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Smoke-Free Ordinances and Policies Protect Youth, but Ordinances Appear to Have Little Impact on Non-Combustible Tobacco Use

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Smoke-free ordinances and policies protect youth from exposure to secondhand smoke (SHS) and cigarette use. This study investigated whether smoke-free ordinances also protect youth from the use of other tobacco products. We compared the prevalence of SHS exposure, cigarette smoking, cigar smoking, smokeless tobacco use, and e-cigarette use among high school students living in a municipality with or without a smoke-free ordinance and in homes with and without smoke-free policies. Data were analyzed using the 2017 Mississippi Youth Tobacco Survey (n = 1923). Smoke-free ordinances were found to be associated with lower prevalence of SHS exposure (41.9% vs. 51.5%), cigarette smoking (5.1% vs. 11.4%), and cigar smoking (7.2% vs. 10.9%). There were no differences in smokeless tobacco use (6.6% vs. 6.5%) or e-cigarette use (11.2% vs 12.1%). Smoke-free homes were associated with lower prevalence of SHS exposure (38.0% vs 74.6%), cigarette smoking (4.8% vs. 17.6%), cigar smoking (6.4% vs. 16.4%), smokeless tobacco use (4.9% vs. 13.2%), and e-cigarette use (9.6% vs. 19.5%), p < 0.05 for all comparisons. The results suggest that smoke-free ordinances and policies protect against exposure to tobacco smoke and use of combustible tobacco products, but smoke-free ordinances do not protect from smokeless tobacco and e-cigarette use. Tobacco-free, rather than smoke-free, ordinances might offer more protection.
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Article
Smoke-Free Ordinances and Policies Protect Youth,
but Ordinances Appear to Have Little Impact on
Non-Combustible Tobacco Use
Nell Valentine 1, Emily McClelland 1and Robert McMillen 1, 2, *
1Mississippi State University, Mississippi State, MS 39759, USA; nell.valentine@ssrc.msstate.edu (N.V.);
emily.mcclelland@ssrc.msstate.edu (E.M.)
2
American Academy of Pediatrics Julius B. Richmond Center of Excellence, Elk Grove Village, IL 60143, USA
*Correspondence: robert.mcmillen@ssrc.msstate.edu; Tel.: +01-662-325-2742
Received: 18 January 2019; Accepted: 7 March 2019; Published: 11 March 2019


Abstract:
Smoke-free ordinances and policies protect youth from exposure to secondhand smoke
(SHS) and cigarette use. This study investigated whether smoke-free ordinances also protect youth
from the use of other tobacco products. We compared the prevalence of SHS exposure, cigarette
smoking, cigar smoking, smokeless tobacco use, and e-cigarette use among high school students
living in a municipality with or without a smoke-free ordinance and in homes with and without
smoke-free policies. Data were analyzed using the 2017 Mississippi Youth Tobacco Survey (n= 1923).
Smoke-free ordinances were found to be associated with lower prevalence of SHS exposure (41.9%
vs. 51.5%), cigarette smoking (5.1% vs. 11.4%), and cigar smoking (7.2% vs. 10.9%). There were no
differences in smokeless tobacco use (6.6% vs. 6.5%) or e-cigarette use (11.2% vs 12.1%). Smoke-free
homes were associated with lower prevalence of SHS exposure (38.0% vs 74.6%), cigarette smoking
(4.8% vs. 17.6%), cigar smoking (6.4% vs. 16.4%), smokeless tobacco use (4.9% vs. 13.2%), and
e-cigarette use (9.6% vs. 19.5%), p< 0.05 for all comparisons. The results suggest that smoke-free
ordinances and policies protect against exposure to tobacco smoke and use of combustible tobacco
products, but smoke-free ordinances do not protect from smokeless tobacco and e-cigarette use.
Tobacco-free, rather than smoke-free, ordinances might offer more protection.
Keywords: smoke-free; tobacco; youth; prevalence; combustible tobacco products; e-cigarette
1. Introduction
Tobacco is the leading cause of preventable death in the United States [
1
]. Although most of the
mortality attributable to tobacco occurs among adults, children’s passive tobacco smoke exposure
harms their health during childhood and adulthood. These harms include higher rates of sudden
infant death syndrome, asthma prevalence and severity, lower respiratory infections, otitis media, and
lung cancer as adults, as well as deleterious effects on behavior and cognition [25].
In recognition of these harms, 25 states, and the District of Columbia, have implemented statewide
smoke-free legislation for indoor public places, including restaurants, bars, and workplaces [
6
]. In
private domains, more than eight in ten U.S. households do not allow anyone to smoke inside the
home [
7
]. These restrictions were initially enacted to protect nonsmokers from the harms of secondhand
smoke (SHS) exposure. Subsequent research illustrated another impact, these restrictions were also
found to be associated with decreased prevalence of cigarette smoking, established smoking, and
lower daily cigarette consumption [824].
