Article
Smoke-Free Policy Implementation: Theoretical and Practical Considerations
Policy, Politics, & Nursing Practice 2014, Vol. 15(3–4) 81–92 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1527154414562301 ppn.sagepub.com
Amanda Fallin, PhD, RN1, Amie Goodin, MPP2, Mary Kay Rayens, PhD3, Sarah Morris, MS4, and Ellen J. Hahn, PhD, RN, FAAN4
Abstract Secondhand smoke exposure is a major public health issue, increasing the risk of cardiovascular and respiratory diseases and cancer. Although best practices for adopting smoke-free policy are well understood, there is limited research on the effective implementation of smoke-free policy. This article presents theoretical and practical considerations for smoke-free policy implementation in three Kentucky communities guided by the Institutional Analysis and Development (IAD) Framework. Although both Danville and Lexington-Fayette County, Kentucky have comprehensive smoke-free policies, Danville had more effective implementation, as well as better outcomes. Further study is needed to understand the critical elements of smokefree policy implementation and their association with population outcomes. The IAD is a promising model to guide the study of both policy adoption and implementation. Keywords smoke-free policy, policy implementation, Institutional Analysis and Development Framework
Introduction Secondhand smoke exposure is a major health hazard, and smoke-free policy is an effective solution (U.S. Department of Health and Human Services, 2006). The World Health Organization (2014a) supports the adoption of smoke-free policies, and a large body of evidence has demonstrated that smoke-free legislation improves worker health (cites) and air quality (Gotz et al., 2008; Lee et al., 2009) and reduces heart and asthma attacks and chronic obstructive pulmonary disease exacerbations (Hahn et al., 2014; Rayens et al., 2008; Tan & Glantz, 2012). These policies can also contribute to reduced smoking rates (Hahn et al., 2008). Best practices for adopting smoke-free policy (Stillman et al., 2003; Stillman, Yang, Figueiredo, Hernandez-Avila, & Samet, 2006), as well as the health and economic outcomes of public and voluntary smokefree indoor policies (Eriksen & Chaloupka, 2007; Hahn, 2010; Hopkins et al., 2010; Institute of Medicine, 2009) are well documented. However, there is limited research on the effective implementation of smoke-free policy, despite the importance of this step in the policy process
(Anderson, 1979). Policy adoption is a crucial first step, but implementation through effective communication and enforcement of the policy is necessary for the desired outcomes. For example, smoke-free laws that are not evenly enforced (e.g., in bars or strip clubs) may cause confusion and poor adherence among business owners and the public and may lead to less than optimal population health outcomes. This distinction is particularly important for public health nurses to understand, as one of their major roles is the promotion of public health policy. It is necessary to remain engaged beyond policy
1
Tobacco Policy Research Program, University of Kentucky, Lexington, KY, USA 2 Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, Lexington, KY, USA 3 Tobacco Policy Research Program, University of Kentucky, Lexington, KY, USA 4 College of Nursing, University of Kentucky, Lexington, KY, USA Corresponding Author: Amanda Fallin, PhD, RN, Tobacco Policy Research Program, University of Kentucky, Lexington, KY 40536, USA. Email: [email protected]
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adoption, as policy implementation is required for policies to have their desired impact (Anderson, 1979). The policy process includes five stages (Anderson, 1979). The first and second stages are setting the agenda and formulating policy proposals. The third phase is adoption, and this occurs when a particular policy solution is enacted. In the fourth stage, implementation, administrative bodies put the provisions of the policy in place, and it involves all activities necessary to execute policy directives (Berman, 1978; Van Meter & Van Horn, 1975). The final stage consists of evaluation, which determines if the policy had the desired effect. Policy implementation research has lagged behind the understanding of policy adoption and innovation (deLeon & deLeon, 2002; O’Toole, 2000). Historically, the policy implementation phase has been resigned to the so-called black box, which alludes to the ambiguous and opaque nature of the typical policy implementation process (Harachi, Abbott, Catalano, Haggerty, & Fleming, 1999). However, there has been some progress toward understanding the policy implementation phase. Two approaches to policy implementation research, topdown and bottom-up, have been tested with mixed success. Top-down approaches to policy implementation involve clear policy directives to match policy goals with targeted outcomes (Berman, 1978; Sabatier & Mazmanian, 1979), though these approaches often lack the flexibility to adapt to local needs and do not necessarily result in the desired policy outcome (Matland, 1995). Bottom-up approaches, on the other hand, incorporate local conditions and the need for policy adaptability; however, these approaches tend to lack generalizability outside the original context, making it difficult to create guidelines for other communities to use (Sabatier & Mazmanian, 1979). These weaknesses in existing approaches to policy implementation research present a barrier to the development of standard methods for measuring effectiveness of policy implementation (e.g., smoke-free policies). Ostrom’s (2005) Institutional Analysis and Development (IAD) Framework has potential to guide the understanding and measurement of smoke-free policy implementation because it is not limited by the constraints of traditional top-down or bottom-up approaches to policy implementation research (O’Toole, 2000). The IAD Framework has been used to guide the study of tobacco control policies in a Spanish hospital system, where it helped outline potential measures to evaluate policy implementation effectiveness (Martinez, 2009). The purposes of this study were to (a) apply the IAD Framework to understanding smoke-free policy implementation effectiveness at the local level; and (b) develop and pilot test a multimethod approach to measure smoke-free policy implementation effectiveness.
Conceptual Framework The IAD Framework (Ostrom, 2005) provides a roadmap for understanding factors that influence the processes and outcomes of institutional policies. This framework has been used in studies of smokeand tobacco-free policy compliance (Fallin, 2011; Martinez, 2009). The IAD encompasses three nested levels of action: constitutional, collective choice, and operational. The constitutional level is the context within which institutional policymaking takes place. In this study, the constitutional level involves state policymaking (e.g., the Kentucky General Assembly). The collective choice level involves local policymaking, and the city councils or fiscal courts (the county-level policymaking body in Kentucky) comprised action at this level. The operational level involves policy implementation, or the street-level activities needed to put a policy into place. Each of the three action levels (constitutional, collective choice, and operational) has two characteristics: rules in use (rules, laws, and boundaries) and community attributes (culture and values). At the constitutional level, relevant rules in use include the existence or absence of state legislation restricting smoking in Kentucky, and community characteristics include Kentucky’s culture, norms, and values surrounding tobacco use. At the collective choice, or local policymaking, level, the rules in use include the regulations governing the policymaking bodies (e.g., existing voluntary smoke-free policies), and the community characteristics include the community’s culture, norms, and values related to tobacco (e.g., tobacco-growing). At the operational, or street, level, the rules in use include programs (e.g., tobacco cessation) and other efforts affecting policy adoption and implementation in the community. Community characteristics include the culture, norms, and values of the individuals involved directly in policy implementation, such as the business owners or enforcement officials (e.g., values business rights). The focal point of the IAD analysis is the action arena. Action arenas can occur at any of the three levels (constitutional, collective choice, and operational), and within each level, they are impacted by the characteristics (rules in use and community attributes). This article focuses on action arenas at the collective choice and operational levels, as the constitutional level was constant and not the target of this exploratory study. The action arena at the collective choice level was adoption of smoke-free ordinances. The action arena at the operational level was implementation of the ordinances. These action arenas directly impact outcomes. See Figure 1 for a visual construction of the IAD Framework as applied to this analysis.
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CONSTITUTIONAL
COLLECTIVE CHOICE Rules in Use
Rules in Use State smoke-free law
Voluntary smoke-free policies
Community A ributes
Community A ributes
State culture, norms, and values surrounding tobacco use
Local community culture, norms, and values surrounding tobacco use
ACTION ARENA Smoke-Free Policy Adop on
OPERATIONAL Rules in Use • • •
Social norms Tobacco cessa on programs Strength of tobacco control
Community A ributes Norms and values of individuals directly involved in implementa on, such as business owners
ACTION ARENA Community Adherence to Policy and Enforcement
OUTCOMES 1. 2. 3. 4. 5.
Reduced exposure to secondhand smoke in the community; Increased demand for cessa on services; Reduced smoking; Reduced healthcare u liza on; Improved health outcomes (e.g., reduced heart a acks, asthma a acks)
*Note: italicized rules in use, action arenas, and outcomes represent variables measured in this study. Figure 1. IAD model applied to smoke-free policy implementation. Note. Italicized rules in use, action arenas, and outcomes represent variables measured in this study.
The ultimate goal of policy adoption and implementation is to solve a problem at the population level. In the case of smoke-free policy, the desired effects are (a) reduction in exposure to secondhand smoke in the community; (b) increased demand for cessation services; (c) reduced smoking prevalence; (d) reduced health care utilization; and (e) improved population health outcomes (e.g., reduced heart and asthma attacks). The IAD Framework was used to guide the study and measurement of smoke-free policy implementation. This article presents an exploratory case study using mixed methods to develop and test selected IAD constructs to describe smoke-free policy implementation in three Kentucky communities with varying policy strength and duration. Smoke-free laws vary in strength from 100% comprehensive (e.g., covering all workplaces, restaurants, and bars) to partial policies with major exemptions (e.g., exemptions for bars, smoking allowed after certain hours; Americans for Nonsmokers’ Rights Foundation, 2013).
