In November 1988, California voters approved the California Tobacco Tax and Health Promotion Act (Proposition 99), making this the first state in the nation to implement a comprehensive tobacco control program. Since that time, the California Department of Health Services Tobacco Control Section (CDHS/TCS) has made large strides in tobacco control and remains the largest of its kind in the world. In an effort to provide an infrastructure that reaches into communities across the state, CDHS/TCS has established tobacco control programs in 61 local health departments known as local lead agencies (58 counties and three cities). The Los Angeles County Department of Health Services’ Tobacco Control and Prevention Program (TCPP) is the largest local lead agency in California in terms of size and funding. TCPP implements a countywide tobacco control program primarily through contracts with community organizations.

Since its inception in 1989, TCPP has gained much valuable experience in the field of tobacco control and continues to evolve in order to tackle the complexities and challenges of implementing a successful tobacco control program. Following the lead of the CDHS/TCS, TCPP has moved away from a health education approach focusing on individual-level behavior change to a policy-based approach targeting community-level social norms.

A comprehensive approach has greater impact on tobacco use, but requires greater amounts of collaboration, resources, partnerships, and commitment among traditional and non-traditional affiliates. TCPP is fully committed to fostering strong collaborations with and among it's contractors, with voluntary health associations, other local lead agencies, and organizations with an interest in tobacco control.

TCPP recently revised its organizational structure to provide a more comprehensive approach to technical assistance. Staff from each unit, including Contract Management, Financial and Administrative Support, Information Technology, Policy, Research and Evaluation, and Special Projects and Training, work as a team to provide contractors and other partners expert technical assistance and training. The team approach, which brings experts together to coordinate tobacco control strategies, priorities, and interventions, is expected to increase the adoption of successful tobacco control policies.

Tobacco Use

Tobacco use is the leading preventable cause of disease and disability in the United States, resulting in over 440,000 deaths each year. It is a major risk factor for cardiovascular disease, respiratory disease, and cancers of the lung, pharynx, mouth, esophagus, pancreas and bladder. In Los Angeles County, tobacco use is directly linked to the top five causes of death: 20% of coronary heart disease, 16% of stroke, 85% of respiratory (lung/tracheal/bronchial) cancer, 25% of pneumonia and 80% of emphysemadeaths. One out of every six deaths (9,000 deaths per year) in Los Angeles County stem from these tobacco-related diseases. Smoking during pregnancy is associated with miscarriage, SIDS, complications of pregnancy and delivery, premature birth, and low infant birth weight. It is estimated that tobacco-related illnesses cost the County $4.3 billion dollars per year, of which $2.3 billion is for direct medical costs.

Secondhand Smoke

Secondhand smoke (SHS) is the third leading preventable cause of death in the U.S. Comprehensive literature reviews of exposure to SHS indicate causal associations to fatal and nonfatal health endpoints in both children and adults. Adverse health effects of SHS include heart disease, lung and nasal sinus cancer, sudden infant death syndrome, childhood asthma, bronchitis and pneumonia, middle ear infection and low birth weight. Annually, SHS is estimated to kill 65,000 non-smoking Americans: 62,000 from heart disease and 3,000 from lung cancer. The 2002-2003 Los Angeles County Health Survey (LACHS) reveals that up to 344,000 children in the County are regularly exposed to SHS in their homes. The Environmental Protection Agency (EPA) estimates that secondhand smoke causes more than 300,000 cases of asthma, bronchitis, middle ear infections and pneumonia in children each year in the U.S.

SHS is a complex mixture of over 4,000 compounds uniquely generated from burning tobacco products. The World Health Organization and U.S. Department of Health and Human Services affirm that SHS causes cancer in humans, and that there is no safe level of exposure to SHS. Secondhand smoke has been classified by the EPA as a Group A carcinogen, placing it in the most dangerous category, reserved for radon, benzene, and asbestos. The constituents in sidestream smoke and exhaled mainstream smoke include reproductive toxicants, potent human carcinogens, and mutagenic compounds such as hydrogen cyanide, formaldehyde, and arsenic. SHS contains polynuclear aromatic hydrocarbons and volatile organic compounds, substances identified as toxic air contaminants by the Air Resources Board of the California EPA.

