Impact of tobacco control policies in hospitals: Evaluation of a national smoke-free campus ban in Spain

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries

CONTEXT

Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries.

METHODS

A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants.

FINDINGS

We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness.

CONCLUSIONS

Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

Smoking behaviour, tobacco sales and tobacco advertising at 40 'Smoke Free Hospitals' in Vietnam

BACKGROUND

Tobacco remains the leading cause of preventable death globally. Vietnam's 2012 Law on Prevention and Control of Tobacco Harms establishes all healthcare facilities as smoke-free environments. We aimed to evaluate the implementation of these policies within health facilities across Vietnam.

METHODS

A cross-sectional study was undertaken at 40 central, provincial, district and commune healthcare facilities in four provinces of Vietnam. The presence of tobacco sales, smoke-free signage, evidence of recent tobacco use and smoking behaviours by patients and staff were observed over a 1-week period at multiple locations within each facility. Adherence with national regulations was reported using descriptive statistics.

RESULTS

23 out of 40 facilities (57.5%) followed the requirements of the national smoke-free policy regarding tobacco sales, advertising and signage. Smoking was observed within health facility grounds at 26 (65%) facilities during the observation period. Indirect evidence of smoking was observed at 35 (88%) facilities. Sites where smoking was permitted (n=2) were more likely to have observed smoking behaviour (relative risk (RR) 2.16, 95% CI 1.83 to 2.56). Facilities where tobacco was sold (n=7) were more likely to have smoking behaviour observed at any of their sites (RR 1.53, 95% CI 0.93 to 2.51).

CONCLUSIONS

Implementation of current smoke-free hospital regulations remains incomplete, with widespread evidence of smoking observed at three levels of the Vietnamese healthcare facilities. Further interventions are required to establish the reputation of Vietnamese healthcare facilities as smoke-free environments.

Attitudes of staff towards smoke-free environments in psychiatric hospitals in Germany

INTRODUCTION

Smoke-free environments have already been successfully introduced in hospitals world-wide. But despite convincing evidence of their success, many countries still struggle to make the necessary changes. Not only is the smoking prevalence higher amongst people with mental health problems and staff working in psychiatric units, but employees in psychiatry often resist the implementation of smoke-free policies. This study explores staff attitudes towards smoke-free environments in psychiatric hospitals in Germany and tries to identify barriers and opportunities for implementation.

METHODS

This cross-sectional online survey was carried out at eight psychiatric units of the state-owned healthcare company Vivantes Netzwerk für Gesundheit GmbH in Berlin, Germany, in 2019. A total of 448 members of staff were surveyed on their views towards creating a smoke-free environment in their workplace.

RESULTS

Psychiatric staff present contradictory attitudes towards implementing smoke-free regulations. On the one hand, a majority recognizes the need for smoke-free environments as they promote physical well-being of staff and patients. On the other hand, a majority opposes comprehensive restrictions like a complete smoking ban. Smokers are more likely than non-smokers to resist restrictive measures and show a tendency to only support those measures which they deem unlikely to affect their own smoking habits.

CONCLUSIONS

The contradictory attitudes towards implementing smoke-free regulations present an entry point to elicit behavior change and a shift in attitudes, for example in staff training on smoke-free environments. Staff who smoke, in particular, should be motivated to reflect on the contradiction that is presented by their private smoking behavior and their role as healthcare professionals.

Second-Hand Tobacco Smoke Exposure and Smoke-Free Environments in Ethiopia: A Scoping Review and Narrative Synthesis

Ethiopia passed a law prohibiting tobacco smoking in all public places in 2019. We conducted a scoping review to identify gaps in the existing literature on second-hand smoke (SHS) exposure and smoke-free environments in Ethiopia that need to be prioritised for future research to support policy and practice. We conducted systematic searches in January 2022 in the following databases: Medline, EMBASE, and PsycInfo. Two reviewers independently screened the identified study reports for eligibility and extracted data from the eligible studies. The extracted data was descriptively analysed, and research recommendations were drawn. A stakeholder consultation workshop was held to identify research topics on SHS exposure and smoke-free environments in Ethiopia that they perceived to be priorities for primary research. Of the 388 research reports identified, only nine were included in the scoping review. The topics explored includes prevalence of SHS exposure (six studies); knowledge on SHS exposure (three studies); compliance to smoke-free environments legislation (two studies); and exposure to anti-smoking messages (one study). The stakeholders prioritised further research addressing compliance monitoring and enforcement of the smoke free laws in Ethiopia. There is a need for studies that test new methods for compliance monitoring and enforcement, evaluate strategies to increase knowledge on the harms of SHS exposure and the smoke-free legislation, and evaluate the current smoke-free legislation in Ethiopia.

