Chapter 2

REVIEW OF RELATED LITERATURE

This chapter presents the related literature and studies after the through and in-

depth search done by the researcher.

Foreign Literature

Governments around the world seek to reduce the adverse health effects of

smoking, both to smokers and non-smokers. Policies have focused on discouraging

smoking through tobacco taxes, restrictions on tobacco advertising, providing services to

assist smokers to quit and taking various steps to inform the community of the health risks

associated with smoking. Many governments have also placed restrictions on the

locations in which people can smoke, including government buildings, office buildings,

shopping centres, restaurants and bars. While restrictions on where people can smoke

have primarily been motivated by reducing harm caused by smoking to non-smokers,

they have also been positioned, at least in Australia, as seeking to reduce smoking rates

(Queensland Health, 2000).

According to a 2013 smoking-related report from the World Health Organization, 6

million people annually die due to smoking and this number is predicted to increase to

approximately 8 million by 2030 . Cigarette smoke contains around 250 harmful chemical

substances, 69 of them can cause cancer, so that the International Agency for Research

on Cancer has classified cigarette and cigarette smoke as group 1 carcinogens

(http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS).

Smoking and exposure to cigarette smoke are associated with health risks such

as the onset of diseases including various cancers as well as cardiovascular and

respiratory diseases. In addition, exposure of pregnant women and infants to indirect

cigarette smoke has unfavorable effects such as premature birth, sudden infant death

syndrome, and asthma . A study reported about 46,000 deaths in South Korea in 2003

due to smoking, and smoking was attributed to 30.8% of deaths in men. Also, the Ministry

of Health and Welfare estimated the economic burden due to labor loss from early death

and diseases induced by smoking to be about 5.6 trillion Korean won (KRW) in 2007. For

that reasons, constant efforts to decrease smoking rates by establishing the smoke-free

policies have been made in South Korea and worldwide (Jee 2006).

One example of non-price smoking policies in South Korea, smoke-free zones

have been expanded since 1995, and a revision of the National Health Promotion Act in

December 2012 banned smoking in public institutions and public facilities. A Cochrane

systematic review the effects of legal regulations such as designation of smoke-free

zones in public places, workplaces, and restaurants showed a decrease of secondhand

smoking exposure rate, but it could not reach the conclusion in current smoking rate. In

Ireland, one year after smoking ban policies were implemented in workplaces including

service businesses in March 2004, the smoking rate decreased from 29% to 26% but

increased to 28% the following year. In the UK, the rate of smoke cessation increased

within a year after implementation of smoke-free legislation in July 2007, but this effect

did not last (Callinan, 2010).

The WHO Framework Convention on Tobacco Control (WHO FCTC) was adopted

by the World Health Assembly in May 2003 and as of April 2014 has been ratified by 178

countries. The WHO FCTC aims to protect present and future generations from the

devastating health, social, environmental and economic consequences of tobacco

consumption and exposure to tobacco smoke. As of 2012, 79% of Parties reported

strengthening their existing legislation or adopting new tobacco control legislation after

ratifying the Convention. Additionally, over half of the Parties to the WHO FCTC reported

having developed and implemented comprehensive tobacco control strategies, plans and

programmes as required in Article 5.1 of the Convention (World Health Organization;

2013).

The Treaty has a specific public health objective of reducing morbidity and

mortality due to tobacco use. However, there are time lags throughout the process from

ratification of the WHO FCTC, the promulgation of the Treaty-compliant tobacco control

legislation, and actual implementation and enforcement of the law. There is also a time

lag from when the policies are implemented until behaviour changes in tobacco use (i.e.

cessation or non-initiation by youth) are seen on a large scale within a country. There is

also the time lag between behaviour change and the accrual of health benefits. Among

smokers who quit, a reduction in risk of cancer may take about a quarter of a century to

manifest, with the most immediate health benefit being a reduction in the risk of heart

disease. At the population level, reduction in overall mortality may begin to show up about

quarter of a century after implementation of tobacco control policies and reach full impact

in about half a century. However, implementation of smoke-free policies has been shown

to have more immediate health effects in populations, including significant reductions in

acute myocardial infarctions (Thun 2012).

