Smoke-free policies for indoor areas
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. Smoke-free state laws and local 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 bans1. Restrictions may also extend to adjacent outdoor areas2.
Note: The term “tobacco” in this strategy refers to commercial tobacco, not ceremonial or traditional tobacco. County Health Rankings & Roadmaps recognizes the important role that ceremonial and traditional tobacco play for many Tribal Nations, and our tobacco-related work focuses on eliminating the harms and inequities associated with commercial tobacco.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved health outcomes
Reduced exposure to secondhand smoke
Reduced tobacco consumption
Reduced mortality
Reduced hospital utilization
Reduced preterm birth
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Increased quit rates
Reduced youth smoking
Reduced health care costs
Reduced infant mortality
What does the research say about effectiveness?
There is strong evidence that comprehensive smoke-free policies for indoor areas improve health1, 2, 3, 4. Smoke-free policies substantially reduce acute coronary events such as heart attacks1, 2, 5, 6, 7, 8 and secondhand smoke (SHS) exposure1, 2, 4, 8. Policies reduce respiratory symptoms among hospitality workers and sensory symptoms among smokers and nonsmokers1. Smoke-free policies reduce asthma attacks and hospitalizations2, 3, 9, 10, have been shown to reduce the risk of preterm birth3, 9, 10, and may reduce Sudden Infant Death Syndrome (SIDS)10.
Smoke-free policies have been shown to reduce hospitalizations and mortality due to cardiovascular2 and respiratory diseases6. Smoke-free policies reduce smoking prevalence4, 11 and cigarette consumption3, 4, 8, and can lead smokers to quit smoking2, 4. Following policy implementation, younger adults appear to reduce smoking more than older adults7, 12, 13; a 25-year study suggests quit attempts may also be concentrated among women, particularly those with lower incomes13. Indoor smoking legislation can improve children’s health outcomes3 and may reduce asthma-related emergency room visits for children14.
Comprehensive policies reduce SHS exposure more than partial bans1, 2, 3, 4 or policies targeted at specific industries2, and appear to be associated with greater reductions in health risks6. Smoke-free policies reduce SHS exposure for hospitality workers and young people the most7, 10.
Some studies suggest that smoke-free policies reduce SHS exposure more in bars in low income areas than higher income areas2. Assessments of a North Dakota law suggest it reduces SHS more in rural areas than urban areas15, 16. Quit rates, prevalence, and SHS exposure may not drop as much for lower income employees as higher income employees17, especially if policies are not uniformly implemented10. Workplaces with higher income employees may be more likely to enforce their community’s smoke-free laws17; for example, a California-based study indicates that young adults in lower income occupations, particularly in non-office environments, continue to report workplace exposure to SHS18. 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 policies17.
Models suggest that smoke-free policies cost up to $25 per person to implement2. Such policies are cost effective based on averted mortality and health care costs2 and quality adjusted life years (QALYs) saved2, 12. Over the long-term, analysts estimate such policies save between $150,000 and $4.8 million per 100,000 persons in health care costs2. Smoke-free policies do not harm hospitality businesses’ profits1, 2, 10.
Experts suggest that states and communities provide and promote cessation services before smoke-free policies take effect2.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact smoke-free policies in indoor areas may have on disparities in exposure to secondhand smoke (SHS) and health outcomes.
While cigarette smoking has declined since 1965, disparities in tobacco use and exposure have persisted. Disparities in smoking by education level have increased, along with SHS exposure by race and socioeconomic status23. SHS exposure is greater among Black adults, adults 25 years or older with less than a college degree, and families with incomes below the federal poverty level23. Individuals with low socioeconomic status have less access to smoke-free homes because they are more likely to live in multi-unit buildings where smoking is permitted in individual housing units. These living conditions increase the risk of SHS exposure in the home24. Many public housing agencies and other housing for residents with low incomes are adopting smoke-free policies that reduce exposure to SHS; however, implementation and enforcement come with many challenges, such as dependence on housing staff to enforce policies and inconsistent policy enforcement, particularly in the evenings and on weekends25. Experts suggest that creating designated outdoor smoking areas may help address some of these challenges26.
