The American Lung Association grades all states annually on their tobacco policies, and each year Kentucky receives among the lowest grades.

Kentucky earned an F for what the association said is its inadequate tobacco prevention and cessation funding, smoke-free air and tobacco taxes, and a failure to raise the minimum smoking age to 21. The Bluegrass State did receive a C for its access to cessation services – which experts attribute to Medicaid.

In Bowling Green, city officials banned smoking in city parks, workplaces and enclosed public spaces by 2011.

“The whole intent of the clean indoor air ordinance was to address the unattended victims of smoking,” said Bowling Green City Commissioner Brian “Slim” Nash, who said there hasn’t been any additional discussion of the ordinance during his time as commissioner.

Since implementation, there have been a total of 25 citations for smoking unlawfully. The majority of citations occurred early, then people began to understand the law, according to Bowling Green Police Department spokesman Officer Ronnie Ward.

“We don’t have those complaints anymore,” Ward said. “This isn’t something we drive around checking, we respond to those as we receive complaints.”

After initial culture shock, Nash believes the measure became a no-brainer. While he witnesses people breaking the city’s smoking ordinances from time to time, “the vast majority” are following the rules respectfully.

“It really has just become part of our community,” Nash said. “It’s become who we are in Bowling Green.”

During Nash’s time as commissioner, there hasn’t been an additional discussion of the clean indoor air ordinance.

But that doesn’t mean there couldn’t be additional measures introduced in the future, he said.

Aligning with the American Lung Association’s smoke-free guidelines, many cities – and states – prohibit smoking within 15 to 25 feet from public buildings. In Arizona, there is a statewide ban on smoking cigarettes within 20 feet of a workplace. In New Mexico, smokers can’t light up within 50 feet of an enclosed workplace, restaurant or bar.

In Bowling Green, Nash believes this kind of regulation would benefit the community – if businesses get on board.

“I wish there was a way to fairly include that into the ordinance,” he said. “Clearly, anyone that is standing directly to the door and is smoking is not honoring the spirit of the clean indoor air ordinance.”

When a city allows cigarette smoking in public spaces, it’s allowing secondhand smoke.

Secondhand smoke poses threats to everyone exposed. For children, it can cause sudden infant death syndrome, ear infections, colds, pneumonia, bronchitis and severe asthma, and harms the development of a children’s lungs. For pregnant women, it can cause pregnancy complications, poor birth outcomes, preterm deliveries and low birth weights. For adults, it can cause premature death, heart disease, stroke, lung cancer, lung disease, chronic obstructive pulmonary disease, emphysema, asthma and chronic bronchitis, according to the National Cancer Institute.

Basically, there is no safe level of exposure to secondhand smoke.

Within five minutes, secondhand smoke stiffens the aorta as much as smoking a cigarette. In 20 to 30 minutes, it causes excess blood clotting and the buildup of fat deposits in blood vessels, increasing the risk of heart attack and stroke. In two hours, it increases the chance of irregular heartbeat and can trigger a fatal cardiac event or heart attack, according to the Cleveland Clinic.

The American Academy of Pediatrics states that tobacco use should be prohibited in all public indoor and outdoor spaces.

This science is clear. But changing engrained behaviors is complex, Nash said.

The desire to be healthy and the actionable steps taken to be healthy don’t usually equate. “We understand the science that (cigarettes or junk food) is bad for us,” Nash said, but “we’re wired to think oh it won’t happen to us, or we’ll start tomorrow.”

That requires a cultural change, according to Nash.

“Cultural encouragement or discouragement tends to influence people’s decision about it,” Nash said.

In an idealized future, a cultural shift would include city residents ridding their habit of dropping cigarette butts on the ground. “It makes our community look so bad,” Nash said.

Tobacco litter also floods storm drains, and drives up the cost of treatment, according to Bowling Green environmental manager Matt Powell.

“It is unbelievable how many of those things are out there,” Powell said. “There’s absolutely no distinction between cigarette butts and any other type of trash.”

But Nash doesn’t think an additional ordinance would solve the issue of tobacco litter because it would be difficult to enforce, as police officers would have to see someone actively throwing a cigarette on the ground in order to write a citation.

Instead, Nash thinks it would be more effective to educate the public on tobacco litter’s effect on stormwater. “Anything you throw on the ground eventually ends up in our water,” he said.

Eventually, the culture could change further.

In Hawaii, lawmakers have proposed bipartisan legislation to incrementally raise the minimum age to use cigarettes to 100 – by 2024.