Environmental tobacco smoke in homes, motor vehicles and licensed premises: community attitudes and practices

Smoking in apartment buildings - Spatiality, meanings and understandings

Increased higher density urban living may exacerbate exposure to environmental tobacco smoke. Using a social practices lens, this research explored the locations, experiences and governance of smoking in apartment buildings in Melbourne, Australia, through semi-structured interviews in high-rise buildings ranging from subsidised housing to luxury apartments. Tacit rules on acceptable locations, building rules and smoke alarms in public areas consigned smoking to balconies and building entrances. The perceived health threat from second hand smoke and mental stress due to invasion of olfactory and visual privacy undermined the full enjoyment of the home environment. Interventions may benefit from targeting the link between smoking and balconies.

An analysis of global youth tobacco survey for developing a comprehensive national smoking policy in Timor-Leste

BACKGROUND

Smoking is a global public health concern. Timor-Leste is facing a rapidly growing epidemic of tobacco use. The trend of smoking in Timor-Leste seems to be increasing and the magnitude of the problem affects people who smoke before reaching adulthood. One of the factors implicated in the continuously rising trend of smoking among young people in Timor-Leste is clearly due to unavailability of restrictive laws and regulations. Therefore, our study sought to analyze available dataset from the Global Youth Tobacco Survey (GYTS) for developing a comprehensive national smoking policy in order to lower smoking risks among young people in Timor-Leste.

METHODS

We conducted a secondary analysis of the 2009 GYTS in Timor-Leste. The 2009 GYTS assessed 1657 in-school students aged 13-15 years for current smoking prevalence and determinants of tobacco use. We used IBM SPSS version 21 software to analyze the data. Frequency analyses were computed to identify demographic characteristics of study participants. Bivariate logistic regression analysis was performed to examine the association between each demographic characteristic as well as each independent variable and the outcome of being current smokers.

RESULTS

Out of 1657 in-school students, 51 % were of ages less than 15; 53 % were girls; and 45 % were in grade 2. Prevalence of current cigarette smoking was found to be 51 %. The prevalence of current smoking among in-school students increased with ages (from 46 % in less than 15 to 57 % in 15 plus). Boys were more likely to be smokers than girls (59 % versus 28 %). Significant factors positively associated with current smoking included parental smoking; closed-peer smoking; number of days people smoked in the house; having family discussion about harmful effects of smoking; being smoking in areas such as school, public places and home; and having seen cigarette advertisements on billboard.

CONCLUSION

Timor-Leste has higher prevalence of cigarette smoking among minors, especially among boys. Our analysis provides evidence-based information for developing comprehensive tobacco control programs - both education and policy interventions to reduce smoking rate among young people in Timor-Leste.

Plain packaging: a logical progression for tobacco control in one of the world's 'darkest markets'

The Australian approach to tobacco control has been a comprehensive one, encompassing mass media campaigns, consumer information, taxation policy, access for smokers to smoking cessation advice and pharmaceutical treatments, protection from exposure to tobacco smoke and regulation of promotion. World-first legislation to standardise the packaging of tobacco was a logical next step to further reduce misleadingly reassuring promotion of a product known for the past 50 years to kill a high proportion of its long-term users. Similarly, refreshed, larger pack warnings which started appearing on packs at the end of 2012 were a logical progression of efforts to ensure that consumers are better informed about the health risks associated with smoking. Regardless of the immediate effects of legislation, further progress will continue to require a comprehensive approach to maintain momentum and ensure that government efforts on one front are not undermined by more vigorous efforts and greater investment by tobacco companies elsewhere.

Attitudes towards smoking restrictions and tobacco advertisement bans in Georgia

OBJECTIVES

This study aims to provide data on a public level of support for restricting smoking in public places and banning tobacco advertisements.

DESIGN

A nationally representative multistage sampling design, with sampling strata defined by region (sampling quotas proportional to size) and substrata defined by urban/rural and mountainous/lowland settlement, within which census enumeration districts were randomly sampled, within which households were randomly sampled, within which a randomly selected respondent was interviewed.

SETTING

The country of Georgia, population 4.7 million, located in the Caucasus region of Eurasia.

PARTICIPANTS

One household member aged between 13 and 70 was selected as interviewee. In households with more than one age-eligible person, selection was carried out at random. Of 1588 persons selected, 14 refused to participate and interviews were conducted with 915 women and 659 men.

