smoking restrictions in public places , or secondhand smoke ( shs ) policies , are increasingly common in many parts of the world . in some countries , smoking restrictions have extended to private spaces ( such as cars ) and outdoor spaces ( such as doorways , patios , parks , and beaches ) . in the province of british columbia ,
canada , smoking restrictions exist in workplaces including restaurants and bars ( since 2001 in some municipalities ) , within 3 metres from doorways of public buildings ( since 2008 ) , and in cars where a person under the age of 16 is present ( since april 2009 ) .
several municipalities have even stronger bylaws . in vancouver , for example , smoking is prohibited on restaurant / bar patios , within 6 metres of doorways , at bus shelters , and on beaches and parks .  
the potential health effects of shs have been widely documented as support for these policies in canada , including the effect of shs exposure in increasing the risk for cancer , heart disease , and lung diseases [ 3 , 4 ] .
some research has concluded that smoking restrictions are associated with a decrease in shs exposure ( callinan , clarke et al . ) , [ 6 , 7 ] and may also be associated with increased smoking reduction or cessation [ 810 ] .
however , the gendered implications of shs initiatives and policies for women and men may result in specific unintended consequences as gendered dynamics shape women 's and men 's smoking behaviours , place of exposure , and management of shs . for example , women may confront challenges in managing shs exposure in the home due to gender inequalities within the domestic sphere . women and men may also face specific vulnerabilities due to the gendered and classed nature of work and the type of jobs women and men living on a low income are more likely to occupy .
for example , one focus group study found that low - income women working primarily in office and retail environments reported a prosmoking environment ( including more opportunities for smoke breaks and the presence of other coworkers who smoke ) .
low - income men , particularly older men working in outdoor environments , also noted a prosmoking context and lack of smoking restrictions .
another study found that smoking restrictions in bars and restaurants in california have resulted in more smokers congregating in bars where restrictions are not enforced , where low - income women are typically employed , thereby increasing their vulnerability to shs exposure .
research also suggests that women and men of different income levels may encounter specific vulnerabilities due to social and physical disadvantage . residing in a low - income area [ 15 , 16 ] or
an area of physical disorder or deprivation   has been linked to greater tobacco use . in a qualitative study exploring the social context of smoking
, participants in low - income groups reported that they had not perceived a decline in smoking , and often described smoking as being more socially acceptable in low - income neighbourhoods .
a review of the unintended consequences of shs policies for disadvantaged women revealed that women living on a low income may experience more barriers to quitting smoking and more vulnerabilities to shs exposure . in short , social , economic , and environmental issues
shape the conditions of women and men 's smoking and exposure to shs and their responses to smoking restrictions .
this study explored the effects of shs policies on diverse groups of women and men who smoke and/or are exposed to shs , and gauges the relationship between their social and built environments and their capacity to manage shs exposure .
in particular , what are the consequences of location restrictions for women and men , and how do the social ( i.e. , social roles , social positions ) and built environments ( i.e. , housing conditions , work facilities , and daily settings ) that women and men experience and inhabit influence their capacity to manage smoke exposure ? to explore these questions , we asked women and men to describe the context of their shs exposure ( source and setting , and challenges in managing exposure ) and discuss their experiences of smoking restrictions in vancouver .
the majority of studies investigating shs policies focus on the impact of various policies on health outcomes and public opinion following implementation .
many studies have examined the impact of shs policies on smoking cessation in the workplace [ 1928 ] and the home [ 2933 ] .
in addition , researchers have investigated attitudes and public support following implementation of shs policies [ 3437 ] .
a body of literature also exists on the connection between smoking restrictions and the denormalization of smoking  the process wherein smoking has gradually been redefined as socially unacceptable [ 38 , 39 ] .
several authors have discussed the potential for discrimination and stigma among smokers as an adverse outcome of location restrictions , particularly among already vulnerable populations [ 3942 ] .
there have been debates among researchers over whether denormalization and stigma are effective tobacco control strategies [ 43 , 44 ] or unethical and discriminatory against smokers [ 45 , 46 ] .
more recently , debates have centred around smoking restrictions in outdoor spaces , with some researchers claiming these policies may be particularly stigmatizing and are backed by relatively weak scientific evidence of health harms [ 45 , 47 , 48 ] .
for example , thompson and colleagues examined the effect of the denormalization of smoking and associated smoking - related stigma on creating  smoking islands  where smoking becomes normalized and smoking reduction and cessation efforts are inhibited .
bell and colleagues explored responses to location restrictions among smokers in vancouver and found that smokers experienced stigma , and changes in their access to and use of space .