Restrictions on smoking appear to reduce smoking via two routes. First, smoke-free policies
interrupt and inconvenience smoking behaviors. Following the implementation of smoke-free policies,
Children 2019,6, 44; doi:10.3390/children6030044 www.mdpi.com/journal/children
Children 2019,6, 44 2 of 8
smokers may quit or reduce consumption due to the inconvenience of leaving a venue in order to
go to a place where smoking is permitted [
16
,
19
]. Second, smoke-free policies influence the social
climate impacting decisions about smoking. Restrictions that limit cigarette smoking and emphasize
the rights of nonsmokers may also change societal and community norms to be more unfavorable
towards smoking behaviors [2528].
Smoke-free local ordinances [
10
] and household policies [
29
31
] protect youth from exposure
to tobacco smoke and cigarette use. This study investigated whether they were also protected from
the use of other tobacco products. We compared the prevalence of cigarette smoking, cigar smoking,
smokeless tobacco (SLT) use, and e-cigarette use among Mississippi high school students living in
a municipality with or without a smoke-free ordinance; and in homes with and without smoke-free
policies. Overall, the use of these tobacco/nicotine products in Mississippi youth were found to be
similar. There was a statistical difference in past 30-day prevalence of cigarette smoking (7.2%), cigar
smoking (8.4%), smokeless tobacco (6.6%), and e-cigarette use (11.5%) [
32
]. This study investigated
how smoke-free ordinances and policies impact the use of each of these products.
2. Materials and Methods
2.1. Design
Data from the 2017 Mississippi Youth Tobacco Survey (YTS) were used in this study. The Center
for Disease Control’s Office on Smoking and Health developed the methodology and the core content
of the Mississippi Youth Tobacco Survey. The authors developed the supplemental survey items.
The Mississippi YTS was administered to public high school students in the fall of 2017 (n= 1923).
All regular public schools in Mississippi containing at least one grade between 9th and 12th were
included in the sampling frame obtained from the Mississippi State Department of Education. The
Research Triangle Institute (RTI) applied a dual-stage cluster sample design to produce a representative
sample of students. In the first stage, public high schools were selected with a probability proportional
to the enrollment size. In the second stage, classrooms were chosen based on systematic equal
probability sampling within each school and all students in selected classes were eligible to participate.
Each participating school received student surveys, an administration guide, pencils, and parental
waiver of consent forms. Teachers administered the anonymous surveys to students during class time.
The Institutional Review Board for the Protection of Human Subjects in Research (IRB) at Mississippi
State University approved the current study; Approval number 16-176.
2.2. Sample Processing and Weights
All completed surveys were sent to RTI for processing and weighting of data. A weighting factor
was applied to each student record to adjust for non-response at the school, class, and student
level. Weight = W1×W2×f1×f2×f3×f4
W1= inverse of the probability of selecting the school
W2= inverse of the probability of selecting the classroom within the school
f
1
= a school-level non-response adjustment factor calculated by school size (small, medium, large)
f2= a class adjustment factor calculated by school
f3= a student-level non-response adjustment factor calculated by class
f4= a post stratification adjustment factor calculated by gender and grade
2.3. Measures
2.3.1. Smoke-Free Ordinances and Household Rules
Although Mississippi has not enacted a statewide smoke-free ordinance, 151 municipalities had
implemented local smoke-free ordinances at the time of data collection. Mississippi Tobacco Data
provides a summary of Mississippi municipalities with smoke-free ordinances [
33
]. Students who
Children 2019,6, 44 3 of 8
attended high school in a municipality with a smoke-free ordinance were compared to those whose
high school was not in a municipality with a smoke-free ordinance in the fall of 2017.
Students were asked, “Inside your home (not including decks, garages, or porches) is smoking
always allowed, allowed only at certain times or in some places, or never allowed”? Those who
reported “never allowed” were considered to live in a smoke-free home.
2.3.2. Demographic Characteristics and Covariates
Students self-reported gender, age, grade in school, and race. Three categories for race were
applied: white, African-American, and other. Students also responded to “Does anyone who lives
with you now smoke cigarettes?” Those who reported yes were categorized as living with a smoker.
We included this variable as a covariate, given that prior research illustrated that living with a smoker
was a strong predictor of youth smoking initiation and past 30-day use [34].
2.3.3. Secondhand Smoke Exposure and Tobacco Use
Students were asked, “In the past 7 days, did someone smoke tobacco products in your home
while you were there?”, “did you ride in a vehicle where someone was smoking?”, “did you breathe
the smoke from someone who was smoking tobacco in an indoor public place?”, “did you breathe in
the smoke from someone who was smoking tobacco in the place where you work?”, and “did you
breathe the smoke from someone who was smoking tobacco at your school?” Students who reported
yes to any of these questions were considered to have past 7-day exposure to tobacco smoke.
