Enforcement Of Smoke-free Policies Research Articles

A qualitative study of barriers and motivators to prevent second-hand smoke exposure among pregnant women and children in Egypt: Identifying appropriate approaches for change.

The prevalence of daily second-hand smoke (SHS) exposure among pregnant non-smoking women and children in Egypt is estimated to be about 50% and 55%, respectively. This study aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking in the home in Egypt. Six focus group discussions with pregnant women/mothers of children residing in urban/rural areas (n=61) were conducted. Data were managed and analyzed using the Framework Method. Sixty one participants aged 18-49 were recruited. They reported being never smokers and SHS exposure for themselves and their children was mainly at home. Pregnant women/mothers had some general knowledge of the dangers of SHS, but their knowledge appeared incomplete. The most commonly reported barriers to preventing SHS exposure/adopting a smoke-free home or workplace were social acceptance of smoking and SHS exposure, masculinity and gender norms of accepting smoking among men as a normative behavior, fear among women of damaging a relationship with family or even divorce, women resigning themselves to SHS exposure, and doctors not being supportive of smoking cessation. The majority of interviewees' families were reported to allow smoking anywhere in the home. Others implemented some measures to prevent SHS; however, these tended to be inconsistently implemented. Changing the norm of accepting smoking among men as a normative behavior within Egyptian society and better enforcement of smoke-free policies, will help to protect pregnant women and children from SHS. This study suggests promising approaches to support the promotion of smoke-free homes (SFH) and prevention of SHS exposure among pregnant women and children in public places in Egypt. Better enforcement of smoke-free policies is needed. Health care professionals (HCPs) should support smoking cessation services in primary health centers (PHCs). SHS policy, practice and research should focus on husbands/fathers as they are the main source of SHS. There is a need for denormalization of SHS exposure in Egyptian society.

Barriers to prevent second-hand smoke (SHS) exposure among pregnant women and children in Egypt

Abstract Background The prevalence of daily second-hand smoke (SHS) exposure among pregnant non-smoking women and children in Egypt is estimated to be about 50% and 55%, respectively. This study aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking behavior at home in Egypt. Methods Focus group discussions (FGDs) with pregnant women/mothers of children residing in urban/rural areas (n = 61). Data were coded and analyzed thematically. Results 61 participants were recruited, aged 18-49. They reported being never smokers and SHS exposure for themselves and their children was mainly at home. Pregnant women/mothers had some general knowledge of the dangers of SHS, but their knowledge appeared incomplete. The most commonly reported barriers to preventing SHS exposure/adopting a smoke free home or workplace were having men who smoke in the household, doctors not being supportive regarding smoking cessation, SHS exposure is socially accepted and fear among women of damaging a relationship; being nervous about asking smokers to stop, and being worried about disputes and arguments with husband. The majority of interviewees’ families were reported to allow smoking anywhere in the home; others implemented some measures to prevent SHS, however, these tended to be inconsistently implemented and unlikely to be effective. Conclusions This study increases our knowledge of the barriers of non-smoking Egyptian pregnant women/mother of children in creating and maintaining smoke free environment for themselves and their children. There is a need to denormalise SHS exposure and better enforcement of smoke free policies. Key messages • Better enforcement of smoke free policies, and more support for smoking cession services are needed in Egypt. • SHS policy, practice, and research should focus on male family members to increase their effectiveness.

“You do not See an Interesting Ads, You See a Cowboy Killers”: A Comprehensive Public Health Communication Approach on Smoke-Free Policy Enforcement

Objectives: While smoke-free policies aiming to protect passive smokers have been identified, some works need to be carried out to implement the policy into stronger regulation. This policy transformation, as the key to policy implementation success, should be considered by researchers and public health advocates to elaborate an effective way of delivering the policy messages. Study Design: This article describes the way Muhammadiyah Tobacco Control Center (MTCC) of Universitas Muhammadiyah Yogyakarta assisted the local government to transform smoke-free policy and its relevant accomplishing measurement into an intense enforcement action by involving a multi-sectoral approach and community. Methods: This research is an independent study, reflecting an evaluation of smoke-free project assisted by Muhammadiyah Tobacco Control Center to the Local Government of Yogyakarta City. Results: We discussed the role of multi-sector of the local government upon their policy interpretation and collaboration to reach our vast community in understanding and further implementing the smoke-free policy by their awareness. In addition, we provide a model of community engagement to support policy implementation and evaluation (monitoring process). Conclusion: As the conclusion, a comprehensive public health communication can enhance the program of policy enforcement and gain support from policy-oriented audiences.

