Do smoke-free policies in work and public places increase smoking in private venues?: Table 1

Prevalence and determinants of smoke-free homes in 12 European countries: the TackSHS Survey

Background

Homes are one of the primary locations where people are exposed to second-hand smoke (SHS) in Europe. We describe the prevalence and identify the main determinants of having home-smoking restrictions in 12 European countries.

Methods

Cross-sectional survey in 12 European countries conducted in 2017-2018 (TackSHS project). Approximately 1000 participants representing the general population aged ≥15 years of each country were interviewed face to face. Individual- and country-level characteristics were explored through adjusted prevalence ratios (PRs) obtained from multilevel Poisson models with random effects.

Results

Among 11 734 participants, 70.2% (95% confidence interval (CI) 69.4-71.0%) had smoke-free homes and 17.5% (95% CI 16.8-18.2%) had partial home-smoking restrictions in place. Prevalence of smoke-free homes ranged from 44.4% in Greece to 84.5% in England. Having a smoke-free home was significantly inversely associated with current (PR=0.60) or former (PR=0.95) smoking and living in a household with one (PR=0.70) or two or more (PR=0.58) people who smoke. It was also significantly associated with being ≥65 years old (PR=1.05), being female (PR=1.07), having a high educational level (PR=1.09) and living with children (PR=1.09). Having a smoke-free home was associated with living in northern Europe, while partial home-smoking restrictions were more likely among respondents from eastern Europe and countries with lower per capita gross domestic product.

Conclusions

The prevalence of smoke-free homes in Europe is relatively high, but with large variability across countries. European countries with a lower prevalence of smoke-free homes should implement tailored interventions targeting identified determinants and incorporate the success of other countries.

Correlation between tobacco control policies and tobacco prevention in Mexico: a sub-national analysis

This study aims to determinate the correlation between tobacco control policies (TCP) and the prevalence of tobacco use in the 32 Mexican states during the 2016-2017 period. This is an ecological study that measured TCP by the Tobacco Control Scale (TCS) which assigns a score (0-100) based on the level of these component's implementation: price, prohibition in public spaces, expenditures of public information campaigns, publicity prohibitions, health warnings, and treatments. We analyzed the associations between the TCS scores and prevalence of tobacco use extracted from the National Survey of Drug, Alcohol and Tobacco Consumption using Spearman correlations. Prevalence of daily smokers is negatively correlated with global TCS scores for adolescents (p = 0.026). Price showed similar negative correlations with daily prevalence in adolescents (p = 0.003), adults (p = 0.040), men (p < 0.006), and women (p = 0.040). Many Mexican states need to improve on tobacco control policies, especially targeting a key population: adolescents.

Air Pollution inside Vehicles: Making a Bad Situation Worse

Thailand has successfully forwarded Article 8, Protection from Exposure to Tobacco Smoke, of the World Health Organization's Framework Convention on Tobacco Control (WHO FCTC). It achieved its 100% smoke-free goals in public places in 2010, next pursuing other bans in outdoor places to lower particulate matter air pollution (PM2.5). Our aim was to expose the secondhand smoke levels in vehicles since SHS is a danger to everyone, but especially to children and youth. This is the first experimental study of its kind in Thailand. We measured PM2.5 for 20 min under four conditions in 10 typical Thai vehicles, including commonly used sedans and small pickup trucks. We used an established protocol with two real-time air monitoring instruments to record PM2.5 increases with different vehicle air exchange and air conditioning conditions. Monitoring was recorded in the vehicle's front and back seats. The most common Thai ventilation condition is all windows closed with fan/air conditioning (AC) in operation because of Thai tropical conditions. Mean exposure levels were three and nearly five times (49 and 72 μg/m3) the 24 h WHO standard of 15 μg/m3 in the back and front seats, respectively. These high PM2.5 exposure levels warrant action to limit vehicle smoking for public health protection.

Global burden of lower respiratory infections attributable to secondhand smoke among children under 5 years of age, 2010-2019: a systematic analysis of the global burden of disease study 2019

BACKGROUND

Epidemiological trends of lower respiratory infections (LRIs) attributable to secondhand smoke (SHS) among children under 5 years since smoking bans have been increasingly applied globally remain unclear. Here, we aimed to estimate the spatiotemporal trends of the global, regional, and national burden of LRIs attributable to SHS among children under 5 years old between 2010 and 2019.

METHODS

Data on the deaths, and disability adjusted life years (DALYs) of the disease burden was retrieved from the Global Burden of Disease (GBD) 2019 for 204 countries and territories between 2010 and 2019. The rates per 100,000 population, along with 95% uncertainty intervals, as well as population-attributable fraction (PAF) was presented for each estimate.

RESULTS

In 2019, an estimated 6.94% (3.80-10.12%) of under-5 LRIs deaths were attributable to SHS globally, with an under-5 mortality rate of 7.02 per 100,000, a decrease of 5.77% since 2010. Similarly, 6.95% (3.81-10.13%) of LRIs DALYs were due to SHS among children under 5 years, with a rate in under-5s of 619.36 DALYs per 100,000, and also a 5.77% decrease since 2010. Azerbaijan, Turkmenistan, and Papua New Guinea showed the highest under-5 mortality and DALYs burden rates of LRIs attributable to SHS in 2019. In contrast, the PAF was stagnant over the past ten years and there is even a year-on-year upward trend in South Asia. Nationally, in 2019, Bosnia and Herzegovina, Armenia, and Montenegro showed the highest PAFSHS of LRIs burden among children under 5 years of age. In addition, the burden was heavier in children under 1 year of age and was significantly negatively associated with sociodemographic index.

