Smoking Ordinances

 

Chapter 2 REVIEW OF RELATED LITERATURE

This chapter presents the related literature and studies after the through and indepth search done by the researcher. Foreign Literature

Governments around the world seek to reduce the adverse health effects of smoking, both to smokers and non-smokers. Policies have focused on discouraging smoking through tobacco taxes, restrictions on tobacco advertising, providing services to assist smokers to quit and taking various steps to inform the community of the health risks associated with smoking. Many governments have also placed restrictions on the locations in which people can smoke, including government buildings, office buildings, shopping centres, restaurants and bars. While restrictions on where people can smoke have primarily been motivated by reducing harm caused by smoking to non-smokers, they have also been positioned, at least in Australia, as seeking to reduce smoking rates (Queensland Health, 2000).  According to a 2013 smoking-related report from the World Healt Health h Organization, 6 million people annually die due to smoking and this number is predicted to increase to approximately 8 million by 2030 . Cigarette smoke contains around 250 25 0 harmful chemical substances, 69 of them can cause cancer, so that the International Agency for Research on Cancer has classified cigarette and cigarette smoke as group 1 carcinogens (http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS).. (http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS) Smoking and exposure to cigarette smoke are associated with health risks such as the onset of diseases including various cancers as well as cardiovascular and

 

respiratory diseases. In addition, exposure of pregnant women and infants to indirect cigarette smoke has unfavorable effects such as premature birth, sudden infant death syndrome, and asthma . A study reported about 46,000 deaths in South Korea in 2003 due to smoking, and smoking was attributed to 30.8% of deaths in men. Also, the Ministry of Health and Welfare estimated the economic burden due to labor loss from early death and diseases induced by smoking to be about 5.6 trillion Korean won (KRW) in 2007. For that reasons, constant efforts to decrease smoking rates by establishing the smoke-free policies have been made in South Korea and worldwide (Jee 2006). One example of non-price smoking policies in South Korea, smoke-free zones have been expanded since 1995, and a revision of the National Health Promotion Act in December 2012 banned smoking in public institutions and public facilities. A Cochrane systematic review the effects of legal regulations such as designation of smoke-free zones in public places, workplaces, and restaurants showed a decrease of secondhand smoking exposure rate, but it could not reach the conclusion in current smoking rate. In Ireland, one year after smoking ban policies were implemented in workplaces including service businesses in March 2004, the smoking rate decreased from 29% to 26% but increased to 28% the following year. In the UK, the rate of smoke cessation increased within a year after implementation of smoke-free legislation in July 2007, but this effect did not last (Callinan, 2010). The WHO Framework Convention on Tobacco Control (WHO FCTC) was adopted by the World Health Assembly in May 2003 and as of April 2014 has been ratified by 178 countries. The WHO FCTC aims to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco

 

consumption and exposure to tobacco smoke. As of 2012, 79% of Parties reported strengthening their existing legislation or adopting new tobacco control legislation after ratifying the Convention. Additionally, over half of the Parties to the WHO FCTC reported having developed and implemented comprehensive tobacco control strategies, plans and programmes as required in Article 5.1 of the Convention (World Health Organization; 2013). The Treaty has a specific public health objective of reducing morbidity and mortality due to tobacco use. However, there are time lags throughout the process from ratification of the WHO FCTC, the promulgation of the Treaty-compliant tobacco control legislation, and actual implementation and enforcement of the law. There is also a time lag from when the policies are implemented until behaviour changes in tobacco use (i.e. cessation or non-initiation by youth) are seen on a large scale within a country. There is also the time lag between behaviour change and the accrual of health benefits. Among smokers who quit, a reduction in risk of cancer may take about a quarter of a century to manifest, with the most immediate health benefit being a reduction in the risk of heart disease. At the population level, reduction in overall mortality may begin to show sh ow up about quarter of a century after implementation of tobacco control policies and reach full impact in about half a century. However, implementation of smoke-free policies has been shown to have more immediate health effects in populations, including significant reductions in acute myocardial infarctions (Thun 2012).  Article 8 of the WHO FCTC aims to provide prote protection ction from exposure to tobacco smoke. According to the Global Progress Report, 2012, Article 8 has been implemented in 83 countries (46.9%), the highest number of countries implementing any WHO FCTC

