Adoption of Smoke-free Laws and Voluntary Policies in Rural Communities in Southern States

摘要 尽管美国其他地区的吸烟率迅速下降，但美国南部农村人口的吸烟率仍然很高。 近几十年来。虽然58.3%的美国公民受到全面无烟（SF）法律的保护， 16.7%居住在东南中部或南大西洋地区的公民受到保护。当前最佳 SF法律宣传的做法并没有有效地缩小农村、南部和南部地区的覆盖面差距， 居民与此同时，采取自愿政策（如无烟学校、公共住房、户外 在全国范围内加速发展。自愿政策的存在可能会增加对SF政策的准备 通过，或者他们可能会破坏南方各州农村城市通过SF法律。我们的研究是创新的 因为我们将纳入一个政治理论，金顿的多流框架，以指导旧金山法律的采用 在烟草使用不均衡的地区进行研究。具体目标是：1）确定差异 有和没有SF法律的农村城市之间在社区准备、问题指标 (e.g.,吸烟率），聚焦事件，和反馈;政治（例如，建立共识）;政策因素 (e.g.,预期的限制）;和政策企业家（例如，烟草控制力度），控制 人口规模和其他人口因素; 1a）比较自愿吸烟的人数和类型， 农村城市的无烟政策（例如，无烟学校、公共住房、户外空间的百分比）， 没有SF法律; 2）描述影响社会政治环境的促进者和障碍 宣传战略、政策窗口（例如，政策通过的临界点），以及在 有和没有SF法律的农村城市。我们将采用混合方法、病例对照设计进行 与当地倡导者（N = 150-250）和当选者进行电话和在线调查，以评估政策采纳因素 来自50个市（城市，城镇或村庄）的官员（N = 150）（25例; 25例对照）嵌套在4个 州：亚拉巴马、肯塔基州、密西西比和南卡罗来纳州。案例市政当局将颁布一项SF法律 在过去3年内;控制将与基于社区人口规模的每个州的病例相匹配 和乡村性。使用定性方法，我们还将与社区领袖，公民和社区领导人进行深入访谈。 活动家和决策者，以防市政当局与最新的SF法律及其匹配的控制， 每个州（每个州两个社区;每个社区10-15名关键举报人）。将要求参与者 描述影响SF政策采用的因素，并要求对可能促成的关键事件发表评论 或阻碍政策的实施。社区咨询委员会，由烟草控制和SF的8位领导人组成 农村地区和代表南部四个州的法律通过情况将指导研究的所有方面。这 这项研究将改变目前的研究范式，以一种新的方式来理解SF法律采用在农村，南部 市.与烟草有关的健康差距将继续导致健康状况不佳， 社会成本在农村南部城市，直到我们可以推进科学的SF政策采用。

Abstract Smoking remains high in America’s rural southern population despite rapid declines in other regions of the U.S. in recent decades. While 58.3% of U.S. citizens are covered by comprehensive smoke-free (SF) laws, only 16.7% of citizens living in the East South Central or the South Atlantic regions are protected. Current best practices for SF law advocacy have not been effective in closing the gaps in coverage for rural, southern residents. Meanwhile, adoption of voluntary policies (e.g, tobacco-free schools, public housing, outdoor spaces) have accelerated nationwide. The presence of voluntary policies may increase readiness for SF policy adoption or they may derail SF law adoption in rural municipalities in southern states. Our study is innovative because we will incorporate a political theory, Kingdon’s Multiple Streams framework, to guide SF law adoption research in a region with tobacco use disparities. The Specific Aims are to: 1) determine the differences between rural municipalities with and without SF laws in regard to community readiness, problem indicators (e.g., smoking prevalence), focusing events, and feedback; politics (e.g., consensus building); policy factors (e.g., anticipated constraints); and policy entrepreneurs (e.g., strength of tobacco control), controlling for population size and other demographic factors; 1a) compare the number and type of voluntary smoke- and tobacco-free policies (e.g, % tobacco-free schools, public housing, outdoor spaces) in rural municipalities with and without SF laws; and 2) describe facilitators and barriers in the sociopolitical environment that impact advocacy strategies, the policy window (e.g., the tipping point for policy adoption), and enactment of SF laws in rural municipalities with and without SF laws. We will use a mixed methods, case-control design to conduct telephone and online surveys to assess policy adoption factors with local advocates (N = 150-250) and elected officials (N = 150) from 50 municipalities (cities, towns or villages) (25 cases; 25 controls) nested within four states: Alabama, Kentucky, Mississippi, and South Carolina. Case municipalities will have enacted a SF law within the past 3 years; controls will be matched with cases in each state based on community population size and rurality. Using qualitative methods, we also will conduct in-depth interviews with community leaders, citizen activists, and policymakers in case municipalities with the most recent SF law and their matched controls from each state (two communities per state; 10-15 key informants per community). Participants will be asked to describe factors affecting SF policy adoption and asked to comment on key events that may have contributed to or inhibited policy adoption. A Community Advisory Board consisting of 8 leaders in tobacco control and SF law adoption in rural areas and representing the four southern states will guide all aspects of the study. This study will shift the current research paradigm to a new way of understanding SF law adoption in rural, southern municipalities. Tobacco-related health disparities will continue to lead to poor health outcomes and enormous societal costs in rural southern municipalities until we can advance the science of SF policy adoption.