Impacts of Smoking Ban Policies on Billiard Hall Sales in South Korea Using Objective Sales Information of a Credit Card Company: Quasi-Experimental Study.

BACKGROUND: Smoking ban policies (SBPs) are potent health interventions and offer the potential to influence antismoking behavior. The Korean government completely prohibited smoking in indoor sports facilities, including billiard halls, since the government revised the National Health Promotion Act in December 2017. OBJECTIVE: This study aimed to examine the impact of the SBP on the economic outcomes of indoor sports facilities, particularly billiard halls. METHODS: This study used credit card sales data from the largest card company in South Korea. Data are from January 2017 to December 2018. Monthly sales data were examined across 23 administrative neighborhoods in Seoul, the capital city of South Korea. We conducted the interrupted time series model using the fixed effects model and the linear regression with panel-corrected standard errors (PCSE). RESULTS: The sales and transactions of billiard halls were not significantly changed after the introduction of the SBP in the full PCSE models. The R2 of the full PCSE model was 0.967 for sales and 0.981 for transactions. CONCLUSIONS: The introduction of the SBP did not result in substantial economic gains or losses in the sales of billiard halls. In addition to existing price-based policies, the enhanced SBP in public-use facilities, such as billiard halls, can have a positive synergistic effect on reducing smoking prevalence and preventing secondhand smoke. Health policy makers can actively expand the application of SBPs and make an effort to enhance social awareness regarding the necessity and benefits of public SBPs for both smokers and the owners of hospitality facilities.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication.

OBJECTIVE: Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC. METHODS: We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance. RESULTS: Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001). CONCLUSIONS: Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

Smoke-Free Air Interventions in Seven Latin American Countries: Health and Financial Impact to Inform Evidence-Based Policy Implementation.

INTRODUCTION: Disease burden due to tobacco smoking in Latin America remains very high. The objective of this study was to evaluate the potential impact of implementing smoke-free air interventions on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a mathematical model. AIMS AND METHODS: We built a probabilistic Monte Carlo microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths and events) and costs. To populate the model, we completed an overview and systematic review of the literature. Also, we calibrated the model comparing the predicted disease-specific mortality rates with those coming from local national statistics. RESULTS: With current policies, for the next 10 years, a total of 137 121 deaths and 917 210 events could be averted, adding 3.84 million years of healthy life and saving USD 9.2 billion in these seven countries. If countries fully implemented smoke-free air strategies, it would be possible to avert nearly 180 000 premature deaths and 1.2 million events, adding 5 million healthy years of life and saving USD 13.1 billion in direct healthcare. CONCLUSIONS: Implementing the smoke-free air strategy would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy. IMPLICATIONS: Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds quality evidence on the potential health effects and savings of implementing smoke-free air policies in countries representing almost 80% of the Latin America and the Caribbean population.

Impacts of Smoking Ban Policies on Restaurants in Seoul, South Korea: Analysis of Objective Sales Information.

BACKGROUND: From July 2013 to January 2015, the smoking ban instituted in restaurants in South Korea gradually expanded to cover all restaurants and bars, moving by size of restaurant (≤99 m2, 100-149 m2, ≥150 m2). This study measured the impacts of the smoking ban for restaurants. METHODS: This study examined credit, check, or debit card sales data for every September and October from 2012 to 2015 in 711 census tracts in Seoul, South Korea. We accounted for total restaurant sales in each census tract. Our model controlled for the sales amounts for each census tract, type of restaurant, monthly business survey index, number of restaurants, daily average temperature, daily precipitation, and day of the week, and a dummy for census tract. RESULTS: These were some positive associations with increase in total sales. However, the significance of the coefficients was not consistent over this period. Overall, our results showed no significant negative effects of smoking ban policy on restaurants. CONCLUSIONS: Smoking ban policies produced benefits in terms of health outcomes, without causing significant negative impacts on sales. IMPLICATIONS: Although the owners of restaurants anticipated negative impacts on sales from smoking ban policies, the results of this study suggest that restaurants experienced no negative economic impacts on sales from policies with health benefits, which suggest that it would be reasonable to promote and keep on the smoking ban. Also, it is important to apply smoking ban policy to all targets without exclusion.

Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries.

INTRODUCTION: Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. METHODS: Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates of 3.5% were used for costs and effectiveness. Sensitivity analyses considered 1%-50% short-term effectiveness estimates, highest cost estimates, and undiscounted effectiveness. FINDINGS: Nonschool bans cost up to €253.23 per healthy life year, school smoking bans up to €91.87 per healthy life year, and school education programs up to €481.35 per healthy life year. Cost-effectiveness depended on the costs of implementation, short-term effectiveness, initial smoking rates, dimension of the target population, and weight of smoking in overall mortality and morbidity. CONCLUSIONS: All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates. IMPLICATIONS: Economic evaluations using real-world data on tobacco control policies implemented at a large scale are scarce, especially considering nonschool bans targeting adolescents. We assessed the cost-effectiveness of five tobacco control policies implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. This study shows that all five policies were highly cost-effective considering the World Health Organization threshold, even when considering the highest costs and most conservative effectiveness estimates.

Workplace Smoke-Free Policies and Cessation Programs Among U.S. Working Adults.

INTRODUCTION: Workplace tobacco control interventions reduce smoking and secondhand smoke exposure among U.S. workers. Data on smoke-free workplace policy coverage and cessation programs by industry and occupation are limited. This study assessed smoke-free workplace policies and employer-offered cessation programs among U.S. workers, by industry and occupation. METHODS: Data from the 2014-2015 Tobacco Use Supplement to the Current Population Survey, a random sample of the civilian, non-institutionalized population, were analyzed in 2018. Self-reported smoke-free policy coverage and employer-offered cessation programs were assessed among working adults aged ≥18 years, overall and by occupation and industry. Respondents were considered to have a 100% smoke-free policy if they indicated smoking was not permitted in any indoor areas of their workplace, and to have a cessation program if their employer offered any stop-smoking program within the past year. RESULTS: Overall, 80.3% of indoor workers reported having smoke-free policies at their workplace and 27.2% had cessation programs. Smoke-free policy coverage was highest among workers in the education services (90.6%) industry and lowest among workers in agriculture, forestry, fishing, and hunting industry (64.1%). Employer-offered cessation programs were significantly higher among workers reporting 100% smoke-free workplace policies (30.9%) than those with partial/no policies (23.3%) and were significantly higher among indoor workers (29.2%) than outdoor workers (15.0%). CONCLUSIONS: Among U.S. workers, 100% smoke-free policy and cessation program coverage varies by industry and occupation. Lower smoke-free policy coverage and higher tobacco use in certain industry and occupation groups suggests opportunities for workplace tobacco control interventions to reduce tobacco use and secondhand smoke exposure.

Voluntary Smoke-Free Measures Among Oklahoma Nightlife Owners: Barriers and Facilitators.

Smoke-free policies prevent exposure to secondhand smoke and encourage tobacco cessation. Local smoke-free policies that are more comprehensive than statewide policies are not allowed in states with preemption, including Oklahoma, which has the sixth highest smoking prevalence in the United States. In states with preemption, voluntary smoke-free measures are encouraged, but little research exists on venue owners' and managers' views of such measures, particularly in nightlife businesses such as bars and nightclubs. This article draws from semistructured interviews with 23 Oklahoma bar owners and managers, examining perceived risks and benefits of adopting voluntary smoke-free measures in their venues. No respondents expressed awareness of preemption. Many reported that smoke-free bars and nightclubs were an inevitable societal trend, particularly as younger customers increasingly expected smoke-free venues. Business benefits such as decreased operating and cleaning costs, improved atmosphere, and employee efficiency were more convincing than improved employee health. Concerns that voluntary measures created an uneven playing field among venues competing for customers formed a substantial barrier to voluntary measures. Other barriers included concerns about lost revenue and fear of disloyalty to customers, particularly older smokers. Addressing business benefits and a level playing field may increase support for voluntary smoke-free nightlife measures.