Effects of Russian tobacco control law on rates of hospital admissions for acute coronary events

Abstract Background The Russian tobacco control law (TCL), implemented nationwide, aims to reduce smoking-related morbidity and mortality. However, its effects may vary among Russian regions. We aimed to assess the effects of TCL on rates of hospital admissions (HA) for angina pectoris (AP) and myocardial infarction (MI) in the Russian Federation (RF) and 10 Russian regions in relation to enforcement of the TCL. Methods We analysed HA rates for AP and MI to compare the periods before and after TCL in 2013, adjusting for possible confounders and long-term trends. Models were based on time-series of annual HA in the RF and 10 Russian regions during the years 2005-2019. We used interrupted time-series design and Poisson regression model with calculation of risk ratio (RR) and 95%CI. Regions were compared by means of TCL implementation scale (TCIS), developed based on the results of Russian TC policy evaluation survey in 10 Russian regions (n = 11625). We analysed the relationship between the TCL measures implementation scores and RR of reduction of HA for AP and MI after the TCL by means of Spearman's rank correlation and linear regression models. Results Results showed a 16.6% decrease in HA rates for AP (RR 0.83 95% CI 0.74-0.93) and 3.5% - for MI (RR 0.96 95% CI 0.96-0.97) after the TCL introduction in RF and effects of various magnitude in the regions. Regions with higher TCIS scores, i.e. better enforcement of full TCL package had greater reduction in HA rates for AP (rsp = −0.627 95%CI−1.05;−0.199; p=.004); with better enforcement of smoke-free policies - grater reduction in HA rates for MI (rsp = −0.793 95%CI−1.08;−0.506, p<.001). Both HA rates for AP and MI correlated with the higher scores for help to quit tobacco use (rsp = −0.56 95%CI −1.1; −0.01, p=.045), (rsp = −0.74 95%CI−1.12;−0.36, p=.027). Conclusions TCL leads to a decrease of HA for AP and MI with sustained effect. Differences in the magnitude of these effects in the regions are related to the extent of enforcement of TC measures. Key messages Tobacco control legislative measures may lead to reduction of hospital admission rates for acute coronary events. The effect of tobacco control law on hospital admission rates for acute coronary events may vary in relation with the extent of enforcement of tobacco control measures.

Effectiveness of legislative actions against tobacco smoking regarding the reduction of in-hospital morbidity of angina pectoris and myocardial infarction in Russia as a whole and 10 Russian constituent entities

