Systematic review and meta-analysis of the economic impact of smoking bans in restaurants and bars

Smoke-free legislation impact on the hospitality sector in the Republic of Georgia

INTRODUCTION

Comprehensive smoke-free (SF) policies reduce secondhand smoke exposure and improve population-level health outcomes. However, some decision-makers heed the tobacco industry's argument that SF policies negatively impact the hospitality sector. This study examines the intermediate economic impact of the Republic of Georgia's SF legislation (effective since early 2018) on the hospitality sector in Georgia.

METHODS

Analyses used 2015-2019 hospitality sector data from Georgia's National Statistics Office. Simple linear regression models were conducted to examine the impact of Georgia's SF policy on economic indicators (ie, number of employees, food service facilities, hotels and international visitor trips; employee remuneration; production value; turnover; hospitality sector value added tax (VAT)).

RESULTS

Analyses indicated no negative impact on any of the economic indicators. Instead, from 2018 to 2019, the number of food service facilities, hotels and international visitor trips increased by 20%, 17% and 7%, respectively. Additionally, there were increases in the number of employees (9%), average employee remuneration (3%), production values (13%), turnover/total revenue (13%) and VAT (26%). Moreover, the economic indicator values during the studied period were strongly correlated with each other (p>0.95) and indicated a consistent and uniform improvement.

CONCLUSIONS

After the SF legislation went into effect, the hospitality sector demonstrated significant growth and no adverse effects in the economic indicators studied. The findings underscore the importance of maintaining and enforcing SF policies in Georgia and expanding the evidence base for SF policies globally.

Impacts of Smoking Ban Policies on Billiard Hall Sales in South Korea Using Objective Sales Information of a Credit Card Company: Quasi-Experimental Study

BACKGROUND

Smoking ban policies (SBPs) are potent health interventions and offer the potential to influence antismoking behavior. The Korean government completely prohibited smoking in indoor sports facilities, including billiard halls, since the government revised the National Health Promotion Act in December 2017.

OBJECTIVE

This study aimed to examine the impact of the SBP on the economic outcomes of indoor sports facilities, particularly billiard halls.

METHODS

This study used credit card sales data from the largest card company in South Korea. Data are from January 2017 to December 2018. Monthly sales data were examined across 23 administrative neighborhoods in Seoul, the capital city of South Korea. We conducted the interrupted time series model using the fixed effects model and the linear regression with panel-corrected standard errors (PCSE).

RESULTS

The sales and transactions of billiard halls were not significantly changed after the introduction of the SBP in the full PCSE models. The R2 of the full PCSE model was 0.967 for sales and 0.981 for transactions.

CONCLUSIONS

The introduction of the SBP did not result in substantial economic gains or losses in the sales of billiard halls. In addition to existing price-based policies, the enhanced SBP in public-use facilities, such as billiard halls, can have a positive synergistic effect on reducing smoking prevalence and preventing secondhand smoke. Health policy makers can actively expand the application of SBPs and make an effort to enhance social awareness regarding the necessity and benefits of public SBPs for both smokers and the owners of hospitality facilities.

Understanding the dynamics of compliance to smoke-free policy regulations: Exploring the perspectives of venue owners and staff in Türkiye

INTRODUCTION

The study aims to understand the facilitators and barriers associated with enforcing and complying with Türkiye's smoke-free policy from the perspective of hospitality venue owners and employees.

METHODS

A qualitative open-ended survey was conducted in Istanbul and Ankara in 2021 with 58 respondents from 3 different districts in each city from four types of venues: restaurants, traditional coffee and waterpipe houses, and European-style cafés. The open-ended survey included questions to understand the knowledge, beliefs, and attitudes of respondents about Türkiye's smoke-free policy and their perceptions of the facilitators and/or barriers to smoke-free policy implementation and changes after COVID-19. The data were analyzed using an inductive approach to identify patterns and categorize the data into themes.

RESULTS

The respondents expressed that the smoke-free policy aimed to protect employees and customers from secondhand smoke (SHS), respect human health, and improve air quality. Findings suggest that the positive attitude of venue owners and staff toward the smoke-free policy serves as a facilitator. However, fear of financial impact, customers' negative attitudes, difficulties in meeting physical requirements, and insufficient enforcement were found to be barriers to implementing the smoke-free policy. The effects of the COVID-19 pandemic were reported as an initial increase in compliance and awareness among customers and staff, but some respondents noted negative changes due to the emotional and financial effects of prolonged restrictions. These challenges have led to decreased attention on the smoke-free policy among venue owners, staff and customers. Respondents' suggested improvements were related to building infrastructure, such as the ventilation systems and educating the public on the harmful health effects of smoking.

