Plain packaging can arguably reduce the appeal of cigarette packages and deter people from smoking. In this study, a 1 (brand type) X 4 (levels of plain packages) betweensubject design was utilized. The method used was an internet survey. 220 adult smokers and non-smokers from Halifax Regional Municipality (HRM) rated packages in terms of their brand imagery characteristics and answered a single multiple choice question to test their recall of the health warning on their package. According to the results of a MANOVA test and a bivariate logistic regression test of perception attributes, the association between plainer packages and the participants’ ratings for some attributes were significant, and ranged from slightly moderate to moderate strength levels of associations. Health warnings recall and plainer packages were also significantly and moderately associated. These associations provide a compelling argument for the need for plain packaging policies as a deterrent for smoking.

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.

Introduction This study aims to provide an assessment of tobacco control methods (e.g., smoking ban policies and smoking cessation services) implemented in mental health facilities (MHFs) by characteristics such as facility type, ownership, Joint Commission Accreditation Healthcare Organization (JCAHO) status, and region in the United States. Methods Secondary analysis was conducted using the 2010-2011 National Mental Health Services Survey (N-MHSS). Binomial frequency, chi-square, and logistic regression were used to determine the proportion of tobacco control methods, the relationship between characteristics and tobacco control methods, and predictors of facilities that use tobacco control methods, respectively. Results Findings show smoking ban policies were in less than half of MHFs and smoking cessation services were offered in less than a quarter of all MHFs. Analyses revealed a strong association across all characteristics and tobacco control methods in MHFs. Multivariate analysis showed that when compared to inpatient facilities, residential treatment centers for adults were less likely to have a smoking ban policy, OR=0.050, CI (0.039-0.065) and less likely to offer smoking cessation services, OR=0.072 CI (0.054- 0.095). Compared to MHFs accredited by JCAHO, MHFs unaccredited by JCAHO were less likely to have a smoking ban policy, OR =0.386 CI, (0.354-0.423) and less likely to offer smoking cessation services, OR =0.295, CI, (0.267-0.327). Discussion There is a clear deficit in tobacco control methods that vary across facility characteristics of MHFs. Findings of facility characteristics and tobacco control methods may direct future researchers, program interventionists, policymakers to target facilities where tobacco control is needed the most.

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.

This is a comprehensive study of tobacco control policy and politics in the European Union, 1970-2000. I develop an instrumental theory of public policy which establishes an approach for connecting policy instruments to policy outcomes. I investigate ways in which political, bureaucratic and interest group (particularly the tobacco industry) factors influence the success of policy instruments aimed at reducing cigarette consumption. I also explore whether and how supranational mandates and directives influence the success of national-level efforts to control tobacco. I test hypotheses empirically using pooled time-series methodologies. The substantive conclusion is that non-price policies are only a qualified success when controlling for addiction, price policy and factors in the policy environment. Price policy is consistently effective, cross-nationally and the public health bureaucracy is a key player in curbing consumption of cigarettes. Major theoretical conclusions include affirmation that supranational policy actions can shape national policy outcomes, that interest group pluralism favors those with a comparative advantage in organizing (in this case, the tobacco industry), and that while policy instruments can be evaluated according to their behavioral attributes, caution should be exercised when simultaneous policy adoption is occurring.

