WHO regions and World Bank income classifications

The number of articles by WHO region and World Bank income classification is presented in Table 1. The study identified 40 articles that discussed smoke-free policies in EURO, 30 articles in AMRO, 21 articles in SEARO, 16 articles in WPRO, 8 articles in EMRO, 7 articles in AFRO. Τwelve articles discussed smoke-free policies within multiple WHO regions. The sample of articles included 79 articles discussing smoke-free policies in HICs, 41 articles discussing smoke-free policies in LMICs, and 14 articles discussing both LMICs and HICs.

Smoke-free environments

The number of articles discussing each environment is outlined in Table 2. This study identified articles discussing smoke-free policies in each of the environments required to be made smoke-free as detailed in the Guidelines for Article 8 of the FCTC, including indoor public spaces (102 articles), indoor workplaces (98 articles), outdoor and quasi-outdoor environments (46 articles), public transport (29 articles), and unspecified public places including outdoor or quasi-outdoor environments (13 articles).

Themes and insights discussed in articles

Table 2 presents the number of articles discussing smoke-free policy development, implementation, enforcement, and compliance. The following paragraphs summarize key insights from our review of the literature. The research team observed a high level of overlap between issues affecting policy development and policy implementation, as well as those affecting compliance and enforcement. Therefore, the results are presented in two main sections (policy development and implementation; policy compliance and enforcement). Specific barriers and opportunities are discussed throughout both main sections.

Policy development and implementation

In all, 67 articles discussed the development of smoke-free policies, and 119 articles discussed policy implementation. Stakeholder involvement was the most commonly identified factor influencing smoke-free policy development and implementation. The literature further coalesced on two sides regarding stakeholder involvement in smoke-free policy – the influence of tobacco industry interference and the importance of civil society engagement. In addition to stakeholder involvement, several studies discussed the importance of communication and educational efforts and effective leadership. Finally, access to resources was an additional factor identified in the literature as an important determinant of smoke-free policy development and implementation.

Tobacco industry interference

Many studies explicitly mentioned tobacco industry interference as a significant barrier to enactment and implementation of smoke-free policies within both HICs and LMICs^13-33. Studies have linked tobacco industry interference to delayed legislation, weak draft bills, improper policy adoption, and limited and ineffective policy implementation^23,24,34,35. Government officials vary in their attitudes toward interactions with the tobacco industry, and there is sometimes limited awareness among government officials with regard to Article 5.3 of the FCTC²². This lack of knowledge, combined with fear of the tobacco industry, poses a significant barrier to implementing comprehensive smoke-free policies. The tobacco industry uses a variety of tactics to prevent or delay the enactment of comprehensive smoke-free policies or to undermine existing smoke-free policies. In addition to directly lobbying government officials to block or weaken smoke-free policies^{15,23,24,26,29,30,32} and using front groups to advance their interests^{15,17,21,23,24,26,32,36,37}, the tobacco industry has challenged smoke-free policies through litigation^{13,23,24,30,32,37}. For example, in Kenya, the tobacco industry challenged the Tobacco Control Act of 2007 in court, resulting in the suspension of smoke-free policies³⁰. The tobacco industry has also promoted weak smoke-free policies to prevent enactment of comprehensive smoke-free policies^18,23,24,30. For example, across multiple countries, tobacco companies (including British Americand Tobacco and Philip Morris International) promoted the ‘Courtesy of Choice program’ to encourage hospitality venues to self-regulate and provide smoking and non-smoking areas^30,32. Additional tobacco industry interference tactics include promoting positive perceptions of the tobacco industry and manipulating and misrepresenting evidence to decision-makers³⁸.

