Implementing smoke-free policies in low- and middle-income countries: A brief review and research agenda

INTRODUCTION Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs. METHODS We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports. We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies. RESULTS The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps. CONCLUSIONS We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

Previous studies have shown a decline in the community rates of myocardial infarction after enactment of these laws. However, data are scarce about the Latin American population. In the first phase of this study, we reported the successful implementation of the law in Sao Paulo city, with a decrease in carbon monoxide rates in hospitality venues. Objective: To evaluate whether the 2009 implementation of a comprehensive smoking ban law in Sao Paulo city was associated with a reduction in rates of mortality and hospital admissions for myocardial infarction. Methods: We performed a time-series study of monthly rates of mortality and hospital admissions for acute myocardial infarction from January 2005 to December 2010. The data were derived from DATASUS, the primary public health information system available in Brazil and from Mortality Information System (SIM). Adjustments and analyses were performed using the Autoregressive Integrated Moving Average with exogenous variables (ARIMAX) method modelled by environmental variables and atmospheric pollutants to evaluate the effect of smoking ban law in mortality and hospital admission rate. We also used Interrupted Time Series Analysis (ITSA) to make a comparison between the period pre and post smoking ban law. Results: We observed a reduction in mortality rate (-11.9% in the first 17 months after the law) and in hospital admission rate (-5.4% in the first 3 months after the law) for myocardial infarction after the implementation of the smoking ban law. Conclusions: Hospital admissions and mortality rate for myocardial infarction were reduced in the first months after the comprehensive smoking ban law was implemented. Malaysia Article Objective: To identify the relationship between knowledge, attitude and perception regarding environmental tobacco smoke (ETS) and smoking among Malaysian adolescents living in states with complete or partial smoke-free legislation (SFL). Methods: A total of 898 respondents aged 13-14 years were randomly selected from 21 secondary schools. The Malay version of the modified Global Youth Tobacco Survey questionnaire was used. Hierarchical logistic regression was performed in examining predictors of smoking attempt among adolescents. Results: Participants exposed to ETS >5 h/day were more likely to have smoked compared to those exposed to ETS <1 h/day (OR 4.1, 95%CI 1.03-16.0). Living in a state with partial SFL was associated with a two-fold increase in self-reported smoking attempts (OR 1.95, 95%CI 1.10-3.43) compared to living in a state with complete SFL. Negative attitudes and perceptions towards smoking and ETS exposure were linked to lower smoking attempts in states with complete SFL. Conclusions: Adolescents with limited ETS exposure who lived in a state with complete SFL were less likely to attempt smoking compared to those exposed more regularly to ETS and living in a state with partial SFL. Preventing adolescents from becoming smokers is the key to reducing national prevalence rates in smoking. There is a need to implement comprehensive smoke-free legislation nationally across Malaysia.
N. Z. Abidin. Knowledge, attitude and perception of second-hand smoke and factors promoting smoking in Malaysian adolescents. . 2014;18 (7):856-861. Agaku et al. 2015 Multiple Article Background: Preventing tobacco use is a key aspect of health promotion during adolescence. We assessed prevalence and impact of school-based tobacco prevention programs in 43 countries. Methods: We performed a secondary analysis of national data of students aged 13-15 years (Global Youth Tobacco Surveys) from 43 countries during 2005-2011. National surveys of the corresponding school personnel (Global School Personnel Surveys) were performed in each country during the same year as the student surveys. Data on status of enforcement of national smoke-free school policies were obtained from the 2008 and 2009 WHO MPOWER reports. Logistic regression was used to measure ecologic-level associations between school-based tobacco prevention programs and tobacco-related knowledge and behaviour among students (P < 0.05). Results: The proportion of students who were taught in class about the dangers of tobacco use during the school year ranged from 31.4% (Georgia) to 83.4% (Papua New Guinea). For every 10% increase (country level) in the proportion of teachers who reported having a tobacco prevention curriculum in their school, the odds of students reporting exposure to education in class about the dangers of tobacco increased by 6.0% (AOR = 1.06; 95% CI: 1.04-1.08). However, didactic education in class about the dangers of tobacco use was not independently associated with student current cigarette smoking behavior. Conversely, the likelihood of being a current smoker was significantly lower among students in countries with moderate/strongly enforced national smoke-free school policies compared with those in countries with poorly enforced/no national smoke-free school policies (AOR = 0.59; 95% CI: 0.45-0.76). Conclusions: Comprehensive tobacco prevention programs that include well-enforced smoke-free school policies may help reduce youth smoking. Turkey Article Introduction In 2009, Turkey extended the smoke-free legislation to hospitality venues. Compliance, however, remains low in some hospitality venues. We identified characteristics associated with knowledge of health effects that can be prevented by the smoke-free law, the attitude towards and enforcement of the law. Methods In 2014, we conducted 400 interviews with hospitality venue owners and employees in 7 cities in Turkey. The venues were identified based on a random sampling strategy in a previous phase of the study. Results Over one-third (37.3%) of hospitality owners and employees had adequate knowledge of the health effects from secondhand smoke (SHS), 71.3% had a positive attitude towards the law and 19.5% had personally enforced the law. Participants who worked 70 hours or more per week were more likely to have a positive attitude towards the law. Older individuals, women, participants working in bars/nightclubs, venue owners receiving fines for non-compliance and current smokers were less likely to have a positive attitude towards the law. Participants working in traditional coffee houses, former smokers, and participants with a high school education or greater were more likely to enforce the law. Smokers who quit or reduced smoking because of the law were more likely to enforce the law compared with those who were not influenced by the law. Conclusions Although the attitude towards the law was positive, interventions are needed to increase knowledge on the health effects of SHS and facilitate enforcement of the law, particularly among subgroups less likely to have a positive attitude and enforce the law. © 2016 by the BMJ Publishing Group Ltd. Multiple Report The report provides a comprehensive overview of the evidence base for protecting people from the harms of second-hand tobacco smoke through legislation and enforcement. There is a special focus on the status of implementation of smoke-free policies, with detailed data collected for the first time ever on a global basis at both the national level and for large subnational jurisdictions. Additional analyses of smoke-free legislation were performed, allowing a more detailed understanding of progress and future challenges in this area.
WHO. WHO report on the global tobacco epidemic, 2009: Implementing smoke-free environments. Geneva Article Objectives In Turkey, smoking has been banned in hospitality establishments since July 2009. The objective of this study was to determine noncompliance to the smoke-free law and its change in 2 consecutive years in enclosed spaces of hospitality venues and also to evaluate the factors associated with noncompliance. Study design This is an observational study. Methods Hospitality venues in Istanbul were visited, and data were collected through direct observation and interviews. Observation of smoking, cigarette butts or existence of ashtrays were defined as noncompliance. The survey was repeated in 2 consecutive years; the venues were visited both in 2013 and 2014. Logistic regression was used to evaluate factors associated with noncompliance. Results In 2013, 450 establishments were visited, and in the next year, 367 (81.6%) were revisited. Noncompliance for 2013 and 2014 were 49.0% and 29.7%, respectively. The highest violation was observed in bars and traditional coffeehouses. There was a significant decrease in noncompliance from 2013 to 2014 among restaurants and cafés, while such a change was not observed among bars and traditional coffeehouses. In the multivariate analysis, venues other than restaurants, venues that did not have no-smoking signs and venues which had been issued fines previously had increased probability of noncompliance. Conclusions While compliance to smoke-free law had increased significantly within 1 year, almost one third of the venues were still violating the law in 2014. The venues which were issued fines continued to violate the law. There is a need to strengthen enforcement efforts and revise the methods of enforcement and penalties in hospitality establishments.

