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Smoking on the margins: a comprehensive analysis of a municipal outdoor smoke-free policy Pederson, Ann; Okoli, Chizimuzo T; Hemsing, Natalie; O’Leary, Renée; Wiggins, Amanda; Rice, Wendy; Bottorff, Joan L; Greaves, Lorraine Aug 22, 2016

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RESEARCH ARTICLE Open AccessSmoking on the margins: a comprehensiveanalysis of a municipal outdoor smoke-freepolicyAnn Pederson1*† , Chizimuzo T. Okoli2†, Natalie Hemsing3, Renée O’Leary4, Amanda Wiggins5, Wendy Rice3,Joan L. Bottorff6,7 and Lorraine Greaves3AbstractBackground: This study examined the formulation, adoption, and implementation of a ban on smoking in theparks and beaches in Vancouver, Canada.Methods: Informed by Critical Multiplism, we explored the policy adoption process, support for and compliancewith a local bylaw prohibiting smoking in parks and on beaches, experiences with enforcement, and potentialhealth equity issues through a series of qualitative and quantitative studies.Results: Findings suggest that there was unanimous support for the introduction of the bylaw among policy makers,as well as a high degree of positive public support. We observed that smoking initially declined following the ban’simplementation, but that smoking practices vary in parks by location. We also found evidence of different levelsof enforcement and compliance between settings, and between different populations of park and beach users.Conclusions: Overall success with the implementation of the bylaw is tempered by potential increases in healthinequities because of variable enforcement of the ban; greatest levels of smoking appear to continue to occurin the least advantaged areas of the city. Jurisdictions developing such policies need to consider how to allocatesufficient resources to enhance voluntary compliance and ensure that such bylaws do not contribute to health inequities.Keywords: Tobacco control, Health equity, Outdoor smoking ban, Marginalization, Municipal, Policy, population healthintervention, Park, Beach, CanadaBackgroundSmoke-free policies are a valuable population health inter-vention to address one of the most common and significantglobal threats to health [1]. When effectively implementedand adequately enforced, smoke-free policies targetingpublic spaces have been instrumental in reducing smokingand improving health outcomes at the population level [2].However, this evidence has primarily come from policiesthat address smoking in indoor and adjacent outdoor pub-lic spaces. Few studies have examined the effectiveness ofsuch policies targeted towards outdoor recreational spaces,such as parks and/or beaches [3, 4].Controversy surrounding the extension of smoke-freepolicies into outdoor spaces [5–7] has been minimized byrecent strong evidence of the substantial tobacco smokeexposure that may occur in outdoor spaces [8–11]. Argu-ments for the adoption of outdoor smoke-free policiesoften focus on reducing the detrimental health effects ofsecondhand tobacco smoke (SHS) exposure (given thatthere is no-known ‘risk free’ level of such exposures), thedenormalization of smoking, aesthetic issues related tocigarette litter, and safety concerns related to fires that canarise from cigarette smoking in high risk areas [12].Another related and often highlighted reason for adoptingsmoke-free policies is an emphasis on the need to protectnonsmokers, especially children, from tobacco smokeexposure in public places [3, 13]. Public support for suchpolicies is increasing and offers municipal officials arationale for their adoption [3]. To date, few studies have* Correspondence: apederson@cw.bc.ca†Equal contributors1BC Women’s Hospital + Health Centre, E305, 4500 Oak Street, Vancouver, BCV6H 3E1, CanadaFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Pederson et al. BMC Public Health  (2016) 16:852 DOI 10.1186/s12889-016-3466-2examined the implementation and enforcement of out-door smoking bans, focusing instead on the policy devel-opment and adoption process though the small number ofstudies which have addressed enforcement of outdoorsmoke-free policies suggest that potential enforcementissues are more of a concern in jurisdictions that have notadopted a policy but that few problems occur in jurisdic-tions that have adopted such policies [14]. Our researchsuggests, however, that enforcement and complianceremain concerns and warrant further study.Moreover, while there is increasing use of smoke-freebylaws in parks and on beaches (as of January 2016, theNon-Smokers’ Rights Association reported that over 52municipalities now have restrictions of smoking inbeaches and 85 prohibit smoking in parks in Canada(see http://database.nonsmokersrights.ca)), there hasbeen relatively little examination of their effects, espe-cially with respect to health equity. In 2008, the WHOCommission on the Social Determinants of Healthrecommended that reducing health inequities—that is,avoidable health inequalities—be considered a goal ofhealth and social policies [15]—which should includetobacco control. However, as a tool for health equity[16, 17] smoke-free policies may not be equally effectiveamong all populations of smokers or all settings, and mayeven contribute to exacerbating existing health and socialinequities, depending upon the effectiveness of theirimplementation [18]. In a review of population tobaccocontrol interventions and their effects on social inequal-ities in smoking, Main et al. [19], for example, found thatfew systematic reviews attempted to examine differentialintervention impacts between population groups. Theyconcluded that while there is clear evidence of theeffectiveness of some tobacco control interventions inreducing overall population smoking prevalence, thehealth benefits are not equitably distributed [19].BackgroundIn 2013, smoking prevalence in the Vancouver HealthAuthority, which includes the City of Vancouver, was15.9 % for all smokers (daily and occasional combined),which is similar to the provincial (British Columbia) rateof 16.2 % [20, 21]. The smoking prevalence for non-Canadian born residents is lower than for native bornCanadians, 5.4 % compared to 14.7 % (possibly arisingfrom the healthy immigrant effect or cultural differences[22] because of a higher proportion of immigrants inVancouver relative to some other cities in Canada [23].There is a gender difference in prevalence: 21.3 % formales and 10.8 % for females. Rates of SHS exposure invehicles and other public spaces in the previous month(among both smokers and nonsmokers) were 15.2 % formales and 14.0 % for females. In British Columbia, thereare higher rates of smoking among groups who arevulnerable to disadvantage such as those on low-incomeand those of aboriginal ethnicity. Smoking rates areinversely correlated with household income: 17.4 % forunder $20,000; 12.5 % for $20,000–$39,999; 10.4 % for$40,000–$59,000; 7.4 % for $60,000–$79,000; and 6.3 %for $80,000+. No survey data were available for Aboriginalprevalence rates in Vancouver in this dataset. Age-standardized Statistics Canada data for those with Aborigi-nal status in British Columbia for 2007 to 2010 estimated31.6 % overall smoking prevalence (29.7 % for males and33.1 % for females) and among non-smokers SHS exposurein the home was 8.7 % (7.7 % among males and 9.6 %among females) and SHS exposure from a vehicle or publicplace in the past month was 22.2 % (25.3 % for males and19.5 % for females) [24].British Columbia initiated smoking restrictions in 1984by requiring non-smoking areas in retail establishments,restaurants, and bars. In 1999, smoking was banned com-pletely in all indoor public spaces, based on the evidenceof the health effects of second hand smoke. In Vancouver,the most populous city in British Columbia, City Councilbanned smoking within six meters of any door, window,or air intake, and also on outdoor patios of bars andrestaurants in 2007. In keeping with this history ofstrong tobacco control efforts, a bylaw prohibitingsmoking in parks and on beaches was approved bythe City’s Board of Parks and Recreation on June22nd, 2010 and came into effect September 1st, 2010.This bylaw, which is limited to the geographic areagoverned by the municipal government and its electedPark Board, prohibits the smoking of any substances(including e-cigarettes, marijuana, and combustibletobacco in any form) in Vancouver’s parks, beaches,and recreational facilities (see Fig. 1).Source: Extracted from A By-law of the City of VancouverBoard of Parks and Recreation to regulate smoking inparks, Appendix A (#131148v8). Retrieved September 5,2011 from: http://vancouver.ca/files/cov/park-smoking-regulation-bylaw.pdf.The purpose of this study was to critically assess theadoption and implementation (including compliance andenforcement) of a ban on smoking in the parks andbeaches in Vancouver, Canada. Four overarching researchquestions guided our study as follows:1. What was the process of adoption of the bylaw?2. To what extent is the bylaw being supported andadhered to?3. What is the process of enforcement?4. What are the health equity impacts of the bylaw?MethodsWe employed a mixed methods approach to evaluatethe policy in context as has been performed recently inPederson et al. BMC Public Health  (2016) 16:852 Page 2 of 13other studies examining bylaw restrictions in New YorkCity [25]. We adopted Critical Multiplism [26] as themethodological frame for the study, which acknowledgesthat different research methods contain weaknesses andbiases which necessitate the use of multiple methodo-logical approaches to minimize the influence of anysingle bias. Accordingly, we use the findings from ninedifferent sources of evidence (see Table 1) to generate anassessment of the bylaw by examining policy adoption,support and compliance, and enforcement. We particu-larly wanted to understand the processes of policyadoption, support, compliance, and enforcement from theperspective of health equity. In 1992, Margaret Whitehead[27] defined health inequities as “differences health thatare unnecessary, avoidable, unfair and unjust”, whileBraveman and Gruskin [28] have argued that,“…equity in health is the absence of systematicdisparities in health (or in the major social determinants ofhealth) between groups with different levels of underlyingsocial advantage/disadvantage—that is, wealth, power, orprestige. Inequities in health systematically put groups ofpeople who are already socially disadvantaged (for example,by virtue of being poor, female, and/or members of adisenfranchised racial, ethnic, or religious group) at furtherdisadvantage with respect to their health.”In the context of tobacco control, Ritchie, Amos &Martin [29] have argued that “Smoking is a major causeof inequalities in health in many high income countries”(p. 461). A recent U.S. study found that lower SES com-munities were less likely to adopt outdoor smoke-freelaws as compared to higher SES communities [30].Several studies have further established that lower socio-economic status (SES) is significantly predicts poorsmoking cessation [31]. For example, a recent studyfrom the UK among 3057 clients of smoking cessationservices found that those with higher SES were 1.4 (95 %CI = 1.1-1.9) times more likely to achieve cessation ascompared to those at a lower SES [32]. A longitudinalstudy in 11 European countries found that althoughoverall smoking cessation rates increased for both lowand high SES groups as a result of tobacco controlpolicies during 1987–2012, the cessation ratio betweenthe two groups also significantly increased [33]. Thesefindings suggest that tobacco control policies that wereimplemented during the 2000’s in those countries didnot mitigate socioeconomic inequalities in smokingcessation [33]. In a similar fashion, SES differences havebeen consistently demonstrated in SHS exposure [34].However, the health inequalities related to the associ-ation between SHS exposure and SES has not been ad-equately examined in Canada. A recent study, however,identified potential subpopulations at greater risk of SHSexposure in Canada, such as children, adolescents, andthose exposed to SHS in the home environments [35].Hence, addressing potential social and health inequalitiesof tobacco policies in Canada is crucial given the evidencethat some tobacco control initiatives (such as workplace in-terventions and tobacco pricing) may exacerbate inequalitiesamong those with different SES levels [36].In the present study, we were concerned with twoaspects of Mahoney et al.’s [37] Equity-focused HealthImpact Assessment Framework (EFHIA), namely, a) anydifferential impacts of the smoking ban across the popu-lation and b) what, if any, measures were used to balancethe burdens/benefits of the policy across the population.Hence, we considered such equity issues using Mahoneyet al.’s approach to equity-focused health impact assess-ment [27, 37] and reviewed debates in the tobacco controlliterature [5, 29, 38–40] to inform our critical analyses ofpolicy adoption, support, compliance, and enforcement.Fig. 1 City of Vancouver BylawPederson et al. BMC Public Health  (2016) 16:852 Page 3 of 13Table 1 Description of SOTM studiesStudy name