Tobacco-free Policies Research Articles

Strengthening tobacco-free worksite policies in India

Strengthening tobacco-free worksite policies in India

Compliance Assessment of Cigarette and Other Tobacco Products Act in Public Places in Delhi Government Hospitals

Objective:Tobacco-free policies in hospital campus reduce exposure to tobacco smoke; change the demeanour of the professionals, patients and people visiting hospitals towards tobacco use. Section-4, 5 and 6 of COTPA (Cigarettes and Other Tobacco Products Act) necessitates the need for implementation of the prohibition on smoking in public places. Against this background, the present work was designed to evaluate the status of compliance Section 4, 5 and 6 of COTPA in Delhi Government hospitalsMethods:A cross-sectional observational study was conducted within Government hospitals. Multistage random sampling was used to select 18 hospitals out of 39 hospitals from 5 zones. Standard assessment Proforma developed by John Hopkins School of Public Health for assessing compliance to Tobacco-Free Law was used and modified to address certain aspects of Section-4, 5 and 6 of COTPA. Hospital campuses were assessed by dividing them into zones like hospital buildings, office buildings, public places outside the hospital and residential areas.Result:Signs of active tobacco use observed in 40.6% of hospital buildings, 35.3% in office buildings, and 75.4% in public places outside the buildings. ‘No smoking signage was not as per the COTPA guidelines in 21.4% of the hospitals and 72% were not tobacco free outdoors in these positions.Conclusion:The study highlighted a lower compliance rate than expected which raises questions on law enforcement concerning tobacco. Hence necessary measures have to be used up for sustained awareness campaigns, backed by enforcement drives. Periodic compliance surveys will strengthen the implementation of tobacco free legislation in health care institutions.

Student, Faculty, and Staff Approval of University Smoke/Tobacco-Free Policies: An Analysis of Campus Newspaper Articles.

Objective:To provide a nontraditional source of data to university policymakers regarding student, faculty, and staff approval of university smoke/tobacco-free policies, as published through campus newspaper articles.Methods:From January to April 2016, a total of 2523 articles were retrieved concerning campus smoking/tobacco at 4-year, public universities. Of these, 54 articles met the inclusion factors, which described 30 surveys about campus approval of tobacco-free policies and 24 surveys about smoke-free policies.Results:In all, the surveys included more than 130 000 respondents. With the exception of 4 surveys, all reported that the most of the respondents approved a tobacco/smoke-free campus policy.Conclusions:Although the study had several limitations, the findings provide a synthesis from a nontraditional data source that is consistent with findings from the peer-reviewed literature, in which most of the students, faculty, and staff on university campuses approve of smoke/tobacco-free campus policies.

Effects of a Tobacco-Free Work Site Policy on Employee Tobacco Attitudes and Behaviors, Travis County, Texas, 2010-2012.

BackgroundThe adoption of tobacco-free policies in behavioral health settings is an important step in reducing staff tobacco use as well as the high rates of tobacco use among people with mental illness and behavioral disorders. Studies have demonstrated the importance of staff support when implementing tobacco-free workplace policies, but there is limited research examining tobacco use prevalence among staff and staff attitude before and after policy adoption.Community ContextIntegral Care, a local authority for behavioral health and developmental disabilities in Austin, Texas, and Austin Public Health embarked on a comprehensive planning process before implementing a 100% tobacco-free campus policy. The objectives were 1) assess staff tobacco use and attitudes toward a tobacco-free policy, 2) communicate policy to staff, 3) provide staff education and training, and 4) provide cessation resources.MethodsIntegral Care and Austin Public Health conducted a web-based employee survey 6 months before and 6 and 12 months after implementation of the policy to measure tobacco use prevalence and attitudes among employees.OutcomeEmployees had significant improvements in tobacco use prevalence and attitudes toward the tobacco-free policy from pre-implementation to post-implementation. Tobacco use prevalence among staff decreased from 27.6% to 13.8%, and support for the policy increased from 60.6% to 80.3% at 12 months post-implementation.InterpretationAdoption of 100% tobacco-free campus policies in behavioral health settings can result in significant reductions in staff tobacco use. Leadership should provide staff with education, training, and cessation support before adoption of tobacco-free work site policies to ensure success.

