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Effect of smoke-free patio policy of restaurants and bars on exposure to

second-hand smoke

Sunday Azagba

Propel Centre for Population Health Impact, University of Waterloo, Canada School of Public Health and Health Systems, University of Waterloo, Canada

a b s t r a c t

a r t i c l e i n f o

Available online 22 April 2015 Keywords:

Smoke-free policy Outdoor patio Second-hand smoke Environmental tobacco smoke Passive smoking

Objective.While there is increasing support for restricting smoking in restaurant and bar patios, there is lim-ited evidence on the effectiveness of this policy. This study examined the effect of smoke-free patio policy of res-taurants and bars on adult second-hand smoke (SHS) exposure.

Methods.Data were drawn from the 2005–2012 Canadian Tobacco Use Monitoring Survey (n = 89,743), a repeated cross-sectional survey of youth and adult. Regression analysis, a quasi-experimental design was used to examine the effect of provincial smoke-free patio policy on self-reported exposure to SHS.

Results.Analyses suggest that exposure to SHS on patios of bars and restaurants declined following the adop-tion of provincial smoke-free patio policy. Relative to ppolicy SHS exposure, regression results showed a re-duction in the probability of SHS exposure of up to 25% in Alberta. Similarly, in Nova Scotia, the probability of SHS exposure declined by up to 21%. Analyses stratified by smoking status found similar significant effect on both smokers and non-smokers.

Conclusions.Findings suggest that provincial patio smoking ban on bars and restaurants had the intended ef-fect of protecting non-smokers from SHS exposure. This study is consistent with a large body of evidence show-ing that a strong smoke-free legislation is an effective public health measure.

© 2015 The Author. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Globally, over 600,000 deaths each year are linked to exposure to second-hand smoke (SHS), also known as environmental tobacco smoke or tobacco smoke pollution (WHO, 2009; Öberg et al., 2011). SHS has been documented as a risk factor for several diseases such as lung cancer, cardiovascular disease, respiratory problems, asthma and sudden infant death syndrome (U.S. Department of Health and Human Services, 2006; U.S. Environmental Protection Agency, 1992). The Interna-tional Agency for Research on Cancer as well as the U.S. Environmental Protection Agency has designated second-hand smoke as a human carcin-ogen for which there is no risk-free level (International Agency for Research on Cancer, 2004; U.S. Environmental Protection Agency, 1992). The U.S. Surgeon General report has also noted that a small amount of SHS exposure can adversely affect the heart, blood and blood vessels (U.S. Department of Health and Human Services, 2006).

Public smoking restriction has become ubiquitous in many jurisdic-tions, in part due to the heightened awareness of the harmful health con-sequences of SHS exposure (U.S. Department of Health and Human

Services, 2006; WHO, 2009). The balance of evidence from the prepon-derance of research suggests that smoke-free legislation is an important public health intervention measure for protecting both non-smokers and smokers from the adverse health effects of SHS exposure (Akhtar et al., 2009; Bondy et al., 2009; Fong et al., 2006; IARC, 2009; Mulcahy et al., 2005; Repace et al., 2013). A large body of evidence has shown sig-nificant reductions in cotinine (a metabolite of nicotine) levels among non-smokers following smoke-free policy implementation in many coun-tries including the U.S. (Jensen et al., 2010; Farrelly et al., 2005), Canada (Bondy et al., 2009), Ireland (Mulcahy et al., 2005), Scotland (Akhtar et al., 2009), Italy (Valente et al., 2007), and New Zealand (Fernando et al., 2007). In addition, some population-based survey studies suggest that smoke-free policy is strongly associated with smoking cessation be-haviors (Callinan et al., 2010; Hahn et al., 2008; Fowkes et al., 2008; Azagba and Asbridge, 2013; Nagelhout et al., 2011). For example, a review study by Mills and colleagues found consistent evidence, at a population-level, that smoking bans promote smoking cessation and decreased ciga-rette consumption in adult smokers (Mills et al., 2009).