ritchie and colleagues ' qualitative study of stigma following shs legislation in scotland revealed that smokers utilized different strategies to cope with stigma , such as managing spaces where they smoke , limiting social activities , stigmatizing other smokers and/or discussing the benefits of location restrictions .
their study of the social context of smoking in scotland following legislation , also revealed changes in participants ' use of public space and smoking behaviours following implementation .
poland and colleagues identified heterogeneity in smokers and nonsmokers attitudes to shs management , distinguishing between the various tolerance levels , interactions , and response styles of smokers and nonsmokers to smoke exposure .
robinson and colleagues discovered a range of implementation styles among participants with home smoking policies in scotland , including those based on informal discussions , to  negotiated  or  enforced  smoking restrictions .
a population based study by germain and co - authors examined the responses of nonsmokers to smokers and shs in australia and found that many nonsmokers were unwilling to confront smokers , despite being bothered by shs exposure .
together , these studies suggest that responses to shs policies and shs management are mixed due to differences in social location and context , smoking status , and individual and personal characteristics and dynamics .
this project built upon this work by examining differential effects on women and men of varied income levels and smoking statuses , in experiences of shs exposure and management ( in both private and public spaces ) and responses to smoking restrictions in vancouver .
to explore the everyday experiences of women and men in relation to smoking , shs , and shs policies , we employed a variety of qualitative methods .
participants were recruited via advertisements in universities , coffee shops , hospitals , local media , and craigslist ( a free online classified advertisement ) .
participants who responded to advertisements completed a telephone screening to determine their eligibility for the study ( exposed to shs daily or almost daily and who were 19 years and older ) .
after telephone interviews were completed with 40 individuals , additional participants were put on a waiting list to participate in focus groups .
forty telephone interviews were held between march 2010 and february 2011 , with 21 women and 19 men in greater vancouver .
women and men were also screened according to their income levels and classified as low income or not low income according to their self - reported combined family income before deductions , using the low - income cut - offs ( licos ) from statistics canada for 2004 , and based on vancouver population size ( 500,000 + ) ( see table 1 ) .
interviews were held with 9 low - income women and 9 low - income men , and 12 non - low - income women and 10 non - low - income men .
although participants ' smoking status was recorded , sampling was not performed based on smoking status .
following individual interviews , we held focus groups with women and men to explore emerging themes in more depth .
focus groups were held with one group of 3 low - income women , one group of 3 non - low - income men , and one non - low - income woman ( additional participants were recruited but did not participate in the focus group ) .
we were unable to recruit men living on a low income to attend a focus group .
after providing consent , participants in phone interviews and focus groups completed a questionnaire ( including demographics , smoking status and measures of exposure ) .
interviews and focus groups were semistructured and included questions about experiences of increasing shs restrictions , how they deal with shs , how shs restrictions impact their own smoking , if and how they negotiate child - caring duties within the context of shs and shs restrictions , how they deal with partners , friends , and family within these contexts , how they experience the built environment , including public and private spaces , and their experience of the general public and their reaction to both smoking , smoke exposure and women and men 's attempts to control shs .
the interviews were conducted by a trained female interviewer over the phone , and the focus groups by a trained , female facilitator in a meeting room at bc women 's hospital ( transportation vouchers and child care reimbursement were offered ) .
participants received gift cards to local retailers as honorarium for their participation , in the amount of $ 20 for the phone interviews and $ 40 for the focus groups . all interviews and groups
were recorded and transcribed , and qualitative analysis ( nvivo 8) software was utilized to analyze interview and focus group transcripts .
recurring themes were identified , paying particular attention to gendered factors and differences between women and men , and income levels .
preliminary themes were discussed and reviewed in a team meeting , and themes further refined , the key themes identified form the basis of this paper .
depending upon their particular experience , women and men described shs exposure and challenges in managing smoke exposure in both public ( in workplaces , bars and restaurants , outside of public buildings , and in beaches and parks ) and private spaces ( particularly the home , but also in cars ) .
examining shs exposure more broadly , in addition to specific experiences of shs policies in vancouver ( situated primarily in public spaces ) allows for an exploration of the specific vulnerabilities that women and men of varied incomes and smoking statuses encounter , and the potential unintended consequences of shs policies .
results are organized according to three key themes : ( 1 ) the reshuffling and relocation of where people are smoking ; ( 2 ) shs management and the impact on social relations and interactions ; ( 3 ) disparities in the effect of policies and management of shs .
when asked about their experience of shs policies , many participants reported being satisfied with smoking restrictions and felt their exposure had decreased as a result .
however , other participants thought that policies have not decreased smoking or smoke exposure , but rather simply reshuffled where people are smoking .
