Elsevier

Health & Place

Volume 16, Issue 3, May 2010, Pages 461-469
Health & Place

Public places after smoke-free—A qualitative exploration of the changes in smoking behaviour

https://doi.org/10.1016/j.healthplace.2009.12.003Get rights and content

Abstract

The social context of smoking behaviours is explored after the introduction of Scottish smoke-free legislation. A longitudinal qualitative study was conducted in four contrasting localities. Whilst post-legislation changes in smoking behaviour were evident in all four localities, they were most apparent in the disadvantaged localities. Changes in the patterns of smoking were linked to the ways in which people interacted in social contexts and how people re-negotiated habitual smoking behaviours in public spaces. Pre-legislation differences in the communities appeared to influence the extent of these changes. Cultural and social contexts are important in shaping smoking behaviours and locating change within public places.

Introduction

An increasing number of countries, regions and communities around the world are taking measures to create smoke-free public places to protect the health of workers and the public at large (WHO, 2008). There is clear international evidence that comprehensive smoke-free policies are effective in reducing second-hand smoke (SHS) exposure (Waa and McGough, 2006) and associated mortality and morbidity (Eisner et al., 1998; Albers et al., 2004, Ludbrook et al., 2004, Hole, 2005). Indeed the WHO Framework Convention on Tobacco Control (FCTC), the first international public health treaty (WHO, 2003), requires that countries take national action to protect citizens from SHS. Scotland was one of the first countries to introduce comprehensive legislation prohibiting smoking in enclosed public places (March 2006) and its implementation has produced significant reductions in SHS exposure in children, adults and bar workers (Semple et al., 2007; Akhtar et al., 2007; Haw and Gruer, 2007) and hospital admissions for heart attacks (Pell et al., 2008). It was also hoped that it would have additional public health benefits by reducing smoking prevalence and changing societal attitudes and norms towards smoking, particularly in disadvantaged areas (Haw et al., 2006).

Smoking is a major cause of inequalities in health in many high income countries including Scotland and the UK (Scottish Executive, 2004; Gordon, 2007; USSG, 2001; Huisman et al., 2005). In 2003, 41% of men and 39% of women in semi-routine and routine occupations in Scotland smoked cigarettes compared to 17% of men and 16% of women in professional and managerial occupations (Bromley et al., 2005). Even greater differences are found at the local level with over 50% of adults being smokers in the most deprived areas (NHS Health Scotland, 2004). Not only is smoking more prevalent in these communities but, prior to the smoke-free legislation, bars, pubs and other workplaces in areas of socio-economic disadvantage were less likely to have smoking policies and more likely to permit smoking than in affluent communities (Plunkett et al., 2000; Eadie et al., 2008).

Several systematic reviews of the effect of smoking bans in workplaces have found associated declines in consumption, increased attempts to quit, increased rates of successful quitting and consequent reductions in smoking prevalence (Ludbrook et al., 2004; Fichtenberg and Glantz, 2002). Although, Borland and Owen (1995) did identify a subset of smokers who do not adjust well to workplace smoke-free interventions. Comprehensive national smoke-free laws have been shown to support quitting and increase support for smoke-free public places (Fong et al., 2006). However, little is known about the impact on specific groups and communities, particularly disadvantaged communities (Dedobbeleer et al., 2004; Whitlock et al., 1998; Amos et al., 2008). There is some evidence that community characteristics and local contextual factors may be important in influencing the nature and level of compliance with and adjustment to smoke-free legislation (Nykiforuk et al., 2007; Eadie et al., 2008). It is also known that social context shapes local smoking cultures, norms of smoking and non-smoking, and the social relationships that sustain or constrain smoking behaviours (Thompson et al., 2007; Poland et al., 2006; Louka et al., 2006; Wiltshire et al., 2003; Stead et al., 2001).

Many low income smokers want to quit smoking and recognise the importance of social norms in maintaining their smoking and hampering quit attempts (Bancroft et al., 2003; Wiltshire et al., 2003). However, experience from a community-based smoking intervention in a deprived area of Scotland, indicates that there could be some reluctance by local workers and community members in disadvantaged communities in engaging with tobacco control interventions (Ritchie et al., 2004, Ritchie et al., 2008). These views resonate with qualitative studies, which highlight how the social circumstances of disadvantaged lives play an important part in sustaining smoking (Bancroft et al., 2003), with smokers using it as a means of coping with living and caring in disadvantaged circumstances (Graham, 1993; Gaunt-Richardson et al., 1999; Wiltshire et al., 2003). Few qualitative studies have investigated the processes and impact of smoke-free legislation at individual and community levels or in different communities. There is thus only a limited understanding of how, and in what ways, such legislation contributes to the creation of a positive or negative social climate towards smoking and its relationship to consumption, particularly in disadvantaged communities (Giskes et al., 2006).

The paper draws its theoretical framework from health promotion, in particular the social-ecological model of promoting health (Elder et al., 2007; Barbara et al., 2001). Health promotion has a theoretical base that is ‘deliberately eclectic, combining psychological cognitive models with a sociological interpretation’ (Wight et al., 1998); in order to reflect the complex interplay between individual health behaviours and social and environmental influences. We draw upon the social-ecological model as it allows for an exploration of health behaviours, in this case smoking, to be located within social cognition theories that consider social norms, personal susceptibility to risk, perceived barriers and risks, and social approval (Bandura, 1977; Connor and Norman, 1996), but also importantly considers the reciprocal relationship between these social cognitions and social environment and policy influences (Levy, 1991; Tones and Green, 2004). We therefore aim to understand how changes in the social and physical environment created by the smoke-free legislation influenced individual social cognitions and a shared social understanding of tobacco use in these newly created environments in the public space.

This paper describes the findings from a longitudinal qualitative study, one of a portfolio of studies commissioned by NHS Health Scotland to evaluate the impact of the Scottish smoke-free legislation (Haw et al., 2006). The overall aim of this study was to explore the impact of the smoke-free legislation on smoking-related attitudes and behaviour, at both individual and community levels, in four socio-economically contrasting localities in Scotland. In this paper we explore how the cultural, environmental and social contexts are important in shaping individual and shared smoking behaviours and social interactions in the public spaces in these localities.

Section snippets

Study design

Longitudinal qualitative studies are relatively unusual in the evaluation of public health policies or interventions, including tobacco control. Their key characteristics are the: ‘collection of data on more than one occasion; the cases analysed are broadly comparable and analysis involves some comparison between or among periods’ (Molloy et al., 2002). Importantly, longitudinal qualitative research can provide detailed understandings of the contextual factors, which may influence outcomes

Discussion

The smoke-free legislation in Scotland has demonstrated significant success with several clear public health benefits (Akhtar et al., 2007; Haw and Gruer, 2007; Semple et al., 2007, Martin et al., 2008; Pell et al., 2008). Although the processes and impact of the smoke-free legislation were explored in only four localities, using a small purposive sample and locality observations, this study has uniquely captured the changing social context of smoke-free public places at the community level, as

Acknowledgments

This study was funded by NHS Health Scotland. The views expressed are those of the authors and not necessarily those of the funder. We would like to thank all those who participated in the study by giving their time to be interviewed; the interviewers Irene Miller, Fiona Rait, and Fenella Hayes who was also the research assistant; Anna Sansom who assisted with data coding and Sally Haw for her advice and support.

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