While estimates of healthcare costs and lost wages due to premature death related to SHS are not available for Los Angeles County, a recent study in Marion County, Indiana, estimated these costs as $62.68 per resident. The total cost to Marion County, a large Midwestern urban area of 860,000 residents, was $53.9 million. Given that Los Angeles County has a population more than ten times larger than that of Marion County, secondhand smoke poses a significant financial burden to Los Angeles County.

National experts point to the importance of decreasing SHS exposure as a leading strategy to reduce tobacco-related disease and death. In addition to the direct benefits, creating smoke-free environments also changes social norms around tobacco use. Such norm changes foster an environment that helps current smokers cut down or quit and encourages former smokers to remain smoke-free. In addition, having smoke-free environments decreases the risk that young people will smoke as they are not exposed to modeling of smoking behavior. Although SHS exposure has been greatly reduced in many of our American cities, exposure continues to occur in outdoor areas, workplaces, and in households and dwellings where smoking is allowed.

Creating smoke-free areas is legally defensible. The Technical Assistance Legal Center (TALC), a project of the Public Health Institute, has concluded that Equal Protection and Right to Privacy are not violated as a result of a smoke-free housing policy because smokers have not been designated as a protected class under anti-discrimination laws. Key legal findings are as follows:
∙ No court has ever recognized smoking as a fundamental right nor has any court ever found smokers to be a protected class. Claims to the contrary have no legal basis,
∙ The "right to privacy" protected by the U.S. Constitution only applies to marriage, contraception, family relationships, and the rearing and education of children, and
∙ There are groups of people - such as groups based on race, national origin and gender - that receive greater protection against discriminatory acts under the U.S. and California Constitutions than do other groups of people. Smokers have never been identified as one of these protected groups. This is because smoking is a behavior, not a condition of birth. Smoking is not an "immutable characteristic" because people are not born as smokers; smoking is a behavior that people can stop.

Youth Access

Cigarette smoking almost always begins in adolescence, with 80% of adult smokers having started before the age of 18. Youth smoking is associated with greater likelihood of adult smoking, heavier use of cigarettes, and more difficulty quitting. About one-third of the 4,000 youth under age 18 who start smoking each day will die prematurely due to smoking.

Although adult smoking rates in Los Angeles County have been steadily declining, youth smoking rates have stabilized in the recent past. According to the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Survey (YRBS), County-specific prevalence data show a decline from 26% in 1997 to 14% in 2001. However, the 2003 YRBS found that the prevalence of current smoking remained at 14%.

Regulating access to cigarettes has considerable potential for postponing or preventing smoking initiation among youth. Strategies that have been identified as successful in reducing minors’ access to tobacco products include restricting distribution, regulating the mechanisms of sale, increasing penalties, enforcing minimum age laws and having civil rather than criminal penalties. Laws that regulate the sale of tobacco products, such as vending machine and self-service display bans, reduce illegal sales to youth, theft, and impulse buying by adults. Laws that restrict distribution of tobacco products such as land use laws and conditional use permits limit the location and number of retailers who sell tobacco in communities.

In California, two state laws, PC 308a and Stop Tobacco Access to Kids (STAKE Act), make it illegal to sell tobacco products to minors. PC 308a has been a part of the California Penal Code for over 100 years. This law makes it a misdemeanor to sell, furnish or give tobacco products to anyone under 18 years of age and imposes limited fines on retailers who break the law. The STAKE Act requires that retailers check the identification of anyone who appears to be under 18 and that warning signs (including a toll-free number to report under-age sales) be posted at all points of sale. The STAKE Act is enforced by the California Department of Health Services. Despite these long standing state laws prohibiting tobacco sales to minors, youth continue to obtain cigarettes and other tobacco products at alarming rates. Each year, the nation’s youth 12 to 17 years of age consume an estimated 924 million packs of cigarettes, yielding the tobacco industry $480 million in profits from under-age smokers.