Article 8 of the WHO FCTC aims to provide protection from exposure to tobacco

smoke. According to the Global Progress Report, 2012, Article 8 has been implemented

in 83 countries (46.9%), the highest number of countries implementing any WHO FCTC
article. By 2012, as many as 109 Parties reached their individual five-year time frame for

implementation of public smoking bans. Eight-eight Parties also reported having

mechanisms for the monitoring and enforcement of smoke-free measures (World Health

Organization, 2012).

A comprehensive review on the impact of public smoking bans was undertaken by

the Cochrane group and published in 2009. Fifty studies were reviewed, including a

variety of methodologies and sizes, with all the studies having taken place in North

America, Europe or Australasia. No meta-analysis was performed due to the

heterogeneity of the studies. This review looked at studies measuring the actual reduction

in SHS exposure (Callinan, 2010).

Reduced exposure to SHS is the first outcome measure for a smoke-free policy.

In this Cochrane review there were 31 studies reporting on exposure to SHS, mostly in

workplaces. All of the studies clearly showed reduced self-reported exposure to SHS after

policy implementation. This was either expressed as reduction in the length of time

exposed (71% to 100% reduction) or in reduction in the proportion of those exposed (22%

to 85%). Eighteen studies, using biomarkers, like salivary cotinine, to validate these self-

reports found 39% to 89% reduction in exposure. The studies reviewed showed that after

the public smoking bans were in place, there was consistent evidence that smoking bans

reduced exposure to SHS in workplaces, restaurants, pubs and other public places.

Hospitality workers showed a greater reduction in exposure than the general public

(Callinan, 2010).

Numerous studies have been conducted to find out whether public smoking bans

could reduce the incidence of heart attacks in the area of implementation. There are
several systematic reviews and meta-analysis that cover a range of studies, from small

studies in small towns to larger studies in a whole state (e.g. New York State) and country

(e.g. Italy). The Cochrane review included twelve studies reporting hospital admission

rates for acute myocardial infarction (AMI) or chest pain caused by heart disease. The

reduction in hospital admissions for such cardiac events after implementation of smoke-

free laws was consistent across the studies (Callinan, 2010).

A systematic review and meta-analysis on 11 studies in 2009 investigated the

relationship between public smoking bans and risk for hospital admission for AMI. This

review included studies from 10 geographic locations (five in the United States, one in

Canada, and four in Europe). The places ranged from small communities, to middle sized

towns, large cities and whole states or regions. The meta-analysis found that AMI risk

decreased by 17% comparing the AMI incidence before and after the ban went into force,

the incidence rate ratio (IRR) being 0.83 (95% CI: 0.75-0.92). The greater protective effect

was among younger persons and among non-smokers (Meyers 20019).

A mathematical simulation study from India attempted to quantify the effects of

various tobacco control measures, including a ban on public smoking, tobacco tax

increases, and pharmacological treatment of tobacco dependence on myocardial

infarction and stroke over the next ten years. Smoke-free laws and tobacco taxation

appeared to be the most effective strategies from the population point of view in

preventing deaths from myocardial infarction and stroke. This model assumed a rather

low level of access to health care as per the current situation in the country (Basu 2013).

For the state of Gujarat in India (over 50 million population), a mathematical model

estimated that a complete public smoking ban would be more cost effective in terms of
lives saved due to acute cardiovascular events and costs averted than a partial one, as

is now in place, with the current law of 2008. While the cost of implementing the partial

ban was $US 59 036 and the cost of implementing the total ban would be about $US 4

million, with a complete public smoking ban, around 17 000 cases of AMI could be

avoided and the government of Gujarat could have a net savings of $US 36 million in

medical treatment costs for heart disease (Donaldson 2011).

