1. Making smoke-free laws work:
experience from Spain
Esteve Fernández, MD, PhD

2. The smoke-free legislation
in Spain (2006)
Law 28/2005 (January 1st, 2006)
• publicity, sales, and supply of tobacco products
• prohibition of smoking in
enclosed public places,
transportation,
and indoor workplaces
BUT…

3. The smoking ban in Spain (2006)
Exceptions in hospitality venues
(bars, pubs, restaurants, cafeterias...) according to
size:
• venues ≥100 m2:
smoking banned but smoking areas allowed
• venues <100 m2:
smoking prohibited or allowed
according to owner’s decision

4. http://www.dkfz.de/de/tabakkontrolle
The “Spanish model”
http://www.biomedcentral.com/1471-2458/11/907

5. Accommodation Programmes
Countries (year)
Designation of smoking
and non-smoking venues
Separation into smoking and
non-smoking rooms
“Traditional Hospitality” “Courtesy of Choice”
Spain (2006) ≤100 m2 (accessible area) >100 m2 (accessible area)
Denmark (2007) ≤ 40 m2 > 40 m2
Austria (2008)
One room venues with < 50 m2
(or 80 m2 if separation legally
not feasible)
Venues with 2 or more rooms
Germany (2008) One room venues with < 75 m2 Venues with 2 or more rooms
Greece (2009) ≤ 70 m2 > 70 m2
Croatia (2009) ≤ 50 m2 > 50 m2
Switzerland (2010) ≤ 80 m2 > 80 m2
The Netherlands (2010)
≤ 70 m2
(if only operated by owner)
> 70 m2
Czech Republic (2010) All venues
Smoking rooms without size
specifications
Impact of tobacco industry’s accommodation
programmes in smoke-free legislation in Europe.
Schneider N, Sebrié E, Fernández E. The origin and failure of partial smoking bans
and its impact in Europe and Latin America. BMC Public Health; 2012:11:907.

6. How to promote a change?
• Fostering a scientific evaluation of the impact of
the partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability
of smoke-free legislation
• Getting support from key persons at the regional and
national public health administration
• Promoting advocacy of politicians, citizens’
associations, trade unions, journalists, etc.

7. Impact of the Spanish Smoking Law
on Exposure to Secondhand Smoke
in Offices and Hospitality Venues:
Before-and-After Study
Nebot et al. Environ Health Perspect. 2009;117:344-7.

8. Impact of the Spanish Smoking Law on
Exposure to Second-Hand Smoke and
Respiratory Health in Hospitality Workers:
A Cohort Study
Fernández et al. PLoS One. 2009;4:4244.

9. “Clearly, the results support a complete ban on
smoking in all indoor places, including hospitality
sector venues.”
“Policy makers in other countries currently considering
the scope of their smoke-free legislation should not
ignore these results.”
“Partial bans, (…) do not completely protect workers and
others against second-hand smoke.”

10. Manel Nebot y Esteve Fernández (coords.)
Carles Ariza
Marcela Fu
Iñaki Galán
María José López
Jose M. Martínez
Albert Moncada
Agustín Montes
Mónica Pérez
Esteve Saltó
Anna Schiaffino
María Jesús Soriano
Working Group on Tobacco Control of the
Spanish Society of Epidemiology
http://www.seepidemiologia.es/monografia.pdf

11. How to promote a change?
• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Promoting a positive social climate and
acceptability of smoke-free legislation
• Getting support from key persons at the regional and
national public health administration
• Promoting advocacy of politicians, citizens’
associations, trade unions, journalists, etc.

12. Manel Nebot y Esteve Fernández (coords.)
Carles Ariza
Marcela Fu
Iñaki Galán
María José López
Jose M. Martínez
Albert Moncada
Agustín Montes
Mónica Pérez
Esteve Saltó
Anna Schiaffino
María Jesús Soriano
Grupo de Trabajo sobre tabaquismo
Sociedad Española de Epidemiología

13. How to promote a change?
• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability
of smoke-free legislation
• Getting support from key persons at the regional
and national public health administration
• Promoting advocacy of politicians, citizens’
associations, trade unions, journalists, etc.

