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B
Clean Air Laws

Diana Bonta

Kaiser Permanente

INTRODUCTION

In 1992, the Environmental Protection Agency (EPA) released a report that concluded that secondhand smoke (also called environmental tobacco smoke [ETS]) causes lung cancer in adult nonsmokers and impairs the respiratory health of children (EPA 1992). Furthermore, this EPA report classified secondhand smoke as a Group A carcinogen. Secondhand smoke has been shown in studies to cause cancer at typical environmental levels.

For more than three decades, federal, state, and local regulations and ordinances have created an increasing number of smoke-free environments. Smoking has been eliminated or restricted at many worksites, restaurants and bars, childcare agencies, and other public places, as well as in airports, on airline flights, and in government offices. The movement toward creating smoke-free environments has been significantly motivated by substantial evidence of the harms of ETS to nonsmokers (NCI 1999). However, the implementation of smoking restrictions to eliminate secondhand smoke exposure not only reduces exposure to nonsmokers of environmental tobacco, but also has proven to be a powerful intervention to enhance cessation and to reduce consumption among smokers (IOM 1998).

This appendix examines evidence of the effectiveness of existing policies that restrict tobacco use on levels of exposure of nonsmokers to ETS and on smoking initiation, consumption, and cessation in the United States. The policy levers currently in use, their outcome measures, and what is known about the effectiveness of these policies are discussed. Additionally, a brief description of the implementation and enforcement of policies is presented. Finally, future trends in the implementation of smoking bans or restrictions are considered.

This section is important because tobacco-use regulations have had a significant impact on tobacco use by limiting the opportunities for smokers to smoke. Regulations have influenced the number of smokers who have quit and decreased the quantity of cigarettes smoked. Additionally, smoking bans have influenced social norms regarding tobacco use, thus influencing the number of individuals who initiate smoking. Finally, tobacco bans decrease the number of individuals involuntarily exposed to secondhand smoke.

CLEAN AIR LAWS

While federal regulations have limited exposure of nonsmokers to ETS by instituting smoking bans on airline flights, in federal buildings, the White House, and childcare facilities that receive federal funds (Brownson 1998), the majority of legislation restricting smoking has occurred at the local and state levels (a current listing of state laws restricting smoking can be accessed on the American Lung Association website at www.slati.lungusa.org). An early leader in tobacco control, Minnesota enacted its Clean Indoor Air Act in 1975, which required the creation of nonsmoking sections at both public and private worksites (Emont et al. 1992; Tsoukalas



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Ending the Tobacco Problem: A Blueprint for the Nation B Clean Air Laws Diana Bonta Kaiser Permanente INTRODUCTION In 1992, the Environmental Protection Agency (EPA) released a report that concluded that secondhand smoke (also called environmental tobacco smoke [ETS]) causes lung cancer in adult nonsmokers and impairs the respiratory health of children (EPA 1992). Furthermore, this EPA report classified secondhand smoke as a Group A carcinogen. Secondhand smoke has been shown in studies to cause cancer at typical environmental levels. For more than three decades, federal, state, and local regulations and ordinances have created an increasing number of smoke-free environments. Smoking has been eliminated or restricted at many worksites, restaurants and bars, childcare agencies, and other public places, as well as in airports, on airline flights, and in government offices. The movement toward creating smoke-free environments has been significantly motivated by substantial evidence of the harms of ETS to nonsmokers (NCI 1999). However, the implementation of smoking restrictions to eliminate secondhand smoke exposure not only reduces exposure to nonsmokers of environmental tobacco, but also has proven to be a powerful intervention to enhance cessation and to reduce consumption among smokers (IOM 1998). This appendix examines evidence of the effectiveness of existing policies that restrict tobacco use on levels of exposure of nonsmokers to ETS and on smoking initiation, consumption, and cessation in the United States. The policy levers currently in use, their outcome measures, and what is known about the effectiveness of these policies are discussed. Additionally, a brief description of the implementation and enforcement of policies is presented. Finally, future trends in the implementation of smoking bans or restrictions are considered. This section is important because tobacco-use regulations have had a significant impact on tobacco use by limiting the opportunities for smokers to smoke. Regulations have influenced the number of smokers who have quit and decreased the quantity of cigarettes smoked. Additionally, smoking bans have influenced social norms regarding tobacco use, thus influencing the number of individuals who initiate smoking. Finally, tobacco bans decrease the number of individuals involuntarily exposed to secondhand smoke. CLEAN AIR LAWS While federal regulations have limited exposure of nonsmokers to ETS by instituting smoking bans on airline flights, in federal buildings, the White House, and childcare facilities that receive federal funds (Brownson 1998), the majority of legislation restricting smoking has occurred at the local and state levels (a current listing of state laws restricting smoking can be accessed on the American Lung Association website at www.slati.lungusa.org). An early leader in tobacco control, Minnesota enacted its Clean Indoor Air Act in 1975, which required the creation of nonsmoking sections at both public and private worksites (Emont et al. 1992; Tsoukalas

