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Brussels, 30.6.2009 
SEC(2009) 894 Part 1 
Accompanying document to the 
Proposal for a COUNCIL RECOMMENDATION on smoke-free environments 
{COM(2008) 328 final} 
{SEC(2008) 895} 
{SEC(2008) 896} 

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Other involved services: DG EMPL, DG ENV, DG INFSO, DG RTD, DG ESTAT, 
LS and SG 
Agenda planning or WP reference:    2008/SANCO/005 

1. Executive 

Procedural issues and consultation of interested parties 

Organisation and timing 

Consultation of experts and stakeholders 

Context and problem definition 
3.1.1.  Health burden of ETS exposure 
3.1.2.  Economic burden of ETS exposure 
obligations resulting from FCTC 
3.2.2.  High and uneven ETS prevalence across EU-27 
of children and young people 
Rationale for EU action 
3.3.1.  Legal basis and institutional setting 
4. Objectives 
5. Policy 
Assessing the options 
Advantages and disadvantages of different options 
Impacts of different options 
Comparing the options 
The preferred option 

6.5. Conclusions 
Monitoring and evaluation 
List of abbreviations 
9. Glossary 
10. Literature 
11. References 

This Impact Assessment considers the need for and potential impact of an EU 
initiative on smoke-free environments. The initiative would aim to assist Member 
States in implementing comprehensive smoke-free policies and thus help to comply 
with and go beyond Member States' and EC obligations under the WHO Framework 
Convention on Tobacco Control (FCTC). 
Exposure to environmental tobacco smoke (ETS) is a source of widespread excess 
morbidity, mortality and disability in the EU. According to this report's conservative 
estimates, 6 000 adults, including 2 500 non-smokers, died as a result of ETS 
exposure at their workplace in the EU in 2008. This translates into a significant cost 
on the economy, including over 1.3 billion euro of medical costs and over 1.1 billion 
euro of non-medical costs linked to productivity losses. These estimates do not 
include exposure to tobacco smoke in non-staff members (such as customers) or 
exposure at home.  
Great progress towards smoke-free environments has been made in the recent years 
in some Member States. So far, comprehensive smoke-free laws in indoor 
workplaces and public places have been adopted in slightly over a third of EU 
Member States. However, in countries with no comprehensive restrictions the 
exposure to second-hand tobacco smoke remains high, particularly in the hospitality 
and leisure sector, and is a source of significant health inequity. 
At EU level, the issue of smoke-free environments has so far been addressed in non-
binding resolutions and recommendations, but they not provide detailed guidance on 
how to achieve fully smoke-free environments. In addition, a number of 
occupational health and safety directives address the issue, in some cases indirectly 
only while in others the level of protection is not comprehensive.  
At international level, the WHO Framework Convention on Tobacco Control 
(FCTC) – ratified so far by 26 Member States and the Community - creates a legal 
obligation for all Parties to ensure comprehensive protection from exposure to 
tobacco smoke. The guidelines adopted by the Parties in July 2007 formulate a "gold 
standard" that every Party should aim to achieve within five years of the 
Convention's entry into force for that Party (i.e. by 2010 for the European 
Community and the majority of its Member States). Under the current trends, it is 
unlikely that all Member States will be able to meet this deadline. 
The Commission's Green Paper consultation on smoke-free environments 
demonstrated a broad support for further EU action. Based on the outcome of the 
consultation, five policy options have been considered in the Impact Assessment: 
status quo, open method of coordination, a Commission or Council 
Recommendation and binding EU legislation.  

The assessment of the possible impacts of the different options has been supported 
by an external study and informed inter alia by the outcome of the Green Paper 
consultation, the results of a targeted stakeholder consultation and the experience 
with existing EU instruments. 
Binding legislation based on Art. 137 could potentially bring the biggest reductions 
to ETS prevalence and related health and economic burden. However the 
implementation would take longer and the scope would be narrower than would be 
the case with a Recommendation. A Council recommendation with elements of 
Open Method of Coordination has been identified as the preferred option in the short 
term because it appears to be the fastest and most comprehensive means of helping 
Member States to implement binding smoke-free legislation at national level in line 
with their international commitments under the FCTC while providing a 
proportionate response to the problem. This option would also enhance the sense of 
ownership and commitment to smoke-free objectives among Member States. 
According to the report's estimates, such instrument would have the potential to 
prevent up to 1 550 premature deaths among office and hospitality workers and 
reduce the direct and indirect costs by up to 630 million euro each year. Substantial 
additional benefits could be expected in non-staff members such as the visitors of 
pubs and bars as well as from changes in smoking behaviour.  
To facilitate and speed up the introduction of comprehensive smoke-free laws in line 
with the FCTC requirements, the Recommendation should include a uniform EU 
deadline for implementation as well as reporting and monitoring mechanisms. On 
top of the provisions of the FCTC guidelines, it should call for measures to tackle 
children's exposure to tobacco smoke (including in private settings and certain 
outdoor venues), flanking measures such as cessation support and pictorial health 
warnings with quit information on tobacco packs as well as  setting up of an 
implementation body to develop common benchmarks and indicators. Further 
measures could be considered in the longer run, depending on the progress made.  
Organisation and timing  
(1)  In its Environment and Health Action Plan (2004-2010)2, the Commission 
committed itself to "develop work on improving indoor air quality, in particular 
by encouraging the restriction of smoking in all workplaces by exploring both 
legal mechanisms and health promotion initiatives at both European and 
Member State level”.  
(2)  In 2005 and 2006, the Commission carried out Eurobarometer surveys on 
attitudes towards tobacco in the EU3. The surveys showed large discrepancies 
in protection from tobacco smoke between Member States. 
(3)  The renewed EU Sustainable Development Strategy adopted by the European 
Council in June 2006 lists public health as one of the seven key challenges. 

Curbing the increase in lifestyle-related and chronic diseases, particularly 
among socio-economically disadvantaged groups and areas and reducing health 
inequalities within and between Member States are among the operational 
objectives identified by the Strategy. Concrete actions for the Commission and 
Member States include tackling tobacco use and improving indoor air quality. 
(4)  The consultation launched by the Commission's Green Paper "Towards a 
Europe free from tobacco smoke: policy options at EU level" (COM(2007) 27 
final) (30 January – 1 June 2007) showed a significant support for 
comprehensive smoke-free policies in all enclosed workplaces and public 
places and for further EU action to promote smoke-free environments 
throughout the Member States. The summary of the consultation is enclosed in 
Annex II. All the replies to the Green Paper and the report on its outcomes are 
published on the Commission's website.4 
(5)  The Employment, Social Policy, Health and Consumer Affairs Council 
(EPSCO) held a public debate on smoke-free environments in May 2007. The 
majority of Member States were of the opinion that the EU’s role in promoting 
smoke-free environments should be mainly to support and coordinate national 
efforts, e.g. through a Council Recommendation.  
(6)  The Parliament's resolution on the Green Paper of October 2007 urged the 
Member States to introduce comprehensive bans on smoking within two years 
and invited the Commission to table a legislative proposal by 2011 in case of 
unsatisfactory progress. It also called on the Commission to propose an 
amendment to the current chemicals and health and safety at work legislation in 
order to classify tobacco smoke as a carcinogen and ensure that the workplace 
is smoke-free. The Community strategy on health and safety at work (2007-
2012) proposed greater efforts to improve health and safety protection for 
workers, by i.a. taking into account the results of the Green Paper consultation 
on smoke-free environments. 
(7)  At international level, the Commission contributed to the development of 
guidelines on the protection from exposure to tobacco smoke under the WHO 
Framework Convention on Tobacco Control (FCTC). The document, adopted 
by the second Conference of the Parties to the Convention in July 2007, 
formulates a "golden standard" that every Party should aim to achieve within 
five years of the Convention's entry into force for that Party, i.e. by 2010 for 
the EC and the majority of Member States.5 
(8)  A Commission proposal for a Council Recommendation on smoke-free 
environments has been included in the Commission's Agenda Planning for 
2008 (reference n° 2008/SANCO/005). 
(9)  An Inter-service Steering Group (ISSG) to support the work on the Impact 
Assessment was set up in December 2007. The Group was led by the 
Directorate General for Health and Consumer Protection (DG SANCO). The 

following DGs were involved in the exercise: DG EMPL, DG ESTAT, DG 
INFSO, DG RELEX, DG RTD, DG TAXUD and SG. The Group held three 
meetings and a final written consultation. The mandate of the Group is set out 
in Annex I. 
(10) In addition, DG SANCO commissioned a study from a consultant (RAND 
Europe) to assess the health, social and economic impacts of exposure to 
tobacco smoke in the EU-27 and examine the likely impacts of five alternative 
policy options. 
(11) The Impact Assessment was also informed by the results of targeted 
stakeholder consultation with civil society, social partners and business 
organisations carried out by DG SANCO in March 2008. 
(12) In parallel, on 19 December 2008, DG EMPL has launched the first stage 
consultation with the social partners on the need for additional measures to 
protect workers from risks to their health arising from exposure to 
environmental tobacco smoke at the workplace. 
(13) The draft Impact Assessment was submitted to the Impact Assessment Board 
on 6 August 2008 and examined by the Board on 3 September 2008. 
(14) The final Impact Assessment takes into account the comments made by the 
Board in its opinion of 16 September 2008. The context of the problem is made 
clearer by comparing the burden of ETS exposure with other health hazards and 
explaining the significant burden in smokers compared to non-smokers. The 
problem definition is enhanced by a more comprehensive description of the 
current situation across all Member States, the reasons behind the differences in 
protection between Member States and the role of regulation in reducing ETS 
exposure in indoor workplaces and public places. The problem of children's 
exposure to tobacco smoke in other settings such as homes and certain outdoor 
places is also explained. More explicit information is provided on the content 
of different policy options and their value added in comparison with the FCTC 
obligation, and two additional policy options are included in the analysis. The 
reasons for discarding one of the options from further assessment are also 
elaborated upon. The estimated impacts are presented in a more cautious way, 
by highlighting their dependence on the assumptions about the options' 
effectiveness in reducing ETS prevalence.  
Consultation of experts and stakeholders  
As part of the Impact Assessment exercise, DG SANCO organised stakeholder 
consultation meetings with business organisations, civil society and social partners 
on 19 March 2008. Targeted consultation was chosen as a more appropriate tool, 
allowing for a more in-depth and focused discussion in particular on the impacts of 
various policy options. In addition, the open written consultation performed through 
the Green Paper in January-June 2007 already provided an opportunity for all 

interested parties to express their views on the problem definition, the possible 
policy options and to submit any further evidence and data.  
As regards the problem definition, health stakeholders asked for data on workplace 
exposure, highlighting the paramount importance of workers’ protection. They also 
stressed the link between active and passive smoking and socio-demographic 
factors, and the impact that smoke-free policies can have on social equity. It was 
emphasised that smoking has not displaced from work to home after the introduction 
of smoking bans, but that on the contrary a ban helped also to reduce ETS 
prevalence at home. Pharmaceutical industry highlighted the importance of cessation 
policies as a flanking measure.  
Tobacco industry insisted that the IA should take into account only the non-smokers' 
exposure in order not to inflate the ETS-related burden. Two organisations 
questioned the health risk of second-hand smoke and the statistical relevance of the 
data used. It was also argued that, in the longer run, smoke-free policies would have 
no impact on reducing tobacco consumption. 
Manufacturers of technological equipment and tobacco industry argued that 
technology-based solutions could achieve the same level of protection from ETS 
exposure as banning smoking, and requested that these are looked into. It was also 
suggested that the IA report include an overview of national smoke-free policies and 
differentiate between policies based on a total ban and policies leaving room for 
technological solutions.  
Regarding the policy options and their impacts, health stakeholders thought that 
binding legislation would be the most effective tool to reduce ETS exposure and 
related health and economic burden, followed by a Council Recommendation. 
Employer organisations expressed preference for a status quo on the grounds that the 
issue is best addressed at national level. Tobacco industry stressed that the analysis 
of policy options should include the considerations related to their content and 
scope, and argued that smoking bans with exemptions would be most appropriate.  
The IA report takes into account, to the extent possible, the stakeholders’ views 
relating to the problem definition and the analysis of impacts. It does not re-open the 
discussion on the scope of smoke-free measures (comprehensive policies vs policies 
with exemptions) as the outcome of the Green Paper consultation demonstrated a 
clear support for comprehensive smoke-free policies. A more detailed information 
on the consultation and its outcomes is presented in Annex III. 

3.1. Context 
3.1.1.  Health burden of ETS exposure 
Environmental Tobacco Smoke (ETS), also referred to as second-hand smoke or 
passive smoke, is a diluted mixture of side-stream smoke, which is released from a 
burning cigarette between puffs, and mainstream smoke, exhaled by the smoker. 
ETS contains over 4 000 gaseous and particulate compounds, including 69 known 
carcinogens.6 The World Health Organisation (WHO), International Agency for 
Research on Cancer (IARC), the U.S. Surgeon General, the U.S. Environmental 
Protection Agency (EPA), and numerous expert scientific and medical bodies 
worldwide have documented the adverse effects of ETS on the respiratory and 
circulatory systems, its role as a carcinogen in adults, and its harmful impact on 
children’s health and development.7 
Relative risk estimates for ETS-associated diseases and conditions  
ETS has been shown to have immediate adverse effects on the cardiovascular 
system and to be a cause of coronary heart disease and lung cancer in adults. There 
is also suggestive evidence that ETS may cause stroke, asthma and chronic 
obstructive pulmonary disease (COPD) in adults8 and worsen pre-existing 
conditions such as asthma and COPD.9 ETS has also been shown to be harmful to 
children, causing sudden infant death syndrome, acute respiratory infections, middle 
ear disease and more severe asthma.10 For most of these effects the level of 
individual risk from passive smoking is low when compared to active smoking, but 
the fact that large numbers of people are exposed results in a substantial burden of 
disease at the population level. 
Table 1 presents the venue-specific relative risks for lung cancer, cerebrovascular 
diseases (stroke), ischaemic heart disease, and chronic lower respiratory diseases 
(including COPD and asthma) used in the two reports that attempted to estimate 
ETS-mortality in the UK11 and in EU-2512. They are based on median figures 
obtained through meta-review of existing literature and are consistent with the 
ranges reported in the literature and summarised in Annex V part A. 
Table 1 Relative risk estimates associated with ETS and specific diseases 
Private home 
Lung cancer 
Stroke I60-I69 
1.45  2.52 
Ischaemic heart 
I20-I25 1.3 
Chronic lower 
J40-J47 1.25 
respiratory disease 

ETS mortality in the EU  
The report “Lifting the Smokescreen” published by the Smokefree Partnership in 
200613 provides the most recent estimate of the number of deaths attributable to 
passive smoking in the EU-25 from lung cancer, stroke, ischaemic heart disease and 
chronic neoplastic pulmonary disease. The report estimates that passive smoking 
accounted for a total of over 79 000 deaths across the EU in 2002, including 7 300 
deaths due to workplace exposure and 72 000 deaths due to exposure at home. 
Among non-smokers, passive smoking at work accounted for about 2 800 deaths in 
the EU in 2002, while exposure at home caused a further 16 400 deaths of non 
smokers. Workplace exposure in the hospitality industry was estimated to cause over 
300 deaths a year, including 90 deaths among non-smoking staff. 
This IA revises the estimates of workers' mortality reported in Lifting the 
smokescreen by applying the updated estimates on the prevalence of ETS exposure 
in the workplace. Annex VII presents in more detail the methodology used. The total 
number of deaths attributable to passive smoking in offices and bars/restaurants is 
estimated at 6 007 in the EU-27 in 2008, including 2,500 deaths among non-
smoking staff. Passive smoking among hospitality workers  is  estimated  to  cause       
1 599 deaths, including 786 deaths in non-smokers. The annual number of deaths 
due to ETS among smoking staff is estimated at 3 507 based on the assumption that 
on top of the high health risks from smoking itself, smokers face an additional risk 
from inhaling other people's smoke (even though this risk is much smaller than the 
direct risk associated with smoking). It should be noted that these estimates are 
conservative as they only take into account ETS exposure of over 1 hour. In 
addition, they do not include workplaces other than offices and bars/restaurants 
where ETS exposure may occur, such as government, education, transport and 
healthcare facilities. However, in most Member States the ETS exposure can be 
expected to be relatively low in these settings because of already existing smoking 
Table 2 Estimated EU-wide mortality due to ETS exposure among smoking and non-smoking staff in 
Non-smokers Smokers 
and Non-
Bars and 
Bars and 
Total Offices 
Lung cancer 
Heart disease 
Chronic lower 


The significant estimated health burden in smokers compared to non-smokers stems 
from the higher (declared) exposure to ETS among smoking staff than non-smoking 
staff. That is in particular the case for offices and for exposure of over 1 hour which 
forms the basis for the mortality estimates. This could be explained by a behavioural 
effect. For instance, non-smoking staff may try to avoid ETS in the workplace (by 
e.g. changing offices), while smoking staff might not mind sharing an office with 
other smoking colleagues, thereby being exposed to each other's smoke. 
Interestingly, there is much less of a difference between smoking and non-smoking 
staff in bars/restaurants. One could assume that in these venues it might be more 
difficult for non-smoking staff to avoid ETS compared to indoor workplaces/office It 
should be noted that "Lifting the smokrescreen" also estimated greater number of 
deaths in smokers (4 500) than in non-smokers (2 800 deaths) across the EU-25 in 
2002 due to ETS exposure at the workplace, which gives a ratio of 0.62 between 
non-smokers and smokers deaths. This ratio is close to this IA's ratio of 0.71 
between estimated deaths among non-smoking staff (2 500 deaths) and smoking staff 
(3 507 deaths). 
While workers' exposure to ETS is of particular concern given its involuntary and 
unavoidable nature, the exposure among non-staff members such as the customers of 
bars and restaurants could be expected to account for a substantial additional health 
burden. It is difficult to estimate the exact effect on customers because reliable data 
on ETS in this group are not currently available. However, it can be assumed that the 
population of non-staff members e.g. in bars, pubs and restaurants is substantially 
larger than the population of staff-members. At the same time, the duration of 
exposure is probably lower in non-staff compared to staff, making it difficult to 
compare the risk of exposure and resulting burden. Finally, a significant health 
burden can be associated with ETS exposure at home, which is an issue that cannot 
be addressed through legislative measures.  
It is possible to compare the estimated number of deaths from ETS exposure to other 
health hazards, both in the workplace and in the general population. The estimated 
number of pre-mature deaths among smoking and non-smoking staff attributable to 
second-hand smoke (6 007) is only slightly lower than the number of fatal 
occupational accidents in the EU-27 (7 460) and equals almost a tenth of all deaths 
caused by exposure to hazardous substances at work such as asbestos, silica, diesel 
fumes, benzene etc. (73 989).15 An earlier estimate (2002) for deaths attributable to 
ETS exposure both at work and at home stood at 79 449. This exceeds the number of 
road accident fatalities in the EU-2007 (42 953)16 and equals around a quarter of 
deaths attributable to air pollution (over 300 000). These comparisons show the 
significant health burden of ETS exposure compared with other types of involuntary 
Table 3: Benchmarking of deaths attributable to ETS against other risks 
General population 
Exposure to ETS  
Road traffic accidents (TREN) 
Accidents at work (OSHA) 
Exposure to ETS 
Exposure to hazardous 
Air pollution (RTD) 
substances (OSHA) 

3.1.2.  Economic burden of ETS exposure 
The overall economic burden of tobacco use has been estimated to be between 1-
1.4% of the EU Gross Domestic Product in 2000.17  In addition to active smoking, 
also passive smoking imposes a significant cost on the economy. 
The macroeconomic burden of ETS exposure includes the medical costs relating to 
increased expenditure on tobacco-related diseases, and the non-medical costs linked 
to productivity losses and lost income tax and social security contributions among 
smokers and second-hand smoke victims who would otherwise be in paid 
employment. The microeconomic burden includes lower workers' productivity, 
increased sickness absenteeism; fire damage caused by smoking materials as well as 
additional cleaning and redecoration costs related to smoking. 
The most recent analysis that estimates the costs of ETS in a systematic and 
comprehensive way was done by the U.S. Society of Actuaries in 200518. Overall, 
the analysis indicates that the impact of ETS is in the order of several billion US 
dollars, with an annual price tag of roughly $10 billion (€8 billion). This 
corresponds to $33 000 (€27 467) for each U.S. resident. More specifically, the 
direct medical cost of ETS-related morbidity is estimated at almost $5 billion (€4.1 
billion) per year for the U.S. population and the indirect productivity costs of ETS-
related mortality and disability (including lost wages, fringe benefits and services) at 
$4.7 billion (€3.9 billion) per year.  
Table  4:    Estimated direct medical costs of exposure to ETS and economic value of lost 
wages, fringe benefits and services per year in the U.S. population, based on present values 
(expressed in 2004 U.S. dollars and 2007 Euro’s) 
Direct medical costs 
Value of lost wages, 
fringe benefits and 

