from partial to complete smoking bans -what we have learned in spain
DESCRIPTION
Presentation of the lessons learned by the Tobacco Unit of the Catalan Institut of Oncology on tobacco partial bans: It is better a total ban than a partial one. But if partial bans cannot be avoided, they have to be a first step towards total bans. Partial bans can be changed thorough action(s) joining scientists, consumers, policitians... Constant presence in mass media, forums, debates and creating alliances with policy decisors. It is not “a day” effort but a long-term run prevention of regressive changes after total bans. UCSF-CTCRE 13th September 2013TRANSCRIPT
From partial to complete smoking bans: What we have learned in Spain
Esteve Fernández, MD, PhD
2002
IARC classified secondhand smoke (SHS) as a type 1 carcinogen to humans
2003
WHO adopted the Framework Convention on Tobacco Control (FCTC)
The epidemic of European smoke-free laws
IrelandNorwayMalta
Italy Sweden
Spain Scotland
DenmarkBelgiumWales
EnglandN. IrelandLithuaniaEstoniaPortugalFinland IcelandSlovenia
2004 2005 2006 2007 2008 2009 2010
Netherlands France
Germany
RomaniaGreeceTurkey
BulgariaLatviaSpain
The smoke-free legislation in Spain (2006)
Law 28/2005 (January 1st, 2006)• publicity, sales, and promotion of tobacco products
• prohibition of smoking in enclosed public places, transportation, and indoor workplaces
The smoking ban in Spain (2006)
Exceptions in hospitality venues (bars, pubs, restaurants, cafeterias...) according to size:
• venues ≥100 m2: smoking banned but smoking areas allowed
• venues <100 m2: smoking prohibited or allowed according to owner’s decision
The “Spanish model”Philip Morris’ “accommodation” programmes
• “courtesy of choice”• “traditional hospitality”
Goldberg H. INTERNATIONAL ACCOMMODATION PROGRAMS. 1999. http://legacy.library.ucsf.edu/tid/trf19c00
The “Spanish model”• “Courtesy of Choice” to establish smoking and non-smoking rooms, using ventilation to accomplish separation
ACCOMMODATION AND SMOKING RESTRICTIONS 990000 PLAN. 1998. http://legacy.library.ucsf.edu/tid/opz37c00
The “Spanish model”• “Traditional Hospitality” to “establish Traditional Hospitality among affected market sector as a reasonable and practical way to accommodate their patron’s expectations regarding smoking”
ACCOMMODATION AND SMOKING RESTRICTIONS 990000 PLAN. 1998. http://legacy.library.ucsf.edu/tid/opz37c00
The “Spanish model”• “A Smoking Place”As a smoking lounge concept for large public spaces to demonstrate the “compatibility of indoor environmental quality and accommodating smoking”
Fernández E, Galán I. Spain: partial airport bans unacceptable. Tob Control. 2008;17(3):148
Tob Control. 2010;19(1):24-30.
http://www.dkfz.de/de/tabakkontrolle
The “Spanish model”
The “Spanish model”
http://www.biomedcentral.com/1471-2458/11/907
BMC Public Health. 2012; 11: 907
Accommodation Programmes
Countries (year) Designation of smoking and non-smoking venues
Separation into smoking and non-smoking rooms
“Traditional Hospitality” “Courtesy of Choice”
Spain (2006) ≤100 m2 (accessible area) >100 m2 (accessible area) Denmark (2007) ≤ 40 m2 > 40 m2
Austria (2008)One room venues with < 50 m2
(or 80 m2 if separation legally not feasible)
Venues with 2 or more rooms
Germany (2008) One room venues with < 75 m2 Venues with 2 or more rooms Greece (2009) ≤ 70 m2 > 70 m2 Croatia (2009) ≤ 50 m2 > 50 m2 Switzerland (2010) ≤ 80 m2 > 80 m2
The Netherlands (2010) ≤ 70 m2(if only operated by owner)
> 70 m2
Czech Republic (2010) All venues Smoking rooms without size specifications
Impact of tobacco industry’s accommodation programmes in smokefree legislation in Europe.
Schneider N, Sebrié E, Fernández E. The origin and failure of partial smoking bans and its impact in Europe and Latin America. BMC Public Health; 2012:11:907.
