Los Angeles CountyLos Angeles County is the largest county in the United States with an estimated population of 10.4 million in 2008. The County covers over 4,000 square miles and has 88 incorporated cities within its boundaries. While covering only 3% of California's land mass, Los Angeles County is home to over 27% of its population.
Los Angeles is also one of the most diverse counties in the nation. It is estimated that 47.3% of the population is Latino, 30.1% White (not of Hispanic/Latino origin), 13.2% Asian/Pacific Islander, 9.1% African American, and 0.3% Native American. Ethnic diversity is largely attributed to continuing immigration from countries in Asia, the Pacific Islands, and Central and South America. According to the 2007 California Health Interview Survey, Los Angeles County is home to a large gay and lesbian community, with estimates approximating 234,000. The median age for Angelenos was 32 years in 2000, and has been rising steadily for the past several decades.
The Tobacco Control and Prevention ProgramIn November 1988, California voters approved the Tobacco Tax and Health Promotion Act (Proposition 99), making this the first state in the nation to implement a comprehensive tobacco control program. Since that time, the California Department of Public Health, California Tobacco Control Program (CDPH/CTCP) has made large strides in tobacco control and remains the largest of its kind in the world. In an effort to provide an infrastructure that reaches into communities across the state, CTCP has established tobacco control programs in 61 local health departments known as local lead agencies (58 counties and three cities). The Los Angeles County Department of Public Health's Tobacco Control and Prevention Program (TCPP) is the largest local lead agency in California in terms of size and funding. TCPP implements a countywide program to reduce youth access to tobacco product, reduce exposure to secondhand smoke and increase access to smoking cessation services.
Since its inception in 1989, TCPP has gained much valuable experience in the field of tobacco control and continues to evolve in order to tackle the complexities and challenges of implementing a successful tobacco control program. Following the lead of the state tobacco control program, TCPP transitioned from a health education approach focusing on individual-level behavior change to a policy-based approach targeting community-level social norms.
A comprehensive approach has greater impact on tobacco use, but requires greater amounts of collaboration, resources, partnerships, and commitment among traditional and non-traditional affiliates. TCPP is fully committed to fostering strong collaborations with and among its contractors, with voluntary health associations, other local lead agencies, and organizations with an interest in tobacco control.
Rationale for Policy-Based Tobacco ControlThe 2007 Centers for Disease Control & Prevention (CDC) Best Practices for Comprehensive Tobacco Control Programs, the 2006 U.S. Surgeon Generals Report: Reducing Tobacco Use, and the 2005 Guide to Community Preventive Services provide recommendations on how to reduce disease and death attributed to tobacco based on systematic reviews of efficacy of interventions and associated economic benefits. These documents recommend that communities develop and maintain comprehensive, multi-faceted prevention programs that include community-level interventions to: 1) promote development and enforcement of tobacco control policies that reduce exposure to SHS, 2) encourage the development and enforcement of policies that reduce the availability of tobacco products, 3) increase smoking cessation for current users, and 4) influence social norms where tobacco use is viewed as unacceptable. In recognition that a comprehensive approach to reducing tobacco use is more effective than focusing on individual behavior, CDPH/CTCP adopted the National Cancer Institute's Standards for Comprehensive Smoking Prevention and Control, which recommend policy, media, and program interventions using community coalitions as the impetus for change.
A primary avenue for achieving social norm change is through enactment of tobacco control policies, such as creating smoke-free environments. According to the Tobacco Education and Research Oversight Committee (TEROC) Master Plan, creating smoke-free environments helps to change social norms, which presents positive models for youth and encourages smokers to quit or reduce their tobacco use. Using a grassroots, bottom-up approach has proven to be successful in the initiation, adoption, and implementation of tobacco control policies. Local tobacco control initiatives are easier to implement and have greater enforcement and compliance rates than statewide efforts. Coalition members and other advocates have a stake in the outcome and take ownership to ensure the success of policy enforcement and compliance. Historically, grassroots tobacco control efforts have served as a springboard to the successful adoption of similar laws statewide (e.g., the California Smoke-Free Workplace Law).
