Decrease In Smoking Prevalence Research Articles

Impact of Smoking Reduction Scenarios on the Burden of Myocardial Infarction in the French Population Until 2035.

Myocardial infarction (MI) is a cardiovascular disease caused by necrosis of the myocardium, which places a heavy burden on patients. In France, the proportion of daily smokers remains high, reaching at 25.5% in 2020. We evaluated the impact of smoking reduction scenarios on the projection of MI prevalence, mean age of incident cases and number of MI prevented cases until 2035. The French government has introduced smoking cessation policies that have led to an annual decrease in smoking prevalence. Based on this annual decline, we implemented three scenarios (SC) simulating an annual decrease in the proportion of smokers aged over 35 (SC1: 1%, ie, natural evolution without intervention, SC2: 2%, SC3: 9.87%) and a fourth scenario (SC4) in which there is a complete discontinuation of smoking from 2024 onwards using MI hospitalization and demographic data, estimations for the proportion of daily smokers between 35 and 95 years and multi-state models. Between 2023 and 2035, MI prevalence increased from 3.18% to 4.23% in males and from 1.00% to 1.46% in females under SC1. MI prevalence was equal to 4.21%, 4.06%, and 3.82% in males and 1.45%, 1.40%, and 1.34% in females in 2035 according to SC2, SC3, and SC4, respectively. Compared with SC1, 0.68% MI cases would be prevented with SC2, 4.52% with SC3 and 10.34% with SC4, with almost half of cases being prevented before 65 years of age. The increase in the mean age of MI incident cases ranged from 3 to 4 years among males and from 1 to 2 years among females. While reducing tobacco use could substantially reduce the number of MI cases prevented, its prevalence would continue to increase due to the ageing population. An integrated prevention strategy that includes the leading cardiovascular risk factors should more efficiently reduce the future burden of MI.

Exploring the Disparity in Indoor/Outdoor Time and Radon Exposure as Possible Factors Contributing to the Unexpected Increase in Lung Cancer Risk among Non-Smoking Women.

According to a NIH study, Lung cancer among individuals who have never smoked is more prevalent in women and occurs at an earlier age than in smokers. The rise in lung cancer rates among female non-smokers might be linked to radon inhalation and should be further investigated. Our theory is based on the differences in radon exposure between males and females, which can be attributed to the variations in time spent indoors versus outdoors. Over the past few years, the smoking rates have shown a steady decline in the United States and other developed countries. This decrease in smoking prevalence has led to a new shift in the primary risk factors associated with lung cancer. Although tobacco smoke historically served as the primary cause of lung cancer, the reduction in smoking rates has allowed other risk factors, such as radon exposure, to come to the forefront. Given that women in certain countries, on average, might spend more time indoors compared to men, they are potentially exposed to higher levels of radon. This increased exposure could explain the rising rates of lung cancer among female non-smokers. The theory is still in its nascent stages and requires further research and validation. However, if proven correct, it could significantly alter our understanding of lung cancer risk factors and lead to new prevention. It is therefore crucial to expedite the review and publication of this theory, given its potential implications for public health.

Increased e-cigarette use prevalence is associated with decreased smoking prevalence among US adults

BackgroundIf US adults who smoke cigarettes are switching to e-cigarettes, the effect may be observable at the population level: smoking prevalence should decline as e-cigarette prevalence increases, especially in sub-populations with highest e-cigarette use. This study aimed to assess such effects in recent nationally-representative data.MethodsWe updated a prior analysis with the latest available National Health Interview Survey data through 2022. Data were cross-sectional estimates of the yearly prevalence of smoking and e-cigarette use, respectively, among US adults and among specific age, race/ethnicity, and sex subpopulations. Non-linear models were fitted to observed smoking prevalence in the pre-e-cigarette era, with a range of ‘cut-off’ years explored (i.e., between when e-cigarettes were first introduced to when they became widely available). These trends were projected forward to predict what smoking prevalence would have been if pre-e-cigarette era trends had continued uninterrupted. The difference between actual and predicted smoking prevalence (‘discrepancy’) was compared to e-cigarette use prevalence in each year in the e-cigarette era to investigate whether the observed decline in smoking was statistically associated with e-cigarette use.ResultsObserved smoking prevalence in the e-cigarette era was significantly lower than expected based on pre-e-cigarette era trends; these discrepancies in smoking prevalence grew as e-cigarette use prevalence increased, and were larger in subpopulations with higher e-cigarette use, especially younger adults aged 18–34. Results were robust to sensitivity tests varying the analysis design.ConclusionsPopulation-level data continue to suggest that smoking prevalence has declined at an accelerated rate in the last decade in ways correlated with increased uptake of e-cigarette use.

