The main idea of Integrated Marketing Communication (IMC) is to combine with multimedia and all interesting shareholders, and concentrate on the major audiences. It has been used in several fields because of its integrated characteristic. In the past, the field of health communication only focused on the dimension of public health, but now both of the smoke industry and drug industry use the varieties of promotion skills to persuade people to buy tobacco and patent medicine. Therefore, the field of health communication should try to use integrated conception to promote correct ideas and then measure the effect of promotion and revise the strategy. The research studies the effect of using IMC strategy in popularizing smoke-free restaurant. The author uses the secondhand data of the popularization program of smoke-free restaurant and then uses questionnaire to try to understand the cognition¡Battitude and behavior of people who eat in the smoke-free restaurant in Kaohsiung city. The research also wants to measure whether or not the program sends ¡§one voice¡¨ to the consumers. The results of the empirical research find out the popularization program of smoke-free restaurant sends ¡§one voice¡¨ to the consumers so that the consumers can easily understand what smoke-free restaurant is. Besides, the cognition of the consumers is relevant with the attitude of the consumers and then the attitude of the consumers is relevant with the behavior of the consumers. Therefore, besides delivering the coherent message with IMC for promotion of Smoke-free restaurant, IMC also does achieve the best effect as a tool for promotion of health communication.

The purpose of the critical review is understood to be a critical reflection and comment on the work presented in the papers. The critical review is centred on the papers, as they form the substance of the submission, and the wider tobacco control literature. This review has not attempted to re-analyse the findings of the studies but attempts to draw wider lessons from the studies and to contribute to the future implementation of tobacco control policy and programmes. It will be claimed that the contribution to the research studies, the publications and the critical review represents a significant body of work and contribution to the advancement of knowledge in tobacco control. The aim of the thesis is to present and critically review six publications on the social de-normalisation of tobacco use, as it relates to public and private smoke-free environments and professional engagement in Scotland. The publications are treated as a coherent body of tobacco control research and draw upon three studies conducted over the period 1999-2007. Breathing Space Study 1: 1999-2002 evaluated an intervention which aimed to produce a significant shift in community norms towards non-smoking in a lowincome area. A process evaluation, as part of a quasi-experimental design, was undertaken in the intervention area, using a range of qualitative methods, including observation, in-depth interviews and focus groups. Papers 1 and 2 explore the context of health promotion professional practice in the development and implementation of tobacco control interventions in one disadvantaged community. The Qualitative Community Study 2: 2005-2007 aimed to explore the impact of the Scottish smoke-free legislation on attitudes and behaviour, at both individual and community levels, in four socio-economically contrasting localities in Scotland. A longitudinal qualitative evaluation was conducted using observation, in-depth interviews with smokers and ex-smokers, key stakeholders and focus groups. Papers 3 and 4 explore qualitative differences in the experience of smoke-free legislation in advantaged and disadvantaged communities, with particular consideration of the unintended consequences of the legislation for some smokers. The Smoke-free Homes Study 3: 2006-2007 aimed to describe changes in smoking behaviour and attitudes to smoking following implementation of the smoke-free legislation. It sought to identify the potential enablers and barriers to reducing SHS exposure in the home. A cross-sectional study was conducted using qualitative interviews. Papers 5 and 6 explore the changing discourses about second-hand smoke exposure, and the development of smoking restrictions in the home, with a particular focus on motivation to protect children. In addition, insight into the changing culture of professional practice in creating smoke-free homes was gained. Key findings A synthesis of key findings from these publications supports the identification of three major themes: the experience of power at each stage of the process of the social de-normalisation of tobacco use; the experience of stigmatisation of smoking as a consequence of policy; and health promotion practice as both barrier to and enabler of the implementation of smoke-free environments in the community and the home. The thesis also highlights the benefits and challenges of two research methodologies, process evaluation and qualitative longitudinal research (QLLR), in capturing both intended and unanticipated aspects of policy and practice implementation. This synthesis of the key findings that cut across the three studies has generated four research questions that are explored in this critical review: 1. How can policy be evaluated in community settings and in the home? 2. How do smokers, particularly disadvantaged smokers, engage with tobacco control policies and interventions? 3. Is professional practice a barrier or facilitator to understanding the impact of tobacco control policies and interventions? 4. What are some of the key unintended consequences of recent tobacco control policies? Conclusion This thesis contributes to knowledge through a critical account of the reshaping of smoking as a collective lifestyle, in both public and private domains. The social de-normalisation of tobacco use is experienced differently in advantaged and disadvantaged social contexts. Population tobacco control strategies may benefit from contextual adjustments, particularly for those smokers who live in areas of disadvantage and thus experience dual stigmatisation. Additionally, the effectiveness of future interventions would be enhanced by a more nuanced understanding of smoking behaviour, as a collective social practice, embedded in specific spaces, places and times.

