Indoor Bans Research Articles

Persistent tobacco smoke residue in multiunit housing: Legacy of permissive indoor smoking policies and challenges in the implementation of smoking bans.

Secondhand smoke (SHS) is a common indoor pollutant in multiunit housing (MUH). It is also the precursor of thirdhand smoke (THS), the toxic mixture of tobacco smoke residue that accumulates in indoor environments where tobacco has been used. This study examined the levels, distribution, and factors associated with THS pollution in low-income MUH. Interviews were conducted 2016-2018 in a cross-sectional study of N=220 MUH homes in San Diego, California. Two surface wipe samples were collected per home and analyzed for nicotine, a THS marker, using liquid chromatography-triple quadrupole mass spectrometry. Nicotine was detected in all homes of nonsmokers with indoor smoking bans (Geo Mean=1.67µg/m2; 95% CI=[1.23;2.30]) and smokers regardless of an indoor ban (Geo Mean=4.80µg/m2; 95% CI=[1.89;12.19]). Approximately 10% of nonsmokers' homes with smoking bans showed nicotine levels higher than the average level in homes of smokers without smoking bans from previous studies (≥30µg/m2). Housing for seniors, smoking bans on balconies, indoor tobacco use, difficult to reach surfaces, and self-reported African-American race/ethnicity were independently associated with higher THS levels. Individual cases demonstrated that high levels of surface nicotine may persist in nonsmoker homes for years after tobacco use even in the presence of indoor smoking bans. To achieve MUH free of tobacco smoke pollutants, attention must be given to identifying and remediating highly polluted units and to implementing smoking policies that prevent new accumulation of THS. As THS is a form of toxic tobacco product waste, responsibility for preventing and mitigating harmful impacts should include manufacturers, suppliers, and retailers.

Enhancing implementation of smoke-free places: A comparative qualitative study across seven European cities

BackgroundAdvocacy, resources and intersubjective reasonable arguments are known as factors that contribute to smoke-free (SF) adoption and implementation in Chinese and Anglo-Saxon places. Less is known about how the implementation of smoking bans differs across European places. The aim of this qualitative comparative study is to identify and classify the SF policy implementation processes and types undertaken at the local level in seven European cities according to the views of local bureaucrats and sub-national stakeholders. MethodSemi-structured expert interviews (n = 56) with local decision makers and stakeholders were conducted as qualitative part of the comparative SILNE-R project in Belgium (Namur), Finland (Tampere), Germany (Hanover), the Republic of Ireland (Dublin), the Netherlands (Amersfoort), Italy (Latina), and Portugal (Coimbra). Qualitative interviews were analyzed using the framework analysis. ResultsImplementation of SF environments predominantly focuses on indoor bans or youth-related settings. Progressive-hungry (Dublin), moderate-rational (Tampere), upper-saturated (Hanover, Amersfoort), and lower saturated (Namur, Coimbra, Latina) implementation types can be distinguished. These four types differ with regards to their engagement in enhancing SF places as well as along their level of perceived tobacco de-normalization and public smoking visibility. In all municipalities SF environments are adopted at national levels, but are differently implemented at the local level due national policy environments, enforcement strategies and the level of collaboration. Major mechanisms to expand SF regulations were found to be scientific evidence, public support, and the child protection frame. However, counter-mechanisms of closure occur if data on declining prevalence and new youth addiction trends trigger low prioritization. ConclusionsThis study found four SF implementation types two mechanisms of progressive expansion and defensive closure. Development and enhancement of smoking bans requires a suitable national policy environment and indirect national-level support of self-governed local initiatives. Future SF policies can be enhanced by laws pertaining to places frequented by minors.

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans

While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities. We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities. The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. We identified "triggering trust," "increasing priorities," and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) limiting opposing interests through the use of the child protection frame. This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation. In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive SF laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO "Healthy Cities Network" objectives.

