Reaction Paper

This letter was accepted May 25, 2010. doi:10.2105/AJPH.2010.202119

Contributors E. J. Hahn originated the letter and took the lead on writing. N. L. York added citations and edited the letter. M. K. Rayens reviewed the design and analysis and edited the letter.

Acknowledgments The authors are supported by a research grant from the National Heart, Lung, and Blood Institute (grant R01HL086450).

Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.

References 1. Ferketich AK, Liber A, Pennell M, Nealy D, Hammer J, Berman M. Clean indoor air ordinance coverage in the Appalachian region of the United States. Am J Public Health. 2010;100(7):1313–8.

2. Ahijevych K, Kuun P, Christman S, Wood T, Browning K, Wewers ME. Beliefs about tobacco among Appalachian current and former users. Appl Nurs Res. 2003;16(2):93–102.

3. Denham SA, Meyer MG, Toborg MA. Tobacco cessation in adolescent females in Appalachian communities. Fam Community Health. 2004;27(2): 170–181.

4. Shannon LM, Havens JR, Mateyoke-Scrivner A, Walker R. Contextual differences in substance use for rural Appalachian treatment-seeking women. Am J Drug Alcohol Abuse. 2009;35(2):59–62.

5. York NL, Hahn EJ, Rayens MK, Talbert J. Local elected officials’ views on smoke-free policy in Kentucky. Kentucky J Communication. 2008;27(2):125–146.

6. Stillman F, Yang G, Figueiredo V, Hernandez- Avila M, Samet J. Building capacity for tobacco control research and policy. Tob Control. 2006;15: i18–i23.

7. York NL, Hahn EJ, Rayens MK, Talbert J. Community readiness for local smoke-free policy change. Am J Health Promot. 2008;23:112–120.

8. Americans for Nonsmokers’ Rights Foundation. Overview list–how many smokefree laws? 2010. Avail- able at http://www.no-smoke.org/pdf/mediaordlist.pdf. Accessed May 17, 2010.

9. O’Connor JC, MacNeil A, Chriqui JF, Tynan M, Bates H, Eidson SK. Preemption of local smoke-free air ordinances: the implications of judicial opinions for meeting national health objectives. J Law Med Ethics. 2008;36(2):403–12, 214.

10. Nykiforuk C, Campbell S, Cameron R, Brown S, Eyles J. Relationships between community characteris- tics and municipal smoke-free bylaw status and strength. Health Policy. 2007;80(2):358–368.

11. US Dept of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: Dept of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease and Prevention and Pro- motion, Office of Smoking and Health; 2006.

BERMAN ET AL. RESPOND

We certainly agree with Hahn et al. that the ultimate goal is for residents of the Appalachian region to be protected by comprehensive, anti- preemptive statewide smoke-free laws, but we evidently disagree about the best strategy to reach that goal.1

Although we do not intend to downplay the determined efforts and tremendous accom- plishments of local advocates in parts of Appalachia, our study found that years of local advocacy for smoke-free laws have produced only modest results. Moreover, the communities that have successfully passed comprehensive smoke-free laws have tended to be those with relatively high socioeconomic profiles, likely further exacerbating the health disparities that already exist within the region.

We believe that all residents of the Appala- chian region deserve protection from breathing toxic environmental tobacco smoke, and a community-by-community approach simply will not move the process along quickly enough. Hahn et al.’s own research has found that there is strong public support for smoke-free laws in the Appalachian region, and the recent passage of a strong smoke-free law in North Carolina—combined with encouraging progress toward a smoke-free law in Virginia— suggests that statewide success is possible even in historically tobacco-growing regions.

We urge a strategy that will enlist the support of local leaders as part of a larger effort to pass and implement comprehensive state- wide smoke-free laws. j

Micah Berman, JD Amy K. Ferketich, PhD

Alex Liber, BS Michael Pennell, PhD

Darren Nealy, JD Jana Hammer, JD

About the Authors Amy K. Ferketich, Alex Liber, and Michael Pennell are with the Ohio State University, Columbus. Micah Berman is with the New England School of Law, Boston, MA. Darren Nealy and Jana Hammer are with the School of Law, Capital University, Columbus.