Research question Design and MethodsDocument review Adoption Design: Review of online, official Park Board meeting records, City Councilminutes and commentaries, and the results of the Park Board’s pre-lawpublic opinion survey from 2007–2012.Analysis strategy: Documents were analyzed thematically to understandthe reasons for adopting the bylaw.Key informant interviews Adoption Design: Semi-structured interviews.Sample: Eight key informant interviews with civic officials, publichealth advocates and health care providers conducted from May toDecember 2011.Analysis strategy: Recorded interviews were transcribed verbatim, andanalyzed thematically to generate a chronological account of theintroduction of the bylaw and to understand the reasons the informantshad for supporting or opposing the bylaw.Social and built environment study [59] Support Design: Semi structured interviews and focus groups between March 2010and February 2011 (prior to the implementation of the smoke-free bylaw)Sample: 40 telephone interviews (with 21 women and 19 men in GreaterVancouver) and focus groups with seven additional participants who wereexposed to secondhand smoke daily or almost daily.Analysis: Recorded interviews were transcribed verbatim and analyzedthematically to obtain information on support for the bylaw.Media analysis [42] Support Design: Content analysis of print news media from January 1, 2010to December 31, 2011.Sample: 90 articles from the Canadian Newsstand Database andindependent newspapers.Analysis: Articles were coded in two stages, first using a custom Perl scriptand then with a set of content variables. The articles were further codedusing 45 content variables into the categories of relevance, geographicfocus, slant, primary approach, theme, and tobacco control topics.Park User Telephone Survey [43] Support Design: A cross-sectional survey using a random digitalized callingsampling process between September 15th and 25th, 2011.Sample: 496 Vancouver residents (446 nonsmokers and 50 smokers) whohad visited a beach or park in the previous year (from Sept 2010 to Sept2011) —the first year of the smoking bylaw.Analysis: Data obtained from respondents included demographicinformation, smoking status, support for the smoke-free bylaw, andopinions regarding the smoke-free bylaw. Unadjusted and adjustedlogistic regression analyses were used to examine the correlates ofsupporting the bylaw.Park and Beach Observation Study [60] Compliance Design: Observations of parks and beaches at nine time-points (pre-bylaw,one-week, one-month, 8-months, 9-months, 10-months, 12-months,22-months, and 24-months after bylaw implementation) fromAugust 2010 to September 2012.Sample: Purposively selected parks (n = 3) and beaches (n = 3) inVancouver, Canada.Analysis: Observed smoking in each venue was recorded during a 30-mintime period. Observation sessions were limited to afternoons andevenings on the weekends (Friday-Sunday). Information on the maximumnumber of persons, total number of smokers, duration of time spent, andaverage daily temperature were recorded per venue. Friedman’s testswere used to assess the changes in the total smoking rates in venuesover time. Wilcoxon signed rank tests were used to assess the differencesbetween prelaw and each subsequent observation time point smokingrates. Mann–Whitney tests were used to examine the differences insmoking rates between parks and beaches.Beach Litter Study Compliance Design: Secondary analysis of observational data from the Great CanadianShoreline Cleanup (see http://www.shorelinecleanup.ca/) which comprisedpark and beach litter data from one year before and two years after theimplementation of the bylaw from 2010–2012.Sample: Litter (from cigarettes/cigarette filters, tobacco packaging,cigarette lighters, and cigar tips) among 40 sites from which litter wasconsistently obtained in all 3 data collection periods.Pederson et al. BMC Public Health  (2016) 16:852 Page 4 of 13The protocols for all studies were approved by the UBC/Children’s & Women’s Health Centre Research EthicsBoard (Certificate Number: CW19-0185/H10-01801).ResultsPolicy adoptionTo examine the policy adoption process, we criticallyreviewed available public documents on the bylaw andnarrative data from key informants regarding the processof policy adoption.Document reviews and key informant interviewsFrom the document review and key informant inter-views, it was clear that there was both official and publicsupport for the introduction of the bylaw (see Fig. 2). Infact, the recommendation to introduce the bylaw gener-ated only limited discussion at the Park Board session atwhich it was debated and most of the discussion focusedon health concerns. One Park Board councillor evenquestioned whether there was any need to hold a discus-sion prior to voting for the bylaw, presumably because itwas felt that the case for supporting it was so transpar-ently sound. To the extent that they were evident at all,equity issues were discussed with respect to whethernon-smokers, especially children, had the right to be freeof smoke in outdoor places. The Park Board and CityCouncil (which had to be involved for legal reasons)both agreed that the enforcement would be handled byPark Rangers (and police) though there was hope thatthe bylaw would be self-enforcing through signage andsocial pressure. To enhance public/self-enforcement, aneducational intervention was started prior to the bylawcoming into effect to raise awareness of the ban. Themajority of the key informants, all of whom were famil-iar with the process of bylaw development in Vancouver,confirmed that equity issues were not part of the debateor decision-making process, and though they weregenerally supportive of the bylaw as a public healthintervention, some questioned its implications for civilliberties and fairness.Public support and complianceTo assess support for and compliance with the bylaw,we conducted a series of studies employing qualitativeand quantitative approaches to using narrative, media,survey, and observational data.Social and built environment studyAt the time the smoke-free bylaw was announced, someof our research team were collecting data regarding SHSexposure in Vancouver [41]. A convenience sample of 47low-income and non-low-income men and women ofvaried smoking statuses was recruited to participate in atelephone interview or a focus group. A subset of thesestudy participants (eight individuals who completedone-on-one individuals and one focus group of four),Table 1 Description of SOTM studies (Continued)Analysis: For each venue, information on number of