1. THE ROLE OF PHOs IN MONITORING THE IMPACT OF SMOKEFREE WORKPLACE LEGISLATION: SECONDHAND REFLECTIONS FROM IRELAND Kevin P Balanda Ireland and Northern Ireland’s Population Health Observatory, Institute of Public Health in Ireland February 2007

2. ACKNOWLEDGEMENTS Dr Fenton Howell, HSE Dr Shane Allwright, TCD Some personal reflections

3. OVERVIEW The ban Monitoring impact Some reflections Role of PHOs

4. THE BAN

5. Authors concluded ETS cause heart disease cancer and respiratory probs Employees need to be protected Ventilation is ineffective Legislative measures are required 30 th January 2003 Allwright Report

6. INTRODUCTION OF THE BAN Fundamental role of OTC and Ash, IrelandFundamental role of OTC and Ash, Ireland Smoke-free workplaces introduced 29 th March 2004Smoke-free workplaces introduced 29 th March 2004 Onus on employer/owner to enforce itOnus on employer/owner to enforce it Part of a comprehensive tobacco control package:Part of a comprehensive tobacco control package: –price, advertising, sales to children, tar & nicotine levels, etc –Smokers Quitline, NRT for low income smokers, brief intervention training for GPs, increased cessation support in the community

7. MONITORING IMPACT

8. ALL IRELAND BAR STUDY Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study (Allwright et al. BMJ October 2005) Objective –To compare exposure to secondhand smoke (SHS) and respiratory health in bar staff in the Republic and Northern Ireland before and one year after the introduction of the ban A. CHANGES IN EXPOSURE TO SHS & MEDICAL SYMPTOMS AMONGST BAR WORKERS (RoI vs NI)

9. Highly significant: improvements in air quality in RoI pubsimprovements in air quality in RoI pubs Difference in air quality in RoI pubs compared to NI pubsDifference in air quality in RoI pubs compared to NI pubs Reductions in work (and non-work) exposure in RoI bar workers compared to NI bar workersReductions in work (and non-work) exposure in RoI bar workers compared to NI bar workers reductions in salivary cotinine in RoI (non- smoking) bar workers compared to NI bar workersreductions in salivary cotinine in RoI (non- smoking) bar workers compared to NI bar workers Reduction in symptoms (respiratory and sensory) in non-smoking RoI bar workers compared to those in NIReduction in symptoms (respiratory and sensory) in non-smoking RoI bar workers compared to those in NI A. FINDINGS – SHS AND MEDICAL SYMPTOMS

10. Air quality in RoI pubs (ultra-fine particles)

11. Air quality in RoI and NI pubs after the ban (ultra-fines) NI pubs Dublin pubs

12. Median (IQR) self reported SHS exposure (non-smokers & smokers) Pre-banPost-banP Republic (n=220) Hours exposed at work 40 (38 to 50) 0 (0 to 0 ) <0.001 Hrs exposed outside work 5 (0 to 20) 0.5 (0 to 9.0) <0.001 N. Ireland (n=29) Hours exposed at work 40 (24.3 to 50) 30.0 (14 to 45) 0.03 Hrs exposed outside work 4.5 (0 to 10) 4.0 (0 to 16) 0.54

13. Median (IQR) SHS exposure in non-smokers Pre-banPost-banP Republic (n=138) Salivary cotinine (ng/ml) 5.1 (3.2 to 7.6) 0.9 (0.5 to 2.3) <0.001 N. Ireland (n=20) Salivary cotinine (ng/ml) 4.5 (1.8 to 10.4) 3.6 (2.3 to 6.0) 0.05

14. % non-smokers reporting symptoms in the past week Pre-banPost-banP Republic (n=138) Any respiratory symptom 65490.001 Any sensory symptom 6745<0.001 N. Ireland (n=20) Any respiratory symptom 45451.00 Any sensory symptom 75550.13

15. Objective –To evaluate the psychosocial and behavioural impact of the first ever national level comprehensive workplace smoke- free law, implemented in Ireland in March 2004 B. REPORTED SMOKING IN WORKPLACES (RoI AND UK)

