RESEARCH PAPER
Support for regulating smoking in private and public places by adults who currently smoke and recently quit smoking in Spain
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1
Tobacco Control Unit,
Catalan Institute of Oncology,
WHO Collaborating Centre for
Tobacco Control, L’Hospitalet
de Llobregat, Barcelona, Spain
2
Tobacco Control Research
Group, Bellvitge Biomedical
Research Institute,
L’Hospitalet de Llobregat,
Barcelona, Spain
3
Department of Public
Health, Mental Health, and
Maternal and Child Health
Nursing, Faculty of Nursing,
University of Barcelona,
Barcelona, Spain
4
Centro de Investigación
Biomédica en Red de
Enfermedades Respiratorias,
Instituto de Salud Carlos III,
Madrid, España
5
Department of Clinical
Sciences, Faculty of Medicine
and Health Sciences,
University of Barcelona,
Barcelona, Spain
6
Department of Preventive
Medicine and Public Health,
University of Santiago de
Compostela, Santiago de
Compostela, Spain
7
Centro de Investigación
Biomédica en Red de
Epidemiología y Salud
Pública, Instituto de Salud
Carlos III, Madrid, España
8
Department of Psychology,
University of Waterloo,
Waterloo, Canada
9
School of Public Health
Sciences, University of
Waterloo, Waterloo, Canada
10
School of Medicine,
University of Crete, Heraklion,
Greece
11
European Network for
Smoking and Tobacco
Prevention, Brussels, Belgium
12
Department of Oral Health
Policy and Epidemiology, Harvard School of Dental
Medicine, Harvard University,
Boston, United States
13
Ontario Institute for
Cancer Research, Toronto,
Canada
Submission date: 2024-06-10
Final revision date: 2024-07-30
Acceptance date: 2024-08-02
Publication date: 2024-08-31
Corresponding author
Marcela Fu
Tobacco Control
Unit, Catalan Institute of
Oncology, WHO Collaborating
Centre for Tobacco Control,
Av. Granvia de L’Hospitalet,
199-203, 08908 L’Hospitalet
de Llobregat, Barcelona,
Spain
Tob. Induc. Dis. 2024;22(August):149
KEYWORDS
TOPICS
ABSTRACT
Introduction:
While indoor smoking restrictions are common, outdoor restrictions
are still rare. We explored opinions and support for regulating smoking in
different indoor and outdoor environments among adults who smoke and those
who recently quit smoking, in Spain.
Methods:
The 2021 ITC EUREST-PLUS Spain Survey is a cross-sectional study
conducted among a nationally representative sample of 1006 adults aged ≥18
years who smoked cigarettes (n=867) or had recently quit smoking (n=139).
Using Poisson regression with robust variance, we estimated adjusted prevalence
and prevalence ratios of favorable opinions on regulating smoking in different
indoor and outdoor environments and support for regulation in unregulated
outdoor environments, by sociodemographic and smoking-related characteristics.
Results:
There were highly favorable opinions for regulating smoking in places
with minors (>95% in primary and secondary playgrounds, and cars with preschool
children and minors) and outdoor transportation (60–80%). There were
less favorable opinions for regulating smoking in outdoor terraces of bars/pubs
and restaurants (15–20%). Support for further total outdoor regulations on
smoking was moderate for markets/shopping centers, public building entrances
and swimming pools (40–60%), and low for restaurants/bars/pubs (29.2%).
Having quit smoking, having no significant others who smoke and/or believing
that cigarette smoke is harmful to others, were factors positively associated with
favorable opinions and support for regulating smoking.
Conclusions:
The settings in Spain with the most favorable opinions for regulation
among adults who smoke and have recently quit smoking are places with minors,
private cars with others and outdoor areas of public transportation, while the
settings with the least favorable opinions were outdoor terraces of bars, pubs,
and restaurants. Support for further total outdoor smoking bans is generally
moderate, but low for restaurants, bars, and pubs. Overall, these findings suggest
the feasibility of extending smoke-free policies to other public and private settings
to protect others from tobacco smoke exposure.
INTRODUCTION
Exposure to secondhand smoke (SHS) is a recognized health hazard1. To address this preventable health risk, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) proposed comprehensive measures, including smoke-free policies2. These policies have been implemented in many countries with varying degrees of success. According to the Tobacco Control Scale, 75% of the 37 European countries assessed in 2021 scored >50% of the 22 available points for policies on bans/restrictions on smoking in workplaces, public places and private cars, but only 32% of the countries scored >90% of the points3. As only total bans comply with Article 8 of the WHO FCTC, further progress is needed to protect people from SHS exposure1.
Understanding the public’s views on smoking restrictions in public and private places is crucial to assessing their acceptability and future compliance, especially among those who smoke, who are directly affected by such restrictions. In this context, the International Tobacco Control Policy Evaluation (ITC) Project has been conducting prospective cohort studies in several countries since 2002 to assess the impact of the WHO FCTC on smoking behavior and attitudes4. In 2016, the EUREST-PLUS ITC 6 European Countries Survey included a cohort of adults who smoke from six European countries, including Spain5. This cohort was followed up in the six countries in 2018 and only in Spain in 20216. Data from this latest survey provide the most up-to-date information available in Spain to assess opinions and attitudes towards regulating smoking in different settings, in the context of new regulations that have not yet been implemented as of June 20247. The current Law 42/2010 represents a major step forward in the promotion of smoke-free environments, extending the partial regulations of the previous Law 28/2005 to all indoor public places without exception and introducing for the first time some restrictions in outdoor areas of healthcare centers, educational centers for minors, and playgrounds and recreational areas for children8. The Spanish health authorities are planning to extend the current smoke-free environments to other indoor and outdoor areas that have not yet been defined7.
