Prevalence and predictors of smoking in “smoke-free” bars. Findings from the ITC Europe Surveys. Gera E. Nagelhout, Ute Mons, Shane Allwright, Romain Guignard,

Prevalence and predictors ofsmoking in “smoke-free” bars.

Findings from the ITC Europe Surveys.Gera E. Nagelhout, Ute Mons, Shane Allwright, Romain Guignard, François Beck,

Geoffrey T. Fong, Hein de Vries, & Marc C. Willemsen

Presentation at ECToH-symposium ‘Minimising exposure to second-hand smoke’, March 2011

Exposure to second-hand smoke

•Exposure to second-hand smoke causes death, disease, and disability

•There is no safe level of exposure to second-hand smoke

•Therefore, non-smokers should be protected from exposure to tobacco smoke

2

Framework Convention on Tobacco Control

Article 8: Protection from exposure to tobacco smoke

Each Party shall adopt and implement in areas of existing national jurisdictions as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or other measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.

3

WHO policy recommendations (2007)

1. 100% smoke-free2. Universal protection3. Proper implementation and

enforcement4. Public education about SHS

4

Smoke-free bars

“Smoke-free” bars are often not 100% smoke-free:• Designated smoking rooms allowed• Smoking bars allowed• Non-compliance

Bars are the “last bastion” of socially acceptable smoking

5

Smoking in bars pre- and post-ban

6

Ireland: March 1, 2004

Comprehensive smoke-free workplace legislation, including bars

No designated smoking rooms. No smoking bars

Strong enforcement

Implementationpreceded bycampaigns aboutsecond-hand smoke

7

France: January 1, 2008

Smoke-free workplace legislation from 2007 extended to bars in 2008

Designated smoking rooms allowed under very strict conditions. No smoking bars allowed.

Strong enforcement

Implementationprecededby campaigns aboutsecond-hand smoke

8

The Netherlands: July 1, 2008

Smoke-free workplace legislation from 2004 extended to bars in 2008

Designated smoking rooms allowed. Smoking bars allowed from July 2009 until March 2010 and from November 2010

Problems with enforcement

Implementation preceded by campaign about a man dressed as a cigarette being thrown out of bars

9

Germany: August 2007 – July 2008

Smoke-free workplace legislation from 2004 extended to bars in German states between August 2007 and July 2008

Designated smoking rooms allowed. Smoking bars allowed.

Problems with enforcement

Implementation notpreceded by campaign

10

The current study

•Comprehensiveness of the ban will mostly affect how much people smoke in bars post-ban

•Attitudes and beliefs of smokers may also have an influence important for the design of educational campaigns

11

Research questions

1. Prevalence of smoking in bars pre- and post-ban

2. Predictors of smoking in bars post-ban

3. Country differences in predictors

4. Educational level differences in predictors

12

International Tobacco ControlPolicy Evaluation (ITC) Project

13

Methods of the ITC Project

•Evaluation of FCTC policies at the individual level

•Longitudinal cohort survey: same individuals surveyed over time

•Cross country comparisons: “natural experiments”

•Use of mediation model: how did policies have their impact?

14

Mediational model

15

ITC Europe

Pre-ban survey wave Post-ban survey wave

Fieldwork period # smokers Fieldwork period # smokers

Ireland December 2003 – January 2004

1,071 December 2004 – January 2005

769

France December 2006 – February 2007

1,735 September 2008 – December 2008

1,231

The Netherlands March 2008 – April 2008

2,072 March 2009 – May 2009

1,632

Germany July 2007 – November 2007

1,515 July 2009 – October 2009

1,002

Total 6,393 4,634

16

3,147

Measures

Policy-specific variables:- Support for bar smoking ban: Do you think

smoking should be allowed in all indoor areas, allowed in some indoor areas, or not allowed indoors at all at bars and pubs?

- SHS harm awareness: How often did you think about the harm your smoking might be doing to other people?