A compartmental model for smoking dynamics in Italy: a pipeline for inference, validation, and forecasting under hypothetical scenarios

We propose a compartmental model for investigating smoking dynamics in an Italian region (Tuscany). Calibrating the model on local data from 1993 to 2019, we estimate the probabilities of starting and quitting smoking and the probability of smoking relapse. Then, we forecast the evolution of smoking prevalence until 2043 and assess the impact on mortality in terms of attributable deaths. We introduce elements of novelty with respect to previous studies in this field, including a formal definition of the equations governing the model dynamics and a flexible modelling of smoking probabilities based on cubic regression splines. We estimate model parameters by defining a two-step procedure and quantify the sampling variability via a parametric bootstrap. We propose the implementation of cross-validation on a rolling basis and variance-based Global Sensitivity Analysis to check the robustness of the results and support our findings. Our results suggest a decrease in smoking prevalence among males and stability among females, over the next two decades. We estimate that, in 2023, 18% of deaths among males and 8% among females are due to smoking. We test the use of the model in assessing the impact on smoking prevalence and mortality of different tobacco control policies, including the tobacco-free generation ban recently introduced in New Zealand.

Impact of Standardised Packaging of Tobacco Products Regulations on cigarette consumption and youth smoking in England: interrupted time-series analysis

BackgroundIn the UK in May 2016, standardised packaging of tobacco products was implemented, including minimum pack sizes of 20 sticks or 30 g loose tobacco. The change was intended to...

Price elasticity of cigarette smoking in Bangladesh: evidence from the Global Adult Tobacco Surveys (GATS)

IntroductionThe overall prevalence of cigarette smoking has not changed significantly for over a decade in Bangladesh. Raising the price of cigarettes through taxation is an important policy instrument for reducing...

Changes in Smoking Behavior in the COVID-19 Pandemic: A Single Center Study in Family Practice

Objective: There are controversial studies on smoking addiction in the COVID-19 pandemic. While some studies show increased tobacco use during the pandemic, others report increased smoking cessation attempts. This study examined changes in tobacco use and quit intentions during the COVID-19 pandemic compared to pre-pandemic. Methods: A cross-sectional study was designed and three groups were formed by including patients over 18 years of age, who were smokers, and who presented to the Education Family Health Center and had RT-PCR test results for COVID-19. Among these patients, patients with COVID-19 symptoms and complaints and positive RT-PCR test results constituted the COVID-19 positive group, patients who were COVID-19 negative but isolated due to their contacts constituted the contact group, and healthy people without any COVID-19 contact and symptoms constituted the healthy group. Demographic characteristics, smoking status before the COVID-19 pandemic, change in smoking status after COVID-19 test result or contact, and Fagerström nicotine dependence test results were compared. Results: Of the total 131 participants enrolled in the study, 70 were in the healthy group, 31 were in the COVID-19 negative group, and 30 were in the COVID-19 positive group. Men were predominant in three groups (60%, 83.9%, and 73.3% in normal, COVID-19-neg, and COVID-19-positive groups, respectively) with a small significant difference (p=0.048). The mean ages were 41.09±12.85, 38.21±11.69, and 39.47±11.66 years in the healthy, COVID-19 negative, and COVID-19 positive groups, respectively, with no significant difference (p>0.05). Fagerström dependence scores were 1.82±1.05, 1.53±0.86, and 1.40±0.72 in the healthy, COVID-19 negative, and COVID-19 positive groups, respectively, and were not statistically different (p>0.05). Smoking prevalence decreased by 1.13 (±4.17) cigarettes per day in the healthy group, by 3.97 (±5.31) cigarettes in the COVID negative group, and by 10.14 (±7.86) cigarettes in the COVID positive group, with a statistically significant decrease in smoking prevalence in all three groups (p

Atherosclerotic cardiovascular disease landscape in Singapore.