Impact of a smoke-free policy on smoking prevalence on hospital grounds: A before-after study

INTRODUCTION

Studies on the impact of smoke-free policies (SFPs) on hospitals grounds on on-site smoking are scarce. On 1 October 2019, an SFP was implemented on the grounds of the Amsterdam UMC hospital in the Netherlands, including measures for sustained enforcement. This study assessed the impact of this SFP on smoking prevalence on hospital grounds up to 18 months after implementation.

METHODS

Observations were systematically conducted 7 weeks before and after the SFP was implemented, and at 5 and 18 months afterwards. A total of 32 sites were included in the study, divided over two hospital locations. On each site, the number of smokers was systematically observed and categorized into staff, patient, student, or visitor. Smoking prevalence on hospital grounds was calculated by the number of observed smokers as a proportion of all people observed. Bubble maps were created to visualize changes in the geographical distribution of smokers.

RESULTS

Smoking prevalence on hospital grounds decreased significantly from 17.4% before to 3.3% after implementation of the SFP. Following implementation, the largest decrease was observed in smoking among staff (-96.7%) and patients (-92.3%). The decrease in smoking prevalence was sustained 18 months after implementation (5.0%). The number of smokers decreased on nearly all sites.

CONCLUSIONS

The substantial and sustained decrease in smoking prevalence found in this study highlights the potential of SFPs on hospital grounds to protect people from exposure to (secondhand) smoking. Continued enforcement of these SFPs seems essential to ensure ongoing compliance.

Impact of an inner-city smoke-free zone on outdoor smoking patterns: a before-after study

Introduction

On September 2, 2019, Rotterdam’s first inner-city outdoor smoke-free zone encompassing the Erasmus MC, a large university hospital in the Netherlands, the Erasmiaans high school, the Rotterdam University of Applied Sciences and the public road in between, was implemented.

Aims and Methods

We aimed to assess spatiotemporal patterning of smoking before and after implementation of this outdoor smoke-free zone. We performed a before–after observational field study. We systematically observed the number of smokers, and their locations and characteristics over 37 days before and after implementation of the smoke-free zone.

Results

Before implementation of the smoke-free zone, 4098 people smoked in the area every weekday during working hours. After implementation, the daily number of smokers was 2241, a 45% reduction (p = .007). There was an increase of 432 smokers per day near and just outside the borders of the zone. At baseline, 31% of the smokers were categorized as employee, 22% as student and 3% as patient. Following implementation of the smoke-free zone, the largest decreases in smokers were observed among employees (–67%, p value .004) and patients (–70%, p value .049). Before and after implementation, 21 and 20 smokers were visibly addressed and asked to smoke elsewhere.

Conclusions

Implementation of an inner-city smoke-free zone was associated with a substantial decline in the number of smokers in the zone and an overall reduction of smoking in the larger area. Further research should focus on optimizing implementation of and compliance with outdoor smoke-free zones.

Implications

A smoke-free outdoor policy has the potential to denormalize and discourage smoking, support smokers who want to quit, and to protect people from secondhand smoke exposure. Implementation of an inner-city smoke-free zone encompassing a large tertiary hospital and two educational institutions was associated with a substantial decline in the number of smokers in the zone, as well as in the larger area. Voluntary outdoor smoke-free zones can help reduce the number of smokers in the area and protect people from secondhand smoke. There is a need to explore effectiveness of additional measures to further improve compliance.

Secondhand smoke presence in outdoor areas in 12 European countries

INTRODUCTION

Secondhand smoke (SHS) causes morbidity and mortality among non-smokers.

OBJECTIVES

To investigate SHS presence in outdoor areas from 12 European countries and its association with country-level characteristics.

METHODS

Cross-sectional study performed in 2017-2018 within the TackSHS project. We conducted a face-to-face survey on a representative sample of the population aged 15 years and older from 12 European countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain. Out of 11,902 participants, 8,562 were non-smokers. SHS presence was assessed in selected outdoor areas and defined as respondents viewing someone smoking the last time they visited each setting within the last 6 months. A ranking score for outdoor SHS presence was assigned to each country based on the SHS presence in each setting. We used Spearman's correlation (r) and the Chi-squared tests to assess the relationship between SHS presence and country-level characteristics.

