Policy, Politics, & Nursing Practice

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1 Policy, Politics, & Nursing Practice Public Opinion and Smoke-Free Laws Mary Kay Rayens, Ellen J. Hahn, Ronald E. Langley, Susan Hedgecock, Karen M. Butler and Lisa Greathouse-Maggio Policy Politics Nursing Practice : 262 DOI: / The online version of this article can be found at: Published by: Additional services and information for Policy, Politics, & Nursing Practice can be found at: Alerts: Subscriptions: Reprints: Permissions: Citations: >> Version of Record - Mar 12, 2008 What is This? Downloaded from ppn.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2014

2 Public Opinion and Smoke-Free Laws Mary Kay Rayens, PhD Ellen J. Hahn, DNS, RN Ronald E. Langley, PhD Susan Hedgecock, MSN, RN Karen M. Butler, DNP, RN Lisa Greathouse-Maggio, MSN, RN Exposure to secondhand smoke (SHS) has immediate negative effects on the cardiovascular system and causes heart disease and lung cancer (U.S. Department of Health and Human Services, 2006). There is no safe level of exposure to tobacco smoke and efforts often used to reduce the harm of SHS such as separating smokers from nonsmokers, cleaning the air, or ventilating buildings, do not protect the public from the dangers of SHS. The only way to protect nonsmokers from the harm caused by tobacco smoke is to completely eliminate exposure (U.S. Department of Health and Human Services, 2006). Smoke-free laws can significantly reduce exposure to SHS (Farrelly et al., 2005; Hahn, Lee, Okoli, Troutman, & Powell, 2005; Hahn et al., 2006; Travers et al., 2004). Although smoke-free laws vary in strength, most recently adopted laws apply to all establishments of a given type or types (e.g., all restaurants and bars, or all workplaces). As of October 1, 2007, 11,305 U.S. municipalities were covered by 100% smoke-free laws (either state or local) including all workplaces and/or restaurants and/or bars (Americans for Nonsmokers Rights Foundation, 2007). Smoke-free laws are beneficial in a number of ways. First, and most obviously, they reduce exposure to SHS. Other benefits include discouraging Public support for Lexington-Fayette County, Kentucky s 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. Keywords: secondhand smoke; smoke-free legislation; public opinion Policy, Politics, & Nursing Practice Vol. 8 No. 4, November 2007, DOI: / Sage Publications 262

3 Rayens et al. / PUBLIC OPINION AND SMOKE-FREE LAWS 263 smoking initiation among youth (Farkas, Gilpin, White, & Pierce, 2000; Siegel, Albers, Cheng, Biener, & Rigotti, 2005) and supporting smokers who are in the process of quitting (Fichtenberg & Glantz, 2002; Moskowitz, Lin, & Hudes, 2000). Yet, despite the benefits of smoke-free laws, they often create controversy and direct opposition from restaurant and bar associations (Bryan-Jones & Chapman, 2006; Dearlove, Bialous, & Glantz, 2002; Greathouse, Hahn, Okoli, Warnick, & Riker, 2005). Those who oppose smoke-free laws often claim that the laws harm business and decrease profits. They argue that patrons will stop frequenting establishments altogether or dine out less often if smoking is prohibited. A look at surveys of public opinion as well as the economic research literature reveals that fears of decreasing profits as a result of smoke-free laws are not realized. In Boston, for example, most diners said they would visit establishments at the same rate as before the smoke-free ordinance went into effect, and many said they frequent establishments more often, not less (Bartosch & Pope, 2002). Research conducted in California, Colorado, New York, Texas, Lexington, Kentucky, and elsewhere, all come to the same conclusion: Smoke-free restaurants and bars do not experience economic harm (Centers for Disease Control and Prevention, 2004; Glantz & Smith, 1994, 1997; Pyles, Mullineaux, Okoi, & Hahn, 2007; Scollo, Lal, Hyland, & Glantz, 2003) and may actually experience economic benefit (Alamar & Glantz, 2004). Although there is a growing acceptance of smoke-free workplaces (Feigelman & Lee, 2006), some may expect that those living in tobaccoproducing states, where smoking prevalence is generally higher than in non-tobacco producing states, might be less likely to accept smoke-free laws. The top tobacco-producing states (North Carolina, Kentucky, South Carolina, Tennessee, and Virginia) have no comprehensive statewide restrictions on workplace smoking (Americans for Nonsmokers Rights Foundation, 2007). Only one study was found that examined the possible relationship between tobacco production and smoking restrictions. Hersch, Del Rossi, and Viscusi (2004) found a significant constraining effect on the passage of state-level restrictions of smoking in hospitals among states where tobacco accounts for a larger percentage of the state economy. The effect was not significant for malls, bars, or restaurants. As efforts to enact smoke-free laws increase, measures of public opinion become more important. Public health advocates in Allen County, Kentucky found that the county judge executive was willing to support