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Abstract
Objective To assess the impact of two Spanish smoking legislations in the adoption of voluntary smoke-free-homes rules in Spain.
Methods This is a longitudinal study, before and after the implementation of two national smoking bans (in 2005 and 2010), in a representative sample (n=1245) of non-institutionalised adults (≥16 years) from Barcelona (Spain) surveyed in 2004–2005 and followed up in 2013–2014. The final sample analysed was 736 individuals (400 women and 336 men). We defined smoking rules in the houses as complete (when smoking was not allowed in the household), partial (when smoking was allowed in some places inside the house) or absent (when smoking was allowed everywhere). We calculated relative changes in the prevalence of smoking rules in homes before and after 2 national smoking legislations by means of prevalence ratios (PRs) and their 95% CIs.
Results The households with voluntary smoke-free rules (complete or partial) relatively increased 31% after Spanish smoking bans (from 55.6% to 72.6%, p<0.001). The houses with complete rules relatively increased 57% (from 23.9% to 37.6%, p<0.001) whereas the houses with partial rules increased 11% (from 31.7% to 35.0%, p=0.148). The increase of any type of rules (complete and partial) was statistically significantly independent of sex (PR between 1.29 and 1.33), age (PR between 1.24 and 1.33), educational level (PR between 1.19 and 1.47) and minimum age in house (PR between 1.12 and 1.40). However, this increase was statistically and significantly higher only among never smokers (PR=1.46) at baseline.
Conclusions The implementation of the smoke-free regulations in public and work places in Spain was associated with an increasing of voluntary adoption of smoke-free rules in homes. According to our data, the Spanish smoking bans did not shift the tobacco consumption from public and work places to private places (homes).
- Secondhand smoke
- Public policy
- Prevention
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Introduction
According to the Tobacco Atlas, globally, about 40% of children and a third of non-smoking adults were exposed to secondhand smoke (SHS) in 2004.1 Moreover, SHS exposure has been classified as a type I carcinogen by the International Agency for Research on Cancer,2 being responsible for around 603, 000 deaths worldwide.3
This has led to several countries to implement tobacco control legislations, particularly smoke-free public and workplaces, as suggested by the WHO Framework Convention on Tobacco Control (WHO FCTC).4 In fact, their implementation has already been associated with a reduction in the exposure to SHS, the incidence of acute coronary events, respiratory symptoms, improvements of perinatal and child health, along with a moderate decrease in tobacco smoking prevalence.5–7 Furthermore, SHS exposure during pregnancy has harmful effects on placenta and fetal growth8 and is associated with preterm labour,9 ,10 intrauterine growth restriction and low birth weight.8
Nevertheless, private places (mainly cars and homes), where children are more exposed,11 are never or rarely included in tobacco control policies. However, the household is usually the main source of exposure to SHS in children.11 A study carried out in 21 countries showed that almost 50% of children had been exposed to SHS in the home (daily, weekly or monthly) between 2009 and 2013.12 In addition, children are especially vulnerable to SHS exposure due to them breathing more rapidly, inhaling more pollutants per pound of body weight than adults,13 with an increased risk of sudden infant death syndrome, acute respiratory infections, ear problems and mental disorders.14–16
In Spain, two smoke-free laws have been passed after the approval of the FCTC. In 2005, a smoke-free legislation (law 28/2005) came into effect. This law was a great advancement for public health in Spain. The ban was a compendium of public health measures against smoking and included regulations on publicity, sale, supply and consumption of tobacco products.17 Smoking was banned in all indoor workplaces, public places, public transport facilities including enclosed stations, hospitals and other healthcare facilities, schools and universities as well as in retail stores and shopping centres. However, hospitality venues were subject to only a partial ban. In bars and restaurants of <100 m2, the proprietor could choose between permitting or prohibiting smoking. Bars and restaurants larger than 100 m2 are defined as smoke free, but the law allows the proprietor to provide a physically separated and independently ventilated smoking area comprising <30% of the total floor area. For this exception the Spanish smoking law was known as the ‘Spanish model’.18 The scientific evaluation of this law showed the need to promote a total ban19–21 and motivate the modification of the law in 2010 (law 42/2010) that extended the smoke-free regulation to all hospitality venues22 without exception and extended the ban to some outdoors areas, including hospital premises, educational campuses and playgrounds.
In Barcelona (Spain), in 2011–2012, 84% of smokers reported smoking at home, and 35.9% of them smoked in outdoor areas of the home.23 Moreover, a common belief among smokers is that cigarette smoking in outdoor places does not affect indoor places,23 whereas a previous study indicated that SHS from outdoors settings drifts to adjacent indoors spaces.24 However, currently, few studies have evaluated the impact of Spanish smoke-free legislations in SHS exposure at home25 ,26 and there is a lack of information in Spain, to the best of our knowledge, on the impact of the smoke-free laws in the adoption of smoke-free homes (SFHs). Therefore, the objective of this study is to assess the impact of Spanish tobacco control legislations in the voluntary adoption of SFHs rules in Spain.