RESULTS

Except for children's playgrounds (39.5%; 95% confidence interval, CI: 37.6%-41.3%), more than half of non-smokers reported SHS presence in outdoor areas: schools (52.0%; 95%CI: 50.2%-53.7%), stadia (57.4%; 95%CI: 55.4%-59.4%), parks (67.3%; 95%CI: 66.0%-68.5%), hospitals (67.3%; 95%CI: 65.8%-68.7%), public transport stops (69.9%; 95%CI: 68.6%-71.2%), bar/restaurant terraces (71.4%; 95%CI: 70.2%-72.6%), and beaches (72.8%; 95%CI: 71.4%-74.1%). Residents in Latvia showed the highest overall outdoor SHS presence rank, followed by Greece, and Portugal. Outdoor SHS presence was directly correlated to the country's smoking prevalence (r = 0.64), and inversely correlated to the Tobacco Control Scale 2016 overall score (r = -0.62), the socio-demographic index 2017 (r = -0.56), and Gross Domestic Product per capita 2018 (r = -0.47) (p < 0.001).

CONCLUSIONS

SHS presence is high in most outdoor areas in Europe, especially in countries with higher smoking prevalence and lower tobacco control performance. To address outdoor SHS exposure, our findings require considering smoking bans along with other strategies to reduce smoking prevalence.

Assessing public support for extending smoke-free policies beyond enclosed public places and workplaces: protocol for a systematic review and meta-analysis

INTRODUCTION

Smoke-free enclosed public environments are effective in reducing exposure to secondhand smoke and yield major public health benefits. Building on this, many countries are now implementing smoke-free policies regulating smoking beyond enclosed public places and workplaces. In order to successfully implement such 'novel smoke-free policies', public support is essential. We aim to provide the first comprehensive systematic review and meta-analysis assessing levels and determinants of public support for novel smoke-free policies.

METHODS AND ANALYSIS

The primary objective of this review is to summarise the level of public support for novel smoke-free policies. Eight online databases (Embase.com, Medline ALL Ovid, Web of Science Core Collection, WHO Library Database, Latin American and Caribbean Health Sciences Literature, Scientific Online Library Online, PsychINFO and Google Scholar) will be searched from 1 January 2004 by two independent researchers with no language restrictions. The initial search was performed on 15 April 2020 and will be updated prior to finalisation of the report. Studies are eligible if assessing support for novel smoke-free policies in the general population (age ≥16 years) and have a sample size of n≥400. Studies funded by the tobacco industry or evaluating support among groups with vested interest are excluded. The primary outcome is proportion of public support for smoke-free policies, subdivided according to the spaces covered: (1) indoor private spaces (eg, cars) (2) indoor semiprivate spaces (eg, multi-unit housing) (3) outdoor (semi)private spaces (eg, courtyards) (4) non-hospitality outdoor public spaces (eg, parks, hospital grounds, playgrounds) and (5) hospitality outdoor public spaces (eg, restaurant terraces). The secondary objective is to identify determinants associated with public support on three levels: (1) within-study determinants (eg, smoking status) (2) between-study determinants (eg, survey year) and (3) context-specific determinants (eg, social norms). Risk of bias will be assessed using the Mixed Methods Appraisal Tool and a sensitivity analysis will be performed excluding studies at high risk of bias.

ETHICS AND DISSEMINATION

No formal ethical approval is required. Findings will be disseminated to academics, policymakers and the general public.

Second-hand smoke exposure in outdoor hospitality venues: Smoking visibility and assessment of airborne markers

INTRODUCTION

After the implementation of smoke-free policies in indoor hospitality venues (including bars, cafeterias, restaurants, and pubs), smokers may have been displaced to their outdoor areas. We aimed to study smoking visibility and second-hand smoke exposure in outdoor hospitality venues.

METHODS

We collected information on signs of tobacco consumption on entrances and terraces of hospitality venues in 2016 in the city of Madrid, Spain. We further measured airborne nicotine concentrations and particulate matter of less than 2.5 µm in diameter (PM2.5) in terraces with monitors by active sampling during 30 min. We calculated the medians and the interquartile ranges (IQR) of nicotine and PM2.5 concentrations, and fitted multivariate models to characterize their determinants.

RESULTS

We found 202 hospitality venues between May and September (summer), and 83 between October and December 2016 (fall) that were opened at the time of observation. We found signs of tobacco consumption on 78.2% of the outdoor main entrances and on 95.1% of outdoor terraces. We measured nicotine and PM2.5 concentrations in 92 outdoor terraces (out of the 123 terraces observed). Overall median nicotine concentration was 0.42 (IQR: 0.14-1.59) μg/m³, and overall PM2.5 concentration was 10.40 (IQR: 6.76-15.47) μg/m³ (statistically significantly higher than the background levels). Multivariable analyses showed that nicotine and PM2.5 concentrations increased when the terraces were completely closed, and when tobacco smell was noticed. Nicotine concentrations increased with the presence of cigarette butts, and when there were more than eight lit cigarettes at a time.

