15.8 Immediate impact of smokefree legislation in improving air quality

Experience both in Australia and internationally shows that smokers and non-smokers support and are readily able to comply with smokefree legislation, resulting in measurable improvements in air quality.

15.8.1 Support for legislation

 

The Cochrane Collaboration published a review in 2010 of 50 studies examining the impact of smokefree legislation.1 Compared with before bans, public approval for smokefree policies increased after implementation. Support for the legislation increased in nine of the studies reviewed (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'(p10).

15.8.2 Compliance with smokefree legislation

The Cochrane Collaboration review also concluded that compliance with smokefree legislation was very high.1 Nine studies 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'(p10).

An evaluation of a legislative ban on smoking inside restaurants, which compared smoking in Sydney restaurants (where legislative bans had been introduced six weeks prior to the study) with smoking in Melbourne restaurants (not subject to a legal ban), showed that compliance with smokefree legislation in restaurants was high; there were few ongoing difficulties for staff, and the laws attracted many more favourable than unfavourable comments from patrons and did not adversely affect trade. Since introduction of the legislation, 76% of restaurants reported normal trade, 14% increased trade, and 9% reduced trade.2

Research conducted on behalf of the Queensland Government following the introduction of new amendments to strengthen smokefree legislation in 2006 revealed that the vast majority of smokers (85%) reported they had 'completely stopped smoking in all areas where it is illegal to smoke at all times' and two-thirds (67%) were 'smoking less in public spaces'(p4).3

Data from the Australian arm of the International Tobacco Control Policy Evaluation Project examined attitudes towards and compliance with Australian legislation prohibiting smoking in licensed venues.4 Three states (Queensland, Tasmania and Western Australia) implemented a total ban on smoking in all enclosed licensed premises in 2006, and two others (Victoria and New South Wales) did so in mid-2007. Following the introduction of the bans, more than 90% of smokers reported they were complying with the bans. Attitudes towards the legislative bans became more positive in the year before the ban, and more than doubled in the year the bans were implemented.4

Research from New Zealand shows evidence of high compliance with smokefree legislation in workplaces, including bars and pubs—where most enforcement problems had been expected. The research also showed increased support for smokefree legislation and its underlying principles among the public and bar managers following implementation of smokefree law.5

A 2009 study examined the impact of smokefree legislation in Scotland and compared it to the rest of the UK, where no ban was in place at that time. The study showed dramatic declines in the observance of smoking in pubs, restaurants and workplaces compared to the rest of the UK.6 Support for smokefree policies increased to a greater extent in Scotland than in the rest of the UK and despite predictions from some segments of the hospitality industry, there was no evidence of a significant decline in patronage of pubs and restaurants following the ban. Self-reported frequenting of pubs and restaurants was generally comparable between Scotland and the rest of the UK; however non-smokers in Scotland were more likely to frequent pubs more often following the smoking ban.6

15.8.3 Improvements in air quality resulting from smokefree legislation

Levels of respirable suspended particles (RSP) are an important marker of secondhand smoke (SHS) and many studies have demonstrated significantly lower levels of RSP in smokefree hospitality venues compared with venues that allowed smoking. Eight studies in the 2010 Cochrane Collaboration Review1 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. At least three further studies published since the review confirms this finding.7–9

There is also evidence that comprehensive legislation results in improvement in sensory and respiratory symptoms associated with exposure to SHS.1,10,11

A Scottish study—the largest evaluation of the effect of smokefree legislation on air quality inside pubs—found substantial improvement in air quality in pubs,12 a pattern that was repeated following the introduction of similar bans in England and in Wales.7 After the smoking ban, many pubs had air particulate levels similar to those found in the ambient outside air.

