Legislative smoking bans for reducing secondhand smoke exposure ...

Legislative smoking bans for reducing secondhand smoke 

exposure, smoking prevalence and tobacco consumption 

(Review) 

Callinan JE, Clarke A, Doherty K, Kelleher C 

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 

2010, Issue 6 

http://www.thecochranelibrary.com 

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

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

T A B L E O F C O N T E N T S 

HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 

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i

[Intervention Review] 

Legislative smoking bans for reducing secondhand smoke 

exposure, smoking prevalence and tobacco consumption 

Joanne E Callinan 1 , Anna Clarke 2 , Kirsten Doherty 3 , Cecily Kelleher 2 

1 Milford Care Centre, Limerick, Ireland. 2 School of Public Health and Population Science, University College Dublin, Dublin 4, 

Ireland. 3 Department of Preventive Medicine and Health Promotion, Education and Research Centre, Dublin 4, Ireland 

Contact address: Joanne E Callinan, Milford Care Centre, Plassey Park Road, Castletroy, Limerick, Ireland. 

joanne_callinan@hotmail.com. 

Editorial group: Cochrane Tobacco Addiction Group. 

Publication status and date: Edited (no change to conclusions), published in Issue 6, 2010. 

Review content assessed as up-to-date: 30 June 2009. 

Citation: Callinan JE, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, 

smoking prevalence and tobacco consumption. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD005992. DOI: 

10.1002/14651858.CD005992.pub2. 


Background 

A B S T R A C T 

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, interruptedtime 

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. 



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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. 

P L A I N L A N G U A G E S U M M A R Y 

Does legislation to ban smoking reduce exposure to secondhand smoke and smoking behaviour? 

There has been an increase in the number of countries and states implementing smoking policies which ban or restrict smoking in 

public places and workplaces. The main reason is to protect nonsmokers from the harmful health effects of exposure to secondhand 

smoke. Another reason is to provide a supportive environment for people who want to quit smoking. Fifty studies were included in this 

review. Legislative bans reduced exposure to secondhand smoke. There was no change in exposure to secondhand smoke in private cars 

after implementing legislative smoking bans. There was no change in self-reported SHS exposure in the home. There are fewer data 

measuring smoking prevalence and smoking behaviour with either no change or a downward trend reported. There is some evidence 

that the health of those affected by the smoking ban improved as a result of its implementation, most impressively in relation to heart 

attacks in hospitals. 

B A C K G R O U N D 

Tobacco is the second major cause of mortality in the world, and 

currently responsible for the death of about one in ten adults 

worldwide (WHO 2005). Measures to control the demand for 

and supply of tobacco products, as well as to protect public health, 

have been highlighted further through the Framework Convention 

on Tobacco Control (WHO 2003). In setting the parameters 

for this systematic review, we take a strict methodological 

approach in keeping with the Cochrane process but we have to 

consider the nature of health promotion interventions in setting 

those parameters. 

Since the publication of the Surgeons General’s Report in 1986 

(WHO 1986), there has been an increase in the number of smok- 

ing bans and restrictions. The US Surgeon General’s Report and 

the National Research Council declared secondhand smoke to be 

a cause of lung cancer in healthy nonsmokers (DHHS 1986; NRC 

1986). Secondhand smoke, also known as environmental tobacco 

smoke (ETS) or passive smoke, is the combination of side-stream 

smoke, i.e. smoke that is emitted between puffs of burning tobacco 

(cigarettes, pipes or cigars), and mainstream smoke, i.e. smoke 

that is exhaled by the smoker (NCI 1999). Secondhand smoke is 

a complex mixture of thousands of gases and particulate matter 

emitted by the combustion of tobacco products and from smoke 

exhaled by those smoking (NRC 1986). Secondhand smoke was 

declared to be carcinogenic by the International Agency for Research 

on Cancer (IARC 2002; IARC 2004). 



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Health effects associated with exposure to SHS have been well 

documented and include lung cancer, lower respiratory tract 

infections, asthma, cardiovascular disease, eye and nasal irritation 

and low birth weight in babies of nonsmokers (Allwright 

2002; Hackshaw 1997; IARC 2002; NCI 1999; NHMRC 1997; 

SCOTH 2004). 

The effect of exposure to secondhand smoke (SHS) on lung function 

is less clear. One review of the evidence published since 1998 

found an association between SHS and respiratory symptoms and 

reduced lung function in adults (SCOTH 2004). Another review 

(Cal EPA 1997) found that the effect of exposure to SHS on pulmonary 

function in healthy adults was likely to be small. The 

effect of exposure to SHS on cardiovascular disease and chronic 

obstructive pulmonary disease (COPD) is unclear, but recent evidence 

suggests that the effects on the cardiovascular system of even 

brief exposure to SHS may be almost as large (80 to 90%) as for 

chronic active smoking (Barnoya 2005). 

In 1986, the Ottawa Charter outlined five priority areas which 

have guided health promotion activities. These were building 

healthy public policies, creating supportive environments, 

strengthening community action, developing personal skills and 

re-orienting the health services (Ottawa 1986). The settings-based 

approach to promoting health recognises the integration of such 

activities into all aspects of the setting, and the need for a more 

co-ordinated, multi-faceted and comprehensive approach. Health 

promotion activities are concerned with both, individual measures 

which aim to target behavioural change and with tobacco control 

measures targeting populations, such as healthy public policies. In 

many settings where legislation is not in place, self regulation can 

be the primary means of controlling exposure to SHS. Smoke-free 

environments have become increasingly common in some settings 

but there is resistance to them in other settings, such as the hospitality 

sector. 

The evaluation of health promotion interventions is controversial 

in the scientific literature. Some argue that the randomized 

controlled trial should serve as the standard for assessing health 

promotion interventions (Davey Smith 2000). It is a concern that 

systematic evidence is not always readily available because of the 

nature of health promotion interventions, as the evidence leans 

towards individual level interventions rather than policy level ones 

(Main 2005; Ogilvie 2005). 

Banning smoking is a public policy issue. The decision-making 

process underpinning it is ultimately a political action which rests 

on a combination of evidence sources, including: 

(i) mechanistic evidence of toxicity of smoke, 

(ii) epidemiological evidence that either smoking or SHS is linked 

to a pathological endpoint, 

(iii) policy evidence that imposing a restriction will be socially 

acceptable and achieve high compliance, 

(iv) action research evidence that it can be successfully implemented. 

Bans and policies can be implemented through public health policies 

or legislation affecting populations at a national, state or community 

level. 

One potential outcome of smoking bans and restrictions is to 

reduce or eliminate the exposure of nonsmokers to the dangers of 

SHS. Another is to reduce tobacco consumption among smokers 

in specified areas e.g. work sites and public places. While SHS in 

the workplace increases the risk of lung cancer among nonsmokers, 

the elevation in risk is modest in comparison with the risk of 

active smoking. The risk estimates vary between 17% and 39% 

(Boffetta 1998; Wells 1998). It has been estimated that for every 

eight smokers who die each year from tobacco use in the United 

States, one nonsmoker will die from the effects of passive smoking 

(Fichtenberg 2002). 

The outcome measure of interest can be problematic. The ultimate 

goal is to reduce the harm from tobacco consumption, and one of 

the main ways is by reducing the prevalence of smoked tobacco. 

The assumption that restricting smoking in some settings will reduce 

overall consumption is often untested. Ethical questions also 

arise in relation to individual civil liberty, and policy makers prefer 

not to interfere with such rights for those who smoke, except for 

minors. It is the harmful effect of passive smoking in nonsmokers 

that justifies the policy action, especially for workers. This means 

that the endpoint is often more likely to be an exposure measure 

to passive smoke than either active smoking rates or a health gain 

of reduced smoking-related morbidity or mortality. 

Legislative smoking bans vary in their comprehensiveness in different 

settings, i.e. the extent to which they allow smoking or restrict 

it to designated areas and where those smoking restrictions occur. 

Legislation prohibiting smoking indoors, including in bars and 

restaurants, is classified in this review as a comprehensive smoking 

ban, even though exemptions may occur in different settings, 

e.g. psychiatric units, prisons, and residential homes, including 

nursing homes. Less comprehensive smoking bans, such as those 

which allow smoking in designated rooms or areas, are classified 

in this review as partial bans. 

In 1998, California became the first state in the USA to implement 

a comprehensive state-wide smoking ban which prohibited 

smoking in all workplaces including restaurants and bars. Since 

then, many American states have enacted similar laws (Arizona, 

Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, 

Massachusetts, Minnesota, New Hampshire, New Jersey, 

New Mexico, New York, Ohio, Rhode Island, Utah, Vermont and 

Washington DC; and the territory of Puerto Rico). In March 2004 

Ireland was the first country in Europe to ban tobacco smoking in 

all workplaces including pubs and restaurants (Tobacco Act 2002). 

Legislation prohibiting smoking in bars and restaurants has been 

enacted in Norway, New Zealand, England, Scotland, Wales and 



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Northern Ireland. Similar legislation restricting smoking further in 

the hospitality sector has been implemented in Italy, Spain, Malta 

and France. Smoking ban legislation is usually preceded and often 

followed by public awareness activities, as well as interventions to 

promote smoking cessation such as those outlined in NICE 2007. 

Smoking bans and restrictions may have the potential to affect 

a large number of individuals in a population at minimal cost 

and to create a supportive environment for those who want to 

quit, thereby helping people who continue smoking to reduce 

their tobacco consumption. Fichtenberg 2002, in a review of the 

effects of totally smoke-free workplaces on daily consumption and 

smoking prevalence, estimated that such policies reduced smoking 

prevalence by 3.8%. An earlier review, however, although detecting 

reduced daily consumption in totally smoke-free work sites, was 

not able definitively to separate this effect from possible secular 

trends (Chapman 1999). The stable long-term effect of bans and 

restrictions remains an open question. 

O B J E C T I V E S 

The overall objective is to assess the extent to which smoking bans 

or restrictions reduce tobacco consumption, smoking prevalence, 

and exposure to secondhand smoke. 

Primary objectives: 

Does the imposition of bans or restrictions have an effect on exposure 

to secondhand smoke? 

Does the imposition of bans or restrictions reduce tobacco consumption 

and smoking prevalence in the area affected by the ban 

or policy? 

Secondary objective: 

What effect does the imposition of bans or restrictions have on 

the smoking-related morbidity and mortality of those affected by 

the ban or restriction? 

M E T H O D S 

Criteria for considering studies for this review 

Types of studies 

We considered studies that report smoking bans which have been 

implemented as a result of legislation. The smoking ban must 

operate at national, state or community level. We do not include 

in this review settings-based bans, such as in workplaces, where 

smoking has been partially or comprehensively restricted, though 

not necessarily as a result of national or state-level legislation. 

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 searched for randomized controlled trials, quasi-experimental 

studies (i.e. non-randomized controlled studies), controlled 

before-and-after studies and interrupted-time series, as defined 

by the Cochrane Effective Practice and Organization of Care 

Group (EPOC 2009 ) and uncontrolled pre- and post-ban data. 

Types of participants 

Smokers and nonsmokers exposed to comprehensive or partial 

smoking bans. The bans must be implemented by legislation or 

policy-making, and may affect populations at a local, regional, or 

national level. 

Types of interventions 

Legislative bans which either ban smoking completely (comprehensive) 

or restrict it to designated areas (partial). For controlled 

studies, the intervention setting may be compared to settings without 

smoking bans or with less restrictive policies. The ban may be 

implemented at national, regional or local level. 

Types of outcome measures 

The primary outcome measures are: 

1. Measures of exposure to secondhand smoke among those affected 

by the ban, including: 

a) measurement of biological markers of exposure in physiological 

fluids e.g. cotinine, or in expired air 

b) self-reported exposure to SHS 

2. Measures of smoking behaviour among those affected by the 

ban, including: 

a) prevalence of tobacco use 

b) tobacco consumption 

c) cessation rates 

The secondary outcome measure is: 

Measures of health outcomes relating to morbidity and mortality, 

e.g. cardiac admissions, respiratory health, and pulmonary function. 

In studies with longer follow up, measures of the incidence 

of lung cancer and cardiovascular disease may also be available. 

We preferred biochemically verified smoking cessation over self 

report, and sustained or prolonged cessation over point prevalence 

cessation. We preferred biochemical verification of exposure 

to environmental tobacco smoke over self-reported perceptions. 

However, we did not exclude studies which did not verify these 

measures biochemically. In order to assess sustained impact, we 

included studies which reported outcomes such as smoking behaviour 

at least six months after the start of the smoking restriction 



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policy. Any measure of smoking behaviour was considered. We 

excluded those studies which reported environmental measures 

of air quality (e.g. particulate matter (PM)2.5, respirable particles 

(RSP), vapour phase nicotine) as their sole measure of exposure to 

SHS. Where possible, we stratified smoking behavioural outcomes 

by age, gender and socio-economic status. 

We also reported on attitudinal outcomes such as acceptability of 

the ban, environmental measures of the concentration of tobacco 

smoke and the characteristics of successful implementation, such 

as compliance as considered in the studies identified, though these 

were not systematic search terms in the review. 

Search methods for identification of studies 

We searched the specialized register of the Cochrane Tobacco Addiction 

Review Group in November 2007. This register includes 

studies identified by regular systematic electronic searches of multiple 

databases (see Cochrane Tobacco Addiction Group for search 

strategies), hand searching of specialist journals and conference 

proceedings, and searching of unpublished reports not normally 

covered by most electronic indexing systems. See Appendix 1 for 

the search terms for this review. 

We conducted the following additional searches: 

• MEDLINE (January 1966 to July 1st 2009); see Appendix 

2 for search strategy. 

• EMBASE (January 1974 to July 1st 2009); see Appendix 3 

for search strategy. 

• OLDMEDLINE (January 1958 to December 1965), via 

the US National Library of Medicine’s Gateway 

• Cumulative Index to Nursing and Allied Health Literature 

(CINAHL) (January 1982 to July 1st 2009), using Ebsco, see 

Appendix 4 for search strategy. 

• PsycInfo (1806 to July 1st 2009), using Cambridge 

Scientific Abstracts, see Appendix 5 for search strategy. 

We also checked the reference lists and bibliographies of included 

studies for further articles, and we contacted other experts for published 

and unpublished trials. We did not exclude any publications 

on the basis of language or publication date. 

We checked web sites for relevant studies, particularly in the USA 

and in Europe where extensive policies are in place restricting 

smoking, although it was not feasible to carry out an exhaustive 

search of all organisations. 

Search terms included ((ban or bans or banned) or restrict* or 

prohibit* or (policy or policies or law or laws)) and (tobacco and 

smoking cessation terms), based on the Tobacco Addiction Group’s 

core search strategies. 

Data collection and analysis 

The review process consisted of the following stages: 

1. One author pre-screened all the results (citations and abstracts) 

to identify studies that may be included or as useful background. 

2. We obtained the full text of any potentially relevant studies. 

Two authors independently assessed them to see whether they 

met the inclusion criteria. Any discrepancies between the authors 

were referred to a third author. Reasons for excluding studies were 

noted. 

3. One author independently extracted data from the included 

studies, and a second author checked their results. 

We rated the overall methodological quality of the included studies 

as being at low, moderate, or high risk of bias. 

We used the following criteria to assess risk of bias: 

1. Method of sequence of generation (if applicable). 

2. Concealment of allocation 

3. Blinding (if applicable) 

4. Follow up (attrition rates and losses to follow up), or response 

rate in studies with cross-sectional data. 

Data collection 

We extracted and reported the following information from each 

study, where it was available: 

1. Country and study setting 

2. Category of study (population- or institution-based) 

3. Size of eligible population 

4. Number of participants or number of clusters and participants 

5. Demographic characteristics (if relevant) of participants 

6. Description and target of the intervention 

7. Definition of smoking status used 

8. Definition of abstinence used 

9. Definition of exposure to secondhand smoke 

10. Outcomes and how they were measured 

11. Additional outcomes, e.g. acceptability, cigarette butt counts. 

12. Biochemical validation (if present) 

13. Length of follow up 

14. Handling of drop-outs and losses to follow up 

15. Adverse effects of intervention 

Meta-analysis was not possible due to the heterogeneity in study 

design, participants, outcomes and nature of the intervention, so 

we have presented summary and descriptive statistics. We report 

any threats to validity or other limitations described by the studies. 

R E S U L T S 

Description of studies 

See: Characteristics of included studies; Characteristics of excluded 

studies; Characteristics of studies awaiting classification. 

We found 50 studies which met the eligibility criteria. See the 

’Characteristics of included studies’ for details of the intervention, 



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participants and outcomes for each study. No randomized controlled 

trials were identified. Twenty four studies included cohort 

follow up pre and post ban, in working populations, 18 studies 

comprised repeated cross-sectional measures mainly in general 

populations and 13 studies were quasi-experimental in design, in 

that they included a reference area. By tracking the same people 

over time, a longitudinal cohort is not affected by extraneous, between 

examination, confounders. 

The studies examined the effect of clean indoor air legislation 

implemented in countries, states and regional areas. The effect 

of the implementation of smoking ban legislation was considered 

in 13 different countries. Seventeen studies were in United States 

of America, eight in Scotland, five in Ireland, four in Italy, three 

each in Spain and Norway, two each in New Zealand, Canada and 

Finland, and one each in France, England, the Netherlands and 

Sweden. 

Legislative smoking bans vary in the extent to which they allow 

smoking or restrict it to designated areas. For this review, legislation 

which prohibits smoking in indoor workplaces, including 

bars and restaurants, is categorised as comprehensive, even though 

it may allow exemptions in particular settings e.g. prisons, or psychiatric 

and mental health settings. Legislation which allows designated 

smoking areas in indoor workplaces, including bars and 

restaurants, is categorised as a partial ban. Ten studies (Alcouffe 

1997; Bondy 2009; Brownson 1995; Fernández 2009; Galán 

2007; Gallus 2007; Heloma 2003; Khuder 2007; Jiménez-Ruiz 

2008; Verdonk-Kleinjan 2009) examined the effects of less restrictive 

legislation which did not prohibit smoking in bars and restaurants, 

and are categorised as partial ban studies. The remaining 

studies are categorised as comprehensive bans. 

Twenty-two studies were concerned with reduction of workplace 

exposure, nineteen of which were concerned with hospitality workers. 

Measures of passive exposure considered in these studies were 

self-reported exposure in general - at work or at home or in cars, 

biomarker verification, and prevailing air quality. 

Measures of active smoking considered were smoking prevalence 

rates, tobacco consumption and smoking cessation. Health outcome 

measures considered were respiratory and sensory symptomatology, 

cardiovascular events, including hospital admission 

rates for acute coronary syndrome or myocardial infarction. 

Risk of bias in included studies 

See Characteristics of included studies for a summary of the 

methodological characteristics. 

Study design 

The predominant type of study design was uncontrolled beforeand-after 

studies, either with cohort follow up or repeated crosssectional 

surveys. We found no randomized controlled trials where 

the primary intervention was a smoking ban. Thirteen quasi-experimental 

studies included a reference area with intervention and 

control conditions but non-randomly allocated, seven in a general 

or workplace setting (Allwright 2005; Biener 2007; Bondy 2009; 

Fernández 2009; Fong 2006; Hahn 2008; Hyland 2009), and six 

which were concerned with hospital admissions (Bartecchi 2006; 

Fichtenberg 2000; Khuder 2007; Pell 2008; Sargent 2004; Seo 

2007). All the remainder were uncontrolled studies with baseline 

measures and at least one or two post-ban assessments, including 

one study with three post-ban follow-up surveys (Farrelly 2005). 

Blinding 

Study investigators and participants could not be blinded since 

the introduction of legislation was public knowledge and was associated 

with a highly visible health behaviour . In one study the 

assessors measuring cotinine concentration were blinded as to the 

smoking status of the participants (Fernández 2009). 

Selection of participants 

Random sampling was used to select the participants in 16 

studies (Biener 2007; Braverman 2008; Brownson 1995; CDC 

2007; Eagan 2006; Fong 2006; Fowkes 2008; Gallus 2007; 

Gilpin 2002; Hahn 2008; Haw 2007; Hyland 2009; Jiménez-Ruiz 

2008; Lemstra 2008; Mullally 2009; Verdonk-Kleinjan 2009;). 

In five studies the method of selection was unclear or not reported 

(Akhtar 2007; Alcouffe 1997; Cesaroni 2008; Galán 2007; 

Palmersheim 2006). Eleven studies used a convenience sample 

(Abrams 2006; Bondy 2009; Ellingsen 2006; Farrelly 2005; 

Fernández 2009; Goodman 2007; Gotz 2008; Heloma 2003; 

Larsson 2008; Menzies 2006; Mulcahy 2005), with all but Abrams 

2006 and Heloma 2003 set in the hospitality sector. In six studies 

the bars were randomly selected for inclusion and their employees 

were invited either to participate (Eisner 1998; Fernando 2007; 

Hahn 2006; Pearson 2009; Semple 2007) or a mixture of random 

and convenience sampling was used (Allwright 2005) to select 

pubs in the intervention and control communities respectively. 

In Waa 2006, a random sample of participants was selected from 

the pre-ban cross-sectional surveys, and a convenience sample was 

used in the follow-up surveys. In one study, the assessors had to 

go through the entire list of randomized bars many times in order 

to achieve adequate sample size (Pearson 2009). 

Comparability of intervention and control 

communities at baseline 

Eight of the quasi-experimental studies described the demographic 

characteristics of participants in the control and intervention conditions 

at baseline (Allwright 2005; Bartecchi 2006; Biener 2007; 

Bondy 2009; Fernández 2009; Fong 2006; Hahn 2008; Seo 2007). 



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Length of follow up 

For smoking behaviour outcomes, we included studies which reported 

follow up at least six months from the implementation of 

the ban. We also included studies with fewer than six months’ 

follow up which measured exposure to secondhand smoke (SHS) 

(Abrams 2006; Eagan 2006; Eisner 1998; Gotz 2008; Menzies 

2006; Mulcahy 2005; Palmersheim 2006; Pearson 2009) 

Biochemical verification 

For randomized controlled trials, biochemical validation of selfreported 

smoking cessation is considered the ’gold standard’ and 

may be obtained through analysis of saliva, urine, blood or expired 

air (Benowitz 2002). In this review, twenty one studies employed 

biomarker verification. Most of them were large population-based 

studies with sample sizes greater than 1000. 

Response rate / missing outcome data 

Cross-sectional independent population surveys were used in 

17 studies (Abrams 2006; Akhtar 2007; Brownson 1995; CDC 

2007; Gallus 2007; Galán 2007; Gilpin 2002; Gotz 2008; Hahn 

2008, Haw 2007, Helakorpi 2008; Heloma 2003, Jiménez-Ruiz 

2008, Lemstra 2008, Mullally 2009; Verdonk-Kleinjan 2009; Waa 

2006). Survey response rates at baseline varied from 29% (Waa 

2006) to 86% (Akhtar 2007), with follow-up response rates ranging 

from 29% (Waa 2006) to 85% (Akhtar 2007). Waa 2006 reports 

on a detailed multi-stage sampling process in its review of 

trends. 

Cohort follow up was employed in 24 studies (Alcouffe 1997; 

Allwright 2005; Biener 2007; Bondy 2009; Braverman 2008; 

Eagan 2006; Eisner 1998; Ellingsen 2006; Farrelly 2005; Fernando 

2007; Fernández 2009; Fong 2006; Fowkes 2008; Goodman 

2007; Gotz 2008; Hahn 2006; Hyland 2009; Larsson 2008; 

Menzies 2006; Mulcahy 2005; Mullally 2009; Palmersheim 2006; 

Pearson 2009; Semple 2007). Nineteen of these studies were set in 

the hospitality sector, with many attributing relatively low followup 

rates to the transience of the workforce or to participants not 

working on the follow-up day. Nonetheless all the cohort studies 

achieved majority response rates, suggesting reasonable representativeness, 

and attempted to deal with problems of attrition affecting 

results. Hahn 2006 conducted an intention-to-treat analysis 

(i.e. including all participants at baseline). One quasi-experimental 

study recruited new participants at follow up to compensate 

for attrition (Hyland 2009). Fifteen studies compared the 

baseline participant characteristics of those who remained in the 

study with those that were not followed up of which five were 

quasi-experimental (Allwright 2005; Biener 2007, Bondy 2009; 

Fernández 2009; Fong 2006) and 10 were uncontrolled studies ( 

Braverman 2008; Eagan 2006; Farrelly 2005; Fowkes 2008; Hahn 

2006; Larsson 2008; Menzies 2006; Mullally 2009; Pearson 2009; 

Semple 2007). Seven of the studies examined differences in outcomes 

measurements at baseline only between respondents and 

non-respondents (Biener 2007; Bondy 2009; Braverman 2008; 

Eagan 2006; Farrelly 2005; Hahn 2006; Mullally 2009). One 

study carried out a repeated cross-sectional analysis and a matched 

sample analysis of cotinine samples of hospitality employees and 

found similar results for both (Gotz 2008). 

Sample size 

Four studies stated that the statistical power of their study was 

limited by the small sample size (Allwright 2005; Biener 2007; 

Eisner 1998; Mulcahy 2005). In one study (Menzies 2006), a 

subsample of asthmatic individuals was considered too small and 

in a Swedish study (Larsson 2008), the low number of smokers 

was outlined as a limitation. In Galán 2007 the sample size was 

considered large enough for the overall analysis but not to allow 

for differences between subgroups. Low numbers of non smoking 

employees was outlined as a potential limitation after stratification 

occurred according to comprehensiveness of the smoking ban in 

Spain (Fernández 2009). 

Effects of interventions 

1 Exposure to secondhand smoke 

Full details of the results of this section are presented in Analysis 

1.1 and Analysis 1.2. Thirty-one studies were identified that examined 

exposure to second-hand smoke, of these, 20 were concerned 

primarily with workplace exposure, predominantly hospitality 

workers the workplace. Nine were confined to self-reported 

workplace exposure (Brownson 1995, Fong 2006, Gilpin 2002, 

Galán 2007; Heloma 2003, Hyland 2009, Palmersheim 2006, 

Verdonk-Kleinjan 2009 and Waa 2006) and 15 considered both 

workplace and total exposure in the wider environment (Abrams 

2006, Allwright 2005, Bondy 2009, CDC 2007, Eisner 1998, 

Farrelly 2005, Fernández 2009, Goodman 2007, Hahn 2006, 

Haw 2007, Jiménez-Ruiz 2008, Mulcahy 2005, Pearson 2009, 

Pell 2008 and Semple 2007). 

Self-reported perceptions of exposure 

All studies clearly showed reduced reported SHS exposure, either 

in duration exposed, ranging from a 71% to 100% reduction 

(Abrams 2006, Allwright 2005, Bondy 2009, Eisner 1998, Farrelly 

2005, Fernández 2009, Goodman 2007, Hahn 2006, Larsson 

2008; Mulcahy 2005, Palmersheim 2006; Pearson 2009, Semple 

2007; Verdonk-Kleinjan 2009) or in percentage of those exposed, 

ranging from 22% to 85% (Brownson 1995; CDC 2007; Farrelly 

2005; Fong 2006; Galán 2007; Gilpin 2002; Haw 2007; Heloma 

2003; Hyland 2009; Jiménez-Ruiz 2008, Larsson 2008, Pell 2008, 

Verdonk-Kleinjan 2009, Waa 2006). See Analysis 1.1 



7

The duration of exposure for hospitality employees ranged from 

30-69 hours before the law was implemented and this was dramatically 

reduced afterwards, whether measured as percentage of 

those exposed (Eagan 2006, Jiménez-Ruiz 2008 or duration of 

exposure (Abrams 2006, Bondy 2009, Eisner 1998, Farrelly 2005, 

Goodman 2007, Hahn 2006, Menzies 2006). One quasi-experimental 

study (Bondy 2009) found a significant reduction (>95%) 

in total hours exposed to SHS (work and other) by non-smoking 

employees in Toronto compared to the control. Whilst some 

venues had designated smoking areas in Toronto, only employees 

from venues with comprehensive bans were included in the study. 

Analysis 1.1 

Biomarkers of exposure to SHS 

Eighteen of these studies considered biomarker validation (Abrams 

2006; Akhtar 2007; Allwright 2005; Bondy 2009; CDC 2007; 

Ellingsen 2006; Farrelly 2005; Fernando 2007; Fernández 2009; 

Goodman 2007; Gotz 2008; Hahn 2006; Haw 2007; Menzies 

2006; Mulcahy 2005; Pearson 2009; Pell 2008; Semple 2007), the 

most frequent being cotinine measures, employed in 17 studies 

and saliva cotinine in 12 of those. 

Of 12 studies utilising saliva cotinine concentration as a measure 

of exposure to SHS, sizeable reductions in exposure ranging from 

39% to 89% were recorded. Five studies examined biomarkers as 

a measure of exposure in both smokers and non smokers, in three 

of which (Goodman 2007, Hahn 2006, Pell 2008), no significant 

change was seen in smokers’ concentrations and in two cases ( 

Ellingsen 2006, Semple 2007) a reduction was seen in cotinine 

for those who smoked, but less than in non smokers. See Analysis 

1.2 

Exposure to SHS in cars 

Five studies measured exposure to SHS in cars and found that it 

remained unchanged before and after the ban was implemented 

(Akhtar 2007; Fong 2006; Hahn 2006; Haw 2007; Pell 2008). 

One of these (Akhtar 2007) measured the percentage of children 

exposed and found both that it was low at baseline and unchanged 

at follow up. See Analysis 1.1.3. 

Exposure to SHS in homes 

Fifteen studies measured exposure to SHS in the home (Abrams 

2006; Akhtar 2007; Biener 2007; Brownson 1995; Fong 2006; 

Galán 2007; Gilpin 2002; Hahn 2006; Haw 2007; Hyland 2009; 

Jiménez-Ruiz 2008; Larsson 2008; Palmersheim 2006; Pell 2008; 

Waa 2006). In general there was no change after the implementation 

of the ban though some studies reported positive findings. 

Fong 2006 reported a significant reduction in homes allowing 

smoking and Gilpin 2002 indicated that the percentage of Californian 

adults reporting smoke-free homes increased one year 

post ban. Similarly Waa 2006 reported reduced exposure in New 

Zealand. In two studies where home smoking was assessed, there 

was no change (Galán 2007 & Biener 2007). Galán 2007 showed 

a drop in smoking at work in compliance with the ban in Spain, 

but not at home. Similarly Biener 2007, in a Boston study showed 

no reduction in home smoking rates. See Analysis 1.1.4. 

In conclusion, in general studies report positive impact of bans on 

exposure to second-hand smoke, the most robust being cotinine 

validated studies, all of which showed the anticipated benefit. The 

high percentage of change reported in many studies reflect the 

absolute nature of the exposure, that is, either being protected or 

not from an environmental hazard - in this case passive tobacco. 

2 Measures of Active smoking 

Full details of the results of this section are presented in Analysis 

2.1. Less than half of the studies considered active smoking and of 

those that did there was little methodological consistency. Three 

measures were considered - smoking prevalence rates, measures of 

tobacco consumption and reported smoking cessation. Twentythree 

of 50 studies contained some reference to active smoking, 

no study reported all three measures. Fifteen studies contained a 

measure of smoking prevalence; six of these considered smoking 

prevalence only with no measure of consumption (Alcouffe 1997; 

Hahn 2008; Helakorpi 2008; Jiménez-Ruiz 2008; Lemstra 2008; 

Pell 2008); one considered both smoking prevalence in designated 

settings and cessation information (Waa 2006); eight studies measured 

both smoking prevalence and consumption (Barone-Aldesi 

2006; Braverman 2008; Cesaroni 2008; Eisner 1998; Gallus 2007; 

Hahn 2006; Heloma 2003; Mullally 2009). Five studies assessed 

both tobacco consumption and cessation (Fong 2006; Galán 2007; 

Hyland 2009; Larsson 2008; Semple 2007), one considered tobacco 

consumption only (Fichtenberg 2000) and two considered 

cessation only (Biener 2007; Fowkes 2008). 

Smoking prevalence 

Whilst 15 studies included information on smoking prevalence, 

it was reported primarily as a confounder or co-variable for interpretation 

of passive smoking exposure rather than an outcome 

measure in itself in five studies (Barone-Aldesi 2006; Eisner 1998; 

Hahn 2006; Jiménez-Ruiz 2008; Pell 2008). Barone-Aldesi 2006 

for instance estimated that the observed reduction in active smoking 

after the ban in Italy could account for 0.7% of the decrease in 

acute myocardial infarction admissions. Eight remaining studies 

indicated a modest fall in smoking, either in relation to a reference 

group, or over time pre-post ban and two showed no change. See 

Analysis 2.1. 

An early French study of office workers in enclosed public places 

(Alcouffe 1997) failed to detect a change in prevalence at two-year 

follow up but indicated the ban was poorly observed. Mullally 

2009 showed that there was no significant change in smoking 

prevalence of bar employees at one year follow up, though a drop 



8

of borderline significance, (3.5%, p=0.06) was observed in the occupationally 

equivalent general population. Two studies compared 

a county or city with a comprehensive smoking ban with adjacent 

areas without a ban, and found significant reductions in prevalence 

in the intervention regions. Hahn 2008 reported a 32% reduction 

in prevalence in Lexington-Fayette County compared with a 

2.8% drop in counties without a ban, while Lemstra 2008 found 

a 24.5% drop in prevalence in Saskatoon (comprehensive ban) 

compared with unchanged prevalence in the rest of Saskatchewan 

(no ban). 

Initial reductions in daily smoking (-4.6%) and in smoking at work 

(-6.8%) at four months in a Norwegian study (Braverman 2008) 

were maintained at 11-month follow up. In one study (Gallus 

2007) there was a 7.2% reduction in smoking prevalence from 

2004 to 2006. Two studies detected reduced prevalence in men 

but not significantly in women, with one Italian study reporting 

post-ban reductions of 12.6% (Cesaroni 2008) in men’s smoking 

compared with women’s reduction of 0.9%. A Finnish study ( 

Heloma 2003) detected a 25% decrease in men’s smoking over 

four years, compared with an 18.6% increase in women’s smoking 

over the same period. However, this study included a relatively 

small number of women smokers, and may have been subject to 

random variation. A further study in Finland examined data over 

a prolonged period 1981-2005 (Helakorpi 2008) and employed 

logistic models to control for other confounding factors. The odds 

of smoking were reduced amongst both working men and women 

compared to the 1994 pre ban period. These data therefore suggest 

a limited evidence base for an impact of bans on active smoking. 

