Introduction Of Smoke-free Legislation Research Articles

Changes in childhood experimentation with, and exposure to, tobacco and e-cigarettes and perceived smoking norms: a repeated cross-sectional study of 10\u201311\u2009year olds\u2019 in Wales

BackgroundToday’s primary school children have grown up in a climate of strong smoking restrictions, decreasing tobacco use, and the emergence of e-cigarettes. Children’s exposure to tobacco declined substantially in years following the introduction of smoke-free legislation, with smoking uptake and perceived smoking norms declining. There is debate regarding whether emergence of e-cigarettes may interrupt trends in children’s smoking perceptions, or offer a means for adults to limit children’s exposure to tobacco. This study examines change in children’s tobacco and e-cigarettes experimentation (ever use), exposure to secondhand smoking and vaping, and perceived smoking norms.MethodsData from four, repeat cross-sectional surveys of Year 6 primary school pupils (age 10–11 years) in Wales in 2007, 2008, 2014 and 2019 (n = 6741) were combined. E-cigarette use and perceptions were included in 2014 and 2019 surveys. Analyses used binary logistic regression analyses, adjusted for school-level clustering.ResultsChild tobacco experimentation and most indicators of exposure to tobacco smoke indicated a graded decreasing trend over time from 2007 to 2019. Exposure to e-cigarettes increased from 2014 to 2019, as did pupil awareness of e-cigarettes (OR = 2.56, 95%CI = 2.12–3.10), and parental use (OR = 1.26, 95%CI = 1.00–1.57). A decrease in child e-cigarette experimentation was not significant (OR = 0.80, 95%CI = 0.57–1.13). Children’s normative perceptions for smoking by adults and children indicated a graded decrease over time (OR = 0.66, 95%CI = 0.54–0.80; OR = 0.69, 95%CI = 0.55–0.86; respectively from 2014 to 2019). However, fewer reported disapproval of people smoking around them in 2019 relative to 2014 (OR = 0.68, 95%CI = 0.53–0.88). Higher exposure to tobacco cigarettes and e-cigarettes in public places, cars and households were associated with favourable normative perceptions for tobacco smoking; however in models adjusted for exposure to both associations of e-cigarette exposure were attenuated.ConclusionChildren’s experimentation with and exposure to tobacco, and their perceptions of smoking as a normative behaviour, have continued to decline alongside growth in exposure to e-cigarettes. Although a large majority of pupils reported they minded people smoking around them, there was some evidence of diminishing disapproval of secondhand smoke since 2007. Further research is needed to understand whether use of e-cigarettes in cars and homes is displacing prior smoking or being introduced into environments where smoking had been eliminated.

Twenty-year sociodemographic trends in lung cancer in non-smokers: A UK-based cohort study of 3.7 million people

Introduction: There are reports that lung cancer in non-smokers (LCINS) is increasing in the United Kingdom (UK) and other high-income countries but evidence from large-scale cohort studies to support this claim is limited. Material and methods: Using The Health Improvement Network (THIN) IQVIA™ Medical Research Data, we identified a cohort of 3,679,831 people from the UK self-reporting to their primary care physician as never or non-smokers. We estimated age-adjusted incidence rates for recorded lung cancer before (1998−2007) and after (2008−2018) the introduction of smoke-free legislation using multivariable Poisson regression. We also explored the impact of geographic location, social deprivation and urbanicity. Results: The analysis included 3,212 lung cancer events and 28 million person-years (PYs). Between 1998 and 2007, the age-adjusted rates in men declined by 9% per year (95 %CI: 7–11%) from an estimated 5.6 to 1.5 per 10,000 PYs and by 3% per year (95 %CI: 1–5%) between 2008 and 2018. These trends for men were similar across sociodemographic strata. Between 1998 and 2007, age-adjusted rates were stable for women at 1.5 per 10,000 PYs. However, there was evidence that time trends for women differed depending on levels of social deprivation with rates increasing by 5% per year (95 %CI: 2–9%) from an estimated 1.3–2.1 per 10,000 PYs for women living in the least socially deprived areas. Sex-specific time trends from 2008 to 2016 were broadly similar in a separate cohort of self-reported never smokers from UK Biobank with cancer events linked to national registries. ConclusionIn summary, the incidence of LCINS has reduced or remained stable for most of the UK with the possible exception of women living in the least socially deprived areas.

Protective Effects of Smoke-free Legislation on Birth Outcomes in England: A Regression Discontinuity Design.