they 're ( smokers ) just finding other places to do it , that 's all , and then people 's exposure increases in different scenarios , like the bus stop or places where maybe they were n't or like a lot less so years ago when people could smoke under a building or whatever ( female , non smoker , not low income ) . with people
no longer permitted to smoke in the workplace , restaurants , bars , hotels , some apartments / housing , and most recently beaches and parks , the spaces where smoking is allowed are shifting and narrowing .
participants clearly articulated a shift in social norms regarding smoking , connected to increasing restrictions on smoking locations . as it has become less socially acceptable to light up
, smokers who abide by smoking restrictions must navigate their use of public space in new ways .
but there 'll be some of those smokers that are really aware that their smoking is , people do not like it , and you 'll see them go into like a corner or something , like kind of out of the way , like they 'll get up out of a restaurant and they wo n't like smoke right in front of the restaurant , because they know the windows are open , the doors are open , it 's going to come inside .
and so you 'll see them either go across the street or you know around the corner , and they 'll be somewhere where you know , that it 's not going to affect somebody else .
some participants described how smokers are being moved to increasingly marginal spaces , such as street - corners or alleyways , spaces physically and visibly divided from the majority of nonsmokers .
further implications of the physical and social marginality were made by participants who compared a smoker to a 
 participants also commented on the increased concentration of smokers in certain public spaces such as at bus stops , sidewalks , outside of workplaces , restaurants , and bars . while smoking policies
do exist for bus stops and business fronts in vancouver , these restrictions are frequently broken or shs travels to the area where others are positioned or waiting . as smokers reshuffle where they are smoking , or cluster in particular smoking areas , those people trying to manage shs must also manoeuvre their environment in new ways .
expanding smoking restrictions therefore impact the use of space , and the social interactions between smokers and nonsmokers over shs exposure . although shs policies are focused primarily on public spaces , another effect of this reshuffling is the displacement of smoking into private spaces , particularly homes and cars where restrictions are less likely to exist .
for example , one participant explained : at my place , we have a condo that used to allow smoking on the balcony , and about six months ago they actually came out with a bylaw that said  no smoking on balconies .
 so my girlfriend now smokes inside ( male , non smoker , not low income ) .
similarly , some female participants spoke about their male partner 's preference to remain in the home ( where he could continue to smoke ) rather than visit restaurants or bars with smoking restrictions .
i can not have a cigarette , so i ai n't going to no  you know , unless we can go somewhere fast food or whatever ,  so a lot of times we just do not go out with him , you know .
i 'll go out on my own or go out with a friend or my daughter or whatever .
( female , low income , former smoker ) with increasing prohibitions around public smoking and the movement of smoking into private spaces , individuals are increasingly required to negotiate smoking in this domain . in cases where smokers and nonsmokers are sharing a space , or where there are disagreements related to home smoking policies
, the power differences between individuals ( and partners in particular ) may come to the fore .
shs policies are transforming the use of public and private space and the social interactions within these spaces .
participants were asked to describe their experience of managing shs and the impact on social relations and interactions .
these experiences were influenced by tolerance to shs and perceived priority of shs management ; place of exposure ( private or public space ) and interactions with smokers in that domain .  
some women and men reported being intolerant to smoking and smokers in their lives , choosing to limit their time with friends and family who smoke .
well there 's a couple of friends i used to go and just visit and have coffee and tea and that , but more and more it turned me off because every time i 'd go i 'd just reek of tobacco , and i could n't handle it no more .
finally i told them too , right , and i said  well it 's not you , it 's the tobacco  it just , you know 
so you avoid some people that it 's , you know , and it 's too much .
so people who were my friends and smoke , i just , i do not spend time with them anymore or if i have family members out of town who smoke , i wo n't stay at their home .
women and men from both income groups discussed choosing partners and friends who are nonsmokers and avoiding those who smoke , but this was more salient for non - low - income women and men .
for these individuals , avoiding shs is such a priority that they made changes to their social groups in an effort to limit exposure .
in contrast , some participants reported that they are not bothered by smoke and therefore have not made any changes to limit their smoke exposure . in some cases
, participants implied that the value of their relationships ( with friends , family , partners ) outweighed their concerns over shs exposure : i do not [ have a smoke - free home ] if i had a smoke - free [ home ] nobody would come visit me ! ( female , non - smoker , low income ) . socially 
honestly i can not say i 've done anything to decrease  like the friends , i 'm not  the friends that i have i 'm not going to drop , right .
