The International Tobacco Control Policy Evaluation Project. Smoke-free Policies. ITC Cross-Country Comparison Report

Transcription

1 The International Tobacco Control Policy Evaluation Project March 2012

2 march 2012 Acknowledgement The preparation of this Report was coordinated by Lorraine Craig with collaboration from Janet Chung-Hall, Michelle Bishop, Pete Driezen, Geoffrey T. Fong, and Mary Thompson of the University of Waterloo; James F. Thrasher of the University of South Carolina; Ernesto Sebrié and Mark Travers of Roswell Park Cancer Institute; K. Michael Cummings of the Medical University of South Carolina; and Ron Borland of The Cancer Council Victoria. Suggested Report Citation ITC Project (March 2012). :. University of Waterloo, Waterloo, Ontario, Canada.

3 Background and Introduction Introduction to this Report and the ITC Project Tobacco smoke pollution (TSP), also known as secondhand smoke, is recognized throughout the world as a significant cause of premature death and disease, including cancer, heart disease, and coronary obstructive pulmonary disease (COPD). 1-4 In 2004 alone, TSP caused 603,000 deaths and 10.9 million disability-adjusted life-years globally. 5 In recent years, the health threat of TSP has led many countries to adopt smoke-free legislation. However, the pace of comprehensive legislation has been slow and as a result, the laws to protect people from TSP only address a small proportion of the world s population. There is a need for research to document the continuing level of exposure to TSP across different venues throughout the world and to evaluate the effectiveness of smoke-free laws where they have been implemented. 4, 6 The International Tobacco Control Policy Evaluation Project (the ITC Project) was created in 2002 as an evidence gathering system for evaluating the effectiveness of tobacco control policies of the WHO Framework Convention on Tobacco Control (FCTC). The ITC Project is now an international collaboration involving over 100 tobacco control researchers and experts across 23 countries inhabited by over 70% of the world s tobacco users. In each country, longitudinal cohort surveys of representative samples of tobacco users (and non-tobacco users in many countries) are being conducted, with an emphasis on measuring key indicators of policy effectiveness. This report presents initial findings on cross-country differences on key indicators of the effectiveness of smoke-free policies across 19 countries of the ITC Project. A primary objective of the ITC Project, and of this report, is to disseminate findings on the effectiveness of smoke-free policies to policymakers and other public health stakeholders to promote the implementation of strong evidence-based smoke-free policies as required by Article 8 of the FCTC. : A Central Component of Effective Tobacco Control Programs Comprehensive smoke-free laws are among the most effective tobacco control strategies available, and are the only way to protect non-smokers from involuntary exposure to TSP. 2, 7 Comprehensive smoke-free laws, if designed well and implemented with strong enforcement measures, have been shown to greatly reduce or eliminate TSP in key public venues. This, in turn, can have a positive impact on the health of smokers and non-smokers In addition, comprehensive smoke-free laws lead to increasing public support for smoking bans 8 and reducing the perceived social acceptability of smoking. 9, 10 11, 12 Such laws have the further benefit of limiting opportunities and reducing social cues for smoking, which may then motivate smokers to think about quitting and to make quit attempts. Article 8 Guidelines: Key Underlying Principles for Effective Smoke-free Laws n require total elimination of tobacco smoke without exemptions n Protect all people from exposure to tobacco smoke n Use legislation that is simple, clear, and enforceable, not voluntary measures n Provide resources for implementing and enforcing the law n Include civil society as an active partner in developing, implementing and enforcing legislation n Monitor and evaluate smoke-free laws n Strengthen and expand protection if effectiveness is low, and as new evidence-based measures are identified FCTC Guidelines for Effective Smoke-free Policies Article 8 of the FCTC requires the adoption of effective measures to provide protection from exposure to tobacco smoke. Guidelines for Article 8 of the FCTC adopted at the Second Conference of the Parties in 2007 established the core principles for achieving 100% smoke-free environments, including monitoring and evaluation of enforcement of legislation. Guidelines for Article 8 recommend a comprehensive ban on smoking in public places and workplaces, without exemptions. 3