South Africa
Article This study sought to investigate the level of tobacco smoke pollution in eight selected popular restaurants in the capital city -Pretoria. Average PM2.5 concentrations recorded were positively correlated with active smoking density (Spearman's correlation coefficient 0.71, P=0.047), indicating that a significant source of PM2.5 in the 'nonsmoking sections' was tobacco smoke generated from designated 'smoking areas'. The median average PM2.5 concentration (183 micro g/m3) was at least seven times higher than the WHO standard of 25 micro g/m3 set for good air quality. Furthermore, the average PM2.5 levels recorded in some restaurants were similar to levels recorded in some smoking sections in the recent Ghanaian study. Multiple Article Introduction: Article 8 of the Framework Convention on Tobacco Control mandates all signatory countries to "protect citizens from exposure to tobacco smoke in workplaces, public transport and indoor public places "Even though there has been great progress in the implementation of Article 8, still most of the world population remains exposed to secondhand smoke (SHS). In this article, we sought to summarize the research that supports Article 8, where do we stand, and current research gaps and future directions. Discussion: Secondhand smoke is an established cause of heart disease and several types of cancer. Additional research is needed to reach final conclusions for diseases where evidence is only suggestive of causality. The only solution to SHS exposure in public places is banning smoking indoors. Research on the gaming industry and nightclubs, particularly in developing countries, needs to be disseminated to support their inclusion in smoke-free laws. Aside from indoor bans, additional research is needed for outdoor and multiunit housing bans and in support of measures that protect children and other vulnerable populations. The impact of smoke-free laws on other health outcomes, besides heart disease and respiratory outcomes, is another area where further research is needed. Thirdhand smoke assessment and health effects are also likely to be a topic of further research. As new tobacco products emerge, evaluating SHS exposure and effects will be vital. We assessed air nicotine levels in bars and restaurants 6 months after the ban (post-ban) and compared them with levels found in 2006 (pre-ban). Methods: Exposure was estimated by passive sampling of vapor-phase nicotine using samplers (n = 50) placed for 7 working days in 10 bars and 11 restaurants in Guatemala City. Air nicotine was measured by gas chromatography, and the time-weighted average concentration in (mu)g/m3 was estimated. Employees answered a survey about smoke-free workplaces (n = 32) and compared with pre-ban (n = 37) results. Results: Nicotine was detectable in all bars pre-and post-ban. In restaurants, it was detectable in all pre-and 73% post-ban. Article For more than 20 years the tobacco industry has considered secondhand smoke to be a threat to its viability. In this article, we describe why secondhand smoke is important to tobacco control and how the tobacco industry's "Latin Project" sought to prevent the creation of smoke-free workplaces and public places in Central and South America. Eliminating secondhand smoke exposure not only reduces the risk of cardiovascular and other diseases, but also creates an environment that substantially reduces smoking and cigarette consumption among smokers. The "Latin Project" was initiated in 1991 by Philip Morris and British American Tobacco and managed by the law firm Covington & Burling. The project assembled a network of well-placed physicians and scientists to divert the attention away from secondhand smoke toward other indoor air pollutants. As proven in Central and South America, the tobacco industry has manipulated the secondhand smoke issue in order to avoid the development of smoke-free environments. Sub-Saharan Africa, facing an epidemiologic transition similar to the one experienced by Central and South America, should be aware of tobacco industry tactics. Further delay in implementing smoke-free environments will only increase the burden of cardiovascular disease in both areas of the world. Article Background: Smoke-free environments decrease smoking prevalence and consequently the incidence of heart disease and lung cancer. Due to issues related to poor enforcement, scant data is currently available from low/middle income countries on the long-term compliance to smoke-free laws. In 2006, high levels of secondhand smoke (SHS) were found in bars and restaurants in Guatemala City. Six months after a smoking ban was implemented in 2009, levels significantly decreased. However, in 2010, poor law compliance was observed. Therefore, we sought to assess long-term compliance to the ban using SHS measurements. Methods: In 2014 we assessed SHS exposure using airborne nicotine monitors in bars (n = 9) and restaurants (n = 12) for 7 days using the same protocol as in 2006 and in 2009. Nicotine was measured using gas-chromatography (mug/m(3)) and compared to levels pre- (2006) and post-ban (2009

2012
Multiple Article Background: The latest amendment to the ban on smoking in public places in Israel was implemented in 2007, adding pubs and bars (P&B) to the list of public places in which smoking is prohibited. However, smoking in most P&B continued. The aim of the study was to identify the theoretically plausible reasons for the partial success of a public ban on smoking in P&B settings. Explanations provided by P&B owners were interpreted as probable causal factors based on the Behavioral Ecological Model (BEM). Methods: Qualitative interviews were performed with 36 P&B owners in Tel-Aviv and 18 Israeli towns and cities of various population size. Results: P&B owners reported a variety of situational factors (i.e., contingencies) and reinforcers as likely explanations of the partial failure of the legislated ban on smoking in public places, particularly P&B. The major reinforcers for non-adherence with the law were no or low frequency of inspections and low penalties from authorities. P&B owners also feared loss of customers and revenue if bans were enforced in their own establishment but not in competing establishments. Finally, owners reported social norms prevailing among some Israeli patrons supporting smoking in P&B settings, in part to express opposition to the new law. Conclusions: Qualitative assessment can uncover probable social situations that operate to prevent greater adherence to smoking bans. The results warrant confirmation by quantitative analyses. Policies with mandated inspections and penalty requirements that are implemented in all bars without prejudice could lead to greater adherence to smoking bans. Positive reinforcing consequences that encourage adherence (such as publicity and support from non-smokers) would be more likely to generate both greater adherence to the policy and good will toward the government. Principles of behavior outlined in the BEM offer guidance for designing quantitative confirmation analyses of future bans. Article Background: The aim of this study was to evaluate the effect of anti-smoking legislation in public places and public support for smoking ban. Methods: A cross-sectional survey was conducted in public places such as market, bus/railway station, workplaces and hospitals in Udaipur, India. Informed consent was obtained. The questionnaire comprised of details about their agreement with the current anti-smoking legislation and their views on the support for smoking ban in public places. FINDINGS: The study was conducted among 314 individuals of whom 255 (81.2%) supported the general ban on smoking in public places. Non-smokers (54.4%) agreed more than smokers that the introduction of legislation would create healthier environment (P < 0.001), second hand smoke is serious threat to health (P < 0.001), more implementation needed for current antismoking legislation (P < 0.001). Smokers (45.5%) agreed more than non-smokers that everyone has the right to smoke in public places (P < 0.001). Conclusion: Local support for a ban on smoking in public places in Udaipur is high. But there is a lack of enforcing mechanism in support of the legislation and hence complete smoking ban along with strong enforcement may provide better results. In the following years, WHO evaluated the level of implementation of MPOWER criteria in the countries. In this article, how Turkey implemented these six criteria will be discussed. Monitor tobacco use and prevention policies: Monitoring of tobacco use prevalence has been successfully monitored in Turkey through Global Adult Tobacco Survey, Global Youth Tobacco Survey and Health Professionals Tobacco Use Survey. Nevertheless, monitoring of tobacco industry activities was not successfully implemented. Protect people from tobacco smoke: Smoking was banned in most of the indoor public places in Turkey since 1996, and Turkey became a complete smoke-free country by the exposion of smoke-free places including the hospitality workplaces in 2008. Offer help to quit tobacco use: Although smoking cessation services has been a bit late in Turkey, availability of smoking cessation drugs and the establishment of free quitline services made Turkey successful in this regard. Warn about the dangers of tobacco: Since 1996, all TV channels have a duty of broadcasting programs on harms of tobacco use, not less than 90 minutes in a month and it has been implemented successfully. Additionally written messages indicating harms of tobacco has been printed on the packs since 1988 and pictures was added in 2010. But since the average surface area covered by the messages in less than 50% of the total surface of the pack, Turkey was not regarded as to meet the requirement. Enforce bans on tobacco advertising, promotion and sponsorship: All kinds of tobacco advertisement and promotion was banned by the Law in 1996. But the tobacco products was not in closed boxes at the sales points. Turkey was not found as successful in this regard. Raise taxes on tobacco: Total tax on the tobacco products is more than 75% level which was recommended by WHO, Turkey meets this criteria. In conclusion, Turkey was regarded as meeting all the MPOWER criteria except the warning about the dangers of tobacco and enforcement of the advertisement ban. In conclusion, Turkey was regarded as meeting all the MPOWER criteria except the warning about the dangers of tobacco and enforcement of the advertisement ban.

