Use of a Living Lab Approach to Implement a Smoke-Free Campus Policy.

While universities have increasingly become tobacco-/smoke-free, to our knowledge, no campus has reported 100% policy compliance. Innovative approaches to encourage compliance and ongoing data collection are needed. This paper describes actions undertaken, framed within a Living Lab (LL) approach, to implement smoke-free campus policies in an Irish university. The action research comprised student-collected data on observed smoking on campus to evaluate adherence and compliance, first to a smoke-free zones policy (June 2016-March 2018), and then to a smoke-free campus policy (March 2019-February 2020). From June 2016-February 2020, 2909 smokers were observed. Adherence, defined as the average reduction in number of observed smokers from baseline in May 2016, reduced by 79% from 5.7 to 4.9 . Compliance, defined as the proportion of smokers who complied when reminded of the policy, was 90% (2610/2909). Additional activities included development of a broader health promotion programme; identification of a pattern of 'social smoking'; and promoting increased awareness of the environmental harms of tobacco. Ongoing policy implementation is essential for smoke-free policies and should include data collection and evaluation. Actions framed within the characteristics of a LL achieved fewer observed smokers. A LL approach is recommended to encourage policy adherence and compliance.

Development and proposed evaluation of an eHealth learning tool for undergraduate university students in Ireland.

Undergraduate university students are at a critical stage of development in terms of their academic, social, psychological and behavioural health. Patterns established during these formative years can last a lifetime. eHealth tools have the potential to be engaging, convenient and accessible to a wide range of students by providing health information and enhancing the uptake of positive health behaviours. The 'Healthy Trinity Online Tool' (H-TOT) was developed in collaboration with students and a transdisciplinary team with decades of experience between them in terms of research, clinical responsibility and service delivery. Developmental steps undertaken included: a literature review to formulate the topic content choices; a survey of students to check the relevance and suitability of topics identified; and, the tacit experience of the development team. This co-design model led to the development of content encompassing academic life, healthy eating, physical activity, mood, financial matters, alcohol, tobacco, drugs and relaxation. Qualitative focus groups were subsequently conducted for in-depth exploration of the usage and functionality of H-TOT. The theoretical underpinnings include the locus of control and social cognitive theory. Evidence-based behavioural change techniques are embedded throughout. During early pre-piloting of H-TOT, the team identified and solved content functionality problems. The tone of the content was also revised to ensure it was non-judgemental. To make the H-TOT as interactive as possible, video scenarios were included and all content was audio-recorded to allow playback for students with visual or learning difficulties. Evaluation plans for the pilot year of H-TOT are outlined.

A multi-faceted intervention to reduce alcohol misuse and harm amongst sports people in Ireland: A controlled trial.

INTRODUCTION AND AIMS: Alcohol misuse and harm are more prevalent amongst sports people than non-sports people. Few studies have trialled interventions to address alcohol misuse for this group. The study aimed to test the effectiveness of an intervention to reduce alcohol misuse and related harms amongst amateur sports people in Ireland. DESIGN AND METHODS: A controlled trial was conducted in two counties in Ireland. A random selection of sports clubs in one county received a 4 month multi-faceted intervention. All sports clubs in a non-adjacent county acted as control sites. Consumption of more than 21 units of alcohol per week and six or more standard drinks on a single occasion at least once per week was the primary study outcome. Alcohol Use Disorders Identification Test scores and number of alcohol-related harms were also reported. Outcomes were assessed for cross-sectional samples of players at pre-intervention and post-intervention and paired samples of players who completed surveys at both times. Generalised linear mixed model analysis was used. RESULTS: There was no evidence of effect for the primary outcomes or Alcohol Use Disorders Identification Test scores. There was a statistically significant difference in the median number of alcohol-related harms reported by intervention group players compared with control group players at post-intervention for the paired samples [intervention: 0; control: 3; incident rate ratio 0.56 (0.37, 0.84); P = 0.005]. DISCUSSION AND CONCLUSIONS: Intervention in community sports clubs may be effective in reducing the number of alcohol-related harms. Low levels of intervention participation and inadequate intervention dose are possible reasons for lack of a broader intervention effect. [O'Farrell A, Kingsland M, Kenny S, Eldin N, Wiggers J, Wolfenden L, Allwright S. A multi-faceted intervention to reduce alcohol misuse and harm amongst sports people in Ireland: A controlled trial. Drug Alcohol Rev 2018;37:14-22].

