HEAD TO HEAD Ara Darzi director, Institute of Global Health Innovation, of the habit.1 The evidence remains clear: Is a smoking Imperial College London and former chair, London Health smoking tobacco is still the largest contributor Commission to ill health and preventable mortality in the Oliver P Keown clinical adviser and policy fellow, Institute ban in parks and of Global Health Innovation, Imperial College London, world today. Despite downward trends in 10th floor, QEQM Building, St Mary’s Hospital, London uptake across North America and Europe it W2 1NY, UK [email protected] persists as a growing epidemic internationally, outdoor spaces a disproportionately affecting the world’s Extending antismoking poorest people.2 In England, despite the good idea? legislation in the United number of smokers having halved in the YES Kingdom to encompass past 30 years through effective public health a ban in parks and squares is an opportunity interventions, it still prematurely kills more Ara Darzi and Oliver P Keown to celebrate the great beacon of healthy living, than 79 000 people a year, contributes to the clean air, and physical activity our green growing prevalence of non-communicable want a ban in the UK to help spaces are designed for. And, crucially, it is disease, costs the NHS an estimated £2.7bn smokers quit and to protect an opportunity to support our population— a year in associated healthcare expenditure, young and old—to make healthier lifestyle and—most frighteningly—attracts the highest children from seeing people choices easier. To tackle the significant burden rates of uptake among the country’s young lighting up. But, argues Simon of disease still associated with smoking, and adolescent populations.3-5 In London public health officials must take confidence alone, at least 60 schoolchildren take up Chapman, there is no scientific and emerging evidence from international smoking every day, which could not be a success stories, resume a national debate on clearer impetus for reinvigorating UK public justification for such a draconian the subject, and innovate across the public policy to tackle this issue.5 attack on basic freedoms policy spectrum to help people make healthier decisions in their everyday lives. The existing ban is a public health triumph thebmj.com Banning smoking in parks and squares To date, such policy has focused largely Ж Letters: Smoking ban in cars will benefit could be one such policy to support healthier on protecting the population from the decision making, as well as being a natural detrimental effect of passive smoking disadvantaged children most next step in the 60 year public health battle through a ban in enclosed public spaces, (BMJ 2014;348:g1720) that has raged in the UK since Richard Doll including food outlets and workplaces. The News: Russia to restrict smoking in public Ж first illustrated the detrimental health effects introduction of these interventions has been places from June (BMJ 2013;346:f1418) Ж Research News: Myocardial infarctions fall by a third after smoking banned in Simon Chapman professor, School of Public Health, The desire to prevent harm to smokers and workplaces (BMJ 2012;345:e7287) University of Sydney, Australia others Ж Head to Head: Should smoking in [email protected] The ethical justification for restricting where outside public spaces be banned? smoking can occur derives entirely from the (BMJ 2008;337:a2806) Smoking restrictions started Millean precept of preventing harm to others.12 NO to be introduced when But evidence soon also mounted about the the weight of evidence about the harms of important collateral benefits of banning chronic exposure to secondhand smoke smoking in workplaces: smokers reduced their had consolidated. This evidence was almost daily consumption by about 21%13—and, exclusively obtained from indoor domestic more importantly, many quit, welcoming the and occupational exposures, where non- bans as a form of imposed self discipline on smokers—including infants11—spent hours on a behaviour that 90% of smokers regret ever most days exposed to others’ tobacco smoke, starting.14 Smoking bans fomented a rapid sometimes for decades and in small, enclosed denormalisation of smoking15: venues that were conditions. Notwithstanding slogans about associated with relaxation and conviviality, “no safe level of exposure,” as with active such as restaurants, no longer allow smoking, smoking the harms of exposure to secondhand and smokers excuse themselves to go outside in tobacco smoke arise from chronic exposure, any weather forced to wonder about how much not from occasional fleeting encounters with they really enjoy smoking. single plumes. The proliferation of smoke-free areas certainly With almost all indoor public spaces contributes to reducing the frequency of smoking now smoke-free in nations that have and the proportion of people who smoke—but comprehensive tobacco control policies, some so would forced incarceration or forfeiting people are now emboldened to turn their smokers’ rights to healthcare (or other draconian attention to outdoor spaces such as parks strategies admittedly too tame for the Ottoman and beaches. One such proposal comes from Sultan Murad IV, who had smokers executed). Ara Darzi’s report for the London Health The ethical test of any policy is plainly not just 5 GIULIA FIORI/ALAMY GIULIA Commission. its efficiency in achieving outcomes. 