Students were asked, “During the past 30 days, on how many days did you smoke cigarettes?”,
“did you smoke cigars, cigarillos, or little cigars?”, “did you use chewing tobacco, snuff, or dip”, and
“did you use e-cigarettes?” Students who did not report 0 days, were considered to be a past 30-day
user of that product.
2.4. Statistical Analyses
Statistical analyses were conducted using SPSS 22.0 with complex sampling procedures.
Chi-square analyses compared past 7-day exposure to SHS and past 30-day tobacco use among
students who lived in municipalities with a smoke-free ordinance and those that did not as well as
those who lived in homes with and without smoke-free policies. Logistic regression models examined
the relationship of SHS exposure and tobacco use with both smoke-free polices in multivariable
analyses, adjusting for living with a smoker, gender, race, and grade.
3. Results
3.1. Response Rate
Among the schools sampled, 42 out of 50 schools participated (84.0%). Among students in the
classes sampled, 1923 of 2174 students completed usable surveys (88.5%). The final response rate
was 74.3%.
3.2. Sample Characteristics
Unweighted and weighted sample characteristics are presented in Table 1. The sample comprised
of an almost equal number of males and females. Sample weights adjusted for under-representation of
11th graders and African-Americans. Approximately two-thirds of students attended a high school in
a municipality with a smoke-free ordinance, 80%of students lived in a home where smoking was not
allowed, and slightly less than half reported past 7-day exposure to secondhand smoke. Fewer than
one in 10 students reported past 30-day use of cigarettes, cigars, or smokeless tobacco; whereas more
than 10% reported past 30-day e-cigarette use.
Children 2019,6, 44 4 of 8
Table 1. Sample characteristics.
Characteristic Unweighted Sample
Size Unweighted Percent Weighted Percent
Gender: Male 967 50.90% 49.80%
Female 934 49.10% 50.20%
Age: 13 11 0.60% 0.50%
14 481 25.00% 19.40%
15 510 26.50% 26.90%
16 323 16.80% 22.80%
17 455 23.70% 24.10%
18 116 6.00% 5.60%
19+ 10 0.50% 0.40%
Grade: 9th 685 35.90% 27.20%
10th 436 22.80% 25.80%
11th 298 15.60% 24.00%
12th 491 25.70% 23.00%
Race: White 976 51.60% 41.80%
AA 715 37.80% 48.70%
Other 200 10.60% 9.50%
Past 7-day SHS exposure:
Yes 880 47.30% 45.20%
No 982 52.70% 54.80%
Past 30-day cigarette use:
Yes 146 8.10% 7.20%
No 1664 91.90% 92.80%
Past 30-day cigar use:
Yes 163 8.70% 8.40%
No 1704 91.30% 91.60%
Past 30-day SLT use: Yes 139 7.50% 6.60%
No 1721 92.50% 93.40%
Past 30-day e-cigarette
use: Yes 237 12.70% 11.50%
No 1629 87.30% 88.50%
Smoke-free ordinance:
Yes 1256 65.30% 66.40%
No 667 34.70% 33.60%
Home is smoke-free: Yes 1473 80.00% 80.70%
No 368 20.00% 19.30%
Smoker in the home: Yes 583 30.30% 29.20%
No 1340 69.70% 70.80%
3.3. Relationship of Smoke-Free Ordinances and Policies with Secondhand Smoke Exposure and Tobacco Use
Youth who lived in municipalities with smoke-free ordinances were less likely to report any
past 7-day exposure to second tobacco smoke than those who did not; and were also less likely to
report past 30-day cigarette smoking and cigar smoking (see Table 2). However, no association with
smoke-free ordinances and non-combustible tobacco use was detected. Youth were equally likely to
report past 30-day SLT and e-cigarette use.
Table 2. SHS exposure and tobacco use by smoke-free ordinance status.
Outcome Smoke-Free Ordinance No Ordinance p
Past 7-Day SHS Exposure 41.90% 51.50% 0.04
Past 30-Day Cigarette Use 5.10% 11.40% 0.003
Past 30-Day Cigar Use 7.20% 10.90% 0.04
Past 30-Day SLT Use 6.60% 6.50% ns
Past 30-Day E-Cigarette Use 11.20% 12.10% ns
Children 2019,6, 44 5 of 8
Youth who lived in homes with smoke-free policies were less likely to report any past 7-day
exposure to secondhand tobacco smoke than those who did not; and were also less likely to report
past 30-day use of both combustible and non-combustible tobacco products (see Table 3).
Table 3. SHS exposure and tobacco use by smoke-free home status.