Methods
This is a longitudinal study of a representative sample of the adult (≥16 years) non-institutionalised population of Barcelona (Spain; n=1,245, 694 women and 551 men) called ‘determinants of cotinine phase 3’ project (dCOT3, website: http://bioinfo.iconcologia.net/es/content/estudio-dcot3). The baseline survey was conducted between 2004 and 2005, and it is detailed elsewhere.27 ,28 We followed up adult participants who responded to a face-to-face questionnaire in 2004–2005 and agreed to take part in future studies. At the beginning of 2013, we updated the vital status and contact information (addresses and telephone numbers) of all participants teaming with Insured Central Registry of Catalonia. We restricted the follow-up to the participants who were alive in 2013 and still lived in the province of Barcelona.
We traced 1010 participants out of the 1245 from the baseline study (101 died, 49 migrated out of the province of Barcelona, and 85 did not give consent to be followed or were minors, <18 years, in 2004–2005 because their parents did not provide consent to be recontacted). The percentage of follow-up in this first stage was 81.1%. The follow-up survey was conducted between May 2013 and February 2014. In total, 72.9% of the eligible sample agreed to participate and answered the questionnaire (736 of 1010 traced, second stage of follow-up), 18.5% refused to participate, 7.2% moved elsewhere and 1.3% died. The final sample analysed was 736 individuals (400 women and 336 men). Finally, the percentage of participation in both stages was 59.1% (736 of 1245). There were no statistically significant differences between the followed up sample (n=736) and the participants lost in the second stage (n=274) according to age, sex, level of education and smoking status. However, there were statistically significant differences according to age, level of education and smoking status between the follow-up sample (n=736) and the participants lost in both stages of the follow-up (n=509; table 1). For this reason, the final sample was skewed as older in comparison with the population of Barcelona. Therefore, we use inverse probability weights to weigh our data according to age distribution of the city of Barcelona to maintain the representativeness of the sample.
Differences (prevalence for qualitative variables and mean (SD) for quantitative variable) between follow-up sample and lost in both stages of the follow-up
Both questionnaires (before and after the two laws) included the following question about the smoking rules at home: ‘Which of the following situations best describe the smoking rules inside your house?’ with three possible answers: ‘Nobody can smoke’, ‘You can only smoke in some places’ and ‘You can smoke everywhere’. According to this question we defined smoking rules inside the household as complete (when smoking was not allowed inside the house), partial (when smoking was allowed in some places inside the house) or absent (when smoking was allowed everywhere inside the house). Finally, we dichotomised the variables as ‘Rules’ indicating whether there were any kind of smoking rules (complete or partial) and ‘No rules’ indicating there were no smoking rules in the house.
We calculated the prevalence and the prevalence ratio (PR) with their 95% CIs of the voluntary adoption level of smoke-free rules in homes before and after the implementation of the two national tobacco control policies. We also used Generalized Estimating Equation (GEE) models with individuals as random effects and using Poisson family with log link, to calculate the PR adjusted for sex, age and month when the survey was conducted. Moreover, the results were stratified by sex, age, educational level (categorised as low: unschooled, elementary school completed or uncompleted and special education; intermediate: high school and training cycles and high: university education), married, minimum age in house (categorised as <5, 5–14 and ≥15 years), smoking status (current, former and never smoker) at baseline, intention to quit (indicating whether the person is trying to quit smoking at that time or not) and the Fagerström Test for Cigarette Dependence (FTCD) score. We also included information about the places where smoking is allowed in houses with partial SFH through the following open question: ‘in what places of your home can you smoke?’. The statistical programs used were STATA V.14 and R V.3.0.2.
Results
A 55.6% of households declared having some type of voluntary SFH (complete or partial) at baseline in 2004–2005 (before the Spanish smoking bans came into force). This percentage significantly rose to 72.6% after the implementation of the two Spanish smoke-free bans (table 2). In particular, we observed a statistically significant relative increase of 57% in the prevalence of complete SFH (from 23.9% to 37.6%, PR=1.57) while the increase in the prevalence of houses with partial SFH was not statistically significant (from 31.7% to 35.0%, PR=1.11). We also observed a statistically significant decrease in the prevalence of houses without smoking rules (from 44.4% to 27.4%, PR=0.62). We obtained similar PR adjusting by sex, age, and month when the survey was conducted (table 2).
