摘要：Objectives. We examined the effects of key political institutional factors on the advancement of state-level clean indoor air laws. Methods. We performed an observational study of state-level clean indoor air law enactment among all 50 US states from 1993 to 2010 by using extended Cox hazard models to assess risk of enacting a relevant law. Results. During the 18-year period from 1993 to 2010, 28 states passed a law covering workplaces, 33 states passed a law covering restaurants, 29 states passed a law covering bars, and 16 states passed a law covering gaming facilities. States with term limits had a 2.15 times greater hazard (95% confidence interval [CI] = 1.27, 3.65; P = .005) of enacting clean indoor air laws. The presence of state-level preemption of local clean indoor air laws was associated with a 3.26 times greater hazard (95% CI = 1.11, 9.53; P = .031) of state-level policy enactment. In the presence of preemption, increased legislative professionalism was strongly associated (hazard ratio = 3.28; 95% CI = 1.10, 9.75; P = .033) with clean indoor air law enactment. Conclusions. Political institutional factors do influence state-level clean indoor air law enactment and may be relevant to other public health policy areas. The rules that govern the policy process in the United States influence policy outcomes. These rules, or political institutional factors, vary greatly among the US states. Examples of political institutional factors include (1) preemption, where a higher level of government restricts a lower level of government’s ability to act on a particular policy issue; (2) the ballot initiative process, in which citizen or private groups are able to place specific proposals on the ballot through the collection of signatures; and (3) legislative professionalism, as measured by state legislators’ salary, time in session, and support staff. Political science and public policy research supports the importance of these and other political institutional factors in influencing the enactment of specific policies. Political institutional factors represent the “rules of the policy game” and understanding these factors could inform public health advocacy efforts and contribute to the advancement of evidence-based policies and programs. Political institutional factors may be especially important when the policy in question is contentious or faces strong opposition from special interests, as is frequently the case with public health policies. Clean indoor air laws restricting smoking in indoor public places are one such example. Cigarette smoking is the leading cause of preventable death and disease in the United States. 1,2 Clean indoor air policies decrease exposure to secondhand smoke, decrease smoking prevalence, and do not have a negative impact on the hospitality industry. 3,4 Clean indoor air laws also generally receive strong public support, but are opposed by the tobacco industry. 4,5 Therefore, as of January 2013, only 22 US states had comprehensive statewide clean indoor air laws that cover workplaces, restaurants, and bars. 6 Fourteen states did not have a statewide law covering any of these businesses ( Table 1 ). 6 TABLE 1— Clean Indoor Air Policy Status Through 2010 by State: American Nonsmokers’ Rights Foundation’s US Tobacco Control Laws Database Year Policy Enacted State Workplaces Restaurants Bars Gaming Alabama . . . . . . . . . . . . Alaska . . . . . . . . . . . . Arizona 2006 2006 2006 2006 Arkansas . . . . . . . . . . . . California . . . 1994 1994 1994 Colorado . . . 2006 2006 2006 Connecticut . . . 2003 2003 . . . Delaware 2002 2002 2002 2002 Florida 2002 2002 . . . 2002 Georgia . . . . . . . . . . . . Hawaii 2006 2006 2006 . . . Idaho . . . 2004 . . . . . . Illinois 2007 2007 2007 2007 Indiana . . . . . . . . . . . . Iowa 2008 2008 2008 . . . Kansas 2010 2010 2010 . . . Kentucky . . . . . . . . . . . . Louisiana 2006 2006 . . . . . . Maine 2009 2003 2003 . . . Maryland 2007 2007 2007 2007 Massachusetts 2004 2004 2004 . . . Michigan 2009 2009 2009 2009 Minnesota 2007 2007 2007 2007 Mississippi . . . . . . . . . . . . Missouri . . . . . . . . . . . . Montana 2005 2005 2005 2005 Nebraska 2008 2008 2008 2008 Nevada 2006 2006 . . . . . . New Hampshire . . . 2007 2007 . . . New Jersey 2006 2006 2006 . . . New Mexico . . . 2007 2007 . . . New York 2003 2003 2003 2003 North Carolina . . . 2009 2009 . . . North Dakota . . . . . . . . . . . . Ohio 2006 2006 2006 . . . Oklahoma . . . . . . . . . . . . Oregon 2007 2007 2007 2007 Pennsylvania 2008 . . . . . . . . . Rhode Island 2004 2004 2004 . . . South Carolina . . . . . . . . . . . . South Dakota 2002 2010 2010 2010 Tennessee . . . . . . . . . . . . Texas . . . . . . . . . . . . Utah 2006 1994 2006 . . . Vermont 2009 2005 2005 . . . Virginia . . . . . . . . . . . . Washington 2005 2005 2005 2005 West Virginia . . . . . . . . . . . . Wisconsin 2009 2009 2009 . . . Wyoming . . . . . . . . . . . . Open in a separate window Using the example of clean indoor air laws, we examined selected political institutional factors identified by researchers and practitioners as being important determinants of the advancement of evidence-based public health policies. Using time-to-event analysis, we then examined the statistical associations between these factors and the enactment of state-level clean indoor air laws. The use of time-to-event analysis focuses our analysis on the enactment of clean indoor air policy as opposed to the maintenance of policy. Although both are important, the focus of health advocacy is the enactment of policy. To our knowledge, this is the first study to quantitatively estimate independent associations between the key political institutional factors we examined and state-level clean indoor air law outcomes within a public health context.
