Bar workers' health and environmental tobacco smoke exposure (BHETSE): symptomatic improvement in bar staff following smoke-free legislation in Scotland

Secondhand smoke exposure and ocular health: A systematic review

The toxicology of secondhand smoke (SHS), along with the harm of its exposure to human health, has been generally acknowledged; however, specific evidence is lacking on the association between SHS exposure and ocular health. In this systematic review (PROSPERO registration number: CRD42022247992), we included 55 original articles published by 12 May 2023, which dealt with SHS exposure and ocular disorders, such as eye irritation, conjunctivitis, dry eye diseases, uveitis, myopia, astigmatism, contact lens discomfort, age-related macular degeneration, glaucoma, and thyroid eye disease that addressed the ocular neurovascular structures of the macular, retinal nerve fiber layer, choroid, and corneal biomechanical parameters. We found compelling correlational evidence for eye irritation, conjunctivitis, and dry eye symptoms-supporting that SHS exposure was positively associated with inflammatory and allergic changes in the eyes. Yet, evidence about the associations between SHS exposure and other ocular disorders, structures, and parameters is still limited or controversial. Given the limitations of existing literature, more investigations with high quality and rigorous design are warranted to elucidate the potentially harmful effects of SHS exposure on ocular health.

The impact of changing cigarette smoking habits and smoke-free legislation on orofacial cleft incidence in the United Kingdom: Evidence from two time-series studies

BACKGROUND

Both active and passive cigarette smoking have previously been associated with orofacial cleft aetiology. We aimed to analyse the impact of declining active smoking prevalence and the implementation of smoke-free legislation on the incidence of children born with a cleft lip and/or palate within the United Kingdom.

METHODS AND FINDINGS

We conducted regression analysis using national administrative data in the United Kingdom between 2000-2018. The main outcome measure was orofacial cleft incidence, reported annually for England, Wales and Northern Ireland and separately for Scotland. First, we conducted an ecological study with longitudinal time-series analysis using smoking prevalence data for females over 16 years of age. Second, we used a natural experiment design with interrupted time-series analysis to assess the impact of smoke-free legislation. Over the study period, the annual incidence of orofacial cleft per 10,000 live births ranged from 14.2-16.2 in England, Wales and Northern Ireland and 13.4-18.8 in Scotland. The proportion of active smokers amongst females in the United Kingdom declined by 37% during the study period. Adjusted regression analysis did not show a correlation between the proportion of active smokers and orofacial cleft incidence in either dataset, although we were unable to exclude a modest effect of the magnitude seen in individual-level observational studies. The data in England, Wales and Northern Ireland suggested an 8% reduction in orofacial cleft incidence (RR 0.92, 95%CI 0.85 to 0.99; P = 0.024) following the implementation of smoke-free legislation. In Scotland, there was weak evidence for an increase in orofacial cleft incidence following smoke-free legislation (RR 1.16, 95%CI 0.94 to 1.44; P = 0.173).

CONCLUSIONS

These two ecological studies offer a novel insight into the influence of smoking in orofacial cleft aetiology, adding to the evidence base from individual-level studies. Our results suggest that smoke-free legislation may have reduced orofacial cleft incidence in England, Wales and Northern Ireland.

From Smoking-Permitted to Smokefree Prisons: A 3-Year Evaluation of the Changes in Occupational Exposure to Second-Hand Smoke Across a National Prison System

OBJECTIVES

Prisons in Scotland were one of the few workplaces exempt from the 2006 comprehensive smoking ban in indoor public places, excluding the prison workforce from the health benefits of smokefree workplaces. The November 2018 introduction of comprehensive restrictions on smoking in Scottish prisons aimed to protect prison staff and people in custody from the harmful impacts of second-hand smoke (SHS) exposure. This study presents SHS exposure data gathered after smokefree policy implementation and compares these with data gathered during and before policy development.

METHODS

Dylos DC1700 monitors were used to measure concentrations of fine particulate matter (PM2.5) derived from SHS across Scotland's 15 prisons. Six days of fixed-site monitoring (09.00 22 May 2019 to 09.00 28 May 2019) were conducted in residential halls in each prison 6 months post-smokefree policy implementation. Prison staff task-based measurements were conducted to assess concentrations of SHS in various locations (e.g. gyms and workshops) and during specific activities (e.g. cell searches, maintenance, and meal service). Utilizing the fixed-site monitoring data, typical daily PM2.5 exposure profiles were constructed for the prison service and time-weighted average (TWA) exposure concentrations were estimated for the typical shift patterns of residential staff pre- and post-smokefree policy implementation. Staff perceptions of changes to SHS exposure were assessed using online surveys.

RESULTS

Analysis of both fixed-site and mobile task-based PM2.5 measurements showed the smokefree policy implementation was successful in reducing SHS exposures across the Scottish prison estate. Measured PM2.5 in residential halls declined markedly; median fixed-site concentrations reduced by more than 91% compared with measures in 2016 before policy announcement. The changes in the TWA concentrations across shifts (over 90% decrease across all shifts) and task-based measurements (89% average decrease for high-exposure tasks) provide evidence that prison staff exposure to SHS has significantly reduced. Following smokefree policy implementation, the majority of staff reported no longer being exposed to SHS at work.