Attitudes toward smokeless tobacco use at all public sports venues among U.S. adults, 2016

Policies prohibiting smokeless tobacco (SLT) use at sports venues have been enacted in California and nine U.S. cities. We measured opposition toward SLT use at all public sports venues and its correlates among U.S. adults. Data were from the 2016 SummerStyles, a web-based survey of U.S. adults aged ≥18years (n=4203). Weighted estimates of opposition (“strongly” or “somewhat”) SLT use were computed overall and by selected characteristics. Multivariable Poisson regression analyses were performed to identify determinants of opposition toward SLT use overall and among current tobacco product users. Overall, 81.8% of U.S. adults opposed SLT use at all public sports venues. Opposition varied by tobacco product use status: 85.9%, 86.9% and 60.4% among never, former, and current tobacco product users, respectively. Among all adults, the likelihood of opposition was higher among females than males (Adjusted Prevalence Ratio [APR]=1.05; 95%CI=1.01–1.08) and increased with every 10-year increase in age (APR=1.01; 95%CI=1.00–1.02). Likelihood was lower among persons with a high school diploma (APR=0.92; 95%CI=0.88–0.96) than those with college degree or higher; persons widowed/divorced/separated (APR=0.92; 95%CI=0.87–0.97) than those married; and current tobacco product users (APR=0.70; 95%CI=0.65–0.76) than never users. Among current tobacco product users, likelihood was lower among persons living in the Midwest (APR=0.81; 95%CI=0.66–0.98) and South (APR=0.78; 95%CI=0.65–0.94) than the Northeast. Most U.S. adults, including three-fifths of current tobacco product users, oppose SLT use at all public sports venues. Complete tobacco-free policies for sports venues that prohibit all forms of tobacco product use can help reduce the social acceptability of SLT use.

Pilot trial and process evaluation of a multilevel smoking prevention intervention in further education settings

Background Preventing smoking uptake among young people is a public health priority. Further education (FE) settings provide access to the majority of 16- to 18-year-olds, but few evaluations of smoking prevention interventions have been reported in this context to date. Objectives To evaluate the feasibility and acceptability of implementing and trialling a new multilevel smoking prevention intervention in FE settings. Design Pilot cluster randomised controlled trial and process evaluation. Setting Six UK FE institutions. Participants FE students aged 16–18 years. Intervention ‘The Filter FE’ intervention. Staff working on Action on Smoking and Health Wales’ ‘The Filter’ youth project applied existing staff training, social media and youth work resources in three intervention settings, compared with three control sites with usual practice. The intervention aimed to prevent smoking uptake by restricting the sale of tobacco to under-18s in local shops, implementing tobacco-free campus policies, training FE staff to deliver smoke-free messages, publicising The Filter youth project’s online advice and support services, and providing educational youth work activities. Main outcome measures (1) The primary outcome assessed was the feasibility and acceptability of delivering and trialling the intervention. (2) Qualitative process data were analysed to explore student, staff and intervention team experiences of implementing and trialling the intervention. (3) Primary, secondary and intermediate (process) outcomes and economic evaluation methods were piloted. Data sources New students at participating FE settings were surveyed in September 2014 and followed up in September 2015. Qualitative process data were collected via interviews with FE college managers (n = 5) and the intervention team (n = 6); focus groups with students (n = 11) and staff (n = 5); and observations of intervention settings. Other data sources were semistructured observations of intervention delivery, intervention team records, ‘mystery shopper’ audits of local shops and college policy documents. Results The intervention was not delivered as planned at any of the three intervention settings, with no implementation of some community- and college-level components, and low fidelity of the social media component across sites. Staff training reached 28 staff and youth work activities were attended by 190 students across the three sites (< 10% of all eligible staff and students), with low levels of acceptability reported. Implementation was limited by various factors, such as uncertainty about the value of smoking prevention activities in FE colleges, intervention management weaknesses and high turnover of intervention staff. It was feasible to recruit, randomise and retain FE settings. Prevalence of weekly smoking at baseline was 20.6% and was 17.2% at follow-up, with low levels of missing data for all pilot outcomes. Limitations Only 17% of eligible students participated in baseline and follow-up surveys; the representativeness of student and staff focus groups is uncertain. Conclusions In this study, FE settings were not a supportive environment for smoking prevention activities because of their non-interventionist institutional cultures promoting personal responsibility. Weaknesses in intervention management and staff turnover also limited implementation. Managers accept randomisation but methodological work is required to improve student recruitment and retention rates if trials are to be conducted in FE settings. Trial registration Current Controlled Trials ISRCTN19563136. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information. It was also funded by the Big Lottery Fund.