Given this national scenario, we explored opinions and support for smoke-free policies in public and private settings, including some not covered by current legislation, among adults who smoke and those who recently quit smoking, in Spain.
METHODS
Study design
This is a cross-sectional study based on the 2021 ITC EUREST-PLUS Spain Survey, which is a follow-up survey of a nationally representative sample of adults aged ≥18 years who smoked at the time of recruitment in 2016 (Wave 1). Respondents were recontacted in 2018 (Wave 2) and 2021 (Wave 3). This analysis uses cross-sectional data from Wave 3. The original sample was randomly selected using a multistage design within geographical strata. Respondents interviewed in 2018 who agreed to be recontacted in the future were invited to participate in 2021. Respondents lost to follow-up were replaced with new participants selected from newly screened households using the same sampling frame. The final sample consisted of 1006 respondents who smoked or had quit smoking and provided valid information; 56.7% had been interviewed in the previous two waves. Further details of the methods can be found elsewhere6. The survey received ethical approval from the Research Ethics Boards of the Bellvitge University Hospital, Spain (PR248/17) and the University of Waterloo, Canada (REB#41105). All participants gave consent for participation.
Measures
We asked participants for their opinions on smoke-free regulations in various indoor/outdoor places, some already regulated and some unregulated, and their support for total outdoor bans, most of which are not regulated by current law (Table 1).
Table 1
Regulation on smoking in different settings at national level in Spain at the time of the survey (2021)
Setting | Regulation |
---|
Schoolyards of primary and secondary schools | Banned |
Children’s playgrounds | Banned |
Outdoor campuses of health care centers | Banned |
Terraces of bars, pubs, and restaurants | Partially banned |
Public transport vehicles | Banned |
Vehicles for commercial and service transport | Banned |
Private vehicles | Unregulated |
Outdoor areas of public transport, including stops | Unregulated |
Entrances to public buildings | Unregulated |
University campuses | Unregulated |
Open sports facilities | Unregulated |
Markets and shopping centers | Unregulated |
Public urban parks | Unregulated |
National parks | Unregulated |
Beaches | Unregulated |
Swimming pools | Unregulated |
Opinions on smoke-free regulations in indoor/outdoor places
These were assessed by asking: ‘At which of the following places do you think smoking should be allowed?’. Settings assessed were schoolyards of primary and secondary schools, outdoor terraces of of bars/pubs and restaurants, outdoor bus stops and subway/train stations, private cars (with pre-school children, with children aged <16 years, with others who do not smoke), within 5 m of public building entrances, beaches, and open stadiums for events. The response options were ‘yes’ or ‘no’. We describe ‘no’ responses as reflecting a favorable opinion on smoke-free regulation in a specific place. ‘Refused’ and ‘Don't know’ (RDK) responses were excluded (0.0–3.4% of responses) (Supplementary file Table S1).
Support for further total outdoor smoking bans
This was measured by the question: ‘Do you support or oppose a complete smoking ban in outdoor areas of the following places?’. Settings assessed were terraces of restaurants/bars/pubs, public buildings including entrances, markets/shopping centers, and swimming pools. The response options were ‘strongly support’, ‘support’, ‘oppose’, ‘strongly oppose’, recoded as support/oppose. We describe ‘support’ to reflect support for further outdoor smoking bans. RDK responses were excluded (2.0–4.4% of responses) (Supplementary file Table S1).
Sociodemographic characteristics
These were sex (male, female), age (<25, 25–39, 40–54, ≥55 years), education level (low: up to lower secondary education; medium: upper secondary to short-cycle tertiary education; high: completed university education), living with children aged <18 (yes/no), significant others who smoke [assuming that having a partner who smokes is more relevant than having friends who smoke, we categorized this variable as ‘a partner who smokes’ (regardless of having friends who smoke), ‘friends but not a partner who smokes’, and ‘no significant others who smoke’].
Smoking-related characteristics
These were smoking status (current smoking: having smoked ≥100 cigarettes in lifetime and currently smoking cigarettes at least less than monthly; former smoking: having quit since the two previous surveys)9; nicotine dependence, assessed with the Heaviness of Smoking Index10 (categorized as low: 0–2 points, moderate: 3–4 points, high: 5–6 points; for former smoking the score was 0); and having tried to quit in the last 18 months (yes/no).
Belief about the harmfulness of SHS to others
This was assessed with the statement: ‘Cigarette smoke is dangerous to non-smokers’. The response options were ‘strongly agree’, ‘agree’, ‘neither agree nor disagree’, ‘disagree’, ‘strongly disagree’, which were recoded as ‘agree’, ‘neither agree nor disagree’, ‘disagree’. RDK responses were excluded (1.3%) (Supplementary file Table S1).
Analysis
We estimate the prevalence (with 95% confidence interval, CI) of favorable opinions on smoke-free regulations in different places and support for further outdoor smoking bans, stratifying by the independent variables. We used Poisson regression models with robust variance to estimate prevalence ratios (PR) and 95% CI for comparing opinions on smoke-free regulation and support for further outdoor smoking bans by all independent variables, adjusting for age, sex, and education level. All tests were two-tailed and statistical significance was set at p<0.05. All analyses used bootstrap replicate weights derived from the complex sampling design. We used Stata® v.14 (Texas, USA) for all analyses.
RESULTS
Opinions on smoke-free regulation in indoor/outdoor places
Tables 2 and 3 show the prevalence of favorable opinions on smoke-free regulations in different settings. Among adults who smoke or recently quit, most think that smoking should not be allowed in schoolyards of primary (98.0%; 95% CI: 96.9–99.1) and secondary schools (97.4%; 95% CI: 96.2–98.6) (Table 2), with no differences according to the independent variables. High versus low nicotine dependence, and not believing versus believing that SHS is harmful to others were factors positively associated with this opinion in these settings (Figure 1) (and Supplementary file Table S2).
