Public places after smoke-free—A qualitative exploration of the changes in smoking behaviour

ARTICLE IN PRESS Health & Place 16 (2010) 461–469

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Public places after smoke-free—A qualitative exploration of the changes in smoking behaviour Deborah Ritchie a,n, Amanda Amos b, Claudia Martin c a

UK Centre for Tobacco Control Studies, Nursing Studies, School of Health in Social Science, University of Edinburgh, UK UK Centre for Tobacco Control Studies, Public Health Sciences, Centre for Population Health Sciences, University of Edinburgh, UK c Scottish Centre for Social Research, Edinburgh, UK b

a r t i c l e in fo

abstract

Article history: Received 18 February 2009 Received in revised form 6 November 2009 Accepted 6 December 2009

The social context of smoking behaviours is explored after the introduction of Scottish smoke-free legislation. A longitudinal qualitative study was conducted in four contrasting localities. Whilst postlegislation changes in smoking behaviour were evident in all four localities, they were most apparent in the disadvantaged localities. Changes in the patterns of smoking were linked to the ways in which people interacted in social contexts and how people re-negotiated habitual smoking behaviours in public spaces. Pre-legislation differences in the communities appeared to influence the extent of these changes. Cultural and social contexts are important in shaping smoking behaviours and locating change within public places. & 2009 Elsevier Ltd. All rights reserved.

Keywords: Community Smoke-free legislation Places qualitative

1. Introduction An increasing number of countries, regions and communities around the world are taking measures to create smoke-free public places to protect the health of workers and the public at large (WHO, 2008). There is clear international evidence that comprehensive smoke-free policies are effective in reducing second-hand smoke (SHS) exposure (Waa and McGough, 2006) and associated mortality and morbidity (Eisner et al., 1998; Albers et al., 2004, Ludbrook et al., 2004, Hole, 2005). Indeed the WHO Framework Convention on Tobacco Control (FCTC), the first international public health treaty (WHO, 2003), requires that countries take national action to protect citizens from SHS. Scotland was one of the first countries to introduce comprehensive legislation prohibiting smoking in enclosed public places (March 2006) and its implementation has produced significant reductions in SHS exposure in children, adults and bar workers (Semple et al., 2007; Akhtar et al., 2007; Haw and Gruer, 2007) and hospital admissions for heart attacks (Pell et al., 2008). It was also hoped that it would have additional public health benefits by reducing smoking prevalence and changing societal attitudes and norms towards smoking, particularly in disadvantaged areas (Haw et al., 2006). Smoking is a major cause of inequalities in health in many high income countries including Scotland and the UK (Scottish

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Corresponding author. Tel.: + 44 1316503894. E-mail address: [email protected] (D. Ritchie).

1353-8292/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2009.12.003

Executive, 2004; Gordon, 2007; USSG, 2001; Huisman et al., 2005). In 2003, 41% of men and 39% of women in semi-routine and routine occupations in Scotland smoked cigarettes compared to 17% of men and 16% of women in professional and managerial occupations (Bromley et al., 2005). Even greater differences are found at the local level with over 50% of adults being smokers in the most deprived areas (NHS Health Scotland, 2004). Not only is smoking more prevalent in these communities but, prior to the smoke-free legislation, bars, pubs and other workplaces in areas of socio-economic disadvantage were less likely to have smoking policies and more likely to permit smoking than in affluent communities (Plunkett et al., 2000; Eadie et al., 2008). Several systematic reviews of the effect of smoking bans in workplaces have found associated declines in consumption, increased attempts to quit, increased rates of successful quitting and consequent reductions in smoking prevalence (Ludbrook et al., 2004; Fichtenberg and Glantz, 2002). Although, Borland and Owen (1995) did identify a subset of smokers who do not adjust well to workplace smoke-free interventions. Comprehensive national smoke-free laws have been shown to support quitting and increase support for smoke-free public places (Fong et al., 2006). However, little is known about the impact on specific groups and communities, particularly disadvantaged communities (Dedobbeleer et al., 2004; Whitlock et al., 1998; Amos et al., 2008). There is some evidence that community characteristics and local contextual factors may be important in influencing the nature and level of compliance with and adjustment to smokefree legislation (Nykiforuk et al., 2007; Eadie et al., 2008). It is also known that social context shapes local smoking cultures, norms of

