Comprehensive smoke-free policies attract more support from smokers in Europe than partial policies

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population

BACKGROUND

National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups.

METHODS

Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position.

RESULTS

Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban.

CONCLUSION

The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

Environmental determinants of infectious and chronic disease prevention behaviours: A systematic review and thematic synthesis of qualitative research

Regulatory health policies facilitate desired health behaviours in communities, and among them, smoke-free policies and COVID-19 restrictions have been widely implemented. Qualitative research studies have explored how these measures and other environmental influences shape preventive behaviours. The objective of this systematic review was to synthesize previously published qualitative research, generate across-study themes, and propose recommendations for behaviour change interventions. We used a comprehensive search strategy, relevance screening and confirmation, data extraction, quality assessment, thematic synthesis, and quality-of-evidence assessment. In total, 87 relevant studies were identified. Findings were grouped under six overarching themes and mapped under three categories: (i) the political environment, (ii) the sociocultural environment, and (iii) the physical environment. These findings provide insights into the environmental influences of behaviour and indicate future interventions may be more effective by considering moral norms, community norms, policy support, and group identity.

Non-smokers' and smokers' support for smoke-free legislation in 14 indoor and outdoor settings across 12 European countries

BACKGROUND

European countries differ considerably in the scope and the extent of their policies to protect people from the harms of secondhand smoke exposure. Public opinion may have a substantial influence on several stages of policy development, implementation, and compliance. For this reason, we aimed to evaluate the population level of support for smoke-free policies and its correlates.

METHODS

We used data from the TackSHS Survey (2017-2018), a cross-sectional study with representative samples of the general population aged ≥15 years from 12 European countries. We described the proportion of non-smokers' and smokers' support for the implementation of smoke-free legislation in 14 indoor and outdoor settings and the country-level characteristics associated with it.

RESULTS

In the total sample (n = 11,902), support for smoke-free legislation were the lowest for restaurants/bar patios (non-smokers = 53.0%; smokers = 29.2%) and the highest for workplaces (non-smokers = 78.5%; smokers = 66.5%). In the country-level analysis, the highest support among non-smokers was for workplaces in Bulgaria (93.1%) and the lowest for restaurants/bars patios in Greece (39.4%). Among smokers, the corresponding estimates were for children's playgrounds in Latvia (88.9%) and for cars in Portugal (21%). For most settings, support for smoke-free legislation was directly related with the countries' prevalence of secondhand smoke presence and reported smoking in each setting.

DISCUSSION

Our results show that the majority of European adults (including a large proportion of smokers) are supportive of implementing smoke-free legislation in indoor settings and extending it to selected outdoor settings. Such expressive support can be seen as an opportunity to advance legislation and protect the European population from secondhand smoke exposure.

Second-Hand Smoking Prevalence in Vietnamese Population Aged 15 and older: A Systematic Review and Meta-Analysis

Background:

Second-hand smoking (SHS) is associated with many health problems. However, its prevalence in the community population aged 15 years and older in Vietnam is unknown.

Objectives:

To quantify the prevalence of SHS in Vietnamese communities aged 15 and above.

Methods:

This is a meta-analysis that reviewed studies of the prevalence of SHS in Vietnam published in MEDLINE, Scopus, Pubmed and the WHO library database between 1 January 2010 and 31 December 2019. MedCalc was used to perform all the analyses, and publication bias was determined using funnel plots and Egger regression asymmetry tests. Q-test and I2 statistic were used to identify heterogeneity across studies.

Results:

There were 7 articles that met our inclusion criteria 2 surveys at the national level, 3 Cross-sectional studies and 2 Case-control studies) involving 184 921 participants. According to the meta-analysis, the overall random-effects pooled prevalence of SHS was 54.6% (95% CIs: 44.900-64.154) with a high level of heterogeneity ( P = .0001, Q = 2245.60, I2 = 99.73%). It is noteworthy that the pooled prevalence of SHS rose throughout the course of the survey years. Our research found no evidence of publication bias.

Conclusions:

Vietnam has ratified the implementation the WHO Framework Convention on Tobacco Control (FCTC) in 2004, there are still a large number of people who are adversely impacted by SHS. Given the tremendous cost that SHS imposes on health systems, our results underscore the critical need for the Vietnamese government to expedite an implementation of a set of stronger tobacco control practices, thus reducing the incidence of smoking-related illnesses and fatalities.

Developing and validating the Malay version instrument to assess knowledge, attitudes and practices regarding second-hand smoke in the workplace: a cross-sectional study in teaching hospital in Malaysia

This research sought to develop and validate the "Workplace Second-hand Smoke: Perception on the SHS Knowledge, Attitude, and Practice" (WSHS: PAP) instrument, which targets non-smoking employees. A cross-sectional study was conducted between April and June 2018 to validate WSHS: PAP among non-smoking employees at Universiti Malaya Medical Centre (UMMC). Experts were invited to validate the instrument. Then, for exploratory factor analysis, a cross-sectional study was conducted among 336 UMMC non-smoking employees who were recruited by convenience sampling. A total of 28 items on KAP, rated on five-point Likert scales, underwent exploratory factor analysis and were tested for internal consistency (Cronbach's alpha). Participants were approached after 2 weeks for the assessment of test-retest reliability. Cronbach's alpha was 0.828, 0.743 and 0.837, respectively, for the domains of perception of the knowledge, attitude and practice, indicating acceptable internal consistency (above 0.7). Exploratory factor analysis identified a one-factor solution for each of the KAP domains. Therefore, the Malay version of the WSHS: PAP instrument demonstrated satisfactory psychometric properties for the assessment of non-smoking employees in workplaces with a smoking ban.

Smokers' and non-smokers' secondhand smoke experiences and interactions to reduce exposure in Armenia and Georgia

INTRODUCTION

Armenia and Georgia have high rates of smoking and secondhand smoke exposure (SHSe). Greater progress in recent smoke-free legislation in Georgia and Armenia provides a pivotal time for examining the impact on smokers' and non-smokers' experiences and interactions regarding SHSe.

METHODS

Surveys were conducted in 28 communities in Armenia (n=705) and Georgia (n=751) in 2018 and assessed past 30-day SHSe and smoking in different contexts, as well as attitudes toward and interactions regarding SHSe.

