Health & Place 31 (2015) 146–153
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Health & Place journal homepage: www.elsevier.com/locate/healthplace
‘A place for healthy activity’: Parent and caregiver perspectives on smokefree playgrounds Alison H. McIntosh a, Damian Collins a,n, Marc Parsons b a b
Human Geography Program (EAS), University of Alberta, Edmonton, AB, Canada School of Public Health, University of Alberta, Edmonton, AB, Canada
art ic l e i nf o
a b s t r a c t
Article history: Received 24 June 2014 Received in revised form 19 November 2014 Accepted 30 November 2014
Restrictions on outdoor smoking are increasingly common, especially for spaces associated with children. In Canada, playground smoking bans are in effect in 102 municipalities. A survey of parents and caregivers at three playgrounds in neighbourhoods of varying income levels was undertaken in Edmonton, Alberta in July 2013. Respondents expressed very strong support for smokefree playgrounds, informed by knowledge of smoking as a health risk that was out of place. Levels of support did not vary significantly across the three sites. Social enforcement of smokefree rules was complicated by low levels of awareness, and fears of confrontation. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Playgrounds Secondhand smoke Smoking bans Survey Canada
1. Introduction The key policy response to the health risks of exposure to secondhand smoke (SHS) has been the implementation of smoking bans in public places. Smokefree rules have expanded in an incremental fashion, with complete bans on smoking in all indoor public places (including workplaces) taking several decades to achieve (Collins and Procter, 2011). With comprehensive indoor bans now in effect in many high income countries, increasing attention is being paid to restricting smoking outdoors. Bans have been implemented for a wide range of outdoor public places, including hospital grounds, university campuses, patios at hospitality venues, public transport facilities, recreation areas, and spaces around building entrances (Thomson et al., 2009; Kaufman et al., 2010). Outdoor environments commonly used by children have been a particular focus of attention, with smoking bans proliferating for school grounds, sports fields and playgrounds. Smoking near children is problematized by increasing knowledge of its health harms, both direct (i.e. SHS exposure) and indirect (i.e. the negative role modelling of adult smoking), and by powerful social norms that prioritize the protection of children (Holdsworth and Robinson, 2008). Uptake of outdoor smoking restrictions has been relatively rapid. In the United States, Bayer and Bachynski (2013) report that from 1993 to 2011, 843 jurisdictions banned smoking in public parks, and 150 banned smoking at beaches. Of the park smoking
n
Corresponding author. E-mail address: [email protected] (D. Collins).
http://dx.doi.org/10.1016/j.healthplace.2014.11.011 1353-8292/& 2014 Elsevier Ltd. All rights reserved.
bans, 41% expressly prohibited smoking in or near children’s play areas—a restriction also in force State-wide in California. In New Zealand, 23 of 73 local governments adopted smokefree outdoor area policies between 2005 and 2009 (Hyslop and Thomson, 2009), with a further 24 implementing such provisions by 2012 (Marsh et al., 2014). In all but one case, these policies specifically applied to playgrounds. Bayer and Bachynski (2013) highlight three main reasons for the adoption of outdoor smoking restrictions. First, they are intended to protect non-smokers from SHS, consistent with World Health Organization warnings that there is no safe level of exposure. Second, they aim to reduce cigarette butt pollution in public places, due in part to concerns about potential toxicity. Third, they seek to reduce the visibility of smoking, particularly so that children do not perceive it as a normal behaviour. The authors contend that because ‘the duty to protect children is an uncontested premise of public health’, bans on smoking in outdoor places associated with children have been adopted even when evidence for their effectiveness is relatively weak (Bayer and Bachynski, 2013, p. 1296). However, the evidential basis for claiming that outdoor exposure to SHS poses a risk to health is increasingly solid. The first peerreviewed study on this topic (Klepeis et al., 2007) established that SHS levels in outdoor areas can be substantial in close proximity to, and downwind of, lit cigarettes. Subsequent outdoor air quality monitoring studies have consistently found fine particulate concentrations near smokers to be significantly higher than background levels. This work has covered an array of outdoor public places, including patios (Cameron et al., 2010; Wilson et al., 2011), building entrances (Kaufman et al., 2011), sidewalks/footpaths (Parry et al.,
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2011; Patel et al., 2012), and city parks and squares used for festivals (Collins et al., 2014). In addition, short-term exposure to SHS – of the sort likely to occur in outdoor environments – is sufficient to cause a range of health harms (USDHHS (United States Department of Health and Human Services), 2006). Knowledge of the role model effect on smoking uptake and prevalence is also increasing. Exposure to parent and sibling smoking is a strong determinant of the risk of smoking uptake by children (Leonardi-Bee et al., 2011). In terms of the visibility of smoking, young people who see smoking at or near school are more likely to initiate smoking (Leatherdale and Manske, 2005). In addition, those who frequently witness smoking in public are likely to perceive that it is socially acceptable for both adults and youth (Alesci et al., 2003). Visual exposure to smoking may also undermine quit attempts and prompt smoking relapse (Nagelhout et al., 2011). Conversely, in places where smoking is not observed due to effective bans, it is perceived as difficult to perform (Klein et al., 2012). Questions around compliance are often raised in relation to outdoor smoking bans, as the places in which they apply are generally open and/or large-scale, rendering formal monitoring and enforcement difficult. Although most jurisdictions provide for penalties (e.g. fines) for non-compliance, the effectiveness of outdoor bans generally relies on voluntary compliance by smokers, and social enforcement by other members of the public (Bayer and Bachynski, 2013). This reliance is particularly marked in New Zealand, where smoking bans for parks, sports facilities and playgrounds are “educative” and lack legal effect (Hyslop and Thomson, 2009). The effectiveness of outdoor bans may be increased by onsite signage, as a visual reminder of both behavioural expectations and ‘a broader anti-smoking ethos’ (Bell, 2013, p. 118). Another major theme in recent examinations of outdoor smoking bans concerns public acceptance. A review of surveys from various high income, English-speaking countries found that support for such restrictions has increased over time, reaching majority levels in many instances (Thomson et al., 2009). In the US, popular support for banning smoking in all public places increased from 40% in 2008 to 59% in 2011 (Bayer and Bachynski, 2013). Support is higher still for playground smoking bans, leading Thomson et al. (2009) to identify a “child effect” in public opinion on this topic. This is consistent with the increasing social opprobrium associated with exposing children to smoking and SHS (Holdsworth and Robinson, 2008). 1.1. Smokefree playgrounds Although playground smoking bans have been widely adopted in several high income countries over recent years, there have been few inquiries into this policy development. There is a modest literature examining public opinion towards, and compliance with, such bans within individual jurisdictions. Several small-scale studies have examined educative smokefree policies in local government areas in New Zealand, reporting variable levels of awareness, but consistently high levels of support (75–94% post-implementation). They also included cigarette butt counts to estimate compliance, generally finding decreases once policies are in effect (e.g. Stevenson et al., 2008; Toi Te Ora, 2009a, 2009b). One report included details on reasons park users offered for supporting a ban, emphasizing positive role modelling, reduced SHS exposure, and the unacceptability of smoking in children’s environments (Stevenson et al., 2008). In Canada, only two studies specific to smokefree playgrounds appear to have been conducted. The first – in Collingwood, Ontario – involved an in-person survey of park users (Simcoe County District Health Unit, 2005). It found strong support for smokefree playgrounds (69% strongly in favour; 15% somewhat in favour), and most respondents (62%) claimed to be aware of the smokefree bylaw. The second – in Bridgewater, Nova Scotia – was based on a telephone survey of local residents (Thinkwell Research, 2010). Again, a
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majority of respondents (87%) said they were aware of the bylaw. Of current smokers surveyed, 86% stated they complied with the restriction, and 81% agreed that smokefree signage reminded them not to smoke in these environments. Beyond these relatively simple measures, little is known about how smokefree playground rules are perceived and understood by users/visitors. In addition, no study has considered whether playground users’ perspectives on smokefree provisions vary across neighbourhoods of different socio-economic status. Local area variation could be anticipated, given the steep social gradient in smoking prevalence in most high income countries (Pearce et al., 2012). Related to this gradient is the enduring normative status of smoking in deprived neighbourhoods (Thompson et al., 2007). In these contexts, smoking can remain widely accepted as ‘a sanctioned form of respite’ (Burgess et al., 2009, p. 154) and ‘a means of coping with living and caring in disadvantaged circumstances’ (Ritchie et al., 2010, p. 462). Such geographically-variable smoking norms may influence the local acceptability of smokefree provisions (Eadie et al., 2010), which typically have universal application within the jurisdictions adopting them (e.g. prohibiting smoking at all playgrounds within municipal boundaries). Knowledge of how new smokefree rules are perceived and understood in diverse neighbourhoods contributes to academic knowledge of smoking as a socio-spatial phenomenon, and is also relevant to policy-makers concerned with issues such as acceptability and enforcement. To address these gaps in knowledge, we undertook a survey of parents and caregivers accompanying children to three playgrounds in Edmonton, Alberta in summer 2013. The playgrounds were distributed across high, medium and low income neighbourhoods. The research had two primary objectives. The first objective was to document parents’ and caregivers’ perceptions of, and attitudes towards, the ban on smoking in playgrounds. The second objective was to analyze whether responses varied across the three playground sites—and specifically whether supportive attitudes towards smokefree playgrounds were positively associated with neighbourhood income levels. The effects of two additional independent variables – gender and smoking status – on respondents’ attitudes were also measured. 1.2. Context In Canada, the Non-Smokers’ Rights Association (NSRA) maintains a comprehensive database of smokefree laws enacted by all levels of government (NSRA, 2014). Analysis of that database reveals that as of May 2014, 102 Canadian municipalities have enacted bylaws with provisions that specifically prohibit smoking at playgrounds. In combination, these municipalities have 12.8 million residents, representing 38.2% of the Canadian population (Statistics Canada, 2014). They are concentrated in Ontario (61) and British Columbia (25), followed by Nova Scotia (7) and Alberta (6). Among the municipalities with smokefree playgrounds are four major metropolitan centres: Toronto, Ottawa, Calgary and Edmonton. Smokefree buffer zones around the edges of playground facilities are specified in 60 bylaws. The size of these zones varies from 3 m to 30 m, with restrictions of 9 m and 10 m the most common. Another way that playgrounds can be made smokefree in Canada is through regulations prohibiting smoking in the larger spaces within which they are situated—for example, public parks. Further analysis of the NSRA database reveals eight municipalities with bylaws that prohibit smoking in parks, but do not specifically mention playgrounds. A second common location for playgrounds is elementary schools, and it is noteworthy that seven of 10 Provinces (and all three Territories) prohibit smoking on school grounds (NSRA, 2014). In Alberta, where this research was conducted, six municipalities adopted playground smoking bans between 2010 and 2013.
