Top of FormNovice Competent Proficient Exemplar Shou.docx

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Novice
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Should you play at all?
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0 (0%)
no answer or incorrect
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0 (0%)
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0 (0%)
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.2 (5%)
Correct
EMV for decision tree
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no answer
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.36 (9%)
some reasonable attempt made: work shown, but not correct
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.48 (12%)
Correct, except forgot to include costs
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.6 (15%)
Correct answer to the dollar
If play and don't lose money, play again?

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no answer or incorrect
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.2 (5%)
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If play and don't lose money, Why or why not play again?
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no answer
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.24 (6%)
insufficient reasoning and no EMV support data
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.32 (8%)
Correct reasoning, but no/incorrect EMV support evidence
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.4 (10%)
Correct reasoning to include EMV support evidence
Decision tree illustration quality
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0 (0%)
no answer

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.96 (24%)
Not all branches shown and/or decision points vs chance events
not distinguished
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1.28 (32%)
All branches, decision points, chance events. Errors in payoffs
and/or branch probabilties
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1.6 (40%)
clearly shows all decision points, chance events; all payoffs and
branch probabilities
EMV shown at each node
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0 (0%)
no answer
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.6 (15%)
>2 errors in EMV and/or not all calculated
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.8 (20%)
1-2 errors in EMV, but all shown

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1 (25%)
EMV at each node and all correct
Bottom of Form
Health Reports, Vol. 16, No. 1, October 2004 Statistics Canada,
Catalogue 82-003
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
Second-hand smoke
exposure—who’s at
risk?
Claudio E. Pérez
9
Abstract
Objectives
This article examines exposure to second-hand smoke
(SHS) in 2003 in various settings by age and sex, and
compares exposure indicators by province and health
region.
Data source
The data are from the 2000/01 and 2003 Canadian
Community Health Survey, conducted by Statistics
Canada.
Analytical techniques

Rates of exposure to SHS among non-smokers are
calculated by sex, age and location for the household
population aged 12 or older. Rates of exposure at work
are examined for employed non-smokers aged 15 or
older. Smoking prevalence is expressed as a
percentage of the household population aged 12 or
older.
Main results
In 2003, 33% of non-smokers reported that they were
regularly exposed to SHS. The risk of exposure was
greatest in public spaces, but regardless of setting, rates
of exposure were higher for men than women. Exposure
rates varied by age and peaked in young adulthood.
However, at home and at work, the younger the non-
smokers, the more likely they were to be exposed to
SHS. Disparities in SHS exposure by province/territory
and by health region were substantial.
Key words
environmental tobacco smoke (ETS), passive smoking,
involuntary smoking, secondary smoking
Author
Claudio E. Pérez (613-951-1733; [email protected])
is with the Health Statistics Division at Statistics Canada,
Ottawa, Ontario, K1A 0T6.
T
he negative health effects of exposure to second-
hand smoke (SHS) are well-documented1-7 and
widely recognized. According to Statistics
Canada’s 1996/97 National Population Health Survey, about

three-quarters of Canadians believed that second-hand
smoke can cause health problems in non-smokers. Most
also agreed that non-smokers should be provided with a
smoke-free work environment, an opinion that was shared
by a large majority of smokers.8
Public health campaigns designed to increase awareness
of the dangers of second-hand smoke have proliferated,
and many jurisdictions have enacted legislation to restrict
smoking in public places and at work.9 In the context of
attitudinal and legislative change, it is useful to determine
who remains at risk of SHS exposure and to what extent.
This analysis uses data from the 2000/01 and 2003 Canadian
Community Health Survey (CCHS) to address these issues
(see Methods and Definitions).
Second-hand smoke exposure
Catalogue 82-003

10
One-third
In 2003, 33 % of non-smokers reported that in the
last month they had been exposed to second-hand
smoke on most days in at least one of four locations:
in public, at work, at home or in private vehicles
(Table 1). The most common setting for SHS
exposure (respondents could indicate more than
one) was public places, reported by 20%, followed
by home and work (both 11%) and in private vehicles
(10%). For the most part, these exposure rates had
not changed from two years earlier (data not shown).
The proportion of non-smokers exposed to SHS
at work was the exception: in 2000/01, the rate had
been higher at 13%.
In all venues, males were more likely than females
to be exposed to second-hand smoke (Chart 1). For
example, 23% of male non-smokers versus 17% of
female non-smokers reported having been exposed
to SHS in public places. While differences between
the sexes were also statistically significant for
exposure at home and in private vehicles, the gaps
were narrower.
The most striking contrast in SHS exposure rates
by sex was at work. In 2003, 16% of employed
men who did not smoke worked in environments
where smoking was not restricted, compared with
6% of their female counterparts. Both figures,
however, were down from two years earlier when
Methods
Data source

The analysis for this article is based on data from the 2000/01
and
2003 Canadian Community Health Survey (CCHS), conducted
by
Statistics Canada. The CCHS collects cross-sectional
information
every two years. The survey covers the household population
aged
12 or older in the provinces and territories, except residents of
Indian
reserves, Canadian Forces bases, and some remote areas.
The first cycle (cycle 1.1) began in September 2000 and
continued
over 14 months. The majority of interviews were conducted
face-
to-face. The response rate for the first cycle was 84.7%,
yielding a
sample of 131,535 respondents. This analysis uses data for the
population aged 12 or older living in the provinces and
territories.
Among the respondents, 95,339 were non-smokers (weighted to
represent approximately 19.1 million individuals), and
therefore, at
risk of exposure to second-hand smoke.
Cycle 2.1 began in January 2003 and ended in December that
year. Most interviews were conducted by telephone. The
response
rate was 80.6%, yielding a sample of 135,573 respondents.
Among
the respondents, 102,950 were non-smokers (weighted to
represent
about 20.4 million individuals).
A description of the CCHS methodology is available in a

published
report.10
Analytical techniques
The prevalence of smoking was expressed as a percentage of the
household population aged 12 or older. Prevalence rates for
exposure to second-hand smoke were expressed as a percentage
of non-smokers. Smoking restrictions at work were examined
for
the non-smoking employed population aged 15 or older.
Answers
coded as “refusal,” “don’t know,” “not stated” or “not
applicable” were
excluded from calculations.
To account for the complex survey design, coefficients of
variation
and p-values for differences between estimates were calculated
using the bootstrap technique.11-13
Limitations
The data on which this article is based are self-reported.
Respondents may give answers that they consider to be socially
acceptable, but that are not accurate descriptions of their
behaviour.
The question used to determine exposure at home does not
address second-hand smoke directly, but rather asks about the
smoking habits of other household members (see Definitions).
It is
possible that people who smoke at home do so only in the
absence
of the non-smoker, or in isolated areas, such as the garage.
Because the CCHS covers only the population aged 12 or older,

this analysis could not examine exposure to second-hand smoke
among children younger than 12.
The boundaries of health regions do not necessarily coincide
with
municipalities that have smoking legislation.
Catalogue 82-003
11
18% of male and 8% of female workers who did
not smoke reported workplace exposure (data not
shown). Male workers’ greater SHS exposure
reflects their comparatively high representation in
occupations such as trades/transport/equipment
operation and farming/forestry/fishing/mining
(data not shown). Much of this work is performed
outdoors where smoking restrictions usually do not
apply.
Youth most at risk
Age is closely associated with exposure to second-
hand smoke (Chart 2). In 2003, the percentage of
non-smokers regularly exposed to SHS in at least
one location was 37% at age 12; at age 20, the
proportion was 55%. From ages 20 to 30 exposure
rates fell sharply to level off around 30%, and
remained in that range until about age 60. At older
ages, exposure rates dropped even more, and by age
80 were around 10%. This pattern generally reflects

the activities in which people engage at different
ages and the settings in which they are likely to be,
either out of necessity or by choice.
Chart 1
Percentage of non-smokers regularly exposed to second-hand
smoke in selected locations, by sex, household population
aged 12 or older, Canada, 2003
Public spaces
Work
Home
Private vehicles
0 5 10 15 20 25
% regularly exposed to SHS
Males
Females
*
†
*
*
*
Data source: 2003 Canadian Community Health Survey

† Employed non-smokers aged 15 or older in workplace with
few or no smoking
restrictions
* Significantly higher than estimate for women (p < 0.05)
Table 1
smoke in selected locations and smoking prevalence, by
province/
territory, household population aged 12 or older, 2003
Total
(at least Public Private Smoking
one location) spaces Work † Home vehicles prevalence‡
Canada 33 20 11 11 10 23
Newfoundland 35* 14* 16* 14* 15* 24
Prince Edward Island 34 13* 18* 12 13 24
Nova Scotia 32 16* 14 13 13* 24
New Brunswick 35* 19 16* 13* 12* 25
Québec 41* 27* 11 16* 12* 26*
Ontario 30* 18* 9* 9* 10 22*
Manitoba 33 20 13 11 11 23
Saskatchewan 38* 24* 20* 11 11 24
Alberta 35* 21 15* 9* 10 23
British Columbia 23* 12* 10 6* 7* 19*
Yukon 39* 23 16 13 15 28
Northwest Territories 47* 32* 10 15 18* 37*
Nunavut 40 21 6 15 18 65*

few or no smoking restrictions
‡ Daily or occasional
* Significantly different from estimate for Canada
Catalogue 82-003
12
Few options at home
The younger the person, the fewer the options for
avoiding second-hand smoke, particularly at home.
In 2003, about a quarter of non-smoking 12- to 15-
year-olds were regularly exposed to SHS in their
home. The percentage declined with advancing age
to about 6% among people in their mid-thirties and
then rose to about 10% for those in their mid-forties
(Chart 3). An almost steady decline thereafter
brought the figure down to about 5% at age 70 or
older, which may reflect spouses surviving a smoking
partner. (Comparable data about SHS exposure for
children younger than 12 are not available from the
CCHS.)
Exposure at work
The highest rates of workplace second-hand smoke
exposure for non-smokers in 2003 were among the
youngest and oldest workers. From their mid-teens
through their twenties, non-smokers’ SHS workplace
exposure rates dropped, and thereafter, stabilized.
After age 55, SHS workplace exposure rates rose.