Cost ($m) 
Cost (€m) 
Cost ($m) 
Cost (€m) 
Lung cancer  
14 12 
110 92 
Respiratory system  
53  44 886 737 
Chronic pulmonary  1,215 1011 2752 2291 
Cardiovascular system  
Coronary heart disease  
Low birth weight  
Total Cost  
Source: Adjusted from Behan et al  (2005) 

While no studies have examined the economic burden of ETS in the EU, the 
regulatory impacts assessments in Northern Ireland, England, Scotland and Wales19 
have estimated the expected health benefits and resource savings associated with 
reduced ETS exposure under comprehensive smoke-free legislation (see Annex VI 
C for details).  
One could assume that these savings give an indication of the current economic 
burden of ETS at workplaces and public places. Based on this assumption the annual 
economic burden of ETS in England, Scotland, Wales and Northern Ireland is £944-
1 354 million20, £204 million21, £120 million22 and £57.4 million23, respectively.  
This IA has calculated the cost of workplace exposure to ETS across EU-27 using 
the methodology described in Annex VII. It is estimated that exposure to ETS at 
work costs EU economy 2.46 billion euro per year. The estimated annual medical 
costs total to 1.336 billion euro (including €566 million in non-smoking staff) and 
are highest for the treatment of stroke (€572 million) and heart disease (€352 
The non-medical costs due to ETS exposure at work, including productivity losses 
due to premature death and morbidity, are slightly less than the medical costs, 
totalling an estimated 1.124 billion euro in 2008 (including €477 million in non-
smoking staff). These estimates exclude the cost of lung cancer for which no recent 
and reliable estimates were available.  
Table 5: Estimated EU-wide medical and non-medical cost due to ETS exposure among 
smoking and non-smoking staff in EU-27 (in € millions) medical 
Medical and 
Medical costs 
Non-medical costs 
Smokers Total 
Lung cancer 
96 n/a  n/a 
572 208  284 492 
Heart disease 
352 134  183 317 
Chronic lower 
315 135  180 315 
respiratory disease 
1336 477 
647 1124 
3.2. Problem 
3.2.1.  Incomplete compliance with international obligations resulting from 

Article 8 of the WHO Framework Convention on Tobacco Control (FCTC), which 
was adopted in June 2003 by all WHO members, creates a legal obligation for its 
Parties to adopt and implement in areas of their jurisdiction and actively promote at 
other jurisdictional levels effective measures to protect people from second-hand 

smoke in all indoor workplaces, public transport and indoor public places. The 
second Conference of the Parties to the Convention in July 2007 adopted 
comprehensive guidelines to help governments meet this obligation. The guidelines 
emphasise that there is no safe level of ETS exposure and call for a total elimination 
of tobacco smoke in all indoor venues under public jurisdiction and possibly other 
(outdoor or quasi-outdoor) public places. Binding legislation, properly enforced and 
monitored, is recommended as the only appropriate means to deal with the problem 
of passive smoking. The FCTC has been ratified by the Community and 26 Member 
States but over half of them have not yet introduced comprehensive smoke-free 
legislation and only partial action to promote national smoke-free efforts has been 
taken at EU level.  
Over half of Member States not yet compliant with Art. 8 of the FCTC  
By now – over five years after the adoption of the FCTC - only slightly over a third 
of Member States are compliant with the Convention's requirement to provide for 
effective protection from tobacco smoke in indoor workplaces and public places.  
Total bans on smoking in all enclosed public places and workplaces, including bars 
and restaurants, are so far in place in Ireland and the UK while Italy, Malta, Sweden, 
Latvia, Finland24, Slovenia, France and the Netherlands have introduced smoke-free 
legislation in these venues allowing for special enclosed smoking rooms.  
However, in more than half of the Member States, citizens and workers are still not 
fully protected from exposure to tobacco smoke in indoor workplaces and public 
places. Bars and restaurants proved to be a particularly difficult area of regulation. 
Partial exemptions for hospitality venues are in place in Portugal, Bulgaria, 
Denmark and most of German Länder (smaller establishments); Belgium and 
Luxembourg (non-food and snack establishments) and Lithuania (special cigars and 
pipe clubs) while in further eight Member States there are virtually no restrictions on 
smoking in bars and restaurants. On top of incomplete regulations, also the 
enforcement of the laws and consequent penalties may be lax or non-existent. 
Figure 1: Implementation of smoke-free laws in the EU (November 2008) 
Comprehensive protection 
Partial protection 
Weak protection 
08.2007 - onwards 

It could be expected that the trend towards smoke-free environments will continue in 
the coming years but at a slower pace. There was a big jump in policies after 2004 
but the momentum seems to have faltered. Stricter smoking rules are due to come 
into force in January 2009 in Austria and Romania and in April 2010 in Latvia - 
however only the latter will provide for a comprehensive protection from tobacco 
smoke. There are policy initiatives to strengthen existing smoke-free regulations in 
six further Member States (Czech Republic, Poland, Slovakia, Hungary, Greece and 
Bulgaria) but most of them are at a very early stage of discussion and some would 
only provide partial protection.  
Figure 2: Policy proposals in the EU 
Advanced smoke-free proposals 
Proposal for a partial smoking ban in hospitality venues approved by the 
parliament. Expected to come into force in Jan. 2009 
Comprehensive smoking ban in hospitality sector adopted by the 
parliament. Expected to come into force in April 2010 
Comprehensive smoking ban in indoor public places and workplaces and 
partial ban in hospitality sector adopted by the parliament. Expected to 
come into force in Jan. 2009 
Fairly advanced smoke-free proposals 
Proposal for a partial smoking ban in hospitality venues awaiting one more 
Czech Republic  
reading in the lower chamber and one in the upper chamber 
Less advanced smoke-free proposals 
Proposal for a comprehensive smoking ban in all indoor public places and 
workplaces incl. hospitality venues presented to the parliament  
Proposal for a comprehensive  smoking ban in all workplaces incl. 
hospitality venues presented to the parliament 
Proposal for a comprehensive  smoking ban in all workplaces incl. 
hospitality venues drafted by the Health Ministry but not yet agreed by the 
Proposal for a comprehensive smoking ban in all indoor public places and 
workplaces incl. hospitality venues tabled in the parliamentary health 
Proposal for a partial smoking ban in hospitality venues drafted by the 
Health Ministry but not yet agreed by the Cabinet  
It should be noted that in a number of countries (Portugal, Czech Republic, Bulgaria, 
Slovakia) comprehensive smoke-free initiatives have failed or were weakened in the 
recent time while German Länder are currently reviewing their smoking regulations. 
At the moment, it seems unlikely that all Member States will be able to meet their 
FCTC obligation unless there is a political stimulus and a monitoring mechanism at 
EU level.  
Drivers of the problem  
There are numerous drivers of the problem impeding the implementation of 
comprehensive smoke-free policies at national level such as concerns about public 
opposition to smoke-free measures, their possible negative impacts (e.g. on the 
hospitality sector), and the modalities of implementation.  

It is noteworthy that those countries which have introduced comprehensive smoke-
free laws have been in general more concerned about the health damage done by 
tobacco. This concern has resulted in various actions including awareness-raising 
campaigns which allowed the population to better understand the health risks of 
active and passive smoking. This in turn resulted in lower smoking rates, increased 
support for smoking restrictions and smooth implementation.   
A 2005 study quantified the implementation of various measures (tobacco taxation, 
consumer information, advertising bans, health warnings and cessation policy) in 30 
European countries, including 27 Member States.25 It is interesting to note that 9 out 
of the 10 best performing countries have by now implemented comprehensive 
smoke-free laws. 
Figure 3: European countries ranked by total Tobacco Control Scale score 
Country Smoke-free  Tobacco 
Public inform. 
law in 2008 

30 15 
11 6 
Iceland * 

25 13 
13 6 


26 5 


23 3 


23 4 


18 1 


19  3 9 7 


19 2 

21 1 


16 4 

16 2 

17 2 

18 0 

17 1 

19  0 9 6 


16 2 

16 0 

14 2 

17 - 

20  0 4 6 

12  0 9 6 

17  0 4 6 


13  0 7 6 

15  4 4 3 

11  1 9 6 

12  3 3 6 

14  0 4 6 


9  1 6 6 

7  0 5 7 

13  0 0 3 

* Not an EU Member State 

On the other hand, Member States that have not yet introduced comprehensive 
smoke-free policies tend to have higher smoking rates than those which have already 
taken action, for instance 42% in Greece and 36% in Bulgaria and Hungary 
compared to 18% in Sweden and 25% in Finland and Malta26. 
Tackling ETS exposure is also more difficult for them as they face greater opposition 
from their societies. Figure 4 demonstrates for example that support for smoke-free 
bars is much lower in countries with no comprehensive restrictions in hospitality 
Figure 4: Opposition towards smoke-free bars in the EU in 2006 
Somewhat opposed
Totally opposed
Smoking ban in bars
Source: Adjusted from Eurobarometer 2007 
In addition, the economic departments in the Member States may be concerned about 
the possible negative effects of smoke-free laws (e.g. on the hospitality sector or 
tobacco-related employment). An EU initiative could address these concerns by 
setting out the evidence from smoke-free jurisdictions and highlighting the economic 
burden of ETS-related diseases.  
A detailed overview of Member States' regulations is presented in Annex IV part C. 
The assessment of various technological solutions to control ETS exposure and cost-
effectiveness of various cessation therapies are discussed in Annexes IX and X, 
Only partial action on ETS taken at EU level 
The issue of passive smoking has so far not been addressed in a comprehensive way 
in the EU. The 1989 Council Resolution 89/C 189/0127 on smoking in public places 
covered only certain categories of venues. The more recent Council 
Recommendation 2003/54/EC28, while calling for a comprehensive protection from 

tobacco smoke, did not provide Member States with a detailed guidance that would 
assist them in implementing smoke-free laws at national level. In addition to non-
binding measures, a number of occupational health and safety directives address the 
issue of workers exposure to tobacco smoke, in some cases indirectly only29 while in 
others the level of protection is not comprehensive. Specific requirements include 
protecting non-smokers against discomfort caused by tobacco smoke in rest areas 
and rest rooms30, banning smoking in areas where carcinogens and mutagens are 
handled31, or protecting pregnant and breast-feeding staff. Annex IV part B presents 
an overview of existing Community provisions on second-hand smoke. 
3.2.2.  High and uneven ETS prevalence across EU-27 
As a result of incomplete regulations or the lack of enforcement, large parts of the 
EU population are still exposed to passive smoking in enclosed workplaces and 
public places. There are huge differences in the prevalence of ETS exposure and 
related health and economic burden both between and within EU-27 countries. 
The most recent estimates on ETS exposure across the EU-27 come from the 2007 
Eurobarometer survey Attitudes of Europeans Towards Tobacco carried out in 
October and November 200632. This survey forms the basis for the analysis 
contained in this report. 
Lack of adequate protection from exposure to ETS in the majority of Member 

A study carried out in 10 Member States in September 2005-November 2006 found 
that tobacco smoke was present in a clear majority of public places in 8 out of 10 
Member States included in the study. The places tested included restaurants, bars, 
transportation venues and other types of public places such as hotels, shopping 
malls, offices and schools. The mean particulate matter levels ranged from 366 
µg/m3 in Romania and 205 µg/m3 in Greece compared to 22 µg/min Ireland where 
comprehensive smoke-free law had been in place.33  
Exposure to ETS in the workplace is of particular concern given that employees are 
under a contractual obligation to carry out their job.34 In addition, workers can be at 
a particular risk of prolonged and high-level exposure to tobacco smoke since most 
of them spend around a third of their time at work. 
Figure 5 shows the percentage of staff exposed to ETS on a daily basis in indoor 
workplaces and offices in 2006 across EU-27. On balance, 32% of respondents 
working in indoor workplaces or offices declared to be exposed to tobacco smoke at 
work on a daily basis. 19% reported to be exposed for over 1 hour and 10% were 
exposed to tobacco smoke for more than five hours a day while at work in EU-27. 
Eight countries had more than 20% of staff being exposed to ETS for more than 1 
hour per day, and 10% of staff being exposed to ETS for more than 5 hours per 
day.35 Greece had the highest percentage of staff (85%) being exposed to ETS, 
including 61% being exposed to ETS more than 1 hour per day and 33% being 

exposed more than 5 hours per day. In comparison countries such as Ireland, 
Sweden, and Finland have relatively low or zero proportion of staff being exposed to 
ETS in the indoor workplaces and offices, which is not surprising given they had 
implemented smoke-free policies prior to the survey. 
Figure 5: Percentage of staff exposure to ETS on a daily basis in indoor workplaces and 
offices – 2006 
Percentage of Staff Exposed to ETS 
ETS Prevalence
(Indoor workplaces and offices)
0-1 hour per day
>1 hour per day
Source: Adjusted from Eurobarometer 2007 
The Eurobarometer data has been updated taking into account that a number of 
Member States have implemented smoke-free laws in indoor workplaces since the 
end of 2006 (comprehensive bans in France and UK, partial in Denmark and 
Portugal). On balance, it is estimated that 28% of staff in offices is exposed to ETS 
on a daily basis as of end-2008, out of which 17% are exposed for more than one 
hour a day (see Annex VII for details).  
Exceptionally high ETS exposure in hospitality venues 

The levels of ETS exposure are exceptionally high in hospitality venues. One study 
showed that a four-hour exposure in a discotheque is similar to that from living with 
a smoker for a month.36 The finding has been confirmed by other studies, which 
found the average exposure in bars to be three or more times higher than the 
exposure sustained from living in a smoking household.37 
Also according to the 2007 Eurobarometer, the largest percentage of employees 
(68%) was exposed to tobacco smoke on a daily basis in restaurants, pubs and bars 
in 2006. The duration of exposure in this group appeared to be significantly longer 
than in other workplaces too, with 47% of respondents declaring exposure of over 
one hour and 29% of over 5 hours per day.  

link to page 1 filename javascript:AL_get(this,%20'jour',%20'J%20Epidemiol%20Community%20Health.'); Figure 6: Percentage of staff exposure to ETS on a daily basis in offices and bars/restaurants 
in 2006 
More than 5 hours a day
1-5 hours a day
Less than 1 hour a day
Never or almost never
80% 100%
Source: Adjusted from Eurobarometer 2007 
The particularly high exposure in the hospitality sector has also been demonstrated 
in the 2005 Fourth European Working Conditions Survey, according to which 50% 
of hospitality employees were exposed to ETS around a quarter of their working 
time or more, followed by the construction sector (37.5%), and public administration 
and defence (22.7%) in 2005.  
The Eurobarometer data has been updated taking into account that a number of 
Member States have implemented smoke-free legislation in the hospitality sector 
since the end of 2006 (comprehensive bans in Lithuania, Estonia, Finland, Slovenia, 
France, UK and the Netherlands; partial bans in Belgium, Denmark, Portugal and 
Germany). On balance, it is estimated that 39% of staff in bars and restaurants is 
exposed to ETS on a daily basis as of end-2008, out of which 27% are exposed for 
more than one hour a day (see Annex VII for details). Also the customers of drinking 
and eating venues are at risk of particularly high levels of exposure to ETS and the 
related health hazards. 
Lower socio-economic groups are at higher risk of ETS exposure 
Evidence suggests that the likelihood of being a smoker and being exposed to 
second-hand smoke is significantly higher for those who have a lower level of 
education, lower income and lower occupational class. 
The 2005 Fourth Working Conditions Survey showed 10.6% of professionals report 
exposure to ETS at work around a quarter of the time or more compared to 31.4% of 
skilled workers and 24% of machine operators38.  
These findings are consistent with studies from the UK, Sweden and New Zealand 
carried out prior to the introduction of comprehensive smoke-free policies in those 
countries. In the UK, manual workers were found to experience greater severity of 
respiratory symptoms, independently of smoking39 and to be 2.25 times more likely 
to be exposed to ETS than those in managerial and professional occupations40. In 
Sweden, male skilled manual workers and female unskilled manual workers were 4 

and 3.2 times more likely, respectively, to be exposed to ETS than non-manual high-
level skilled employees.41 In New Zealand, ETS exposure was steeply and inversely 
associated with all three indicators of socioeconomic status (education level, 
occupational status and median neighbourhood household income).42 
Greater ETS exposure might contribute to the higher risks of disease and death 
among lower socio-economic groups, exacerbating the existing inequalities in health. 
Legislation is a crucial factor in reducing ETS exposure in indoor workplaces and 
public places 

The prevalence of ETS exposure in different Member States is to some extent 
influenced by factors other than legislation such as the rates of active smoking, 
social acceptability of smoking or public awareness of the risks of second-hand 
smoke. However, the scope and strength of national smoke-free laws is a crucial 
factor responsible for the differences in ETS exposure between countries.  
In 2006, 100% of Irish hospitality workers declared to be never or almost never 
exposed to tobacco smoke at work compared to 8% of their Greek counterparts.43 
However, prior to the introduction of the smoking ban, the workplace exposure to 
ETS among Irish barmen had also been very heavy, averaging 40.5 hours a week.44 
Evidence from jurisdictions which have introduced strict smoke-free laws 
(summarised in Annex VI) demonstrates that indoor air quality improved 
dramatically and ETS exposure has practically disappeared in indoor workplaces and 
public places after the smoking bans went into effect. This is confirmed by numerous 
studies based on self-reported data, biomarkers as well as measurements of ETS 
components in indoor air.  
This shows the huge impact that can be achieved through adequate regulation. It also 
allows to expect that the introduction by all Member States of strict smoke-free laws 
as a rule covering all indoor workplaces and public places and equipped with proper 
enforcement mechanisms as prescribed by the FCTC guidelines would virtually 
eliminate the problem of exposure to tobacco smoke in indoor workplaces and public 
3.2.3.  Inadequate protection of children and young people from tobacco 

Children's and young people's exposure to tobacco smoke is a particular health 
concern. Children have little or no control over their exposure to ETS from adult 
smokers in settings such as home and cars, not to mention exposure in utero. Infants 
and children are also particularly vulnerable to the health effects of ETS. Scientific 
reviews have concluded that exposure to ETS is a major risk to child health as is 
maternal smoking in pregnancy, and maternal exposure to ETS while pregnant (see 
Annex VB). In addition to the health risks of ETS, exposure to tobacco smoke makes 
children more likely to perceive smoking as common adult behaviour and thus take 
up smoking themselves in adolescence. Most adult smokers began to smoke in 
childhood or adolescence. Smokers who begin to smoke at younger ages have higher 

rates of tobacco-related mortality and morbidity, and suffer tobacco-related diseases 
earlier.45 Preventing adolescent smoking is therefore of crucial importance. 
Children's exposure to tobacco smoke in homes  
While children are also exposed to ETS in public places such as cafes, restaurants 
and public transport, most of children’s exposure to tobacco smoke comes from 
parents, and occurs in the home.  
In the last Eurobarometer survey, over a third of smokers (36%) declared to smoke 
inside their home in the company of children. There was a considerable variation 
between the counties, ranging from 10% in Sweden to 51% in Austria and 52% in 
Fig 7: Smoking at home in the company of children 
Yes, regularly
Yes, occasionally
In addition, almost a quarter (23%) of EU smokers declared to smoke at home in 
presence of pregnant women, ranging from 6% in Lithuania and 9% in Malta to 58% 
in Spain and 61% in Austria. 
Fig 8. Smoking at home in the company of pregnant woman 
Yes, regularly
Yes, occasionally