OUTCOME MEASURES

Respondents were interviewed about their level of agreement with eight possible smoking restrictions/bans, used to calculate a single dichotomous (agree/do not agree) opinion indicator. The level of agreement with restrictions was analysed in bivariate and multivariate analyses by age, gender, education, income and tobacco use status.

RESULTS

Overall, 84.9% of respondents indicated support for smoking restrictions and tobacco advertisement bans. In all demographic segments, including tobacco users, the majority of respondents indicated agreement with restrictions, ranging from a low of 51% in the 13-25 age group to a high of 98% in the 56-70 age group. Logistic regression with all demographic variables entered showed that agreement with restrictions was higher with age, and was significantly higher among never smokers as compared to daily smokers.

CONCLUSIONS

Georgian public opinion is normatively supportive of more stringent tobacco-control measures in the form of smoking restrictions and tobacco advertisement bans.

Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis

BACKGROUND

Governments can intervene to change health-related behaviours using various measures but are sensitive to public attitudes towards such interventions. This review describes public attitudes towards a range of policy interventions aimed at changing tobacco and alcohol use, diet, and physical activity, and the extent to which these attitudes vary with characteristics of (a) the targeted behaviour (b) the intervention and (c) the respondents.

METHODS

We searched electronic databases and conducted a narrative synthesis of empirical studies that reported public attitudes in Europe, North America, Australia and New Zealand towards interventions relating to tobacco, alcohol, diet and physical activity. Two hundred studies met the inclusion criteria.

RESULTS

Over half the studies (105/200, 53%) were conducted in North America, with the most common interventions relating to tobacco control (110/200, 55%), followed by alcohol (42/200, 21%), diet-related interventions (18/200, 9%), interventions targeting both diet and physical activity (18/200, 9%), and physical activity alone (3/200, 2%). Most studies used survey-based methods (160/200, 80%), and only ten used experimental designs. Acceptability varied as a function of: (a) the targeted behaviour, with more support observed for smoking-related interventions; (b) the type of intervention, with less intrusive interventions, those already implemented, and those targeting children and young people attracting most support; and (c) the characteristics of respondents, with support being highest in those not engaging in the targeted behaviour, and with women and older respondents being more likely to endorse more restrictive measures.

CONCLUSIONS

Public acceptability of government interventions to change behaviour is greatest for the least intrusive interventions, which are often the least effective, and for interventions targeting the behaviour of others, rather than the respondent him or herself. Experimental studies are needed to assess how the presentation of the problem and the benefits of intervention might increase acceptability for those interventions which are more effective but currently less acceptable.

Smoking prevalence, attitudes, and confidence about tobacco roles among Australian nursing students

This study identified major challenges to be addressed before student nurses can achieve their full potential in providing effective and comprehensive smoking cessation interventions. Smoking behaviors were assessed among undergraduate nursing students. In addition, students' attitudes, confidence levels, and support for extra training in tobacco control were examined. A nonprobability sample of 381 students at an Australian university was surveyed. The consent rate was 81%. Prevalence of current smoking was 21%. In the regression analysis, age group was the only statistically significant predictor of smoking status. Over one third (36%) did not endorse the nonsmoking exemplar role of their future profession. Most (60%) did not support the concept of routine smoking cessation intervention. Students who were smokers had significantly higher tobacco control confidence levels than nonsmokers. Smoking-related variables did not differ between students in different years of the course. Improved tobacco control training is needed at undergraduate level.

Paying women to quit smoking during pregnancy? Acceptability among pregnant women

INTRODUCTION

There is growing international interest in the use of financial incentives in smoking cessation, yet little research on public opinion of the scheme. This paper reports on the acceptability of incentives for reducing smoking in pregnant women and the perceived size of incentive that would encourage smoking cessation during pregnancy.

METHODS

A cross-sectional survey was conducted on a convenience sample of 213 women attending the antenatal clinic of a large public hospital in Australia. Participants completed a questionnaire on their views on the use of incentives with responses measured on a 5-point Likert scale.

