Enforcement strategies for effective smoke-free policy implementation: A systematic review

Background: Enforcement strategies are often cited as critical to the initial success and adoption of a smoke-free policy; however, there is limited literature guiding their implementation and use. Aims: A systematic review of the effectiveness of enforcement strategies that aim to facilitate the implementation of and compliance with smoke-free environment policies relating to both the person(s) responsible for the smoke-free space and to individual smokers was conducted. Methods: Medline, Medline in Process, The Cochrane Library, Embase, PsycInfo and CINAHL databases were searched using MeSH and keywords for relevant studies published between January 1980 and September 2015. A methodological quality assessment and narrative analysis of included studies was undertaken. Results: Twenty-four studies were identified; 19 related to the person(s) responsible for the smoke-free space, 4 studies related to the behavior of the individual smoker and 1 related to both. Policy promotion and awareness raising activities, signage and enforcement officers or penalties for violations were the enforcement strategies most frequently cited as being associated with successful policy implementation. In terms of compliance, total smoke-free bans were easier to comply with compared to policies that had only partial restrictions. Additionally, workplaces were more likely to comply with smoke-free policies where they were aware of the laws, had non smoking management and lower staff smoking rates and were members of a network guiding the policy implementation. Conclusions: This review outlines enforcement strategies necessary for the successful implementation of smoke-free policies as well as factors to consider that may impact on policy compliance. Translational research aspect: Traditionally, the responsibility has been on the introduction of smoke-free policies across a range of environments and settings. However, there is limited information available to guide the inclusion of effective enforcement strategies that translate to increased policy compliance. This research is in T3 stage on the translational pipeline.