The effects on smokers of Boston's smoke-free bar ordinance: a longitudinal analysis of changes in compliance, patronage, policy support, and smoking at home

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans

INTRODUCTION

While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities.

METHODS

We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities.

RESULTS

The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. We identified "triggering trust," "increasing priorities," and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) limiting opposing interests through the use of the child protection frame.

CONCLUSIONS

This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation.

IMPLICATIONS

In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive SF laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO "Healthy Cities Network" objectives.

Social Acceptance of Smoking Restrictions During 10 Years of Policy Implementation, Reversal, and Reenactment in the Netherlands: Findings From a National Population Survey

INTRODUCTION

Little is known about the extent to which smoking restrictions are socially accepted in a country such as the Netherlands where smoking restrictions have been implemented and reversed several times. The current study assessed trends as well as factors associated with two indicators of social acceptance of smoking restrictions in the Netherlands: acceptance of smoking in public places and implementation of home smoking bans.

METHODS

We used data from the Dutch Continuous Survey of Smoking Habits (DCSSH) between 2005 and 2014 (n = 182826). The DCSSH is a national population survey with a cross-sectional design in which respondents aged 15 years and older are surveyed weekly.

RESULTS

Acceptance of smoking in public places decreased for six out of eight included venues, with the largest decrease for smoking in restaurants. The decrease in acceptance was larger among younger respondents and smokers. Smoking on terraces was an exception: decrease in acceptance there was larger among older respondents and ex-smokers. Implementation of home smoking bans increased over time. Having implemented a home smoking ban was associated with being male, being younger, having a high socioeconomic status, and being ex- or never smoker.

CONCLUSIONS

Social acceptance of smoking restrictions has increased in the Netherlands, despite a suboptimal implementation process of smoking restrictions. However, there is still potential for improvement as acceptance of smoking is still quite high for some public venues like bars. It is important to strengthen smoking restrictions in order to further denormalize smoking in the Netherlands.

IMPLICATIONS

We examined the extent to which smoking restrictions are socially accepted in the Netherlands where smoking restrictions have been implemented and reversed several times. Acceptance of smoking in public places decreased and implementation of home smoking bans increased between 2005 and 2014. Social acceptance of smoking restrictions increased in the Netherlands despite a suboptimal implementation process of smoking restrictions. However, acceptance of smoking in bars remains relatively high.

Tobacco policies and on-premise smoking in bars and clubs that cater to young African Americans following the Maryland Clean Indoor Air Act of 2007

African American young adults ages 18-25 smoke less than their Caucasian peers, yet the burden of tobacco-related illness is significantly higher in African Americans than in Caucasians across the lifespan. Little is known about how clean indoor air laws affect tobacco smoking among African American young adults. We conducted a systematic observation of bars and clubs with events targeted to African American adults 18-25 in Baltimore City at two timepoints (October and November of 2008 and 2010) after enforcement of the Maryland Clean Indoor Air Act (CIAA). Twenty venues-selected on the basis of youth reports of popular venues-were rated during peak hours. All surveillance checklist items were restricted to what was observable in the public domain. There was a significant decrease in observed indoor smoking after CIAA enforcement. Observed outdoor smoking also decreased, but this change was not significant. Facilities for smoking outdoors increased significantly. The statewide smoking ban became effective February 1, 2008, yet measurable changes in smoking behavior in bars were not evident until the City engaged in stringent enforcement of the ban several months later.

Effects of Enactment of Legislative (Public) Smoking Bans on Voluntary Home Smoking Restrictions: A Review

INTRODUCTION

The positive effects of worldwide increases in enactment of legislative bans on smoking in public areas have been well documented. Relatively little is known about the effects of such bans on voluntary home smoking behavior. Meanwhile, private spaces, such as homes, have replaced public spaces as the primary milieu of secondhand smoke exposure.

METHODS

A systematic search of peer-reviewed articles was conducted using multiple databases including Cochrane Library, Cinahl, Embase, Global Health, Health Star, Joanna Briggs, MEDLINE, PsycINFO, PAIS International, PubMed, and Web of Science. We examined peer-reviewed studies that considered the impact of legislation-based public smoking bans on enactment of private home smoking restrictions.

RESULTS

Sixteen articles published between 2002 and 2014 were identified and included. Our results suggest overall positive effects post-legislative ban with the majority of studies demonstrating significant increases in home smoking restrictions. Studies focusing on smoking and nonsmoking samples as well as child populations are discussed in depth.