In addition to economic arguments, the tobacco industry has attempted to appeal to social or cultural norms and values, such as individual rights or freedom. One study of street smoking bans in Japan found that many municipalities permit smoking in streets as long as an ashtray is provided or the smoker carries a portable ashtray to dispose cigarette butts¹⁸. The authors suggested these partial outdoor smoking bans reflect tobacco industry marketing strategies that emphasize cleanliness and ‘proper etiquette’ (e.g. not littering), with the underlying premise that smoking is acceptable within these constraints – and further finding that tobacco interest groups used these outdoor restrictions to oppose indoor smoking restrictions¹⁸.

Civil society engagement

The literature frequently identified civil society engagement as a specific form of stakeholder involvement that was an effective strategy for successful smoke-free policy development and implementation^{9,18-20,23,24,37,39-51}. Involving public health officials^30,43,44, researchers⁵¹, community groups^37,43,45,51, journalists^23,24,43, and those most affected by the policy^40,42,46 was found to enhance the policymaking process. A weak or fragmented civil society was identified as a barrier to smoke-free policy implementation in Latin America³². Stakeholder involvement was critical at every stage of the policymaking process, including policy formulation^23,24,40, adoption^52,53, implementation^46,47, and evaluation⁵¹. Media pressure and engagement were highlighted as ways to increase civic support, awareness, education, youth advocacy, and stakeholder engagement^{18,23,24,26,27,34,36,37,54-63}. Civil society organizations can also help countries monitor and counter tobacco industry interference, and build capacity for implementing and evaluating smoke-free policies^23,24. Additionally, civil society can engage in litigation and lobbying to advance tobacco control efforts. For example, after the tobacco industry filed cases in the Supreme Court against a comprehensive tobacco control law in Nepal, the civil society groups, Action Nepal, and Health and Environment Awareness Forum Nepal, met with health professionals, lawyers, and media groups to increase awareness of this issue and also lobbied Nepal’s Attorney General to hasten the hearing^23,24. Additionally, civil society groups in Nepal filed a case against the government in the Supreme Court to pressure for immediate implementation of comprehensive tobacco control policies^23,24.

Government engagement

Engagement from all levels of government, including national, state/provincial, and local governments, can contribute to successful policy development and implementation, particularly in countering tobacco industry interference^22-24. One study emphasized the importance of ‘bottom-up’ approaches, in which local or district-level policies and actions can encourage action from state/provincial or national governments by serving as role models²². Given that the tobacco industry uses similar interference tactics globally, governments and tobacco control advocates can anticipate opposition strategies from the tobacco industry and plan their response in advance³². Several countries have developed national plans, strategies, and innovative approaches to counter tobacco industry interference, including ratifying the FCTC and implementing provisions specified in Article 5.3^{25-27,32,34,37,51,64,65}. The literature also emphasized the importance of increasing awareness and compliance with FCTC Article 5.3 in countering tobacco industry interference²². For example, following efforts to sensitize health officials to obligations under Article 5.3, health officials in Bangladesh discontinued engagement with the tobacco industry²². One study suggested that raising awareness of Article 5.3 across different sectors, not just the health sector (i.e. horizonal coordination), as well as cooperation between national, state/provincial, and local governments (i.e. vertical cooperation) was important for successfully countering tobacco industry interference²⁴.

Effective leadership

Effective leadership was another key factor identified in the literature, including leadership from government and civil society^{9,23,24,36,37,40,46,47,49,54,66-69}. Leaders provide a central authority and convene disparate stakeholder groups^20,69. Effective leaders also serve as champions and positive advocates for smoke-free policies, thereby increasing support and buy-in⁶⁹. For example, Kansas City (Missouri, United States) had clear, identifiable policy champions, who had extensive networks and worked to actively connect different stakeholder groups, ‘including the media, coalitions, public health agencies, policymakers, and other partners’⁶⁹. These policy champions ‘built a case for non-smokers’ rights’ and were instrumental in moving a smoke-free policy forward⁶⁹. Stakeholders were well-connected (not siloed), and all stakeholders actively engaged and communicated throughout the policy process⁶⁹. For smoke-free policies directed at hospitals, schools, or similar institutions, involvement of senior management was consistently identified as a crucial component to successful implementation of smoke-free policies^{40,66,68,70-72}.