CONCLUSIONS

Outdoor hospitality venues are areas where non-smokers, both employees and patrons, continue to be exposed to second-hand smoke. These spaces should be further studied and considered in future tobacco control interventions.

Impact of the Spanish smoking laws on tobacco consumption and secondhand smoke exposure: A longitudinal population study

BACKGROUND

In Spain, two smoke-free laws have been passed after the approval of the WHO-FCTC. This study assesses the impact of these Spanish smoking legislations on the active and passive smoking through a population cohort in Barcelona (Spain).

METHODS

This is a longitudinal study before and after the implementation of two national smoking bans in Spain in a representative sample (n=1245) of adults (≥16years old) from Barcelona (Spain) surveyed in 2004-2005 and followed-up in 2013-2014. The final sample analyzed was 736 individuals. Both questionnaires (before and after the two laws) included the same variables about active and passive smoking. We calculated the prevalence and the prevalence ratio (PR, with their 95% confidence intervals, 95% CI) of smoking cigarettes and hand-rolled tobacco and also the prevalence of exposure to secondhand smoke (SHS) at home, work, public transport, leisure time and at any setting after vs. before Spanish legislations.

RESULTS

After the implementation of the two Spanish smoke-free bans, a significant decrease was observed in the smoking prevalence (from 34.5% to 26.1%, PR=0.76, p<0.001), in the average cigarettes per day (median from 15.2 to 10.0, p<0.001), and in the percentage of conventional tobacco consumption (from 92.6% to 74.4%, PR=0.80, p<0.001). Furthermore, a significant increase in the use of hand-rolled tobacco (from 6.1% to 30.9%, PR=5.07, p<0.001) and other tobacco products (from 17.1% to 32.8%, PR=1.92, p<0.001) was observed. In addition, a significant decrease in the self-reported SHS exposure was observed in all the assessed settings (home, work, transport, and leisure time).

CONCLUSIONS

The implementation of the two smoke-free legislations in Spain is related to a reduction in smoking prevalence and SHS exposure. However, the smoking of other tobacco products, particularly hand-rolled tobacco, has increased among young population.

Assessment of salivary cotinine concentration among general non-smokers population: Before and after Spanish smoking legislations

BACKGROUND

In Spain, two smoke-free laws have been passed (Law 28/2005 and Law 42/2010).This study evaluates the association between Spanish smoking legislations and the second-hand smoke (SHS) exposure in an adult non-smoking population cohort in Barcelona (Spain).

METHODS

This is a longitudinal study, before and after the implementation of two national smoking bans, in a representative sample of adults (≥16years old) from Barcelona (Spain) surveyed in 2004-2005 and followed up in 2013-2014 (n=736). We only analyzed non-smokers (n=397). We obtained 9ml of saliva sample for analysis of cotinine, a biomarker of recent tobacco exposure. We calculated geometric means of salivary cotinine concentration and their geometric standard deviation. We used linear mixed effect models, with individuals as random effects, to model the percentage change in salivary cotinine concentration and their 95% confidence intervals.

RESULTS

The percentage of participants with saliva samples with measurable concentrations of cotinine fell from 92.4% to 64.2% after both Spanish smoking legislations. The geometric mean of salivary cotinine concentration significantly decreased 88% (from 0.98ng/mL to 0.12ng/mL, p<0.001) after the implementation of the two Spanish smoke-free legislations. The decrease of the GM salivary cotinine concentration was statistically significant independently of the sociodemographic variables.

CONCLUSION

There was a large reduction in the salivary cotinine concentration among adult non-smokers and higher cotinine concentrations among those declaring exposure to SHS at home after both legislations. Moreover, after both Spanish smoke-free laws salivary cotinine concentration was homogenized according to sociodemographic variables.

Impact of institutional smoking bans on reducing harms and secondhand smoke exposure

BACKGROUND

Smoking bans or restrictions can assist in eliminating nonsmokers' exposure to the dangers of secondhand smoke and can reduce tobacco consumption amongst smokers themselves. Evidence exists identifying the impact of tobacco control regulations and interventions implemented in general workplaces and at an individual level. However, it is important that we also review the evidence for smoking bans at a meso- or organisational level, to identify their impact on reducing the burden of exposure to tobacco smoke. Our review assesses evidence for meso- or organisational-level tobacco control bans or policies in a number of specialist settings, including public healthcare facilities, higher education and correctional facilities.

