Smokefree Policies to Reduce Tobacco Use

Abstract

In 2001, a systematic review for the Guide to Community Preventive Services identified strong evidence of effectiveness of smoking bans and restrictions in reducing exposure to environmental (secondhand) tobacco smoke. As follow-up to that earlier review, the focus here was on the evidence on effectiveness of smokefree policies in reducing tobacco use. Smokefree policies implemented by worksites or communities prohibit smoking in workplaces and designated public areas. The conceptual approach was modified for this review; an updated search for evidence was conducted; and the available evidence was evaluated. Published articles that met quality criteria and evaluated changes in tobacco-use prevalence or cessation were included in the review. A total of 57 studies were identified in the period 1976 through June 2005 that met criteria to be candidates for review; of these, 37 met study design and quality of execution criteria to qualify for final assessment. Twenty-one studies measured absolute differences in tobacco-use prevalence with a median effect of −3.4 percentage points (interquartile interval: −6.3 to −1.4 percentage points). Eleven studies measured differences in tobacco-use cessation among tobacco users exposed to a smokefree policy compared with tobacco users not exposed to a smokefree policy. The median absolute change was an increase in cessation of 6.4 percentage points (interquartile interval: 1.3 to 7.9 percentage points). The qualifying studies provided sufficient evidence that smokefree policies reduce tobacco use among workers when implemented in worksites or by communities. Finally, a systematic economic review identified four studies that, overall, demonstrated economic benefits from a smokefree workplace policy. Additional research is needed to more fully evaluate the total economic effects of these policies.

Introduction

Involuntary exposure to environmental tobacco smoke, or secondhand smoke, contributes to morbidity and mortality in nonsmokers, including an estimated 35,000 deaths due to cardiovascular disease and 3000 deaths due to lung cancer every year.1, 2, 3 Smoking in workplaces and indoor public areas represents an important source of secondhand smoke exposure for nonsmoking adults.4, 5, 6, 7 Increasingly, communities and workplaces have adopted smokefree policies, which prohibit the smoking of tobacco products in the workplace and in public areas,8, 9, 10 with the primary intent of providing the best possible protection for employees and patrons from repeated, extended exposures to secondhand tobacco smoke.2, 7, 11

In 2001, the Task Force on Community Preventive Services (Task Force) published the results of a systematic review for the Guide to Community Preventive Services (Community Guide) of the evidence on effectiveness of smoking bans and restrictions for reducing exposure to environmental tobacco smoke.12, 13 For that review, the Task Force examined ten studies14, 15, 16, 17, 18, 19, 20, 21, 22, 23 published prior to June 2000 that met quality criteria for study design and execution, and found strong evidence that these interventions reduced exposure to secondhand smoke in a variety of worksite and community settings.¹³

In the original review, the Task Force examined smoking bans and restrictions on tobacco use, but found insufficient evidence to draw a conclusion on the effect.12, 13 Fifty studies were evaluated, almost all of which measured tobacco use among workers exposed to worksite-based policies or to community regulations affecting workplaces. The Task Force noted that several qualifying studies observed substantial reductions in daily consumption of cigarettes by workers exposed to a smoking ban or restriction. In addition, some of the qualifying studies evaluating smoking bans observed increases in tobacco-use cessation and reductions in tobacco-use prevalence in their study populations.¹³

As part of the current Task Force review of interventions appropriate for worksite health promotion efforts, smokefree policies were selected for inclusion as an important intervention option for consideration by many worksites and communities. This report complements the previously completed Community Guide review¹² by focusing on: (1) policies that prohibit smoking in designated venues (i.e., smokefree policies); and (2) the evidence that smokefree policies reduce tobacco use.

Smokefree policies include private-sector rules and public-sector regulations that prohibit smoking in indoor workspaces and designated public areas. Private-sector smokefree policies may establish a complete ban on tobacco use on worksite property or restrict smoking to designated outdoor locations. Community smokefree ordinances establish smokefree standards for all or for designated indoor workplaces and public areas.

A worksite may adopt a smokefree policy alone or in combination with additional interventions to support tobacco-using employees who might seek assistance in quitting. These additional interventions include tobacco cessation groups, client educational materials or activities, telephone-based cessation support, counseling and assistance from healthcare providers, and access to pharmacologic therapies.

A community may adopt a smokefree policy as part of a focused or comprehensive effort to reduce tobacco use and exposure to secondhand tobacco smoke. Studies evaluating the impact of community smokefree policies have noted, and in several cases attempted to control for, the presence of concurrent interventions such as state tobacco excise tax increases, mass media campaigns, community-wide educational activities, and telephone cessation support services.

For this update, the Task Force elected to focus on smokefree policies, as opposed to policies that restrict smoking to designated indoor areas, for both practical and conceptual reasons. First, smokefree policies provide the best possible protection for nonsmokers from exposure to secondhand tobacco smoke.² Second, a review of the evidence on effectiveness of smokefree policies is more appropriate to current efforts to reduce exposure to secondhand smoke in the U.S. (smoking restrictions in indoor settings were more commonly adopted in the 1970s and 1980s). Third, the potential effects on tobacco consumption and cessation are conceptually stronger for efforts that prohibit smoking than for restrictions that permit smoking in a designated indoor area.

This review does not revisit the finding from the earlier review of strong evidence of the effectiveness of smoking bans and restrictions in reducing exposure to secondhand tobacco smoke. These policies remain as intervention options, recommended by the Task Force, for use in worksites and community-wide as part of a strategy to reduce exposure to secondhand tobacco smoke. In this report, the review team (the team) examines the available evidence about the impact of smokefree policies in reducing the prevalence of tobacco use among workers when measured as a change in cessation by workers who smoked prior to adoption of the policy.

In addition to the findings from the earlier Community Guide review, information about the impact of smokefree policies on tobacco use is available from narrative and systematic reviews by other agencies. This is discussed in greater detail (see Results from Other Reviews).

The systematic reviews in this report present the findings of the independent, nonfederal Task Force on Community Preventive Services. The Task Force is developing the Community Guide with the support of the USDHHS in collaboration with public and private partners. The CDC provides staff support to the Task Force for development of the Community Guide. The book, The Guide to Community Preventive Services: What Works to Promote Health?²⁴ (also available online at www.thecommunityguide.org) presents the background and the methods used in developing the Community Guide.

The interventions reviewed here may be useful in reaching several objectives specified in Healthy People 2010.²⁵ These objectives include:

• 27-1 Adult tobacco use: reduce cigarette smoking prevalence from 24% (1998, age adjusted to year 2000 standard population) to 12%

• 27-5 Smoking cessation by adults: increase the percentage of adult smokers stopping smoking for 1 day or longer from 41% (1998, age adjusted to year 2000 standard population) to 75%