Tobacco consumption and smoking cessation 

Thirteen studies reviewed tobacco consumption as an outcome. 

Eight of these had also considered impact on prevalence (Barone- 

Aldesi 2006, Braverman 2008, Cesaroni 2008, Eisner 1998, Gallus 

2007, Hahn 2006, Heloma 2003, Mullally 2009) and all but one 

(Eisner 1998) indicated a drop in average consumption of tobacco. 

One study (Fichtenberg 2000) only considered consumption measures 

as part of a regression model to assess impact of passive smoke 

exposure on heart disease death rates but did note reduction in 

pack sales associated with the ban period. Gallus 2007 and Hahn 

2008 both noted reductions in number of cigarettes smoked per 

day and Heloma 2003 noted a drop in tobacco consumption. See 

Analysis 2.1 

Five studies (Fong 2006, Galán 2007, Hyland 2009, Larsson 

2008 and Semple 2007) looked at both tobacco consumption and 

cessation. Two further studies considered only cessation (Biener 

2007 and Fowkes 2008. See Analysis 2.1. Semple 2007 and Fowkes 

2008 demonstrated quit rates of 4% and 12% respectively, whereas 

Hyland 2009 showed no change in cessation rates in Scotland 

compared to the rest of the UK where a ban had not yet been 

introduced. Larsson 2008 found no change in smoking quit status 

in hospitality employees in Sweden at 12 months follow up, but 

the number of smokers was small. Waa 2006 showed drops in selfreported 

smoking rates by smokers in various hospitality settings. 

3 Health outcomes 

In this review, we report included studies that also measure the 

effects of smoking ban legislation on health outcomes. They have 

been categorised as a) respiratory symptoms b) sensory symptoms 

and c) admission rates for acute coronary events. Ten of these 

studies reported on both respiratory and sensory symptoms and 

two other studies reported on respiratory or sensory symptoms 

alone. Twelve studies reported on the impact of the legislation on 

admission rates for acute coronary events. 

Respiratory symptoms 

Twelve included studies reported respiratory symptoms as an outcome 

(Allwright 2005; Eagan 2006; Eisner 1998; Farrelly 2005; 

Fernández 2009; Goodman 2007; Hahn 2006; Larsson 2008; 

Menzies 2006; Palmersheim 2006; Pearson 2009; Semple 2007). 

Ten of the 12 studies reported some significant reduction in respiratory 

symptoms. (Analysis 3.1) All studies were carried out in 

the hospitality or bar worker settings, although some of the studies 

only examined the outcome in nonsmokers. Length of follow 

up varied from one month to 12 months post implementation of 

ban. Five of these studies and an additional study, Ellingsen 2006, 

looked at the impact of the legislation on lung function measurements. 

(Analysis 3.2) The impact was mixed with only two studies 

showing a significant increase in forced expiratory volume in one 

second (FEV1), three studies an increase in forced vital capacity 

(FVC) and two studies showing an reduction in forced expiratory 

flow (FEF). 

Sensory symptoms 

Ten included studies reported sensory symptoms as an outcome, 

(Allwright 2005; Eisner 1998; Farrelly 2005; Goodman 

2007; Hahn 2006; Larsson 2008; Menzies 2006; Palmersheim 

2006; Pearson 2009; Semple 2007). (Analysis 3.3) The impact on 

sensory symptoms was clear; there was a reduction of symptoms 

in non smokers and smokers. In nonsmokers, the reduction in 

symptoms was seen especially relating to eye, nose and throat. Five 

studies also showed reduction of symptoms in smokers but the 

pattern differed in each study with a reduction in eye symptoms 

being the most common finding. One study of non smokers and 

smokers groups each showed that legislation had no effect on sensory 

symptoms. 

Hospital admission for acute coronary syndrome 

Twelve studies reported hospital admission rates for acute myocardial 

infarction (AMI) or coronary heart disease following 

implementation of a ban; five in USA (Bartecchi 2006; Juster 



9

2007; Khuder 2007; Sargent 2004; Seo 2007); three in Italy 

(Barone-Aldesi 2006; Cesaroni 2008; Vasselli 2008); one in Scotland 

(Pell 2008) and one in Canada (Lemstra 2008). Four studies 

had control groups without a ban. The impact on admissions for 

AMI showed a reduction in numbers in all 10 studies. (Analysis 

3.4) Two further studies showed an impact on deaths from coronary 

heart disease (Fichtenberg 2000) and better prognosis post 

acute coronary syndrome amongst non smokers (Pell 2009) following 

legislation. One study measured individual exposure to active 

smoking (Pell 2008) and three further studies used measures 

of population smoking prevalence and/or cigarette consumption, 

not individual exposure. Two of these studies measured cotinine 

levels and one examined pollution reduction by measuring PM10 

(Cesaroni 2008). It is evident that in every study looking at an effect 

of smoking legislation on acute coronary syndrome, the overall 

impact of the legislation was positive. 

4 Other outcomes 

Other outcomes such as support for the ban, compliance with the 

legislation, air quality, economic impact of the legislation and any 

adverse effects were reported from the included studies. 

Support for the ban 

Studies also reported acceptability or support of smoking bans 

as an outcome. Support for the legislation increased in nine of 

the studies (Biener 2007; Fong 2006; Fowkes 2008; Gallus 2007; 

Heloma 2003; Hyland 2009; Larsson 2008; Palmersheim 2006; 

Waa 2006). Two studies showed no significant change in support 

pre and post ban. One study showed greater than 70% support 

post ban with greater support amongst smokers who had stopped 

or tried to stop smoking. Four studies showed that support was 

greater amongst non smokers than smokers but support for the 

smoking ban legislation increased for both smokers and non smokers 

after implementation. 

Compliance with the legislation 

Nine studies were included in this review which also reported 

compliance with smoking bans as an outcome (Biener 2007; 

Fernando 2007; Fong 2006; Galán 2007; Goodman 2007; Gotz 

2008; Heloma 2003; Lemstra 2008; Mulcahy 2005). Four studies 

reported full compliance in no smoking hospitality venues, 

three others reported significant decrease in observed smoking or 

smoking in the workplace. Two others showed compliance with 

the ban in terms of signage. Only one study reported that 31% 

of smokers reported no change post ban or seeing more smoking 

after implementation of ban. 

Air quality 

Eight included studies in this review reported environmental measures 

of air quality (Cesaroni 2008; Ellingsen 2006; Goodman 

2007; Gotz 2008; Heloma 2003; Larsson 2008; Mulcahy 2005; 

Semple 2007). The impact was clear with all studies showing a 

significant reduction in levels of markers of poor air quality such 

as nicotine, dust, benzene and particulate matter. 

Economic impact of the smoking ban legislation 

Seven studies reviewed the economic impact of the smoking 

legislation (Biener 2007; Cesaroni 2008; Gallus 2007; Helakorpi 

2008; Hyland 2009; Juster 2007; Waa 2006). Three reported 

there was no significant decrease on bar patronage as measured 

pre and post ban, two of these also reported no significant decrease 

on restaurant attendance with one of them showing a significant 

increase in numbers of nonsmokers attending restaurants. 

Two of the studies examined the numbers of cigarette sales pre 

and post ban and found a significant reduction in cigarette sales 

post introduction of legislation. One study reported on savings 

in health care expenditure attributable to a decrease in MI admissions 

post introduction of legislation (Juster 2007). One study 

included economic indicators in its model assessing the impact of 

a ban (Helakorpi 2008). Many other studies looked at the economic 

impact of smoking legislation, however these studies did 

not examine health outcomes and thus were excluded. 

Adverse effects 

Three studies which we included in this review report on other 

adverse or otherwise negative effects of implementing smoking 

bans (Fernando 2007, Gilpin 2002, Mulcahy 2005). All of the 

studies reported that there was still a potential for smoke from 

outdoor areas to drift into indoor areas. 

D I S C U S S I O N 

Legislation restricting or prohibiting smoking in workplaces and 

public places is a public health measure at the population level. 

There were no randomized controlled trials where the intervention 

of the study was a smoking ban. The predominant study design 

when evaluating the effectiveness of smoking bans were uncontrolled 

studies with a before and after design which were often 

unable to control for possible confounders and changes in secular 

trends over time. Nonetheless the balance of evidence from both 

the repeated cross-sectional and cohort studies strongly suggests 

that the primary objective of reducing tobacco smoke exposure 

was achieved, particularly amongst hospitality workers. This was 

validated in many studies by cotinine measures and corroborated 

in some cases also by improvements in air quality. Exposure to secondhand 

smoke in workplaces, public places, bars and restaurants 



10

was reduced, but there was no evidence of a change in exposure to 

SHS in private cars or vehicles. There was no consistent change 

in either the prevalence of reported exposure to SHS or the duration 

in exposure to SHS in the home as a result of implementing 

legislative bans. 

The studies were heterogeneous in their design, populations and 

intervention and we were unable to perform statistical comparisons 

or meta-analyses. Ten studies were classified for the purposes 

of this review as having partial bans. However, the extent to 

which the law allowed smoking in bars and restaurants differed 

in these studies with some allowing smoking indoors or in designated 

smoking areas if certain conditions were met such as the 

venue been a certain size or having a ventilation system in place. 

Other limitations in the studies included small sample sizes and 

convenience sampling which leads to a potential risk of selection 

bias. Attrition bias from loss to follow up was mainly due to the 

employees having left their workplace at follow up, though the retention 

rates in the cohort studies reported were very respectable. 

In the cohort studies, there was no difference between baseline 

characteristics of the respondents at follow up and non-respondents 

for half the studies. In the remainder, non-respondents were 

younger and were more likely to be smokers than those who participated 

at follow up. Cohort follow up was employed primarily 

in working populations, whereas cross-sectional surveys were the 

methodology of choice in general surveys. 

Compared with before the ban, approval of the smoking policies 

as well as their compliance with them increased after implementation 

of smoking bans. There is evidence of reduction in reporting 

of respiratory and sensory symptoms. There is inconsistent 

evidence that pulmonary function tests improved as a result of 

the implementation of smoke-free legislation. There was a shift 

towards acceptance of the smoking policy after the ban. 

There was persuasive evidence of a reduction in hospital admissions 

rates for acute coronary syndrome from pre- to post-ban periods. 

All 12 studies concerned with hospital care showed an improvement 

consistent with the ban, the most persuasive of these 

being able to link the outcome positively to the relative presence 

of the ban compared to other possibly confounding factors. Taken 

together, the benefits for workers and the reduction of hospitalrelated 

morbidity are impressive. 

From a public health perspective, smoking bans implemented due 

to legislation are concerned with reducing employee exposure to 

passive smoke. There were a greater number of studies evaluating 

the effect of smoking bans on outcomes measuring exposure to 

passive smoke and health than smoking behaviour as an outcome 

measure. Surprisingly little attention was given to active smoking 

behaviour, measured in less than half of all included studies. The 

measurements used were also diverse, making it difficult to compare 

the findings. The effect of smoking bans on smoking prevalence 

was inconclusive with smoking prevalence declining slightly 

in most of the population based studies, particularly amongst 

working men but remaining unchanged or not adequately assessed 

in the studies of workplaces. There was inconsistent evidence of a 

reduction in cigarette consumption, but in studies where declines 

in prevalence were recorded, consumption levels also fell. Whilst 

several country-based studies did show improvements in smoking 

trends, the question of active smoking merits further investigation. 

Other associated findings reported, while not a primary objective 

in the included studies, were acceptability or support for the smoking 

ban legislation, compliance with the legislation, air quality in 

those venues affected by the ban, the economic impact as well 

as any reports from the included studies of adverse effects from 

implementing the legislation. Enforcement of the smoking ban 

legislation is necessary to ensure high level of compliance for its 

successful implementation. 

Smoking policies usually comprise multi-component efforts to 

tackle smoking cessation as well as the public health objective of reducing 

exposure to environmental tobacco smoke. Populations exposed 

to smoking restrictions accordingly are likely to be exposed 

to other interventions. The implementation of comprehensive legislation 

on smoking policy will necessitate other tobacco control 

measures to prepare for its successful implementation such as increased 

media awareness, telephone smoking cessation helplines 

and smoking cessation support services to ensure awareness, comprehension 

and support of those affected by it (hospitality sector, 

patrons, population). The effectiveness of legislative efforts 

will also depend on successful enforcement of smoking bans and 

compliance with the legislation. Other tobacco control measures 

such as taxation on tobacco products, limits on advertising and 

sponsorship and limits on the sale of tobacco products may vary 

between jurisdictions. A comprehensive approach to tobacco control 

will utilize both individual and population based intervention 

strategies causing difficulties in evaluating the effect of a single 

intervention such as the smoking ban legislation 

A U T H O R S ’ C O N C L U S I O N S 

Implications for practice 

Support for smoking bans has increased with time and compliance 

with the legislation is high. Workers, particularly in the hospitality 

sector have benefited from reduced exposure to passive smoke and 

attributable health benefits associated with cardiac care particularly 

are suggestive of a benefit. The balance of evidence suggests that 

legislative smoking bans have achieved their primary objective of 

reducing exposure to second hand smoke. The impact on active 

smoking is not yet conclusively demonstrated. 

Implications for research 

More research on the impact of smoking bans on active smoking 

is warranted. Whilst more comprehensive bans are now being en- 



11

acted in many jurisdictions, there is also a need for research into the 

extent to which exposure to SHS in non-smoking areas is a result 

of smoke coming from the outdoor smoking areas. Further studies 

should utilise larger sample sizes with common agreed measures 

for smoking behaviour and exposure to SHS of the study population. 

The lack of a reference group in many studies means that it is 

difficult to differentiate between secular trends and impact of the 

intervention, particularly on secondary outcomes such as active 

smoking rates. The use of factorial design in research, that is a two 

way comparison of interventions, utilizing randomized or quasiexperimental 

allocation, would enable differentiation between the 

effectiveness of a) smoking ban in comparison to a control or reference 

region with no ban and b) population subjected to a smoking 

ban with or without other smoking cessation intervention(s). 

References to studies included in this review 

Abrams 2006 {published data only} 

Abrams SM, Mahoney MC, Hyland A, Cummings KM, Davis W, 

Song L. Early evidence on the effectiveness of clean indoor air 

legislation in New York State. American Journal of Public Health 

2006;96:296–8. 

Akhtar 2007 {published data only} 

Akhtar PC, Currie DB, Currie CE, Haw SJ. Changes in child 

exposure to environmental tobacco smoke (CHETS) study after 

implementation of smoke-free legislation in Scotland:national 

cross-sectional survey. BMJ 2007;335(7619):546–9. 

Alcouffe 1997 {published data only} 

Alcouffe J, Fabin C, Brehier M, Fleuret C, Botran-Aly C, Simonnet 

M, et al. Smoking prohibition effect on tobacco habits in Paris area 

small firms. Archives des Maladies Professionnelles et de Medecine du 

Travail 1997;58(5):455. 

Allwright 2005 {published data only} 

Allwright S, Paul G, Greiner B, Mullally BJ, Pursell L, Kelly A, et 

al. Legislation for smoke-free workplaces and health of bar workers 

in Ireland: before and after study. BMJ 2005;331:1117–20. 

Barone-Aldesi 2006 {published data only} 

Barone-Aldesi F, Vizzini L, Merletti F, Richiardi L. Short-term 

effects of Italian smoking regulation on rates of hospital admission 

for acute myocardial infarction. European Heart Journal 2006;27: 

2468–72. 

Bartecchi 2006 {published data only} 

Bartecchi C, Alsever RN, Nevin-Woods C, Thomas WM, Estacio 

RO, Bucher Bartelson B. Reduction in the incidence of acute 

myocardial infarction associated with a citywide smoking 

ordinance. Circulation 2006;114:1490–96. 

Biener 2007 {published data only} 

Biener L, Garrett CA, Skeer M, Siegel M, Connolly G. 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. Journal of Public Health Management and 

Practice 2007;13:630–6. 

R E F E R E N C E S 

Such designs are feasible in large countries with federal, regional 

and state level structures and preliminary evidence to date suggests 

that public bans are effective but need to be contextualized 

as part of wider anti-smoking policy. More research is required on 

the long term impact of smoking bans on the health outcomes of 

specific subgroups of the population such as the young children, 

disadvantaged and minority groups. 

A C K N O W L E D G E M E N T S 

We wish to acknowledge support and advice from the Cochrane 

Tobacco Addiction Review Group. 

Bondy 2009 {published data only} 

Bondy SJ, Zhang B, Kreiger N, Selby P, Benowitz N, et al. Impact 

of an indoor smoking ban on bar workers’ exposure to secondhand 

smoke. Journal of Occupational and Environmental Medicine 2009; 

51:612–9. 

Braverman 2008 {published data only} 

Braverman MT, Aarø LE, Hetland J. Changes in smoking among 

restaurant and bar employees following Norway’s comprehensive 

smoking ban. Health Promotion International 2008;23:5–15. 

Brownson 1995 {published data only} 

Brownson RC, Davis JR, Jackson-Thompson J, Wilkerson JC. 

Environmental tobacco smoke awareness and exposure: impact of a 

statewide clean indoor air law and the report of the US 

Environmental Protection Agency. Tobacco Control 1995;4:132–8. 

CDC 2007 {published data only} 

Pechacek T, Kaufmann R, Trosclair A, Caraballo R, Caudill S. 

Reduced secondhand smoke exposure after implementation of a 

comprehensive statewide smoking ban-New York, June 26, 2003- 

June 30 2004. Morbidity & Mortality Weekly Report 2007;56(28): 

705–8. 

Cesaroni 2008 {published data only} 

Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci 

CA. Effect of the Italian smoking ban on population rates of acute 

coronary events. Circulation 2008;117:1183–8. 

Eagan 2006 {published data only} 

Eagan T. Decline in respiratory symptoms in service workers five 

months after a public smoking ban. Tobacco Control 2006;15: 

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Eisner 1998 {published data only} 

Eisner MD, Smith AK, Blanc PD. Bartenders’ respiratory health 

after establishment of smoke-free bars and taverns. JAMA 1998; 

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Ellingsen 2006 {published data only} 

Ellingsen DG, Fladseth G, Daae HL, Gjolstad M, Kjaerheim K, 

Skogstad M, et al. Airborne exposure and biological monitoring of 



12

ar and restaurant workers before and after the introduction of a 

smoking ban. Journal of Environmental Monitoring 2006;8:362–8. 

Skogstad M, Kjaerheim K, Fladseth G, Gjolstad M, Daae HL, 

Olsen R, et al. Cross shift changes in lung function among bar and 

restaurant workers before and after implementation of a smoking 

ban. Occupational and Environmental Medicine 2006;63:482–7. 

Farrelly 2005 {published data only} 

Farrelly MC, Nonnemaker JM, Chou R, Hyland A, Peterson KK, 

Bauer UE. Changes in hospitality workers’ exposure to secondhand 

smoke following the implementation of New York’s smoke-free law. 

Tobacco Control 2005;14:236–41. 

Fernando 2007 {published data only} 

Fernando D, Fowles J, Woodward A, Christophersen A, Dickson S, 

Hosking M, et al. Legislation reduces exposure to second-hand 

tobacco smoke in New Zealand bars by about 90%. Tobacco 

Control 2007;16:235–8. 

Fernández 2009 {published data only} 

Fernández E, Fu M, Pascual JA, López MJ, Pérez-Ríos M, 

Schiaffino A, et al. Impact of the Spanish smoking law on exposure 

to second-hand smoke and respiratory health in hospitality workers: 

A cohort study. PLoS ONE 2009;4:e4244. 

Fichtenberg 2000 {published data only} 

Fichtenberg CM, Glantz SA. Association of the California Tobacco 

Control Program with declines in cigarette consumption and 

mortality from heart disease. New England Journal of Medicine 

2000;343:1772–7. 

Fong 2006 {published data only} 

Fong GT, Hyland A, Borland R, Hammond D, Hastings G, 

McNeill A, et al. Reductions in tobacco smoke pollution and 

increases in support for smoke-free public places following the 

implementation of comprehensive smoke-free workplace legislation 

in the Republic of Ireland: findings from the ITC Ireland/UK 

Survey. Tobacco Control 2006;15 Suppl 3:iii51–8. 

Fowkes 2008 {published data only} 

Fowkes FJ, Stewart MC, Fowkes GR, Amos, A, Price JF. Scottish 

smoke-free legislation and trends in smoking cessation. Addiction 

2008;103:1888–95. 

Gallus 2007 {published data only} 

Gallus S, Pacifici R, Colombo P, Scarpino V, Zuccaro P, Bosetti C, 

et al. Prevalence of smoking and attitude towards smoking 

regulation in Italy, 2004. European Journal of Cancer Prevention 

2006;15:77–81. 

Gallus S, Zuccaro P, Colombo P, Apolone G, Pacifici R, Garattini S, 

La Vecchia C. Effects of new smoking regulations in Italy. Annals of 

Oncology 2006;17:346–7. 

∗ Gallus S, Zuccaro P, Colombo P, Apolone G, Pacifici R, Garattini 

S, et al. Smoking in Italy 2005-2006: Effects of a comprehensive 

national tobacco regulation. Preventive Medicine 2007;45:198–201. 

Gorini G, Costantini AS, Paci E. Smoking prevalence in Italy after 

the smoking ban: Towards a comprehensive evaluation of tobacco 

control programs in Europe. Preventive Medicine 2007;45:123–4. 

Galán 2007 {published data only} 

Gálan I, Mata N, Estrada C, Díez-Ganán L, Velázquez L, Zorrilla 

B, et al. Impact of the “Tobacco Control Law” on exposure to 

environmental tobacco smoke in Spain. BMC Public Health 2007; 

7:224. 

Gilpin 2002 {published data only} 

Gilpin EA. Clean indoor air: Advances in California, 1990-1999. 

American Journal of Public Health 2002;92:785–91. 

Goodman 2007 {published data only} 

Goodman P, Agnew M, McCaffrey M, Paul G, Clancy L. Effect of 

the Irish smoking ban on respiratory health of bar workers and air 

quality in Dublin pubs. American Journal of Respiratory and Critical 

Care Medicine 2007;175:840–5. 

Gotz 2008 {published data only} 

Gotz NK, van Tongeren M, Wareing H, Wallace LM, Semple S, 

MacCalman L. Changes in air quality and second-hand smoke 

exposure in hospitality sector businesses after introduction of the 

English Smoke-free legislation. Journal of Public Health 2008;30: 

421–8. 

Hahn 2006 {published data only} 

∗ Hahn E, Rayens M, York N, Okoli C, Zhang M, Dignan M, et al. 

Effects of a smoke-free law on hair nicotine and respiratory 

symptoms of restaurant and bar workers. Journal of Occupational 

and Environmental Medicine 2006;48(9):906–913. 

Hahn EJ, Rayens MK, York N, Dignan M, Al-Delaimy WK. 

Secondhand smoke exposure in restaurant and bar workers before 

and after Lexington’s smoke-free ordinance. University of 

Kentucky, College of Nursing 2005. 

Okoli CTC, Rayens MK, Hahn EJ. Behavioral effects of nicotine 

exposure from secondhand smoke among bar and restaurant 

workers. Addictive Behaviors 2007;32:1922–8. 

Hahn 2008 {published data only} 

Hahn EJ, Rayens MK, Butler KM, Zhang M, Durbin E, Steinke D. 

Smoke-free laws and adult smoking prevalence. Preventive Medicine 

2008;47:206–9. 

Haw 2007 {published data only} 

Haw SJ, Gruer L. Changes in exposure of adult non-smokers to 

secondhand smoke after implementation of smoke-free legislation 

in Scotland:national cross-sectional survey. BMJ 2007;335(7619): 

549–552. 

Helakorpi 2008 {published data only} 

Helakorpi SA, Martelin TP, Torppa JO, Patja KM, Kiiskinen UA, 

Vartiainen EA, Uutela AK. Did the Tobacco Control Act 

Amendment in 1995 affect daily smoking in Finland? Effects of a 

restrictive workplace smoking policy. Journal of Public Health 2008; 

30:407–14. 

Heloma 2003 {published data only} 

∗ Heloma A, Jaakkola MS. Four-year follow-up of smoke exposure, 

attitudes and smoking behaviour following enactment of Finland’s 

national smoke-free work-place law. Addiction 2003;98:1111–17. 

Heloma A, Jaakkola MS, Kahkonen E, Reijula K. The short-term 

impact of national smoke-free work place legislation on passive 

smoking and tobacco use. American Journal of Public Health 2001; 

91:1416–18. 

Hyland 2009 {published data only} 

Hyland A, Hassan LM, Higbee C, Boudreau C, Fong G, et al. The 

impact of smokefree legislation in Scotland: results from the 

Scottish ITC Scotland/UK longitudinal surveys. European Journal 

of Public Health 2009;19(2):198–205. 



13

Jiménez-Ruiz 2008 {published data only} 

Jiménez-Ruiz CA, Riesco Miranda JA, Hurt RD, Ramos Pinedo A, 

Solano Reina S, Carrión Valero F. Study of impact of laws regulating 

tobacco consumption on the prevalence of passive smoking in 

Spain. European Journal of Public Health 2008;18:622–5. 

Juster 2007 {published data only} 

Juster HR, Loomis BR, Hinman TM, et al. Declines in hospital 

admissions for acute myocardial infarction in New York State after 

implementation of a comprehensive smoking ban. American 

Journal of Public Health 2007;97:2035–9. 

Khuder 2007 {published data only} 

Khuder SA, Milz S, Jordan T, Price J, Silvestri K, Butler P. The 

impact of a smoking ban on hospital admissions for coronary heart 

disease. Preventive Medicine 2007;45:3–8. 

Larsson 2008 {published data only} 

Larsson M, Boëthius G, Axelsson S, Montgomery SM. Exposure to 

environmental tobacco smoke and health effects among hospitality 

workers in Sweden - before and after the implementation of a 

smoke-free law. Scandinavian Journal of Work, Environment and 

Health 2008;34:267–77 . 

Lemstra 2008 {published data only} 

Lemstra M, Neudorf C, Opondo J. Implications of a public 

smoking ban. Canadian Journal of Public Health 2008;99:62–5. 

Menzies 2006 {published data only} 

Menzies D, Nair A, Williamson P, Schembri S, Al-Khairalla M, 

Barnes M, et al. Respiratory symptoms, pulmonary function, and 

markers of inflammation among bar workers before and after a 

legislative ban on smoking in public places. JAMA 2006;296: 

1742–8. 

Mulcahy 2005 {published data only} 

Mulcahy M, Evans DS, Hammond SK, Repace JL, Byrne M. 

Secondhand smoke exposure and risk following the Irish smoking 

ban: an assessment of salivary cotinine concentrations in hotel 

workers and air nicotine levels in bars. Tobacco Control 2005;14(6): 

384–8. 

Mullally 2009 {published data only} 

Mullally BJ, Greiner BA, Allwright S, Paul G, Perry IJ. Prevalence 

of smoking among bar workers prior to the Republic of Ireland 

smokefree workplace legislation. Irish Journal of Medical Science 

2008;177:309–16. 

Mullally BJ, Greiner BA, Allwright S, Paul G, Perry IJ. The effect of 

the Irish smoke-free workplace legislation on smoking among bar 

workers. European Journal of Public Health 2009;19:206–11. 

Palmersheim 2006 {published data only} 

Palmersheim K, Remington P, Gundersen D. The impact of a 

smoke-free ordinance on the health and attitudes of bartenders. 

The impact of a smoke-free ordinance on the health and attitudes of 

bartenders. Tobacco Surveillance Evaluation Programme. Madison, 

WI: University of Wisconsin Comprehensive Center, 2006. 

Pearson 2009 {published data only} 

Pearson J, Windsor R, El-Mohandes A, Perry DC. Evaluation of the 

immediate impact of the Washington D.C. smoke-free indoor air 

policy on bar employee environmental tobacco smoke exposure. 

Public Health Reports 2009;124 Suppl 1:135–42. 

Pell 2008 {published data only} 

Pell JP, et al. Smoke-free legislation and hospitalizations for acute 

coronary syndrome. New England Journal of Medicine 2008;359: 

482–91. 

Pell 2009 {published data only} 

Pell JP, Haw S, Cobbe S, Newby DE, Pell ACH, Fischbacher C, et 

al. Secondhand smoke exposure and survival following acute 

coronary syndrome: prospective cohort study of 1261 consecutive 

admissions among never smokers. Heart 2009;95:1415–8. 

Sargent 2004 {published data only} 

Sargent RP, Shepard RM, Glantz SA. Reduced incidence of 

admissions for myocardial infarction associated with public 

smoking ban: Before and after study. BMJ 2004;328(7446): 

977–80. 

Semple 2007 {published data only} 

Ayres JG, Semple S, MacCalman L, Dempsey S, Hilton S, et al. 

Bar workers’ health and environmental tobacco smoke exposure 

(BHETSE): symptomatic improvement in bar staff following 

smoke-free legislation in Scotland. Occupational and Environmental 

Medicine 2009;66:339–46. 

Semple S, Maccalman L, Naji AA, Dempsey S, Hilton S, Miller 

BG, Ayres JG. Bar workers’ exposure to secondhand smoke: the 

effects of Scottish smokefree legislation on occupational exposure. 

Annals of Occupational Hygiene 2007;51:571–80. 

Seo 2007 {published data only} 

Seo DC, Torabi MR. Reduced admissions for acute myocardial 

infarction associated with a public smoking ban: Matched 

controlled study. Journal of Drug Education 2007;37:217–26. 

Vasselli 2008 {published data only} 

Vasselli S, Papini P, Gaelone D, Spizzichino L, De Campora E, 

Gnavi R, et al. Reduction incidence of myocardial infarction with a 

national legislative ban on smoking. Minerva Cardioangiologica 

2008;56:197–203. 

Verdonk-Kleinjan 2009 {published data only} 

Verdonk-Kleinjan WMI, Knibbe RA, Tan FES, Willemsen MC, de 

Groot HN, de Vries H. Does the workplace smoking ban eliminate 

differences in risk for environmental tobacco smoke exposure at 

work. Health Policy 2009;92:197-202 (epub 2009 Apr 26). 

Waa 2006 {published data only} 

Waa A, McGough S. Reducing exposure to second hand smoke: 

changes associated with the implementation of the amended New 

Zealand Smoke-free Environments Act 1990: 2003-2006. 

www.hsc.org.nz/pdfs/SFEWorkplace_Final.pdf (accessed 17th February 

2010). Wellington: HSC Research and Evaluation Unit, 2006. 

References to studies excluded from this review 

Akbar-Khanzadeh 2003 {published data only} 

Akbar-Khanzadeh F. Exposure to environmental tobacco smoke in 

restaurants without separate ventilation systems for smoking and 

nonsmoking dining areas. Archives of Environmental Health 2003; 

58(2):97–103. 

Akbar-Khanzadeh 2004 {published data only} 

Akbar-Khanzadeh F, Milz S, Ames A, Spino S, Tex C. Effectiveness 

of clean indoor air ordinances in controlling environmental tobacco 

smoke in restaurants. Archives of Environmental Health 2004;59 

(12):677–85. 



14

Albers 2004 {published data only} 

Albers AB, Siegel M, Cheng DM, Rigotti NA, Biener L. Effects of 

Restaurant and Bar Smoking Regulations on Exposure to 

Environmental Tobacco Smoke Among Massachusetts Adults. 

American Journal of Public Health 2004;94:1959-64. 

Albers 2007 {published data only} 

Albers AB, Siegel M, Cheng DM, Biener L, Rigotti NA. Effect of 

smoking regulations in local restaurants on smokers’ anti-smoking 

attitudes and quitting behaviours. American Journal of Public 

Health 2007;16:101–6. 

Albers AB, Siegel M, Cheng DM, Biener L, Rigotti NA. Relation 

between local restaurant smoking regulations and attitudes towards 

the prevalence and social acceptability of smoking: a study of 

youths and adults who eat out predominantly at restaurants in their 

town. Tobacco Control 2004;13(4):347–55. 

Areias 2009 {published data only} 

Areias A, Duarte J, Figueiredo J, Lucas R, Matos I, et al. Asthma 

and the new anti-smoking legislation. What has changed?. Revista 

Portuguesa de Pneumologia 2009;15(1):27–42. 

Bates 2002 {published data only} 

Bates MN, Fawcett J, Dickson S, Berezowski R, Garrett N. 

Exposure of hospitality workers to environmental tobacco smoke. 

Tobacco Control 2002;11(2):125–9. 

Bauer 2005 {published data only} 

Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. A 

longitudinal assessment of the impact of smoke-free worksite 

policies on tobacco use. American Journal of Public Health 2005;95 

(6):1024–1029. 

Biener 1999b {published data only} 

Biener L, Nyman AL. Effect of workplace smoking policies on 

smoking cessation: Results of a longitudinal study. Journal of 

Occupational and Environmental Medicine 1999;41(12):1121–27. 

Bloor 2006 {published data only} 

Bloor RN, Meeson L, Crome IB. The effects of a non-smoking 

policy on nursing staff smoking behaviour and attitudes in a 

psychiatric hospital. Journal of Psychiatric and Mental Health 

Nursing 2006;13(2):188–96. 

Borders 2005 {published data only} 

Borders TF, Xu KT, Bacchi D, Cohen L, SoRelle-Miner D. College 

campus smoking policies and programs and students’ smoking 

behaviors. BMC Public Health 2005;5(1):74. 

Borland 1991b {published data only} 

Borland R, Owen N, Hill D, Schofield P. Predicting attempts and 

sustained cessation of smoking after the introduction of workplace 

smoking bans. Health Psychology 1991;10:336–42. 

