In the past 2 decades, a growing body of scientific evidence has demonstrated the dangers of secondhand smoke (1,2). New evidence showing that secondhand smoke in outdoor areas also presents health risks (3) has elevated efforts to control tobacco use in outdoor spaces and recreational areas to protect people from exposure to secondhand smoke. Furthermore, prohibiting smoking in parks, on beaches, and in other outdoor recreation areas reduces tobacco litter (ie, cigarette butts) and its resulting toxins, which can be harmful (4), and discourages adults from modeling smoking, which may influence youth (5). Finally, most US citizens support smoke-free policy in many outdoor recreation areas (6,7). For all these reasons, securing outdoor smoke-free policy has become a recommended strategy by the Centers for Disease Control and Prevention (CDC) for states and local jurisdictions (8), and California's tobacco control program likewise supports community policies to restrict outdoor area smoking (9).

Policy theorists and tobacco control researchers provide some guidance in their analysis of factors that lead to successful local policy change (10-12). Many variables may explain adoption of policy, including the support of key decision makers, emulation of comparable jurisdictions (13), and alignment of the policy with the local political climate (12,14). Affluent communities appear more likely to support costly local policies (12-14). There is also evidence that the presence of "political entrepreneurs" and strong advocacy organizations facilitate policy adoption (15,16). Finally, the likelihood of local policy adoption of smoking-related laws is higher when the local health community promotes the efforts (17).

Since 2000, local jurisdictions in California have enacted hundreds of policies and ordinances in an effort to protect their citizens from the harmful effects of secondhand smoke. The California Tobacco Control Program (CTCP) funds tobacco control programs of county health departments statewide, a small number of metropolitan areas, and selected community-based organizations, and supports the Tobacco Control Evaluation Center (TCEC) of the University of California, Davis. CTCP coordinates a comprehensive approach of multifaceted strategies; its goal is "to change the broad social norms around the use of tobacco," and by doing so "creating a social environment and legal climate in which tobacco use becomes less desirable, less acceptable, and less accessible" (18). Local projects focus on 1 or more programmatic objectives, such as implementing tobacco retail licensing, limited smoking in apartment complexes, and increasing the number of smoke-free outdoor spaces and recreational facilities. At the conclusion of their work, they are required by CTCP to submit final evaluation reports (FERs), which TCEC analyzes and scores.

Despite the evidence of the many external factors that are related to adoption of tobacco control policies, little is known about the strategies local organizations use to change local policies. Our objective was to analyze local policy initiatives to identify common strategies used to adopt smoking policies in outdoor spaces and recreational areas at the local level in California.

FERs followed a standard format that included an abstract, introduction, intervention activities, evaluation methods and results, and conclusions and recommendations. Each main section included subsections of required information. TCEC scored FERs to ensure accountability and to offer feedback to the local projects for future tobacco control evaluations. Of the 400 FERs submitted, we selected only those with an objective related to adopting smoke-free policy in outdoor spaces and recreational areas for analysis. Outdoor spaces and recreational areas included parks, beaches, piers, sport stadiums, and places where other local community events are held, including fairs, rodeos, and parades. Local projects submitted FERs in June and July of 2007, and we analyzed them between May and September of 2010.

We used a qualitative data analysis with an evolving coding scheme (19) to identify strategies employed in promoting smoking policies in outdoor spaces and recreational areas. Local FERs were analyzed, and variables emerged during the coding process. The data used for this study were collected from 23 FERs that 20 local tobacco control projects submitted to CTCP for the 2004 through 2007 funding period.

After identifying the relevant FERs, a reviewer used open coding, whereby "similar events/actions/interactions are grouped together to form categories and subcategories" (20). As in grounded theory field work (21), categories emerged from the reading of the first papers through "questioning and constant comparison" and were modified and expanded with the reading of subsequent papers. This quasi-inductive, pattern-level analysis considered the frequency, weight, and contextual factors of items across FER data (22). The reviewer performed several readings of all reports. After the reviewer had coded all reports, she created summary tables and narratives. Then, a second reviewer read all reports to confirm or dismiss any categorization, to look for trends that were missed, and to seek evidence that conflicted with the first reviewer's findings (23). Two other members of the research team then compared the results to findings in existing literature.

Nineteen of the 20 projects passed some form of policy to promote smoke-free recreational facilities (Table). The 1 project unable to secure passage of an official policy did succeed in having its county board of supervisors approve a preliminary plan. Some projects advocated for voluntary or administrative changes that could be made without a formal vote, such as making a music festival or a ski resort smoke-free. Other projects sought policy changes with local fair boards to add smoke-free days to county fairs or rodeos, which typically required a formal vote of the respective boards. Policies pursued by projects working with city councils ranged from seeking a single smoke-free park to enacting smoke-free policies that affected all parks and recreational areas in the city's jurisdiction. In 2 cases, policies legislated at the county level provided the impetus to municipalities in the county to create and enact their own citywide ordinances. Projects unable to secure stringent legislative policies sometimes decided to pursue more "doable" administrative or voluntary policies in their place.

