The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States

The crossroads of work and home: linkages between smoke-free policies at work and household environments

BACKGROUND

Tobacco use causes over eight million global deaths annually, with seven million directly attributed to tobacco use and 1.2 million to second hand smoke (SHS). Smoke-free environments are crucial to counter SHS. Although India banned smoking in public places in 2008, SHS exposure remains high. Studies have noted that limiting smoking in workplaces, restaurants, etc., helps to reduce overall smoking and reduce SHS exposure. Under this background, the study explores the linkages between smoke-free workplaces and living in smoke-free homes in India.

METHODS

The two rounds of the GATS India (2009-10 and 2016-17) have been used for the study. The study focuses on male tobacco smokers working indoors or outdoors or both indoors and outdoors. The sample for the study was 2,969 for GATS 1 and 2,801 for GATS 2. Dependent variables include living in a smoke-free home, while the independent variables were adherence to a smoke-free office policy and socio-demographic variables. The two rounds of the GATS data were pooled for analysis. Statistical analysis involves bivariate and multivariate analysis.

RESULTS

Findings reveal that 41% of respondents worked in smoke-free workplaces in GATS 2. Nationally, smoke-free homes increased from 35% in 2009-2010 to 44% in 2016-17. Individuals with smoke-free workplaces were more likely to have smoke-free homes. The Southern region consistently exhibited the highest proportion of smoke-free homes. Urban areas and higher education correlated with increased smoke-free homes. Logistic regression analysis confirmed that workplace smoke-free status is a significant predictor of smoke-free homes. In GATS 2, respondents aged 30 years and above were less likely to have smoke-free homes, while education and Southern region residence positively influenced smoke-free homes.

CONCLUSIONS

The correlation between smoke-free workplaces and smoke-free homes is linked to stringent workplace no-smoking policies, potentially deterring individuals from smoking at home. Opportunities exist for the expansion and stringent implementation of the smoke-free policies among Indian working adults, leveraging the workplace as a key setting for evidence-based tobacco control. The study highlights positive trends in India's smoke-free homes, crediting workplace policies. Effective policies, education, and regional strategies can advance smoke-free homes, stressing the pivotal role of workplace policies and advocating broader implementation.

Is social media our new quitline? A descriptive study assessing youtube coverage of tobacco cessation

Background

Tobacco use and exposure are leading causes of morbidity and mortality worldwide. In the past decade, educational efforts to reduce tobacco use and exposure have extended to social media, including video-sharing platforms. YouTube is one of the most publicly accessed video-sharing platforms.

Purpose

This cross-sectional descriptive study was conducted to identify and describe sources, formats, and content of widely viewed YouTube videos on smoking cessation.

Methods

In August to September 2023, the keywords "stop quit smoking" were used to search in YouTube and identify 100 videos with the highest view count.

Results

Collectively, these videos were viewed over 220 million times. The majority (n = 35) were posted by nongovernmental/organization sources, with a smaller number posted by consumers (n = 25), and only eleven were posted by governmental agencies. The format used in the highest number of videos was the testimonial (n = 32 videos, over 77 million views). Other popular formats included animation (n = 23 videos, over 90 million views) and talk by professional (n = 20 videos, almost 43 million views). Video content included evidence-based and non-evidence-based practices. Evidence-based strategies aligned with U.S. Public Health Service Tobacco Treatment Guidelines (e.g. health systems approach in tobacco treatment, medication management). Non-evidence-based strategies included mindfulness and hypnotherapy. One key finding was that environmental tobacco exposure received scant coverage across the videos.

Conclusions

Social media such as YouTube promises to reach large audiences at low cost without requiring high reading literacy. Additional attention is needed to create videos with up-to-date, accurate information that can engage consumers.

De-normalizing smoking in urban areas: Public smoking bans and smoking prevalence

The effectiveness of command-and-control policies related to tobacco use has been studied in high-income countries. Still, there is limited evidence of their effects in low and middle-income countries. We explore the case of Colombia, a country that introduced a business-supported smoking ban in bars and restaurants and all public indoor spaces in 2010. This paper investigates the effect of smoking bans in bars and restaurants on smoking prevalence in Bogotá, Colombia. In this paper, we use the matching with triple-differences technique in analyzing household consumption data from the 2007 and 2011 quality of life surveys. This is done by exploiting their geographical proximity and variation in the density of commercial areas. We found that after the smoking ban implementation, smoking prevalence reduced in households near high-density commercial blocks compared to households near low-density commercial blocks (-10.8 pp.). The impact is larger for households with children and older household heads. Since households near high-density commercial blocks are more frequently exposed to smoking than households near low-density commercial blocks, the former would be more willing to internalize the smoking de-normalization process.

Patterns and prevalence of daily tobacco smoking in Australia by industry and occupation: 2007-2016

INTRODUCTION

Australian workers' daily tobacco smoking over time was examined by industry, and occupation, to identify factors associated with high/low prevalence.

METHODS

Secondary analyses of 2007, 2010, 2013 and 2016 National Drug Strategy Household Surveys were undertaken (pooled n=49,395). Frequency analyses informed subsequent modelling of select industries and occupations. Four logistic regression models estimated adjusted effects of demographics on daily smoking in industries with high (≥20%) and low (≤15%) daily smoking prevalence, and occupations with high (≥20%) and moderate/low (<20%) daily smoking prevalence.

RESULTS

The sample comprised: 55.7% men; 34.1% 25-39 year olds; 31.4% New South Wales residents; 70.1% metropolitan residents; 66.9% high SES workers; and 70.6% with low psychological distress. Daily smoking prevalence differed by industry and occupation in 2007, generally decreasing between 2007-2016. In high prevalence industries, daily smoking was associated with male gender and age (25-39 year olds); and in low prevalence industries with males and non-metropolitan workers. In high prevalence occupations, daily smoking was associated with males, female non-metropolitan workers, and age 25-39 years; and in moderate/low prevalence occupations with non-metropolitan workers, and negatively associated with females aged 14-24 years. In all models, increased odds of daily smoking were associated with low socio-economic status and very high psychological distress.

CONCLUSIONS

Low socio-economic status and very high psychological distress were risk factors for daily smoking regardless of industry, occupation, or high pre-existing smoking prevalence. Targeted, as well as universal, interventions are required for workplaces and workers with greatest smoking vulnerability and least smoking cessation progress.

IMPLICATIONS

Specific strategies are warranted for identified industries, occupations and subgroups with increased odds of daily tobacco smoking. Industries/occupations with moderate/low smoking prevalence may confer workers some protection but are not without risk; some subgroups in these settings (e.g., non-metropolitan areas), had elevated daily smoking risk. Hence, the following are supported: 1. Universal interventions directed at low socio-economic workers, and workers with very high psychological distress regardless of workplace; 2. Interventions targeted at high prevalence industries; 3. Cessation efforts targeted for young workers in high prevalence industries/occupations, and 4. Focussed interventions addressing specific needs of non-metropolitan at-risk workers in low prevalence industries.