volunteers, distancecleaned, and litter (cigarettes/cigarette filters, cigarette lighters, cigar tips,tobacco packaging) was obtained. Repeated measures analysis fornegative binomial regression was based on the generalized estimatingequation (GEE) approach and was used to evaluate differences in theamount of litter obtained between parks and beaches over the 3-yearstudy period. Each model included the factors of venue type (park vs.beach), year (2010, 2011 and 2012) and the interaction between venuetype and year as well as the time-dependent covariates for number ofvolunteers and kilometers covered.Park Ranger Focus Group and CitationInformationEnforcement Design: Two semi-structured focus groups in October 2011 (13 monthsfollowing implementation) and then again a year later in August 2012.Citation data was obtained from the metro police department.Sample: Twelve individuals participated in the focus groups (6 individualsparticipated in both groups). Rangers who participated in the focusgroups included novices and senior officers (8+ years), and both seasonaland permanent employees. (The permanent Park Ranger contingent istiny, consisting of a full-time Lead Ranger, a full-time Homeless Liaison,and four part-time Rangers; in the summer months, when park and beachusage peaks, 36 seasonal auxiliary Rangers join the permanent staff).Analysis: Focus group data were analyzed with a 23-item coding framecreated by the Principal Investigator (PI) and a team member. Inter-coderreliability with a third team member was .849 (Krippendorff's alpha).A saturation of themes was demonstrated when no additional codes werecreated during the coding process. A narrative summary was compiledfor each code for each focus group, and the number and density ofresponses analyzed; the two focus groups were also compared forchanges from year one to year two. The identification of themes wasformulated by the PI in conjunction with the research team. Citationdata from Municipal Ticket Information system reported as frequencies.Pederson et al. BMC Public Health  (2016) 16:852 Page 5 of 13spontaneously remarked on the new bylaw in the cityand these results are discussed here.The majority of study participants who commented onthe proposed smoking ban on beaches and in parksdisagreed with the implementation of the ban. Reasonsfor opposition included: concerns over infringement onthe rights of smokers, the potential for stigma, andissues with enforcement and compliance. For example,one participant noted:“I think in public places if people want to rest andstop and have a social interaction while they’re havinga cigarette then there needs to be designated smokingareas because that’s the – I think an outright ban ofpeople on beaches is just not the way to go”(female non-smoker, April 19, 2010).Several participants commented that smokers are capableof managing their smoking in outdoor spaces and respectingthe rights of nearby non-smokers. To support their stance,they suggested that such bans would be indicative of a“nanny-state” and defended the legality of smoking and ar-gued that there were practical challenges with enforcement.While most participants who spoke about smokingbans on beaches and parks were critical or concernedabout effectiveness, two non-smoking participants (onefemale, one male) expressed complete support for publicsmoking bans. One participant, who had been lobbyingthe city to implement smoking bans on beaches andparks, commented:“So I’m hoping that they’re going to pass this [ban onsmoking in beaches and parks] and put it through toclean up the air for most of us. That would bewonderful, a dream come true” (male, non-smoker,April 16, 2010).Reasons for supporting the ban included a reduc-tion in cigarette-related litter, increase in smoking reduc-tion and cessation with expanding denormalization ofsmoking, a reduction in children’s exposure to SHS, andthe discomfort engendered by SHS exposure (one partici-pant noted that he could smell someone smoking “twoblocks away”).In sum, there was variation in both tolerance for SHSand support for smoking restrictions among this study’sinterviewees. The results of this study offered a windowinto the range of opinions and experiences of bothwomen and men, smokers and non-smokers, and helpset the context for our other data collection processesand analyses.Media analysisWe examined newspaper coverage of the smoking banprior to and following implementation. Articles were sepa-rated into three categories: news stories (60 %, n = 54),letters to the editor (18.9 %, n = 17), and opinions andeditorials (21.1 %, n = 19). We observed the greatestnewspaper coverage when the bylaw was announced inApril 2010, with a total of 19 articles published, althougha small number of articles were published every monthFig. 2 Milestones in the Development of the Outdoor Smoke-free Policy in VancouverPederson et al. BMC Public Health  (2016) 16:852 Page 6 of 13during the study period. The April 2010 announcementalso had the largest number of letters to the editor (n = 9).An analysis of article slant showed differences in viewstowards the bylaw: for the news articles, 50 % (n = 27)were positive and 7.4 % (n = 4) negative, while for theletters to the editor only 23.5 % (n = 4) were positiveand 64.7 % (n = 11) were negative. The most frequenttopic related to enforcement and implementation (i.e.,signage, enforcement officers, and implementation is-sues: 64 articles), followed by unintended consequencesof smoking (i.e., litter, fire, public nuisance: 39 articles),and second hand smoke exposure (31 articles). Equityissues (i.e., the rights of smokers and non-smokers, fair-ness of the law) was discussed in only 21 articles [42].Park user telephone surveyThe bylaw was supported by 85 % (n = 421) of surveyrespondents with a significantly greater proportion of fe-males supporting the bylaw than males (89 % vs. 78 %),and a significantly greater proportion of nonsmokerssupporting the law than smokers (89 % vs. 52 %). Beliefsregarding the bylaw were that it would: improve the healthof people in the city (total = 82 %, nonsmokers= 86 % vs.smokers = 43 %); protect the health of non-smokers, in-cluding children who visit parks and beaches (total =83 %, nonsmokers = 86 % vs. smokers = 56 %); encouragepeople to quit smoking (Total = 49 %, nonsmokers = 52 %vs. smokers = 22 %); discourage youth from starting smok-ing (Total = 49 %, nonsmokers = 50 % vs. smokers =33 %), infringe on the right of smokers (total = 42 %, non-smokers = 39 % vs. smokers = 71 %); and protect peoplefrom exposure to secondhand smoke (total = 84 %, non-smokers = 88 % vs. smokers = 52 %) [43]. Women weresignificantly more likely than men to believe that the by-law would protect the health of nonsmokers (includingchildren) who visit parks and beaches (64.1 % vs. 35.9 %)and protect people from exposure to secondhand smoke(63.6 % vs. 36.4 %). There were no further significantgender differences in beliefs regarding the bylaw.Results of multivariate analysis suggest that favourablebeliefs regarding the bylaw were associated with increasedsupport for the law. Support for the bylaw varied by sex,self-identified ethnicity, education and marital status.Females were significantly more likely to support the by-law than were males (aOR = 2.8, 95 % CI = 1.5-5.1); indi-viduals from different visible minority groups weresignificantly more likely to support the law than thosefrom White or European Ancestry (aOR = 2.1, 95 % CI =1.0-5.0); and those with a university degree were signifi-cantly more likely to support the law as compared to thosewith a high school degree or lower (aOR = 2.5, 95 % CI =1.1-5.5) [43]. Never married individuals were significantlyless likely to support the law than those who were married(aOR = 0.5, 95 % CI = 0.2-1.0) [43].Although the majority of residents participating inthe telephone survey endorsed the smoke-free bylaw,they recognized its potential for stigmatizing smokersand smoking. About three-quarters agreed that thebylaw could increase negative attitudes or stigma to-wards smokers. Smokers were significantly more likelyto voice concerns that the bylaw infringes smokers’rights (71 % vs. 39 %) [43]. Thus survey respondents,particularly if they were smokers, recognized potentialnegative consequences.Park and beach observational studyA total of 23,815 persons were observed in selectedparks and/or beaches during the observation time pointsfrom 2010–2012 with a median of 11.5 smokers (min =0.0 to max = 32.0) and a median smoking rate of 4.8smokers per 100 persons (min = 0.0 to max = 64). Parkshad significantly higher smoking rates as compared tobeaches (mean rate parks = 17.9 vs. beaches =1.9). Sig-nificant changes in smoking rates were observed overallfrom pre-bylaw to 24-months post-bylaw (pre-bylawmean rate = 20.6 vs. 24-month mean rate = 8.6). Instratified analyses (see Fig. 3), changes in mean smokingFig. 3 Changes in Mean Smoking Rates in Selected Parks and Beaches (Pre-bylaw to 24-month Post-bylaw)Pederson et al. BMC Public Health  (2016) 16:852 Page 7 of 13rates were significant in both beaches and parks.However, the differences between pre-bylaw, 12-month,and 24-month were no longer significant in the stratifiedanalyses.Despite the inherent weaknesses in design (such aslack of randomization of observed venues), these find-ings are strengthened by multiple detailed observationscarried out in the same venues. Total observed smokingrates in all venues decreased over time; however, novenue had 100 % compliance with the smoke-free bylaw.Moreover there was lower compliance in the parks ascompared to the beaches.Beach litter studyThe number of lighters, cigarette butts/filters, cigar tipsand/or packaging found were analysed by venue type, year,number of volunteers and/or distance covered (Fig. 4).The following significant relationships were found:there was a decline in the number of lighters ob-tained, with significant reductions between years 2010and 2012 (p = .005) and years 2011 and 2012 (p = .016).Cigarette butts/filters were more likely to be obtainedfrom beaches than parks (RR = 1.98 (95 % CI 1.13, 3.48).Our analysis of the park and beach litter data suggestthat in 2010 there were more cigarette/cigarette filterson beaches (n = 25687) than parks (n = 9670), but by2012 there were a larger number of cigarette/cigarettefilters in parks (n = 25456) than on beaches (n = 14963).However, the change in total beach litter counts was notsignificant (with the exception of cigarette lighters) overthe three year data collection time point (see Fig. 4).EnforcementTo assess the enforcement of the bylaw, we collectednarrative data from enforcement officers through focusgroups and obtained information on issued citations dueto violations of the bylaw.Park ranger focus groups and citation informationAs reported by key informants and in Park Board minutes,Vancouver opted to have its small contingent of Park Rangersfunction as bylaw enforcement officers as part of its imple-mentation strategy. Although members of the VancouverPolice Department were also given the authority to enforcethe ban, bylaw enforcement per se was not a new functionfor them nor were they expected to be the main enforcers ofthis bylaw, so they were not interviewed for this study.Though it is not the focus of the present discussion, itis noteworthy that the introduction of the smoking banrepresented a major change in the work of the city’s ParkRangers. Prior to the introduction of the bylaw, theRangers regarded themselves as “ambassadors” for theparks. Following the introduction of the ban, they had tolearn how to function as “bylaw enforcement officers”, amore policing role. During the focus groups, the ParkRangers described various aspects of their day-to-dayenforcement experience. Among their observations wasFig. 4 Beach litter data 2010–2012Pederson et al. BMC Public Health  (2016) 16:852 Page 8 of 13the fact that they witnessed and participated in differen-tial enforcement based on locations and populations.Given available staffing, the Rangers reported that therewas consensus among management that it would be im-possible to cover all the city’s parks and beaches, so popu-lar tourist beaches were subject to the most enforcement.At the same time, Rangers explained that ticketing wasnot done in specific parks "for safety reasons" becausesome parks located in the city's lower-income areas were"charged environments", that is, environments in whichvisitors were more resistant to enforcement and could bethreatening to the enforcement Rangers.According to the Rangers, some populations were notsubject to enforcement. For example, we learned that ParkBoard Department policies exempt the homeless and tour-ists from ticketing. Uncooperative violators could also avoidtickets by refusing to supply identification; indeed, ParkRangers do not have the authority to demand identification.The Rangers observed that these “scoff-laws” were oftenfrom the less affluent East Side of the city. Rangers also ex-plained that First Nations individuals would sometimesprotest that the bylaw did not apply to them given landclaim and jurisdictional disputes, and that this put the ParkRangers into "a weird position". Other Rangers pointed tothe