Repercusión de las prohibiciones del acto de fumar en el nivel institucional sobre la reducción de los efectos perjudiciales y la exposición pasiva al humo del cigarrillo
Resumen
Antecedentes
Las prohibiciones o restricciones del acto de fumar pueden ayudar a eliminar la exposición de los no fumadores a los peligros de la exposición pasiva al humo del cigarrillo y pueden reducir el consumo de tabaco entre los propios fumadores. Existen pruebas que identifican la repercusión de regulaciones e intervenciones para el control del consumo de tabaco implementadas en los lugares de trabajo en general y a nivel individual. Sin embargo, es importante que también se revisen las pruebas para las prohibiciones del acto de fumar en el nivel meso u organizacional para identificar su repercusión sobre la reducción de la carga de la exposición al humo del tabaco. La presente revisión evalúa las pruebas de las prohibiciones o políticas en el nivel meso u organizacional para el control del consumo de tabaco en varios contextos especializados, que incluyen las instituciones públicas de asistencia sanitaria, la educación superior y los establecimientos correccionales.
Objetivos
Evaluar el grado en el que las prohibiciones del acto de fumar a nivel institucional pueden reducir la exposición pasiva al humo y el tabaquismo activo y afectar otros resultados relacionados con la salud.
Métodos de búsqueda
Se hicieron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials ‐ CENTRAL); MEDLINE, EMBASE y en las listas de referencias de los estudios identificados. Se estableció contacto con los autores para identificar estudios completados o en curso elegibles para su inclusión en esta revisión. También se verificaron los sitios web de organismos y organizaciones estatales, como los registros de ensayos. La fecha de la última búsqueda fue el 22 de de junio de 2015.
Criterios de selección
Se consideraron los estudios que informaron los efectos de las prohibiciones o las políticas del acto de fumar, ya sea de manera completa o parcial, sobre la reducción de la exposición pasiva al humo del cigarrillo, el consumo de tabaco, la prevalencia del tabaquismo y otros resultados de salud, en los establecimientos públicos de asistencia sanitaria, de la educación superior y en las instituciones correccionales, desde 2005 en adelante.
El estándar mínimo de inclusión fue que el estudio implementara una prohibición o política a nivel de contexto y un mínimo de seis meses de seguimiento para las medidas del hábito de fumar. Se incluyeron los ensayos cuasiexperimentales (es decir, estudios controlados tipo antes y después, series de tiempo interrumpido como se definió por el Grupo Cochrane para una Práctica y Organización Sanitaria Efectivas (Cochrane Effective Practice and Organization of Care Group) y datos no controlados antes y después de la prohibición.
Obtención y análisis de los datos
Dos o más autores de la revisión, de forma independiente, evaluaron los estudios para su inclusión en la revisión. Debido a la variación en la medición de los resultados no se realizó un metanálisis de todos los estudios incluidos en esta revisión, pero se realizó un metanálisis de efectos fijos de Mantel‐Haenszel que agrupó a 11 de los estudios incluidos. Todos los estudios se evaluaron mediante una síntesis narrativa cualitativa.
Resultados principales
Se incluyeron 17 estudios observacionales en esta revisión. No se encontraron ensayos controlados aleatorios. Doce estudios se realizaron en hospitales, tres en prisiones y dos en universidades. Tres estudios utilizaron un diseño controlado tipo antes y después y utilizaron otro sitio para la comparación. Los 14 estudios restantes utilizaron un diseño de estudio no controlado tipo antes y después. Cinco estudios informaron pruebas de dos grupos de participantes e incluyeron al personal y a pacientes o prisioneros (según el contexto especializado), y los 12 estudios de investigación restantes sólo investigaron un grupo de participantes.
Los cuatro estudios (dos en prisiones, dos en hospitales) que proporcionaron datos de resultados de salud informaron un efecto de la exposición pasiva al humo del cigarrillo y una reducción de la mortalidad asociada con enfermedades relacionadas con el tabaquismo. Ningún estudio incluido en la revisión midió los niveles de cotinina para validar la exposición pasiva al humo del cigarrillo. Once estudios que informaron las tasas de tabaquismo activo en 12 485 participantes estuvieron disponibles para el agrupamiento, pero hubo pruebas significativas de heterogeneidad estadística (I² = 72%). La heterogeneidad fue menor en los subgrupos definidos por contexto, y proporcionaron pruebas de un efecto de las prohibiciones del acto de fumar sobre la reducción de las tasas de tabaquismo activo. Un análisis que exploró la heterogeneidad dentro de los contextos hospitalarios mostró pruebas de un efecto sobre la reducción de las tasas de tabaquismo activo en el personal (cociente de riesgos [CR] 0,71; intervalo de confianza [IC] del 95%: 0,64 a 0,78) y en los pacientes (CR 0,86; IC del 95%: 0,76 a 0,98), pero se mantuvo la heterogeneidad en el subgrupo del personal (I² = 76%). En las prisiones, a pesar de las pruebas de la reducción de la mortalidad asociada con enfermedades relacionadas con el tabaquismo en dos estudios, no hubo pruebas del efecto sobre las tasas de tabaquismo activo (un estudio, CR 0,99; IC del 95%: 0,84 a 1,16).
La calidad de las pruebas se consideró baja mediante el enfoque GRADE, ya que todos los estudios incluidos son observacionales.
Conclusiones de los autores
Se encontraron pruebas de un efecto de las políticas contra el tabaquismo basadas en contextos sobre la reducción de las tasas de tabaquismo en los hospitales y las universidades. En las prisiones se informó una reducción en las tasas de mortalidad y en la exposición pasiva al humo del cigarrillo. Sin embargo, la base de pruebas se consideró de baja calidad. Por lo tanto, se necesitan estudios más consistentes que evalúen las pruebas para las prohibiciones y las políticas contra el acto de fumar en estos importantes contextos especializados.
Resumen en términos sencillos
¿Las prohibiciones del acto de fumar a un nivel institucional ayudan a que las personas abandonen el hábito de fumar?
Desde que algunos países prohibieron fumar en los lugares públicos en 2004, ha habido una reducción de la exposición pasiva al humo del cigarrillo (el daño por el humo de los cigarrillos de otras personas), y la salud de los fumadores y los no fumadores ha mejorado. La exposición pasiva al humo del cigarrillo puede aumentar las probabilidades de enfermedad y muerte, por lo que varias organizaciones internacionales de salud apoyan la introducción de métodos para reducir la exposición al tabaquismo y la exposición pasiva al humo del cigarrillo, que incluyen las prohibiciones del acto de fumar.
Los estudios han mostrado que los lugares de trabajo que prestan servicios para ayudar a los fumadores a dejar de fumar han sido eficaces. Los servicios pueden incluir proporcionar tratamiento de reemplazo de nicotina (TRN) y proporcionar asesoría para ayudar a los fumadores a abandonar el hábito. Sin embargo, no se conoce si las políticas para que las personas dejen de fumar en las instituciones son efectivas. Aunque el acto de fumar se prohíbe en muchos lugares públicos, no se prohíbe en todos. Fumar se permite en algunas organizaciones de asistencia sanitaria, universidades y prisiones.
Características de los estudios
Se buscaron los estudios que midieron si la introducción de una política o una prohibición del acto de fumar en los hospitales, las universidades o las prisiones redujo la exposición pasiva al humo del cigarrillo y ayudó a los pacientes a abandonar el hábito de fumar. El estudio podía ser en cualquier idioma. Tenía que informar sobre la salud y el tabaquismo antes de que se implementara la política o la prohibición y durante al menos seis meses después. Se han incluido 17 estudios en esta revisión. Doce estudios aportan pruebas de hospitales, tres de prisiones y dos de universidades. Las pruebas están actualizadas hasta junio 2015.
Resultados clave
Se agruparon 11 de los estudios incluidos y se incluyeron 12 485 personas. Se encontró que la prohibición del acto de fumar en los hospitales y las universidades aumentó el número de intentos de abandono del hábito de fumar y redujo el número de personas que fumaban. En las prisiones hubo una reducción en el número de personas que murieron por enfermedades relacionadas con el tabaquismo y una reducción de la exposición pasiva al humo del cigarrillo después de introducir las políticas y las prohibiciones, pero no hubo pruebas de una reducción en las tasas de tabaquismo.
Calidad de la evidencia
No se encontraron estudios relevantes de alta calidad para incluir en la revisión. Estudios de investigación futuros de alta calidad pueden dar lugar a un cambio en estas conclusiones y no es posible establecer conclusiones firmes a partir de las pruebas actuales. Se necesitan más estudios de investigación más grandes para investigar las prohibiciones y las políticas contra el acto de fumar en estos contextos importantes.
Conclusiones de los autores
Summary of findings
| Smoking rates and smoking‐related mortality, pre‐ and post‐smoking ban/policy change | ||||||
| Patient or population: Smokers | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| No policy | Active smoking rates after policy | |||||
| Active smoking, hospital setting | Study population | RR 0.75 | 5986 | ⊕⊕⊝⊝ | ||
| 335 per 1000 | 251 per 1000 | |||||
| Active smoking, university setting | Study population | RR 0.72 | 6369 | ⊕⊕⊝⊝ | ||
| 194 per 1000 | 140 per 1000 | |||||
| Active smoking, prison setting | Study population | RR 0.99 | 130 | ⊕⊕⊝⊝ | ||
| 829 per 1000 | 820 per 1000 | |||||
| Smoking‐related mortality ‐ prison setting | Study population | Not estimable | 0 | Reductions in mortality for smoking‐related diseases noted in 2 studies (Binswanger 2014; Dickert 2015) after prisons adopted no‐smoking policies. | ||
| See comment | See comment | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1No control group | ||||||
Antecedentes
Efectos sobre la salud del tabaquismo y la exposición pasiva al humo del cigarrillo
Más de 5 000 000 de muertes en todo el mundo son atribuibles al tabaquismo, y la exposición pasiva al humo del cigarrillo causa 600 000 muertes anualmente (WHO 2009; WHO 2013a). No hay un nivel seguro de exposición pasiva al humo del cigarrillo (EPHC) (US Department of Health and Human Services 2014); sin embargo, en 2009 la Organización Mundial de la Salud (OMS) identificó sólo una minoría de países en todo el mundo que habían implementado las medidas exigidas en la Framework Convention on Tobacco Control (WHO 2009), con un aumento de la implementación de las medidas en los años siguientes WHO 2014). Una de estas medidas es un contexto sin humo de tabaco con legislaciones específicas, y se identificó que las prohibiciones voluntarias eran inapropiadas e inaceptables (WHO 2009).
Descripción de la intervención
Implementación de las prohibiciones a nivel institucional
Para los años setenta, la OMS había identificado la salud como un derecho humano fundamental (WHO 1978), y en la Carta de Ottawa se esbozaron los principios clave de la promoción de la salud que preconizaban los enfoques de contextos (WHO 1986), que incluían las escuelas, los lugares de trabajo, los hospitales, las prisiones y las ciudades. En los años siguientes, la OMS ha continuado expresando la necesidad de políticas de salud pública como un requisito clave para la promoción de la salud, más recientemente en 2013 (WHO 2013b). Existe un grupo de pruebas que destacan la repercusión de las regulaciones e intervenciones de control del consumo de tabaco en los lugares de trabajo en general y a nivel individual. Las prohibiciones o restricciones del acto de fumar pueden ayudar a eliminar la exposición de los no fumadores a los peligros de la exposición pasiva al humo del cigarrillo y pueden reducir el consumo de tabaco entre los propios fumadores.
Baric 1993 identificó varias condiciones necesarias para lograr la promoción de la salud en un contexto particular, que incluyen un ambiente sano, la integración de la promoción de la salud en las actividades diarias y la creación de condiciones para extenderse a la comunidad (Green 2015). Para facilitar el desarrollo de la salud pública y la actividades de promoción de la salud, el enfoque de un marco basado en sistemas permite el desarrollo de iniciativas a través de tres estratos o niveles de promoción de la salud, es decir micro, meso y macro (WHO 2002). Los niveles influyen entre sí y cuando funcionan juntos pueden proporcionar iniciativas de salud pública exitosas.