Changing patterns and prevalence of daily tobacco smoking among Australian workers: 2007-2016

OBJECTIVE

To map patterns and prevalence of daily smoking among employed Australians over time.

METHODS

Data from four waves of the triennial National Drug Strategy Household Survey (2007, 2010, 2013 and 2016) were used to assess daily smoking. Frequency analyses and significance testing examined smoking prevalence by sex, age, state, remoteness, Indigeneity, socioeconomic status (SES) and psychological distress. Logistic regression models estimated adjusted effects of demographics on smoking prevalence.

RESULTS

Workers' daily smoking prevalence reduced by 32% between 2007 and 2016. The adjusted model showed the lowest smoking reductions among men and non-metropolitan workers. Other interaction effects showed the highest daily smoking rates for: male workers aged 14-39 years; low SES non-metropolitan workers; and low SES workers aged 40-59 years.

CONCLUSIONS

Specific workplace policies, prevention and intervention strategies are warranted for male workers, especially those aged 14-39; non-metropolitan workers, especially low SES rural workers; and low SES workers especially 40-59-year-olds. Implications for public health: In spite of significant smoking reductions among workers over time, reductions were unevenly distributed. Tailored, innovative workplace prevention and intervention strategies that apply principles of proportionate universalism and address individual, workplace settings and cultural factors are warranted to reduce smoking disparities among male, rural and low SES workers.

Evaluating a tobacco-free university policy: A repeated cross-sectional survey of faculty and staff in Lebanon

INTRODUCTION

A growing body of research has evaluated the effect of university tobacco-free policies on faculty and staff, however, none of these studies has been carried out in the Eastern Mediterranean Region. This study evaluates changes in faculty and staff attitudes, perceptions and smoking behavior, at 1 year post adoption of a tobacco-free policy in a medium-sized university in Lebanon and the region.

METHODS

Two cross-sectional surveys were conducted in 2017 and 2018: baseline and at 1 year post policy implementation. A random sample of 625 and 624 participants took part in the 2017 and 2018 studies, respectively.

RESULTS

Faculty and staff had a positive attitude towards the policy at the two time points. The belief that there should be exceptions to the policy significantly decreased from 79% to 59% (p=0.002) among all smokers, particularly those with lower educational attainment (81% to 57%, p=0.007). Perception of compliance among peer smokers increased from 73% to 87% (p=0.009). The proportion of smokers did not significantly change at 1 year post policy implementation, however, 44% of smokers with lower educational attainment, compared to only 7% of those with higher educational attainment (p<0.001), reported a decrease in their smoking behavior outside campus.

CONCLUSIONS

The policy had a positive effect on the attitude, behavior and perception of policy benefits among smokers with lower educational attainment, who constitute the majority of smokers. Findings from this study inform and support future efforts to develop university and workplace tobacco-free policies.

Associations of home and workplace vaping restrictions with e-cigarette use among U.S. adults

The current study examined home and workplace vaping restrictions and their associations with e-cigarette use, frequency of e-cigarette use, and exposure to environmental vape aerosol among adults in the U.S. We used data from the 2018 Tobacco Use Supplement to the Current Population Survey to determine these associations. Analysis was done with a multivariable logistic and zero-inflated Poisson regression. Of 46,751 participants, 2.1% currently used e-cigarettes and 89% reported restricted home vaping. Of 19,091 working participants, 83% had worksite vaping restrictions and 6% reported environmental vapor exposure. Respondents with household vaping restrictions had lower odds of current e-cigarette use (full ban: aOR: 0.07, 95% CI: 0.05-0.09; partial ban: aOR: 0.51, 95% CI: 0.40-0.66). The expected number of days of past-month e-cigarette use for those with some household vaping restrictions was significantly fewer than for those without restrictions (full ban: IRR: 0.92, 95% CI: 0.85-0.99; partial ban, IRR: 0.89, 95% CI: 0.81-0.97). Workers with full workplace vaping restrictions had lower odds of workplace environmental vape aerosol exposure than those without a restriction (aOR: 0.21, 95% CI: 0.17-0.25). Vaping restrictions in homes were associated with lower prevalence and frequency of e-cigarette use. Those in worksites with complete vaping bans were less likely to be exposed to environmental aerosol at work. Home e-cigarette restrictions appear to have a stronger association with e-cigarette use behaviors than workplace restrictions.

Evaluating the impact of the California 1995 smoke-free workplace law on population smoking prevalence using a synthetic control method

The objective of this study is to assess the impact of the California 1995 Smoke-Free Workplace Act (SFWA) on cigarette smoking prevalence in the population. We used survey responses related to cigarette smoking from the Behavioral Risk Factor Surveillance System (BRFSS) from 1990 to 2000. We utilize a synthetic control method which creates a weighted combination of control states to produce a single ‘synthetic’ control group to best approximate the counterfactual trend in California in the absence of the SFWA. Variables known to be associated with smoking were included to weight each state in the pre-intervention period as medians by state and included: distribution of race/ethnicity (White, Black, Asian, Hispanic), sex (Male/Female), marital status (married/unmarried), high school education (yes/no) and employment status (yes/no).

We find evidence that there was a small decrease in population smoking prevalence in California in the year immediately following the SFWA, but this effect was not sustained beyond 1995. We hypothesize that one potential explanation for the lack of prolonged impact on population smoking prevalence is that there are sustained effects from the passage of 1989 California Proposition 99, which enacted an excise tax on tobacco products. Understanding how workplace smoking ban legislation affects population smoking behaviors is necessary to better inform policy development in other states and counties and to improve existing policies. Future work should consider the impact of smoking legislation impacts subgroups of the population by socioeconomic status, occupation or race/ethnicity.

Perceived non-smoking norms and motivation to stop smoking, quit attempts, and cessation: a cross-sectional study in England

This study examined the prevalence of non-smoking norms in England and their associations with motivation to stop smoking, quit attempts, and cessation. Data were from a representative cross-sectional survey of 1,521 adults (301 combustible tobacco smokers). Descriptive non-smoking norms were endorsed, with just 16% of adults (12% of smokers) believing smoking was uncommon. Injunctive non-smoking norms were more prevalent, with 60-77% of adults (17-48% of smokers) viewing smoking as something of which others disapproved. Personal non-smoking norms were also prevalent among all adults (73% indicated they would prefer to live with a non-smoker) but not smokers (69% had no preference). Smokers who endorsed stronger descriptive non-smoking norms had increased odds of reporting high motivation to stop smoking (ORadj = 1.63, 95%CI 1.06-2.52). Female (but not male) past-year smokers who endorsed stronger injunctive (ORadj = 2.19, 95%CI 1.41-3.42) and personal (ORadj = 1.90, 95%CI 1.29-2.82) non-smoking norms had increased odds of having made a past-year quit attempt. In conclusion, perceived descriptive non-smoking norms are not held by the majority of adults in England. Injunctive and personal non-smoking norms are prevalent among all adults but lower among smokers. There is some evidence that smokers - in particular, women - who endorse stronger non-smoking norms are more likely to be motivated to stop smoking and to make a quit attempt.

