Journal of Public Health Advance Access originally published online on February 17, 2006
Journal of Public Health 2006 28(1):24-30; doi:10.1093/pubmed/fdi080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact?
Sally J. Haw
Sally J. Haw, Senior Public Health Advisor, NHS Health Scotland, Rosebery House, Haymarket Terrace, Edinburgh EH12 5EZ, UK
Laurence Gruer
Laurence Gruer, Director of Public Health Science, OBE, NHS Health Scotland, Clifton House, Clifton Place, Glasgow G3 7LS, UK
Amanda Amos
Amanda Amos, Reader in Health Promotion, Public Health Sciences, University of Edinburgh Medical School, Edinburgh EH8 9AG, UK
Candace Currie
Candace Currie, Director of the Child & Adolescent Health Research Unit, The University of Edinburgh, St Leonard’s Land, Holyrood Road, Edinburgh EH8 8AQ, UK
Colin Fischbacher
Colin Fischbacher, Consultant in Public Health Medicine, Information Services Division (ISD) Scotland, Gyle Square, Edinburgh EH12 9EB, UK
Geoffrey T. Fong
Geoffrey T. Fong, Associate Professor of Applied & Social Psychology, Department of Psychology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1 Canada
Gerard Hastings
Gerard Hastings, Director of Cancer Research UK Centre for Tobacco Control, University of Stirling and the Open University, Stirling FK9 4LA, UK
Sally Malam
Sally Malam, Senior Associate Director, BMRB, Ealing Gateway, 26-30 Uxbridge Road, London W5 2BP, UK
Jill Pell
Jill Pell, Professor of Epidemiology, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
Calum Scott
Calum Scott, Health Economist, Scottish Executive, St Andrews House, Regent Road, Edinburgh EH1 3DG, UK
Sean Semple
Sean Semple, Lecturer, Department of Environmental & Occupational Medicine, University of Aberdeen, Aberdeen AB25 2ZP, UK
Address correspondence to Sally J. Haw. Email: sally.haw{at}health.scot.nhs.uk
Background From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts.
Methods Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas – knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities.
Conclusion The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.
Keywords: air pollution, public health, tobacco
 |
Introduction |
|---|
TOP
Introduction
Health impacts of smoke-free...The recent disagreement in the UK Government that preceded the publication of the Health Bill1 contrasts sharply with the political consensus in Scotland a year ago that accompanied the publication of the Smoking, Health and Social Care (Scotland) Bill (2005) and its subsequent smooth passage through the Scottish Parliament. While similar arguments were made for and against a comprehensive ban both north and south of the border, the view in Scotland was that everyone should be protected from exposure to environmental tobacco smoke (ETS) in public places. This led to the conclusion that a comprehensive ban was the only possible solution. Evidence from the Republic of Ireland that this was a workable approach was very influential.
From 26 March 2006, smoking will be banned in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. Unlike the planned legislation for England, the Scottish legislation2 will cover all workplaces including pubs, restaurants and private members clubs. There will only be a small number of exemptions such as residential accommodation and designated rooms in adult care homes and psychiatric units.
The Health Bill1 proposed only a partial ban for England, but in February 2006 the House of Commons voted to include both pubs that do not sell food and private members clubs within the legislation. Both the Assembly for Wales and the Northern Ireland Office have already announced their intention to implement a comprehensive ban. Therefore, if the amendments to the Health Bill are passed by the House of Lords, a comprehensive ban on smoking in enclosed public places will be in place across the UK by the summer of 2007.
This legislation has the potential to have a major impact on public health across the UK. The aim of this article is to present the logic model of expected outcomes that provides the framework for the evaluation strategy and to describe the extensive set of interrelated research studies that have been commissioned to evaluate the impacts of the forthcoming comprehensive ban on smoking in public places in Scotland.