Shared care across the interface between primary and specialty care in management of long term conditions.

BACKGROUND: Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care. OBJECTIVES: To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.Secondary questions include the following:1. Which shared care interventions or portions of shared care interventions are most effective?2. What do the most effective systems have in common? SEARCH METHODS: We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015. SELECTION CRITERIA: One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types. MAIN RESULTS: We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty). AUTHORS' CONCLUSIONS: This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.

Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys.

INTRODUCTION: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries. METHODS: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country. RESULTS: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries. CONCLUSIONS: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Socioeconomic and country variations in cross-border cigarette purchasing as tobacco tax avoidance strategy. Findings from the ITC Europe Surveys.

BACKGROUND: Legal tobacco tax avoidance strategies such as cross-border cigarette purchasing may attenuate the impact of tax increases on tobacco consumption. Little is known about socioeconomic and country variations in cross-border purchasing. OBJECTIVE: To describe socioeconomic and country variations in cross-border cigarette purchasing in six European countries. METHODS: Cross-sectional data from adult smokers (n=7873) from the International Tobacco Control (ITC) Surveys in France (2006/2007), Germany (2007), Ireland (2006), The Netherlands (2008), Scotland (2006) and the rest of the UK (2007/2008) were used. Respondents were asked whether they had bought cigarettes outside their country in the last 6 months and how often. FINDINGS: In French and German provinces/states bordering countries with lower cigarette prices, 24% and 13% of smokers, respectively, reported purchasing cigarettes frequently outside their country. In non-border regions of France and Germany, and in Ireland, Scotland, the rest of the UK and The Netherlands, frequent purchasing of cigarettes outside the country was reported by 2-7% of smokers. Smokers with higher levels of education or income, younger smokers, daily smokers, heavier smokers and smokers not planning to quit smoking were more likely to purchase cigarettes outside their country. CONCLUSIONS: Cross-border cigarette purchasing is more common in European regions bordering countries with lower cigarette prices and is more often reported by smokers with higher education and income. Increasing taxes in countries with lower cigarette prices, and reducing the number of cigarettes that can be legally imported across borders could help to avoid cross-border purchasing.

Attitudes of women from five European countries regarding tobacco control policies.

AIMS: Tobacco-related cancers and, in particular, lung cancer still represents a substantial public health epidemic across Europe as a result of high rates of smoking prevalence. Countries in Europe have proposed and implemented tobacco control policies to reduce smoking prevalence, with some countries being more progressive than others. The aim of this study was to examine factors that influenced women's attitudes across five European countries relative to comprehensive smokefree laws in their countries. METHODS: A cross-sectional landline telephone survey on attitudes towards tobacco control laws was conducted in five European countries: France, Ireland, Italy, the Czech Republic, and Sweden. Attitudinal scores were determined for each respondent relative to questions about smokefree laws. Logistic regression models were used to obtain odds ratios with 95% confidence intervals. RESULTS: A total of 5000 women were interviewed (1000 women from each country). The majority of women, regardless of smoking history, objected to smoking in public buses, enclosed shopping centers, hospitals, and other indoor work places. More women who had quit smoking believed that new tobacco control laws would prompt cessation - as compared with women who still smoked. CONCLUSIONS: In general, there is very high support for national smokefree laws that cover bars, restaurants, and public transport systems. As such laws are implemented, attitudes do change, as demonstrated by the differences between countries such as Ireland and the Czech Republic. Implementing comprehensive smokefree laws will gain high approval and will be associated with prompting people to quit.

Impact of national smoke-free legislation on home smoking bans: findings from the International Tobacco Control Policy Evaluation Project Europe Surveys.

