published_or_final_version / Politics and Public Administration / Master / Master of Public Administration

Background Smoking prevalence is the highest in people with mental illness. As more and more countries develop governmental regulations to protect employees from exposure to environmental tobacco smoke, complete smoking bans or partial smoking bans have been introduced in many psychiatric hospitals. Objectives To systematically review the literature to examine the impact of smoking bans in psychiatric hospitals, to identify the obstacles to implement tobacco-free policy and provide recommendations for policy-making in Mainland China on implementing tobacco-free policy in psychiatric hospitals. Methods Multiple searches for key words were conducted through electronic sources including PubMed, Medline, PsycINFO, Cochrane Library, Google Scholar, and CNKI database for all relevant English language and Chinese language articles. The PICO (patient problem or population, intervention, comparison and outcomes) indicators were used as basic inclusion/exclusion criteria, data extraction and quality assessment. Results A total of 227 studies were identified (188 English language articles including 4 reviews and 39 Chinese language articles), and 25 articles (19 English articles and 5 Chinese articles) were included in this paper. For the English language studies, psychiatric inpatients generally had positive attitudes towards the tobacco-free policy in psychiatric hospitals and increasing number of inpatients wanted to quit smoking after hospitalized in a tobacco-free psychiatric hospital. Increasing number of staff members working in psychiatric hospitals were supportive of the tobacco-free policy compared to previous reviews. No change in patients’ aggressive behaviors after implementing smoking bans in the psychiatric hospitals was observed in most studies. Factors identified for successful implementation of tobacco-free policy in psychiatric hospitals included comprehensive planning time, good leadership and significant attitudinal and system changes, high level and consistency of staff support and cohesive teamwork, extensive training for staff and effective use of nicotine replacement therapy (NRT). For the Chinese language studies, negative outcomes of psychiatric inpatients were observed after a total smoking ban in one psychiatric hospital, but positive effects were observed when only the smoking amount was controlled in four psychiatric hospitals. Conclusions The tobacco-free policy aims at eliminating tobacco smoking for both staff members and patients in psychiatric hospitals so as to create a healthy place for work and stay. This goal can be achieved with the efforts of the hospitals and staff, and the cooperation of patients. National legislation to ban smoking in all hospitals, indoor and outdoor, are urgently needed in China Mainland. / published_or_final_version / Public Health / Master / Master of Public Health

The social norms concept provides a fresh basis for thinking about how public health policies and campaigns impact health behaviour. Social norms offer much promise to the field of public health, nonetheless, the potential role of norms in changing health behaviour have not been fully embraced. This thesis demonstrates that one of the mechanisms by which national level policies (e.g. tobacco control) can promote health behaviour change, such as an increase in quit intentions, is by making smoking less normative and an undesirable behaviour. This study is vital as it provides a broad conceptualization of tobacco denormalisation and shows how its reasoning is able to influence normative beliefs and smoking behaviour. A review of literature was carried out to establish the generic origins of denormalisation as well as demonstrate that this approach (i.e. social norms) has been widely adopted in schools and college settings to influence health behaviour. As a broader perspective of this thinking was imperative to address public health issues at a societal level, tobacco control was employed to investigate how individual polices influence behaviour and normative beliefs. The research methodology used was pluralistic in nature, given that the majority of past tobacco control policy studies employed either quantitative or qualitative methods. Thus adopting both methods a richer amount of data would be obtained in order to generate an improved understanding of how public policy affects norms and smoking behaviour. To empirically examine the relationship between public policy, social norms and smoking behaviour a broad conceptualization was developed to investigate the normative pathways between national level tobacco policy effects on youth and adults’ smoking behaviour. Quantitative results from the longitudinal study, the International Tobacco Control (ITC) Scotland/UK survey, indicate that a comprehensive smoke-free law that covers, without exception, an entire nation (i.e. Scotland) has increased adult smokers’ perceived social unacceptability of smoking, to some extent higher in Scotland than rest of the UK which, in turn, is associated with quit intentions at follow-up, in both countries. The examination of data from the UK Youth Tobacco Policy Study (YTPS) also demonstrated that the influence of tobacco marketing awareness on adolescents’ smoking intentions is mediated by perceived norms. Prior to the enactment of the UK Tobacco Advertising and Promotion Act (TAPA), higher levels of awareness of tobacco advertising and promotion were independently associated with higher levels of perceived sibling approval which, in turn, were positively related to smoking intentions. Independent paths from perceived smoking prevalence and benefits fully mediated the effects of advertising and promotion awareness on intentions, during and after the enactment of the TAPA. Results from the qualitative study generally supported the quantitative findings and provided new insights into how adolescents’ normative beliefs and smoking behaviour are influenced by tobacco control policies. The qualitative group discussion suggests that smoke-free legislation and anti-smoking ads influence perceptions of prevalence, acceptability and smoking behaviour. A number of theoretical implications were presented, including the belief that social norms campaigns and interventions must be focal and salient in individuals’ consciousness so as to effect the desired behaviour change. A theoretical framework of the various normative mechanisms should consequently be integrated into tobacco control policies and norm-based interventions to work in a synergistic manner to influence health-related behaviour. Practical implications of this conceptualization include the view that, instead of public health interventions focusing on conventional approaches (for example, scare tactics), an appropriate strategy would be to incorporate specific information that corrects normative misperceptions and ambiguities among referent populations at individual and societal levels, with consequential normative and health behaviour change. It is recommended that future research employing tobacco industry perceptions and possibly a descriptive norm as additional normative mediators, aside from unacceptability, would be of value to examine whether smoke-free legislation influences quitting partly via changing favourable tobacco industry perceptions, social acceptability of smoking and perceived prevalence of smoking. To sum up, the findings demonstrate that societal level policy measures such as smoke-free legislation and the TAPA are critical elements of a comprehensive tobacco control program that can significantly influence adult smokers’ quit intentions and reduce adolescents’ smoking intentions respectively, by signifying smoking to be less normative and to be socially unacceptable.

Indiana University-Purdue University Indianapolis (IUPUI) / Smoke-free legislation in the United States has unintentionally resulted in a decline in alcohol consumption. However, more recently electronic-cigarettes (e-cigs), which are associated with alcohol use, are reportedly being used to circumvent smoking bans. The present study surveyed community dwelling individuals in the United States reporting e-cigs may be used where they drink (N=365, mean age=33.63, SD=9.91, 53.2% female, 78.9% Caucasian) to examine how e-cig use and alcohol consumption varies by the presence of smoking prohibition where one consumes alcohol. Results indicated that smoking prohibition was associated with a greater likelihood of being an ecig user than a cigarette user (OR=3.40, p<.001) and a higher likelihood of being an e-cig user than a dual user (OR=3.37, p<.001). Smoking prohibition was not associated with AUDIT scores (B=-0.06, p=.21), total drinks (B=-.07, p=.19), or average drinks (B=-0.02, p=.76). E-cig users reported significantly fewer average drinks when smoking is prohibited as compared to allowed, t(55)=3.26, p=.002. Overall, current results suggest smoking prohibition is associated with a greater likelihood of being an e-cig user; however, smoking prohibitions are not associated with alcohol consumption and related problems in the current participants, who all reported being able to use e-cigs where they consume alcohol. Future research should address potential conceptual, methodological, and sample limitations in order to better discern this relationship, as this line of research could have important implications for e-cig policy and alcohol use treatment