The impact of workplace smoking ordinances in California on smoking cessation

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.

A Cross-Sectional Survey on the Use of Tobacco, Attempts on Cessation, and Locus of Control Among College Students

Background Socio-cultural considerations (such as drug availability) and psychological traits play a significant role in predicting whether a person will use drugs in the future and dependency on the drugs. Second-, third-, and fourth-hand smoking and E-cigarettes are influencing factors for the use of tobacco in college students. This study conducted research to ascertain whether there is a potential relationship between tobacco consumption and various factors, including internal and external control sites and demographics. Materials and methods Participants in the study were found by walk-up distribution at multiple campus-wide smoking places, department announcements, and on-campus advertisements. Social media and participant references were also used in this study as recruitment tools. In addition, the locus of control questionnaire also identifies if the participating individual had extrinsic or intrinsic reinforcing routines. The classification of the participating individuals into respective internal and external locus of control was in accordance with their response survey after which a statistical analysis was done. Results This study found an association between smoking on campus and reported attempts to quit. Additionally, there is a strong association (r(85) = 0.31, p < 0.01) between reported tobacco use status and cigarette use on campus. Participants' gender and smoking status also had r(85) = 0.39, p-value < 0.01 correlation. The bulk of respondents indicated that they were seniors and off-campus living concluding for 36% (n = 34) and 60% (n = 51) of the total. Twenty-seven percent (n = 24) of the respondents were first-year college students and the rest 33% (n = 29) said their parents had no college education at all or incomplete college education. Conclusion Whenever there is a strong perception of organizational support for anti-tobacco policies, and improving compliance, there is a drastic increase in cigarette cessation and a drop in tobacco usage among those who still smoke. Perceived organizational support is strongly and positively connected with cessation among the organization's members.

A Comprehensive Tobacco Control Policy Program in a Mining Industry in Indonesia: Did It Work?

Background

Risk factor controls, including smoking cessation and prevention, impact health costs. This study aimed to describe the Kaltim Prima Coal (KPC), one of Indonesia's largest coal mining operations, comprehensive tobacco control policy program in 2015 and its impact on smoking behavior among the employees.

Method

A survey among 404 employees was conducted to assess the impact of the smoke-free KPC programs. In addition to the descriptive analysis, logistic regression was used to measure the association of intention to the smoking behavior change and the association between intention and the determinants using the Theory of Planned Behavior in 102 smokers.

Results

A series of tobacco control programs: advocacy, health education, brief interventions for smoking cessation, peer counselor training, media campaigns, and policy regulations were implemented. About 95.5% of the respondents attended the KPC Smoke-Free 2015 programs, and 97.8% reported they already knew that KPC is a total smoke-free area. Nearly 50% of the respondents expressed that the staff complied with the rules and no longer smoked in KPC. Majority of smokers (76.6%) reduced their consumption, and 5.6% of them quit smoking. Among smokers, we found that attitude toward smoking cessation, subjective norm, and perceived control for quitting were related to the intention to stop smoking.

Conclusions

The KPC smoke-free policy has been comprehensively implemented. Regulations on smoking and tobacco controls should be maintained, and monitoring should be consistently done. Media campaigns on the regulations and the availability of trained peer educators for smoking cessation help need to be applied continuously.

Education-smoking gradient and upstream health policies: comparing Generation X with millennials

Purpose

Over the years, many upstream health policies have sought to reduce smoking across populations. While smoking has been substantially reduced, the effects of these policies on education-smoking gradient remain unclear. The present paper compares the education-smoking gradient among the Generation X and the millennials, who grew up with different types of upstream policies.

Design/methodology/approach

The study relies on regression analysis. The data are from the Canadian Tobacco, Alcohol and Drugs Survey of 2017, with the sample restricted to those born between 1965 and 1995.

Findings

At the zero-order, the education-smoking gradient has not significantly flattened from Generation X to millennials. And, accounting for the channels of impact of education on smoking does not substantially change this pattern.

Social implications

The implications for health inequalities associated with socioeconomic status, and tobacco consumption reduction policies, are discussed.

Originality/value

This paper is the first study of the kind using Canadian data.

Testing effects of awareness of statewide smoke-free air law and risk perception on smoking behaviors

Purpose

To reduce the smoking rates and alleviate societal problems associated with smoking, health administrators and policy makers have attempted to promote and implement statewide smoking free policy. The present study examined how adults' awareness of and attitude toward the smoke-free air law, their perceived risks of secondhand smoke and current smoking status were associated with smoking attitude and behaviors.

Design/methodology/approach

As part of the Indiana Adult Tobacco Survey, 2,027 respondents participated in cross-sectional telephone surveys. A series of independent sample t-test and binary logistic regression analyses were performed.

Findings

Awareness of the state law was inversely related to negative attitude toward smoking behaviors. Individuals who reported favorable attitude toward the state smoke-free air law and higher risk perceptions of secondhand smoke showed negative attitude toward smoking behaviors. Non-smokers and former smokers were significantly different from current smokers with regard to attitude toward smoking. Negative attitude was significantly related to intention to quit smoking. Awareness of the state law, perceived risk and current smoking status were key determinants for anti-smoking attitude and behavior.

Originality/value

Findings highlight the importance of effective dissemination of the state law and recommend a strategic intervention design that invokes risk perceptions of secondhand smoke.

Design and baseline data of a randomized trial comparing two methods for scaling-up an occupational sun protection intervention

Background

Successful methods for scaling-up evidence-based programs are needed to prevent skin cancer among adults who work outdoors in the sun.

Methods

A randomized trial is being conducted comparing two methods of scaling-up the Sun Safe Workplaces (SSW) intervention. Departments of transportation (DOTs) from 21 U.S. states are participating and their 138 regional districts were randomized following baseline assessment. In districts assigned to the in-person method (n = 46), project staff meets personally with managers, conducts trainings for employees, and provides printed materials. In districts assigned to the digital method (n = 92), project staff conduct these same activities virtually, using conferencing technology, online training, and electronic materials. Delivery of SSW in both groups was tailored to managers' readiness to adopt occupational sun safety. Posttesting will assess manager's support for and use of SSW and employees' sun safety. An economic evaluation will explore whether the method that uses digital technology results in lower implementation of SSW but is more cost-effective relative to the in-person method.