The lower the level of education of smokers, the more likely they are to smoke at 
home in the company children and pregnant women. Moreover, the unemployed, 
house persons and manual workers are more likely to do so than managers and other 
white collar workers. This suggests that children from disadvantaged background are 
at greatest risk of exposure. 
While there is currently no EU-wide data on the percentage of children exposed to 
ETS in their homes, the Global Youth Tobacco Study (GYTS)46, a WHO survey of 
children aged between 13 and 15 in 76 countries, provides data for twelve E
Member States in Central and Eastern Europe.47 Across these countries, the 
proportion of 13–15-year-olds exposed to ETS in their homes during the week 
preceding the survey ranged from 40% to 90%. In all the countries except for the 
Czech Republic and Lithuania, over 50% children were exposed to tobacco smoke at 
home while in Poland, Cyprus, Greece and Romania this was the case for roughly 9 
out of 10 children. 
Table 6: Proportion of children aged 13-15 exposed to tobacco smoke at home in the past 
Czech Rep., 2007 
38.0%  Estonia, 2003 
Lithuania, 2005 
43.1%  Hungary, 2003 
Latvia, 2007 
55.2%  Poland, 2003 
Slovenia, 2003 
65.9%  Cyprus, 2005 
Bulgaria, 2002 
67.7%  Greece, 2005 
Slovakia, 2003 
79.5%  Romania, 2004 
Studies in western Europe found that the proportion of children aged 6–12 years 
living with a current smoker in the household was around 50%: 46% in Germany, 
58% in Italy and the Netherlands and 62% in Austria.48 In the UK, around four out 
of every 10 children live in homes where at least one person regularly smokes 
The negative consequences of parental smoking include not only the direct effects of 
ETS on children's health but also the influence of parents’ smoking on their 
children’s likelihood to smoke. Evidence demonstrates that children and adolescents 
who live with smokers are more likely to become regular smokers themselves. 
Smoke-free homes may therefore have a protective effect for the risk of child 
smoking uptake.50  
In addition to homes, it is likely that parental smoking in cars is a significant source 
of exposure to ETS for children. In the Eurobarometer survey, almost one in ten 
(9%) smokers admitted to smoking in a car with children present. There are big 
variations between the countries, the Swedish and Estonian smokers being the least 
(1%) and the Danish (17%) the most likely to do so. As is the case with smoking at 
home, the likelihood of smoking in the car in the presence of children is higher 
among those with lower level of education and lower occupational status.  
Studies have shown that smoking in confined spaces such as a car or truck, results in 
particularly high levels of particulate matter and other harmful substances, exceeding 

those measured in smoky bars.51 Another concern about smoking in cars is road 
safety, studies suggesting that smokers have significantly higher risk of motor 
vehicle accidents than non-smokers.52 Passengers, including children, are thus at 
greater risk of being involved in an accident if driving with a smoker.53 
Laws banning smoking in cars carrying children have been so far adopted by 
Cyprus, Puerto Rico, South Africa, and a number of regional and local jurisdictions 
in the U.S, Australia and Canada (see Annex IVD). Similar initiatives are actively 
considered in a number of other jurisdictions.  
Children's exposure to ETS in outdoor areas 
Besides indoor public places and homes, children are also routinely exposed to 
tobacco smoke in outdoor places such as public playgrounds; outdoor areas of 
schools, hospitals and other institutions providing services to children as well as 
during outdoor sports or cultural events. 
While there are at present no studies on the health effects of outdoor exposure to 
ETS, the main concern about adult role models such as parents, teachers or doctors 
smoking in areas frequented by children is its impact on children's perceptions about 
smoking as socially acceptable behaviour.54  
A number of jurisdictions, mainly outside the EU, have banned smoking in certain 
outdoor places visited by children and adolescents to protect them from seeing 
smoking as a common adult behaviour to be imitated.  
A mix of interventions is needed to reduce children's exposure to tobacco smoke 
Evidence suggests that the introduction of smoke-free public places and workplaces 
shifts public attitudes towards smoking and, as a consequence, reduces smoking in 
the home. To maximise its potential, smoke-free legislation should be complemented 
by comprehensive programmes aimed at informing parents and future parents about 
the risks of ETS exposure to children, promoting smoke-free homes and cars and 
supporting smoking cessation. Such programmes should be targeted in particular at 
the disadvantaged groups in the society. In addition, legal restrictions on smoking 
should be considered in areas frequented primarily by children. 
Rationale for EU action 
3.3.1.  Legal basis and institutional setting 
Legal basis 
The initiative is intended to help implement Treaty requirements of a high level of 
health protection (Articles 3(1)(p) and 152) and protection of health and safety of 
workers (Article 137). 
The Community has a long history of common policy-shaping debates on ETS 
(Council Resolution from 1989, Council Recommendation from 2002). This reflects 

an obligation under Article 152 of the Treaty to encourage cooperation between the 
Member States and lend support to their action in the area of improving public 
health, preventing human illness and diseases, and obviating sources of danger to 
human health.  
In addition, Article 137(1) (a) of the Treaty obliges the Community to support and 
complement the activities of the Member States, particularly to improve the working 
environment to protect the health and safety  of  workers.  For this purpose the 
Community may adopt, by means of directives, minimum requirements for gradual 
implementation. Such minimum requirements have been adopted for most 
occupational risks, including risks resulting from exposure to dangerous substances 
such as carcinogens and mutagens. 
Furthermore, as a Party to the WHO Framework Convention on Tobacco Control 
, the Community is under a legal obligation to take action on smoke-free 
environments. Under Article 8 of the FCTC each Party has undertaken to “adopt and 
implement (…) effective legislative, executive, administrative and/or other 
measures, providing for protection from exposure to tobacco smoke in indoor 
workplaces, public transport, indoor public places and, as appropriate, other public 
places.” As all but one Member States have also individually ratified the convention, 
they are bound to the same commitment as the EC.  
Political momentum 
The Commission Green Paper consultation demonstrated an overwhelming support 
for an EU initiative on smoke-free environments, a Recommendation and binding 
EU legislation being the two most popular policy options (see Annex II). Both the 
European Parliament and the Council recognised the need for further EU action, the 
former calling for a binding legislation and the latter for support and coordination of 
national efforts e.g. through an EU Recommendation. 
In addition, the Council Conclusions on cancer adopted in June 2008 call for 
strengthened EU action on all aspects of cancer control, including the prevention of 
main risk factors.  
The desirability of intervention at European level has been further highlighted in the 
conclusions from the international conference "Towards a smoke-free society" in 
September 2007.55 
3.3.2.  Subsidiarity test   
Coherent and timely implementation of FCTC guidelines 
So far, less than half of the Member States have adopted policies to comply with 
their FCTC obligation while a number of others have encountered serious difficulties 
in introducing and/or enforcing comprehensive smoke-free legislation. In addition, 
the non-ratification of the FCTC by one Member State means that it is not legally 
bound by the provisions of the Treaty. 

The intervention at EU level should help the timely and coherent implementation of 
the FCTC provisions in line with the Member States' and EU international 
An EU initiative based on Art. 152 would be intended to assist Member States in 
developing comprehensive smoke-free policies in line and beyond the FCTC 
guidelines. It would strengthen the implementation of the FCTC provisions by 
adding a clear monitoring mechanism and a uniform EU deadline for implementation 
for all Member States. An EU initiative based on Art. 137 would ensure an 
enforceable basic level of protection from the risk of ETS exposure in the workplace 
throughout the EU. While potentially narrower in scope that the FCTC provisions, it 
would allow Member States to adopt more stringent measures. 
Health inequities  
Differing national laws result in huge differences in protection between Member 
States. In the latest Eurobarometer on Tobacco, 4% of Irish office staff declared to 
be ever exposed to tobacco smoke at work compared to 85% of Greek workers.  
In addition, the lack of comprehensive smoke-free regulations in the majority of 
Member States (in particular in hospitality and leisure sector) results in inequalities 
between different occupational and socio-economic groups, hospitality workers 
being three times more likely to be exposed to tobacco smoke for over 5 hours a day 
than office workers. 
Given the health risks of exposure to second-hand smoke, these differences result in 
avoidable health status disparities both between and within Member States 
exacerbating the existing significant differences in healthy life expectancy. An EU 
intervention can favour the development of a high level of protection in all Member 
States, according to Art 3(1)(b), 137 and 152 EU Treaty and in line with the Lisbon 
Agenda structural indicators for Healthy Life (HLY). By helping Member States to 
prevent tobacco-related deaths in productive age, it would also contribute to 
maintaining the healthy workforce and overall social cohesion and economic 
Internal market distortions  
Differing national laws may also have negative cross-border implications. A worker 
in a country with comprehensive smoke-free regulations who wants to take up a job 
in a country with less stringent approach would have to forgo the protection they 
enjoy in their country of origin to do so. This is likely to impinge on workers' 
mobility, in particular in the case of some categories of workers such as pregnant 
workers or those with pre-existing health problems. Patchy smoke-free rules can  
also create an uneven playing field for operators in different Member States. For 
instance, hospitality venues in border regions where strict smoking bans apply may 
lose clients due to "smoking tourism" to neighbouring countries with less stringent 
rules. By encouraging comprehensive smoke-free legislation across all Member 
States, an EU initiative would contribute to eliminating competitive distortion within 

and between Member States and favour the free circulation of workers and services 
throughout the EU. 
Added value of EU support 
The added value of the Community action would consist in bringing the evidence 
base, facilitating the exchange of experience and best practice among Member 
States, providing Member States that have not yet implemented comprehensive 
smoke-free legislation with guidance for doing so (possibly accompanied by 
minimum EU standards for worker protection), translating the FCTC guidelines into 
EU institutional and legal context; and monitoring the progress towards reducing 
ETS exposure throughout the EU.  
An EU initiative based on Art. 152 could be expected to put the issue on a high 
political agenda in the Member States, thus stirring the drive towards smoke-free 
environments and providing the health sector with political justification for action. 
Such impact has in the past been made on other health issues where the EU took 
coordinating and complementing powers, e.g. in the case of cancer screening or 
electromagnetic fields, where Council recommendations, even though non-binding, 
triggered important national action.56 Even more so, the Framework Directive on 
health and safety at work and its individual directives (Art. 137) brought about a 
considerable improvement and modernisation of national standards for occupational 
health and safety.57 
Also the impact of earlier initiatives on ETS at EU and international level suggests 
that EU action could be instrumental in stimulating Member States' efforts. For 
instance the 1989 Council Resolution on smoking in public places – however weak 
in its actual recommendations by today's standards – resulted in some kind of smoke-
free regulations being adopted by all then Member States.58 The first push for 100% 
smoke-free policies seems to have come with the adoption of the WHO Framework 
Convention on Tobacco Control (WHO FCTC). Subsequent to the adoption of the 
Convention in May 2003, Ireland became the first country worldwide to adopt 
comprehensive smoke-free legislation in April 2004, followed by four other EU 
jurisdictions within the next two years. The policy process continued with the 
negotiations and adoption of the FCTC guidelines (July 2007) and the publication of 
the Commission's Green Paper on smoke-free environments in January 2007.  
These supranational initiatives certainly helped stimulate the debate in the Member 
States about the harm of exposure to ETS and the benefits of smoke-free 
environments. For instance the Commission's Green Paper (translated into all EU 
languages) received a huge coverage in the national media, thus helping to move the 
discussion forward in different Member States. 

In response to the issues outlined in the previous section, the overall objective of the 
proposal is to contribute to a high level of public health and working conditions as 
stipulated in Articles 3(1)(1p), 152 and 137 of the EC Treaty by assisting Member 
States in reducing tobacco-related morbidity and mortality. It can be expected that 
the initiative will also help reduce healthcare and productivity costs linked to ETS 
exposure, thus contributing to Member States' reform efforts as part of the Lisbon 
The specific objective is to comply with EC and Member States' international 
obligations under the FCTC. This would consist in assisting Member States in the 
development of laws to eliminate exposure to second-hand tobacco smoke in 
workplaces and public places in line with the FCTC commitment and to promote 
smoke-free homes. Indirectly, the initiative could be expected to increase citizens' 
knowledge of the hazards of tobacco (smoke) and their support for tobacco-free 
policies and lifestyles; and – as a result – reduce the rates of active smoking.  
It is intended that the main outputs of the initiative will include translating the FCTC 
provisions into the EU institutional and legal context and monitoring progress 
towards reducing ETS exposure throughout the EU.  
The initiative is linked to a number of EU strategic policies, including the Health 
Strategy, the Strategy on health and safety at work, the Environment and Health 
Strategy as well as the Sustainable Development Strategy. 

General objective
Improve the health of citizens and workers in 
line with Art. 152 and 137 EC Treaty through 
reductions in tobacco–related illness and 
Specific objectives 
Comply with EU and 
Assist MS to eliminate ETS 
MS obligations under 
exposure in workplaces/public 
places and to promote smoke-
free homes
Specific objectives 
Translate FCTC 
Monitor progress towards 
provisions into
smoke-free environments 
5.1. Scope of EU initiative 
The FCTC guidelines on protection from exposure to tobacco smoke, adopted 
unanimously by all the FCTC Parties, state that all indoor workplaces and public 
places should be free from tobacco smoke. As a Party to the FCTC, the EU and 26 
Member States are bound by this commitment. Any change to the substance of the 
FCTC guidelines would make it necessary to re-open the international agreement.  
The advantages and disadvantages of measures of different scope to tackle passive 
smoking, including a total ban on smoking in virtually all enclosed public places and 
workplaces and exemptions of different types (e.g. for restaurants and bars) have 
been analysed in the Commission's Green Paper on smoke-free environments. The 
analysis concluded that the policy of widest scope would bring the highest 
reductions in ETS exposure and related harm, on an equal basis to all European 
citizens, and would also be easier to implement than partial restrictions. 
The contributions to the Green Paper consultation (summarised in Annex II and 
described in detail in a separate report on the consultation outcome59) demonstrated 
clear support for comprehensive smoke-free policy. Over 60% of all institutional 
respondents (including 13 out of 17 Member States that replied to the consultation) 
believed that the best option is a comprehensive ban on smoking in all enclosed 

workplaces and public places, with only minimum exemptions for places that are de 
facto somebody's homes, such as designated rooms in nursing homes or mental 
health settings. A quarter of respondents (including four Member States) favoured 
different types of exemptions, in particular for hospitality venues or separate 
smoking areas. 70% of organisations that opted for exemptions were tobacco-related.  
Based on the FCTC commitment and the outcome of the Green Paper consultation, it 
is intended that all policy options should strive for the widest possible scope of 
protection from ETS exposure and, where possible, include also supporting measures 
to maximise the effects of smoke-free policies. It should be noted that the exact 
content of the initiative would be to some extent dependant on the choice of the legal 
instrument. For instance initiatives based on Art. 152 of EC Treaty (public health) 
could be wider in scope than those based on Art. 137 (health and safety at work). 
The likely content of each policy is described below. 
5.2. Available legal instruments 
In its Green Paper consultation, the Commission presented five possible forms of 
intervention to promote smoke-free environments in the EU. The consultation 
showed a strong support for further EU action in this area.  
  Overall, an EU Recommendation (from the Commission or the Council) and 
binding EU legislation were the two most popular policy options, supported 
by around 40% of institutional respondents each.  
  Open Method of Coordination was supported by only 10% of respondents. 
However, it was the second most popular policy option among Member 
States’ governments, either alone or in combination with other instruments. 
  Voluntary measures, while supported by 6% of respondents, were strongly 
criticised as ineffective in the area of tobacco control by the health 
stakeholders and some Member States.  
  One in eight contributors was of the opinion that the EU should not undertake 
any new activities on smoke-free environments, mainly on subsidiarity 

Figure 9: Support for various forms of EU intervention in the Green Paper consultation 
o re
atus qu
ry m
g le
All instruments presented in the Green Paper – except voluntary measures - have 
been included for further analysis. In addition, the Commission and Council 
Recommendation are examined separately as they differ slightly in terms of 
Voluntary measures have not been retained for further assessment as they have 
consistently proved ineffective in reducing exposure to tobacco smoke, in particular 
in hospitality and leisure venues.  
Voluntary agreements (self-regulation) tend to work most efficiently in clearly 
defined markets with a rather small number of key stakeholders where in addition a 
certain degree of basic framing legislation already exists. In the case of smoke-free 
environments, the multitude of stakeholders, who also differ significantly in size and 
character, would mean that proper monitoring and enforcement would be either 
impossible or trigger non proportionally high administrative and transaction costs. In 
addition, where there is a serious risk to people's health and safety, binding measures 
is usually the most appropriate choice to provide protection. National experience 
from countries such as the UK, Germany, Spain or the Netherlands showed that 
voluntary measures failed to achieve significant reductions in ETS exposure. For 
instance, in the UK, after five years of a voluntary agreement between the 
Department of Health and the key hospitality associations, fewer than 1% of bars 
were found to be smoke-free.60 In Spain, the legislation gave bars and restaurants 
below 100 m² the option to become smoke-free on a voluntary basis. After two and a 
half years only 10% of eligible bars and 15% of restaurants have decided to do so.61 
Likewise, in Germany only 10% of establishments were compliant with the 
voluntary agreement with the Federal Ministry of Health two years after its entry 
into effect.62 
The FCTC guidelines adopted unanimously by all FCTC Parties clearly state that 
voluntary policies are ineffective in reducing exposure to tobacco smoke. They were 

also considered of little value to solve the identified problem by the vast majority of 
contributors to the Green Paper consultation. 
5.3. Policy options 
1) No change from status quo 
This option would mean no new activity on the part of the EU, while continuing the 
current work
 on second-hand smoke under the different Community programmes 
(Second Health Programme 2008-2013, Seventh Research Framework Programme 
2007-2013, Life+ programme 2007-2010, Progress programme for employment and 
solidarity 2007-2013), information and education campaigns and networking 
2)  Open method of coordination  (OMC)  in respect of Member States' smoke-
free policies 

Under this option, Member States' would be encouraged to cooperate on smoke-free 
environments with a view to:  
-  Exchanging experiences and best practices on how to develop, enforce and 
monitor effective smoke-free policies, 
-  Agreeing common targets based on successful experiences, 
-  Developing a common set of indicators to monitor and evaluate progress, 
-  Periodic peer review, for example in the form of regular reports from the 
Member States. 
A co-ordinating body (working group, task force, network of competent authorities) 
bringing together the representatives of the Member States and the European 
Commission would need to be set up to facilitate the process by providing a forum 
for discussion, exchange of experience and peer review for the Member States. This 
needs to be seen in the context of the envisaged establishment of an implementation 
mechanism for the EU Health Strategy. Also existing structures, such as the Network 
of Competent Authorities on Heath Information and Knowledge, the EU Working 
Party on Health Indicators and/or the informal group of Member States liaison 
officials on tobacco advertising could be used.  
The content of this option would depend on agreements between Member States but 
theoretically could be comprehensive in scope. It could go beyond the FCTC 
guidelines (focused on protection from ETS in indoor public places and workplaces) 
to tackle additional settings such as homes and certain outdoor areas as well as 
flanking measures to encourage smoking cessation and raise awareness of the risks 
of active and passive smoking. Under this option, Member States would only agree 
on common policy objectives rather than prescribe the way to achieve them. 
3) / 4) Commission or Council Recommendation on smoke-free environments 
A Recommendation from the Commission or the Council based on Art. 152 of the 
EC Treaty would provide guidance and encouragement to Member States in 
introducing comprehensive smoke-free policies. Such recommendation would take 

into account and help enforce the FCTC requirement by introducing a uniform EU 
deadline for its implementation by all Member States and a clear reporting and 
monitoring mechanism (Member States to report periodically on the basis of 
indicators listed in the FCTC guidelines, Commission to report on the progress 
achieved based on Member States’ reporting). On top of the provisions of the FCTC 
guidelines, an EU Recommendation should include measures to tackle ETS exposure 
among children and adolescents (including in private settings and certain outdoor 
venues) as well as flanking measures such as awareness raising, smoking cessation 
support and the introduction of picture warnings with quit information on tobacco 
3+ / 4+  Combination of Commission or Council Recommendation and Open 
Method of Coordination 

Options 2 and 3/4 are not mutually exclusive and could complement each other. In 
particular, a Commission or Council Recommendation could be an incentive for 
strengthened cooperation between Member States. In this scenario, the text of the 
Recommendation would serve as a basis and point of reference while Member States 
would exchange information and best practice on its implementation, adopt common 
targets and benchmarks for reaching and possibly going beyond its requirements 
(e.g. on reduction of ETS exposure at home) and develop common indicators to 
monitor progress.  
5) Binding legislation on workers' protection from ETS 
The adoption of binding legislative measures could consist in revision of the 
existing directives 
based on the Framework Directive on the introduction of 
measures to encourage improvements in the safety and health of workers at work 
89/391/EEC. This could include, in particular, strengthening the requirements for 
the protection of workers from tobacco smoke in Directive 89/654/EEC on 
minimum health and safety requirements for workplaces and/or extending the scope 
of the Carcinogens and Mutagens Directive 2004/37 to cover tobacco (smoke).  
Tobacco (smoke) could be also automatically brought within the scope of the 
Carcinogens Directive by the amendment of Dangerous Substances Directive 
(67/548/EEC) to classify tobacco smoke or tobacco as a carcinogen. Another 
possibility would be to enact a separate directive on workplace smoking based on 
Art. 137 of TEC. 
A policy initiative based on Art. 137 TEC would be restricted in scope to the 
workplace environment and would not cover either public places that are not 
workplaces or self-employed workers (e.g. family-owned shops or restaurants that 
employ family members) who constitute around 12% of EU workforce overall and 
15% of hospitality workers.  

