Assessment of the smoke-free outdoor regulation in the WHO European Region

doi:10.1016/j.ypmed.2014.03.020

Preventive Medicine

Volume 64, July 2014, Pages 37-40

https://doi.org/10.1016/j.ypmed.2014.03.020 Get rights and content

Highlights

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First study to assess outdoor smoke-free legislation in the WHO European Region.
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The majority of laws fail to implement smoke-free outdoor areas.
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Few countries are early adopters in passing outdoor smoke-free policies.
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Legislation provides little protection for the public in most outdoor areas.
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The education sector is the highest protected from outdoor secondhand smoke.

Abstract

Objective

The aim of this study is to assess the level of protection of secondhand smoke in outdoor locations among countries belonging to the WHO European Region.

Method

This cross-sectional study measures the level of protection provided by laws in outdoor locations. A protocol to evaluate the outdoor smoke-free legislation was developed according to the recommendations provided by the WHO Guidelines for implementing smoke-free outdoor places. For each law 6 main sectors and 28 outdoor locations were evaluated.

Results

68 laws from 48 countries were reviewed, totally assessing 1758 locations. Overall 3.1% of the locations specified 100% smoke-free outdoor regulation without exceptions, 2.5% permitted smoking in designated outdoor areas, 37.5% allowed smoking everywhere, and 56.9% did not provide information about how to deal with smoking in outdoor places. In the Education sector 17.8% of the laws specified smoke-free outdoor regulation, mainly in the primary and secondary schools. Three pioneering laws from recreational locations and two from general health facilities specified 100% outdoor smoke-free regulation.

Conclusion

Outdoor smoke-free policies among countries belonging to the WHO European Region are limited and mainly have been passed in the primary and secondary schools, which protect minors from the hazards of secondhand smoke in educational settings.

Introduction

There is no safe level of exposure from secondhand smoke (SHS), which has been proven to cause death, disease and disability (IARC Working Group, 2009). The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) addresses SHS protection in Article 8 (WHO, 2007). In 2007, the guidelines for implementing Article 8 recommended adopting smoke-free legislation ‘wherever the evidence shows that hazard exists’ including quasi-outdoor and outdoor places (WHO, 2007).

Most studies report the existence of high SHS levels in outdoor and in entrances of smoke-free indoor areas where smoking is prohibited, although SHS levels could differ depending on atmospheric and structural conditions (Sureda et al., 2013). Current evidence on the impact of SHS outdoor exposure in health includes the increase of risk of respiratory symptoms (Balmes et al., 2014) and the increase of clinical exacerbations (Barnett et al., 2005). Regardless of the lack of complete evidence on the health effects, outdoor smoke-free legislation could have other beneficial effects such as decreasing youth initiation, trigger quit attempts, reducing smoking, and denormalizing its consumption in our society (Chapman, 2008, Thomson et al., 2009, Zablocki et al., 2014). Policy improvements occur when local innovations are advanced to a national level, increasing their coverage, setting a common social norm, and decreasing confusion about the policy (Francis et al., 2010). Several jurisdictions have passed smoke-free restrictions in outdoor spaces at the province, state or national level (Globalsmokefree Partnership, 2009, Hyland et al., 2012, IARC Working Group, 2009). While in the United States, Canada, and Australia early progress in smoke-free legislation occurred primarily at the local level (Americans for Nonsmokers' Rights, 2004), smoke-free laws in Europe have been introduced through passing nation-wide laws (Martinez et al., 2013).

Most WHO European Region countries have passed national indoor smoking bans (Britton and Bogdanovica, 2013), however there are no systematic evaluations of outdoor smoke-free legislation in this region. This study assessed outdoor smoke-free legislation in the WHO European Region countries, according to the FCTC Article 8 Guidelines for implementation (WHO, 2007).

Section snippets

Methods

We conducted a cross-sectional study of smoke-free legislation in the WHO European Region countries. Using procedures previously reported (Martinez et al., 2013) we collected and analyzed national/regional smoke-free laws in force from July to October 2011 and available in English, German, Portuguese or Spanish. The laws were retrieved through three different sources: 1) legal database of the Tobacco Free Initiative at WHO, 2) the database of the European Network for Smoke-free Prevention

Results

We assessed 1758 outdoor locations from the 66 laws obtained. From all the locations, 3.1% (95% CI: 2.4–4.0) had 100% smoke-free outdoor regulations without exception, 2.5% (95% CI: 1.9–3.3) permitted smoking in designated outdoor areas, 37.5% (95% CI: 35.3–39.8) allowed smoking everywhere, and 56.9% (95% CI: 54.6–59.2) did not provide information about outdoor smoking.