PURPOSE: To evaluate Canada’s most comprehensive outdoor smoke-free ordinance, in Woodstock, Ontario, using both quantitative (longitudinal cohort survey) and qualitative methods (key informant interviews with policy makers). Measures include levels of support for outdoor smoking restrictions, smoking behaviour in outdoor environments, measures of the social denormalization of smoking, measures of concern about litter or fires caused by discarded cigarette butts, and reported changes in use of services, facilities or businesses that were regulated by the by-law. This study also sought to understand aspects of the policy development process and determine to how relevant the findings may be to other communities across Canada, and the world. BACKGROUND: The City of Woodstock, Ontario created a comprehensive outdoor smoke-free ordinance (OSFO) that came into effect on September 1, 2008. This by-law restricted or banned smoking in 5 different outdoor environments owned or regulated by the city including patios on downtown sidewalk cafés, parks and recreational fields, areas around transit stops and shelters, and doorways of city run facilities such as city hall. The by-law also created two schedules to further regulate smoking in other outdoor environments if elected by citizens in the community; one for non-city-owned properties such as private business to regulate smoking in their doorway environments and a second schedule for outdoor events organized by groups in the community. The schedules allowed council to pass a by-law that could easily regulate and enforce additional smoke-free environments, as requested by citizens, without the need for council approval. METHODS: Qualitative and quantitative methods were used to address the research objectives. Quantitative measures were collected using a pre-post survey design, interviewing smokers and non-smokers, in the City of Woodstock, and a neighbouring community (Ingersoll) in the same county (Oxford County). Before the by-law was enacted, two surveys were conducted. The telephone survey (August 13-28, 2008) was a random digit dialled (RDD) general adult population survey of non-smokers (n=373) and smokers (n=234). A face-to-face survey (August 13-19, 2008) was conducted among a targeted sample of smokers who were observed smoking in one of the outdoor areas that was to become smoke-free in accordance with the by-law (n=176). Face-to-face interviewers used handheld Palm III devices to assist in the interviewing of these respondents. Surveying both samples ensured the beliefs, attitudes, and behaviour of those smokers who, given circumstances of their recruitment, would be more likely to be affected by the by-law, would be measured in this evaluation study. Using a longitudinal cohort design, respondents from both Wave 1 surveys were re-contacted by telephone in approximately one year after the ban was implemented (August 18-September 15, 2009), to measure changes in the key outcome variables. The Wave 2 survey was conducted entirely by telephone with no replenishment. The Wave 2 survey included respondents that were successfully re-contacted from the general population sample (non-smokers n=299, smokers n=182), and respondents from the targeted sample (n=61). This qualitative study sought to identify any specific lessons or findings from the process undertaken that would be applicable or helpful to other communities. The qualitative study involved 6 key informant interviews with identified public health and city staff and an elected official who were involved in different aspects of the by-law, from development to enforcement. The data collected from the key informant interviews was analysed using an inductive qualitative method called the ‘framework approach’. RESULTS: After the Woodstock outdoor smoking restrictions had been in place for approximately 1 year, most respondents from the general population survey, smokers, (71%), and non-smokers (93%), supported or strongly supported the by-law. Most smokers (82%) and non-smokers (96%) agreed or strongly agreed that the by-law had been good for the health of the children of Woodstock. The by-law was also associated with increased quit intentions; 15% of the smokers from the general population sample reported that the smoke-free by-law made them more likely to quit, and approximately 26% of the smokers from the targeted sample reported the by-law made them more likely to quit. Smokers from both the general population (30%) and the targeted sample (42%) reported that the smoke-free outdoor by-law had helped them cut down on the number of cigarettes they smoke. There were 30 respondents in the Wave 1 survey that were smokers, who had successfully quit at the time of the Wave 2 survey. Of these ‘quitters’, 33% reported that they outdoor smoke-free by-law had helped them to quit smoking, and approximately half (48%) reported that they by-law had helped them to stay a non-smoker. The overwhelming majority of smokers reported that the by-law did not impact their use of facilities or businesses that had been regulated by the by-law. The key informant interviews revealed that the outdoor smoke-free ordinance was developed by following a standard public health policy development process that involved community (public) participation, exploration of policy options, and a political decision made by the city’s elected officials. It was identified that the implementation of two schedules in the by-law, which allows for expansion of the environments regulated and enforced by the city, was an effective strategy to gradually increase smoke-free spaces without burdening the City Council with regular needs to amend or update a by-law. Appropriate public relations were engaged including disseminating information about the by-law, and publicizing it through established networks in the community. Signage in the regulated environments, and enforcement were considered critical by the implementation team. City staff members recommended that other communities should consider passing similar by-laws and dedicate more effort to implementing and enforcing restrictions, rather than discussing or debating whether or not to enact a by-law. An analysis of the key informant interviews revealed that there were no unique features or circumstances specific to Woodstock that would suggest this by-law could not be developed or passed in another area municipality provided the community already has established smoke-free policies in indoor or enclosed public spaces. If Woodstock is unique in any way, it was in the presence of conditions such as high smoking prevalence and close proximity to tobacco growing regions that make it less likely to have successfully enacted an outdoor smoke-free ordinance. CONCLUSION: Support for the Woodstock comprehensive outdoor smoking by-law is high among smokers and non-smokers. The overwhelming majority of residents interviewed supported the by-law and felt that the by-law was good for the health of the children of Woodstock. The by-law has not had negative impacts on use of facilities including parks and recreational fields. Further, a third of smokers reported that the outdoor by-law has helped them to cut down how much they smoke and almost a fifth of smokers reported that the by-law has made them more likely to quit smoking. Approximately half of the quitters in the sample also reported the by-law helped them to stay quit. These findings suggest that expanding smoke-free ordinances to include a range of outdoor environments will be supported by citizens, and will help smokers to reduce how much they smoke, encourage quitting and help those that quit, remain abstinent. The findings from the key informant interviews suggest that other jurisdictions should explore expanding their smoke-free ordinances to include outdoor environments, particularly environments frequented by children.

