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The efficacy of different models of smoke-free laws in reducing exposure to second-hand smoke: A multi-country comparison

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Abstract

Exposure to second-hand tobacco smoke is a serious public health concern and while all EU Member States have enacted some form of regulation aimed at limiting exposure, the scope of these regulations vary widely and many countries have failed to enact comprehensive legislation creating smoke-free workplaces and indoor public places. To gauge the effectiveness of different smoke-free models we compared fine particles from second-hand smoke in hospitality venues before and after the implementation of smoking bans in France, Greece, Ireland, Italy, Portugal, Turkey, and Scotland. Data on PM2.5 fine particle concentration levels were recorded in 338 hospitality venues across these countries before and after the implementation of smoke-free legislation. Changes in mean PM2.5 concentrations during the period from pre- to post-legislation were then compared across countries. While a reduction in PM2.5 was observed in all countries, those who had enacted and enforced more fully comprehensive smoke-free legislation experienced the greatest reduction in second-hand tobacco smoke. Comprehensive smoke-free laws are more effective than partial laws in reducing exposure to second-hand tobacco smoke. Also, any law, regardless of scope must be actively enforced in order to have the desired impact. There is continued need for surveillance of smoke-free efforts in all countries.

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... 7 Several studies have evaluated the impact of the legislation in eliminating smoking in public places in Turkey. [8][9][10] Most were based on convenience sampling 10 and on only a few types of public venues. [8][9][10] The Global Adult Tobacco Survey has monitored trends in exposure to second-hand smoke in Turkey -based on self-reported exposure in health-care facilities, government buildings, transport hubs and some hospitality venues -but it does not verify if or where smoking is occurring in any of the reported locations. ...
... 7 Several studies have evaluated the impact of the legislation in eliminating smoking in public places in Turkey. [8][9][10] Most were based on convenience sampling 10 and on only a few types of public venues. [8][9][10] The Global Adult Tobacco Survey has monitored trends in exposure to second-hand smoke in Turkey -based on self-reported exposure in health-care facilities, government buildings, transport hubs and some hospitality venues -but it does not verify if or where smoking is occurring in any of the reported locations. ...
... [8][9][10] Most were based on convenience sampling 10 and on only a few types of public venues. [8][9][10] The Global Adult Tobacco Survey has monitored trends in exposure to second-hand smoke in Turkey -based on self-reported exposure in health-care facilities, government buildings, transport hubs and some hospitality venues -but it does not verify if or where smoking is occurring in any of the reported locations. 6,11 In an attempt to evaluate compliance with the legislation on smoking in indoor public places in Turkey more comprehensively, we adapted a guide on compliance studies that was published by the International Union Against Tuberculosis and Lung Disease, the Campaign for Tobacco Free Kids and the Johns Hopkins Bloomberg School of Public Health in 2014. ...
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Objective To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey. Methods Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts. Findings Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9–570.8 and aOR: 165.4; 95% CI: 98.0–279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3–0.8. Conclusion Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs.
... The growing number of studies on the effectiveness of SF policies indicates an apparent difference between partial and comprehensive designs. [10][11][12][13] Comprehensive SF environments can be defined as strict smoking bans without any exceptional rules, whereas partial designs allow separated smoking areas at bars, restaurants, hospitals, workplaces, or airports. Only 16% of the world's population lives under the jurisdiction of comprehensive SF laws, found mostly in high-or middle-income countries. ...
... This publication period was chosen because we were particularly interested in the European experience, and smoking bans became part of the legislation in many EU member states in 2004. 10,12,49 By using electronic databases-Social Sciences Citation Index (Web of Science) and PubMed/MEDLINE-we identified primary studies relevant to the study scope and research question. We conducted telephone interviews with two national-level tobacco control experts to define our search strategy and relevant search terms. ...
Article
Introduction: While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities. Methods: We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3,829 references were screened, of which 43 were synthesized. Studies dating from 2004-2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, non-smoking compliance, and public support in cities. Results: The explanatory realist framework links 4 innovation stages with 3 context-mechanism-outcome configurations (CMOs). We identified "triggering trust", "increasing priorities", and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMOs support practical recommendations, such as (a) providing authorities with local data when establishing and developing bans, (b) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (c) limiting opposing interests through the use of the child protection frame. Conclusions: This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation. Implications: In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive smoke-free (SF) laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO Healthy Cities Network objectives.
... Accordingly, extensive literature focused on the evaluation of public health policies that may produce and keep healthy lifestyle or change unhealthy lifestyle. Public interventions mainly involve the following policies on lifestyle determinants of health: policies on tobacco control [60][61][62][63], policies on alcohol, sugar-sweetened beverage, food and nutrition [64][65][66][67][68], and promoting physical activity [69][70][71][72]. ...
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Health policies are regarded as a governance mechanism crucial for reducing health inequity and improving overall health outcomes. Policies that address chronic conditions or health inequity suggest a governance shift toward active health over past decades. However, the current literature in health policy largely focused on some specific health policy changes and their tangible outcomes, or on specific inequality of health policies in gender, age, racial, or economic status, short of comprehensively responding to and addressing the shift. This is exacerbated further by a common confusion that equates health policy with health care policy, which has been burdened by increased population ageing, growing inequalities, rising expenditures, and growing social expectations. This study conducted a narrative literature review to comprehensively and critically analyze the most current knowledge on health policy in order to help us establish a theoretical framework on active health governance. The comprehensive framework proposed in this paper identifies the main elements of a well-defined active health governance and the interactions between these elements. The proposed framework is composed of four elements (governance for health, social determinants of health, lifestyle determinants of health, and health system) and three approaches (whole-of-government approach, whole-of-society approach, and lifespan/life-course approach) that are dynamically interacted to achieve two active health outcomes (health equity and health improvement). The framework provides a conceptual solution to the issues of current literature on health policy and practically serves as a new guide for health policymaking.
... Moritsugu noted that enacting more comprehensive tobacco-control legislation could effectively prevent exposure to secondhand smoke and reduce the number of smokers [35]. Based on European studies, Ward found that the indoor PM2.5 concentration generally decreased by 68.4%, while for areas with partial bans on smoking, indoor PM2.5 concentration reduced by 40%, after introducing comprehensive smoke-free legislation [36]. This provided sufficient evidence that enacting comprehensive smoke-free legislation was associated with lower level of exposure to secondhand smoke. ...
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Background: Several studies have demonstrated that smoke-free legislation is associated with a reduced risk of mortality from acute myocardial infarction (AMI). This study aimed to examine and quantify the potential effect of smoke-free legislation on AMI mortality rate in different countries. Methods: Studies were identified using a systematic search of the scientific literature from electronic databases, including PubMed, Web of Science, ScienceDirect, Embase, Google Scholar, and China National Knowledge Infrastructure (CNKI), from their inception through September 30, 2017. A random effects model was employed to estimate the overall effects of smoke-free legislation on the AMI mortality rate. Subgroup analysis was performed to explore the possible causes of heterogeneity in risk estimates based on sex and age. The results of meta-analysis after excluding the studies with a high risk of bias were reported in this study. Results: A total of 10 eligible studies with 16 estimates of effect size were included in this meta-analysis. Significant heterogeneity in the risk estimates was identified (overall I2 = 94.6%, p < 0.001). Therefore, a random effects model was utilized to estimate the overall effect of smoke-free legislation. There was an 8% decline in AMI mortality after introducing smoke-free legislation (RR = 0.92, 95% confidence interval (CI): 0.90-0.94). The results of subgroup analyses showed that smoke-free legislation was significantly associated with lower rates of mortality for the following 5 diagnostic subgroups: smoke-free in workplaces, restaurants and bars (RR = 0.92, 95% CI: 0.90-0.95), smaller sample size (RR = 0.92, 95% CI: 0.89-0.95), study location in Europe (RR = 0.90, 95% CI: 0.85-0.94), regional study area (RR = 0.92, 95% CI: 0.89-0.94), and no previous local smoke-free legislation (RR = 0.91, 95% CI: 0.90-0.93). However, there was not much difference in AMI mortality rates after the legislation between the longer (RR = 0.92, 95% CI: 0.86-0.98) and shorter follow-up duration subgroups (RR = 0.92, 95% CI: 0.89-0.94). Conclusion: Smoke-free legislation could significantly reduce the AMI mortality rate by 8%. The reduction in the AMI mortality rate was more significant in studies with more comprehensive laws, without prior smoke-free bans, with a smaller sample size, at the regional level, and with a location in Europe.
