Secondhand smoke in outdoor settings: smokers' consumption, non-smokers' perceptions, and attitudes towards smoke-free legislation in Spain

Impact of local tobacco control policies on the prevalence of smoke-free sports clubs

OBJECTIVES

In absence of national legislation, local governments may stimulate outdoor sports clubs to become smoke-free. However, it is unknown whether and to what extent such efforts are effective in encouraging sports clubs to adopt a smoke-free policy (SFP). The aim of this study was to assess the association between tobacco control policies of municipalities and the prevalence of SFPs among outdoor sports clubs.

STUDY DESIGN

Retrospective, cross-sectional.

METHODS

Information on Dutch sports clubs (N = 3068) was linked to information on tobacco control policies of municipalities (i.e., "smoking prevention policies", "smoke-free environment policies", and "smoke-free sports policies") (N = 218). Multilevel logistic regression models examined the association between municipal tobacco control policies and the prevalence of SFPs among outdoor sports clubs, while controlling for sports clubs' characteristics.

RESULTS

We found a positive, dose-response association between tobacco control policies of municipalities and the prevalence of SFPs among outdoor sports clubs. The odds of having an SFP in place was significantly higher for sports clubs in municipalities with moderate "smoking prevention policies" (OR = 1.85, 95%CI = 1.18-2.89), strong "smoke-free environment policies" (OR = 1.95, 95%CI = 1.19-3.20), and strong "smoke-free sports policies" (OR = 1.66, 95%CI = 1.02-2.24) compared to sports clubs in municipalities with no/weak policies.

CONCLUSIONS

The results suggest that local tobacco control policies can increase the prevalence of SFPs among outdoor sports clubs. In order to create maximum effect, local policies need to be comprehensive and widely implemented.

Evaluation of a smoke-free beaches intervention in Barcelona: a quasi-experimental study

BACKGROUND

We aim to assess the effect of a smoke-free beaches (SFB) intervention in Barcelona on smoking during the 2021 bathing season.

METHODS

Quasi-experimental pre-post design (pre-intervention period: 15-28 May; post-intervention period: 29 May-12 September). Based on users' profiles and location, four beaches were assigned to the intervention group (IG) and five to the comparison group (CG). The intervention involved: a mayoral decree (29 May), a communication campaign and beach on-site information. We established two 3 m × 3 m transects per beach from the coastline to the promenade. Trained teams collected smoking-related information in the transects through observations and surveys to beach users. Outcomes are as follows: percentage of people reporting witnessing smoking behaviours the last fortnight and percentage of people observed smoking. We calculated and compared prevalence ratios (PRs) with adjusted Poisson regressions.

RESULTS

3751 interviews (1721 IG; 2030 CG) and 1108 observations (498 IG, 610 CG) were carried out. SFB were associated with a significant reduction in the percentage of people reporting witnessing smoking (IG (pre: 87.2%; post: 49.7%); CG (pre: 86.2%; post: 74.1%); PR (95% CI): 0.7 (0.6 to 0.8)); and in the users observed smoking in the beach (IG (pre: 3.8%; post: 3.0%); CG (pre: 2.3%; post: 9.9%); PR (95% CI): 0.3 (0.3 to 0.4)). Satisfaction scores were 8.3 (IG) and 8.1 (CG) out of 10.

CONCLUSION

An SFB intervention is an effective and well-accepted measure to reduce smoking and smokers' visibility. Smoke-free measures should be extended to beaches and other non-regulated outdoor areas.

Assessment of exposure to secondhand tobacco smoke in Spain: A scoping review

INTRODUCTION

There is no consensus on the questions that should be included in questionnaires to properly ascertain exposure to secondhand tobacco smoke (SHS). The objective of this study is to analyze the questions included in studies which have assessed SHS exposure in Spain.

METHODS

A scoping review was performed, using PubMed, Embase and Web of Science databases, selecting original articles published in English and Spanish, across the period 2012-2021. We extracted data from each study regarding its design, target population, sample size or geographical scope; we also collected data regarding how studies dealt with exposure to SHS including assessment and intensity of SHS, exposure setting, geographical scope, and the verbatim questions used.

RESULTS

Finally, 75 studies were identified. In the 23 studies carried out in children, verbatim questions were included in 8 studies, and the setting most studied was the home. SHS exposure was assessed during pregnancy and postnatally by 8 studies, the verbatim questions used were described in 2 studies, being exposure ascertained at home and workplace. In the adult population, 14 of 44 studies described the verbatim questions; the setting most studied was the home. Verbatim questions varied among studies.

CONCLUSIONS

Questionnaire-based assessment of SHS exposure is highly heterogeneous, hindering comparability between studies. Therefore, it is necessary to set a standard questionnaire to assess exposure to SHS.

Impact of secondhand smoke on air quality in partially enclosed outdoor hospitality venues: a review

BACKGROUND

Smoking is a leading cause of premature mortality and morbidity globally. The pollutants generated from smoke are not only harmful to smokers, but also to those exposed to secondhand smoke. As a result of increasingly restrictive indoor smoke-free policies in many countries, there is a tendency for tobacco smoking to move outdoors into partially enclosed settings in hospitality venues. The aim of this systematic review was to evaluate the impact of secondhand smoke on air quality in outdoor hospitality venues.

