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Smoke-free policies for indoor areas

Evidence Rating

Scientifically Supported

Health Factors

Smoke-free policies for indoor areas prohibit smoking in designated enclosed spaces. Private sector smoke-free policies can ban smoking on worksite property or restrict it to designated, often outdoor, locations. State and local smoke-free ordinances can establish standards for all workplaces, designated workplaces, and other indoor spaces. Policies can be comprehensive, prohibiting smoking in all areas of workplaces, restaurants, and bars, or limit smoking to designated areas via partial bans (). Restrictions may also extend to adjacent outdoor areas (CG-Tobacco use). Some local governments cannot enact smoke-free measures due to state preemption legislation (Grassroots Change).

Expected Beneficial Outcomes (Rated)

  • Improved health outcomes

  • Reduced exposure to secondhand smoke

  • Reduced tobacco consumption

  • Reduced mortality

  • Reduced hospital utilization

Other Potential Beneficial Outcomes

  • Increased quit rates

  • Reduced youth smoking

  • Reduced health care costs

  • Reduced preterm birth

  • Reduced infant mortality

Evidence of Effectiveness

There is strong evidence that comprehensive smoke-free policies for indoor areas improve health (Hoffman 2015CG-Tobacco use, ). Smoke-free policies substantially reduce acute coronary events such as heart attacks (US DHHS SG-Smoking 2014CG-Tobacco use, Lin 2013, , ) and secondhand smoke (SHS) exposure (Hoffman 2015US DHHS SG-Smoking 2014CG-Tobacco use). Policies reduce respiratory symptoms among hospitality workers and sensory symptoms among smokers and nonsmokers (). Smoke-free policies can also reduce asthma attacks and hospitalizations (, CG-Tobacco use), and may reduce the risk of preterm birth (, ) and Sudden Infant Death Syndrome (SIDS) ().

Smoke-free policies have been shown to reduce hospitalizations and mortality due to cardiovascular (CG-Tobacco use) and respiratory diseases (). Smoke-free policies reduce smoking prevalence (Hoffman 2015, ) and cigarette consumption (Hoffman 2015, US DHHS SG-Smoking 2014), and can lead smokers to quit smoking (Hoffman 2015CG-Tobacco use). Young people appear to reduce smoking more than older people following policy implementation (, ) and heart attack incidence appears to drop more in communities with larger reductions in smoking prevalence (Lin 2013).

Comprehensive policies reduce SHS exposure more than partial bans (, Hoffman 2015, CG-Tobacco use) or policies targeted at specific industries (CG-Tobacco use), and appear to be associated with greater reductions in health risks (). Smoke-free policies reduce SHS exposure for hospitality workers and young people the most (, ).

Some studies suggest that smoke-free policies reduce SHS exposure more in bars in low income areas (CG-Tobacco use). Other studies suggest that quit rates, prevalence, and SHS exposure may not drop as readily for lower income employees (Hill 2013a), especially if policies are not uniformly implemented (). Workplaces with higher income employees may be more likely to enforce their community’s smoke-free laws. However, in communities without such laws, workplaces with low income employees appear less likely than those with higher income employees to voluntarily institute smoke-free policies (Hill 2013a).

Models suggest that smoke-free policies cost up to $25 per person to implement (CG-Tobacco use). Such policies are cost effective based on averted mortality and health care costs (CG-Tobacco use) and quality adjusted life years (QALYs) saved (CG-Tobacco use, ). Over the long-term, analysts estimate such policies save between $0.15 and $4.8 million per 100,000 persons in health care costs (CG-Tobacco use). Smoke-free policies do not harm hospitality businesses’ profits (CG-Tobacco use, , ).

Experts suggest that states and communities provide and promote cessation services before smoke-free policies take effect (CG-Tobacco use).