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Ending the Tobacco Problem: A Blueprint for the Nation and Glantz 2003). In the same year, 14 other states passed new or amended clean indoor air laws (Emont et al. 1992). As of July 1, 2006, 17 states have laws in effect that require 100 percent smoke-free workplaces and/or restaurants and/or bars (ANRF 2005a). Overall, 6,845 municipalities are covered by state or local laws requiring workplaces and/or restaurants and/or bars, to be 100 percent smoke-free, protecting 44.5 percent of the United States population (ANRF 2005b). Notably, 140 municipalities in the United States require workplaces, restaurants, and bars to be 100 percent smoke-free (ANRF 2005a). Additionally, many sites have voluntarily become smoke-free (Jacobson and Wasserman 1997). A review by Serra and colleagues (2004) of interventions that prevent tobacco smoking in public places found that carefully planned and resourced, multicomponent strategies to implement policies banning smoking effectively reduce smoking in public places (Serra et al. 2004). Not surprisingly, less comprehensive strategies, such as posted warnings and educational material, were less effective. Furthermore, the Centers for Disease Control and Prevention (CDC) Task Force conducted a systematic review of tobacco intervention studies (n = 10) and concluded that smoking bans or limits on tobacco smoking in workplaces and public areas are strongly recommended to reduce exposure to ETS based on the following key findings (CDC 2000b): First, smoking bans and restrictions effectively reduce workplace exposure to ETS in several different settings and populations. Second, following the implementation of smoking bans, decreases in daily tobacco consumption among smokers and increased rates of cessation were identified. More stringent clean indoor air laws are associated with decreased smoking prevalence and cigarette consumption and a higher proportion of quitters. For example, Emont and colleagues (1992) found that the average smoking prevalence was 28 percent in states without clean indoor air laws and 24 percent in states with extensive clean indoor air laws (J * = 3.33, p < .001). Additionally, average cigarette consumption per head was about 119 packets in states without laws and 105 in states with laws (J * = 2.79, p < .005). Finally, the average proportion of quitters in states without laws was 44 percent and in states with laws was 50 percent (J * = 3.96, p < .00005) (Emont et al. 1992). Comprehensive public clean air laws have the potential to reduce prevalence and consumption rates of the entire population (including nonworking and non–indoor-working smokers) by about 10 percent (Levy and Friend 2003). Additionally, clean air regulations may contribute to a changing social norm with regard to smoking by altering the perceived social acceptability of smoking (CDC 2000c). Because of changes in social attitudes and the need to smoke in less hospitable places, smokers may be induced to attempt to quit or not initiate (Levy and Friend 2001a). Workplace Workplace smoking restrictions are likely to have the greatest impact on both ETS and smoking habits because of the number of hours that workers are subject to these restrictions. Worksite bans may include a total prohibition of smoking onsite, less stringent bans that limit smoking to separate ventilated areas, or smoking in designated areas only. A 1994 report by the EPA estimated that the net benefit of a nationwide, comprehensive clean indoor air law would exceed the estimated costs by $39 billion to $72 billion (EPA 1994). Cost savings to employers include an estimate $4 billion to $8 billion annually in operational and maintenance costs of buildings (EPA 1994).

