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Smoking in Public Places
A Consultation on Reducing Exposure to Second Hand Smoke
Evidence Report

CHAPTER TWO - SUMMARY OF REPORTS FROM RESEARCH AND EVIDENCE GATHERING

2.1 This section contains summaries of the three reports commissioned by NHS Health Scotland. These are:

• "Passive Smoking and Associated Causes of Death in Adults", David Hole, Public Health and Health Policy Division of Community Based Sciences, University of Glasgow

• "The International Review of the Health and Economic Impact of the Regulation of Smoking in Public Places", Anne Ludbrook, Sheona Bird and Edwin Van Teijlingen, Health Economics Research Unit, University of Aberdeen

• "Workplace Smoking Policies in Scotland" by Sally Malam, Helen Barnard, Tracy Mackey and Rachel Roberts, BMRB.

2.2 The summaries provided here were provided by each author for their respective reports.

David Hole, Public Health and Health Division of Community Based Sciences, University of Glasgow

2.3 The full report is available at http://www.healthscotland.com/researchcentre/pdf/MortalityStudy.pdf

Background and objectives

2.4 The aim of the research was to estimate the number of deaths from the four major smoking-related causes of death in Scottish adults which can be attributed to passive smoking. The objective of the report was to estimate how much past ETS exposure impacts on current levels of death in Scotland.

Methodology

2.5 The report used appropriate local information where possible and international estimates where this was not feasible, with sensible adjustments for local conditions.

2.6 Estimates of the numbers of deaths among adults in Scotland caused by exposure to ETS were calculated using local data on the distribution of exposure categories where possible and international estimates of the level of risk posed.

2.7 Four major disease categories were considered as they are the causes of death most strongly related to smoking and unsurprisingly are the main causes of death in Scotland - lung cancer, ischaemic heart disease (IHD), stroke and respiratory disease.

Key Findings

• As most available data relates to the impact of ETS exposure on lifelong non-smokers, estimates were specifically for this sub-group of individuals.

• ETS exposure is associated with 865 deaths per year in Scotland among lifelong non-smokers from the four main causes listed.

• Individually, this divides into 395 ischaemic heart disease (IHD) deaths, 335 stroke deaths, 91 respiratory deaths and 44 lung cancer deaths.

• Over 75% of the ETS related deaths occur amongst women.

• Including other diseases known to be related to smoking, up to 1,000 deaths per year might be attributed to ETS exposure among lifelong non-smokers.

• Whilst it is extremely difficult to quantify the risk of ETS exposure to ex-smokers as no reliable information exists, there would appear to be as many ex-smoking men and women exposed to ETS as there are lifelong non-smokers. It would not be unreasonable to assume that they are at similar risk after a suitable latent period and that the numbers of ETS related deaths would be similar to that seen for lifelong non-smokers.

• This would imply that some 1,500 to 2,000 deaths per year in Scotland are related to ETS exposure among non-smokers (lifelong or quitters).

• Passive smoking represents the greatest risk to public health when compared to other forms of "involuntary" environmental exposure.

• A ban on smoking in the workplace might be considered to be capable of reducing the number of ETS related deaths by however much it reduces the total ETS exposure in individuals (e.g. 50% reduction in total ETS exposure might lead to a 50% reduction in ETS related deaths).

• It should be recognised that there is a substantial benefit to be gained from such a ban in terms of the impact it would have on active smoking rates. A modest reduction in active smoking rates would have major benefits in terms of reducing numbers of deaths among the Scottish population generally.

2.8 This strand of research is hereafter referred to as "the morbidity and mortality study".

Anne Ludbrook ¹⁵, Shoena Bird ¹⁶ and Edwin van Tijlingen ¹⁷ University of Aberdeen

2.9 The full report is available at http://www.healthscotland.com/researchcentre/pdf/InternationalReviewFullReport.pdf

The up-dated summary is available at http://www.healthscotland.com/researchcentre/pdf/InternationalReviewShortReport.pdf

Background and Objectives

2.10 The aim of the review was to determine the health and economic impact of smoking bans and smoking restrictions in public places.