... Comprehensive smoke-free laws have been shown to be more effective than partial laws in reducing exposure to secondhand tobacco smoke [80,81]. Indeed, while a reduction in fine particulate matter (PM 2.5 ) concentrations had been observed in France, Greece, Ireland, Italy, Portugal, Scotland, and Turkey following enactment of smoke-free legislations, the countries that enacted comprehensive smoke-free legislation (France, Ireland, Italy, Scotland, and Turkey) experienced greater reductions in PM 2.5 concentrations [82]. In studies in Malaysia and Chile, which have partial smoking legislations, exposure to secondhand smoke, measured by air nicotine and PM 2.5 concentrations, remained high in hospitality venues following enactment of legislation [83,84]. ...
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Background: Legislations banning smoking in indoor public places and workplaces are being implemented worldwide to protect the population from secondhand smoke exposure. Several studies have reported reductions in hospitalizations for acute coronary events following the enactment of smoke-free laws. Objective: We set out to conduct a systematic review and meta-analysis of epidemiologic studies examining how legislations that ban smoking in indoor public places impact the risk of acute coronary events. Methods: We searched MEDLINE, EMBASE, and relevant bibliographies including previous systematic reviews for studies that evaluated changes in acute coronary events, following implementation of smoke-free legislations. Studies were identified through December 2013. We pooled relative risk (RR) estimates for acute coronary events comparing post- vs. pre-legislation using inverse-variance weighted random-effects models. Results: Thirty-one studies providing estimates for 47 locations were included. The legislations were implemented between 1991 and 2010. Following the enactment of smoke-free legislations, there was a 12 % reduction in hospitalizations for acute coronary events (pooled RR: 0.88, 95 % CI: 0.85-0.90). Reductions were 14 % in locations that implemented comprehensive legislations compared to an 8 % reduction in locations that only had partial restrictions. In locations with reductions in smoking prevalence post-legislation above the mean (2.1 % reduction) there was a 14 % reduction in events compared to 10 % in locations below the mean. The RRs for acute coronary events associated with enacting smoke-free legislation were 0.87 vs. 0.89 in locations with smoking prevalence pre-legislation above and below the mean (23.1 %), and 0.87 vs. 0.89 in studies from the Americas vs. other regions. Conclusion: The implementation of smoke-free legislations was related to reductions in acute coronary event hospitalizations in most populations evaluated. Benefits are greater in locations with comprehensive legislations and with greater reduction in smoking prevalence post-legislation. These cardiovascular benefits reinforce the urgent need to enact and enforce smoke-free legislations that protect all citizens around the world from exposure to tobacco smoke in public places.
... The latter has been well documented in Spain, where the implementation of comprehensive bans in 2011, which replaced the ineffective 'Spanish model' of partial bans, resulted in a >90% decrease in nicotine and PM2.5 concentrations in hospitality venues. 17 A recent study by Ward et al. 18 showed similar results to our Table 2 The role of sociodemographic and policy determinants on exposure of non-smokers to SHS in bars (n = 13 858), restaurants (n = 15 273) and the workplace (n = 7970) in 27 EU Member States, in 2012 Logistic regression ORs were adjusted for geographic region, smoke-free policies at country level and for all variables included in the table. analysis, highlighting the importance of comprehensive smoke-free policies. ...
Article
Background: To explore whether exposure to secondhand smoke (SHS) among non-smokers in the European Union (EU) showed any association with sociodemographic factors and/or the extent of national tobacco control policies. Methods: A secondary analysis was performed on data from 26 751 individuals ≥15 years old from 27 EU member states (EU MS), collected during the 2012 Special Eurobarometer survey (wave 77.1). Respondents were asked whether they had been exposed to SHS in eating or drinking establishments during the past 6 months, and/or in their workplace. Data on smoke-free policies were extracted from the European Tobacco Control Status Report and the European Tobacco Control Scale (TCS) in 2013. Results: In total, 29.0% of non-smoking participants reported being exposed to SHS in indoor areas. Males (vs. females) as well as individuals with difficulties to pay bills (vs. those with no difficulties), had significantly greater odds of being exposed to SHS in bars, restaurants and workplaces. For every unit increase of a country's score on the Smoke-free Component of the TCS (indicating greater adherence to smoke-free legislations) the odds ratio of reporting exposure to SHS was 0.82 in bars, 0.85 in restaurants and 0.94 in workplaces. Conclusions: Differences in exposure to SHS clearly exist between and within EU MS, despite the fact that they all have signed the Framework Convention on Tobacco Control, with the burden found to disproportionally affect younger people and individuals with financial difficulties. Moreover, enforcement of smoke-free legislation was inversely associated with SHS exposure, highlighting the importance of enforcing comprehensive smoking bans.
... [10][11][12] Moreover, hospitality workers absorb considerable amount of SHS and often experience greater respiratory symptoms compared with workers in other public settings. 13 There are a plethora of studies, spanning multiple countries across all continents (eg, Americas, Asia and Europe and now more recently Africa) which have shown that strong smoke-free laws lead to dramatic reductions in indoor air pollution in public places [14][15][16][17][18] and that locations that do not have smoking regulations have very high levels of SHS 18 19 For example, in a 2008 study of 32 countries, the level of tobacco-related fine particulate matter of diameter less than 2.5 μm (PM 2.5 )-a validated atmospheric marker for the presence of SHS 9 16 20 -was on average 87% lower in countries with comprehensive smoke-free laws in comparison to countries without such laws. 21 Additionally, a recent study carried out in Ghana (where there is no national smoke-free law and smoking is allowed in designated smoking areas in indoor public places and workplaces), 19 showed that smoking venues had markedly elevated PM 2.5 compared non-smoking venues (median 553 μg/m 3 vs 16 μg/m 3 , respectively) and also higher hair nicotine concentrations in non-smoking employees working in venues that allowed smoking compared with non-smoking establishments (median 2.49 ng/mg vs median 0.16 ng/mg, respectively). ...
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Objective This study evaluated knowledge, opinions and compliance related to Uganda’s comprehensive smoke-free law among hospitality venues in Kampala Uganda. Design This multi-method study presents cross-sectional findings of the extent of compliance in the early phase of Uganda’s comprehensive smoke-free law (2 months postimplementation; pre-enforcement). Setting Bars, pubs and restaurants in Kampala Uganda. Procedure and participants A two-stage stratified cluster sampling procedure was used to select hospitality sites stratified by all five divisions in Kampala. A total of 222 establishments were selected for the study. One hospitality representative from each of the visited sites agreed to take part in a face-to-face administered questionnaire. A subsample of hospitality venues were randomly selected for tobacco air quality testing (n=108). Data were collected between June and August 2016. Outcome measures Knowledge and opinions of the smoke-free law among hospitality venue staff and owners. The level of compliance with the smoke-free law in hospitality venues through: (1) systematic objective observations (eg, active smoking, the presence of designated smoking areas, ‘no smoking’ signage) and (2) air quality by measuring the levels of tobacco particulate matter (PM2.5) in both indoor and outdoor venues. Results Active smoking was observed in 18% of venues, 31% had visible ‘no smoking’ signage and 47% had visible cigarette remains. Among interviewed respondents, 57% agreed that they had not been adequately informed about the smoke-free law; however, 90% were supportive of the ban. Nearly all respondents (97%) agreed that the law will protect workers’ health, but 32% believed that the law would cause financial losses at their establishment. Indoor PM2.5 levels were hazardous (267.6 µg/m³) in venues that allowed smoking and moderate (29.6 µg/m³) in smoke-free establishments. Conclusions In the early phase of Uganda’s smoke-free law, the level of compliance in hospitality venues settings in Kampala was suboptimal. Civil society and the media have strong potential to inform and educate the hospitality industry and smokers of the benefits and requirements of the smoke-free law.