Advantages and disadvantages of different options 
Table 5 provides a qualitative description of the identified policy options across a 
number of parameters which supports the subsequent quantitative assumptions about 
the options impact on ETS prevalence made in the next section. The quantification of 
this table is presented in Annex VII. 
The parameters include: 
-  EU contribution: what does EU involvement bring compared to Member 
States action only. 
-  Timing: the expected speediness of adoption of the given policy instrument. 
-  Scope: the likely content of the policy option. For instance, an instrument 
based on Art. 137 of EC Treaty (health and safety at work) could not be as 
wide in scope as instruments based on Art. 152. 
-  Degree of bindingness: the level of political or legal obligation to comply on 
the part of the Member States.  
-  Risks:  possible unintended consequences 
Out of these, the level of bindingness is considered as most important, followed by 
scope and timing. 

Table 7: Advantages and disadvantages of the five policy options  
Status quo 
COM Recomm 
Council Recomm.  
COM Recomm. + 
Council Recomm +  
Binding legislation 
EU awareness raising campaigns 
There is a wealth of good practice in the  Would transpose the FCTC guidelines into the EU context, thus strengthening them and  Would impose enforceable 
can be effective in informing  EU, over a third of Member States having 
showing that the EU takes the FCTC process seriously and is committed to implementing  minimum level of protection 
about the risks of passive adopted comprehensive smoke-free laws.  
international resolutions. 
from workplace exposure to 
smoking (positive experience with 
tobacco in all Member 
Would assist Member States to comply and go beyond their international commitments 
HELP campaign) and increase  Coordination of national efforts could 
under the FCTC.
bring about a process of mutual learning 
the effectiveness of regulatory 
measures at national level.  
and sharing of best practices in particular 
At the same time, Member 
The requirement to report progress and  Could bring about a process of mutual 
on novel/sensitive policy issues such as 
States would be free to 
Projects realised under various 
make the results publicly available could  learning and sharing of best practices in 
tackling ETS exposure in semi-residential 
maintain or adopt measures 
Community programmes (health, 
further support Member States in policy  particular on novel/sensitive policy issues 
settings (e.g. prisons, long-term hospitals) 
going beyond EU "minimum 
research, environment, 
development and enforcement. 
such as tackling ETS exposure in semi-
or certain outdoor places. And EU 
employment) could provide 
residential settings or certain outdoor places. 
monitoring mechanism could encourage 
further evidence base (e.g. on the 
policy development and enforcement. 
The reporting and monitoring mechanism, 
prevalence of ETS exposure, 
On the other hand, the utility of OMC is 
common targets and harmonised set of 
impact of smoke-free policies) 
limited by the fact that what is "best 
indicators could further support Member 
and support policy developments 
practice" in the area of protection from 
States in policy development and 
in the MS.  
ETS (at least in indoor workplaces and 
public places) has been already agreed 
upon and codified in the FCTC guidelines. 
Current trend towards smoke-free 
The establishment of a coordinating body 
Likely to be adopted  Likely to be adopted  While developing 
While developing 
The time period for the 
environments would probably 
and developing common targets, 
within a short time.  
within a relatively  common 
realisation of the benefits 
continue but at a slower pace. 
indicators and implementation modalities 
short time. 
benchmarks and 
benchmarks and, 
stemming from a new legal 
There was a big jump in policies 
would be relatively lengthy and resource-
Could be speedier 
indicators would be 
indicators would be 
instrument is likely to be 
since 2004 but the momentum 
and easier to adopt  Could be more 
rather lengthy, the 
rather lengthy, the 
relatively lengthy given the 
seems to have faltered and some 
than Council 
difficult to adopt 
background Council 
mandatory two-stage 
countries (e.g. Germany) are 
than Commission 
consultation of the 
experiencing roll-backs. 
could be adopted 
European social partners, 
given some MS’ 
could be adopted 
within a relatively 
the duration of the co-
reluctance to 
within a short time. 
short time (though 
decision procedure and the 
somewhat longer 
transition period before its 
smoke-free policies 
than would be the 
entry into force.  
and/or EU action in 
case with 
this area. 

Status quo 
COM Recomm 
Council Recomm.  
COM Recomm. + 
Council Recomm +  
Binding legislation 


The scope of national smoke-free 
Depending on agreements of Member 
Could have wider scope than a legislative instrument based on Art. 137 TEC and cover all  Legislation based on Art. 
measures would continue to 
States, but could be comprehensive in 
workplaces, public places and home environment as well as supporting measures such as  137 TEC would be focused 
differ. It could be expected that 
cessation policies or awareness raising campaigns 
on workers' health and 
the hospitality sector would 
safety and would not cover 
remain the most difficult area of 
Could set a "golden standard" to guide countries in their smoke-free efforts instead of  self-employed workers nor 
"minimum requirements" 
would it cover public places 
that are not workplaces or 
flanking measures. 
There would be no new 
Non-binding. While there would be no 
Would not have binding force. There would be no sanctions for non-compliance 
Binding. Sanctions for non-
commitments, neither binding nor 
sanctions for non-compliance, Member 
non-binding, under this option. 
States could be expected to experience 
Member States 
MS would be 
MS would not be 
Involvement in 
would not be part of  involved in 
involved in 
developing the 
some peer pressure. 
the process and developing the 
developing the 
might thus feel less  Recommendation 
and the modalities 
bound by the 
which would 
and might thus feel 
for its 
enhance their sense 
less bound by its 
of ownership and 
would create a 
the commitment to 
However, the peer 
strong sense of 
agreed objectives  
pressure from other 
ownership and the 
MS would likely 
commitment to 
create some political 
agreed objectives 
among MS.  

Treaty requirement of high level 
Would only set objectives rather than 
Could be criticised for not providing sufficient response to tackle the problem. 
Could require adaptations of 
of health protection and 
prescribe concrete way to achieve them.  
existing comprehensive 
international obligations under 
Could possibly only encourage already 
national smoke-free laws / 
the FCTC would not be met.  
better-performing countries to improve the 
Lost opportunity to build on the 
measures in place but would constitute 
It might be difficult to 
support received in the Green 
limited incentive for less advanced 
demonstrate that smoke-
Paper consultation.  
countries to introduce smoke-free laws 
free legislation cannot be 
Funds for tobacco awareness 
achieved by MS alone 
campaigns limited until 2010.  
without giving them the 
chance to do so via non-
binding measures.  


Impacts of different options 
Based on the considerations in the previous section, this section attempts to predict 
the potential impacts of each of the policy options by also taking into account 
previous experience in similar policy areas and developments at national level. These 
scenarios constitute only a rough approximation of policy options as the impact of 
each policy option not only depends on the proposed policy measures but also on the 
approach to implementation by Member States, making it difficult to provide an exact 
If all Member States adopted and enforced strict smoke-free laws, ETS prevalence  
rates could theoretically drop by up to 100% and the prevalence could go down to 0%. 
The level of implementation in all Member States equal to that in Ireland would result 
in an 89% reduction in ETS prevalence ratios in indoor workplaces/offices (from the 
current 28% to 3% among  staff) and a 100% reduction in bars and restaurants (from 
the current 39% to 0% among staff). The implementation throughout the EU equal to 
the average of Ireland, Italy and Sweden would result in a 54% reduction in 
prevalence ratios in workplaces/offices and a 57% reduction in bars and restaurants, 
with staff exposure going down to 12.7% and 16.7%, respectively.  
The following assumptions have been made about the potential reductions in ETS 
prevalence under each of the policy options by 2013 (i.e. the last year of the current 
Health Strategy):  
•  Policy 1 (status quo) would bring the least (around 6%) reduction in ETS 
prevalence ratios, decreasing the overall prevalence by around 2 percentage 
points. The existing trend towards smoke-free could be expected to continue, but 
at a slower pace. The 6% reduction would be largely consistent with a situation in 
which countries with advanced or fairly advanced smoke-free legislation 
proposals (Latvia, Romania, Austria and the Czech Republic) have implemented 
their proposed policies by 2013 (assuming the level of implementation equal to 
the average of Ireland, Italy and Sweden for comprehensive bans and half that 
effect for partial bans). Under this option, almost two thirds of Member States 
would not meet their FCTC obligation by 2013.  
•  The effects of the five non-regulatory options - Open Method of Coordination, 
Commission Recommendation (with OMC) and Council Recommendation (with 
OMC) - are likely to be somehow similar in the sense that they would offer 
support for policy development but could not oblige Member States to adopt and 
enforce smoke-free laws. They are expected to have the potential to bring about a 
two- (13%) to fourfold (26%) reduction in ETS prevalence ratios as compared to 
the status quo, which would translate to a reduction in prevalence ranging from 
around 4 to 8 percentage points.  
-  Policy 2 (OMC) and Policy 3 (Commission Recommendation) can be 
expected to primarily improve the performance of already more advanced 
countries by encouraging them to strengthen their legislation and/or ensure 
better enforcement. The implementation of OMC would be relatively slow and 
it does not seem well suited to tackling a "mature" problem like ETS. The 

impact of a Commission Recommendation would be limited by the fact that it 
would not create a sense of commitment among Member States. For the 
purpose of the analysis, it is thus assumed that the impact of these two options 
would be closer to the lower bound of 13% reduction in ETS prevalence 
ratios. This would be equivalent e.g. to smoke-free legislation proposals in 
Latvia, Romania, Austria, the Czech Republic and Poland being successful 
(assuming the level of implementation equal to the average of Ireland, Italy 
and Sweden for comprehensive bans and half that effect for partial bans). 
-  Policy option 4 (Council Recommendation) is potentially more effective, 
primarily due to the ownership effect and could be expected to incite 
additional countries to adopt more stringent smoke-free measures and enhance 
the implementation of existing measures. Historical experience indicates that 
Council Recommendations often result in quick implementation of EU 
proposals by Member States. For instance following the adoption of the 
Council Recommendation on Cancer screening, eight, nine and eleven 
additional Member States were running and establishing population-based 
programmes in breast, cervical and corolectar cancer in 2007 compared to 
fifteen, fourteen and six in 2002-4, respectively. Similar effects could be 
assumed for option 3+ (a combination of OMC and a Commission 
Recommendation), which would likely be more effective than any of these 
two options in isolation. Commission Recommendation could be equal in its 
content as a Council Recommendation and the OMC could create a level of 
political commitment equal to that under a Council instrument. The 
combination of these two options could therefore achieve similar results as 
option 4, however the implementation of OMC would be more lengthy. For 
the purpose of the analysis, it has been assumed that options 4 and 3A would 
bring a reduction to ETS prevalence ratios in the range of 13% to 26%.  
-  Policy option 4+ (Council Recommendation with OMC) could be expected to 
be most effective out of the non-regulatory options. It would create the 
strongest sense of ownership and commitment among Member States who 
would be involved both in adopting the text of the Recommendation and in 
developing benchmarks and indicators for its implementation.  That is why it 
is assumed to be most likely to reach the upper range of 26% reduction in ETS 
prevalence ratios. This would be equivalent to all current smoke-free 
legislation proposals (Latvia, Romania, Austria, the Czech Republic, Bulgaria, 
Greece, Hungary, Poland and Slovakia) being successful in addition to 
Portugal, Denmark and the Czech Republic brining down exposure in 
workplaces/offices and Portugal, Denmark and Belgium in bars/restaurants to 
the average of Ireland, Italy and Sweden. 
•  Policy 5 (binding legislation) is likely to result in all Member States having strict 
and properly enforced smoke-free laws in place. In the best-case scenario, it could 
be expected to bring down the prevalence rates in all Member States to those in 
Ireland, corrected for the fact that it would be somewhat narrower in scope than 
the Irish ban since self-employed workers would not be covered by the legislation. 
As a result, after this correction, the ETS prevalence ratios in offices would be 

reduced by 76-78% and by 85% in bars/restaurants. This would mean that the 
ETS prevalence would go down to 6.7% and 6%, respectively. The benefits, 
however, would only realise once the legislation is adopted and transposed. 
These assumptions are largely consistent with those of the stakeholder organisations 
that provided their ratings in reply to targeted stakeholder consultation (see Annex II). 
However, the expected reductions in ETS prevalence are slightly larger for policies 1-
3 and substantially more conservative for policy 4. It should also be noted that only 
health stakeholders chose to take part in the exercise. 
6.2.1. Social 
Reduced morbidity and mortality from passive smoking 
By reducing the prevalence of ETS exposure in workplaces and public places, an EU 
initiative could be expected to reduce illness and mortality from major ETS-associated 
diseases (lung cancer, stroke, heart disease and chronic lower respiratory diseases) 
and increase healthy life years. Although the full health benefits may take longer to be 
realised for some diseases (such as the lung cancer), they may occur relatively quickly 
for others (such as short term respiratory symptoms).  
Various studies have shown substantial reductions in the incidence of heart attacks 
following the introduction of smoke-free policies, including a drop of 11% in Ireland 
and Italy, a 17% drop in Scotland and even greater reductions in the US 
jurisdictions.63 Studies in Ireland, Scotland, Spain and the US have also shown 
substantial reductions in respiratory symptoms in hospitality workers as a result of 
smoke free workplaces ranging from 13 to 50%.64  
Annex VII calculates the expected annual reductions in premature mortality from lung 
cancer, stroke, heart disease and chronic lower respiratory disease under each of the 
policy options based on the assumptions about their potential to reduce the prevalence 
of ETS exposure. Policy option 5 (binding legislation) is expected to bring the largest 
reduction in annual deaths - up to 4,884 prevented deaths in office and hospitality 
staff, including 2,151 deaths among non-smoking employees. This means that around 
80% of deaths due to ETS among employees would be prevented. The corresponding 
figures under option 4+ (Council Recommendation with OMC) would be 1,550 and 
646, respectively, which would prevent a quarter of staff deaths. The impact would be 
somehow smaller under options 4/3+ (Commission Recommendation with OMC/ 
Council Recommendation) and 2/3 (OMC / Commission Recommendation) and 
significantly smaller under the status quo. The impact on mortality should be regarded 
as annual deaths prevented in the longer run as the full effects of reduced ETS 
exposure will not fully materialise until several years have passed.  
These estimates only include staff members of offices and bars, pubs and restaurants. 
However, visitors of these places will be affected as well. It is difficult to estimate the 
effect on non-staff members because reliable data on ETS in this group are not 
currently available. As an example, the English Impact Assessment estimated the 
monetary value of averted deaths from ETS among customers (after implementation 

of the full ban) to be over 15 times greater at £350 million than the value of averted 
deaths among employees at £21 million. Modest additional reductions in mortality 
could also be expected in workplaces other than offices and bars/restaurants where 
exposure to ETS may occur.  
Reduced morbidity and mortality from active smoking 
In addition to the direct effect on exposure to tobacco smoke, the initiative could also 
be expected to have an indirect effect on active smoking. 
Smoke-free policies have been reported to reduce tobacco consumption and 
encourage quit attempts among smokers, thus contributing to a reduction in smoking 
prevalence. Estimates on reductions in cigarette consumption due to smoking bans 
range from 1.2 to 3 cigarettes per day at the individual level, and 4% to 29% at the 
population level. Various studies have reported people quitting smoking after the 
introduction of smoke-free policies. Eight studies and two reviews showed reductions 
in smoking prevalence, ranging from about two to six percentage points. Workplace 
smoking bans have also been shown to reduce smoking uptake in young people.65 The 
four UK impact assessments estimated a 1.7% (England) to 2% (Scotland, Wales, 
Northern Ireland) fall in smoking prevalence as a result in comprehensive smoke-free 
Increased quitting and reduced consumption could bring significant health benefits by 
contributing to the decrease of morbidity and mortality associated with smoking. The 
largest benefits could be associated with binding legislation and the smallest with 
status quo option. 
Reduction in socio-economic inequalities 
Given that both active and passive smoking are strongly correlated with socio-
economic status, an EU smoke-free initiative might be expected to bring particular 
benefits to the most deprived groups in society. 
The equitable potential of smoke-free legislation has been demonstrated in a number 
of studies which showed that smoking bans reduced ETS exposure as well as tobacco 
consumption particularly in disadvantaged communities and have not resulted in 
displacement of ETS into home.66 
While in New Zealand the higher level of ETS home exposure among Maori 
disappeared after the introduction of smoke-free legislation67, in Ireland the 
disparities in smoking in the home persisted between socio-economic groups68. This 
seems to suggest that smoke-free legislation should be supported by awareness-raising 
programmes targeted at disadvantaged groups in order to maximise the effects of 
smoking bans in venues not covered by the legislation such as private homes. 
Impact on attitudes  
Attitudes towards smoking bans are diverse and vary between Member States. An EU 
initiative could be expected to help create the awareness about the dangers of passive 

smoking and increase support for smoke-free measures. Evidence from many 
countries suggests that public support for smoke-free laws increases after they are 
introduced, for instance in Ireland from 59% to 93%.69 
A possible unintended consequence for smokers could be a sense of stigma and 
alienation linked to decreasing social acceptability of smoking.70 
Reduction of ETS exposure at home 
An indirect consequence of an EU smoke-free initiative could be a reduction in the 
prevalence of smoking at home. Studies from Scotland, Ireland, New Zealand and the 
US reported reductions in the prevalence of smoking at home after the introduction of 
smoking bans, ranging from 5 to 20 percentage points.71  
It is anticipated that all of the social impacts described above will occur under each 
policy option, but policy option 5 (binding legislation) would bring about the 
strongest change, followed by option 4+ (Council Recommendation with OMC), 4/3+ 
(Commission Recommendation with OMC/Council Recommendation) and 2/3 
(OMC/Commission Recommendation) while the status quo would bring only modest 
6.2.2 Economic 
The health improvement resulting from an EU smoke-free initiative could have an 
important economic effect. Some gains (such as averted direct and indirect costs of 
respiratory and cardiovascular diseases) could be expected to materialise relatively 
quickly while others (e.g. related to the reduction in the incidence of lung cancer) 
would be longer-term. 
The regulatory impact assessments carried out in the UK estimated the net benefits of 
comprehensive smoke-free legislation at £1,689-2,094 million in England (long-term 
annual benefits), £136.93 million in Wales (annual total net present value based on 30 
years appraisal) and £82.68 million in Northern Ireland (annual benefits based on 30 
years appraisal). In Scotland, the total net present value over a 30 year period was 
calculated at £4,387 million.  
Macroeconomic impacts  
By reducing the prevalence of ETS exposure, an EU initiative can also be expected to 
reduce medical and non-medical costs associated with major ETS-associated diseases 
(lung cancer, stroke, heart disease, and chronic lower respiratory disease) and result in 
substantial cost savings. As is the case with the previous health benefit estimates, the 
cost savings estimates under each of the options are linearly related to the assumptions 
these options' impact on ETS prevalence reductions. 
Indirect impact on medical and non-medical costs 