CONCLUSIONS

To our knowledge, this is the first comprehensive international study to objectively measure SHS levels before, during, and after implementation of a smokefree policy across a country's prison system. The findings confirm that such a policy change can be successfully implemented to eliminate occupational exposures to SHS. The results are highly relevant for other jurisdictions considering changes to prison smoking legislation.

Smoking ban and health at birth: Evidence from Hungary

In 2012, smoking restrictions were extended to hospitality venues in Hungary. Women working in bars and restaurants were primarily affected by the intervention. In this research, we analyze the effect of this smoking ban on the outcomes of their pregnancies. Using individual live birth, fetal loss, and infant mortality registry data, we examine the probability of live birth, indicators of health at birth, and the probability of death in the first year of life. We apply a difference-in-differences framework and show that the smoking ban has improved health at birth. We observed birth weight to increase by 56 g (95% CI: 4.2 to 106.8) and gestation length by 0.19 weeks (95% CI: 0.02 to 0.36). Due to the ban, the probability of being born with very low and low birth weight has decreased by 1.2 and 2.2 percentage points, respectively (95% CI: -0.2 to -2.2 and 0.06 to -4.4), and we see a 0.9 percentage points reduction in the chance of being born very preterm (95% CI: -0.03 to -1.9). We also observe a decrease in the probability of being born with a low Ponderal index (decrease of 4.1 percentage points, 95% CI: -0.7 to -7.5). Performing a series of robustness and placebo tests, we provide evidence that supports the causal interpretation of our results. We also show that the ban was more beneficial for newborns of parents with low educational attainment and at the bottom of the fetal health endowment distribution.

Characterising the Exposure of Prison Staff to Second-Hand Tobacco Smoke

Second-hand tobacco smoke (SHS) is an avoidable and harmful exposure in the workplace but >25000 prison staff continue to be exposed on a daily basis in the UK and many more worldwide. SHS exposures in prisons are incompletely understood but may be considerable given the large proportion of smoking prisoners and limited ventilation. This study characterized the exposure of prison staff to SHS in all 15 prisons in Scotland using multiple methods. Exposure assessment strategies included 6-day area measurement of fine Particulate Matter (PM_2.5) and airborne nicotine in each prison together with short (30-minute) measurements of PM_2.5 covering a range of locations/activities. Pre- and post-shift saliva samples were also gathered from non-smoking staff and analysed for cotinine to estimate exposure. There was evidence of exposure to SHS in all prisons from the results of PM_2.5 and nicotine measurements. The salivary cotinine results from a sub-sample of non-smoking workers indicated SHS exposures of similar magnitude to those provided by the 6-day area measurements of PM_2.5. There was a high degree of exposure variability with some locations/activities involving exposure to SHS concentrations that were comparable to those measured in bars in Scotland prior to smoke-free legislation in 2006. The median shift exposure to SHS-PM_2.5 was ~20 to 30 µg m⁻³ and is broadly similar to that experienced by someone living in a typical smoking home in Scotland. This is the most comprehensive assessment of prison workers’ exposure to SHS in the world. The results are highly relevant to the development of smoke-free policies in prisons and should be considered when deciding on the best approach to provide prison staff with a safe and healthy working environment.

Factors associated with secondhand smoke incursion into the homes of non-smoking residents in a multi-unit housing complex: a cross-sectional study in Seoul, Korea

Background

In a multi-unit housing (MUH) complex, secondhand smoke (SHS) can pass from one living space to another. The aim of this study was to determine the prevalence of SHS incursion, and to establish the relationship between SHS incursion and socio-demographic and built environmental factors in MUH in Korea.

Methods

A population-based sample of 2600 residents (aged ≥19 years) living in MUH from across the city of Seoul, Korea, was obtained through a web-based selection panel. The residents completed a questionnaire detailing socio-demographic factors, smoking status, frequency of SHS incursion, and built environmental factors. The presence of a personal smoke-free home rule was determined by residents declaring that no one smoked inside the home.

Results

Of the 2600 participants, non-smoking residents who lived in homes with a personal smoke-free rule were selected for further analysis (n = 1784). In the previous 12 months, 74.7% of residents had experienced SHS incursion ≥1 times. A multivariate ordinal logistic regression analysis indicated that residents who spent more time at home, lived with children, supported the implementation of smoke-free regulations in MUH, lived in small homes, lived in homes with natural ventilation provided by opening a front door or the windows and front door, and lived in homes with more frequent natural ventilation were more likely to report SHS incursion into their homes.

Conclusions

The majority of the non-smoking residents experienced SHS incursion, even with a personal smoke-free rule in their homes. A smoke-free policy in MUH is needed to protect residents from SHS exposure when they are at home.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4774-x) contains supplementary material, which is available to authorized users.

Smokefree legislation effects on respiratory and sensory disorders: A systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis is to synthesize the available evidence in scientific papers of smokefree legislation effects on respiratory diseases and sensory and respiratory symptoms (cough, phlegm, red eyes, runny nose) among all populations.