... Therefore, a better control and accomplishment of the law may be required. The previous experience in Europe established that a fully comprehensive smoke-free legislation is more effective than partial laws in reducing exposure to second-hand smoking [29]. Any law should be also actively enforced in order to have the desired impact. ...
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Background Second-hand smoking has not been detailedly studied in Peru, where smoking is prohibited in all indoor workplaces, public places, and public transportation. Second-hand smoke exposure may occur at home or any other places. This study aimed to estimate the prevalence of second-hand smoking and assess its association with hypertension and cardiovascular risk in Peru. Materials and methods Secondary analysis of a nationally-representative population-based survey including individuals aged 18–59 years. There were two outcomes: hypertension and 10-year cardiovascular risk using the Framingham and the 2019 World Health Organization (WHO) risk scores. The exposure was self-reported second-hand smoking during the 7 days before the survey. The association between second-hand smoking and hypertension was quantified with Poisson models reporting prevalence ratio (PR) and 95% confidence interval (95% CI); the association between second-hand smoking and cardiovascular risk was quantified with linear regressions reporting coefficients and their 95% CI. Results Data from 897 individuals, mean age: 38.2 (SD: 11.8) years, and 499 (55.7%) females, were analyzed, with 8.7% subjects reporting second-hand smoking at home and 8.3% at work or any other place. Thus, 144 (15.5%; 95% CI: 12.8%-18.6%) subjects reported any second-hand smoking. In multivariable model second-hand smoking was associated with hypertension (PR = 2.42; 95% CI: 1.25–4.67), and with 1.2% higher Framingham cardiovascular risk, and 0.2% higher 2019 WHO risk score. Conclusions There is an association between second-hand smoking and hypertension as well as with cardiovascular risk, and 15% of adults reported second-hand smoke exposure overall with half of them exposed at home. There is a need to guarantee smoking-free places to reduce cardiovascular risk.
... National and local authorities can enact public policies to protect people from exposure to secondhand tobacco smoke, and in so doing protect children from smoking-related morbidity and mortality. There is support for comprehensive laws and implementation and penalties from the success in Ireland which was the first country to introduce comprehensive smoke-free laws [22], it is the best choice to complement national comprehensive smoke-free policy in China for preventing secondhand tobacco smoke exposure. ...
Article
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Objective: To evaluate the association between smoke-free regulations in public places and secondhand smoke exposure and related beliefs, awareness, attitudes, and behavior among urban residents in China. Methods: We selected one city (Hangzhou) as the intervention city and another (Jiaxing) as the comparison. A structured self-administered questionnaire was used for data collection, and implemented at two time points across a 20-month interval. Both unadjusted and adjusted logistic methods were considered in analyses. Multiple regression procedures were performed in examining variation between final and baseline measures. Results: Smoke-free regulations in the intervention city were associated with a significant decline in personal secondhand smoke exposure in government buildings, buses or taxis, and restaurants, but there was no change in such exposure in healthcare facilities and schools. In terms of personal smoking beliefs, awareness, attitudes, and practices, the only significant change was in giving quitting advice to proximal family members. Conclusions: There was a statistically significant association between implementation of smoke-free regulations in a city and inhibition of secondhand tobacco smoking exposure in public places. However, any such impact was limited. Effective tobacco control in China will require comprehensive laws implemented fully and supported by penalties and a combination of strong public health education.
... Particle exposure can cause premature death in people with heart or lung disease, nonfatal heart attacks, irregular heart beat, aggravated asthma, decreased lung function, and increased respiratory symptoms such as irritation of the airways, coughing, or difficulty breathing (Atkinson et al. 2010;Cadelis et al. 2014;Correia et al. 2013;Fang et al. 2013;Meister et al. 2012). On another aspect, Ward et al. (2013) used data on PM 2.5 concentration levels recorded in 338 hospitality venues across France, Greece, Ireland, Italy, Portugal, Turkey, and Scotland before and after the functioning of smoke-free legislation. Table 1 shows the linking of the above mentioned air pollutants with the body systems which affect. ...
Article
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Pollution is associated with serious environmental and health problems. For instance particulate matter (PM2.5) causes severe health problems like respiratory and cardiovascular diseases and outdoor exposure may be carcinogenic to humans. In this study data envelopment analysis is used to estimate the efficiencies of 18 European countries for the years 2000, 2005, 2010, 2014, 2015 and 2016. Directional distance function is utilized to deal with undesirable outputs. Two models are specified one with labour and capital as inputs and GDP/c and mortality from exposure to PM2.5 as desirable and undesirable outputs respectively and the other with environmental related tax revenues as additional input. The results derived are bias corrected to obtain the accurate efficiency scores of every country considered. On the whole the most efficient countries are revealed to be Sweden, Finland, France, the Netherlands and the UK. The inclusion of environmentally related tax revenues seems to have a little influence in efficiency scores.
... Research on SF implementation in continental EU cities has been scarcely studied and has focused on healthcare or hospital domains (llén et al., 2002;Giraldi et al., 2013). Moreover, existing European studies researched often large-scale population effects such as the impact of SF laws on home smoking bans or SHS exposure (Lotrean, 2008;Mons et al., 2013;Ward et al., 2013;Kuntz and Lampert, 2016). ...
Article
Background Advocacy, resources and intersubjective reasonable arguments are known as factors that contribute to smoke-free (SF) adoption and implementation in Chinese and Anglo-Saxon places. Less is known about how the implementation of smoking bans differs across European places. The aim of this qualitative comparative study is to identify and classify the SF policy implementation processes and types undertaken at the local level in seven European cities according to the views of local bureaucrats and sub-national stakeholders. Method Semi-structured expert interviews (n = 56) with local decision makers and stakeholders were conducted as qualitative part of the comparative SILNE-R project in Belgium (Namur), Finland (Tampere), Germany (Hanover), the Republic of Ireland (Dublin), the Netherlands (Amersfoort), Italy (Latina), and Portugal (Coimbra). Qualitative interviews were analyzed using the framework analysis. Results Implementation of SF environments predominantly focuses on indoor bans or youth-related settings. Progressive-hungry (Dublin), moderate-rational (Tampere), upper-saturated (Hanover, Amersfoort), and lower saturated (Namur, Coimbra, Latina) implementation types can be distinguished. These four types differ with regards to their engagement in enhancing SF places as well as along their level of perceived tobacco de-normalization and public smoking visibility. In all municipalities SF environments are adopted at national levels, but are differently implemented at the local level due national policy environments, enforcement strategies and the level of collaboration. Major mechanisms to expand SF regulations were found to be scientific evidence, public support, and the child protection frame. However, counter-mechanisms of closure occur if data on declining prevalence and new youth addiction trends trigger low prioritization. Conclusions This study found four SF implementation types two mechanisms of progressive expansion and defensive closure. Development and enhancement of smoking bans requires a suitable national policy environment and indirect national-level support of self-governed local initiatives. Future SF policies can be enhanced by laws pertaining to places frequented by minors.