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Ending the Tobacco Problem: A Blueprint for the Nation Research has verified that the institution of smoke-free workplaces effectively reduces nonsmokers’ exposure to ETS (CDC 2000c). Stillman and colleagues (1990) evaluated the effectiveness of efforts to institute a complete institutional ban on smoking in all areas of the Johns Hopkins Medical Institutions in Baltimore (about 8,700 employees) (Stillman et al. 1990). The implementation plan of the ban included health-oriented information campaigns, free screening and smoking cessation treatment, training for managers and supervisors, educational programs, and posted signs. Participants included employees and visitors to the medical institutions. This prospective study found significant reductions in nicotine vapor concentrations in all areas except restrooms. Additionally, the reported consumption of cigarettes by employees who continued to smoke and the total number of cigarettes smoked at work decreased by an average of 25 percent. Finally, significant reductions were noted in the level of smoking observed and the amount of cigarette remnants. Many other studies have also demonstrated the effects of smoking bans on the prevalence and consumption of tobacco. Totally smoke-free workplaces had about twice the effect on consumption and prevalence as policies that allowed smoking in some areas (Farrelly et al. 1999; Fichtenberg and Glantz 2002; Glasgow et al. 1997). Using data from two large, nationally representative samples, Evans and colleagues (1999) concluded that workplace bans reduce smoking prevalence by 5 percent and average daily consumption among smokers by 10 percent (Evans et al. 1999). Farrelly and colleagues (1999) analyzed responses from a total of 97,882 indoor workers who completed supplemental tobacco questionnaires regarding their smoking behavior and the smoking policies at their place of work in a series of national surveys conducted between September 1992 and May 1993. Researchers found that a 100 percent smoke-free workplace reduced smoking prevalence by 5.7 percent and average daily cigarette consumption among smokers by 14 percent relative to workplaces with weak or no smoking restrictions. These results were found to be true for all demographic groups and nearly all industries (Farrelly et al. 1999). A study by Evans and colleagues (1999) also investigated the effects of work area smoking bans on smoking behavior. Data from the 1991 and 1993 National Health Interview Surveys were used to obtain data for more than 18,000 workers. Researchers found that workplace smoking bans are associated with a 5 to 6 percent decline in smoking prevalence and an average reduction in cigarette consumption of 2.3 cigarettes per smoker per day (Evans et al. 1999). Fichtenberg and Glantz (2002) investigated the effects of smoke-free workplaces on smoking prevalence and cigarette consumption. Twenty-six studies on workplaces in the United States, Australia, Canada, and Germany were subjected to a process of systematic review and meta-analysis. Entirely smoke-free workplaces were associated with a 3.8 percent reduction in smoking prevalence and 3.1 fewer cigarettes per day per smoker. The combined effects of reduced prevalence and lower consumption corresponded to a 29 percent relative reduction in tobacco use among all employees. Based on these findings, the authors concluded that if all workplaces became smoke-free, consumption per capita in the entire population would drop by 4.5 percent in the United States (Fichtenberg and Glantz 2002). Levy and Friend (2003) also concluded that studies on private worksite regulations suggest that strong worksite restrictions have the potential to reduce the smoking prevalence rate of the entire population by about 6 percent over the long term and the quantity smoked by continuing smokers by 2 to 8 percent, depending on the length of time after the ban was implemented (Levy and Friend 2003).The authors indicate that the effects appear to erode over time, since those who

