1.  2007 Johns Hopkins Bloomberg School of Public Health Secondhand Tobacco Smoke in Public Places Ana Navas-Acien, MD, PhD, MPH Johns Hopkins Bloomberg School of Public Health

2.  2007 Johns Hopkins Bloomberg School of Public Health Section A Smoke-Free Environments

3.  2007 Johns Hopkins Bloomberg School of Public Health 3 Learning Objectives Discuss the main direct and indirect benefits of smoke-free environments View creating smoke-free environments as a key strategy for tobacco control worldwide Describe policy relevant methods to track exposure to secondhand tobacco smoke in public places and to evaluate smoke-free policies Provide country and state examples with complete smoke-free policies in public places

4.  2007 Johns Hopkins Bloomberg School of Public Health 4 WHO Framework Convention on Tobacco Control Article 8: Protection from Exposure to Tobacco Smoke  “Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease, and disability”  “Each party shall adapt and implement, in areas of existing rational jurisdiction as determined by national law, and actively promote at other jurisdictional levels the adoption and implementation of effective, legislative, administrative, and/or other measures providing for protection from exposure to tobacco smoke in indoor workplaces; public transport, indoor public places and, as appropriate, other public places” Source: World Health Organization. (2005).

5.  2007 Johns Hopkins Bloomberg School of Public Health 5 Why Are Smoke-Free Environments Important? Smoke-free environments prevent death and disease Direct health benefits  Protect nonsmokers from the health consequences of involuntary exposure to tobacco smoke  Less people exposed to tobacco smoke  less disease Indirect health benefits  Motivate smokers to quit and reduce tobacco consumption  Reduce the number of people initiating smoking  Less people smoke  less disease

6.  2007 Johns Hopkins Bloomberg School of Public Health 6 Source: Fichtenberg and Glantz. (2002). Evidence Supporting Smoke-Free Workplaces Systematic review of 26 studies found that smoke-free workplaces were associated with:  Reduction in smoking prevalence = 3.8% (95% CI*: 2.8%, 4.7%)  Reduction in cigarettes/day among smokers = 3.1 (95% CI*: 2.4, 3.8)  Limitation: cross-sectional evidence *CI: confidence interval

7.  2007 Johns Hopkins Bloomberg School of Public Health 7 Evidence Supporting Smoke-Free Workplaces Source: Bauer, et al. (2005). Impact of Worksite Smoking Policies (Three Levels) on Quitting and Amount Smoked QuittingAmount smoked Worksite smoking policy (1993–2001) No. of respondents Quit, Raw % OR (95% CI) Unadjusted mean CPD † No. of respondents  weight (95% CI) Level 1: maintained or changed to smoking allowed everywhere 9320.1Reference21.888Reference Level 2: maintained or changed to smoking in designated areas 33527.4 1.73 (0.96, 3.11) 19.8262 –0.82 (–0.96, 1.21) Level 3: maintained or changed to smoking prohibited 1,39130.5 1.92* (1.11, 3.32) 16.91,038 –2.57 (–4.40, –0.59)* *P <.05; † CPD = cigarettes per day

8.  2007 Johns Hopkins Bloomberg School of Public Health 8 Positive Health Impact of Smoke-Free Environments Source: Navas, A. (2007).

9.  2007 Johns Hopkins Bloomberg School of Public Health 9 Impact on Cardiovascular Health Source: adapted by CTLT from Bartecchi, et al. (2006).

10.  2007 Johns Hopkins Bloomberg School of Public Health 10 Impact on Respiratory Health Source: Menzies, et al. (2006). Symptoms and Spirometry Before and After Introduction of the Smoking Ban (N=77) Before Ban 1 Month After Ban Change from Baseline (95% CI) P Value Symptoms, % (No.) Any79.2 (61)53.2 (41)–26 (–13.8 to –38.1)<.001 Respiratory62.3 (48)41.5 (32)–20.8 (–7.6 to –33.9).005 Sensory71.4 (55)40.3 (31)–31.2 (–18.1 to –44.3)<.001 No. of symptoms, median (IQR)2 (1 to 4)1 (0 to 3)–1 (–2 to 0).001 FEV1, mean (SE), % Entire cohort96.6 (2.26)104.8 (2.53)8.2 (3.9 to 12.4)<.001 Otherwise healthy98.7 (2.52)104.4 (2.94)5.7 (1.0 to 10.3).04 Asthma90.3 (4.86)106.1 (5.06)15.7 (5.7 to 25.7).008 CI=confidence interval; FEV1=forced expiratory volume in the first second; IQR=interquartile range

11.  2007 Johns Hopkins Bloomberg School of Public Health 11 Other Reasons to Support Smoke-Free Environments Large public support for smoke-free legislations Support increases when legislation passes  In Ireland, support for a total ban in workplaces increased from 40% before the ban to 65% after the smoking ban* No economic damage to business  Best designed studies report no impact or a positive impact of smoke-free legislations in bars and restaurants on sales or employment † Strong opposition of tobacco industry Source: *Fong, et al. (2006); † Scollo, et al. (2003).

12.  2007 Johns Hopkins Bloomberg School of Public Health 12 Challenge to Smoke-Free Policies: Industry Tactics Industry promotes ineffective policies  Accommodation  Ventilation Influence on legislation Negation or minimization of health effects Image source: adapted by CTLT from Tobacco Atlas 2nd Edition. (2006); Text source: Ramsey S. (2002). “If smoking were banned in all workplaces, the industry’s average consumption would decline… and the quitting rate would increase… Clearly, it is most important for PM to continue to support accommodation for smokers in the workplace.” - Philip Morris, 1992

13.  2007 Johns Hopkins Bloomberg School of Public Health 13 Challenge to Smoke-Free Policies: Industry Tactics “According to PAHO, the report reveals that tobacco companies hired scientists throughout Latin America and the Caribbean to misrepresent the science linking second-hand smoke to serious diseases, while cloaking in secrecy any connection of these scientists with the tobacco industry” —S. Ramsey, 2002

14.  2007 Johns Hopkins Bloomberg School of Public Health 14 Reasons Why Smoke-Free Environments Are Important Protect nonsmokers Help smokers to quit and to reduce consumption Denormalization of tobacco use to reduce initiation of tobacco by youth Large support for smoking bans by population No economic damage to business