Table 1 summarizes the percentages of the four possible outdoor smoking regulations by the 28 locations. In the Health & Social

Discussion

This is the first systematic study of outdoor smoke-free legislation in the WHO European Region countries. Previous studies have shown that non-smokers are exposed to SHS in outdoor areas where smoking is allowed (Licht et al., 2013, Sureda et al., 2013), and that SHS concentration is higher in outdoor locations such as bus stops, stadiums, bars and restaurants. In addition, when smoking is allowed in entrance areas, smoke-free indoor locations have high levels of SHS (Licht et al., 2013,

Contribution statement

C Martinez and J Guydish conceptualized this study and led the manuscript. C Martinez and G Robinson conducted the assessment of the laws. J Martinez executed the analysis, and participated in the data interpretation. All authors read and commented the final version of this manuscript.

Funding

C Martinez was supported by the Spanish Government through the BAE Grant (BA12/00074) to conduct a postdoctoral research stay at the University of California San Francisco. This work was also supported by the National Institute on Drug Abuse (P50 DA 009253) and by the California Tobacco Related Disease Research Program (21T-0088). CM, JMMS and EF received support from Instituto de Salud Carlos III (RD12/0036/0053 and PI1102054) and Directorate of Universities and Research, Government of

Conflict of interest statement

None of the authors have any connection with the tobacco, alcohol, pharmaceutical or gaming industries or anybody substantially funded by one of these organizations.

Acknowledgments

The authors would like to especially thank Christina Bethker (Independent layer) for helping in the assessment process of the German laws, and Armando Peruga (Chair of the TFI at WHO) for providing expert counselling during the conceptual and assessment work on this research and facilitating access to the data. In addition, the authors express their gratitude to the European Network for Smoking Prevention members for their contribution in facilitating information.

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Cited by (22)

Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis
2021, The Lancet Public Health
Citation Excerpt :
No eligible studies assessing policies for private homes, outdoor hospital grounds, or parks were identified, even though these policies could potentially have a great impact on children's health. Several studies have found that such policies can decrease TSE among adults, and cross-sectional studies have also supported the potential health benefits of these policies in children.42,64–68 We did not identify any study exploring the differential effects of novel smoke-free policies in low-income countries.
Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy.
In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before–after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563.
We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55–0·87; 161 466 participants); heterogeneity was substantial (I² 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy.
Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health.
Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.
Second-hand tobacco exposure in children: evidence for action
2021, The Lancet Public Health
Secondhand smoke exposure in outdoor children's playgrounds in 11 European countries
2021, Environment International
Citation Excerpt :
These tobacco leftovers contain toxins and carcinogenic substances, posing a potential hazard for children, who might play with or even swallow cigarette butts (Moriwaki et al., 2009; Novotny et al., 2011). Although progress on adopting smoke-free legislation in most European countries has been made after the World Health Organization (WHO) Framework Convention on Tobacco Control, outdoor smoke-free regulations continue to be limited, at least in the WHO European region (Martinez et al., 2014). Besides, even when national or local measures exist, legislation can be complex or not communicated sufficiently, via signposting or other means, making enforcement and compliance a challenge.
Tobacco presence in outdoor children’s playgrounds is concerning not only because it leads to secondhand smoke (SHS) exposure, but also cigarette butt pollution and tobacco normalization.
This study aimed to assess SHS exposure in children’s playgrounds, according to area-level socioeconomic status (SES), smoke-free regulations, national smoking prevalence, and SHS exposure prevalence in playgrounds (2017–2018).
We monitored vapor-phase nicotine concentration and tobacco-related variables in 20 different playgrounds in 11 European countries (n = 220 measurements) from March 2017 to April 2018. Playgrounds were selected according to area-level SES. Data on the number of people smoking, and cigarette butts inside the playground and on playground surroundings (<1 m away) were recorded. Playground smoking bans, the Tobacco Control Scale (TCS) score, national smoking prevalence and SHS exposure prevalence in playgrounds were used to group countries. To determine nicotine presence, we dichotomized concentrations using the limit of quantification as a cut-off point (0.06 μg/m³). Nicotine median concentrations were compared using non-parametric tests, and nicotine presence and tobacco-related observational variables using the Chi-squared test.
Airborne nicotine presence was found in 40.6% of the playgrounds. Median nicotine concentration was <0.06 μg/m³ (Interquartile range: <0.06–0.125) and higher median concentrations were found in more deprived neighborhoods, non-regulated playgrounds, in countries with lower overall TCS scores, higher national smoking prevalence and higher SHS exposure prevalence in playgrounds. Overall, people were smoking in 19.6% of the playgrounds. More than half of playgrounds had cigarette butts visible inside (56.6%) and in the immediate vicinity (74.4%). Presence of butts inside playgrounds was higher in sites from a low area-level SES, in countries with low TCS scores, and greater smoking prevalence and SHS exposure prevalence (p<0.05).
There is evidence of SHS exposure in children’s playgrounds across Europe. These findings confirm the need for smoking bans in playgrounds and better enforcement in those countries with smoking bans in playgrounds.
Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European countries
2020, Science of the Total Environment
Citation Excerpt :
We found disparities in SHS exposure according to European regions, SHS levels being higher in the Southern and Eastern regions. To date, there is a generalized lack of smoking bans for most outdoor areas in Europe (Martinez et al., 2014). Therefore, these results cannot be directly explained by the smoking restrictions adopted but could reflect the differences in the extent of coverage, the level of enforcement, or the later implementation of comprehensive smoke-free policies in countries in the Southern and Eastern regions.
Although smoking restrictions at child-related settings are progressively being adopted, school outdoor entrances are neglected in most smoke-free policies across Europe.
To describe secondhand smoke (SHS) exposure and tobacco-related signs in outdoor entrances of primary schools in Europe according to area-level socioeconomic status (SES), smoke-free policy, national smoking prevalence, and geographical region.
In this cross-sectional study we monitored vapor-phase nicotine concentrations at 220 school outdoor entrances in 11 European countries (March 2017–October 2018). To account for nicotine presence, we used the laboratory's limit of quantification of 0.06 μg/m³ as point threshold. We also recorded the presence of smell of smoke, people smoking, cigarette butts, and ashtrays. Half of the schools were in deprived areas. We grouped countries according to their Tobacco Control Scale (TCS) score, smoking prevalence (2017–2018), and United Nations M49 geographical region.
There were detectable levels of nicotine in 45.9% of the outdoor entrances, in 29.1% smell of smoke, in 43.2% people smoking, in 75.0% discarded butts, and in 14.6% ashtrays. Median nicotine concentration was below the laboratory's limit of quantification <0.06 μg/m³ (Interquartile range:<0.06–0.119). We found higher SHS levels in countries with lower TCS scores, higher national smoking prevalence, and in the Southern and Eastern European regions. People smoking were more common in schools from lower area-level SES and in countries with lower TCS scores (p<0.05).
Smoking at school outdoor entrances is a source of SHS exposure in Europe. These findings support the extension of smoking bans with a clear perimeter to the outdoor entrances of schools.
Enhancing implementation of smoke-free places: A comparative qualitative study across seven European cities
2020, Social Science and Medicine
Citation Excerpt :