2012
Turkey Article Objective: In this descriptive study, it was aimed to assess attitudes and behaviours of some taxi-drivers in Ankara on the smoking ban in cabs under the Law of Preventing the Harmful effects of Tobacco Products. Material and Methods: Face to face interviews were done with 277 taxi-drivers by visiting taxi stations in Alti{dotless}ndag and Cankaya districts. Additionally, breath carbon monoxide levels were measured in some drivers after obtaining their informed consent. As a part of this study, the actual smoking status of the drivers and/or clients were recorded by observing the travelling taxies on the junctions of the main streets of the two districts of Ankara. Results: Sixty-four percent of taxi drivers (177 of 277) were current smokers. The majority of these current smokers (108 of 177; 61.0%) reported that they also smoked in the cabs. While more than half of the respondents (55.2%) supported the smoking ban in the cabs, one third (33.2%) of the drivers strongly disagreed with this legislation. Among the taxi drivers, there was an agreement on supporting the smoking bans in certain public places like court halls and the town bus stations (80.2% and 73.6% respectively), but on the other hand, they s were less supportive of the bans in cafes and restaurants, particularly serving alcoholic drink (41.5% and 32.9% respectively). Non-smoker drivers supported the smoking ban legislations more. Conclusion: Findings showed that compliance with the items of the Law which ban smoking in the cabs, were not sufficient. In daily life many traffic policemen are responsible for the regulation of the traffic. It will be efficacious in the eradication of smoke from the cabs, if these traffic police are informed about their authorization and duty on the tobacco control, including fining the taxi drivers who ignore the smoking ban legislation. Multiple Article Tobacco is already the world's leading cause of preventable death, claiming over 5 million lives annually, and this toll is rising. Even though effective tobacco control policies are well researched and widely disseminated, they remain largely unimplemented in most low-and middle-income countries (LMICs). For the most part, control attempts by advocates and government regulators have been frustrated by transnational tobacco companies (TTCs) and their supporters. One reason tobacco is so difficult to control is that its political economy has yet to be adequately understood and addressed. We conducted a review of the literature on tobacco control in LMICs using the databases PubMed, EconLit, PsychInfo and AGRICOLA. Among the over 2500 papers and reports we identified, very few explicitly applied political economy analysis to tobacco control in an LMIC setting. The vast majority of papers characterized important aspects of the tobacco epidemic, including who smokes, the effects of smoking on health, the effectiveness of advertising bans, and the activities of TTCs and their allies. But the political and economic dynamics of policy adoption and implementation were not discussed in any but a handful of papers. To help control advocates better understand and manage the process of policy implementation, we identify how political economy analysis would differ from the traditional public health approaches that dominate the literature. We focus on five important problem areas: information problems and the risks of smoking; the roles of domestic producers; multinational corporations and trade disputes in consumption; smuggling; the barriers to raising taxes and establishing spatial restrictions on smoking; and incentive conflicts between government branches. We conclude by discussing the political economy of tobacco and its implications for control strategies. Multiple Article Background: Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect. Objectives: To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009. SELECTION CRITERIA: We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before and after studies, interrupted-time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre-and post-ban data. DATA COLLECTION AND ANALYSIS: Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis. MAIN Results: There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban. AUTHORS' Conclusions: Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome.
There is an increase in support for and compliance with smoking bans after the legislation. Chang et al.

2009
Mongolia Article Objectives: Exposure to second-hand smoke (SHS) is widespread in restaurants in Ulaanbaatar, the capital city of Mongolia. While a smoke-free policy is the most effective way of protecting restaurant workers and customers from SHS, this has not been well accepted in Mongolia. Furthermore, little is known about restaurants' attitude toward the smoke-free policy. Methods: A cross-sectional survey directed to restaurant owners or managers was conducted in 475 representative restaurants in Ulaanbaatar. Face-to-face interviews using a questionnaire and on-site observation were performed. Results: Only 29.3% of the restaurants claimed to prohibit smoking; none of the remaining had any protection toward SHS, and half of the restaurants estimated that more than 20% of customers would smoke inside. None of them had visible "no smoking'' signs and the majority never received complaints about SHS. Despite the generally high level of knowledge of the health effects of SHS, of the 336 restaurants that were not smoke free, only 25.9% expressed that they planned to take action in the near future. By contrast, 87.8% of restaurants would support the government if it asked all restaurants to ban smoking. Multivariate analysis identified that restaurants having menus in foreign languages, selling cigarettes and predicting business decline were less likely to support the government smoke-free policy. Conclusions: This survey demonstrates that restaurants owners and managers were reluctant to take action on their own, but would support government policy. The government can assume a stronger role first by revising the law on tobacco control following the Framework Convention on Tobacco Control guideline. Article Objective To analyse the process of implementing and enforcing smoke-free environments, tobacco advertising, tobacco taxes and health warning labels from Costa Rica's 2012 tobacco control law. Method Review of tobacco control legislation, newspaper articles and interviewing key informants. Results Despite overcoming decades of tobacco industry dominance to win enactment of a strong tobacco control law in March 2012 consistent with WHO's Framework Convention on Tobacco Control, the tobacco industry and their allies lobbied executive branch authorities for exemptions in smoke-free environments to create public confusion, and continued to report in the media that increasing cigarette taxes led to a rise in illicit trade. In response, tobacco control advocates, with technical support from international health groups, helped strengthen tobacco advertising regulations by prohibiting advertising at the point-of-sale (POS) and banning corporate social responsibility campaigns. The Health Ministry used increased tobacco taxes earmarked for tobacco control to help effectively promote and enforce the law, resulting in high compliance for smokefree environments, advertising restrictions and health warning label (HWL) regulations. Despite this success, government trade concerns allowed, as of December 2015, POS tobacco advertising, and delayed the release of HWL regulations for 15 months. Conclusions The implementation phase continues to be a site of intensive tobacco industry political activity in low and middle-income countries. International support and earmarked tobacco taxes provide important technical and financial assistance to implement tobacco control policies, but more legal expertise is needed to overcome government trade concerns and avoid unnecessary delays in implementation. © 2016 by the BMJ Publishing Group Ltd. Article The public health rewards of smoke-free policies are well documented. But in their enthusiasm to achieve such policies, public health advocates and policymakers frequently underestimate the political complexity of passing laws, and then implementing and enforcing them. Using 12 African countries as the focus of discussion, this research examines the basic political process for and the barriers to achieving smoke-free policies. Moreover, in addition to the obstacles, it examines why some countries have been experiencing comparatively more success in the smoke-free policy area. The findings of the research suggest strongly that the presence of a vigorous tobacco control civil society movement, some will on the part of government institutions, and active research support contribute significantly to successful smoke-free policies. It is also apparent that the emerging battle fronts in smoke-free policies are in the areas of implementation and enforcement, and while similar variables that affect the passing of new laws also condition these outcomes, there are the added distinct challenges of policy fatigue and additional resource constraints. The implementation of smoking bans in Albania has been quite difficult, especially because of the high smoking rates. The aim of this study was to utilise the general theory of deterrence (GTD) to understand non-compliance with smoke-free policies in public places. Participants were 333 university student smokers (Mage ¼ 21.2 years). Measures: A self-report questionnaire was administered to assess variables from the GTD, attitudes and norms. Results: Smokers reported high noncompliance rates, strong social norms but weak attitude towards non-compliance with smoke-free policies. Furthermore, non-compliance was predicted by weak legal, moral and social deterrents. Discussion: The findings suggest that although Albanian smokers were negative towards noncompliance, they still violate smokefree policies in public settings, mainly as a result of weak legal and social deterrents. From a practical perspective, strengthening the barriers to noncompliance is particularly important (e.g. campaigns, frequent controls, fines, etc. Article Background: China is the world's largest consumer of tobacco, with hundreds of millions of people exposed daily to secondhand smoke (SHS). Comprehensive smoke-free policies are the only effective way to protect the population from the harms of SHS. China does not have a comprehensive national smoke-free law but some local-level regulations have been implemented. Objective: To evaluate local level smoke-free regulations across 7 cities in China by measuring the prevalence of smoking in public places (workplaces, restaurants and bars), and support for smoke-free policies over time. Methods: Data were from Waves 2 to 4 of the International Tobacco Control (ITC) China Survey (2007-2012), a face-to-face cohort survey of approximately 800 smokers in each of 7 cities in mainland China. Multivariate logistic regression models estimated with generalised estimating equations were used to test the changes in variables over time. Results: As of 2012, over three-quarters of respondents were exposed to smoking in bars; more than two-thirds were exposed to smoking in restaurants and more than half were exposed to smoking in indoor workplaces. Small decreases in the prevalence of smoking were found overall from Waves 2 to 4 for indoor workplaces, restaurants and bars, although the decline was minimal for bars. Support for complete smoking bans increased over time for each venue, although it was lowest for bars. Conclusions: Existing partial smoking bans across China have had minimal impact on reducing smoking in public places. A strongly enforced, comprehensive national smoke-free law is urgently needed in order to achieve greater public health gains. Status Report on Article 8. 