4 Research Evidence on Smoke-Free Policies Framework for Evaluating Figure 1 illustrates a framework for evaluating the effectiveness of smoke-free laws in reducing tobacco-related morbidity and mortality. The main objective of banning smoking in public places is to eliminate TSP exposure and improve public health. 1 However, there are other indirect effects of smoke-free policies on smokers attitudes and behaviors that can lead to voluntary bans on smoking in the home and also reductions in smoking prevalence. This section of the report will present scientific evidence on the components of the evaluation framework from the ITC Project and other studies. Figure 1. Framework for evaluating smoke-free policies (adapted from IARC Handbooks of Cancer Prevention, Tobacco Control, Vol. 13: Evaluating the effectiveness of smoke-free policies (2009: Lyon, France)) 54 Increased awareness of health risks of TSP and support for smoke-free policies Implementation of Comprehensive Increase in voluntary bans on home smoking Reduced exposure to TSP Increase in quit attempts and quitting Reduced tobacco-related morbidity and mortality Compliance with Smoke-free Laws Comprehensive smoke-free policies can lead to strong compliance and dramatic reductions in smoking indoors The ITC Project has conducted surveys of smokers before and after the implementation of indoor smoke-free policies in workplaces and hospitality venues to evaluate the effectiveness of policies in reducing the prevalence of smoking. Smokers are asked whether people were smoking inside the (restaurant or pub/bar) the last time they visited. The results of these surveys provide evidence of dramatic reductions in smoking indoors in countries where there was strong implementation of comprehensive smoke-free policies. For example: n In Ireland, 9 months after the 2004 law, reported smoking declined in workplaces (62% to 14%), restaurants (85% to 3%), and bars/pubs (98% to 5%). 16 n In Scotland, 1 year after the 2006 law, reported smoking declined in workplaces (37% to 7%), restaurants (61% to 1%), and bars/pubs (97% to 3%). 54 n In France, 8 months after the 2008 law, reported smoking declined in bars from 84% to 3%. 33 n In Mexico City, 6 months after its comprehensive law, smoking declined in restaurants (75% to 5%), bars (99% to 31%) and workplaces (44% to 21%), whereas the rest of the country under a weaker federal law experienced lower reductions. 56 In contrast, less dramatic reductions in indoor smoking were seen in countries where smoke-free laws allowed exemptions and were implemented without effective mass media campaigns. For example, post-ban reductions in smoking in bars were lower in The Netherlands and Germany (countries with partial bans) than in Ireland and France (countries with comprehensive bans): 33 n In Germany, after smoking bans were implemented in states between August 2007 and July 2008, reported smoking in bars decreased from 87% to 44%. n In The Netherlands, 8 months after the 2008 smoking ban in bars, reported smoking decreased from 88% to 34%. Smokers who were more supportive of the ban, were more aware of the harm of tobacco smoke pollution, and who had negative opinions of smoking were less likely to smoke in bars post-ban. The following key requirements for successful implementation of smoke-free policies were identified: n Implement strong, comprehensive legislation without exceptions. n Build public support for smoke-free policies through education campaigns in which the public health rationale for the legislation is clearly explained.

5 Smoke-free laws, air quality, and public health Levels of tobacco smoke pollution in public venues decrease after smoke-free policies are implemented Air quality studies conducted by members of the ITC Project team and other researchers have shown that smoke-free laws lead to dramatic reductions in indoor air pollution. For example, there is evidence that smoke-free laws can effectively decrease the levels of PM2.5 (fine particles of air pollution that serve as an indicator of exposure to TSP) in bars, restaurants, and other hospitality venues. n In Ireland, levels of PM2.5 were 93% lower in smoke-free pubs than in pubs that allowed smoking. 37 n across 32 countries, the levels of PM2.5 were on average 87% lower in countries with comprehensive smoke-free laws in comparison to countries without comprehensive smoke-free laws in effect. 38 n Following the implementation of a comprehensive smoke-free law in western New York, levels of PM2.5 were 84% lower across 20 hospitality venues. 39 Smoke-free policies reduce the health harms of tobacco smoke pollution among smokers and non-smokers Comprehensive smoke-free legislation is associated with significant health benefits. Studies by members of the ITC Project team and other researchers provide evidence that smoke-free laws can rapidly lead to marked improvements in respiratory and cardiac health outcomes. n 10 months after the implementation of national comprehensive smoke-free legislation in Scotland, the number of hospital admissions for acute coronary syndrome decreased by 17%, with non-smokers accounting for 67% of the reduction. 40 n The number of hospital admissions for acute myocardial infarction decreased by 22% in Uruguay in the two years following the implementation of national smoke-free laws. 41 n Non-smoking employees working in bars showed significant improvements in lung function, and reductions in respiratory and irritative upper airway symptoms one year after workplace smoking bans were implemented in Ireland. 42 The connections between public smoke-free laws, home smoking bans, and cessation Public Smoke-free Laws Home Smoking Bans Smoking Cessation Home smoking bans increase after smoke-free policies are implemented Research evidence suggests that workplace smoking bans may be associated with an increase in the prevalence of smoke-free homes. 13,14 Findings from the ITC Project provide strong evidence that smoke-free laws in public venues and workplaces do not lead to more smoking in the home and may help to encourage smokers to make their homes smoke-free. n The number of smoke-free homes in Australia, Canada, and the United Kingdom increased after the implementation of smoking bans in public places such as bars, restaurants, and recreational venues. 15 n Following the implementation of a national comprehensive smoke-free workplace law in the Republic of Ireland, there was a significant decrease in the percentage of homes where smoking was allowed. 16 n after implementation of national smoke-free legislation in France, Germany, the Netherlands, and the United Kingdom, the proportion of smokers with a total home smoking ban increased significantly. 17 Smoke-free homes help smokers to quit In addition to protecting non-smokers against exposure to TSP, studies have established that smoke-free households also help to promote quit attempts and cessation among smokers Longitudinal data from the ITC Project extends research in this area by showing that in addition to encouraging smokers to quit smoking, smoke-free homes may play an important role in helping smokers to stay quit. n Smoke-free homes facilitated quit attempts and reduced relapse after quitting among nationally representative samples of smokers in Australia, Canada, the United Kingdom, and the United States. 15 5

