The smoking ban: should we just ditch it? Main opposition
1. On Social Liberty Grounds "Tobacco is not an illegal substance yet the government is persecuting a minority. I think that's a disgrace in a social democracy.” Sir Ronald Harwood, Playwright and screenwriter.
“Health is important, but putting doctors in charge of public policy is like putting plumbers in charge of architecture.” Joe Jackson
2. On harming business
The Smoking Ban in England
Since 1st July 2007
55% workplaces already smoke-free before, 100% after
Surprising early findings (to me)
What we did – Childhood asthma admissions
•1.1 million children in UK have asthma
•Second-hand Smoke is a key predictor of asthma incidence and exacerbation
•Hypothesised that Smoke Free Legislation will reduce hospital admissions for asthma
•This already demonstrated in 3 studies to date (Scotland, US and Canada)
Methods
• Study period: April 2002 to November 2010
• Obtained extract of Hospital Episode Statistics (HES) data covering all admissions in children (< 15 years) with a primary diagnosis of asthma
• Denominator data: census data from Office for National Statistics
• Both datasets had information on age, sex, Index of Multiple Deprivation, urban or rural area
• Statistical analysis: interrupted time series provides three outputs: (1) underlying trend before policy (2) immediate policy impact (3) trend change after policy
Results
Results
Incidence Rate Ratios (IRRs) 95% CI P-Value
1.03 (1.03, 1.04) 0.0005 Time (per year)
0.91 (0.87, 0.94) 0.0005 Smokefree law
0.94 (0.93, 0.96) 0.0005 Time after smoke-free law (per year)
Age group (Pre-school as reference group)
0.51 (0.50, 0.52) 0.0005 School age
Gender (Male as reference group)
0.61 (0.60, 0.62) 0.0005 Female
Location (Urban as reference group)
1.25 (1.22, 1.28) 0.0005 Rural
Socioeconomic Status (most deprived as reference group)
1.07 (1.04, 1.10) 0.0005 Quintile 2
0.89 (0.86, 0.91) 0.0005 Quintile 3
0.74 (0.72, 0.77) 0.0005 Quintile 4
0.71 (0.69, 0.74) 0.0005 Quintile 5 (the least deprived) Results
Time after smoke-free Smoke-free law 95% CI 95% CI law (per year)
Sex Male 0.89 (0.84, 0.94) 0.94 (0.92, 0.97)
Female 0.93 (0.88, 0.98) 0.94 (0.92, 0.97)
Age Group
Pre-school 0.94 (0.89, 0.99) 0.94 (0.91, 0.96)
School-age 0.87 (0.82, 0.92) 0.94 (0.92, 0.97) Area
Urban 0.91 (0.87, 0.95) 0.95 (0.94, 0.97)
Rural 0.89 (0.83, 0.95) 0.91 (0.89, 0.94)
Socio-economic status
Quintile 1 (least deprived) 0.94 (0.88, 1.01) 0.92 (0.90, 0.95)
Quintile 2 0.86 (0.80, 0.93) 0.94 (0.91, 0.97)
Quintile 3 0.91 (0.84, 0.99) 0.94 (0.91, 0.98)
Quintile 4 0.88 (0.81, 0.95) 0.98 (0.95, 1.01)
Quintile 5 (most deprived) 0.93 (0.86, 1.01) 0.93 (0.90, 0.97) Discussion
• Admissions increasing by 3.4% per year before legislation
• Declining by 5.8% per year afterwards (and an immediate change of -9.1%)
• This equates to 4320 fewer admissions in the first year Discussion – where does this fit into other evidence
Reductions in Asthma Admissions
Where Who Fall after ban
Scotland Children <15 18.2% (14.7 ; 21.8)
U.S. (Kentucky) Children <18 18.0% (16.0 ; 29.0)
U.S. (Arizona) Adults 22.0% (19.6 ; 25.4)
Canada Adults 35.0% (18.0 ; 53.0) Location of smoking before and after the English legislation
Lee et al (2011) PLOS ONE
Other impacts of the smoking ban
Where Outcome Effect of ban 95% Cis England Heart Attacks -2.4% -4.06 ; -0.66
Toronto Cardiovasular conditions -39% 38% ; 40%
Toronto Respiratory conditions -33% 32% ; 34% Uraguay Heart Attacks -22% Unknown
Argentina Acute Coronary Syndrome -20.8% 19.3 to 22.6
Meta Analysis (17 studies) Acute Coronary Events -10% 14% to 16%
Meta Analysis included 10 studies from North America; 6 from Europe; and 1 from New Zealand
Mackay D F et al. Heart 2010;96:1525-1530
We conducted a telephone survey of all workers involved in the cleaning, repair, maintenance and renovation of accordions in the Republic of Ireland. We managed successfully to contact 6 out of 7 such workers.... All who were questioned stated categorically that these signs [smoke damage to accordions] had definitely improved in accordions they had worked on since the introduction of the smoking ban in Ireland.... The smoking ban has improved air quality in Irish bars and its implementation in the face of initial opposition has been music to the ears of the people of Ireland! And those negatives again Total number of pubs in the UK 80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Source: Guardian Data Blog - http://www.guardian.co.uk/news/datablog/2010/apr/12/general- election-labour-manifesto-pub-closures Number of pubs closed per week 50
40
30
20
10
0
-10
-20 Room for complacency?
Tobacco industry is vigorously opposed to Smoke Free Legislation
Indirect action: organise and fund hospitality and ‘smokers rights’ groups
Netherlands extended Smoke Free Legislation to hospitality venues in 2008
But industry represented these measures as unpopular and forced an exemption for small owner-run venues
What to look forward to
From us: similar work on COPD
From the wider world - plain packaging likely to be the next battle for public health.
John Noble, Director of the British Brands From www.forestonline.org/ Group, explains: Britain, like many other countries, is ‘Branding fulfils many significant and facing a precarious financial situation. A positive functions for both consumers and global recession has resulted in a sharp markets. Take it away and consumers lose drop in international trade, rising out and markets become commoditised, unemployment and slumping commodity with price rather than quality being the prices. As a result many people are influencing factor.’ suffering profound hardship. With all this As the IEA monograph Prohibitions sets going on the fanatical tobacco control out, there is a strong relationship between industry wants government to devote restrictive lifestyle legislation and the black precious parliamentary time to debating market, where products are not safely and introducing legislation that would tested and are sold to the more vulnerable remove all branded logos from cigarette sections of society. packs. In addition, they want packs printed in a uniformly drab colour. In conclusion
The smoking ban, should we just ditch it?
No, I don’t think so
Thanks To Christopher Millett, John T Lee, Stan Glantz, Azeem Majeed
Questions?