... Our findings strengthen those of previous studies in other countries and demonstrate that partial bans are not as effective as comprehensive bans in reducing SHS exposure. [35][36][37][38] For example, comprehensive smoke-free legislation in Greece reduced SHS by 67%, which was 37% higher than that achieved by a partial ban. 14 Similarly, a comprehensive ban in Norway reduced total PM 2.5 concentrations in bars and restaurants from 262 µg/m 3 to 77 µg/m 3 (71% reduction), 31 while an 86% average reduction was reported in Scotland (246-20 µg/ m 3 ) 21 In Israel, after the implementation of partial smoke-free legislation, the SHS reduced by only 34%. ...
Article
Objectives This study quantified the secondhand smoke (SHS) concentration in a sample of public places in Vietnam to determine changes in SHS levels 5 years after a public smoking ban was implemented. Methods Two monitoring campaigns, one in 2013 (before the tobacco control law was implemented) and another in 2018 (5 years after the implementation of the law) were conducted in around 30 restaurants, cafeterias and coffee shops in major cities of Vietnam. Concentrations of PM 2.5 , as an indicator of SHS, were measured by portable particulate matter monitors (TSI SidePak AM510 and Air Visual Pro). Results The geometric mean PM 2.5 concentration of all monitored venues was 87.7 µg/m ³ (83.7–91.9) in the first campaign and 55.2 µg/m ³ (53.7–56.7) in the second campaign. Pairwise comparison showed the PM 2.5 concentrations in the smoking observed area was triple and double those in the non-smoking area and the outdoor environment. After adjusting for sampling locations and times, the SHS concentration 5 years after the implementation of the tobacco control law reduced roughly 45%. Conclusion The study results indicate an improvement in air quality in public places in Vietnam via both the reduction in PM 2.5 levels and the number of people observed smoking. However, greater enforcement of the free-smoke legislation is needed to eliminate SHS in public places in Vietnam.
... Our findings strengthen those of previous studies in other countries and demonstrate that partial bans are not as effective as comprehensive bans in reducing SHS exposure. [35][36][37][38] For example, comprehensive smoke-free legislation in Greece reduced SHS by 67%, which was 37% higher than that achieved by a partial ban. 14 Similarly, a comprehensive ban in Norway reduced total PM 2.5 concentrations in bars and restaurants from 262 µg/m 3 to 77 µg/m 3 (71% reduction), 31 while an 86% average reduction was reported in Scotland (246-20 µg/ m 3 ) 21 In Israel, after the implementation of partial smoke-free legislation, the SHS reduced by only 34%. ...
... Exposure to environmental tobacco smoke increases the severity of asthma and is an important preventable exposure predisposing asthma exacerbations in children. 1 2 Secondhand smoke exposure can effectively be reduced by creating comprehensive smoke-free public environments enacted through legislation. [3][4][5] While the research on the effects of legislation for smoke-free public environments on adults is well informed, studies on the effects for children are limited and varying. There was no association, immediate nor gradual, between smoke-free legislation and hospital admissions for asthma among children in Canada and Spain. ...
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Objective This study will add to existing literature by examining the impact of smoke-free legislation in outdoor areas among children with asthma. We aimed to examine the effect of the 2015 Smoke-Free Ontario Act (SFOA) amendment, which prohibited smoking on patios, playgrounds and sports fields, on health services use (HSU) rates in children with asthma. Methods We conducted a population-based open cohort study using health administrative data from the province of Ontario, Canada. Each year, all Ontario residents aged 0–18 years with physician diagnosed asthma were included in the study. Annual rates of HSU (emergency department (ED) visits, hospitalisations and physician office visits) for asthma and asthma-related conditions (eg, bronchitis, allergic rhinitis, influenza and pneumonia) were calculated. Interrupted time-series analysis, accounting for seasonality, was used to estimate changes in HSU following the 2015 SFOA. Results The study population ranged from 618 957 individuals in 2010 to 498 812 in 2018. An estimated average increase in ED visits for asthma in infants aged 0–1 years of 0.42 per 100 individuals (95% CI: 0.09 to 0.75) and a 57% relative increase corresponding to the 2015 SFOA was observed. A significant decrease in ED visits for asthma-related conditions of 0.19 per 100 individuals (95% CI: −0.37 to –0.01) and a 22% relative decrease corresponding to the 2015 SFOA was observed. Conclusion Based on the observed positive effect of restricting smoking on patios, playgrounds and sports fields on respiratory morbidity in children with asthma, other jurisdictions globally should consider implementing similar smoke-free policies.
Article
Background: Decreases in circulatory/respiratory morbimortality after the January-2006 Spanish partial smoke-free law have been found using designs without control groups, such as single-group interrupted time series (ITS), which are prone to biases. The aim was to reassess the law's impact on mortality using ITS designs with robustness checks. Methods: A comprehensive cohort of people aged ≥25 in each calendar-year of 2002-2007, living in 13 of 18 Spanish regions, was followed up between 01/2002 and 12/2007. The law included a smoking ban in indoor public and workplaces, allowing exceptions in catering, hospitality and leisure venues, and other interventions. Post-law changes in monthly coronary/respiratory mortality were estimated using segmented regression, adjusting for relevant covariates, including seasonality, extreme temperatures, influenza incidence and air pollution. The validity of results was assessed using control outcomes, hypothetical law dates, and non-equivalent control groups, analysing their results as difference-in-differences (DID) designs. Results: Significant immediate post-law decreases in coronary, respiratory and non-tobacco-related mortality were observed among people aged ≥70. A significant immediate post-law decrease in respiratory mortality (-12.7%) was also observed among people age 25-69, although this was neutralized by a subsequent upward trend before 1.5 years. More favourable post-law changes in coronary/respiratory mortality among the target (people aged 25-69) than control groups (people aged ≥70 or women aged ≥80) were not identified in DID designs. Establishing hypothetical law dates, immediate decreases began in February/March 2005 with maxima between April and July 2005. Conclusions: After robustness checks, the results do not support a clear positive impact of the 2006 Spanish smoke-free law on short-term coronary/respiratory mortality. The favourable immediate changes observed pre- and post-law could derive mainly from the harvesting effect of the January-2005 cold wave. This highlights the risks of assessing the impact of health interventions using both morbimortality outcomes and designs without a control group and adequate robustness checks.
Article
Penelitian ini bertujuan untuk menganalisis Faktor Penguat dalam Implementasi Kebijakan Kawasan Tanpa Rokok di Instansi Pemerintahan Kota Palembang. Jenis penelitian ini merupakan penelitian deksriptif kualitatif dengan fokus penelitian menganalisis Faktor Penguat dalam Implementasi Kebijakan Kawasan Tanpa Rokok di Instansi Pemerintahan Kota Palembang, yang terdiri dari himbauan organisasi, pengawasan internal dan penerapan sanksi. Data dikumpulkan melalui wawancara dengan key informant serta Tim Penegakan Hukum Peraturan Daerah Kawasan Tanpa Rokok (Perda KTR). Analisis data terdiri dari tahap Data Condensation, Data Display dan Conclusion Drawing/ Verifications. Hasil penelitian menunjukan bahwa berdasarkan faktor penguat, pihak Instansi yang melakukan pelanggaran terhadap Perda KTR hanya mendapat SP1 maupun SP2 saja, belum pernah diterapkan sanksi berupa hukum pidana kurungan paling lama tiga bulan atau denda administratif seperti yang tertuang pada Perda Kota Palembang No. 7 Tahun 2009 tentang Kawasan Tanpa Rokok.
