A mixed-methods evaluation of the indoor and outdoor smoking ban in dining venues in Armenia: Early successes and challenges

INTRODUCTION

Since March 2022, Armenia introduced a comprehensive smoking ban on all types of tobacco products in indoor and outdoor areas of hospitality venues. We aimed to rapidly appraise the implementation of the ban in the dining areas of the capital Yerevan and explore any differences in compliance and enforcement patterns between indoor and outdoor areas of the venues.

METHODS

We used a mixed-methods approach through quantitative air quality monitoring, qualitative observations, and in-depth interviews (IDIs). We visited one venue in each remote district of the city and more venues from the central districts that have a much higher density of dining areas. Overall, we made 24 measurements of PM2.5 particles, 24 unobtrusive observations in the 19 visited venues, and 11 IDIs with six visitors and five workers. We used Stata13 for the analysis of numerical data and completed direct deductive content analysis of the textual data.

RESULTS

Active tobacco use was observed in 12 out of 24 venues (50.0%) with more cases of smoking in outdoor areas (10 out of 12; 83.3%). No warning by workers or no reports to the police were observed. We detected elevated levels of PM2.5 particles in indoor and outdoor areas. The IDIs revealed predominantly negative attitudes towards the outdoor ban and the lack of awareness of and readiness to engage in the enforcement measures. The lack of enforcement by the owners and the respective bodies was mentioned as a contributor to continued violations of the ban. The change in the dynamic and the characteristics of the visitors, cleaner air, and less unpleasant work were mentioned as important positive aftermaths of the ban.

CONCLUSIONS

The Government of Armenia should enhance the monitoring and enforcement activities and organize tailored awareness-raising campaigns to inform the general public and the hospitality industry of the health and social implications of the ban.

Implementation of Clean Indoor Air Laws: Complaints, Citations, and Fines or Sanctions Related to Possible Violations of the Kansas Clean Indoor Air Act

OBJECTIVE

To determine how well the Kansas Clean Indoor Air Act was being observed and enforced.

DESIGN

A survey inquired about complaints, citations, and fines or sanctions after the implementation of the Kansas Clean Indoor Air Act; inquiry was also made about the law's effectiveness. Descriptive statistics and Poisson tests of statistical significance were used.

SETTING

Each of the 55 Kansas cities with more than 5000 in population.

PARTICIPANTS

Law enforcement personnel.

MAIN OUTCOME MEASURES

Monthly rates of complaints, citations, fines or sanctions, and reports of the law's effectiveness during the 30-month period after implementation of the act.

RESULTS

Responses were received from 100% of the sampled cities. The number of citizen complaints and citations decreased over time from 4.33 to 2.42 per month and from 3.17 to 0.92 per month, respectively. The number of fines or sanctions decreased from 1.67 per month to 0.50 per month. In 51 of 55 cities (92.7%), respondents reported that the Kansas Clean Indoor Act appeared to be working effectively. There was a statistically significant difference between the first and second and first and third time periods for citations and fines or sanctions. However, there was only a statistically significant difference between the first and third time periods for citizen complaints.

CONCLUSIONS

The law appears to be functioning effectively. This approach could be used to supplement measured or self-reported exposures to secondhand smoke in future studies in other jurisdictions, particularly in identifying areas with potential problems. Given the conservative nature of Kansas, adoption of such a law in the remaining states seems realistic.

The Reliability of Naturalistic Observations of Social, Physical and Economic Environments of Bars

Drinking in bars contributes to numerous public health problems, including violence and motor vehicle crashes. In order to formulate effective preventive interventions it is essential to identify which specific features of bar environments are related to increased risks. Unobtrusive ethnographic observations are one approach that has been used to characterize these features; however no studies have assessed reliability in a representative sample of bars. We performed brief scouting assessments in all 165 bars in six purposively selected California cities, followed by unobtrusive observations from a subsequent representative sample of 97 bars which were located in low and high bar density areas of the cities. Inter-rater reliability between two independent observers assessed individual item reliability, and principal components analyses assessed the reliability of a series of scales describing the physical, social, and economic characteristics of the bars. For the scouting assessment, items exhibited at least moderate reliability (κ or r ≥ 0.40). For the unobtrusive observations, items assessing physical and economic environments (e.g., pool table present, κ = 0.90; index beer cost, r = 0.82) had moderate to outstanding reliability (κ or r > 0.80). Items describing the social environment generally had poorer reliability, though group aspects (e.g., patron count, r = 0.78; patron circulation, r = 0.64) had better reliability than individual behaviors (e.g., derogatory speech, κ = 0.12). Scales constructed from specific sets of items exhibited modest reliability. The individual metrics and principal components we present will enable future studies seeking to disaggregate relationships between bar characteristics and public health problems.

Are Barroom and Neighborhood Characteristics Independently Related to Local-Area Assaults?