Communication, education, and training

Limited awareness of the dangers of SHS and of existing policies, even among policymakers, can be a barrier to policy implementation^27,28,34. Clear, effective communication and education about the dangers of SHS and about smoke-free policies was discussed in many studies as key to successful policy implementation^{23,24,31,32,34,36,42-44,46,47,50,53,55,60,69,73-79}. For example, public colleges and universities in New Zealand utilized several communication strategies to improve smoke-free policy implementation, including signage, providing information about the smoke-free policies during orientation and in student handbooks, local media publicity, providing information through websites and social media, and sharing positive comments from students and staff about the policy⁴⁶. The literature also identified communication between stakeholder groups as an important contributor to the development and implementation of smoke-free policies^20,39,72,80.

In addition to raising awareness about the need for smoke-free policies, clear communication and education can potentially increase support and buy-in for smoke-free policies from governments, businesses, institutions, and the public. This support, or lack thereof, can impact the success of smoke-free policy implementation^{39,43,44,46,47,81-84}. One factor that can negatively impact support from policymakers is perceived public opposition to smoke-free policies^{39,44,46,81-84}. Given that policymakers often underestimate the level of public support for smoke-free policies, fear of public opposition can be a barrier to successful implementation^{39,44,46,81-84}. For example, studies suggest there is strong public support for implementing at least some smoking restrictions in India, with 98% of respondents from India in a global study supporting public smoking bans⁸³. However, in a sample of representatives from local self-government bodies in two districts in the state of Kerala, 25% reported fear of public opposition as a major barrier to implementing FCTC provisions, including smoke-free policies⁸³. These findings suggest that educational efforts are needed to address policymakers’ concerns about public opposition⁸³.

Furthermore, several studies discuss the lack of training for those tasked with implementation as a barrier to successful smoke-free policy implementation^{40,66,68,73,85,86}. In particular, staff in healthcare settings (including psychiatric units) often lack training to deliver smoking cessation services to patients who smoke, which is an important component of successful smoke-free policy implementation in these settings^{40,66,68,73,85,86}. For example, a study of 192 psychiatric service centers in Catalonia, Spain, found that only 27.5% provided information briefings on how to implement smoke-free policies, and only 37.9% had ‘smoking intervention training’ available to staff⁸⁵. Thus, training for stakeholders tasked with implementation of smoke-free policies can potentially increase the success of smoke-free policies.

Access to resources

Access to adequate resources, including financial, technical, and legal resources, was a key policy development and implementation factor identified in the literature, with the lack of resources identified as a barrier to successful policy implementation^{25,32-34,51,52,76}. The need for financial resources to aid policy implementation was most frequently identified in LMICs³⁷. Limited access to information, including smoking prevalence data, was a related constraint identified²⁵. One study found that the lack of reliable and complete data on smoking prevalence information in Sub-Saharan African countries was a limiting factor for policy development; such data could be an important agenda-setting driver, providing evidence of smoking as a problem needing to be addressed²⁵. Support from non-governmental organizations (NGOs) can mitigate resource constraints through grants, training, and technical support. For example, in Latin America, the Pan American Health Organization (PAHO) launched the Smoke-Free Americas Initiative in 2001, organized training workshops for tobacco control advocates and decision-makers, and provided seed grants to support smoke-free campaigns³². Grants from universities, NGOs and government agencies (e.g. Johns Hopkins University, Canadian International Development Research Center) also supported implementation of the FCTC and trained researchers throughout Latin America³². In December 2020, South America became the first subregion in the Americas to have 100% smoke-free environments in line with Article 8 of the FCTC⁸⁷. Additionally, earmarked tobacco taxes (e.g. from cigarette taxes) could be used to fund tobacco control efforts such as smoke-free policies⁶⁴. One study suggested that ‘user fees’ on the tobacco industry could also provide funding to support tobacco control efforts⁶⁴.