a ban on smoking in the courthouse only if he had proof that the people wanted it (Wilson, Duncan, & Nicholson, 2004). The opinion poll that followed demonstrated that 43% of Allen County residents were supportive of a smoke-free courthouse; 45% favored setting aside areas for smoking, and 6% opposed any restrictions. Tobacco-related public opinion surveys can be instrumental in promoting smokefree environments and used as an effective tool in attracting coverage by the media (Hill, Wise, Wilson, & Berkel, 2006). Given that public opinion is a vital tool in the battle against exposure to SHS, it is important to monitor opinion shifts and trends. It is also important to evaluate the effects of smoke-free laws on public opinion. Feedback from the public is an important element of policy development in that these data can help frame the problem and tip the balance of support for a policy issue (Kingdon, 2003). The purpose of this study was to measure adults opinions and behaviors before and after implementation of the comprehensive smoke-free public places law in Lexington-Fayette County, Kentucky. Public support for the smoke-free law; perception of health risks from exposure to SHS; smoking behaviors; and frequency of visiting restaurants, bars, and entertainment venues were assessed pre- and post-law. Given that tobacco adds more than $330 million to Kentucky s economy (U.S. Department of Agriculture, 2007), one might expect protobacco sentiment and opposition to smoke-free laws. METHOD Design and Sample Two cohorts of Lexington-Fayette County noninstitutionalized adults (18 years or older) were randomly selected by a modified list-assisted Mitofsky-Waksberg Random-Digit Dialing method (Casady & Lepkowski, 1993; Waksberg, 1978), giving every household telephone line in Lexington-Fayette County an equal probability of being contacted. The University of Kentucky Survey Research Center contacted participants by

4 264 POLICY, POLITICS, & NURSING PRACTICE / November 2007 telephone, described the purpose of the study, assured anonymity, and asked for their participation in a 10- to 15-min phone survey. Cohort I (N = 1,091) was interviewed from July 19 to August 17, 2003, prior to the original implementation date of the ordinance (September 26, 2003). There was a 7-month delay in implementation of the law because of a legal challenge, with enactment ultimately occurring on April 27, Cohort II (N = 1,055) was interviewed from October 4 to November 22, 2004, approximately 6 months after the ordinance had been in effect. For the preordinance survey (Cohort I), the response rate was 46.1%, and the margin of error was approximately ± 2.96% at the 95% confidence level. For the postordinance survey (Cohort II), the response rate was 52%, and the margin of error was approximately ± 3.01% at the 95% confidence level. Measures In addition to demographic characteristics and an assessment of current smoking status, the survey contained items that measured the respondent s opinion of the smoke-free law, their rating of how serious SHS is as a health hazard, and their opinion on whether SHS increased risk of heart attack or cancer. Behavior items on the survey included the indoor home smoking policy, and frequency of going out to restaurants and bars as well as bingo, bowling, or racing (see Table 1 for survey items and response options). Data Analysis To facilitate interpretation, each of the opinion and behavior survey items was recoded to a binary variable prior to analysis, combining the most similar categories to form each of the two groups. For example, support for the smoke-free law was originally on an ordinal scale with possible responses of strongly support, somewhat support, somewhat oppose, and strongly oppose. The two support categories were combined into a single group (and used as the reference group in the analysis) as were the two oppose categories. The reference group for the exposure to SHS being a health hazard included those who answered either serious health hazard or moderate health hazard. Those who indicated that they thought living or working in a place that allowed smoking lead to a higher risk of heart attack or cancer were in the reference group for those two questions. Exposure to SHS at home in the last 30 days was already a binary variable; the reference group for this item was those who answered yes. Finally, for the three items that assessed the frequency of going to restaurants, bars, and either bowling alleys, bingo halls or racetracks, the reference category consisted of those who said they patronized these establishments either more than once a week or about once a week. Participants who indicated they visited less often were in the other group. The demographic characteristics and the opinion and behavior survey questions were summarized using descriptive statistics, including the frequency distribution or mean and standard deviation. Bivariate comparisons of categorical personal characteristics and the percentage of respondents in the reference category between pre- and post-law were made using the chisquare test