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Background: this study aims to examine the different factors associated with exposure to second-hand smoke (SHS) between urban and rural areas and to facilitate a reduction in SHS exposure in Northeast China. Methods: a multistage stratified random cluster sampling design was used in this 2012 cross-sectional survey in Jilin Province, Northeast China. A total of 13 056 non-smokers were included in this study. The Rao-Scott χ2 test, multiple regression analysis and discriminant function analysis were used. Results: the SHS prevalence among adult non-smokers was 60.2% in urban areas and 61.8% in rural areas. In urban areas, males were more likely to be exposed to SHS, while in rural areas, females were more likely to be exposed to SHS (P < 0.05). Increasing age was a protective factor against SHS exposure both in urban and rural areas (P < 0.05). Tobacco-relevant knowledge was positively associated with SHS exposure. Among urban non-smokers, high education level and engagement in manual work were risk factors for SHS exposure, and retired subjects were less likely to be exposed to SHS (P < 0.01). Conclusions: non-smokers from urban and rural areas differ in the factors associated with SHS exposure, and urban-rural differentials, especially with regard to gender, should be considered in tobacco control.
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The world population is ageing and increasing in size. As a result, the numbers of people diagnosed with and dying of cancer are increasing. Cancer is also a growing problem in developing countries. Government, be it local, state, provincial, national, or even a union of nations, has clear roles in the control of cancer. It is widely appreciated that much of the research that has defined the causes and treatment of cancer was, and is, government funded. Less appreciated, the body of work about how to control cancer shows the importance of an environment that encourages individuals to adopt healthy behaviours, and government has a vitally important role. Through regulation, education, and support programmes, governments can create an environment in which tobacco use is reduced and citizens maintain good levels of physical activity, healthy bodyweight, and good nutrition. Cancer prevention and the creation of a culture of health is an essential mission of government, beyond that of the traditional health-focused departments such as health ministries; it is in the domain of governmental agencies involved in environmental protection, occupational safety, and transportation. Cancer prevention and health promotion are also in the realm of the zoning board, the board of education, and the board of health.
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The response of pregnant women to tobacco policy is of particular interest due to these women being in a unique position to pass health capital to the next generation. By comparing estimates in the literature, we highlight that while pregnant women are responsive to taxes and taxes improve child health, their responsiveness has declined over time. We show that these trends reflect a compositional change; specifically, the least addicted smokers quit in the 1990s, leaving the pool of smoking mothers to be dominated by less price elastic smokers. Reviewing the literature on other tobacco policies, we show that a state-level U.S. smoking ban has roughly three times the effect on pregnant women of a 10% increase in prices using elasticity estimates from more recent periods. Throughout this review, we identify areas for improvement in the literature and offer a number of ideas for future research projects.
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Objectives We assessed the impact of varying levels of smokefree regulations on birth outcomes and prenatal smoking. Methods We exploited variations in timing and regulation restrictiveness of West Virginia's county smokefree regulations to assess their impact on birthweight, gestational age, low birthweight, very low birthweight, preterm birth, and prenatal smoking. We conducted regression analysis using state Vital Statistics individual-level data for singletons born to West Virginia residents between 1995-2010 (N = 293,715). Results Only more comprehensive smokefree regulations were associated with statistically significant favorable effects on birth outcomes in the full sample: Comprehensive (workplace/restaurant/bar ban) demonstrated increased birthweight (29 grams, p < 0.05) and gestational age (1.64 days, p < 0.01), as well as reductions in very low birthweight (-0.4 %, p < 0.05) and preterm birth (-1.5 %, p < 0.01); Restrictive (workplace/restaurant ban) demonstrated a small decrease in very low birthweight (-0.2 %, p < 0.05). Among less restrictive regulations: Moderate (workplace ban) was associated with a 23 g (p < 0.01) decrease in birthweight; Limited (partial ban) had no effect. Comprehensive's improvements extended to most maternal groups, and were broadest among mothers 21+ years, non-smokers, and unmarried mothers. Prenatal smoking declined slightly (-1.7 %, p < 0.01) only among married women with Comprehensive. Conclusions Regulation restrictiveness is a determining factor in the impact of smokefree regulations on birth outcomes, with comprehensive smokefree regulations showing promise in improving birth outcomes. Favorable effects on birth outcomes appear to stem from reduced secondhand smoke exposure rather than reduced prenatal smoking prevalence. This study is limited by an inability to measure secondhand smoke exposure and the paucity of data on policy implementation and enforcement.
Article
Secondhand smoke (SHS) exposure among children is associated with a wide variety of adverse health risks, including: asthma, otitis media, respiratory infections, impaired lung growth and function, decreased exercise tolerance, cognitive impairments, behavior problems, and sudden infant death syndrome. Unfortunately, over 40% of children aged 3-11 years-15.1 million children-are currently exposed to SHS, with nearly 70% of black children in this age group being exposed. Over the past three decades, great strides have been made in establishing smokefree environments for adults, ultimately reducing their SHS exposure. Regulations have been passed at the organizational, local, and state levels that increasingly ban smoking in the workplace and public places. Children's SHS exposure patterns, however, differ from adults' exposures, with greater time spent in the home and other potentially unregulated venues (school, child care, and car). This means that children have been afforded relatively less protection from SHS by these smokefree regulations. It is imperative, therefore, to seek alternative options for promoting smokefree environments for children throughout the United States. This article explores policy options that promote smokefree environments for children and adolescents: comprehensive smokefree/tobacco-free policies covering indoor/outdoor public places, housing, private vehicles, and child care, as well as Clinical Guidelines regarding patient/family interviews on smoking, SHS, cessation, and voluntary smokefree efforts. The policy section highlights the role of child and adolescent health practitioners in promoting these policies with the hope of fostering engagement of these key stakeholders in the policy process. Note, there are a wide range of important policy and regulatory strategies aimed at reducing tobacco initiation and use among children, adolescents, and young adults; while essential in tobacco prevention and control efforts, a discussion of these strategies is beyond the scope of this article. Copyright © 2015 Mosby, Inc. All rights reserved.
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Suggested citation for this article: Chandora RD, Whitney CF, Weaver SR, Eriksen MP. Changes in Georgia Restaurant and Bar Smoking Policies From 2006 to 2012. Prev Chronic Dis 2015;12:140520. DOI: http://dx.doi.org/10.5888/pcd12.140520.
Article
Objective Using data on fine particulate matter less than 2.5 μm (PM2.5) concentrations in smoking and non-smoking homes in Scotland to estimate the mass of PM2.5 inhaled by different age groups. Methods Data from four linked studies, with real-time measurements of PM2.5 in homes, were combined with data on typical breathing rates and time-activity patterns. Monte Carlo modelling was used to estimate daily PM2.5 intake, the percentage of total PM2.5 inhaled within the home environment and the percentage reduction in daily intake that could be achieved by switching to a smoke-free home. Results Median (IQR) PM2.5 concentrations from 93 smoking homes were 31 (10–111) μg/m3 and 3 (2–6.5) μg/m3 for the 17 non-smoking homes. Non-smokers living with smokers typically have average PM2.5 exposure levels more than three times higher than the WHO guidance for annual exposure to PM2.5 (10 μg/m3). Conclusions Fine particulate pollution in Scottish homes where smoking is permitted is approximately 10 times higher than in non-smoking homes. Taken over a lifetime many non-smokers living with a smoker inhale a similar mass of PM2.5 as a non-smoker living in a heavily polluted city such as Beijing. Most non-smokers living in smoking households would experience reductions of over 70% in their daily inhaled PM2.5 intake if their home became smoke-free. The reduction is likely to be greatest for the very young and for older members of the population because they typically spend more time at home.