14 28 February 2015 | the bmj the bmj | 28 February 2015 15 HEAD TO HEAD a public health triumph and has led to clear Smoking tobacco is still the largest international pilot studies in regions and cities and sustained reductions in passive smoke contributor to ill health and where smoking bans have been successfully exposure, reductions in acute cardiovascular preventable mortality in the world introduced. incidents, and a downward trend in the today New York City, for example, has been prevalence of smoking.6 Although this one of several global leaders in banning legislation was initially censured as an The study of behavioural economics smoking, with the staged implementation attack on public freedom and civil liberty, the highlights the importance of societal “norms” of its Smoke-Free Air Act of 2002. This 2007 ban in England stoked an unexpected as a powerful influence on decision making. legislation initially prohibited smoking in and ongoing cultural shift against the habit By reducing the geographical footprint workplaces and recreational venues but and recent polls have shown 78% public where smoking is sanctioned and by limiting was later extended in 2011 to cover all approval for the 2007 public smoking bans.5 exposure to the practice itself, we can redress public spaces, including parks, squares, There is, therefore, a precedent and quite the observed norms against which park users beaches, and public plazas. In parallel possibly an appetite for renewed policy and young people compare their personal with a package of public health measures, innovation in this area. smoking habits. If we are to celebrate the including tobacco taxation and media Today, emerging evidence supports cultural and community assets that parks campaigns, these efforts led to a significant extending these public bans beyond the and community spaces represent and, fall in the number of smokers from a 2002 parameters of passive smoke exposure concomitantly, to protect children and young pre-prohibition rate of 22%—incidentally, and enclosed public spaces. Targeting the people from the normalising effect of observed the same as the UK’s current national behaviours and physical environments that smoking behaviours, then extending the average—to a globally competitive rate facilitate the uptake of smoking by banning it smoking ban to other public spaces will have of about 15% in 2011.9 Although it is in parks and squares is a logical progression. a positive effect. Discerning where to draw the difficult to unpick the relative influence Evidence has shown the significant effect that line on any public smoking ban is difficult, of the specific public smoking ban in New the media and peer to peer role modelling but, using the rationale above, it should York, significant compliance of 97% has can have on young people and adolescents arguably encompass the spectrum of public been shown across the city.10 As evidence taking up smoking.7 And emerging evidence spaces where exposure to smoking occurs. emerges from pilot schemes in cities such illustrates the significant effect of the physical as New York, Hong Kong, and Toronto, an environment on such behaviours, with one Evidence from pilot schemes around the world opportunity exists to conduct comparative study highlighting the positive influence that Evidence to better understand the links studies to further explore the effects of childhood access to recreational space can have between behaviour and the physical smoking bans on population behaviours, in deterring young people from smoking.8 environment should be harvested from but already the trend is quite clear. The evidence base about the risks of Thirdly, some have invoked the virtues of As with active smoking the harms outdoor smoking has grown. In a 2013 shielding children from the sight of smoking of exposure to secondhand tobacco review I worked on,17 no studies looked at as worthy evidence in this debate.18 They smoke arise from chronic exposure, exposure in parks or on beaches—almost may concede that smoking in wide open not from occasional fleeting certainly because researchers with any spaces such as parks and beaches poses a encounters with single plumes knowledge of airborne exposures would near homeopathic level of risk to others, appreciate that such exposures would be so but they point to an indirect negative effect the open air event was non-smoking but that small, dissipated, and transitory as to be of from the mere sight of smoking. This line of smoking areas were available on the periphery no concern.