Outcome Home is
Smoke-Free
Home is Not
Smoke-Free p
Past 7-Day SHS Exposure 38.00% 74.60% <0.001
Past 30-Day Cigarette Use 4.80% 17.60% <0.001
Past 30-Day Cigar Use 6.40% 16.40% <0.001
Past 30-Day SLT Use 4.90% 13.20% <0.001
Past 30-Day E-Cigarette Use 9.60% 19.50% <0.001
Although both local smoke-free ordinances and household policies influenced SHS exposure
and at least some forms of tobacco use, household policies appear to have a greater impact than
local ordinances in multivariable analyses (see Table 4). In logistic regression models including local
ordinances and household policies, as well as gender, race, and grade; youth who did not live in
smoke-free homes were more likely to be exposed to SHS and use tobacco products than those who
lived in smoke-free homes. Local smoke-free ordinances were not associated with these outcome
measures in multivariable analyses.
Table 4. Logistic regression of SHS exposure and tobacco use on smoke-free policies 1.
Outcome No Smoke-Free Ordinance Home is Not Smoke-Free
OR (95% CI) OR (95% CI)
Past 7-Day SHS Exposure 1.1 (0.9–1.3) 4.3 (3.1–6.1)
Past 30-Day Cigarette Use 1.2 (0.8–1.7) 3.7 (2.3–6.0)
Past 30-Day Cigar Use 1.4 (0.8–2.4) 2.6 (1.5–4.4)
Past 30-Day SLT Use 0.6 (0.4–1.0) 2.6 (1.6–4.2)
Past 30-Day E-Cigarette Use 0.7 (0.4–1.3) 2.1 (1.5–2.9)
1Adjusted for smoker in the home, gender, race, and grade.
4. Discussion
Local smoke-free ordinances and household policies were associated with lower rates of SHS
exposure and cigarette smoking among youth. These results are consistent with previous research
on youth and smoking policies [
29
31
]. To our knowledge, this was one of the first studies to
examine whether or not these restrictions also protected youth against other forms of tobacco use.
Household smoke-free policies were also protective against cigar, SLT, and e-cigarette use. Although,
local smoke-free ordinances were also protective against cigar use, they were not associated with
non-combustible use. Youth who lived in places with a smoke-free ordinance were no less likely to use
SLT or e-cigarettes than those who were not protected by a local ordinance.
The results also suggested that household policies had a stronger influence on SHS exposure
and tobacco use than for smoke-free ordinances. Associations in bivariate analyses were stronger and
more consistent for smoke-free home policies than local ordinances; and in multivariable analyses,
smoke-free home policies remained significant predictors of SHS exposure and tobacco use, whereas
local policies did not.
Our data cannot directly explain why household policies had a stronger association with SHS
exposure and tobacco use. Perhaps youth spent more time in their homes than in restaurants and
workplaces, or perhaps youth were more impacted by household norms than community norms.
Household members have more direct control over rules for their homes than for their
municipality, and thus decisions to prohibit smoking may have a greater impact on household youth
Children 2019,6, 44 6 of 8
than local ordinances. Results clearly demonstrated that both of these smoke-free policies were
protective against SHS exposure and combustible tobacco use. Future research should investigate why
local ordinances have a weaker impact on SHS exposure and combustible tobacco use, and why there
was no relationship with non-combustible tobacco use.
There are potential limitations to this study. The sample was limited to youth in Mississippi
public schools and may not be generalized to other populations. Furthermore, youth self-reported
SHS exposure and tobacco use, and these reports were not biologically verified.
5. Conclusions
The results suggested that smoke-free ordinances and policies offer protection against exposure
to tobacco smoke and the use of combustible tobacco products However, smoke-free ordinances
and policies did not appear to impact on non-combustible tobacco use such as through smokeless
tobacco and e-cigarettes. Tobacco-free, rather than smoke-free ordinances might offer more protection
for youth.
Author Contributions:
All authors participated in the conceptual development, the study design, the writing and
editing of the article. Conceptualization, R.M., N.V., and E.M.; methodology, R.M., N.V., and E.M; formal analysis,
R.M., N.V., E.M.; recruitment, N.V. and E.M; project administration, N.V.; writing—original draft preparation,
R.M. and N.V.; writing—review and editing, R.M., N.V., and E.M.; supervision, N.V.; funding acquisition, R.M.
Funding:
This publication was made possible by the Office of Tobacco control, Mississippi State Department of
Health and the Flight Attendant Medical Research Institute (FAMRI) under Award Number #052302_CoE to the
American Academy Pediatrics (AAP). The information, views, and opinions contained herein are those of the
authors and do not necessarily reflect the views and opinions of these organizations.
Conflicts of Interest: The authors declare no conflict of interest.
References
1.
U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. The
Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General; Centers for Disease
Control and Prevention (US): Atlanta, GA, USA, 2014.
