Trish Groves in Edinburgh: Towards a smoke free society

Monday 10 September 2007
I walked into Edinburgh’s impressive international conference centre just as a couple of minibuses pulled up outside, spilling a gaggle of protesters armed with cigarettes, Scottish flags, and placards decrying “junk science”. There were no other smokers by the front door, as there are outside most UK public buildings nowadays. If there were delegates wanting to smoke they must have been in hiding.

The Scottish Government (then the Scottish Executive) banned smoking in all enclosed public places in March 2006. We were all in Edinburgh to hear how that ban and others had fared, and to debate what to do next. The conference kicked off, and two small screens on the main stage drove home our real reason for being there: as we sat listening, the numbers of deaths related to secondhand smoke in the EU and worldwide mounted inexorably.

Banning smoking in public places in a wide range of countries, states, and cities has mostly been a success. Smokers and public venue staff have complied, the public are happy, and indoor air quality has improved markedly. I say mostly a success, but there are exceptions: for instance, several delegates from India reported how bans there have been enforced poorly and are largely ignored. In Scotland many experts and policy makers feared public outcry and resistance. Scots, as one speaker explained, really don’t like being told what to do, and the smoky pub was a national institution. But even hardened smokers caved in quietly. Public approval was higher after the ban than before, and more than four fifths of 18-24 year olds said the ban made them feel proud. All in all, it was a fair cop.

Ireland was the first country in the world to implement a national ban on smoking in public places back in 2004, and it too went pretty smoothly. An Irish delegate told me over lunch about a “lock-in” very late one night at a country bar, where men who were drinking illegally many hours after closing time nevertheless insisted that a smoker went outside to light up.

Two studies presented at the conference and just published in the BMJ showed that exposure to second-hand smoke (reported and measured by salivary cotinine) has fallen by nearly 40% in both primary school children and adult non-smokers. Another study from the Scottish evaluation, by Jill Pell and colleagues, reported a 17% reduction in admissions from acute myocardial infarction in nine hospitals in the six months after the ban.

Nick Mills, a cardiologist, showed evidence that even low exposure to secondhand tobacco smoke causes oxidative damage to arterial endothelium and increases platelet stickiness. This, he argued, makes it plausible that a public smoking ban can cut heart attack rates in non smokers. Francesco Barone-Adesi, an epidemiologist from Turin, reported that the handful of studies on rates of myocardial infarction after smoking bans have found widely variable effect sizes, with some showing no association at all: yet his forest plot suggested that something was going on. The smoke thins and the plot thickens.

What about adverse effects from smoking bans? Just after this July’s smoking ban in England James Oyebola, the 6ft 9ins former British heavyweight champion boxer, was shot and mortally wounded in a London bar. Witnesses said he had asked some men to stop smoking. It’s hard to know what to make of this, other than to be shocked by it.

Closer to the public health debate, John Reid, former UK health secretary, once said that people would just smoke more at home if they couldn’t do it in the pub. Not so, at least in families with young children, as Patricia Akhtar and colleagues’ Scottish study reports in the BMJ.

Meanwhile, Deborah Ritchie gamely sat in Scottish bars and pubs for weeks after the ban as a “mystery drinker” to directly observe compliance. Although the news was mainly good, we heard how people with restricted social lives had suffered post ban. Lonely old men who went to the pub to read the racing press and see which horses to bet on didn’t want to smoke outside in the cold, so they avoided the pub. The bookie’s office is smokefree too. Single mothers who used to go to the bowling alley to smoke and chat in the café area, while their kids bowled, now stay away. They don’t want to go outside and leave their children unwatched.

I’ve experienced one more minor adverse event in Italy. The ban there has tainted the joy of sitting in a pavement cafe in the warm still air, because the smokers are all out there too (not such a problem in Scotland’s less balmy climate). An Italian researcher, who measures air quality, acknowledged the problem and said he’s now thinking of doing his tests outside.

On the policy front, the news was also mixed. The WHO Framework Convention on Tobacco Control, which encourages strong measures against secondhand smoke and gives health considerations precedence over commercial ones, is the world’s first public health treaty. Dr Haik Nikogosian, who has just stepped into the brand new role of WHO tobacco control supremo (with the formal title of head of the convention’s secretariat) heartened us by explaining how 149 countries covering 80% of the world’s population have now ratified this international law. But turning that legal commitment into action is going to be a long haul.

In the EU, where you might expect almost universal support, 9 member states have still not signed up to the WHO convention. But policy on smokefree public places is gathering speed, and the European parliament is due to vote next month on the recommendations in the green paper for a smokefree Europe.

As the first day drew to a close we met up for a plenary, only to hear that a mathematical screw up had wrongly set the death clocks on the stage. The 80,000 EU deaths from secondhand smoke by 5pm more or less matched the real annual mortality. Gerard Hastings, professor of social marketing in Stirling, saved the day with a smile and the comment that “maybe that many would be dying if people like us weren’t working so hard to save them”.

Checking into my hotel late that night, I was confronted by another IT screw up. “I’m afraid our computer’s down and we can’t allocate you a room, even though you’ve prepaid”, apologised the manager. “But we’ve found you a room instead at the very nice hotel down the road. Unfortunately, it’s a smoking room”. Ironic and, in the end, happily wrong.