Las microintervenciones se dirigen al nivel individual y hay pruebas dentro de la promoción de la salud para el control del consumo de tabaco de la repercusión de las intervenciones conductuales para reducir el consumo y aumentar las tasas de abandono(Rigotti 2012; Stanton 2013). Las intervenciones a nivel meso, con las que se relaciona la presente revisión, operan a nivel de los contextos organizacionales y comunitarios (WHO 2002). A partir de las iniciativas de control del consumo de tabaco, hay pruebas de la repercusión de las intervenciones a nivel meso, incluidas las escuelas (Coppo 2014; Thomas 2013), y los lugares de trabajo en general(Cahill 2014; IARC 2008, IARC 2009; Tan 2012). Las pruebas de las iniciativas a nivel comunitario son limitadas y requieren estudios de investigación adicionales (Carson 2011). Una revisión reciente de las intervenciones a nivel de políticas y su repercusión sobre la exposición al humo de los cigarrillos en los fumadores y los no fumadores proporciona ejemplos de las intervenciones a nivel macro, o marcos legislativos, para la promoción global de la salud (Frazer 2016; WHO 2002).
Por qué es importante realizar esta revisión
La base de pruebas ha aumentado notablemente desde la primera publicación de la revisión de las prohibiciones legislativas (Callinan 2010) y la actualización reciente (Frazer 2016). Informes adicionales en curso apoyan la mejoría en los resultados de salud asociados con la legislación que prohíbe fumar (Been 2014; Kelleher 2014; Lee 2014). Los esfuerzos de la Framework Convention on Tobacco Control para reducir el consumo del tabaco a nivel global desde 2003 han dado lugar al apoyo internacional y a un aumento de las acciones legislativas contra el tabaco (WHO 2008; WHO 2009; WHO 2014). Las medidas basadas en pruebas de 2008 MPOWER incluyeron la protección del humo del tabaco en la lucha internacional para reducir la carga de mortalidad y morbilidad relacionada con el tabaquismo(WHO 2009; WHO 2013a). Aunque Frazer 2016 ha identificado la efectividad de las prohibiciones a nivel macro, es esencial que se examinen las pruebas para las prohibiciones del acto de fumar a un nivel meso, para identificar su repercusión sobre la reducción de la carga de exposición al humo del tabaco. Por lo tanto, se examina la bibliografía disponible sobre las prohibiciones en ámbitos especializados, específicamente en las instituciones públicas de asistencia sanitaria, la educación superior y en los establecimientos correccionales, para identificar la repercusión de dichas prohibiciones, ya sea de manera completa o parcial, en la reducción de la exposición al humo del cigarrillo, el consumo de tabaco, la prevalencia del tabaquismo y los resultados de salud.
Objetivos
Evaluar el grado en el que las prohibiciones del acto de fumar a nivel institucional pueden reducir la exposición pasiva al humo y el tabaquismo activo y afectar otros resultados relacionados con la salud.
Métodos
Criterios de inclusión de estudios para esta revisión
Tipos de estudios
Se incluyeron los ensayos controlados aleatorios(ECA), los no ECA (en los que los investigadores asignan los grupos a las condiciones de una manera no aleatoria), los estudios controlados tipo antes y después (en los que los investigadores no realizan la asignación a las diferentes condiciones de comparación) y las series de tiempo interrumpido (en los que los datos se recogen en múltiples puntos temporales antes y después de una intervención para detectar si la intervención tuvo un efecto significativamente mayor que cualquier tendencia secular subyacente), como los definen el Grupo Cochrane para una Práctica y Organización Sanitaria Efectivas (EPOC). También se consideraron los estudios no controlados tipo antes y después (que comparan los resultados en los mismos participantes o contextos antes y después de la implementación de la intervención). Se exigió un mínimo de seis meses de seguimiento para la inclusión.
Tipos de participantes
Se incluyeron las prohibiciones en ámbitos especializados, que incluyen las instituciones de asistencia sanitaria (hospitales, locales de asistencia sanitaria, residencias), la educación superior y los establecimientos correccionales (prisiones e instituciones militares), en los que se han implementado prohibiciones o políticas internas parciales o completas del acto de fumar. Estos contextos especializados se incluyeron cuando no se prohibió o se restringió completamente el acto de fumar con la introducción de legislaciones nacionales que prohibían fumar en muchas jurisdicciones.
Aunque cumplen con la definición de contextos especializados, no se incluyeron los lugares de trabajo o las escuelas generales porque ya se han examinado previamente (Cahill 2014; Coppo 2014; Fichtenberg 2002; IARC 2009; Thomas 2013). No se incluyeron los automóviles o las áreas de juego recreativo.
Se incluyeron participantes dentro de contextos especializados, ya fueran fumadores o no fumadores.
Tipos de intervenciones
Para ser incluido en esta revisión, el estudio debería identificar una prohibición parcial o completa o una política interna contra el acto de fumar en ámbitos especificados. Los estudios se limitaron a los que aparecieron desde la introducción de la primera Ley de Salud Pública (Tabaco), que prohibió fumar en los lugares de trabajo(GOI 2004), y los que se realizaron después de la implementación del Treaty on Framework Convention on Tobacco Control en 2005 WHO 2003). La razón para darle preferencia a los estudios con el respaldo de una prohibición nacional del acto de fumar (que incluye las prohibiciones estatales o regionales) tiene una fuerte base política. Muchas prohibiciones se implantaron primero en las áreas públicas, y actualmente han progresado a prohibiciones en ámbitos especializados. Por lo tanto, es posible comparar y contrastar estudios con y sin una prohibición nacional.
Tipos de medida de resultado
Resultados primarios
Las medidas de resultado primarias fueron la repercusión de las prohibiciones o las políticas internas contra el acto de fumar en ámbitos especializados sobre la protección de la exposición pasiva al humo del cigarrillo o sobre los resultados relacionados con la salud, o ambos. Para examinar la repercusión mantenida se requerían estudios que informaran datos iniciales y resultados durante al menos seis meses después de la introducción de la prohibición del acto de fumar en espacios cerrados. La implementación de las iniciativas de promoción de la salud es desafiante; estudios de investigación anteriores identificaron la necesidad de un período de obtención de datos de un mínimo de seis meses a un año, y hasta dos años para la evaluación del mantenimiento, a niveles individuales y organizacionales (Glasgow 1999; Green 2006). La sostenibilidad de las intervenciones a nivel de los contextos es fundamental(Glasgow 2006).
Para evaluar la exposición pasiva al humo del cigarrillo se prefirió la confirmación bioquímica de la exposición ambiental al humo del cigarrillo, con indicadores biológicos en las personas como la cotinina o las medidas de monóxido de carbono, o la información sobre la repercusión sobre la salud, que incluye las tasas de ingresos hospitalarios debido a afecciones que se sabe que están relacionadas con la exposición al humo del cigarrillo, o ambos tipos de medidas.
Resultados secundarios
Se evaluaron los resultados del hábito de fumar activo, que incluyen las tasas de tabaquismo informadas en la población expuesta u objetivo y las pruebas de abandono del hábito de fumar o los intentos de abandono. Se prefirieron los estudios que informaron datos validados bioquímicamente sobre el abandono del hábito de fumar, al igual que para la exposición pasiva al humo de cigarrillos.
Results
Description of studies
See Characteristics of included studies; Table 1; Table 2; Table 3; Characteristics of excluded studies.
| Study ID | Country | Setting | National Ban and Settings ban |
| Spain | Hospital | National ban: 28/2005. National indoor smoking ban enacted 1st January 2006 banned direct and indirect tobacco publicity and sponsorship; it reduced points of sale, and it banned smoking in enclosed workplaces and public spaces, with exemptions in the restaurant and hospitality sector (Partial ban at time of study). Settings: Hospital policy not described. | |
| Switzerland, Geneva | Hospital | No national ban. Settings: Smoking prohibited in February 2004 everywhere except smoking rooms. January 2006 smoking rooms removed and smoking totally prohibited inside hospital. | |
| Australia, Melbourne | Hospital | State ban Victoria: 1st July 2007. All restaurants, cafes, dining areas and shopping centres, enclosed workplaces, covered railway platforms, bus and tram stops and underage music and dance events are smoke‐free. Enclosed licensed premises and outdoor eating and drinking areas (where there is a roof and the wall surface area is more than 75%) must also be smoke‐free as of July 1, 2007. The gambling floors of casinos exempt. Settings: Total smoking ban implemented in the inpatient psychiatric unit in June 2008, including outdoor areas. | |
| Ireland, Dublin | Hospital | National ban: March 2004. Smoking banned in general workplace, enclosed public places, restaurants, bars, education facilities, healthcare facilities and public transport. However, it is permitted in designated hotel rooms and there is no ban in residential care, prisons and in outdoor areas. Settings: Hospital ban in 2004 following national smoke‐free ban. Total smoke‐free hospital campus policy in 2009. No smoking permitted indoors or outdoors. | |
| USA, New York | Hospital | National ban: New York State Smoke‐free air act 2002, enacted 2003. Banned smoking in virtually all workplaces and indoor recreational venues. Amendment to the City’s 1995 Smoke‐Free Air Act, the new law banned smoking in all restaurants and most bars regardless of seating and size. The law restricted smoking in some outdoor restaurant and bar seating areas. Settings: Smoke‐free medical campus implemented on July 1, 2006, which included an NRT programme and additional signage. | |
| Croatia, Kopriivnica‐ Krizevci county | Hospital | National ban: November 2008. Smoking officially banned in government buildings, private worksites, educational and healthcare facilities, taxis, and domestic or international air flights after 1999 legislation enacted. Smoking restricted (not banned) on trains, ferries,restaurants, nightclubs and bars, and other public places. 22nd November 2008 law extended to bars, restaurants and cafes. This is not reported in paper. Settings: Smoking bans in healthcare facilities. | |
| Canada, Ontario | Hospital | National: Not indoor smoke‐free legislation. Ontario's Tobacco Control Act in 1994 banned smoking in all government buildings. Large psychiatric facilities, including MHCP, sought and received special dispensation to allow patients and some staff to smoke in specially ventilated rooms. "Smoking rooms" were already in existence on most wards and some common patient areas at MHCP. The hospital constructed smoking gazebos outside various buildings for patients and staff to use. Ontario smoke‐free indoor legislation implemented in 2006. Settings: Comprehensive tobacco ban. Tobacco products no longer allowed anywhere on 225‐acre grounds after May 6, 2003. | |
| Switzerland, Geneva | Hospital | No national ban. Settings: A partial smoking ban established in a psychiatric university hospital, where only 1 ventilated room was made available for smoking for inpatients. Indoor smoking was comprehensively banned for staff January 2002. | |
| Spain | Hospital | National ban: 2006 to 2010. Spain had a partial ban on smoking in public places. Offices, schools, hospitals and public transportation were smoke‐free, but restaurants and bars could create a "smokers' section" or allow smoking if they were small (under 100 m²). Extension of ban January 2011 restricted smoking in every indoor public place, including restaurants, bars and cafes. Hotels may designate up to 30% of rooms for smoking; mental hospitals, jails and old people's residences may have public rooms where workers cannot enter. Outdoor smoking is also prohibited at childcare facilities, in children's parks and around schools and hospital grounds. Settings: Smoke‐free centre policy was progressively introduced. Tobacco control programme (2000 ‐ 2012) | |
| Japan,Fukuoka | Hospital | No national ban. Settings: 2002 to 2006. Introduced smoke‐free zones in hospital. Smoking areas and smoking tables subsequently removed. Hospital became smoke‐free (indoors) in 2007. | |
| USA, North Carolina | Hospital | No national ban. Settings: Tobacco‐free hospital policy introduced 4 July 2007. Employees offered free NRT, signage posted up and no smoking advertising 1 yr. lead in to policy. 100% tobacco‐free campus. | |
| Spain, Barcelona | Hospital | National ban: National smoking law introduced on January 1st 2006, and indoor smoking banned. Settings ban: not included. Evaluated national ban. |
| Study ID | Country | Setting | National Ban and Settings ban |
| USA | Prisons | National: Enactment varied by state/ordinance. Since 1993 US Supreme Court ruling that suggested exposure of prisoners to environmental tobacco smoke considered "cruel and unusual punishment" in violation of 8th Amendment. Settings: Either smoke‐free (indoor ban), comprehensive (indoor and outdoor), or tobacco‐free policy. | |
| USA, New Jersey | Prisons | National ban: New Jersey’s Smoke‐Free Air Act prohibits smoking in enclosed indoor spaces (2006). March 2010, an amendment banned the use of electronic smoking devices in indoor public places and workplaces and the sale to people 19 years and younger. Settings: NJDOC policy decision for tobacco‐free prisons, including grounds 2012. 13th Feb 2013 policy to ban sales and use of all tobacco products for employees, visitors and prisoners enacted. | |
| Switzerland | Prison | No national ban. Settings: In prison A, the SHS intervention consisted of an extension of smoke‐free zones and in 2009 smoking allowed everywhere except some indoor workplaces. From 2010 smoking only allowed in cells and outdoors. In prisons B and C in 2009, prisoners were allowed to smoke only in cells, during their outdoor exercise, and in 1 smoking room in prison C. Rules were loosely enforced and respected. There was no policy change regarding SHS in prison B. In prison C, the SHS intervention was limited to better enforcement of the smoking ban in the waiting rooms of the medical service. No cessation programmes in Prison A, inmates charged for NRT, prisons B and C in 2010/2011 medical staff trained to provide smoking cessation counselling and provide NRT. NRT was free in Prison C only. Smoking cessation booklets distributed to all prisons. |
NJDOC: New Jersey Department of Corrections
SHS: secondhand smoke
| Study ID | Country | Setting | National Ban and Settings ban |
| USA,Oklahoma | University | No national ban. Settings: 100% tobacco‐free campus policy introduced in July 2008. The use, sale and promotion of tobacco products were prohibited. | |
| USA, Indiana | University | No national ban. Settings: Indiana university total campus ban began 1 January 2008: smoking prohibited in all indoor and outdoor areas on campus. Smoking prohibited in university vehicles but not prohibited in personal vehicles. Purdue University in West La Fayette allowed smoking at distance of at least 30 ft. from university facilities during study period. |
Results of the search
We searched the literature for this review in June 2015. The database search yielded 1144 records. The Google Scholar search, handsearches, reference lists and information from authors about studies yielded 532 additional records. We excluded 1537 titles and abstracts, and reviewed 139 full‐text papers. Figure 1 provides further information on the identification and screening of relevant records and studies.