Smoking and Tobacco-Free Policies in Women's Residential Substance Use Disorder Treatment Facilities: A Community-Engaged Approach.

The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment. This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis. There were two themes related to the role of smoking in the women's lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges. Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs. To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Smoking-related outcomes and associations with tobacco-free policy in addiction treatment, 2015–2016

ObjectiveThis study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes. MethodClients in 25 programs were surveyed in 2015 (N=1176) and 2016 (N=1055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016. ResultsThere was one difference across years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=0.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=0.031), mean CPD decreased (10.62v. 8.24, p<0.001) and mean tobacco services received by clients increased (2.08v. 3.05, p<0.001). ConclusionAddiction treatment programs, and agencies responsible for licensing, regulating and funding these programs, should implement tobacco-free grounds policies.

An Experiment Assessing Punitive versus Wellness Framing of a Tobacco-Free Campus Policy on Students' Perceived Level of University Support.

The objective of this study was to examine how different ways of describing a hypothetical tobacco-free campus policy would impact college students’ perceived level of support from the college. In the spring of 2016, we randomized 1885 undergraduate students in a required course to three message conditions in an online survey: control (no message), wellness (emphasizing promoting health and quitting support), and punitive (emphasizing consequences for violating the policy). The dependent variable was perceived organizational support. We selected items previously shown to be relevant for college students (alpha = 0.92 in our data). Given significant non-normality, we used non-parametric Kruskal-Wallis tests with pairwise comparisons to examine differences in perceived organizational support across the three conditions. We examined results by smoking status and if the participant correctly reported the message they received. We found no significant difference in perceived organizational support among students exposed to different tobacco-free campus policy announcements (p = 0.75). We also found no significant difference among smokers (p = 0.66). However, among smokers who correctly reported the message they received, we found significantly lower perceived university support (p = 0.01). Messages about tobacco-free campus policies should focus on the role of policy in supporting a healthy environment instead of punitive enforcement. Campus administrators should use caution when using message frames focusing on consequences of violating newly adopted policies.

Tobacco-free policies at worksites in Kansas

BackgroundThis study sought to examine the relationship between tobacco-free policies at worksites to worksite demographics such as company size and geographic location.MethodsWorksites participating in a worksite wellness workshop were asked to complete a worksite wellness instrument, which provided an assessment of their wellness practices already in place in the worksite, including the degree to which tobacco-free policies were in place at the worksite.ResultsAt a bivariate level, those more likely to have tobacco-free policies included: urban employers (76.8% versus 50% rural employers, p = 0.0001); large employers (> = 250 employees) (74.3% versus 43.1% small employers (<50 employees), p = 0.0003); and schools (69.4%) and hospitals (61.5%) (versus 35.5%, agricultural/ manufacturing employers, p = 0.0125). At the multivariate level, rural employers (AOR = 0.47, 95% CI 0.23, 0.95) and small employers (AOR = 0.34, 95% CI 0.16, 0.71) had decreased odds, compared to their urban and large employer counterparts, of having tobacco-free policies.ConclusionsRural and smaller employers are less likely to have tobacco-free policies than their urban and large counterparts.

Transitioning to 100% Tobacco-Free: Perspectives from a Jesuit University

Aim: The purpose of this study is to examine the current social climate around tobacco at a Jesuit University and begin implementation procedures to transition the campus to a 100% tobacco free environment in a manner consistent with Jesuit and personal values.Background: Smoke-free campus policies are shown to be successful in reducing the amount of smoking and exposure to second-hand smoke. A comprehensive policy which includes traditional cigarettes, e-cigarettes, smokeless products, and hookah is recommended to eliminate the cultural acceptance of all tobacco products.Methods: A web-based survey was conducted following feedback from student led focus groups.Results: The majority of students (71%) agreed or strongly agreed with a transition to a tobacco-free policy with only 18% of the participants reporting negative feelings towards the policy change. Slightly more than half of the sample (53%) reported having a knowledge deficit related to available smoking cessation resources.Conclusions: There is an important balance between individual freedoms and upholding core Jesuit values in caring for the whole person. When implementing a new tobacco-policy, the current social climate, educational and cessation resources, and policy enforcement should be considered.