|
Health impacts of smoke-free legislation |
|---|
We anticipate that introduction of the smoke-free legislation in Scotland will result in health gains associated with reductions in both exposure to ETS and personal tobacco consumption. The associations between exposure to ETS and lung cancer,3,4 coronary heart disease (CHD),5,6 respiratory disease7,8 and stroke5,9 are well established. A recent study has estimated that the elimination of ETS from public places could result in a reduction of about 400 deaths per annum in Scotland by 2024.10
Health gains because of the Scottish law may be realized much more quickly in some groups, particularly those who are currently heavily exposed to ETS or at high risk of CHD. A study of bar workers in the Republic of Ireland11 has recently confirmed earlier US findings of an improvement in respiratory symptoms following the implementation of a ban on smoking.12 An analysis of routine hospital admission data from Helena, Montana found a dramatic reduction in the incidence of acute myocardial infarction following the introduction of smoke-free legislation.13 While this study has been criticized for its weak design, the findings are consistent with predictions based on research findings on the adverse physiological impact of tobacco smoke.14
Workplace studies indicate that smoking bans and restrictions lead to a reduction in the number of cigarettes smoked by continuing smokers and an increase in quit attempts and successful quitting. Complete bans are associated with a greater reduction in active smoking.15,16 We anticipate that the health gains from reduced personal tobacco consumption following the introduction of the legislation will match or exceed those resulting from reduced exposure to ETS.17
|
Other impacts of smoke-free legislation |
|---|
One obstacle to the introduction of a comprehensive ban in England appears to have been a concern about public opinion. New data from Ireland indicate that support among smokers for a comprehensive ban rose after legislation was introduced.18 Support among smokers before and after the ban rose from 43 to 67 per cent, from 45 to 77 per cent and from 13 to 46 per cent for bans in workplaces, restaurants and pubs, respectively. After the ban was implemented, 83 per cent of Irish smokers also said that the legislation was a ‘good’ or ‘very good’ thing.
A second concern has been the potential negative economic impact on the hospitality industry, particularly pubs and bars. The evidence here is not as robust as for the health impacts. Overall studies demonstrate a small positive effect on profit,19 but the possibility remains of a negative impact on the hospitality industry for some types of businesses or for businesses in particular geographical areas.
|
Evaluation framework and strategy |
|---|
Logic model
Health Scotland in conjunction with Information Services Division (ISD) Scotland and the Scottish Executive have developed an evaluation framework to describe the expected short-term (up to 2 months), intermediate (>2–12 months) and long-term (>12 months) health-related, attitudinal and cultural and economic outcomes. The framework is presented as a logic model (Fig. 1) and has been adapted from one developed by the US Centers for Disease Control and Prevention.20 Our evaluation focuses on eight of the 12 key outcome areas identified in the framework – knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities. Assessment of each outcome will be based on a combination of secondary analysis of routine health, behavioural and economic data as well as research commissioned to address specific questions. The research will focus on intermediate impacts up to one year after implementation of the legislation, while the routine data will permit changes to be monitored over a much longer period – 3 years in the first instance.
|
Routine health and behavioural data
Several useful routine health and behaviour data sets are available in Scotland. The Scottish Morbidity Record (SMR) provides discharge diagnoses on all Scottish hospital admissions and is linked to death data from the General Register Office for Scotland (GROS). Diagnostic accuracy of SMR data is estimated to be 97 per cent compared with case notes.21 Initial analyses will focus on temporal trends in hospital admissions (SMR01) for CHD and asthma and CHD deaths.
ISD Scotland’s Practice Team Information (PTI) provides data on all consultations from a representative sample of 45 Scottish practices, which include about 6 per cent of the Scottish population. Analyses will focus on trends in consultations for CHD, chronic obstructive pulmonary disease (COPD) and asthma.
The Scottish Household Survey,22 an annual population sample survey, will provide data on smoking prevalence. More detailed data on quit attempts and levels of tobacco consumption before and after the implementation will be available from the 2003 and subsequent Scottish Health Surveys.23
Routine economic data on the hospitality sector
A number of indicators of performance – employment, turnover, profitability and openings and closures – will provide a detailed picture of trends in the performance of the hospitality sector. The Labour Force Survey (LFS)24 will allow comparisons of employment levels before and after the legislation, and gross domestic product (GDP)25 data will provide an indication of trends in turnover in the sector.