Environmental tobacco smoke has an adverse association with preterm birth and birth weight. England introduced a new law to make virtually all enclosed public places and workplaces smoke free on July 1, 2007. We investigated the effect of smoke-free legislation on birth outcomes in England using Hospital Episode Statistics (HES) maternity data. We used regression discontinuity, a quasi-experimental study design, which can facilitate valid causal inference, to analyze short-term effects of smoke-free legislation on birth weight, low birth weight, gestational age, preterm birth, and small for gestational age. We analyzed 1,800,906 pregnancies resulting in singleton live-births in England between 1 January 2005 and 31 December 2009. In the 1 to 5 months following the introduction of the smoke-free legislation, for those entering their third trimester, the risk of low birth weight decreased by between 8% (95% confidence interval [CI]: 4%, 12%) and 14% (95% CI: 5%, 23%), very low birth weight between 28% (95% CI: 19%, 36%) and 32% (95% CI: 21%, 41%), preterm birth between 4% (95% CI: 1%, 8%) and 9% (95% CI: 2%, 16%), and small for gestational age between 5% (95% CI: 2%, 8%) and 9% (95% CI: 2%, 15%). The estimated impact of the smoke-free legislation varied by maternal age, deprivation, ethnicity, and region. The introduction of smoke-free legislation in England had an immediate estimated beneficial impact on birth outcomes overall, although we did not observe improvements across all age, ethnic, or deprivation groups.See video abstract at http://links.lww.com/EDE/B85.

Has Childhood Smoking Reduced Following Smoke-Free Public Places Legislation? A Segmented Regression Analysis of Cross-Sectional UK School-Based Surveys.

Introduction:Smoke-free legislation has been a great success for tobacco control but its impact on smoking uptake remains under-explored. We investigated if trends in smoking uptake amongst adolescents differed before and after the introduction of smoke-free legislation in the United Kingdom.Methods:Prevalence estimates for regular smoking were obtained from representative school-based surveys for the four countries of the United Kingdom. Post-intervention status was represented using a dummy variable and to allow for a change in trend, the number of years since implementation was included. To estimate the association between smoke-free legislation and adolescent smoking, the percentage of regular smokers was modeled using linear regression adjusted for trends over time and country. All models were stratified by age (13 and 15 years) and sex.Results:For 15-year-old girls, the implementation of smoke-free legislation in the United Kingdom was associated with a 4.3% reduction in the prevalence of regular smoking (P = .029). In addition, regular smoking fell by an additional 1.5% per annum post-legislation in this group (P = .005). Among 13-year-old girls, there was a reduction of 2.8% in regular smoking (P = .051), with no evidence of a change in trend post-legislation. Smaller and nonsignificant reductions in regular smoking were observed for 15- and 13-year-old boys (P = .175 and P = .113, respectively).Conclusions:Smoke-free legislation may help reduce smoking uptake amongst teenagers, with stronger evidence for an association seen in females. Further research that analyses longitudinal data across more countries is required.Implications:Previous research has established that smoke-free legislation has led to many improvements in population health, including reductions in heart attack, stroke, and asthma. However, the impacts of smoke-free legislation on the rates of smoking amongst children have been less investigated. Analysis of repeated cross-sectional surveys across the four countries of the United Kingdom shows smoke-free legislation may be associated with a reduction in regular smoking among school-aged children. If this association is causal, comprehensive smoke-free legislation could help prevent future generations from taking up smoking.

Smoke-free legislation and the incidence of paediatric respiratory infections and wheezing/asthma: interrupted time series analyses in the four UK nations.

We investigated the association between introduction of smoke-free legislation in the UK (March 2006 for Scotland, April 2007 for Wales and Northern Ireland, and July 2007 for England) and the incidence of respiratory diseases among children. We extracted monthly counts of new diagnoses of wheezing/asthma and RTIs among children aged 0–12 years from all general practices in the Clinical Practice Research Datalink during 1997–2012. Interrupted time series analyses were performed using generalised additive mixed models, adjusting for underlying incidence trends, population size changes, seasonal factors, and pandemic influenza, as appropriate. 366,642 new wheezing/asthma diagnoses and 4,324,789 RTIs were observed over 9,536,003 patient-years. There was no statistically significant change in the incidence of wheezing/asthma after introduction of smoke-free legislation in England (incidence rate ratio (IRR) 0.94, 95% CI 0.81–1.09) or any other UK country (Scotland: IRR 0.99, 95% CI 0.83–1.19; Wales: IRR 1.09, 95% CI 0.89–1.35; Northern Ireland: IRR 0.96, 95% CI 0.76–1.22). Similarly no statistically significant changes in RTI incidence were demonstrated (England: IRR 0.95, 95% CI 0.86–1.06; Scotland: IRR 0.96, 95% CI 0.83–1.11; Wales: IRR 0.97, 95% CI 0.86–1.09; Northern Ireland: IRR 0.90, 95% CI 0.79–1.03). There were no demonstrable reductions in the incidence of paediatric wheezing/asthma or RTIs following introduction of smoke-free legislation in the UK.