2.
Weitzman, M. The effects of tobacco exposure on children’s behavioral and cognitive functioning:
Implications for clinical and public health policy and future research. Neurotoxicol. Teratol.
2002
,24,
397–406. [CrossRef]
3.
California Environmental Protection Agency. Health Effects of Exposure to Environmental Tobacco Smoke;
California Environmental Protection Agency: Sacramento, CA, USA, 1997.
4.
American Academy of Pediatrics, Committee on Environmental Health. Environmental Tobacco Smoke: A
Hazard to Children. Pediatrics 1997,99, 639–642. [CrossRef]
5.
Cook, D.G.; Strachan, D.P. Health effects of passive smoking-10: Summary of effects of parental smoking
on the respiratory health of children and implications for research. Thorax
1999
,54, 357–366. [CrossRef]
[PubMed]
6.
American Nonsmokers’ Rights. US 100% Smokefree Laws in Non-Hospitality Workplaces and Restaurants
and Bars. 2018. Available online: https://no-smoke.org/wp-content/uploads/pdf/WRBLawsMap.pdf
(accessed on 7 January 2019).
7.
King, B.A.; Patel, R.; Babb, S.D.; Hartman, A.M.; Freeman, A. National and state prevalence of smoke-free
rules in homes with and without children and smokers: Two decades of progress. Prev. Med.
2016
,82, 51–58.
[CrossRef] [PubMed]
8.
Wakefield, M.; Chaloupka, F.; Kaufman, N.; Orleans, C.T. Do Smoking Restrictions at Home, at School and in
Public Places, Influence Youth Smoking? University of Illinois: Chicago, IL, USA, 2000.
9.
Farrelly, M.C.; Evans, W.N.; Sfekas, A.E. The impact of workplace smoking bans: Results from a national
survey. Tob. Control 1999,8, 272–277. [CrossRef] [PubMed]
10.
Farkas, A.J.; Gilpin, E.A.; Distefan, J.M.; Pierce, J.P. The effects of household and workplace smoking
restrictions on quitting behaviours. Tob. Control 1999,8, 261–265. [CrossRef] [PubMed]
Children 2019,6, 44 7 of 8
11.
Kinne, S.; Kristal, A.R.; White, E.; Hunt, J. Work-site smoking policies: Their population impact in Washington
State. Am. J. Public Health 1993,83, 1031–1033. [CrossRef] [PubMed]
12.
Sorsensen, G.; Rigotti, N.; Journal, A.R.A.; Pinney, J. Effects of a worksite nonsmoking policy: Evidence for
increased cessation. Am. J. Public Health 1991,81, 202–204. [CrossRef] [PubMed]
13.
Siegel, M. Effect of local restaurant smoking regulations on progression to established smoking among
youths. Tob. Control 2005,14, 300–306. [CrossRef] [PubMed]
14.
Wakefield, M.A.; Chaloupka, F.J.; Kaufman, N.J.; Orleans, C.T.; Barker, D.C.; Ruel, E.E. Effect of restrictions
on smoking at home, at school, and in public places on teenage smoking: Cross sectional study. BMJ
2000
,
321, 333–337. [CrossRef] [PubMed]
15.
Wakefield, M. Growing evidence for new benefit of clean indoor air laws: Reduced adolescent smoking. Tob.
Control 2005,14, 292–293. [CrossRef] [PubMed]
16.
Borland, R.; Chapman, S.; Owen, N.; Hill, D. Effects of workplace smoking bans on cigarette consumption.
Am. J. Public Health 1990,80, 178–180. [CrossRef] [PubMed]
17.
Pierce, J.P.; White, M.M.; Messer, K. Changing age-specific patterns of cigarette consumption in the United
States, 1992–2002: Association with smoke-free homes and state-level tobacco control activity. Nicotine Tob.
Res. 2009,11, 171–177. [CrossRef] [PubMed]
18.
Borland, R.; Yong, H.-H.; Cummings, K.M.; Hyland, A.; Anderson, S.; Fong, G.T. Determinants and
consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country
Survey. Tob. Control 2006,15 (Suppl. 3), iii42–iii50. [CrossRef] [PubMed]
19.
Mills, A.L.; Messer, K.; Gilpin, E.A.; Pierce, J.P. The effect of smoke-free homes on adult smoking behavior: A
review. Nicotine Tob. Res. 2009,11, 1131–1141. [CrossRef] [PubMed]
20.
Song, A.V.; Dutra, L.M.; Neilands, T.B.; Glantz, S.A. Association of smoke-free laws with lower percentages of
new and current smokers among adolescents and young adults. JAMA Pediatr.
2015
,169, e152285. [CrossRef]
[PubMed]
21.
