Legislative smoking bans for reducing secondhand smoke exposure ...

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2007; Khuder 2007; Sargent 2004; Seo 2007); three in Italy (Barone-Aldesi 2006; Cesaroni 2008; Vasselli 2008); one in Scotland (Pell 2008) and one in Canada (Lemstra 2008). Four studies had control groups without a ban. The impact on admissions for AMI showed a reduction in numbers in all 10 studies. (Analysis 3.4) Two further studies showed an impact on deaths from coronary heart disease (Fichtenberg 2000) and better prognosis post acute coronary syndrome amongst non smokers (Pell 2009) following legislation. One study measured individual exposure to active smoking (Pell 2008) and three further studies used measures of population smoking prevalence and/or cigarette consumption, not individual exposure. Two of these studies measured cotinine levels and one examined pollution reduction by measuring PM10 (Cesaroni 2008). It is evident that in every study looking at an effect of smoking legislation on acute coronary syndrome, the overall impact of the legislation was positive. 4 Other outcomes Other outcomes such as support for the ban, compliance with the legislation, air quality, economic impact of the legislation and any adverse effects were reported from the included studies. Support for the ban Studies also reported acceptability or support of smoking bans as an outcome. Support for the legislation increased in nine of the studies (Biener 2007; Fong 2006; Fowkes 2008; Gallus 2007; Heloma 2003; Hyland 2009; Larsson 2008; Palmersheim 2006; Waa 2006). Two studies showed no significant change in support pre and post ban. One study showed greater than 70% support post ban with greater support amongst smokers who had stopped or tried to stop smoking. Four studies showed that support was greater amongst non smokers than smokers but support for the smoking ban legislation increased for both smokers and non smokers after implementation. Compliance with the legislation Nine studies were included in this review which also reported compliance with smoking bans as an outcome (Biener 2007; Fernando 2007; Fong 2006; Galán 2007; Goodman 2007; Gotz 2008; Heloma 2003; Lemstra 2008; Mulcahy 2005). Four studies reported full compliance in no smoking hospitality venues, three others reported significant decrease in observed smoking or smoking in the workplace. Two others showed compliance with the ban in terms of signage. Only one study reported that 31% of smokers reported no change post ban or seeing more smoking after implementation of ban. Air quality Eight included studies in this review reported environmental measures of air quality (Cesaroni 2008; Ellingsen 2006; Goodman 2007; Gotz 2008; Heloma 2003; Larsson 2008; Mulcahy 2005; Semple 2007). The impact was clear with all studies showing a significant reduction in levels of markers of poor air quality such as nicotine, dust, benzene and particulate matter. Economic impact of the smoking ban legislation Seven studies reviewed the economic impact of the smoking legislation (Biener 2007; Cesaroni 2008; Gallus 2007; Helakorpi 2008; Hyland 2009; Juster 2007; Waa 2006). Three reported there was no significant decrease on bar patronage as measured pre and post ban, two of these also reported no significant decrease on restaurant attendance with one of them showing a significant increase in numbers of nonsmokers attending restaurants. Two of the studies examined the numbers of cigarette sales pre and post ban and found a significant reduction in cigarette sales post introduction of legislation. One study reported on savings in health care expenditure attributable to a decrease in MI admissions post introduction of legislation (Juster 2007). One study included economic indicators in its model assessing the impact of a ban (Helakorpi 2008). Many other studies looked at the economic impact of smoking legislation, however these studies did not examine health outcomes and thus were excluded. Adverse effects Three studies which we included in this review report on other adverse or otherwise negative effects of implementing smoking bans (Fernando 2007, Gilpin 2002, Mulcahy 2005). All of the studies reported that there was still a potential for smoke from outdoor areas to drift into indoor areas. D I S C U S S I O N Legislation restricting or prohibiting smoking in workplaces and public places is a public health measure at the population level. There were no randomized controlled trials where the intervention of the study was a smoking ban. The predominant study design when evaluating the effectiveness of smoking bans were uncontrolled studies with a before and after design which were often unable to control for possible confounders and changes in secular trends over time. Nonetheless the balance of evidence from both the repeated cross-sectional and cohort studies strongly suggests that the primary objective of reducing tobacco smoke exposure was achieved, particularly amongst hospitality workers. This was validated in many studies by cotinine measures and corroborated in some cases also by improvements in air quality. Exposure to secondhand smoke in workplaces, public places, bars and restaurants 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. 10