Over half of workers aged 15 to 20 were
employed in sales and service, which includes
restaurants and bars where smoking may not be
restricted (data not shown). Substantial shares of
older workers were in sales/service or trades/
transport/equipment operation, which have
relatively few smoking restrictions.
Going out/Settling down/Getting old
Non-smokers’ exposure to second-hand smoke in
public spaces and in private vehicles followed
roughly the same age patterns, with rates rising
through adolescence (Chart 4). In 2003, the
proportion of 12-year-olds regularly exposed to SHS
in public spaces was 16%, and in private vehicles,
17%; among non-smokers who were aged 19, the
corresponding figures were much higher at 37% and
23%. This rise in exposure rates parallels an increase
in smoking prevalence throughout the teenage years.
Fewer than 1% of 12-year-olds were smokers in
2003, compared with 37% of 20-year-olds.
Consequently, even non-smoking teenagers may
have friends who smoke. As well, time spent in
social situations where smoking may be unrestricted
tends to increase.
Non-smokers’ SHS exposure in public spaces and
private vehicles dropped in their early twenties.
Chart 2
smoke in at least one location,† by single year of age,
household population aged 12 or older, Canada, 2003

† Public spaces, work, home, private vehicles
15 20 25 30 35 40 45 50 55 60 65 70 75 80+
Single year of age
0
10
20
30
40
50
60
%
12
Chart 3
smoke at home or work, by single year of age, household
population aged 12 or older, Canada, 2003
15 20 25 30 35 40 45 50 55 60 65 70 75 80+
Single year of age
0
10

20
30
%
Home
Work †
12
few or no smoking
restrictions
Catalogue 82-003
13
Chart 4
smoke in public spaces or in private vehicles, by single year
of age, household population aged 12 or older, Canada, 2003
15 20 25 30 35 40 45 50 55 60 65 70 75 80+
Single year of age
0

10
20
30
40
%
Public spaces
Private vehicles
Smoking prevalence
12
Family formation often occurs at these ages, the
results of which may be less time in social settings
where smoking is allowed, or a spouse changing his
or her smoking habits.
The low SHS exposure rates among the elderly
may be attributable to even less time spent in venues
where smoking is permitted.
Provincial/Territorial differences
Levels of second-hand smoke exposure vary among
the provinces and territories. Moreover, the patterns
are not always consistent, in that a province with a
significantly high rate of exposure in one setting
may have a significantly low rate in another (Table 1).
In 2003, Ontario and British Columbia stood out

with SHS exposure in public places, at work, at home
and in private vehicles either matching or
significantly below the national level. These two
provinces also had the lowest proportions of daily
or occasional smokers. Québec, on the other hand,
with a high prevalence of smoking, also had high
rates of SHS exposure in public spaces, at home
and in private vehicles.
The Atlantic provinces had significantly low
exposure rates in public spaces, but significantly high
rates in at least one of the other locations. The
exception was New Brunswick with an SHS
exposure rate in public spaces that matched the
national level, and significantly high rates in each of
the other three venues.
Among the three Prairie provinces, Manitoba’s
exposure rates in all settings did not differ
significantly from the national figures. Alberta had
a high rate of workplace exposure, but a low rate at
home. In Saskatchewan, rates were high in public
spaces and at work.
In the Northwest Territories, SHS exposure was
high in public spaces and in private vehicles. In the
Yukon and Nunavut, rates in all locations were
similar to those for Canada as a whole, even though
Nunavut had the highest proportion of daily and
occasional smokers.
Definitions
In cycles 1.1 and 2.1 of the Canadian Community Health
Survey,

respondents were asked, “At the present time, do you smoke
cigarettes daily, occasionally or not at all?” Those who said
they
smoked daily or occasionally were defined as current smokers.
Cycle 1.1 respondents were asked, “Does anyone in this
household smoke regularly inside the house?” (Yes/No). In
cycle
2.1, the question was, “Including both household members and
regular visitors, does anyone smoke inside your home every day
or almost every day?”
Respondents aged 12 or older were asked, “In the past month,
were you exposed to second-hand smoke every day or almost
every day:
… in a car or other private vehicle?” (Yes/No)
… in public places (such as bars, restaurants, shopping malls,
arenas, bingo halls, bowling alleys)? (Yes/No)
Respondents aged 15 or older who were employed were asked,
“At your place of work, what are the restrictions on smoking?”
The choices read to the respondent were:
1. Restricted completely
2. Allowed in designated areas (smokers must go to specific
areas because smoking is generally not allowed)
3. Restricted only in certain places (for instance, where
flammable materials are stored)
4. Not restricted at all
Respondents who indicated either of the first two choices were
defined as having smoking restrictions at work.

Catalogue 82-003
14
While rates of second-hand smoke exposure in
specific venues may be significantly high or low at
the provincial level, this is not necessarily the case
in every health region within that province. A single
province may contain health regions where rates of
SHS exposure were significantly high and other
health regions where rates were low (Appendix
Table A).
Legislation designed to curb SHS exposure
obviously cannot extend to homes or private
vehicles, but hundreds of municipalities have laws
that restrict smoking in public places and at work.14-20
However, bylaws and regulations vary in scope, and
levels of compliance differ across communities.21
Low rates of SHS exposure in public spaces and in
the workplace generally tend to be more common
in larger urban areas, and high rates, in rural or
northern areas where substantial numbers of
residents are engaged in primary industries.
Concluding remarks
Despite steady declines in the prevalence of
smoking, widespread awareness of the hazards of

second-hand smoke, and legislative efforts to curb
exposure, in 2003, 20% of non-smokers were
regularly exposed to second-hand smoke in public
spaces, and 11% of employed non-smokers worked
in environments without smoking restrictions.
SHS exposure rises through adolescence to peak
in young adulthood. However, exposure varies with
the venue, and parallels activities that tend to occur
at different ages. Exposure also reflects different
degrees of choice.
In some instances, non-smokers have no options.
For example, a 12-year-old living in a household
where parents smoke, or a worker employed in an
environment where smoking is not restricted, has
little control. In other cases, SHS exposure may be
voluntary. Teenagers may spend time in social
situations where smoking is permitted or drive with
friends who smoke.
The relationship between age and SHS exposure
at home is striking. In 2003, the percentage of
12-year-olds regularly exposed to SHS in their home
exceeded the percentage exposed in public spaces:
24% versus 16%.
Legislation does not cover smoking in private
locales such as homes or vehicles. Nonetheless, the
increasing restrictions on smoking in public places
and in the workplace suggest that awareness of the
potential harm is growing. Restrictions on smoking
in these locations may ultimately affect behaviour
in private settings.22,23
1 US Department of Health and Human Services. The Health

Consequences of Involuntary Smoking. A Report of the
Surgeon
General, 1986. DHHS Pub. No. (PHS) 87-8398. Washington,
DC: US Department of Health and Human Services, 1987.
2 National Research Council: Committee on Passive Smoking.
Environmental Tobacco Smoke. Measuring Exposures and
Assessing
Health Effects. Washington, DC: National Academy Press,
1986.
3 International Agency for Research on Cancer. Tobacco
Smoking. IARC Monographs on the Evaluation of the
Carcinogenic Risk of Chemicals to Humans, Volume 38.
Lyon, France: World Health Organization, International
Agency for Research on Cancer, 1986.
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○References
4 US Department of Health and Human Services. Reducing
the Health Consequences of Smoking: 25 Years of Progress. A
Report of the Surgeon General. DHHS Pub. No. (CDC).
Rockville, Maryland: Public Health Services, Center for
Chronic Disease Prevention and Health Promotion, Office
of Smoking and Health, 1989.
5 National Cancer Institute. Health Effects of Exposure to
Environmental Tobacco Smoke: The Report of the California
Environmental Protection Agency. Smoking and Tobacco
Control
Monog raph No. 10. (NIH. No. 99-4645) Bethesda,
Maryland: US Department of Health and Human Services,
National Institutes of Health, National Cancer Institutes,
1999.
6 US Environmental Protection Agency. Respiratory Health

Effects of Passive Smoking (Also Known as Exposure to
Secondhand
Smoke or Environmental Tobacco Smoke - ETS) (EPA/600/6-
90/
006F) Washington, DC: US Environmental Protection
Agency, 1992.
Catalogue 82-003
15
7 International Agency for Research on Cancer. Tobacco
Smoke
and Involuntary Smoking. IARC Monographs on the Evaluation
of the Carcinogenic Risk of Chemicals to Humans,
Volume 83. Lyon, France: International Agency for Research
on Cancer, 2002.
8 Ross N, Pérez C. Attitudes toward smoking. Health Reports
(Statistics Canada, Catalogue 82-003) 1998; 10(3): 23-33.
9 Health Canada. The National Strategy: Moving Forward.
The 2003 Progress Report on Tobacco Control. Progress
in Strategic Directions. Available at http://www.hc-
sc.gc.ca/hecs-
sesc/tobacco/policy/prog03/05_progress.html.
10 Béland Y. Canadian Community Health Sur vey—
Methodological overview. Health Reports (Statistics Canada,
Catalogue 82-003) 2002; 13(3): 9-14.

