Tobacco Use: Smoke-Free Policies

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends smoke-free policies to reduce secondhand smoke exposure and tobacco use on the basis of strong evidence of effectiveness. Evidence is considered strong based on results from studies that showed effectiveness of smoke free policies in:
  • Reducing exposure to secondhand smoke
  • Reducing the prevalence of tobacco use
  • Increasing the number of tobacco users who quit
  • Reducing the initiation of tobacco use among young people
  • Reducing tobacco-related morbidity and mortality, including acute cardiovascular events

Economic evidence indicates that smoke-free policies can reduce healthcare costs substantially. In addition, the evidence shows smoke-free policies do not have an adverse economic impact on businesses, including bars and restaurants.

Intervention

Smoke-free policies are public-sector regulations and private-sector rules that prohibit smoking in indoor spaces and designated public areas. State and local ordinances establish smoke-free standards for all, or for designated, indoor workplaces, indoor spaces, and outdoor public places. Private-sector smoke-free policies may ban all tobacco use on private property or restrict smoking to designated outdoor locations.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

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About The Systematic Review

This CPSTF finding is based on evidence from a systematic review of legislative smoke-free policies published in 2010 (Callinan et al., 50 studies, search period through-July 2009) combined with more recent evidence and evidence on additional outcomes (82 studies, search period January 2000-December 2011). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to reducing tobacco use and secondhand smoke exposure. The finding updates and replaces two previous CPSTF findings on smoke-free policies and smoking bans and restrictions.

Context

As of December 2012, 26 U.S. states plus Washington, D.C. had enacted comprehensive 100% smoke-free indoor air laws covering government and private worksites, restaurants, and bars (CDC, 2012a).
  • Ten additional states plus Washington, D.C. have 100% smoke-free indoor air laws covering one or more of these settings (government and private worksites must both be covered to be counted; CDC, 2012a).
  • Twelve states have laws or court decisions pre-empting the implementation of local smoke-free air laws in government or private worksites or restaurant settings; however, some of these states do have smoke-free air laws covering at least one setting (CDC, 2012a; CDC, 2012b).

Summary of Results

Eighty-two studies were included in the review. Results showed that smoke-free policies were associated with decreases in: secondhand smoke exposure; tobacco use prevalence among young people and adults; and adverse health effects.

Updated Evidence (search period 2000-2011)

  • Exposure to Secondhand Smoke (search period 2009-2011)
    • Self-reported exposures (presence, frequency, or duration): median relative reduction of 50% (Interquartile interval [IQI]: -60% to -43%; 6 studies)
    • Secondhand smoke biomarkers in study participants: median relative reduction of 50% (IQI: -79% to -12%; 5 studies)
    • Indoor air pollution, as measured by vapor-phase nicotine or respirable suspended particle mass: median relative reduction of 88% (IQI: -95% to 81.2%; 11 studies)
  • Tobacco Use (search period 2009-2011)
    • Prevalence of tobacco use: median absolute reduction of 2.7 percentage points (IQI: -4.7 to -1.5 pct pts;11 studies)
      • Ten additional studies used different measures, eight of which reported favorable findings.
    • Cessation of tobacco use: median absolute increase of 3.8 percentage points (range: 2 to 17.4 percentage points; 4 studies)
      • Six additional studies that used different measures also reported increases in quitting activity.
    • Tobacco consumption (measured as changes in the amount of tobacco used per person): median absolute reduction of 1.2 cigarettes/day (range: -3.6 to 0 cigarettes/day; 5 studies)
      • Four additional studies that used different measures also found reductions in tobacco use.
  • Tobacco Use Among Young People (Adolescents and Young Adults) (search period 2000-2011)
    • The prevalence of tobacco use was lower among young people who were exposed to smoke-free policies: median odds ratio [OR] =0.85 (IQI: 0.68 to 0.93; 6 studies).
    • Eight additional studies used different measurements. In general, these studies found reductions in tobacco use.
  • Health Effects (search period 2000-2011)
    • Cardiovascular events: median relative reduction in hospital admissions of 5.1% (IQI: -11.6% to -2.2%; 9 studies)
      • Different measures were used in four additional studies reporting on hospital admissions for cardiovascular events. Two of these studies found reductions.
      • Three studies (two additional) reported on changes in cardiovascular mortality, two of which found reductions.
    • Asthma morbidity: median relative reduction in hospital admissions of 20.1% (range: -22.0% to -1.3%; 4 studies)
      • One additional study that used different measures of asthma related hospital admissions also found a reduction.
      • Two studies reported on self-reported asthma, one of which found a reduction.

