Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000–2019

Abstract

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.

However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.

Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.

The US adult cigarette smoking prevalence declined from 20.9% to 14.0% between 2005 and 2017.¹ Although the overall prevalence fell across all racial and ethnic groups,² differences in prevalence remained among US subpopulations, resulting in continuing tobacco-related health disparities. Subpopulations disproportionately burdened by tobacco use include low-income people,³ people with mental health or substance use disorders,³ and rural residents³ (Table 1). In 2016, the smoking prevalence among individuals living below the poverty line was 1.6 times higher than the prevalence in the general population (25.3% vs 15.5%^3,4); however, among certain low-income populations (e.g., the homeless population), the prevalence of smoking is 4.5 times higher than that in the general population (70%⁵).

TABLE 1—

Cigarette Smoking Among Adults Aged 18 Years and Older: United States, 2017

Group	%
Overall	14.0
Race/ethnicity
Non-Hispanic White	15.2
Non-Hispanic Black	14.9
Non-Hispanic Asian	7.1
Non-Hispanic American Indian/Alaska Native	24.0
Hispanic	9.9
Non-Hispanic multirace	20.6
Census region
Northeast	11.2
Midwest	16.9
South	15.5
West	11.0
Annual household income, $
< 35 000	21.4
35 000–74 999	15.3
75 000–99 999	11.8
≥ 100 000	7.6
Serious psychological distress
Yes	35.2
No	13.2

Source. Centers for Disease Control and Prevention.³

Tobacco-caused morbidity is higher among these subpopulations than in the general population, with tobacco-caused diseases the leading causes of premature mortality.^6–8 The disparity in tobacco-related health outcomes is compounded by the fact that these populations face substantial barriers to accessing comprehensive smoke-free coverage (smoke-free laws prohibiting all smoking in workplaces, restaurants, and bars), evidence-based smoking cessation care, and smoke-free residences.⁹ Although tobacco control interventions are benefiting the overall population, inequity in access to smoke-free laws and policies has contributed to perpetuating tobacco-related health disparities.

Here we examine the role comprehensive smoke-free laws have played in reducing smoking prevalence and how coverage by these smoke-free laws (legally binding legislative mandates) and policies (rules developed and enforced by the institution enacting the policy) can be expanded to reduce health disparities. We also investigate the impact of smoke-free laws on establishment of voluntary smoke-free polices in private settings (i.e., within homes). (Because e-cigarettes are so new, the existing literature deals with the impact of smoke-free laws and policies on reducing combustible cigarette smoking–related disparities; similar issues would apply to the implications of other products such as e-cigarettes and inhaled cannabis.) Promising practices and policies to reduce tobacco-related health disparities would specifically target at-risk subgroups, such as racial/ethnic and low socioeconomic subpopulations that have driven smoking-related disparities,¹⁰ while continuing to strengthen the policy framework in place that has been beneficial with respect to decreasing overall smoking prevalence.

LITERATURE REVIEW

We searched PubMed with the search terms “smoke-free policies,” “smoke-free homes,” and “comprehensive smoke free policies” within studies investigating smoke-free laws and policies. We also searched with the terms “rural U.S. communities,” “low-income populations,” “people living below federal poverty line,” “public housing,” “low-income subsidized housing,” and “smoking cessation.” We reviewed reference lists in these publications and used the Science Citation Index and Google Scholar to identify articles that cited the publications to determine whether the findings had changed or been updated. We also searched the Web sites of the Centers for Disease Control and Prevention, the American Nonsmokers’ Rights Foundation, the US Census Bureau, and the US Department of Housing and Urban Development to identify unpublished (non-industry-funded) research reports, surveys, databases, and maps regarding coverage and content of smoke-free laws and policies as well as multiunit housing information.

Because of length constraints, we did not address smoking in cars or in outdoor venues. Searches were conducted between July 2018 and August 2018. Searches of the American Nonsmokers’ Rights Foundation and US Census Bureau sites were updated in June 2019.

