Factsheet 2. Smokefree policies

Key Facts

• There is no safe level of exposure to secondhand smoke
• Comprehensive smokefree policies improve health, motivate smokers to quit, and help reduce tobacco consumption.
• Only 5% of the world’s population is protected by comprehensive smokefree legislation.
• Smokefree policies are popular with the public.

What is a smokefree policy?
A smokefree policy prohibits smoking in a certain area. It is usually supported by legislation, with penalties for non-compliance. A comprehensive smokefree policy prohibits smoking in the following areas: workplaces, public places, public transport, bars and restaurants. Its effectiveness is weakened if designated smoking rooms are allowed.^{(1) (2)}

The need for smokefree policies
There is no safe level of exposure to secondhand smoke.⁽³⁾ In places with secondhand smoke, people are exposed to significant levels of pollution, including carbon monoxide. Studies have shown that pollution levels in indoor places that allow smoking are higher than levels found in busy roadways, closed motor garages and during firestorms.⁽⁴⁾

Passive smoking causes a number of diseases including lung cancer, coronary heart disease and cardiac death. In children it causes Sudden Infant Death Syndrome, middle ear infections, acute lower respiratory tract infections, and exacerbation of asthma. The greater the risk of exposure to secondhand smoke, the greater the risk of most diseases.

Although a growing number of countries have introduced smokefree legislation, the vast majority of countries have no smokefree laws, very limited laws or ineffective enforcement of laws. Approximately 40% of countries do not protect children from secondhand smoke at school. More than half of countries worldwide allow smoking in government offices, workplaces and other indoor places. Only 9% of low-and middle-income countries have smokefree restaurants, compared with 29% of high-income countries. Only 5% of the world’s population (16 countries) is currently protected by comprehensive smokefree legislation.⁽²⁾

Examples of improved health

• Smokefree policies improve health, as shown in the following examples:
• Reductions in hospital admissions for myocardial infarctions after the introduction of smokefree legislation have been observed in Scotland, Italy and the USA. ^{(5) (6) (7) (8) (9)}
• Studies showed that smokefree legislation has reduced the exposure of non-smokers to secondhand smoke.10 There was no evidence of increased exposure to secondhand smoke among young people because of increased parental smoking at home.⁽¹¹⁾
• Improvements in bar workers’ health have been observed in Ireland,^{(12) (13)} California,⁽¹⁴⁾ New York⁽¹⁵⁾ and Scotland⁽¹⁶⁾ after introduction of smokefree legislation.
• The rates of lung and bronchial cancer in California declined six times faster from 1988 to 1998 than in other US states without smokefree laws.⁽¹⁷⁾

Other benefits of smokefree policies

• Smokefree workplaces help to motivate smokers to quit and motivate people who have quit to remain non–smokers.⁽¹⁸⁾ Smoking prevalence can be cut by 4%.⁽¹⁹⁾
• They also help to reduce tobacco consumption. The World Bank estimates that smoking restrictions reduce overall tobacco consumption by an estimated 4-10%.20 Smokefree workplaces may
  reduce overall tobacco consumption by as much as 29%. The number of cigarettes smoked by people who continue to smoke is also likely to fall.⁽¹⁸⁾
• They reduce overall tobacco sales, as has occurred in Ireland,⁽²¹⁾ Norway⁽²²⁾ and Italy.⁽²³⁾
• Children are less exposed to secondhand smoke when fewer adults smoke.⁽²⁴⁾
• Smokefree policies may lead to an increase in the number of smokefree homes.^{(2) (25) (26)}
• Smokefree policies have either a neutral or positive impact on business.
• Smokefree legislation is very popular wherever it is enacted, and
  compliance is high.^{(27) (28)} Support for smokefree legislation tends to increase after implementation.