Policy compliance and enforcement

Following successful implementation of a smoke-free policy, challenges may remain for reaching full compliance^21,67,82,88. This study identified 78 studies that discussed compliance with smoke-free policies and 75 studies that discussed enforcement. Key factors identified in the literature as inhibiting smoke-free policy compliance include: a lack of awareness and training among stakeholders, limited government involvement in policy implementation and enforcement, lack of resources, negative attitudes and perceptions of smoke-free policies, and social and cultural norms^{21,44,46,59,81,89-92}. To combat these challenges, studies recommend educational efforts, stakeholder involvement, and taking action to address social norms^{27,74,78,81,93-99}.

Awareness of smoke-free policies and dangers of SHS

Limited awareness of smoke-free policies, including where smoking is prohibited, as well as the dangers of tobacco use and SHS, is a key barrier to policy compliance and enforcement^{27,31,47,50,100,101}. Several studies found that the required ‘no-smoking’ signage was often absent in places where smoking is prohibited, potentially contributing to a lack of awareness of smoke-free policies in these settings^{27,74,102-104}. For example, an observational study conducted in Pakistan reported the presence of no-smoking signage at the main entrance and inside for only 6% and 10% of places, respectively¹⁰³. Additionally, one study in Thailand suggested that there was limited awareness of the dangers of SHS among the public²⁷. Several studies recommend clear communication and educational efforts to improve knowledge about the dangers of SHS and to increase awareness of the smoke-free policies and of the penalties for non-compliance^{27,48,55,63,68,72-74,81,82,94,97,102,104-107}. These efforts can include educational campaigns through various media channels, peer education, and no-smoking signage specifying penalties for non-compliance^{27,48,55,63,68,72-74,81,82,94,97,102,104-107}. For example, representatives from civil society organizations in Uganda suggested communicating specific policy details (e.g. distance of buffer around smoke-free places, specific penalties, signage requirements, inclusion of shisha use in the smoke-free policy), roles and responsibilities of venue staff, and the health risks of smoking⁸². Stakeholders also emphasized the need to translate educational materials into local languages and to use multiple communications channels (e.g. radio, in-person meetings) to reach people with lower levels of literacy⁸². Comprehensive education programs surrounding the dangers of tobacco use is an approach found to improve compliance among schools in rural India⁷². However, one study of campus smoke-free policies in Sudan found that most university students who smoked cigarettes or hookah, or who dipped tombac, were aware of their school’s smoke-free policies⁹², and Wynne et al.⁷⁴ described a study from Greece suggesting that the presence of ‘no-smoking’ signage did not impact levels of SHS in some locations. These findings suggest that awareness is an important step but is insufficient on its own to improve compliance with smoke-free policies.

Stakeholder training

In addition to limited knowledge about smoke-free policies and the dangers of SHS, several studies cited a lack of training for stakeholders responsible for policy enforcement (e.g. law enforcement, hospital staff) as a barrier to enforcing smoke-free policies^21,27,44,108. For example, one study of middle managers in a private company in Denmark found that, while middle managers supported smoke-free policies, they did not feel they were responsible for ‘regulating other peoples’ actions’ and did not feel adequately prepared to address violations and discuss smoking cessation with their employees¹⁰⁸. Thus, training for enforcement stakeholders that discusses the extent of their roles and responsibilities, protocol for responding to violations, and (in healthcare settings) providing smoking cessation services, can potentially increase compliance^{27,44,66,68,73,74,95,108,109}.