Cardiovascular disease (CVD) is the leading cause of death worldwide, accounting for over one-third of all deaths in Singapore. An analysis of age-standardized mortality rates (ASMR) for CVD in Singapore revealed a deceleration in the initial rapid decline in ASMR. A decrease in smoking prevalence may have contributed to the initial rapid decline in ASMR. Furthermore, other major risk factors, such as diabetes mellitus, hypertension, elevated low-density lipoprotein levels, and obesity, are steadily rising. Singapore's CVD economic burden is estimated to be 8.1 billion USD (11.5 billion SGD). The burden of CVD can only be reduced using individual and population-based approaches. Prevention programs must also be developed based on an understanding of risk trends. Therefore, this article attempts to capture the burden of CVD, trends in risk factor control, preventive care, disparities, and current unmet needs, particularly in atherosclerotic cardiovascular disease management in Singapore.

Trends in COPD mortality from 1983 to 2018: protocol for a population-based cohort study in Denmark

IntroductionChronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide, which is partly contributed to the increasing prevalence of COPD owning to a demographic shift towards...

Trends in U.S. self-reported health and self-care behaviors during the COVID-19 pandemic.

The COVID-19 pandemic represents a unique stressor in Americans' daily lives and access to health services. However, it remains unclear how the pandemic impacted perceived health status and engagement in health-related behaviors. To assess changes in self-reported health outcomes during the COVID-19 pandemic, and to explore trends in health-related behaviors that may underlie the observed health changes. Interrupted time series stratified by age, gender, race/ethnicity, educational attainment, household income, and employment status. United States. All adult respondents to the 2016-2020 Behavioral Risk Factor Surveillance System (N = 2,146,384). Survey completion following the U.S. public health emergency declaration (March-December 2020). January 2019 to February 2020 served as our reference period. Self-reported health outcomes included the number of days per month that respondents spent in poor mental health, physical health, or when poor health prevented their usual activities of daily living. Self-reported health behaviors included the number of hours slept per day, number of days in the past month where alcohol was consumed, participation in any exercise, and current smoking status. The national rate of days spent in poor physical health decreased overall (-1.00 days, 95% CI: -1.10 to -0.90) and for all analyzed subgroups. The rate of poor mental health days or days when poor health prevented usual activities did not change overall but exhibited substantial heterogeneity by subgroup. We also observed overall increases in mean sleep hours per day (+0.09, 95% CI 0.05 to 0.13), the percentage of adults who report any exercise activity (+3.28%, 95% CI 2.48 to 4.09), increased alcohol consumption days (0.27, 95% CI 0.18 to 0.37), and decreased smoking prevalence (-1.11%, 95% CI -1.39 to -0.83). The COVID-19 pandemic had deleterious but heterogeneous effects on mental health, days when poor health prevented usual activities, and alcohol consumption. In contrast, the pandemic's onset was associated with improvements in physical health, mean hours of sleep per day, exercise participation, and smoking status. These findings highlight the need for targeted outreach and interventions to improve mental health in individuals who may be disproportionately affected by the pandemic.

Internet-Based Flipbook as A Health Education Medium on The Dangers of Smoking for Teenagers

A strategy to decrease smoking prevalence in Indonesia is to conduct health education. Various health education media have been widely developed and published, but there has not been found a flipbook educational media with the theme of adolescent smoking control this study aimed to identify the effectiveness of internet-based flipbook media in changing adolescents' knowledge and attitudes about the dangers of smoking. This research is a pre-experimental design of the type one group pretest-posttest. Researchers treated the youth group using an internet-based flipbook on adolescents' knowledge and attitudes. The results obtained that the Wilcoxon test results on the knowledge variable produced a 2-tailed sig value of 0.0 and the pairT-Testest on the attitude variable is 0.000 at a 2-tailed sig value. The flipbook used for this intervention has proven effective in changing adolescents' knowledge and attitudes about the dangers of smoking.

