Signs, Fines and Compliance Officers: A Systematic Review of Strategies for Enforcing Smoke-Free Policy.

Background. Smoke-free environment policies limit or eliminate the use of smoke-producing tobacco in designated areas thereby reducing second hand smoke. Enforcement is perceived as critical to the successful adoption of a smoke-free policy. However, there is limited guidance available regarding effective enforcement strategies. A systematic review was conducted to examine the effectiveness of enforcement strategies at increasing compliance with and enforcement of smoke-free policies; and to determine circumstances other than enforcement strategies that are associated with compliance with smoke-free policies. Design. Medline, Medline in Process, The Cochrane Library, Embase, PsycInfo and CINAHL databases were searched using MeSH and keywords for relevant studies published between January 1980 and August 2017. A narrative synthesis and methodological quality assessment of included studies was undertaken. Results. Policy promotion and awareness-raising activities, signage, enforcement officers, and penalties for violations were the enforcement strategies most frequently cited as being associated with successful policy enforcement. Additionally, awareness of the laws, non-smoking management and lower staff smoking rates, and membership of a network guiding the policy enforcement contributed to higher compliance with smoke-free policies. Conclusions. There is weak evidence of the effectiveness of strategies associated with compliance with smoke-free policies. Given the evidence base is weak, well-designed trials utilizing appropriate evaluation designs are needed. Overall enforcement strategies associated with total smoke-free bans resulted in higher levels of compliance than strategies for policies that had only partial smoke-free bans.