Making hospitals in China smoke-free: a prospective study of implementing the new standard

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Smokers' responses to being addressed when smoking in an outdoor voluntary smoke-free zone: An observational study

INTRODUCTION

Addressing smokers who smoke in a voluntary smoke-free area is vital to its successful implementation. Many people perceive barriers in addressing smokers due to fear of negative responses. Insights in actual responses are currently lacking.

METHODS

This is an observational field study at the voluntary smoke-free zone surrounding the Erasmus MC and two schools in Rotterdam, the Netherlands. In the first month after implementing the zone, Erasmus MC representatives performed rounds to address smokers who were smoking inside the zone. Four people observed addressors for two weeks then they also addressed the smokers. Smokers were classified as employees, patients, students, or other. We noted whether smokers were addressed directly or indirectly, and their verbal and behavioral responses to being addressed. Differences between the responses of the groups were assessed using chi-squared tests.

RESULTS

In all, 331 smokers were observed of whom 73% were addressed directly. Most verbal reactions were positive (46%) or neutral (18%). Employees were more likely to respond guiltily, whereas patients more often responded angrily than the others. After being addressed, the majority of smokers either extinguished their cigarette (41%) or left to continue smoking outside the smoke-free zone (34%).

CONCLUSIONS

Most smokers showed a positive or neutral response when being addressed about smoking inside the smoke-free zone and the majority adapted their behavior to comply with the policy. These findings may help decrease barriers for those in doubt about addressing smokers that fail to comply with a smoke-free policy.

Impact of a Comprehensive Anti-Smoking Program at a Regional University Hospital and Predictive Variables of Being a Smoker among Hospital Workers

The objective of this study was to evaluate the impact of a comprehensive anti-smoking health program conducted over twelve years at a regional university hospital in southern Spain. Prevalence of tobacco was compared retrospectively using data collected during occupational health assessments (n = 4291). Bivariate and logistic regression analyses were carried out to evaluate tobacco consumption differences according to age, sex, professional category, and workplace building. The results show a reduction in the active smoking rate among hospital staff evaluated (from 22.8% to 19.8%) with significant differences between non-health and health workers. Accumulated smoking consumption fell to 13.45 ± 14.60 packs/year with men presenting a higher consumption (p < 0.001). The predictive variables of tobacco use were sex (greater consumption among men, p = 0.021), number of cigarettes (greater consumption among professionals who smoked less than 1 pack/day, p < 0.001), and time smoking (greater use among professionals with more than 10 years smoking, p < 0.001). There was a higher rate of staff smokers at the hospital building with a majority of mental health inpatients. This study provides a practical example of making the optimum use of digital medical records in the evaluation of a comprehensive anti-smoking health program.

Implementing lung health interventions in low- and middle-income countries: a FRESH AIR systematic review and meta-synthesis

The vast majority of patients with chronic respiratory disease live in low- and middle-income countries (LMICs). Paradoxically, relevant interventions often fail to be effective particularly in these settings, as LMICs lack solid evidence on how to implement interventions successfully. Therefore, we aimed to identify factors critical to the implementation of lung health interventions in LMICs, and weigh their level of evidence.

This systematic review followed Cochrane methodology and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting standards. We searched eight databases without date or language restrictions in July 2019, and included all relevant original, peer-reviewed articles. Two researchers independently selected articles, critically appraised them (using Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT)), extracted data, coded factors (following the Consolidated Framework for Implementation Research (CFIR)), and assigned levels of confidence in the factors (via Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)). We meta-synthesised levels of evidence of the factors based on their frequency and the assigned level of confidence (PROSPERO:CRD42018088687).

We included 37 articles out of 9111 screened. Studies were performed across the globe in a broad range of settings. Factors identified with a high level of evidence were: 1) “Understanding needs of local users”; 2) ensuring “Compatibility” of interventions with local contexts (cultures, infrastructures); 3) identifying influential stakeholders and applying “Engagement” strategies; 4) ensuring adequate “Access to knowledge and information”; and 5) addressing “Resource availability”. All implementation factors and their level of evidence were synthesised in an implementation tool.

To conclude, this study identified implementation factors for lung health interventions in LMICs, weighed their level of evidence, and integrated the results into an implementation tool for practice. Policymakers, non-governmental organisations, practitioners, and researchers may use this FRESH AIR (Free Respiratory Evaluation and Smoke-exposure reduction by primary Health cAre Integrated gRoups) Implementation tool to develop evidence-based implementation strategies for related interventions. This could increase interventions’ implementation success, thereby optimising the use of already-scarce resources and improving health outcomes.

This systematic review and meta-synthesis shows why implementation of lung health interventions often fails in low- and middle-income countries, and it provides critical factors to prevent failure with their level of evidencehttps://bit.ly/2UYJOSa

Smoking cessation interventions on health-care workers: a systematic review and meta-analysis

Objective

The authors carried out a systematic review and a meta-analysis on smoking cessation interventions on health -care workers to clarify the state of the art interventions and to identify the best one.

Materials and Methods

This review was registered with PROSPERO: CRD42019130117. The databases PubMed, Scopus, Web of Science and CINAHL were searched until December 2018. Quality of all studies included in the systematic review was assessed according to the Newcastle-Ottawa Scale (NOS) on cohort or cross-sectional studies and to the Cochrane Risk of Bias Tool for Randomized Controlled Trials. Meta-analysis and meta-regression analyses were also carried out for cohort studies (quasi-experimental or a before-after studies design) and clinical trials.

