Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: findings from the International Tobacco Control Four Country Survey

Support for nicotine reduction in cigarettes: findings from the 2016 and 2020 ITC Four Country Smoking and Vaping Surveys

INTRODUCTION

The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020.

METHODS

Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11 150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know).

RESULTS

A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%).

CONCLUSION

More than half of respondents in all four countries-including those who smoked daily-supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.

Secondhand Smoke Exposure Inside the Home Among Adults in Eight Countries in Sub-Saharan Africa: Global Adult Tobacco Survey, 2012-2018

INTRODUCTION

Secondhand tobacco smoke (SHS) exposure causes diseases and death in adults and children. Evidence indicates that most SHS exposures occur at home and in the workplace. Therefore, home is a major place where adults and children can be effectively protected from SHS. This study examined the magnitude of SHS exposure at home and associated factors in eight sub-Saharan African countries.

AIMS AND METHODS

We analyzed 2012-2018 Global Adult Tobacco Survey data for Botswana, Cameroon, Ethiopia, Kenya, Nigeria, Senegal, Tanzania, and Uganda. We computed prevalence estimates of self-reported monthly SHS exposure at home reported as anyone smoking inside their home daily, weekly, or monthly. We calculated SHS exposure at home prevalence and applied multivariable logistic regression models to identify related factors.

RESULTS

Overall median prevalence of SHS exposure at home was 13.8% in the eight countries; ranging from 6.6% (95% CI: 5.7%, 7.6%) in Nigeria to 21.6% (95% CI: 19.4%, 24.0%) in Senegal. In multivariable analysis across the countries, SHS exposure at home was associated with living with a smoker, ranging from an adjusted odds ratio (AOR) of 4.6 (95% CI: 3.6, 5.8) in Botswana to 27.6 (95% CI: 20.1, 37.8) in Nigeria. SHS exposure at home was significantly associated with lower education attainment (Kenya and Ethiopia), and lower wealth index (Uganda, Senegal, and Botswana).

CONCLUSIONS

SHS exposure in homes was associated with the presence of a smoker in the home and lower socioeconomic status.

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.

Comparison and determination of factors associated with smoking status, smoking knowledge, attitude and practice (S-KAP) between smoke-free and non-smoke-free campuses in public universities in Malaysia: a cross-sectional study

OBJECTIVES

We compared the smoking prevalence, smoking knowledge, attitudes and practices (S-KAP) between smoke-free campuses (SFCs) and non-SFCs (NSFCs) and determined the associated factors of smoking status and S-KAP.

DESIGN

Cross-sectional study.

SETTINGS

The research was conducted in four public universities in Malaysia; two SFCs and two NSFCs.

PARTICIPANTS

Students and staff from SFCs (n=1063) and NSFCs (n=1040).

MAIN OUTCOME MEASURES

Compared the smoking prevalence, S-KAP between SFCs and NSFCs and determined the associated factors.

RESULTS

The prevalence of smokers among the SFC and NSFC respondents was 5.2% and 6.7%, respectively. University type and smoking attitude were significantly related (p=0.02). At the SFCs, the factors associated with becoming a smoker were male gender (p<0.001), monthly income ≥RM3000 (p=0.02), positive smoking attitude (p=0.003) and positive smoking practice (p<0.001); at NSFCs, the associated factors were male gender (p<0.001), low smoking knowledge (p=0.004), positive smoking attitude (p=0.001) and practice (p<0.001). The factors associated with good smoking knowledge were female gender (SFCs: p=0.001; NSFCs: p=0.004), and monthly income ≥RM3000 (NSFCs: p=0.02). Male respondents were likely to have positive smoking attitudes (SFCs: p<0.001; NSFCs: p<0.001) and negative smoking practices (SFCs: p<0.001; NSFCs: p<0.001).

CONCLUSION

Overall, smoking prevalence, knowledge and practice were not much different between SFCs and NSFCs. However, there was a significant relationship between university type and smoking attitude due to the existence of the SFC policy likely rendering smoking a less acceptable social norm. Continual education programmes on smoking harms and smoking cessation strategies are highly recommended to aid the SFC policy in preventing secondhand smoke in universities.

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.

Exposure to new smoking environments and individual-level cigarette smoking behavior: Insights from exogenous assignment of military personnel

Despite overall declines in cigarette smoking prevalence in the United States (U.S.) in the past several decades, smoking rates remain highly variable across geographic areas. Past work suggests that smoking norms and exposure to other smokers in one's social environment may correlate with smoking risk and cessation, but little is known about how exposure to other smokers in one's community is causally linked to smoking behavior - in part due to endogeneity and inability to randomly assign individuals to different 'smoking environments.' The goal of this study was to evaluate how exposure to localities with high population-level smoking prevalence affects individual-level cigarette smoking behaviors, including quitting. The study addresses key limitations in the literature by leveraging a unique natural experiment: the plausibly exogenous compulsory assignment of military personnel to installations. Logistic and multivariate regressions estimated cross-sectional associations between smoking/quitting behaviors and our proxy for social environments for smoking, county-level smoking prevalence (CSP). Across 563 U.S. counties, CSP ranged from 3.8 to 37.9%. Among the full sample, a 10 percentage point increase in CSP was associated with an 11% greater likelihood of smoking. In subgroup analyses, young adults, women, those without children in the household, and risk/sensation-seekers were more likely to smoke and less likely to quit when exposed to counties with higher CSP. Relocation to areas with high population-level smoking prevalence may increase likelihood of smoking and impede quitting, and may disparately affect some population subgroups. Findings provide novel evidence that community smoking environments affect adult smoking risk and underscore a need for sustained, targeted efforts to reduce smoking in areas where prevalence remains high.

Adolescents' support for an outdoor smoke-free policy at sports clubs in the Netherlands

INTRODUCTION

Outdoor smoke-free policies (SFPs) at sports clubs may contribute to the prevention of smoking among adolescents. Adolescents' support for such policy is important to its success. The aim of this study is to explore adolescents' perceptions with regard to an outdoor SFP at sports clubs in the Netherlands.

METHODS

Focus group discussions (n=27) were held with 180 participants (aged 13-18 years) at 16 sports clubs. Thematic analysis was used to analyze the data.

RESULTS

Participants generally supported an outdoor SFP at sports clubs. Five reasons for this support were reported: 1) children should not be exposed to smoking, 2) smoking and sports (clubs) do not fit together, 3) secondhand smoke is undesirable, 4) an outdoor SFP may enhance a sports club's image, and 5) an outdoor SFP contributes to the prevention of smoking. Some participants voiced considerations against an outdoor SFP, arguing amongst others, that smokers need to be taken into account, and that problems may occur with compliance and enforcement. Support for an outdoor SFP was stronger among participants at clubs with an outdoor SFP than among those without such policy.