Healthcare Costs of Secondhand Smoke Exposure at Home for U.S. Children.

INTRODUCTION: The purpose of this study is to estimate healthcare utilization and healthcare costs due to secondhand smoke exposure at home for children in the U.S. METHODS: Using data from the 2000, 2005, and 2010 U.S. National Health Interview Surveys, the authors analyzed the association between secondhand smoke exposure at home and utilization of three types of healthcare services (hospital nights, emergency room visits, and doctor visits) for children aged 3-14 years (N=16,860). A zero-inflated Poisson regression model was used to control for sociodemographic characteristics and the number of months without health insurance. The authors determined excess healthcare utilization attributable to secondhand smoke exposure at home for children and then estimated annual secondhand smoke-attributable healthcare costs as the product of annual excess healthcare utilization and unit costs obtained from the 2014 Medical Expenditures Panel Survey. This study was conducted from 2016 to 2018. RESULTS: The prevalence of secondhand smoke exposure at home for children in 2000, 2005, and 2010 was 25.0%, 12.3%, and 9.1%, respectively. Secondhand smoke exposure at home was positively associated with emergency room visits, but was not significantly associated with nights at the hospital or doctor visits for children. Secondhand smoke exposure at home for children resulted in an excess of 347,156 emergency room visits in 2000, 124,412 visits in 2005, and 101,570 visits in 2010, which amounted to $215.1 million, $77.1 million, and $62.9 million in excess annual healthcare costs (2014 dollars) in 2000, 2005, and 2010, respectively. CONCLUSIONS: Although U.S. healthcare costs attributable to secondhand smoke exposure at home for children are declining, interventions to reduce secondhand smoke exposure at home for children are still needed to reduce the economic burden attributable to secondhand smoke exposure.

Passive Smoking Indicators in Italy: Does the Gross Domestic Product Matter?

BACKGROUND: The aim of this study is to analyse the correlation between regional values of Gross Domestic Product (GDP) and passive smoking in Italy. METHODS: The outcome measures were smoking ban respect in public places, workplaces and at home, derived from the PASSI surveillance for the period 2011⁻2017. The explanatory variable was GDP per capita. The statistical analysis was carried out using bivariate and linear regression analyses, taking into consideration two different periods, Years 2011⁻2014 and 2014⁻2017. RESULTS: GDP is showed to be positively correlated with smoking ban respect in public places (r = 0.779 p < 0.001; r = 0.723 p < 0.001 in the two periods, respectively), as well as smoking ban respect in the workplace (r = 0.662 p = 0.001; r = 0.603 p = 0.004) and no smoking at home adherence (r = 0.424 p = 0.056; r = 0.362 p = 0.107). In multiple linear regression GDP is significantly associated to smoking ban respect in public places (adjusted ß = 0.730 p < 0.001; ß = 0.698 p < 0.001 in the two periods, respectively), smoking ban in workplaces (adjusted ß = 0.525 p = 0.020; ß = 0.570 p = 0.009) and no smoking at home (adjusted ß = 0.332 p = 0.070; ß = 0.362 p = 0.052). CONCLUSIONS: Smoking ban is more respected in Regions with higher GDP. For a better health promotion, systematic vigilance and sanctions should be maintained and strengthened, particularly in regions with low compliance with smoking bans.

Income disparities in smoking cessation and the diffusion of smoke-free homes among U.S. smokers: Results from two longitudinal surveys.