Borland 1992 {published data only} 

Borland R. Changes in prevalence of and attitudes to restrictions on 

smoking in the workplace among indoor workers in the State of 

Victoria, Australia, 1988-90. Tobacco Control 1992;1:19–24. 

Borland 1992b {published data only} 

Borland R, Pierce JP, Burns DM, Gilpin E, Johnson M, Bal D. 

Protection from environmental tobacco smoke in California: The 

case for a smoke-free workplace. JAMA 1992;268:749–52. 


Borland R, Owen N. Need to smoke in the context of workplace 

smoking bans. Preventive Medicine 1995;24:56–60. 


Borland R, Cappiello M, Owen N. Leaving work to smoke. 

Addiction 1997;92:1361–8. 

Botello-Harbaum 2009 {published data only} 

Botello-Harbaum MT, Haynie DL, Iannotti RJ, Wang J, Gase L, 

Simons-Morton B. Tobacco control policy and adolescent cigarette 

smoking status in the United States. Nicotine & Tobacco Research 

2009;11:875–85. 

Brenner 1992 {published data only} 

Brenner H, Mielck A. Smoking prohibition in the workplace and 

smoking cessation in the Federal Republic of Germany. Preventive 

Medicine 1992;21:252–61. 

Brenner 1994 {published data only} 

Brenner H, Born J, Novak P, Wanek V. Smoking behavior and 

attitude toward smoking regulations and passive smoking in the 

workplace. Preventive Medicine 1997;26:138–43. 

Brenner H, Fleischle B. Smoking regulations at the workplace and 

smoking behavior: A study from southern Germany. Preventive 

Medicine 1994;23:230–4. 

Bronaugh 1990 {published data only} 

Bronaugh TA, Frances RJ. Establishing a smoke-free inpatient unit: 

is it feasible?. Hospital & Community Psychiatry 1990;41:1303–5. 

C.-Thompson 1998 {published data only} 

Clements-Thompson M, Klesges RC, Haddock K, Lando H, 

Talcott W. Relationships between stages of change in cigarette 

smokers and healthy lifestyle behaviors in a population of young 

military personnel during forced smoking abstinence. Journal of 

Consulting and Clinical Psychology 1998;66:1005–11. 

Carroll 1989 {published data only} 

Carroll DA, Lednar W, Carter WB. The short-term impact of army 

smoking policies. Military Medicine 1989;154:603–7. 

Chaloupka 1992 {published data only} 

Chaloupka F. Clean indoor air laws, addiction and cigarette 

smoking. Applied Economics 1992;24:193–205. 

Chaloupka FJ, Pacula RL. Sex and race differences in young 

people’s responsiveness to price and tobacco control policies. 


Chaloupka FJ, Wechsler H. Price, tobacco control policies and 

smoking among young adults. Journal of Health Economics 1997; 

16:359–73. 

Chapman 1997 {published data only} 

Carpenter MJ, Hughes JR, Solomon LJ, Powell TA. Do work-place 

smoking bans cause smokers to smoke ’harder’? Results from a 

naturalistic observational study. Addiction 1997;92:607–610. 

Cooreman 1997 {published data only} 

Cooreman J, Mesbah H, Leynaert B, Segala C. Evaluation of the 

impact of a smoking ban in a large Paris hospital [Evaluation des 

effets de la loi antitabac sur les habitudes et attitudes du personnel 

paramédical en activité dans un hopital de l’assistance publique de 

Paris]. Semaine des Hopitaux de Paris 1997;73(11-12):317–23. 



15

Cropsey 2005 {published data only} 

Cropsey KL, Kristeller JL. Motivational factors related to quitting 

smoking among prisoners during a smoking ban. Addictive 

Behaviors 2003;28:1081–93. 

∗ Cropsey KL, Kristeller JL. The effects of a prison smoking ban on 

smoking behavior and withdrawal symptoms. Addictive Behaviors 

2005;30:589–94. 

Darling 2006 {published data only} 

Darling H, Reeder AI, Williams S, McGee R. Is there a relation 

between school smoking policies and youth cigarette smoking 

knowledge and behaviors?. Health Education Research 2006;21: 

108–15. 

Daughton 1992 {published data only} 

Daughton DM, Andrews CE, Orona CP, Patil KD, Rennard SI. 

Total indoor smoking ban and smoker behavior. Preventive 

Medicine 1992;21(5):670–6. 

Dawley 1993 {published data only} 

Dawley H. A comprehensive worksite smoking control, 

discouragement, and cessation program. International Journal of 

Addiction 1991;26:685–96. 

Dawley LT, Dawley HH, Glasgow RE, Rice J, Correa P. Worksite 

smoking control, discouragement, and cessation. International 

Journal of Addiction 1993;28:719–33. 

Dwyer 2005 {published data only} 

Dwyer M. The integration of tobacco dependence treatment and 

tobacco-free standards into residential addictions treatment in New 

Jersey. Journal of Substance Abuse Treatment 2005;28:331–40. 

Eadie 2008 {published data only} 

Eadie D, Heim D, MacAskill S, Ross A, Hastings G, Davies J. A 

qualitative analysis of compliance with smoke-free legislation in 

community bars in Scotland: implications for public health. 

Addiction 2008;103:1019–26. 

Echer 2008 {published data only} 

Echer IC, Luz AM, Lucena A de F, Motta G de C, Goldim JR, 

Barreto SS. The contribution of social restrictions to smoking 

cessation. Revista Gaúcha de Enfermagem 2008;29(4):520–7. 

Emont 1990 {published data only} 

Emont SL, Cummings KM. Organizational factors affecting 

participation in a smoking cessation program and abstinence 

among 68 auto dealerships. American Journal of Health Promotion 

1990;5:107–114. 


Emont SL, Choi WS, Novotny TE, Giovino GA. Clean indoor air 

legislation, taxation, and smoking behaviour in the United States: 

an ecological analysis. Tobacco Control 1992;2:13–7. 


Emont SL, Zahniser SC, Marcus SE, Trontell AE, Mills S, Frazier 

EL, et al. Evaluation of the 1990 Centers for Disease Control and 

Prevention smoke- free policy. American Journal of Health 

Promotion 1995;9:456–61. 

Evans 1999 {published data only} 

Evans W, Farrelly MC, Montgomery E. Do workplace bans reduce 

smoking?. American Economic Review 1999;89:728–47. 

Farkas 1999 {published data only} 

Farkas AJ, Gilpin EA, Distefan JM, Pierce JP. The effects of 

household and workplace smoking restrictions on quitting 

behaviours. Tobacco Control 1999;8:261–5. 

Farkas 2000 {published data only} 

Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between 

household and workplace smoking restrictions and adolescent 

smoking. JAMA 2000;284:717–22. 

Farrelly 1999 {published data only} 

Farrelly MC, Evans WN, Sfekas AE. The impact of workplace 

smoking bans: results from a national survey. Tobacco Control 

1999;8:272–7. 

Fernandez 2008 {published data only} 

Fernández E, Fu M, Martínez C, Martínez-Sánchez JM, López MJ, 

et al. Secondhand smoke in hospitals of Catlonia (Spain) before 

and after a comprehensive ban on smoking at the national level. 

Preventive Medicine 2008;47:624–8. 

Fletcher 2009 {published data only} 

Fletcher PC, Camblin A. Preliminary examination of first year 

female university students: smoking practices and beliefs in a city 

with no-smoking legislation. College Student Journal 2009;43(1): 

234–40. 

Franchini 2008 {published data only} 

Franchini M, Caruso C, Perico A, Pacifici R, Monleon T, et al. 

Assessment of foetal exposure to cigarette smoke after recent 

implementation of smoke-free policy in Italy. Acta Paediatrica 

2008;97:546–550. 

Frieden 2005 {published data only} 

Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel 

M. Adult tobacco use levels after intensive tobacco control 

measures: New York City, 2002-2003. American Journal of Public 

Health 2005;95:1016–23. 

Gallus 2006 {published data only} 

Gallus S, Zuccaro P, Colombo P, Apolone G, Pacifici R, Garattini S, 

et al. Effects of new smoking regulations in Italy. Annals of 

Oncology 2006;17:346–7. 

Gasparrini 2006 {published data only} 

Gasparrini A, Gorini G, Marcolina D, Albertini M, Fondelli MC, 

Tamang E, Nebot M. Second-hand smoke exposure in Florence and 

Belluno before and after the Italian smoke-free legislation. 

Epidemiologia e Prevenzione 2006;30(6):348–51. 

Gerst 1995 {published data only} 

Gerst D, Lamothe E, Ameille J, Giard AM. Results of a survey on 

the consequences of the ban of smoking at the workplace. Archives 

des Maladies Professionnelles et de Medecine du Travail 1995;56(1): 

56–8. 

Goldstein 1992 {published data only} 

Goldstein AO, Westbrook WR, Howell RE, Fischer PM. Hospital 

efforts in smoking control: Remaining barriers and challenges. 

Journal of Family Practice 1992;34(6):729–34. 

Gomel 1993 {published data only} 

Gomel. Pilot study of the effects of a workplace smoking ban on 

indexes of smoking, cigarette craving, stress and other health 

behaviours. Psychology and Health 1993;8:223–9. 



16

Gorini 2008a {published data only} 

Gorini G, Gasparrini A, Tamang E, Nebot M, Lopez MJ, et al. 

Prevalence of secondhand smoke exposure after introduction of the 

Italian smoking ban: the Florence and Belluno survey. Tumori 

2008;94:798–802. 

Gorini 2008b {published data only} 

Gorini G, Moshammer H, Sbrogio L, Gasparrini A, Nebot M, et 

al. Italy and Austria before and after study: second-hand smoke 

exposure in hospitality premises before and 2 years from the 

introduction of the Italian smoking ban. Indoor Air 2008;18: 

328–34. 

Hamilton 2003 {published data only} 

Hamilton G, Cross D, Lower T, Resnicow K, Williams P. School 

policy: what helps to reduce teenage smoking?. Nicotine & Tobacco 

Research 2003;5:507–13. 

Hamilton 2008 {published data only} 

Hamilton WL, Biener L, Brennan T. Do local tobacco regulations 

influence perceived smoking norms? Evidence from adult and 

youth surveys in Massachusetts. Health Education Research 2008;23 

(4):709–22. 

Harvey 2002 {published data only} 

Harvey HD, Fleming P, Patterson M. Ethical dilemmas and human 

rights considerations arising from the evaluation of a smoking 

policy in a health promoting setting. International Journal of 

Environmental Health Research 2002;12(3):269–75. 

Helakorpi 2004 {published data only} 

Helakorpi S, Martelin T, Torppa J, Patja K, Vartiainen E, Uutela A. 

Did Finland’s Tobacco Control Act of 1976 have an impact on ever 

smoking? An examination based on male and female cohort trends. 

Journal of Epidemiology and Community Health 2004;58(8):649–54. 

Hilton 2008 {published data only} 

Hilton S, Cameron J, MacLean A, Petticrew M. Observations from 

behind the bar: changing patrons’ behaviours in response to smokefree 

legislation in Scotland. BMC Public Health 2008;8:238. 

Hu 2005 {published data only} 

Hu SC, Huang SY, Li D, Wen CP, Tsai SP. Workplace smoking 

policies in Taiwan and their association with employees’ smoking 

behaviours. European Journal of Public Health 2005;15:270–5. 

Hyland 2007 {published data only} 

Hyland A, Higbee C, Hassan L, Fong GT, Borland R, Cummings 

KM, Hastings G. Does smoke-free Ireland have more smoking 

inside the home and less in pubs than the United Kingdom? 

Findings from the international tobacco control policy evaluation 

project. European Journal of Public Health 2007;18:63–65. 

Kassab 1992 {published data only} 

Kassab J, Morgan G, Williams E, Davies C. Smoking prevalence 

and attitudes of Gwynedd Health Authority staff towards passive 

smoking and the Authority’s non-smoking policy. Health Trends 

1992;24(1):8–13. 

Kelly 2009 {published data only} 

Kelly BC. Smoke-free air policy: subcultural shifts and secondary 

health effects among club-going young adults. Sociology of Health & 

Illness 2009;31:569–82. 

Kinne 1993 {published data only} 

Kinne S, Kristal AR, White E, Hunt J. Work-site smoking policies: 

Their population impact in Washington State. American Journal of 

Public Health 1993;83(7):1031–3. 

Kitabayashi 2006 {published data only} 

Kitabayashi Y, Narumoto J, Shibata K, Nakamae T, Kamei J, Sano 

K, et al. Effect of institutional smoking prohibition on Japanese 

inpatients with chronic schizophrenia. Nihon Arukoru Yakubutsu 

Igakkai Zasshi 2006;41(2):128–33. 

Klein 2009 {published data only} 

Klein EG, Forster JL, Erickson DJ, Lytle LA, Schillo B. The 

relationship between local clean indoor air policies and smoking 

behaviours in Minnesota youth. Tobacco Control 2009;18(2): 

132–7. 

Kumar 2005 {published data only} 

Kumar R. School tobacco control policies related to students’ 

smoking and attitudes toward smoking: national survey results, 

1999-2000. Health Education Behaviour 2005;32(6):780–94. 

Larrrere 1994 {published data only} 

Larrere C, Olivier J, Chretien I, Gelibert A, Hegron C, Lemaire E. 

[Etude sur l’application de la loi sur le tabagisme dans les petites et 

moyennes entreprises]. Archives des Maladies Professionnelles et de 

Medecine du Travail 1994;55(8):650. 

Lee 2008 {published data only} 

Lee DJ, Dietz NA, Arheart KL, Wilkinson JD, Clarke JD, Caban- 

Martinez AJ. Respiratory effects of secondhand smoke exposure 

among adults residing in a “clean” indoor air state. Journal of 

Community Health 2008;33:117–25. 

Levy 2003 {published data only} 

Levy DT, Friend K. Examining the effects of tobacco treatment 

policies on smoking related deaths using the SimSmoke computer 

simulation model. Tobacco Control 2002;11:47–54. 

Levy DT, Friend K, Polishchuk E. Effect of clean indoor air laws on 

smokers: the clean air module of the SimSmoke computer 

simulation model. Tobacco Control 2001;10:345–51. 

Levy DT, Mumford EA, Pesin B. Tobacco control policies and 

reductions in smoking rates and smoking-related deaths. Expert 

Review of Pharmacoeconomics and Outcomes Research 2003;3: 

457–68. 

Levy 2004 {published data only} 

Levy DT, Romano E, Mumford EA. Recent trends in home and 

work smoking bans. Tobacco Control 2004;13:258–63. 

Levy 2005a {published data only} 

Levy DT, Nikolayev L, Mumford E. Recent trends in smoking and 

the role of public policies: Results from the SimSmoke tobacco 

control policy simulation model. Addiction 2005;100:1526–36. 

Levy 2005b {published data only} 

Levy DT, Romano E, Mumford E. The relationship of smoking 

cessation to sociodemographic characteristics, smoking intensity, 

and tobacco control policies. Nicotine & Tobacco Research 2005;7: 

387–96. 

Levy 2006a {published data only} 

Levy DT, Mumford EA, Compton C. Tobacco control policies and 

smoking in a population of low education women, 1992-2002. 

Journal of Epidemiology and Community Health 2006;60 Suppl 2: 

ii20–ii26. 



17

Levy 2006b {published data only} 

Levy DT, Bales S, Lam NT, Nikolayev L. The role of public policies 

in reducing smoking and deaths caused by smoking in Vietnam: 

Results from the Vietnam tobacco policy simulation model. Social 

Science and Medicine 2006;62:1819–30. 

Levy DT, Bauer JE, Lee HR. Simulation modelling and tobacco 

control: creating more robust public health policies. American 


Lewit 1997 {published data only} 

Lewit EM, Hyland A, Kerrebrock N, Cummings KM. Price, public 

policy, and smoking in young people. Tobacco Control 1997;6 

Suppl 2:S17–24. 

Lin 2006 {published data only} 

Lin D, Stahl DC, Ikle D, Grannis FW, Jr. Employee attitudes and 

smoking behavior at the city of hope national medical center 

smoke-free campus. Journal of the National Comprehensive Cancer 

Network 2006;4(6):535–42. 

Longo 1996 {published data only} 

Longo DR, Brownson RC, Johnson JC, Hewett JE, Kruse RL, 

Novotny TE, et al. Hospital smoking bans and employee smoking 

behavior: Results of a national survey. JAMA 1996;275(16): 

1252–7. 

Longo 2001 {published data only} 

Longo DR, Johnson JC, Kruse RL, Brownson RC, Hewett JE. A 

prospective investigation of the impact of smoking bans on tobacco 

cessation and relapse. Tobacco Control 2001;10(3):267–72. 

Lushchenkova 2008 {published data only} 

Lushchenkova O, Fernandez E, Lopez MJ, Fu M, Martinez- 

Sanchez JM, Nebot M, et al. Secondhand smoke exposure in 

Spanish adult non-smokers following the introduction of an antismoking 

law. Revista Española de Cardiologí 2008;61:687–94. 

Marcus 1992 {published data only} 

Marcus BH, Emmons KM, Abrams DB, Marshall RJ, Kane M, 

Novotny TE, et al. Restrictive workplace smoking policies: Impact 

on nonsmokers’ tobacco exposure. Journal of Public Health Policy 

1992;13:42–51. 

Martínez 2009 {published data only} 

Martínez C, Fu M, Martínez-Sánchez JM, Ballbè M, Puig M, 

García M, et al. Tobacco control policies in hospital before and 

after the implementation of a national smoking ban in Catalonia, 

Spain. BMC Public Health 2009;9:160. 

Maurice 2006 {published data only} 

Maurice E, Thorne S, Ajani U, Malarcher A, Merritt R, Husten C. 

State-specific prevalence of current cigarette smoking among adults 

and secondhand smoke rules and policies in homes and workplaces, 

United States, 2005. Morbidity and Mortality Weekly Reports 2006; 

55(42):1148–51. 

McCaffrey 2006 {published data only} 

McCaffrey M, Goodman PG, Kelleher K, Clancy L. Smoking, 

occupancy and staffing levels in a selection of Dublin pubs pre and 

post a national smoking ban, lessons for all. Irish Journal of Medical 

Science 2006;175(2):37–40. 

McMullen 2005 {published data only} 

McMullen KM, Brownson RC, Luke D, Chriqui J. Strength of 

clean indoor air laws and smoking related outcomes in the USA. 


Miller 2006 {published data only} 

Miller C, Hickling JA. Phased-in smoke-free workplace laws: 

reported impact on bar patronage and smoking, particularly among 

young adults in South Australia. Australian and New Zealand 


Minihan 1999 {published data only} 

Minihan PM. Smoking policies and practices in a state-supported 

residential system for people with mental retardation. American 

Journal on Mental Retardation 1999;104(2):131–42. 

Minov 2008 {published data only} 

Minov J, Karadzinska-Bislimovska J, Vasilevska K, Risteska-Kuc S, 

Stoleski S. Exposure to environmental tobacco smoke in the 

workplace in Macedonia: where are we now?. Arhiv Za Higijenu 

Rada i Toksikologiju 2008;59(2):103–9. 

Mizoue 2000 {published data only} 

Mizoue T. Impact of workplace smoking restrictions on smoking 

behaviour and attitudes toward quitting in Japan. Tobacco Control 

2000;9:435–7. 

Montner 1996 {published data only} 

Montner P, Bennett G, Brown C, Green S. Smoking policy and 

cessation in an inner-city hospital. Journal of the National Medical 

Association 1996;88:43–7. 

Moore 2001 {published data only} 

Moore L, Roberts C, Tudor-Smith C. School smoking policies and 

smoking prevalence among adolescents: multilevel analysis of crosssectional 

data from Wales. Tobacco Control 2001;10:117–23. 

Moskowitz 2000 {published data only} 

Moskowitz JM, Lin Z, Hudes ES. The impact of workplace 

smoking ordinances in California on smoking cessation. American 


Mullally 2008 {published data only} 

Mullally BJ, Greiner BA, Allwright S, Paul G, Perry IJ. Prevalence 

of smoking among bar workers prior to the Republic of Ireland 

smokefree workplace legislation. Irish Journal of Medical Science 

2008;177:309–16. 

Murnaghan 2007 {published data only} 

Murnaghan DA, Sihvonen M, Leatherdale ST, Kekki P. The 

relationship between school-based smoking policies and prevention 

programs on smoking behavior among grade 12 students in Prince 

Edward Island: a multilevel analysis. Preventive Medicine 2007;44: 

317–22. 

Nebot 2009 {published data only} 

Nebot M, Lopez MJ, Ariza C, Pérez-Ríos M, Fu M, et al. Impact of 

the Spanish smoking law on exposure to secondhand smoke in 

offices and hospitality venues: before and after study. 

Environmental Health Perspectives 2009;117:344–7. 

Nerin 2005 {published data only} 

Nerin I, Crucelaegui A, Mas A, Villalba JA, Guillen D, Gracia A. 

Results of a comprehensive workplace program for the prevention 

and treatment of smoking addiction. Archivos de Bronconeumologia 

2005;41(4):197–201. 

Northrup 1998 {published data only} 

Northrup DA, Ashley MJ, Ferrence R. The Ontario ban on 

smoking on school property: Perceived impact on smoking. 

Canadian Journal of Public Health 1998;89(4):224–8. 



18

Offord 1992 {published data only} 

Offord KP, Hurt RD, Berge KG, Frusti DK, Schmidt L. Effects of 

the implementation of a smoke-free policy in a medical center. 

Chest 1992;102(5):1531–6. 

Olive 1996 {published data only} 

Olive KE, Ballard JA. Changes in employee smoking behavior after 

implementation of restrictive smoking policies. South Medical 

Journal 1996;89(7):699–706. 

Ong 2003 {published data only} 

Ong M, Lightwood J, Glantz S. Health and economic impacts of the 

proposed smokefree for health initiative. San Francisco: Center for 

Tobacco Control Research and Education, University of California, 

2003. 


Ong MK, Glantz SA. Cardiovascular health and economic effects 

of smoke-free workplaces. American Journal of Medicine 2004;117: 

32–38. 


Ong MK, Glantz SA. Free nicotine replacement therapy programs 

vs implementing smoke-free workplaces: A cost-effectiveness 

comparison. American Journal of Public Health 2005;95:969–75. 

Osthus 2007 {published data only} 

Osthus S, Pape H, Lund KE. [Smoking restrictions and smoking 

prevalence in high schools]. Tidsskrift for den Norske Lægeforening : 

Tidsskrift for Praktisk Medicin, ny Række 2007;127(9):1192–4. 

Owen 1997 {published data only} 

Owen N, Borland R. Delayed compensatory cigarette consumption 

after a workplace smoking ban. Tobacco Control 1997;6:131–5. 

Panagiotakos 2007 {published data only} 

Panagiotakos DB, Pitsavos C, Stefanadis C. Chronic exposure to 

second hand smoke and 30-day prognosis of patients hospitalised 

with acute coronary syndromes: the Greek study of acute coronary 

syndromes. Heart 2007;93:309–12. 

Parry 2000b {published data only} 

Parry O, Platt S, Thomson C. Out of sight, out of mind: 

Workplace smoking bans and the relocation of smoking at work. 

Health Promotion International 2000;15:125–33. 

Patten 1995b {published data only} 

Patten CA. Workplace smoking policy and changes in smoking 

behaviour in California: a suggested association. Tobacco Control 

1995;4:36–41. 

Patten 1995c {published data only} 

Patten CA. Progress in protecting non-smokers from environmental 

tobacco smoke in California workplaces. Tobacco Control 1995;4: 

139–144. 

Patten 1995d {published data only} 

Patten CA, Bruce CK, Hurt RD, et al. Effects of a smokefree policy 

on an inpatient psychiatric unit. Tobacco Control 1995;4:372–9. 

Paulozzi 1992 {published data only} 

Paulozzi LJ, Spengler RF, Gower MA. An evaluation of the Vermont 

worksite smoking law. Public Health Reports 1992;107:724–6. 

Pederson 1992 {published data only} 

Pederson LL, Bull SB, Ashley MJ, Kozma D. Restrictions on 

smoking: Changes in knowledge, attitudes and predicted behaviour 

in metropolitan Toronto from 1983 to 1988. Canadian Journal of 

Public Health 1992;83:408–12. 


Pederson LL, Bull SB, Ashley MJ, Garcia JM, Lefcoe NM. An 

evaluation of the workplace smoking bylaw in the city of Toronto. 



Pederson LL, Bull SB, Ashley MJ. Smoking in the workplace: do 

smoking patterns and attitudes reflect the legislative environment?. 


Pentz 1989 {published data only} 

Pentz MA, Brannon BR, Charlin VL, Barrett EJ, MacKinnon DP, 

Flay BR. The power of policy: the relationship of smoking policy to 

adolescent smoking. American Journal of Public Health 1989;79: 

857–62. 

Petersen 1988 {published data only} 

Petersen LR, Helgerson SD, Gibbons CM, Calhoun CR, Ciacco 

KH, Pitchford KC. Employee smoking behavior changes and 

attitudes following a restrictive policy on worksite smoking in a 

large company. Public Health Reports 1988;103:115–20. 

Phillips 2007 {published data only} 

Phillips R, Amos A, Ritchie D, Cunningham-Burley S, Martin C. 

Smoking in the home after the smoke-free legislation in Scotland: 

qualitative study. BMJ 2007;335:553–7. 

Philpot 1999 {published data only} 

Philpot SJ, Ryan SA, Torre LE, Wilcox HM, Jalleh G, Jamrozik K. 

Effect of smoke-free policies on the behaviour of social smokers. 


Pickett 2006 {published data only} 

Pickett MS, Schober SE, Bridy DJ, Curtin LR, Giovino GA. 

Smoke-free laws and secondhand smoke exposure in US nonsmoking 

adults, 1999-2002. Tobacco Control 2006;15(4):302–7. 

Pierce 1994 {published data only} 

Pierce JP, Shanks TG, Pertschuk M, Gilpin E, Shopland D, 

Johnson M, Bal D. Do smoking ordinances protect smokers from 

environmental tobacco smoke at work?. Tobacco Control 1994;3: 

15–20. 

Prochaska 2006 {published data only} 

Prochaska JJ, Fletcher L, Hall SE, Hall SM. Return to smoking 

following a smoke-free psychiatric hospitalization. The American 

Journal on Addictions 2006;15(1):15–22. 

Proescholdbell 2008 {published data only} 

Proescholdbell SK, Foley KL, Johnson J, Malek SH. Indoor air 

quality in prisons before and after implementation of a smoking 

ban law. Tobacco Control 2008;17:123–7. 

Ratschen 2008 {published data only} 

Ratschen E, Britton J, McNeill A. Smoke-free hospitals-The 

English experience: results from a survey, interviews and site visits. 

BMC Health Services Research 2008;18:41. 

Rayens 2008 {published data only} 

Rayens MK, Burkhart PV, Zhang M, Lee S, Moser DK, et al. 

Reduction in asthma-related emergency department visits after 

implementation of a smoke-free law. Journal of Allergy and Clinical 

Immunology 2008;122:537–41. 



19

Reitsma 2004 {published data only} 

Reitsma AH, Manske S. Smoking in Ontario schools: does policy 

make a difference?. Canadian Journal of Public Health 2004;95: 

214–8. 

Resnick 1989 {published data only} 

Resnick MP, Bosworth EE. A smoke-free psychiatric unit. Hospital 

& Community Psychiatry 1989;40:525–7. 

Richiardi 2009 {published data only} 

Richiardi L, Vizzini L, Merietti F, Barone-Adesi F. Cardiovascular 

benefits of smoking regulations: The effect of decreased exposure to 

passive smoking. Preventive Medicine 2009;48:167–72. 

Ringel 2005 {published data only} 

Ringel JS, Wasserman J, Andreyeva T. Effects of public policy on 

adolescents’ cigar use: Evidence from the National Youth Tobacco 

Survey. American Journal of Public Health 2005;95:995–8. 

Rosen 1995 {published data only} 

Rosen AK, McCarthy EP, Moskowitz MA. Effect of a hospital 

nonsmoking policy on patients’ knowledge, attitudes, and smoking 

behavior. American Journal of Health Promotion 1995;9:361–70. 

Rosenstock 1986 {published data only} 

Rosenstock IM, Stergachis A, Heaney C. Evaluation of smoking 

prohibition policy in a health maintenance organization. American 

Journal of Public Health 1986;76(8):1014–5. 

Schaap 2008 {published data only} 

Schaap MM, Kunst AE, Leinsalu M, Regidor E, Ekholm O. Effect 

of nationwide tobacco control policies on smoking cessation in 

high and low educated groups in18 European countries. Tobacco 

Control 2008;17(4):248–55. 

Schnohr 2008 {published data only} 

Schnohr CW, Kreiner S, Rasmussen M, Due P, Currie C, 

Diderichsen F. The role of national policies intended to regulate 

adolescent smoking in explaining the prevalence of daily smoking: 

a study of adolescents from 27 European countries. Addiction 2008; 

103:824–31. 

Scott 1989 {published data only} 

Scott CJE, Gerberich SG. Analysis of a smoking policy in the 

workplace. AAOHN J 1989;37:265–73. 

Semple 2007b {published data only} 

Semple S, Creely KS, Naji A, Miller BG, Ayres JG. Secondhand 

smoke levels in Scottish pubs: the effect of smoke-free legislation. 


Shavers 2006 {published data only} 

Shavers VL, Fagan P, Jouridine Alexander LA, Clayton R, Doucet J, 

Baezconde-Garbanati L. Workplace and home smoking restrictions 

and racial/ethnic variation in the prevalence and intensity of current 

cigarette smoking among women by poverty status, TUS-CPS 

1998-1999 and 2001-2002. Journal of Epidemiology and 

Community Health 2006;60 Suppl 2:ii34–43. 

Shields 2004 {published data only} 

Shields M. The journey to quitting smoking. Health Reports 2004; 

16(3):19–36. 

Shields 2007 {published data only} 

Shields M. Smoking bans: Influence on smoking prevalence. 

Health Reports 2007;18(3):8–24. 

Shirres 1996 {published data only} 

Shirres G. Successful implementation of a no-smoking policy. 

Collegian 1996;3(4):30–8. 

Siegel 2005 {published data only} 

Siegel M, Albers AB, Cheng DM, Biener L, Rigotti NA. Effect of 

local restaurant smoking regulations on progression to established 

smoking among youths. Tobacco Control 2005;14(5):300–6. 

Siegel 2008 {published data only} 

Siegel M, Albers AB, Cheng DM, Hamilton WL, Biener L. Local 

restaurant smoking regulations and the adolescent smoking 

initiation process. Archives of Pediatric and Adolescent Medicine 

2008;162:477–83. 

Sinha 2004 {published data only} 

Sinha DN, Gupta PC, Warren CW, Asma S. Effect of school policy 

on tobacco use by school personnel in Bihar, India. Journal of 

School Health 2004;74(1):3–5. 

Skeer 2005 {published data only} 

Skeer M, Cheng DM, Rigotti NA, Siegel M. Secondhamd smoke 

exposure in the workplace. American Journal of Preventive Medicine 

2005;28(4):331–7. 

Smith 1989 {published data only} 

Smith WR, Grant BL. Effects of a smoking ban on a general 

hospital psychiatric service. Hospital & Community Psychiatry 1989; 

40:497–502. 

Sorensen 1991a {published data only} 

Sorensen G, Rigotti NA, Rosen A, Pinney J, Prible R. Employee 

knowledge and attitudes about a work-site nonsmoking policy: 

Rationale for further smoking restrictions. Journal of Occupational 

Medicine 1991;33:1125–30. 

Sorensen 1991b {published data only} 

Sorensen G, Rigotti N, Rosen A, Pinney J, Prible R. Effects of a 

worksite nonsmoking policy: Evidence for increased cessation. 


Stark 2007 {published data only} 

Stark MJ, Rohde K, Maher JE, Pizacani BA, Dent CW, et al. The 

impact of clean indoor air exemptions and preemption policies on 

the prevalence of a tobacco-specific lung carcinogen among 

nonsmoking bar and restaurant workers. American Journal of Public 

Health 2007;97:1457–63. 

Stephens 1997 {published data only} 

Stephens T, Pederson LL, Koval JJ, Kim C. The relationship of 

cigarette prices and no-smoking bylaws to the prevalence of 

smoking in Canada. American Journal of Public Health 1997;87: 

1519–21. 

Stillman 1995 {published data only} 

Stillman F, Warshow M, Aguinaga S. Patient compliance with a 

hospital no-smoking policy. Tobacco Control 1995;4:145–9. 

Strobl 1998 {published data only} 

Strobl J, Latter S. Qualified nurse smokers’ attitudes towards a 

hospital smoking ban and its influence on their smoking behaviour. 

Journal of Advanced Nursing 1998 Jan;27:179–88. 

Styles 1998 {published data only} 

Styles G, Caewell S. No smoking at work: the effect of different 

types of workplace smoking restrictions on smokers’ attitudes, 



20

ehaviour and cessation intentions. Health Education Journal 1998; 

57:385–95. 

Sussman 1990 {published data only} 

Sussman S, Pentz MA, Hahn G. The relationship of a worksite nosmoking 

policy to employee smoking behavior and attitudes. 

Progress in Clinical and Biological Research 1990;339:119–31. 

Tang 2003 {published data only} 

Tang H, Cowling DW, Lloyd JC, Rogers T, Koumjian KL, Stevens 

CM, et al. Changes of attitudes and patronage behaviors in 

response to a smoke-free bar law. American Journal of Public Health 

2003;93(4):611–7. 

Tang 2004 {published data only} 

Tang H, Cowling DW, Stevens CM, Lloyd JC. Changes in 

knowledge, attitudes, beliefs, and preference of bar owner and staff 

in response to a smoke-free bar law. Tobacco Control 2004;13:87–9. 

Tauras 2004 {published data only} 

Tauras JA. Public policy and smoking cessation among young 

adults in the United States. Health Policy 2004;68:321–332. 

Tillgren 1998a {published data only} 

Tillgren P, Jansson M, Hoijer Y, Ullen H. Maintaining a smoke-free 

policy: An observational and interview study at a university hospital 

in Sweden. European Journal of Cancer Prevention 1998;7(5):403–8. 

