A Policy Analysis of Preparedness for Hurricane Evacuations in the United States, 1990 to 2019: Implementation in Coastal States.

Hurricane or typhoon evacuations in the United States are typically managed by state, territorial, or tribal emergency management officials with federal, state, and local agency operational support. The evacuation process may involve issuing mandatory or "voluntary" evacuation orders to alert the community and mitigate loss of life and injury. We conducted an analysis of state and local hurricane evacuation policies identified through a literature review (January 1990 to June 2019) and key informant interviews with state public health and emergency management officials in Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas in October and November 2019. Findings from the literature review show that most gaps in hurricane evacuation preparedness-based on 44 policy-related publications identified in the review-could be categorized into 4 themes: shelters, evacuation decisionmaking, at-risk populations, and transportation. Findings from key informant interviews for 7 states revealed that coastal states have been able to address most of these gaps since Hurricane Katrina in 2005. However, an important remaining gap in preparedness is providing timely warnings to at-risk populations during hurricane evacuations.

Hurricane Evacuation Laws in Eight Southern U.S. Coastal States - December 2018.

National Preparedness month is observed every September as a public service reminder of the importance of personal and community preparedness for all events; it coincides with the peak of the hurricane season in the United States. Severe storms and hurricanes can have long-lasting effects at all community levels. Persons who are prepared and well-informed are often better able to protect themselves and others (1). Major hurricanes can devastate low-lying coastal areas and cause injury and loss of life from storm surge, flooding, and high winds (2). State and local government entities play a significant role in preparing communities for hurricanes and by evacuating coastal communities before landfall to reduce loss of life from flooding, wind, and power outages (3). Laws can further improve planning and outreach for catastrophic events by ensuring explicit statutory authority over evacuations of communities at risk (4). State evacuation laws vary widely and might not adequately address information and communication flows to reach populations living in disaster-prone areas who are at risk. To understand the range of evacuation laws in coastal communities that historically have been affected by hurricanes, a systematic policy scan of the existing laws supporting hurricane evacuation in eight southern coastal states (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas) was conducted. After conducting a thematic analysis, this report found that all eight states have laws to execute evacuation orders, traffic control (egress/ingress), and evacuation to shelters. However, only four of the states have laws related to community outreach, delivery of public education programs, and public notice requirements. The findings in this report suggest a need for authorities in hurricane-prone states to review how to execute evacuation policies, particularly with respect to community outreach and communication to populations at risk. Implementation of state evacuation laws and policies that support hurricane evacuation management can help affected persons avoid harm and enhance community resiliency (5). Newly emerging and re-emerging infectious diseases, such as SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), have and will continue to additionally challenge hurricane evacuations.

Attitudes, Motivators, and Barriers to Emergency Preparedness Using the 2016 Styles Survey.

This study assessed adults' perceptions toward preparedness to better inform emergency planning efforts for households and communities. The 2016 Styles, an Internet panel survey, was used to assess emergency preparedness competencies. Descriptive analyses were performed to describe the sociodemographic factors by preparedness status. Multivariable logistic regressions were used to examine the association between perceived preparedness and characteristics associated with preparedness attitudes, motivators, and barriers. Approximately 40% of adults surveyed reported that they were prepared for emergencies. The main motivator for those prepared was awareness of local disasters (38.9%), and a leading barrier was confusion about how to plan for the unknown (23.7%). Those prepared were more likely to have the right supplies (adjusted odds ratio [AOR] = 1.25, 95% confidence interval [CI] = [1.05, 1.50]), discuss emergency plans (AOR = 1.21, 95% CI = [1.02-1.42]), and act before an emergency occurred (AOR = 1.35, 95% CI = [1.15, 1.59]), compared with adults who did not report being prepared. Results from this research indicate that identifying motivation to prepare for emergencies can contribute to public health disaster planning. Preparation is a critical step that allows the community and its citizens to be more equipped to function during and after a disaster.

Community Lifeline Framework for Leveraging Stabilization in Response and Recovery to Major Hurricanes.