BACKGROUND

Two separate but complementary literatures examine bar-related violence: one has focused on barroom features, and the other has focused on features of neighborhoods near bars. This study unifies these 2 perspectives using a microenvironmental approach.

METHODS

In a purposive sample of 65 bars in 4 California cities, we used premise assessments to characterize the physical, social, and economic environments of barrooms (e.g., patron count, average pace of drinking, and restaurant service); and a combination of systematic social observation, census, and alcohol license data to characterize the neighborhoods in which they were located (e.g., physical disorder, alcohol outlet density, and median household income). Hierarchical Poisson models then assessed relationships between these features and counts of police-reported assaults within buffer areas around bars.

RESULTS

Aspects of both barroom environments (more patrons, more dancing, and louder music) and neighborhood environments (greater bar density, greater physical disorder, lower population density, and lower income) were independently related to increased incidence of assaults.

CONCLUSIONS

Preventive intervention to reduce bar-area violence may be directed at both bar environments (e.g., limiting the number of patrons) and neighborhood environments (e.g., limiting outlet density).

Changes in smoking-related norms in bars resulting from California's Smoke-Free Workplace Act

California's Smoke-Free Workplace Act--CA Labor Code Sec. 6404.5(a)--was extended to bars in 1998. This article analyzes changes in normative beliefs and behaviors related to bar smoking in the decade following the adoption of the Act. In a series of studies evaluating the smoke-free workplace law in bars, researchers conducted extensive observations and interviews with bar staff and patrons, health officials, and law enforcement personnel in three California counties. Smoking outside became a normal pause in the social environment and created a new type of bar socializing for outside smokers. Although some bar owners and staff reported initially resenting the responsibility to uphold the law, once norms regarding cigarettes and smoking began changing, bar workers experienced less conflict in upholding the law. Non-smoking behavior within bars also became the normative behavior for bar patrons. California's Smoke-Free Workplace Act has both reflected and encouraged normative beliefs and behaviors related to smoking in bars. The findings indicate that such shifts are possible even in contexts where smoking behaviors and attitudes supporting smoking were deeply entrenched. Recommendations include attending to the synergistic effect of education and policy in effective tobacco control programs.

CHALLENGES TO IMPLEMENTING AND ENFORCING CALIFORNIA'S SMOKE-FREE WORKPLACE ACT IN BARS

California's 1995 Smoke-Free Workplace Act-Assembly Bill 13 (AB 13)-was extended to bars in 1998. This paper examines the challenges faced by officials responsible for implementing and enforcing the law. As part of a series of studies evaluating AB 13 in bars, researchers conducted confidential in-depth interviews with 35 state, county and municipal authorities and representatives of non-governmental agencies. The interviews were recorded, transcribed, coded and analyzed by themes and respondent categories. Data from structured observations in sampled bars and interviews with bar staff and patrons offer contextual information. Analyses indicated the following challenges: 1) an ineffective administrative structure, 2) problems associated with the complaint-driven system used to enforce the law, 3) lack of funding for enforcement, 4) low prioritization of enforcement, and 5) the minimal deterrence effect of the sanctioning penalties. The findings indicate why indoor smoking may continue in some bars despite the state law prohibiting smoking in workplaces. Many municipalities, states and countries may be considering restricting smoking in workplaces including bars, and our findings show that clear delineation of procedures and enforcement criteria, as well as funding and substantive penalties, should be considered in drafting these laws.

Unintended consequences of smoke-free bar policies for low-SES women in three California counties

BACKGROUND

To amplify earlier studies of unintended consequences of public policies, this article illustrates both negative and positive unanticipated consequences of smoke-free workplace policies in California bars for women of low SES.

METHODS

The article relies on thematic analysis in 2008 of qualitative data gathered between 2001 and 2007 from three mixed-method studies of tobacco use in and around bars where indoor smoking is prohibited.

RESULTS

Unanticipated consequences primarily occurred when bars did comply with the law and smokers went outside the bar to smoke, particularly when smokers stood on the street outside the bar. Key negative consequences for women who smoked outside of bars included threats to their physical safety and their public image. For women living near bars, increased smoking on the street may have increased their exposure to secondhand smoke and disruptive noise. For some women, however, unanticipated negative consequences were identified with noncompliant bars. Smokers were conjectured to congregate in the smaller number of bars where smoking was still allowed, resulting in increased exposure to secondhand smoke for low-SES women working in these bars. A common positive unintended consequence of the tobacco control ordinance was increased social circulation and solidarity, as smokers gathered outside bars to smoke.

CONCLUSIONS

Smoke-free workplace laws in bars can have both negative and positive consequences for workers and smokers, and low-income women in particular.

