Smoke-free Regulations Research Articles

Impacts of revised smoke-free regulations under the 2020 Japan Health Promotion Act on cigarette smoking and heated tobacco product use in indoor public places and homes: findings from 2018 to 2021 International Tobacco Control (ITC) Japan Surveys

BackgroundIn April 2020, Japan’s revised Health Promotion Act (HPA) banned cigarette smoking and heated tobacco products (HTP) use in indoor public places but exempted small establishments and permitted smoking-designated/HTP-designated rooms....

Smoke Free Regulation for Clean and Healthy Evironment in Blitar District Indonesia

Introduction: The implementation of smoke-free regulations is an effort to create a clean and healthy environment in the Blitar District, Indonesia. The main purpose of this research is to analyze public opinion on the smoke-free regulations drafting in the Blitar District. Methods: To analyze public opinion about the smoke-free regulations, we used a cross-sectional design with a RAPID survey conducted in 2015. The research involved distributing questionnaires to 1,008 respondents, with the sample size proportionally divided across 22 districts. For the implementation of the regulation, we conducted observational research over four years. The effort to draft the smoke-free regulations continued until 2019, and the implementation of the regulations is ongoing until 2023. Results and Discussion: Results showed that 94.5% supported the regulations. The RAPID survey results provided evidence for drafting the smoke-free regulations. This evidence was used to advocate for stakeholder support in drafting and implementing the regulations in the Blitar District. Although the smoke-free regulations were released in 2019, their implementation has been very challenging and requiring significant effort. Conclusion: A RAPID survey showed that almost all people in Blitar support the drafting and implementation of the smoke-free regulations. The implementation requires significant effort to ensure it proceeds smoothly and needs support from all stakeholders in the Blitar District.

Implementation Of Regional Regulation Policy Number 10 Of 2018 Concerning The Prohibition Of Smoking In The Environment Of The Katingan District Regional Government Agencies

The aim of this research is to explore, explain and illustrate how the No-Smoking Area Regional Regulation (KTR) policy in Katingan Regency is implemented. The approach used in this research is descriptive qualitative, by collecting primary and secondary data. The research results show that Regional Regulation Number 10 of 2018 concerning No-Smoking Areas in Katingan Regency has been implemented. However, there are challenges in implementing this policy, such as limited resources, lack of understanding and a bureaucratic structure that does not work, resulting in a lack of employee discipline regarding non-smoking areas, and a lack of areas provided for smokers in government institutions. Based on the background, the two problems raised in this research are, the author suggests to the agency authorized to handle the Katingan Regency Civil Service Police Unit (Satpol PP) and the Katingan Regency Health Service to increase the socialization of Regional Regulation Number 10 of 2018 concerning No-Smoking Areas, increase the number of Civil Servant Investigators (PPNS) related to adequate human (technical) resources and facilities (facilities and infrastructure). Apart from that, the author emphasizes the importance of regional government's firmness in implementing the Katingan Regency Regional Regulation policy by forming a Non-Smoking Area Supervision Task Force Team in accordance with existing provisions. Finally, the author highlights the importance of a strong commitment from the local government of Katingan Regency in enforcing smoke-free area regulations with the cooperation of all Regional Apparatus Organizations (OPD) to socialize this policy to employees as the main target. Recommended steps include installing no-smoking stickers and signs, as well as law enforcement measures such as unannounced inspections and imposing sanctions. It is hoped that these steps will increase the effectiveness and efficiency of implementing the policy.

Effect of children secondhand smoke exposure associated with GABA concentration: Influence from parents who are extremely heavy smokers in urban households

