Smoke-free Legislation Research Articles

Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey.

This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005–2014, cohort 2: 2016, and cohort 3: 2020–present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.

Securing Smokefree Laws Covering Casinos and Bars in Louisiana via Messaging, Continuous Campaigning and Health Coalitions.

In this paper, we examine efforts by health organizations seeking comprehensive smokefree ordinances over Louisiana casinos and bars between 2010 and 2020 to determine best practices for increasing coverage. Bars and casinos remain less protected from secondhand smoke compared to other workplaces in the United States. Casino behavior is compared to the Policy Dystopia Model (PDM), a tobacco industry strategy framework. We performed a historical case study using snowball searches for news on the Access World News Database and the internet. We performed web searches using the names of key actors, organizations, and locations and interviewed nine participants. Starting in 2010, the Louisiana Campaign for Tobacco-Free Living ran ordinance campaigns supplemented by an ongoing statewide smokefree media initiative. Utilizing consistent strategies, including promoting performers as cultural emblems deserving protection, health organizations coalesced in New Orleans during 2014 and Baton Rouge in 2016 and 2017 to pursue ordinances. The coalitions secured ordinances in Louisiana’s population and tourism centers despite business resistance. Organizations obtained 30 smokefree laws across Louisiana by 2021. Casinos used PDM strategies to resist ordinances, indicating the framework may predict strategies by non-tobacco entities resisting tobacco control. Louisiana shows that ongoing local campaigns, social justice themes and cultural messaging with coalitions in cities can secure smokefree laws covering casinos and bars and that local ordinance campaigns are a viable method for advancing smokefree protections over those venues in states where the state legislatures are resistant to action.

Social Norms and Potency of Local Wisdom as A Social Enforcement of Smoking Behavior

Since 2013, the government of Denpasar City has adopted smoke-free law (KTR). However, the implementation of this law faces several obstacles, one of which is the high social acceptability of smoking in the community. Cigarettes and smoking have been deeply embedded within social and cultural life of the community and become part of the hospitality. Hence, this study aims to explore the social norms of smoking and the potency of local wisdom as a social enforcement for smoking behavior particularly at worship places. This study was a qualitative study located in four sub-districts in Denpasar. Informants and participants were selected purposively. Data was collected through in-depth interviews and FGDs. The study succeeded in interviewing 14 informants and conducting 3 FGDs. The results show that smoking in public places remains common among male, particularly adolescents and the elderly. Smoking behavior is perceived as group identity, however also considered less beneficial due to moral value. Community leaders also noticed smoking in public places. Hence, those leaders have important role to control smoking behavior in public places. Moreover, public education, supervision and enforcement should be considered to engage cultural approach and establish local policy which could accelerate the social enforcement in the community.

Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City.

BackgroundSmoke-free legislation banning tobacco smoking in public places was implemented across Nepal in 2014 with the ambition to reduce the impact of second-hand smoking. As part of a comprehensive policy package on tobacco control, the implementation of the legislation has seen a marked reduction in tobacco consumption. Yet there remains uncertainty about the level of compliance with smoke-free public places.ObjectivesThis study assesses the compliance with smoke-free laws in public places and the factors associated with active smoking in public places in Biratnagar Metropolitan City, Nepal.MethodsA cross-sectional study was conducted in the Biratnagar metropolitan city in Province 1 of Nepal from July to December 2019. A total of 725 public places within the metropolitan city were surveyed using a structured survey tool. Active smoking was the primary outcome of the study which was defined as smoking by any person during the data collection time at the designated public place.ResultsThe overall compliance with smoke-free legislation was 56.4%. The highest compliance (75.0%) was observed in Government office buildings. The lowest compliance was observed in eateries, entertainment, and shopping venues (26.3%). There was a statistically significant association between active smoking and the presence of ‘no smoking’ notices appended at the entrance and the odds of active smoking in eateries, entertainment, hospitality, shopping venues, transportations and transits was higher compared to education and health care institutions. None of the ‘no smoking’ notices displayed fully adhered to the contents as prescribed by the law.ConclusionAs more than half of the public places complied with the requirements of the legislation, there was satisfactory overall compliance with the smoke-free public places law in this study. The public venues (eateries, shopping venues and transportations) that are more frequently visited and have a high turnover of the public have lower compliance with the legislation. The content of the message in the ‘no smoking’ notices needs close attention to adhere to the legal requirements.

Smoke-free Ordinances and Youth Tobacco Use in Kentucky.