In the longer term, the Office of National Statistics (ONS) Inter-Departmental Business Register (IDBR)26 and Annual Business Inquiry (ABI)27 will provide more detailed data on employment, turnover and profitability. Along with Liquor Licensing Statistics,28 these sources will also track openings and closures in the hospitality sector.
Primary research
Seven studies have been commissioned to address specific research questions. All employ a before and after design. A summary of study designs is given in Table 1.
|
The changes in CHild Exposure to ETS (CHETS) study and the Health Education Population Study (HEPS) will measure changes in child and adult exposure to ETS. Both HEPS and CHETS will assess population level changes in ETS exposure from any source. In addition, CHETS will also determine whether there is any evidence of displacement of smoking into the homes of children who live with smokers. Both studies employ a repeat cross-sectional study design and will collect detailed data on awareness of health risks associated with ETS exposure, self-reported ETS exposure as well as salivary cotinine, a biomarker of ETS exposure. HEPS will also collect data on attitudes towards the legislation.
The primary focus of both the STudy Of Public place Intervention on Tobacco exposure (STOPIT) and the study of Bar-workers’ Health and ETS Exposure (BHETSE) is on health gains achieved within one year of implementation of the legislation. STOPIT is a prospective study designed to test the hypothesis raised by the Montana study13 that a reduction in ETS exposure is accompanied by a rapid reduction in the incidence of acute coronary syndrome (ACS). STOPIT’s prospective design allows patients’ smoking status and levels of ETS exposure to be determined thus overcoming some of the methodological problems associated with the Montana study. Specifically, it will be possible to determine the extent to which any overall reduction in incidence of ACS is due to reductions in incidence among smokers and non-smokers. The findings from STOPIT will be interpreted within the context of temporal trends in CHD hospital admissions and CHD deaths determined by analyses of the routine health data sets.
The BHETSE study will follow a cohort of bar workers and assess changes in their ETS exposure and self-reported respiratory symptoms 2 and 9 months after the implementation of the smoking ban. Measures of particulate matter of less than 2.5 microns (PM2.5), an air-marker of ETS exposure, will also be taken in selected premises. Unlike the Irish11 and US12 bar worker studies, BHETSE will also test associations between reduced ETS exposure and objective measurements of lung function – forced expiratory volume in one second (FEV1) and forced vital capacity (FVC).
Two qualitative studies have been commissioned to assess the impact of the legislation on smoking behaviour and smoking cultures. Both will use a range of qualitative methods including in-depth interviews, focus group discussions and observation in enclosed and outdoor public places. The Bar Study will examine changes in attitudes and smoking behaviour among bar customers from selected bars and changes in the cultural contexts in which smoking and drinking takes place. It will study three contrasting (high, medium and low affluence) but geographically related communities located around a single urban centre. The Community Study will examine the broader impact of the legislation at individual, family and community levels in two contrasting local authority areas, one urban and one semi-rural. In each local authority, two communities, one of high and one of low affluence, have been selected for study.
Finally, the International Tobacco Control (ITC) Ireland/UK Scotland extension will use a quasi-experimental prospective cohort design to compare changes in attitudes towards legislation on smoking in public places in Scotland, England (control) and Republic of Ireland. It will also compare social norms about smoking, self-reported smoking behaviour in both public and private venues and self-reported smoking cessation and quit attempts. Data will be collected by telephone interview from nationally representative samples of smokers and non-smokers.
The outcome areas, outcome measures and data sources are summarized in Table 2. Baseline data collection are now under way in all seven studies to enable before and after comparisons to be made.
|
|
National and cross-national collaboration |
|---|
The findings from individual studies will begin to be available about one year after the implementation of the legislation. The CLEAN Collaboration (see Members of the CLEAN Collaboration for members) will then combine these and the routine monitoring data to create an integrated overview. We anticipate that the findings will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.
The plans for a comprehensive ban on somking in public place across the UK provide further opportunity to build on the Scottish evaluation. We are thus in discussion with colleagues to develop a UK-wide evaluation strategy in preparation for this eventuality.
|
Contributors |
|---|
All authors reviewed and approved the final draft of the article. SH and LG developed the evaluation framework and are responsible for the overall co-ordination of the evaluation. CF and CS developed the specifications for the analysis of the routine health and economic data sets. AA, CC, GF, GH, SM, JP and SS designed and are supervising the primary research. Other members of the CLEAN collaboration contributed to the design and supervision of their respective studies. SH also contributed to study designs and is guarantor for the article.
|
Members of the CLEAN Collaboration |
|---|
NHS Health Scotland: Sally Haw and Laurence Gruer.
