have smoking bans after who framework convention on tobacco control worked in reducing harms of...
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Have smoking bans after WHO Framework
Convention on Tobacco Control worked in reducing harms of passive smoking?Professor Cecily C Kelleher 1,2, Dr Kate Frazer 3
UCD School of Public Health, Physiotherapy and Sports Science 1, Department of Preventive Medicine & Health Promotion, St Vincent’s University Hospital 2,
UCD School of Nursing, Midwifery and Health Systems 3, Belfield, Dublin 4, Republic of Ireland
In this talk
• Brief background and context• Findings of Cochrane systematic reviews of 2010 and update
of 2016 on impact of legislative smoking bans• Total smoke free hospital campus ban: an example from
Dublin, Ireland• Cochrane systematic review 2016 on impact of institutional
bans• Commentary and conclusions
FRAMEWORK CONVENTION ON TOBACCO CONTROL (FCTC)
FCTC is the first international treaty negotiated under the auspices of WHO
It is an evidence-based treaty that represents a milestone for the promotion of public health
Provides new legal dimensions for international health cooperation
Since the treaty entered into force in 2005, it has become one of the most rapidly and widely embraced treaties in the history of the United Nations.
Dr Margaret Chan, Tobacco Atlas 2015:4
FCTC – why it is required……
Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J.,(2015). The Tobacco Atlas: revised, expanded, and updated. Atlanta, USA: American Cancer Society.
Growth of SupportEriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J.,(2015). The Tobacco Atlas: revised, expanded, and updated. Atlanta, USA: American Cancer Society.
The Tobacco Atlas Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J., (2015). The Tobacco Atlas: revised, expanded, and updated. Atlanta, USA: American Cancer Society.
Smoke-free laws
Smoke-free legislation by income level; High, middle, low income countries, 2012
An International smoking ban-how many lives will be saved? Kelleher CC, Frazer K. Curr Atheroscler Rep. 2014 Jun;16(6):418. doi: 10.1007/s11883-014-0418-0. Review. PubMed PMID: 24771033.
• Multi-component tobacco strategies are crucial to combat the ongoing global smoking challenge• In the 21st century, many countries
have signed up to the WHO Framework Convention on Tobacco Control (FCTC)• Several reports have appeared from
different countries showing a temporal relationship between smoking bans and reduced hospital admissions• This will have a measurable benefit
for public health, saving many lives
Legislative Smoking Bans: Levels of Impact
•Macro: Policy level intervention•Meso: Institutional or
settings level intervention•Micro: Individual or inter-
personal level interventionLegislative Smoking
Bans
MACRO
MESO MICRO
Legislative Smoking BansCallinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992.
• Studies reporting legislative smoking bans affecting populations• Minimum standard was a ban
explicitly in the study• Minimum follow-up of six
months for measures of smoking behaviour• RCTs, Quasi-experimental,
Controlled before-after, interrupted time series (ITS) designs
AIM: Assess the extent to which legislation-based smoking bans or restrictions:Callinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992.
Reduce exposure to
Second-hand smoke (SHS)
Help people who smoke to
reduce tobacco consumption/
prevalence
Affect health of those in
areas which have a ban or restriction in
place
Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsychINFO, CINAHL, Conference Paper Index, reference lists , bibliographies – up to 2009
Evidence in Review Callinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992.