A health impact assessment was conducted prior to the implementation of smoke-

free public places legislation in Hungary to map the impact of this policy on disease

burden. It was found that smoke-free policies would have an unambiguously positive

public health impact, particularly as Hungary has such a high burden of tobacco-related

diseases. Specifically, it was estimated that prohibition of smoking in public places would

lead to about 1700 deaths postponed and 16 000 life years saved annually. The expected

decrease in exposure to second-hand smoke was predicted to have a stronger

contribution than just the reduction in smoking prevalence. Reduction in exposure to SHS

would lead to quantifiable reductions in four diseases: coronary heart diseases, stroke,

chronic pulmonary diseases, and lung cancer. More immediate effects were predicted for

the first three diseases, with reductions in lung cancer seen after about a 15-20 year lag

time (Adam 2012).

A number of studies from various regions, particularly in North America and

Europe, have shown that implementation of 100% smoke-free legislation has led to

significant improvement in respiratory symptoms within populations. In Norway, a study

evaluated the effect of a total ban on indoor smoking on hospitality workers. A significant

decrease in respiratory symptoms was found five months after enactment of the ban (18).
In a study of 42 bars in Ireland, statistically significant improvements in lung function were

found in nonsmoking barmen one year after the ban (Eagan 2006).

A study among bar and restaurant workers in the city of Neuquén, Argentina (which

adopted sub-national smoke-free legislation in 2007), also showed that, consistent with

the other studies, smoke-free legislation led to substantial and immediate reduction of

respiratory symptoms (from pre-ban level of 57.5% to a post-ban level of 28.8%). There

was also significant reduction in sensory irritation symptoms as well as significant

improvement in the respiratory function of study participants as measured by spirometry

(Schoj 2010).

A systematic review and meta-analysis of the effect of smoke-free legislation on

child health (the first one ever conducted), was published in the Lancet in 2014.

Researchers combined the results of 11 studies from Europe and North America

published between 2008 and 2013 involving more than 2.5 million births and almost

250,000 cases of asthma exacerbations in children. After the results of the studies were

pooled in a meta-analysis, it was found that hospital visits for childhood asthma and

premature births both declined about 10% in the year after smoking bans took effect in

each of the jurisdictions covered by the study (Been 2014).

Researchers concluded that smoke free legislation was associated with a 10%

reduction in the relative risk of preterm birth (-10.4%, 95% Confidence Interval [CI] -18.8

to -2.0) and with a 10% reduction in the relative risk of hospital attendances for childhood

asthma (-10.1%, 95% CI -15.2 to -5.0). According to the researchers, when considered

along with the health benefits shown in adults, this study provides strong support for the

implementation of smoke free polices in line with the WHO FCTC (Been 2014).
 Lopez and colleagues described the different patterns of diffusion of cigarette

smoking across world cultures, noting the early adoption of Western high-income

countries and the slower adoption in many lower-income and middle-income countries.

The three groups of countries are worth noting. Countries in Western Europe, North

America and Australasia were early adopters of smoking, and experienced a rapid

increase to a high per-capita cigarette consumption in the beginning of the 20th century

that peaked in the 1960s (Lopez, et al 1994).

Since the start of tobacco control programmes, these countries have experienced

dramatic declines (over 70% in the USA) from that peak consumption. It shows that in

2006, male smoking prevalence in these countries was generally in the 21% to 30%

category, considerably below those with the highest smoking prevalence such as the

Russian Federation, Greece and Indonesia. Similarly for women, smoking prevalence in

these early adopter countries has declined to the 10% to 20% level.

A second large group of countries (eg, China, Malaysia and Thailand) has a low

female smoking prevalence, which is in stark contrast to the male smoking prevalence.