CONCLUSIONS

SHS remains a risk factor that cannot be ignored for LRIs burden worldwide. Hence, governments and health systems should continue to take steps to reduce SHS pollution among young children to mitigate this burden.

Measurement of airborne nicotine, as a marker of secondhand smoke exposure, in homes with residents who smoke in 9 European countries

OBJECTIVE

Smoke-free policies are effective in preventing secondhand smoke (SHS) exposure, but their adoption at home remains largely voluntary. This study aimed to quantify SHS exposure in homes with residents who smoke in Europe according to households' characteristics, tobacco consumption habits, and national contextual factors.

METHODS

Cross-sectional study (March 2017-September 2018) based on measurements of air nicotine inside 162 homes with residents who smoke from nine European countries. We installed passive samplers for seven consecutive days to monitor nicotine concentrations. Through self-administered questionnaires, we collected sociodemographic information and the number of individuals who smoke, smoking rules, frequency, location, and quantity of tobacco use in households. Country-level factors included the overall score in the Tobacco Control Scale 2016, the smoking prevalence, and self-reported SHS exposure prevalence. Nicotine concentrations were analyzed as continuous and dichotomous variables, categorized based on the limit of quantification of 0.02 μg/m³.

RESULTS

Overall, median nicotine concentration was 0.85 μg/m³ (interquartile range (IQR):0.15-4.42), and there was nicotine presence in 93% of homes. Participants reported that smoking was not permitted in approximately 20% of households, 40% had two or more residents who smoked, and in 79% residents had smoked inside during the week of sampling. We found higher nicotine concentrations in homes: with smell of tobacco smoke inside (1.45 μg/m³ IQR: 0.32-6.34), where smoking was allowed (1.60 μg/m³ IQR: 0.68-7.63), with two or more residents who smoked (2.42 μg/m³ IQR: 0.58-11.0), with more than 40 cigarettes smoked (2.92 μg/m³ IQR: 0.97-10.61), and where two or more residents smoked inside (4.02 μg/m³ IQR: 1.58-11.74). Household nicotine concentrations were significantly higher in countries with higher national smoking prevalence and self-reported SHS exposure prevalence (p < 0.05).

CONCLUSIONS

SHS concentrations in homes with individuals who smoke were approximately twenty times higher in homes that allowed smoking compared to those reporting smoke-free household rules. Evidence-based interventions promoting smoke-free homes should be implemented in combination with strengthening other MPOWER measures.

Change in exposure of children to second-hand smoke with impact on children's health and change in parental smoking habits after smoking ban in Bavaria - a multiple cross-sectional study

BACKGROUND

Concerns about smoking displacement from public places to private amenities aroused following smoking ban implementation in Bavaria in 2008. We analysed children's exposure to second-hand smoke (SHS) before and after the ban, its effect on children's health and prevalence of active smoking in adults.

METHODS

Six cross-sectional surveys (n = 32,443) on pre-school children in Bavaria were analysed, two surveys before the smoking ban in years 2004 and 2005 (S1 and S2) and four after the ban in 2008, 2012, 2014 and 2016 (S4, S6, S7 and S8). Using multivariable logistic regression, we analysed change in children's intra- and extrauterine SHS exposure and its adverse health effects (Asthma, wheezing, bronchitis and neurodermatitis) as well as change in parental active smoking.

RESULTS

The response rates were 78% for S1, 73% for S2, 61% for S4, 62% for S6, 56% for S7 and 54% for S8. Odds of parents never smoked at home in presence of children increased significantly from before to after the ban with odds ratios (OR) 1.17 (CI_95% 1.01-1.35), 1.65 (CI_95% 1.39-1.95), 2.85 (CI_95% 2.32-3.51), 2.24 (CI_95% 1.84-2.72) and 3.66 (CI_95% 2.89-4.63) for S2, S4, S6, S7 and S8, respectively with S1 as reference. Compared to S4, odds of parents who were not actively smoking is significantly higher in S7 (OR = 1.13 (CI_95% 1.03-1.24)) and S8 (OR = 1.24 (CI_95% 1.13-1.36)). The odds of mothers who never smoked during pregnancy increased over time with OR = 1.22 (CI_95% 1.06-1.40) for S2 and 1.57 (CI_95% 1.33-1.86) for S8 compared to S1. Adverse health effects related to children's exposure to SHS are significantly less in S8 compared to S1.

CONCLUSION

After 11 years of smoking ban in Bavaria, smoking displacement to homes was disproved. Exposure of children to SHS intrauterine and at home is decreasing. Number of parents who are not actively smoking is increasing over time. Prevalence of health problems in children related to exposure to SHS is decreasing.