11 Rao JNK, Wu CFJ, Yue K. Some recent work on resampling
methods for complex surveys. Survey Methodology (Statistics
Canada, Catalogue 12-001) 1992; 18(2): 209-17.
12 Rust K, Rao JNK. Variance estimation for complex surveys
using replication techniques. Statistical Methods in Medical
Research 1996; 5: 281-310.
13 Yeo D, Mantel H, Liu TP. Bootstrap variance estimation for
the National Population Health Survey. American Statistical
Association: Proceedings of the Survey Research Methods
Section.
Baltimore, August 1999.
14 The City of Calgary. Guide to Calgary’s updated Smoking
Bylaw. Available at http://www.calgar y.ca/docgaller y/BU/
environmental_management/smoking_brochure_final1.pdf.
15 The City of Edmonton. Bylaw 13333 Smoking Bylaw.
Available at htt p://www.edmonton.ca/smokingbylaw/
smoking_bylaw_13333.pdf.
16 City of Ottawa. Public Places By-law - Summary. Available
at http://ottawa.ca/city_services/bylaws/1_3_3_1_en.shtml.
17 City of Ottawa. Workplaces By-law – Summary. Available
at http://ottawa.ca/city_services/bylaws/1_3_3_2_en.shtml.
18 Drope J, Glantz S. British Columbia Capital Regional
District
100% smokefree bylaw: a successful public health campaign
despite industry opposition. Tobacco Control 2003; 12(3):
264-8.
19 Santé et Services sociaux du Québec. Plan Québécois de
lutte contre le tabagisme 2001-2005. Available at http://

www.msss.gouv.qc.ca.
20 Northwest Territories Health and Social Services. Smoke
Alarm. A Summary Report on Smoking in the Northwest
Territories. Available at http://www.hlthss.gov.nt.ca/content/
Publications/Reports/Tobacco/tobacco/tobacco.pdf.
21 Health Canada. The Facts about Tobacco. Impact of
Workplace Smoking Restriction—Compliance Issues.
Available at http://www.hc-sc.gc.ca/hecs-sesc/tobacco/facts/
workplace/part3_compliance.html.
Workplace Smoking Restriction—Impact on Cigarette
Consumption and Uptake. Available at http://www.hc-sc.gc.ca/
hecs-
sesc/tobacco/facts/workplace/part3_impact_consumption.html.
Workplace Smoking Restriction—Impact on Smoking
Prevalence. Available at http://www.hc-sc.gc.ca/hecs-
sesc/tobacco/
facts/workplace/part3_impact_prev.html.
Catalogue 82-003
16
Canada 20 11 23
Newfoundland 14* 16* 24

Health and Community Services
St. John's Region (1001) 15 9E1 22
Eastern Region (1002) 13* 17 26
Central Region (1003) 12* 20 22
Western Region (1004) 14 25* 26
Grenfell Regional Health Services
Board (1005) 8E2* 36E1* 23
Health Labrador Corporation (1006) 20 8E2 34
Prince Edward Island 13* 18* 24
West Prince (1101) 14E1 28E1 28
East Prince (1102) 17 22 24
Queens (1103) 12* 11E1 22
Kings (1104) 9E1* 26* 26
Nova Scotia 16* 14 24
Zone 1 (1201) 14 28* 26
Zone 2 (1202) 12* 21E1 28
Zone 3 (1203) 11* 20E1 28
Zone 4 (1204) 8E1* 15E1 23
Zone 5 (1205) 18 12E1 28
Zone 6 (1206) 19 9E1 19
New Brunswick 19 16* 25
Region 1 (1301) 15 12 25
Region 2 (1302) 24 16 23
Region 3 (1303) 13* 14E1 26
Region 4 (1304) 22 24E1 31
Region 5 (1305) 26 18E1 27
Region 6 (1306) 25 25* 26
Region 7 (1307) 17E1 21E1 27
Québec 27* 11 26*

Région du Bas-Saint-Laurent (2401) 32* 10E1 22
Région du Saguenay -
Lac-Saint-Jean (2402) 34* 12E1 27
Région de Québec (2403) 26* 7* 25
Région de la Mauricie et du
Centre-du-Québec (2404) 30* 11E1 23
Région de l'Estrie (2405) 25 11E1 24
Région de Montréal-Centre (2406) 24* 7* 27*
Région de l'Outaouais (2407) 24 11 26
Région de l'Abitibi-
Témiscamingue (2408) 30* 14E1 27
Région de la Côte-Nord (2409) 32* 21E1 29
Région du Nord-du-Québec (2410) 39* 14E1 29
Région de la Gaspésie -
Îles-de-la-Madeleine (2411) 28 17 27
Région de la Chaudière-
Appalaches (2412) 27* 17E1 24
Région de Laval (2413) 28* 10 28
Appendix
Table A
smoke in public spaces and at work and smoking prevalence, by
health region, household population aged 12 or older, 2003
Région de Lanaudière (2414) 29* 14 28*
Région des Laurentides (2415) 32* 12 28
Région de la Montérégie (2416) 26* 12 25
Région des Terres-Cries-de-
la-Baie-James (2418) 33* 17 46*
Ontario 18* 9* 22
District of Algoma Health Unit (3526) 27 9E1 27
Brant County Health Unit (3527) 14 9E1 26
Durham Regional Health Unit (3530) 21 9 25

Elgin-St Thomas Health Unit (3531) 18 15E1 24
Grey Bruce Health Unit (3533) 7E1* 13E1 19
Haldimand-Norfolk Health Unit (3534) 22 29* 29
Haliburton, Kawartha, Pine Ridge
District Health Unit (3535) 22 13E1 22
Halton Regional Health Unit (3536) 14* 8E1 21
City of Hamilton Health Unit (3537) 17 11 23
Hastings and Prince Edward Counties
Health Unit (3538) 19 13E1 22
Huron County Health Unit (3539) 21 24E1 22
Chatham-Kent Health Unit (3540) 18 13E1 26
Kingston, Frontenac and Lennox and
Addington Health Unit (3541) 18 12 26
Lambton Health Unit (3542) 18 15E1 24
Leeds, Grenville and Lanark District
Health Unit (3543) 18 14E1 27
Middlesex-London Health Unit (3544) 16 10 20
Muskoka-Parry Sound Health Unit (3545) 16 20E1 22
Niagara Regional Area Health Unit (3546) 20 11 24
North Bay and District Health Unit (3547) 23 10E1 25
Northwestern Health Unit (3549) 25 11E1 27
City of Ottawa Health Unit (3551) 14* 5E1* 20
Oxford County Health Unit (3552) 16 15 24
Peel Regional Health Unit (3553) 19 8 21
Perth District Health Unit (3554) 14E1 10E1 23
Peterborough County-City
Health Unit (3555) 18 15E1 24
Porcupine Health Unit (3556) 27 17 31*
Renfrew County and District
Health Unit (3557) 17 18 28
Eastern Ontario Health Unit (3558) 17 12 25
Simcoe County District Health Unit (3560) 20 14 25
Sudbury and District Health Unit (3561) 18 7E1 25
Thunder Bay District Health Unit (3562) 28* 9E1 29
Timiskaming Health Unit (3563) 25 17E1 29
Waterloo Health Unit (3565) 12* 10 23

Wellington-Dufferin-Guelph
Health Unit (3566) 17 13E1 21
Windsor-Essex County Health Unit (3568) 19 8E1 21
York Regional Health Unit (3570) 18 8* 21
City of Toronto Health Unit (3595) 19 7* 20
Manitoba 20 13 23
Winnipeg Regional Health Authority (4610) 19 8 22
Brandon Regional Health Authority (4615) 6E2* 9E1 23
North Eastman Regional Health
Authority (4620) 14E1 17E1 21
Second-hand
smoke exposure
Smoking
Public pre-
Health region (code) spaces Work† valence‡
%
Second-hand
smoke exposure
Smoking
Public pre-
%

Catalogue 82-003
17
South Eastman Regional Health
Authority (4625) 25 21 23
Interlake Regional Health Authority (4630) 22 18E1 23
Central Regional Health Authority (4640) 18 24* 22
Assiniboine Regional Health
Authority (4645) 20 25* 20
Parkland Regional Health Authority (4660) 27 28* 23
Norman Regional Health Authority (4670) 33* 20E1 29
Burntwood/Churchill Regional Health
Authority§ (4680) 40* 15E1 44
Saskatchewan 24* 20* 24
Sun Country Regional Health
Authority (4701) 26 33* 24
Five Hills Regional Health Authority (4702) 32* 22 24
Cypress Regional Health Authority (4703) 24 25 19
Regina Qu'Appelle Regional Health
Authority (4704) 22 13 24
Sunrise Regional Health Authority (4705) 30* 29* 24
Saskatoon Regional Health Authority (4706) 24 15 24
Heartland Regional Health Authority (4707) 16 36* 19
Kelsey Trail Regional Health Authority (4708) 26 26E1 21
Prince Albert Parkland Regional Health
Authority (4709) 24 27* 25
Prairie North Regional Health
Authority (4710) 20 29* 26
Athabasca/Keewatin/Mamawetan
Regional Health Authority†† (4714) 30 19E1 42
Alberta 21 15* 23
Chinook Regional Health Authority (4820) 17 20 20

