Smoke-free laws and direct democracy initiatives on smoking bans in Germany: a systematic review and quantitative assessment

Time trend of exposure to secondhand tobacco smoke and polycyclic aromatic hydrocarbons between 1995 and 2019 in Germany - Showcases for successful European legislation

Starting in 2002, regulations and legislative amendments in Germany focused on the non-smoker protection with several measures to reduce exposure to secondhand tobacco smoke (SHS). The present work aimed to evaluate the relationship between polycyclic aromatic hydrocarbons (PAHs) and SHS exposure and to determine to which extent enforced non-smoking regulations and smoking bans affected the exposure of the non-smoking population in Germany since their implementation in the early 2000s until today. For this purpose, cotinine and selected monohydroxylated PAHs (OH-PAHs) were analyzed by means of (UP)LC-MS/MS in 510 24-h-urine samples of the Environmental Specimen Bank collected over a time span of 24 years from 1995 to 2019. Median urinary cotinine levels were found to steadily and significantly decline by 82% from 1995 to 2019. A significant decrease of urinary 3-hydroxybenzo[a]pyrene (19%), 1-OH-pyrene (39%), 1-naphthol (66%), 1- (17%), 2- (25%), and 3-OH-phenanthrene (22%) was also observed throughout the same time span. The decline in urinary levels of cotinine and several OH-PAHs can most likely be attributed to smoking bans and regulations limiting SHS and PAH exposure. This study therefore emphasizes the relevance of human biomonitoring to investigate the exposure of humans to chemicals of concern, assess the effectiveness of regulatory measures, and help policies to enforce provisions to protect public health.

Human Dignity as Leading Principle in Public Health Ethics: A Multi-Case Analysis of 21st Century German Health Policy Decisions

BACKGROUND

There is ample evidence that since the turn of the millennium German health policy made a considerable step towards prevention and health promotion, putting the strategies of 'personal empowerment' and 'settings based approach' high on the federal government's agenda. This phenomenon has challenged the role of ethics in health policy. Concurrently, increasing relevance of the Concept of Human Dignity for health and human rights has been discussed. However, a direct relationship between Human Dignity and Public Health Ethics (PHE) has surprisingly not yet been established.

METHODS

We here conduct a systematic ethical analysis of eminent German health prevention policy case-examples between the years 2000-2016. Specifically, our analysis seeks to adapt and apply the principalism (autonomy, beneficence, justice)-based Concept of Human Dignity of Italian philosopher Corrado Viafora, contextualizing it with the emerging field of PHE. To further inform this health policy analysis, index databases (PubMed, Google Scholar) were searched to include relevant published and grey literature.

RESULTS

We observe a systematic approach of post-millennial health policy decisions on prevention and on defined health targets in Germany, exemplified by (1) the fostering of the preparedness against pandemic infectious diseases, (2) the development and implementation of the first cancer vaccination, (3) major legal provisions on non-smokers protection in the public domain, (4) acts to strengthen long term care (LTC) as well as (5) the new German E-Health legislation. The ethical analysis of these health prevention decisions exhibits their profound ongoing impact on social justice, probing their ability to meet the underlying Concept of Human Dignity in order to fulfill the requirements of the principle of non-maleficence.

CONCLUSION

The observed health policy focus on prevention and health promotion has sparked new public debates about the formation of/compliance with emerging standards of PHE in Germany. We believe that the overall impact of this novel policy orientation will gradually show over mid- and long-term periods, both in terms of improvements in health system performance and concurrently in diagnostics, therapies and health outcome on individual patient level. The Concept of Human Dignity may soon play an even greater role in European PHE debates to come.

Temporal changes in predicted risk of type 2 diabetes in Germany: findings from the German Health Interview and Examination Surveys 1997-1999 and 2008-2011

OBJECTIVE

Over time, prevalence changes in individual diabetes risk factors have been observed for Germany and other European countries. We aimed to investigate the temporal change of a summary measure of type 2 diabetes risk in Germany.

DESIGN

Comparison of data from two cross-sectional surveys that are about 12 years apart.

SETTING

Two nationwide health examination surveys representative for the non-institutionalised population aged 18-79 years in Germany.

PARTICIPANTS

The study included participants without diagnosed diabetes from the national health examination surveys in 1997-1999 (n=6457) and 2008-2011 (n=6095).

OUTCOME MEASURES

Predicted 5-year type 2 diabetes risk was calculated using the German Diabetes Risk Score (GDRS), which considers information on age, anthropometry, lifestyle factors, hypertension and family history of diabetes.

RESULTS

Between the two survey periods, the overall age- and sex-standardised predicted 5-year risk of type 2 diabetes decreased by 27% from 1.5% (95% CI 1.4% to 1.6%) to 1.1% (1.0% to 1.2%). The decrease in red meat intake and waist circumference had the highest impact on the overall decrease in diabetes risk. In stratified analyses, diabetes risk decreased among both sexes and within strata of age and body mass index. Diabetes risk also decreased among highly educated persons, but remained unchanged among persons with a middle or low educational level.

CONCLUSIONS

Monitoring type 2 diabetes risk by a summary measure such as the GDRS could essentially contribute to interpret the dynamics in diabetes epidemiology.

The Effects of Smoking Bans on Self-Assessed Health: Evidence from Germany

We examine the effects of smoking bans on self-assessed health in Germany taking into account heterogeneities by smoking status, gender and age. We exploit regional variation in the dates of enactment and dates of enforcement across German federal states. Using data from the German Socio-Economic Panel, our difference-in-differences estimates show that non-smokers' health improves, whereas smokers report no or even adverse health effects in response to bans. We find statistically significant health improvements especially for non-smokers living in households with at least one smoker. Non smokers' health improvements materialise largely with the enactment of smoking bans. Copyright © 2016 John Wiley & Sons, Ltd.