Overview of the ProblemTobacco Use
Tobacco use is the leading preventable cause of disease and disability in the United States, resulting in over 440,000 deaths each year. It is a risk factor for four of the five leading causes of death: cardiovascular disease, stroke, lung cancer, and emphysema/COPD. In Los Angeles County, tobacco use is directly linked to the top five causes of death: 14.6% of coronary heart disease, 9.3% of stroke, 77% of respiratory (lung/tracheal/bronchial) cancer, 14.7% of pneumonia, and 85.2% of emphysema deaths. One out of every seven deaths (8,500 deaths per year) in Los Angeles County stem from these tobacco-related diseases. In addition, smoking during pregnancy is associated with miscarriage, Sudden Infant Death Syndrome (SIDS), complications of pregnancy and delivery, premature birth, and low infant birth weight. It is estimated that tobacco-related illnesses cost the county $4.3 billion dollars per year, of which $2.3 billion is for direct healthcare expenditures.
Exposure to secondhand smoke (SHS) is the third leading cause of preventable death in the U.S., killing 49,830 non-smokers each year, including 3,400 deaths from lung cancer, 46,000 deaths from coronary heart disease (CHD), and 430 deaths from SIDS. Comprehensive literature reviews of exposure to SHS indicate causal associations to fatal and nonfatal health endpoints in both children and adults. Adverse health effects of SHS include heart disease, lung and nasal sinus cancer, and respiratory illnesses. While adults generally have some control over exposure to SHS, children rarely do. The most serious type of exposure to children occurs in two ways: 1) exposure before birth via maternal smoking and 2) childhood exposure by parental smoking. Data from the 2007 Los Angeles County Health Survey estimate that approximately 336,000 children in the County are regularly exposed to SHS in their homes. The Environmental Protection Agency (EPA) estimates that secondhand smoke causes more than 300,000 cases of asthma, bronchitis, middle ear infections, and pneumonia in children each year in the U.S.
SHS consists of a complex mixture of over 4,000 compounds primarily composed of side stream smoke and exhaled mainstream smoke. The constituents in side stream smoke and exhaled mainstream smoke include reproductive toxicants, potent human carcinogens, and mutagenic compounds such as hydrogen cyanide, formaldehyde, and arsenic. More importantly, SHS has been classified by the EPA as a Group A carcinogen, placing it in the most dangerous category, reserved for radon, benzene, and asbestos. The U.S. Surgeon General has concluded that there is no risk-free level of exposure to secondhand smoke and in January 2006, the California Air Resources Board (ARB) identified SHS as a toxic air contaminant.
Recommendations from national experts, including the Surgeon General, point to the importance of reducing exposure to SHS as a leading strategy to reduce tobacco-related disease and death. Reducing exposure of SHS can be done by creating more indoor and outdoor smoke-free environments. Along with its direct effects, creating smoke-free environments has the added benefit of changing social norms around tobacco use. For instance, having smoke-free outdoor areas decreases the risk that young people will smoke, as they are not exposed to modeling of smoking behavior. In addition, current smokers can be prompted and supported in their attempts to quit, as smoke-free environments can enable those trying to quit smoking by limiting cues for relapse. Research has verified that smoke-free environments can increase both the number of people who attempt to quit smoking and the number of quit attempts made by an individual. Although SHS exposure has been greatly reduced in many of our American cities, exposure continues to occur in outdoor areas, workplaces, and in single-family dwellings, condominiums, and multi-unit housing.
Creating smoke-free areas is legally defensible. According to the Technical Assistance Legal Center (TALC):
- Under the United States constitution and the California constitution, there is no constitutional right to smoke. No court has ever recognized smoking as a fundamental right nor has any court ever found smokers to be a protected class. Claims to the contrary have no legal basis,
- The "right to privacy" protected by the U.S. Constitution only applies to marriage, contraception, family relationships, and the rearing and education of children, and
- There are groups of people that receive greater protection against discriminatory acts under the United States constitution and the California constitution than do other groups of people (e.g., groups based on race, national origin, and gender). Smokers have never been identified as one of these protected groups.
Cigarette smoking almost always begins in adolescence, with 80% of adult smokers having started before the age of 18. Youth smoking is associated with greater likelihood of adult smoking, heavier use of cigarettes, and more difficulty quitting. About one-third of the 4,000 youth under age 18 who start smoking each day will die prematurely due to smoking.