Results

The state DOTs range in size from 997 to 18,415 employees. At baseline, 1113 managers (49.0%) completed the pretest (91.5% male, 91.1% white, 19.77 years on the job, 66.5% worked outdoors; and 24.4% had high-risk skin types). They were generally supportive of occupational sun safety. A minority reported that the employer had a written policy, half reported training, and two-thirds, messaging on sun protection.

Conclusions

Digital methods are available that may make scale-up of SSW cost-effective in a national distribution to nearly half of the state DOTs.

Trial registration: The ClinicalTrials.gov registration number is NCT03278340.

Lung cancer mortality among never-smokers in the United States: estimating smoking-attributable mortality with nationally representative data

PURPOSE

Lung cancer mortality among never-smokers is an often overlooked yet important cause of adult mortality. Moreover, indirect approaches for estimating smoking-attributable mortality use never-smoker lung cancer death rates to approximate smoking burden. To date, though, most studies using indirect approaches import rates from the Cancer Prevention Study II (CPS-II), which is not representative of the U.S.

POPULATION

METHODS

We use the nationally representative 1985-2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) to calculate lung cancer death rates among never-smokers aged 50 years or older. We then import rates from NHIS-LMF and CPS-II into the Preston-Glei-Wilmoth indirect method to determine whether smoking-attributable fractions differ.

RESULTS

Never-smokers account for 16% of U.S. lung cancer deaths among women and 11% among men. Lung cancer death rates among never-smokers are higher in NHIS-LMF than CPS-II for several age groups. Smoking-attributable fractions of mortality are slightly lower with NHIS-LMF rates (19% of male deaths and 16% of female deaths) than with CPS-II rates (21% of male deaths and 17% of female deaths).

CONCLUSIONS

Fractions based on nonrepresentative CPS-II data may modestly overestimate smoking-attributable mortality. Thus, indirect methods should use never-smoker lung cancer death rates from such nationally representative datasets as NHIS-LMF.

Sun Safe Workplaces: Effect of an Occupational Skin Cancer Prevention Program on Employee Sun Safety Practices

OBJECTIVE

Occupational skin cancer prevention is a priority because outdoor workers are exposed to high levels of ultraviolet radiation, the primary risk factor for skin cancer.

METHODS

A 2-year follow-up assessment of the impact of Sun Safe Workplaces (SSW), a workplace sun safety program that promoted policy adoption and education, on employee sun safety behavior was conducted. Sixty-three of 98 local government organizations from the original study participated.

RESULTS

Outdoor workers (n = 1724) completed surveys on personal sun protection practices. Employees' sun protection improved statistically significantly in the intervention group receiving the SSW program. SSW's effect was mediated by the number of workplace actions to implement elements of the policy, including sun protection messages and equipment and employee reports of sun safety training.

CONCLUSION

Policy promotion is a feasible approach to occupational skin cancer prevention.

Smoke-Free Policies and Smoking Cessation in the United States, 2003-2015

(1) Background: Smoking restrictions have been shown to be associated with reduced smoking, but there are a number of gaps in the literature surrounding the relationship between smoke-free policies and cessation, including the extent to which this association may be modified by sociodemographic characteristics. (2) Methods: We analyzed data from the Tobacco Use Supplement to the Current Population Survey, 2003-2015, to explore whether multiple measures of smoking restrictions were associated with cessation across population subgroups. We examined area-based measures of exposure to smoke-free laws, as well as self-reported exposure to workplace smoke-free policies. We used age-stratified, fixed effects logistic regression models to assess the impact of each smoke-free measure on 90-day cessation. Effect modification by gender, education, family income, and race/ethnicity was examined using interaction terms. (3) Results: Coverage by workplace smoke-free laws and self-reported workplace smoke-free policies was associated with higher odds of cessation among respondents ages 40-54. Family income modified the association between smoke-free workplace laws and cessation for women ages 25-39 (the change in the probability of cessation associated with coverage was most pronounced among lower-income women). (4) Conclusions: Heterogeneous associations between policies and cessation suggest that smoke-free policies may have important implications for health equity.

Implementation of Occupational Sun Safety at a 2-Year Follow-Up in a Randomized Trial: Comparison of Sun Safe Workplaces Policy Intervention to Attention Control

PURPOSE

Implementation of employer sun safety actions was assessed in a 2-year follow-up to an occupational sun protection policy intervention.

DESIGN

Two-year follow-up assessment in a randomized pretest-posttest controlled design.

SETTING

Local government organizations with workers in public safety, public works, and parks and recreation.

PARTICIPANTS

Sixty-three local government organizations (participation = 64%) and 330 frontline supervisors and 1454 workers.

INTERVENTION

Sun Safe Workplaces (SSW) intervention promoting occupational sun safety policy and education.

MEASURES

Observations of SSW messages and sun safety items and surveys on organizations' communication and actions on sun safety.

ANALYSIS

Comparison between SSW and control groups was conducted using regression models and adjusted for clustering where appropriate, with α criterion set at P = .05 (2-tailed).

RESULTS

At intervention worksites, more SSW messages ( P < .001) and sun safety items ( P = .025) were observed; more frontline supervisors reported organizations provided free/reduced price sunscreen ( P = .005) and communicated about sun safety ( P < .001); and more workers recalled receiving sun safety messages ( P < .001) and sun safety training ( P <.001) compared to control organizations. Implementation was greater at larger than smaller intervention organizations for wide-brimmed hats ( P = .009), long work pants ( P = .017), and shade structures ( P = .036). Older workers received the most written messages ( P = .015).

CONCLUSIONS

Sun Safe Workplaces appeared to produce actions by organizations to support employee sun safety. Large organizations may have processes, communication channels, and slack resources to achieve more implementation.