of association. A t-test for independent samples was used to compare the average age of participants between the pre- and post-law samples. Logistic regression was used to determine if there were differences between the preand post-law percentages on the opinion and behavior survey items after controlling for differences in personal characteristics. Logistic modeling provided an odds ratio and corresponding 95% confidence interval for the test of whether there was a significant effect of time (pre vs. post) after adjusting for demographic factors; the personal characteristics included in the models were age, sex, race, education, tobacco allotment ownership status, and smoking status. Although the population of Lexington-Fayette County is only slightly more than half female (51%), the sample included a larger percentage of females (61%). The survey responses were weighted to correct for the overrepresentation of women in the pre- and post-law cohorts, both for the bivariate comparisons of the opinion and behavior items and for the logistic regressions. Data analysis was conducted using SAS for Windows, v. 9.1; an alpha level of.05 was used throughout. RESULTS The average age of the combined pre- and post-law sample was 46.5 years (SD = 15.8). As shown in Table 2, the combined sample of preand post-law participants was predominantly

5 Rayens et al. / PUBLIC OPINION AND SMOKE-FREE LAWS 265 TABLE 1: Item Survey Items and Response Choices From the Telephone Interview Possible Responses Opinion items: On July 1, 2003, the Lexington Fayette Urban County Council passed a law prohibiting smoking in most public places in Lexington, including all enclosed public buildings, restaurants, and bars. Would you say that you strongly support, somewhat support, somewhat oppose, or strongly oppose the new law? (This was only asked in the pre-law survey.) On April 27, 2004, the law prohibiting smoking in most public places in Lexington went into effect, including all enclosed public buildings, restaurants, and bars. Would you say that you strongly support, somewhat support, somewhat oppose, or strongly oppose the smoke-free law? (This was only asked in the post-law survey.) In general, do you feel that exposure to secondhand smoke is a serious health hazard, a moderate hazard, a minor health hazard, or not a health hazard at all? In your opinion, if you lived or worked in a place that allowed smoking, would your risk of a heart attack be higher, lower, or about the same as people who live or work in a smoke-free place? In your opinion, if you lived or worked in a place that allowed smoking, would your risk of developing cancer be higher, lower, or about the same as people who live or work in a smoke-free place? Behavior items: In the past 30 days, has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home? How often do you go to a restaurant in Lexington? How often do you go to a bar or nightclub in Lexington? How often do you go to a bowling alley, bingo hall, or race track in Lexington? 1 = strongly support; 2 = somewhat support; 3 = somewhat oppose; 4 = strongly oppose 1 = strongly support; 2 = somewhat support; 3 = somewhat oppose; 4 = strongly oppose 1 = serious health hazard; 2 = moderate health hazard; 3 = minor health hazard; 4 = not a health hazard at all 1 = higher; 2 = about the same; 3 = lower 1 = higher; 2 = about the same; 3 = lower 1 = yes; 2 = no 1 = more than once a week; 2 = about once a week; 3 = a few times a month; 4 = less than once a month; 5 = never 1 = more than once a week; 2 = about once a week; 3 = a few times a month; 4 = less than once a month; 5 = never 1 = more than once a week; 2 = about once a week; 3 = a few times a month; 4 = less than once a month; 5 = never female (61%), Caucasian (86%), and had some postsecondary education (78%). Nearly one fourth (22%) were current smokers and only 4% owned tobacco allotments. The pre-law sample was younger (M = 45.8, SD = 16.0) than those who responded post-law (M = 47.2, SD = 15.6; t = 2.0, p =.04). There was a smaller percentage of female participants at pre-law (57%) compared to postlaw (65%; see Table 2). Those who responded during the pre-law period were more likely to have some postsecondary education (79%) compared with the post-law sample (76%). Other demographic comparisons between the pre- and postlaw samples including race, allotment ownership, and smoking status were not significant. Public Support for Smoke-free Laws For the combined sample of 2,146 participants, most were supportive of the smoke-free law (60%). There was an increase from 56% to 63% between the pre- and post-law periods, and this was significant (see Table 3). When adjusting for the demographic characteristics in the logistic regression model, those who responded post-law had more than 1.5 times the odds of somewhat or strongly supporting the law, compared with prelaw participants. Among smokers, although there was an increase in the percentage of respondents who supported the law, from 17% during the prelaw period to 20% post-law, this comparison was not significant (chi-square = 0.7, p =.4).