6 Public support for new frontiers in smoke-free policies Comprehensive smokefree legislation banning smoking in indoor workplaces and public places is increasingly being adopted in many countries. In order to further protect the general public against exposure to TSP, some jurisdictions have started to extend smoke-free laws to outdoor public places and private spaces, such as private vehicles and multi-unit housing. Support for bans on smoking in outdoor patios increases after indoor smoke-free policies are implemented Allowing smoking in outdoor environments poses a health risk by exposing the 43, 44 general public to dangerous levels of TSP. Findings from the ITC Project and other studies indicate that a large majority of smokers and non-smokers in countries with comprehensive smoke-free legislation support the extension of smoking bans to outdoor patios. n 63% of adults in California support bans on smoking in outdoor restaurant dining patios. 45 n 83% of adult smokers in New Zealand support bans on smoking in some outdoor eating areas of pubs. 46 n 74% of non-smokers and 74% of former smokers in France support bans on smoking in outdoor areas of restaurants. 47 The majority of smokers support bans on smoking in cars with children It is well-established that smoking in cars causes very high levels of TSP that cannot sufficiently be reduced by ventilation. 22 There is a growing body of evidence showing that children are particularly vulnerable for exposure to 2, 21-24, 25 hazardous levels of TSP produced by smoking in cars. Numerous studies have shown that there is very high public support for restrictions on smoking in cars with children, with over 80% of smokers supporting such smoke-free laws in cars Findings from the ITC Project expand existing research on smoking in cars with non-smokers by showing that public awareness on the dangerous effects of TSP may play a significant role in bolstering support for car smoking bans, and that the implementation of smoke-free laws in public venues may encourage smokers to make their cars smoke-free as well. n Smokers are more likely to support bans when they believe that cigarette smoke is dangerous to non-smokers. 31 n Smokers in countries with comprehensive smoke-free laws in effect in (Australia and the United Kingdom) had lower reports of smoking in cars with non-smokers than smokers in countries without comprehensive smoke-free laws (Canada and the United States). 31 n Smokers in European countries who had smoke-free homes, were less likely to allow smoking in cars. This suggests that the introduction of measures that increase smoke-free homes, such as comprehensive smoke-free laws, may also promote smoke-free cars. 57 Because jurisdictions are beginning to adopt laws which prohibit smoking in outdoor spaces and private vehicles carrying children, research that evaluates the downstream impact of these laws on smoking behavior in these settings is becoming increasingly important. 6

7 ITC Survey Methods and Measurements Smoke-free Policy Evaluation Measures in the ITC Survey All ITC surveys are developed using the same conceptual framework and methods, and the survey questions are designed to be identical or functionally equivalent in order to allow strong comparisons across countries. The use of standardized methods and measures across all ITC surveys ensures that the effectiveness of smoke-free policies and other policies can be compared across countries in order to provide guidance on best practice in tobacco control. ITC surveys include a broad set of questions to assess smoke-free policy effectiveness. Questions in the ITC surveys that are designed to measure the impact of smoke-free policies fall under three categories: compliance with smokefree laws; smoking behavior in private spaces (i.e., home and cars); and support for smoke-free laws (see Table 1 for additional details). ITC Smoke-free policy evaluation measures provide: n Evidence to support the implementation of comprehensive smoke-free legislation n Insight into the direct and indirect effects of smoke-free laws on smoking norms and behavior Compliance. Compliance with smoke-free legislation is an integral component of implementation. Significant reductions in exposure to TSP can only occur when there is a high degree of compliance with comprehensive smoke-free laws. Measures of compliance with workplace and public smoking bans are a primary indicator of the overall effectiveness of smoke-free legislation, and can help inform public health authorities on how to strengthen enforcement and public education. Smoking behavior in private spaces. Smoke-free laws may also have an indirect public health impact by encouraging people to go smoke-free outside of workplaces and public venues. Measures of smoking in homes and cars allows for the assessment of how public smoking bans may influence smoking behavior in private spaces. Support for smoke-free laws. Measures of public support for smoke-free policies in workplaces and public places are important for several reasons. First, public support for smoke-free policies plays an important role in initiating the process of passing smokefree legislation. 1 Second, changes in public support following the implementation of smoke-free laws may serve as an indicator of changes in societal smoking norms. 32 Finally, widespread public support may facilitate compliance with smoke-free laws. 33 The use of standardized methods and measures across all ITC surveys ensures that the effectiveness of smoke-free policies and other policies can be compared across countries in order to provide guidance on best practice in tobacco control. 7