BACKGROUND: Lower rates of successful quitting among low-income populations in the United States may be from slower dissemination of smoke-free homes, a predictor of cessation. OBJECTIVES: To explore the role of smoke-free homes in cessation behavior across income levels. PARTICIPANTS: Current smokers who were ≥18 years and who participated in the longitudinal 2002-2003 (n = 2801) or 2010-2011 (n = 2723) Tobacco Use Supplements to the Current Population Survey. MEASUREMENTS: We categorized income as multiples of the federal poverty level (FPL) (<300% FPL versus ≥300% FPL). We examined the association of smoke-free homes with 1+day quit attempts and 30+days abstinence at 1-year follow-up. We then conducted a mediation analysis to examine the extent that smoke-free homes contributed to income disparities in 30+days abstinence. RESULTS: Between the two surveys, heavy smoking (≥ 1 pack/day) declined by 17%, and smoking prevalence declined by 15% among those with higher-incomes (>300%FPL). Although similar in 2002, the prevalence of smoke-free homes was 33% lower among individuals living <300% FPL than those living ≥300% FPL. Although the quit attempt rate was similar, the 30+days abstinence rate was higher in the 2010-11 cohort than in 2002-3 cohort (20.6% versus 15.5%, p<0.008). Whereas smoking ≥ 1 pack/ day was associated with lower odds of 30+days abstinence (Adjusted odds ratio [AOR] 0.7; 95% CI 0.5-0.9), having a higher income (AOR 1.9, 95% CI 1.4-2.6) and a smoke-free home (AOR 1.6, 95% CI 1.2-2.1) were associated with greater odds of 30+day abstinence. Differential changes in smoke-free homes across income groups between the two surveys contributed to 36% (95% CI 35.7-36.3) of the observed income disparity in 30+days abstinence. CONCLUSIONS: Increasing the diffusion of smoke-free homes among low-income populations may attenuate at least a third of the income disparities in smoking cessation, highlighting the need for interventions to increase adoption of smoke-free homes among low-income households.

The health effects of smoking bans: Evidence from German hospitalization data.

This paper studies the short-term impact of public smoking bans on hospitalizations in Germany. It exploits the staggered implementation of smoking bans over time and across the 16 federal states along with the universe of hospitalizations from 2000 to 2008 and daily county-level weather and pollution data. Smoking bans in bars and restaurants have been effective in preventing 1.9 hospital admissions (-2.1%) due to cardiovascular diseases per day, per 1 million population. We also find a decrease by 0.5 admissions (-6.5%) due to asthma per day, per 1 million population. The health prevention effects are more pronounced on sunny days and days with higher ambient pollution levels.

The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard.

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demand-reducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

Feasibility, Efficacy, and Cost Analysis of Promoting Smoking Cessation at Outdoor Smoking "Hotspots": A Pre-Post Study.

Introduction: To motivate smokers to quit, there is a need for enhanced smoking cessation (SC) recruitment and for innovative and proactive approaches to SC. This study evaluated the feasibility, efficacy, and cost of promoting SC in public outdoor areas where smokers gather to smoke (smoking hotspots). Methods: We selected 14 smoking hotspots in Hong Kong for SC promotion in 2015. University students were trained as SC ambassadors to deliver brief SC intervention, and to recruit smokers for telephone follow-up. The proportion of smokers accepting the intervention components was recorded. Self-reported abstinence in the past 7 days and knowledge of smoking and health were assessed at the 6-month follow-up. The average costs of each smoker receiving our intervention and quitting were also compared. Results: Of 3,080 smokers approached, 1,278 (41.5%) accepted the souvenir and 920 (29.9%) received brief advice. Of the 210 (6.8%) who consented to the follow-up, 24.5% were aged 15-29 and 46.4% were aged 30-49. Of the 151 smokers successfully contacted within 1 month after recruitment, 16 (10.6%; 1.3% of the 1,278 who received any form of intervention) reported abstinence, and their overall knowledge improved. The average costs for a smoker to receive brief advice, consent to follow up by telephone, attempt to quit, and quit successfully at the 6-month follow-up were US$30, US$132, US$601, and US$1,626, respectively. Conclusions: Promoting SC at smoking hotspots could be a feasible way to achieve satisfactory quitting outcomes at low cost and is useful in the absence of the strengthening of tobacco policies. Implications: Our study indicates that outdoor smoking hotspots are feasible platforms for promoting SC and recruiting smokers for cessation services; satisfactory outcomes can be achieved at a reasonable cost. Our promotion was particularly useful for recruiting young smokers and those who want to quit. It is feasible and efficacious to raise smokers' awareness of SC when other tobacco control policies not feasible. Indoor smoking bans or other substantial tobacco control policies could enhance the efficiency with which SC is promoted.

