Impacts of smoke free implementation – to do or not to do
Nguyen Ngoc Bich1*
ABSTRACT
Tobacco health effects are a major public health issue in the world. It is estimated that tobacco use is responsible for up to 90% of lung cancers, 30% of all cancers, 75% of chronic obstructive pulmonary diseases (COPD) and 35% of ischemic heart diseases. The World Health Organization (WHO) also indicated that Tobacco use could be attributed to 14% of deaths in men and 11% of deaths in women in the Western Pacific region. In Vietnam only, non-communicable diseases are on an increasing trend, accounting for more than 62%
of all hospital deaths with tobaccouse attributing to 17% of all deaths and 21% of deaths caused by non-communicable diseases.
A smoke free environment was indicated to have an important impact on the health of non- smokers as well as smokers. It created a supportive environment for smokers to quit or reduce smoking while it did not pose any negative impact on business or the situation of smoking at home. After implementing smoke free policy, quality of air at different settings such as workplaces, bar, restaurants was reported significantly improved. Different studies also showed significant reduction of incidence of related illness.
Keywords: review, second-hand smoke, impact, health, policy, smoke free
1 Hanoi School of Public Health
* Corresponding author: Nguyen Ngoc Bich, Faculty of Environmental and Occupational Health, Hanoi School of Public Health, 138 GiangVo, Ba Dinh, Hanoi, Vietnam. Tel: 00-84-913347141. Email: [email protected]
Tobacco is the most significant legal killer in the world. According to recent studies, tobacco smoke contains 7,357 chemical compounds, hundreds of them are toxic and 69 of them are carcinogens1. It is estimated that tobacco use can beattributed to 6.4 million deaths in 2015 and 8.3 million deaths in 2030, 1.5 time higher than HIV/AIDS2. Besides causing diseases and deaths in smokers, tobacco smoke poses significant impact on the health of non-smokers exposed to Second Hand Smoke (SHS).
According to research based on data from 192 countries, in 2004, SHS lead to 603,000 deaths (1% of mortality worldwide). Most severe health problems in terms of mortality and Disability Adjusted Life Years (DALYs) lost were ischemic heart disease, lower respiratory infections, asthma and lung cancer3. The results also showed that 40% of children in the world exposed to SHS, the prevalence of non-smoking males and females exposed to SHS were 33%
and 35% respectively.
Other studies also show evidence of additional consequences of exposure to SHS like breast cancer4, decrease of mental development in infants of mothers exposed to SHS during pregnancy5and asthma6-8.
SHS exposure was also found to be high in Vietnam. Results in the GATS9survey showed that 73.1% of Vietnamese adults were exposed to SHS at home. Among non – smokers 67.6%
are exposed to SHS at home. The occurrence of exposure to SHS at public places was highest at bars and cafes (92.6%) and restaurants (84.95). The occurrence of SHS at workplaces, universities and government offices where previous smoke free policies were introduced, was still high as reported by workers with prevalence of 55.9%, 54.3% and 38.7%, respectively. Among 14 countries that complete GATS, Vietnam ranked number 4th
with 49% of non-smoking workers exposed to SHS at workplaces9.
Vietnam ratified FCTC and passed its own Tobacco Control Law in 2012 to totally ban smoking at specific places such as hospitals, on transportation means, kindergartens, schools etc. and in indoor areas of different places such as universities, restaurants, bars, hotels etc.10. This review aims to provide evidences from different studies on the impacts of implementing smoke free policies in different countries.
IMPACT OF SMOKE FREE ENVIRONMENT ON HEALTH
Implementation of smoke free regulations was shown to have positive impacts on reducing tobacco related health problems and helping smokers to reduce smoking or quit smoking11. Recent studies have shown that, after implementing a smoke free policy, air quality improved at indoor places. A survey in New Zealand indicated that, after the introduction of Smoke-free Environments Amendment Act in 2003, the air quality at different settings improved significantly indicated by the decrease of salivary cotinine by 90% when taking samples from bar volunteers. Air quality measurements of this survey also showed the reduction of indoor particulate level from 13 to 22mg/m3, much lower compared to that in hospitality industries in other countries’ studies and also lower than before implementing the Act in New Zealand12. In this study, data of exposure from self- reporting of workers also showed the reduction of exposure to second hand smoke from 20% in 2003 to 8% in 2006.
A follow up survey among bar workers in 2006 in Scotland showed significant reduction of
serum cotinine levels of 105 employees from 5.15 ng/mL before the smoke-free policy to respectively 3.22ng/mL after one month and 2.93 ng/mL after two months13.