CDHS/TCS conducts an annual Youth Tobacco Purchase Survey to determine California retailers’ illegal sales rate to youth, as required by the Federal Synar Amendment and the STAKE ACT. The CDHS/TCS found that the 14% illegal sales rate to minors in 2004 has not changed significantly from the 2003 rate.

A recent compliance study of over 750 retailers in the City of Los Angeles documented that nearly 40% of businesses surveyed illegally sold tobacco to children. Of these retailers, almost half were within1,000 feet or walking distance of schools. The study showed that every type of retailer sold tobacco to minors, from large grocery chains to “mom and pop” markets, liquor stores and gas stations. Retailers with the highest illegal sales rate in 2003 were discount stores (75%), followed by doughnut/dairy shops (59.6%), mini-markets (46.7%), gas stations (38.7%), liquor stores (30.8%), pharmacy/drug stores (29.2%), supermarkets (27.8%) and gas/convenience stores (13.5%).

Smoking Cessation

Research has shown that smokers who had some form of smoking cessation assistance have nearly double the chance of successfully quitting smoking. A number of strategies have been shown to be effective particularly when used in combination. Physician advice is the briefest cessation method and has been found to result in a 5% long-term abstinence rate. Individual/group/telephone counseling cessation treatment methods usually incorporate some formal smoking cessation program or cognitive therapy. Counseling interventions are especially useful for providing participants with problem solving skills and social support and have been found to be very effective. Furthermore, counseling treatment effectiveness has been shown to increase with treatment intensity.

Pharmacotherapy treatment for smoking cessation includes nicotine replacement therapy (NRT) and antidepressant medication therapy. NRT is hypothesized to help smokers quit by reducing nicotine withdrawal symptoms and the pleasure associated with cigarette smoking through its action on nicotinic receptors in the brain. The most common delivery forms of NRT are gum, nasal spray, inhaler, lozenge/tablet, and patch. Studies of the effectiveness of NRT cessation methods have shown an almost doubling of quit rates achieved by non-pharmacological methods alone.

Antidepressant therapy is thought to help people quit smoking through its ability to reduce the severity of nicotine withdrawal symptoms by its action on select neurotransmitters. The antidepressant most commonly prescribed for smoking cessation is bupropion. Two other medications, clonidine and nortriptyline, are available for treatment if bupropion is not beneficial for a particular patient.

In order to reduce the substantial toll of tobacco-related illness and death, continued vigorous and comprehensive tobacco control efforts are needed. The Centers for Disease Control and Prevention (CDC) have developed a set of Best Practices for Comprehensive Tobacco Control Programs that identify the following four goals: (1) Preventing the initiation of tobacco use among young people, (2) Promoting quitting among young people and adults, (3) Eliminating nonsmokers’ exposure to secondhand smoke, and (4) Identifying and eliminating the disparities related to tobacco use and its effects among different population groups. The California Department of Health Services, California Tobacco Control Section (CDHS/TCS) has adopted these CDC Best Practices as the basis for their strategic priority areas: (1) Eliminate exposure to secondhand smoke, (2) Counter pro-tobacco influences, (3) Reduce availability of tobacco to youth, and (4) Cessation.

To address these priority areas, CDHS/TCS utilizes a social norm change approach that attempts to indirectly influence current and potential future tobacco users by creating a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible. The social norm change approach has been very effective in California for reducing tobacco use and exposure tosecondhand smoke. With this success has come an increase in the number of smokers who desire to quit smoking and need the assistance of cessation services.

Research has demonstrated that educating store owners and clerks about illegal tobacco sales does not reduce tobacco sales to children. Tobacco industry-sponsored merchant education programs, such as "We Card," and educational campaigns sponsored by local health departments have proven to be ineffective at reducing illegal sales.

Active enforcement of laws prohibiting the sale of tobacco to minors has been shown to be the most significant factor in reducing the percentage of retailers who illegally sell tobacco to children. However, because of the lack of enforcement of existing state law, retailers continue to illegally sell tobacco.