METHODS

Two electronic databases PubMed and Scopus were searched from 1 January 2010 to 30 June 2022 for studies of air quality impacts from tobacco smoking in outdoor hospitality venues. A total of 625 studies were screened and 13 studies were included in this review.

RESULTS

The majority (9 studies) of reviewed studies monitored PM2.5 concentration as an indicator of secondhand smoke. PM2.5 was reported from 10.9 µg/m3 to 91.0 µg/m3 in outdoor smoking areas, compared to 4.0 µg/m3 to 20.4 µg/m3 in outdoor control sites unaffected by smoking. Secondhand smoke can also drift into adjacent outdoor areas or infiltrate into indoor environments thus affecting air quality in spaces where smoking is not permitted.

CONCLUSIONS

The reviewed studies indicated that air quality within outdoor hospitality venues where smoking is permitted is unlikely to meet current World Health Organization (WHO) ambient air quality guidelines for PM2.5. Customers and staff in outdoor hospitality venues with active smoking, and in adjacent outdoor and indoor non-smoking areas, are potentially exposed to secondhand smoke at levels exceeding WHO guidelines. Stronger smoking control policies are recommended for outdoor hospitality venues to protect the health of customers and staff from harmful secondhand smoke exposure.

PROSPERO REGISTRATION

CRD42022342417.

Live to die another day: novel insights may explain the pathophysiology behind smoker's paradox in SARS-CoV-2 infection

The severe acute respiratory coronavirus 2 (SARS-CoV-2) infection demonstrates a highly variable and unpredictable course. Several reports have claimed a smoker's paradox in coronavirus disease 2019 (COVID-19), in line with previous suggestions that smoking is associated with better survival after acute myocardial infarction and appears protective in preeclampsia. Several plausible physiological explanations exist accounting for the paradoxical observation of smoking engendering protection against SARS-CoV-2 infection. In this review, we delineate novel mechanisms whereby smoking habits and smokers' genetic polymorphism status affecting various nitric oxide (NO) pathways (endothelial NO synthase, cytochrome P450 (CYP450), erythropoietin receptor (EPOR); β-common receptor (βcR)), along with tobacco smoke modulation of microRNA-155 and aryl-hydrocarbon receptor (AHR) effects, may be important determinators of SARS-CoV-2 infection and COVID-19 course. While transient NO bioavailability increase and beneficial immunoregulatory modulations through the above-mentioned pathways using exogenous, endogenous, genetic and/or therapeutic modalities may have direct and specific, viricidal SARS-CoV-2 effects, employing tobacco smoke inhalation to achieve protection equals self-harm. Tobacco smoking remains the leading cause of death, illness, and impoverishment.

Diffusion of smoke-free policies at outdoor sports clubs in the Netherlands

BACKGROUND

Although outdoor smoke-free policies (SFPs) at sports clubs represent an important new area of tobacco control, the majority of sports clubs are not smoke free. This study aims to assess diffusion patterns of outdoor SFPs at sports clubs in the Netherlands.

METHODS

Using a retrospective, registry-based design, an inventory was made of football, field hockey, tennis and korfball clubs that became smoke free between 2016 and 2020. We determined the type of sports, number of members and proportion of youth members. The degree of urbanisation and density of smoke-free sports clubs were measured at the municipality level. The association between sports clubs' characteristics, degree of urbanisation and SFP adoption was analysed using multilevel regression analysis. Horizontal diffusion was tested by analysing the association between the density and annual incidence of smoke-free sports clubs.

RESULTS

Since 2016, the number of sports clubs with an outdoor SFP increased from 0.3% to 26.4%. Field hockey and korfball clubs and clubs with many (youth) members were more likely to be smoke-free. SFPs spread from the most urbanised to less urbanised municipalities, which could mostly be attributed to sports clubs' characteristics. A higher density of smoke-free sports clubs within municipalities was associated with an increased incidence of new SFPs in the following year.

CONCLUSION

Outdoor SFPs at sports clubs in the Netherlands diffused across horizontal and hierarchical lines. National strategies for smoke-free sports should monitor clubs that are more likely to stay behind, such as football and tennis clubs, smaller clubs and clubs in less urbanised areas.

Passive exposure and perceptions of smoke-free policies in hospital and university campuses among nursing students: A cross-sectional multicenter study

INTRODUCTION

Outdoor smoke-free regulations reduce exposure to secondhand smoke (SHS) and help to denormalize tobacco use. As future key agents in health promotion, nursing students' attitudes should agree with tobacco-control policies. The objectives of this study were: 1) assess nursing students' exposure to SHS in nursing schools, 2) explore their perceptions of compliance with the existing smoke-free regulations in acute-care hospitals; and 3) describe their support for indoor and outdoor smoking bans on hospital and university campuses.