CONCLUSIONS

This study shows that adolescents generally support an outdoor smoke-free policy at sports clubs. After implementation, the outdoor SFP was generally experienced as a normal practice. These results could encourage sports clubs without an outdoor SFP to become smoke-free as well.

Evaluating a tobacco-free university policy: A repeated cross-sectional survey of faculty and staff in Lebanon

INTRODUCTION

A growing body of research has evaluated the effect of university tobacco-free policies on faculty and staff, however, none of these studies has been carried out in the Eastern Mediterranean Region. This study evaluates changes in faculty and staff attitudes, perceptions and smoking behavior, at 1 year post adoption of a tobacco-free policy in a medium-sized university in Lebanon and the region.

METHODS

Two cross-sectional surveys were conducted in 2017 and 2018: baseline and at 1 year post policy implementation. A random sample of 625 and 624 participants took part in the 2017 and 2018 studies, respectively.

RESULTS

Faculty and staff had a positive attitude towards the policy at the two time points. The belief that there should be exceptions to the policy significantly decreased from 79% to 59% (p=0.002) among all smokers, particularly those with lower educational attainment (81% to 57%, p=0.007). Perception of compliance among peer smokers increased from 73% to 87% (p=0.009). The proportion of smokers did not significantly change at 1 year post policy implementation, however, 44% of smokers with lower educational attainment, compared to only 7% of those with higher educational attainment (p<0.001), reported a decrease in their smoking behavior outside campus.

CONCLUSIONS

The policy had a positive effect on the attitude, behavior and perception of policy benefits among smokers with lower educational attainment, who constitute the majority of smokers. Findings from this study inform and support future efforts to develop university and workplace tobacco-free policies.

In favour of tobacco control? Former smokers' support for tobacco policies

Background

Tobacco control (TC) in Sweden is being continuously strengthened.

Aims

The study aimed to examine attitudes towards different TC policies among former smokers, the difference between nicotine-free former smokers and those who use nicotine in the form of snus or nicotine replacement therapies (NRTs), and whether different TC strategies tend to become more acceptable over time.

Methods

Respondents are part of a seven-year follow-up of former smokers in Sweden. Initially, 1400 respondents were contacted regarding participation and 705 answered a survey (response rate 50%). The present study used cross-sectional data on attitudes towards different TC policies and respondent's level of support were measured on a 4-point scale. Analyses consist of percentage distribution of level of agreement, in total and between nicotine-free individuals and users of nicotine in the form of snus or NRTs, as well as logistic regressions in order to predict the odds for supporting the different policies. In addition, a percentage distribution of support for different policies introduced during different time-periods is shown.

Results

There is an overall support for smoke-free environments. Nicotine users are, however, overall slightly more opposed, especially to policies aiming at denormalising smoking. Public support is important for successful implementation but resistance can pass, and interventions tend to become more acceptable over time.

Conclusion

While smoke-free indoor environments can be justified by scientific evidence of harm to others, bans against smoking outdoors might be experienced as intrusive. Policies need to rest on scientific arguments and be seen as appropriate actions, underlining the importance of information for successful implementations.

Real-world unassisted quit success and related contextual factors: a population-based study of Chinese male smokers

OBJECTIVES

To examine the association of exposure to secondhand smoke (SHS) and tobacco advertising with unassisted smoking cessation among Chinese male smokers.

METHODS

A questionnaire was administered to 6500 male adult smokers from six cities in China selected in a cross-sectional multistage sampling design. The survey collected self-reported demographic characteristics, smoking and cessation status, SHS exposure and tobacco advertising exposure, with 5782 valid questionnaires included in this study. Multiple logistic regression analysis was used to assess the association of unassisted smoking cessation with exposure to SHS and tobacco advertising.

RESULTS

42.1% of smokers who made unassisted quit attempts achieved abstinence (95% CI 32.5% to 51.7%). SHS (adjusted OR (aOR) 0.36; 95% CI 0.18 to 0.71; p=0.033) and tobacco advertising exposure (aOR 0.63; 95% CI 0.37 to 0.95; p=0.039) were negatively associated with unassisted smoking cessation.

CONCLUSION

The vast majority of Chinese male smokers rely on unassisted methods to quit smoking. Success prevalence is high, which is very beneficial to health. This study suggests that exposure to secondhand smoking and tobacco advertising hinders the success of unassisted cessation. These findings speak to the need for environmental tobacco control measures to promote unassisted smoking cessation among Chinese adult male smokers.

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.

Secondhand Smoke Exposure in Primary School Children: A Survey in Dhaka, Bangladesh

Introduction

We report on second-hand smoke (SHS) exposure based on saliva cotinine levels among children in Bangladesh—a country with laws against smoking in public places.

Methods

A survey of primary school children from two areas of the Dhaka district was conducted in 2015. Participants completed a questionnaire and provided saliva samples for cotinine measurement to assess SHS exposure with a cut-off range of ≥0.1ng/mL.

Results

Four hundred and eighty-one children studying in year-5 were recruited from 12 primary schools. Of these, 479 saliva samples were found sufficient for cotinine testing, of which 95% (453/479) were positive for recent SHS exposure. Geometric mean cotinine was 0.36 (95% CI = 0.32 to 0.40); 43% (208/479) of children lived with at least one smoker in the household. Only 21% (100/479) reported complete smoking restrictions for residents and visitors; 87% (419/479) also reported being recently exposed to SHS in public spaces. Living with a smoker and number of tobacco selling shops in the neighborhood had positive associations with recent SHS exposure.

Conclusions

Despite having a ban on smoking in public places, recent SHS exposure among children in Bangladesh remains very high. There is an urgent need to reduce exposure to SHS in Bangladeshi children.

Implications

Children bear the biggest burden of disease due to SHS exposure than any other age group. However, children living in many high-income countries have had a sharp decline in their exposure to SHS in recent years. What remains unknown is if children living in low-income countries are still exposed to SHS. Our study suggests that despite having a ban on smoking in public places, most primary school children in Dhaka, Bangladesh are still likely to be exposed to SHS.

Attitudes of Korean smokers towards smoke-free public places: findings from the longitudinal ITC Korea Survey, 2005-2010

OBJECTIVE

Prior to December 2012, restaurants in South Korea were required to implement only partial smoking bans. This study documents the changes in Korean smokers' attitudes towards smoking bans between 2005 and 2010 and explores the effects of anti-smoking advertising as a correlate of support for total smoking bans in public places.

DESIGN

Longitudinal cohort study of Korean adult smokers.

SETTING

The data were derived from three waves (2005, 2008 and 2010) of the International Tobacco Control (ITC) Korea Survey.

PARTICIPANTS

The ITC Korea Survey respondents were a probability-based, nationally representative sample of Korean smokers aged 19 and older. The current analysis includes 995 smokers who participated in Wave 1 (2005), 1737 smokers who participated in Wave 2 (2008) and 1560 smokers who participated in Wave 3 (2010).

