Establishing the public health evidence for policy change is critical to engaging diverse stakeholders with varied tobacco-related interests and for policy implementation and compliance (9). We outlined 4 main areas of evidence related to an outdoor smoke-free policy affecting municipal spaces. First, secondhand smoke can be harmful not only indoors but also in outdoor settings (10). Children, with their developing lungs, are particularly vulnerable to secondhand smoke (11), and in 2010, 23% of children in Philadelphia had been diagnosed with asthma (PHMC data, 2010).

Second, smoke-free policies support a normative message that smoking is unsafe and that nonsmokers have the right to be protected. This is especially significant for children because children are influenced by their perceptions of normal behavior (12). Clean indoor air laws are associated with lower odds of youth progressing from experimental to regular smoking (13). Accordingly, places that serve youth should be protected spaces for children.

Third, smoke-free policies are a strong motivator for smokers to try to quit. Smoke-free workplace policies are associated with increased cessation attempts (14). Because the City of Philadelphia employs 25,000 staff members and provides primary care to 90,000 patients through 8 community health centers, it stands much to gain from increased attempts to quit smoking and decreased smoking.

Fourth, outdoor smoke-free policies can alleviate sanitation burdens related to discarded cigarette butts and packages. Municipal cost savings are particularly important when localities are facing budget constraints. One analysis suggests that every pack of cigarettes leads to $0.22 in litter removal costs (15). This results in millions to tens of millions of dollars in costs annually for a large city.

Key internal and external stakeholders included 1) civic leaders, 2) PPR leadership and staff, and 3) community and public health advocates, including youth. Stakeholder engagement focused on identifying motivators for and concerns about outdoor smoke-free policies and deciding which spaces should be included in such policies.

Having championed passage of CIAWPL, the mayor knew of the tobacco control challenges in Philadelphia and the importance of smoke-free policies. A focus on child-serving institutions within government aligned with 1 of the mayor’s core objectives — improving children’s health and education. Thus, in mid-2010, he directed PDPH to explore outdoor smoke-free policy options with PPR leadership.

PDPH initiated a conversation with PPR in fall 2010. Discussion centered on the public health benefits of focusing on child-serving spaces and the potential challenges with compliance. PDPH had learned from other jurisdictions that signage, earned media, and staff and patron education could be sufficient for achieving compliance (4). PDPH and PPR discussed how these tasks could be shared across agencies and, as appropriate, with external partners.

PPR oversees municipal recreation centers (n = 55), playgrounds (n = 97), pools (n = 70), and parks (n = 64) serving millions of visitors annually. The first 3 spaces are clustered in low-income neighborhoods and used primarily by children during after-school hours and by families on weekends (Figure 1). As in many large cities, recreation centers in Philadelphia are large complexes comprising athletic fields, playgrounds, buildings, and, in some cases, pools.

PDPH and PPR decided to focus on these child-serving spaces because they allowed for the strongest case to be made about public health benefits, mitigating harm from secondhand smoke, and creating nonsmoking norms. Additionally, parks presented numerous logistical barriers. Philadelphia’s parks system consists of 63 small neighborhood parks and Fairmount Park, an 8,000-acre park with vast green spaces, performance venues, museums, and historical buildings. PPR leadership noted that Fairmount Park’s size would make implementation in that setting particularly difficult. Moreover, neighborhood parks are represented by a decentralized network of local associations with varying degrees of influence, creating potential barriers to consensus development.

PPR leadership contacted 2 groups in late 2010 and early 2011 regarding a smoke-free policy for recreation spaces: on-the-ground agency staff and resident-led advisory councils. Key staff included 8 district managers, who oversee 10 to 15 recreation centers each. They expressed concerns similar to those of PPR leadership regarding enforcement, particularly in light of more pressing challenges such as violence and drug use on recreation center grounds. These issues were addressed in the educational sessions provided to PPR staff before roll-out. Advisory council leaders, who also have long-standing community ties to recreation centers, were generally supportive of the policy change. They identified a smoke-free policy as a way to protect children and perceived such policy as a natural extension of recreation center standards. Although accommodating adult smokers (both staff and patrons) was discussed, designated smoking areas were rejected because they would compromise the core goal of protecting children from the normative effects of seeing trusted adults smoking.

PDPH also engaged community and public health leaders outside of government through a variety of existing forums. The SmokeFree Philly Coalition brings together cessation providers, clinicians, employers, insurers, and public health organizations to promote cessation, decrease smoking initiation, and reduce secondhand smoke exposure among Philadelphians. The coalition recommended involving clean air and environmental organizations as allies, enhancing cessation support for municipal employees directly affected by the policy, and incorporating youth voices in the policy launch. To this point, the Philadelphia Youth Commission — comprising 15 youth commissioners appointed by the mayor and city council to represent the city’s youth — served as a critical partner. Commission members emphasized that teens are frequent users of recreation centers and pools even though most programming is oriented toward younger children. They also expressed interest in helping communicate the benefits of smoke-free spaces to peers, adults, and the media.

