15.9 Effectiveness of smokefree legislation in reducing exposure to tobacco toxins, improving health, and changing smoking behaviours

Last updated: June 2018             

Suggested citation: Greenhalgh, EM., and Scollo, M. 15.9 Effectiveness of smokefree legislation in reducing exposure to tobacco toxins, improving health, and changing smoking behaviours. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from http://www.tobaccoinaustralia.org.au/chapter-15-smokefree-environment/15-9-effectiveness-of-smokefree-legislation-in-reducing-exposure-to-tobacco          

Smokefree legislation primarily aims to protect non-smokers from the harmful health effects of secondhand smoke. It also provides an environment that is conducive to smokers’ efforts to quit.1  A robust body of evidence shows that smokefree legislation reduces exposure to tobacco toxins,1-3 reduces respiratory symptoms in workers2, 3 and reduces consumption among continuing smokers.2, 4, 5 There is strong evidence 2, 5 that such bans encourage smokers to quit and to remain abstinent,2 and reduce social inequalities in secondhand smoke exposure at work.2 There is also evidence of reduced mortality rates from smoking-related illnesses post-smoking bans.1 

The most comprehensive and rigorous evidence review was provided by the International Agency for Research on Cancer (IARC) in 2009. Results are summarised in Table 15.9.1.

Table 15.9.1
Evaluation of the weight of evidence for the effectiveness of smokefree legislation

 

Sufficient evidence

Strong evidence

Limited evidence

Evidence of no effect

Inadequate or no evidence

Smokefree policies do not cause a decline in the business activities of the restaurant and bar industry (Ch 4)

X

 

 

 

 

Implementation of smokefree policies leads to a substantial decline in exposure to SHS (Ch 6)

X

 

 

 

 

Implementation of smokefree legislation reduces social inequalities in SHS exposure at work (Ch 6)

 

X

 

 

 

Implementation of smokefree legislation causes a decline in heart disease morbidity (Ch 6)

 

X

 

 

 

Implementation of smokefree legislation decreases respiratory symptoms in workers (Ch 6)

X

 

 

 

 

Smokefree workplaces lead to reduced cigarette consumption among continuing smokers (Ch 7)

X

 

 

 

 

Smokefree workplaces lead to increased successful cessation among smokers (Ch 7)

 

X

 

 

 

Smokefree homes policies reduce tobacco use among youth (Ch 7)

 

X

 

 

 

Smokefree home policies reduce exposure to children to SHS (Ch 8)

X

 

 

 

 

Smokefree home policies reduce adult smoking (Ch 8)

X

 

 

 

 

Smokefree homes policies reduce youth smoking (Ch 8)

 

X

 

 

 

Source: International Agency for Research on Cancer 2009 1 refer to table p260.
*Chapter number refers to chapter of IARC report

15.9.1 Effects of smokefree environments on exposure to secondhand smoke

Smokefree legislation leads to reductions in population exposure to secondhand smoke.1-3 Research in New Zealand,6 Canada,7 the US,8 Spain,9, 10 Switzerland,11 Ireland,12 Scotland,13 India,14 and Korea15 has provided evidence of reduced tobacco smoke pollution and secondhand smoke exposure following the implementation of smoking bans, and studies have shown that smokefree laws may also reduce secondhand smoke exposure among children and adolescents living in non-smoking homes.16-18   

Smoking bans are increasingly being adopted in places where people have disproportionately high smoking rates, such as in prisons and in social housing. Early evidence suggests such bans are likely to reduce exposure to secondhand smoke.19, 20 A growing number of educational facilities have also introduced complete smoking bans on campus, and a 2016 study on a total smoking ban at a large Australian university found that exposure to secondhand smoke was significantly reduced one year after policy implementation.21

15.9.2 Effects of smokefree environments on health outcomes

Legislative smoking bans lead to improved health outcomes in the community through reduction in exposure to secondhand smoke, with the clearest evidence for reduced heart attacks and other cardiovascular disease.1, 2, 22-27 There appear to be rapid reductions in acute myocardial infarctions following passage of strong smokefree legislation that includes restrictions in public venues such as restaurants and bars,6, 13, 28-48 and many studies2, 3, 45-51 have concluded that acute coronary events reduce by at least 10% following the implementation of comprehensive smokefree legislation, with the benefits increasing over time. There is also evidence of reduced mortality from smoking-related illnesses among smokers.1  

There is robust evidence that smokefree policies improve respiratory and sensory symptoms12, 52-54 and the general health of hospitality workers.2, 55, 56 These benefits appear to extend to both non-smoking and smoking employees, indicating that smokefree working environments may also be beneficial for smokers.55, 57 Findings are mixed regarding the impact of bans on respiratory health more generally;1 although there is evidence of improved asthma health outcomes for non-smokers.158 Several studies have noted significant reductions in hospital admissions for asthma following the introduction of smokefree laws, both among adults and children,48, 51, 58-64 and also reductions in hospital admissions for chronic obstructive pulmonary disease65, 66 and in childhood hospital admissions for respiratory infections.63, 67

Benefits of smokefree legislation to children can also begin prior to birth. There is emerging evidence of an association between smoking bans and reduction in active smoking in pregnant women, and consequent reduction in foetal passive smoke exposure.1 The evidence is less consistent for other perinatal health outcomes,1 although there appears to be an association between smokefree legislation and reductions in preterm births.1, 58, 63  