2010. India Article Background: Compliance survey of smoke-free law is an effective means of measuring progress towards a smoke-free society. They also help policy makers to take action where strengthening measures are required. India has a comprehensive tobacco control law known as Cigarettes and Other Tobacco Products Act (COTPA 2003) which prohibits smoking in public places and requires display of 'No smoking' signages with proper specifications at conspicuous points. However, its implementation and enforcement are still a matter of concern. AIMS AND Objectives: To ascertain the level of compliance with smoke-free law in public places of a district of North Using the Delphi method, the relevance and ranking of criteria from an existing protocol for measuring compliance was evaluated. Results: Consensus was reached on all five compliance survey indicators through three rigorous rounds of discussion. The highest priority was assigned to the absence of the act of smoking in public places (33%), followed by the display of no-smoking signage in public places (32%), absence of cigarette butts or bidi stubs (15%), absence of smoking aids (10%) and absence of tobacco smoke and ash (10%). Conclusion: Tobacco control advocates can effectively inform local policy makers using weights that prioritise directed enforcement and targeted interventions, which in turn will ensure stronger compliance and sustainable smokefree settings. (copyright)  The overall prevalence of current smoking among study participants was 25%. Around 96% were aware of the fact that smoking is harmful to health, 45% viewed second-hand smoke to be equally harmful as active smoking, 84.2% knew that smoking is prohibited in public places and 88.3% wanted the government to take strict actions to control the menace of public smoking. Multivariate logistic regression analysis showed that people aged 20 years and above, unemployed, urban, literate and non-smokers had significantly better perception towards harms of smoking. The knowledge about smoke free provisions of COTPA was significantly better among males, employed individuals, urban residents, and literate people. Conclusions: There was high knowledge about deleterious multi-dimensional effects of smoking among residents and a high support for implementation of COTPA. Efforts should be taken to make Mohali a "smoke-free district".  (2005) requires all signatory countries to adopt measures to protect people from tobacco smoke in indoor workplaces, indoor public places, public transport and other public places as appropriate. The aims of this symposium were to review progress across the world, to assess the evidence for the impact of legislation on health, and to identify the continuing challenges in making universal protection a reality. There was agreement that even in countries where strict legislation is enforced, many children continue to be dangerously exposed to parental second-hand smoke in the womb, the home and private cars. The importance of using accurate estimates of the burden of disease caused by second-hand smoke was agreed, in order to present an unassailable case for legislation and enforcement. (

Georgia
Article Before year 2008 smoking was partially restricted in cafes and restaurants of Georgia. In 2009 Georgian Parliament adopted amendment in law "Concerning Tobacco Control" and strengthened partial restriction in cafes and restaurants, namely required that 50% of territory of those facilities must be smoke free. To observe status of implementation of tobacco control legislation in field of prohibition/restriction of smoking in cafes and restaurants conducted observation of those facilities and in-depth interviews of their owners/staff. Observation in cafes and restaurants were done in big regional centers of Georgia, namely in Tbilisi (Capital), Telavi, Kutaisi, Batumi, Rustavi, Gori, Akhaltsikhe and Zugdidi. At all 176 cafes/restaurants were observed (22,4% of all registered cafes/restaurants in Georgia). For qualitative part of the study 1-2 persons from staff of the cafe or restaurant or its owner available during the observation was interviewed. Field work was done during 2011-2012. It must be mentioned that during this period was not observed any important change in legislation and/or enforcement of smoking ban/restrictions in those facilities. Study instrument were guide for observer that contained two parts -observational and open-ended questions for owners and staff. Observation of cafes/restaurants in Georgia shows that 89,8% of them violate existing restriction on smoking. All restaurants and 85% of cafes violate the law. Only 18 (10,2%) cafes are in compliance with the legislation and all of them have total ban. Despite to the fact that more than 50% of observed cafes/restaurants were located in Tbilisi, absolute majority (88,1%) of smoke free facilities are in regions (mainly in Kutaisi, Zugdidi and Gori). Qualitative study of owners/staff of the facilities found factors that probably are influential in determination of smoking status of cafes/restaurants. Namely, decisions on those kinds of issues are made by owners according to business interest and private attitude. Because of absence of enforcement activities requirement of tobacco control legislation is not taken into consideration. Existing partial restriction doesn't have support from great majority of cafes/restaurants, because it is difficult to implement. At the same time part of owners/staff don't support any type of ban or restriction, because of their fear to loose smoker clients. At that qualitative study and observation shows that this opinion is assumption and not on practice or evidence based argument. Despite to this assumption, total ban on smoking in cafes and restaurants is understood as "coming legislation" and main requirement to this possible development is to provide "ban for all" and information of general public. Iran Article Background: Creating smoke-free public places is essential to protect non-smokers and it also motivates smokers to quit. Considering the smoking ban law in public places of Iran and weakly enforcement of this law, we decided to study the circumstances in Tehran. Methods: It was a cross-sectional study which has been done during 2009. Firstly, Tehran's geographic map was divided into 3 areas of north, center and south and secondly 10 spots in each area were selected randomly. By reaching to that addresses easy sampling was done and going straightly toward the right side to collect enough cases. The indicators including "the existence of smoking ban signs, ashtrays and smoking areas and also the way of showing objection against smoking" were questioned and observed. Results: 458 restaurants and food courts were studied. In 60 places (13%) there were no smoking ban signs. In 140 places (30%) there were ash trays and in 54 places (12%) there were smoking areas. In 132 places (29%) the in-charge people had no objection against smoking in restaurants. All the cases were aware of smoking ban law in public places. More than 50% considered it as a useful law and 106 restaurants (23%) believed that the law enforcement would increase the number of customers. There was no statistically relationship between the place and working year of restaurants and law enforcement but it was shown a statistically relationship between smoking ban signs and showing objection against smoking and increasing the number of customers (p=0.000). Conclusion: In spite of the fact that it has been a long time since the law adaptation, but it has not been fully implemented, so it is necessary to reinforce the law. Article The aim of this cross-sectional study was to quantify the implementation of MPOWER tobacco control policies among Eastern Mediterranean Region countries. Information was obtained from the 2011 WHO MPOWER report. A checklist was designed and its scoring was agreed by Iranian and international tobacco control specialists. Seven questions were scored from 0-4 and 3 from 0-3. The 22 countries were ranked by their total score on a scale of 0 to 37. The highest scores were achieved by the Islamic Republic of Iran, Egypt and Jordan 29, 28 and 26 respectively. Twelve of the countries (55%) scored more than half of the possible score (19). The lowest and highest scores for all countries summed were on sections related to banning smoking in public places (18) and tobacco advertising bans (66) respectively. Compliance with smoke-free policies was especially low. MPOWER programmes are accepted in the Region but there is considerable room for improvement. Input from countries based on their successes and challenges is needed to strengthen the programmes. Multiple Article Background: Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force. Methods: An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored. Results: Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention. Conclusion: When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies. Article Tobacco smoking prevalence remains low in many African countries. However, growing economies and the increased presence of multinational tobacco companies in the African Region have the potential to contribute to increasing tobacco use rates in the future. This paper used data from the 2014 Global Progress Report on implementation of theWorld Health Organization Framework Convention on Tobacco Control (WHO FCTC), aswell as the 2015 WHO report on the global tobacco epidemic, to describe the status of tobacco control and prevention efforts in countries in theWHO African Region relative to the provisions of theWHO FCTC andMPOWER package. Among the 23 countries in the African Region analyzed, there are large variations in the overall WHO FCTC implementation rates, ranging from 9% in Sierra Leone to 78% in Kenya. The analysis of MPOWER implementation status indicates that opportunities exist for the African countries to enhance compliance withWHO recommended best practices for monitoring tobacco use, protecting people fromtobacco smoke, offering help to quit tobacco use, warning about the dangers of tobacco, enforcing bans on tobacco advertising and promotion, and raising taxes on tobacco products. If tobacco control interventions are successfully implemented, African nations could avert a tobacco-related epidemic, including premature death, disability, and the associated economic, development, and societal costs.