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smoking and non-smoking, and the social relationships that sustain or constrain smoking behaviours (Thompson et al., 2007; Poland et al., 2006; Louka et al., 2006; Wiltshire et al., 2003; Stead et al., 2001). Many low income smokers want to quit smoking and recognise the importance of social norms in maintaining their smoking and hampering quit attempts (Bancroft et al., 2003; Wiltshire et al., 2003). However, experience from a communitybased smoking intervention in a deprived area of Scotland, indicates that there could be some reluctance by local workers and community members in disadvantaged communities in engaging with tobacco control interventions (Ritchie et al., 2004, 2008). These views resonate with qualitative studies, which highlight how the social circumstances of disadvantaged lives play an important part in sustaining smoking (Bancroft et al., 2003), with smokers using it as a means of coping with living and caring in disadvantaged circumstances (Graham, 1993; GauntRichardson et al., 1999; Wiltshire et al., 2003). Few qualitative studies have investigated the processes and impact of smoke-free legislation at individual and community levels or in different communities. There is thus only a limited understanding of how, and in what ways, such legislation contributes to the creation of a positive or negative social climate towards smoking and its relationship to consumption, particularly in disadvantaged communities (Giskes et al., 2006). The paper draws its theoretical framework from health promotion, in particular the social-ecological model of promoting health (Elder et al., 2007; Barbara et al., 2001). Health promotion has a theoretical base that is ‘deliberately eclectic, combining psychological cognitive models with a sociological interpretation’ (Wight et al., 1998); in order to reflect the complex interplay between individual health behaviours and social and environmental influences. We draw upon the social-ecological model as it allows for an exploration of health behaviours, in this case smoking, to be located within social cognition theories that consider social norms, personal susceptibility to risk, perceived barriers and risks, and social approval (Bandura, 1977; Connor and Norman, 1996), but also importantly considers the reciprocal relationship between these social cognitions and social environment and policy influences (Levy, 1991; Tones and Green, 2004). We therefore aim to understand how changes in the social and physical environment created by the smoke-free legislation influenced individual social cognitions and a shared social understanding of tobacco use in these newly created environments in the public space. This paper describes the findings from a longitudinal qualitative study, one of a portfolio of studies commissioned by NHS Health Scotland to evaluate the impact of the Scottish smoke-free legislation (Haw et al., 2006). The overall aim of this study was to explore the impact of the smoke-free legislation on smokingrelated attitudes and behaviour, at both individual and community levels, in four socio-economically contrasting localities in Scotland. In this paper we explore how the cultural, environmental and social contexts are important in shaping individual and shared smoking behaviours and social interactions in the public spaces in these localities.

2. Methods 2.1. Study design Longitudinal qualitative studies are relatively unusual in the evaluation of public health policies or interventions, including tobacco control. Their key characteristics are the: ‘collection of data on more than one occasion; the cases analysed are broadly

comparable and analysis involves some comparison between or among periods’ (Molloy et al., 2002). Importantly, longitudinal qualitative research can provide detailed understandings of the contextual factors, which may influence outcomes among different groups over time, through a long immersion by the researchers in the field (Flick et al., 2004). The study, which was conducted in four contrasting localities in Scotland between October 2005 and March 2007, used a prospective longitudinal qualitative design involving repeat data collection time points, one pre- and two post-legislation, to describe changes in tobacco consumption; smoking behaviours and perceptions and to explore whether and in what ways these might be patterned, including by place and social position. The study, as is common in longitudinal qualitative studies (Molloy et al., 2002) incorporated different methods of data collection: discrete observations; semi-structured interviews and daily life grids. 2.2. Observations The aim of the observation method is to understand particular phenomena of social life within their natural setting (Green and Thorogood, 2009). This method was chosen in order to observe how people interacted and behaved within the public context of smoke-free across time points. Discrete observations were conducted by two researchers working together in the same public places across all time points. The researchers adopted a covert role in order to minimally impact upon the environment (Green and Thorogood, 2009). The aim was to observe changes in the physical spaces, smoking behaviour and social interaction of individuals and groups in the localities as a public account of the observed phenomena. Discrete observations can be contentious as those observed are non-participative in the data collection (Peeticrew et al., 2007). A number of the challenges of this method were addressed (Peeticrew et al., 2007). In particular, safety concerns (in one locality) were reduced by recruiting local people to accompany the researcher in the fieldwork setting to enable a blending into the environment. Ethical issues were addressed in that all observations were in public spaces and the individuals and public places were anonymised. The accuracy of the observations was optimised by using two researchers and immediately recording the observations after the fieldwork. A total of 54 observations across all time points were undertaken in four to five community venues in each locality and included bars, cafe´s, and community centres. The observations were semi-structured and recorded the venue layout, smoking-related signage, non-smoking areas, how many smokers and non-smokers were present, how often and for how long smokers left to smoke outside, whether smokers congregated or smoked alone. Any smoking-related incidents were recorded as ‘‘vignettes’’, along with any infringements of the law. The observations lasted for one hour in each venue. 2.3. Interviews The observations provided data ‘on what people do’, while the semi-structured interviews provided data on ‘what they say they do’ (Green and Thorogood, 2009). Semi-structured interviews were chosen to explore contextual accounts of smoking and the meanings participants attributed to any change; and their perceptions of the smoke-free legislation and its impact upon their lives across time. The interview topic guides explored participants’ past and current relationship with tobacco including: smoking behaviour and/or exposure within the context of

