Ellen J. Hahn

Building Consensus Using the Policy Delphi Method

This article describes the use of the policy Delphi method in building consensus for public policy and proposes a technique for measuring the degree of consensus. The policy Delphi method is a systematic method for obtaining, exchanging, and developing informed opinion on an issue. It can be used to develop consensus either for or against policy issues. The method includes a multistage process involving the initial measurement of opinions (first stage), followed by data analysis, design of a new questionnaire, and a second measurement of opinions (second stage). The interquartile deviation is presented as one way of measuring consensus, and the McNemar test is described as a way to quantify the degree of shift in responses from the first to second stage. The application of the method is illustrated by a case example from a study of state legislators’ views on tobacco policy.

Impact of Smokeless Tobacco Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment A Policy Statement From the American Heart Association

Various forms of smokeless tobacco (ST) products (snuff, chewing tobacco) are used by individuals of all ages. Over the past several years, US tobacco companies have expanded marketing and promotion of ST products. A major aim of this statement is to review and summarize the scientific evidence regarding ST product use and the potential cardiovascular risks associated with ST product use that can be used to inform policy related to tobacco control and strategies related to tobacco harm reduction. A specific policy question is whether ST products should be recommended to smokers instead of cigarettes to reduce the morbidity and mortality associated with smoking and/or as an approach to enhance smoking cessation. Although evidence is consistent with the suggestion that the cardiovascular risks are lower with ST products compared with cigarette smoking, ST products are not without harm. As reviewed in this statement, there is evidence that long-term ST product use may be associated with a modest risk of fatal myocardial infarction (MI) and fatal stroke, suggesting that ST product use may complicate or reduce the chance for survival after a MI or stroke. In addition, there is inadequate evidence to support the use of ST products as a smoking cessation strategy. Based on the findings reviewed in this statement, clinicians should continue to discourage use of all tobacco products and emphasize prevention of smoking initiation and smoking cessation as primary goals for tobacco control. In the United States, various forms of ST products (snuff, chewing tobacco) are used by individuals of all ages, including adolescents and young adults.1 Over the past several years, US cigarette companies have been purchasing companies that only previously sold ST products.2 Consequently, there has been a proliferation of ST products such as moist snuff and snus that are sold under cigarette brand …

Smokefree legislation: a review of health and economic outcomes research.

CONTEXT Smokefree legislation is a powerful public health intervention. Despite progress in smokefree legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation. EVIDENCE ACQUISITION This paper reviews the scientific literature on health and economic outcome studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy. EVIDENCE SYNTHESIS There is a wealth of research showing the health benefits to entire populations when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, economic studies confirm that smokefree laws do not adversely affect business revenues or operating costs. CONCLUSIONS While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations.

Effects of a smoke-free law on hair nicotine and respiratory symptoms of restaurant and bar workers

Objective: Bar and restaurant workers’ exposure to secondhand smoke (SHS) was compared before and 3 and 6 months after implementation of a smoke-free ordinance. Methods: Hair nicotine, self-reported exposure to SHS, and respiratory symptoms were assessed on 105 smoking and nonsmoking workers from randomly selected establishments in Lexington, Kentucky. Thirty-eight percent were current smokers with more than half smoking 10 or fewer cigarettes per day. Workers provided a hair sample at baseline and at the 3-month interview. Results: There was a significant decline in hair nicotine 3 months postlaw when controlling for cigarettes smoked per day. Bar workers showed a significantly larger decline in hair nicotine compared with restaurant workers. The only significant decline in SHS exposure was in the workplace and other public places. Regardless of smoking status, respiratory symptoms declined significantly postlaw. Conclusions: Hospitality workers demonstrated significant declines in hair nicotine and respiratory symptoms after the law. Comprehensive smoke-free laws can provide the greatest protection to bar workers who are the most vulnerable to SHS exposure at work.

Reduction in asthma-related emergency department visits after implementation of a smoke-free law

BACKGROUND Secondhand tobacco smoke increases the risk for the development and increasing severity of asthma among adults and children. Reducing exposure to secondhand smoke decreases symptomatic exacerbations among patients with asthma. Emergency department (ED) visits for asthma were assessed before and after the implementation of smoke-free legislation in Lexington-Fayette County, Ky. OBJECTIVE To evaluate the effects of a smoke-free law on the rate of ED visits for asthma. METHODS The study included ED visits for asthma from 4 hospitals in Lexington-Fayette County, Ky. Age-adjusted rates of asthma ED visits were determined. Poisson regression analysis of ED visits from January 1, 2001, to December 31, 2006 compared the ED visit rates between prelaw and postlaw, adjusting for seasonality, secular trends over time, and differences among demographic subgroups. The actual rates were graphed with the Poisson curve showing the rates predicted by the model. A second prediction curve was generated to show the projected rates in the postlaw period if the law had not been implemented. RESULTS Adjusting for seasonality, secular trends, and demographic characteristics, ED visits for asthma declined 22% from prelaw to postlaw (P < .0001; 95% CI, 14% to 29%). The rate of decline was 24% in adults age 20 years and older (P < .0001), whereas the decrease among children 19 years or younger was 18% (P = .01). CONCLUSION Although this study did not establish causation, the smoke-free law was associated with fewer asthma ED visits among both children and adults, with a more significant decline among adults.

E-Cigarettes: Promise or Peril?