Prevalence, prevalence ratio (PR), adjusted prevalence ratio (PRa) and their 95% CIs of the voluntary adoption of smoke-free homes (SFHs) rules (complete and partial) before (2004–2005) and after (2013–2014) the implementation of both Spanish smoking bans
The increase of any type of rules (complete and partial) was statistically significantly independent of sex (PR man=1.33 vs PR women=1.29), age (PR 65–98 years=1.24 and PR in 26–44 years 1.33), educational level (PR intermediate level=1.19 and PR high level=1.47) and minimum age in house (PR 0–4 years=1.12 and PR ≥15 years=1.40). However, the increase was statistically and significantly higher only among never smokers (PR=1.46) at baseline (table 2). We obtained similar PR after adjusting for sex, age and month where the survey was conducted (table 2). The prevalence of any type of SFH rules before and after the implementation of the two national smoke-free legislations were the highest in house where minors lived (<15 years); however, the increase was not statistically significant (table 2). Among smokers, the highest increase of SFH was observed among those who had intention to quit and higher FTCD (>5 points) although the increase was not statistically significant (table 2).
Regarding complete SFH, we observed a higher increase among men than women (PR in men=1.66 vs PR in women=1.51), young people26–44 (PR=1.65), with higher education (PR=1.74), with a minor member at home (<15 years) (PR=1.60) and never smokers at baseline (PR=1.73). A similar pattern was observed in the PR of partial SFH (table 2).
We observed that, in houses with partial SFH rules, outside areas of the houses (balconies, courtyard, terraces and gardens) were the places where there was increase in smoking after the Spanish smoking bans (from 32.6% to 70.0%; PR=2.15, 95% CI 1.66 to 2.86) while inside it decreased, such as common areas (from 9.9% to 2.3%, PR=0.23, 95% CI 0.05 to 0.49) and the dining room (20.7% to 2.5%; PR=0.12, 95% CI 0.03 to 0.23). Similar results were observed in the PR of the places where smoking is allowed in houses adjusting by sex, age and the month where the survey was conducted.
Discussion
Our results show that there is an increase in the prevalence of SFH, particularly in the case of a complete SFH, after the implementation of the two Spanish smoke-free bans in 2006 and 2011. This result is in agreement with previous ecological studies conducted in Europe29 ,30 which found a positive correlation between the level of implementation of the smoke-free legislation and the prevalence of SFH rules adoption. At individual level, data from Scotland,11 Ireland, France, Germany and the Netherlands31 show a significant increase in SFH prevalence after the implementation of tobacco control laws. Similar results were found in the USA,32 Canada, the UK and Australia.33 Confirming the positive impact of smoke-free bans in adopting SFH rules in a Southern Mediterranean population with still a relatively high prevalence of smoking is of importance to reassure the power of smoke-free bans for tobacco control.
Our results show a greater impact of complete SFH than partial SFH. In this line, the study conducted in five European countries among adult smokers,31 showed a greater impact of complete SFH while the PR of houses with partial rules remained more stable. The Scottish study conducted among children showed that children surveyed after the implementation of the smoke-free legislation were 25% less likely to have partial home rules than those surveyed before its introduction.11 Moreover, a US study found a dose–response relationship between the implementation of tobacco control laws and the voluntary adoption of SFH, being full coverage laws associated with higher odds of adopting a complete SFH than partial coverage laws.34
Furthermore, previous studies showed that the SFH rules are more common in households inhabited with married people,31 non-smoking adults33 ,35–37 and with children.31 ,33 ,35–37 Some studies also showed the SFH can result in a reduced exposure to SHS in children37 ,38 and in a reduction in consumption over time, and increased quitting among smokers helping them to remain abstinent.39 We found a higher increase of SFH after the implementation of Spanish smoking bans among men, young people, persons with high educational level, singles and never smokers. However, we found the lowest increase of SFH rules in houses where a minor lives and an indirect relation between the minimum age at home and the prevalence of SFH (data not shown). This result could be due to a ‘ceiling effect’, since the prevalence of SFH in these households was the highest before the bans.
