Association between smoke-free legislation in hospitality venues and smoking behavior of young people: a systematic review

Compliance with smoke-free laws in hospitality venues in Ethiopia: A cross-sectional observational study in 10 cities

BACKGROUND

The 2019 Ethiopia's comprehensive tobacco control proclamation mandates 100% smoke-free public places and workplaces. Despite the proclamation, compliance remains uncertain, particularly at hospitality venues (HVs). The aim of this study was to evaluate the extent of compliance with smoke-free laws in HVs and to also understand the factors associated with non-compliance.

METHODS

This cross-sectional observational study was conducted in 10 cities in Ethiopia-Addis Ababa, Adama, Assosa, Bahir Dar, Dire Dawa, Gambella, Harar, Hawassa, Jigjiga, and Semera-Logia -between December 5th and 28th, 2022. Data were collected electronically using smartphones, utilizing a pre-tested, standardized checklist and covert observation. The subjects were selected through multi-stage cluster sampling. A total of 1,370 HVs (hotels, restaurants, bars, bars and restaurants, café and restaurants, butcher houses and restaurants, groceries, and nightclubs/ lounges) were observed. Specific and composite compliance indicators were computed for indoor and outdoor spaces. Poisson regression analyses identified factors associated with indoor active smoking and non-compliance. Statistical significance was set at P<0.05. Data were analyzed using SPSS version 26.

RESULTS

Among the 1,370 HVs included in this study, 1,368 had indoor spaces, 327 had both indoor and outdoor spaces, and two had only outdoor spaces. Active smoking was observed in 32.2% (95% CI:30-35) of indoor HVs, with the highest rates in nightclubs/lounges (68.6%) and bars (65.7%). Semera-Logia reported the highest prevalence of active smoking (70.4%). Adherence with 'no smoking' signage was low (35.2%), while ashtrays, lighters, and designated smoking areas (DSAs) were rarely present. Outdoor active smoking was observed in 46.5% (95% CI:41-52) of HVs. Only 12.8% of indoor spaces were fully adherent to the smoke-free law requirements. Venues in Semera-Logia were over twice as likely to have active smoking (adjusted prevalence ratio [aPR]: 2.71; 95% CI: 2.00-3.66) compared to Addis Ababa. Bars and nightclubs/lounges had significantly higher prevalence of active smoking than cafés/restaurants. 'No smoking' signs were associated with reduced prevalence of indoor active smoking (aPR: 0.77; 95% CI: 0.67-0.89), while smoking within a 10-meter range (aPR: 2.67; 95% CI: 2.13-3.32), the presence of lighters (aPR: 1.69; 95% CI: 1.41-2.02), and the sale of tobacco products (aPR: 1.58; 95% CI: 1.34-1.86) were all associated with higher prevalence of indoor active smoking.

CONCLUSION

Compliance with 'no active smoking' and adherence to smoke-free laws in HVs remain low, particularly in bars, nightclubs/lounges, and Semera-Logia, with high rates of active smoking both indoors and outdoors. Enhanced enforcement and targeted are needed to educate the public and HV owners about the risks of SHS and the importance of tobacco control laws.

Coverage of Indoor Smoking and Vaping Restrictions in the U.S., 1990-2021

INTRODUCTION

Secondhand smoke exposure increases the risk of premature death and disease in children and non-smoking adults. As a result, many U.S. states and local jurisdictions have enacted comprehensive indoor smoking restrictions (ISR). Indoor vaping restrictions (IVR) have also been adopted to protect against exposure to secondhand e-cigarette aerosol. This study aimed to quantify state and national U.S. coverage of policies restricting indoor cigarette and e-cigarette use over time.

METHODS

Data from the American Nonsmokers Rights' Foundation on U.S. ISR from 1990 to 2021 and IVR from 2006 to 2021 were analyzed. Combining these data with 2015 U.S. Census population estimates, the percentage of state and national residents covered by partial and comprehensive restrictions in bars, restaurants, and workplaces, were calculated (analysis in 2023-2024) over time.

