The San Francisco Tobacco Free Project (TFP) receives numerous complaints from San Franciscans demanding greater protections through restrictions on smoking in areas such as multi unit housing, outdoor dining areas, and other public venues. TFP also collected data during its Communities of Excellence needs assessment indicating strong support for smoke free policies at multi-unit housing complexes (MUHC’s) and other venues as top priorities for the 2004-2007 plan.

The TFP developed the following objective for this project: By June 30, 2007, San Francisco will adopt one of the following two policies to reduce exposure to secondhand smoke:

• Policy placing restrictions on smoking in those indoor worksite areas exempted by the state smoke-free workplace law such as owner operated bars and tobacco shops (excluding hotels).
• Policy impacting multi-unit housing complexes (e.g., apartment owners, condo associations and public housing boards) that protects residents from drifting secondhand smoke between units and incorporates enforcement/compliance remedies such as including secondhand smoke exposure in nuisance abatement statutes.

This is a primary objective, addressing Communities of Excellence primary indicator #2.2.13 and secondary indicator #2.2.4.

Project activities focused on members of the Board of Supervisors as the policy makers with the authority to adopt and monitor implementation of secondhand smoke policies for San Francisco. Intervention activities utilized the San Francisco Tobacco Free Project’s 5-step Community Action Model (CAM). Train participants, name the issue, and choose area of focus; define, design and do a community diagnosis; analyze the results of community diagnosis; select an action or activity and implement; and maintain and enforce the action or activity.

Using background information, the Coalition chose the focus of its campaign and developed an initial list of policy options. A community diagnosis (stakeholder and public discussion groups and a public opinion survey) was conducted with findings showing evidence of strong public support in San Francisco to increase the number of outdoor smoking bans and smoke-free environments. The Coalition reviewed and modified the list of policy options, developed specific language, and voted on “bottom line” options that they would not be willing to change and “bargaining chip” options that they would be willing to change. The final model policy included 12 sections that would expand protection from secondhand smoke in indoor and outdoor areas and multi unit housing complexes by updating existing law and close loopholes in existing law.

Coalition members sought and obtained several endorsements from health and labor, received training for educational meetings with policy makers, and developed criteria for selecting potential sponsors for the legislation. Meetings were arranged to educate policy makers about secondhand smoke issues and a Board member was identified as a sponsor in December 2006. The Coalition engaged in extensive negotiations with the policy maker’s legislative aide believing he had authority to negotiate on behalf of the supervisor. But months of negotiations fell apart when the aide informed Coalition leaders that the supervisor was not willing to sponsor all the policy options that had been negotiated between the Coalition and the aide.

The Coalition quickly identified another potential sponsor, however, until the first policy maker “passes off” sponsorship to another Board member, the future of the comprehensive policy remains in political limbo. Having to start over with a new Board member means that introduction of the policy to the Board of Supervisors will not occur until after June 30, 2007.

The evaluation selected for this objective was a non-experimental, high-level case study design. Because the policy adoption sought was a countywide policy, no control or comparison group within the city was possible. Also, because the ordinance being pursued was developed specifically to address gaps in San Francisco’s existing secondhand smoke laws, finding a control or comparison group outside the city would have been very difficult. Finally, a case study design often provides more detail on how outcomes are achieved (strategies, challenges, etc.) than other design types, and as a result can be extremely valuable to other cities pursuing similar policy goals. No sampling procedures were used. Data collection procedures included conducting stakeholder and general public discussion groups, a public opinion survey, and key informant interviews in San Francisco.

A secondhand smoke policy was developed that closes many of the loopholes in San Francisco’s previous secondhand smoke ordinance. Despite strong public support for a more comprehensive secondhand smoke policy and the Coalition’s best efforts to negotiate in good faith, the ordinance has not yet been introduced to the Board of Supervisors due, in large part, to political circumstances beyond its control. The new policy hopefully will be introduced to the Board over the coming months.