In Lexington in the United State, after smoke free Law was enacted in 2004, a measurement of exposure showed that the median nicotine level among 105 restaurants and bar workers reduced from 1.71 ng/mg to 0.75 ng/mg after 3 months. When analysing the data controlling for cigarette smoke per dayin workers who currently were smokers, the decline in hair nicotine was still significant with 1.79 ng/mg before and 1.30ng/mg after the law was introduced. The results explained the reduction in exposure to second-hand smoke at works of those smokers. These changes were more significantly in non – smokers compared to smokers. Second-hand exposure reduction was also indicated by self - reporting. The average number of hours workers exposed to second – hand smoke in the last 7 days reduced significantly from 31 hours per week to 1 – 2 hours per week even though there were no change in number of working hours perday14. A study conducted in Rome, Italy in 40 public places including bars, pubs, restaurants, fast food restaurants and game rooms before and after smoking ban showed that the quality of air improved significantly after smoke free Law. Level of PM2.5 (fine particles in the air 2.5 micrometres or less in size) decrease dramatically from 119.3 mg/m3to 38.2 mg/m3 after 3 months (p<0.005), and to 43.3 mg/m3 after 12 months (p<0.01), the level of ultrafine particles with a diameter <0.1 mm also decreased significantly from 76,956 particles/cm3 to 38,079 particles/cm3 (p<0.0001) after 3 months and then to 51,692 particles/cm3 (p<0.01) after 12 months.
Measurement of urinary cotinine among non- smoking workers also showed the decrease 3 months and 12 months after implementing smoke free Law15. A study of Michigan bar workers also showed significant reduction of second - hand smoke biomarkers after Smoke free Law was enacted16.
The reduction of exposure to second-hand smoke at work and public places lead to improvement in health status of non-smokers.
Different studies show decreases in reporting of ill health especially respiratory and cardiovascular diseases.
A study by Menzies et al.13of 105 bar workers showed reduced reporting of respiratory or sensory symptom from 79.2% to 53.2% and 46.8% after one and two months implementing smoke free at bars in Scotland. The difference was statistically significant. This study also showed improvement in quality of life of employees in an asthma group with the Juniper Mini Asthma Quality of Life score increased by 7.3 points (95% CI, 0.1 to 14.6 points;
P=.049) after two months of the introduction of a smoke free environment. Clinical examinations also showed improvement of lung function and systematic inflammation indicators. The FEV1 (the volume exhaled during the first second of a forced expiratory maneuver) improved in the whole study group by 8.2% and significantly by 15.7% in asthma group. Changes in the absolute white blood cells were also identified as decreasing significantly after two months from 630 cells/μLto 410 cells/μL.
Similar results were also found in a survey in the United State in 105 bars and restaurant workers at 37 restaurants and 5 bars. For most of respiratory symptoms such as wheeze/whistle, dyspnea, phlegm, cough in
the morning and cough in the rest of day, there was a significant decrease in the prevalence of symptom over time. The reductions of symptoms were especially dramatically in cough in the morning and cough in the rest of the day and phlegm with the prevalence reduced nearly 50% after 6 months. Some sensory symptoms likered, runny, irritated eyes, irritated and scratchy, sore throat also reduced significantly14.
Measurement of the incidence of Asthma admissions to emergency department 40 months before and 32 months after the enforcement of smoke free Law in Lexington County showed reduction in asthma admissions. After adjusting for demographic, trend and seasonal factors, the relative risk of asthma visit after versus before the law was 0.78 (CI 95% was 0.71 to 0.86, P <0.0001).
The decrease in adults was 24% while that of children was 18%. Reduction in visits among adults, children and combined group were statistically significant17.
Beside respiratory diseases, smoke free environment also contributed to the decrease of incidence of other diseases such as cardiovascular disease. A quasi – experimental study in two cities showing the reduction of Coronary Heart disease admissions in the intervention city, Bowling Green, in Ohio, United State from 36 per 10,000 populations in 2002 to 22 per 10,000 populations in 2003 and to 19 per 10,000 populations in the first half of 2005; the differences were statistically significant. In the control city, Kent, another city of Ohio, there was no significant change during the same period. There were no changes in non- smoking-related diseases’ admissions in both cities18.
A study among the US worker using Monte Carlo simulation estimated that, by applying smoke free policies in the US, there would be 1540 myocardial infarctions and 360 strokes prevented in the first year. Total deaths prevented in the first year would be 480 deaths due to myocardial infarction and 130 deaths due to stroke. Among those, passive smoking effects would be 59% of the total myocardial infarction and 61% of the total deaths due to myocardial infarction19. Results of this study showed that not only non-smokers but also smokers benefited regarding health outcomes from smoke free workplaces. Similar results were also found in the study of Richiardi L. et al.20. There was estimation of acute myocardial infarction reduction of 5 – 15% in non-smokers if smoke free law was implemented.
