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

Abstract

INTRODUCTIONSome 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.METHODSWe 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.RESULTSThe 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.CONCLUSIONSWe 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.

Exposure to secondhand smoke in hospitality settings in Ghana: Evidence of changes since implementation of smoke-free legislation

“…There is no riskfree level of SHS and even brief/minimal exposure can cause immediate harm 2,33 . Non-compliance with smoke-free laws among hospitality venues has also been found in other LMICs including those of Africa 21,31 . The results and outcome of this research serve as a basis for discussions on the need to develop specific policies to protect consumers and employees of such premises, and also implement enforcement measures to improve compliance.…”

“…Lessons could be learnt from Seychelles, a similar country in Africa, where the compliance to smoke-free laws was impressively high in bars and restaurants after only nine months of the enactment of the smoke-free law 30 . Contributing factors for the situation in Seychelles included a smaller country size (thus requiring fewer resources for implementation), high awareness and knowledge of the smoking ban among hospitality staff, training of hospitality staff on how to enforce the ban, and active enforcement of the ban by venue workers 31 .…”

Impact of expanding smoke-free policies beyond enclosed public places and workplaces on children’s tobacco smoke exposure and respiratory health: protocol for a systematic review and meta-analysis

“…From eligible studies, we will extract the following items: (1) the first author's name, (2) his or her affiliation, (3) publication year, (4) type of publication (journal, book, dissertation, etc), (5) access information (URL or doi), (6) study design, (7) observational period (the beginning and end dates), (8) exact places covered by the policy, (9) whether the policy covers outdoor or indoor places, (10) whether the policy covers public or (semi)private, places, (11) timing of policy, (12) institution/government that initiated the policy, (13) country/location where the policy had been implemented, (14) compliance with the policy, (15) enforcement of the policy, (16) eligibility criteria for inclusion, (17) description of control group(s), (18) population at risk, (19) number of participants/events, (20) control and treatment group size, (21) characteristics of the population and the treatment groups (eg, age, gender and socioeconomic status), (22) data source(s) used for the study, (23) definition(s) of outcome measure(s), (24) controlled confounders (if applicable), (25) applied statistical techniques to draw inference, (26) number of clusters (if applicable), (27) cluster size (if applicable), (28) whether the results were adjusted for clustering (if clustered study), (29) whether the intraclass correlation coefficient is reported and what it is (if clustered study), (30) the number of drop-outs/ missing values, (31) techniques for handling missing values, (32) preintervention population at risk(n)/ events(n)/rates (%) of outcome variable(s), (33) postintervention population at risk(n)/events(n) rates (%) of outcome variable(s), (34) association between smoke-free policy and outcome(s) (coefficients, CIs and p values), (35) any unintended effects (eg, TSE displacement), (36) proportion of children exposed to TSE in the location covered by the smoke-free policy, before and after the implementation of the policy, (37) risk ratios (RRs) of respiratory disease for different levels of TSE according to specific locations covered by the smoke-free policy, (38) bias assessment (see section 'Risk of bias assessment'), (39) elements supporting causal inference (see section 'Elements supporting causal inference'), (40) any conflict of interest reported by the authors and (41) the funding source(s).…”

“…[4][5][6][7][8] Although in low-income and middle-income countries high background air pollution, poor economic conditions and low awareness of tobacco-related harm might obscure the positive effects of smoke-free legislation, evidence suggests that smokefree policies can have a similarly positive impact in these countries as in high-income countries. [9][10][11] As a result, smoke-free legislation is increasingly recognised as an important policy tool to protect children from the adverse health effects of TSE (eg, incorporated in Sustainable Development Goals 3.2, 3.4, 3.9 and 3.A that aim to improve health and well-being). 3 Recently, policies to provide additional protection of children to TSE beyond enclosed public places have been implemented in a number of places, both at a national and a subnational level.…”

Implementation of Smoke-Free Law in Denpasar Bali: Between Compliance and Social Norms of Smoking

“…In LMIC countries, the implementation should be performed together with measures to change smoker’s beliefs, social and cultural smoking norms, along with the increase of ground-level will to enforce policies. 10 , 11 Thus, exploration on factors related to compliance with smoke-free law in setting such as Indonesia should include an assessment of social norms. There are two type of social norms that should be taken into accounts in such study: descriptive norms and injunctive norms.…”