RESULTS

The majority of participants (60%) did not agree that paying pregnant smokers to quit is a good idea. Opinions regarding the likely effectiveness were mixed with 30% of respondents in agreement and 22% undecided. Most (62%) were not willing to pay smokers any amount to quit. Smokers were more likely to have more favorable views about incentives than nonsmokers (p < .0001) and considered payments of between $100 and >$1,000 acceptable as reward for quitting smoking.

CONCLUSIONS

Acceptability for the use of financial incentives in reducing antenatal smoking is low among pregnant women. Future research should explore views of a wider audience and continue to gather stronger evidence of the efficacy of rewards for reducing smoking in pregnancy.

Policy guidance on threats to legislative interventions in public health: a realist synthesis

Background

Legislation is one of the most powerful weapons for improving population health and is often used by policy and decision makers. Little research exists to guide them as to whether legislation is feasible and/or will succeed. We aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the 'case study' of legislation to ban smoking in cars carrying children.

Methods

We conceptualised legislative interventions as a complex social interventions and so used the realist synthesis method to systematically review the literature for evidence. 99 articles were found through searches on five electronic databases (MEDLINE, HMIC, EMBASE, PsychINFO, Social Policy and Practice) and iterative purposive searching. Our initial searches sought any studies that contained information on smoking in vehicles carrying children. Throughout the review we continued where needed to search for additional studies of any type that would conceptually contribute to helping build and/or test our framework.

Results

Our framework identified a series of transferable threats to public health legislation. When applied to smoking bans in vehicles; problem misidentification; public support; opposition; and enforcement issues were particularly prominent threats. Our framework enabled us to understand and explain the nature of each threat and to infer the most likely outcome if such legislation were to be proposed in a jurisdiction where no such ban existed.

Specifically, the micro-environment of a vehicle can contain highly hazardous levels of second hand smoke. Public support for such legislation is high amongst smokers and non-smokers and their underlying motivations were very similar - wanting to practice the Millian principle of protecting children from harm. Evidence indicated that the tobacco industry was not likely to oppose legislation and arguments that such a law would be 'unenforceable' were unfounded.

Conclusion

It is possible to develop a coherent and transferable evidence based framework of the ideas and assumptions behind the threats to legislative intervention that may assist policy and decision makers to analyse and judge if legislation is feasible and/or likely to succeed.

Support and correlates of support for banning smoking in cars with children: findings from the ITC Four Country Survey

BACKGROUND

Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries.

METHODS

6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries.

RESULTS

The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower-but still high-in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children.

CONCLUSIONS

These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure.

The effect of cigarette smoke exposure on developing folate binding protein-2 null mice

Environmental tobacco smoke exposures have been linked to adverse health effects. Folate is essential for normal development, with deficiencies often causing fetal growth restriction. Mice lacking the folate binding protein-2 receptor (Folr2) exhibit increased susceptibility to teratogens. The purpose of the current study was to determine if the loss of Folr2 would increase sensitivity to cigarette smoke-induced effects on development. Pregnant Folr2(-/-), Folr2(+/+), and C57BL/6J mice were exposed to sidestream cigarette smoke during gestation. Exposure to sidestream smoke on gd 6-9 had no adverse effects on fetal outcomes. However, cigarette smoke exposure on gd 6-18.5 increased the number of fetal resorptions (Folr2(-/-) cohort) and decreased crown-rump length (Folr2(+/+) fetuses). These data confirm an association between sidestream smoke exposure and fetal growth restriction, but do not suggest that loss of Folr2 increased susceptibility to these effects.

Public support for anti-smoking legislation varies with smoking status

OBJECTIVE

Rural Australians have higher rates of smoking than their urban counterparts, contributing to poorer health outcomes. In 2004, the Queensland Government introduced legislation to reduce the impact of environmental tobacco smoke on the community. The aims of the study were to describe smoking behaviours and associations between smoking behaviour and agreement with current anti-smoking laws.

PARTICIPANTS

A total of 1208 people over the age of 18 years and living in rural, remote and very remote central Queensland participated in this telephone survey.

RESULTS

About 22% (n = 130) of female and 21% of male (n = 125) participants identified themselves as smokers. No difference existed between the mean age of smokers (47.3 years) and non-smokers (47.1 years). While there is high level of support for smoking restrictions in public places (75%), attitudes vary with smoking status. Smokers were less likely than smokers to agree that the legislation would create a healthier environment, reduce exposure to passive smoking or agree that 'it is right to ban smoking in public places'. Smokers were significantly more likely to agree that the legislation had gone too far.