Changes in childhood experimentation with, and exposure to, tobacco and e-cigarettes and perceived smoking norms: a repeated cross-sectional study of 10-11 year olds' in Wales

BACKGROUND

Today's primary school children have grown up in a climate of strong smoking restrictions, decreasing tobacco use, and the emergence of e-cigarettes. Children's exposure to tobacco declined substantially in years following the introduction of smoke-free legislation, with smoking uptake and perceived smoking norms declining. There is debate regarding whether emergence of e-cigarettes may interrupt trends in children's smoking perceptions, or offer a means for adults to limit children's exposure to tobacco. This study examines change in children's tobacco and e-cigarettes experimentation (ever use), exposure to secondhand smoking and vaping, and perceived smoking norms.

METHODS

Data from four, repeat cross-sectional surveys of Year 6 primary school pupils (age 10-11 years) in Wales in 2007, 2008, 2014 and 2019 (n = 6741) were combined. E-cigarette use and perceptions were included in 2014 and 2019 surveys. Analyses used binary logistic regression analyses, adjusted for school-level clustering.

RESULTS

Child tobacco experimentation and most indicators of exposure to tobacco smoke indicated a graded decreasing trend over time from 2007 to 2019. Exposure to e-cigarettes increased from 2014 to 2019, as did pupil awareness of e-cigarettes (OR = 2.56, 95%CI = 2.12-3.10), and parental use (OR = 1.26, 95%CI = 1.00-1.57). A decrease in child e-cigarette experimentation was not significant (OR = 0.80, 95%CI = 0.57-1.13). Children's normative perceptions for smoking by adults and children indicated a graded decrease over time (OR = 0.66, 95%CI = 0.54-0.80; OR = 0.69, 95%CI = 0.55-0.86; respectively from 2014 to 2019). However, fewer reported disapproval of people smoking around them in 2019 relative to 2014 (OR = 0.68, 95%CI = 0.53-0.88). Higher exposure to tobacco cigarettes and e-cigarettes in public places, cars and households were associated with favourable normative perceptions for tobacco smoking; however in models adjusted for exposure to both associations of e-cigarette exposure were attenuated.

CONCLUSION

Children's experimentation with and exposure to tobacco, and their perceptions of smoking as a normative behaviour, have continued to decline alongside growth in exposure to e-cigarettes. Although a large majority of pupils reported they minded people smoking around them, there was some evidence of diminishing disapproval of secondhand smoke since 2007. Further research is needed to understand whether use of e-cigarettes in cars and homes is displacing prior smoking or being introduced into environments where smoking had been eliminated.

Burden of disease from exposure to secondhand smoke in children in Europe

BACKGROUND

Secondhand smoke (SHS) exposure at home and fetal SHS exposure during pregnancy are a major cause of disease among children. The aim of this study is quantifying the burden of disease due to SHS exposure in children and in pregnancy in 2006-2017 for the 28 European Union (EU) countries.

METHODS

Exposure to SHS was estimated using a multiple imputation procedure based on the Eurobarometer surveys, and SHS exposure burden was estimated with the comparative risk assessment method using meta-analytical relative risks. Data on deaths and disability-adjusted life years (DALYs) were collected from National statistics and from the Global Burden of Disease Study.

RESULTS

Exposure to SHS and its attributable burden stalled in 2006-2017; in pregnant women, SHS exposure was 19.8% in 2006, 19.1% in 2010, and 21.0% in 2017; in children it was 10.1% in 2006, 9.6% in 2010, and 12.1% in 2017. In 2017, 35,633 DALYs among children were attributable to SHS exposure in the EU, mainly due to low birth weight.

CONCLUSIONS

Comprehensive smoking bans up to 2010 contributed to reduce SHS exposure and its burden in children immediately after their implementation; however, SHS exposure still occurs, and in 2017, its burden in children was still relevant.

IMPACT

Exposure to secondhand smoke at home and in pregnancy is a major cause of disease among children. Smoking legislation produced the adoption of voluntary smoking bans in homes; however, secondhand smoke exposure at home still occurs and its burden is substantial. In 2017, the number of deaths and disability-adjusted life years in children attributable to exposure to secondhand smoke in the European Union countries were, respectively, 335 and 35,633. Low birth weight caused by secondhand smoke exposure in pregnancy showed the largest burden. Eastern European Union countries showed the highest burden.

The Tobacco Control Scale as a research tool to measure country-level tobacco control policy implementation

INTRODUCTION

The Tobacco Control Scale (TCS) was designed for advocacy purposes but has also been used as a research tool. In the present study, we characterized TCS use, its limitations and strengths, and critically assessed its use as a research instrument.

METHODS

We conducted an extensive search of the biomedical databases PubMed and Web of Science for the keyword ‘tobacco control scale’ in all fields. The search was limited to studies published in the period March 2006 to December 2019. Out of 69 hits, 32 studies met the inclusion criteria. Two reviewers independently extracted information from each publication regarding their general characteristics, publication and research aspects, and the characteristics of the use of the TCS.

RESULTS

We found that researchers have used the TCS as a tool to monitor tobacco control policies mainly in cross-sectional observational studies with ecological and multilevel designs directed to advocacy and the promotion of further research. Different outcomes, such as smoking prevalence and quit ratios, have been associated with tobacco control policy scores. The main reported limitations of the TCS were a low variance across countries and a failure to express enforcement and to incorporate the most recent legislation.

CONCLUSIONS

The TCS has been commonly used to assess differences in outcomes according to tobacco control policies. However, there are still areas for improvement in its use in research regarding the lack of comparability of TCS scores across time. The lessons that have been learned should be used to adapt and expand the TCS overseas.