Impact on Disparities

No impact on disparities likely

Implementation Examples

Nationally, efforts are underway to enact or strengthen smoke-free policies, eliminate exemptions, and remove state restrictions on local policies (CG-Tobacco use). As of 2013, smoke-free legislation has been adopted by 36 states (US DHHS SG-Smoking 2014). Many states ban smoking indoors on college and school campuses, and in day care centers, hospitals, restaurants, and grocery stores (CDC-STATE). Some states also ban smoking in casinos, bars, personal vehicles, and common areas of government housing. Some communities are expanding such policies to outdoor public areas such as parks, applying smoke-free policies to public multi-unit housing, or requiring landlords of multi-unit properties to disclose the property smoking policy to prospective tenants (CG-Tobacco use). State legislation pre-empts local government control of smoke-free policies in 12 states, while 27 states allow local communities to adopt restrictions that are stronger than the state-level restrictions (CDC-STATE).

Implementation Resources

ANR-Going smokefree - Americans for Nonsmokers’ Rights (ANR). Getting started.

PFP-Smoke-free 2007 - Partnership for Prevention (PFP). Smoke-free policies: Establishing a smoke-free ordinance to reduce exposure to secondhand smoke in indoor worksites and public places - An action guide. Washington, DC: Partnership for Prevention (PFP); 2007.

ChangeLab-Smokefree work, outdoors - ChangeLab Solutions. Smokefree workplaces and outdoor areas.

ChangeLab-Smokefree housing - ChangeLab Solutions. Smokefree housing.

US HUD-Smoke-free - US Department of Housing and Urban Development (HUD). Smoke-free multifamily housing.

HealthPartners-CHA - HealthPartners Institute for Education and Research. Community health advisor (CHA): Resource for information on the benefits of evidence-based policies and programs: Helping communities understand, analyze, and model costs.

Citations - Evidence

* Journal subscription may be required for access.

CG-Tobacco use - The Guide to Community Preventive Services (The Community Guide). Tobacco.

Hahn 2010* - Hahn EJ. Smokefree legislation: A review of health and economic outcomes research. American Journal of Preventive Medicine. 2010;39(6 Suppl 1):S66-S76.

Hopkins 2010* - Hopkins DP, Razi S, Leeks KD, et al. Smokefree policies to reduce tobacco use: A systematic review. American Journal of Preventive Medicine. 2010;38(2 Suppl):S275-89.

Cochrane-Frazer 2016* - Frazer K, Callinan JE, McHugh J, et al. Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database of Systematic Reviews. 2016;(2):CD005992.

Meyers 2009* - Meyers DG, Neuberger JS, He J. Cardiovascular effect of bans on smoking in public places. Journal of the American College of Cardiology. 2009;54(14):1249-55.

Hill 2013a - Hill S, Amos A, Clifford D, Platt S. Impact of tobacco control interventions on socioeconomic inequalities in smoking: Review of the evidence. Tobacco Control. 2013;0:1–9.

Lin 2013 - Lin H, Wang H, Wu W, et al. The effects of smoke-free legislation on acute myocardial infarction: A systematic review and meta-analysis. BMC Public Health. 2013;13:529.

Been 2014* - Been JV, Nurmatov UB, Cox B, Nawrot TS, et al. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. The Lancet. 2014;383(9928):1549-1560.

Hoffman 2015 - Hoffman SJ, Tan C. Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC Public Health. 2015;15:744.

Lupton 2015* - Lupton RJ, Townsend LJ. A systematic review and meta-analysis of the acceptability and effectiveness of university smoke-free policies. Journal of American College Health. 2015;63(4):238-247.

Tan 2012* - Tan CE, Glantz SA. Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: A meta-analysis. Circulation. 2012;126(18):2177-2183.

US DHHS SG-Smoking 2014 - US Department of Health and Human Services (US DHHS). The health consequences of smoking- 50 years of progress: A report of the Surgeon General, executive summary. 2014.

Citations - Implementation Examples

* Journal subscription may be required for access.

CG-Tobacco use - The Guide to Community Preventive Services (The Community Guide). Tobacco.

CDC-STATE - Centers for Disease Control and Prevention (CDC). State tobacco activities tracking and evaluation (STATE) system.

US DHHS SG-Smoking 2014 - US Department of Health and Human Services (US DHHS). The health consequences of smoking- 50 years of progress: A report of the Surgeon General, executive summary. 2014.

Date Last Updated

Nov 17, 2016