OBJECTIVES: To measure changes in prevalence and predictors of home smoking bans (HSBs) among smokers in four European countries after the implementation of national smoke-free legislation. DESIGN: Two waves of the International Tobacco Control Policy Evaluation Project Europe Surveys, which is a prospective panel study. Pre- and post-legislation data were used from Ireland, France, Germany and the Netherlands. Two pre-legislation waves from the UK were used as control. PARTICIPANTS: 4634 respondents from the intervention countries and 1080 from the control country completed both baseline and follow-up and were included in the present analyses. METHODS: Multiple logistic regression models to identify predictors of having or of adopting a total HSB, and Generalised Estimating Equation models to compare patterns of change after implementation of smoke-free legislation to a control country without such legislation. RESULTS: Most smokers had at least partial smoking restrictions in their home, but the proportions varied significantly between countries. After implementation of national smoke-free legislation, the proportion of smokers with a total HSB increased significantly in all four countries. Among continuing smokers, the number of cigarettes smoked per day either remained stable or decreased significantly. Multiple logistic regression models indicated that having a young child in the household and supporting smoking bans in bars were important correlates of having a pre-legislation HSB. Prospective predictors of imposing a HSB between survey waves were planning to quit smoking, supporting a total smoking ban in bars and the birth of a child. Generalised Estimating Equation models indicated that the change in total HSB in the intervention countries was greater than that in the control country. CONCLUSIONS: The findings suggest that smoke-free legislation does not lead to more smoking in smokers' homes. On the contrary, our findings demonstrate that smoke-free legislation may stimulate smokers to establish total smoking bans in their homes.

Comparative impact of smoke-free legislation on smoking cessation in three European countries.

BACKGROUND: Little is known about the differential impact of comprehensive and partial smoke-free legislation on smoking cessation. This study aimed to examine the impact of comprehensive smoke-free workplace legislation in Ireland and England, and partial hospitality industry legislation in the Netherlands on quit attempts and quit success. METHODS: Nationally representative samples of 2,219 adult smokers were interviewed in three countries as part of the International Tobacco Control (ITC) Europe Surveys. Quit attempts and quit success were compared between period 1 (in which smoke-free legislation was implemented in Ireland and the Netherlands) and period 2 (in which smoke-free legislation was implemented in England). RESULTS: In Ireland, significantly more smokers attempted to quit smoking in period 1 (50.5%) than in period 2 (36.4%) (p < 0.001). Percentages of quit attempts and quit success did not change significantly between periods in the Netherlands. English smokers were significantly more often successful in their quit attempt in period 2 (47.3%) than in period 1 (26.4%) (p = 0.011). In the first period there were more quit attempts in Ireland than in England and fewer in the Netherlands than in Ireland. Fewer smokers quitted successfully in the second period in both Ireland and the Netherlands than in England. CONCLUSION: The comprehensive smoke-free legislation in Ireland and England may have had positive effects on quit attempts and quit success respectively. The partial smoke-free legislation in the Netherlands probably had no effect on quit attempts or quit success. Therefore, it is recommended that countries implement comprehensive smoke-free legislation.

Prevalence and predictors of smoking in "smoke-free" bars. Findings from the International Tobacco Control (ITC) Europe Surveys.

National level smoke-free legislation is implemented to protect the public from exposure to second-hand tobacco smoke (SHS). The first aim of this study was to investigate how successful the smoke-free hospitality industry legislation in Ireland (March 2004), France (January 2008), the Netherlands (July 2008), and Germany (between August 2007 and July 2008) was in reducing smoking in bars. The second aim was to assess individual smokers' predictors of smoking in bars post-ban. The third aim was to examine country differences in predictors and the fourth aim was to examine differences between educational levels (as an indicator of socioeconomic status). This study used nationally representative samples of 3147 adult smokers from the International Tobacco Control (ITC) Europe Surveys who were surveyed pre- and post-ban. The results reveal that while the partial smoke-free legislation in the Netherlands and Germany was effective in reducing smoking in bars (from 88% to 34% and from 87% to 44%, respectively), the effectiveness was much lower than the comprehensive legislation in Ireland and France which almost completely eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively). Smokers who were more supportive of the ban, were more aware of the harm of SHS, and who had negative opinions of smoking were less likely to smoke in bars post-ban. Support for the ban was a stronger predictor in Germany. SHS harm awareness was a stronger predictor among less educated smokers in the Netherlands and Germany. The results indicate the need for strong comprehensive smoke-free legislation without exceptions. This should be accompanied by educational campaigns in which the public health rationale for the legislation is clearly explained.

Alcohol use among amateur sportsmen in Ireland.