The California Department of Public Health, California Tobacco Control Program (CDPH/CTCP) estimates that 73,000 kids per year, or 200 children per day, become addicted to tobacco in California. Prevalence data from the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance (YRBS) conducted in Los Angeles Unified School District schools showed a 51.7% decrease in youth smoking prevalence from 26.5% in 1997 to 12.0% in 2008.
Regulating access to cigarettes has considerable potential for postponing or preventing smoking initiation among youth. Strategies that have been identified as successful in reducing minors access to tobacco products include restricting distribution, regulating the mechanisms of sale, increasing penalties, and enforcing minimum age laws. Laws that regulate the sale of tobacco products, such as vending machine and self-service display bans, reduce illegal sales to youth, theft, and impulse buying by adults. Laws that restrict distribution of tobacco products such as land use laws and conditional use permits limit the location and number of retailers who sell tobacco in communities.
In California, two state laws, Penal Code Section 308(a) and STAKE Act: Stop Tobacco Access to Kids (California Business and Professions Code Sections 22958, 22952, 22957; California Code of Regulations, Title 17, Section 6903) make it illegal to sell tobacco products to minors. Penal Code 308(a) has been a part of the California Penal Code for over 100 years. This law makes it a misdemeanor to sell, furnish or give tobacco products to anyone under 18 years of age and imposes limited fines on retailers who break the law. The STAKE Act requires that retailers check the identification of anyone who appears to be under 18 and that warning signs (including a toll-free number to report under-age sales) be posted at all points of sale.
As part of the STAKE Act, the CDPH monitors and assesses Californias illegal sales rate to minors and conducts ongoing compliance checks. The assessment of the illegal sales rate to minors is done via the annual Youth Tobacco Purchase Survey (YTPS), which involves youth decoy stings where youth between the ages of 15-16 go into stores to buy cigarettes. The STAKE Act protocol is a comprehensive consummated buy protocol where the youth purchases cigarettes from a tobacco vendor; after the sale is complete, a law enforcement agent notifies the retailer that a youth purchase sting had occurred and the retailer is penalized. Findings from the 2009 YTPS show that the rate of illegal tobacco sales to minors has decreased from 12.6% in 2008 to an all-time low of 8.5% in 2009. Despite the overall decrease in illegal sales statewide, the YTPS found that illegal sales to minors in certain retail outlets remained high. Non-traditional retail stores, such as discount stores or deli/meat markets, were found on average to sell tobacco to minors at 13%. Meanwhile, the highest rate of illegal sales to minors was at doughnut shops at 21.6% and tobacco shops at 21.1%. The lowest rate of illegal sales to minors was at drugstores/ pharmacies at 2.3%.
In LA County, community-based organizations working with the Tobacco Control and Prevention Program (TCPP) conducted Youth Purchase Surveys (YPSs) to assess the rate of retailers willing to sell cigarettes to minors. These surveys were conducted using a comprehensive attempted buy protocol developed by TCPP where youth between the ages of 15 to 17 go into stores and attempt to buy cigarettes. YPSs conducted during 2005 and 2009 in 25 cities and the unincorporated areas of LA County found high rates of retailers willing to sell cigarettes to minors. For example, in Palmdale the rate of retailers willing to sell to minors was 29%, in San Fernando the rate was 39%, in Burbank the rate was 27%, in San Gabriel the rate was 33%, in Inglewood the rate was 51%, in Compton the rate was 37%, in Beverly Hills the rate was 49%, and in the unincorporated areas of LA County the rate was 31%. Santa Clarita had the lowest rate of 9.2% and Sierra Madre had the highest rate of 60%. On average, these rates are more than three times as high as the states illegal sales rate of 8.5%.
YPSs have proven to be an invaluable source of data, assisting community leaders and policy/decision makers in raising awareness about the problem of youth access to tobacco and in generating innovative policy solutions to prevent youth smoking.
Tobacco Control Priority AreasTobacco Retail Licensing
Research has demonstrated that educating store owners and clerks about illegal tobacco sales does not reduce tobacco sales to children. Tobacco industry-sponsored merchant education programs, such as "We Card," and educational campaigns sponsored by local health departments have proven to be ineffective at reducing illegal sales.
