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.

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.

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.

This study was the first to examine the effect of tobacco policies in prisons on the health of inmates. Kentucky has two types of tobacco policies in its 16 state prisons: indoor smoke-free policies, where smoking is allowed outdoors and tobacco-free policies, in which no tobacco of any kind is allowed on the grounds of the prison. The smoking rate of inmates is three times higher than that of current smokers in the non-incarcerated population which results in high rates of tobacco-related health conditions such as heart disease and lung cancer. A literature review discussed the evolution of tobacco policies in prisons , the motivations for strengthening policies in prisons and the unintended consequences. Health outcomes in the non-incarcerated population on the benefits to cardiovascular and respiratory health following passage of smoke-free laws in public places were reviewed. No studies have been found on the health outcomes of inmates with varying degrees of smoke-free or tobacco-free policies. The first study was a time series analysis comparing the frequency of medication refills for asthma and/or COPD before and after a tobacco-free policy was implemented. Short-acting inhaler refills decreased in the first few months following the tobacco-free policy date but returned to baseline within 12 to 15 months. Rapid turnover of inmates, minimum security status of the prisons, and possible loosening of enforcement may have been related to the gradual increase in use. The second study was a survival analysis on the time to an inmate’s first acute myocardial infarction (AMI) with tobacco policy status (tobacco-free or smoke-free) of the prison as the primary predictor variable. Controlling for the multiple movements over time, facilities, co-morbidities, past smoking history, age and race, there was a 2.87 hazard for AMI for time spent in a smoke-free (indoors) prison compared to a tobaccofree prison. This finding may be due to the fact that tobacco is considered contraband after prisons become tobacco-free and inmates risk disciplinary action by smuggling or using tobacco in the prison, thereby reducing secondhand smoke for non-smokers and probably reducing the consumption of current smokers.

Tobacco use and secondhand smoke exposure are leading causes of preventable morbidity and mortality in the United States. Outdoor tobacco smoke exposure conveys many of the same risks as indoor secondhand smoke exposure. Tobacco-free campuses policies are an intervention to promote a positive social norm that encourages smoking cessation, as well as reduces exposure to outdoor tobacco smoke. This dissertation contains a review of the policy implementation literature; findings from a psychometric analysis of the newly developed Tobacco-free Compliance Assessment Tool (TF-CAT) to assess compliance with tobacco-free campus policies; and results of a campus intervention study to promote compliance. The TF-CAT protocol is designed to count cigarette butts, observe smokers, and use GIS mapping to display hot spots. A total of 413 observations in primary and secondary campus locations yielded compliance data on both the academic healthcare and main campuses. Results show support for the concurrent validity of the TF-CAT. Inter-rater reliability of the measure is strong, and the tool is feasible, though time- and resource-intensive. The intervention study tested the effects of an efficacy-based messaging campaign on the number of cigarette butts observed on campus. After distributing 6,000 message cards in high-traffic areas over three days, there were fewer cigarette butts per day per site post-intervention compared to pre-intervention (n = 312 observations; median = 4.7 vs. 1.9; U=2239, p=.004). It is crucial for tobacco control advocates to ensure implementation effectiveness of tobacco-free policies. Future research needs to refine methods to measure policy implementation effectiveness. In addition, interventions need to be developed and tested to promote policy implementation effectiveness.

Purpose To estimate the prevalence of secondhand smoke (SHS) exposure among never-smoking adolescents and identify key factors associated with such exposure. Methods Data were obtained from nationally representative Global Youth Tobacco Surveys conducted in 168 countries during 1999-2008. SHS exposure was ascertained in relation to the location - exposure inside home, outside home, and both inside and outside home, respectively. Independent variables included parental and/or peer smoking, knowledge about smoke harm, attitudes toward smoking ban, age, sex, and World Health Organization region. Simple and multiple logistic regression analyses were conducted. Results Of 356,414 never-smoking adolescents included in the study, 30.4%, 44.2%, and 23.2% were exposed to SHS inside home, outside home, and both, respectively. Parental smoking, peer smoking, knowledge about smoke harm, and positive attitudes toward smoke ban were significantly associated with increased odds of SHS exposure. Approximately 14% of adolescents had both smoking parents and peers. Compared with never-smoking adolescents who did not have both smoking parents and peers, those who had both smoking parents and peers had 19 (adjusted odds ratio [aOR], 19.0; 95% confidence interval [CI], 16.86-21.41), eight (aOR, 7.71; 95% CI, 7.05-8.43), and 23 times (aOR, 23.16; 95% CI, 20.74-25.87) higher odds of exposure to SHS inside, outside, and both inside and outcome home, respectively. Conclusions Approximately one third and two fifths of never-smoking adolescents were exposed to SHS inside or outside home, and smoking parents and/or peers are the key factors. Study findings highlight the need to develop and implement comprehensive smoke-free policies consistent with the World Health Organization Framework Convention on Tobacco Control.