Hyland et al. 2012
Multiple Article Smoke-free policies have been an important tobacco control intervention. As recently as 20 years ago, few communities required workplaces and hospitality venues to be smoke-free, but today approximately 11% of the world's population live in countries with laws that require these places to be smoke-free. This paper briefly summarises important milestones in the history of indoor smoke-free policies, the role of scientific research in facilitating their adoption, a framework for smoke-free policy evaluation and industry efforts to undermine regulations. At present, smoke-free policies centre on workplaces, restaurants and pubs. In addition, many jurisdictions are now beginning to implement policies in outdoor areas and in shared multiunit housing settings. The future of smoke-free policy development depends on credible scientific data that documents the health risks of secondhand smoke exposure. Over the next 20 years smoke-free policies will very likely extend to outdoor and private areas, and changes in the types of tobacco products that are consumed may also have implications for the nature and scope of the smoke-free policies of the future. Multiple Article This publication reviews the effectiveness of measures enforced to eliminate tobacco smoking and tobacco smoke from environments where exposure takes place. It also offers a critical review of the evidence on the economic effects and health benefits (focusing on cancer, cardiovascular, and respiratory diseases) of smoke-free legislation and the adoption of voluntary smoke-free policies in households. Chapters particularly discussed the health effects of exposure and reduced exposure to second-hand tobacco smoke (SHS), evolution of smoke-free policies, economic impacts and incidental outcomes of smoke-free policies, public attitudes and compliance, effect of smoke-free policies on smoking behaviour, and home smoking restrictions.
.  2003). Objectives: The aim of this study was to assess the level of compliance of Sections 4, 5, 6-a, and 6-b, and 7, 8, and 9 of COTPA with respect to public places, educational institutes, point of sale (PoS), and warning on packaging (COTPA) in public places of Alwar District of Rajasthan. Methods: A cross-sectional observational study was conducted in 2014 in Alwar city and four blocks of the district. The study was done around 365 public places for observing the compliance of Section 4 of COTPA, 357 educational institutions for observing the compliance of Section 6-b of COTPA, and 357 tobacco retailers for observing the compliance of Sections 5 and 6-a of COTPA. Results: The criteria for the evaluation (the core indicators) and decision criteria for a district to qualify for the "Smoke free" status include six parameters. From the total of 365 places visited, 90% places displayed the "No-smoking" signage and out of total 328 places, 99% were as per the COTPA specification. Alwar city, Ramgarh, Thanagaji, and Alwar rural block followed the compliance of Section 4. The PoS visited Alwar district displayed 93% (332) signage and all the displayed signage followed the COTPA compliance. In Alwar city, Thanagaji, Ramgarh, and Alwar rural block, the compliance of Section 6-a was above 90%. The compliance of Section 6-b was above 90% in Alwar city, Ramgarh, Thanagaji, and Alwar rural block. Ninety-three percent (332) of the PoS did not display tobacco advertisement in Alwar district, which is a positive sign of COTPA compliance. Conclusion: This finding suggest a high level of compliance of Section 4, Section 5, Section 6-a, and Section 6-b of COTPA at Alwar district.
M. L. Jain, M. Chauhan and R.
Singh. Compliance assessment of cigarette and other tobacco products act in public places of Alwar district of Rajasthan. Indian journal of public health. 2016;60(2):107-11. India Article In 2003, the Parliament of India passed the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA) to counter the growing societal and health burdens of tobacco in India. The major provisions (Sections 4-7) of COTPA mandate the display of pictorial health warnings on all tobacco product packets and strictly prohibit: smoking in public places, direct and indirect forms of tobacco advertisements, promotion and sponsorship of tobacco products, sale of tobacco products to a minor, and sale within 100 yards of any educational institution. However, India continues to have a high prevalence of tobacco consumption and the provisions of COTPA are routinely flouted. The purpose of the study is to analyze the trends in and the prevalence of COTPA violations in a sample test site (Haryana) to develop informed and practical tobacco control policy recommendations. Violations in five districts of the State of Haryana were observed and recorded. The data overwhelmingly show that the most fundamental provisions (Sections 4-7) of COTPA were frequently violated in each of the five districts. All districts had a high rate of noncompliance, with Sites having at least one violation of Sections 4-7 of COTPA, with rates fluctuating between nearly 70 and 90 percent. Such violations however, were unequally distributed between Sections 4-7 within the five districts with some districts having a higher frequency of Section 4 violations (Panipat and Jhajjar) and other districts with higher violation frequency of Section 5 (Mewat and Kurukshetra). However, all five districts had relatively low numbers of Section 7 violations (i.e., the required display of pictorial health warnings on all tobacco products). The study highlights the challenges of the tobacco control policy in India including: engagement of state and district level enforcement officials for effective enforcement of existing legislation, encouragement for civil society to partner and complement governmental efforts in monitoring progress and reporting violations of COTPA, and the need for supply-level controls on tobacco (e.g., pictorial health warnings and increased taxation) to reduce tobacco consumption.  ) and workplaces, and with moderate restrictions in pubs and restaurants.Objectives: In order to monitor and evaluate implementation and effects of the new smoke-free law, the National Committee for Tobacco Prevention of the Ministry of Health has organized the follow-up of public support, compliance, smoking cessation services activities and health benefits related to the new legislation.Data will be obtained by public surveys, from smoking cessation services, inspections and hospitals (admissions due to acute myocardial infarction).Materials and Methods: Survey of the representative sample of the Serbian population (over 1100 participants) has been carried out before the implementation and after 3 months of the implementation of the Law; it will be carried out after 6 and 12 months as well.Both rounds of survey were carried out by using the same methodology, on representative random samples of Serbian adult population (over 1000 participants each).Results: The survey revealed that the public support for the new smokefree law has increased, from 77% in the baseline study to 80% after 3 months of implementation.The majority of participants (around 90%) agreed that smoking was the significant cause of cancer, heart diseases and stroke, that ETS was harmful to nonsmokers and that smokers should take care not to expose others to tobacco smoke.In comparison with the baseline survey, the percentage of population exposed to tobacco smoke in workplaces and at schools has decreased significantly (from 45 to 35% in workplaces and from 44 to 23% at schools).The exposure to tobacco smoke in bars and restaurants haven't changed -the Law provided only minor restrictions.More than 20% of the population thinks that smoking should be completely allowed in restaurants, pubs and night clubs.The number of homes where smoking was allowed everywhere has decreased from 48% to 42%.The new law had effects on smokers as well -one quarter of smokers reduced the number of daily cigarettes and one fifth begun considering quitting smoking because of it.Among those that quit smoking, 38% said that they were motivated by this Law. More than half of the population (53%) thought that the Law was mostly or completely respected.Conclusions: Evaluation results indicate that there is a strong support for the new smoke-free law in Serbia and that, after 3 months, it is already showing positive effects.Regular follow up will enable evaluation of the Law and its impact and enable plan measures for the improvement.