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Objective To examine trends in population exposure to secondhand smoke (SHS) and consider two exposure metrics as appropriate targets for tobacco control policy-makers. Design Comparison of adult non-smokers’ salivary cotinine data available from 11 Scottish Health Surveys between 1998 and 2016. Methods The proportions of non-smoking adults who had measurable levels of cotinine in their saliva were calculated for the 11 time points. The geometric mean (GM) concentrations of cotinine levels were calculated using Tobit regression. Changes in both parameters were assessed for the whole period and also for the years since implementation of smoke-free legislation in Scotland in 2006. Results Salivary cotinine expressed as a GM fell from 0.464 ng/mL (95% CI 0.444 to 0.486 ng/mL) in 1998 to 0.013 ng/mL (95% CI 0.009 to 0.020 ng/mL) in 2016: a reduction of 97.2%. The percentage of non-smoking adults who had no measurable cotinine in their saliva increased by nearly sixfold between 1998 (12.5%, 95% CI 11.5% to 13.6%) and 2016 (81.6%, 95% CI 78.6% to 84.6%). Reductions in population exposure to SHS have continued even after smoke-free legislation in 2006. Conclusions Scotland has witnessed a dramatic reduction in SHS exposure in the past two decades, but there are still nearly one in five non-smoking adults who have measurable exposure to SHS on any given day. Tobacco control strategies globally should consider the use of both the proportion of non-smoking adults with undetectable salivary cotinine and the GM as targets to encourage policies that achieve a smoke-free future.
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The objective of this article is to describe the process of approval of the Italian smoking ban, enacted in 2005. The method is to conduct a review of proposed and approved legislation 2000- 2005, and of articles published in Italian newspapers, 1998-2008. Enabling factors in the process were: the leadership of two consecutive Health Ministers, both physicians, who introduced the bill four times between 2000-2002; the repeated presentation and final approval of the bill as an amendment within a bill on public administration which enabled timely approval of the ban; and the stringent air quality standards in the 2003 regulation that made building smoking rooms impracticable and prohibitively expensive. Limiting factors in the process were: the 6-month delay in approving the regulation on smoking rooms; the 1.5-year delay in approving the regulation establishing owners' responsibility for enforcing the ban in hospitality premises and the legal action in August 2005, which shifted responsibility for enforcement to police. Eighty-three percent of the 808 articles published on smoking in 1998-2008 were released between 2000-2005, during the policy process. While the press devoted considerable attention to the issues raised by the hospitality sector, the long legislative process of the bill and its regulations also stimulated coverage on tobacco control issues.
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Smoking prevention should be a primary public health priority for all governments, and effective preventive policies have been identified for decades. The heterogeneity of smoking prevalence between European Union (EU) Member States therefore reflects, at least in part, a failure by governments to prioritise public health over tobacco industry or possibly other financial interests, and hence potentially government corruption. The aims of this study were to test the hypothesis that smoking prevalence is higher in countries with high levels of public sector corruption, and explore the ecological association between smoking prevalence and a range of other national characteristics in current EU Member States. Ecological data from 27 EU Member States were used to estimate univariate and multivariate correlations between smoking prevalence and the Transparency International Corruption Perceptions Index, and a range of other national characteristics including economic development, social inclusion, quality of life and importance of religion. We also explored the association between the Corruption Perceptions Index and measures of the extent to which smoke-free policies have been enacted and are enforced. In univariate analysis, smoking prevalence was significantly higher in countries with higher scores for corruption, material deprivation, and gender inequality; and lower in countries with higher per capita Gross Domestic Product, social spending, life satisfaction and human development scores. In multivariate analysis, only the corruption perception index was independently related to smoking prevalence. Exposure to tobacco smoke in the workplace was also correlated with corruption, independently from smoking prevalence, but not with the measures of national smoke-free policy implementation. Corruption appears to be an important risk factor for failure of national tobacco control activity in EU countries, and the extent to which key tobacco control policies have been implemented. Further research is needed to assess the causal relationships involved.
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To compare levels of particulate matter, as a marker of secondhand smoke (SHS) levels, in pubs before and 2 months after the implementation of Scottish legislation to prohibit smoking in substantially enclosed public places. Comparison of SHS levels before and after the legislation in a random selection of 41 pubs in 2 Scottish cities. Fine particulate matter <2.5 microm in diameter (PM2.5) was measured discreetly for 30 min in each bar on 1 or 2 visits in the 8 weeks preceding the starting date of the Smoking, Health and Social Care (Scotland) Act 2005 and then again 2 months after the ban. Repeat visits were undertaken on the same day of the week and at approximately the same time of the day. PM2.5 levels before the introduction of the legislation averaged 246 microg/m3 (range 8-902 microg/m3). The average level reduced to 20 microg/m3 (range 6-104 microg/m3) in the period after the ban. Levels of SHS were reduced in all 53 post-ban visits, with the average reduction being 86% (range 12-99%). PM2.5 concentrations in most pubs post-ban were comparable to the outside ambient air PM2.5 level. This study has produced the largest dataset of pre- and post-ban SHS levels in pubs of all worldwide smoke-free legislations introduced to date. Our results show that compliance with the Smoking, Health and Social Care (Scotland) Act 2005 has been high and this has led to a marked reduction in SHS concentrations in Scottish pubs, thereby reducing both the occupational exposure of workers in the hospitality sector and that of non-smoking patrons.
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Since the publication of the US Surgeon General Reports in 1996 and 2006 and the report of the California Environmental Protection Agency in 1999, many reports have appeared on the contribution of air and biomarkers to different facets of the secondhand smoke (SHS) issue, which are the targets of this review. These recent studies have allowed earlier epidemiological surveys to be biologically validated, and their plausibility demonstrated, quantified the levels of exposure to SHS before the bans in various environments, showed the deficiencies of mechanical control methods and of partial bans and the frequently correct implementation of the efficient total bans. More stringent regulation remains necessary in the public domain (workplaces, hospitality venues, transport sector, etc.) in many countries. Personal voluntary protection efforts against SHS are also needed in the private domain (homes, private cars). The effects of SHS on the cardiovascular, respiratory and neuropsychic systems, on pregnancy and fertility, on cancers and on SHS genotoxicity are confirmed through experimental human studies and through the relationship between markers and prevalence of disease or of markers of disease risk.
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Evaluate the effect of smoke-free legislation on fine particulate [particulate matter <2.5 microm in diameter (PM(2.5))] air pollution levels in bars in Scotland, England, and Wales. Design: Air quality was measured in 106 randomly selected bars in Scotland, England, and Wales before and after the introduction of smoking restrictions. PM(2.5) concentrations were measured covertly for 30-min periods before smoke-free legislation was introduced, again at 1-2 months post-ban (except Wales) and then at 12-months post-baseline (except Scotland). In Scotland and England, overt measurements were carried out to assess bar workers' full-shift personal exposures to PM(2.5). Postcode data were used to determine socio-economic status of the bar location. PM(2.5) levels prior to smoke-free legislation were highest in Scotland (median 197 microg m(-3)), followed by Wales (median 184 microg m(-3)) and England (median 92 microg m(-3)). All three countries experienced a substantial reduction in PM(2.5) concentrations following the introduction of the legislation with the median reduction ranging from 84 to 93%. Personal exposure reductions were also within this range. There was evidence that bars located in more deprived postcodes had higher PM(2.5) levels prior to the legislation. Prior to legislation PM(2.5) concentrations within bars across the UK were much higher than the 65 microg m(-3) 'unhealthy' threshold for outdoor air quality as set by the US Environmental Protection Agency. Concentrations in Scottish and Welsh bars were, on average, two or more times greater than in English bars for which seasonal influences may be responsible. Legislation in all three countries produced improvements in indoor air quality that are consistent with other international studies.
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The present study examined indoor air quality in a global sample of smoke-free and smoking-permitted Irish pubs. We hypothesized that levels of respirable suspended particles, an important marker of secondhand smoke, would be significantly lower in smoke-free Irish pubs than in pubs that allowed smoking. Indoor air quality was assessed in 128 Irish pubs in 15 countries between 21 January 2004 and 10 March 2006. Air quality was evaluated using an aerosol monitor, which measures the level of fine particle (PM(2.5)) pollution in the air. A standard measurement protocol was used by data collectors across study sites. Overall, the level of air pollution inside smoke-free Irish pubs was 93% lower than the level found in pubs where smoking was permitted. Levels of indoor air pollution can be massively reduced by enacting and enforcing smoke-free policies.
