Local ordinances in Appalachian states with weak statewide smoking regulations do not offer most residents adequate protection against second-hand smoke, according to a new study.
Researchers examined smoking-related ordinances at the community level in six Appalachian states. Based on their analysis, they said that efforts should be focused on enacting strong statewide clean indoor air laws rather than relying on local ordinances to make public places smoke-free in some of these states.
The study shows that by the summer of 2008, fewer than 20 percent of cities and counties in these states had adopted comprehensive ordinances that ban smoking in workplaces, restaurants and/or bars. The researchers examined these laws in the Appalachian regions of Alabama, Georgia, Kentucky, Mississippi, South Carolina and West Virginia.
In an area known for its poverty and poor health, higher levels of education and lower unemployment increased the likelihood that a community had passed stronger smoking restrictions. But overall, ordinances were considered weak based on analyses of the extent of public areas they covered, the severity of punishment and how they were enforced.
West Virginia emerged as an outlier among these six states: More than 80 percent of its counties were covered by ordinances banning smoking in either workplaces, restaurants or bars.
"West Virginia is leading the way," said Amy Ferketich, lead author of the study and associate professor of epidemiology at Ohio State University. "But I was surprised to see that so few communities in the other states had a really strong clean indoor air ordinance.
"A lot of people working in tobacco policy suggest that smoking ban efforts have to start in communities before moving to the state level, but we strongly believe that that is not the best model for every state. Based on our findings in these states, with the exception of West Virginia, we recommend that attempts to enact clean indoor air laws must be made on a statewide level to work. Clearly, leaving the effort to local communities does not result in a large number of strong local clean indoor air ordinances in these states."
The research appears online May 13 and is scheduled for print publication in the July issue of the American Journal of Public Health.
Appalachia encompasses 420 counties in 13 states stretching from New York to Mississippi. Though smoking has declined in the United States in recent years, its average prevalence in Appalachian states exceeds the overall U.S. average (24.1 percent of adults vs. 19.8 percent, according to the Centers for Disease Control and Prevention).
Poverty is widespread in Appalachia, and lower socioeconomic status is linked to higher rates of smoking. The region also produces 97 percent of the burley tobacco, primarily used in cigarettes, in the United States. These two characteristics prompted Ferketich and colleagues to examine community approaches to smoking regulation in the region.
The researchers selected the six states for study because they had statewide smoking regulations on the books, but the laws were not comprehensive, meaning communities had the option to try to enact their own clean indoor air ordinances.
When the study began in 2008, New York, Ohio and Maryland had strong statewide laws banning smoking in workplaces, restaurants and bars, so individual communities had no reason to pursue their own smoking bans.
North Carolina, Tennessee and Virginia at the time had weak state clean indoor air laws that did not prohibit smoking in public places. But these states also had preemption provisions that prohibit local communities from passing smoking bans that differ from or are stronger than state law. Pennsylvania was in litigation over a weak smoking ban effort at the time of the study, and has since enacted a stronger statewide law that also prohibits the enactment of even stronger local ordinances.
North Carolina this year banned smoking in most bars and restaurants and government work sites -- which Ferketich cites as evidence that a relatively strong statewide law can be passed in a tobacco-growing state.
The researchers collected information about communities with populations exceeding 2,000 residents in the six Appalachian states under study. They analyzed city- or county-level clean indoor air ordinances that were in place in 322 communities during the summer of 2008.
They scored the ordinances based on how extensively they applied to different types of indoor areas: government or private work sites, retail or recreational spaces, restaurants, bars, schools and childcare facilities. The scoring system also considered penalties imposed on violators and enforcement practices. The possible scores ranged from 0 to 13, with higher scores representing more comprehensive laws.
On average, the communities as a group achieved only 43 percent of the possible points.
West Virginia clearly had the highest proportion of communities with comprehensive ordinances, all passed at the county level. Over three-quarters of counties mandated smoke-free workplaces and more than half banned smoking in restaurants.
When it came to bars, however, West Virginia was similar to the other states: Only 20 percent of its counties prohibited smoking in free-standing bars.
In the other five states, percentages of ordinances covering workplaces ranged from a low of 1.9 percent in Georgia to a high of 14.3 percent in Mississippi. Similarly, just 3.7 percent of Georgia ordinances and 17.9 percent of Mississippi local laws mandated smoke-free restaurants.
Ordinances banning smoking in bars typically had slightly higher percentages, but the number of bars affected varied widely because about one-third of communities in Alabama and Mississippi and two-thirds in Kentucky prohibit the sale of alcohol within their limits.
The researchers collected demographic data on the cities and counties to look for links between community characteristics and the presence of indoor smoking bans. The two characteristics linked to the presence of laws were education -- specifically, the percentage of residents who had completed a high-school education -- and employment levels in the community.
"The more educated a community was, the higher the odds were of having either a workplace or restaurant smoking ban," Ferketich said. "Unemployment was negatively related, so the higher the unemployment, the lower the odds of having either a workplace or restaurant ordinance in place."
Specifically, a 1 percent increase in the high-school completion rate was associated with a 9 percent increase in the odds of a restaurant policy and a 10 percent increase in the odds of a workplace policy. In contrast, a 1 percent increase in the unemployment rate translated to an approximate 50 percent decrease in the odds that a community had passed a policy for workplaces or restaurants.
"These are measures of advantage, so this means that the more advantaged communities, even in Appalachia, show this variability," Ferketich said. "Even in this area that's characterized by a high poverty rate, we do find these predictors that we thought we'd find -- that more advantaged communities would be the ones that passed ordinances."
This work was supported by the Robert Wood Johnson Foundation.
Co-authors on the paper included undergraduate Alex Liber and Michael Pennell of the College of Public Health faculty, both at Ohio State; Darren Neely and Jana Hammer of Capital University Law School; and Micah Berman of New England Law Boston.
- Amy K. Ferketich, Alex Liber, Michael Pennell, Darren Nealy, Jana Hammer, and Micah Berman. Clean Indoor Air Ordinance Coverage in the Appalachian Region of the United States. American Journal of Public Health, 2010; DOI: 10.2105/AJPH.2009.179242
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