Palliser Health Region (4821) 20 20 28
Calgary Health Region (4822) 22 12 20
David Thompson Regional Health Authority (4823) 20 23* 27
East Central Health (4824) 27 29* 23
Capital Health (4825) 19 10 23
Aspen Regional Health Authority (4826) 30* 29* 28
Peace Country Health (4827) 26 22* 25
Northern Lights Health Region (4828) 26 19 30
British Columbia 12* 10 19*
East Kootenay (5911) 10E1* 15E1 22
Kootenay-Boundary (5912) 20E1 16E1 21
Okanagan (5913) 12* 15 22
Thompson/Cariboo (5914) 9* 14 20
Fraser East (5921) 13* 16 19
Fraser North (5922) 12* 10 18
Fraser South (5923) 12* 8E1 15
Richmond (5931) 15 7E1 14*
Vancouver (5932) 14* 7E1 19*
North Shore/Coast Garibaldi (5933) 12* 6E1 15*
South Vancouver Island (5941) 8* 8E1 18
Central Vancouver Island (5942) 13 6E2* 23
North Vancouver Island (5943) 13 20 22
Northwest (5951) 14E1 13E2 26
Northern Interior (5952) 12* 15 24
Northeast (5953) 19 13E1 22
Yukon Territory (6001) 23 16 28
Northwest Territories (6101) 32* 10E1 37*
Nunavut (6201) 21E1 F 65
few or no smoking restrictions

‡ Daily or occasional
§ Churchill Regional Health Authority (4690) is combined with
Burntwood Regional Health Authority (4680).
†† Athabasca Health Authority (4713), Mamawetan Churchill
River Regional Health Authority (4711) and Keewatin Yatthé
Regional Health Authority
* Significantly different from estimate for Canada (p < 0.05).
E1 Coefficient of variation 16.6% to 25.0%
E2 Coefficient of variation 25.1% to 33.3%
F Coefficient of variation greater than 33.3%
Second-hand
smoke exposure
Smoking
Public pre-
%
Second-hand
smoke exposure
Smoking
Public pre-
%
COLL300 I005

4 September 2015
Annotated Bibliography- MLA
Model from APUS Citation Guide (MLA)
ARTICLE IN AN ONLINE JOURNAL
Öberg, Mattias, et al. "Worldwide Burden of Disease from
Exposure to Second-Hand Smoke: A
Retrospective Analysis of Data from 192 Countries." The
Lancet 377.9760 (2011): 139-
46. ProQuest. Web. 6 Sep. 2015.
Öberg and the other authors of Worldwide Burden of Disease
from Exposure to Second-Hand Smoke: A Retrospective
Analysis of Data from 192 Countries discuss the risks of
second-hand smoke and relate it to the diseases and sicknesses
that can happen as a result of exposure. By showing the data
and information to support a case for a ban on smoking in
public places this journal will aid me in adding strength to my
argument.
Forsyth, Alasdair J. M. "The Impact Of The Scottish Ban On
Smoking In Public Places Upon
Nightclubs And Their Patrons." Journal Of Substance Use 17.3
(2012): 203-217.CINAHL
Complete. Web. 6 Sept. 2015.
Forsyth discusses the trends and changes that have happened in
Scotland as a result of a ban on smoking in public places. The
data gathered shows conditions before the ban and conditions
after the ban. This information will aid me in showing results
from other countries and what the United States could
accomplish with a nation-wide smoking ban.

Al-Sayed, Eman, et al, and Khadiga Salah Ibrahim. "Second-
Hand Tobacco Smoke And
Children." Toxicology And Industrial Health 30.7 (2014): 635-
644. MEDLINE Complete.
Web. 6 Sept. 2015.
Al-Sayed and the other authors use parental questionnaires,
nicotine and cotinine body levels, and evaluate expired carbon
monoxide concentration. This journal focuses strictly on the
effects of second-hand tobacco smoke on children and the
health risks and disorders that are possible due to exposure. By
bringing this data into my work the case for a smoking ban in
places like cars, playgrounds and kid friendly environments will
be stronger.
Pérez, Claudio E. "Second-Hand Smoke Exposure--Who's At
Risk?." Health Reports 16.1
(2004): 9-17. MEDLINE Complete. Web. 6 Sept. 2015.
Pérez's article examines exposure to second-hand smoke in
various settings by age, sex, and region. This article will give
an idea of the risks that the elderly are faced with as a result of
being exposed to second-hand smoke. Showing the effects of
second-hand smoke on a variety of age groups is important to
show that no one is immune to this danger and that all people
regardless of age, sex, and region can be affected.
E-BOOK
Protection from Exposure to Second-hand Smoke : Policy
Recommendations. Geneva, CHE:
World Health Organization (WHO), 2007. ProQuest ebrary.
Web. 6 September 2015.
The World Health Organization (WHO) lays out their policy
recommendations to help with the risk of being exposed to

second-hand smoke. This book will help clarify the direction
that my work will go in the recommended fix for my problem.
Articles
www.thelancet.com Vol 377 January 8, 2011 139
Lancet 2011; 377: 139–46
Published Online
November 26, 2010
DOI:10.1016/S0140-
6736(10)61388-8
See Comment page 101
Institute of Environmental
Medicine, Karolinska Institute,
Stockholm, Sweden
(M Öberg PhD); Respiratory
Medicine Unit, Center for
Environmental and Respiratory
Health Research and Institute
of Clinical Medicine, University
of Oulu, Oulu, Finland
(Prof M S Jaakkola PhD); School
of Population Health,
University of Auckland,
Auckland, New Zealand
(Prof A Woodward PhD); and
World Health Organization,
Geneva, Switzerland
(A Peruga DrPH,

A Prüss-Ustün PhD)
Correspondence to:
Dr Annette Prüss-Ustün, World
Health Organization,
Department of Public Health and
Environment, 20 Avenue Appia,
1211 Geneva 27, Switzerland
[email protected]
Worldwide burden of disease from exposure to second-hand
smoke: a retrospective analysis of data from 192 countries
Mattias Öberg, Maritta S Jaakkola, Alistair Woodward,
Armando Peruga, Annette Prüss-Ustün
Summary
Background Exposure to second-hand smoke is common in
many countries but the magnitude of the problem
worldwide is poorly described. We aimed to estimate the
worldwide exposure to second-hand smoke and its burden
of disease in children and adult non-smokers in 2004.
Methods The burden of disease from second-hand smoke was
estimated as deaths and disability-adjusted life-years
(DALYs) for children and adult non-smokers. The calculations
were based on disease-specifi c relative risk estimates
and area-specifi c estimates of the proportion of people exposed
to second-hand smoke, by comparative risk assessment
methods, with data from 192 countries during 2004.
Findings Worldwide, 40% of children, 33% of male non-
smokers, and 35% of female non-smokers were exposed to
second-hand smoke in 2004. This exposure was estimated to
have caused 379 000 deaths from ischaemic heart
disease, 165 000 from lower respiratory infections, 36 900 from
asthma, and 21 400 from lung cancer. 603 000 deaths
were attributable to second-hand smoke in 2004, which was

about 1·0% of worldwide mortality. 47% of deaths from
second-hand smoke occurred in women, 28% in children, and
26% in men. DALYs lost because of exposure to second-
hand smoke amounted to 10·9 million, which was about 0·7% of
total worldwide burden of diseases in DALYs in
2004. 61% of DALYs were in children. The largest disease
burdens were from lower respiratory infections in children
younger than 5 years (5 939 000), ischaemic heart disease in
adults (2 836 000), and asthma in adults (1 246 000) and
children (651 000).
Interpretation These estimates of worldwide burden of disease
attributable to second-hand smoke suggest that
substantial health gains could be made by extending eff ective
public health and clinical interventions to reduce passive
smoking worldwide.
Funding Swedish National Board of Health and Welfare and
Bloomberg Philanthropies.
Introduction
The harmful eff ects of second-hand smoke have been
recorded since 1928.1 In the 1970s, scientifi c interest in
potential adverse health eff ects of second-hand smoke
expanded.2,3 Since then, evidence about ill health because
of second-hand smoke has accumulated from many
studies done in diff erent parts of the world. However,
second-hand smoke remains a common indoor air
pollutant in many regions. Comprehensive legislation to
protect non-smokers from exposure to second-hand smoke
in all indoor workplaces and public places has been
implemented in some countries and subnational
jurisdictions, but 93% of the world’s population is still
living in countries not covered by fully smoke-free public
health regulations.4–8

Knowledge about the links between second-hand
smoke and specifi c diseases has been summarised in
comprehensive assessments or reviews by the Inter-
national Agency for Research on Cancer,9 WHO,10 the
California Environmental Protection Agency,11 and the
US Surgeon General.12 Studies of the eff ects of smoke-
free laws have drawn attention to the importance of
second-hand smoke as a preventable cause of disease
and disability. The International Agency for Research on
Cancer reported in 2009 that “wide-ranging bans on
smoking in the workplace are followed by as much as a
10–20% reduction in acute coronary events in the fi rst
year post-ban”.13,14 The 171 countries that are parties to the
WHO Framework Convention on Tobacco Control
“recognize that scientifi c evidence has unequivocally
established that exposure to tobacco smoke causes death,
disease, and disability”.15 Furthermore, they recognise
that there is no safe level of exposure to tobacco smoke
and therefore recommend eff ective measures to provide
protection from exposure to tobacco smoke, as envisioned
by Article 8 of the WHO Framework Convention. The
guidelines for imple mentation of Article 8 stipulate that
smoking and tobacco smoke be totally eliminated in all
indoor workplaces, indoor public places, and on public
transport, and be eliminated as appropriate in other
public places.16
Some country-specifi c studies of the health eff ects
attributable to second-hand smoke have been reported;17–19
however, this study provides the fi rst assessment of the
worldwide burden of disease from second-hand smoke.
Information about the magnitude and distribution of the
burden of disease from second-hand smoke is particularly
important for policy makers to plan preventive strategies.
We aimed to estimate the worldwide burden of disease

