Protect people from tobacco smoke

Second-hand tobacco smoke is dangerous to health

Second-hand tobacco smoke is the smoke more than 50 of which are known to cause are closed. Toxic chemicals from second- emitted from the burning end of a cigarette cancer (8, 9). People in places that allow hand tobacco smoke contamination persist (side-stream smoke) or from other tobacco smoking can be subject to significant levels well beyond the period of active smoking, products, usually in combination with the of toxins, as pollution from tobacco smoke and then cling to rugs, curtains, clothes, mainstream smoke exhaled by the smoker, can reach levels that are much higher than food, furniture and other materials. These and has similar components to inhaled levels of other environmental toxins, such toxins can remain in a room weeks and or mainstream smoke (6). However, it is as particles found in automobile exhaust. months after someone has smoked there three to four times more toxic per gram Studies have shown that pollution levels (11, 12), even if windows are opened of particulate matter than mainstream in indoor places that allow smoking are or fans or air filters are used. Filters can tobacco smoke, and the toxicity of side- higher than levels found on busy roadways, become a source for deposited chemicals stream smoke is higher than the sum of the in closed motor garages and during that are then recycled back into the air toxicities of its constituents (7). firestorms (10). of a room rather than removed. Tobacco toxins that build up over time, coating the More than 4 000 chemicals have been Second-hand tobacco smoke can spread surfaces of room elements and materials identified in tobacco smoke, at least 250 from one room to another within a and smokers’ belongings, are sometimes of which are known to be harmful and building, even if doors to the smoking area referred to as “third-hand smoke” (13).

18 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 Chemicals contained in second-hand tobacco smoke (partial list)

Stearic Acid Butane Candle wax Lighters

Paint Methanol Rocket fuel

Acetic acid Vinegar Hexamine Barbecue starter

Methane Sewer gas Nicotine Insecticide Cadmium Batteries

Arsenic Toluene Poison Industrial solvent

Carbon monoxide Ammonia Exhaust gas Detergent

More than 4 000 chemicals have been identified in tobacco smoke.

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 19 Exposure to second-hand tobacco smoke and early death

Second-hand tobacco smoke is present in least one smoking parent, according to the 50 000 deaths in the United States each virtually all public places where smoking is definition used by the GlobalY outh Tobacco year – about 11% of all tobacco-related permitted (14), and there is no safe level of Survey (GYTS), is estimated to be 43% (20). deaths – are attributable to exposure to exposure (15). Data from the GYTS indicate that, among second-hand tobacco smoke (22). In the those surveyed, nearly half of youth aged European Union, second-hand tobacco Globally, it is estimated that about one 13 to 15 years who have never smoked are smoke exposure at work is estimated to third of adults are regularly exposed to exposed to second-hand tobacco smoke at cause about 7 600 deaths per year, with second-hand tobacco smoke (16). In the home, with a similar percentage exposed in exposure at home causing an additional European Union, 14% of non-smokers are places other than the home; these youth are 72 100 deaths (23). exposed to other people’s tobacco smoke 1.5 to 2 times more likely to initiate smoking at home, and a third of working adults are than those not exposed (20). exposed to second-hand tobacco smoke at the workplace at least some of the time Second-hand tobacco smoke is estimated (17). In Canada, about a quarter of non- to cause about 600 000 premature deaths smokers report regular exposure at home, per year worldwide (16), approximately in vehicles or in public places (18). the same number of people who are killed by measles or women who die during An estimated 700 million children worldwide childbirth each year (21). Of all deaths – about 40% of all children – are exposed attributable to second-hand tobacco to second-hand tobacco smoke at home smoke, 31% occur among children and (19). The global average of children with at 64% occur among women (16). About

20 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 Average percentage of 13–15-year-olds living in a home where others smoke, by WHO region, 2008

100%

90%

80%

70%

60% Exposure to second-hand tobacco smoke at home to second-hand tobacco smoke Exposure

50%

40% 78%

30%

51% 20% 41% 38% 43% 34% 28% 10%

0%

Africa The Americas South-East Asia Europe Eastern Western Pacific TOTAL Mediterranean Source: (20).