Determine associations of strength of local smoke-free laws and urban/rural location with cigarette and smokeless tobacco use among high school students in grades 10 and 12. Secondary data analysis from the 2004-2018 biennial Kentucky Incentives for Prevention Survey. Public high schools in Kentucky. N = 353502 10th/12th graders. County-level smoke-free law status from the Kentucky Center for Smoke-free Policy; Rural Urban Continuum Codes; self-reported last 30-day alcohol, marijuana, cigarette, and smokeless tobacco use. Generalized estimating equations modeling assessed the association of law status and urban/rural location with tobacco use across cohorts, controlling for demographics and other substance use. Students in counties with a comprehensive smoke-free law were 23% less likely to smoke cigarettes and 16% less likely to use smokeless, compared to those in counties without a law. Students in counties with moderate/weak laws did not differ in likelihood of use for either product, compared to those in counties without a law. Students in urban counties were 14% less likely to smoke, but there was no difference in likelihood of smokeless use by urban/rural location. Comprehensive smoke-free laws are associated with a lower likelihood of youth cigarette and smokeless use. Rural youth may be at increased risk of cigarette smoking relative to youth in urban areas.

Association between Inclusion of E-Cigarettes in Statewide Comprehensive Smoke-Free Indoor Air Laws and Vaping Behaviors: Results from a Longitudinal Population Study

Background Several states have included e-cigarettes in their comprehensive smoke-free indoor air laws (i.e., aerosol-free policies), prohibiting the use of e-cigarettes––in addition to combustible tobacco products––in workplaces, restaurants, and bars. However, whether these policies contribute to reductions in e-cigarette use remains largely unknown. Objective This study utilized a nationally representative longitudinal sample to examine the association between the implementation of statewide aerosol-free policies and e-cigarette use behaviors. Methods: This longitudinal retrospective study implemented a quasi-experimental design. Waves 1–4 (2013–2018) restricted-use data from adult participants (weighted N = 22,838,787; unweighted N = 8,663) in the Population Assessment of Tobacco and Health (PATH) study were analyzed. The generalized difference-in-difference approach along with weighted hurdle and multinomial logistic regressions were conducted to examine the associations between aerosol-free policies and three measures of e-cigarette use (past 30-day e-cigarette abstinence status and number of use days, and past-12-month use frequency) pre- and post-policy implementation. Results Results indicated there were not statistically significant differences in e-cigarette use behaviors between participants living in states with and without the aerosol-free policies (ps ranged from 0.301 to 0.831), considering pre- and post-policy implementation. Conclusions Findings indicated that the effectiveness of the aerosol-free policies on e-cigarette use behaviors was not supported by longitudinal national data. States that have implemented aerosol-free policies should make pertinent efforts to enhance the awareness of these policies and to strengthen their enforcement. Future investigation into e-cigarette use in places where it is prohibited and implications with regard to effectiveness of aerosol-free policies is warranted.

Children's exposure to second-hand smoke 10 years on from smoke-free legislation in England: Cotinine data from the Health Survey for England 1998-2018

SummaryBackgroundWe aimed to investigate trends in children's exposure to second-hand tobacco smoke in England from 1998 to 2018.MethodsWe used twenty-one years of data from the Health Survey for England, a yearly repeated cross-sectional population study. A total of 49,460 children participated between 1998 and 2018, of whom 17,463 were biochemically confirmed non-smokers aged 4-15. We examined changes in (i) the proportion of children living in reported smoke-free homes and (ii) second-hand smoke uptake, measured quantitatively using saliva cotinine concentration.FindingsThe percentage of children living in a home reported to be smoke-free increased from 63.0% (95% CI 60.5%-65.2%) in 1998 to 93.3% (91.8%-94.6%) in 2018. This increase was most pronounced among children with a smoker parent, rising from 17.1% (14.7%-19.8%) to 75.9% (70.8%-80.4%). Segmented regression showed that the rate of adoption of smoke-free homes accelerated leading up to the 2007 ban on smoking in public places, growing most rapidly in the four years after its entry into law. Between 1998 and 2018, there was a ten-fold decline in geometric mean cotinine among non-smoking children, from 0.50 ng/ml (0.46-0.56) to 0.05 ng/ml (0.04-0.06). A total of 65.0% (61.2%-68.6%) of children had undetectable cotinine in 2018, up from 14.3% (12.7%-16.0%) in 1998. Children living in rented accommodation were more exposed than those from owner-occupied households, but they experienced similar relative declines across years.InterpretationCotinine data show that children's exposure to second-hand smoke has fallen by some 90% since 1998, with an apparent acceleration in adoption of smoke-free homes since the 2007 ban on smoking in public places. A norm has emerged that sees smoking in the home as inappropriate, almost universally where parents are non-smokers, but also increasingly among smoking parents.FundingPublic Health England, now the Office for Health Improvement and Disparities, and Cancer Research UK.