Methodology

2.11 The study combined a literature review with a modelling exercise to place the likely impacts of restrictions on smoking in public places in a Scottish context. The literature review had to cover a number of distinct areas: health impacts of exposure to ETS or passive smoking; impact of restrictions on exposure levels; impact of restrictions on tobacco use behaviour; economic impacts of restrictions on the hospitality sector; costs of workplace smoking; and the costs of smoking related diseases.

2.12 Existing reviews of evidence were sought first and primary studies were only reviewed where such studies were lacking or did not provide sufficient information for the nature and quality of the evidence to be judged. Quality assessment of reviews and primary literature was carried out with respect to the study methods and whether or not peer review had taken place.

2.13 The model for Scotland was estimated to show the impact of moving from the present situation, under the existing voluntary code, to a possible legislative restriction. The model was estimated on the basis of the best available evidence and using expert judgement where evidence does not exist. The model was estimated to show the impact of a complete ban on smoking in public places as there is no evidence base available to estimate the differential effect of lesser restrictions, such as smoke-free areas and improved ventilation, but the weight of evidence relating to health effects suggested that such interventions reduce but do not remove the harmful effects of ETS.

Health Impacts of ETS

2.14 The findings from the literature review are presented below. Please note that the data about health impacts have been taken from the summary at the beginning of chapter five in the full version of the report. Readers are advised to consult the full report directly to identify the sources for these findings.

• Lung cancer: the excess risk of lung cancer associated with domestic exposure to ETS is about 25%. The range of estimates for workplace exposure is similar to domestic exposure.

• Coronary heart disease (Ischaemic Heart Disease): the excess risk associated with domestic exposure to ETS is also about 25%. The range of estimates for workplace exposure is similar to domestic exposure.

• The risks appear to increase with the extent of exposure to ETS, although in the case of CHD the relationship is not linear.

• Stroke: there appears to be an association between excess risk of stroke and exposure to ETS. Although recent studies report an excess risk of about 34%, further research is required.

• Respiratory disorders: exposure to ETS has a detrimental effect on lung function and may be associated with poorer respiratory health.

• Pregnancy: exposure to ETS in pregnancy can lead to low birth weight and poor gestational growth.

• The literature relating to lung cancer and CHD is substantial and contains a number of good quality meta-analyses of primary studies.

• Studies that have examined the impact of ETS on health can be affected by bias and confounding. However, good quality studies that have adjusted for these factors still find significant effects.

Key Findings

2.15 The remaining findings discussed below were derived from the authors' summary report which identified the health and economic impact of the regulation of smoking in public places.

Health Gains

• There is strong evidence that exposure to ETS (passive smoking) increases mortality and morbidity from lung cancer and coronary heart disease. There is also weaker evidence of an effect in relation to stroke and respiratory diseases.

• The estimated effect of eliminating exposure to ETS in public places in Scotland is an annual reduction in deaths from lung cancer and IHD of 219, with a possible additional reduction in deaths from stroke and respiratory diseases of 187. The full benefit may take between 10 and 30 years to be realised.

• These estimates are based on the number of adults reporting exposure to ETS only in public places. There will be some additional benefit to people who are exposed to ETS both in public places and at home.

Reducing exposure to ETS

• Studies of the introduction of workplace smoking bans and restrictions show a reduction in exposure to ETS. No similar studies were found for other public places.

• Complete smoking bans are associated with greater reductions in exposure to ETS than other forms of restrictions.

Effects on smoking behaviour

• Workplace smoking bans and restrictions are also associated with reductions in the number of cigarettes smoked by continuing smokers, increases in quit attempts and successful quitting and reductions in smoking prevalence.

• Complete smoking bans are associated with greater reductions in smoking than other forms of restriction.

• At a population level, the health gains in Scotland from reductions in active smoking may be at least as great as those from reduced passive smoking.

Economic impacts

• Studies of the impact of smoking restrictions on the hospitality sector (hotels, bars and restaurants), using objective data such as sales tax and employment, have failed to find any statistically significant effect. The evidence from these studies is not as robust as the evidence relating to health effects in terms of quantity of published studies, study design and sample size. However, the findings are consistent in demonstrating a small and mainly positive effect.