In its comprehensive review of evidence concerning the effectiveness of smokefree policies, the International Agency for Research on Cancer found that evidence internationally was 'sufficient' (p 260)—that is, 'an association has been observed in studies in which chance, bias and confounding can be ruled out with reasonable confidence. The association is highly likely to be causal' (p259).13

15.8.3.1 Partial restrictions are ineffective

To be effective, smokefree legislation must be comprehensive. Partial smoking restrictions can deliver some improvements in air quality, but do not sufficiently protect the public or hospitality workers from the effects of SHS.14,15 For example, smokefree laws in Spain introduced in 2006 affected all enclosed workplaces except hospitality venues, whose proprietors could choose among a totally smokefree policy, a partial restriction with designated smoking areas, or no restriction on smoking on the premises. An evaluation of the impact of these laws showed that salivary cotinine levels decreased by 56% after the ban among non-smoking workers in venues where smoking was totally prohibited. Cotinine concentrations decreased by only 28% among workers in venues with designated smoking areas, and by only 11% among workers in venues where smoking was allowed.8

A 2009 US study also clearly demonstrated the ineffectiveness of partial smokefree air laws. The study examined the impact of complete and partial smoking bans in seven Kentucky communities. The impact of different strengths of smokefree air laws on indoor air quality was assessed. When comprehensive smokefree air laws were implemented, indoor particulate matter PM(2.5) concentrations decreased significantly from 161 to 20 mcg/m(3). In one community that implemented a comprehensive smokefree law after initially passing a partial law, indoor PM(2.5) concentrations were 304 mcg/m(3) before the law, 338 mcg/m(3) after the partial law, and 9 mcg/m(3) after the comprehensive law.9

15.8.3.2 Comprehensive bans are effective

Following implementation of smoking bans in restaurants and bars in 2007 in Washington D.C, a 2009 study by Pearson et al found sensory symptoms reported four weeks after the ban declined by 70%–100% and employee saliva cotinine levels declined significantly by 70%.10

A study of 106 randomly selected bars in Scotland, England and Wales before and after the introduction of smoking restrictions found that prior to legislation, PM(2.5) concentrations within bars across the UK were much higher than the 65 mcg/m(-3) 'unhealthy' threshold for outdoor air quality as set by the US Environmental Protection Agency. Legislation in all three countries produced improvements in indoor air quality with the median reduction ranging from 84% to 93%. Personal exposure reductions for bar staff were also within this range. There was also evidence that bars located in more deprived postcodes had higher PM(2.5) levels prior to the legislation.7

15.8.3.3 Smoke drift must be minimised

Smoke drift from outdoor smoking areas where smoking is allowed can compromise the air quality of smokefree areas indoors.1 To address the issue of smoke drift, legislation in most Australian jurisdictions contains provisions to require the occupier of the premises to take reasonable steps to prevent smoke from entering no-smoking areas, including any neighbouring premises. This may require that smoking not occur in some outdoor (unenclosed or enclosed) public places, such as areas near to windows, doorways and air intakes.16

In 2010, Brennan et al examined the extent to which SHS drifts from outdoor smoking areas to adjacent indoor areas. The study found that indoor particulate matter less than 2.5 mum in diameter PM(2.5) concentrations reduced by 66% from pre-ban to post-ban. Following the ban, indoor concentrations of PM(2.5) were positively associated with outdoor concentrations of PM(2.5). A 100% increase in mean outdoor PM(2.5) was associated with a 36% increase in mean indoor PM(2.5) exposure. The study concluded that indoor smoking bans are an effective means of improving air quality in pubs and bars, although the air quality of smokefree indoor areas may be compromised by smoking in adjacent outdoor areas.17

Recent news and research

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Reference

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2. Chapman S, Borland R and Lal A. Has the ban on smoking in New South Wales restaurants worked? A comparison of restaurants in Sydney and Melbourne. Medical Journal of Australia 2001;174(10):512–5. Available from: http://www.mja.com.au/public/issues/174_10_210501/chapman/chapman.html

3. Queensland Health. Review of smokefree laws: discussion paper. Brisbane, Australia: Government of Queensland, 2007. Available from: http://www.health.qld.gov.au/tobaccolaws/documents/33161.pdf

4. Cooper J, Borland R, Yong H and Hyland A. Compliance and support for bans on smoking in licensed venues in Australia: findings from the International Tobacco Control Four-Country Survey. Australian and New Zealand Journal of Public Health 2010;34(4):379–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20649778