The lack of enforcement of existing laws is largely due to the fact that agencies such as local police and sheriff departments are not provided sufficient resources and funding for enforcement programs. California’s own enforcement program, STAKE, is also under-funded. The STAKE program conducts approximately 2,500 compliance checks annually, checking only about 3% of the estimated 80,000 tobacco retailers in the state.

More recently, tobacco control efforts to reduce youth access to tobacco have shifted from an educational to a retail licensing approach. Retail licensing policies require each merchant to obtain a license to sell tobacco products and provide for the suspension or revocation of the license if the merchant sells tobacco to minors or violates other local, state, or federal tobacco laws. Because tobacco sales comprise a substantial portion of revenue, losing the ability to sell tobacco products will cost most merchants far more than a fine. Hence, tobacco retail licensing policies create a strong financial deterrent to retailers violating the law.

Tobacco retail licensing has support from both smokers and nonsmokers. According to the LACHS, 78% of Los Angeles County adults agree that store owners should be licensed to sell cigarettes in the same way they are licensed to sell liquor or beer, and 74% of cigarette smokers support a tobacco retail license requirement.

In 2003 a statewide tobacco retail licensing law (Assembly Bill 71) was passed. AB 71 increases tax revenue by decreasing tobacco counterfeiting and smuggling, but does NOT contain provisions to reduce youth access to tobacco products. This law, however, is non-preemptive and specifically allows local governments to enact and enforce tobacco retail licensing laws that will reduce youth access to tobacco products. A strong local tobacco retail licensing policy has the following components:

∙ Requirements that all retailers who sell tobacco products obtain a license and renew it annually,
∙ A fee set high enough to sufficiently fund an effective program including administration of the program and enforcement efforts. An enforcement plan, that includes compliance checks, should be clearly stated,
∙ Coordination of tobacco regulations so that a violation of any existing local, state or federal tobacco regulation violates the license,
∙ Financial deterrents through fines and penalties including suspension and revocation of the
license, and
∙ Fines and penalties should be outlined in the policy.

Strong local tobacco retail licensing policies have been passed by the cities of San Luis Obispo, Pasadena, Sacramento, El Cajon, Elk Grove, Berkeley, San Francisco and the counties of Sacramento and Contra Costa. Many of these communities used the "Model California Ordinance Requiring a Tobacco Retailer License," developed by TALC, as their guide. These policies have fee and enforcement provisions that are effective in reducing youth access to tobacco products.

These policy successes combined with public support provide a solid foundation to develop tobacco retail licensing in our communities. Strong retail licensing policies with active enforcement are a key component of our efforts to prevent youth from experimenting with or considering initiation of tobacco use, thereby precluding habit formation, regular use, and premature death.

Although secondhand smoke (SHS) exposure has been greatly reduced in many of our cities, exposure continues to occur in households where smoking is allowed. Multi-unit dwellings present a particular challenge for dealing with the health and nuisance problem related to SHS. Tobacco smoke from one unit may drift through doors and windows, seep through cracks, or circulate through a shared ventilation system and enter the living space of other residents. Like other activities that cause annoyance, irritation, or health problems, smoking can be regulated or prohibited outright, even in private dwellings. Exposure to SHS affects young children while they are still developing, and can initiate disease or aggravate existing illnesses in adults.

According to the 2002-2003 Los Angeles County Health Survey (LACHS), 22% of County adults reported being exposed to someone else’s cigarette smoke in their home within the previous week. In these households, up to 344,000 children under age 18 have also been exposed to SHS. Further, individuals with disabilities, including respiratory problems, have special rights under state and federal fair housing laws. Both the California Fair Employment and Housing Act (FEHA) and the Federal Housing Act of 1988 require that “reasonable accommodations” be made in rules, policies, practices, or services to ensure equal access to and enjoyment of a dwelling unit. Creating nonsmoking sections or entire smoke-free buildings addresses the need for reasonable accommodation for individuals with respiratory and other disabilities.

Los Angeles County residents support smoke-free housing, according to the 2002-2003 LACHS. Over 60% of smokers and 85% of nonsmokers believe having designated smoke-free apartments and condominiums is important. Half of smokers and 78% of nonsmokers believe there should be greater protections from secondhand smoke in multi-unit dwellings, such as public housing or apartments.