RESULTS

In this sample (mean age 43.4 years, SD=13.5; 60.5% female; 27.3% smokers), SHSe among non-smokers was usually in homes (42.7%), cars (42.4%), and outdoor public places (38.2%); smokers also reported smoking usually in these places (70.0%, 62.1%, and 60.0%, respectively). Smokers indicated greater likelihood of putting out cigarettes and non-smokers indicated greater likelihood of asking smokers to put them out in places where smoking was prohibited versus allowed (76.5% vs 57.3%, and 46.6% vs 30.7%, respectively). Moreover, 89.9% of smokers indicated being very likely to put out cigarettes around small children if asked and 75.8% indicated trying to minimize SHSe. While 39.7% of participants reported seeing requests to smokers to put out cigarettes in the past 6 months, only 23.3% of smokers reported being asked to do so. Non-smokers in Georgia versus Armenia reported greater likelihood of engaging in behaviors to lower SHSe (p<0.001).

CONCLUSIONS

Smoke-free legislation may catalyze more behaviors to lower SHSe, particularly among non-smokers; however, private settings (e.g. homes) remain prominent SHSe sources. Public health efforts must consider implications of such policies on SHSe in private settings.

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans

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, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities.

RESULTS

The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. 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 CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) 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 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.

Secondhand Smoke Exposure in Public Places and Support for Smoke-Free Laws in Japan: Findings from the 2018 ITC Japan Survey

Comprehensive smoke-free policies such as those called for by the WHO FCTC are the only way to protect the public effectively from the harms of secondhand smoke (SHS), yet Japan has been slow to implement this important health measure. This study examines baseline levels of smoking and SHS exposure in public places and support for smoking bans in Japan prior to the implementation of the 2018 national smoke-free law. Data are from the International Tobacco Control (ITC) Japan Wave 1 Survey (Feb-Mar 2018), a web survey of adult cigarette smokers, heated tobacco product users, dual users, and non-users (total N = 4684). Measures included prevalence of smoking (whether respondents noticed people smoking inside restaurants and bars at their last visit, and workplaces in the last month), and support for complete smoking bans in these venues. Smoking prevalence in each venue was high overall in 2018 (49% of workplaces, 55% of restaurants, and 83% of bars), even higher than in China, the country with the greatest toll of SHS. Support for complete smoking bans was very high overall (81% for workplaces, 78% for restaurants, and 65% for bars). Non-users were less likely to be exposed to SHS and had higher support for smoking bans than tobacco users. These findings point to the ineffectiveness of partial smoke-free laws in Japan and reinforce the call for comprehensive smoke-free laws, which even smokers would support at higher levels than in many other ITC countries.

Smoke-free hospital grounds

This study investigated whether the implementation of a multicomponent intervention project could improve compliance with the New South Wales (NSW) Health smoke-free healthcare policy. Environmental interventions were implemented on the hospital grounds for a 12-week period. Compliance was measured by a pre- and postintervention observational count of smokers on the hospital grounds. After implementation, there was a significant 73% reduction in people smoking on the hospital grounds, indicating improved compliance with the NSW smoke-free healthcare policy through the use of a non-punitive multicomponent intervention. What is known about the topic?Lack of compliance with the NSW Health smoke-free healthcare policy was reflected by the large numbers of smokers outside the front of an inner-city hospital in Sydney, Australia. This issue had been raised by staff, patients and visitors as an ongoing problem requiring a solution. What does this paper add?Designing and implementing a non-punitive multicomponent intervention using modelling, operant and associative learning principles can successfully increase compliance with policies designed to stop smoking on hospital grounds. What are the implications for practitioners?Implementing non-punitive multicomponent interventions to improve compliance with the NSW Health smoke-free healthcare policy may increase patients’ acceptance of smoking cessation support when offered. Healthcare staff need to be equipped with the knowledge and confidence to offer this support.

National Tobacco Control Policies from the Perspectives of Singapore Young Male Adults

Between 2016 and 2018, tobacco control legislation has undergone several amendments to further restrict tobacco use in Singapore. This study explored the attitudes toward these policy changes and the perceived effectiveness of legislations from the perspectives of young male adults in Singapore. Twenty-nine semi-structured telephone interviews were conducted among young male adults who have completed their National Service in 2017/18 and self-reported as a smoker at pre-enlistment screening. Young male smoker perspectives on Singapore tobacco policies including taxation, smoke-free environment, point-of-sale display ban on tobacco products, graphic health warnings, and raising the minimum legal age of smoking to 21, were evaluated. Participants held the view that cigarette pricing was a highly effective approach to control their smoking behavior because it has a direct impact on tobacco affordability, and they shared that the least effective approaches were point-of-sale display bans and graphic health warnings. Results demonstrate that participants were well aware of tobacco control policies in Singapore, but they did not always fully accept them or understand the rationale behind them. Tobacco control measures should be implemented along with public education to correct misperceptions and increase public support for tobacco control measures in Singapore.

Secondhand smoke exposure and support for smoke-free policies in cities and rural areas of China from 2009 to 2015: a population-based cohort study (the ITC China Survey)

OBJECTIVES

To examine trends in smoking prevalence in key venues (workplaces, restaurants, bars) and in public support for comprehensive smoke-free laws, with comparisons between cities and rural areas in China.

DESIGN

Data are from Waves 3-5 (2009-2015) of the International Tobacco Control (ITC) China Survey, a cohort survey of smokers and non-smokers. Logistic regression analyses employing generalised estimating equations assessed changes in smoking prevalence and support for smoke-free laws over time; specific tests assessed whether partial smoking bans implemented in three cities between Waves 3 and 4 had greater impact.

SETTING

Face-to-face surveys were conducted in seven cities (Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan) and five rural areas (Changzhi, Huzhou, Tongren, Yichun and Xining).

PARTICIPANTS

In each survey location at each wave, a representative sample of approximately 800 smokers and 200 non-smokers (aged 18+) were selected using a multistage cluster sampling design.

MAIN OUTCOME MEASURES

Prevalence of smoking (whether respondents noticed smoking inside restaurants, bars and workplaces); smoking rules inside these venues; and support for complete smoking bans in these venues.

RESULTS

Although smoking prevalence decreased and support increased over time, neither trend was greater in cities that implemented partial smoke-free laws. Smoking was higher in rural than urban workplaces (62% vs 44%, p<0.01), but was equally high in all restaurants and bars. There were generally no differences in secondhand smoke (SHS) exposure between smokers and non-smokers except in rural workplaces (74% vs 58%, p<0.05). Support for comprehensive bans was equally high across locations.