Study flow diagram
Included studies
Seventeen studies met our eligibility criteria. Twelve of these report the impact of smoking policies in healthcare settings (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Fitzpatrick 2012; Gadomski 2010; Gazdek 2013; Harris 2007; Keizer 2009; Martínez 2014; Morito 2015; Ripley‐Moffitt 2010; Santina 2011). Three studies investigate the effect of smoking policies in prisons (Binswanger 2014; Dickert 2015; Etter 2012); and two studies investigate the effect in university settings (Lechner 2012; Seo 2011).
Eight countries are represented in this review, including the USA (Binswanger 2014; Dickert 2015; Gadomski 2010; Lechner 2012; Ripley‐Moffitt 2010; Seo 2011); Spain (Alonso‐Colmenero 2010; Martínez 2014; Santina 2011); Switzerland (Etter 2008; Etter 2012; Keizer 2009); Australia (Filia 2015); Canada (Harris 2007); Croatia (Gazdek 2013); Ireland (Fitzpatrick 2012) and Japan (Morito 2015).
Eight studies were located in countries or US states that had a national legislative smoke‐free ban and a specialist setting policy or ban (either partial or comprehensive) in place: three in Spain (Alonso‐Colmenero 2010; Martínez 2014; Santina 2011); two in the USA (New York‐ Gadomski 2010; New Jersey‐ Dickert 2015) and one each in Australia (Filia 2015); Ireland (Fitzpatrick 2012); and Croatia (Gazdek 2013) .
Eight studies included in this review were in countries or in US states with no legislative bans, with only a specialist setting tobacco control policy or ban in place, including: three studies in Switzerland (Etter 2008; Etter 2012; Keizer 2009); three in the USA (North Carolina Ripley‐Moffitt 2010; Oklahoma Lechner 2012; Indiana Seo 2011); one in Canada (Harris 2007) and one in Japan (Morito 2015). The final study in the review, Binswanger 2014, included all 50 US States (some with legislative bans and some without) and compared smoking‐related mortality outcomes in prisons with a ban to those without a ban or policy.
The smoking policy interventions included in the specialist settings in this review had to be implemented and evaluated for a minimum period of six months (pre‐intervention data required). The intervention varied from partial indoor tobacco control bans or policies to comprehensive tobacco control bans or policies. In countries with national legislative bans, the local “settings” tobacco control policy or ban sometimes mirrored partial national legislation banning smoking indoors in these specialist settings (Alonso‐Colmenero 2010; Gazdek 2013; Santina 2011). However, a number of studies included in this review evaluated policies in hospitals which implemented more comprehensive smoking bans or extensions of national smoking bans; namely total campus bans and banning indoor and outdoor smoking activities (Filia 2015; Fitzpatrick 2012; Gadomski 2010).
Martínez 2014 evaluated the impact of a number of smoking bans prior to and then following national smoke‐free legislative bans. These hospital smoking bans progressed to a comprehensive indoor and outdoor smoking ban. Binswanger 2014 evaluated the impact of smoke‐free policies in prisons, including smoke‐free policies when indoor smoking was banned, or policies which comprehensively banned smoking both indoors and outdoors, depending on state laws. Similarly Dickert 2015 evaluated the impact of a tobacco‐free policy in a prison banning the sale and use of tobacco products for all employees, visitors and prisoners, again reflecting the New Jersey State ban.
Eight studies with no national legislative smoking bans described varying stages of indoor smoke‐free policies in all of the specialist settings. Harris 2007 evaluated the implementation of a comprehensive smoke‐free ban prohibiting tobacco products from a large maximum security forensic mental health hospital, at a time when psychiatric hospitals were exempted from legislation. Etter 2008 evaluated a policy that provided “designated indoor smoking rooms” progressing to a total prohibition of smoking indoors in a psychiatric hospital. Morito 2015 identified a progressive hospital policy in Japan which introduced smoke‐free zones in a general hospital initially, and then subsequent removal of these zones when the hospital became smoke‐free over a period of five years. Keizer 2009 evaluated a partial smoking ban in a psychiatric unit which permitted patients to smoke in a designated ventilated room; staff smoking was totally prohibited indoors. Ripley‐Moffitt 2010 evaluated a comprehensive tobacco‐free hospital policy which banned smoking indoors and outdoors on a hospital campus.
In a prison setting in Switzerland, Etter 2012 evaluated the effect of increased smoke‐free zones. In one prison, smoking was permitted anywhere with the exception of indoor workplaces initially. The policy was extended one year later to permit prisoners to smoke only in cells and outdoors. This prison was compared to two others with different smoking policies that permitted smoking in cells, during exercise outdoors, and in one of the control prisons smoking was also permitted in a designated smoking room.
Lechner 2012 and Seo 2011 evaluated the introduction of a comprehensive tobacco‐free campus policy in university settings, where the sale, use and promotion of tobacco products were banned. These studies were located in US states with no national legislative smoking bans.
Thirteen studies reported active smoking measures as a primary outcome, including smoking prevalence (smoking rates) and quit rates; four of these studies (Etter 2008; Etter 2012; Keizer 2009; Lechner 2012) also included self‐reported outcomes for environmental tobacco smoke exposures. There were four studies that identified health or mortality as a primary outcome measure (Binswanger 2014; Dickert 2015; Harris 2007; Morito 2015).
We found no randomized controlled studies for inclusion. All included studies are observational in design; three studies use a controlled before‐and‐after design, employing another setting as a comparison (Binswanger 2014; Etter 2012; Seo 2011); 14 studies used uncontrolled before‐and‐after designs (Alonso‐Colmenero 2010; Dickert 2015; Etter 2008; Filia 2015; Fitzpatrick 2012; Gazdek 2013; Keizer 2009; Lechner 2012; Martínez 2014; Morito 2015; Santina 2011; Gadomski 2010; Harris 2007; Ripley‐Moffitt 2010), three of which used a cohort design (Gadomski 2010; Harris 2007; Ripley‐Moffitt 2010). Seo 2011 employed a separate smaller nested cohort study design within the larger controlled before‐and‐after study. Binswanger 2014 and Dickert 2015 used interrupted time series mortality data.
Five studies in this review analysed data on two separate specialist populations (Etter 2008; Etter 2012; Fitzpatrick 2012; Gadomski 2010; Keizer 2009), in their specialist settings of hospitals or prison (i.e. staff and patients or staff and prisoners). The remaining studies report outcomes for one specialist population group: employees, prisoners, inpatients or students.
Further information can be found in the Characteristics of included studies table.
Excluded studies
We excluded from this review studies which did not meet the inclusion criteria. Connell 2010 evaluated the effect of introducing tobacco‐free policies into prisons with smoke‐free policies in Kentucky; however, this study did not include any pre‐ban data. We excluded Pagano 2015 from this review as pre‐ban data were collected after the implementation of the tobacco control policy in some of the healthcare units. We report all reasons for exclusion in the Characteristics of excluded studies table.
Risk of bias in included studies
We made explicit judgements of bias according to the criteria in the Cochrane Handbook (Higgins 2011). See Characteristics of included studies table. A summary of the assessments is provided in Figure 2. We consider the study designs used in this review, evaluating a policy‐level health promotion outcome, and the evidence, to be at high risk of bias. However, it must be acknowledged that two of the studies employed mortality data from national registries (Binswanger 2014; Dickert 2015); three studies included a control reference area for comparison (Binswanger 2014; Etter 2012; Seo 2011).
Selection bias
We assessed whether studies used appropriate methods to obtain representative samples of participants. Two studies used nationally representative data from registries (Binswanger 2014; Dickert 2015) and three studies described random sampling methods (Fitzpatrick 2012; Lechner 2012; Santina 2011). Fitzpatrick 2012 employed a quota system to obtain a randomly‐selected sample of staff. Using HR records, they obtained a 10% sample stratified by occupational health grouping. Earlier surveys had also included randomly‐selected methods (Fitzpatrick 2009). A census of inpatients was also achieved in this study and in pre‐ban data collection (Fitzpatrick 2009). Santina 2011 also employed randomization to obtain a sample of staff. If a staff member did not want to participate they were replaced by another, matched for age, sex and occupation. Lechner 2012 reported using a clustered random sampling method, from a list of university courses, to access a sample. Volunteer sampling methods were described by Seo 2011 in the recruitment of students for a longitudinal cohort study, and convenience sampling was employed in larger cross‐sectional surveys at baseline and follow‐up; the sample consisted of white non‐Hispanic students. Ripley‐Moffitt 2010 described a sampling method that involved selecting staff with email addresses; 16 per cent of staff were subsequently reported not to have email addresses.
Blinding
It was not possible to blind participants, as the intervention was a policy or ban and smoking is a visible activity. The use of large national registries of data also negated blinding. Environmental tobacco exposures reported in this review are all self‐reported. Biochemical verification of active smoker status was measured at baseline in two studies (Alonso‐Colmenero 2010; Fitzpatrick 2012). The remaining studies including active smoking measures were all self‐reported. Three studies report using face‐to‐face data collection methods (Alonso‐Colmenero 2010; Fitzpatrick 2012; Santina 2011), with Santina 2011 acknowledging a potential Hawthorne effect bias in using this method for data collection. Etter 2012 indicated that assistance from researchers was available if prisoners were unable to complete questionnaires themselves, but did not report whether this method was employed. Five studies reported using anonymised questionnaires for data collection purposes (Etter 2008; Etter 2012 (staff); Filia 2015; Gazdek 2013; Martínez 2014).
Incomplete outcome data
The use of imputed scores was not reported in any of the studies in this review. Low response rates or high attrition rates were reported over the course of studies in Etter 2012; Gazdek 2013; Martínez 2014; Ripley‐Moffitt 2010; Seo 2011. Retention was encouraged in two cohort studies by offering gift cards to participants (Ripley‐Moffitt 2010; Seo 2011). Fitzpatrick 2009 reported a low response rate for one staff survey in 2002, due to an alternative data collection process.