OBJECTIVES

To assess the extent to which institutional smoking bans may reduce passive smoke exposure and active smoking, and affect other health-related outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE, EMBASE, and the reference lists of identified studies. We contacted authors to identify completed or ongoing studies eligible for inclusion in this review. We also checked websites of state agencies and organisations, such as trial registries. Date of latest searches was 22nd June 2015.

SELECTION CRITERIA

We considered studies that reported the effects of tobacco bans or policies, whether complete or partial, on reducing secondhand smoke exposure, tobacco consumption, smoking prevalence and other health outcomes, in public healthcare, higher educational and correctional facilities, from 2005 onwards.The minimum standard for inclusion was having a settings-level policy or ban implemented in the study, and a minimum of six months follow-up for measures of smoking behaviour. We included quasi-experimental studies (i.e. controlled before-and-after studies), interrupted time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently assessed studies for inclusion in the review. Due to variation in the measurement of outcomes we did not conduct a meta-analysis for all of the studies included in this review, but carried out a Mantel-Haenszel fixed-effect meta-analysis, pooling 11 of the included studies. We evaluated all studies using a qualitative narrative synthesis.

MAIN RESULTS

We included 17 observational studies in this review. We found no randomized controlled trials. Twelve studies are based in hospitals, three in prisons and two in universities. Three studies used a controlled before-and-after design, with another site used for comparison. The remaining 14 studies used an uncontrolled before-and-after study design. Five studies reported evidence from two participant groups, including staff and either patients or prisoners (depending on specialist setting), with the 12 remaining studies investigating only one participant group.The four studies (two in prisons, two in hospitals) providing health outcomes data reported an effect of reduced secondhand smoke exposure and reduced mortality associated with smoking-related illnesses. No studies included in the review measured cotinine levels to validate secondhand smoke exposure. Eleven studies reporting active smoking rates with 12,485 participants available for pooling, but with substantial evidence of statistical heterogeneity (I² = 72%). Heterogeneity was lower in subgroups defined by setting, and provided evidence for an effect of tobacco bans on reducing active smoking rates. An analysis exploring heterogeneity within hospital settings showed evidence of an effect on reducing active smoking rates in both staff (risk ratio (RR) 0.71, 95% confidence interval ( CI) 0.64 to 0.78) and patients (RR 0.86, 95% CI 0.76 to 0.98), but heterogeneity remained in the staff subgroup (I² = 76%). In prisons, despite evidence of reduced mortality associated with smoking-related illnesses in two studies, there was no evidence of effect on active smoking rates (1 study, RR 0.99, 95% CI 0.84 to 1.16).We judged the quality of the evidence to be low, using the GRADE approach, as the included studies are all observational.

AUTHORS' CONCLUSIONS

We found evidence of an effect of settings-based smoking policies on reducing smoking rates in hospitals and universities. In prisons, reduced mortality rates and reduced exposure to secondhand smoke were reported. However, we rated the evidence base as low quality. We therefore need more robust studies assessing the evidence for smoking bans and policies in these important specialist settings.

Short-Term Impact of a Comprehensive Smoke-Free Law Following a Partial Smoke-Free Law on PM₂.₅ Concentration Levels at Hospitality Venues on the Peripheries of College Campuses

Tobacco-free policies on college campuses are spreading in Korea. However, the impact of the smoking ban legislation at venues on the boundary of a college campus is still limited. This study aimed to assess short-term changes in PM2.5 concentrations before and after the enactment of the smoking ban legislation to evaluate the impact. In this cross-sectional study, PM2.5 measurements (pre-ban: n = 99, post-ban: n = 64) were conducted in randomly selected billiards, pubs, and computer game rooms on the peripheries of college campuses in October 2013, prior to implementation of the smoking ban, and in May 2014, after the ban. The median (interquartile range, IQR) of the PM2.5 concentration for all venues was 31 μg/m³ (0-80 μg/m³) in the pre-ban period and 11 μg/m³ (0-36 μg/m³) in the post-ban period implying indoor PM2.5 concentration levels of the peripheries of college campuses likely decreased one year after implementation of the ban. However, the differences were not significant yet. The results support the introduction of more rigorous monitoring of SHS exposure levels toward the ultimate goal of encouraging a complete smoking ban in hospitality venues, including billiards, pubs, and computer game rooms located on the peripheries of college campuses.