general policy of Ranger discretion, which meant thatthey could withdraw from potential enforcement actionswith uncooperative violators. Finally, some Rangers saidthey targeted cannabis users for enforcement rather thantobacco smokers, rationalizing that cannabis use is (still)illegal in Canada independently of this particular bylaw andhence they found it easier to justify its enforcement.Few Rangers acknowledged the possible consequences ofdifferential enforcement. Some Park Rangers explainedthey were initially reluctant to enforce the bylaw, particu-larly in the parks, whereas there was greater confidenceabout both the legitimacy of enforcing the bylaw over timeand about the process for doing so (following specifictraining). This is supported by data indicating that initiallywarnings were the primary form of ticketing following theapproval of the smoke-free bylaw, but the use of fines in-creased with time (see Fig. 5).Some Park Rangers commented that enforcement islikely to have different consequences depending upon thecircumstances of the person of interest. For example, abylaw infraction could result in a $250 fine; this expensefor noncompliance burdens low-income smokers morethan more affluent smokers. Yet without robust enforce-ment in parks in the lower-income areas, lower-incomepopulations and marginalized communities could also re-ceive less protection from SHS, and derive less tobaccocontrol benefit (denormalization, temporary abstinence,quit motivation). These populations are already at greaterrisk for tobacco use and exposure. In the early phase ofimplementing the ban, the Park Rangers noted thatenforcement focused on education and warnings; asnoted, ticketing for non-compliance increased with time(see Fig. 5) even as these other aspects of enforcementcontinued.DiscussionThis study is one of the first to conduct a comprehen-sive, multi-year assessment of the adoption and imple-mentation of a municipal bylaw prohibiting smoking inparks and on beaches. The use of critical multiplism toorganize the study proved to be a useful approach to un-derstanding a complex population health intervention incontext as it explicitly involved collecting, comparingand reflecting upon multiple forms and sources of dataover time. The various methods generated complemen-tary findings regarding the policy-making process andthe nuances of implementing an outdoor smoke-freepolicy. For example, despite evidence of some oppositionand resistance to the introduction of the outdoorsmoke-free bylaw in Vancouver from civil rights groupsand smokers, the public documentary record, ourtelephone survey, the newspaper media analysis, and keyinformant interview data confirm a high level of supportfor the bylaw. This degree of support is consistent withstudies in other jurisdictions, including Britain, NewZealand, Australia, Canada, and the United States [44,45], and should be encouraging to policy makers andpublic health advocates.A closer examination of the literature on public sup-port for smoke-free bylaws indicates that proponentssupport such policies because they denormalize smokingand limit children’s exposure to smokers and tobaccosmoke [3, 44]. For example, a recent Canadian studyfound very strong parental and caregiver support forsmoke-free polices in playgrounds to reduce potentialhealth risks associated with SHS exposure amongchildren [13]. However, our park user telephone surveysuggested that park users in Vancouver differed regard-ing support for the bylaw by smoking status, gender,ethno-cultural affiliation, education, and marital status[43]. That is, smokers were less supportive of the bylaw;Fig. 5 Citations issued by year since implementation of bylaw 2010–2013Pederson et al. BMC Public Health  (2016) 16:852 Page 9 of 13women were significantly more likely to support thebylaw; individuals from various visible minority groupswere significantly more likely to support the law thanthose of White or European Ancestry; and those with auniversity degree were significantly more likely tosupport the law as compared to those with a high schooldegree or lower. Findings from our media analysissuggested that support for the bylaw was captured in dif-ferent forms (i.e., letters versus news items) in the printmedia. Other media analyses also suggest that the extentand nature of news coverage is associated with variationin support for smoke-free bylaws [46]. These findingsare consistent with other studies of the introduction ofsmoke-free laws [47] and suggest that implementersshould be mindful of both opportunities to mobilizesupport and address resistance.We also uncovered skepticism about the likely effective-ness of the ban, the risks of SHS in an outdoor setting, andawareness that such bylaws increase the stigmatizing ofsmokers and smoking. Similar concerns have recently beendocumented in other studies [38, 44, 48]. Our focus groupsand interviews with smokers and nonsmokers and findingsfrom the public opinion survey, suggest that a number ofrespondents expected the bylaw to increase thestigmatization of smokers. This challenge of greaterstigmatization and its potential consequences is a concernin current tobacco control efforts (e.g., [38, 49]). Increasedfeelings of being stereotyped and stigmatized have been re-ported by smokers facing increasing restrictions on publicsmoking in other studies [48]. Such smoking restrictions,which increase the social unacceptability of smoking, mayfurther marginalize these groups and create more barriersto accessing health services [38, 50, 51]. Further, these pro-cesses are gendered, in that women and men who smokemay face different degrees of stigma [52] and differentialaccess to private and public recreation spaces [53, 54].Based on these findings, it may be important to includesub-groups (such as male and female smokers and low-income individuals) when developing implementationplans for outdoor smoke-free policies to potentially miti-gate unintended adverse effects of such policies.Overall lower rates of compliance with the smoke-freelaw were observed in our study in the parks which werelocated in lower-income areas of Vancouver relative tobeaches, which are primarily located in the more affluentareas of the city. This finding can be explained in partby the higher smoking prevalence in the lower-incomeareas and the lack of prioritization of bylaw enforcementby Park Rangers in these areas. These findings areconsistent with the results of the study reported byRitchie et al. [29] which demonstrated that post-regulation use of public spaces was related to a var-iety of pre-legislation differences in