Globally, it is estimated that about one third of adults are regularly exposed to second-hand tobacco smoke.

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 21 Second-hand tobacco smoke exposure causes serious health problems

The scientific evidence of the health Agency (29), and the United Kingdom among people who have never smoked, harms of smoking has been conclusively Scientific Committee on Tobacco with higher levels of exposure resulting established for more than 50 years (24). and Health (30) leave no doubt that in a greater reduction in quality-of-life However, smokers are not the only ones exposure to second-hand tobacco smoke measures (32). Even house pets in homes sickened and killed by tobacco: non- contributes to a range of serious and where people smoke are more likely to smokers who breathe air containing often fatal diseases in non-smokers. develop cancer (33–35). second-hand tobacco smoke also face increased risk of disease and death. Multiple studies confirm that exposure Among newborns exposed either in utero to second-hand tobacco smoke causes or after birth, there is an increased risk of In the quarter century since evidence illness, disability and death from a wide premature birth (36) and low birth weight confirmed the health hazards of second- range of diseases (31). Second-hand (37) and a doubling of the risk for Sudden hand tobacco smoke (25–27), 14 scientific tobacco smoke exposure contributes to Infant Death Syndrome (38). Among children consensus reports by virtually all major about 1% of the total global disease exposed to second-hand tobacco smoke, medical and scientific organizations, burden, and represents about 10–15% there is a 50–100% higher risk of acute including the WHO International of the disease burden caused by active respiratory illness (39), higher incidence Agency for Research on Cancer (6), the smoking (16). Second-hand tobacco of ear infections (28) and an increased United States Surgeon General (28), smoke exposure is also associated with likelihood of developmental disabilities and the California Environmental Protection reduced health-related quality of life behavioural problems (40, 41).

22 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 Diseases caused by second-hand smoke

FEMALE CHILDREN FEMALE ADULTS

Breathing Brain tumours* Middle ear disease Stroke* Nasal irritation, second-hand Lymphoma* Nasal sinus cancer*

Respiratory symptoms, Breast cancer* Impaired lung function tobacco smoke Coronary heart disease Asthma* Sudden Infant Death Lung cancer Syndrome (SIDS) has serious Chronic obstructive Leukemia* pulmonary disease (COPD)*, Chronic repiratory Lower respiratory illness symptoms*, Asthma*, and often Impaired lung function*

Reproductive effects in fatal health women: Low birth weight; Pre-term delivery* consequences. Atherosclerosis*

* Evidence of causation: suggestive Evidence of causation: sufficient

MALE CHILDREN MALE ADULTS

Brain tumours*

Middle ear disease Stroke* Nasal irritation, Lymphoma* Nasal sinus cancer*

Respiratory symptoms, Impaired lung function Coronary heart disease Asthma* Lung cancer Sudden Infant Death Syndrome (SIDS) Atherosclerosis* Leukemia* Chronic obstructive pulmonary disease (COPD)*, Chronic repiratory Lower respiratory illness symptoms*, Asthma*, Impaired lung function*

* Evidence of causation: suggestive Evidence of causation: sufficient

Source: (28).

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 23 The economic threat of second-hand tobacco smoke

In addition to a large and growing health Several studies estimate that 10% of hand tobacco smoke exposure elsewhere burden, second-hand tobacco smoke total tobacco-related economic costs are roughly similar to those in the United exposure also imposes economic burdens are attributable to second-hand tobacco States. In the China, Hong Kong Special on individuals and countries, both for smoke exposure (44). The economic costs Administrative Region, for example, the the costs of direct health care as well as related to tobacco use in the United cost of direct medical care, long-term care indirect costs from reduced productivity. States total approximately US$ 193 billion and productivity losses attributable to Second-hand tobacco smoke exposure in per year (smoking-attributable health- second-hand tobacco smoke exposure is the United States alone costs an estimated care expenditures of US$ 96 billion and approximately US$ 156 million annually US$ 5 billion annually in direct medical productivity losses of US$ 97 billion) (22). (about US$ 24 per capita, or 23% of total costs and another US$ 5 billion in indirect tobacco-related costs) (45). costs caused by productivity losses from Economic studies on the cost of tobacco lost wages due to disability and premature use have been conducted in some other death (42). The US Occupational Health countries, but in most cases these do not and Safety Administration estimated in assess costs specifically related to second- 1994 that clean air increases productivity hand tobacco smoke exposure. Where data by 3% (43). exist, economic costs related to second-

