Strength of clean indoor air laws and smoking related outcomes in the USA

Initial leadership concerns and availability of tobacco cessation services moderate changes in employee-reported concerns about tobacco-free workplace policy implementation over time

Tobacco-free workplace policies (TFWPs) are underused evidence-based interventions that reduce the elevated use of tobacco among substance use treatment center (SUTC) employees and patients. SUTC employees' anticipated concerns about stakeholder pushback are barriers to TFWP adoption. Examination of discrepancies between anticipated and actualized employee-reported TFWP concerns arising from coworkers, patients, and community members in the context of leadership concerns and tobacco cessation care availability for employees may inform strategies to increase TFWP uptake. This study analyzed changes in employee-reported TFWP concerns from before to after a comprehensive tobacco-free workplace intervention that included TFWP implementation, using Chi-square/Fisher's exact tests. Preimplementation leadership policy concerns and tobacco cessation care availability were examined as moderators in generalized linear mixed models. Overall, 452 employees and 13 leaders provided data from 13 SUTCs collectively serving >82 000 patients annually. Results revealed significant decreases over time in employee-reported concerns about TFWP resistance from coworkers. Moderation analyses indicated that employee-anticipated concerns from coworkers and patients, respectively, were less likely to be actualized in SUTCs where leadership endorsed preimplementation TFWP concerns, whereas employee-reported patient concerns rose over time in SUTCs where leadership had no initial implementation concerns. Additionally, employee-anticipated concerns from coworkers were overestimated in SUTCs that did not offer tobacco cessation care to employees. Results supporting the nonactualization of anticipated employee concerns following TFWP implementation can be used to engage other SUTCs for TFWP adoption. Furthermore, moderation effects may suggest that center characteristics translate to greater attention to rollout, ultimately enhancing TFWP stakeholder acceptance.

Online Tobacco Advertising and Current Chew, Dip, Snuff and Snus Use among Youth and Young Adults, 2018-2019

OBJECTIVE

To understand the relationship between exposure to online tobacco advertising and current smokeless tobacco use in the context of tobacco control policies.

METHODS

Three waves of a national probability-based sample of (n = 15,985) youth and young adults were used. Analysis consisted of GEE logistic models controlling for social media use, demographics, tobacco use, average price of smokeless tobacco inclusive of taxes, smoke-free indoor air laws (SFIA) and state tobacco control expenditures.

RESULTS

Frequent exposure to tobacco advertising on social media is associated with greater odds of current smokeless use (aOR: 2.05, 95% CI: 1.62, 2.60). Higher prices and SFIA coverage were associated with reduced current smokeless use when examined separately from other tobacco policy variables (aOR: 0.79, CI: 0.73, 0.85; aOR: 0.44, CI: 0.28, 0.70).

CONCLUSIONS

Greater exposure to tobacco advertising online is associated with greater odds of smokeless use among surveyed youth and young adults. This effect of social media marketing exposure on smokeless use outweighs the mitigating impact of existing tobacco control policies. The findings underscore the need for strong advertising regulation of evolving tobacco products, including smokeless products, on social media and surveillance of digital marketing tactics to young people.

CIGARETTE TAXES AND TEEN MARIJUANA USE

The spillover effect of cigarette taxes on youth marijuana use has been the subject of intense public debate. Opponents of cigarette taxes warn that tax hikes will cause youths to substitute toward marijuana. On the other hand, public health experts often claim that because tobacco is a "gateway" drug, higher cigarette taxes will deter youth marijuana use. Using data from the National and State Youth Risk Behavior Surveys (YRBS) for the period 1991-2017, we explore the relationship between state excise taxes on cigarettes and teen marijuana use. In general, our results fail to support either of the above hypotheses. Rather, we find little evidence to suggest that teen marijuana use is sensitive to changes in the state cigarette tax. This null result holds for the sample period where cigarette taxes are observed to have the largest effect on teen cigarette use and across a number of demographic groups in the data. Finally, we find preliminary evidence that the recent adoption of state e-cigarette taxes is associated with a reduction in youth marijuana use.

Clean indoor air laws, cigarette excise taxes, and smoking: Results from the current population survey-tobacco use supplement, 2003-2011

There was an increase in the number and coverage of state and local clean indoor air laws in the US during the past fifteen years. These laws coincided with increases in federal, state, and local cigarette excise taxes. In light of these changes, the objective of this study was to examine the association between clean indoor air laws, cigarette excise taxes and smoking patterns between 2003 and 2011. Using data on 62,165 adult participants in the 2003 and 2010/2011 Current Population Survey-Tobacco Use Supplement who reported smoking cigarettes in the past year, we examined the association of state and county workplace, bar, and restaurant clean indoor air laws and cigarette excise taxes with quitting and current every-day smoking. Between 2003 and 2011, quitting increased and daily smoking among those who continued to smoke decreased significantly. Participants living in states and counties with higher excise taxes and more comprehensive clean indoor air laws had a higher likelihood of quitting and lower likelihood of everyday smoking. Based on the assumption of no uncontrolled confounding, changes in taxes and laws accounted for 64.8% of the increase in smoking cessation and all of the reduction in everyday smoking. Implementation of state and county-level clean indoor air laws and cigarette taxes appears to have achieved the intended goal of encouraging smokers to either quit or reduce their frequency of smoking.