BACKGROUND: The objective of this study was to establish baseline data on alcohol consumption patterns, behaviours and harms among amateur sportsmen in the Republic of Ireland. FINDINGS: The study presents findings from the baseline survey for a cluster randomised controlled trial to evaluate the effectiveness of a community intervention programme to reduce problem alcohol use among a representative sample of Gaelic Athletic Association (GAA) clubs in two counties in the Republic of Ireland. Self reported alcohol use, prevalence of binge drinking, AUDIT scores and alcohol-related harms were assessed in amateur GAA sportsmen aged 16 years and over.Nine hundred and sixty (960) players completed questionnaires (72% response rate). Mean age was 24.0 years (S.D. 5.2). Of those aged 18 years or over, 75% had post-primary education; most (864, 90%) were current drinkers and 8.2% were regular smokers. The self-reported average yearly alcohol consumption was 12.5 litres. Almost one third (31%) of current drinkers reported drinking over the recommended limit of 21 standard drinks per week and just over half (54.3%) reported drinking 6 or more standard drinks in a row at least once a week (regular binge drinking). Of those who (self) completed the Alcohol Use Disorder Identification Test (AUDIT) questionnaire, three-quarters (74.7%) had a score of 8 or more; 11.5% had a score of 20 or above warranting referral for diagnostic evaluation and treatment. Almost all (87.6%) of the 864 drinkers reported experiencing at least one harm due to their drinking. These alcohol misuse outcomes were higher than those found in a nationally representative sample of males of a similar age. There were strong associations between regular binge drinking and reporting harms such as being in a fight (adjusted odds ratio (OR) 2.02, p < 0.001), missing time from work or college (adjusted OR 1.39, p = 0.04) or being in an accident (adjusted OR 1.78, p = 0.04). CONCLUSIONS: These male amateur sportsmen reported high rates of alcohol consumption and alcohol-related harm.

Knowledge and beliefs about smoking and cancer among women in five European countries.

BACKGROUND: Lung cancer mortality in women is increasing across Europe, reflecting the alarming increase in smoking prevalence. Understanding women's perception of smoking may help to identify ways to reduce its prevalence and prevent uptake of smoking. The aim of this study was to examine factors associated with knowledge and beliefs about smoking and cancer among European women. METHODS: A cross-sectional landline telephone survey on health attitudes and knowledge was conducted in five European countries: France, Ireland, Italy, the Czech Republic, and Sweden. A general linear modeling was used to explore the factors related to knowledge and beliefs about smoking and cancer. RESULTS: A total of 5,000 women were interviewed (1,000 women from each country). The mean knowledge and belief scores about smoking and cancer were lower in current smokers than those of never and former smokers (P < 0.05). Women with above-the-median income (P = 0.001) and women who held skilled occupations seemed to be more knowledgeable about tobacco health risks (P < 0.001). The number of friends and family who smoked was inversely associated with knowledge on the harmful effects of tobacco (P = 0.001). Swedish women were the most knowledgeable about tobacco-related cancer risk, whereas in France and Italy, current smokers were less knowledgeable. CONCLUSIONS: Knowledge and beliefs about cancer and smoking varied significantly by smoking status. IMPACT: Results emphasize the need to develop health education programs that enhance cancer knowledge among women who currently smoke and are in low socioeconomic groups.

A telephone survey of parental attitudes and behaviours regarding teenage drinking.

BACKGROUND: Irish teenagers demonstrate high rates of drunkenness and there has been a progressive fall in age of first drinking in recent decades. International research indicates that parents exert substantial influence over their teenager's drinking. We sought to determine the attitudes and behaviours of Irish parents towards drinking by their adolescent children. METHODS: We conducted a telephone survey of a representative sample of of 234 parents who had a teenager aged between 13 and 17 years. RESULTS: Six per cent reported that they would be unconcerned if their son or daughter was to binge drink once per month. On the issue of introducing children to alcohol in the home, 27% viewed this as a good idea while 63% disagreed with this practice. Eleven per cent of parents reported that they had given a drink to their teenager at home. Parents who drank regularly themselves, who were from higher socio-demographic groups and who lived in the east of Ireland demonstrated more permissive attitudes to teenage drinking. CONCLUSIONS: We found no evidence of widespread permissive attitudes and behaviours among Irish parents. Given that parental influences have been demonstrated to exert substantial impact on teenage drinking, it may be possible to harness the concerns of Irish parents more effectively to reverse the trends of escalating alcohol related harm in Ireland.