Fallin, A.; Roditis, M.; Glantz, S.A. Association of campus tobacco policies with secondhand smoke exposure,
intention to smoke on campus, and attitudes about outdoor smoking restrictions. Am. J. Public Health 2015,
105, 1098–1100. [CrossRef] [PubMed]
22.
Patel, M.; Thai, C.L.; Meng, Y.Y.; Kuo, T.; Zheng, H.; Dietsch, B.; McCarthy, W.J. Smoke-free car legislation
and student exposure to smoking. Pediatrics 2018,141 (Suppl. 1), S40–S50. [CrossRef] [PubMed]
23.
Katikireddi, S.V.; Der, G.; Roberts, C.; Haw, S. Has childhood smoking reduced following smoke-free public
places legislation? a segmented regression analysis of cross-sectional UK school-based surveys. Nicotine Tob.
Res. 2016,18, 1670–1674. [CrossRef] [PubMed]
24.
Mayne, S.L.; Auchincloss, A.H.; Tabb, L.P.; Stehr, M.; Shikany, J.M.; Schreiner, P.J.; Widome, R.;
Gordon-Larsen, P. Associations of bar and restaurant smoking bans with smoking behavior in the CARDIA
Study: A 25-Year Study. Am. J. Epidemiol. 2018,187, 1250–1258. [CrossRef] [PubMed]
25.
Leventhal, H.; Cleary, P. The smoking problem: A review of the research and theory in behavioral risk
modification. Psychol. Bull. 1980,88, 370–405. [CrossRef] [PubMed]
26.
Gilpin, E.A. Changes in population attitudes about where smoking should not be allowed: California versus
the rest of the USA. Tob. Control 2004,13, 38–44. [CrossRef] [PubMed]
27.
Albers, A.B. Relation between local restaurant smoking regulations and attitudes towards the prevalence
and social acceptability of smoking: A study of youths and adults who eat out predominantly at restaurants
in their town. Tob. Control 2004,13, 347–355. [CrossRef] [PubMed]
28.
Hammond, D.; Fong, G.T.; Zanna, M.P.; Thrasher, J.F.; Borland, R. Tobacco Denormalization and Industry
Beliefs Among Smokers from Four Countries. Am. J. Prev. Med. 2006,31, 225–232. [CrossRef] [PubMed]
29.
Biener, L.; Cullen, D.; Di, Z.X.; Hammond, S.K. Household smoking restrictions and adolescents’ exposure
to environmental tobacco smoke. Prev. Med. 1997,26, 358–363. [CrossRef] [PubMed]
30.
Farkas, A.J.; Gilpin, E.A.; White, M.M.; Pierce, J.P. Association Between Household and Workplace Smoking
Restrictions and Adolescent Smoking. JAMA 2000,284, 717–722. [CrossRef] [PubMed]
31.
Proescholdbell, R.J.; Chassin, L. MacKinnon DP. Home smoking restrictions and adolescent smoking. Nicotine
Tob. Res. 2000,2, 159–167. [CrossRef] [PubMed]
32.
Mississippi Tobacco Data. The Mississippi Youth Tobacco Data Survey, 1998–2017. 2018. Available
online: https://mstobaccodata.org/wp-content/uploads/2018/06/YTS-publication-2018.pdf (accessed on
4 March 2019).
Children 2019,6, 44 8 of 8
33.
Mississippi Tobacco Data. 100% Smoke-free Communities in Mississippi. 2018. Available online:
https://mstobaccodata.org/wp-content/uploads/2018/12/ms-smoke-free-communities.pdf (accessed on
7 January 2019).
34.
Leonardi-Bee, J.; Jere, M.L.; Britton, J. Exposure to parental and sibling smoking and the risk of smoking
uptake in childhood and adolescence: A systematic review and meta-analysis. Thorax
2011
,66, 847–855.
[CrossRef] [PubMed]
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Purpose While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps. Methods We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded. Results A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco. Conclusions This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.
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Introduction: Smoke-free legislation has been a great success for tobacco control but its impact on smoking uptake remains under-explored. We investigated if trends in smoking uptake amongst adolescents differed before and after the introduction of smoke-free legislation in the United Kingdom. Methods: Prevalence estimates for regular smoking were obtained from representative school-based surveys for the four countries of the United Kingdom. Post-intervention status was represented using a dummy variable and to allow for a change in trend, the number of years since implementation was included. To estimate the association between smoke-free legislation and adolescent smoking, the percentage of regular smokers was modeled using linear regression adjusted for trends over time and country. All models were stratified by age (13 and 15 years) and sex. Results: For 15-year-old girls, the implementation of smoke-free legislation in the United Kingdom was associated with a 4.3% reduction in the prevalence of regular smoking (P = .029). In addition, regular smoking fell by an additional 1.5% per annum post-legislation in this group (P = .005). Among 13-year-old girls, there was a reduction of 2.8% in regular smoking (P = .051), with no evidence of a change in trend post-legislation. Smaller and nonsignificant reductions in regular smoking were observed for 15- and 13-year-old boys (P = .175 and P = .113, respectively). Conclusions: Smoke-free legislation may help reduce smoking uptake amongst teenagers, with stronger evidence for an association seen in females. Further research that analyses longitudinal data across more countries is required. Implications: Previous research has established that smoke-free legislation has led to many improvements in population health, including reductions in heart attack, stroke, and asthma. However, the impacts of smoke-free legislation on the rates of smoking amongst children have been less investigated. Analysis of repeated cross-sectional surveys across the four countries of the United Kingdom shows smoke-free legislation may be associated with a reduction in regular smoking among school-aged children. If this association is causal, comprehensive smoke-free legislation could help prevent future generations from taking up smoking.