Comprehensive Laws and Policies

Smoke-free laws and their associated change in social norms have been a key contributor to the decline of smoking.^11,12 As of July 2019, 25 US states had adopted comprehensive 100% smoke-free laws in workplaces, restaurants, and bars, and 11 more had adopted laws covering at least one of these areas.¹³ Localities have historically led efforts on clean indoor air laws; when adding the effect of local legislation, 59.0% and 81.8% of US residents are covered, respectively.¹⁴ This legislation has protected nonsmokers from secondhand smoke (SHS) exposure. The prevalence of SHS exposure among US nonsmokers fell by half between 1999–2000 and 2013–2014, from 52.5% to 25.2%.¹⁵

Smoke-free laws are followed by drops in hospital admissions due to cardiovascular and respiratory disease; reduced perinatal risks, including stillbirths, low birthweight, and pediatric asthma; and decreased risks of alcohol use disorder.^16–18

In addition to protecting people from SHS, smoke-free laws and policies stimulate quit attempts and support smoking cessation.^19,20 They also contribute to reducing cigarette smoking among adolescents and young adults.²¹ Data collected from 1997 to 2007 showed that 100% smoke-free workplace laws were associated with significantly lower odds of young people initiating smoking (odds ratio [OR] = 0.66; 95% confidence interval [CI] = 0.44, 0.99) and that 100% smoke-free bars were associated with reduced odds of being a current smoker (OR = 0.80; 95% CI = 0.71, 0.90) and fewer days of smoking (incidence rate ratio = 0.85; 95% CI = 0.80, 0.90).²¹

Furthermore, smoke-free laws are associated with a decline in cigarette smoking among adolescents in general,^22,23 as well as a decline among adolescents in high socioeconomic status and male subpopulations.²³ Although smoke-free laws covering combustible cigarettes have helped reduce the smoking prevalence among adolescents and young adults, use of electronic cigarettes increased rapidly in 2018.²⁴ As of April 2019, 13 states and 841 localities had expanded smoke-free laws to also restrict electronic cigarette smoking in 100% smoke-free venues.²⁵

There has been a substantial movement toward implementing smoke-free policies beyond workplaces and public places, including hospitals²⁶ and inpatient psychiatric facilities,²⁷ correctional facilities,²⁸ and multiunit²⁹ and public^30,31 housing. These sites tend to serve individuals who are disproportionately affected by tobacco use, so extending smoke-free laws and policies to such environments could contribute to reducing health disparities. Implementing smoke-free policies in settings that serve individuals with high rates of smoking presents an important opportunity to combine smoking cessation resources with smoke-free policies to further reduce tobacco-induced harm among these high-risk populations.

Diffusion of Laws and Policies

Although substantial evidence shows that comprehensive smoke-free laws reduce smoking prevalence, coverage and passage of clean indoor air laws have varied by sociodemographic characteristics (which in turn vary by region and state³²) and shift over time.^32,33 Localities with higher socioeconomic status are more likely to pass comprehensive smoke-free laws.^32–36 Other correlates of smoke-free legislation coverage and breadth include a larger proportion of workers who live and work in the same locality,³² bordering localities with strong regulations,³⁴ and voter and government support for clean indoor air policies.³⁴

A systematic review of publications from 1995 to 2013 studying population-level interventions and policies and reporting smoking-related outcomes examined the equity impact of smoke-free policies on adults of lower relative to higher socioeconomic status.³⁷ Included studies were based in countries at stage 4 of the tobacco epidemic or countries in the World Health Organization’s European Region. Seventy-six percent of studies (19 of 25) assessing voluntary regional or partial smoke-free policies reported a negative equity impact, meaning that higher socioeconomic status groups were relatively more responsive to the intervention or policy as a result of varying protection from SHS.³⁷ By contrast, only 32% of studies (6 of 19) of comprehensive smoke-free legislation reported a negative equity impact.³⁷ This analysis suggests that more comprehensive tobacco control interventions, including comprehensive smoke-free legislation, reduce smoking inequalities.

Political barriers to diffusion of smoke-free laws.