( male , smoker , low income ) . women and men from both low and
non - low - income groups reported tolerance for shs or no actions to manage shs , but this feedback more often came from low - income women and men .
these quotes ( particularly the first quote ) also indicate how the composition of the social group influences reactions to smoking restrictions and shs management . if most or all individuals in a social group are smokers , reducing exposure may mean reducing or eliminating time spent with friends and family who smoke .
many participants did not want to reduce or give up social activities and relationships they share with people who smoke .
often , the greatest and most sustained source of exposure to shs came from friends and family members within private spaces ( their home , car or during social gatherings with friends / family ) rather than strangers in public spaces .
for those people who have a partner or family member who smokes or are sharing a living space with someone who smokes , the effect of public smoking restrictions on decreasing overall shs exposure may be negligible .
participants who experienced shs exposure in the home and were trying to limit or reduce their exposure , discussed how they negotiated smoking restrictions in the home , or experienced challenges or conflict with friends or family over smoking in the home .
for example , the following nonsmoking participants explained how they have negotiated smokefree spaces in their homes and social environment to avoid exposure while still maintaining relationships .
[ one ] of my friends , he 's kind of an addict to it .
we 're friends up to a point , but you know he does not smoke in front of me , he goes outside  he came to my place ; i make it abundantly clear , if you want to smoke you go outside . and that 's it , he knows the rules  in my case i wo n't bend on that .
if someone comes over to my house and wants to smoke , you know , it 's kind of my house , my rules , but i do not have that control over other people 's environments so it 's a lot harder ( female , non - smoker , not low income ) .
all respondents suggested that they negotiate smoke - free spaces with friends , family , and partners , yet non - low - income participants more often described the process of negotiating a smoke - free space .
these participants implied that they have the means to negotiate rules around smoking , particularly in their homes or cars .
in addition , some smokers revealed ways in which they cooperate in either reducing their smoking around others or their partner .
i think  rules or not , if you 're respectful of the people that you have relationships with , then you take their feelings into consideration when it comes to something like smoking .
i do not apologize to anybody for the fact that i do smoke cigarettes , but i 'm very respectful of their wishes .
agreements are made between smokers and nonsmokers , and smokers may also willingly accommodate the requests or 
, there is a sense of cooperative exchange between smokers and nonsmokers . yet for other participants , managing shs exposure in the home was marked by conflict with partners , friends , or family members .
the only thing i find is that with my husband , a lot of people wo n't come and visit because of his smoking .
and you know , he 's really stubborn when it comes to trying to tell him that he can not smoke inside a house , right .
p : [ i 'm ] fighting with my mom and my dad all the time .
i : what 's the gist of the fight ? like are you trying to tell them to stop , or you 're trying to tell them to smoke someplace else , or?p : smoke someplace else , do not waste our money , i work hard , you smell , i do not want to kiss you , i do not want to touch you , you stink , it goes on .
( female , smoking status unknown , low income ) . women and men from low - income and
non - low - income groups reported arguing with partners or family members over their smoking and some participants indicated that smoking had resulted in a previous break - up with a partner .
however , women , and particularly women living on a low income , were more likely to cite challenges in negotiating a smoking restriction in the home .
differences in smoking status , tolerance to shs , and decision - making power contribute to the interpersonal challenges and conflict associated with the management of shs . for some individuals ,
the main source of shs exposure is from strangers , mostly in public outdoor spaces .
participants who reported having strict no - smoking policies within their homes and cars often discussed challenges in managing their shs exposure in outdoor public spaces . in attempting to limit their smoke exposure in these environments , participants described avoidance strategies , or confrontation and in some cases conflict with smokers .
for example , women and men from both income groups discussed how they reposition themselves in public spaces , avoid particular activities ( smoky clubs or bars ) , or change their commuting route to avoid smokers .
sometimes what i do is i try to like i put my hands up and kind of air out the air in front of my face , or sometimes i 'll just walk fast and try to avoid it , or i 'll move myself away , try to move myself away as much from the area ( female , non smoker , low income ) .
i 'm always , you know , juggling myself around so i 'm out of it .
conscious repositioning allowed participants to create and maintain distance from shs and avoid contact with smoke and smokers .
similarly , some participants described how they alter their smoking behaviour to avoid affecting nonsmokers .
however , other participants reported difficulties in managing their smoke exposure in public spaces , sometimes escalating into conflict when confronting strangers who were not respecting shs policies .
i went to the salvation army for a meal , you know , so a guy comes and sits beside me , picks up a cigarette and starts blowing smoke at me , you know .
and then i asked him , you know  that 's kind of rude  and he says 
oh well , this is the way people smoke  , you know , right .  i 'm allowed to smoke at this table here ! 
i 've had one where the guy came back and i was sitting there waiting in a line - up to buy tickets and i asked him politely .
he looked at me and said  get lost  and  moron  and this and that and started mouthing off to me .
