Place and Policy: Secondhand Smoke Exposure in Bars and Restaurants.

Background: Rural populations have been identified as having tobacco use disparities, with contributing factors including less demand for policy change than in urban areas, resulting in higher age-adjusted death rates related to tobacco use. In 2012, the rural state of North Dakota enacted a statewide comprehensive law requiring all bars and restaurants to be smoke-free.

Objectives: The purpose of this longitudinal study, performed in three phases, was to assess the continued effects of a statewide comprehensive smoke-free law in a primarily rural state, using a stratified random sample.

Methods: Particulate matter and compliance indicators were assessed in restaurants and bars 21 months after enactment of the comprehensive law. Results were compared with the findings from the Phase 1 and Phase 2 samples, in which venues were assessed before passage of the law and approximately 3 months after enactment, respectively.

Results: The comprehensive, statewide, smoke-free law led to immediate, sustained, and substantial reductions in secondhand smoke and eliminated previous significant disparities in secondhand smoke exposure in rural communities. Although indoor smoke-free compliance with the law was generally high, compliance in required outdoor smoke-free areas was low. Compliance with signage requirements, both indoors and outdoors, was low.

Discussion: The comprehensive statewide smoke-free law created a just distribution of smoke-free laws statewide, resulting in increased protection of rural populations from secondhand smoke. Targeted public health interventions to address compliance may reduce secondhand smoke levels in outlier venues that continue to have high levels of secondhand smoke.