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their daily lives; beliefs and understandings of SHS; ‘rules’ or regulation of smoking within the home; awareness, understandings and attitudes towards the legislation; any changes in patterns of smoking and consumption. Interviews were recorded (with consent) and transcribed. Participants received £15 for each interview. 2.4. Daily life grids Daily life grids were completed at the end of each interview to systematically record participants’ daily consumption and context of their tobacco use at each time point. Participants described a typical 24-h period using an adapted version of the ‘life grid’, which annotated the number of cigarettes smoked over the course of a day in terms of when, where and in what social context (for example, with friends, colleagues, partner) smoking occurred (Bancroft et al., 2003; Wiltshire et al., 2003). The daily grids, with the interview data, provided a more robust account of selfreported changes in consumption and context. 2.5. Reflexivity Reflexivity is a process whereby researchers turn a critical gaze towards themselves in order to engage in a critical self-reflection of how their own social background, assumptions, positioning can impact upon the research process (Finlay and Gough, 2003). In this study the research team worked reflexively together with the data collection, the context within which it was collected and the analysis (Finlay and Gough, 2003; Barry et al., 1999; Hertz, 1997). The team was experienced and committed public health researchers and were thus reflexive of their professional and personal positions regarding smoking and smoke-free. They were open to participant opinions against the smoke-free legislation and also those who may not have experienced positive benefits from smoke-free. The team revisited and challenged shared assumptions, as a constant reflective process, about the benefits of smoke-free in the data collection and analysis. 2.6. Settings

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were nevertheless rather different. D1 is located on the edge of a major city. It has retail outlets, community facilities, bars and is the location for local government and health service investment and activity including urban regeneration and community health development. In contrast, D2 is located adjacent to a small semirural town and has few retail and virtually no recreational venues. The advantaged localities (A1 and A2) had similar socio-economic profiles, but were rather different. A1 is effectively a small suburban village, located about 5 miles from a city centre. The area is largely residential with two pubs and several cafes and restaurants. A2 is a more discrete small town located in a rural setting. It has a number of bars and cafes and is a tourist centre. 2.7. Participants The participants comprised a purposively selected panel of 40 men and women aged 18 + (Table 2), recruited within the localities by trained interviewers using a variety of methods, including: door knocking, opportunistic street recruitment and by visiting community venues, such as community centres and cafe´s. Pre-defined quotas were used, based on three primary criteria (smoking status, age, gender) and three secondary criteria (the presence of children under the age of 12 in the household use of licensed premises, employment outside the home). The aim was not to obtain a statistically representative sample, but to include participants who represented particular characteristics of current and recent ex-smokers in all localities. The panel at Time Point 3 had an almost identical age and gender profile to the original panel with no biases in attrition by locality, age or gender. Of the 34 smokers interviewed pre-legislation, 30 were re-interviewed post-legislation. Panel participants were interviewed at least twice. The first interview took place 3–6 months before the legislation came into force (Time Point 1). Twelve participants from all the localities who were identified as regular users of social and leisure venues were interviewed in the 3 months following the legislation (Time Point 2) to provide data on its immediate impact on tobacco consumption and compliance for policy makers. All the panel Table 2 Panel characteristics at Time 1 (pre-legislation) by gender.

The study was conducted in two local authority areas in Scotland, one urban and one semi-rural. Within each area, two socio-economically contrasting localities were identified (using a range of indices, including socio-economic status and smoking rates among adults and during pregnancy) to provide four casestudy sites: two were characterised by relative socio-economic disadvantage and two by relative advantage (Table 1). The four localities were clearly defined communities which, apart from D2 which directly bordered a town, contained a range of community resources including shops, bars and community venues. The advantaged and disadvantaged localities, while respectively sharing certain socio-economic and smoking characteristics,

Age group 18–30 31–59 60 + Smoking status Smoker Ex-smoker Children under 12 in household Yes No Total

Male

Female

4 12 4

4 12 4

16 4

18 2

8 12 20

10 10 20

Table 1 Characteristics of the four case-study localities. Locality

D1 A1 D2 A2 a b

Location

Urban Suburban Semi-rural Semi-rural

Socio-economic profile

Disadvantaged Advantaged Disadvantaged Advantaged

Social gradea A–B (%)

E (%)

7.1 48.1 11.7 30.5

37.1 11.2 23 15.3

Adult smoking rateb (%)

Smoking rate in pregnancyb (%)

50.7 18.8 38.0 21.0

37.7 16.5 44.3 12.7

A–B = higher and intermediate managerial/administrative/professional occupations, E=on state benefits, unemployed or in lowest grade workers. Source: NHS Health Scotland (2004).