8 Table 1. The ITC Survey: Measures for evaluating smoke-free policies Measures Survey Question Response Options Compliance Smoking Behavior Support The last time you visited (in last 6 months), were people smoking inside the pub or bar? The last time you visited (in last 6 months), were people smoking inside the restaurant or cafe? In the last month, have people smoked in indoor areas where you work? Which of the following best describes the smoking policy where you work? Which of the following best describes smoking inside your home? What are the rules about smoking in your car or cars when there are children in the car (among respondents who own one or more cars)? Would you support a law that banned smoking in cars when children are in them? For workplaces, please indicate if you think smoking should be allowed in For indoor areas of drinking establishments (e.g., pubs/bars), please indicate if you think smoking should be allowed in For indoor areas of restaurants/cafes, please indicate if you think smoking should be allowed in * Results for these response options are presented in this report Methods for Cross-Country Comparisons Yes* No Yes* No Yes* No Smoking is not allowed in any indoor area* Smoking is allowed only in some indoor areas Smoking is allowed in any indoor areas Smoking is allowed anywhere in your home Smoking is never allowed anywhere in your home* Something in between Smoking is never allowed in any car* Smoking is allowed sometimes or in some cars Smoking is allowed in all cars Yes* No All indoor areas Some indoor areas Not at all* All indoor areas Some indoor areas Not at all* All indoor areas Some indoor areas Not at all* The graphs on pages 10 to 19 present initial results from cross-country comparisons of ITC surveys conducted in 19 countries. The cross-country comparison data are meant to be qualitative descriptions. More formal statistical tests will be conducted for scientific publications, presentations, and reports arising from the cross-country comparison data. The percentages presented in the graphs were estimated from regression models that control for potential differences across countries in age, smoking status, and the number of times respondents were surveyed in each of the countries. The percentages also take into account the different sampling designs used in each of the countries. The results presented in this report come from the most recent wave of ITC surveys of smokers conducted in each of the 19 countries with the year of each survey given after the country name. Additional Notes: n across the 19 countries, there are considerable differences in prevalence of smoking among females. In non-asian countries, female prevalence is often fairly close to that of males. In the Asian countries, the female prevalence rate is much lower than that of males. Although female smokers were oversampled in many of these countries, the resulting sample size of females in Asian countries was still much lower than for males and too low for meaningful estimates. Thus, the graphs present ITC results in the Asian countries for male smokers only whereas for the non-asian countries, results are presented for males and also for male and female smokers combined. n In each graph, countries are presented in order of GDP per capita, from highest to lowest. They are also colour-coded according to three World Bank income classifications: High Income, Middle Income, and Low Income. n In this report, Canada and Australia are presented as countries that have implemented complete smoking bans. Smoking is prohibited in all indoor public places and workplaces (including restaurants and bars) in the majority of provinces, territories and/ or states in Canada and Australia. At the time of survey, smoking areas were only permitted in bars in the Northern Territory of Australia; and 9 of 13 provinces and 1 territory in Canada had complete smoking bans in bars, restaurants, and workplaces.

9 SMOKE-FREE LAWS IN ITC COUNTRIES This table provides information on the smoke-free policies that were in place at the time of the ITC Survey Wave noted in brackets. Table 2. Smoke-free laws in public places, workplaces, and cars in ITC countries Country (Year) Restaurants Bars Indoor Workplaces Cars New Zealand (2008) n n n x United Kingdom (2010) n n n x Scotland (2007) n n n x France (2008) n 1 n n x Australia (2010) n n 2 n n 6/8 states and territories Ireland (2006) n n n x South Korea (2010) 3 x Canada (2010) n n n 4 n 8/13 provinces & territories n 5 municipalities Germany (2009) x United States (2010) n 5 n 5 n 5 n 4/50 states n 9 municipalities n 1 commonwealth territory Netherlands (2011) n x Mauritius (2011) n n n 6 n 7 Thailand (2009) n n n x Uruguay (2010) n n n x Malaysia (2009) 8 x x x China ( ) Mexico (2011) Brazil (2009) Bangladesh (2010) x x x x Notes: 1. Designated smoking rooms are permitted in cafes and restaurants without any services. 2. Smoking areas are permitted in bars in the Northern Territory of Australia. 3. Hospitals and schools in South Korea are 100% smoke-free. 4. In Nunavut, the Northwest Territories, and Newfoundland and Labrador, designated smoking rooms in specific areas of workplaces are permitted. 5. Complete smoking bans are in effect in more than 300 municipalities, 30 states, Puerto Rico, and the District of Columbia. 6. Designated smoking areas are permitted in indoor workplaces. 7. Smoking is prohibited in private motor vehicles with passengers, regardless of age. 8. Smoking is banned in air-conditioned restaurants however, designated smoking areas are permitted. 9. Complete smoking bans are in effect in the following jurisdictions: Mexico City and Tabasco. 10. Complete smoking bans are in effect in the following jurisdictions: Amazonas, Paraiba, Parana, Rio de Janeiro, Rondonia, Roraima, Sao Paulo. n = complete smoking ban (no allowances for designated smoking rooms/areas); legislation prohibiting smoking in cars with minors present. = Partial smoking ban (allowances for designated smoking rooms/areas). X = No smoke-free legislation in effect. 9

