J. Environ. Res. Public Health 2015, 12, 504-520; doi:10.3390/ijerph120100504OPEN ACCESSInternational Journal ofEnvironmental Research andPublic HealthISSN 1660-4601www.mdpi.com/journal/ijerphArticleThe Effect of Smoke-Free Air Law in Bars on SmokingInitiation and Relapse among Teenagers and Young AdultsCe ShangInstitute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL 60608, USA;E-Mail:

J. Environ. Res. Public Health 2015, 12, 504-520; doi:10.3390/ijerph120100504OPEN ACCESSInternational Journal ofEnvironmental Research andPublic HealthISSN 1660-4601www.mdpi.com/journal/ijerphArticleThe Effect of Smoke-Free Air Law in Bars on SmokingInitiation and Relapse among Teenagers and Young AdultsCe ShangInstitute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL 60608, USA;E-Mail:
cshang@uic.edu; Tel.: +1-312-996-0774; Fax: +1-312-996-2703Academic Editor: Adriana Blanco Marquizo (Ms. Adriana Blanco is a staff member of the PanAmerican Health Organization. Her views do not necessarily represent the decisions or policies ofthe Pan American Health Organization.)Received: 27 October 2014 / Accepted: 23 December 2014 / Published: 9 January 2015Abstract: Background: Existing evidence has shown that most smoking uptake andescalation occurs while smokers are teenagers or young adults. Effective policies that reducesmoking uptake and escalation will play an important role in curbing cigarette smoking.This study aims to investigate the effect of smoke-free air (SFA) laws in bars on smokinginitiation/relapse while controlling for other confounders. Methods: The nationallongitudinal Survey of Youth 1997 (NLSY97) from 19972009 was linked to state-levelscores for the strength of SFA laws in order to carry out the analysis. Results and Conclusion:We find that SFA laws in bars with exemptions significantly reduce (p 0.01) the probabilityof smoking initiation (one-puff, daily, and heavy smoking initiation). The 100% SFA law inbars without exemption significantly deters smoking relapse from abstinence into dailysmoking (p 0.05) or relapse from abstinence into heavy smoking (p 0.01) among peopleage 21 or older. The reduction of one-puff and daily smoking initiation is larger among ages20 or younger than ages 21 or older, while the reduction in relapse does not differ by whetherrespondents reach the drinking age. Results also indicate that higher cigarette taxessignificantly reduce daily smoking initiation and relapse into nondaily and light smoking.Keywords: smoke-free air laws in bars; smoking initiation; smoking relapse;longitudinal study; cigarette taxes; NLSY97; youth and young adults; hazard modelInt. J. Environ. Res. Public Health 2015, 125051. IntroductionExisting evidence suggests that smoking initiation often occurs at an early age and develops intoregular smoking through dependence or addiction later [16]. Therefore, effective tobacco controlpolicies that deter smoking initiation and escalation are crucial in curbing tobacco use. However,current evidence of the effectiveness of policies including price/tax and other tobacco control laws isbest described as mixed. For example, increasing cigarette taxes or prices are found to significantly detersmoking initiation in some studies [611] but not in others [1215]. Moreover, studies of the effects ofsmoke-free air (SFA) laws on reducing smoking initiation and escalation are very limited and almost allsupporting evidence is suggestive [1621].In particular, among all the venues where SFA laws are imposed, SFA laws in bars merit more attentionregarding their potential impacts on smoking initiation and escalation. This is because, first, SFA laws inworkplaces, bars, and restaurants have been the center of state and local SFA legislations [16,17], and,second, substantial evidence has shown that, similar to smoking initiation, drinking also initiates at anearly age and escalates in young adulthood [2227]. Given that a significant number of underage drinkinghappens at bars [26,28], and that smoking and drinking are complementary risky behaviors [2933], SFAlaws in bars may play a more important role in deterring smoking initiation and escalation comparedwith SFA laws in other venues. Third, there is lack of evidence on whether the effectiveness of SFAlaws in bars varies by whether people have reached legal drinking age [34].In sum, current research on SFA laws in bars have been focused on justifying that these laws have noeconomic consequences on the revenues of the affected bars [3537] and their effects on reducingsecondhand smoking exposure [34,3842]. Research is regarding on the effectiveness of these laws onreducing smoking initiation/escalation and whether their impacts on smoking behaviors differ by legaldrinking status is clearly needed. Moreover, given SFA laws in bars are shown to correlate with lessdrinking [3133] and less secondhand smoke exposure [3842], such studies will add evidence to thepotential significant public health impact of SFA laws in bars.This study will utilize the National Longitudinal Survey of Youth 1997 (NLSY97) from 19972007to analyze the impact of SFA laws in bars on smoking initiation and relapse into multiple levels ofsmoking. The NLSY 97 is particularly suitable to conduct such a study as it has run parallel with theperiod during which states gradually adopted SFA laws or more restrictive SFA laws [43]. In addition,NLSY97 is longitudinal data and, unlike a synthetic panel created using retrospective information incross-sections, it has the following advantages in studying smoking initiation/relapse: (1) the actualtransitions were observed and are less likely to contain recall errors; (2) the state of residence was trackedover years and is less likely to induce measurement errors in the linkage to policy data;(3) time-variant socioeconomic characteristics such as marital status can be controlled.We find that SFA laws in bars with exemptions significantly reduce smoking initiation (one-puff,daily smoking initiation, heavy smoking initiation) among all ages and smoking relapse into non-dailysmoking among ages 20 or younger. Th

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