Table 2
Prevalencea of favorable opinions on smoke-free regulation in outdoor places with different regulation among a nationally representative sample of adults who smoke and recently quit smoking, ITC EUREST-PLUS Spain Survey, Spain, 2021 (N=1006)
Characteristics | Total | Schoolyards of primary schools | Schoolyards of secondary schools | Open terraces of bars/pubs | Open terraces of restaurants | Bus stops | Subway and train stations |
---|
n | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) |
---|
Total | 1006 | 98.0 (96.9–99.1) | 97.4 (96.2–98.6) | 15.2 (12.4–17.9) | 18.4 (14.8–21.9) | 62.3 (57.9–66.7) | 78.3 (75.0–81.7) |
Sociodemographic characteristics | | | | | | | |
Sex | | | | | | | |
Male | 542 | 97.4 (95.9–98.9) | 97.3 (95.8–98.8) | 13.9 (10.5–17.2) | 16.8 (13.2–20.5) | 64.5 (59.2–69.8) | 79.3 (75.3–83.2) |
Female | 464 | 98.7 (97.6–99.7) | 97.6 (96.1–99.0) | 16.5 (12.6–20.4) | 20.0 (15.1–24.8) | 60.1 (54.9–65.3) | 77.4 (73.1–81.7) |
Age (years) | | | | | | | |
<25 | 68 | 97.60 (94.3–100) | 97.1 (93.7–100) | 16.7 (7.2–26.3) | 26.2 (14.3–38.1) | 49.3 (35.5–63.2) | 76.3 (64.2–88.4) |
25–39 | 272 | 98.0 (96.1–99.9) | 98.2 (96.4–100) | 15.1 (10.6–19.5) | 15.1 (10.6–19.6) | 63.1 (55.9–70.2) | 79.9 (74.8–84.9) |
40–54 | 360 | 99.1 (98.3–99.8) | 97.7 (96.1–99.2) | 12.9 (8.3–17.5) | 15.8 (10.6–20.9) | 63.6 (57.0–70.2) | 78.2 (73.4–82.9) |
≥55 | 306 | 97.2 (94.8–99.7) | 96.8 (94.2–99.4) | 16.9 (12.9–20.9) | 21.3 (15.5–27.2) | 63.4 (56.9–69.9) | 77.8 (72.5–83.2) |
Education level | | | | | | | |
Low | 506 | 98.6 (97.7–99.6) | 97.9 (96.6–99.3) | 13.5 (10.6–16.5) | 16.7 (12.5–21.0) | 59.3 (54.0–64.6) | 73.7 (69.0–78.5) |
Medium | 391 | 98.2 (96.8–99.5) | 98.0 (96.7–99.4) | 16.4 (12.0–20.7) | 20.3 (14.2–26.5) | 63.8 (57.6–70.0) | 83.3 (79.0–87.7) |
High | 109 | 94.5 (87.5–100) | 93.0 (85.8–100) | 18.9 (8.5–29.2) | 19.4 (9.2–29.7) | 72.0 (60.5–83.5) | 83.0 (72.5–93.5) |
Children aged <18 years | | | | | | | |
Yes | 331 | 99.4 (98.7–100) | 99.1 (98.2–99.9) | 13.0 (8.8–17.2) | 16.0 (10.9–21.1) | 62.0 (56.1–67.9) | 79.0 (74.6–83.4) |
No | 675 | 97.4 (95.8–98.9) | 96.7 (95.0–98.4) | 16.2 (12.8–19.5) | 19.5 (15.4–23.6) | 62.5 (57.5–67.5) | 78.0 (74.1–82.0) |
Significant others who smoke | | | | | | | |
Partner | 287 | 96.0 (92.7–99.2) | 95.6 (92.3–99.0) | 10.9 (7.0–14.9) | 12.2 (7.5–16.9) | 58.7 (50.5–67.0) | 74.8 (69.2–80.5) |
Friends, but not the partner | 620 | 98.7 (97.8–99.6) | 98.0 (96.9–99.1) | 15.9 (12.3–19.4) | 20.1 (15.5–24.7) | 62.1 (57.2–67.0) | 78.6 (74.5–82.7) |
Neither | 98 | 100 (-) | 99.5 (98.6–100) | 24.0 (15.1–32.9) | 26.6 (17.7–35.5) | 75.6 (66.3–84.9) | 88.5 (81.7–95.3) |
Smoking characteristics | | | | | | | |
Smoking status | | | | | | | |
Current | 867 | 97.9 (96.7–99.1) | 97.3 (96.0–98.6) | 12.9 (10.1–15.7) | 16.3 (12.8–19.9) | 59.9 (54.8–64.9) | 76.2 (72.5–80.0) |
Former | 139 | 98.5 (95.9–100) | 98.2 (95.6–100) | 27.8 (19.2–36.5) | 30.0 (21.5–38.5) | 76.2 (68.9–83.4) | 90.2 (85.0–95.5) |
Nicotine dependence | | | | | | | |
Low | 450 | 98.2 (97.0–99.3) | 97.5 (96.0–99.1) | 15.6 (11.8–19.4) | 19.4 (14.5–24.3) | 65.9 (60.0–71.9) | 81.2 (76.8–85.6) |
Moderate | 338 | 98.5 (97.4–99.7) | 97.8 (96.2–99.3) | 10.7 (7.1–14.3) | 14.2 (8.0–20.3) | 52.3 (46.0–58.6) | 72.4 (66.2–78.5) |
High | 39 | 100 (-) | 100 (-) | 7.0 (0–14.4) | 9.6 (1.1–18.1) | 46.0 (31.0–61.1) | 57.0 (41.5–72.4) |
Quit attempts (last 18 months) | | | | | | | |
Yes | 132 | 95.9 (90.5–100) | 95.3 (89.8–100) | 18.5 (11.9–25.2) | 23.3 (16.8–29.9) | 63.8 (55.1–72.5) | 75.1 (66.5–83.7) |
No | 735 | 98.3 (97.4–99.2) | 97.7 (96.6–98.8) | 11.9 (9.10–14.7) | 15.1 (11.3–18.8) | 59.2 (53.9–64.5) | 76.5 (72.6–80.3) |
Belief about the harmfulness of SHS to others | | | | | | | |
Agree | 833 | 98.1 (96.8–99.3) | 97.4 (96.0–98.7) | 16.8 (13.5–20.2) | 19.5 (15.8–23.3) | 66.7 (62.5–70.9) | 80.7 (77.2–84.1) |
Neither agree nor disagree | 121 | 96.8 (93.0–100) | 96.8 (92.9–100) | 5.5 (1.4–9.5) | 13.3 (2.9–23.8) | 39.7 (28.1–51.3) | 62.9 (53.5–72.3) |
