Smoke-free Public Places Research Articles

Toward Primary Prevention of Cancer: The Case for a Global Strategy to Limit Avoidable Exposures

Vol. 121, No. 4 News | Science SelectionsOpen AccessToward Primary Prevention of Cancer: The Case for a Global Strategy to Limit Avoidable Exposures Valerie J. Brown Valerie J. Brown Search for more papers by this author Published:1 April 2013https://doi.org/10.1289/ehp.121-a137View Article in:中文版AboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit At least one-third of all cancer cases worldwide could be prevented, according to recent estimates. Tobacco use, poor diet, physical inactivity, and other behaviors are some of the preventable risk factors involved; other cancers have been attributed to environmental exposures such as outdoor air pollution and occupational hazards such as asbestos, metals, and substances used in consumer products. An international team of public and occupational health experts from the World Health Organization (WHO), universities, and independent agencies now makes a case for a global strategy for preventing these exposures [EHP 120(4):420–426; http://dx.doi.org/1205897].The authors reviewed accounts of effective policies and interventions in PubMed as well as government and nongovernmental organization reports, and supplemented their data with recommendations from a WHO-sponsored conference held in March 2011. Most efforts now concentrate on secondary prevention and treatment, neglecting cost-effective primary prevention approaches, probably because the results are not easily quantifiable. Yet, the authors state, “Primary prevention that controls a common source of exposure to proven and probable carcinogens is far more effective and cost-effective than persuading thousands of persons to each change their individual behaviors.”Persuading people to change their behaviors for health reasons is not always efficient or cost-effective. But primary prevention measures that address communal exposures, such as instituting smoke-free public areas, can protect a large number of people—while potentially encouraging individuals to make healthy lifestyle changes.© Edyta Pawlowska/ShutterstockBut avoiding exposures to many carcinogens can be difficult. The public and workers are often ignorant of both their exposures and ways to prevent them. Further difficulty arises from the long latency period for many cancers, which tends to obscure the connection between exposure to carcinogens and later health effects. The researchers emphasize that widespread “invisible” exposures such as persistent organic pollutants and substances in consumer products should be addressed through policies that work across sectors including housing, food, energy production, and industry. In other words, preventing more cancer cases depends on addressing more sources of a given carcinogen.Yet, a broader perspective indicates there are many ways to reduce environmental risk factors, and some have multiple co-benefits, especially against noncommunicable diseases. For instance, the authors note that legislating smoke-free public places not only prevents secondhand cigarette smoke exposure but also encourages smokers to cut down or quit, potentially reducing cardiovascular disease risk. Likewise, reducing outdoor air pollution, particularly diesel exhaust, also reduces lung disease cases. What’s most needed, the authors say, is recognition that primary prevention is not only important but also feasible. With this recognition, as well as coordination of existing knowledge and tools, they believe primary prevention can become part of the policy framework for all governments.FiguresReferencesRelatedDetails Vol. 121, No. 4 April 2013Metrics About Article Metrics Publication History Originally published1 April 2013Published in print1 April 2013 Financial disclosuresPDF download License information EHP is an open-access journal published with support from the National Institute of Environmental Health Sciences, National Institutes of Health. All content is public domain unless otherwise noted. Note to readers with disabilities EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. If you need assistance accessing journal content, please contact [email protected]. Our staff will work with you to assess and meet your accessibility needs within 3 working days.

The efficacy of different models of smoke-free laws in reducing exposure to second-hand smoke: A multi-country comparison

Exposure to second-hand tobacco smoke is a serious public health concern and while all EU Member States have enacted some form of regulation aimed at limiting exposure, the scope of these regulations vary widely and many countries have failed to enact comprehensive legislation creating smoke-free workplaces and indoor public places. To gauge the effectiveness of different smoke-free models we compared fine particles from second-hand smoke in hospitality venues before and after the implementation of smoking bans in France, Greece, Ireland, Italy, Portugal, Turkey, and Scotland.Data on PM2.5 fine particle concentration levels were recorded in 338 hospitality venues across these countries before and after the implementation of smoke-free legislation. Changes in mean PM2.5 concentrations during the period from pre- to post-legislation were then compared across countries.While a reduction in PM2.5 was observed in all countries, those who had enacted and enforced more fully comprehensive smoke-free legislation experienced the greatest reduction in second-hand tobacco smoke.Comprehensive smoke-free laws are more effective than partial laws in reducing exposure to second-hand tobacco smoke. Also, any law, regardless of scope must be actively enforced in order to have the desired impact. There is continued need for surveillance of smoke-free efforts in all countries.