Active enforcement of laws prohibiting the sale of tobacco to minors has been shown to be the most significant factor in reducing the percentage of retailers who illegally sell tobacco to children. However, because of the lack of enforcement of existing state laws, retailers continue to illegally sell tobacco to children. Insufficient enforcement is due, at least in part, to a lack of dedicated resources and funding. California's own enforcement program, STAKE, is under-funded. The STAKE program conducts approximately 2,170 compliance checks annually, checking only about 5.8% of the 37,171 registered tobacco retailers in the state.
More recently, tobacco control efforts to reduce youth access to tobacco have shifted from an educational to a retail licensing approach. Retail licensing policies require each merchant to obtain a license to sell tobacco products and provide for the suspension or revocation of the license if the merchant sells tobacco to minors or violates other local, state, or federal tobacco laws. Because tobacco sales comprise a substantial portion of revenue, losing the ability to sell tobacco products will cost most merchants far more than a fine. According to a 2008 report from the Center for Tobacco Policy and Organizing, tobacco is by far the number one product sold in convenience stores, accounting for nearly a third (32.9%) of sales and generating nearly $500,000 in revenue for the average convenience store. Hence, tobacco retail licensing policies create a strong financial deterrent to retailers violating the law.
Tobacco retail licensing has support from both smokers and nonsmokers. According to the 2007 Los Angeles County Health Survey, 79.6% of LA County adults agree that store owners should be licensed to sell cigarettes in the same way they are licensed to sell liquor or beer, and 66.8% of current cigarette smokers support a tobacco retail license requirement.
In 2003, a statewide tobacco retail licensing law (California Business and Professions Code Sections 22971.3, 22972-22973.1, 22980.2, 22981) was adopted. This law increases tax revenue by decreasing tobacco counterfeiting and smuggling, but does NOT contain provisions to reduce youth access to tobacco products. This law, however, is non-preemptive and specifically allows local governments to enact and enforce tobacco retail licensing laws that reduce youth access to tobacco products.
According to the Center for Tobacco Policy and Organizing, 63 California communities have adopted strong local tobacco retail licensing policies to reduce illegal sales of tobacco products to minors. In Los Angeles County, 23 of the 88 cities have adopted such policies (i.e., Los Angeles, El Segundo, Lawndale, Pasadena, Carson, Lancaster, Sierra Madre, Burbank, Compton, Glendale, Inglewood, Lomita, Baldwin Park, Cerritos, Gardena, Hawthorne, Long Beach, San Fernando, Santa Monica, Calabasas, Culver City, La Canada Flintridge, and South Pasadena). In December 2007, the Board of Supervisors adopted a tobacco retail licensing ordinance for the unincorporated areas of LA County.
Strong tobacco retail licensing ordinances, like those implemented in LA County, have proven to be effective in reducing youth access to tobacco products. For example, in Pasadena, illegal tobacco sales to minors dropped from 20% to 5% and then to 0% after the city adopted a retail licensing law. In Burbank, the rate fell from 26.7% down to 4% after a tobacco licensing program was implemented. According to the Technical Assistance Legal Center's Tobacco Retail License Model Ordinance (refer to Attachment Z: Resource Guide), a strong local tobacco retail licensing ordinance includes the following policy provisions:
- A requirement that all retailers who sell tobacco products obtain a license and renew it annually,
- An annual licensing fee that fully covers all program costs, including administration and enforcement,
- A clearly stated enforcement plan that includes compliance checks,
- Coordination of tobacco regulations so that a violation of any existing local, state or federal tobacco regulation is a violation of the license, and
- Clearly stated penalties, including suspension and revocation of the license.
Smoke-Free Outdoor Areas
In the fourteen years since the Smoke-Free Workplace Law (California Labor Code Section 6404.5) was adopted, residents have grown accustomed to and reaped the health benefits of smoke-free indoor environments. Smoking in restaurants, bars and other workplaces, once commonplace, is now, for the most part, a thing of the past.
