Smoke-free policies for indoor areas

Evidence Rating  
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Date last updated
Community in Action

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. Some local governments cannot enact smoke-free measures due to state preemption legislation3.

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, 4, 5. Smoke-free policies substantially reduce acute coronary events such as heart attacks1, 2, 6, 7, 8, 9 and secondhand smoke (SHS) exposure1, 2, 5, 9. Policies reduce respiratory symptoms among hospitality workers and sensory symptoms among smokers and nonsmokers1. Smoke-free policies reduce asthma attacks and hospitalizations2, 4, 10, 11, have been shown to reduce the risk of preterm birth4, 10, 11, and may reduce Sudden Infant Death Syndrome (SIDS)11.

Smoke-free policies have been shown to reduce hospitalizations and mortality due to cardiovascular2 and respiratory diseases7. Smoke-free policies reduce smoking prevalence5, 12 and cigarette consumption4, 5, 9, and can lead smokers to quit smoking2, 5. Following policy implementation, younger adults appear to reduce smoking more than older adults8, 13, 14; a 25-year study suggests quit attempts may also be concentrated among women, particularly those with lower incomes14. Indoor smoking legislation can improve children’s health outcomes4 and may reduce asthma-related emergency room visits for children15.

Comprehensive policies reduce SHS exposure more than partial bans1, 2, 4, 5 or policies targeted at specific industries2, and appear to be associated with greater reductions in health risks7. Smoke-free policies reduce SHS exposure for hospitality workers and young people the most8, 11.

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 areas16, 17. Quit rates, prevalence, and SHS exposure may not drop as much for lower income employees as higher income employees18, especially if policies are not uniformly implemented11. Workplaces with higher income employees may be more likely to enforce their community’s smoke-free laws18; 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 SHS19. 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 policies18.

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, 13. 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, 11.

Experts suggest that states and communities provide and promote cessation services before smoke-free policies take effect2.

How could this strategy impact health disparities? This strategy is rated 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 policies2. As of 2018, 28 states and Washington, D.C. have comprehensive smoke-free laws that ban smoking in all public places and workplaces20, 21 and 36 states banned smoking in some combination of workplaces, restaurants, bars, and casinos22. 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 indoors22. Many states also ban smoking in day care centers, grocery stores23, 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 restrictions23.

Implementation Resources

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.

CDC-STATE-SF air - Centers for Disease Control and Prevention (CDC). State tobacco activities tracking and evaluation (STATE) system. Legislation - smokefree indoor air.


* 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 Grassroots Change - Grassroots Change: Connecting for better health. Preemption Watch.

4 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.

5 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.

6 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.

7 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.

8 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.

9 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.

10 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.

11 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.

12 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.

13 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.

14 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.

15 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.

16 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.

17 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.

18 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

19 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.

20 ALA-Smoke-free air - American Lung Association. Smokefree air laws. 2018.

21 ALA-SLATI-SF policies - American Lung Association, Tobacco Policy Project/State Legislated Actions on Tobacco Issues. Smoke-free laws and policies. 2018.

22 ANRF-Smoke-free lists - American Nonsmokers’ Rights Foundation. Smokefree lists and maps. 2018.

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