Smoking and Variation in the Hispanic Paradox: A Comparison of Low Birthweight Across 33 US States

The Hispanic Paradox in birth outcomes is well documented for the US as a whole, but little work has considered geographic variation underlying the national pattern. This inquiry is important given the rapid growth of the Hispanic population and its geographic dispersion. Using birth records data from 2014 through 2016, we document state variation in birthweight differentials between US-born white women and the three Hispanic populations with the largest numbers of births: US-born Mexican women, foreign-born Mexican women, and foreign-born Central and South American women. Our analyses reveal substantial geographic variation in Hispanic immigrant-white low birthweight disparities. For example, Hispanic immigrants in Southeastern states and in some states from other regions have reduced risk of low birthweight relative to whites, consistent with a "Hispanic Paradox." A significant portion of Hispanic immigrants' birthweight advantage in these states is explained by lower rates of smoking relative to whites. However, Hispanic immigrants have higher rates of low birthweight in California and several other Western states. The different state patterns are largely driven by geographic variation in smoking among whites, rather than geographic differences in Hispanic immigrants' birthweights. In contrast, US-born Mexicans generally have similar or slightly higher odds of low birthweight than whites across the US. Overall, we show that the Hispanic Paradox in birthweight varies quite dramatically by state, driven by geographic variation in low birthweight among whites associated with white smoking disparities across states.

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.

Smoke-Free Laws and Hazardous Drinking: A Cross-Sectional Study among U.S. Adults

Tobacco and alcohol use are strongly associated. This cross-sectional study examined the relationship of smoke-free law coverage and smoke-free bar law coverage with hazardous drinking behaviors among a representative sample of U.S. adult drinkers (n = 17,057). We merged 2009 National Health Interview Survey data, American Nonsmokers’ Rights Foundation U.S. Tobacco Control Laws Database, and Census Population Estimates. Hazardous drinking outcomes included heavy drinking (>14 drinks/week for men; >7 drinks/week for women) and binge drinking (≥5 drinks on one or more days during past year). Chi-square tests compared hazardous drinking by sociodemographic factors. Multivariable logistic regression models were used to examine if smoke-free law and bar law coverages were associated with hazardous drinking, controlling for sociodemographics and smoking status. Subset analyses were conducted among drinkers who also smoked (n = 4074) to assess the association between law coverages and hazardous drinking. Among all drinkers, smoke-free law coverage was not associated with heavy drinking (adjusted odds ratio (AOR) = 1.22, 95% confidence interval (CI) = 0.99–1.50) or binge drinking (AOR = 1.09, 95% CI = 0.93–1.26). Smoke-free bar law coverage was also found to be unrelated to hazardous drinking. Similar results were found among those drinkers who smoked. Findings suggest that smoke-free laws and bar laws are not associated with elevated risk for alcohol-related health issues.

Strategic Planning for Chronic Disease Prevention in Rural America: Looking Through a PRISM Lens

CONTEXT

Community-level strategic planning for chronic disease prevention.

OBJECTIVE

To share the outcomes of the strategic planning process used by Mississippi Delta stakeholders to prevent and reduce the negative impacts of chronic disease in their communities. A key component of strategic planning was participants' use of the Prevention Impacts Simulation Model (PRISM) to project the reduction, compared with the status quo, in deaths and costs from implementing interventions in Mississippi Delta communities.

DESIGN

Participants in Mississippi Delta strategic planning meetings used PRISM, a user-friendly, evidence-based simulation tool that includes 22 categories of policy, systems, and environmental change interventions, to pose what-if questions that explore the likely short- and long-term effects of an intervention or any desired combination of the 22 categories of chronic disease intervention programs and policies captured in PRISM. These categories address smoking, air pollution, poor nutrition, and lack of physical activity. Strategic planning participants used PRISM outputs to inform their decisions and actions to implement interventions.

SETTING

Rural communities in the Mississippi Delta.

PARTICIPANTS

A diverse group of 29 to 34 local chronic disease prevention stakeholders, known as the Mississippi Delta Strategic Alliance.

MAIN OUTCOME MEASURE(S)

Community plans and actions that were developed and implemented as a result of local strategic planning.

RESULTS

Existing strategic planning efforts were complemented by the use of PRISM. The Mississippi Delta Strategic Alliance decided to implement new interventions to improve air quality and transportation and to expand existing interventions to reduce tobacco use and increase access to healthy foods. They also collaborated with the Department of Transportation to raise awareness and use of the current transportation network.

CONCLUSIONS

The Mississippi Delta Strategic Alliance strategic planning process was complemented by the use of PRISM as a tool for strategic planning, which led to the implementation of new and strengthened chronic disease prevention interventions and policies in the Mississippi Delta.

A systematic literature review of the effectiveness of occupational health and safety regulatory enforcement

BACKGROUND

We aimed to determine the strength of evidence on the effectiveness of legislative and regulatory policy levers in creating incentives for organizations to improve occupational health and safety processes and outcomes.

METHODS

A systematic review was undertaken to assess the strength of evidence on the effectiveness of specific policy levers using a "best-evidence" synthesis approach.

RESULTS

A structured literature search identified 11,947 citations from 13 peer-reviewed literature databases. Forty-three studies were retained for synthesis. Strong evidence was identified for three out of nine clusters.

CONCLUSIONS

There is strong evidence that several OHS policy levers are effective in terms of reducing injuries and/or increasing compliance with legislation. This study adds to the evidence on OHS regulatory effectiveness from an earlier review. In addition to new evidence supporting previous study findings, it included new categories of evidence-compliance as an outcome, nature of enforcement, awareness campaigns, and smoke-free workplace legislation. Am. J. Ind. Med. 59:919-933, 2016. © 2016 Wiley Periodicals, Inc.

Tobacco Use Prevention and Cessation Policies in Manufacturing Facilities in the Tobacco-Growing State of Kentucky

Purpose.

To assess workplace tobacco use prevention and cessation policies in manufacturing facilities and explore factors associated with tobacco policies and practices in the tobacco-growing state of Kentucky.

Design.

Cross-sectional, descriptive, correlational design.

Setting.

Telephone survey of Kentucky manufacturing facilities.

Subjects.

A total of 437 human resource managers (77% participation rate).

Measures.

Telephone interviews by trained local health department staff to assess indoor and outdoor smoking policies, sale of cigarettes on company property, and provision of cessation and prevention programs.

Results.

