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Association between local indoor smoking ordinances in Massachusetts and cigarette smoking during pregnancy: a multilevel analysis
  1. K H Nguyen1,
  2. R J Wright2,3,
  3. G Sorensen4,5,
  4. S V Subramanian4
  1. 1Helen Diller Family Comprehensive Cancer Center, Department of Medicine, University of California, San Francisco, California, USA
  2. 2Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA
  4. 4Department of Society, Health and Human Development, Harvard School of Public Health, Boston, Massachusetts, USA
  5. 5Center for Community-Based Research, Dana Farber Cancer Institute, Boston, Massachusetts, USA
  1. Correspondence to Dr KH Nguyen, Helen Diller Family Comprehensive Cancer Center, University of California, 1450 3rd Street, San Francisco, CA 94111, USA; nguyenk{at}


Objective To estimate the association between local clean indoor air ordinances and prenatal maternal smoking across 351 municipalities in Massachusetts before the 2004 statewide ban and to test the effect of time since ordinance adoption on the association.

Methods The authors linked 2002 birth certificate data of women who gave birth in the state and reported a Massachusetts residence (n=67 584) to a database of indoor smoking ordinances in all municipalities. Multilevel regression models accounting for individual- and municipality-level variables estimate the associations between the presence of local smoking ordinances, strength of the ordinances, time since ordinance adoption and prenatal smoking.

Results Compared with those living in municipalities with no ordinances, women living in municipalities with a smoking ordinance had lower odds of prenatal smoking (OR=0.72, CI=0.53 to 0.98). No effect was found for 100% smoke-free ordinances. For the analyses testing the effect of time, pregnant women living in municipalities with ordinances enacted >2 years were less likely to smoke than those in municipalities with more recent (<1 year) ordinances.

Conclusions Preventing smoking among women of reproductive age is a public health priority. This study suggests that indoor smoking ordinances were associated with lower prenatal smoking prevalence and the favourable effect increased over time. Findings highlight the public health benefit of tobacco control policies.

  • Clean indoor air policy
  • cigarette smoking
  • multilevel analyses
  • prenatal smoking
  • priority/special populations
  • public policy
  • denormalisation
  • prevention

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  • Funding KHN received support from the National Cancer Institute Diversity Supplement Award (R01CA129096). SVS was supported by the National Heart, Lung, and Blood Institute Career Development Award (K25 HL081275) and the Robert Wood Johnson Investigator Award in Health Policy Research. GS was supported by the National Cancer Institute (K05 CA108663).

  • Competing interests None.

  • Ethics approval Harvard School of Public Health and Massachusetts Department of Public Health.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Study data belongs to the Massachusetts Department of Public Health and not to the study authors. Access to the birth certificate data is given exclusively by the Department.