Russian anti-tobacco policy is aimed at reducing long-term morbidity and mortality from smoking-related diseases.Aim. To assess the associations of tobacco control (TC) legislative measures with hospitalization rate for myocardial infarction (MI) and angina in Russia as a whole and in 10 Russian constituent entities, as well as to compare the effectiveness of anti-smoking measures in regions.Material and methods. We analyzed data on hospitalizations of patients with angina (I20) and acute (I21) and subsequent (I22) MI, as well as chronic rheumatic heart diseases (I05-I09), for 2005-2019 in Russia as a whole and in 10 Russian constituent entities. We analyzed hospital admission rates for angina and MI to compare the periods before and after introduction of Federal TC law in 2013, adjusting for possible confounders and long-term trends. We used interrupted time-series design and Poisson regression model with calculation of rate ratio (RR) and 95% CI. Regions were compared by means of original TC law implementation scale (TCIS) developed based on the results of Russian TC policy evaluation survey in 10 Russian regions (n=11625). We analyzed the relationship between the TC law measures implementation scores and RR of hospital admissions reductions for angina and MI after the TC law by means of Spearman’s rank correlation (coefficient with 95% CI) and linear regression models. Statistical package STATA 11.2 was used.Results. The actual trend of hospital admission rates for angina after TC law introduction demonstrates the greatest slope change from the predicted trend (without the law) (p=0,004); less, but still significant slope change for MI (p=0,049), and no slope change for chronic rheumatic heart disease (p=0,332). Results showed a 16,6% decrease in hospital admission rates for angina (RR, 0,83; 95% CI, 074-0,93) and 3,5% — for MI (RR, 0,96; 95% CI, 0,96-0,97) after the TC law introduction in RF and effects of various magnitude in the regions. Regions with higher TCIS scores, i.e. better enforcement of full TC package had greater reduction in hospital admission rates for angina (rsp=-0,627; 95% CI, -1,05−-0,199; p=0,004); with better enforcement of smoke-free policies — grater reduction in hospitalization rates for MI (rsp= -0,793 95%CI, -1,08−-0,506, p<0,001). Reduction of hospital admission rates for angina and MI correlated with the higher scores for help to quit tobacco use (rsp=-0,555; 95% CI, -1,098−-0,01, p=0,045), (rsp= -0,736; 95% CI, -1,12−-0,357, p=0,027). Also, hospital admission rates for angina and MI were associated with the changes in smoking cessation prevalence in 2013-2018 in the regions (β=-0,345; 95% CI, -0,67−-0,02 p=0,041) and smoking prevalence in 2019 (β=2,964; 95% CI, 1,28-5,92, p=0,049), respectively.Conclusion. TC legislation can lead not only to immediate reductions in hospital admission rates for angina and MI, but also to longer-term results. These effects may be due not only to the introduction of TC law, as such, but also to the enforcement of the law, as well as the direct results of TC measures — the decrease in smoking prevalence in the population.

A qualitative study of the process of adoption, implementation and enforcement of smoke-free policies in privately-owned affordable housing

BackgroundHousehold smoke-free home rules cannot fully protect nonsmokers from secondhand smoke (SHS) if they live in multi-unit housing (MUH). Instead, property-level smoke-free policies are needed to prevent SHS incursion into apartment units and to keep common areas smoke-free. Smoke-free policies are usually at the discretion of property management companies and owners within the context of market-rate and privately-owned affordable housing in the U.S.MethodsSemi-structured interviews on the policy development, implementation and enforcement experiences of 21 different privately-owned affordable housing management companies were conducted with representatives from properties in North Carolina and Georgia who had established smoke-free policies before 2016.ResultsThe decision to adopt was typically made by corporate leadership, board members, owners or property managers, with relatively little resident input. Policy details were influenced by property layout, perceptions of how best to facilitate compliance and enforcement, and cost of creating a designated smoking area. Policies were implemented through inclusion in leases, lease addenda or house rules with 6 months’ notice most common. Participants thought having a written policy, the norms and culture of the housing community, public norms for smoke-free environments, and resident awareness of the rules and their consequences, aided with compliance. Violations were identified through routine inspections of units and resident reporting. Resident denial and efforts to hide smoking were shared as challenges to enforcement, along with a perception that concrete evidence would be needed in eviction court and that simply the smell of SHS was insufficient evidence of violation. Over half had terminated leases or evicted residents due to violations of the smoke-free policy. The most common benefits cited were reduced turnover cost and time, and lower vacancy rates.ConclusionsUnderstanding the smoke-free policy process in privately-owned affordable housing can help practitioners encourage policies within subsidized housing contexts. The study identified salient benefits (e.g., reduced cost, time, and vacancies) that can be highlighted when encouraging MUH partners to adopt policies. Additionally, study findings provide guidance on what to consider when designing smoke-free policies (e.g., layout, costs), and provide insights into how to enhance compliance (e.g., resident awareness) and manage enforcement (e.g., routine inspections).

Implementation and enforcement of smoke-free policies in public housing.

