http://www.theheart.org/article/1075575.do

Smoking bans reduce smoke exposure across socioeconomic spectrum

May 7, 2010 | Shelley Wood

Prague , Czech Republic - New research on the effects of smoking bans should help dispel one of the enduring criticisms of smoke-free legislation, namely that sweeping bans benefit those higher on the socioeconomic ladder but potentially increase harmful exposures among society's poorest citizens.

Dr Jennifer Mindell ( University College London , UK ) presented the new findings here at EuroPREVENT 2010. According to Mindell, skeptics of England 's July 1, 2007 smoke-free legislation predicted that banning smoking in public places would produce "inequalities." The theory went as follows: since smoking is more prevalent among people earning lower incomes, with lower education levels, children and nonsmokers in lower socioeconomic classes might actually face increased smoke exposure if smoking family members started lighting up more at home, having been banned from doing so at work.

Mindell et al used data from the Health Survey for England that asked adults across the socioeconomic spectrum about smoking habits and exposure to secondhand smoke. Nurses also visited survey participants, taking saliva samples that were tested for cotinine, a byproduct of nicotine that indicates recent exposure to tobacco smoke—low levels indicating secondhand smoke exposure and levels over 12 ng/mL indicating personal tobacco use.

Objective and subjective indices of exposure dropped postban

When prevalence of undetectable cotinine was analyzed by income, Mindell and colleagues found significant increases in the proportion of respondents with no tobacco exposure after England 's comprehensive smoking ban went into effect July 1, 2007, as compared with the period before the ban, with no differences seen across the income spectrum. Further analyses indicated that the proportion of nonsmokers, with no detectable cotinine, increased in every subset analyzed, regardless of age, sex, income, socioeconomic group, employment status, education, area deprivation, or whether smoking occurred in the home most days.

Mindell reminded her audience about the much ballyhooed comments by British Health Secretary John Reid in 2004, who suggested Britain shouldn't encourage poor people to stop smoking because smoking was one of their "few pleasures in life."

She continued, "There was also concern that people who couldn't smoke at work would then smoke more at home, which would be particularly concerning if their children would be more exposed." If that were occurring, she noted, cotinine levels would have increased not only in the adults surveyed in this study, but also in children, something her group has also looked at. "We haven't seen that. There's definitely been no group in which it has gotten worse, and in virtually every group it's improved."

Of note, self-reported tobacco exposure in fact showed a steady decline from 1995 through 2007, Mindell noted, an observation that speaks to the impact of increasing awareness of the harms of secondhand smoke that preceded the implementation of legislation. In some cases, this was employers banning smoking in the workplace in the hopes of avoiding lawsuits, but she also believes it speaks to increased sensitivity among smokers of the effects their habit had on others.

"This study I'm presenting here was in adults, but I've also looked at children, and even where both parents smoke, an increasing number of parents were making their homes smoke-free. The most important thing for governments [planning to implement public smoking bans] to do is to make it very well publicized what the effects are in children and nonsmokers, so that people realize why it's being implemented," Mindell explained. "The main purpose of smoke-free legislation is to protect the majority of the population who don't smoke—children, nonsmokers, ex-smokers, and never smokers—because other people's smoke is harmful. . . . Most people would not knowingly expose children to harmful things."

The difficulties of day-to-day

Session moderator Dr Susana Sans-Menendez (Institute of Health Studies, Barcelona, Spain) steered Mindell back into the more treacherous territory broached by the health secretary, noting that smoking in the lower socioeconomic groups, especially in women, is a way of coping with "the difficulties of survival."

"No doubt [antismoking] legislation and all these measure are helping to reduce smoking, but still the inequalities in some way or other persist," she noted. "What are your suggestions" to counter the more endemic problems that make it more likely that smokers will continue to smoke?

In response, Mindell said that a key component of antismoking strategies is to reach out in a targeted way, to provide smoking-cessation support where it's most needed, "in the pubs and local centers, where the most deprived people are."

But she agreed a broader approach should also play a role.

"The other thing, of course, is dealing with social determinants that affect people's lives, such as having people in more optimistic circumstances. If they have more money, if they are not so worried about how they are going to buy their children new shoes next week, then they might be more interested in their own health 10 years down the line."