Failure of Tobacco Control in Central Europe

Failure of tobacco control in Europe is mainly due to lack of enforcement of smoke-free workplaces and public places, low tobacco tax and price, easy access of cigarettes for adolescents, and public smoking visible to children as the normal adult behavior. Driving force behind alibi laws without implementation is the corruption by the tobacco industry. An example of an EU member country is given, where tobacconists distribute the newspapers and the government resists amendments of the tobacco law to meet article 5.3 and article 8 of the Framework Convention on Tobacco Control. This WHO convention should be included in binding directives of the European Union.

Knowledge and opinion about smoke-free laws and second-hand smoke among hospitality venue managers in Gujarat and Andhra Pradesh, India.

India's Smoke-Free Law (SFL) was implemented in 2004 and reinforced on 2nd October 2008. This research attempts to understand the knowledge and opinion of hospitality venue (HV) managers about second-hand smoke (SHS) and SFL as well as self-reported compliance with SFL in two Indian states. A survey was conducted among 804 randomly sampled HVs from project STEPS (Strengthening of tobacco control efforts through innovative partnerships and strategies) in Gujarat and Andhra Pradesh, India. Four hundred and three HVs from two districts in Gujarat and 401 HVs from six districts in Andhra Pradesh were selected. The owner, manager or supervisor of each HV was interviewed using a pre-tested structured interview schedule. Association of opinion scales with respondents' background characteristics was assessed through the analysis of variance (ANOVA) method. Out of the 403 respondents in Gujarat and 401 in Andhra Pradesh, 56.1% and 84.3% had knowledge about SFL respectively. Compliance of HVs with SFL was 21.8% in Gujarat and 31.2% in Andhra Pradesh as reported by the managers. Knowledge about SHS was noted among 39.7% of respondents in Gujarat and 25.4% in Andhra Pradesh. Bivariate results indicated that more educated HV managers showed higher support for smoke-free public places (P < 0.001) and were more concerned about the health effects of SHS exposure (P = 0.002). Complete self-reported compliance with, and knowledge of SFL as well as SHS was not found in Gujarat and Andhra Pradesh. The education level of HV managers is an important determinant to ensure compliance with SFL in public places.

Sidebar: Community Leaders and Health Agencies Partner to Stop the Devastation of Diabetes and Hypertension Among African American Men in Hyde County

NCMJ vol. 73, no. 6 ncmedicaljournal.com ment toward making public places smoke-free began to take place. Representative Hugh Holliman introduced House Bill 76, legislation which would have made restaurants smokefree. The bill did not pass, but the good news was that a legislative champion had emerged: Holliman was a lung cancer survivor who was passionate about the smoke-free issue. Between the 2005 and 2006 legislative sessions, a statewide strategy to move North Carolina toward smoke-free work sites and public places was born. The 2006 legislative session accomplished additional incremental steps toward the long-range goal of making all work sites and public places smoke-free. Advocates focused on making the North Carolina General Assembly smoke-free as their first step. In June of that same year, the US Surgeon General’s Report provided incontrovertible evidence that there is no safe level of exposure to secondhand smoke [7]. From there, advocates were ready to pursue legislation that would further restrict smoking in public places. Representative Holliman introduced House Bill 259, which would have banned smoking in work sites and public places. The legislation made history by making it through committee and was voted on the floor of the House, where it was defeated narrowly, by 6 votes Community Leaders and Health Agencies Partner to Stop the Devastation of Diabetes and Hypertension Among African American Men in Hyde County

A cross-country comparison of secondhand smoke exposure among adults: findings from the Global Adult Tobacco Survey (GATS)

ObjectiveExposure to secondhand smoke (SHS) from burning tobacco products causes disease and premature death among non-smoking adults and children. The objective of this study was to determine the nature, extent...