Securing passage of policy was often difficult. The FERs described various challenges, including polarization related to perceived economic and individual rights issues, difficulties in gaining access to policy makers, internal organizational barriers such as staff turnover, and local political orientation that centered around conservative versus liberal viewpoints of the proposed policies (24).

Six strategies for success emerged from our analysis: 1) having a "champion" who helped to carry an objective forward, 2) tapping into a pool of potential youth volunteers, 3) collecting and using local data as a persuasive tool, 4) educating the community in smoke-free policy efforts, 5) working strategically in the local political climate, and 6) framing the policy appropriately.

For the most part, our findings confirmed the results from other studies on policy change. For instance, several communities benefited from being near cities or counties that had already passed outdoor smoking bans, normalizing the issue for policy makers (26). The policy literature concludes that less affluent rural areas may face resistance to tobacco control regulations (12), which may explain why projects located in rural, less affluent counties were more likely to pursue weaker voluntary and administrative policy changes. Our findings that local health departments tailored policies to the local political climate and that they enlisted an influential champion to take up the cause follow the conclusions of existing literature (12,14-16), as does the influence of a health agency in the advocacy process (17). Also consistent with findings from other studies on tobacco control policy at the local level (14,26), we found no reports of tobacco industry lobbying.

This study identified 2 effective strategies used in local policy change not previously mentioned in other studies: 1) using local data to advance a policy position to decision makers, particularly displaying cigarette litter as a visual representation of the environmental problems that smoking causes, and 2) training youth advocates to collect cigarette litter and to present their findings to policy makers. These strategies are relevant for environmental policy change, which tended to appeal to constituents and decision makers across the political spectrum. In essence, these strategies enabled local projects to frame the issue around the more intuitively compelling issue of environmental protection as opposed to the less persuasive issue of secondhand smoke, which is perceived by the public and by policy makers as an indoor, not an outdoor, health problem. In many cases, policy makers who opposed the latter point on the basis of economic or individual-rights arguments (24) could still agree with a proposed outdoor smoke-free policy in the context of more wide-ranging local environmental concerns. Likewise, using youth volunteers to present the policy argument to decision makers tended to fortify the value of these policy positions.

This study also offers a more nuanced view of local tobacco control policy change, where policies are enacted not only by city councils or county boards of supervisors, but also by rodeo and fair boards, organizers of outdoor fairs and concerts, and administrators of parks and recreation districts. Policies can be legislative changes passed by elected officials, voluntary changes by concert organizers, or administrative changes by a host of different local agencies and organizations. The range of voluntary to legislative policies is in keeping with the "continuum of tobacco control policy" concept of Francis et al that progresses over time from voluntary to enforceable legislative policy (9).

One unexpected finding was the similarity of many of the policy strategies used in outdoor spaces and recreation areas to policy strategies used in other tobacco control policy campaigns. Blaine et al reached similar conclusions from their evaluation of 7 communities that successfully used similar methods to reduce youth access to tobacco. The authors concluded that a general set of strategies could be applied successfully to almost any "narrowly focused public health problem" (26).

We also did not anticipate that 19 of the 20 cases we studied would successfully enact smoke-free policies. This finding could be interpreted to mean that policy to create smoke-free outdoor areas is simple to enact; alternatively, we would argue that the projects in this study correctly assessed their local political climates and tailored their approaches accordingly. They were sufficiently sophisticated to propose voluntary or administrative policy change when they anticipated resistance to outdoor smoke-free policies, recognizing the need to postpone plans for adopting more stringent legislative policy.

One limitation of this study is that the findings are not necessarily generalizable, in part because of the unique support the local projects in this study received from the state tobacco control program. CTCP guarantees minimum funding to local health departments, encourages local policy change to reduce exposure to secondhand smoke, and hosts frequent training sessions for staff on community organizing and assessment, factors that give these projects certain advantages. Another limitation is that the number of projects for this comparative analysis was small. However, these 20 projects covered more than 200 communities in California, so the effect of their enacted policies is potentially large.

Smoke-free outdoor policies are a relevant new area in tobacco control efforts and are consistent with CDC's emphasis on eliminating tobacco smoke from public areas (8). To our knowledge, this study is the first to investigate the internal strategies that advance local smoke-free outdoor policies. More research on this topic is needed to determine whether these strategies are equally effective when used by nongovernmental agencies that are funded for a limited time and to isolate the factors that explain the diffusion of new outdoor smoke-free policies across jurisdictions. A careful examination of the effect of outdoor policies on protection from secondhand smoke, reduction of negative modeling for children, and reduction of litter and toxins from cigarette butts would add public health legitimacy to this policy approach.