Feasibility and practicability studies of an evaluation index system for implementation of smoke-free laws and regulations of cities in China.

INTRODUCTIONThe aim of the study is to adjust and improve the feasibility and practicability of an evaluation index system, developed for the implementation of smoke-free laws and regulations, by applying it to analyze and compare the contents and implementation of smoke-free laws and regulations in eight legislative cities in China.METHODSIn regard to indicators of the established evaluation index system, data on tobacco control/smoke-free laws and regulations and their implementation in some legislative cities in China were collected, sorted, and compared, to examine and adjust the feasibility and practicality of the indicators.RESULTSThe evaluation index system for implementation of smoke-free laws and regulations of cities in China has been adjusted to include 5 first-level indicators, including: 1) Simple, clear and executable legislation; 2) Careful planning and sufficient resources for law enforcement; 3) Participation of civil society; 4) Communication; and 5) Monitoring and evaluation of the implementation and impact of laws. There were 27 second-level indicators, including management department, scope of smoke-free places, requirements for non-smoking places etc. There were 27 third-level indicators, including construction of law enforcement, coordination network, work of coordination agencies, staffing situation etc.CONCLUSIONSThe preliminary adjusted evaluation index system for the implementation of smoke-free laws and regulations of cities in China provides a reference and standardization for evaluating effectiveness of implementation of Chinese tobacco control laws and regulations.

Secondhand smoke exposure from the indoor and outdoor shisha centers located at the perimeter of educational institutions in Malaysia: a cross-sectional study.

Shisha is a centuries-old traditional smoking habit rapidly gaining popularity among the students and young adults in Malaysia. The present study evaluated secondhand smoke exposure (SHS) and characteristics of 25 indoor and 25 outdoor shisha centers (SC) operating around the educational institutes such as universities in Petaling Jaya, Malaysia. We observed a significantly higher particulate matter (PM)2.5 concentration in indoor than outdoor SC (3595.28 μg/m3 and 65.12 μg/m3, p < 0.001, respectively). SCs are offering different flavors to attract clients and exposing students and young professionals to a significantly high concentration of SHS. Such exposures may pose a serious health risk. Therefore, policymakers need to strengthen tobacco guidelines and eliminate loopholes in the sale of shisha by enforcing comprehensive and strict smoke-free laws.

Comparison of Urinary Heavy Metals and Pulmonary Function Test in Cafe Workers Based on Exposure to Secondhand Tobacco Smoke, Tehran 2021.

Secondhand tobacco smoke exposure is one of the morbidity causes but it is ignored occasionally. Various studies have shown that hookah and cigarette smoke contain significant volume of heavy metals. This study was designed aiming biological monitoring of the level of heavy metals in the urine samples of workers in smoking cafés and its association with their lung function and respiratory symptoms in Tehran City. The list of cafés in Tehran was provided, and they were divided into water pipe cafés (WPC), cigarette smoking cafés (CSC), and non-smoking cafés (NSC); and then, 10 cafés were randomly selected from each group. Sampling was performed after explaining the study and obtaining the consent of the manager and staff. A check list of demographic data and smoking history was completed and analyzed. A total of 96 individuals were studied; there were 32 subjects in each group. All subjects were male. Six days a week, they worked about 10 h a day in café. The concentration of heavy metals in the groups of hookah and cigarettes was significantly higher and respiratory indices in these groups were significantly lower than non-smoking group. Exposure to secondhand smoke increases the urinary level of heavy metals and reduces the respiratory capacity of people and this can be highly pathogenic in the future. Comprehensive informing on human rights should be provided in this regard and smoking bans in public places must be properly enforced.

More than a Ban on Smoking? Behavioural Spillovers of Smoking Bans in the Workplace

Are workplace smoking bans (WSBs) more than a ban on smoking? We study whether WSBs influence smoking cessation and exert behavioural spillover effects on (i) a number of health behaviours, and (ii) on individuals not directly affected by the bans. Drawing upon quasi-experimental evidence from Russia (a country where about half of the population smokes), which introduced a WBS (in addition to a smoking ban on public places), and adopting a difference-in-differences (DiD) strategy, which compares employed individuals (exposed to the work and public place ban) to those unemployed (exposed only to the ban in public places), we document three sets of findings. First, unlike previous studies (focusing on smoking bans in public places), we find robust evidence that WSBs increase smoking cessation in 2.9 percentage points (pp) among men. Second, we find that upon the WSB, quitters are less likely to use alcohol (6.7pp reduction among men and 3.5 pp among women), reduce their alcohol consumption (10 percent among men) and increase their physical activity (in 4.3 percentage points among men). WSBs are found to influence health behaviours of those not directly affected by the reform, such as never smokers. Our findings are consistent with a model of joint formation of health behaviours, and suggest of the needs to account for a wider set of spillover effects when estimating the welfare effect of WSBs.