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Ending the Tobacco Problem: A Blueprint for the Nation most reduce their quantity may quit and are no longer represented as smokers with reduced quantities smoked. Further, Farkas and colleagues (2000) found that workplace smoking restrictions can significantly reduce smoking rates among young adults. Using data from the Current Population Surveys from 1992–1993 and 1995–1996, researchers surveyed 17,185 adolescents between the ages of 15 and 17. Adolescents who worked in a smoke-free workplace were found to be 68 percent as likely to smoke than adolescents who worked in a workplace with no smoking restrictions (Farkas et al. 2000). Workplace smoking restrictions have demonstrated an effect on the quit rates of smokers as well. Findings from COMMIT, a population-based survey of 8,271 employed adult smokers who completed surveys in 1988 and 1993, found that employees who worked in a smoke-free worksite were over 25 percent more likely to make a serious quit attempt between 1988 and 1993, and over 25 percent more likely to achieve cessation than those who worked in a worksite that permitted smoking. Among continuing smokers, employees in smoke-free worksites consumed an average of 2.75 fewer cigarettes per day than those who worked in places with a nonrestrictive smoking policy (Glasgow et al. 1997). Using data from the 1990 California Tobacco Survey—which collected information about 4,680 adult indoor smokers—Moskowitz and colleagues (2000) investigated the effects of local workplace smoking laws on smoking cessation. The results of the study revealed that smoke-free ordinances significantly increased the rate of smoking cessation and did so along a “dose-response” relationship—the stronger the ordinance, the higher the rate of cessation. While there was only a 19.1 percent cessation rate in areas with no ordinance, there was a 24.6 percent cessation rate in areas with weak ordinances, and a 26.4 percent cessation rate in areas with strong ordinances. Overall, researchers found that smokers who worked in communities with strong ordinances were 38 percent more likely to quit smoking than smokers in communities with no ordinances (Moskowitz et al. 2000). Longo and colleagues (2001) conducted a prospective investigation of the impact of smoking bans on tobacco cessation and relapse. The researchers concluded that employees in workplaces with smoking bans have higher rates of smoking cessation than employees in workplaces where smoking is permitted (however, relapse rates were similar between these two groups). Quit rates were higher and the time it took to quit smoking was shorter among employees with smoking bans (Longo et al. 2001). Hospitals, Medical Campuses, and Nursing Homes In 1992, the Joint Commission on Accreditation of Healthcare Organizations mandated that hospitals must be smoke-free. Many studies have shown the benefit of smoking restrictions on employees (e.g., Stillman et al. 1990). Various studies have also considered the effects of a hospital-wide smoking ban on patients, particularly in the psychiatric unit of hospitals. Researchers consistently concluded that the smoking bans were implemented with minimal or no adverse effects (Rauter et al. 1997; Ryabik et al. 1994; Smith et al. 1999; Thorward and Birnbaum 1989). Additionally, smoking bans were found to have a significant impact on ETS exposure (Rauter et al. 1997). In 1998, the Kaiser Permanente (KP) Northern California Region initiated the multifaceted Tobacco Dependence Program. A critical component of this program—whose goal was to reduce tobacco use among its members—was the establishment of smoke-free campuses. Before 1998, no KP campus was completely smoke-free, whereas 16 campuses had become smoke-free as of