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were re-contacted 6–9 months after the legislation was enacted (Time Point 3) and 35 (88% of the initial sample) were reinterviewed. 2.8. Ethics The study complied with the Code of Practice on Ethical Standards for Social Research Involving Human Participants operating in Public Health Sciences at Edinburgh University. Participants were informed that they could withdraw from the study at any stage. Confidentiality and anonymity were assured. It was not necessary to seek approval from a NHS ethics committee. 2.9. Data analysis An inductive process of analysis that was theoretically informed by the grounded theory approach, the constant comparative method (Green and Thorogood, 2009), was used. The intention was to locate the data within the contrasting community contexts and then to analyse change across participant categories and through the observations of public spaces at different time points. This was achieved by drawing upon participants’ narratives and locating them within the environmental contexts of the public places within each locality. Firstly the day grids were independently scrutinised by the authors to ascertain the amount, location and context of daily smoking for each participant at each time point. Any disagreements were re-examined until a consensus was reached about consumption levels and changes between time points. The narrative accounts in the interviews were then independently scrutinised by the authors who, by comparing accounts and through open coding, identified recurrent descriptive themes from which a descriptive coding frame was developed. The data were then coded using QSR N6 software. Next the coded descriptive data were scrutinised through further immersion to identify emergent analytical categories, which were explored in relation to locality, time point and age and gender of participants. Finally the narratives from the interviews were read in conjunction with the observational data in order to contextualise individual changes within different community places. Observations were categorised descriptively for each public place and collated across time points to identify changes within the descriptive categories. These categories emerged from the systematic recording of the observations: environment; social interaction, smoking restrictions and smoking visibility.

highly visible with heavy and chain smoking common in public venues. The pub culture was male dominated, with smoking and drinking the main activities, though these were often solitary behaviours, with little or no observed round buying or sharing of cigarettes. Overall the panel participants who smoked expressed limited or little support for the ban in the pubs or the community venues, with several expressing concerns that older people would cease to use community facilities and pubs post-ban, and that this, in turn, might increase their social isolation. The local pubs already had reputations for violence and we observed that some had overtly aggressive atmospheres. The panel interviewees also expressed concerns about increased violence and increased drinking in the home. While some participants hoped that the legislation might help them to quit smoking, several believed that local people would seek or find ways around the ban. In the rural disadvantaged locality (D2) we observed a high visibility of smoking in public spaces. Much of the social activity took place in the adjacent town, which had several lively bars. This appeared to be a close-knit small town and the prevailing view in the pre-ban panel interviews, in contrast to (D1), was that people would adapt to the legislation, albeit somewhat reluctantly. There was less expressed concern among the panel that older people would be adversely affected. Generally it was expected that most people would remain loyal to local businesses, would continue to visit the same venues post-legislation and would comply with the law. Unlike the disadvantaged localities, we observed that the two advantaged localities already had several smoke-free venues and non-smoking areas within venues. The bars and pubs in these localities were more likely to have gardens or access to outdoor spaces, which smokers could use, and plans were being made, in advance of the legislation, to create pleasant outdoor spaces, for example, by installing heaters. A telling concern in A2 was that the ban would adversely affect the appearance of the town, which many participants regarded as a quiet, clean place which might be disturbed by groups of smokers and cigarette butts on the streets. There was an expectation among participants in both localities that there would be compliance and that the legislation offered positive opportunities to change smoking behaviour. Thus, while panellists in one disadvantaged locality expressed more hostility and potential resistance through getting around the law, the panellists in the other were more accepting of the impending legislation. The advantaged localities had already started to create smoke-free environments and people living there were largely optimistic that the new legislation would be beneficial to the community as a whole.