PRIMARY AND SECONDARY OUTCOME MEASURES

Changes in respondents' awareness of secondhand smoke (SHS) harm, attitudes towards smoking bans and personal rules for smoking in private homes and/or vehicles were analysed. Correlates of support for smoking bans in public places were examined using generalised estimating equation regression models.

RESULTS

More than 80% of Korean smokers are aware of the harms of SHS. The proportion of smokers who support smoke-free restaurants or smoke-free bars increased twofold between 2005 and 2010. Smokers who were aware of the dangers of SHS were more likely to support a total smoking ban in workplaces. Noticing anti-smoking advertising or information was not significantly associated with support for a total smoking ban in public places.

CONCLUSIONS

Korean smokers became more supportive of smoking bans in public places between 2005 and 2008. These results show that smokers' attitudes towards smoking bans can change with the implementation of smoke-free policies, even in a country that has a high prevalence of smokers.

Variations in support for secondhand smoke restrictions across diverse rural regions of the United States

Significant disparities exist between rural-urban U.S.

POPULATIONS

Besides higher smoking rates, rural Americans are less likely to be protected from SHS. Few studies focus across all regions, obscuring regional-level differences. This study compares support for SHS restrictions across all HHS regions.

DATA

2014/15 TUS-CPS; respondents (n = 228,967): 47,805 were rural residents and 181,162 urban. We examined bi-variates across regions and urban-rural adjusted odds ratios within each. Smoking inside the home was assessed along with attitudes toward smoking in bars, casinos, playgrounds, cars, and cars with kids. Urban respondents were significantly more supportive of all SHS policies: (e.g. smoking in bars [57.9% vs. 51.4%]; support for kids in cars [94.8% vs. 92.5%]. Greatest difference between urban-rural residents was in Mid-Atlantic (bar restrictions) and Southeast (home bans): almost 10% less supportive. Logistic regression confirmed rural residents least likely, overall, to support SHS in homes (OR = 0.78, 95% CI 0.74, 0.81); in cars (OR = 0.87, 95% CI 0.79, 0.95), on playgrounds (OR = 0.88, 95% CI.83, 0.94) and in bars OR = 0.88, 95% CI 0.85, 0.92), when controlling for demographics and smoking status. South Central rural residents were significantly less likely to support SHS policies-home bans, smoking in cars with kids, on playgrounds, in bars and casinos; while Heartland rural residents were significantly more supportive of policies restricting smoking in cars, cars with kids and on playgrounds. Southeast and South Central had lowest policy score with no comprehensive state-level SHS policies. Understanding differences is important to target interventions to reduce exposure to SHS and related health disparities.

Acceptance and patterns of personal vaporizer use in Australia and the United Kingdom: Results from the International Tobacco Control survey

BACKGROUND

This study examined the prevalence and correlates of (1) perceived social acceptability of personal vaporizer (PV)/e-cigarette use, and (2) reported vaping in public and private places, in the UK and Australia with different regulatory environments for PVs.

METHODS

Data analyzed come from 2849 smokers and recent ex-smokers in the UK and Australia who participated in the 2014 wave of the International Tobacco Control Survey.

RESULTS

UK respondents were more likely to think vaping is socially acceptable than Australians (56.4% vs. 27.9%; p < 0.001). Having quit smoking, observing vaping in smoke-free (SF) public places, and believing vaping is less harmful than smoking was all significantly associated with greater perceived social acceptability of vaping in both countries. However, vaping status and that of friends and family were more influential in Australia than in the UK. Vaping was reported as much more common in private, than public, settings in both countries. UK vapers were more likely to report vaping in SF public places (OR = 2.66; 95% CI = 1.5-4.7; p < 0.01) and at home (OR = 2.44; 95% CI = 1.5-3.9; p < 0.001), but not in their car when controlling for demographic factors and vaping and smoking status.

CONCLUSION

The acceptability of vaping was greater among those who were more exposed to vaping and not just among those with some personal experience of vaping, suggesting no strong social barriers to increased use. Vaping in SF public places was less common than in homes, and both were more common in the UK than in Australia, suggesting some social constraints on use, particularly in Australia.

Attitudes and experiences with secondhand smoke and smoke-free policies among subsidised and market-rate multiunit housing residents living in six diverse communities in the USA

BACKGROUND

Given that higher smoking rates persist among lower socioeconomic populations, multiunit housing (MUH) environments may result in higher secondhand smoke (SHS) exposures among subsidised MUH residents. This cross-sectional assessment compares experiences with SHS and smoke-free policies among subsidised and market-rate MUH residents living in six US communities.

METHODS

MUH residents (n=1565) were surveyed regarding their smoke-free rules (home and building), SHS exposures and preferences towards smoke-free policies. Binary logistic regression identified predictors of each outcome, focusing on differences by subsidised housing status (subsidised vs market rate).

RESULTS

Among residents enforcing smoke-free home rules (76%, overall), 50% reported SHS incursions into their unit. Only 23% reported living in a smoke-free building; 56% of those living in smoking-allowable buildings reported preferences towards smoke-free building policies. Among market-rate housing residents, smoke-free home (OR=4.18) and building (OR=2.26) rules were significantly higher when children were present. Smoke-free building rules reduced the odds of SHS incursions among market-rate housing residents (OR=0.50), but no association was observed among subsidised housing residents. Non-smoking subsidised housing residents exhibited stronger preferences for smoke-free policies compared with those in market-rate housing.

DISCUSSION

Smoke-free home rules may not protect MUH residents from SHS exposures, particularly in subsidised MUH. Although strong preferences towards smoke-free policies were present overall, subsidised MUH residents may have fewer alternative smoke-free housing options available. Therefore, all publicly funded housing should be smoke free to protect these vulnerable populations. However, continued efforts to encourage privately owned MUH operators to adopt smoke-free policies are also necessary.

Support for Food and Beverage Worksite Wellness Strategies and Sugar-Sweetened Beverage Intake Among Employed U.S. Adults

PURPOSE

Sugar-sweetened beverage (SSB) consumption is high among U.S. adults and is associated with obesity. Given that more than 100 million Americans consume food or beverages at work daily, the worksite may be a venue for interventions to reduce SSB consumption. However, the level of support for these interventions is unknown. We examined associations between workday SSB intake and employees' support for worksite wellness strategies (WWSs).

DESIGN

We conducted a cross-sectional study using data from Web-based annual surveys that gather information on health-related attitudes and behaviors.

SETTING

Study setting was the United States.

SUBJECTS

A total of 1924 employed adults (≥18 years) selected using probability-based sampling.

MEASURES

The self-reported independent variable was workday SSB intake (0, <1 or ≥1 times per day), and dependent variables were employees' support (yes/no) for the following WWSs: (1) accessible free water, (2) affordable healthy food/drink, (3) available healthy options, and (4) less available SSB.

ANALYSIS

Multivariable logistic regression was used to control for sociodemographic variables, employee size, and availability of cafeteria/vending machine.

