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 bans (Cochrane-Frazer 2016*). 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).

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.

Expected Beneficial Outcomes (Rated)

  • Improved health outcomes

  • Reduced exposure to secondhand smoke

  • Reduced tobacco consumption

  • Reduced mortality

  • Reduced hospital utilization

  • Reduced preterm birth

Other Potential Beneficial Outcomes

  • Increased quit rates

  • Reduced youth smoking

  • Reduced health care costs

  • Reduced infant mortality

Evidence of Effectiveness

There is strong evidence that comprehensive smoke-free policies for indoor areas improve health (CG-Tobacco use, Cochrane-Frazer 2016*, Faber 2017, Hoffman 2015). Smoke-free policies substantially reduce acute coronary events such as heart attacks (CG-Tobacco use, Cochrane-Frazer 2016*, Lin 2013, Tan 2012, Meyers 2009*, US DHHS SG-Smoking 2014) and secondhand smoke (SHS) exposure (CG-Tobacco use, Cochrane-Frazer 2016*, Hoffman 2015, US DHHS SG-Smoking 2014). Policies reduce respiratory symptoms among hospitality workers and sensory symptoms among smokers and nonsmokers (Cochrane-Frazer 2016*). Smoke-free policies reduce asthma attacks and hospitalizations (Faber 2017, CG-Tobacco use, Been 2014*, Hahn 2010*), have been shown to reduce the risk of preterm birth (Faber 2017, Been 2014*, Hahn 2010*), and may reduce Sudden Infant Death Syndrome (SIDS) (Hahn 2010*).

Smoke-free policies have been shown to reduce hospitalizations and mortality due to cardiovascular (CG-Tobacco use) and respiratory diseases (Tan 2012). Smoke-free policies reduce smoking prevalence (Hoffman 2015, Lupton 2015*) and cigarette consumption (Faber 2017, Hoffman 2015, US DHHS SG-Smoking 2014), and can lead smokers to quit smoking (Hoffman 2015, CG-Tobacco use). Following policy implementation, younger adults appear to reduce smoking more than older adults (Meyers 2009*, Hopkins 2010*, Mayne 2018*); a 25-year study suggests quit attempts may also be concentrated among women, particularly those with lower incomes (Mayne 2018*). Indoor smoking legislation can improve children’s health outcomes (Faber 2017) and may reduce asthma-related emergency room visits for children (Ciaccio 2016).

Comprehensive policies reduce SHS exposure more than partial bans (Faber 2017, Cochrane-Frazer 2016*, CG-Tobacco use, Hoffman 2015) or policies targeted at specific industries (CG-Tobacco use), and appear to be associated with greater reductions in health risks (Tan 2012). Smoke-free policies reduce SHS exposure for hospitality workers and young people the most (Meyers 2009*, Hahn 2010*).

Some studies suggest that smoke-free policies reduce SHS exposure more in bars in low income areas than higher income areas (CG-Tobacco use). Assessments of a North Dakota law suggest it reduces SHS more in rural areas than urban areas (Buettner-Schmidt 2018*, Buettner-Schmidt 2017). Quit rates, prevalence, and SHS exposure may not drop as much for lower income employees as higher income employees (Hill 2014b), especially if policies are not uniformly implemented (Hahn 2010*). Workplaces with higher income employees may be more likely to enforce their community’s smoke-free laws (Hill 2014b); 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 SHS (Holmes 2017). 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 2014b).

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, Hopkins 2010*). Over the long-term, analysts estimate such policies save between $150,000 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, Cochrane-Frazer 2016*, Hahn 2010*).

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 2018, 28 states and Washington DC have comprehensive smoke-free laws that ban smoking in all public places and workplaces (ALA-Smoke-free air, ALA-SLATI-SF policies) and 36 states banned smoking in some combination of workplaces, restaurants, bars, and casinos (ANRF-Smoke-free lists). 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 indoors (ANRF-Smoke-free lists). Many states also ban smoking in day care centers, grocery stores (CDC-STATE), personal vehicles, and common areas of government housing (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

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.

Citations - Evidence

* Journal subscription may be required for access.

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

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.

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.

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.

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.

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.

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.

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; 2014.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

Citations - Implementation Examples

* Journal subscription may be required for access.

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

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

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

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

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

Date Last Updated