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This includes Edmonton, which amended its Public Places Bylaw to prohibit smoking at playgrounds (along with skating rinks, skate parks, sports fields and spray parks) in April 2012. A $250 fine applies to smoking within 10 m of these facilities. However, the City downplays the prospect of ticketing, cautioning that ‘the ability to enforce individual infractions is limited,’ and instead encourages members of the public to ‘discuss [their] concerns with the smoker’ (City of Edmonton, 2013a).
2. Methods This research involved a survey of parents and caregivers accompanying children at playgrounds in Edmonton. We sought the opinions of these adults because they had direct knowledge of the playground environment, and responsibility for the welfare of children within it. In selecting survey sites, we identified three areas in the city’s inner western suburbs of varying socio-economic status. These were classified by the City of Edmonton (2010) as being ‘high’, ‘medium’ and ‘low’ income neighbourhoods, based on 2006 median household income data. Their respective income levels were $84,700, $48,000 and $35,900—compared to $57,100 for the city as a whole. Next, we chose one large public (municipal) playground located near the centre of each neighbourhood at which to conduct the surveys. The playgrounds were similar in size and amenities (all included a water spray park), and were rated as being in generally good condition (City of Edmonton, 2013b). All had several City-issued no smoking stickers; however, the small size (12.7 cm 12.7 cm) and obscure placement of these signs limited their visibility (see Fig. 1). The survey was approved by the Research Ethics Board at the University of Alberta, and was conducted in July 2013. Sampling times that included evenings and weekends were scheduled for each site. The sampling procedure involved the first author approaching each adult in/near the playground area, providing a brief overview of the study, and asking if he/she met the eligibility criteria for the study (aged 18 years or older; accompanying a child to the playground). Those who were eligible and expressed an interest in completing the 5–10 min survey were then asked to give verbal consent to participation. Once all adults present at a playground had been approached, the first author would wait 5 min, and if no additional parents/caregivers arrived, she would either proceed to the next site or conclude data collection for the day. The survey comprised of a mixture of close- and open-ended questions. The close-ended questions provided for both scaled
responses (scored on five-level Likert items) and binary (yes/no) answers. Resulting data were analyzed using ordinal logistic regression and logistic regression, respectively. Both uni- and multi-variate models were generated. The outputs of these analyses were odds ratios (with 95% confidence intervals) using the survey results as outcomes. Multi-variate models were adjusted for gender, neighbourhood income level, and smoking status (current smoker, past smoker, never smoker). For some analyses, past smokers and never smokers were combined into a single category (nonsmokers), and their responses compared with those of current smokers. The 95% confidence intervals for these comparisons were calculated using the exact binomial method. Analysis and graphing were conducted using R (R Core Team, 2014). Open-ended questions allowed respondents to make comments, which were recorded as fully as possible in written notes, and subsequently coded by two authors according to the dominant idea (s) expressed. Frequency counts were then calculated to identify the most common responses. In addition, representative quotations were selected for the purposes of illustration and discussion.
3. Results The survey was conducted over 12 days, during which the first author spent 55 h across the three sites. Over this time, 193 people were approached to complete the survey. All indicated that they were eligible to participate, and 181 agreed to do so—a response rate of 93.8%. One person was unable to finish the survey, leaving 180 completed responses. These were distributed across the three neighbourhoods as follows: high income (67 responses, 37.2%); middle income (52 responses, 28.9%); low income (61 responses, 33.9%). In terms of the respondents, 140 (77.8%) were female, and 40 (22.2%) were male. Overall, 101 (56.1%) were never smokers, 53 were past smokers (29.4%) and 26 (14.4%) were current smokers. 3.1. Awareness To gauge respondents’ level of awareness of the playground smoking ban in Edmonton, they were asked: ‘Do you know what the rules are about smoking at playgrounds in Edmonton?’ For those who replied in the affirmative, a follow-up question asked: ‘Can you tell me what those rules are?’ These questions revealed a low level of awareness (see Table 1). First, almost two-thirds of respondents (118, 65.6%) answered ‘no’ to the initial question. Second, of the 62 respondents who answered ‘yes’, most could not describe the rules fully, generally because they were unaware of the 10 m buffer. Only 15 respondents (8.3%) provided an accurate description of the rules. These findings may be partially explained by the inconspicuous signage illustrated above. Current smokers reported relatively high levels of awareness, with 16 of 26 (61.5%; 95% C.I. [40.6%, 80.0%]) stating that they knew of the smoking ban—compared to just 46 of 154 nonsmokers (29.9%; [22.8%, 37.8%]). Moreover, five smokers (19.2%) provided a correct description of the rules in effect. These results are consistent with smokers being the group whose behaviour is directly affected by the ban. 3.2. Attitudes
Fig. 1. No smoking sign (circled) at a case study playground.
Following the questions about awareness, respondents were given a brief description of the playground smoking ban in Edmonton, and asked to what extent they agreed with it. As indicated in Table 2, the overall level of support expressed was very high, with 171 respondents (95.0%) saying they agreed or strongly agreed. This figure included 23 of 26 current smokers (88.5%; [69.8%, 97.6%]) and 148 of 154 nonsmokers (96.1%; [91.7%, 98.5%]).
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Table 1 Awareness of Edmonton’s playground smoking ban. Frequency (% of 180 respondents) Knowledge of the rules ‘No’ ‘Yes’ Description of the rules (for ‘Yes’ answers only) Aware of ban, but unsure/incorrect about buffer zone Aware of ban, and identified correct buffer zone Thought smoking was permitted
118 (65.6%) 62 (34.4%) 45 (25.0%) 15 (8.3%)
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Table 3 Reasons for implementing smoking ban at playgrounds. Reason for ban
Frequency (% of 265 responses)
Negative role modelling Protecting children’s health from SHS General health risks of SHS Cigarette litter Smoking out of place in playgrounds Personal dislike of smoking Smoking is disrespectful Other
77 66 58 34 16 8 3 3
(29.1%) (24.9%) (21.9%) (12.8%) (6.0%) (3.0%) (1.1%) (1.1%)
2 (1.1%) Table 4 Perceived importance of smokefree playgrounds.