A recent statewide survey of 602 apartment residents demonstrated broad support for smoke-free areas in apartment complexes. The survey, commissioned by the American Lung Association of California’s Center for Tobacco Policy and Organizing, found that almost half of the residents experienced tobacco smoke drifting into their units and 69% would favor requiring all apartment buildings to offer nonsmoking sections. Ninety percent of tenants believe exposure to SHS is harmful, with 70% saying it is very harmful. Of the tenants who believe exposure to be very harmful, 81% endorse separate nonsmoking sections in apartment buildings.

There are two general approaches to limiting exposure to SHS in multi-unit dwellings. The first approach is for individual apartment owners/management to voluntarily adopt smoke-free policies (e.g., common areas). The second approach is for state, county, and local governments or governmental agencies to adopt legislative policies that create smoke-free areas in housing. This second approach can apply to existing housing developments, new developments, market rate housing and affordable housing.

Property managers, owners, and owners’ associations have a legal right to voluntarily adopt reasonable safety policies for their property, including banning smoking indoors and outdoors. Often these smoke-free policies are gradually phased in with each new lease containing a clause that prohibits smoking both indoors and on all grounds. A growing number of voluntary policies have been implemented throughout Los Angeles County. These policies have designated common areas, swimming pools, laundry rooms, hallways, individual units and, in some cases, entire buildings as smoke-free. Such smoke-free policies have the added benefit of reducing the building damage associated with cigarette smoke and the risk forfire. The Smoke-free Apartment House Registry, a project of Smoke-free Air For Everyone (SAFE) and Community Partners, has a database of 272 apartment owners operating smoke-free market rate apartments in California. Eighty-one of these smoke-free apartment complexes are in the City of Los Angeles.

Historically, local, state, and federal government entities have created and adopted many policies and programs to protect the health and safety of the public. Several states including Utah, Minnesota and California support the legality of smoke-free housing policies. California’s Legislative Counsel reported in September 1999 that a “local ordinance that authorizes residential rental agreements to include a prohibition on or the allowance of smoking tobacco products within the rental unit would not be pre-empted by state law.” In addition, the California Department of Housing and Community Development also issued an opinion that smoke-free sections in affordable multi-unit housing are legal and that funding is feasible.

Recently, the City of Thousand Oaks, California, passed a resolution supporting smoke-free affordable housing in 30% of newly constructed units. The law firm of McDonough Holland & Allen PC provided counsel and concluded that “equal protection” and “right to privacy” laws are not violated as a result of smoke-free affordable housing policies because “[courts] have not recognized a fundamental constitutional right to smoke, even in the privacy of one’s own home. Where the Supreme Court has not designated a particular activity as a fundamental right, it will generally uphold government regulations that are rationally related to any conceivable legitimate end of government.”

The Smoke-free Affordable Housing Work Group surveyed a sample of lenders and brokers in Los Angeles to determine the feasibility of funding new affordable housing developments. Over 60% of the respondents believe developers can successfully receive funding to construct affordable housing complexes that have smoking and nonsmoking sections. In fact, 62% of the lenders and brokers currently fund or support the funding of non-profit corporations that build or would apply to build affordable housing with smoke-free sections. Lenders and other housing development representatives stated that smoke-free affordable housing is also an amenity that could be significant enough to generate an additional point in the funding scoring process. Various smoke-free policies have been adopted and operated by municipal housing authorities, housing developments for senior citizens, non-profit developers, colleges and universities for affordable student housing, and housing complexes subsidized by the US Department of Housing and Urban Development (HUD). There is no HUD policy that restricts landlords from adopting a prohibition of smoking in common areas or in individual units.

With significant public support and both government and private attorneys affirming that smoke-free housing is legally defensible, much work can be done to reduce exposure to secondhand smoke in multi-unit housing dwellings. Normative changes that have occurred over the last decade regarding smoking in the workplace have set a tone that is conducive for both local governments and private apartment owners to adopt smoke-free housing policies.