Methods An exploratory case study using mixed methods was used to assess selected IAD constructs at two levels (collective choice and operational) and population health outcomes related to smoke-free policy implementation effectiveness (the pilot constructs are in italics in Figure 1). Three communities in Kentucky were purposively selected, as they differed in smoke-free policy strength and duration. Two communities, Danville and Lexington-Fayette County, had 100% smoke-free workplace laws (Kentucky Center for Smoke-free Policy, 2013). Danville’s law was implemented in August 2008 and had been in place for 3 years when data were collected. Lexington-Fayette county’s ordinance was implemented in April 2004 (Greathouse, Hahn, Okoli, Warnick, & Riker, 2005) and had been in place for 7 years before data collection. The third community, Kenton County, had a weak smoke-free ordinance with multiple major exemptions. Kenton County’s law,
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implemented in April 2010, had been in place for 6 months when data were collected. We randomly selected five restaurants and five bars from the health department list of all eating and drinking venues in Danville and Lexington-Fayette, as per a protocol used previously by our team (Hahn et al., 2006). Data were collected in 19 venues in Kenton County, as part of an evaluation of the smoke-free ordinance by the local coalition. Data collected from the 39 venues included observations of community adherence to the policy (collective choice action arena) and fine particle air pollution (PM2.5) to assess secondhand smoke exposure (population health outcome). Data at the operational level were collected via key informant interviews, and secondary data analysis to assess rules in use as well as the selected population health outcomes.
comprise the indicators of tobacco-free schools, and an administrator at the school must indicate tobacco restrictions for each item for the school to be classified as tobacco-free. The estimate of the percent of smoke-free manufacturing facilities per county was obtained from a secondary data analysis of the 2010 Kentucky Workplace Tobacco Policy Survey conducted biannually via telephone with human resource managers, using a list of all manufacturing facilities with 50 or more employees obtained from the Kentucky Economic Development Cabinet (Hahn, Rayens, Okoli, Love, & Kim, 2004). Trained staff administered a 42-item telephone survey, including two items that assessed written indoor and outdoor smoke-free policies.
Measures and Data Sources
The operational phase involves street-level policy implementation.
The measures developed and tested in this exploratory case study were selected based on the IAD Framework, and they assess the collective choice and operational levels, as well as population health outcomes.
Constitutional Level The presence or absence of a state law prohibiting smoking in indoor venues was determined based on a review of Kentucky Regulatory Statutes.
Collective Choice The collective adoption.
choice
phase
encompasses
policy
Action arena. The action arena at the collective choice level was the presence, strength, and duration of a local smokefree ordinance enacted by a city council, urban county government, or county fiscal court. The source of information was the Kentucky Center for Smoke-free Policy’s (2013) ordinance database (Hahn, 2013). Rules in use. Rules in use for this study included percent of schools with voluntary tobacco-free school policies and percent of manufacturers with voluntary smokefree policies. A tobacco-free school is one that prohibits all forms of tobacco use on the school grounds at all hours (including during school-related events that occur after hours) and applies this policy to all students, employees, and guests. The estimate of the percent of tobacco-free schools per county was obtained from secondary data analysis of a 2011 Kentucky School Tobacco Policy Survey conducted biannually via telephone with principals and assistant principals in public and private schools, grades 6 to 12. Twelve questions
Operational Level
Action arena. The action arena at the operational level was conceptualized as community adherence and enforcement capacity related to the policy. Community adherence was operationalized using a 10-item community observation tool adapted from Skeer, Land, Cheng, and Siegel (2004) to assess level of compliance with the policy in selected businesses. Research staff conducted field observations using the tool to assess signage (four items), smoking paraphernalia (e.g., ashtrays, matchbooks; three items), and observed smoking (three items) in each of the 39 study venues in the three communities (see observational tool in the Appendix). Subscale scores were determined for each of the three aspects of adherence: signage, smoking paraphernalia, and observed smoking. Total adherence, the sum of the three subscales, ranged from 0 to 28, with high scores reflecting greater adherence to the policy than lower scores. Among the study venues, there was a significant Spearman’s rank correlation between smoking paraphernalia and observed smoking (rho ¼ 0.54, p ¼ .002), but these subscales were not associated with signage. Validity of the observation tool is further established by the correlation between smoking paraphernalia and air quality (rho ¼ 0.41, p ¼ .02); the negative correlation is consistent with the fact that better adherence (i.e., high paraphernalia score) reflects lower indoor air pollution (lower PM2.5). The correlations between air quality and each of observed smoking and signage subscales were not significant. This could be because the observed smoking subscale includes outdoor smoking, and signage alone may be a weak link to adherence. Data collection took place during peak times in each venue and data collectors attempted to appear as inconspicuous as possible in each venue. For example, data collectors ordered meals at the restaurants.
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To determine enforcement capacity, we contacted the individual responsible for policy enforcement in each of the three communities to determine the number of people assigned to enforcement of the smoke-free law. Enforcement capacity was then calculated using an investigator-developed measure: The estimate is obtained by dividing the number of personnel by the number of hospitality venues, multiplied by the adult population divided by 1,000.
the maximum score was based on the number and range of items in the scale. Once each component was converted to a percentage, the total score was determined by adding the percentages for the four components. The potential scores ranged from 0 to 4, with higher scores representing more comprehensive tobacco cessation programs.
Rules in use. Rules in use at the operational level was conceptualized as availability of tobacco cessation programs. These data were obtained from a secondary analysis of the 2010 Local Health Department Tobacco Cessation Survey; this survey was conducted annually from 2000 to 2010 via telephone with tobacco control specialists in all local health departments in Kentucky to assess the presence or absence of a menu of tobacco cessation services (Hahn & Rayens, 2010). The tobacco cessation measure for this study included four components: (a) the number of cessation programs per 10,000 smokers; (b) the number of channels promoting the quitline (“distributed brochures/fliers, distributed Quit Line prescription pads, paid advertising, earned (unpaid) media, Cooper-Clayton or other programs, hospitals/ clinics, health fairs, other,” with each assessed as a yes/ no variable and the total score equal to the sum of the “yes” responses); (c) the frequency of cessation medications recommended by health department providers (“How frequently do your healthcare providers prescribe or recommend the following medications for tobacco use cessation?” “nicotine gum,” “nicotine patch,” “nicotine spray,” “nicotine inhaler,” “nicotine lozenges,” “Buproprion,” “Varenicline,” “other medications,” each was scored on a 5-point ordinal scale ranging from 1 ¼ Never to 5 ¼ Always, with the total score equal to the sum of the seven items); and (d) barriers to providing cessation programs (“We have enough staff to provide tobacco cessation programs,” “Our staff is not trained to provide tobacco cessation,” “We are too busy to provide tobacco cessation,” “We have few requests for tobacco cessation programs,” “Tobacco cessation programs are too expensive,” and “Tobacco cessation programs are effective.”); each were rated on a 4-point Likert scale ranging from 1 Strongly disagree to 4 Strongly agree. The total score of this barriers scale was obtained after reverse scoring the ones with negative polarity (i.e., higher scores indicate fewer barriers) and summing the items. Once the summary scores were obtained for the four components, each was converted to a percentage by dividing it by the corresponding maximum possible score. For the rate of number of cessation programs per 10,000 smokers, the maximum score was determined by assessing the rate at all health departments in the state. For the remaining three components,
The goal of smoke-free policy adoption and implementation is to reduce exposure to secondhand smoke, increase demand for cessation services, decrease healthcare utilization, and promote other positive health outcomes.
Population Health Outcomes
Exposure to secondhand smoke. Two trained members of the research team measured fine particle air pollution in 39 venues in the three study communities using a TSI Sidepak, a standard technique (Cameron et al., 2010; Hyland, Travers, Dresler, Higbee, & Cummings, 2008; Thornley, Dirks, Edwards, Woodward, & Marshall, 2013). The machine was placed inside an empty backpack or purse, with the tube protruding for data collection. The data collectors sat away from doors and open windows, as well as grills or open flames whenever possible. While in the venue, the data collectors recorded the volume of the venue, the number of patrons, and the number of lit cigarettes. Demand for cessation services. Demand for cessation services was the number of participants in cessation programs annually per 10,000 smokers. This was obtained through a secondary analysis of the 2010 Local Health Department Tobacco Cessation Survey, conducted annually via telephone with tobacco control specialists in all local health departments in Kentucky. We summed the number of participants in seven tobacco cessation programs, divided by the estimated number of adult smokers in the county (Centers for Disease Control and Prevention, 2013) and multiplied by 10,000 to obtain this rate.