BackgroundSecondhand smoke (SHS) poses the most considerable health risk to children in urban households. However, limited evidence exists regarding the impact of children exposure to SHS on gamma-aminobutyric acid (GABA) levels. This study aimed to investigate the level of cotinine and GABA and their association with variables related to children exposed to SHS. MethodsA cross-sectional analysis was conducted to assess urinary cotinine and GABA levels in respondents. The study involved 85 participants aged 2–4 years who resided with parents exhibiting heavy smoking habits in urban households in Bangkok, Thailand. Urinary cotinine and GABA concentrations were utilized as biomarkers and measured using an enzyme-linked immunosorbent assay kit. An independent t-test was employed to compare contributing factors with urinary cotinine metabolites. Spearman's correlation test was utilized to assess the relationship between cotinine metabolites and GABA concentration. ResultsThe study found a correlation between urinary cotinine metabolites and GABA concentration among children's (r = 0.260, p-value = 0.016), particularly influenced by parents exhibiting extreme heavy smoking in urban households. Male children exhibited significantly higher urinary cotinine metabolite concentrations than females (p-value = 0.040). Moreover, significantly elevated levels of cotinine metabolites (57.37 ± 10.27 ng/ml) were observed in households where parents engaged in extreme heavy smoking. ConclusionsThis research establishes a link between urinary cotinine metabolite levels and GABA concentration among children exposed to extreme heavy smoking by their parents in urban households. Consequently, smoking might impact neurobehavioral effects, potentially leading to insomnia. The study emphasizes the importance of promoting and safeguarding non-smokers from exposure to SHS in indoor workplaces, public spaces, and households, advocating for the implementation of smoke-free public health regulations.

Understanding the dynamics of compliance to smoke-free policy regulations: Exploring the perspectives of venue owners and staff in Türkiye.

The study aims to understand the facilitators and barriers associated with enforcing and complying with Türkiye's smoke-free policy from the perspective of hospitality venue owners and employees. A qualitative open-ended survey was conducted in Istanbul and Ankara in 2021 with 58 respondents from 3 different districts in each city from four types of venues: restaurants, traditional coffee and waterpipe houses, and European-style cafés. The open-ended survey included questions to understand the knowledge, beliefs, and attitudes of respondents about Türkiye's smoke-free policy and their perceptions of the facilitators and/or barriers to smoke-free policy implementation and changes after COVID-19. The data were analyzed using an inductive approach to identify patterns and categorize the data into themes. The respondents expressed that the smoke-free policy aimed to protect employees and customers from secondhand smoke (SHS), respect human health, and improve air quality. Findings suggest that the positive attitude of venue owners and staff toward the smoke-free policy serves as a facilitator. However, fear of financial impact, customers' negative attitudes, difficulties in meeting physical requirements, and insufficient enforcement were found to be barriers to implementing the smoke-free policy. The effects of the COVID-19 pandemic were reported as an initial increase in compliance and awareness among customers and staff, but some respondents noted negative changes due to the emotional and financial effects of prolonged restrictions. These challenges have led to decreased attention on the smoke-free policy among venue owners, staff and customers. Respondents' suggested improvements were related to building infrastructure, such as the ventilation systems and educating the public on the harmful health effects of smoking. Despite the general understanding of the dangers of secondhand smoke and the smoke-free policy, this study highlights the challenges in implementing smoke-free policy measures and the continued need to raise awareness about the importance of a 100% smoke-free venue. A comprehensive approach to addressing the tobacco epidemic as a multifaceted public health issue is essential.

An Association Between State Laws Limiting Local Control and Community Smoke-Free Indoor Air in the United States.

This study examines the association between state laws limiting local control (preemption laws) and local smoke-free policies. We utilized policy data from the American Nonsmokers' Rights Foundation. The primary outcome variable is the presence of a "100% smoke-free policy," across any of 4 indoor settings: workplaces, restaurants, bars, and gaming venues. We employed generalized structural equation modeling to investigate the relationship between state laws pre-empting smoke-free indoor air regulation and local adoption of policies requiring smoke-free air in any public venues, or for specific venues, adjusting for sociodemographic characteristics. Our findings reveal a significant association between state preemption laws and the presence of a local 100% smoke-free indoor policy as of 2023. In states with preemption laws, cities were less likely to have a 100% smoke-free indoor policy at any venue than cities in states without preemption laws (OR = 0.07, 95% CI = 0.05-0.10). When considering specific smoke-free venues, cities in states with preemption laws were less likely to have a 100% smoke-free indoor policy covering workplaces (OR = 0.05, 95% CI = 0.03-0.09), restaurants (OR = 0.04, 95% CI = 0.02-0.07), bars (OR = 0.04, 95% CI = 0.03-0.08), and gaming venues (OR = 0.03, 95% CI = 0.01-0.09) compared to cities in states without preemption laws. Our study suggests that state preemption laws limit local decision-making and the implementation of public health policies focused on tobacco harms.