Disagree | 39 | 100 (-) | 100 (-) | 9.9 (0–20.6) | 12.1 (0.8–23.4) | 44.6 (28.9–60.2) | 71.7 (56.7–86.8) |
Table 3
Prevalencea of favorable opinions on smoke-free regulation in outdoor places currently not regulated by law among a nationally representative sample of adults who smoke and recently quit smoking, ITC EUREST-PLUS Spain Survey, Spain, 2021 (N=1006)
Characteristics | Total | Private cars with preschool children | Private cars with children aged <16 years | Private cars with others who do not smoke | Public building entrances | Beaches | Open stadiums |
---|
n | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) |
---|
Total | 1006 | 97.5 (96.4–98.7) | 96.9 (95.7–98.1) | 87.8 (84.5–91.1) | 35.9 (31.1–40.7) | 28.9 (24.7–33.0) | 59.6 (54.8–64.3) |
Sociodemographic characteristics | | | | | | | |
Sex | | | | | | | |
Male | 542 | 97.2 (95.7–98.8) | 97.2 (95.7–98.6) | 86.4 (82.0–90.8) | 36.7 (31.2–42.1) | 30.2 (24.7–35.6) | 56.7 (51.0–62.4) |
Female | 464 | 97.9 (96.7–99.0) | 96.7 (95.0–98.3) | 89.2 (85.8–92.6) | 35.1 (29.7–40.5) | 27.5 (22.8–32.2) | 62.6 (57.1–68.1) |
Age (years) | | | | | | | |
<25 | 68 | 96.1 (92.4–99.8) | 96.7 (93.2–100) | 85.3 (76.6–94.0) | 34.7 (20.2–49.2) | 21.3 (11.7–30.9) | 52.3 (38.5–66.1) |
25–39 | 272 | 97.1 (95.0–99.3) | 96.3 (93.5–99.1) | 86.3 (81.0–91.7) | 38.6 (32.3–44.8) | 26.2 (20.9–31.6) | 60.0 (52.8–67.3) |
40–54 | 360 | 99.0 (98.2–99.8) | 97.3 (95.8–98.9) | 85.3 (80.4–90.2) | 34.0 (27.5–40.4) | 28.8 (22.9–34.7) | 60.4 (54.2–66.6) |
≥55 | 306 | 97.0 (94.6–99.3) | 97.1 (94.7–99.4) | 91.4 (87.5–95.3) | 35.9 (29.0–42.8) | 32.5 (26.0–39.1) | 60.1 (52.4–67.8) |
Education level | | | | | | | |
Low | 506 | 98.2 (97.1–99.2) | 97.3 (95.9–98.7) | 89.3 (85.7–92.9) | 32.8 (27.2–38.5) | 25.4 (20.5–30.3) | 56.0 (49.5–62.4) |
Medium | 391 | 98.0 (96.8–99.3) | 97.9 (96.5–99.3) | 86.4 (81.9–90.8) | 38.7 (32.9–44.5) | 31.8 (26.4–37.2) | 63.8 (57.5–70.2) |
High | 109 | 92.8 (85.8–99.8) | 91.8 (84.7–99.0) | 85.6 (75.1–96.0) | 41.1 (29.7–52.5) | 35.3 (23.7–46.9) | 61.4 (49.5–73.3) |
Children aged <18 years | | | | | | | |
Yes | 331 | 98.6 (97.6–99.7) | 97.4 (95.5–99.3) | 87.5 (83.0–91.9) | 31.9 (25.7–38.1) | 28.9 (23.2–34.6) | 62.4 (55.4–69.5) |
No | 675 | 97.0 (95.5–98.6) | 96.7 (95.1–98.3) | 88.0 (84.3–91.6) | 37.8 (32.5–43.0) | 28.9 (24.0–33.7) | 58.2 (52.8–63.5) |
Significant others who smoke | | | | | | | |
Partner | 287 | 96.5 (93.4–99.5) | 95.9 (92.7–99.1) | 86.1 (80.9–91.3) | 35.9 (28.7–43.2) | 20.0 (13.8–26.2) | 58.1 (49.7–66.5) |
Friends, but not the partner | 620 | 97.7 (96.5–98.9) | 97.0 (95.7–98.2) | 87.3 (83.3–91.3) | 34.4 (28.8–40.0) | 29.6 (24.3–34.9) | 58.0 (52.5–63.6) |
Neither | 98 | 100 (-) | 100 (-) | 96.7 (93.2–100) | 45.9 (35.7–56.2) | 52.6 (43.2–62.0) | 74.4 (65.8–83.0) |
Smoking characteristics | | | | | | | |
Smoking status | | | | | | | |
Current | 867 | 97.2 (96.0–98.5) | 96.5 (95.1–97.9) | 86.3 (82.5–90.1) | 33.3 (28.0–38.6) | 25.8 (20.9–30.6) | 58.3 (53.1–63.4) |
Former | 139 | 99.3 (97.9–100) | 99.2 (97.9–100) | 96.1 (93.3–98.9) | 50.6 (42.3–59.0) | 46.1 (37.6–54.6) | 66.8 (58.8–74.8) |
Nicotine dependence | | | | | | | |
Low | 450 | 97.5 (96.1–98.9) | 97.5 (96.1–98.9) | 89.2 (85.7–92.8) | 38.3 (32.1–44.5) | 28.2 (22.6–33.7) | 62.5 (56.3–68.6) |
Moderate | 338 | 97.9 (96.5–99.4) | 96.2 (94.2–98.2) | 83.8 (78.8–88.9) | 28.3 (21.9–34.7) | 21.9 (14.3–29.5) | 54.2 (47.2–61.3) |
High | 39 | 97.9 (94.2–100) | 96.9 (92.7–100) | 85.1 (74.7–95.5) | 23.4 (12.4–34.4) | 27.8 (13.1–42.5) | 40.9 (26.2–55.7) |
Quit attempts (last 18 months) | | | | | | | |
Yes | 132 | 94.1 (88.5–99.7) | 94.0 (88.4–99.7) | 82.8 (70.8–94.8) | 38.2 (29.4–47.1) | 26.9 (18.3–35.5) | 57.3 (48.0–66.5) |
No | 735 | 97.8 (96.7–98.9) | 97.0 (95.7–98.2) | 86.9 (83.3–90.6) | 32.4 (26.8–38.0) | 25.6 (20.5–30.7) | 58.5 (53.2–63.8) |
Belief about the harmfulness of SHS to others | | | | | | | |
Agree | 833 | 97.7 (96.4–98.9) | 97.4 (96.1–98.7) | 91.6 (88.7–94.5) | 38.8 (33.8–43.8) | 31.8 (27.1–36.6) | 62.7 (57.9–67.6) |