attributable to second-hand smoke, measured as deaths
Articles
140 www.thelancet.com Vol 377 January 8, 2011
and disability-adjusted life-years (DALYs) lost for children
and adult non-smokers.
Methods
Framework for estimation
We estimated the burden of disease from second-hand
smoke by the comparative risk assessment method.20,21 In
this approach, the contribution of a risk factor to disease
is based on the population attributable fraction, which is
derived from the proportion of people exposed to the
pollutant of interest and the relative risk of disease related
to the exposure, and defi ned as the proportional reduction
in disease or death that would occur if exposure was
reduced to zero.20,21
Proportion exposed and relative risk were specifi ed for
every outcome, age-group, and sex. Estimates were
calculated for 192 countries and then grouped into
14 regions (panel) for comparability with previous
worldwide assessments of other risk factors.22 The
assessment was done for 2004, the most recent year for
which comprehensive disease data were available for
analysis by country, disease, age, and sex.23
Estimation of exposure
We estimated the proportion of people exposed to second-
hand smoke with methods matching as closely as

possible the measures used in the epidemiological
studies that provided the relative risks of diseases from
second-hand smoke. Exposure to second-hand smoke
was estimated for every country, separately for children
(classifi ed as 0–14 years for this assessment), and for men
and women (older than 15 years).
Panel: WHO subregional country grouping, by region
Africa
Region D
Algeria, Angola, Benin, Burkina Faso, Cameroon, Cape Verde,
Chad, Comoros, Equatorial Guinea, Gabon, The Gambia,
Ghana, Guinea, Guinea-Bissau, Liberia, Madagascar, Mali,
Mauritania, Mauritius, Niger, Nigeria, Sao Tome and Principe,
Senegal, Seychelles, Sierra Leone, Togo
Region E
Botswana, Burundi, Central African Republic, Congo,
Côte d’Ivoire, Democratic Republic of the Congo, Eritrea,
Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia,
Rwanda, South Africa, Swaziland, Uganda, Tanzania,
Zambia, Zimbabwe
The Americas
Region A
Canada, Cuba, USA
Region B
Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize,
Brazil, Chile, Colombia, Costa Rica, Dominica,
Dominican Republic, El Salvador, Grenada, Guyana, Honduras,
Jamaica, Mexico, Panama, Paraguay, Saint Kitts and Nevis,
Saint Lucia, Saint Vincent and the Grenadines, Suriname,
Trinidad and Tobago, Uruguay, Venezuela

Region D
Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru
Eastern Mediterranean region
Region B
Bahrain, Iran, Jordan, Kuwait, Lebanon, Libya, Oman,
Qatar, Saudi Arabia, Syrian Arab Republic, Tunisia,
United Arab Emirates
Region D
Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan,
Somalia, Sudan, Yemen
(Continues on next column)
(Continued from previous column)
Europe
Region A
Andorra, Austria, Belgium, Croatia, Cyprus, Czech Republic,
Denmark, Finland, France, Germany, Greece, Iceland, Ireland,
Israel, Italy, Luxembourg, Malta, Monaco, Netherlands,
Norway, Portugal, San Marino, Slovenia, Spain, Sweden,
Switzerland, UK
Region B
Albania, Armenia, Azerbaijan, Bosnia and Herzegovina,
Bulgaria, Georgia, Kyrgyzstan, Poland, Romania,
Serbia and Montenegro, Slovakia, Tajikistan,
Former Yugoslav Republic of Macedonia, Turkey,
Turkmenistan, Uzbekistan
Region C
Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania,
Republic of Moldova, Russian Federation, Ukraine

Southeast Asia region
Region B
Indonesia, Sri Lanka, Thailand
Region D
Bangladesh, Bhutan, North Korea, India, Maldives, Myanmar
(Burma), Nepal, Timor Leste
Western Pacifi c region
Region A
Australia, Brunei, Japan, New Zealand, Singapore
Region B
Cambodia, China, Cook Islands, Fiji, Kiribati, Laos, Malaysia,
Marshall Islands, Micronesia, Mongolia, Nauru, Niue, Palau,
Papua New Guinea, Philippines, South Korea, Samoa,
Solomon Islands, Tonga, Tuvalu, Vanuatu, Vietnam
Data for 2004. Regions are categorised as follows (WHO-
approved classifi cations): A=very
low child mortality and very low adult mortality; B=low child
mortality and low adult mor-
tality; C=low child mortality and high adult mortality; D=high
child mortality and high
adult mortality; E=high child mortality and very high adult
mortality. Adapted from WHO.22
Articles
For children, exposure to second-hand smoke was often
operationally defi ned as having one or both parents who
smoke or being exposed to tobacco smoke or to a person

who smokes indoors. For adults, the defi nitions of
exposure were often based on having a spouse who
smokes or exposure to tobacco smoke at work, and can be
further characterised by the number of cigarettes smoked
by the spouse, the duration of exposure (in years), or the
frequency of exposure (in number of days per week).11,12
Estimates of the exposure of children to second-hand
smoke were obtained mainly from the global youth
tobacco survey (GYTS),24 a school-based survey of children
aged between 13 years and 15 years in more than
120 countries. Data for children and adults were also
obtained from various national and multinational
surveys. To identify national data for second-hand smoke,
the keywords “second hand smoke”, “environmental
tobacco smoke”, and “passive smoking” were combined
with names of countries or regions, by searching Google
and the PubMed database from January, 1980, to
December, 2007. We used data from 1980 to 1995 when
estimating the burden from lung cancer because of the
long latency period for this disease,25 and data for
exposures since 2000 were included in the calculations
for other disease outcomes. 19 studies could be used in
the analysis, fi ve of which reported data for several
countries. 186 datapoints on exposure to second-hand
smoke were extracted from these studies, most of which
were for children.
Data were selected as follows: information indicating
regular exposure was preferred (eg, having a parent who
smoked or being regularly exposed to tobacco smoke);
nationally representative survey data were used when
possible; if several GYTS reports were available, the
survey closest to 2004 was selected; when several
subnational GYTS reports were available, the mean value
was calculated; and for a few countries, only one

subnational survey was available and was used for the
whole country in the absence of other data.
For countries without survey data about second-hand
smoke, exposure was modelled. Models using linear,
power, and logarithmic regressions were tested and
selected according to the highest coeffi cient of
determination (R²) value obtained. Several covariates
were tested: whether smokers were women, men, or
parents; the percentage of urban population and the per
head gross national income (webappendix p 1). For
children, separate exposure models were tested for every
region. For adults, the sparse data available allowed only
for separate models for men and women worldwide and
for women in developing countries. Webappendix pp 2–4
provides detailed information about data availability,
models used, and data sources.
Many reports on exposure estimates with biomarkers
are also available from many regions,12 including an
assessment of hair nicotine content for people from
31 countries across three continents.26 Biomonitoring
data were not directly used in exposure estimation in this
Description Age
(years)
Risk (95% CI) Exposure Source*
WHO10 Cal-EPA11 US Surgeon
General12
IARC9
Children

Lower respiratory
infections12
Incidence of acute lower respiratory
infections and admission to hospital
<2 Odds ratio
1·55† (1·42–1·69)
Either parent A A A ··
Asthma onset11 Incidence of new cases of asthma <14 Odds
ratio
1·32 (1·24–1·41)
Either parent ·· A B ··
Acute otitis
media11
Incidence of acute otitis media
(with or without recurrent otitis)
<8 Incidence density ratio
1·38 (1·21–1·56)‡
Either parent ·· A A ··
Adult non-smokers
Induction of
asthma27
Adult-onset incident asthma >20 Odds ratio
1·97 (1·19–3·25)

At home and/or
at work
·· A B ··
Lung cancer12 Incidence >15 Relative risk
1·21 (1·13–1·30);
1·22 (1·13–1·33)
At home; at work ·· A A A
Ischaemic heart
disease12
Incidence of any ischaemic heart
disease
>15 Relative risk
1·27 (1·19–1·36)
Non-smokers at
home or at work
·· A A§ ··
··=not available or not relevant in view of quantifi cation.
ALRI=acute lower respiratory tract infection. Cal-
EPA=Californian Environmental Protection Agency.
IARC=International Agency for Research and Cancer. *The
conclusions in the report about the level of evidence are
designated as follows: A=“suggestive” or “supportive”; and
B=“suggestive”, “some”, or “may contribute” for a causal
relation. †Although the Surgeon General’s Report12 did not do
a formal analysis of the size of risk in older children,
the meta-analysis by Li and colleagues28 estimated an excess
risk reduced to about a third for children aged 3–6 years

compared with those aged 0–2 years. The same
reduction was therefore applied in this study (ie, a relative risk
of 1·18 for children aged 3–6 years). ‡On the basis of the Cal-
EPA reviews (1997, 2005);11 the risk estimate from
Etzel and colleagues (1992)29 of 1·38 (1·21–1·56) was used.
This risk estimate corresponds to the midpoint values reported
in other reviews. §Further confi rmed by a recent
report by the Institute of Medicine (2009).30
Table 1: Health outcomes included in this assessment, eff ect
estimate for exposure to second-hand smoke, and rating of the
strength of evidence for
every outcome
See Online for webappendix
Articles
analysis because exposure measures in relevant
epidemiological studies were almost invariably self-report
survey questions. However, we did use bio marker data
for comparison of exposure intensity across continents.
Selection of exposure-risk relations
Health outcomes were included in the burden of disease
estimates if recent reviews judged the evidence to be
suffi cient for inferring a causal association with second-
hand smoke, and if national incidence statistics were
available. The exposure-risk relation was taken from the
most up-to-date meta-analysis; if none was available, this
information was taken from the results of large, high-
quality epidemiological studies. Table 1 provides the

outcomes that were selected on this basis, alongside the
ratings of the strength of evidence.
In addition to the health outcomes listed in table 1,
low birthweight and sudden infant death syndrome
had suffi cient evidence for quantifi cation. However, no
worldwide statistics exist for these outcomes, so they
could not be included in this estimation of disease burden.
Several other health outcomes have been linked to second-
hand smoke, but available evidence is deemed insuffi cient
or non-supportive for a causal relation.11,12
Estimation of burden of disease
The attributable burden of disease (AB), in deaths or
DALYs, was estimated for every outcome by multiplication
of the population attributable fraction (PAFSHS) by the
total burden attributable to that disease (B):
The population attributable fractions were applied
equally to the burden in deaths and DALYs, and we
assumed that the case fatality of cases related to second-
hand smoke was the same as the mean case fatality of the
disease. Results were calculated separately for every age-
group, sex, and country, and then summed as appropriate.
For adults, the population attributable burden was
estimated for non-smokers only because studies of health
eff ects of second-hand smoke exposure have, with few
exceptions, included only non-smokers. The following
equation was used to approximate the burden of relevant
health outcomes in non-smokers:
where Bns is the total burden, in deaths or DALYs, of non-
smokers, psm is the active smoking rate, and PAFsm is the
population attributable fraction from active smoking. All
children were regarded as non-smokers.

