Smoking Ban Research Articles

Prevalence and determinants of second-hand tobacco smoking in Pakistan.

Exposure to second-hand tobacco smoke is a public health problem in countries with high prevalence of active smoking such as Pakistan. However, few studies have assessed the prevalence and risk factors for exposure to second-hand tobacco smoke. To estimate the prevalence and factors associated with exposure to second-hand tobacco smoke in Pakistan. This study used data from the 2017-2018 Pakistan Demographic and Health Survey to calculate the prevalence and determinants of second-hand tobacco smoke exposure. Sociodemographic characteristics, family size and exposure to media by the respondents were the independent variables. The chi-square test and logistic regression analyses were used to evaluate the relationship between exposure to second-hand tobacco smoke and the independent variables.hy9. The survey included 61 940 adults, of which 30 027 (48.5%) were males and 31 913 (51.5%) females. The overall prevalence of exposure to second-hand tobacco smoke was 34.3%: 35.6% among males and 33.2% among females. Higher education level and rural residence were significantly positively associated with exposure to second-hand tobacco smoke among both sexes. Having a radio was inversely associated with exposure while having a television was positively associated with exposure among both sexes. Large family size was inversely associated with exposure. Currently and previously married females had significantly greater risk of exposure than never-married females. Tailored health interventions and policies are needed that target populations at high-risk of exposure to second-hand tobacco smoke. Strict smoking bans in public places should be implemented to limit exposure to second-hand tobacco smoke in Pakistan.

De-normalizing smoking in urban areas: Public smoking bans and smoking prevalence

The effectiveness of command-and-control policies related to tobacco use has been studied in high-income countries. Still, there is limited evidence of their effects in low and middle-income countries. We explore the case of Colombia, a country that introduced a business-supported smoking ban in bars and restaurants and all public indoor spaces in 2010. This paper investigates the effect of smoking bans in bars and restaurants on smoking prevalence in Bogotá, Colombia. In this paper, we use the matching with triple-differences technique in analyzing household consumption data from the 2007 and 2011 quality of life surveys. This is done by exploiting their geographical proximity and variation in the density of commercial areas. We found that after the smoking ban implementation, smoking prevalence reduced in households near high-density commercial blocks compared to households near low-density commercial blocks (−10.8 pp.). The impact is larger for households with children and older household heads. Since households near high-density commercial blocks are more frequently exposed to smoking than households near low-density commercial blocks, the former would be more willing to internalize the smoking de-normalization process.

Effectiveness of a Social Marketing Mix Intervention on Changing the Smoking Behavior of Santri in Traditional Islamic Boarding Schools in Indonesia.

This study investigated the effectiveness of the social marketing mix approach in increasing students' knowledge about smoking, promoting positive attitudes toward smoking cessation, and decreasing smoking behavior. This quantitative research study incorporated a quasi-experimental method with a pretest-posttest non-equivalent group design. Using the purposive sampling technique, 152 smoking students were selected as participants. They were divided into 2 equal groups, with 76 students in the control group and 76 in the intervention group. The data were collected using questionnaires and analyzed with the chi-square test, independent t-test, Wilcoxon signed-rank test, and Mann-Whitney U-test. The social marketing mix intervention was effective in increasing the students' knowledge about smoking (p<0.001), improving their attitude toward smoking cessation (p<0.001), and reducing their smoking behavior (p=0.014). This approach should be implemented by local governments to reduce smoking behavior in the community, especially among teenagers, in addition to instituting a smoking ban and applying fines.

The Impact of the Danish National Smoking Ban From 2007 on the Incidence of Eight Smoking-related Diseases: A Nationwide Register-based Interrupted Time Series Analysis.