Many lessons were learned from this experience:

• Clearly assess policy makers and their level of support for the issues.
• Be sure you know where the policymaker stands before beginning a negotiating process.
• Don’t put all your eggs in one basket regarding sponsorship.
• Wait until the right policymaker is identified, ideally someone the coalition has worked well with in the past.
• Have access to allies who can educate the coalition about how the political process works.
• It is more difficult to try to pass many different policies in one effort.

Evaluation Design

Type of Design

This objective was categorized as “single policy, adoption only.” The design selected was a non-experimental, high-level case study design. This design was selected for a number of reasons. First, the policy adoption sought was a countywide policy, therefore no control or comparison group within the city was possible. Also, because the ordinance being pursued was developed specifically to address gaps in San Francisco’s existing secondhand smoke laws, finding a control or comparison group outside the city would have been very difficult. Finally, a case study design often provides more detail on how outcomes are achieved (strategies, challenges, etc.) than other design types, and as a result can be extremely valuable to other cities pursuing similar policy goals.

Details of the Design

In addition to evaluating the outcomes of the intervention, the Coalition also collected process data. Specifically, a public opinion survey was conducted before the intervention and key informant interviews were conducted before and after the intervention. More information on these surveys is provided below.

Design Limitations

The major limitation of this design is that because it is not a non-experimental design, attribution or causal relationships cannot be determined. Therefore, even if the Tobacco Free Coalition is successful in getting their secondhand smoke policy passed, it will not be possible to prove definitively that the passage of the policy was the direct work of the Tobacco Coalition and not the result of other environmental or contextual factors.

Sample

This was a non-experimental evaluation design. No sampling procedures were used.

Data Collection Instruments and Procedures

Stakeholder and general public discussion groups, a public opinion survey, and key informant interviews were conducted in San Francisco.

Stakeholder/Public Discussion Groups: Dave Binder Research conducted two waves of in-person discussion groups. The first took place in January 2006 and the second in February 2006. The first groups were conducted in January 2006 with members of the public and included six groups of a total of 44 people. Among the participants, 14 were smokers and 30 were nonsmokers. They were diverse groups in terms of ethnicity, gender, age, income, and San Francisco neighborhoods. For the stakeholder groups, a total of 9 opinion leaders were selected from various stakeholder organizations and participated in three triad discussion groups: hospitality, outdoors, and housing.

A discussion guide was developed by Dave Binder Research with consultation from Tobacco Free Project staff to conduct the triad groups to obtain feedback from stakeholders regarding receptiveness to closing the gaps of the California Smokefree Workplace law that would include some outdoor areas and housing restrictions. The triad setting was chosen because the discussions would provide more in-depth reactions than may be obtained in a one-on-one setting. Opinion leaders often have more complex opinions than an interactive discussion can reveal.

Hospitality. This triad dealt with policy options including removing the owner operated bar exemption; hotel lobbies; increasing percentage of smoke free hotel and motel rooms; and outdoor dining areas. Key informants included a restaurant owner/consultant, Golden Gate Restaurant Association executive director, and the Hotel Council director of events.

Outdoors. This triad dealt with restricting smoking at building entrances, outdoor recreation areas not already covered, and outdoor waiting lines. Key informants included representatives from the Commercial Real Estate/Building Owners and Managers Association (BOMA), Castro Theater, Hispanic Chamber of Commerce, Pier 39, and BOMA/Embarcadero.

Housing. This triad dealt with smoke free common areas of multi unit housing complexes and identifying secondhand smoke as a nuisance in multi unit housing complexes. Key informants included representatives from the Tenderloin Neighborhood Development Corporation, a Rent Board employee, SRO/Mission United, and the Housing Rights Committee.

Public Opinion Phone Survey: A public opinion survey was developed and also conducted by Dave Binder Research in April 2006 to measure support for 10 restrictions on smoking that would provide further protection from secondhand smoke.