Table 2 Level of agreement with Edmonton’s playground smoking ban. Level of agreement
Frequency (% of 180 respondents)
Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree
0 3 6 62 109
(0.0%) (1.7%) (3.3%) (34.4%) (60.6%)
Respondents were also asked an open-ended question about what they considered to be the main reasons for the playground smoking ban. As illustrated in Table 3, 265 reasons were offered, with the most frequent responses centred on the health threats associated with smoking. Respondents’ comments provided additional insight into their support for banning smoking at playgrounds. For example, the emphasis on negative role modelling was informed by concerns about children being exposed to the ‘bad example’ and ‘negative influence’ of adult smoking. Remarks to the effect that ‘the less children see smoking, the better’ and ‘if kids see it a lot they’ll think it’s normal’ were common across all three sites. Implicit in many of the comments prompted by this question was the notion that smoking – as a bad example, a direct threat to health, and/or a source of litter – was out of place in the context of a public place intended for children’s enjoyment and recreation. In 16 cases, respondents made this point explicit. They highlighted that children are less able than adults to avoid SHS in playgrounds: ‘kids playing can’t leave the playground like an adult can’; ‘children don’t have the choice to smoke or not—adults can move away’. They also suggested that the fundamental purpose of the playground was incompatible with smoking: ‘playgrounds are a place for healthy activity’; ‘playgrounds should be a safe space for children’. Supportive attitudes towards the smoking ban were also evident when respondents were asked how important smokefree playgrounds were to them personally. As indicated in Table 4, 162 respondents (90.0%) thought they were important or very important. This number included 141 nonsmokers (91.6%; [86.0%, 95.4%]) and 21 current smokers (80.8%; [60.6%, 93.4%]).
3.3. Compliance and enforcement In Edmonton, as in other jurisdictions, there is limited formal enforcement of smokefree playground provisions, and a reliance on smokers complying with the rules voluntarily, or due to social pressure. To explore these issues, respondents were first asked who they thought should be ‘most responsible’ for ensuring the city’s playgrounds were smokefree, from a list of six possible options. More than one option could be selected, and 216 responses were given (see Table 5).
Level of importance
Frequency (% of 180 respondents)
Unimportant Of little importance Moderately important Important Very important
3 2 13 28 134
(1.7%) (1.1%) (7.2%) (15.6%) (74.4%)
Table 5 Preferred responsibility for smokefree playground enforcement. Preferred enforcement agency/method
Frequency (% of 216 responses)
Smokers should follow rules without 82 (38.0%) pressure City bylaw enforcement officers 79 (36.6%) Other parents/adults should remind smokers 47 (21.8%) Police or other law enforcement 4 (1.9%) Other agency 2 (0.9%) No enforcement 2 (0.9%)
Respondents generally preferred voluntary compliance by smokers, followed by enforcement by City bylaw officers. However, many qualified their support for the second of these options. For example, they noted that formal enforcement was ‘ideal, but not realistic’ and that ‘there aren’t enough bylaw enforcement officers.’ The possibility of improving signage at playgrounds to encourage compliance was also mentioned. Only two respondents believed enforcement was not necessary; of these, one suggested there was ‘no need for enforcement because there's such a stigma already—that’s why it’s working’. To explore respondents’ perspectives on these themes in more detail, they were also asked how they would feel if they saw someone smoking at the playground. Consistent with the generally negative attitudes towards smoking in this context, most answered they would feel uncomfortable or very uncomfortable (76.7%) (see Table 6). Many of these respondents added that they would experience emotions besides discomfort, such as ‘shock’, ‘annoyance’, ‘anger’, and being ‘disturbed’ or ‘pissed off’. To test the strength/limits of social norms around smoking in playgrounds in Edmonton, respondents were next asked if they would approach the non-compliant smoker to ask them to move or stop, and why/why not. A majority (103 respondents, 57.2%) indicated that they would approach a smoker. In response to the open-ended question as to ‘why’, these respondents offered 150 reasons, which were grouped into eight broad categories (see Table 7). The most common explanation centred on the need to protect children—which encompassed both general references to smoking around children being ‘unacceptable’, and more specific concerns about the health dangers of SHS exposure. Here, many respondents emphasized that smoking was fundamentally inappropriate around children: e.g., ‘it’s
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Table 6 Feelings towards presence of smoker in playground.
Table 8 Reasons not to approach a smoker in playground (77 respondents).
Level of comfort
Frequency (% of 180 respondents)
Reason given
Frequency (% of 102 responses)
Very uncomfortable Uncomfortable Neutral Comfortable Very comfortable
61 77 37 2 3
Avoid confrontation Afraid of smokers Not my job/place to enforce rules Would rather move self and child Would only approach if close to children Smokers should know/follow the rules Not a priority Respect smoker’s choice Other
27 15 12 10 9 6 6 5 12
(33.9%) (42.8%) (20.6%) (1.1%) (1.7%)
Table 7 Reasons to approach a smoker in playground (103 respondents). Reason given
Frequency (% of 150 responses)
Protect children/smoking unacceptable around children Would only approach if close to children Uphold the bylaw Negative role modelling Smoking is disrespectful Smoking out of place in playgrounds Personal dislike of smoking Other
68 (45.3%) 31 18 10 8 7 6 2
(26.5%) (14.7%) (11.8%) (9.8%) (8.8%) (5.9%) (5.9%) (4.9%) (11.8%)
(20.7%) (12.0%) (6.7%) (5.3%) (4.7%) (4.0%) (1.3%)
not something children should have to endure’, ‘my kids deserve healthy lungs’. The second most-frequent response qualified the ‘yes’ response, with respondents explaining they would only approach a smoker if that person was smoking near children. Respondents also identified place-based reasons for intervening, pointing to both the existence of the ban (18 responses; e.g. ‘I believe in following the rules’) and the view that smoking was fundamentally out of place in playgrounds (7 responses; e.g. ‘Out of every place to smoke, why here?’). The 77 respondents (42.8%) who stated they would not approach a smoker to request compliance with the smokefree playgrounds rule were asked to explain ‘why not’. They offered 102 responses, which were organized into nine categories (see Table 8). Most commonly, they expressed a desire to avoid confrontation—either as a general preference (‘I don’t like confrontation’; ‘I’m uncomfortable approaching strangers’) or due to more specific concern about an adversarial response from the smoker (‘they might get angry’; ‘they might be rude in other ways besides smoking in playgrounds’). A second, related response expressed an overt fear of the smoker in this scenario, who was characterized as potentially ‘dangerous’, ‘aggressive’ and ‘unpredictable’—and even capable of violence (‘I don’t want a punch in the face’; ‘they might knife me’). Also noteworthy is that nine of the 77 respondents who said they would not approach a smoker clarified that they would do so if a smoker was near children; this answer was also offered by 31 respondents who had answered ‘yes’ to the initial question. In combination, these 40 responses suggest that willingness to undertake social enforcement of playground smoking bans may be dependent in part on the spatial proximity of a non-compliant smoker to children. What counts as “close” to children in these circumstances may bear no particular connection to formal buffer zones: indeed, three participants explained that their threshold for intervention would be when a smoker was ‘blowing smoke in kids’ faces’. 3.4. Influence of neighbourhood, gender and smoking status Previous studies have identified a steep social gradient in smoking prevalence, as well as the enduring normative status of smoking in some deprived areas (Pearce et al., 2012). It follows that support for smokefree playgrounds, and social disapproval of smoking near children, may correlate with neighbourhood socio-economic status.
Fig. 2. Associations between respondent characteristics and level of agreement for Edmonton’s playground smoking ban (with 95% C.I.).
This research explored this possibility by surveying parents/caregivers at playgrounds in three neighbourhoods of varying income levels. In the tables that follow, the high income neighbourhood is the reference against which responses from the middle and low income neighbourhoods are compared. Also illustrated are variations in responses by gender (with women as the reference group) and smoking status (with never smokers as the reference group). Fig. 2 illustrates that the level of agreement with Edmonton’s smokefree playgrounds was lower among respondents in low income neighbourhood (OR: 0.705 [0.348–1.427]) than among those in the high income neighbourhood, although this difference was not significant. Current smokers were significantly more likely than never smokers to express a lower level of agreement (OR: 0.336 [0.143–0.789]). In terms of the level of importance respondents placed on smokefree playgrounds, a broadly similar pattern of results was found. As shown in Fig. 3, the perceived importance of smokefree rules was lower among respondents in the medium income (OR: 0.439 [0.182–1.059]) and low income (OR: 0.520 [0.220–1.226]) neighbourhoods than among those in the high income neighbourhood, although again these differences were not significant. The only significant difference in perceived importance was for current smokers compared to never smokers (OR: 0.200 [0.082–0.486]). In terms of respondents’ feelings towards the presence of a smoker in the playground, those from medium income (OR: 2.007 [0.999–4.032]) and low income (OR: 1.831 [0.953–3.520]) neighbourhoods expressed a higher level of comfort than those in the high
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Fig. 3. Associations between respondent characteristics and level of importance of smokefree playgrounds (with 95% C.I.).
