Professor Cecily C Kelleher and Dr Kate Frazer

1. Have smoking bans after WHO
Framework Convention on Tobacco
Control worked in reducing harms of
passive smoking?
Professor Cecily C Kelleher 1,2, Dr Kate Frazer3
UCD School of Public Health, Physiotherapy and Sports Science 1, Department of
Preventive Medicine & Health Promotion, St Vincent’s University Hospital 2,
UCD School of Nursing, Midwifery and Health Systems 3,
Belfield, Dublin 4, Republic of Ireland

2. In this talk
• Brief background and context
• Findings of Cochrane systematic reviews of 2010 and update
of 2016 on impact of legislative smoking bans
• Total smoke free hospital campus ban: an example from
Dublin, Ireland
• Cochrane systematic review 2016 on impact of institutional
bans
• Commentary and conclusions

3. FRAMEWORK CONVENTION ON TOBACCO
CONTROL (FCTC)
FCTC is the first international treaty negotiated under the auspices of WHO
It is an evidence-based treaty that represents a milestone for the
promotion of public health
Provides new legal dimensions for international health cooperation
Since the treaty entered into force in 2005, it has become one of the most
rapidly and widely embraced treaties in the history of the United Nations.
Dr Margaret Chan, Tobacco Atlas 2015:4

4. FCTC – why it is required……
Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J.,(2015). The Tobacco
Atlas: revised, expanded, and updated. Atlanta, USA: American Cancer Society.

5. Growth of Support
Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J.,(2015). The Tobacco Atlas: revised, expanded,
and updated. Atlanta, USA: American Cancer Society.

6. The Tobacco Atlas Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J., (2015). The
Tobacco Atlas: revised, expanded, and updated. Atlanta, USA: American Cancer Society.
Smoke-free laws
Smoke-free legislation by income level; High, middle,
low income countries, 2012

7. An International smoking ban-how many lives
will be saved?
Kelleher CC, Frazer K. Curr Atheroscler Rep. 2014 Jun;16(6):418. doi: 10.1007/s11883-014-0418-0. Review. PubMed PMID: 24771033.
• Multi-component tobacco
strategies are crucial to combat the
ongoing global smoking challenge
• In the 21st century, many countries
have signed up to the WHO
Framework Convention on Tobacco
Control (FCTC)
• Several reports have appeared from
different countries showing a
temporal relationship between
smoking bans and reduced hospital
admissions
• This will have a measurable benefit
for public health, saving many lives

8. Legislative Smoking Bans:
Levels of Impact
• Macro: Policy level
intervention
• Meso: Institutional or
settings level intervention
• Micro: Individual or inter-
personal level interventionLegislative
Smoking
Bans
MACRO
MESOMICRO

9. Legislative Smoking Bans
Callinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992.
• Studies reporting legislative
smoking bans affecting
populations
• Minimum standard was a ban
explicitly in the study
• Minimum follow-up of six
months for measures of
smoking behaviour
• RCTs, Quasi-experimental,
Controlled before-after,
interrupted time series (ITS)
designs

10. AIM: Assess the extent to which legislation-
based smoking bans or restrictions:
Callinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992.
Reduce
exposure to
Second-hand
smoke (SHS)
Help people
who smoke to
reduce tobacco
consumption/
prevalence
Affect health
of those in
areas which
have a ban or
restriction in
place
Cochrane Tobacco Addiction Group Specialised
Register, MEDLINE, EMBASE, PsychINFO, CINAHL,
Conference Paper Index, reference lists , bibliographies
– up to 2009

11. Evidence in Review
Callinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992.
50 studies – all
SHS exposure(19
with biomarkers)
12 studies
Cardiac
ACS
12 studies
Respiratory
Health
outcomes
Lung function
5 studies
SHS cars
Tobacco
consumption
Cotinine
15 studies
SHS homes
Tobacco
consumption
Cotinine
23 studies
Active
smoking
Smoking prevalence
Tobacco
consumption
Population-level
13 Quasi
experimental
37 uncontrolled
before and after