• Removing owner operated bar exemption
• Hotel lobbies
• Increasing percentage of smoke free hotel and motel rooms
• Outdoor dining areas
• Near building entrances
• Outdoor recreation areas not already covered
• Outdoor waiting lines
• Common areas of multi unit housing complexes
• Identifying secondhand smoke as a nuisance in multi unit housing complexes
• Designating non smoking units in multi unit housing complexes
• Tobacco retail shops

A random sample of 600 San Francisco residents representing the demographic makeup of the city was selected and surveyed by telephone. Interviews were conducted in English, Cantonese, and Spanish. The survey included questions about the level of concern respondents had about secondhand smoke and how frequently the person was bothered by secondhand smoke, as well as questions about support for expanding protections from secondhand smoke exposure. The survey instrument also tested whether providing additional information on secondhand smoke would impact support.

Key informant interviews: Key informant interviews were to be conducted pre and post intervention activities. However, since the policy was not introduced to the Board of Supervisors before June 30, 2007, the only set of interviews that could be collected was for the pre intervention phase. In mid-June 2007, the TFP evaluator conducted 10 interviews. The evaluator developed the protocol for the interviews in conjunction with TFP staff (see Appendix A). These interviews were conducted with Tobacco Free Project staff, Tobacco Free Coalition members, and the San Francisco Bureau of Environmental Health. Initially policy makers involved in either supporting or opposing the proposed policy were also slated to be interviewed, however because the Coalition was still in delicate negotiations with Board members, it was decided these interviews should not be conducted at this time.

Due to the challenges faced in getting a member of the Board of Supervisors to sponsor the Secondhand Smoke Ordinance, time ran out before the ordinance was actually passed. As a result, no interviews with policy makers following passage of the ordinance could be conducted to gain Board members perspective about the strategies used by the Coalition and derive any lessons from their point of view for future efforts,

Data Analysis

Qualitative data obtained from the discussion groups and key informant interviews
were analyzed using standard techniques. For the discussion groups, documented responses and statements to identified policy options that receive favorable and unfavorable responses by stakeholders in each of the triad groupings were presented to Tobacco Free Project staff. Qualitative data was also analyzed to identify concerns, objections, and statements of support for the 9 different policy options. Common themes were identified and the impact of providing additional information about secondhand smoke was analyzed to see if providing certain additional information results in more or less favorable responses to the various policy options. For the key informant interviews, responses were grouped by question, summarized and then incorporated into the case study.

Quantitative data obtained from the phone survey was entered into an SPSS data base, cleaned and then a series of frequencies and cross-tabs were reviewed by Dave Binder Research staff and staff from the Tobacco Free Project.

Evaluation Results

Major Evaluation Findings

A secondhand smoke policy was developed that closes many of the loopholes in the previous secondhand smoke ordinance. The new policy will hopefully be introduced to the Board over the coming months.

A large amount of process data was collected throughout the three years to develop a policy that would both protect the greatest number of San Francisco residents and also have the support needed from Board members and the larger community to be passed. Reports on all of the data below have been submitted to the Tobacco Control Section as part of a number of progress reports, however highlights from each follow.

General Public Discussion Group Results

Six general public discussion groups were conducted in January 2006. A summary of key findings follows.

General opinions on secondhand smoke:

• Varying degrees of concern regarding secondhand smoke.
• Smokers and nonsmokers see indoor secondhand smoke as more of a danger than outdoor secondhand smoke.
• Many think that avoiding secondhand smoke outside is a personal issue rather than one to be regulated.
• Nonsmokers make an effort to avoid secondhand smoke and confront smokers only when necessary.

Awareness of current laws:

• Smokers and nonsmokers are aware of bans on smoking in public places, but some are confused about the specifics of the restrictions.
• Some smokers and nonsmokers were unclear about where smoking is allowed outside.

Opinion of current restrictions:

• Participants are satisfied with current levels of restrictions. There is little desire for changes to the current law.
• Smokers and nonsmokers both accept bans on smoking indoors, but many do not see a strong need to legislate outdoor smoking.
• Among those who think current bans are too restrictive, there is concern for the rights of individuals and businesses that are negatively impacted by the laws.

Support for future bans:

• Participants do not feel it is a priority for the city to increase restrictions on smoking in public places at this time.
• Participants cited smoker rights, privacy rights, and over-regulation as reasons to oppose further bans.
• Nonsmokers and smokers generally feel that smokers can police themselves, without the need for future legislation.
• Concerns are voiced about the difficulties of enforceability of any new legislation.