inconsiderate  in subjecting them to shs and were hostile when confronted about their smoking .
however , variations clearly exist in how nonsmokers cope with and control their exposure , and the interaction that occurs between smokers and nonsmokers .
participants suggested that not all women and men are experiencing the potential benefits of shs policies ( i.e. , reduced shs exposure , improved health ) .
gender roles and responsibilities , and social and economic differences impact women and men 's vulnerabilities to smoking and shs exposure .
an unintended and undesirable consequence of smoking restrictions is the potential to reinforce or enhance these vulnerabilities , contributing to disparities in health between women and men , and subpopulations of women and men .
we have identified the potential for the following disparities related to shs exposure and management : stigma during pregnancy and parenting , gender differences in vulnerabilities to exposure in the home and workplace , gender differences in the management of shs and socioeconomic disadvantage .  
however , one of the key vulnerabilities that emerged for women in regards to shs is the effects of the denormalization of smoking particularly during pregnancy and mothering , and the heightened potential for stigma and shaming within this context .
the following quotes demonstrate the strong pressures that exist in regards to smoking during pregnancy : p :  i have not been friends with anyone that smokes when they 're pregnant , and in this day and age i do not know if i could be friends with them .
like so what happens if you live with that woman who 's pregnant , right ?
p : if i was a man , i would probably say  i 'm going to divorce you if you do not , and i 'm going to fight for the child .
[ my partner ] knows she can not , she 's pretty , she 's aware that she can not , you know , endanger another person or a child or a life , so i know for a fact that if she was to get pregnant she would n't be smoking , i know that .
( male , non smoker , not low income ) . during interviews and focus groups , smoking during pregnancy was framed as an irresponsible behaviour .
media and health advocacy around shs have often focused on exposure during pregnancy and among children . for women who are not able to spontaneously quit ,
the moral implications associated with smoking during pregnancy and parenthood exacerbates the feeling of stigma and shame for women , hindering their capacity to reduce or quit smoking .
an unintended consequence is that women may avoid seeking cessation help from practitioners or their partners or families for fear of conflict , judgement , or incrimination .
women more often talked about their challenges in managing their smoke exposure in the home .
higher rates of smoking among men were understood to result in greater rates of exposure for women in the home if they have a male partner who smokes .
furthermore , participants articulated experiences of conflict related to shs as stemming from gender differences in power or control over financial resources . for example
, the following female participants suggested that they lack decision - making power in the home .
i : okay . now can you describe any challenges you have in managing your smoke exposure ?
i like having air in my house ( female , non smoker , low income ) . well the way it is right now , i mean my husband 's the one that smokes , so he does not , like  oh no , eh , whoever wants to come and smoke , eh , why not ?  excuse me .
that 's all , i mean this  it 's almost gotten us for , you know , a divorce over this issue .
the ownership of private space ( homes , cars ) was understood to warrant the decision - making authority around smoking or smoking restrictions . due to sex segregation of both paid and domestic work
, women may have more responsibilities within the domestic sphere but a limited ability to participate in decision making on shs policies . with increasing public smoking restrictions
, a potential unintended consequence is that women may endure more shs exposure and challenges related to shs management in the home .
while women face particular vulnerabilities in the home , participants thought that men were more likely to be exposed to shs in the workplace .
in particular , men involved in trades - based occupations , which tend to be male dominated , were perceived to be more vulnerable to smoking and smoke exposure
. these types of occupations may in certain cases be exempt from workplace shs laws . for example , although smoking in work vehicles is prohibited in british columbia , participants still reported observing or experiencing male workers smoking during their commute to work sites .
similarly , if work is done outdoors , employees may be permitted to smoke on the job site .
gender divisions in the home and workplace shape women and men 's vulnerabilities to smoking and smoke exposure .
findings suggest that men confront a particular set of challenges in managing shs . according to feedback from participants ,
men face more pressure to smoke and less social support to assist with reduction or cessation
. there might be more peer pressure to smoke with men , because it 's , i do not know , like from the crowd that i come from , it 's not really like okay for the women to smoke , but the men typically smoke all the time and because my boyfriend does not smoke , so when he comes over my father is like  oh , here a smoke , have a smoke ,  and my boyfriend 's like  oh no , that 's fine .  and then it 's like  no , no , no , no , here have one .
 so it 's , it 's just a little awkward , so i guess a man thing i guess .
men may be encouraged by other men to smoke , possibly due to expectations regarding  masculinity  or the use of smoking as a socialization tool . while women may be more likely to be exposed to their partner 's smoking
, men may face unique vulnerabilities to shs due to their gender identities and social expectations regarding smoking and tolerance to shs .