Our results also show an increased prevalence of allowing smoking in most ventilated places or outside areas, in houses with partial SFH after the implementation of the Spanish smoke-free legislations. This could be due to an increasing risk perception of SHS exposure in the population. However, although this could lead to a decrease in the SHS exposure at homes, it could also result in an increase in the SHS exposure between neighbours. In a study carried out in 2010 in Denmark, 22% of those living in multiunit dwellings reported exposure to neighbour smoke and 58% of the exposed people preferred to live in smoke-free buildings.40 In any case, currently smoke-free multiunit housing are still uncommon in Europe although are gaining popularity in the USA where multiunit housing operators reported having complete or partial smoke-free building policies for at least some of their properties.41
The tobacco industry and the hospitality sector, during the debate on implementation of smoke-free policies in different countries, argued that the restriction of smoking in public places will displace tobacco consumption to private venues, particularly in homes.42 Hence, it was expected that the exposure to SHS among children in households would have increased after the implementation of the two national smoking bans. In this sense, there are only two studies,14 ,43 to the best of our knowledge, conducted in the USA and Hong Kong supporting that hypothesis. Our results, and the results from other studies,11 ,29–34 counteract the displacement hypothesis. Moreover, we observed a higher increase in complete SFH and in the outdoor places as the venues designed to smoking in partial SFH. In addition, some other studies44 ,45 have shown a widespread support to smoking restrictions in all public places in those countries where tobacco control policies are more advanced. In particular, an ecological study, found a positive strong correlation between the level of smoke-free legislation across European countries and the support to smoking bans in restaurants, bars, pubs and clubs.44 Similar results were observed in the USA, where increasing antismoking climate correlates with the decline in smoking prevalence, the increase in antismoking policies and public health awareness reports.45
Although the prevalence of SFH has increased, our data showed that currently around 30% of households did not have any voluntary smoke-free rules after the implementation of the Spanish smoking legislation in 2010. Moreover, around half of the houses with SFH rules have a partial rule. In this sense, a previous study46 using cotinine as a biomarker of SHS exposure concluded that the home continues to be the main source of SHS exposure for non-smokers who live in non-SFHs. Therefore, there is a need to implement some public health interventions to continuing reducing SHS exposure in homes. The interventions may focus in convincing or helping smokers to quit or in getting smokers moving their smoking away from their home, that is to say, trying to promote SFHs and smoke-free multiunit housing.47 ,48
The main limitation of our study is the potential of participation bias due to the attrition of the cohort of participants. In this sense, there were statistically significant differences according to age, level of education and smoking status between the follow-up sample and the participants lost in both stages of the follow-up. Follow-up participants overestimated the young people and smokers in comparison with lost participants (table 1), for this reason the increase of SFH could be higher among lost participants. On the other hand, our final sample overestimated the older people compared with the distribution of population in Barcelona. However, we weighted the sample to minimise these limitations and to generate estimations representative of the general population. Moreover, the baseline sample size was representative of the city of Barcelona27 ,28 and the longitudinal design of our work maximises the internal validity of the study. Other potential limitations are those related to survey-based studies, as the use of a questionnaire to collect self-reported information, the potential for over-reporting of SFH due to social desirability (unlikely, since it has received few or null attention by the media) and bias due to non-response. However, by using a face-to-face questionnaire with trained interviewers we potentially increased the internal validity of our results as compared with internet and self-administered surveys in order to avoid misinterpretation of the questions.49 Finally, we have not gathered information about the prevalence of SFH between both surveys to assess the impact of both Spanish legislations (independently or combined)
In conclusion, the implementation of the two smoke-free legislations in Spain is related to an increasing of voluntary adoption of SFH rules, in particular with an increase in complete SFH rules. According to our data, the Spanish smoke-free bans did not shift the tobacco consumption from public and work places to private places (homes). Unfortunately, one of three households in Spain still do not have any type of smoke-free rule. For this reason, in Spain, a public health priority should be promoting the adoption of SFH rules.
What this paper adds
The implementation of the smoke-free regulations in public and workplaces in Spain (law 28/2005 and law 42/2010) was associated with an increase in voluntary adoption of smoke-free rules in homes, particularly complete smoke-free homes.
In houses with partial smoke-free rules, outside areas of the houses (balconies, courtyard, terraces, and gardens) were the places that showed increase in smoking after Spanish smoking bans.
According to our data, the Spanish smoke-free bans did not shift the tobacco consumption from public and work places to private places (homes).
References
Footnotes
Contributors JMM-S conceived the study. CL-M collected the data, prepared the database and analysed the data. CL-M drafted the manuscript, which was critically revised by JMM-S. All authors contributed substantially to the interpretation of the data and to revising the manuscript. All authors approved its final version.
Funding This project was co-funded by the Instituto de Salud Carlos III, Subdirección General de Evaluación, Government of Spain (RTICC RD12/0036/0053 and PI12/01114), the Ministry of Universities and Research, Government of Catalonia (grant number 2009SGR192), and the Directorate of Public Health, Ministry of Health (GFH 20051) from the Government of Catalonia, and co-funded by ISCIII-Subdirección General de Evaluación and by FEDER funds/ European Regional Development Fund (ERDF) -a way to build Europe. This work was also partially funded by the European Union's Horizon 2020 Research and Innovation Programme (The TackSHS Project; grant agreement: 681040).
Competing interests None declared.
Ethics approval The research and ethics committee of the Bellvitge University Hospital provided ethical approval for the study. This study meets the code of the Declaration of Helsinki.
Provenance and peer review Not commissioned; externally peer reviewed.