Esteve Fernández, University of Barcelona, Spain

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  • 1. Making smoke-free laws work:experience from SpainEsteve Fernández, MD, PhD
  • 2. The smoke-free legislationin Spain (2006)Law 28/2005 (January 1st, 2006)• publicity, sales, and supply of tobacco products• prohibition of smoking inenclosed public places,transportation,and indoor workplacesBUT…
  • 3. The smoking ban in Spain (2006)Exceptions in hospitality venues(bars, pubs, restaurants, cafeterias...) according tosize:• venues ≥100 m2:smoking banned but smoking areas allowed• venues <100 m2:smoking prohibited or allowedaccording to owner’s decision
  • 4. http://www.dkfz.de/de/tabakkontrolleThe “Spanish model”http://www.biomedcentral.com/1471-2458/11/907
  • 5. Accommodation ProgrammesCountries (year)Designation of smokingand non-smoking venuesSeparation into smoking andnon-smoking rooms“Traditional Hospitality” “Courtesy of Choice”Spain (2006) ≤100 m2 (accessible area) >100 m2 (accessible area)Denmark (2007) ≤ 40 m2 > 40 m2Austria (2008)One room venues with < 50 m2(or 80 m2 if separation legallynot feasible)Venues with 2 or more roomsGermany (2008) One room venues with < 75 m2 Venues with 2 or more roomsGreece (2009) ≤ 70 m2 > 70 m2Croatia (2009) ≤ 50 m2 > 50 m2Switzerland (2010) ≤ 80 m2 > 80 m2The Netherlands (2010)≤ 70 m2(if only operated by owner)> 70 m2Czech Republic (2010) All venuesSmoking rooms without sizespecificationsImpact of tobacco industry’s accommodationprogrammes in smoke-free legislation in Europe.Schneider N, Sebrié E, Fernández E. The origin and failure of partial smoking bansand its impact in Europe and Latin America. BMC Public Health; 2012:11:907.
  • 6. How to promote a change?• Fostering a scientific evaluation of the impact ofthe partial ban on SHS exposure and morbidity• Promoting a positive social climate and acceptabilityof smoke-free legislation• Getting support from key persons at the regional andnational public health administration• Promoting advocacy of politicians, citizens’associations, trade unions, journalists, etc.
  • 7. Impact of the Spanish Smoking Lawon Exposure to Secondhand Smokein Offices and Hospitality Venues:Before-and-After StudyNebot et al. Environ Health Perspect. 2009;117:344-7.
  • 8. Impact of the Spanish Smoking Law onExposure to Second-Hand Smoke andRespiratory Health in Hospitality Workers:A Cohort StudyFernández et al. PLoS One. 2009;4:4244.
  • 9. “Clearly, the results support a complete ban onsmoking in all indoor places, including hospitalitysector venues.”“Policy makers in other countries currently consideringthe scope of their smoke-free legislation should notignore these results.”“Partial bans, (…) do not completely protect workers andothers against second-hand smoke.”
  • 10. Manel Nebot y Esteve Fernández (coords.)Carles ArizaMarcela FuIñaki GalánMaría José LópezJose M. MartínezAlbert MoncadaAgustín MontesMónica PérezEsteve SaltóAnna SchiaffinoMaría Jesús SorianoWorking Group on Tobacco Control of theSpanish Society of Epidemiologyhttp://www.seepidemiologia.es/monografia.pdf
  • 11. How to promote a change?• Fostering a scientific evaluation of the impact of thepartial ban on SHS exposure and morbidity• Promoting a positive social climate andacceptability of smoke-free legislation• Getting support from key persons at the regional andnational public health administration• Promoting advocacy of politicians, citizens’associations, trade unions, journalists, etc.
  • 12. Manel Nebot y Esteve Fernández (coords.)Carles ArizaMarcela FuIñaki GalánMaría José LópezJose M. MartínezAlbert MoncadaAgustín MontesMónica PérezEsteve SaltóAnna SchiaffinoMaría Jesús SorianoGrupo de Trabajo sobre tabaquismoSociedad Española de Epidemiología
  • 13. How to promote a change?• Fostering a scientific evaluation of the impact of thepartial ban on SHS exposure and morbidity• Promoting a positive social climate and acceptabilityof smoke-free legislation• Getting support from key persons at the regionaland national public health administration• Promoting advocacy of politicians, citizens’associations, trade unions, journalists, etc.
  • 14. J Epidemiol Community Health. 2013;67(7):542-3.
  • 15. [The Department of] Healthbegins to impose penaltiesas a conequence of thetobacco law[The Department of] Healthproposes a veto to tobaccoin all bars and restaurants
  • 16. How to promote a change?• Fostering a scientific evaluation of the impact of thepartial ban on SHS exposure and morbidity• Promoting a positive social climate and acceptabilityof smoke-free legislation• Getting support from key persons at the regional andnational public health administration• Promoting advocacy of politicians, citizens’associations, trade unions, journalists, etc.
  • 17. www.cnpt.es
  • 18. The new smoke-free legislationin SpainLaw 42/2010 (that 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)• outdoor children’s playgrounds
  • 19. ... and after the new law?Fernández & Nebot. Tob Control. 2010;20(1):6-7.
  • 20. After law 42/2010• dissemination of the new “Spanish model”• enforcement of the law• impact evaluation in terms of• exposure to SHS• changes in morbidity (asthma, CVD)• changes in smoking behaviour• prevention of regressive changes!
  • 21. López MJ, Fernández E, Pérez-Ríos M et al.Impact of the 2011 Spanish smoking ban in hospitalityvenues: indoor secondhand smoke exposure andinfluence 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, Galizia and Madrid• Sample: 180 venues (semiprobabilistic multistage weighted sample)• SHS environmental markers: Airborne nicotine and PM2.5
  • 22. Airborne nicotine concentration (µg/m3)5.73Reduction of 90.1%p<0.001n=1710.57Pre-ban(year 2010)Post-ban(year 2011)
  • 23. PM2.5 concentrations in real time02004006008001,0001,2001,4000 200 400 600 800 1,000 1,200 1,400 1,600 1,800PM2.5(µg/m3)Time (seconds)Pre-banPost-ban
  • 24. Changes in exposure of adult non-smokers to secondhandsmoke after smoke-free legislation in Spain.Sureda X, Fernandez E, Fu M, Martínez-Sánchez J et al.Methods• Design: repeated cross-sectional (independent) surveys• Field work: pre (2004-05) and post (2011-12) ban• Target: adult population (>16 y) inBarcelona, Spain.• Sample: 1300 peoplein each survey• Outcomes: Salivary cotinine andself-reported exposureto SHS
  • 25. Salivary cotinine concentration (ng/ml)0.1 1 2 3 4 5 6 7 8 9 100200100300400500No.ofsamplesAfter 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), SpainReduction 90%p<0.001
  • 26. Lessons learned• if partial bans cannot be avoided, they have to be a firststep towards total bans• partial bans can be changed:- join action(s) by scientists, consumers, politicians...- 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
  • 27. In memoriam:Manel Nebot (1957-2012)http://manelnebot.blogspot.com
  • 28. Making smoke-free laws work: experience from SpainEsteve Fernández, MD, PhD efernandez@iconcologia.nettobaccorelated.org@stvfdzwww.iconcologia.net/tobaccoTobacco Control UnitCancer Prevention & Control ProgrammeCatalan Institute of Oncology