Smoke-free legislation and childhood hospitalisations for respiratory tract infections.

Second-hand smoke exposure is a major risk factor for respiratory tract infections (RTIs). Although evidence suggests important early-life health benefits of smoke-free public environments, the impact on childhood RTIs is unclear. We investigated the association between England's smoke-free legislation and childhood RTI hospitalisations.We used the Hospital Episode Statistics database to obtain nationwide data on hospital admissions for acute RTIs among children (<15 years of age) from 2001 to 2012. Hospitalisation counts were disaggregated by month, age group, sex and small-area level, and linked to urbanisation, region, deprivation index and corresponding population estimates. Negative binomial regression analyses were adjusted for confounders, seasonal variation, temporal autocorrelation, population-size changes and underlying incidence trends. Models allowed for sudden and gradual changes following the smoke-free legislation. We performed sensitivity and subgroup analyses, and estimated number of events prevented.We analysed 1 651 675 hospital admissions. Introduction of smoke-free legislation was followed by an immediate reduction in RTI admissions (-3.5%, 95% CI -4.7- -2.3%), this mainly being attributable to a decrease in lower RTI admissions (-13.8%, 95% CI -15.6- -12.0%). The reductions in admissions for upper RTI were more incremental.The introduction of national smoke-free legislation in England was associated with ∼11 000 fewer hospital admissions per year for RTIs in children.

Effect of Smoke-Free Legislation on Perinatal and Child Health

Smoking kills approximately 5.7 million people each year. Although smoke-free legislation and tobacco controls are keys to reducing this death toll, most studies on their effectiveness have involved only adults. Children are known to be especially vulnerable to the adverse effects of second-hand smoke, which has been linked to many adverse outcomes during early life and the development of noncommunicable diseases in later life. This review was conducted to evaluate the effect of smoke-free legislation on perinatal and child health. The search included online databases for studies published from January 1975 to May 2013. Eligible studies investigated the association between introduction of a smoking ban in work or public places and one or more prespecified health outcomes in children. The study included children 12 years or younger to minimize potential confounding by self-smoking but accepted ages up to 20 years if most of the population met the original age criterion. Primary outcomes were preterm birth, low birth weight, and asthma. Secondary outcomes included various perinatal mortality indicators. Parental or maternal smoking was defined as the main confounder for which adjustment was recorded. Of 9228 screened titles, 20 potentially eligible studies were found and 11, reported between 2008 and 2013, were included in the analysis. Four studies described the effect on pediatric asthma; all others reported on perinatal outcomes. Three of 5 studies reported a significant reduction in preterm births after introduction of smoke-free legislation. Meta-analysis of 4 studies showed that smoke-free legislation was associated with a clinically important and statistically significant drop in preterm birth (1,366,862 participants; 10.4%; 95% confidence interval [CI], 18.8 to 2.0) with no later effect on preterm birth rate change over time. One of 6 studies reported a reduction in neonates with low birth weight (<2500 g) after smoke-free legislation. Three of 4 studies reported a significant drop in hospital attendance because of asthma after introduction of legislation. An immediate reduction was reported in 3 studies (225,753 events; 10.1%; 95% CI, 15.2 to 5.0), and an additional nonsignificant trend toward an annual rate decrease was reported in 3 studies (241,846 events; 7.5% per year; 95% CI, 16.0 to 0.9). One study reported a reduction in very preterm birth, and 1 of 2 studies found a significant effect on the rate of neonates with very low birth weight (<1500 g). Two of 3 studies showed a significant step reduction in small for gestational age. These reductions were statistically significant after pooling (1,305,965 participants; step change: 5.3%; 95% CI, 5.4 to 5.2; slope change: 0.6%; 95% CI, 0.604% to 0.596%). In a small study, no effect was noted on birth defects. This study provides evidence supporting the effectiveness of smoke-free legislation to improve perinatal and child health outcomes. Rates of preterm birth and pediatric hospital admissions for asthma were reduced by 10% along with reductions in the risk for being born very small for gestational age. The results support mandates for worldwide implementation of smoke-free legislation to improve population health. Early-life protection from involuntary second-hand smoke exposure has the potential to reduce disease burdens and associated economic losses in society.

