Impact of Scotland's comprehensive, smoke-free legislation on stroke

Effect of a two-phase tobacco control regulation on incidence from ischemic stroke and hemorrhagic stroke, Shenzhen, China, 2007-2016

INTRODUCTION

The Shenzhen government is widely considered to be most efficiently implementing smoke-free legislation in China. We evaluated and compared the impact of Shenzhen's two-phase smoke-free regulation on the incidence rates for ischemic and hemorrhagic stroke.

METHODS

An interrupted time series design was used to capture immediate and annual incidence changes from 2007 to 2016 for both ischemic and hemorrhagic stroke due to two-phase smoke-free regulation in Shenzhen, China, by using a generalized additive model. The first phase, implemented on 9 March 2010, required five main public places to be smoke-free. In the second phase, the comprehensive law was expanded to the whole city on 1 March 2014.

RESULTS

The regulation implementation during phase I was associated with a strong immediate decline in the incidence rate of ischemic stroke (-14.2%, 95% CI: -19.6 - -8.4) and hemorrhagic stroke (-10.1%, 95% CI: -18.2 - -1.2), but without showing the annual changes (p>0.05). Following the implementation of the comprehensive law, the gradual annual effect showed a significant change in ischemic stroke, with a 6.3% (95% CI: 8.9 - -3.6) reduction. Neither the immediate nor gradual decreases in hemorrhagic stroke incidences associated with the comprehensive regulation were statistically significant during phase II (p>0.05). Subgroup analyses indicate that a much larger health effect of the regulation during phase I was greater among those aged ≥65 years than among those aged 35-64 years.

CONCLUSIONS

Shenzhen's two-phase smoke-free regulation was well implemented. Even though the regulation did not extend to the whole city, the immediate health benefits on the incidence rates of ischemic stroke and hemorrhagic stroke could be seen. However, the health benefits brought by the implementation of comprehensive smoke-free legislation were attenuated by previous smoke-free regulations in five main public places, which were more evident in hemorrhagic stroke.

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

The Economics of Tobacco Regulation: A Comprehensive Review

Tobacco regulation has been a major component of health policy in the developed world since the UK Royal College of Physicians' and the US Surgeon General's reports in the 1960s. Such regulation, which has intensified in the past two decades, includes cigarette taxation, place-based smoking bans in areas ranging from bars and restaurants to workplaces, and regulations designed to make tobacco products less desirable. More recently, the availability of alternative products, most notably e-cigarettes, has increased dramatically, and these products are just starting to be regulated. Despite an extensive body of research on tobacco regulations, there remains substantial debate regarding their effectiveness, and ultimately, their impact on economic welfare. We provide the first comprehensive review of the state of research in the economics of tobacco regulation in two decades.

The impact of comprehensive tobacco control policies on cardiovascular diseases in Beijing, China

BACKGROUND AND AIMS

China has a high smoking prevalence, but lacks effective tobacco control interventions. In 2015, comprehensive policies that incorporated all six aspects of MPOWER were implemented in Beijing and were considered the strictest tobacco control policy implemented in China to date. Decreases in the prevalence of active smoking and secondhand smoke (SHS) exposure were observed thereafter. This study aimed to evaluate the impact of Beijing's 2015 tobacco control policy package on cardiovascular diseases (CVDs).

DESIGN

Interrupted time-series study.

SETTING

Beijing, China.

PARTICIPANTS

A total of 17.7 million employees enrolled in Urban Employee Basic Medical Insurance (UEBMI) between January 2013 to June 2017.

INTERVENTIONS

Beijing's 2015 comprehensive tobacco policy package, combining a complete ban on smoking in indoor public places, cessation support, more comprehensive bans on advertising, and tax rises.

MEASUREMENTS

The main outcome was hospital admissions for all CVDs and five major cause-specific CVDs, including ischaemic heart disease (IHD), heart failure (HF), heart rhythm disturbances (HRDs), stroke and other cerebrovascular diseases (CBDs). The absolute number and proportion of reductions in the number of hospital admissions after the policies are reported.

FINDINGS

A total of 419 875 hospital admissions for CVD were identified. In total, 13.4% [95% confidence interval (CI) = 11.5%, 15.3%] of hospital admissions for CVD were averted by the tobacco control policies. For major cause-specific CVDs, significant hospital admission reductions occurred for IHD (5.4%, 95% CI = 2.6%, 8.3%), stroke (21.2%, 95% CI = 17.8%, 24.6%) and other CBDs (25.9%, 95% CI = 20.8%, 31.0%), but not for HF (4.7%, 95% CI = -4.2%, 13.5%) or HRDs (4.7%, 95% CI = -2.9%, 12.3%).