2011
India Article Smoke-free legislation is gaining popularity; however, it must accompany effective implementation to protect people from secondhand smoke (SHS) which causes 600,000 deaths annually. Increasing numbers of smoke-free cities in the world indicate that municipalities have an important role in promoting smoke-free environments. The objectives were to describe the local initiative to promote smoke-free environments and identify the key factors that contributed to the process. Observations were based on a case study on the municipal smoke-free initiatives in Chandigarh and Chennai, India. India adopted the Cigarette and Other Tobacco Products Act in 2003, the first national tobacco control law including smoke-free provisions. In an effort to enforce the Act at the local level, a civil society organization in Chandigarh initiated activities urging the city to support the implementation of the provisions of the Act which led to the initiation of city-wide law enforcement. After the smoke-free declaration of Chandigarh in 2007, Chennai also initiated a smoke-free intervention led by civil society in 2008, following the strategies used in Chandigarh. These experiences resonate with other cases in Asian cities, such as Jakarta, Davao, and Kanagawa as well as cities in other areas of the world including Mexico City, New York City, Mecca and Medina. The cases of Chandigarh and Chennai demonstrate that civil society can make a great contribution to the enforcement of smoke-free laws in cities, and that cities can learn from their peers to protect people from SHS. Indonesia Article Objective: District policies were recently put into place in Indonesia prohibiting smoking in public spaces. This study sought to (1) assess participants' general knowledge of secondhand smoke (SHS) dangers; (2) assess participants' awareness of and specific knowledge of smoke-free (SF) policies; and (3) assess the extent to which such policies are socially enforced and gather examples of successful social enforcement. Methods: Qualitative in-depth interviews and focus group discussions were conducted in Bogor and Palembang cities with both community members and key informants such as government officials, non-government agency staff, religious leaders and health workers. Results: Participants in both Palembang and Bogor find SF policy important. Although there was awareness of SHS dangers and SF policies, accurate knowledge of the dangers and an in-depth understanding of the policies varied. There was a high level of support for the SF policies in both cities among both smokers and non-smokers. Many participants did have experience asking a smoker not to smoke in an area where it was restricted, even if their comfort in doing so varied. There was, however, a higher level of comfort in telling smokers to stop or to move away from pregnant women and children. Hesitation to socially enforce the policies was especially present when asking men of status and/or community leaders to stop smoking, but overall participants felt they could comfortably ask someone to obey the law. Conclusion: Palembang and Bogor may be evolving towards creating social norms in support of prohibiting smoking in public spaces. If provided with more support from government and law officials, such as government officials themselves promoting the policies and demonstrating compliance, and renewed efforts to promote and enforce policies in general were made, Indonesians in these cities may feel more confident protecting non-smokers from SHS. Article Background: Air nicotine monitoring is an established method of measuring exposure to second hand smoke (SHS). Not much research has been done in India to measure air nicotine for the purpose of studying exposure to SHS. It is a risk factor and many diseases are known to occur among non smokers if they are exposed to second hand smoke. Objective: To conduct monitoring of air nicotine for second hand smoke exposure in public places across major cities in India. MATERIALS AND Methods: A cross sectional survey was conducted across four cities across the country, using passive air monitoring. The buildings included hospitals, secondary schools, Governmental offices, bars and restaurants. The buildings were selected through convenience sampling method keeping in view specific sentinel locations of interest. RESULT: The presence of air nicotine was recorded in most of the buildings under the study, which included government buildings, hospitals, schools, restaurants and entertainment venues (bars) in all four cities under the study. The highest median levels of air nicotine were found in entertainment venues and restaurants in cities. Conclusion: The presence of air nicotine in indoor public places indicates weak implementation of existing smoke free law in India. The findings of this study provide a baseline characterization of exposure to SHS in public places in India, which could be used to promote clean indoor air policies and programs and monitor and evaluate the progress and future smoke-free initiatives in India. Gujarat. The youth visited each restaurant thrice in one month; first to make observations on compliance status, second to orient the owners/ managers on legal provisions, and third to monitor if the restaurant complied after last visit. Crucial aspects of compliance were observed and analyzed by using McNemar's test to inform impact assessment. Results: While only 21.59% of restaurants displayed any tobacco warning at first visit, 80.68% of the restaurants had displayed a warning board. The youth also observed a six times increase in restaurants which displayed a warning board on each entrance; five times increase in restaurants displaying warning board at each floor; six times increase in restaurants displaying the board at each staircase; and while no restaurant displayed a warning board at each elevator before intervention, over 8.42% restaurants did at third visit (p<0.001). 83.47% restaurants displayed prescribed sized boards post intervention as against 12.81% restaurants at pre intervention. Restaurants displaying boards as specified and carry authorized person's name to report violations increased from 18.94% and 12.40% respectively to 85.06% and 81.82%. Youth categorized twice as many restaurants as 'completely smoke free' after campaign ( Kegler et al.

2014
China Article Background: A certain level of public support for smoke-free environments is a prerequisite for adoption and enforcement of policies and can be used as an indicator of readiness for legislative action. This study assessed support for comprehensive smoke-free policies in a range of settings such as hotels and colleges among government workers in China and identified factors associated with support for smoke-free policies. Understanding the extent to which government workers, a large segment of the working population in China, report a smoke-free workplace and support for smoke-free policies may be important indicators of readiness for strengthened policies given their role in formulating, implementing and enforcing regulations. Methods: Data were from an evaluation of the Tobacco Free Cities initiative of Emory University's Global Health Institute-China Tobacco Control Partnership. Self-administered surveys were completed by 6,646 workers in 160 government agencies in six Chinese cities. Multivariate logistic regression was used to identify factors associated with support for smoke-free worksites, bars, hotels, and colleges. Results: Over half (54.6%) of participants were male. A large percentage of the male workers smoked (45.9%,) whereas very few women did (1.9%). Fewer than 50% of government workers reported smoke-free policies at work, with 19.0% reporting that smoking is allowed anywhere. Support for smoke-free policies was generally very high, with the lowest levels of support for smoke-free bars (79.0%) and hotels (82.3%), higher levels of support for restaurants (90.0%) and worksites (93.0%), and above 95% support for hospitals, schools, colleges, public transportation and religious settings. Knowledge of the harmfulness of secondhand smoke was positively associated with support for smoke-free policies. Stricter worksite smoking policies were associated with support for smoke-free workplaces and bars, but not hotels and colleges. Women and nonsmokers were more supportive of smoke-free policies in general. Conclusion: Government workers play important roles in formulating, implementing and enforcing regulations; results suggest support for a more comprehensive approach to smoke-free environments in China among workers across a broad range of agencies. Pakistan Article Objective: In order to limit the high prevalence of tobacco use in Pakistan various tobacco control laws have been implemented. The objective of this study is to serve as a pilot study to assess the implementation of these laws in the largest city of Pakistan, Karachi. Methods: A cross-sectional study was conducted in Karachi. The implementation of tobacco control laws in 'smoke-free' places, the adherence of tobacco companies to these laws, the regulation of cigarette sale, and the awareness and views of the general public regarding tobacco control laws were assessed via direct observation by visits and through self-administered questionnaires. Results: The implementation of tobacco control laws in 'smoke-free' public places was found to be poor. Out of 37, only 23(62%) brands displayed pictorial warnings on their packs. 3(8%) of the brands were available in two different kinds of packs, both with and without pictorial warnings. Cigarette sale to minors was taking place at 80(85%) of the visited cigarette outlets. 50(53%) of the outlets displayed cigarette advertisements in the form of posters. 46(40%) of the persons questioned had awareness regarding the existence of ban on smoking in public places and 126(90%) of these were in favour of it. Conclusions: The implementation of tobacco control law in Pakistan is poor. Non adherence to the law in public places was alarmingly high. Also, the study demonstrates the poor compliance to the tobacco control laws by tobacco companies. Article Background: India has been implementing smoke-free legislation since 2008 prohibiting smoking in public places. This study aimed to assess the level of compliance with smoke-free legislation (defined as the presence of no-smoking signage and the absence of active smoking, smoking aids, cigarette butts/ bidi ends and smoking smell) and the role of enforcement systems in Indian jurisdictions. Methods: This was a cross-sectional, retrospective review of reports and primary data sheets of surveys conducted in 38 selected jurisdictions across India in 2012-2013. Results: Of 20 455 public places (in 38 jurisdictions), 10 377 (51%) demonstrated full compliance with smoke-free law. Educational institutions and healthcare facilities performed well at 65% and 62%, respectively, while eateries and frequently visited other public places (such as bus stands, railway stations, shopping malls, stadia, cinema halls etc.) performed poorly at 37% and 27%, respectively. Absence of no-smoking signage was the largest contributor to non-compliance across all types of public places. Enforcement systems were present in all jurisdictions, but no associations could be demonstrated between these and smoke-free compliance. Conclusion: Smoke-free compliance in public places in India was suboptimal and was mainly related to the absence of no-smoking signage. This warrants further pragmatic and innovative ways to improve the situation. . Multiple Article This paper examines the social, cultural, economic and legal dimensions of tobacco control in the South-East Asia Region in a holistic view through the review of findings from various studies on prevalence, tobacco economics, poverty alleviation, women and tobacco and tobacco control laws and regulations. Methods were Literature review of peer reviewed publications, country reports, WHO publications, and reports of national and international meetings on tobacco and findings from national level surveys and studies. Tobacco use has been a social and cultural part of the people of South-East Asia Region. Survey findings show that 30% to 60% of men and 1.8% to 15.6% of women in the Region use one or the other forms of tobacco products. The complex nature of tobacco use with both smoking and smokeless forms is a major challenge for implementing tobacco control measures. Prevalence of tobacco use is high among the poor and the illiterate. It is higher among males than females but studies show a rising trend among girls and women due to intensive marketing of tobacco products by the tobacco industry. Tobacco users spend a huge percent of their income on tobacco which deprives them and their families of proper nutrition, good education and health care. Some studies of the Region show that cost of treatment of diseases attributable to tobacco use was more than double the revenue that governments received from tobacco taxation. Another challenge the Region faces is the application of uniform tax to all forms of tobacco, which will reduce not only the availability of tobacco products in the market but also control people switching over to cheaper tobacco products. Ten out of eleven countries are Parties to the WHO Framework Convention on Tobacco Control and nine countries have tobacco control legislation. Enforcement of control measures is weak, particularly in areas such as smoke-free environments, advertisement at the point of sale and sale of tobacco to minors. Socio-cultural acceptance of tobacco use is still a major challenge in tobacco control efforts for the governments and