RESULTS

About half of employees supported accessible free water (54%), affordable healthy food/drink (49%), and available healthy options (46%), but only 28% supported less available SSB. Compared with non-SSB consumers, daily SSB consumers were significantly less supportive of accessible free water (adjusted odds ratio, .67; p < .05) or less available SSB (odds ratio, .49; p < .05).

CONCLUSION

Almost half of employees supported increasing healthy options within worksites, although daily workday SSB consumers were less supportive of certain strategies. Lack of support could be a potential barrier to the successful implementation of certain worksite interventions.

Update on Performance in Tobacco Control: A Longitudinal Analysis of the Impact of Tobacco Control Policy and the US Adult Smoking Rate, 2011-2013

CONTEXT

Tobacco use remains the leading cause of preventable death in the United States. States and municipalities have instituted a variety of tobacco control measures (TCMs) to address the significant impact tobacco use has on population health. The American Lung Association annually grades state performance of tobacco control using the State of Tobacco Control grading framework.

OBJECTIVE

To gain an updated understanding of how recent efforts in tobacco control have impacted tobacco use across the United States, using yearly State of Tobacco Control TCM assessments.

DESIGN

The independent TCM variables of smoke-free air score, cessation score, excise tax, and percentage of recommended funding were selected from the American Lung Association State of Tobacco Control reports. Predictors of adult smoking rates were determined by a mixed-effects model.

SETTING/PARTICIPANTS

The 50 US states and District of Columbia.

MAIN OUTCOME MEASURE

Adult smoking rate in each state from 2011 to 2013.

RESULTS

The average adult smoking rate decreased significantly from 2011 to 2013 (21.3% [SD: 3.5] to 19.3% [SD: 3.5], P = .016). All forms of TCMs varied widely in implementation levels across states. Excise taxes (β = -.812, P = .006) and smoke-free air regulations (β = -.057, P = .008) were significant, negative predictors of adult smoking. Cessation services (β = .015, P = .46) did not have a measurable effect on adult smoking.

CONCLUSION

Tobacco control measures with the strongest influence on adult smoking include the state excise tax and state smoke-free air regulations. The lack of robust funding for tobacco cessation services across the majority of US states highlights an important shortfall in current tobacco control policy.

A cross sectional evaluation of a total smoking ban at a large Australian university

BACKGROUND

Total smoking bans have been found to contribute positively to the health of non-smokers by reducing exposure to second-hand smoke, and to enhance the likelihood of cessation among smokers.

METHODS

Two cross-sectional electronic surveys of staff and students at a large Australian university were conducted prior (n = 969) and 1 year post (n = 670) the implementation of a smoke free campus policy. Demographics, tobacco use, intention to quit, attitudes towards smoking and smoking restrictions and awareness of and attitudes towards the campus smoking policy were measured.

RESULTS

Exposure to second-hand smoke (SHS) reduced significantly (p < 0.001) one year after policy implementation. Smoking prevalence was similar at both time periods (T1 9.3 %; T2 8.4 %) and over half of smokers indicated they were planning to quit smoking in the future (T1 65.5 vs T2 62.3 %). There was a significant increase in positive responses to the statement the campus should be totally smoke free including all outdoor areas at T2 compared to T1 (T1 60.8 vs T2 71.4 %; p < 0.001), however respondents felt there should be places on campus for smokers to smoke (T1 53.6 vs T2 47 %; p < 0.05).

CONCLUSIONS

This study found a significant positive difference in exposure SHS after implementation of the total ban. Although prevalence of smoking in this study was low, the proportion of respondents who were contemplating smoking cessation suggests support for smokers would be beneficial. Continued awareness raising, education and enforcement is likely to enhance the long term outcomes of the total ban.

Prevalence of passive smoking in the community population aged 15 years and older in China: a systematic review and meta-analysis

OBJECTIVES

To estimate the prevalence and distribution of passive smoking in the community population aged 15 years and older in China.

DESIGN

A systematic review and meta-analysis of cross-sectional studies reporting the prevalence of passive smoking in China and a series of subgroup, trend and sensitivity analyses were conducted in this study.

DATA SOURCE

The systematic review and meta-analysis, which included 46 studies with 381,580 non-smokers, estimated the prevalence and distribution of passive smoking in China. All studies were published between 1997 and 2015.

RESULTS

The pooled prevalence of passive smoking was 48.7% (95% CI 44.8% to 52.5%) and was relatively stable from 1995 to 2013. The prevalence in the subgroups of gender, area, age and time varied from 35.1% (95% CI 31.8% to 38.3%) in the elderly (≥60 years) to 48.6% (95% CI 42.9% to 54.2%) in urban areas. The prevalence was lower in the elderly (≥60 years) than in those between 15 and 59 years of age (OR 1.61, 95% CI 1.44 to 1.81). The difference between females and males in urban and rural areas was not statistically significant (OR: 1.27, 95% CI 0.93 to 1.74 and OR: 1.14, 95% CI 0.82 to 1.58, respectively). In addition, a significantly increasing trend was found among males from 2002 to 2010. Heterogeneity was high in all pooled estimates (I(2)>98%, p<0.001).

CONCLUSIONS

The high and stable prevalence of passive smoking in China is raising increasing national concern regarding specific research and tobacco control programmes. Attention should be focused on young, middle-aged and male non-smokers regardless of region.

Effect of a smoke-free policy on staff attitudes and behaviours within an Australian metropolitan health service: a 3 year cross-sectional study

Objective In 2010, Peninsula Health (Vic., Australia), became smoke free as part of the locally developed smoking prevention and cessation strategy. The aim of the present study was to determine the effect of a smoke-free policy on smoking status and employee attitudes over a 3-year period. Methods Data were collected by three surveys 6 months before and 6 months and 3 years after policy introduction. Demographic data, smoking status and attitudes to the introduction of the smoke-free policy were collected for analysis. Results There were 3224 individual responses collected over three time points with similar demographics at each time. There were fewer employees smoking at 6 months (P=0.010) and 3 years (P<0.001) after implementation of the policy. There were more employees who felt positive towards the policy 3 years after its introduction (P=0.028). There were greater odds of an employee not identifying as a smoker after the policy was in place than before the policy was implemented. Conclusions The introduction of a smoke-free policy within a health service was an upstream health intervention that was well accepted by staff and appeared to have a positive effect on smoking behaviours. What is known about the topic? There are an increasing number of environmental changes that seek to decrease smoking behaviours. Bans within workplaces have a direct effect on employee smoking behaviour. What does this paper add? Some employee groups demonstrated the greater odds of smoking when a smoke-free policy was in place. Employees felt positive towards this policy. What are the implications for practitioners? This policy change supports environmental changes affecting individual health-related behaviours.

Perceptions of harm from secondhand smoke exposure among U.S. adults, 2009-2010

Background

Exposure to secondhand smoke (SHS) causes significant disease and death. We assessed the prevalence and correlates of perceptions about the health harm of SHS among U.S. adults at the national and state level.