Previous research has documented the effect of comprehensive smoking bans on preventing various adverse health outcomes in the years post-ban. In 2007, Denmark implemented a national smoking ban that prohibited indoor smoking in workplaces and public settings, although only partial restrictions applied in specific premises such as small bars, one-person offices, and in psychiatric units. We tested the hypothesis that the implementation of the national smoking ban was associated with a decrease in incidence of smoking-related morbidity in the Danish population compared to the pre-ban period. Interrupted time series analyses including the entire Danish population (≥30 years) was conducted. Information of hospitalizations and cause-specific mortality due to acute myocardial infarction, heart failure, hemorrhagic stroke, ischemic stroke, chronic obstructive pulmonary disease, cancer in bronchus and lung, cancer in lip, mouth, oral cavity, and pharynx, and bladder cancer were obtained from population-based registers. Poisson regression models accounting for seasonal variations and secular trends quantified immediate changes in incidence rates occurring at the time of the smoking ban as well as changes in the post-ban trend compared to pre-ban levels. Overall, we observed no consistent declines in incidence of cardiovascular diseases, chronic obstructive pulmonary disease, or the specific types of cancer in the post-ban period compared with the pre-ban period. No consistent reduction in incidence of smoking-related diseases was observed after the smoking ban was introduced in Denmark. This probably reflects that the Danish smoking ban included several exemptions, resulting in a less comprehensive ban compared to those introduced in other countries. In this study, we found that the Danish national smoking ban from 2007 did not consistently reduced the incidence of eight smoking-related outcomes in the post-ban period compared to pre-ban levels. We argue that due to the exemptions in the smoking ban, which for example allowed smoking in specific premises of the care and nursing sector, in one-person offices, and small bars, the ban was not sufficiently comprehensive to influence smoking behavior and thereof the incidence of smoking-related morbidity. Our findings highlight the importance of introducing comprehensive legislative measures to yield largest health benefits at a population level.

Extent of implementation of smoking ban among Senior High School students in Zambales, Philippines

ABSTRACT
 The Department of Education, Zambales Division is also adopting anti-smoking measures in accordance with the above Deped guidelines and rules. Consequently, this study would assess the extent to which smoking ban was implemented among senior high school. The study utilizes descriptive research design where survey checklist was the main instrument to gather data. The study was conducted in Zone 2, Division of Zambales which consisted of municipalities of Palauig, Iba and Botolan. The study used simple random sampling. There are five hundred twenty seven (527) senior high school students from different municipalities have served as respondents. The instrument was validated by three experts and treated through reliability testing. There are two parts of the instrument, (a) demographic profile of the respondents; (b) perception of the student-respondents towards extent of smoking ban implementation. Based from the results, therefore it conclude that the student-respondents assessed “Implemented” on the level of smoking ban implementation as to school policies and intervention, teachers’ participation and students’ participation respectively; that there is significant difference when grouped according all profile variables except for gender as to school policies and intervention and students’ participation; and that there is no significant differences on the assessment towards dimensions on the level of extent of implementation of smoking ban as to school policies and intervention, teachers and student participation respectively.

Compliance with Section 7 (2) of the Cigarettes and Other Tobacco Products Act (COTPA) 2003, Ban of Sale of Loose Tobacco, in Karnataka: A Cross-Sectional Study.

Banning smoking in public places has considerably reduced the number of smokers. However, the sale of loose tobacco encourages tobacco use. There is limited data on compliance with section 7(2) of the Cigarettes and Other Tobacco Products Act (COTPA), 2003, concerning the ban on loose tobacco sales in India. The aim of this study is to assess the compliance of section 7(2) of COTPA concerning the ban on loose tobacco sales in four selected cities of Karnataka. This community-based study used a cross-sectional design. Two neighboring cities, that is, district headquarter from North (Bidar and Vijayapura) and South (Mandya and Chikkamagaluru) Karnataka were considered for the study. A total of 207 vendors and 204 smokers were selected using time-cluster sampling. Data was collected using observation and interview methods. Semi-structured interview schedules were administered to smokers and vendors. Percentages and frequencies were used to describe the data. Most tobacco vendors (92%) and smokers (91%) were unaware of the loose tobacco ban. Most smokers (76%) perceive that buying cigarettes in packets would increase smoking. Most smokers (96%) prefer to buy cigarettes in loose. The sale of loose tobacco was widely prevalent (94%) in the four surveyed cities. Point of sale of loose tobacco includes tea shops (38%), petty shops (31%), pan shops (25%), and bakeries (6%). There is a high degree of noncompliance with Section 7 (2) of COTPA, 2003 regarding ban on selling loose tobacco.