Impact of a Stepwise Introduction of Smoke-Free Legislation on the Rate of Preterm Births

Objective To investigate the incidence of preterm delivery in the Belgian population after implementation of smoke-free legislation in three phases (in public places and most workplaces January 2006, in restaurants January 2007, and in bars serving food January 2010). Design Logistic regression analyses on routinely collected birth data from January 2002 to December 2011. Setting Flanders, Belgium. Population All live born singleton births delivered at 24–44 weeks of gestation (n=606 877, with n=448 520 spontaneous deliveries). Main outcome measures Preterm birth (gestational age Results We found reductions in the risk of preterm birth after the introduction of each phase of the smoking ban. No decreasing trend was evident in the years or months before the bans. We observed a step change in the risk of spontaneous preterm delivery of −3.13% (95% CI −4.37% to −1.87%; P Conclusion Our study shows a consistent pattern of reduction in the risk of preterm delivery with successive population interventions to restrict smoking. This finding is not definitive but it supports the notion that smoking bans have public health benefits from early life.

Interpreting Long-Term Trends in Time Series Intervention Studies of Smoke-Free Legislation and Health

Background: Numerous studies have investigated the impact of smoke-free laws on health outcomes. Large differences in estimates are in part attributable to how the long-term trend is modelled. However, the choice of appropriate trend is not always straightforward. We explore these complexities in an analysis of myocardial infarction (MI) mortality in England before and after the introduction of smoke-free legislation in July 2007. Methods: Weekly rates of MI mortality among men aged 40+ between July 2002 and December 2010 were analysed using quasi-Poisson generalised additive models. We explore two ways of modelling the long-term trend: (1) a parametric approach, where we fix the shape of the trend, and (2) a penalised spline approach, in which we allow the model to decide on the shape of the trend. Results: While both models have similar measures of fit and near identical fitted values, they have different interpretations of the legislation effect. The parametric approach estimates a significant immediate reduction in mortality rate of 13.7% (95% CI: 7.5, 19.5), whereas the penalised spline approach estimates a non-significant reduction of 2% (95% CI:-0.9, 4.8). After considering the implications of the models, evidence from sensitivity analyses and other studies, we conclude that the second model is to be preferred. Conclusions: When there is a strong long-term trend and the intervention of interest also varies over time, it is difficult for models to separate out the two components. Our recommendations will help further studies determine the best way of modelling their data.

The role of anti-smoking legislation on cigarette and alcohol consumption habits in Italy

The short-term effects of public smoking bans on individual smoking and drinking habits were investigated in this paper. In 2005, a smoking ban was introduced in Italy, and we exploited this exogenous variation to measure the effect on both smoking participation and intensity and the indirect effect on alcohol consumption. Using data from the Everyday Life Aspects survey, for the period 2001–2007, we show that the introduction of smoke-free legislation in Italy significantly affected smoking behavior. We also document significant indirect effects on alcohol consumption for the main alcoholic beverage categories. A robustness analysis is also performed, to test the extent to which unobservable variables may bias our estimated parameters. Our results are then used to perform a cost-effectiveness analysis of the anti-smoking legislation in Italy.

Short-term impact of the smokefree legislation in England on emergency hospital admissions for asthma among adults: a population-based study

BackgroundComprehensive smokefree laws have now been introduced in several jurisdictions. Few studies have examined the association between smokefree laws and asthma in adults and these have limitations, such as lacking...

'They don't live in my house every day': How understanding lives can aid understandings of smoking.

While the prevalence of smoking in western countries has substantially reduced following the introduction of comprehensive tobacco control programs, reduction strategies such as the introduction of smokefree legislation, media campaigns and individual and group support for people trying to quit have been less successful with people living on low income, suggesting the need for new ways to engage with people who smoke. We argue that, rather than focusing solely on researching smoking behaviors to generate new understandings of why people smoke, people working in the broad area of public health should look more widely at peoples' lives in order to understand their smoking. Using a biographical, narrative perspective as part of a wider ethnographic study of 12 families living in one community within Liverpool in 2006, we argue that understandings that position smoking purely as a harmful, deviant behavior, fail to capture the cultural complexity of the lives of smokers and the changing place and meaning of cigarettes over a person's lifetime, and may explain why smokers fail to engage with smoking cessation services and continue to smoke.