Impact of Presence of Children on Indoor Tobacco Restrictions in Households of Urban and Rural Adult Tobacco Users

ObjectivesSecondhand smoke exposure in children is changing as a result of new public policy and electronic nicotine products (e-cigarettes). We examined factors related to self-imposed indoor household tobacco restrictions, with emphasis on children in the household and associations with combustible and noncombustible product use. MethodsA cross-sectional survey of urban and rural Ohio adult tobacco users classified participants as exclusive combustible users, smokeless tobacco (SLT) users, e-cigarette users, or dual users. They were further stratified according to combustible or noncombustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions. ResultsA total of 1210 tobacco users participated, including 25.7% with children living in the home. Half allowed combustible and two thirds allowed noncombustible tobacco use indoors. Urban location (odds ratio [OR] = 1.58), younger age (OR = 0.88 per 5 year), male sex (OR = 1.40), college education (OR = 1.40), household income of more than $15,000 (OR = 1.78), and being married (OR = 2.43) were associated with a higher likelihood of banning combustible products indoors. SLT (OR = 8.12) and e-cigarette (OR = 5.85) users were more likely to have indoor bans compared to combustible users. Children in the household (OR = 1.89), older age (OR = 1.12 per 5 years), and nonwhite race (OR = 1.68) were associated with a higher likelihood of banning noncombustible products indoors. Combustible (OR = 4.54) and e-cigarette (OR = 3.04) users were more likely than SLT users to have indoor bans. ConclusionsIndoor restrictions on tobacco use remain infrequent in homes with children and are associated with user type and socioeconomic factors. Public policy should target modifiable risk factors for in-home secondhand smoke exposure.

Compliance with indoor and outdoor smoke-free ban in Catalan hospitals: what do patients think?

Compliance with indoor and outdoor smoke-free ban in Catalan hospitals: what do patients think?

Compliance with indoor tanning bans for minors among businesses in the USA.

Indoor tanning is a known risk factor for skin cancer and is especially dangerous for adolescents. Some states have passed indoor tanning bans for minors, but business compliance with the bans is not well understood. Thus far, studies have assessed ban compliance in one or two states at a time. This study aimed to assess compliance with indoor tanning bans for minors and knowledge of dangers and benefits of tanning among indoor tanning businesses. Female research assistants posing as minors telephoned a convenience sample of 412 businesses in 14 states with tanning bans for minors under age 17 or 18. We evaluated differences in compliance by census region and years since ban was implemented and differences in reported dangers and benefits by compliance. Most (80.1%) businesses told the "minor" caller she could not use the tanning facilities. Businesses in the south and in states with more recent bans were less compliant. Among those (n=368) that completed the full interview, 52.2% identified burning and 20.1% mentioned skin cancer as potential dangers. However, 21.7% said dangers were no worse than the sun and 10.3% denied any dangers. Stated benefits included vitamin D (27.7%), social/cosmetic (27.2%), and treats skin diseases (26.4%), with only 4.9% reporting no benefits. While most businesses followed the indoor tanning ban when a minor called, one-fifth did not. Many stated inaccurate health claims. Additional enforcement or education might increase compliance with indoor tanning bans and action is needed to prevent businesses from stating false health information.

Thirdhand Smoke in the Homes of Medically Fragile Children: Assessing the Impact of Indoor Smoking Levels and Smoking Bans.

Thirdhand smoke (THS) residue results from secondhand smoke, and is emerging as a distinct public health hazard, particularly for medically fragile pediatric patients living with smokers. THS is difficult to remove and readily reacts with other pollutants to form carcinogens and ultrafine particles. This study investigated THS found in homes of high-risk infants admitted to a neonatal intensive care unit and their association with characteristics (eg, number of household smokers) hypothesized to influence THS. Baseline data from 141 hospitalized infants' homes were analyzed, along with follow-up data (n = 22) to explore household smoking characteristics and THS changes in response to indoor smoking ban policies. Households with an indoor ban, in which not more than 10 cigarettes/d were smoked, had the lowest levels of THS contamination compared to homes with no ban (P < .001) and compared to homes with an indoor ban in which greater numbers of cigarettes were smoked (P < .001). Importantly, homes with an indoor ban in which at least 11 cigarettes/d were smoked were not different from homes without a ban. The follow-up sample of 22 homes provided initial evidence indicating that, unless a ban was implemented, THS levels in homes continued to increase over time. Preliminary longitudinal data suggest that THS may continue to accumulate in homes over time and household smoking bans may be protective. However, for homes with high occupant smoking levels, banning indoor smoking may not be fully adequate to protect children from THS. Unless smoking is reduced and bans are implemented, medically fragile children will be exposed to the dangers of THS.