the communitiesand the ways that people engaged in particular socialand cultural spaces. Similar patterns have also beenobserved in a recent study that found improvementsin smoking behaviours (e.g., decreased cigarette con-sumption and increased quitting) among affluentlocalities but little improvements in less affluent local-ities after the introduction of a smoke-free law inScotland [29]. However, our finding of a minimal re-duction in smoking-related litter is somewhat differ-ent from the results of other studies, such as the oneconducted by Johns et al. in New York City [55]. Thelack of significant change in the volume of cigarette-related litter in Vancouver suggests the need for greaterenforcement of this aspect of the smoke-free bylaw.An important element of this project was assessingwhether equity concerns were an element of policydevelopment and implementation. The historical docu-ment trail, key informant interviews and media analysissuggested there was almost no concern expressed in thepolicy adoption phase with issues of fairness or differen-tial effects. However, important equity concerns wereraised during discussions with the Park Rangers regard-ing their experiences of actual, day-to-day implementa-tion of the smokefree policy. For example, theyacknowledged differential enforcement levels at vari-ous sites (more enforcement at beaches than parks,for example). We also learned that some groups ofpark users are exempt from ticketing while others aresubject to the discretion of the enforcement officers.Yet without adequate enforcement, park visitors inlower-income areas of Vancouver may continue todisproportionately experience SHS exposure whilevisitors in the parks and on the beaches of wealthierneighbourhoods are more likely to be protected.By applying an equity lens to all our findings, a finetension emerges between the potential unintended conse-quences of the bylaw (i.e., stigmatizing an already disad-vantaged groups of smokers with low socioeconomicstatus) and the detrimental effects of inadequate enforce-ment and non-compliance (i.e., increased risk of the samedisadvantaged groups to the adverse health effects of SHSexposure). There may be no direct solution to this conun-drum. For example, designated smoking areas in outdoorvenues, have been shown to continue being a source ofsignificant SHS exposure [56]. Creative approaches toenforcement of the bylaw may mitigate the degree of theinequitable effects of the policy. For example, those whoenforce the bylaw may provide tobacco treatment assist-ance (i.e., brochures, vouchers for medications) and othersimilar resources to violators of the bylaw; or repeatoffenders may be asked to attend mandatory tobaccotreatment in lieu of fines. Nonetheless, for the smoke-freepolicy to be maintained as intended, it will be necessary tohave ongoing bylaw communication and investments inresources for enforcement.Pederson et al. BMC Public Health  (2016) 16:852 Page 10 of 13Our equity analysis was informed by tools such asMahoney et al.’s EFHIA [37], which encourages ques-tioning throughout all phases of a project, including apotential policy, not simply applying an equity analysisto intervention outcomes. The aim of EFHIA is to “putequity and health on [the] agenda in a more obvious andsystematic way” (p. 1) and was therefore a useful startingpoint for generating questions for our data collectionprocesses regarding the extent to which equity concernswere or were not in the minds of key decision makersthroughout the policy development, adoption and imple-mentation process. Critically, EFHIA asks whether anyobserved difference in health outcome or its precursor-s—in this case, for example, exposure to SHS—is avoid-able and unfair. Although health equity has had significantinternational attention since the publication of the WHOCommission on the Determinants of Health report in2008 [15], it is clear that additional tools, strategies andsupports for applying an equity lens are still needed,including in the field of tobacco control, particularly withregard to smoking prevention or cessation supports fordisadvantaged groups of smokers. As Beauchamp et al.[57] suggest, underlying material, social and environmen-tal factors associated with disadvantage are likely topresent significant barriers to the effectiveness ofinterventions.This study has several limitations that need to be con-sidered in interpreting the findings. This study employeda mixed-methods approach, employing both qualitativeand quantitative approaches to data collection andanalysis. The findings from our qualitative data at bestrepresent the unique perspectives of the study partici-pants and contexts of analyses. Although we employedrigour in our qualitative approaches (including memberchecks, triangulation, and respondent validation) at bestour findings are constrained by the limitations inherentin qualitative research. Moreover, our quantitative datawere obtained through observational methods withoutcomparison groups or randomization which affects theinternal validity of our findings. In addition, the outcomeof each quantitative study was constrained by the vari-ables obtained during data collection, affecting externalvalidity. Nonetheless, the use of multiple data sourcesderived from both qualitative and quantitative sources isa strength of the critical multiplism approach [55].Future studies with more rigorous designs should beemployed to examine specific features of smoke-freepolicies. For example, the use of comparator jurisdic-tions in our study design may have strengthened thetransferability of our study findings.ConclusionsIn this study, we explored the introduction of a smoke-free bylaw in one municipality. We learned that thebylaw was enthusiastically supported by both City andPark Board councillors and introduced with little oppos-ition or debate. Yet our set of studies suggests that theban on smoking in the parks and at the beaches in Van-couver has had mixed results to date. With a large in-ventory of parks and beaches and a small staff ofenforcement officers, there is significant reliance on pas-sive enforcement, and even when enforcement officersare engaged, a number of factors determine whetherthey will insist upon compliance in a given setting or cir-cumstance. Our field observations suggest that there aresome park and beach areas in which smoking continues,particularly in lower-income areas of the city, and thatsome populations of smokers are less likely to be chal-lenged for non-compliance. Accordingly, both direct andSHS exposure may be differentially greater in some set-tings than