Fig. 4. Associations between respondent characteristics and level of comfort with smoker in playground (with 95% C.I.).
income neighbourhood (see Fig. 4). This was also the case for past smokers (OR: 2.526 [1.337–4.773]) and current smokers (OR: 3.199 [1.374–7.449]) compared to never smokers, at statistically significant levels. As shown in Fig. 5, there was little variation across the three study sites in terms of whether respondents’ would approach a non-compliant smoker (a binary variable). However, male respondents were significantly more likely to answer ‘yes’ to this question than female respondents (OR: 2.861 [1.314–6.692]).
4. Discussion Developing a stronger understanding of how smoking bans for outdoor public places are perceived and interpreted by those who use these environments is valuable for at least three reasons. First, in
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Fig. 5. Associations between respondent characteristics and willingness to approach smoker in playground (with 95% C.I.).
contexts where comprehensive bans on indoor smoking are in effect, outdoor bans are now a focus of regulatory activity. Outdoor environments have rapidly emerged as a new “frontier” in the ongoing expansion of smoking bans (see Collins and Procter, 2011). Second, evidence of the direct and indirect health risks of outdoor smoking is increasing. Knowledge of these risks problematizes outdoor smoking and makes policy intervention increasingly likely —especially for environments associated with children (Thomson et al., 2009). Third, many outdoor public places are open and expansive, which renders formal enforcement of smoking bans difficult. Consequently, the efficacy of such bans depends in large part on voluntary compliance and social enforcement. Our analysis of the NSRA database reveals that in Canada – as in the United States (Bayer and Bachynski, 2013) and New Zealand (Marsh et al., 2014) – playground smoking bans are becoming widespread. This study has contributed to documenting how parents and caregivers who visit playgrounds perceive and interpret these bans—a topic that has received little attention internationally, and none in Canada beyond a single report in the grey literature (Simcoe County District Health Unit, 2005). Critically, it found very strong support for the smokefree playgrounds bylaw among 180 survey respondents in Edmonton. This support approached unanimity, with 171 respondents (95.0%) agreeing or strongly agreeing with the ban, and 162 (90.0%) indicating it was important or very important to them personally. Current smokers expressed lower levels of support than nonsmokers—but most still favoured the smokefree playgrounds bylaw (88.5% agreed or strongly agreed with it; 80.8% deemed it important or very important). These numbers, which are high by international standards (see Hyslop and Thomson, 2009), contribute to establishing the acceptability of smoking bans at playgrounds in Canada. This is important given that many local governments have yet to consider this issue, and – as of May 2014 – only a minority of Canadians (38.2%) live in municipalities that specifically prohibit smoking in playgrounds. In addition to addressing policy concerns, this project has sought to connect two areas of tobacco control research that have previously existed largely in parallel. Specifically, analyses of smoking ban policy have seldom engaged with geographically-informed work highlighting the ways in which the social gradient in smoking prevalence is expressed at the neighbourhood level (see Pearce
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et al., 2012). As a consequence, little is known about whether perceptions of smoking bans vary according to the socio-economic status of neighbourhoods. This said, several qualitative studies have reported strongly-ingrained opposition to smoking bans in deprived neighbourhoods (see Stead et al., 2001)—and in one instance these were contrasted with supportive views in advantaged communities (Eadie et al., 2010). To explore such (potential) differences in more detail – and in the context of a recently-enacted playground smoking ban – we conducted a survey across three Edmonton neighbourhoods of different socio-economic status. Our key finding was that levels of support for smokefree playgrounds did not vary significantly by neighbourhood (see Figs. 2 and 3). That levels of support were not significantly lower in the low income neighbourhood is noteworthy, given that higher smoking prevalence and smoking-supportive attitudes could be expected in such a context. This finding may speak to the strength of the “child effect” in public attitudes towards restrictions on smoking (see Thomson et al., 2009). Specifically, objections grounded in the localized normality of smoking in poorer neighbourhoods (see Eadie et al., 2010) may be blunted by broader social norms that problematize exposing children to health harms. Consistent with this explanation, respondents had generally high levels of awareness of both the direct (SHS-related) and indirect (role modelling) health risks of smoking near children, identifying these as the main reasons for implementing bans at playgrounds (see Table 3). This calls to mind the observation that contemporary public health works not only by communicating knowledge of health risk, but also by ‘problematizing the spaces in which exposure to risk occurs’ (Collins and Kearns, 2007, p. 19). The alternative framing of smoking as a valid adult choice (see Rouch et al., 2010) was largely absent from the data. For example, it was mentioned by only 5 of 77 respondents as a reason not to approach a noncompliant smoker in a playground (see Table 8). These neighbourhoods are situated in an urban context where spatial restrictions on smoking are already far-reaching. Collectively, such restrictions mean that smoking and SHS exposure are no longer routinely embedded in many of the public places of everyday life in Edmonton. Moreover, precedents have been set for restricting smoking in outdoor areas, which likely encourages acceptance of playground bans (Bayer and Bachynski, 2013). The attitudes expressed by participants towards the ‘extension’ of smoking restrictions to the playground environment were consistent with a broader denormalization of smoking. A critical question surrounding the adoption of playground smoking bans is whether restrictions will be respected in the absence of routine, formal enforcement. In Edmonton, as elsewhere, there is an emphasis on voluntary compliance and social enforcement—both of which depend on public awareness. Awareness among our respondents was low, with only 62 (34.4%) stating they knew the rules, including 61.5% of current smokers and 29.9% of nonsmokers. Moreover, of these 62 respondents, only 15 could provide an accurate description of the restrictions. Put simply, parents and caregivers are not “empowered” to confront smokers at playgrounds if they are not aware of the restriction. Once informed of the no smoking provisions in effect at Edmonton playgrounds, respondents expressed generally negative attitudes towards non-compliance: more than three-quarters stated that they would feel uncomfortable or very uncomfortable if they saw someone smoking in the playground. Concerns about the effects of negative role modeling were common, resonating with observations in the tobacco control literature about the visibility of smoking in public places contributing to normalizing the behaviour (e.g. Leonardi-Bee et al., 2011). However, past and current smokers expressed higher levels of comfort than never smokers (see Fig. 4). In terms of ensuring that the restriction was respected, a majority of respondents (57.2%) indicated a willingness to approach a smoker
to request compliance. The substantial minority who would not intervene emphasized social boundaries: approaching another adult about their behaviour is a form of confrontation—which may carry with it the potential for angry and even violent responses. Similar fears about intervening in the health-related behaviours of strangers in public space have been noted elsewhere (Collins and Kearns, 2007). Men were more willing to intervene than women (see Fig. 5), which may indicate a higher level of comfort and/or confidence in entering adversarial scenarios. In interpreting these results, it is important to acknowledge several potential limitations. First, respondents may have been influenced by social desirability bias—for example, some may have expressed support for smokefree playgrounds because they recognize that smoking around children is denormalized (see Wilson et al., 2009). We sought to reduce this effect by emphasizing that participation was anonymous, and that the study was situated within a human geography program (reducing potential associations with medicine or public health). Second, although our response rate was very high, it is possible that smoking parents and caregivers were under-represented, if they are deterred from visiting playground areas declared smokefree (see Hyslop and Thomson, 2009). The proportion of current smokers in our sample (14.4%) was lower than the smoking prevalence rate for Albertans aged 15 years and over (17.4%) (Health Canada, 2013). Third, some respondents may not have been residents of the neighbourhood where the playground at which they were surveyed was located. Future research could collect information on respondents’ place of residence, as well as household income levels, in order to tease out contextual and compositional influences on attitudes towards smoking bans. It could also extend beyond playgrounds to consider other outdoor environments associated with children, such as sports fields.
5. Conclusion Parents and caregivers in Edmonton were strongly supportive of smokefree rules for playgrounds. This support held across neighbourhoods of varying income levels, and was similar for men and women. However, awareness of the rules was very low. Clear, conspicuous signage – currently lacking in the Edmonton context – may help to address this (Bell, 2013). However, even with effective signs, relying on social enforcement is problematic, as it involves confrontation and risk. A more ethical approach may be to undertake formal enforcement of outdoor smoking bans on an occasional basis. The widespread adoption of playground smoking bans is part of a broader trend towards restricting outdoor smoking. This said, many respondents in this research emphasized that playgrounds were not simply “another” environment where smoking should not occur—rather, they were places where it was particularly inappropriate. They referred – with varying levels of directness – to the function of playgrounds as places intended for children. More specifically, smoking was widely perceived to be incompatible with children’s healthy activity. There was a sense in which smoking in playgrounds was doubly objectionable: first, as a threat to children’s health, and second, as a behaviour that was fundamentally out of place.
