Smoking bans more effective on women than men – Study

Macau’s smoking bans “did not successfully achieve their health goals” among the male population.

The authors of the first study that analyses ten years of “strict total smoking bans” in Macau (2012-2022) begin with evidence: during the past decade, smoking rates among Macau women have dropped by half.

To reach this conclusion, they evaluated the link between smoking rates and mortality from circulatory system diseases (CSD), not only in this decade of smoking bans in Macau but also from 2001.

It is true that CSD mortalities in general also show a declining trend, but there remains a mystery to solve: why aren’t men as responsive to these efforts as women, given that smoking rates are the most important factor affecting CSD mortality among the Macau population?

Another datum that the four authors bring to the discussion: while the population smoking rate was an average of 15 per cent during the study period, the smoking rate was as high as 33 per cent among men, in contrast to about 2 per cent among women in Macau.

However, the smoking rate “consistently remains the primary factor among Macau’s female population. Each year, on average 5 CSD-caused deaths were avoided among every 100,000 women, equivalent to about 11.45 per cent of the mean annual CSD mortality.”

Therefore, if women in Macau “may have obtained substantial health benefits from smoking bans, while men had few,” there must be an explanation: according to Peng, Tang, Zhang, and Chen, “two major reasons for this difference may be considered. First, women may have directly benefited from their own smoking cessation encouraged and supported by public health policies, as evidenced by a significantly lower smoking rate following the smoking bans.” Second, the authors added, “after full smoking bans in the local community, women usually have extra health benefits from less exposure to second-hand smoke (SHS). In particular, decreased exposure to SHS among non-smokers may result in a decrease in myocardial infarctions.”

Faced with the facts, the four authors of the study (Macao University of Science and Technology and the University of Macau) have no choice but to verify that “Macau’s smoking bans did not successfully achieve their health goals among the male population.”

They remember that the full smoking ban in Macau’s casinos “was expected to help many casino workers quit smoking.” They quote a casino employee survey in 2008 (before the implementation of the initial smoking ban in Macau), with more than half of the respondents (52.4 per cent) reported that they would try to quit smoking if smoking was outlawed at work.

“Nevertheless, despite the eventual implementation of the smoking ban, the men’s smoking rate in Macau did not significantly decline, and the associated mortality could not be avoided,” the paper reads.

(In addition, the findings of this study also reveal that alcohol use may be among the leading risk factors for CSD mortality among men in Macau.)

“Nevertheless, despite the eventual implementation of the smoking ban, the men’s smoking rate in Macau did not significantly decline and the associated mortality could not be avoided” – Study

That’s why the four authors understand that “the findings of this study have significant public health policy implications for Macau. Although smoking bans have been successfully implemented in the city’s casinos, Macau nevertheless needs to focus on reducing the male smoking rate and promoting a healthy lifestyle.”

So, they recommend that mainland China and other emerging economies with high smoking rates “adopt total smoking bans and strong legal enforcement. Additional steps, including health education and cessation support services, should be taken to further realize smoking rate reduction in high-risk population groups.”

“Despite strong resistance from the gaming industry…”

Since more than twenty percent of Macau’s working population is in the gaming industry, “which is infamous for heavy smoking and poor indoor air quality,” it was estimated that, when there were no smoking bans, each year, 20 percent of local deaths were caused by smoking.

“Despite strong resistance from the gaming industry, during the past decade,” the Macau government has put “significant efforts into establishing a smoke-free local environment through a variety of approaches, including legislation, law enforcement, health education, and smoking cessation aid.”

As the authors pointed out, smoking bans were phased in from 2012 “to ensure that indoor air quality meets safety standards, protecting the health of residents and visitors alike.” A partial ban with casinos as the exception in January of 2012, a full smoking ban allowing smoking lounges in local casinos in October 2014, and later “a blanket smoking ban without smoking lounges after 2018” were implemented in Macau. “Virtually all forms of tobacco advertising and promotion through any medium are prohibited,” Peng, Tang, Zhang, and Chen also wrote.

In August 2022, an amendment to the smoking ban was passed in Macau, prohibiting the manufacturing, transporting, distribution, importing, or exporting of e-cigarettes in and out of Macau. The retail sale, advertising, or promotion of e-cigarettes is also prohibited.

“The Macau government has demonstrated firm determination and action to enforce these smoking bans,” according to these researchers. From 2018 to 2020, tobacco control law enforcement officers of Macau inspected a total of 859,000 locations, and the total number of prosecutions for smoking ban offenses reached 13,300. They also quote that the maximum fine for smoking offenses was raised from USD 75 equivalent to USD 188.

(Peng, X.; Tang, X.; Zhang, J.H.; Chen, Y. Smoking Bans and Circulatory System Disease Mortality Reduction in Macau (China): Using GRA Models. Int. J. Environ. Res. Public Health 2023, 20, 4516.