The U.S. Surgeon General has described secondhand smoke (SHS) as being potentially more toxic than the direct smoke inhaled from a filtered cigarette (U.S. Department of Health and Human Services [HHS], 2010). Exposure to SHS increases mortality risk from heart disease and lung cancer (HHS, 2014b; Liu, Jiang, Li, & Hammond, 2014), while also increasing morbidity risks from other respiratory infections, nasal and sinus diseases, and other forms of cancer (Hanaoka et al., 2005; Johnson, 2005; Liu, Bohac, et al., 2014; Liu, Jiang, et al., 2014; National Can cer Institute, 2007; Tammemagi et al., 2007; Zhou, Zou, Hazucha, & Carson, 2011).
Research has even linked SHS exposure during childhood to higher rates of behavioral issues such as attention deficit hyperactivity disorder (ADHD) and other mental health disorders (Bandiera, Richardson, Lee, He, & Merikangas, 2011; Kabir, Connolly, & Alpert, 2011; Max, Sung, & Shi, 2014). As a result of this increased morbidity, SHS is linked to rising costs to both the healthcare and the educational systems in the U.S. In 2010, the Centers for Disease Control and Prevention (CDC) reported a $96 billion annual medical expenditure related to tobacco, with another $97 billion reported annually in lost productivity. Max and coauthors (2014) estimated that SHS-related ADHD costs the U.S. education system $2.9-$9.2 billion. As a direct result of the high costs, the Healthy People 2020 initiative lists as a goal to "reduce illness, disability, and death related to tobacco use and SHS exposure" (HHS, 2014a).
Although it has been nearly 25 years since leading health organizations distinguished SHS as a cause of cancer (U.S. Environmental Protection Agency [U.S. EPA], 1992), SHS still causes approximately 46,000 heart disease deaths each year and is associated with premature death among nonsmoking children and adults (Centers for Disease Control and Prevention [CDC], 2010; National Cancer Institute, 2011).
Significant progress has been made since the 1980s to reduce involuntary exposure of SHS by implementing smoke-free ordinances; however, many individuals are still exposed to the harmful health effects of SHS in the workplace, and in other public venues such as bars and restaurants not protected by such ordinances (Hall, Williams, & Hunt, 2015; HHS, 2006; Sheffer, Squier, & Gilmore, 2013; Williams, Barnes, Hunt, & Winborne, 2011). Smoke-free laws that prohibit smoking in indoor venues fully protect nonsmokers from SHS exposure (CDC, 2011) and have shown a decrease in overall cigarette usage, an improvement in multiple health outcomes (CDC, 2009; Lightwood & Glantz, 2009; Meyers, Neuberger, & He, 2009; Rigotti Regan, Moran, & Wechsler, 2003; Roberts, Davis, Taylor, & Pearlman, 2012), and the reduction of carcinogenic exposure (Bauer, Hyland, Li, Steger, & Cummings, 2005; Farkas, Gilpin, Distefan, & Pierce, 1999; Fichtenberg & Glantz, 2002; Hopkins et al., 2001; Rigotti et al., 2003); yet, there is still resistance at the local level to implement smoke-free ordinances (Satterlund, Cassady, Treiber, & Lemp, 2011).
As of July 2016, 1,295 municipalities in the U.S. have enacted comprehensive smokefree laws, while 36 U.S. states and territories have enacted 100% smoke-free laws in nonhospitality bars and restaurants (Americans for Nonsmokers' Rights, 2016). Despite the increase in restrictive ordinances, an estimated one third of nonsmokers in the U.S. are still not protected from SHS exposure (Frieden, 2014).
