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From partial to complete smoking bans  -what we have learned in spain
 

From partial to complete smoking bans -what we have learned in spain

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Presentation of the lessons learned by the Tobacco Unit of the Catalan Institut of Oncology on tobacco partial bans: ...

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

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    From partial to complete smoking bans  -what we have learned in spain From partial to complete smoking bans -what we have learned in spain Presentation Transcript

    • 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 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
    • 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 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”
    • 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
    • 0 10 20 30 40 50 60 70 1987 1993 1997 2001 9 11 Prevalence(%) 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 impact No. of persons employed in hospitality sector Source: Active Population Surveys Year Thousandsofpersons 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 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
    • 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 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
    • 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%)
    • 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 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
    • 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 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
    • 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(µg/m3) Year 12.48 8.32 n=429 n=485 2009 2011
    • Location OutsideConflict point Main entrance, campus Main entrance, door Dressing room Fire escape CafeteriaGeneral medicine Emergency department Hall 0,00 PM2.5(µg/m3) 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 Review Environmental 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 efernandez@iconcologia.net tobaccorelated.org @stvfdz bioinfo.iconcologia.net/tobacco Tobacco Control Unit Catalan Institute of Oncology