5. Edwards R, Thomson G, Wilson N, Waa A, Bullen C, O'Dea D, et al. After the smoke has cleared: evaluation of the impact of a new national smoke-free law in New Zealand. Tobacco Control 2008;17(1):e2. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/17/1/e2

6. Hyland A, Hassan L, Higbee C, Boudreau C, Fong G, Borland R, et al. The impact of smokefree legislation in Scotland: results from the Scottish ITC Scotland/UK longitudinal surveys. European Journal of Public Health 2009;19(2):198–205. Available from: http://eurpub.oxfordjournals.org/cgi/content/full/ckn141v1

7. Semple S, Van Tongeren M, Galea K, Maccalman L, Gee I, Parry O, et al. UK smoke-free legislation: changes in PM2.5 concentrations in bars in Scotland, England, and Wales. Annals of Occupational Hygiene 2010;54(3):272–80. Available from: http://annhyg.oxfordjournals.org/cgi/reprint/mep094v3

8. Fernández E, Fu M, Pascual J, López M, Pérez-Ríos M, Schiaffino A, et al. Impact of the Spanish smoking law on exposure to second-hand smoke and respiratory health in hospitality workers: a cohort study. PLoS One 2009;4(1):e4244. Available from: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0004244

9. Lee K, Hahn E, Robertson H, Lee S, Vogel S and Travers M. Strength of smoke-free air laws and indoor air quality. Nicotine and Tobacco Research 2009;11(4):381–6. Available from: http://ntr.oxfordjournals.org/cgi/content/abstract/ntp026v1

10. Pearson J, Windsor R, El-Mohandes A and Perry DC. Evaluation of the immediate impact of the Washington, D.C., smoke-free indoor air policy on bar employee environmental tobacco smoke exposure. Public Health Reports 2009;124(suppl. 1):S134–42. Available from: http://www.hivatlas.org/blog/classifieds/11059-evaluation-immediate-impact-washington-dc-smoke-free-indoor-air-policy-bar-em

11. Jensen J, Schillo B, Moilanen M, Lindgren B, Murphy S, Carmella S, et al. Tobacco smoke exposure in nonsmoking hospitality workers before and after a state smoking ban. Cancer Epidemiology, Biomarkers & Prevention 2010;19(4):1016–21. Available from: http://cebp.aacrjournals.org/content/19/4/1016.long

12. Semple S, Creely K, Naji A, Miller B and Ayres J. Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation. Tobacco Control 2007;16(2):127–32. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/16/2/127

13. International Agency for Research on Cancer. Evaluating the effectiveness of smoke-free policies. Handbooks of cancer prevention, tobacco control, vol. 13. Lyon, France: IARC, 2009. Available from: http://com.iarc.fr/en/publications/pdfs-online/prev/handbook13/

14. Reijula J and Reijula K. The impact of Finnish tobacco legislation on restaurant workers' exposure to tobacco smoke at work. Scandinavian Journal of Public Health 2010;38(7):724–30. Available from: http://sjp.sagepub.com/content/early/2010/08/04/1403494810379168.long

15. Erazo M, Iglesias V, Droppelmann A, Acuña M, Peruga A, Breysse PN, et al. Secondhand tobacco smoke in bars and restaurants in Santiago, Chile: evaluation of partial smoking ban legislation in public places. Tobacco Control 2010;19(6):469–74. Available from: http://tobaccocontrol.bmj.com/content/19/6/469.abstract

16. Smoke-Free Public Places Act 2003 (ACT) Available from: http://www.legislation.act.gov.au/a/2003-51/current/pdf/2003-51.pdf

17. Brennan E, Cameron M, War ne C, Durkin S, Borland R, Travers M, et al. Secondhand smoke drift: examining the influence of indoor smoking bans on indoor and outdoor air quality at pubs and bars. Nicotine and Tobacco Research 2010;12(3):271–7. Available from: http://ntr.oxfordjournals.org/cgi/content/full/ntp204v1

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