[ secondhand smoke is ] not as that much of an issue for us [ men ] , like it is on women . like men
it 's not that big of a deal  [ have ] a smoke around [ a woman ] , she 'll cover her nose , she 'll pull her shirt over her nose , and she goes 
can you smoke over , go down the street ,  like she 'll actually freak out , she hates it .
the girls always are just like running around and like , trying to like get away from it .
i think that men generally , when they 're exposed , they  my impression is that they just put up with it , they do not really , or it does not seem to bother them as much  just because , well , i do not know , to me it 's perceived like a macho thing and you know , like they seem to be just more compliant or more acceptable of it .
it may be more socially acceptable for men to smoke compared to women and more acceptable for women to ask others not to smoke .
while women may have less power or capacity to make decisions regarding smoke exposure in partnerships ( particularly in the home ) , in certain contexts women may be more likely to ask others not to smoke or demonstrate less tolerance for smoke exposure .
well , i would have to say that the men that i know are less likely to complain to friends who happen to be smokers , and are more likely to put up with it .
women possibly who are in relationships may not be as likely to complain to the partner that they happen to be with , but that 's just an assumption .
women , on the other hand , were regarded as being more health conscious and more likely to limit their exposure to shs .
however , under different conditions , participants thought that women would be less assertive and less likely to confront a stranger about their shs .
i guess if it were a group of men smoking and a woman being exposed to it , she may feel sort of , either a little bit more daunted if she were going to approach them about it or ask them to move away , or something like that , opposed to a guy asking a group of women .
( female , non - smoker , not low income ) . it may not be that either women or men are more at risk for shs exposure , but rather that they encounter unique vulnerabilities based on gender roles and expectations , and power differences in relationships or social situations .
the majority of participants thought that people living on a low income would be more vulnerable to shs , face more smoking - related challenges and be less likely to benefit from shs policies .
[ people living on a low income ] would have more challenges in life , so it could be a coping mechanism , or someone in their family is the one smoking so there would be even greater chances of being exposed to second - hand smoke
 they may not be able to afford other options that someone more well off could if they wanted to choose a healthier lifestyle ( female , non smoker , not low income ) .
participants noted that smokers tend to be poor and have fewer resources to afford healthier options , experience more stress and anxiety and are more likely to use smoking as a coping mechanism .
some people living on a low income use smoking to cope with mental illness , and therefore face more barriers to reducing or quitting smoking .
participants thought that people living on a low income tend to be surrounded by more smokers , and also that smoking restrictions are less likely to be regulated .
low - income neighbourhoods or housing areas often lack access to private outdoor space , creating challenges for those individuals trying to reduce their smoking or shs exposure .
um , i would feel that if you 're in a lower income area for example , living - wise , you are kind of grouped together in a smaller area and more pushed together , i guess , and it 's just a smaller space with more people smoking , so it would be harder to get away from ( female , smoker , low income ) .
women and men living on a low income are more likely to live in more crowded areas , with more smokers and less safe , open spaces .
the physical , social , and economic barriers low - income women and men encounter to reducing smoking and smoke exposure may reinforce or intensify health - related disparities .
participants described a reshuffling and relocating of where people are smoking , bringing new challenges both for smokers and for those managing smoke exposure .
these findings align with previous qualitative work done by bell and colleagues that found that smokers in vancouver are experiencing a narrowing of space due to location restrictions .
a study by kaufman and colleagues   in toronto also revealed how nonsmokers are navigating their environment in new ways to avoid smoking in outdoor urban spaces , particularly around doorways of businesses where smoking continues to cluster .  
likewise , participants in our study discussed difficulties in avoiding outdoor shs , particularly in bus stops and near businesses .
while smoking is prohibited in these spaces in vancouver , the lack of other available spaces for smoking in public , coupled with the difficulty of enforcement in all places at all times , impedes the effect of policies in these spaces . without the effective enforcement of smoking restrictions in public outdoor spaces , the narrowing of available space for smokers , along with the increasing denormalization of smoking , may increase the presence and frequency of social tensions between smokers and nonsmokers .
smoking restrictions need to be coupled with strong and tailored tobacco reduction and cessation support , particularly for vulnerable populations who experience more barriers to quitting .
there was variation in participants ' management of shs and the impact of restrictions on social relations and interactions .
the differences identified by participants in the effects of shs policies and shs management on social interactions include the attitudes towards and tolerance of smoking and shs , relationship dynamics , place of exposure , and capacity or power to control exposure .
smoking restrictions appear to be contributing to the increasing division of smokers and nonsmokers and are impacting social exchanges related to shs . but
differences in tolerance to shs and/or power differences structure some participants ' ability to modify their shs , sometimes leading to conflict in the private domain .