Accommodation Programmes
Countries (year) Designation of smoking and non-smoking venues
Separation into smoking and non-smoking rooms
“Traditional Hospitality” “Courtesy of Choice”
Chile (2006) ≤100 m2 Bars, restaurants & casinos >100 m2
Peru (2006) Venues >100 m2
Province of Buenos Aires, Argentina (2008) >400 m2 > 400 m2
Mexico (2008) Smoking rooms without size specification
State of Rio Grande do Sul, Brazil (2009)
Smoking rooms without size specification
Impact of tobacco industry’s accommodation programmes in smokefree legislation in Latin America.
Schneider N, Sebrié E, Fernández E. The origin and failure of partial smoking bans and its impact in Europe and Latin America. BMC Public Health; 2012:11:907.
How to promote a change?• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Supporting a positive social climate and acceptability of smoke-free legislation
• Getting support from key persons at the regional and national public health administration
• Promoting advocacy of politicians, citizens’ associations, trade unions, journalists, etc.
How to promote a change?• Fostering a scientific evaluation of the impact of
the partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability of smoke-free legislation
• Getting support from key persons at the regional and national public health administration
• Promoting advocacy of politicians, citizens’ associations, trade unions, journalists, etc.
Impact of the Spanish Smoking Law on Exposure to Secondhand Smoke in Offices and Hospitality Venues: Before-and-After Study
Nebot et al. Environ Health Perspect. 2009;117:344-7.
Nebot et al. Environ Health Perspect. 2009;117:344-7.
Impact of the Spanish Smoking Law on Exposure to Second-Hand Smoke and Respiratory Health in Hospitality Workers: A Cohort Study
Fernández et al. PLoS One. 2009;4:4244.
“Clearly, the results support a complete ban on smoking in all indoor places, including hospitality sector venues.”
“Policy makers in other countries currently considering the scope of their smoke-free legislation should not ignore these results.”
“Partial bans, (…) do not completely protect workers and others against second-hand smoke.”
Manel Nebot y Esteve Fernández (coords.)
Carles ArizaMarcela FuIñaki GalánMaría José LópezJose M. MartínezAlbert MoncadaAgustín MontesMónica PérezEsteve SaltóAnna SchiaffinoMaría Jesús Soriano
Working Group on Tobacco Control of theSpanish Society of Epidemiology
http://www.seepidemiologia.es/monografia.pdf
Impact evaluation of the “Tobacco Control Law”
Acceptability of the Law 28/2005 by the population (mean scores),
2005-2008
Ban in public places
Ban in pubs & taverns
Ban in restaurants
mean score
Source: Eurobarometer Surveys
Legal sales of cigarettes (per capita)
Source: Tobacco Market Commission
1978 1987 1993 1997 2001 2006 9 110
10
20
30
40
50
60
70Pr
eval
ence
(%)
Prevalence (%) of daily smokers, adults ( ≥16 y), Spain, 1978-2011.
Fernández E. SEE-SESPAS Conference 2011.
Men
Women
Prevalence of smoking in Spain
Bilal U, Fernández E, Beltrán et al. Am J Epidemiol. In press.
Economic impactNo. of persons employed in hospitality sector
Source: Active Population Surveys
Year
Thou
sand
s of
per
sons
Restaurants Pubs & bars
How to promote a change?• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability of smoke-free legislation
• Getting support from key persons at the regional and national public health administration
• Promoting advocacy of politicians, citizens’ associations, trade unions, journalists, etc.
Manel Nebot y Esteve Fernández (coords.)
Carles ArizaMarcela FuIñaki GalánMaría José LópezJose M. MartínezAlbert MoncadaAgustín MontesMónica PérezEsteve SaltóAnna SchiaffinoMaría Jesús Soriano
Grupo de Trabajo sobre tabaquismoSociedad Española de Epidemiología
How to promote a change?• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability of smoke-free legislation
• Getting support from key persons at the regional and national public health administration
• Promoting advocacy of politicians, citizens’ associations, trade unions, journalists, etc.
