Effect of smoke-free legislation on adult smoking behaviour in England in the 18 months following implementation

Impact of Total Indoor Smoking Ban on Cardiovascular Disease Hospitalizations and Mortality: The Case of Chile

INTRODUCTION

The harmful effects of first and secondhand smoking are well-established. Smoke-free laws aim at protecting nonsmokers. This study aimed to assess the impact of the 2013 total ban on indoor smoking in Chile on hospitalizations and deaths of major cardiovascular events.

AIMS AND METHODS

The logarithm of the monthly hospitalization and death rates, standardized by age for every 100 000 inhabitants, were estimated for ischemic heart disease, acute myocardial infarction, strokes, and a composite outcome of ischemic heart diseases (which includes acute myocardial infarction) and strokes. In addition, interrupted time series with synthetic control groups were used to assess changes in levels and trends after the intervention.

RESULTS

The total ban on indoor smoking caused significant reductions in death rates for the three diseases studied for age groups above 20 years old. In addition, there were substantial decreases in the post-intervention hospitalization rates for ischemic heart disease: for the 20-44 age group, the decrease was 8.7% compared to the pre-intervention period (p < .01). In comparison, such a reduction was 4% (p < .01) for the ≥65 age group. For acute myocardial infarction, the decrease was 11.5% (p < .01) for the 20-44 age group, while for stroke, it was a 1.2% (p < .01) decrease for the total population. It is estimated that the smoking ban averted 15.6% of the deaths compared with the synthetic control groups.

CONCLUSIONS

The implementation of total smoke-free environments in Chile contributed to the reduction of mortality for main cardiovascular diseases. This study provides additional evidence of causality linking the policy to health outcomes.

IMPLICATIONS

The total indoor smoking ban significantly affected age-standardized hospitalization and deaths. The number of deaths averted by this policy is estimated at approximately 4758 and 5256 for IHD and stroke, respectively, during the 2013-2017 period (15.6% fewer deaths than predicted by the synthetic control groups). The study contributes to the body of evidence that supports total indoor smoking bans.

Association of national smoke-free policies with per-capita cigarette consumption and acute myocardial infarction mortality in Europe

BACKGROUND

Evidence on the association between smoke-free policies and per-capita cigarette consumption and mortality due to acute myocardial infarction (AMI) in Europe is limited. Hence, we aimed to assess this association and to evaluate which factors influence it.

METHODS

We performed an interrupted time series analysis, including 27 member states of the European Union and the UK, on per-capita cigarette consumption and AMI mortality.A multivariate meta-regression was used to assess the potential influence of other factors on the observed associations.

RESULTS

Around half of the smoke-free policies introduced were associated with a level or slope change, or both, of per-capita cigarette consumption and AMI mortality (17 of 35). As for cigarette consumption, the strongest level reduction was observed for the smoking ban issued in 2010 in Poland (rate ratio (RR): 0.47; 95% CI: 0.41, 0.53). Instead, the largest level reduction of AMI mortality was observed for the intervention introduced in 2012 in Bulgaria (RR: 0.38; 95% CI: 0.34, 0.42).Policies issued more recently or by countries with a lower human development index were found to be associated with a larger decrease in per-capita cigarette consumption. In addition, smoking bans applying to bars had a stronger inverse association with both cigarette consumption and AMI mortality.

CONCLUSIONS

The results of our study suggest that smoke-free policies are effective at reducing per-capita cigarette consumption and AMI mortality. It is extremely important to monitor and register data on tobacco, its prevalence and consumption to be able to tackle its health effects with concerted efforts.

Barriers and opportunities for improving smoke-free area implementation in Banda Aceh city, Indonesia: a qualitative study

OBJECTIVES

To investigate the challenges and opportunities for implementing smoke-free areas (SFAs) within eight area categories using the WHO Framework Convention on Tobacco Control as a framework for analysis.

DESIGN

This study used qualitative methods (in-depth interviews and document reviews). All transcripts from the interviews and formal documents were coded using NVivo V.11 software and analysed using an inductive thematic analysis.

SETTING

Banda Aceh, Indonesia.

PARTICIPANTS

Seventy-three participants were interviewed, stratified by ages (18-59 years): policymakers (n=4), SFA implementers (n=33), SFA's non-compliance prosecutors (n=2), SFA observers (n=4), communities/respected figures (n=30); and 10 documents were reviewed.

RESULTS

Barriers to the effective implementation of SFAs were identified: conflict of interests of Banda Aceh authorities in implementing SFA policies; inadequate monitoring, evaluation and implementation of SFAs among involved actors; inadequate public communication of SFAs to communities; and misunderstanding of 'enclosed areas' as SFAs. However, some important opportunities were identified: the Ministry of Education promotes SFA at schools; and smoking prohibition as part of sharia and other religions' recommendations.

CONCLUSIONS

This research is the first study to examine SFAs to understand the challenges and opportunities for improving SFA policy implementation by interviewing various key respondents in Banda Aceh (religious leaders and respected figures). These key stakeholders' roles are crucial to enhance the implementation of SFA policies in Banda Aceh (currently suboptimal) and other populous Muslim areas in Indonesia or other countries because smoking contradicts Islamic teachings and other religions' tenets. Further, the findings propose policymakers and involved agencies strengthen public communication, execution, monitoring and evaluation, and enforcement of SFA policies in Aceh. Finally, the application of methods and results from this study to other local areas in Indonesia or other developing nations is necessary to facilitate further understanding more about the applicability, advantages and limitations of this study.

Association between the extension of smoke-free legislation and incident acute myocardial infarctions in Singapore from 2010 to 2019: an interrupted time-series analysis

BACKGROUND

We examined the association between smoke-free laws implemented in the outdoors and the common areas of residential apartment blocks and reported acute myocardial infarctions (AMI) in Singapore.

METHODS

We used an interrupted time-series design and seasonal autoregressive integrated moving average models to examine the effect of the smoke-free law extensions in 2013 (common areas of residential blocks, covered pedestrian linkways, overhead bridges and within 5 m of bus stops), 2016 (parks) and 2017 (educational institutions, buses and taxis) on the monthly incidence rate of AMIs per 1 000 000 population.

RESULTS

We included 133 868 AMI reports from January 2010 to December 2019. Post-2013, there was a decrease in the AMI incidence trend (β=-0.6 per month, 95%CI -1.0 to -0.29) and 2097 (95% CI 2094 to 2100) more AMIs may have occurred without the extension. There was a significant step-decline in male AMIs and a non-significant step-increase in female AMIs post-2013. Those 65 years and older experienced a greater decline to the postlegislation 2013 trend (β=-5.9, 95% CI -8.7 to -3.1) compared with those younger (β=-0.4, 95% CI -0.6 to -0.2), while an estimated 19 591 (15 711 to 23472) additional AMI cases in those 65 years and above may have occurred without the extension. We found a step-increase in monthly AMI incidence post-2016 (β=14.2, 95%CI 3.3 to 25.0).