Attitudes, beliefs, and perceptions about smoke-free policies

Stakeholders’ attitudes, beliefs and perceptions about smoke-free policies and their outcomes can significantly impact the success of smoke-free policy compliance and enforcement. Among businesses and institutions, perceptions of public support or opposition to smoke-free policies may contribute to willingness or hesitancy to comply with smoke-free policies⁸⁴. These attitudes, beliefs, and perceptions can lead to a lack of organizational, administrative, and managerial buy-in and support, which can be a barrier to compliance and enforcement of smoke-free policies^{16,50,66,73,84,110}. One study found that those charged with implementing smoke-free policies for bars and gaming venues in Australia significantly underestimated community support for smoke-free policies, suggesting that demonstrated community support could aid compliance and enforcement⁸⁴. Additionally, the misperception that smoke-free laws will negatively impact businesses, particularly the hospitality industry and bars, can be a barrier to enforcing smoke-free policies, suggesting there is a need to address these misperceptions through educational efforts^47,82,84.

Several studies also found that some institutions, businesses, or stakeholders do not enforce smoke-free policies because it is a low priority amid competing needs and interests^{39,44,52,53,73,110,111}. For example, police at public universities in California stated that enforcing tobacco-free policies on campus was not a priority because they ‘have real crimes [such as armed robbery] to investigate’⁴⁴. Resource constraints, including limited money, time, and personnel, may further exacerbate this issue and contribute to low prioritization of enforcing smoke-free policies^{29,33,37,39,44,50,72,89,104,110-113}. For example, a study conducted in schools across multiple European cities found that teachers and principals, who already face time constraints and have competing priorities, may be unable or unwilling to accept additional responsibilities related to enforcing smoke-free school policies³⁹.

Additionally, some enforcement stakeholders believed that enforcing smoke-free policies would interfere with more important goals and values^70,111. For example, school principals in Sweden expressed concern that punishing students (e.g. especially through suspension or expulsion) for violating their schools’ smoke-free policies would interfere with the more important goal of students staying in school and learning¹¹¹. In mental healthcare settings, some staff and management were opposed to smoke-free policies because they were concerned that such polices would take away more freedoms from patients whose freedom of choice is already being restricted⁷⁰. Staff and management were also concerned that focusing on smoking cessation would detract from addressing patients’ primary mental health concerns⁷⁰. In settings where current enforcement mechanisms conflict with these other goals, stakeholders can consider adopting different strategies to improve compliance, such as initiating dialogue and counselling instead of more punitive measures¹¹¹. Furthermore, communication and education efforts should emphasize that smoke-free policies promote the well-being of those impacted by these policies. For example, to address stakeholders’ beliefs about patients’ right to smoke, communication efforts can emphasize patients’ right to a safe and health-promoting environment (i.e. as patients in other healthcare settings receive) and discuss how smoke-free policies work to reduce existing health disparities that impact people with severe mental illness by reducing premature mortality in this population⁷⁰.

Government involvement

Achieving high levels of policy compliance is challenging without clear, specific guidance from national, state/provincial, and local governments^{21,44,74,81,82,91,112}. For example, local governments in California, tasked with enforcing the state’s smoke-free law, were only provided with a penalty schedule for violations (i.e. a $100 maximum fine for a first violation) and were not given specific frameworks or mechanisms for enforcing smoke-free policies¹¹². Local governments were given discretion to determine who was tasked with enforcing the smoke-free policies, stating only that the policy ‘was to be enforced by local law enforcement agencies, including, but not limited to, local health departments’¹¹². Additionally, local administrative structures were described as ‘administrative maze[s]’, leading to a lack of clarity regarding roles and responsibilities and inconsistent enforcement¹¹². Several articles highlighted the need for legislation to incorporate a formal enforcement mechanism with clear guidelines on enforcement recommendations and expectations^44,74,82. Additionally, some studies highlighted a lack of funding from state or national governments for carrying out enforcement tasks as a barrier to enforcing smoke-free policies^27,112. Limited legal infrastructure in certain countries poses an additional enforcement challenge⁶³.