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Ending the Tobacco Problem: A Blueprint for the Nation August 2004. The remaining campuses also restricted smoking to minimal outdoor areas or to a single outdoor shelter. KP also implemented a policy mandating that all KP campuses opening in 2003 and thereafter be smoke-free (Goldstein et al. 2005). According to Bergman (2003), most state laws allow nursing homes some discretion regarding smoking, but require some form of designated smoking area if smoking is permitted. Federal laws also allow smoking in nursing homes, although federal and most state laws permit nursing homes to be totally smoke-free. Bergman also found that, among current policies at nursing homes, 64 percent do not permit any smoking inside while the remaining 36 percent allowing smoking only in designated smoking areas (Bergman 2003). Restaurants and Bars As of July 1, 2006, 15 states had laws requiring 100 percent smoke-free restaurants and 11 states had laws eliminating smoking in bars. Two additional states and the Commonwealth of Puerto Rico have laws enacted, but not yet in effect, that eliminate smoking in restaurants, bars, or both. Additionally, there are 305 municipal ordinances mandating 100 percent smoke-free restaurants and 222 municipal ordinances creating smoke-free bars (ANRF 2005a). Restaurant and bar ordinances reduce exposure of nonsmokers to ETS. For smokers, although the actual number of hours spent in a restaurant or bar is small, eating, drinking, and smoking often are linked activities (Levy and Friend 2001b). Therefore, bans on smoking in restaurants and bars also have the potential to decrease tobacco use among smokers. According to a study by Albers and colleagues (2004), strong local clean indoor air regulations are associated with lower levels of reported exposure to ETS in restaurants and bars. Researchers sampled 6,739 adults in Massachusetts households to examine the association of local restaurant and bar regulations with self-reported exposure to ETS among adults. Compared to adults from towns with no restaurant smoking restrictions, those from towns with strong regulations were more than twice as likely to report no exposure to ETS (Odds Ratio [OR] = 2.74; 95 percent Confidence Interval [CI] = 1.97, 3.80), and those from towns with some restrictions were 1.62 times as likely to report no exposure to ETS (OR = 1.62; 95 percent CI = 1.29, 2.02). Bar smoking bans had even greater effects on exposure (Albers et al. 2004). Eliminating smoking in these environments has been controversial, and the tobacco industry as well as many restaurant and bar proprietors have argued that restrictions on smoking in such establishments would be detrimental to business. However, a review of the literature by Scollo and Lal (2004) concluded that there was “no negative economic impact from the introduction of smoke-free policies in restaurant and bars indicated by 21 studies where findings are based on an objective measure such as taxable sales receipts, where data points several years before and after the introduction of smoke-free policies were examined, where changes in economic conditions are appropriately controlled for, and where appropriate statistical tests are used to control for underlying trends and fluctuations in data” (Scollo and Lal 2004). For example, Glantz and Smith (1997) compiled sales tax data for 15 cities with smoke-free restaurant ordinances as well as 5 cities and 2 counties with smoke-free bar ordinances, and matched comparison locations. Data were analyzed by multiple regression, including time and a dummy variable for the ordinance. The results indicated that the ordinances did not adversely affect either restaurant or bar sales (Glantz and Smith 1997). Scollo and Lal (2004) further indicate that studies concluding a negative economic impact have based findings primarily on outcomes predicted before the introduction of policies. on subjective impression or estimates of changes rather than actual, objective, verified, or audited data

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Ending the Tobacco Problem: A Blueprint for the Nation (Scollo and Lal 2004). Additionally, these studies were funded predominantly by the tobacco industry or organizations allied with the tobacco industry. Schools, Colleges, and Commercial Day Care Centers By 1993, all schools had classrooms bans through federal and state laws (Levy et al. 2001). Almost two-thirds of schools (62.8 percent) had smoke-free building policies in 1994, but fewer (36.5 percent) reported such policies that included the entire school environment (CDC 2000c). Wakefield and colleagues (2000) conducted a cross-sectional survey of 17,287 high school students to study the effects of restrictions on smoking—at home, at school, and in public places—on teenage smoking. Researchers found that the existence of a school ban was not associated with a reduction in smoking uptake (interestingly, it was associated with an increase in the likelihood of transition from an advanced experimenter to established smoker); however, enforced school bans were associated with 11 percent reductions in uptake of smoking across all stages of uptake (p < .05) (CDC 2000c; Wakefield et al. 2000). As of July 1, 2006, 29 colleges and universities in the United States had smoke-free policies for the entire campus, both indoors and out (ANRF 2004). More than 225 additional colleges and universities had smoke-free policies for all residential housing. Using a nationally representative sample of approximately 15,699 respondents to the 1997 Harvard School of Public Health College Alcohol Study, Czart and colleagues (2001) found that complete smoking bans on college campuses are associated with decreased consumption among current smokers but have no significant impact on smoking prevalence (Czart et al. 2001). As of December 31, 2005, 17 states had laws preventing smoking or requiring separate ventilation at commercial daycare centers, 13 states did not allow smoking when children are on premises, and 6 states required or allowed a designated smoking area. Thirteen states had no restrictions (CDC 2005). Airlines and Airports As early as 1970, the Federal Aviation Administration (FAA) initiated an in-depth study to determine to what extent tobacco smoke was harmful to nonsmokers. In May 1973, the Civil Aeronautics Board required airlines to provide separate sections for smokers and nonsmokers for reasons of consumer comfort and protection. In August 1986, the National Academy of Sciences issued a report on airliner cabin air quality and related safety issues, which recommended a smoking ban on all domestic commercial flights. The authors cited four major reasons for the recommendation: (1) to lessen discomfort of passengers and crew, (2) to reduce potential health hazards to cabin crewmembers from environmental tobacco smoke, (3) to eliminate possible fires, and (4) to align cabin air quality with standards for other closed environments. Effective April 23, 1988, the FAA placed a 2-year ban on smoking on all domestic scheduled airline flights of 2 hours or less, and on February 25, 1990, prohibition of smoking went into effect on virtually all scheduled U.S. domestic airline flights. In 2000, the U.S. Department of Transportation banned smoking on all U.S. international flights. A cross-sectional telephone survey of personnel at primary commercial-service airports found that only 61.9 percent of airports reported being smoke-free in 2002 and that larger airports, which account for the majority of passenger boardings, were less likely than smaller airports to have a smoke-free policy. The researchers concluded that increased adoption and enforcement of smoke-free policies were needed to protect the health of workers and travelers at U.S. airports (CDC 2004).