16. Significant reductions in reported smoking in public places (particularly bars and restaurants) in RoI compared to UKSignificant reductions in reported smoking in public places (particularly bars and restaurants) in RoI compared to UK No increase in smoking at home or in carsNo increase in smoking at home or in cars B. FINDINGS - SMOKING IN WORKPLACES (RoI AND UK)

19. C. CIGARETTE SALES The Sunday Times, 18 th July 2004

20. D. “THE ONE YEAR REVIEW” 93% think the law was a good idea, including 80% of smokers93% think the law was a good idea, including 80% of smokers 96% of people feel the law is successful, including 89% of smokers96% of people feel the law is successful, including 89% of smokers 98% believe that workplaces are healthier, including 94% of smokers98% believe that workplaces are healthier, including 94% of smokers RTE New Year Poll 2004 – How was it for you? Smoke-free law voted the no 1 high of 2004RTE New Year Poll 2004 – How was it for you? Smoke-free law voted the no 1 high of 2004

21. E. SMOKING PREVALENCE IN RoI

24. Promising resultsPromising results In some cases initial falls in smoking prevalence reversed (eg females)In some cases initial falls in smoking prevalence reversed (eg females) Some evidence of reduction in percentage of heavy smokersSome evidence of reduction in percentage of heavy smokers Temporal changes (eg falling rates in some cases) confound mattersTemporal changes (eg falling rates in some cases) confound matters Complex message reflecting other factors (eg price)Complex message reflecting other factors (eg price) C. FINDINGS – POPULATION SMOKING PREVALENCE

25. SOME REFLECTIONS

26. SOME REFLECTIONS (1) Important public health battle won! Fall out: Tobacco no longer an issue - problem solved!Tobacco no longer an issue - problem solved! Media moved on to other issues (alcohol, drugs, RTA, obesity, etc)Media moved on to other issues (alcohol, drugs, RTA, obesity, etc) Government allowed off the hook on other tobacco related issues (price, FCTC – difficulty in getting signed, non implementation of Public Health Tobacco Acts)Government allowed off the hook on other tobacco related issues (price, FCTC – difficulty in getting signed, non implementation of Public Health Tobacco Acts) The bigger public health war is still going on! It’s not all about the smoking ban!

27. SOME REFLECTIONS (2) It facilitated the development of statutory and NGO community working together Burn-out: Building public health advocacy for over 20 yearsBuilding public health advocacy for over 20 years NGOs expended huge resources on this issue, before and after the legislationNGOs expended huge resources on this issue, before and after the legislation Difficulty of “doing it on the cheap”Difficulty of “doing it on the cheap” Balance between: research to build the evidence-baseresearch to build the evidence-base information to support advocacy (needed sooner)information to support advocacy (needed sooner) There is a need for continuing public health advocacy. There is a need for ongoing monitoring of impacts at different levels and other tobacco control activities.

28. ROLE OF PHOs

29. SOME ISSUES PHOs can make a contribution at local/regional, national and international levels Individual PHOs and the APHO Advocating for tobacco control as well as for public health information? Are PHOs in this for the short term or the longer term?

30. TAPPING INTO THE APHO NETWORK (1) Supporting implementation –the smoking ban –other tobacco control activities –ongoing public health advocacy Providing methodological & analytical expertise –research & evaluation support –tools and resources Monitoring impacts at different levels using routine data: –sickness/absence data –primary care data –hospital data (acute asthma attacks, AMI, etc) –cancer incidence and mortality data

31. TAPPING INTO THE APHO NETWORK (2) Filling the gap between “academic” and “service” public health Studies across regions within England; studies across the five nations in APHO (staggered introduction?) Monitoring & reviewing progress –follow-up meetings –sharing the learning Building infrastructure & capacity –monitoring & surveillance –anti-tobacco coalitions and partnerships

32. THANK YOU

33. AREAS OF INTEREST –Public opinion and support for the ban –Compliance, prosecutions –Air quality, ETS, smoke migration –Smoking in other places (eg homes and in cars) –Bar, restaurant, etc trade –Health impacts on workers –Smoking cessation services & other tobacco control measures –Tobacco sales –Cessation attempts, smoking rates –Population health impacts –Fall out?