Prevalence and predictors of smoking 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) % smoke-free 2. Universal protection 3. Proper implementation and enforcement 4. 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 Implementation preceded by campaigns about second-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 Implementation preceded by campaigns about second-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 not preceded 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 Control Policy 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 wavePost-ban survey wave Fieldwork period# smokersFieldwork period# smokers IrelandDecember 2003 – January ,071December 2004 – January FranceDecember 2006 – February ,735September 2008 – December ,231 The NetherlandsMarch 2008 – April ,072March 2009 – May ,632 GermanyJuly 2007 – November ,515July 2009 – October ,002 Total6,3934, ,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 smoking Policy-relevant outcome: - Smoking inside bars post-ban: Did you smoke inside the pub or bar during your last visit? 18

Measures Moderators: - Country - Educational level Control 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 20

Prevalence of smoking in bars 21

Prevalence of smoking in bars 22

Prevalence of smoking in bars 23

Odds Ratio – OR (95% confidence interval) Policy-specific variables Support for bar smoking ban Total ban0.44 ( )** Partial ban0.72 ( )** No ban1.00 Think about harm of smoking to others Very often0.42 ( )** Often / sometimes1.01 ( ) Rarely / never1.00 Psychosocial mediators Overall opinion of smoking Positive1.01 ( ) Negative0.70 ( )* Neutral1.00 Society disapproves of smoking Agree0.97 ( ) Disagree1.31 ( ) Neutral1.00 * p<0.05 ** p<0.01 *** p<0.001 Predictors of smoking in bars post-ban 24 Odds 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.

Odds Ratio – OR (95% confidence interval) Policy-specific variables Support for bar smoking ban Total ban0.44 ( )** Partial ban0.72 ( )** No ban1.00 Think about harm of smoking to others Very often0.42 ( )** Often / sometimes1.01 ( ) Rarely / never1.00 Psychosocial mediators Overall opinion of smoking Positive1.01 ( ) Negative0.70 ( )* Neutral1.00 Society disapproves of smoking Agree0.97 ( ) Disagree1.31 ( ) Neutral1.00 Predictors of smoking in bars post-ban 25 Odds 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. Stronger predictor in Germany Stronger predictors in France

Odds Ratio – OR (95% confidence interval) Policy-specific variables Support for bar smoking ban Total ban0.44 ( )** Partial ban0.72 ( )** No ban1.00 Think about harm of smoking to others Very often0.42 ( )** Often / sometimes1.01 ( ) Rarely / never1.00 Psychosocial mediators Overall opinion of smoking Positive1.01 ( ) Negative0.70 ( )* Neutral1.00 Society disapproves of smoking Agree0.97 ( ) Disagree1.31 ( ) Neutral1.00 Predictors of smoking in bars post-ban 26 Odds 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. 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: 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