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Ending the Tobacco Problem: A Blueprint for the Nation Prison Restrictions According to a 2002 survey conducted by the American Correctional Association, at least 38 of 50 state correctional departments reported that they either are smoke-free or have partial smoking bans. Recent additions to that list includes California, whose governor signed a bill to amend the state’s penal code to bar tobacco products from prisons and youth correctional facilities, effective July 1, 2005. In addition, on July 15, 2004, the Federal Bureau of Prisons instituted a policy establishing a near-total ban on smoking for both employees and inmates at 105 prisons. Other Public Places A leader in tobacco control, California has the nation’s longest running comprehensive anti-tobacco program, a significant element of which is workplace bans. In November 1988, Proposition 99, the landmark Tobacco Tax and Health Protection Act, was approved by California voters and instituted a 25-cent tax on cigarettes and earmarked 5 cents of every cigarette pack sold to fund the California Tobacco Control Program. California's smoke-free workplace law took effect in 1995. A recent California Department of Health and Human Services report indicates that the state’s smoke-free workplace law has had a major impact on smoking behavior and cessation efforts, and that the majority of Californians support the law. According to the 2004 Field Poll (CDHS 2005), 58 percent of smokers who quit in the past 10 years said that having smoke-free public places made it easier for them to quit smoking. 69 percent of current smokers who attempted to quit in the past 10 years said that smoke-free public places helped them reduce the number of cigarettes they smoke. Additionally 90 percent of Californians surveyed, including the majority of smokers, said they approve of the smoke-free workplace law. A study by Burns (2002) also indicates that California has higher rates of cessation activity and cessation success compared to other states (Burns 2002). Perhaps reflective of the strong support for smoke-free environments, many local communities within the state have recently enacted strong restrictions on smoking. In November 2003, Solana Beach in California became the first municipality in the United States to institute a local ordinance banning cigarette smoking on the beach. Since this time, several additional California cities have also implemented bans. The impetus for these ordinances was not only to reduce the amount of ETS to which nonsmokers are exposed, but also to decrease litter and reduce chemical leaching from cigarette butts. Effective January 1, 2004, Californians were further protected from ETS by Assembly Bill 846, which expanded smoke-free zones around public buildings. The bill prohibits smoking within 20 feet of main entrances, exits, and operable windows of all city, county, and state buildings as well as buildings on the campuses of the University of California system, California state universities, and community colleges (California Legislature 2004). Legislators in San Francisco city voted to ban smoking in public parks on January 25, 2005. California state law currently prohibits smoking or disposing of any tobacco-related products within 25 feet of a playground or tot lot sandbox area. Eleven other cities in California had previously enacted additional restrictions on outdoor smoking. However, San Francisco’s smoking ban is a “curb-to-curb” prohibition of smoking in city parks, plazas, piers, gardens, and recreational fields, making San Francisco the first county in the state with such an expansive ban (Van de Water 2004).