6 266 POLICY, POLITICS, & NURSING PRACTICE / November 2007 TABLE 2: Frequency Distributions for the Categorical Demographic Characteristics of the Sample, With Comparisons Between Pre- and Post-Law Using the Chi-Square Test of Association (N = 2,146) Comparison of Pre- and Post-Law; Full Sample Pre-Law Sample Post-Law Sample Chi-Square Personal Characteristic (N = 2146); n (%) (n = 1091); n (%) (n = 1055); n (%) (p Value) Sex Female 1,304 (60.8) 621 (56.9) 683 (64.7) 13.8 (.0002) Male 842 (39.2) 470 (43.1) 372 (35.3) Race Caucasian 1,803 (86.1) 922 (86.4) 881 (85.7) 0.2 (.6) Minority 292 (13.9) 145 (13.6) 147 (14.3) Education High school or less 480 (22.5) 225 (20.7) 255 (24.5) 4.5 (.03) Some post-secondary 1,650 (77.5) 864 (79.3) 786 (75.5) Own tobacco allotment Yes 75 (3.5) 40 (3.7) 35 (3.3) 0.2 (.7) No 2,056 (96.5) 1,046 (96.3) 1,010 (96.7) Current smoker Yes 479 (22.4) 233 (21.4) 246 (23.5) 1.3 (.2) No 1,658 (77.6) 856 (78.6) 802 (76.5) Public Perception of SHS as a Health Hazard More than 70% of the sample considered exposure to SHS a moderate or severe health hazard; the percentage of participants increased from 69% to 73% between the pre- to post-law periods. Although this bivariate comparison was not significant, after controlling for personal characteristics in the logistic model, the post-law respondents had 1.3 times the odds of rating SHS exposures as a moderate or severe health hazard, compared with those who participated pre-law (p =.02). For the questions pertaining to increased disease risk because of SHS exposure, most respondents agreed the risk would be higher as a result of exposure for both heart attack (66%) and cancer (69%). The percentage who thought heart attack risk was higher living or working at a place where smoking was allowed increased significantly from 64% to 68%, whereas the change from pre- to post-law for the cancer risk question (68% to 71%) was not statistically significant. When demographic variables were included as controls, the logistic models indicated significant differences between pre- and post-law for both diseasespecific risk questions. Compared to pre-law respondents, those who participated post-law were 32% more likely to perceive a higher risk of heart attack and 24% more likely to perceive a greater risk of developing cancer as a result of SHS exposure. Smoking in the Home As shown in Table 3, about one fourth of respondents reported smoking in the home in the last month. This percentage was consistent from pre- to post-law, and there was no difference between pre- and post-law samples when controlling for demographic factors. Visiting Restaurants, Bars, and Other Entertainment Venues The percentage of respondents in the total sample who indicated they went to restaurants in Lexington at least once a week was 75%. The percentages at pre- and post-law were 76% and 73%, a decline that was not significant. Consistently, when demographic factors were included as controls in the logistic model, this difference between pre- and post-law was not significant. Sixteen percent of respondents in the full sample reported visiting bars or nightclubs in Lexington one or more times weekly. This percentage increased from 15% pre-law to 18% post-law, a significant change (p =.02). This increase remained significant when controlling for demographic characteristics: Those who responded

7 TABLE 3: Weighted Percentages of Respondents in the Reference Category at Pre- and Post-Law for Each Survey Item With a Corresponding Bivariate Comparison and a Logistic Regression Comparison of These Percentages Controlling for Personal Characteristics a Weighted Percentages of Respondents in the Comparison of Weighted Pre- and Post-Law Reference Category at Pre- and Post-Law and Percentages, Controlling for Personal Bivariate Comparison Characteristics Survey Item (Categories Combined Chi-Square Odds Ratio Wald Chi-Square To Form Reference) Pre-Law % Post-Law % (p Value) (95% Confidence Interval) (p Value) Support for smoke-free law (strongly and (.003) 1.52 ( ) 16.3 (<.0001) somewhat support) Exposure to secondhand smoke a health (.08) 1.28 ( ) 5.6 (.02) hazard (moderate to severe hazard) Secondhand smoke and risk of heart attack (.01) 1.32 ( ) 7.6 (.006) (perceive higher risk) Secondhand smoke and risk of developing (.09) 1.24 ( ) 4.2 (.04) cancer (perceive higher risk) Indoor smoking in the home? (yes) (.7) 0.89 ( ) 0.9 (.30) How often do you go to restaurants in (.07) 0.86 ( ) 2.2 (.10) Lexington? (at least weekly) How often do you go to bars in Lexington? (.02) 1.35 ( ) 5.5 (.02) (at least weekly) How often do you go to bowl/bingo/racing (.05) 1.39 ( ) 2.8 (.09) in Lexington? (at least weekly) a. Control variables included in the logistic regression model were age, sex, race, education, tobacco allotment ownership status, and smoking status. 267

