Tobacco and Public Health - TCSC Indonesia

RON BORLAND AND CLAIRE DAVEY 723
(Eriksen and Gottlieb 1998). The main difference between the Hopkins et al. finding
and that of the other two was that the Hopkins review relied on quasi randomized trials
whereas the other two included before–after comparison studies. In our view, this is
a situation where the use of comparison groups is not the strongest method for estimating
the size of consumption changes. This is because the introduction of restrictions
on smoking is a social phenomenon, and the organizations introducing bans are likely
to differ in important and relevant ways to those not (yet) introducing them. For
example, several of the comparison studies used hospitals as the workplace where bans
were implemented. These are not typical environments. Many staff refrained from
smoking around patients before bans were implemented and other refrained from
smoking while on duty (smoking is unhealthy and health care workers should set a
good example). To the extent this happened, bans on smoking would be likely to have a
smaller effect on overall consumption. Further, prior to the moves to restrict smoking,
estimates of tobacco consumption were very stable, and the effects of bans so big (in
some cases) that there is no other plausible alternative explanation for the observed
drop in consumption. Indeed, unpublished work from our group is tracking a small
group of smokers close to the introduction of a total workplace bans. This found a
drop in consumption. This decrease occurred from the workday before the bans were
introduced to the first day of the bans. This effect is very similar to the observed effect
on the larger population studied before and some months after the bans (Borland et al.
1990b). We believe that the average estimate of between 3 and 4 cigarettes per day is the
most valid.
That said, there is no magic amount that one should expect when bans are implemented.
Indeed a small number of studies have found no effects of bans on consumption, while
others have found large effects (Eriksen and Gottlieb 1998). Understanding what influence
the magnitude of effects is of considerable interest. Variance in effect on
consumption may be due to the type of smoking restriction, the amount of consumption
before the restrictions, the ability to access places where smoking is allowed,
number and length of legitimate work breaks, degree of compliance, and implementation
issues.
Evidence indicates that more restrictive workplace policies have a greater impact on
consumption (Farrelly et al. 1999; Mizoue et al. 2000). Farrelly et al. (1999), in a large
study concluded that partial restrictions (allowing smoking areas) cut the level of
reduction by about half.
A characteristic of the decline in cigarette consumption has been that heavy smokers
report the largest reductions (Borland et al. 1990b;Borland and Owen 1995; Owen and
Borland 1997; Hopkins et al. 2001). However, this might vary as a function of ease of
cutting down. Borland and Owen (1995) found that heavy smokers who no longer felt
the need to smoke cut down a lot, but those heavy smokers with a strong need to
smoke were less likely to change as they were prepared to put in the effort to find places
where smoking was allowed (Borland and Owen 1995).