To smoke or not to smoke? A qualitative study among young adults

Smoking is the major preventable cause of disease and premature death in many countries, including France, where approximately 30% of adults are daily smokers. About 60% of them want to quit, however, long-term smoking cessation rates are low, particularly among individuals with low socio-economic position. The aim of this study is to examine whether motivations for smoking cessation among young adults differ across socio-economic groups.

3 focus groups of smokers and former smokers aged 22–40 years were constituted and conducted in November 2014 in Paris. Data from the focus groups were analyzed thematically and in a cross-cutting manner. Our study shows the existence of social “communities” of smokers, in occupational and festive contexts. In addition, new forms of resistance to public health messages are observed (“neutralization”), particularly among smokers with low socioeconomic position. Finally, stress is often cited as a source of unsuccessful smoking cessation or smoking relapse. Tobacco smoking is a social behavior and is associated with symbolic as well as relational benefits, particularly among smokers who have low socioeconomic position. To be effective, interventions aiming to decrease smoking levels in the population should aim to create group dynamics encouraging smokers to quit and address the physical as well as the psychological consequences of smoking withdrawal.

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Young adults who smoke congregate in social “communities”, at work or at parties.

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Persons with low socioeconomic status “neutralize” the risks related to smoking.

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Smoking is a social behavior, associated with symbolic and relational benefits.

THE ROLE OF EMPLOYERS IN FACILITATING SMOKING CESSATION AMONG STAFF: PERSPECTIVE OF DRIVERS IN A NIGERIAN UNIVERSITY

BACKGROUND

Several interventions have been instituted to encourage smoking cessation among smokers. Many adults are currently working and spend several hours a day at work. Employers thus have a role to play in encouraging staff who smoke to quit. This study investigated the perception of drivers employed in the University of Ibadan, Nigeria on the role of their employers in facilitating smoking cessation among staff who smoke.

METHOD

All 176 drivers employed by the University and who were available on the days of the interviews were interviewed. A semi-structured questionnaire was used to obtain information on drivers' opinion on the role of employers in facilitating smoking cessation among staff.

RESULTS

All the drivers were male and had a mean age of 51.2 ± 5.8 years. Five (2.8%) drivers were current smokers. One hundred and thirty-six (77.3%) drivers were of the opinion that their employers had a role to play in encouraging smoking cessation among staff who smoke. They felt this could be done by organizing workshops to sensitize staff on the dangers of smoking 73 (53.7%), educating staff about the health effects of smoking 26 (19.1%) and arresting staff caught smoking during official hours 20 (14.7%).

CONCLUSION

Many of the drivers felt that their employers had a role to play in encouraging smoking cessation among staff. The University authorities should build on this and take specific steps to institute a comprehensive workplace antitobacco policy which includes smoking cessation interventions to assist staff who smoke to quit.

Compliance with smoke-free legislation and smoking behaviour: observational field study from Punjab, India

Background

Indian smoke-free legislation requires prohibition of smoking at public places and owners of public places to display ‘no smoking’ signages.

Aims and objectives

The study aims to assess the compliance of public places with smoke-free legislation and determine the factors associated with active smoking in public places.

Methodology

This was a cross-sectional analytic observational quantitative survey conducted by a team of trained field investigators using a structured observational checklist across 6875 public places in Punjab state of India. The study was carried out over a period of 3 years.

Results

A total of 6875 public places across 22 districts of Punjab were observed. The overall compliance to smoke-free law in Punjab was 83.8%. The highest overall compliance was observed in healthcare facilities (89.6%) and least in transit stations (78.8%). Less active smoking was observed in public places where display of ‘no smoking’ signage compliant with smoke-free law of India was present (adjusted OR 0.6). Further, there was a positive association between active smoking and places where the owner of public places smoked (OR 5.2, CI 2.5 to 11.1).

Conclusion

More than 80% of the public places in a jurisdiction in north India were compliant with the smoke-free legislation of India. ‘No smoking’ signages displayed as per legislation have an effect on curbing smoking behaviours at public places. It is recommended that policymakers should focus more on implementing the smoke-free law at transit sites and structured training sessions should be organised for owners of workplaces.

A 14-year longitudinal study of the impact of clean indoor air legislation on state smoking prevalence, USA, 1997-2010

While clean indoor air legislation at the state level is an evidence-based recommendation, only limited evidence exists regarding the impact of clean indoor air policies on state smoking prevalence. Using state smoking prevalence data from 1997 to 2010, a repeated measures observational analysis assessed the association between clean indoor air policies (i.e., workplace, restaurant, and bar) and state smoking prevalence while controlling for state cigarette taxes and year. The impacts from the number of previous years with any clean indoor air policy, the number of policies in effect during the current year, and the number of policies in effect the previous year were analyzed. Findings indicate a smoking prevalence predicted decrease of 0.13 percentage points (p=0.03) for each additional year one or more clean indoor air policies were in effect, a predicted decrease of 0.12 percentage points (p=0.09) for each policy in effect in the current year, and a predicted decrease of 0.22 percentage points (p=0.01) for each policy in effect in the previous year on the subsequent year. Clean indoor air policies show measurable associations with reductions in smoking prevalence within a year of implementation above and beyond taxes and time trends. Further efforts are needed to diffuse clean indoor air policies across states and provinces that have not yet adopted such policies.

Unobtrusive Observations of Smoking in Urban California Bars

This paper describes initial findings from a project utilizing unobtrusive participant observation to investigate noncompliance with workplace tobacco control regulations within stand-alone bars in one California city. Early findings indicate that half of the bars in the sample fully complied with the law, while other bars could be described as in transition from smoking to nonsmoking, and a minority of bars remained consistently noncompliant. No smoking at all was observed in 50.4% of bars. Of the 49.6% of bars in which smoking was observed at least once, 14.9% were characterized by endemic smoking. Nine percent of smoking bars may have converted from smoking to nonsmoking over the course of the study, and the remaining bars were characterized by incidental smoking (including doorway smoking, lone smokers, and closing time smoking). Implications for enhancing compliance with tobacco control policies are discussed.