12. Evidence 2010
Smoking bans
reduced
exposure to SHS
in workplaces,
restaurants, pubs
and in public
places
Greater
reduction in
exposure to SHS
in hospitality
workers
compared to
general
population
No difference in SHS
exposure in cars
No change in either
the prevalence or
duration of SHS in the
home
No consistent
evidence of a
reduction in
smoking
prevalence
Callinan et al, Cochrane Database Syst
Rev. 2010 Apr 14;(4):CD005992:
Following introduction of legislative
smoking bans:
• Evidence for reduced second hand
smoke exposure clear
• Some emerging evidence for
reduced admissions for acute
coronary syndrome (ACS)
• Limited evidence impact on active
smoking rates

13. Updated Review 2016

14. Legislative Smoking Bans
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C.
Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
PICO
• Population: Smokers and non-
smokers
• Intervention: Comprehensive
or partial smoking bans
implemented by legislation
• Comparison: No bans
• Outcomes: health outcomes
associated with second-hand
smoke exposure. Active
smoking, tobacco
consumption
Eligibility Criteria
• Settings: Country, Region or State
• Minimum standard was having indoor
smoking ban explicitly stated in the
study
• 6 months follow up period
• Measured health outcomes
• Population smoking prevalence rates

15. Evidence
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C.
Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
A number of studies provided evidence for multiple outcomes
77 studies
44 studies
Cardiovascular
ACS / AMI
Stroke
21 studies
Respiratory
Asthma
COPD
Lung function
7 studies
Perinatal
LBW
Pre term birth
Maternal
smoking
11 studies
Mortality
Smoking
related deaths
24 studies
Active smoking
Smoking prevalence
Tobacco consumption
Population-level
36 ITS
23 Controlled before
and after
18 uncontrolled
before and after

16. Cardiovascular Evidence
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C.
Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
44 studies
Consistent
evidence
ACS/ AMI
33 studies
Consistent
evidence
Stroke
5 studies
Reductions in
admissions for
smokers and
non smokers
43 studies
Cardiac
38 Cardiac
5 Cardiac &
Stroke
6 studies
Stroke
Multiple methods
ITS, Controlled before and
after studies,
Uncontrolled before and
after studies

17. Evidence in Update
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb
4;2:CD005992
Respiratory
21 studies
Reductions in
asthma & COPD
admissions
Lung function
improved
Evidence not
consistent across all
studies for asthma
or COPD
Perinatal
7 studies
Evidence of
reductions in LBW
and pre term birth
Reduction maternal
smoking
Evidence not
consistent
Mortality
11 studies
Reductions in
mortality rates
consistent in 8
studies
Active
Smoking
24 studies
Inconsistent
evidence

18. Features of the Evidence Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K,
Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
Bias
Use of data
sets
Unverified
smoking status
Sample sizes
Statistical
modelling

19. Acute Coronary Syndrome/ Acute Myocardial
Infarction outcomes
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
UK and Ireland International evidence
Cronin et al. (2012) Ireland
12% reduction in ACS admissions in 1st year after ban.
ACS admissions reduced from 34% in 2003 to 29% in 2009.
Aguero et al. (2013) Spain
REGICOR study. 11% reduction in AMI rates.
Kent et al. (2012) Ireland
18% reduction in ACS admissions in those aged 50 to 55 years and aged 60 to 69
years
Alsever et al. (2009) USA
19% reduction in AMI admissions post ban. No
change in controls.
Liu et al. (2013) England
Age-adjusted rates for MI admissions fell by 42% (39–45%) overall.
41.6% in men and by 42.6% in women
Barone Adesi et al. (2011) Italy
4% reduction in ACS in aged <70 years
Pell et al.(2008) Scotland
ACS admissions reduced 14% smokers, 19% in ex smokers and 21% in non
smokers.
Di Valentino et al. (2015) Switzerland
Reductions in `STEMI admissions from 123.7/100,000
to 89.6/100,000
Schmucker et al. (2014) Germany
16% reduction in STEMI admissions overall. 26%
reduction in non smokers
Sebrie (2014) Uruguay
17% reduction in AMI admissions