CONCLUSIONS

Beijing's 2015 tobacco control policy package appears to have been associated with a more than 10% reduction in all cardiovascular hospital admissions, including a more than 20% reduction in admissions for cerebrovascular diseases.

Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model

BACKGROUND

Diabetes-related foot ulcers give rise to considerable morbidity, generate a high monetary cost for health and social care services and precede the majority of diabetes-related lower extremity amputations. There are many clinical prediction rules in existence to assess risk of foot ulceration but few have been subject to validation.

OBJECTIVES

Our objectives were to produce an evidence-based clinical pathway for risk assessment and management of the foot in people with diabetes mellitus to estimate cost-effective monitoring intervals and to perform cost-effectiveness analyses and a value-of-information analysis.

DESIGN

We developed and validated a prognostic model using predictive modelling, calibration and discrimination techniques. An overview of systematic reviews already completed was followed by a review of randomised controlled trials of interventions to prevent foot ulceration in diabetes mellitus. A review of the health economic literature was followed by the construction of an economic model, an analysis of the transitional probability of moving from one foot risk state to another, an assessment of cost-effectiveness and a value-of-information analysis.

INTERVENTIONS

The effects of simple and complex interventions and different monitoring intervals for the clinical prediction rules were evaluated.

MAIN OUTCOME MEASURE

The main outcome was the incidence of foot ulceration. We compared the new clinical prediction rules in conjunction with the most effective preventative interventions at different monitoring intervals with a 'treat-all' strategy.

DATA SOURCES

Data from an electronic health record for 26,154 people with diabetes mellitus in one Scottish health board were used to estimate the monitoring interval. The Prediction Of Diabetic foot UlcerationS (PODUS) data set was used to develop and validate the clinical prediction rule.

REVIEW METHODS

We searched for eligible randomised controlled trials of interventions using search strategies created for Ovid® (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Randomised controlled trials in progress were identified via the International Standard Randomised Controlled Trial Number Registry and systematic reviews were identified via PROSPERO. Databases were searched from inception to February 2019.

RESULTS

The clinical prediction rule was found to accurately assess the risk of foot ulceration. Digital infrared thermometry, complex interventions and therapeutic footwear with offloading devices were found to be effective in preventing foot ulcers. The risk of developing a foot ulcer did not change over time for most people. We found that interventions to prevent foot ulceration may be cost-effective but there is uncertainty about this. Digital infrared thermometry and therapeutic footwear with offloading devices may be cost-effective when used to treat all people with diabetes mellitus regardless of their ulcer risk.

LIMITATIONS

The threats to the validity of the results in some randomised controlled trials in the review and the large number of missing data in the electronic health record mean that there is uncertainty in our estimates.

CONCLUSIONS

There is evidence that interventions to prevent foot ulceration are effective but it is not clear who would benefit most from receiving the interventions. The ulceration risk does not change over an 8-year period for most people with diabetes mellitus. A change in the monitoring interval from annually to every 2 years for those at low risk would be acceptable.

FUTURE WORK RECOMMENDATIONS

Improving the completeness of electronic health records and sharing data would help improve our knowledge about the most clinically effective and cost-effective approaches to prevent foot ulceration in diabetes mellitus.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016052324.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 62. See the NIHR Journals Library website for further project information.

Impact of Qingdao's smoke-free legislation on hospitalizations and mortality from acute myocardial infarction and stroke: an interrupted time-series analysis

BACKGROUND AND AIMS

More than 20 cities in China have enacted local smoke-free laws that prohibit smoking in public places. Only two of these cities have examined the health impact of the law. Enacted in 2013, Qingdao's smoke free-law was stricter than most other municipal smoke-free laws because it did not allow designated smoking rooms. This study aimed to estimate the impact of Qingdao's smoke-free legislation on acute myocardial infarction (AMI) and stroke.

DESIGN, SETTING AND PARTICIPANTS

We used an interrupted time-series design adjusting for underlying secular trends, seasonal patterns and meteorological factors to estimate the impact of the smoke-free law on AMI and stroke events among permanent residents aged 35 years or older in Qingdao, China. The study period was from 1 January 2010 to 31 December 2015, with a post-ban follow-up of approximately 2.5 years.

