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Published in final edited form as: Prev Med. 2014 Apr 1;64:37–40. doi: 10.1016/j.ypmed.2014.03.020

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

Cristina Martínez 1,2,3,4, Joseph Guydish 2, Gillian Robinson 5, Jose María Martínez-Sánchez 1,3,4, Esteve Fernández 1,3,7
PMCID: PMC4102698  NIHMSID: NIHMS588741  PMID: 24704133

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 include 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 (IARC Working Group, 2009, Globalsmokefree Partnership, 2009, Hyland, et al., 2012). While in the United States, Canada, and Australia early progress in smoke-free legislation occurred primarily at the local level (Americans for Nonsmokers’ Rights, August 2004), smoke-free laws in Europe has 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 WHO European Region countries, according to the FCTC Article 8 Guidelines for Implementation (WHO, 2007).

Methods

We conducted a cross-sectional study of smoke-free legislation in 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 (ENSP), and 3) personal contacts through email to ENSP National representatives and/or tobacco control experts. Of the 53 countries of the WHO European Region (http://www.euro.who.int/en/countries) we obtained a total of 61 smoke-free laws from 48 countries. Germany has 16 federal laws (one per each land) for all the sectors except for workplaces and public transports (ruled by a national law). The United Kingdom has separate laws for England, Northern Ireland, Scotland and Wales. Overall, 5 smoke-free WHO European laws were not included in the study, because they were not available in any of our 3 sources and/or were not available in English, German, Portuguese or Spanish. An assessment protocol was created to define the type of outdoor smoke-free legislation provided by each law in each sector and location selected. The six main sectors of evaluation were: 1-Health and social care facilities, 2-Education, 3-Public places, 4-Workplaces, 5-Hospitality, and 6-Public transportation. Each main sector was composed of several locations, with a total of 28 outdoor locations.

The protocol described whether or not smoking outdoors was allowed in the selected location and, if smoking was allowed, under what conditions. Four possible classifications were established: 1) 100% Smoke-free outdoor regulation without exceptions; 2) Smoking outdoors allowed in designated areas; 3) Smoking outdoors allowed; 4) No information provided about how to regulate smoking outdoors. This evaluation protocol was based on the WHO’s Guidelines for implementation of Article 8 (WHO, 2007).

We evaluated 66 laws for the Health & Social Care sector and 66 laws for the Education sector. Within the Public Places sector, there were 67 laws for Governmental facilities, 66 for Recreational facilities, Commercial/Shopping facilities, Sport facilities, 51 for Workplaces including Offices and Manufacturing facilities, and 65 for Prisons. There were 66 laws for the Hospitality sector, and 51 laws for Public transportation sector. The laws were independently assessed by two researchers. We calculated the percentage of locations in each category and their 95% confident intervals (CI), using the Wald or the Wilson method as appropriate, by each sector and by each of the four outdoor smoke-free policy categories in the 28 outdoor locations.

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 Care sector more than 50% of laws provided no information about regulating outdoor smoking. Between 40.9% and 45.5% of the laws allowed smoking in all outdoor areas. In the general health facility location, 2 out of the 66 laws had a smoke-free outdoor policy, meaning that smoking was completely prohibited on the hospital grounds, and 1 of 66 laws limited outdoor smoking to designated areas.

Table 1.

Percentage of locations that rule: 100% Smoke-free outdoors, allow smoking in designated areas only, allow smoking everywhere and do not provide information about smoking outdoors.

SECTORS (LOCATIONS) N 100% Smoke-free regulation Smoking allowed in designated areas Smoking allowed everywhere No information provided
n % n % n % n %
Sectors and locations
 Health care Sector
 GENERAL HEALTH FACILITY 66 2 3.0 1 1.5 30 45.5 33 50.0
 MENTAL HEALTH (Long) 66 0 0.0 2 3.0 27 40.9 37 56.1
 MENTAL HEALTH (Short) 66 0 0.0 2 3.0 28 42.4 36 54.6
 MENTAL HEALTH OUTPATIENTS 66 1 1.5 1 1.5 29 44.0 35 53.0
 NURSING HOME (Long) 66 0 0.0 1 1.5 28 42.4 37 56.1
 NURSING HOME (Short) 66 0 0.0 1 1.5 28 42.4 37 56.1
 NURSING HOME AMBULATORY 66 0 0.0 1 1.5 29 44.0 36 54.5
 SOCIAL CARE 66 0 0.0 1 1.5 29 44.0 36 54.5
 Education Sector
 PRIMARY 66 18 27.3 2 3.0 20 30.3 26 39.4
 SECONDARY SCHOOL 66 15 22.7 3 4.6 20 30.3 28 42.4
 UNIVERSITY SCHOOL 66 2 3.0 1 1.5 34 51.5 29 44.0
 OTHER 66 12 18.2 3 4.6 18 27.2 33 50.0
 Public Places Sector
 GOVERNMENTAL FACILITIES 67 0 0.0 2 3.0 32 47.8 33 49.2
 PRISONS 65 0 0.0 0 0.0 23 35.4 42 64.6
 HEALTH MINISTRY 66 0 0.0 2 3.0 28 42.4 36 54.6
 CULTURAL FACILITIES 66 0 0.0 1 1.5 28 42.4 37 56.1
 RECREATIONAL FACILITIES 66 3 4.6 1 1.5 24 36.4 38 57.5
 SHOPPING FACILITIES 66 0 0.0 1 1.5 26 39.4 39 59.1
 SPORT FACILITIES 66 1 1.5 2 3.0 26 39.4 37 56.1
51 0 0.0 3 5.9 9 17.7 39 76.5
 Workplaces Sector
 OFFICES
 MANUFACTURERS 51 0 0.0 3 5.9 10 19.6 38 74.5
 Hospitality Sector
 RESTAURANTS AND CAFETERIAS 66 0 0.0 3 4.5 31 46.9 32 48.5
 PUBS, BARS, NIGHTCLUBS 66 0 0.0 3 4.5 29 43.9 34 51.5
 HOTELS 66 0 0.0 0 0.00 26 39.4 40 60.6
 Transport Sector
 PUBLIC VEHICLES 51 0 0.0 1 1.9 15 29.4 35 68.6
 TRAINS 51 0 0.0 1 1.9 13 25.5 37 72.5
 SHIPS 51 0 0.0 1 1.9 10 19.6 40 78.4
 STATIONS 51 0 0.0 1 1.9 10 19.6 40 78.4
 Overall locations 1758 54 3.1 44 2.5 660 37.5 100 56.9
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In the Education sector, 27.3% of laws in primary schools, 22.7% in secondary schools, and 18.2% in other education facilities had 100% smoke-free outdoor regulation. Overall, about 17.8% of the laws (47 from the 264 locations- pulled out from the assessment of the 66 laws in 4 locations) had 100% smoke-free outdoor regulation. In the Public Places sector, none of the laws had 100% smoke-free outdoor regulation in governmental facilities, prisons, health ministry or cultural facilities. However, three laws in recreational facilities and one law in open sport facilities specified 100% smoke-free outdoor areas. In the Workplace sector, approximately 75% of the laws contained no restriction on outdoor smoking. In the Hospitality sector, no law had 100% smoke-free outdoor regulation, but three laws limited smoking to designated areas. Between 43.9% and 46.9% of the laws of this sector allowed smoking in outdoor areas of bars and restaurants. Finally, in the Public transport sector 68.6% to 78.4% of the laws – depending on the type of transportation – did not mention restrictions regarding outdoor smoking.