CONCLUSION

The 2013 smoke-free law extension to residential estates and other outdoor areas were associated with a decline in AMIs and those above the age of 65 years and men appeared to be major beneficiaries. Additional epidemiological evidence is required to support the expanded smoke-free legislation to parks, educational institutions, buses and taxis.

Environmental determinants of infectious and chronic disease prevention behaviours: A systematic review and thematic synthesis of qualitative research

Regulatory health policies facilitate desired health behaviours in communities, and among them, smoke-free policies and COVID-19 restrictions have been widely implemented. Qualitative research studies have explored how these measures and other environmental influences shape preventive behaviours. The objective of this systematic review was to synthesize previously published qualitative research, generate across-study themes, and propose recommendations for behaviour change interventions. We used a comprehensive search strategy, relevance screening and confirmation, data extraction, quality assessment, thematic synthesis, and quality-of-evidence assessment. In total, 87 relevant studies were identified. Findings were grouped under six overarching themes and mapped under three categories: (i) the political environment, (ii) the sociocultural environment, and (iii) the physical environment. These findings provide insights into the environmental influences of behaviour and indicate future interventions may be more effective by considering moral norms, community norms, policy support, and group identity.

Implementation of the Smoke-Free Policy in Medan City, Indonesia: Compliance and Challenges

Background:

Indonesia has an estimated 61.4 million current smokers, and the smoking prevalence among adults is persistently high while that among youth is increasing. In 2014, Medan city enacted the smoke-free policy (SFP) to protect community members against the adverse effects of smoking. Our study examines the implementation of SFP in terms of compliance and challenges.

Methods:

We conducted a mixed-methods study. Quantitative analyses examined the compliance with six criteria including having signage, no active smoking, no selling, no advertisement, no smoke, and no ashtray at SFP facilities. They included health facilities, educational facilities, places of worship, workplaces, and indoor/outdoor public facilities. The qualitative analysis examined the challenges through in-depth interviews of six key informants.

Results:

We found the overall compliance of 44%, ranging from 0% at outdoor public facilities to 83% at health facilities. We found relatively higher compliance among facilities within 1-km from the provincial and city health offices compared to those outside of the buffer (but not significant at 5% level, P = 0.070). The challenges identified were lack of budget, monitoring, enforcement, and sensitization.

Conclusions:

The implementation of SFP in Medan city still has lower compliance and faces many challenges.

Estimating the equity impacts of the smoking ban in England on cotinine levels: a regression discontinuity design

OBJECTIVE

To estimate the equity impacts of the 2007 smoking ban in England, for both smokers and non-smokers.

DESIGN

Doubly robust regression discontinuity analysis of salivary cotinine levels. Conditional average treatment effects were used to estimate differential impacts of the ban by socioeconomic deprivation (based on the Index of Multiple Deprivation). Distributional impacts were further assessed using conditional quantile treatment effects and inequality treatment effects.

SETTING

In 2007, England introduced a ban on smoking in public places. This had little impact on tobacco consumption by smokers but was associated with decreases in environmental tobacco smoke exposure for non-smokers. However, the impact of the ban on socioeconomic inequalities in exposure is unclear.

PARTICIPANTS

766 smokers and 2952 non-smokers responding to the Health Survey for England in 2007.

OUTCOME MEASURE

Levels of salivary cotinine.

RESULTS

Before the ban, socioeconomic deprivation was associated with higher cotinine levels for non-smokers but not for smokers. The ban caused a significant reduction in average cotinine levels for non-smokers (p=0.043) but had no effect for smokers (p=0.817). Reductions for non-smokers were greater for more deprived groups with higher levels of exposure, and there was a significant reduction in socioeconomic-related inequality in cotinine. Across the whole population (both smokers and non-smokers), there was no significant increase in the concentration of cotinine levels among the socioeconomically deprived.

CONCLUSION

The 2007 ban on smoking in public places had little impact on smokers, but was, as intended, associated with reductions in both (1) average levels of environmental tobacco smoke exposure and (2) deprivation-related inequality in exposure among non-smokers.

Changes in tobacco use patterns and motivation to quit related to the new smoke-free legislation in the Czech Republic

BACKGROUND

Smoke-free policy belongs to key public health instruments to promote health in populations. In 2017, new comprehensive smoke-free law prohibiting smoking in indoor public places was implemented. We aimed to measure changes in tobacco smoking patterns and changes in motivation to quit in adult smokers prior to and after the new smoke-free legislation came into force.

METHODS

We conducted a prospective cohort study prior to and post the implementation of Act No. 65/2017 Coll. Self-reported questionnaires were administered to 131 adult smokers by trained nurses in general practitioner offices in Prague. We analysed changes in cigarette consumption per day; ratio of cigarettes smoked in pub, street, work and home; and motivation to quit using regression modelling.

RESULTS

We found a statistically significant decrease in the daily consumption of cigarettes (an average of 1.7 cigarettes per day, P < 0.001, d = 0.34). Smoking in indoor public spaces decreased to almost zero, while tobacco consumption in outdoor public spaces (such as streets and squares) increased by nearly 20%. We observed statistically significant increase of motivation to quit smoking (P = 0.021, d = 0.21).

CONCLUSION

The study brings valuable indication of the desired public health impact related to key legislative change in the Czech Republic.

Interrupted time series study found mixed effects of the impact of the Bavarian smoke-free legislation on pregnancy outcomes

In 2007 the German government passed smoke-free legislation, leaving the details of implementation to the individual federal states. In January 2008 Bavaria implemented one of the strictest laws in Germany. We investigated its impact on pregnancy outcomes and applied an interrupted time series (ITS) study design to assess any changes in preterm birth, small for gestational age (primary outcomes), and low birth weight, stillbirth and very preterm birth. We included 1,236,992 singleton births, comprising 83,691 preterm births and 112,143 small for gestational age newborns. For most outcomes we observed unclear effects. For very preterm births, we found an immediate drop of 10.4% (95%CI - 15.8, - 4.6%; p = 0.0006) and a gradual decrease of 0.5% (95%CI - 0.7, - 0.2%, p = 0.0010) after implementation of the legislation. The majority of subgroup and sensitivity analyses confirm these results. Although we found no statistically significant effect of the Bavarian smoke-free legislation on most pregnancy outcomes, a substantial decrease in very preterm births was observed. We cannot rule out that despite our rigorous methods and robustness checks, design-inherent limitations of the ITS study as well as country-specific factors, such as the ambivalent German policy context have influenced our estimation of the effects of the legislation.