POSB167 Cost-Effectiveness of Tobacco Control Strategies in Indonesia

In Indonesia, tobacco smoking is a major public health problem that continues to grow, with a prevalence that is among the highest in the world. To assess the cost-effectiveness of government-funded varenicline, smoking bans in public places and an additional 10% tobacco tax in Indonesia.

Tobacco Cessation Program among Cab Drivers in Mumbai, India: An Interventional Study.

Tobacco epidemic is one of the biggest public health threats, killing nearly seven million people annually. With implementation of smoke-free public places legislation, cabs in India are smoke free. However, large majority of cab drivers are addicted to tobacco. The objectives were to measure cab drivers' knowledge, attitude, and practices about tobacco pre and post intervention, educate them regarding hazards of tobacco and need for smoke-free cabs, perform oral cancer screening, and provide assistance to quit tobacco. This interventional study among cab drivers was conducted in Mumbai during 2015-2018. Different cab unions in Mumbai were contacted and 400 cab drivers were enrolled and interviewed. They were offered health education, oral cancer screening, and tobacco cessation assistance at regular intervals for 1 year. About 63.8% of cab drivers used tobacco, mainly in smokeless forms. Almost 94.1% intended to quit, 66.3% had made previous quit attempts, and 69.8% expressed the need of assistance for quitting. One hundred and twelve cab drivers were diagnosed with oral precancers and one with oral carcinoma. About 49.4% of cab drivers quit tobacco and 46.7% reduced tobacco consumption at the end of 1 year. According to multivariate logistic regression analysis, Muslim cab drivers were less likely to quit tobacco as compared to Hindus. Adherence to smoke-free laws plays a significant role in reducing exposure of cab drivers to secondhand smoke. This program demonstrates the successful implementation of tobacco cessation program that could be replicated among other workforces.

"Tobacco denormalization at home": the contribution of the smoking ban in enclosed workplaces in Brazil.

Estimates suggest that exposure to environmental tobacco smoke is related to 1.2 million deaths per year worldwide. Synergy between various anti-smoking legislative and educational measures is essential to stimulate cessation and prevent initiation. This article aimed to explore how legislative protection from exposure to environmental tobacco smoke in enclosed workplaces in Brazil, whose strengthening occurred in a phased manner between 1996 and 2014, possibly contributed to the protection from passive smoking at home. We evaluated, via generalized linear models, the absolute and relative differences in the proportion of individuals living in smoke-free homes between those exposed and not exposed to passive smoking in enclosed workplaces, both crude and adjusted by sociodemographic and smoking behavior variables, and stratified by non-smokers and smokers. Data from three national surveys conducted in 2008, 2013, and 2019 were used. Regardless of smoking status and year when the data were analyzed, individuals who were employed in smoke-free workplaces were more likely to live in smoke-free homes than smokers who were employed in workplaces that allowed smoking. Adjusted absolute difference increased from +5.5% in 2008 to +10.5% in 2013 among non-smokers, and from +7.1% in 2013 to 15.6% in 2019 among smokers (p-values for additive interaction ≤ 0.05). Strengthening the Brazilian smoke-free legislation was likely associated with a reduction in passive smoking at home, which, therefore, may also reduce the burden of mortality, morbidity, and costs for society related to smoking.

RFMonitor: Monitoring smoking behavior of minors using COTS RFID devices

The protection laws of minors in various countries have clearly banned minors from smoking. However, due to various social factors and the psychological conditions of minors, smoking among minors cannot be effectively controlled. A typical example is that many countries ban smoking in public places, and many places have special smoking areas. Previous work designed wearable sensor devices or used wireless signals (e.g., WIFI and Bluetooth etc.) to identify smoking activities. System deployment and implementation are rarely considered in existing system application scenarios. Here, we show that we can use the backscatter signal of the passive RFID tag, combined with the improved radio frequency chromatographic imaging technology, to analyze the RSSI signal of the human smoking action. Therefore, the system is specially designed for application scenarios and can realize the height detection of minors and the recognition of smoking behavior. In the end, related comparative experiments were also carried out to verify the effectiveness and real-time performance of the system. Aiming at the classification problem of different age groups, this paper proposed to distinguish population categories and identify smoking behaviors by analyzing RSSI signals extracted from commercial readers. Finally, the validity and real-time performance of the system are verified by comparative experiments.