RESULTS

Between 1990 and 2021, national coverage of comprehensive ISR increased for bars (0% to 67.3%), restaurants (0%-78.2%), and workplaces (0%-77.5%). Partial ISR coverage decreased for bars (14.8%-13.9%), restaurants (40.2%-15.4%) and workplaces (40.2%-22.5%). From 2006 to 2021, comprehensive IVR coverage increased for bars (0%-43.5%), restaurants (0%-51.5%), and workplaces (0%-53.2%). Despite these increases in coverage, by the end of 2021, <50% of the population was protected by comprehensive ISR for bars, restaurants, and workplaces in 19, 12, and 14 states, respectively.

DISCUSSION

The percentage of the U.S. population protected by ISR and IVR has increased over time. However, gaps in coverage remain, which may contribute to disparities in tobacco-related disease and death.

The Influence of Lifestyle on High-Density Lipoprotein Concentration among Mexican Emerging Adults

Previous studies have highlighted the role of lifestyle on HDL-C concentrations in adults. To our knowledge, the health and nutritional status of emerging adults have been understudied. The present study aimed to explore the most important lifestyle factors, including micronutrient intake adequacy and the percentage of energy from food processing, according to HDL-C concentrations in emerging adults. In this context, a cross-sectional analysis was conducted on 261 Mexican emerging adults who were apparently healthy. Lifestyle factors were collected through a structured survey and the prevalence of micronutrient intake inadequacy was estimated using the estimated average requirement cut-point method. The percentage of energy from ultra-processed foods was assessed using the NOVA system. HDL-C was determined using the enzymatic colorimetric method. Statistical analyses were conducted in SPSS. The results revealed that lifestyle factors do not differ according to HDL-C status. The participants showed a poor nutritional diet that was energy-dense and micronutrient-inadequate. Nearly half of their energy came from processed and ultra-processed foods. Most participants did not meet the recommendations for key nutrients (ϖ3 fatty acids and phytosterols) that promote a healthy lipid status. In conclusion, regardless of their HDL-C levels, emerging adults exhibited lifestyle-related risk factors. The persistence of these findings over time could contribute to the development of metabolic disorders in the future. It is crucial to increase understanding and to develop effective nutritional interventions during this critical phase of life.

A systematic review for the impacts of global approaches to regulating electronic nicotine products

Background

The rapid increase in electronic nicotine product (ENP) use among young people has been a global public health challenge, given the potential harm of ENPs and nicotine dependence. Many countries have recently introduced legislations to regulate ENPs, but the impacts of these policies are poorly understood. This systematic review aims to critically synthesise empirical studies on the effects of global regulations regarding ENPs on the prevalence of use, health outcomes and their determinants, using the 4A marketing mix framework (acceptability, affordability, accessibility and awareness).

Methods

Following the PRISMA guideline, we searched PubMed, Embase, Scopus, Web of Science, Academic Search Complete, Business Source Complete, and APA PsycINFO databases from inception until June 14, 2022 and performed citation searches on the included studies. Reviewed literature was restricted to peer-reviewed, English-language articles. We included all pre-post and quasi-experimental studies that evaluated the impacts of e-cigarette policies on the prevalence of ENP use and other health outcomes. A modified Joanna Briggs Institute (JBI) Critical Appraisal checklist for quasi-experimental studies was used for quality assessment. Due to heterogeneity of the included studies, we conducted a narrative synthesis of evidence.

Results

Of 3991 unduplicated records screened, 48 (1.2%) met the inclusion criteria, most were from high-income countries in North America and Europe and 26 studies measured self-reported ENPs use. Flavour restrictions significantly decreased youth ENP use and taxation reduced adult use; mixed results were found for the impacts of age restrictions. Indoor vaping restrictions and the European Tobacco Products Directive (TPD) did not seem to reduce ENP use based on existing studies. Changes in determinants such as sales and perceptions corroborated our conclusions. Few studies assessed the impacts of other regulations such as advertising restrictions and retail licensing requirements.