Factors associated with secondhand smoke exposure in different settings: Results from the German Health Update (GEDA) 2012

BACKGROUND

The ubiquity of secondhand smoke (SHS) exposure at home or in private establishments, workplaces and public areas poses several challenges for the reduction of SHS exposure. This study aimed to describe the prevalence of SHS exposure in Germany and key factors associated with exposure. Results were also differentiated by place of exposure.

METHODS

A secondary data analysis based on the public use file of the German Health Update 2012 was conducted (n = 13,933). Only non-smokers were included in the analysis. In a multivariable logistic regression model the factors associated with SHS exposure were calculated. In addition, a further set of multivariable logistic regressions were calculated for factors associated with the place of SHS exposure (workplace, at home, bars/discotheques, restaurants, at the house of a friend).

RESULTS

More than a quarter of non-smoking study participants were exposed to SHS. The main area of exposure was the workplace (40.9 %). The multivariable logistic regression indicated young age as the most important factor associated with SHS exposure. The odds for SHS exposure was higher in men than in women. The likelihood of SHS exposure decreased with higher education. SHS exposure and the associated factors varied between different places of exposure.

CONCLUSIONS

Despite several actions to protect non-smokers which were implemented in Germany during the past years, SHS exposure still remains a relevant risk factor at a population level. According to the results of this study, particularly the workplace and other public places such as bars and discotheques have to be taken into account for the development of strategies to reduce SHS exposure.

Health Impact Assessment for Second-Hand Smoke Exposure in Germany--Quantifying Estimates for Ischaemic Heart Diseases, COPD, and Stroke

Evidence of the adverse health effects attributable to second-hand smoke (SHS) exposure is available. This study aims to quantify the impact of SHS exposure on ischaemic heart diseases (IHD), chronic obstructive pulmonary diseases (COPD), and stroke in Germany. Therefore, this study estimated and forecasted the morbidity for the three outcomes in the German population. Furthermore, a health impact assessment was performed using DYNAMO-HIA, which is a generic software tool applying a Markov model. Overall 687,254 IHD cases, 231,973 COPD cases, and 288,015 stroke cases were estimated to be attributable to SHS exposure in Germany for 2014. Under the assumption that the population prevalence of these diseases and the prevalence of SHS exposure remain constant, the total number of cases will increase due to demographic aging. Assuming a total eradication of SHS exposure beginning in 2014 leads to an estimated reduction of 50% in cases, compared to the reference scenario in 2040 for all three diseases. The results highlight the relevance of SHS exposure because it affects several chronic disease conditions and has a major impact on the population’s health. Therefore, public health campaigns to protect non-smokers are urgently needed.

Normative misperceptions of tobacco use among university students in seven European countries: baseline findings of the 'Social Norms Intervention for the prevention of Polydrug usE' study

INTRODUCTION

Research conducted in North America suggests that students tend to overestimate tobacco use among their peers. This perceived norm may impact personal tobacco use. It remains unclear how these perceptions influence tobacco use among European students. The two aims were to investigate possible self-other discrepancies regarding personal use and attitudes towards use and to evaluate if perceptions of peer use and peer approval of use are associated with personal use and approval of tobacco use.

METHODS

The EU-funded 'Social Norms Intervention for the prevention of Polydrug usE' study was conducted in Belgium, Denmark, Germany, Slovak Republic, Spain, Turkey and United Kingdom. In total, 4482 students (71% female) answered an online survey including questions on personal and perceived tobacco use and personal and perceived attitudes towards tobacco use.

RESULTS

Across all countries, the majority of students perceived tobacco use of their peers to be higher than their own use. The perception that the majority (>50%) of peers used tobacco regularly in the past two months was significantly associated with higher odds for personal regular use (OR: 2.66, 95% CI: 1.90-3.73). The perception that the majority of peers approve of tobacco use was significantly associated with higher odds for personal approval of tobacco use (OR: 6.49, 95% CI: 4.54-9.28).

CONCLUSIONS

Perceived norms are an important predictor of personal tobacco use and attitudes towards use. Interventions addressing perceived norms may be a viable method to change attitudes and tobacco use among European students, and may be a component of future tobacco control policy.

Overview of systematic reviews on the health-related effects of government tobacco control policies

BACKGROUND

Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

METHODS

An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

RESULTS

Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

CONCLUSION

When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.

Public responses to a comprehensive smoking ban

Purpose

– The purpose of this paper is to report public reactions to a total workplace smoking ban, including smoking behavior, attendance at bars and clubs, and attitudes toward a broader ban.

Design/methodology/approach

– Surveys were conducted in two adjacent jurisdictions, one of which instituted a total workplace smoking ban. Surveys took place before (n=1,609) and after (n=1,600) enactment of the ban in the relevant jurisdiction.

Findings

– No change in smoking prevalence occurred in the jurisdiction enacting the ban. Strong majorities of non-smokers supported the ban, while strong majorities of smokers expressed opposition. In the jurisdiction that enacted the ban, smokers who appeared to be high-volume consumers at bars and clubs were most likely to report reducing attendance at these establishments and to oppose the ban.

Research limitations/implications

– Surveys depend on accurate self-reporting of behavior and attitudes.

Practical implications

– Some bars and clubs may incur financial losses due to smoking bans. A core of strong opponents can undermine public consensus regarding smoking bans. Licensing a limited number of bars and clubs to allow smoking can safeguard this consensus.

Social implications

– Limited smoking bans can serve as a means of harm reduction, as non-smokers are protected from environmental tobacco smoke, and accommodation of smokers reduces their motivation to oppose bans.

Originality/value

– This investigation makes use of detailed data on the public’s thinking and reactions to a comprehensive smoking ban and is a before-after study with controls.