Costs of tobacco-related illness and death, china, Hong Kong Special Administrative Region, 1998

Mortality: US$ 1 716 million

Morbidity: US$ 142 million

Source: (45).

24 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 Smoke-free laws reduce exposure to second-hand tobacco smoke

The International Agency for Research workers (48). Non-smoking adults who carbon monoxide and an 81% reduction in on Cancer concluded: “there is sufficient live in communities with comprehensive salivary cotinine* among bar workers. Bar evidence that implementation of smoke- smoke-free laws are 5–10 times less likely workers’ exposure to second-hand tobacco free policies substantially decreases to be exposed to second-hand tobacco smoke plunged from 30 hours per week to second-hand smoke exposure” (46). smoke than those who live where there zero (50, 51). Studies of the effects of smoke-free policies is no smoke-free legislation (49). Ireland consistently show that these policies provides strong evidence of the effects These findings were confirmed in numerous decrease exposure to second-hand tobacco of reducing exposure to second-hand other places that enacted comprehensive smoke by 80–90% in high-exposure tobacco smoke. Following the country’s smoke-free legislation. In Toronto, Canada, settings, and that they can lead to overall implementation of smoke-free legislation in a complete smoke-free law for bars decreases in exposure of up to 40% 2004, ambient air nicotine and particulate implemented in 2004 led to a reduction (47). People who work in places that are matter concentrations in monitored indoor of 68% in the level of urinary cotinine* smoke-free are exposed to 3–8 times less environments decreased by 83%, and there of bar workers in one month, while bar second-hand tobacco smoke than other was a 79% reduction in exhaled breath workers of a control community without

Smoke-free policies decrease exposure to second-hand tobacco smoke by 80–90% in high-exposure settings.

Urinary cotinine levels among bar workers in Toronto, Canada, before and after introduction of comprehensive smoke-free legislation

30

25

24.2 Urinary cotinine (ng/ml) 20

15

10

7.8 5

0

Before law After law Source: (52).

* Analysis of salivary or urinary cotinine concentrations is used as a biological marker to measure exposure to second-hand tobacco smoke.

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 25 smoke-free legislation did not experience In New York State, salivary cotinine implemented smoke-free law resulted any significant change in the level of levels in non-smoking adults decreased in a reduction in second-hand tobacco urinary cotinine levels (52). In Scotland, 47% in the year after enactment of a smoke exposure in workplaces covered by comprehensive smoke-free legislation comprehensive smoking ban in 2003 (54); this law, from 51% of workers reporting enacted in 2006 resulted in an 86% in New Zealand, comprehensive smoke- exposure before the law to 12% reporting decrease in the concentration of airborne free legislation enacted in 2004 appears exposure three years after the law became particulate matter in pubs (53) and a 39% to have reduced exposure of bar patrons effective (56). reduction in salivary cotinine levels among to second-hand tobacco smoke by about adult non-smokers (47). 90% (55); and in Finland, a nationally