Hitchman and Fong have noted that many countries in this group have low levels of

female gender empowerment (measured by participation in economics and politics

including decision-making roles). The tobacco industry has a history of adeptly linking

cigarette smoking to the female empowerment movement that occurred in earlier years

in high-income countries. There appears to be a third small group (eg, Ghana, Ethiopia)

where cigarette smoking may have never been a common behaviour for either gender

(Hitchman et al 2011).
 Starting in the 1980s, tobacco companies have launched programmes in at least

26 countries ostensibly to prevent smoking initiation among the school-aged population.

However, internal documents show that tobacco industry leaders viewed such initiatives

as a way to prevent or delay legislation, regulation, or even threatened litigation. In

addition, by controlling the prevention intervention, the tobacco industry could ensure that

more effective strategies were suppressed. In 1990, Philip Morris was temporarily

successful in convincing the California Department of Education to distribute a tobacco

industry sponsored ‘anti-smoking’ set of materials to schools (Landman 2002).

There is substantial literature on interventions aimed at reducing smoking initiation,

mainly from high-income countries. These interventions include school programmes,

increasing price through excise tax increases, large graphic warning labels on packages,

restricting the tobacco industry's ability to advertise, tobacco control mass media

programmers, smoke-free policies and restricting the ability of minors from purchasing

tobacco products. It is important to note that the effectiveness of an overall approach is

more than the sum of the effectiveness of the independent strategies. In Australia and

California comprehensive community-wide programmers using multiple strategies have

documented large declines in smoking initiation. The key goal of such programmers is

the denormalization of tobacco in the entire community (Bal 1990).

Warning labels on cigarette packs, which were introduced in the USA in 1966, are

often one of the first tobacco control initiatives. Whereas obscure text-only warnings

appear to have little impact, recently implemented prominent graphic health warnings on

packages have been demonstrated to serve as a key source of health information for

smokers and non-smokers, increasing health knowledge and perceptions of

risk. Prominent pictorial warning labels have been found to lower smoking intentions

among adolescent smokers and non-smokers (White 2008).

Australia is the first country to attempt to counter the tobacco industry's package

advertising and require that cigarette packages do not include any tobacco marketing (ie,

plain packaging). Formative research on plain packaging among Australian youth found

that they would be less likely to purchase the product and more likely to take the health

warnings seriously. Should the Australian government successfully defend its new law in

2012, this will result in a major demonstration project that will be carefully followed by the

tobacco industry and tobacco control advocates across the world (Germain 2010).

Price elasticity refers to the relationship between price and demand for a particular

consumer product. In the context of adolescent smoking, there is significant literature on

the price elasticity of youth demand for cigarettes. Key studies in the early years of USA

tobacco control interventions estimated that price elasticity of adolescent demand for

cigarettes was −1.44; in other words, for every US$0.10 increase in the price/pack of

cigarettes, youth smoking declines by approximately 14%. While the price of cigarettes

does not appear to influence whether or not an adolescent experiment with

cigarettes, there is strong evidence that price matters once teens progress as far as

buying their own cigarettes (Chaloupka 1996).

However, many USA states dramatically increased state cigarette taxes after 1999

and some recent studies have not found this price increase associated with the expected

high adolescent elasticity. Nonnemaker et al (2011) found a significant but smaller effect

of tax and price on youth smoking initiation. In this study, higher price responsiveness

among minorities explained a lot of the price elasticity. It may be that price elasticity is
influenced by the number of tobacco control strategies implemented in the community. A

recent European study examined the influence of price along with several other tobacco

control policies on smoking participation and did not find the expected association

between increased price and lower smoking. However such a study is an outlier in the

literature. A recent Australian study found that increases in the price of cigarettes over a

12-month period were associated with lower likelihood of smoking after adjusting for other

policy factors including point-of-sale advertising restrictions, clean indoor air laws and

tobacco control funding.