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Ending the Tobacco Problem: A Blueprint for the Nation Household Bans Established by at least one individual in a home, household smoking restrictions have repeatedly been found to be effective at influencing smoking levels of individuals. Using data from three current population surveys with a supplement on tobacco use, Farkas and colleagues (1999) considered the effects of household and workplace smoking restrictions on quitting behaviors. Smokers who lived or worked under a total smoking ban were more likely to report a quit attempt in the previous year. Among those who made an attempt, those who lived or worked under a total smoking ban were more likely to be in cessation for at least 6 months. Current daily smokers who lived or worked under a total smoking ban were more likely to be light smokers. Household bans are even more effective than workplace bans (Farkas et al. 1999). Farkas and colleagues (2000) also found that household smoking restrictions were found to significantly reduce adolescent cigarette consumption. Adolescents who lived in households with smoking restrictions were 26 percent less likely to be smokers than adolescents who lived in households with no smoking restrictions. Household smoking restrictions also had positive effects on cessation rates—adolescents were1.80 times more likely to be former smokers if they lived in smoke-free homes (95 percent CI, 1.23, 2.65) (Farkas et al. 2000). Smoke-free homes have a greater association with lower rates of smoking prevalence than smoke-free workplaces do and are associated with an increased likelihood of smoking cessation by adolescent smokers. Adoption of a smoke-free home policy sends a message to family members that smoking is not condoned, while the lack of such a policy may send the opposite message. Wakefield and colleagues (2000) found that more restrictive arrangements on smoking at home were associated with a greater likelihood of being in an earlier stage of smoking uptake (p < .05) and a lower 30-day prevalence (OR = 0.79; 95 percent CI = 0.67, 0.91, p < .001) (Wakefield et al. 2000). IMPLEMENTATION AND ENFORCEMENT Compliance with both voluntary restrictions and regulations on smoking in public places varies substantially. Compliance is high where changes have occurred through a combination of legislation and changes in public attitudes. Success of bans and their effect on smoking is dependent on efforts to increase compliance. For effective implementation, strict bans may require publicity and enforcement in areas without strong antismoking norms. Secondhand smoke issues may mobilize political support for other programs, but there may likely be opposition from the tobacco industry and some other businesses (Levy et al. 2004). The enforcement of smoking bans relates to potential sanctions included in state legislation or local ordinances, such as license removal, fines, or other penalties resulting from specific law enforcement activity. A review of implementation and enforcement of state clean indoor air laws concluded that the laws are typically self-enforcing and are not systematically enforced by state or local authorities (Jacobson and Wasserman 1997). People voluntarily comply with the law in the absence of proactive enforcement. Nevertheless, greater government enforcement and media publicity may increase compliance with the law (Levy and Friend 2001a). SUMMARY Clean air laws effectively reduce exposure to ETS. Additionally, the more stringent the policy, the greater the impact on decreasing smoking prevalence, decreasing consumption, and en-

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Ending the Tobacco Problem: A Blueprint for the Nation hancing cessation. Furthermore, smoking restrictions may positively influence social norms by decreasing the number of people observed smoking and decreasing opportunities to smoke. State and local governments continue to expand regulations limiting smoking. In 2006, both Arkansas and Louisiana enacted legislation that prohibits smoking in all motor vehicles in which a child is restrained in a child passenger safety seat (Arkansas Legislative Information 2006; Louisiana Legislative Information 2006). Similar legislation is being considered in both California and New York. In March 2006, Calabasas, California, a small Los Angeles suburb, implemented a Comprehensive Secondhand Smoke Control Ordinance to limit public exposure to secondhand smoke in both indoor and outdoor public areas within the city. The law prohibits smoking in “all public places in the City of Calabasas where other persons can be exposed to second-hand smoke.” Places where smoking is prohibited include indoor and outdoor businesses, hotels, parks, apartment common areas, restaurants and bars where people can be “reasonably expected to congregate or meet”(City of Calabasas, California 2006). Given the success of home smoking bans at decreasing smoking consumption and initiation, and increasing quit rates, an important area to consider for new public policy is the role of government in supporting the institution of home smoking bans. For example, some hospitals voluntarily distribute information to new parents on the health effects of secondhand smoke on children and the importance of establishing a smoke-free home. Perhaps a state or local government could approve legislation, requiring that all hospitals provide this information and ask parents to sign a pledge to establish a smoke-free home. McMillen and colleagues (2003) found that the majority of adults, both smokers and nonsmokers, support smoking bans in a wide variety of places (McMillen et al. 2003). Ultimately, most studies have concluded that even among smokers, support for smoking restrictions and smoke-free environments is high (CDC 2000a).

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