2.10. Findings 2.12. Changes in patterns and levels of consumption We firstly consider the differences in the social context and social norms around smoking in the localities pre-legislation. Changes in smoking behaviour are then explored in relation to the changes in public spaces generated by the legislation and the disruption and changes in the social interactions within public places in the localities. Finally we explore smokers’ adjustments to the new post-legislation social norms around smoking. Quotes are provided to illustrate analytical points being made and the acronyms specify respondent number, sex (M/F), locality (A1, A2, D1, D2) and time point (TP1, TP2, TP3). 2.11. Differences in the localities pre-legislation Prior to March 2006, the four localities differed in both reported and observed patterns and levels of smoking and attitudes towards the impending legislation. In the urban disadvantaged locality (D1), we observed that smoking was

In all localities there were accounts of changes in smoking consumption and behaviour among participants post-legislation. While there were changes in all four communities, these were most apparent among those in the disadvantaged localities. Although there were self-reported increases in smoking for some, more significant were reductions in the number of cigarettes smoked and quitting. Smokers’ narratives in the disadvantaged localities described more decreases in consumption and successful quitting than those in the affluent localities. Participants’ narratives suggested that a range of factors underlay the decreases in consumption and most of these were connected to the environmental constraints of smoke-free legislation and the nature of any newly created public social spaces for smoking. These appear to have been particularly influential for smokers living in the more disadvantaged areas. As explored below, for many participants the environmental constraints impacted not

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only on the number of cigarettes they smoked but where they were smoked, how they smoked, and how smokers felt about their smoking.

2.13. Re-created outdoor spaces The smoke-free legislation had re-shaped habitual smoking behaviours in public spaces in these localities in a number of ways. The implementation of the formal control of smoking in public spaces, through legislation, led to a re-creation of the use of space and a re-negotiation of the social interactions embedded within these spaces. In the pre-legislation data it was noted, particularly in the advantaged localities that the social norms around the acceptability of smoking were changing, both by smokers themselves and by non-smokers. These shifts were less notable in the disadvantaged localities, where there was, at prelegislation, less evidence of the creation of smoke-free places within the locality. This inevitably meant that the legislation would impact more profoundly in disadvantaged localities, requiring a greater degree of adjustment. However, it was found that post-legislation the degree of adjustment required was generally even greater. For a while there were observed changes in the smoking spaces in all localities post-legislation, the quality of the smoking spaces varied across the localities, with less provision for smokers in the disadvantaged communities. For example, Table 3 describes the physical space adjustments that were created post-legislation to accommodate smokers in a pub in advantaged area A2 and thus maintain busy pub atmosphere within the pub and extend it to the new comfortable smoking area outside, which included heater and a television. One participant who went to a different pub in A2 spoke positively about the new outdoor smoking area at his pub. The pub that I drink in has been fantastic with the smoking ban, they’ve put out a big gas heater sponsored by Foster’s. And it’s got a canopy; he has got a gazebo over it. And a couple of folding chairs and what have you, it’s actually quite nice. (15M A2 T2)

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In contrast in the disadvantaged localities very few adjustments were made to accommodate smokers and smoking mostly took place on outside pavements with little or no shelter provided. Table 4 describes a pub where the only change was the provision of wall mounted ashtrays on the exterior walls, which were on the pavement. As one participant from D1 described, even where there some shelter had been created it provided little protection from the weather. They’ve got this stupid wee ‘bus shelter’ down there and the way it’s facing is you’re open tae the weather coming from the West and it comes from the West anyway. INT: And where is that ‘bus shelter’? Just outside the pub. INT: And was that new, was that put in since the ban? Aye but it’s only about, the roof it is about that wide so it’s not a shelter really (26M D1 T3). 2.14. Disruptions to social networks and social Interactions Pre-legislation, many smokers were unsure how it would affect them. Some thought they would simply go out less and stay home more, while others insisted that it would not change their social lives. Post-legislation, the ‘‘hassle’’ of going out for a cigarette combined with disruptions to the social flow was a real deterrent. Going outside to smoke often meant leaving not just the premises, but the social activities taking place in the bar or club. Thus many participants reported that they therefore chose to smoke fewer cigarettes rather than experience the disruption to social interaction and activities. Participant 22 illustrates both the engagement in and provision of more social activities within the pub. He engaged in more social activities in the pub as a way of distracting himself from the need to smoke. When he did go outside he tended to only smoke half a cigarette in order to be able to return to his activity I haven’t normally played a load of pool but I play it quite often now. Because I do not go out for a smoke that much. You’re always getting them complaining I’m away for a smoke, you know how long it takes for a cigarette outside, but if you’re

Table 3 Observations in a pub in the A2 advantaged locality pre-and post-ban. Pub

Pre-ban

Post ban—TP4

Environment

Busy pub with 2 bar areas: one bar had snooker table and younger crowd. Window and ceiling extractor fans working. Beer garden closed (as dark). Stays open later than other pubs. Lots of staff cleaning tables.

New covered smoking area outside at the back: light, TV, comfortable chairs, and heaters provided. About 10 people (men and women) sitting and standing outside.

Social interaction

Mixed ages and gender, very busy. High customer turnover. Younger people playing snooker.