Tramacere 2009 {published data only} 

Tramacere I, Gallus S, Fernandez E, Zuccaro P, Colombo P, La 

Vecchia C. Medium-term effects of Italian smoke-free legislation: 

findings from four annual population-based surveys. Journal of 

Epidemiology and Community Health 2009;63:559–62. 

Trudeau 1995 {published data only} 

Trudeau DL, Isenhart C, Silversmith D. Efficacy of smoking 

cessation strategies in a treatment program. Journal of Addictive 

Diseases 1995;14(1):109–16. 

Velasco 1996a {published data only} 

Velasco J, Eells TD, Anderson R, Head M, Ryabik B, Mount R, et 

al. A two-year follow-up on the effects of a smoking ban in an 

inpatient psychiatric service. Psychiatric Services 1996;47(8): 

869–71. 

Wakefield 1992 {published data only} 

Wakefield MA, Wilson D, Owen N, Esterman A, Roberts L. 

Workplace smoking restrictions, occupational status, and reduced 

cigarette consumption. Journal of Occupational Medicine 1992;34: 

693–7. 


Wakefield M, Cameron M, Inglis G, Letcher T, Durkin S. 

Secondhand smoke exposure and respiratory symptoms among 

casino, club, and office workers in Victoria, Australia. Journal of 

Occupational and Environmental Medicine 2005;47:698–703. 


Wakefield M, Cameron M, Murphy M. Potential for smoke-free 

policies in social venues to prevent smoking uptake and reduce 

relapse: a qualitative study. Health Promotion International 2009; 

10:119–27. 

White 2008 {published data only} 

White VM, Hayman J, Hill DJ. Can population-based tobaccocontrol 

policies change smoking behaviors of adolescents from all 

socio-economic groups? Findings from Australia: 1987-2005. 

Cancer Causes and Control 2008;19:631–40. 

Woodruff 1993 {published data only} 

Woodruff TJ, Rosbrook B, Pierce J, Glantz SA. Lower levels of 

cigarette consumption found in smoke-free workplaces in 

California. Archives of Internal Medicine 1993;153:1485–93. 

References to studies awaiting assessment 

Tominz 2006 {published data only} 

Tominz R, Murolo G, Montina G, Poropat C, Zorzut F, Peresson 

M, Barbierato D. Exposure to passive smoking in local health units 

of northern Italy before and after the enforcement of the smoking 

ban. Epidemiologia e Prevenzione 2006;30:338–342. 

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Barnoya 2005 

Barnoya J, Glantz SA. Cardiovascular effects of secondhand smoke: 

nearly as large as smoking. Circulation 2005;111(20):2684–98. 

Benowitz 2002 

SRNT Subcommittee on Biochemical Verification. Biochemical 

verification of tobacco use and cessation. Nicotine and Tobacco 

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Boffetta 1998 

Boffetta P, Agudo A, Ahrens W, Benhamou E, Benhamou S, Darby 

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∗ Indicates the major publication for the study 



22

C H A R A C T E R I S T I C S O F S T U D I E S 

Characteristics of included studies [ordered by study ID] 

Abrams 2006 

Methods Country: USA 

Setting: New York Community 

Design: Observational study, cross-sectional surveys, pre and post-ban tests. Analysis: Chi 2 to test whether there were 

significant differences in demographic variables between pre-law and post-law groups; Mann-Whitney to test for 

significance. 

Participants Total sample (baseline and follow up):168. 14 casino employees, 63 non-casino hospitality, 91 non-hospitality 

employees. Female: 60%, White: 78%. Never smokers: 83%. 

Baseline: 107 

Follow up: 61 at 5 months post-ban 

Ethnicity and education were significantly different from pre-law to post-law. Hispanics pre-law 13.1% vs post-law 

4.7%; college graduates pre-law 34.4% vs post-law 44.4%. 

Interventions Clean Indoor Air Act in New York State in 2003 which banned smoking in workplaces including bars and restaurants. 

Outcomes Self-reported exposure to SHS as defined by the number of exposures, number of days exposed and total duration of 

exposure. 

Biochemical verification: Yes. Urinary cotinine measured exposure to SHS. Non-smoking status was verified with 

CO breath test

Akhtar 2007 (Continued) 

Outcomes Self-reported exposure to SHS in the home, cafes or restaurants, buses or trains, indoor leisure facility or someone 

else’s home. 

Biochemical verification: Yes; Exposure to SHS measured by geometric mean saliva cotinine concentration. 

Notes Parental smoking was reported by children in both baseline and follow-up surveys. Pupils with saliva cotinine >15ng/ 

ml were considered active smokers and were excluded from analysis. 

Alcouffe 1997 

Methods Country: France 

Setting: Employees in small and medium sized workplaces in Paris 

Design: Observational study, pre and post-ban tests. 

Participants Total population: 27,228 employees in 3261 firms. 12,170 office staff 

Baseline: 572 employees of which 120 office staff 

Follow up at 2 yrs: 200 office staff 

Interventions French Tobacco ban law in November 1st 1992 which prohibited smoking in small and medium sized firms in Paris. 

Outcomes Self-reported smoking status 

Biochemical verification: No 

Notes 

Allwright 2005 

Methods Country: Ireland 

Setting: Pubs in Ireland (Dublin, Cork and Galway) and Northern Ireland (NI) (Derry, Limavady and Strabane) 

Design: Quasi-experimental, pre- and post-ban tests. Analysis: Compared paired differences using Wilcoxon signed 

rank test or McNemar’s χ2 test for bivariate analysis and non-paired differences using Wilcoxon rank sum test. 

Analyses of changes within pairs were restricted to participants who responded to baseline and follow-up surveys, 

remained employed in a bar and didn’t change their smoking status. 

Participants 329 bar workers recruited at baseline (288 ROI and 41 in NI). Total ineligible: 48 (40 were no longer in the bar 

trade, 7 moved, 1 died). Lost to follow up: 23 uncontactable; 9 refused. 

Follow-up rate 89% (220/248) of those eligible or 76% overall in Rep of Ireland 

Follow-up rate 88% (29/33) of those eligible or 71% in NI 

Analysis restricted 158 (138 ROI and 20 in NI) who were nonsmokers at baseline and follow up 

Age: 45.5 yrs (35.0-54.9) for Republic of Ireland & 36.1 yrs (20.9-43.8) for NI, P value

Allwright 2005 (Continued) 

Outcomes Self-reported exposure to SHS as defined by number of hrs (median) of exposure in work and outside work (domestic 

and social) over the past seven days. 

Self-reported respiratory symptoms: wheezing, shortness of breath, cough-morning, cough-rest of day or night, 

phlegm production. 

Self-reported sensory symptoms such as eyes-red or irritated, nose-runny or sneezing, throat-sore or scratchy. 

Biochemical verification: Yes, salivary cotinine concentration measured exposure to SHS and verified non-smoking 

status of participants (

Bartecchi 2006 (Continued) 

Outcomes AMI hospitalization rates pre and post ban inside, and outside city limits of Puebloand a neighbouring county (El 

Paso County); adjustment for seasonality was made 

Biochemical verification: No. 

Notes 

Biener 2007 


Setting: Boston and other Massachusetts cities 

Design: Observational study, cross-sectional surveys, pre and post-ban surveys. Analysis: P values based on chi 2 test. 

Bivariate comparisons and multinomial logistic analysis to determine independent predictors of changes from preto 

post-law. 

Participants Baseline sample: Sub-sample of all baseline smokers and recent quitters and all young adults between 18-30 yrs from 

large longitudinal study. 

Follow up: Cohort 986. 83 live in Boston and 903 live in other Massachusetts towns without smoke-free regulations. 

57% of all the baseline smokers who completed the follow-up interview. Only smokers who completed both the 

baseline and follow-up surveys and whose follow-up interview occurred after the implementation of the smoking 

ordinance were included in the analysis. This excluded 316 eligible respondents who lived in one of 78 Massachusetts 

cities or towns that had a smoke-free bar regulation in place prior to July 2004. 

Sample characteristics: Boston n=83, Female: 54.8% 95% CI (42.3 to 66.7), Age yrs: 31 and over 71.9% (58.9, 

82.5). Education: Some college or more: 48.4% (36.7, 60.2). 

Other MA town % (95% CI), n=903. Female 53.9% (50 to 57.8), Age 31 and over: 75.6% (72.0 to 78.8). Education: 

Some college or more: 50.1%(46.2 to 54.0). 

No significant difference in demographics such as age, gender, ethnicity, education or marital status or in smoking 

patterns, patronage patterns or support for the smoking ban at baseline between those smokers at baseline who 

responded at follow up and those who did not. 

Differences between participants in Boston and other Massachusetts (MA) towns at baseline: More minorities (48.4% 

vs 11.4%, 95% CI), unmarried people (76.6% vs 51.5%, 95% CI), less heavy smokers (27% vs 39.9%, 95% CI) 

and more support for the smoking ban at baseline in Boston than in other MA towns (15.7% vs 7.4%, 95% CI). 

Interventions Evaluated a smoke-free workplace ordinance in May 2003 in Boston. It prohibited smoking in all workplaces including 

bars and restaurants. 

Outcomes Self-reported exposure to SHS at home 

Self-reported smoking at home 


Notes Other outcomes include compliance with smoking bans, economic impact such as bar patronage and support for the 

implementation of bans. 



26

Bondy 2009 

Methods Country: Canada 

Setting: Toronto (intervention) and Windsor city (control), Ontario 

Design: Quasi-experimental study. Pre-ban (15th-31st May) and three surveys at 1, 2 and 9 months post-ban. Analysis: 

to model the effect of time on urinary cotinine, multilevel mixed effects linear models and log transformation were 

used to normalise distribution in regression analysis. 

Participants Non-smokers at baseline and all subsequent follow ups. Respondents were included if they were aged >18 yrs and 

had worked three full 8 hr shifts in bars in the 3 days prior to testing for urinary cotinine and attended the interview 

within 19 hrs of their work shift. 

Total recruited: 129 in Toronto and 57 in Windsor. 

27 (24 in Toronto and 3 in Windsor) were excluded because >8 ppm CO and 31 excluded because ≥100 ng/ml 

urinary cotinine (26 in Toronto and 5 in Windsor) at baseline or follow up. 

Eligible sample at baseline in the intervention: n= 79. Female: 54%, Age yr (SD): 30.6 (8.4). 

Eligible sample at baseline in the control: n= 49. Female: 61%, Age yr(SD): 38.4(12.1). Casino employees: 71%. 

Follow up at 1 month: 73 in Toronto and 47 in Windsor. Follow up at 2 months: 68 in Toronto and 42 in Windsor. 

Follow up at 9 months: 44 in Toronto and 30 in Windsor. 

No significant difference between respondents and non-respondents in Toronto with regard to age, gender, total selfreported 

hrs exposed at baseline and urinary cotinine conc. at baseline. Those non-respondents in Windsor were 

younger and more likely to be employed in casinos than respondents. 

Interventions Smokefree workplace bylaw implemented in Toronto, Ontario on June 1st 2004 prohibited smoking in bars, casinos, 

gambling venues with licences. Some venues allow designated smoking rooms with ventilation. Only bar workers 

employed in venues affected by the legislation (had no designated smoking areas) were included and compared with 

bar workers in Windsor city which did not have a bylaw. 

Outcomes Self-reported duration of exposure over three work days. Calculated as mean number of hrs. 

Biochemical verification: Yes; urinary cotinine analysis measured exposure to SHS. Non-smokers were defined as 

those reporting not smoking in the previous 30 days, and were verified as non-smokers if CO≤ 8 ppm and urinary 

cotinine was ≤100 ng/ml. 

Notes Participants were given $40 to compensate for time and travel expenses and were recruited through advertisements 

in the media, flyers and subway stations. 

Braverman 2008 

Methods Country: Norway. 

Setting: Employees from bars, restaurants, cafeterias and other eating and drinking establishments. 

Design: Cohort study, pre and 4 & 11 months follow up post legislation. Analysis: McNemar’s test, general linear 

modelling and logistic regression analysis. 

Participants Baseline: Cohort of 1525 respondents. 

Baseline: Female 52.9%, Age 15-34 yrs 52.3%, Worked 21-40 hrs per wk 63.4%, Daily smokers 52.9%. 

Follow up at 4 months 879/1525 (57.6%). 

Follow up at 11 months : 579 (38%). 

Attrition: No significant difference (α=0.05) between those who responded at T1(879) and those who didn’t respond 

at 4 months follow up (646) when comparing a number of demographic variables as well as smoking status, intention 

to quit, time of day worked and cigarette consumption. Attrition bias between those who were not followed up after 

4 months when compared with those who responded at baseline, 4 & 11 months follow up: significant difference for 



27

Braverman 2008 (Continued) 

two variables - a) age (P =0.004) with respondents being older and b) having changed jobs(P =0.018). No significant 

change in smoking prevalence and tobacco consumption between T1 and T2 in those who responded at baseline 

and 4 months and those who responded for all surveys. 

Interventions Legislative smoking ban introduced in Norway on 1st June 2004 in indoor workplaces including smoking in bars, 

nightclubs and restaurants. 

Outcomes Self-reported smoking status (daily, occasional, non-smoker) self-reported average number of cigarettes consumption 

smoked daily and at work. 


Notes Examined predictors of smoking cessation such as age, gender, income, smoking behaviour, attitudes towards the 

ban and SHS, exposure to SHS, and respiratory symptoms. 

Brownson 1995 


Setting: Missouri, USA 

Design: Observational study, cross-sectional population based surveys carried out on a monthly basis between January 

1990 and December 1993. Analysis of never and former smokers which were defined as having smoked less than 

100 cigarettes in their lifetime and not currently smoking. 

Participants Population based sample of Missouri residents aged ≥ to 18 yrs. 

Total: 6052 interviews over study period; approx. 126 interviews per month. 

Response rate: 73%. Sample age 18-34 yrs: 31.8% , Census % Missouri 18-34 yrs: 35.9% 

Sample Female: 59.6%, Census % Missouri Female: 52.9%. 

Sample representative of overall Missouri population although slightly under-represented in younger persons, males, 

blacks, and persons with lesser education. 

Analysis: Student’s t test. Regression analyses. Two tailed. 

Interventions Missouri statewide clean indoor air legislation implemented in August 28th 1992 restricted smoking in workplaces, 

public buildings, and restaurants. Bars, taverns, bowling alleys, restaurants with seating for less than 50 persons and 

certain public places were exempt from the law. 

Outcomes Self-reported exposure of nonsmokers to tobacco smoke at work and in the home. 


Notes Other outcomes reported in the study were awareness of the state clean indoor air law and extent to which they 

requested no-smoking seating in restaurants. 



28

CDC 2007 


Setting: New York State 

Design: Observational study, quarterly population based cross-sectional surveys and saliva cotinine analysis one 

month before the legislation and one yr post implementation. Analysis: t test for trend: P < 0.001 

Participants Total Sample for each quarterly survey: Approx 2000 nonsmokers resident in NY State. 

22% (range: 21%-24%) average response rate for the quarterly surveys from June 2003 until June 2004 

33% (2008/6152 participants) submitted saliva cotinine samples. 

Excluded 414 samples because cotinine

Cesaroni 2008 (Continued) 

Outcomes Smoking prevalence as measured by self-reported smoking status. Age-standardised rates of acute coronary events 

annually, stratified prior to analysis by age categories 35-64 yrs, 65-74 yrs, 75-84 yrs for 2000-2005. Acute coronary 

event defined as acute myocardial infarction (AMI) and other acute and subacute forms of ischemic heart disease, 

ICD-9, Code 411. Myocardial infarction defined as all diagnosis with principle diagnosis of AMI (ICD-9-CM code 

410) or a secondary diagnosis of AMI where principal diagnosis indicated AMI complications. Two events occurring 

within 28 days of each other were analysed as one single episode. 


Notes Possible confounders are that measurement of troponin as a new diagnostic criteria for AMI became available in 

hospitals in Rome during the study period. There was an increase in daily dose of cardiac medication such as statins 

from 10 to 55 per 1000 residents when this study was carried out. Other outcomes are economic impact as measured 

from cigarette sales in Rome, air quality by average concentrations of PM10, temperature and flu epidemics. 

Eagan 2006 

Methods Country: Norway 

Setting: Hospitality premises 

Design: Cohort study, pre and 5 months follow-up surveys. Analysis: McNemar’s test for change in symptom 

prevalence and ANOVA for repeated measures. Chi 2 for the exposure variables, and test for trend for the symptom 

variables to test differences in baseline characteristics by response or non-response at follow up. 

Participants Employees in a random sample of companies. 

Baseline: 1525 employees participated 

Follow up: 906/1525 responded 5 months post-ban, 59% response rate 

Cohort sample : Females 51.9%; Age 15-29 yrs 38%, 30-39 yrs 30%, 40+ 31.8%; Smokers (persistent and starters) 

56%. 

Missing outcome data: Used Chi 2 to test for differences in baseline characteristics between respondents and nonrespondents 

at follow up. No difference except in response rate of smokers (57.4%) and nonsmokers (62.6%). No 

difference between respondents and non-respondents in baseline prevalence for any of the respiratory symptoms. 

Interventions Legislative smoking ban introduced in Norway on 1st June 2004 in indoor workplaces including smoking in bars, 

nightclubs and restaurants. 

Outcomes Self-reported smoking status 

Self-reported exposure to SHS 

Prevalence of self-reported respiratory symptoms before and 5 months post-ban. Respiratory symptoms included 

were morning cough, daytime cough, phlegm cough, dyspnoea and wheezing. 


Notes An incentive of prize money was offered to one randomly selected participant. Exposure to SHS and smoking status 

were also recorded at baseline. 



30

Eisner 1998 


Setting: Bars and taverns in San Francisco 

Design: Cohort study, pre and post-ban tests. Analysis: paired t test for normally distributed variables, paired Wilcoxon 

signed rank test for nonnormally distributed continuous variables and McNemar’s Chi 2 test for dichotomous variables 

and logistic regression analysis. 

Participants 124 participating bars and restaurants. 30% participation rate. No statistically significant differences between participating 

and non-participating bars but bartenders in participating bars in sample were younger (mean [SD] 42.2[14] 

vs 51.0[11.4] yrs; P < 0.001) and more likely to be female (28% vs 17%, P =0.05) than the general population of 

San Francisco bar workers. 

67 bartenders worked at least one weekly day shift. 

54/67 (81%) bartenders participated at baseline. 

53/54 (98%) bartenders participated at 1 month follow up 

Cohort n=53: Mean age 42.5 yrs SD (14.0); Female 28%; White 62%, Hispanic 19%, African American 4%, Asian 

Pacific Islander 11%, Other 4%. College or greater 76%, High-school 25%. 45% smokers at baseline and follow up. 

Interventions Legislative ban (California State Assembly Bill 13) which prohibits tobacco smoking in bars and taverns. 

Outcomes Self-reported exposure to SHS as measured by median number of hrs in the past seven days in the bar / tavern as well 

as total exposure to SHS. 

Self-reported respiratory symptoms as well sensory irritation symptoms as measured by change in prevalence in 

symptoms. 

Pulmonary function as measured by forced expiratory volume (FEV1 ), FVC and forced expiratory flow, mid expiratory 

flow (FEF 25%−75%). 


Notes 30% of bars and taverns participated in this study. Smoking behaviour is measured but follow up is less than 6 

months. 

Ellingsen 2006 

Methods Country: Norway 

Setting: Bars and restaurants in Oslo 

Design: Cohort study, pre and post-ban tests. Analysis: Student’s t test, least square regression analysis, Pearson’s 

correlation coeffecients. Correlation for lung function were calculated using Spearman’s rank test. All tests were two 

sided with significance level of 5%. 

Participants 112 employees in bars and restaurants from 13 participating establishments, smoker and nonsmokers. 

93/112 (83%) participated pre legislation 

69/93 (79.6%) participated 4-8 months legislation 

Cohort n=69. Females: 50.7%, Mean age of women yrs (SD): 30.7 (8.8), Mean age of men yrs (SD): 31.9(7.1). Total 

smokers: 43 (62%) of which 21 women and 22 men smoked. 

Missing outcome data: at follow up, 13 no longer working in the same venue at follow up. 8 were on leave, 3 had 

changed their smoking status. 

Interventions Legislative ban introduced in Norway on 1st June 2004 on smoking in bars, nightclubs and restaurants; previous 

legislation in 1988 included prohibition of smoking in public places. 



31

Ellingsen 2006 (Continued) 

Outcomes Mean concentration of urinary cotinine as a measurement of nicotine intake before the smoking ban and between 4-8 

months post-ban. The concentration of urinary nicotine was measured directly after the work shift and the following 

morning (ug cotinine g −1 creatinine). 

Biochemical verification: Yes; Exposure to SHS measured by urinary cotinine. 

Notes Other outcomes include measurements of air quality such as airborne nicotine and total dust concentration in the 

air. 

Farrelly 2005 


Setting: Bars, restaurants and bowling facilities in New York 

Design: Cohort study, Pre and post-ban tests. Analysis: Wilcoxon signed rank test for non-normally distributed 

variables and t tests for normally distributed variables. McNemar’s χ 2 tests for dichotomous variables (such as 

respiratory symptoms). 

Participants Non-smoking employees of hospitality venues which allowed smoking at baseline. 

Baseline: 104 eligible employees, 8 ineligible, 2 refused, 53/104 (62.9%) completed both questionnaire and saliva 

sample ≤15 ng/ml at baseline. 

47 employees at 3 months, 38 employees at 6 months and 29 employees completed both questionnaire and saliva 

sample ≤15 ng/ml at 12 months. 

Analysis = 24 employees who responded to all baseline and follow-up surveys and provided saliva samples. Age: 18 

yrs or older, Male (95% CI): 29.2% (14.2% to 50.6%), White (95% CI): 95.8% (74.4% to 99.5%), Education 

(95% CI)-High school diploma 50% (30.4% to 69.6%) 

Missing outcome data: No significant differences in baseline demographics between all respondents at baseline and 

those that did not respond at follow up. 

Interventions Legislative ban on smoking in New York State which prohibits smoking in all workplaces including bars, restaurants, 

bingo and bowling facilities. 

Outcomes Self-reported exposure to SHS as defined by hrs of exposure to environmental tobacco smoke. 

Self-reported sensory symptoms such as irritated eyes, runny nose, sneezing, nose irritation, scratchy throat. 

Self-reported respiratory symptoms such as wheezing/whistling in chest, shortness of breath, coughing in the morning, 

during the day, in the night or bringing up any phlegm. 

Biochemical verification: Yes, mean concentration of cotinine in saliva sample, sensitivity of 3 ng/ml at baseline,3 

months, 6 months and 0.1 ng/ml at 12 months. 

Cotinine values ≥15 ng/ml were considered active smokers and excluded from the analysis. 

Notes Exemptions to the smoking ban include hotel rooms rented by one or more guests, existing cigar bars, retail tobacco 

businesses and certain membership associations. Participants were offered monetary incentives for completing the 

surveys and collecting the saliva samples. Recruitment for the study occurred through advertisements on television, 

radio and flyers along with snowball sampling. 



32

Fernando 2007 

Methods Country: New Zealand 

Setting: 30 randomly selected bars in Auckland, Wellington and Invercargill, New Zealand. 

Design: Pre and post-test. Saliva cotinine analysis before the legislation and one yr post implementation. Analysis: 

Two tailed t test, Spearman correlation and analysis of variance. 

Participants Nonsmokers, age range: 24-45 yrs 

Baseline: Winter 2004 Total: n=139, Auckland 49%, Wellington 33%, Invercargill 18% 

Baseline: Spring 2004 Total n=127, Auckland 38%, Wellington 43%, Invercargill 19% 

Follow up: Winter 2005 Total n=103, Auckland 49%, Wellington 32%, Invercargill 19% 

Follow up: Spring 2005 Total n=101, Auckland 54%, Wellington 30%, Invercargill 16% 

Interventions Enactment of Smokefree Environments Amendment Act 2003 on 10 December 2004 which prohibited smoking in 

bars, restaurants and hotels. 

Outcomes Exposure to SHS in bars as measured by saliva cotinine samples taken just before entering the venue and 5-15 minutes 

after exiting the venue. Five individuals per bar venue for a 3 hr stay between 18.00 and 24.00h on Friday or Saturday 

night. 

Biochemical verification: Yes; Exposure to SHS as measured by saliva cotinine analysis. Excluded those with cotinine 

≥15 ng/ml and those who did not participate in all waves of data collection. 

Notes All participants were volunteers in the study. Other outcomes measured were perceived air quality and compliance 

as measured by the number of lit cigarettes in the bars visited. 

Fernández 2009 

Methods Country: Spain 

Setting: Hospitality employees from pubs, bars, restaurants, hotels and discotheques in Spain, Portugal and Andorra 

Design: Quasi-experimental study comparing Spanish venues according to different regulation type (smoking completely 

banned, allowed in restricted areas, allowed in the entire venue) with Portugal and Andorra (control with 

no legislation). Cohort of non-smokers before (Oct-Dec 2005), 6 months (April-June 2006) and 12 months after 

(Oct-Dec 2006). Analysis: Paired comparisons using Wilcoxon’s signed rank test to compare medians of cotinine 

conc. McNemar’s chi-square to compare frequency of respiratory symptoms before and after the law and magnitude 

of change using linear and logistic regression models. Used generalised least squares regression models with random 

effects to model changes in saliva cotinine and logistic regression models with random effects to model changes in 

prevalence of respiratory symptoms to control for confounding by time independent and time dependent. 

Participants 62.9% (215/342) participation rate by hospitality venues. 

Inclusion criteria: Participants who worked minimum of 6 hrs daily, were employed in same venue for >1 yr, reported 

no intention to leave place of employment for at least 2 yrs. 

Baseline: 476 employees recruited; 431 in Spain. 45 in Portugal & Andorra. Follow up at 12 months: 318 (66.8%). 

Analysis restricted to those who were non smokers at baseline and 12 month follow up. Also excluded non smokers 

from Spain who were employed in smoke free venues pre-implementation of legislation. 

Total cohort: 137 employees. Spain (intervention): 117. Portugal & Andorra (control): 20. In Spain cohort: Female 

39.3%. In control cohort: Female: 70%, p= 0.014. No significant difference for other baseline characteristics such 

as age and hrs worked daily between Spanish employees and those employed in the Portugal or Andorra. 

Missing outcome data: At 12-months follow up in Spain, 70 were not located , 31 refused, 33 changed jobs, 6 were 

on sick leave, and 3 were unemployed. In Portugal & Andorra, 8 were not located, 2 refused, 4 changed jobs and 1 

was on sick leave. Excluded 143 smokers (133 in Spain and 10 in Portugal & Andorra) and 38 nonsmokers in Spain 

who were employed in smoke-free venues before the legislation. Participants not followed up in the intervention were 



33

Fernández 2009 (Continued) 

more likely to be younger, of foreign origin and smokers whereas there was no difference in the control group. 

Interventions The legislation implemented on January 1st 2006 prohibits smoking in indoor workplaces but this doesn’t include 

bars and restaurants. For bars and restaurants less than 100 sq m, the proprietor can decide whether to ban smoking 

or not. For premises

Fong 2006 


Setting: Representative sample of population in Ireland and the UK. 

Design: Quasi-experimental study, cohort study, pre and 8-9 months post- ban. Analysis: Generalised estimating 

equation models (GEE), McNemar’s test to conduct changes in proportions over time, t tests were conducted for 

difference in country means, and chi 2 tests were conducted for differences in country proportions. Analyses and 

descriptive statistics were weighted. 

Participants 1679 adult smokers from Ireland, n=1071, 70.9% co-operation rate. In the UK, n=608, 70.3% co-operation rate. 

Follow-up survey Ireland: 769. Follow-up survey U.K: 414. 

Follow up UK & Ireland: 1185, overall response rate: 70.6%. 

Female: 58.3% Ireland, 55.5% UK 

Age: Ireland 10.5% 18-24 yrs, 26.1% 25-39 yrs, 39.3% 40-54 yrs, 55+ 24.1yrs; UK 5.3% 18-24 yrs, 38.2% 25-39 

yrs, 30.5% 40-54 yrs, 26% 55+yrs. 

Missing outcome data: No significant difference in baseline measures between non-respondents and those who 

responded at follow up on daily cigarette consumption, intention-to-quit, income level or gender. Significantly more 

non-respondents were younger (Mean yrs 36 vs 41.7, t= 7.31, P < 0.001) and less likely to be white (χ2=8.02, P = 

0.005). 

Interventions Legislation implemented in the Republic of Ireland on March 29th 2004 banning smoking in indoor workplaces 

including bars and restaurants. 

Outcomes Self-reported smoking behaviour as defined by number of smokers who reported quitting. 

Self-reported exposure to SHS as measured by percentage who observed smoking in workplaces and public places 

such as pubs and bars, restaurants, public buses and shopping centres, home and private vehicles. 


Notes Participants received incentive of £7 (UK) or EURO10 Ireland following each survey. Other outcomes reported 

were support for the ban and compliance with the ban; adapted from the International Tobacco Control Evaluation 

Survey. 

Fowkes 2008 

Methods Country: Scotland 

Setting: Scottish population 

Design: Cohort study. Analysis: Comparison of smokers between June 2005-June 2006 and June 2006-June 2007. 

Chi-square tests to examine frequency of categorical variables by smoking status and Mann-Whitney U-test for 

continuous variables. Logistic regression using generalised equation models to analyse the association of different 

variables (gender, age, area of residency, baseline smoking characteristics) with the probability of quitting smoking. 

Participants Respondents were participants in a randomized controlled trial of low aspirin for the prevention of cardiovascular 

events and deaths. Participants did not have clinical cardiovascular disease but were at risk. They enrolled between 

1998 - 2002 and were followed up annually. Recruited men and women aged 50-75 yrs in the trial. 

Baseline: 1087/3330 current smokers at baseline and 54 former smokers that resumed smoking during the study. 

Total smokers: 1141. Female: 66.7%, Mean age (SD): 60.9 (6.25), 13% most affluent category, 36% most deprived 

with remainder in other socioeconomic categories. 

Response rate: In June 2006-June 2007, 75.1% (474/631) of current smokers from previous yr responded. Did not 

differ significantly by age, gender, area of residence or affluence score from the baseline sample of smokers (n= 1087) 

. 



35

Fowkes 2008 (Continued) 

Interventions Smokefree legislation (Smoking, Health and Social Care (Scotland) Bill) implemented on 26th March 2006 prohibiting 

smoking in indoor workplaces including bars, restaurants and cafes. 

Outcomes Self reported smoking status. 

Smoking cessation defined as having stopped smoking for at least 3 months. 


Notes Other outcomes reported were support for the smoking ban. 

Gallus 2007 

Methods Country: Italy 

Setting: Italian population 

Design: population based surveys conducted before and after implementation of the legislation in 2004, 2005 and 

2006. Analysis: per cent prevalence of current smokers of the adult population. 

Participants Representative multistage sampling of adults from 147 municipalities. 

Baseline sample (2004): 3535 respondents. Female: 1836 (52%) 

2005 sample: 3114 respondents. Female: 1603 (51.4%) 

2006 sample: 3039 respondents. Female: 1578 (52%) 

Age: 15 yrs or older 

Interventions Legislation implemented in Italy on January 10th 2005 which prohibits smoking in indoor public places including 

bars, restaurants, cafes unless they have a separate smoking area with continuous floor-to-ceiling walls and a ventilation 

system (Law n. 3). 

Outcomes Self-reported smoking status and mean number of cigarettes consumed per day. 


Notes Other outcomes reported are support for economic impact. 

Galán 2007 


Setting: Population of Madrid region 

Design: Observational study, cross-sectional surveys, pre and post- ban surveys. Analysis: P value: comparison of 

period post-law (January-July 2006) vs period pre-law (October-November 2005), Chi 2 test, t test, binary and 

multinomial logistic regression models. 

Participants Baseline n=1750. Follow up n=1252. Overall Response rate: 66% 

Baseline: Female 51.7%, Age 18-29 yrs 26.3%; 30-44 yrs 40.4%; 45-64 yrs 33.3% 

Follow up: Female 50.9%, Age 18-29 yrs 26.8%; 30-44 yrs 38.3%; 45-64 yrs 34.9% 

Interventions Evaluation of exposure to SHS in Spain before and after the implementation of legislation on January 1st 2006. 

The legislation prohibits smoking in indoor workplaces but this doesn’t include bars and restaurants. For bars and 

restaurants less than 100 sq m, the proprietor can decide whether to ban smoking or not. For premises

Galán 2007 (Continued) 

provided. 

Outcomes Self-reported smoking at home and work by smokers. 

Self-reported exposure to SHS at home, workplaces and in bars and restaurants. 


Notes Other outcomes are compliance as indicated by self-reported smoking in the workplace. 

Gilpin 2002 


Setting: California 

Study Design: population based cross-sectional surveys, California Tobacco Surveys in 1990, 1992, 1996 and 1999 

to evaluate California Tobacco Control Program. Pre and post-law. Analysis: Weighted percentages and confidence 

interval. Weights are based on the probability of selection for interview and ratio adjusted to population demographic 

totals. 

Participants Adults 18 yrs or older 

Response rate pre-law 1990 75.3%, 1992 71.3%, 1993 99.4% 

post-law 1996 72.9% and 1998 68.4% 

Interventions Clean indoor air legislation was enacted in California in 1994 which prohibited smoking in indoor workplaces. This 

was extended to bars, gaming clubs and bar areas of restaurants in January 1st 1998. California Tobacco Control 

Program had been in place since 1988. 

Outcomes Self-reported exposure to SHS defined as the % reporting SHS exposure in the past two wks. 


Notes 

Goodman 2007 


Setting: Dublin pubs 

Design: Observational study, one group, and one yr follow up. Analysis: McNemar’s test for changes in responses 

using Chi 2 . Pulmonary function tests-used the paired-sample t test. 

Participants Recruited bar workers from 1,100 trade union members. Female: 20% 

81 volunteer participants, Females: None 

75 participated pre and post-law, 2 participants excluded as their smoking status changed. 