Many cities and counties in California are working to protect their residents from secondhand smoke (SHS) exposure by passing policies that restrict smoking in outdoor areas, especially recreation areas and other places where people congregate. These outdoor areas include public parks, beaches, dining areas and around doorways and windows of public buildings. In spite of these successes in reducing exposure to SHS, outdoor exposure remains a serious, yet preventable, health threat. Outdoor SHS accounts for a significant amount of nonsmokers exposure to hazardous tobacco byproducts. Every day, Californians visit parks, beaches, golf courses, outdoor seating areas of restaurants, public events such as concerts, and service areas such as ATM lines and bus stops only to find themselves and their children exposed to toxic secondhand smoke and discarded cigarette butts.
The dangers of secondhand smoke are well documented, especially for children and adults with asthma or other chronic illnesses, pregnant women, and the elderly. Secondhand smoke has been designated as a known human carcinogen by the U.S. Environmental Protection Agency. The California Air Resources Board has put secondhand smoke in the same category as automotive and industrial air pollutants by categorizing it as a toxic air contaminant for which there is no safe level of exposure. A growing body of research has found that under some conditions, exposure to secondhand smoke in outdoor areas can be as harmful as exposure in enclosed areas. For example, a recent Stanford study concluded that short-term exposure to secondhand smoke on outdoor patios can exceed secondhand smoke exposure measured inside cars and houses.
In addition to the health risks associated with outdoor smoking, discarding cigarette butts is a serious litter issue. Cigarette litter damages the environment and poses a hazard to children, pets and wildlife that may pick up or swallow these cigarette butts. Besides the possible burns from cigarette butts, children are at risk for swallowing or choking on this litter. In 2006, the American Association of Poison Control Centers received over 7,000 reports of potentially toxic exposures due to ingestion of tobacco products among children. Additionally, fish, birds, and other animals often swallow discarded cigarette butts, resulting in malnutrition, starvation, and blocked air passages. Furthermore, cigarettes contain a non-biodegradable plastic that takes nearly one decade to decompose. Cigarettes are also responsible for causing fires in parks and other outdoor areas. For instance, the 2007 fire in Griffith Park was caused by a discarded cigarette.
Public health and well-being can be protected by adopting smoke-free outdoor areas policies. Such policies also affect changes in social norms regarding tobacco use, thereby fostering an environment that helps current smokers cut down or quit and encourages former smokers to remain smoke-free. In addition, adopting smoke-free outdoor areas policies decreases the risk that young people will smoke, as they will become less exposed to modeling of smoking behavior. Every day, over 4,000 children in the U.S. smoke their first cigarette and 2,000 teenagers become daily smokers; three out of four smokers start before they are 18 years old.
There is strong public support for smoke-free outdoor areas. According to a statewide survey conducted by the California Department of Public Health in 2008, 75.8% of Californians agree that smoking should be prohibited in outdoor dining areas at restaurants and 74.9% of Californians agree that smoking should not be allowed in outdoor entertainment areas, such as amusement parks, zoos, and fairgrounds. According to the 2007 Los Angeles County Health Survey, a majority of Los Angeles County adults agree that there should more restrictions on smoking in outdoor public places. For example, 70.5% of respondents favored a ban on smoking within 20 feet of public building entrances, 66.1% of respondents favored a ban on smoking in waiting areas such as bus stops, movie lines, or at ATMs, 65.9% of respondents favored a ban on smoking in outdoor dining areas, and 58.7% of respondents favored a ban on smoking in parks.
In response to the groundswell of public support, cities, counties and the state of California have adopted a number of laws that protect its citizens from exposure to secondhand smoke in outdoor areas. For instance, in 2001, a law was adopted (California Health and Safety Code Section 104495) prohibiting smoking within 25 feet of playgrounds or tot lot sand box areas. This law is non-preemptive and gives authority to local governments to enact stronger policies. In 2003, the state adopted a law prohibiting smoking within 20 feet of main exits, entrances, or operable windows of public buildings. Public buildings include buildings owned or leased by any city, any county, the State, every campus of the California community colleges, the California State University, and the University of California. This bill also includes anti-preemption language that allows local governments and campuses to adopt and enforce more restrictive tobacco control policies.