The United States (US) and Caribbean regions remain vulnerable to the impact of severe tropical storms, hurricanes, and typhoons. In 2017, a series of hurricanes posed threats to residents living in inland and coastal communities as well as on islands isolated from the US mainland. Harvey, Irma, Jose, and Maria caused catastrophic infrastructure damage, resulting in a loss of electrical power and communications due to damaged or downed utility poles, cell towers, and transmission lines. Critical services were inoperable for many months. Emergency managers are public officials who are accountable to both political leaders and the citizens. During disaster events, emergency managers must prioritize areas of effort, manage personnel, and communicate with stakeholders to address critical infrastructure interdependences. Essential lifeline services (eg, energy and communications) were inoperable for many months, which led to increased attention from policy-makers, media, and the public.

Cigarettes point of purchase patterns in 19 low-income and middle-income countries: Global Adult Tobacco Survey, 2008-2012.

BACKGROUND: There is little information on cigarette-purchasing behaviour among smokers globally. Understanding cigarette purchase and point-of-sale patterns can help guide the development and implementation of tobacco-control strategies in retail environments. OBJECTIVE: The purpose of this study was to identify where adults in 19 countries last purchased cigarettes. METHODS: Data were from 19 low-income and middle-income countries that conducted the Global Adult Tobacco Survey (GATS) during 2008-2012. GATS is a nationally representative household survey of adults aged 15 years or older using a standardised protocol to measure tobacco-related behaviours. Data were weighted to yield nationally representative estimates within each country and summarised by using descriptive statistics. RESULTS: Overall prevalence of current cigarette smoking ranged from 3.7% in Nigeria to 38.5% in the Russian Federation. Among current cigarette smokers, locations of last purchase were as follows: stores, from 14.6% in Argentina to 98.7% in Bangladesh (median=66.8%); street vendors, from 0% in Thailand to 35.7% in Vietnam (median=3.0%); kiosks, from 0.1% in Thailand to 77.3% in Argentina (median=16.1%); other locations, from 0.3% in China and Egypt to 57.5% in Brazil (median=2.6%). CONCLUSION: Cigarettes are purchased at various retail locations globally. However, stores and kiosks were the main cigarette purchase locations in 18 of the 19 countries assessed. Knowledge of where cigarette purchases occur could help guide interventions to reduce cigarette accessibility and use.

School District Crisis Preparedness, Response, and Recovery Plans - United States, 2006, 2012, and 2016.

Children spend the majority of their time at school and are particularly vulnerable to the negative emotional and behavioral impacts of disasters, including anxiety, depressive symptoms, impaired social relationships, and poor school performance (1). Because of concerns about inadequate school-based emergency planning to address the unique needs of children and the adults who support them, Healthy People 2020 includes objectives to improve school preparedness, response, and recovery plans (Preparedness [PREP]-5) (2). To examine improvements over time and gaps in school preparedness plans, data from the 2006, 2012, and 2016 School Health Policies and Practices Study (SHPPS) were analyzed to assess changes in the percentage of districts meeting PREP-5 objectives. Findings from these analyses indicate that districts met the PREP-5 objective for requiring schools to include post-disaster mental health services in their crisis preparedness plans for the first time in 2016. However, trend analyses did not reveal statistically significant increases from 2006 to 2016 in the percentage of districts meeting any of the PREP-5 objectives. Differences in preparedness were detected in analyses stratified by urbanicity and census region, highlighting strengths and challenges in emergency planning for schools. To promote the health and safety of faculty, staff members, children, and families, school districts are encouraged to adopt and implement policies to improve school crisis preparedness, response, and recovery plans.

Enhancing individual and community disaster preparedness: Individuals with disabilities and others with access and functional needs.

Preparedness planning is essential to minimizing the impact of disasters on communities and individuals. Attention to the needs of people with disabilities is vital as they have additional needs before, during and after a disaster that are specific to the disabling condition. In this Commentary, we emphasize national guidelines on disability inclusion in emergency preparedness. We examine some potential areas of planning and response that need attention as suggested by preparedness data for people with self-reported disabilities (also referred to as access and functional needs) and highlight selected resources (e.g., tools, trainings, and online webinars) to enhance whole community preparedness and disability inclusion efforts. This Commentary intends to bridge the gap between those various facets of preparedness, at all levels of government and among individuals, with the aim of ensuring that the whole community is prepared to adapt, withstand and rapidly recover from disruptions due to disasters.