The attributable burden of disease (AB), in deaths or
DALYs, was estimated for every outcome by multi-
plication of the population attributable fraction (PAFSHS)
by the total burden attributable to that disease in non-
smokers (Bns):
We used country-specifi c estimates of population
attributable fractions from active smoking for lung
Lower
respiratory
infections
in children
<5 years
Otitis
media in
children
<3 years
Asthma
in
children
<15 years
Asthma
in adults
Lung
cancer in
adults
Ischaemic
heart
disease in

adults
Total
Africa (D) 23 219 2 63 1634 177 3063 28 200
Africa (E) 20 025 4 62 1796 276 2568 24 700
The Americas (A) 65 1 11 288 596 12 604 13 600
The Americas (B) 4169 12 60 932 681 11 427 17 300
The Americas (D) 1555 1 9 140 93 982 2800
Eastern
Mediterranean
regions (B)
1771 0 13 727 142 6223 8900
Eastern
Mediterranean
regions (D)
30 518 11 96 2243 318 22 011 55 200
Europe (A) 60 1 10 1112 1993 32 283 35 500
Europe (B) 5367 1 106 1306 751 29 966 37 500
Europe (C) 818 2 3 3277 1096 94 109 99 300
Southeast Asia
region (B)
4465 0 135 3681 631 18 433 27 300

Southeast Asia
region (D)
55 956 23 333 9827 1864 67 095 135 000
Western Pacifi c
region (A)
39 0 5 697 938 8769 10 400
Western Pacifi c
region (B)
17 150 13 243 8113 11 850 69 659 107 000
Worldwide 165 000 71 1150 35 800 21 400 379 000 603 000
Totals provided are rounded to the nearest signifi cant fi gure.
*For country grouping see panel.
Table 3: Number of deaths from exposure to second-hand smoke
in 2004, by WHO subregion*
AB=PAFSHS×B
Bns=[B–(B×PAFsm)]×(1–psm)
AB=PAFSHS×Bns
Children†‡ (%) Men (%) Women (%)
Africa (D) 13 7 11
Africa (E) 12 4 9

The Americas (A) 24 16 15
The Americas (B) 29 14 22
The Americas (D) 22 15 19
Eastern Mediterranean region (B) 38 24 25
Eastern Mediterranean region (D) 33 21 35
Europe (A) 51 35 32
Europe (B) 56 52 54
Europe (C) 61 66 66
Southeast Asia region (B) 53 32 56
Southeast Asia region (D) 36 23 19
Western Pacifi c region (A) 51 50 54
Western Pacifi c region (B) 67 53 51
Worldwide 40 33 35
*For country grouping see panel. †Children younger than 15
years. ‡Approximation based on having one or more
parents who smoke.
Table 2: Proportion of children and adult non-smokers exposed
regularly to second-hand smoke based
on survey data and modelling for 2004, by WHO subregion*

Articles
cancer, ischaemic heart disease, and asthma supplied by
Colin Mathers (Department of Health Statistics and
Informatics, World Health Organization, Geneva,
Switzerland, personal communication). These fi gures
were based on WHO 2009 data31 that used methods
previously developed by Ezzati and Lopez.32
Support for the estimation of country-specifi c disease
burden from second-hand smoke is available as a
methods guide by WHO on the assessment of the burden
of disease at national and local levels.33 Öberg and
colleagues34 provide additional details about the data and
methods presented in this manuscript.
Role of the funding source
The sponsors of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. The corresponding author had full
access to all the data in the study and had fi nal
responsibility for the decision to submit for publication.
Results
Worldwide, 40% of children, 33% of male non-smokers,
and 35% of female non-smokers were exposed to second-
hand smoke. The highest proportions exposed were
estimated in Europe, the western Pacifi c, and region B of
southeast Asia, with more than 50% of some population
groups exposed (table 2). Proportion of people exposed
was lower in the Americas and east ern Mediterranean
regions and the lowest in Africa (table 2).
Second-hand smoke was estimated to have caused

603 000 premature deaths and the loss of 10·9 million
DALYs in 2004. The largest number of estimated deaths
attributable to second-hand smoke exposure in adults
was caused by ischaemic heart disease, followed by lower
respiratory infections in children, and asthma in adults
(table 3). In assessment of burden of disease in terms of
DALYs lost because of exposure to second-hand smoke,
most DALYs lost were from lower respiratory infections,
followed by those from ischaemic heart disease and then
from asthma in adults (table 4). Almost half of the total
burden attributable to exposure to second-hand smoke
was in southeast Asia and the western Pacifi c, with a
high burden of disease also estimated in eastern Europe,
Africa, and eastern Mediterranean region D (table 3,
table 4, and webappendix p 5.
In non-smokers, there are clear inequalities in the
burden of disease from second-hand smoke according to
sex and age. Women have the greatest burden of deaths
of the total attributable to second-hand smoke, whereas
children are most aff ected in terms of DALYs (fi gure).
Lower
respiratory
infections
in children
<5 years
Otitis
media in
children
<3 years
Asthma
in

children
<15 years
Asthma
in adults
Lung
cancer
in
adults
Ischaemic
heart
disease in
adults
Total
Africa (D) 816 314 816 22 006 39 237 1937 29 316 910 000
Africa (E) 698 731 966 29 433 52 135 3229 24 255 809 000
The Americas (A) 2428 442 27 550 28 727 5424 61 859 126 000
The Americas (B) 185 495 1725 66 575 73 437 7203 92 088 427
000
The Americas (D) 57 441 244 10 741 12 575 998 7786 89 800
Eastern
Mediterranean
region (B)
68 477 571 13 278 26 079 1633 60 083 170 000
Eastern

Mediterranean
region (D)
1 082 990 2057 39 202 97 177 3829 213 995 1 439 000
Europe (A) 2267 805 35 771 51 190 16 760 152 457 259 000
Europe (B) 184 938 696 22 571 33 044 7592 207 638 456 000
Europe (C) 28 191 502 8308 35 428 10 279 587 626 670 000
Southeast Asia
region (B)
173 780 1477 25 651 71 700 7108 176 240 456 000
Southeast Asia
region (D)
1 995 618 6655 129 772 323 801 20 515 683 310 3 160 000
Western Pacifi c
region (A)
1421 275 18 146 44 057 7585 48 931 120 000
Western Pacifi c
region (B)
641 279 7779 202 391 357 362 121 456 489 983 1 820 000
Worldwide 5 939 000 24 900 651 000 1 246 000 216 000 2 836
000 10 913 000
Data are the number of DALYs from exposure to second-hand
smoke, by outcome. Totals provided are rounded to the

nearest signifi cant fi gure. DALYs=disability-adjusted life-
years (a weighted measure of death and disability). *For
country grouping see panel.
Table 4: Number of DALYs from exposure to second-hand
smoke in 2004, by WHO subregion*
Figure: Distribution of disease burden from second-hand smoke
in non-smokers by age and sex in 2004
(A) Total deaths attributable to second-hand smoke. (B). Total
DALYs attributable to second-hand smoke. DALY=disability-
adjusted life-year.
Children Men Women Children Men Women
0
50 000
100 000
150 000
200 000
250 000
300 000
350 000
N
um
be
r o

f d
ea
th
s
0
1 000 000
2 000 000
3 000 000
4 000 000
5 000 000
6 000 000
7 000 000
8 000 000
N
um
be
r o
f D
A
LY
s