Exposure to secondhand aerosol of electronic cigarettes in indoor settings in 12 European countries: data from the TackSHS survey

INTRODUCTION

Exposure to secondhand aerosol from e-cigarette (SHA) may pose harmful effects to bystanders. This study aims to investigate the prevalence, duration and determinants of SHA exposure in various indoor settings in 12 European countries.

METHODS

In 2017-2018, we conducted a cross-sectional study, the TackSHS survey, on a representative sample of the population aged ≥15 years in 12 European countries (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain). We described the prevalence and duration of exposure to SHA in several indoor settings among 11 604 e-cigarette non-users. Individual-level and country-level characteristics associated with SHA exposure were also explored using multilevel logistic regression analyses.

RESULTS

Overall, 16.0% of e-cigarette non-users were exposed to SHA in any indoor setting at least weekly, ranging from 4.3% in Spain to 29.6% in England. The median duration of SHA exposure among those who were exposed was 43 min/day. 'Other indoor settings' (eg, bar and restaurant) was reported as the place where most of e-cigarette non-users were exposed (8.3%), followed by workplace/educational venues (6.4%), home (5.8%), public transportation (3.5%) and private transportation (2.7%). SHA exposure was more likely to occur in certain groups of non-users: men, younger age groups, those with higher level of education, e-cigarette past users, current smokers, those perceiving SHA harmless and living in countries with a higher e-cigarette use prevalence.

CONCLUSIONS

We found inequalities of SHA exposure across and within European countries. Governments should consider extending their tobacco smoke-free legislation to e-cigarettes to protect bystanders, particularly vulnerable populations such as young people.

TRIAL REGISTRATION NUMBER

NCT02928536.

Mapping the visibility of smokers across a large capital city

BACKGROUND

Smoking visibility may affect smoking norms with implications for tobacco initiation, particularly amongst youths. Understanding how smoking is distributed across urban environments would contribute to the design and implementation of tobacco control policies. Our objective is to estimate the visibility of smokers in a large urban area using a novel GIS-based methodological approach.

METHODS

We used systematic social observation to gather information about the presence of smokers in the environment within a representative sample of census tracts in Madrid city in 2016. We designed a GIS-based methodology to estimate the visibility of smokers throughout the whole city using the data collected in the fieldwork. Last, we validated our results in a sample of 40 locations distributed across the city through direct observation.

RESULTS

We mapped estimates of smokers' visibility across the entire city. The visibility was higher in the central districts and in streets with a high density of hospitality venues, public transportation stops, and retail shops. Peripheral districts, with larger green areas and residential or industrial land uses, showed lower visibility of smokers. Validation analyses found high agreement between the estimated and observed values of smokers' visibility (R = 0.845, p=<0.001).

DISCUSSION

GIS-based methods enable the development of novel tools to study the distribution of smokers and their visibility in urban environments. We found differences in the visibility by population density and leisure, retail shops and business activities. The findings can support the development of policies to protect people from smoking.

Relation between tobacco control policies and population at high risk of lung cancer in the European Union

INTRODUCTION

Lung cancer accounts for nearly 2 million deaths per year worldwide, the majority of cases due to smoking as the main risk factor associated. The aim of this study was to assess the relation between the level of implementation of tobacco control policies and the population at high risk of lung cancer in the European Union (EU).

METHODS

The Special Eurobarometer 458 "Attitudes of Europeans towards tobacco and electronic cigarettes", conducted in 2017, and the Tobacco Control Scale (TCS) 2010, 2013, and 2016 were the sources of our data. High risk of lung cancer was defined by the inclusion criteria in the National Lung Screening Trial (NLST) and the Dutch-Belgian Lung Cancer Screening Trial (NELSON), the largest lung cancer screening trials carried out in the US and the EU. We calculated Spearman's rank correlation coefficients (rsp) and fitted multilevel generalized linear mixed models using the quasi-Poisson family to assess the correlation at the national level and analyze the association at the individual level, respectively, between the scores in the TCS (higher scores means better implementation of tobacco control policies) and the proportion of individuals at high risk of lung cancer in member states of the EU.

RESULTS

The scores in the TCS 2010 were statistically negatively correlated with the current proportion of ever and former smokers at high risk according to NELSON criteria (-0.41; 95%CI -0.68, -0.04 and -0.49; 95%CI -0.73, -0.13, respectively). We observed statistically significant inverse associations between the scores in the TCS 2010 for the highest quartiles and the proportion of individuals at high risk of lung cancer according to both criteria. Non-statistically significant negative correlations and inverse associations were observed with other TCS.

CONCLUSION

There is a lag between the implementation of tobacco control policies and the reduction of the rates of high risk of lung cancer. Member states should reinforce comprehensive tobacco control policies to reduce the population at high risk of lung cancer in the EU.