10 Cross-Country Comparison Graphs Observed Smoking in Restaurants Figure 2. Percentage of smokers and former smokers who observed smoking in restaurants in the last 6 months, by country The percentage of smokers and former smokers who reported observing smoking in restaurants was highest in China and lowest in Scotland. Compliance with smoke-free policies in restaurants was generally higher in high-income countries with comprehensive smoking bans. South Korea, China, and Bangladesh had very weak partial (or local) smoke-free laws and as a result, the observed smoking in restaurants is very high. NOTE: Among those respondents who reported visiting a restaurant in the last 6 months. 10

11 Observed Smoking in Bars Figure 3. Percentage of smokers and former smokers who observed smoking in bars in the last 6 months, by country The percentage of smokers and former smokers who reported observing smoking in bars was highest in South Korea and lowest in Scotland. In general, compliance with smoke-free laws in bars was higher in countries with comprehensive smoking bans than in countries with partial or no smoking bans. NOTE: Among those respondents who reported visiting a bar in the last 6 months. 11

12 Smoking Bans at Work Figure 4. Percentage of smokers and former smokers who reported smoking is not allowed at work among those employed outside the home, by country The percentage of smokers and former smokers reporting that smoking is not allowed in the workplace was highest in the United Kingdom and lowest in China. Overall, complete bans on smoking in the workplace are less common in low and middle income countries. 12

13 Observed Smoking at Work Figure 5. Percentage of smokers and former smokers who observed smoking at work among those employed outside the home, by country The percentage of smokers and former smokers who reported observing smoking in the workplace was highest in China and Bangladesh and lowest in the United Kingdom. Compliance with smoke-free policies in the workplace was generally higher in countries with comprehensive smoking bans than in countries with partial or no smoking bans. 13

14 Smoking in Homes Figure 6. Percentage of smokers who reported smoking is never allowed in their home, by country The percentage of smokers and former smokers reporting that smoking is not allowed in the home was highest in New Zealand and Mauritius and lowest in China and Scotland. With the exception of China and Scotland, approximately onethird or more of smokers reported that smoking was not allowed in their homes. 14

15 Smoking in Cars Figure 7. Percentage of smokers who reported that smoking is never allowed in the car(s) when children are present (among respondents who own one or more cars), by country Among the ITC countries surveyed, the percentage of smokers and former smokers reporting that they did not allow smoking in privately owned cars carrying children was highest in South Korea and lowest in the United States. Overall, the majority of smokers and former smokers (over 70%) across all countries reported that smoking was not allowed in their cars when children are present. 15

16 Support for Smoke-free Workplaces Figure 8. Percentage of smokers who thought smoking should not be allowed at all in workplaces, by country The percentage of smokers and former smokers who reported that smoking should not be allowed in workplaces was highest in Mauritius and lowest in Germany and South Korea. In 10 out of 16 ITC countries, more than two-thirds of smokers support complete bans on smoking in the workplace. 16

17 Support for Smoke-free Restaurants Figure 9. Percentage of smokers and former smokers who think that smoking should not be allowed at all in restaurants, by country The percentage of smokers and former smokers who agreed that smoking should not be allowed in restaurants was highest in Thailand and Malaysia and lowest in South Korea. With the exception of China, South Korea, and Bangladesh, more than half of smokers and former smokers support 100% smokefree restaurants. The lower support is similar to that of Ireland before its successful 2004 smoke-free law. And Ireland s support for smoke-free restaurants continued to grow after the law. As shown here, in 2006, support among smokers in Ireland for smoke-free restaurants was over 80%. 17

18 Support for Smoke-free Bars Figure 10. Percentage of smokers and former smokers who think that smoking should not be allowed at all in bars, by country The percentage of smokers and former smokers who agreed that smoking should not be allowed in bars was highest in Thailand, and lowest in Germany. In general, the percentage of smokers and former smokers who supported 100% smoke-free bars was higher in countries with comprehensive smoke-free bans than in countries with partial or no smoking bans. 18

19 Support for Smoke-free Cars Figure 11. Percentage of smokers and former smokers who would support a law banning smoking in cars when children are present, by country The percentage of smokers and former smokers who would support a law banning smoking in cars with children was highest in Germany and lowest in the United States. On the whole, over 80% of smokers and former smokers across the countries surveyed reported high levels of support for banning smoking in cars with children. 19

20 Summary n There are cross-country variations in compliance with smoking bans in restaurants, bars, and workplaces. Overall, the lowest levels of compliance with bans in these venues were seen in Bangladesh, China, and South Korea. The highest levels of compliance were seen in Canada, the United Kingdom, Scotland, and Ireland. n There are high levels of support for smoke-free policies in the workplace and public places in ITC countries that have implemented comprehensive smoke-free legislation. n In the majority of ITC countries (with the exception of China and South Korea), one-third or more of smokers and former smokers have adopted smoke-free homes. It is notable that in New Zealand, which was the first country in the world to go 100% smoke-free, the vast majority of smokers and former smokers report having smoke-free homes. n In general, there is a high level of support for 100% smoke-free cars, workplaces, bars and restaurants among smokers and former smokers across all ITC countries. n These results highlight the need for continued global effort to implement stronger and more comprehensive smoke-free laws in accordance with the FCTC guidelines for Article 8.