Compliance with Smoke-Free Policy and Challenges in Implementation: Evidence from Bengkulu, Indonesia

Background:

Smoking is among the top contributors to deaths and disability-adjusted life years in Indonesia, particularly among males. In 2012, a presidential decree encouraged provinces and districts to implement a smoke-free policy (SFP). This study aims to evaluate compliance and explore the challenges in the implementation.

Methods:

Through a mixed-methods design, we used quantitative methods to examine the compliance with six criteria including signage, no active smoking, no selling, no advertisement, no smoke, and no ashtray at SFP facilities in Bengkulu city. We observed SFP compliance at 105 facilities, including health/educational facilities, places of worship, workplaces, and indoor/outdoor public facilities. We also used a qualitative method to explore challenges in the implementation through interviews with the government and legislators.

Results:

The compliance rate to all six criteria was 38% overall, ranging from 17% at outdoor public facilities to 67% at health facilities. We found no spatial patterning, as shown by non-significant differences in compliance rates between SFP facilities inside and outside of 1-kilometer around the provincial and city health offices. Implementation challenges included lack of sensitization, lack of coordination, and limited budget.

Conclusion:

The compliance was relatively low due to several challenges, which could serve as a tobacco control policy lesson in a lower-middle-income country.

Frequency-risk relationships between second-hand smoke exposure and respiratory symptoms among adolescents: a cross-sectional study in South China

OBJECTIVES

Although previous studies have suggested an association between second-hand smoke (SHS) exposure and respiratory symptoms, current evidence is inconsistent. Additionally, it remains unclear whether there are frequency-risk relationships between SHS exposure and respiratory symptoms among adolescents.

METHODS

A cross-sectional survey was conducted using a stratified cluster sampling method to obtain a representative sample of high school students in Guangzhou, China. The respiratory symptoms were defined as persistent cough or sputum for three consecutive months during the past 12 months. Self-reported SHS exposure was defined as non-smokers' inhalation of the smoke exhaled from smokers on ≥1 day a week in the past 7 days. The univariable and multivariable logistic regression models were fitted to explore the potential frequency-risk relationships between SHS exposure and respiratory symptoms.

RESULTS

Among 3575 students, the overall prevalence of SHS exposure was 69.2%, including 49.5% for SHS in public places, 34.5% in homes, 22.7% in indoor campuses and 29.2% in outdoor campuses. There were significantly increased risks of having respiratory symptoms corresponding to SHS exposure in public places (OR=1.60, 95% CI 1.30 to 1.95), in homes (OR=1.53, 95% CI 1.25 to 1.87), in indoor campuses (OR=1.43, 95% CI 1.14 to 1.79) and in outdoor campuses (OR=1.37, 95% CI 1.10 to 1.69) using no exposure as reference. Notably, we observed monotonic frequency-risk relationships between setting-specific(eg, homes, public places and campuses) SHS exposure and respiratory symptoms.

CONCLUSION

Our findings suggest that setting-specific SHS exposure is associated with a significant, dose-dependent increase in risk of respiratory symptoms.

Impacts of smoke-free public places legislation on inequalities in youth smoking uptake: study protocol for a secondary analysis of UK survey data

INTRODUCTION

Smoke-free public places legislation has been introduced in many countries to protect the public from the harmful effects of secondhand smoking. While evaluations of smoke-free policies have demonstrated major public health benefits, the impact on youth smoking and inequalities in smoking remains unclear. This project aims to evaluate how smoke-free public places legislation in the UK has impacted on inequalities in youth smoking uptake, and how much of any impact is via changes in parental smoking behaviour.

METHODS AND ANALYSIS

The study will constitute secondary analyses of UK data (from the British Household Panel Survey and the Understanding Society study). Merging these datasets gives coverage of the period from 1994 to 2016. Missing data will be handled using multiple imputation. The primary outcomes are the rates and inequalities in initiation, experimentation, escalation to daily smoking and quitting among youths aged 11-15 years. Secondary outcomes include the prevalence of smoking among parents of these youths. Discrete-time event history analysis will be conducted to examine whether changes in the probability of youth smoking transitions are associated with the implementation of the smoke-free public places legislation; and whether any observed effects differ by socioeconomic position and parental smoking. A multilevel logistic regression model will be used to investigate whether there is a step change or change in trend for the prevalence of parental smoking after the policy was implemented. The models will be adjusted for relevant factors (including cigarette taxation, the change in the legal age for purchase of cigarettes and e-cigarette prevalence) that may be associated with the implementation of the legislation.

ETHICS AND DISSEMINATION

This project will use anonymised survey data which have been collected following independent ethical review. The dissemination of the study findings will adopt multiple communication channels targeting both scientific and non-scientific audiences.

Prevalence and factors associated with smoking among adults in Malaysia: Findings from the National Health and Morbidity Survey (NHMS) 2015

INTRODUCTION

The continuous monitoring of smoking prevalence and its associated factors is an integral part of anti-smoking programmes and valuable for the evaluation of the effectiveness of anti-smoking measures and policies. This study aimed at determining prevalence of smoking and identifying socio-demographic factors associated with smoking among adults in Malaysia aged 15 years and over.

METHODS

This is a cross-sectional study with a representative sample of 21 445 adults in Malaysia, aged 15 years and over, selected via a stratified, two-stage proportionate-to-size sampling method. Data were obtained from face-to-face interviews by trained research assistants, using a standard validated questionnaire. Multivariable logistic regression was performed to determine socio-demographic factors associated with smoking among Malaysians.

RESULTS

The overall prevalence of smoking was 22.8% (95% CI: 21.9-23.8%), with males having a significantly higher prevalence compared to females (43.0%, 95% CI: 41.1-44.6 vs 1.4%, 95% CI: 1.1-1.7). The highest smoking prevalence was observed among other ethnicities (35.7%), those aged 25-44 years (59.3%), and low educational attainment (25.2%). Males, those with lower educational attainment and Malays were significantly associated with smoking.

CONCLUSIONS

The prevalence of smoking among Malaysians, aged 15 years and over, remains high despite the implementation of several anti-smoking measures over the past decades. Specially tailored anti-smoking policies or measures, particularly targeting males, the Malays, younger adults and those with lower educational attainment, are greatly warranted to reduce the prevalence of smoking in Malaysia.

Exposure to tobacco secondhand smoke and its associated factors among non-smoking adults in smoking-restricted and non-restricted areas: findings from a nationwide study in Malaysia

OBJECTIVES

Secondhand smoke (SHS) has been associated with increased morbidity and mortality. Therefore, the aims of the paper are to assess SHS exposure among non-smoking adults in Malaysia attending various smoking-restricted and non-restricted public areas according to the Control of Tobacco Product Regulations (CTPR) as well as its relationship with various sociodemographic variables.