Political institutional factors, such as term limits, may influence passage of smoke-free laws.³⁸ States with term limits have a 2.15 times greater probability of enacting smoke-free laws, perhaps reflecting breaking associations between legislatures and special interests.³⁸ Conversely, the presence of a previous (generally weak) clean indoor air law inhibits the enactment of a state-level smoke-free law (hazard ratio of 0.20).³⁸ Once enacted, local and state smoking restrictions passed between 1970 and 2009 tended not to be strengthened.³⁹ This finding suggests that rather than incrementally passing stronger smoke-free laws, it is better to work toward passing comprehensive smoke-free laws from the beginning; the reason is that it is much more likely that laws will not be changed than that they will be strengthened.³⁹

The tobacco industry has played a key role in opposing tobacco control legislation. In addition to direct campaign contributions to legislators,⁴⁰ the industry uses litigation^41,42 and front groups and third-party allies funded by tobacco companies to influence policymakers and the public to block or weaken regulatory measures.^43–46 The tobacco industry has also recruited historically disenfranchised groups such as African Americans, gays and lesbians, and homeless populations to support its agenda.^44,47–51 In addition, the tobacco industry works through the hospitality and gaming industries to oppose initiatives that restrict smoking in public places.^44,52,53 Health advocates have worked to counter these influences by exposing industry connections and arguing that partner organizations have prioritized the tobacco industry’s interests over the interests of their own constituencies.

Impact of lack of diffusion of smoke-free laws.

The impact of smoke-free legislation on different racial/ethnic groups (Hispanics, Asians, and non-Hispanic Blacks) may differ owing to a correlation between US regions where smoke-free laws have been passed and regions where specific ethnic groups tend to live.⁵⁴ From 2000 to 2009, the proportions of the population covered by 100% smoke-free laws were highest among US Asian and Hispanic groups because higher concentrations of those groups live on the coasts and in Texas, where smoke-free laws have tended to pass. As of 2017, Asian and Hispanic populations had the lowest smoking prevalence among racial/ethnic groups in the United States (Table 1). By contrast, non-Hispanic African American populations had the lowest proportion covered because they were more likely to live in the South (where many tobacco-growing states are located) and the Midwest (where fewer comprehensive smoke-free laws exist).⁵⁴

Changing resistance to smoke-free laws in tobacco-growing states.

Diffusion of strong smoke-free laws to rural regions has been affected by significant historical barriers. Smaller rural communities are less likely to adopt smoke-free laws than are larger urban areas,^35,55,56 particularly communities in southern states, Appalachia, and other rural regions.^57–60 Historically, there was strong political resistance to tobacco control policies, including smoke-free laws, in tobacco-growing states because of the alliance between manufacturers and farmers, with manufacturers providing political clout and farmers providing grassroots support.⁶¹ This changed after manufacturers supported ending the tobacco farm price support program in 2004 and farmers stopped viewing manufacturers as allies and started moving to other crops.

The end of the federal price support program for tobacco led smaller farmers to stop growing tobacco and initiated a decline in the amount of tobacco grown per year in all 5 of the major tobacco-growing states (Kentucky, North Carolina, South Carolina, Tennessee, and Virginia).^61,62 This change reduced tobacco farmers’ interest in opposing tobacco control policies,⁶¹ as reflected in farmers’ changing attitudes toward tobacco control.⁶³ North Carolina tobacco farmers’ perceptions of tobacco control measures as a threat declined between 1997 and 2005, increasing the receptiveness of tobacco-growing communities and rural areas to public health measures.⁶³

Furthermore, in South Carolina, although legislators from tobacco-growing areas remained allies with tobacco manufacturers, agriculture organizations shifted from opposition to neutrality on tobacco control to better represent their farming constituency.⁶⁴ This realignment broke the iron triangle^65–68 consisting of the Farm Bureau, commissioners of agriculture, and tobacco-area legislators who had aligned with tobacco manufacturers. The change to a neutral stance on tobacco control on the part of the Farm Bureau and commissioners of agriculture created a crucial opening for public health groups to make progress in tobacco-growing states.⁶⁴ Between 2006 and 2009, advocates in South Carolina passed 23 local clean indoor air ordinances (affecting 26% of the state population).^64,69 As of 2019, 47 municipalities in South Carolina (32% of the state population) had implemented comprehensive 100% smoke-free laws.^70,71