Nearly seven in 10 manufacturing facilities had a written smoking policy, but only 43% banned indoor smoking. About one-fourth of companies reimbursed for cessation treatment and/or provided cessation resources. Companies with unions were more likely than those without unions to provide cessation resources but were also more likely to allow indoor smoking. Although large companies had more than two and a half times the odds as small companies to have a written smoking policy, they were more likely to allow cigarette sales on company property.

Conclusion.

Despite the importance of smoke-free policies in the workplace, most manufacturing facilities surveyed allowed indoor smoking and few helped smokers quit. Companies with unions were more likely to cater to their smoking employees. Manufacturing facilities provide an opportunity to protect large numbers of adult workers from the hazards of secondhand smoke and to provide quit assistance for smokers.

The influence of societal individualism on a century of tobacco use: modelling the prevalence of smoking

Background

Smoking of tobacco is estimated to have caused approximately six million deaths worldwide in 2014. Responding effectively to this epidemic requires a thorough understanding of how smoking behaviour is transmitted and modified.

Methods

We present a new mathematical model of the social dynamics that cause cigarette smoking to spread in a population, incorporating aspects of individual and social utility. Model predictions are tested against two independent data sets spanning 25 countries: a newly compiled century-long composite data set on smoking prevalence, and Hofstede’s individualism/collectivism measure (IDV).

Results

The general model prediction that more individualistic societies will show faster adoption and cessation of smoking is supported by the full 25 country smoking prevalence data set. Calibration of the model to the available smoking prevalence data is possible in a subset of 7 countries. Consistency of fitted model parameters with an additional, independent, data set further supports our model: the fitted value of the country-specific model parameter that determines the relative importance of social and individual factors in the decision of whether or not to smoke, is found to be significantly correlated with Hofstede’s IDV for the 25 countries in our data set.

Conclusions

Our model in conjunction with extensive data on smoking prevalence provides evidence for the hypothesis that individualism/collectivism may have an important influence on the dynamics of smoking prevalence at the aggregate, population level. Significant implications for public health interventions are discussed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2576-6) contains supplementary material, which is available to authorized users.

Relationship of Smokefree Laws and Alcohol Use with Light and Intermittent Smoking and Quit Attempts among US Adults and Alcohol Users

Introduction

Light and intermittent smoking (LITS) has become increasingly common. Alcohol drinkers are more likely to smoke. We examined the association of smokefree law and bar law coverage and alcohol use with current smoking, LITS, and smoking quit attempts among US adults and alcohol drinkers.

Methods

Cross-sectional analyses among a population-based sample of US adults (n = 27,731) using restricted data from 2009 National Health Interview Survey and 2009 American Nonsmokers' Rights Foundation United States Tobacco Control Database. Multivariate logistic regression models examined the relationship of smokefree law coverage and drinking frequency (1) with current smoking among all adults; (2) with 4 LITS patterns among current smokers; and (3) with smoking quit attempts among 6 smoking subgroups. Same multivariate analyses were conducted but substituted smokefree bar law coverage for smokefree law coverage to investigate the association between smokefree bar laws and the outcomes. Finally we ran the above analyses among alcohol drinkers (n = 16,961) to examine the relationship of smokefree law (and bar law) coverage and binge drinking with the outcomes. All models controlled for demographics and average cigarette price per pack. The interactions of smokefree law (and bar law) coverage and drinking status was examined.

Results

Stronger smokefree law (and bar law) coverage was associated with lower odds of current smoking among all adults and among drinkers, and had the same effect across all drinking and binge drinking subgroups. Increased drinking frequency and binge drinking were related to higher odds of current smoking. Smokefree law (and bar law) coverage and drinking status were not associated with any LITS measures or smoking quit attempts.

Conclusions

Stronger smokefree laws and bar laws are associated with lower smoking rates across all drinking subgroups, which provides further support for these policies. More strict tobacco control measures might help reduce cigarette consumption and increase quit attempts.

Smoke-Free Workplaces Are Associated with Protection from Second-Hand Smoke at Homes in Nigeria: Evidence for Population-Level Decisions

The evidence suggests that smoke-free workplace policies may change social norms towards exposing others to second-hand smoke at home. The aim of the study was to assess whether being employed in a smoke-free workplace (SFWP) is associated with living in a smoke-free home (SFH). We used the data from the Global Adult Tobacco Survey conducted in Nigeria in 2012, in which 9,765 individuals were interviewed including 1,856 persons who worked indoors. The percentage of Nigerians employed in SFWP that reported living in a SFH was higher compared to those employed in a workplace where smoking occurred (95% versus 73%). Working in a SFWP was associated with a significantly higher likelihood of living in a SFH (OR = 5.3; p < 0.001). Urban inhabitants indicated more frequently that they lived in SFH compared to rural residents (OR = 2.0; p = 0.006). The odds of living in a SFH were significantly higher among nonsmokers and nonsmokeless tobacco users compared to smokers and smokeless tobacco users (OR = 28.8; p < 0.001; OR = 7.0; p < 0.001). These findings support the need for implementation of comprehensive smoke-free policies in Nigeria that result in substantial health benefits.

Home exposure to secondhand smoke among people living in multiunit housing and single family housing: a study of California adults, 2003-2012

Public health education efforts continue to encourage people to adopt voluntary smoking bans at home; nonetheless, the home remains a place where many people are exposed to secondhand smoke (SHS). Little is known about how SHS exposure in the home differs between adults residing in multiunit housing (MUH) and those residing in single family housing (SFH). This study (1) compared the socio-demographic characteristics, chronic disease conditions, and smoking status of adults living in MUH with those living in SFH, (2) assessed the correlates of living in MUH for adults, and (3) evaluated the association of residency in MUH and SFH with the odds of being exposed to SHS at home using population-based survey data of California adults. Smoking prevalence was significantly higher among MUH residents than SFH residents. The adjusted odds of exposure to SHS at home were 32 % higher for MUH smokers than SFH smokers but were not significantly different for non-smokers. This study presents evidence that there are significant socio-demographic differences between MUH residents and SFH residents and that MUH smokers have higher rates of exposure to SHS at home than SFH smokers after adjusting for other covariates. To reduce home exposure to SHS among MUH residents, it is important to adopt tobacco control policies that are aimed at reducing SHS exposure in and around MUH and at reducing cigarette smoking among current smokers in MUH.