Materials and methods

Systematic review and meta-analysis were carried out. A search between January 1995 and February 2015 was performed in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and Google Scholar databases. Inclusion criteria were: 1) original scientific studies about smokefree legislation, 2) Data before and after legislation were collected, and 3) Impact on respiratory and sensory outcomes were assessed. Paired reviewers independently carried out the screening of titles and abstracts, data extraction from full-text articles, and methodological quality assessment.

Results

A total number of 1606 papers were identified. 50 papers were selected, 26 were related to symptoms (23 concerned workers). Most outcomes presented significant decreases in the percentage of people suffering from them, especially in locations with comprehensive measures and during the immediate post-ban period (within the first six months). Four (50%) of the papers concerning pulmonary function reported some significant improvement in expiratory parameters. Significant decreases were described in 13 of the 17 papers evaluating asthma hospital admissions, and there were fewer significant reductions in chronic obstructive pulmonary disease admissions (range 1–36%) than for asthma (5–31%). Six studies regarding different respiratory diseases showed discrepant results, and four papers about mortality reported significant declines in subgroups. Low bias risk was present in 23 (46%) of the studies.

Conclusions

Smokefree legislation appears to improve respiratory and sensory symptoms at short term in workers (the overall effect being greater in comprehensive smokefree legislation in sensory symptoms) and, to a lesser degree, rates of hospitalization for asthma.

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.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effect of a smoking ban on respiratory health in nonsmoking hospitality workers: a prospective cohort study

OBJECTIVE

The aim of this study was to examine the effect of a smoking ban on lung function, fractional exhaled nitric oxide, and respiratory symptoms in nonsmoking hospitality workers.

METHODS

Secondhand smoke exposure at the workplace, spirometry, and fractional exhaled nitric oxide were measured in 92 nonsmoking hospitality workers before as well as twice after a smoking ban.

RESULTS

At baseline, secondhand smoke-exposed hospitality workers had lung function values significantly below the population average. After the smoking ban, the covariate-adjusted odds ratio for cough was 0.59 (95% confidence interval, 0.36 to 0.93) and for chronic bronchitis 0.75 (95% confidence interval, 0.55 to 1.02) compared with the preban period.

CONCLUSIONS

The below-average lung function before the smoking ban indicates chronic damages from long-term exposure. Respiratory symptoms such as cough decreased within 12 months after the ban.

Air Quality, Biomarker Levels, and Health Effects on Staff in Korean Restaurants and Pubs Before and After a Smoking Ban

INTRODUCTION

The Korean government implemented a smoking ban at square floor area of ≥150 m(2), rather than <150 m(2), restaurants and pubs from July 2013. This study examined the effects of the smoking regulations in restaurants and pubs in terms of the air quality, biomarker levels and health effects on staff.

METHODS

Particulate matter smaller than 2.5 µm (PM2.5) was measured in 146 facilities before and 1 month after the ban. The urinary cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1- butanol (NNAL) levels were measured in 101 staff members at 77 facilities before and 1 month after the ban. We also measured self-reported respiratory and sensory symptoms on both phases.

RESULTS

Of the 146 facilities, 121 facilities were included in the PM2.5 analysis. In ≥150 m(2) pubs, the indoor PM2.5 concentration was significantly reduced after the ban (p < .05). While the urinary cotinine concentrations of the staff in all facilities were not changed after the ban, the total NNAL concentrations of the staff in ≥150 m(2) pubs were significantly reduced after the ban (p < .05). The health effects on staff show that only sensory symptoms significantly improved in ≥150 m(2) facilities after the ban (p < .05).

CONCLUSIONS

The smoking ban significantly reduced the levels of PM2.5 and total NNAL concentrations in ≥150 m(2) pubs and improved sensory health among staff in ≥150 m(2) facilities. The results of this study can be useful in supporting an expansion of the smoking ban in all indoor places, including <150 m(2) restaurants and pubs.

Second-hand smoke in public spaces: how effective has partial smoke-free legislation been in Malaysia?

BACKGROUND

This study was performed to gather data on second-hand smoke (SHS) concentrations in a range of public venues following the implementation of partial Smoke-Free Legislation in Malaysia in 2004.

MATERIALS AND METHODS

PM2.5 was measured as a marker of SHS levels in a total of 61 restaurants, entertainment centres, internet cafes and pubs in Kuala Lumpur, Malaysia.

RESULTS

Under the current smoke-free laws smoking was prohibited in 42 of the 61 premises. Active smoking was observed in nearly one-third (n=12) of these. For premises where smoking was prohibited and no active smoking observed, the mean (standard deviation) indoor PM2.5 concentration was 33.4 (23.8) μg/m3 compared to 187.1 (135.1) μg/m3 in premises where smoking was observed The highest mean PM2.5 was observed in pubs [361.5 (199.3) μg/m3].

CONCLUSIONS

This study provides evidence of high levels of SHS across a range of hospitality venues, including about one-third of those where smoking is prohibited, despite 8 years of smoke-free legislation. Compliance with the legislation appeared to be particularly poor in entertainment centres and internet cafes. Workers and non-smoking patrons continue to be exposed to high concentrations of SHS within the hospitality industry in Malaysia and there is an urgent need for increased enforcement of existing legislation and consideration of more comprehensive laws to protect health.

