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

Smoking rates are high in America’s rural southern population and the disparity is growing. Fewer residents of southern states are covered by strong smoke-free (SF) laws compared to other regions of the U.S. The goal of our currently funded mixed methods study is to determine differences in rural municipalities with and without SF laws as well as to describe facilitators and barriers in the sociopolitical environment that might impact advocacy strategies. We are on track to complete the aims of the currently funded study. It is our ultimate goal to translate the lessons learned from this ongoing study into a large-scale community level intervention. However, prior to launching such an intervention, we need to examine how two emerging issues- the dramatic escalation in adolescent and young adult electronic cigarette (e-cigarette) use and the associated emergence of e-cigarette product use-associated lung injury (EVALI) - may impact SF policy adoption in rural, southern communities. It is possible that the heightened focus on the health impacts of e-cigarettes could be related to an increase in comprehensive SF policy adoption; or this attention may derail efforts toward adoption of SF laws. Our specific aims are to: 1A: Determine if there was a change in comprehensive SF law coverage in the original four study states (Al, KY, MS, and SC) before and after the peak of the EVALI health crisis; 1B: Explore whether the escalation of adolescent and young adult e-cigarette use and the associated EVALI health crisis are facilitators or barriers to adopting or strengthening SF laws; 2) Test the feasibility of a new stagebased tailored intervention informed by our IMPART framework to promote SF policy adoption by executing a case study in one rural, southern community. Our team previously tested a tailored intervention to promote SF law adoption that showed modest but positive outcomes. The currently funded grant and completion of new Aims 1a and 1b will together lead to a new way of understanding SF law adoption in rural, southern municipalities. We will use these findings to update our intervention and pilot test its feasibility in one rural, southern community. This intervention will be informed by the IMPART framework, which incorporates the Community Readiness Model and ASSIST strategies with a political theory (Kingdon’s Multiple Streams Approach). A community advisor (CA) will guide a community coalition of tobacco control policy advocates through the process of selecting and implementing stage-based strategies to increase readiness for SF policy adoption. To test the feasibility, we will use the RE-AIM framework (reach, effectiveness, adoption, implementation and maintenance). The use of RE-AIM to evaluate and modify a feasibility intervention can facilitate more rapid translation to “real world” settings. Successful completion of the aims of this expansion grant will allow us to collect the critical preliminary data for our next R01 to conduct a community level randomized controlled trial to test this intervention. The overarching goal of this work is to reduce tobacco use disparities in rural, southern municipalities to improve health outcomes.