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

Tobacco use has rapidly declined in recent decades, due in large part to effective tobacco control policies. However, smoking remains high in America’s rural southern population. Rural residents of southern states disproportionately lack access to comprehensive smoke-free (SF) laws. While 58.3% of U.S. citizens are covered by comprehensive SF laws, only 16.7% of citizens living in in the East South Central or the South Atlantic regions are protected. Current best practices for SF policy advocacy strategies have not been effective in closing the gaps in coverage for rural, southern residents. Meanwhile, adoption of voluntary policies (e.g, tobacco-free schools, multi-unit housing, outdoor spaces) have accelerated nationwide. Municipalities with low readiness to address SF public policy may be more ready to work on lower impact strategies such as voluntary policies. It is also possible that the presence of voluntary policies may change the social norm in these municipalities and increase readiness for future SF policy adoption. More research is needed on the dynamic and complex interplay between public and voluntary SF policies, especially in rural southern municipalities experiencing health disparities in tobacco use where best practices in policy development have had less than optimal success. Guided by a combined Community Readiness Model and Kingdon’s Multiple Streams framework, we will use a case-control design to examine factors associated with SF policy adoption and explore facilitators and barriers among rural southern municipalities with and without SF laws in four southern states. Our long-term goal is to accelerate progress in adoption of comprehensive smoke- and tobacco-free policies in municipalities experiencing tobacco use disparities. Our specific aims are to: 1): To 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., administrative turnover); policy factors (e.g., anticipated constraints); and policy entrepreneurs (e.g., strength of tobacco control), controlling for population size and other demographic factors; 1a) To 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; 2) To describe facilitators and barriers in the sociopolitical environment that could impact the use of ASSIST strategies, the policy window (e.g, the tipping point for policy adoption), and enactment of SF policy by conducting in-depth key informant interviews with community leaders, citizen activists, and policymakers in rural municipalities in southern states. This study will shift the current research paradigm to a new way of understanding and designing tailored, culturally appropriate SF policy advocacy interventions in rural, southern municipalities. The overarching goal is to reduce tobacco use disparities in rural, southern municipalities and promote social justice by fostering smoke- and tobacco-free policy and improving health outcomes in this disparate population.