Enforcement needed to ensure protection against second-hand tobacco smoke

Based on the scientific evidence, the support through active and uniform exposure, and legislation that covers only Conference of the Parties to the WHO enforcement that achieves high compliance some places, even if well enforced, also Framework Convention of Tobacco Control levels, at least until such time as the does not provide significant protection. (WHO FCTC) has concluded that 100% law becomes self-enforcing. Although smoke-free environments are the only an increasing number of countries have Full enforcement of smoke-free laws is proven way to adequately protect the passed legislation mandating smoke-free critical to establishing their credibility, health of people from the harmful effects environments, the overwhelming majority especially immediately following their of second-hand tobacco smoke because no of countries have no smoke-free laws, very enactment (57). It may be necessary to level of exposure is acceptable (2). limited laws, or ineffective enforcement. actively and publicly enforce the law Legislation that is comprehensive, but in the period directly after smoke-free Once smoke-free laws have been enacted, that is not well enforced, does not protect laws are enacted to demonstrate the governments must maintain strong against second-hand tobacco smoke government’s commitment to ensuring

100% smoke-free environments are the only proven way to adequately protect the health of people from the harmful effects of second-hand tobacco smoke.

26 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 compliance. Unannounced inspections by and legislation. Placing the responsibility Enforcement of legislation and its impact the appropriate government agency can be for enforcing smoke-free places on facility should be regularly monitored. Assessing and very effective. owners and managers is the most effective publicizing the lack of negative impact on way to ensure that the laws are enforced. business following enactment of smoke-free Once a high level of compliance is achieved, In many countries, laws have established legislation will further enhance compliance it may be feasible to reduce the level of that business owners have a legal duty to with and acceptance of smoke-free laws. formal enforcement, as maintenance of provide safe workplaces for their employees. smoke-free places is largely self-enforcing Levying of fines and other sanctions against in areas where the public and business business owners is more likely to ensure communities support smoke-free policies compliance than fining individual smokers.

Ventilation and designated smoking rooms are not effective

Smoking anywhere in a building significantly The American Society of Heating, exposure (60, 61). This position statement increases concentrations of second-hand Refrigerating and Air-Conditioning concurs with other findings that ventilation tobacco smoke, even in parts of the building Engineers concluded in 2005 that and designated smoking rooms do not where people do not smoke (58). Physically comprehensive smoke-free laws are the prevent exposure to second-hand tobacco separating smokers from non-smokers only effective means of eliminating the smoke (62, 63). by allowing smoking only in designated risks associated with second-hand tobacco smoking rooms reduces exposure to second- smoke, and that ventilation techniques hand tobacco smoke only by about half, and should not be relied upon to control health thus provides only partial protection (59). risks from second-hand tobacco smoke

Ventilation and designated smoking rooms do not prevent exposure to second-hand tobacco smoke.

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 27 Health impact of smoke-free regulations

Smoke-free laws reduce confirmed decreases in hospital admissions development of lung cancer, complete respiratory symptoms for heart attacks after comprehensive data are not yet available regarding the smoke-free legislation was enacted expected decline in lung cancer after Because of the immediate drop in pollution (69–74). Moreover, many of these studies, implementation of smoke-free policies. levels and second-hand tobacco smoke conducted in subnational areas (states/ Between 1988 and 2004, a period during exposure after implementation of smoke- provinces and cities) where smoke-free which the state of California implemented free laws (64), improvements in respiratory laws had not been enacted on a national comprehensive smoke-free legislation, health are experienced very quickly. In level, show not only the impact of such rates of lung and bronchial cancer declined Scotland, bar workers reported a 26% laws, but also the potential benefit of four times faster in California than in the decrease in respiratory symptoms, and enacting smoke-free legislation on a local rest of the United States, although at least asthmatic bar workers had reduced airway level when national bans are not in place. some of this decrease may result from the inflammation within three months after sharper decline in smoking prevalence comprehensive smoke-free legislation was experienced in California compared with enacted (65). In California, bartenders Smoke-free laws are the rest of the country that began in the reported a 59% reduction in respiratory expected to reduce lung early 1980s (75). symptoms and a 78% reduction in sensory cancer irritation symptoms within eight weeks after implementation of the law requiring Because of the long time lag between bars to be smoke-free (66). second-hand smoke exposure and the

Smoke-free laws reduce illness from heart disease Respiratory symptoms of bar workers in Scotland, Even low-level exposure to second-hand before and after introduction of comprehensive tobacco smoke has a clinically significant smoke-free legislation effect on cardiovascular disease risk (67). Smoke-free environments reduce 100% the incidence of heart attack among the 90% general population almost immediately, even in the first few months after being 80% 79% implemented (68). Several studies have

Respiratory symptoms Respiratory 70%

60%

53% 50% 47%

40%

30%

20%

10%

0%

Before law 1 month after law 2 months after law Source: (65).