Smoking cessation intervention trial outcomes for sexual and gender minority young adults

OBJECTIVE

Sexual and gender minority (SGM) individuals are more likely to smoke than are non-SGM individuals. It is unclear whether smoking cessation interventions for young adults are effective in the SGM population. The purpose of this study was to compare smoking cessation, other health risk behaviors, and intervention usability between SGM and non-SGM young adult smokers participating in a digital smoking cessation intervention trial.

METHODS

Young adult smokers (N = 500; 135 SGM) were assigned to a 90-day Facebook smoking cessation intervention (treatment) or referred to Smokefree.gov (control). Intervention participants were assigned to private Facebook groups tailored to their readiness to quit smoking. Participants reported their smoking status and other health risk behaviors at baseline, 3, 6, and 12 months. Usability of the intervention (i.e., perceptions of the intervention and treatment engagement) was assessed in the intervention group at 3 months.

RESULTS

Smoking cessation and intervention usability did not significantly differ between SGM participants and non-SGM participants. A greater proportion of SGM participants were at high risk for physical inactivity over the 12-month follow-up period (odds ratio [OR] = 1.55, p = .005).

CONCLUSION

SGM and non-SGM young adult smokers did not differ in their smoking cessation rates, perceptions of, or engagement in a digital intervention. Health risk behavior patterns were mostly similar; however, the disparity in physical activity between SGM and non-SGM smokers widened over time. Tailored interventions for SGM young adult smokers could increase focus on SGM experiences that can underlie multiple health risk behaviors, such as discrimination and the normativity of smoking. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Exposure to workplace smoking bans and continuity of daily smoking patterns on workdays and weekends

INTRODUCTION

Individuals may compensate for workplace smoking bans by smoking more before or after work, or escaping bans to smoke, but no studies have conducted a detailed, quantitative analysis of such compensatory behaviors using real-time data.

METHODS

124 daily smokers documented smoking occasions over 3weeks using ecological momentary assessment (EMA), and provided information on real-world exposure to smoking restrictions and type of workplace smoking policy (full, partial, or no bans). Mixed modeling and generalized estimating equations assessed effects of time of day, weekday (vs weekend), and workplace policy on mean cigarettes per hour (CPH) and reports of changing location to smoke.

RESULTS

Individuals were most likely to change locations to smoke during business hours, regardless of work policy, and frequency of EMA reports of restrictions at work was associated with increased likelihood of changing locations to smoke (OR=1.11, 95% CI 1.05-1.16; p<0.0001). Workplace smoking policy, time block, and weekday/weekend interacted to predict CPH (p<0.01), such that individuals with partial work bans -but not those with full bans - smoked more at night (9pm - bed) on weekdays compared to weekends.

CONCLUSIONS

There was little evidence that full bans interfered with subjects' smoking during business hours across weekdays and weekends. Smokers largely compensate for exposure to workplace smoking bans by escaping restrictions during business hours. Better understanding the effects of smoking bans on smoking behavior may help to improve their effectiveness and yield insights into determinants of smoking in more restrictive environments.

Key Factors Inhibiting Legislative Progress Toward Smoke-Free Coverage in Appalachia

The Appalachian Region has among the highest rates of smoking and smoking-related illness in the United States. Strong smoke-free legislation could help protect nonsmoking residents from the harmful effects of secondhand smoke. However, there is a dearth of state, county, city, and subcounty smoke-free law coverage throughout Appalachia. As of July 2016, only 21% of Appalachian residents were covered by comprehensive smoke-free laws (i.e., 100% coverage for workplaces, restaurants, and bars). Only 46% of Appalachians lived in places with 100% smoke-free workplace laws, only 30% lived in places with 100% smoke-free restaurant laws, and only 29% lived in places with 100% smoke-free bar laws. Reasons for this lack of smoke-free law coverage include socioeconomic disadvantage, the historical importance of tobacco in Appalachian economies, and preemptive state legislation. By understanding the contextual issues that have inhibited smoke-free legislation, smoke-free advocates will be better prepared to lead efforts that expand smoke-free coverage in this region.

A Multilevel Test of Constrained Choices Theory: The Case of Tobacco Clean Air Restrictions

According to Bird and Rieker's sociology of constrained choices, decisions and priorities concerning health are shaped by the contexts-including policy, community, and work/family-in which they are formulated. While each level received attention in the original and subsequent research, we contend their constrained choices theory provides a powerful multilevel framework for modeling health outcomes. We apply this framework to tobacco clean air restrictions, combining a comprehensive database of tobacco policies with the National Longitudinal Survey of Youth 1997 from ages 19 to 31. Using multilevel panel models, we find that clean air policies lower the odds of past 30 day smoking and dependence while controlling for other policy-, city-, and individual-level constraints. We also find unique between- and within-person effects, as well as gender effects, for the constraint levied by smoking bans. We argue for the theory's broad applicability beyond commonly cited findings regarding gender and biological influences.