Prevalence of and Factors Related to Tobacco Ban Implementation in Substance Use Disorder Treatment Programs.

This study examined the prevalence of and factors (psychological climate for change and staff attributes) related to indoor and outdoor tobacco bans for patients, employees, and visitors in U.S. substance use disorder treatment programs. Data were collected from a random sample of 1,026 program administrators. Almost all programs banned tobacco use indoors and around one third banned tobacco use outdoors. When there was no tobacco ban, the majority of programs restricted smoking to designated indoor and/or outdoor areas. Further, all psychological climate for change factors (perceived program support, perceived tobacco culture, and tobacco ban beliefs) but none of the staff attributes (percentage licensed/certified clinicians, percentage clinicians with master's degrees, total staff with education in health-related field) were significantly related to the implementation of comprehensive tobacco bans (both indoors and outdoors).

Support for indoor bans on electronic cigarettes among current and former smokers.

Objectives: Electronic cigarette (e-cigarette) use is increasing in the U.S. Although marketed as a safer alternative for cigarettes, initial evidence suggests that e-cigarettes may pose a secondhand exposure risk. The current study explored the prevalence and correlates of support for e-cigarette bans. Methods: A sample of 265 current/former smokers completed a cross-sectional telephone survey from June–September 2014; 45% Black, 31% White, 21% Hispanic. Items assessed support for home and workplace bans for cigarettes and e-cigarettes and associated risk perceptions. Results: Most participants were aware of e-cigarettes (99%). Results demonstrated less support for complete e-cigarette bans in homes and workplaces compared to cigarettes. Support for complete e-cigarette bans was strongest among older, higher income, married respondents, and former smokers. Complete e-cigarette bans were most strongly endorsed when perceptions of addictiveness and health risks were high. While both e-cigarette lifetime and never-users strongly supported cigarette smoking bans, endorsement for e-cigarette bans varied by lifetime use and intentions to use e-cigarettes. Conclusions: Support for indoor e-cigarette bans is relatively low among individuals with a smoking history. Support for e-cigarette bans may change as evidence regarding their use emerges. These findings have implications for public health policy.

Making Hospitals in China Smoke-Free: A Prospective Study of Implementing the New Standard

In the run-up to all Chinese health care facilities becoming smoke-free, the feasibility of the new standard was assessed by monitoring its implementation in a sample of Chinese hospitals. Forty-one hospitals across 20 provinces were asked to ban smoking inside the hospital and provide advice and referral to stop-smoking treatment. Smoking status of more than 24,000 members of staff at 21 hospitals was surveyed at baseline (April 2009) and at follow-up (October 2010). Surveys monitored implementation of several specific aspects of the new standard to identify potential barriers to nationwide implementation. All hospitals managed to implement the ban and most set up smoking cessation clinics. Routine recording of patients' smoking status proved more difficult to implement. The hospitals improved significantly in 8 out of 11 monitored policy parameters. Smoking prevalence among staff decreased from 14.8% to 10.7% (p < .001), suggesting an important collateral benefit of making hospitals smoke-free. Outdoor smoking areas facilitated the indoor ban. Staff education emerged as the key priority. The smoke-free standard is feasible even in a country with a widespread acceptance of smoking inside health facilities. Several challenges need to be addressed when the new standard is disseminated across China.

Protecting the World From Secondhand Tobacco Smoke Exposure: Where Do We Stand and Where Do We Go From Here?