Neither agree nor disagree | 121 | 97.2 (93.4–100) | 94.8 (89.4–100) | 70.3 (61.3–79.3) | 24.6 (13.1–36.0) | 13.0 (6.7–19.3) | 47.0 (33.5–60.5) |
Disagree | 39 | 96.9 (91.7–100) | 94.0 (87.3–100) | 61.4 (44.3–78.6) | 17.5 (3.2–31.8) | 17.8 (6.4–29.2) | 41.9 (26.5–57.4) |
Figure 1
Factors associated with favorable opinions on smoke-free regulation in outdoor places with different regulation among a nationally representative sample of adults who smoke and recently quit smoking, ITC EUREST-PLUS Spain Survey, Spain, 2021 (N=1006)
![https://www.tobaccoinduceddiseases.org/f/fulltexts/191797/TID-22-149-g001_min.jpg](https://www.tobaccoinduceddiseases.org/f/fulltexts/191797/TID-22-149-g001_min.jpg)
A favorable opinion on smoke-free regulation was less prevalent for outdoor transportation (bus stops: 62.3%; 95% CI: 57.9–66.7; subways/train stations: 78.3%; 95% CI: 75.0–81.7) (Table 2). Those who formerly smoked, have low nicotine dependence, and believe that SHS is harmful to others are more likely to agree with smoke-free regulations in these settings. As shown in Figure 1, factors positively associated with this opinion were moderate/high (vs low) education level, not having significant others who smoke (vs having a partner who smokes) and former (vs current) smoking. In contrast, factors negatively associated were moderate/high nicotine dependence and neither agreeing nor disagreeing with the statement that SHS is harmful to others (Figure 1) (and Supplementary file Table S2).
Conversely, few adults who smoke or recently quit have favorable opinions on smoke-free regulation for outdoor terraces of bars/pubs (15.2%) and restaurants (18.4%); this is higher among those who have quit smoking (27.8% and 30.0%, respectively) (Table 2). Factors positively associated with this opinion were having no significant others who smoke, having previously smoked, and having recently tried to quit smoking (Figure 1) (and Supplementary file Table S2).
Another setting for which adults who smoke or recently quit are most in favor of smoking restrictions was in private cars with: pre-school children (97.5%; 95% CI: 96.4–98.7), children aged <16 years (96.9%; 95% CI: 95.7–98.1), and others who do not smoke (87.8%; 95% CI: 84.5–91.1) (Table 3). Favorable opinions about smoking restrictions in a car with others who do not smoke were more frequent among those without significant others who smoke, who had previously smoked, and believing that SHS is harmful to others (all >90%). Having no significant others who smoke and having previously smoked were more positively associated with support for such a regulation, whereas being aged 40–54 years (vs the oldest age group) and disagreeing and neither agreeing nor disagreeing that SHS is harmful to others were negatively associated with such support (Figure 2) (and Supplementary file Table S3).
Figure 2
Factors associated with favorable opinions on smoke-free regulation in outdoor places currently not regulated by law among a nationally representative sample of adults who smoke and recently quit smoking, ITC EUREST-PLUS Spain Survey, Spain, 2021 (N=1006)
![https://www.tobaccoinduceddiseases.org/f/fulltexts/191797/TID-22-149-g002_min.jpg](https://www.tobaccoinduceddiseases.org/f/fulltexts/191797/TID-22-149-g002_min.jpg)
Around 30–60% of adults who smoke or recently quit are in favor of smoke-free regulations on beaches, at public building entrances and in open-air stadiums, particularly those with no significant others who smoked, have previously smoked, and believe that others are adversely affected by SHS (Table 3). Factors positively associated with this opinion were moderate education level, the absence of a significant other who smokes, and having previously smoked. Conversely, moderate/high nicotine dependence and neither agreeing nor disagreeing with the statement that SHS is harmful to others were more negatively associated with this opinion (Figure 2) (and Supplementary file Table S3).