Impact of Tobacco Control Policies on Adolescent Smoking

PURPOSE

Our aims were to examine the impact of cigarette taxes and smoke-free legislation on current adolescent smoking and smoking frequency overall as well as test whether there were differential policy effects by age.

METHODS

Using data on 717,543 adolescents from 43 states in the 1999-2013 Youth Risk Behavior Surveys, we used difference-in-differences regression models to evaluate the impact of tobacco control policies on current adolescent smoking (yes/no) and, separately, smoking frequency (defined as 0, 1-5, 6-29, 30+ days per month). We tested an interaction between age and cigarette taxes and, separately, smoke-free legislation.

RESULTS

From 1999 to 2013, adolescent smoking decreased from 35.3% to 13.9% and 41 of 43 states increased their cigarette tax in real terms by an average of 257%. By the end of the study period, 29 of 43 states had 100% smoke-free restaurant legislation. Although we found no overall effect of cigarette taxes on current smoking, there was a significant interaction by age. Among 14- and 15-year olds, every $1.00 cigarette tax increase was associated with a 2.2 and 1.6 percentage point reduction in smoking, respectively. The enactment of 100% smoke-free restaurant legislation was associated with an overall reduction in adolescent smoking by 1.1 percentage points and there were no differences by age. Cigarette taxes and smoke-free legislation were also associated with decreased smoking frequency.

CONCLUSIONS

The youngest adolescents are the most price sensitive, and cigarette taxes continue to be a successful approach to reduce adolescent smoking. Smoke-free legislation may also be an effective strategy to reduce smoking among all adolescents.

Asthma, tobacco smoke and the indoor environment: a qualitative study of sheltered homeless families

OBJECTIVE

Asthma is common in homeless children with an incidence of 28-40%. There are few published studies investigating asthma in homeless children. This study examines the perspectives of both caregivers and shelter staff regarding challenges and opportunities of caring for children with asthma.

METHODS

A focus group of sheltered parents (n = 10) with children who have asthma was conducted to identify barriers to optimal asthma management. Key informant interviews (n = 6) were conducted with shelter staff to discuss the shelter systems and policies to address childhood asthma. Data were audio-recorded and transcribed. A representative analysis team performed qualitative theme analysis.

RESULTS

Key themes across 5 domains were identified: asthma education, access to asthma medication and equipment, asthma action plans, structural barriers to asthma management and environmental triggers. Parents identified multiple asthma triggers present in the shelter environment but cited lack of control as a barrier to remediation. Shelter staff desired elimination of asthma triggers but refer to the lack of resources as the primary barrier. Shelter staff favored a smoking ban on shelter property but named challenges to policy implementation. Both parents and staff identified asthma education and increased access to medications would be helpful.

CONCLUSIONS

Policies to reduce environmental exposures, such as a smoking ban, to asthma triggers has the potential to improve the health of sheltered children with asthma.

Association between local indoor smoking ordinances in Massachusetts and cigarette smoking during pregnancy: a multilevel analysis

OBJECTIVE

To estimate the association between local clean indoor air ordinances and prenatal maternal smoking across 351 municipalities in Massachusetts before the 2004 statewide ban and to test the effect of time since ordinance adoption on the association.

METHODS

The authors linked 2002 birth certificate data of women who gave birth in the state and reported a Massachusetts residence (n=67,584) to a database of indoor smoking ordinances in all municipalities. Multilevel regression models accounting for individual- and municipality-level variables estimate the associations between the presence of local smoking ordinances, strength of the ordinances, time since ordinance adoption and prenatal smoking.

RESULTS

Compared with those living in municipalities with no ordinances, women living in municipalities with a smoking ordinance had lower odds of prenatal smoking (OR=0.72, CI=0.53 to 0.98). No effect was found for 100% smoke-free ordinances. For the analyses testing the effect of time, pregnant women living in municipalities with ordinances enacted >2 years were less likely to smoke than those in municipalities with more recent (<1 year) ordinances.

CONCLUSIONS

Preventing smoking among women of reproductive age is a public health priority. This study suggests that indoor smoking ordinances were associated with lower prenatal smoking prevalence and the favourable effect increased over time. Findings highlight the public health benefit of tobacco control policies.

A comprehensive examination of the influence of state tobacco control programs and policies on youth smoking

OBJECTIVES

We examined the influence of tobacco control policies (tobacco control program expenditures, smoke-free air laws, youth access law compliance, and cigarette prices) on youth smoking outcomes (smoking susceptibility, past-year initiation, current smoking, and established smoking).