Acknowledgements This research was supported by a grant from the University of Alberta.
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Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
‘A place for healthy activity’: Parent and caregiver perspectives on smokefree playgrounds Alison H. McIntosh a, Damian Collins a,n, Marc Parsons b a b
Human Geography Program (EAS), University of Alberta, Edmonton, AB, Canada School of Public Health, University of Alberta, Edmonton, AB, Canada
art ic l e i nf o
a b s t r a c t
Article history: Received 24 June 2014 Received in revised form 19 November 2014 Accepted 30 November 2014
Restrictions on outdoor smoking are increasingly common, especially for spaces associated with children. In Canada, playground smoking bans are in effect in 102 municipalities. A survey of parents and caregivers at three playgrounds in neighbourhoods of varying income levels was undertaken in Edmonton, Alberta in July 2013. Respondents expressed very strong support for smokefree playgrounds, informed by knowledge of smoking as a health risk that was out of place. Levels of support did not vary significantly across the three sites. Social enforcement of smokefree rules was complicated by low levels of awareness, and fears of confrontation. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Playgrounds Secondhand smoke Smoking bans Survey Canada
1. Introduction The key policy response to the health risks of exposure to secondhand smoke (SHS) has been the implementation of smoking bans in public places. Smokefree rules have expanded in an incremental fashion, with complete bans on smoking in all indoor public places (including workplaces) taking several decades to achieve (Collins and Procter, 2011). With comprehensive indoor bans now in effect in many high income countries, increasing attention is being paid to restricting smoking outdoors. Bans have been implemented for a wide range of outdoor public places, including hospital grounds, university campuses, patios at hospitality venues, public transport facilities, recreation areas, and spaces around building entrances (Thomson et al., 2009; Kaufman et al., 2010). Outdoor environments commonly used by children have been a particular focus of attention, with smoking bans proliferating for school grounds, sports fields and playgrounds. Smoking near children is problematized by increasing knowledge of its health harms, both direct (i.e. SHS exposure) and indirect (i.e. the negative role modelling of adult smoking), and by powerful social norms that prioritize the protection of children (Holdsworth and Robinson, 2008). Uptake of outdoor smoking restrictions has been relatively rapid. In the United States, Bayer and Bachynski (2013) report that from 1993 to 2011, 843 jurisdictions banned smoking in public parks, and 150 banned smoking at beaches. Of the park smoking
n
Corresponding author. E-mail address: [email protected] (D. Collins).
http://dx.doi.org/10.1016/j.healthplace.2014.11.011 1353-8292/& 2014 Elsevier Ltd. All rights reserved.
bans, 41% expressly prohibited smoking in or near children’s play areas—a restriction also in force State-wide in California. In New Zealand, 23 of 73 local governments adopted smokefree outdoor area policies between 2005 and 2009 (Hyslop and Thomson, 2009), with a further 24 implementing such provisions by 2012 (Marsh et al., 2014). In all but one case, these policies specifically applied to playgrounds. Bayer and Bachynski (2013) highlight three main reasons for the adoption of outdoor smoking restrictions. First, they are intended to protect non-smokers from SHS, consistent with World Health Organization warnings that there is no safe level of exposure. Second, they aim to reduce cigarette butt pollution in public places, due in part to concerns about potential toxicity. Third, they seek to reduce the visibility of smoking, particularly so that children do not perceive it as a normal behaviour. The authors contend that because ‘the duty to protect children is an uncontested premise of public health’, bans on smoking in outdoor places associated with children have been adopted even when evidence for their effectiveness is relatively weak (Bayer and Bachynski, 2013, p. 1296). However, the evidential basis for claiming that outdoor exposure to SHS poses a risk to health is increasingly solid. The first peerreviewed study on this topic (Klepeis et al., 2007) established that SHS levels in outdoor areas can be substantial in close proximity to, and downwind of, lit cigarettes. Subsequent outdoor air quality monitoring studies have consistently found fine particulate concentrations near smokers to be significantly higher than background levels. This work has covered an array of outdoor public places, including patios (Cameron et al., 2010; Wilson et al., 2011), building entrances (Kaufman et al., 2011), sidewalks/footpaths (Parry et al.,
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2011; Patel et al., 2012), and city parks and squares used for festivals (Collins et al., 2014). In addition, short-term exposure to SHS – of the sort likely to occur in outdoor environments – is sufficient to cause a range of health harms (USDHHS (United States Department of Health and Human Services), 2006). Knowledge of the role model effect on smoking uptake and prevalence is also increasing. Exposure to parent and sibling smoking is a strong determinant of the risk of smoking uptake by children (Leonardi-Bee et al., 2011). In terms of the visibility of smoking, young people who see smoking at or near school are more likely to initiate smoking (Leatherdale and Manske, 2005). In addition, those who frequently witness smoking in public are likely to perceive that it is socially acceptable for both adults and youth (Alesci et al., 2003). Visual exposure to smoking may also undermine quit attempts and prompt smoking relapse (Nagelhout et al., 2011). Conversely, in places where smoking is not observed due to effective bans, it is perceived as difficult to perform (Klein et al., 2012). Questions around compliance are often raised in relation to outdoor smoking bans, as the places in which they apply are generally open and/or large-scale, rendering formal monitoring and enforcement difficult. Although most jurisdictions provide for penalties (e.g. fines) for non-compliance, the effectiveness of outdoor bans generally relies on voluntary compliance by smokers, and social enforcement by other members of the public (Bayer and Bachynski, 2013). This reliance is particularly marked in New Zealand, where smoking bans for parks, sports facilities and playgrounds are “educative” and lack legal effect (Hyslop and Thomson, 2009). The effectiveness of outdoor bans may be increased by onsite signage, as a visual reminder of both behavioural expectations and ‘a broader anti-smoking ethos’ (Bell, 2013, p. 118). Another major theme in recent examinations of outdoor smoking bans concerns public acceptance. A review of surveys from various high income, English-speaking countries found that support for such restrictions has increased over time, reaching majority levels in many instances (Thomson et al., 2009). In the US, popular support for banning smoking in all public places increased from 40% in 2008 to 59% in 2011 (Bayer and Bachynski, 2013). Support is higher still for playground smoking bans, leading Thomson et al. (2009) to identify a “child effect” in public opinion on this topic. This is consistent with the increasing social opprobrium associated with exposing children to smoking and SHS (Holdsworth and Robinson, 2008). 1.1. Smokefree playgrounds Although playground smoking bans have been widely adopted in several high income countries over recent years, there have been few inquiries into this policy development. There is a modest literature examining public opinion towards, and compliance with, such bans within individual jurisdictions. Several small-scale studies have examined educative smokefree policies in local government areas in New Zealand, reporting variable levels of awareness, but consistently high levels of support (75–94% post-implementation). They also included cigarette butt counts to estimate compliance, generally finding decreases once policies are in effect (e.g. Stevenson et al., 2008; Toi Te Ora, 2009a, 2009b). One report included details on reasons park users offered for supporting a ban, emphasizing positive role modelling, reduced SHS exposure, and the unacceptability of smoking in children’s environments (Stevenson et al., 2008). In Canada, only two studies specific to smokefree playgrounds appear to have been conducted. The first – in Collingwood, Ontario – involved an in-person survey of park users (Simcoe County District Health Unit, 2005). It found strong support for smokefree playgrounds (69% strongly in favour; 15% somewhat in favour), and most respondents (62%) claimed to be aware of the smokefree bylaw. The second – in Bridgewater, Nova Scotia – was based on a telephone survey of local residents (Thinkwell Research, 2010). Again, a
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majority of respondents (87%) said they were aware of the bylaw. Of current smokers surveyed, 86% stated they complied with the restriction, and 81% agreed that smokefree signage reminded them not to smoke in these environments. Beyond these relatively simple measures, little is known about how smokefree playground rules are perceived and understood by users/visitors. In addition, no study has considered whether playground users’ perspectives on smokefree provisions vary across neighbourhoods of different socio-economic status. Local area variation could be anticipated, given the steep social gradient in smoking prevalence in most high income countries (Pearce et al., 2012). Related to this gradient is the enduring normative status of smoking in deprived neighbourhoods (Thompson et al., 2007). In these contexts, smoking can remain widely accepted as ‘a sanctioned form of respite’ (Burgess et al., 2009, p. 154) and ‘a means of coping with living and caring in disadvantaged circumstances’ (Ritchie et al., 2010, p. 462). Such geographically-variable smoking norms may influence the local acceptability of smokefree provisions (Eadie et al., 2010), which typically have universal application within the jurisdictions adopting them (e.g. prohibiting smoking at all playgrounds within municipal boundaries). Knowledge of how new smokefree rules are perceived and understood in diverse neighbourhoods contributes to academic knowledge of smoking as a socio-spatial phenomenon, and is also relevant to policy-makers concerned with issues such as acceptability and enforcement. To address these gaps in knowledge, we undertook a survey of parents and caregivers accompanying children to three playgrounds in Edmonton, Alberta in summer 2013. The playgrounds were distributed across high, medium and low income neighbourhoods. The research had two primary objectives. The first objective was to document parents’ and caregivers’ perceptions of, and attitudes towards, the ban on smoking in playgrounds. The second objective was to analyze whether responses varied across the three playground sites—and specifically whether supportive attitudes towards smokefree playgrounds were positively associated with neighbourhood income levels. The effects of two additional independent variables – gender and smoking status – on respondents’ attitudes were also measured. 1.2. Context In Canada, the Non-Smokers’ Rights Association (NSRA) maintains a comprehensive database of smokefree laws enacted by all levels of government (NSRA, 2014). Analysis of that database reveals that as of May 2014, 102 Canadian municipalities have enacted bylaws with provisions that specifically prohibit smoking at playgrounds. In combination, these municipalities have 12.8 million residents, representing 38.2% of the Canadian population (Statistics Canada, 2014). They are concentrated in Ontario (61) and British Columbia (25), followed by Nova Scotia (7) and Alberta (6). Among the municipalities with smokefree playgrounds are four major metropolitan centres: Toronto, Ottawa, Calgary and Edmonton. Smokefree buffer zones around the edges of playground facilities are specified in 60 bylaws. The size of these zones varies from 3 m to 30 m, with restrictions of 9 m and 10 m the most common. Another way that playgrounds can be made smokefree in Canada is through regulations prohibiting smoking in the larger spaces within which they are situated—for example, public parks. Further analysis of the NSRA database reveals eight municipalities with bylaws that prohibit smoking in parks, but do not specifically mention playgrounds. A second common location for playgrounds is elementary schools, and it is noteworthy that seven of 10 Provinces (and all three Territories) prohibit smoking on school grounds (NSRA, 2014). In Alberta, where this research was conducted, six municipalities adopted playground smoking bans between 2010 and 2013.