MEASUREMENT

Outcome measures were weekly numbers of hospitalizations and deaths due to AMI/stroke.

FINDINGS

A total of 10 371 and 56 101 patients were hospitalized, with a principal discharge diagnosis of AMI and stroke, respectively; 32 196 AMI and 49 711 stroke deaths occurred during the study period. Following the smoke-free legislation, an incremental 20% [95% confidence interval (CI) = 14-26%] and 8% (95% CI = 3-13%) decrease per year was observed in AMI and stroke hospitalization rates, respectively. Neither the immediate nor gradual change in AMI nor stroke mortality rates associated with the law was statistically significant (P > 0.05). Post-hoc subgroup analyses indicated that statistically significant reductions in AMI hospitalizations were evident among both the 35-64 (18% per year, 95% CI = 12-27%) and 65-84 (20% per year, 95% CI = 12-27%) age groups. Statistically significant reductions in stroke hospitalization were only in the older subgroup (13% per year, 95% CI = 8-18%).

CONCLUSIONS

The 2013 smoke-free legislation in Qingdao, China was associated with reduction in hospitalization from acute myocardial infarction and stroke among permanent residents aged 35 years or older. There was no statistically significant reduction in mortality from acute myocardial infarctions or stroke.

Impact of a comprehensive tobacco control policy package on acute myocardial infarction and stroke hospital admissions in Beijing, China: interrupted time series study

OBJECTIVE

To evaluate a comprehensive tobacco control policy package on hospital admissions for acute myocardial infarction (AMI) and stroke in a global city.

DESIGN

Interrupted time series study.

SETTING

Beijing, China.

POPULATION

31 707 AMI and 128 116 stroke hospital admissions recorded by the Beijing Medical Claim Data for Employees in 17.7 million residents from January 2013 to June 2017.

INTERVENTION

The policy package including all components of MPOWER has been implemented since June 2015.

MAIN OUTCOME MEASURES

The immediate change of AMI and stroke hospital admissions and the annual change in the secular trend.

RESULTS

There was a secular increase trend for the crude hospital admission rates of AMI and stroke during the observational period. After implementation of the policy, immediate reductions were observed in the hospital admissions for both AMI (-5.4%, 95% CI -10.0% to -0.5%) and stroke (-5.6%, 95% CI -7.8% to -3.3%). In addition, the secular increase trend for stroke was slowed down by -15.3% (95% CI -16.7% to -13.9%) annually. Compared with the hypothetical scenario where the policy had not taken place, an estimated 18 137 (26.7%) stroke hospital admissions had been averted during the 25 months of postpolicy period.

CONCLUSIONS

The results indicated significant health benefits on cardiovascular morbidity after the Beijing tobacco control policy package, which highlighted the importance for a comprehensive tobacco control policy at the national level in China. Similar tobacco control policy which consists of all components of MPOWER is urgently needed in other areas, especially in settings with high tobacco consumption, to achieve greater public health gains.

Impact of smoke-free legislation on acute myocardial infarction and stroke mortality: Tianjin, China, 2007-2015

BACKGROUND

Smoke-free legislation is an effective way to protect the population from the harms of secondhand smoke and has been implemented in many countries. On 31 May 2012, Tianjin became one of the few cities in China to implement smoke-free legislation. We investigated the impact of smoke-free legislation on mortality due to acute myocardial infarction (AMI) and stroke in Tianjin.

METHODS

An interrupted time series design adjusting for underlying secular trends, seasonal patterns, population size changes and meteorological factors was conducted to analyse the impact of the smoke-free law on the weekly mortality due to AMI and stroke. The study period was from 1 January 2007 to 31 December 2015, with a 3.5-year postlegislation follow-up.

RESULTS

Following the implementation of the smoke-free law, there was a decline in the annual trends of AMI and stroke mortality. An incremental 16% (rate ratio (RR): 0.84; 95% CI: 0.83 to 0.85) decrease per year in AMI mortality and a 2% (RR: 0.98; 95% CI: 0.97 to 0.99) annual decrease in stroke mortality among the population aged ≥35 years in Tianjin was observed. Immediate postlegislation reductions in mortality were not statistically significant. An estimated 10 000 (22%) AMI deaths were prevented within 3.5 years of the implementation of the law.

CONCLUSION

The smoke-free law in Tianjin was associated with reductions in AMI mortality. This study reinforces the need for large-scale, effective and comprehensive smoke-free laws at the national level in China.