15.9.3 Effects of smokefree environments on smoking behaviours 

15.9.3.1 Effects on smoking behaviour among workers and residents

Smokefree policies create fewer opportunities to smoke and contribute to the denormalisation of smoking.68 Smoking bans can be helpful to smokers who are trying to quit by encouraging more quit attempts69 and increasing the chances of a successful quit attempt.70-72 There is robust evidence that smokefree workplaces lead to reduced cigarette consumption among smokers, and such policies appear to increase the likelihood of successful cessation.2, 5, 73-76 Smokefree legislation may increase the life satisfaction of smokers who would like to quit,77 and some studies suggest that it can act as a trigger for renewed quit attempts,74, 78 and for help-seeking among smokers.6, 79, 80 Smokefree laws may have a delayed effect on cessation among adults; that is, the longer a smokefree law is in effect, the more likely adults will attempt to quit smoking and become former smokers.81 Smoking bans may also reduce smoking among pregnant women.1

Researchers have also looked at whether smoking bans at an institutional level can help reduce smoking rates. A 2016 Cochrane review found that banning smoking in hospitals and universities increased the number of quit attempts and reduced the number of people smoking. In prisons, reduced mortality rates and reduced exposure to secondhand smoke were reported.82 Other research has similarly concluded that complete prison smoking bans (rather than partial bans) can effectively interrupt smoking behaviour.83 Within inpatient psychiatric facilities, smokefree policies in may lead to reduced consumption and increase quitting motivation and beliefs, both during admission and post-discharge.84 Smokefree policies may also have a positive effect on the smoking behaviour of health service staff.85  

In light of evidence showing that secondhand smoke can infiltrate smokefree apartments from units and shared areas where smoking occurs, a growing number of public housing authorities, private landlords and body corporates have implemented complete smokefree apartment building policies—see Section 15.6.5. Limited evidence suggests such policies are likely to yield considerable cost savings for landlords and society, and that they may improve cessation outcomes among current smokers.20, 86  

15.9.3.2 Effects on youth smoking

A number of studies have identified the positive impact of smokefree legislation on reducing smoking among children.87-91 Research in the US has found that strong smokefree legislation appears to reduce uptake, and reduce the likelihood of progressing from experimental to established smoking.87, 88  An analysis in the UK concluded that smokefree legislation may be associated with a reduction in regular smoking among school-aged children.92 Australian research has similarly concluded that smokefree policies were directly related to the decline in smoking prevalence among young people between 1990 and 2015.89 Among young adults, strong smokefree policies at US college campuses are associated with reduced smoking frequency, reduced exposure to second-hand smoke, and a reduction in pro-smoking attitudes.93 Smoking bans in the home also appear to reduce tobacco use among youth.2   

15.9.3.3 Effects on reducing socioeconomic disparities in smoking

Higher smoking prevalence and lower cessation rates are consistently observed among lower socioeconomic status (SES) groups (see Chapter 9). The introduction of tobacco control strategies can result in greater initial benefits for higher income and educational groups because such policies tend to be adopted earlier in white collar environments. While smokefree legislation reduces social inequalities in secondhand smoke exposure at work,2 and reduces smoking-related mortality in lower socioeconomic groups,1 evidence on their effectiveness for reducing socioeconomic inequalities in smoking prevalence is mixed. Some research has concluded that smoking bans are more effective in promoting quitting and reducing smoking among more advantaged groups, and can therefore widen socioeconomic inequalities,74, 94-97 while others find that smokefree legislation can contribute to a reduction in inequalities by encouraging quitting35, 98-100 and the adoption of smokefree homes101 among those with a lower socioeconomic status.  A 2016 Cochrane review of legislative smoking bans found some evidence of reductions in smoking prevalence among lower socioeconomic groups, but notes the inconsistency of the findings.1 National, comprehensive smokefree policies appear to be more effective at reducing inequities than voluntary, regional, and partial policies.102

There is limited evidence on the impact of smoking bans on Indigenous peoples. Australian research in 2012–13 found that more than half (56%) of Aboriginal and Torres Strait Islander smokers and 80% of non-smokers reported that smoking was never allowed anywhere in their home; similar proportions to the general Australian population. Most employed Aboriginal and Torres Strait Islander daily smokers (88%) reported that smoking was not allowed in any indoor area at work. Smokers working in smokefree workplaces were more likely to have smokefree homes than those in workplaces where smoking was allowed indoors, and smokers who lived in smokefree homes were more likely to have attempted to quit or want to quit.103 More than two thirds (70%) of Aboriginal and Torres Strait Islander daily smokers reported that there are increasingly fewer places they feel comfortable smoking.104 An analysis of the New Zealand Smokefree Environments Amendment Act concluded that it reduced secondhand smoke exposure in the home and workplace among Maori people, and reduced socially-cued smoking and increased calls to the Quitline. There was also widespread support for the legislation among Maori.105   

15.9.4 Adoption of smokefree homes and increasing the chances of a successful quit attempt.

Despite initial concerns regarding potential displacement of smoking into the home following smokefree legislation, legislative bans on smoking in public places appear to encourage people to establish voluntary home smoking restrictions through their influence on social norms.6, 78, 106-112 Such restrictions in turn reduce adult smoking,2 and smokefree homes reduce children’s exposure to secondhand smoke and may reduce tobacco use among youth.2 

 

15.9.5 Effects on overall smoking prevalence

While the aim of smokefree legislation is primarily to protect public health, and particularly employee health, there is also some evidence of an impact on smoking prevalence and tobacco consumption.1 Some studies have reported a decline in smoking prevalence following the implementation of smokefree legislation,113-115 while others have found no change.115, 116 Inconsistent findings may be attributable to differences in policy environments and rates of implementation.117 Australian researchers found that stronger smokefree laws were independently associated with—and played a substantial role in—reduced smoking prevalence between 2001 and 2011; a period of time over which such laws became notably stronger.117 Smokefree legislation may also have indirect effect on smoking prevalence via encouraging the adoption of smoking bans in the home, which in turn reduce adult smoking.2

References

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