Time trend of exposure to secondhand tobacco smoke and polycyclic aromatic hydrocarbons between 1995 and 2019 in Germany – Showcases for successful European legislation

Starting in 2002, regulations and legislative amendments in Germany focused on the non-smoker protection with several measures to reduce exposure to secondhand tobacco smoke (SHS). The present work aimed to evaluate the relationship between polycyclic aromatic hydrocarbons (PAHs) and SHS exposure and to determine to which extent enforced non-smoking regulations and smoking bans affected the exposure of the non-smoking population in Germany since their implementation in the early 2000s until today. For this purpose, cotinine and selected monohydroxylated PAHs (OH-PAHs) were analyzed by means of (UP)LC-MS/MS in 510 24-h-urine samples of the Environmental Specimen Bank collected over a time span of 24 years from 1995 to 2019. Median urinary cotinine levels were found to steadily and significantly decline by 82% from 1995 to 2019. A significant decrease of urinary 3-hydroxybenzo[a]pyrene (19%), 1-OH-pyrene (39%), 1-naphthol (66%), 1- (17%), 2- (25%), and 3-OH-phenanthrene (22%) was also observed throughout the same time span. The decline in urinary levels of cotinine and several OH-PAHs can most likely be attributed to smoking bans and regulations limiting SHS and PAH exposure. This study therefore emphasizes the relevance of human biomonitoring to investigate the exposure of humans to chemicals of concern, assess the effectiveness of regulatory measures, and help policies to enforce provisions to protect public health.

Creating smoke free environments by local policy

Abstract In The Netherlands, around 20.000 people die each year from the effects of smoking and passive smoking. Every week, hundreds of children become addicted to smoking. To improve the overall public health in the Netherlands, it is important to substantially reduce the prevalence of smokers. Until recent years, municipalities played next to no role in helping to reduce smoking in the Netherlands. The start of a large campaign that aims a smokefree generation by 2040 has changed that. Part of that campaign is to create smoke-free environments. In a two-year program, 90% of the Dutch municipalities started policy and actions to ban smoking from public places, as part of the National Prevention Agreement. The participating municipalities were supported by all 25 Regional Health Services (GGDs) by providing knowledge and manpower on a regional level, together with national, regional and local organisations. The project has a number of successful elements: the GGD received a (very small) budget to actively participate in the region; knowledge was shared between the regions and from national to local level and legal issues were dealt with by the Nat Assoc of Municipalities (VNG). In 2021, 317 out of 352 Dutch municipalities were active in this project. There is a significant increase of smoke-free environments, mostly schoolyards, playgrounds, sports facilities, smoke-free bus stops and municipal institutions. Other results are integrated plans for smoking cessation care and accessible stop smoking service, e.g. in GGD Fryslan the number of registrations for smoking cessation care increased dramatically and 80% actually quit smoking. All parties involved agree that the strength of this project is its positive approach and the broad social support it generates for the Smokefree Generation. It is about persuasion, not compulsion. Working from a national focus towards a smoke-free environment, while taking into account local differences and needs, makes this project a success. Key messages • This project resulted in more local and regional partnerships and an increase of smoke-free environments, bringing the ultimate goal of a Smokefree Generation closer. • 90% of Dutch municipalities have created smoke-free environments with the guidance of the regional GGD, financed by Ministry of Health: multilevel governance works.

Cost-Effectiveness Analysis of Tobacco Control Strategies in Indonesia

In Indonesia, tobacco smoking is a significant public health problem that continues to grow, with a prevalence among the highest worldwide. This study aimed to assess the cost-effectiveness of government-funded varenicline, smoking bans in public places, and an additional 10% tobacco tax in Indonesia. Markov modeling of Indonesians aged 15 to 84 years was undertaken, with simulated follow-up until age 85 years. Data on demographics, smoking prevalence, and mortality were drawn from the Global Burden of Disease Study 2017. Data regarding the efficacy and costs of the 3 interventions were gathered from published sources. Costs and benefits accrued beyond one year were discounted at 3% per annum. The year value of costing data was2020. Government-funded varenicline, smoking bans in public places, and an additional 10% tobacco tax were predicted to save 5.5 million, 1.6 million, and 1.7 million years of life, respectively (all discounted). In terms of quality-adjusted life-years, 3 tobacco interventions were predicted to gain 11.9 million, 3.47 million, and 3.78 million in quality-adjusted life-years, respectively. The savings in smoking-related healthcare costs amounted to US $313.8 billion, US $97.5 billion, and US $106 billion, respectively. Hence, from the perspective of the healthcare system, all 3 interventions were cost saving (dominant). In Indonesia, tobacco control measures are likely to be highly cost-effective and even cost saving from the healthcare system's perspective. These cost savings can be balanced against economic losses that would result from the impact on the sizable Indonesian tobacco industry.

