Application of a rating system to state clean indoor air laws (USA)

OBJECTIVE: To develop and implement a system for rating state clean indoor air laws. DESIGN: The public health interest of state clean indoor air laws is to limit non-smoker exposure to environmental tobacco smoke (ETS). Current estimates of health risks and methods available for controlling ETS provided a framework for devising a ratings scale. An advisory committee applied this scale to each of seven site specific smoking restrictions and two enforcement related items. For each item, a target score of +4 was identified. The nine items were then combined to produce a summary score for each state. A state that achieved the target across all nine items would receive a summary score of 36 points and be eligible to receive an additional 6 points for exceeding the target on six of the nine items, resulting in a maximum summary score of 42 points. Individual scores were also adjusted to reflect state level preemption measures. Each state's law was evaluated annually from 1993 through 1999. SETTING: USA. MAIN OUTCOME MEASURE: A summary score measuring the extensiveness of the state's clean indoor air law. RESULTS: State laws restricting smoking in the seven individual locations of interest were relatively weak. The overall mean score across the location restrictions ranged from 0.72 in 1993 to 0.98 in 1999. Mean scores were higher for the enforcement items than for the location restrictions. Summary scores ranged from 0 to 20 in 1993 and 0 to 31 in 1994 through 1999. Average summary scores ranged from 8.71 in 1993 to 10.98 in 1999. By the end of 1999, scores increased for 22 states; however, between 1995 and 1997 there were no changes in the summary scores. Three states scored zero points across all years. From 1993 through 1999, there was a 41% increase in the number of states that had in place state level preemption measures. CONCLUSION: The number of newly enacted state clean indoor air laws has remained relatively stagnant since 1995. With a few exceptions, as of the end of 1999, progress in enacting state laws to meet specified public health targets for reducing exposure to ETS was relatively low. Thus, state laws in the USA provide, on average, only minimal protection in specified areas and, given the increase in preemption, are increasingly undermining those passed in localities.     

Reducing children's exposure to environmental tobacco smoke in homes: issues and strategies

It is now well established that children's exposure to environmental tobacco smoke (ETS) results in substantial public health and economic impacts. Children are more likely than adults to suffer health effects from ETS exposure, and the home is the most important site of such exposure.
  Although the responsibility and authority of the community and health professionals to protect children from harm are entrenched in North American society, social, economic, legal, and political factors contribute to a lower level of support for ETS control measures in homes compared with workplaces and public places. It is now clear that ETS control in home environments must be a priority on the public health agenda. Programme and policy options and strategies for ETS control in home environments are outlined. We conclude that the current research base is inadequate to fully support programme and policy development in this area and priorities for research are identified.


Keywords: environmental tobacco smoke; homes; children     

Tobacco industry success in preventing regulation of secondhand smoke in Latin America: the "Latin Project"

OBJECTIVE: To examine the tobacco industry's strategy to avoid regulations on secondhand smoke exposure in Latin America. METHODS: Systematic search of tobacco industry documents available through the internet. All available materials, including confidential reports regarding research, lobbying, and internal memoranda exchanged between the tobacco industry representatives, tobacco industry lawyers, and key players in Latin America. RESULTS: In Latin America, Philip Morris International and British American Tobacco, working through the law firm Covington & Burling, developed a network of well placed physicians and scientists through their "Latin Project" to generate scientific arguments minimising secondhand smoke as a health hazard, produce low estimates of exposure, and to lobby against smoke-free workplaces and public places. The tobacco industry's role was not disclosed. CONCLUSIONS: The strategies used by the industry have been successful in hindering development of public health programmes on secondhand smoke. Latin American health professionals need to be aware of this industry involvement and must take steps to counter it to halt the tobacco epidemic in Latin America.     

Hair as a biomarker for exposure to tobacco smoke

This article provides an overview of the hair nicotine biomarker for assessment of exposure to tobacco smoke, with emphasis on environmental tobacco smoke (ETS). Measurement of nicotine in hair can be an informative tool for research looking at ETS and related illnesses. There are still unresolved issues in relation to this biomarker such as influence of hair treatment, hair colour, and growth rate on nicotine levels in hair, which need to be addressed in order to further refine this biomarker for exposure assessment. Nevertheless, hair nicotine promises to be a valid and reliable measure of longer term exposure that can be readily applied in epidemiological studies of exposure to tobacco smoke, and more specifically ETS, and its risk to health.     