Impact of 2 Successive Smoking Bans on Hospital Admissions for Cardiovascular Diseases in Spain

INTRODUCTION AND OBJECTIVES

To evaluate the impact of 2 smoking bans enacted in 2006 (partial ban) and 2011 (comprehensive ban) on hospitalizations for cardiovascular disease in the Spanish adult population.

METHODS

The study was performed in 14 provinces in Spain. Hospital admission records were collected for acute myocardial infarction (AMI), ischemic heart disease (IHD), and cerebrovascular disease (CVD) in patients aged ≥ 18 years from 2003 through 2012. We estimated immediate and 1-year effects with segmented-linear models. The coefficients for each province were combined using random-effects multivariate meta-analysis models.

RESULTS

Overall, changes in admission rates immediately following the implementation of the partial ban and 1 year later were -1.8% and +1.2% for AMI, +0.1 and +0.4% for IHD, and +1.0% and +2.8% for CVD (P>.05). After the comprehensive ban, immediate changes were -2.3% for AMI, -2.6% for IHD, and -0.8% for CVD (P>.05), only to return to precomprehensive ban values 1 year later. For patients aged ≥ 65 years of age, immediate changes associated with the comprehensive ban were -5.0%, -3.9%, and -2.3% for AMI, IHD, and CVD, respectively (P<.05). Again, the 1-year changes were not statistically significant.

CONCLUSIONS

In Spain, smoking bans failed to significantly reduce hospitalizations for AMI, IHD, or CVD among patients ≥ 18 years of age. In the population aged ≥ 65 years, hospital admissions due to these diseases showed significant decreases immediately after the implementation of the comprehensive ban, but these reductions disappeared at the 1-year evaluation.

Investigating the Extent to Which Patients Should Control Access to Patient Records for Research: A Deliberative Process Using Citizens' Juries

BACKGROUND

The secondary use of health data for research raises complex questions of privacy and governance. Such questions are ill-suited to opinion polling where citizens must choose quickly between multiple-choice answers based on little information.

OBJECTIVE

The aim of this project was to extend knowledge about what control informed citizens would seek over the use of health records for research after participating in a deliberative process using citizens' juries.

METHODS

Two 3-day citizens' juries, of 17 citizens each, were convened to reflect UK national demographics from 355 eligible applicants. Each jury addressed the mission "To what extent should patients control access to patient records for secondary use?" Jurors heard from and questioned 5 expert witnesses (chosen either to inform the jury, or to argue for and against the secondary use of data), interspersed with structured opportunities to deliberate among themselves, including discussion and role-play. Jurors voted on a series of questions associated with the jury mission, giving their rationale. Individual views were polled using questionnaires at the beginning and at end of the process.

RESULTS

At the end of the process, 33 out of 34 jurors voted in support of the secondary use of data for research, with 24 wanting individuals to be able to opt out, 6 favoring opt in, and 3 voting that all records should be available without any consent process. When considering who should get access to data, both juries had very similar rationales. Both thought that public benefit was a key justification for access. Jury 1 was more strongly supportive of sharing patient records for public benefit, whereas jury 2 was more cautious and sought to give patients more control. Many jurors changed their opinion about who should get access to health records: 17 people became more willing to support wider information sharing of health data for public benefit, whereas 2 moved toward more patient control over patient records.

CONCLUSIONS

The findings highlight that, when informed of both risks and opportunities associated with data sharing, citizens believe an individual's right to privacy should not prevent research that can benefit the general public. The juries also concluded that patients should be notified of any such scheme and have the right to opt out if they so choose. Many jurors changed their minds about this complex policy question when they became more informed. Many, but not all, jurors became less skeptical about health data sharing, as they became better informed of its benefits and risks.

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.