CONCLUSIONS

Partial laws have had no effect on reducing SHS in China. There is an urgent need for comprehensive smoke-free laws to protect the public from exposure to deadly tobacco smoke in both urban and rural areas. The high support among Chinese smokers for such a law demonstrates that public support is not a barrier for action.

Partial Smoking Ban and Secondhand Smoke Exposure in Japan

Implementing smoking bans is a worldwide common practice for tobacco control. However, if the policy prohibits smoking partially rather than comprehensively, it may increase nonsmokers’ exposure to secondhand smoke (SHS) in nonprohibited places. This paper investigates how a partial smoking ban affected nonsmokers’ SHS exposure (measured by frequency of having exposure to SHS in days per month) in households, workplaces, and restaurants by examining the case of a partial smoking ban introduced in a large Japanese prefecture in 2013. Using data from the National Health and Nutrition Survey (NHNS) in 2010, 2013, and 2016 (n = 30,244) and the Comprehensive Survey of Living Conditions (CSLC) from 2001 to 2016 (n = 2,366,896), this paper employs a difference-in-differences (DID) approach. We found that the partial smoking ban significantly increased their SHS exposure in households and workplaces by 2.64 days and 4.70 days per month, respectively, while it did not change nonsmokers’ SHS exposure in restaurants. The results imply that the smoking ban displaced smokers from public places to private places. We also found that neither smokers’ smoking status nor smoking intensity changed significantly after implementing the partial smoking ban. Comprehensive smoking bans are needed to better protect nonsmokers from SHS exposure.

Correlates of the support for smoke-free policies among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC EUROPE SURVEYS

INTRODUCTION

This report describes the support for smoke-free policies in different settings among smokers in six European countries and the relationship between their opinions about the places where smoking should be banned and their beliefs about the harms of secondhand smoke to non-smokers.

METHODS

A cross-sectional survey (the ITC 6 European Country Survey, part of the EUREST-PLUS Project) was conducted using nationally representative samples of adult smokers in Germany, Greece, Hungary, Poland, Romania and Spain (n=6011). We describe the prevalence of agreement and support for smoke-free policies in different settings according to sociodemographics, smoking characteristics and beliefs about the danger of secondhand smoke to non-smokers.

RESULTS

There was high agreement with smoking regulations in cars with preschool children and in schoolyards of primary/secondary schools (>90% overall) and low agreement with banning smoking in outdoor terraces of bars/pubs (8.6%; 95%CI: 7.5%-9.8%) and restaurants (10.1%; 95%CI: 8.9%-11.4%). The highest support for complete smoking bans inside public places came from smokers in Poland, among women, people aged ≥25 years, who had low nicotine dependence, and who tried to quit smoking in the last 12 months. About 78% of participants agreed that tobacco smoke is dangerous to non-smokers, ranging from 63.1% in Hungary to 88.3% in Romania; the highest agreement was noted among women, the 25-54 age groups, those with higher education, low cigarette dependence, and those who tried to quit in the last 12 months. The support for complete smoking bans in public places was consistently higher among smokers who agreed that secondhand smoke is dangerous to non-smokers.

CONCLUSIONS

Smokers in six European countries declared strong support for smoke-free policies in indoor settings and in settings with minors but low support in outdoor settings, particularly leisure facilities. More education is needed to increase the awareness about the potential exposure to secondhand smoke in specific outdoor areas.

Signs, Fines and Compliance Officers: A Systematic Review of Strategies for Enforcing Smoke-Free Policy

Background. Smoke-free environment policies limit or eliminate the use of smoke-producing tobacco in designated areas thereby reducing second hand smoke. Enforcement is perceived as critical to the successful adoption of a smoke-free policy. However, there is limited guidance available regarding effective enforcement strategies. A systematic review was conducted to examine the effectiveness of enforcement strategies at increasing compliance with and enforcement of smoke-free policies; and to determine circumstances other than enforcement strategies that are associated with compliance with smoke-free policies. Design. Medline, Medline in Process, The Cochrane Library, Embase, PsycInfo and CINAHL databases were searched using MeSH and keywords for relevant studies published between January 1980 and August 2017. A narrative synthesis and methodological quality assessment of included studies was undertaken. Results. Policy promotion and awareness-raising activities, signage, enforcement officers, and penalties for violations were the enforcement strategies most frequently cited as being associated with successful policy enforcement. Additionally, awareness of the laws, non-smoking management and lower staff smoking rates, and membership of a network guiding the policy enforcement contributed to higher compliance with smoke-free policies. Conclusions. There is weak evidence of the effectiveness of strategies associated with compliance with smoke-free policies. Given the evidence base is weak, well-designed trials utilizing appropriate evaluation designs are needed. Overall enforcement strategies associated with total smoke-free bans resulted in higher levels of compliance than strategies for policies that had only partial smoke-free bans.

Extent and correlates of self-reported exposure to tobacco advertising, promotion, and sponsorship in smokers: Findings from the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Tobacco advertising, promotion, and sponsorship (TAPS) are known to promote tobacco consumption and to discourage smoking cessation. Consequently, comprehensive TAPS bans are effective measures to reduce smoking. The objective of this study was to investigate to what extent smokers are exposed to TAPS in general, and in various media and localities, in different European countries.

METHODS

A Cross-sectional analysis of national representative samples of adult smokers in 2016 from Germany, Greece, Hungary, Poland, Romania, and Spain (EUREST-PLUS Project, n=6,011), as well as England (n=3,503) and the Netherlands (n=1,213) (ITC Europe Surveys) was conducted. Prevalence of self-reported TAPS exposure is reported by country, and socio-economic correlates were investigated using logistic regression models.

RESULTS

Self-reported exposure to TAPS varied widely among the countries, from 15.4 % in Hungary to 69.2 % in the Netherlands. In most countries, tobacco advertising was most commonly seen at the point of sale, and rarely noticed in mass media. The multivariate analysis revealed some variation in exposure to TAPS by sociodemographic factors. Age showed the greatest consistency across countries with younger smokers (18-24-year-olds) being more likely to notice TAPS than older smokers.