 

article. By 2012, as many as 109 Parties reached their individual five-year time frame for implementation of public smoking bans. Eight-eight Parties also reported having mechanisms for the monitoring and enforcement of smoke-free measures (World Health Organization, 2012).  A comprehensive review on the impact of public smoking bans was undertaken by the Cochrane group and published in 2009. Fifty studies were reviewed, including a variety of methodologies and sizes, with all the studies having taken place in North  America, Europe or Australasia. No meta-analysis was performed due to the heterogeneity of the studies. This review looked at studies measuring the actual reduction in SHS exposure (Callinan, 2010). Reduced exposure to SHS is the first outcome measure for a smoke-free policy. In this Cochrane review there were 31 studies reporting on exposure to SHS, mostly in workplaces. All of the studies clearly showed reduced self-reported exposure to SHS after policy implementation. This was either expressed as reduction in the length of time exposed (71% to 100% reduction) or in reduction reduc tion in the proportion of those exposed (22% to 85%). Eighteen studies, using biomarkers, like salivary cotinine, to validate these selfreports found 39% to 89% reduction in exposure. The studies reviewed r eviewed showed that after the public smoking bans were in place, there was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and other public places. Hospitality workers showed a greater reduction in exposure than the general public (Callinan, 2010). Numerous studies have been conducted to find out whether public smoking bans could reduce the incidence of heart attacks in the area of implementation. There are

 

several systematic reviews and meta-analysis that cover a range of studies, from small studies in small towns to larger studies in a whole state (e.g. New York State) and country (e.g. Italy). The Cochrane review included twelve studies reporting hospital admission rates for acute myocardial infarction (AMI) or chest pain caused by heart disease. The reduction in hospital admissions for such cardiac events after implementation of smokefree laws was consistent across the studies (Callinan, 2010).  A systematic review and meta-analysis on 11 studies in 2009 investigated the relationship between public smoking bans and risk for hospital admission for AMI. This review included studies from 10 geographic locations (five in the United States, one in Canada, and four in Europe). The places ranged from small communities, to middle sized towns, large cities and whole states or regions. The meta-analysis found that AMI risk decreased by 17% comparing compa ring the AMI incidence before and after the ban went into force, the incidence rate ratio (IRR) being 0.83 (95% CI: 0.75-0.92). The greater protective effect was among younger persons and among non-smokers (Meyers 20019).  A mathematical simulation study from India attempted to quantify the effects of various tobacco control measures, including a ban on public smoking, tobacco tax increases, and pharmacological treatment of tobacco dependence on myocardial infarction and stroke over the next ten years. Smoke-free laws and tobacco taxation appeared to be the most effective strategies from the population point of view in preventing deaths from myocardial infarction and stroke. This model assumed a rather low level of access to health care as per the current situation in the country (Basu 2013). For the state of Gujarat in India (over ( over 50 million population), a mathematical model estimated that a complete public smoking ban would be more cost effective in terms of

 

lives saved due to acute cardiovascular events and costs averted than a partial one, as is now in place, with the current law of 2008. While the cost of implementing the partial ban was $US 59 036 and the cost of implementing the total ban would be about $US 4 million, with a complete public smoking ban, around 17 000 cases of AMI could be avoided and the government of Gujarat could have a net savings of $US 36 million in medical treatment costs for heart disease (Donaldson 2011).  A health impact impact assessment was conducted prior to the implementation o off smokefree public places legislation in Hungary to map the impact of this policy on disease burden. It was found that smoke-free policies would have an unambiguously positive public health impact, particularly as Hungary has such a high burden of tobacco-related diseases. Specifically, it was estimated that prohibition proh ibition of smoking in public places would lead to about 1700 deaths postponed and 16 000 life years saved annually. The expected decrease in exposure to second-hand smoke was predicted to have a stronger contribution than just the reduction in smoking prevalence. Reduction in exposure to SHS would lead to quantifiable reductions in four diseases: coronary heart diseases, stroke, chronic pulmonary diseases, and lung cancer. c ancer. More immediate effects were predicted for the first three diseases, with reductions in lung cancer seen after about a 15-20 year lag time (Adam 2012).  A number of studies from various regions, particularly in North America and Europe, have shown that implementation of 100% smoke-free legislation has led to significant improvement in respiratory symptoms within populations. In Norway, a study evaluated the effect of a total ban on indoor smoking on hospitality workers. A significant decrease in respiratory symptoms was found five months after enactment of the ban (18).

 

In a study of 42 bars in Ireland, statistically significant improvements in lung function were found in nonsmoking barmen one year after the ban (Eagan 2006).  A study among bar and restaurant workers in the city city of Neuquén, Argentina Argentina (which adopted sub-national smoke-free legislation in 2007), also showed that, consistent with the other studies, smoke-free legislation led to substantial and immediate reduction of respiratory symptoms (from pre-ban level of 57.5% to a post-ban level of 28.8%). There was also significant reduction in sensory irritation symptoms as well as significant improvement in the respiratory function of study participants as measured by spirometry (Schoj 2010).  A systematic review and meta-analysis of the effect of smoke-free legislation on child health (the first one ever conducted), was published in the Lancet in 2014. Researchers combined the results of 11 studies from Europe and North America published between 2008 and 2013 involving more than 2.5 million births and almost 250,000 cases of asthma exacerbations in children. After the results of the studies were pooled in a meta-analysis, it was found that hospital visits for childhood asthma and premature births both declined about 10% in the year after smoking bans took effect in each of the jurisdictions covered by the study (Been 2014). Researchers concluded that smoke free legislation was associated with a 10% reduction in the relative risk of preterm birth (-10.4%, 95% Confidence Interval [CI] -18.8 to -2.0) and with a 10% reduction red uction in the relative risk of hospital attendances for childhood asthma (-10.1%, 95% CI -15.2 to -5.0). According to the researchers, when considered along with the health benefits shown in adults, this study provides strong support for the implementation of smoke free polices in line with the WHO FCTC (Been 2014).