Selective reporting
Two studies used existing data sets (Binswanger 2014; Dickert 2015); Harris 2007 employed a retrospective chart audit including reported smoking status. Morito 2015 used inpatient admissions details and a chart review to identify inpatient acute myocardial infarction (AMI) cases. Gadomski 2010 accessed staff occupational health records reporting smoking prevalence and used a hospital database of NRT‐prescribing records to identify changes in prescribing patterns for patients. A number of studies identified higher response rates from female staff at either baseline or follow‐up (Martínez 2014; Ripley‐Moffitt 2010; Santina 2011) or a higher response from one occupational health group over another, e.g. nurses (Keizer 2009). Ripley‐Moffitt 2010 reported a 12 per cent smoking prevalence at baseline which was 10 per cent lower than population estimates, suggesting a lower response to the survey among staff who smoked. Fitzpatrick 2009 combined data from two separate patient surveys (1997 and 1998) into one reported data set. Both surveys had been conducted within six months of each other, with no seasonal differences noted.
Two studies verified smoking status at baseline (Alonso‐Colmenero 2010; Fitzpatrick 2012). There is a reliance on self‐reported unverified smoking status in studies included in this review. However, these weaknesses are likely to reflect the methods employed rather than selective reporting by the authors.
Other potential sources of bias
Smoking status variables were self‐reported for the majority of studies reporting active smoke exposure (Etter 2008; Etter 2012; Filia 2015; Gadomski 2010; Gazdek 2013; Keizer 2009; Lechner 2012; Martínez 2014; Ripley‐Moffitt 2010; Santina 2011; Seo 2011). Passive smoke exposure was self‐reported in four studies included in this review (Etter 2008; Etter 2012; Keizer 2009; Lechner 2012). The sample sizes used in a number of studies included in this review are small (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Harris 2007; Keizer 2009; Morito 2015); however, other studies did employ larger sample sizes (Binswanger 2014; Dickert 2015; Gadomski 2010 (NRT records); Gazdek 2013; Lechner 2012; Seo 2011). Seo 2011 used a matched university for comparison, but acknowledged that smoking prevalence was lower at baseline in the control setting. Lechner 2012 reported that a downward trend in smoking at the universities, after a smoking policy was introduced, could be explained by other activities or secular changes. Martínez 2014 acknowledged that smoking prevalence rates among employees in a cancer centre may be lower than other hospitals, as the participants were an informed group of employees.
Other biases include a change to healthy heart diets in prisons during the period of Dickert 2015. Binswanger 2014, Dickert 2015, Etter 2012 all reported issues with the reallocation of prisoners between prisons during the data collection periods for their studies, to other prisons with more or less stringent or enforced smoking tobacco policies. In addition, higher smoking rates in prisons with poorly‐ventilated areas may have influenced study outcomes.
Etter 2012 reported that due to limited resources, no follow‐up surveys of staff were completed in one of the comparison prisons and that the follow‐up period for the survey of prisoners was only three months. This prison was identified as having difficulties with overcrowding, resulting in nonsmokers being placed in cells with smokers.
Effects of interventions
Passive smoking
No studies assessed the effect on passive smoke exposures using measurements of cotinine. We identified four observational studies that reported the impact of passive smoke exposure on health and mortality outcomes (Binswanger 2014; Dickert 2015; Harris 2007; Morito 2015). We identified four observational studies providing self‐reported passive smoke exposure in addition to reporting active smoking rates for each specialist setting (Etter 2008; Etter 2012; Keizer 2009; Lechner 2012).
A reduction in passive smoke exposure was reported in all three settings after the introduction of smoking policies or bans restricting or limiting exposure. Lechner 2012 reported reduced smoke exposure at entrances to university campus buildings amongst students, and a greater preference for the smoke‐free environment in Oklahoma. Etter 2008 identified a reduction in duration of SHS exposure per day amongst hospital inpatients in Switzerland, with staff also reporting significant reductions in SHS exposure. In this study nonsmokers reported reduced SHS exposure after the introduction of a partial smoking ban, with no further decrease in exposure soon after a total indoor smoke‐free ban was introduced and 27 months after the partial ban was introduced. Similar results were reported by Keizer 2009, who reported that staff who smoked were less bothered about SHS exposure than nonsmokers in this Swiss study. In the prison setting in Switzerland, Etter 2012 observed comparable results, with reduced exposure time among prisoners and staff after the introduction of a smoking policy and restricted smoking. No significant reductions in reported SHS exposure were identified by prisoners in the two comparison prisons in this study. Staff did acknowledge reduced smoke exposure in the control prison sites with fewer restrictions ( Analysis 1.1).
Health and smoking‐related mortality outcomes
Four studies in this review evaluated the impact of smoking policies on health and smoking‐related mortality outcome measures in prisons and hospitals (Binswanger 2014 prison; Dickert 2015 prison; Harris 2007 secure mental hospital; Morito 2015 hospital) ( Analysis 2.1 ). Binswanger 2014, in a review of mortality data, reports that mortality associated with smoking‐related illness was reduced in prisons which had a smoking ban established for a period of nine or more years, when compared to prisons with no smoking policies. They identified 48 states in the USA with a smoking ban and prison policies in place in 2011, an increase from 25 states in 2001 (baseline).
Dickert 2015 detected significantly higher smoking rates amongst prisoners with mental health needs in their review of New Jersey mortality data. Significant annual reductions in smoking‐related mortality in prisons were identified for all prisoners, and particularly for those with a diagnosed mental illness, after the introduction of smoking bans. However Dickert 2015 acknowledges that the changes may be confounded by other factors in prisons, including improved healthy heart diets introduced between 2005 and 2007, during the period of the study.
Within the hospital setting, Morito 2015 identified a significant reduction in the onset of AMI inpatient events after the introduction of a phased smoking policy over a 12‐year period; four cases detected in 2002 prior to any policy, 14 cases detected between 2003 to 2006 and seven cases occurring during a seven‐year period after the hospital became smoke‐free. The reduction was significant after statistically adjusting for smoking status and other confounders, with the exception of dyslipidaemia.
Harris 2007's retrospective audit of 119 inpatients' charts in a secure mental hospital in Canada reported improved health assessments one year after the introduction of a hospital campus‐wide smoking ban for 17 of the 23 smokers. No smoking prevalence data were reported in the study, but smoking status was identified from chart information in this study. The identified health effects included improved cardiopulmonary health assessments for 17 of the 23 inpatients.
Active smoking rates
The effect of smoking policies in specialist settings on smoking prevalence amongst some participant groups are reported in 13 studies in this review. Ten studies are based in hospital settings (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Fitzpatrick 2012; Gadomski 2010; Gazdek 2013; Keizer 2009; Martínez 2014; Ripley‐Moffitt 2010; Santina 2011), one study reported smoking rates in a Swiss prison (Etter 2012), and Lechner 2012 and Seo 2011 reported smoking rates in university settings in two US states ( Analysis 3.1).
Five of these studies included outcomes for two populations: employees and patients in hospitals (Etter 2008; Fitzpatrick 2012; Gadomski 2010; Keizer 2009) and employees and prisoners in prison (Etter 2012). Inconsistent evidence emerged within hospital and prison settings.
All studies reporting active smoking rates used uncontrolled before‐and‐after study designs, with the exception of Etter 2012 and Seo 2011, which had comparison groups.
Hospital settings
Keizer 2009 did not detect a significant reduction in smoking rates post‐ban in a psychiatric hospital in Switzerland. The study did identify that consumption of cigarettes amongst staff reduced post‐ban, but no difference was reported in patient smoking rates. Trends in patient smoking rates reported an initial decrease in consumption, but a return to usual levels by day 10 of admission. Respondent's qualitative responses identified the following reasons for increased smoking rates: boredom, mental health issues including stress, cravings, or simply due to being in hospital.
Etter 2008 did not detect a reduction in smoking rates for either staff or patients after either a partial or a subsequent total smoking policy was introduced in a psychiatric hospital in Switzerland. An increase in quit attempts by patients was reported. However, the reported confidence interval is very wide and the sample size in the study was small.
Whilst Fitzpatrick 2012 detected a reduction in patient smoking rates, there was no significant difference after the introduction of an additional smoke‐free campus ban. A significant reduction in staff smoking rates was reported, especially amongst female staff and those aged 30 to 39 years after the further campus ban.
A significant reduction in smoking rates amongst staff was reported in Gadomski 2010's cohort study after the introduction of a hospital policy in New York. Whilst no baseline smoking prevalence data were available for patients before the policy, NRT prescribing patterns for patients tripled after the introduction of the policy and no increase in patients leaving the hospital against advice was observed. Gazdek 2013 reported significant reductions in staff smoking rates and tobacco consumption, with the highest decrease in the period two to six years after the hospital policy was introduced in 1999. The national ban was introduced in 2008 during the period of the study. Martínez 2014 also detected significant reductions in staff smoking rates, similar to Fitzpatrick 2012; reductions in 2010 were greater amongst female employees and in those aged over 35 years compared to 2006. Smoking rates decreased in men, but not significantly.
Similar reductions in staff smoking rates were reported by Santina 2011 for all staff groups, with the exception of nursing staff. Significant increases in quit attempts and readiness to quit were reported by Martínez 2014, whilst Ripley‐Moffitt 2010 observed increased quit attempts in their cohort over time. Santina 2011 detected significant increases in the provision of help and assistance with quitting smoking.
Alonso‐Colmenero 2010 did not observe any statistically significant reduction in the number of patients who smoked during their inpatient stay after a policy was introduced. All patients in the study population were smokers and the authors identified 55 patients who smoked whilst in hospital at some point during the study. The percentage of these 55 patients smoking during their hospital stay increased after the hospital policy was introduced.
Prison settings
One study reported smoking prevalence rates in prison. Etter 2012 identified little change in smoking prevalence among staff or prisoners, with no significant change in quit rates either in the intervention prison or when compared to the two control prisons. Staff smoking rates increased in one comparison prison during the reporting period of the study. Prisoners in the intervention prison reported receiving more medical help to quit smoking after the introduction of the smoking policy. NRT in this prison was not free, unlike one of the comparison prisons.
University settings
Finally, within the specialist university setting some positive impacts of campus bans were observed. Lechner 2012 identified a significant reduction in “more frequent smokers” who were male, following the introduction of a campus ban at Oklahoma university; however, this was not observed in women. "More frequent smokers" were defined in this study as individuals who had smoked over 100 cigarettes in a lifetime and who had consumed cigarettes on at least 10 of the last 30 days.
Similarly, Seo 2011 detected a significant reduction in smoking rates at an Indiana university after the introduction of a campus policy, whereas smoking rates increased at Purdue University (La Fayette), which acted as the control. However, it should be noted that the baseline levels of smoking were different across universities. Students also reported significant reductions in peer smoking in Indiana compared to Purdue University. The longitudinal cohort component of this study identified a significant decline in the number of cigarettes consumed in Indiana when compared to Purdue.
Effect on active smoking rates
Due to heterogeneity, it was not possible to conduct a meta‐analysis and pool data from all of the 17 observational studies included in this review. We assessed the impact of smoking policies using uncontrolled before‐and‐after data from 11 of the studies in this review. Eight studies assessed the effect of smoking bans on smoking prevalence rates in hospital settings (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Fitzpatrick 2012; Gazdek 2013; Keizer 2009; Martínez 2014; Santina 2011). One of the studies assessed smoking prevalence in the prison setting (Etter 2012); only before‐and‐after data from the intervention prison are included in this analysis. The final two studies assessed smoking prevalence in university settings (Lechner 2012; Seo 2011). Only before‐and‐after data from Seo 2011 are used in analyses, with data from the control university and from the smaller nested cohort study excluded. The implementation of policies may have varied from study to study, but all measured the effect of the settings‐based policy on active smoking rates.
Four studies assessed outcomes for patient groups (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Keizer 2009), and three for hospital employees (Gazdek 2013; Martínez 2014; Santina 2011). Fitzpatrick 2012 assessed outcomes for both staff and patient groups, and therefore the data from this study have been split into these two groups and entered into meta‐analyses separately. Included pre‐ban data for the analyses of staff and patients is reported in Fitzpatrick 2009, prior to the first hospital ban in 2004.
There was evidence of substantial heterogeneity when pooling all 11 studies (I² = 72%), so we report estimates by setting (hospital/university/prison).