Smoke-Free Homes and Multiunit Housing

In addition to protecting its occupants from SHS, a smoke-free home (i.e., a voluntary adoption of no-smoking rules in one’s home) is a major predictor of successful smoking cessation.^20,72 In 2010–2011, only 60.1% of households with children had a voluntary smoke-free home rule.⁷³ Nationally representative surveys showed that smoke-free homes were associated with reduced consumption, increased successful cessation, and reduced relapse to smoking.^72,74

Although smoke-free homes are more prevalent among lighter smokers, the benefit of smoke-free homes is seen among all smokers.⁷⁴ Because implementing a voluntary smoke-free home rule makes it more difficult to smoke at will, it is possible that the implementation of a smoke-free home leads to a reduction in smoking intensity prior to a quit attempt.²⁰ Smoke-free homes also pose challenges to smoking previously favorite cigarettes (e.g., after a meal, first cigarette in the morning), potentially reducing relapse back to smoking.^72,75 The efficacy of pharmaceutical aids for smoking cessation is increased in the setting of a smoke-free home, suggesting that combining a smoke-free home with smoking cessation resources would increase the chances of a smoker quitting successfully.⁷⁶

Lower-income adults are less likely than higher-income adults to adopt smoke-free homes, reflecting differential smoking norms in the respective communities.^75,77,78 The slower diffusion of smoke-free homes among low-income smokers could be related to pervasiveness of protobacco social norms in poor neighborhoods.⁹ The increased presence of tobacco retailers and marketing in these neighborhoods may serve as one contributing factor.⁷⁹ Lack of agency to negotiate the adoption of a smoke-free home is another common barrier among low-income smokers.⁸⁰

Smoke-free laws and voluntary smoke-free home policies.

The passage of smoke-free laws in communities both indicates and reinforces social norms prioritizing nonsmoking.⁸¹ This is reflected by the association with increased adoption of smoke-free homes among smokers and nonsmokers in most but not all studies.^82–85 No studies have shown an increase in smoking at home following the implementation of smoke-free laws in workplaces and public places.

This phenomenon is not limited to the United States. In India from 2009 to 2010, 64% of respondents who were employed in smoke-free workplaces also lived in a smoke-free home, as compared with 41.7% of respondents who worked where smoking occurred.⁸⁶ In addition, smoke-free legislation was associated with a higher proportion of adults reporting a smoke-free home (OR = 2.07; 95% CI = 1.64, 2.52).⁸⁶ In 2007, England implemented a nationwide law prohibiting smoking in enclosed public places. Researchers found that establishment of smoke-free homes accelerated among parents who smoked after the comprehensive nationwide smoke-free law was implemented.⁸⁷ Furthermore, the number of home smoking rules among smokers increased after smoke-free hospitality venues were implemented in France.⁸⁸

By contrast, one study conducted in London, England, from 1970 to 2007 showed that smoke-free laws displaced smoking into private locations (homes and backyards) and that levels of cotinine, a nicotine metabolite used to assess exposure to tobacco smoke, increased among nonsmokers after smoke-free laws were implemented.⁸⁹ Locations where no changes were observed either in the general population or among smokers and other subpopulations include Scotland; Quebec, Canada; and Australia.^90–92

Taken together, most of these studies support the hypothesis that the change in social norms embodied in smoke-free workplaces and public places stimulates implementation of voluntary smoke-free policies in private settings such as homes.^74,81,86

Smoke-free policies in multiunit housing.