Conclusions

Flavour restrictions and taxes have the strongest evidence to support effective control of ENPs, while others need powerful enforcement and meaningful penalties to ensure their effectiveness. Future research should focus on under-examined policies and differential impacts across sociodemographic characteristics and countries.

Registration

PROSPERO CRD42022337361.

Associations between e-cigarette policies and adolescent use and access to e-cigarettes

Background

Tobacco control policies have been adapted to address rising levels of adolescent e-cigarette use. Despite new restrictions, adolescents are continuing to access e-cigarettes.

Methods

We linked 2015-2019 Youth Risk Behavior Survey data on 503,154 14-18-year-olds from 40 states with state-level e-cigarette minimum legal sales age (MLSA) laws, taxes, and smoke-free legislation. Using two-way fixed effects probit regression models, we first examined the associations between these statewide e-cigarette policies and adolescent use and, second, with access to e-cigarettes. We subsequently tested interactions between age and each policy and present average marginal effects as percentage point (pp) changes.

Results

While MLSA laws for e-cigarettes were associated with slight increases in e-cigarette use (2.72 pp; 1.29, 4.15), associations were no longer significant after at least 1-year post-implementation. MLSA laws were also associated with decreases in e-cigarette purchases in stores (-9.50 pp; -18.21, -0.79) and increases in acquiring them from someone else (13.26 pp; 4.10, 22.42), particularly among 18-year-olds. E-cigarette taxes were associated with decreases in use (-9.18 pp; -11.63, -6.73), but there were limited associations with e-cigarette access. While smoke-free legislation prohibiting e-cigarettes was associated with slight increases in use (1.87 pp; 0.23, 3.50), after at least 1-year post-implementation, they were associated with decreases in use. Smoke-free legislation was also associated with decreases in purchases in stores by 14-year-olds, but increases in online purchases by 18-year-olds.

Conclusion

Understanding the immediate and longer-term consequences of e-cigarette policies is essential to influence adolescent e-cigarette use. Adolescents will continue acquiring e-cigarettes across varying sources if measures are not taken to address access alongside policies aimed at reducing use.

Facilitating conditions for staff's confidence to enforce school tobacco policies: qualitative analysis from seven European cities

Background

School staff members’ consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff’s confidence, indicating their perceived ability to cope with students’ negative responses, explains variations in staff’s STPs enforcement, yet understanding of the determinants for confidence is lacking. We analyzed the conditions in which the staff feel confident in addressing students who violate STPs to support staff’s enforcement. 

Methods

Data consists of 81 semi-structured interviews with the staff members from 26 secondary schools in seven European cities in Belgium, Finland, Germany, Ireland, Italy, The Netherlands, and Portugal. In every city, 3–4 staff members (senior management, teachers, supportive staff) in 3–4 schools (academic–vocational, high–low SES area) were interviewed. Transcripts were analyzed with thematic analysis.

Results

When staff felt confident in their ability to prevent, diminish, or handle students’ negative responses, they were more likely to address students on STP violations. The staff was more confident (1) when consistent policy enforcement within school and regarding the wider society ensured staff legitimacy for STPs enforcement, (2) when dialog and mutual familiarity with students allowed the staff to facilitate constructive interaction with STP violators, and (3) when organizational backup structures provided staff collegial support to overcome challenges in the enforcement. These conditions would support consistent enforcement, especially with persistent misbehavers and among the more uncertain staff members.

Conclusions

Our study stresses the need to implement strategies at multiple levels to strengthen staff’s confidence for STP enforcement. To support staff’s legitimacy for enforcement, we suggest reinforcing structures and practices that facilitate consistency in STP enforcement; to support staff’s ability for constructive interaction with STP violators, we suggest strengthening staff’s social and emotional learning; and to support staff’s experience of collegial support, we suggest reinforcing staff’s collective ability to cope with students’ negative responses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00362-7.