CONCLUSIONS

Despite the general understanding of the dangers of secondhand smoke and the smoke-free policy, this study highlights the challenges in implementing smoke-free policy measures and the continued need to raise awareness about the importance of a 100% smoke-free venue. A comprehensive approach to addressing the tobacco epidemic as a multifaceted public health issue is essential.

Rates of Severe Influenza-Associated Outcomes Among Older Adults Living With Diabetes-Influenza Hospitalization Surveillance Network (FluSurv-NET), 2012-2017

BACKGROUND

Diabetes mellitus (DM) is common among older adults hospitalized with influenza, yet data are limited on the impact of DM on risk of severe influenza-associated outcomes.

METHODS

We included adults aged ≥65 years hospitalized with influenza during 2012-2013 through 2016-2017 from the Influenza Hospitalization Surveillance Network (FluSurv-NET), a population-based surveillance system for laboratory-confirmed influenza-associated hospitalizations conducted in defined counties within 13 states. We calculated population denominators using the Centers for Medicare and Medicaid Services county-specific DM prevalence estimates and National Center for Health Statistics population data. We present pooled rates and rate ratios (RRs) of intensive care unit (ICU) admission, pneumonia diagnosis, mechanical ventilation, and in-hospital death for persons with and without DM. We estimated RRs and 95% confidence intervals (CIs) using meta-analysis with site as a random effect in order to control for site differences in the estimates.

RESULTS

Of 31 934 hospitalized adults included in the analysis, 34% had DM. Compared to those without DM, adults with DM had higher rates of influenza-associated hospitalization (RR, 1.57 [95% CI, 1.43-1.72]), ICU admission (RR, 1.84 [95% CI, 1.67-2.04]), pneumonia (RR, 1.57 [95% CI, 1.42-1.73]), mechanical ventilation (RR, 1.95 [95% CI, 1.74-2.20]), and in-hospital death (RR, 1.48 [95% CI, 1.23-1.80]).

CONCLUSIONS

Older adults with DM have higher rates of severe influenza-associated outcomes compared to those without DM. These findings reinforce the importance of preventing influenza virus infections through annual vaccination, and early treatment of influenza illness with antivirals in older adults with DM.

Support for smoke-free public places among adults in four countries in sub-Saharan Africa

INTRODUCTION

There is no known safe level of secondhand smoke exposure; yet, less than 30% of the global population is covered by comprehensive smoke-free policies as of 2016 and there are few smoke-free policies in sub-Saharan Africa (SSA). This study examines the support for smoke-free public places in SSA and delineates their correlates.

METHODS

Data collected through the Global Adult Tobacco Survey (2012-2017) were analyzed using SAS for descriptive and multivariable analyses, with a significance level set at p < .05.

RESULTS

No SSA country had comprehensive smoke-free policies, defined as a prohibition of smoking in eight public places. In the four countries whose Global Adult Tobacco Survey data were analyzed (Nigeria, Cameroon, Kenya, and Uganda), support for the prohibition of smoking in public places was over 90% in all eight public places except bars. Support for smoking prohibition in bars was 65.8%, 81.1%, 81.4%, and 91.0% in Nigeria, Cameroon, Kenya, and Uganda, respectively. Factors associated with support for smoke-free bars differed across the four countries, but in all countries, current smokers had decreased odds of support for smoke-free bars. Knowledge of secondhand smoke harm and living in smoke-free homes were associated with increased odds of support for smoke-free bars in all countries except Kenya.

CONCLUSION

The high support for smoke-free public places should inform the efforts of the public health community and policymakers in these four SSA countries toward meeting their obligations of Article 8 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

IMPLICATIONS

Much of the population in SSA is not protected by comprehensive smoke-free policies. It was found that the overwhelming majority of adults in four large countries in SSA support the prohibition of smoking in public places and that knowledge of the health dangers of smoking and exposure to secondhand smoke and home smoking rules increased support for the prohibition. High support for the prohibition of smoking in these four SSA countries suggests tobacco control proponents should advocate for comprehensive smoke-free policies.