Discussion

This is the first systematic study of outdoor smoke-free legislation in 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, Sureda, et al., 2013). In the absence of complete evidence of its impact on health, prohibiting smoking outdoors may have other potential benefits such as.making its use less socially acceptable, reducing smoking initiation, reducing fire risk, and decreasing pollution (Francis, et al., 2010, Thomson, et al, 2009).

In our study, primary and secondary schools were the outdoor locations most protected from SHS. One study reported that the majority of the public support smoking bans in selected outdoor areas such as hospitals (79.9%) and school grounds (85.9%) (Gallus, et al., 2012). On the other hand, another study found that only 24% of non-smokers and 10.3% of smokers support smoke-free outdoor bars and restaurants (Kennedy, et al., 2012). Public support for smoke-free outdoor areas is higher for areas frequented by children (schools, playgrounds) than for any other areas (Gallus, et al., 2012, Kennedy, et al., 2012, Thomson, et al., 2009).

Smoke-free legislation is one of the six evidence-based components included in the WHO MPOWER package to reduce tobacco consumption (WHO, 2008). WHO FCTC signatories should address these six measures to effectively tackle tobacco in our society, but smoke-free legislation is, with doubt, the first step to protect non-smokers from the hazards of SHS (Nikogosian, 2010). The majority of European indoor smoke-free legislation (Britton and Bogdanovica, 2013) was implemented after signing the WHO FCTC and motivated by the successful experiences of neighbouring countries (Gorini, et al., 2010). Our study identified few laws prohibiting smoking in outdoor spaces, and these laws may reflect early adopting countries and may also set precedent for future change (Rogers, 2003).

Regulation of tobacco is a controversial public policy (Jacobson, et al., 1997), and is under threat from the tobacco industry (Tsoukalas and Glantz, 2003). Current Spanish outdoor smoke-free legislation, which prohibits smoking on hospital grounds and playgrounds, is an example of how health advocates are able to advance smoke-free outdoor legislation by supporting policy-makers through a strong community coalition (Gruer, et al., 2012, Fernandez and Martinez, 2010).

Study limitations include evaluation of the presence of outdoor smoking laws, and protections described in those laws. We also did not assess compliance with existing legislation. However, a recent study evaluating the Spanish comprehensive smoke-free legislation, – which bans smoking in outdoor areas in playgrounds and hospital campuses, – confirms a high reduction in SHS exposure, mainly during leisure time (Sureda et.al, 2014). In addition, we were not able to include data from all the 53 countries of the WHO European region, only 48 of them (representing 71 % of the Region’s population). We were not able include local or province laws implemented in some European municipalities and regions. Although less frequent than in the United States (Americans for Nonsmokers’ Rights, 12/2012) some municipalities in Italy and Spain have launched outdoor smoke-free initiatives in parks, playgrounds and beaches (Globalsmokefree Partnership, 2009). Nevertheless, ours is the only work available to benchmark how outdoor smoke-free legislation is implemented in the WHO European Region, and offers a baseline for future evaluation.

Outdoor smoke-free legislation in the WHO European Region is limited, and mainly has been passed in primary and secondary schools. More countries should adopt outdoor smoke-free regulation in locations where minors and vulnerable populations are exposed to the hazards of SHS, such as school grounds and areas surrounding hospitals.

Highlights.

  • First study to assess outdoor smoke-free legislation in the WHO European Region.

  • The majority of laws fail to implement smoke-free outdoor areas.

  • Few countries are early adopters in passing outdoor smoke-free policies.

  • Legislation provides little protection for the public in most outdoor areas.

  • The education sector is the highest protected from outdoor secondhand smoke.

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 to facilitating information.

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 Catalonia (2009SGR192).

Footnotes

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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.

Competing iuterests

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

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