While public support is increasing for outdoor smoke-free legisla-tion (Thomson et al., 2009), not much is known about SHS exposure in outdoor dining areas of bars and restaurants (St. Helen et al., 2012; Klepeis et al., 2007). Prior research has demonstrated similar levels of tobacco smoke concentrations in outdoor and indoor settings, especially ⁎ Propel Centre for Population Health Impact, Faculty of Applied Health Sciences,

University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. E-mail address:sazagba@uwaterloo.ca.

http://dx.doi.org/10.1016/j.ypmed.2015.04.012

0091-7435/© 2015 The Author. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Contents lists available atScienceDirect

Preventive Medicine

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in a close proximity to smokers (Klepeis et al., 2007). In a crossover study,St. Helen et al. (2012)found a significant increase in salivary co-tinine and NNAL (a metabolite of tobacco-related nitrosamines) in non-smokers following SHS exposure in outdoor patios of a restaurant and bar. Thesefindings underscore the potential public health benefit of banning smoking in outdoor patios.

In Canada, four provinces (Newfoundland and Labrador, Nova Scotia, Alberta and Ontario) and Yukon Territory have implemented full province-wide smoking bans on outdoor patios of bars and restaurants. Ontario, the most populated province in Canada implemented province-wide ban in January, 2015. Other provinces (Prince Edward Is-land, New Brunswick, Quebec, Manitoba, Saskatchewan, Ontario and British Columbia) have implemented weak or no bans (e.g., Prince Ed-ward Island outdoor patio ban is not enforced between 10 pm and 3 am, seeTable 1for details). In the United States, a number of states and local municipalities have also implemented smoke-free outdoor dining policy including bar patios (American Nonsmokers' Rights Foun-dation, 2014). As the number of jurisdictions implementing smoking bans on outdoor patios of bars and restaurants is increasing, to my knowledge, no study has evaluated the effect of this policy on SHS expo-sure. This may not be surprising given that only few jurisdictions have so far implemented this policy, and also evaluation of this policy will re-quire collecting information on venue-specific SHS exposure. The Cana-dian Tobacco Use Monitoring Survey (CTUMS) provides an ample opportunity for evaluating the effectiveness of this policy given that it collects information on a venue-specific information on SHS exposure. The main objective of this study is to address this gap by examining the effect of smoke-free patio policy of restaurants and bars on adult SHS exposure using a quasi-experimental framework.

Methods Data

This study used a repeated cross-sectional population survey from the Cana-dian Tobacco Use Monitoring Survey to examine the effect of smoking ban on outdoor patios of bars and restaurants on SHS exposure. The survey is nationally representative of Canadians aged 15+ years. CTUMS primarily collects informa-tion about the attitudes and behaviors of adults with respect to tobacco use, as well as corresponding socio-demographic variables. The survey excludes those living in institutions, and Canadians living in the northern Territories (Yukon, Nunavut and Northwest Territories). CTUMS is based on a two-phase stratified

random sampling framework. In thefirst phase, households are sampled from telephone numbers using a random digit dialing methodology. Individuals are selected in the second stage based on household composition, with an equal representation of respondents in each of ten Canadian provinces. CTUMS com-menced in 1999 and was conducted annually. Data from the 2005–2012 annual CTUMS cycles were used given that our outcome variable was not available in previous iterations. Those in Newfoundland and Labrador were excluded in this study since smoking ban on outdoor patios of bars and restaurants was im-plemented in this province in 2005 and data is not available to capture baseline SHS exposure. The province of British Columbia was also excluded since most of the large cities/municipalities have implemented a similar policy. Analysis was restricted to those aged 21 and above. Ethics review was not required given that this research relied exclusively on anonymous secondary survey data. Variables

Exposure to secondhand smoke

The outcome variable was derived from self-reported response to questions on venue-specific exposure to second-hand smoke in the past month. In partic-ular, a dichotomous variable indicating SHS exposure in the past month was cre-ated from the question:“The next questions are about exposure to second-hand smoke in places other than your own home. Second-hand smoke is what smokers exhale and the smoke from a burning cigarette. In the past month, excluding your own smoking were you exposed to second-hand smoke on an outdoor patio of a res-taurant or bar?”Previous study has shown strong association between self-reported exposure to SHS and biomarkers of nicotine (Okoli et al., 2007). Independent variables