CONCLUSIONS

TAPS exposure tended to be higher in countries with less restrictive regulation but was also reported in countries with more comprehensive bans, although at lower levels. The findings indicate the need for a comprehensive ban on TAPS to avoid a shift of marketing efforts to less regulated channels, and for stronger enforcement of existing bans.

Factors that influence attitude and enforcement of the smoke-free law in Turkey: a survey of hospitality venue owners and employees

INTRODUCTION

In 2009, Turkey extended the smoke-free legislation to hospitality venues. Compliance, however, remains low in some hospitality venues. We identified characteristics associated with knowledge of health effects that can be prevented by the smoke-free law, the attitude towards and enforcement of the law.

METHODS

In 2014, we conducted 400 interviews with hospitality venue owners and employees in 7 cities in Turkey. The venues were identified based on a random sampling strategy in a previous phase of the study.

RESULTS

Over one-third (37.3%) of hospitality owners and employees had adequate knowledge of the health effects from secondhand smoke (SHS), 71.3% had a positive attitude towards the law and 19.5% had personally enforced the law. Participants who worked 70 hours or more per week were more likely to have a positive attitude towards the law. Older individuals, women, participants working in bars/nightclubs, venue owners receiving fines for non-compliance and current smokers were less likely to have a positive attitude towards the law. Participants working in traditional coffee houses, former smokers, and participants with a high school education or greater were more likely to enforce the law. Smokers who quit or reduced smoking because of the law were more likely to enforce the law compared with those who were not influenced by the law.

CONCLUSIONS

Although the attitude towards the law was positive, interventions are needed to increase knowledge on the health effects of SHS and facilitate enforcement of the law, particularly among subgroups less likely to have a positive attitude and enforce the law.

Social Acceptance of Smoking Restrictions During 10 Years of Policy Implementation, Reversal, and Reenactment in the Netherlands: Findings From a National Population Survey

INTRODUCTION

Little is known about the extent to which smoking restrictions are socially accepted in a country such as the Netherlands where smoking restrictions have been implemented and reversed several times. The current study assessed trends as well as factors associated with two indicators of social acceptance of smoking restrictions in the Netherlands: acceptance of smoking in public places and implementation of home smoking bans.

METHODS

We used data from the Dutch Continuous Survey of Smoking Habits (DCSSH) between 2005 and 2014 (n = 182826). The DCSSH is a national population survey with a cross-sectional design in which respondents aged 15 years and older are surveyed weekly.

RESULTS

Acceptance of smoking in public places decreased for six out of eight included venues, with the largest decrease for smoking in restaurants. The decrease in acceptance was larger among younger respondents and smokers. Smoking on terraces was an exception: decrease in acceptance there was larger among older respondents and ex-smokers. Implementation of home smoking bans increased over time. Having implemented a home smoking ban was associated with being male, being younger, having a high socioeconomic status, and being ex- or never smoker.

CONCLUSIONS

Social acceptance of smoking restrictions has increased in the Netherlands, despite a suboptimal implementation process of smoking restrictions. However, there is still potential for improvement as acceptance of smoking is still quite high for some public venues like bars. It is important to strengthen smoking restrictions in order to further denormalize smoking in the Netherlands.

IMPLICATIONS

We examined the extent to which smoking restrictions are socially accepted in the Netherlands where smoking restrictions have been implemented and reversed several times. Acceptance of smoking in public places decreased and implementation of home smoking bans increased between 2005 and 2014. Social acceptance of smoking restrictions increased in the Netherlands despite a suboptimal implementation process of smoking restrictions. However, acceptance of smoking in bars remains relatively high.

Compliance to the smoke-free law in Guatemala 5-years after implementation

BACKGROUND

Smoke-free environments decrease smoking prevalence and consequently the incidence of heart disease and lung cancer. Due to issues related to poor enforcement, scant data is currently available from low/middle income countries on the long-term compliance to smoke-free laws. In 2006, high levels of secondhand smoke (SHS) were found in bars and restaurants in Guatemala City. Six months after a smoking ban was implemented in 2009, levels significantly decreased. However, in 2010, poor law compliance was observed. Therefore, we sought to assess long-term compliance to the ban using SHS measurements.

METHODS

In 2014 we assessed SHS exposure using airborne nicotine monitors in bars (n = 9) and restaurants (n = 12) for 7 days using the same protocol as in 2006 and in 2009. Nicotine was measured using gas-chromatography (μg/m(3)) and compared to levels pre- (2006) and post-ban (2009). Employees responded to a survey about SHS exposure, perceived economic impact of the ban and customers' electronic cigarette use. In addition, we estimated the fines that could have been collected for each law infringement.

RESULTS

Most (71 %) venues still have a smoking section, violating the law. The percentage of samples with detectable nicotine concentrations was 100, 85 and 43 % in 2006, 2009 and 2014, respectively. In bars, median (25(th) and 75(th) percentiles) nicotine concentrations were 4.58 μg/m(3) (1.71, 6.45) in 2006, 0.28 (0.17, 0.66) in 2009, and 0.59 (0.01, 1.45) in 2014. In restaurants, the corresponding medians were 0.58 μg/m(3) (0.44, 0.71), 0.04 (0.01, 0.11), and 0.01 (0.01, 0.09). Support for the law continues to be high (88 %) among bar and restaurant employees. Most employees report no economic impact of the law and that a high proportion of customers (78 %) use e-cigarettes. A total of US$50,012 could have been collected in fines.

CONCLUSIONS

Long-term compliance to the smoking ban in Guatemala is decreasing. Additional research that evaluates the determinants of non-compliance is needed and could also contribute to improve enforcement and implementation of the smoke-free law in Guatemala.

Attrition analysed in five waves of a longitudinal yearly survey of smokers: findings from the ITC Netherlands survey

BACKGROUND

Attrition bias can affect the external validity of findings. This article analyses attrition bias and assesses the effectiveness of replenishment samples on demographic and smoking-related characteristics for the International Tobacco Control Netherlands Survey, a longitudinal survey among smokers.

METHODS

Attrition analyses were conducted for the first five survey waves (2008-12). We assessed, including and excluding replenishment samples, whether the demographic composition of the samples changed between the first and fifth waves. Replenishment samples were tailored to ensure the sample remained representative of the smoking population. We also constructed a multivariable survival model of attrition that included all five waves with replenishment samples.