Previous Review (Callinan et al., search period through July 2009)

Fifty studies were included in the review. Results showed that smoke-free policies were associated with decreases in exposure to secondhand smoke, tobacco use prevalence, and negative health effects.

  • Exposure to secondhand smoke
    • Self-reported exposures (presence, frequency, or duration): median relative reduction of 61% (IQI: -81% to -44%; 14 studies)
    • Secondhand smoke biomarkers in study participants: median relative reduction of 69% (IQI: -87% to -43%; 18 studies)
    • Indoor air pollution (as measured by vapor-phase nicotine or respirable suspended particle mass): median relative reduction of 88% (IQI: -97% to 26%; 8 studies)
  • Tobacco Use
    • Prevalence of active smoking: median absolute reduction of 3 percentage points (IQI: -5 to -0.8 percentage points; 10 studies)
      • One additional study that used different measurements reported favorable findings.
    • Smoking cessation: median absolute change of 0 percentage points (range: -2 to 4 percentage points; 3 studies)
      • Two additional studies provided different measurements and reported favorable findings.
    • Tobacco consumption (measured as changes in the amount of tobacco used: median absolute reduction of -2 cigarettes/day (IQI: -3 to -0.4 cigarettes/day; 8 studies)
  • Health Effects
    • Cardiovascular events: median relative reduction in hospital admissions of -13.5% (range: -26% to 1%; 5 studies)
      • Different measurements were used from five additional studies reporting on hospital admissions for cardiovascular events. All of these studies found reductions.
    • Asthma: two of three studies reported favorable findings in people with asthma

Summary of Economic Evidence

Eleven studies were included in the economic review, of which two assessed cost-effectiveness, one measured cost-benefit, and eight considered benefits only (costs-averted). All monetary values are reported in 2011 U.S. dollars.
  • Cost per quality-adjusted life year (QALY) gained: $1,138 (1 study)
  • Cost per life year saved (LYS): $8,803 (1 study)
  • Estimated net savings that would result from a U.S nationwide smoke-free policy ranged from $700 to $1,297 per person not currently covered by a smoke-free policy (1 study)
  • One year healthcare costs averted: median estimate of $409,000 per 100,000 persons (range of values: $148,000 to $1.6 million; 5 studies)
  • Annual healthcare costs averted over five or more years: median estimate of $1.1 million per 100,000 persons (range of values: $0.15 million to $4.8 million; 3 studies)
  • Annual smoking-related costs averted for multi-unit housing in the state of California, including averted cleaning, repair, maintenance, and other costs: $18 million (1 study)

The economic impact of smoke-free policies on hospitality establishments (restaurants, bars, hotels, tourist venues, gaming establishments) was also considered using evidence from a systematic review published in 2008 (Scollo & Lal, 158 studies, search period 1988 January 2008) combined with more recent evidence (21 studies, search period January 2008 July 2012).

  • Smoke-free policies did not have an adverse economic impact on the business activity of restaurants, bars, or establishments catering to tourists; some studies found a small positive effect of these policies.

Applicability

Smoke-free policies were shown to be effective in reducing exposure to secondhand smoke when implemented:
  • In the United States or other high-income countries
  • At national, state, and local levels
  • As comprehensive smoke-free policies (laws that prohibit smoking in all indoor areas of private workplaces, restaurants and bars, with no exceptions)
  • Alone, or in the setting of other interventions to reduce tobacco use and secondhand smoke exposure

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)
  • More research is needed to examine the effectiveness of state and local smoke-free policies on tobacco use among young people.
  • Additional research should examine the effects of smoke-free polices on tobacco product substitution among tobacco users who do not quit (e.g., adding or switching to smokeless tobacco, including recently introduced forms such as snus and dissolvables).
  • Future policy evaluations should include assessments of dual or multiple product use among tobacco users.
  • Additional evaluations of smoke-free policies are needed to capture and quantify the broad range of health effects attributable to reductions in both secondhand smoke exposure and tobacco use in the population.
  • Additional implementation and evaluation research is needed for smoke-free policies in settings with unique issues and concerns (i.e. multi-unit housing, addiction and treatment facilities and outdoor settings such as parks and beaches).
  • Additional research is needed to identify effective strategies to encourage change in tobacco use behaviors in homes.
  • Future economic research should consider and report actual costs of implementing smoke-free policies (including efforts to disseminate information to the public and to conduct enforcement).
  • Additional economic evaluations should capture costs and economic outcomes from the tobacco user’s perspective.
  • Research is needed to determine the benefits and costs of implementing smoke-free policies in new settings such as multi-unit housing

Study Characteristics

  • While most of the included studies evaluated smoke-free policies in the United States, studies also evaluated policies from Canada, England, Scotland, Wales, Australia, New Zealand, and several countries in Europe.
  • Studies evaluated policies implemented at national, state, and local levels.
  • Most studies evaluated tobacco use outcomes using large, population-based surveys with representative samples of working age adults or young people.
  • Included studies used different designs including cross-sectional comparisons between populations exposed and not exposed to smoke-free policies, before-after evaluations, interrupted time series, and other designs with longitudinal follow-up.