Public opinion on smoke-free policies among Egyptians

A smoke-free law was passed in Egypt in 2007. In 2010 a bylaw was issued, leading to a drive by the Ministry of Health and Population (MOHP) to launch a smoke-free initiative in Alexandria, the second largest city. To assess public opinion with regard to 100% smoke-free legislation and its implementation in the Alexandria governorate. The Union Middle-East Office, in collaboration with the Central Agency for Public Mobilization and Statistics and the MOHP, conducted a cross-sectional survey among 427 randomly selected adults (206 males and 221 females), covering the seven major districts of the Alexandria governorate. The majority of the interviewed subjects (98%) expressed support of the government in enacting 100% smoke-free indoor legislation in all public places and public transport. Respondents endorsed the government plan to implement legislation imposing 100% smoke-free public places. More than one third (33.5%) of all respondents indicated that they would increase visits to restaurants if they were smoke-free, and 63% indicated no impact at all. The results of the poll clearly support results from different countries worldwide that smoke-free policies are popular and supported by the public.

Integrating a quantitative risk appraisal in a health impact assessment: analysis of the novel smoke-free policy in Hungary

Although the quantification of health outcomes in a health impact assessment (HIA) is scarce in practice, it is preferred by policymakers, as it assists various aspects of the decision-making process. This article provides an example of integrating a quantitative risk appraisal in an HIA performed for the recently adopted Hungarian anti-smoking policy which introduced a smoking ban in closed public places, workplaces and public transport vehicles, and is one of the most effective measures to decrease smoking-related ill health. A comprehensive, prospective HIA was conducted to map the full impact chain of the proposal. Causal pathways were prioritized in a transparent process with special attention given to those pathways for which measures of disease burden could be calculated for the baseline and predicted future scenarios. The proposal was found to decrease the prevalence of active and passive smoking and result in a considerably positive effect on several diseases, among which lung cancer, chronic pulmonary diseases, coronary heart diseases and stroke have the greatest importance. The health gain calculated for the quantifiable health outcomes is close to 1700 deaths postponed and 16,000 life years saved annually in Hungary. The provision of smoke-free public places has an unambiguously positive impact on the health of the public, especially in a country with a high burden of smoking-related diseases. The study described offers a practical example of applying quantification in an HIA, thereby promoting its incorporation into political decision making.

Tobacco control in China: small steps towards a giant leap

China's 12th 5-year Plan, endorsed by the National People's Congress in March, 2011, has, as a major goal, the improvement of life expectancy by 1 year for the Chinese population during the next 5 years. 1 Xinhua NewsKey targets of China's 12th five-year plan (2011–2015). http://news.xinhuanet.com/english2010/china/2011-03/05/c_13762230.htmDate: March 5, 2011 Google Scholar The Plan also mentions tobacco control for the first time, calling for smoke-free public places.

Erratum.

IN THE ARTICLE entitled 'Compliance surveys: an effective tool to validate smoke-free public places in four jurisdictions in India' by P. G. Lal, N. C. Wilson, R. J. Singh (Int J Tuberc Lung Dis 2011; 15(4): 565-566; http://dx.doi.org/10.5588/ijtld.10.0372), an error occurred in the wording of the Table.

Smoke-Free Laws, Gender, and Reduction in Hospitalizations for Acute Myocardial Infarction

We examined gender differences in the incidence of acute myocardial infarction (AMI) after the passage of a smoke-free law in Lexington, Kentucky. The initial legislation had exemptions not covering manufacturing facilities and government buildings, which may have put men at greater risk for AMI. We examined the effect of Lexington's smoke-free public places law on hospitalizations for AMI (i.e., heart attack) among men and women 40 months prior to and 32 months after enactment of the law. We used the statewide administrative database (Comp Data) for all hospital billing records for the four health-care systems in Lexington-Fayette County. Cases were included in the analysis if (1) the patient was $35 years of age; (2) the patient had a primary discharge diagnosis of AMI, with an International Classification of Diseases, Ninth Revision code in the range of 410.00 to 410.99; and (3) the date of service was between January 1, 2001, and December 31, 2006. Among women, AMI hospitalizations declined 23% after the law took effect. The rate of AMI events among men did not change significantly. There was an overrepresentation of women in the hospitality industry and a disproportionate number of men working in manufacturing facilities and government worksites not mandated by the law. We found gender differences in the reduction of AMI hospitalizations following implementation of a smoke-free law that covered only some sectors of the workforce. Enacting smoke-free laws that cover all places of employment and strengthening existing partial laws may extend protection against AMIs to female and male workers.