Article 8 of the Framework Convention on Tobacco Control mandates all signatory countries to "protect citizens from exposure to tobacco smoke in workplaces, public transport and indoor public places." Even though there has been great progress in the implementation of Article 8, still most of the world population remains exposed to secondhand smoke (SHS). In this article, we sought to summarize the research that supports Article 8, where do we stand, and current research gaps and future directions. Secondhand smoke is an established cause of heart disease and several types of cancer. Additional research is needed to reach final conclusions for diseases where evidence is only suggestive of causality. The only solution to SHS exposure in public places is banning smoking indoors. Research on the gaming industry and nightclubs, particularly in developing countries, needs to be disseminated to support their inclusion in smoke-free laws. Aside from indoor bans, additional research is needed for outdoor and multiunit housing bans and in support of measures that protect children and other vulnerable populations. The impact of smoke-free laws on other health outcomes, besides heart disease and respiratory outcomes, is another area where further research is needed. Thirdhand smoke assessment and health effects are also likely to be a topic of further research. As new tobacco products emerge, evaluating SHS exposure and effects will be vital. Furthering research in support of Article 8 can contribute to reach the final goal of protecting everyone from SHS exposure.

Outdoor smoking behaviour and support for outdoor smoking restrictions before and after France's national smoking ban.

On January 1, 2008, the French government implemented a national ban on indoor smoking in hospitality venues. Survey results indicate the indoor ban has been successful at dramatically reducing indoor smoking; however, there are reports of an increased number of outdoor hospitality spaces (patios) where smoking can take place. This study sought to understand if the indoor ban simply moved smoking to the outdoors, and to assess levels of support for smoking restrictions in outdoor hospitality settings after the smoke-free law. Telephone interviews were conducted among 1067 adult smokers before and after the 2008 indoor ban as part of the International Tobacco Control (ITC) France Survey. Among other topics, this survey measures how the smoking ban has influenced smoking behaviour relevant to outdoor sections of hospitality venues. In addition, 414 non-smoking adults and 164 respondents who had quit smoking between waves were also asked about support for outdoor smoking restrictions. Reported smoking outdoors at cafés/pubs/bars increased from 33.6% of smokers at Wave 1 to 75.9% at Wave 2. At restaurants, smoking outdoors increased from 28.9% to 59.0%. There was also an increase in reported non-smoking for both visits to cafés/pubs/bars, and restaurants from 13.4% to 24.7%, and 30.4% to 40.8% respectively. The majority of smokers (74.5%), non-smokers (89.4%) and quitters (74.0%) support a partial or complete ban on smoking in outdoor areas of restaurants. The indoor smoking ban moved smoking to outdoor spaces; however, the ban is also associated with increased non-smoking behaviour. The majority of respondents support outdoor smoking restrictions in patio environments.

Post-ban self-reports on economic impact of smoke-free bars and restaurants are biased by pre-ban attitudes. A longitudinal study among employees

Objective sales data have indicated that the Norwegian indoor smoke-free regime implemented in June 2004 did not affect the hospitality business negatively. This paper investigates whether self-reports on the economic impact of the smoking ban from employees in the hospitality sector gave similar results, and whether post-ban self-reports on the economic impact of the ban were influenced by pre-ban attitudes towards smoke-free policies. A random sample of 516 employees in bars and restaurants stated their attitudes towards smoke-free policies shortly before the ban became effective. One year later, the same respondents gave their perceptions of changes in patronage for their workplace. Data were collected using self-administered questionnaires and telephone interviews. 56.4% of the hospitality workers stated that the ban on smoking had led to a large reduction (28.2%) or some reduction (28.2%) in the number of patrons, a result inconsistent with analysis of sales data. After adjusting for demographic and smoking-related variables, a negative pre-ban attitude significantly increased the odds for reporting a negative economic impact post ban (odds ratio 2.48, confidence interval 1.48-4.14). Subjective reports of the economic impact from an indoor ban on smoking are influenced by attitudes towards smoke-free policies and should not be considered as a valid measure of the economic effect.