Results At the constitutional level, there is no statewide smokefree law in Kentucky, nor is there preemption of local smoke-free laws (Kentucky Center for Smoke-free Policy, 2013), meaning local communities have the authority to enact smoke-free laws at the community level. At the collective choice level, all three communities had a local smoke-free ordinance, which was built into the design of this study. There was variation in strength and duration of the ordinances. Two communities had 100% or comprehensive smoke-free ordinances; one
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community had a partial law with major exemptions. Of the two with 100% laws, one had been in effect for 7 years (Lexington-Fayette) and the other was more recently enacted (Danville; 3 years). The community with a partial law had been in effect for 6 months (Kenton). The percent of tobacco-free schools varied by community. The community with the more recently enacted comprehensive policy had the largest percentage of tobacco-free schools (100%; Table 1), while the other two communities were considerably lower in this measure of rules in use at the collective choice level. On the other hand, the percent of smoke-free manufacturers was relatively consistent across communities and close to 100%. At the operational level, Danville had the highest community adherence based on observation, followed closely by the other two communities. Enforcement effectiveness was highest in Danville, with the other two communities being quite a bit lower. Danville also had a slight advantage in the tobacco cessation programs score compared with the other two communities, but summary scores in the range of 2.0 to 2.7 indicate that all three communities were reaching only 50% to 68% of the maximum possible score in this area. The average PM2.5 was lower in Danville (mean ¼ 11.5) compared with Lexington-Fayette and Kenton, both with means of approximately 15.0. Danville had the highest demand for cessation per 10,000 population (678.7), compared with 32.9 in Lexington-Fayette and 21.5 in Kenton County.
Discussion Although Lexington-Fayette County and Danville both have comprehensive smoke-free workplace ordinances,
Danville scored higher on indicators of street-level implementation, including community adherence to the policy and enforcement capacity, as well as tobacco cessation programs. Similarly, Danville had better population health outcomes than Lexington-Fayette County. Danville had lower average PM2.5 and higher demand for cessation services compared with Lexington-Fayette County. Although it might be expected that Danville and Lexington-Fayette County, both with comprehensive smoke-free laws, would have similar outcomes, it is interesting that there is a disparity in both indicators of implementation effectiveness and population health outcomes between these two communities. In fact, in some areas, the outcomes of the Lexington-Fayette County law more closely resemble the outcomes of the Kenton County ordinance, which is not considered comprehensive. For example, the demand for cessation per 10,000 was 32.2 in Lexington-Fayette and 16.2 in Kenton County compared with 238.5 in Danville. We hypothesize that variation in policy implementation may explain differences in outcomes. Smoke-free policy implementation effectiveness may also drift over time; the Lexington-Fayette County’s ordinance had been in effect for 7 years. However, the Weber, Bagwell, Fielding, and Glantz (2003) study reported that compliance with smoke-free bar policies increased over time in California. Given these divergent findings, further research on the measurement of policy implementation effectiveness over time and impact on population health outcomes is warranted. We also need a more rigorous method of evaluating policy strength and comprehensiveness. The two comprehensive ordinances were defined based on the commonly used Americans for Nonsmokers’ Rights definition (Americans for
Table 1. Institutional Analysis and Development (IAD) Measures of Smoke-Free Policy Implementation: Action Arenas, Rules in Use, and Population Outcomes in Three Communities. Community Measure Local law status
Tobacco-free schools (%) Smoke-free manufacturers (%) Community adherence (observation) Enforcement effectiveness Tobacco cessation programs score Exposure to SHS (average PM2.5 mg/m3) Demand for cessation per 10,000
Level of IAD variable
IAD characteristic
Collective choice
Action arena
Operational level
Rules in use Rules in use Action arena Action arena Rules in use
Outcome
Lexington 100% smoke-free workplaces, restaurants, and bars 20.0 100.0 21.3
Danville
Kenton
100% smoke-free workplaces, restaurants, and bars 100.0 90.0 24.1
Exemptions for bars; allows smoking after 4:00 p.m. 33.3 94.7 21.1
5.0 2.2 14.7
15.2 2.7 11.5
4.6 2.0 15.0
35.9
678.7
21.5
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Nonsmokers’ Rights Foundation, 2012), but the minor exemptions in each ordinance were different, perhaps, resulting in varied implementation effectiveness and population outcomes. Though the definition of policy implementation is consistent in the literature, there is no consensus on when the implementation stage begins. Some define the beginning of the implementation phase as the point at which the policy has been adopted and funding committed (Van Meter & Van Horn, 1975). Anderson (1979) argues that the divide between the policy adoption phase and policy implementation is not so clear. This nebulous transition between policy adoption and policy implementation occurs for two reasons. First, policies tend to be modified during the implementation phase. For example, in the Kenton County ordinance, the split shift exemption (i.e., smoking allowed after 4:00 p.m.) was created by the county attorney after the ordinance was enacted by the fiscal court. Second, given the complexities of government, laws are increasingly written in a general way, giving administrative agencies leeway in how to implement the policy. In some instances, laws are so vague that administrative agencies have leeway to create the policy provisions, which effectively transforms these agencies into a fourth branch of government (Meier, 1993). Given these complexities in policy implementation, it is important to both measure and consistently define the implementation phase. In the case of smoke-free policies, the legislation typically defines the implementation date (i.e., 30–60 days after enactment; Centers for Disease Control and Prevention, 2008). One of the Lexington venues, an adult entertainment club, had a PM2.5 level significantly higher than the other locations in that community. This finding suggests that specific types of hospitality workers, such as employees in adult entertainment venues, may be particularly vulnerable to secondhand smoke exposure due to uneven implementation of smoke-free laws. Future studies are needed to assess the impact of policy implementation effectiveness among disparate populations. This is further evidence that effectively implementing a policy may be as (or more) impactful as simply enacting the law. In addition, it is possible that this framework for measuring implementation effectiveness could be translated to other policy issues. Although this study focused on implementation of local smoke-free ordinances, results of this research have implications for tobacco control policy implementation at all levels. The World Health Organization Framework Convention on Tobacco Control (FCTC) is an international treaty adopted by 178 nations, excluding the United States, which addresses the tobacco epidemic on a global level (World Health Organization, 2014b). Among FCTC mandates, Article 13 is a ban
on tobacco advertising, sponsorship and promotion, and Article 16 is a prohibition on tobacco sales to minors. There have been many implementation challenges, including lack of enforcement and a lack of clear direction to countries on how to implement these restrictions. Implementation research, including surveillance and compliance checks, is needed to understand and promote policy implementation effectiveness (Nagler & Viswanath, 2013) to maximize the health outcomes from tobacco control policy. This study did not assess the use of e-cigarettes inside observed venues. Use of e-cigarettes, a relatively new trend in tobacco products, are a possible policy loophole (Yamin, Bitton, & Bates, 2010), particularly in the case of older smoke-free ordinances. E-cigarettes are battery operated devices that heat a vapor solution. None of the three communities in this study had covered e-cigarettes in their ordinances. The use of e-cigarettes inside a smoke-free venue may present an implementation challenge. In future studies, the impact of e-cigarette use on policy implementation could be assessed, including observations of e-cigarette use and interviews with restaurant/bar owners about patron use and perceived impact on policy adherence. Future research is needed to develop and test innovative techniques for measuring policy implementation effectiveness.
Limitations This was a small exploratory study including only three communities. Future research with a larger group of communities is critically important to assess the differential effects of policy strength and comprehensiveness, implementation effectiveness, and population health outcomes. Further, this exploratory study measured only selected variables based on the IAD to describe implementation effectiveness of smoke-free laws. Development and testing of other IAD construct measures is needed.
Conclusion The IAD shows promise as a model to guide the study of policy adoption and implementation effectiveness. Better outcomes in Danville compared with Lexington-Fayette County, both with comprehensive smoke-free workplace laws, may have been attributed to more effective policy implementation. Although Lexington had a comprehensive smoke-free law, implementation indicators were more similar to Kenton, with a partial law, and subsequently, population outcomes in these two communities were more negative compared to Danville with a strong law and positive implementation indicators. It is important for public health nurses to remain actively engaged in the policy process beyond the period of policy adoption to ensure adequate implementation.