Medical costs include primary care, accident and emergency care, hospital inpatient 
care (including day cases and cardiac rehabilitation systems), outpatient care, and 
medications. Non-medical costs include informal care, productivity costs due to 
mortality and productivity costs due to morbidity (such as sickness absences). As 
shown in detail in Annex VII, policy option 5 (binding legislation) would have the 
largest expected reduction in both medical and non-medical costs, up to €1.073 billion 
and 893 million, respectively, among smoking and non-smoking staff in indoor 
workplaces/offices and bars/restaurants each year, followed by option 4+ (Council 
Recommendation with OMC with a potential of €344 million and €290 million 
reduction, respectively, options 3+/4 (Commission Recommendation with 
OMC/Council Recommendation) and options 2/3 OMC/Commission 
Recommendation. In contrast, reduction under the status quo would be only modest. 
Similarly to the previous health benefit estimates, these figures are probably 
conservative since they exclude reduction of medical and non-medical costs 
associated with reduced ETS exposures among non-staff members and in settings 
other than offices and bars/restaurants. 
Regulatory impacts assessments in the UK have also shown the medical and non-
medical savings as a result of comprehensive smoke-free legislation to be substantial. 
The annual monetary health benefits due to reductions in active and passive smoking 
were estimated at £3211- £3621 million in England72 £155.9 million in Wales73, 
£221.5 million (range: £44.4 million – £399.3 million) in Scotland 74 and £55.1 
million in Northern Ireland 75 
Table 8:    Expected health benefits and resource savings from comprehensive smoke-free 
legislation in UK Impact Assessments 
England * 
Scotland *  
Wales *** 
Health benefits 
Economic value  Reduced exposure to  371 (21 – 
5.47 91.4 
of lives saved 
employees + 350 
16.8 – 176.7) 
Reduced active 
1,780 (1,600 
19.35 108.5 
employees + 180 
11.7 – 169.7) 
Reduced uptake of  550 - - - 
Reduced exposure to  - 14.42 
savings (Human  ETS  
10.8 – 36) 
Cost of ill Reduced active 
- 11.14 

Resource savings 
NHS Treatment  Reduced exposure to   
5.3 (range: 4.5  2.9 
– 11.5) 
Reduced active 
2.8  (range 1.2  2.2 
– 4.2) 
Reduced exposure to  70-140 0.6  4.1 – 5.2 

Reduced active 
0.8 (0.34 – 1.2) 
Production gains (from reduced exposure  340-680 


to ETS) 
Total  (£million) 
3,211 – 3,621 
221.5 (range: 
44.4  – 399.3) 
* Annual benefits   
** Annual benefits based on 30 years appraisal   
*** Annual net present value based on 30 years appraisal 
Direct impact on revenue from tobacco taxes 
A reduction in the levels of active smoking as a result of an EU initiative could 
theoretically result in some decrease in revenue from taxes (excise duty and VAT) on 
tobacco products. It should be noted, however, that - although tobacco taxation 
generates significant revenues – in the majority of Member States it does not make up 
a major share of the state budget. Tobacco excise duties represented between 0.7% 
and 7.3% of the total tax revenues of the Member States in 2005 but exceeded 5% 
only in four countries (Greece, Romania, Bulgaria, Luxembourg). In addition to a 
reduction of the societal costs associated with smoking the disposable income of 
smoking households would increase if smoking bans were introduced, and the 
revenue from VAT accruing from alternative investments and expenditure by such 
households would to some extent off-set the revenue lost. 
Moreover, tobacco taxation forms part of the overall strategy of prevention and 
dissuasion of tobacco consumption. In recent years tobacco taxes have significantly 
increased in the EU, resulting on the one hand in a decrease of tobacco consumption 
and, on the other hand, in almost all cases in an increase or at least a stabilisation of 
the revenue from tobacco taxation. This trend will probably continue. In this context a 
possible reduction in the levels of active smoking as a result of a smoke-free initiative 
is unlikely to have a noticeable impact on the budget of the Member States. 
Table 9: Tobacco excise duties as a % of total tax receipts in 2005 
Sweden 0,7% 
Slovenia 0,8% 
Denmark 0,9% 
Finland 1,2% 
Poland 4,8% 
Netherlands 1,5% 
Belgium 1,8% 
Greece 5,6% 
Lithuania 1,8% 
Austria 2,0% 
France 2,1% 
Micro-economic impacts  
The economic impacts at the micro-level include reduced cleaning, maintenance and 
redecorating costs and reduced costs related to fire damage. The total savings to the 
cost of fires, cleaning and redecoration resulting from a smoking ban estimated in the 
four impact assessments for the UK added up to £197 million, or 0.015% of the UK 
GDP. Applying this fraction to the GDP of Member States that did not have a full 
smoking ban by 2008, the total annual savings from a smoking ban across the EU-27 

(i.e. policy 5) are estimated at €965 million. The other policy options would also help 
reduce the costs but to a lesser degree.  
Potential productivity gains could also be expected from a reduced number of 
smoking breaks. It is unclear, however, to what extent these savings could be fully 
realised in practice, as workers might choose to take smoking breaks outside 
buildings. It is interesting to note, that while the impact assessments carried out in 
Scotland and Northern Ireland predicted positive impact on workers' productivity as a 
result of reduced smoking breaks, in England and Wales production losses were 
expected from smokers who were previously allowed to smoke at work and would 
continue to smoke outside the building.  
Distributional effects 
The economic effects of smoking bans have been assessed for two different sectors: 
the tobacco industry and the hospitality industry. These estimates do not have the 
same degree of certainty as the results for health effects as the scientific evidence is 
not as well-established. 
Impact on hospitality industry 
The evidence reported in the literature on the magnitude and impact of smoking bans 
on the hospitality sector appears mixed, ranging from reductions (a 4.4% decline in 
bar and pub sales in Ireland and 10% decline in pub sales in Scotland), to increases (a 
6% increase in sales in restaurants/licensed cafes in Norway and 9% increase in New 
Zealand). These estimates however, need to take into account the context within 
which these changes occur and the methodology of the studies. For example, the 
effect of a 4.4% reduction in retail sales in bars and clubs in Ireland was in line with 
pre-existing trends while the Scottish study was based on self-reported data.  
It is noteworthy that a 2008 update of the 2003 international review by Scollo of the 
quality of the studies on the economic effects of smoke-free policies on the hospitality 
industry found that 47 of the 49 studies that are best designed report no negative 
impact on measures such as taxable sales.76 A summary of results of the 2008 update 
is provided in the box below. 

Box 1: Summary of studies assessing the economic impact of smoke-free policies in the 
hospitality industry  
•  No negative economic impact from the introduction of smoke-free policies in restaurants and 
bars is indicated by 47 of the 49 studies which meet all four of Siegel's criteria on 
methodological quality, i.e. where findings are based on an objective measure such as taxable 
sales receipts, where data points several years before and after the introduction of smoke-free 
policies were examined, where changes in economic conditions are appropriately controlled 
for, and where appropriate statistical tests are used to control for underlying trends and 
fluctuations in data. 
•  One of the two studies meeting all four of Siegel’s criteria (that did find a negative impact 
(Evans 2005), was not peer-reviewed and was based on assessments from a highly selective 
sample of proprietors. The other (Lal and Siahpush 2008) assessed the impact of smoke-free 
policies in gaming venues, a measure intended to reduce problem gambling in Victoria and 
introduced in parallel with a number of other measures aimed at reducing worrying levels of 
spending among low-income earners living in neighbourhoods with high numbers of poker 
machines in accessible venues such as corner pubs. 
•  Apart from the notable exception of Lal and Siahpush (2008), studies concluding a negative 
economic impact have predominantly based findings on outcomes predicted before 
introduction of policies, or on proprietors’ subjective impressions or estimates of changes 
rather than actual, objective, verified or audited data. These studies were funded 
predominantly by the tobacco industry or organisations allied with the tobacco industry.  
•  Almost none of the studies finding a negative impact are published in peer-reviewed journals. 
Source: Adapted from: Scollo and Lal (2008) 
Based on the comprehensive Scollo and Lal (2008) review it is expected that an EU 
initiative would have no major impact on the hospitality industry. However, it is still 
informative to extrapolate the range of effects reported in the literature to an EU-wide 
The revenue for bars and restaurants for EU countries with no smoking bans stands at 
€114 billion, and the number of staff employed in this sector is approximately 3.6 
million. According to the literature, the effect of a smoking ban on hospitality 
revenues ranges from a reduction of 10%77 to an increase by 9%78. As a result, the 
estimated change in revenues due to an EU-wide smoking ban (policy 5) varies 
between -€11 and +€10 billion annually. The estimated changes in employment in 
restaurants/pubs/bars also vary. Following the range of effect estimates reported in the 
literature (from an 8.82% reduction79 to 9% increase80), it is estimated that an EU-
wide smoking ban (i.e. policy 5) would result in one-off changes  in  the  range  of     
265 000 jobs lost to 271 000 jobs gained. The magnitude of impacts would be 
somehow smaller under options 4+, 3+/4 and 2/3 and significantly smaller under 
option 1. 
Previous regulatory impact assessments which have estimated the economic impacts 
for the hospitality sector have also reported a range of estimates. Overall, there 
appears to be a largely neutral effect. In Northern Ireland and Wales, the effect of a 
full ban on the hospitality sector, based on 30 year appraisal, was estimated at -£46 
million and +£160 million , respectively. 

Impact on tobacco industry 
As smoke-free policies are reported to reduce the sales of cigarettes, there may be a 
loss of profit to the tobacco industry and, consequently, reductions in tobacco-related 
employment. However, these impacts are expected to be relatively small. 
The revenue from tobacco sales across the EU-27 in 2007 is estimated at €67 089 
million. According to the literature, the effect of a smoking ban on tobacco revenue 
ranges from a reduction of 5.5%81 to 14%82. One could expect to see about half of this 
effect if an EU-wide smoking ban would be implemented, because various countries 
already have smoking bans in place. For the entire EU-27, the expected loss in 
revenue under Policy 5 is within a range from €1 844 million to €4 696 million. It is 
interesting to note that the regulatory impact assessment for England estimated the 
annual loss of profit to the tobacco industry and tobacco retailers to be slightly over 
two times greater at £97 million with a full ban, compared with voluntary action 
(equivalent to “no change from status quo”) at £43 million.  
The number of staff employed in the tobacco industry across the entire EU in 2007 is 
estimated at 53 500. Assuming the ratio of employment/revenue to be constant in the 
longer run, an EU-wide smoking ban (Policy option 5) would lead to a loss within a 
range from 1 472 to 3 746 jobs ) in the tobacco industry in the longer run. As is the 
case with hospitality impacts, this is not an annual loss, but rather an overall shrinkage 
of the tobacco industry workforce. Considering that the current EU-27 labour force 
contains 218 million workers, even the upper bound estimate on jobs lost would 
represent less than 0.002% of the entire EU-27 labour force. The magnitude of 
impacts would be somehow smaller under options 4+, 3+/4 and 2/3 and significantly 
smaller under option 1. 
Table 10 Estimated lost revenues in tobacco sales and jobs due to EU-wide smoking ban  
Lost revenues and jobs due to smoking 
2007 estimate 
Lower bound 
Upper bound 
EU-27 revenues 
€67,089 M 
€1,844 M 
€4,696 M 
EU-27 jobs 
1,472 3,746 
Impact on other industries  

There is little evidence available on the impact of smoke-free legislation on revenues 
and employment in other industry sectors.  
Given that the sales of pharmacological cessation aids increase with the introduction 
of smoking bans, it could be expected that the initiative will have a positive impact on 
the pharmaceutical industry in the short run. On the other hand, this could be offset by 
decreased sales of prescription drugs as a result of reduced morbidity due to ETS. At 
the same time, smoke-free policies save many people from dying prematurely, and 
these people will likely consume many prescription drugs, leading to increased 
revenues for pharmaceutical industry in the longer run. 

In the event that some Member States allow for the possibilities of technological 
solutions for controlling ETS (such as separately ventilated smoking rooms), there 
would be benefits to the indoor air treatment industry. 
It could be also expected that money not spent on tobacco products would be spent on 
other goods and services, generating revenue and employment in other sectors of the 
Implementation and enforcement costs  
There are various implementation and enforcement costs which may arise with an EU 
initiative. These affect both public authorities (adoption, enforcement, monitoring and 
evaluation of legislation, smoking cessation support, public awareness measures) and 
private actors (signage, possible technological investments) However, these costs are 
likely to be rather small compared to the costs saving achieved through lives saved 
and morbidity savings.  
The annual costs of compliance checks, monitoring and evaluation to public 
administration have been estimated at 2.7 million pounds (3.3 million euro) in the 
Northern Irish IA and 30 million pounds (36 million Euro) the English IA. This 
represents 1/26 and 1/1000 of the expected benefits in the respective countries. The 
implementation and enforcement costs could be expected to be highest for binding 
legislation (which would impose binding minimum requirements throughout the EU) 
and the continuous multi-tier cooperation under the open method of coordination  
(options 2, 3+ and 4+). The cost of setting up a coordination body under the OMC 
could be offset by making use of one of the existing structures such as the informal 
network on tobacco advertising. 
Private actors' implementation costs are higher in the presence of partial bans or laws 
with exemptions than in full bans given the need for increased signage and investment 
costs when e.g. smoking rooms are allowed. The UK IA estimated implementation 
costs to be 5 million pounds with a full ban annually, but pointed to international 
evidence suggesting that as compliance for smoke free legislation builds quickly once 
implemented, costs decrease significantly in subsequent years.  
6.2.3 Environmental 
The main environmental impact would be a significant improvement in indoor air 
quality thus contributing to the objectives set out in the European Environment and 
Health Strategy. It expected the largest improvements in air quality will arise with a 
binding legislation. However the other four policy options will also bring about 
improvements in air quality, but to a lesser degree. For the eight studies that reported 
on the effects of smoking bans on air quality, all showed large reductions in 
particulate matter (PM) pollution, ranging from 83% (Irish bars) to 93% (U.S. bars).83  

The potential negative impacts could include an increase in the use of patio heaters 
outside bars and restaurants as well as the increase in litter from cigarette butts in the 
streets. However, these impacts are likely to be relatively small. 
Comparing the options 
Table 11: Expected impacts of different options  
Policy 1 
Policy 2/ 
Policy 3+ 
Policy 4+ 
Policy 5 
 Policy 3 
/Policy 4 
Social impacts   
Reduction in annual mortality due to ETS exposure 
-386 -774 
-774 to -
-1,550 -4,884 
among staff  
Reduction in morbidity due to ETS exposure 
+ ++ +++ 
Reduction in mortality from reduced active smoking 
+ ++ +++ 
Reduction in morbidity from reduced active 
+ ++ +++ 
Reduction of ETS at home 
+ ++ ++ ++ +++ 
Reduction in socio-economic inequalities 
+ ++ ++ ++ ++++ 
Increased support for smoke-free policies 
+ ++ ++ ++ ++++ 
Economic impacts 
Reduction in annual medical costs due to reduced 
-€172 mn to 
-€ 85 mn 
-€172 mn 
-€344 mn 
-€1073 mn 
ETS exposure among staff  
-€344 mn 
Reduction in annual non-medical costs due to 
-144 mn to -
-73 mn 
-144 mn 
-290 mn 
-893 mn 
reduced ETS exposure among staff  
290 mn 
Reduced revenues from tobacco taxes 
 - -- --- ---- 
Workers' productivity related to smoking breaks  
+/- ++/-- 
Reduced costs of fires, cleaning and redecoration 
+ ++ +++ 
€965 mn 
Annual change in revenues in hospitality sector  
€114 bn 
+/- ++/-- 
-€11bn to 
+€10 bn 
Change in employment in hospitality sector 
+/- ++/-- 
-265,000 to 
Annual lost revenues in tobacco industry 
- -- --- ---- ----- 
-€3.3 bn 
Lost  jobs in tobacco industry 
- -- --- ---- ----- 
Implementation and enforcement costs 
- --- 
--  --- 
Environmental impacts 
Reduction in indoor air pollution 
+ ++ ++ +++ 
Increased street litter and use of air heaters 
 -  -  -  --  --- 
Policy 1 = No change from status quo; Policy 2 = OMC; Policy 3 = Commission recommendation; Policy 3+ = Commission recommendation with OMC; 
Policy 4 = Council recommendation; Policy 4+ = Council recommendation with OMC; Policy 5 = Binding legislation 

The preferred option 
The analysis has shown that status quo, Open Method of Coordination and 
Commission Recommendation would bring only modest reductions to ETS 
prevalence and the related health and economic burden. Commission 
Recommendation with OMC/Council Recommendation 
and Commission 
Recommendation with OMC are likely to have more impact primarily due to the 
ownership effect. The impact could also be expected to materialise relatively quickly. 
Binding legislation would bring the maximum possible reduction in ETS exposure 
and virtually eliminate exposure in indoor workplaces and the related deaths among 
staff members and visitors. However, the implementation would take longer and the 
scope would be narrower than would be the case with a Recommendation.  
While binding legislation could potentially bring the biggest health and economic 
benefits, a Council Recommendation complemented by strengthened cooperation 
between Member States has been identified as the preferred option in the short term 
since binding legislation would either not be wide enough in scope or raise 
subsidiarity issues.  
Such a Recommendation would enhance the sense of ownership and commitment to 
smoke-free objectives among Member States and assist them in meeting their 
international obligations under the FCTC, while providing a proportionate approach to 
the problem. In order to increase the effectiveness of the measure, it should include 
reporting and monitoring requirements and the establishment of an implementation 
body to develop common benchmarks and indicators.  
In case Member States do not adopt or enforce clear smoke-free policies within a 
certain time period, a Recommendation could be complemented in the longer term by 
binding EU legislation aimed at workplace protection from tobacco smoke. 
6.5. Conclusions 
The adverse health effects of exposure to second-hand smoke have been well 
researched and established during the past 20 years. The analysis has shown that the 
current burden of ETS is substantial. It is estimated that 6 000 adults, including        2 
500 non-smokers, died to ETS exposure at their workplace in 2008. This translates 
into over 1.3 billion euro of medical costs and over 1.1 billion euro of non-medical 
costs, including productivity losses. Additional preventable deaths and costs occur 
among customers (non-staff members), in particular of bars and restaurants. 
On average, it is estimated that 28% of EU employees are exposed to ETS in indoor 
workplaces and offices and 39% are exposed in bars, cafes and restaurants, as of end-
2008. There are huge disparities in protection both between and within Member 
States, resulting in avoidable health inequities.     