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Results of epidemiologic studies provide strong evidence that exposure of children to environmental tobacco smoke is associated with increased rates of lower respiratory illness and increased rates of middle ear effusion, asthma, and sudden infant death syndrome. Exposure during childhood may also be associated with development of cancer during adulthood. This statement reviews the health effects of environmental tobacco smoke on children and offers pediatricians a strategy for promoting a smoke-free environment.
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Objective: To determine the relation between extent of restrictions on smoking at home, at school, and in public places and smoking uptake and smoking prevalence among school students. Design: Cross sectional survey with merged records of extent of restrictions on smoking in public places. Setting: United States. Participants: 17 287 high school students. Main outcome measures: Five point scale of smoking uptake; 30 day smoking prevalence. Results: More restrictive arrangements on smoking at home were associated with a greater likelihood of being in an earlier stage of smoking uptake (P<0.05) and a lower 30 day prevalence (odds ratio 0.79 (95% confidence interval 0.67 to 0.91), P<0.001). These findings applied even when parents were smokers. More pervasive restrictions on smoking in public places were associated with a higher probability of being in a earlier stage of smoking uptake (P<0.05) and lower 30 day prevalence (0.91 (0.83 to 0.99), P=0.03). School smoking bans were related to a greater likelihood of being in an earlier stage of smoking uptake (0.89 (0.85 to 0.99), P<0.05) and lower prevalence (0.86 (0.77 to 0.94), P<0.001) only when the ban was strongly enforced, as measured by instances when teenagers perceived that most or all students obeyed the rule. Conclusions: These findings suggest that restrictions on smoking at home, more extensive bans on smoking in public places, and enforced bans on smoking at school may reduce teenage smoking.
Article
Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.
Article
Background: Policies protecting children from exposure to secondhand smoke (SHS) may help prevent SHS-related negative health outcomes in children and discourage them from intending to smoke in the future. In this study, we assess the impact of California's 2007 smoke-free vehicle law on changes in middle and high school students' reported exposure to smoking in cars. Secondary aims included assessing the association of student-reported exposure to smoking in vehicles and lifetime asthma diagnosis and future intentions to smoke. Methods: Population-weighted data from the California Student Tobacco Survey and the National Youth Tobacco Survey were used to evaluate California and national trends, respectively. Weighted logistic regression models using California Student Tobacco Survey 2011 data assessed the association between the number of days of exposure to smoking in cars and student-reported lifetime asthma diagnosis as well as intention to smoke in the future. Results: The proportion of California students reporting exposure to smoking in cars in the last 7 days declined <1% annually from 2001 through 2005, but declined 12% annually from 2007 to 2011. National trends did not show comparable declines after 2006. Students reporting exposure to smoking in vehicles were more likely to report having ever been diagnosed with asthma and intending to smoke in the future than students who were not exposed to SHS. Conclusions: These findings support the legislative intent that public policies that are designed to protect children from exposure to smoking in vehicles will yield better adolescent health outcomes and a lower risk of future adolescent cigarette smoking.
Article
Objective: The home is the primary source of secondhand smoke (SHS) exposure for children. We assessed national and state progress in smoke-free home (SFH) rule adoption in homes with and without children and adult smokers. Methods: Data came from the 1992-1993 and 2010-2011 Tobacco Use Supplements to the Current Population Survey, a U.S. national probability household survey. Households were defined as having a SFH rule if all household respondents aged ≥18 indicated no one was allowed to smoke inside the home at any time. Households with children were those with occupants aged <18. Smokers were those who smoked ≥100 lifetime cigarettes and now smoked "everyday" or "some days". Results: From 1992-1993 to 2010-2011, SFH rule prevalence increased from 43.0% to 83.0% (p<.05). Among households with children, SFH rules increased overall (44.9% to 88.6%), in households without smokers (59.7% to 95.0%), and households with ≥1 smokers (9.7% to 61.0%) (p<.05). Among households without children, SFH rules increased overall (40.8% to 81.1%), in households without smokers (53.4% to 90.1%), and households with ≥1 smokers (6.3% to 40.9%) (p<.05). Prevalence increased in all states, irrespective of smoker or child occupancy (p<.05). In 2010-2011, among homes with smokers and children, SFH rule prevalence ranged from 36.5% (West Virginia) to 86.8% (California). Conclusions: Considerable progress has been made adopting SFH rules, but many U.S. children continue to be exposed to SHS because their homes are not smoke-free. Further efforts to promote adoption of SFH rules are essential to protect all children from this health risk.
