The Carrot Not The Stick: Creating Incentives for Voluntary Enforcement of Smoke-Free Policies Through Smoke-Free Zone Certification

Background and context: Jordan's Public Health Law bans smoking in public places. However, law-enforcement mechanisms are lagging and Jordanians continue to be exposed to second-hand smoke. The Global Tobacco Control Report 2017 rates enforcement at 2/10 dropping even below the previous 3/10 rating of 2015. Aim: Our intervention aims to provide alternative routes for protection from exposure to second-hand smoke. Strategy/Tactics: The intervention builds on results from a 2012 survey which indicated that 85% of the public supports banning smoking in healthcare institutions, schools, and work places. In 2013 King Hussein Cancer Foundation and Center launched the Smoke-free Zone Certificate Program in collaboration with Global Smoke-free Worksite Challenge. The program, currently in its fifth round, recognizes institutions that voluntarily enforce smoke-free environments. Program/Policy process: Interested institutions submit an application requesting certification. Applications go through a screening process to confirm initial alignment with the program criteria. Institutions passing the initial screening are physically inspected for compliance through unannounced spot-check visits. Those passing the inspection receive certification. To qualify, an institution should meet two criteria. The first is enforcing a 100% smoke-free policy within all indoor premises. Designated smoking areas are not allowed. For schools, the criteria require that the smoke-free policy extends to cover both indoor and outdoor premises. The second criterion is that the smoke-free policy should be in effect for a minimum of 9 months on the day of certification. The appeal of the program builds on (1) the institution's belief in the importance of providing a safe and healthy environment, (2) the association of the program with the name of a well-respected national organization, and (3) the media exposure that the certified institutions receive. Active promotion of the program is performed during the application period to recruit additional applicants. Outcomes: Fig. 1 depicts the growth in numbers of applications and of certified organizations. On average 67% of applicants receive certification. Interest varies by category with schools outweighing all other applicants (62%). What was learned: Incentives for voluntary enforcement of smoke-free policies have the potential to support law enforcement. The growing interest and the modifications that institutions undergo to meet the program criteria are a testimony to our success. Several institutions went through three rounds of applications prior to receiving certification, indicating the ability of the program to motivate compliance. There is a need to continue to grow the number of applicants especially in the 'restaurants' and 'healthcare' categories. Sensitization about the benefits of smoke-free environments, technical assistance to interested institutions, and additional media exposure can help. [Figure: see text]