Analytic Framework

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Studies from the Updated Search Period (2000 2011)
Secondhand Smoke Exposure

Akhtar PC, Haw SJ, Levin KA, Currie DB, Zachary R, Currie CE. Socioeconomic differences in second-hand smoke exposure among children in Scotland after introduction of the smoke-free legislation. Journal of Epidemiology & Community Health 2010;64(4):341-6.

Bohac DL, Hewett MJ, Kapphahn KI, Grimsrud DT, Apte MG, Gundel LA. Change in indoor particle levels after a smoking ban in minnesota bars and restaurants. American Journal of Preventive Medicine 2010;39(6 SUPPL. 1):S3-9.

Brennan E, Cameron M, Warne C, Durkin S, Borland R, Travers MJ, et al. Secondhand smoke drift: Examining the influence of indoor smoking bans on indoor and outdoor air quality at pubs and bars. Nicotine and Tobacco Research 2010;12(3):271-7.

Carter CL, Carpenter MJ, Higbee C, Travers M, Hyland A, Bode A, et al. Fine particulate air pollution in restaurants and bars according to smoking policy in Charleston, South Carolina. Journal of the South Carolina Medical Association 2008;104(4):82-5.

Connolly GN, Carpenter CM, Travers MJ, Cummings KM, Hyland A, Mulcahy M, et al. How smoke-free laws improve air quality: A global study of Irish pubs. Nicotine and Tobacco Research 2009;11(6):600-5.

Dove MS, Dockery DW, Connolly GN. Smoke-free air laws and secondhand smoke exposure among nonsmoking youth. Pediatrics 2010;126(1):80-7.

Ho SY, Wang MP, Lo WS, Mak KK, Lai HK, Thomas GN, et al. Comprehensive smoke-free legislation and displacement of smoking into the homes of young children in Hong Kong. Tobacco Control 2010;19(2):129-33.

Holliday JC, Moore GF, Moore LAR. Changes in child exposure to secondhand smoke after implementation of smoke-free legislation in Wales: A repeated cross-sectional study. BMC Public Health 2009;9(430).

Hyland A, Travers MJ, Dresler C, Higbee C, Cummings KM. A 32-country comparison of tobacco smoke derived particle levels in indoor public places. Tobacco Control 2008;17(3):159-65.

Jensen JA, Schillo BA, Moilanen MM, Lindgren BR, Murphy S, Carmella S, et al. Tobacco smoke exposure in nonsmoking hospitality workers before and after a state smoking ban. Cancer Epidemiology Biomarkers and Prevention 2010;19(4):1016-21.

Kim B. Workplace smoking ban policy and smoking behavior. Journal of Preventive Medicine and Public Health2009;42(5):293-7.

Lee K, Hahn EJ, Robertson HE, Lee S, Vogel SL, Travers MJ. Strength of smoke-free air laws and indoor air quality. Nicotine and Tobacco Research 2009;11(4):381-6.

Marin HA, Diaz-Toro E. The effect of the smoke-free workplace policy in the exposure to secondhand smoke in restaurants, pubs, and discos in San Juan, Puerto Rico. Puerto Rico Health Sciences Journal 2010;29(3):279-85.

Muller S, Kraus L, Piontek D, Pabst A. Changes in exposure to secondhand smoke and smoking behavior in the general population after the introduction of new smoke-free laws in Germany. Sucht 2010;56(5):373-84.

Naiman AB, Glazier RH, Moineddin R. Is there an impact of public smoking bans on self-reported smoking status and exposure to secondhand smoke? BMC Public Health 2011;11(146).

Nebot M, Lopez MJ, Ariza C, Perez-Rios M, Fu M, Schiaffino A, et al. Impact of the Spanish smoking law on exposure to secondhand smoke in offices and hospitality venues: before-and-after study. Environmental Health Perspectives 2009;117(3):344-7.

Reijula JP, Reijula KE. The impact of Finnish tobacco legislation on restaurant workers’ exposure to tobacco smoke at work. Scandinavian Journal of Public Health 2010;38(7):724-30.