 

Lopez and colleagues described the different patterns of diffusion of cigarette smoking across world cultures, noting the early adoption of Western high-income countries and the slower adoption in many lower-income and middle-income countries. The three groups of countries are worth noting. Countries in Western Europe, North  America and Australasia were early adopters of smoking, and experienced a rapid increase to a high per-capita cigarette consumption in the beginning of the 20th century that peaked in the 1960s (Lopez, et al 1994). Since the start of tobacco control programmes, these countries have experienced dramatic declines (over 70% in the USA) from that peak consumption.  consumption.  It It  shows that in 2006, male smoking prevalence in these countries was generally in the 21% to 30% category, considerably below those with the highest smoking prevalence such as the Russian Federation, Greece and Indonesia. Similarly for women, smoking prevalence in these early adopter countries has declined to the 10% to 20% level.  A second large group of countries (eg, China, Malaysia and Thailand) Th ailand) has a low female smoking prevalence, which is in stark contrast to the male smoking prevalence. Hitchman and Fong have noted that many countries in this group have low levels of female gender empowerment (measured by participation in economics and politics including decision-making roles). The tobacco industry has a history of adeptly linking cigarette smoking to the female empowerment movement that occurred in earlier years in high-income countries. There appears to be a third small group (eg, Ghana, Ethiopia) where cigarette smoking may have never been a common behaviour for either gender (Hitchman et al 2011).

 

Starting in the 1980s, tobacco companies have launched programmes in at least 26 countries ostensibly to prevent smoking initiation among the school-aged population. However, internal documents show that tobacco industry leaders viewed such initiatives as a way to prevent or delay legislation, regulation, or even threatened litigation. In addition, by controlling the prevention intervention, the tobacco toba cco industry could ensure that more effective strategies were suppressed. In 1990, Philip Morris was temporarily successful in convincing the California Department of Education to distribute a tobacco industry sponsored ‘anti‘anti-smoking’ set of materials to schools (Landman ( Landman 2002). There is substantial literature on interventions aimed at reducing smoking initiation, mainly from high-income countries. These interventions include school programmes, increasing price through excise tax increases, large graphic graph ic warning labels on packages, packages , restricting the tobacco industry's ability to advertise, tobacco control mass media programmers, smoke-free policies and restricting the ability of minors from purchasing tobacco products. It is important to note that the effectiveness of an overall approach is more than the sum of the effectiveness of the independent strategies. In Australia and California comprehensive community-wide programmers using multiple strategies have documented large declines in smoking initiation. The key goal of such programmers is the denormalization of tobacco in the entire community (Bal 1990). Warning labels on cigarette packs, which were introduced in the USA in 1966, 196 6, are often one of the first tobacco control initiatives. Whereas obscure text-only warnings appear to have little impact, recently implemented prominent graphic health warnings on packages have been demonstrated to serve as a key source of health information for smokers and non-smokers, increasing health knowledge and perceptions of

 

risk. Prominent pictorial warning labels have been found to lower smoking intentions among adolescent smokers and non-smokers (White 2008).  Australia is the first country to attempt to counter the tobacco industry's package advertising and require that cigarette packages do not no t include any tobacco marketing (ie, plain packaging). Formative research on plain packaging among Australian youth found that they would be less likely to purchase the product and more likely to take the health warnings seriously. Should the Australian government successfully defend its new law in 2012, this will result in a major demonstration project that will be carefully car efully followed by the tobacco industry and tobacco control advocates across the world (Germain 2010). Price elasticity refers to the relationship between price and demand for a particular consumer product. In the context of adolescent smoking, there is significant literature on the price elasticity of youth demand for cigarettes. Key studies in the early years of USA tobacco control interventions estimated that price elasticity of adolescent demand for cigarettes was −1.44; in other words, for every US$0.10 increase in the price/pack of cigarettes, youth smoking declines by approximately 14%. While the price of cigarettes does not appear to influence whether or not an adolescent experiment with cigarettes, there is strong evidence that price matters once teens progress as far as buying their own cigarettes (Chaloupka 1996). However, many USA states dramatically increased state cigarette taxes after aft er 1999 and some recent studies have not found this price increase associated with the expected high adolescent elasticity. Nonnemaker et al  (2011)  (2011) found a significant but smaller effect of tax and price on youth smoking initiation. In this study, higher price responsiveness among minorities explained a lot of the price elasticity. It may be that price elasticity is