CONCLUSIONS

Existing evidence indicates an overall significant positive effect post-legislative ban on voluntary home smoking restrictions. While disentangling these effects over space and time remains a challenge, scientific research has converged in dispelling any notion of significant displacement of smoking into the home. Policy makers, especially those in countries without existing public smoking legislation, can rest assured that these types of bans contribute to the minimization of tobacco-related harm.

IMPLICATIONS

Findings converge in dispelling notions of displacement of smoking into the home as a consequence of legislative bans that prohibit smoking in public spaces. Evidence from the studies reviewed suggests that through their influence on social norms, legislative bans on smoking in public places may encourage citizens to establish voluntary home smoking restrictions, thus decreasing harm related to secondhand smoke.

Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans affecting populations. The minimum standard was having an indoor smoking ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. Our search included a broad range of research designs including: randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before-and-after studies, interrupted time series as defined by the Cochrane Effective Practice and Organisation of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

The effect of smoke-free policies on hospitality industry revenues in Cyprus: an econometric approach

OBJECTIVE

Smoke-free policies aiming to improve quality of indoor air and significantly reduce exposure to secondhand smoke in the hospitality industry are faced with strong opposition from the tobacco industry and hospitality venue owners claiming that they lead to reductions of revenues. The objective of our study was to examine the impact of a recently introduced smoke-free legislation on the revenues of the hospitality industry in Cyprus.

METHODS

Anonymous information on revenues was obtained from the Cyprus government value added tax office for the entire hospitality industry in Cyprus including hotels, bars, restaurants and cafeterias between 2005 and 2011. Panel data methodology was used to examine the effect of a smoke-free legislation, on tourism, businesses' revenues adjusting for gross domestic product, inflation, unemployment rate, tourists' arrivals, seasonal variation and the economic crisis.

RESULTS

Our study showed that the implementation of the smoke-free policy did not have negative effects on the hospitality industry profitability.

CONCLUSIONS

We conclude that even in regions with relatively high smoking rates, pro-smoking societal attitudes and weak social norms against tobacco control, and even during periods of economic crisis, smoke-free legislation does not impact negatively on hospitality industry revenues and if anything may lead to a small positive increase.

Smoking restrictions in homes after implementation of a smoking ban in public places

INTRODUCTION

This Canadian study examines the prevalence of smoking restrictions in homes before and after the implementation of a public smoking ban, and their relation to tobacco use and cessation among a cohort of smokers.

METHODS

Data were from a longitudinal cohort study of 1,058 smokers in the province of Québec, Canada. Baseline data were collected through a population-based survey conducted 1 month before the implementation of the smoking ban with a representative sample of smokers. Follow-up data were collected 18 months after the ban with a response rate of 68%. Logistic regressions, paired t tests and chi-square statistics were used to examine the factors associated with smoking restrictions in homes, cigarette consumption, and quit attempts.

RESULTS

Many smokers imposed partial or full smoking restrictions in their homes but proportions of smoke-free homes did not change significantly between baseline and follow-up. The presence of young children and nonsmokers significantly predicted full smoking restriction in the home. Knowledge about risks associated with exposure to secondhand smoke (SHS) and skepticism about the efficacy of methods to reduce exposure in the home also predicted maintenance of voluntary smoking restrictions in homes. The uptake of smoke-free homes was not associated with the quantity of cigarettes smoked or quit attempts.

CONCLUSIONS

No significant change in home smoking bans was found 18 months after implementation of a public smoking ban. There remains a need for efforts to better inform smokers about health risks from exposure to SHS in homes and the reality that strategies other than a total smoking ban inside the home are ineffective.

Multiple streams approach to tobacco control policymaking in a tobacco-growing state

Smokefree policies (SFPs) have diffused throughout the US and worldwide. However, the development of SFPs in the difficult policy environment of tobacco-producing states and economies worldwide has not been well-explored. In 2007, Tennessee, the third largest tobacco producer in the US, enacted the Non-Smoker Protection Act (NSPA). This study utilizes the multiple streams model to provide understanding of why and how this policy was developed by triangulating interviews with key stakeholders and legislative debates with archival documents. In June 2006, the Governor unexpectedly announced support for SFP, which created a window of opportunity for policy change. The Campaign for Healthy and Responsible Tennessee, a health coalition, seized this opportunity and worked with the administration and the Tennessee Restaurant Association to negotiate a comprehensive SFP, however, a weaker bill was used by the legislative leadership to develop the NSPA. Although the Governor and the Tennessee Restaurant Association's support generated an environment for 100% SFP, health groups did not fully capitalize on this environmental change and settled for a weak policy with several exemptions. This study suggests the importance for proponents of policy change to understand changes in their environment and be willing and able to capitalize on these changes.