‘I Think That It’s a Pain in the Ass That I Have to Stand Outside in the Cold and Have a Cigarette’

Smokers in Greece and the UK are habitually exposed to different levels of social disapproval. This qualitative study explored the accounts of smoking and disapproval offered by 32 UK and Greek smokers. Accounts were framed with reference to a highly moralized construction of smoking. Participants were sensitive to social disapproval of their smoking. While disapproval from those close to them was accepted, disapproval from the general public was not. Two discursive repertories ‘smoking works for me now’ and ‘the struggle to quit’ were identified as resources that participants drew upon to enable continued smoking while acknowledging the health issues. While there were many similarities in the accounts provided, there were important differences that seem to reflect the different ‘smoking worlds’ inhabited.

An exploratory study of smokers' and stakeholders' expectations of the implementation of a smoke-free policy in a university setting

ISSUES ADDRESSED

Smoke-free policies restricting tobacco use in public places are common in many middle- and high-income countries. Implementation of a smoke-free policy does not automatically result in a smoke-free environment, and appropriate enforcement procedures must be clearly communicated and implemented. Safety and restrictions in private spaces, especially student housing, are also issues that need to be explored. This research explored perceptions and attitudes of staff and student smokers and key stakeholders before the implementation of a complete campus ban on smoking at a large Australian university.

METHODS

Interviews were conducted with staff and student smokers (n=9) and stakeholders (n=9). The interviews explored attitudes towards a completely smoke-free policy in the university environment, perceptions relating to enforcement of and compliance with a completely smoke-free policy, and support needed from the university for smokers.

RESULTS

Participants generally supported a complete smoke-free policy. Key themes associated with the policy implementation included health implications, stigmatisation and labelling, liberty, and enforcement.

CONCLUSION

Smoke-free policies require careful planning, evaluation, and appropriate enforcement to ensure maximum impact. Further research is needed to improve compliance with smoke-free policies in outdoor environments and diverse spaces. SO WHAT? A better understanding of attitudes and intentions towards a smoke-free policy before implementation may provide useful insight into the potential challenges and provide guidelines for the development of strategies to improve policy readiness and adherence. University support for smokers to quit is essential when implementing a smoke-free policy.

The support for smoke free policy and how it is influenced by tolerance to smoking - experience of a developing country

This cross sectional survey was conducted to determine the support in making Penang UNESCO World Heritage Site (GTWHS) smoke free and to determine the influence of tolerance towards smoking on this support. This is the first phase in making Penang, Malaysia a smoke free state. A multistage sampling process was done to select a sample of respondents to represent the population of GTWHS. Attitude towards smoking was assessed using tolerance as a proxy. A total of 3,268 members of the community participated in the survey. A big majority (n = 2969; 90.9%) of the respondents supported the initiative. Support was lowest among the owners and residents/tenants, higher age groups, the Chinese, men, respondents who had poor knowledge of the places gazetted as smoke free, and respondents with poor knowledge of the health effects on smokers and on passive smokers. The odds (both adjusted and unadjusted) of not supporting the initiative was high among those tolerant to smoking in public areas. Tolerance towards smoking was associated with 80.3% risk of non-support in the respondents who were tolerant to smoking and a 57.2% risk in the population. Health promotion and education concerning the harm of tobacco smoke in Malaysia, which has mainly targeted smokers, must change. Health education concerning the risks of second hand smoke must also be given to non-smokers and efforts should be made to denormalize smoking.

Exposure to secondhand smoke and voluntary adoption of smoke-free home and car rules among non-smoking South African adults

BACKGROUND

Secondhand smoke (SHS) exposure is a well-established health hazard. To determine the effectiveness of existing smoke-free policies and adoption of smoke-free rules in South Africa, we assessed exposure to SHS from several sources among non-smoking adults during 2010.

METHODS

Data were analyzed for 3,094 adults aged ≥16 years who participated in the 2010 South African Social Attitudes Survey. Descriptive statistics and multivariate analyses were used to assess presence of smoke-free rules among all South Africans, and prevalence and correlates of SHS exposure at work, at home, and at hospitality venues among non-smokers.

RESULTS

Overall, 70.6% of all South African adults had 100% smoke-free rules in their private cars, 62.5% in their homes, while 63.9% worked in places with 100% smoke-free policies. Overall, 55.9% of all non-smokers reported exposure to SHS from at least one source (i.e., in the home, workplace or at a hospitality venue). By specific source of exposure, 18.4% reported being exposed to SHS at work, 25.2% at home, 33.4% in a restaurant, and 32.7% at a bar. Presence of work bans on indoor smoking conferred lower likelihood of SHS exposure at work among non-smokers (adjusted odds ratio [aOR] = 0.23; 95% CI: 0.09-0.60). Similarly, smoke-free home rules decreased the odds of being exposed to SHS at home among non-smokers (aOR =0.16; 95% CI: 0.09-0.30).

CONCLUSION

Over half of South African adults reported SHS exposure in the home or at public places such as the workplace and at hospitality venues. This underscores the need for comprehensive smoke-free laws that prohibit smoking in all public indoor areas without exemptions.

No smoking here: examining reasons for noncompliance with a smoke-free policy in a large university

INTRODUCTION

A large Australian university introduced a campuswide smoke-free policy in 2012. Almost 1 year after implementation, reasons for noncompliance among people observed smoking on campus were examined.

METHODS

Six smoking locations on campus were identified after a campuswide audit of smoking indicators (i.e., discarded cigarette butts packets and people observed smoking). At these locations, those observed smokers were interviewed. Interview responses were examined to elicit underlying themes.

RESULTS

Fifty people were seen smoking during the observation period. Those smokers interviewed comprised staff (27%) and students (73%) aged between 18 and 24 (45.9%). The majority of the students were international students (51.8%). All respondents acknowledged their awareness of the smoke-free policy. Five explanatory themes for noncompliance emerged: defiance against the policy's perceived threat to self-governance; inconvenience to travel off campus to smoke; smoking as a physiological necessity; unintentional noncompliance through unawareness or confusion of policy boundaries; and ease of avoidance of detection or exposing others to cigarette smoke.

CONCLUSIONS

Creating a culture of compliance at the university remains a significant challenge, especially considering the size of the campus, the high proportion of international students, and the logistics associated with monitoring smoking behavior in outdoor areas and on-campus student housing.