ISD Scotland: Colin Fischbacher and Diane Stockton.
Scottish Executive: Calum Scott.
CHETS: Candace Currie, Patricia Akhtar and Dorothy Currie, CAHRU, University of Edinburgh, Edinburgh.
HEPS: Sally Malam and Ruth Gosling, BMRB, London.
STOPIT: Jill Pell, University of Glasgow, Glasgow; Stuart Cobbe and John Rodgers, Glasgow Royal Infirmary, Glasgow; Frank Dunn, Anne Wright and Nat Hawkins, Stobhill Hospital, Glasgow; Timothy Gilbert and James Young, Hairmyres Hospital, East Kilbride; Paul MacIntyre and Jacqueline Dougall, Royal Alexandra Hospital, Helensburgh; David Murdoch and Anne Andrews, Southern General Hospital, Glasgow; David Newby and Sharon Cameron, Royal Infirmary Edinburgh; Keith Oldroyd, Joanne Kelly and Fiona Stevenson, Western Infirmary, Glasgow; Alastair Pell and Judith Anderson, Monklands Hospital, Lanarkshire; Stuart Pringle and Helen Marshall, Ninewells Hospital, Dundee.
BHETSE: Jonathon Ayres, Sean Semple and Anne Ludbrook, University of Aberdeen, Aberdeen; Fintan Hurley and Graeme Hughson, Institute of Occupational Medicine, Edinburgh; Mark Petticrew, MRC Unit, Glasgow.
Bar Study: Gerard Hastings, Douglas Eadie and Susan MacAskill, University of Stirling and the Open University, Stirling; John Davies, Derek Heim and Alastair Ross, University of Strathclyde, Glasgow.
Community Study: Claudia Martin, Scottish Centre for Social Research, Edinburgh; Amanda Amos and Deborah Ritchie, University of Edinburgh, Edinburgh.
ITC Ireland/UK Scotland extension: Geoffrey T. Fong, Department of Psychology, University of Waterloo, Waterloo, Canada; Gerard Hastings and Louise Hassan, University of Stirling and the Open University, Stirling; Andy Hyland, Roswell Park Cancer Institute, New York.
|
Copyright declaration |
|---|
The corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors an exclusive licence to The Faculty of Public Health to permit this article (if accepted) to be published in the Journal of Public Health.
|
Competing interests |
|---|
All authors declare that the answer to the questions in your conflict of interests form at http://www.oxfordjournals.org/our_journals/pubmed/for_authors/conflict%20of%20interest.pdf are all No and, therefore, have nothing to declare.
|
Funding sources |
|---|
The research teams for CHETS, HEPS, STOPIT, BHETSE and the Bar and Community Studies were commissioned by Health Scotland and are co-funded by Health Scotland and the Scottish Executive Health Improvement Directorate (SEHID) to conduct the respective studies. The ITC Ireland/UK Scotland extension was commissioned by SEHID and is co-funded by SEHID, Cancer Research UK and the Flight Attendants’ Research Institute (FAMRI) and the US National Cancer Institute. The Centre for Tobacco Control Research is core funded by Cancer Research UK.
|
Acknowledgements |
|---|
We are very grateful for the support given by Sarah Davidson, Molly Robertson, David Palmer and Mary Cuthbert of the Tobacco Control Division of the Scottish Executive, Edinburgh. We also thank Luke Clancy of the Research Institute for a Tobacco-free Ireland, Dublin; Shane Allwright of Trinity College for Health Sciences, Dublin; and Steve Babb of the US Centers for Disease Control and Prevention, Atlanta, for their advice in developing the evaluation strategy.
|
References |
|---|
- Health Bill 2005, Part 1. London: The Stationary Office Ltd, 2005.
- The Smoking, Health and Social Care (Scotland) Act 2005, Part 1. Edinburgh: The Stationary Office Ltd, 2005.