Identifying factors influencing local governments' adoption of comprehensive smoke-free policies: an event history analysis based on panel data from 36 key cities in China (2013-2021).

The issue of tobacco control remains a significant concern for public health worldwide. In recent years, remarkable progress has been made toward adopting smoke-free measures in indoor public places. Although China has yet to introduce a national regulation, specifically for smoke-free public places, more than a dozen cities have successively approved and implemented comprehensive smoke-free regulations. Different cities in China have diverse attitudes and behaviors toward smoke-free policies; however, the reasons for these policy differences and the influencing factors have not received sufficient attention and research. On the basis of the multiple streams framework, this study selects 36 key Chinese cities as research samples and uses a directed dyad-year event history analysis method to analyze the factors influencing the implementation of comprehensive smoke-free policies in cities. Results show that the adoption of such policies is positively influenced by scientific evidence, focal events, media coverage, institutional foundations, economic comparisons, and the influence of health departments and of tobacco control groups. By contrast, policy adoption is negatively affected by the differences in administrative levels, central policy signals, and the influence of the tobacco industry. This study contributes to understanding the internal logic behind local governments' adoption of comprehensive smoke-free policies, offering insights for further advocacy at the city and national levels in China and providing experiences that can promote the global tobacco control movement.

Smoking behaviour, tobacco sales and tobacco advertising at 40 ‘Smoke Free Hospitals’ in Vietnam

BackgroundTobacco remains the leading cause of preventable death globally. Vietnam’s 2012 Law on Prevention and Control of Tobacco Harms establishes all healthcare facilities as smoke-free environments. We aimed to evaluate...

Effect of a two-phase tobacco control regulation on incidence from ischemic stroke and hemorrhagic stroke, Shenzhen, China, 2007-2016.

The Shenzhen government is widely considered to be most efficiently implementing smoke-free legislation in China. We evaluated and compared the impact of Shenzhen's two-phase smoke-free regulation on the incidence rates for ischemic and hemorrhagic stroke. An interrupted time series design was used to capture immediate and annual incidence changes from 2007 to 2016 for both ischemic and hemorrhagic stroke due to two-phase smoke-free regulation in Shenzhen, China, by using a generalized additive model. The first phase, implemented on 9 March 2010, required five main public places to be smoke-free. In the second phase, the comprehensive law was expanded to the whole city on 1 March 2014. The regulation implementation during phase I was associated with a strong immediate decline in the incidence rate of ischemic stroke (-14.2%, 95% CI: -19.6 - -8.4) and hemorrhagic stroke (-10.1%, 95% CI: -18.2 - -1.2), but without showing the annual changes (p>0.05). Following the implementation of the comprehensive law, the gradual annual effect showed a significant change in ischemic stroke, with a 6.3% (95% CI: 8.9 - -3.6) reduction. Neither the immediate nor gradual decreases in hemorrhagic stroke incidences associated with the comprehensive regulation were statistically significant during phase II (p>0.05). Subgroup analyses indicate that a much larger health effect of the regulation during phase I was greater among those aged ≥65 years than among those aged 35-64 years. Shenzhen's two-phase smoke-free regulation was well implemented. Even though the regulation did not extend to the whole city, the immediate health benefits on the incidence rates of ischemic stroke and hemorrhagic stroke could be seen. However, the health benefits brought by the implementation of comprehensive smoke-free legislation were attenuated by previous smoke-free regulations in five main public places, which were more evident in hemorrhagic stroke.

Passive exposure and perceptions of smoke-free policies in hospital and university campuses among nursing students: A cross-sectional multicenter study.