Smoking restrictions Smoking visibility

No signs Earlier in the evening most smokers were around the bar but, as the evening went on, more of those seated were smoking too. Cigars on sale. Cigarette packets and lighters on tables—at least half the packets were Spanish (Marlboro and Mayfair). Discreet smokers/cigarettes kept low by people’s sides. One customer alone with his dog and chain smoking.

Unpleasant air freshener and human smells inside. Younger people on one side. Very busy. Party groups, individuals and couples. Lots of people knew each other. One raucous group of men causing disturbance (arm wrestling and swearing). Local man apologised for their behaviour. Sign at entrance Ashtrays on tables (outside).

No cigarettes/lighters visible inside except for one man with cigarette behind his ear. 2 people smoking on pavement, but most people smoking in the new outside smoking space.

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Table 4 Observations in a pub in the D2 disadvantaged locality pre- and post-ban. Pub

Pre-ban

Post ban—TP3

Environment

Small bar, crowded with 10 + people and 2 young men in the back room. Very bright lights, snooker, MTV on TV but no sound, music intermittent and juke box. 2 Bars and snooker room. No food served. Most people drinking in the bar. About 11 customers, middle-aged and older, 3 women. Female staff member moved from behind bar to talk to a group of men. People polite. No smoking policies detected and no signs Cigarette machine and cigars, cigarette papers and lighters for sale at the bar. Ashtrays on all surfaces. Most customers were smoking, many of them smoking roll-upsa. Bar staff were not smoking but there were cigarettes and a lighter at the back of the bar.

As before re layout and de´cor. New poster from the NHS: ‘‘Come out of the cold—help to stop smoking’’. New competition guessing the Lottery bonus ball. Second bar lights off and no one inside. Juke box.

Social interaction

Smoking restrictions Smoking visibility

2 men playing pool in the back room. 3 young women going clubbing, young couple at the end of the bar, 1 man on his own at the bar, 3 men sitting together. Signs visible Ashtray on side wall by bridge overlooking river off main pavement creating alleyway for smoking, and ashtray on main pavement, no butts on floor. No seats or heaters.

One woman in bar with cigarettes visible in her handbag. One man prepared roll-ups at the bar, went out for a very short time, commented on the bad weather on his return. Old man came into the bar, rolled a cigarette and put it away in a tin. a

Roll ups are loose tobacco and papers to make your own cigarette).

only having a fag and you’re throwing the other half anyway and then you can go and play pool (22M D1 T3). Activities and conversations within a bar or club, even for those who enjoyed the opportunity to meet people outside, were described as generally having exerted a greater pull than smoking. The practice of going outside to smoke often involved a decision based on the social pull to go outside with others as part of a social interaction. For example, one participant who often watched televised football matches at his pub said Usually the game takes precedence. If I do go outside for a cigarette when I’m in the pub it’s usually because somebody else is wanting to go outside and ’come on K, come on let’s just go outside’ and I think ’aye right okay’ you know, but it wouldn’t bother me if I had to stay in and without a cigarette at all. Since the smoking ban came in I just, I’ve never really thought about smoking when I’m in the pub (7M D1 T2). Others experienced a disruption to the ‘normal’ flow of conversation and the decision to go outside often led to discontinuity in the social interaction. If you’re sitting having a conversation and you just get up and go and have a cigarette and come back down, it’s not very nice. You seem to lose track of what’s happening in the club if you’re outside all the time. (5M, D2, TP2) Because you are still going out, you just have to go outside for a cigarette, your social life was never organised around you know whether you could smoke or not, or where you could smoke you know. Soythe only thing it’s affectedyoh I will be back in five minutes and you maybe miss a wee bit of the conversation. (15M A2 T2) Camaraderie between smokers (and indeed non-smokers) gathered outside bars were reported as a benefit of the legislation, but this was not the dominant experience. I never went out with anybody else. And I think that was mostly part of the problem as well, there was nobody else going out and having a fag at the same time as me so I didn’t bother. (28F D1 T3) Participant 25 illustrates the disruption of social networks and daily routines of some smokers, particularly older men. This pensioner had expected pre-legislation that his friends with whom he met every day in the pub would just congregate in each