DESIGN

Data were extracted from a cross-sectional study, the Global Adults Tobacco Survey (GATS) 2011 which involved 3269 non-smokers in Malaysia. Data was obtained through face-to-face interviews using a validated pre-tested questionnaire. Factors associated with exposure to SHS were identified via multivariable analysis.

RESULTS

The study revealed that almost two-thirds of respondents were exposed to SHS in at least one public area in the past 1 month, with a significantly higher exposure among males (70.6%), those with higher educational attainment (81.4%) and higher income (quintile 1%-73.9%). Besides, the exposure to SHS was almost four times higher in non-restricted areas compared with restricted areas under the CTPR (81.9% vs 22.9). Multivariable analysis revealed that males and younger adults at non-restricted areas were more likely to be exposed to SHS while no significant associated factors of SHS exposure was observed in restricted areas.

CONCLUSIONS

The study revealed the prevalence of SHS exposure was higher among Malaysian adults. Although smoke-free laws offer protection to non-smokers from exposure to SHS, enforcement activities in restricted areas should be enhanced to ensure strict public abidance. In addition, legislation of restricted areas should also be extended to greatly reduce the SHS exposure among non-smokers in Malaysia.

Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis

BACKGROUND

Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health.

METHODS

We searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448.

FINDINGS

We identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (-3·77% [95% CI -6·37 to -1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (-9·83% [-16·62 to -3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (-3·45% [-4·64 to -2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (-18·48% [-32·79 to -4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias.

INTERPRETATION

Smoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world.

FUNDING

Chief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC.

Manufactured and roll-your-own cigarettes: A changing pattern of smoking in Barcelona, Spain

AIMS

The objectives of the present study were to describe smoking prevalence and compare the smoking attributes of adult smokers according to the type of tobacco product consumed.

METHODS

Repeated cross-sectional surveys (2004-2005 and 2011-2012) of a representative sample of the adult (≥16 years) population in Barcelona, Spain, were used to assess self-reported tobacco consumption, smoking attributes, and salivary cotinine concentration. The survey conducted in 2004-2005 included information on 1245 subjects and the survey in 2011-2012 on 1307 individuals.

RESULTS

Smoking prevalence decreased over the study period (from 26.6% to 24.1% in self-reported daily smokers). The prevalence of daily smokers who reported the use of manufactured cigarettes declined from 23.7% in 2004-2005 to 17.3% in 2011-2012. The prevalence of roll-your-own cigarette users increased from 0.4% to 3.7%. According to data obtained in 2011-2012, the proportion of self-reported roll-your-own cigarette users was higher among men (19.8% vs. 9.5% of women), participants aged 16-44 years (22.9% vs. 5.8% of participants aged 45-65 years and 4.0% of participants aged ≥65 years), and participants with secondary and university education (17.7% and 18.5% vs. 7.9% of participants with less than primary and primary education). We did not observe differences in cotinine concentrations according to the type of tobacco product consumed.

CONCLUSIONS

Systematic collection of data on smoking prevalence and smoker attributes from representative samples of the population is necessary for policymakers to develop efficient tobacco control interventions. Considering the increase of roll-your-own cigarette users and the unclear health consequences of their use, policymakers should aim to implement tax policies to equalize the prices of different types of tobacco products.

Impact on smoking of England's 2012 partial tobacco point of sale display ban: a repeated cross-sectional national study

BACKGROUND

A partial tobacco point of sale (PoS) display ban was introduced in large shops (>280 m2 floor area) in England on 6 April 2012. The aim of this study was to assess the medium-term effects of the partial tobacco PoS display ban on smoking in England.

METHODS

Data were used from 129 957 respondents participating in monthly, cross-sectional household surveys of representative samples of the English adult population aged 18+ years from January 2009 to February 2015. Interrupted-time series regression models assessed step changes in the level of current smoking and cigarette consumption in smokers and changes in the trends postban compared with preban. Models were adjusted for sociodemographic variables and e-cigarette use, seasonality and autocorrelation. Potential confounding by cigarette price was accounted for by time, as price was almost perfectly correlated with time.

RESULTS

Following the display ban, there was no immediate step level change in smoking (-3.69% change, 95% CI -7.94 to 0.75, p=0.102) or in cigarette consumption (β -0.183, 95% CI -0.602 to 0.236). There was a significantly steeper decline in smoking post display ban (-0.46% change, 95% CI -0.72 to -0.20, p=0.001). This effect was demonstrated by respondents in manual occupations (-0.62% change, 95% CI -0.72 to -0.20, p=0.001), but not for those in non-manual occupations (-0.42, 95% CI -0.90 to 0.06, p=0.084). Cigarette consumption declined preban period (β -0.486, 95% CI -0.633 to -0.339, p<0.001), but no significant change in cigarette consumption trend was observed (β 0.019, 95% CI -0.006 to 0.042, p=0.131).

CONCLUSIONS

The partial tobacco PoS display ban introduced in England in April 2012 did not lead to an immediate decline in smoking, but was followed by a decline in the trend of smoking prevalence that could not be accounted for by seasonal factors, e-cigarette use or price changes.

Smoke-free legislation and child health

In this paper, we aim to present an overview of the scientific literature on the link between smoke-free legislation and early-life health outcomes. Exposure to second-hand smoke is responsible for an estimated 166 ,000 child deaths each year worldwide. To protect people from tobacco smoke, the World Health Organization recommends the implementation of comprehensive smoke-free legislation that prohibits smoking in all public indoor spaces, including workplaces, bars and restaurants. The implementation of such legislation has been found to reduce tobacco smoke exposure, encourage people to quit smoking and improve adult health outcomes. There is an increasing body of evidence that shows that children also experience health benefits after implementation of smoke-free legislation. In addition to protecting children from tobacco smoke in public, the link between smoke-free legislation and improved child health is likely to be mediated via a decline in smoking during pregnancy and reduced exposure in the home environment. Recent studies have found that the implementation of smoke-free legislation is associated with a substantial decrease in the number of perinatal deaths, preterm births and hospital attendance for respiratory tract infections and asthma in children, although such benefits are not found in each study. With over 80% of the world’s population currently unprotected by comprehensive smoke-free laws, protecting (unborn) children from the adverse impact of tobacco smoking and SHS exposure holds great potential to benefit public health and should therefore be a key priority for policymakers and health workers alike.