Occupational exposure to second hand smoke and respiratory and sensory symptoms: a cross-sectional survey of hospital workers in Egypt

OBJECTIVE

Exposure to Second Hand Smoke (SHS) has been associated with an increased risk of respiratory symptoms, upper and lower respiratory tract diseases and an increased risk of asthma and chronic obstructive pulmonary disease. The majority of cases of mortality and morbidity is attributable to exposure of adults to SHS and is related to cardiovascular diseases and lung cancer. In Egypt, comprehensive smoke-free laws exist, however, in many workplaces they are poorly enforced consequently exposing workers to the detrimental health hazards of SHS. We aimed at determination of workplace exposure to Second Hand Smoke (SHS) and its association with respiratory and sensory irritation symptoms in hospital workers in Port-said governorate in Egypt.

MATERIAL AND METHODS

A cross-sectional face to face survey was conducted by the use of a standardised questionnaire among 415 adult hospital workers; representing 50% of all employees (81% response rate); recruited from 4 randomly selected general hospitals in Port-said governorate in Egypt.

RESULTS

All hospitals employees reported exposure to SHS - on average 1.5 (SD = 2.5) hours of exposure per day. After controlling for potential confounders, exposure to SHS at work was significantly associated with an increased risk of wheezes (OR = 1.14, p < 0.01), shortness of breath (OR = 1.17, p < 0.01), phlegm (OR = 1.23, p < 0.01), running and irritated nose (OR = 1.14, p < 0.01) as well as a sore, scratchy throat (OR = 1.23).

CONCLUSIONS

These findings point out that workplace exposure to SHS is evident in hospitals in Port-said governorate and that workers are adversely affected by exposure to it at work. This underlines the importance of rigorous enforcement of smoke-free policies to protect the workers' health in Egypt.

Total prohibition of smoking but not partial restriction effectively reduced exposure to tobacco smoke among restaurant workers in Finland

OBJECTIVES

To assess work-related exposure to tobacco smoke in Finnish restaurants, a series of nationwide questionnaire surveys were conducted among restaurant workers and the levels of indoor air nicotine concentrations were measured in restaurants. The survey aimed to evaluate the impact of the smoke-free legislation in general and in particular after the total smoking ban launched in 2007.

MATERIALS AND METHODS

In 2003-2010, four national questionnaire surveys were conducted among restaurant workers and the concentration of nicotine in indoor air was measured in different types of restaurants, bars and nightclubs.

RESULTS

Between 2003 and 2010, the proportion of restaurant workers reporting occupational exposure to tobacco smoke dropped from 59% to 11%. Among pub workers, the decrease was from 97% to 18% and in workers of dining restaurants from 49% to 10%, respectively. The median concentration of nicotine in indoor air of all restaurants decreased from 11.7 μg/m(3) to 0.1 μg/m(3). The most significant decrease was detected in pubs where the decrease was from 16.1 μg/m(3) to 0.1 μg/m(3). Among all restaurant workers, in 2003-2010 the prevalence of daily smokers was reduced from 39% to 31% in men and from 35% to 25% in women.

CONCLUSION

Total prohibition of smoking but not partial restriction in restaurants was effective in reducing work-related exposure to tobacco smoke. Strict tobacco legislation may partly be associated with the significant decrease of daily smoking prevalence among restaurant workers.

Evaluation of a smoke-free law on indoor air quality and on workers' health in Portuguese restaurants

Workplace bans on smoking are interventions to reduce exposure to secondhand smoke (SHS) to try to prevent harmful health effects. The Portuguese Government on January 1, 2008, introduced the first national law banning smoking in public workplaces, including restaurants. The main aim of this study was to examine the impact of this law on indoor air quality (IAQ) in restaurants and on the respiratory and sensory health of restaurant workers. Concentrations of respirable suspended particulate matter (RSP), total volatile organic compounds (TVOC), carbon monoxide (CO), and carbon dioxide (CO2) in 10 restaurants were measured and compared before and after the ban. Benzene (C6H6) concentrations were also measured in all restaurants. Fifty-two and twenty-eight restaurant workers, respectively, answered questionnaires on exposure to SHS, and respiratory and sensory symptoms in the pre- and post-ban phases. There was a statistically significant decrease in RSP, CO, TVOC, and C6H6 concentrations after the ban. Additionally, in both phases the monitored CO2 concentrations greatly exceeded 1800 mg x m(-3), suggesting inefficient ventilation of the indoor spaces. Between pre- and post-ban phases a significant reduction in self-reported workplace SHS exposure was also observed after the enforcement of the law, as well as a significant marked reduction in dry, itching, irritated, or watery eyes, nasal problems, sore or dry throat, cough, wheeze, and headache. This study provides, in a single investigation, comparison of IAQ and respiratory health in Portugal before and after the introduction of the smoke-free law, the first data reported in the literature to our knowledge. Our findings suggest that a total workplace smoking ban results in a significant reduction in indoor air pollution and an improvement in the respiratory health of restaurant workers. These observations may have implications for policymakers and legislators currently considering the nature and extent of their smoke-free workplace legislation and could provide a useful contribution to the implementation of public health prevention programs.