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research

INTRODUCTION

The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated.

METHOD

A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018.

RESULTS

The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes.

CONCLUSION

This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry.

IMPLICATIONS

This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Impacts of Smoking Ban Policies on Restaurants in Seoul, South Korea: Analysis of Objective Sales Information

BACKGROUND

From July 2013 to January 2015, the smoking ban instituted in restaurants in South Korea gradually expanded to cover all restaurants and bars, moving by size of restaurant (≤99 m2, 100-149 m2, ≥150 m2). This study measured the impacts of the smoking ban for restaurants.

METHODS

This study examined credit, check, or debit card sales data for every September and October from 2012 to 2015 in 711 census tracts in Seoul, South Korea. We accounted for total restaurant sales in each census tract. Our model controlled for the sales amounts for each census tract, type of restaurant, monthly business survey index, number of restaurants, daily average temperature, daily precipitation, and day of the week, and a dummy for census tract.

RESULTS

These were some positive associations with increase in total sales. However, the significance of the coefficients was not consistent over this period. Overall, our results showed no significant negative effects of smoking ban policy on restaurants.

CONCLUSIONS

Smoking ban policies produced benefits in terms of health outcomes, without causing significant negative impacts on sales.

IMPLICATIONS

Although the owners of restaurants anticipated negative impacts on sales from smoking ban policies, the results of this study suggest that restaurants experienced no negative economic impacts on sales from policies with health benefits, which suggest that it would be reasonable to promote and keep on the smoking ban. Also, it is important to apply smoking ban policy to all targets without exclusion.

Evaluation of the Effectiveness of Comprehensive Smoke-Free Legislation in Indoor Public Places in Shanghai, China

This study evaluated compliance with the comprehensive smoke-free law in public indoor places introduced in Shanghai in March 2017. Observations and PM2.5 monitoring over 30 min intervals in 8 types of the venue were conducted three times: within a month before implementation and 3- and 12-months post implementation. Observations of evidence of smoking decreased from 66.2% before legislation to 52.8% three months after (p = 0.002) and 49.7% one year after (p < 0.001). The density of lit cigarettes also reduced significantly after implementation (p < 0.001). When adjusting for outdoor, indoor PM2.5 levels were significantly lower after the legislation, but only by a small amount (three months later: −0.27, p = 0.08; one year later: −0.12; p = 0.03). Evidence of compliance was weakest in farmer’s markets and bars, and smoking in male toilets did not change significantly. The reduction in smoking was affected by the management performance of their obligations. The comprehensive smoke-free law led to modest reductions in smoking and PM2.5 levels as a result, but from levels suggesting quite high levels of pre-compliance. However, compliance was limited in some areas, suggesting more effort is required on management to gain better compliance in some places like farmer’s markets, bars, and toilets.

The effect of the United Kingdom smoking ban on alcohol spending: Evidence from the Living Costs and Food Survey

The effect of smoking bans on alcohol consumption is unclear, and this is especially true of the differing effect on smokers and non-smokers. This paper uses spending survey data to examine the effect of the United Kingdom smoking bans on alcohol spending. It finds the introduction of a smoking ban decreased alcohol expenditure, specifically in the on-trade (pubs and restaurants) and amongst smoking households. Smoking households are estimated to have reduced their weekly on-premise alcohol expenditure by £1.70 (approximately 15-20%), whilst non-smoking households do not significantly change their expenditure. The smoking ban may therefore have affected on-premise outlets through a reduction in revenue. This study provides further evidence that tobacco policies affect drinking behaviour.

Impact of US Smoke-free Air Laws on Restaurant and Bar Employment, 1990-2015

INTRODUCTION

Secondhand smoke exposure is responsible for an estimated 50000 deaths per year among nonsmokers in the United States. Smoke-free air laws reduce secondhand smoke exposure but often encounter opposition over concerns about their economic impact. Expansion of these laws has stagnated and efforts to weaken existing laws may exacerbate existing disparities in exposure. Studies at the state and local levels have found that smoke-free air laws do not generally have an adverse effect, but there are no recent estimates of the impact of these laws nationally.

METHODS

Employment and sales are two measures commonly used to estimate the economic impact of smoke-free air laws. Sales data are gathered by state and local taxing authorities but not uniformly across jurisdictions. Dynamic panel models are used to estimate a population-weighted national average treatment effect of smoke-free air laws on restaurant and bar employment using data from the Quarterly Census of Employment and Wages for 1990 to 2015.

