Tobacco Use: Smoke-Free Policies

Related Pages

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) 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.

The full CPSTF Finding and Rationale Statement and supporting documents for Tobacco Use: Smoke-Free Policies are available in The Community Guide Collection on CDC Stacks.

Intervention

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 workplaces, indoor spaces, and outdoor public places.

About The Systematic Review

This finding is based on evidence from a systematic review published in 2010 (Callinan et al., 50 studies, search period through July 2009) combined with more recent evidence (82 studies, search period January 2000-December 2011). The finding updates and replaces two previous CPSTF findings on smoke-free policies and smoking bans and restrictions.

Study Characteristics

  • Studies evaluated policies in the United States, Canada, England, Scotland, Wales, Australia, New Zealand, and several European countries
  • Policies implemented at national, state, and local levels
  • Most studies evaluated tobacco use outcomes using large, population-based surveys
  • Studies used different designs including cross-sectional comparisons, before-after evaluations, and interrupted time series

Summary of Results

Eighty-two studies (search period 2000-2011) showed smoke-free policies were associated with decreases in secondhand smoke exposure, tobacco use prevalence, and adverse health effects.

Exposure to Secondhand Smoke

  • Self-reported exposures: median relative reduction of 50% (6 studies)
  • Secondhand smoke biomarkers: median relative reduction of 50% (5 studies)
  • Indoor air pollution: median relative reduction of 88% (11 studies)

Tobacco Use

  • Prevalence: median absolute reduction of 2.7 percentage points (11 studies)
  • Cessation: median absolute increase of 3.8 percentage points (4 studies)
  • Consumption: median absolute reduction of 1.2 cigarettes/day (5 studies)

Tobacco Use Among Young People

  • Prevalence lower among youth exposed to smoke-free policies: median odds ratio = 0.85 (6 studies)

Health Effects

  • Cardiovascular events: median relative reduction in hospital admissions of 5.1% (9 studies)
  • Asthma morbidity: median relative reduction in hospital admissions of 20.1% (4 studies)

Summary of Economic Evidence

Eleven studies were included. Two assessed cost-effectiveness, one measured cost-benefit, and eight considered benefits only (costs-averted). All monetary values in 2011 U.S. dollars.

  • Cost per quality-adjusted life year gained: $1,138 (1 study)
  • Cost per life year saved: $8,803 (1 study)
  • One year healthcare costs averted: median $409,000 per 100,000 persons (5 studies)
  • Annual healthcare costs averted over five or more years: median $1.1 million per 100,000 persons (3 studies)
  • Smoke-free policies did not have adverse economic impact on restaurants, bars, or hospitality establishments
  • 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)

Applicability

Smoke-free policies were effective when implemented:

  • In the United States or other high-income countries
  • At national, state, and local levels
  • As comprehensive smoke-free policies
  • Alone or with other tobacco control interventions

Evidence Gaps

  • More research is needed to examine the effectiveness of state and local smoke-free policies on tobacco use among young people.
  • Additional research should examine the effects of smoke-free polices on tobacco product substitution among tobacco users who do not quit (e.g., adding or switching to smokeless tobacco, including recently introduced forms such as snus and dissolvables).
  • Future policy evaluations should include assessments of dual or multiple product use among tobacco users.
  • Additional evaluations of smoke-free policies are needed to capture and quantify the broad range of health effects attributable to reductions in both secondhand smoke exposure and tobacco use in the population.
  • Additional implementation and evaluation research is needed for smoke-free policies in settings with unique issues and concerns (i.e. multi-unit housing, addiction and treatment facilities and outdoor settings such as parks and beaches).
  • Additional research is needed to identify effective strategies to encourage change in tobacco use behaviors in homes.
  • Future economic research should consider and report actual costs of implementing smoke-free policies (including efforts to disseminate information to the public and to conduct enforcement).
  • Additional economic evaluations should capture costs and economic outcomes from the tobacco user’s perspective.
  • Research is needed to determine the benefits and costs of implementing smoke-free policies in new settings such as multi-unit housing

Implementation Considerations and Resources

Barriers to adoption include policy exemptions, political opposition, and concerns about economic impact. However, evidence indicates smoke-free policies do not negatively impact business activity.

Implementation of new policies will motivate some tobacco users to quit; tobacco control programs should provide and promote cessation services starting when the policy is adopted.

Resources available for guidance include American Lung Association, Americans For Nonsmokers’ Rights, Tobacco Technical Assistance Consortium, and CDC National Center for Environmental Health.

Crosswalks