Increasing prevalence of mental disorders in smokers seeking treatment of tobacco dependence: a retrospective observational study

BackgroundThere has been a noticeable relative increase in psychiatric comorbidities among smokers as opposed to the general population. This is likely due to comparatively slower decrease in smoking prevalence among individuals with mental health conditions. This study aims to assess the prevalence trend of past or current mental health disorders in individuals seeking specialized smoking cessation assistance.MethodsWe conducted a retrospective single-centre observational study to assess the presence of mental disorders such as anxiety, depression, bipolar affective disorder, or schizophrenia in personal history of 6,546 smokers who sought treatment at the Centre for Treatment of Tobacco Dependence in Prague, Czech Republic between 2006 and 2019. The study examined the impact of gender, age, and the effect of successive years on the prevalence of the mental disorders using Poisson distribution regression.ResultsIn the studied cohort, 1,743 patients (26.6%) reported having one or more mental disorders. Compared to patients without a psychiatric disorder, they exhibited similar levels of carbon monoxide in expired air (mean 17 ppm, SD 11 ppm) and scored one point higher on the Fagerström Test of Cigarette Dependence. Among smokers with a mental disorder, women were more prevalent (62%) than men (38%). The prevalence of mental disorders increased on average by 4% every year, rising from 23% in 2006 to 35% in 2019.ConclusionsConsistent with the observation that the prevalence of smoking among people with any mental disorder is higher and declining at a slower rate than in the general population, there is a steadily increasing percentage of these patients seeking specialized treatment over time. Professionals who offer tobacco dependence treatment should be aware of the upward trend in psychiatric disorders among smokers, as more intensive treatment may be needed. Similarly, psychiatric care should pay attention to smoking of their patients.

Is self-reported 7-day point prevalence abstinence an useful measure for smoking cessation effectiveness among individuals with mental disorders?

Smoking rates among individuals with mental disorders are higher compared to general population. We aimed to investigate the effectiveness of a smoking cessation treatment among individuals with and without mental disorders. Self-report 7-day point prevalence was used to assess abstinence status among ‘intention to treat’ (n = 1,213) and ‘completers-only’ (n = 578) samples. Participants were distributed in (1) ND-only; (2) ND and other substance use disorder (ND-SUD); (3) ND associated with mental disorder but no other SUD (ND-MD); and (4) co-morbid ND, SUD and MD (ND-SUMD). The treatment program was composed by six weeks of group Cognitive Behavioral Therapy (CBT) and medical consultations. Multivariate logistic regression models were applied. Rates of abstinence between ND-only and both ND-MD and ND-SUMD differed in the ‘intention-to-treat’ sample, with the former group showing the best rate (62.5%, 48% and 45.4% respectively). ND-SUD had the second-best rate of abstinence (56.1%). Differences between groups were not observed among ‘completers-only’. Self-report 7-day point prevalence abstinence is economical and reliable to be used in low to middle-income countries. In this study, it showed that the 6-week smoking cessation treatment had a positive effect among completers, which supports the importance of investing in treatment to decrease smoking prevalence in this population.

TRENDS IN RISK FACTORS FOR DISABILITY AND REDUCED PHYSICAL FUNCTIONING AMONG US ADULTS DURING THE COVID-19 PANDEMIC

Abstract The COVID-19 pandemic has caused widespread societal disruptions that may have impacted risk factors for disability and functional limitations. Current research suggests that physical inactivity, BMI, and smoking increased during the early phase of the pandemic, but less is known about whether these risk factors remained elevated as the pandemic progressed and mitigation measures were less disruptive. In this study, we assess trends in exercise frequency, BMI, and smoking among American adults aged 45 and over during the first year of the COVID-19 pandemic. We use data from the Understanding America Study (UAS) Coronavirus in America study, a nationally representative online survey that followed American adults from March 2020 to July 2021. We find that exercise frequency was highly seasonal throughout the pandemic, increasing during warmer months and decreasing during the colder winter months. Throughout this period, exercise frequency was highest among those with more education and those who were retired. Average BMI remained similar throughout this period, but less educated individuals and those working away from home and those who were unemployed experienced increases in BMI. Consistent with media reports suggesting increased interest in quitting smoking during the pandemic, we find decreases in smoking prevalence and frequency of smoking over this period. Decreases in smoking prevalence were concentrated among less educated individuals, who had higher prevalence of smoking to begin with. In sum, changes in risk factors for disability and reduced physical functioning during the pandemic were mixed and varied by education and employment status.