We found an effect of a smoking policy on reducing smoking rates across eight hospital‐based studies (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Fitzpatrick 2012Gazdek 2013; Keizer 2009; Martínez 2014; Santina 2011), with a risk ratio (RR) of 0.75, (95% confidence interval (CI) 0.69 to 0.81; n = 5986; I² = 68%) (Figure 3; Analysis 4.1). Heterogeneity in this subgroup was attributable to the large reduction in smoking amongst hospital staff in Fitzpatrick 2012. The baseline survey used in the analysis preceded the introduction of a comprehensive national ban and hospital ban by over five years, and may reflect secular change in smoking. Similarly in Gazdek 2013, baseline pre‐ban data were collected during this period; however the hospital policy was introduced the following year after the introduction of a partial legislative smoking ban, progressing to a comprehensive smoke‐free ban nine years later during the period of the study. There was also evidence of reduced smoking in the university setting (Lechner 2012; Seo 2011), RR 0.72, 95% CI 0.64 to 0.80; n = 6369, I² = 59%. Only one small study was included in the prison subgroup (Etter 2012), which in contrast showed no evidence of change (RR 0.99, 95% CI 0.84 to 1.16; n = 130).
Comparison of active smoking rates in hospitals, universities and prison settings
Subgroup analysis; staff and patient smoking rates in hospitals
The effect of smoking policies in hospital settings was compared between two participant groups (staff and patients). Four studies assessed the impact on staff smoking rates (Fitzpatrick 2012; Gazdek 2013; Martínez 2014; Santina 2011) and five studies assessed the impact on patient smoking rates (Alonso‐Colmenero 2010; Etter 2008; Filia 2015; Fitzpatrick 2012; Keizer 2009). The Alonso‐Colmenero 2010 study measured the effect of a policy on the number of smokers who actively smoked as inpatients in hospital. .
There was evidence of a pooled effect of policies on reducing active smoking rates in both staff (RR 0.71, 95% CI 0.64 to 0.78; n = 4544; I² = 76%) and patients (RR 0.86, 95% CI 0.76 to 0.98; n = 1442; I² = 20%) (Analysis 4.2). Heterogeneity remained in the staff subgroup, attributable to Fitzpatrick 2012 as noted above.
Subgroup analysis; status of national legislation
Six studies assessed the impact of smoking policies on active smoking rates in countries where a national smoking ban existed during the period of data collection (Alonso‐Colmenero 2010 Spain; Filia 2015 Australia; Fitzpatrick 2012 Ireland; Gazdek 2013 Croatia; Martínez 2014 Spain; Santina 2011 Spain). Pre‐ban data for these studies were collected prior to the introduction of the national smoking ban, as smoking would have been banned in these settings after the introduction of legislation. Five studies assessed the impact in countries (Switzerland, US states) with no national smoke‐free legislation (Etter 2008; Etter 2012; Keizer 2009; Lechner 2012; Seo 2011). There was no evidence that effect sizes, pooled across settings, differed by the status of national legislation, but there was considerable heterogeneity within the studies included in the 'no national ban' subgroup (I² = 78%), so pooled effects are not reported (Analysis 4.3).
Adverse events
Four studies in the review reported adverse events during the period of the studies, with three studies specifically reporting events in psychiatric hospitals (Etter 2008; Filia 2015; Harris 2007) and Etter 2012 reporting events from the prison setting. Etter 2012 reported that smoking continued outdoors and in the cells of all prisons, due to a lack of enforcement of the smoking bans by staff.
In the hospital setting, Etter 2008 reported that after a total ban was introduced, both staff and patients significantly perceived that the smoking ban's rules were too strict and this perception increased with the ongoing progression of the smoking ban in the hospital (staff and patients: pre‐ban 9.4% versus 55.0% post‐total ban, P < 0.001). The total ban resulted in significantly more patients reporting that they became angry with staff because of the policy (4.5% partial ban versus 24.5% after total ban). However, whilst staff also reported a significant increase in patient complaints, this increase was not statistically significant. After the total ban was introduced, staff reported that patients were still smoking in bedrooms. There was an increase in patients reporting tobacco smoke as a source of conflict with staff (pre‐ban 24.7% versus 36.4% post‐total ban, P = 0.005), but a nonsignificant reduction reporting tobacco smoke as a source of conflict with other patients after the total ban was introduced (pre‐ban 49.0% versus 37.7% post‐total ban). However, the follow‐up period after the introduction of the total ban was short, at approximately three months, and the authors suggest this time period may not reflect acceptability.
Filia 2015 reported 75% of smokers held negative or very negative views about the introduction of a total smoke‐free policy in comparison with 7.1% of nonsmokers in the hospital. Smokers viewed smoking as a coping strategy for stress and were concerned about nicotine withdrawal symptoms. Patients reported difficulties including negative emotions, frustration, restlessness and anger with increased craving and symptoms of nicotine withdrawal. They reported drinking more tea and coffee. The authors suggest that reduced nicotine can increase caffeine levels and patients should be encouraged to limit caffeine intake, as high levels of caffeine can mimic the symptoms of nicotine withdrawal.
Harris 2007 reported negative health effects including increased prescribing for clozapine, reported cases of increased aggression and evidence of weight gain amongst inpatients in the study. The authors report that increased physical aggression by patients in the open wards was little to do with the tobacco ban as nonsmokers exhibited more aggression than those in maximum security and was probably due to selection, as only very violent patients would be inpatients for a long period of time. The ban was associated with a reduction in mood and increased weight gain of 5 kg, and with a decrease in clozapine dose. The authors report that the aggression levels returned to pre‐ban levels within a year, but weight gain was unchanged. They report that weight gains were no great than would be expected in the literature. The authors report that the increase in physical aggression was not seen in patients in maximum security units, and that few ill effects of the ban were observed in this group of patients. They suggest that the increased physical aggression in patients in open wards may have been due to staffing by nonforensic employees and less successful attempts at stopping tobacco use among patients, and also due to patients themselves having an opportunity to access tobacco from visitors or when they were off the hospital grounds while on recreation or work duties.
Discusión
Resumen de los resultados principales
En esta revisión se incluyeron 17 estudios que evalúan el grado en el que las prohibiciones institucionales del acto de fumar reducen la exposición activa y pasiva al humo del cigarrillo y sus efectos sobre los resultados relacionados con la salud en varios países. Las prohibiciones y políticas contra el acto de fumar incluidas en esta revisión variaron de parcialmente sin tabaco, que incluyeron áreas interiores designadas para fumar, a prohibiciones generales del acto de fumar en zonas interiores sin tabaco, a prohibiciones completas del acto de fumar en las que no se podía comprar ni consumir tabaco en interiores ni al aire libre. Las extensiones de las políticas de prohibición del acto de fumar no se limitaron a las jurisdicciones con prohibiciones legislativas nacionales. Ocho estudios incluidos en esta revisión se localizaron en países sin prohibiciones legislativas nacionales del acto de fumar.
Se observaron reducciones en las tasas de tabaquismo activo en el personal después de la introducción de una política contra el acto de fumar en dos de los contextos especializados (prisiones, universidades), así como en los pacientes en el contexto hospitalario. También hubo un aumento en los intentos de abandono del hábito de fumar y un aumento en la prescripción de productos de TRN en algunos estudios. Sin embargo, se reconocen el sesgo y la posibilidad de los factores de confusión, y se consideró que la calidad general de las pruebas es baja. También se informó la reducción de las exposición pasiva al humo del cigarrillo; sin embargo, no se realizaron validaciones bioquímicas y se encontraron inconsistencias en la implementación de las políticas dentro de los contextos de las prisiones. Aunque las políticas contra el acto de fumar en las prisiones han ido en aumento en las prisiones de los EE.UU. y se han identificado pruebas de la reducción de la mortalidad por enfermedades relacionadas con el tabaco, la implementación de dichas prohibiciones y las políticas para el control del consumo de tabaco es limitada en otras jurisdicciones. Sin embargo, en 2016 comenzará una prohibición del acto de fumar en las prisiones de Inglaterra y Gales (Ministry of Justice 2015).
Se mantienen las discrepancias en los tipos de prohibiciones del acto de fumar que se introducen en las prisiones dentro de la Unión Europea (UE). Los resultados de esta revisión actual aportan pruebas que provienen de un estudio de los EE.UU. durante un período de diez años, en el que las prohibiciones del acto de fumar que se han implementado han evolucionado (Binswanger 2014). Fitzpatrick 2012 y Gazdek 2013 informan mejores resultados para el personal en particular después de establecer las políticas durante un período de tiempo más prolongado. Por lo tanto, parece haber potencial para la implementación de mejorías significativas para reducir la exposición pasiva al humo del cigarrillo en ámbitos especializados.
Las prisiones y los hospitales psiquiátricos eran contextos especializados exonerados de las legislaciones iniciales que prohibían el acto de fumar en muchas jurisdicciones internacionales, a pesar del hecho de que son lugares de trabajo y se han identificado como contextos con tasas de prevalencia mayores de tabaquismo. En estos contextos, los cigarrillos se han utilizado supuestamente para calmar y controlar, utilizados para el "alivio del estrés", y dentro de las prisiones el tabaco se puede considerar una moneda de cambio (Connell 2010). En 2005, O'Dowd 2005 informó los riesgos para el personal si el acto de fumar se prohíbe en las prisiones; McCaffery 2012 reconoció disturbios en prisiones en Canadá después de la introducción de las prohibiciones del acto de fumar, pero informó que el 79% de los miembros de la Unión Europea habían introducido una prohibición del acto de fumar en las prisiones (n = 22) en sus documentos. Las tasas de tabaquismo y los índices de consumo de tabaco son mayores en los prisioneros en comparación con la población general, con estimaciones de alrededor del 64% al 88% (Hartwig 2008) y tasas de tabaquismo en los pacientes con enfermedades mentales que varían del 44% al 64% (McManus 2010). Se han reconocido los resultados negativos para la salud y las repercusiones del tabaquismo y se han documentado bien (Royal College of Physicians 2013). McCaffery 2012 observó que las medidas de la calidad del aire en hospitales psiquiátricos irlandeses fueron ampliamente similares a las encontradas en los bares irlandeses antes de la prohibición legislativa del acto de fumar de 2004, con concentraciones de partículas excesivamente altas detectadas en los hospitales psiquiátricos y las residencias geriátricas.
MacKay 2016 reconoce que la introducción de las prohibiciones del acto de fumar en áreas cerradas (prisiones, hospitales psiquiátricos) es polémica; sin embargo, los derechos de los fumadores al humo no se ha defendido en los tribunales bajo la legislación de los Derechos Humanos (Christie 2014). Es fundamental la reducción de los efectos perjudiciales y las mejorías para alcanzar las metas de salud pública. Sin embargo, la introducción de las prohibiciones en estas áreas debe tener en cuenta las poblaciones y realizarse como parte de varias medidas multicomponente de control del consumo de tabaco para apoyar el abandono del hábito de fumar. Por ejemplo, es importante que las prohibiciones en los hospitales psiquiátricos se introduzcan en consulta con los psiquiatras, para asegurar que los mejores intereses y la mejoría de los resultados de salud de los pacientes sea lo fundamental. Lo anterior coincidiría con las guías NICE del Reino Unido (NICE 2013), el Framework on Tobacco Control (WHO 2003), y los avances en curso que se han logrado (WHO 2014).
La importancia de las actitudes del personal y sus experiencias se reconocen como factores esenciales al decretar las políticas de prohibición del acto de fumar. Lawn 2015 reconoce que las actitudes del personal en las prisiones son importantes para el cumplimiento de las políticas de prohibición del acto de fumar. En esta revisión actual Etter 2012 describió la autorización de fumar para el personal en áreas no designadas en las prisiones, de manera similar a la revisión Lawn 2015.
Han surgido pruebas de una reducción en la mortalidad por enfermedades relacionadas con el tabaquismo en las poblaciones de las prisiones. La asociación es consistente con una respuesta temporal a la dosis, ya que el número de prohibiciones aumentó con el transcurso del tiempo. Sin embargo, los resultados están limitados a estudios en los EE.UU., y la repercusión de otros factores de confusión, que incluyen cambios en las dietas de las prisiones, puede haber influido en los resultados informados. Existen pruebas limitadas de otras repercusiones en la salud a nivel de contextos. Las pruebas de esta revisión están limitadas a un estudio que identifica tendencias decrecientes en las tasas de IAM en los pacientes y mejorías en las evaluaciones de salud en una cohorte de pacientes con enfermedades mentales de larga duración.