Smoke-free policies such as those required by the US Department of Housing and Urban Development have the potential to reduce persistent income-related disparities in secondhand smoke exposure. To understand the implementation and enforcement process, as well as barriers and facilitators to compliance and enforcement, we conducted semi-structured interviews (n=37) with representatives from 23 Public Housing Authorities (PHAs) with some level of smoking restriction in place, along with residents from 14 of these PHAs, from January to August 2016. Residents were typically notified of the new policy through group meetings, new resident orientations and/or one-on-one discussions during lease renewal or annual recertification. Timing of implementation varied, with advanced notice of 6 months or a year most common. Enforcement typically involved a series of verbal and/or written warnings, followed by written notice of lease violation, and eventual notice of lease termination and/or eviction. Challenges in enforcement were generally classified as monitoring difficulties or legal concerns. Characterizing current practices (e.g. advance notice, clear communication of escalating consequences, cessation support and concrete evidence of violation) from early adopters sets the stage for identifying best practices and helps to ensure successful and fair implementation of smoke-free policies in subsidized housing.

Signs, Fines and Compliance Officers: A Systematic Review of Strategies for Enforcing Smoke-Free Policy.

Background. Smoke-free environment policies limit or eliminate the use of smoke-producing tobacco in designated areas thereby reducing second hand smoke. Enforcement is perceived as critical to the successful adoption of a smoke-free policy. However, there is limited guidance available regarding effective enforcement strategies. A systematic review was conducted to examine the effectiveness of enforcement strategies at increasing compliance with and enforcement of smoke-free policies; and to determine circumstances other than enforcement strategies that are associated with compliance with smoke-free policies. Design. Medline, Medline in Process, The Cochrane Library, Embase, PsycInfo and CINAHL databases were searched using MeSH and keywords for relevant studies published between January 1980 and August 2017. A narrative synthesis and methodological quality assessment of included studies was undertaken. Results. Policy promotion and awareness-raising activities, signage, enforcement officers, and penalties for violations were the enforcement strategies most frequently cited as being associated with successful policy enforcement. Additionally, awareness of the laws, non-smoking management and lower staff smoking rates, and membership of a network guiding the policy enforcement contributed to higher compliance with smoke-free policies. Conclusions. There is weak evidence of the effectiveness of strategies associated with compliance with smoke-free policies. Given the evidence base is weak, well-designed trials utilizing appropriate evaluation designs are needed. Overall enforcement strategies associated with total smoke-free bans resulted in higher levels of compliance than strategies for policies that had only partial smoke-free bans.

An Exploration of the Perspectives of Associate Nurse Unit Managers Regarding the Implementation of Smoke-free Policies in Adult Mental Health Inpatient Units

ABSTRACTContext: In Adult Mental Health Inpatient Units, it is not unexpected that leadership of Associate Nurse Unit Managers contributes to successful implementation of smoke-free policies. Aim: In light of challenges facing mental health nursing, and limited research describing their leadership and the role it plays in addressing smoke-free policy implementation, the aim of this study is to explore Associate Nurse Unit Managers perspectives' regarding the implementation of smoke-free policies, which were introduced on 1 July, 2015. Design, Setting, Participants: Individual in-depth semi-structured interviews were undertaken six months post the implementation of smoke-free policies. In this qualitative descriptive study, six Associate Nurse Unit Managers working in a Victorian public Adult Mental Health Inpatient Unit, were asked eight questions which targeted leadership and the implementation and enforcement of smoke-free policies. Associate Nurse Unit Managers provide leadership and role modeling for staff and they are responsible for setting the standards that govern the behavior of nurses within their team. All participants interviewed believed that they were leaders in the workplace. Main Outcomes: Education and consistency were identified as crucial for smoke-free policies to be successful. Participants acknowledged that the availability of therapeutic interventions, staff resources and the accessibility of nicotine replacement therapy were crucial to assist consumers to remain smoke-free while on the unit. Conclusion: The findings from this research may help to improve the understanding of the practical challenges that Associate Nurse Unit Manager's face in the implementation of smoke-free policies with implications for policies, nursing practice, education and research.

Hospital Smoke-Free Policy: Compliance, Enforcement, and Practices. A Staff Survey in Two Large Public Hospitals in Australia.