RESULTS

Of the original 1820 respondents recruited in 2008, 46% participated again in 2012. Demographic differences between waves due to attrition were generally small and replenishment samples tended to minimize them further. The multivariable survival analysis revealed that only two of the 10 variables analysed were significant predictors of attrition: a weak effect for gender (men dropped out more often) and weak to moderate effects for age (respondents aged 15-24 years dropped out more than aged 25-39 years, who dropped out more than those aged 40+ years).

CONCLUSIONS

Weak to moderate attrition effects were found for men and younger age groups. This information could be used to minimize respondent attrition. Our findings suggest that sampling weights and tailored replenishment samples can effectively compensate for attrition effects. This is already being done for the International Tobacco Control Netherlands Survey, including the categories that significantly predicted attrition in this study.

Evaluation of smoke-free policies in seven cities in China, 2007-2012

BACKGROUND

China is the world's largest consumer of tobacco, with hundreds of millions of people exposed daily to secondhand smoke (SHS). Comprehensive smoke-free policies are the only effective way to protect the population from the harms of SHS. China does not have a comprehensive national smoke-free law but some local-level regulations have been implemented.

OBJECTIVE

To evaluate local level smoke-free regulations across 7 cities in China by measuring the prevalence of smoking in public places (workplaces, restaurants and bars), and support for smoke-free policies over time.

METHODS

Data were from Waves 2 to 4 of the International Tobacco Control (ITC) China Survey (2007-2012), a face-to-face cohort survey of approximately 800 smokers in each of 7 cities in mainland China. Multivariate logistic regression models estimated with generalised estimating equations were used to test the changes in variables over time.

RESULTS

As of 2012, over three-quarters of respondents were exposed to smoking in bars; more than two-thirds were exposed to smoking in restaurants and more than half were exposed to smoking in indoor workplaces. Small decreases in the prevalence of smoking were found overall from Waves 2 to 4 for indoor workplaces, restaurants and bars, although the decline was minimal for bars. Support for complete smoking bans increased over time for each venue, although it was lowest for bars.

CONCLUSIONS

Existing partial smoking bans across China have had minimal impact on reducing smoking in public places. A strongly enforced, comprehensive national smoke-free law is urgently needed in order to achieve greater public health gains.

From global agenda-setting to domestic implementation: successes and challenges of the global health network on tobacco control

Global policy attention to tobacco control has increased significantly since the 1990 s and culminated in the first international treaty negotiated under the auspices of the World Health Organization--the Framework Convention on Tobacco Control (FCTC). Although the political process that led to the creation of the FCTC has been extensively researched, the FCTC's progression from an aspirational treaty towards a global health governance framework with tangible policy effects within FCTC member countries has not been well-understood to date. This article analyses the role of the global health network of tobacco control advocates and scientists, which formed during the FCTC negotiations during the late 1990 s, in translating countries' commitment to the FCTC into domestic policy change. By comparing the network's influence around two central tobacco control interventions (smoke-free environments and taxation), the study identifies several scope conditions, which have shaped the network's effectiveness around the FCTC's implementation: the complexity of the policy issue and the relative importance of non-health expertise, the required scope of domestic political buy-in, the role of the general public as network allies, and the strength of policy opposition. These political factors had a greater influence on the network's success than the evidence base for the effectiveness of tobacco control interventions. The network's variable success points to a trade-off faced by global health networks between their need to maintain internal cohesion and their ability to form alliances with actors in their social environment.

Public responses to a comprehensive smoking ban

Purpose

– The purpose of this paper is to report public reactions to a total workplace smoking ban, including smoking behavior, attendance at bars and clubs, and attitudes toward a broader ban.

Design/methodology/approach

– Surveys were conducted in two adjacent jurisdictions, one of which instituted a total workplace smoking ban. Surveys took place before (n=1,609) and after (n=1,600) enactment of the ban in the relevant jurisdiction.

Findings

– No change in smoking prevalence occurred in the jurisdiction enacting the ban. Strong majorities of non-smokers supported the ban, while strong majorities of smokers expressed opposition. In the jurisdiction that enacted the ban, smokers who appeared to be high-volume consumers at bars and clubs were most likely to report reducing attendance at these establishments and to oppose the ban.

Research limitations/implications

– Surveys depend on accurate self-reporting of behavior and attitudes.

Practical implications

– Some bars and clubs may incur financial losses due to smoking bans. A core of strong opponents can undermine public consensus regarding smoking bans. Licensing a limited number of bars and clubs to allow smoking can safeguard this consensus.

Social implications

– Limited smoking bans can serve as a means of harm reduction, as non-smokers are protected from environmental tobacco smoke, and accommodation of smokers reduces their motivation to oppose bans.

Originality/value

– This investigation makes use of detailed data on the public’s thinking and reactions to a comprehensive smoking ban and is a before-after study with controls.

An exploratory study of smokers' and stakeholders' expectations of the implementation of a smoke-free policy in a university setting

ISSUES ADDRESSED

Smoke-free policies restricting tobacco use in public places are common in many middle- and high-income countries. Implementation of a smoke-free policy does not automatically result in a smoke-free environment, and appropriate enforcement procedures must be clearly communicated and implemented. Safety and restrictions in private spaces, especially student housing, are also issues that need to be explored. This research explored perceptions and attitudes of staff and student smokers and key stakeholders before the implementation of a complete campus ban on smoking at a large Australian university.

METHODS

Interviews were conducted with staff and student smokers (n=9) and stakeholders (n=9). The interviews explored attitudes towards a completely smoke-free policy in the university environment, perceptions relating to enforcement of and compliance with a completely smoke-free policy, and support needed from the university for smokers.

RESULTS

Participants generally supported a complete smoke-free policy. Key themes associated with the policy implementation included health implications, stigmatisation and labelling, liberty, and enforcement.

CONCLUSION

Smoke-free policies require careful planning, evaluation, and appropriate enforcement to ensure maximum impact. Further research is needed to improve compliance with smoke-free policies in outdoor environments and diverse spaces. SO WHAT? A better understanding of attitudes and intentions towards a smoke-free policy before implementation may provide useful insight into the potential challenges and provide guidelines for the development of strategies to improve policy readiness and adherence. University support for smokers to quit is essential when implementing a smoke-free policy.