Smoking ban on outdoor patios of bars and restaurants was derived by using the dates of implementation of province-wide school smoking ban, respon-dents' province of residence and date of interview (seeTable 1). A number of

15 18 21 24 27 30 33 2005 2006 2007 2008 2009 2010 2011 2012 SH S exposure (%)

Alberta Saskatchewan Linear (Saskatchewan) Fig. 1.Trend of SHS exposure, 2005–2012—Alberta and Saskatchewan. Table 2

Average key sample characteristics (%), 2005–2012.

Alberta Nova Scotia Saskatchewan Gender

Male 50.9 48.3 49.1

Female 49.1 51.7 50.9

Age 45.2 48.7 47.8

Education level

Less than secondary 11.1 18.3 18.1

Secondary 37.0 34.2 41.7 College 22.5 20.4 17.9 University 29.4 27.1 22.3 Marital status Married 72.2 67.9 70.7 Separated 10.0 13. 5 12.3 Single 17.8 18.6 17.0 Smoking status Smoker 19.6 20.0 21.1 Non-smoker 80.4 80.0 78.9 Observations 12,003 11,308 11,455 Age is in years. Table 1

Smoke-free policy—outdoor patios of bars and restaurants in Canadian provinces. Source: Non-Smokers' Rights Association (Smoking and Health Action Foundation— March 2014) and author's compilation.

Province Policy date & coverage Strong or full policy

Newfoundland July 1, 2005—enforced with or without roof Nova Scotia December 1, 2006—enforced with or without roof Alberta January 1, 2008—enforced with or without roof Ontario January 1, 2015—enforced with or without roof Weak or partial policy

Manitoba October 1, 2004—prohibited if more than 25% of thefloor area is covered by a roof and more than 50% of its perimeter is more than 50% enclosed

New Brunswick October 1, 2004—prohibited if more than 70% enclosed by walls and/or a roof

Quebec May 31, 2006—prohibited on bar and restaurant patios if they have more than 2 sides and a roof

British Columbia

March 31, 2008—prohibited if it has a roof or other covering and more than 50% of the nominal wall space is enclosed such that airflow is impeded

Prince Edward Island

September 15, 2009—prohibited on outdoor patios except between the hours of 10 pm and 3 am

No policy

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socio-demographic variables were included in the analysis: sex age, marital sta-tus, education, smoking stasta-tus, and unemployment status.

Statistical strategy

The implementation dates of smoking ban on outdoor patios of bars and res-taurants in two Canadian provinces (Alberta and Nova Scotia) are used to create a natural experiment. A difference-in-difference estimator (DD) was used to ex-amine the causal effect of a smoking ban on outdoor patios of bars and restau-rants on SHS exposure (Angrist and Pischke, 2009; IARC, 2009). The DD method estimates changes in exposure to SHS for individuals in provinces with the policy of interest, treatment group (Alberta and Nova Scotia) over time relative to individuals in provinces without comparable policy, control group (Saskatchewan). Specifically, a DD model of the following form is esti-mated:

Yipt¼αþβ1ð ÞitTG þβ2ð ÞitP þβ3ðTGitPitÞ þφXiptþτtþProvpþεipt whereYiptrepresents outcome of interest (SHS exposure) for individualiin provincepat survey timet.TGis a dummy variable that equaled one if the indi-vidual is in a treated province and zero otherwise, with the corresponding coef-ficient,β1, indicating the difference between treated and control groups not due to the policy. The variablePis a dummy variable with a value of 1 for post-policy periods and zero for baseline periods.β2captures the average change between post-policy and pre-policy periods. A linear probability model was estimated for the ease of interpretation. The interaction of the treated and post-policy vari-ables measures the causal effect of the policy of interest on SHS exposure. The main coefficient of interest,β3represents the average change in the probability of SHS exposure due to smoking ban on outdoor patios of bars and restaurants. The analysis also controlled for individual socio-demographic characteristics, vectorXipt, including gender, age, education, marital status, smoking status and unemployment status.τtcaptures time effect (linear and quadratic trends) as well as seasonal effects (month of interview).Provrepresents time-variant provincial variable (unemployment rate). In a sensitivity analysis, provinces (Prince Edward Island, New Brunswick, Quebec, Ontario and Manitoba) with weak or partial smoking restriction on outdoor patios of bars and restaurants were used as additional control group. Fay-modified balanced repeated