he health consequences of SHS became evident in the 1980s and, in 1992, the

Environmental Protection Agency of the USA categorised SHS as a class A

carcinogen.59 Local jurisdictions in the USA responded by increasing the number of laws

and ordinances requiring smoke-free workplaces and in 1994, California passed a state

law. Evidence of the effectiveness of this policy in reducing SHS exposure led to its

inclusion in the unprecedented WHO treaty, the Framework Convention for Tobacco

Control (FCTC). As a result of this treaty, smoke-free laws are expected to increase

significantly over the next few years. The introduction of strong smoke-free regulations in

public spaces such as restaurants and cafes contributes to the denormalisation of

tobacco in a community, and reduces the likelihood of an adolescent becoming a regular

smoker. The implementation of smoke-free workplace and public space laws has been

associated with the voluntary adoption of smoke-free homes, which has resulted in

increased protection of children from exposure to SHS. There are numerous cross-

sectional surveys that have demonstrated the association between smoke-free homes
and lower initiation rates among teens although these results are awaiting confirmation in

ongoing longitudinal studies (Hamilton 2008).

Perhaps the most controversial intervention to reduce smoking initiation are

policies focused on restricting adolescents' access to purchase cigarettes.24 Many

USA states had laws dating back to the early 20th century (mostly not enforced)

that limited purchase of cigarettes to people over the age of 18 years. The

California experience has demonstrated that, as cigarette smoking becomes

increasingly denormalised, adults are more likely to express opinions that

enforcement of sales to minors laws are inadequate. However, adolescent

smokers are adept at ensuring that these laws do not limit their ability to obtain

cigarettes by knowing which stores have lax monitoring or by paying older teens

to purchase for them. Indeed, most experimenters and occasional smokers obtain

their cigarettes from social sources. While these laws may not influence an

adolescent's ability to obtain cigarettes, significant declines in the proportion of

never smokers who thought it was easy to get cigarettes was associated with

enforcement of the laws (Al-Delaimy 2008).

Local Literature

Most people know that smoking is bad for their health. But do they really

understand how dangerous smoking really is? Tobacco contains nicotine, a highly

addictive drug that makes it difficult for the smokers to kick the habit. Tobacco products

also contain many poisonous and harmful substances that cause disease and premature

death (Harry 2005).

 On the other hand, smokers often say that smoking keeps them alert and calm and

it adds concentration. Some researchers assert that tobacco’s calming effects simply

result from alleviation of the nicotine withdrawal syndrome (New Book of Knowledge,

2006).

In 2003, the Philippines enacted a smoke free law that restricts smoking in

enclosed public places and work places. Smoking areas are permitted in most public

places other than health care and educational facilities. In July 2011, Manila implemented

a smoke free ordinance for schools, gyms, parks, hospitals, elevators and stairwells, of

all buildings, buses and bus depots, restaurants, and government facilities. The city of

Las Piñas adopted a smoke free ordinance that covers government workplaces and many

public places. The local ordinance is stronger than the national law, but still exempts many

private workplaces and all hospitality establishments (Rillorta, 2011).

The City Government has to protect our environment and protect our children, our

youth, our women, the unborn and our constituents from the pernicious effects of tobacco,

cigarettes or their derivatives which has been proven to produce cancer (Ordinance NO.

1S. 2012).

The local government of Batangas City share the same view about the alarming

and disastrous effects of smoking on health, therefore, the Sangguniang Panglungsod

created an ordinance called “The AntiSmoking Ordinance of 2012” or the No Smoking

Ordinance No. 1S.2012 with its noble objectives to promote the health and safety of our

people, particularly the protection of youth, children and the unborn from the hazard of

the cancer-producing habit of smokers. This Ordinance of Batangas City shall take effect

fifteen (15) days after its complete publication in a newspaper of general circulation and
compliance with he posting required by Republic Act 7160. This ordinance was enacted

by SangguniangPanlungsod of Batangas City on 28th day of February 2012 and

approved on March 8, 2012 by Mayor Vilma A. Dimacuha (Ordinance NO. 1S. 2012).
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