METHODS

This was a cross-sectional multicenter study conducted in 2015-2016 in all 15 university nursing schools in Catalonia, Spain. A questionnaire gathered information on SHS exposure, awareness of the smoke-free regulation in acutecare hospitals, and support for smoke-free policies in indoor and outdoor areas of hospitals and university campuses. Participants were nursing students attending classes on the day of the survey. We performed descriptive analyses and calculated adjusted prevalence ratios (APR) and 95% confidence interval (CI).

RESULTS

Of 4381 respondents, 99.1% had seen people smoking in outdoor areas of their university campus, and 75.2% had been exposed to SHS on the campus (6.0% indoors and 69.2% outdoors). Nearly 60% were aware of the smoking regulation in place in acute-care hospitals. There was widespread support for smoke-free indoor hospital regulation (98.7%), but less support (64.8%) for outdoor regulations. Approximately 33% supported the regulation to make outdoor healthcare campuses smoke-free, which was higher among third-year students compared to first-year students (APR=1.41; 95% CI: 1.24-1.62), among never smokers (41.4%; APR=2.84; 95% CI: 2.21-3.64) compared to smokers, and among those who were aware of the regulation (38.4%; 95% CI: 1.37-1.75).

CONCLUSIONS

Exposure to SHS on university campuses is high. Nursing students express low support for strengthening outdoor smoking bans on hospital and university campuses. Interventions aiming to increase their support should be implemented.

Public support for smoke-free policies in outdoor areas and (semi-)private places: a systematic review and meta-analysis

Background

Smoke-free policies are essential to protect people against tobacco smoke exposure. To successfully implement smoke-free policies that go beyond enclosed public places and workplaces, public support is important. We undertook a comprehensive systematic review of levels and determinants of public support for indoor (semi-)private and outdoor smoke-free policies.

Methods

In this systematic review and meta-analysis, six electronic databases were searched for studies (published between 1 January 2004 and 19 January 2022) reporting support for (semi-)private and outdoor smoke-free policies in representative samples of at least 400 respondents aged 16 years and above. Two reviewers independently extracted data and assessed risk of bias of individual reports using the Mixed Methods Appraisal Tool. The primary outcome was proportion support for smoke-free policies, grouped according to location covered. Three-level meta-analyses, subgroup analyses and meta-regression were performed.

Findings

14,749 records were screened, of which 107 were included; 42 had low risk of bias and 65 were at moderate risk. 99 studies were included in the meta-analyses, reporting 326 measures of support from 896,016 individuals across 33 different countries. Support was pooled for indoor private areas (e.g., private cars, homes: 73%, 95% confidence interval (CI): 66-79), indoor semi-private areas (e.g., multi-unit housing: 70%, 95% CI: 48-86), outdoor hospitality areas (e.g., café and restaurant terraces: 50%, 95% CI: 43-56), outdoor non-hospitality areas (e.g., school grounds, playgrounds, parks, beaches: 69%, 95% CI: 64-73), outdoor semi-private areas (e.g., shared gardens: 67%, 95% CI: 53-79) and outdoor private areas (e.g., private balconies: 41%, 95% CI: 18-69). Subcategories showed highest support for smoke-free cars with children (86%, 95% CI: 81-89), playgrounds (80%, 95% CI: 74-86) and school grounds (76%, 95% CI: 69-83). Non-smokers and ex-smokers were more in favour of smoke-free policies compared to smokers. Support generally increased over time, and following implementation of each smoke-free policy.

Interpretation

Our findings suggested that public support for novel smoke-free policies is high, especially in places frequented by children. Governments should be reassured about public support for implementation of novel smoke-free policies.

Funding

Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation and Netherlands Thrombosis Foundation.

Applying persuasive messages to reduce public outdoor smoking: A pseudo-randomized controlled trial

Despite efforts to create dedicated smoking areas and no-smoking signs, many smokers continue to light their cigarettes in front of public building entrances-leading to concerns over health consequences for non-smokers passing by. To increase compliance with no-smoking requests, behavioral interventions that tap into habitual and automatic processes seem promising. A pseudo-randomized controlled trial was conducted to assess the differential impact of seven behavioral interventions based on Cialdini's principles of persuasion. Over a period of 9 weeks, the number of smokers was counted (total n = 17,930 observations) in front of a German University Medical Center. Relative to a baseline and a control condition, interventions based on the principles of reciprocity, scarcity, and authority were most effective in reducing the number of observed smokers in front of the building entrance (41.5%, 45.7%, and 52.1% reduction rates, respectively). Having observed smokers' behavior in vivo, this study provides substantial evidence for the impact of persuasive strategies on outdoor smoking. In the future, this knowledge should be used to protect non-smokers from second-hand smoke by increasing the use of designated smoking areas, leave to another place to smoke, or not smoke at all.

The impact of smoke-free policies on smoking at outdoor sports clubs: a qualitative study

OBJECTIVES

Smoking may still occur at sports clubs with an outdoor smoke-free policy (SFP). This study aims to map the occurrence of smoking at various sports clubs in the Netherlands and to understand why smoking occurs at some clubs but not at others.

