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Title: Effect of smoke-free legislation on adult smoking behavior in England in the 18 months following implementation

Authors: T Lee, S Glantz, C Millett

Reference: PLoS One: 6(6): e20933 (open access)
http://bit.ly/skSkMv

Reviewer: Joaquin Barnoya, MD, MPH, Contributing Editor, ProCor; Research Assistant, Professor of Surgery, Washington University in St. Louis, Missouri, USA; Director, Research and Education, Unidad de Cirugia Cardiovascular de Guatemala, Guatemala

Reviewer comments: Even though the implementation of smoke-free legislation did not lead to an accelerated drop in smoking prevalence and cigarette consumption, it did lead to a shift in social norms. However, countries where smoking prevalence is not yet decreasing might experience a significant drop in smoking prevalence and cigarette consumption after the implementation of smoke-free legislation. As expected smoking indoors (including at home) and inside cars significantly decreased as smoking outdoors increased. This should reflect in a larger percentage of non-smokers not being exposed to the harmful effects of secondhand smoke.

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Purpose of study: England introduced a comprehensive smoke-free legislation on July 2007. The legislation includes all workplaces, including bars and restaurants. This study sought to examine the impact of this policy on smoking prevalence, volume of cigarettes smoked, and where people smoke in England.

Location of study: England, UK

Methods: This study used data from six waves (2003-2008) of the Health Survey for England (HSE). This is an annual survey of people living in private households and is a mechanism for monitoring population health in England. Interviewers obtain household, socioeconomic and personal data, information on health and illness, and health service use from respondents. All respondents are over age 16 years and then are visited by a trained nurse. This analysis excludes respondents below age 18 years. The main outcome variable was self-reported smoking as determined by responses to the question "Do you smoke cigarettes at all nowadays?" Main predictor variable was the introduction of smoke-free legislation. Covariates included age, sex, social class and frequency of alcohol use.

Results: Smoking prevalence decreased from 25% in 2003 to 21% in 2008. The mean number of cigarettes consumed daily by smokers also decreased from 14.1 to 13.1 during the same period of time. There was a statistically significant time trend with smoking prevalence falling over time (AOR = 0.96 per year, p<0.001) and number of cigarettes smoked (-0.28 cigarettes/day, p<0.001). The implementation of smoke-free legislation was not associated with neither of them. After controlling for all other covariates and time trend, the was no additional reduction in smoking prevalence or number of cigarettes smoked per day in the six months prior to the legislation being implemented. The percentage of smokers who reported that they smoked ‘at work' and ‘inside pubs or bars' decreased significantly from 15% to 2% and from 36% to 3%, respectively. Those that responded that they smoked ‘inside their home' decreased significantly from 65% to 55% as did those that smoked inside the car (32% to 26%).