Support for further total outdoor smoking bans
Less than 60% of adults who smoke or recently quit support further complete smoking bans in outdoor environments (Table 4), including markets/shopping centers (57.2%; 95% CI: 51.7–62.6), public building entrances (50.9%; 95% CI: 46.2–55.5), and swimming pools (43.4%; 95% CI: 39.2–47.7). In this last setting, the highest levels of support come from older participants (48.9%; 95% CI: 42.5–55.3), with no significant others who smoke (62.9%; 95% CI: 52.5–73.3) and believing that SHS is harmful to others (46.5%; 95% CI: 41.8–51.3) (Table 4). Support for smoke-free swimming pools was positively associated with having no significant others who smoke and having previously smoked; negatively associated factors included being aged 25–39 years, moderate nicotine dependence, and not agreeing or disagreeing with the statement that SHS is harmful to others. Only moderate education level and having previously smoked were positively associated with support for public building entrances (Figure 3) (and Supplementary file Table S4).
Table 4
Prevalencea of support for further total outdoor smoking bans among a nationally representative sample of adults who smoke and recently quit smoking, ITC EUREST-PLUS Spain Survey, Spain, 2021 (N=1006)
Characteristics | Total | Restaurants, bars, and pubs | Public buildings, including entrances | Markets and shopping centers | Swimming pools |
---|
n | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) |
---|
Total | 1006 | 29.2 (24.9–33.6) | 50.9 (46.2–55.5) | 57.2 (51.7–62.6) | 43.4 (39.2–47.7) |
Sociodemographic characteristics | | | | | |
Sex | | | | | |
Male | 542 | 29.3 (23.7–34.9) | 51.1 (45.7–56.5) | 57.9 (51.5–64.4) | 46.4 (41.0–51.9) |
Female | 464 | 29.2 (24.1–34.2) | 50.6 (45.2–56.0) | 56.4 (50.6–62.2) | 40.4 (35.3–45.4) |
Age (years) | | | | | |
<25 | 68 | 26.3 (14.9–37.8) | 44.1 (30.0–58.1) | 56.7 (41.4–72.1) | 35.7 (21.7–49.6) |
25–39 | 272 | 31.1 (24.5–37.6) | 51.0 (44.2–57.7) | 58.7 (51.3–66.2) | 36.8 (31.2–42.4) |
40–54 | 360 | 24.6 (17.9–31.3) | 51.6 (45.3–57.8) | 56.9 (49.6–64.1) | 44.6 (37.9–51.2) |
≥55 | 306 | 32.5 (26.6–38.4) | 51.7 (44.5–58.8) | 56.4 (48.7–64.1) | 48.9 (42.5–55.3) |
Education level | | | | | |
Low | 506 | 27.7 (22.9–32.6) | 47.1 (41.4–52.8) | 55.8 (49.4–62.1) | 43.8 (37.9–49.7) |
Medium | 391 | 29.1 (23.0–35.3) | 56.4 (50.3–62.4) | 59.6 (52.9–66.4) | 42.5 (36.5–48.5) |
High | 109 | 36.8 (25.9–47.8) | 49.5 (39.8–59.1) | 55.3 (44.3–66.4) | 45.0 (33.5–56.5) |
Children aged <18 years | | | | | |
Yes | 331 | 29.0 (21.5–36.5) | 53.8 (47.0–60.6) | 58.2 (51.0–65.4) | 43.3 (37.4–49.2) |
No | 675 | 29.4 (25.1–33.6) | 49.5 (44.5–54.5) | 56.7 (50.8–62.7) | 43.5 (38.6–48.4) |
Significant others who smoke | | | | | |
Partner | 287 | 29.8 (23.4–36.2) | 50.0 (42.7–57.3) | 51.1 (43.3–58.9) | 38.1 (30.6–45.6) |
Friends, but not the partner | 620 | 27.7 (22.8–32.7) | 50.3 (44.9–55.8) | 59.3 (52.9–65.7) | 43.1 (38.6–47.7) |
Neither | 98 | 37.2 (26.5–47.8) | 56.7 (46.3–67.1) | 62.2 (52.0–72.4) | 62.9 (52.5–73.3) |
Smoking characteristics | | | | | |
Smoking status | | | | | |
Current smoking | 867 | 27.1 (21.8–32.3) | 48.9 (43.7–54.0) | 55.7 (49.7–61.7) | 40.3 (35.3–45.2) |
Former smoking | 139 | 42.2 (24.7–59.8) | 61.7 (42.9–80.5) | 70.4 (55.2–85.7) | 46.5 (25.5–67.4) |
Nicotine dependence | | | | | |
Low | 450 | 28.4 (22.4–34.3) | 51.6 (45.6–57.6) | 58.3 (51.1–65.6) | 45.3 (38.8–51.7) |
Moderate | 338 | 26.7 (19.4–33.9) | 47.1 (39.4–54.8) | 54.1 (46.2–62.1) | 34.5 (28.2–40.7) |
High | 39 | 17.2 (5.3–29.1) | 33.8 (16.4–51.1) | 40.6 (24.5–56.7) | 31.6 (16.5–46.8) |
Quit attempts (last 18 months) | | | | | |
Yes | 132 | 32.5 (25.0–40.1) | 49.0 (39.9–58.2) | 58.2 (49.2–67.2) | 45.9 (38.3–53.5) |
No | 735 | 26.8 (21.3–32.3) | 49.5 (44.3–54.7) | 56.0 (49.8–62.2) | 39.6 (34.2–45.0) |
Belief about the harmfulness of SHS to others | | | | | |
Agree | 833 | 31.9 (27.0–36.9) | 53.0 (48.2–57.8) | 59.1 (53.6–64.6) | 46.5 (41.8–51.3) |
Neither agree nor disagree | 121 | 17.3 (9.1–25.6) | 42.4 (28.7–56.2) | 49.6 (34.5–64.7) | 28.2 (18.4–38.0) |
Disagree | 39 | 13.1 (3.5–22.6) | 37.6 (21.2–54.1) | 46.0 (30.3–61.7) | 32.5 (16.8–48.1) |
Figure 3
Factors associated with support for further total outdoor smoking bans among a nationally representative sample of adults who smoke and recently quit smoking, ITC EUREST-PLUS Spain Survey, Spain, 2021 (N=1006)
![https://www.tobaccoinduceddiseases.org/f/fulltexts/191797/TID-22-149-g003_min.jpg](https://www.tobaccoinduceddiseases.org/f/fulltexts/191797/TID-22-149-g003_min.jpg)
Restaurants/bars/pubs were found to have the lowest level of support for further total outdoor smoking bans (29.2%; 95% CI: 24.9–33.6) (Table 4). The only factor negatively associated with such support was disagreeing or neither agreeing nor disagreeing with the statement that SHS is harmful to others (Figure 3) (and Supplementary file Table S4).