Point-of-sale cigarette purchase patterns among U.S. adult smokers-National Adult Tobacco Survey, 2012-2014.

Tobacco products are ubiquitous in most U.S. retail environments. Given that data on preferred point-of-sale purchase locations among U.S. adult tobacco users are limited, an enhanced understanding of tobacco purchase locations can help inform tobacco control policy, planning, and practice. We investigated prevalence and sociodemographic characteristics associated with cigarette purchase location among U.S. adult smokers. Pooled data came from the 2012-2013 (N=60,192) and 2013-2014 (N=75,233) National Adult Tobacco Surveys. Current cigarette smokers (n=18,005) aged ≥18 were asked if they purchased cigarettes within the previous 30days (n=15,182) and, if so, where they last purchased cigarettes. In 2016, logistic regression adjusted for sex, age, race/ethnicity, education level and annual household income was used to assess characteristics associated with purchase location. Among current smokers, 90.2% reported purchasing cigarettes in the past 30days. The most common purchase locations were convenience stores/gas stations (69.1%), tobacco discount stores (9.9%), drug stores (5.0%), supermarkets (4.9%), and liquor stores (3.6%). The odds of purchasing cigarettes at convenience stores/gas stations were higher among men (adjusted odds ratio (AOR)=1.4; 95% confidence interval (CI)=1.2-1.5) than women; and among adults aged 18-24 (AOR=3.1; 95% CI=2.4-3.9), 25-44 (AOR=3.1; 95% CI=2.7-3.7), and 45-64years (AOR=1.8 95% CI=1.6-2.1) than adults aged ≥65years. Over two-thirds of U.S. smokers last purchased cigarettes from convenience stores/gas stations. Understanding the relationship between purchase location and smoker characteristics may inform tobacco control strategies in the retail environment.

Smoke-Free Rules and Secondhand Smoke Exposure in Vehicles among U.S. Adults-National Adult Tobacco Survey, 2009-2010 and 2013-2014.

In the United States (U.S.), secondhand smoke (SHS) exposure causes more than 41,000 deaths among nonsmoking adults annually. Adoption of smoke-free laws in public areas has increased, but private settings such as vehicles remain a source of SHS exposure. This study assessed change in voluntary smoke-free vehicle rules and SHS exposure in personal vehicles among U.S. adults between two periods, 2009-2010 and 2013-2014, using data from the National Adult Tobacco Survey (NATS). NATS is a national landline and cellular telephone survey of non-institutionalized adults aged ≥18 years in the 50 U.S. states and the District of Columbia. We assessed percentage change in the prevalence of smoke-free vehicle rules among all adults and SHS exposure in vehicles among nonsmoking adults, overall, by sociodemographic factors (sex, age, race/ethnicity, education, marital status, annual household income, U.S. region), and by cigarette smoking status. During 2009-2010 to 2013-2014, the percentage of adults with a 100% smoke-free vehicle rule increased from 73.6% to 79.5% (% change = +8.0%; p < 0.05). Among nonsmokers, SHS exposure in vehicles in the previous 7 days decreased from 9.2% to 8.2% (% change = -10.9%; p < 0.05). Smoke-free rules in private settings such as vehicles, in coordination with comprehensive smoke-free policies in indoor public settings, can help reduce SHS exposure and promote smoke-free norms.

National and State-Specific Attitudes toward Smoke-Free Parks among U.S. Adults.