73 participants (90%) included for analysis. Mean age: 47.9 yrs (range: 22-68 yrs). Smoking status: 8/73 (11%) 

current smokers, 34/73 (47%) never smokers, 31/73 (42%) ex-smokers. 

Interventions Evaluated the effect of Public Health (Tobacco) Act 2002 in Ireland which implemented prohibition on smoking in 

indoor workplaces which included bars and restaurants in March 29th 2004. 



37

Goodman 2007 (Continued) 

Outcomes Self-reported exposure to SHS in the workplace as defined by number of hrs exposed in the workplace and total hrs 

exposed. 

Self-reported respiratory and sensory irritant symptoms 

Pulmonary function tests 

Biochemical verification: Yes; exposure to SHS measured by saliva cotinine and exhaled CO. 

Notes Barworkers recruited through their trade union and participation was voluntary. Other outcomes reported are support 

for the ban, air quality as well as compliance with the ban by observations of smoking pre and 1 yr post-law. 

Gotz 2008 

Methods Country: England 

Setting: Public houses, bars, clubs, bingo halls, cafes, betting shops and private member clubs selected from six regions 

in England: East of England, East Midlands, North East, South East, South West and West Midlands. 

Design: Pre and post-ban tests. Cross-sectional surveys and a cross-sectional analysis of cohort who had completed 

both surveys. Analysis: Means and log-transformed t-test values for cotinine concentrations at baseline and follow 

up. 

Participants Total: 83 participants. Excluded those who reported been smokers or having smoked in the last yr, those who reported 

been exposed to SHS outside work, those with breath carbon monoxide, >10 ppm. or salivary cotinine >20ng/ml. 

Baseline = 66 employees. Female: 58%,18-34 yrs: 62% 

Follow up = 48 employees. Female: 50%, 18-34 yrs: 60%. 39 employees in matched analysis 

Interventions Smoke-free (Premises and Enforcement) Regulations 2006 implemented in England on 1 July 2007 which bans 

smoking in enclosed public places including bars and restaurants. 

Outcomes Exposure to SHS as measured by salivary cotinine analysis one month before and at one month follow up. 

Biochemical verification: Yes 

Notes Other outcomes measured were air quality in the venues visited and compliance with the smoking ban legislation. 

Hahn 2006 


Setting: Bars and restaurants in Lexington, Kentucky 

Design: Observation study. One group. Cross-sectional surveys pre and post- ban. Analysis: paired t test, ANCOVA 

, Fischer least significant difference procedure for ANOVA and GEE (generalised estimating model). 

Participants 105 employees participated in randomly selected bars and restaurants at Lexington-Fayette County. 

(67.6%) 71/105 responded 3 months post-ban. 32% attrition. 

(57.1%) 60/105 responded 6 months post-ban. 43% attrition from baseline; due to changing jobs or moving. 

Missing outcome data: No difference between respondents at both baseline and 3 months compared to non-respondents 

at 3 months for gender, age, ethnicity, education, smoking status and cigarettes smoked per day. Carried out 

Intention to Treat analysis and assumed that participants not followed up at three months had the same nicotine 

values as they had at baseline. Participants not followed up at three months had higher nicotine values at baseline 

than those who were also tested at three month follow up (t=2.3, P =0.02). 



38

Hahn 2006 (Continued) 

Interventions Implementation of a smoking policy which banned smoking in all public places including bars, restaurants, bingo 

parlours, pool halls and public areas of hotels/motels in April 2004 in Lexington-Fayette County, Kentucky. 

Outcomes Self-reported exposure to SHS as measured by number of hrs exposed at work in the past seven days and self-reported 

exposure to SHS at home, in private motor vehicles and public places. 

Self-reported cigarette consumption daily 

Self-reported respiratory and sensory symptoms. Respiratory symptoms included wheezing, dyspnoea, morning 

cough, cough during the rest of the day or night and phlegm production. Sensory symptoms include red irritated 

eyes, runny nose, sneezing or irritated nose and scratchy or sore throat. 

Biochemical verification: Yes; hair nicotine as a measure to exposure to SHS at three month follow up. 

Notes Questions from the International Union against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire 

were used to assess upper respiratory and sensory symptoms. Other outcomes measured were support for the ban. 

Hahn 2008 

Methods Country: USA Setting: Fayette County, Kentucky 

Method: Quasi-experimental; population based survey data (Behavioral Risk Factor Surveillance Survey) from 2001- 

2005 using stratified random sampling and telephone questionnaire. Intervention: Fayette County. Control: 30 

counties with similar demographics which did not have smoking legislation. 

Analysis: Smoking behaviour assessed in cross-sectional surveys at pre-law period (January 2001-April 2004) and postlaw 

period (May 2004-December 2005). Counties ranked for each demographic variable. Data weights are adjusted 

prior to analysis. Logistic regression estimates from the model to compare smoking rates between intervention and 

control groups. Controlling for seasonality, time (continuous variable to control for secular trends) and respondents 

age, gender, ethnicity and education, marital status and household income. Regression coefficient, Wald χ 2 . 

Participants Total sample: 10413 respondents. Male & Female, Age ≥18 yrs. Fayette County: Education (% of adults aged ≥25 

yrs with a high school diploma) 85.8%, Income (median annual household income) $39,813, Smoking rate: 26.1%. 

30 control counties: Education (% of adults aged ≥25 yrs with a high school diploma) 79.3%, Income (median 

annual household income): $40,390, smoking rate: 27.9% 

Pre-law: 7139 respondents. Fayette County: 579 (8.1%). Control counties: 6560 (91.9%) 

Post-law : 3274 respondents. Fayette County: 281 (8.6%). Control counties: 2993 (91.4%) 

Interventions Implementation of a smoking policy which banned smoking in all public places including bars, restaurants, bingo 

parlours, pool halls and public areas of hotels/motels in April 2004 in Lexington-Fayette County, Kentucky. 

Outcomes Smoking prevalence as measured by self-reported smoking status. Current smokers defined as smoking on “some 

days”, “every day”, and having smoked at least 100 cigarettes in their lifetime. non-smoker defined as former and 

never smokers. 


Notes In the period after implementing smoke free ordinance, no change was reported in activities relating to smoking 

cessation, media campaigns or discounts for medications to quit smoking in Fayette County. 



39

Haw 2007 


Setting: Population in mainland Scotland 

Design: Observational study, population based cross-sectional surveys pre and 6 months post-law. Clustered random 

sampling; pre-law surveys carried out between September 1st and November 20th 2005 and again between 9 January 

and 25th March 2006. post-law surveys carried out between September 1st and December 10th 2006 and between 

January 8th and April 2nd 2007. Analysis: Calculated the adjusted percentage reduction in geometric mean saliva 

cotinine concentration. 

Participants Pre-law: Total=1815. Response rate Two surveys 70% and 71%. Final sample after excluding smokers: 1170. 

Post-law: Total= 1834. Response rate Two surveys 66% and 71%. Final sample after excluding smokers: 1190. 

Samples were similar in age, sex, marital status and smoking status. pre-law sample significantly more likely to have 

more than 11 yrs education (P < 0.01) and less likely to live in the most deprived areas (P < 0.01). 



Outcomes Self-reported exposure to SHS in public places, homes and private cars. 

Biochemical verification: Yes; exposure to SHS as measured by saliva cotinine. Baseline: cotinine analysis 627/1170 

(53.6%). 

Post-law: cotinine analysis 592/1190 (49.7%). 

Notes Participants with cotinine

Heloma 2003 (Continued) 

Participants Employees in Helsinki metropolitan area who work in office, service sector and industrial workplaces. 

880/1251 employees response rate: 70%. Women: 29.5%, 

940/1251 employees 1 yr post-ban response rate: 75%, Women:27.1% 

659/ 878 employees 3 yrs post-ban response rate:75%, Women:36% 

Interventions National smoke-free workplace legislation in Finland. Tobacco Act came into effect on 1 March 1995 which imposed 

a total ban on smoking or 2) to provide designated smoking rooms with separate ventilation systems and lower air 

pressure to prevent any escape of smoke to the non-smoking spaces. 

Outcomes Self-reported smoking status and number of cigarettes consumed daily by continuing smokers. 

Self-reported exposure in the workplace as defined by number of hrs exposed to daily i.e. Not at all, < 1 hr, 1-4 hrs, 

>4 hrs. 


Notes Workplaces with a total smoking ban before enforcement of the Tobacco Act were ineligible for this study. Other 

outcomes reported were employees support of the ban, compliance with the law and concentration of indoor air 

nicotine in workplaces. 

Hyland 2009 


Setting: Scottish and UK population 

Design: Quasi-experiemental study. Longitudinal pre-law survey and follow up one yr after implementation. Telephone 

surveys. Geographically stratified probability sampling, randomly selected from the population in each country. 

Analysis: For respondents at follow up, pre-legislation weights were adjusted for attrition and all respondents 

weighted to be representative of population. Covariates were country (Scotland vs UK), wave (pre vs post), gender, 

SES, heaviness of smoking and ethnicity. Generalised estimating equations with Gaussian variations. Significance 

level of 0.01 used. Country vs wave interaction. 

Participants Smoker and non smokers aged ≥18 yrs 

Pre-law: Total = 1335 (507 in Scotland and 828 rest of UK). Smokers: 301- Scotland, 300 - rest of UK. Response 

rate: 29% Scotland, 30% rest of UK. 

Follow up: Total = 958. Total smokers = 513 (263 Scotland and 250 rest of UK ). Total non smokers = 445; 216 

Scotland, 229 rest of the UK. 

Sample was replenished at follow up. 397 smokers (198 Scotland & 199 rest of UK) and 263 non smokers (116 

Scotland & 147 rest of UK) added. 

Total sample at follow up: 910 smokers and 708 non smokers. 



Outcomes Exposure to SHS as defined as self-reported observations of someone smoking in pubs, restaurants, or cafes; observing 

smoking in workplaces and percentage who have smoking bans in the home. 

Self-reported smoking status. Smokers considered those who had smoked at least 100 cigarettes and who reported 

having smoked at least once in the previous month. 




41

Hyland 2009 (Continued) 

Notes Incentives of £4 Boots vouchers were given to non smoker and £7 vouchers to smokers. Other outcomes were 

support for the smoking ban legislation, quit attempts and use of stop smoking medications and the economic impact 

measured as hospitality patronage. 

Jiménez-Ruiz 2008 


Setting: Spanish population 

Design: Observational study, cross-sectional surveys 11 months and 12 months post legislation. Random stratified 

sampling. Analysis: Calculated percentage reduction in exposure to SHS. 

Participants Analysis of nonsmokers 

Baseline: 6533 respondents. nonsmokers: 3907 (59.8%), female nonsmokers: 57% vs male nonsmokers 43% (P < 

0.0001). 62.5% of 13-65yrs, 99% of those 65 yrs were nonsmokers (P < 0.0001). % 

nonsmokers among urban population was 84% compared to 16% in the rural population (P < 0.0049) 

12 months post legislation: 3298 respondents, nonsmokers: 2174 (65.9%). Similar characteristics in follow-up survey 

as for baseline survey. 

Interventions Legislation in Spain which came into effect in January 2006 restricting smoking in bars and restaurants in larger bars 

and restaurants. Larger bars and restaurants (>100m 2 ) are required to provide separate designated smoking and nonsmoking 

sections and those less than

Khuder 2007 


Setting: Bowling Green, Ohio, with control city, Kent, Ohio 

Design:Quasi-experimental design with an intervention city and a matched control city; hospital discharge data 

used. Analysis: Differences in standardized admission rates between the two cities were examined using the Mantel- 

Haenszel. Chi 2 test. ARIMA intervention time series analysis was used to model the monthly distribution of hospital 

admissions. 

Participants Total sample admissions to hospitals with primary diagnosis for smoking related diseases. 

Interventions Clean indoor air ordinance banning smoking in workplaces and public places implemented in March 2002 in Bowling 

Green, Ohio. Partial. 

Outcomes Monthly admission rates for coronary heart disease and non smoking-related admissions. 


Notes 

Larsson 2008 

Methods Country: Sweden 

Setting: Bingo halls, casino, bars and restaurants in nine Swedish communities 

Design: Cohort study, 1 month pre- and 12 months follow up post legislation. Analysis: Total sample. Chi-square 

test to test statistical significance of participant characteristics and test for trend for changes in tobacco consumption.Change 

in symptoms between pre- and post- using XT-logit logistic regression. Paired-sample t-test to compare 

pre- and post pulmonary function tests as well as linear regression analysis, adjusting for gender, age and height and 

smokers excluded from analysis. 

Participants Pre-ban 91 employees volunteered. Female: 70%, Smoker: 26%, Gaming workers: 41%, Other hospitality workers: 

59%, Spirometry: 99%, Urine cotinine: 79%. 

Post-ban 71 employees (79%). Female: 70%, Smoker: 20%, Gaming workers: 38%, Other hospitality workers: 62%, 

Spirometry: 94%, Urine cotinine: 79%. Attrition: 21% 

71 participated in pre- and post-ban surveys. Criteria for inclusion: Must be employed in bars, restaurants, casinos, 

night-clubs or bingo halls in venues where smoking was allowed before implementation of the legislation and 

employees who work a minimum of 3 consecutive days per wk. Smokers and non-smokers included. 

Interventions Smokefree workplace legislation in Sweden extended to include bars and restaurants on the 1st June 2005. 

Outcomes Self-reported exposure to SHS over the previous 7 days 

Self-reported number of cigarettes consumed by smokers 

Self-reported respiratory and sensory symptoms 

Measurements of lung function: FVC and FEV1 of which smokers were excluded. 

Biochemical verification: Yes. Smoking status verified by urinary cotinine. 

Notes Other outcomes measured are attitudes such as support for the legislation and air quality. Nonsmokers wore nicotine 

samplers. 



43

Lemstra 2008 

Methods Country: Canada 

Setting: Saskatoon, Saskatchewan and Canada 

Design: Observational study, population based cross-sectional surveys. pre and post-ban surveys. Analysis: Paired 

samples t-test. Stratification used to test for confounding by age, gender and previous MI. Analysis of hospital 

admissions from age-standardised incidence rate of AMI per 100,000 population four yrs before the ban and in the 

follow up one yr post-ban using incidence rate ratio and CI. 

Participants Baseline survey: 1301 respondents in 2003 in Saskatoon 

Follow-up survey: 1244 respondents in 2005 in Saskatoon; data on hospital admissions for AMI in Saskatoon; non- 

Saskatoon residents were excluded from the analysis; stratification used to test for confounders of age, gender and 

previous MI. 

Interventions Legislation implemented on July 1 st 2004 in the city of Saskatoon which bans smoking or holding a lit tobacco 

product in any enclosed public space including outdoor seating areas of restaurants and licensed premises. 

Outcomes Smoking prevalence as measured from self-reported smoking status. Age-standardised incidence rates of hospital 

admissions for AMI (using ICD-10 codes) per 100,000 population for 12 month period post-ban from 1st July 2004 

to 30th June 2005 was compared with period from 1st July 2000-June 3oth 2004. 

Biochemical verification: Not for smoking status or exposure to SHS 

Notes Conversion from ICD-9 to ICD-10 coding occurred in April 2000. Other outcomes measured were compliance with 

the smoking ban legislation. 

Menzies 2006 

Methods Country: Scotland. 

Setting: Dundee and Perth in East Scotland. 

Design: Observational study, one group, pre and post-ban tests. Analysis: Wilcoxon signed rank test or where 

appropriate data logarithmically transformed before analysis.% reporting symptoms were compared with McNemar’s 

χ2 test. Analysis of variance for comparisons of continuous data. 

Participants Bar owners who were nonsmokers. 

105 participants, 1 current smoker and 14 lost to follow up. 

90 participants at 1 month post-ban. 13 lost to follow up. 

77 participant at 2 months post-ban. 

Cohort n = 77, Mean age (sd): 37.5 yrs (13.7), Male No. (%): 41 (53). 

Missing outcome data: Non-respondents at follow up were an average of 8.7 yrs younger (95% CI 2.8 to 14.6, P = 

0.004) than those who responded at follow up and had been working in a bar 3.2 yrs fewer (95% CI, -1.3 -7.7 yrs, 

P =0.16). 

Interventions Legislative ban implemented in Scotland on March 26th, 2006 which banned smoking in enclosed public places 

including bars (Smoking, Health and Social Care (Scotland) Bill). 

Outcomes Self-reported hrs of exposure per wk to SHS (workplace and home) 

Self-reported presence or absence of respiratory symptoms (wheeze, shortness of breath, cough and phlegm) 

Self-reported presence or absence of sensory symptoms (red or irritated eyes, painful throat and nasal itch, runny 

nose, and sneeze 

FEV 1 , exhaled nitric oxide, peripheral blood white cell and neutrophil count, C-reactive protein. 

Biochemical verification: Yes. Serum cotinine as a measure of exposure to SHS. 



44

Menzies 2006 (Continued) 

Notes Only bar workers who did not have a history of significant respiratory disease except asthma or rhinitis were included 

in the study. Subgroup study of asthmatic participants was carried out. Larger number of participants in the cohort 

who participated in the three measurements with pre existing asthma or rhinitis (23/77) compared with those who 

dropped out of the study (6/28). Subsample of asthmatics was considered a potential confounder. Monetary incentive 

offered to all participants of £10 for each visit. 

Mulcahy 2005 


Setting: Hotels in Galway City, Ireland 

Design: Observational study, one group, pre and post-ban test. Analysis: Calculated reduction in median saliva 

cotinine concentration and reduction in median hrs of exposure from baseline to follow up. 

Participants Hotel staff that were nonsmokers and living in smoke-free or restricted smoking residences of less than 45 minutes 

exposure per day. 

Baseline: 52 employees participated (saliva sample and questionnaire), 

Follow up: 35 employees participated 4-6 wks post-ban. 

Cohort = 35. Females: 53%. 

8 refused participation at follow up. 11 lost to follow up as a result of no longer working at the venues and six 

exceeded saliva cotinine concentrations of 15ng/ml (to control for misreported smoking status) and were excluded. 

Interventions Evaluated legislation implemented on 29th March 2004 in Ireland banning smoking in indoor workplaces including 

bars, restaurants, cafes and hotels (excluding bedrooms, outdoor areas and designated smoking shelters). 

Outcomes Self-reported exposure to SHS at work as measured by median number of hrs per wk. 

Biochemical verification: Yes. Saliva cotinine concentration ng/ml as a measure of exposure to SHS. 

Notes Other outcomes included measurements of airborne nicotine concentration (ug/m 3 ) in Galway city centre bars before 

and 6 wks post-ban and compliance with the ban by measuring the mean number of people observed smoking 

indoors. 

Mullally 2009 


Setting: Pubs in Cork city and population sample from Ireland 

Design: Cohort study of bar employees pre (January-March 2004) and one yr post-ban (January-March 2005) 

compared with cross-sectional sample from the Irish population during the same period. Analysis of bar employees in 

cohort: McNemar’s χ2 to test changes in smoking prevalence within each gender, age group and occupational class. 

Changes in consumption using paired sample t-tests and general linear model function to test statistical interaction 

of subgroups. Analysis of population sub-sample: Pearson’s chi 2 to test differences in prevalence and independent 

sample t-tests to examine differences in consumption. 

Participants 98/141 bars participated (69.5%). Smokers and nonsmokers. 

Baseline: 129 bar employees. Follow-up cohort: 107 bar employees (83%) of which 16 no longer employed in bar 

work but were included in the analysis. 

Female: 29%, mean age yrs (SD): 33.2 (12.1); bar managers/owners: 42% & bar staff: 58%. 



45

Mullally 2009 (Continued) 

Missing outcome data: Non-respondents at follow up were not significantly different in age, gender occupational 

class or smoking status but more likely to be younger, women and to be smokers than those who did respond at 

follow up (n= 22). 

Irish population: Random subsample. Analysis based on those aged 18-78 yrs and employed in equivalent occupational 

class to bar managers/owner and bar staff. Baseline: 1240 participants. 1 yr follow up: 1221 participants. 

Barworkers at baseline 88%

Pearson 2009 

Methods Country: America 

Setting: Pubs, clubs, nightclubs and taverns in Washington D.C. 

Design: One group, pre- and post-ban tests. Analysis: Cotinine data analysed using Wilcoxon’s signed rank test for 

difference in medians and paired t-test for difference in means. McNemar’s chi square test to obtain p value for change 

in median number of respiratory and sensory symptoms, 1000 repetitions to obtain 95% CI. 

Participants Hospitality employees who were nonsmokers, non-users of NRT or tobacco products, live with non-smokers, working 

≥20 hrs per wk at the site, restricted to employees who participated at baseline (2nd-21st December 2006) and 

follow up (1st-21st February 2007) and worked at the same venue during both periods. 

Baseline: 102 employees at 41 bars recruited. 1 employee did not have enough English to consent, 1 worked in a bar 

with existing smoking ban. 17 smokers (ineligible) and 17 refused. 66 eligible employees at baseline. 

Cohort: 46 employees. Female: 11%, worked mean 5 yrs in current job. Those who did not respond at follow up 

were more likely to be female and have worked for less yrs in hospitality establishments. 

Missing outcome data: 6 ineligible due to changing jobs, 6 due to bar closing, 1 due to bar exemption, 1 due to 

death. 2 were uncontactable (lost to follow up) and 1 refused. 3 were excluded with saliva cotinine >10 ng/ml. 

Interventions Legislation implemented on 2nd January 2007 in Washington D.C. banning smoking in indoor workplaces including 

bars, restaurants and pool halls. Establishments that earned ≥10% of their income from tobacco sales or had a 15% 

reduction in sales for a 3 month period during the ban compared to the previous 2 yrs could apply for an exemption. 

Outcomes Self-reported presence of respiratory and sensory symptoms from the validated International Union against Tuberculosis 

and Lung Disease Bronchial Symptoms questionnaire. 

Exposure to SHS measured by saliva cotinine concentration ng/ml. 

Biochemical verification: Yes. Smoking status verified by saliva cotinine with >10 ng/ml confirmed as smokers and 

excluded from the analysis. 

Notes Other outcomes included measurements of attitudes such as support for the ban. 

Pell 2008 


Setting: Scottish and English population. 

Design: Pre- and post-ban tests. Comparative analysis of hospital admissions for acute coronary syndrome for 10 

months before the ban (June 2005 to March 2006) and in the follow-up period up to 10 months after the legislation 

was implemented (June 2006 - March 2007) in Scotland (intervention area) and England (control area without 

similar legislation). Data from England was 

obtained from Hospital Episode Statistics. 

Analysis: Chi 2 test used to calculate P values for trend. Two-sample t-tests to logarithmically transform data on 

cotinine. Calculated % reduction in the number of admissions and subgroup analysis according to gender and age 

group. 

Participants Patients admitted to hospital for acute coronary syndrome in Scotland and England during the same period of time. 

Participation rate patients with acute coronary syndrome: pre-law 2806/3235 (87%), post-law 2322/2684 (87%), P 

=0.80, chi 2 test. 

Interventions Smokefree legislation (Smoking, Health and Social Care (Scotland) Bill) implemented on 26th March, 2006 prohibiting 




47

Pell 2008 (Continued) 

Outcomes Self-reported exposure to SHS as defined by the number of hrs per wk in the home, work, “bars, pubs or clubs”, 

“cars, buses or trains”, other public places, other people’s homes and “all locations”. 

Number of hospital admissions and relative risk reduction (95% CI) of acute coronary syndrome (ACS) by age, 

gender and smoking status. Analysis of ACS in men 55 yrs, in women < 65 yrs and > 65 yrs and for 

all patients with ACS. Acute coronary syndrome (ICD-10) defined by a detectable level of cardiac troponin after 

emergency admission for chest pain. 

Self-reported smoking status 

Biochemical verification: Yes; smoking status and exposure to SHS as measured by geometric mean serum cotinine 

ng/ml. 

Notes Nonsmokers defined as those with 12ng/ml serum cotinine or less. Limit of detection 0.1ng/ml. 

Pell 2009 


Setting: Scottish Acute Hospital Population 

Design: Pre and post-ban tests. Prospective cohort study. Data was collected pre and post ban in Scotlandon consecutive 

patients who were non smokers admitted with ACS to nine Scottish acute hospitals. Follow-up data were 

obtained from routine hospital admissions and death databases. Chi 2 tests for trend and logistic regression, both 

univariate and multivariate. 

Participants Consecutive admissions who were non smokers admitted with ACS to nine Scottish acute hospitals from May 2005 

to March 2007 

Baseline:1261 

Follow up: 30 days post admission 

50 had died and 35 had a non fatal MI. 

Interventions Smokefree legislation (Smoking, Health and Social Care (Scotland) Bill) implemented on 26 th March, 2006 prohibiting 

smoking in indoor workplaces, including bars, restaurants and cafes. 

Outcomes Cotinine levels. All cause death, cardiovascular death or readmission for a principal diagnosis of AMI. 

Biochemical verification: Yes. Urinary cotinine measured exposure to SHS. 

Notes 

Sargent 2004 


Setting: Helena, Montana 

Design: Observational study, cross-sectional surveys, pre and post-ban tests. Analysis: Analysis of admission admitted 

for AMI for people living in and outside Helenausing Poisson analysis. 

Participants Total sample: 304 admissions living in and outside Helena 

During ban period: 42 admissions 

Interventions Local law in place in Helena, Montana from June-Nov 2002 which banned smoking in workplaces and public places. 



48

Sargent 2004 (Continued) 

Outcomes Number of admissions for AMI 


Notes 

Semple 2007 


Setting: Seventy-two bars in three cities Aberdeen, Glasgow, Edinburgh and small towns in two rural regions (Borders 

and Aberdeenshire) 

Design: Longitudinal cohort of bar workers. Baseline survey prior to implementation of the legislation in March 26th 

2006 and follow-up surveys between May and July 2006 and again between January and March 2007. Saliva cotinine 

measurements obtained at the time of the surveys. Analysis: Change in cotinine concentration calculated using paired 

t test on the log values of cotinine. McNemar’s assessed changes in numbers of participants with symptoms from 

baseline to 12 months follow up. Wilcoxon-Mann-Whitney tested if change in median number of symptoms was 

significant. 

Participants 159/861 bars randomly selected. Participation rate: 45% bars (72/159). 

Location of bars in baseline cohort: 32% Aberdeen(shire), 33% Glasgow and 35% Edinburgh/borders. 

Convenience sample of 371 employees, included managers, owners and bar staff. Female: 48%; mean age: 27.9 yrs; 

smokers: 55%. 

Response rate two months post implementation: 72% (266 / 371). Female: 51%. Mean age: 28.7 yrs. 

Response rate at one yr post implementation: 51.5% (191/371). Female: 49%. Mean age: 29.5 yrs. 

Missing outcome data: Demographic characteristics of those who did not respond at follow up were not different. 

Bar staff who responded at one yr follow up were more likely to be owners and managers than non-respondents. 

Cohort: 67 non-smokers and 65 smokers. 69 from cohort were inconsistent smokers or unclassifiable and were 

excluded from the analysis of respiratory and sensory symptoms. 

Saliva cotinine analysis in equal numbers of smokers and nonsmokers (84% vs 84%) but more smokers than non 

smokers at one yr follow up (97% vs 88%) due to insufficient saliva volume in 12 nonsmokers samples vs 2 smokers 

samples. 

Baseline: Saliva cotinine: 301/371 (81%) bar employees of the total cohort. 53 insufficient samples, 2 refused and 

15 excluded due to using NRT. 

Follow up at 2 months: 220/266 (83%) bar employees. 22 insufficient samples, 3 refused and 21 excluded due to 

using NRT. 

Follow up at 1 yr: 174/191 (91%) bar employees. 14 insufficient samples, zero refused and three excluded due to 

using NRT. 

Interventions Implementation of the Smoking, Health and Social Care Act in Scotland in March 2006 which prohibited smoking 

in enclosed public places including bars, pubs and restaurants. 

Outcomes Self-reported number of hrs exposed to SHS at work in the last seven days 

Self-reported smoking status and number of cigarettes smoked per day 

% reduction in saliva cotinine concentrations, grouped by self-reported smoking status 

Self-reported presence of respiratory and sensory symptoms 

Biochemical verification: Yes; self-reported nonsmokers (never and ex-smokers) verified as saliva cotinine 20 ng ml −1 . 



49

Semple 2007 (Continued) 

Notes Other outcomes reported were PM2.5 as measured from personal aerosol monitors. Those who had reported using 

NRT were excluded when considering saliva cotinine analysis. 

Seo 2007 


Setting: Bloomington Hospital, Monroe County and Ball Memorial Hospital, Delaware County, Indiana 

Design: Observational study, Matched control group design with pre and post-ban data. Analysis: Comparisons of 

the number of hospital admissions between pre and post-law periods using Poisson analysis. 

Participants Patients who had a primary or secondary diagnosis of AMI (ICD-9-CM codes 410.xx); 2) with no past cardiac 

procedure that could have precipitated AMI nor co-morbidity such as hypertension, high cholesterol that could have 

precipitated AMI. Selection criteria also included having chemical evidence such as increased troponin I concentrations 

or creatine phosphokinase activity and onset of symptoms in the study area. For the secondary diagnosis of AMI, the 

chemical evidence had to be present at the time of admission. Control county was selected from Indiana Counties. 

Delaware County is geographically distant; at least 50 miles away from Monroe County. Delaware didn’t have a similar 

ordinance in place banning smoking in public places and it had similar demographic profiles to those of Monroe 

County primarily in terms of population size (120,563 Monroe vs 118,769 Delaware), racial/ethnic proportions, 

similar median household income to that of Monroe County, have similar heart disease mortality rate to that of 

Monroe County among annual deaths. 

Interventions Local ordinance which banned smoking in restaurants, retails stores and workplaces in Monroe County in August 1st 

2003 (extended to bars and clubs in January 2005) was compared to a control county; Delaware County, Indiana. 

Medical records from Bloomington Hospital, Monroe County and Ball Memorial Hospital in Delaware County, 

Indiana were used to compare the incidence of admission for AMI in non-smoking patients who were resident in 

Monroe County and Delaware County. 

Outcomes Incidence rates of non-smoking patients admitted to hospital with a primary or secondary diagnosis of AMI for 

twenty-two month period and who did not have any past cardiac history before the admission nor have hypertension 

or high cholesterol co-morbidity for the periods (August 2001-May 2003 vs August 2003-May 2005). 

Biochemical verification of smoking status: No 

Notes Population increased by 0.4% in Monroe and decreased by 0.8% in Delaware County between 2000 and 2004. 

Vasselli 2008 


Setting: Piedmont, Fruili Venezia, Giulia, Lazio and Campania 

Design: Pre and post-ban tests. Admission rates for AMI analysed. Analysis: Age Standardised rates were calculated 

and expected values and rates of admission were calculated using a linear regression model. 

Participants Total sample patients aged between 40 and 64 years in the period between January and March 2001-2005 with a 

diagnosis of AMI. Repeat admissions were excluded. 

Interventions Protection of the health of nonsmokers’ legislation 2003. Ban on smoking in all indoor public places, including cafes, 

bars, restaurants and discotheques. 



50

Vasselli 2008 (Continued) 

Outcomes Admission rates standardised by age and specifically by region and gender. 

Biochemical verification: No. 

Notes 

Verdonk-Kleinjan 2009 

Methods Country: Netherlands 

Setting: Dutch population 

Design: Pre- and post-ban tests. Internet-based cross-sectional surveys from July 2003-June 2005. 

Analysis: Chi-square test used to analyse proportion reporting SHS exposure, differences in exposure to SHS for 

subgroups and differences in characteristics of respondents from before to after. Multivariable logistic and linear 

regression analyses examining different factors (gender, age, education, type of employer & wkly working hrs) 

association with SHS exposure. 

Participants Random weekly selection of 200 non-smoking employees who had worked ≥15 hrs weekly and were aged 16-65 yrs. 

Sample is weighted. Total: 9856. 

Pre-ban: 2092 employees. Female: 43.3%. Aged 16-29 yrs: 17.8%; 30-49 yrs: 61.3%, 50-65 yrs: 20.9%. Education 

Level- Low: 26.5% ; Middle: 39.2%; High: 34.3%. Type of employer- Non-government: 84.2%; Government: 

15.8%. Weekly working hrs- 15-34 hrs: 36.1%; ≥35 hrs: 63.9%. 

Post-ban period: 7764 employees. No significant difference in characteristics of employees between pre- and postban 

samples. 

Compared this sample with sample of employees from National Bureau of Statistics by gender, age and level of 

education. Difference ranged from 0.5%-5.0%. 

Interventions Legislation which banned smoking in workplaces (excluding bars, cafes and restaurants) in the Netherlands in January 

2004. 

Outcomes Self-reported exposure to SHS in workplaces and frequency of exposure to SHS defined as: no exposure, sometimes, 

regular, often or always. 


Notes 

Waa 2006 

Methods Country: New Zealand 

Setting: New Zealand population 

Design: Observational study. Cross-sectional surveys from 2003-2006. Pre and post-ban tests, telephone questionnaire. 

Analysis: Data weighted by age and ethnicity; % reduction in prevalence of those exposed to SHS. 

Participants Age ≥15 yrs 

Survey in 2003: 2002 (38%) respondents, Maori 6.7%, smokers 17.9%, Female: 50%, 15-35 yrs 36.4% 

2004 survey: 2431 (35%) respondents, Maori 7.5%, smokers 18.4%, Female: 50%, 15-35 yrs 32.2% 

2005 survey: 2393 (29%) respondents, Maori 8.2%, smokers 18.7%, Female: 50.1%, 15-35 yrs 32.1% 

2006 survey: 2413 (34%) respondents, Maori 8.5%, smokers 16.4%, Female: 51.5%, 15-35 yrs 27.6% 



51

Waa 2006 (Continued) 

Interventions Enactment of Smokefree Environments Amendment Act 2003 on 10th December 2004 in New Zealand which 

prohibited smoking in bars, restaurants and hotels. 

Outcomes Self-reported exposure to SHS in indoor workplaces and at home defined as people who reported that other people 

had smoked around them over the previous seven days. 