The effect of Philadelphia and Pennsylvania Clean Indoor Air Act on food services and drinking places sales and numbers, 1998-2011

Introduction

Philadelphia enacted its Clean Indoor Air Act (CIAA) nearly 2 years before the statewide CIAA. In this study, we assessed the economic impact of CIAAs on 4 types of food services and drinking places and addressed the predominant limitation of previous pre–post ban studies, namely the lack of control for confounders and changes in secular trends over time.

Methods

We analyzed data from Pennsylvania Department of Revenue Quarterly 1998–2011 taxable county-level revenue sales and number of food services and drinking places. Region-specific and type-specific adjusted sales and number of food services and drinking places accounted for consumer spending as a general economic indicator. Segmented regression analysis of interrupted time-series methodology assessed changes in trend and level.

Results

Pennsylvania CIAA had no significant effect on adjusted sales or numbers except for an increase in sales in Philadelphia for limited-service eating places and in the surrounding 4 counties for special food services. Philadelphia CIAA was associated with an increase in adjusted numbers of full-service restaurants in Philadelphia and the rest of the state, special food services in Philadelphia, and drinking places in the rest of the state, and a decrease in the number of special food services in the surrounding counties. Philadelphia CIAA had no significant effect on adjusted sales except for an increase in special food services in the rest of the state.

Conclusion

Overall, CIAAs had no negative business-related impact and, for the most part, suggest a positive impact on restaurant sales and numbers. Our results provide further support for comprehensive CIAA ordinance for restaurants.

How society treats smoking

Bans on smoking in bars and other public places can make an important contribution to public health. However, for these bans to be effective, they require broad public support. Qualitative studies of the attitudes and perceptions of bar owners and patrons can help public health professionals identify the steps needed to promote public support for smoking bans. Such studies can also generate narratives and quotes that can help public health professionals translate findings on perceptions and attitudes into effective public education campaigns and related policy changes.

Economic effect of smoke-free ordinances on 11 Missouri cities

Introduction

The harmful effects of secondhand smoke are convincing more and more communities across the United States and the world to prohibit smoking in public places, especially in eating and drinking establishments. A 1993 Missouri state law allows smoking in designated areas in indoor public places such as restaurants and bars. Consequently, some Missouri communities have adopted local ordinances that prohibit smoking in all indoor workplaces, including restaurants and bars. We used an objective measure of economic activity, the taxable sales revenues of eating and drinking establishments, to empirically examine the economic effect of smoke-free ordinances.

Methods

We studied the economic effect of smoke-free ordinances in 11 Missouri cities using multivariate log-linear regression models with log-transformed taxable sales revenues of eating and drinking establishments as the dependent variable and the smoke-free ordinance as the independent variable, while controlling for seasonality, economic condition and unemployment. We used data from 20 quarters before the smoke-free ordinances and at least 10 quarters after the smoke-free ordinances for all cities. The null hypothesis of no effect of smoke-free ordinance on taxable sales of the eating and drinking establishments was tested.

Results

Eight of the 11 cities had increased taxable sales for eating and drinking establishments postordinance. The remaining 3 experienced no change.

Conclusion

The findings of our study are consistent with findings from most published economic studies that a smoke-free ordinance does not harm a local economy.

The impact of Massachusetts' smoke-free workplace laws on acute myocardial infarction deaths

OBJECTIVES

We examined the rate of acute myocardial infarction (AMI) deaths in Massachusetts before and after the implementation of a comprehensive smoke-free workplace law in July 2004.

METHODS

We used Poisson regression models to examine the impact of the state law in cities and towns with and without previous local smoking bans and the effect of the local laws for the period of 1999 through 2006.

RESULTS

The AMI mortality rate decreased by 7.4% (95% confidence interval [CI] = 3.3%, 11.4%) after implementation of the state law. The state ban had an impact in cities and towns with no prior local smoking ban (9.2% decrease; P < .001) but not cities and towns with a prior local smoking ban. However, there was a nonsignificant 4.9% (95% CI = -5.0%, 13.9%) decrease associated with the local smoking ban that preceded the effect of the state ban. The effect of the state ban was modest (-1.6%) in the first 12 months after implementation but much larger after the first 12 months (-18.6%; P < .001).

CONCLUSIONS

Comprehensive statewide smoke-free workplace laws in Massachusetts were associated with an estimated 270 fewer AMI deaths per year. These results add to the evidence suggesting that smoke-free air laws are associated with lower rates of AMI.