others throughout the city’s parks andbeaches.The introduction of the smoke-free bylaw changed therole of the city’s Park Rangers. In choosing to make theRangers responsible for bylaw enforcement, greaterattention should have been given at the outset todeveloping their skills in handling the wide range ofpeople they might encounter. In addition, given the nu-merous locations and vast network of parks and beaches,decision makers should have allocated sufficient re-sources to hire an appropriate number of officers andplanned for meeting the needs of more disadvantagedsmokers.As public and population health researchers, we arecommitted to ensuring that population health interven-tions meet the aims of both tobacco control and healthequity [58]. This means ensuring that the developers andimplementers of outdoor smoke-free bylaws considerhow the bylaw may affect various populations ofsmokers and develop strategies to improve the way thatthe bylaw is managed to ensure that it does not inadvert-ently contribute to greater health inequities. This mightmean providing better training to enforcement officersin dealing with non-compliant park and beach users. Itmight also mean reducing the fine level so that it is lessonerous for low-income violators, and providing greatersupports for smoking reduction and cessation in thecommunity. To increase the likelihood that lower-income smokers could enjoy the benefits of smoke-freeparks, enforcement should be consistent across settings,and resources for enforcement should be adequate.Finally, proponents of tobacco control should join withthe broader public and population health community inadvocating for action on the determinants of health;adequate housing, income, education, and social equityare likely to contribute to reducing tobacco use in thefirst place and hence the demand for smoking in thepark or at the beach.Pederson et al. BMC Public Health  (2016) 16:852 Page 11 of 13AcknowledgmentsThis project was supported by the Canadian Institutes of Health Researchthrough a Population Health Intervention Research Operating Grant. Manyindividuals served as academic, policy and clinical advisors to the project,including Milan Khara, Jack Boomer, Thomas Soullière, Deborah McLellan,and Ellen Hahn. We would like to thank Steven Chasey for conducting thekey informant interviews and Natasha Jategaonkar for her analysis of outdoorsmoking in parks and beaches from the perspective of public health ethics.FundingThis project was funded by the Canadian Institutes of Health ResearchInstitute for Population and Public Health as an Operating Grant: PopulationHealth Intervention Research (FRN#112694).Availability of data and materialsThe data gathered in this research are available from the co-principal applicants.Please contact apederson@cw.bc.ca if you are interested in accessing the dataor related project materials.Authors’ contributionsThis project is the result of the combined efforts of all authors. Various authorscontributed to each section, according to their involvement in data collection,analysis and writing of previous manuscripts as well as this particular article. APwas the lead investigator and led the qualitative elements of the project (policyadoption, Park Ranger focus groups) and media analysis. CO was the co-principalinvestigator on the project and led the park user telephone survey, park andbeach observational study, and analyses of citation and litter data. NH wrote thesection on the social and built environment and participated in all elements ofthe overall project. RO contributed to the analysis of the Park Ranger focusgroups and to the background section of the paper. AW conducted severalstatistical analyses and wrote the results for the park and beach observationalstudy and beach litter data. WR conducted several aspects of the project asresearch coordinator, including the focus groups with AP, and contributed to thepolicy analysis. JB contributed to the conceptualization of several elements of theproject and provided input to this manuscript, particularly the qualitativeanalyses. As the principal investigator on the social and built environmentsproject and a co-investigator on this study, LG also contributed to theconceptualization of several elements of the project and provided input to thismanuscript. All authors read and approved the final manuscript.Competing interestsAnn Pederson, Natalie Hemsing, Renée O’Leary, Amanda Wiggins, WendyRice, Joan L. Bottorff and Lorraine Greaves declare that they have nocompeting interests.Dr. Chizimuzo Okoli has received consultation fees from the VancouverCoastal Health Authority, The Breathing Association, and Bluegrass.orgin the previous 12 months.Consent for publicationNot applicable.Ethics approval and consent to participateThis project received ethics approval for all included studies from the UBC/Children’s & Women’s Health Centre Research Ethics Board (CertificateNumber: CW19-0185/H10-01801). Where applicable, this approval includedconsent for participation in individual and group interviews.Author details1BC Women’s Hospital + Health Centre, E305, 4500 Oak Street, Vancouver, BCV6H 3E1, Canada. 2Faculty of Nursing, University of Kentucky, Lexington, KY,USA. 3BC Centre of Excellence for Women’s Health, Vancouver, BC, Canada.4University of Victoria, Victoria, BC, Canada. 5University of Kentucky,Lexington, KY, USA. 6Institute for Healthy Living and Chronic DiseasePrevention, University of British Columbia, Kelowna, BC, Canada. 7Faculty ofHealth Sciences, Australian Catholic University, Melbourne, Australia.Received: 10 December 2015 Accepted: 5 August 2016References1. Hawe P, Potvin L. What Is Population Health Intervention Research? Can JPublic Health. 2009;100(1):I8–I14.2. International Agency of Research on Cancer. IARC Handbooks of CancerPrevention, Tobacco Control. Evaluating the effectiveness of smoke-freepolicies. vol. 13. 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Examining Tobacco Control Strategies and AimsThrough a Social Justice Lens: An Application of Sen’s Capability Approach.Public Health Ethics. 2011;4(2):149–59.59. Hemsing N, Greaves L, Poole N, Bottorff J. Reshuffling and Relocating:The Gendered and Income-Related Differential Effects of RestrictingSmoking Locations. J Environ Public Health. 2012;2012:12. doi:10.1155/2012/907832.60. Okoli CTC, Johnson A, Pederson A, Adkins S, Rice W. Changes in smokingbehaviours following a smoke-free legislation in parks and beaches.BMJ OPen. 2013;3.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Pederson et al. 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