This is a comprehensive study of tobacco control policy and politics in the European Union, 1970-2000. I develop an instrumental theory of public policy which establishes an approach for connecting policy instruments to policy outcomes. I investigate ways in which political, bureaucratic and interest group (particularly the tobacco industry) factors influence the success of policy instruments aimed at reducing cigarette consumption. I also explore whether and how supranational mandates and directives influence the success of national-level efforts to control tobacco. I test hypotheses empirically using pooled time-series methodologies. The substantive conclusion is that non-price policies are only a qualified success when controlling for addiction, price policy and factors in the policy environment. Price policy is consistently effective, cross-nationally and the public health bureaucracy is a key player in curbing consumption of cigarettes. Major theoretical conclusions include affirmation that supranational policy actions can shape national policy outcomes, that interest group pluralism favors those with a comparative advantage in organizing (in this case, the tobacco industry), and that while policy instruments can be evaluated according to their behavioral attributes, caution should be exercised when simultaneous policy adoption is occurring.

Background: The implementation of comprehensive smoking ban policies results in reduced population exposure to secondhand smoke, yielding health benefits such as improved respiratory function and decreased risk of cardiovascular events. However, smoking ban effects on respiratory and cerebrovascular mortality and effect differences by socioeconomic status (SES) are unknown. Methods: A literature review was conducted to understand the health benefits of smoking ban policies and to identify areas of research that needed to be addressed. Subsequently, an epidemiologic study employing an interrupted time-series approach was conducted with a national mortality dataset from the Republic of Ireland to determine effects following the implementation of the national workplace smoking ban. Irish census data were used to calculate frequencies of deprivation at the level of the local authority and principal component analysis was conducted to generate a composite SES index. To determine whether the smoking ban policy impacted inequalities, Poisson regression with interrupted time-series analysis was conducted to examine mortality rates, stratified by tertiles of discrete SES indicators and the composite index. Results: The review identified strong evidence for post-ban reductions in cardiovascular morbidity and mortality, and suggestive evidence of reductions in respiratory morbidity following smoking ban implementation. Few studies assessed ban effects by SES and findings were inconsistent; hence, insufficient evidence was available to determine smoking ban policy impacts on health inequalities. Epidemiologic analyses demonstrated that the national Irish smoking ban was associated with immediate reductions in early mortality for cardiovascular, cerebrovascular, and respiratory causes. Further analyses by discrete socioeconomic indicators and a composite index indicated that the national Irish smoking ban was associated with decreased inequalities in smoking-related mortality. Conclusions: Smoking ban policies are effective public health interventions for the prevention of cardiovascular, cerebrovascular, and respiratory mortality. Furthermore, findings indicate that smoking ban policies have the potential to reduce inequalities in mortality.