Environmental tobacco smoke exposure in public places of European cities

Background: Exposure to environmental tobacco smoke (ETS) has important public health implications. The results of the first European multi-centre study that measured ETS exposure in a range of public places (transport, educational settings, and leisure facilities such as bars and restaurants) are presented.     

Strength of clean indoor air laws and smoking related outcomes in the USA

Objectives: Environmental tobacco smoke (ETS) is often encountered in the workplace. There have been efforts to apply and enforce state laws limiting workplace smoking. There has been little study of the relative effectiveness of state and/or local laws in affecting both rates of workplace ETS exposure and adult smoking rates. This study investigates these hypotheses, as well as the effect of these laws on youth smoking.

Design: This is a secondary data analysis using sources including the Current Population Survey (CPS), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Survey (YRBS), and the National Household Survey of Drug Abuse (NHSDA) between the years of 1996 and 1999. Linear regression models were used to investigate the effect of a state's clean indoor air (CIA) law (using a measure of extensiveness) on the overall amount of people who reported working in a smoke-free environment, youth smoking rates and adult smoking rates.

Results: The extensiveness of a state's CIA law was found to be a reliable predictor of the percentage of indoor workers who report a smoke-free work environment and the rates of youth smoking. State CIA laws were not conclusively associated with adult smoking rates.

Conclusions: The extensiveness of a state's CIA law is strongly associated with a higher percentage of indoor workers reporting a smoke-free work environment. This study did not reveal a similar association between local laws and smoke-free work environments. Youth smoking rates, shown to be related to state CIA laws, may be further affected with more stringent CIA policy.

     

Ausmaß und Folgen des Tabakkonsums und Passivrauchens in Deutschland

In consequence of the health hazards of smoking and environmental tobacco smoke (ETS) and the high prevalence in the German population there are more than 100,000 deaths annually in Germany. Still more than half of the German population ever starts smoking and currently about a third of the adult population and a fifth of the adolescents are smokers at present. Additionally about 55 percent of all non-smokers between the age of 18 and 79 are often exposed to ETS at home, at work or in their leisure time. A differentiation of smoking prevalence and of exposure to ETS concerning socio-economic determinants shows that social differences have grown with successive birth cohorts. Thus, significant social inequalities can be observed today. In contrast to this, gender differences are becoming increasingly irrelevant, particularly in smoking prevalence. Tobacco consumption and ETS therefore has become one high-priority field of action of health and prevention politics in Germany, which manifests in an improved tobacco control policy. International achievements in the implementation of a comprehensive tobacco control policy show however, that in Germany further efforts are needed to reduce smoking prevalence significantly. Eingegangen: 11. Mai 2007; Angenommen: 15. Mai 2007     

State laws on youth access to tobacco in the United States: measuring their extensiveness with a new rating system

OBJECTIVE: To develop and implement a rating system evaluating the extensiveness of state laws restricting youth access to tobacco. DESIGN: State laws on youth access to tobacco were analysed and assigned ratings on nine items. Six items addressed specific tobacco-control provisions, and three related to enforcement provisions. For each item, a target was specified reflecting public health objectives. Achieving the target resulted in a rating of +4 points; for three items, a rating of +5 was possible if the target was exceeded. Criteria for lower ratings were established for situations when the target was not met. SETTING: United States. RESULTS: State scores (sum of the ratings across all nine items) ranged from 0-18 in 1993, 2-21 in 1994, and 1-21 in 1995 and 1996, out of a possible total of 39. The average score across states was 7.2 in 1993, 7.9 in 1994, 8.2 in 1995, and 9.0 in 1996. The overall mean rating (per item) was 0.80 in 1993, 0.88 in 1994, 0.91 in 1995, and 1.00 in 1996, on a scale where 4.0 indicates that the target goals (per item) were met. From 1993 to 1996, scores increased for 20 states, decreased for one state, and remained unchanged for the others. The number of states for which state preemption of local tobacco regulation was a factor doubled from 10 states in 1993 to 20 states in 1996. CONCLUSIONS: Although all states have laws addressing youth access to tobacco, this analysis reveals that, as of the end of 1996, the progress towards meeting health policy targets is slow, and state legislation that preempts local tobacco regulation is becoming more common.     

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND: Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda. OBJECTIVE: To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures. DESIGN: This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports. RESULTS: In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states. CONCLUSIONS: The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.     