Policy support, norms, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico city

OBJECTIVES

We assessed attitudes and beliefs about smoke-free laws, compliance, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico City.

METHODS

Trends and odds of change in attitudes and beliefs were analyzed across 3 representative surveys of Mexico City inhabitants: before implementation of the policy (n=800), 4 months after implementation (n=961), and 8 months after implementation (n=761).

RESULTS

Results indicated high and increasing support for 100% smoke-free policies, although support did not increase for smoke-free bars. Agreement that such policies improved health and reinforced rights was high before policy implementation and increased thereafter. Social unacceptability of smoking increased substantially, although 25% of nonsmokers and 50% of smokers agreed with smokers' rights to smoke in public places at the final survey wave. Secondhand smoke exposure declined generally as well as in venues covered by the law, although compliance was incomplete, especially in bars.

CONCLUSIONS

Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions.

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before and after studies, interrupted-time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

Smoke-free policies and the social acceptability of smoking in Uruguay and Mexico: findings from the International Tobacco Control Policy Evaluation Project

INTRODUCTION

Little research has been conducted to determine the psychosocial and behavioral impacts of smoke-free policies in middle-income countries.

METHODS

Cross-sectional data were analyzed from the 2006 waves of the International Tobacco Control Policy Evaluation. Survey comparing adult smokers in Mexico (n = 1,080), where smoke-free legislation at that time was weak, and Uruguay (n = 1,002), where comprehensive smoke-free legislation was implemented. Analyses aimed to determine whether exposure to smoke-free policies and perceived antismoking social norms were associated with smokers' receiving cues about the bothersome nature of secondhand smoke (SHS), with smokers' reactance against such cues, and with smokers' level of support for smoke-free policies in different venues.

RESULTS

In bivariate analyses, Uruguayan smokers were more likely than Mexican smokers to experience verbal anti-SHS cues, lower reactance against anti-SHS cues, stronger antismoking societal norms, and stronger support for 100% smoke-free policies in enclosed workplaces, restaurants, and bars. In multivariate models for both countries, the strength of voluntary smoke-free policies at home was independently associated with support for smoke-free policies across all venues queried, except for in bars among Uruguayans. Perceived strength of familial antismoking norms was consistently associated with all indicators of the social acceptability of smoking in Uruguay but only with the frequency of receiving anti-SHS verbal cues in Mexico.

DISCUSSION

These results are generally consistent with previous research indicating that comprehensive smoke-free policies are likely to increase the social unacceptability of smoking and that resistance against such policies is likely to diminish once such policies are in place.

Changes in air quality and second-hand smoke exposure in hospitality sector businesses after introduction of the English Smoke-free legislation

BACKGROUND

To monitor and disseminate the short-term effects of the English Smoke-free legislation on air quality and employee exposure in businesses of the hospitality industry.

METHODS

Indoor particle concentrations and salivary cotinine levels were measured in businesses in the hospitality sector and non-smoking employees one month before and after the implementation of the legislation. Results were immediately released to the media to announce the improvements in air quality and employee exposure to the wider public.

RESULTS

Measurements were collected in 49 businesses and from 75 non-smoking individuals. Indoor PM(2.5) concentrations decreased by 95% from 217 microg/m(3) at baseline to 11 microg/m(3) at follow-up (P < 0.001). Salivary cotinine in employees was reduced by 75%, from 3.6 ng/ml at baseline to 0.9 ng/ml at follow-up (P < 0.001). The findings were presented to the public through press releases and interviews and were cited in over 20 media articles.

CONCLUSION

The project demonstrates the positive effects of the English Smoke-free legislation on air quality and second-hand smoke exposure in the hospitality industry sector. We believe that quick and positive feedback to the public on the effects of smoking restrictions is essential when introducing public health legislation such as the Smoke-free legislation.

The impact of banning smoking in workplaces: what are the early effects?

Smoke-free workplace legislation reduces the exposure of both the general public and the workforce to second-hand smoke (SHS) without evidence of an increased exposure to SHS in children in the home. The reductions in exposure are linked to improved respiratory health in previously heavily exposed occupational groups such as bar, restaurant and casino staff. From some countries, there is evidence suggesting that smoking bans have led to declines in hospital admissions for myocardial infarction. There is general agreement that smoking bans, if associated with other tobacco control measures such as tax increases, together with provision of cessation supports, lead to a reduction in the numbers of cigarettes smoked and probably lower smoking rates. Most cities, regions and countries report neutral or positive economic impacts.