How do policy advisors and practitioners prioritise the protection of children from secondhand smoke exposure in a country with advanced tobacco control policy?

OBJECTIVES

The aim is to extend understanding of the policy and practice discourses that inform the development of national tobacco control policy to protect children from secondhand smoke exposure (SHSE) in the home, particularly in a country with successful implementation of smoke-free public places legislation. The Scottish experience will contribute to the tobacco control community, particularly those countries at a similar level of tobacco control, as normalising discourses about protecting children from SHSE are becoming more widespread.

DESIGN

Case study design using qualitative interviews and focus groups (FGs) with policy makers, health and childcare practitioners during which they were presented with the findings of the Reducing Families' Exposure to Secondhand Smoke (REFRESH) intervention and discussed the implications for their policy and practice priorities.

SETTING

Scotland, UK PARTICIPANTS: Qualitative interviews and FGs were conducted with 30 policy makers and practitioners who were purposively recruited.

RESULTS

Participants accepted the harm of SHSE to children; however, action is limited by political expedience due to-the perception of a shift of the public health priority from smoking to alcohol, current financial constraints, more immediate child protection concerns and continuing unresolved ethical arguments.

CONCLUSIONS

In a country, such as Scotland, with advanced tobacco control strategies, there continue to be challenges to policy and practice development in the more contentious arena of the home. Children's SHSE in their homes is unequivocally accepted as an important health priority, but it is not currently perceived to be a top public health priority in Scotland.

Changes in smoking behaviours following a smokefree legislation in parks and on beaches: an observational study

OBJECTIVE

To examine the effect of an outdoor smokefree law in parks and on beaches on observed smoking in selected venues.

METHODS

The study involved repeated observations in selected parks and beaches in Vancouver, British Columbia, Canada. The main outcome measure was changes in observed smoking rates in selected venues from prelaw to 12 months postlaw.

RESULTS

No venue was 100% smokefree at the 12-month postlaw observation time point. There was a significant decrease in observed smoking rates in all venues from prelaw to 12-month postlaw (prelaw mean smoking rate=20.5 vs 12-month mean smoking rate=4.7, p=0.04). In stratified analysis by venue, the differences between the prelaw and 12-month smoking rates decreased significantly in parks (prelaw mean smoking rate=37.1 vs 12-month mean smoking rate=6.5, p=0.01) but not in beaches (prelaw mean smoking rate=2.9 vs 12-month mean smoking rate=1.0, p=0.1).

CONCLUSIONS

Smokefree policies in outdoor recreational venues have the potential to decrease smoking in these venues. The effectiveness of such policies may differ by the type and usage of the venue; for instance, compliance may be better in venues that are used more often and have enforcement. Future studies may further explore factors that limit and foster the enforcement of such policies in parks and beaches.

Air quality, mortality, and economic benefits of a smoke - free workplace law for non-smoking Ontario bar workers

We estimated the impact of a smoke-free workplace bylaw on non-smoking bar workers' health in Ontario, Canada. We measured bar workers' urine cotinine before (n = 99) and after (n = 91) a 2004 smoke-free workplace bylaw. Using pharmacokinetic and epidemiological models, we estimated workers' fine-particle (PM2.5 ) air pollution exposure and mortality risks from workplace secondhand smoke (SHS). workers' pre-law geometric mean cotinine was 10.3 ng/ml; post-law dose declined 70% to 3.10 ng/ml and reported work hours of exposure by 90%. Pre-law, 97% of workers' doses exceeded the 90th percentile for Canadians of working age. Pre-law-estimated 8-h average workplace PM2.5 exposure from SHS was 419 μg/m(3) or 'Very Poor' air quality, while outdoor PM2.5 levels averaged 7 μg/m(3) , 'Very Good' air quality by Canadian Air Quality Standards. We estimated that the bar workers' annual mortality rate from workplace SHS exposure was 102 deaths per 100000 persons. This was 2.4 times the occupational disease fatality rate for all Ontario workers. We estimated that half to two-thirds of the 10620 Ontario bar workers were non-smokers. Accordingly, Ontario's smoke-free law saved an estimated 5-7 non-smoking bar workers' lives annually, valued at CA $50 million to $68 million (US $49 million to $66 million).

Protecting the world from secondhand tobacco smoke exposure: where do we stand and where do we go from here?

INTRODUCTION

Article 8 of the Framework Convention on Tobacco Control mandates all signatory countries to "protect citizens from exposure to tobacco smoke in workplaces, public transport and indoor public places." Even though there has been great progress in the implementation of Article 8, still most of the world population remains exposed to secondhand smoke (SHS). In this article, we sought to summarize the research that supports Article 8, where do we stand, and current research gaps and future directions.

DISCUSSION

Secondhand smoke is an established cause of heart disease and several types of cancer. Additional research is needed to reach final conclusions for diseases where evidence is only suggestive of causality. The only solution to SHS exposure in public places is banning smoking indoors. Research on the gaming industry and nightclubs, particularly in developing countries, needs to be disseminated to support their inclusion in smoke-free laws. Aside from indoor bans, additional research is needed for outdoor and multiunit housing bans and in support of measures that protect children and other vulnerable populations. The impact of smoke-free laws on other health outcomes, besides heart disease and respiratory outcomes, is another area where further research is needed. Thirdhand smoke assessment and health effects are also likely to be a topic of further research. As new tobacco products emerge, evaluating SHS exposure and effects will be vital.