Methods

Data came from the 2009–2010 National Adult Tobacco Survey, a national landline and cellular telephone survey. Perceptions about the health harms of SHS were assessed as follows: ‘not at all harmful’, ‘somewhat harmful’, and ‘very harmful’. Descriptive statistics were used to assess the prevalence of SHS harm perceptions by tobacco use and sociodemographic factors, including sex, age, race/ethnicity, education, marital status, annual household income, region, sexual orientation, children in the household, and smoke-free law coverage. Logistic regression was used to assess odds of perceiving SHS to be “very harmful” (vs. “not at all harmful” or “somewhat harmful”), adjusting for the aforementioned factors.

Results

Nationally, 64.5 % of adults perceived SHS as ‘very harmful’ (state range: 73.5 % [Utah] to 53.7 % [Kentucky]). By tobacco use, the perception that SHS is ‘very harmful’ was: 76.5 % among nonusers of tobacco; 62.1 % among noncombustible only users; 47.9 % among combustible only users; and 40.8 % among dual combustible and noncombustible users. Following adjustment, the perception that SHS was ‘very harmful’ was higher among females, non-Hispanic minorities and Hispanics, respondents living with children, and states with 100 % smoke-free law coverage. Among current tobacco users the odds of perceiving SHS to be ‘very harmful’ was lower in the Midwest than the West.

Conclusions

Almost two-thirds of American adults perceive SHS as ‘very harmful’; however, currently only half of all Americans are protected by comprehensive state or local smoke-free laws. These findings underscore the importance of public education campaigns to increase awareness of SHS exposure harm and the benefits of smoke-free environments. Expanding comprehensive smoke-free laws could protect all Americans from SHS.

Reactions to smoke-free public policies and smoke-free home policies in the Republic of Georgia: results from a 2014 national survey

OBJECTIVES

We examined receptivity to public smoke-free policies and smoke-free home status among adults in the Republic of Georgia.

METHODS

In Spring 2014, we conducted a national household survey of 1163 adults.

RESULTS

Our sample was on average 42.4 years old, 51.1 % male, and 43.2 % urban. Current smoking prevalence was 54.2 % in men and 6.5 % in women. Notably, 42.2 % reported daily secondhand smoke exposure (SHSe). Past week SHSe was 29.9 % in indoor public places and 33.0 % in outdoor public places. The majority reported no opposition to public smoke-free policies. Correlates of greater receptivity to public policies included being older, female, and a nonsmoker. Past week SHSe in homes was 54.2 %; 38.8 % reported daily SHSe at home. Only 14.3 % reported complete smoke-free home policies; 39.0 % had partial policies. The only correlate of allowing smoking in the home was being a smoker. Among smokers, correlates of allowing smoking in the home were being male and lower confidence in quitting.

CONCLUSIONS

SHSe is prevalent in various settings in Georgia, requiring efforts to promote support for public smoke-free policies and implementation of personal policies.

Who smokes in smoke-free public places in China? Findings from a 21 city survey

Efforts toward controlling secondhand smoke in public places have been made throughout China. However, in contrast to the western world, significant challenges remain for effectively implementing smoke-free regulations. This study explores individual and regional factors which influence smoking in smoke-free public places. Participants included 16 866 urban residents, who were identified through multi-stage sampling conducted in 21 Chinese cities. The reported smoking prevalence in smoke-free public places was 41.2%. Of those who smoked in smoke-free public places, 45.9% had been advised to stop smoking. Participants stated that no-smoking warnings/signs with 'please' in the statement had a better likelihood of gaining compliance and preventing smoking in public spaces. Multilevel logistic regression analysis showed that ethnicity, education, occupation, type of smoking, age of smoking initiation, smoking situation, stress, household smoking restrictions and city population were all associated with smoking in smoke-free public places. Interestingly local smoke-free regulations were not associated with smoking in public places. The findings underscore that efforts to restrict smoking in public places in China should emphasize strong enforcement, while simultaneously raising public awareness of the perils of second hand smoke.

Reactions to Smoke-free Policies and Messaging Strategies in Support and Opposition: A Comparison of Southerners and Non-Southerners in the US

OBJECTIVES

We explored differences in support for smoke-free policies among Southerners versus non-Southerners within a quota-based non-probability sample of adults in the United States.

METHODS

In 2013, a cross-sectional online survey was conducted among 2501 adults assessing tobacco use, reactions to personal and public smoke-free policies, and persuasiveness of various message frames regarding smoke-free bar/restaurant policies.

RESULTS

Southerners were no different from non-Southerners in support for most public and private smoke-free policies. The most effective pro-policy messages regarded hospitality, health, and individual rights/responsibilities; the most persuasive anti-policy messages involved individual rights/responsibilities. Compared to non-Southerners, Southerners rated pro-policy messages involving economic impact, religion/morality, and hospitality as more persuasive.

CONCLUSIONS

Factors other than public opinion accounting for lagging policy adoption must be explored.

Perceived Harm of Secondhand Electronic Cigarette Vapors and Policy Support to Restrict Public Vaping: Results From a National Survey of US Adults

INTRODUCTION

There is ongoing debate over banning electronic cigarette (e-cigarette) use (vaping) in public places. Many people perceive secondhand e-cigarette vapors (SHV) to be relatively harmless, which may affect their support for policies to restrict vaping in public places. Given that awareness of secondhand cigarette smoke risks predicts public support for clean air policies, we hypothesized that greater perceived harm of SHV to personal health would be associated with stronger support for vaping restrictions.

METHODS

Data from 1449 US adults in a national online panel was collected from October to December 2013. Using multiple regressions, we predict a three-item scale of support for e-cigarette restricting policies in restaurants, bars/casinos/clubs, and parks using a two-item scale measuring concern and perceptions of harm to personal health from breathing SHV. Analyses adjusted for demographic covariates, smoking status and e-cigarette use, and were weighted to represent the US adult population.

RESULTS

Overall, respondents considered SHV exposure to be moderately harmful to their health and tended to favor restricting vaping in public places. Perceived harm of SHV to personal health was associated with support for vaping restrictions in public spaces (unstandardized regression coefficient, B = 0.18, 95% CI = 0.16, 0.20). Current smokers (vs. nonsmokers), those who ever tried e-cigarettes (vs. never), those who directly observed others vaping, and those with some college education (vs. high school or less) demonstrated less support for such policies.

IMPLICATIONS

This study shows that support for banning vaping in public spaces in the United States is positively associated with perceived health harms of SHV exposure. The findings suggest that continued monitoring of public perception of SHV harm and the accuracy of e-cigarette marketing claims about reduced harm would be needed to guide clean air policy decisions. With the emergence of new scientific evidence of the potential effects of SHV exposure, these results will serve as an important baseline of public perceptions and opinion during a time when such evidence was particularly limited.