stakeholders in the South-East Asia Region. The myth that chewing tobacco is less harmful than smoking tobacco needs to be addressed with public awareness campaigns. Advocacy on the integration of tobacco control with poverty alleviation campaigns and development programs is urgently required. Law enforcement is a critical area to be strengthened and supported by WHO and the civil society organizations working in the area of tobacco control. Multiple Article Objective: Identify the psychosocial variables that predict smokers' compliance with smoke-free policies at work, and non-smokers' assertiveness for smoke-free rights in Greek and Bulgarian workplaces. Methods: Data were collected from employees in Greece and Bulgaria. The main outcome measures were smokers' compliance with smoke-free policies, and non-smokers' assertiveness intentions. Demographic variables, tobacco use and dependence, as well as beliefs about second-hand smoke (SHS) exposure and smoking at work were also assessed. Results: Regression analyses showed that smokers' compliance with smoke-free policies was predicted by age, perceived health risks of smoking, and beliefs related to the benefits of smoking at work. Non-smokers' assertiveness was predicted by annoyance from exposure to SHS at work, and assertiveness-related social cognitions (e.g., attitudes, social norms, and self-efficacy). Conclusions: Interventions to promote support for tobacco control policies at work in Greece and Bulgaria may benefit from targeting smokers' beliefs about the actual effects of tobacco use on health and job performance. Accordingly, efforts to promote non-smokers assertiveness should build stronger assertiveness-related attitudes, convey anti-smoking normative messages, and strengthen self-efficacy skills. Multiple Article Purpose: To understand transnational tobacco companies' (TTCs) practices in low and middle-income countries which serve to block tobacco-control policies and promote tobacco use. Methods: Systematic review of published research on tobacco industry activities to promote tobacco use and oppose tobacco-control policies in low and middle-income countries. Results: TTCs' strategies used in low and middle-income countries followed four main themes-economic activity; marketing/promotion; political activity; and deceptive/manipulative activity. Economic activity, including foreign investment and smuggling, was used to enter new markets. Political activities included lobbying, offering voluntary self-regulatory codes, and mounting corporate social responsibility campaigns. Deceptive activities included manipulation of science and use of third-party allies to oppose smoke-free policies, delay other tobacco-control policies, and maintain support of policymakers and the public for a pro-tobacco industry policy environment. TTCs used tactics for marketing, advertising, and promoting their brands that were tailored to specific market environments. These activities included direct and indirect tactis, targeting particular populations, and introducing new tobacco products designed to limit marketing restrictions and taxes, maintain the social acceptability of tobacco use, and counter tobacco-control efforts. Conclusions: TTCs have used similar strategies in high-income countries as these being described in low and middle-income countries. As required by FCTC Article 5.3, to counter tobacco industry pressures and to implement effective tobacco-control policies, governments and health professionals in low and middle-income countries should fully understand TTCs practices and counter them.  Multiple Article Our objective was to review the research on the effects of public clean air laws on smoking rates, compare these effects to those found in studies on the impact of private worksite restrictions and derive estimates of the potential reductions in smoking rates that might be expected from the implementation of the two types of policies. Data sources were computerized databases, references identified from pertinent peer-reviewed journal articles and books, and suggestions by experts on tobacco control policy. Comprehensive public clean air laws have the potential to reduce prevalence and consumption rates of the entire population (including non-working and non-indoor working smokers) by about 10%. Studies on private worksite regulations also suggest that strong worksite restrictions have the potential to reduce the prevalence rate of the entire population by about 6% over the long-term and the quantity smoked by continuing smokers by 2-8%, depending on the length of time after the ban. Further research is needed on the effects of the different types of public clean air policies on the entire smoking population and on different sociodemographic groups, how the effects of public clean indoor air laws depend on private restrictions already in place, and how the effect of private restrictions depend on whether or not they are supported by public clean air laws. To evaluate the compliance with this policy as well as its impact on exposure to secondhand smoke (SHS), respiratory symptoms, and related attitudes among employees in five kinds of workplaces (schools, kindergartens, hospitals, hotels, and shopping malls). Methods:A cross-sectional survey was conducted six months before and then six months after the policy was implemented. Five types of occupational employees from 52 work settings were surveyed anonymously using multistage stratified cluster sampling.Results:Six months after implementation, 82% of the participants agreed that "legislation is enforced most of the time". The percentage of self-reported exposure to secondhand smoke declined from round up to 49% to 36%. High compliance rates were achieved in schools and kindergartens (above 90%), with less compliance in hotels and shopping malls (about 70%). Accordingly, prevalence of exposure to SHS was low in schools and kindergartens (less than 10%) and high in hotels and shopping malls (40% and above). The prevalence of respiratory and sensory symptoms (e.g., red or irritated eyes) among employees decreased from 83% to 67%. Conclusions:Initial positive effects were achieved after the implementation of Shanghai Smoking Control legislation including decreased exposure to SHS. However, compliance with the policies was a considerable problem in some settings. Further evaluation of such policy implementation should be conducted to inform strategies for increasing compliance in the future. . Face-to-face interviews were conducted with 4815 smokers and 1270 non-smokers. Multivariate logistic regression models were used to identify factors associated with support for comprehensive smoke-free policies. Results: About one in two Chinese urban smokers and four in five non-smokers believed that secondhand smoke (SHS) causes lung cancer. The majority of respondents supported comprehensive smoke-free policies in hospitals, schools and public transport vehicles while support for smoke-free workplaces, restaurants and bars was lower. Levels of support were generally comparable between smokers and non-smokers. Support for comprehensive smoke-free policies was positively associated with knowledge about the harm of SHS. Respondents who worked in a smoke-free worksite or who frequented smoke-free indoor entertainment places were more likely to support comprehensive smoking restriction in bars and restaurants. Conclusion: Considerable support for smoke-free policies exists in these six large cities in China. Greater public education about the dangers of SHS may further increase support. Experiencing the benefits of smoke-free indoor entertainment places and/or workplaces increases support for these policies and suggests that some initial smoke-free policy implementation may hasten the diffusion of these public health policies.

2013
Egypt Article Introduction: Tobacco use in low-to middle-income countries is a major public health concern for both smokers and those exposed to environmental tobacco smoke (ETS). Egypt has made important strides in controlling tobacco use, but smoking and ETS remain highly prevalent. This randomized intervention sought to improve the target population's knowledge regarding the hazards of smoking and ETS and to change attitudes and smoking behaviors within the community and the household. Methods: In this 2005-2006 study in Egypt's Qalyubia governorate, trained professionals visited schools, households, mosques, and health care centers in rural villages randomly selected for the intervention to discuss the adverse effects of smoking and ETS exposure and ways to reduce one's ETS exposure. Data collected in interviewer-facilitated surveys before and after the intervention period were analyzed in pairwise comparisons with data from control villages to assess the effectiveness of the intervention in achieving its aims. Results: The intervention group showed a greater increase in understanding the dangers associated with smoking cigarettes and waterpipes and became more proactive in limiting ETS exposure by asking smokers to stop, avoiding areas with ETS, and enacting smoking bans in the home. However, the intervention had little to no impact on the number of smokers and the amount of tobacco smoked. Armenia's total score on Tobacco Control Scale has considerably improved from 2005 to 2009, mostly due to larger health warnings and advertising ban, and increased public spending on tobacco control. The scores for smoke-free public places, advertising ban, health warnings and treatment categories were below the European average in 2005 and 2007, while the price score was higher. Neither total tobacco control score nor any of its components showed a significant predictive value in a simple regression analysis using the total score and subscores as predictors for log-transformed per capita tobacco consumption. Conclusions: Higher than the European average price score for Armenia cannot be explained by the concept of affordability alone and may reflect a measurement error due to peculiarities of transition economies. The applicability of the Tobacco Control Scale could be limited to countries with mature economies, but not to transition countries such as Armenia with different social, political and economic environment. The scale modification, such as an adjustment for the policy enforcement and the effectiveness of public tobacco control spending along with alternative measures of affordability would be warranted to enhance its applicability in low-income and middle-income countries. Nigeria Article Objective. This study determined the awareness and attitude towards the Osun state prohibition of smoking in public places law. Method. Descriptive cross-sectional study design. 520 consenting respondents recruited using a convenience sampling method were interviewed using a semi-structured questionnaire covering their smoking pattern, awareness and attitude towards the law of prohibition of smoking in public places in Osun State. Data analyzed using descriptive and chi-square statistics. Results: Only 38% were aware of the law while none had seen the document. Fifty six percent felt cigarette smoking is a problem that required the law to be implemented, while only 20% agreed that the law will stop tobacco use. The radio (58%), bill boards (45%) and newspapers (44%) were the major sources of awareness of the law. The perception of risk posed to the public and family health by cigarette smoking was poor among the participants. Conclusion: There is poor awareness and attitude to the law of prohibition of smoking in public places in Osun State. It is necessary to increase sensitization of the general public and enforcement of the law. Article Background: One of the requirements of the Osun State smoke-free legislation is to ensure smoke-free enclosed and partially enclosed workplaces. This survey was conducted to assess the knowledge and attitude of workers in indoor bars, beer parlors and discotheques to smoke-free legislation in general and the Osun State smoke-free law in particular. Methods: A convenience sampling of 36 hospitality centers was conducted. Interviewer-administered questionnaires were used to elicit responses about the objectives from non-smoking workers. The questionnaires had sections on knowledge of the Osun State smoke-free law, attitude toward the law and smoke-free legislation in general and exposure to second-hand tobacco smoke by the workers. Questions were also asked about the second-hand tobacco smoking status of these workers. The data were analyzed using SPSS version 15.0. Results: We had 154 participants recruited into the study. There were 75 males (48.0%) and 79 females (52.0%). On the overall, respondents had a good knowledge of the effects of second-hand smoke on health (70.2%) with 75.0% of them being aware of the general smoke-free law and 67.3% being aware of the Osun State smoke-free law although none of them had ever seen a copy of the law. A high proportion (60.0%) was in support of the Osun smoke-free law although all of them think that the implementation of the law could reduce patronage and jeopardize their income. Attitude toward second-hand smoking was generally positive with 72.0% of them having no tolerance for second-hand tobacco smoke in their homes. Most participants (95.5%) had been exposed to tobacco smoke in the workplace within the past week. Conclusion: Despite the high level of awareness of the respondents about the dangers of second hand smoke and their positive attitude to smoke-free laws, nearly all were constantly being exposed to second hand smoke at work. This calls for policy level interventions to improve the implementation of the smoke-free law. Owusu-Dabo et al.