Background: Smoke-free hospital policies are becoming increasingly common to promote good health and quit attempts among patients who smoke. This study aims to assess: staff perceived enforcement and compliance with smoke-free policy; the current provision of smoking cessation care; and the characteristics of staff most likely to report provision of care to patients. Methods: An online cross-sectional survey of medical, nursing, and allied staff from two Australian public hospitals was conducted. Staff report of: patient and staff compliance with smoke-free policy; perceived policy enforcement; the provision of the 5As for smoking cessation (Ask, Assess, Advise, Assist, and Arrange follow-up); and the provision of stop-smoking medication are described. Logistic regressions were used to determine respondent characteristics related to the provision of the 5As and stop-smoking medication use during hospital admission. Results: A total of 805 respondents participated. Self-reported enforcement of smoke-free policy was low (60.9%), together with compliance for both patients (12.9%) and staff (23.6%). The provision of smoking cessation care was variable, with the delivery of the 5As ranging from 74.7% (ask) to 18.1% (arrange follow-up). Medical staff (odds ratio (OR) = 2.09, CI = 1.13, 3.85, p = 0.018) and full time employees (OR = 2.03, CI = 1.06, 3.89, p = 0.033) were more likely to provide smoking cessation care always/most of the time. Stop-smoking medication provision decreased with increasing age of staff (OR = 0.98, CI = 0.96, 0.99, p = 0.008). Conclusions: Smoke-free policy enforcement and compliance and the provision of smoking cessation care remains low in hospitals. Efforts to improve smoking cessation delivery by clinical staff are warranted.

Australian university smoke-free policy implementation: a staff and student survey.

Issue addressed Universities represent important settings for the implementation of public health initiatives such as smoke-free policies. The study aimed to assess staff and student attitudes towards policy enforcement and compliance as well as the acceptability of the provision of cessation support in this setting. Methods A cross-sectional study was conducted following the introduction of a designated-areas partial smoke-free policy at two campuses of one Australian university in 2014. Staff (n=533) and students (n=3060) completed separate online surveys assessing attitudes towards smoke-free policy enforcement and compliance, and acceptability of university-provided cessation support. Results Students held significantly stronger beliefs than staff that the smoke-free policy required staff enforcement (69% vs 60%) and violation penalties (67% vs 60%; both P's <0.01); however, most staff (66%) did not believe enforcement was part of their role. Only 55% of student smokers were aware that the university provided any cessation support. 'Free or cheap nicotine replacement therapy' (65%) and 'free stop smoking counselling service' (60%) were the most popular strategies student smokers thought the university should provide. Conclusions University staff and students hold conflicting views over the need for policy enforcement and who is responsible for enforcement roles. Students view the university as an acceptable setting for the provision of smoking cessation support. So what? Where staff are expected to enforce smoke-free policies, specific education and training should be provided. Ongoing monitoring of compliance and enforcement behaviour appears necessary to avoid the pervasive kind of non-compliance to smoke-free policies that have been seen in other settings.

Secondhand smoke exposure and susceptibility to initiating cigarette smoking among never-smoking students in selected African countries: Findings from the Global Youth Tobacco Survey

BackgroundExposure to secondhand smoke (SHS) causes premature death and illness in non-smokers. We examined SHS exposure at home and in public places, as well as susceptibility to initiate cigarette smoking among never cigarette smokers. We used 2006–2011 Global Youth Tobacco Survey (GYTS) data from 29 African countries (56,967 students). MethodsGYTS is a nationally representative, self-administered school-based survey, conducted among students aged 13–15years. Prevalence ratio, estimates and 95% confidence intervals were computed for SHS exposure in the homes and public places separately. The two-sample t-test was used to assess the difference in susceptibility to smoking by SHS exposure among never-smoking students (α=0.05). ResultsAmong never-smoking students, exposure to SHS at home ranged from 12.7% (Cape Verde) to 44.0% (Senegal). The prevalence ratio (PR) comparing susceptibility to smoking initiation among never smokers exposed to SHS at home to those who were not exposed at home ranged from 1.2 to 2.6. Exposure to SHS in public places ranged from 23.9% (Cape Verde) to 80.4% (Mali). Of the countries being studied, 8 countries showed a significant difference in susceptibility to smoking initiation among never smokers exposed to SHS in public places compared to those not exposed in public places. (PR ranged from 0.5–3.5). ConclusionIn many African countries in the study, a substantial proportion of students who never smoked are exposed to SHS at home and in public places. Majority of never smokers who were exposed to SHS at home and in public places had a higher prevalence of susceptibility to initiate smoking than those that were not exposed to SHS at home and in public places. Adoption and enforcement of smoke-free policies in public places and smoke-free rules at home could substantially contribute to reducing SHS exposure in many of these countries.