Effects of Enactment of Legislative (Public) Smoking Bans on Voluntary Home Smoking Restrictions: A Review

INTRODUCTION

The positive effects of worldwide increases in enactment of legislative bans on smoking in public areas have been well documented. Relatively little is known about the effects of such bans on voluntary home smoking behavior. Meanwhile, private spaces, such as homes, have replaced public spaces as the primary milieu of secondhand smoke exposure.

METHODS

A systematic search of peer-reviewed articles was conducted using multiple databases including Cochrane Library, Cinahl, Embase, Global Health, Health Star, Joanna Briggs, MEDLINE, PsycINFO, PAIS International, PubMed, and Web of Science. We examined peer-reviewed studies that considered the impact of legislation-based public smoking bans on enactment of private home smoking restrictions.

RESULTS

Sixteen articles published between 2002 and 2014 were identified and included. Our results suggest overall positive effects post-legislative ban with the majority of studies demonstrating significant increases in home smoking restrictions. Studies focusing on smoking and nonsmoking samples as well as child populations are discussed in depth.

CONCLUSIONS

Existing evidence indicates an overall significant positive effect post-legislative ban on voluntary home smoking restrictions. While disentangling these effects over space and time remains a challenge, scientific research has converged in dispelling any notion of significant displacement of smoking into the home. Policy makers, especially those in countries without existing public smoking legislation, can rest assured that these types of bans contribute to the minimization of tobacco-related harm.

IMPLICATIONS

Findings converge in dispelling notions of displacement of smoking into the home as a consequence of legislative bans that prohibit smoking in public spaces. Evidence from the studies reviewed suggests that through their influence on social norms, legislative bans on smoking in public places may encourage citizens to establish voluntary home smoking restrictions, thus decreasing harm related to secondhand smoke.

Compliance to the smoke-free law in Guatemala 5-years after implementation

BACKGROUND

Smoke-free environments decrease smoking prevalence and consequently the incidence of heart disease and lung cancer. Due to issues related to poor enforcement, scant data is currently available from low/middle income countries on the long-term compliance to smoke-free laws. In 2006, high levels of secondhand smoke (SHS) were found in bars and restaurants in Guatemala City. Six months after a smoking ban was implemented in 2009, levels significantly decreased. However, in 2010, poor law compliance was observed. Therefore, we sought to assess long-term compliance to the ban using SHS measurements.

METHODS

In 2014 we assessed SHS exposure using airborne nicotine monitors in bars (n = 9) and restaurants (n = 12) for 7 days using the same protocol as in 2006 and in 2009. Nicotine was measured using gas-chromatography (μg/m(3)) and compared to levels pre- (2006) and post-ban (2009). Employees responded to a survey about SHS exposure, perceived economic impact of the ban and customers' electronic cigarette use. In addition, we estimated the fines that could have been collected for each law infringement.

RESULTS

Most (71 %) venues still have a smoking section, violating the law. The percentage of samples with detectable nicotine concentrations was 100, 85 and 43 % in 2006, 2009 and 2014, respectively. In bars, median (25(th) and 75(th) percentiles) nicotine concentrations were 4.58 μg/m(3) (1.71, 6.45) in 2006, 0.28 (0.17, 0.66) in 2009, and 0.59 (0.01, 1.45) in 2014. In restaurants, the corresponding medians were 0.58 μg/m(3) (0.44, 0.71), 0.04 (0.01, 0.11), and 0.01 (0.01, 0.09). Support for the law continues to be high (88 %) among bar and restaurant employees. Most employees report no economic impact of the law and that a high proportion of customers (78 %) use e-cigarettes. A total of US$50,012 could have been collected in fines.

CONCLUSIONS

Long-term compliance to the smoking ban in Guatemala is decreasing. Additional research that evaluates the determinants of non-compliance is needed and could also contribute to improve enforcement and implementation of the smoke-free law in Guatemala.

Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans affecting populations. The minimum standard was having an indoor smoking ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. Our search included a broad range of research designs including: randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before-and-after studies, interrupted time series as defined by the Cochrane Effective Practice and Organisation of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

Smoking behaviors before and after implementation of a smoke-free legislation in Guangzhou, China

Background

According to the partial smoke-free legislation implemented on 1 September 2010 in Guangzhou, China, smoke-free did not cover all indoor areas. Some places have a full smoking ban (100 % smoke-free), other places have a partial smoking ban, and homes have no ban. This study aimed to compare the smoking behaviors before and after implementation of a smoke-free legislation.

Method

A repeated cross-sectional survey was conducted on smoking-related behaviors with a total of 4,900 respondents before, and 5,135 respondents after the legislation was instituted. For each wave of the survey, a three-stage stratified sampling process was used to obtain a representative sample. Pearson’s Chi-square test was used to determine differences of smoking prevalence and quit ratio between the two samples. Logistic regression models were used to examine the associations of a smoke-free legislation with smoking behaviors.

Results

The overall daily smoking rate declined significantly from 20.8 % to 18.2 % (p < 0.05), especially among those aged 15–24 years. The quit ratios increased significantly (from 14.5 % to 17.9 %), but remained low among 15–44 year olds. The overall self-reported smoking behaviors in locations with a full smoking ban decreased significantly from 36.4 % to 24.3 % with the greater drops occurring in cultural venues, public transport vehicles, and government offices. Smoking in places with partial smoking bans remained high (89.6 % vs. 90.4 %), although a slight decrease was observed in some of these areas. The implementation of a smoke-free legislation did not lead to more smoking in homes (91.0 % vs 89.4 %), but smoking in homes remained high.

Conclusions

These findings highlight the urgent need for a comprehensive smoke-free legislation covering all public places in Guangzhou, simultaneously educational interventions and campaigns promoting voluntary changes in home smoking need to occur.

Impact of smoke-free legislation on perinatal and infant mortality: a national quasi-experimental study

Smoke-free legislation is associated with improved early-life outcomes; however its impact on perinatal survival is unclear. We linked individual-level data with death certificates for all registered singletons births in England (1995–2011). We used interrupted time series logistic regression analysis to study changes in key adverse perinatal events following the July 2007 national, comprehensive smoke-free legislation. We studied 52,163 stillbirths and 10,238,950 live-births. Smoke-free legislation was associated with an immediate 7.8% (95%CI 3.5–11.8; p < 0.001) reduction in stillbirth, a 3.9% (95%CI 2.6–5.1; p < 0.001) reduction in low birth weight, and a 7.6% (95%CI 3.4–11.7; p = 0.001) reduction in neonatal mortality. No significant impact on SIDS was observed. Using a counterfactual scenario, we estimated that in the first four years following smoke-free legislation, 991 stillbirths, 5,470 cases of low birth weight, and 430 neonatal deaths were prevented. In conclusion, smoke-free legislation in England was associated with clinically important reductions in severe adverse perinatal outcomes.