Support for specific restrictions:

• Nonsmokers support bans in outdoor recreation areas, indoor common areas, and the doorways of private buildings – places they use frequently.
• Smokers support bans in areas that don’t directly affect their lives or where they can choose not to go.
• Smokers oppose bans where they smoke and in places they view as open areas.

Facts on secondhand smoke:

• Reaction to facts about secondhand smoke was largely dependent on previously held beliefs about the dangers of smoking.
• The facts did impact opinion on future restrictions. Opinion was further entrenched among those who already support more bans while many of the participants who do not support further bans were at least moved to reevaluate their stance.

Stakeholder Discussion Group Results

Three stakeholder discussion groups – hospitality, outdoor, and housing – were conducted in February 2006. Some common themes from across the three interest groups were found:

• These stakeholders see indoor secondhand smoke as more of a danger than outdoor secondhand smoke. Many think that avoiding secondhand smoke is a personal issue, rather than one to be regulated.
• Participants are satisfied with current levels of restrictions and have little desire to change current laws.
• Reasons to oppose further bans include smoker rights, privacy rights, potential loss of business, and over-regulation.
• Concerns were voiced about the difficulties of enforcing any new legislation.
• Fewer cigarette butts was continually mentioned as a good incentive to support future bans.

Specific findings from summaries of the three triads follow:

Hospitality

Participants in the hospitality triad discussed proposed policies that prohibit smoking in hotel, youth hostel, and bed and breakfast lobbies, designate at least 75% of guestrooms as smoke free in tourist lodging facilities, and prohibit smoking in all bars and tobacco shops.

• Hospitality participants believe that local bans would have a negative impact on vendors in San Francisco, and they strongly prefer bans that are statewide rather than local.
• Participants generally support bans at building entrances and hotel lobbies, show limited support for bans in outdoor dining areas, and oppose regulating smoking in hotel rooms, believing that hotel rooms should be regulated by individual hotels.
• They agree that owner operated bars are a reasonable exemption from smoking restrictions.
• Facts regarding the health risks of secondhand smoke do not affect their opinion about secondhand smoke laws.
• Participants dismissed examples of current outdoor bans in other cities. The cities with bans are perceived to be very liberal and do not reflect how new laws banning secondhand smoke would impact San Francisco.

Hospitality participants were especially concerned that:

• Tourists will have difficulty with the laws
• There would be a strong negative impact for some business owners
• Radical changes might create stronger opposition from businesses
• San Francisco laws would disadvantage businesses here relative to other California cities.

Outdoor

Participants in the outdoor triad discussed policy proposals prohibiting smoking in outdoor areas of restaurants, cafes, and coffee shops; prohibit smoking in outdoor service areas such as ATMs, movie theater and concert event lines; prohibit smoking within 20 feet of private non-residential buildings entrances, exits, and operable windows, and prohibit smoking at street fairs and commercial piers such as Pier 39.

• Outdoor participants believed that many of the bans would be unenforceable, despite the fact that many participants support current regulations.
• Support was mixed for building entrances, but participants oppose most other bans because of the enforceability issue.
• Outdoor participants misinterpret the health facts on secondhand smoke. Statistics on low smoking rates in the City actually made participants see smoking issues as less of a problem and many wonder why it is necessary to have further bans if smoking isn’t prevalent in San Francisco.
• Overall, participants showed little concern for furthering smoking bans and do not want to shoulder the costs that would be associated with enforcing these laws.

Housing

The housing discussion group talked about a number of proposals. These include prohibiting smoking in enclosed common areas of multi unit residents, adding secondhand smoke to the list of defined public health nuisances, requiring at least 50% of existing units in multi unit residences be designated as smoke free, and requiring at least 75% of units in multi unit residences be designated as smoke free.