• These studies were carried out in the context of claims that there would be a negative impact of 30%. The studies were designed with sufficient power to detect effects of this size and they demonstrated that impacts of this order of magnitude had not occurred in the locations studied.

• The possibility of small overall negative effects cannot be ruled out, nor can the possibility of negative impacts for some businesses or small areas which are balanced out by gains elsewhere.

• The annual effect on the hospitality sector in Scotland is estimated to lie in the range -104m to +299m with a central estimate of +97m. Most of the uncertainty relates to the estimated impact on bars. The net effect on the Scottish economy, however, will be smaller than this as any change in spending will be redistributed to or from other sectors of the economy.

• Other economic impacts include savings to the NHS (range: +5.7m to +15.7m), productivity gains from reductions in sickness absence (range: +3.8m to +6.4m) and smoking breaks (range:0 to +73.7m); and savings on fire damage (range: +4.0m to +5.0m) and cleaning costs (+11.7m). These are annual estimates but the full savings on NHS costs and sickness absence may take between 10 and 30 years to be realised, although some benefits may accrue more rapidly.

Estimated total impact

• The total effect of eliminating exposure to ETS is estimated by applying financial values to the health gains and adding these to the economic impacts.

• The central estimate for the full annual effect is +335m (undiscounted range: +23m to +555m). This is equivalent to +124m when discounted to take account of the timing of effects (discounted range: +8m to +205m), with a net present value over 30 years of +4,620m (net present value range: +55m to +7,395m).

• The main areas of uncertainty relate to the possible productivity gains from smoking breaks and the estimated impact on the hospitality sector.

2.16 This strand of research is hereafter referred to as "the international review".

Sally Mallam, Helen Barnard, Tracy Mackey and Rachel Roberts, BMRB Social Research

2.17 The full report is available at http://www.healthscotland.com/researchcentre/pdf/WorkplaceSmokingPoliciesScotland.pdf

Background and objectives

2.18 NHS Health Scotland commissioned BMRB Social Research to conduct a study of smoking and smoking policies in the workplace on behalf of the Scottish Executive.

2.19 The principal objectives were to identify:

• The patterns of provision of policies in commercial workplaces in Scotland and to measure the extent of policy enforcement

• What smoking cessation support is currently in place for employees and how this could be extended

• The barriers and facilitators to establishing employee smoking policies

• The potential impact of the introduction of smoking policies and the perceived need for legislation.

Methodology

2.20 The study involved two stages:

• Quantitative Survey. A fifteen minute telephone questionnaire was conducted with managers in 1,604 workplaces (both Small and Medium Enterprises and larger organisations ¹⁸) who are responsible for developing and implementing smoking policies.

• Qualitative Research. Face to face interviews were conducted with a range of managers and employees in 17 of the workplaces that had participated in the quantitative survey.

Key Findings

Attitudes to smoking

• The qualitative research indicated that smoking was viewed very negatively by both smokers and non-smokers, as a result of both comfort and health concerns. While the quantitative survey found that almost all of those responsible for smoking policies believed passive smoking carried health risks (88%), the qualitative research revealed that there was a great deal of uncertainty about the real level of risk for smokers and those breathing in second hand smoke.

Attitudes to smoking and smoking policies at work

• The quantitative research focused on the benefits and negative consequences of smoking policies and found that workplaces could see the health benefits of implementing some kind of smoking restriction or ban. This widespread acceptance of the health risks of passive smoking could be a strong facilitator of smoking policies. Productivity was seen as more likely to be improved than reduced by a smoking ban although feelings were more mixed about the impact of smoking restrictions.

• There was clear evidence of some support for a smoking ban, since 89% of responses were able to cite one or more benefits of a ban, and only 11% could see no benefits at all. There was, however, evidence of a preference for smoking restrictions over a ban, particularly in the leisure and hospitality sector. The main barrier to a total ban was the fear of confrontation amongst staff. Resources were a further barrier for smaller organisations.

• The qualitative research found that attitudes to smoking at work were underpinned by the concepts of fairness and choice, with strong support for the perceived rights of both smokers and non-smokers. There was also a great deal of hostility to measures which were seen as being reminiscent of a 'big brother' state.