A Deaths B DALYs
166 000
(28%)
6·6 million
(61%)
1·7 million
(16%)
2·6 million
(24%)
156 000
(26%)
281 000
(47%)
Articles
Discussion
Exposure to second-hand smoke is still one of the most
common indoor pollutants worldwide. On the basis of
the proportions of second-hand smoke exposure, as
many as 40% of children, 35% of women, and 33% of
men are regularly exposed to second-hand smoke
indoors. We noted wide regional variations of exposure,
ranging from 13% or less in Africa to 50% or more in the
western Pacifi c or eastern Europe. These diff erences can
be mostly explained by the stages of the tobacco epidemic

of a country because second-hand smoke is closely related
to active smoking rates where no robust and extensive
smoke-free indoor policies exist.
We have estimated that second-hand smoke caused
603 000 deaths and 10·9 million DALYs worldwide in
2004, corresponding to 1·0% of all deaths and 0·7% of
the worldwide burden of disease in DALYs in this year.
These deaths should be added to the estimated 5·1 million
deaths31 attributable to active smoking to obtain the full
eff ect of both passive and active smoking. Smoking,
therefore, was responsible for more than 5·7 million
deaths every year in 2004. Worldwide, children are more
heavily exposed to second-hand smoke than any other
age-group, and they are not able to avoid the main source
of exposure—mainly their close relatives who smoke at
home. Furthermore, children are the group that has the
strongest evidence of harm attributable to second-hand
smoke. These two factors should form the basis of public
health messages and advice to policy makers.
Almost two-thirds of all deaths in children and adults
and a quarter of DALYs attributable to exposure to second-
hand smoke were caused by ischaemic heart disease in
adult non-smokers. Smoke-free laws banning smoking
in indoor workplaces rapidly reduce numbers of acute
coronary events.35,36 Therefore, policy makers should bear
in mind that enforcing complete smoke-free laws will
probably substantially reduce the number of deaths
attributable to exposure to second-hand smoke within
the fi rst year of its implementation, with accompanying
reduction in costs of illness in social and health systems.
The largest eff ects on deaths occurred in women. The
absolute number of deaths is higher in women than in
men for two main reasons. First, the number of female

non-smokers (thus susceptible to be exposed to second-
hand smoke by defi nition) is about 60% higher than
that of male non-smokers.4 Second, in Africa and some
parts of the Americas, the eastern Mediterranean, and
southeast Asia, women are at least 50% more likely to
be exposed to second-hand smoke than are men. Our
data do not specify where the burden occurs; however,
some setting-specifi c information about exposure is
available. In the European Union, for example, exposure
is almost equally distributed between the workplace
and home, and women constitute about 40% of the
workforce.37 In the western Pacifi c and east Asia, women
equally constitute an important part of the workforce38
and about half of the women are exposed to second-hand
smoke. In the eastern Mediterranean region, 32% of
women, substantially more than the 22% of men, are
exposed to second-hand smoke. Because these women
constitute only 25% of the labour force, much of the
exposure probably occurs at home.
We estimated that 165 000 children younger than
5 years die every year from lower respiratory infections
caused by exposure to second-hand smoke. Two-thirds of
these deaths occur in Africa and south Asia. Children’s
exposure to second-hand smoke most likely happens at
home. The combination of infectious diseases and
tobacco seems to be a deadly combination for children in
these regions and might hamper the eff orts to reduce the
mortality rate for those aged younger than 5 years as
sought by Millennium Development Goal 4. In addition
to ischaemic heart disease in adults and asthma in
children and adults, lower respiratory infections were
also the cause of many DALYs lost because of second-
hand smoke exposure. The largest burden of DALYs from
second-hand smoke exposure was in children.

Information about the magnitude and distribution of
the burden of disease caused by second-hand smoke is
particularly pertinent to policy makers because the harm
done by second-hand smoke is eminently preventable.
There are well documented and eff ective interventions to
reduce exposure to second-hand smoke in public and
private places. For example, by the end of 2007,
16 countries had passed national smoke-free legislation
covering all workplaces and public sites,39 and many
other countries have state or local government ordinances
that restrict smoking. In a review of the eff ectiveness of
legislation of this type, exposure to second-hand smoke
in high-risk settings (such as bars and restaurants) was
typically reduced by about 90%, and the exposure of adult
non-smokers in the general population to second-hand
smoke cut by as much as 60%.13
Most epidemiological studies have been done in
developed countries. Conditions in developing countries
can diff er from those in high-income countries, and, in
particular, exposure to second-hand smoke in the home
is often not well characterised by the presence or absence
of parents or spouses who smoke. Factors contributing
to the diff erences in intensity of indoor exposure to
second-hand smoke between developing and developed
countries include: intensity of tobacco smoking (mean
cigarettes and other smoking tobacco per day per
smoker); natural ventilation (eg, the climate allows open
architectural structures or opening of windows);
crowding at home (eg, sharing of bedrooms with people
who smoke); the pathogens most frequently associated
with respiratory illnesses; smoke from solid fuels used
for cooking; and enforcement of legal protection from
exposure to second-hand smoke in indoor workplaces
and public places. However, on the basis of the biomarker

and epidemiological data reviewed and additional
analyses done, we concluded that exposures in
households in which someone smokes are broadly the
Articles
same across regions, with higher intensities in Asia and
the Middle East than in Europe, and lower levels
in Latin America. Factors such as crowding, ventil-
ation, and smoke from solid fuels seem to have
little eff ect on actual exposure and health eff ects
across regions on the basis of available evidence
(webappendix pp 6–9). Webappendix p 10 shows results
of the sensitivity analyses.
There are uncertainties inherent in any assessment of
this type. These limitations include uncertainties in: the
underlying health data; the exposure data; the choice of
study population (particularly the exclusion of potential
eff ects in smokers); the eff ect sizes and their transferability
to other populations and exposure conditions; the burden
of active smoking (deduced from the total burden before
estimation of the burden from second-hand smoke); and
the susceptibility of ex-smokers. Estimation of exposure
is one of the weaknesses of this approach because of the
gaps in data for specifi c regions, the age-groups that had
to be completed by modelling, and the variations in
defi nitions of exposure across available studies.
Webappendix p 10 shows the results of sensitivity analyses
that tested the eff ects of varying the key assumptions on
the number of deaths attributable to second-hand smoke
per year. We took the most parsimonious approach to

change only one variable at a time. We varied the eff ect
sizes within their confi dence interval, used specifi c eff ect
sizes by region and by sex when available, and used
diff erent hypotheses of susceptibility of smokers and ex-
smokers to second-hand smoke. The number of deaths
was most sensitive to the assumption that smokers are
not aff ected by second-hand smoke, which would
otherwise have been 30% higher.
Previously reported national estimates of the burden of
disease caused by second-hand smoke are generally
similar to those reported here. Variations result from
diff erences in the burden from active smoking, the active
and passive smoking rates used, and the methods used
(eg, whether or not active smokers are deemed
susceptible). The size of the relative risk estimates used
did not generally vary across studies of health eff ects
from exposure to second-hand smoke.
This assessment shows that second-hand smoke poses
a substantial health risk and disease burden for children
and adult non-smokers worldwide. The fi ndings are
relevant to health policy decisions and public health
strategies in all regions.
Only 7·4% of the world population lives in jurisdictions
with comprehensive smoke-free laws at present, and the
enforcement of these laws is robust in only a few of those
jurisdictions.4 We recommend that the provisions of the
WHO Framework Convention on Tobacco Control15 should
be enforced immediately to create complete smoke-free
environments in all indoor workplaces, public places,
and on public transport. When policy makers implement
these measures they are likely to record a substantial and
rapid decline in the mortality attributable to tobacco and

long-term reduction of DALYs lost from second-hand
smoke. Fully smoke-free policies have a net positive eff ect
on businesses, including the hospitality sector, and
enforcement and education about smoke-free policies will
have minimum costs to governments. Additionally, they
are supported by much of the population, and this support
increases after its enforcement—even in most smokers.13
In addition to the protection they off er to non-smokers,
such smoke-free policies reduce cigarette consumption
among continuing smokers and lead to increased
successful cessation in smokers. Above all, these policies
contribute decisively to denormalise smoking, and help
with the approval and implementation of other policies
that reduce tobacco demand, such as increased tobacco
taxes and a comprehensive ban of tobacco advertising,
promotion, and sponsorship.
Policy makers should also take action in two other
areas to protect children and adults. First, although the
benefi ts of smoke-free laws clearly extend to homes,
protection of children and women from second-hand
smoke in many regions needs to include complementary
educational strategies to reduce exposure to second-hand
smoke at home. Voluntary smoke-free home policies
reduce exposure of children and adult non-smokers to
second-hand smoke, reduce smoking in adults, and
seem to reduce smoking in youths.13 Second, exposure to
second-hand smoke contributes to the death of thousands
of children younger than 5 years in low-income countries.
Prompt attention is needed to dispel the myth that
developing countries can wait to deal with tobacco-
related diseases until they have dealt with infectious
diseases. Together, tobacco smoke and infections lead to
substantial, avoidable mortality and loss of active life-
years of children.

Contributors
MÖ and AP-U reviewed the literature and developed the
methods and
estimates. AP-U drafted the report. MJ, AW, and AP provided
input to
the development of the methods and to the drafting process.
Confl icts of interest
We declare that we have no confl icts of interest.
Acknowledgments
We thank the Swedish National Board of Health and Welfare
and the
Bloomberg Philanthropies for their funding support. The authors
alone
are responsible for the views expressed in this publication,
which do not
necessarily refl ect the decisions or the stated policy of WHO or
of its
Member States. ©World Health Organization, 2010.
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Worldwide burden of disease from exposure to second-hand
smoke: a retrospective analysis of data from 192
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estimationEstimation of exposureSelection of exposure-risk