28 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 Other benefits of smoke-free regulations

Smoke-free laws help with comprehensive smoke-free laws than with smoke-free policies are nearly twice smokers to reduce smoking in states without such laws (77). as likely to quit smoking as those in or quit worksites without such policies, and people Complete workplace smoking bans who continue to smoke decrease their Smoke-free environments not only protect implemented in several industrialized average daily consumption by nearly four non-smokers, they reduce tobacco use nations are estimated to have reduced cigarettes per day (79). in continuing smokers by 2–4 cigarettes smoking prevalence among workers by an a day (76) and help smokers who want average of 3.8%, reduced average tobacco After comprehensive smoke-free legislation to quit, as well as former smokers who consumption by 3.1 cigarettes per day was enacted in Ireland, about 46% of have already stopped, to quit successfully among workers who continue to smoke, smokers reported that the law had made over the long term. Per capita cigarette and reduced total tobacco consumption them more likely to quit; among those who consumption in the United States is among workers by an average of 29% did quit, 80% reported that the law had between 5% and 20% lower in states (78). People who work in environments helped them to quit and 88% reported

Smoke-free environments not only protect non-smokers, they reduce tobacco use in continuing smokers and help smokers who want to quit.

effects of Ireland’s smoke-free law on smokers’ reported behaviours

100%

90% Smokers

80%

70%

60% 60%

50% 46%

40%

30%

20%

10%

More likly to quit? Made you cut down? Source: (80).

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 29 that the law helped them to maintain to make their homes smoke-free (82), smoke-free legislation is enacted (85, cessation (80). In Scotland, 44% of people which protects children and other family 86). who quit smoking said that smoke-free members from exposure to second-hand legislation had helped them to quit (81). tobacco smoke (83). In Australia, the Voluntary smoke-free home policies also introduction of smoke-free workplace decrease adult and youth smoking. Home laws in the 1990s was accompanied by smoking bans reduce progression to Smoke-free laws encourage a steep increase in the proportion of smoking experimentation among youths establishment of smoke-free adults who avoided exposing children who live with non-smokers. Teenagers who homes to second-hand tobacco smoke in the live in homes where smoking is allowed are home (84). Even smokers are likely to nearly twice as likely to start smoking, even Legislation mandating smoke-free voluntarily implement a “no smoking” if adults are non-smokers themselves, than public places also encourages families rule in their homes after comprehensive in homes where smoking is prohibited (87).

Smoke-free laws are popular Public opinion surveys show that smoke- In 2006, Uruguay became the first 2004, 69% of its citizens said they free legislation is extremely popular country in the Americas to become supported the right of people to work in wherever it is enacted, even among 100% smoke-free by enacting a ban a smoke-free environment (92). smokers, and that support tends to on smoking in all public spaces and increase over time after these laws are in workplaces, including bars, restaurants The smoke-free workplace law introduced place. Support is generally strongest for and casinos. The law won support from in Ireland in March 2004 has been judged making hospitals and other health-care eight out of every 10 Uruguayans, successful by 96% of people, including facilities smoke-free, while there is usually including nearly two thirds of the 89% of smokers (93). In California, 75% the least support for making bars and pubs country’s smokers (91). After New of the population approved of smoke-free smoke-free (88–90). Zealand passed smoke-free laws in workplace laws that included restaurants

In every country where comprehensive smoke-free legislation has been enacted, smoke-free environments are popular and result in either a neutral or positive impact on business.