20. UK and Ireland Studies in Review
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
England Scotland Ireland
Lee et al. (2011) Smoking
prevalence
Jones et al. (2015)
Scotland and England
smoking prevalence
Cronin et al. (2012) ACS
admissions
Liu et al. (2013) CHD
admissions
MacKay et al. (2010) Asthma
admissions
Goodman et al. (2007) Lung
function
Millett et al.(2013)
Asthma admissions
MacKay et al. (2011) Smoking
prevalence
Kabir et al. (2009) Maternal
smoking and perinatal
outcomes
Sims et al. (2013)
Asthma admissions
MacKay et al. (2012) Peri
natal outcomes & maternal
smoking
Kabir et al. (2013) Perinatal
outcomes
MacKay et al. (2013) Stroke Kent et al. (2012) ACS
admissions
Pell et al. (2008) ACS
admissions
Stallingsmith (2013)
Mortality rates
Pell et al. (2009) Mortality
rates

21. Stroke Outcomes
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
Stroke outcomes Examples
Mackay 2013 Scotland 8.9% reduction in admissions for
cerebral infarction post ban
Loomis 2012 USA 5.2% reduction in admissions in
Florida
Herman USA 14% reduction in admissions in
counties with ban compared to no ban

22. Implications for practice
•Countries and populations benefit from enacting national
legislative smoking bans
 Evidence (Moderate)
 Improved health outcomes, specifically cardiovascular disease.
 Evidence (Low)
 Reduced mortality rates for smoking related illnesses.
Evidence (Low)
 Improved perinatal and respiratory health outcomes.
 Reductions in tobacco consumption.

23. Implications for Research
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
• Additional research with longer term impact on health
outcomes in sub groups of the population
Young children
Disadvantaged and minority groups
• More research on health impact of smoking bans
Respiratory health
Perinatal health
Active smoking
• More systematic indicators to allow for quantifying effects

24. Key Message
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
Introduction of a legislative smoking ban leads to
improved health outcomes through a reduction in
second-hand smoke exposure for countries and their
populations

25. St Vincent’s University Hospital, Partner to
University College Dublin

26. Implementation of a campus-wide Irish hospital smoking ban in
2009: prevalence and attitudinal trends among staff and patients in
lead up.
Fitzpatrick P, Gilroy I, Doherty K, Corradino D, Daly L, Clarke A, Kelleher CC. Health Promot Int. 2009 Sep;24(3):211-22.
• Three separate data sources, 8 staff
and patient surveys between 1997-
2006, 1-week observational survey
in smoke shelters and attitudinal
interviews with patients and staff
• Smoking rates in patients remained
steady but declined in staff
• Those using shelters were mainly
women and staff members
• Early majority tipping point support
for implementing total smoke-free
campus ban

27. Smoke-Free Campus Policy
Fitzpatrick et al, Health Promo Int 2009; 24(3): 211-22
2006
Survey of staff
and patients
2007
Commitment of
Senior
management
Legal advice sought
Meetings with Trade
Unions & other
stakeholder groups
2008
Steering Group:
Senior
Management
Project group:
All stakeholders
Implementation &
Communication plan
2009
1st January 2009
SMOKE FREE
CAMPUS POLICY
INITIATED
2010
One year post-
introduction
evaluation
Survey of staff
and patients

28. Smoke free hospital campus: Strong positive shift in
attitudes post implementation but paradox in nursing
and medical attitudes
Fitzpatrick P, Gilroy, I, Doherty K, Clarke A, Comerford D, Daly L, Kelleher C. Clinical Health Promotion 2012 Apr;2 (1): 12-16
• Significant fall in smoking rates
in staff (17.8% v 10.7%; p=0.02)
but not patients (22.7% v
18%;NS)
• Positive shift in attitude of
patients (58.6%v 84.2%;
p<0.001) and staff (52.4% v
83.3%; p<0.001)
• Nurses more likely than other
groups, including doctors, to
agree they had a role in
implementation

29. National and International Impact: ENSH
Award Fitzpatrick P, Gilroy I, Doherty K, Conlon G, Daly L, Kelleher C. Exempting patients from a smoke-free hospital policy on compassionate grounds.
BMJ. 2014 Jan 21;348:g389

30. New Evidence 2016
Search Strategy 2005 to 2015
• Cochrane Central Register of Controlled
Trials (CENTRAL);
• MEDLINE,
• EMBASE,
• Reference lists of identified studies

31. Institutional Ban Evidence
Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure.
Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
Complete or partial
smoking bans
National legislative ban
No National legislative ban
Healthcare facilities
Third level education
institutions
Prisons / correctional
facilities