European Code against Cancer, 4th Edition: Tobacco and cancer

Tobacco use, and in particular cigarette smoking, is the single largest preventable cause of cancer in the European Union (EU). All tobacco products contain a wide range of carcinogens. The main cancer-causing agents in tobacco smoke are polycyclic aromatic hydrocarbons, tobacco-specific N-nitrosamines, aromatic amines, aldehydes, and certain volatile organic compounds. Tobacco consumers are also exposed to nicotine, leading to tobacco addiction in many users. Cigarette smoking causes cancer in multiple organs and is the main cause of lung cancer, responsible for approximately 82% of cases. In 2012, about 313,000 new cases of lung cancer and 268,000 lung cancer deaths were reported in the EU; 28% of adults in the EU smoked tobacco, and the overall prevalence of current use of smokeless tobacco products was almost 2%. Smokeless tobacco products, a heterogeneous category, are also carcinogenic but cause a lower burden of cancer deaths than tobacco smoking. One low-nitrosamine product, snus, is associated with much lower cancer risk than other smokeless tobacco products. Smoking generates second-hand smoke (SHS), an established cause of lung cancer, and inhalation of SHS by non-smokers is still common in indoor workplaces as well as indoor public places, and more so in the homes of smokers. Several interventions have proved effective for stopping smoking; the most effective intervention is the use of a combination of pharmacotherapy and behavioural support. Scientific evidence leads to the following two recommendations for individual action on tobacco in the 4th edition of the European Code Against Cancer: (1) "Do not smoke. Do not use any form of tobacco"; (2) "Make your home smoke-free. Support smoke-free policies in your workplace".

Socioeconomic differentials in the immediate mortality effects of the national Irish smoking ban

BACKGROUND

Consistent evidence has demonstrated that smoking ban policies save lives, but impacts on health inequalities are uncertain as few studies have assessed post-ban effects by socioeconomic status (SES) and findings have been inconsistent. The aim of this study was to assess the effects of the national Irish smoking ban on ischemic heart disease (IHD), stroke, and chronic obstructive pulmonary disease (COPD) mortality by discrete and composite SES indicators to determine impacts on inequalities.

METHODS

Census data were used to assign frequencies of structural and material SES indicators to 34 local authorities across Ireland with a 2000-2010 study period. Discrete indicators were jointly analysed through principal component analysis to generate a composite index, with sensitivity analyses conducted by varying the included indicators. Poisson regression with interrupted time-series analysis was conducted to examine monthly age and gender-standardised mortality rates in the Irish population, ages ≥35 years, stratified by tertiles of SES indicators. All models were adjusted for time trend, season, influenza, and smoking prevalence.

RESULTS

Post-ban mortality reductions by structural SES indicators were concentrated in the most deprived tertile for all causes of death, while reductions by material SES indicators were more equitable across SES tertiles. The composite indices mirrored the results of the discrete indicators, demonstrating that post-ban mortality decreases were either greater or similar in the most deprived when compared to the least deprived for all causes of death.

CONCLUSIONS

Overall findings indicated that the national Irish smoking ban reduced inequalities in smoking-related mortality. Due to the higher rates of smoking-related mortality in the most deprived group, even equitable reductions across SES tertiles resulted in decreases in inequalities. The choice of SES indicator was influential in the measurement of effects, underscoring that a differentiated analytical approach aided in understanding the complexities in which structural and material factors influence mortality.

Second-hand smoke exposure in different types of venues: before and after the implementation of smoke-free legislation in Guangzhou, China

OBJECTIVES

Smoke-free legislation was implemented in Guangzhou on 1 September 2010. However, the smoke-free policy did not cover all indoor areas and smoking rooms can be set in some public places. This study aimed to assess changes in self-reported second-hand smoke (SHS) exposure in different types of venues and in homes, in order to evaluate the effectiveness of smoke-free legislation.

METHODS/DESIGN

A repeated cross-sectional survey of representative participants was conducted in Guangzhou before and after the smoke-free legislation. Logistic regression models were used to examine the effectiveness of smoke-free legislation.

MAIN OUTCOME MEASURES

Self-reported exposure to SHS,antitobacco advertisements and tobacco advertisements.

PARTICIPANTS

A total of 4900 participants before the ban and 5135 participants after the ban were selected using a multistage stratified design.

RESULTS

In full smoking ban places, overall self-reported SHS exposure has declined significantly from 58.8% to 50.3% (p<0.05) with greater drops in cultural venues, government offices and commercial venues. The smoke-free policy did not alter SHS exposure in smokers' homes (39.6% in 2009 vs 40.0% in 2011; p=0.454). Although a slight decrease in SHS exposure was observed in smoking rooms in hotels, workplaces, restaurants, cafes/bars/nightclubs and amusement parks, SHS continued to be high in those areas. The implementation of smoke-free legislation was accompanied by an increase in antitobacco advertisements.

CONCLUSIONS

SHS exposure declines more significantly in full smoking ban places than in partial smoking ban places. The smoke-free policy in public places does not lead to more SHS exposure in homes. Therefore, it is recommended that Guangzhou should implement a 100% smoke-free policy in all public places and workplaces in the future.