PURPOSE: To evaluate Canada’s most comprehensive outdoor smoke-free ordinance, in Woodstock, Ontario, using both quantitative (longitudinal cohort survey) and qualitative methods (key informant interviews with policy makers). Measures include levels of support for outdoor smoking restrictions, smoking behaviour in outdoor environments, measures of the social denormalization of smoking, measures of concern about litter or fires caused by discarded cigarette butts, and reported changes in use of services, facilities or businesses that were regulated by the by-law. This study also sought to understand aspects of the policy development process and determine to how relevant the findings may be to other communities across Canada, and the world. BACKGROUND: The City of Woodstock, Ontario created a comprehensive outdoor smoke-free ordinance (OSFO) that came into effect on September 1, 2008. This by-law restricted or banned smoking in 5 different outdoor environments owned or regulated by the city including patios on downtown sidewalk cafés, parks and recreational fields, areas around transit stops and shelters, and doorways of city run facilities such as city hall. The by-law also created two schedules to further regulate smoking in other outdoor environments if elected by citizens in the community; one for non-city-owned properties such as private business to regulate smoking in their doorway environments and a second schedule for outdoor events organized by groups in the community. The schedules allowed council to pass a by-law that could easily regulate and enforce additional smoke-free environments, as requested by citizens, without the need for council approval. METHODS: Qualitative and quantitative methods were used to address the research objectives. Quantitative measures were collected using a pre-post survey design, interviewing smokers and non-smokers, in the City of Woodstock, and a neighbouring community (Ingersoll) in the same county (Oxford County). Before the by-law was enacted, two surveys were conducted. The telephone survey (August 13-28, 2008) was a random digit dialled (RDD) general adult population survey of non-smokers (n=373) and smokers (n=234). A face-to-face survey (August 13-19, 2008) was conducted among a targeted sample of smokers who were observed smoking in one of the outdoor areas that was to become smoke-free in accordance with the by-law (n=176). Face-to-face interviewers used handheld Palm III devices to assist in the interviewing of these respondents. Surveying both samples ensured the beliefs, attitudes, and behaviour of those smokers who, given circumstances of their recruitment, would be more likely to be affected by the by-law, would be measured in this evaluation study. Using a longitudinal cohort design, respondents from both Wave 1 surveys were re-contacted by telephone in approximately one year after the ban was implemented (August 18-September 15, 2009), to measure changes in the key outcome variables. The Wave 2 survey was conducted entirely by telephone with no replenishment. The Wave 2 survey included respondents that were successfully re-contacted from the general population sample (non-smokers n=299, smokers n=182), and respondents from the targeted sample (n=61). This qualitative study sought to identify any specific lessons or findings from the process undertaken that would be applicable or helpful to other communities. The qualitative study involved 6 key informant interviews with identified public health and city staff and an elected official who were involved in different aspects of the by-law, from development to enforcement. The data collected from the key informant interviews was analysed using an inductive qualitative method called the ‘framework approach’. RESULTS: After the Woodstock outdoor smoking restrictions had been in place for approximately 1 year, most respondents from the general population survey, smokers, (71%), and non-smokers (93%), supported or strongly supported the by-law. Most smokers (82%) and non-smokers (96%) agreed or strongly agreed that the by-law had been good for the health of the children of Woodstock. The by-law was also associated with increased quit intentions; 15% of the smokers from the general population sample reported that the smoke-free by-law made them more likely to quit, and approximately 26% of the smokers from the targeted sample reported the by-law made them more likely to quit. Smokers from both the general population (30%) and the targeted sample (42%) reported that the smoke-free outdoor by-law had helped them cut down on the number of cigarettes they smoke. There were 30 respondents in the Wave 1 survey that were smokers, who had successfully quit at the time of the Wave 2 survey. Of these ‘quitters’, 33% reported that they outdoor smoke-free by-law had helped them to quit smoking, and approximately half (48%) reported that they by-law had helped them to stay a non-smoker. The overwhelming majority of smokers reported that the by-law did not impact their use of facilities or businesses that had been regulated by the by-law. The key informant interviews revealed that the outdoor smoke-free ordinance was developed by following a standard public health policy development process that involved community (public) participation, exploration of policy options, and a political decision made by the city’s elected officials. It was identified that the implementation of two schedules in the by-law, which allows for expansion of the environments regulated and enforced by the city, was an effective strategy to gradually increase smoke-free spaces without burdening the City Council with regular needs to amend or update a by-law. Appropriate public relations were engaged including disseminating information about the by-law, and publicizing it through established networks in the community. Signage in the regulated environments, and enforcement were considered critical by the implementation team. City staff members recommended that other communities should consider passing similar by-laws and dedicate more effort to implementing and enforcing restrictions, rather than discussing or debating whether or not to enact a by-law. An analysis of the key informant interviews revealed that there were no unique features or circumstances specific to Woodstock that would suggest this by-law could not be developed or passed in another area municipality provided the community already has established smoke-free policies in indoor or enclosed public spaces. If Woodstock is unique in any way, it was in the presence of conditions such as high smoking prevalence and close proximity to tobacco growing regions that make it less likely to have successfully enacted an outdoor smoke-free ordinance. CONCLUSION: Support for the Woodstock comprehensive outdoor smoking by-law is high among smokers and non-smokers. The overwhelming majority of residents interviewed supported the by-law and felt that the by-law was good for the health of the children of Woodstock. The by-law has not had negative impacts on use of facilities including parks and recreational fields. Further, a third of smokers reported that the outdoor by-law has helped them to cut down how much they smoke and almost a fifth of smokers reported that the by-law has made them more likely to quit smoking. Approximately half of the quitters in the sample also reported the by-law helped them to stay quit. These findings suggest that expanding smoke-free ordinances to include a range of outdoor environments will be supported by citizens, and will help smokers to reduce how much they smoke, encourage quitting and help those that quit, remain abstinent. The findings from the key informant interviews suggest that other jurisdictions should explore expanding their smoke-free ordinances to include outdoor environments, particularly environments frequented by children.