Outdoor smoke-free regulations reduce exposure to secondhand smoke (SHS) and help to denormalize tobacco use. As future key agents in health promotion, nursing students' attitudes should agree with tobacco-control policies. The objectives of this study were: 1) assess nursing students' exposure to SHS in nursing schools, 2) explore their perceptions of compliance with the existing smoke-free regulations in acute-care hospitals; and 3) describe their support for indoor and outdoor smoking bans on hospital and university campuses. This was a cross-sectional multicenter study conducted in 2015-2016 in all 15 university nursing schools in Catalonia, Spain. A questionnaire gathered information on SHS exposure, awareness of the smoke-free regulation in acutecare hospitals, and support for smoke-free policies in indoor and outdoor areas of hospitals and university campuses. Participants were nursing students attending classes on the day of the survey. We performed descriptive analyses and calculated adjusted prevalence ratios (APR) and 95% confidence interval (CI). Of 4381 respondents, 99.1% had seen people smoking in outdoor areas of their university campus, and 75.2% had been exposed to SHS on the campus (6.0% indoors and 69.2% outdoors). Nearly 60% were aware of the smoking regulation in place in acute-care hospitals. There was widespread support for smoke-free indoor hospital regulation (98.7%), but less support (64.8%) for outdoor regulations. Approximately 33% supported the regulation to make outdoor healthcare campuses smoke-free, which was higher among third-year students compared to first-year students (APR=1.41; 95% CI: 1.24-1.62), among never smokers (41.4%; APR=2.84; 95% CI: 2.21-3.64) compared to smokers, and among those who were aware of the regulation (38.4%; 95% CI: 1.37-1.75). Exposure to SHS on university campuses is high. Nursing students express low support for strengthening outdoor smoking bans on hospital and university campuses. Interventions aiming to increase their support should be implemented.

How Do National Laws Filter Down to the Local? Tobacco Control Regulations and Smoke Free Areas in a Decentralised Indonesia

The proliferation of provinces and districts in Indonesia since 1998 has led to an array of new local laws across the country. This study focuses on how laws made at the national level become enacted at the local level. We offer a cross-comparison of three case studies of the implementation of smoke-free area regulations, as mandated by Government Regulation No. 109/2012. We investigate this process in Aceh province and the cities of Bandung and Malang, exploring the process of law creation and the context that influences it. We find that local political dynamics shaped unique regulations and outline how these differences manifested, both in the law-making process and in its outcomes. We also reflect on the decentralised law-making system, arguing that top-down diffusion of policy is problematic, with the case studies raising concerns in terms of inconsistencies due to localised variations, as well as inefficiencies and tobacco industry influence.

Implementation level indicators of public facilities in Surabaya to smoke-free area regulation

Background and purpose: The regulation of smoke-free area in Surabaya was adopted since 2008 and amended in 2019. Hotel, restaurants, and cafes are smokefree dedicated area under the regulation. Therefore, it is very important to review the implementation level of smoke-free area regulations in public places such as hotels, restaurants and cafes. This study aims to analyze how strong the indicators that forms the implementation level of public facilities with smoke free area regulations in Surabaya. Methods: This was a cross sectional survey carried out in 88 public facilities consisting of hotels and restaurants between June-August 2021. Confirmatory Factor Analysis (CFA) was carried out with the Analysis of Moment Structures (AMOS) Application to test the strength of each smoke-free area monitoring indicators that forms the implementation level of these public facilities. These indicators include: awareness of smoke-free area regulations, smoke-free area internal promotion, installation of smoke-free signs, no colaboration with tobacco industries, no violations and owning an internal policy related to smoke-free. Results: There were three strong indicators that are strongest in shaping smoke-free area implementation level at public facilities in Surabaya, including awareness of smoke-free area regulations (CFA 4.681), smoke-free area internal promotion (CFA 2.609) and installing a smoke-free sign (CFA 1.000). Meanwhile, the other three indicators showed weak association. Conclusion: Awareness of smoke-free area regulations, smoke-free area internal promotion and installation of smoke-free sign were the strong indicators for smokefree law (SFL) implementation. It is important to push for more internal dissemination involving cross sectors and improve other indicators.

Specific vs Unspecific Smoke-Free Regulation: Which One is More Effective?