People who live in single-family homes are more likely to adopt voluntary home smoke-free rules than are people who live in multiunit housing.⁹³ Residents in multiunit housing are particularly susceptible to SHS exposure because smoke infiltrates into smoke-free living units from other units in which people are smoking.^94–97 In 2017, 80 million Americans lived in multiunit housing, including 7 million in government-subsidized public housing.⁹⁸ Voluntary home smoking rules in multiunit housing are more common among more educated individuals and those with young children in their homes and less common among older individuals, those with more friends who smoke, and those who live with a smoker.⁹⁹

Multiunit housing residents in urban and rural areas express high levels of support for smoke-free public housing.^100,101 In 2013, 91.3% of US survey respondents who were living in multiunit housing with children agreed that tenants have a right to live in a smoke-free building.¹⁰⁰ A 2016 survey showed that 73.7% of adults living in public housing favored smoke-free public housing.¹⁰¹ Of those in favor, 44.3% were current cigarette smokers, 73.2% were former smokers, and 80.4% had never smoked.¹⁰¹ These findings suggest that most US adults favor smoke-free public housing. The widespread adoption of smoke-free public housing laws could protect vulnerable populations such as low-income individuals.

Smoke-free policies and voluntary smoke-free homes have the potential to reduce smoking among both lower and higher income populations.⁷² Nationally, the prevalence of smoke-free homes among smokers increased by 60% between 2002 and 2010, but low-income smokers were 33% less likely to adopt smoke-free homes than higher income smokers.¹⁰² Furthermore, individuals with a higher income (adjusted OR = 1.9; 95% CI = 1.4, 2.6) and a smoke-free home (adjusted OR = 1.6; 95% CI = 1.2, 2.1) had higher odds of achieving 30-day smoking abstinence. The increase in smoke-free homes between 2002 and 2010 could explain up to 36% of the difference in cessation between individuals living above and below 300% of the federal poverty limit.¹⁰² Increased access to smoke-free homes among low-income smokers could contribute to substantially reducing the disparity in cessation rates between low- and high-income smokers. Smoke-free policies in multiunit housing combined with access to cessation services could substantially reduce tobacco-related disparities.

At an institutional (as opposed to individual family) level, smoke-free policies in multiunit housing have largely been left to the discretion of individual developers and property managers¹⁰³ with the exception of jurisdictions where there are local ordinances prohibiting smoking in multiunit housing.⁵⁸ Few “comprehensive” smoke-free local ordinances apply to multiunit housing. As of 2018, 42 municipalities had 100% smoke-free multiunit housing laws, all of which were in California.¹⁰⁴

Although a high percentage of multiunit housing residents (ranging from 50%¹⁰⁵ to 95%¹⁰⁶ based on data collected between 2005 and 2011) had implemented voluntary smoke-free rules in their living units, in 2008 the percentage of buildings in which all units adopted voluntary smoke-free rules was just 9% to 19% in New York State.^99,107,108 Multiunit building-level smoke-free policies were more frequent in senior housing, buildings that catered to high-income individuals, new buildings, and public housing.⁹⁹

The efficacy of multiunit smoke-free policies in reducing exposure to SHS depends on how well the policies are enforced.^109,110 A survey of 15 multiunit housing properties in Florida in 2013–2014 revealed that, after implementation of smoke-free policies, the percentage of residents reporting SHS exposure dropped from 31.1% to 23.6%.¹¹¹ Similarly, a longitudinal community-based study of multiunit housing residents in 2012 showed that respondents who lived in a smoke-free building had significantly reduced odds of SHS exposure (OR = 0.59; 95% CI = 0.44, 0.80) relative to those living in buildings where smoking was permitted.¹¹²

These disparities highlight the value of the Department of Housing and Urban Development’s mandate for public housing authorities to implement indoor smoke-free policies in all of their buildings by July 2018.¹¹³ This policy is expected to affect more than 1.2 million low-income households and more than 700 000 children, the majority from racial/ethnic minority groups.¹¹⁴ However, the policy does not apply to Section 8 or other voucher- or project-based housing in clustered properties or scattered units within free-market rental properties or to not-for-profit supportive housing for formerly homeless adults, where the implementation of such policies is left to the discretion of property management. The inequitable access to these policies among subgroups of low-income smokers could further increase disparities in tobacco-related outcomes.