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.

Public support for smoke-free policies in Jordan, a high tobacco burden country with weak implementation of policies: Status, opportunities, and challenges

Several Eastern Mediterranean (EM) countries, including Jordan, suffer from high smoking prevalence but weak implementation of smoking bans (SB). Public support (PS) influences successful implementation of SB, but little is known about PS for SB in EM countries with weak SB implementation. We conducted a cross-sectional survey measuring knowledge and perceptions of a large purposive sample of the Jordanian public regarding tobacco harms and anti-tobacco laws. Among 1169 respondents, 46% of whom used tobacco, PS for SB varied from 98% to 39% based on venue, being highest for health facilities and lowest for coffee shops. In venues with relatively lower PS (restaurants, coffee shops), lower educational groups, older age groups, nonsmokers, and those who had more knowledge regarding tobacco and secondhand smoke harms were significantly more likely to support SB than the highest educational group, the youngest age group, smokers, and those who had less knowledge (respectively). Our results suggest that aggressive promotion of SB is needed in countries like Jordan (where smoking is increasing), tailored to venue and specific sociodemographic characteristics of the public accessing these venues, particularly restaurants and coffee shops. Multifaceted health messages that enhance public knowledge can be of benefit in improving PS for SB.

Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people

OBJECTIVES

To describe general knowledge and perceived risk of the health consequences of smoking among Aboriginal and Torres Strait Islander people; and to assess whether knowledge varies among smokers and whether higher knowledge and perceived risk are associated with quitting.

DESIGN, SETTING AND PARTICIPANTS

The Talking About The Smokes project used quota sampling to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 2522 Aboriginal and Torres Strait Islander adults from April 2012 to October 2013.

MAIN OUTCOME MEASURES

Knowledge of direct effects of smoking and harms of second-hand smoke (SHS), risk minimisation, health worry, and wanting and attempting to quit.

RESULTS

Most Aboriginal and Torres Strait Islander participants who were daily smokers demonstrated knowledge that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%). Similarly, almost all daily smokers knew of the harms of SHS: that it is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%). Levels of knowledge among daily smokers were lower than among non-daily smokers, ex-smokers and never-smokers. Among smokers, greater knowledge of SHS harms was associated with health worry, wanting to quit and having attempted to quit in the past year, but knowledge of direct harms of smoking was not.

CONCLUSION

Lack of basic knowledge about the health consequences of smoking is not an important barrier to trying to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages about the negative health effects of smoking in ways that encompass the health of others is likely to contribute to goal setting and prioritising quitting among Aboriginal and Torres Strait Islander people.

Smoke-Free Policies in Multiunit Housing: Smoking Behavior and Reactions to Messaging Strategies in Support or in Opposition

INTRODUCTION

Given the high proportion of US adults living in multiunit housing (MUH) and the related risks of secondhand smoke, we examined correlates of having smoke-free MUH policies, level of support for such policies, and reactions to related messaging among a quota-based nonprobability sample of US adults.

METHODS

In 2013, 752 adult MUH residents were recruited through an online survey panel to complete a cross-sectional survey assessing tobacco use, personal smoke-free policies in homes and cars, smoke-free MUH policies, and reactions to messaging on smoke-free MUH policies. We sought sufficient representation of smokers, racial/ethnic minorities, and residents of the Southeast.

RESULTS

Overall, 56.3% had no smoke-free MUH policies and 16.2% had complete policies; 62.8% favored living in smoke-free MUH, and 28.9% said they would move if their building became smoke-free. Multivariate regression indicated that correlates of living in MUH with partial or no policies included younger age, less education, lower income, and current smoking (P's ≤ .01); more restrictive smoke-free MUH policies were associated with lower cigarette consumption and recent quit attempts among current smokers (P's < .05); and correlates of support for MUH policies included greater education, nonsmoker status, and having complete MUH policies (P's < .05). Of 9 messages opposing smoke-free MUH policies, the most persuasive was "People have the right to smoke in their own homes"; the most persuasive message of 11 in support was "You have the right to breathe clean air in your home."

CONCLUSION

Smoke-free MUH policies may reduce smoking. Messaging in favor of smoke-free MUH policies was more persuasive than messaging opposing such policies, indicating the potential for using these approaches.

"You're made to feel like a dirty filthy smoker when you're not, cigar smoking is another thing all together." Responses of Australian cigar and cigarillo smokers to plain packaging

OBJECTIVE

To explore experiences of cigar and cigarillo smokers under Australian laws requiring plain packaging (PP) and strengthened graphic health warnings (GHWs).

METHODS

In February/March 2014, we conducted: in-depth interviews with 10 regular premium cigar smokers; two focus groups with occasional premium cigar and premium cigarillo smokers (n=14); four focus groups with non-premium cigarillo smokers (n=28); and a national online survey of cigar and/or cigarillo smokers (n=268).

RESULTS

Premium cigar smokers had limited exposure to PP, with many purchasing fully branded cigars in boxes duty free or online and singles in non-compliant packaging. Those who were exposed noticed and were concerned by the warnings, tried to avoid them and felt more like 'dirty smokers'. Changes in perceived taste, harm and value were minimal for experienced premium cigar smokers. Occasional premium cigar and premium cigarillo smokers with higher PP exposure (gained by purchasing boxes rather than singles) perceived cigar/package appeal and value had declined and noticed the GHWs. Non-premium cigarillo smokers reported high PP exposure, reduced perceived appeal, quality, taste, enjoyment and value, somewhat increased perceived harm, greater noticeability of GHWs and concealment of packs and more contemplation of quitting. Online survey participants reported increased noticeability of GHWs (33%), decreased appeal of packaging (53%) and reduced consumption of cigars (42%) and cigarillos (44%) since PP implementation.

CONCLUSIONS

Non-premium cigarillo smokers appear to have been most exposed and influenced by PP, with cigar smokers less so, especially regular premium cigar smokers who have maintained access to fully branded products.

Knowledge and attitude toward smoke-free legislation and second-hand smoking exposure among workers in indoor bars, beer parlors and discotheques in Osun State of Nigeria

BACKGROUND

One of the requirements of the Osun State smoke-free legislation is to ensure smoke-free enclosed and partially enclosed workplaces. This survey was conducted to assess the knowledge and attitude of workers in indoor bars, beer parlors and discotheques to smoke-free legislation in general and the Osun State smoke-free law in particular.

METHODS

A convenience sampling of 36 hospitality centers was conducted. Interviewer-administered questionnaires were used to elicit responses about the objectives from non-smoking workers. The questionnaires had sections on knowledge of the Osun State smoke-free law, attitude toward the law and smoke-free legislation in general and exposure to second-hand tobacco smoke by the workers. Questions were also asked about the second-hand tobacco smoking status of these workers. The data were analyzed using SPSS version 15.0.