Smoke-free legislation and childhood hospitalisations for respiratory tract infections

Second-hand smoke exposure is a major risk factor for respiratory tract infections (RTIs). Although evidence suggests important early-life health benefits of smoke-free public environments, the impact on childhood RTIs is unclear. We investigated the association between England's smoke-free legislation and childhood RTI hospitalisations.

We used the Hospital Episode Statistics database to obtain nationwide data on hospital admissions for acute RTIs among children (<15 years of age) from 2001 to 2012. Hospitalisation counts were disaggregated by month, age group, sex and small-area level, and linked to urbanisation, region, deprivation index and corresponding population estimates. Negative binomial regression analyses were adjusted for confounders, seasonal variation, temporal autocorrelation, population-size changes and underlying incidence trends. Models allowed for sudden and gradual changes following the smoke-free legislation. We performed sensitivity and subgroup analyses, and estimated number of events prevented.

We analysed 1 651 675 hospital admissions. Introduction of smoke-free legislation was followed by an immediate reduction in RTI admissions (−3.5%, 95% CI −4.7– −2.3%), this mainly being attributable to a decrease in lower RTI admissions (−13.8%, 95% CI −15.6– −12.0%). The reductions in admissions for upper RTI were more incremental.

The introduction of national smoke-free legislation in England was associated with ∼11 000 fewer hospital admissions per year for RTIs in children.

Financial Incentives and Inequalities in Smoking Cessation Interventions in Primary Care: Before-and-After Study

INTRODUCTION

The Quality and Outcomes Framework (QOF) is a financial incentive scheme that rewards UK general practices for providing evidence-based care, including smoking cessation advice mainly as a secondary prevention intervention. We examined the effects on smoking outcomes and inequalities of a local version of QOF (QOF+), which ran from 2008 to 2011 and extended financial incentives to the provision of cessation advice as a primary prevention intervention.

METHODS

Before-and-after study using data from 28 general practices in Hammersmith & Fulham, London, United Kingdom. We used logistic regression to examine changes in smoking outcomes associated with QOF+ within and between sociodemographic groups.

RESULTS

Recording of smoking status increased from 55.5% to 64.3% for men (P < .001) and from 67.9% to 75.8% for women (P < .001). All groups benefitted from the increase, but younger patients remained less likely to be asked about smoking than older patients. White patients were less likely to be asked than those from other ethnic groups. Smoking cessation advice increased from 32.7% to 54.0% for men (P < .001) and from 35.4% to 54.1% for women (P < .01) and there was little variation between groups for this outcome. Recorded smoking prevalence reduced from 25.0% to 20.8% for men (P < .001) and from 16.1% to 12.5% for women (P < .001). White patients and those from more deprived areas remained more likely to be smokers than other groups.

CONCLUSION

The introduction of QOF+ was associated with general improvements in recording of smoking outcomes, but inequalities in ascertainment and smoking prevalence with respect to age, ethnicity, and deprivation persisted.

Ruptured abdominal aortic aneurysms: decreasing incidence may reduce the impact of a Scottish screening programme

Objectives

The aim of this study was to determine whether there has been a change in annual ruptured abdominal aortic aneurysm admissions and elective abdominal aortic aneurysm repairs in a tertiary vascular surgery department.

Methods

All patients admitted with ruptured abdominal aortic aneurysm from 1987 to 2009 and all undergoing elective abdominal aortic aneurysm repair from 1995 to 2009 were identified from the local surgical audit database. Annual ruptured abdominal aortic aneurysm admissions were calculated and compared in the first and second halves of the study period.

Results

During a 23-year period, 888 patients (male 728, female 158, gender was not documented for two patients) were identified with a ruptured abdominal aortic aneurysm. The annual number of admissions remained relatively constant from 1987 to 1997, with a mean of 44 (95% CI 39.91–48.09). There was a significant decrease to a mean of 33.67 per annum (95% CI 28.53–38.8) in the period 1998–2009, p = 0.006. The mean mortality was 39.8% and showed no significant decrease. There was no increase in the number of elective abdominal aortic aneurysm repairs during the study period.

Conclusions

This study suggests that the incidence of ruptured abdominal aortic aneurysms is decreasing, mirroring the trend seen in other cardiovascular disease. As such, further analysis as to the cost-effectiveness of a Scottish screening programme is merited.

Time series analysis of the impact of tobacco control policies on smoking prevalence among Australian adults, 2001-2011

OBJECTIVE

To determine the impact of tobacco control policies and mass media campaigns on smoking prevalence in Australian adults.

METHODS

Data for calculating the average monthly prevalence of smoking between January 2001 and June 2011 were obtained via structured interviews of randomly sampled adults aged 18 years or older from Australia's five largest capital cities (monthly mean number of adults interviewed: 2375). The influence on smoking prevalence was estimated for increased tobacco taxes; strengthened smoke-free laws; increased monthly population exposure to televised tobacco control mass media campaigns and pharmaceutical company advertising for nicotine replacement therapy (NRT), using gross ratings points; monthly sales of NRT, bupropion and varenicline; and introduction of graphic health warnings on cigarette packs. Autoregressive integrated moving average (ARIMA) models were used to examine the influence of these interventions on smoking prevalence.

FINDINGS

The mean smoking prevalence for the study period was 19.9% (standard deviation: 2.0%), with a drop from 23.6% (in January 2001) to 17.3% (in June 2011). The best-fitting model showed that stronger smoke-free laws, tobacco price increases and greater exposure to mass media campaigns independently explained 76% of the decrease in smoking prevalence from February 2002 to June 2011.

CONCLUSION

Increased tobacco taxation, more comprehensive smoke-free laws and increased investment in mass media campaigns played a substantial role in reducing smoking prevalence among Australian adults between 2001 and 2011.

Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis

BACKGROUND

Smoke-free legislation has the potential to reduce the substantive disease burden associated with second-hand smoke exposure, particularly in children. We investigated the effect of smoke-free legislation on perinatal and child health.

METHODS

We searched 14 online databases from January, 1975 to May, 2013, with no language restrictions, for published studies, and the WHO International Clinical Trials Registry Platform for unpublished studies. Citations and reference lists of articles of interest were screened and an international expert panel was contacted to identify additional studies. We included studies undertaken with designs approved by the Cochrane Effective Practice and Organisation of Care that reported associations between smoking bans in workplaces, public places, or both, and one or more predefined early-life health indicator. The primary outcomes were preterm birth, low birthweight, and hospital attendances for asthma. Effect estimates were pooled with random-effects meta-analysis. This study is registered with PROSPERO, number CRD42013003522.