replication approach was used in the analysis to enable variance estimates to ac-count for the complex survey design (Judkins, 1990).

Results

The average key characteristics of the main analysis are reported in Table 2. The trend of exposure to SHS for each year is represented in Figs. 1–2. There has been a decline in SHS exposure following the imple-mentation of smoke-free patio legislation in Nova Scotia and Alberta. In the control province with no patio policy (Saskatchewan), a graphic dis-play showed an upward trend in SHS exposure.

Results from the difference––difference estimator showing the aver-age treatment effect of smoke-free patio policy of restaurants and bars on adult SHS exposure are reported inTables 3–6. Analysis adjusting for age, gender, education, marital status, smoking status and unem-ployment status is reported in column 1 (model 1) while column 2 (model 2) presents results adjusting for additional covariates (provin-cial unemployment rates, seasonality, linear and quadratic trends). Re-gression results were consistent across all model specifications indicating a statistically significant effect of smoking ban on outdoor pa-tios of bars and restaurants on SHS exposure. Specifically, inTable 3, the probability of reporting SHS exposure on outdoor patios of bars and res-taurants reduced in Alberta by up to 7.7 percentage points when com-pared to those living in Saskatchewan (no provincial-level smoking ban on outdoor patios of bars and restaurants). Relative to Alberta aver-age pre-policy SHS exposure of 30.7% in 2007, the 7.7 percentaver-age-point decrease can be expressed as a 25.1% decrease in the probability of SHS exposure. Similarly, the implementation of smoking ban on outdoor pa-tios of bars and restaurants in Nova Scotia reduced the probability of SHS exposure by up to 5.5 percentage points when compared to those living in Saskatchewan. Relative to Nova Scotia average pre-policy SHS exposure of 26.1% in 2006 (January to November), result showed a Table 4

Estimated effect of smoke-free patio policy on SHS exposure—strong vs. weak policy.

Model 1 Model 2 Outdoor policy −0.049 (−0.065 to−0.033) −0.042 (−0.064 to−0.019) Male 0.061 (0.045 to 0.076) 0.061 (0.045 to 0.076) Age −0.003 (−0.004 to−0.002) −0.003 (−0.004 to−0.002) Smoker 0.125 (0.110 to 0.141) 0.125 (0.109 to 0.141) Observations 78,288 78,288

Regression results are obtained from linear probability model with 95% confidence inter-vals in parenthesis.

Treated province: Alberta and Nova Scotia.

Control province: Prince Edward Island, New Brunswick, Quebec, Ontario and Manitoba. Ontario was included among provinces with weak policy given that the data analyzed only covered up to 2012. Before January 2015, Ontario only prohibited smoking if patio had partial or complete roof.

Model 1 controlled for age, gender, education, smoking status, marital status and unem-ployment status.

Model 2 controlled for age, gender, education, smoking status, marital status, unemploy-ment status, provincial unemployunemploy-ment rates, seasonality, and linear and quadratic trends.

Table 3

Estimated effect of smoke-free patio policy on SHS exposure—strong vs. no policy.