Policies and interventions that are intended to reduce children’s exposure to SHS may help improve health equity across populations. Children who are exposed to SHS are more likely to become smokers themselves; breaking this cycle can help improve health outcomes27.
In the United States, people who identify as American Indian and Alaska Native (AIAN) adults use commercial tobacco at significantly higher rates than adults in the general population28. This is consistent with health disparities, such as myocardial infarction, lung cancer, stroke, and respiratory illnesses, among people identified as AIAN related to commercial tobacco use28.
What is the relevant historical background?
Tobacco has been used in a variety of forms for recreational purposes for centuries. Beginning in the early 1900s and continuing through the 1950s, research was conducted to confirm the link between smoking and lung cancer29. Alongside this research, public health advocates highlighted the growing evidence of health hazards associated with smoking, such as lung cancer, resulting in educational campaigns, policy changes, and the inclusion of health warnings on tobacco products starting in the late 1960s29.
Since the 1970s, smoke-free policies for indoor and outdoor areas have been implemented by states, communities, and private businesses to address the harm caused by secondhand smoke (SHS) and to reduce the risk of lung cancer29. The Minnesota Clean Indoor Air Act went into effect in 1975, marking the first statewide law to require separate smoking areas in public places29. In 1987, Congress prohibited smoking on short domestic flights (under two hours), later expanding to a complete smoking ban on all flights29.
However, there is still uneven access to smoke-free policies, especially in housing situations such as multi-unit residences26. Individuals with low incomes use tobacco at a higher rate than the general population and are more likely to live in multi-unit homes that lack enforcement of smoke-free policies, which may contribute to increased SHS exposure26.
In the United States, tribal communities are exempt from smoke-free laws within their state. Tribes can adopt smoke-free policies that meet their communities’ unique needs and take their culture and traditions into account28.
Equity Considerations
- What smoke-free policies exist in your community? How are they implemented and enforced? Are there places that don’t have smoke-free policies for indoor spaces (e.g. restaurants, workplaces, businesses, etc.)?
- If your community includes members of local tribes, are local smoke-free policies considerate of tribal sovereignty and are they culturally sensitive to the use of tobacco for ceremonial purposes?
Implementation Examples
Nationally, efforts are underway to enact or strengthen smoke-free policies, eliminate exemptions, and remove state restrictions on local policies2. As of 2018, 28 states and Washington, D.C. have comprehensive smoke-free laws that ban smoking in all public places and workplaces19, 20 and 36 states banned smoking in some combination of workplaces, restaurants, bars, and casinos21. In addition, there are 2,279 smoke-free university campuses; 4,043 hospitals, healthcare systems, and clinics with smoke-free campuses; and 782 state-regulated gambling facilities that are 100% smoke-free indoors21. Many states also ban smoking in day care centers, grocery stores22, personal vehicles, and common areas of government housing2.
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 restrictions22.
Implementation Resources
‡ Resources with a focus on equity.
ChangeLab-Smokefree housing - ChangeLab Solutions. Smokefree housing.
ChangeLab-SF places - ChangeLab Solutions. Comprehensive smokefree places: A model California ordinance regulating smoking in indoor & outdoor areas.
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.
PHLC-Smoke-free - Tobacco Control Legal Consortium (TCLC). Smoke-free & tobacco-free places. Saint Paul: Public Health Law Center (PHLC).
ANRF-Smoke-free lists - American Nonsmokers’ Rights Foundation. Smokefree lists and maps. 2018.
San Francisco Tobacco-Free - San Francisco Tobacco-Free. San Francisco tobacco control laws.
Footnotes
* Journal subscription may be required for access.
1 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.
2 CG-Tobacco - The Guide to Community Preventive Services (The Community Guide). Tobacco.
3 Faber 2017 - Faber T, Kumar A, Mackenbach JP, et al. Effect of tobacco control policies on perinatal and child health: A systematic review and meta-analysis. Lancet Public Health. 2017;2(9):e420-e437.
4 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.
5 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.
6 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.
7 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.
8 US DHHS SG-Smoking 2014 - U.S. Department of Health and Human Services (U.S. DHHS). The health consequences of smoking- 50 years of progress: A report of the Surgeon General; 2014.