The effect of smoke-free policies on hospitality industry revenues in Cyprus: an econometric approach

OBJECTIVE

Smoke-free policies aiming to improve quality of indoor air and significantly reduce exposure to secondhand smoke in the hospitality industry are faced with strong opposition from the tobacco industry and hospitality venue owners claiming that they lead to reductions of revenues. The objective of our study was to examine the impact of a recently introduced smoke-free legislation on the revenues of the hospitality industry in Cyprus.

METHODS

Anonymous information on revenues was obtained from the Cyprus government value added tax office for the entire hospitality industry in Cyprus including hotels, bars, restaurants and cafeterias between 2005 and 2011. Panel data methodology was used to examine the effect of a smoke-free legislation, on tourism, businesses' revenues adjusting for gross domestic product, inflation, unemployment rate, tourists' arrivals, seasonal variation and the economic crisis.

RESULTS

Our study showed that the implementation of the smoke-free policy did not have negative effects on the hospitality industry profitability.

CONCLUSIONS

We conclude that even in regions with relatively high smoking rates, pro-smoking societal attitudes and weak social norms against tobacco control, and even during periods of economic crisis, smoke-free legislation does not impact negatively on hospitality industry revenues and if anything may lead to a small positive increase.

Antismoking mass media campaigns and support for smoke-free environments, Mobile County, Alabama, 2011-2012

Introduction

In 2011, the Mobile County Health Department began a 12-month antismoking educational media campaign to educate citizens on the dangers of secondhand smoke. The campaign overlapped with the Centers for Disease Control and Prevention’s 3-month national antismoking Tips from Former Smokers media campaign. We aimed to evaluate the effect of these campaigns on support for smoke-free environments and knowledge of the dangers of secondhand smoke.

Methods

Cross-sectional precampaign and postcampaign telephone surveys collected data from a random sample of Mobile County adults in the summers of 2011 and 2012. Outcome measures included changes in support for smoke-free environments and knowledge of the dangers of secondhand smoke. The participation rate among the households that were successfully reached was 45% in 2011 and 44% in 2012.

Results

On the postcampaign survey, 80.9% of respondents reported seeing a television advertisement, 29.9% reported hearing a radio advertisement, and 49.0% reported seeing a billboard. Overall, support for smoke-free bars increased significantly after the intervention (38.1% to 43.8%; P = .01) but not for workplaces or restaurants. Self-reported exposure to the media campaign was associated with higher levels of support for smoke-free workplaces, restaurants, and bars.

Conclusion

Educational mass media campaigns have the potential to increase support for smoke-free protections and may increase knowledge about the dangers of secondhand smoke among certain populations.

Population support before and after the implementation of smoke-free laws in the United States: trends from 1992-2007

INTRODUCTION

Several states implemented comprehensive smoke-free laws in workplaces (14 states), restaurants (17 states), and bars (13 states) between 2002 and 2007. We tested the hypothesis that public support for smoke-free laws increases at a higher rate in states that implemented smoke-free laws between 2002 and 2007 (group A) than in states that implemented smoke-free laws after that time or not at all (group B). The period before the implementation (1992-2001) was also considered.

METHODS

Data was used from the Current Population Survey (CPS) Tobacco Use Supplements (TUS), which is representative for the U.S. adult population. Respondents were asked whether they thought smoking should not be allowed in indoor work areas, restaurants, and bars and cocktail lounges. Differences in trends were analyzed with binomial mixed effects models.

RESULTS

Population support for smoke-free restaurants and bars was higher among group A than among group B before 2002. After 2002, support for smoke-free restaurants and bars increased at a higher rate among group A than among group B. Population support for smoke-free workplaces did not differ between group A and B, and the increase in support for smoke-free workplaces also did not differ between these groups.

CONCLUSIONS

The positive association between the implementation of smoke-free restaurant and bar laws and the rate of increase in support for these laws partly supported the hypothesis. The implementation of the laws may have caused support to increase, but also states that have higher support may have been more likely to implement smoke-free laws.

Patterns of adherence to and compliance with the Portuguese smoke-free law in the leisure-hospitality sector

Background

In 2008, the Portuguese smoke-free law came into effect including partial bans in the leisure-hospitality (LH) sector. The objective of the study is to assess the prevalence of smoking control policies (total ban, smoking permission and designated smoking areas) adopted by the LH sector in Portugal. The levels of noncompliance with each policy are investigated as well as the main factors associated with smoking permission and noncompliance with the law.

Methods

Cross-sectional study conducted between January 2010 and May 2011. A random sample of venues was selected from the Portuguese LH sector database, proportionally stratified according to type, size and geographical area. All venues were assessed in loco by an observer. The independent effects of venues' characteristics on smoking permission and the level of noncompliance with the law were explored using logistic regression.

Results

Overall, 1.412 venues were included. Total ban policy was adopted by 75.9% of venues, while 8.4% had designated smoking areas. Smoking ban was more prevalent in restaurants (85.9%). Only 29.7% of discos/bars/pubs opted for complete ban. Full or partial smoking permission was higher in discos/bar/pubs (OR = 7.37; 95%CI 4.87 to 11.17). Noncompliance with the law was higher in venues allowing smoking and lower in places with complete ban (33.6% and 7.6% respectively, p<0.001). Discos/bars/pubs with full smoking permission had the highest level of noncompliance (OR = 3.31; 95%CI 1.40 to 7.83).

Conclusions

Our findings show a high adherence to smoking ban policy by the Portuguese LH sector. Nonetheless, one quarter of the venues is fully or partially permissive towards smoking, with the discos/bars/pubs considerably contributing to this situation. Venues with smoking permission policies were less compliant with the legislation. The implementation of a comprehensive smoke-free law, without any exceptions, is essential to effectively protect people from the second hand smoke.

Temporal changes in the attitude towards smoking bans in public arenas among adults in the Capital Region of Denmark from 2007 to 2010

AIM

The population's attitude towards smoking bans in public arenas is important for their passing, implementation and compliance. Smoking bans are believed to reduce the social acceptability of smoking, and once people experience them, public support increases--also among pre-ban sceptics. This study aimed to examine the temporal changes in public attitude towards smoking bans in public arenas from 2007 to 2010 and whether these changes differed across educational attainment, smoking status and intention to quit among smokers.