Outdoor places, such as parks, remain a source of secondhand smoke (SHS) exposure. We assessed attitudes toward smoke-free parks among U.S. adults. Data came from the 2009-2010 National Adult Tobacco Survey, a landline and cellular telephone survey of noninstitutionalized adults aged ≥18 in the 50 U.S. states and D.C. Descriptive statistics and logistic regression were used to assess the prevalence and sociodemographic correlates of attitudes toward smoke-free parks, overall and by current tobacco use. Overall, 38.5% of adults reported favorable attitudes toward complete smoke-free parks; prevalence ranged from 29.2% in Kentucky to 48.2% in Maine. Prevalence of favorable attitudes toward smoke-free parks was higher among nonusers of tobacco (44.6%) and noncombustible-only users (30.0%) than any combustible users (21.3%). The adjusted odds of having a favorable attitude were higher among: women; Hispanics and Black non-Hispanics, American Indian and Alaska Native non-Hispanics, and other non-Hispanics; those with an unspecified sexual orientation; and those with children aged ≤17 in the household, relative to each characteristics respective referent group. Odds were lower among: any combustible tobacco and noncombustible-only tobacco users; adults aged 45-64; and those with some college or an undergraduate degree. Opportunities exist to educate the public about the benefits of smoke-free outdoor environments.

School District Crisis Preparedness, Response, and Recovery Plans - United States, 2012.

The unique characteristics of children dictate the need for school-based all-hazards response plans during natural disasters, emerging infectious diseases, and terrorism (1-3). Schools are a critical community institution serving a vulnerable population that must be accounted for in public health preparedness plans; prepared schools are adopting policies and plans for crisis preparedness, response, and recovery (2-4). The importance of having such plans in place is underscored by the development of a new Healthy People 2020 objective (PREP-5) to "increase the percentage of school districts that require schools to include specific topics in their crisis preparedness, response, and recovery plans" (5). Because decisions about such plans are usually made at the school district level, it is important to examine district-level policies and practices. Although previous reports have provided national estimates of the percentage of districts with policies and practices in place (6), these estimates have not been analyzed by U.S. Census region* and urbanicity.(†) Using data from the 2012 School Health Policies and Practices Study (SHPPS), this report examines policies and practices related to school district preparedness, response, and recovery. In general, districts in the Midwest were less likely to require schools to include specific topics in their crisis preparedness plans than districts in the Northeast and South. Urban districts tended to be more likely than nonurban districts to require specific topics in school preparedness plans. Southern districts tended to be more likely than districts in other regions to engage with partners when developing plans. No differences in district collaboration (with the exception of local fire department engagement) were observed by level of urbanicity. School-based preparedness planning needs to be coordinated with interdisciplinary community partners to achieve Healthy People 2020 PREP-5 objectives for this vulnerable population.

Perceptions of harm from secondhand smoke exposure among U.S. adults, 2009-2010.

BACKGROUND: Exposure to secondhand smoke (SHS) causes significant disease and death. We assessed the prevalence and correlates of perceptions about the health harm of SHS among U.S. adults at the national and state level. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a national landline and cellular telephone survey. Perceptions about the health harms of SHS were assessed as follows: 'not at all harmful', 'somewhat harmful', and 'very harmful'. Descriptive statistics were used to assess the prevalence of SHS harm perceptions by tobacco use and sociodemographic factors, including sex, age, race/ethnicity, education, marital status, annual household income, region, sexual orientation, children in the household, and smoke-free law coverage. Logistic regression was used to assess odds of perceiving SHS to be "very harmful" (vs. "not at all harmful" or "somewhat harmful"), adjusting for the aforementioned factors. RESULTS: Nationally, 64.5 % of adults perceived SHS as 'very harmful' (state range: 73.5 % [Utah] to 53.7 % [Kentucky]). By tobacco use, the perception that SHS is 'very harmful' was: 76.5 % among nonusers of tobacco; 62.1 % among noncombustible only users; 47.9 % among combustible only users; and 40.8 % among dual combustible and noncombustible users. Following adjustment, the perception that SHS was 'very harmful' was higher among females, non-Hispanic minorities and Hispanics, respondents living with children, and states with 100 % smoke-free law coverage. Among current tobacco users the odds of perceiving SHS to be 'very harmful' was lower in the Midwest than the West. CONCLUSIONS: Almost two-thirds of American adults perceive SHS as 'very harmful'; however, currently only half of all Americans are protected by comprehensive state or local smoke-free laws. These findings underscore the importance of public education campaigns to increase awareness of SHS exposure harm and the benefits of smoke-free environments. Expanding comprehensive smoke-free laws could protect all Americans from SHS.

Receipt of evidence-based brief cessation interventions by health professionals and use of cessation assisted treatments among current adult cigarette-only smokers: National Adult Tobacco Survey, 2009-2010.