Primary medical care in Irish prisons.

BACKGROUND: An industrial dispute between prison doctors and the Irish Prison Service (IPS) took place in 2004. Part of the resolution of that dispute was that an independent review of prison medical and support services be carried out by a University Department of Primary Care. The review took place in 2008 and we report here on the principal findings of that review. METHODS: This study utilised a mixed methods approach. An independent expert medical evaluator (one of the authors, DT) inspected the medical facilities, equipment and relevant custodial areas in eleven of the fourteen prisons within the IPS. Semistructured interviews took place with personnel who had operational responsibility for delivery of prison medical care. Prison doctors completed a questionnaire to elicit issues such as allocation of clinician's time, nurse and administrative support and resources available. RESULTS: There was wide variation in the standard of medical facilities and infrastructure provided across the IPS. The range of medical equipment available was generally below that of the equivalent general practice scheme in the community. There is inequality within the system with regard to the ratio of doctor-contracted time relative to the size of the prison population. There is limited administrative support, with the majority of prisons not having a medical secretary. There are few psychiatric or counselling sessions available. CONCLUSIONS: People in prison have a wide range of medical care needs and there is evidence to suggest that these needs are being met inconsistently in Irish prisons.

Determinants of smoking initiation among women in five European countries: a cross-sectional survey.

BACKGROUND: The rate of smoking and lung cancer among women is rising in Europe. The primary aim of this study was to determine why women begin smoking in five different European countries at different stages of the tobacco epidemic and to determine if smoking is associated with certain characteristics and/or beliefs about smoking. METHODS: A cross-sectional telephone survey on knowledge and beliefs about tobacco was conducted as part of the Women in Europe Against Lung Cancer and Smoking (WELAS) Project. A total of 5,000 adult women from France, Ireland, Italy, Czech Republic, and Sweden were interviewed, with 1,000 from each participating country. All participants were asked questions about demographics, knowledge and beliefs about smoking, and their tobacco use background. Current and former smokers also were asked questions about smoking initiation. Basic statistics on the cross-sectional data was reported with chi-squared and ANOVA p-values. Logistic regression was used to analyze ever versus never smokers. Linear regression analyses were used to analyze age of smoking initiation. RESULTS: Being older, being divorced, having friends/family who smoke, and having parents who smoke were all significantly associated with ever smoking, though the strength of the associations varied by country. The most frequently reported reason for initiation smoking was friend smoking, with 62.3% of ever smokers reporting friends as one of the reasons why they began smoking. Mean age of smoking initiation was 18.2 years and over 80% of participants started smoking by the age of 20. The highest levels of young initiators were in Sweden with 29.3% of women initiating smoking at age 14-15 and 12.0% initiating smoking younger than age 14. The lowest level of young initiators was in the Czech Republic with 13.7% of women initiating smoking at age 14-15 and 1.4% of women initiating smoking younger than age 14. Women who started smoking because their friends smoked or to look 'cool' were more likely to start smoking at a younger age. Women who started smoking to manage stress or to feel less depressed were more likely to start smoking at an older age. CONCLUSIONS: In all five participating countries, friends were the primary factor influencing ever smoking, especially among younger women. The majority of participants began smoking in adolescence and the average reported age of smoking initiation was youngest in Sweden and oldest in the Czech Republic.

The effect of the Irish smoke-free workplace legislation on smoking among bar workers.

BACKGROUND: On 29 March 2004, the Republic of Ireland (ROI) became the first EU country to introduce a nationwide ban on workplace smoking. While the focus of this measure was to protect worker health by reducing exposure to second-hand smoke, other effects such as a greater reduction in smoking prevalence and consumption were likely among bar workers. METHODS: A random sample of bar workers from Cork city were surveyed before (n = 129) and after (n = 107; 82.9% follow-up rate) implementation of the smoke-free legislation. Self report and combined self report and cotinine concentration were used to determine smoking status. For comparison a cross-sectional random telephone survey of the general population (ROI) was conducted before and 1 year after the smoke-free legislation. There were 1240 pre- and 1221 participants post-ban in the equivalent age and occupational subset of the general population. RESULTS: There was a non-significant decline in smoking prevalence among bar workers 1 year post-ban (self report: -2.8% from 51.4% to 48.6%, P = 0.51; combined self report and cotinine: -4.7% from 56.1% to 51.4%, P = 0.13), but a significant decline in consumption of four cigarettes (95% CI 2.21-6.36) per day. Within the occupationally equivalent general population sub-sample there was a significant drop (3.5%, P = 0.06) in smoking prevalence but no significant change in consumption. CONCLUSIONS: Ireland's smoke-free workplace legislation was accompanied by a drop in smoking prevalence in both bar workers and the general population sub-sample.