RESULTS

A one-percentage point increase in population covered by a restaurant smoke-free air law is associated with a small increase (approximately 0.01%) in restaurant employment (b = .0001, p < .001). The percentage of state population covered by a bar smoke-free air law was not associated with bar employment.

DISCUSSION

Smoke-free air laws are a powerful tool for protecting hospitality workers and patrons from the dangers of secondhand smoke. Using data from over more than two decades, these results suggest that smoke-free air laws in the United States do not generally have any meaningful effect on restaurant and bar employment.

IMPLICATIONS

Smoke-free air laws are associated with reductions in negative health outcomes and decreased smoking prevalence. Despite this clear public health argument and strong public support, passage of new laws has stagnated and exemptions are being used to weaken existing laws. The ability to make both a health and business case in support of existing laws may also bolster the case for expansion. This study provides an updated look at the economic impact of smoke-free air laws nationally through 2015. The lack of adverse findings provides additional support for these laws as public health win-win.

Impact of the Spanish smoke-free laws on cigarette sales, 2000-2015: partial bans on smoking in public places failed and only a total tobacco ban worked

In January 2006, the Spanish government enacted a tobacco control law that banned smoking in bars and restaurants, with exceptions depending on the floor space of the premises. In January 2011, further legislation in this area was adopted, removing these exceptions. We analyse the effect produced on cigarette sales by these two bans. We approach this problem using an interrupted time series analysis while accounting for the potential effects of autocorrelation and seasonality. The data source used was the official data on legal sales of tobacco in Spain, from January 2000 to December 2015 (excluding the Canary Islands and the autonomous cities of Ceuta and Melilla). As confounder variables, we use the log-transformed average prices for manufactured and hand-rolled cigarettes (or the average minimum excise tax as a proxy), and log-transformed real-household disposable income. The implementation of a total smoke-free ban in Spain was associated with an immediate reduction in cigarette sales between 9% to 11%. In contrast, in the period immediately following the partial ban, no such reduction was detected, beyond the trend already present. Our results indicate that, in Spain, partial bans on smoking in public places failed, and that only a total tobacco ban worked.

Impact of US smoke-free air laws on restaurants and bars by employer size: a panel study

OBJECTIVES

Thirty states have smoke-free air laws that ban smoking in restaurants and bars, covering nearly two-thirds of the US population. It is well established that these laws generally have a null or positive economic impact on restaurants and bars. However, all establishments in a geographic area are usually treated as a homogeneous group without considering the potential for differential effects by establishment characteristics. This study uses variation in smoke-free air laws over time to estimate their impact on employment in restaurants and bars with a focus on potential differences by employer size (number of employees). A two-pronged approach with a national-level and state-level analysis is used to take advantage of more granular data availability for a single state (North Carolina).

DESIGN

Observational study using panel data.

SETTING

1) US, 2) North Carolina INTERVENTIONS: Smoke-free air laws.

OUTCOME MEASURES

State-level accommodation and food services employment for all 50 states and District of Columbia from 1990 through 2014 (Quarterly Census of Employment and Wages); county-level restaurant and bar employment in North Carolina from 2001 through 2014 (North Carolina Department of Commerce).

RESULTS

There is no evidence of a redistributive effect of smoke-free air laws on restaurant and bar employment by employer size.

CONCLUSION

The lack of a redistributive effect is an important finding for policy-makers considering implementation or expansion of a smoke-free air law to protect employees and patrons from the dangers of exposure to secondhand smoke.

Social Inequalities in Secondhand Smoke Among Japanese Non-smokers: A Cross-Sectional Study

BACKGROUND

Secondhand smoke (SHS) causes many deaths. Inequalities in SHS have been reported in several countries; however, the evidence in Asian countries is scarce. We aimed to investigate the association between socioeconomic status (SES) and SHS at home and the workplace/school among non-smoking Japanese adults.

METHODS

Cross-sectional data from the Miyagi Prefectural Health Survey 2014 were analyzed. Self-reported questionnaires were randomly distributed to residents ≥20 years of age and 2,443 (92.8%) responded. The data of the 1,738 and 1,003 respondents were included to the analyses for SHS in the past month at home and at the workplace/school, respectively. Ordered logistic regression models considering possible confounders, including knowledge of the adverse health effects of tobacco, were applied.