Large-scale unassisted smoking cessation over 50 years: lessons from history for endgame planning in tobacco control

In the 50 years since the twentieth century's smoking epidemic began to decline from the beginning of the 1960s, hundreds of millions of smokers around the world have stopped smoking permanently. Overwhelmingly, most stopped without any formal assistance in the form of medication or professional assistance, including many millions of former heavy smokers. Nascent discussion about national and global tobacco endgame scenarios is dominated by an assumption that transitioning from cigarettes to alternative forms of potent, consumer-acceptable forms of nicotine will be essential to the success of endgames. This appears to uncritically assume (1) the hardening hypothesis: that as smoking prevalence moves toward and below 10%, the remaining smokers will be mostly deeply addicted, and will be largely unable to stop smoking unless they are able to move to other forms of 'clean' nicotine addiction such as e-cigarettes and more potent forms of nicotine replacement; and (2) an overly medicalised view of smoking cessation that sees unassisted cessation as both inefficient and inhumane. In this paper, we question these assumptions. We also note that some vanguard nations which continue to experience declining smoking prevalence have long banned smokeless tobacco and non-therapeutic forms of nicotine delivery. We argue that there are potentially risky consequences of unravelling such bans when history suggests that large-scale cessation is demonstrably possible.

Nicotine yesterday, today, and tomorrow: a global review

This intentionally selective global review reflects the views and frustrations of a public health physician with 45 years of frontline experience in tobacco control. In particular, it focuses on the nexus between research and policy and the long periods between relevant discoveries and application as policy. Consideration is given to the relative neglect of the possibility of reducing the carcinogenicity and toxicity of the cigarette on the grounds that it is the preferred source of nicotine for the global majority of nicotine users. Although the outcome of such change is unquantifiable, there is much in cigarette smoke that can be changed to make it less carcinogenic and less toxic. It is difficult to think of excuses for accepting the status quo.

Achieving smoke-free mental health services: lessons from the past decade of implementation research

The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from smoke-free policy because of complex held views about the capacity of people with mental disorder to tolerate such policy whilst they are acutely unwell, with stakeholders' continuing fierce debate about rights, choice and duty of care. This culture has played a significant role in perpetuating physical, social and economic smoking associated impacts experienced by people with mental disorder who receive care within mental health care settings. The past decade has seen a clear policy shift towards smoke-free mental health settings in several countries. While many services have been successful in implementing this change, many issues remain to be resolved for genuine smoke-free policy in mental health settings to be realized. This literature review draws on evidence from the international published research, including national audits of smoke-free policy implementation in mental health units in Australia and England, in order to synthesise what we know works, why it works, and the remaining barriers to smoke-free policy and how appropriate interventions are provided to people with mental disorder.

Occupational gradients in smoking behavior and exposure to workplace environmental tobacco smoke: the multi-ethnic study of atherosclerosis

OBJECTIVE

This study examines associations of occupation with smoking status, amount smoked among current and former smokers (number of cigarettes per day and lifetime cigarette consumption (pack-years)), and workplace exposure to environmental tobacco smoke (ETS) independent from income and education.

METHODS

This is a cross-sectional analysis of data from a community sample (n = 6355, age range: 45-84) using logistic and multinomial regression. All analyses were stratified by sex and adjusted for socio-demographic variables.

RESULTS

Male blue-collar and sales/office workers had higher odds of having consumed more than 20 pack-years of cigarettes than managers/professionals. For both male and female current or former smokers, exposure to workplace ETS was consistently and strongly associated with heavy smoking and greater pack-years.

CONCLUSIONS

Blue-collar workplaces are associated with intense smoking and ETS exposure. Smoking must be addressed at both the individual and workplace levels especially in blue-collar workplaces.

Stability of cigarette consumption over time among continuing smokers: a latent growth curve analysis

OBJECTIVES

This paper examined the stability over time of daily cigarette consumption of continuing smokers and explored factors that might account for the patterns of change in consumption using a latent growth curve (LGC) analytic approach.

METHODS

Data come from the first 5 waves of the International Tobacco Control Four-Country Survey, conducted in Canada, the United States, the United Kingdom, and Australia where a cohort of over 2,000 smokers from each country were recruited and followed up annually with replenishment.

RESULTS

Raw data revealed that continuing smokers showed a marked steep decline in cigarettes per day during the first 2 waves followed by a gentler linear decline in consumption over the remaining waves of the study period. This pattern of change in cigarette consumption was best modelled using a piecewise linear LGC model. Baseline consumption level was highest in Australia and lowest in the United Kingdom, although the rate of decline was similar across the 4 countries. Being older than 55 years and having made at least 1 quit attempt were related to greater rate of decline in consumption.

CONCLUSIONS

Continuing smokers who are unwilling or unable to quit smoking can and do attempt to reduce their daily cigarette consumption over time. Factors such as making a quit attempt even if unsuccessful and experiencing smoking bans at work and at homes can contribute to reduced smoking among this group, which suggests that interventions focusing in on these factors, along with providing cessation help, may greatly improve their chances of quitting smoking altogether.

The role of worksite and home smoking bans in smoking cessation among U.S. employed adult female smokers

PURPOSE

Examine the association of work and home smoking bans with quitting behaviors among employed female smokers in the United States.

DESIGN

Secondary analyses using cross-sectional data from the 2006/2007 Tobacco Use Supplement to the Current Population Survey.

SUBJECTS

Nationally representative sample of 7610 U.S. employed female smokers, aged 18 to 64 years, who reported working indoors. Setting . N/A.

METHODS

Multivariate logistic regression analyses were conducted to examine the association of smoking ban policies (complete work and home bans, complete work ban only, complete home ban only, and no complete work or home ban) with intention to quit in the next 30 days, at least one quit attempt in the past year, and sustained abstinence of at least 3 months in the past year.

RESULTS

Twenty-nine percent of women reported complete work and home smoking bans. Smoking bans were not associated with intention to quit and were marginally associated with sustained abstinence. Regardless of intention to quit, women with complete work and home bans were significantly more likely than those without complete work and home bans to report quit attempts. Among women with no intention to quit, the odds of having a quit attempt were significantly higher among women who had a complete home ban only compared with women without complete work and home bans.

CONCLUSIONS

Efforts to promote quitting behaviors among employed female smokers may be facilitated by increasing rates of complete smoking bans at both work and home settings.

Exposure to tobacco smoke and prevalence of symptoms decreased among Finnish restaurant workers after the smoke-free law

INTRODUCTION

The impact of tobacco legislation and exposure to environmental tobacco smoke (ETS) in bars and restaurants were assessed in a national survey.

METHODS

Questionnaire surveys among restaurant workers were conducted in 2007 before the smoking ban, and in 2009.

RESULTS

The exposure to ETS decreased significantly after the launch of the 2007 smoke-free law. During 2007-2009, the prevalence of those restaurant workers with no exposure increased from 54% to 82% (P-value < 0.0001), and among bartenders from 10% to 70% (P < 0.0001). Employees exposed daily for more than 4 hr decreased from 24% to 4% (P < 0.0001) and from 67% to 9% among bartenders (P < 0.0001). The prevalence of respiratory symptoms decreased from 18% to 4% (P < 0.0001) and of eye symptoms from 23% to 6% (P < 0.0001).