14. J Epidemiol Community Health. 2013;67(7):542-3.

15. [The Department of] Health
begins to impose penalties
as a conequence of the
tobacco law
[The Department of] Health
proposes a veto to tobacco
in all bars and restaurants

16. How to promote a change?
• Fostering a scientific evaluation of the impact of the
partial ban on SHS exposure and morbidity
• Promoting a positive social climate and acceptability
of smoke-free legislation
• Getting support from key persons at the regional and
national public health administration
• Promoting advocacy of politicians, citizens’
associations, trade unions, journalists, etc.

17. www.cnpt.es

18. The new smoke-free legislation
in Spain
Law 42/2010 (that amends law 28/2005)
• smoking banned
• in all enclosed hospitality places (bars,
restaurants, taverns, pubs, ...)
• health care services and educational centers
(both indoors and outdoors)
• outdoor children’s playgrounds

21. ... and after the new law?
Fernández & Nebot. Tob Control. 2010;20(1):6-7.

22. After law 42/2010
• dissemination of the new “Spanish model”
• enforcement of the law
• impact evaluation in terms of
• exposure to SHS
• changes in morbidity (asthma, CVD)
• changes in smoking behaviour
• prevention of regressive changes!

23. López MJ, Fernández E, Pérez-Ríos M et al.
Impact of the 2011 Spanish smoking ban in hospitality
venues: indoor secondhand smoke exposure and
influence of outdoor smoking.
Nicotine & Tobacco Research. 2013.
Methods
• Design: pre-post evaluation
• Field work: Pre-ban: Oct-Des 2010; post-ban: May -July 2011 (post)
• Target: cafeterias, bars & pubs in Catalonia, Galizia and Madrid
• Sample: 180 venues (semiprobabilistic multistage weighted sample)
• SHS environmental markers: Airborne nicotine and PM2.5

24. Airborne nicotine concentration (µg/m3)
5.73
Reduction of 90.1%
p<0.001
n=171
0.57
Pre-ban
(year 2010)
Post-ban
(year 2011)

25. PM2.5 concentrations in real time
0
200
400
600
800
1,000
1,200
1,400
0 200 400 600 800 1,000 1,200 1,400 1,600 1,800
PM2.5(µg/m3)
Time (seconds)
Pre-ban
Post-ban

26. Changes in exposure of adult non-smokers to secondhand
smoke after smoke-free legislation in Spain.
Sureda X, Fernandez E, Fu M, Martínez-Sánchez J et al.
Methods
• Design: repeated cross-sectional (independent) surveys
• Field work: pre (2004-05) and post (2011-12) ban
• Target: adult population (>16 y) in
Barcelona, Spain.
• Sample: 1300 people
in each survey
• Outcomes: Salivary cotinine and
self-reported exposure
to SHS

27. Salivary cotinine concentration (ng/ml)
0.1 1 2 3 4 5 6 7 8 9 10
0
200
100
300
400
500
No.ofsamples
After legislation (n=878)
Before legislation (n=724)
Salivary cotinine concentration (ng/ml) among the non-
smoker adult population, before (2004-05) and after (2011-
12) the smoke-free legislation, Barcelona (Catalonia), Spain
Reduction 90%
p<0.001

28. Lessons learned
• if partial bans cannot be avoided, they have to be a first
step towards total bans
• partial bans can be changed:
- join action(s) by scientists, consumers, politicians...
- constant presence in mass media, forums, debates…
- alliances with policy decisors
- not “a day” effort but a long-term run
• prevention of regressive changes after total bans

29. In memoriam:
Manel Nebot (1957-2012)
http://manelnebot.blogspot.com

30. Making smoke-free laws work: experience from Spain
Esteve Fernández, MD, PhD efernandez@iconcologia.net
tobaccorelated.org
@stvfdz
www.iconcologia.net/tobaccoTobacco Control Unit
Cancer Prevention & Control Programme
Catalan Institute of Oncology