Geographical Inequality in Tobacco Control in China: Multilevel Evidence From 98†058 Participants.

Background: We investigated the spatial patterning and correlates of tobacco smoking, exposure to secondhand smoke, smoking in public places, workplace smoking prohibition, pro- and counter-tobacco advertisements in mainland China. Methods: Choropleth maps and multilevel models were used to assess geographical variation and correlates of the aforementioned outcome variables for 98 058 participants across 31 provinces of China in 2010. Results: Current tobacco smoking prevalence was higher in the central provinces for men and in the north eastern provinces and Tibet for women. Secondhand smoke was higher for both genders in Qinghai and Hunan provinces. Workplace tobacco restrictions was higher in the north and east, whereas smoking in public places was more common in the west, central, and far northeast. Protobacco advertising was observed in public places more often by men (18.5%) than women (13.1%). Men (35.5%) were also more likely to sight counter-tobacco advertising in public places than women (30.1%). Awareness of workplace tobacco restrictions was more common in affluent urban areas. Lower awareness of workplace tobacco restrictions was in less affluent urban and rural areas. Sightings of tobacco smoking in public places was highest in restaurants (80.4% for men, 75.0% for women) and also commonly reported in less affluent urban and rural areas. Exposure to secondhand smoke was lower among women (but not men) where workplace tobacco restrictions was more common and higher regardless of gender in areas where smoking in public places was more commonly observed. Conclusions: Geographical and gender-sensitive targeting of tobacco prevention and control initiatives are warranted. Implications: This study demonstrates spatial patterning of China's 300 million smokers across the country that are different for men and women. Many of the factors that influence tobacco use, such as pro- and counter-advertising, also vary geographically. Workplace smoking restrictions are more commonly reported among individuals with higher educational attainment, but this not does appear to translate into reduced exposure to secondhand smoke. There is a need to intervene in other contexts, especially in restaurants and on public transport. Geographically targeted and gender-sensitive policy is required to advance effective tobacco control and prevention of noncommunicable diseases across all of China.

The Economic Impact of Smoke-Free Policies on Restaurants, Cafés, and Bars: Panel Data Estimates From European Countries.

In this paper, we investigate the extent to which the economic outcomes of restaurants, bars, and cafés have been affected by the introduction of anti-smoking regulations in Europe. We use an unexploited panel database to collect a comprehensive set of information on financial indicators regarding the balance sheets of private and public companies in various economic sectors. The results show that smoke-free policies did not significantly affect the firms' economic performance, irrespective of the balance sheet indicators analyzed. Moreover, the results are robust to various econometric specifications and suggest that the recent enforcement of anti-smoking legislation in Europe has improved public health without a corresponding negative impact on revenues and employment in the hospitality industry.

Exploring Impacts of Taxes and Hospitality Bans on Cigarette Prices and Smoking Prevalence Using a Large Dataset of Cigarette Prices at Stores 2001-2011, USA.

In the USA, little is known about local variation in retail cigarette prices; price variation explained by taxes, bans, and area-level socio-demographics, and whether taxes and hospitality bans have synergistic effects on smoking prevalence. Cigarette prices 2001-2011 from chain supermarkets and drug stores (n = 2973) were linked to state taxes (n = 41), state and county bar/restaurant smoking bans, and census block group socio-demographics. Hierarchical models explored effects of taxes and bans on retail cigarette prices as well as county smoking prevalence (daily, non-daily). There was wide variation in store-level cigarette prices in part due to differences in state excise taxes. Excise taxes were only partially passed onto consumers (after adjustment, $1 tax associated with $0.90 increase in price, p < 0.0001) and the pass-through was slightly higher in areas that had bans but did not differ by area-level socio-demographics. Bans were associated with a slight increase in cigarette price (after adjustment, $0.09 per-pack, p < 0.0001). Taxes and bans were associated with reduction in smoking prevalence and taxes had a stronger association when combined with bans, suggesting a synergistic effect. Given wide variation in store-level prices, and uneven state/county implementation of taxes and bans, more federal policies should be considered.