Rosen LJ, Zucker DM, Rosen BJ, Connolly GN. Second-hand smoke levels in Israeli bars, pubs and cafes before and after implementation of smoke-free legislation.European Journal of Public Health 2011;21(1):15-20.

Semple S, van Tongeren M, Galea KS, MacCalman L, Gee I, Parry O, et al. UK smoke-free legislation: changes in PM2.5 concentrations in bars in Scotland, England, and Wales. Annals of Occupational Hygiene 2010;54(3):272-80.

Vorspan F, Bloch V, Guillem E, Dupuy G, Pirnay S, Jacob N, et al. Smoking ban in a psychiatry department: Are nonsmoking employees less exposed to environmental tobacco smoke? European Psychiatry 2009;24(8):529-32.

Wheeler JG, Pulley L, Felix HC, Bursac Z, Siddiqui NJ, Stewart MK, et al. Impact of a smoke-free hospital campus policy on employee and consumer behavior. Public Health Reports 2007;122(6):744-52.

York NL, Lee K. A baseline evaluation of casino air quality after enactment of Nevada’s Clean Indoor Air Act. Public Health Nursing 2010;27(2):158-63.

Zhang B, Bondy S, Ferrence R. Do indoor smoke-free laws provide bar workers with adequate protection from secondhand smoke? Preventive Medicine 2009;49(2-3):245-7.

Zhang B, Bondy SJ, Chiavetta JA, Selby P, Ferrence R. The impact of Ontario smoke-free legislation on secondhand smoke in enclosed public places. Journal of Occupational and Environmental Hygiene 2010;7(3):133-43.

Tobacco Use

**Ahijevych K, Ford J. The relationships between menthol cigarette preference and state tobacco control policies on smoking behaviors of young adult smokers in the 2006-07 Tobacco Use Supplements to the Current Population Surveys (TUS CPS). Addiction 2010;105 Suppl 1:46-54.

Biener L, Hamilton WL, Siegel M, Sullivan EM. Individual, social-normative, and policy predictors of smoking cessation: a multilevel longitudinal analysis. American Journal of Public Health 2010(3):547-54.

Bitler MP, Carpenter C, Zavodny M. Smoking restrictions in bars and bartender smoking in the US, 1992-2007.Tobacco Control 2011(3):196-200.

**Boris NW, Johnson CC, Huang S, Myers L, Andrew K, Webber LS. Targeting school tobacco policy: lessons from the Acadiana Coalition of Teens Against Tobacco (ACTT). Health Promotion Practice 2009(4):549-56.

Dinno A, Glantz S. Tobacco control policies are egalitarian: a vulnerabilities perspective on clean indoor air laws, cigarette prices, and tobacco use disparities.Social Science & Medicine 2009(8):1439-47.

Edwards R, Gifford H, Waa A, Glover M, Thomson G, Wilson N. Beneficial impacts of a national smokefree environments law on an indigenous population: a multifaceted evaluation. International Journal for Equity in Health 2009:12.

Gadomski AM, Stayton M, Krupa N, Jenkins P. Implementing a smoke-free medical campus: impact on inpatient and employee outcomes. Journal of Hospital Medicine 2010(1):51-4.

Grassi MC, Enea D, Ferketich AK, Lu B, Nencini P. A smoking ban in public places increases the efficacy of bupropion and counseling on cessation outcomes at 1 year. Nicotine and Tobacco Research 2009(9):1114-21.

Hackshaw L, McEwen A, West R, Bauld L. Quit attempts in response to smoke-free legislation in England. Tobacco Control 2010(2):160-4.

Hahn EJ, York NL, Rayens MK. Smoke-free legislation in Appalachian counties. American Journal of Public Health2010(11):2012-3.

Kabir Z, Clarke V, Conroy R, McNamee E, Daly S, Clancy L. Low birthweight and preterm birth rates 1 year before and after the Irish workplace smoking ban. BJOG2009(13):1782-7.

Khang Y-H, Yun S-C, Cho H-J, Jung-Choi K. The impact of governmental antismoking policy on socioeconomic disparities in cigarette smoking in South Korea. Nicotine and Tobacco Research 2009;11(3):262-9.

Kim B. Workplace smoking ban policy and smoking behavior. Journal of Preventive Medicine and Public Health 2009(5):293-7.

Klein EG, Forster JL, Erickson DJ, Lytle LA, Schillo B. The relationship between local clean indoor air policies and smoking behaviours in Minnesota youth. Tobacco Control 2009(2):132-7.

