Reactions to Smoke-free Policies and Messaging Strategies in Support and Opposition: A Comparison of Southerners and Non-Southerners in the US.

States in the southeastern United States (US) are among those with the highest prevalence of tobacco use. Whereas the national aver-age for smoking prevalence is 19.0%, the average in this region is 22.0%, with prevalence as high as 26.5% in Kentucky.1 Unfortunately, states in the southeastern US also have among the highest proportions of their populations living at or below the federal poverty level; greater inequalities between the highest and lowest income groups; a larger proportion of the state population comprised of persons with less than a high school education; and greater racial and ethnic diversity than other regions of the US.2 Lower income individuals, those without a college education, and racial and ethnic minorities are more likely to be targeted by tobacco marketing and to use tobacco products than other populations,3 making tobacco use prevention a particular challenge in southeastern states. A major factor contributing to this health disparity may be lagging tobacco control policies in the southeastern US.4 Comprehensive smoke-free indoor air laws ban smoking of tobacco products in all indoor areas in worksites, restaurants, bars, and hotels, and do not allow for separately ventilated areas. Research strongly supports the effectiveness of public, smokefree policies for increasing cessation attempts among current smokers and reducing exposure to secondhand smoke (SHS), tobacco use prevalence, the initiation of tobacco use among young people, tobacco-related morbidity and mortality, and healthcare costs.5 In addition, despite common concern about the impact of such policies on businesses including bars and restaurants,6 evidence suggests that smoke-free policies do not have an adverse economic impact on businesses and may have a positive impact in some contexts.5 Because of the importance of these policies, 28 states and the District of Columbia have passed comprehensive smoke-free laws.7 The region of the US least likely to have adopted public smoke-free policies is the southeastern US.4 One contributing factor to the lagging policy adoption in the southeastern US may be the fact that this region is home to 6 of the top 10 tobacco growing states in the nation (ie, North Carolina, Kentucky, Virginia, Tennessee, South Carolina, and Georgia, respectively).8 However, the role of tobacco farming in the US economy and in the so-called tobacco states’ economies has been decreasing in the last few decades,9 largely due to US cigarette companies using more foreign tobacco for domestic consumption and reducing cigarette exports because it is more cost-effective to cultivate tobacco outside the US.10 Regardless, congressional lawmakers from tobacco-growing states are less likely to vote in favor of tobacco control legislation, and as a result, this region lags behind other US regions in the adoption of a range of tobacco control policies, including smoke-free policies.11 On a related note, the home remains a significant venue for SHS exposure,12 with 52% of US smokers and 19% of nonsmokers allowing smoking inside their home.13 Despite strong support for smoke-free public policies among US adults in general,14,15 research documenting support for policy implementation in personal living areas and practices around enforcing smoke-free policies in private settings is limited.16 The implementation and enforcement of smoke-free homes may indicate that a person is more likely to support smokefree public places. This might be particularly the case in areas that are lagging in such policy implementation, such as the southeastern US. Media coverage and advocacy efforts to promote support for and opposition to tobacco control policies have used a range of arguments related to the impact of such policies on health, economic issues, youth prevention, individual rights, and morality.17-22 Given that many of the settings most impacted by comprehensive smoke-free policies, such as bars and restaurants, are part of the hospitality industry, another possible messaging strategy both in support for or opposition to smoke-free public policies may be the value placed on hospitality itself. Although research has assessed public discourse about smoke-free policies, limited research has examined the persuasiveness of different messaging strategies to support or oppose smoke-free policies. Future messaging strategies could target values that are more prevalent in the southeastern US. For example, the 2013 Nielsen data on US households documented that southeastern households contain a greater proportion of individuals who value individual rights, are married with children, attend religious services, and value hospitality.23 As such, messages that appeal to ideals of youth prevention, individual rights and responsibilities, religion and morality, or hospitality might be particularly effective in the southeastern states of the US. Given the aforementioned literature, we used a national panel survey to examine differences between Southerners and non-Southerners in relation to: (1) adoption and enforcement of smoke-free policies in personal settings; (2) perceptions and reactions toward public smoke-free policies; (3) participant characteristics related to greater receptivity to such policies; and (4) reported persuasiveness of messaging strategies related to smoke-free policies in bars and restaurants.