Burden of disease attributable to second-hand smoke exposure: A systematic review

Our aim was to provide a systematic review of studies on the burden of disease due to second-hand smoke (SHS) exposure, reviewing methods, exposure assessment, diseases causally linked to SHS, health outcomes, and estimates available to date. A literature review of studies on the burden of disease from SHS exposure, available in PubMed and SCOPUS, published 2007-2018 in English language, was carried out following the PRISMA recommendations. Overall, 588 studies were first identified, and 94 were eligible. Seventy-two studies were included in the systematic review. Most of them were based on the comparative risk assessment approach, assessing SHS exposure using mainly surveys on exposure at home/workplaces. Diseases more frequently studied were: lung cancer, ischemic heart disease, stroke, chronic obstructive pulmonary disease, asthma and breast cancer in adults; lower respiratory tract infection, otitis media, asthma, sudden infant death syndrome and low birth weight in children. The SHS exposure assessment and the reported population attributable fractions (PAF) were largely heterogeneous. As an example, the PAF from lung cancer varied between 0.6% and 20.5%. Moreover, PAF were estimated applying relative risks and SHS exposures with no consistent definitions or with different age classes. The research gap on the SHS exposure burden is shrinking. However, estimates are not yet available for a number of countries, particularly the Middle Eastern and African countries, and not all diseases with the strongest evidence of causation, such as sudden infant death syndrome, have been explored. Moreover, in some cases the applied methodology revealed relatively low quality of data.

The limits of single-group interrupted time series analysis in assessing the impact of smoke-free laws on short-term mortality

BACKGROUND

Decreases in circulatory/respiratory morbimortality after the January-2006 Spanish partial smoke-free law have been found using designs without control groups, such as single-group interrupted time series (ITS), which are prone to biases. The aim was to reassess the law's impact on mortality using ITS designs with robustness checks.

METHODS

A comprehensive cohort of people aged ≥25 in each calendar-year of 2002-2007, living in 13 of 18 Spanish regions, was followed up between 01/2002 and 12/2007. The law included a smoking ban in indoor public and workplaces, allowing exceptions in catering, hospitality and leisure venues, and other interventions. Post-law changes in monthly coronary/respiratory mortality were estimated using segmented regression, adjusting for relevant covariates, including seasonality, extreme temperatures, influenza incidence and air pollution. The validity of results was assessed using control outcomes, hypothetical law dates, and non-equivalent control groups, analysing their results as difference-in-differences (DID) designs.

RESULTS

Significant immediate post-law decreases in coronary, respiratory and non-tobacco-related mortality were observed among people aged ≥70. A significant immediate post-law decrease in respiratory mortality (-12.7%) was also observed among people age 25-69, although this was neutralized by a subsequent upward trend before 1.5 years. More favourable post-law changes in coronary/respiratory mortality among the target (people aged 25-69) than control groups (people aged ≥70 or women aged ≥80) were not identified in DID designs. Establishing hypothetical law dates, immediate decreases began in February/March 2005 with maxima between April and July 2005.

CONCLUSIONS

After robustness checks, the results do not support a clear positive impact of the 2006 Spanish smoke-free law on short-term coronary/respiratory mortality. The favourable immediate changes observed pre- and post-law could derive mainly from the harvesting effect of the January-2005 cold wave. This highlights the risks of assessing the impact of health interventions using both morbimortality outcomes and designs without a control group and adequate robustness checks.

Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014

BACKGROUND

Tobacco use is still highly prevalent in Europe, despite the tobacco control efforts made by the governments. The development of tobacco control policies varies substantially across countries. The Tobacco Control Scale (TCS) was introduced to quantify the implementation of tobacco control policies across European countries OBJECTIVE: To assess the midterm association of tobacco control policies on smoking prevalence and quit ratios among 27 European Union (EU) Member States (EU27).

METHODS

Ecological study. We used the TCS in EU27 in 2007 and the prevalence of tobacco and quit ratios data from the Eurobarometer survey (2006 (n=27 585) and 2014 (n=26 793)). We analysed the relationship between the TCS scores and smoking prevalence and quit ratios and their relative changes (between 2006 and 2014) by means of scatter plots and multiple linear regression models.

RESULTS

In EU27, countries with higher scores in the TCS, which indicates higher tobacco control efforts, have lower prevalence of smokers, higher quit ratios and higher relative decreases in their prevalence rates of smokers over the last decade. The correlation between TCS scores and smoking prevalence (rsp=-0.444; P=0.02) and between the relative changes in smoking prevalence (rsp=-0.415; P=0.03) was negative. A positive correlation was observed between TCS scores and quit ratios (rsp=0.373; P=0.06). The percentage of smoking prevalence explained by all TCS components was 28.9%.

CONCLUSION

EU27 should continue implementing comprehensive tobacco control policies as they are key for reducing the prevalence of smoking and an increase tobacco cessation rates in their population.

Impacts of smoke-free public places legislation on inequalities in youth smoking uptake: study protocol for a secondary analysis of UK survey data

INTRODUCTION

Smoke-free public places legislation has been introduced in many countries to protect the public from the harmful effects of secondhand smoking. While evaluations of smoke-free policies have demonstrated major public health benefits, the impact on youth smoking and inequalities in smoking remains unclear. This project aims to evaluate how smoke-free public places legislation in the UK has impacted on inequalities in youth smoking uptake, and how much of any impact is via changes in parental smoking behaviour.