At this moment, an EU initiative on smoke-free environments would undoubtedly 
bring an added value to Member States' efforts to tackle the problem of passive 
smoking, thus contributing to reducing the health, social and economic burden of ETS 
According to the report's estimates, a Council Recommendation with strengthened 
Member States' cooperation would have the potential to prevent at least 1 550 
premature deaths among office and hospitality workers and reduce the related costs by 
over 630 million euros each year. Additional benefits could be expected in non-staff 
members such as the visitors.  
The Commission proposes a gradual approach to address the problem at hand and 
achieve the policy objectives, i.e. first a Council Recommendations, possibly followed 
by further measures. 
Such a gradual approach should provide the necessary encouragement for Member 
States’ action while respecting the principles of subsidiarity and proportionality.  
In addition, current work on second-hand smoke under the different Community 
programmes will continue. The Commission will also continue its media prevention 
campaign beyond 2010 provided that adequate resources are made available. 
The indicators used to monitor the effects of the chosen policy option need to cover 
the following data: 
1. Prevalence and quality of national smoke-free policies 
2. Exposure to tobacco smoke in different settings, including: 
-  workplaces,  
-  public places, 
-  private homes. 
3. Tobacco use, including: 
-  prevalence,  
-  consumption,  
-  quit attempts  
4. Knowledge and attitudes related to tobacco (smoke)  
5. Incidence of and mortality from tobacco-related diseases 
There are a number of sources of information in place or under development that can 
provide information on tobacco-control indicators.  
European Health Interview Survey (EHIS) is currently being implemented in most 
Member States (data will be available in 2010 at the earliest) and will then be carried 
out every 5 years (second round in 2013).  The questionnaire contains eight tobacco-
related questions (see Annex VIII) including smoking status and quantity of 

consumption as well as exposure to tobacco smoke at home, at work and in public 
places and transport. 
In addition, it is planned that the European Household Survey (EHS) will be piloted in 
2008 and fully implemented from 2010 onwards on an annual basis in all Member 
States, will contain some questions on health coming from the EHIS questionnaire, 
including on smoking and exposure to tobacco smoke at work and in public places 
and transport.   
These two surveys will constitute a fully harmonised source of data for all Member 
States, based on the same questions and concept and using surveys with a strong 
statistical sampling methodology.  
Information on workplace exposure to tobacco smoke can also be obtained from the 
European Working Conditions Surveys (EWCS) carried out every five years by the 
European Foundation on Working and Living Conditions (next survey in 2010). 
In addition Eurobarometer surveys - while based on smaller samples than EHIS and 
EHS- will provide useful data on an almost yearly basis on various issues such as 
attitudes towards smoke-free policies, quit attempts or smoking in the presence of 
As for the evaluation, a wider review of all EU policies and legal instruments in the 
area of tobacco control policy (Communication on tobacco control strategy) is 
expected in 2010 or 2011. Among other things, the impact of the smoke-free initiative 
will be assessed and, if necessary, further steps will be proposed. 
Data source 
Assist Member States in  Proportion of Member States that have laws  National legislation 
implementing smoke-free  requiring smoke-free workplaces and public  and Member 
laws and monitor 
places, and robust enforcement mechanisms 
States' reporting 
Reduce exposure

on of workers reporting exposure to ETS 
tobacco smoke 
in the workplace 
Proportion of population reporting exposure to 
ETS  in public places  
Proportion of population reporting exposure to 
ETS at home 
Increase knowledge and  Proportion of the population that thinks second-
attitudes towards smoke-
hand smoke is harmful 
free policies 
Attitudes about the acceptability of exposing  EB 
others to second-hand smoke 
Level of support for smoke-free policies in public 
places and workplaces 
Reduce rates of active  Per capita sales of tobacco products 
Tax  records  from 
the sales of 
tobacco products - 
Number of cigarettes smoked per smokers 

Proportion of the population who are smokers 
Rate of quit attempts 
Intentions to quit smoking 
Reduce tobacco-related Changes in incidence and mortality from  Hospital 
mortality and morbidity 
tobacco-related diseases 
admissions and 
mortality data 

Chronic obstructive pulmonary disease 
Directorate General Health and Consumer 
Environmental tobacco smoke 
European Union 
Framework Convention on Tobacco Control 
Great British Pound 
Gross Domestic Product 
Impact assessment  
International Agency for Research on Cancer 

Member State 
National Institute for Health and Clinical 
Nicotine Replacement Therapy 
Open Method of Coordination 
Particulate Matter 
Quality Adjusted Life Year 
Research and development 
Second-hand smoke 
United Kingdom 
United States of America 
U.S. Environmental Protection Agency 
Value added tax 
Volatile organic compounds 
World Health Organisation 

Secondhand smoke 
Second-hand smoke (SHS) is smoke 
that is breathed in from other people's 
tobacco smoke. This smoke is also 
referred to as environmental tobacco 
smoke (ETS). SHS is made up of 
‘sidestream’ and ‘mainstream’ smoke. 
Sidestream smoke comes from the 
burning tip of the cigarette and is the 
major component of SHS. Mainstream 
smoke is the smoke that is exhaled by 
the smoker. Because it is inhaled by 
people that are not actively smoking, it 
is also commonly referred to as 
involuntary or passive smoking.  
Odds ratio 
A comparison of the presence of a risk 
factor for disease in a sample of 
diseased subjects and non diseased 
controls. The number of people with 
disease who were exposed to a risk 
factor (Ie) over those with disease who 
were not exposed (Io) divided by those 
without disease who were exposed 
(Ne) over those who were not exposed 
(No). Thus OR = (Ie/Io)/(Ne/No) = Ie 
No/Io Ne. 
Relative Risk 
The proportion of diseased people 
amongst those exposed to the relevant 
risk factor divided by the proportion 
amongst those not exposed to the risk 
The total number of cases of the 
disease in the population at a given 
time, or the total number of cases in 
the population, divided by the number 
of individuals in the population. 
The rate at which new cases of 
infection arise in a population 
Death in population 
Illness in a population  

Adam, E. K., C. Melvin, et al. (no date). The Costs of Environmental Tobacco Smoke (ETS): 
An International Review: 15. 
Adda, J., S. Berlinski, et al. (2006). "Short-run economic effect of the Scottish smoking ban." 
International Journal of Epidemiology. 
Ahmad, S. (2005). "Closing the youth access gap: the projected health benefits and cost 
savings of a national policy to raise the legal smoking age to 21 in the United States." Health 
Policy 75: 74-84. 
Akbar-Khanzadeh, F. (2003). "Exposure to Environmental Tobacco Smoke in Restaurants 
without Separate Ventilation Systems for Smoking and Nonsmoking Dining Areas." Archives 
of Environmental Health 58(2): 97-103. 
Akhtar, P. A., D. B. Currie, et al. (2007). "Changes in child exposure to environmental 
tobacco smoke (CHETS) study after implementation of smoke-free legislation in Scotland: 
national cross sectional survey." British Medical Journal 335: 545-549. 
Allwright, S. (2004). "Republic of Ireland's indoor workplace smoking ban." British Journal 
of General Practice 54(508): 811-812. 
Alpert, H. R., C. M. Carpenter, et al. (2007). "Environmental and economic evaluation of the 
Massachusetts smoke-free workplace law." Journal of Community Health 32(4): 269-281. 
American Society of Heating, R., and Air Conditioning Engineers (2005). Environmental 
tobacco smoke: position paper document approved by the ASHRAE Board of Directors, June 
30 Atlanta, ASHRAE. 
Andreeva, T. (2007). Why the government should ban smoking at workplaces. Towards a 
Smokefree Society. Edinburgh, Scotland. 
Antonanzas, F. and F. Portillo (2003). "Economic evaluation pharmacoterapies for smoking 
cessation." Gaceta Sanitaria 17(5): 393-403. 
ASH (2006). Half the workforce still exposed to smoke: New figures show workplace health 
divide. ASH Press Release. U.K. 
ASH Scotland (2004). ASH Scotland Briefing Ventilation: 6. 
Barone-Adesi, F., L. Vizzini, et al. (2006). "Short-term effects of Italian smoking regulation 
on rates of hospital admission for acutre myocardial infarction." European Heart Journal 27: 
Bauer, J. E., S. M. Carlin-Menter, et al. (2006). "GIving away free nicotine medications and a 
cigarette substitute (Better Quit) to promote calls to a quit line." Journal of Public Health 
Management and Practice 12(1): 60-67. 
Bauld, L. (2007). Specialist Services: NHS Stop Smoking Services and Smokefree. Towards a 
Smokefree Society. Edinburgh, Scotland. 
Behan, D. F., M. P. Eriksen, et al. (2005). Economic effects of environmental tobacco smoke. 
U.S., Society of Actuaries: 95. 
Bialous, S. and S. Glantz (2002). "ASHRAE Standard 62: tobacco industry's infleunce over 
national ventilation standards." Tobacco Control 11(4): 315-328. 

Biener, L., C. Garrett, et al. (2007). "The Effects on Smokers of Boston's Smoke-free Var 
Ordinance: A Longitudinal Analysis of Changes in Compliance, Patronage, Policy Support, 
and Smoking at Home." Journal of Public Health Management Practice 13(6): 640-646. 
Blenkinsopp, A., C. Anderson, et al. (2003). "Systematic review of the effectiveness of 
community pharmacy-based interventions to reduce risk behaviours and risk factors for 
coronary heart disease." Journal of Public Health Medicine 25(2): 144-153. 
Bobak, K., P. Jha, et al. (2000). Poverty and Smoking. Tobacco Control in Developing 
Countries. P. Jha and F. J. Chaloupka. 
Bolin, K., B. Lindgren, et al. (2006). "The cost utility of bupropion in smoking cessation 
health program: simulation model results for Sweden." Chest 129(3): 651-660. 
Braverman, M. T., L. E. Aarø, et al. (2007). "Changes in smoking among restaurant and bar 
employees following Norway’s comprehensive smoking ban." Health Promotion Journal 
23(1): 5-15. 
Broadbent, C. (2005). Ventilation and environmental tobacco smoke. 
Brownson, R. C., D. P. Hopkins, et al. (2002). "Effects of smoking restrictions in the 
workplace." Annu. Rev. Public Health 23: 333-348. 
Buck, D., C. Godfrey, et al. (1997). Cost-effectivness of smoking cessation interventions. 
Carpenter, C. (2007). The effects of local smoking laws on smoking restrictions and exposure 
to smoke at work: Evidence from Ontario, Canada, The Paul Merage School of Business, UC 
Irvine: 36. 
Carrington, J., A. F. R. Watson, et al. (2003). "The effects of smoking status and ventilation 
on environmental tobacco smoke concentrations in public areas of UK pubs and bars." 
Atmospheric environment 37(23): 3255-3266. 
Cesaroni, G., F. Forastiere, et al. (2008). "Effect of the Italian Smoking ban on Population 
Rates of Acute Coronary Events." Circulation 117. 
Chapman, S. and B. Freeman (2008). "Markers of the denormalisation of smoking and the 
tobacco industry." Tobacco Control 17: 25-31. 
Chirikos, T. N., T. A. Herzog, et al. (2004). "Cost-effectivess analysis of a complementary 
health intervention: the case of smoking relapse prevention." International Journal of 
Technology Assessment in Health Care 20(4): 475-480. 
Christenhusz, L., M. Pieterse, et al. (2007). Cost-effectiveness of an intensive smoking 
cessation intervention for COPD outpatients. Smoking Cessation: Interventions for targetting 
vulnerble groups, Rio. 
Clancy, L., P. Goodman, et al. (2007). Session: Measurement of second-hand smoke and 
evaluation of regulatory policies in Europe-pre- post- ban SHS measurements in pubs in 
Ireland: the efficacy of the legislation. Passsive smoking workshop: Measurement of second-
hand smoke, Osaka. 
Cornuz, J., C. Pinget, et al. (2006). "Cost-effectiveness of pharmacotherapies for nicotine 
dependence in primary care settings: a multinational comparison." Tobacco Control 15: 152-
Crealey, G. E., J. C. McElnay, et al. (1998). "Costs and effects associated with a community 
pharmacy-based smoking-cessation programme." Pharmacoeconomics 14(3): 323-333. 

Cronin, E., P. Kearney, P. Kearney and P. Sullivan (2007). Impact of a national smoking ban 
on the rate of admissions to hospital with acute coronary syndromes. European Society of 
Cardiology Congress. 
Cruse, S. M., N. J. D. Forster, et al. (2001). "Smoking cessation in the workplace: results of 
an intervention programme using nicotine patches." Occupational Medicine 51(8): 501-506. 
Cummings, K. M., B. Fix, et al. (2006). "Reach. efficacy and cost effectiveness of free 
nicotine medication giveaway programs." Journal of Public Health Management and Practice 
12(1): 37-43. 
Curtiss, F. and B. Crownover (2005). ""U can’t touch this” with pharmacotherapy alone for 
weight loss or smoking cessation." Journal of Managed Care Pharmacy 11(6): 516-20. 
de Gids, W. F. and P. Jacobs (2006). An investigation into the possible reduction in 
Environmental Tobacco Smoke (ETS) in the day-to-day operations of the hospitality industry, 
Netherlands Organisation for Applied Scientific Research. 
de Gids, W. F. and A. Opperhuizen (2004). Reduction of exposure to environmental tobacco 
smoke in the Hospitality Industry by Ventiliation and Air Cleaning. Bilthoven, RIVM: 80. 
Department of Health (2007). Final regulatory impact assessment for regulations to be made 
under powers in Part 1, Chapter 1 of the Health Act 2006 (Smoke-free premises, places and 
vehicles), Department of Health. 
Department of Health, S. S. a. P. S. (2006). Smoking (Northern Ireland) Order 2006: Health 
and Regulatory Impact Assessment. Belfast, Department of Health, Social Services and 
Public Safety: 51. 
DiFranza, J. R., R. M. Peck, et al. (2001). "What is the potential cost-effectiveness of 
enforcing a prohibition on the sale of tobacco to minors." Preventative Medicine 32: 168-174. 
Directorate for Health and Social Affairs (2005). Norway's ban on smoking in bars and 
restaurants - A review of the first year. Oslo, Directorate for Health and Social Affairs: 19. 
Drope, J., S. A. Bialous, et al. (2004). "Tobacco industry efforts to present ventilation as an 
alternative to smoke-free environments in North America." Tobacco Control 13: 41-47. 
Edwards, R., C. Bullen, et al. (2008). After the smoke has cleared; Evaluation of the impact of 
a new smokefree law. Wellingotn, Ministry of Health: 156. 
Edwards, R., H. Gifford, et al. (2007). The impact of smokefree policies on an indigenous 
population: The experience of smokefree legislation and the Maori population in New 
Zealand. Towards a Smokefree Society. Edinburgh, Scotland. 
Eisner, M. D., A. K. Smith, et al. (1998). "Bartenders' respiratory health after establishment of 
smoke-free bars and tavers." Journal of the Americal Medical Association 280(22): 1909-
Emmons, K. M., E. Puleo, et al. (2005). "Peer-delivered smoking counseling for childhood 
cancer survivors increases rate of cessation: the Partnership for Health study." Journal of 
Clincal Oncology 23(27): 6516-6523. 
Environmental Protection Agency (2008). Residential air cleaning devices: A summary of 
available information. Washington, DC, Office of Air and Radiation Indoor Environments 
European Commission (2007). Attitudes of Europeans towards Tobacco, European 

European Network for Smoking Prevention. (2007). "European trends towards smoke-free 
provisions."   Retrieved April 2007. 
European Respiratory Society (2003). European Lung White Book. London, European 
Respiratory Society. 
Evans, D. S., C. Byrne, et al. (2007). The 2004 Irish smoking ban? Is there a ‘knock on effect’ 
on smoking in the home? 4th European Conference Tobacco or Health. Basel, Switzerland. 
Farkas, A., E. Gilpin, et al. (2000). "Association between household and workplace smoking 
restrictions and adolescent smoking." JAMA 284: 717-722. 
Farrelly, M. C., J. M. Nonnemaker, et al. (2005). "Changes in the hospitality workers' 
exposure to secondhand smoke following the implementation of New York's smoke-free 
law." Tobacco Control 14: 236-241. 
Feenstra, T. L., H. H. Hamberg-van Reenen, et al. (2005). "Cost-effectiveness of face-to-face 
smoking cessation interventions: a dynamic modeling study." Value in Health 8(3): 178-190. 
Fichtenberg, C. M. and S. A. Glantz (2002). "Effect of smoke-free workplaces on smoking 
behaviour: systematic review." British Medical Journal 325. 
Flannery, B. and N. Cronin (2007). Role of the national smokers quitline in support of 
smokefree at work legislation. Smoking Cessation: Quit lines, Montreal. 
Fong, G. T., A. Hyland, et al. (2006). "Reductions in tobacco smoke pollution and increases 
in support for smoke-free public places following the implementation of comprehensive 
smoke-free workplace legislation in the Republic of Ireland: findings from the ITC 
Ireland/UK survey." Tobacco Control 15: 51-58. 
Foreman, M. G., D. L. DeMeo, et al. (2007). "Clinical determinants of exacerbations in 
severe, early-onset COPD." European Respiratory Journal 30(6): 1124-113-. 
Gallus, S., P. Zuccaro, et al. (2007). "Smoking in Italy 2005-2006: Effects of a comprehensive 
National Tobacco Regulation." Preventative Medicine 45(2-3): 198-201. 
Gallus, S., P. Zuccaro, et al. (2006). "Effects of new smoking regulations in Italy." Annals of 
Oncology 17: 346-347. 
Geens, A., D. Snelson, et al. (2006). "Ventilation performance for spaces where smoking is 
permitted: a review of previous work and field study results." Building Serv. Eng. Technol 
27(3): 235-248. 
German Cancer Research Center (DKFZ) (2007). Smoking room and ventilation: no 
alternative to smoke-free restaurants. Heidelberg, Deutsches Krebsforschungszentrum. 
Global Smokefree Partnership (2007). Global voices for a smokefree world: Movement 
Towards a Smokefree Future, 2007 Status Report, Global Smokefree Partnership. 
Global Smokefree Partnership (no date). Smokefree progress: An overview of smokefree laws 
around the world Global Smokfree Partnership. 
Godfrey, C., S. Parrott, et al. (2006). "The cost-effectiveness of the English smoking 
treatment services: evidence from practice." Addiction 100(Supplement 2): 70-83. 
Godfrey, F. (2007). "Hold the front page: Smoking bans good for (most) workers' health." 
American Journal of Respiratory and Critical Care Medicine 175: 751-752. 

Goodman, P., M. Agnew, et al. (2007). "Effects of the Irish Smoking Ban on Respiratory 
Health of Bar Workers and Air Quality in Dublin Pubs" :Am J Respir Crit Care Med. 
Gorini, G., H. Moshammer, et al. (2007). Approaches to measuring secondhand smoke: Italy 
and Austria before and after study - secondhand smoke exposure in Italian and Austrian 
hospitality premises before and after two years from the intriduction of the Italian smoking 
ban. Towards a Smokefree Society. Edinburgh, Scotland. 
Gorini, G., H. Moshammer, et al. (2007). Italy and Austria project: nicotine measurements 
before and after the coming into force of the Italian smoking ban. Passive Smoking 
Workshop: Measurment of second-hand smoke, Osaka. 
Gorinin, G., A. S. Costantini, et al. (2007). "Smoking prevalence in Italy after the smoking 
ban: Towards a comprehensive evaluation of tobacco control programs in Europe." 
Preventative Medicine 45(2-3): 123-124. 
Greaves, L. (2007). The meaning of smokefree intiatives in Women's lives. Towards a 
Smokefree Society. Edinburgh, Scotland. 
Greiner, B. A., B. J. Mullally, et al. (2007). Smoking prevalence and consumption in the 
republic of Ireland before and after the legislative ban on workplace smoking. 4th European 
Tobacco or Health Conference. Basel, Switzerland. 
Halpin, H. A., S. B. McMenamin, et al. (2006). "The costs and effectiveness of different 
benefit designs for treating tobacco dependence: results from a randomized trial " Inquiry 
43(1): 54-65. 
Hammond, S. (2002). The efficacy of strategies to reduce environmental tobacco smoke 
concentrations in homes, workplaces, restaurants, and corrections facilities. Indoor Air 2000: 
Proceedings of the 9th International Conference on Indoor Air Quality and Climate, 
Monterey, CA. 
Hassan, L. (2007). Age, sex and socio-economic inequalities: Cross-national comparisons 
from ITC. Towards a Smokefree Society. Edinburgh, Scotland. 
Hassan, L. M., G. Walsh, et al. (2007). "Modeling persuasion in social advertising." Journal 
of Advertising 36(2): 15-31. 
Haw, S. (2007). Evaluation of Scottish Smokefree Legislation: main findings NHS Health 
Heidrich, J., J. Wellmann, et al. (2007). "Mortality and Morbidity from coronary heart disease 
attributable to passive smoking." European Heart Journal. 
Helakorpi, S., K. Patja, et al. (2007). Health behaviour and health among the Finnish Adult 
Population, Spring 2006. Helsinki, National Public Health Institute 209. 
Helasoja, V., R. Prattala, et al. (2001). "Smoking and passive smoking in Estonia, Lithuania, 
and Finland." European Journal of Public Health 11(2): 206-210. 
Heloma, A., E. Kahkonen, et al. (2000). "Smoking and exposure to tobacco smoke at 
medium-sized and large-scale workplaces." Americal Journal of Industrial Medicine 37: 214-
Hill, A. (2006). "A cost-effectiveness evaluation of single and combined smoking cessation 
interventions in Texas." Texas Medicine 102(8): 50-55. 

