Problem/Objective: Rural communities are less likely than their urban counterparts to pass smoke-free legislation; yet there are typically higher smoking rates in rural communities. This study examined the process and outcomes of enacting and maintaining a comprehensive smoke-free law in a small, rural, Appalachian community.

Methods: A multi-method study including case study and air quality monitoring was conducted. Similarities and differences in smoke-free policy development in rural vs. urban areas were analyzed. Indoor air quality was assessed in nine venues in Letcher County, KY, including six restaurants, the bingo hall, and two other venues before and after the smoke-free law was implemented on July 1, 2006.

Results: A top-down approach was successful in passing the law, with very little grassroots capacity building. Legislative turnover presented a threat to the integrity of the ordinance. Of the nine venues sampled before and after the law, eight (89%) were in compliance with the law. There was a 75% drop in indoor air pollution after the law took effect. The average PM2.5 in the bingo hall was 635 µg/m3 before the law took effect and 249 µg/m3 after the law took effect, 9.8 and 3.8 times higher, respectively, than the national ambient air quality standard for outdoor air. These data were helpful in increasing adherence in the bingo hall.

Conclusions: Grassroots coalition building played a role in the campaign after enactment of the law. Air quality testing was critical in maintaining the integrity of the law.