In its recently published MPOWER package, WHO recommends that a step by step process is used to create smokefree environments⁽²⁾ : (1) educate the public and businesses about the dangers of secondhand smoke; (2) after building widespread support for smokefree public places, draft legislation for public comment; (3) pass comprehensive smokefree legislation; (4) Once enacted, maintain strong support for the law by uniform and aggressive enforcement that generates high levels of compliance.
It recommends emphasising that the main purpose of smokefree workplaces is to protect workers’ health. It also stresses that countering false arguments by the tobacco industry is crucial to gaining support for smokefree legislation.

Best practice - the FCTC Article 8 guidelines
Article 8 of The WHO Framework Convention on Tobacco Control (FCTC) covers measures to protect people from exposure to secondhand smoke.29 In July 2007, the draft Article 8 Guidelines were adopted with unanimous support from all parties to the FCTC. The key principles of the guidelines are as follows⁽³⁰⁾ :

• Effective measures to protect against exposure to secondhand smoke require the total elimination of smoking and tobacco smoke in a particular space or environment.
• Ventilation or designated smoking rooms do not offer protection.
• All people should be protected from exposure to secondhand smoke. All indoor workplaces, indoor public places and public transport should be smokefree.
• Legislation is needed to protect people from secondhand smoke. Voluntary agreements are ineffective.
• Good planning and adequate resources are needed for implementation and enforcement of legislation.
• Civil society should be an active partner in developing, implementing and enforcing smokefree legislation.
• Smokefree legislation should be monitored and evaluated, to assess its impact and build support for the most effective possible measures.
• The protection of people from secondhand smoke should be strengthened and expanded if needed. This may require new or amended legislation or improved enforcement measures.

The need for care when defining key terms such as ‘secondhand smoke’, ‘smoking’, ‘indoor’ and ‘enclosed’ is also stressed.

For more information visit The WHO Tobacco Free Initiative http://www.who.int/tobacco/en/,
The Global Smokefree Partnership at http://www.globalsmokefreepartnership.org and
The Union at http://www.theunion.org http://www.tobaccofreeunion.org tobaccofreeunion@theunion.org