Correspondence should be sent to Amy K. Ferketich, Division of Epidemiology, The Ohio State University College of Public Health, B-209 Starling-Loving Hall, 320 West 10th Avenue, Columbus, OH 43210 (e-mail: aferketich@ cph.osu.edu). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.

This letter was accepted June 7, 2010. doi:10.2105/AJPH.2010.202333

Contributors M. Berman drafted the letter. A. K. Ferketich worked with M. Berman on the content. A. Liber, D. Nealy, M. Pennell, and J. Hammer all read the letter, provided edits, and agreed with the content.

Reference 1. Rayens MK, Hahn EJ, Langley RE, Zhang M. Public support for smoke-free laws in rural communities. Am J Prev Med. 2008;34(6):519–522.

LOCAL SMOKE-FREE ORDINANCES ARE PASSING IN TOBACCO-GROWING STATES

Ferketich et al. studied demographic factors associated with the passage of clean indoor air ordinances in Appalachian communities.1

Based on reported lack of progress at the local level despite strong public support for clean indoor air laws, they recommended that efforts be focused on the state level instead. This conclusion goes beyond the data that they present and does not consider the power of the tobacco industry in state-level politics.2–6

Additionally, recent experience in South Caro- lina,7 a state Ferketich et al. included in their research, shows that strong progress on local clean indoor air ordinances is possible even in an Appalachian, tobacco-growing state.

South Carolina’s weak state clean indoor air ordinances passed in 1996 with an assumed preemption clause pushed by cigarette manu- facturer lobbyists and hospitality industry allies that halted clean indoor ordinance progress for a decade. However, between May 2006 and January 2008, local advocates, supported by national tobacco control technical assistance and funding, challenged this presumed pre- emption by passing clean indoor air ordinances in 12 localities, two of which were sued under claims that state preemption did not allow local clean air ordinances. In March 2008, the state Supreme Court ruled that local clean indoor air ordinances were not preempted; since then, advocates have passed 21 more local clean indoor air ordinances. The passage of these local clean indoor air ordinances as of May 2010 has been recognized as the highest number of strong local ordinances passed in any US state for two years in a row.8

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Cigarette manufacturing interests responded with an effort to pass explicit state preemption. During the 2007 and 2008 legislative session, 11 neutral to strong clean indoor air bills were introduced; three were co-opted to include weak clean indoor air provisions and preemp- tive language as a result of tobacco manufac- turer lobbying. Tobacco control advocates stopped all weak bills with preemption and convinced legislators to delay state laws, which could become vehicles for preemption.7

The trajectory of South Carolina clean in- door air ordinance progress provides a strong counterpoint to Ferketich et al.’s conclusion that there is a lack of motivation among tobacco control advocates at the local level in tobacco-growing states and that clean indoor air ordinance efforts should focus at the state level. Developing clean indoor air laws at the state level without strong local support pro- vides an opportunity for cigarette manufac- turers to preempt more comprehensive local activity, where tobacco manufacturers have less sway.3,9 In contrast, developing the capac- ity of local advocates can result in a strong smoke-free movement through local smoke- free ordinance adoption. j

Sarah Sullivan, BA Stanton A. Glantz, PhD

About the Authors The authors are with the Center for Tobacco Control Research and Education, University of California, San Francisco.

Correspondence should be sent to Stanton A. Glantz, PhD, Professor of Medicine, Center for Tobacco Control Research and Education, 530 Parnassus Suite 366, University of California, San Francisco, CA 94143-1390 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.

This letter was accepted June 23, 2010. doi:10.2105/AJPH.2010.204156

Contributors Both authors contributed to writing this letter.

Acknowledgments This work was supported by the National Cancer Institute (grant CA-61021).

References 1. Ferketich AK, Liber A, Pennell M, Nealy D, Hammer J, Berman M. Clean indoor air ordinance coverage in the Appalachian region of the United States. Am J Pub Health. 2010;100:1313–1318.

2. Givel MS, Glantz SA. Tobacco lobby political influence on US state legislatures in the 1990s. Tob Control. 2001;10:124–134.

3. Traynor MP, Begay ME, Glantz SA. New tobacco industry strategy to prevent local tobacco control. JAMA. 1993;270(4):479–486.