Implementing an Indoor Smoking Ban in Prison: Enforcement Issues and Effects on Tobacco Use, Exposure to Second-hand Smoke and Health of Inmates

To describe the issues encountered during the implementation of an indoor smoking ban in prison and its effects on self-reported tobacco use, perceived exposure to second-hand smoke (SHS) and perceived health status of inmates in Quebec's provincial correctional facilities. Quantitative data were obtained from 113 inmates in three provincial correctional facilities in the province of Quebec, Canada. Qualitative data were obtained from 52 inmates and 27 staff members. Participants were recruited through a self-selection process. Particular efforts were made to enrol proportions of men, women, smokers and non-smokers similar to those generally found among correctional populations. Despite the indoor smoking ban, 93% of inmates who declared themselves smokers reported using tobacco products inside the correctional facilities and 48% did not report any reduction in their tobacco use. Only 46% of smokers declared having been caught smoking inside the facility, and more than half of them (58%) reported no disciplinary consequences to their smoking. A majority of inmates incarcerated before the implementation of the ban (66%) did not perceive a reduction of their exposure to SHS following the indoor ban. Enforcement issues were encountered during the implementation of the indoor ban, notably because of the amendment made to the original regulation (total smoking ban) and tolerance from smokers in the staff towards indoor smoking. They were also related to perceptions that banning indoor smoking is complex and poses management problems. This study's findings emphasize the importance of considering organizational and environmental factors when planning the implementation of an indoor smoking ban in correctional facilities.

Smoking Restrictions and Treatment for Smoking: Policies and Procedures in Psychiatric Inpatient Units in Australia

Tobacco smoking is the leading preventable cause of death and disease in Australia. Even though smoking prevalence in the general population has been reduced (20% smoke), prevalence rates remain high among psychiatric inpatients (70%-90%). This study aimed to identify smoking policies and procedures in public psychiatric inpatient units in New South Wales, Australia; the provision of "smoking care" in such units (for example, quit-smoking advice or nicotine replacement therapy); and policies and procedures associated with the assessment of smoking status and provision of smoking care. A cross-sectional survey was mailed to all public psychiatric inpatient units in New South Wales for completion by nurse unit managers. Of the 131 units, 123 units completed and returned surveys (94%). Over one-third (36%) of respondents reported instances in which inpatients began smoking during their admission. A similar proportion (39%) reported that staff provided cigarettes to patients who smoked when patients' supply was expended. Fifty percent of respondents reported that all patients were assessed for smoking status; however, 70% reported that nicotine dependence was not assessed. Units on which staff adhered to smoking restrictions were three times as likely to assess patients' smoking status as units where staff never adhered to restrictions (odds ratio=3.05, p=.01). Inadequate establishment of nonsmoking environments and of smoking restriction enforcement as well as inconsistencies in the provision of smoking care were evident. The findings suggest that failure of psychiatric services to provide smoking care is systemic and not related to particular types of services (for example acute versus nonacute or regional versus metropolitan).

Tobacco policy in American prisons, 2007

Objective:To examine current tobacco policy in US prisons and explore changes in prison tobacco policies over time.Data source:Telephone survey of the 52 US departments of correction.Main outcome measures:Current tobacco policy;...

Smoking in correctional facilities: a survey of employees

OBJECTIVETo assess level of endorsement and expected consequences of worksite smoking restriction policies among correctional employees.DESIGNMailed survey to Vermont state correctional employees.MAIN OUTCOME MEASURESSupport for various policy alternatives for both...

HOSPITAL PSYCHIATRIC UNITS: Nonsmoking Policies

Establishing nonsmoking policies in hospitals--even on acute psychiatric units--requires patience, planning, and a bit of nerve. The benefits of such a move, however, can be significant for patients and staff. When Vancouver General Hospital implemented a complete indoor nonsmoking policy on its psychiatric assessment and inpatient psychiatry units, workplace conditions noticeably improved, and some long-standing beliefs about psychiatric patients were disproved. Several conditions provided the impetus to change to a nonsmoking policy. With a few exceptions (palliative care, the burn unit) the indoor areas were nonsmoking; nevertheless, the hospital environmental committee considered a site-wide (indoor and outdoor) ban on smoking. One reason was that the community funding that had provided psychiatric patients with cigarettes would soon be cut off. Another reason was that all psychiatry units were anticipating moving into the new hospital tower--a facility slated to be smoke-free--on its completion.