30 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 and bars within the first few years after – support a ban on smoking on public bars (95). In Russia, which also has few being enacted by that state in 1998 (94). transport and in schools and hospitals restrictions on smoking in public places, (95). More than 80% of urban residents nearly a third of people support a complete Although China has few smoke-free public in China support smoke-free legislation ban on smoking in restaurants (96). places, 90% of people living in large in workplaces, and about half support cities – smokers and non-smokers alike banning smoking in restaurants and

Smoke-free laws do not hurt business

Despite tobacco and hospitality industry In New York City, which implemented among hospitality industry economic claims, experience shows that in every smoke-free legislation in two stages indicators in Massachusetts (106), no country where comprehensive smoke-free (covering most workplaces including most economic harm to bar and restaurant legislation has been enacted, smoke- restaurants in 1995 and adding bars and businesses reported in the mid-sized US free environments are popular, easy to remaining restaurants in 2003), restaurant city of Lexington, Kentucky (107), and implement and enforce, and result in either employment increased after enactment no adverse economic impact on tourism a neutral or positive impact on businesses, of the 1995 law (105). Combined bar in Florida (108). When bars located in including the hospitality sector (97, 98). and restaurant employment and receipts communities with smoke-free laws were These findings were similar in all places increased in the year after enactment sold, they commanded prices comparable studied, including in Australia, Canada, of the 2003 ordinance (103), and have to prices paid for similar bars in areas the United Kingdom and the United States continued increasing since. with no restrictions on smoking (109). This (99); Norway (100); New Zealand (101); type of economic evidence can be used the state of California (102); New York After comprehensive smoke-free legislation to counter false tobacco industry claims City (103); and various US states and was implemented, there were no that establishing smoke-free places causes municipalities (104). statistically significant changes observed economic harm (97, 110).

Average annual employment in New York City restaurants and bars, before and after comprehensive smoke-free legislation

12 000 250

Active on premise liquor licences Employment

10 000 200

8 000

150

6 000

100

Average annual active on premise liquor licences annual active on premise Average 4 000

50 2 000 (000s) and bars annual employment in restaurants Average

0 NYC law passed in 2003 0

2000 2001 2002 2003 2004 2005 2006 2007 2008

Source: (103) and additional unpublished data from the New York State Liquor Authority Year and New York City Economic Development Corporation. Note: Average annual employment calculated from monthly totals.

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 31 Tobacco industry efforts to avoid 100% smoke-free legislation

The tobacco industry has long known the social acceptability of smoking and industry has also resorted to attacks that side-stream second-hand tobacco prevent adoption of meaningful smoke-free on researchers studying the effects of smoke contains higher concentrations policies in public places and in workplaces second-hand tobacco smoke by criticizing of carcinogenic substances than does (113). Measures such as ventilation and their motives or qualifications, even while mainstream tobacco smoke (7). In a separate smoking rooms, promoted as acknowledging internally the validity of confidential 1978 report, the industry “reasonable” accommodations by the their research findings (120, 121). described increasing public concerns tobacco industry, also undermine the about second-hand tobacco smoke intended effects of legislative measures by Researchers funded by or affiliated with exposure as “the most dangerous continuing to expose people to second- the tobacco industry are nearly 100 development to the viability of the hand tobacco smoke and reducing the times more likely than independent tobacco industry that has yet occurred” incentive for smokers to quit (114). researchers to conclude that second-hand (111). The industry acknowledges the tobacco smoke is not harmful to health effectiveness of smoke-free environments, Despite the incontrovertible scientific (122). Much of the research funded by and how creating exceptions can evidence of the harms of second-hand the tobacco industry is not published in undermine their impact. A 1992 internal tobacco smoke, the tobacco industry has peer-reviewed medical journals, is of poor report by Philip Morris stated: “Total referred to such findings as “junk science” scientific quality, and should not be used in prohibition of smoking in the workplace in an attempt to discredit them (115). The scientific, legal or policy settings unless its strongly affects industry volume. … industry has also used front groups in an quality has been independently assessed Milder workplace restrictions, such as attempt to successfully convince some (123). The tobacco industry has even smoking only in designated areas, have people to resist accepting these findings. attempted to create its own peer-reviewed much less impact on quitting rates and Much of the impetus for discrediting medical journals to publish papers on the very little effect on consumption” (112). scientific studies of the health effects of effects of second-hand tobacco smoke second-hand tobacco smoke comes from that are favourable to its interests (124). The tobacco industry has a history of the tobacco industry, which develops A US federal court has ruled that tobacco creating the appearance of scientific and publicizes its own biased research to industry assertions that second-hand controversy in an attempt to counter minimize the harmful effects of second- tobacco smoke exposure does not cause initiatives intended to restrict tobacco use. hand tobacco smoke because it fears disease are “fraudulent” (125). However, the ultimate goal of these types that restrictions on smoking will reduce of industry-backed initiatives is to maintain sales and profits 116–119( ). The tobacco