METHODS

Data from two surveys among adults (aged 25-79 years) in 2007 and 2010 in the Capital Region of Denmark (n=36,472/42,504, response rate = 52.3) was linked with data on sex, age and educational attainment from central registers. Age-standardised prevalence of supportive attitude towards smoking bans was estimated. Temporal changes in supportive attitude were explored in workplaces, restaurants and bars using logistic regression models.

RESULTS

The prevalence of supportive attitude towards smoking bans increased significantly in all arenas from 2007 to 2010. Positive temporal changes in supportive attitude towards smoking bans were seen across educational attainment, smoking status and intention to quit smoking in restaurants and across smoking status for smoking bans in workplaces and bars.

CONCLUSIONS

The results of this study show that the public's attitude towards smoking in public arenas has changed after the implementation of a comprehensive smoking ban. This change in attitude can support implementation of future legislation on smoking and may lead to positive changes in smoking norms.

Associations between tobacco control policy awareness, social acceptability of smoking and smoking cessation. Findings from the International Tobacco Control (ITC) Europe Surveys

This study examined whether awareness of tobacco control policies was associated with social unacceptability of smoking and whether social unacceptability had an effect on smoking cessation in three European countries. Representative samples (n = 3865) of adult smokers in France, the Netherlands and Germany were used from two survey waves of the longitudinal International Tobacco Control Europe Surveys. Associations were examined of aspects of social unacceptability of smoking (i.e. feeling uncomfortable, important people disapproval and societal disapproval) with tobacco policy awareness (i.e. awareness of warning labels, anti-tobacco information and smoking restrictions at work) and smoking cessation. Only the positive association of awareness of anti-tobacco information with feeling uncomfortable about smoking was significant in each of the three countries. Important people disapproval predicted whether smokers attempted to quit, although this did not reach significance in the French and German samples in multivariate analyses. Our findings suggest that anti-tobacco information campaigns about the dangers of second-hand smoke in France and about smoking cessation in the Netherlands and Germany might have reduced the social acceptability of smoking in these countries. However, campaigns that influence the perceived disapproval of smoking by important people may be needed to ultimately increase attempts to quit smoking.

Attitudes of detainees and prison staff towards tobacco control policy in Switzerland: a qualitative interview study

PURPOSE

To explore detainees and staff's attitudes towards tobacco use, in order to assist prison administrators to develop an ethically acceptable tobacco control policy based on stakeholders' opinion.

DESIGN

Qualitative study based on in-depth semi-structured interviews with 31 prisoners and 27 staff prior (T1) and after the implementation (T2) of a new smoke-free regulation (2009) in a Swiss male post-trial prison consisting of 120 detainees and 120 employees.

RESULTS

At T1, smoking was allowed in common indoor rooms and most working places. Both groups of participants expressed the need for a more uniform and stricter regulation, with general opposition towards a total smoking ban. Expressed fears and difficulties regarding a stricter regulation were increased stress on detainees and strain on staff, violence, riots, loss of control on detainees, and changes in social life. At T2, participants expressed predominantly satisfaction. They reported reduction in their own tobacco use and a better protection against second-hand smoke. However, enforcement was incomplete. The debate was felt as being concentrated on regulation only, leaving aside the subject of tobacco reduction or cessation support.

CONCLUSION

Besides an appropriate smoke-free regulation, further developments are necessary in order to have a comprehensive tobacco control policy in prisons.

Do smokers support smoke-free laws to help themselves quit smoking? Findings from a longitudinal study

BACKGROUND

A growing number of smokers support smoke-free laws. The theory of self-control provides one possible explanation for why smokers support laws that would restrict their own behaviour: the laws could serve as a self-control device for smokers who are trying to quit.

OBJECTIVE

To test the hypothesis that support for smoke-free laws predicts smoking cessation.

METHODS

We used longitudinal data (1999-2000) from a US national sample of adult smokers (n=6415) from the Current Population Survey, Tobacco Use Supplements. At baseline, smokers were asked whether they made a quit attempt in the past year. They were also asked whether they thought smoking should not be allowed in hospitals, indoor sporting events, indoor shopping malls, indoor work areas, restaurants, or bars and cocktail lounges. At 1-year follow-up, smokers were asked whether they had quit smoking.

FINDINGS

Smokers who supported smoke-free laws were more likely to have made a recent quit attempt. At 1-year follow-up, those who supported smoke-free laws in 4-6 venues were more likely to have quit smoking (14.8%) than smokers who supported smoke-free laws in 1-3 venues (10.6%) or smokers who supported smoke-free laws in none of the venues (8.0%). These differences were statistically significant in multivariate analyses controlling for demographics.

CONCLUSIONS

Support for smoke-free laws among smokers correlates with past quit attempts and predicts future quitting. These findings are consistent with the hypothesis that some smokers support smoke-free laws because the laws could help them quit smoking.

Smoke-free laws and direct democracy initiatives on smoking bans in Germany: a systematic review and quantitative assessment

BACKGROUND

Germany's 16 states regulate smoking differently within health protection principles laid down in the federal law. All state smoke-free laws in Germany have undergone at least one change since taking effect.

METHODS

We systematically review federal and state laws regulating smoking, as well as petitions, popular initiatives and referenda that aimed at changing statutory smoking bans. Data generated through the systematic review were correlated with state smoking rates.

RESULTS

The protection from the dangers of secondhand smoke is the primary motive for smoking bans in Germany. The first smoke-free laws affecting smoking in pubs, restaurants and several other public places were introduced in 2007. In 2008, the Federal Constitutional Court of Germany ruled in a leading decision on the smoke-free laws of two states that some common smoking ban exemptions of the introduced smoke-free laws violate the basic right to freely exercise a profession and mandated revisions. All states but Bavaria and Saarland, whose smoking bans were more and less comprehensive than those judged by the constitutional court, respectively, needed to change the smoking ban exemptions to reconcile their smoke-free laws with the constitution. Direct democracy initiatives to change smoking bans were only successful in Bavaria in 2010, but a total of 15 initiatives by citizens' or interest groups attempted to influence non-smokers protection legislation through direct democratic procedures. Early ratification of a smoking ban in a federal state correlates with a higher reduction in the smoking rate from 2005 to 2009 (Spearman's ρ = 0.51, p = 0.04).

CONCLUSIONS

The federal government structure and direct democratic participation in smoke-free legislation in Germany has produced a diversity of local smoking bans and exemptions.