Notes Other outcomes reported are support for the ban and economic impact such as patronage in hospitality venues. A 

campaign “Smokefree homes” was launched in 2004 and was identified as a possible confounding factor. 

Characteristics of excluded studies [ordered by study ID] 

Akbar-Khanzadeh 2003 Measured urinary cotinine and self reported exposure to secondhand smoke of employees before and after 

work shift in restaurants with different smoking policies. 

Akbar-Khanzadeh 2004 No pre and post data for implementation of smoking policies. 

Albers 2004 Cross-sectional study to measure association of local restaurant and bar smoking regulations with self 

reported exposure to secondhand smoke in adults. 

Albers 2007 No data on pre and post implementation of smoking ban. Two population based surveys and hierarchical 

linear modelling was used to assess the association between baseline strength of town-level restaurant 

smoking policy and smoking cessation and attitudinal outcomes at follow-up survey. 

Areias 2009 Cross-sectional survey. Post-test only. 

Bates 2002 No pre and post-ban data. Evaluated exposure to secondhand smoke pre and post work shift in employees 

who worked in hospitality venues with different levels smoking restrictions. 

Bauer 2005 Analysis of cohort of smokers as part of the Community Intervention Trial for Smoking Cessation. Surveys 

administered to assess change in smoking policy and smoking behaviour in 1993 and 2001. 

Biener 1999b Population based surveys of a cohort of Massachusetts adults over a three year period to assess changes in 

smoking policy, smoking cessation and exposure to SHS. No pre and post data. 

Bloor 2006 One group, post-ban survey. Sent to all employees in a psychiatric hospital to audit the effectiveness of a 

non-smoking policy on smoking habits and attitudes. 

Borders 2005 Cross-sectional survey . Obtained data on smoking restrictions from college administrators and analysed 

relationship between smoking policy type at the college and smoking behaviour of the students. 

Borland 1991b Pre-ban survey. Examined predictors of smoking cessation attempts and predictors of the outcome of those 

attempts after the introduction of a workplace smoking ban. 



52

(Continued) 

Borland 1992 Three cross-sectional surveys assessed changes in the restrictiveness of smoking bans and attitudes towards 

them in 1988, 1989 and 1990. No pre and post data. 

Borland 1992b Population based sample as part of California Tobacco Survey. Determined the extent of exposure to 

environmental tobacco smoke based on type of work site smoking policy, work area, workplace size and 

demographic characteristics. 

Borland 1995 Post-ban survey. Carried out two years after the workplace smoking ban. 

Borland 1997 Baseline survey. Examined smoking behaviour on working and non-working days of employees who spent 

more than half their working day in non-smoking areas. 

Botello-Harbaum 2009 Examined relationship between tobacco policies and cigarette consumption of minors using cross-sectional 

surveys. No pre- and post-data. 

Brenner 1992 Population based sample. Assessed smoking restrictions in the workplace and smoking cessation as measured 

by their quit ratio. 

Brenner 1994 One group, cross-sectional survey. Examined the relationship between smoking regulations and the smoking 

behaviour of employees in Southern Germany. 

Bronaugh 1990 Structured interviews over a four month period. Carried out in a psychiatric unit and examined smoking 

habits, nicotine addiction and compliance with the ban. 

C.-Thompson 1998 No pre and post test data. Examines relationship between smoking history and willingness and motivation 

to remain smoke free in smokers forced to undergo a mandatory six week ban from smoking. 

Carroll 1989 Cross-sectional study. Assessed impact of army smoking policies on smoking prevalence. 

Chaloupka 1992 Analysis of survey data in conjunction with county level cigarette prices, excise taxes and state level measures 

of restrictions. 

Chapman 1997 No pre and post data. Observational study of smokers in workplace with smoking bans compared to those 

smoking in social settings. 

Cooreman 1997 Eight years between the pre-ban and follow-up survey. Effect of smoking ban on attitudes and smoking 

behaviour of employees of a public hospital in Paris. 

Cropsey 2005 Follow-up of smoking outcomes is less than six months. Effect of a prison smoking ban on withdrawal 

symptoms and smoking behaviour of incarcerated males. 

Darling 2006 Cross-sectional survey. Examines relationship between school tobacco policy and the prevalence of tobacco 

use among students. 

Daughton 1992 Surveys five months and seventeen months post implementation of the hospital smoking ban. Assessed 

tobacco consumption and quit rates of employees who smoked. 



53

(Continued) 

Dawley 1993 Follow-up for only four months. A programme of smoking cessation treatment alone was offered in one 

company versus smoking control, discouragement and cessation in a second company. 

Dwyer 2005 Evaluation of a smoke free residential addiction treatment program. Data on smoking behaviour of clients 

reported at admission and discharge to the program. 

Eadie 2008 Primary outcome of review was not measured in this study. 

Echer 2008 No pre- and post-ban data. 

Emont 1990 No pre and post-ban data. Assesses the association between changes in the restrictiveness of the smoking 

ban from baseline to follow-up and smoking cessation in smoking employees. 

Emont 1992 No pre and post-test data. Cross-sectional population-based survey examining association between presence 

of state clean indoor air legislation and smoking behaviour of respondents. 

Emont 1995 Post-test only. Examined the effect of the smoke-free policy on daily cigarette consumption, attitudes and 

perceived air quality in the workplace. 

Evans 1999 No pre and post-ban data. Population based surveys analyse workers relationship between smoking policies 

at baseline and follow-up and smoking prevalence and cigarette consumption. 

Farkas 1999 Cross-sectional survey. Examined the relationship between household and workplace smoking restrictions 

with quit attempts, six month cessation, and light smoking. 

Farkas 2000 Cross-sectional surveys in 1992 to 1993 and 1995 to 1996. Assessed smoking status of the adolescents 

and association to whether they had home and workplace smoking restrictions. 

Farrelly 1999 Population surveys, not pre and post-test. Analysis of the impact of workplace smoking restrictions on the 

smoking prevalence and cigarette consumption among all indoor workers. 

Fernandez 2008 No measures of self-reported or biomarkers of exposure to secondhand smoke 

Fletcher 2009 Cross-sectional survey. Post-ban only. 

Franchini 2008 Survey and cord serum cotinine used to assess foetal exposure to secondhand smoke in the post-ban period. 

Frieden 2005 Follow-up data was combined from two surveys carried out in 2003. One survey had follow-up of less 

than six months for smoking outcomes. 

Gallus 2006 Evaluation of smoking status was less than six months post-ban. 

Gasparrini 2006 No measure of secondhand smoke exposure by self report or biochemically. 

Gerst 1995 Not pre and post data. 



54

(Continued) 

Goldstein 1992 Survey of employees and inpatients of five hospitals. Carried out four months after the implementation of 

the smoke-free policies. 

Gomel 1993 Evaluation of smoking outcome is less than six months follow-up. 

Gorini 2008a Cross-sectional survey. Post-ban only. 

Gorini 2008b No self-reported or biochemical measures of exposure to secondhand smoke. 

Hamilton 2003 Cross-sectional survey in 31 schools in Perth, Australia. To evaluate the relationship between different 

school smoking policies and ever-smoking and regular smoking rates in students. 

Hamilton 2008 Cross-sectional surveys of Massachuset adults and youths to examine association between smoking norms 

and smoking regulations. Data on tobacco related ordinances present n the cities and towns were used in 

the analysis. 

Harvey 2002 Survey of staff and students. Evaluation of the smoking prohibition on smoking behaviour in the university. 

Helakorpi 2004 Analysis of population surveys from 1978 to 2001. Examined the effects of the 1976 Tobacco Control Act 

in Finland. 

Hilton 2008 No pre and post data. 

Hu 2005 Cross-sectional surveys. Examined current status of smoking policies in the workplace and the association 

between smoking policies and employees’ smoking behaviours. 

Hyland 2007 Post-ban survey only. 

Kassab 1992 Follow-up survey after implementing a no-smoking policy in a health authority. 

Kelly 2009 No pre and post-test data. 

Kinne 1993 Population based survey of employed adults to determine the effect of work site smoking restrictions on 

their smoking behaviour. 

Kitabayashi 2006 Follow-up survey was three months post implementation of the smoking ban. Evaluated the effect of a 

smoking ban on smoking status in an institution for schizophrenia patients. 

Klein 2009 Not pre and post-law data. 

Kumar 2005 No pre and post-test data. Surveys examined smoking behaviour of 8th-, 10th-, and 12th-grade students 

and data on school policies and practices were obtained from administrators in these schools. 

Larrrere 1994 Outcome of smoking behaviour is less than six months follow-up. 

Lee 2008 Cross-sectional survey. 



55

(Continued) 

Levy 2003 Simulation model used to predict smoking prevalence and premature mortality associated with tobacco 

control policies over a forty year period. 

Levy 2004 Cross-sectional surveys from 1992/93 and 1998/99. No pre and post-test data. 

Levy 2005a Simulation model used to estimate the effect of public policies on smoking prevalence in the United States. 

Levy 2005b Population based survey. Examined the relationship between tobacco control policies, smoking cessation 

activities, demographic characteristics and smoking intensity among smokers. 

Levy 2006a Not pre and post test data. Population-based surveys in 1992-2002. Examined association between tobacco 

control policies and smoking in women with low socioeconomic status. 

Levy 2006b Not pre and post-test. 

Lewit 1997 No pre and post-test data. Two cross-sectional surveys in schools as part of Community Intervention Trial 

for Smoking Cessation assessed the relationship between cigarette taxes, clean indoor air laws and smoking 

behaviour. 

Lin 2006 Post-test only. Surveyed employees on their smoking behaviour and attitudes towards the medical centre’s 

smoke-free campus. 

Longo 1996 Cross-sectional survey. No pre and post-test data. Compared smoking behaviour of employees in smoke 

free hospitals to those whose workplaces did not having a smoking ban. 

Longo 2001 Not pre and post-test data. Examined the impact of a hospital smoking ban two years post implementation 

on employee smoking cessation and relapse. 

Lushchenkova 2008 Cross-sectional survey. Examined smoking prevalence and exposure to secondhand smoke following implementation 

of anti-smoking legislation in Spain. 

Marcus 1992 No pre and post data. Examines relationship between exposure to SHS and workplace smoking policy. 

Martínez 2009 Assesses implementation of tobacco control policies in hospitals before and after national smoking legislation. 

Maurice 2006 Cross-sectional population-based survey of adults in US in 2005. No pre and post data. 

McCaffrey 2006 Compares the number observed smoking inside bars or pubs before the ban with those smoking outside 

the same venues in the post-ban period. 

McMullen 2005 No pre and post-test data. Analysis of smoking prevalence and percentage of people not exposed to secondhand 

smoke in their workplace as a function of the strength of state legislation on smoking restrictions. 

Miller 2006 Follow-up survey on smoking behaviour is four months post implementation of the smoking ban. 



56

(Continued) 

Minihan 1999 Cross-sectional surveys examined smoking policies in residences and smoking behaviour for people with 

intellectual disabilities. Not pre and post implementation of smoking ban. 

Minov 2008 Cross-sectional survey after implementation of restrictive smoking law in Macedonia. No pre and postlaw 

data. 

Mizoue 2000 Cross-sectional survey. Assessed level of restrictiveness of workplace smoking policies in Japan and employee 

smoking behaviour. 

Montner 1996 Survey of hospital employees’ smoking prevalence, support for a smoking policy, readiness to quit and 

preferred method of quitting prior to implementation of a smoking restrictions and smoking cessation 

campaign. 

Moore 2001 Cross-sectional survey. Examined association between having different school smoking policies and smoking 

prevalence of students. 

Moskowitz 2000 Cross-sectional survey. Assessed relationship between a work site smoking policy and smoking cessation. 

Mullally 2008 No post-ban data. 

Murnaghan 2007 Not pre and post-test data. Evaluated the relationship between school smoking policies and smoking 

prevention programs on smoking behaviour of a cohort of students in1999 and 2001. 

Nebot 2009 Measured air quality as measure of exposure to SHS. 

Nerin 2005 The smoking restriction was implemented six months after start of the program. No post-ban measurement. 

Northrup 1998 Telephone interviews evaluating the Impact of the smoking ban in the school premises. 

Offord 1992 Follow-up study on smoking cessation of employees after the implementation of a smoke-free policy in a 

medical centre. 

Olive 1996 One hospital had post implementation data only. Evaluated smoking behaviour of employees six months 

after implementing restrictive smoking policies in the hospitals. 

Ong 2003 Estimate of the health and economic effect of proposed legislation in Florida. 

Ong 2004 No pre and post-test data. An analytical model predicts the effect of making all workplaces smoke free on 

myocardial infarction and stroke. 

Ong 2005 Simulation model comparing the costs, number of people who stopped smoking and quality-adjusted life 

years of a free nicotine replacement therapy with a smoke free workplace policy in Minnesota State. 

Osthus 2007 Cross-sectional survey of high school students. Assesses the relationship between different school smoking 

policies and smoking behaviour. 



57

(Continued) 

Owen 1997 Two cross-sectional surveys examining tobacco consumption of continuing smokers at six months and 

two years post implementation of a workplace smoking ban. 

Panagiotakos 2007 No smoking ban in this study. 

Parry 2000b Post-test only. Qualitative and quantitative investigation on staff’s smoking behaviour and attitudes in a 

university setting since the smoking ban. 

Patten 1995b Population based telephone surveys of adult indoor employees in Californian in 1990 and 1992. To assess 

whether changes in smoking status and cigarette consumption are related to their workplace smoking 

policy, and length of time the ban had been in place. 

Patten 1995c Population based surveys of California adults employed indoors in 1990, 1992 and 1993 and to examine 

the relationship between having a workplace smoking policy and self-reported exposure to secondhand 

smoke. 

Patten 1995d Less than six months follow-up for smoking outcome. 

Paulozzi 1992 Post-test only. Evaluates impact of tobacco control law in private workplaces in Vermont. 

Pederson 1992 Pre implementation, population based surveys. Assessed changes in knowledge of the health effects of 

active and passive smoking, attitudes towards smoking restrictions and smoking behaviour between 1983 

and 1988. 

Pederson 1993 Follow-up survey only for smoking outcomes. 

Pederson 1996 Cross-sectional survey of residents in Ontario, Canada. Compared smoking behaviour of employees living 

in areas with different workplace smoking restrictions. 

Pentz 1989 Cross-sectional survey. Assessed the relationship between smoking policies in twenty-three schools and 

adolescent smoking prevalence and mean cigarettes consumed daily. 

Petersen 1988 Cross-sectional survey three months after implementing smoking policy restricting smoking in the work 

site. 

Phillips 2007 Cross-sectional study of adults in Scotland after implementing legislation in March 2006. 

Philpot 1999 Cross-sectional survey of bars and night club patrons. Assessed the likelihood that they would change their 

patronage and smoking behaviour in response to proposed legislation. 

Pickett 2006 Population based survey and serum cotinine samples . Examined the relationship between serum cotinine 

levels and the extent of the restrictiveness of the smoke free law in that area. 

Pierce 1994 Population based survey. Examines the relationship between non-smokers exposure to environmental 

tobacco smoke and the presence and extent of workplace smoking policies. 

Prochaska 2006 Not pre and post-test data. 



58

(Continued) 

Proescholdbell 2008 No data on baseline smoking prevalence for group with partial smoking ban and group with total smoking 

ban. 

Ratschen 2008 Post-ban test only. 

Rayens 2008 No measures of smoking behaviour or exposure to SHS. 

Reitsma 2004 Not pre and post-test data. Carried out secondary analysis of cross-sectional surveys to assess the relationship 

between school tobacco policy and smoking status in Ontario elementary and secondary schools. 

Resnick 1989 Follow-up for smoking outcome was less than six months. Surveys of patients admitted to a psychiatric 

unit in the pre and post-ban period. 

Richiardi 2009 Model is used to estimate the effect of the smoking ban on AMI. 

Ringel 2005 No pre and post-ban data. Analysis of large population based survey data merged with data on state tobacco 

control policies. 

Rosen 1995 Follow-up data less than six months for smoking status. Evaluated the effect of a hospital no smoking 

policy on patients smoking behaviour. 

Rosenstock 1986 Cross-sectional survey. Assessed the impact of smoking prohibition in a health maintenance organization 

four months after its implementation. 

Schaap 2008 Analysis of cross-sectional survey of adults from eighteen countries. No pre and post data. 

Schnohr 2008 Analysis of cross-sectional survey of adolescents merged with national level data. No pre and post data. 

Scott 1989 Follow-up survey. Examined the relationship between implementing a smoking policy on tobacco consumption 

and smoking cessation. 

Semple 2007b No measures of self-reported or biomarkers of exposure to secondhand smoke. 

Shavers 2006 No pre and post-test data. Population based cross-sectional studies in 1998 to1999 or 2000 to 2001 

evaluated the association of workplace smoking policies and home smoking restrictions with smoking 

prevalence and consumption. 

Shields 2004 Cross-sectional population based surveys in Canada. Examined factors associated with smoking cessation 

such as having home smoking bans and workplace smoking bans. 

Shields 2007 No pre and post-data. Cross-sectional surveys to examine trends in smoking prevalence and their association 

with smoking restrictions. 

Shirres 1996 Two cross-sectional surveys to evaluate education programs and smoking cessation courses at manufacturing 

company. Less than six months follow-up of smoking outcomes. 



59

(Continued) 

Siegel 2005 No pre and post data. Population based surveys of a cohort of Massachusetts young adults aged 12-17 years 

and compared the relationship between those living in towns with different types of smoking restrictions 

and having progressed to established smoking i.e. smoked 100 or more cigarettes. 

Siegel 2008 No pre and post-ban test. Data on strength of local smoking regulations was obtained from respondents 

reported zip code in baseline survey and used in analysis to examine their association with smoking 

initiation at follow-up. 

Sinha 2004 Cross-sectional survey. Assessed relationship between schools with different policies on tobacco use and 

prevalence of tobacco use amongst school personnel. 

Skeer 2005 Population based survey in Massachusetts. Assessed the relationship between exposure to secondhand 

smoke, smoking status and employees smoking restriction / ban in the workplace. 

Smith 1989 Follow-up survey is less than six months post-implementation of the smoking ban. Evaluated the effect of 

the smoking ban in a psychiatric unit on patient’s smoking behaviours as well as their treatment. 

Sorensen 1991a Post-test only. Effect of a restrictive smoking policy on perceived exposure to environmental tobacco smoke 

in the workplace. 

Sorensen 1991b Survey 20 months post implementation of a restrictive work site smoking policy in conjunction with free 

onsite smoking cessation classes. Assessed the effect on smoking cessation. 

Stark 2007 Measured exposure to secondhand smoke in nonsmoking bar and restaurant workers before and after work 

shift. 

Stephens 1997 Population based surveys. Analysed the association of smoking prevalence and cigarette prices and nosmoking 

bylaws. 

Stillman 1995 Follow-up of smoking cessation was reported one month post discharge from the hospital. 

Strobl 1998 Post-test only. Assessed the effects of a smoking ban on the smoking behaviour and attitudes of nurses in 

a teaching hospital. 

Styles 1998 Cross-sectional survey of employees in Glasgow. Evaluated the relationship between the level of restiveness 

of the smoking ban in the workplace and employees smoking behaviour. 

Sussman 1990 Cross-sectional survey. No pre and post-test data. Examined the relationship between having a work site 

no-smoking policy and smoking behaviour of employees. 

Tang 2003 Three surveys post-ban. Impact of smoke-free law on bar patrons. 

Tang 2004 Two cross-sectional surveys post-ban. Examined attitudinal changes and bartenders concerns about the 

effect of exposure to environmental smoke on their health. 

Tauras 2004 No pre and post-test data. Utilises longitudinal data from population-based surveys of students and matches 

it with information from clean indoor air restrictions. 



60

(Continued) 

Tillgren 1998a Post-test only. Evaluation of a hospital smoking ban four years after its implementation using data and 

method triangulation. 

Tramacere 2009 Primary outcome of review was not measured in this study. 

Trudeau 1995 There was no pre-ban data. Evaluated the effect of a smoking restriction in a German university. 

Velasco 1996a Post-test only. Effect on prohibiting smoking in an inpatient psychiatric unit on observed behavioural 

disruptions. 

Wakefield 1992 Cross-sectional survey of employees. Association of having different levels of smoking restriction in the 

workplace and cigarette consumption were examined. 

Wakefield 2005 Saliva cotinine as a measurement of exposure to secondhand smoke obtained pre and post work shift in 

workplaces with different smoking policies. Self reported respiratory symptoms assessed in cross-sectional 

survey. 

Wakefield 2007 No pre and post-ban data. 

White 2008 Not pre and post-test. 

Woodruff 1993 Population based survey. Respondents asked about workplace smoking policy and their smoking behaviour. 

Characteristics of studies awaiting assessment [ordered by study ID] 

Tominz 2006 


Setting: Local Health Authority in Triestina, Northern Italy 

Method: Observational study. Cross-sectional surveys in 2004 and 2005, pre and post-ban tests. 

Participants Baseline: 746 employees 

Follow up post-law: 200 employees 

Interventions Legislation implemented in Italy on January 10th 2005 which prohibits smoking in indoor public places including 

bars, restaurants, cafes unless they have a separate smoking area with continuous floor-to-ceiling walls and a ventilation 

system (Law n. 3, 2003) 

Outcomes Smoking prevalence as measured by self-reported smoking status. 


Notes Other outcomes measured indoor levels of RSP PM2.5 and PM10 in workplaces and attitudes towards smoking. 



61

AMI: Acute myocardial infarction; CI: Confidence interval; cigs: cigarettes; CO: carbon monoxide; DF: Degrees of freedom; FEV: 

Forced expiratory flow; FEV1: Forced expiratory volume in one second; FVC: Forced vital capacity; hr: hour(s); Mass: Massachusetts; 

NI: Northern Ireland; NRT: nicotine replacement therapy; OR: odds ratio; PM 2.5: Particulate matter of less than 2.5 micrometers 

in diameter; ppm: parts per million; ROI: Republic of Ireland; RR: relative risk; RSP: respirable suspended particles; SD: standard 

deviation; SE: standard error; SHS: secondhand smoke: T1, T2: timepoint 1, timepoint 2; UK: United Kingdom; vs: versus; wk: 

week; yr: years 



62

D A T A A N D A N A L Y S E S 

Comparison 1. Results: Secondhand smoke exposure 

Outcome or subgroup title 

No. of 

studies 

No. of 

participants Statistical method Effect size 

1 Self-reported perceptions Other data No numeric data 

1.1 Total Other data No numeric data 

1.2 Workplace Other data No numeric data 

1.3 Cars Other data No numeric data 

1.4 Homes Other data No numeric data 

1.5 Public and other places Other data No numeric data 

2 Biomarkers of exposure Other data No numeric data 

Comparison 2. Results: Smoking behaviour 


1 Measures of Active Smoking: 

Smoking Prevalence, Tobacco 

Consumption and Smoking 

Cessation 

No. of 

studies 

Comparison 3. Results: Health measures 


No. of 

studies 

No. of 


Other data No numeric data 

No. of 


1 Respiratory Other data No numeric data 

2 Lung function Other data No numeric data 

3 Sensory Other data No numeric data 

4 Hospital admission for acute 

coronary syndrome 

Other data No numeric data 



63

Analysis 1.1. Comparison 1 Results: Secondhand smoke exposure, Outcome 1 Self-reported perceptions. 

Self-reported perceptions 

Study Type of ban Intervention Result 

Total 

Abrams 2006 Comprehensive 

New York, AMERICA 

July 2003 

Bondy 2009 Partial 

Toronto, CANADA 

June 2004 

Eisner 1998 Comprehensive 

California State, AMERICA 

January 1998 

Farrelly 2005 Comprehensive 

AMERICA 

July 2003 

Clean Indoor air Act (CIAA) 

prohibited smoking in most indoor 

workplaces. American Indian 

owned casinos were exempt 

from the CIAA. Study of nonsmoking 

workers recruited from 

the community. 

Legislation prohibiting smoking 

in indoor workplaces including 

bingo halls, casinos and licensed 

gambling venues and in most 

restaurants and bars. Designated 

smoking rooms with ventilation 

were allowed in some venues. 

Quasi - experimental study comparing 

non smoking hospitality 

employees in Toronto, Ontario 

(with smoke-free bylaw) with 

comparison community Windsor 

(no bylaw), Ontario. 

Legislation which prohibits smoking 

in bars and taverns. Examines 

the effect on a cohort of bartenders 

(smokers and non-smokers) 

in San Francisco whose owners 

agreed to participate in the 

study. 

New York State Clean Indoor Air 

Act. Longitudinal sample of nonsmoking 

employees working in 

Non-casino hospitality workers 

71% reduction in reported duration 

of exposure to SHS in all locations 

during the 4 days prior 

to the interview post- implementation 

of the ban (median: 20.8 

hrs exposed vs 6 hrs post-ban, P 

< 0.05). No significant reduction 

in self reported exposure during 

the previous 4 days in all locations 

(home, work and other locations) 

among casino workers (18 hrs prelaw 

vs 19.8 hrs post-law) for nonhospitality 

workers (3.0 hrs vs 2.3 

hrs). 

Mean (SD) Total hrs exposed to 

SHS (work and other): Toronto 

8.5(2.8) baseline vs 1.0(2.6) 1 m 

vs 1.3(2.4) 2 m vs 0.5(1.8) 9 

m. Windsor: 11.1(5.0) baseline vs 

10.5(4.9)1 m vs 11.7(4.8) 2 m vs 

11.6(12.8) 9 m. 

Exposure to SHS in the past 

7 days, median (25th -75th interquartile 

range): 75% reduction 

in self reported total hrs exposedd 

to SHS from a median of 40(30- 

55) one month pre-law period to 

10(2-30) hrs/wk (P

Self-reported perceptions (Continued) 

Fong 2006 Comprehensive 

IRELAND 

March 2004 

Goodman 2007 Comprehensive 

IRELAND 

March 2004 

Hahn 2006 Comprehensive 

AMERICA 

July 2003 

Jiménez-Ruiz 2008 Partial 

SPAIN 

January 2006 

bars, restaurants and bowling facilities 

who were not subject to a 

smoking ban in their workplace 

prior to the law. 

Legislation implemented in the 

Republic of Ireland banning 

smoking in indoor workplaces 


Quasi-experimental study comparing 

a cohort of smokers in the 

ROI (intervention) with those in 

a control area which had no ban 

(U.K.) before and 8-9 months after 

the legislation. 

Public Health (Tobacco) Act 2002 

which banned smoking in indoor 

workplaces including bars 

and restaurants. Cohort of bar 

workers (smokers and non-smokers) 

before and one yr after the implementation 

of legislation. 

The legislation introduced by 

Lexington-Fayette Urban County 

Council prohibiting smoking in 

public places including restaurants, 

bars and bingo halls. Studied 

a cohort of bar and restaurant 

workers before and after implementation 

of a smoking ban. 

The law required that bars and 

restaurants >100m 2 provide separate 

designated smoking and 

non-smoking sections but those 

less than ≤100 m 2 could decide 

whether to allow smoking or not. 

Cross-sectional population based 

surveys pre-law and at 12 months 

follow up. 

all sources (work, home, car and 

other locations (P


Menzies 2006 Comprehensive 

SCOTLAND 

March 2006 

Pell 2008 Comprehensive 

SCOTLAND 

March 2006 

Workplace 



July 2003 

Allwright 2005 Comprehensive 

Republic of IRELAND (R.O.I.) 

March 2004 

Examined the effect of banning 

smoking in enclosed public places 

on non-smoking barworkers in 

East Scotland. One group, pre and 

post-ban tests. 

Smoking banned in enclosed public 

places. Examined hospital admissions 

for acute coronary syndrome 

and patients’ exposure to 

secondhand smoke in the pre and 

1 yr post-law period. 










bars and restaurants. Quasi-experimental 

study of a cohort of nonsmoking 

bar workers enrolled 

from three areas in the Republic 

of Ireland (Dublin, Cork and 

County Galway) and one area in 

the control (Northwest region in 

Northern Ireland). 

posure. 

Self reported total hrs exposure to 

SHS by barworkers reduced significantly 

from median (IQR): 30 

(20-46.5) hrs per wk to 0 (0-1.75) 

hrs 2 months after the ban came 

into effect (P




June 2004 

Brownson 1995 Partial 

Missouri State, AMERICA 

August 1992 

CDC 2007 Comprehensive 

New York State, AMERICA 

July 2003 

Eagan 2006 Comprehensive 

NORWAY 

June 2004 



January 1998 



bingo halls, casinos and licenced 

gambling venues and in most 

restaurants and bars. Designated 

smoking rooms with ventillation 

were allowed in some venues. 

Quasi - experimental study comparing 


employees in Toronto, Ontario 

(with smoke-free bylaw) with 

comparison community Windsor 

(no bylaw), Ontario. 

Legislation restricting smoking in 

public places but allowed smoking 

in designated areas and exempted 

certain public places including 

bars, bowling alleys and 

restaurants with less than 50 seats. 

Cross-sectional population surveys. 


in many indoor workplaces including 

bars, restaurants and public 

transport. Cross-sectional population 

based surveys in prelaw 

period (June 26th-July 23rd 

2003) and post-law period (April 

1-June 30 2004). 

Legislation banning smoking indoors 

in restaurants and other 

hospitality business premises. Cohort 

study, pre and 5 months postlaw. 




in San Francisco whose 

owners agreed to participate in the 

study. 

Mean (SD) hrs exposed to SHS 

at work: Reduction in Toronto 

7.8(2.7) baseline vs 0.5(1.8) 1 m 

vs 0.8(2.1) 2 m vs 0.4(1.8) 9 

m. Windsor: 10.5(5.1) baseline vs 

10.2(4.9) 1 m vs 11.4(4.8) 2 m vs 

11.3(12.8) 9 m. 

% of respondents reporting exposure 

to SHS in the workplace during 

the last 7 days: 44.2% ± 2.6 

95% CI vs 34.7%± 4.1 95% CI 5- 

16 months post implementation 

of the law, P



AMERICA 

July 2003 

Fernández 2009 Partial 

SPAIN 

January 2006 

New York State Clean Indoor Air 

Act. Longitudinal sample of nonsmoking 


bars, restaurants and bowling facilities 

who were not subject to a 

smoking ban in their workplace 

prior to the law. 






whether to allow smoking 

or not. Quasi-experimental study 

comparing non smoking hospitality 

employees in Spain with those 

in two countries (without similar 

legislation), Portugal & Andorra 

pre-law and at 12 months follow 

up. 

hibition, 55% continued to report 

some SHS exposure (≥1 hrs/wk) 

while working as a bartender. 

Significant reduction in hrs of 

exposure to SHS in hospitality 

workplace within the past four 

days from mean 12.1 hrs (95% 

CI:8.0 to 16.3 hrs) pre-law to 0.2 

hrs (95% CI: -0.1 to 0.5 hrs) 

at 12 months post-law period (P 


Galán 2007 Partial 

SPAIN 

January 2006 

Gilpin 2002 Comprehensive 

AMERICA 

January 1998 

The legislation prohibited smoking 

in most indoor workplaces but 

included a partial ban on smoking 

in bars and restaurants. Cross-sectional 

surveys before and after the 

implementation of tobacco control 

legislation in Spain. 

Population based cross-sectional 

surveys. Clean indoor air legislation 

was extended to bars, gaming 

clubs and bar areas of restaurants 

in January 1st 1998 and had 

been prohibited in indoor workplaces 

since 1994. California Tobacco 

Control Program had been 

in place since 1988 

hrs reported exposure to SHS in 

hospitality venues in Andorra and 

Portugal (control, n= 19) from 8 

hrs (4.5-8.0) vs 8 hrs (8.0-9.5), P 

=0.18. 

40.5% pre-law vs 9%. OR=0.14, 

95% CI 0.11 to 0.19, P



IRELAND 

March 2004 


AMERICA 

April 2004 

Haw 2007 Comprehensive 

SCOTLAND 

March 2006 

Heloma 2003 Partial 

FINLAND 

March 1995 




and restaurants. Cross-sectional 

surveys of bar workers before and 

one yr after the implementation of 

legislation. 

Smoking was prohibited in all 

public places including bars, 

restaurants, bingo parlours, pool 

halls and public areas of hotels/ 

motels. One group with pre and 

post- ban surveys of hospitality 

employees in Lexington-Fayette 

County, Kentucky. 

Smokefree legislation (Smoking, 

Health and Social Care Bill) 

prohibiting smoking in indoor 

workplaces including bars, restaurants 

and cafes. Population based 

cross-sectional surveys pre and 6 

months post-law. 

Employer choice of total prohibition 

of smoking in the workplace, 

or designated areas with an adequate 

ventilation system. 

Cross-sectional surveys in 8 workplaces 

pre-law and 3 yrs after implementation. 

tories (17.9%, 95% CI=9.7 to 

26.1), and stores and warehouses 

(24.5%, 95% CI=20.0 to 29.0). 

Increase in the % California indoor 

workers reporting smokefree 

workplaces from 1990 (35%, 

95% CI=33.7 to 36.3) to 1999 

(93.4%, 95% CI 92.9 to 94.2). 

Males, minorities, younger workers 

and the less educated have 

higher rates of work area exposure 

to SHS. 

Significant reduction by 99% in 

workplace exposure to SHS of 

non-smoking barworkers, mean 

40.5 hrs pre-law vs 0.42 hrs at 1 

yr post-law. 

Significant reduction in reported 

average number of hrs exposed to 

SHS over the past seven days at 

work from 31 hrs per wk to 1- 

2 hrs at 3 & 6 month followup. 

No significant difference between 

restaurant and bar workers 

in hrs exposed at baseline or at follow 

up. Significant reduction for 

both groups between baseline and 

6 months follow up. 

Significant reduction in the proportion 

who reported exposure to 

SHS in workplaces 12.4% (145/ 

1169) vs 4.3% (51/1190), OR 

0.32, 95% CI: 0.23 to 0.45, P 


Hyland 2009 Comprehensive 

SCOTLAND 

March 2006 


SPAIN 

January 2006 

Larsson 2008 Comprehensive 

SWEDEN 

June 2005 


in enclosed public places including 

bars, pubs and restaurants. 