Smoking bans have been implemented in most middle- and high-income countries at public places, the hospitality sector, workplaces as well as in schools (Eriksen et al., 2015; Mlinarić et al., 2018). The large majority of European Union (EU) member states remains at the level of indoor bans (Muilenburg et al., 2010; Martínez et al., 2014; Fu et al., 2016). The persistence of SF indoor settings with often partial designs, such as exceptional smoking rules and designated smoking areas, is not compatible with urban health objectives of the WHO European Healthy Cities Network initiative (Lawrence and Fudge, 2009; Lawrence, 2013; Farrington et al., 2015).
Advocacy, resources and intersubjective reasonable arguments are known as factors that contribute to smoke-free (SF) adoption and implementation in Chinese and Anglo-Saxon places. Less is known about how the implementation of smoking bans differs across European places. The aim of this qualitative comparative study is to identify and classify the SF policy implementation processes and types undertaken at the local level in seven European cities according to the views of local bureaucrats and sub-national stakeholders.
Semi-structured expert interviews (n = 56) with local decision makers and stakeholders were conducted as qualitative part of the comparative SILNE-R project in Belgium (Namur), Finland (Tampere), Germany (Hanover), the Republic of Ireland (Dublin), the Netherlands (Amersfoort), Italy (Latina), and Portugal (Coimbra). Qualitative interviews were analyzed using the framework analysis.
Implementation of SF environments predominantly focuses on indoor bans or youth-related settings. Progressive-hungry (Dublin), moderate-rational (Tampere), upper-saturated (Hanover, Amersfoort), and lower saturated (Namur, Coimbra, Latina) implementation types can be distinguished. These four types differ with regards to their engagement in enhancing SF places as well as along their level of perceived tobacco de-normalization and public smoking visibility. In all municipalities SF environments are adopted at national levels, but are differently implemented at the local level due national policy environments, enforcement strategies and the level of collaboration. Major mechanisms to expand SF regulations were found to be scientific evidence, public support, and the child protection frame. However, counter-mechanisms of closure occur if data on declining prevalence and new youth addiction trends trigger low prioritization.
This study found four SF implementation types two mechanisms of progressive expansion and defensive closure. Development and enhancement of smoking bans requires a suitable national policy environment and indirect national-level support of self-governed local initiatives. Future SF policies can be enhanced by laws pertaining to places frequented by minors.
Patient perceptions of tobacco control after smoke-free hospital grounds legislation: Multi-center cross-sectional study
2020, International Journal of Nursing Studies
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Thus, our study is the first quantitative study with a large and representative sample that explores inpatient perceptions towards tobacco control after the introduction of national legislation on smoke-free grounds in hospitals. Though other jurisdictions have passed such regulations (Shopik et al., 2012; Ripley-Moffitt et al., 2010; Kennedy et al., 2012), Spain is the first country to pass smoke-free hospital grounds regulation at the national level (Martinez et al., 2014). Therefore, this experience and the positive findings regarding its association with patient agreement with tobacco control policies should drive other countries to consider similar national-level legislation.
To examine patient perceptions of the role of health care providers in tobacco control and tobacco-related services they should provide after the introduction of national smoke-free hospital grounds legislation in Spain.
Multi-center cross-sectional study.
Thirteen hospitals in Barcelona province in 2014–2015.
A total of 1,047 adult hospital patients, with a stay ≥ 24 h were randomly selected.
We explored participants’ perceptions of the role of health professionals and hospitals in tobacco control by asking about their agreement with several statements after the introduction of national legislation on smoke-free hospital grounds: (i) health professionals “should set an example and not smoke” and “should provide smoking cessation support”; (ii) hospitals “should provide smoking cessation treatments” and are “role model organizations in compliance with the smoke-free legislation”, and (iii) “hospitalization is a perfect moment to quit smoking”. Responses were described overall and according to participant and hospital characteristics: patient sex and age, type of hospital unit, number of beds, and smoking prevalence among hospital staff.
The majority of participants considered that health professionals should be role models in tobacco cessation (75.3%), should provide smoking cessation support to patients (83.0%), and that hospitalization is a good opportunity for initiating an attempt to quit (71.5%). Inpatients admitted to general hospitals where smoking cessation was not given as part of their portfolio, with a low level of implementation in tobacco control, and who stayed in surgical units had higher expectations of receiving smoking cessation interventions.
Inpatients strongly support the role of hospitals and health professionals in tobacco control and expect to receive smoking cessation interventions during their hospital stay. Systematically providing smoking cessation services in hospitals may have a relevant impact on health outcomes among smokers and on health care system expenditures.

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Brief Original ReportAssessment of the smoke-free outdoor regulation in the WHO European Region

Highlights

Abstract

Objective

Method

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Contribution statement

Funding

Conflict of interest statement

Acknowledgments

Environ. Res.

Lancet

Med. Clin. (Barc.)

Public Health

Prev. Med.

Common Mistakes in Drafting Smokefree Indoor Air Ordinances 2012

Smokefree List, Maps, and Data 2013

Air pollution and child respiratory health: a case-crossover study in Australia and New Zealand

Am. J. Respir. Crit. Care Med.

Global perspective on tobacco control. Part II. The future of tobacco control: making smoking history?

Int. J. Tuberc. Lung Dis.

Policy-driven tobacco control

Tob. Control.

Attitudes towards the extension of smoking restrictions to selected outdoor areas in Italy

Tob. Control.

The Trend Toward Smokefree Outdoor Areas

The epidemics of smoking bans in Europe: contributions of Italy and Spain

Epidemiol. Prev.

Brief Original Report
Assessment of the smoke-free outdoor regulation in the WHO European Region