How cigarette additives are used to mask environmental tobacco smoke

OBJECTIVE: To understand the tobacco industry's research on and use of cigarette additives that alter the perception of exposure to environmental tobacco smoke (ETS). DATA SOURCES: Internal documents from four websites maintained by the major US tobacco manufacturers and company patents pertaining to the use of ETS altering additives obtained from the US Patent and Trademark Office online database. STUDY SELECTION: Electronic searches of the four industry websites and the US patent database were conducted using keywords to identify relevant data. DATA EXTRACTION: Industry documents and patents obtained using an exploratory snowball sampling method were reviewed and grouped into four general categories according to whether the additive(s) described affected ETS visibility, odour, irritation, or emissions. Accuracy of isolated findings was validated through cross comparison of the data sources. DATA SYNTHESIS: Results of this preliminary study provide evidence that tobacco manufacturers have conducted extensive research on the use of chemical additives to reduce, mask, or otherwise alter the visibility, odour, irritation, or emission of ETS. CONCLUSIONS: Findings suggest that the tobacco industry uses additives to reduce the perception of ETS. To protect the public, appropriate regulation of tobacco additives should be mandated.     

Preferences and practices among renters regarding smoking restrictions in apartment buildings

Objective: This study assessed renters' preferences for official smoking policies in their buildings and their practices concerning restricting tobacco smoking in their apartments.

Design: Renters (n = 301) living in large apartment complexes in a suburb of Minneapolis, Minnesota, completed a mail survey.

Main outcome measures: The survey asked about the official smoking policies in place in their apartment buildings, their preferences for policies, whether they had smelled tobacco smoke coming into their apartments from without, and, if so, what they had done about it.

Results: The majority of non-smokers (79%) preferred that their building be smoke-free. When asked to identify the current smoking policy in their buildings, residents disagreed substantially. Most renters (60%) reported smoke-free policies in their own apartments and another significant proportion (23%) restricted smoking to certain areas or occasions or persons. 75% thought that enforcing a smoke-free policy for guests would not be difficult. 53% of those in non-smoking households had smelled tobacco smoke in their apartments; most of these reported being bothered by it. However, very few complained to the building owner or manager (15.5%) or to the smoker (6.9%).

Conclusions: The majority of non-smokers preferred that their buildings be smoke-free. A failure to report problems to apartment managers might be an impediment to instituting smoke-free policies in apartment buildings. The considerable disagreement among residents within apartment complexes about the current official smoking policy in their buildings suggests that policies are lacking or are not well communicated.

     

What should be the elements of any settlement with the tobacco industry?

Litigation and regulatory assaults on the tobacco companies may create a willingness among tobacco manufacturers to bargain resources and acceptance of public policy changes for limitations of liability, as has been seen by the recent settlement with the Liggett Group. Two elements absolutely critical to any plan are the elimination of tobacco advertising and promotion and the removal of addiction as a reason for tobacco use. Minimal components of any settlement should include: (a) acceptance by the tobacco manufacturers of the causal relationship between tobacco use and disease, and the addictive nature of nicotine; (b) a total ban on tobacco advertising and promotion; (c) FDA jurisdiction over tobacco products and their nicotine content, with the intent of removing nicotine as soon as acceptable nicotine substitution products are available; (d) reimbursement to the states for Medicaid and other state expenditures attributable to smoking, to the maximum extent feasible; (e) funding for local, state, and federal programmes and research in tobacco control; (f) acceptance of legislation and regulations protecting the right of non-smokers to breathe air free of tobacco smoke; (g) funding for a large, national, media-led, anti- tobacco campaign; and (h) cessation assistance for addicted smokers. If negotiations toward a settlement proceed, it is essential that the public health community participate in defining the elements of any agreement to ensure that whatever agreement develops is focused on reducing tobacco-related disease rather than continuing the profitability of American tobacco companies. That participation requires articulation of the core elements essential to an acceptable agreement. If resolution of the public health issues surrounding continued sale of tobacco products can be reached in the United States, it may provide a model for similar resolution in other countries.


     

State legislators' perceptions of lobbyists and lobbying on tobacco control issues

OBJECTIVE: To determine state legislators' perceptions about health and tobacco lobbyists, their frequency of contact with these lobbyists, and the amount of campaign contributions from health professional organisations and the tobacco industry. DESIGN: Cross-sectional study. SUBJECTS: State legislators from North Carolina, Texas, and Vermont (USA), serving in 1994. MAIN OUTCOME MEASURES: Perceptions about lobbyists representing the tobacco industry, non-profit health organisations, and state medical societies with respect to their credibility, importance as sources of information, and persuasiveness; extent of lobbying activities; campaign contributions from health professional organisations and the tobacco industry. RESULTS: Almost all legislators reported that medical society and non-profit health organisation lobbyists are credible on tobacco issues and just over half believed that these lobbyists are important sources of information. More legislators said they could be persuaded by medical and health lobbyists than by tobacco lobbyists. Although health professional Political Action Committees (PACs) gave campaign contributions to more state legislators, and gave higher amounts on average, than tobacco PACs, legislators reported less contact with medical society lobbyists than tobacco lobbyists about tobacco issues. CONCLUSIONS: State legislators have positive attitudes toward lobbyists for non-profit health organisations and state medical societies regarding tobacco issues. These groups may be an underused resource for educating legislators about tobacco control measures.