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A smoking law was passed by the Spanish Parliament in December 2005 and was enforced by 1 January 2006. The law bans smoking in all indoor workplaces but only in some hospitality venues, because owners are allowed to establish a smoking zone (venues>100 m2) or to allow smoking without restrictions (venues<100 m2). The objective of the study is to assess the impact of the Spanish smoking law on exposure to secondhand smoke (SHS) in enclosed workplaces, including hospitality venues. The study design is a before-and-after evaluation. We studied workplaces and hospitality venues from eight different regions of Spain. We took repeated samples of vapor-phase nicotine concentration in 398 premises, including private offices (162), public administration offices (90), university premises (43), bars and restaurants (79), and discotheques and pubs (24). In the follow-up period, SHS levels were markedly reduced in indoor offices. The median decrease in nicotine concentration ranged from 60.0% in public premises to 97.4% in private areas. Nicotine concentrations were also markedly reduced in bars and restaurants that became smoke-free (96.7%) and in the no-smoking zones of venues with separate spaces for smokers (88.9%). We found no significant changes in smoking zones or in premises allowing smoking, including discotheques and pubs. Overall, this study shows the positive impact of the law on reducing SHS in indoor workplaces. However, SHS was substantially reduced only in bars and restaurants that became smoke-free. Most hospitality workers continue to be exposed to very high levels of SHS. Therefore, a 100% smoke-free policy for all hospitality venues is required.
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Background: A smoke-free law came into effect in Spain on 1st January 2006, affecting all enclosed workplaces except hospitality venues, whose proprietors can choose among totally a smoke-free policy, a partial restriction with designated smoking areas, or no restriction on smoking on the premises. We aimed to evaluate the impact of the law among hospitality workers by assessing second-hand smoke (SHS) exposure and the frequency of respiratory symptoms before and one year after the ban. Methods and finding: We formed a baseline cohort of 431 hospitality workers in Spain and 45 workers in Portugal and Andorra. Of them, 318 (66.8%) were successfully followed up 12 months after the ban, and 137 nonsmokers were included in this analysis. We obtained self-reported exposure to SHS and the presence of respiratory symptoms, and collected saliva samples for cotinine measurement. Salivary cotinine decreased by 55.6% after the ban among nonsmoker workers in venues where smoking was totally prohibited (from median of 1.6 ng/ml before to 0.5 ng/ml, p<0.01). Cotinine concentration decreased by 27.6% (p = 0.068) among workers in venues with designated smoking areas, and by 10.7% (p = 0.475) among workers in venues where smoking was allowed. In Portugal and Andorra, no differences between cotinine concentration were found before (1.2 ng/ml) and after the ban (1.2 ng/ml). In Spain, reported respiratory symptom declined significantly (by 71.9%; p<0.05) among workers in venues that became smoke-free. After adjustment for potential confounders, salivary cotinine and respiratory symptoms decreased significantly among workers in Spanish hospitality venues where smoking was totally banned. Conclusions: Among nonsmoker hospitality workers in bars and restaurants where smoking was allowed, exposure to SHS after the ban remained similar to pre-law levels. The partial restrictions on smoking in Spanish hospitality venues do not sufficiently protect hospitality workers against SHS or its consequences for respiratory health.
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To compare exposure to secondhand smoke and respiratory health in bar staff in the Republic of Ireland and Northern Ireland before and after the introduction of legislation for smoke-free workplaces in the Republic. Comparisons before and after the legislation in intervention and control regions. Public houses in three areas in the Republic (intervention) and one area in Northern Ireland (control). 329 bar staff enrolled in baseline survey; 249 (76%) followed up one year later. Of these, 158 were non-smokers both at baseline and follow-up. Salivary cotinine concentration, self reported exposure to secondhand smoke, and respiratory and sensory irritation symptoms. In bar staff in the Republic who did not themselves smoke, salivary cotinine concentrations dropped by 80% after the smoke-free law (from median 29.0 nmol/l (95% confidence interval 18.2 to 43.2 nmol/l)) to 5.1 nmol/l (2.8 to 13.1 nmol/l) in contrast with a 20% decline in Northern Ireland over the same period (from median 25.3 nmol/l (10.4 to 59.2 nmol/l) to 20.4 nmol/l (13.2 to 33.8 nmol/l)). Changes in self reported exposure to secondhand smoke were consistent with the changes in cotinine concentrations. Reporting any respiratory symptom declined significantly in the Republic (down 16.7%, -26.1% to -7.3%) but not in Northern Ireland (0% difference, -32.7% to 32.7%). After adjustment for confounding, respiratory symptoms declined significantly more in the Republic than in Northern Ireland and the decline in cotinine concentration was twice as great. The smoke-free law in the Republic of Ireland protects non-smoking bar workers from exposure to secondhand smoke.
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To investigate whether the Irish smoking ban has had an impact on secondhand smoke (SHS) exposures for hospitality workers. Before and after the smoking ban a cohort of workers (n = 35) from a sample of city hotels (n = 15) were tested for saliva cotinine concentrations and completed questionnaires. Additionally, a random sample (n = 20) of city centre bars stratified by size (range 400-5000 square feet), were tested for air nicotine concentrations using passive samplers before and after the ban. Salivary cotinine concentrations (ng/ml), duration of self reported exposures to secondhand smoke, air nicotine (microg/cubic metre). Cotinine concentrations reduced by 69%, from 1.6 ng/ml to 0.5 ng/ml median (SD 1.29; p < 0.005). Overall 74% of subjects experienced decreases (range 16-99%), with 60% showing a halving of exposure levels at follow up. Self reported exposure to SHS at work showed a significant reduction from a median 30 hours a week to zero (p < 0.001). There was an 83% reduction in air nicotine concentrations from median 35.5 microg/m3 to 5.95 microg/m3 (p < 0.001). At baseline, three bars (16%) were below the 6.8 microg/m3 air nicotine significant risk level for lung cancer alone; at follow up this increased to 10 (53%). Passive smoking and associated risks were significantly reduced but not totally eliminated. Exposure to SHS is still possible for those working where smoking is still allowed and those working where smoke may migrate from outdoor areas. Further research is required to assess the true extent and magnitude of these exposures.
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From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts. Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas--knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities. The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.
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To monitor indoor air quality index in a few Italian hospitality industry venues before and after the implementation of the smoking ban in January 2005. Indoor PM2.5 measurements were carried out in four Milan restaurants during evening hours in the period January-February 2004, and again in January-February 2005, with concurrent outdoor PM2.5 monitoring. The measures were recorded with a portable laser-operated aerosol analyzer with a sampling time of 2 minutes, calibrated by comparison with gravimetric method PM2.5 ranged between 187+/-52 and 709+/-180 mg/m3, and between 24+/-10 e 141+/-28 mg/m3 (p <0.0001) in the years 2004 and 2005, respectively. After the 2005 smoking ban, overall indoor fine particle pollution decreased by values in the range from 81 to 96%. Within the limits of a small sample, the study showed a good compliance with the smoking ban in the hospitality industry which resulted in a remarkable improvement in air quality index. Smoking ban thus appears to achieve the aims of protecting people from exposure to an unwanted dangerous pollutant such as environmental tobacco smoke.