Hilton, S., S. Semple, et al. (2007). "Expectations and chnaging attitudes of bar workers 
before and after the implementation of smoke-free legislation in Scotland." BMC Public 
Health 7(206). 
Hole, D. (2005). Passive smoking and associated cause of death in adults in Scotland., Health 
Hoogendoorn, M., P. Welsing, et al. (2008). "Cost-effectiveness of varenicline compared with 
bupropion, NRT, and nortriptyline for smoking cessation in the Netherlands." Current 
Medical Research and Opinion 24(1): 51-61. 
HSC (2006). Second-hand Smoke in the Home. Wellington, Research and Evaluation Unit, 
Hyland A., Travers M.J., et al. (2008). "A 32-country comparison of tobacco smoke derived 
particle levels in indoor public places." Tob Control. 
Institute for Occupational Health and Safety (2007). Grundsätze für die Prüfung und 
Zertifizierung von Nichtraucherschutzsystemen, BGIA. 
Jackson, K., R. Nahoopii, et al. (2007). "An employer-based cost-benefit analysis of a novel 
pharmacotherapy agent for smoking cessation." Journal of Occupational and Environmental 
Medicine 49(4): 453-60. 
Jacobs, P., P. de Jong, et al. (2006). Decentralised smoke displacement system using 
recirculation and filtration. Delft, TNO Built Environment and Geocciences: 19. 
Jamrozik, K. (2005). "Estimate of deaths attributable to passive smoking among UK adults: 
database analysis." British Medical Journal 330. 
Jenkins, R., D. Finn, et al. (2001). "Environmental Tobacco Smoke in the Nonsmoking 
section of a restaurant: A case study." Regulatory Toxicology and Pharmacology 34: 213-220. 
Johansson, P. M., P. E. Tillgren, et al. (2005). "A model for cost-effectiveness analyses of 
smoking cessaton interventions applied to a quit-and-win contest for mothers and small 
children." Scandinavian Journal of Public Health 33(5): 343-352. 
Johnsson, T., T. Tuomi, et al. (2006). "Environmental tobacco smoke in Finnish restaurants 
and bars before and after smoking restrictions were introduced." Ann Occup Hyg 50(4): 331-
Kaper, J., E. Wagena, et al. (2006). "Encouraging smokers to quit: the cost effectiveness of 
reimbursing the costs of smoking cessation treatment." PharmacoEconomics 24(5): 453-64. 
Kaper, J., E. J. Wagena, et al. (2005). "Healthcare financing systems for increasing the use of 
tobacco dependence treatment." Cochrane Database of Systematic Reviews: Reviews(1). 
Kauppinen, T., J. Toikkanen, et al. (1998). Occupational Exposure to Carcinogens in the 
European Union in 1990-93. Helsinki, Finnish Institute of Occupational Health. 
Kjaer, N., T. Evald, et al. (2007). Effectiveness of Danish standard smoking cessation 
interventions. Smoking cessation: National Programs, Community-based projects. Singapore. 
Koh, H., L. Joosens, et al. (2007). "Making smoking history worldwide." New England 
Journal of Medicine 356(15): 1496-1498. 
Kotzias, D., O. Geiss, et al. (2006). Why ventilation is not a viable alternative to a complete 
smoking ban. Lifting the smokescreen. t. S. f. Partnership. Brussels European Respiratory 
Society: 105-116. 

Kunst, A., K. Giskes, et al. (2004). Socio-economic inequalities in smoking in the European 
Union. Applying and equity lens to tobacco control policies. Rotterdam, Department of Public 
Health: 83. 
Larsson, M. L., M. Frisk, et al. (2001). "Environmental Tobacco Smoke Exposure During 
Childhood Is Associated With Increased Prevalance of Asthma in Adults." Chest 120: 711-
Leinsalu, M., M. Tekkel, et al. (2007). "Social determinants of ever initiating smoking differ 
from those of quitting: a cross sectional study in Estonia." European Journal of Public Health. 
Levy, D. T. and K. Friend (2002). "A simulation model policies directed at treated tobacco 
use and dependence." Medical Decision Making 22: 6-16. 
Loddenkemper, R., Ed. (2003). European Lung White Book: The first comprehensive survey 
on respiratory health in Europe. Lausanne, European Respiratory Society. 
Lofroth, E., L. Lindholm, et al. (2006). "Optimising health care within given budgets: primary 
prevention of cardiovascular disease in different regions of Sweden." Health Policy 75: 214-
Lopez, M. J., M. Nebot, et al. (2007). Environmental tobacco smoke exposure in Spain: 
evaluation before and after the non-smoking law. Passive Smoking: Legislation 2, Sydney. 
Low, A., L. Unsworth, et al. (2007). "Avoiding the danger that stop smoking services may 
exacerbate health inequalities: building equity into performance assessment." BMC Public 
Lund, K. E. and A. R. Helgason (2005). "Environmental tobacco smoke in Norweigian 
homes, 1995 and 2001: changes in children's exposure and parents attitudes and health risk 
awareness." European Journal of Public Health 15(2): 123-127. 
MacAskill, S. and A. Amos (2007). Stop smoking projects for pregnant women and people 
faced with inequalities: evaluation of the impact of the PATH support fund. Uk National 
Smoking Cessation Conference (UKNCC), Novotel London West, Hammersmith, London  
Martin, C., D. Ritchie, et al. (2008). Evaluation of the Smoke-free legislation in Scotland: 
Qualitative Community Study. Edinburgh, Scotish Centre for Social Research: 35. 
McAlister, A. L., V. Rabius, et al. (2004). "Telephone assistance for smoking cessation: one 
year cost effectiveness estimations." Tobacco Control 13(1): 85-86. 
McCaffrey, M., P. Goodman, et al. (2006). "Smoking, occupancy and staffing levels in a 
selection of Dublin pubs pre and pst a national smoking ban, lessons for all." Irish Journal of 
Medical Science 175(2): 37-40. 
Menzies, D., A. Nair, et al. (2006). "Respiratory symptoms, pulmonay function, and markers 
of inflammation among bar workers before and after a legislative ban on smoking in public 
places." Journal of the American Medical Association 296(14): 1742-1748. 
Milz, S., F. Akbar-Khanzadeh, et al. (2007). "Indoor air quality in restaurants with and 
without designated smoking rooms." J Occup Environ Hyg 4(4): 246-252. 
Moshammer, H., G. Hoek, et al. (2006). "Parental smoking and lung function in children: an 
international study." Am J Respir Crit Care Med 173(11): 1184-1185. 
Moussa, K. M., M. Lindstrom, et al. (2004). "Socioeconomic and demographic differences in 
exposure to environmental tobacco smoke at work: the Scania Public Health Survey 2000." 
Scandanavian Journal of Public Health 32: 194-202. 

Mulcahy, M., D. S. Evans, et al. (2005). "Secondhand smoke exposure and risk following the 
Irish smoking ban: an assessment of salivery cotinine concentrations in hotel workers and air 
nicotine levels in bars." Tobacco Control 14: 384-388. 
Naidoo, B., W. Stevens, et al. (2000). "Modelling the short term consequences of smoking 
cessation in England on the hospitalisation rates for acute myocardial infarction and stroke." 
Tobacco Control 9(4): 397-400. 
National Institute for Public Health and the Environment (2006). Beoordeling van het RIVM 
van het TNO-rapport 'Verdring de rook, niet de roker'. 
NHS Health Scotland, A. Ludbrook, et al. (2005). International review of the health and 
economic impact of the regulaton of smoking in public places, NHS Health Scotland: 135. 
NHS Health Scotland (2005) Draft regulatory Impact Assessment, Annex C of the Smoking, 
Health and Social Care (Scotland) Act 2005 (Prohibition of smoking in certain 
premises)REgulations 2005: draft. 
NICE (2006). Costing report. Briefing interventions and referral for smoking cessation in 
primary care and other settings. London, National Institute for Health and Clinical 
Excellence: 23. 
Nielsen, K. and M. C. Fiore (2000). "Cost-benefit analaysis of sustained-release bupropion, 
nicotine patch, or both for smoking cessation." Preventative Medicine 30: 209-216. 
Nurminen, M. M. and M. S. Jaakkola (2001). "Mortality from occupational exposure to 
environmental tobacco smoke in Finland." Journal of Occupational Environmental Medicine 
43(8): 687-693. 
O’Connor, R., B. Fix, et al. (2006). "Financial incentives to promote smoking cessation: 
evidence from 11 quit and win contests." Journal of Public Health Management and Practice 
12(1): 44-51. 
Office of Tobacco Control (2005). Smoke-Free Workplaces in Ireland: A One-Year Review. 
Ireland, Office of Tobacco Control: 11. 
Office of Tobacco Control (2007). Annual Report 2006. Ireland, Office of Tobacco Control. 
Olsen, K. R., L. Bilde, et al. (2006). "Cost-effectiveness of the Danish smoking cessation 
interventions: subgroup analysis based on the Danish Smoking Cessation Database." 
European Journal of Health Economics 7: 225-264. 
Ong, M. K. and S. A. Glantz (2005). "Free nictone replacement therapy program vs 
implementing smoke-free workplaces: a cost effectiveness comparison." American Journal of 
Public Health 95(6): 969-975. 
Osman, L. M., J. G. Douglas, et al. (2007). "Indoor air quality in homes of patients with 
chronic obstructive pulmonary disease." Am J Respir Crit Care Med 176(5): 465-472. 
Parrott, S. and C. Godfrey (2004). "Economic effects of smoking cessation." British Medical 
Journal 328: 947-949. 
Pattenden, S., T. Antova, et al. (2006). "Parental smoking and children's respiratory health: 
independent effects of prenatal and postnatal exposure." Tobacco Control 15: 294-301. 
Phillips, R., A. Amos, et al. (2007). "Smoking in the home after the smoke-free legislation in 
Scotland: qualitative study." British Medical Journal 335: 553-557. 
Piha, T. (2006). Ventilation as a means for controlling ETS exposure in hospitality venues. 
Brussels, European Commission. 

Pilkington, P. and A. Gilmore (2004). "The Linving Tomorrow Project: how Phillip Morris 
has used a Belgium tourist attraction to promote ventilation approaches to the control of 
second hand smoke." Tobacco Control 13(4): 375-378. 
Pinget, C., E. Martin, et al. (2007). "Cost-effectiveness analysis of a European primary-care 
physician training in smoking cessation counselling." European Journal of Cardiovascular 
Prevention and Rehabilitation 14(3): 451-5. 
Pion, M. and M. S. Givel (2004). "Airport smoking rooms don't work." Tobacco Control 
13(Suppl 1): i36-i40. 
Pirkle, J. L. and et al (1996). "Exposure of the US population to ETS: the Third National 
Health and Nutrition Examination Survey, 1998-1991." Journal of the American Medical 
Association 275: 1233-1240. 
Ponniah, S. (2007). Persisting inequalities in second hand smoke exposure in a country with a 
national smoke free law. Towards a Smokefree Society. Edinburgh, Scotland. 
Quist-Paulsen, P., S. Lydersen, et al. (2006). "Cost effectiveness of a smoking cessation 
program in patients admitted for coronary heart disease." European Journal of Cardiovascular 
Prevention and Rehabilitation 13(2): 274-280. 
Redpath, A. (2007). Changes in myocardial infarction and mortality following the Scottish 
smokefree legislation. Towards a Smokefree Society. Edinburgh, Scotland. 
Repace, J. (2000). Can ventilation control secondhand smoke in the hospitality industry? 
Bowie, MD, Repace Associates, Inc: 36. 
Repace, J. and K. C. Johnson (2006). Can displacement ventiliation control secondhand ETS. 
ASHRAE IAQ Applications. 7. 
Riemsma, R. P., J. Pattenden, et al. (2003). "Systematic review of the effectiveness of stage-
based interventions to promote smoking cessation." British Medical Journal 326: 1175. 
Ronckers, E., W. Groot, et al. (2005). "Systematic review of economic evaluations of 
smoking cessation: standardizing the cost-effectiveness." Medical Decision Making 25(4): 
Ross, H., L. Powell, et al. (2006). "Community-based youth tobacco control interventions: 
cost effectiveness of the Full Court Press project." Applied Health Economics and Health 
Policy 5: 167-76. 
Royal College of Physicians (2005). Going smoke-free: The medical case for clean air in the 
home, at work and in public places: A report on passive smoking by the Tobacco Advisory 
Group of the Royal College of Physicians. London, Royal College of Physicians of London,. 
Ruger, J., M. Weinstein, et al. (2007). "Cost-effectiveness of motivational interviewing for 
smoking cessation and relapse prevention among low-income pregnant women: a randomised 
controlled trial." Value in Health, published online 13 September 2007. 
Salto, E., A. Valverde, et al. (2007). Spain’s 2006 Law: What is the opinion of the 
population? 4th European Tobacco or Health Conference. Basel, Switzerland. 
Samet, J. (2006). "Smoking bans prevent heart attacks." Circulation 114: 1450-1451. 
Sargent, R. P., R. M. Shepard, et al. (2004). "Redcued incidence of admissions for myocardial 
infarction associated with public smoking ban: before and after study." British Medical 
Journal 328: 977-980. 

Scharf, D. and S. Shiffman (2004). "Are there gender differences in smoking cessation, with 
and without bupropion: pooled- and meta-anlyses of clincal trials of Bupropion SR." 
Addiction 99(11): 1462-1469. 
Schauffler, H. H., S. McMenamin, et al. (2001). "Variations in treatment benefits influence 
smoking cessation: results of a randomised controlled trial." Tobacco Control 10(2): 175-180. 
Schoberberger, R. and D. Zeidler (2007). Experiences with patients in the first year after 
inpatient smoking cessation therapy. Smoking cessation: Interventions targetting vulnerbale 
groups, Rio. 
Scollo, M. and A. Lal (2008). Summary of studies assessing the economic impact of smoke-
free policies in the hospitality industry. Melbourne, VicHealth Centre for Tobacco Control: 
Secker-Walker, R., R. Holland, et al. (2005). "Cost effectiveness of a community based 
research project to help women quit smoking." Tobacco Control 14(1): 37-42. 
Semple, S., L. Maccalman, et al. (2007). "Bar workers' Exposure to Second-Hand Smoke: 
The effect of Scottish Smoke-Free Legislation on Occupational Exposure." Ann. Occup. Hyg 
51(7): 571-580. 
Shearer, J. and M. Shanahan (2006). "Cost effectiveness analysis of smoking cessation 
interventions." Australian and New Zealand Journal of Public Health 30(5): 428-434. 
Simoni, M., S. Baldacci, et al. (2007). "Respiratory symptoms/diseases and environmental 
tobacco smoke (ETS) in never smoking Italian women." Respiratory Medicine 101: 531-538. 
Skeer, M., D. M. Cheng, et al. (2005). "Secondhand smoke exposure in the workplace." 
Americal Journal of Preventative Medicine 28(4): 331-337. 
Smokefree Northern Ireland. Health Promotion Agency Factsheet: Second-hand smoke and 
ventilation. Belfast. 
Spizzichino, L. (2007). The effect of the Italian smoking ban on hospital admissions for acute 
myocardial infarction. Towards a Smokefree Society. Edinburgh, Scotland. 
Stantec Consulting (2004). Environmental Tobacco Smoke Monitoring in Toronto 
Restaurants and Bars, Stantec Consulting Ltd: 22. 
Stayner, L., J. Bena, et al. (2007). "Lung Cancer Risk and Workplace Exposure to 
Environmental Tobacco Smoke." Americal Journal of Public Health 97(3): 545-551. 
Surgeon General (2006). The Health Consequences of Involuntary Exposure to Tobacco 
Smoke: A Report of the Surgeon General. Atlanta, Ga, U.S. Dept. of Health and Human 
Services, Centers for Disease Control and Prevention, Coordinating Center for Health 
Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on 
Smoking and Health. 
Taylor, R., F. Najafi, et al. (2007). "Meta-analysis of studies of passive smoking and lung 
cancer: effects of study type and continent." International Journal of Epidemiology 36: 1048-
The GTSS Collaborative Group (2006). "A cross country comparison of exposure to 
secondhand smoke among youth." Tobacco Control 15: 4-19. 
The Smoke free Partnership (2006). Lifting the smokescreen: 10 reasons for a smoke free 
Europe Brussels, Belgium, European Respiratory Society: 146. 

link to page 1 filename javascript:AL_get(this,%20'jour',%20'J%20Epidemiol%20Community%20Health.');  
Theodor Sterling Associates (2007). Indoor air quality and ventilation case study of 
hospitality venues in the United Kingdom. Vancouver, Theodor Sterling Associates: 19. 
Thomson, G. G. (2006). "One year of smokefree bars and restaurants in New Zealand: 
impacts and responses." BMC public health 6(1): 64. 
Tillgren, P., M. Rosen, et al. (1993). "Cost-effectiveness of a tobacco "Quit and Win" contest 
in Sweden." Health Policy 26: 43-53. 
Tocque, K., R. Edwards, et al. (2005). "The impact of partial smokefree legislation on health 
inequalities: Evidence from a survey of 1150 pubs in North West England." BMC Public 
Health 5: 91. 
Tran, M. T., D. A. Holdford, et al. (2002). "Modeling the cost-effectiveness of a smoking 
cessation program in a community pharmacy practice." Pharmacotherapy 22(12): 1623-1631. 
Travers, M., K. M. Cummings, et al. (2004). "Indoor air quality in hospitality venues before 
and after the implementation of a Clean Indoor Air Law - Western New York." Morb Mortal 
Wkly Rep 53(44): 1038-1041. 
Trinder et al (2000). ”Social class, smoking and the severity of respiratory symptoms in the 
general population.” J Epidemiol Community Health 54(5):340-3 
Twose, J., A. Schiaffino, et al. (2007). "Correlates of exposure to second-hand smoke in an 
urban Mediterranean population." BMC Public Health 7(194). 
Vaughan, W. M. and S. K. Hammond (1990). "Impact of "designated smoking area" policy on 
nicotine vapor and particle concentrations in a modern office building." Journal of the Air & 
Waste Management Association 40(7): 1012-7. 
Vineis, P., G. Hoek, et al. (2007). "Lung cancers attributable to environmental tobacco smoke 
and air pollution in non-smokers in different European countries: a prospective study." 
Environmental Health 6. 
Waa, A. and S. McGough (2006). Reducing exposure to second hand smoke: Changes 
associated with the implementation of the amended New Zealand Smokefree Environments 
Act 1990: 2003-2006. Wellington, Research and Evaluation Unit, HSC: 33. 
Wagner, J., D. Sullivan, et al. (2004). "Environmental tobacco smoke leakage from smoking 
rooms." J Occup Environ Hyg Feb 1(2): 110-118. 
Wakefield MA et al (2000). ”Effect of restrictions on smoking at home, at school and in 
public places on teenage smoking: cross sectional study.” British Medical Journal 321:333-
Wakefield and et al (2007). "Potential for smoke-free policies in social venues to prevent 
smoking uptake and reduce  relapse: A qualitative study. ." Health Promotion Practice. 
Ward, C., S. Lewis, et al. (2007). "Prevalence of maternal smoking and environmental 
tobacco smoke exposure during pregnancy and impact on birth weight: retrospective study 
using Millenium Cohort." BMC Public Health. 
Warren, C. G., L. Riley, et al. (2000). "Tobacco use by youth: a surveillance report from the 
Global Youth Tobacco Survey project." Bulletin of the World Health Organisation 78(7): 
Welsh Assembly Government (2007). Smoke-Free Premises etc (Wales) Regulations 2007: 
Regulatory Appraisal (Annex B: Draft Regulatory Appraisal): 17. 

Whitlock, G., S. MacMahon, et al. (1998). "Association of environmental tobacco smoke 
exposure with socioeconomic status in a population of 7725 New Zealanders." Tobacco 
Control 7(3): 276-280. 
WHO (2007). Gender and tobacco control: a policy brief. Geneva, World Health 
WHO (2007). Protection from exposure to second-hand smoke. Policy recommendations. 
Geneva, World Health Organisation: 50. 
WHO (2007). Smoke-free inside: Create and enjoy 100% smoke-free environments, WHO. 
Wiebing, M., M. Uittenbogaard, et al. (2007). Smokers deserve a reward-a campaign for 
lower socio-economic groups creating an intention to quit. Smoking cessation: Interventions 
Targeting Vulnerable Groups, Rio. 
Willemsen, M. C. (2007). Psychological impact of a smoke-free legislation on smokers: the 
mediating effects of social-economic status. 4th European Conference Tobacco or Health, 11-
13 October 2007, Basel. 
Woodall, A. A., E. J. Sandbach, et al. (2005). "The partial smoking ban in licensed 
establishments and health inequalities in England: modelling study." British Medical Journal 
331: 488-489. 


On the basis of SEC (2005) 791 of 15 June 2005 (Impact Assessment Guidelines) 

COM (2003) 311 (not published in the Official Journal). 

“Attitudes of Europeans towards tobacco”, Special Eurobarometer 239, January 2006, 
Attitudes of Europeans towards tobacco”, Special Eurobarometer 272c, May 2007. 