FINDINGS

We identified 11 eligible studies (published 2008-13), involving more than 2·5 million births and 247,168 asthma exacerbations. All studies used interrupted time-series designs. Five North American studies described local bans and six European studies described national bans. Risk of bias was high for one study, moderate for six studies, and low for four studies. Smoke-free legislation was associated with reductions in preterm birth (four studies, 1,366,862 individuals; -10·4% [95% CI -18·8 to -2·0]; p=0·016) and hospital attendances for asthma (three studies, 225,753 events: -10·1% [95% CI -15·2 to -5·0]; p=0·0001). No significant effect on low birthweight was identified (six studies, >1·9 million individuals: -1·7% [95% CI -5·1 to 1·6]; p=0·31).

INTERPRETATION

Smoke-free legislation is associated with substantial reductions in preterm births and hospital attendance for asthma. Together with the health benefits in adults, this study provides strong support for WHO recommendations to create smoke-free environments.

FUNDING

Thrasher Fund, Lung Foundation Netherlands, International Paediatric Research Foundation, Maastricht University, Commonwealth Fund.

Comprehensive smoke-free policies: a tool for improving preconception health?

Lower income women are at higher risk for preconception and prenatal smoking, are less likely to spontaneously quit smoking during pregnancy, and have higher prenatal relapse rates than women in higher income groups. Policies prohibiting tobacco smoking in public places are intended to reduce exposure to secondhand smoke; additionally, since these policies promote a smoke-free norm, there have been associations between smoke-free policies and reduced smoking prevalence. Given the public health burden of smoking, particularly among women who become pregnant, our objective was to assess the impact of smoke-free policies on the odds of preconception smoking among low-income women. We estimated the odds of preconception smoking among low-income women in Ohio between 2002 and 2009 using data from repeated cross-sectional samples of women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). A logistic spline regression was applied fitting a knot at the point of enforcement of the Ohio Smoke-free Workplace Act to evaluate whether this policy was associated with changes in the odds of smoking. After adjusting for individual- and environmental-level factors, the Ohio Smoke-free Workplace Act was associated with a small, but statistically significant reduction in the odds of preconception smoking in WIC participants. Comprehensive smoke-free policies prohibiting smoking in public places and workplaces may also be associated with reductions in smoking among low-income women. This type of policy or environmental change strategy may promote a tobacco-free norm and improve preconception health among a population at risk for smoking.

Tobacco smoke exposure in public places and workplaces after smoke-free policy implementation: a longitudinal analysis of smoker cohorts in Mexico and Uruguay

OBJECTIVE

To determine the prevalence, correlates and changes in secondhand smoke (SHS) exposure over the period after comprehensive smoke-free policy implementation in two Latin American countries.

METHODS

Data were analysed from population-based representative samples of adult smokers and recent quitters from the 2008 and 2010 waves of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 1766 and 1840, respectively) and Uruguay (n = 1379 and 1411, respectively). Prevalence of SHS exposure was estimated for regulated venues, and generalized estimating equations were used to determine correlates of SHS exposure.

RESULTS

Workplace SHS exposure in the last month was similar within and across countries (range: Mexico 20-25%; Uruguay 14-29%). At the most recent restaurant visit, SHS exposure was lower where comprehensive smoke-free policies were implemented (range: Uruguay 6-9%; Mexico City 5-7%) compared with Mexican cities with weaker policies, where exposure remained higher but decreased over time (32-17%). At the most recent bar visit, SHS exposure was common (range: Uruguay 8-36%; Mexico City 23-31%), although highest in jurisdictions with weaker policies (range in other Mexican cities: 74-86%). In Uruguay, males were more likely than females to be exposed to SHS across venues, as were younger compared with older smokers in Mexico.

CONCLUSIONS

Comprehensive smoke-free policies are more effective than weaker policies, although compliance in Mexico and Uruguay is not as high as desired.

Association between clean indoor air laws and voluntary smokefree rules in homes and cars

OBJECTIVES

This study examines the influence that smokefree workplaces, restaurants and bars have on the adoption of smokefree rules in homes and cars, and whether there is an association with adopting smokefree rules in homes and cars.

METHODS

Bivariate probit models were used to jointly estimate the likelihood of living in a smokefree home and having a smokefree car as a function of law coverage and other variables. Household data were obtained from the nationally representative Social Climate Survey of Tobacco Control 2001, 2002 and 2004-2009; clean indoor air law data were from the American Nonsmokers' Rights Foundation Tobacco Control Laws Database.

RESULTS

'Full coverage' and 'partial coverage' smokefree legislation is associated with an increased likelihood of having voluntary home and car smokefree rules compared with 'no coverage'. The association between 'full coverage' and smokefree rule in homes and cars is 5% and 4%, respectively, and the association between 'partial coverage' and smokefree rules in homes and cars is 3% and 4%, respectively. There is a positive association between the adoption of smokefree rules in homes and cars.

CONCLUSIONS

Clean indoor air laws provide the additional benefit of encouraging voluntary adoption of smokefree rules in homes and cars.

Hospital admissions for childhood asthma after smoke-free legislation in England

OBJECTIVE

To assess whether the implementation of English smoke-free legislation in July 2007 was associated with a reduction in hospital admissions for childhood asthma.

METHODS

Interrupted time series study using Hospital Episodes Statistics data from April 2002 to November 2010. Sample consisted of all children (aged ≤14 years) having an emergency hospital admission with a principle diagnosis of asthma.

RESULTS

Before the implementation of the legislation, the admission rate for childhood asthma was increasing by 2.2% per year (adjusted rate ratio 1.02; 95% confidence interval [CI]: 1.02-1.03). After implementation of the legislation, there was a significant immediate change in the admission rate of -8.9% (adjusted rate ratio 0.91; 95% CI: 0.89-0.93) and change in time trend of -3.4% per year (adjusted rate ratio 0.97; 95% CI: 0.96-0.98). This change was equivalent to 6802 fewer hospital admissions in the first 3 years after implementation. There were similar reductions in asthma admission rates among children from different age, gender, and socioeconomic status groups and among those residing in urban and rural locations.

CONCLUSIONS

These findings confirm those from a small number of previous studies suggesting that the well-documented population health benefits of comprehensive smoke-free legislation appear to extend to reducing hospital admissions for childhood asthma.

Smokefree home rules adoption by smokers and nonsmokers: Minnesota, 1999-2010

BACKGROUND

Smokefree workplace policies have successfully limited indoor exposure to secondhand smoke. However, exposure still exists in other indoor locations, most notably in the home.

PURPOSE

This paper examines change in the public's awareness of secondhand smoke harm, exposure to secondhand smoke, and prevalence of smokefree home rules between 1999 and 2010 in Minnesota.