Ghana
Article Background: Preventing an epidemic increase in smoking prevalence is a major challenge for developing countries. Ghana, has maintained a low smoking prevalence despite the presence of cigarette manufacturing for many decades. Some of this success may have been contributed by cultural factors and attitudes. We have studied public awareness of health risks, attitudes to smoke-free policy, tobacco advertising/promotion and other factors in a Ghanaian population sample. Methods: We used two-stage cluster randomized sampling to study household members aged 14 and over in a representative household sample in the Ashanti Region of Ghana. Results: 6258 people, 88% of those eligible, took part in the study. Knowledge of health risks of smoking and passive smoking was high; radio was the main source of such information. Most people work and/or spend time in places where smoking is permitted. There was very strong support (97%) for comprehensive smoke-free legislation, particularly among Christians and Muslims. Despite the advertising ban, a third of respondents (35%), particularly in urban areas, had noticed advertising of tobacco or tobacco products, on the radio (72%) and television (28%). Among smokers, 76% had attempted to quit in the last 6 months, with the main sources of advice being friends and spouses. Use of nicotine replacement therapy was very rare. Low levels of health awareness were seen in females compared with males (Adjusted Odds Ratio (AOR); 0.51, 95% CI 0.39-0.69, p<0.001). High levels of health awareness was seen among Traditionalists compared with Christians (AOR; 2.16 95% CI 0.79-5.94, p<0.05) and the relatively well educated (AOR; 1.70 95% CI 1.12-2.58, p<0.05) and those living in rural areas (AOR 1.46 95% CI 1.14-1.87, p=0.004). Conclusion: Awareness of health risks and support for smoke-free policy are high in Ghana. Exposure to tobacco advertising or promotion is limited and most smokers have tried to quit. Whether these findings are cause or effect of current low smoking prevalence is uncertain. Multiple Article More and more legislation regulating smoking in public places is being enacted. A conceptual model is proposed incorporating a large number of factors that may affect smokers' compliance with resulting restrictions. The model stems from findings in our own research and from a consideration of the literature. It includes individual variables such as personality characteristics and attitudes, as well as population variables such as social norms and political and economic factors. Education about the health effects of environmental tobacco smoke and attitudes toward legislative measures regulating smoking, in the context of a supportive environment, are postulated to directly affect personal compliance with regulations. Some directions for future research and implications for public policy are presented.
Pederson LL, Wanklin JM, Bull SB, Ashley MJ. A conceptual framework for the roles of legislation and education in reducing exposure to environmental tobacco smoke. American journal of health promotion : AJHP. 1991;6(2):105-111.
Perkins and E et al.

2014
Multiple Article Objectives: We examine the determinants governing both countries' enactment of smoking bans in public places and their ability to successfully put these bans into effect. Methods: Using a large sample (N = 99-184) of low-, middle-and high-income countries, econometric techniques are used to estimate the influence of several variables on cross-national variations in the adoption and compliance of second-hand smoke laws (2010). Results: We find similarities in the determinants of adoption and compliance. Yet more notable are the differences, with several political economy factors which have a statistically significant influence on countries' level of compliance with existing smoke-free laws in public places found not to consistently influence their propensity to adopt bans in the first place. Possible explanations for this discrepancy are that governments are motivated to adopt smoking bans for reasons other than protecting the health of their citizens and that the real costs of smoking bans are predominantly borne at the compliance stage.
Conclusions: More effort needs to be made to ensure that governments realize their existing policy commitments through effective enforcement of bans.

Persai et al. 2016
India Article Introduction. While extensive scientific evidence exists on the tobacco epidemic, a lack of understanding of both policies and their appropriate way of implementation continues to hinder effective tobacco control. This is especially so in the developing countries such as India. The present study aims to understand current implementation practices and the challenges faced in mainstreaming tobacco control policy and program. Methods. We chose a qualitative study design to conduct the case analysis. A total of 42 in-depth interviews were undertaken with seven district officials in six districts of Andhra Pradesh. A conceptual framework was developed by applying grounded theory for analysis. Analysis was undertaken using case analysis approach. Results and Discussion. Our study revealed that most program managers were unfamiliar with the comprehensive tobacco control policy.
Respondents have an ambiguous opinion regarding integration of tobacco control program into existing health and development programs. Respondents perceive lack of resources, low prioritization of tobacco control, and lack of monitoring and evaluation of smoke-free laws as limiting factors affecting implementation of tobacco control policy. Conclusion. The findings of this study highlighted the need for a systematic, organized action plan for effective implementation of tobacco control policy and program. In 2010 a bylaw was issued, leading to a drive by the Ministry of Health and Population (MOHP) to launch a smoke-free initiative in Alexandria, the second largest city. Objective: To assess public opinion with regard to 100% smoke-free legislation and its implementation in the Alexandria governorate. DESIGN: The Union Middle-East Office, in collaboration with the Central Agency for Public Mobilization and Statistics and the MOHP, conducted a cross-sectional survey among 427 randomly selected adults (206 males and 221 females), covering the seven major districts of the Alexandria governorate. Results: The majority of the interviewed subjects (98%) expressed support of the government in enacting 100% smoke-free indoor legislation in all public places and public transport. Respondents endorsed the government plan to implement legislation imposing 100% smoke-free public places. More than one third (33.5%) of all respondents indicated that they would increase visits to restaurants if they were smoke-free, and 63% indicated no impact at all. Conclusion: The results of the poll clearly support results from different countries worldwide that smoke-free policies are popular and supported by the public. Malaysia Article This cross sectional survey was conducted to determine the support in making Penang UNESCO World Heritage Site (GTWHS) smoke free and to determine the influence of tolerance towards smoking on this support. This is the first phase in making Penang, Malaysia a smoke free state. A multistage sampling process was done to select a sample of respondents to represent the population of GTWHS. Attitude towards smoking was assessed using tolerance as a proxy. A total of 3,268 members of the community participated in the survey. A big majority (n = 2969; 90.9%) of the respondents supported the initiative. Support was lowest among the owners and residents/tenants, higher age groups, the Chinese, men, respondents who had poor knowledge of the places gazetted as smoke free, and respondents with poor knowledge of the health effects on smokers and on passive smokers. The odds (both adjusted and unadjusted) of not supporting the initiative was high among those tolerant to smoking in public areas. Tolerance towards smoking was associated with 80.3% risk of non-support in the respondents who were tolerant to smoking and a 57.2% risk in the population. Health promotion and education concerning the harm of tobacco smoke in Malaysia, which has mainly targeted smokers, must change. Health education concerning the risks of second hand smoke must also be given to non-smokers and efforts should be made to denormalize smoking.