Tobacco kills up to half of its users, and smoking prevalence and tobacco exposure among Indonesian youth are increasing. A comprehensive ban on Tobacco Advertising, Promotion, and Sponsorship (TAPS) is a recommended tobacco control measure. Thus, this study aimed to analyze and compare political economy factors that contribute to the effectiveness of the TAPS ban implementation in Surabaya and Kulon Progo. In-depth interviews and a focus group discussion were conducted, recorded, transcribed, then analyzed using thematic analysis. We find that the role of local government was pivotal in creating and implementing regulations for tobacco control, while the leaders’ will and capability were also essential. However, the COVID-19 pandemic had limited all tobacco control measures in both studied districts. Furthermore, the lack of political will and low support from the political parties are the several factors hindering tobacco control measures at the district level, including TAPS ban enforcement. We also find that there is a need to strengthen the understanding of local government, society, and other related stakeholders toward the urgency of the TAPS ban. Further studies calculating the impact of the total TAPS ban on local revenue and the potential benefit of a total TAPS ban are urgently needed for advocating total TAPS ban implementation in a broader scope of the country.

Nursing students' perception towards smoke-free regulations in hospitals and university campuses: a cross-sectional multicenter study

Nursing students' perception towards smoke-free regulations in hospitals and university campuses: a cross-sectional multicenter study

Support for smoke-free regulation in private and public places: Findings from the 2021 ITC EUREST-PLUS Spain Survey

Support for smoke-free regulation in private and public places: Findings from the 2021 ITC EUREST-PLUS Spain Survey

Smoking Behavior and Cigarette Expenditure in a Household: Evidence for Smoke-Free Houses Initiation in Indonesia.

The household is considered as a private area that is untouched tobacco control policies in developing countries, especially in Indonesia, which has not ratified the Framework Convention on Tobacco Control (FCTC) treaty. This study aims to identify smoking behavior and expenditure on cigarettes in the household, which are part of the initiation of a policy including a smoke-free home, so it assumes that the home is a public domain in Tegal Regency, Central Java Province, Indonesia. This research is an observational study with a quantitative descriptive design. A total of 225 subjects in the seven regions designated as smoke-free areas were all selected as samples in this study and were willing to be the subject of research. The results found that 76.1% of smokers smoked with their nuclear family (wife/children/husband) present. Smoking behavior with the nuclear family inside the home (39.13%) and outside the home (36.96%) was more common than not smoking with the nuclear family. Expenditure for cigarettes per month was one-third of household revenue (IDR 607,521.74) based on the regency minimum wage (UMR) set by the local government. The study concludes that smokers who smoke with family still lack knowledge on smoking's impact on health and household economics. The smoke-free regulation that is initiated should include households as a parameter.

Product variety and regulation avoidance in the sale of new tobacco products: findings from a point-of-sale survey in Indonesia.

Since the imposition of the 2018 excise tax, new tobacco products (electronic nicotine delivery system, heated tobacco products, and nicotine pouches) have been considered legal, and their sale has grown rapidly in Indonesia. This study aims to assess the variety of new tobacco products available on the market and evaluate the point-of-sale (POS) environment. Data collection was carried out by 12 trained surveyors between March 7 and 13, 2022, in three provinces that had the most e-cigarette users: Yogyakarta, East Kalimantan, and Jakarta. All the vape stores with a Google rating of 4.5 stars or higher and a minimum of 100 reviews were included. In addition to vape stores, the nearest retail stores were included. The data collected included information about available products, product displays, and whether the POS followed tobacco-control measures, such as health warnings and smoke-free regulations. A total of 27 vape stores and 35 retail stores were observed. The available liquid volumes ranged from 15 to 100 ml, with nicotine levels from 3 to 50mg. No stores sold flavorless products, and all the products were sold without pictorial health warnings (PHWs). Most of the vape stores (92.6%) reported selling products that used cartoon images or public figures, and most (96.3%) allowed customers to use the products inside the store. Five vape stores and four retail stores reported that they did not require customers to undergo an identity-verification process to buy products. More than half (55.6%) of the vape stores and 46.6% of the retail stores reported that they were located less than 500m from a school. The available products were widely varied, and they were easy to access through online and offline stores. The new tobacco products had successfully avoided several tobacco-control measures, including smoke-free regulations and the appearance of PHWs on the products. The government needs to impose regulations sufficient to prevent youth from consuming new tobacco products.