METHODS AND ANALYSIS

The study will constitute secondary analyses of UK data (from the British Household Panel Survey and the Understanding Society study). Merging these datasets gives coverage of the period from 1994 to 2016. Missing data will be handled using multiple imputation. The primary outcomes are the rates and inequalities in initiation, experimentation, escalation to daily smoking and quitting among youths aged 11-15 years. Secondary outcomes include the prevalence of smoking among parents of these youths. Discrete-time event history analysis will be conducted to examine whether changes in the probability of youth smoking transitions are associated with the implementation of the smoke-free public places legislation; and whether any observed effects differ by socioeconomic position and parental smoking. A multilevel logistic regression model will be used to investigate whether there is a step change or change in trend for the prevalence of parental smoking after the policy was implemented. The models will be adjusted for relevant factors (including cigarette taxation, the change in the legal age for purchase of cigarettes and e-cigarette prevalence) that may be associated with the implementation of the legislation.

ETHICS AND DISSEMINATION

This project will use anonymised survey data which have been collected following independent ethical review. The dissemination of the study findings will adopt multiple communication channels targeting both scientific and non-scientific audiences.

Smoke-free homes and attitudes towards banning smoking in vehicles carrying children in Spain (2016)

OBJECTIVE

To describe the voluntary adoption of smoke-free homes and social attitudes in Spain towards banning smoking in vehicles in which children are present.

METHODS

Cross-sectional study of a representative sample of the adult Spanish population age range, 18-75 years (n=1036). The field work was conducted via a computer-assisted telephone survey in March and April 2016. Survey respondents answered questions about smoking rules at home and attitudes towards a smoking ban in cars with or without children. Home smoking rules were defined as complete (smoking not allowed anywhere in the house), partial (smoking allowed in some areas inside the house) or absent (smoking allowed everywhere).

RESULTS

Most (83.0%) of the surveyed population had some type of smoking restriction in place at home (45.6% complete and 37.5% partial). There were significant differences between groups according to age group (the highest prevalence was 86.1% from 66 to 75 years and the lowest prevalence was 77.8% from 46 to 65 years) and smoking status (the highest prevalence was 89.4% in people who had never been smokers and the lowest prevalence was 75.0% in current smokers) with regards to the prevalence of smoke-free homes (p<0.05), with partial bans more prevalent in smoking households (49.0%). Most (61.6%) of the population favored banning smoking in cars, and 90.1% supported a ban in cars carrying minors. Attitudes towards smoking regulation in cars (with or without children) varied significantly by age group (the highest prevalence was 81.9% from 66 to 75 years and the lowest prevalence was 54.5% from 18 to 45 years) and smoking status (the highest prevalence was 71.4% in people who had never been smokers and the lowest prevalence was 46.0% in current smokers). However, no significant differences were found with regard to attitudes towards smoking regulation in cars carrying children, regardless of sex, age, social class, or smoking status.

CONCLUSION

Approximately half of the adult population in Spain have implemented a complete smoke-free rule at home. More than 9 out of 10 adults favor regulating smoking in cars in the presence of minors. These findings support the expansion of smoke-free regulations to include private vehicles, particularly when minors are in the car.

Children's exposure to secondhand smoke at home before and after smoke-free legislation in Taiwan

INTRODUCTION

In January 2009, Taiwan broadened smoke-free legislation, requiring mass transportation systems, indoor public areas and indoor workplaces with 3 or more people, to become smoke-free. We investigated the secondhand smoke (SHS) exposure at home for children aged 3-11 years in Taiwan before and after the implantation of the legislation.

METHODS

We studied 7911 children from the 2005, 2009 and 2013 National Health Interview Surveys (cross-sectional, nationally representative household surveys). Logistic regression modelling estimated adjusted ORs (AOR) and 95% CIs for children's SHS exposure at home in 2009 and 2013 (2005 as reference) for the overall sample and for each category of household socioeconomic status (SES) and household composition.

RESULTS

Prevalence of children SHS exposure at home decreased from 51% (2005) to 32% (2009) and 28% (2013). Compared to 2005, children in 2009 and 2013 had lower likelihoods of SHS exposure at home with AOR of 0.45 (95% CI 0.41 to 0.51) and 0.41 (95% CI 0.36 to 0.46), respectively. All children had reduced SHS exposure at home after the legislation, irrespective of household SES and compositions. Low household income, low parental education level, living with grandparents or living with other adults was individually associated with increased SHS exposure.

DISCUSSION

The proportion of children exposed to SHS at home in Taiwan declined substantially from 2005 to 2009 after smoke-free legislation, and fell further by 2013, irrespective of SES and household compositions. Still, inequality in SHS exposure at home by SES and household composition warrants future research.

Correlation between tobacco control policies, consumption of rolled tobacco and e-cigarettes, and intention to quit conventional tobacco, in Europe

OBJECTIVE

To analyse the correlation between the implementation of tobacco control policies and tobacco consumption, particularly rolling tobacco, electronic cigarettes (e-cigarettes) users and the intent to quit smoking in 27 countries of the European Union.

DESIGN

Ecological study with the country as the unit of analysis.

DATA SOURCES

We used the data from tobacco control activities, measured by the Tobacco Control Scale (TCS), in 27 European countries, in 2010, and the prevalence of tobacco consumption data from the Eurobarometer of 2012.

ANALYSIS

Spearman correlation coefficients (r_sp) and their 95% CIs.