Alberta Nova Scotia

Model 1 Model 2 Model 1 Model 2

Outdoor policy −0.077 (−0.102 to−0.052) −0.073 (−0.104 to−0.041) −0.055 (−0.085 to−0.026) −0.045 (−0.077 to−0.012)

Male 0.061 (0.045 to 0.076) 0.061 (0.045 to 0.076) 0.054 (0.041 to 0.068) 0.055 (0.041 to 0.068)

Age −0.003 (−0.004 to−0.002) −0.003 (−0.004 to−0.002) −0.004 (−0.004 to−0.003) 0.004 (−0.004 to−0.003) Smoker 0.090 (0.070 to 0.110) 0.090 (0.070 to 0.110) 0.135 (0.117 to 0.152) 0.135 (0.118 to 0.153)

Pre-policy estimated mean of SHS exposure 30.7% 30.7% 26.1% 26.1%

Observations 23,458 23,458 22,763 22,763

Regression results are obtained from linear probability model with 95% confidence intervals in parenthesis. Control province: Saskatchewan.

Model 1 controlled for age, gender, education, smoking status, marital status and unemployment status.

Model 2 controlled for age, gender, education, smoking status, marital status, unemployment status, provincial unemployment rates, seasonality, and linear and quadratic trends. 15 18 21 24 27 30 33 2005 2006 2007 2008 2009 2010 2011 2012 SHS exposure (%)

Nova Scotia Saskatchewan Linear (Saskatchewan) Fig. 2.Trend of SHS exposure, 2005–2012—Nova Scotia and Saskatchewan.

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21.1% decrease in the probability of SHS exposure. As expected, regres-sion results also showed that smokers were more likely to be exposed to SHS.

In a sensitivity analysis, provinces with weak or partial smoking re-striction on outdoor patios of bars and restaurants were used as addi-tional control group. Similar results were obtained indicating that smoking ban on outdoor patios of bars and restaurants had a statistically significant effect on SHS exposure (seeTable 4). Analysis examining whether the effect of the policy varies by smoking status is reported in Tables 5–6. For smokers in Alberta compared to smokers in Saskatche-wan, the policy significantly reduced SHS exposure by about 8.8 per-centage points yielding a relative decrease of 23.5% based on pre-policy exposure (37.5%). Likewise, relative to non-smokers pre-pre-policy SHS exposure (28.7%), the policy had a larger effect (26.8%) on non-smokers. Analysis comparing Nova Scotia with Saskatchewan relative to pre-policy SHS exposure showed that the policy had a larger impact on smokers (26.2%) than non-smokers (19.5%).

Discussion

This study examined the effect of province-wide smoke-free patio policy of bars and restaurants on self-reported SHS exposure in Canada. The results suggest that the policy had a statically significant re-duction in SHS exposure. Analysis examining the potential heteroge-neous effects of this policy by smoking status also found similar effects showing benefits for both smokers and non-smokers. To my knowledge, this is thefirst study to provide empirical evidence on the effectiveness of a smoke-free patio policy of bars and restaurants on SHS exposure. The currentfindings represent a unique and timely contribution to the literature, especially as public support for this policy grows and policy makers in numerous jurisdictions are considering adopting this policy (Thomson et al., 2009). The results of this study are consistent with the extant literature showing that smoke-free legislation is beneficial to health, in part due to a reduction in SHS exposure (e.g., e.g.,Hahn et al., 2008; Fowkes et al., 2008; Nagelhout et al., 2011; Millett et al., 2013; Naiman et al., 2010).

Thefinding of a recent longitudinal study further provides justifi ca-tion for ensuring that outdoor patios of bars and restaurants are smoke-free (Chaiton et al., 2014). Examining the effect of exposure to smoking on patios on smoking behavior,Chaiton et al. (2014)found that smokers exposed to smoking on patios was strongly associated with unsuccess-ful quit and were equally less likely to have made a quit attempt. Anoth-er longitudinal study assessing the effects of local restaurant smoking regulations on anti-smoking attitudes in the United States reported pos-itive association between having a strong local regulation and making a quit attempt at follow-up among adult-smokers who already made a quit attempt at baseline (Albers et al., 2007). Beyond the primary

bene-fits of reduced SHS exposure and promoting smoking cessation behav-iors, evidence also suggests that smoke-free legislation may positively influence societal norms about tobacco use (Albers et al., 2004, 2007; Brown et al., 2009; Fong et al., 2006). In addition, previous studies have shown that smoke-free policy may encourage positive behavioural change in other settings, referred to as norm spreading (Cheng, Glantz and Lightwood, 2011; Cheng et al., 2015). Future research may want to examine the possibility of‘norm spreading’due to smoke-free patio policy.