Comprehensive smoke-free laws impact the incidence of preterm birth

Comprehensive smoke-free laws impact the incidence of preterm birth

Analysis of saliva cotinine and 3'-hydroxynicotinine concentration levels among restaurant workers in six cities of China

This study was conducted between November to December 2020, consisting of six representative cities, Beijing, Shanghai, Shenzhen (with comprehensive smoke-free legislation), and Changsha, Chongqing, Shenyang (without comprehensive smoke-free legislation), 678 subjects were enrolled eventually, the mean age of the 678 subjects was (35.61±12.91)years old. Subjects from cities with comprehensive smoke-free legislation accounted for 49.71% of the total; male subjects accounted for 19.47%; meanwhile subjects from large, medium, and small restaurants accounted for 13.57% (92), 37.32% (253) and 49.11% (333) respectively. The analysis results indicate that the positive rate of restaurants staff of cotinine and 3'-hydroxynicotinine was lower in cities with comprehensive smoke-free legislation(34.12% vs 68.04%, χ²=78.01, P<0.001; 16.32% vs 41.94%, χ²=53.79, P<0.001), with staff from cities with comprehensive smoke-free legislation have lower concentrations of cotinine and 3'-hydroxynicotinine than their counterparts from cities without comprehensive smoke-free legislation(0.250 ng/ml vs 0.742 ng/ml, P<0.001; 0.250 ng/ml vs 0.250 ng/ml, P<0.001). No statistically significant difference in the concentration of cotinine and 3'-hydroxynicotinine in saliva between staff from restaurants of different sizes was detected (P>0.05).

Impact of comprehensive smoke-free policy compliance on SHS exposure and health condition of the Georgian population.

INTRODUCTIONGeorgia made steps forward in 2017 and adopted new amendments to its tobacco control legislation, which mostly correspond to the FCTC requirements. Among other changes in the regulations is a ban on smoking in public buildings and public transport, with a few exemptions (casinos, big slot clubs, performances in theatres, taxis). The regulation entered into force on 1 May 2018.METHODSThe aim of the study is to assess the outcomes of the comprehensive smoke-free legislation in Georgia. We used a logical model for data collection and analysis. Our evaluation focuses on smoking prevalence related survey data, SHS exposure, monitoring results on compliance of new tobacco control regulations, Quitline data, and air quality measurement results.RESULTSThe indoor air quality improved by 91% in the hospitality sector (from 1408 to 126 μg/m3 in 2018 and 117 μg/m3 in 2019), by 80% in public settings (from 531 to 112 μg/m3 in 2018 and 98 μg/m3 in 2019) and sufficiently in healthcare facilities (from 219 to 97–98 μg/m3 in 2018–2019). Demand for Quitline services increased by 30%. New cases of AMI declined by 32% during 2017–2019.CONCLUSIONSA comprehensive smoke-free policy with a high level of compliance (≥95%) had a positive impact on the decline of SHS exposure and tremendous improvement of indoor air quality in public places and promotes a decrease in illnesses related to the cardiovascular system in Georgia. Also, demand increased for smoking-cessation services.

Commentary on Titus et al.: Understanding how smoke-free policies can contribute to smoke-free generations.

Commentary on Titus et al.: Understanding how smoke-free policies can contribute to smoke-free generations.

Support of the Implementation of a Whistleblowing System for Smoke-Free Environments: A Mixed Methods Approach.

Enforcement of a smoke-free policy is of vital concern in support of the health of smokers and bystanders. Indonesia has issued a smoke-free law, but implementation and enforcement lie with the regional and municipal governments. In a survey of 225 respondents recruited via schools, knowledge about the health effects of smoking and the smoke-free regulation, as well as attitudes towards and commitment and support of the enforcement of the smoke-free regulation in the Kendari City through an electronic whistleblowing system was examined. Furthermore, the participants were asked about the smoking status and smoking behavior. About half of the respondents were students (teenagers), the other half—their parents. Male respondents were strongly overrepresented (85%). Only 18% of the respondents declared to be smokers, mostly adults and males. Both the smokers and the non-smokers supported the smoke-free law and its enforcement through a whistleblowing system. Representatives of the local government were interviewed and participated in focus group discussions. In general, they also exhibited strong support of an electronic enforcement tool. However, issues of efficiency, costs, and responsibility must still be resolved. Nevertheless, an electronic whistleblowing system has the potential to further the health and livelihoods in a community like the Kendari City.