Location restrictions on smoking: assessing their differential impacts and consequences in the workplace

OBJECTIVES

To analyze existing evidence on the impact of two types of location restrictions on smoking: workplace bans and bans in hospitality settings, and to assess the extent to which they differentially affect subpopulations.

METHODS

A review of international studies on location restrictions on smoking published between 1990-2007.

RESULTS

Although workplace smoking bans reduce exposure to second-hand smoke (SHS) at work, their effects on overall cigarette consumption and smoking prevalence may be uneven across the population. Bans in hospitality settings reduce SHS exposure among workers, but have potentially uneven effects based on the interactions between gender, socio-economic status (SES) and ethnicity. The unintended consequences of smoking bans are also more likely to be experienced by low SES groups.

CONCLUSIONS

Although location restrictions on smoking reduce SHS exposure and may serve to positively impact smoking behaviours, there is preliminary evidence that they may have a reduced impact on subpopulations such as low-income groups, although further research is needed.

Correlates of persistent smoking in bars subject to smokefree workplace policy

This study's goal was to characterize physical and social environments of stand-alone bars associated with indoor smoking despite California's smokefree workplace law. In a random sample of 121 stand-alone bars in San Francisco, trained observers collected data on patrons, staff, neighborhood, indoor settings and smoking behaviors. Using bivariate (chi-square) and hierarchical linear modeling analyses, we identified four correlates of patrons' indoor smoking: 1) bars serving predominantly Asian or Irish patrons, 2) ashtrays, 3) bartender smoking, and 4) female bartenders. Public health officials charged with enforcement of smokefree bar policies may need to attend to social practices within bars, and heighten perceptions of consistent enforcement of smokefree workplace laws.

Cultural factors related to smoking in San Francisco's Irish bars

California's Smoke-Free Workplace Act was extended to include bars in 1998. While the majority of bars in the state have become smoke free, in many bars patrons and staff continue to smoke despite the law. The authors present findings from a study which assessed cultural factors related to continued smoking in bars in the city of San Francisco. In bars serving primarily Irish migrants, tight-knit relations within the local Irish bar community together with a reluctance to be the first Irish bar to ban smoking were found to contribute to continued indoor smoking. The findings illustrate challenges to implementing tobacco control policies within ethnic subpopulations and particularly highlight the importance of considering how cultural dynamics within subpopulations may help or hinder such policies.

Law in practice: obstacles to a smokefree workplace policy in bars serving Asian patrons

The California smokefree workplace ordinance (AB13) has been well-received, even in bars where deeply established traditions of smoking may exist. However, a closer investigation of bars where indoor smoking persists revealed that bar workers in some ethnic minority communities continue to be exposed to secondhand smoke in their workplaces. To identify sociocultural factors that may impede the adoption of AB13, the researchers conducted 150 observations and 29 patron and staff interviews in 50 California bars serving Asian patrons in Los Angeles and San Francisco counties. Observers witnessed indoor smoking in 82% of the bars. Interviews revealed that social relationships, social interactions, and a tendency to avoid confrontation complicated the positive reception of AB13 within these bars. Accounting for sociocultural factors provides a nuanced understanding of the challenges involved in implementing tobacco control policy in such diverse settings and may allow for culturally appropriate tobacco policy development and implementation in other jurisdictions.

Social Organization in Bars: Implications for Tobacco Control Policy

This paper considers social roles and relationships of the patrons, staff and owners of bars as critical factors determining adherence to public health policies, and specifically California's smokefree workplace law. Specific elements of social organization in bars affecting health policy include the community within which the bar is set, the unique identity the bar creates, the bar staff and patrons who enact this identity, and their bar society. These elements were found to contribute to the development of power relations within the bar and solidarity against the outside world, resulting in either resistance to or compliance with smokefree workplace policy.

Smoking in Boston bars before and after a 100% smoke-free regulation: an assessment of early compliance

The objective of this study was to assess compliance with Boston's 100% smoke-free bar regulation within the first 3 months of implementation. An observational survey was conducted of a random sample of 102 bars in Boston before and after the smoking ban went into effect. Forty bars were observed both pre- and postban, serving as a true comparison group; 62 additional bars were observed postban only. From preban to postban, highly significant decreases were found in the mean proportion of patrons smoking inside (22.5% to 0.19%, p < 0.0001), in the proportion of bars with smoking patrons (100% to 2.5%, p < 0.0001), and in the average number of ashtrays present in each bar (24 to 0, p < 0.0001). A highly significant increase was found in the average number of "no smoking" signs posted in each bar (0 to 3.3, p < 0.0001). Within the 3 months immediately following the 100% smoke-free bar regulation in Boston, bars were highly compliant with the ban, including not allowing patrons and employees to smoke, removing ashtrays, and posting signs indicating that smoking is prohibited. Therefore, with proper time and preparation, public health practitioners can change social norms before a ban goes into effect and can implement smoke-free policies smoothly and with immediate compliance.