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Reducing Tobacco Use and Secondhand Smoke Exposure: Smoke-Free Policies

Task Force Finding

The Community Preventive Services Task Force recommends smoke-free policies to reduce secondhand smoke exposure and tobacco use on the basis of strong evidence of effectiveness. Evidence is considered strong based on results from studies that showed effectiveness of smoke‑free policies in:

  • Reducing exposure to secondhand smoke
  • Reducing the prevalence of tobacco use
  • Increasing the number of tobacco users who quit
  • Reducing the initiation of tobacco use among young people
  • Reducing tobacco-related morbidity and mortality, including acute cardiovascular events

Economic evidence indicates that smoke-free policies can reduce healthcare costs substantially. In addition, the evidence shows smoke-free policies do not have an adverse economic impact on businesses, including bars and restaurants.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

Smoke-free policies are public-sector regulations and private-sector rules that prohibit smoking in indoor spaces and designated public areas. State and local ordinances establish smoke-free standards for all, or for designated, indoor workplaces, indoor spaces, and outdoor public places. Private-sector smoke-free policies may ban all tobacco use on private property or restrict smoking to designated outdoor locations.

As of December 2012, 26 U.S. states plus Washington, D.C. had enacted comprehensive 100% smoke-free indoor air laws covering government and private worksites, restaurants, and bars (CDC, 2012a).

  • Ten additional states plus Washington, D.C. have 100% smoke-free indoor air laws covering one or more of these settings (government and private worksites must both be covered to be counted; CDC, 2012a).
  • Twelve states have laws or court decisions pre-empting the implementation of local smoke-free air laws in government or private worksites or restaurant settings; however, some of these states do have smoke-free air laws covering at least one setting (CDC, 2012a; CDC, 2012b).

About the Systematic Review

This Task Force finding is based on evidence from a systematic review of legislative smoke-free policies published in 2010 (Callinan et al., 50 studies, search period through-July 2009) combined with more recent evidence and evidence on additional outcomes (82 studies, search period January 2000-December 2011). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to tobacco use and secondhand smoke exposure. The finding updates and replaces two previous Task Force findings on smoke-free policies and smoking bans and restrictions.

Results

Updated Evidence (search period 2000-2011)

Eighty-two studies were included in the review. Results showed that smoke-free policies were associated with decreases in: secondhand smoke exposure; tobacco use prevalence among young people and adults; and adverse health effects.

  • Exposure to Secondhand Smoke (search period 2009-2011)
    • Self-reported exposures (presence, frequency, or duration): median relative reduction of 50% (Interquartile interval [IQI]: -60% to -43%; 6 studies)
    • Secondhand smoke biomarkers in study participants: median relative reduction of 50% (IQI: -79% to -12%; 5 studies)
    • Indoor air pollution, as measured by vapor-phase nicotine or respirable suspended particle mass: median relative reduction of 88% (IQI: -95% to ‑81.2%; 11 studies)
  • Tobacco Use (search period 2009-2011)
    • Prevalence of tobacco use: median absolute reduction of 2.7 percentage points (IQI: -4.7 to -1.5 pct pts;11 studies)
      • Ten additional studies used different measures, eight of which reported favorable findings.
    • Cessation of tobacco use: median absolute increase of 3.8 percentage points (range: 2 to 17.4 percentage points; 4 studies)
      • Six additional studies that used different measures also reported increases in quitting activity.
    • Tobacco consumption (measured as changes in the amount of tobacco used per person): median absolute reduction of 1.2 cigarettes/day (range: -3.6 to 0 cigarettes/day; 5 studies)
      • Four additional studies that used different measures also found reductions in tobacco use.
  • Tobacco Use Among Young People (Adolescents and Young Adults) (search period 2000-2011)
    • The prevalence of tobacco use was lower among young people who were exposed to smoke-free policies: median odds ratio [OR] =0.85 (IQI: 0.68 to 0.93; 6 studies).
    • Eight additional studies used different measurements. In general, these studies found reductions in tobacco use.
  • Health Effects (search period 2000-2011)
    • Cardiovascular events: median relative reduction in hospital admissions of 5.1% (IQI: -11.6% to -2.2%; 9 studies)
      • Different measures were used in four additional studies reporting on hospital admissions for cardiovascular events. Two of these studies found reductions.
      • Three studies (two additional) reported on changes in cardiovascular mortality, two of which found reductions.
    • Asthma morbidity: median relative reduction in hospital admissions of 20.1% (range: -22.0% to -1.3%; 4 studies)
      • One additional study that used different measures of asthma related hospital admissions also found a reduction.
      • Two studies reported on self-reported asthma, one of which found a reduction.
Previous Review (Callinan et al., search period through July 2009)

Fifty studies were included in the review. Results showed that smoke-free policies were associated with decreases in exposure to secondhand smoke, tobacco use prevalence, and negative health effects.