8 268 POLICY, POLITICS, & NURSING PRACTICE / November 2007 post-law had 1.35 times the odds of visiting a bar or nightclub at least weekly, compared to pre-law participants. Approximately 6% of respondents in the combined sample indicated they visited bowling, bingo, or racetracks at least once a week, with the percentage increasing from 5% to 7% from pre- to post-law (p =.05). When adjusting for demographic variables in the logistic model, pre- to post-law change in visiting bowling alleys, bingo halls, and racetracks was not significant. DISCUSSION Although Lexington-Fayette County, Kentucky is located in a tobacco-growing state, public support for the smoke-free law was high, and it improved from pre- to post-law. On average, 60% of adults favored the smoke-free law, consistent with other public opinion studies that estimate increasing support for smoke-free workplaces (Feigelman & Lee, 2006; Moore, 2005; Shopland, Hartman, Repace, & Lynn, 1995; Siapush & Scollo, 2001). Similarly, our finding that public support increased after the law took effect was consistent with a recent study in the Republic of Ireland, which implemented a comprehensive smoke-free law 1 month prior to Lexington s law. A nationally representative survey of adult smokers in Ireland pre- and post-law revealed increased public support in all venues: workplaces, 43% to 67%; restaurants, 45% to 77%; and bars/pubs, 13% to 46% (Fong et al., 2006). Although the magnitude of the increase in public support for Lexington s smokefree law, 56% to 63% pre- to post-law, was less than that in the Ireland study, this represented a statistically significant increase in public support, even when controlling for personal characteristics. Our findings were closer to those reported in a New Zealand study in which public support rose from 56% to 69% 1 year after a smoke-free law was implemented (Thomson & Wilson, 2006). In addition to increased public support for the smoke-free law, Lexington adults perceived exposure to SHS as a serious health risk, and this awareness was heightened after the law took effect. Specifically, they were more likely to perceive a higher risk of heart attack and a greater risk of developing cancer as a result of SHS exposure after the law was implemented. Given that Lexington s smoke-free law was the first in the tobacco-growing state of Kentucky and there was a planned media advocacy effort for nearly 3 years prior to enactment of the law (Greathouse et al., 2005), it was not surprising that 7 of 10 adults viewed SHS as a moderate to serious health hazard. However, after the law was implemented, there was no public education campaign (except for the immediate news media attention on the law itself) about the dangers of SHS nor its cardiac or cancer effects, and the U.S. Surgeon General s Report on involuntary exposure to SHS (U.S. Department of Health and Human Services, 2006) had not yet been released at the time of the post-law survey. We conclude that it was the smoke-free law itself that increased adults perceived risk of SHS exposure. Because public health education interventions aim to increase the public s view that diseases are serious and that they are susceptible, our findings support the fact that smoke-free laws are cost-effective public health interventions that increase perception of risk of SHS exposure and have the potential to change health behavior. Despite not being able to smoke in buildings open to the public, Lexington adults did not report a change in home smoking post-law, nor did they change their smoking behavior. About one fourth reported smoking in the home. This finding is not consistent with the Ireland study that reported a significant decline in home smoking from 85% to 80% after the smoke-free law took effect (Fong et al., 2006). The smoking rate among Lexington adults was similar in pre- and post-law cohorts; in the combined sample, 22% reported smoking cigarettes. Although the increase in support for the law among smokers from pre- to post-law was not significant, the direction of the change suggests that smokers may become more supportive of the law the longer it is in effect. In a four-country survey (Unites States, Canada, United Kingdom, and Australia), cigarette smokers living where smoking was prohibited by law reported adjusting, accepting, and complying with smoke-free laws (Borland, Yong, & Siapush, 2006). Despite the fact that home smoking and smoking behaviors did not change, Lexington adults continued to visit public venues with at least the same frequency after the smoke-free law took effect. Adjusting for demographic differences, there was no change in the rate of visiting restaurants or bowling alleys, bingo halls, or racetracks,