STUDY DESIGN

This was a qualitative design in the form of semistructured interviews.

METHODS

Semistructured interviews (n = 34) were held online with smoking and non-smoking members of 17 Dutch outdoor sports clubs (in field hockey, korfball, football, and tennis) with an outdoor SFP. Data were analyzed using content analysis.

RESULTS

We identified four situations where smoking still occurred: (1) directly at the entrance, (2) at some distance from the entrance, (3) in particular places on the premises, and (4) in various places or on occasions when alcohol is consumed. Smoking directly at the entrance was most often perceived as a bothersome situation that was difficult to avoid. The occurrence of these situations differed per sports club depending on the scope of the SFP (the comprehensiveness of the SFP and the presence or absence of a smoking area) and factors influencing policy compliance (physical characteristics of the sports club's premises, the presence or absence of children, and several enforcement difficulties).

CONCLUSION

In some sports clubs, smoking remained common on the premises despite an outdoor SFP. Exposure to second-hand smoke might be reduced by formulating a comprehensive SFP, improving policy compliance also in situations where children are absent, and organizing the enforcement of the policy.

Compliance Surveillance of the Tobacco Control Legislation in a Spanish Region and Characterization of Passive Exposure to Tobacco Smoke and E-Cig in Children in Outdoor Spaces

(1) Background: Exposure to environmental tobacco smoke has decreased in recent years in Spain, due to the implementation of tobacco control policies. However, there is no regulation that protects against second-hand smoke (SHS) in outdoor environments. Our goal is to describe the smoking prohibition signage in public spaces and to characterize tobacco consumption in outdoor environments describing the SHS exposure in children. (2) Methods: A cross-sectional study using direct observation was carried out with a convenience sample (n = 179) that included hospitality venues with terraces, schools and healthcare facilities in the municipality of Sant Cugat del Vallès (Barcelona, Spain). The observations were made without notifying the owners by one single field researcher between April and June 2018. The variables were evaluated by signage and signs of tobacco consumption (ashtrays, cigarette butts and presence of smokers). (3) Results: Smoke-free zone signage outside public spaces was present in 30.7% of all venues, with only 50.9% correctness. When analysing terraces of hospitality venues, in 35.8% of them there were children present with 66.7% of tobacco consumption. (4) Conclusions: Our results show a low prevalence of antismoking signage, without an impact on tobacco consumption regardless of the presence of children.

Smoke-free spaces: a decade of progress, a need for more?

Adoption of smoke-free measures has been one of the central elements of tobacco control activity over the past 30 years. The past decade has seen an increasing number of countries and proportion of the global population covered by smoke-free policies to some extent. Despite reductions in global smoking prevalence, population growth means that the number of non-smokers exposed to the harms caused by secondhand smoke remains high. Smoke-free policy measures have been shown to be useful in protecting non-smokers from secondhand smoke, and can additionally increase cessation and reduce smoking initiation. Policies tend to be aimed primarily at enclosed public or workplace settings with very few countries attempting to control exposure in private or semiprivate spaces such as homes and cars, and, as a result, children may be benefiting less from smoke-free measures than adults. Compliance with legislation also varies by country and there is a need for education and empowerment together with guidance and changing social norms to help deliver the full benefits that smoke-free spaces can bring. Restrictions and policies on use of electronic cigarettes (e-cigarettes) in smoke-free settings require more research to determine the benefits and implications of bystanders' exposure to secondhand e-cigarette aerosol, dual use and smoking cessation.

Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries

OBJECTIVE

Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in outdoor hospitality venues across Europe and identify contextual exposure determinants.

METHODS

Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, cafeterias, and pubs from 11 European countries in 2017-2018. Sites were selected considering area-level socioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017-2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants.

RESULTS

Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30-3.74) μg/m³ and increased during nighttime (1.45 IQR:0.65-4.79 μg/m³), in enclosed venues (2.97 IQR:0.80-5.80 μg/m³), in venues with more than two smokers (2.79 IQR:1.03-6.30 μg/m³), in venues in countries with total indoor smoking bans (1.20 IQR:0.47-4.85 μg/m³), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49-5.34 μg/m³). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues' degree of enclosure.

CONCLUSIONS

Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues.

Secondhand smoke presence in outdoor areas in 12 European countries

INTRODUCTION

Secondhand smoke (SHS) causes morbidity and mortality among non-smokers.

OBJECTIVES

To investigate SHS presence in outdoor areas from 12 European countries and its association with country-level characteristics.

METHODS

Cross-sectional study performed in 2017-2018 within the TackSHS project. We conducted a face-to-face survey on a representative sample of the population aged 15 years and older from 12 European countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain. Out of 11,902 participants, 8,562 were non-smokers. SHS presence was assessed in selected outdoor areas and defined as respondents viewing someone smoking the last time they visited each setting within the last 6 months. A ranking score for outdoor SHS presence was assigned to each country based on the SHS presence in each setting. We used Spearman's correlation (r) and the Chi-squared tests to assess the relationship between SHS presence and country-level characteristics.