Executive function moderates the intention-behavior link for physical activity and dietary behavior

Dominant theories of health behavior posit that social-cognitive and conative variables are sufficient to explain health behavior tendencies. The current studies challenge this assumption in two ways: (1) by demonstrating that unique variance in health protective behavior is predictable by knowing about individual differences in executive functioning, and (2) by demonstrating that executive function moderates the association between intention and behavior. In Studies 1 and 2, participants completed a computer-based task of executive function (Go/NoGo task) and articulated 1-week behavioral intentions for physical activity (Study 1) and dietary behavior (Study 2). Hierarchical regression analyses revealed that executive function predicts unique variance in both behaviors, and strongly moderates the association between behavioral intention and behavioral performance. Together behavioral intention and executive function explain more variance in health protective behavior than 'rational actor' models that have been widely adopted and disseminated.

A controlled community-based trial to promote smoke-free policy in rural communities

PURPOSE

Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak tobacco control policies. The purpose was to test the effects of a stage-specific, tailored policy-focused intervention on readiness for smoke-free policy, and policy outcomes in rural underserved communities.

METHODS

A controlled community-based trial including 37 rural counties. Data were collected annually with community advocates (n = 330) and elected officials (n = 158) in 19 intervention counties and 18 comparison counties over 5 years (average response rate = 68%). Intervention communities received policy development strategies from community advisors tailored to their stage of readiness and designed to build capacity, build demand, and translate and disseminate science. Policy outcomes were tracked over 5 years.

FINDINGS

Communities receiving the stage-specific, tailored intervention had higher overall community readiness scores and better policy outcomes than the comparison counties, controlling for county-level smoking rate, population size, and education. Nearly one-third of the intervention counties adopted smoke-free laws covering restaurants, bars, and all workplaces compared to none of the comparison counties.

CONCLUSIONS

The stage-specific, tailored policy-focused intervention acted as a value-added resource to local smoke-free campaigns by promoting readiness for policy, as well as actual policy change in rural communities. Although actual policy change and percent covered by the policies were modest, these areas need additional resources and efforts to build capacity, build demand, and translate and disseminate science in order to accelerate smoke-free policy change and reduce the enormous toll from tobacco in these high-risk communities.

Prevalence and factors associated with hardcore smoking in Poland: findings from the Global Adult Tobacco Survey (2009-2010)

Background

Estimating the prevalence of hardcore smoking and identifying linked factors is fundamental to improve planning and implementation of effective tobacco control measures. Given the paucity of data on that topic, we aimed to assess the prevalence of and factors associated with hardcore smoking in Poland.

Methods

We used data from the Global Adult Tobacco Survey (GATS). GATS is a representative, cross-sectional, household based survey conducted in Poland between 2009 and 2010. Binary logistic regression analysis was used to explore the associations of socio-demographic and smoking related variables with hardcore smoking among daily smokers.

Results

The prevalence of hardcore smoking was 10.0% (13.0% among men and 7.3% among women) in the whole population of Poland at age 26 years and above. Hardcore smokers constitute 39.9% (41.6% among men and 37.7% among women) of all daily smokers in analyzed age frame. Being older, having started smoking at earlier ages, living in large cities (in women only), being less aware of negative health effects of smoking, having less restrictions on smoking at home was associated with higher risk of being hardcore smoker. Educational attainment and economic activity were not associated with hardcore smoking among daily smokers.

Conclusions

High prevalence of hardcore smokers may be a grand challenge for curbing non-communicable diseases epidemic in Poland. Our findings should urge policy makers to consider hardcore smoking issues while planning and implementing tobacco control policies. Prevention of smoking uptake, education programs, and strengthening cessation services appeared to be the top priorities.

Smoke-free or not: a pilot evaluation in selected Beijing Hospitals

Background

China enacted a policy to ban smoking in hospitals. The Chinese Association for Tobacco Control (CATC) developed a program to help hospitals implement this policy. They conducted a program and an assessment in 3 Chinese cities (Beijing, Shanghai and Guangdong). A more in-depth evaluation was implemented with a sub-sample of hospitals in Beijing (N = 7) to provide an independent assessment. This independent assessment focused on evaluating policy development and an assessment of secondhand smoke (SHS) to determine compliance with the smoke-free policy initiative.

Methods

Pre- and post-survey data were collected at each of the selected hospitals with a total sample of 2835 physicians at pre-intervention and 2812 at post-intervention. Smoking rates pre- and post-policy implementation, change in knowledge, attitudes and practices among physicians, and compliance with policy were assessed. Measurements of airborne nicotine concentrations in selected locations in each hospital were taken: main hospital lobby; main outpatient center; emergency waiting room; and stairwell adjacent to a large inpatient ward. Hospital policies were collected, translated and rated for incorporated components necessary to implement a smoke-free policy.

Results

Physicians’ smoking rates decreased and attitudes towards tobacco control improved significantly from pre-to post-intervention. Smoking was still reported in certain areas of the hospital with 96% of passive nicotine monitors as well as self-report indicating continued smoking. Nicotine levels ranged from <0.0056 to 3.94 μg/m³), with an overall mean of .667 μg/m³. Hospitals that established stronger policies seemed to have lower levels of nicotine, suggesting a relationship between policy development and compliance. This finding is interesting but just suggestive and requires further investigation to truly demonstrate if stronger policies improve compliance and produce better outcomes.

Conclusion

As implementation strategies for smoke-free environments are improved and more resources are focused on hospitals, China is making progress toward achieving smoke-free hospitals. Using a model program could increase the prevalence of SHS policies across China. However, relying only on survey data may not provide an accurate assessment of this progress, and more extensive evaluation efforts are useful to understand how change can and does occur.