Quasi-experiemental study comparing 

population-based samples 

in Scotland with the rest of the 

UK pre-law and one yr after implementation. 






whether to allow smoking or not. 



follow up. 

Smokefree legislation in Sweden 

prohibiting smoking in workplaces 

include bars and restaurants 

from the 1st June 2005. Cohort 

study of hospitality employ- 

pre-law vs 54.2% after 1 yr vs 

70.7% at 3 yrs follow-up. Self reported 

non-exposure to secondhand 

smoke by employees is greatest 

in industry (8.4% pre-law vs 

85.3% 3 yrs post-law, P


Mulcahy 2005 Comprehensive 

IRELAND 

March 2004 

Palmersheim 2006 Comprehensive 

Wisconsin, AMERICA 

July 2005 

Pearson 2009 Comprehensive 

Washington, D.C. AMERICA 

January 2007 


SCOTLAND 

March 2006 

Semple 2007 Comprehensive 

SCOTLAND 

March 2006 

ees including casino and bingo 

hall workers pre and 12 month 

follow up. 

Legislation banned smoking in indoor 

workplaces including bars, 

restaurants, cafes and hotels (excluding 

bedrooms, outdoor areas 

and designated smoking shelters) 

. Studied a cohort of hospitality 

workers (n=35) before and after 

the ban. 

A smoking ordinance was introduced 

in two Wisconsin cities 

Madison and Appleton. Cohort 

study, pre and post-ban tests at 3- 

5 months. 

Legislation banning smoking in 

bars, restaurants and pool halls. 

Studied a cohort of hospitality 

workers (n=46) before (2nd-21st 

December 2006) and after the ban 

(1st-21st February 2007). 






one yr post-law period. 




Longitudinal cohort of bar workers 

prior to the legislation and fol- 

low-up, P


Verdonk-Kleinjan 2009 Partial 

NETHERLANDS 

January 2004 

Waa 2006 Comprehensive 

NEW ZEALAND 

December 2004 

low-up surveys upto one yr after. , smokers (29.3 vs 1.4) and nonsmokers 

(27.7 vs 0.21). Change in 

duration of SHS exposure at work 

from pre-law to one yr follow-up 

for both smokers and nonsmokers 

(30.5 hrs per wk, 95% CI: -33.5 

to -27.5). 


in workplaces but allowing designated 

smoking areas in bars, 

pubs and restaurants. Cross-sectional 

surveys of employees prior 

to the legislation (3rd and 4th 

quarter of 2003) and follow-up 

surveys (2004, and the 1st and 

2nd quarter of 2005). 

Examined the effect of legislation 

prohibiting smoking in bars, 

restaurants and hotels on exposure 

to secondhand smoke. Cross-sectional 

surveys 2003-2006. 

Percentage reporting been exposed 

to SHS at work: Significant 

reduction from 70.7% preban 

to 51.9% post-ban, P< 0.001. 

Significant reduction in the frequency 

of SHS exposure, P< 

0.001. Increase in the % of those 

exposed ”sometimes“ from 51.7% 

to 58.8%. Reduction in % that reported 

”regular“ (31.2% vs 27%) 

, ”often“ (10.7% vs 8.5%) or ”always“ 

(6.4% vs 5.8%) exposed to 

SHS after the ban. Among individuals 

at risk, exposure to SHS 

at baseline was significantly higher 

for men, lower educated employees, 

non-government employees 

and those working >35 hrs per wk. 

Logistic regression analysis conducted 

before and after found that 

men were almost twice as likely to 

be to exposed to SHS than women 

(76.5% vs 59.8%, OR 1.75 and 

63.2% vs 42.2%, 1.95) and lower 

educated employees were more 

than twice as likely to be exposed 

to SHS than highly educated employees 

(79.7% vs 61.5%, OR 

2.29 and 63.5% vs 41.7%, OR: 

2.17). The other groups at risk 

did not show significant interaction 

after the ban. 

Reduction in percentage of all respondents 

reporting exposure to 

SHS in the previous seven days in 

indoor workplaces from 21.3% in 

2003 (95% CI 19.0 to 23.6) to 

8.4% in 2006 (95% CI 7.1 to 9.8) 

. Reduction in % of nonsmokers 

exposed to SHS in 2003 from 



73


Cars 

Akhtar 2007 Comprehensive 

SCOTLAND 

March 2006 


IRELAND 

March 2004 


AMERICA 

April 2004 

Implementation 

of legislation prohibiting smoking 

in most indoor public places including 

bingo halls, theatres, hotels, 

bars and restaurants. Pre-law 

and follow-up cross-sectional surveys 

10 months after the legislation 

of children in final yr of primary 

school. 
















post- ban surveys of hospitality 

employees in Lexington-Fayette 


16.3% (95% CI 14.0 to 18.6) 

to 7.8% (95% CI 6.3 to 9.3) in 

2006. Reduction in % of smokers 

exposed in 2003 from 35.3% 

(95% CI 29.4 to 41.2) to 10.4% 

(95% CI 7.1 to 13.7) in 2006. 

Difference in exposure to SHS 

between smokers and nonsmokers 

was not statistically significant 

at follow-up. Higher prevalence 

of exposure to secondhand smoke 

in Maori compared to non-Maori 

pre-law. (29.7% vs 21.3%) but 

exposure post-law was similar for 

both. 2006 - Maori 9.9% (95% 

CI 7.7 to 12.1) vs Non-Maori 

8.2% (95% CI 6.4 to 10.0). 

No change in percentage of children 

reporting SHS exposure in 

the car from pre-law to follow-up 

: 6.7 vs 6.5, P = 0.817. 

In Ireland, there was no significant 

change in the percentage of 

those who observed smoking in 

cars from 42% to 45%, P = 0.33), 

whereas there was a significant reduction 

in the U.K. from 38% to 

30%, P = 0.005. 

Reported exposure to SHS in motor 

vehicles remained unchanged 

from pre-law to 6 months followup 

(8-11 hrs per wk). 



74



SCOTLAND 

March 2006 


SCOTLAND 

March 2006 

Homes 



July 2003 


SCOTLAND 

March 2006 

Biener 2007 Comprehensive 

AMERICA 

May 2003 













post-law period. 
















school. 

Smoke-free ordinance in Boston 

banning smoking in 

all workplaces including bars and 

restaurants. Cross-sectional surveys 

which compared smokers interviewed 

in Massachusetts cities 

and towns which didn’t have a 

smoking ordinance and those living 

in Boston which had a smoking 

ordinance. 

No change in reported exposure 

to SHS in private cars; 8.1% (95/ 

1169) pre-law vs 6.8% (81/1190) 

at follow up, OR 95% CI= 0.81 

(0.59-1.11), P>0.05. 

No significant change in prevalence 

for either nonsmokers or 

former smokers (all admitted for 

acute coronary syndrome) reporting 

no exposure to SHS from 

pre to post-law in ”cars, buses or 

trains“. 

Non-hospitality workers reported 

an increase in mean number of hrs 

exposure to SHS in the home over 

a 4 day period post-law compared 

to pre-law ( mean (SD) 1.9±6.2 

pre-law vs 5.3 ± 9.9 post-law, P < 

0.05). Noncasino hospitality and 

casino employees reported no significant 

change in the mean hrs 

exposed to SHS at home. 

No change in the percentage of 

children reporting exposure in the 

home from pre-law to follow-up: 

27.8% vs 27.4, P =0.747. Significant 

reduction percentage of children 

reporting exposure to SHS in 

someone elses home (11.6% before 

vs 9.5% in 2007, P =0.029). 

Changes in reports of smoking at 

home before and after implementation 

of a smoking ban in Boston 

bars: 66.9% (95% CI 54.9 to 

77.1%, n= 83) reported no change 

in exposure to SHS at home. In 

other MA cities with no ordinance, 

62.5% (CI 95% 58.5 to 

66.4) reported no change in expo- 



75


Brownson 1995 Partial 

Missouri State, AMERICA 

August 1992 


IRELAND 

March 2004 


SPAIN 

January 2006 

Gilpin 2002 Comprehensive 

AMERICA 

January 1998 

Legislation restricting smoking in 

public places but allowed smoking 

in designated areas and exempted 

certain public places including 

bars, bowling alleys and 

restaurants with less than 50 seats. 

Cross-sectional surveys. 











Cross-sectional surveys before and 

after the implementation of tobacco 

control legislation in Spain. 

The legislation prohibited smoking 

in most indoor workplaces but 

included a partial ban on smoking 

in bars and restaurants. 

Population based cross-sectional 

surveys. Clean indoor air legislation 

was extended to bars, gaming 

clubs and bar areas of restaurants 

in January 1st 1998 and had 

been prohibited in indoor workplaces 

since 1994. California Tobacco 

Control Program had been 

sure to SHS at home. No significant 

difference in reported exposure 

to SHS between Boston and 

other MA towns. 

% of residents reporting exposure 

to SHS in the home: No significant 

change. (Percent± S.D.) 

18.5% ± 1.6 vs 16.8% ±2.4 at 5- 

16 months follow-up, P >0.1. 

Similar decrease in percentage of 

homes where smoking was allowed 

in both intervention and 

control regions from 85% to 80% 

(P =0.002) in R.O.I. and from 

82% to 76% in U.K 8-9 months 

post-law (P =0.003) 

Percentage of households where 

smoking occurred from pre-law to 

follow-up: 34% pre-law vs 30% 

post-law (OR=0.84, 95% CI 0.71 

to 1.00, P =0.044). 

Exposure to SHS at home for 0-3 

hrs daily was 13.9% (95% CI 12.3 

to 15.7) pre-ban vs 14.8% postlaw 

(95% CI 12.8 to 17.0) OR= 

1.00, 95% CI 0.80 to 1.25) P = 

0.998. 

Decrease in exposure for < 3 hrs: 

8.3% pre-law (95% CI 7.0 to 9.7) 

vs 5.4% post-law (95% CI 4.1 to 

6.8), OR=0.65, 95% CI 0.47 to 

0.90, P =0.009. 

All respondents reporting smoke 

free homes increased from 37.6% 

in 1992, 50.9% in 1993, 63.8% 

in 1996 and 73.7% in 1999. 

For non-smoker: 43.8% in 1992, 

58.5% in 1993, 70.8% in 1996 

and 79.6% in 1999. 

% children and adolescents with 



76



AMERICA 

April 2004 


SCOTLAND 

March 2006 


SCOTLAND 

March 2006 


SPAIN 

in place since 1988 smoke free homes (household in 

which all adults smoked): 7.5% in 

1992, 13.5% in 1993, 31.7% in 

1996, 52.5% in 1999. % children 

and adolescents with smoke free 

homes (household with at least 

1 adult smoker):32.5% in 1992, 

33.1% in 1993, 50.6% in 1996, 

66.9% in 1999. All racial groups 

increased but Hispanic children 

and adolescents reported highest 

% smoke free homes in 1999 and 

African Americans the lowest. 





motels. One group of with pre 

and post- ban surveys of hospitality 

employees in Lexington- 

Fayette County, Kentucky. 
















restaurants >100m 2 provide sep- 

Reported exposure to SHS in 

homes remained unchanged from 

pre-law to 6 months follow-up 

(15-19 hrs per wk). 

No significant reduction in reported 

exposure to SHS in the 

home. 17.4% (203/1169) pre-law 

vs 17.1% (203/1190) follow-up, 

OR (95% CI): 1.05 (0.84-1.30), 

P >0.05 

No significant reduction in reported 

exposure to SHS in the 

”other people’s homes“. 21.3% 

(249/1169) pre-law vs 20.8% 

(247/1190) follow-up, OR (95% 

CI): 0.97 (0.79-1.18), P >0.05 

No difference in the percentage 

who didn’t allow smoking in the 

home at post-legislation between 

countries. Weighted % (95% CI): 

32%(28-36) pre-law vs 40%(36- 

44) follow up in Scotland. 38% 

(34-41) vs 51%(47-54) in rest of 

UK. No difference in cigarettes 

smoked at home in Scotland in 

comparison to the rest of the UK 

Exposure to SHS in the home for 

nonsmokers: 27% reduction from 



77



SWEDEN 

June 2005 



July 2005 


SCOTLAND 

March 2006 

January 2006 arate designated smoking and 



whether to allo smoking or not. 



follow up. 





study of hospitality employees 

including casino and bingo 


follow up. 





5 months. 







29.5% pre-law vs 21.4% post-law. 

Exposure to SHS was defined as a 

nonsmokers living with a smoker. 

Prevalence of SHS exposure of 

nonsmoking children to SHS at 

home was 40.9% pre-law 2005 vs 

39.2% post-law 2007. 

No change in duration of SHS exposure 

at home from pre-law to 

follow up. 

No change in exposure to SHS 

during the past 7 days at home 

from pre-law to 3-5 months. 

Mean 3.4 hrs pre-law vs 3.2 hrs 

follow-up, P =0.717. 

No significant change for nonsmokers 

or former smokers (all 

admitted for acute coronary syndrome) 

reporting ”no exposure“ 

to SHS from pre to post-law period 

in either ”own home“ or 

”other people’s homes“. Never 

smokers reporting ”no exposure“ 

in own home: 83% (565/677) 

pre-law vs 86% (460/537) postlaw, 

P =0.64. Never smokers reporting 

”no exposure“ in ”other 

people’s homes: 91% (617/677) 

pre-law vs 92% (495/537) postlaw, 

P =0.34. 

Percentage of never smokers reporting 

1-5 hrs exposure in own 

home: 6% pre-law vs 3% followup, 

P =0.64. ≥ 6 hrs exposure 

in own home: 10% pre-law vs 

11% follow-up, p=0.64. Percentage 

of never smokers reporting 1- 

5 hrs exposure in “other people’s 

homes”: 5% pre-law vs 5% followup, 

P =0.34. ≥ 6 hrs exposure in 



78



NEW ZEALAND 

December 2004 

Public and other places 


SCOTLAND 

March 2006 


Republic of IRELAND (R.O.I.) 

March 2004 


New York State, AMERICA 

July 2003 


prohibiting smoking in bars, 

restaurants and hotels on exposure 

to secondhand smoke. Cross-sectional 

surveys 2003-2006. 









school. 



bars and restaurants. Quasi-experimental 

study of a cohort of nonsmoking 

bar workers enrolled 

from three areas in the Republic 

of Ireland (Dublin, Cork and 

County Galway) and one area in 

the control (Northwest region in 

Northern Ireland). 


in many indoor workplaces including 

bars, restaurants and pub- 

“other people’s homes”: 4% prelaw 

vs 3% follow-up, P =0.34. 

Self reported exposure in the previous 

seven days at home: Increase 

% reporting no exposure 

from 78% (95% CI 74.4 to 80.0 

in 2003 to 88.5% (95% CI 87.2 

to 89.8) in 2006. Decrease in % 

reporting “any exposure” in the 

previous seven days from 21.6% 

(95% CI 19.8 to 23.4) in 2003 

to 11.5% (95% CI 10.2 to 12.8) 

. Decrease in prevalence of % reporting 

exposure to SHS at home 

everyday over the previous seven 

days from 12.3%% (95% CI 10.9 

to 13.7) in 2003 to 6.3% (95% 

CI 5.3 to 7.3) in 2006. 

Significant reduction percentage 

of children reporting exposure 

to SHS in “cafes or restaurants” 

(3.2% before vs 0.9% in 2007, P 




January 1998 


SPAIN 

January 2006 


IRELAND 

March 2004 

lic transport. Cross-sectional population 

based surveys in prelaw 

period (June 26th-July 23rd 

2003) and post-law period (April 

1-June 30 2004). 




in San Francisco whose 

owners agreed to participate in the 

study. 






whether to allow smoking 

or not. Quasi-experimental study 

comparing non smoking hospitality 

employees in Spain with two 

countries (without similar legislation), 

Portugal & Andorra pre-law 

and at 12 months follow up. 





in restaurants from 19.8% prelaw 

period (95% CI 15.6-24.1, n= 

856 ) to 3.1% (95% CI 2.0-4.2, 

n=1812) at follow-up period and 

from 52.4% (95% CI 41.5-63.4, 

n=203 ) to 13.4% (95% CI 9.5- 

17.3, n=417) at follow-up in bar 

patrons over the same 1 yr period. 

Exposure to SHS in the past 

7 days, median (25th -75th interquartile 

range): self reported 

other SHS exposure (excluding 

workplace) decreased from a median 

of 7(0-20) one month prelaw 

period to 2(0-15) hrs/wk (P 



SPAIN 

January 2006 







Cross-sectional surveys before and 

after the implementation of tobacco 

control legislation which 


workplaces but included a 

partial ban on smoking in bars and 

restaurants. 

rants and shopping malls) in the 

Republic of Ireland from pre to 

post legislation, relative to the 

control in the U.K, P9. 

Reduction in the prevalence of 

observed smoking in bars in Ireland 

from 98% to 5% (P < 0.001) 

whilst it remained the same in the 

control (98% to 97%, P = 0.462) 

. 

Reduction in the prevalence of 

those who reported seeing smoking 

in restaurants from 85% to 

3% (P < 0.001), compared to the 

control 78% to 62% (P < 0.001) 

. 

Reduction in prevalence of observed 

smoking in shopping malls 

from 40% to 3% P < 0.0001 in 

Ireland compared to a reduction 

from 29% to 22% (P = 0.012) in 

the control. 

No significant difference in observed 

smoking on buses in Ireland 

relative to the control (U.K.) 

p=0.121. The percentage of respondents 

that observed smoking 

on buses at baseline was low (less 

than 10%) in both Ireland (intervention) 

and the U.K.(control). 

Smoking was prohibited on buses 

in Ireland and the U.K. prior 

to implementation of comprehensive 

smoking ban legislation in Ireland. 

Increase in the percentage of respondents 

who reported no exposure 

to SHS when visiting bars 

from before to after the smoking 

restriction: 3.0% (95% CI 2.2 

to 3.9) pre-law to 8.1% post-law 

(95% CI 6.6 to 10.0). 

Increase in the percentage of respondents 

who reported no exposure 

to SHS when visiting restaurants: 

11.9% (95% CI 10.2 to 

13.8) pre-law to 32.4 (95% CI 



81



IRELAND 

March 2004 


AMERICA 

April 2004 


SCOTLAND 

March 2006 




and restaurants. Cross-sectional 

surveys of bar workers before and 

one yr after the implementation of 

legislation. 






post- ban surveys of employees in 

Lexington-Fayette County, Kentucky. 


Health and Social Care Bill) prohibiting 


including bars, restaurants 

and cafes. Population based cross- 

29.4 to 35.6) post-law. Significant 

reduction in percentage who reported 

a “Very high level” exposure 

to SHS in bars from 24.6% 

pre-law to 10.9% post-law, OR= 

0.16, 95% CI: 0.10 to 0.24. 

Significant reduction in the percentage 

who reported a “Very high 

level” exposure to SHS in restaurants 

from 7.9% pre-law to 2.4% 

post-law, OR= 0.11 95% CI: 0.07 

to 0.19. Comparison of exposure 

to SHS in bars for “low”, “fairly 

high” and “very high” against nonexposure 

for the period post-law 

to pre-law: 0.54 (95% CI:0.37 

to 0.80), 0.30 (95% CI: 0.20 to 

0.44) and 0.16 (95% CI 0.10 

to 0.24). Comparison of exposure 

to SHS in restaurants for 

“low”, “fairly high” and “very 

high” against non-exposure for the 

period post-law to pre-law: OR= 

0.31 (95% CI: 0.25 to 0.39), 0.24 

(95% CI: 0.18 to 0.32) and 0.11 

(95% CI: 0.07 to 0.19). 

Exposure to SHS outside of work: 

Mean 6.4 hrs pre-law vs 3.7 hrs at 

1 yr post-law (% change, -42%; P 



SCOTLAND 

March 2006 


SPAIN 

January 2006 

sectional surveys pre and at least 6 












non-smoking sectionsbut those 


whether to allo smoking or not. 



follow up. 

nificant reduction in reported exposure 

to SHS in other enclosed 

public places: 9.4% (110/1169) vs 

2.6% (31/1190); OR (95% CI): 

0.25 (0.17-0.38), P



SWEDEN 

June 2005 



July 2005 


SCOTLAND 

March 2006 






including casino and bingo 


follow up. 





5 months. 







law vs 8.8% (46/521) post-law; 

equivalent to 50.4% reduction. 

Significant reduction in participants 

reporting SHS exposure for 

>1 hr outside work or at home. 35/ 

71 (49%) pre-law vs 7/71(10%), 

P< 0.001. 

Exposure to SHS during an past 

7 days in “other places” outside 

work and home decreased from 

mean 7.9 to 3.6 hrs P =0.000. 

Prevalence of nonsmoking patients 

(all admitted for acute coronary 

syndrome) reporting no exposure 

from pre-law period vs 

post-law period: 77% vs 96% 

pubs, bars or clubs (P

Analysis 1.2. Comparison 1 Results: Secondhand smoke exposure, Outcome 2 Biomarkers of exposure. 

Biomarkers of exposure 



July 2003 


SCOTLAND 

March 2006 

Clean 

Indoor air Act (CIAA) prohibited 

smoking in most 

indoor workplaces. American 

Indian owned casinos 

were exempt from 

the CIAA. Study of nonsmoking 

workers recruited 

from the community. 

Implementation of legislation 

prohibiting smoking 

in most indoor public 

places including bingo 

halls, theatres, hotels, bars 

and restaurants. Pre-law 

and follow-up test 10 

months after the legislation 

of children in final 

year of primary school. 

Concentration urinary cotinine 

decreased significantly 

among non-casino 

hospitality workers (median 

4.93 ng/ml pre-law 

vs 0.3 ng/ml post-law, P 

< 0.01) and non-hospitality 

workers (median 2.03 

ng/ml pre-law vs 0.3 ng/ 

ml post-law, P < 0.01) 

but did not change significantly 

in casino employees. 

Proportion of non-detectable 

urine cotinine levels 

among non-casino hospitality 

workers: 3% prelaw 

vs 62% post-law, P 

< 0.01), and for non-hospitality 

workers increased 

from 20% pre-law vs 63% 

post-law, P < 0.01). 

Significant reduction in 

mean saliva cotinine concentration 

for all pupils 

from 0.35 ng/ml (95% 

CI: 0.32 to 0.38) prelaw 

to 0.21 ng/ml (95% 

CI: 0.19 to 0.23) post-law, 

P8 ppm CO in expired 

hair (n= 7, 4%) and were 

eliminated from analysis. 

Pupils with >15 ng/ml 

saliva cotinine were considered 

active smokers and 

were excluded from the 

analysis. Cotinine confirmed 

smokers : 1.8% (n= 

46) pre-law vs 1.5% (n= 

35) post-law. Self reported 

exposure to SHS verified 

by salivary cotinine analysis. 

85

Biomarkers of exposure (Continued) 


Republic of IRELAND 

(R.O.I.) 

March 2004 

Legislation prohibiting 


including bars and 

restaurants. Quasi-experimental 

study of a cohort 

of nonsmoking bar workers 

enrolled from three areas 

in the Republic of Ireland 

(Dublin, Cork and 

County Galway) and one 

area in the control (Northwest 

region in Northern 

Ireland). 

ng/ml (95% CI: 0.13 to 

0.16) pre-law to 0.07 ng/ 

ml (95% CI: 0.06 to 0.08) 

at follow up. P




June 2004 


New York State, AMER- 

ICA 

July 2003 

Legislation 


in indoor workplaces 

including bingo halls, casinos 

and licensed gambling 

venues and in most restaurants 

and bars. Designated 

smoking rooms with ventilation 

were allowed in 

some venues. Quasi - experimental 

study comparing 


employees in Toronto, 

Ontario (with smoke-free 

bylaw) with comparison 

community Windsor (no 

bylaw), Ontario. 


smoking in many 

indoor workplaces including 

bars, restaurants and 

public transport. Crosssectional 

population based 

surveys in pre-law period 

(June 26th-July 23rd 

2003) and post-law period 

(April 1-June 30 2004). 

creased in 106/111 (95%) 

of nonsmokers in R.O.I 

and in 14/20 (70%) in NI 

during the same period. 

Mean ng/ml (SD) urinary 

cotinine concentration in 

Toronto: 24.2 (20.1) baseline 

vs 7.8(9.4) at 1 m, 

8.3 at 2 m (10.7) vs 8.4 

(16.7) at 9 m. Windsor: 

17.3(16.8) baseline vs 

14.4(16.0) at 1m vs 13.4 

(13.7) at 2 m vs 12.0 

(10.7) at 9 m. Significant 

reduction from baseline to 

follow up (P 100 ng/ml (26 Toronto 

and 5 in Windsor) and > 8 

ppm CO (24 Toronto & 3 

in Windsor) were excluded 

from the analysis. 

Self reported exposure to 

SHS validated by saliva 

cotinine. Participants with 

cotinine >15 ng/ml were 

considered active smokers 

and were excluded from 

analysis. 

2008/6162 saliva samples. 

1594/2008 were included 

in the analysis as they had 

sufficient saliva and had 

cotinine


Ellingsen 2006 Comprehensive 

NORWAY 

June 2004 



July 2003 

Effects of a smoking policy 

in a cohort of restaurants 

and bar employees in Norway. 

Legislation was implemented 

which banned 

smoking in bars, restaurants 

and night-clubs. 

New York State Clean Indoor 

Air Act. Longitudinal 

sample of non-smoking 


bars, restaurants and bowling 

facilities who were not 

subject to a smoking ban 

in their workplace prior to 

the law. 

Statistically significant reduction 

in geometric mean 

concentration of cotinine 

in urine from GM 9.5 

(95% CI: 6.5 to13.7) ug/ 

g creatinine to 1.4 (95% 

CI: 0.8 to 2.5) ug/g creatinine 

in the nonsmokers 

sample (n=25) directly after 

a shift before and after 

implementing the ban, 

P


Fernando 2007 Comprehensive 

NEW ZEALAND 

December 2004 


SPAIN 

January 2006 

Compares two measures of 

exposure to SHS in nonsmoking 

patrons across 

three cities before and after 

legislation which prohibited 

smoking in bars, 

restaurants and hotels. Prelaw 

and 1 yr follow up. 

The law required that bars 

and restaurants >100m 

2 provide separate designated 

smoking and nonsmoking 

sections but those 

less than ≤100 m 2 could 

decide whether to allow 

smoking or not. Quasi-experimental 

study comparing 


employees in Spain 

with two countries (without 

similar legislation), 

Portugal & Andorra prelaw 

and at 12 months follow 

up. 

follow up, p



IRELAND 

March 2004 

Gotz 2008 Comprehensive 

ENGLAND 

July 2007 

Public Health (Tobacco) 

Act 2002 which banned 



restaurants. One group, 

pre- and post-tests of 

bar workers (smokers and 

nonsmokers) before and 

one yr after the implementation 


Legislation which bans 

smoking in enclosed public 

places including bars 

and restaurants. Study assesses 

exposure to SHS 

in nonsmoking hospitality 

employees from pre-law to 

post-law periods 

No signficant reduction in 

saliva cotinine for employees 

working in venues allowing 

smoking throughout 

their venue (n=63) 

. 2.5 ng/ml (1.7-3.9) vs 

2.6 (1.7-3.7), P =0.475. 

In Portugal and Andorra 

(control), there was no 

change from pre-law to 12 

month follow up, n= 20 

from 1.2 ng/ml (0.6-1.6) 

vs 1.2 ng/ml (0.5-1.6), P = 

0.962. 

Significant 

reduction in carboxyhaemoglobin 

by 5% 

in the never-smoker group, 

but no significant reduction 

in ex-smokers and 

current smokers. 79% reduction 

in exhaled CO for 

never and exsmokers but 

no significant change in 

current smokers. Exhaled 

CO Median (interquartile 

range) ppm: 4.0 (IQR, 3- 

5) pre-law vs 2.0 (IQR, 2- 

3) follow up, P



AMERICA 

April 2004 


SCOTLAND 

March 2006 

Smoking was prohibited 

in all public places including 

bars, restaurants, 

bingo parlours, pool halls 

and public areas of hotels/ 

motels. One group with 

pre and post- ban surveys 

of hospitality employees 

(smokers and nonsmokers) 

in Lexington-Fayette 


Smokefree legislation 

(Smoking, Health 

and Social Care Bill) prohibiting 

smoking in indoor 

workplaces including 

saliva cotinine of cohort 

(n= 39) : 75% reduction 

from pre-law to post-law. 

3.6 ng/ml vs 0.9 ng/ml at 

1 month follow-up, t (df)= 

9.1. P



SCOTLAND 

March 2006 

Mulcahy 2005 Comprehensive 

IRELAND 

March 2004 

bars, restaurants and cafes. 

Population based crosssectional 

surveys pre and 6 


Examined the effect of 

banning smoking in enclosed 

public places on 

non-smoking bar workers 

in East Scotland. One 

group, pre and post-ban 

tests. 

Legislation banned smoking 

in indoor workplaces 

including 


cafes and hotels (excluding 

bedrooms, outdoor areas 

and designated smoking 

shelters). Studied a cohort 

of non-smoking hos- 

tion for nonsmokers (0.43 

ng/ml at baseline to 0.26 

ng/ml post-law, P



Washington, D.C. 

AMERICA 

January 2007 


SCOTLAND 

March 2006 

pitality workers (n=35) before 

and after the ban. 

Legislation banning smoking 

in bars, restaurants and 

pool halls. Studied a cohort 

of hospitality workers 

(n= 46) before (2nd-21st 

December 2006) and after 

the ban (1st-21st February 

2007). 

Smoking banned in enclosed 

public places. Examined 

hospital admissions 

for acute coronary 

syndrome and patients’ exposure 

to SHS in the pre 

and post-law period. 

cotinine between 16% to 

99% with 60% showing 

halving of exposure levels 

and 34% had a reduction 

> 70% from pre-law 

to 4-6 weeks follow-up. 

Significant reductions in 

median cotinine concentration 

were obtained for 

waiters and other workers 

such as accommodation, 

leisure club, kitchen staff, 

porters and front desk staff 

(P



SCOTLAND 

March 2006 



places including bars, 

pubs and restaurants. Longitudinal 

cohort of bar 

workers prior to the legislation 

and follow-up surveys 

up to one yr after. 

patients admitted for acute 

coronary syndrome from 

0.68 ng/ml pre-law to 0.56 

ng/ml post-law (P


95% CI: 3 to 20%). Geometric 

mean of 207.4 ng/ 

ml to 190.7 ng/ml at 1 yr 

follow up. 

No relationship between 

change in saliva cotinine 

and change in respiratory 

and sensory symptoms. 

Analysis 2.1. Comparison 2 Results: Smoking behaviour, Outcome 1 Measures of Active Smoking: Smoking 

Prevalence, Tobacco Consumption and Smoking Cessation. 

Measures of Active Smoking: Smoking Prevalence, Tobacco Consumption and Smoking Cessation 

Alcouffe 1997 Partial 

FRANCE 

November 1992 

Biener 2007 Comprehensive 

AMERICA 

May 2003 

Braverman 2008 ComprehensiveNOR- 

WAY 

June 2004 

Restricted smoking in all 

enclosed public places, including 

on Métro and in 

Métro stations. Synthesis 

of 4 surveys. 

Smoke-free ordinance in 

Boston banning smoking 

in all workplaces including 


Cross-sectional surveys 

which compared smokers 

interviewed in Massachusetts 

cities and towns 

which didn’t have a smoking 

ordinance and those 

living in Boston which had 

a smoking ordinance. 

Indoor smoking ban in 

restaurants and other hospitality 

premises. Survey of 

restaurant and bar employees 

pre-law and at 4m and 

11m follow up. 

Baseline: Population 

prevalence 43%; 

among office staff 44%, 

NS. 

2-yr follow up: Population 

prevalence 43%, 

office staff 45%, NS 

No significant change in 

respondents who reported 

that smokers 

in their households continued 

smoking inside the 

home after implementing 

the Boston smoking ban 

in 2003 when compared 

with other cities which did 

not have similar legislation 


in bars up to July 5th 2004. 

Boston 69.6% (CI 95% 

57.1 to 79.7) vs 76.9% (CI 

95% 73.4 to 80.0) in other 

MA cities which had no ordinance, 

ns. 


daily smoking at 4m (- 

4.6%, P

Measures of Active Smoking: Smoking Prevalence, Tobacco Consumption and Smoking Cessation (Continued) 

Cesaroni 2008 Partial 

ITALY 

January 2005 


Ireland 

March 2004 

Restricted smoking in indoor 

public places including 

bars, restaurants, cafes. 

Study measures smoking 

prevalence of residents in 

Rome from pre- to postlegislation. 

Restricted smoking in indoor 



Study measures included 

self reported smoking behaviour 

and 

reported smoking in public 

venues.It also reports 

the behavioural impact of 

the smoke-free law among 

smokers 

work at 4m follow-up (- 

6.8%, P


Fowkes 2008 Comprehensive 

SCOTLAND 

March 2006 

Gallus 2007 Partial 

ITALY 

January 2005 



places including bars, 

pubs and restaurants. Cohort 

of smokers were compared 

in the years before 

the ban (1998-2005) and 

one year after it (June 

2006-June 2007). 

Population-based crosssectional 

surveys. 

57/474 (12%) smokers 

stopped smoking during 

the year after the ban. 

There was a 2.2 fold increase 

in the proportion of 

smokers quitting smoking 

in the 3 months before the 

ban (5.1%) compared to 

the same period in the previous 

year. Odds of smokers 

quitting in the seven 

years pre-ban to the 2 years 

after the ban (from 1999- 

2007) increased by 9% 

annually (OR 1.09, 95% 

CI: 1.05-1.12, P



SPAIN 

January 2006 


AMERICA 

April 2004 


Kentucky, USA 

April 2004 

The legislation prohibited 

smoking in most indoor 

workplaces but included 

a partial ban on smoking 

in bars and restaurants. 

Cross-sectional surveys before 

and after the implementation 

of the legislation 

in Spain. 

Smoking was prohibited in 

all public places including 

bars, restaurants, bingo 

parlours, pool halls and 

public areas of hotels/motels. 