Beside respiratory and cardiovascular diseases, smoke free implementation was expected to reduce the risk of lung cancer. A report on Tobacco Control update in California showed that during the period from 1988 and 2004 when California State introduced smoke free Law, the rates of lung and bronchial cancer reduced four times faster compared to other states in the United State11.
In Vietnam, when using a model to estimate the effectiveness of Tobacco Control Policies, with around 65% of workforces in agriculture, a labour participation rate in the country population of 65% and assuming effectiveness was 50%, it was estimated that a comprehensive smoke free law would save 3111 male and 117 female lives per year by 2033 and smoke free policies would have immediate effect compared to other policies like taxpolicies21.
IMPACT OF SMOKE FREE
ENVIRONMENT ON SMOKING AND CESSATION
Smoke free implementations not only benefit non-smokers by protecting them from second - hand smoke but also help smokers to reduce their tobacco use and to quit smoking11. A three year follow up study in staff of different hospitals in France showed that after implementing smoke free law in hospitals, 71.6% of smokers in Marseille hospitals reported a reduction in their cigarette consumption and among them 48% reduced half of the daily consumption22. Other studies in hospital settings also found the reduction of smoking prevalence and cigarette consumptions of workers23, 24.
Results from a quasi - experimental study also showed that after implementing a smoke free environment, there was a decline of 31.9% of smokers in Fayette County, compared to 2.8%
decline in 30 other controlled counties in the United States. These changes werestatistically significant25. Similar results were found in a study involved school teachers in Japan where 15.4% of smokers successfully quit smoking after 9 months (from 13% to 11%) and a number of heavy smokers also reduced their consumption26. In the university setting, smoke free environments also had positive impact on smoking behaviours of students. A longitudinal in Indiana University and Purdue University, USA showed that total ban policy in all indoor and outdoor areas of Indiana University resulted in a significant reduce of prevalence of tobacco use as well as number of cigarette among current smokers after two years27.
There was an argument from the tobacco industry and concerns from policy makers that implementing of a smoke free environment at the workplace and public places might lead to
an increase in smoking at home and thus increase the prevalence of children exposed to second - hand smoke. However, a study in four European countries showed that there were relatively increase in total home smoking ban in Ireland, France, Germany and the Netherlands (25%, 17%, 38% and 28%
respectively). The changes among post and pre legislations were statistically significant28. Smoke free implementation also leads to a reduction in smoking at home from 20% in all households in 2003 to 9% in 2006, thus increase the percentage of smoke-free homesfrom 64%
(2003) to 70% (2006) in New Zealand12.
ECONOMIC IMPACT OF SMOKE FREE ENVIRONMENT
Smoke-free environments do not harm business and they save the cost for treatment of smoking and SHS related diseases11.
Research in New Zealand also showed that the per capita release of tobacco onto the New Zealand market (a marker for overall consumption) was constant from 2003 to 2005.
Even though there was a slight decline in supermarket tobacco sales after the law change, there was no change in total sales within the liquor retailers, accommodation sector (hotel), pubs, bars, cafes and restaurants and a slight increase of the number of overseas visitors to New Zealand with an increase inexpenditure from 1.5% to 3.3% in 200512. These results showed that there was no evidence of negative economic effects to the hospitality industry when applying smoke free environment in New Zealand. Similar results also found in studies in Argentina29and Ohio, the United State30.
Monitoring in New York city after the Smoke free laws became effective in 1995 showed
that even though smokers dining out less and spending less timeat dinners after the Smoke Free Act was enacted, restaurants in New York city did not suffer any negative economic effect. The reason was that non-smokers, the majority group, spent more time and went more often to restaurants after smoke free environments set up31. Another study in this city also showed that the Act did not harm employment in hospitality sector in New York32. The rates of growth in number of restaurants and new restaurant jobs in New York City were as fast as in other neighbouring counties and other parts of the United States.
When accounting for the cost of diseases saved by setting up smoke free environment, a study in the United States found that after implementing smoke free workplaces, nearly 280 million US dollars were saved when just accounting onlyfor myocardial infarction and
stroke after 7 years of implementation. And 61% of the saved money came from preventing myocardial infarctions in former passive smokers19.
CONCLUSION AND RECOMMENDATION Smoke free implementation posed significant impacts on improving quality of air at different settings. Health of non-smokers as well as smokers was also improved significantly.
Smoker free environment also supported smokers to reduce their consumption and to quit smoking.
Vietnam successfully passed Tobacco Control Law and sub Law documents, which regulated ban of smoking in different areas. The implementation of Law should be conducted in different settings strictly and evaluation measurement should also be implemented to improve the impacts of the Law.
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