The tobacco industry has a history of creating the appearance of scientific controversy in an attempt to counter initiatives intended to restrict tobacco use.

32 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 Key recommendations

These key recommendations – consistent designated smoking rooms) or providing and strong public support. Other countries with the WHO FCTC Article 8 guidelines ventilation of smoking areas does not can learn from these experiences as – build on lessons learned from the eliminate the health risk resulting from they create and expand smoke-free experiences of several countries and exposure to second-hand tobacco smoke. environments for the vast majority of hundreds of subnational and local people worldwide who remain without jurisdictions that have successfully Because smokers and non-smokers alike protection against the harm of second- implemented laws requiring indoor are vulnerable to the harmful health hand tobacco smoke exposure. workplaces and public places to be 100% effects of second-hand tobacco smoke, smoke-free, as follows (4): governments are obligated to protect There is no risk-free level of exposure to health as a fundamental human right (3). tobacco smoke. The health risk resulting 1. Legislation that mandates completely This duty is implicit in the right to life from exposure to second-hand tobacco smoke-free environments – not voluntary and the right to the highest attainable smoke is the primary reason to ban smoking policies – is necessary to protect public health. standard of health as recognized in in workplaces and public places, because 2. Legislation should be simple, clear and many international legal instruments, an individual’s decision to smoke results in enforceable, and comprehensive. including the International Covenant on damage to others. Smoke-free environments Economic, Social and Cultural Rights; help guarantee the right of non-smokers to 3. Action should be taken at any and the Convention on the Elimination of All breathe clean air, motivate smokers to quit, all jurisdictional level(s) where effective Forms of Discrimination against Women; and allow governments to take the lead in legislation can be achieved. and the Convention on the Rights of the tobacco prevention through highly popular 4. Anticipating and responding to the Child. These are formally incorporated into health measures. tobacco industry’s opposition, often the Preamble of the WHO FCTC, and have mobilized through third parties, is crucial. been ratified in the constitutions of more than 100 countries. Voluntary agreements, 5. Involving civil society is central to often promoted by the tobacco industry as achieving effective legislation. a “compromise”, have proven insufficient to achieve public health goals because 6. Education and consultation with they do not eliminate, and at best only stakeholders are necessary to ensure reduce, exposure to second-hand tobacco smooth implementation. smoke (126). Comprehensive smoke-free 7. An implementation and enforcement legislation with strong enforcement is the plan together with an infrastructure best strategy for reducing exposure to for enforcement, including high-profile second-hand tobacco smoke. prosecutions to include fines or closing of businesses of repeat violators, are critical Recent progress has highlighted the for successful implementation. feasibility of achieving smoke-free environments and generated increased 8. Monitoring of implementation worldwide interest in promoting them. and compliance is essential, as is Although much more work remains measurement of the impact of smoke-free to be done, there are many examples environments; ideally, experiences should where there have been improvements in also be documented and the results made smoke-free policies. Even smoking bans available to other jurisdictions to support in restaurants, bars and other hospitality their efforts to successfully introduce and venues, generally considered the most implement effective legislation. difficult places to make smoke-free, have 9. Physically separating smokers from been successfully implemented in several non-smokers (for example by establishing countries with near universal compliance

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2009 33