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To examine changes in bar workers' exposure to second-hand smoke (SHS) over a 12-month period before and after the introduction of Scottish smoke-free legislation on the 26 March 2006. A total of 371 bar workers were recruited from 72 bars in three cities: Aberdeen, Glasgow, Edinburgh and small towns in two rural regions (Borders and Aberdeenshire). Prior to the introduction of the smoke-free legislation, we visited all participants in their place of work and collected saliva samples, for the measurement of cotinine, together with details on work patterns, self-reported exposure to SHS at work and non-work settings and smoking history. This was repeated 2 months post-legislation and again in the spring of 2007. In addition, we gathered full-shift personal exposure data from a small number of Aberdeen bar workers using a personal aerosol monitor for fine particulate matter (PM(2.5)) at the baseline and 2 months post-legislation visits. Data were available for 371 participants at baseline, 266 (72%) at 2 months post-legislation and 191 (51%) at the 1-year follow-up. The salivary cotinine level recorded in non-smokers fell from a geometric mean of 2.94 ng ml(-1) prior to introduction of the legislation to 0.41 ng ml(-1) at 1-year follow-up. Paired data showed a reduction in non-smokers' cotinine levels of 89% [95% confidence interval (CI) 85-92%]. For the whole cohort, the duration of workplace exposure to SHS within the last 7 days fell from 28.5 to 0.83 h, though some bar workers continued to report substantial SHS exposures at work despite the legislation. Smokers also demonstrated reductions in their salivary cotinine levels of 12% (95% CI 3-20%). This may reflect both the reduction in SHS exposure at work and falls in active cigarette smoking in this group. In a small sub-sample of bar workers, full-shift personal exposure to PM(2.5), a marker of SHS concentrations, showed average reductions of 86% between baseline and 2 months after implementation of the legislation. Most bar workers have experienced very large reductions in their workplace exposure to SHS as a result of smoke-free legislation in Scotland. These reductions have been sustained over a period of 1 year.
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A smoking ban in all indoor public places was enforced in Italy on 10 January 2005. We compared indoor air quality before and after the smoking ban by monitoring the indoor concentrations of fine (<2.5 microm diameter, PM2.5) and ultrafine particulate matter (<0.1 microm diameter, UFP). PM2.5 and ultrafine particles were measured in 40 public places (14 bars, six fast food restaurants, eight restaurants, six game rooms, six pubs) in Rome, before and after the introduction of the law banning smoking (after 3 and 12 months). Measurements were taken using real time particle monitors (DustTRAK Mod. 8520 TSI; Ultra-fine Particles Counter-TRAK Model 8525 TSI). The PM2.5 data were scaled using a correction equation derived from a comparison with the reference method (gravimetric measurement). The study was completed by measuring urinary cotinine, and pre-law and post-law enforcement among non-smoking employees at these establishments In the post-law period, PM2.5 decreased significantly from a mean concentration of 119.3 microg/m3 to 38.2 microg/m3 after 3 months (p<0.005), and then to 43.3 microg/m3 a year later (p<0.01). The UFP concentrations also decreased significantly from 76,956 particles/cm3 to 38,079 particles/cm3 (p<0.0001) and then to 51,692 particles/cm3 (p<0.01). Similarly, the concentration of urinary cotinine among non-smoking workers decreased from 17.8 ng/ml to 5.5 ng/ml (p<0.0001) and then to 3.7 ng/ml (p<0.0001). The application of the smoking ban led to a considerable reduction in the exposure to indoor fine and ultrafine particles in hospitality venues, confirmed by a contemporaneous reduction of urinary cotinine.
Article
To determine current secondhand smoke (SHS) concentrations in bars previously assessed as part of an evaluation of Scottish smoke-free legislation 5 years ago. Comparison between SHS levels measured in 2006 and 2011 in 39 pubs in 2 Scottish cities. Fine particulate matter (PM(2.5)) was measured discreetly for 30 min in each bar on one or two visits 5 years after the previous visit in May/June 2006. These 5-year follow-up visits were undertaken on the same day of the week and at approximately the same time of day. Average PM(2.5) levels measured in a total of 51 bar visits in 2011 were 12 μg/m(3) (range 2-155 μg/m(3)) compared to 20 μg/m(3) (range 6-104 μg/m(3)) in the period immediately after the ban in 2006. Fine particulate concentrations in all but two visits in 2011 were comparable to PM(2.5) levels measured in outside ambient air on the same day, with 92% of visits (n=47) providing 30-min average PM(2.5) concentrations less than 25 μg/m(3). These results are one of the longest follow-up of any national smoke-free legislation and indicate that, 5 years after introduction, compliance is high and that the legislation continues to provide bar workers and non-smoking customers protection from SHS.
Article
To estimate the risk of ischaemic heart disease caused by exposure to environmental tobacco smoke and to explain why the associated excess risk is almost half that of smoking 20 cigarettes per day when the exposure is only about 1% that of smoking. Meta-analysis of all 19 acceptable published studies of risk of ischaemic heart disease in lifelong non-smokers who live with a smoker and in those who live with a non-smoker, five large prospective studies of smoking and ischaemic heart disease, and studies of platelet aggregation and studies of diet according to exposure to tobacco smoke. The relative risk of ischaemic heart disease associated with exposure to environmental tobacco smoke was 1.30 (95% confidence interval 1.22 to 1.38) at age 65. At the same age the estimated relative risk associated with smoking one cigarette per day was similar (1.39 (1.18 to 1.64)), while for 20 per day it was 1.78 (1.31 to 2.44). Two separate analyses indicated that non-smokers who live with smokers eat a diet that places them at a 6% higher risk of ischaemic heart disease, so the direct effect of environmental tobacco smoke is to increase risk by 23% (14% to 33%), since 1.30/1.06 = 1.23. Platelet aggregation provides a plausible and quantitatively consistent mechanism for the low dose effect. The increase in platelet aggregation produced experimentally by exposure to environmental tobacco smoke would be expected to have acute effects increasing the risk of ischaemic heart disease by 34%. Breathing other people's smoke is an important and avoidable cause of ischaemic heart disease, increasing a person's risk by a quarter.
Article
Environmental tobacco smoke (ETS) causes disease in nonsmokers. Workplace bans on smoking are interventions to reduce exposure to ETS to try to prevent harmful health effects. On March 29, 2004, the Irish government introduced the first national comprehensive legislation banning smoking in all workplaces, including bars and restaurants. This study examines the impact of this legislation on air quality in pubs and on respiratory health effects in bar workers in Dublin. Exposure study. Concentrations of particulate matter 2.5 microm or smaller (PM(2.5)) and particulate matter 10 microm or smaller (PM(10)) in 42 pubs were measured and compared before and after the ban. Benzene concentrations were also measured in 26 of the pubs. Health effects study. Eighty-one barmen volunteered to have full pulmonary function studies, exhaled breath carbon monoxide, and salivary cotinine levels performed before the ban and repeated 1 year after the ban. They also completed questionnaires on exposure to ETS and respiratory symptoms on both occasions. Exposure study. There was an 83% reduction in PM(2.5) and an 80.2% reduction in benzene concentration in the bars. Health effects study. There was a 79% reduction in exhaled breath carbon monoxide and an 81% reduction in salivary cotinine. There were statistically significant improvements in measured pulmonary function tests and significant reductions in self-reported symptoms and exposure levels in nonsmoking barmen volunteers after the ban. A total workplace smoking ban results in a significant reduction in air pollution in pubs and an improvement in respiratory health in barmen.
Article
in Italy law n.3/2003 has banned smoking in closed places, with the exception of private venues and of public venues reserved for smokers and marked as such. The present report estimates the effects of the ban. comparison between periods (before-after enforcement of the law). City of Trieste. Six bars and four shops (convenience sample). particulate matter fractions PM10 and PM2.5 in bars and stores before and after enforcement of the law, outdoor PM10. Concentrations were estimated over the normal working hours of the premises. after enforcement of the law the concentration of PM2.5 in bars fell by 73% (p < 0.01), whereas the concentration of the PM10-2.5 fraction did not decrease significantly. Overall, the mean concentration of PM2.5 and PM10-2.5 in shops showed no statistically significant change. mean hourly PM2.5 concentrations, used as a proxy for indoor pollution caused by environmental tobacco smoke in bars were significantly reduced.
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