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Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Hahn, E. J., Rayens, M. K., Adkins, S., Simpson, N., Frazier, S., & Mannino, D. M. (2014). Fewer hospitalizations for chronic obstructive pulmonary disease in communities with smoke-free public policies. American Journal of Public Health, 104(6), 1059–1065. Hahn, E. J., Rayens, M. K., Butler, K. M., Zhang, M., Durbin, E., & Steinke, D. (2008). Smoke-free laws and adult smoking prevalence. Preventive Medicine, 47(2), 206–209. Hahn, E. J., Rayens, M. K., Okoli, C. T., Love, K., & Kim, S. (2004). Tobacco use prevention and cessation policies in manufacturing facilities in the tobacco-growing state of Kentucky. American Journal of Health Promotion, 18(3), 225–231. Hahn, E. J., Rayens, M., York, N., Okoli, C., Zhang, M., Dignan, M., . . . ;Al-Delaimy, W. K. (2006). Effects of a smoke-free law on hair nicotine and respiratory symptoms in restaurant and bar workers. Journal of Occupational and Environmental Medicine, 48(9), 906–913. Harachi, T. W., Abbott, R. D., Catalano, R. F., Haggerty, K. P., & Fleming, C. B. (1999). Opening the black box: Using process evaluation measures to assess implementation and theory building. American Journal of Community Psychology, 27(5), 711–731. Hopkins, D. P., Razi, S., Leeks, K. D., Priya Kalra, G., Chattopadhyay, S. K., & Soler, R. E. (2010). Smokefree policies to reduce tobacco use a systematic review. American Journal of Preventive Medicine, 38(2 Suppl.): S275–S289. Hyland, A., Travers, M. J., Dresler, C., Higbee, C., & Cummings, K. M. (2008). A 32-country comparison of tobacco smoke derived particle levels in indoor public places. Tobacco Control, 17(3), 159–165. Institute of Medicine. (2009). Secondhand smoke exposure and cardiovascular effects: Making sense of the evidence. Washington, DC: The National Academies Press. Kentucky Center for Smoke-free Policy. (2013). Tobacco use and policy fact sheets by county. Retrieved from http:// www.mc.uky.edu/tobaccopolicy/KCSP/UseAndPolicyFact Sheets2011.HTM Lee, K., Hahn, E., Robertson, H., Lee, S., Vogel, S., & Travers, M. (2009). Strength of smoke-free laws and indoor air quality. Nicotine & Tobacco Research, 11(4), 381–386. Martinez, C. (2009). Barriers and challenges of implementing tobacco control policies in hospitals: Applying the institutional analysis and development framework to the catalan network of smoke-free hospitals. Policy Politics and Nursing Practice, 10(3), 224–232. Matland, R. E. (1995). Synthesizing the implementation literature: The ambiguity-conflict model of policy implementation. Journal of Public Administration Research and Theory: J-PART, 5(2), 145–174. Meier, K. J. (1993). Politics and the bureaucracy: Policymaking in the fourth branch of government. New York, NY: Harcourt-Brace. Nagler, R. H., & Viswanath, K. (2013). Implementation and research priorities for FCTC Articles 13 and 16: Tobacco advertising, promotion and sponorship and sales to and by minors. Nicotine & Tobacco Research, 15(4), 832–846. Ostrom, E. (2005). Understanding institutional diversity. Princeton, NJ: Princeton University Press.
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O’Toole, L. J. (2000). Research on policy implementation: Assessment and prospects. Journal of Public Administration Research and Theory, 10(2), 263–288. Rayens, M. K., Burkhart, P. V., Zhang, M., Lee, S., Moser, D. K., Mannino, D., . . . ;Hahn, E. J. (2008). Reduction in asthma-related emergency department visits after implementation of a smoke-free law. Journal of Allergy and Clinical Immunology, 122(3), 537–541.e533. Sabatier, P. A., & Mazmanian, D. (1979). The conditions of effective implementation: A guide to accomplishing policy objectives. Policy Analysis, 5(4), 481–504. Skeer, M., Land, M. L., Cheng, D. M., & Siegel, M. B. (2004). Smoking in Boston bars before and after a 100% smoke-free regulation: An assessment of early compliance. Journal of Public Health Management and Practice, 10(6), 501–507. Stillman, F., Hartman, A., Graubard, B., Gilpin, E., Murray, D., & Gibson, J. (2003). Evaluation of the American Stop Smoking Intervention Study (ASSIST): A report of outcomes. Journal of the National Cancer Institute, 95(22), 1681–1691. Stillman, F., Yang, G., Figueiredo, V., Hernandez-Avila, M., & Samet, J. (2006). Building capacity for tobacco control research and policy. Tobacco Control, 15, i18–i23. Tan, C. E., & Glantz, S. A. (2012). Association between smokefree legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: A meta-analysis. Circulation, 126, 2177–2183. Thornley, S., Dirks, K. N., Edwards, R., Woodward, A., & Marshall, R. (2013). Indoor air pollution levels were halved as a result of a national tobacco ban in a New Zealand prison. Nicotine & Tobacco Research, 15(2), 343–347. U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease and Prevention and Promotion, Office of Smoking and Health. Van Meter, D. S., & Van Horn, C. E. (1975). The policy implementation process: A conceptual framework. Administration & Society, 6(4), 445–488. Weber, M. D., Bagwell, D. A., Fielding, J. E., & Glantz, S. A. (2003). Long term compliance with California’s Smoke-Free Workplace Law among bars and restaurants in Los Angeles county. Tobacco Control, 12(3), 269–273. World Health Organization. (2014a). Framework convention on tobacco control. Retrieved from http://www.who.int/fctc/en/ World Health Organization. (2014b). Tobacco Free Initiative (TFI): Smoke-free policies. Retrieved from http://
www.who.int/tobacco/training/success_stories/smokefree_ policies/en/ Yamin, C., Bitton, A., & Bates, D. (2010). E-cigarettes: A rapidly growing Internet phenomenon. Annals of Internal Medicine, 153(9), 607–609.
Author Biographies Amanda Fallin, PhD, RN, is a postdoctoral fellow at the University of California San Francisco. Her research interests primarily focus on the adoption and implementation of tobacco control policies, and tobacco use among vulnerable populations. Amie Goodin, MPP, is a doctoral student at the Martin School of Public Policy and Administration. Her research interests include health policy, pharmaceutical policy, and Health Economics and Outcomes Research. She is currently working as a researcher and analyst at the Institute for Pharmaceutical Outcomes and Policy, University of Kentucky. Mary Kay Rayens, PhD, is Professor and Associate Director of the Tobacco Policy Research Program at the University of Kentucky College of Nursing. Dr. Rayens is a biostatistician; her research interests include tobacco policy and health outcomes. Sarah Morris, MS, is an Assistant Professor and biostatistician in the College of Safety & Justice at Eastern Kentucky University. She is currently completing her DrPH degree in biostatistics at the University of Kentucky, in the College of Public Health. She is a statistician at the University of Kentucky College of Nursing and College of Public Health. Ellen J. Hahn, PhD, RN, FAAN, is Professor and Director of the Tobacco Policy Research Program at the University of Kentucky College of Nursing. Dr. Hahn and colleagues have assisted 39 Kentucky communities to adopt or enact smoke-free policies since 2003. She is the current Principal Investigator on a NIEHSfunded project to test a dual home screening intervention to reduce home exposure to radon and secondhand smoke.
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Appendix: UK Clean Indoor Air Partnership Smoke-Free Law Adherence Evaluation
Community name (city/county): ___________________________________ Establishment name: ________________________________ Establishment type: ___Bar ___Restaurant If bar, select type: _____Free-standing bar ___Nightclub ____Bar with restaurant Date: ___________________ Temperature: ___Hot ___Warm ___Cool ___Cold Weather: ____Clear ____Drizzling ___Raining ____Light Snow ___Heavy Snow Time started: _____________
1. Total number of patrons smoking outside the main entrance:______ 2. Total number of males smoking outside the main entrance: ______ 3. Total number of females smoking outside the main entrance: _______ 4. Is a “no-smoking” sign posted at entrance to establishment?
__ Yes __ No
If yes, is it in clear view? If yes, is the sign the official health department stick?
__ Yes __ No __ Yes __ No
5. Number of “NO SMOKING” signs that are displayed conspicuously: _____ 6. Approximate number of people present inside: _______ 7. Are any ashtrays present inside the establishment?
__ Yes __ No
8. Number of ashtrays present with ashes inside: _______ 9. Number of matchbooks present: _______ 10. At any point during your stay was a patron smoking? (If no, skip to question #14) ___Yes ___No 11. Total number of patrons smoking INSIDE the establishment: ________ 12. Total number of males smoking INSIDE the establishment:_______ 13. Describe any interactions between an employee and a smoking patron: _________
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14. At any point during your stay was an employee smoking? (If no, skip to question #16) __Yes __No 15. Total number of employees: _____ 16. Number of employees smoking: _________ 17. Gender of employees and indicate gender of smoking employees (if applicable): _________________________________________________________________ 18. Number of rooms in the establishment: ________ 19. Establishment capacity: ________ 20. Number of seats: _______ 21. Smell in establishment: __Clear ___Musty (stale smoke) ____Somewhat smoky ___Very smoky 22. Is the establishment carpeted? __Yes ___No 23. Are there draperies or wall coverings? ___Yes ___No 24. Number of cigarette vending machines present: _____ 25. Location of cigarette vending machines: ________ 26. Number of cigarette advertisements: ________ 27. Is there an outside seating area? (If no, skip to end of questions)
__ Yes __ No
28. Were those smoking outside doing so a reasonable distance from the entrance to prevent smoke from filtering into the establishment? 29. Where are the patrons smoking?
About how many feet away from entrance to building?
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__ Yes __ No
__ Outside front entrance __ Outside back entrance __ Patio __ Other __ 0-5 __ 6-10 __ More than 10
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30. Are butt receptacles available?
__ Yes __ No
I f y e s , w he r e a re t h ey l oca t ed ? __ Outside front entrance __ Outside back entrance __ Patio __ Other 31. How much cigarette butt litter is present and where is it located? (i.e. rough number of butts and location observed) __ 0 __ 1-5 __6-10 __ 11-20 __ More than 20
Ending time: __________ Notes: __________
Modified from Skeer et al., 2004.
