Tobacco control in Europe: a deadly lack of progress

Prevalence of second-hand tobacco smoke in relation to smoke-free legislation in the European Union

Exposure to second-hand smoke (SHS) is an important public health problem. We assessed SHS exposure in restaurants and bars across the European Union (EU) and studied associations with country-level smoke-free legislation. Data of Eurobarometer surveys 2014 and 2017 were used to estimate country-specific prevalence of observing smoking in restaurants and bars, which can be considered a marker of SHS exposure. Additionally, we used multilevel logistic regression models to study associations with comprehensiveness of national smoke-free regulations in restaurants and bars, which were derived from the Tobacco Control Scale. In total, 44,809 people from all 28 EU member states were included in the analysis. The results of the multilevel logistic analysis show that in countries with complete and extensive bans, respondents were less likely to have observed people smoking inside restaurants than in countries with partial bans, which represented the lowest level of smoke-free policy implementation (OR 0.24, 95%CI 0.10-0.57 for complete ban and OR 0.23, 95%CI 0.10-0.54 for incomplete but extensive ban). Also, the prevalence of seeing people smoking in a bar was lower in the countries with an extensive ban (OR 0.23 95%CI 0.11-0.45) and with a complete ban (OR 0.20 95%CI 0.10-0.40). Between 2014 and 2017, SHS exposure in restaurants and bars decreased significantly. Our results confirm that in countries with extensive or complete smoking bans, people were less exposed to SHS in restaurants and bars; and that partial bans are less effective in reducing SHS exposure.

The association between tobacco control policy implementation and country-level socioeconomic factors in 31 European countries

European countries have made significant progress in implementing tobacco control policies to reduce tobacco use; however, whether socioeconomic status (SES) of a country may influence the implementation of such policies is unknown. The aim of this study is to assess the association between country-level SES and the implementation level of tobacco control policies in 31 European countries. An ecological study using data from Eurostat, Human Development Reports on several SES indicators and the Tobacco Control Scale (TCS) of 2016 was conducted to measure country-level tobacco control policies. We analysed the relationship between SES indicators and the TCS by means of scatter-plots and Spearman's rank correlation coefficients (r_sp) and multivariable linear regression analysis. In Europe, no statistically significant association was found between SES factors and the level of implementation of tobacco control policies. Only public spending on tobacco control was associated with all SES factors, except for Gini Index (an income inequality index). The strongest associations of TCS scores for this policy domain were found with the Human Development Index (r_sp = 0.586; p < 0.001) and the Gross Domestic Product per capita (in Euros) (r_sp = 0.562; p = 0.001). The adjusted linear regression model showed an association of tobacco control policy implementation with countries' geographical location (Western Europe, β = - 15.7; p = 0.009, compared to Northern Europe). In conclusion, no association was found between SES factors and the level of implementation of tobacco control policies in 31 European countries; policymakers should be aware that tobacco control policies could be successfully implemented despite socioeconomic constraints, especially when these policies are of low cost and cost-effective (i.e., smoke-free bans and taxation).

Mental health professionals' perspectives on the implementation of smoke-free policies in psychiatric units across England

BACKGROUND

The original audit on which this 2013 secondary analysis is based, was conducted in 2010. It explored implementation of smoke-free policies from the perspective of unit managers in 147 psychiatric units across England comprising a randomly selected sample of nine different unit types.

MATERIAL

Two main themes are presented: positive perspectives of smoke-free policy implementation, and barriers and problems with smoke-free policy implementation. Analysis of unit managers' experiences and perspectives found that 96% of participants thought smoke-free policy had achieved positive outcomes for staff, patients, services and care.

DISCUSSION

Consistency of response was the most prominent factor associated with policy success. Quality of the physical environment and care delivery were clear positive outcomes which enabled the environment to be more conducive to supporting staffs' and patients' quit attempts. Lack of consistency and a prevailing culture of acceptance of smoking were identified as some of the most reported perceived continuing problems. Solutions included the need to acknowledge that this type of complex systems change takes time and ongoing staff education and training.

CONCLUSION

Our results demonstrate the importance of taking into account the experiences and attitudes of staff responsible for enacting smoke-free policy.