Law Enforcement Complaints, inspections and sanctions imposed by
period 2006-2008 in five Spanish regions
[The Department of] Health begins to impose penalties following the tobacco law
[The Department of] Health proposes a veto to tobacco in all bars and restaurants
J Epidemiol Community Health. 2013;67(7):542-3
How to promote a change?• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability of smoke-free legislation
• Getting support from key persons at the regional and national public health administration
• Promoting advocacy of politicians, citizens’ associations, trade unions, journalists, etc.
www.cnpt.es
www.xqnn.org • Promoting contacts with politicians• Being available to the media• Engageing celebrities and social leaders• Working with civil organizations• Disseminating in social networks
The new smoke-free legislationin Spain
Law 42/2010 (amends law 28/2005)
• smoking banned • in all enclosed hospitality places (bars,
restaurants, taverns, pubs, ...)• health care services and educational centers
(both indoors and outdoors) • outdoors children’s playgrounds
The new smoke-free legislationin Spain
Law 42/2010 (amends law 28/2005)
• a few exceptions --smoking rooms• mid- and long stay psychiatric services• nursing homes• prisions• rooms for smokers in hotels (up to 30%)
Fernández & Nebot. Tob Control. 2010;20(1):6-7.
After law 42/2010
After law 42/2010
• dissemination the new “Spanish model”• enforcement of the law• impact evaluation in terms of
• exposure to SHS• changes in morbility (asthma, CVD)• changes in smoking behaviour
• prevention of regressive changes!
Studies after law 42/2010
Nicotine and PM2.5 levels in hospitality venues after law 42/2010
Changes in SHS prevalence and cotinine levels in the population after law 42/2010
Changes in PM2.5 levels in hospitals (indoor/outdoor) after law 42/2010
SHS levels in selected outdoor settigs
López MJ, Fernández E, Pérez-Ríos M et al.
Impact of the 2011 Spanish smoking ban in hospitality venues: indoor secondhand smoke exposure and influence of outdoor smoking.
Nicotine & Tobacco Research. 2013.
Methods
• Design: pre-post evaluation
• Field work: Pre-ban: Oct-Des 2010; post-ban: May -July 2011 (post)
• Target: cafeterias, bars & pubs in Catalonia, Galicia, and Madrid
• Sample: 180 venues (semiprobabilistic multistage sample)
• SHS environmental markers: Airborne nicotine and PM2.5
Airborne nicotine concentration (µg/m3)
5.73
Reduction of 90.1%p<0.001
n=171
0.57
Pre-ban Post-ban
PM2.5 concentrations in real time
3711151923273135394347515559636771757983879195991031071111151191231271311351391431471511551591631671711751791831871911951992032072112152192232272312352392432472512552592632672712752792832872912952993033073113153193233273313353393433473513553593633673713753793833873913953994034074114154194234274314354394434474514554594634674714754794834874914954995035075115155195235275315355395435475515555595635675715755795835875915955996036076116156196236276316356396436476516556596636676716756796836876916956997037077117157197237277317357397437477517557597637677717757797837877917957998038078118158198238278318358398438478518558598638678718758798838878918958999039079119159199239279319359399439479519559599639679719759799839879919959991003100710111015101910231027103110351039104310471051105510591063106710711075107910831087109110951099110311071111111511191123112711311135113911431147115111551159116311671171117511791183118711911195119912031207121112151219122312271231123512391243124712511255125912631267127112751279128312871291129512991303130713111315131913231327133113351339134313471351135513591363136713711375137913831387139113951399140314071411141514191423142714311435143914431447145114551459146314671471147514791483148714911495149915031507151115151519152315271531153515391543154715511555155915631567157115751579158315871591159515991603160716111615161916231627163116351639164316471651165516591663166716711675167916831687169116951699170317071711171517191723172717311735173917431747175117551759176317671771177517791783178717911795179918031807181118151819182318271831183518391843184718511855185918631867187118751879188318871891189518991903190719111915191919231927193119351939194319470
200
400
600
800
1,000
1,200
1,400
Time (seconds)
PM
2.5
(µg
/m3)
Pre-ban
Post-ban
Changes in exposure of adult non-smokers to secondhand smoke after smoke-free legislation in Spain.Sureda X, Fernandez E, Fu M, Martínez-Sánchez J et al. Submitted.
Methods
• Design: repeated cross-sectional (independent) surveys
• Field work: pre (2004-05) and post (2011-12) ban
• Target: adult population (>16 y) in Barcelona, Spain.