Knudsen HK, Boyd SE, Studts JL. Substance abuse treatment counselors and tobacco use: a comparison of comprehensive and indoor-only workplace smoking bans.Nicotine and Tobacco Research 2010(11):1151-5.

Muller S, Kraus L, Piontek D, Pabst A. Changes in exposure to secondhand smoke and smoking behavior: In the general population after the introduction of new smoke-free laws in Germany. Sucht: Zeitschrift fur Wissenschaft und Praxis (5):373-84.

Nagelhout GE, Willemsen MC, Vries Hd. The population impact of smoke-free workplace and hospitality industry legislation on smoking behaviour. Findings from a national population survey. Addiction (4):816-23.

Naiman AB, Glazier RH, Moineddin R. Is there an impact of public smoking bans on self-reported smoking status and exposure to secondhand smoke? Do smoking bans decrease exposure? BMC Public Health (1):146.

Orbell S, Lidierth P, Henderson CJ, et al. Social-cognitive beliefs, alcohol, and tobacco use: a prospective community study of change following a ban on smoking in public places. Health Psychology 2009(6):753-61.

Overland S, Aaro LE, Lindbak RL. Associations between schools’ tobacco restrictions and adolescents’ use of tobacco. Health Education Research 2010(5):748-56.

Prochaska JD, Burdine JN, Bigsby K, et al. The impact of a communitywide smoke-free ordinance on smoking among older adults. Preventing Chronic Disease 2009(1):A17.

Regidor E, Mateo Sd, Ronda E, et al. Heterogeneous trend in smoking prevalence by sex and age group following the implementation of a national smoke-free law. Journal of Epidemiology and Community Health 2011(65):702-8.

Reijula JP, Reijula KE. The impact of Finnish tobacco legislation on restaurant workers’ exposure to tobacco smoke at work. Scandinavian Journal of Public Health 2010(7):724-30.

Ripley-Moffitt C, Viera AJ, Goldstein AO, Steiner JB, Kramer KD. Influence of a tobacco-free hospital campus policy on smoking status of hospital employees. American Journal of Health Promotion 2010(1):e25-8.

Ruge J, Broda A, Ulbricht S, et al. Workplace smoking restrictions: smoking behavior and the intention to change among continuing smokers. International Journal of Public Health 2010(6):599-608.

Shetty A, Alex R, Bloye D. The experience of a smoke-free policy in a medium secure hospital. Psychiatry 2010(7):287-9.

Verdonk-Kleinjan WM, Candel MJ, Knibbe RA, Willemsen MC, Vries Hd. Effects of a workplace-smoking ban in combination With tax increases on smoking in the Dutch population. Nicotine Tobacco Research 2011 (13):412-7.

Wheeler JG, Pulley L, Felix HC, et al. Impact of a smoke-free hospital campus policy on employee and consumer behavior. Public Health Reports 2007(6):744-52.

Tobacco Use Among Young People

**Ahijevych K, Ford J. The relationships between menthol cigarette preference and state tobacco control policies on smoking behaviors of young adult smokers in the 2006-07 Tobacco Use Supplements to the Current Population Surveys (TUS CPS). Addiction 2010:46-54.

**Boris NW, Johnson CC, Huang S, Myers L, Andrew K, Webber LS. Targeting school tobacco policy: lessons from the Acadiana Coalition of Teens Against Tobacco (ACTT). Health Promotion Practice 2009(4):549-56.

Botello-Harbaum MT, Haynie DL, Iannotti RJ, Wang J, Gase L, Simons-Morton B. Tobacco control policy and adolescent cigarette smoking status in the United States. Nicotine and Tobacco Research 2009(7):875-85.

Buddelmeyer H, Wilkins R. Effects of tightening smoking regulations on take-up and cessation of smoking.Australian Economic Review 2011(2):167-181.

Darling H, Reeder AI, Williams S, McGee R. Is there a relation between school smoking policies and youth cigarette smoking knowledge and behaviors? Health Education Research 2006(1):108-15.

Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking. JAMA 2000(6):717-22.

Hahn EJ, Rayens MK, Ridner SL, Butler KM, Zhang M, Staten RR. Smoke-free laws and smoking and drinking among college students. Journal of Community Health(5):503-11.

Hublet A, Schmid H, Clays E, Godeau E, Gabhainn SN, Joossens L, et al. Association between tobacco control policies and smoking behaviour among adolescents in 29 European countries. Addiction 2009(11):1918-26.

Klein EG, Forster JL, Erickson DJ, Lytle LA, Schillo B. The relationship between local clean indoor air policies and smoking behaviours in Minnesota youth. Tobacco Control 2009(2):132-7.