was reduced, but there was no evidence of a change in exposure to SHS in private cars or vehicles. There was no consistent change in either the prevalence of reported exposure to SHS or the duration in exposure to SHS in the home as a result of implementing legislative bans. The studies were heterogeneous in their design, populations and intervention and we were unable to perform statistical comparisons or meta-analyses. Ten studies were classified for the purposes of this review as having partial bans. However, the extent to which the law allowed smoking in bars and restaurants differed in these studies with some allowing smoking indoors or in designated smoking areas if certain conditions were met such as the venue been a certain size or having a ventilation system in place. Other limitations in the studies included small sample sizes and convenience sampling which leads to a potential risk of selection bias. Attrition bias from loss to follow up was mainly due to the employees having left their workplace at follow up, though the retention rates in the cohort studies reported were very respectable. In the cohort studies, there was no difference between baseline characteristics of the respondents at follow up and non-respondents for half the studies. In the remainder, non-respondents were younger and were more likely to be smokers than those who participated at follow up. Cohort follow up was employed primarily in working populations, whereas cross-sectional surveys were the methodology of choice in general surveys. Compared with before the ban, approval of the smoking policies as well as their compliance with them increased after implementation of smoking bans. There is evidence of reduction in reporting of respiratory and sensory symptoms. There is inconsistent evidence that pulmonary function tests improved as a result of the implementation of smoke-free legislation. There was a shift towards acceptance of the smoking policy after the ban. There was persuasive evidence of a reduction in hospital admissions rates for acute coronary syndrome from pre- to post-ban periods. All 12 studies concerned with hospital care showed an improvement consistent with the ban, the most persuasive of these being able to link the outcome positively to the relative presence of the ban compared to other possibly confounding factors. Taken together, the benefits for workers and the reduction of hospitalrelated morbidity are impressive. From a public health perspective, smoking bans implemented due to legislation are concerned with reducing employee exposure to passive smoke. There were a greater number of studies evaluating the effect of smoking bans on outcomes measuring exposure to passive smoke and health than smoking behaviour as an outcome measure. Surprisingly little attention was given to active smoking behaviour, measured in less than half of all included studies. The measurements used were also diverse, making it difficult to compare the findings. The effect of smoking bans on smoking prevalence was inconclusive with smoking prevalence declining slightly in most of the population based studies, particularly amongst working men but remaining unchanged or not adequately assessed in the studies of workplaces. There was inconsistent evidence of a reduction in cigarette consumption, but in studies where declines in prevalence were recorded, consumption levels also fell. Whilst several country-based studies did show improvements in smoking trends, the question of active smoking merits further investigation. Other associated findings reported, while not a primary objective in the included studies, were acceptability or support for the smoking ban legislation, compliance with the legislation, air quality in those venues affected by the ban, the economic impact as well as any reports from the included studies of adverse effects from implementing the legislation. Enforcement of the smoking ban legislation is necessary to ensure high level of compliance for its successful implementation. Smoking policies usually comprise multi-component efforts to tackle smoking cessation as well as the public health objective of reducing exposure to environmental tobacco smoke. Populations exposed to smoking restrictions accordingly are likely to be exposed to other interventions. The implementation of comprehensive legislation on smoking policy will necessitate other tobacco control measures to prepare for its successful implementation such as increased media awareness, telephone smoking cessation helplines and smoking cessation support services to ensure awareness, comprehension and support of those affected by it (hospitality sector, patrons, population). The effectiveness of legislative efforts will also depend on successful enforcement of smoking bans and compliance with the legislation. Other tobacco control measures such as taxation on tobacco products, limits on advertising and sponsorship and limits on the sale of tobacco products may vary between jurisdictions. A comprehensive approach to tobacco control will utilize both individual and population based intervention strategies causing difficulties in evaluating the effect of a single intervention such as the smoking ban legislation A U T H O R S ’ C O N C L U S I O N S Implications for practice Support for smoking bans has increased with time and compliance with the legislation is high. Workers, particularly in the hospitality sector have benefited from reduced exposure to passive smoke and attributable health benefits associated with cardiac care particularly are suggestive of a benefit. The balance of evidence suggests that legislative smoking bans have achieved their primary objective of reducing exposure to second hand smoke. The impact on active smoking is not yet conclusively demonstrated. Implications for research More research on the impact of smoking bans on active smoking is warranted. Whilst more comprehensive bans are now being en- 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. 11
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