METHODS

We combined data from the 2002 to 2008 National Surveys on Drug Use and Health with state and municipality population data from the US Census Bureau to assess the associations between state tobacco control policy variables and youth smoking outcomes, focusing on youths aged 12 to 17 years. We also examined the influence of policy variables on youth access when these variables were held at 2002 levels.

RESULTS

Per capita funding for state tobacco control programs was negatively associated with all 4 smoking outcomes. Smoke-free air laws were negatively associated with all outcomes except past-year initiation, and cigarette prices were associated only with current smoking. We found no association between these outcomes and retailer compliance with youth access laws.

CONCLUSIONS

Smoke-free air laws and state tobacco control programs are effective strategies for curbing youth smoking.

Improving state health policy assessment: an agenda for measurement and analysis

We examine the scope of inquiry into the measurement and assessment of the state public health policy environment. We argue that there are gains to be made by looking systematically at policies both within and across health domains. We draw from the public health and public policy literature to develop the concepts of interdomain and intradomain policy comprehensiveness and illustrate how these concepts can be used to enhance surveillance of the current public health policy environment, improve understanding of the adoption of new policies, and enhance evaluations of the impact of such policies on health outcomes.

Coded statutory data sets for evaluation of public health law

BACKGROUND AND OBJECTIVES

The evaluation of public health law requires reliable accounts of underlying statutes and regulations. States often enact public health-related statutes with nonuniform provisions, and variation in the structure of state legal codes can foster inaccuracy in evaluating the impact of specific categories of law. The optimal format for empirical analysis is a machine-readable 50-state coded data set. This study provides a comprehensive assessment of these resources and related materials with a focus on statutory data sets.

RESEARCH DESIGN

An exhaustive literature search was followed by a "pearling" or "snowball" approach to assure the most complete inventory of this very diverse and diffuse information. We also interviewed three leading investigators to identify barriers to wider use and availability of coded legal data sets.

RESULTS

We identified relatively few accessible coded statutory data sets, and others that are not available for use outside the group or individual that compiled them. The Robert Wood Johnson Foundation-funded Public Health Law Research Program has made funding available for the development and dissemination of additional data sets, as well as extensive guidance regarding their use in the evaluation of public health law. Investigators reported serious obstacles to these activities in the past.

CONCLUSIONS

Compilation of coded statutory data sets requires a focused investment of resources that has only recently become available. Funders should require grantees to make their work accessible to other investigators so as to assure development of public health law research and evaluation.

The impact of local U.S. tobacco policies on youth tobacco use: A critical review

Tobacco use continues to be the leading preventable cause of premature death in the United States, killing over 430,000 people annually. Tobacco initiation and use among youth remains a significant public health concern. Despite declines in U.S. youth tobacco use in recent years, state and national survey results are still cause for alarm. Although traditional school-based curricular programs are the most common strategy to prevent or reduce youth tobacco use, their effectiveness may be limited because young people are immersed in a broader social context in which tobacco is readily available. Environmental strategies change this social context by focusing on policy, enforcement, and media. A compelling body of evidence suggests that interventions at the state and federal levels can, when implemented in combination, reduce youth tobacco use. The impact of policies implemented at the local levels is less well understood and effects of environmental strategies on smokeless tobacco consumption have been largely ignored. The purpose of this paper is to review the literature on environmental strategies implemented at the local level on youth use of both cigarettes and smokeless tobacco. We highlight results of the extant literature, hypothesize possible effects where research is lacking, and suggest where future studies might be warranted.

Clean indoor air ordinance coverage in the Appalachian region of the United States

OBJECTIVES

We sought to quantitatively examine the pattern of, and socioeconomic factors associated with, adoption of clean indoor air ordinances in Appalachia.

METHODS

We collected and reviewed clean indoor air ordinances in Appalachian communities in 6 states and rated the ordinances for completeness of coverage in workplaces, restaurants, and bars. Additionally, we computed a strength score to measure coverage in 7 locations. We fit mixed-effects models to determine whether the presence of a comprehensive ordinance and the ordinance strength were related to community socioeconomic disadvantage.

RESULTS

Of the 332 communities included in the analysis, fewer than 20% had adopted a comprehensive workplace, restaurant, or bar ordinance. Most ordinances were weak, achieving on average only 43% of the total possible points. Communities with a higher unemployment rate were less likely and those with a higher education level were more likely to have a strong ordinance.

CONCLUSIONS

The majority of residents in these communities are not protected from secondhand smoke. Efforts to pass strong statewide clean indoor air laws should take priority over local initiatives in these states.

Legislative smoking bans for reducing 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 smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included 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 Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

From the American Academy of Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Stealing a march in the 21st century: accelerating progress in the 100-year war against tobacco addiction in the United States

Tobacco use in the United States has declined dramatically over the past 50 years, with the prevalence of cigarette smoking falling from about 42% of all adults to less than 20% by 2007. If this rate of decline continues, smoking could be eliminated in the United States by 2047. Framed in military parlance, we may be halfway through a 100-year war against the leading public health killer of our time. We describe factors that have contributed to progress over the last 50 years and identify policy and other initiatives that can contribute to the elimination of tobacco use in the United States.