Are physicians aware of their role in tobacco control? A conference-based survey in Portugal

BACKGROUND

The crucial role of physicians in tobacco control (TC) is widely recognized. In 2008, Portugal implemented a non-comprehensive smoke-free policy (SFP). In 2009, a conference-survey was carried out to explore Portuguese physicians' engagement in tobacco control, by evaluating the following: 1) attendance at TC training and awareness of training needs; 2) participation in TC activities; 3) attitudes and beliefs regarding SFPs.

METHODS

Questionnaire-based cross-sectional study conducted during two major national medical conferences targeting GPs, hospitalists, and students/recent graduates. Descriptive analysis and logistic regression were performed.

RESULTS

Response rate was 63.7% (605/950). Of the 605 participants, 58.3% were GPs, 32.4% hospitalists, 9.3% others; 62.6% were female; mean age was 39.0 ± 12.9 years. Smoking prevalence was 29.2% (95% CI: 23.3-35.1) in males; 15.8% (95% CI: 12.1-19.5) in females, p < 0.001. While the overwhelming majority of physicians strongly agreed that second-hand smoke (SHS) endangers health, awareness of SFP benefits and TC law was limited, p < 0.001. A significant minority (35.5%) believed that SHS can be eliminated by ventilation systems. Most physicians lacked training; only a minority (9.0%) participated regularly in TC. Training was the most consistent predictor of participation in TC. General agreement with SFP was high; but significantly lower for indoor leisure settings, outdoors bans in healthcare/schools settings and smoking restrictions in the home/car, p < 0.001. Smoking behaviour strongly predicted support for smoking restrictions in restaurants and bars/discos, healthcare outdoors and private settings.

CONCLUSIONS

The findings suggest that Portuguese physicians are not aware of their role in tobacco control. Poor engagement of physicians in TC may contribute to the current lack of comprehensive policies in Portugal and Europe and undermine social norm change. Medical and professional continuing education on tobacco control should be made top priorities.

Tobacco control efforts in Europe

Smoking is prevalent across Europe, but the severity and stage of the smoking epidemic, and policy responses to it, vary substantially between countries. Much progress is now being made in prohibition of paid-for advertising and in promotion of smoke-free policies, but mass media campaigns are widely underused, provision of services for smokers trying to quit is generally poor, and price policies are undermined by licit and illicit cheap supplies. Monitoring of prevalence is inadequate in many countries, as is investment in research and capacity to address this largest avoidable cause of death and disability across Europe. However, grounds for optimism are provided by progress in implementation of the WHO Framework Convention on Tobacco Control, and in the development of a new generation of nicotine-containing devices that could enable more widespread adoption of harm-reduction strategies. The effect of commercial vested interests has been and remains a major barrier to progress.

Compliance and enforcement of a partial smoking ban in Lisbon taxis: an exploratory cross-sectional study

Background

Research evaluating enforcement and compliance with smoking partial bans is rather scarce, especially in countries with relative weak tobacco control policies, such as Portugal. There is also scarce evidence on specific high risk groups such as vehicle workers. In January 2008, Portugal implemented a partial ban, followed by poor enforcement. The purpose of this study was to explore the effectiveness of a partial smoking ban in a pro-smoking environment, specifically transportation by taxi in the city of Lisbon. Ban effectiveness was generally defined by ban awareness and support, compliance and enforcement.

Methods

Exploratory cross-sectional study; purposive sampling in selected Lisbon streets. Structured interviews were conducted by trained researchers while using taxi services (January 2009-December 2010). Participants: 250 taxi drivers (98.8% participation rate). Chi-square, McNemar, Man Whitney tests and multiple logistic regression were performed.

Results

Of the participants, 249 were male; median age was 53.0 years; 43.6% were current smokers. Most participants (82.8%) approved comprehensive bans; 84.8% reported that clients still asked to smoke in their taxis; 16.8% allowed clients to smoke. Prior to the ban this value was 76.9% (p < 0.001). The major reason for not allowing smoking was the legal ban and associated fines (71.2%). Of the smokers, 66.1% admitted smoking in their taxi. Stale smoke smells were detected in 37.6% of the cars. None of the taxi drivers did ever receive a fine for non-compliance. Heavy smoking, night-shift and allowing smoking prior the ban predicted non-compliance.

Conclusions

Despite the strong ban support observed, high smoking prevalence and poor enforcement contribute to low compliance. The findings also suggest low compliance among night-shift and vehicle workers. This study clearly demonstrates that a partial and poorly-enforced ban is vulnerable to breaches, and highlights the need for clear and strong policies.