Article
Importance: Smoke-free laws are associated with a lower prevalence of smoking. Objective: To quantify the effect of 100% smoke-free laws on the smoking behavior of adolescents and young adults in a longitudinal analysis. Design, setting, and participants: Pooled logistic regression and zero-inflated negative binomial regression analysis of participants in the National Longitudinal Survey of Youth 1997 (data from 1997 to 2007), with complete data on initiation of smoking (n = 4098) and number of days respondents reported smoking in the past 30 days (n = 3913). Exposures: Laws for 100% smoke-free workplaces, laws for 100% smoke-free bars, and state cigarette taxes. Main outcomes and measures: Smoking initiation (first report of smoking cigarette), current (for 30 days) smoking, and number of days respondents reported smoking in the past 30 days among current smokers. Results: Laws for 100% smoke-free workplaces, but not bars, were associated with significantly lower odds of initiating smoking (odds ratio, 0.66 [95% CI, 0.44-0.99]). Laws for 100% smoke-free bars were associated with lower odds of being a current smoker (odds ratio, 0.80 [95% CI, 0.71-0.90]) and fewer days of smoking (incidence rate ratio, 0.85 [95% CI, 0.80-0.90]) among current smokers. Taxes were associated with a lower percentage of new smokers but not current smokers among adolescents and young adults. The effect of smoke-free workplace laws on smoking initiation is equivalent to a $1.57 (in 2007 dollars) tax increase. Smoke-free bar laws are associated with lower rates of current smoking, as well as a decrease in the number of days reported smoking among current smokers. Conclusions and relevance: Smoke-free laws are an important tobacco control tool. They not only protect bystanders from secondhand smoke but also contribute to less smoking among adolescents and young adults.
Article
College campus tobacco-free policies are an emerging trend. Between September 2013 and May 2014, we surveyed 1309 college students at 8 public 4-year institutions across California with a range of policies (smoke-free indoors only, designated outdoor smoking areas, smoke-free, and tobacco-free). Stronger policies were associated with fewer students reporting exposure to secondhand smoke or seeing someone smoke on campus. On tobacco-free college campuses, fewer students smoked and reported intention to smoke on campus. Strong majorities of students supported outdoor smoking restrictions across all policy types. Comprehensive tobacco-free policies are effective in reducing exposure to smoking and intention to smoke on campus.
Article
This article presents data from a population-based, random-digit dialing telephone survey of 1228 employed adults in Washington State, conducted 1989 through 1990. Eighty-one percent of men and 91% of women reported work-site smoking restrictions. Employees in work sites with no-smoking policies were less likely to be current smokers; men in work sites with policies restricting smoking smoked fewer cigarettes on both workdays and nonworkdays. Forty-eight percent of male and 53% of female smokers reported reduced smoking as a result of a work-site policy. Work-site smoking policies, intended to protect against smoke exposure, may also reduce employee smoking.
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There is increasing evidence that contact with other smokers, particularly in the family, is a strong determinant of risk of smoking uptake. A systematic review and meta-analysis of the magnitude of these effects is reported. Studies were identified by searching four databases to March 2009 and proceedings from international conferences. Meta-analyses were performed using random effects, with results presented as pooled ORs with 95% CIs. 58 studies were included in the meta-analyses. The relative odds of uptake of smoking in children were increased significantly if at least one parent smoked (OR 1.72, 95% CI 1.59 to 1.86), more so by smoking by the mother (OR 2.19, 95% CI 1.73 to 2.79) than the father (OR 1.66, 95% CI 1.42 to 1.94), and if both parents smoked (OR 2.73, 95% CI 2.28 to 3.28). Smoking by a sibling increased the odds of smoking uptake by 2.30 (95% CI 1.85 to 2.86) and smoking by any household member by 1.92 (95% CI 1.70 to 2.16). After adjusting for overestimation of RRs it is estimated that, in England and Wales, around 17,000 young people take up smoking by the age of 15 each year as a consequence of exposure to household smoking. Parental and sibling smoking is a strong and significant determinant of the risk of smoking uptake by children and young people and, as such, is a major and entirely avoidable health risk. Children should be protected from exposure to smoking behaviour, especially by family members.