Compliance surveys: an effective tool to validate smoke-free public places in four jurisdictions in India [Notes from the field

Smoke-free initiatives have gained significant momentum since India enacted comprehensive smoke-free legislation in October 2008. The International Union Against Tuberculosis and Lung Disease has actively supported various levels of government, legislators, civil society, and communities across the country to implement smoke-free public places and comply with the law. On World No Tobacco Day 2010, four jurisdictions demonstrated that public places within their jurisdictions were smoke-free. These jurisdictions cover a wide spectrum of demographic and geographic variation and include an entire state. The demonstration of being 'smoke-free' in these jurisdictions was supported by a simple survey that documented compliance with the smoke-free law in the country.

Public, private and personal: Qualitative research on policymakers' opinions on smokefree interventions to protect children in 'private' spaces

BackgroundGovernments use law to constrain aspects of private activities for purposes of protecting health and social wellbeing. Policymakers have a range of perceptions and beliefs about what is public or private. An understanding of the possible drivers of policymaker decisions about where government can or should intervene for health is important, as one way to better guide appropriate policy formation. Our aim was to identify obstacles to, and opportunities for, government smokefree regulation of private and public spaces to protect children. In particular, to seek policymaker opinions on the regulation of smoking in homes, cars and public parks and playgrounds in a country with incomplete smokefree laws (New Zealand).MethodsCase study, using structured interviews to ask policymakers (62 politicians and senior officials) about their opinions on new smokefree legislation for public and private places. Supplementary data was obtained from the Factiva media database, on the views of New Zealand local authority councillors about policies for smokefree outdoor public places.ResultsOverall, interviewees thought that government regulation of smoking in private places was impractical and unwise. However, there were some differences on what was defined as 'private', particularly for cars. Even in public parks, smoking was seen by some as a 'personal' decision, and unlikely to be amenable to regulation. Most participants believed that educative, supportive and community-based measures were better and more practical means of reducing smoking in private places, compared to regulation.ConclusionsThe constrained view of the role of regulation of smoking in public and private domains may be in keeping with current political discourse in New Zealand and similar Anglo-American countries. Policy and advocacy options to promote additional smokefree measures include providing a better voice for childrens' views, increasing information to policymakers about the harms to children from secondhand smoke and the example of adult smoking, and changing the culture for smoking around children.

‘Neighbour smoke’: proposal for a new term

Transfer of secondhand smoke (SHS) between apartments in multi-unit dwellings is an emerging public health issue, an issue of health equity and it is a challenge for property managers and operators who try to deal with the problem. As public knowledge about SHS increases, renters are becoming increasingly concerned about SHS transfer between apartments. Moreover, the increase in smoke-free workplaces and public places has been associated with increased support for further regulations. Although SHS is a known health hazard studies on SHS transfer in multi-unit dwellings are few. Moreover, they are difficult to search for because a common term has not been established. A common term would help researchers to describe this issue and make it easier to collect information on the topic. To date, different terms have been used such as environmental tobacco smoke (ETS) transfer,1 ETS incursion,2 drifting …

‘Balancing acts’: The politics and processes of smokefree area policymaking in a small state

To examine the influences on contemporary smokefree area policy development in New Zealand. Semi-structured interviews were conducted with 62 New Zealand politicians and senior officials. They were asked about their views of possible interventions to reduce smoking around children, and how to achieve progress on smokefree homes, cars and public places. Transcribed data were analysed for themes, some of which were determined by the questions asked, and some emerged from the dynamic nature of the interviews. Policymaking for smokefree areas was seen by participants as a complex, highly politicised activity, concerned with balancing a number of factors including evidence, personal experience, concern for smokers, and the desire for public support for policy. The majority of participants were cautious about making substantive policy moves on smokefree places because of their perception of the issue as highly controversial, their wish to avoid public resistance and their desire for community engagement. Preference was shown for a policy approach based on persuasion rather than legislation, as a means to make progress on smokefree cars and outdoor spaces. The results indicate the need for good communication of the acceptability and benefits of legislative smokefree changes to both the political and public arena.