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Smoke-Free Policy Implementation: Theoretical and Practical Considerations
Policy, Politics, & Nursing Practice 2014, Vol. 15(3–4) 81–92 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1527154414562301 ppn.sagepub.com
Amanda Fallin, PhD, RN1, Amie Goodin, MPP2, Mary Kay Rayens, PhD3, Sarah Morris, MS4, and Ellen J. Hahn, PhD, RN, FAAN4
Abstract Secondhand smoke exposure is a major public health issue, increasing the risk of cardiovascular and respiratory diseases and cancer. Although best practices for adopting smoke-free policy are well understood, there is limited research on the effective implementation of smoke-free policy. This article presents theoretical and practical considerations for smoke-free policy implementation in three Kentucky communities guided by the Institutional Analysis and Development (IAD) Framework. Although both Danville and Lexington-Fayette County, Kentucky have comprehensive smoke-free policies, Danville had more effective implementation, as well as better outcomes. Further study is needed to understand the critical elements of smokefree policy implementation and their association with population outcomes. The IAD is a promising model to guide the study of both policy adoption and implementation. Keywords smoke-free policy, policy implementation, Institutional Analysis and Development Framework
Introduction Secondhand smoke exposure is a major health hazard, and smoke-free policy is an effective solution (U.S. Department of Health and Human Services, 2006). The World Health Organization (2014a) supports the adoption of smoke-free policies, and a large body of evidence has demonstrated that smoke-free legislation improves worker health (cites) and air quality (Gotz et al., 2008; Lee et al., 2009) and reduces heart and asthma attacks and chronic obstructive pulmonary disease exacerbations (Hahn et al., 2014; Rayens et al., 2008; Tan & Glantz, 2012). These policies can also contribute to reduced smoking rates (Hahn et al., 2008). Best practices for adopting smoke-free policy (Stillman et al., 2003; Stillman, Yang, Figueiredo, Hernandez-Avila, & Samet, 2006), as well as the health and economic outcomes of public and voluntary smokefree indoor policies (Eriksen & Chaloupka, 2007; Hahn, 2010; Hopkins et al., 2010; Institute of Medicine, 2009) are well documented. However, there is limited research on the effective implementation of smoke-free policy, despite the importance of this step in the policy process
(Anderson, 1979). Policy adoption is a crucial first step, but implementation through effective communication and enforcement of the policy is necessary for the desired outcomes. For example, smoke-free laws that are not evenly enforced (e.g., in bars or strip clubs) may cause confusion and poor adherence among business owners and the public and may lead to less than optimal population health outcomes. This distinction is particularly important for public health nurses to understand, as one of their major roles is the promotion of public health policy. It is necessary to remain engaged beyond policy
1
Tobacco Policy Research Program, University of Kentucky, Lexington, KY, USA 2 Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, Lexington, KY, USA 3 Tobacco Policy Research Program, University of Kentucky, Lexington, KY, USA 4 College of Nursing, University of Kentucky, Lexington, KY, USA Corresponding Author: Amanda Fallin, PhD, RN, Tobacco Policy Research Program, University of Kentucky, Lexington, KY 40536, USA. Email: [email protected]
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adoption, as policy implementation is required for policies to have their desired impact (Anderson, 1979). The policy process includes five stages (Anderson, 1979). The first and second stages are setting the agenda and formulating policy proposals. The third phase is adoption, and this occurs when a particular policy solution is enacted. In the fourth stage, implementation, administrative bodies put the provisions of the policy in place, and it involves all activities necessary to execute policy directives (Berman, 1978; Van Meter & Van Horn, 1975). The final stage consists of evaluation, which determines if the policy had the desired effect. Policy implementation research has lagged behind the understanding of policy adoption and innovation (deLeon & deLeon, 2002; O’Toole, 2000). Historically, the policy implementation phase has been resigned to the so-called black box, which alludes to the ambiguous and opaque nature of the typical policy implementation process (Harachi, Abbott, Catalano, Haggerty, & Fleming, 1999). However, there has been some progress toward understanding the policy implementation phase. Two approaches to policy implementation research, topdown and bottom-up, have been tested with mixed success. Top-down approaches to policy implementation involve clear policy directives to match policy goals with targeted outcomes (Berman, 1978; Sabatier & Mazmanian, 1979), though these approaches often lack the flexibility to adapt to local needs and do not necessarily result in the desired policy outcome (Matland, 1995). Bottom-up approaches, on the other hand, incorporate local conditions and the need for policy adaptability; however, these approaches tend to lack generalizability outside the original context, making it difficult to create guidelines for other communities to use (Sabatier & Mazmanian, 1979). These weaknesses in existing approaches to policy implementation research present a barrier to the development of standard methods for measuring effectiveness of policy implementation (e.g., smoke-free policies). Ostrom’s (2005) Institutional Analysis and Development (IAD) Framework has potential to guide the understanding and measurement of smoke-free policy implementation because it is not limited by the constraints of traditional top-down or bottom-up approaches to policy implementation research (O’Toole, 2000). The IAD Framework has been used to guide the study of tobacco control policies in a Spanish hospital system, where it helped outline potential measures to evaluate policy implementation effectiveness (Martinez, 2009). The purposes of this study were to (a) apply the IAD Framework to understanding smoke-free policy implementation effectiveness at the local level; and (b) develop and pilot test a multimethod approach to measure smoke-free policy implementation effectiveness.
Conceptual Framework The IAD Framework (Ostrom, 2005) provides a roadmap for understanding factors that influence the processes and outcomes of institutional policies. This framework has been used in studies of smokeand tobacco-free policy compliance (Fallin, 2011; Martinez, 2009). The IAD encompasses three nested levels of action: constitutional, collective choice, and operational. The constitutional level is the context within which institutional policymaking takes place. In this study, the constitutional level involves state policymaking (e.g., the Kentucky General Assembly). The collective choice level involves local policymaking, and the city councils or fiscal courts (the county-level policymaking body in Kentucky) comprised action at this level. The operational level involves policy implementation, or the street-level activities needed to put a policy into place. Each of the three action levels (constitutional, collective choice, and operational) has two characteristics: rules in use (rules, laws, and boundaries) and community attributes (culture and values). At the constitutional level, relevant rules in use include the existence or absence of state legislation restricting smoking in Kentucky, and community characteristics include Kentucky’s culture, norms, and values surrounding tobacco use. At the collective choice, or local policymaking, level, the rules in use include the regulations governing the policymaking bodies (e.g., existing voluntary smoke-free policies), and the community characteristics include the community’s culture, norms, and values related to tobacco (e.g., tobacco-growing). At the operational, or street, level, the rules in use include programs (e.g., tobacco cessation) and other efforts affecting policy adoption and implementation in the community. Community characteristics include the culture, norms, and values of the individuals involved directly in policy implementation, such as the business owners or enforcement officials (e.g., values business rights). The focal point of the IAD analysis is the action arena. Action arenas can occur at any of the three levels (constitutional, collective choice, and operational), and within each level, they are impacted by the characteristics (rules in use and community attributes). This article focuses on action arenas at the collective choice and operational levels, as the constitutional level was constant and not the target of this exploratory study. The action arena at the collective choice level was adoption of smoke-free ordinances. The action arena at the operational level was implementation of the ordinances. These action arenas directly impact outcomes. See Figure 1 for a visual construction of the IAD Framework as applied to this analysis.
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CONSTITUTIONAL
COLLECTIVE CHOICE Rules in Use
Rules in Use State smoke-free law
Voluntary smoke-free policies
Community A ributes
Community A ributes
State culture, norms, and values surrounding tobacco use
Local community culture, norms, and values surrounding tobacco use
ACTION ARENA Smoke-Free Policy Adop on
OPERATIONAL Rules in Use • • •
Social norms Tobacco cessa on programs Strength of tobacco control
Community A ributes Norms and values of individuals directly involved in implementa on, such as business owners
ACTION ARENA Community Adherence to Policy and Enforcement
OUTCOMES 1. 2. 3. 4. 5.
Reduced exposure to secondhand smoke in the community; Increased demand for cessa on services; Reduced smoking; Reduced healthcare u liza on; Improved health outcomes (e.g., reduced heart a acks, asthma a acks)
*Note: italicized rules in use, action arenas, and outcomes represent variables measured in this study. Figure 1. IAD model applied to smoke-free policy implementation. Note. Italicized rules in use, action arenas, and outcomes represent variables measured in this study.
The ultimate goal of policy adoption and implementation is to solve a problem at the population level. In the case of smoke-free policy, the desired effects are (a) reduction in exposure to secondhand smoke in the community; (b) increased demand for cessation services; (c) reduced smoking prevalence; (d) reduced health care utilization; and (e) improved population health outcomes (e.g., reduced heart and asthma attacks). The IAD Framework was used to guide the study and measurement of smoke-free policy implementation. This article presents an exploratory case study using mixed methods to develop and test selected IAD constructs to describe smoke-free policy implementation in three Kentucky communities with varying policy strength and duration. Smoke-free laws vary in strength from 100% comprehensive (e.g., covering all workplaces, restaurants, and bars) to partial policies with major exemptions (e.g., exemptions for bars, smoking allowed after certain hours; Americans for Nonsmokers’ Rights Foundation, 2013).