La implementación de prohibiciones y políticas contra el acto de fumar en los recintos universitarios en dos estudios de esta revisión presenta pruebas de un efecto positivo de la introducción de prohibiciones del acto de fumar, que incluye la reducción en las tasas de tabaquismo activo, el aumento de los intentos de abandono del hábito de fumar, pruebas de reducción de las exposición pasiva al humo del cigarrillo y la influencia positiva en las normas sociales y las percepciones de los compañeros de las actitudes y las conductas con respecto al hábito de fumar.
Compleción y aplicabilidad general de las pruebas
El objetivo clave de esta revisión fue evaluar el grado en el que las prohibiciones institucionales del acto de fumar pueden reducir el tabaquismo activo y el consumo de tabaco, la exposición pasiva al humo del cigarrillo y los efectos sobre resultados relacionados con la salud en tres contextos especializados que incluyen las instalaciones de asistencia sanitaria públicas, la educación superior y los establecimientos correccionales. Se encontraron 17 estudios en total; sin embargo, sólo dos analizaron la pregunta en el contexto de la educación superior y tres en las prisiones. La mayoría de los estudios de esta revisión proporcionaron pruebas de instalaciones públicas de asistencia sanitaria. Las pruebas provinieron de ocho países; sin embargo, en los EE.UU., España y Suiza se realizaron 12 de los 17 estudios de esta revisión.
Calidad de la evidencia
La calidad de las pruebas incluidas en esta revisión es baja, informadas principalmente a partir de diseños de estudios observacionales no controlados tipo antes y después. Sólo tres estudios utilizaron una ubicación control para la comparación. Por lo tanto, es necesario considerar los factores de confusión, que incluyen la repercusión de otras actividades contra el acto de fumar sobre los resultados del tabaquismo. Los 17 estudios incluidos en esta revisión son heterogéneos e incluyen encuestas a los pacientes, encuestas al personal, encuestas a estudiantes universitarios, encuestas a prisioneros y una revisión de los datos de mortalidad y los datos de resultados de salud, que incluyen la prescripción de clozapina y las tasas de IAM en pacientes ingresados. Los contextos hospitalarios incluyeron hospitales generales, un centro de atención del cáncer y hospitales psiquiátricos. Algunos de los estudios utilizaron tamaños de la muestra pequeños o análisis estadísticos inferenciales limitados (Filia 2015; Ripley‐Moffitt 2010), y sólo dos estudios utilizaron la comprobación bioquímica para identificar a los fumadores en sus poblaciones de pacientes; la mayoría de los estudios utilizó el estado de fumador autoinformado. Sin embargo, se utilizaron grupos grandes de datos en Binswanger 2014 y Dickert 2015, y varios estudios incluyeron encuestas con muestras grandes. En general la evaluación mediante GRADE y el Resumen de los hallazgos para la comparación principal identifican las pruebas en esta revisión como de baja calidad debido al diseño utilizado en los estudios. La confianza en la estimación del efecto es limitada y el efecto verdadero puede ser significativamente diferente de la estimación del efecto realizada en la presente revisión.
Sesgos potenciales en el proceso de revisión
Esta revisión grande contiene tres fuentes de datos que incluyen el Registro Cochrane CENTRAL, MEDLINE y EMBASE. El idioma no fue una limitación para este estudio, y se tradujeron dos artículos para su inclusión en esta revisión (Alonso‐Colmenero 2010; Santina 2011). De manera similar, la razón para darle preferencia a los estudios con el respaldo de una prohibición nacional del acto de fumar (que incluye las prohibiciones estatales o regionales) después de 2005 tiene una fuerte base política. Muchas prohibiciones se implantaron primero en las áreas públicas y progresaron a la implementación de las prohibiciones del acto de fumar en estos contextos especializados.
Los metanálisis informados no incluyen todos los estudios de esta revisión. Se presenta un análisis agrupado de 11 estudios que informan medidas de resultados de tabaquismo activo. Se reconoce la heterogeneidad resultante y se ha tratado de investigar de manera adicional.
Acuerdos y desacuerdos con otros estudios o revisiones
Los resultados de esta revisión son, en parte, consistentes con los informados por Callinan 2010 yCallinan 2010 en su revisión del efecto de las prohibiciones nacionales del acto de fumar, que incluyen los lugares de trabajo. Sin embargo, existen pruebas limitadas para los tres contextos especializados incluidos en esta revisión cuando se compara con los estudios descritos en Callinan 2010. Las pruebas insuficientes del efecto del tabaquismo activo en el contexto de las prisiones se pueden deber a la exoneración inicial de las prisiones de las legislaciones y las leyes contra el tabaquismo, identificada por Ginn 2013. De manera similar, se informaron pruebas limitadas de la repercusión de las políticas de control del consumo de tabaco en las escuelas en Coppo 2014; dicha revisión incluyó datos de un ECA grupal. La revisión actual incluye estudios observacionales no aleatorios porque es posible que las intervenciones de políticas no sean apropiadas para los métodos de asignación al azar cuando el resultado es la exposición al humo del cigarrillo y la intervención es una política a un nivel mesoorganizacional.
Study flow diagram
Comparison of active smoking rates in hospitals, universities and prison settings
| Study | Country | Setting | National Ban and Settings ban | Participants | Results |
| Etter 2008 | Switzerland, Geneva | Hospital | No national ban. Settings: Smoking prohibited in February 2004 everywhere except smoking rooms. January 2006 smoking rooms removed and smoking totally prohibited inside hospital. | Patients 2003 Pre: n = 49 2004 Post: n = 54 2005 Post: n = 66 2006 Post: n = 77 Staff Pre: n = 57 2004 Post: n = 54 2005 Post: n = 53 2006 Post: n = 57 | Among nonsmokers, ETS reduced in bedrooms after partial ban, but did not decrease after total ban. After total ban, self‐reported exposure to ETS decreased from 69 min/day (2005) to 12 min/day (2006) after total ban, P = 0.012. 52.8% of respondents agreed with smoking restrictions post‐ban in 2006. Patients reported statistically significant difference in opinion pre‐/post‐ban "tobacco smoke is source of conflict with staff", 24.7% (pre), 36.4% post, P = 0.005. Fewer patients reported cohabitation between smokers and nonsmokers is very difficult post‐ban 54.4% (pre), 44.9% (post), P = 0.033. Patients locked in rooms identified prohibition on smoking "hard to bear" 75% (pre) and 78% post. After total ban number of patients getting angry with staff because of policy increased 4.5% (pre) 24.5% (post), P = 0.02, OR 6.8, 95% CI 1.2 to 47.3. No significant increase in staff reporting that patients were angry. 32.7% of staff in 2005 and 42.8% of staff in 2006 (P = 0.28) agreed with the statement that "after totally prohibiting smoking in clinic they would face strong protest from patients". Question not asked after total ban. After total ban staff reported that patients still smoked in bedroom (80.7%) and left clinic to buy cigarettes (82.4%). |
| Etter 2012 | Switzerland | Prison | No national ban. Settings: In prison A, the SHS intervention consisted of an extension of smoke‐free zones and in 2009 smoking was allowed everywhere except some indoor workplaces. From 2010 smoking only allowed in cells and outdoors. In prisons B and C in 2009, prisoners were allowed to smoke only in cells, during their outdoor exercise and in 1 smoking room in prison C. Rules were loosely enforced and respected. There was no policy change regarding SHS in prison B. In prison C, the SHS intervention was limited to better enforcement of the smoking ban in the waiting rooms of the medical service. No cessation programmes in Prison A, inmates charged for NRT, prison B and C in 2010/2011 medical staff trained to provide smoking cessation counselling and provide NRT. In Prison C NRT was free in this prison only. Smoking cessation booklets distributed to all prisons. | Prisoners Prison A Pre: n = 70 Post: n = 60 Prison B Pre: n = 27 Post: n = 30 Prison C Pre: n = 116 Post: n = 66 Staff Prison A Pre: n = 51 Post: n = 48 Prison B Pre: n = 27 Post: n = 24 Prison C Pre: n = 126 Post: n = 0 | In prison A, prisoners and staff reported less exposure to SHS in 2011 than in 2009: 31% of prisoners were exposed to smoke at indoor workplaces in 2009 vs 8% in 2011 (P = 0.001); in common rooms: 43% vs 8%, (P < 0.001); but not outdoor workplaces. No changes were observed in prisons B and C. All prisons, staff reported reductions in SHS exposure. Prison A: median significant decrease in time of smoke exposure 25 mins/day (2009) reduced to 2 mins (2011), P < 0.001. No significant difference when compared to prison B. Prisoner ETS exposure significantly reduced in follow‐up in prison A in cafeteria, common rooms, break rooms and indoor workplaces, but not outdoor workplaces. |
| Keizer 2009 | Switzerland, Geneva | Hospital | No national ban. Settings: A partial smoking ban established in a psychiatric university hospital, where only 1 ventilated room was made available for smoking for inpatients. Indoor smoking was comprehensively banned for staff January 2002. | Staff Pre‐ban: n = 110/281 Post‐ban: n = 85/160 Patients Pre‐ban 2001: n = 91/167 Post‐ban 2005: n = 134/263 | There was a perceived decrease in the amount of smoke in the hospital reported by staff (and patients), P = 0.00005. Smokers less bothered by SHS exposure than nonsmokers, P = 0.005 amongst staff. |
| Lechner 2012 | USA, | University | No national ban. Settings:100% tobacco‐free campus policy introduced in July 2008. The use, sales and promotion of tobacco products was prohibited. | Students Pre: n = 1185 2008 n = 1197 2009 n = 1257 2010 n = 1242 | Results indicated that exposure to smoke at an entrance to a campus building had significantly decreased over the 4‐year assessment period, F (3, 4908) = 126.38, P < 0.001, η2 = 0.071. Students reported significant increase in preference to socialise in smoke‐free environment F (3, 4836) = 4.48, P = 0.004, η2 = 0.002. Noted in 2008, and 2010 but not in 2009. Significant agreement over time that campus be smoke‐free, P < 0.001. |
Comparison 1 Passive exposure (narrative), Outcome 1 Passive smoke exposure.