Lipperman-Kreda S, Paschall MJ, Grube JW. Perceived enforcement of school tobacco policy and adolescents’ cigarette smoking. Preventive Medicine 2009(6):562-6.

McMullen KM, Brownson RC, Luke D, Chriqui J. Strength of clean indoor air laws and smoking related outcomes in the USA. Tobacco Control 2005(1):43-8.

Ringel JS, Wasserman J, Andreyeva T. Effects of public policy on adolescents’ cigar use: evidence from the National Youth Tobacco Survey. American Journal of Public Health 2005(6):995-8.

Schnohr CW, Kreiner S, Rasmussen M, Due P, Currie C, Diderichsen F. The role of national policies intended to regulate adolescent smoking in explaining the prevalence of daily smoking: a study of adolescents from 27 European countries. Addiction 2008(5):824-31.

Siegel M, Albers AB, Cheng DM, Biener L, Rigotti NA. Effect of local restaurant smoking regulations on progression to established smoking among youths.Tobacco Control 2005(5):300-6.

Siegel M, Albers AB, Cheng DM, Hamilton WL, Biener L. Local restaurant smoking regulations and the adolescent smoking initiation process: results of a multilevel contextual analysis among Massachusetts youth.Archives of Pediatrics & Adolescent Medicine 2008(5):477-83.

Tauras JA. Public policy and smoking cessation among young adults in the United States. Health Policy2004(3):321-32.

Tauras JA. Can public policy deter smoking escalation among young adults? Journal of Policy Analysis and Management 2005(4):771-84.

Tworek C, Yamaguchi R, Kloska DD, Emery S, Barker D, Giovino GA, O’Malley PM, Chaloupka FJ. State-level tobacco control policies and youth smoking cessation measures. Health Policy 2010;97(2-3):136-144.

Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Ruel EE. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ 2000(7257):333-7.

White VM, Warne CD, Spittal MJ, Durkin S, Purcell K, Wakefield MA. What impact have tobacco control policies, cigarette price and tobacco control programme funding had on Australian adolescents’ smoking? Findings over a 15-year period. Addiction 2011(8):1493-502.

Health Outcomes: Cardiovascular Morbidity and Mortality

Barnett R, Pearce J, Moon G, Elliott J, Barnett P. Assessing the effects of the introduction of the New Zealand Smokefree Environment Act 2003 on acute myocardial infarction hospital admissions in Christchurch, New Zealand. Australian and New Zealand Journal of Public Health 2009(6):515-20.

Barone-Adesi F, Gasparrini A, Vizzini L, Merletti F, Richiardi L. Effects of Italian smoking regulation on rates of hospital admission for acute coronary events: A country-wide study. PLoS ONE 2011(3):e17419.

Bonetti PO, Trachsel LD, Kuhn MU, Schulzki T, Erne P, Radovanovic D, et al. Incidence of acute myocardial infarction after implementation of a public smoking ban in Graubunden, Switzerland: Two year follow-up. Swiss Med Wkly 2011(141):w13206.

Bruintjes G, Bartelson BB, Hurst P, Levinson AH, Hokanson JE, Krantz MJ. Reduction in acute myocardial infarction hospitalization after implementation of a smoking ordinance. American Journal of Medicine 2011(7):647-54.

Dove MS, Dockery DW, Mittleman MA, Schwartz J, Sullivan EM, Keithly L, et al. The impact of Massachusetts’ smoke-free workplace laws on acute myocardial infarction deaths. American Journal of Public Health 2010(11):2206-12.

Gasparrini A, Gorini G, Barchielli A. On the relationship between smoking bans and incidence of acute myocardial infarction. European Journal of Epidemiology 2009(10):597-602.

Gupta R, Luo J, Anderson R, Ray A. Clean indoor air regulation and incidence of hospital admissions for acute coronary syndrome in Kanawha County, West Virginia.Preventing Chronic Disease 2011(4):A77.

**Halbesleben JRB, Wheeler AR. Coverage by smoke-free workplace policies by race/ethnicity and health outcomes: Can workplace health policies improve worker health? International Journal of Workplace Health Management 2010(2):111-130.

**Herman PM, Walsh ME. Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona’s comprehensive statewide smoking ban. American Journal of Public Health 2011;101(3):491-6.

**Naiman A, Glazier RH, Moineddin R. Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions. CMAJ 2010(8):761-7.

**Shetty KD, DeLeire T, White C, Bhattacharya J. Changes in U.S. hospitalization and mortality rates following smoking bans. Journal of Policy Analysis and Management 2011(1):6-28.