This study has some limitations that warrant noting. First, this study draws on respondent self-report and thus is susceptible to varying forms of bias (recall, social desirability, under-reporting). Though self-reported SHS has been validated (Okoli et al., 2007), there is still a pos-sibility of bias in the results shown here. Second, the results shown in this study may be conservative given that only province-wide smoke-free policy on outdoor patios of bars and restaurants was examined, it was not possible to match respondents to local towns/municipalities were similar policy was implemented using publicly available version of CTUMS. For example, a city (Saskatoon) in the control province (Sas-katchewan) banned smoking in outdoor patios in July, 2004. Finally, while this study adjusted for educational attainment, other standard measures of SES (e.g., income) are not available in CTUMS. Despite these limitations, the use of this large survey provides the opportunity to assess the population-level effect of smoke-free patio policy of res-taurants and bars on adult SHS exposure.

Table 6

Estimated heterogeneous effect of smoke-free patio policy on SHS exposure by smoking status: Nova Scotia.

Smoker Non-smoker

Model 1 Model 2 Model 1 Model 2

Outdoor policy −0.010 (−0.174 to−0.025) −0.089 (−0.168 to−0.011) −0.044 (−0.076 to−0.012) −0.034 (−0.068 to−0.001)

Male 0.064 (0.029 to 0.099) 0.063 (0.028 to 0.097) 0.055 (0.037 to 0.073) 0.055 (0.038 to 0.073)

Age −0.004 (−0.006 to−0.003) −0.004 (−0.006 to−0.003) −0.003 (−0.004 to−0.003) −0.003 (−0.004 to−0.003)

Pre-policy estimated mean of SHS exposure 38.1% 38.1% 22.6% 22.6%

Observations 4872 4872 17,891 17,891

Regression results are obtained from linear probability model with 95% confidence intervals in parenthesis. Control province: Saskatchewan.

Model 1 controlled for age, gender, education, smoking status, marital status and unemployment status.

Model 2 controlled for age, gender, education, smoking status, marital status, unemployment status, provincial unemployment rates, seasonality, and linear and quadratic trends. Table 5

Estimated heterogeneous effect of smoke-free patio policy on SHS exposure by smoking status: Alberta.

Smoker Non-smoker

Model 1 Model 2 Model 1 Model 2

Outdoor policy −0.085 (−0.145 to−0.024) −0.088 (−0.160 to−0.017) −0.077 (−0.105 to−0.050) −0.071 (−0.104 to−0.038)

Male 0.086 (0.045 to 0.076) 0.087 (0.051 to 0.122) 0.055 (0.037 to 0.073) 0.055 (0.038 to 0.073)

Age −0.003 (−0.004 to−0.001) −0.003 (−0.004 to−0.001) −0.003 (−0.003 to−0.002) −0.003 (−0.003 to−0.002)

Pre-policy estimated mean of SHS exposure 37.5% 37.5% 28.7% 28.7

Observations 5006 5006 18,452 18,452

Regression results are obtained from linear probability model with 95% confidence intervals in parenthesis. Control province: Saskatchewan.

Model 1 controlled for age, gender, education, smoking status, marital status and unemployment status.

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Conclusion

In summary, as the momentum grows for developing endgame strategy aimed at reducing tobacco use or tobacco-related diseases to the barest minimum worldwide, implementing a comprehensive tobacco-control strategy that includes smoke-free legislation would provide both short- and long-term health benefits (e.g., reduction in tobacco-related healthcare expenditures) (Yao et al., 2014).

Conflict of interest statement None.

Acknowledgment

This research is supported by the Canadian Cancer Society grant#2011-701019.

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