RESULTS

There was a negative correlation between TCS and prevalence of smoking (r_sp=-0.41; 95% CI -0.67 to -0.07). We also found a negative correlation (r_sp=-0.31) between TCS and the prevalence of ever e-cigarette users, but it was not statistically significant. Among former cigarette smokers, there was a positive and statistically significant correlation between TCS and the consumption of hand-rolled tobacco (r_sp=0.46; 95% CI 0.06 to 0.70). We observed a similar correlation between TCS and other tobacco products (cigars and pipe) among former cigarette smokers. There was a significant positive correlation between TCS and intent to quit smoking in the past 12 months (r_sp=0.66; 95% CI 0.36 to 0.87).

CONCLUSIONS

The level of smoke-free legislation among European countries is correlated with a decrease in the prevalence of smoking of conventional cigarettes and an increase in the intent to quit smoking within the past 12 months. However, the consumption of other tobacco products, particularly hand-rolled tobacco, is positively correlated with TCS among former cigarette smokers. Therefore, tobacco control policies should also consider other tobacco products, such as rolling tobacco, cigars and pipes.

An international systematic review of smoking prevalence in addiction treatment

AIMS

Smoking prevalence is higher among people enrolled in addiction treatment compared with the general population, and very high rates of smoking are associated with opiate drug use and receipt of opiate replacement therapy (ORT). We assessed whether these findings are observed internationally.

METHODS

PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database were searched for papers reporting smoking prevalence among addiction treatment samples, published in English, from 1987 to 2013. Search terms included tobacco use, cessation and substance use disorders using and/or Boolean connectors. For 4549 papers identified, abstracts were reviewed by multiple raters; 239 abstracts met inclusion criteria and these full papers were reviewed for exclusion. Fifty-four studies, collectively comprising 37,364 participants, were included. For each paper we extracted country, author, year, sample size and gender, treatment modality, primary drug treated and smoking prevalence.

RESULTS

The random-effect pooled estimate of smoking across people in addiction treatment was 84% [confidence interval (CI) = 79, 88%], while the pooled estimate of smoking prevalence across matched population samples was 31% (CI = 29, 33%). The difference in the pooled estimates was 52% (CI = 48%, 57%, P < .0001). Smoking rates were higher in programs treating opiate use compared with alcohol use [odds ratio (OR) = 2.52, CI = 2.00, 3.17], and higher in ORT compared to out-patient programs (OR = 1.42, CI = 1.19, 1.68).

CONCLUSIONS

Smoking rates among people in addiction treatment are more than double those of people with similar demographic characteristics. Smoking rates are also higher in people being treated for opiate dependence compared with people being treated for alcohol use disorder.

Tobacco Use Among Healthcare Workers: Impact of a Worksite Policy Change at a US Military Community Hospital

Introductions:Healthcare workers use less tobacco than other working populations. In contrast, US military members use more tobacco than civilians. Military healthcare workers, therefore, represent a unique group with regard to occupational factors that may influence tobacco use.

Aims/Methods:Records of workers at a military community hospital were reviewed to describe tobacco use. An anonymous survey assessed impressions of a worksite policy change that prohibited tobacco use anywhere on hospital grounds.

Results:Hospital staff included 2,074 professionals. Tobacco use was significantly associated with male sex and being a military enlisted worker. In fact, 37% of male enlisted members used tobacco; fewer than 10% of all other workers used tobacco. Among 232 survey respondents, 61% agreed with tobacco-restrictive worksite policies, but only 33% thought policies were effective. Nearly one-third of tobacco users reported decreasing use in the past year. In multivariable modelling, changing habits in response to worksite policy was the only factor significantly associated with decreased tobacco use.

Conclusions:Tobacco use among US military healthcare workers varies markedly by demographic characteristics. Male, military enlisted workers use tobacco at very high rates, paralleling the troops they serve. Implementation of tobacco-restrictive worksite policies is associated with decreased tobacco use in this population.

Impact of National Smoke-Free Legislation on Educational Disparities in Smoke-Free Homes: Findings from the SIDRIAT Longitudinal Study

Families with lower socioeconomic status are less likely to adopt household smoking bans (HSB). The aim of this study was to determine whether socioeconomic disparities in HSB prevalence in Italy decreased 7–9 years after the introduction of the Italian ban on smoking in public places. A longitudinal, 12-year, two-wave study was conducted on a sample of 3091 youths aged 6–14 years in 2002; 1763 (57%) were re-interviewed in 2012–2014. A Poisson regression with a robust error variance was used to assess the association between socioeconomic disparities and HSB prevalence. The adoption of HSBs significantly increased from 60% in 2002 to 75% in 2012–2014, with the increase recorded in youths with ≥1 smoking parent only (from 22% at baseline to 46% at follow-up). The presence of HSBs at baseline was more likely in families with ≥1 graduate parent compared to those with no graduate parents (prevalence ratio (PR) = 1.34, 95% confidence interval (CI) = 1.15–1.57), either in families with ≥1 smoking parent (PR = 1.36, 95% CI = 1.17–1.58) or in families with non-smoking parents (PR = 1.61, 95% CI = 1.01–2.56). Conversely, at follow-up socioeconomic disparities dropped since families with no graduate parents were 1.5-fold more likely to introduce a HSB between the two waves. The Italian ban on smoking in public places may have increased the adoption of smoke-free homes in families with smoking and non-graduate parents, causing the drop of the socioeconomic gap in smoke-free homes.