• Sample: 1300 people in each survey
• Outcomes: Salivary cotinine and self-reported exposure to SHS
Self-reported exposure of non-smokers to SHS (%) before (2004-05) and after (2010-11) the Spanish smoke-free legislation
Self-reported exposure to secondhand smoke
n % of non-smokers exposed (95% CI)
Prevalence ratio* (95% CI)
Any setting Before the legislation 720 75.7 (72.6-78.8) 1 After the legislation 871 56.7 (53.4-60.0) 0.46 (0.40 to 0.54) Home Before the legislation 721 32.5 (29.1-35.9) 1 After the legislation 878 27.6 (24.6-30.6) 0.78 (0.65 to 0.94) Work/education venues Before the legislation 364 42.9 (37.8-48.0) 1 After the legislation 507 37.5 (33.3-41.7) 0.79 (0.63 to 0.98) Leisure time Before the legislation 723 61.3 (57.7-64.9) 1 After the legislation 872 38.9 (35.7-42.1) 0.38 (0.32 to 0.44) Transport (private or public) Before the legislation 693 18.2 (15.3-21.1) 1 After the legislation 807 10.9 (8.7-13.1) 0.50 (0.38 to 0.66) *Based on multivariate log-binomial models, adjusted for sex, age, and educational level
Salivary cotinine concentration (ng/ml)
0.1 1 2 3 4 5 6 7 8 9 100
200
100
300
400
500
No.
of s
ampl
es After legislation (n=878)Before legislation (n=724)
Salivary cotinine concentration (ng/ml) among the non-smoker adult population, before (2004-05) and after (2011-12) the smoke-free legislation, Barcelona (Catalonia), Spain
Reduction 90%p<0.001
Sureda X, Ballbè M, Martínez C, et al. Tobacco control policies in hospitals: evaluation of a national smoke-free campus ban. Submitted.
Measurement of PM2.5 as environmental SHS marker in:- 53 hospitals pre-ban (2009) - 60 hospitals post-ban (2011)
• 429 measurements in 2009• 485 measurements in 2011
PM2.5 concentration (µg/m3) for all locations combined in 2009 and 2011, Catalonia, Spain
20112009
40,00
30,00
20,00
10,00
0,00
PM2.
5 (µ
g/m
3 )
Year
12.48
8.32
n=429 n=4852009 2011
Location
OutsideConflict point
Main entrance, campus
Main entrance,
door
Dressing room
Fire escape
CafeteriaGeneral medicine
Emergency department
Hall
0,00
PM
2.5 (
µg/m
3)
30,00
20,00
10,00
PM2.5 concentration (µg/m3) by specific locations in 2011, Catalonia, Spain
WHO limit
Sureda X, Fernández E, López MJ, Nebot M.Secondhand Tobacco Smoke Exposure in Open
and Semi-Open Settings: A Systematic ReviewEnvironmental Health Perspectives. 2013.
Figure 2. Outdoor PM2.5 concentrations reported for hospitality venues and other settings according to the presence or absence of smokers.
Fu M, Fernández E, Martínez-Sánchez JM et al. Tobacco Second-Hand Smoke in Hospitality Venues:Indoor and Outdoor PM2.5 Concentrations.
(Preliminary results)
Methods:- Simultaneous measures indoors and outdoors (entrance) - PM2.5 and airborne nicotine- Observation of smokers’ behaviour - 32 bars and restaurants - April-July 2013
Figure 2. Indoors, entrances, and terraces PM2.5 concentrations in 32 bars and restaurants in Barcelona, Catalonia (Spain), 2013.
Figure 1. Indoors and entrance PM2.5 concentrations in 32 bars and restaurants in Barcelona, Catalonia (Spain), 2013.
Lessons learned(Better a total ban than a partial ban)• if partial bans cannot be avoided, they have to be a first step
towards total bans
• partial bans can be changed:
- join action(s) by scientists, consumers, policitians...
- constant presence in mass media, forums, debates
- alliances with policy decisors
- not “a day” effort but a long-term run• prevention of regressive changes after total bans
Esteve Fernández, MD, PhD
tobaccorelated.org
@stvfdz
bioinfo.iconcologia.net/tobacco
Tobacco Control UnitCatalan Institute of Oncology