21 References 1. International Agency for Research on Cancer (2002, July). IARC monographs on the evaluation of carcinogenic risks to humans: Tobacco smoke and involuntary smoking summary of data reported and evaluation. Available at: Monographs/vol83/ volume83.pdf 2. U.S. Department of Health and Human Services (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General - executive summary. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 3. Sandler, D.P., Comstock, G.W., Helsing, K.J., & Shore, D.L. (1989). Deaths from all causes in non-smokers who lived with smokers. American Journal of Public Health, 79, World Health Organization (1999). International consultation on environmental tobacco smoke (ETS) and child health. Geneva: World Health Organization. Available at: 5. Öberg, M., Jaakkola, M.S., Woodward, A., Peruga, A., & Prüss-Ustün, A. (2011). Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. Lancet, 377(9760), Eriksen, M.P., & Cerak, R.L. (2008). The diffusion and impact of clean indoor air laws. Annual Review of Public Health, 29, Fichtenberg, C.M., & Glantz, S.A. (2002). Effect of smoke-free workplaces on smoking behaviour: Systematic review. British Medical Journal, 325 (7357), hyland, A., Higbee, C., Borland, R., Travers, M., Hastings, G., Fong G.T., & Cummings, K.M. (2009). Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 11, albers, A.B., Siegel, M., Cheng, D.M., Biener, L., & Rigotti, N.A. (2004). Relation between local restaurant smoking regulations and attitudes towards the prevalence and social acceptability of smoking: A study of youths and adults who eat out predominantly at restaurants in their town. Tobacco Control, 13, alesci, N.L., Forster, J.L., & Blaine, T. (2003). Smoking visibility, perceived acceptability, and frequency in various locations among youth and adults. Preventive Medicine, 36, Longo, D.R., Johnson, J.C., Kruse, R.L., Brownson, R.C., & Hewett, J.E. (2001). A prospective investigation of the impact of smoking bans on tobacco cessation and relapse. Tobacco Control, 10, Trotter, L., Wakefield, M., & Borland, R. (2002). Socially cued smoking in bars, nightclubs, and gaming venues: A case for introducing smoke-free policies. Tobacco Control, 11, Borland, R., Mullins, R., Trotter, L., & White, V. (1999). Trends in environmental tobacco smoke restrictions in the home. Tobacco Control, 8, Merom, D., & Rissel, C. (2001). Factors associated with smoke-free homes in NSW: Results from the 1998 NSW Health Survey. Australian and New Zealand Journal of Public Health, 25, Borland, R., Yong, H.H., Cummings, K.M., Hyland, A., Anderson, S., & Fong, G.T. (2006). Determinants and consequences of smokefree homes: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl. 3), doi: /tc Fong, G.T., Hyland, A., Borland, R., Hammond, D., Hastings, G., McNeill, A., et al. (2006). 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, 15, Mons, U. Nagelhout, G., Allwright, S., Guignard, R., van den Putte, B., Fong, G., et al. (2012). Impact of national smoke-free legislation on home smoking bans Findings from the International Tobacco Control (ITC) Policy Evaluation Project Europe Surveys. Tobacco Control. Advance online publication. doi: /tobaccocontrol Farkas, A.J., Gilpin, E.A., Distefan, J.M., & Pierce, J.P. (1999). The effects of household and workplace smoking restrictions on quitting behaviors. Tobacco Control, 8, Shopland, D.R., Anderson,C.M., & Burns, D.M. ( 2006 ). Association between home smoking restrictions and changes in smoking behavior among employed women. Journal of Epidemiology and Community Health, 60(Suppl. 2), Pizacani, B.A., Martin, D.P., Stark, M.J., Koepsell, T., Thompson, B., & Diehr, P. (2004). A prospective study of household smoking bans and subsequent cessation related behaviour: The role of stage of change. Tobacco Control, 13, continued on page 22 21