One group with pre 

and post- ban surveys of 

employees in Lexington- 

Fayette County, Kentucky. 

Ban on smoking in all public 

places including bars 

and restaurants. 

Surveys of pre- and postlaw 

prevalence compared 

to control counties without 

smoking policy. 

Of those who smoked 

(31.7% of sample), 57.9% 

smoked at work pre-law vs 

10.6% post-law, OR=0.08 

(95% CI 0.05 to 0.13, 

P


Helakorpi 2008 FINLAND 

1995 

Heloma 2003 Partial 

FINLAND 

March 1995 


SCOTLAND 

March 2006 


SWEDEN 

June 2005 

1995 Tobacco Control 

Amendment Act. Population-based 

cross-sectional 

surveys. 

Employer choice of total 

prohibition of smoking in 

the workplace, or designated 

areas with an adequate 

ventilation system. 

Cross-sectional surveys in 

8 workplaces before and 

after implementation . 


smoking in enclosed 

public places including 

bars, pubs and restaurants.Quasi-experiemental 

study comparing population-based 

samples in 

Scotland with the rest of 

the UK pre-law and one 

year after implementation. 

Smokefree legislation in 

Sweden prohibiting smoking 

in workplaces include 

bars and restaurants from 

the 1st June 2005. Cohort 


including casino 

and bingo hall workers pre 

Results: Adjusted odds ratio 

after 1995 among employed 

men was 0.83 ((5% 

CI 0.73-0.94) 

and for employed women 

(0.78 (95% CI 0.68-0.91) 

. These data suggest an impact 

of the ban on smoking 

behaviour. 

Smoking prevalence: 

1994-1995: 29.8%, down 

to 24.6% at 1yr, 25.2% at 

3yrs, P=0.026. 

Over 4yrs, smoking decreased 

in men (33.1% to 

24.8%, P=0.006) but increased 

in women (22% 

to 26.1%, P=0.128). But 

number of smoking females 

was low (n=57) so 

possibly random variation. 

16% reduction in average 

number of cigarettes consumed 

daily by continuing 

smokers from 19 in 1994/ 

5 to 16 at one yr followup 

and remained at 16 in 

1998. 

Smoking cessation was not 

statistically significant after 

the legislation between 

countries. Quit smoking 

at follow-up (Weighted % 

and 95% CI): 19% (9.8- 

29) in Scotland vs 21% 

(14-28) in rest of UK. 

No change in median 

cigarettes per day: 17 

cig/day pre- to 15 cig/ 

day at 12 month followup, 

P for trend= 0.788, 

ns. No significant reduction 

for cigarette consumption 

for either gam- 



Non-validated self report 



Smoking status verified by 

urinary cotinine. 

99


Lemstra 2008 Comprehensive 

Saskatoon, CANADA 

July 2004 

Mullally 2009 Comprehensive 

IRELAND 

March 2004 

and 12 month follow up. ing (casino or bingo gall) 

or for other hospitality employees. 

Small number of 

smokers at baseline. 

No change in smoking status 

from baseline to 12 

months follow up. Small 

number of smokers at 

baseline that responded at 

follow-up n= 14. 

Population-based crosssectional 

surveys of smoking 

ban in public places in 

the city. 

Legislation 



bars and restaurants. Cohort 

of bar workers from 

Cork city pre- and one yr 

follow up. 

2003: 

pre-law 24.1% (95% CI 

20.4 to 27.7); post-law to 

18.2% (95% CI15.7 to 

20.9) = reduction: 24.5%. 

Saskatchewan 

(control): No change from 

pre-law to post-law 23.8% 

(95% CI 22.6 to 25.3) = 

reduction: 0%. 

Canada: 

pre-law 22.9% (95% CI 

22.5 to 23.3) to post-law 

21.3% (95% CI 20.8 to 

21.8)= reduction: 7%. Statistically 

significant reduction 

in smoking prevalence 

in Saskatoon compared to 

Saskatchewan and Canada 

(P



SCOTLAND 

March 2006 

Smoking banned in enclosed 

public places. Examined 

hospital admissions 

for acute coronary 

syndrome and patients’ 

exposure to secondhand 

0.5. 

Changes in smoking 

prevalence among general 

population in Republic 

of Ireland N (%): 351 

(28.3%) pre-ban vs 303 

(24.8%) one yr follow up, 

P =0.055. Significant reductions 

in men, 18-28 yrs 

and bar owners/managers. 


self reported number of 

cigarettes consumed per 

day amongst cohort bar 

workers in Cork- Mean 

(SD): 18.1 (11.8) pre-law 

vs 13.9 (8.5) one yr follow 

up, P< 0.001. No 

statistical interaction between 

pre- vs post-ban 

measurements for gender, 

age group or occupational 

class. 

Analysis of 16 participants 

that were no longer employed 

in bars at follow 

up. 12/16 were smokers 

at follow-up and had significant 

reduction in daily 

cigarettes consumed by 

9.25, P= 0.001. 

Self reported number of 

cigarettes consumed per 

day amongst among general 

population in Republic 

of Ireland Mean 

(SD): 16.9(9.8) pre-ban vs 

16.0 (8.4) one yr follow 

up, P=0.19. No significant 

change in daily cigarette 

consumption by gender or 

age group. 

In patients admitted for 

acute coronary syndrome 

in Scotland, there was 

no significant reduction in 

self reported number of 

cigarettes smoked by pa- 



Smoking status validated 

by serum cotinine 

101



SCOTLAND 

March 2006 


NEW ZEALAND 

December 2004 

smoke in the pre and postlaw 

period. 

Legislation 


in enclosed public places 

including bars, pubs and 

restaurants. Longitudinal 

cohort of bar workers prior 

to the legislation and follow-up 

surveys upto one yr 

after. 



in bars, restaurants 

and hotels on exposure to 

secondhand smoke. Crosssectional 

surveys 2003- 

2006. 

tients in the pre or postlaw 

periods or the geometric 

mean cotinine level 

(152 to 147 ng/ml, P= 

0.72). 


daily cigarette consumption 

of 2.5 cigs per day 

from before the legislation 

in 2006 to one yr followup 

(n= 60, 95% CI -4.0 to 

-1.1). 

Smoking Cessation: 4% 

(8/201) of bar workers 

stopped smoking after one 

year follow-up. 

Frequency of smoking at 

nightclubs relative to respondents 

usual smoking 

level: Significant reduction 

from 80.1% (95% CI 

72.8-87.4, n=114) reporting 

smoking “more than 

normal” in 2003 compared 

to 50.4% (40.8- 

69.0, n= 105) in 2006. 

Frequency 

of smoking at hotels, bars, 

pubs to relative to respondents 

usual smoking level: 

Significant reduction from 

65.8% (95% CI 59.2-72.4 

, n= 196) reporting smoking 

“more than normal” in 

2003 compared to 30.8% 

(24.5-37.1, n= 209) in 

2006. There was a significant 

increase in the % reporting 

“less than normal” 

and “not at all” from 2004 

to 2005. 


restaurants and cafes relative 

to respondents usual 

smoking level: Smokers 

were likely to report smok- 



Smoking status validated 

by saliva cotinine 


102


ing “less than normal” or 

“not at all” compared to 

other venues. There was an 

increase in the % reporting 

smoking “Less than 

normal” from 2003 to 

2004. 29.8(24.1-35.5, n= 

245) pre-law to 44.9(39.4 

- 50.4, n= 316) in 2006 


casinos relative to respondents 

usual smoking level: 


smokers reporting “more 

than normal” in casinos 

from 2003 to 2005. However, 

numbers of smokers 

in sample was small. 

53.8% (36.8-70.8, n=33) 

pre-law to 21% (6.2 - 35.8, 

n=29) 

Smokers were those who 

smoked at least monthly 

and who attended nightclubs, 

hotels, bars/pubs, 

restaurant/cafés, and casinos 

at least monthly. 



103

Respiratory 

Analysis 3.1. Comparison 3 Results: Health measures, Outcome 1 Respiratory. 



(R.O.I.) 

March 2004 

Eagan 2006 Comprensive 

NORWAY 

1st June 













Ireland). 

Legislation 

banning smoking 

indoors in restaurants and 

other hospitality business 

premises. Cohort study of 

hospitality employees, pre 

and 5 months post-law. 

In R.O.I., there was a significant 

reduction in nonsmokers 

reporting one or 

more respiratory symptoms 

(65% baseline vs 

49% one yr follow-up, P = 

0.001). After the ban significantly 

fewer reported 

cough during the day or 

night (38% vs 25%, P = 

0.004) or production of 

phlegm (43% vs 29%, 

P =0.002) in intervention 

group. In NI for the 

same time-period, there 

was no significant change 

between baseline and one 

yr follow-up in reporting 

any respiratory symptoms 

(45% vs 45%, P = 1.00) 

. There was no significant 

change in the prevalence 

of the following symptoms 

in the R.O.I. from 

baseline to one follow-up: 

wheezing/whistling (21% 

vs 20%, P =0.86), shortness 

of breath (16% vs 

16%, P =1.0), cough, 

morning (21% vs 15%, P 

=0.14). 

There was a significant 

reduction in percentage 

of all participants having 

“any respiratory symptom” 

from before to 5 

months after implementation 

of the law (40.6% vs 

32.9%). Morning cough 

decreased from 20.6% to 

16.2% (P

Respiratory (Continued) 


California State, AMER- 

ICA 

January 1998 

Legislation which prohibits 

smoking in bars 

and taverns. Examines the 

effect on a cohort of 

7.8%, P




July 2003 


SPAIN 

January 2006 

bartenders (smokers and 

nonsmokers) in San Francisco 

whose owners agreed 

to participate in the study. 

New York State Clean 

Indoor Air Act. Longitudinal 

sample of nonsmoking 

employees working 

in bars, restaurants 

and bowling facilities who 

were not subject to a 

smoking ban in their 

workplace prior to the law. 

The law required that bars 

and restaurants >100m 2 

provide separate 

designated smoking 

and non-smoking sections 

but those less than ≤100 

m 2 could decide whether 

to allow smoking or not. 

Quasi-experimental study 

comparing non smoking 

hospitality employees in 

Spain with two countries 

(without similar legislation), 

Portugal & Andorra 

pre-law and at 12 months 

follow up. 

baseline vs 32% followup, 

P



IRELAND 

March 2004 


AMERICA 

April 2004 






of bar workers before 

and one yr after the implementation 





Portugal 

& Andorra (Control) 

- 70.0% (49.9-90.1) prelaw 

vs 40.0 (18.5-61.5) 

follow up, P = 0.07, n= 

20. 

No significant change in 

prevalence of individual 

symptoms from pre to 

post-law in Spain except 

for cough and phlegm 

production for employees 

with complete smoking 

bans from 40.6% to 

15.6%, P < 0.05. No 

change in the prevalence 

of individual symptoms 

from pre- to post-law. 

Significant reduction for 

coughing in the morning 

(32% pre-law vs 17% 

post-law, P =0.04) and 

in coughing during the 

day (55% pre-law vs 34% 

post-law, P



SWEDEN 

June 2005 





of employees in Lexington-Fayette 



Sweden prohibiting 

smoking in workplaces include 

bars and restaurants 

from the 1st June 2005. 

Cohort study of hospitality 

employees including 

casino and bingo hall 

workers pre and 12 month 

follow up. 

symptoms such as morning 

cough (34.3% pre to 

13.3% six months prelaw, 

P =0.0006), cough at 

other times (54.8% pre 

to 30.0% six months prelaw, 

P =0.009) 

and phlegm production 

(52.4% pre to 28.8% six 

months pre-law, P =0.01) 

after smoking legislation 

was introduced in Lexington, 

Kentucky: The 

reduction in prevalence 

was not significant over 

time for wheeze/whistle 

(31.4% pre and 23.3% 

six months post-law, ns) 

or dyspnea (8.6% pre and 

5.0% six months post-law, 

ns). Smokers reported a 

significantly higher prevalence 

of wheeze/whistle 

(35.6% vs 21.5%, P = 

0.02) and phlegm production 

(51.1% vs 35.0%, P 

=0.05) over the course of 

the study than their nonsmoking 

counterparts at 

all time points. The reduction 

in prevalence of all 

symptoms over time was 

the same for smokers and 

nonsmokers. 

In cohort, statistically 

significant reduction 

for cough in the morning 

and cough during the rest 

of the day. 

For nonsmokers in cohort 

(n= 57): 

Wheezing/whistling chest 

15.8% vs 10.5%, shortness 

of breath 19.3% vs 

10.5%, cough first thing 

in the morning 40.4% vs 

15.8%, cough during the 

rest of the day 54.4% vs 



108



SCOTLAND 

March 2006 



July 2005 




non-smoking bar workers 



tests. 

A smoking ordinance was 

introduced in two Wisconsin 

cities Madison and 

Appleton. Cohort study, 

pre and post-ban tests at 

3-5 months. 

21.1%, phlegm production 

35.1% vs 21.1%. 

Among smokers (n= 14) 

, no significant change 

from pre- to post-law. 

No statistically significant 

difference in symptoms 

between gaming and 

other hospitality employees. 

Significant reduction in % 

bar workers (n= 77) with 

“any respiratory and sensory 

symptoms” decreased 

from 79.2% pre-ban to 

53.2% after 1 month and 

46.8% after 2 months (P 




AMERICA 

January 2007 


SCOTLAND 

March 2006 

Legislation 

banning smoking 


pool halls. Studied a cohort 

of hospitality workers 

(n=46) pre (2nd-21st 

December 2006) and post 

the ban (1st-21st February 

2007). 

Legislation 





cohort of bar workers 

prior to the legislation 

and follow-up surveys at 2 

months and up to one yr 

after. 

throat (Table 3.2). Paired 

t-tests carried out. 

Difference in respiratory 

symptoms was inconclusive. 

Among cohort (n= 191) 

, prevalence of those reporting 

respiratory symptoms 

from baseline to 

12 months follow up: 

significant reduction in 

prevalence of any respiratory 

symptoms from 

131(69%) vs 109(57%), 

P =0.02. Significant reduction 

for all individual 

respiratory symptoms. 

Wheezing/whistling: 

33% vs 26% p= 0.029, 

shortness of breath: 32% 

vs 24% p=0.02, cough in 

morning: 30% vs 22% 

p= 0.016, cough during 

rest of day or night: 46% 

vs 38% p= 0.03, phlegm 

production: 39% vs 30% 

p= 0.011. Similar pattern 

when those with cold at 

baseline or follow up were 

excluded (n= 62) except 

for cough during rest of 

day or night. 

Nonsmokers (n=57): Reduction 

in all symptoms 

but significant reduction 

for phlegm production 18 

(32%)vs 8(14%), P = 

0.011 and remained significant 

when those reporting 

a cold at base- 



110


Lung function 

line or follow up were excluded 

from analysis 33% 

vs 14%, P = 0.02. 

Smokers (n= 65): Reduction 

in all symptoms but 

significant reduction for 

wheezing / whistling 31 

(48%) vs 20(31%), P= 

0.006 and shortness of 

breath: 27(42%) vs 19 

(29%), P =0.038 and remained 

significant when 

those reporting a cold at 

baseline or follow up were 

excluded from analysis. 

Analysis 3.2. Comparison 3 Results: Health measures, Outcome 2 Lung function. 



ICA 

January 1998 

Ellingsen 2006 Comprehensive 

NORWAY 

June 2004 


smoking in bars and 

taverns. Examines the effect 

on a cohort of bartenders 

in San Francisco 

whose owners agreed to 

participate in the study. 

Effects of a smoking policy 

in a cohort of restaurants 

and bar employees 

in Norway. Legislation 

was implemented 

which banned smoking 


night-clubs. 

Mean FVC (L) increased 

by 4.2% from pre-law 

to one month post-law.. 

Change mean(95% CI): 

0.189(0.082 to 0.296). 

Mean 

FEV1(L/s) increased by 

1.2% from pre-law to one 

month post-law. Change 

mean (95% CI): 0.039 

(-0.030 to 0.107). Mean 

FEF 25−75%(L/s) reduced 

by 5.7% from pre-law 

to one month post-law. 

Change mean (95% CI): 

-0.190 (-0.405 to 0.025) 

. 95% CI are based on 

paired t test. 

Cross-shift reduction in 

FVC from 81 ml (sd=136) 

in the period before to 52 

ml (sd=156, P =0.24) following 

the smoking ban 

(n=69). 

Significant cross-shift reduction 

in FEV1 compared 

to follow-up by 89 



111

Lung function (Continued) 


IRELAND 

March 2004 






of bar workers before 

and one yr after the implementation 


ml (sd=132) vs 46ml (sd= 

152), P =0.09. Reductions 

were significant for nonsmokers 

and asthmatics 

but not for smokers. 

Significant cross-shift reduction 

in FEF 25−75% 

from 199 ml/s (sd=372) to 

64 ml/s (sd=307) at follow-up, 

P =0.01. Overall, 

a larger cross-shift decrease 

in lung function before 

the ban compared to 

after implementation of 

the ban. Significant crossshift 

reduction in PEF (l/ 

min) in smokers only by 

5.8 l/min before to 2.6 

l/min after the ban, P 



SWEDEN 

June 2005 


SCOTLAND 

March 2006 










follow up. 




non-smoking barworkers 



tests. 

ers. No change in RV 

(residual volume) for either 

smokers or nonsmokers. 

Significant increase 

in Total lung capacity 

(TLC) for exsmokers and 

never smokers but not for 

smokers. DLCO (Diffusing 

lung capacity for carbon 

monoxide) corrected 

for carboxyhaemoglobin): 

statistically significant increase 

in never-smokers 

but not in ex-smokers or 

current smokers from pre 

to post-ban period. 

No change in mean FVC 

of nonsmokers from prelaw 

to follow up. 93% prelaw 

vs 92% follow up. For 

smokers 94% vs 92%. 

No change in mean FEV1 

of nonsmokers from prelaw 

to follow-up. No significant 

reduction in delta 

FEV1 over the study period. 

Regression analysis 

adjusted coefficient 0.020 

(95% CI -0.050-0.090, 

p=0.566) for nonsmokers 

and -0.004 (95% CI 

-0.144-0.137, P=0.957) 

for smokers. 

FEV1 mean (SE), %: Cohort 

96.6(2.26) pre-ban 

to 104.8(2.53) at one 

month and 101.7(1.87) 

after two months, P = 

0.002. 

Asthmatic barworkers 

also had less airway 

inflammation with a 

reduction in exhaled nitric 

oxide from 34.3 ppb 

to 27.6 ppb 2 month after 

the ban and Juniper Quality 

of Life scores increased 



113




July 2005 






3-5 months. 

from 80.2 to 87.5 points, 

P =0.049. 

Nonsmokers 

(n= 44): FVC, 

FEV1 and FEF25%−75% 

increased but was not statisticallysignificant. 

Smokers (n= 29) 

: FVC and FEV1reduced 

but were not statistically 

significant. FEF25%−75% 

increased but not significantly. 

In a sub-sample 

of nonsmokers (n= 26) 

that did not have a cold 

or flu within previous 4 

weeks of either baseline 

or follow-up tests, there 

was an increase for FVC 

FEV1 and FEF25%−75% 

but the change was statistically 

significant for FVC 

only. 



114

Sensory 

Analysis 3.3. Comparison 3 Results: Health measures, Outcome 3 Sensory. 



(R.O.I.) 

March 2004 



ICA 

January 1998 



July 2003 













Ireland). 


smoking in bars and 

taverns. Examines the effect 

on a cohort of bartenders 

in San Francisco 

whose owners agreed to 

participate in the study. 

New York State Clean 

Indoor Air Act. Longitudinal 

sample of nonsmoking 

employees work- 

% reporting “any sensory 

symptom” in R.O.I. from 

pre-law to one year follow 

up decreased from 67% 

to 45% (P

Sensory (Continued) 


IRELAND 

March 2004 


AMERICA 

April 2004 

ing in bars, restaurants 

and bowling facilities who 

were not subject to a 

smoking ban in their 

workplace prior to the law. 





restaurants. Cross-sectional 

surveys of bar workers 

before and one year after 

the implementation of 

legislation. 






(88% pre to 38% postlaw, 

P



SWEDEN 

June 2005 


SCOTLAND 

March 2006 



of employees in Lexington-Fayette 











follow up. 




non-smoking barworkers 



tests. 

ing symptoms such as “red 

irritated eyes” (55.2% pre 

vs 33.3 six months postlaw, 

P =0.007), “runny irritated 

nose” (81.7% pre 

vs 51.7% six months postlaw, 

P =0.003) and “scratchy, 

sore throat” (74% pre vs 

26.7%,P




July 2005 



AMERICA 

January 2007 


SCOTLAND 

March 2006 






3-5 months. 

Legislation 

banning smoking in bars, 

restaurants and pool halls. 

Studied a cohort of hospitality 

workers (n=46) before 

(2nd-21st December 

2006) and after the ban 

(1st-21st February 2007). 

Legislation 





cohort of bar workers 

prior to the legislation 

and follow-up surveys at 2 

months and up to one year 

after. 

ing “any sensory symptom” 

from 71.4% to 

36.4% at two months 

post-law, P


21%, p< 0.001. Similar 

pattern when those with 

cold at baseline or follow 

up were excluded (n= 62) 

but the reduction was significant 

for red or irritated 

eyes (33% vs 19%, 

P

Analysis 3.4. Comparison 3 Results: Health measures, Outcome 4 Hospital admission for acute coronary 

syndrome. 

Hospital admission for acute coronary syndrome 

Barone-Aldesi 2006 ITALY 

January 2005 

Bartecchi 2006 ComprehensivePueblo City, Colorado, 

USA 

July 2003 

Cesaroni 2008 Partial 

ITALY 

January 2005 

Fichtenberg 2000 California, USA 

1989 

Restricted smoking in indoor public 

places including bars, restaurants, 

cafes. Study measures rates 

of admission for AMI in Piedmont 

from pre to post legislation. 

Smoke-Free Air Act which banned 

smoking in workplaces and all 

building open to the public, including 

bars, restaurants, bowling alleys 

and other business establishments 

within city limits of Pueblo, Colorado. 

Restricted smoking in indoor public 

places including bars, restaurants, 

cafes. Study measures smoking 

prevalence of residents in Rome 

from pre- to post-legislation. 

The California Tobacco Control 

Programme implemented in 1989 

increased the tax on cigarettes by 

25 cents per package and allocated 

5 cents of the new tax for 

an anti tobacco education campaign. 

This programme combined 

the effects of the of the tax increase 

with an aggressive media campaign, 

Significant drop in admissions for 

AMI among both men and women 

under 60(RR 0.89, 95% CI 0.81 to 

0.98). The effect of the law was statistically 

significant on people aged 

60 years and younger. The effect 

was seen in both men and women. 

Significant drop in admissions 

for AMI among residents within 

Pueblo city limits. No significant 

changes were observed among residents 

outside the city limits (RR= 

0.85, 95% CI 0.63 to 1.16) or 

in El Paso County (rr=0.97, 95% 

CI 0.89 to 1.06). AMI rates per 

100,000 persons for each of the 3 

locations were also calculated. Population 

adjusted AMI death rated 

in 2002 were compared to 2004 

Significant reduction in acute coronary 

events in 35-64 yr olds from 

pre-law to post-law period (RR 

0.89, 95% CI 0.85 to 0.93) and 

in 65-74 yr olds (RR 0.92, 95% 

CI 0.88 to 0.97) but no change in 

75-84 yr olds (RR 1.02, 95% CI 

0.98 to1.07). Data from the postlaw 

was compared with data in the 

previous yr , the effect of the law was 

statistically significant on men but 

not on women and was greater for 

residents living in lower socioeconomic 

areas than those from higher 

socioeconomic areas. 

The introduction of the Control 

Programme was associated with a 

significantly greater annual decline 

in mortality for heart disease in California 

than in the rest of the UD 

(by 2.93 deaths per 100,000 pop 

per year. Although the death rate 

continued to decline ) after 1992 

when the programme was cut back, 



120

Hospital admission for acute coronary syndrome (Continued) 

Juster 2007 Comprehensive 

New York, USA 

2003 

Khuder 2007 Partial 

Bowling Green, Ohio, USA 

March 2002 

Lemstra 2008 Comprehensive 

Saskatoon, CANADA 

July 2004 


SCOTLAND 

March 2006 

and with community-based programmes 

promoting clear indoor 

air and policies designed to foster a 

smoke-free society. 

Implementation of comprehensive 

smoking ban in 2003 in New York 

Statethat prohibited smoking in all 

workplaces, including restaurants 

and bars.. 

Clean indoor air ordinance banning 

smoking in workplaces and 

public places implemented in 

March 2002 

Population-based 

cross-sectional surveys of smoking 

ban in public places in the city. 




and patients’ exposure to secondhand 

smoke in the pre and post-law 

period. 

the rate of decline was significantly 

reduced. The programme was associated 

with 33,000 fewer deaths 

from heart disease between 1989 

and 1997. 

Hospital Admission Rates for AMI 

and stroke. In 2004, hospital admissions 

for AMI were reduced by 

8% as a result of the comprehensive 

ban. No effect on stroke admissions. 

Healthcare cost savings of 

$56m in 2004. 

Admission rates for smoking-related 

diseases. Comparison with 

control city Data collected for 6 

years from pre to post ban. Bowling 

Green (47% decrease, 95% 

CI, 41% to 55%). No significant 

change seen in control city 

Age-standardised incidence rate of 

AMI per 100,000 population in 

Saskatoon 176.1(95% CI 165.3 

to 186.8) pre-law period (1st July 

2000 to 30 June 2004) to 152.4 

(95% CI 135.3 to 169.3) post-law 

period (1 July 2004 to 30 June 

2005). Incidence rate ratio: 0.87 

(95% CI 0.84 to 0.90). 13% reduction 

in AMI from pre-law to postlaw 

period. 

Pre-law period (June 2005 to 

March 2006) to post-law period 

(June 2006 to March 2007): 17% 

reduction, 3235 patients admitted 


pre-law vs 2684 patients post-law. 

(95% CI 16 to 18). 4% reduction 

in England (control) during 

the same time period. 

Smokers: 14% reduction, 1176 

pre-law vs 1016 post-law (95% CI 

12 to 16). 

Former smokers: 19% reduction, 

953 pre-law vs 769 post-law (95% 

CI 17 to 21). 



121



SCOTLAND 

March 2006 

Sargent 2004 ComprehensiveHelena, Montana, 

USA June 2002 

Seo 2007 ComprehensiveMonroe, USA 

August 2003 


places. Examined consecutive admissions 

with ACS who were non 

smokers to nine Scottish acute hospitals 

from May 2005 to March 

2007 

Hospital based analysis of admissions 

pro and post ban for people 

living in and outside Helena 

Comparison of hospital admissions 

for AMI between non-smoking patients 

before and after the introduction 

of a public smoking ban 

in Monroe County which had implemented 

it and Delaware County 

which had not during the same 

time period. 

Never smokers: 21% reduction, 

677 pre-law vs 537 post-law (95% 

CI 18 to 24). Current smokers: 

Greater reduction among women 

(19%, 95% CI 15 to 23) than 

men (11%, 95% CI 9 to 13). nonsmokers: 

Greater reduction among 

women (23%, 95% CI 20 to 26) vs 

men (18%, 95% CI 16 to 20). Current 

smokers: Greater reduction in 

men aged >55 yrs & women aged 

>65 yrs (18%, 95% CI 15 to 21) 

than men aged 65 yrs (22%, 95% CI 20 to 24) 

than men aged


Vasselli 2008 Piedmont, Friuli Venezia Giulia, 

Lazio, Campania, ITALY 

2003 

A P P E N D I C E S 

Examined hospital admissions for 

acute myocardial infarction in patients 

aged 40-64 years in the pre 

and post-law period 

Appendix 1. Search strategy for Tobacco Addiction Group specialised register 

effect for non-smoking patients 

(Monroe:17 to 5; 95% CI [-21.19 

to -2.81] vs Delaware:18 to 16; 

95% CI [-13.43 to 9.43] ) There 

were no admissions for AMI among 

non-smoking people from January 

1st to May 2005 when the ban was 

extended to include bars and clubs. 

Non-significant reduction in admissions 

for AMI amongst smoking 

patients in Monroe from 8 prelaw 

to 7 post-law and in Delaware 

from 8 pre-law to 6 post-law. This 

was extended to bars in January 1st 

2005. There were no admissions 

for AMI among non-smoking people 

from January 1st to May 2005 

when the ban was extended to include 

bars and clubs. No hypertension, 

high cholesterol or past cardiac 

procedure that could have recipitated 

the AMI. 

Decrease seen in number of admissions 

for AMI post ban. Analysis by 

gender shows that the effect is seen 

only in men and in the age groups 

45-49 and 50-54. 

#1 smok* or cigar* or tobacco 

#2 smoking/ 

#3 tobacco/ 

#4 Tobacco smoke pollution/ 

#5 Smoking cessation/ 

#6 passive smok* or “environmental tobacco smoke” or “involuntary smoking” or “secondhand smoke” or “second-hand smoke” or 

“second hand smoke” in ti,ab 

#7 #1 or #2 or #3 or #4 or #5 or #6 

#8 ban OR policy OR law OR restrict* OR prohibit* in ‘,ab 

#9 #7 and #8 



123

Appendix 2. Search strategy for MEDLINE (1966 - July 2009) 

#1 (exp “Tobacco-Use-Disorder” (MeSH)) or (exp “Tobacco-Smokeless” (MeSH)) or (exp “Tobacco-Use-Cessation” (MeSH)) 

#2 exp “Tobacco-Smoke-Pollution” (MeSH) 

#3 (exp “Tobacco-” (MeSH)) or (exp “Nicotine-” (MeSH) 

#4 exp “Smoking-Cessation” (MeSH) 

#5 exp “Smoking-” / drug-therapy ,prevention-and-control , legislation and jurisprudence 

#6 smoking cessation tw 

#7 (quit* or stop* or ceas* or giv*) AND smoking tw 

#8 smok* or tobacco or cigar* in ti 

#9 (passive smok* or (secondhand smoke) or (second hand smoke) or (second-hand smoke) or (environmental tobacco smoke) or 

(involuntary smok*)) in ti, ab 

#10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 

#11 ((ban or bans or banned) or (prohibit*) or (restrict*) or (policy or policies) or (law or laws)) in ti,ab 

#12 #10 and #11 

Appendix 3. Search strategy for EMBASE (1974 - July 2009) 

#1 Exp cigarette smoking 

#2 smoking/ 

#3 smoking habit/ 

#4 tobacco dependence/ or 

#5 smokeless tobacco/ 

#6 indoor air pollution/ 

#7 tobacco/ 

#8 nicotine/ 

#9 tobacco smoke pollution in ti,ab 

#10 involuntary and smok* in ti,ab 

#11 ’environmental tobacco smoke’ in ti, ab 

#12 ’second hand smoke’ or ’secondhand smoke’ or ’second-hand smoke’ in ti, ab 

#13 (passive and smok*) in ti,ab 

#14 ’smoking cessation’ 

#15 smok* or cigar* or ’tobacco in ti 

#16 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 

#17 ban or bans or banned or law or laws or policy or policies or prohibit* or restrict* in ti,ab 

#18 #16 and #17 

Appendix 4. Search strategy for CINAHL (1982 - July 2009) 

#1 Exp Smoking Cessation 

#2 Tobacco/ 

#3 Smoking Cessation Programs/ 

#4 Smoking/ 

#5 Nicotine/ 

#6 Passive Smoking/ 

#7 Tobacco abuse control/ 

#8 Tobacco, Smokeless/ 

#7 (quit* or stop* or ceas* or giv*) and smok* in ti,ab 

#8 smok* OR cigar* OR tobacco in ti,ab 

#9 “secondhand smoke” or “second-hand smoke” or “second hand smoke” or “environmental tobacco smoke” or “involuntary smoking” 

or “tobacco smoke pollution” in ti,ab 

#10 smoking cessation in ti,ab 



124

#11 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 

#12 ban OR policy OR law OR restrict* OR prohibit* in ti,ab 

#13 #11 and #12 

Appendix 5. Search strategy for PsycINFO (1806 - July 2009) 

#1 Exp smoking cessation/ 

#2 tobacco-smoking/ 

#3 passive smoking/ 

#4 smokeless tobacco/ 

#5 nicotine/ 

#6 “smoking cessation” in ti,ab 

#7 anti-smoking or antismoking in ti,ab 

#8 (quit$ or cessat$ or abstain$ or abstin$ or prevent$) near smok*in ti,ab 

#9 smok* or cigar* or tobacco in ti,ab 

#10 passive smok$ OR “secondhand smoke” or “second hand smoke” or “second-hand smoke” or “environmental tobacco smoke” or 

involuntary smok$ in ti,ab 

#11 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 

#12 ban or bans or banned OR prohibit$ or restrict$ or policy or policies or law or laws in ti,ab 

#13 #11 and #12 

W H A T ’ S N E W 

Last assessed as up-to-date: 30 June 2009. 

12 May 2010 Amended Minor edits 

H I S T O R Y 

Protocol first published: Issue 2, 2006 

Review first published: Issue 4, 2010 

C O N T R I B U T I O N S O F A U T H O R S 

JC did the search and screened the results 

AC and KD carried out the study selection and checked by CK 

JC extracted the data and was checked by CK 

JC, CK and AC wrote the text of the review 



125

D E C L A R A T I O N S O F I N T E R E S T 

None known 

S O U R C E S O F S U P P O R T 

Internal sources 

• UCD School of Public Health and Population Science, University College Dublin, Ireland. 

External sources 

• Health Research Board, Ireland. 

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W 

The protocol for this review was published with the title ’Smoking bans for reducing smoking prevalence and tobacco consumption’ 

and covered both bans introduced with legislation, and also no-smoking policies introduced at an institutional or workplace level. The 

scope of this review has been limited to legislative bans and restrictive policies. 

We have included data on health and also information on levels of support for and compliance with smoking bans and restrictions, 

where this was reported. 



126

Legislative smoking bans for reducing secondhand smoke exposure ...

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