⁽¹⁾ Global voices. Working for smokefree air: 2008 Status report. Global Smokefree Partnership. http://www.globalsmokefreepartnership.org
⁽²⁾ WHO report on the global tobacco epidemic, 2008. The MPOWER packgage. Geneva, World Health Organization, 2008. http://www.who.int/tobacco/mpower/en/index.html
⁽³⁾ The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: Dept of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; Washington, DC: 2006. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2006/ and at http://www.surgeongeneral.gov
⁽⁴⁾ Invernizzi G, Ruprecht A, Mazza R, Rossetti E, Sasco A, Nardini S, et al. Particulate matter from tobacco versus diesel car exhaust: an educational perspective. Tobacco Control 2004;13:219-21. http://tc.bmjjournals.com/cgi/content/abstract/13/3/219?etoc(abstract)
⁽⁵⁾ http://www.scotland.gov.uk/News/Releases/2007/09/10081400
⁽⁶⁾ http://society.guardian.co.uk/health/news/0,,2166561,00.html
⁽⁷⁾ http://society.guardian.co.uk/health/news/0,,2166561,00.html
⁽⁸⁾ Barone-Adesi F et al. Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. Eur Heart J 2006 ;27:2468-72
⁽⁹⁾ Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004; 328:977-80.
⁽¹⁰⁾ Haw S, Gruer L. Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey. BMJ 2007;335:549. http://www.bmj.com/cgi/content/abstract/335/7619/549
⁽¹¹⁾ Akhtar P, Currie D, Currie C, Haw S. Changes in child exposure to environmental tobacco smoke (CHETS) study after implementation of smoke-free legislation in Scotland: national cross sectional survey. BMJ 2007;335:545. http://www.bmj.com/cgi/content/full/335/7619/545
⁽¹²⁾ Mulcahy M, Evans DS, Hammond SK, Repace JL, Byrne M. Secondhand smoke exposure and risk following the Irish smoking ban: an assessment of salivary cotinine concentrations in hotel workers and air nicotine levels in bars. Tob Control 2005;14:384-8
⁽¹³⁾ Allwright S, Paul G, Greiner B, Mullally BJ, Pursell L, Kelly A et al. Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study. BMJ 2005;331:1117 http://www.bmj.com/cgi/content/abstract/331/7525/1117
⁽¹⁴⁾ Eisner M, Smith A, Blanc P. Bartenders’ respiratory health after establishment of smoke-free bars and taverns. JAMA 1998;280:1909-14. http://jama.ama-assn.org/content/vol280/issue22/index.dtl
⁽¹⁵⁾ Farrelly M, Nonnemaker J, Chou R, Hyland A, Peterson K, Bauer U. Changes in hospitality workers’ exposure to secondhand smoke following the implementation of New York’s smoke-free law. Tobacco Control 2005;14:236-241. http://tobaccocontrol.bmj.com/cgi/content/abstract/14/4/236 (abstract)
⁽¹⁶⁾ Semple S, Maccalman L, Naji A, Dempsey S, Hilton S, Miller B, Ayers J. Bar workers’ exposure to second-hand smoke: the effect of Scottish smoke-free legislation on occupational exposure. Annals of Occupational Hygiene 2007. Published online on 10 September 2007 as doi:10.1093/annhyg/mem044. http://annhyg.oxfordjournals.org/cgi/content/abstract/mem044v1 (abstract)
⁽¹⁷⁾ California Department of Health Services, Tobacco Control Section. California tobacco control update. California Department of Health Services; 2002. http://www.dhs.ca.gov/tobacco/documents/pubs/TCSupdate.pdf
⁽¹⁸⁾ Longo DR, Johnson JC, Kruse RL, Brownson RC, Hewett JE. A prospective investigation of the impact of smoking bans on tobacco cessation and relapse. Tob Control 2001;10:267-72. http://tobaccocontrol.bmj.com/cgi/content/abstract/10/3/267 (abstract)
⁽¹⁹⁾ Fichtenberg C, Glantz S. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ 2002;325:188. http://www.bmj.com/cgi/content/full/325/7357/188
⁽²⁰⁾ Curbing the epidemic. Governments and the economics of tobacco control. Washington, DC: The World Bank, 1999. http://www1.worldbank.org/tobacco/reports.htm
⁽²¹⁾ http://www.rte.ie/news/2004/0909/smoking.html
⁽²²⁾ http://www.euromonitor.com/Tobacco_in_Norway
⁽²³⁾ http://news.bbc.co.uk/1/hi/business/4195249.stm
⁽²⁴⁾ Jarvis MJ, Goddard E, Higgins V, Feyerabent C, Bryant A, Cook DG. Children’s exposure to passive smoking in England since the 1980s: cotinine evidence from population survey. BMJ 2000;321:343-5. http://www.bmj.com/cgi/content/full/321/7257/343
⁽²⁵⁾ Borland R, Mullins R, Trotter L, White V. Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia. Tob Control 1999;8:266-71. http://tobaccocontrol.bmj.com/cgi/content/abstract/8/3/266 (abstract)
⁽²⁶⁾ After the smoke has cleared: evaluation of the impact of a new smokefree law. Wellington, Ministry of Health, 2006. http://www.hpac.govt.nz/moh.nsf/UnidPrint/MH5599?OpenDocument#information
⁽²⁷⁾ Borland R, Yong HH, Siahpush M, Hyland A, Campbell S, Hastings G, Cummings KM, Fong GT. Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control 2006;15 Suppl 3:iii34-41.
⁽²⁸⁾ Pan American Health Organization. Conocimiento y actitudes hacia el decreto 288/005. October 2006. http://www.presidencia.gub.uy/_web/noticias/2006/12/informeo_dec268_mori.pdf
⁽²⁹⁾ The Framework Convention Alliance for Tobacco Control. http://www.fctc.org
⁽³⁰⁾ First report of Committee A. Conference of the parties to the WHO Framework Convention on Tobacco Control. Second session. 4 July 2007. http://www.who.int/gb/fctc/PDF/cop2/FCTC_COP2_17P-en.pdf