Results

Twenty–four studies have been included in the analysis: four before-after, 13 cross-sectional, three quasi-experimental studies and four clinical trials. Articles were heterogeneous (P for homogeneity <0.01), but they have all shown positive results since they reached the goal of smoking cessation among health-care workers, even if with different proportions. Meta-analysis was performed on 10 studies (six cohort studies and four clinical trials), showing a 21% of success rate from the application of smoking cessation interventions, either pharmacological or behavioral ones. The resulted pooled RR (Risk Ratio) was 1.21 (95% CI [1.06–1.38]), being 24% of success rate from clinical trials (pooled RR 1.244; 95% CI [1.099–1.407]) and 19% of success rate from cohort studies (pooled RR 1.192; 0.996–1.426). However, two studies have confidence intervals which include unity and one study has a wide confidence interval; as a consequence, the meta-analysis for its results depends heavily on one single study. Meta-regression analysis revealed that results were influenced by the number of participants.

Conclusion

Both policy and pharmaceutical interventions can obtain positive results in quitting smoking among health-care workers. However, as shown by our review, combination approaches can produce better results in terms of cessation percentages and smoking abstinence.

Subnational smoke-free laws in China

INTRODUCTION

Implementing comprehensive smoke-free laws is an important part of tobacco control and has been promoted since China ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2005. This study shows the predictors of adopting subnational smoke-free laws and their alignment with Article 8 of WHO FCTC.

METHODS

The legislations of 125 cities from China’s top three city grades were assessed, covering the cities that have smoke-free laws. Logistic regression is applied to evaluate the characteristics of cities that adopted a smoke-free law. We also compare each smoke-free law with the WHO FCTC Article 8 requirements.

RESULTS

Provincial capital cities were more likely to adopt smoke-free laws compared with other cities. Smoke-free laws vary from comprehensive to partial bans with major exemptions. Among the 21 cities that have enacted smoke-free laws, 9 cities prohibited smoking in all indoor workplaces, indoor public places (restaurants, bars, health facilities, government buildings and schools) and public transportation. More than half of the smoke-free laws still allow designated indoor smoking rooms. Smoke-free laws that clearly ban e-cigarettes in smoke-free areas have been implemented in only two cities (Nanning and Hangzhou).

CONCLUSIONS

This study shows that a number of Chinese cities have taken legislative measures to protect people from exposure to tobacco smoke. It identifies signs of progress but also areas for improvement, such as the scope of smoke-free laws, imperfect implementation of such laws, and the potential omission of e-cigarettes from the legislation.

Tobacco and the lung cancer epidemic in China

China is in the midst of a lung cancer epidemic on an unprecedented scale. In 2015, there were an estimated 733,000 new lung cancer cases (17% of total cancer incidence) and 610,000 deaths (21.7% of total cancer mortality) in China. Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality in China. Tobacco smoke exposure is the primary factor driving current lung cancer trends. In 2015, smoking prevalence was 27.7% (52.1% among men and 2.7% among women). China has taken substantial steps to control tobacco use in recent years, including 19 cities implementing comprehensive smoke free laws and expansion of cessation services. However, significant challenges remain in order to meet the 2030 Healthy China goal of reducing smoking prevalence to 20%. In particular, ongoing attention is needed to continuing to control secondhand smoke exposure, to further enhance smoking cessation services, and to address novel alternative nicotine delivery devices (ANDS).

National survey of smoking cessation provision in China

INTRODUCTION

Treatment for smoking cessation is an important part of tobacco control and has been promoted within the Chinese health service for many years. The aim of this study was to assess the current status of smoking cessation treatment provision within the Chinese health service.

METHODS

A nationwide survey, sponsored by the National Health and Family Planning Commission, assessed smoking cessation activities in all 31 Provincial Health and Family Planning Commissions (PHFPCs) in China. Within the 31 provinces, 366 hospitals and primary care centers running smoking cessation clinics provided details of their activities.

RESULTS

Findings show that all PHFPCs took steps to promote smoking cessation, such as by conducting inspections and supervising local cessation clinics. Specifically, among the 366 health institutions,73% were based in general hospitals, with smoking cessation clinics predominantly located in respiratory departments. Furthermore, only 43% provided smoking cessation medications.

CONCLUSIONS

This was the first nationwide survey of smoking cessation support available to smokers in China. It provides the most comprehensive picture of the treatment arm of smoking cessation activities so far. The Chinese government has taken measures to support smoking cessation, however, further efforts are needed to address the imbalanced distribution of resources and the limited availability of medications. On-going monitoring of barriers and facilitators affecting treatment provision is needed, as well as an understanding of the importance of each hospital focusing on working priorities specific to their needs. This survey could be a reference for other countries starting to promote smoking cessation.

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.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

An international smoking ban-how many lives will be saved?

Multicomponent tobacco control strategies are crucial to combat the ongoing global smoking challenge. In the twenty-first century, many countries have signed up to the World Health Organization Framework Convention on Tobacco Control, and in recent years a mounting number of countries and regions have implemented partial or complete smoking bans to protect the general public from passive smoke exposure. There is substantial evidence that workers, particularly in the hospitality sector, benefit from reduced exposure. More recently, several reports have appeared from different countries showing a temporal relationship between the introduction of a smoking ban and reduced hospital admissions for cardiovascular, respiratory and maternity outcomes. This will have a measurable benefit for public health, saving many lives. Multicomponent strategies could also reduce active smoking significantly if successfully implemented worldwide.