Political climate and smoke-free laws in rural Kentucky communities

The purpose was to determine factors associated with rural communities' political readiness to enact smoke-free laws. Data from baseline assessment of a longitudinal intervention study to promote smoke-free policy in rural Kentucky communities; key informants (n = 144) and elected officials (n = 83) from 29 counties participated in cross-sectional telephone interviews. Controlling for population size and county-level smoking rate, the following factors predicted elected officials' perception of the likelihood of a local smoke-free law passing in the next 12 months: (1) support from the local board of health; (2) support from local leaders; and (3) smoke-free hospitals. Communities with lower adult smoking prevalence were more ready for smoke-free laws. Rural health advocates can increase political readiness for smoke-free laws by educating and engaging Board of Health members and local leaders, promoting the voluntary adoption of smoke-free policies in rural hospitals, and investing in effective population-based approaches to evidence-based tobacco treatment in rural communities.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

The association between implicit and explicit attitudes toward smoking and support for tobacco control measures

INTRODUCTION

This study examined the association between implicit and explicit attitudes toward smoking and support for tobacco control policies.

METHODS

Participants were from an ongoing longitudinal study of the natural history of smoking who also completed a web-based assessment of implicit attitudes toward smoking (N = 1,337). Multiple regression was used to test the association between covariates (sex, age, educational attainment, parent status, and smoking status), implicit attitude toward smoking, and explicit attitude toward smoking and support for tobacco control policies. The moderating effect of the covariates on the relation between attitudes and support for policies was also tested.

RESULTS

Females, those with higher educational attainment, parents, and nonsmokers expressed more support for tobacco control policy measures. For nonsmokers, only explicit attitude was significantly associated with support for policies. For smokers, both explicit and implicit attitudes were significantly associated with support. The effect of explicit attitude was stronger for those with lower educational attainment.

CONCLUSIONS

Both explicit and implicit smoking attitudes are important for building support for tobacco control policies, particularly among smokers. More research is needed on how to influence explicit and implicit attitudes to inform policy advocacy campaigns.

Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades?

This paper reviews the literature on smoking cessation interventions, with a focus on the last 20 years (1991 to 2010). These two decades witnessed major development in a wide range of cessation interventions, from pharmacotherapy to tobacco price increases. It was expected that these interventions would work conjointly to increase the cessation rate on the population level. This paper examines population data from the USA, from 1991 to 2010, using the National Health Interview Surveys. Results indicate there is no consistent trend of increase in the population cessation rate over the last two decades. Various explanations are presented for this lack of improvement, and the key concept of impact = effectiveness × reach is critically examined. Finally, it suggests that the field of cessation has focused so much on developing and promoting interventions to improve smokers' odds of success that it has largely neglected to investigate how to get more smokers to try to quit and to try more frequently. Future research should examine whether increasing the rate of quit attempts would be key to improving the population cessation rate.

The three Ts of adopting tobacco-free policies on college campuses

This article describes a 3-pronged compliance strategy to implement a tobacco-free campus policy at 1 large, land grant public university in the South, and evaluates its impact on outcomes and costs. Although there has been a recent wave of tobacco-free colleges, policy restrictiveness and implementation vary, and compliance remains a challenge. The 3 Ts strategy (Tell-Treat-Train) involves regular, consistent communications, access to tobacco treatment medications and counseling, and ongoing training of supervisors and student leaders. Administrative support, access to tobacco treatment, campus buy-in, sustained communications, and careful implementation planning are critical to instituting a tobacco-free university policy.

Knowledge of the New Tobacco Hazards Prevention Act Is Associated With Smokers’ Behavior of Seeking Help in Smoking Cessation in Taiwan

Evidence that smoking area restrictions and raising cigarette taxes affect smokers’ behavior of seeking help in cessation is limited. The authors conducted a case-control study of 200 participants in Taipei City, Taiwan, from December 2008 to June 2009 to evaluate the association between knowledge on legislation and the behavior of seeking help in smoking cessation. They compared smokers who sought assistance in clinics/classes and smokers who did not, matching for age, gender, and recruitment time. In a univariate model, both banning smoking and increasing prices had positive effects on smokers’ behavior, but the effect size of the latter was larger ( P = .021). A better knowledge of the regulations was associated with cessation effort (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.44-5.23), as were being more influenced by increased prices (OR = 2.44; 95% CI = 1.38-4.34) and by smoking bans (OR = 2.32; 95% CI = 1.29-4.16). Increased knowledge of the regulations is associated with seeking help for smoking.

Smoking behaviors and attitudes during adolescence prospectively predict support for tobacco control policies in adulthood

INTRODUCTION

Several cross-sectional studies have examined factors associated with support for tobacco control policies. The current study utilized a longitudinal design to test smoking status and attitude toward smoking measured in adolescence as prospective predictors of support for tobacco control policies measured in adulthood.

METHODS

Participants (N = 4,834) were from a longitudinal study of a Midwestern community-based sample. Hierarchical multiple regression analyses tested adolescent smoking status and attitude toward smoking as prospective predictors (after controlling for sociodemographic factors, adult smoking status, and adult attitude toward smoking) of support for regulation of smoking in public places, discussion of the dangers of smoking in public schools, prohibiting smoking in bars, eliminating smoking on television and in movies, prohibiting smoking in restaurants, and increasing taxes on cigarettes.

RESULTS

Participants who smoked during adolescence demonstrated more support for discussion of the dangers of smoking in public schools and less support for increasing taxes on cigarettes but only among those who smoked as adults. Those with more positive attitudes toward smoking during adolescence demonstrated less support as adults for prohibiting smoking in bars and eliminating smoking on television and in movies. Moreover, a significant interaction indicated that those with more positive attitudes toward smoking as adolescents demonstrated less support as adults for prohibiting smoking in restaurants, but only if they became parents as adults.

CONCLUSIONS

This study's findings suggest that interventions designed to deter adolescent smoking may have future benefits in increasing support for tobacco control policies.

The effect of a smoke-free campus policy on college students' smoking behaviors and attitudes

OBJECTIVE

To evaluate the impact of a smoke-free campus policy on college students' smoking behaviors and attitudes.

METHODS

The current study utilized repeated cross-sectional surveys with a nested 4-wave longitudinal cohort design. Data were collected from undergraduate students at two large matched public universities in Indiana before and after one of the campuses went smoke-free in January 2008. Baseline data were collected in fall 2007 (n=3266) and follow-up data were collected in fall 2009 (n=3207). In addition, volunteers provided longitudinal follow-up data at four different time points.