Smokers’ Perception of Their Health Status and Health-Seeking Behaviour: A Narrative Review

Background: Smoking has been primarily studied as a public health problem involving mapping continued smoking patterns and interventions designed to decrease smoking prevalence. This paper aims to discuss the available literature on smokers’ perception on their health, the smokers’ health-seeking behaviour and factors influence the smokers’ continuity in smoking. Method: Review literature conducted by using databases such as Science Direct, Sage Journals, Wiley, PubMed, and Scopus with the keywords smoking, health perception, health seeking behavior, health status, and health screening. Result: Eighteen articles were reviewed, selected, and summarized. These include six qualitative studies, ten quantitative studies, and two randomized control studies. Findings showed that smokers underestimate the effects of smoking and overestimate their ability to quit before becoming addicted. Thus, communication of health risk must be in line with smokers’ perception of health risks which they tend to minimize and ignore. Smokers’ perceived smoking bring benefits and they could retain control over their actions but could not easily stop having frequent desires to smoke. Also, healthcare providers should develop passion, equipped with expected skills and aid while intervene smokers’, which might increase their motivation to quit smoking. Conclusion: Further study perhaps could bring a better understanding on the factors contribute to smokers’ judgment in making decisions whether to continue or stop smoking and how these factors influence their actions. Smoking rates might be reduced if smokers understood the risks of smoking, which were more accurate as evidenced by a medical check-up and held to the beliefs on smoking-related risks that led to their firm decision to stop smoking.

Progress and challenges in tobacco control policies in Mexico, 2003-2017: an approach using the Tobacco Control Scale.

The study aims to assess the implementation of tobacco control policies in Mexico from 2003 through 2017 using the Tobacco Control Scale (TCS). The TCS is a research tool widely used in the European region. It facilitates assessment of tobacco control policy implementation based on six cost-effective interventions: tobacco taxes, smoke-free policies, advertising bans, public spending on the information campaign, health warnings, and smoking cessation treatment, reflecting results in a total score between 0 and 100. From 2003 through 2017, Mexico's total score improved from 24/100 to 55/100, with substantial progress in raising tobacco taxes, 11 subnational smoke-free laws, and with placement on cigarette packs of large health warnings with pictograms. Progress in tobacco control policies implemented in this period corresponds with a decrease in smoking prevalence across Mexico. This tool is useful for monitoring tobacco policy implementation in low- and middle-income countries and be used for advocacy purposes to enforce and improve tobacco control legislation.

The impact of low-dose CT on smoking behavior among non-smokers, former-smokers, and smokers: A population-based screening cohort in rural China.

Lung cancer screening may provide a "teachable moment" for the smoking cessation and relapse prevention. However, the impact of lung cancer screening on smoking initiation in non-smokers has not been reported. A baseline smoking behavior survey was conducted in 2000 participants who were screened by low-dose computed tomography (LDCT) from 2014 to 2018. All participants were re-surveyed on their smoking behavior in 2019. Of these, 312 participants were excluded, leaving 1688 participants in the final analysis. The smoking initiation rate in baseline non-smokers, the relapse rate in baseline former smokers, and the abstinence rate in baseline current smokers were calculated, respectively. The associations between screening results, demographic characteristics, and smoking behavior change were analyzed using multivariable logistic regression. From 2014 to 2019, smoking prevalence significantly decreased from 52.6% to 49.1%. The prevalence of smoking initiation, relapse, and abstinence in baseline non-smokers, former, and current smokers was 16.8%, 22.9%, and 23.7%, respectively. The risk of smoking initiation in baseline non-smokers was significantly higher in those with negative screening result (adjusted OR=2.97, 95% CI: 1.27-6.94). Compared to smokers who only received baseline screening, the chance of smoking abstinence in baseline current smokers was reduced by over 80% in those who attended 5 rounds of screening (adjusted OR=0.15, 95% CI:0.08-0.27). No significant associations were found between smoking relapse and prior screening frequency, with at least one positive screening result. Age, gender, occupational exposure, income, and smoking pack years were also associated with smoking behavior changes. The overall decreased smoking prevalence indicated an overwhelming effect of "teachable moment" on "license to smoke." A tailored smoking cessation strategy should be integrated into lung cancer screening.

Testing Club Convergence in Female Smoking Prevalence.

