Legislative smoking bans for reducing secondhand smoke exposure ...

The duration of exposure for hospitality employees ranged from
30-69 hours before the law was implemented and this was dramatically
reduced afterwards, whether measured as percentage of
those exposed (Eagan 2006, Jiménez-Ruiz 2008 or duration of
exposure (Abrams 2006, Bondy 2009, Eisner 1998, Farrelly 2005,
Goodman 2007, Hahn 2006, Menzies 2006). One quasi-experimental
study (Bondy 2009) found a significant reduction (>95%)
in total hours exposed to SHS (work and other) by non-smoking
employees in Toronto compared to the control. Whilst some
venues had designated smoking areas in Toronto, only employees
from venues with comprehensive bans were included in the study.
Analysis 1.1
Biomarkers of exposure to SHS
Eighteen of these studies considered biomarker validation (Abrams
2006; Akhtar 2007; Allwright 2005; Bondy 2009; CDC 2007;
Ellingsen 2006; Farrelly 2005; Fernando 2007; Fernández 2009;
Goodman 2007; Gotz 2008; Hahn 2006; Haw 2007; Menzies
2006; Mulcahy 2005; Pearson 2009; Pell 2008; Semple 2007), the
most frequent being cotinine measures, employed in 17 studies
and saliva cotinine in 12 of those.
Of 12 studies utilising saliva cotinine concentration as a measure
of exposure to SHS, sizeable reductions in exposure ranging from
39% to 89% were recorded. Five studies examined biomarkers as
a measure of exposure in both smokers and non smokers, in three
of which (Goodman 2007, Hahn 2006, Pell 2008), no significant
change was seen in smokers’ concentrations and in two cases (
Ellingsen 2006, Semple 2007) a reduction was seen in cotinine
for those who smoked, but less than in non smokers. See Analysis
1.2
Exposure to SHS in cars
Five studies measured exposure to SHS in cars and found that it
remained unchanged before and after the ban was implemented
(Akhtar 2007; Fong 2006; Hahn 2006; Haw 2007; Pell 2008).
One of these (Akhtar 2007) measured the percentage of children
exposed and found both that it was low at baseline and unchanged
at follow up. See Analysis 1.1.3.
Exposure to SHS in homes
Fifteen studies measured exposure to SHS in the home (Abrams
2006; Akhtar 2007; Biener 2007; Brownson 1995; Fong 2006;
Galán 2007; Gilpin 2002; Hahn 2006; Haw 2007; Hyland 2009;
Jiménez-Ruiz 2008; Larsson 2008; Palmersheim 2006; Pell 2008;
Waa 2006). In general there was no change after the implementation
of the ban though some studies reported positive findings.
Fong 2006 reported a significant reduction in homes allowing
smoking and Gilpin 2002 indicated that the percentage of Californian
adults reporting smoke-free homes increased one year
post ban. Similarly Waa 2006 reported reduced exposure in New
Zealand. In two studies where home smoking was assessed, there
was no change (Galán 2007 & Biener 2007). Galán 2007 showed
a drop in smoking at work in compliance with the ban in Spain,
but not at home. Similarly Biener 2007, in a Boston study showed
no reduction in home smoking rates. See Analysis 1.1.4.
In conclusion, in general studies report positive impact of bans on
exposure to second-hand smoke, the most robust being cotinine
validated studies, all of which showed the anticipated benefit. The
high percentage of change reported in many studies reflect the
absolute nature of the exposure, that is, either being protected or
not from an environmental hazard - in this case passive tobacco.
2 Measures of Active smoking
Full details of the results of this section are presented in Analysis
2.1. Less than half of the studies considered active smoking and of
those that did there was little methodological consistency. Three
measures were considered - smoking prevalence rates, measures of
tobacco consumption and reported smoking cessation. Twentythree
of 50 studies contained some reference to active smoking,
no study reported all three measures. Fifteen studies contained a
measure of smoking prevalence; six of these considered smoking
prevalence only with no measure of consumption (Alcouffe 1997;
Hahn 2008; Helakorpi 2008; Jiménez-Ruiz 2008; Lemstra 2008;
Pell 2008); one considered both smoking prevalence in designated
settings and cessation information (Waa 2006); eight studies measured
both smoking prevalence and consumption (Barone-Aldesi
2006; Braverman 2008; Cesaroni 2008; Eisner 1998; Gallus 2007;
Hahn 2006; Heloma 2003; Mullally 2009). Five studies assessed
both tobacco consumption and cessation (Fong 2006; Galán 2007;
Hyland 2009; Larsson 2008; Semple 2007), one considered tobacco
consumption only (Fichtenberg 2000) and two considered
cessation only (Biener 2007; Fowkes 2008).
Smoking prevalence
Whilst 15 studies included information on smoking prevalence,
it was reported primarily as a confounder or co-variable for interpretation
of passive smoking exposure rather than an outcome
measure in itself in five studies (Barone-Aldesi 2006; Eisner 1998;
Hahn 2006; Jiménez-Ruiz 2008; Pell 2008). Barone-Aldesi 2006
for instance estimated that the observed reduction in active smoking
after the ban in Italy could account for 0.7% of the decrease in
acute myocardial infarction admissions. Eight remaining studies
indicated a modest fall in smoking, either in relation to a reference
group, or over time pre-post ban and two showed no change. See
Analysis 2.1.
An early French study of office workers in enclosed public places
(Alcouffe 1997) failed to detect a change in prevalence at two-year
follow up but indicated the ban was poorly observed. Mullally
2009 showed that there was no significant change in smoking
prevalence of bar employees at one year follow up, though a drop
Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
8