Attitudes towards electronic cigarettes regulation in indoor workplaces and selected public and private places: a population-based cross-sectional study

BACKGROUND

Currently, there is an intensive debate about the regulation of the use of electronic cigarettes (e-cigarettes) in indoor places. The aim of this study was to assess the attitudes toward e-cigarette use in indoor workplaces and selected public and private venues among the general population in Barcelona (Spain) in 2013-2014.

METHODS

This is a cross-sectional study of a representative sample of the population of Barcelona (n = 736). The field work was conducted between May 2013 and February 2014. We computed the prevalence and the adjusted odds ratios (OR) derived from multivariable logistic regression models.

RESULTS

The awareness of e-cigarettes was 82.3%. Forty five percent of respondents did not agree with the use of e-cigarettes in public places and 52.3% in workplaces. The proportion of disapproval of the use of e-cigarettes in indoor places was higher at 71.5% for schools and 65.8% for hospitals and health care centers; while the prevalence of disapproval of e-cigarette use in homes and cars was lower (18.0% and 32.5%, respectively). Respondents who disagreed on the use of e-cigarettes in indoor workplaces were more likely to be older (OR = 1.64 and 1.97 for groups 45-64 and ≧65 years old, respectively), those with a high educational level (OR = 1.60), and never and former smokers (OR = 2.34 and 2.16, respectively). Increased scores in the Fagerström test for cigarette dependence were also related to increased support for their use.

CONCLUSIONS

Based on this population based study, half of the general population of Barcelona does not support the use of e-cigarettes in indoor workplaces and public places, with the percentage reaching 65% for use in schools, hospitals and health care centers. Consequently, there is good societal support in Spain for the politicians and legislators to promote policies restricting e-cigarettes use in workplaces and public places, including hospitality venues.

Secondhand smoke exposure at home: assessment by biomarkers and airborne markers

OBJECTIVE

We assessed and characterized the relationship among biomarkers of secondhand smoke (SHS) exposure in non-smokers according to their exposure at home as measured by airborne markers.

METHODS

We conducted an observational study on exposure to SHS at home using airborne markers (nicotine and benzene) and biomarkers from the non-smokers living in these homes. We selected 49 non-smoking volunteers from different homes: 25 non-smokers living with at least one smoker and 24 non-smokers living in smoke-free homes. We installed two passive devices to measure nicotine and benzene concentrations in the main room of the house (i.e., the living room). One week later, the researcher returned to the volunteer's home to collect the two devices, obtain saliva and urine samples, and administer a SHS questionnaire.

RESULTS

Salivary and urinary cotinine concentrations highly correlated with air nicotine concentrations measured at the volunteers'homes (rsp=0.738 and rsp=0.679, respectively). The concentrations of airborne markers of SHS and biomarkers in non-smokers increased with increasing self-reported intensity and duration of SHS exposure at home during the previous week (p<0.05). The multivariable regression model showed a significant association with nicotine in air at home (β=0.126, p=0.002 for saliva and β=0.115, p=0.010 for urine).

CONCLUSIONS

Our findings suggest that, even in countries with comprehensive smoke-free legislation, exposure to SHS at home continues to be the main source of exposure for non-smokers who live in non-smoke-free homes. Therefore, public health policies should promote smoke-free homes.

Impact of the Spanish smoke-free legislation on adult, non-smoker exposure to secondhand smoke: cross-sectional surveys before (2004) and after (2012) legislation

Background

In 2006, Spain implemented a national smoke-free legislation that prohibited smoking in enclosed public places and workplaces (except in hospitality venues). In 2011, it was extended to all hospitality venues and selected outdoor areas (hospital campuses, educational centers, and playgrounds). The objective of the study is to evaluate changes in exposure to secondhand smoke among the adult non-smoking population before the first law (2004-05) and after the second law (2011–12).

Methods

Repeated cross-sectional survey (2004–2005 and 2011–2012) of a representative sample of the adult (≥16 years) non-smoking population in Barcelona, Spain. We assess self-reported exposure to secondhand smoke (at home, the workplace, during leisure time, and in public/private transportation vehicles) and salivary cotinine concentration.

Results

Overall, the self-reported exposure to secondhand smoke fell from 75.7% (95%CI: 72.6 to 78.8) in 2004-05 to 56.7% (95%CI: 53.4 to 60.0) in 2011–12. Self-reported exposure decreased from 32.5% to 27.6% (−15.1%, p<0.05) in the home, from 42.9% to 37.5% (−12.6%, p = 0.11) at work/education venues, from 61.3% to 38.9% (−36.5%, p<0.001) during leisure time, and from 12.3% to 3.7% (−69.9%, p<0.001) in public transportation vehicles. Overall, the geometric mean of the salivary cotinine concentration in adult non-smokers fell by 87.2%, from 0.93 ng/mL at baseline to 0.12 ng/mL after legislation (p<0.001).

Conclusions

Secondhand smoke exposure among non-smokers, assessed both by self-reported exposure and salivary cotinine concentration, decreased after the implementation of a stepwise, comprehensive smoke-free legislation. There was a high reduction in secondhand smoke exposure during leisure time and no displacement of secondhand smoke exposure at home.