Association of Residence Type on Smoking in South Korean Adolescents during the COVID-19 Pandemic: Findings from a National Survey.

The closure of schools due to the COVID-19 pandemic has forced adolescents to stay home. These disruptions, as well as a significant decrease in social access, have impacted smoking behavior. This study identified the association between the adolescents’ type of residence and tobacco product use. A cross-sectional study (using data from the Korea Youth Risk Behavior Web-based Survey) examined 3774 students in 2019 (pre-pandemic) and 2575 students in 2020 (during the pandemic). The participants were South Korean middle and high school students aged 13–19 years. Using multinomial logistic regression, it was shown that adolescents who lived alone or in a boarding house had a higher risk of being an e-cigarette smoker compared with those who lived with family or relatives (OR = 6.49, CI = 2.06–20.45). Living in a dormitory or orphanage also increased the risk of dual tobacco use compared with living with family (OR = 2.09, 95% CI = 1.13–3.84). With the advent and continuation of the COVID-19 pandemic, this effect became more significant in 2020 than in 2019. Our findings support the theory that residential differences affect adolescent smoking behavior and highlight the importance of integrated smoking bans and educational programs to control adolescent smoking.

Public support for car smoking bans in Poland: a 2022 national cross-sectional survey

ObjectiveThe objectives of this study were to assess the prevalence of self-reported secondhand smoke exposure in cars among adults in Poland and to characterise public attitudes towards the implementation of...

Assessing Smoking Habits, Attitudes, Knowledge, and Needs among University Students at the University of Milan, Italy.

Background: College campuses and universities are valuable settings for smoking prevention programs targeting young adults. Aim: To investigate smoking habits, electronic cigarette (e-cig) and heated tobacco product (HTP) use, exposure to passive smoke, compliance with smoking bans on campus, attitudes toward the anti-smoking policies, and educational needs among students at the University of Milan, Italy. Methods: A validated questionnaire was web-submitted to 64,801 students in the period May–July 2021. For each item, the frequency was calculated and χ2 test with Bonferroni correction was used to compare differences among the 10 faculties of the University. Results: 7162 students participated in the survey, while 6605 questionnaires were included in this report (62% female, 84% aged 18–25 years). Sixty-four percent of participants were never smokers, 19% were smokers, 2.8% were e-cig or HTP users, 3.7% were dual smokers, 10% were former smokers, and 66% reported routinely spending free time with smokers. Almost all students were aware of the dangers of active and passive smoking of cigarettes, while about 20% did not have an opinion on the dangers of e-cigs/HTPs. Only 49% were aware of the smoking ban in the outdoor areas of the university. Students from the faculties of Law and Political, Economic, and Social Sciences smoked more frequently and were more frequently exposed to passive smoke than other students. Medicine students were the most aware of the dangers of passive smoking and using e-cigs/HTPs. Conclusions: This is the first study in Italy involving the entire student population of a university and highlighting differences among faculties in terms of active and passive smoking and opinions. The results suggest that prevention campaigns addressed to students should consider their specific study curricula and give information tailored to the different educational needs to efficiently support health promotion.

A longitudinal analysis of MPOWER implementation, 2008-2018

Background In 2008, the World Health Organization (WHO) introduced MPOWER-a package of evidence-based, high-impact policy measures to help countries reduce tobacco use. These measures align with selected articles within the World Health Organization’s Framework Convention on Tobacco Control (FCTC), a global public health treaty to prevent and reduce tobacco use. Methods Observational longitudinal study involving 195 countries that submitted biannual national reports between 2008 and 2018. To report changes in MPOWER scores, countries were assessed using a validated checklist of the seven MPOWER indicators and a maximum possible unweighted composite score of 34 points. Covariate analysis was conducted among selected health, sociopolitical, and economic indicators. Results 176 out of 195 countries improved their MPOWER scores between 2008 and 2018, with two achieving full implementation (Brazil and Turkey). Twenty-three (23) countries representing 11.2% of the global population recorded an MPOWER scoring increase of at least 10 points between 2008 and 2018. The overall mean 10-year scoring increase was 5.1 points or a relative improvement of 27.1%. In 2018, 20 countries representing 10.4% of the global population excelled in MPOWER implementation by receiving a total composite score of at least 30 of 34 possible points. The MPOWER elements with the highest degree of implementation in 2018 include Warn (package), Protect (smoking ban) and Enforce (ad ban). Several covariates were positively associated with higher levels of MPOWER implementation, including cigarette affordability, the existence of national tobacco control objectives, the human development index score, the national corruption index score, national literacy rates and the political regime index score. Conclusions MPOWER implementation increased markedly between 2008 and 2018 in all seven WHO regions and countries representing all four World Bank income classifications. However, only two countries achieved full implementation by 2018. More work is needed to improve MPOWER implementation. Countries with low-income levels, compromised human development, reduced literacy rates, higher rates of corruption, and autocratic political regimes appear to struggle more with MPOWER implementation.