RESULTS

In the cross-sectional analyses, students exposed to the smoke-free campus policy demonstrated significant favorable changes in smoking behavior (16.5% to 12.8%, p<0.001), perceptions of peer tobacco use (73.6% to 66.8%, p<0.001), and smoking norms (45.5% to 40.4%, p<0.001) compared to students on the control campus. In the longitudinal analyses, students exposed to the smoke-free campus policy demonstrated these changes plus significant favorable changes in attitudes toward regulation of tobacco (83.2% to 89.9%, p<0.01).

CONCLUSIONS

The implementation of a smoke-free campus policy may be an effective intervention for reducing tobacco use among college students.

Moving from evidence-based medicine to evidence-based health

While evidence-based medicine (EBM) has advanced medical practice, the health care system has been inconsistent in translating EBM into improvements in health. Disparities in health and health care play out through patients' limited ability to incorporate the advances of EBM into their daily lives. Assisting patients to self-manage their chronic conditions and paying attention to unhealthy community factors could be added to EBM to create a broader paradigm of evidence-based health. A perspective of evidence-based health may encourage physicians to consider their role in upstream efforts to combat socially patterned chronic disease.

Applying the Theory of Planned Behavior to Explore the Relation Between Smoke-Free Air Laws and Quitting Intentions

Smoke-free air policies have been shown to reduce smoking, but the mechanism of behavior change is not well understood. The authors used structural equation modeling to conduct a theory of planned behavior analysis with data from 395 smokers living in seven Texas cities, three with a comprehensive smoke-free air law and four without a comprehensive law. Agreement with regulating smoking in public places was significantly associated with attitudes and perceived normative pressure about quitting. Nicotine dependence was significantly associated with attitudes and perceived behavioral control. There was also a direct effect of nicotine dependence on intention to take measures to quit smoking. Smoke-free air laws appear to influence quitting intentions through the formation of positive attitudes about regulating smoking in public places and the perception of normative pressure to take measures to quit. Implications for smoke-free air policy campaigns and challenges in evaluating their effectiveness are discussed.

The population impact of smoke-free workplace and hospitality industry legislation on smoking behaviour. Findings from a national population survey

AIMS

To study the impact of implementing smoke-free workplace and hospitality industry legislation on smoking behaviour.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional population survey from 2001 to 2008 (n ≈ 18,000 per year) was used to assess trends and seasonal patterns in smoking and quitting, and to examine whether changes could be observed after the workplace smoking ban in the Netherlands in 2004 and the hospitality industry ban in 2008.

MEASUREMENTS

Outcome measures were smoking prevalence, quit attempts and successful quit attempts. Interactions with educational level (socio-economic status) and bar visiting (exposure to the hospitality industry ban) were tested.

FINDINGS

The workplace ban was followed by a decrease in smoking prevalence (OR = 0.91, P < 0.001), but the hospitality industry ban was not (OR = 0.96, P = 0.127). Both bans, especially the workplace ban, were followed by an increase in quit attempts and successful quit attempts: workplace ban, OR = 1.31, P < 0.001; OR = 1.49, P < 0.001; hospitality industry ban, OR = 1.13, P = 0.013; OR = 1.44, P < 0.001. The workplace ban had a larger effect on successful quitting among higher-educated (OR = 0.35, P < 0.001) than on lower-educated respondents (OR = 0.74, P = 0.052). The hospitality industry ban had a larger effect on quit attempts among frequent bar visitors (OR = 1.48, P = 0.003) than on non-bar visitors (OR = 0.71, P = 0.014).

CONCLUSIONS

A workplace smoking ban in the Netherlands was followed by more changes in smoking and quitting than a hospitality industry ban. The hospitality industry ban only appeared to have an impact on quit attempts, and not on smoking prevalence.

The combined effect of behavioral intention and exposure to a smoke-free air law on taking measures to quit smoking

Because of the large burden of disease attributable to cigarette smoking, a variety of tobacco control interventions, some focused on changing individual behavior and others focused on influencing societal norms, have been introduced. The current study tested the combined effect of behavioral intention and exposure to a comprehensive smoke-free air law as a prospective predictor of taking measures to quit smoking. Participants were 187 adults living in 7 Texas cities, 3 with a comprehensive smoke-free air law and 4 without such a law, who reported current cigarette smoking at baseline and completed a 1-month follow-up interview. Data were collected by telephone administration of a questionnaire. Results showed that, compared with smokers with low behavioral intention to take measures to quit smoking and no exposure to a comprehensive smoke-free air law, the smokers with high behavioral intention and exposure to a comprehensive law had the greatest odds of taking measures to quit smoking. This longitudinal study provides further evidence that the most successful smoking cessation campaigns will be multifaceted addressing individual factors with educational strategies designed to change beliefs and intentions and environmental factors with policy-based interventions.

Smokefree legislation: a review of health and economic outcomes research

CONTEXT

Smokefree legislation is a powerful public health intervention. Despite progress in smokefree legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation.

EVIDENCE ACQUISITION

This paper reviews the scientific literature on health and economic outcome studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy.

EVIDENCE SYNTHESIS

There is a wealth of research showing the health benefits to entire populations when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, economic studies confirm that smokefree laws do not adversely affect business revenues or operating costs.

CONCLUSIONS

While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations.

Do smoke-free laws in rural, distressed counties encourage cessation?

The authors examined the association between smoke-free laws and smoking/cessation behaviors and secondhand smoke exposure among current and former smokers in rural, distressed counties. A quasi-experimental, two-group design compared outcomes between participants from a county with a longstanding smoke-free law (n = 252) and those living in four demographically similar counties without smoke-free laws ( n = 250). Participants were recruited using random digit dialing. Controlling for demographic factors, those in the treatment group reported greater nicotine dependence, were more likely to have smoke-free workplaces, and less likely to have smoke-free homes. There were no differences in smoking status, past-year quit attempts, intent to quit in 5 years, cigarettes per day, or time since last cigarette. Smokers in the treatment group were just as likely to attempt to quit, despite greater nicotine dependence. Findings showed that making nonsmoking the social norm through policy change may be more difficult in rural, distressed areas.