CONCLUSION

The gradual implementation of the anti-smoking legislation is changing social beliefs on what are acceptable smoking practices. It is likely that the legislation within Queensland and the subsequent forced changes in social conditions for smokers will continue to reduce the number of people smoking and reduce exposure to environmental tobacco smoke.

Banning smoking in cars carrying children: an analytical history of a public health advocacy campaign

OBJECTIVE

Framing public health policy reform in ways that attract public and political support is a core skill of advocacy. In this paper we summarise the 12-year Australian history of advocacy for banning smoking in cars carrying children, culminating in the governments of the Australian States of South Australia and Tasmania enacting legislation.

METHOD

'Smoking in cars' was searched on the factiva.com print news media database, with returns limited to Australian newspapers published before 1 June 2007.

RESULTS

The issue of smoking in cars received extensive and emotive media coverage, primarily in support of legislating a ban. Invoking the protection of vulnerable children in the debate about smoking in cars was a powerful and persuasive theme. Unlike all other advocacy for smoke-free areas, this debate was not contested by the tobacco industry or other commercial interest groups.

CONCLUSIONS

Even in the absence of a co-ordinated advocacy campaign, public opinion studies on support for such legislation have been consistently strong. Communities view the protection of children as paramount and non-negotiable.

IMPLICATIONS

Smoke-free cars legislation can and should be fast tracked in order to capitalise on this community support.

Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: findings from the International Tobacco Control (ITC) Four Country Survey

OBJECTIVE

To explore determinants of support for and reported compliance with smoke-free policies in restaurants and bars across the four countries of the International Tobacco Control (ITC) Four Country Survey.

DESIGN

Separate telephone cross-sectional surveys conducted between October and December 2002 with broadly representative samples of over 2000 adult (>or=18 years) cigarette smokers in each of the following four countries: the United States, Canada, the United Kingdom, and Australia.

OUTCOME MEASURES

Support for smoke-free policies in restaurants and pubs/bars and reported compliance with existing policies.

RESULTS

Reported total bans on indoor smoking in restaurants varied from 62% in Australia to 5% in the UK. Smoking bans in bars were less common, with California in the USA being the only major part of any country with documented bans. Support for bans in both restaurants and bars was related to the existence of bans, beliefs about passive smoking being harmful, lower average cigarette consumption, and older age. Self-reported compliance with a smoking ban was generally high and was associated with greater support for the ban.

CONCLUSIONS

Among current cigarette smokers, support for smoking bans was associated with living in a place where the law prohibits smoking. Smokers adjust and both accept and comply with smoke-free laws. Associates of support and compliance are remarkably similar across countries given the notably different levels of smoke-free policies.

Observed smoking in cars: a method and differences by socioeconomic area

OBJECTIVES

To establish a reproducible method to estimate he point prevalence of smoking and second-hand smoke (SHS) exposure in cars, and to compare this prevalence between two areas of contrasting socioeconomic status.

METHOD

A method involving two teams of observers was developed and evaluated. It involved observing 16,055 cars in Wellington, New Zealand. Two of the observation sites represented a high and a low area of deprivation (based on a neighbourhood deprivation index) and three were in the central city.

RESULTS

A 4.1% point prevalence of smoking in cars was observed (95% confidence interval (CI) 3.8% to 4.4%). There was a higher prevalence of smoking in cars in the high deprivation area relative to the other sites, and particularly compared to the low deprivation area (rate ratio relative to the latter 3.2, 95% CI 2.6 to 4.0). Of cars with smoking, 23.7% had other occupants being exposed to SHS. Cars with smoking and other occupants were significantly more likely to have a window open (especially if the smoker was not the driver). The observation method developed was practical, and inter-observer agreement was high (kappa value for the "smoking seen in car" category 0.95).

CONCLUSIONS

Observational studies can be an effective way of investigating smoking in cars. The data from this survey suggest that smoking in cars occurs at a higher rate in relatively deprived populations and hence may contribute to health inequalities. Fortunately, there are a number of policy options for reducing SHS exposure in cars including mass media campaigns and laws for smoke-free cars.