In this paper, we applied the concept of convergence to examine the evolution of smoking prevalence among women in 191 countries worldwide from 1990 to 2019. First, the non-linear time-varying factor model proposed by Phillips and Sul was adopted to identify potential clusters (clubs), wherein groups of countries converge to similar female smoking rates. Second, an ordered logit regression model was used to assess the impact of cigarette affordability on the probability of falling within a given cluster. The hypothesis of global convergence was rejected. However, the clustering algorithm successfully identified five and nine clubs, within countries with increasing and decreasing smoking prevalence, respectively. A higher relative income-price ratio (i.e., lower cigarette affordability) increased the likelihood of belonging to a club of countries with a low prevalence of female tobacco smoking.

Optimum Urine Cotinine and NNAL Levels to Distinguish Smokers from Non-Smokers by the Changes in Tobacco Control Policy in Korea from 2008 to 2018.

We examined the age- and sex-specific distributions of biomarkers of tobacco smoke exposure to determine the optimal cutoffs to distinguish smokers from non-smokers over the last 10 years in Korea, during which smoking prevalence and secondhand smoke (SHS) exposure declined due to changes in tobacco control policy. We analyzed data from the Korea National Health and Nutrition Examination Survey on creatinine-adjusted urinary cotinine (2008-2018; 33 429 adults: 15 653 males and 17 776 females) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; 2016-2018; 6337 adults: 3091 males and 3246 females). We determined the optimal cutoffs and confidence intervals (CIs) to distinguish smokers from non-smokers using receiver operator characteristic curve analysis and bootstrapping (1000 resamples). The optimal cutoff values of creatinine-adjusted urine cotinine and NNAL concentration were 20.9 ng/mg (95% CI: 20.8-21.0, sensitivity: 96.6%, specificity: 93.8%) and 8.9 pg/mg (95% CI: 8.8-8.9, sensitivity: 94.0%, specificity: 94.7%), respectively, in 2016-2018. The optimal cutoffs of both biomarkers increased with age and were higher in females than in males for NNAL concentration. In both sexes, the optimal cutoff of urine cotinine continuously declined over the study period. The optimal cotinine cutoff declined along with smoking prevalence and levels of SHS exposure due to enforcement of tobacco control policies, including smoke-free ordinances and tax increases. Monitoring of biomarkers of tobacco exposure appears necessary for verification of smoking status and regulatory use. Our results based on nationally representative data suggest that a large decrease in the optimal cutoff value of urine cotinine to distinguish smokers from non-smokers was caused by decreases in smoking prevalence and SHS exposure following enforcement of tobacco control policies over the last 10 years. We determined the optimal cutoff values of urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), which were not previously reported in representative population in Asia, to enable more accurate estimation of exposure to tobacco smoke and proper assessment of disease risks. Gender- and age-specific differences in the optimal cutoffs require further study. Monitoring of biomarkers of tobacco smoke exposure seems necessary for verification of smoking status and regulatory use.

Impact of a smoke-free policy on smoking prevalence on hospital grounds: A before-after study.

INTRODUCTIONStudies on the impact of smoke-free policies (SFPs) on hospitals grounds on on-site smoking are scarce. On 1 October 2019, an SFP was implemented on the grounds of the Amsterdam UMC hospital in the Netherlands, including measures for sustained enforcement. This study assessed the impact of this SFP on smoking prevalence on hospital grounds up to 18 months after implementation.METHODSObservations were systematically conducted 7 weeks before and after the SFP was implemented, and at 5 and 18 months afterwards. A total of 32 sites were included in the study, divided over two hospital locations. On each site, the number of smokers was systematically observed and categorized into staff, patient, student, or visitor. Smoking prevalence on hospital grounds was calculated by the number of observed smokers as a proportion of all people observed. Bubble maps were created to visualize changes in the geographical distribution of smokers.RESULTSSmoking prevalence on hospital grounds decreased significantly from 17.4% before to 3.3% after implementation of the SFP. Following implementation, the largest decrease was observed in smoking among staff (-96.7%) and patients (-92.3%). The decrease in smoking prevalence was sustained 18 months after implementation (5.0%). The number of smokers decreased on nearly all sites.CONCLUSIONSThe substantial and sustained decrease in smoking prevalence found in this study highlights the potential of SFPs on hospital grounds to protect people from exposure to (secondhand) smoking. Continued enforcement of these SFPs seems essential to ensure ongoing compliance.