Sims M, Maxwell R, Bauld L, Gilmore A. Short term impact of smoke-free legislation in England: retrospective analysis of hospital admissions for myocardial infarction.BMJ 2010:c2161.

Trachsel LD, Kuhn MU, Reinhart WH, Schulzki T, Bonetti PO. Reduced incidence of acute myocardial infarction in the first year after implementation of a public smoking ban in Graubuenden, Switzerland. Swiss Med Wkly 2010(9-10):133-8.

Villalbi JR, Castillo A, Cleries M, Salto E, Sanchez E, Martinez R, et al. Acute myocardial infarction hospitalization statistics: apparent decline accompanying an increase in smoke-free areas. Revista Espa ola de Cardiolog a 2009(7):812-5.

Villalbi JR, Sanchez E, Benet J, Cabezas C, Castillo A, Guarga A, et al. The extension of smoke-free areas and acute myocardial infarction mortality: before and after study. BMJ 2011(1):e000067.

Health Outcomes: Asthma Morbidity

Dove MS, Dockery DW, Connolly GN. Smoke-free air laws and asthma prevalence, symptoms, and severity among nonsmoking youth. Pediatrics 2011(1):102-9.

**Halbesleben JRB, Wheeler AR. Coverage by smoke-free workplace policies by race/ethnicity and health outcomes: Can workplace health policies improve worker health? International Journal of Workplace Health Management 2010(2):111-130.

**Herman PM, Walsh ME. Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona’s comprehensive statewide smoking ban. American Journal of Public Health 2011;101(3):491-6.

Mackay D, Haw S, Ayres JG, Fischbacher C, Pell JP. Smoke-free legislation and hospitalizations for childhood asthma. New England Journal of Medicine 2010(12):1139-45.

**Naiman A, Glazier RH, Moineddin R. Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions. CMAJ 2010(8):761-7.

**Shetty KD, DeLeire T, White C, Bhattacharya J. Changes in U.S. hospitalization and mortality rates following smoking bans. Journal of Policy Analysis and Management 2011(1):6-28.

** Study evaluated multiple outcomes and is listed under more than one subheading.

Economic Review

American Cancer Society Cancer Action Network. Saving Lives, Saving Money: A State-by-State Report on the Health and Economic Impact of Comprehensive Smoke-Free Laws. ACS CAN: Washington(DC); 2011. Available at URL: http://www.acscan.org/pdf/tobacco/reports/acscan-smoke-free-laws-report.pdf.

Hauri DD, Lieb CM, Rajkumar S, Kooijman C, Sommer HL, Roosli M. Direct health costs of environmental tobacco smoke exposure and indirect health benefits due to smoking ban introduction. European Journal of Public Health 2010(21):316-22.

Herman PM, Walsh ME. Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona’s comprehensive statewide smoking ban. American Journal of Public Health 2011(3):491-6.

Hojgaard B, Olsen KR, Pisinger C, Tonnesen H, Gyrd-Hansen D. The potential of smoking cessation programmes and a smoking ban in public places: comparing gain in life expectancy and cost effectiveness.Scandinavian Journal of Public Health 2011(8):785-96.

Juster HR, Loomis BR, Hinman TM, Farrelly MC, Hyland A, Bauer UE, et al. Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban.American Journal of Public Health 2007;97(11):2035-9.

Mudarri D. The costs and benefits of smoking restrictions: an assessment of the Smoke Free Environment Act of 1993 (HR 3434). In: Environmental Protection Agency, Office of Radiation and Indoor Air, Indoor Air Division, editors. Washington (DC);1994.

Ong MK, Diamant AL, Zhou Q, Park HY, Kaplan RM. Estimates of smoking-related property costs in California multiunit housing. American Journal of Public Health 2012(3):490-3.

Ong MK, Glantz SA. Cardiovascular health and economic effects of smoke-free workplaces. American Journal of Medicine 2004(1):32-8.

Ong MK, Glantz SA. Free nicotine replacement therapy programs vs. implementing smoke-free workplaces: a cost-effectiveness comparison. American Journal of Public Health 2005(6):969-75.

Ong M, Lightwood J, Glantz SA. Health and Economic Impacts of the Proposed Florida Smoke free for Health Initiative. San Francisco(CA): University of California, San Francisco (UCSF), Center for Tobacco Control Research and Education, January 2002. Available at URL: http://www.escholarship.org/uc/item/619328sg.

