences in the incidence of acute myocardial infarction (AMI) after the passage of a smoke-free law in Lexington, Kentucky. The initial legislation had exemptions not covering manufacturing facilities and government buildings, which may have put men at greater risk for AMI.

METHODS

We examined the effect of Lexington's smoke-free public places law on hospitalizations for AMI (i.e., heart attack) among men and women 40 months prior to and 32 months after enactment of the law. We used the statewide administrative database (Comp Data) for all hospital billing records for the four health-care systems in Lexington-Fayette County. Cases were included in the analysis if (1) the patient was $35 years of age; (2) the patient had a primary discharge diagnosis of AMI, with an International Classification of Diseases, Ninth Revision code in the range of 410.00 to 410.99; and (3) the date of service was between January 1, 2001, and December 31, 2006.

RESULTS

Among women, AMI hospitalizations declined 23% after the law took effect. The rate of AMI events among men did not change significantly. There was an overrepresentation of women in the hospitality industry and a disproportionate number of men working in manufacturing facilities and government worksites not mandated by the law.

CONCLUSIONS

We found gender differences in the reduction of AMI hospitalizations following implementation of a smoke-free law that covered only some sectors of the workforce. Enacting smoke-free laws that cover all places of employment and strengthening existing partial laws may extend protection against AMIs to female and male workers.

Smoking behaviors and attitudes during adolescence prospectively predict support for tobacco control policies in adulthood

INTRODUCTION

Several cross-sectional studies have examined factors associated with support for tobacco control policies. The current study utilized a longitudinal design to test smoking status and attitude toward smoking measured in adolescence as prospective predictors of support for tobacco control policies measured in adulthood.

METHODS

Participants (N = 4,834) were from a longitudinal study of a Midwestern community-based sample. Hierarchical multiple regression analyses tested adolescent smoking status and attitude toward smoking as prospective predictors (after controlling for sociodemographic factors, adult smoking status, and adult attitude toward smoking) of support for regulation of smoking in public places, discussion of the dangers of smoking in public schools, prohibiting smoking in bars, eliminating smoking on television and in movies, prohibiting smoking in restaurants, and increasing taxes on cigarettes.

RESULTS

Participants who smoked during adolescence demonstrated more support for discussion of the dangers of smoking in public schools and less support for increasing taxes on cigarettes but only among those who smoked as adults. Those with more positive attitudes toward smoking during adolescence demonstrated less support as adults for prohibiting smoking in bars and eliminating smoking on television and in movies. Moreover, a significant interaction indicated that those with more positive attitudes toward smoking as adolescents demonstrated less support as adults for prohibiting smoking in restaurants, but only if they became parents as adults.

CONCLUSIONS

This study's findings suggest that interventions designed to deter adolescent smoking may have future benefits in increasing support for tobacco control policies.

An evidence-based cessation strategy using rural smokers' experiences with tobacco

Little is known about the most effective strategies to motivate rural smokers to quit. This article describes the personal narratives of current and former smokers living in an economically distressed, rural area of Appalachian Kentucky. Three categories emerged: personal motivators to quit smoking, external influences, pride of place. Capturing personal narratives represents an evidence-based, data-rich strategy for development of culturally sensitive, population-based interventions for rural smokers. Such strategies may be effective in reaching rural smokers and motivating them to quit, thereby reducing tobacco-related disease and premature death in rural, economically distressed communities.

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.