50 studies – all SHS exposure(19 with biomarkers)
12 studiesCardiac
ACS
12 studiesRespiratory
Health outcomes
Lung function
5 studies SHS cars
Tobacco consumption
Cotinine
15 studies SHS homes
Tobacco consumption
Cotinine
23 studies Active
smoking
Smoking prevalenceTobacco
consumption Population-level
13 Quasi experimental
37 uncontrolled before and after
Evidence 2010 Smoking bans
reduced exposure to SHS in workplaces,
restaurants, pubs and in public
places
Greater reduction in
exposure to SHS in hospitality
workers compared to
general population
No difference in SHS exposure in cars No change in either the prevalence or duration of SHS in the home
No consistent evidence of a reduction in
smoking prevalence
Callinan et al, Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992:Following introduction of legislative smoking bans:
• Evidence for reduced second hand smoke exposure clear
• Some emerging evidence for reduced admissions for acute coronary syndrome (ACS)
• Limited evidence impact on active smoking rates
Updated Review 2016
Legislative Smoking Bans Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
PICO• Population: Smokers and
non- smokers • Intervention: Comprehensive
or partial smoking bans implemented by legislation• Comparison: No bans• Outcomes: health outcomes
associated with second-hand smoke exposure. Active smoking, tobacco consumption
Eligibility Criteria• Settings: Country, Region or
State• Minimum standard was having
indoor smoking ban explicitly stated in the study• 6 months follow up period • Measured health outcomes • Population smoking
prevalence rates
Evidence Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
A number of studies provided evidence for multiple outcomes
77 studies
44 studies Cardiovascular
ACS / AMI Stroke
21 studiesRespiratory
Asthma COPD
Lung function
7 studies Perinatal
LBWPre term birth
Maternal smoking
11 studies Mortality
Smoking related deaths
24 studies Active smoking
Smoking prevalenceTobacco consumption
Population-level
36 ITS 23 Controlled before
and after18 uncontrolled before and after
Cardiovascular EvidenceFrazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
44 studies
Consistent evidence ACS/ AMI
33 studies
Consistent evidence
Stroke 5 studies
Reductions in admissions for smokers and non smokers
43 studies Cardiac
38 Cardiac5 Cardiac &
Stroke
6 studies Stroke
Multiple methods ITS, Controlled before and
after studies, Uncontrolled before and
after studies
Evidence in Update Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016
Feb 4;2:CD005992
Respiratory
21 studies
Reductions in asthma & COPD
admissions Lung function
improved Evidence not
consistent across all studies for asthma
or COPD
Perinatal
7 studies
Evidence of reductions in LBW and pre term birth Reduction maternal
smoking Evidence not consistent
Mortality
11 studies
Reductions in mortality rates consistent in 8
studies
Active Smoking
24 studies
Inconsistent evidence
Features of the Evidence Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
Bias Use of data sets
Unverified smoking status Sample sizes
Statistical modelling
Acute Coronary Syndrome/ Acute Myocardial Infarction outcomesFrazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
UK and Ireland International evidence
Cronin et al. (2012) Ireland12% reduction in ACS admissions in 1st year after ban.ACS admissions reduced from 34% in 2003 to 29% in 2009.
Aguero et al. (2013) SpainREGICOR study. 11% reduction in AMI rates.
Kent et al. (2012) Ireland 18% reduction in ACS admissions in those aged 50 to 55 years and aged 60 to 69 years
Alsever et al. (2009) USA19% reduction in AMI admissions post ban. No change in controls.
Liu et al. (2013) EnglandAge-adjusted rates for MI admissions fell by 42% (39–45%) overall. 41.6% in men and by 42.6% in women
Barone Adesi et al. (2011) Italy4% reduction in ACS in aged <70 years
Pell et al.(2008) ScotlandACS admissions reduced 14% smokers, 19% in ex smokers and 21% in non smokers.