• Respondents' views of smoking in the workplace were also influenced by their desire to be able to smoke when they socialised in pubs or bars, or a sense that it would not be natural for bars and pubs not to be smoky.

Smoking policies in the workplace

• The quantitative research found that three in four workplaces (77%) reported having an employee smoking policy, although policies for members of the general public (where applicable) were slightly more common (82%). Over half of these policies (55%) were not written policies, particularly those in SME workplaces (64%).

• Half of workplaces (48%) banned smoking by employees anywhere on the premises. Three in ten (28%) restricted smoking to designated areas or smoking rooms and only 1% had a policy allowing employees to smoke anywhere on the premises. Two in ten (22%) had no policy at all.

• The smaller, indoor-based, less manual sectors such as retail and wholesale, and finance and real estate were most likely to implement a complete ban on employee smoking. In contrast, workplaces from the manufacturing and leisure and hospitality sectors, traditionally manual, indoor and site-based organisations, were most likely to have policies that restricted smoking by employees to smoking rooms or designated areas. Those in the traditionally manual, outdoor, off-site sectors such as transport, construction and agriculture were least likely to have a policy in place at all for employees, and were also least likely to have a policy for the general public.

• The qualitative interviews with staff and managers showed that stated policies were not always followed in practice.

Provisions in areas where smoking is not banned

• A third of workplaces (33%) required employees to work in areas where smoking was not banned, rising to six in ten (60%) in the leisure and hospitality sector.

• Eight in ten workplaces with areas where smoking was permitted ventilated at least some of these areas (81%). This ventilation, however, tended to be through 'natural' methods such as an open window. Workplaces in the manufacturing and leisure and hospitality sectors were more likely to use mechanical ventilation. There was a widespread belief that ventilation reduces the health risks of passive smoking and this could act as a strong disincentive to implement a smoking ban in the workplace.

Policy implementation, communication and enforcement

• The quantitative research found that workplaces with a policy tended to rely on verbal methods of communication when informing employees of the smoking policy, with four in ten (42%) relying solely on this method. Policy enforcement also tended to be informal.

• The majority of respondents felt that there was very little non-compliance with the employee smoking policy (90% said rarely or never).

• The qualitative case studies also showed a general acceptance of smoking policies or rules. Staff and managers often viewed some rule bending as both normal and acceptable.

Smoking Cessation Support

• Smoking cessation support was only offered by one in ten organisations (12%) although this rose to two thirds (64%) of the largest workplaces.

• The qualitative research indicated that staff were not always aware of cessation support services offered by their company or available in the community.

• Staff as well as managers did not believe that providing cessation support was the duty of the employer, but rather the duty of government.

Policy initiatives and legislation

• In the survey, perhaps the most widely accepted facilitator to policy implementation was legislation. Seven in ten (72%) felt that legislation would be necessary to assist the implementation of smoking restrictions in the workplace.

• Support for legislation to restrict employee smoking was slightly higher (82%) than support for legislation to ban smoking (71%).

Conclusions

• This study found that most workplaces currently have smoking policies for employees in place. In addition, there was widespread support for smoking restrictions and legislation, and together these factors should facilitate the implementation of any future legislation on smoking in public places. However, support for legislation should be interpreted within the context of continuing doubt amongst employers and employees about the true health risks of passive smoking, and the somewhat flexible way existing policies work in practice. In addition, businesses and individuals have considerable fears, particularly in the leisure and hospitality sector, and smaller organisations. For these types of business, fears tend to centre on potential loss of trade or profit, and also on the resources needed to implement such a policy.

• Smoking restrictions are likely to meet less resistance from businesses than a total ban. However, there are practical barriers for smaller businesses without the space to allocate as smoking areas, which may make a total ban easier to manage for some. Furthermore, despite managers' perceptions that introducing a full ban would cause greater conflict with staff, the experience of those with an existing ban suggests that, once the policy is established, there are lower levels of non-compliance with a ban than restrictions, making the policy easier to enforce.

2.21 This strand of research is hereafter referred to as "the workplace policies study".

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