Views About Secondhand Smoke and Smoke-Free Policies Among North Carolina Restaurant Owners Before Passage of a Law to Prohibit Smoking

This study examined the knowledge, attitudes, and beliefs about secondhand smoke and smoke-free policies among North Carolina restaurant owners and managers before passage of House Bill 2, which prohibited smoking in most restaurants and bars. A random sample of North Carolina restaurants was selected to participate. A 15-minute telephone survey was completed by 523 restaurant owners and managers (one per participating restaurant) who spoke English and operated a restaurant that had seating for guests and was not a corporate headquarters for a restaurant chain (response rate, 36.7%). Bivariable analyses using chi2 tests of association were conducted. Multivariable modeling with logistic regression was used to examine relationships among several predictor variables and current smoking policies at participating restaurants, support among owners and managers for a statewide ban on smoking in restaurants, and beliefs among owners and managers about the economic impact of smoke-free policies. Restaurant owners and managers were aware that secondhand smoke causes cancer and asthma (79% and 73% or respondents, respectively) but were less aware that it causes heart attacks (56%). Sixty-six percent of restaurants did not permit any smoking indoors. Sixty percent of owners and managers supported a statewide smoke-free law. Owners and managers who were current smokers, those who worked at a restaurant with an employee smoking prevalence of more than 25%, and those who worked in a restaurant without a 700% smoke-free policy were significantly less likely to support a statewide law requiring smoke-free public places. Only owner and manager smoking status and no current smoke-free indoor policy were significant independent predictors of the belief that instituting a smoke-free policy would have negative economic consequences for the restaurant. Although participating establishments were a representative sample of North Carolina restaurants, an overall survey response rate of 36.7% limits the generalizability of these findings. Most North Carolina restaurant owners and managers in our sample had a smoke-free indoor policy and supported a law to make public places smoke-free. Results were used to strengthen interventions that create a safe and healthy environment for restaurant employees and customers, in anticipation of passage of House Bill 2.

The Spanish smoking law: a model to be followed?

During the last few years, numerous countries have developed and implemented smoking control policies (IARC 2009). However, the overall approach to tobacco control has been considerably different among them. In Spain, a new Smoking Law came into force in January 2006 (Ministerio de Sanidad 2005), including regulations on the sale, supply, consumption, and publicity of tobacco products (Fernandez 2006). Among its main goals, the law intended to protect non-smokers from secondhand smoke (SHS). For this reason, smoking was prohibited in all enclosed public and private workplaces with the exception of the hospitality sector, where partial restrictions were established depending on the size of the venue. Hospitality venues larger than 100 m could be completely smoke-free, or keep a smoking section (up to 30% of the total area) physically separated and independently ventilated. Owners of venues smaller than 100 m, however, might decide to be smoke-free or to allow smoking without restrictions. The Spanish smoking law is currently being promoted by the tobacco industry as a ‘‘model’’ to be followed by other countries (Muggli et al. 2009; Schneider and PotschkeLanger 2008). However, the scientific evidence, far from supporting the partial restrictions, has clearly shown that total bans are the only way of protecting hospitality workers (IARC 2009). In Spain, where it is estimated that only 10–20% of hospitality venues banned smoking (MartinLuengo 2007)—probably as a consequence of unfounded fears of a potential negative impact on sales—the studies evaluating the impact on SHS levels have shown extremely high levels of SHS exposure in most hospitality workers. A recent overall evaluation study (GTT-SEE 2009) collected the scientific evidence of the impact of the Spanish law on different issues such as public attitudes regarding the law, tobacco consumption, secondhand smoke exposure or health effects. Regarding public attitudes, data from a national survey (CIS 2005) showed that in November 2005 more than 77% of the general population agreed with the smoking law that was going to be enacted. These data seem to be consistent with those shown in the paper of Halpern and Taylor (2009), where a strong support was found for smoking bans in workplaces in Spain (66% employees and 97% employers). The paper of Lazuras et al. (2009) shows that smokers are less supportive of smoke-free public places than nonsmokers, but both groups—smokers and non-smokers—are predominantly supportive of these measures, even in countries with pro-smoking social norms and high smoking rates. In Spain, where the support was also lower among smokers, regional surveys (Departament de Salut 2009) carried out before and after the implementation of the law, showed that this support increased after the law in both smokers and nonsmokers. The impact of the law on tobacco consumption has also been analyzed. So far, the available information (GTT-SEE 2009) does not suggest any impact of the Spanish smoking law on the tobacco consumption indicators. The decrease in the prevalence of smokers and the number of cigarettes smoked, as well as the increase in quitting, continues the time trend observed before the implementation of the law, according to the expected smoking epidemic model evolution (Lopez et al. 1994). M. J. Lopez belongs to the Smoking Working Group of the Spanish Society of Epidemiology.