METHODS

The Minnesota Adult Tobacco Survey is a statewide, cross-sectional, random-digit-dial telephone-based survey. The survey measures tobacco use, behaviors, attitudes, and beliefs among adults aged 18 and older in 1999, 2003, 2007, and 2010. Analysis was conducted in 2011.

RESULTS

There was a significant decrease in self-reported exposure to secondhand smoke among all nonsmokers in Minnesota from 2003 (60.9%) to 2010 (37.7%) (p<0.05). The prevalence of smokefree home rules adoption among all Minnesotans increased significantly between each time point: 1999 (64.5%); 2003 (74.8%); 2007 (83.2%); 2010 (87.2%) (p<0.05). Although smokers tended to adopt smokefree home rules at rates lower than nonsmokers, the percentage of smokefree home rules among smokers nearly doubled between 1999 (31.4%) and 2010 (58.1%) (p<0.05).

CONCLUSIONS

Over 10 years, Minnesotans reported a significant decline in exposure to secondhand smoke and a significant increase in voluntary smokefree home rules. Such a trend is notable as virtually all public tobacco control efforts were aimed at raising awareness and support for smokefree policies within workplaces. These findings demonstrate positive changes in social norms and suggest that behavior change in public settings might also be translated into practice in private settings.

Impact of the 2005 smoke-free policy in Italy on prevalence, cessation and intensity of smoking in the overall population and by educational group

AIMS

To estimate the immediate as well as the longer-term impact of the 2005 smoke-free law on smoking prevalence, cessation and intensity both in the overall population and separately by educational level.

DESIGN

Interrupted time-series analyses of 11 cross-sectional nationally representative surveys.

SETTING

Italy, 1999-2010.

PARTICIPANTS

Adults aged 20-64 years.

MEASUREMENTS

For each year we computed the prevalence of current smoking, the quit ratio and the mean number of cigarettes smoked per day. All measures were standardized by age. Segmented linear regression analyses were performed for each smoking variable separately by sex.

FINDINGS

Among males, smoking prevalence decreased by 2.6% (P = 0.002) and smoking cessation increased by 3.3% (P = 0.006) shortly after the ban, but both measures tended to return to pre-ban values in the following years. This occurred among both highly and low-educated males. Among low-educated females, the ban was followed by a 1.6% decrease (P = 0.120) in smoking prevalence and a 4.5% increase in quit ratios (P < 0.001). However, these favourable trends reversed over the following years. Among highly educated females, trends in smoking prevalence and cessation were not altered by the ban. Among both males and females, long-term trends in the daily number of cigarettes, which were already declining well before the implementation of the policy, changed to a minor extent.

CONCLUSION

The impact of the Italian smoke-free policy on smoking and inequalities in smoking was short-term. Smoke-free policies may not achieve the secondary effect of reducing smoking prevalence in the long term, and they may have limited effects on inequalities in smoking.

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

Background. Policymakers need estimates of the impact of tobacco control (TC) policies to set priorities and targets for reducing tobacco use. We systematically reviewed the independent effects of TC policies on smoking behavior. Methods. We searched MEDLINE (through January 2012) and EMBASE and other databases through February 2009, looking for studies published after 1989 in any language that assessed the effects of each TC intervention on smoking prevalence, initiation, cessation, or price participation elasticity. Paired reviewers extracted data from studies that isolated the impact of a single TC intervention. Findings. We included 84 studies. The strength of evidence quantifying the independent effect on smoking prevalence was high for increasing tobacco prices and moderate for smoking bans in public places and antitobacco mass media campaigns. Limited direct evidence was available to quantify the effects of health warning labels and bans on advertising and sponsorship. Studies were too heterogeneous to pool effect estimates. Interpretations. We found evidence of an independent effect for several TC policies on smoking prevalence. However, we could not derive precise estimates of the effects across different settings because of variability in the characteristics of the intervention, level of policy enforcement, and underlying tobacco control environment.

Comparative impact of smoke-free legislation on smoking cessation in three European countries

BACKGROUND

Little is known about the differential impact of comprehensive and partial smoke-free legislation on smoking cessation. This study aimed to examine the impact of comprehensive smoke-free workplace legislation in Ireland and England, and partial hospitality industry legislation in the Netherlands on quit attempts and quit success.

METHODS

Nationally representative samples of 2,219 adult smokers were interviewed in three countries as part of the International Tobacco Control (ITC) Europe Surveys. Quit attempts and quit success were compared between period 1 (in which smoke-free legislation was implemented in Ireland and the Netherlands) and period 2 (in which smoke-free legislation was implemented in England).

RESULTS

In Ireland, significantly more smokers attempted to quit smoking in period 1 (50.5%) than in period 2 (36.4%) (p < 0.001). Percentages of quit attempts and quit success did not change significantly between periods in the Netherlands. English smokers were significantly more often successful in their quit attempt in period 2 (47.3%) than in period 1 (26.4%) (p = 0.011). In the first period there were more quit attempts in Ireland than in England and fewer in the Netherlands than in Ireland. Fewer smokers quitted successfully in the second period in both Ireland and the Netherlands than in England.

CONCLUSION

The comprehensive smoke-free legislation in Ireland and England may have had positive effects on quit attempts and quit success respectively. The partial smoke-free legislation in the Netherlands probably had no effect on quit attempts or quit success. Therefore, it is recommended that countries implement comprehensive smoke-free legislation.

Predictors of car smoking rules among smokers in France, Germany and the Netherlands

BACKGROUND

As exposure to tobacco smoke pollution (TSP) has been identified as a cause of premature death and disease in non-smokers, and studies have demonstrated that smoking in cars produces high levels of TSP, this study will investigate smokers' rules for smoking in their cars, and predictors of car smoking rules, including potentially modifiable correlates.

METHODS

Data were drawn from nationally representative samples of current smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), and the Netherlands (2008). Smokers in France and Germany were asked about smoking rules in their cars, and smokers in the Netherlands were asked about smoking rules in cars carrying children.

RESULTS

In France and Germany, 59% and 52% of smokers respectively, allowed smoking in their cars. In the Netherlands, 36% of smokers allowed smoking in cars carrying children. Predictors of allowing smoking in cars included: being a daily vs. non-daily smoker, being younger vs. older age, having no (young) children in the home, being a heavier smoker, and allowing smoking in the home. In the Netherlands, smokers who agreed that TSP is dangerous to non-smokers were less likely to allow smoking in cars carrying children.

CONCLUSION

Overall, a sizeable proportion of smokers allowed smoking in their cars across the three countries. Media campaigns with information about the dangers of TSP may increase the adoption of smoke-free cars. These media campaigns could target smokers who are most likely to allow smoking in cars.