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 2013
4. The epidemic of European smoke-free laws
Ireland
Norway
Malta
Italy
Sweden
Spain
Scotland
Denmark
Belgium
Wales
England
N. Ireland
Lithuania
Estonia
Portugal
Finland
Iceland
Slovenia
2004 2005 2006 2007 2008 2009 2010
Netherlands
France
Germany
Romania
Greece
Turkey
Bulgaria
Latvia
Spain
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. Nebot et al. Environ Health Perspect. 2009;117:344-7.
19. 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.
20. “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.”
21. Manel Nebot y Esteve Fernández (coords.)
Carles Ariza
Marcela Fu
Iñaki Galán
María José López
Jose M. Martínez
Albert Moncada
Agustín Montes
Mónica Pérez
Esteve Saltó
Anna Schiaffino
María Jesús Soriano
Working Group on Tobacco Control of the
Spanish Society of Epidemiology
http://www.seepidemiologia.es/monografia.pdf
Impact evaluation of the
“Tobacco Control Law”
22. 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
25. Prevalence of smoking in Spain
Bilal U, Fernández E, Beltrán et al. Am J Epidemiol. In press.
26. Economic impact
No. of persons employed in hospitality sector
Source: Active Population Surveys
Year
Thousandsofpersons
Restaurants Pubs & bars
27. 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.
28.
29. Manel Nebot y Esteve Fernández (coords.)
Carles Ariza
Marcela Fu
Iñaki Galán
María José López
Jose M. Martínez
Albert Moncada
Agustín Montes
Mónica Pérez
Esteve Saltó
Anna Schiaffino
María Jesús Soriano
Grupo de Trabajo sobre tabaquismo
Sociedad Española de Epidemiología
30. 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.
32. [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
34. 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.
36. 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
37.
38.
39.
40. The new smoke-free legislation
in 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
41. The new smoke-free legislation
in 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%)
43. 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!
44. 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
45. 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
47. PM2.5 concentrations in real time
0
200
400
600
800
1,000
1,200
1,400
0 200 400 600 800 1,000 1,200 1,400 1,600 1,800
PM2.5(µg/m3)
Time (seconds)
Pre-ban
Post-ban
48. 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
49. 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
50. Salivary cotinine concentration (ng/ml)
0.1 1 2 3 4 5 6 7 8 9 10
0
200
100
300
400
500
No.ofsamples
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
51. 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
52. 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(µg/m3)
Year
12.48
8.32
n=429 n=485
2009 2011
54. Sureda X, Fernández E, López MJ, Nebot M.
Secondhand Tobacco Smoke Exposure in Open
and Semi-Open Settings: A Systematic Review
Environmental Health Perspectives. 2013.
55. Figure 2. Outdoor PM2.5 concentrations reported for hospitality venues
and other settings according to the presence or absence of smokers.
56. 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
57. Figure 2. Indoors, entrances, and terraces PM2.5 concentrations in
32 bars and restaurants in Barcelona, Catalonia (Spain), 2013.
58. Figure 1. Indoors and entrance PM2.5 concentrations in 32 bars
and restaurants in Barcelona, Catalonia (Spain), 2013.
59. 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
60. Esteve Fernández, MD, PhD
efernandez@iconcologia.net
tobaccorelated.org
@stvfdz
bioinfo.iconcologia.net/tobacco
Tobacco Control Unit
Catalan Institute of Oncology