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This includes Edmonton, which amended its Public Places Bylaw to prohibit smoking at playgrounds (along with skating rinks, skate parks, sports fields and spray parks) in April 2012. A $250 fine applies to smoking within 10 m of these facilities. However, the City downplays the prospect of ticketing, cautioning that ‘the ability to enforce individual infractions is limited,’ and instead encourages members of the public to ‘discuss [their] concerns with the smoker’ (City of Edmonton, 2013a).
2. Methods This research involved a survey of parents and caregivers accompanying children at playgrounds in Edmonton. We sought the opinions of these adults because they had direct knowledge of the playground environment, and responsibility for the welfare of children within it. In selecting survey sites, we identified three areas in the city’s inner western suburbs of varying socio-economic status. These were classified by the City of Edmonton (2010) as being ‘high’, ‘medium’ and ‘low’ income neighbourhoods, based on 2006 median household income data. Their respective income levels were $84,700, $48,000 and $35,900—compared to $57,100 for the city as a whole. Next, we chose one large public (municipal) playground located near the centre of each neighbourhood at which to conduct the surveys. The playgrounds were similar in size and amenities (all included a water spray park), and were rated as being in generally good condition (City of Edmonton, 2013b). All had several City-issued no smoking stickers; however, the small size (12.7 cm 12.7 cm) and obscure placement of these signs limited their visibility (see Fig. 1). The survey was approved by the Research Ethics Board at the University of Alberta, and was conducted in July 2013. Sampling times that included evenings and weekends were scheduled for each site. The sampling procedure involved the first author approaching each adult in/near the playground area, providing a brief overview of the study, and asking if he/she met the eligibility criteria for the study (aged 18 years or older; accompanying a child to the playground). Those who were eligible and expressed an interest in completing the 5–10 min survey were then asked to give verbal consent to participation. Once all adults present at a playground had been approached, the first author would wait 5 min, and if no additional parents/caregivers arrived, she would either proceed to the next site or conclude data collection for the day. The survey comprised of a mixture of close- and open-ended questions. The close-ended questions provided for both scaled
responses (scored on five-level Likert items) and binary (yes/no) answers. Resulting data were analyzed using ordinal logistic regression and logistic regression, respectively. Both uni- and multi-variate models were generated. The outputs of these analyses were odds ratios (with 95% confidence intervals) using the survey results as outcomes. Multi-variate models were adjusted for gender, neighbourhood income level, and smoking status (current smoker, past smoker, never smoker). For some analyses, past smokers and never smokers were combined into a single category (nonsmokers), and their responses compared with those of current smokers. The 95% confidence intervals for these comparisons were calculated using the exact binomial method. Analysis and graphing were conducted using R (R Core Team, 2014). Open-ended questions allowed respondents to make comments, which were recorded as fully as possible in written notes, and subsequently coded by two authors according to the dominant idea (s) expressed. Frequency counts were then calculated to identify the most common responses. In addition, representative quotations were selected for the purposes of illustration and discussion.
3. Results The survey was conducted over 12 days, during which the first author spent 55 h across the three sites. Over this time, 193 people were approached to complete the survey. All indicated that they were eligible to participate, and 181 agreed to do so—a response rate of 93.8%. One person was unable to finish the survey, leaving 180 completed responses. These were distributed across the three neighbourhoods as follows: high income (67 responses, 37.2%); middle income (52 responses, 28.9%); low income (61 responses, 33.9%). In terms of the respondents, 140 (77.8%) were female, and 40 (22.2%) were male. Overall, 101 (56.1%) were never smokers, 53 were past smokers (29.4%) and 26 (14.4%) were current smokers. 3.1. Awareness To gauge respondents’ level of awareness of the playground smoking ban in Edmonton, they were asked: ‘Do you know what the rules are about smoking at playgrounds in Edmonton?’ For those who replied in the affirmative, a follow-up question asked: ‘Can you tell me what those rules are?’ These questions revealed a low level of awareness (see Table 1). First, almost two-thirds of respondents (118, 65.6%) answered ‘no’ to the initial question. Second, of the 62 respondents who answered ‘yes’, most could not describe the rules fully, generally because they were unaware of the 10 m buffer. Only 15 respondents (8.3%) provided an accurate description of the rules. These findings may be partially explained by the inconspicuous signage illustrated above. Current smokers reported relatively high levels of awareness, with 16 of 26 (61.5%; 95% C.I. [40.6%, 80.0%]) stating that they knew of the smoking ban—compared to just 46 of 154 nonsmokers (29.9%; [22.8%, 37.8%]). Moreover, five smokers (19.2%) provided a correct description of the rules in effect. These results are consistent with smokers being the group whose behaviour is directly affected by the ban. 3.2. Attitudes
Fig. 1. No smoking sign (circled) at a case study playground.
Following the questions about awareness, respondents were given a brief description of the playground smoking ban in Edmonton, and asked to what extent they agreed with it. As indicated in Table 2, the overall level of support expressed was very high, with 171 respondents (95.0%) saying they agreed or strongly agreed. This figure included 23 of 26 current smokers (88.5%; [69.8%, 97.6%]) and 148 of 154 nonsmokers (96.1%; [91.7%, 98.5%]).
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Table 1 Awareness of Edmonton’s playground smoking ban. Frequency (% of 180 respondents) Knowledge of the rules ‘No’ ‘Yes’ Description of the rules (for ‘Yes’ answers only) Aware of ban, but unsure/incorrect about buffer zone Aware of ban, and identified correct buffer zone Thought smoking was permitted
118 (65.6%) 62 (34.4%) 45 (25.0%) 15 (8.3%)
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Table 3 Reasons for implementing smoking ban at playgrounds. Reason for ban
Frequency (% of 265 responses)
Negative role modelling Protecting children’s health from SHS General health risks of SHS Cigarette litter Smoking out of place in playgrounds Personal dislike of smoking Smoking is disrespectful Other
77 66 58 34 16 8 3 3
(29.1%) (24.9%) (21.9%) (12.8%) (6.0%) (3.0%) (1.1%) (1.1%)
2 (1.1%) Table 4 Perceived importance of smokefree playgrounds.