• The housing discussion group did not see secondhand smoke as a top concern among tenants. Participants agree that smoking in apartments does cause some issues for other residents, but they don’t support stronger bans.
• Participants see little need for further bans because of drawbacks to all the options, although they are most agreeable toward bans in indoor common areas.
• Despite concern that secondhand smoke negatively impacts residents, participants were hesitant to support laws that might have unintended consequences. For example, there was concern that bans on smoking inside apartments could be used by landlords to evict unwanted tenants – this is especially a concern for the nuisance law.
• Participants were also concerned that smoking bans would have strong negative effects for those who were formerly homeless and might push them back onto the street.
• Another objection to bans inside of apartments is that laws regulating a behavior are seen as a barrier to communication between affected groups and can intensify some problems.
• The triad also raised issues around privacy and individual rights that caused the group to resist any further regulation in individual residences.

Public Opinion Survey Results Highlights

A public opinion survey of 600 San Francisco adults was conducted in April 2006 in English, Cantonese, and Spanish. The survey included general questions related to the level of concern about secondhand smoke, how frequently the person was bothered by secondhand smoke, and questions about each of several policy options regarding secondhand smoke.

Survey results – provided to the task force in May 2006 – found that San Franciscans clearly identify secondhand smoke as a health problem.

• Over half (57%) of San Franciscans interviewed reported being occasionally or frequently bothered by secondhand smoke.
• San Franciscans support further restrictions on secondhand smoke. Nearly two-thirds (64%) support increasing restrictions on public smoking.
• Liberal women, parents, nonsmokers, and Asian San Francisco residents are the strongest supporters of future restrictions. Daily smokers, moderate and conservative men, African Americans, younger smokers and smokers without children are the most consistent opponents.

Survey respondents also support a variety of policy options to ban or limit secondhand smoke, as shown in Figure 5 and summarized below.

• San Franciscans strongly or somewhat support restrictions on smoking in hotel lobbies (65%) and hotel rooms (70%), outdoor dining areas (62%), outdoor waiting lines (60%), and near private non-residential building entrances (60%).
• Support (strong or somewhat) is much weaker for prohibiting smoking for owner operated bars (48%), street fairs (46%), Pier 39 (46%), golf courses (42%), and tobacco shops (35%)

San Franciscans are also quite supportive of increasing smoking restrictions in multi-unit housing complexes (Figure 6). Survey respondents strongly or somewhat support:

• Prohibiting smoking in the enclosed common areas of multi-unit apartment buildings (63%).
• Declaring exposure to secondhand smoke a nuisance in the multi-unit housing complex setting (66%).
• Prohibiting smoking in the enclosed common areas of apartment buildings (61%).

The level of support for expanding protections from secondhand smoke varied widely among different ethnic/racial groups, from 85% of Chinese respondents to 58% of white respondents.

Key Informant Interview Results

Evaluators conducted 10 key informant interviews in June 2007 (see Appendix A for interview protocol). Respondents included eight Coalition members, one TFP staff person, and one staff person from Environmental Health in the Department of Public Health. The findings are summarized below. Quotes taken from key informant interviews have been used in textboxes throughout the case study.

Respondents were asked about what they thought about the decisions the Coalition made concerning which elements of the new policy were “negotiable” and which were not.

• All of the respondents said they supported the decisions that were made. Respondents commented that the choices made were “reasonable,” “well thought out,” “strategic,” and “pragmatic” in considering different possibilities. The process was viewed as being very collaborative, democratic, and inclusive, one in which “we managed to come up as a team with what we wanted to stand for.”

Respondents were asked if compromises were made with which they didn’t agree.

• Three respondents said that nothing was compromised that they disagreed with. One disagreed with the policy maker who was chosen to introduce the legislation, even though at the time there wasn’t another alternative. Another felt that the coalition hadn’t really made any compromises, which resulted in the first policy maker backing out. And another thought that the coalition stayed in negotiations with the legislative aide longer than it should have.
• Respondents were asked to talk about the point at which the coalition realized it had to find another Board member to sponsor the ordinance.
• Most respondents expressed frustration – and being “blindsided” – when negotiations broke down after months of working with the legislative aide of a potential sponsor. One respondent said the Coalition had the impression that the Board member was on board, but in reality was not. Several respondents also commented on how the lack of communication between the aide and the supervisor damaged the process, resulting in the coalition “wasting a lot of time” negotiating with a Board member’s aide. One respondent, on the other hand, viewed the need to shift from one policy maker to another as a normal part of the political process.