BACKGROUND: Helping tobacco smokers to quit during a medical visit is a clinical and public health priority. Research suggests that most health professionals engage their patients in at least some of the '5 A's' of the brief cessation intervention recommended in the U.S. Public Health Service Clinical Practice Guideline, but information on the extent to which patients act on this intervention is uncertain. We assessed current cigarette-only smokers' self-reported receipt of the 5 A's to determine the odds of using optimal cessation assisted treatments (a combination of counseling and medication). METHODS: Data came from the 2009-2010 National Adult Tobacco Survey (NATS), a nationally representative landline and mobile phone survey of adults aged ≥18 years. Among current cigarette-only smokers who visited a health professional in the past 12 months, we assessed patients' self-reported receipt of the 5 A's, use of the combination of counseling and medication for smoking cessation, and use of other cessation treatments. We used logistic regression to examine whether receipt of the 5 A's during a recent clinic visit was associated with use of cessation treatments (counseling, medication, or a combination of counseling and medication) among current cigarette-only smokers. RESULTS: In this large sample (N = 10,801) of current cigarette-only smokers who visited a health professional in the past 12 months, 6.3 % reported use of both counseling and medication for smoking cessation within the past year. Other assisted cessation treatments used to quit were: medication (19.6 %); class or program (3.8 %); one-on-one counseling (3.7 %); and telephone quitline (2.6 %). Current cigarette-only smokers who reported receiving all 5 A's during a recent clinic visit were more likely to use counseling (odds ratio [OR]: 11.2, 95 % confidence interval [CI]: 7.1-17.5), medication (OR: 6.2, 95 % CI: 4.3-9.0), or a combination of counseling and medication (OR: 14.6, 95 % CI: 9.3-23.0), compared to smokers who received one or none of the 5 A's components. CONCLUSIONS: Receipt of the '5 A's' intervention was associated with a significant increase in patients' use of recommended counseling and medication for cessation. It is important for health professionals to deliver all 5 A's when conducting brief cessation interventions with patients who smoke.

Smoke-free home and vehicle rules by tobacco use status among US adults.

OBJECTIVE: To assess the prevalence and characteristics of smoke-free home and vehicle rules by tobacco use. METHODS: Data came from the 2012-2013 National Adult Tobacco Survey, a telephone survey of adults aged ≥18. Respondents who reported smoking is 'never allowed' inside their home or any family vehicle were considered to have smoke-free home and vehicle rules, respectively. Prevalence and characteristics of smoke-free rules were assessed overall and by current tobacco use (combustible only, noncombustible only, combustible and noncombustible, no current tobacco use). Assessed characteristics included: sex, age, race/ethnicity, education, marital status, income, region, and sexual orientation. RESULTS: Nationally, 83.7% of adults (n=48,871) had smoke-free home rules and 78.1% (n=46,183) had smoke-free vehicle rules. By tobacco use, prevalence was highest among nonusers of tobacco (homes: 90.8%; vehicles: 88.9%) and lowest among combustible-only users (homes: 53.7%; vehicles: 34.2%). Prevalence of smoke-free home and vehicle rules was higher among males, adults with a graduate degree, and adults living in the West. CONCLUSIONS: Most adults have smoke-free home and vehicle rules, but differences exist by tobacco use. Opportunities exist to educate adults about the dangers of secondhand smoke and the benefits of smoke-free environments, particularly among combustible tobacco users.

Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians.

BACKGROUND: The US Public Health Service clinical practice guideline treating tobacco use and dependence: 2008 update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication. FINDINGS: To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended "any" (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange). CONCLUSIONS: This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued.

The relation between tobacco taxes and youth and young adult smoking: what happened following the 2009 U.S. federal tax increase on cigarettes?