  • Exposure to secondhand smoke
    • Self-reported exposures (presence, frequency, or duration): median relative reduction of 61% (IQI: -81% to -44%; 14 studies)
    • Secondhand smoke biomarkers in study participants: median relative reduction of 69% (IQI: -87% to -43%; 18 studies)
    • Indoor air pollution (as measured by vapor-phase nicotine or respirable suspended particle mass): median relative reduction of 88% (IQI: -97% to ‑26%; 8 studies)
  • Tobacco Use
    • Prevalence of active smoking: median absolute reduction of 3 percentage points (IQI: -5 to -0.8 percentage points; 10 studies)
      • One additional study that used different measurements reported favorable findings.
    • Smoking cessation: median absolute change of 0 percentage points (range: -2 to 4 percentage points; 3 studies)
      • Two additional studies provided different measurements and reported favorable findings.
    • Tobacco consumption (measured as changes in the amount of tobacco used: median absolute reduction of -2 cigarettes/day (IQI: -3 to -0.4 cigarettes/day; 8 studies)
  • Health Effects
    • Cardiovascular events: median relative reduction in hospital admissions of -13.5% (range: -26% to 1%; 5 studies)
      • Different measurements were used from five additional studies reporting on hospital admissions for cardiovascular events. All of these studies found reductions.
    • Asthma: two of three studies reported favorable findings in people with asthma

Applicability

Smoke-free policies were shown to be effective in reducing exposure to secondhand smoke when implemented:

  • In the United States or other high-income countries
  • At national, state, and local levels
  • As comprehensive smoke-free policies (laws that prohibit smoking in all indoor areas of private workplaces, restaurants and bars, with no exceptions)
  • Alone, or in the setting of other interventions to reduce tobacco use and secondhand smoke exposure

Economic Evidence

Eleven studies were included in the economic review, of which two assessed cost-effectiveness, one measured cost-benefit, and eight considered benefits only (costs-averted). All monetary values are reported in 2011 U.S. dollars.

  • Cost per quality-adjusted life year (QALY) gained: $1,138 (1 study)
  • Cost per life year saved (LYS): $8,803 (1 study)
  • Estimated net savings that would result from a U.S nationwide smoke-free policy ranged from $700 to $1,297 per person not currently covered by a smoke-free policy (1 study)
  • One year healthcare costs averted: median estimate of $409,000 per 100,000 persons (range of values: $148,000 to $1.6 million; 5 studies)
  • Annual healthcare costs averted over five or more years: median estimate of $1.1 million per 100,000 persons (range of values: $0.15 million to $4.8 million; 3 studies)
  • Annual smoking-related costs averted for multi-unit housing in the state of California, including averted cleaning, repair, maintenance, and other costs: $18 million (1 study)

The economic impact of smoke-free policies on hospitality establishments (restaurants, bars, hotels, tourist venues, gaming establishments) was also considered using evidence from a systematic review published in 2008 (Scollo & Lal, 158 studies, search period 1988 – January 2008) combined with more recent evidence (21 studies, search period January 2008 – July 2012).

  • Smoke-free policies did not have an adverse economic impact on the business activity of restaurants, bars, or establishments catering to tourists; some studies found a small positive effect of these policies.

Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.

Promotional Materials

Community Guide News

More promotional materials for Community Guide reviews about Reducing Tobacco Use and Secondhand Smoke Exposure.

References

Callinan JE, Clarke A, Doherty K, and Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption (Review). The Cochrane Library 2010; Issue 6.

CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. STATE (State Tobacco Activities Tracking & Evaluation System): State Smoke-free Indoor Air Fact Sheet External Web Site Icon. Centers for Disease Control and Prevention. 2012a.

CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health STATE (State Tobacco Activities Tracking & Evaluation System): State Preemption Fact Sheet: Preemption Can Impede Local Tobacco Protection Efforts External Web Site Icon. Centers for Disease Control and Prevention, 2012b.

Scollo M, Lal A. Summary of studies assessing the economic impact of smoke free policies in the hospitality industry. Melbourne, Australia, Vic Health Centre for Tobacco Control; 2008. Available at URL: http://www.vctc.org.au/tc-res/Hospitalitysummary.pdf.




Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: smoke-free policies. www.thecommunityguide.org/tobacco/smokefreepolicies.html. Last updated: MM/DD/YYYY.

Review completed: November 2012