Background: According to the partial smoke-free legislation implemented on 1 September 2010 in Guangzhou, China, smoke-free did not cover all indoor areas. Some places have a full smoking ban (100 % smoke-free), other places have a partial smoking ban, and homes have no ban. This study aimed to compare the smoking behaviors before and after implementation of a smoke-free legislation. Method: A repeated cross-sectional survey was conducted on smoking-related behaviors with a total of 4,900 respondents before, and 5,135 respondents after the legislation was instituted. For each wave of the survey, a three-stage stratified sampling process was used to obtain a representative sample. Pearson's Chi-square test was used to determine differences of smoking prevalence and quit ratio between the two samples. Logistic regression models were used to examine the associations of a smoke-free legislation with smoking behaviors. Results: The overall daily smoking rate declined significantly from 20.8 % to 18.2 % (p∈<∈0.05), especially among those aged 15-24 years. The quit ratios increased significantly (from 14.5 % to 17.9 %), but remained low among 15-44 year olds. The overall self-reported smoking behaviors in locations with a full smoking ban decreased significantly from 36.4 % to 24.3 % with the greater drops occurring in cultural venues, public transport vehicles, and government offices. Smoking in places with partial smoking bans remained high (89.6 % vs. 90.4 %), although a slight decrease was observed in some of these areas. The implementation of a smoke-free legislation did not lead to more smoking in homes (91.0 % vs 89.4 %), but smoking in homes remained high. Conclusions: These findings highlight the urgent need for a comprehensive smoke-free legislation covering all public places in Guangzhou, simultaneously educational interventions and campaigns promoting voluntary changes in home smoking need to occur.

No description available.

Background: With almost 80,000 Europeans estimated to die annually from the consequences of exposure to second-hand smoke (SHS) and over a quarter of all Europeans being exposed to the toxins of cigarette smoke at work on a daily basis, SHS is a major European public health problem. Smoke-free policies, i.e. policies which ban smoking in public places and workplaces, are an effective way to reduce exposure. Policy options to reduce public exposure to SHS were negotiated by European Union (EU) decision makers between 2006 and 2009, resulting in the European Council Recommendation on smoke-free environments. A variety of stakeholders communicated their interests prior to the adoption of the policy. This thesis aims to analyse the engagement and collaboration of organisational stakeholders in the development of the Council Recommendation on smoke-free environments. Methods: The case study employs a mixed method approach to analyse data from policy documents, consultation submissions and qualitative interviews. Data from 176 consultation submissions serve as a basis to analyse the structure of the policy network using quantitative network analysis. In addition, data from these submissions, selected documents of relevance to the policy process and 35 in-depth interviews with European decision makers and stakeholders are thematically analysed to explore the content of the network and the engagement of and interaction between political actors. Results: The analysis identified a sharply polarised network which was largely divided into two adversarial advocacy coalitions. The two coalitions took clearly opposing positions on the policy initiative, with one coalition supporting and the other opposing comprehensive European smoke-free policy. The Supporters’ Alliance, although consisting of diverse stakeholders, including public health advocacy organisations, professional organisations, scientific institutions and pharmaceutical companies, was largely united by its members’ desire to protect Europeans from the harms caused by SHS and campaign for comprehensive European tobacco control policy. Seemingly coordinated and guided by an informal group of key individuals, alliance members made strategic decisions to collaborate and build a strong, cohesive force against the tobacco industry. The Opponents’ Alliance consisted almost exclusively of tobacco manufacturers’ organisations which employed a strategy of damage limitation and other tactics, including challenging the scientific evidence, critiquing the policy process and advancing discussions on harm reduction, to counter the development of effective tobacco control measures. The data show that the extent of tobacco company engagement was narrowed by the limited importance that industry representatives attached to opposing non-binding EU policy and by the companies’ struggle to overcome low credibility and isolation. Discussion: This study is the first that applies social network analysis to the investigation of EU public health policy and systematically analyses and graphically depicts a policy network in European tobacco control. The analysis corroborates literature which highlights the polarised nature of tobacco control policy and draws attention to the complex processes of information exchange, consensus-seeking and decision making which are integral to the development of European public health policy. The study identifies the European Union’s limited competence as a key factor shaping stakeholder engagement at the European level and presents the Council Recommendation on smoke-free environments as an example of the European Commission’s successful management of the policy process. An increased understanding of the policy network and the factors influencing the successful development of comprehensive European smoke-free policy can help to guide policymaking and public health advocacy in current European tobacco control debates and other areas of public health.