Roberts C, Davis PJ, Taylor KE, Pearlman DN. The impact of Rhode Island’s statewide smoke-free ordinance on hospital admissions and costs for acute myocardial infarction and asthma. Rhode Island Medical Journal 2012(1):23-5

Search Strategies

To update the evidence, the following databases were searched from January 2000 to December 2011 to identify English-language studies that assessed the effectiveness of interventions to reduce tobacco use and secondhand smoke exposure: Cochrane database, Embase, Medline, PsycINFO, PubMed. Intervention studies specific to this review were subsequently identified during the screening process.

Effectiveness Review

Search Strategy

Limit to 2000 December 2011

English language articles only

PART 1:

(Title or Abstract words: law or laws or legal or legalistic or legislate or legislation or legislative or ordinance(s) or rule(s) or ruling(s) or restriction(s) or jurisprudence or policy or policies or statute(s)

OR

MeSH terms: Legislation as Topic or Jurisprudence[MeSH] or Criminal Law[MeSH] or Legislation[Publication Type])

AND

(Title or Abstract words: smoke-free or smokefree or secondhand smoke or tobacco smoke

OR

MeSH terms: tobacco smoke pollution)

PART 2

(Title or Abstract words: (tobacco or smoking or cigar(s) or cigarette(s)

OR

MeSH terms: tobacco or smoking or tobacco use disorder or tobacco industry)

AND

All Fields: air

AND

(Title or Abstract words: law or laws or legal or legalistic or legislate or legislation or legislative or ordinance(s) or rule(s) or ruling(s) or restriction(s) or jurisprudence or policy or policies or statute(s)

OR

MeSH terms: Legislation as Topic or Jurisprudence[MeSH] or Criminal Law[MeSH] or Legislation[Publication Type])

PART 1 OR PART 2

Economic Review

To conduct the economic review, the review team also searched the following economics databases using the search strategies noted below.

Databases: PubMed, EconLit, JSTOR, social sciences citation index (SSCI), Centre for Reviews & Dissemination at the University of York (http://www.crd.york.ac.uk/crdweb/)

Keywords: (economic(s), cost, benefit, cost-benefit, benefit-cost, utility, cost-utility, QALY, cost effectiveness, efficiency, $, dollar(s))

Review References

Callinan JE, Clarke A, Doherty K, and Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption (Review). The Cochrane Library 2010; Issue 6.

CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. STATE (State Tobacco Activities Tracking & Evaluation System): State Smoke-free Indoor Air Fact Sheet. Centers for Disease Control and Prevention; 2012a.

CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health STATE (State Tobacco Activities Tracking & Evaluation System): State Preemption Fact Sheet: Preemption Can Impede Local Tobacco Protection Efforts. Centers for Disease Control and Prevention; 2012b.

Scollo M, Lal A. Summary of studies assessing the economic impact of smoke free policies in the hospitality industry. Melbourne, Australia, Vic Health Centre for Tobacco Control; 2008. Available at URL: http://www.vctc.org.au/tc-res/Hospitalitysummary.pdf [PDF – 651 kB].

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

Barriers to adoption and implementation of smoke-free policies are common.

  • Policy exemptions and loopholes in legislation at the state and local level can block efforts to protect patrons and employees from secondhand smoke exposure in hospitality venues and attached outdoor areas, casinos, hookah lounges, cigar bars, and smoke-shops.
  • Direct political opposition to new or expanded smoke-free policies is also common, including advocacy by tobacco users, hospitality organizations and businesses, and the tobacco industry.
  • Concerns that smoke-free policies may have an adverse economic impact on restaurants and bars are routinely raised as a barrier to implementation of such policies. However, a substantial body of evidence indicates that smoke-free policies do not have negative impact on business activity, especially for restaurants and bars, and may in some cases provide a small positive effect.
  • In the U.S., enforcement of state and local smoke-free policies has not required substantial time or resources from public health or law enforcement officials. Addressing sporadic non-compliance, however, requires clear enforcement powers, defined responsibilities, and adequate resources.
  • Although the evidence indicates that community and worksite smoke-free policies do not increase smoking in the home, in general, smoke-free policies will relocate smoking from protected indoor areas to nearby outdoor areas and this may require additional assessment, regulation, and enforcement.
  • Implementation of a new or an expanded smoke-free policy will motivate some tobacco users to try to quit; efforts should be made to maximize this outcome. Specifically, state and local tobacco control programs and their partners should plan to provide and promote cessation services in conjunction with policy implementation, starting when the policy is adopted, well ahead of its effective date.
  • Substantial resources are available for guidance and support tobacco control programs and smoke-free policy interventions, such as the:
    • American Lung Association
    • Americans For Nonsmokers’ Rights (ANR)
    • Tobacco Technical Assistance Consortium (TTAC)
    • National African American Tobacco Prevention Network
    • CDC National Center for Environmental Health