32. Observational level data
Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure.
Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
17 studies
12 hospitals
Active Smoking Mortality
3 Prisons
Mortality
Active smoking
2 Universities
Active smoking
3 controlled before
and after studies
14 uncontrolled
studies

33. Evidence of institutional policies
Frazer K, McHugh J, Callinan JE, Kelleher C. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
• No change patient smoking rates
• Reduction in staff smoking rates
• Reduction in SHS exposure
Hospitals
• No evidence reduction in prevalence
• Reduction in mortality rates
• Reduction in SHS exposure
Prisons
• Reduction in smoking rates
• Reduction in SHS exposureUniversity

34. Impact of institutional smoking bans on reducing harms and
secondhand smoke exposure
Frazer K, McHugh J, Callinan JE, Kelleher C. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856

35. Evidence of impact on active smoking rates
Frazer K, McHugh J, Callinan JE, Kelleher C. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
11
Observational
Studies pooled
data
N=12,485
Heterogeneity
evident

36. Quality of Evidence for institutional smoking
bans
• We found evidence of an effect of
settings-based smoking policies on
reducing smoking rates in hospitals
and universities.
• In prisons, reduced mortality rates
and reduced exposure to
secondhand smoke were reported.
• However, we rated the evidence
base as low quality using GRADE
criteria, as all studies observational
• We therefore need more robust
studies assessing the evidence for
smoking bans and policies in these
important specialist settings.
Quality of
evidence low
Impact of national bans V
no national bans not
consistent – weak
evidence / heterogeneity
Inconsistent
evidence and
confidence in
effect is limited

37. Implications for Practice and Research
Settings bans components of multifactorial tobacco control
activities
Further robust studies using control groups and longer
follow up

38. References
Callinan JE, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure,
smoking prevalence and tobacco consumption. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992. doi:
10.1002/14651858.CD005992.pub2. Review. Update in: Cochrane Database Syst Rev. 2016;2:CD005992. PubMed
PMID: 20393945.
Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J.,(2015). The Tobacco Atlas: revised, expanded, and
updated. Atlanta, USA: American Cancer Society.
Fitzpatrick P, Gilroy I, Doherty K, Corradino D, Daly L, Clarke A, Kelleher CC. Implementation of a campus-wide Irish
hospital smoking ban in 2009: prevalence and attitudinal trends among staff and patients in lead up. Health Promot
Int. 2009 Sep;24(3):211-22. doi: 10.1093/heapro/dap020. PubMed PMID: 19531558.
Fitzpatrick P, Gilroy, I, Doherty K, Clarke A, Comerford D, Daly L, Kelleher C. Smoke free hospital campus: Strong
positive shift in attitudes post implementation but paradox in nursing and medical attitudes. Clinical Health
Promotion 2012 Apr;2 (1): 12-16.
Fitzpatrick P, Gilroy I, Doherty K, Conlon G, Daly L, Kelleher C. Exempting patients from a smoke-free hospital policy on
compassionate grounds. BMJ. 2014 Jan 21;348:g389. doi: 10.1136/bmj.g389. PubMed PMID: 24448418.
Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand
smoke exposure. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856. doi: 10.1002/14651858.CD011856.pub2.
Review. PubMed PMID: 27230795.
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing
harms from secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database Syst
Rev. 2016 Feb 4;2:CD005992. doi: 10.1002/14651858.CD005992.pub3. Review. PubMed PMID: 26842828.
Kelleher CC, Frazer K. An international smoking ban-how many lives will be saved? Curr Atheroscler Rep. 2014
Jun;16(6):418. doi: 10.1007/s11883-014-0418-0. Review. PubMed PMID: 24771033.

39. Acknowledgements
• Ms Joanne Callinan and Dr Kate Frazer each received Health Research
Board of Ireland 2-year Cochrane Training Fellowships to conduct
these reviews
• Mr Jack McHugh was funded as a SSRA summer student placement
to work on the institutional review
• We thank the University of Oxford Cochrane Tobacco Addiction
Group for their unfailing assistance with these reviews
• All the empirical research presented was approved by either the UCD
Human Research Ethics Committee or SVUH Ethics Committee
• There are no conflicts of interest to declare
Thank you