- Brennan P, Buffler PA, Reynolds P et al. Secondhand smoke exposure in adulthood and risk of lung cancer among never smokers: a pooled analysis of two large studies. Int J Cancer 2004; 109: 125–131.[CrossRef][ISI][Medline]
- International Agency for Research on Cancer 2002. Monograph. Volume 83. Involuntary smoking. Available from http://cie.iarc.fr/htdocs/indexes/ (4 January 2006, date last accessed).
- Whincup PH, Glig JA, Emberson JR et al. Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement. Br Med J 2004; 329: 1–6.
[Free Full Text] - Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. Br Med J 1997; 31: 973–980.
- Chan-Yeung M, Dimich-Ward H. Respiratory health effects of exposure to environmental tobacco smoke. Respirology 2003; 8: 131–139.[CrossRef][ISI][Medline]
- Carey IM, Cook DG. The effects of environmental tobacco smoke exposure on lung function in a longitudinal study of British adults. Epidemiology 1999; 10: 319–326.[CrossRef][ISI][Medline]
- Iribarren C, Darbinian J, Klatsky AL, Friedman GD. Cohort study of exposure to environmental tobacco smoke and risk of first ischemic stroke and transient ischemic attack. Neuroepidemiology 2004; 23: 38–44.[CrossRef][ISI][Medline]
- Ludbrook A, Bird S, van Teijlingen E. International review of the health and economic impact of the regulation of smoking in public places. Edinburgh: NHS Health Scotland, 2005.
- Allwright S, Paul G, Greiner B et al. Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after design. Br Med J 2005; 331: 1117.
- Eisner MD, Smith AK, Blanc PD. Bartenders’ respiratory health after establishment of smoke-free bars and taverns. JAMA 1998; 280: 1909–1914.
[Abstract/Free Full Text] - Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. Br Med J 2004; 328: 977–980.
[Abstract/Free Full Text] - Pechacek T, Babbs S. How acute and reversible are the cardiovascular risks of secondhand smoke? Br Med J 2004; 328: 980–983.
[Free Full Text] - Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. Br Med J 2002; 325: 188.
- Levy DT, Friend KB. The effects of clean indoor air laws: what do we know and what do we need to know? Health Educ Res 2003; 18: 592–609.
[Abstract/Free Full Text] - Ong MK, Glantz SA. Cardiovascular health and economic effects of smoke-free workplaces. Am J Med 2004; 117: 32–38.[CrossRef][ISI][Medline]
- Fong GT, Hyland A, Borland R et al. Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tobacco Control in press.
- Scollo M, Lal A, Hyland A, Glantz S. Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control 2003; 12: 13–20.
[Abstract/Free Full Text] - Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key outcome indicators for evaluating comprehensive tobacco control programs. Atlanta, GA: Centers for Disease Control and Prevention, 2005.
- Harley K, Jones C. Quality of Scottish Morbidity Record (SMR) data. Health Bull 1993; 51: 72–79.
- Scottish Household Survey. Welcome to the Scottish household survey web site. Available from http://www.scotland.gov.uk/Topics/Statistics/16002/4031 (4 January 2006, date last accessed).
- Scottish Executive. Scottish Health Survey–2003 result. Available from http://www.scotland.gov.uk/Publications/2005/11/25145024/50251 (04 January 2006, date last accessed).
- National Statistics. Labour Force Survey. Available from http://www.statistics.gov.uk/STATBASE/Source.asp?vlnk=358 (4 January 2006, date last accessed).
- National Statistics. Gross Domestic Product. Available from http://www.statistics.gov.uk/cci/nscl.asp?id=5900 (4 January 2006, date last accessed).
- National Statistics. Inter-Departmental Business Register; a key survey source. Available from http://www.statistics.gov.uk/cci/nugget.asp?id=195 (4 January 2006, date last accessed).
- National Statistics. Annual Business Inquiry. Available from http://www.statistics.gov.uk/abi/default.asp (4 January 2006, date last accessed).
- Scottish Executive. Liquor Licensing Statistics. Available from http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=559&More=Y (4 January 2006, date last accessed).
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||