Family matters: the influence of partner and familial encouragement on home and car smoking bans

Background: Secondhand smoke exposure (SHSe) poses health risks to neonatal intensive care unit (NICU) infants after they are discharged; these risks can be mitigated by the implementation of parent-enforced total home and car smoking bans. Understanding the influence that various family members have on household smoking policies may inform interventions to reduce SHSe among vulnerable infants.Methods: In a cross-sectional, secondary analysis of data collected between 2013 and 2015, mothers of NICU infants who reported smoking or living with a smoker (N=242) were asked about whether members of 9 separate relationship types (e.g., partner, mother, father) encouraged or discouraged smoking in the home and car. The influence of perceived encouragement from each relationship type on the odds of having a total smoking ban in place was estimated.Results: Participants reported that partners (47%) and siblings (32%) were most likely to encourage smoking in the home/car. In a multivariate model, both partner (p=0.0002) and sibling (p=0.004) encouragement of indoor smoking decreased the likelihood of having a total smoking home and car ban in place.Conclusions: Family members have significant influence on SHSe reduction practices. Innovative family-based interventions may be needed in order to reduce SHSe in this particularly vulnerable group of infants.

Smoking Bans, Leisure Time and Subjective Well-being

During 2007 and 2008 smoking bans were gradually implemented in all of Germany’s sixteen federal states to prohibit smoking in bars, restaurants, and dance clubs. Aimed at reducing smoking and improving health, tobacco control policies are often controversially discussed as they entail potential side effects. We exploit regional variation to identify effects of smoking bans on life satisfaction and leisure time satisfaction. Difference-in-differences estimates reveal that predicted smokers who used to visit bars regularly are less satisfied with life and leisure time, following the enforcement of a smoking ban. We show that changes in use of leisure time likely explain these findings. On the contrary, predicted non-smokers who did not visit bars and restaurants frequently benefit from the smoking bans, as their satisfaction with leisure time increases. They show an increase in hours spent on free-time activities and are more likely to go out with smoking bans in effect.

Implementation of Tobacco Control Strategies in Psychiatric Institutions for Children and Adolescents: an Online Survey of Leading Staff Members

Tobacco control measures are relevant also in child and adolescent psychiatric institutions and their implementation in Germany will be assessed in this study. In an online survey, n=78 leading staff members responded to standardized questions assessing how smoking in patients was dealt in such institutions. The majority of institutions (70-87%) had smoking bans in the psychiatric clinic buildings and premises. Depending on the type of psychiatric ward, exceptions were in place in the form of a designated smoking area (38%), smoking pavilion (19%), or when patients suffered from certain mental disorders (28%). Documentation of violations of the ban varied with the type of ward (30-79%), while in most cases violations led to consequences (84-93%) including confiscation of smoking utilities (42-63%) or a curfew (25-38%). Smoking cessation aids were reported by 78% of the institutions, most often as consultations (64%). Pharmacological treatments for smoking were provided in inpatient wards (71-83%). One in two institutions documented the result of cessation attempts (54%). Smoking-related working groups (14%) or the use of standardized diagnostic instruments (0-4%) were much less frequently reported. We provide a first look at tobacco control policy measures in child and adolescent psychiatric institutions on a national scale. This allows us to derive future areas for tobacco control.