Employee and employer support for workplace-based smoking cessation: results from an international survey

OBJECTIVES

Workplace smoking cessation programs can increase smoking cessation rates, improve employee health, reduce exposure to second-hand smoke, and decrease costs. To assist with the development of such programs, we conducted a Global Workplace Smoking Survey to collect information on workplace attitudes towards smoking cessation programs.

METHODS

Data were collected from 1,403 employers (smoking and non-smoking) and 3,525 smoking employees participating in surveys in 14 countries in Asia, Europe, and South America in 2007. Results were weighted to ensure that they were representative of smokers and employers at companies with the specified number of employees.

RESULTS

More than two-thirds of employers (69%) but less than half of employees (48%) indicated that their company should help employees with smoking cessation. Approximately two-thirds of employees and 81% of employers overall felt that smoke-free policies encourage cessation, but fewer individuals from Europe (vs. from Asia or South America) agreed with this. In companies with a smoke-free policy, 76% of employees and 80% of employers felt that their policy had been somewhat, very, or extremely effective in motivating employees to quit or reduce smoking. Employers and employees differed substantially regarding appropriate methods for encouraging cessation, with more employees favouring financial incentives and more employers favouring education.

CONCLUSIONS

Both employees and employers value smoke-free workplace programs and workplace cessation support activities, although many would like their companies to offer more support. These results will be useful for organizations exploring means of facilitating smoking cessation amongst employees.

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.

Assessing the effects of the introduction of the New Zealand Smokefree Environment Act 2003 on acute myocardial infarction hospital admissions in Christchurch, New Zealand

OBJECTIVE

To examine trends in Acute Myocardial Infarction (AMI) hospital admissions in Christchurch, New Zealand before and after the implementation of the New Zealand Smokefree Environments Act 2003 in December 2004.

METHODS

Data on AMI hospital admissions to Christchurch Public Hospital were extracted for the period 2003 to 2006. Poisson regression was used to calculate rate ratios by comparing for AMI rates of hospital admissions before (2003/04) and after (2005/06) the introduction of the Smokefree legislation, and to assess whether there was a significant change over time.

RESULTS

The introduction of the smokefree legislation was associated with a 5% reduction in AMI admissions. The 55-74 age group recorded the greatest decrease in admissions (9%) and this figure rose to 13% among never smokers in this group. Reductions were more marked for men. Adding the effects of area deprivation increased the reduction to 21% among 55-74 year olds living in more affluent (quintile 2) areas. Overall however, the statistical association of changing levels of AMI admissions with smoking status and with deprivation was not consistently significant.

CONCLUSION

At this early stage following the smokefree legislation, there are hints emerging of a positive impact on AMI admissions but these suggestions cannot yet be treated with certainty. Further research could usefully evaluate the longer-term effects of smoking legislation on the prevalence of smoking and exposure to second hand smoke, especially in more deprived urban communities.

Disparity in smoking prevalence by education: can we reduce it?

Can an intervention program that is highly effective in reducing the prevalence of an unhealthy behavior in the general population also reduce the disparity among its subgroups? That depends on what measure of disparity is used. Using simple algebraic models, this study demonstrates that disparity measured in terms of relative difference between two groups tends to increase when the prevalence of the behavior is in decline. The study then shows an empirical example, by analyzing the effects of the California tobacco control program on smoking prevalence of two education groups, the lowest (less than 12 years) and the highest (16 years or more). It examines the data from four California Tobacco Surveys covering the years 1996, 1999, 2002, and 2005. The effects of three components of the tobacco control program known to be effective in decreasing prevalence (media, worksite policy, and price) on the two education groups are assessed. The smoking prevalence for the two groups is obtained from these four surveys and a regression line is computed for each education group from 1996 to 2005. Results show that the California program is effective with both low education and high education groups and that the rate of decline in smoking prevalence from 1996 to 2005 is no smaller for the low education group than for the high education group. The paper then discusses that an analysis of disparity based on relative difference, however, could result in misleading recommendations that an intervention like the California tobacco program needs to change from its current whole-population approach to one that focuses on targeting subgroups because it has not reduced disparity. It proposes that research should focus more on increasing the rate of change among less advantage groups and less on the relative disparity compared to some other group.

Smokefree policies to reduce tobacco use. A systematic review

In 2001, a systematic review for the Guide to Community Preventive Services identified strong evidence of effectiveness of smoking bans and restrictions in reducing exposure to environmental (secondhand) tobacco smoke. As follow-up to that earlier review, the focus here was on the evidence on effectiveness of smokefree policies in reducing tobacco use. Smokefree policies implemented by worksites or communities prohibit smoking in workplaces and designated public areas. The conceptual approach was modified for this review; an updated search for evidence was conducted; and the available evidence was evaluated. Published articles that met quality criteria and evaluated changes in tobacco-use prevalence or cessation were included in the review. A total of 57 studies were identified in the period 1976 through June 2005 that met criteria to be candidates for review; of these, 37 met study design and quality of execution criteria to qualify for final assessment. Twenty-one studies measured absolute differences in tobacco-use prevalence with a median effect of -3.4 percentage points (interquartile interval: -6.3 to -1.4 percentage points). Eleven studies measured differences in tobacco-use cessation among tobacco users exposed to a smokefree policy compared with tobacco users not exposed to a smokefree policy. The median absolute change was an increase in cessation of 6.4 percentage points (interquartile interval: 1.3 to 7.9 percentage points). The qualifying studies provided sufficient evidence that smokefree policies reduce tobacco use among workers when implemented in worksites or by communities. Finally, a systematic economic review identified four studies that, overall, demonstrated economic benefits from a smokefree workplace policy. Additional research is needed to more fully evaluate the total economic effects of these policies.

Smoker-free workplace policies: developing a model of public health consequences of workplace policies barring employment to smokers

A marked shift in tobacco-related workplace health promotion intervention involves the adoption of policies barring employment to smokers. We discuss the potential public health consequences of these policies on those affected-smokers, their families, the surrounding community and society at large. We find a lack of published evidence evaluating the effectiveness and consequences of these policies. By developing a model of policy effects, we outline possible unintended consequences. With such large gaps in the evidence base and the potential for deleterious consequences, we argue for increased discussion about the use of smoker-free employment policies as a public health intervention and for increased engagement of employers by the public health community in worksite health promotion.