     

Behavioral counseling for reducing children's ETS exposure: implementation in community clinics.

The present randomized controlled trial tested the effectiveness of a behavioral counseling program for reducing children's exposure to environmental tobacco smoke (ETS). Counseling was delivered by clinic staff as part of well-child health care services in a community clinic setting. A total of 150 mothers with children aged 4 years or younger were recruited. Parent-reported and children's urinary cotinine measures of ETS exposure were obtained at baseline, 3 months, 6 months (post-test), and 12 months (follow-up). Saliva samples were obtained from mothers who reported quitting smoking, for objective verification by thiocyanate analysis. After baseline, mothers were randomly assigned to a measures-only control condition or an intervention consisting of seven behavioral counseling sessions over 6 months. Counseling included behavioral contracting, self-monitoring, problem solving, and positive reinforcement. Results indicated acceptable test-retest reliability and validity of measures. Parent-reported measures indicated that, in both groups, children's exposure to their mothers' tobacco smoke in the home and to all tobacco smoke declined steeply from baseline to 6 months post-test, and remained essentially level during follow-up. Mothers' smoking rates followed the same pattern. Children's urinary cotinine concentrations did not show significant change over time in either group. Findings on the fidelity of treatment implementation suggest that the structure and funding of the community clinic health care system and associated staff turnover and training issues resulted in participants receiving a less efficacious intervention than in our past efficacy trials. Implications for future effectiveness trials are discussed.     

Tobacco industry efforts hindering enforcement of the ban on tobacco sales to minors: actions speak louder than words

OBJECTIVE: The tobacco manufacturers state that they want to see laws that prohibit the sale of tobacco to minors enacted and enforced. Our purpose was to compare these public statements with the US tobacco industry's legislative agenda at the federal and state levels. DESIGN: A review of the industry's comments to the US Department of Health and Human Services (DHHS) regarding proposed federal regulations, and an analysis of pro-tobacco state legislation concerning tobacco sales to minors. RESULTS: The industry is strongly opposed to federal regulations requiring states to effectively enforce their laws prohibiting the sale of tobacco to minors. A food industry newsletter reports that the Tobacco Institute has circulated a model state bill concerning underage tobacco sales. Striking similarities between bills from several states would seem to confirm this report. These bills strip communities of enforcement authority while making effective enforcement by state officials virtually impossible. CONCLUSION: The evidence strongly suggests an industry strategy to undermine efforts to enforce laws prohibiting the sale of tobacco to minors. As has been the case in the past, the tobacco industry is publicly endorsing a socially responsible goal while apparently taking action behind the scenes to ensure that the goal is not achieved.


     

Litigation in Argentina: challenging the tobacco industry

Objective

To evaluate the processes and outcomes of tobacco litigation in Argentina and to analyse the strategies of the tobacco industry to oppose litigation using tobacco industry documents.

Methods

A systematic search of tobacco industry documents on the internet dating from 1978 to 2002. Law library searches using Argentinean official and unofficial reports systems were combined with computerised online searches.

Results

There have been at least 15 failed litigation cases in Argentina and the tobacco industry presented a concerted defence in every claim regardless of cost. We categorised 11 cases as product liability and nicotine addiction, two as health care reimbursement, and two as criminal law and secondhand smoke. Industry strategies included hiring legal consultants from prestigious international and Argentinean law firms and developing litigation prevention programmes. Industry monitored legal academic meetings, controlled the development of new product liability legislation, obtained favourable opinions from experts, and closely observed the development of litigation in Argentina.

Conclusion

The strategies used by the industry have been successful in preventing recovery for tobacco injuries through litigation. Argentinean health advocates and lawyers need to be aware of the roles and strategies of the tobacco industry in order to develop effective litigation in Argentina.     