Increasing cesarean section rates: exploring the role of culture in an Australian community

BACKGROUND

The proportion of births by cesarean section in Australia has recently increased by 35 percent, rising from 17 percent in 1990 to 23 percent in 2000. Unlike previous research, which has focused on women's role in increasing rates of cesarean section, this study aimed to explore the existence of wider cultural norms of acceptance of cesarean section in the Australian community, and the implications these might have for rising rates.

METHODS

A postal self-completion questionnaire was sent to a consecutive sample of 148 women who delivered 7 weeks earlier at the Women's and Children's Hospital, a tertiary-referral public maternity hospital in metropolitan Adelaide, South Australia. These women were recruited at 18 weeks' gestation, and had been involved in a wider study. The questionnaire included three sections, one section on agreement with statements pertaining to cultural acceptance of cesarean section, a second on personal consideration of cesarean section in early pregnancy, and a third including sociodemographic questions.

RESULTS

Of the total sample, 92 women responded to the questionnaire (response rate 62%). Of 6 items relating to community acceptance of cesarean section, responses ranged from 71.4 percent agreement ("common for people to think that cesarean section offers an easier way of giving birth") to 23.1 percent agreement ("the media seems to portray cesarean section as a better option than vaginal delivery"). The option of having a cesarean section was considered by almost 15 percent (10/68) of women early in their pregnancy. For the vast majority (8/10) this consideration was clinically based.

CONCLUSIONS

This investigation demonstrated that these Australian women, independent of sociodemographic variables such as age and education level, agreed that cesarean section was perceived as an easy, convenient way of giving birth.

Support for smoking restrictions in bars and gaming areas: review of Australian studies

OBJECTIVE

To document levels of public support in Australia for smoking restrictions in licensed premises, including trends over time, and to examine the potential effects of a ban on patronage.

METHOD

Systematic review of published and unpublished studies of community and staff attitudes towards smoking in bars, gaming areas and related venues were identified using Medline, Current Contents, PsycINFO and AUSTHealth prior to September 2002. State and Territory health departments, cancer organisations and branches of the National Heart Foundation were approached. Cross-sectional surveys reporting data on attitudes towards smoking restrictions and/or perceptions of effects on patronage were sought. Two reviewers assessed studies for inclusion. One extracted data using pre-coded categories with checking by the second.

RESULTS

Thirty-four community and seven staff surveys were synthesised qualitatively, with greater emphasis given to surveys using random selection. All surveys conducted since 1993, which included the separate smoking area response option, have demonstrated majority support for some form of smoking restriction on licensed premises. From 2000, surveys with the ban option alone report majority support for prohibiting smoking completely in bars (52-68%) and gaming areas (64-76%). Support increased significantly after the Sharp damages award. Customer preference data indicate banning smoking is most likely to have a neutral or positive effect on patronage.

CONCLUSIONS AND IMPLICATIONS

Support for a ban on smoking in licensed premises has increased by almost 20% in the past decade. State and Territory governments should introduce legislation banning smoking in all indoor drinking and gaming areas immediately.

Community attitudes towards environmental tobacco smoke in licensed premises: follow-up study after the Sharp case

OBJECTIVE

To examine community attitudes towards environmental tobacco smoke in licensed premises after the Sharp case decision.

METHOD

723 randomly selected New South Wales residents aged 18 years and over completed a telephone survey in November 2001.

RESULTS

The vast majority supported some form of smoking restriction in licensed clubs (92.1%) and hotels (90.0%). Compared with a 2000 survey, respondents in the 2001 survey were significantly more likely to support a total smoking ban in licensed clubs and hotels. When support was assessed using a ban-only question, 66.8% supported banning smoking in pubs/clubs. Approximately half reported being less likely to visit non-eating areas of licensed clubs (51.2%) and hotels (49.8%) if smoking were permitted and these proportions were significantly higher than in the 2000 survey. A majority (83.1%) thought bar workers' health should be a major consideration when deciding how to handle smoking in pubs/clubs. More than half (56.8%) believed pubs/clubs would experience significant financial problems if smoking bans were introduced.

CONCLUSIONS AND IMPLICATIONS

In New South Wales, majority support exists for banning smoking in pubs and clubs. Legislation banning smoking in all indoor drinking and gaming areas should be introduced immediately.