Table 2 Level of agreement with Edmonton’s playground smoking ban. Level of agreement
Frequency (% of 180 respondents)
Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree
0 3 6 62 109
(0.0%) (1.7%) (3.3%) (34.4%) (60.6%)
Respondents were also asked an open-ended question about what they considered to be the main reasons for the playground smoking ban. As illustrated in Table 3, 265 reasons were offered, with the most frequent responses centred on the health threats associated with smoking. Respondents’ comments provided additional insight into their support for banning smoking at playgrounds. For example, the emphasis on negative role modelling was informed by concerns about children being exposed to the ‘bad example’ and ‘negative influence’ of adult smoking. Remarks to the effect that ‘the less children see smoking, the better’ and ‘if kids see it a lot they’ll think it’s normal’ were common across all three sites. Implicit in many of the comments prompted by this question was the notion that smoking – as a bad example, a direct threat to health, and/or a source of litter – was out of place in the context of a public place intended for children’s enjoyment and recreation. In 16 cases, respondents made this point explicit. They highlighted that children are less able than adults to avoid SHS in playgrounds: ‘kids playing can’t leave the playground like an adult can’; ‘children don’t have the choice to smoke or not—adults can move away’. They also suggested that the fundamental purpose of the playground was incompatible with smoking: ‘playgrounds are a place for healthy activity’; ‘playgrounds should be a safe space for children’. Supportive attitudes towards the smoking ban were also evident when respondents were asked how important smokefree playgrounds were to them personally. As indicated in Table 4, 162 respondents (90.0%) thought they were important or very important. This number included 141 nonsmokers (91.6%; [86.0%, 95.4%]) and 21 current smokers (80.8%; [60.6%, 93.4%]).
3.3. Compliance and enforcement In Edmonton, as in other jurisdictions, there is limited formal enforcement of smokefree playground provisions, and a reliance on smokers complying with the rules voluntarily, or due to social pressure. To explore these issues, respondents were first asked who they thought should be ‘most responsible’ for ensuring the city’s playgrounds were smokefree, from a list of six possible options. More than one option could be selected, and 216 responses were given (see Table 5).
Level of importance
Frequency (% of 180 respondents)
Unimportant Of little importance Moderately important Important Very important
3 2 13 28 134
(1.7%) (1.1%) (7.2%) (15.6%) (74.4%)
Table 5 Preferred responsibility for smokefree playground enforcement. Preferred enforcement agency/method
Frequency (% of 216 responses)
Smokers should follow rules without 82 (38.0%) pressure City bylaw enforcement officers 79 (36.6%) Other parents/adults should remind smokers 47 (21.8%) Police or other law enforcement 4 (1.9%) Other agency 2 (0.9%) No enforcement 2 (0.9%)
Respondents generally preferred voluntary compliance by smokers, followed by enforcement by City bylaw officers. However, many qualified their support for the second of these options. For example, they noted that formal enforcement was ‘ideal, but not realistic’ and that ‘there aren’t enough bylaw enforcement officers.’ The possibility of improving signage at playgrounds to encourage compliance was also mentioned. Only two respondents believed enforcement was not necessary; of these, one suggested there was ‘no need for enforcement because there's such a stigma already—that’s why it’s working’. To explore respondents’ perspectives on these themes in more detail, they were also asked how they would feel if they saw someone smoking at the playground. Consistent with the generally negative attitudes towards smoking in this context, most answered they would feel uncomfortable or very uncomfortable (76.7%) (see Table 6). Many of these respondents added that they would experience emotions besides discomfort, such as ‘shock’, ‘annoyance’, ‘anger’, and being ‘disturbed’ or ‘pissed off’. To test the strength/limits of social norms around smoking in playgrounds in Edmonton, respondents were next asked if they would approach the non-compliant smoker to ask them to move or stop, and why/why not. A majority (103 respondents, 57.2%) indicated that they would approach a smoker. In response to the open-ended question as to ‘why’, these respondents offered 150 reasons, which were grouped into eight broad categories (see Table 7). The most common explanation centred on the need to protect children—which encompassed both general references to smoking around children being ‘unacceptable’, and more specific concerns about the health dangers of SHS exposure. Here, many respondents emphasized that smoking was fundamentally inappropriate around children: e.g., ‘it’s
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Table 6 Feelings towards presence of smoker in playground.
Table 8 Reasons not to approach a smoker in playground (77 respondents).
Level of comfort
Frequency (% of 180 respondents)
Reason given
Frequency (% of 102 responses)
Very uncomfortable Uncomfortable Neutral Comfortable Very comfortable
61 77 37 2 3
Avoid confrontation Afraid of smokers Not my job/place to enforce rules Would rather move self and child Would only approach if close to children Smokers should know/follow the rules Not a priority Respect smoker’s choice Other
27 15 12 10 9 6 6 5 12
(33.9%) (42.8%) (20.6%) (1.1%) (1.7%)
Table 7 Reasons to approach a smoker in playground (103 respondents). Reason given
Frequency (% of 150 responses)
Protect children/smoking unacceptable around children Would only approach if close to children Uphold the bylaw Negative role modelling Smoking is disrespectful Smoking out of place in playgrounds Personal dislike of smoking Other
68 (45.3%) 31 18 10 8 7 6 2
(26.5%) (14.7%) (11.8%) (9.8%) (8.8%) (5.9%) (5.9%) (4.9%) (11.8%)
(20.7%) (12.0%) (6.7%) (5.3%) (4.7%) (4.0%) (1.3%)
not something children should have to endure’, ‘my kids deserve healthy lungs’. The second most-frequent response qualified the ‘yes’ response, with respondents explaining they would only approach a smoker if that person was smoking near children. Respondents also identified place-based reasons for intervening, pointing to both the existence of the ban (18 responses; e.g. ‘I believe in following the rules’) and the view that smoking was fundamentally out of place in playgrounds (7 responses; e.g. ‘Out of every place to smoke, why here?’). The 77 respondents (42.8%) who stated they would not approach a smoker to request compliance with the smokefree playgrounds rule were asked to explain ‘why not’. They offered 102 responses, which were organized into nine categories (see Table 8). Most commonly, they expressed a desire to avoid confrontation—either as a general preference (‘I don’t like confrontation’; ‘I’m uncomfortable approaching strangers’) or due to more specific concern about an adversarial response from the smoker (‘they might get angry’; ‘they might be rude in other ways besides smoking in playgrounds’). A second, related response expressed an overt fear of the smoker in this scenario, who was characterized as potentially ‘dangerous’, ‘aggressive’ and ‘unpredictable’—and even capable of violence (‘I don’t want a punch in the face’; ‘they might knife me’). Also noteworthy is that nine of the 77 respondents who said they would not approach a smoker clarified that they would do so if a smoker was near children; this answer was also offered by 31 respondents who had answered ‘yes’ to the initial question. In combination, these 40 responses suggest that willingness to undertake social enforcement of playground smoking bans may be dependent in part on the spatial proximity of a non-compliant smoker to children. What counts as “close” to children in these circumstances may bear no particular connection to formal buffer zones: indeed, three participants explained that their threshold for intervention would be when a smoker was ‘blowing smoke in kids’ faces’. 3.4. Influence of neighbourhood, gender and smoking status Previous studies have identified a steep social gradient in smoking prevalence, as well as the enduring normative status of smoking in some deprived areas (Pearce et al., 2012). It follows that support for smokefree playgrounds, and social disapproval of smoking near children, may correlate with neighbourhood socio-economic status.
Fig. 2. Associations between respondent characteristics and level of agreement for Edmonton’s playground smoking ban (with 95% C.I.).
This research explored this possibility by surveying parents/caregivers at playgrounds in three neighbourhoods of varying income levels. In the tables that follow, the high income neighbourhood is the reference against which responses from the middle and low income neighbourhoods are compared. Also illustrated are variations in responses by gender (with women as the reference group) and smoking status (with never smokers as the reference group). Fig. 2 illustrates that the level of agreement with Edmonton’s smokefree playgrounds was lower among respondents in low income neighbourhood (OR: 0.705 [0.348–1.427]) than among those in the high income neighbourhood, although this difference was not significant. Current smokers were significantly more likely than never smokers to express a lower level of agreement (OR: 0.336 [0.143–0.789]). In terms of the level of importance respondents placed on smokefree playgrounds, a broadly similar pattern of results was found. As shown in Fig. 3, the perceived importance of smokefree rules was lower among respondents in the medium income (OR: 0.439 [0.182–1.059]) and low income (OR: 0.520 [0.220–1.226]) neighbourhoods than among those in the high income neighbourhood, although again these differences were not significant. The only significant difference in perceived importance was for current smokers compared to never smokers (OR: 0.200 [0.082–0.486]). In terms of respondents’ feelings towards the presence of a smoker in the playground, those from medium income (OR: 2.007 [0.999–4.032]) and low income (OR: 1.831 [0.953–3.520]) neighbourhoods expressed a higher level of comfort than those in the high
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Fig. 3. Associations between respondent characteristics and level of importance of smokefree playgrounds (with 95% C.I.).