22 References 21. rees, V.W., & Connolly, G.N. (2006). Measuring air quality to protect children from secondhand smoke in cars. American Journal of Preventive Medicine, 31, Sendzik, T., Fong, G.T., Travers, M.J., & Hyland, A. (2009). An experimental investigation of tobacco smoke pollution in cars. Nicotine & Tobacco Research, 11, Vardavas, C.I., Linardakis, M., & Kafatos, A.G. (2006). Environmental tobacco smoke exposure in motor vehicles: A preliminary study. Tobacco Control, 15, Semple, S., Apsley, A., Galea, K.S., MacCalman, L., Friel, B., & Snelgrove, V. (2012). Secondhand smoke in cars: Assessing children s potential exposure during typical journey conditions. Tobacco Control. Advance online publication. doi: / tobaccocontrol royal College of Physicians Tobacco Advisory Group (2010). Passive smoking and children. London: Royal College of Physicians Tobacco Advisory Group. 26. Bauman, A., Chen, X.C., & Chapman, S. (1995). Protecting children in cars from tobacco smoke. British Medical Journal, 11, Thomson, G., Wilson, N., Weerasekera, D., & Edwards, R. (2008). Ninety-six percent of New Zealand smokers support smokefree cars containing preschool children. New Zealand Medical Journal, 121, Thomson, G., & Wilson, N. (2009). Public attitudes to laws for smokefree private vehicles: A brief review. Tobacco Control, 18, Jalleh, G., Donovan, R.J., Stewart, S., & Sullivan, D. (2006). Is there public support for banning smoking in motor vehicles? Tobacco Control, 15, hitchman, S.C., Fong, G.T., Zanna, M.P., Hyland, A., & Bansal-Travers, M. (2010). Support and correlates of support for banning smoking in cars with children: Findings from the ITC Four Country Survey. European Journal of Public Health, 21(3), hitchman, S.C., Fong, G.T., Borland, R., & Hyland, A. (2010). Predictors of smoking in cars with nonsmokers: Findings from the 2007 wave of the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(4), Brown, A., Moodie, C., & Hastings, G. (2009). A longitudinal study of policy effect (smoke-free legislation) on smoking norms: ITC Scotland/United Kingdom. Nicotine & Tobacco Research, 11, Nagelhout, G.E., Mons, U., Allwright, S., Guignard, R., Beck, F., Fong, G.T., & Willemsen, M.C. (2011). Prevalence and predictors of smoking in smoke-free bars: Findings from the International Tobacco Control (ITC) Europe Surveys. Social Science & Medicine, 72, Eisner, M.D., Smith, A.K., & Blanc, P.D. (1998). Bartenders respiratory health after establishment of smoke-free bars and taverns. Journal of the American Medical Association, 280(22), Institute of Medicine (2009). Secondhand smoke exposure and cardiovascular effects: Making sense of the evidence. Washington: National Academy of Sciences, Institute of Medicine. 36. Goodman, P.G., Haw, S., Kabir, Z., & Clancy, L. (2009). Are there health benefits associated with comprehensive smoke-free laws. International Journal of Public Health, 54, connolly, G.N., Carpenter, C.M., Travers, M.J., Cummings, K.M., Hyland, A., Mulcahy, M., & Clancy, L. (2009). How smoke-free laws improve air quality: A global study of Irish pubs. Nicotine & Tobacco Research, 11(6), hyland, A., Travers, M.J., Dresler, C., Higbee, C., & Cummings, K.M. (2008). A 32-country comparison of tobacco smoke derived particle levels in indoor public places. Tobacco Control, 17, Travers, M. J., Cummings, K. M., Hyland, A., Repace, J., Babb, S., Pechacek, T. & Caraballo, R. (2004). Indoor air quality in hospitality venues before and after Implementation of a clean indoor air law. Oncology Times, 26(23), Pell, J.P., Haw, S., Cobbe, S., Newby, D.E., Pell, A.C.H., Fischbacher, C. et al. (2008). Smoke-free legislation and hospitalizations for acute coronary syndrome. New England Journal of Medicine, 359, Sebrié, E.M., Sandoya, E., Hyland, A., Bianco, E., Glantz, S.A., & Cummings, M.K. (2012). Hospital admissions for acute myocardial infarction before and after implementation of a comprehensive smoke-free policy in Uruguay. Tobacco Control. Advance online publication. doi: /tobaccocontrol Goodman, P., Agnew, M., McCaffrey, M., Paul, G., & Clancy, L. (2007). Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs. American Journal of Respiratory and Critical Care Medicine, 175(8),