OP53 Defining the Long-Term Trend in a Public Health Intervention Study: A Cautionary Tale

BackgroundNumerous studies have reported on the impact of comprehensive smoke-free laws on population health. Many early studies have ignored the potential effect of the long-term trend of the health outcome,...

Stop Smoking Service Clients’ Views Following the Introduction of Smoke-Free Legislation in England

This study aimed to explore smoker's perspectives of continued smoking and smoking cessation following the introduction of smoke-free legislation in England. Seventeen semi-structured interviews were conducted with smokers who were making a quit attempt with the support of stop smoking services delivered by the National Health Service. Interviews explored opinions of smoke-free legislation before it was implemented in July 2007, as well as attitudes towards the legislation, beliefs about the influence of legislation on smoking behaviours, as well as changes to public attitudes about smoking. Framework analysis highlighted five key themes: attitudes towards smoke-free legislation prior to its introduction, support for smoke-free legislation following implementation, smoke-free legislation and smoking behaviour, stigma, and returning to smoking. Overall, smokers were positive about smoke-free legislation and reported reductions in smoking and an increase in quit attempts after introduction of the legislation. Change in attitudes towards smoking and smokers were noted, which at times could transpire to stigmatisation felt by the participants. Few quitters expressed a wish to return to smoking if the legislation was reversed.

Did Smokefree Legislation in England Reduce Exposure to Secondhand Smoke among Nonsmoking Adults? Cotinine Analysis from the Health Survey for England

BackgroundOn 1 July 2007, smokefree legislation was implemented in England, which made virtually all enclosed public places and workplaces smokefree.ObjectivesWe examined trends in and predictors of secondhand smoke exposure among nonsmoking adults to determine whether exposure changed after the introduction of smokefree legislation and whether these changes varied by socioeconomic status (SES) and by household smoking status.MethodsWe analyzed salivary cotinine data from the Health Survey for England that were collected in 7 of 11 annual surveys undertaken between 1998 and 2008. We conducted multivariate regression analyses to examine secondhand smoke exposure as measured by the proportion of nonsmokers with undetectable levels of cotinine and by geometric mean cotinine.ResultsSecondhand smoke exposure was higher among those exposed at home and among lower-SES groups. Exposure declined markedly from 1998 to 2008 (the proportion of participants with undetectable cotinine was 2.9 times higher in the last 6 months of 2008 compared with the first 6 months of 1998 and geometric mean cotinine declined by 80%). We observed a significant fall in exposure after legislation was introduced—the odds of having undetectable cotinine were 1.5 times higher [95% confidence interval (CI): 1.3, 1.8] and geometric mean cotinine fell by 27% (95% CI: 17%, 36%) after adjusting for the prelegislative trend and potential confounders. Significant reductions were not, however, seen in those living in lower-social class households or homes where smoking occurs inside on most days.ConclusionsWe found that the impact of England’s smokefree legislation on secondhand smoke exposure was above and beyond the underlying long-term decline in secondhand smoke exposure and demonstrates the positive effect of the legislation. Nevertheless, some population subgroups appear not to have benefitted significantly from the legislation. This finding suggests that these groups should receive more support to reduce their exposure.

The impact of the introduction of smoke‐free legislation on prescribing of stop‐smoking medications in England