RESULTS

We had 154 participants recruited into the study. There were 75 males (48.0%) and 79 females (52.0%). On the overall, respondents had a good knowledge of the effects of second-hand smoke on health (70.2%) with 75.0% of them being aware of the general smoke-free law and 67.3% being aware of the Osun State smoke-free law although none of them had ever seen a copy of the law. A high proportion (60.0%) was in support of the Osun smoke-free law although all of them think that the implementation of the law could reduce patronage and jeopardize their income. Attitude toward second-hand smoking was generally positive with 72.0% of them having no tolerance for second-hand tobacco smoke in their homes. Most participants (95.5%) had been exposed to tobacco smoke in the workplace within the past week.

CONCLUSION

Despite the high level of awareness of the respondents about the dangers of second hand smoke and their positive attitude to smoke-free laws, nearly all were constantly being exposed to second hand smoke at work. This calls for policy level interventions to improve the implementation of the smoke-free law.

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 support for smoke free policy and how it is influenced by tolerance to smoking - experience of a developing country

This cross sectional survey was conducted to determine the support in making Penang UNESCO World Heritage Site (GTWHS) smoke free and to determine the influence of tolerance towards smoking on this support. This is the first phase in making Penang, Malaysia a smoke free state. A multistage sampling process was done to select a sample of respondents to represent the population of GTWHS. Attitude towards smoking was assessed using tolerance as a proxy. A total of 3,268 members of the community participated in the survey. A big majority (n = 2969; 90.9%) of the respondents supported the initiative. Support was lowest among the owners and residents/tenants, higher age groups, the Chinese, men, respondents who had poor knowledge of the places gazetted as smoke free, and respondents with poor knowledge of the health effects on smokers and on passive smokers. The odds (both adjusted and unadjusted) of not supporting the initiative was high among those tolerant to smoking in public areas. Tolerance towards smoking was associated with 80.3% risk of non-support in the respondents who were tolerant to smoking and a 57.2% risk in the population. Health promotion and education concerning the harm of tobacco smoke in Malaysia, which has mainly targeted smokers, must change. Health education concerning the risks of second hand smoke must also be given to non-smokers and efforts should be made to denormalize smoking.

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.

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.

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.

Cardiovascular Events Following Smoke-Free Legislations: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Legislations banning smoking in indoor public places and workplaces are being implemented worldwide to protect the population from secondhand smoke exposure. Several studies have reported reductions in hospitalizations for acute coronary events following the enactment of smoke-free laws.

OBJECTIVE

We set out to conduct a systematic review and meta-analysis of epidemiologic studies examining how legislations that ban smoking in indoor public places impact the risk of acute coronary events.

METHODS

We searched MEDLINE, EMBASE, and relevant bibliographies including previous systematic reviews for studies that evaluated changes in acute coronary events, following implementation of smoke-free legislations. Studies were identified through December 2013. We pooled relative risk (RR) estimates for acute coronary events comparing post- vs. pre-legislation using inverse-variance weighted random-effects models.

RESULTS

Thirty-one studies providing estimates for 47 locations were included. The legislations were implemented between 1991 and 2010. Following the enactment of smoke-free legislations, there was a 12 % reduction in hospitalizations for acute coronary events (pooled RR: 0.88, 95 % CI: 0.85-0.90). Reductions were 14 % in locations that implemented comprehensive legislations compared to an 8 % reduction in locations that only had partial restrictions. In locations with reductions in smoking prevalence post-legislation above the mean (2.1 % reduction) there was a 14 % reduction in events compared to 10 % in locations below the mean. The RRs for acute coronary events associated with enacting smoke-free legislation were 0.87 vs. 0.89 in locations with smoking prevalence pre-legislation above and below the mean (23.1 %), and 0.87 vs. 0.89 in studies from the Americas vs. other regions.

CONCLUSION

The implementation of smoke-free legislations was related to reductions in acute coronary event hospitalizations in most populations evaluated. Benefits are greater in locations with comprehensive legislations and with greater reduction in smoking prevalence post-legislation. These cardiovascular benefits reinforce the urgent need to enact and enforce smoke-free legislations that protect all citizens around the world from exposure to tobacco smoke in public places.

Voluntary smoking bans at home and in the car and smoking cessation, obesity, and self-control

This study of female former and current smokers assessed the associations between voluntary smoking bans at home and in the car and smoking cessation, obesity, and self-control. Data from self-reported female smokers (N = 194) who were in a community-based random cohort at four points in time, from 1983 to 2009, were analyzed. These female participants (M age = 63.7 yr.) were given self-administered questionnaires. Analyses showed that complete smoking bans at home and in the car were positively associated with a greater likelihood of smoking cessation. Complete smoking bans at home and in the car were positively associated with greater self-control. Public health policies should focus on the positive health effects of smoking bans on smoking cessation and greater self-control.

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.

Public support for smoke-free air strategies among smokers and nonsmokers, New York City, 2010-2012

INTRODUCTION

From 2010 through 2012, the New York City Department of Health and Mental Hygiene engaged in multiple smoke-free-air activities in collaboration with community, institution, and government partners. These included implementing a law prohibiting smoking in all parks and beaches as well as working to increase compliance with existing Smoke-free Air Act provisions.

METHODS

We investigated trends in awareness of existing smoke-free rules publicized with new signage and public support for new smoke-free air strategies by using 3 waves of survey data from population-based samples of smoking and nonsmoking adults in New York City (2010-2012). Analyses adjusted for the influence of sociodemographic characteristics.

RESULTS

Among both smokers and nonsmokers, we observed increased awareness of smoke-free regulations in outdoor areas around hospital entrances and grounds and in lines in outdoor waiting areas for buses and taxis. Regardless of smoking status, women, racial/ethnic minorities, and adults aged 25 to 44 years were more likely than men, non-Hispanic whites, and adults aged 65 years or older to support smoke-free air strategies.

CONCLUSION

New signage was successful in increasing population-wide awareness of rules. Our analysis of the association between demographic characteristics and support for tobacco control over time provide important contextual information for community education efforts on secondhand smoke and smoke-free air strategies.

Prevalence of smoke-free car and home rules in Maine before and after passage of a smoke-free vehicle law, 2007-2010

INTRODUCTION

This is the first study to examine the prevalence of self-reported smoke-free rules for private cars and homes before and after the passage of a smoke-free vehicle law.

METHODS

Data were examined for 13,461 Maine adults aged 18 or older who participated in the Behavioral Risk Factor Surveillance System, a state-based telephone survey covering health topics. Self-reported smoke-free car and home rules, smoking behavior, and demographic variables of age, sex, education, income, and children in household were analyzed for prevalence before and after the state's smoke-free vehicle law was passed.