Tobacco control policy and adolescent cigarette smoking status in the United States

INTRODUCTION

Tobacco policies that limit the sale of cigarettes to minors and restrict smoking in public places are important strategies to deter youth from accessing and consuming cigarettes.

METHODS

We examined the relationship of youth cigarette smoking status to state-level youth access and clean indoor air laws, controlling for sociodemographic characteristics and cigarette price. Data were analyzed from the 2001 to 2002 U.S. Health Behavior in School-Aged Children survey, a cross-sectional survey conducted with a nationally representative sample of 13,339 students in the United States.

RESULTS

Compared with students living in states with strict regulations, those living in states with no or minimal restrictions, particularly high school students, were more likely to be daily smokers. These effects were somewhat reduced when logistic regressions were adjusted for sociodemographic characteristics and cigarette price, suggesting that higher cigarette prices may discourage youth to access and consume cigarettes independent of other tobacco control measures.

DISCUSSION

Strict tobacco control legislation could decrease the potential of youth experimenting with cigarettes or becoming daily smokers. The findings are consistent with the hypothesis that smoking policies, particularly clean indoor air provisions, reduce smoking prevalence among high school students.

Evidence and argument in policymaking: development of workplace smoking legislation

Background

We sought to identify factors that affect the passage of public health legislation by examining the use of arguments, particularly arguments presenting research evidence, in legislative debates regarding workplace smoking restrictions.

Methods

We conducted a case-study based content analysis of legislative materials used in the development of six state workplace smoking laws, including written and spoken testimony and the text of proposed and passed bills and amendments. We coded testimony given before legislators for arguments used, and identified the institutional affiliations of presenters and their position on the legislation. We compared patterns in the arguments made in testimony to the relative strength of each state's final legislation.

Results

Greater discussion of scientific evidence within testimony given was associated with the passage of workplace smoking legislation that provided greater protection for public health, regardless of whether supporters outnumbered opponents or vice versa.

Conclusion

Our findings suggest that an emphasis on scientific discourse, relative to other arguments made in legislative testimony, might help produce political outcomes that favor public health.

Does the workplace-smoking ban eliminate differences in risk for environmental tobacco smoke exposure at work?

OBJECTIVES

A workplace-smoking ban in the Netherlands was introduced on January 1, 2004. Before the ban male and low educated employees were at higher risk for exposure to environmental tobacco smoke (ETS). Effective implementation of the ban should result not only in an overall decline of exposure, but also in the disappearance of systematic differences in exposure between subgroups of employees.

METHODS

Data from a Dutch continuous Internet survey were used. From July 2003 through June 2005, 200 respondents were randomly selected each week. The sample consisted of 11,291 non-smoking, working respondents, aged 16-65 years.

RESULTS

ETS exposure decreased among all employees and among subgroups at higher risk before the ban. However, also after the ban, males and low educated employees were still most likely to be exposed to ETS.

CONCLUSIONS

The workplace-smoking ban was effective in reducing ETS exposure among employees. However, after the ban still 52.2% of non-smoking workers reported to be exposed. We did not find the expected stronger effect among employees who were at higher risk. Both before and after implementation of the ban, males and lower educated employees were about two times more likely to be exposed to ETS.

Smoke-free ordinances in Texas worksites, restaurants, and bars, 2000-2007

BACKGROUND

Policies to protect citizens from secondhand smoke (SHS) exposure are widely noted to bring numerous economic and health benefits and contribute to changes in public norms. In 2000, the Texas Department of State Health Services established a database to track changes in the number and content of municipal secondhand smoke ordinances. This study utilizes that data to describe existing municipal ordinances; identify changes in population coverage across worksites, restaurants, and bars; and examine disparities in coverage associated with race/ethnicity.

METHODS

Ordinance features are examined in five settings: municipal worksites, private-sector worksites, restaurants, bars in restaurants, and bars not in restaurants. This descriptive, time-series study analyzes changes in smoke-free ordinance content and population coverage from 2000 to 2007.

RESULTS

In 2000, no Texas municipal populations were covered by smoke-free ordinances in more than one study setting. By 2007, over 25% of the state's municipal population resided in cities with smoke-free ordinances in all five settings, and 40% were smoke-free in three or more settings. By 2007, over 50% of the municipal population had smoke-free worksite ordinance protections; 40% had smoke-free protections in private worksites, restaurants, and bars in restaurants; and over 25% were protected in bars not in restaurants. Populations in predominantly minority cities had more ordinance protection from SHS.

CONCLUSIONS

Changes in smoke-free ordinance provisions have been rapid in Texas cities of all sizes and locations. Evaluating whther these local gains can translate into continued support for further municipal and state SHS legislation will be important.

