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Should Smoking In Outside Public Spaces Be Banned? Yes

BMJ – Published 11 December 2008, doi:10.1136/bmj.a2806

George Thomson, senior research fellow1, Nick Wilson, senior lecturer1, Richard Edwards, associate professor1, Alistair Woodward, professor2

1 University of Otago, Wellington, Box 7343, Wellington, New Zealand, 2 University of Auckland, Private Bag 92019, Auckland, New Zealand – Correspondence to: G Thompson

After success in stopping smoking in public buildings, campaigns are turning outdoors. George Thomson and colleagues argue that a ban will help to stop children becoming smokers but Simon Chapman (doi:10.1136/bmj.a2804) believes that it infringes personal freedom Legislation to ban smoking indoors in public places is now commonplace, driven mainly by the need to protect non-smokers from exposure to secondhand smoke. A new domain for tobacco control policy is outdoor settings, where secondhand smoke is usually less of a problem. However, the ethical justification for outdoor smoking bans is compelling and is supported by international law. The central argument is that outdoor bans will reduce smoking being modelled to children as normal behaviour and thus cut the uptake of smoking. Outdoor smoke-free policies may in some circumstances (such as crowded locations like sports stadiums) reduce the health effects of secondhand smoke1; will reduce fires and litter2; and are likely to help smokers’ attempts at quitting.

Need to reduce modelling

There is no simple answer to the question of what causes children to take up smoking.3 4 We know, however, that children tend to copy what they observe and are influenced by the normality and extent of smoking around them.5 6 7 Many smokers recognise that their smoking affects children’s behaviour.8 The primary strategy for tobacco control is reducing the prevalence of smoking, and such reduction will in itself mean that smoking is less visible in society. But the modelling of smoking can also be reduced by policies to restrict smoking in the presence of children. The entrenched nature of tobacco use in most societies, and its highly addictive qualities, require that such policies are far reaching. Smoking bans in many outdoor public areas are therefore an important additional approach to tobacco control. The need for outdoor smoking restrictions is increasingly recognised. Finland, five Canadian provinces, two US states, and New Zealand use law to require smoke-free school grounds. Other jurisdictions (such as Australian states) use administrative policies. California has banned smoking within 25 feet (7.6 metres) of outdoor playgrounds. United Kingdom, Scottish, Australian, and New Zealand authorities have been explicit about the need to reduce the modelling of smoking to children as a justification for this type of outdoor smoking restrictions.9 10 11 12 Policies encouraging or requiring other outdoor smoke-free areas have been introduced in the past 10 years in North America, Australasia, Hong Kong, Singapore, and elsewhere.13 Reducing the modelling of smoking to children has often been given as a justification for introducing these restrictions.

Are outdoor smoke-free policies practical?

How best to reduce the visibility of smoking? Media campaigns can promote not smoking in the presence of children as a social norm.14 Legislation and other uses of law can expand smoke-free policies to ensure the inclusion of all public areas where children predominate. These areas include schools, parks and playgrounds, swimming pool complexes, sports grounds, and parts of beaches. The success of outdoor bans depends on the size of the areas covered, the ways the policy is communicated (for example, signage), and the extent of public support.15 Reports from Britain, New Zealand, and parts of Australia and the United States indicate majority support for restricting or banning smoking in outdoor areas where there are children.15 16 17 18 19 20 We are aware of no evidence that outdoor smoke-free policies have resulted in a public backlash against other advances in tobacco control.

Ethical and international treaty considerations

Children are a highly vulnerable population, susceptible to the influences of adult behaviours. Protection from addiction can be considered to enhance overall freedom, given that most smokers regret ever starting.21 We may not yet be certain that outdoor smoke-free areas reduce smoking uptake; the necessary studies have not been carried out. However, where there is uncertainty in policy making, any assessment of the balance of benefit and harm should put the protection of children first.22 This is because of the extent and severity of the hazard that taking up smoking poses to children and the theoretical and empirical evidence for a role modelling effect on smoking uptake. The principle of giving primacy to the protection of children is also underpinned by international treaty obligations. The United Nations Convention on the Rights of the Child requires that in making policy, children’s rights must be put first, and governments “shall undertake all appropriate legislative, administrative, and other measures for the implementation of the rights.”23 Adverse effects from outdoor smoke-free areas are largely restricted to the possible loss of amenities for some smokers. We argue that society has an ethical duty to minimise the risk of children becoming nicotine dependent smokers. A reasonable step is banning smoking in selected outdoor areas frequented by children. Children need smoke-free outdoor places now, to help normalise a smoke-free society. Cite this as: BMJ 2008;337:a2806

Competing interests: All authors have done contract work for health non-governmental organisations, the New Zealand Ministry of Health, or WHO on tobacco control research.


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