| Study | Country | Setting | National Ban and Settings ban | Participants | Results |
| Binswanger 2014 | USA | Prisons | National: Enactment varied by state ordinance. Since 1993 US Supreme Court ruling that suggested exposure of prisoners to environmental tobacco smoke considered "cruel and unusual punishment" in violation of 8th Amendment. Settings: Either smoke‐free (indoor ban), comprehensive (indoor and outdoor) or tobacco‐free policy. | Prisoners n = 287 prisons n = 14,499 prisoners | Smoking bans in place for 9 or more years were associated with reductions in smoking‐related mortality: RR 0.89, 95% CI 0.85 to 0.94. Cancer deaths: RR 81, 95% CI 0.74 to 0.90. Pulmonary deaths RR 0.66, 95% CI 0.54 to 0.80 compared to states with no bans. After adjusting for deaths from smoking‐related causes in the population, little change in point estimates, 95% CI were marginally wider. No significant results when analysed deaths from other causes 2001 to 2011, RR 1.05, 95% CI 1.00 to 1.09. 2004, 75.8% had ever smoked. Current male smokers aged 35 ‐ 64 years = 38.5%, and 17.7% for 65 years and older. Current female smokers: 46.7% (35 ‐ 64 years) and 5.9% (65 years and older). In 2001 25 states had a smoking ban. By 2011 48 states had a smoking ban. 44 banned smoking indoors and 39 banned smoking or tobacco outdoors. |
| Dickert 2015 | USA, New Jersey | Prisons | National ban: New Jersey’s Smoke‐Free Air Act prohibits smoking in enclosed indoor spaces (2006). March 2010, an amendment banned the use of electronic smoking devices in indoor public places and workplaces and the sale to people 19 years and younger. Settings: NJDOC policy decision for tobacco‐free prisons, including grounds 2012. 13th Feb 2013 policy enacted to ban sales and use of all tobacco products for employees, visitors and prisoners. | Prisoners n = 13 prisons Census prisoners Jan ‐ June 2005 n = 26,239, prisoners special needs n = 3533 Census Jan ‐ June 2011, n = 22,318, prisoners special needs n = 3020 | Total mortality was 3 times higher for persons with special health needs compared to all prisoners. Annual mortality rate decreased 13% from 232 to 203/100,000 population between 2005 and 2013 after smoking ban introduced. The mortality rate for persons with special mental health needs decreased 48% from average of 676/100,000 to 353/100,000 in 18 months after ban introduced. |
| Harris 2007 | Canada, Ontario | Hospital | National: Ontario's Tobacco Control Act in 1994 banned smoking in all government buildings. Large psychiatric facilities, including MHCP, sought and received special dispensation to allow patients and some staff to smoke in specially ventilated rooms. "Smoking rooms" were already in existence on most wards and some common patient areas at MHCP. The hospital constructed smoking gazebos outside various buildings for patients and staff to use. Ontario's national smoke‐free legislation adopted in 2006. Settings: Comprehensive tobacco ban. Tobacco products no longer allowed anywhere on 225‐acre grounds after May 6, 2003. | Patients n = 119 n = 83 maximum security division n = 32 open wards | 89% male, mean age 46.8 years (SD 11.1 yrs). Among 23 smokers rated as having signs of compromised cardiopulmonary health at their annual medical check‐ups in the year before the tobacco ban, 17 received a clear/healthy assessment at their annual physical examinations in the year after (P < 0.05, Fisher's exact test). For the majority of patients who were in the maximum security forensic division, the tobacco ban was associated with almost no detectable ill effects with some clear benefits. The ban was associated with an increase in physical aggression towards staff members in open wards only F (1,106) = 4.33, P < 0.05. Clozapine prescribing increased in smokers and weight increased in max security patients. |
| Morito 2015 | Japan, Fukuoka | Hospital | No national ban. Settings: 1981 ‐ 2002 hospital provided separate facilities for smokers and nonsmokers. 2003 to 2006 introduced smoke‐free zones in hospital. Smoking areas and smoking tables subsequently removed. Hospital became smoke‐free (indoors) in 2007. | Patients Pre‐ changes 2002: n = 4 Stage 1 2003 ‐ 2006: n = 14 Stage 2 2007 ‐ 2010: n = 4 Stage 3 2011 ‐ 2014: n = 3 | AMI data from January 2002 ‐ June 2014. Patients with an in‐hospital onset of AMI were defined as those who had AMI but were not under the care of Departments of Cardiology or Emergency. N = 25 patients identified in total Pre changes 2002: n = 4 Stage 1 2003 ‐ 2006: n = 14 Stage 2 2007 ‐ 2010: n = 4 Stage 3 2011 ‐ 2014: n = 3 P for trend = 0.010. n = 6 died ( Age 76 (SD 7)) ( 3 were smokers) n = 19 survived (Age 68 (SD 9)) (12/19 smokers) 10/ 25 AMI after surgical operation. 16 men and 9 women. No statistically significant difference in patient characteristics between operation and non‐operation groups except for DL (lipid‐lowering therapy). No differences between smoking and nonsmoking groups except for DL. Increasing nonsmoking policy decreased in hospital onset of AMI. |
Comparison 2 Health and mortality outcomes (narrative), Outcome 1 Health and mortality outcomes.
| Study | Country and Setting | Population | National Ban | Outcomes | B io chemical verification |
| Alonso‐Colmenero 2010 | Spain | Hospital | Yes | N = 135 smokers in study. No significant difference reported at baseline. n = 53 smokers identified as smoking in hospital in study. 2005: 34.2% of the 53 smoked in hospital (95% CI 22.6 to 45.8). 2006: 45.1% of the 53 smoked in hospital after the policy (95% CI 31.9 to 58.3), P = 0.26. | Cotinine measure define smoker |
| Alonso‐Colmenero 2010 | |||||
| Etter 2008 | Switzerland,Geneva, Psychiatric hospital | Staff | No | Pre‐ban n = 57 staff Post‐ban 2004: n = 54/55, 2005: n = 53/63, 2006: n = 57/62. Participation rates 84.1% to 100%. Current prevalence of smokers unchanged over time. 26.3% (baseline) and at final follow‐up. Significantly more staff perceived rules about smoking were too strict. This changed over time as the smoking ban increased, 7.0% at baseline to 59.6% (final follow‐up), P < 0.001. Rules on smoking not respected (staff and patients) 51.36% at baseline and 16.1% (partial ban 2005) and 32.6% ( total ban 2006), P < 0.001. | None |
| Etter 2008 | Patients | 73.5% of patients were daily smokers 2003, reduced to 65.8% in 2006. No significant change in mean number of cigarettes 2003 and post‐ban 2006. 24.1 vs 23.7, P = 0.81. Increased quit attempts reported 2.2% in 2005 to 18.4% in 2006, P = 0.01, OR 10.1, 95% CI 1.21 to 222.7 (wider interval). | |||
| Etter 2012 | Switzerland, Prisons | Staff | No | Response rates among staff higher than prisoners. Ranged from 40% to 77% over time in the 3 prisons. Majority of staff surveyed were men. No follow‐up in Prison C for staff. In prison A, staff smoking reduced from 10% to 6% at follow‐up. In prison B, staff smoking increased from 26% to 38% at follow‐up. | None |
| Etter 2012 | Prisoners | Response rate 17% to 44% over period. Prisoner smoking unchanged. At baseline prison A 75% smoked (n = 52/70) and 72% (n = 43/60) at follow‐up. Prison B 69% (19/27) smoked 2009 and 57% (17/30) in 2011. Prison C 58% (67/116) at baseline and 56% 40/66) 2011. No significant change detected in any of the prisoners in smoking status, quit attempts or relapse. Smoking behaviour prison A: more prisoners reported receiving medical help to quit smoking in 2011 (20%) than in 2009 (4%, P = 0.012). Prison A compared to Prison B, prisoners felt that staff should do more to help quit attempts, P = 0.015. In prison A, prisoners and staff reported less exposure to SHS in 2011 than in 2009: 31% of prisoners were exposed to smoke at workplaces in 2009 vs 8% in 2011 (P = 0.001); in common rooms: 43% vs 8%, (P < 0.001). No changes were observed in prisons B and C. | None | ||
| Filia 2015 | Australia, Melbourne | Hospital | Yes | Before the totally smoke‐free policy, 69.6% smoked, with 67.7% smoking more when admitted to the psychiatry ward smoking average 18.1 cigs/day. (Alternatives to smoking identified included use of NRT, having a designated smoking area, keeping busy). After the totally smoke‐free policy, 57.7% smoked heavily before hospital (mean cigarettes/day = 24.9), with consumption reduced after admission to a totally smoke‐free psychiatric unit (mean cigarettes/day = 8.3). 5.8% of patients reported quitting since admission following the ban. | None |
| Filia 2015 | |||||
| Fitzpatrick 2012 | Ireland, Dublin | Hospital Staff | Yes | Pre‐ban data: smoking prevalence rates in staff : 1998: 27.4%; 2001: 17.3%; 17.8% of staff reported smoking in 2006 (post‐1st ban and pre‐2nd phase) and this significantly reduced to 10.7% in 2010, P = 0.02. Significantly in female staff 17.6% vs 9.5%, P = 0.02 and in age group 30 ‐ 39 years. Positive attitude among staff (52.4% vs 83.3%, P < 0.001) to the campus‐wide ban increased significantly between 2006 and 2010; the greatest increase was seen in doctors. Campus ban resulted in a positive attitude amongst staff irrespective of smoking status. When perception of own role in implementation was examined, younger staff were less likely to agree they had a role, while ex‐smokers were more likely to agree they had a role in implementation. Nurses more likely to agree than all other occupational groups. | None |
| Fitzpatrick 2012 | Patients | Pre ban data: smoking prevalence in patients: 1997/1998: 24.2%; 2002: 15.5%; 2004: 24.5%. No significant change in patients smoking at follow‐up in 2010 after total campus ban introduced in 2009: 22.7% vs 18.0% (2006), P = 0.22. Reducing trends noted for men and women, but not statistically significant. Positive attitude of patients (58.6% vs 84.2%, P < 0.001) to the campus‐wide ban increased significantly between 2006 and 2010. Univariate analysis of factors associated with agreement with campus ban significantly associated with being a non‐ or ex‐smoker (patients), but not current smokers, P = 0.286. Multivariate analysis identified being aged 60 years or older and being a current smoker as significant. | Patients with CO levels > 10 ppm were considered to be current smokers. | ||
| Gadomski 2010 | USA, New York Hospital | Staff | Yes | Cohort of 489 hospital employees 2005 and 2007, 12% reported smoking in 2005 and 7.5% in 2007 (McNemar was significant P < 0.001). 2006 not reported. | None |
| Gadomski 2010 | Patients (NRT use) | No change in % patients signing out against advice. 69.8% inpatients received brief intervention post‐ban. NRT orders tripled post‐ban. Inpatient orders increased 832 in 2 years pre‐ban to 2475 in 2 years post‐ban. The Chow test is highly significant for break point in June 2006, P = 0.008. 1 month prior to ban. | |||
| Gazdek 2013 | Croatia, Kopriivnica‐ Krizevci county Hospital | Staff | Yes | Baseline smoking prevalence 34.3% reduced to 26.4% 2011. A reduction of 7.9%. Reduction in population 1994 to 2005 was 5.2%. Larger change in non‐health workers 39.2% to 26.4% (Change 12.8%). Number of cigarettes decreased per person from 15 to 12 per day. Percent of < 10 cigs consumed/day increased 33.7% to 57.4% in first 2 years of Act. Decrease greatest 2 ‐ 6 years after ban. | None |
| Gazdek 2013 | |||||
| Keizer 2009 | Switzerland, Geneva Psychiatric hospital | Staff | No | No significant change in staff smoking prevalence 2001 and 2005. 2001 30.8% vs 29.9% 2005, P = 0.94. Daily consumption of cigarettes among staff: 13% of staff were heavy smokers (> 20 /day) compared to 53.5% of patients, P < 0.001. | None |
| Keizer 2009 | Patients | No significant changes in current smoking among patients post‐ban (n = 86) 72.1% vs 65.2% (n = 62), P = 0.54. Daily consumption of cigs by patients was 29.47 (SD 16.79) and 17.83 (SD 13.26) for staff, P < 0.001. 13% of staff were heavy smokers (> 20/day) compared to 53.5% of patients, P < 0.001. 34.9% of patients and 52.2% of staff were moderate smokers. Patients displayed an increased desire to stop smoking post‐ban . Trends in patient smoking showed initial decrease in consumption but returned by day 10. Inconclusive as may be due to heavy‐smoker cohort. Increased smoking post‐ban (qualitative) identified boredom, waiting and mental state as reasons. Decreased smoking was explained by restrictions (smoking rooms), lack of cigarettes, tiredness, treatment, decrease in tension, less desire to smoke and respect for others. | None | ||
| Lechner 2012 | USA, Oklahoma | University | No | Significant reduction in percentage of more frequent smokers over time Chi² = 8.53 (3, n = 4947), P = 0.036; especially between years 2009 and 2010, Chi² =7.06 (1, n = 2486), P = 0.009, and between 2007 and 2010: Chi² = 5.00 (1, n = 2454), P = 0.025. Proportion of smokers reduced but NS. Significant decreases in the proportion of more frequent smokers occurred in men, Chi² = 14.58 (3, n = 2290), P = 0.002, but not women. Significant decrease in the proportion of less frequent smokers across assessment points, Chi² = 20.87 (4, n = 4947), P < 0.001. Significant decrease occurred between years 2007 and 2010, Chi² = 15.38 (1, n = 2454), P < 0.001. Results indicated that exposure to smoke at an entrance to a campus building had significantly decreased over the 4‐year assessment period, F (3, 4908) = 126.38, P < 0.001, η2 = 0.071. Students reported significant increase in preference to socialise in smoke‐free environment F (34836) = 4.48, P = 0.004, η2 = 0.002. Noted in 2008 and 2010, but not in 2009. Significant agreement over time that campus be smoke‐free, P < 0.001. | None |
| Lechner 2012 | |||||
| Martínez 2014 | Spain | Hospital | Yes | Smoking prevalence decreased from 33.1% (95% CI 29.3 to 36.9) to 30.5% (95% CI 26.3 to 34.7) and in 2012 22.2% (95% CI 16.7 to 27.6), P < 0.005. Prevalence decreased in all hospital groups. Decreased amongst women 35.1% Baseline to 33.0% (1st ban), 23.1% (2nd ban), P = 0.009, and in aged > 35 years 31.9% baseline, 23.3% (1st ban), 16.3% (2nd ban), P = 0.0001. Smoking decreased in men, but not statistically significant. Smoking reduced in all staff groups, not statistically significant. Smoking patterns: occasional smokers increased 2‐fold. 12.1% to 24.5% (2nd ban), P = 0.012. No clear trend in number of cigs or time to first cig reported. First cig after awakening ≤ 30 mins 3.6% at baseline and 39.1% (2nd law), P < 0.001. Readiness to quit 60.3% baseline, 28.2% (1st ban), 11.5% (2nd ban), P < 0.001. Significant reduction in concern about tobacco use, readiness to fix date to quit and, consulted professional to quit and refrain from smoking in working hrs post‐bans. Attitude to ban: agreed with policy P < 0.001, and parents should set example. Support for the tobacco control policies increased from 59% at baseline to 80.5% following the passage of the 2nd bill. | None |
| Martínez 2014 | |||||
| Ripley‐Moffitt 2010 | USA, Hospital | Staff | No | Total sample was 5534, with 2024 respondents to initial survey, of which 307 were current smokers or had quit in preceding 6 months. Follow up n = 210 smokers agreed to be interviewed at 6 months and 1 year post‐ban. n = 166 responded at 6 months. Of 179 participants in study who were smokers, 45% reported quit attempt in previous 6 months. At 6 months, of the 133 participants currently smoking, 53% reported quit attempt. At 1 yr, 39 participants reported not smoking (18.5%). Of the 117 participants who were current smokers at 12 months, 48% reported attempts to quit during preceding 6 months. | None |
| Ripley‐Moffitt 2010 | |||||
| Santina 2011 | Spain, Barcelona | Hospital | Yes | The number of workers smoking decreased from 35.2% to 27.4%, P < 0.05. This reduction was seen across all hospital workers, less in nursing staff. People only smoked in smoking areas, P < 0.0001. Policy supported by smokers and nonsmokers. 8.2% received help to quit pre‐ban, 19.7% post‐ban, P = 0.02. | None |
| Santina 2011 | |||||
| Seo 2011 | USA, University | Students | No | Prevalence and tobacco consumption fell in Indiana (pre‐ban: 16.5%; post‐ban: 12.8%) and increased at Purdue (control) during the same time period. In addition, perceptions of peer tobacco use and smoking norms improved at Indiana University. Peer tobacco use: significant decrease in percentage of Indiana students who perceived 26% of students or more were smoking, P < 0.001. Control: significant increase in perceived smoking, P ≤ 0.001. Percentage of friends smoking decreased in Indiana, P < 0.001. Longitudinal panel comparisons samples: n = 170 for Indiana and n = 128 for Purdue. Significant declines in number of cigs smoked in Indiana post‐policy, ‐5.0, P < 0.05, compared to Purdue. Indiana students had significant increases in agreement that smoking regulation is good, P < 0.05; should be banned on all university property, P < 0.05, compared to Purdue for both fixed‐effect and random‐effects modelling. | None |
| Seo 2011 | |||||
Comparison 3 Active smoking (narrative), Outcome 1 Active smoking rates.