Aims: To identify factors, which were related to being smoke-free and snus-free, respectively, among adolescents in relation to adolescents who were smoking and/or using snus, and de-termine if there were any sex differences. Me- thods: A questionnaire study was performed among students in year two in upper secondary schools (17-years-old) in southern Sweden in 2009. More than 2200 students completed the questionnaire regarding health and living habits anonymously. The variables were tested by χ²-test, before selection into the logistic model. Because of the salutogenic approach in the study, the results of the logistic regression analyses were expressed as Positive Odds Ratio (POR). Results: The prevalence of being smoke- free was 75.6 percent for girls and 70.2 percent for boys, whilst the prevalence of being snus- free was 95.1 percent for girls and 70.2 percent for boys. Having a tobacco-free best friend was the most important factor that correlated with being smoke- and snus-free as an adolescent, for both boys and girls. Good living habits, such as drinking less alcohol, were also central to being smoke-free and snus-free. Conclusions: The results show that a tobacco-free environ-ment has a great influence on whether or not adolescents stay tobacco-free. As the environ-ment has a big impact, the school has a big challenge to work with the school environment and policies but also with family responsibility, norms and attitudes to tobacco.

ABSTRACT Background: Asthma is a chronic lung disease that inflames and narrows the airways. This results in recurrent episodes of coughing, wheezing, shortness of breath, and chest tightness. Although the causes of asthma are poorly understood, genetic and environmental factors have been implicated in the development and exacerbation of the disease. Among environmental risk factors, cigarette smoke is a well-known risk factor to trigger asthma symptoms. Exposure to secondhand smoke irritates the airways and may trigger an attack in adults with asthma. Smoke-free laws and regulations in the United States differ by state. The enforcement of smoke-free legislation has been related to asthma rates as it has been shown that they lead to a sustained drop in emergency hospital admission for asthma among adults. These laws and regulations are also necessary in reducing smoking rate and secondhand smoke exposure. Objective: The purpose of this thesis is to examine the association between tobacco smoke rates and asthma status among adults at the national and state levels and to evaluate the effects of state smoke-free laws and regulations on tobacco smoking rate among adults with asthma. Methods: The Centers for Disease Control and Prevention’s 2009–2010 Behavioral Risk Factor Surveillance System data was used for the analyses. SAS-callable SUDAAN (version 10.0.0, RTI International, NC) was utilized to account for the complex sampling design of the BRFSS, and sample weights were used to produce estimates that were generalizable to the state and U.S. adult population. In addition to calculating descriptive statistics, chi-square tests and multivariate logistic regression were used to test for group differences and association between variables of interest. State level smoking rates were ranked to identify states that are in the lower and upper 20th percentiles and compare them with states’ smoke-free laws and regulation status. Results were considered significantly different if 95% confidence intervals (CIs) did not overlap or if statistical testing at p<0.05 was applicable. Results: Asthma prevalence rates are higher among adults that smoke cigarettes (10.5%, [aPR] =1.2) compared to non-smokers (7.8%, [aPR] =1.0). Of the 869,519 adult respondents in the survey, 8.5% reported having asthma. Nearly one-fifth (17.2%) of adults without asthma smoked cigarettes, while (21.7 %) of adults with asthma smoked. Females (10.5%) had higher asthma prevalence rates than males (6.4%). Black persons (10.0%), persons of American Indian (13.0%) descent had higher, and those of Hispanic (6.7%) descent had lower asthma rates than white persons (8.6%). Adults with a high school education or less (9.1%) had higher asthma rates than those with an education level that was equivalent to a 4 year college or more (7.3%) , and those with low income (<$15,000) had higher rates (13.3%) than those with high income (6.8%). Percentage of male (23.4%) and females (20.7%) with asthma who smoke are higher than those that do not smoke (19.3% and 15.1%, respectively). Asthma prevalence rates and smoking rates vary by geographic location. Smoking rates among adults with asthma was highest in the South (LA, AL, SC, TN, OK, MS, AR, WV, KY) and a couple of Midwest states (OH, IN,). Evaluating the association between the 2008 State of Tobacco Control Report and smoking rate among adults with asthma by state showed a statistically significant relationship between smoking rate among adults with asthma and smoke-free policy and regulation at the state and national level. On average, states with the lowest smoking rate among persons with asthma (smoking rates less than 20th percentile) had significantly higher smoke-free policy grades (mean grade [sd]=7.2 [1.99]) than states with a high smoking rate (smoking rate of 80th percentile or more) (mean grade [sd]=2.0 [2.00]) (p-value < 0.00001). Conclusion: Although most U.S. state smoke-free policies and regulations are relatively new, it is evident that these laws are effective in promoting cessation among adults and reducing nonsmokers’ exposure to secondhand smoke. The study found that smoke-free laws may improve health by lowering asthma prevalence and smoking rates among adult smokers. Also, these policies in turn protect non-smokers from the harmful health effects of secondhand smoke.