RESULTS

Except for children's playgrounds (39.5%; 95% confidence interval, CI: 37.6%-41.3%), more than half of non-smokers reported SHS presence in outdoor areas: schools (52.0%; 95%CI: 50.2%-53.7%), stadia (57.4%; 95%CI: 55.4%-59.4%), parks (67.3%; 95%CI: 66.0%-68.5%), hospitals (67.3%; 95%CI: 65.8%-68.7%), public transport stops (69.9%; 95%CI: 68.6%-71.2%), bar/restaurant terraces (71.4%; 95%CI: 70.2%-72.6%), and beaches (72.8%; 95%CI: 71.4%-74.1%). Residents in Latvia showed the highest overall outdoor SHS presence rank, followed by Greece, and Portugal. Outdoor SHS presence was directly correlated to the country's smoking prevalence (r = 0.64), and inversely correlated to the Tobacco Control Scale 2016 overall score (r = -0.62), the socio-demographic index 2017 (r = -0.56), and Gross Domestic Product per capita 2018 (r = -0.47) (p < 0.001).

CONCLUSIONS

SHS presence is high in most outdoor areas in Europe, especially in countries with higher smoking prevalence and lower tobacco control performance. To address outdoor SHS exposure, our findings require considering smoking bans along with other strategies to reduce smoking prevalence.

Does support for smoke-free outdoor spaces increase after implementation?: A case study of a Dutch research center's smoke-free campus transition

INTRODUCTION

Policymakers may sometimes be reluctant to develop policies for smoke-free outdoor spaces due to concerns about public reaction. In this study, we investigated the support for a smoke-free campus before and after the campus of a Dutch research institute became smoke-free.

METHODS

We conducted two surveys among employees to measure the level of support for a smoke-free campus. The first survey (n=129) was conducted 3 months before and the second 13 months after the implementation of a smoke-free campus policy (n=134).

RESULTS

More employees supported the smoke-free campus after (82.1%) than before (64.3%) implementation (OR=2.55; 95% CI: 1.39–4.70; p=0.003). In addition, more employees (75.4%) employees believed it is important to have a smoke-free campus than was the situation before (56.6%) the implementation (OR=2.28; 95% CI: 1.31–3.97; p=0.004).

CONCLUSIONS

This case study adds to the knowledge that support for a smoke-free campus increases after implementation of a smoke-free policy. This may encourage other organizations or local governments to create policies for smoke-free outdoor spaces.

[Fourteen years of tobacco control law in Spain. Current situation and proposals]

Spain has made progress in tobacco control policies, highlighting the prohibition of tobacco consumption in closed public spaces. A continued decrease in the proportion of smokers is observed. Exposure to environmental tobacco smoke has decreased in entertainment venues, with a reduction of environmental nicotine and particulate levels over 90%, without negative impact at home. There are reductions in hospital admissions and in mortality from heart attack, decrease in hospitalizations for chronic lung disease and asthma, and decrease in the risk of prematurity and low birth weight. We must advance in: plain packaging, advertising campaigns to prevent consumption, equalize the price of different tobacco products, regulate electronic cigarettes in public places, consider new smoke-free spaces where minors and other vulnerable groups may be exposed, expand aid for cessation and promote health professionals training.

Qualitative examination of the perceived effects of a comprehensive smoke-free law according to neighborhood socioeconomic status in a large city

Smoke-free legislations aim to protect non-smokers from second-hand smoke (SHS) exposure and improve population health outcomes. The aim of this study was to explore residents' perceptions to understand how people living in distinctive SES neighborhoods are differently affected by comprehensive smoke-free laws in a large city like Madrid, Spain. We conducted a qualitative project with 37 semi-structured interviews and 29 focus group discussions in three different SES neighborhoods within the city of Madrid. Constructivist grounded theory was used to analyze the transcripts. One core category arose in our analyses: Neighborhood inequalities in second-hand smoke (SHS) exposure in outdoor places. The enactment of the comprehensive smoke-free law resulted in unintended consequences that affected neighborhoods differently: relocation of smokers to outdoor setting, SHS exposure, noise disturbance and cigarette butt littering. Changes in the urban environment in the three neighborhoods resulted in the denormalization of smoking in outdoor public places, which was more clearly perceived in the high SES neighborhood. Changes in the built environment in outdoor areas of hospitality venues were reported to actually facilitate smoking. Comprehensive smoke-free laws resulted in denormalization of smoking, which might be effective in reducing SHS exposure. Extending smoking bans to outdoor areas like bus stops and hospitality venues is warranted and should include a public health inequalities perspective.

Estimating and mapping cigarette butt littering in urban environments: A GIS approach

BACKGROUND

Cigarette butts are some of the most common form of litter in the World, causing severe environmental damage. Analysing spatial distribution of cigarette butts in the urban environment may lead to useful insights for further interventions to reduce this form of litter. In this study, we present a GIS-based methodology to estimate the density of cigarette butts across a large urban area.