CONCLUSIONS

Furthering research in support of Article 8 can contribute to reach the final goal of protecting everyone from SHS exposure.

The relationship between workers' self-reported changes in health and their attitudes towards a workplace intervention: lessons from smoke-free legislation across the UK hospitality industry

Background

The evaluation of smoke-free legislation (SFL) in the UK examined the impacts on exposure to second-hand smoke, workers’ attitudes and changes in respiratory health. Studies that investigate changes in the health of groups of people often use self-reported symptoms. Due to the subjective nature it is of interest to determine whether workers’ attitudes towards the change in their working conditions may be linked to the change in health they report.

Methods

Bar workers were recruited before the introduction of the SFL in Scotland and England with the aim of investigating their changes to health, attitudes and exposure as a result of the SFL. They were asked about their attitudes towards SFL and the presence of respiratory and sensory symptoms both before SFL and one year later. Here we examine the possibility of a relationship between initial attitudes and changes in reported symptoms, through the use of regression analyses.

Results

There was no difference in the initial attitudes towards SFL between those working in Scotland and England. Bar workers who were educated to a higher level tended to be more positive towards SFL. Attitude towards SFL was not found to be related to change in reported symptoms for bar workers in England (Respiratory, p = 0.755; Sensory, p = 0.910). In Scotland there was suggestion of a relationship with reporting of respiratory symptoms (p = 0.042), where those who were initially more negative to SFL experienced a greater improvement in self-reported health.

Conclusions

There was no evidence that workers who were more positive towards SFL reported greater improvements in respiratory and sensory symptoms. This may not be the case in all interventions and we recommend examining subjects’ attitudes towards the proposed intervention when evaluating possible health benefits using self-reported methods.

Positive impact of the Portuguese smoking law on respiratory health of restaurant workers

The impact of smoke-free law on the respiratory and sensory symptoms among restaurant workers was evaluated. Fifty-two workers in 10 Portuguese restaurants were interviewed before and 2 years after implementation of the smoke-free law. A significant reduction in self-reported workplace environmental tobacco smoke (ETS) exposure was observed after the enforcement of the law, as well as a marked reduction in adverse respiratory and sensory symptoms such as dry, itching, irritated, or watery eyes, nasal problems, and sore or dry throat or cough, between pre- and post-ban. This study demonstrates that the smoking ban was effective in diminishing the exposure symptoms among workers and consequently in improving their respiratory health. These observations may have implications for policymakers and legislators in other countries currently considering the nature and extent of their smoke-free workplace legislation.

Impact of Scotland's smoke-free legislation on pregnancy complications: retrospective cohort study

BACKGROUND

Both active smoking and environmental tobacco smoke exposure are associated with pregnancy complications. In March 2006, Scotland implemented legislation prohibiting smoking in all wholly or partially enclosed public spaces. The aim of this study was to determine the impact of this legislation on preterm delivery and small for gestational age.

METHODS AND FINDINGS

We conducted logistic regression analyses using national administrative pregnancy data covering the whole of Scotland. Of the two breakpoints tested, 1 January 2006 produced a better fit than the date when the legislation came into force (26 March 2006), suggesting an anticipatory effect. Among the 716,941 eligible women who conceived between August 1995 and February 2009 and subsequently delivered a live-born, singleton infant between 24 and 44 wk gestation, the prevalence of current smoking fell from 25.4% before legislation to 18.8% after legislation (p<0.001). Three months prior to the legislation, there were significant decreases in small for gestational age (-4.52%, 95% CI -8.28, -0.60, p = 0.024), overall preterm delivery (-11.72%, 95% CI -15.87, -7.35, p<0.001), and spontaneous preterm labour (-11.35%, 95% CI -17.20, -5.09, p = 0.001). In sub-group analyses, significant reductions were observed among both current and never smokers.

CONCLUSIONS

Reductions were observed in the risk of preterm delivery and small for gestational age 3 mo prior to the introduction of legislation, although the former reversed partially following the legislation. There is growing evidence of the potential for tobacco control legislation to have a positive impact on health.

[Smoking ban in restaurants and respiratory symptoms among employees]

BACKGROUND

Along with the introduction of a smoking ban in restaurants in 2004, respiratory symptoms, urinary cotinine and lung function among employees in 13 different bars and restaurants were studied before and after the ban came into force. At the same time measurements of air quality were taken at the respective restaurants and bars. The purpose of this study was to compare self-respiratory symptoms before and after the smoking ban among the staff at the establishments.

MATERIAL AND METHODS

The study included 93 men and women. These were followed during a work-shift before the smoking ban and three to eight months later. Initially 86 of the participants answered a questionnaire about respiratory tract symptoms , while 67 did so at follow-up.