RESULTS

Prevalence of smoke-free car and home rules was significantly higher after Maine's smoke-free vehicle law was passed in the state (P = .004 for car rules and P = .009 for home rules). Variations in smoking rules differed by smoking and demographic variables. People with household incomes of less than $20,000 saw an increase of 14.3% in smoke-free car rules; overall, those with annual incomes of less than $20,000 and those with less than a high school education reported a lower prevalence of smoke-free car rules both before and after the law was passed than did people with higher incomes and higher education levels. The prevalence of smoke-free home rules after the law was implemented was higher among those with 4 or more years of college education than among those with lower levels of education (P = .02).

CONCLUSION

The prevalence of smoke-free car and home rules among Maine adults was significantly higher after the passage of a statewide smoke-free vehicle law. This apparent change in smoke-free rule prevalence may be indicative of changing social norms related to the unacceptability of secondhand smoke exposure.

Prevalence and determinants of SHS exposure in public and private areas after the 2010 smoke-free legislation in Greece

The objective of the present survey was to assess the extent and socio-economic determinants of population exposure to secondhand smoke (SHS) in Greece in 2011. The national household survey Hellas Health IV was conducted in October 2011. SHS exposure was based on self-reported exposure within home, workplace and public places. Thirty-three per cent of the respondents reported living in a smoke-free home. Smokers (p < 0.001) and single individuals (p < 0.017) were less likely to prohibit smoking at home. SHS exposure at work, in restaurants and in bars/clubs/cafes was frequently mentioned by 41.6, 84.2 and 90.5%, respectively. SHS exposure in a bar/club/cafe was noted more among single individuals (p = 0.004) and those aged 18-34 years (p = 0.007). Inhabitants of rural areas were more likely to report someone smoking indoors in all the above venues. Public health education and effective enforcement of the nationwide smoke-free legislation are imperative.

Ashtrays and signage as determinants of a smoke-free legislation's success

Introduction

Successful smoke-free legislation is dependent on political will, enforcement and societal support. We report the success and pitfalls of a non-enforced nationwide smoke-free legislation in Greece, as well as ways in which compliance and enforcement-related factors, including ashtrays and signage, may impact indoor secondhand smoke (SHS) concentrations.

Methods

A follow-up study of venues (n = 150, at baseline, n = 75 at 2-year follow-up) in Greece assessed indoor particulate matter with a diameter less than 2.5 micrometers (PM_2.5) concentrations attributable to SHS smoke every six months for two years (n = 455 venue/measurements).

Results

Following the implementation of the 2010 smoke-free legislation, mean PM_2.5 concentrations attributable to SHS fell from 175.3 µg/m³ pre-ban to 84.52 µg/m³ immediately post-ban, increasing over subsequent waves (103.8 µg/m³ and 158.2 µg/m³ respectively). Controlling for potential influential factors such as ventilation, time of day, day of week, city and venue type, all post-ban measurements were still lower than during the pre-ban period (Wave 2 beta: −118.7, Wave 3 beta: −87.6, and Wave 4 beta: −69.9). Outdoor or indoor signage banning smoking was not found to affect SHS concentrations (beta: −10.9, p = 0.667 and beta: −18.1, p = 0.464 respectively). However, ashtray or ashtray equivalents were strong determinants of the existence of indoor SHS (beta: +67 µg/m³, p = 0.017).

Conclusions

While the public may be supportive of smoke-free legislation, adherence may decline rapidly if enforcement is limited or nonexistent. Moreover, enforcement agencies should also focus on the comprehensive removal of ashtray equivalents that could act as cues for smoking within a venue.

Smoke-Free Workplace Ballot Campaigns: Case Studies from Missouri and Lessons for Policy and Media Advocacy

Purpose.

To assess the key components of smoke-free campaigns that may have influenced voting outcomes in three communities.

Design.

Community case studies with content analysis of tobacco-related newspaper articles.

Setting.

Three semiurban Missouri communities.

Subjects.

One hundred eighty-one articles referencing tobacco published during the campaigns and five key informant interviews.

Measures.

Articles were coded for type, community referenced, tobacco control position, source of quotations, use of evidence, and frame. Semistructured interviews with key informants collected additional information.

Analysis.

Descriptive statistics were utilized to examine media coverage in each community. Key themes and events for each campaign were identified from qualitative interviews.

Results.

The only community that failed to pass its initiative had the highest proportion of letters to the editor (81.1%), anti–tobacco control articles (34.2%), use of a rights frame (28.8%), no evidence used (36.9%), no neighboring communities with policies, strong Tea Party presence, and no support from the chamber of commerce. Across all communities, more articles incorporating health frames were pro–tobacco control (70.7%) and more articles with a rights frame were anti–tobacco control (62.0%), compared to other positions.

Conclusion.

Several factors can influence the policy process. Tobacco control policy advocates facing strong opposition should consider the many factors (demographics, proximity to other adopting localities, politics) driving the debate and use media as an avenue to influence the discussion, connect with the public and policymakers, and mobilize proponents.

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.

Do health policy advisors know what the public wants? An empirical comparison of how health policy advisors assess public preferences regarding smoke-free air, and what the public actually prefers

BACKGROUND

Health policy-making, a complex, multi-factorial process, requires balancing conflicting values. A salient issue is public support for policies; however, one reason for limited impact of public opinion may be misperceptions of policy makers regarding public opinion. For example, empirical research is scarce on perceptions of policy makers regarding public opinion on smoke-free public spaces.

METHODS

Public desire for smoke-free air was compared with health policy advisor (HPA) perception of these desires. Two representative studies were conducted: one with the public (N = 505), and the other with a representative sample of members of Israel's health-targeting initiative, Healthy Israel 2020 (N = 34), in December 2010. Corresponding questions regarding desire for smoke-free areas were asked. Possible smoke-free areas included: 100% smoke-free bars and pubs; entrances to health facilities; railway platforms; cars with children; college campuses; outdoor areas (e.g., pools and beaches); and common areas of multi-dweller apartment buildings. A 1-7 Likert scale was used for each measure, and responses were averaged into a single primary outcome, DESIRE. Our primary endpoint was the comparison between public preferences and HPA assessment of those preferences. In a secondary analysis, we compared personal preferences of the public with personal preferences of the HPAs for smoke-free air.

RESULTS

HPAs underestimated public desire for smoke-free air (Public: Mean: 5.06, 95% CI:[4.94, 5.17]; HPA: Mean: 4.06, 95% CI:[3.61, 4.52]: p < .0001). Differences at the p = .05 level were found between HPA assessment and public preference for the following areas: 100% smoke-free bars and pubs; entrances to healthcare facilities; train platforms; cars carrying children; and common areas of multi-dweller apartment buildings. In our secondary comparison, HPAs more strongly preferred smoke-free areas than did the public (p < .0001).

CONCLUSIONS

Health policy advisors underestimate public desire for smoke-free air. Better grasp of public opinion by policy makers may lead to stronger legislation. Monitoring policy-maker assessment of public opinion may shed light on incongruities between policy making and public opinion. Further, awareness of policy-maker misperceptions may encourage policy-makers to demand more accurate information before making policy.