METHODS

We collected information about discarded cigarette butts in outdoor public spaces by systematic social observation in a diverse sample of areas in Madrid, Spain. We used these data to estimate the density of cigarette butts in public spaces around the entire city by performing GIS analyses based on Kernel Density Estimations. Last, we validated these measures using on-field observations in a set of locations across the city.

RESULTS

Hospitality venues and public transportation stops were the places with the highest concentrations of cigarette butts, followed by the entrances to educational venues and playgrounds. Central districts showed the highest amount of cigarette butts in contrast to peripheral ones. We found that our measure had good validity, with a correlation coefficient of 0.784.

DISCUSSION

This is the first study estimating and mapping cigarette butt litter in a large urban area. We identified a set of outdoor public places with high concentrations of cigarette butts and found geographical unevenness in the distribution of this pervasive form of litter across the study area. Our findings demonstrate the ubiquitous nature of cigarette butts in the urban environment and the need for interventions to reduce its impact on both people's health and the environment.

Mapping the visibility of smokers across a large capital city

BACKGROUND

Smoking visibility may affect smoking norms with implications for tobacco initiation, particularly amongst youths. Understanding how smoking is distributed across urban environments would contribute to the design and implementation of tobacco control policies. Our objective is to estimate the visibility of smokers in a large urban area using a novel GIS-based methodological approach.

METHODS

We used systematic social observation to gather information about the presence of smokers in the environment within a representative sample of census tracts in Madrid city in 2016. We designed a GIS-based methodology to estimate the visibility of smokers throughout the whole city using the data collected in the fieldwork. Last, we validated our results in a sample of 40 locations distributed across the city through direct observation.

RESULTS

We mapped estimates of smokers' visibility across the entire city. The visibility was higher in the central districts and in streets with a high density of hospitality venues, public transportation stops, and retail shops. Peripheral districts, with larger green areas and residential or industrial land uses, showed lower visibility of smokers. Validation analyses found high agreement between the estimated and observed values of smokers' visibility (R = 0.845, p=<0.001).

DISCUSSION

GIS-based methods enable the development of novel tools to study the distribution of smokers and their visibility in urban environments. We found differences in the visibility by population density and leisure, retail shops and business activities. The findings can support the development of policies to protect people from smoking.

Outdoor smoking in Nigeria: prevalence, correlates and predictors

BACKGROUND

There is a lack of data on smoking in outdoor-open bars in Nigeria that may translate into effective legislation on public smoking.

METHOD

This study determined the prevalence, demographic and clinical correlates as well as predictors of smoking among a community sample of 1119 patrons of open place bars in Ibadan, Nigeria. Data on current smoking was obtained using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), while smoking intensity was calculated using the Pack-Year. Prevalence of alcohol use was determined using the Alcohol Use Disorders Identification Test (AUDIT), while depression was diagnosed using the Mini International Neuropsychiatry Interview (MINI). Analysis was carried out by SPSS version 20.0 software using Chi square statistics, t test and ANOVA, and was set at 95% confidence interval.

RESULTS

Prevalence of current smoking was 63.8% and the mean pack years of smoking of all respondents was 19.38 ± 17.16 years. Predictors of outdoor smoking were depression OR = 1.41, 95% CI (1.09-1.83) and alcohol use OR = 2.12, 95% CI (1.44-3.13). Predictors of high pack years were depression OR = 1.47, 95% CI (1.08-2.01), being married, OR = 1.78, 95% CI (1.29-2.45), high income, OR = 1.95, 95% CI (1.42-2.68) and alcohol use OR = 2.82, 95% CI (1.51-5.27). There was no significant relationship between stage of readiness to quit smoking and mean pack years of smoking, F = 0.3, p = 0.5.

CONCLUSION

The high prevalence of outdoor smoking in the sample calls for urgent public health initiatives for intervention. Thus, outdoor bars are potential tobacco use intervention sites to minimize the health consequences of smoking.

Smoking in bars in eight European countries in 2010 and 2016: an observational comparative study

Background

Most European countries established laws against smoking in public places. We aimed to describe the prevalence of smoking in bars in 2010 and 2016 in eight European countries and to characterise those bars in which smoking still occurred in 2016.

Methods

Smoking in bars was studied in 16 cities in 8 European countries (Austria, Belgium, Czech Republic, Denmark, England, France, Germany and the Netherlands). In 2010, 96 bars were visited. In 2016, 51 bars were revisited and 45 new bars were visited. Smoking indoors and characteristics of bars, terrace and customers were observed using a standard observation template. Associations between bar characteristics and smoking were analyzed using logistic regression.

Results

Overall prevalence of in-bar smoking was 39.6% in 2010 and 34.4% in 2016. Prevalence in bars covered by smoke-free legislation decreased from 24.2 to 13.0% between 2010 and 2016 whereas prevalence in bars where smoking was legally allowed increased from 73.3 to 88.9%. In-bar smoking almost exclusively occurred in countries with partial smoke-free legislation compared with more comprehensive legislation. Smoking was more prevalent in bars for locals, with a counter for drinks, slot-machines, no outside seating and no food service. Size of the bar, comfort of the terrace and the presence of cigarette vending machines were not associated with in-bar smoking.