Second-hand smoke levels in Israeli bars, pubs and cafes before and after implementation of smoke-free legislation

In 2007, Israel passed a law to extend existing restrictions on smoking in public places and to strengthen enforcement. Responsibility for ensuring smoke-free indoor public places was placed on establishment owners. Bars and pubs were included in the law for the first time. This study aimed to assess changes in air quality in popular Israeli bars, pubs and cafes after the implementation of law, and to examine changes in patron numbers, percentage of smoking patrons and venue-seating sections. Air quality was determined by measuring respirable suspended particles (PM(2.5) μg(-3)) in 33 randomly selected venues in Jerusalem and Tel Aviv, including bars, pubs and cafes, before and after law implementation. Numbers of patrons and smoking patrons were recorded. Average respirable small particles (RSP) level was 245 μg(-3) prior to implementation and 161 μg(-3) following implementation of the law, representing a decline of 34% (P = 0.0043). RSP levels decreased in bars and pubs and in cafes. Percentage of smoking patrons declined from 19% to 9% (P = 0.0036). The magnitude of the effect decreased over time (P = 0.0039). Non-smoking establishments were more common following the legislation (P = 0.0047). Indoor air pollution from second-hand smoke in Israeli bars, pubs and cafes in Jerusalem and Tel Aviv declined following the implementation of law. This demonstrates that a law to extend existing restrictions and enforcement policies may help protect workers and patrons from tobacco smoke. However, RSP levels in Israeli bars and pubs, especially in Tel Aviv, remain unacceptably high. Enforced, 100% smoke-free laws are essential for complete protection.

Air nicotine monitoring study at Chennai, Tamil Nadu to assess the level of exposure to second hand smoke in public places

Air nicotine monitoring study at Chennai, Tamil Nadu to assess the level of exposure to second hand smoke in public places

Social–cognitive beliefs, alcohol, and tobacco use: A prospective community study of change following a ban on smoking in public places.

To examine social-cognitive change associated with behavior change after the introduction of a smoke-free public places policy. Adults (N = 583) who use public houses licensed to sell alcohol (pubs) completed questionnaires assessing alcohol and tobacco consumption and social-cognitive beliefs 2 months prior to the introduction of the smoking ban in England on July 1, 2007. Longitudinal follow-up (N = 272) was 3 months after the introduction of the ban. Social-cognitive beliefs, daily cigarette consumption, and weekly alcohol consumption. Smokers consumed considerably more alcohol than did nonsmokers at both time points. However, a significant interaction of Smoking Status x Time showed that while smokers had consumed fewer units of alcohol after the ban, nonsmokers showed an increase over the same period. There was a significant reduction in number of cigarettes consumed after the ban. Subjective norms concerning not smoking, and perceived severity of smoking-related illness increased across time. Negative outcomes associated with not smoking were reduced among former smokers and increased across time among smokers. Regression analyses showed that changes in subjective norm and negative outcome expectancies accounted for significant variance in change in smoking across time. Results suggest that the smoking ban may have positive health benefits that are supported by social-cognitive change.