Association between percentage of smokers and prevalence of smoking attributable morbidity in Indonesia: one decade after implementation of smoke-free area regulation

BackgroundFor more than ten years, Indonesia has health law, one of which states that local governments are mandated to establish Smoke Free Area (SFA). The results of 2018 National Basic Health Research shows tobacco consumption is still quite high and increasing compared to the results of 2007 and 2013 National Basic Health Research. The burden of disease in Indonesia is increasing every year. MethodsThis study aims to describe SFA regulation and analyze the relationship between the percentage of smokers and the prevalence of smoking attributable morbidity. Data from the 2018 Basic Health Research in Indonesia with the number of units of analysis were 514 districts and cities level. The design of the study was cross-sectional study. The variables analyzed were the percentage of smokers, the prevalence of diabetes, hypertension, upper respiratory tract infections (URTI), pneumonia, lung tuberculosis, asthma, and mental emotional disorders. Geographical mapping of the distribution of District/City with Smoking-Free Areas was made using QGIS 3·16. ResultsAround 72% of districts/cities in Indonesia already had local regulations of SFA after more than ten years implementation of the regulation of the health law. There was a significant relationship between the high percentage of smokers and the high prevalence of diabetes (p value: 0·000, PR: 1·342, 95%CI 1·135 to 1·587), hypertension (p value: 0·000, PR 1·631, 95%CI 1·252 to 2·124), and lung tuberculosis (p value: 0·008, PR 1·219, 95%CI 1·049 to 1·417) at the District/City level. However, there was no significant association between URTI, pneumonia, asthma, and mental emotional disorders.ConclusionThe percentage of smokers in an area was associated with diabetes, hypertension, and lung tuberculosis. The implementation of Smoke Free Area should be evaluated.

THE ADVOCACY AND COMMUNICATION OF SMOKE-FREE AREA REGULATION IN EAST JAVA, INDONESIA

Background: The negative impact of tobacco, especially second-hand smokers, requires imperative actions. Introducing tobacco control measures helps protect the public health. Data suggest that there were approximately 44 million daily smokers in Indonesia comprising 49.8 million males and 3.9 million females over ten years of age. East Java Province had the biggest number of smokers in Indonesia. To reduce trends in smoking behavior, we need to advocate local government to release and implement smoke-free regulations. Aims: The study aims to do action research through advocacy and communication for the regulation of smoke-free areas in East Java Province. Methods: The action research involved 12 districts of East Java Province, Indonesia. The method used in this study was Focus Group Discussion (FGD), one-on-one meeting, in-depth interviews, public speaking, press conference, and press release. Results: Intensive advocacy and communication worked successfully. Eight districts of East Java Province implemented local regulations of smoke-free areas. The advocacy and communication of the regulations made it possible to be implemented. Conclusion: Intensive advocacy and communication improve the awareness of executive and legislative government about the importance of smoke-free area regulations. It will be successful if regular meetings, discussions, press conferences, public speaking, and team work are conducted with many stakeholders.

Attitudes of staff towards smoke-free environments in psychiatric hospitals in Germany.

INTRODUCTIONSmoke-free environments have already been successfully introduced in hospitals world-wide. But despite convincing evidence of their success, many countries still struggle to make the necessary changes. Not only is the smoking prevalence higher amongst people with mental health problems and staff working in psychiatric units, but employees in psychiatry often resist the implementation of smoke-free policies. This study explores staff attitudes towards smoke-free environments in psychiatric hospitals in Germany and tries to identify barriers and opportunities for implementation.METHODSThis cross-sectional online survey was carried out at eight psychiatric units of the state-owned healthcare company Vivantes Netzwerk für Gesundheit GmbH in Berlin, Germany, in 2019. A total of 448 members of staff were surveyed on their views towards creating a smoke-free environment in their workplace.RESULTSPsychiatric staff present contradictory attitudes towards implementing smoke-free regulations. On the one hand, a majority recognizes the need for smoke-free environments as they promote physical well-being of staff and patients. On the other hand, a majority opposes comprehensive restrictions like a complete smoking ban. Smokers are more likely than non-smokers to resist restrictive measures and show a tendency to only support those measures which they deem unlikely to affect their own smoking habits.CONCLUSIONSThe contradictory attitudes towards implementing smoke-free regulations present an entry point to elicit behavior change and a shift in attitudes, for example in staff training on smoke-free environments. Staff who smoke, in particular, should be motivated to reflect on the contradiction that is presented by their private smoking behavior and their role as healthcare professionals.