BMJ, doi: 10.1136/bmj.39315.616169.BE, (Published 9 September 2007)

Editorials

The future of smoke-free legislation

Will cars and homes follow bans on smoking in public spaces?

A tide of epidemiological,¹ clinical,² and toxicological³ research has gradually transformed the meaning of the quiet, convivial cigarette into a health hazard for others, and smokers into stigmatised, regulated exiles from public spaces.⁴ Bans on smoking in enclosed public places have moved into global overdrive in the past decade. Three studies in this week's BMJ provide evidence of the clinical and social effects of legislation to prohibit smoking in almost all enclosed public places and work places—including bars, restaurants, and cafés—in Scotland implemented in March 2006.^{5 6 7}

The hospitality and tobacco industries forecast the end of civilisation after banishing smoking from bars.⁸ The bar economy and tourism would collapse. The vibrant tradition of pub life would be sacrificed on the altar of risk aversion. Drinks left on the bar while smokers stepped outside would be spiked by rapists,⁹ and street fights would increase. Smoking would be displaced to homes where angry men would ruin their families' health, beat their wives, and even cause more house fires.¹⁰ At least these were the arguments the tobacco industry used publicly. Privately, they admitted as long as 13 years ago that "These arguments simply had no credibility with the public, which isn't surprising when you consider that our dire predictions in the past rarely came true."¹¹

Smoke-free bars remain full from Dublin to New York, Auckland, Vancouver, Oslo, Sydney, Rome, and Glasgow. The study in this issue by Haw and colleagues shows that the Scottish smoke-free legislation has been followed by remarkable falls in cotinine concentrations in smokers and non-smokers living in both smoking and non-smoking households.⁶ The study also found no evidence of displacement of smoking from public places into homes, confirming earlier findings from Ireland.¹² The study by Akhtar and colleagues also in this issue found that cotinine reductions in primary school children were significant only in households where no parent or only the father smoked,⁵ suggesting that mothers' smoking in houses and cars continues to be an important source of exposure in children.

Cars are an intriguing and symbolically important interface between public and private worlds. While the interior of cars is considered by many to be a "private" space, the law has long regarded cars as effectively public spaces. Their occupants are subjected to legal requirements regarding seat belts, car standards, driving conduct, and mobile phone use designed to protect public safety (harm to others) and the safety of the occupants (via the benevolent paternalism inherent in seat belt legislation).

Several US jurisdictions and South Australia have legislated bans on smoking in cars when children are on board. These laws have taken a legislative first step into outlawing what has until now been assumed to be a private self regulated behaviour (parents' freedom to expose their children to high concentrations of tobacco smoke in settings assumed to be private). The ability of parents to exercise this "freedom" in public settings such as on public transport and in enclosed shopping precincts is now denied in many nations, including Scotland, through reference to the health and amenity of others. This creates a paradox—why should parents be prevented from placing their children's and others' health at risk in public vehicles but be allowed to do so in private vehicles? Legislation on smoking in cars—which is focused on a setting where those harmed are most likely to be family members—moves the boundaries of health protection legislation in an important new direction.

As public smoking bans proliferate, homes are now the most important source of exposure to secondhand smoke, and unconsenting minors are often exposed. No nation has ventured to legislate against domestic smoking, although increasingly public awareness campaigns are successfully urging many people to make their homes smoke free.¹³ Homes are assumed to be the "castles" of their occupants, where a wide range of private freedoms of expression are sanctified that are prohibited in public. It would seem inconceivable in any but the most authoritarian states for smoking to be banned in homes.

However, there are many ways that households can be encouraged and supported to implement smoke-free rules. The qualitative study in the trio of papers reported in this week's issue⁷ offers many insights into themes that have resonated with people who have already taken this step. Public awareness campaigns are important, but health workers such as general practitioners, hospital consultants (for example, those in paediatric asthma clinics), health visitors, midwives, and specialists in cessation have vital roles. They should offer advice and support to individuals, particularly parents, grandparents, and other carers. Ex-smokers often cite their children as important influences on their decision to quit. Children should therefore also be supported in their efforts to request their parents to at least smoke outdoors.

University of Sydney, NSW 2006, Australia

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

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6. Haw S, 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 doi: 10.1136/bmj.39315.670208.47 [Abstract/Free Full Text]
7. 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 doi: 10.1136/bmj.39301.497593.55 [Abstract/Free Full Text]
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9. Brady B. Submission No.46 to inquiry into tobacco smoking in New South Wales. Parliament of New South Wales, 2006. www.parliament.nsw.gov.au/prod/parlment/committee.nsf/0/2B14B998DDA58536CA2571620017ECD2
10. Elliot D. Clearing the air about the impact of smoking bans. Australian Hotels Association News (NSW). 2007:10. http://tobacco.health.usyd.edu.au/share/AHA.jpg.
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12. Hyland A, Higbee C, Hassan L, Fong GT, Borland R, Cummings KM, et al. 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. Eur J Public Health 2007 Jun 20. Epub ahead of print. http://eurpub.oxfordjournals.org/cgi/content/abstract/ckm054v3
13. State-specific prevalence of smoke-free home rules—United States, 1992-2003. MMWR Morb Mortal Wkly Rep 2007;56:501-4.[Medline]

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