To date a growing number of cities and counties throughout the state have adopted policies prohibiting smoking in outdoor areas such as parks, beaches, dining patios, service lines and theme parks. In Los Angeles County, 27 cities have adopted smoke-free parks policies (i.e. Alhambra, Baldwin Park, Calabasas, Carson, Cerritos, Claremont, Culver City, El Monte, Gardena, Glendora, Hawthorne, Huntington Park, La Puente, Los Angeles, Lomita, Manhattan Beach, Maywood, Monterey Park, Palmdale, Pasadena, Rosemead, San Dimas, San Fernando, Santa Clarita, Temple City and Walnut) and in September 2009, the Board of Supervisors adopted a smoke-free parks ordinance for the unincorporated areas of LA County. Furthermore, 6 cities have adopted policies that prohibit smoking on outdoor dining patios (i.e. Los Angeles, Beverly Hills, Culver City, Malibu, South Pasadena, and Sierra Madre), 6 cities have adopted comprehensive outdoor area policies that prohibit smoking on outdoor dining patios, in parks, in service lines, and on sidewalks (i.e. Calabasas, Baldwin Park, Santa Monica, Burbank, Glendale, and Pasadena), and with the exception of Avalon, all city and county beaches are smoke-free.
Smoke-Free Multi-Unit Housing
Although California has made great progress in eliminating secondhand smoke in the workplace, for the many Californians who live in multi-unit housing, breathing secondhand smoke drifting from neighboring units, balconies, and outdoor areas is an ongoing and real health problem.
Secondhand smoke can seep under doorways and through wall cracks. Persons living in apartments near smokers can be exposed to elevated pollution levels for 24 hours a day, and at some times, the particulate matter exposure can exceed the U.S. Environmental Protection Agencys 24-Hour Health Based Standard. The Surgeon General has concluded that eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from secondhand smoke exposure; separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot completely eliminate secondhand smoke exposure.
Surveys conducted by the Center for Tobacco Policy and Organizing have shown that apartment residents recognize the dangers of secondhand smoke exposure and that it is a problem in multi-unit housing. According to a 2004 survey, 46% of California renters have experienced secondhand smoke drift into their apartment, while a 2006 survey found that 63% of Latino renters experienced secondhand smoke drift into their apartment. In addition, a 2003 survey found that 41% of Los Angeles renters have experienced secondhand smoke drift in their apartment. According to the 2007 Los Angeles County Health Survey, about 585,000 adults in LA County reported being exposed to someone elses cigarette smoke in their home within the previous week. In these households, up to 336,000 children under age 18 have also been exposed to secondhand smoke.
There is public support for restricting smoking in multi-unit housing throughout California. According to surveys conducted by the Center for Tobacco Policy and Organizing, a 2008 survey found that 78% of California voters support a law requiring apartment buildings to offer nonsmoking sections, while a 2006 survey found that 82% of Latino renters support a law requiring apartment buildings to offer non-smoking sections of units. According to the 2006 California Adult Tobacco Survey, 72.6% of Californians think multi-unit housing or apartment complexes should require that at least half of their rental units be smoke-free. The majority of Los Angeles County residents also support smoke-free housing. According to the 2007 LA County Health Survey, approximately 60% of smokers and 77% of nonsmokers believe that there should be a law requiring separate smoking and non-smoking units in multi-unit housing.
According to the Technical Assistance Legal Center, there is no Constitutional right to smoke. California law declares that anything which is injurious to health or obstructs the free use of property, so as to interfere with the comfortable enjoyment of life or property, is a nuisance. Local governments have broad latitude to declare nuisances and are not constrained by prior definitions of nuisance. Local ordinances that authorize residential rental agreements to include a prohibition on smoking of tobacco products within rental units are not prohibited by state law.
Cities and counties throughout the state have adopted laws that protect residents from exposure to secondhand smoke in multi-unit housing. Strong smoke-free housing policies that address the issue of drifting secondhand smoke from neighboring units have been adopted in twenty-five California communities, including Richmond, Belmont, Dublin, and Thousand Oaks. In Los Angeles County, the city of Calabasas adopted a strong smoke-free multi-unit housing policy, while the cities of Glendale and Santa Monica have adopted multi-unit housing policies that are less restrictive.