Editorials
Smoke-Free Legislation and Acute Coronary Syndrome
2018 Volume 82 Issue 7 Pages 1749-1751
Details
2018 Volume 82 Issue 7 Pages 1749-1751
Smoking is the single most preventable cause of death, especially in developed countries. It is reported that tobacco use kills more than 7 million people each year. Another 600,000 non-smokers die from secondhand smoke. The WHO launched the Framework Convention on Tobacco Control (FCTC), which is a comprehensive countermeasure against the tobacco epidemic.1 FCTC is the first global public health treaty and 181 countries and parties joined it, including Japan. The major contents of FCTC are as follows:
• Article 5: General obligations engendered by the treaty
• Article 6: Price and tax measures
• Article 8: Smoke-free legislation in all indoor workplaces
• Article 9: Regulation of the contents and emissions of tobacco products
• Article 10: Disclosure the information on the constituents of tobacco products.
• Article 11: Large health warnings on the packages
• Article 12: Education, communication, and public awareness of tobacco control issues
• Article 13: Ban of all tobacco advertising, promotion and sponsorship
• Article 14: Support for reducing tobacco dependence and cessation
• Article 15: Elimination of all forms of illicit trade in tobacco products
• Article 16: Prohibition the sales of tobacco products to minors
• Article 17: Support of economical alternative activities to tobacco growers.
The FCTC periodically surveys and summarizes the implementation of each Article by countries as “MPOWER”, which stands for the measures of FCTC:2
M: Monitor tobacco use and prevention policies
P: Protect people from tobacco smoke
O: Offer help to quit tobacco use
W: Warn about the dangers of tobacco
E: Enforce bans on tobacco advertising, promotion and sponsorship
R: Raise taxes on tobacco.
Article p 1852
It has been 13 years since the FCTC came into effect and most countries have made great progress in tobacco control. For example, the average price of a packet of cigarettes (measure of “R”) in high-income countries is PPP $7.19 (PPP: Purchasing Power Parity adjusted dollars). Pictorial warnings using photos are printed on cigarette packets. Media campaigns through TV and newspapers are repeatedly carried out (measure of “W”). Free telephone counseling (e.g., “Quit-line”) is available to encourage smokers to begin cessation treatment (measure of “O”).
As for the measure of “P”, each country’s legislation has been assessed to determine whether smoke-free laws provide for a complete indoor smoke-free environment at all times in all the facilities of each of the following eight public places:
• Healthcare facilities
• Educational facilities other than universities
• Universities
• Government facilities
• Indoor offices and workplaces not considered in any other category
• Restaurants of facilities that serve mostly food
• Cafés, pubs and bars or facilities that serve mostly beverages
• Public transport.
Figure 1 shows a Japanese style tavern where smoking is allowed at all seats, with the concentration of particulate matter less than 2.5 micrometer (PM2.5) emitted from cigarettes. The concentration of PM2.5 reached 200 or 300 μg/m3.3 which is categorized as “Hazardous” by the Air Quality Index of the US Environmental Protection Agency.4
The concentration of particulate matter less than 2.5 micrometer (PM2.5) in a Japanese style tavern (Izakaya), which was fully seated and 3 or 5 cigarettes were always smoked.
The first legislation that prohibited smoking in all indoor workplaces, including the hospitality industry, was implemented in Ireland in 2004. A total of 55 countries had already implemented complete smoke-free legislation in all eight public places by 31 December 2016.5 As for the USA, smoke-free legislation is implemented by the states. The CDC survey found that 27 states and 3 territories had implemented complete smoke-free legislation by 31 March 2018.6
As smoke-free legislation expanded worldwide, much research reported on the health effects of decreased hospitalization for smoking-related diseases in those countries. Tan and Glantz7 analyzed the decrease in smoking-related diseases after the implementation of smoke-free legislation. Comprehensive smoke-free legislation was associated with significantly lower rates of hospital admissions and their results emphasized that effect on smoking-related diseases was greater with more comprehensive laws. For example, admission for coronary events decreased by 8% after a smoking ban only at workplaces, but decreased by 15% after a complete ban including restaurants and bars. Similar decreases were also observed for other heart diseases, cerebrovascular diseases and respiratory diseases.
Japan was one of the first 40 parties to ratify the FCTC but implementation of the anti-smoking measures has been minimal. The area in which Japan is most behind in terms of tobacco control is Article 8 (i.e., national smoke-free legislation). Kanagawa Prefecture and Hyogo Prefecture enforced partial smoking bans in 2011 and 2013, respectively, because the Japanese Government did not implement complete smoke-free legislation.8 Hyogo prefectural legislation requires schools, hospitals, government buildings, and municipal offices to be smoke-free. Restaurants (>100 m2 of space reserved for customers) are required to enforce a complete ban or to install designated smoking rooms. Bars, taverns and restaurants where the space for customers is less than 100 m2 are only obliged to make an effort to reduce secondhand smoke. Sato et al previously reported that a significant decrease in the number of acute coronary syndrome (ACS) admissions in Kobe City whereas it increased in other districts in Hyogo prefecture, especially in Amagasaki City.9
In this issue of the Journal, Sato et al10 investigate the compliance with the smoking restriction at eating and drinking establishments in 2 big cities in Hyogo Prefecture (i.e., Amagasaki and Kobe). Their hypothesis was that Kobe City being the capital of the prefecture would have better compliance with the legislation than other cities. Amagasaki City was chosen as the control because the increase in ACS admissions was the largest in the Hyogo prefecture. Their survey revealed that both recognition and compliance with the legislation in restaurants were much better in Kobe City. The rate of complete smoking ban in restaurants was 31.4% in Kobe City, but only 13.0% in Amagasaki City. As for the decrease in the number of ACS admissions in Kobe City, it was 895 admissions in the year before the legislation and decreased to 830 admissions (−7.3%) in the 1st year, then 792 admissions (−11.5%) in the 2nd year after the legislation was enacted. According to the result of the meta-analysis done by Tan and Glantz, the reduction in ACS admissions after a complete ban legislation including bars was −15%. The reduction rate observed in Kobe City was less. These numbers are reasonable because the Hyogo Prefecture legislation is a partial ban, the percentage of smoke-free restaurants in Kobe City was only 31.4% and smoke-free bars in the 2 cities was also 4.7%. Further more, designated smoking seats can be chosen in restaurants. Figure 2 shows the PM2.5 concentration before and after eliminating a smoking area.11 It is necessary to implement a complete smoking ban in order to protect not only customers but also workers and owners in the hospitality industry.
Secondhand smoke (PM2.5) in a restaurant before (Left) and after (Right) smoking section was removed.
The Japanese Government decided to implement smoke-free legislation in schools, hospitals and governmental offices by revising the Health Promotion Law (March 9 2018). However, it will be still allowed to install designated smoking rooms and also allow smoking in small-scale restaurants and bars even after the revision of the law. Academic societies should send this scientific data to the policy makers in order to push the Japanese Government to implement complete smoke-free legislation like the other 55 countries (Figure 3). On 20 April 2018, Tokyo Metropolitan City announced new legislation that prohibits smoking in the hospitality industry wherever a worker is hired regardless of the size of the place. It is expected this legislation will initiate smoke-free laws that covers the whole of Japan.
Sign in a restaurant showing Italian smoke-free law with the penalty information.
H.Y. receives lecture fees from Pfizer and consultancy fee from T-PEC Corporation.