Monitoring the tobacco use epidemic V: The environment: factors that influence tobacco use

OBJECTIVE

This environment paper (V of V) summarizes important surveillance and evaluation systems that monitor influences on tobacco use such as smoke-free laws and other legislation, excise taxes, mass media, and a broad range of tobacco control activities, discusses their strengths and weaknesses, and makes recommendations for enhancement.

METHODS

We summarize and expand on the recommendations from the Environment Working Group of the National Tobacco Monitoring, Research, and Evaluation Workshop prioritized surveillance needs. This group rank-ordered surveillance needs various environmental influences, considering both the perceived importance of each environmental influence and the adequacy of the current surveillance systems. Based on this ranking and subsequent discussion, the group identified key priorities for enhancement.

RESULTS

The group arrived at two key priorities: (1) develop and implement a national system for local tobacco control ordinance surveillance, and (2) develop and implement a comprehensive program monitoring system that is used by all states and supported by all funding agencies. Other environmental influences recommended for priority monitoring include cigarette prices and tobacco countermarketing.

CONCLUSION

Systematic surveillance and monitoring of key program inputs and outputs and environmental influences is central to understand the effectiveness and cost-effectiveness of tobacco control efforts.

Examining antecedents of clean indoor air policy support: implications for campaigns promoting clean indoor air

This investigation sought to examine the association between knowledge of the risks associated with environmental tobacco smoke and voter support for clean indoor air policies. In doing so, 2 antecedents were employed to enhance understanding of this relationship: attitudes and subjective norms. In addition, differences between nonsmokers and smokers were assessed across the aforementioned variables. The study sampled participants (N = 550) living in the Appalachian foothills as a means of conducting formative research prior to developing messages promoting clean indoor air policies. The study controlled for tobacco usage, age, biological sex, and income. Results revealed that awareness of risk is a good predictor of attitudes and social norms, and in return, attitudes and social norms are good predictors of support for clean indoor air policies. In addition, results reveal that nonsmokers maintain a significantly stronger belief in the dangers associated with environmental tobacco smoke, as well as more favorable attitudes, subjective norms, and support for clean indoor air policies when compared with smokers. These findings are discussed with a focus on message design strategies for practitioners and academics with interests in promoting clean indoor air policies.

The relationship between local clean indoor air policies and smoking behaviours in Minnesota youth

BACKGROUND

While clean indoor air (CIA) policies are intended to reduce exposure to second-hand smoke in the workplace, restrictions in public workplaces have the potential to discourage youth smoking. There is growing evidence from cross-sectional and ecological studies, but limited evidence from longitudinal studies that this is so.

OBJECTIVE

To evaluate the association between local CIA policies and smoking behaviours among Minnesota youth over time.

DESIGN, SETTING AND SUBJECTS

A cohort of 4233 Minnesota youths, ages 11 to 16 at baseline, was interviewed via telephone for 6 years (2000-2006). Individual, family and community level variables were collected from participants every 6 months. A generalised estimating equation (GEE) logistic regression was used to assess the relationship between CIA policies and past-month smoking in youth over time. The analysis was controlled for potential confounders at individual and community levels.

RESULTS

There was not significant association between CIA policies and youth smoking behaviours in the multivariate analyses. At the individual level, parental smoking significantly increased the odds of smoking nearly 40% and close friend smoking increased the odds of past-month smoking by nearly 100% for each close friend. Banning smoking in the home was significantly associated with a 12% reduction in the odds of past-month smoking.

CONCLUSION

After accounting for other community and individual level factors known to be associated with youth smoking, there was no significant association between CIA policies and past-month smoking for youth over time.

Community readiness for local smoke-free policy change

PURPOSE

The purpose of this study was to use the Community Readiness Model to examine local smoke-free policy development.

DESIGN, SETTING, AND SUBJECTS

A descriptive, cross-sectional design was used to assess 64 Kentucky communities. Dimensions of readiness included a community's knowledge of the problem and existing voluntary smoke-free policies; leadership for policy development; resources for policy development; climate surrounding policy development; existing voluntary policy efforts; and political climate for policy development. Dimension scores were summed to identify one of six overall readiness stages: (1) unawareness; (2) vague awareness; (3) preplanning; (4) preparation; (5) initiation; and (6) endorsement.

ANALYSES

Correlations between dimensions and overall readiness scores were evaluated. One-way analysis of variance was used to evaluate regional trends, and multiple regression was used to assess the influence of sociodemographic/political variables on policy readiness.

RESULTS

The knowledge dimension rated highest, and community climate rated lowest. Most communities were in the lower stages of readiness. No relationship was found between overall readiness and region (F [4,59] = 1.17; p > .05); nor were there regional differences among dimension scores. Smaller communities were less ready for local policy development than larger ones (adjusted R2 = .25; p = .003).

CONCLUSIONS

The Community Readiness Model is appropriate for understanding local policy development, and it provides advocates with information that may prove helpful in advancing smoke-free policy.