Occult maternal exposure to environmental tobacco smoke exposure

Background

Environmental tobacco smoke (ETS) is a recognised air pollutant. Its harmful effects have been found to be implicated in health disorders, including unfavourable pregnancy outcomes. The discrepancy between self‐reported emvironmental tobacco smoke exposure and cotinine levels in pregnant non‐smokers in France was examined.

Method

Plasma cotinine was determined by a CPG‐SM method on women who had answered a self‐questionnaire describing their habits and environment during pregnancy.

Results

Of 698 pregnant women reported as non‐smokers, 305 (43.7%) claimed not to be exposed to ETS, yet 196 of these (64.3%) had plasma cotinine levels above the limit of detection.

Conclusion

Self‐reported data on ETS exposure in pregnant women therefore underestimate actual exposure. However, cotinine assay cab rectify this misclassification. An accurate identification of this risk factore will help to change attitudes towards ETS and avert its adverse effects on mother and fetus.Although environmental tobacco smoke (ETS) has not yet been monitored in France, it is probably, as in the United States National Health and Nutrition Examination Survey (1999–2002), a major source of indoor air pollution. Low levels of ETS exposure can result in unfavourable pregnancy outcomes,^1,2 and many pregnant women still believe that not smoking is sufficient to protect their fetus from ETS. Moreover, far less attention has been paid to perinatal ETS exposure. A better appraisal of these non‐maternal sources and measurement of corresponding prenatal exposure will provide a useful basis for further work and discussion on its effects.     

Tobacco industry litigation to deter local public health ordinances: the industry usually loses in court

Background: The tobacco industry uses claims of state preemption or violations of the US Constitution in litigation to overturn local tobacco control ordinances.

Methods: Collection of lawsuits filed or threatened against local governments in the USA; review of previously secret tobacco industry documents; interviews with key informants.

Results: The industry is most likely to prevail when a court holds that there is explicit preemption language by the state legislature to exclusively regulate tobacco. The industry has a much weaker record on claims of implied preemption and has lost all challenges brought under equal protection claims in the cases we located. Although the tobacco industry is willing to spend substantial amounts of money on these lawsuits, it never won on constitutional equal protection grounds and lost or dropped 60% (16/27) of the cases it brought claiming implied state preemption.

Conclusions: Municipalities should continue to pass ordinances and be prepared to defend them against claims of implied preemption or on constitutional grounds. If the ordinance is properly prepared they will likely prevail. Health advocates should be prepared to assist in this process.

     

Exposure to environmental tobacco smoke at work, at home, and during leisure time: a cross-sectional population sample

Environmental tobacco smoke (ETS) is among the most common environmental health risks, with a striking and immediate biological response and increased disease risk. Exposure studies have looked mostly at worksite or home exposures, whereas total exposure levels at the population level are rarely reported. This study examined ETS exposure at work, at home, and during leisure time in a cross-sectional population sample of working-age adults. Our aim was to monitor changes in ETS exposure from 1992 to 2002. More detailed information on duration of exposure, distribution of exposure sites, and patterns of exposure was obtained in 2002. Data were based on Finland's national population chronic disease risk-factor surveys (conducted every 5 years). Total sample size varied from 8,000 to 13,500. The survey includes a self-administered questionnaire about ETS exposure at different sites. The proportion of nonsmoking persons exposed to ETS declined throughout the study period among both men and women. In 2002, 5.9% of male and 3.6% of female nonsmokers were exposed to ETS 1 hour or more per day, whereas 5.8% of men and 1.7% women were exposed less than 1 hour daily. Worksite exposure was more common among younger age groups of both sexes, but nonsmoking women in older age groups received more exposure at home than at worksites. Policy developments on ETS should aim to protect the whole population from ETS in all environments given that health risks from ETS often persist at home and in leisure environments. Total exposure levels should be studied to assess the health impacts of ETS.     

Individual rights advocacy in tobacco control policies: an assessment and recommendation

Efforts to control environmental tobacco smoke (ETS) could be assisted if the tobacco control movement gave greater emphasis to the issue of individual rights. Benefits that may accrue from the promotion of a clear individual rights perspective in tobacco control include adding coherence to the tobacco control advocacy agenda and winning support from those who may have been concerned about loss of personal freedom, excessive governmental power, use of social coercion, or the rights of smokers. Risks also attend to such a policy. It might inadvertently assist the tobacco industry, stir resistance to ETS limitation efforts, or confuse tobacco control supporters. On balance, though, liabilities are outweighed by the ethical and operational merits in tobacco control of a heightened pro-individual rights stance.