Tobacco-Free Policy Compliance Behaviors among College Students: A Theory of Planned Behavior Perspective

The purpose of this study was to examine the theory of planned behavior (TPB) as a framework for understanding tobacco-free policy compliance behaviors. Undergraduate student smokers (n = 479) on a college campus with a tobacco-free policy were randomly selected to report their tobacco-free compliance behaviors and respond to TPB items. A path analysis found all constructs of the TPB model to be significantly related to tobacco-free policy compliance behaviors. The results obtained from this study fill gaps in the mostly atheoretical literature regarding our understanding of tobacco-free policy compliance behaviors as well as extend our knowledge of the TPB. Implications for this study provide recommendations for universities, health organizations, and government agencies currently attempting to enforce compliance with a tobacco-free policy.

Implementation of a tobacco-free workplace program at a local mental health authority.

Tobacco-free workplace policies that incorporate evidence-based practices can increase the reach and effectiveness of tobacco dependence treatment among underserved populations but may be underutilized due to limited knowledge about implementation processes. This paper describes the implementation of a comprehensive tobacco-free workplace program at a behavioral healthcare community center in Texas. The center participated in a tobacco-free workplace program implementation project that provided guidance and resources and allowed center autonomy in implementation. Six employee-based subcommittees guided implementation of program components including consumer and staff surveys, policy development, signage, tobacco use assessments, communication, and nicotine replacement distribution. Timeline development, successes, challenges, lessons learned, and sustainability initiatives are delineated. Concerns about the tobacco-free workplace policy from the center's staff and consumers were gradually replaced by strong support for the initiative. Program success was enabled by consistent support from the center's leadership, publicity of program efforts, and educational campaigns. The center surpassed the program expectations when it adopted a tobacco-free hiring policy, which was not an initial program goal. This center's path to a tobacco-free workplace provides an implementation and sustainability model for other behavioral health community centers and other organizations to become tobacco free.

Consequences of Inconsistency in Air Force Tobacco Control Policy.

Although the United States Air Force (USAF) has been a leader in efforts to reduce tobacco use among service members, tobacco continues to be a problem and initiatives to decrease tobacco use further require buy-in from leadership. We explored line leaderships' perspectives on tobacco. A diverse group of 10 senior commissioned and 10 non-commissioned personnel were interviewed. Respondents reported substantial changes in the culture of tobacco use during their years of service, from near ubiquity to restricted use areas. They also perceived mixed messages coming from the USAF, including simultaneous discouragement of and accommodations for tobacco use, and variability in policies and enforcement. Many respondents indicated that allowing tobacco use creates conflict and undermines military discipline and suggested that a tobacco-free policy would be the best way to eliminate these contradictions. Although there has been substantial movement away from a culture of tobacco in the USAF, current policies and variable enforcement of these policies create unnecessary contradictions. Establishing a tobacco-free service would resolve these issues in addition to improving the health of service members and veterans.

Smoking behavior among third year dental students in Latin American countries: prevalence, perceptions, and risk factors.

To examine the association between tobacco-related risk factors and smoking among third-year dental students in Latin American countries. Logistic regression models were used to analyze Global Health Professions Student Survey (GHPSS) data. Of 5 605 respondents, 33% smoked and 45% had been exposed to secondhand smoke during the previous month, 34% smoked in school buildings during the past year, and 85% had never received formal training in smoking cessation. Smoking was significantly associated with male sex; Bolivian, Chilean, or Mexican nationality; exposure to secondhand smoke; lacking self-perception of being a "role model" for patients; and not believing that health professionals who smoke are less likely to advise patients to quit smoking. All dental schools should encourage tobacco-free policies and offer cessation services. Cessation training must be incorporated into dental curricula to include dental professionals in the battle against the tobacco epidemic.

Tobacco‐free policy in MH hospital reduces patient agitation

Mental Health WeeklyVolume 27, Issue 11 p. 3-4 Articles Tobacco-free policy in MH hospital reduces patient agitation Valerie A. Canady, Valerie A. CanadySearch for more papers by this author Valerie A. Canady, Valerie A. CanadySearch for more papers by this author First published: 20 March 2017 https://doi.org/10.1002/mhw.30966Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume27, Issue1113 March 2017Pages 3-4 RelatedInformation

Addressing Tobacco Use Among Consumers and Staff at Behavioral Health Treatment Facilities Through Comprehensive Workplace Programming.