Methods An exploratory case study using mixed methods was used to assess selected IAD constructs at two levels (collective choice and operational) and population health outcomes related to smoke-free policy implementation effectiveness (the pilot constructs are in italics in Figure 1). Three communities in Kentucky were purposively selected, as they differed in smoke-free policy strength and duration. Two communities, Danville and Lexington-Fayette County, had 100% smoke-free workplace laws (Kentucky Center for Smoke-free Policy, 2013). Danville’s law was implemented in August 2008 and had been in place for 3 years when data were collected. Lexington-Fayette county’s ordinance was implemented in April 2004 (Greathouse, Hahn, Okoli, Warnick, & Riker, 2005) and had been in place for 7 years before data collection. The third community, Kenton County, had a weak smoke-free ordinance with multiple major exemptions. Kenton County’s law,
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implemented in April 2010, had been in place for 6 months when data were collected. We randomly selected five restaurants and five bars from the health department list of all eating and drinking venues in Danville and Lexington-Fayette, as per a protocol used previously by our team (Hahn et al., 2006). Data were collected in 19 venues in Kenton County, as part of an evaluation of the smoke-free ordinance by the local coalition. Data collected from the 39 venues included observations of community adherence to the policy (collective choice action arena) and fine particle air pollution (PM2.5) to assess secondhand smoke exposure (population health outcome). Data at the operational level were collected via key informant interviews, and secondary data analysis to assess rules in use as well as the selected population health outcomes.
comprise the indicators of tobacco-free schools, and an administrator at the school must indicate tobacco restrictions for each item for the school to be classified as tobacco-free. The estimate of the percent of smoke-free manufacturing facilities per county was obtained from a secondary data analysis of the 2010 Kentucky Workplace Tobacco Policy Survey conducted biannually via telephone with human resource managers, using a list of all manufacturing facilities with 50 or more employees obtained from the Kentucky Economic Development Cabinet (Hahn, Rayens, Okoli, Love, & Kim, 2004). Trained staff administered a 42-item telephone survey, including two items that assessed written indoor and outdoor smoke-free policies.
Measures and Data Sources
The operational phase involves street-level policy implementation.
The measures developed and tested in this exploratory case study were selected based on the IAD Framework, and they assess the collective choice and operational levels, as well as population health outcomes.
Constitutional Level The presence or absence of a state law prohibiting smoking in indoor venues was determined based on a review of Kentucky Regulatory Statutes.
Collective Choice The collective adoption.
choice
phase
encompasses
policy
Action arena. The action arena at the collective choice level was the presence, strength, and duration of a local smokefree ordinance enacted by a city council, urban county government, or county fiscal court. The source of information was the Kentucky Center for Smoke-free Policy’s (2013) ordinance database (Hahn, 2013). Rules in use. Rules in use for this study included percent of schools with voluntary tobacco-free school policies and percent of manufacturers with voluntary smokefree policies. A tobacco-free school is one that prohibits all forms of tobacco use on the school grounds at all hours (including during school-related events that occur after hours) and applies this policy to all students, employees, and guests. The estimate of the percent of tobacco-free schools per county was obtained from secondary data analysis of a 2011 Kentucky School Tobacco Policy Survey conducted biannually via telephone with principals and assistant principals in public and private schools, grades 6 to 12. Twelve questions
Operational Level
Action arena. The action arena at the operational level was conceptualized as community adherence and enforcement capacity related to the policy. Community adherence was operationalized using a 10-item community observation tool adapted from Skeer, Land, Cheng, and Siegel (2004) to assess level of compliance with the policy in selected businesses. Research staff conducted field observations using the tool to assess signage (four items), smoking paraphernalia (e.g., ashtrays, matchbooks; three items), and observed smoking (three items) in each of the 39 study venues in the three communities (see observational tool in the Appendix). Subscale scores were determined for each of the three aspects of adherence: signage, smoking paraphernalia, and observed smoking. Total adherence, the sum of the three subscales, ranged from 0 to 28, with high scores reflecting greater adherence to the policy than lower scores. Among the study venues, there was a significant Spearman’s rank correlation between smoking paraphernalia and observed smoking (rho ¼ 0.54, p ¼ .002), but these subscales were not associated with signage. Validity of the observation tool is further established by the correlation between smoking paraphernalia and air quality (rho ¼ 0.41, p ¼ .02); the negative correlation is consistent with the fact that better adherence (i.e., high paraphernalia score) reflects lower indoor air pollution (lower PM2.5). The correlations between air quality and each of observed smoking and signage subscales were not significant. This could be because the observed smoking subscale includes outdoor smoking, and signage alone may be a weak link to adherence. Data collection took place during peak times in each venue and data collectors attempted to appear as inconspicuous as possible in each venue. For example, data collectors ordered meals at the restaurants.
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To determine enforcement capacity, we contacted the individual responsible for policy enforcement in each of the three communities to determine the number of people assigned to enforcement of the smoke-free law. Enforcement capacity was then calculated using an investigator-developed measure: The estimate is obtained by dividing the number of personnel by the number of hospitality venues, multiplied by the adult population divided by 1,000.
the maximum score was based on the number and range of items in the scale. Once each component was converted to a percentage, the total score was determined by adding the percentages for the four components. The potential scores ranged from 0 to 4, with higher scores representing more comprehensive tobacco cessation programs.
Rules in use. Rules in use at the operational level was conceptualized as availability of tobacco cessation programs. These data were obtained from a secondary analysis of the 2010 Local Health Department Tobacco Cessation Survey; this survey was conducted annually from 2000 to 2010 via telephone with tobacco control specialists in all local health departments in Kentucky to assess the presence or absence of a menu of tobacco cessation services (Hahn & Rayens, 2010). The tobacco cessation measure for this study included four components: (a) the number of cessation programs per 10,000 smokers; (b) the number of channels promoting the quitline (“distributed brochures/fliers, distributed Quit Line prescription pads, paid advertising, earned (unpaid) media, Cooper-Clayton or other programs, hospitals/ clinics, health fairs, other,” with each assessed as a yes/ no variable and the total score equal to the sum of the “yes” responses); (c) the frequency of cessation medications recommended by health department providers (“How frequently do your healthcare providers prescribe or recommend the following medications for tobacco use cessation?” “nicotine gum,” “nicotine patch,” “nicotine spray,” “nicotine inhaler,” “nicotine lozenges,” “Buproprion,” “Varenicline,” “other medications,” each was scored on a 5-point ordinal scale ranging from 1 ¼ Never to 5 ¼ Always, with the total score equal to the sum of the seven items); and (d) barriers to providing cessation programs (“We have enough staff to provide tobacco cessation programs,” “Our staff is not trained to provide tobacco cessation,” “We are too busy to provide tobacco cessation,” “We have few requests for tobacco cessation programs,” “Tobacco cessation programs are too expensive,” and “Tobacco cessation programs are effective.”); each were rated on a 4-point Likert scale ranging from 1 Strongly disagree to 4 Strongly agree. The total score of this barriers scale was obtained after reverse scoring the ones with negative polarity (i.e., higher scores indicate fewer barriers) and summing the items. Once the summary scores were obtained for the four components, each was converted to a percentage by dividing it by the corresponding maximum possible score. For the rate of number of cessation programs per 10,000 smokers, the maximum score was determined by assessing the rate at all health departments in the state. For the remaining three components,
The goal of smoke-free policy adoption and implementation is to reduce exposure to secondhand smoke, increase demand for cessation services, decrease healthcare utilization, and promote other positive health outcomes.
Population Health Outcomes
Exposure to secondhand smoke. Two trained members of the research team measured fine particle air pollution in 39 venues in the three study communities using a TSI Sidepak, a standard technique (Cameron et al., 2010; Hyland, Travers, Dresler, Higbee, & Cummings, 2008; Thornley, Dirks, Edwards, Woodward, & Marshall, 2013). The machine was placed inside an empty backpack or purse, with the tube protruding for data collection. The data collectors sat away from doors and open windows, as well as grills or open flames whenever possible. While in the venue, the data collectors recorded the volume of the venue, the number of patrons, and the number of lit cigarettes. Demand for cessation services. Demand for cessation services was the number of participants in cessation programs annually per 10,000 smokers. This was obtained through a secondary analysis of the 2010 Local Health Department Tobacco Cessation Survey, conducted annually via telephone with tobacco control specialists in all local health departments in Kentucky. We summed the number of participants in seven tobacco cessation programs, divided by the estimated number of adult smokers in the county (Centers for Disease Control and Prevention, 2013) and multiplied by 10,000 to obtain this rate.