Di Valentino et al. (2015) Switzerland Reductions in `STEMI admissions from 123.7/100,000 to 89.6/100,000
Schmucker et al. (2014) Germany16% reduction in STEMI admissions overall. 26% reduction in non smokers
Sebrie (2014) Uruguay17% reduction in AMI admissions
UK and Ireland Studies in ReviewFrazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
England Scotland Ireland
Lee et al. (2011) Smoking prevalence
Jones et al. (2015)Scotland and England smoking prevalence
Cronin et al. (2012) ACS admissions
Liu et al. (2013) CHD admissions
MacKay et al. (2010) Asthma admissions
Goodman et al. (2007) Lung function
Millett et al.(2013)Asthma admissions
MacKay et al. (2011) Smoking prevalence
Kabir et al. (2009) Maternal smoking and perinatal outcomes
Sims et al. (2013)Asthma admissions
MacKay et al. (2012) Peri natal outcomes & maternal smoking
Kabir et al. (2013) Perinatal outcomes
MacKay et al. (2013) Stroke Kent et al. (2012) ACS admissions
Pell et al. (2008) ACS admissions
Stallingsmith (2013) Mortality rates
Pell et al. (2009) Mortality rates
Stroke OutcomesFrazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
Stroke outcomes Examples
Mackay 2013 Scotland 8.9% reduction in admissions for cerebral infarction post ban
Loomis 2012 USA 5.2% reduction in admissions in Florida
Herman USA 14% reduction in admissions in counties with ban compared to no ban
Implications for practice
•Countries and populations benefit from enacting national legislative smoking bans Evidence (Moderate)
Improved health outcomes, specifically cardiovascular disease. Evidence (Low)
Reduced mortality rates for smoking related illnesses.
Evidence (Low) Improved perinatal and respiratory health outcomes. Reductions in tobacco consumption.
Implications for Research Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
• Additional research with longer term impact on health outcomes in sub groups of the population
Young childrenDisadvantaged and minority groups
• More research on health impact of smoking bans Respiratory health Perinatal health Active smoking
• More systematic indicators to allow for quantifying effects
Key Message Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992
Introduction of a legislative smoking ban leads to improved health outcomes through a reduction in
second-hand smoke exposure for countries and their populations
St Vincent’s University Hospital, Partner to University College Dublin
Implementation of a campus-wide Irish hospital smoking ban in 2009: prevalence and attitudinal trends among staff and patients in lead up. Fitzpatrick P, Gilroy I, Doherty K, Corradino D, Daly L, Clarke A, Kelleher CC. Health Promot Int. 2009 Sep;24(3):211-22.
• Three separate data sources, 8 staff and patient surveys between 1997-2006, 1-week observational survey in smoke shelters and attitudinal interviews with patients and staff• Smoking rates in patients
remained steady but declined in staff• Those using shelters were mainly
women and staff members• Early majority tipping point
support for implementing total smoke-free campus ban
Smoke-Free Campus PolicyFitzpatrick et al, Health Promo Int 2009; 24(3): 211-22
2006
Survey of staff and patients
2007
Commitment of Senior
management
Legal advice sought
Meetings with Trade Unions & other
stakeholder groups
2008
Steering Group:Senior
Management
Project group: All stakeholders
Implementation & Communication plan
2009
1st January 2009 SMOKE FREE
CAMPUS POLICY INITIATED
2010
One year post-introduction evaluation
Survey of staff and patients
Smoke free hospital campus: Strong positive shift in attitudes post implementation but paradox in nursing and medical attitudes Fitzpatrick P, Gilroy, I, Doherty K, Clarke A, Comerford D, Daly L, Kelleher C. Clinical Health Promotion 2012 Apr;2 (1): 12-16
• Significant fall in smoking rates in staff (17.8% v 10.7%; p=0.02) but not patients (22.7% v 18%;NS)• Positive shift in attitude of
patients (58.6%v 84.2%; p<0.001) and staff (52.4% v 83.3%; p<0.001)• Nurses more likely than other
groups, including doctors, to agree they had a role in implementation
National and International Impact: ENSH Award Fitzpatrick P, Gilroy I, Doherty K, Conlon G, Daly L, Kelleher C. Exempting patients from a smoke-free hospital policy on compassionate grounds. BMJ. 2014 Jan 21;348:g389
New Evidence 2016
Search Strategy 2005 to 2015 • Cochrane Central Register of Controlled
Trials (CENTRAL); • MEDLINE, • EMBASE, • Reference lists of identified studies
Institutional Ban Evidence Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
Complete or partial smoking bans
National legislative ban No National legislative ban
Healthcare facilities
Third level education institutions
Prisons / correctional facilities
Observational level dataFrazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
17 studies
12 hospitals
Active Smoking Mortality
3 Prisons
MortalityActive smoking
2 Universities
Active smoking
3 controlled before and after studies14 uncontrolled
studies
Evidence of institutional policies Frazer K, McHugh J, Callinan JE, Kelleher C. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
•No change patient smoking rates•Reduction in staff smoking rates •Reduction in SHS exposure
Hospitals •No evidence reduction in prevalence •Reduction in mortality rates•Reduction in SHS exposure
Prisons
•Reduction in smoking rates•Reduction in SHS exposure
University
Impact of institutional smoking bans on reducing harms and secondhand smoke exposure Frazer K, McHugh J, Callinan JE, Kelleher C. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
Evidence of impact on active smoking ratesFrazer K, McHugh J, Callinan JE, Kelleher C. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856
11 Observational Studies pooled dataN=12,485
Heterogeneity evident
Quality of Evidence for institutional smoking bans
• We found evidence of an effect of settings-based smoking policies on reducing smoking rates in hospitals and universities.• In prisons, reduced mortality rates
and reduced exposure to secondhand smoke were reported. • However, we rated the evidence
base as low quality using GRADE criteria, as all studies observational• We therefore need more robust
studies assessing the evidence for smoking bans and policies in these important specialist settings.