the differences between participants ' experiences of policies and shs management are backed up by other qualitative studies that have identified different levels of tolerance , interaction styles , and power dynamics related to smoke exposure [ 53 , 54 ] , the implementation of home smoking policies , and reducing or quitting smoking during pregnancy .
they distinguish between  reluctant  smokers who demonstrate concern over smoking around others ,  easygoing  smokers who support restrictions and limit their smoking around others , and  adamant smokers  who are less inclined to limit their smoking around nonsmokers .
similarly , they identified nonsmokers as either  adamant  or highly intolerant to smoking ,  unempowered  smokers who oppose but do not or can not manage their exposure , or 
laissez - faire  nonsmokers who are less opposed and therefore less likely to manage their exposure .
different relationship dynamics related to the implementation of a home shs policy , ranging from voluntary to negotiated or enforced restrictions have also been described .
finally , bottorff and colleagues have discussed the social context and relationship dynamics associated with smoking reduction and cessation , within the context of pregnancy .
they found complex tobacco - related interaction patterns between couples when quitting during pregnancy , including disengaged ( individualized decision - making ) , conflictual ( shaming , monitoring , hostility ) , and accommodating ( work together / open communication ) interaction patterns .
for example , for couples with a conflictual interaction pattern , smoking cessation during pregnancy may result in the  policing  of the other partner 's smoking behaviour   or even abusive and controlling behaviour . together with our findings , these suggest that shs management is a complex process , influenced by individual tolerance of shs and responses to smoking restrictions , along with social and situational differences and interpersonal dynamics and relationships .
tobacco control policies and programs are needed that respond to these complexities and support varied approaches to reduction , cessation , and shs management . while the process of denormalization may in fact encourage some people to quit smoking , for smokers who are unable or lack the resources to quit , smoking - related stigma negatively impacts their health and quality of life and may undermine their ability to quit .
individuals who experience social stigma may be more likely to conceal their smoking , inhibiting access to cessation support from health care providers and friends and family . in particular , our study revealed high levels of denormalization and potential for smoking - related stigma in the context of pregnancy and motherhood .
policies aimed at reducing shs have also been found to contribute to smoking stigmatization among mothers by others , and that these effects are particularly harmful for socially disadvantaged mothers . given that women who smoke during pregnancy are more likely to be socially disadvantaged and experience more barriers to quitting
, these findings support the need for women - centred approaches to smoking cessation and reduction during pregnancy that reduce stigma and focus on the health of women in and of itself . emerging qualitative
research reveals that new fathers who smoke experience negative judgement , and perceive smoking to conflict with dominant ideals of masculinity and their role as provider and protector of the family .
while this theme did not emerge during interviews and focus groups in our study , this remains an important area for further research .
participants described unique vulnerabilities related to power differentials , access to economic resources and gendered roles and relations .
our findings suggest that women have more challenges in reducing smoke exposure in the home and men in the workplace . in support of this , a study by paul and colleagues found that low - income men working outdoors were vulnerable to smoking and smoke exposure . while participants in our study thought men are more exposed to shs at work , other research suggests that women may also face special challenges in managing shs in the workplace . for example
, research reveals that women more often occupy restaurant and bar jobs and face challenges in enforcing smoke - free establishments in these settings   and also encounter a prosmoking context when working in office and retail positions .
together , these findings suggest that both men and women are at risk of shs exposure at work , in part due to a gendered and classed division of labour .
the finding that women tend to cite more difficulties in negotiating a smoke - free home may in part be due to higher smoking rates among men , making it more likely that a woman would be exposed to a male partner 's smoking .
furthermore , research reveals that as smoking restrictions intensify , smoking may shift into the home , valued by some smokers as one of the last  comfortable  places to smoke .
yet these differences are also indicative of power differences that exist between women and men , particularly related to the control of financial resources and home ownership .
men more often control the financial resources in the home , and women may be less able to speak up about shs exposure . given that women and children living with smokers are at an increased risk of disease and death , these reports have serious health implications .
smoking cessation interventions are needed for women that explicitly address these factors and differences in power and incorporate negotiation skills and empowerment principles . on the other hand ,
our findings indicate that men encounter specific vulnerabilities to shs due to perceptions of masculinity .
smoking among men appears to be more socially acceptable , and asking others not to smoke conflicts with social understandings of  manliness  .
for example , a study by germain and colleagues found that males were less likely than females to move away from shs .
smoking may also be used as a tool for socializing , in the absence of other opportunities for meaningful connections between men .
morrow and colleagues discuss how the practice of risk behaviours , such as smoking , by men are used as an expression of masculinity .