Aim: To examine director’s experiences of the process to implement smoke-free working hours and also their need of support to make it feasible in the municipality of Östhammar. Method: A qualitative interview study with a descriptive design was used. Semi-structured interviews were made with six directors who were selected from different levels, localities and administrations in the municipality of Östhammar. A qualitative content analysis was used to analyze the data. Results: Many positive aspects were pointed out regarding the implementation of smoke-free working hours. The aspects of time and the support which had been offered to the smokers stood out among these. The majority of the directors considered that the support at the time of the implementation had been adequate.  The difficulties that were experienced were mostly related to practical issues. Only a few proposals of support concerning the difficulties that had been experienced were presented. Two of the study’s participants had not experienced difficulties. Two positive effects of the policy were reduction in smoking or quitting smoking. Particularly one director stated that the policy did not function at all up to that point. The requested types of support in the future were continuing existing support, activities connected to the policy and a follow-up of the policy. Conclusion: The experiences of the informants were that the implementation process has functioned well with the exception of a few particular difficulties. Few proposals of support emerged in addition to already existing ones. Some form of activity connected to the policy or a follow-up of the policy is important to once again make it a pressing issue.

The three research studies included in this dissertation aimed to examine the reasons for e-cigarette use among U.S. adults, and to examine the U.S. public opinion on allowing e-cigarette use where smoking is otherwise prohibited. Mixed (quantitative and qualitative) research methods were used. Data from an online survey (2012) and focus groups (2014) were analyzed. Among 307 survey respondents who had ever used e-cigarettes, the three most common reasons for e-cigarette use were curiosity (40.8%), the belief that “it helps people quit smoking” (19.1%), and perceiving e-cigarettes “less harmful than regular cigarettes” (9.3%). About 40% of U.S. adults were uncertain whether e-cigarette use should be allowed in smoke-free public areas, 37% opposed, while 23% favored allowing their use in smoke-free environments. The majority of the focus group participants have used e-cigarettes to complement regular cigarette smoking and intake nicotine where smoking is restricted. E-cigarette use was viewed to be less harmful and more convenient than smoking regular cigarettes. The findings of the three studies suggest that curiosity about e-cigarettes lead to experimentation and the convenience to use e-cigarettes in smoke-free areas lead to continual use. With impending regulation and the changing e-cigarette landscape, there is a need for continued monitoring and research on reasons for and attitudes about e-cigarette use, and on public opinion pertaining to e-cigarette use in smoke-free areas.

In 2007 Tennessee enacted and implemented the Nonsmoker Protection Act (NSPA) to protect nonsmokers by creating 100% smoke-free restaurants. Several venues were exempted, including age-restricted ones such as bars, and tobacco regulation was preempted. Thus, the NSPA is not equitable smoke free policy (SFP) because it has left vast segments of nonsmokers such as employees and patrons of bars unprotected from second-hand smoke (SHS) exposure and thwarted any local initiative to pursue 100% comprehensive SFPs. While this predisposes these nonsmokers to the health dangers of SHS exposure, it makes the NSPA incompatible with the objectives of the Healthy People 2020 and 2030 as well as goals of the state health plan. In 2021, the American Lung Association graded the NSPA “C,” and the United Health Foundation ranked it 42nd out of 50 states. This project assessed the effects of smoke-free venues across different economic domains through quantitative and qualitative data review to determine the implications for venues exempted by NSPA. By delineating any economic effects of SFP across several economic domains, the quantitative data gleaned from NAICS, Census Bureau, and Tennessee Dept. of Revenue were supplemented with interviews of establishments in Tennessee that voluntarily transitioned to smoke-free environment. A total of 7 such establishments with capacities ranging from 50 to over 69,000 people and number of employees ranging from 6 to over 1300 were interviewed. It was discovered that smoke-free environments have positive economic effects on restaurant establishments in Tennessee. By focusing on the SFP effect on restaurant establishments, the findings can be extrapolated to support the case for 100% smoke-free environments for other hospitality locations such as bars, music venues, and casinos. After analysis of trends for retail sales, number of establishments, employment, and payrolls by size of establishment and Metropolitan Statistical Area, a positive economic effect was identified for majority of these indicators between 2010 and 2019, a 10-year period following restaurants becoming smoke-free. Highlights include: Retail sales in Tennessee eating and drinking establishments increased by 62% The number of restaurant establishments increased by 16% Employment in the restaurant sector increased by 23% The qualitative data from the interviews reinforces these findings, with 100% of respondents supporting smoke-free age-restricted venues in their local communities. Thus, it can be inferred from these Tennessee-specific data with high degree of confidence that other hospitality venues will benefit economically in some way by becoming smoke-free with the following considerations: Provide protections from SHS exposure and health risks to nonsmokers; Do not adversely affect sales or employment in the hospitality, entertainment or sport industries, including bars, hotels and motels, and restaurants; Have strong public support and compliance.