 

influenced by the number of tobacco commu nity. A tob acco control strategies implemented in the community. recent European study examined the influence of price along with several other tobacco control policies on smoking participation and did not find the expected association between increased price and lower smoking. However such a study is an outlier in the literature. A recent Australian study found that increases in the price of cigarettes over a 12-month period were associated with lower likelihood of smoking after adjusting for other policy factors including point-of-sale advertising restrictions, clean indoor air laws and tobacco control funding. he health consequences of SHS became evident in the 1980s and, in 1992, the Environmental Protection Agency of the USA categorised SHS as a class A carcinogen.59 carcinogen .59 Local jurisdictions in the USA responded by increasing the number numb er of laws and ordinances requiring smoke-free workplaces and in 1994, California passed a state law. Evidence of the effectiveness of this policy in reducing SHS exposure led to its inclusion in the unprecedented WHO treaty, the Framework Convention for Tobacco Control (FCTC). As a result of this treaty, smoke-free laws are expected to increase significantly over the next few years. The introduction of strong smoke-free smoke -free regulations in public spaces such as restaurants and cafes contributes to the denormalisation of tobacco in a community, and reduces r educes the likelihood of an adolescent becoming a regular smoker. The implementation of smoke-free workplace and public space laws has been associated with the voluntary adoption of smoke-free homes, which has resulted in increased protection of children from exposure to SHS. There are numerous crosssectional surveys that have demonstrated the association between smoke-free homes

 

and lower initiation rates among teens although these results are awaiting confirmation in ongoing longitudinal studies (Hamilton 2008).

Perhaps the most controversial intervention to reduce smoking initiation are policies focused on restricting adolescents' access to purchase cigarettes. cigarettes .24 Many USA states had laws dating back to the early 20th century (mostly not enforced) that limited purchase purcha se of cigarettes to people over the age of 18 years. The California experience experie nce has demonstrated that, as cigarette cig arette smoking becomes increasingly denormalised, adults are more likely to express opinions that enforcement of sales to minors laws are inadequate. However, adolescent smokers are adept at ensuring that these laws do not limit their ability to obtain cigarettes by knowing which stores have lax monitoring or by paying older teens to purchase for them. Indeed, most experimenters and occasional o ccasional smokers obtain their cigarettes from social sources. While these laws may not influence an adolescent's ability to obtain cigarettes, significant declines in the proportion of never smokers who thought it was easy to get cigarettes was associated with enforcement of the laws (Al-Delaimy 2008).  Local Literature

Most people know that smoking is bad for their health. But do they really understand how dangerous smoking really is? Tobacco contains nicotine, a highly addictive drug that makes it difficult for the smokers to kick the habit. Tobacco products also contain many poisonous and harmful substances that cause disease and premature pr emature death (Harry 2005).

 

On the other hand, smokers often say that smoking keeps kee ps them alert and calm and it adds concentration. Some researchers assert that tobacco’s calming effects simply result from alleviation of the nicotine withdrawal syndrome (New Book of Knowledge, 2006). In 2003, the Philippines enacted a smoke free law that restricts smoking in enclosed public places and work places. Smoking areas are permitted in most public places other than health care car e and educational facilities. In July 2011, Manila implemented a smoke free ordinance for schools, gyms, parks, hospitals, elevators and stairwells, of all buildings, buses and bus depots, restaurants, and government facilities. The city of Las Piñas adopted a smoke free f ree ordinance that covers government workplaces a and nd many public places. The local ordinance is stronger than the national law, but still exempts many private workplaces and all hospitality establishments (Rillorta, 2011). The City Government has to protect our ou r environment and protect our children, our youth, our women, the unborn and our constituents from the pernicious effects of tobacco, cigarettes or their derivatives which has been proven to produce cancer (Ordinance NO. 1S. 2012). The local government of Batangas City share the same view about the alarming and disastrous effects of smoking on health, therefore, the Sangguniang Panglungsod created an ordinance called “The AntiSmoking Ordinance of 2012” or the No Smoking Ordinance No. 1S.2012 with its noble objectives to promote the health and safety of our people, particularly the protection of youth, children and the unborn from the hazard of the cancer-producing habit of smokers. This Ordinance Ordinanc e of Batangas City shall take effect fifteen (15) days after its complete publication in a newspaper of general circulation and

 

compliance with he posting required by Republic Act 7160. This ordinance was enacted by SangguniangPanlungsod of Batangas City on 28th day of February 2012 and approved on March 8, 2012 by Mayor Vilma A. Dimacuha (Ordinance NO. 1S. 2012).

 

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