Review article
Smokefree Legislation: A Review of Health and Economic Outcomes Research

https://doi.org/10.1016/j.amepre.2010.08.013Get rights and content

Context

Smokefree legislation is a powerful public health intervention. Despite progress in smokefree legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation.

Evidence acquisition

This paper reviews the scientific literature on health and economic outcome studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy.

Evidence synthesis

There is a wealth of research showing the health benefits to entire populations when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, economic studies confirm that smokefree laws do not adversely affect business revenues or operating costs.

Conclusions

While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations.

Introduction

Smokefree legislation is a powerful public health intervention.1 There is a wealth of research showing the health benefits to entire populations when communities implement smokefree laws and/or regulations. Exposure to secondhand smoke (SHS) decreases, indoor air quality improves, workers are protected, adult and youth smoking levels decrease, smokers are more likely to quit, acute myocardial infarctions (AMI) and asthma exacerbations decline, and infant/birth outcomes may improve. In addition to health benefits, economic studies confirm that smokefree laws do not hurt business revenues or operating costs.

Smokefree laws reduce exposure to SHS. After Scotland's smokefree legislation was implemented, there was a 39% reduction in salivary cotinine among nonsmoking primary schoolchildren, especially among those with nonsmoking parents,2 and a similar reduction in adults.3 Similarly, adults in Spain self-reported an overall 22% reduction in exposure to SHS following their smokefree law, with the greatest reductions in the workplace.4 A New Zealand study recruited volunteer patrons and measured salivary cotinine before and after a 3-hour visit to a bar, and reported a 90% reduction after the smokefree legislation.5 Further, the more extensive the smokefree law, the lower the serum cotinine among nonsmoking adults.6 Massachusetts adults living in a town with strong restaurant and bar smoking restrictions self-reported lower exposure to SHS compared to those living in towns that allowed smoking in restaurants and bars.7

Despite a global trend to adopt smokefree legislation, it is estimated that 53% of Americans remain unprotected by comprehensive smokefree workplace laws that include restaurants and bars.8 As of July 5, 2010, there were 3161 U.S. municipalities and 39 states that had laws or regulations restricting where smoking is allowed; however, only 405 municipalities and 22 states had comprehensive protection (Table 1).9 There is much work to do in protecting the entire population from SHS exposure. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but also that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age.

The purpose of this paper is to review the research on the health and economic outcomes of smokefree legislation. Other reviews have examined the effects of voluntary or private sector policies on smoking prevalence and cessation behaviors.10 The focus of this review is to summarize the outcomes research related to smokefree public policy interventions over the past 10 years, from 2000 through early 2010. The search was conducted using MEDLINE and the following search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy. The paper is organized based on outcomes related to health (worker and population health), air quality, smoking prevalence and cessation, economics, and subpopulations.

Section snippets

Health Outcomes

There is a wealth of health outcomes research showing that hospitality workers are immediately protected when smokefree legislation takes effect. There also is an abundance of research demonstrating that smokefree legislation protects entire populations from AMIs, asthma, and other health conditions.

Air Quality Outcomes

There is an abundance of air quality monitoring research in the U.S. and worldwide, revealing that comprehensive smokefree legislation substantially improves air quality in indoor work environments, and the effects are immediate in reducing fine particle air pollution. A 32-country study of indoor air pollution revealed that countries with national smokefree indoor public places legislation had lower fine particle air pollution levels than those without restrictions.45 Another air quality study

Smoking Prevalence and Cessation Outcomes

While there is a wealth of cessation outcomes research related to smokefree legislation, there is less research on population-level smoking prevalence. The literature on smoking prevalence outcomes and smokefree laws is mixed.

Economic Outcomes

There is clear evidence that smokefree legislation does not hurt restaurant or bar businesses, and in some cases business may improve. There have been several published reviews of the economics of smokefree laws.98, 99 In the 1990s, there were multiple economic impact studies published, including an analysis of taxable sales receipts after New York City's 1995 Smoke-Free Air Act.100 More recently, Hyland and Tuk report an 18% increase in per capita employment after New York City's law.105 In

Subpopulations

Exposure to SHS varies by occupation type, gender, SES, race/ethnicity, and age,118 and smokefree legislation may have a differential impact on subpopulations such as low-SES groups.119 Ten years prior to the statewide Massachusetts smokefree law, there was a documented disparity in health protections, with populations that had low education levels less likely to live in a locale covered by smokefree restaurant regulations.120 One Swedish study revealed that gaming workers (i.e., bingo and

Conclusion

Research from 2000 to early 2010 provides evidence that smokefree legislation has a myriad of public health benefits and does not harm business. Despite decades of progress in protecting the public from SHS in workplaces and public places, vulnerable populations remain disproportionately affected by tobacco consumption, SHS exposure, and smoking-attributable disease and premature death. There is a need for research on the differential effects of smokefree legislation on subpopulations who may

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