Tobacco use continues to be the leading cause of preventable death in the world. The disproportionate increase in tobacco use in low- and middle-income countries needs immediate attention. Many smokers begin smoking as adolescents and are most likely to become permanent smokers. Moreover, youth are highly targeted by tobacco industry strategies. However, a gap exists in literature to understand worldwide youth tobacco use and control. The purpose of this study is to 1) identify factors that influence never-smoking youths‟ smoking susceptibility, 2) explore characteristics that influence youth exposure to environmental tobacco smoke (ETS) and 3) to delineate key determinants of youth support for smoke-free policies (SFPs). Data related to worldwide youth tobacco use was obtained from the Global Youth Tobacco Survey for the years 1999-2008. Simple and multiple logistic regression analyses were conducted, after the sample was weighted for design effect, nonresponse patterns and poststratification. Unadjusted and adjusted odds ratios along with 95% confidence intervals were reported. Around 14% of never-smoking youth were susceptible to smoking worldwide. Around 40% and 50% youth were exposed to ETS inside and outside the home respectively, and 78% supported SPFs globally. Parental and peer smoking was strongly associated with smoking susceptibility in never-smoking youth [AOR 2.63, 95% CI 2.43 to 2.84], and youth exposure to ETS inside [AOR 5.09, 95% CI 4.84 to 5.35] and outside [AOR 2.51, 95% CI 2.39 to 2.63] the home, while anti-smoking school education was negatively associated. Youth having knowledge about smoking harm [AOR 2.37, 95% CI 2.22 to 2.54] supported SFPs, while youth exposed to tobacco industry promotion [AOR 0.83, 95% CI 0.78 to 0.89] did not support. The study highlighted a number of modifiable factors that can be used for augmenting global tobacco control in youth. Well-executed anti-smoking campaigns, parental and peer education, inclusion of anti-tobacco education in school curricula, comprehensive SFPs, and comprehensive ban on tobacco industry strategies are important approaches to prevent tobacco use and advance global tobacco control in youth.

Introdução - As leis de restrição ao fumo têm sido amplamente difundidas pelo mundo principalmente na última década. Estudos prévios e meta análises têm demonstrado uma redução nas taxas de infarto do miocárdio após a vigência dessas leis. Entretanto, para a população latino-americana, as informações ainda são escassas. Na primeira fase deste estudo foi demonstrada a implementação bem sucedida da lei anti fumo na cidade de São Paulo, com uma redução expressiva nos níveis de monóxido de carbono em restaurantes, bares e casas noturnas. Objetivo - Avaliar se a implementação da lei anti fumo na cidade de São Paulo em 2009 foi associada a uma redução nas taxas de mortalidade e internação hospitalar por infarto do miocárdio e acidente vascular cerebral. Métodos - Foi realizado um estudo de séries temporais mensais entre janeiro de 2005 e dezembro de 2010. Os dados foram provenientes do DATASUS, o principal sistema de informação pública de saúde disponível no Brasil e do Sistema de Informação sobre Mortalidade (SIM). A análise foi realizada utilizando o método Auto-regressivo, Integrado e de Médias Móveis com variáveis exógenas (ARIMAX), modelado por variáveis ambientais e poluentes atmosféricos para avaliar as taxas de mortalidade e internação hospitalar antes da lei e prever os eventos após a lei. Também foi realizada análise utilizando o método de Análise de Séries Temporais Interrompida (ITSA), em conjunto com o ARIMAX, para comparar o período anterior à lei, o momento em que entrou em vigor e o período após a lei. Resultados - Foi observada uma redução nas taxas de internação hospitalar (-5.4% nos primeiros 3 meses após a lei) e mortalidade (-11.9% nos primeiros 17 meses após a lei) por infarto do miocárdio com o método ARIMAX e uma redução na taxa de internação hospitalar (-7,4% entre o 7º e o 12º mês após a lei) e mortalidade (-5,3% nos primeiros 17 meses após a lei) por acidente vascular cerebral, com a mesma metodologia. Conclusão - As taxas de internação hospitalar e mortalidade por infarto do miocárdio e acidente vascular cerebral foram reduzidas após o início da vigência da lei anti fumo / Background - Smoking restriction laws have spread worldwide during the last decade. Previous studies and meta-analyses have shown a decline in the community rates of myocardial infarction and/or heart attack after enactment of these laws. However, data are scarce about the Latin American population. In the first phase of this study, we reported the successful implementation of the law in São Paulo city, with a decrease in carbon monoxide rates in places like restaurants, bars, and nightclubs. Objective - To evaluate whether the 2009 implementation of a smoking ban law in São Paulo city was associated with a reduction in rates of mortality and hospital admissions for myocardial infarction and stroke. Methods - We performed a time series study of monthly rates of mortality and hospital admissions for acute myocardial infarction and stroke from January 2005 to December 2010. The data were derived from DATASUS, the primary public health information system available in Brazil and from Mortality Information System (SIM). Adjustments and analyses were performed using the Autoregressive Integrated Moving Average with exogenous variables (ARIMAX) method modeled by environmental variables and atmospheric pollutants to evaluate the mortality and hospital admission rate before the law and forecast events after the law. We also used Interrupted Time Series Analysis (ITSA) in conjunction with ARIMAX to compare the period before the law, the moment of implementation of the law, and the period after the law. Results - We observed a reduction in hospital admission rate (-5.4% in the first 3 months after the law) and mortality rate (-11.9% in the first 17 months after the law) for myocardial infarction with ARIMAX method. We observed a reduction in hospital admission rate (-7,4% between the 7th and the 12th month after the law) and mortality rate (-5,3% in the first 17 months after the law) for stroke with ARIMAX method. Conclusions - Hospital admission rate and mortality rate for myocardial infarction and stroke were reduced after the smoking ban law was implemented