9 Rayens et al. / PUBLIC OPINION AND SMOKE-FREE LAWS 269 whereas the frequency of visits to bars increased post-law. This is consistent with the findings of Lexington s economic impact study revealing no economic harm from the smoke-free legislation despite the fact that Lexington is located in a tobacco-growing state with higher than average smoking rates (Pyles et al., 2007). In conclusion, Lexington adults favored the smoke-free legislation despite living in a traditionally protobacco climate. The smoke-free law acted as a public health intervention insofar as it increased perception of risk of heart disease and cancer from SHS exposure. Indeed, Lexington s smoke-free law had positive health benefits as it reduced exposure to SHS in restaurants, bars, and other public venues (Hahn et al., 2005; Hahn et al., 2006). Although adult smoking behavior and home exposure to SHS did not change after the law took effect, adults frequented public venues at least as often as before the smoke-free law, consistent with Lexington s economic impact study (Pyles et al., 2007). Our findings from this and other studies show that the smoke-free law not only protected workers and patrons from SHS, but it was also acceptable to the public. REFERENCES Alamar, B., & Glantz, S. (2004). Smoke-free ordinances increase restaurant profit and value. Contemporary Economic Policy, 22(4), Americans for Nonsmokers Rights Foundation. (2007). Overview list how many smokefree laws? Retrieved November 17, 2007, from Bartosch, W. J., & Pope, G. C. (2002). Economic effect of restaurant smoking restrictions on restaurant business in Massachusetts, 1992 to Tobacco Control, 11(90002), 38ii-42. Borland, R. H., Yong, H. H., & Siapush, M. (2006). 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10 270 POLICY, POLITICS, & NURSING PRACTICE / November 2007 Travers, M. J., Cummings, K. M., Hyland, A., Repace, J., Babb, S., Pechacek, T., et al. (2004). Indoor air quality in hospitality venues before and after implementation of a clean indoor air: Western New York, MMWR, 53, U.S. Department of Agriculture. (2007). U.S. & all states data: Tobacco (all classes). Retrieved April 25, 2007, from QuickStats/PullData_US.jsp U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease and Prevention and Promotion, Office of Smoking and Health. Waksberg, J. (1978). Sampling methods for random digit dialing. Journal of the American Statistical Association, 73(361), Wilson, R., Duncan, D. F., & Nicholson, T. (2004). Public attitudes toward smoking bans in a tobacco-producing county. Southern Medical Journal, 97(7), Mary Kay Rayens, PhD, is an associate professor in the colleges of Nursing and Public Health at the University of Kentucky in Lexington. She is a biostatistician; her research interests include tobacco policy development and evaluation, women s mental health, farm safety, and asthma management. Ellen J. Hahn, DNS, RN, is an alumni professor in the colleges of Nursing and Public health at the University of Kentucky in Lexington, and is a faculty associate at the UK Prevention Research Center. She directs the Tobacco Policy Research Program in the College of Nursing (see Ronald E. Langley, PhD, is a director of the University of Kentucky Survey Research Center. He is a political scientist who researches the policy effects of public opinion, is Chairman of the National Network of State Polls, and serves on the Standards Committee of the American Association for Public Opinion Research. Susan Hedgecock, MSN, RN, is a former public health nurse and current predoctoral fellow of the UK Prevention Research Center. Her primary interest is tobacco control among underserved Appalachian populations. Karen M. Butler, DNP, RN, is an assistant professor in the College of Nursing at the University of Kentucky in Lexington, and is a faculty associate in the Tobacco Policy Research Program. Her primary interests are nursing education, health promotion, and tobacco dependence prevention and treatment. Lisa Greathouse-Maggio, MSN, RN, is a public health nurse and an Oncology Clinical Coordinator for Genentech BioOncology, providing educational programs on breast, lung, and pancreatic cancer. Her primary interests are tobacco policy and tobacco use dependence education and treatment.