others’ homes to smoke and drink, but post-legislation they did not appear to have re-created their social network. You cannae smoke there either, you cannae smoke in the Bookies [betting shop] either. Oh I just go in and put my bet on and up the road again. When I was going to the pub I was putting my bet on and having a couple of pints and then home but this standing outside you know, it is blowing a gale on us, you know there’s no shelter, just standing out there in the open. (25F D2 T3) Other participants already lived fairly restricted social lives and their use of the public spaces was minimal and as such they experienced little impact on their social interactions and made few adjustments to their smoking or adapting to the new social norms. The legislation had also impacted on consumption in other ways. Not only were some smoking fewer cigarettes, they also smoked in a rather different way, for example, only smoking part of a cigarette and/or smoking more quickly. On days like this where it’s rain I’ll just stand out under an umbrella, so I’d actually smoke less of a cigarette. What I found is I’m smoking cigarettes a lot faster now and not smoking as much of them. (32M A1, T2) You only take a couple of puffs because you are worried about your drink inside. A few wee puffs and then you throw it away. (21M D1 T3) This was confirmed in several of the observations where lone smokers were seen outside venues smoking rapidly and often stubbing out semi-smoked cigarettes. Smoking outside in the street was experienced by participants as problematic and some experienced outside smoking as stigmatising. I feel a lot more guilty, conscientious about I’m smoking on the street. (29M D1 T2) Not very comfortable really. It’s like being banned fromyyou know it’s this feeling that you are notyit’s not appropriate for you to be in that place you know. I know that that’s silly because you are entitled to be in the place provided you are not smoking you know. But it just has that sort of feel about it, a leper! You knowyaye that’s what I feel. (11F A2 T3)

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For some this was due to what they felt was their increased visibility as smokers since the ban was implemented. I think because the ban is in, it’s made everybody so much more aware of people smoking. People are looking out for smokers more I think, they spot them easier. We are easier spotted now. (15M A2 T3)

2.15. Smokers’ attitudes and adjustments to the new social norms In all the localities, having a cigarette in a public place had moved from being a habitual routinised social behaviour to something that smokers had to make a conscious decision about. Some smokers welcomed the impact this had had on their consumption. In actual fact it’s better for you because you would find that before when you could sit and have a drink and a cigarette you would probably some about 20 cigarettes, whereas now if you go out on a night out I would say you smoke about 4 if you are lucky because you can’t be bothered to go outside. So in that way it’s a good thing. (16M A2 T3) However, for some narratives of ambivalence about the smoke-free legislation, which had been expressed pre-implementation continued to be expressed post-implementation. Conforming and adjusting to the new social norms required participants to rationalise their and others’ compliance to the legislation, as well as make sense of the potential costs of not complying. For even in the deprived locality D2, where many local participants had expected that people would not comply with the legislation, over time people appeared to have become more accepting of, and not simply resigned to, the changes. Well when it first came in I was kind of humped about it but now it doesn’t bother us. (6M D2 T3) Participant 5 illustrates an acceptance of the requirement not to smoke and an awareness of the potential loss of his ‘social place’ if he did not comply with the legislation. You’re not allowed to smoke and that’s it, I think if you get caught you get reprimanded for it or you get flung out of the premises so it’s a waste of time. If you dinnae want to lose your social places, that’s it. (5M D2 T2) Other smokers rationalised their continuing lack of acceptance of the smoke-free legislation albeit alongside behavioural compliance, not only because they were law-abiding and fearful of the repercussions, but rather more because as ‘considerate’ smokers they had ‘‘respect’’ for non-smokers and/or the managers and owners of public venues whose position might be compromised. In this sense, several participants extended their moral identity as a considerate smoker beyond that claimed in the pre-legislation interviews, which focused more on consideration for nonsmokers and smoking at inappropriate times and places, such as during a meal, to encompass venue staff and managers. For participant 15 his behaviour is explained as reflecting his consideration for non-smokers, whereas for participant 29 it was more out of concern and respect for the bar staff. As a smoker I do not mind going outside. I was a conscientious smoker before the ban came in anyway. I would try not to smoke in front of non-smokers, or not blow smoke in their face. (15M A2 T2) I think the reason that everybody down there does actually go out for a smoke is because we dinnae want the bar staff or the likes of the Licensee getting in trouble. It’s not because we

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dinnae want to get in trouble, it’s because we dinnae want to get them in trouble because we respect them more, well it’s probably because we respect them, that’s why we go out for a cigarette, it’s not because we’re feared of getting maybe caught ourselves, it’s because the bar staff and because we know the bar staff will get in trouble. (29M D1 T3) The observations confirmed the participant accounts that any breaches of the legislation were generally small-scale, largely involving a blurring of the boundaries between enclosed public and outdoor space and appeared to be tolerated or accepted by staff. For example, smokers in some D2 pubs were observed lighting their cigarette just before leaving the pub or coming in smoking and then extinguishing their cigarette. In one bar in D2, it became apparent that regulars were allowed to use a room behind the bar to smoke, with bar staff providing air fresheners to disguise the smell. These actions were absorbed into the everyday management of the ban at the local level and were un-remarked upon.