CONCLUSION

The reform of tobacco legislation in 2007, which prohibited smoking in restaurants and bars, significantly decreased the exposure to ETS and the prevalence of symptoms among restaurant workers.

Social norms, collective efficacy, and smoking cessation in urban neighborhoods

OBJECTIVES

We examined the separate and combined relations of neighborhood-level social norms and collective efficacy with individuals' cigarette smoking cessation.

METHODS

We modeled the hazard of quitting over a 5-year period among 863 smokers who participated in the 2005 New York Social Environment Study.

RESULTS

In adjusted Cox proportional hazard models, prohibitive neighborhood smoking norms were significantly associated with higher rates of smoking cessation (second quartile hazard ratio [HR] = 1.17; 95% confidence interval [CI] = 0.59, 2.32; third quartile HR = 2.37; 95% CI = 1.17, 4.78; fourth quartile HR = 1.80; 95% CI = 0.85, 3.81). We did not find a significant association between neighborhood collective efficacy and cessation or significant evidence of a joint relation of collective efficacy and smoking norms with cessation.

CONCLUSIONS

Neighborhood social norms may be more relevant than is collective efficacy to smoking cessation. The normative environment may shape health behavior and should be considered as part of public health intervention efforts.

Does the introduction of comprehensive smoke-free legislation lead to a decrease in population smoking prevalence?

AIMS

To investigate changes in population smoking prevalence in jurisdictions which have implemented comprehensive smoke-free legislation, taking into account long-term trends in smoking behaviour.

DESIGN

Interrupted time series analysis of population-level survey data using segmented regression.

SETTING

Twenty-one countries, American states or Canadian provinces which have implemented comprehensive smoke-free legislation.

PARTICIPANTS

Respondents sampled in large representative surveys of smoking prevalence.

MEASUREMENTS

For each jurisdiction, segmented regression models quantify any upwards or downwards trend in smoking prevalence prior to the introduction of smoke-free legislation, any immediate change in the level of smoking prevalence at the time smoke-free legislation was introduced, and any change in the trend in smoking prevalence post-legislation compared to the pre-legislation period.

FINDINGS

In all but three locations there was a statistically significant decline in smoking prevalence prior to the introduction of smoke-free legislation. In two locations, Washington and the Republic of Ireland, there was an immediate decline in the level of smoking prevalence at the introduction of legislation. In six American states there was a significant change in the rate of decline in smoking prevalence, with smoking prevalence declining more steeply in the post-legislation period compared to the pre-legislation period. No change in the level or trend of population smoking prevalence was seen in 13 of the 21 locations studied.

CONCLUSIONS

The introduction of comprehensive smoke-free legislation has increased the rate at which smoking prevalence was declining in some locations, but in the majority of jurisdictions had no measureable impact on existing trends in smoking prevalence.

Association of secondhand smoke exposure with nicotine dependence among Black smokers

INTRODUCTION

Exposure to secondhand smoke (SHS) is influenced by norms and regulations, socioeconomic status and immediate personal interactions. SHS exposure may occur in various settings, including the living space, workplace, and other social environments. This study examines the association between exposure to SHS and nicotine dependence among current smokers.

METHODS

A cross-sectional sample of 246 Black (60% male and 40% female) current smokers age 40 and older, from Baltimore, Maryland and Washington, D.C, responded to an interviewer-administered questionnaire. We examined nicotine dependence using clinical guidelines based on the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (2000). We performed multivariate logistic regression to assess the association between SHS and nicotine dependence.

RESULTS

SHS exposure in the current home environment and exposure in settings outside the home, as well as difficulty to quit smoking and heaviness of smoking, were associated with nicotine dependence. After adjustment for age, gender, education, income, employment status, current alcohol consumption, history of marijuana use, and number of cigarettes smoked per day; exposure to SHS at home only, and in both current home environment and other settings, continued to be associated with clinically-defined nicotine dependence (OR=2.25; 95% CI 1.05, 4.86 vs. OR=2.31; 95% CI 1.03, 5.18), respectively.

DISCUSSION

These findings highlight the relative importance of examining SHS exposure in personal (residential and automobile) and public (workplace and outdoor) settings by current smokers. Promotion of smoke-free environments may reduce the prevalence of nicotine dependence among current smokers.

Rural print media portrayal of secondhand smoke and smoke-free policy

The purpose of this article is to describe how the print media portrays secondhand smoke and smoke-free policy in rural communities. Baseline print media clips from an ongoing 5-year study of smoke-free policy development in 40 rural communities were analyzed. The authors hypothesized that community population size would be positively associated with media favorability toward smoke-free policy. Conversely, pounds of tobacco produced and adult smoking prevalence would be negatively associated with media favorability. There was a positive correlation between population size and percentage of articles favorable toward smoke-free policy. The authors did not find a correlation between adult smoking or tobacco produced and media favorability toward smoke-free policy, but we did find a positive relationship between tobacco produced and percentage of pro-tobacco articles and a negative relationship between adult smoking prevalence and percentage of articles about health/comfort. Implications for targeting pro-health media in rural communities as well as policy-based initiatives for tobacco control are discussed.

Effects of a workplace-smoking ban in combination with tax increases on smoking in the Dutch population

INTRODUCTION

In the Netherlands, between 2003 and 2005, 3 tobacco control measures were implemented: a workplace-smoking ban and 2 tax increases on tobacco products. This study explores how the combination of measures influences the smoking behavior of the general population divided into subpopulations with and without paid work (all aged 16-65 years).

METHODS

Data from the Dutch Continuous Survey of Smoking Habits were used. The total sample consisted of 32,014 respondents (27,150 with paid work and 4,864 without paid work) aged 16-65 years. Analyses were done by linear and logistic regression, controlling for relevant factors.

RESULTS

For respondents with paid work, the combination of a smoking ban and 2 tax increases led to a decrease in the number of cigarettes per day and in the prevalence of daily smoking. For respondents without paid work, there was no significant effect on any of the outcome parameters. In both groups, there was no evidence that the effect of the measures on smoking was moderated by the respondent's gender, age, or level of education.

CONCLUSIONS

The combination of policy measures has influenced the smoking behavior of respondents with paid work in a positive way. Compared with most other studies, the effect of the workplace-smoking ban alone is smaller. However, the effect of the combined interventions is higher than the that of tax increases in other studies. Among respondents without paid work who were exposed to tax increases only, no significant effects were found.

Teaching tobacco cessation skills to Uruguayan physicians using information and communication technologies

INTRODUCTION

Since 2004, with the ratification of the Framework Convention on Tobacco Control, Uruguay has implemented a wide range of legal restrictions designed to reduce the devastating impacts of tobacco. This legal process generated an increase in demand for tobacco cessation treatment, which led to the need to train a large number of physicians. Information and Communication Technologies (ICTs) are evolving constantly, creating new opportunities to make online education more interactive. The evolution of ICTs presents an opportunity to develop innovative continuing medical education (CME) experiences to meet the increasing demand for this topic.