To investigate whether there were changes in the rate of prescribing of smoking cessation medications in the months leading up to, and after, the introduction of smoke-free legislation in England. Interrupted time-series analysis of prescribing rates using Autoregressive Integrated Moving Average (ARIMA) models. A total of 350 general practices in England who contribute data to The Health Improvement Network (THIN) database. Patients in THIN aged 16+ identified from their medical records as smokers. Monthly rates of prescribing of nicotine replacement therapy (NRT), bupropion and varenicline were calculated from THIN from 2000 to 2009 for all smokers and for subgroups defined by patient sex, age group, history of chronic disease and quintile of the Townsend Index of Deprivation. ARIMA models were built to assess whether there were changes in prescribing before or after the introduction of smoke-free legislation over and above any long-term and seasonal trends. There was a 6.4% (0.7-12.1) increase in prescribing of all smoking cessation medications in the 9 months before the introduction of smoke-free legislation and a 6.4% (1.1-11.7) reduction in the 9-month period afterwards. A 6.2% (1.4-11.0) increase in NRT prescribing and a 13.2% (4.3-22.2) increase in bupropion prescribing occurred in the 6- and 3-month periods, respectively, before smoke-free legislation was introduced, and a 5.5% (2.3-8.7) decline in NRT prescribing and a 13.7% (4.6-22.8) decline in bupropion prescribing in the 9 months post-legislation. The patterns of change in prescribing did not vary with patient demographics. Numbers of primary care prescriptions for smoking cessation medications increased prior to the introduction of smoke-free legislation but decreased afterwards, suggesting a temporal displacement in prescribing activity rather than a change in the overall volume of prescribing. Effects observed were consistent across all population subgroups, suggesting that the changes in prescribing will neither widen nor reduce smoking-related health inequalities.

One last puff? Public smoking bans and smoking behavior

This paper investigates the short-term effects of public smoking bans on individual smoking behavior. In 2007 and 2008, state-level smoking bans were gradually introduced in all of Germany's federal states. We exploit this variation to identify the effect that smoke-free policies had on individuals’ smoking propensity and smoking intensity. Using rich longitudinal data from the German Socio-Economic Panel Study, our difference-in-differences estimates show that the introduction of smoke-free legislation in Germany did not change average smoking behavior within the population. However, our estimates point to important heterogeneous effects. Individuals who go out more often to bars and restaurants did adjust their smoking behavior. Following the ban, they became less likely to smoke and also smoked less.

One Last Puff? Public Smoking Bans and Smoking Behavior

This paper investigates the short-term effects of public smoking bans on individual smoking behavior. In 2007 and 2008, state-level smoking bans were gradually introduced in all of Germany's sixteen federal states. We exploit this variation in the timing of state bans to identify the effect that smoke-free policies had on individuals' smoking propensity and smoking intensity. Using rich longitudinal data from the German Socio-Economic Panel Study, our difference-in-differences estimates show that the introduction of smoke-free legislation in Germany did not change average smoking behavior within the population. However, our estimates also point to important heterogeneous effects. Groups that go out more often, and hence are more exposed to the constraints of public smoking bans in everyday life, did adjust their smoking behavior. Specifically, we find that young, unmarried individuals, men, and those living in urban areas are groups that are both less likely to smoke and smoke less intensively following the introduction of public smoking bans. Furthermore, effects on individual smoking habits proved stronger in states that had more strict smoking bans. Public smoking bans, therefore, have important health benefits over and above the reduction in exposure of non-smokers to second-hand smoke that is their immediate and prime objective.

One Last Puff? - Public Smoking Bans and Smoking Behavior

This paper investigates the short-term effects of public smoking bans on individual smoking behavior. In 2007 and 2008, state-level smoking bans were gradually introduced in all of Germany's federal states. We exploit this variation to identify the effect that smoke-free policies had on individuals’ smoking propensity and smoking intensity. Using rich longitudinal data from the German Socio-Economic Panel Study, our difference-in-differences estimates show that the introduction of smoke-free legislation in Germany did not change average smoking behavior within the population. However, our estimates point to important heterogeneous effects. Individuals who go out more often to bars and restaurants did adjust their smoking behavior. Following the ban, they became less likely to smoke and also smoked less.

One Last Puff? Public Smoking Bans and Smoking Behavior

This paper investigates the short-term effects of public smoking bans on individual smoking behavior. In 2007 and 2008, state-level smoking bans were gradually introduced in all of Germany's sixteen federal states. We exploit this variation in the timing of state bans to identify the effect that smoke-free policies had on individuals' smoking propensity and smoking intensity. Using rich longitudinal data from the German Socio-Economic Panel Study, our difference-in-differences estimates show that the introduction of smoke-free legislation in Germany did not change average smoking behavior within the population. However, our estimates also point to important heterogeneous effects. Groups that go out more often, and hence are more exposed to the constraints of public smoking bans in everyday life, did adjust their smoking behavior. Specifically, we find that young, unmarried individuals, men, and those living in urban areas are groups that are both less likely to smoke and smoke less intensively following the introduction of public smoking bans. Furthermore, effects on individual smoking habits proved stronger in states that had more strict smoking bans. Public smoking bans, therefore, have important health benefits over and above the reduction in exposure of non-smokers to second-hand smoke that is their immediate and prime objective.