Fig. 4. Associations between respondent characteristics and level of comfort with smoker in playground (with 95% C.I.).
income neighbourhood (see Fig. 4). This was also the case for past smokers (OR: 2.526 [1.337–4.773]) and current smokers (OR: 3.199 [1.374–7.449]) compared to never smokers, at statistically significant levels. As shown in Fig. 5, there was little variation across the three study sites in terms of whether respondents’ would approach a non-compliant smoker (a binary variable). However, male respondents were significantly more likely to answer ‘yes’ to this question than female respondents (OR: 2.861 [1.314–6.692]).
4. Discussion Developing a stronger understanding of how smoking bans for outdoor public places are perceived and interpreted by those who use these environments is valuable for at least three reasons. First, in
151
Fig. 5. Associations between respondent characteristics and willingness to approach smoker in playground (with 95% C.I.).
contexts where comprehensive bans on indoor smoking are in effect, outdoor bans are now a focus of regulatory activity. Outdoor environments have rapidly emerged as a new “frontier” in the ongoing expansion of smoking bans (see Collins and Procter, 2011). Second, evidence of the direct and indirect health risks of outdoor smoking is increasing. Knowledge of these risks problematizes outdoor smoking and makes policy intervention increasingly likely —especially for environments associated with children (Thomson et al., 2009). Third, many outdoor public places are open and expansive, which renders formal enforcement of smoking bans difficult. Consequently, the efficacy of such bans depends in large part on voluntary compliance and social enforcement. Our analysis of the NSRA database reveals that in Canada – as in the United States (Bayer and Bachynski, 2013) and New Zealand (Marsh et al., 2014) – playground smoking bans are becoming widespread. This study has contributed to documenting how parents and caregivers who visit playgrounds perceive and interpret these bans—a topic that has received little attention internationally, and none in Canada beyond a single report in the grey literature (Simcoe County District Health Unit, 2005). Critically, it found very strong support for the smokefree playgrounds bylaw among 180 survey respondents in Edmonton. This support approached unanimity, with 171 respondents (95.0%) agreeing or strongly agreeing with the ban, and 162 (90.0%) indicating it was important or very important to them personally. Current smokers expressed lower levels of support than nonsmokers—but most still favoured the smokefree playgrounds bylaw (88.5% agreed or strongly agreed with it; 80.8% deemed it important or very important). These numbers, which are high by international standards (see Hyslop and Thomson, 2009), contribute to establishing the acceptability of smoking bans at playgrounds in Canada. This is important given that many local governments have yet to consider this issue, and – as of May 2014 – only a minority of Canadians (38.2%) live in municipalities that specifically prohibit smoking in playgrounds. In addition to addressing policy concerns, this project has sought to connect two areas of tobacco control research that have previously existed largely in parallel. Specifically, analyses of smoking ban policy have seldom engaged with geographically-informed work highlighting the ways in which the social gradient in smoking prevalence is expressed at the neighbourhood level (see Pearce
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et al., 2012). As a consequence, little is known about whether perceptions of smoking bans vary according to the socio-economic status of neighbourhoods. This said, several qualitative studies have reported strongly-ingrained opposition to smoking bans in deprived neighbourhoods (see Stead et al., 2001)—and in one instance these were contrasted with supportive views in advantaged communities (Eadie et al., 2010). To explore such (potential) differences in more detail – and in the context of a recently-enacted playground smoking ban – we conducted a survey across three Edmonton neighbourhoods of different socio-economic status. Our key finding was that levels of support for smokefree playgrounds did not vary significantly by neighbourhood (see Figs. 2 and 3). That levels of support were not significantly lower in the low income neighbourhood is noteworthy, given that higher smoking prevalence and smoking-supportive attitudes could be expected in such a context. This finding may speak to the strength of the “child effect” in public attitudes towards restrictions on smoking (see Thomson et al., 2009). Specifically, objections grounded in the localized normality of smoking in poorer neighbourhoods (see Eadie et al., 2010) may be blunted by broader social norms that problematize exposing children to health harms. Consistent with this explanation, respondents had generally high levels of awareness of both the direct (SHS-related) and indirect (role modelling) health risks of smoking near children, identifying these as the main reasons for implementing bans at playgrounds (see Table 3). This calls to mind the observation that contemporary public health works not only by communicating knowledge of health risk, but also by ‘problematizing the spaces in which exposure to risk occurs’ (Collins and Kearns, 2007, p. 19). The alternative framing of smoking as a valid adult choice (see Rouch et al., 2010) was largely absent from the data. For example, it was mentioned by only 5 of 77 respondents as a reason not to approach a noncompliant smoker in a playground (see Table 8). These neighbourhoods are situated in an urban context where spatial restrictions on smoking are already far-reaching. Collectively, such restrictions mean that smoking and SHS exposure are no longer routinely embedded in many of the public places of everyday life in Edmonton. Moreover, precedents have been set for restricting smoking in outdoor areas, which likely encourages acceptance of playground bans (Bayer and Bachynski, 2013). The attitudes expressed by participants towards the ‘extension’ of smoking restrictions to the playground environment were consistent with a broader denormalization of smoking. A critical question surrounding the adoption of playground smoking bans is whether restrictions will be respected in the absence of routine, formal enforcement. In Edmonton, as elsewhere, there is an emphasis on voluntary compliance and social enforcement—both of which depend on public awareness. Awareness among our respondents was low, with only 62 (34.4%) stating they knew the rules, including 61.5% of current smokers and 29.9% of nonsmokers. Moreover, of these 62 respondents, only 15 could provide an accurate description of the restrictions. Put simply, parents and caregivers are not “empowered” to confront smokers at playgrounds if they are not aware of the restriction. Once informed of the no smoking provisions in effect at Edmonton playgrounds, respondents expressed generally negative attitudes towards non-compliance: more than three-quarters stated that they would feel uncomfortable or very uncomfortable if they saw someone smoking in the playground. Concerns about the effects of negative role modeling were common, resonating with observations in the tobacco control literature about the visibility of smoking in public places contributing to normalizing the behaviour (e.g. Leonardi-Bee et al., 2011). However, past and current smokers expressed higher levels of comfort than never smokers (see Fig. 4). In terms of ensuring that the restriction was respected, a majority of respondents (57.2%) indicated a willingness to approach a smoker
to request compliance. The substantial minority who would not intervene emphasized social boundaries: approaching another adult about their behaviour is a form of confrontation—which may carry with it the potential for angry and even violent responses. Similar fears about intervening in the health-related behaviours of strangers in public space have been noted elsewhere (Collins and Kearns, 2007). Men were more willing to intervene than women (see Fig. 5), which may indicate a higher level of comfort and/or confidence in entering adversarial scenarios. In interpreting these results, it is important to acknowledge several potential limitations. First, respondents may have been influenced by social desirability bias—for example, some may have expressed support for smokefree playgrounds because they recognize that smoking around children is denormalized (see Wilson et al., 2009). We sought to reduce this effect by emphasizing that participation was anonymous, and that the study was situated within a human geography program (reducing potential associations with medicine or public health). Second, although our response rate was very high, it is possible that smoking parents and caregivers were under-represented, if they are deterred from visiting playground areas declared smokefree (see Hyslop and Thomson, 2009). The proportion of current smokers in our sample (14.4%) was lower than the smoking prevalence rate for Albertans aged 15 years and over (17.4%) (Health Canada, 2013). Third, some respondents may not have been residents of the neighbourhood where the playground at which they were surveyed was located. Future research could collect information on respondents’ place of residence, as well as household income levels, in order to tease out contextual and compositional influences on attitudes towards smoking bans. It could also extend beyond playgrounds to consider other outdoor environments associated with children, such as sports fields.
5. Conclusion Parents and caregivers in Edmonton were strongly supportive of smokefree rules for playgrounds. This support held across neighbourhoods of varying income levels, and was similar for men and women. However, awareness of the rules was very low. Clear, conspicuous signage – currently lacking in the Edmonton context – may help to address this (Bell, 2013). However, even with effective signs, relying on social enforcement is problematic, as it involves confrontation and risk. A more ethical approach may be to undertake formal enforcement of outdoor smoking bans on an occasional basis. The widespread adoption of playground smoking bans is part of a broader trend towards restricting outdoor smoking. This said, many respondents in this research emphasized that playgrounds were not simply “another” environment where smoking should not occur—rather, they were places where it was particularly inappropriate. They referred – with varying levels of directness – to the function of playgrounds as places intended for children. More specifically, smoking was widely perceived to be incompatible with children’s healthy activity. There was a sense in which smoking in playgrounds was doubly objectionable: first, as a threat to children’s health, and second, as a behaviour that was fundamentally out of place.
Acknowledgements This research was supported by a grant from the University of Alberta.
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