METHODS

A blended-learning course on tobacco cessation was developed and implemented, combining face-to-face and online activities. Educational strategy focused on (1) facilitating interaction among generalists and between generalists and experts, and (2) providing high impact CME incorporating multifaceted interventions with wiki-type collaborative construction of practical knowledge. Multiple-choice tests and commitments-to-change were used for evaluation.

RESULTS

Three hundred thirty-five health professionals participated in the course. Of these, 145 (43.3%) attended the on-site workshop, 216 (64.5%) participated in the online activities, and 109 (32.5%) completed both phases. Fifty of the 105 (47.6%) participants completing the pretest had a passing score, while 78.1% received a passing score on the final test (p < .001). Differences between mean pretest and posttest scores among those who completed both phases compared with those who only did the online phase were statistically significant (p = .003 and p = .009, respectively).

DISCUSSION

The need to train physicians on tobacco cessation skills can be addressed via ICTs and educational activities that include participant interaction.

Workplace smoking policies and their association with male employees' smoking behaviours: a cross-sectional survey in one company in China

OBJECTIVES

The present work sought to evaluate different worksite smoking control policies and their associations with employees' smoking behaviours and attitudes among Chinese male workers.

METHODS

This was a cross-sectional survey with a self-administered standardised questionnaire, conducted among seven production workplaces of one multinational company in Shanghai in 2008. In total, 1043 male workers were involved. Current smoking prevalence, daily cigarette consumption, quitting intention and their potential association with workplace smoking control policies (smoke free or restricted smoking) were measured.

RESULTS

Current smoking prevalence in workplaces where smoke-free policies had been imposed for 3 years was 55.5%, about 18% lower than in workplaces that only restricted smoking. Smokers in smoke-free workplaces also smoked 3.4 cigarettes less per day, made more quit attempts, were more confident of successfully quitting and more willing to accept a company sponsored cessation programme. Those patterns declined or were not found among the workplaces where smoking control policies had been imposed for 10 years. Smoker quitting intentions were not associated with workplace smoking policies regardless of the duration of the policies imposed.

CONCLUSIONS

A smoke-free workplace policy was found to have a significant association with lower smoking prevalence and daily cigarette consumption, but not with employee quitting intentions. Restrictive smoking policies had no impact on employee smoking behaviours. The impact of workplace smoking control policies may vary over time.

Smoking behaviour, involuntary smoking, attitudes towards smoke-free legislations, and tobacco control activities in the European Union

Background

The six most important cost-effective policies on tobacco control can be measured by the Tobacco Control Scale (TCS). The objective of our study was to describe the correlation between the TCS and smoking prevalence, self-reported exposure to secondhand smoke (SHS) and attitudes towards smoking restrictions in the 27 countries of the European Union (EU27).

Methods/Principal Findings

Ecologic study in the EU27. We used data from the TCS in 2007 and from the Eurobarometer on Tobacco Survey in 2008. We analysed the relations between the TCS and prevalence of smoking, self-reported exposure to SHS (home and work), and attitudes towards smoking bans by means of scatter plots and Spearman rank-correlation coefficients (r_sp). Among the EU27, smoking prevalence varied from 22.6% in Slovenia to 42.1% in Greece. Austria was the country with the lowest TCS score (35) and the UK had the highest one (93). The correlation between smoking prevalence and TCS score was negative (r_sp = −0.42, p = 0.03) and the correlation between TCS score and support to smoking bans in all workplaces was positive (r_sp = 0.47, p = 0.01 in restaurants; r_sp = 0.5, p = 0.008 in bars, pubs, and clubs; and r_sp = 0.31, p = 0.12 in other indoor workplaces). The correlation between TCS score and self-reported exposure to SHS was negative, but statistically non-significant.

Conclusions/Significance

Countries with a higher score in the TCS have higher support towards smoking bans in all workplaces (including restaurants, bars, pubs and clubs, and other indoor workplaces). TCS scores were strongly, but not statistically, associated with a lower prevalence of smokers and a lower self-reported exposure to SHS.

Progress in tobacco control

AIM

To present the Tobacco Control interventions which are currently accepted as effective.

METHODS

Review the available regulatory strategy laid down in the Framework Convention for Tobacco Control and explore the basis for the Treaty and the appropriateness of the response with particular reference to Europe.

RESULTS

An evidence-based approach was built up over some sixty years. At first a slow revelation of the catastrophic health effects of smoking is revealed. Then a reluctance to see tobacco addiction as a disease or even as an addiction delays attempts to develop active treatments. A powerful, corrupt industry demanding to be treated as normal delays effective interventions to control demand or supply.

DISCUSSION

The pace of Tobacco Control is too slow. An effective FCTC would still see millions of unnecessary premature deaths in this century. Most deaths will not be in the west where the true effects of this industry are accepted and where mechanisms to combat the worst abuses of industrial power exist. They will occur in the developing world. The FCTC provisions must be achieved and then some. It would be foolish to rely on it alone especially on its approach to control of supply. The role of the treatment of tobacco dependence may be underrated in Tobacco Control. In many other diseases, whether infections such as tuberculosis or lifestyle related such as hypertension, the role and availability of effective treatments often provides the catalyst to drive the social changes necessary to lead to commitment to effective change.

Compliance and support for bans on smoking in licensed venues in Australia: findings from the International Tobacco Control Four-Country Survey

OBJECTIVE

To examine attitudes towards and compliance with the recent Australian bans on smoking in licensed venues, and to explore effects on smoking behaviour.

METHODS

Three Australian states (Queensland, Tasmania and Western Australia) implemented a total ban on smoking in all enclosed licensed premises in 2006, and two others (Victoria and New South Wales) did so in mid-2007. We used data from smokers residing in these states for each of the six waves of the ITC-4 country survey (2002-2007; average n=1,694).

RESULTS

Consistent with the majority of international findings, observed compliance was reported by more than 90% of smokers from a pre-ban situation of indoor smoking being the norm. Attitudes became more positive in the year before the ban, but more than doubled in the year the bans were implemented. The associations found for the leading states were replicated by the lagging states a year later. We found no evidence for any increase in permitting smoking inside the home after the bans took effect. Further, we were unable to find any evidence of reductions in daily cigarette consumption or any increase in quitting activity due to the bans.

IMPLICATIONS

These results add to a growing body of international research that suggests that smokers are readily able to comply with, and increasingly support, smoke-free bars, though the bans may have limited effect on their smoking habits.

