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