Does sharing care across the primary-specialty interface improve outcomes in chronic disease? A systematic review.

OBJECTIVE: To determine the effectiveness of shared care interventions designed to improve the management of chronic disease across the primary-specialty care interface. STUDY DESIGN AND METHODS: Systematic review using the Cochrane Collaboration method. RESULTS: Twenty studies were identified, 19 of which were randomized controlled trials. The majority of studies examined complex interventions and were of short duration. Results were mixed, with no consistent improvements in physical or mental health outcomes, psychosocial outcomes, hospital admissions, default or participation rates, recording of risk factors, and satisfaction with treatment. However, there were improvements in prescribing in the studies that considered this outcome. The methodologic quality of studies varied, with only a minority of studies of high-quality design. Cost data were limited and difficult to interpret across studies. CONCLUSIONS: At present, there is insufficient evidence to support the introduction of shared care services into clinical practice. However, methodologic shortcomings, particularly inadequate length of follow-up, may account for this lack of evidence. Further research is needed to test models of collaboration across the primary-specialty care divide both in terms of effectiveness and sustainability over longer periods of time.

The impact of banning smoking in workplaces: what are the early effects?

Smoke-free workplace legislation reduces the exposure of both the general public and the workforce to second-hand smoke (SHS) without evidence of an increased exposure to SHS in children in the home. The reductions in exposure are linked to improved respiratory health in previously heavily exposed occupational groups such as bar, restaurant and casino staff. From some countries, there is evidence suggesting that smoking bans have led to declines in hospital admissions for myocardial infarction. There is general agreement that smoking bans, if associated with other tobacco control measures such as tax increases, together with provision of cessation supports, lead to a reduction in the numbers of cigarettes smoked and probably lower smoking rates. Most cities, regions and countries report neutral or positive economic impacts.

Before and after study of bar workers' perceptions of the impact of smoke-free workplace legislation in the Republic of Ireland.

OBJECTIVES: To compare support for, and perceptions of, the impacts of smoke-free workplace legislation among bar workers in the Republic of Ireland (ROI) pre- and post-implementation, and to identify predictors of support for the legislation. SETTING: Public houses (pubs) in three areas of the ROI. DESIGN: Comparisons pre- and post-implementation of smoke-free workplace legislation. PARTICIPANTS: From a largely non-random selection, 288 bar workers volunteered for the baseline survey; 220 were followed up one year later (76.4%). OUTCOME MEASURES: Level of support for the legislation, attitude statements concerning potential impacts of the law and modelled predictors of support for the legislation. RESULTS: Pre-implementation 59.5% of participants supported the legislation, increasing to 76.8% post-implementation. Support increased among smokers by 27.3 percentage points from 39.4% to 66.7% (p < 0.001) and among non-smokers by 12.4% percentage points from 68.8% to 81.2% (p = 0.003).Pre-legislation three-quarters of participants agreed that the legislation would make bars more comfortable and was needed to protect workers' health. Post-legislation these proportions increased to over 90% (p < 0.001). However, negative perceptions also increased, particularly for perceptions that the legislation has a negative impact on business (from 50.9% to 62.7%, p = 0.008) and that fewer people would visit pubs (41.8% to 62.7%, p < 0.001). After adjusting for relevant covariates, including responses to the attitude statements, support for the ban increased two to three-fold post-implementation. Regardless of their views on the economic impact, most participants agreed, both pre- and post-implementation, that the legislation was needed to protect bar workers' health. CONCLUSION: Smoke-free legislation had the support of three-quarters of a large sample of bar workers in the ROI. However, this group holds complex sets of both positive and negative perspectives on the legislation. Of particular importance is that negative economic perceptions did not diminish the widely held perception that the ban is needed to protect workers' health.