Perceived risk and benefit for self and others as predictors of smokers' attitudes towards smoking restrictions

Studies have investigated perceived own risk as a predictor of behavioural change, but only few have investigated perceived risk to others. However, many risks are distributed, affecting other people as much as the 'agents' of the behaviour in question. Further, research on health perceptions has focussed more on risk than benefit even though people generally choose to engage in behaviours because of benefits not risks. The present study investigated the acceptance of smoking restrictions in Germany, a country that at the time of conducting the research had few restrictions on smoking. Smokers (N = 147) rated the benefits and risks of smoking for themselves and others, and their attitudes towards smoking restrictions. We replicated comparative optimism and reality constraints concerning smoking risks. Additionally, we found that participants overestimated their own benefits compared to other smokers ('comparative utility'). Importantly, own benefits but risks to others best predicted the acceptance of smoking regulations. Moreover, smokers who intended to quit differed from those who did not intend to quit. These findings are potentially important for policy makers aiming to broaden acceptance of regulations for risky behaviours: It may be more effective to remind people they are putting others at risk rather than themselves.

Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff

BACKGROUND

The introduction of total smoking bans represents an important step in addressing the smoking and physical health of people with mental illness. Despite evidence indicating the importance of staff support in the successful implementation of smoking bans, limited research has examined levels of staff support prior to the implementation of a ban in psychiatric settings, or factors that are associated with such support. This study aimed to examine the views of psychiatric inpatient hospital staff regarding the perceived benefits of and barriers to implementation of a successful total smoking ban in mental health services. Secondly, to examine the level of support among clinical and non-clinical staff for a total smoking ban. Thirdly, to examine the association between the benefits and barriers perceived by clinicians and their support for a total smoking ban in their unit.

METHODS

Cross-sectional survey of both clinical and non-clinical staff in a large inpatient psychiatric hospital immediately prior to the implementation of a total smoking ban.

RESULTS

Of the 300 staff, 183 (61%) responded. Seventy-three (41%) of total respondents were clinical staff, and 110 (92%) were non-clinical staff. More than two-thirds of staff agreed that a smoking ban would improve their work environment and conditions, help staff to stop smoking and improve patients' physical health. The most prevalent clinician perceived barriers to a successful total smoking ban related to fear of patient aggression (89%) and patient non-compliance (72%). Two thirds (67%) of all staff indicated support for a total smoking ban in mental health facilities generally, and a majority (54%) of clinical staff expressed support for a ban within their unit. Clinical staff who believed a smoking ban would help patients to stop smoking were more likely to support a smoking ban in their unit.

CONCLUSIONS

There is a clear need to more effectively communicate to staff the evidence that consistently applied smoking bans do not increase patient aggression. There is also a need to communicate the benefits of smoking bans in aiding the delivery of smoking cessation care, and the benefits of both smoking bans and such care in aiding patients to stop smoking.

Legislative smoking bans for reducing 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 smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included 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 Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

College students' exposure to tobacco marketing in nightclubs and bars

OBJECTIVE

to examine whether a college student's exposure to tobacco marketing in nightclubs and bars was affected by the presence of a smoke-free law.

PARTICIPANTS

a random sample (N = 478) of students participated in the survey (no smoke-free law, n = 240; smoke-free law, n = 238). The analysis was limited to students who reported being in nightclubs and bars (n = 171).

METHODS

a nonexperimental, cross-sectional, 2-group design was used.

RESULTS

students in the smoke-free law city were more likely to be approached by tobacco marketers (34.7% versus 20.2%, p = .02), offered free gifts (41.7% versus 24.2%, p = .02), and take free gifts for themselves (34.7% versus 19.2%, p = .02). They were more likely to be exposed to direct marketing strategies (1.83 versus 1.12, p = .02). There was no difference on indirect tobacco marketing by site.

CONCLUSIONS

tobacco marketing is pervasive in nightclubs and bars. Smoke-free laws may protect against exposure to secondhand smoke but not the "pro" smoking messages students encounter.

Impact of the Spanish smoking law in smoker hospitality workers

INTRODUCTION

A smoke-free law went into effect in Spain on 1 January 2006, affecting all enclosed workplaces except hospitality venues, where only partial bans were implemented. The objective was to evaluate the impact of the law among hospitality workers who smoke.

METHODS

The study design is a before-and-after evaluation. We formed a cohort at baseline, during the 3 months before the law went into effect, with 431 hospitality workers (222 smokers). From them, 288 were successfully followed-up 12 months after the ban (118 were smokers at baseline). We analyzed the quit rate, the reduction in the number of cigarettes smoked per day, changes in the Fagerström Test for Nicotine Dependence (FTND) scores, and changes in salivary cotinine concentrations in smokers from baseline to 1 year after the ban.

RESULTS

Among 118 smokers, six (5.1%) quit smoking. Among the 112 remaining smokers, the mean number of cigarettes smoked decreased by 8.9% after the ban (from 17.9 to 16.3 cigarettes/day, p < .01). The proportion of workers with a high nicotine dependence (FTND score >6) was reduced by half after the ban (19.5% vs. 9.7%, p = .03). Salivary cotinine decreased by 4.4% after the ban (geometric mean 104.3 vs. 99.7 ng/ml, p = .02). No meaningful differences were found in quit rates and the FTND scores according to type of regulation.

DISCUSSION

The Spanish smoking law has had beneficial effects (reduction in number of cigarettes smoked, cotinine levels, and FTND score) among hospitality workers who smoke.

The effect of smoke-free homes on adult smoking behavior: a review

INTRODUCTION

Smoke-free homes are known to reduce exposure to harmful secondhand smoke. Recent studies suggest that they may also positively affect smoking behavior among smokers themselves.

METHODS

We review the literature on the effect of smoke-free homes on adult smoking behavior. The literature search included database (PubMed) and manual searches of related articles and reference lists for English-language studies published from 1 January 1990 to 16 November 2008.

RESULTS

We identified 16 cross-sectional and 7 longitudinal studies of the population-level association of smoke-free homes with adult smoking behavior. Additional studies provided population estimates of trends in and correlates of smoke-free homes. Prevalence of smoke-free homes varies but has been increasing over time in the countries studied and was greater among smokers who were younger, of higher income or educational attainment, smoked fewer cigarettes per day, or lived with a nonsmoking adult or child. Both longitudinal and cross-sectional studies showed that smokers who had or who newly implemented a smoke-free home were significantly more likely to make a quit attempt and to be abstinent, after controlling for confounding factors. In longitudinal studies, those who continued to smoke had a modest, but significant, decrease in cigarette consumption at follow-up.

DISCUSSION

There is strong and consistent population-level evidence that a smoke-free home is associated with increased smoking cessation and decreased cigarette consumption in adult smokers. As they not only reduce exposure to secondhand smoke but also increase cessation rates, promotion of smoke-free homes should be a key element in tobacco control programs.