Introdução - As leis de restrição ao fumo têm sido amplamente difundidas pelo mundo principalmente na última década. Estudos prévios e meta análises têm demonstrado uma redução nas taxas de infarto do miocárdio após a vigência dessas leis. Entretanto, para a população latino-americana, as informações ainda são escassas. Na primeira fase deste estudo foi demonstrada a implementação bem sucedida da lei anti fumo na cidade de São Paulo, com uma redução expressiva nos níveis de monóxido de carbono em restaurantes, bares e casas noturnas. Objetivo - Avaliar se a implementação da lei anti fumo na cidade de São Paulo em 2009 foi associada a uma redução nas taxas de mortalidade e internação hospitalar por infarto do miocárdio e acidente vascular cerebral. Métodos - Foi realizado um estudo de séries temporais mensais entre janeiro de 2005 e dezembro de 2010. Os dados foram provenientes do DATASUS, o principal sistema de informação pública de saúde disponível no Brasil e do Sistema de Informação sobre Mortalidade (SIM). A análise foi realizada utilizando o método Auto-regressivo, Integrado e de Médias Móveis com variáveis exógenas (ARIMAX), modelado por variáveis ambientais e poluentes atmosféricos para avaliar as taxas de mortalidade e internação hospitalar antes da lei e prever os eventos após a lei. Também foi realizada análise utilizando o método de Análise de Séries Temporais Interrompida (ITSA), em conjunto com o ARIMAX, para comparar o período anterior à lei, o momento em que entrou em vigor e o período após a lei. Resultados - Foi observada uma redução nas taxas de internação hospitalar (-5.4% nos primeiros 3 meses após a lei) e mortalidade (-11.9% nos primeiros 17 meses após a lei) por infarto do miocárdio com o método ARIMAX e uma redução na taxa de internação hospitalar (-7,4% entre o 7º e o 12º mês após a lei) e mortalidade (-5,3% nos primeiros 17 meses após a lei) por acidente vascular cerebral, com a mesma metodologia. Conclusão - As taxas de internação hospitalar e mortalidade por infarto do miocárdio e acidente vascular cerebral foram reduzidas após o início da vigência da lei anti fumo / Background - Smoking restriction laws have spread worldwide during the last decade. Previous studies and meta-analyses have shown a decline in the community rates of myocardial infarction and/or heart attack after enactment of these laws. However, data are scarce about the Latin American population. In the first phase of this study, we reported the successful implementation of the law in São Paulo city, with a decrease in carbon monoxide rates in places like restaurants, bars, and nightclubs. Objective - To evaluate whether the 2009 implementation of a smoking ban law in São Paulo city was associated with a reduction in rates of mortality and hospital admissions for myocardial infarction and stroke. Methods - We performed a time series study of monthly rates of mortality and hospital admissions for acute myocardial infarction and stroke from January 2005 to December 2010. The data were derived from DATASUS, the primary public health information system available in Brazil and from Mortality Information System (SIM). Adjustments and analyses were performed using the Autoregressive Integrated Moving Average with exogenous variables (ARIMAX) method modeled by environmental variables and atmospheric pollutants to evaluate the mortality and hospital admission rate before the law and forecast events after the law. We also used Interrupted Time Series Analysis (ITSA) in conjunction with ARIMAX to compare the period before the law, the moment of implementation of the law, and the period after the law. Results - We observed a reduction in hospital admission rate (-5.4% in the first 3 months after the law) and mortality rate (-11.9% in the first 17 months after the law) for myocardial infarction with ARIMAX method. We observed a reduction in hospital admission rate (-7,4% between the 7th and the 12th month after the law) and mortality rate (-5,3% in the first 17 months after the law) for stroke with ARIMAX method. Conclusions - Hospital admission rate and mortality rate for myocardial infarction and stroke were reduced after the smoking ban law was implemented