Journal of Public Health
325–326
doi:10.1093/pubmed/fdh187
Why we need to ban smoking in public places
now
Martin McKee, Helen Hogan and Anna Gilmore
Keywords: tobacco, tobacco industry, smoking bans
The recent introduction on bans on smoking in bars and restaur-
ants in New York, Ireland and Norway has given fresh impetus
to the debate on how best to reduce the toll of premature
smoking-related deaths in the United Kingdom. The Scottish
first minister, after returning from a visit to Ireland, has raised the
real possibility of implementing a ban in Scotland.1
This debate has long been characterized by the public health
and tobacco control communities on one side and the tobacco
industry, supported by hospitality industry organizations, many
of which have been established by tobacco companies to voice
opposition to a ban. The alignment of forces is, however, chang-
ing as the voice of the general public is at last being heard. Con-
trary to the myths that have been peddled by the tobacco industry,
public consultations are revealing the true extent to which the
British people oppose being subjected to second-hand smoke. For
example, the ‘Big Smoking Debate’ organized by the London
Health Commission involving over 30 000 respondents indicated
that the vast majority (76 per cent) wanted completely smoke free
public places, including both smokers and non-smokers.2
These findings are unsurprising, given the unpleasant physical
effects of exposure to concentrated tobacco smoke. However,
public opinion is also being galvanized by growing recognition of
the adverse health effects of second-hand smoke, something the
tobacco industry has striven hard to refute as part of a campaign
sustained over many years to prevent the introduction of bans on
smoking in public places. There is now an overwhelming con-
sensus among independent tobacco researchers that exposure to
second-hand smoke causes many deaths, with recent research
using more precise measures of exposure revealing how exposure
to second-hand smoke is considerably more dangerous than was
previously believed.3 This is consistent with recently discovered
tobacco industry documents showing that second-hand smoke is
even more harmful, volume for volume, than directly inhaled
smoke.4 Yet the industry continues to place the highest priority
on preventing the introduction of restrictions on smoking in pub-
lic places and has been especially active in spreading misinforma-
tion about the effects of the bans in Ireland and New York.
The main reason it has pursued this policy with such tenacity
is clear; bans, together with increased taxation, are the most
effective ways of reducing smoking overall.5 However, it is also
Journal of Public Health vol. 26 no. 4 © Faculty of Public Health 2004; all rights reserved.
Vol. 26, No. 4, pp.
Printed in Great Britain
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/26/4/325/1565971 by guest on 25 September 2019
concerned that to concede that second-hand smoke is harmful
would undermine its argument that smoking is a matter of
personal choice.
The strategy pursued by the industry has several elements.
One, now largely discredited, has been to attack the link between
second-hand smoking and disease has included commissioning
research, some of which was fraudulent and some simply designed
to mislead, undermining the communication of research showing
the harm caused by second-hand smoke, and lobbying govern-
ments and regulators.6,7
Another is to argue that any irritation (again denying the
possibility of harm) can be dealt with by ventilation. This too is
incorrect, with extensive evidence that the force of ventilation
that would be required is far beyond the capacity of existing
systems and would be similar to sitting outside during a gale.8 It
is important to be aware that many harmful components of
tobacco smoke are odourless and the tobacco industry has put
much effort into masking the smell and visibility of environ-
mental tobacco smoke.9
The third argument, and one with which it has had some
success so far in the United Kingdom, is that the introduction of
smoking bans in bars and restaurants will reduce takings, and
thus sales tax and employment. To sustain this, it has engaged in
a wide-ranging campaign directed at the hospitality industry.
Yet, like its other arguments, this too is false. The most recent
evidence is from New York where, in the 9 months after a ban on
smoking in public places was introduced, sales tax receipts on
food and drink increased by 12 per cent and employment in the
hospitality industry increased.10 However, the most convincing
evidence comes from a systematic review of research on the
impact of bans on bar and restaurant revenue.11 The details
results merit study. The authors examined 97 studies of the
economic impact of smoking bans. Every one of the 37 studies
1
London School of Hygiene and Tropical Medicine, Keppel Street,
London WC1E 7HT, UK and 2North East London Strategic Health Authority,
Aneurin Bevan House, 81 Commercial Road, London E1 1RD, UK
Martin McKee1,2
Helen Hogan2
Anna Gilmore1
Address correspondence to Martin McKee, London School of Hygiene and
Tropical Medicine.