DISCUSSION
Depending on the settings and the regulations in place, there were mixed opinions and support for smoke-free regulations by adults who smoke and recently quit smoking. Opinions on indoor/outdoor smoke-free regulation ranged from 98.0% for schoolyards of primary schools to 15.2% for outdoor bars/pub terraces, while support for further outdoor smoking bans ranged from 57.2% for markets/shopping centers to 29.2% for restaurants/bars/pubs. There are several possible explanations for this wide range of opinions and support.
Opinions on smoke-free regulation in indoor/outdoor places
Given that smoking is already banned in schoolyards of primary and secondary schools, and that these are places where minors are present, the opinion on smoke-free regulations in these settings is highly favorable. The same occurs for cars with minors, and slightly less for cars with adults who do not smoke, although private cars are not covered by the current legislation (Table 1). Compared to the 2016 survey, favorable opinions in these settings increased slightly since then (i.e. >90%)11. This may reflect the public’s awareness of the health effects of SHS exposure on vulnerable populations, such as children12. It may also be an indicator of their readiness to introduce regulations on smoking in private cars with vulnerable groups such as children and pregnant women, both circumstances in which smoking may be banned under further legislation, as in other European countries3. In some countries, the prevalence of voluntary smoke-free rules in private cars with children was as high as 65% in 2010–2011, consistent with the widely expressed support (>80%) for banning smoking in cars with children11,13.
Spanish tobacco Law 28/2005 regulated smoking on public transportation, but only indoors. Although moderate proportions of adults who smoke are in favor of not allowing smoking in outdoor areas, we observed important increases compared to opinions expressed in 2016, by 30 percentage points for bus stops and 15 percentage points for subway/train stations11, suggesting the feasibility of further regulation in these settings. Outdoor terraces of restaurants/bars/pubs receive, however, less favorable opinions. This was not surprising, because a weak regulation was initially established for the indoor areas of these venues, which was amended (by Law 42/2010) to a complete ban on smoking indoors and a partial ban outdoors, affecting those terraces with a roof and more than two walls or faces8,14. While favorable opinions increased from 3.4% to 15.2% for bar/pub terraces and from 4.2% to 18.4% for restaurant terraces between 2016 and 2021, they remain relatively low and consistent with observed low compliance15. This may be because people usually perceive SHS to dissipate quickly and the potential for exposure is low. However, there is evidence that SHS exposure can be as high as in indoor smoking areas16. Therefore, further regulation is expected to include these settings. The growing support for regulation of these settings in our study and others17, suggests that it can be implemented. In fact, smoking in these settings was already regulated during the COVID-19 pandemic in Spain18,19, based on WHO recommendations in response to the pandemic20, although this was a temporary measure.
Another setting where SHS exposure is typically underestimated is access to public buildings. Our data show that only 36% of adults who currently smoke or recently quit favor regulating smoking in this setting, but this prevalence is higher than that in 2016 (20.5%). Although some studies have demonstrated the potential for outdoor smoke to drift indoors16,21, smoking bans in building entrances are still rare, having been implemented in only a few jurisdictions22,23. The same is true for beaches and stadiums, although there is increasing favorable opinion on regulations in these settings24. In Spain, voluntary regulations for beaches are increasing25. In Barcelona, a city council intervention that included a smoking ban on beaches was well accepted and effective in reducing smoking and the visibility of people smoking26.
Support for further total outdoor smoking bans
Support for complete smoking bans in outdoor places is generally moderate (40–60% for public buildings entrances, markets/shopping centers, and swimming pools), which is consistent with evidence showing high support (69%) for smoke-free outdoor non-hospitality settings (playgrounds, streets, beaches), with no difference between countries with and without existing regulations27. However, total outdoor bans in restaurants/bars/pubs, which are partially regulated in Spain, had the lowest support, probably due to strong lobbying from the hospitality sector since the enactment of the Law 28/200528, which predicted negative economic consequences for the hospitality sector that never materialized29. Cultural reasons may also be linked to low support in these settings. The terraces are places where people socialize, so cultural changes are hard to achieve. Although low support in these settings among adults who smoke has also been found in other countries without regulation30,31, it increased after ban implementation32-34.
Our data indicate relevant factors associated with opinion and support for smoke-free outdoor environments, which are particularly strong among those who quit smoking, without significant others who smoke, and believing that SHS is harmful to others. These findings highlight the importance of promoting not only cessation but also educational campaigns focusing on the health effects of SHS exposure. In Spain, there are several local initiatives to ban smoking in outdoor settings, such as beaches, stadiums, and bus stops, with good acceptance25. It therefore seems feasible to include smoke-free outdoor areas in national legislation35. Nevertheless, it is crucial to raise awareness of SHS exposure in outdoor environments, especially on the terraces of restaurants, bars, and pubs, where exposure can be high15.