Quality of evidence low
Impact of national bans V no national bans not consistent – weak evidence / heterogeneity
Inconsistent evidence and confidence in effect is limited
Implications for Practice and Research
Settings bans components of multifactorial tobacco control activities
Further robust studies using control groups and longer follow up
ReferencesCallinan JE, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure,
smoking prevalence and tobacco consumption. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005992. doi: 10.1002/14651858.CD005992.pub2. Review. Update in: Cochrane Database Syst Rev. 2016;2:CD005992. PubMed PMID: 20393945.
Eriksen, M., Mackay, J., Schluger, N., Gomeshtapeh, F. and Drope, J.,(2015). The Tobacco Atlas: revised, expanded, and updated. Atlanta, USA: American Cancer Society.
Fitzpatrick P, Gilroy I, Doherty K, Corradino D, Daly L, Clarke A, Kelleher CC. Implementation of a campus-wide Irish hospital smoking ban in 2009: prevalence and attitudinal trends among staff and patients in lead up. Health Promot Int. 2009 Sep;24(3):211-22. doi: 10.1093/heapro/dap020. PubMed PMID: 19531558.
Fitzpatrick P, Gilroy, I, Doherty K, Clarke A, Comerford D, Daly L, Kelleher C. Smoke free hospital campus: Strong positive shift in attitudes post implementation but paradox in nursing and medical attitudes. Clinical Health Promotion 2012 Apr;2 (1): 12-16.
Fitzpatrick P, Gilroy I, Doherty K, Conlon G, Daly L, Kelleher C. Exempting patients from a smoke-free hospital policy on compassionate grounds. BMJ. 2014 Jan 21;348:g389. doi: 10.1136/bmj.g389. PubMed PMID: 24448418.
Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database Syst Rev. 2016 May 27;(5):CD011856. doi: 10.1002/14651858.CD011856.pub2. Review. PubMed PMID: 27230795.
Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database Syst Rev. 2016 Feb 4;2:CD005992. doi: 10.1002/14651858.CD005992.pub3. Review. PubMed PMID: 26842828.
Kelleher CC, Frazer K. An international smoking ban-how many lives will be saved? Curr Atheroscler Rep. 2014 Jun;16(6):418. doi: 10.1007/s11883-014-0418-0. Review. PubMed PMID: 24771033.
Acknowledgements
• Ms Joanne Callinan and Dr Kate Frazer each received Health Research Board of Ireland 2-year Cochrane Training Fellowships to conduct these reviews• Mr Jack McHugh was funded as a SSRA summer student placement
to work on the institutional review• We thank the University of Oxford Cochrane Tobacco Addiction
Group for their unfailing assistance with these reviews• All the empirical research presented was approved by either the UCD
Human Research Ethics Committee or SVUH Ethics Committee• There are no conflicts of interest to declare
Thank you
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