Norms

Another barrier to policy compliance and policy enforcement found in the literature is the issue of ingrained social norms and the need to develop tailored, culturally appropriate tobacco policy to specific jurisdictions and settings^{16,27,29,48,66,68,73,79,89,90,101,114,115}. These norms can include a persistent ‘smoking culture’ in certain settings, such as bars or psychiatric units, as well as other social norms, such as cigarette sharing or gifting (a common social practice in China) and avoiding interpersonal conflict, which can be barriers to compliance and enforcement^{66-68,73,79,101,114,115}. Such norms, combined with a lack of managerial support and a norm supporting the social acceptability of smoking, make it difficult for smoke-free policies to be accepted and enforced in many settings^22,67,83,116. For example, some bar and club patrons and owners may suggest that smoking is an integral part of the experience in these venues, and this belief poses barriers to implementing and enforcing smoke-free policies in these settings^114,115. The literature discusses several potential strategies for addressing these social norms^{27,44,48,81,102}. These strategies include communication and education campaigns that aim to decrease the acceptability of tobacco use and promote a tobacco-free lifestyle^44,48,81. Communication efforts can include messaging that extends accepted non-smoking scenarios, such as the idea that ‘exposing adults to toxic smoke is no more appropriate than exposing children to it’⁴⁸. Other studies suggest removing smoking-cues, such as ashtrays or cigarette butts, which may indirectly communicate the social acceptability of smoking in venues^48,75,102. In settings where stakeholders are reluctant to engage in confrontation to address violations of smoke-free policies, one study suggested reframing enforcement efforts as ‘teachable moments’, rather than viewing these efforts as confrontational²⁷.

Community engagement

In addition to formal enforcement mechanisms (e.g. police enforcing smoke-free policies), some studies discussed engaging community members to improve compliance and to aid enforcement efforts^{27,43,44,55,75}. For example, the Beijing Tobacco Control Association launched ‘The Complaint Map’, in which users could report violations of smoke-free policies via WeChat and recruited tobacco control volunteers to help respond to violations of smoke-free policies⁷⁵. Location services were used to generate a map of violations to identify where and when violations most frequently occur, allowing for more targeted and efficient enforcement⁷⁵. Participatory processes for developing enforcement mechanisms, which involve stakeholders most impacted by smoke-free policies (e.g. business owners and patrons), can potentially improve support for smoke-free policies and improve compliance⁷⁹. For example, key informants from traditional villages in Denpasar, Bali, suggested developing smoke-free policies through Pararem (‘local wisdom or local policy … generated through community meeting and agreement’ that include ‘social sanctions’) to improve buy-in and compliance among indigenous Balinese people who are members of the desa adat (traditional village system)⁷⁹.

Strengths and limitations

This review provides an overview of what is reported in the current literature related to smoke-free policies, including their development, implementation, enforcement, and compliance in each World Bank income strata and WHO region of the world. The study provides examples of key factors related to smoke-free policy development, implementation, enforcement, and compliance in different types of environments. This review also includes evidence from academic as well as gray literature and used consensus-based inclusion criteria.

Although this study used relevant databases and gray literature to produce a comprehensive literature search, only English articles were included in this study and only two databases were utilized in the search strategy. Therefore, it is possible that some literature may have been unintentionally excluded. Additionally, this study, building on previous work by Byron et al.⁸, excluded the 168 studies covered in that review, which reported findings from LMICs. Therefore, it is possible that the current study disproportionately reports findings from HICs. Despite these limitations, the results of this review provide useful insights to support international jurisdictions seeking to create 100% smoke-free environments through effective smoke-free policies.

This study followed the principles of a narrative review and excluded steps taken in other review processes such as conducting a risk of bias assessment and using a PICO framework for data extraction. However, a narrative review design allowed the research team to conduct a comprehensive overview of the global evidence on smoke-free policies given the large number of included articles and time-constraints of producing an up-to-date review. Moreover, this approach allowed the research team to answer a research question with wider parameters and put forward a more nuanced understanding of the complexities surrounding global smoke-free policies.