Do local tobacco regulations influence perceived smoking norms? Evidence from adult and youth surveys in Massachusetts

Smoking behavior has been shown to be influenced by individuals' perceptions of social norms about smoking. This study examines whether local regulations regarding clean indoor air and youth access to tobacco are associated with residents' subsequent perceptions of smoking norms. Data came from Massachusetts surveys of adults and youths and from records of local tobacco control policies. Indices of perceived smoking norms were based on perceived smoking prevalence and perceived community acceptance of smoking. Multilevel models tested the association between perceived norms and the presence of strong local regulations in four policy domains (restaurant smoking bans, smoking restrictions in other venues, enforcement of laws prohibiting sales to youths and youth-oriented marketing restrictions). The model controlled for town voting results on a tobacco tax referendum, which served as a measure of antismoking sentiment pre-dating the regulations. Results showed that youths perceived community norms to be significantly more 'antismoking' if they lived in a town that had strong regulations in at least three of the four domains. For adults, having strong regulations in as few as one to two domains was associated with perceiving community norms to be significantly more antismoking. Implementing and publicizing local regulations may help shape perceptions of community smoking norms.

The diffusion and impact of clean indoor air laws

Over the past quarter century, primarily as a result of scientific discovery, citizen advocacy, and legislative action, comprehensive clean indoor air laws have spread rapidly throughout the world. Laws that establish completely smoke-free indoor environments have many relative advantages including being low cost, safe, effective, and easy to implement. The diffusion of these laws has been associated with a dramatic and rapid reduction in population levels of serum cotinine among nonsmokers and has also contributed to a reduction in overall cigarette consumption among smokers, with no adverse economic impact, except to the tobacco industry. Currently, nearly half of the U.S. population lives in jurisdictions with some combination of completely smoke-free workplaces, restaurants, or bars. The diffusion of clean indoor air laws is spreading rapidly throughout the world, stimulated by the first global health treaty, the Framework Convention on Tobacco Control.

Did the Tobacco Control Act Amendment in 1995 affect daily smoking in Finland? Effects of a restrictive workplace smoking policy

BACKGROUND

This study examined changes in adult daily smoking in 1981-2005 in Finland, in order to evaluate the impact of the 1995 Tobacco Control Act Amendment (TCAA) and accompanying measures on the proportion of daily smokers. The main focus of the TCAA was to prohibit smoking at workplaces (designated rooms excluded) in order to protect workers from environmental tobacco smoke.

METHODS

The study was based on data from annual postal surveys among 15- to 64-year-olds in 1981-2005 (average response rate 73%). The data set for this study comprised men and women aged 25-64 years (n = 73 471). Logistic models were used to test the effect of the 1995 TCAA across employment status while controlling for the effect of changes in the real price of tobacco and in gross domestic product per capita, and adjusting for age, education, secular trend and prevalence of ever-smokers in each birth cohort.

RESULTS

Controlling for confounding factors, the odds ratio (OR) for daily smoking after 1995 among employed men was 0.83 (95% CI 0.73-0.94) compared with the OR (1.0) for the period ending 1994. The corresponding figure for employed women was 0.78 (95% CI 0.68-0.91). The results can be interpreted as a positive effect of the 1995 TCAA on employees' daily smoking. Moreover, a similar decrease in daily smoking was not seen among those not targeted by the TCAA (including farmers, students, housewives, pensioners and the unemployed).

CONCLUSION

Smoking behaviour was and can be influenced by national tobacco policy measures.

Development of a School Nutrition-Environment State Policy Classification System (SNESPCS)

BACKGROUND

As policy strategies are rapidly being developed to address childhood overweight, a system was developed to systematically and reliably classify state policies related to the school nutrition environment. This study describes the development process, the inter-rater reliability to code state policies enacted as of December 2003, and the variability in state policies related to the school nutrition environment.

METHODS

The development of the School Nutrition Environment State Policy Classification System (SNESPCS) included a comprehensive review of published literature, reports from government and nongovernmental sources, input from an expert panel, and select experts. Baseline statutes and regulations for each of the 50 states and the District of Columbia were retrieved from Westlaw (data retrieved in 2005-2006 and analyzed in 2006) and pilot testing of the system was conducted.

RESULTS

SNESPCS included 11 policy areas that relate to a range of environmental and surveillance domains. At baseline, states had no (advertising/promotion and preferential pricing) or modest (school meal environment, reimbursable school meals, coordinating or advisory councils, body mass index screening) activities in many of the policy areas. As of 2003, 60% of the states had policies related to the sale of foods in school that compete with the school meal program.

CONCLUSIONS

Evaluation of policies that affect the school-nutrition environment is in its earliest stage. SNESPCS provides a mechanism for assessing variation in state policies that can be incorporated in an evaluation framework aimed at elucidating the impact of state policies on the school environment, social norms, and children's dietary behaviors in schools.