Conclusions

Whereas comprehensive smoke-free legislation resulted in high compliance, smoking increased in bars in countries with partial or no smoke-free legislation. This study confirms that comprehensive smoke-free legislation is needed to protect customers and personnel against second-hand-smoke exposure in all bars.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Second-hand smoke exposure in outdoor hospitality venues: Smoking visibility and assessment of airborne markers

INTRODUCTION

After the implementation of smoke-free policies in indoor hospitality venues (including bars, cafeterias, restaurants, and pubs), smokers may have been displaced to their outdoor areas. We aimed to study smoking visibility and second-hand smoke exposure in outdoor hospitality venues.

METHODS

We collected information on signs of tobacco consumption on entrances and terraces of hospitality venues in 2016 in the city of Madrid, Spain. We further measured airborne nicotine concentrations and particulate matter of less than 2.5 µm in diameter (PM2.5) in terraces with monitors by active sampling during 30 min. We calculated the medians and the interquartile ranges (IQR) of nicotine and PM2.5 concentrations, and fitted multivariate models to characterize their determinants.

RESULTS

We found 202 hospitality venues between May and September (summer), and 83 between October and December 2016 (fall) that were opened at the time of observation. We found signs of tobacco consumption on 78.2% of the outdoor main entrances and on 95.1% of outdoor terraces. We measured nicotine and PM2.5 concentrations in 92 outdoor terraces (out of the 123 terraces observed). Overall median nicotine concentration was 0.42 (IQR: 0.14-1.59) μg/m³, and overall PM2.5 concentration was 10.40 (IQR: 6.76-15.47) μg/m³ (statistically significantly higher than the background levels). Multivariable analyses showed that nicotine and PM2.5 concentrations increased when the terraces were completely closed, and when tobacco smell was noticed. Nicotine concentrations increased with the presence of cigarette butts, and when there were more than eight lit cigarettes at a time.

CONCLUSIONS

Outdoor hospitality venues are areas where non-smokers, both employees and patrons, continue to be exposed to second-hand smoke. These spaces should be further studied and considered in future tobacco control interventions.

German Public Support for Tobacco Control Policy Measures: Results from the German Study on Tobacco Use (DEBRA), a Representative National Survey

Smoking prevalence in Germany remains high at approximately 28%. We assessed public support for tobacco legislation and associations between level of support and smoking and socio-demographic characteristics. Data from 2087 people were collected as part of the German Study on Tobacco Use ("DEBRA"): a nationally representative, face-to-face household survey. Public support was measured on total ban of sale, raising the minimum age for sales, taxation of tobacco industry sales, research into e-cigarettes, and ban of smoking in cars when children are present. Associations were assessed with multivariate logistic regression. Over 50% of the German population support taxing industry profits (57.3%) and assessing e-cigarettes as an aid to quit smoking (55.5%). Over 40% support raising the legal age of sale (43.1%), and 22.9% support a total ban on tobacco sales. A smoking ban in cars when children are present was most popular (71.5%), even among current smokers (67.0%). There is public support for stricter tobacco control measures in Germany. A smoking ban in cars when children are present could be a feasible policy to implement.

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.

Impact of the Spanish smoking laws on tobacco consumption and secondhand smoke exposure: A longitudinal population study

BACKGROUND

In Spain, two smoke-free laws have been passed after the approval of the WHO-FCTC. This study assesses the impact of these Spanish smoking legislations on the active and passive smoking through a population cohort in Barcelona (Spain).

METHODS

This is a longitudinal study before and after the implementation of two national smoking bans in Spain in a representative sample (n=1245) of adults (≥16years old) from Barcelona (Spain) surveyed in 2004-2005 and followed-up in 2013-2014. The final sample analyzed was 736 individuals. Both questionnaires (before and after the two laws) included the same variables about active and passive smoking. We calculated the prevalence and the prevalence ratio (PR, with their 95% confidence intervals, 95% CI) of smoking cigarettes and hand-rolled tobacco and also the prevalence of exposure to secondhand smoke (SHS) at home, work, public transport, leisure time and at any setting after vs. before Spanish legislations.

RESULTS

After the implementation of the two Spanish smoke-free bans, a significant decrease was observed in the smoking prevalence (from 34.5% to 26.1%, PR=0.76, p<0.001), in the average cigarettes per day (median from 15.2 to 10.0, p<0.001), and in the percentage of conventional tobacco consumption (from 92.6% to 74.4%, PR=0.80, p<0.001). Furthermore, a significant increase in the use of hand-rolled tobacco (from 6.1% to 30.9%, PR=5.07, p<0.001) and other tobacco products (from 17.1% to 32.8%, PR=1.92, p<0.001) was observed. In addition, a significant decrease in the self-reported SHS exposure was observed in all the assessed settings (home, work, transport, and leisure time).

CONCLUSIONS

The implementation of the two smoke-free legislations in Spain is related to a reduction in smoking prevalence and SHS exposure. However, the smoking of other tobacco products, particularly hand-rolled tobacco, has increased among young population.