Electronic cigarettes (e-cigarettes) use a heating element to vaporize nicotine and other ingredients, simulating the visual, sensory, and behavioral aspects of smoking without the combustion of tobacco. An ever-growing number of companies around the world manufacture a wide variety of e-cigarette brands, despite scant information on the safety of the ingredients for human inhalation. This article provides an overview of the history, production, and marketing of e-cigarettes, the contents of e-cigarettes and vapor, how they are used, public health concerns, and implications for nursing practice, research, and policy development.

Smoke-free laws and adult smoking prevalence

OBJECTIVE To evaluate whether the adult smoking rate changed in Lexington-Fayette County, Kentucky, following the enactment of a smoke-free public places ordinance. METHODS Behavioral Risk Factor Surveillance System (BRFSS) data from 2001-2005 were used to test whether smoking rates changed in Fayette County from the pre- to post-law period, relative to the change in 30 Kentucky counties with similar demographics. The sample consisted of 10,413 BRFSS respondents: 7139 pre-law (40 months) and 3274 post-law (20 months). RESULTS There was a 31.9% decline in adult smoking in Fayette County (25.7% pre-law to 17.5% post-law). In the group of 30 Control counties, the rate was 28.4% pre-law and 27.6% post-law. Controlling for seasonality, time trend, age, gender, ethnicity, education, marital status, and income, there was a significant Time (pre- vs. post-law) by Group (Fayette vs. Controls) interaction. There were an estimated 16,500 fewer smokers in Fayette County during post-law compared to pre-law. CONCLUSION There was a significant effect of smoke-free legislation on adult smoking rates.

Immediate impact of smoke-free laws on indoor air quality.

Smoke-free laws significantly impact indoor air quality. However, the temporal effects of these laws on indoor air pollution have not been determined. This paper assesses the temporal impact of one smoke-free law on indoor air quality. This quasi-experimental study compared the indoor air quality of nine hospitality venues and one bingo hall in Georgetown, Kentucky, before and after implementation of a 100% smoke-free workplace law. We made real-time measurements of particulate matter with 2.5 &mgr;m aerodynamic diameter or smaller (PM2.5). Among the nine Georgetown hospitality venues, the average indoor PM2.5 concentration was 84 &mgr;g/m3 before the law took effect. The average indoor PM2.5 concentrations in nine compliant venues significantly decreased to 18 &mgr;g/m3 one week after the law took effect. Three venues having 82 &mgr;g/m3 before the law had significantly lower levels from the first day the law was implemented, and the low level was maintained. Compliance with the law is critical to achieving clean indoor air. Indoor air pollution in the bingo hall was not reduced until the establishment decided to comply with the law. The smoke-free law showed immediate impact on indoor air quality.

The Effects of Prenatal Secondhand Smoke Exposure on Preterm Birth and Neonatal Outcomes

OBJECTIVE To examine the relationship between prenatal secondhand smoke (SHS) exposure, preterm birth and immediate neonatal outcomes by measuring maternal hair nicotine. DESIGN Cross-sectional, observational design. SETTING A metropolitan Kentucky birthing center. PARTICIPANTS Two hundred and ten (210) mother-baby couplets. METHODS Nicotine in maternal hair was used as the biomarker for prenatal SHS exposure collected within 48 hours of birth. Smoking status was confirmed by urine cotinine analysis. RESULTS Smoking status (nonsmoking, passive smoking, and smoking) strongly correlated with low, medium, and high hair nicotine tertiles (ρ=.74; p<.001). Women exposed to prenatal SHS were more at risk for preterm birth (odds ratio [OR]=2.3; 95% Confidence Interval [CI] [.96, 5.96]), and their infants were more likely to have immediate newborn complications (OR=2.4; 95% CI [1.09, 5.33]) than nonexposed women. Infants of passive smoking mothers were at increased risk for respiratory distress syndrome (RDS) (OR=4.9; 95% CI [1.45, 10.5]) and admission to a Neonatal Intensive Care Unit (NICU) (OR=6.5; CI [1.29, 9.7]) when compared to infants of smoking mothers (OR=3.9; 95% CI [1.61, 14.9]; OR=3.5; 95% CI [2.09, 20.4], respectively). Passive smokers and/or women with hair nicotine levels greater than .35 ng/ml were more likely to deliver earlier (1 week), give birth to infants weighing less (decrease of 200-300 g), and deliver shorter infants (decrease of 1.1-1.7 cm). CONCLUSIONS Prenatal SHS exposure places women at greater risk for preterm birth, and their newborns are more likely to have RDS, NICU admissions, and immediate newborn complications.

Public Opinion and Smoke-Free Laws

Public support for Lexington-Fayette County, Kentuckys smoke-free law, perception of health risks from exposure to secondhand smoke (SHS), smoking behaviors, and frequency of visiting restaurants, bars, and entertainment venues were assessed pre- and post-law. Two cohorts of noninstitutionalized adults (N = 2,146) were randomly selected and invited to participate in a 10- to 15-min telephone survey. Public support for the smoke-free law increased from 56% to 63%, and respondents were 1.3 times more likely to perceive SHS exposure as a health risk after the law took effect. Although adult smoking and home smoking policy did not change post-law, adults frequented public venues at least as much as before the law. Lexington adults favored the smoke-free legislation despite living in a traditionally protobacco climate. The smokefree law acted as a public health intervention as it increased perception of risk of heart disease and cancer from SHS exposure.