Results At the constitutional level, there is no statewide smokefree law in Kentucky, nor is there preemption of local smoke-free laws (Kentucky Center for Smoke-free Policy, 2013), meaning local communities have the authority to enact smoke-free laws at the community level. At the collective choice level, all three communities had a local smoke-free ordinance, which was built into the design of this study. There was variation in strength and duration of the ordinances. Two communities had 100% or comprehensive smoke-free ordinances; one
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community had a partial law with major exemptions. Of the two with 100% laws, one had been in effect for 7 years (Lexington-Fayette) and the other was more recently enacted (Danville; 3 years). The community with a partial law had been in effect for 6 months (Kenton). The percent of tobacco-free schools varied by community. The community with the more recently enacted comprehensive policy had the largest percentage of tobacco-free schools (100%; Table 1), while the other two communities were considerably lower in this measure of rules in use at the collective choice level. On the other hand, the percent of smoke-free manufacturers was relatively consistent across communities and close to 100%. At the operational level, Danville had the highest community adherence based on observation, followed closely by the other two communities. Enforcement effectiveness was highest in Danville, with the other two communities being quite a bit lower. Danville also had a slight advantage in the tobacco cessation programs score compared with the other two communities, but summary scores in the range of 2.0 to 2.7 indicate that all three communities were reaching only 50% to 68% of the maximum possible score in this area. The average PM2.5 was lower in Danville (mean ¼ 11.5) compared with Lexington-Fayette and Kenton, both with means of approximately 15.0. Danville had the highest demand for cessation per 10,000 population (678.7), compared with 32.9 in Lexington-Fayette and 21.5 in Kenton County.
Discussion Although Lexington-Fayette County and Danville both have comprehensive smoke-free workplace ordinances,
Danville scored higher on indicators of street-level implementation, including community adherence to the policy and enforcement capacity, as well as tobacco cessation programs. Similarly, Danville had better population health outcomes than Lexington-Fayette County. Danville had lower average PM2.5 and higher demand for cessation services compared with Lexington-Fayette County. Although it might be expected that Danville and Lexington-Fayette County, both with comprehensive smoke-free laws, would have similar outcomes, it is interesting that there is a disparity in both indicators of implementation effectiveness and population health outcomes between these two communities. In fact, in some areas, the outcomes of the Lexington-Fayette County law more closely resemble the outcomes of the Kenton County ordinance, which is not considered comprehensive. For example, the demand for cessation per 10,000 was 32.2 in Lexington-Fayette and 16.2 in Kenton County compared with 238.5 in Danville. We hypothesize that variation in policy implementation may explain differences in outcomes. Smoke-free policy implementation effectiveness may also drift over time; the Lexington-Fayette County’s ordinance had been in effect for 7 years. However, the Weber, Bagwell, Fielding, and Glantz (2003) study reported that compliance with smoke-free bar policies increased over time in California. Given these divergent findings, further research on the measurement of policy implementation effectiveness over time and impact on population health outcomes is warranted. We also need a more rigorous method of evaluating policy strength and comprehensiveness. The two comprehensive ordinances were defined based on the commonly used Americans for Nonsmokers’ Rights definition (Americans for
Table 1. Institutional Analysis and Development (IAD) Measures of Smoke-Free Policy Implementation: Action Arenas, Rules in Use, and Population Outcomes in Three Communities. Community Measure Local law status
Tobacco-free schools (%) Smoke-free manufacturers (%) Community adherence (observation) Enforcement effectiveness Tobacco cessation programs score Exposure to SHS (average PM2.5 mg/m3) Demand for cessation per 10,000
Level of IAD variable
IAD characteristic
Collective choice
Action arena
Operational level
Rules in use Rules in use Action arena Action arena Rules in use
Outcome
Lexington 100% smoke-free workplaces, restaurants, and bars 20.0 100.0 21.3
Danville
Kenton
100% smoke-free workplaces, restaurants, and bars 100.0 90.0 24.1
Exemptions for bars; allows smoking after 4:00 p.m. 33.3 94.7 21.1
5.0 2.2 14.7
15.2 2.7 11.5
4.6 2.0 15.0
35.9
678.7
21.5
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Nonsmokers’ Rights Foundation, 2012), but the minor exemptions in each ordinance were different, perhaps, resulting in varied implementation effectiveness and population outcomes. Though the definition of policy implementation is consistent in the literature, there is no consensus on when the implementation stage begins. Some define the beginning of the implementation phase as the point at which the policy has been adopted and funding committed (Van Meter & Van Horn, 1975). Anderson (1979) argues that the divide between the policy adoption phase and policy implementation is not so clear. This nebulous transition between policy adoption and policy implementation occurs for two reasons. First, policies tend to be modified during the implementation phase. For example, in the Kenton County ordinance, the split shift exemption (i.e., smoking allowed after 4:00 p.m.) was created by the county attorney after the ordinance was enacted by the fiscal court. Second, given the complexities of government, laws are increasingly written in a general way, giving administrative agencies leeway in how to implement the policy. In some instances, laws are so vague that administrative agencies have leeway to create the policy provisions, which effectively transforms these agencies into a fourth branch of government (Meier, 1993). Given these complexities in policy implementation, it is important to both measure and consistently define the implementation phase. In the case of smoke-free policies, the legislation typically defines the implementation date (i.e., 30–60 days after enactment; Centers for Disease Control and Prevention, 2008). One of the Lexington venues, an adult entertainment club, had a PM2.5 level significantly higher than the other locations in that community. This finding suggests that specific types of hospitality workers, such as employees in adult entertainment venues, may be particularly vulnerable to secondhand smoke exposure due to uneven implementation of smoke-free laws. Future studies are needed to assess the impact of policy implementation effectiveness among disparate populations. This is further evidence that effectively implementing a policy may be as (or more) impactful as simply enacting the law. In addition, it is possible that this framework for measuring implementation effectiveness could be translated to other policy issues. Although this study focused on implementation of local smoke-free ordinances, results of this research have implications for tobacco control policy implementation at all levels. The World Health Organization Framework Convention on Tobacco Control (FCTC) is an international treaty adopted by 178 nations, excluding the United States, which addresses the tobacco epidemic on a global level (World Health Organization, 2014b). Among FCTC mandates, Article 13 is a ban
on tobacco advertising, sponsorship and promotion, and Article 16 is a prohibition on tobacco sales to minors. There have been many implementation challenges, including lack of enforcement and a lack of clear direction to countries on how to implement these restrictions. Implementation research, including surveillance and compliance checks, is needed to understand and promote policy implementation effectiveness (Nagler & Viswanath, 2013) to maximize the health outcomes from tobacco control policy. This study did not assess the use of e-cigarettes inside observed venues. Use of e-cigarettes, a relatively new trend in tobacco products, are a possible policy loophole (Yamin, Bitton, & Bates, 2010), particularly in the case of older smoke-free ordinances. E-cigarettes are battery operated devices that heat a vapor solution. None of the three communities in this study had covered e-cigarettes in their ordinances. The use of e-cigarettes inside a smoke-free venue may present an implementation challenge. In future studies, the impact of e-cigarette use on policy implementation could be assessed, including observations of e-cigarette use and interviews with restaurant/bar owners about patron use and perceived impact on policy adherence. Future research is needed to develop and test innovative techniques for measuring policy implementation effectiveness.
Limitations This was a small exploratory study including only three communities. Future research with a larger group of communities is critically important to assess the differential effects of policy strength and comprehensiveness, implementation effectiveness, and population health outcomes. Further, this exploratory study measured only selected variables based on the IAD to describe implementation effectiveness of smoke-free laws. Development and testing of other IAD construct measures is needed.
Conclusion The IAD shows promise as a model to guide the study of policy adoption and implementation effectiveness. Better outcomes in Danville compared with Lexington-Fayette County, both with comprehensive smoke-free workplace laws, may have been attributed to more effective policy implementation. Although Lexington had a comprehensive smoke-free law, implementation indicators were more similar to Kenton, with a partial law, and subsequently, population outcomes in these two communities were more negative compared to Danville with a strong law and positive implementation indicators. It is important for public health nurses to remain actively engaged in the policy process beyond the period of policy adoption to ensure adequate implementation.
