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标题：Clean Indoor Air Ordinance Coverage in the Appalachian Region of the United States
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作者：Amy K. Ferketich ; Alex Liber ; Michael Pennell 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2010
卷号：100
期号：7
页码：1313-1318
DOI：10.2105/AJPH.2009.179242
语种：English
出版社：American Public Health Association
摘要：Objectives. We sought to quantitatively examine the pattern of, and socioeconomic factors associated with, adoption of clean indoor air ordinances in Appalachia. Methods. We collected and reviewed clean indoor air ordinances in Appalachian communities in 6 states and rated the ordinances for completeness of coverage in workplaces, restaurants, and bars. Additionally, we computed a strength score to measure coverage in 7 locations. We fit mixed-effects models to determine whether the presence of a comprehensive ordinance and the ordinance strength were related to community socioeconomic disadvantage. Results. Of the 332 communities included in the analysis, fewer than 20% had adopted a comprehensive workplace, restaurant, or bar ordinance. Most ordinances were weak, achieving on average only 43% of the total possible points. Communities with a higher unemployment rate were less likely and those with a higher education level were more likely to have a strong ordinance. Conclusions. The majority of residents in these communities are not protected from secondhand smoke. Efforts to pass strong statewide clean indoor air laws should take priority over local initiatives in these states. The prevalence of smoking continues to decline in the United States, with an estimated 19.8% of adults who identified as current smokers in 2007.¹ There is still, however, a divide between groups defined by socioeconomic status, with smoking being a more prevalent behavior among adults in the lower socioeconomic status groups. The dramatic decline in smoking that has occurred since 1965, when 42.4% of the population smoked, can be attributed to a number of factors, including policies that restrict smoking in public places.^{2 , 3} Clean indoor air (CIA) ordinances have been associated with lower per capita cigarette consumption⁴ and lower smoking rates.^{4 , 5} In addition, strong CIA ordinances are related to improvements in air quality,⁶ reductions in exposure to nicotine among nonsmoking employees,⁷ reductions in the rates of coronary heart disease admissions,^{8 , 9} and improvements in the success of smoking cessation treatments.¹⁰ Local CIA ordinances can also set the stage for a statewide CIA law. Indeed, the Americans for Nonsmokers' Rights organization indicates that a state needs to have a significant number of communities with a local CIA ordinance before it should start a statewide campaign to ban smoking entirely in indoor locations.¹¹ Not all communities have CIA ordinances and there has been limited examination of the factors that are associated with their adoption. Identifying these community-level characteristics is important because the information could be used to predict which communities successfully pass CIA ordinances. Skeer et al. analyzed data from towns in Massachusetts to determine the characteristics associated with the strength of restaurant CIA ordinances.¹² The strongest predictors were receipt of Massachusetts Tobacco Control Program funding, having a higher percentage of the town residents that voted in favor of the formation of the Massachusetts Tobacco Control Program in 1992, and bordering a town with a strong ordinance and 2 measures of community advantage—education and income. In a study that focused on “smoke-free” campaigns in Wisconsin, experienced campaign leaders and newspaper coverage predicted a successful campaign result.¹³ Socioeconomic status of the communities was not examined in this study. Tobacco-growing communities may be difficult environments in which to pass CIA ordinances. However, strong grassroots coalitions¹⁴ and efforts to build consensus among legislators¹⁵ may be critical factors in regions that are heavily dependent on tobacco farming and closely tied to the tobacco industry. To date, there has not been an examination of the prevalence of CIA ordinances or the characteristics of the communities that have adopted ordinances in tobacco-growing regions, which, in the United States, are primarily in the Appalachian states.¹⁶ In 1965, the Appalachian Regional Development Act was passed in response to the high concentration of poverty, unemployment, and harsh living conditions in this region.¹⁷ The Act created a standard definition of Appalachia, which includes 420 counties in 13 states from New York to Mississippi. Residents here experience high rates of unemployment, poverty, and poor health.^{18 , 19} Appalachian residents, in general, experience higher rates of morbidity and mortality compared with residents of non-Appalachian regions, and this is particularly true for tobacco-related illnesses such as heart disease, pulmonary disease, and cancer.^{20 , 21} With respect to smoking, the average smoking prevalence among adults in Appalachian states in 2007 was 24.1% (from 18.4% in Maryland to 28.8% in Kentucky).¹ Maryland was the only state below the national median of 19.8%. These results do need to be interpreted with some caution, however, because 12 of the states have Appalachian and non-Appalachian counties, and these prevalence estimates were for the entire state. It is possible that the Appalachian counties have a much higher smoking prevalence than do the other counties in a particular state. In Ohio, for example, the smoking prevalence among adults in the non-Appalachian counties is 20.8% whereas it is much higher, 30.5%, in the Appalachian counties.²² The Appalachian region has a long history of tobacco farming and it now produces 97% of all burley tobacco, which is primarily used in cigarettes, in the United States.¹⁶ Most of the farms are family operated and, though small, they generate significant income. Because of this economic dependence, the social norms surrounding use are unique and residents may be resistant to tobacco control efforts.²³ The objectives of this study were to quantitatively examine the pattern of, and factors associated with, adoption of local, community-level CIA ordinances in the Appalachian region of the United States. The factors considered for this study were community measures of socioeconomic status, such as income, education, and unemployment. Although it is true that Appalachia is characterized by widespread poverty,^{18 , 19} there are some communities that are more affluent than others. We hypothesized that these measures are related to whether a community passed a CIA ordinance.