Strengths and limitations
The main strength of this research is its robust survey design, which allowed us to study a nationally representative sample of adults who smoke and recently quit smoking in Spain. The use of the same questionnaire as in previous surveys allowed us to assess the reliability of the results; the current survey included additional settings that will be useful to explore changes in opinion and support for further regulation in the near future, examining several socio-economic and smoking-related variables.
A limitation of this study is the cross-sectional nature of the analysis, which precludes any causal relationship between the variables examined. In addition, responses may be subject to information bias, although the results are consistent with the previous survey11, with higher favorable opinions and support for smoke-free policies in all settings. Also, we did not adjust the analyses for wave of recruitment to account for the number of times participants had previously responded to the survey, nor did we stratify for this variable to assess effect modification; therefore, we cannot disregard some overestimation of favorable opinions and support. Finally, although we used a common questionnaire used in other ITC surveys, our results are not necessarily generalizable to other countries.
CONCLUSIONS
Opinions and support in Spain for smoke-free regulations in different settings were heterogeneous among adults who smoke and those who recently quit smoking, depending on the setting assessed and the current regulation in place. Settings receiving the most favorable opinions to be regulated were places where minors are present, private cars with others, and outdoor areas of public transportation, while the least favorable opinions were expressed for outdoor terraces of bars, pubs, and restaurants. Support for further total outdoor smoking bans is generally moderate, but low for restaurants, bars, and pubs, which are partially regulated. Overall, these results suggest that smoke-free policies could be extended to other public and private settings to protect others from exposure to SHS. In Spain, legislation for smoke-free outdoor environments is on the horizon36, so there is a need for educational campaigns to raise awareness of SHS, especially in outdoor settings.
ACKNOWLEDGEMENTS
This project has received funding from the European Union’s Horizon
2020 research and innovation programme under the Marie Skłodowska-
Curie (grant agreement No 101008139). The authors of ICO-IDIBELL
thank the CERCA program of the Generalitat de Catalunya, for its
institutional support to IDIBELL.
CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for
disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the
current work. M. Fu, Y. Castellano, O. Tigova and E. Fernández report
that since the initial planning of the work, they received funding
for the conduct of the study from Instituto de Salud Carlos III (grant
PI17/01338, co-funded by European Regional Development Fund ERDF,
a way to build Europe) and support for the article processing charges
from the European Union’s Horizon 2020 research and innovation
programme under the Marie Skłodowska-Curie (grant agreement No
101008139). Furthermore, they report that in the past 36 months there
was support for the Tobacco Control Research Group of the Institut
d’Investigació Biomèdica de Bellvitge – IDIBELL from the Ministry of
Universities and Research, Government of Catalonia (2021SGR00906).
P. Driezen, S.C. Kaai., A.C.K. Quah, and G.T. Fong report that during
the initial planning of the work they were supported by the Canadian
Institutes of Health Research (FDN-148477) grant. C.I. Vardavas
reports that in the past 36 months he has been the journal’s strategic
development officer and that he was not involved in the peer review
or decision-making process of the manuscript. G.T. Fong reports that in
the past 36 months he received a Senior Investigator Award, Ontario
Institute for Cancer Research (IA-004) and that he has served as an
expert witness or consultant for governments defending their country’s
policies or regulations in litigation.
FUNDING
The EUREST-PLUS Spain Project is partially funded by the Instituto de
Salud Carlos III (grant PI17/01338, co-funded by European Regional
Development Fund ERDF, a way to build Europe) and the Canadian
Institutes of Health Research (Foundation grant FDN-148477). YC, EF,
MF and OT are partly supported by the Ministry of Universities and
Research, Government of Catalonia (2021SGR00906). Additional support
is provided by the Canadian Institutes of Health Research (FDN-148477)
to GTF, PD, SCK and ACKQ for the work on this manuscript. Additional
support to GTF is provided by a Senior Investigator Grant from the
Ontario Institute for Cancer Research. The funders had no role in the
design of the study; in the collection, analysis, or interpretation of the
data; in writing the manuscript; or in the decision to publish the results.
ETHICAL APPROVAL AND INFORMED CONSENT
Ethical approval was obtained from the Research Ethics Boards of the
Bellvitge University Hospital, Spain (Approval number: PR248/17; Date:
6 September 2018) and the University of Waterloo, Canada (Approval
number: REB#41105; Date: 10 December 2019). Participants provided
informed consent.
DATA AVAILABILITY
The data supporting this research are available from the authors on
reasonable request.
AUTHORS' CONTRIBUTIONS
Conceptualization: GTF, EF, MF, OT and CIV. Visualization: YC, EF, MF
and MPR. Investigation: SCK, ACKQ and CIV. Methodology: YC, PD,
GTF, EF, MF, MPR and ACKQ. Validation: YC, PD, GTF, SCK and ACKQ.
Formal analysis: YC, PD and EF. Data curation: PD, GTF, SCK and ACKQ.
Software: YC, ACKQ. Resources: GTF and ACKQ. Supervision: GTF, EF, MF,
SCK and ACKQ. Project administration: GTF, EF, MF, SCK, ACKQ and OT.
Funding acquisition: GTF, EF and MF. Writing of original draft: EF and
MF. Writing, reviewing and editing: all authors. All authors read and
approved the final version of the manuscript.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
DISCLAIMER
Geoffrey T. Fong, Editorial Board member, and Constantine I. Vardavas,
Development Editor, of the journal, had no involvement in the peerreview
or acceptance of this article and had no access to information
regarding its peer-review. Full responsibility for the editorial process for
this article was delegated to a handling editor of the journal.
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