Smoke-Free Universities Help Students Avoid Establishing Smoking by Means of Facilitating Quitting.

Background: This study aimed to clarify whether smoke-free policies affect the initiation or the quitting of smoking among young adults. Methods: In this natural quasi-experiment study, three universities with different enforcement of smoke-free policies were considered in Kazan City, Russian Federation. Exposure data were collected in 2008-2009 through measurement of particulate matter concentrations in typical sets of premises in each university to distinguish smoke-free universities (SFU) and those not smoke-free (NSFU). All present third year students were surveyed in class in April-June 2011. Number of valid questionnaires equaled 635. The questionnaire was adapted from the Health Professions Students Survey and contained questions on smoking initiation, current tobacco use, willingness to quit, quit attempts, percep­tion of smoke-free policies enforcement, and the demographic data. Results: Among students of SFU, the percentage of current smokers was smaller than in NSFU: 42% vs. 64% in men and 32% vs. 43% in women. Prevalence of daily smoking was 11-12% in SFU, 26% in NSFU overall and 42% among male students. No advantage of SFU in limiting smoking initiation was found. Percentage of former smokers in SFU was 33% vs. 10% in NSFU. Among current smokers, 57% expressed willingness to quit in SFU and only 28% in NSFU. About 60% of current smokers in SFU attempted to quit within a year and only 36% did so in NSFU with 23% vs. 3% having done three or more attempts. Conclusion: Smoke-free universities help young adults to avoid establishing regular smoking by means of facilitating quitting smoking.

The Clinical Assessment and Treatment of Nicotine Dependence

In the United States and around the world, nicotine dependence is a leading cause of preventable death. Smoking cessation results in immediate and enduring health benefits. A wide range of clinical interventions have been shown to facilitate smoking cessation and to have a favorable cost-benefit profile. Practice guidelines and national reports have issued calls to action and have made smoking cessation resources readily available. Yet utilization of smoking cessation interventions and resources is lagging. Health care systems and providers have a shared responsibility to ensure that all smokers are offered appropriate interventions. This article summarizes the epidemiology and pathophysiology of nicotine dependence as a background for reviewing the central components of clinical evidence-based smoking cessation interventions: screening, assessment, advice, assistance, and follow-up. Specific patient populations are discussed, as well as emerging strategies to address nicotine dependence.

Implementation of smoke-free policies in mental health in-patient settings in England

Mental health units in England had to become smoke-free by law from July 2008. Concerns regarding the implementation and enforcement of smoke-free policies in these settings have been raised. To study difficulties and challenges associated with smoke-free policy implementation in English National Health Service (NHS) mental health settings. Questionnaire survey of all 72 English NHS trusts providing mental health in-patient services and facilities, supplemented by semi-structured telephone interviews at a systematic sample of 7 trusts and site visits at a convenience sample of 5 trusts. Questionnaires were returned by 79% of the trusts, all of whom had implemented smoke-free policies. Most respondents (91%) believed that mental health settings faced particular challenges, arising from the high smoking prevalence among patients (81%), related safety risks (70%), adverse effects on the clinician-patient relationship (36%), and potential interactions with antipsychotic medication (34%). Interviews indicated that sustained policy enforcement was perceived as difficult, but that despite challenges and concerns, the impact of the policy was regarded as beneficial, with some evidence of positive behavioural changes occurring in people. Many mental health trusts across England have implemented comprehensive smoke-free policies but the majority state that they are facing specific difficulties. Challenges and concerns need to be explored in depth and addressed to ensure that smoke-free policies implemented under the terms of the Health Act in July 2008 are not undermined.

Indoor Air Quality and Enforcement of Smoke-Free Policies in Public Venues and Schools

Indoor Air Quality and Enforcement of Smoke-Free Policies in Public Venues and Schools