PDPH also presented evidence on the public health effects of smoke-free policies to the Get Healthy Philly Leadership Team, which is chaired by the mayor and includes leaders from private corporations, universities, health insurers, foundations, the School District of Philadelphia, and city council. Members viewed a smoke-free recreation policy as a natural extension of the city’s prior clean indoor air efforts and cited the new policy as motivation for other large employers to make their outdoor campuses smoke-free.

At the direction of the mayor, PDPH considered various vehicles for enacting the smoke-free policy (Table 2). Potential vehicles included legislation via city council, a regulation from a city agency, and an executive order of the mayor. PDPH leadership consulted with its legal counsel early in the process to vet these options because local policy vehicle options depend on local and state laws.

Each policy vehicle has potential benefits and risks (Table 2). An executive order is a mayoral directive that affects management and operations of city government but lacks the full force of law. An executive order alone would not have been enforceable among the general public but can still be a powerful tool in commanding attention for an important issue. Legislation and regulation (rule making), on the other hand, carry the full force of law but each has pros and cons. A regulation is potentially quicker and involves the agency responsible for implementation; however, administrative regulators are perceived as less accountable because they are not elected, and a successor administration may quickly reverse a regulation. Legislation is potentially slower and may not sufficiently engage the agency responsible for implementation; nevertheless, legislators are directly accountable to the people, and efforts to reverse a policy will also require legislative action.

We targeted recreation centers and not parks more broadly, confirmed widespread stakeholder support, and focused on the public health benefits of protecting children from secondhand smoke. The mayor decided that these factors allowed the city to proceed with an executive order (directing the Parks and Recreation Commissioner to adopt a smoke-free policy) and PPR regulation (adopting a smoke-free policy). The executive order helped garner media attention and demonstrated the mayor’s strong commitment to this policy, and the regulation gave the policy the full force of law.

Once agreement was reached on the policy and the policy enactment vehicle, PDPH and SmokeFree Philly Coalition members began educating recreation center directors in early 2011. Seven sessions were conducted at meetings with individual district managers and the directors of the 10 to 15 recreation centers overseen by them. Education focused on the policy rationale; its applicability to all recreation centers, playgrounds, and pools; and how PPR staff should respond to noncompliance. Practical suggestions included pointing to a nearby smoke-free sign, providing a wallet card with information on cessation resources, and politely asking patrons to stop smoking. We believed that enforcement could be accomplished by educating patrons and encouraging self-enforcement, not by punishing or fining (4).

Recreation center leaders were provided with more than 4,000 wallet cards and 250 informational posters (Figure 2) for distribution and posting. PDPH developed a hotline through which staff and patrons could report violations of the policy. In response, PDPH educators would reach out to recreation center leaders to reinforce the policy and, as needed, provide in-person education for staff and patrons. PDPH distributed a memorandum explaining the policy to more than 400 sports leagues that hold permits for using PPR facilities. The memorandum was tailored to league organizers and coaches who could communicate the policy change to players and families.

Another key aspect of enforcement was facilitating compliance through cessation support because smoke-free policies can induce smokers to make quit attempts (14). Wallet cards, informational posters, and signage were meant to encourage people to call the Pennsylvania Free Quitline (1-800-QUIT-NOW) and visit a website (www.smokefreephilly.org). PDPH and PPR staff collaborated to offer free community-based cessation classes at recreation centers. Even before adopting an outdoor smoke-free policy, the City of Philadelphia expanded cessation benefits for 7,000 city employees and their dependents. PDPH partnered with local Medicaid plans to put Food and Drug Administration (FDA)-approved cessation therapies on their formularies at low to no cost for patients. PDPH implemented a large mass media campaign to promote quitting and sponsored a quitline-based nicotine patch giveaway in 2010 and 2011 for 10,000 Philadelphians.

In May 2011, Mayor Michael Nutter signed Executive Order 5–11 at Kingsessing Recreation Center. Attendees included Health and Parks and Recreation commissioners, a youth commissioner, and children from the neighborhood. We selected the location based on high rates of smoking in the area, and we facilitated youth involvement by selecting locations with child-oriented facilities (eg, swing sets), and proximity to a nearby school. This setting highlighted the policy’s public health potential to reduce secondhand smoke exposure of vulnerable populations and promote nonsmoking norms. Press, partners, and community members attended the event in response to a media advisory, a press release, and communications through the SmokeFree Philly Coalition.

In subsequent weeks, PDPH and SmokeFree Philly Coalition members continued educational sessions with recreation center leaders, sports league organizers and coaches, and other stakeholders. In July 2011, the Parks and Recreation commissioner promulgated a regulation making city recreation centers and playgrounds smoke-free. The regulation became effective in August 2011. During the next 6 months, more than 1,000 permanent smoke-free signs were installed at all recreation centers, playgrounds, and pools.