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Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Hahn, E. J., Rayens, M. K., Adkins, S., Simpson, N., Frazier, S., & Mannino, D. M. (2014). Fewer hospitalizations for chronic obstructive pulmonary disease in communities with smoke-free public policies. American Journal of Public Health, 104(6), 1059–1065. Hahn, E. J., Rayens, M. K., Butler, K. M., Zhang, M., Durbin, E., & Steinke, D. (2008). Smoke-free laws and adult smoking prevalence. Preventive Medicine, 47(2), 206–209. Hahn, E. J., Rayens, M. K., Okoli, C. T., Love, K., & Kim, S. (2004). Tobacco use prevention and cessation policies in manufacturing facilities in the tobacco-growing state of Kentucky. American Journal of Health Promotion, 18(3), 225–231. Hahn, E. J., Rayens, M., York, N., Okoli, C., Zhang, M., Dignan, M., . . . ;Al-Delaimy, W. K. (2006). Effects of a smoke-free law on hair nicotine and respiratory symptoms in restaurant and bar workers. Journal of Occupational and Environmental Medicine, 48(9), 906–913. Harachi, T. W., Abbott, R. D., Catalano, R. F., Haggerty, K. P., & Fleming, C. B. (1999). Opening the black box: Using process evaluation measures to assess implementation and theory building. American Journal of Community Psychology, 27(5), 711–731. Hopkins, D. P., Razi, S., Leeks, K. D., Priya Kalra, G., Chattopadhyay, S. K., & Soler, R. E. (2010). Smokefree policies to reduce tobacco use a systematic review. American Journal of Preventive Medicine, 38(2 Suppl.): S275–S289. Hyland, A., Travers, M. J., Dresler, C., Higbee, C., & Cummings, K. M. (2008). A 32-country comparison of tobacco smoke derived particle levels in indoor public places. Tobacco Control, 17(3), 159–165. Institute of Medicine. (2009). Secondhand smoke exposure and cardiovascular effects: Making sense of the evidence. Washington, DC: The National Academies Press. Kentucky Center for Smoke-free Policy. (2013). Tobacco use and policy fact sheets by county. Retrieved from http:// www.mc.uky.edu/tobaccopolicy/KCSP/UseAndPolicyFact Sheets2011.HTM Lee, K., Hahn, E., Robertson, H., Lee, S., Vogel, S., & Travers, M. (2009). Strength of smoke-free laws and indoor air quality. Nicotine & Tobacco Research, 11(4), 381–386. Martinez, C. (2009). Barriers and challenges of implementing tobacco control policies in hospitals: Applying the institutional analysis and development framework to the catalan network of smoke-free hospitals. Policy Politics and Nursing Practice, 10(3), 224–232. Matland, R. E. (1995). Synthesizing the implementation literature: The ambiguity-conflict model of policy implementation. Journal of Public Administration Research and Theory: J-PART, 5(2), 145–174. Meier, K. J. (1993). Politics and the bureaucracy: Policymaking in the fourth branch of government. New York, NY: Harcourt-Brace. Nagler, R. H., & Viswanath, K. (2013). Implementation and research priorities for FCTC Articles 13 and 16: Tobacco advertising, promotion and sponorship and sales to and by minors. Nicotine & Tobacco Research, 15(4), 832–846. Ostrom, E. (2005). Understanding institutional diversity. Princeton, NJ: Princeton University Press.
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O’Toole, L. J. (2000). Research on policy implementation: Assessment and prospects. Journal of Public Administration Research and Theory, 10(2), 263–288. Rayens, M. K., Burkhart, P. V., Zhang, M., Lee, S., Moser, D. K., Mannino, D., . . . ;Hahn, E. J. (2008). Reduction in asthma-related emergency department visits after implementation of a smoke-free law. Journal of Allergy and Clinical Immunology, 122(3), 537–541.e533. Sabatier, P. A., & Mazmanian, D. (1979). The conditions of effective implementation: A guide to accomplishing policy objectives. Policy Analysis, 5(4), 481–504. Skeer, M., Land, M. L., Cheng, D. M., & Siegel, M. B. (2004). Smoking in Boston bars before and after a 100% smoke-free regulation: An assessment of early compliance. Journal of Public Health Management and Practice, 10(6), 501–507. Stillman, F., Hartman, A., Graubard, B., Gilpin, E., Murray, D., & Gibson, J. (2003). Evaluation of the American Stop Smoking Intervention Study (ASSIST): A report of outcomes. Journal of the National Cancer Institute, 95(22), 1681–1691. Stillman, F., Yang, G., Figueiredo, V., Hernandez-Avila, M., & Samet, J. (2006). Building capacity for tobacco control research and policy. Tobacco Control, 15, i18–i23. Tan, C. E., & Glantz, S. A. (2012). Association between smokefree legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: A meta-analysis. Circulation, 126, 2177–2183. Thornley, S., Dirks, K. N., Edwards, R., Woodward, A., & Marshall, R. (2013). Indoor air pollution levels were halved as a result of a national tobacco ban in a New Zealand prison. Nicotine & Tobacco Research, 15(2), 343–347. U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease and Prevention and Promotion, Office of Smoking and Health. Van Meter, D. S., & Van Horn, C. E. (1975). The policy implementation process: A conceptual framework. Administration & Society, 6(4), 445–488. Weber, M. D., Bagwell, D. A., Fielding, J. E., & Glantz, S. A. (2003). Long term compliance with California’s Smoke-Free Workplace Law among bars and restaurants in Los Angeles county. Tobacco Control, 12(3), 269–273. World Health Organization. (2014a). Framework convention on tobacco control. Retrieved from http://www.who.int/fctc/en/ World Health Organization. (2014b). Tobacco Free Initiative (TFI): Smoke-free policies. Retrieved from http://
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Author Biographies Amanda Fallin, PhD, RN, is a postdoctoral fellow at the University of California San Francisco. Her research interests primarily focus on the adoption and implementation of tobacco control policies, and tobacco use among vulnerable populations. Amie Goodin, MPP, is a doctoral student at the Martin School of Public Policy and Administration. Her research interests include health policy, pharmaceutical policy, and Health Economics and Outcomes Research. She is currently working as a researcher and analyst at the Institute for Pharmaceutical Outcomes and Policy, University of Kentucky. Mary Kay Rayens, PhD, is Professor and Associate Director of the Tobacco Policy Research Program at the University of Kentucky College of Nursing. Dr. Rayens is a biostatistician; her research interests include tobacco policy and health outcomes. Sarah Morris, MS, is an Assistant Professor and biostatistician in the College of Safety & Justice at Eastern Kentucky University. She is currently completing her DrPH degree in biostatistics at the University of Kentucky, in the College of Public Health. She is a statistician at the University of Kentucky College of Nursing and College of Public Health. Ellen J. Hahn, PhD, RN, FAAN, is Professor and Director of the Tobacco Policy Research Program at the University of Kentucky College of Nursing. Dr. Hahn and colleagues have assisted 39 Kentucky communities to adopt or enact smoke-free policies since 2003. She is the current Principal Investigator on a NIEHSfunded project to test a dual home screening intervention to reduce home exposure to radon and secondhand smoke.
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Appendix: UK Clean Indoor Air Partnership Smoke-Free Law Adherence Evaluation
Community name (city/county): ___________________________________ Establishment name: ________________________________ Establishment type: ___Bar ___Restaurant If bar, select type: _____Free-standing bar ___Nightclub ____Bar with restaurant Date: ___________________ Temperature: ___Hot ___Warm ___Cool ___Cold Weather: ____Clear ____Drizzling ___Raining ____Light Snow ___Heavy Snow Time started: _____________
1. Total number of patrons smoking outside the main entrance:______ 2. Total number of males smoking outside the main entrance: ______ 3. Total number of females smoking outside the main entrance: _______ 4. Is a “no-smoking” sign posted at entrance to establishment?
__ Yes __ No
If yes, is it in clear view? If yes, is the sign the official health department stick?
__ Yes __ No __ Yes __ No
5. Number of “NO SMOKING” signs that are displayed conspicuously: _____ 6. Approximate number of people present inside: _______ 7. Are any ashtrays present inside the establishment?
__ Yes __ No
8. Number of ashtrays present with ashes inside: _______ 9. Number of matchbooks present: _______ 10. At any point during your stay was a patron smoking? (If no, skip to question #14) ___Yes ___No 11. Total number of patrons smoking INSIDE the establishment: ________ 12. Total number of males smoking INSIDE the establishment:_______ 13. Describe any interactions between an employee and a smoking patron: _________
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14. At any point during your stay was an employee smoking? (If no, skip to question #16) __Yes __No 15. Total number of employees: _____ 16. Number of employees smoking: _________ 17. Gender of employees and indicate gender of smoking employees (if applicable): _________________________________________________________________ 18. Number of rooms in the establishment: ________ 19. Establishment capacity: ________ 20. Number of seats: _______ 21. Smell in establishment: __Clear ___Musty (stale smoke) ____Somewhat smoky ___Very smoky 22. Is the establishment carpeted? __Yes ___No 23. Are there draperies or wall coverings? ___Yes ___No 24. Number of cigarette vending machines present: _____ 25. Location of cigarette vending machines: ________ 26. Number of cigarette advertisements: ________ 27. Is there an outside seating area? (If no, skip to end of questions)
__ Yes __ No
28. Were those smoking outside doing so a reasonable distance from the entrance to prevent smoke from filtering into the establishment? 29. Where are the patrons smoking?
About how many feet away from entrance to building?
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__ Yes __ No
__ Outside front entrance __ Outside back entrance __ Patio __ Other __ 0-5 __ 6-10 __ More than 10
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30. Are butt receptacles available?
__ Yes __ No
I f y e s , w he r e a re t h ey l oca t ed ? __ Outside front entrance __ Outside back entrance __ Patio __ Other 31. How much cigarette butt litter is present and where is it located? (i.e. rough number of butts and location observed) __ 0 __ 1-5 __6-10 __ 11-20 __ More than 20
Ending time: __________ Notes: __________
Modified from Skeer et al., 2004.
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