BACKGROUND: On April 1, 2009, the federal government raised cigarette taxes from $0.39 to $1.01 per pack. This study examines the impact of this increase on a range of smoking behaviors among youth aged 12 to 17 and young adults aged 18 to 25. METHODS: Data from the 2002-2011 National Survey on Drug Use and Health (NSDUH) were used to estimate the impact of the tax increase on five smoking outcomes: (1) past year smoking initiation, (2) past-month smoking, (3) past year smoking cessation, (4) number of days cigarettes were smoked during the past month, and (5) average number of cigarettes smoked per day. Each model included individual and state-level covariates and other tobacco control policies that coincided with the tax increase. We examined the impact overall and by race and gender. RESULTS: The odds of smoking initiation decreased for youth after the tax increase (odds ratio (OR)=0.83, p<0.0001). The odds of past-month smoking also decreased (youth: OR=0.83, p<0.0001; young adults: OR=0.92, p<0.0001), but the odds of smoking cessation remained unchanged. Current smokers smoked on fewer days (youth: coefficient=-0.97, p=0.0001; young adults: coefficient=-0.84, p<0.0001) and smoked fewer cigarettes per day after the tax increase (youth: coefficient=-1.02, p=0.0011; young adults: coefficient=-0.92, p<0.0001). CONCLUSIONS: The 2009 federal cigarette tax increase was associated with a substantial reduction in smoking among youths and young adults. The impact of the tax increase varied across male, female, white and black subpopulations.

National and State Attitudes of US Adults Toward Tobacco-Free School Grounds, 2009-2010.

INTRODUCTION: Schools are an important environment for addressing tobacco use among youth. Tobacco-free school policies can help reduce the social acceptability of tobacco use and prevent tobacco initiation among youth. This study assessed attitudes toward tobacco-free school grounds among US adults. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of adults aged 18 or older in the 50 US states and District of Columbia. Respondents were considered to have a favorable attitude toward tobacco-free school grounds if they reported tobacco use should be completely banned on school grounds, including fields and parking lots, and at all school events. Data were assessed using descriptive statistics and multivariable logistic regression, overall and by tobacco use status. Correlates were sex, age, race/ethnicity, education, marital status, income, sexual orientation, US region, and whether respondent lived with any children aged 17 years or younger. RESULTS: Nationally, 86.1% of adults had a favorable attitude toward tobacco-free school grounds, with larger percentages among nontobacco users (91.9%) than current users (76.1%). State prevalence ranged from 80.0% (Kentucky) to 90.9% (Washington). Overall odds of favorable attitudes were higher among nontobacco users (referent, current users), women (referent, men), and adults aged 25 or older (referent, aged 18-24); odds were lower among residents of the South (referent, West) and lesbian, gay, bisexual, or transgender adults (referent, heterosexual or straight). CONCLUSION: Nearly 9 in 10 US adults have a favorable attitude toward tobacco-free school grounds, but attitudes vary across states and subpopulations. Opportunities exist to educate the public about the benefits of tobacco-free school grounds, which might help reduce tobacco use among youth.

Secondhand smoke and smoking restrictions in casinos: a review of the evidence.

OBJECTIVE: There is no safe level of secondhand smoke (SHS) exposure. Most US casinos continue to allow smoking, thus exposing workers and patrons to the hazards of SHS. This paper reviews the scientific literature on air quality, SHS exposure, health effects and economic outcomes related to SHS and smoking restrictions in casinos, as well as on smoking prevalence among casino patrons and problem gamblers. DATA SOURCES: Peer reviewed studies published from January 1998 to March 2011. DATA SYNTHESIS: Evidence from air quality, biomarker and survey studies indicates that smoking in casinos is a significant public health problem. Workers and patrons in casinos that allow smoking are exposed to high levels of SHS, as documented by elevated levels of SHS constituents in the air of casinos and by elevated levels of tobacco-specific biomarkers in non-smokers' blood, urine and saliva. Partial smoking restrictions in casinos do not effectively protect non-smokers from SHS. Findings suggest that the smoking prevalence of casino patrons is comparable with that of the general public, although this prevalence may be higher among problem gamblers. Few studies have examined the economic impact of smoke-free policies in casinos, and the results of these studies are mixed. CONCLUSIONS: Employees and patrons are exposed to SHS in casinos, posing a significant, preventable risk to their health. Policies completely prohibiting smoking in casinos would be expected to greatly reduce or eliminate SHS exposure in casinos, thereby protecting the health of casino workers and patrons.