4. Siegel M, Carol J, Jordan J, et al. Preemption in tobacco control: review of an emerging public health problem. JAMA. 1997;278(10):858–863.

5. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Preemptive State Tobacco-Control Laws - United States, 1982-1998. MMWR Morb and Mortal Wkly Rep. 1999;47(51): 1112–1114.

6. Ibrahim JK, Glantz SA. The Rise and Fall of Tobacco Control Media Campaigns, 1967-2006. Am J Public Health. 2007;97:1383–1396.

7. Sullivan SE, Barnes RL, Glantz SA. Shifting attitudes towards tobacco control in tobacco country: Tobacco industry political influence and tobacco policy making in South Carolina. San Francisco, CA: Center for Tobacco Control Research and Education, University of California, San Francisco; 2009. Available at: http:// escholarship.org/uc/item/278790h5. Accessed July 29, 2010.

8. South Carolina Tobacco Collaborative. S.C. recog- nized for 2nd year of smoke free leadership. Available at: http://www.sctobacco.org/news.aspx?article=1046. Published June 6, 2010. Accessed July 29, 2010.

9. Samuels B, Glantz SA. The politics of local tobacco control. JAMA. 1991;266(15):2110–2117.

BERMAN AND FERKETICH RESPOND

Contrary to Sullivan and Glantz’s assertion, our article never stated that ‘‘there is a lack of motivation among tobacco control advocates at the local level in tobacco-growing states,’’ nor did we intend any such implication. We have deep admiration and profound respect for the efforts of local tobacco control advocates, particularly those working in the challenging political environment of Appalachia.

Recognizing the limitations of a community- by-community approach identified in our research, we urged local tobacco control ad- vocates to prioritize the adoption of compre- hensive statewide smoke-free laws while not abandoning efforts to promote local smoke- free ordinances. Sullivan and Glantz fear that tobacco manufacturers may seek to weaken proposed statewide laws and insert preemp- tive provisions that would limit local authority. We have no doubt that tobacco companies will attempt such tactics. But, as the experience in South Carolina shows, well-organized to- bacco control advocates are fully capable of defeating the tobacco industry at the state level.

Around the country, tobacco control advo- cates have been far more successful in pursuing the adoption of anti-preemptive state laws than the tobacco industry has been in seeking preemption. In just the last five years, explicit anti-preemptive language clarifying that local smoke-free ordinances can be broader than state law has been enacted (either as part of a smoke-free law or separately) in Arizona, Arkansas, Colorado, Georgia, Hawaii, Idaho, Illinois, Louisiana, Maryland, Minnesota, Nevada, New Jersey, New Mexico, North Dakota, and Ohio.1

Preemptive statewide laws are an appropri- ate area of concern, but as tobacco control advocates around the country have demon- strated, the best defense is a good offense. j

Micah Berman, JD Amy K. Ferketich, PhD

About the Authors Micah Berman is with New England Law, Boston, MA. Amy K. Ferketich is with the Ohio State University, Columbus.

Correspondence should be sent to Amy K. Ferketich, Division of Epidemiology, The Ohio State University College of Public Health, B-209 Starling-Loving Hall, 320 West 10th Avenue, Columbus, OH 43210 (e-mail: aferketich@cph. osu.edu). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.

This letter was accepted June 30, 2010. doi:10.2105/AJPH.2010.204628

Contributors M. Berman drafted the letter. A. K. Ferketich worked with M. Berman on the content.

Reference 1. Americans for Nonsmokers’ Rights. History of Pre- emption of Smokefree Air by State. April 1, 2010. Available at: http://www.protectlocalcontrol.org/docs/ HistoryofPreemption.pdf. Accessed July 29, 2010.

RELATIVE MEASURES ALONE TELL ONLY PART OF THE STORY

In their article on HIV/AIDS mortality, Rubin et al. approvingly cite Braveman’s definition of a health inequality as ‘‘a difference in which disadvantaged social groups . . . systematically experience worse health or greater health risks than more advantaged social groups.’’1(p1053)

Later in her work, Braveman discusses two common effect measures used when comparing two groups, the rate ratio and the rate difference, and observes that ‘‘both absolute and relative

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