17

Measures

Psychosocial mediators:- Attitudes towards smoking: What is your

overall opinion of smoking?- Perceived societal approval of smoking:

Society disapproves of smokingPolicy-relevant outcome:- Smoking inside bars post-ban: Did you

smoke inside the pub or bar during your last visit?

18

Measures

Moderators:- Country- Educational levelControl variables:- Interviewing mode- Gender- Age- Heaviness of smoking- Smoking inside bars pre-ban- Bar visiting in last six months

19

Prevalence of smoking in bars

97%

Ireland; 3%

0%

25%

50%

75%

100%

Pre-ban Post-ban20


97%

Ireland; 3%

84%

France; 3%0%

25%

50%

75%

100%

Pre-ban Post-ban21


Netherlands; 34%

88% 97%

Ireland; 3%

84%

France; 3%0%

25%

50%

75%

100%

Pre-ban Post-ban22


87%

Germany; 44%

88%

Netherlands; 34%

Ireland; 3%

97%

France; 3%

84%

0%

25%

50%

75%

100%

Pre-ban Post-ban23

Odds Ratio – OR (95% confidence interval)

Policy-specific variables

Support for bar smoking ban

Total ban 0.44 (0.26-0.75)**

Partial ban 0.72 (0.58-0.91)**

No ban 1.00

Think about harm of smoking to others

Very often 0.42 (0.23-0.77)**

Often / sometimes 1.01 (0.80-1.26)

Rarely / never 1.00

Psychosocial mediators

Overall opinion of smoking

Positive 1.01 (0.75-1.36)

Negative 0.70 (0.54-0.93)*

Neutral 1.00

Society disapproves of smoking

Agree 0.97 (0.74-1.27)

Disagree 1.31 (0.91-1.90)

Neutral 1.00

* p<0.05** p<0.01*** p<0.001

Predictors of smoking in bars post-ban

24Odds Ratio’s are adjusted for country, interviewing mode, gender, age, educational level,heaviness of smoking, smoking in bars pre-ban, and bar visiting in last 6 months.




Total ban 0.44 (0.26-0.75)**

Partial ban 0.72 (0.58-0.91)**

No ban 1.00


Very often 0.42 (0.23-0.77)**


Rarely / never 1.00



Positive 1.01 (0.75-1.36)

Negative 0.70 (0.54-0.93)*

Neutral 1.00


Agree 0.97 (0.74-1.27)

Disagree 1.31 (0.91-1.90)

Neutral 1.00



Stronger predictor in Germany

Stronger predictors in France




Total ban 0.44 (0.26-0.75)**

Partial ban 0.72 (0.58-0.91)**

No ban 1.00


Very often 0.42 (0.23-0.77)**


Rarely / never 1.00



Positive 1.01 (0.75-1.36)

Negative 0.70 (0.54-0.93)*

Neutral 1.00


Agree 0.97 (0.74-1.27)

Disagree 1.31 (0.91-1.90)

Neutral 1.00



Stronger predictor for high educated

Stronger predictor for low educated

Stronger predictor for high educated

Conclusion

Findings:• Prevalence smoking in bars post-ban much higher in countries with weaker smoke-free legislation

Recommendation:Implement comprehensive smoke-free legislation without exceptions and enforce the legislation strongly

27

Conclusion

Findings:• Smokers who were supportive of the ban and who were aware of the harm of SHS were less likely to smoke in bars post-ban• SHS harm awareness is a stronger predictor among low educated smokers

Recommendation:Run educational campaigns in which the public health rationale for the legislation is clearly explained

28

Thank you for your attention!

More information:[email protected]

Nagelhout, Mons, Allwright, Guignard, Beck, Fong, De Vries, & Willemsen (2011). Prevalence and predictors of smoking in “smoke-free” bars. Findings from the International Tobacco Control (ITC) Europe Surveys. Accepted for publication in Social Science & Medicine.

29

Documents

Prevalence and predictors of smoking in “smoke-free” bars. Findings from the ITC Europe Surveys. Gera E. Nagelhout, Ute Mons, Shane Allwright, Romain Guignard,