Tobacco use is the leading cause of death and disability in the United States; cigarette smoking is the most common form of tobacco use. Smoking has become increasingly concentrated among individuals with behavioral health needs (e.g., persistent mental illness) and has led to increased morbidity and mortality in this group relative to the general population. Comprehensive tobacco-free workplace programs are effective in reducing tobacco use and cigarette smoke exposure among behavioral health consumers and the individuals who serve them. Taking Texas Tobacco-Free (TTTF) represents an academic-community partnership formed to address tobacco use among consumers and employees at behavioral health clinics across Texas via the dissemination of an evidence-based, multicomponent tobacco-free workplace program. Program components of TTTF include tobacco-free campus policy implementation and enforcement, staff education about tobacco use hazards, provider training to regularly screen for and address tobacco dependence via intervention, and community outreach. These components, the nature of the academic-community partnership, the process of behavioral health facility involvement and engagement, and the benefits and challenges of implementation from the perspectives of the project team and participating clinic leaders are described. This information can guide similar academic and community partnerships and inform the implementation of other statewide tobacco-free workplace programming.

Becoming tobacco-free: Changes in staff and patient attitudes and incident reports in a large academic mental health and addictions hospital.

Complete tobacco bans in mental health facilities are thought to have the potential for adverse consequences. We evaluated staff and patient attitudes and adverse events associated with implementing Canada's largest, multi-site academic psychiatric hospital tobacco ban. A total of 1,173 staff and 422 patients completed an anonymous attitudes survey at prior to implementation (baseline), and 4-6 months and 10-12 months post-implementation. The tobacco-free initiative was implemented in a phased approach, allowing the prospective measurement of changes in attitudes and adverse outcomes such as agitation over a 1-year period. We observed positive changes in staff and patient attitudes toward the tobacco-free policy for both staff and patients. Moreover, there was also a statistically significant decrease in patient agitation F (2, 99) = 3.25, p = .04, but no change F (2, 21) = 1.09, p = .35 in fire-related incidents. We observed positive changes in staff and patients attitudes and significant decrease in patient agitation during the first year of this tobacco-free hospital initiative. During the first year of this tobacco-free psychiatric hospital policy, implementation of a tobacco-free environment in a large mental health and addictions setting was feasible and perceived as desirable by the majority of staff and patients surveyed and a decrease in incidents related to patient agitation was also observed. Further well-controlled studies with longer study durations are warranted. (Am J Addict 2017;26:183-191).

Using the Theory of Planned Behavior to Guide Focus Group Development of Messages Aimed at Increasing Compliance With a Tobacco-Free Policy.

This study details the persuasive message development for a theory-based campaign designed to increase compliance with a university's tobacco-free policy. The theory of planned behavior (TPB) guided message design and evaluation for focus group-tested messages that were adapted to the context of complying with a tobacco-free policy. The study was conducted at a university located in the tobacco belt. Undergraduate focus group participants (n = 65) were mostly male (69%), white (82%), and freshman (62%) who smoked at least 1 cigarette in the last 30 days; on-campus smoking percentages were never/rare (60%), occasionally (23%), and often/frequently (16%). Data analysis used a theoretical thematic approach to identify how the TPB constructs related to perceptions of message effectiveness. Participants responded favorably to attitudinal strategies about health, respect, and university figures; they rejected approaches they considered juvenile and offensive. They also discussed the impact of noncompliance and avoiding overgeneralized statements for addressing subjective norms, suggesting shortening text, adjusting picture location, and emphasizing the importance of compliance to increase perceptions of behavioral control. Applying theory to preexisting messages is challenging. The design approach in this study is an evidence-based strategy that can be used as a universal process for message adaptation. Results offer health promotion suggestions for designing messages aimed at improving undergraduate smokers' willingness to comply with tobacco-free campus policies.

Tobacco-Free Policy Outcomes for an Inpatient Substance Abuse Treatment Center

We assessed changes in patient census, smoking prevalence, and intention to remain abstinent associated with the voluntary enactment of a campus-wide tobacco-free policy in a for-profit residential addictions treatment center. Employing nationally recognized tobacco-free policy strategies, steps toward implementation were tailored to addictions treatment settings. Census data and survey of client tobacco use data were collected for 1 year before the policy began and for 1 year following the policy. Average daily census increased for both the inpatient and extended residential treatment programs after enactment of the tobacco-free policy. Number of tobacco users admitted to treatment increased significantly, while the number of tobacco users who left treatment early did not significantly change. In addition to reducing smoking, the policy was associated with a significant increase of patients reporting the intention to remain abstinent after discharge. Contrary to common concern, a tobacco-free policy implemented in an inpatient residential addictions treatment setting did not negatively affect census rates. This study suggests potential clinical and organizational benefits for campus-wide tobacco-free policies.