E-mail: Martin.mckee@lshtm.ac.uk
326 JOURNAL OF PUBLIC HEALTH
finding a negative economic impact had been funded by the
tobacco industry or written by consultants known to have indus-
try links; these papers were 20 times as likely as those finding
either no effect or an economic benefit to appear other than in a
peer reviewed journal. In total, 94 per cent of the tobacco indus-
try supported studies reported a negative economic impact. How-
ever, this was found in none of the 60 independent studies. The
authors concluded that all of the best designed studies report no
impact or a positive impact of smoke-free restaurant and bar laws
on sales or employment and urged policymakers to protect work-
ers and patrons from the effects of second-hand smoke, confident
in the knowledge that industry claims of an adverse economic
impact have no basis in fact.
The case for action therefore seems overwhelming. Yet we
have been struck by the fatalistic believe among both the public
and health professionals that nothing can be done. At a recent
public meeting organized by North East London Strategic Health
Authority, as part of the Government’s consultation on Choos-
ing Health, this single initiative was identified by both the public
and health professionals as one of the most important factors in
improving the health of the population and one where political
leadership is needed. Yet there was also widespread misunder-
standing about the evidence and, in particular, the argument that
a ban would adversely affect the income of bars and restaurants
was widely believed. As a result, Directors of Public Health
expressed real doubts about their ability to persuade local coun-
cils to adopt such measures.
Yet, the examples from abroad show that something can be
done. The health and economic evidence is clear and there is
widespread public support for action. The only thing that is
missing is the high level political commitment that there has been
in places like New York and Ireland. This can partly be explained
by the dominance of the political agenda in the United Kingdom
by the tabloid press, with its constant preoccupation, shared by
some politicians but few others, with the concept of the ‘nanny
state’. However, as our consultation showed, this is not an excuse
that will be accepted by the British public.
The international momentum has created a window of oppor-
tunity that public health professionals should seize. A first step
is to ensure that all health facilities are smoke free; that some
hospitals now under construction should actually be building
smoking rooms is an indictment on our profession.12 However,
there is also a need for us all to counter the mythology perpetu-
ated by the tobacco industry, whether it is in our discussions with
national and local politicians, the voluntary sector, the media, or
those in the hospitality industry.
References
1 URL: http://news.bbc.co.uk/1/hi/scotland/3612808.stm (last accessed
6th September 2004).
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/26/4/325/1565971 by guest on 25 September 2019
2 Crosier A. The Big Smoke Debate. Briefing Paper. London Health
Commission, 2004
3 Whincup PH, Gilg JA, Emberson JR et al. Passive smoking and risk of
coronary heart disease and stroke: prospective study with cotinine
measurement. Br Med J 2004; 329: 200–205.
4 Gugel H, Reininghaus W, Romer E. INBIFO, Institut für Biologische
Forschung. Integrating Report A 0500/3047 21-Day Smoke Inhalation
Study with Mainstream and Sidestream Cigarette Smoke of Standard
Reference Cigarette Type 2R1 on Rats. 29 July 1982. Philip Morris.
Bates No. 2029190329/0354.
5 Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on
smoking behaviour: systematic review. Br Med J 2002; 325: 188.
6 McKee M. Smoke and mirrors: clearing the air to expose the tactics of
the tobacco industry. Eur J Publ Hlth 2000; 10: 161–163.
7 Ong EK, Glantz SA. Tobacco industry efforts subverting International
Agency for Research on Cancer’s second-hand smoke study. Lancet
2000; 355: 1253–1259.
8 Drope J, Bialous SA, Glantz SA. Tobacco industry efforts to present
ventilation as an alternative to smoke-free environments in North
America. Tob Control 2004; 13 [Suppl 1]: i41–i47.
9 Connolly GN, Wayne GD, Lymperis D, Doherty MC. How cigarette
additives are used to mask environmental tobacco smoke. Tob Control
2000; 9: 283–291.
10 Stark M. Commissioner to the New York City Department of Finance.
Letter to the Editor. New York Times, 4 January 2004.
11 Scollo M, Lal A, Hyland A, Glantz S. Review of the quality of studies
on the economic effects of smoke-free policies on the hospitality
industry. Tob Control 2003; 12: 13–20.
12 McKee M, Gilmore A, Novotny T. Smoke-free hospitals. Br Med J
2003; 326: 941–942.