Smoke-free policies for indoor areas

There is strong evidence that comprehensive smoke-free policies for indoor areas improve health^{1, 2, 4, 5}. Smoke-free policies substantially reduce acute coronary events such as heart attacks^{1, 2, 6, 7, 8, 9} and secondhand smoke (SHS) exposure^{1, 2, 5, 9}. Policies reduce respiratory symptoms among hospitality workers and sensory symptoms among smokers and nonsmokers¹. Smoke-free policies reduce asthma attacks and hospitalizations^{2, 4, 10, 11}, have been shown to reduce the risk of preterm birth^{4, 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 prevalence^{5, 12} and cigarette consumption^{4, 5, 9}, and can lead smokers to quit smoking^{2, 5}. Following policy implementation, younger adults appear to reduce smoking more than older adults^{8, 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 bans^{1, 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 most^{8, 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 areas^{16, 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) saved^{2, 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’ profits^{1, 2, 11}.

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

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 workplaces^{20, 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.