other research found that men hesitate to use cessation resources due to dominant ideals of masculinity such as  independence  and  strength  .
findings from our study support similar dominant ideals of masculinity that prevent men from limiting their exposure to shs .
gender - specific and gender - sensitive policies and smoking cessation interventions are needed that account for and address these differences in a men - centred manner .
furthermore , women and men living on a low income experience numerous barriers to smoking reduction and cessation and shs management .
smoking in low - income areas may be normalized , smoking restrictions less enforced , and individuals experiencing the many stresses associated with living on a low income may find it difficult to quit [ 13 , 49 ] .
these findings support previous research revealing that people living on a low income are more likely to inhabit a  prosmoking context ,  receive less education on the health risks of smoking and shs exposure and are less likely to have smoke - free homes . while there may be less stigma associated with smoking in low - income areas , the relative normalization of smoking within low - income areas makes reducing or quitting smoking or managing smoke exposure a greater challenge .
christakis and fowler found that the presence of smokers in one 's social network discourages smoking cessation , as smokers tend to group together and in effect normalize smoking within the social group .
in a similar vein , the combined stigmatization of smokers with the spatial segregation of low - income groups has been described as producing  smoking islands  that encourage continued smoking and impede cessation efforts . it has been suggested that the perception of smoking as socially unacceptable and the stigmatization of smokers is facilitated by the shift in tobacco consumption to low - income groups .
tobacco control initiatives are required that acknowledge and respond to these inequities and prevent further stigmatization , by addressing the social determinants of health in tailored smoking reduction and cessation interventions .  
first , due to the qualitative nature of this study , we can not draw conclusions about the observed differences between women and men of varied income levels in british columbia or canada , in general .
second , we were unable to recruit men living on a low income to attend a focus group , and only met with one non - low - income women for a focus group ( more women were recruited , but did not show up to the focus group ) .
because of this , we were only able to collect rich focus group data from low - income women and non - low - income men .
third , although participants ' smoking statuses were recorded , sampling was not performed based on smoking status .
we recruited more nonsmokers ( 25 ) than smokers ( 15 ) for the telephone interviews .
therefore , the data collected and presented here does not capture the experiences and viewpoints of smokers and nonsmokers equally .
finally , focus group participants were not identified in connection with questionnaire data during the audio recording or on transcripts . because focus groups were not organized according to the smoking status of participants , we are therefore unable to include smoking statuses for the quotes of some focus group participants . despite these limitations , this qualitative study surfaced important themes related to the experience of smoking restrictions and shs management for women and men of varied income levels and smoking statuses , that warrant further research and consideration during policy development .
the experience of smoking restrictions and the management of shs is influenced by the social context ( relationship with a partner , family member or stranger , and control of resources ) , the space of exposure ( outdoor / public or private space , worksite ) , the social location of individuals involved ( gender , income ) , and tolerance to shs . as smoking restrictions increase ,
both smokers and nonsmokers are required to develop new skills to navigate the built and social environment in new ways .
tobacco control policies and interventions are required that acknowledge and respond to the specific vulnerabilities of women and men , and low - income subpopulations .
approaches are needed that prevent further marginalization of the groups most vulnerable to smoking and shs smoke exposure , such as low - income women , while maximizing the effect and impact of policies . for example , these may include health education messaging that is gender and diversity sensitive , gender - specific workplace interventions , the training of health care providers to address and respond to stigma , and the integration of tobacco control policies with economic and social policies ( including housing , child care , and antiviolence ) . policies need to be gender sensitive and tailored with women and men in mind , to target ( and measure ) the unique issues that women and men , and subpopulations of women and men , encounter when managing shs .
 this study investigates secondhand smoke ( shs ) exposure and management in the context of smoking location restrictions , for nonsmokers , former , and current smokers . a purposive sample of 47 low income and non - low - income men and women of varied smoking statuses was recruited to participate in a telephone interview or a focus group . 
 amidst general approval of increased restrictions there were gendered patterns of shs exposure and management , and effects of shs policies that reflect power , control , and social roles that need to be considered as policies are developed , implemented and monitored . 
 the experience of smoking restrictions and the management of shs is influenced by the social context ( relationship with a partner , family member , or stranger ) , the space of exposure ( public or private , worksite ) , the social location of individuals involved ( gender , income ) , and differential tolerance to shs . 
 this confluence of factors creates differing unintended and unexpected consequences to the social and physical situations of male and female smokers , nonsmokers , and former smokers . 
 these factors deserve further study , in the interests of informing the development of future interventions and policies restricting shs . 
1. Introduction
2. Background
3. Methods
4. Results
5. Discussion
6. Conclusions