Impact of smoking bans and other smoking cessation interventions in prisons, mental health and substance use treatment settings: A systematic review of the evidence

We conducted a systematic review to examine whether smoking bans alone are effective in achieving smoking cessation in people released from prison, and patients discharged from mental health or substance use settings. We searched health, criminology and social science databases. Detailed search strings were used to combine terms related to smoking bans and cessation interventions in prison, mental health and substance use treatment settings. We used backward and forward snowballing and manual hand searching to find additional studies. Studies were included if they: were published between 1 January 2000 and 25 February 2022; included a complete smoking ban; measured people released from prison and/or mental health and/or substance use patients smoking post-release/discharge from a smoke-free facility; and reported smoking cessation intervention and/or smoking ban outcomes. Methodological quality was assessed using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies and reviewed by two authors. People released from prison, mental health and substance use in-patients who experience a smoking ban while incarcerated or in in-patient settings often relapse to smoking shortly after release or discharge. We found that although smoking bans alone do not promote cessation, multi-component interventions in combination with smoking bans can significantly increase cessation rates post-release/discharge provided they support participants during this time. There is limited evidence to suggest tobacco bans alone in prison, mental health and substance use treatment settings are effective in achieving long-term smoking cessation. This review suggests that combining smoking bans and cessation interventions including pre- and post-release/discharge support can be effective in achieving smoking cessation.

Sociodemographic predictors for smoking persistence among young males in Indonesia

The prevalence and burden of non-communicable diseases (NCDs) in Indonesia are increasing. One major risk factor for NCDs is smoking. Thus, this study assessed sociodemographic predictors of smoking persistence among young males in Indonesia, who are at high risk for smoking and NCDs. We analysed the Indonesian Demographic and Health Survey (IDHS) conducted in 2017, a nationally representative survey in 34 provinces of Indonesia. We included data from 9957 young males aged 15-24 who had tried smoking and were interviewed by the IDHS enumerators for their smoking patterns and sociodemographic characteristics. Logistic regression analyses were used to assess the predictors of smoking persistency. Our analyses uncovered that those who started smoking at high-school age, lived in rural areas, had an occupation, and had lower education levels, had higher odds of smoking persistence than other young males. The use of internet, also increased the odds of smoking persistence, while those reading newspapers had lower odds of smoking persistence. Regarding household characteristics, young males who came from poor households, whose household heads were smokers or not married, also had higher odds of smoking. In conclusion, this study also showed the significance of several individual variables and household sociodemographic factors related to smoking persistence. Based on our findings, we recommend the need for intervention that aims not only at large-scale policy to ban smoking and educational campaigns through the internet but also specific educational intervention targeting families, particularly poor families with active smokers. The educational campaign is also needed to target the younger population, who are at higher risk for smoking persistence if they start smoking earlier.

Factors associated with smoking behaviour changes during the COVID-19 pandemic in Japan: a 6-month follow-up study

BackgroundSmoking behaviour may have changed due to the COVID-19 pandemic, the April 2020 revised smoke-free policy and the high prevalence of heated tobacco product (HTP) use in Japan (10.9% in...

Attitudes of staff towards smoke-free environments in psychiatric hospitals in Germany.

INTRODUCTIONSmoke-free environments have already been successfully introduced in hospitals world-wide. But despite convincing evidence of their success, many countries still struggle to make the necessary changes. Not only is the smoking prevalence higher amongst people with mental health problems and staff working in psychiatric units, but employees in psychiatry often resist the implementation of smoke-free policies. This study explores staff attitudes towards smoke-free environments in psychiatric hospitals in Germany and tries to identify barriers and opportunities for implementation.METHODSThis cross-sectional online survey was carried out at eight psychiatric units of the state-owned healthcare company Vivantes Netzwerk für Gesundheit GmbH in Berlin, Germany, in 2019. A total of 448 members of staff were surveyed on their views towards creating a smoke-free environment in their workplace.RESULTSPsychiatric staff present contradictory attitudes towards implementing smoke-free regulations. On the one hand, a majority recognizes the need for smoke-free environments as they promote physical well-being of staff and patients. On the other hand, a majority opposes comprehensive restrictions like a complete smoking ban. Smokers are more likely than non-smokers to resist restrictive measures and show a tendency to only support those measures which they deem unlikely to affect their own smoking habits.CONCLUSIONSThe contradictory attitudes towards implementing smoke-free regulations present an entry point to elicit behavior change and a shift in attitudes, for example in staff training on smoke-free environments. Staff who smoke, in particular, should be motivated to reflect on the contradiction that is presented by their private smoking behavior and their role as healthcare professionals.