Respondents listed other key barriers or challenges:

• There are challenges in working with social justice organizations such as tenants rights groups who would view policies like defining secondhand smoke as a nuisance as having the potential to negatively impact their constituents, e.g. landlords using the policy as a way to unfairly evict tenants. The coalition was not able to convince tenants rights representatives of the importance of keeping the nuisance provision in and the two groups were not able to find common ground around the issue, so it was deleted.
• There is an ongoing lack of broad awareness by the general population about secondhand smoke exposure as a serious health issue.
• It is difficult to get the attention of potential sponsors or their aides to try to set up meetings around election or budget time.
• A major challenge is being caught in events that are beyond the coalition’s control, such as working with a legislative aide who – it was later revealed – “was not being honest with the coalition.”
• There is currently no real champion for tobacco control on the Board of Supervisors.
• Maintaining continuity within the coalition when the current funding cycle ends – given the policy has not yet been introduced to the Board of Supervisors and the two coalition co-chairs are staff at agencies funded by TFP only through June 30 – will be a challenge.

Public opinion polls, stakeholder groups, and focus groups revealed significant support to close loopholes in the secondhand smoke ordinance previously passed in San Francisco. The results from the process data that was collected guided the formation of the policy. The areas that had considerable public support were incorporated into the ordinance proposed by the Coalition.

Despite their best efforts to negotiate in good faith, the ordinance has not yet been introduced due, in large part, to political circumstances beyond the control of the Coalition. Many lessons were learned from this experience:

• Have clear and up to date assessments on the legislators and their level of support for the issues, and to use that assessment in deciding which legislator to work with most closely as a sponsor.
• Talk directly to the supervisor from the beginning so that it is clear where he or she stands before beginning a negotiating process.
• Don’t put all our eggs in one basket regarding sponsorship. Go to a number of supervisors to see who is interested in sponsoring the policy instead of going to one at a time.
• Wait until the right policymaker is identified, ideally someone the coalition has worked well with in the past.

Have access to allies who can educate the coalition about how City Hall works. Remember this is a political process.

Consider that having a big menu with many different policies that you’re trying to pass in one effort makes it much more difficult to please many people on many different issues. Focusing on less rather than more would have helped the process.

Consider the many victories that have been won vs. the few battles left to fight in San Francisco. It’s great leadership development to get young people involved, but there should be a sense of scale – “we don’t need a hammer to push in a thumbtack.”

It’s a delicate process to balance the experience of staff in knowing how to accomplish objectives through the legislative process and their commitment to developing and honoring consensus. As seasoned leaders and mentors, staff have much to contribute to young people.

Many San Francisco politicians are tired of the issue. People coming up should be patient and stay with it. These are still important issues.

Find opportunities to present to and be in touch with members of the Board of Supervisors at least on an annual basis, not just when it is time to introduce legislation. Use information and education days with state legislators in Sacramento as a chance to talk about what the coalition is working on in tobacco control.

Be patient. It’s a process.

• What organization are you affiliated with?
• How long have you been involved with the TFP Coalition?
•  Were you a member of the SHS negotiating committee?
• If not what was your involvement in developing the SHS policy?
• How would you describe the strategy being used by the Coalition to get the SHS policy adopted?
• The policy you are trying to pass is designed to close some of the loopholes not covered in the SHS law that was previously passed. I know the Coalition met a number of times to decide which of the elements/parts of the new policy were ‘negotiable’ and which were not. What did you think of those decisions?

Do you feel the coalition had made compromises you didn’t agree with? If so explain?

I know at one point you had to switch sponsors and find another member of the Board to sponsor the ordinance. Can you tell me a little about that?

What lessons do you think should be learned from the Coalition’s efforts to get the new SHS policy passed?