Surgeon General (2006). The Health Consequences of Involuntary Exposure to Tobacco 
Smoke: A Report of the Surgeon General. Atlanta, Ga, U.S. Dept. of Health and Human Services, 
Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National 
Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 

WHO (2007). Protection from exposure to second-hand smoke. Policy recommendations. 
Geneva, World Health Organisation: 50. 

Surgeon General (2006). op. cit. 

Foreman, M. G., D. L. DeMeo, et al. (2007). "Clinical determinants of exacerbations in 
severe, early-onset COPD." European Respiratory Journal 30(6): 1124-113-. 
Surgeon General (2006). op. cit. 
11 Royal College of Physicians (2005). Going smoke-free: The medical case for clean air in the home, 
at work and in public places: A report on passive smoking by the Tobacco Advisory Group of the 
Royal College of Physicians. London, Royal College of Physicians of London. 
The Smoke free Partnership (2006). Lifting the smokescreen: 10 reasons for a smoke free 
Europe Brussels, Belgium, European Respiratory Society: 146. 
13 Ibidem. 
In the Eurobarometer survey, 59% of respondents who were employed worked in offices 
(56%) and hospitality venues (3%); 17% worked in healthcare, educational and government facilities 
and a further 19% worked in other places. 
15 Based on the country estimates of the International Labour Organisation. 
16 European Commission. Directorate-General for Energy and Transport (2007) EU energy  and 
transport in figures. Statistical pocketbook 2007/2008 
ASPECT Consortium (2004)Tobacco or health in European Union: Past, present and future. 
Behan, D. F., M. P. Eriksen, et al. (2005). Economic effects of environmental tobacco smoke. 
U.S., Society of Actuaries95. 
NHS Health Scotland, A. Ludbrook, et al. (2005). International review of the health and 
economic impact of the regulaton of smoking in public places, NHS Health Scotland: 135. 
Welsh Assembly Government (2007). Smoke-Free Premises etc (Wales) Regulations 2007: Regulatory 
Appraisal (Annex B: Draft Regulatory Appraisal): 17. 
Department of Health, S. S. a. P. S. (2006). Smoking (Northern Ireland) Order 2006: Health and 
Regulatory Impact Assessment. Belfast, Department of Health, Social Services and Public Safety: 51. 
Department of Health (2007). Final regulatory impact assessment for regulations to be made under 
powers in Part 1, Chapter 1 of the Health Act 2006 (Smoke-free premises, places and vehicles), 
Department of Health. 

This figure was calculated as follows: Averted deaths from ETS among employees (£21M) 
and customers (£350M) + reduced sickness absences (£70-140M) + production gains (from reduced 
exposure to ETS) (£340-680M) + reduced fire hazards and reduced cleaning and decoration costs (£163 M). 
This figure includes value of deaths avoided from reduced exposure to ETS (£91.4 M)  + 
human cost of ill health (morbidity saving) from reduced exposure to ETS (£12.8 M) + saving on NHS 
costs from reduced exposure to ETS (£5.3 M) + saving on sickness absence from reduced exposure to 
ETS (£4.1M) +  productivity gains from reduced smoking breaks (£73.7M) + reduced fire hazards and 
reduced cleaning and decoration costs (£16.7 M). 
This figure was calculated as follows: economic value of lives saved: reduced exposure to 
ETS (£86.9M) + human cost of ill health (morbidity saving) from reduced exposure to ETS (£12.6M) + 
NHS treatment cost savings from reduced exposure to ETS (£2.9Ml) + reduced sickness absences from 
reduced exposure to ETS (£4M) + reduced fire hazards and reduced cleaning and decoration costs (£13.6M). 
This figure was calculated as follows: economic value of lives saved due to reduced exposure 
to ETS (£5.47M) + human cost of ill health (morbidity saving) from reduced exposure to ETS 
(£14.42M)  + NHS treatment cost savings (£4.10M) + reduced sickness absences (£0.6M) + 
productivity gains from reduced smoking breaks (£28.2M) + reduced fire hazards and reduced cleaning and 
decoration costs (£4.6 M). 
But possibility of transition period until June 2007. 
25  Joossens L, Raw M. The Tobacco Control Scale: a new scale to measure country activity. Tob 
Control. 2006 Jun;15(3):247-53. 
Based on Eurobarometer survey 2007 
OJ C 189, 26.7.1989, p. 1-2. 
OJ L 22, 25.1.2003, p. 31–34. 
OJ L 183, 29.6.1989, p. 1–8. 
OJ L 393, 30.12.1989, p. 1–12, OJ L 245, 26.8.1992, p. 6–22, OJ L 404, 31.12.1992, p. 10–25. 
OJ L 263, 24.9.1983, p. 25–32. 
32 European Commission (2007). Attitudes of Europeans towards Tobacco, European Commission. 
33 A 32-country comparison of tobacco smoke derived particle levels in indoor public places. Hyland 
A, Travers MJ, Dresler C, Higbee C, Cummings KM. Tob Control. 2008 Jun;17(3):159-65. Epub 2008 
Feb 26. 
British Medical Association (2002). Towards smoke-free public places. Board of Science and 
Education and Tobacco Control Resource Centre. 
The eight countries are: FR, PT, HU, DE, PL, AT, EL, DE 
Nebot M, Lopez MJ, Gorini G, Neuberger M, Axelsson S, Pilali M, Fonseca C, Abdennbi K, 
Hackshaw A, Moshammer H, Laurent AM, Salles J, Georgouli M, Fondelli MC, Serrahima E, 
Centrich F, Hammond SK.Environmental tobacco smoke exposure in public places of 
European cities. Tob Control. 2005 Feb;14(1):60-3. 
37 Jarvis 
Quantitative survey of exposure to other people's smoke in London bar staff
London: Department of Epidemiology and Public Health, University College, 2001. 
Jarvis MJ, Foulds J, Feyerabend C. Exposure to passive smoking among bar staff. Br.J Addict. 
Siegel M. Involuntary smoking in the restaurant workplace. A review of employee exposure 
and health effects. JAMA 1993;270:490-3. 
Wakefield M, Cameron M, Inglis G, Letcher T, Durkin S. Secondhand smoke exposure and 
respiratory symptoms among casino, club, and office workers in Victoria, Australia. J Occup 
Environ Med. 2005 Jul;47(7):698-703. 

These occupational groups are defined according to the International Standard Classification 
of Occupations (ISCO) 
Trinder et al (2000). ”Social class, smoking and the severity of respiratory symptoms in the 
general population.” J Epidemiol Community Health 54(5):340-3. 
ASH (2006). Half the workforce still exposed to smoke: New figures show workplace health 
divide. ASH Press Release. U.K. 
Moussa, K. M., M. Lindstrom, et al. (2004). "Socioeconomic and demographic differences in 
exposure to environmental tobacco smoke at work: the Scania Public Health Survey 2000." 
Scandanavian Journal of Public Health 32: 194-202. 
Whitlock, G., S. MacMahon, et al. (1998). "Association of environmental tobacco smoke 
exposure with socioeconomic status in a population of 7725 New Zealanders." Tobacco Control 7(3): 
43 European Commission (2007). Special Eurobarometer "Attitudes of Europeans towards Tobacco", 
European Commission. 
44 Goodman, P., M. Agnew, et al. (2007). "Effects of the Irish Smoking Ban on Respiratory Health of 
Bar Workers and Air Quality in Dublin Pubs" :Am J Respir Crit Care Med. 175(8):840-5. 
45 Breaking the cycle of children’s. exposure to tobacco smoke. April 2007. BMA Board of Science. 
46 Warren CW, Jones NR, Peruga A, Chauvin J, Baptiste JP, et al. Global Youth Tobacco Surveillance, 
2000-2007. CDC Morbidity and Mortality Weekly Report. 2008:57(SS-1). 
47 GYTS has not been completed in countries in Western Europe. 
48 Pattenden S, Antova T, Neuberger M, Nikiforov B, De Sario M, Grize L, Heinrich J, Hruba F, 
Janssen N, Luttmann-Gibson H, Privalova L, Rudnai P, Splichalova A, Zlotkowska R, Fletcher T.  
Parental smoking and children's respiratory health: independent effects of prenatal and postnatal 
exposure.  Tob Control. 2006 Aug;15(4):294-301. Review. 
49 Scottish Executive (2005) The Scottish health survey – 2003 results. Edinburgh: Scottish Executive. 
 Breaking the cycle of children’s. exposure to tobacco smoke, op. cit
50 Darling, H. and Reeder, A. Is exposure to secondhand tobacco smoke in the home related to daily 
smoking among youth? Australian and New Zealand Journal of Public Health 27(6): pp.655-656, 
Scragg, R. et al. Parental smoking and related behaviours influence adolescent tobacco smoking: results 
from the 2001 New Zealand national survey of 4th form students. New Zealand Medical Journal 
116(1187): U707, 2003.  
Centers for Disease Control and Prevention. State-specific prevalence of cigarette smoking among 
adults, and children’s and adolescent’s exposure to environmental tobacco smoke-United States. 
Morbidity and Mortality Weekly Report 46: pp.1038-1043, 1997. 
Wakefield, M.A. et al. Effect of restrictions on smoking at home, at school, and in public places on 
teenage smoking: cross sectional study. British Medical Journal 321(7257): pp.333-337, 2000. 

Szabo E, White V, Hayman J. Can home smoking restrictions influence adolescents' smoking behaviors 
if their parents and friends smoke? Addict Behav. 2006 Dec;31(12):2298-303. 
Albers AB, Biener L, Siegel M, Cheng DM, Rigotti N.Household smoking bans and adolescent 
antismoking attitudes and smoking initiation: findings from a longitudinal study of a Massachusetts 
youth cohort.Am J Public Health. 2008 Oct;98(10):1886-93.  
Conley Thomson C, Siegel M, Winickoff J, Biener L, Rigotti NA.Household smoking bans and 
adolescents' perceived prevalence of smoking and social acceptability of smoking. Prev Med. 2005 
51 Rees VW & Connolly GN (2006) Measuring air quality to protect children from second-hand smoke 
in cars. American Journal of Preventive Medicine 31: 363-8. 
Edwards R, Wilson N & Pierse N (2006) Highly hazardous air quality associated with smoking in cars: 
New Zealand pilot study. New Zealand Medical Journal 119: U2294. 
Ott W, Klepeis N, Switzer P., Air change rates of motor vehicles and in-vehicle pollutant 
concentrations from secondhand smoke. J Expo Sci Environ Epidemiol. 2008 May;18(3):312-25.  
Rees VW, Connolly GN. Measuring air quality to protect children from secondhand smoke in cars. 
Am J Prev Med. 2006 Nov;31(5):363-8.  
52 Sacks JJ & Nelson DE (1994) Smoking and injuries: an overview. Preventive Medicine 23: 515-20. 
Wen CP, Tsai SP & Cheng TY et al (2005) Excess injury mortality among smokers: a neglected 
tobacco hazard. Tobacco Control 14: i28-32. 
Leistikow BN, Martin DC & Samuels SJ (2000) Injury death excesses in smokers: a 1990-95 United 
States national cohort study. Injury Prevention 6: 277-80. 
Leistikow BN, Martin DC, Jacobs J, Rocke DM.Smoking as a risk factor for injury death: a meta-
analysis of cohort studies. Prev Med. 1998 Nov-Dec;27(6):871-8. 
53 Breaking the cycle of children’s. exposure to tobacco smoke. op. cit. 
54 Wilson N, Thomson G, Edwards R. Lessons from Hong Kong and other countries for outdoor 
smokefree areas in New Zealand? N Z Med J. 2007 Jun 29;120(1257):U2624.  
Bloch M, Shopland DR.Outdoor smoking bans: more than meets the eye. Tob Control. 2000 
55 The conference statement called on the Commission "to produce a proposal on how legislative 
safeguards against second-hand smoke can be promoted in all those EU countries that have not yet 
introduced them, and to show leadership in implementing the FCTC smoke free guidelines at a global 

57 Communication from the Commission to the European Parliament, the Council, the European 
Economic and Social Committee and the Committee of Regions on the practical implementation of the 
provisions of the Health and Safety at Work Directives 89/391 (Framework), 89/654 (Workplaces), 
89/655 (Work Equipment), 89/656 (Personal Protective Equipment), 90/269 (Manual Handling of 
Loads) and 90/270 (Display Screen Equipment) COM/2004/0062 final. 
COM(96) 573 final. 
The Public Places Charter on smoking. Industry progress report. The Charter Group, April 
Inspection by Spanish consumer organisation OCU -
See also Fernandez E. Spain: going smoke free. Tob Control. 2006 Apr;15(2):79-80.  
Press statement from Sabine Bätzing and the German Health Ministry, 27 February 2007
63 Glantz Stanton A., Meta-analysis of the effcts of smokfree laws on acute myocardial infarction: An 
update, Preventive Medicine (2008), 
Pierce JP and Leon ME, on behalf of the IARC Handbook Volume 13 Working Group and IARC 
Secretariat. Special report: policy. Effectiveness of smoke-free policies. Lancet Oncol 2008; 9:614-615. 
Pell J (2007) Testing the Montana Hypothesis: Results from Scotland. Presentation at Towards a 
Smokefree Society Conference, Edinburgh: 10-11th September 2007. 
Cronin, E., P. Kearney, P. Kearney and P. Sullivan (2007). Impact of a national smoking ban on the 
rate of admissions to hospital with acute coronary syndromes. European Society of Cardiology 
Cesaroni, G., F. Forastiere, et al. (2008). "Effect of the Italian Smoking ban on Population Rates of 
Acute Coronary Events." Circulation 117. 
64 Allwright, S. (2004). "Republic of Ireland's indoor workplace smoking ban." British Journal of 
General Practice 54(508): 811-812. 
Semple, S., L. Maccalman, et al. (2007). "Bar workers' Exposure to Second-Hand Smoke: The effect of 
Scottish Smoke-Free Legislation on Occupational Exposure." Ann. Occup. Hyg 51(7): 571-580. 
Menzies, D., A. Nair, et al. (2006). "Respiratory symptoms, pulmonay function, and markers of 
inflammation among bar workers before and after a legislative ban on smoking in public places." 
Journal of the American Medical Association 296(14): 1742-1748. 
Farrelly, M. C., J. M. Nonnemaker, et al. (2005). "Changes in the hospitality workers'exposure to 
secondhand smoke following the implementation of New York's smoke-free law." Tobacco Control 14: 
Eisner, M. D., A. K. Smith, et al. (1998). "Bartenders' respiratory health after establishment of smoke-
free bars and tavers." Journal of the Americal Medical Association 280(22): 1909-1914. 
Farkas, A., E. Gilpin, et al. (2000). "Association between household and workplace smoking 
restrictions and adolescent smoking." JAMA 284: 717-722 
Wakefield MA et al (2000). ”Effect of restrictions on smoking at home, at school and in public places 
on teenage smoking: cross sectional study.” British Medical Journal 321:333-337. 
Wakefield et al (2007). "Potential for smoke-free policies in social venues to prevent smoking uptake 
and reduce relapse: A qualitative study." Health Promotion Practice. 

Edwards, R., H. Gifford, et al. (2007). The impact of smokefree policies on an indigenous 
population: The experience of smokefree legislation and the Maori population in New Zealand. 
Towards a Smokefree Society. Edinburgh, Scotland. 
Hassan L. M., G. Walsh, et al. (2007). "Modeling persuasion in social advertising." Journal of 
Advertising 36(2): 15-31. 
Martin, C., D. Ritchie, et al. (2008). Evaluation of the Smoke-free legislation in Scotland: Qualitative 
Community Study. Edinburgh, Scotish Centre for Social Research: 35.  
Carpenter, C. (2007). The effects of local smoking laws on smoking restrictions and exposure to smoke 
at work: Evidence from Ontario, Canada, The Paul Merage School of Business, UC Irvine: 36 
Edwards, R., H. Gifford, et al. (2007). op. cit
Evans, D. S., C. Byrne, et al. (2007). The 2004 Irish smoking ban? Is there a ‘knock on effect’ 
on smoking in the home? 4th European Conference Tobacco or Health. Basel, Switzerland. 
Global Smokefree Partnership (2007). Global voices for a smokefree world: Movement 
Towards a Smokefree Future, 2007 Status Report, Global Smokefree Partnership. 
Martin et al. 2008, op. cit. 
Phillips, R., A. Amos, et al. (2007). "Smoking in the home after the smoke-free legislation in 
Scotland: qualitative study." British Medical Journal 335: 553-557. 
Fong, G. T., A. Hyland, et al. (2006). "Reductions in tobacco smoke pollution and increases in support 
for smoke-free public places following the implementation of comprehensive smoke-free workplace 
legislation in the Republic of Ireland: findings from the ITC Ireland/UK survey." Tobacco Control 15: 
Edwards, R., C. Bullen, et al. (2008). After the smoke has cleared; Evaluation of the impact of a new 
smokefree law. Wellingotn, Ministry of Health156 
This figure was calculated as follows: Averted deaths from SHS: employees (£21mill)  + 
customers (£350mill) + averted deaths from smokers giving up: employees (£1600mill) + customers 
(£180mill) +  averted deaths from reduced uptake smoking (£550mill) + NHS expenditure saved 
through reduced smoking prevalence (£100mill) + reduced sickness absences (£70-140mill) + 
production gains (from reduced exposure to SHS) (£340-680mill) 
This figure was calculated as follows: economic value of lives saved: reduced exposure to 
ETS (£974.50mill) and reduced active smoking (£524.81mill) + human cost of ill health (morbidity 
saving): reduced exposure to ETS (£141.30mill) + NHS treatment cost savings reduced exposure to 
ETS (£32.50mill) and reduced active smoking (£24.67mill) + reduced sickness absences: reduced 
exposure to ETS (£44.86mill) and reduced active smoking (£5.27mill). 
This figure includes value of deaths avoided: reduced exposure to ETS (£91.4 mill) and 
reduced active smoking  (£108.5 mill) + human cost of ill health (morbidity saving): reduced exposure 
to ETS (£12.8 mill) + saving on NHS costs: reduced exposure to ETS (£5.3 mill) and reduced active 
smoking  (£2.8 mill) + saving on sickness absence: reduced exposure to ETS (£4.1mill) and reduced 
active smoking  (£0.8 mill)  
This figure was calculated as follows: economic value of lives saved: reduced exposure to 
ETS (£5.47mill) and reduced active smoking (£19.35mill) + human cost of ill health (morbidity 
saving): reduced exposure to ETS (£14.42mill) and reduced active smoking (£11.14mill) + NHS 
treatment cost savings: reduced exposure to ETS (£4.10mill) + reduced sickness absences (£0.6mill). 
Scollo, M. and A. Lal (2008). Summary of studies assessing the economic impact of smoke-
free policies in the hospitality industry. Melbourne, VicHealth Centre for Tobacco Control: 84. 
77  Adda, J., S. Berlinski, et al. (2006). "Short-run economic effect of the Scottish smoking ban." 
International Journal of Epidemiology. 

78 Thomson, G. G. (2006). "One year of smokefree bars and restaurants in New Zealand: impacts and 
responses." BMC public health 6(1): 64. 
79 McCaffrey, M., P. Goodman, et al. (2006). "Smoking, occupancy and staffing levels in a selection of 
Dublin pubs pre and pst a national smoking ban, lessons for all." Irish Journal of Medical Science 
175(2): 37-40. 
80 Thomson, G. G. (2006). "One year of smokefree bars and restaurants in New Zealand: impacts and 
responses." BMC public health 6(1): 64. 
81 Cesaroni, G., F. Forastiere, et al. (2008). "Effect of the Italian Smoking ban on Population Rates of 
Acute Coronary Events." Circulation 117. 
82 Directorate for Health and Social Affairs (2005). Norway's ban on smoking in bars and restaurants - 
A review of the first year. Oslo, Directorate for Health and Social Affairs19. 
Goodman, P., M. Agnew, et al. (2005). Effects of the Irish Smoking Ban on Respiratory 
Health of Bar Workers and Air Quality in Dublin Pubs: 27. 
Travers, M., Cummings, K.M., Hyland, A., Repace, J., Pechacek, T.F., et al. (2004). Indoor air quality 
in hospitality venues before and after the implementation of a Clean Indoor Air Law - Western New 
York, 2003. Morb Mortal Wkly Rep, 53(44), 1038-1041. 

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