Evaluating the Effectiveness of France's Indoor Smoke-Free Law 1 Year and 5 Years after Implementation: Findings from the ITC France Survey

France implemented a comprehensive smoke-free law in two phases: Phase 1 (February 2007) banned smoking in workplaces, shopping centres, airports, train stations, hospitals, and schools; Phase 2 (January 2008) banned smoking in hospitality venues (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France’s smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1) and two waves after the implementation (Waves 2 and 3). Results show that the smoke-free law led to a very significant and near-total elimination of observed smoking in key venues such as bars (from 94–97% to 4%) and restaurants (from 60–71% to 2–3%) at Wave 2, which was sustained four years later (6–8% in bars; 1–2% in restaurants). The reduction in self-reported smoking by smoking respondents was nearly identical to the effects shown in observed smoking. Observed smoking in workplaces declined significantly after the law (from 41–48% to 18–20%), which continued to decline at Wave 3 (to 14–15%). Support for the smoke-free laws increased significantly after their implementation and continued to increase at Wave 3 (p<.001 among smokers for bars and restaurants; p<.001 among smokers and p = .003 for non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in indoor smoking while also leading to high levels of support by the public. Moreover, contrary to arguments by opponents of smoke-free laws, smoking in the home did not increase after the law was implemented and prevalence of smoke-free homes among smokers increased from 23.2% before the law to 37.2% 5 years after the law.

Evaluation of the smoking ban in public places in France one year and five years after its implementation: Findings from the ITC France survey

France implemented a comprehensive smoke-free policy in public places in February 2007 for workplaces, shopping centres, airports, train stations, hospitals and schools. On January 2008, it was extended to meeting places (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France's smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1, conducted December 2006 to February 2007) and two waves after the implementation (Wave 2, conducted between September-November 2008; and Wave 3, conducted between September-December 2012). Results show that the smoke-free law led to a very significant and near total elimination of indoor smoking in key venues such as bars (from 95.9% to 3.7%) and restaurants (from 64.7% to 2.3%) at Wave 2, which was sustained four years later at Wave 3 (1.4% in restaurants; 6.6% in bars). Smoking in workplaces declined significantly after the law (from 42.6% to 19.3%), which continued to decline at Wave 3 (to 12.8%). Support for the smoke-free law increased significantly after their implementation and continued to increase at Wave 3 (among smokers for bars and restaurants; among smokers and non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in tobacco smoke in public places while also leading to high levels of support by the public.

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.

Individual, social, and environmental factors associated with support for smoke-free housing policies among subsidized multiunit housing tenants

INTRODUCTION

Mandatory smoke-free policies in subsidized, multiunit housing (MUH) may decrease secondhand smoke exposure in households with the highest rates of exposure. Ideally, policies should be based on a strong understanding of factors affecting support for smoke-free policies in the target population to maximize effectiveness.

METHODS

A face-to-face survey was conducted from August to October 2011 using a stratified random sample of private subsidized housing units in Columbus, OH, without an existing smoke-free policy (n = 301, 64% response rate). Lease holders were asked to report individual, social, and environmental factors hypothesized to be related to support for smoke-free policies. Multiple logistic regression models were used to identify factors independently associated with policy support.

RESULTS

Most tenants supported smoke-free policies in common areas (82.7%), half supported policies inside units (54.5%), and one third supported a ban outside the building (36.3%). Support for smoke-free policies in units and outdoors was more common among nonsmokers than smokers (71.5% vs. 35.7%, p < .001 and 46.2% vs. 25.4%, p < .001, respectively). Several individual and social, but no environmental, factors were independently associated with policy support. Smokers who intended to quit within 6 months or less were more likely than other smokers to support in-unit policies (45.3% vs. 21.1%; p = .003).

CONCLUSIONS

More than half of subsidized MUH tenants supported smoke-free policies inside their units. Strategies to address individual- and social-level barriers to behavior change should be implemented in parallel with smoke-free policies. Policies should be evaluated with objective measures to determine their effectiveness.

Does smoke-free legislation and smoking outside bars increase feelings of stigmatization among smokers? Findings from the International Tobacco Control (ITC) Netherlands Survey

This study examined whether smokers' perceived level of stigmatization changed after the implementation of smoke-free hospitality industry legislation and whether smokers who smoked outside bars reported more perceived stigmatization. Longitudinal data from the International Tobacco Control (ITC) Netherlands Survey was used, involving a nationally representative sample of 1447 smokers aged 15 years and older. Whether smoke-free legislation increases smokers' perceived stigmatization depends on how smokers feel about smoking outside. The level of perceived stigmatization did not change after the implementation of smoke-free hospitality industry legislation in the Netherlands, possibly because most Dutch smokers do not feel negatively judged when smoking outside.

Pathways of change explaining the effect of smoke-free legislation on smoking cessation in The Netherlands. An application of the international tobacco control conceptual model

INTRODUCTION

This study aims to test the pathways of change from individual exposure to smoke-free legislation on smoking cessation, as hypothesized in the International Tobacco Control (ITC) Conceptual Model.

METHODS

A nationally representative sample of Dutch smokers aged 15 years and older was surveyed during 4 consecutive annual surveys. Of the 1,820 baseline smokers, 1,012 participated in the fourth survey. Structural Equation Modeling was employed to test a model of the effects of individual exposure to smoke-free legislation through policy-specific variables (support for smoke-free legislation and awareness of the harm of [secondhand] smoking) and psychosocial mediators (attitudes, subjective norm, self-efficacy, and intention to quit) on quit attempts and quit success.

RESULTS

The effect of individual exposure to smoke-free legislation on smoking cessation was mediated by 1 pathway via support for smoke-free legislation, attitudes about quitting, and intention to quit smoking. Exposure to smoke-free legislation also influenced awareness of the harm of (secondhand) smoking, which in turn influenced the subjective norm about quitting. However, only attitudes about quitting were significantly associated with intention to quit smoking, whereas subjective norm and self-efficacy for quitting were not. Intention to quit predicted quit attempts and quit success, and self-efficacy for quitting predicted quit success.

CONCLUSIONS

Our findings support the ITC Conceptual Model, which hypothesized that policies influence smoking cessation through policy-specific variables and psychosocial mediators. Smoke-free legislation may increase smoking cessation, provided that it succeeds in influencing support for the legislation.