Comparison 4 Active smoking rates pre‐ and post‐smoking ban, Outcome 1 Active smoking. Subgroups by setting.
Comparison 4 Active smoking rates pre‐ and post‐smoking ban, Outcome 2 Active smoking. Hospital setting, staff/patients subgroups.
Comparison 4 Active smoking rates pre‐ and post‐smoking ban, Outcome 3 Active smoking. Subgroups ± national ban.
| Smoking rates and smoking‐related mortality, pre‐ and post‐smoking ban/policy change | ||||||
| Patient or population: Smokers | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| No policy | Active smoking rates after policy | |||||
| Active smoking, hospital setting | Study population | RR 0.75 | 5986 | ⊕⊕⊝⊝ | ||
| 335 per 1000 | 251 per 1000 | |||||
| Active smoking, university setting | Study population | RR 0.72 | 6369 | ⊕⊕⊝⊝ | ||
| 194 per 1000 | 140 per 1000 | |||||
| Active smoking, prison setting | Study population | RR 0.99 | 130 | ⊕⊕⊝⊝ | ||
| 829 per 1000 | 820 per 1000 | |||||
| Smoking‐related mortality ‐ prison setting | Study population | Not estimable | 0 | Reductions in mortality for smoking‐related diseases noted in 2 studies (Binswanger 2014; Dickert 2015) after prisons adopted no‐smoking policies. | ||
| See comment | See comment | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1No control group | ||||||
| Study ID | Country | Setting | National Ban and Settings ban |
| Spain | Hospital | National ban: 28/2005. National indoor smoking ban enacted 1st January 2006 banned direct and indirect tobacco publicity and sponsorship; it reduced points of sale, and it banned smoking in enclosed workplaces and public spaces, with exemptions in the restaurant and hospitality sector (Partial ban at time of study). Settings: Hospital policy not described. | |
| Switzerland, Geneva | Hospital | No national ban. Settings: Smoking prohibited in February 2004 everywhere except smoking rooms. January 2006 smoking rooms removed and smoking totally prohibited inside hospital. | |
| Australia, Melbourne | Hospital | State ban Victoria: 1st July 2007. All restaurants, cafes, dining areas and shopping centres, enclosed workplaces, covered railway platforms, bus and tram stops and underage music and dance events are smoke‐free. Enclosed licensed premises and outdoor eating and drinking areas (where there is a roof and the wall surface area is more than 75%) must also be smoke‐free as of July 1, 2007. The gambling floors of casinos exempt. Settings: Total smoking ban implemented in the inpatient psychiatric unit in June 2008, including outdoor areas. | |
| Ireland, Dublin | Hospital | National ban: March 2004. Smoking banned in general workplace, enclosed public places, restaurants, bars, education facilities, healthcare facilities and public transport. However, it is permitted in designated hotel rooms and there is no ban in residential care, prisons and in outdoor areas. Settings: Hospital ban in 2004 following national smoke‐free ban. Total smoke‐free hospital campus policy in 2009. No smoking permitted indoors or outdoors. | |
| USA, New York | Hospital | National ban: New York State Smoke‐free air act 2002, enacted 2003. Banned smoking in virtually all workplaces and indoor recreational venues. Amendment to the City’s 1995 Smoke‐Free Air Act, the new law banned smoking in all restaurants and most bars regardless of seating and size. The law restricted smoking in some outdoor restaurant and bar seating areas. Settings: Smoke‐free medical campus implemented on July 1, 2006, which included an NRT programme and additional signage. | |
| Croatia, Kopriivnica‐ Krizevci county | Hospital | National ban: November 2008. Smoking officially banned in government buildings, private worksites, educational and healthcare facilities, taxis, and domestic or international air flights after 1999 legislation enacted. Smoking restricted (not banned) on trains, ferries,restaurants, nightclubs and bars, and other public places. 22nd November 2008 law extended to bars, restaurants and cafes. This is not reported in paper. Settings: Smoking bans in healthcare facilities. | |
| Canada, Ontario | Hospital | National: Not indoor smoke‐free legislation. Ontario's Tobacco Control Act in 1994 banned smoking in all government buildings. Large psychiatric facilities, including MHCP, sought and received special dispensation to allow patients and some staff to smoke in specially ventilated rooms. "Smoking rooms" were already in existence on most wards and some common patient areas at MHCP. The hospital constructed smoking gazebos outside various buildings for patients and staff to use. Ontario smoke‐free indoor legislation implemented in 2006. Settings: Comprehensive tobacco ban. Tobacco products no longer allowed anywhere on 225‐acre grounds after May 6, 2003. | |
| Switzerland, Geneva | Hospital | No national ban. Settings: A partial smoking ban established in a psychiatric university hospital, where only 1 ventilated room was made available for smoking for inpatients. Indoor smoking was comprehensively banned for staff January 2002. | |
| Spain | Hospital | National ban: 2006 to 2010. Spain had a partial ban on smoking in public places. Offices, schools, hospitals and public transportation were smoke‐free, but restaurants and bars could create a "smokers' section" or allow smoking if they were small (under 100 m²). Extension of ban January 2011 restricted smoking in every indoor public place, including restaurants, bars and cafes. Hotels may designate up to 30% of rooms for smoking; mental hospitals, jails and old people's residences may have public rooms where workers cannot enter. Outdoor smoking is also prohibited at childcare facilities, in children's parks and around schools and hospital grounds. Settings: Smoke‐free centre policy was progressively introduced. Tobacco control programme (2000 ‐ 2012) | |
| Japan,Fukuoka | Hospital | No national ban. Settings: 2002 to 2006. Introduced smoke‐free zones in hospital. Smoking areas and smoking tables subsequently removed. Hospital became smoke‐free (indoors) in 2007. | |
| USA, North Carolina | Hospital | No national ban. Settings: Tobacco‐free hospital policy introduced 4 July 2007. Employees offered free NRT, signage posted up and no smoking advertising 1 yr. lead in to policy. 100% tobacco‐free campus. | |
| Spain, Barcelona | Hospital | National ban: National smoking law introduced on January 1st 2006, and indoor smoking banned. Settings ban: not included. Evaluated national ban. |
| Study ID | Country | Setting | National Ban and Settings ban |
| USA | Prisons | National: Enactment varied by state/ordinance. Since 1993 US Supreme Court ruling that suggested exposure of prisoners to environmental tobacco smoke considered "cruel and unusual punishment" in violation of 8th Amendment. Settings: Either smoke‐free (indoor ban), comprehensive (indoor and outdoor), or tobacco‐free policy. | |
| USA, New Jersey | Prisons | National ban: New Jersey’s Smoke‐Free Air Act prohibits smoking in enclosed indoor spaces (2006). March 2010, an amendment banned the use of electronic smoking devices in indoor public places and workplaces and the sale to people 19 years and younger. Settings: NJDOC policy decision for tobacco‐free prisons, including grounds 2012. 13th Feb 2013 policy to ban sales and use of all tobacco products for employees, visitors and prisoners enacted. | |
| Switzerland | Prison | No national ban. Settings: In prison A, the SHS intervention consisted of an extension of smoke‐free zones and in 2009 smoking allowed everywhere except some indoor workplaces. From 2010 smoking only allowed in cells and outdoors. In prisons B and C in 2009, prisoners were allowed to smoke only in cells, during their outdoor exercise, and in 1 smoking room in prison C. Rules were loosely enforced and respected. There was no policy change regarding SHS in prison B. In prison C, the SHS intervention was limited to better enforcement of the smoking ban in the waiting rooms of the medical service. No cessation programmes in Prison A, inmates charged for NRT, prisons B and C in 2010/2011 medical staff trained to provide smoking cessation counselling and provide NRT. NRT was free in Prison C only. Smoking cessation booklets distributed to all prisons. | |
| NJDOC: New Jersey Department of Corrections | |||
| Study ID | Country | Setting | National Ban and Settings ban |
| USA,Oklahoma | University | No national ban. Settings: 100% tobacco‐free campus policy introduced in July 2008. The use, sale and promotion of tobacco products were prohibited. | |
| USA, Indiana | University | No national ban. Settings: Indiana university total campus ban began 1 January 2008: smoking prohibited in all indoor and outdoor areas on campus. Smoking prohibited in university vehicles but not prohibited in personal vehicles. Purdue University in West La Fayette allowed smoking at distance of at least 30 ft. from university facilities during study period. |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Passive smoke exposure Show forest plot | Other data | No numeric data | ||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Health and mortality outcomes Show forest plot | Other data | No numeric data | ||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Active smoking rates Show forest plot | Other data | No numeric data | ||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Active smoking. Subgroups by setting Show forest plot | 11 | 12485 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.74 [0.70, 0.79] |
| 1.1 Hospitals | 8 | 5986 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.75 [0.69, 0.81] |
| 1.2 Universities | 2 | 6369 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.72 [0.64, 0.80] |
| 1.3 Prisons | 1 | 130 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.99 [0.84, 1.16] |
| 2 Active smoking. Hospital setting, staff/patients subgroups Show forest plot | 8 | 5986 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.75 [0.69, 0.81] |
| 2.1 Staff | 4 | 4544 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.71 [0.64, 0.78] |
| 2.2 Patients | 5 | 1442 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.86 [0.76, 0.98] |
| 3 Active smoking. Subgroups ± national ban Show forest plot | 11 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 National ban in force | 6 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 No national ban in force | 5 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