3. Discussion The smoke-free legislation in Scotland has demonstrated significant success with several clear public health benefits (Akhtar et al., 2007; Haw and Gruer, 2007; Semple et al., 2007, Martin et al., 2008; Pell et al., 2008). Although the processes and impact of the smoke-free legislation were explored in only four localities, using a small purposive sample and locality observations, this study has uniquely captured the changing social context of smoke-free public places at the community level, as well as providing insights about the processes and factors that influenced changes in smoking behaviour and consumption in different social contexts. The social-ecological model of health behaviour provides a useful theoretical lens to explore the complex interplay between individual health behaviour and the social and environmental context of such behaviours (Elder et al., 2007; Tones and Green, 2004). Moreover, it has been suggested in relation to tobacco control that the social-ecological model provides a useful framework for understanding the inter-relationships between the social context of smoking and the shared smoking behaviours of a community (Elder et al., 2007). There is increasing recognition in tobacco control research of the importance of locating smoking behaviours within a wider understanding of social context and that the concept of the collective smoking lifestyle is a useful focus for understanding how health behaviours are shaped by environmental and cultural influences in different groups and communities (Dedobbeleer et al., 2004; Poland et al., 2006; Frohlich et al., 2000). In this study we can clearly see from a social-ecological perspective how prior to March 2006 the four localities appeared to be at very different stages of development in terms of cultural, social and environment and the shared social readiness to embrace the changes that the smoke-free legislation would entail. Post-legislation the most notable changes were in the social and cultural environments of the two disadvantaged communities, where changes in smoking consumption and behaviour in public places appeared to have been shaped by the environmental constraints of the smoke-free legislation. Poland et al. (2006) has also explored how different social groups use and re-create outside spaces as the acceptability of smoking is re-framed through tobacco policy in the different outside spaces. In our localities the physical environments were shaped by different provisions of comfortable outside accommodation. Comfortable spaces were more evident in the advantaged localities, with

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relatively limited and uncomfortable accommodation provided outside pubs in the disadvantaged localities. Thus the re-creation of the physical space and place was found to either enhance/ support or devalue/constrain smoking behaviours (and smokers), leading to differing responses through a nuanced interplay between the environmental policy constraints and individual social cognitions. Recent work by Christakis and Fowler (2008) suggests that a person’s social network ties influence whether they continue to smoke. Those who continue to smoke tend to become more marginalised and cluster together. While they did not find neighbourhood effects over the period of their study, our study suggests that the characteristics and context of a community or locality can play a role in shaping the different adjustments to smoke-free legislation. Furthermore, this study has shown how the social environment can influence the context and level of consumption, even in communities where there may be less support for smoke-free legislation (Richmond et al., 2007). The social-ecological perspective also helps illuminate how the smoke-free legislation shaped individual social cognitions. The literature has identified a new moral discourse of the considerate smoker who wishes to retain public approval for their smoking and resist social and legal restrictions by positioning themselves as ‘considerate’ smokers. (Poland, 2000). Nybborg and Rege (2003), in an economic study of the formation of norms of considerate smoking and the impact of these norms on social relationships and interactions, proposed that smokers will vary their consumption when their smoking is regulated. A more regulated environment creates more of an awareness of the perceived social sanctions and thus changes in smoking behaviour. Poutvaara and Siemers (2008) also suggest that changing social norms determine the behaviour and social interactions of smokers. Our study suggests that the participants engaged in a process of both social and behavioural adjustment within the public places. Smokers achieved this by adjusting their habitual smoking behaviours, social interactions and their use of the public space. There were high levels of compliance in all the localities and the smokers’ narratives of rationalising their ambivalence about the smoke-free legislation suggests that the environmental constraints did contribute further to the re-shaping of individual social cognitions and the social norms of unacceptability of public smoking. However, their ambivalence about, and the discomforts for some of, outside smoking indicates that these smokers, similar to the mechanisms identified in Nyborg’s model (2003), were weighing up the costs and benefits of complying; with most not only choosing to be ‘considerate’ smokers but extending this moral identity to include consideration for staff and managers who would also bare the brunt of any legal repercussions of the smoker’s behaviour. This also serves to provide a justification for holding negative attitudes about the legislation while appearing to actively comply. Also noticeable were how smokers engaged in stigmatising themselves and other smokers, as smoking became less socially acceptable. These findings support other literature that has argued that the processes of stigmatisation, whether or not intentional by the policy makers, enable a de-normalisation of smoking and that perceived public disapproval shapes smoking behaviours in ways that can reduce consumption and increase quitting (Chapman and Freeman, 2008). In conclusion, smoke-free legislation can influence individual and collective smoking behaviour in public spaces within reshaped socio-cultural environments. This study, using a socialecological perspective has further developed the understanding of the complex interplay between changing individual social cognitions about smoking and smokers and the re-creation of social environments, which are shaped by smoke-free policy.

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