Smoke-free bar policies and smokers’ alcohol consumption: Findings from the International Tobacco Control Four Country Survey
Introduction
Cigarette smokers consume alcohol more frequently and more heavily than nonsmokers (Anthony and Echeagaray-Wagner, 2000, Chiolero et al., 2006, Dawson, 2000, Kahler et al., 2008, Falk et al., 2006), and smoking status is particularly strongly associated with hazardous alcohol consumption and with alcohol use disorders. McKee et al. (2007) found that smokers were more than twice as likely to meet National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria for hazardous drinking, and were more than three times as likely to meet DSM-IV criteria for alcohol use disorders.
Smokers also tend to smoke more when they are consuming alcohol (Glautier et al., 1996, Griffiths et al., 1976, Mintz et al., 1985), and alcohol consumption increases among smokers when they are smoking (Mello et al., 1987, Barrett and Paschos, 2006). In addition to the health risks caused by smoking (e.g., cardiovascular disease, chronic obstructive pulmonary disease, several cancers, and death, World Bank, 1999), and heavy alcohol consumption (e.g., hemorrhagic stroke, cirrhosis of the liver, hypertension, gastrointestinal bleeding, several cancers, and death, Rehm et al., 2003), the concurrent use of tobacco and alcohol further exacerbates the relative risk of death (Grucza et al., 2007, Rosengren et al., 1988), along with the risk of head and neck cancers, cirrhosis, and pancreatitis (Blot et al., 1988, Klatsky and Armstrong, 1992, Marrero et al., 2005, Pelucchi et al., 2006, Vaillant et al., 1991).
Given the disease burden caused by tobacco use, imposed on both smokers and non-smokers who are exposed to secondhand smoke, the World Health Organization Framework Convention on Tobacco Control, Article 8, calls for the implementation of comprehensive smoke-free indoor air laws (World Health Organization, 2011). Accordingly, smoking in indoor public places has been completely banned in the United Kingdom (UK) and Australia since 2007 (Global Smokefree Partnership, 2009). Smoking bans have been increasingly implemented in Canada, with most of the country becoming smoke-free by 2008. The United States (US) has been comparatively slow to implement smoke-free legislation, with only 13 states having such policies as of 2008.
It is well established that smoking bans are effective in protecting non-smokers from second-hand smoke (Heloma et al., 2001, Farrelly et al., 2005, Eisner et al., 1998, Menzies et al., 2006). In addition, such policies may reduce overall levels of smoking (Fitchenberg and Glantz, 2002), may reduce the rate of coronary heart disease (Barnoya and Glantz, 2006, Juster et al., 2007, Sargent et al., 2004), and may motivate smokers to adopt smoke-free policies in their own homes (Borland et al., 2006a, Borland et al., 2006b). Further, given the direct association between smoking and alcohol consumption, theory suggests that the advantages of smoking bans may extend beyond smoking-related benefits to alcohol-related benefits.
Few studies have evaluated the association between smoke-free policies and alcohol consumption. McKee et al. (2009) compared change in alcohol consumption among Scottish smokers before and after Scotland became smoke-free to change in alcohol consumption among smokers in the rest of the UK which did not have smoke-free policies, and found no differences in consumption levels. However, following the implementation of smoke-free policies, moderate and heavy drinking smokers in Scotland did experience greater reductions in the amount of drinks they consumed in bars and pubs relative to smokers in the rest of the UK. Second, Picone et al. (2004), using longitudinal data from the US Health and Retirement Survey (1992–2002), reported that smoking restrictions were associated with reduced alcohol consumption among older adult women. However, smoke-free policies were enacted on a state-by-state basis and measures of alcohol consumption were not specifically tied to the state policies, nor were subgroups of drinkers or smokers evaluated. Lastly, Gallet and Eastman (2007), using economic indicators of alcohol consumption in the US between 1982 and 1998, concluded that smoke-free policies reduced the demand for beer and liquor. They too, however, did not evaluate whether differential associations among subpopulations existed.
Given the limited evidence regarding the association between smoke-free policies and alcohol consumption, particularly among those smokers who stand to gain the most from reduced alcohol consumption (i.e., hazardous drinkers), the purpose of this study was to examine the relationship between change in smoke-free bar policies and change in alcohol consumption using a large-scale, multi-country population survey. Further, we examined this relationship specifically among hazardous drinkers, among heavy smokers, and among those who were both hazardous drinkers and heavy smokers.
Section snippets
Participants
Nationally representative samples of adult smokers (aged 18+) from the United Kingdom (UK), Australia, Canada, and the United States (US), who were interviewed as part of the International Tobacco Control Four Country Survey (ITC-4), participated in this study. The ITC-4 is an annual cohort survey designed to evaluate the psychosocial and behavioral impacts of national tobacco control policies using standardized data collection methods and measurements. Beginning in 2002, random digit dialing
Prevalence of smoke-free bar policies during the study period, by country
The percentages of respondents who reported the presence of smoke-free bar policies during the study period are presented in Table 1. Among those who reported the presence of these policies, the percentages who indicated that people were smoking inside bars at last visit are also indicated (i.e., % incompliant). The largest increase in the prevalence of smoke-free bar policies occurred between 2005 and 2007 in the UK. At the end of the study period, nearly all bars in the United Kingdom,
Discussion
Findings from this study indicate that indoor smoke-free bar policies, which are generally implemented alongside other clean indoor air policies, are not associated with significant reductions in alcohol consumption among smokers in general, but changing to a smoke-free air environment may be associated with small reductions in the amount of alcohol typically consumed by hazardous drinkers, along with small reductions in the frequency of alcohol consumption among heavy smokers.
These findings
Role of funding source
Major funders of multiple surveys were: National Cancer Institute, US (P50 CA111326, P01 CA138389, R01 CA100362, R01 CA125116); Canadian Institutes of Health Research (57897 and 79551), National Health and Medical Research Council of Australia (265903 and 450110), Cancer Research UK (C312/A3726), Robert Wood Johnson Foundation (045734), and Canadian Tobacco Control Research Initiative (014578), with additional support from the Centre for Behavioural Research and Program Evaluation, National
Contributors
All authors contributed to the design of the study. Kasza conducted the statistical analyses and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
No conflict declared.
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2020, American Journal of Drug and Alcohol Abuse