RESULTS

The prevalence of SHS at home and the workplace/school was 19.0% and 39.0%, respectively. Compared with ≥13 years of education, odds ratios (ORs) and 95% confidence intervals (CIs) for SHS at home were 1.94 (95% CI, 1.42-2.64) for 10-12 years and 3.00 (95% CI, 1.95-4.60) for ≤9 years; those for SHS at the workplace/school were 1.80 (95% CI, 1.36-2.39) and 3.82 (95% CI, 2.29-6.36), respectively. Knowledge of the adverse health effects of tobacco was significantly associated with lower SHS at home (OR 0.95; 95% CI, 0.91-0.98) but it was not associated with SHS at the workplace/school (OR 1.02; 95% CI, 0.98-1.06).

CONCLUSIONS

Social inequalities in SHS existed among Japanese non-smoking adults. Knowledge about tobacco was negatively associated with SHS at home but not at workplace/school.

The Economic Impact of Smoke-Free Policies on Restaurants, Cafés, and Bars: Panel Data Estimates From European Countries

In this paper, we investigate the extent to which the economic outcomes of restaurants, bars, and cafés have been affected by the introduction of anti-smoking regulations in Europe. We use an unexploited panel database to collect a comprehensive set of information on financial indicators regarding the balance sheets of private and public companies in various economic sectors. The results show that smoke-free policies did not significantly affect the firms' economic performance, irrespective of the balance sheet indicators analyzed. Moreover, the results are robust to various econometric specifications and suggest that the recent enforcement of anti-smoking legislation in Europe has improved public health without a corresponding negative impact on revenues and employment in the hospitality industry.

Economic Impact of Smoke-Free Air Laws in North Dakota on Restaurants and Bars

INTRODUCTION

In late 2012, North Dakota expanded its statewide smoke-free air law to cover all restaurants and bars in the state. Several North Dakota communities also had local ordinances that prohibited smoking in restaurants and bars prior to the statewide law. Previous work found no effect of the initial statewide law or several local laws on restaurant and bar sales.

METHODS

Using quarterly county-level employment data from 1990 to 2014, we examined whether the expanded statewide law or pre-existing local laws were associated with significant changes in employment in restaurants and bars in North Dakota. Separate models were estimated for restaurant and bar employment using two methods of controlling for smoke-free air law coverage.

RESULTS

We found no evidence of a significant association between employment in restaurants and bars in North Dakota and the expanded statewide law or pre-existing local laws. Prior employment levels in restaurants and bars and prevailing economic conditions were the main drivers of restaurant and bar employment, not smoke-free air laws.

CONCLUSIONS

This study examines the economic impact of smoke-free air laws in North Dakota on restaurant and bar employment following the expansion of the statewide law in late 2012 to cover all restaurants and bars. We find no significant adverse effect of smoke-free air laws on restaurants and bars, consistent with results from previous studies conducted in North Dakota and throughout the United States.

IMPLICATIONS

This study is the first to analyze the economic impact of smoke-free air laws in North Dakota on restaurant and bar employment following the 2012 expansion of the statewide law to cover all restaurants and bars. We find no evidence of a significant adverse effect of smoke-free air laws on restaurants and bars, consistent with results from previous studies conducted in North Dakota and throughout the United States. Prior employment levels and prevailing economic conditions proved to be the main drivers of restaurant and bar employment, not smoke-free air laws.

The impact of commonly used air filters in eliminating the exposure to secondhand smoke constituents

Exposure to secondhand tobacco smoke (SHS) also known as environmental tobacco smoke (ETS) has been well established scientifically as a human health hazard. Despite this and warnings from health agencies, concerns over the economic impact of smoke-free bans have limited political resolve to enact these regulations. Arguments against smoke-free bans include the contention that air filters can eliminate the health risks from SHS exposure. In this study, we assessed the effectiveness of air filters (MERV 4 and MERV 8) commonly used in homes and businesses in reducing the concentrations of total suspended particulates, fine particles and carbon monoxide from SHS as a measure of their potential to reduce the toxicity associated with SHS exposure. Our results demonstrate that these filters are not effective at reducing carbon monoxide levels or PM 2.5, which have been correlated with human health toxicity/disease. Thus, our findings, from a public health perspective, do not support the use of common air filters as a viable alternative to smoke-free bans.