9 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.
10 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.
11 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.
12 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.
13 Mayne 2018 - Mayne SL, Auchincloss AH, Tabb LP, et al. Associations of bar and restaurant smoking bans with smoking behavior in the CARDIA study: A 25-year study. American Journal of Epidemiology. 2018;187(6):1250-1258.
14 Ciaccio 2016 - Ciaccio CE, Gurley-Calvez T, Shireman TI. Indoor tobacco legislation is associated with fewer emergency department visits for asthma exacerbation in children. Annals of Allergy, Asthma and Immunology. 2016;117(6):641-645.
15 Buettner-Schmidt 2018 - Buettner-Schmidt K, Boursaw B, Lobo ML. Place and policy: Secondhand smoke exposure in bars and restaurants. Nursing Research. 2018;67(4):324-330.
16 Buettner-Schmidt 2017 - Buettner-Schmidt K, Boursaw B, Lobo ML, Travers MJ. Tobacco smoke pollution in hospitality venues before and after passage of statewide smoke-free legislation. Public Health Nursing. 2017;34(2):166-175.
17 Hill 2014b - Hill S, Amos A, Clifford D, Platt S. Impact of tobacco control interventions on socioeconomic inequalities in smoking: Review of the evidence. Tobacco Control. 2014;23:e89-e97
18 Holmes 2017 - Holmes LM, Ling PM. Workplace secondhand smoke exposure: a lingering hazard for young adults in California. Tobacco Control. 2017;26(e1):e79-e84.
19 ALA-Smoke-free air - American Lung Association. Smokefree air laws. 2018.
20 ALA-SLATI-SF policies - American Lung Association, Tobacco Policy Project/State Legislated Actions on Tobacco Issues. Smoke-free laws and policies. 2018.
21 ANRF-Smoke-free lists - American Nonsmokers’ Rights Foundation. Smokefree lists and maps. 2018.
22 CDC-STATE - Centers for Disease Control and Prevention (CDC). State tobacco activities tracking and evaluation (STATE) system.
23 US DHHS tobacco fact sheet - U.S. Department of Health and Human Services (U.S. DHHS), Office of the Surgeon General. (2024, November 18). Tobacco reports and publications: Addressing tobacco-related health disparities, TRHD fact sheet. Retrieved February 10, 2026.
24 Kingsbury 2016 - Kingsbury, J. H., & Reckinger, D. (2016). Clearing the air: Smoke-free housing policies, smoking, and secondhand smoke exposure among affordable housing residents in Minnesota, 2014–2015. Preventing Chronic Disease, 13, 160195.
25 Anthony 2019 - Anthony, J., Goldman, R., Rees, V. W., Frounfelker, R. L., Davine, J., Keske, R. R., Brooks, D. R., & Geller, A. C. (2019). Qualitative assessment of smoke-free policy implementation in low-income housing: Enhancing resident compliance. American Journal of Health Promotion, 33(1), 107–117.
26 Hafez 2019 - Hafez, A. Y., Gonzalez, M., Kulik, M. C., Vijayaraghavan, M., & Glantz, S. A. (2019). Uneven access to smoke-free laws and policies and its effect on health equity in the United States: 2000–2019. American Journal of Public Health, 109(11), 1568–1575.
27 Semple 2022 - Semple, S., Dobson, R., O’Donnell, R., Zainal Abidin, E., Tigova, O., Okello, G., & Fernández, E. (2022). Smoke-free spaces: A decade of progress, a need for more? Tobacco Control, 31(2), 250–256.
28 Soto 2022 - Soto, C., Ramos, G., Martinez, D., Moerner, L., Salinas, E., Battle, R., & Yerger, V. (2022). A qualitative assessment of the perceptions and attitudes towards commercial tobacco policies and education among tribal communities in California. The American Journal of Drug and Alcohol Abuse, 48(1), 49–57.
29 ALA-Tobacco control milestones - American Lung Association (ALA). (2026, February 6). Tobacco control milestones. Research & Reports: State of Tobacco Control. Retrieved March 11, 2026.
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