POLICY RECOMMENDATIONS

Comprehensive smoke-free policies have played a key role in the decline of smoking prevalence. However, uneven passage of these policies has contributed to maintaining tobacco-caused health disparities. Expanding coverage access to more regions and living spaces within the United States will help reduce smoking among subpopulations with a high smoking prevalence. Several types of smoke-free laws and policies could further reduce tobacco-related health disparities, beginning with implementation of comprehensive smoke-free laws covering 100% of the US population, including 100% smoke-free legislation and policies for multiunit housing and all forms of subsidized housing.

Furthermore, comprehensive smoke-free laws are positively associated with the presence of smoking cessation services and smoke-free policies in substance abuse treatment facilities in the United States.¹¹⁵ Therefore, smoke-free policies would also benefit from increasing funding and infrastructure for cessation services and incorporating appropriately tailored cessation help into health care and mental health settings.^116,117

Smoke-free policies in combination with smoking cessation services should also be extended to nonclinical settings including public housing, shelters for homeless adults, community centers, and other sites serving low-income populations. Although such services are typically not present at these sites, results from pilot studies of cessation interventions suggest an increase in delivery of cessation services at these sites^118,119 and more use of services and higher cessation rates when the interventions are accompanied by smoke-free policies.¹²⁰ Furthermore, these policies should ensure that smoking cessation services are widely accessible. Integration of smoke-free laws and smoking cessation services should be done in a way that does not exacerbate existing disparities in access to cessation services, which are now more accessible in high-SES groups.¹²¹

Smoke-free laws and policies would also benefit from further investing in language-appropriate mass media campaigns focused on high prevalence groups as has been done in California, where reducing disparities has been a long-standing explicit goal of the state’s tobacco control program.¹²²

To reach remaining smokers in underserved communities, it is important to promote community engagement (among leaders, stakeholders, community review boards, and constituents) when formulating smoke-free laws and policies. Policies need to be constructed with feedback from the community they will be affecting (e.g., residents in multiunit housing) to ensure buy-in among residents. Public health practitioners should play a leadership role in facilitating community engagement to create and implement smoke-free laws and policies. Furthermore, policymakers should ensure that legislation language is strong from the beginning, rather than implementing partial policies with the expectation that they will be strengthened over time, and that laws and policies are enforced and their success monitored so that any problems can be addressed in a timely manner.

CONCLUSIONS

The overall smoking prevalence in the United States has declined as a result of the implementation of tobacco control measures, including smoke-free laws. Smoke-free legislation has been an essential line of defense for protecting nonsmokers from the harmful effects of SHS exposure, including cardiovascular and respiratory disease and perinatal risks. Smoke-free laws are also associated with improved cessation attempts among the groups with the highest smoking prevalence, low-income individuals and people living with mental health disorders. Furthermore, the smoke-free local and state laws enacted in southern states have improved population health. In Kentucky, smoke-free laws were followed by reductions in smoking rates¹²³ and improvements in worker health and air quality,^124,125 as exemplified by reductions in asthma attacks,¹²⁶ chronic obstructive pulmonary disease hospitalizations,¹²⁷ lung cancer,¹²⁸ and myocardial infarctions.¹²⁹ Expanding the reach of comprehensive smoke-free laws will improve health outcomes and reduce health disparities in the United States.

Disparities exist in the adoption of home smoke-free policies according to housing type, as individuals who live in single-family homes are more likely to adopt voluntary smoke-free home rules than are individuals who live in multiunit housing. As noted, individuals living in multiunit housing are particularly susceptible to SHS exposure because smoke infiltrates into smoke-free units from units where smoking occurs. Smoke-free policies in multiunit housing have largely been left to the discretion of individual developers and property managers or residents at the unit level, except in jurisdictions where there are local ordinances prohibiting smoking in multiunit housing. Despite comprehensive smoke-free local ordinances, the policy still may not apply to all forms of multiunit housing, leaving gaps in exposure to SHS among residents in multiunit housing, particularly low-income residents.

Expanding the reach of comprehensive smoke-free laws and smoking cessation services not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will reduce exposure to SHS and further improve health outcomes in the United States.