Debates against the implementation of smoke-free ordinances in local communities focus on issues such as individual rights, business owner rights, or political party preferences (Berg et al., 2016; Katz, 2005, 2006; Satterlund et al., 2011; Satterlund, Lee, & Moore, 2012). Smoke-free opponents also argue that smoke-free ordinances will result in financial loss to local businesses despite research suggesting otherwise (Alamar & Glantz, 2004, 2007; Sheffer et al., 2013) and deny the scientific link between SHS exposure and health outcomes (Jamrozik, 2005; Smith, 2003). Despite the evidence of immediate health impacts linked to smoke-free air (Dinno & Glantz, 2007; Jones, Barnoya, Stranges, Losonczy, & Navas-Acien, 2014; Khuder et al., 2007), many communities face significant challenges in smoke-free advocacy with ordinance adoption (Americans for Nonsmokers' Rights, 2003).
In addition to the SHS health risks, a relatively new concept of thirdhand smoke (THS) has emerged (Acuff, Fristoe, Hamblen, Smith, & Chen, 2016; Winickoff et al., 2009). THS is composed of lingering tobacco smoke particles that settle on surfaces in the immediate environment (Burton, 2011; Winickoff et al., 2009). While research on THS is limited, there is some evidence of the health risks related to THS, as well as suggestions that THS remains present in the environment for months after smoking behavior has ceased (Matt et al., 2011). The frequent delaying of smoke-free ordinance adoption not only can increase community exposure to SHS but also can increase residual THS that might still present health risks to the exposed population.
Both short-term and long-term studies of SHS in public settings have focused on exposure to particulate matter (PM), which has been directly linked to increased health risks (Eftim, Samet, Janes, McDermott, & Dominici, 2008; Levy, Hammitt, & Spengler, 2000; Pope & Dockery, 2006; Zanobetti, Schwartz, & Dockery, 2000). PM is composed of tiny particles that are often examined based on size: [PM.sub.10] and [PM.sub.2.5]. While both forms of air pollution can be inhaled during respiration, [PM.sub.2.5] is composed of fine particles that are 2.5 pm or smaller in diameter. These smaller particles are more likely to travel deeper into the lungs during inhalation; therefore, [PM.sub.2.5] is considered a greater threat to respiratory health (U.S. EPA, 2016). Clinical and toxicological research have indicated that [PM.sub.2.5] inhalation can lead to increased free radical production, oxidative stress, DNA damage, and suppression of DNA repair--all of which increase overall cancer risk (Xing, Xu, Shi, & Lian, 2016).
Higher [PM.sub.2.5] exposure has been linked to elevated population-based morbidity and mortality, including lung cancer and other pulmonary diseases (Xing et al., 2016). Based on a 26-year cohort study, the American Cancer Society reported a 15-27% increase in lung cancer mortality for every 10 [micro]g/[m.sup.3] increase in [PM.sub.2.5] (Turner et al., 2011). Research has also indicated a 4% increase in overall mortality due to [PM.sub.2.5] exposure (Pope et al., 2002). Similar trends of increased mortality and morbidity linked to [PM.sub.2.5] exposure have been found throughout the U.S. as well as other countries (Correia et al., 2013; Katanoda et al., 2011; Raaschou-Nielsen et al., 2013).
Ordinances are often delayed for months, sometimes years because of the opposition to smoke-free policy implementation, which can lead to prolonged and increased health risks for those exposed (Barnoya & Glantz, 2006; Hyland, Barnoya, & Corral, 2012; Kentucky Center for Smoke-Free Policy, 2010). The use of air quality measurements of [PM.sub.2.5] can indicate direct health risks (Miller & Nazaroff, 2001; St. Helen et al., 2011) and might strengthen smoke-free advocacy efforts. The purpose of this study was to measure indoor air quality in bars and pubs prior to the adoption of a comprehensive, citywide smoke-free ordinance, as well as at multiple time points after adoption. It was hypothesized that at 1-month postordinance, [PM.sub.2.5] would be reduced to within the healthy range according to the U.S. Environmental Protection Agency's (U.S. EPA) standard limit for unhealthy daily exposure (
Indoor air quality was measured using a cross-sectional design to sample a total of 10 pub and bar venues in one Southern U.S. city. Informal...