23 43. Travers, M.J., Higbee, C., & Hyland, A. (2007). Vancouver Island outdoor smoking area air monitoring study Roswell Park Cancer Institute. 44. Mulcahy, M., Evans, D.S., Hammond, S.K., Repace, J.L., & Byrne, M. (2005). Secondhand smoke exposure and risk following the Irish smoking ban: An assessment of salivary cotinine concentrations in hotel workers and air nicotine levels in bars. Tobacco Control, 14, Gilpin, E.A., Lee, L., Pierce, J P., Tang, H., & Lloyd, J. ( 2004 ). Support for protection from secondhand smoke: California Tobacco Control, 13, Wilson, N., Blakely, T., Edwards, R., Weerasekera, D., & Thomson, G. (2009). Support by New Zealand smokers for new types of smokefree areas: National survey data. The New Zealand Medical Journal, 122, Kennedy, R.D., Behm, I., Craig, L., Thompson, M.E., Fong, G.T., Guignard, R., & Beck, F. (2012). Outdoor smoking behaviour and support for outdoor smoking restrictions before and after France s national ban. European Journal of Public Health, 22(1), Non-smokers Rights Association (2011). Second-hand smoke: Provincial and territorial legislation. Available at: campaign for Tobacco-free Kids (2011). Country overviews and tobacco laws. Available at: andhttp://tobaccocontrollaws.org 50. The Global Smoke-free Partnership (2011). Global map of smoke-free laws. Available at: World Health Organization (2010). Country profiles: Tobacco control measures and programmes as of 31 December Available at: canadian Cancer Society (2011, August). Laws banning smoking in vehicles carrying children international overview. Available at: Framework Convention Alliance (2011, September). Countries ban smoking in vehicles with children. Available at: International Agency for Research on Cancer (2009). IARC handbook of cancer prevention, Volume 13: Evaluating the effectiveness of smoke-free policies. Lyon, France: WHO Press. 55. hyland, A., Hassan, L.M., Higbee, C., Boudreau, C., Fong, G.T., Borland, R., et al. (2009).The impact of smokefree legislation in Scotland: Results from the Scottish ITC Scotland/UK longitudinal surveys. European Journal of Public Health, 19(2), Thrasher, J.F., Swayampakala, K., Arillo-Santillán, E., Sebrié, E., Walseman, K., & Bottai, M. (2010). Differential impact of local and federal smoke-free legislation in Mexico: A longitudinal study among adult smokers. Salud Pública de México, 52(Suppl. 2), hitchman, S.C., Guignard, R., Nagelhout, G.E., Mons, U., Beck, F., van den Putte, B., et al. (2012). Predictors of car smoking rules among smokers in France, Germany and the Netherlands. European Journal of Public Health, 22( Suppl. 1),

24 ITC PROJECT FUNDING AND SUPPORT The ITC Research Team Major grant support has been provided by: The ITC International Research team includes over 100 tobacco control researchers in 23 countries worldwide. Its Principal Investigators are: U.S. National Cancer Institute International Development Research Center (IDRC) Research for International Tobacco Control (RITC) Canadian Institutes of Health Research National Health and Medical Research Council (Australia) Robert Wood Johnson Foundation Geoffrey T. Fong University of Waterloo, Canada Mary E. Thompson University of Waterloo, Canada K. Michael Cummings Medical University of South Carolina, United States Ron Borland The Cancer Council Victoria, Australia Cancer Research U.K. Andrew Hyland Roswell Park Cancer Institute, United States Richard J. O Connor Roswell Park Cancer Institute, United States Future Directions The ITC Project continues to explore opportunities for collaborating with low- and middle-income countries to help policy makers design, implement, and evaluate FCTC policies. David Hammond University of Waterloo, Canada Gerard Hastings University of Stirling and the Open University, United Kingdom Ann McNeill University of Nottingham, United Kingdom The ITC Project: Evaluating the Impact of FCTC Policies in countries 50% of the world s population 60% of the world s smokers 70% of the world s tobacco users Australia Bangladesh Bhutan Brazil Canada China (Mainland) France Germany India Ireland Kenya Malaysia Mauritius Mexico Netherlands New Zealand Nigeria South Korea Thailand United Kingdom Uruguay United States of America Zambia Design by Sentrik Inc. Version 1 March 2012 For information contact: Additional sources of funding and support: Geoffrey T. Fong, Ph.D. Department of Psychology University of Waterloo 200 University Avenue West, Waterloo, Ontario N2L 3G1 Canada Ontario Institute for Cancer Research, American Cancer Society, U.S. Centers for Disease Control and Prevention, Canadian Tobacco Control Research Initiative, Canadian Cancer Society Research Institute, Propel Centre for Population Health Impact, Health Canada, Scottish Executive, Malaysia Ministry of Health, Korean National Cancer Center, GlaxoSmithKline, Pfizer, Australia Commonwealth Department of Health and Ageing, Health Research Council of New Zealand, ThaiHealth Promotion Foundation, Flight Attendant Medical Research Institute (FAMRI), Institut national de prévention et d éducation pour le santé (INPES) and Institut national du cancer (INCa), German Cancer Research Center, German Ministry of Health and the Dieter Mennekes Umweltstiftung, ZonMw (the Netherlands Organisation for Health Research and Development), National Tobacco Control Office, Chinese Center for Disease Control and Prevention, National Cancer Institute of Brazil (INCA), National Secretariat for Drug Policy/Institutional Security Cabinet/ Presidency of the Federative Republic of Brazil (SENAD), Alliance for the Control of Tobacco Use (ACTbr), Bloomberg Global Initiative International Union Against Tuberculosis and Lung Disease, Consejo Nacional de Ciencia y Tecnología (CONACyT)/Mexican National Council on Science and Technology. itc@uwaterloo.ca Tel: ext