RESULTS

Before the ban 39 of the subjects (45.3%) reported wheezing in the chest and 28 (32.6%) said they had recently had an upper respiratory tract infection. 43.3% of the participants reported fewer symptoms and 20.9% more symptoms after the ban, while 35.8% reported no change. The corresponding figures among smokers were 47.5%, 15.0% and 37.5%.

INTERPRETATIONS

This study shows that the introduction of a smoking ban in restaurants contributes to a reduction in reported respiratory symptoms among employees, and may therefore be advantageous for the health of this group.

Impact of Scottish smoke-free legislation on smoking quit attempts and prevalence

Objectives

In Scotland, legislation was implemented in March 2006 prohibiting smoking in all wholly or partially enclosed public spaces. We investigated the impact on attempts to quit smoking and smoking prevalence.

Methods

We performed time series models using Box-Jenkins autoregressive integrated moving averages (ARIMA) on monthly data on the gross ingredient cost of all nicotine replacement therapy (NRT) prescribed in Scotland in 2003–2009, and quarterly data on self-reported smoking prevalence between January 1999 and September 2010 from the Scottish Household Survey.

Results

NRT prescription costs were significantly higher than expected over the three months prior to implementation of the legislation. Prescription costs peaked at £1.3 million in March 2006; £292,005.9 (95% CI £260,402.3, £323,609, p<0.001) higher than the monthly norm. Following implementation of the legislation, costs fell exponentially by around 26% per month (95% CI 17%, 35%, p<0.001). Twelve months following implementation, the costs were not significantly different to monthly norms. Smoking prevalence fell by 8.0% overall, from 31.3% in January 1999 to 23.7% in July–September 2010. In the quarter prior to implementation of the legislation, smoking prevalence fell by 1.7% (95% CI 2.4%, 1.0%, p<0.001) more than expected from the underlying trend.

Conclusions

Quit attempts increased in the three months leading up to Scotland's smoke-free legislation, resulting in a fall in smoking prevalence. However, neither has been sustained suggesting the need for additional tobacco control measures and ongoing support.

The case for a worldwide ban on smoking in public places

PURPOSE OF REVIEW

Second-hand smoke (SHS) is a major cause of morbidity and mortality on a global scale. Governments have increasingly sought to mitigate the effects of SHS by introducing legislation that restricts tobacco consumption in public places. There is emerging evidence that such legislation leads to direct and indirect health benefits.

RECENT FINDINGS

Exposure to SHS is now shown to be associated with development of cardiovascular disease, and poorer health outcomes in patients with established chronic obstructive pulmonary disease. Childhood (including in-utero) exposure to SHS has recently been linked with increased risk of cleft palate, demonstrable signs of atherosclerosis, and the development of emphysema and lung cancer in adulthood. Comprehensive bans on smoking in public lead to a reduction in overall exposure to SHS for both adults and children and have also been shown to immediately attenuate the incidence of myocardial infarction and paediatric hospital attendances with acute asthma.

SUMMARY

Banning smoking in public places is an effective tool for reducing tobacco-related morbidity across a multiplicity of diseases. Countries that have not already done so should introduce legislation to enforce effective legislation that prohibits smoking in public places.

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.

Smoke-free legislation and hospitalizations for childhood asthma

BACKGROUND

Previous studies have shown that after the adoption of comprehensive smoke-free legislation, there is a reduction in respiratory symptoms among workers in bars. However, it is not known whether respiratory disease is also reduced among people who do not have occupational exposure to environmental tobacco smoke. The aim of our study was to determine whether the ban on smoking in public places in Scotland, which was initiated in March 2006, influenced the rate of hospital admissions for childhood asthma.

METHODS

Routine hospital administrative data were used to identify all hospital admissions for asthma in Scotland from January 2000 through October 2009 among children younger than 15 years of age. A negative binomial regression model was fitted, with adjustment for age group, sex, quintile of socioeconomic status, urban or rural residence, month, and year. Tests for interactions were also performed.

RESULTS

Before the legislation was implemented, admissions for asthma were increasing at a mean rate of 5.2% per year (95% confidence interval [CI], 3.9 to 6.6). After implementation of the legislation, there was a mean reduction in the rate of admissions of 18.2% per year relative to the rate on March 26, 2006 (95% CI, 14.7 to 21.8; P<0.001). The reduction was apparent among both preschool and school-age children. There were no significant interactions between hospital admissions for asthma and age group, sex, urban or rural residence, region, or quintile of socioeconomic status.

CONCLUSIONS

In Scotland, passage of smoke-free legislation in 2006 was associated with a subsequent reduction in the rate of respiratory disease in populations other than those with occupational exposure to environmental tobacco smoke. (Funded by NHS Health Scotland.)

Secondhand smoke at work

PURPOSE OF REVIEW

Secondhand smoke (SHS) exposure in the workplace remains common and has important acute and chronic health effects. The present study reviews the recent evidence linking workplace SHS exposure with poor health and the benefits of smoke-free workplace legislation.

RECENT FINDINGS

Workplace SHS exposure continues to occur in many parts of the United States and around the world. Occupational SHS exposure has been linked to serious chronic health effects including lung cancer, cardiovascular disease, chronic obstructive pulmonary disease, and poor general health. Smoke-free workplace laws rapidly reduce workplace SHS exposure and improve respiratory health including symptoms and lung function. Smoke-free workplace legislation is also expected to reduce the chronic health effects of passive smoking, including cardiopulmonary disease and lung cancer.