Patterns of childhood obesity prevention legislation in the United States

INTRODUCTION

Because of the public's growing awareness of the childhood obesity epidemic, health policies that address obesogenic environments by encouraging healthy eating and increased physical activity are gaining more attention. However, there has been little systematic examination of state policy efforts. This study identified and described state-level childhood obesity prevention legislation introduced and adopted from 2003 through 2005 and attempted to identify regional geographic patterns of introduced legislation.

METHODS

A scan of legislation from all 50 states identified 717 bills and 134 resolutions that met study inclusion criteria. Analyses examined patterns in the introduction and adoption of legislation by time, topic area, and geography.

RESULTS

Overall, 17% of bills and 53% of resolutions were adopted. The amount of legislation introduced and adopted increased from 2003 through 2005. The topic areas with the most introduced legislation were school nutrition standards and vending machines (n = 238); physical education and physical activity (n = 191); and studies, councils, or task forces (n = 110). Community-related topic areas of walking and biking paths (37%), farmers' markets (36%), and statewide initiatives (30%) had the highest proportion of bills adopted, followed by model school policies (29%) and safe routes to school (28%). Some regional geographic patterns in the introduction of legislation were observed. There was no statistical association between state-level adult obesity prevalence and introduction of legislation.

CONCLUSION

Public health and health policy practitioners can use this information to improve advocacy efforts and strengthen the political climate for establishing childhood obesity prevention legislation within state governments. Expanded surveillance (including standardized identification and cataloging) of introduced and adopted legislation will enhance the ability to assess progress and identify effective approaches. Future policy research should examine determinants, implementation, and effectiveness of legislation to prevent childhood obesity.

Trends in socioeconomic inequalities in adult health behaviors among U.S. states, 1990-2004

OBJECTIVE

The purpose of this study was to measure state trends in educational inequalities in smoking, binge alcohol use, physical inactivity, obesity, and seatbelt use.

METHODS

The authors calculated the Relative Concentration Index of educational inequality for five health behaviors on adults from all 50 states and the District of Columbia using data from 1990 to 2004 in the Behavioral Risk Factor Surveillance System (n=2,118,562). Linear regression was used to measure changes and trends in the Relative Concentration Index of health inequality across education groups in each state.

RESULTS

Except for binge alcohol use, poorer health behaviors were concentrated among the less educated. The largest educational inequalities were for physical inactivity. From 1990 to 2004, significant increases in relative educational inequalities occurred in 40 states for smoking and 31 states for physical inactivity. For binge alcohol use, 27 states showed significant declining inequality trends, but educational inequalities reversed direction and binge alcohol use is now more prevalent among the less educated in 19 states. Significant decreases in educational inequalities occurred in 36 states for obesity and 24 states for seat belt use. Changes in educational inequalities across the different health behaviors were not associated, except for a modest correlation between changes in inequality in smoking and binge alcohol use (r=0.40; p=0.004). Similarly, there was little association between changes in the population prevalence of health behaviors and changes in educational inequality in health behaviors, with substantial heterogeneity among states.

CONCLUSIONS

State trends in relative educational inequality among health behaviors were mixed, increasing for smoking and physical inactivity and decreasing for obesity and seat belt use. The factors influencing relative inequality trends may differ from those affecting overall prevalence trends.

Researchers and policymakers: travelers in parallel universes

Public policy, in the form of laws, guidelines, and regulations, has a profound effect on our daily lives and health status. Reasons for a lack of consistent and systematic translation of public health research into public policy is examined, including differences in decision-making processes, poor timing, ambiguous findings, the need to balance objectivity and advocacy, personal demands of the process, information overload, lack of relevant data, and the mismatch of randomized thinking with nonrandom problems. Next, several actions are suggested that should help bridge the chasm between science and policy, such as greater involvement in the process, better understanding of political decision making, building of effective teams, and development of political champions. Scientists are obligated not only to discover new knowledge but also to ensure that discoveries are applied to improve health.

How state counter-industry campaigns help prime perceptions of tobacco industry practices to promote reductions in youth smoking

OBJECTIVE

This study assessed the impact of state media campaigns that prominently feature counter-industry messages on youth cigarette smoking, beyond the effects of price, secular trends, tobacco control efforts, and the national truth campaign.

METHODS

Rates of youth smoking were compared in three groups of states: (1) those with long funded counter-industry campaigns (California, Florida, and Massachusetts); (2) states with more recently funded counter-industry media campaigns (Indiana, Minnesota, Mississippi, and New Jersey); and (3) other states. An analysis was performed for a series of national telephone surveys of 12-17 year olds between 1999 and 2002, controlling for differences in demographic background, the price of cigarettes, and exposure to the national truth campaign.

RESULTS

Between 1999 and 2002, rates of current smoking and established smoking decreased significantly faster in states with established or more newly funded counter-industry campaigns than in other states. State counter-industry campaigns appear to prime, or make more salient, negative perceptions about tobacco industry practices.

CONCLUSION

Results highlight the value of continued state counter-industry campaigns.