Use of electronic cigarettes in public and private settings in Barcelona (Spain)

OBJECTIVES

To describe the prevalence of e-cigarette users who use them in selected indoor public and workplaces, and private venues in Barcelona (Spain) in 2015.

METHODS

This is a cross-sectional study of a sample of e-cigarette users (≥ 18 years) from Barcelona (n = 600). We calculated the proportion of e-cigarette users who used the device in public and private settings (in the last 30 days). We fit multivariate logistic regression models adjusted for sex and age to calculate the odds ratios (OR) with their 95% confidence intervals (CI) of e-cigarette use by socio-demographic factors, dual use and nicotine-containing e-cigarettes.

RESULTS

The highest proportion of e-cigarette users who used them in public places was found at restaurants or bars (69.4%) and nightclubs or pubs (55.4%). Also being current conventional tobacco smokers (dual users) was significantly associated with lower use of e-cigarettes in workplaces (OR = 0.61, 95%CI:0.41-0.91), restaurants (OR = 0.66, 95%CI:0.45-0.97) and nightclubs (OR = 0.56, 95%CI:0.37-0.86). Moreover, being a nicotine-containing e-cigarette user was associated with higher odds of using the device in workplaces (OR = 2.01, 95%CI:1.34-3.01), and lower odds of using it in nightclubs (OR = 0.56, 95%CI:0.39-0.82). 96.8% of the included e-cigarette users declared to use the device at home. Being a current tobacco smoker was associated with increased odds of using e-cigarettes at home (OR = 3.17, 95%CI:1.22-8.22).

CONCLUSIONS

E-cigarette use in private settings and in public settings where their use is not regulated by law is high. Therefore, the public health administration in Spain should consider expanding the prohibition of e-cigarette use to indoor public places and should take into account the possibility of exposure to aerosol from e-cigarettes.

Attitudes of students of a health sciences university towards the extension of smoke-free policies at the university campuses of Barcelona (Spain)

OBJECTIVE

To assess attitudes towards the extension of outdoor smoke-free areas on university campuses.

METHODS

Cross-sectional study (n=384) conducted using a questionnaire administered to medical and nursing students in Barcelona in 2014. Information was obtained pertaining to support for indoor and outdoor smoking bans on university campuses, and the importance of acting as role models. Logistic regression analyses were performed to examine agreement.

RESULTS

Most of the students agreed on the importance of health professionals and students as role models (74.9% and 64.1%, respectively) although there were statistically significant differences by smoking status and age. 90% of students reported exposure to smoke on campus. Students expressed strong support for indoor smoke-free policies (97.9%). However, only 39.3% of participants supported regulation of outdoor smoking for university campuses. Non-smokers (OR=12.315; 95% CI: 5.377-28.204) and students ≥22 years old (OR=3.001; 95% CI: 1.439-6.257) were the strongest supporters.

CONCLUSIONS

The students supported indoor smoke-free policies for universities. However, support for extending smoke-free regulations to outdoor areas of university campuses was limited. It is necessary to educate students about tobacco control and emphasise their importance as role models before extending outdoor smoke-free legislation at university campuses.

Second-hand smoke exposure in indoor and outdoor areas of cafés and restaurants: Need for extending smoking regulation outdoors?

Smoke-free legislation in indoor public places has concentrated smokers in the areas outside building entrances or other outdoor areas. This study assessed the drift of second-hand smoke between outdoor and indoor areas of cafés and restaurants in Barcelona, Spain, and characterized the exposure on outdoor terraces. Using a cross-sectional design, we monitored vapor-phase nicotine in indoor areas and outside entrances simultaneously (n=47), and on some outdoor terraces (n=51). We computed the median nicotine concentration and interquartile range (IQR) to describe the data and performed multivariate analysis to describe nicotine concentration and its determinants. The overall median nicotine concentration indoors was 0.65µg/m(3) (IQR: 0.29-1.17µg/m(3)), with significant differences based on the number of smokers at the entrance (p=0.039). At outside entrances, the overall median nicotine concentration was 0.41µg/m(3) (IQR: 0.21-1.17µg/m(3)). The nicotine concentrations indoors and at the corresponding outside entrances were not significantly different, and the multivariate analysis confirmed the relationship between these variables. On terraces, the overall median nicotine concentration was 0.54µg/m(3) (IQR: 0.25-1.14µg/m(3)), but it increased to 0.60µg/m(3) when a tobacco smell was perceived, 0.72µg/m(3) on closed terraces, 1.24µg/m(3) when there were >6 smokers, and 1.24µg/m(3) when someone smoked >20min. Multivariate analysis confirmed the outdoor terrace area, the season, the type of enclosure, and the number of smokers as the most relevant variables explaining nicotine concentration (R(2)=0.396). These findings show that second-hand smoke exposure exists in indoor areas due to smokers smoking at the outside entrances. In addition, exposure may occur on outdoor terraces when smokers are present and the terrace is enclosed to some extent. Thus, the current Spanish law does not fully protect non-smokers from second-hand smoke and supports extending regulation to some outdoor areas.