SUMMARY

Occupational exposure to SHS has serious negative health consequences and will shorten lifespan. Smoke-free workplace legislation should be universally adopted around the world.

Secondhand tobacco smoke in bars and restaurants in Santiago, Chile: evaluation of partial smoking ban legislation in public places

Objective

To compare air nicotine concentrations according to the smoking policy selected by bars/restaurants in Santiago, Chile before and after the enactment of partial smoking ban legislation in 2007 (establishments could be smoke free, have segregated (mixed) smoking and non-smoking areas, or allow smoking in all areas).

Methods

The study measured air nicotine concentrations over 7 days to characterise secondhand smoke exposure in 30 bars/restaurants in 2008. Owner/manager interviews and physical inspections were conducted.

Results

Median IQR air nicotine concentrations measured in all venues were 4.38 (0.61–13.62) μg/m³. Air nicotine concentrations were higher in bars (median 7.22, IQR 2.48–15.64 μg/m³) compared to restaurants (1.12, 0.15–9.22 μg/m³). By smoking status, nicotine concentrations were higher in smoking venues (13.46, 5.31–16.87 μg/m³), followed by smoking areas in mixed venues (9.22, 5.09–14.90 μg/m³) and non-smoking areas in mixed venues (0.99, 0.19–1.27 μg/m³). Air nicotine concentrations were markedly lower in smoke-free venues (0.12, 0.11–0.46 μg/m³). After adjustment for differences in volume and ventilation, air nicotine concentrations were 3.2, 35.5 and 56.2 times higher in non-smoking areas in mixed venues, smoking areas in mixed venues and smoking venues, respectively, compared to smoke-free venues.

Conclusions

Exposure to secondhand smoke remains high in bars and restaurants in Santiago, Chile. These findings demonstrate that the partial smoking ban legislation enacted in Chile in 2007 provides no protection to employees working in those venues. Enacting a comprehensive smoke-free legislation which protects all people from exposure to secondhand smoke in all public places and workplaces is urgently needed.

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.

Are there health benefits associated with comprehensive smoke-free laws

INTRODUCTION

In the past few years, comprehensive smoke-free laws that prohibit smoking in all workplaces have been introduced in many jurisdictions in the US, Canada, and Europe. In this paper, we review published studies to ascertain if there is any evidence of health benefits resulting from the implementation of these laws.

METHODS

All papers relating to smoke-free legislation published in or after 2004 were considered for inclusion in this review. We used Pubmed, Google scholar, and Web of Science as the main search tools. The primary focus of the paper is on health outcomes, and thus many papers that only report exposure data are not included.

RESULTS

Studies using subjective measures of respiratory health based on questionnaire data alone consistently reported that workers experience fewer respiratory and irritant symptoms following the introduction of smoke-free laws. Some studies also found measured improvements in the lung function of workers. However, the most dramatic health outcome associated with smoke-free laws has been the reduction in myocardial infarction in the general population. This outcome has been observed in the US, Canada, and Europe, with studies reporting reductions of between 6 and 40%, post-legislation, the larger reductions being mostly from studies with smaller population groups. The evidence as to whether these smoke-free laws have helped smokers to stop smoking or to reduce tobacco consumption is less clear.

CONCLUSIONS

There is now significant body of published literature that demonstrates that smoke-free laws can lead to improvements in the health of both workers who are occupationally exposed and of the general population. There is no longer any reason why non-smokers should be exposed to SHS in any workplace. We recommend that all countries adopt national smoke-free laws that are in line with article 8 of the WHO Framework Convention on Tobacco Control that sets out recommendations for the development, implementation, and enforcement of national, comprehensive smoke-free laws.

Biomass fuel use and indoor air pollution in homes in Malawi

Background:

Air pollution from biomass fuels in Africa is a significant cause of mortality and morbidity both in adults and children. The work describes the nature and quantity of smoke exposure from biomass fuel in Malawian homes.

Methods:

Markers of indoor air quality were measured in 62 homes (31 rural and 31 urban) over a typical 24 h period. Four different devices were used (one gravimetric device, two photometric devices and a carbon monoxide (HOBO) monitor. Gravimetric samples were analysed for transition metal content. Data on cooking and lighting fuel type together with information on indicators of socioeconomic status were collected by questionnaire.

Results:

Respirable dust levels in both the urban and rural environment were high with the mean (SD) 24 h average levels being 226 μg/m³ (206 μg/m³). Data from real-time instruments indicated respirable dust concentrations were >250 μg/m³ for >1 h per day in 52% of rural homes and 17% of urban homes. Average carbon monoxide levels were significantly higher in urban compared with rural homes (6.14 ppm vs 1.87 ppm; p<0.001). The transition metal content of the smoke was low, with no significant difference found between urban and rural homes.

Conclusions:

Indoor air pollution levels in Malawian homes are high. Further investigation is justified because the levels that we have demonstrated are hazardous and are likely to be damaging to health. Interventions should be sought to reduce exposure to concentrations less harmful to health.