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sourceResultsDiscussionAcknowledgmentsReferences
Journal of Substance Use, 2012; 17(3): 203–217
ORIGINAL ARTICLE
The impact of the Scottish ban on smoking in public places
upon nightclubs and their patrons
ALASDAIR J. M. FORSYTH
Scottish Centre for Crime and Criminal Justice Research,
Glasgow Centre for the Study of Violence,
Glasgow Caledonian University, Glasgow, UK
Abstract
In many jurisdictions around the world, the policy of banning
tobacco smoking from public places has
been progressively introduced. This has included the prohibition
of smoking on premises licensed for the
sale and consumption of alcohol, such as bars, restaurants and
pubs. Of all these types of venues, the one
which would appear to present the greatest challenge for
operators attempting to manage the impact of
this policy is nightclubs. This article examines how the
introduction of a comprehensive nationwide
smoking ban in Scotland was managed by city centre nightclubs
and how this was viewed by their patrons.
On the plus side, there was a high level of compliance and
support for the ban among nightclub patrons
who had quickly accepted the (tobacco) smoke-free environment
as normal. However, there were also
some problems, including door management difficulties, the

stretching of security staff resources,
increased fear of drinks “spiking” and the prospect that outdoor
smoking scene (i.e. “smirting” – smoking
and flirting) had very quickly become a desirable part of the
nightclub experience.
Keywords: Smoking-ban, licensed premises
Introduction
On 26 March 2006, the Scottish Government banned smoking
from all enclosed public
spaces, including all of the nation’s licensed premises, in order
to safeguard the health of those
working in such environments. This article will report findings
from an observational study of
alcohol-related disorder (violence) conducted within Scottish
nightclubs over the period of
this smoking ban. The research was conducted in Glasgow, a
city with historical and inter-
nationally high levels of tobacco smoking and alcohol-related
problems (Bauld, Ferguson,
Lawson, Chesterman, & Judge, 2006; Hanlon, Walsh, & Whyte,
2006).
The Scottish ban, as defined in the “Smoking Health and Social
Care (Scotland) Act”
(2005), covered all “wholly and substantially enclosed public
spaces,” and unlike similar bans
or proposed bans in other jurisdictions (e.g. England), this
legislation included all licensed
premises. This legislation was intended to protect the health of
bar workers. However, the
Correspondence: Dr. Alasdair J. M. Forsyth, Department of
Psychology, Glasgow Caledonian University, Cowcaddens

Road,
Glasgow G4 0BA, UK. Tel. þ0141 331 8301. Fax: þ0141 331
3636. E-mail: [email protected]
ISSN 1465-9891 print/ISSN 1475-9942 online © 2012 Informa
UK Ltd.
DOI: 10.3109/14659891.2012.688396
blanket nature of the Scottish ban did raise some concerns that
these health gains maybe offset
by the displacement of smoking, or drinking, practices towards
private enclosed spaces
(e.g. the family home), which might expose children or other
non-smokers to smoke and
smoking behaviours (Adda & Cornaglia, 2005; Haw et al.,
2006). Concerns about this would
seem particularly salient in Scotland as the weather and climate
in this country are not
conducive to outdoor smoking and drinking. Additionally, there
were concerns that the
ban would harm the alcohol and licensed trade industry, one of
Scotland’s largest employers
and revenue generators (Adda, Berlinski, & Machin, 2006; Tran,
2006).
Of all sectors of the on-trade, nightclubs are seen as the type of
licensed premises that might
expectedtobe mostaffected by this legislation as,unlikepubs or
restaurants,customers who had
paid an entrance fee (late at night) would not be free to simply
vacate and then re-enter the
premiseswhenevertheywantedtosmokeacigarette(Perrett,2006;Pi
cken,2006).Additionally,
in comparison to pubs or restaurants, nightclubs are usually
quite large and employ “smoke

machines” (dry ice) to add to their visual effects, thus creating
extra difficulties for staff charged
withenforcement ofthe ban, should intoxicatedcustomers
decidetofloutit. Thus,nightclubs in
Scotland would appear to represent an extreme example of the
difficulties faced in imposing
smoking bans in licensed premises, both in terms of their likely
impact to the industry and in the
potential for resistance by patrons (e.g. violence resulting from
enforcement attempts).
This research used a combination of observation and interview
methods to measure the
impact of the ban, with half of these observations being
conducted in the weeks before it came
into effect and the other half afterwards. The research aimed to
assess the level of compliance
with the ban among smoking patrons, how different nightclub
premises managed the ban and
what patrons (both smokers and non-smokers) felt about the
issues it had raised. As well as
looking at the positive (health) aspects of the ban, this article
will also look at some of its other,
unintended, consequences upon this sector, including the impact
on disorder risk, levels of
violence, level of smokers’ group affinity, changing attitudes to
outdoor smoking, patterns of
drinking and illegal drug consumption.
Method
The observational phase of research involved two teams of two
fieldworkers (one female and
one male in each) visiting a sample of eight of Glasgow’s 70
nightclubs for 3 hours, twice each,
once on a Friday and once on a Saturday night (midnight to 3.00

AM – which approximates to
100 hours observation taking into account “drinking up time”).
These observations were
supplemented by 32 in-depth interviews with Glasgow nightclub
patrons conducted by the
author.
The eight nightclubs observed were selected in consultation
with the local police force
(Strathclyde Police) to represent the range of call-outs to
disorder, which they received from
such premises in the city centre (i.e. including some premises
with high levels of recorded
violent crime and some with low levels of recorded violent
crime). The selected premises all
held an Entertainment License (i.e. they were open till 3.00 AM
at weekends), charged
admission and offered mainstream “high street,” regular dance
promotions (i.e. the sample
excluded niche venues such as gay clubs, strip clubs, comedy
clubs or ceilidhs). Each of the
observed premises is assigned a suitable pseudonym for the
purposes of this article.
The smoking ban came into effect at 6.00 AM on Sunday, 26
March 2006. Thus, to
measure its impact, half of the nightclub observations were
conducted before this date and
half afterwards. That is, the observational research was divided
into two sweeps of data
204 A. J. M. Forsyth
collection, during which both teams of observers visited each of

the nightclubs in the sample
once before and once after the smoking ban. The first sweep of
observations began on Friday,
24 February, and ceased on Saturday, 25 March, that is, the
night the smoking ban was
implemented. Observations resumed on Friday, 21 April (by
which time smoking ban
management practices were assumed to have settled into place),
before finishing on
Saturday, 27 May. So as to not compromise the observational
fieldwork, all interviews with
nightclub patrons were conducted post-ban.
Observers made extensive field notes about what they had
witnessed on each occasion when
they visited a nightclub. They also completed two extensive
research instruments (question-
naires or checklists) on returning home after each observational
session. These instruments
have been extensively used in work of this nature in Canada and
elsewhere (Graham, 1999,
2000). One of these, “Form 2,” was used to record any incidents
of violence witnessed, and the
other, “Form 1,” was used to detail the nightclub (barroom)
setting in each of the premises
(including a measure of “smokiness” and other environmental
features all scored 0–9, and
various percentage scores including estimates of the percentage
of patrons who were observed
smoking). Additional items were added to this form to gauge the
impact of the smoking ban
(including items relating to whether the ban was being complied
with by both staff and patrons).
First, interviewees were recruited via the observers handing out
project recruitment cards

to clubbers (n ¼ 8), then via chain referral from students (n ¼
17, not the students themselves)
and finally from direct approach by the author on the streets of
Glasgow city centre, targeting
any demographic types, apparent from observations but not
already recruited for interview
(n ¼ 7). All interviews were semi-structured, taped and, with
the exception of the first
interview, conducted at the university. All interviewees were
first required to read an infor-
mation sheet about the project before completing a consent
form. The interview topic guide
included the prompt “Views on smoking ban.” Complete details
of this research, its rationale,
methods and findings can be found elsewhere (Forsyth, 2006).
Results
Observations in nightclubs (impact on premises management)
During the first sweep of field observations (i.e. during the
month before the smoking ban
came into effect), and in especially on the night of the ban
(Saturday, 25 March 2006),
observers paid particular attention to how the nightclubs in the
sample were preparing for it.
For example, whether they informed patrons of this new law and
how it would be managed.
How this was handled appeared to vary greatly. Only one of the
eight nightclubs (“Saturn”)
provided detailed information more than a week in advance of
the ban but others seemed to
ignore it completely, with at least one (“Sinatra’s”) even failing
to mention it on the night that
the ban came into force. The observers’ field notes below
illustrate these two extremes in the

provision of information about how the ban would impact upon
nightclub patrons.
No one really mentioned the smoking ban, there weren’t any
signs up or announcements
made. The tables all still had ashtrays on them and a lot of
people were smoking. (Male
Observer Team B at “Sinatra’s” nightclub on the night of the
ban)
There were posters about the club informing patrons about the
smoking ban and warning
that patrons who smoked risked a fine as did the club. It stated
that they intended to issue
all patrons with a wristband so that they could leave to smoke
outside the club entrance. It
Smoking bans and late-night drinking premises 205
also stated due to the ban on drinking in public patrons should
remember not to take their
drinks outside with them. This was a notice made by ‘Saturn’
themselves rather than being
provided by a company or the Scottish Executive. There was
also a similar sign in the
female toilets warning patrons about drink spiking and to avoid
leaving drinks unattended
or accepting drinks from strangers. (Female Observer Team A at
“Saturn” nightclub 1
week before ban)
The second field note above, concerning “Saturn,” is of
particular interest as this nightclub’s
operators had taken it upon themselves to produce posters and

print leaflets informing their
patronsabout the ban.And
oneothernightclub(“Chocolate”)wasobservedgivingoutinforma-
tion about the ban, though only on the night that
itcameintoforce (it remains possiblethatsome
of the remaining five premises in the sample may have done so
on the night of the ban).
Table I details the eight nightclubs observed and summarises
how the ban had an impact on
them. It should be noted that the difference in the overall
estimated proportion of patrons
observed smoking before and after the ban was non-significant
(from 16.1% smoking inside
before to 15.8% smoking outside afterwards, by paired t-test p
¼ 0.772, figures derived from
the means of all four observers’ estimated percentages, made at
each nightclub before and
after the ban). Also, this figure was easier for observers to
estimate before the ban, as post-ban
this involved making trips to outdoor smoking areas (during
most of their 100 hours of
observation, observers’ had little else to do but to calculate this
and other percentage ques-
tions on “Form 1”).
As indicated in the above field note, “Saturn” nightclub
intended to use a wristband door-
pass system to allow patrons to go outside to smoke and then re-
enter without having to pay
again. This approach, or something similar (e.g. a hand stamp),
was also adopted by three other
nightclubs, “Xanadu,” “Rapture” and “Sinatra’s,” to allow
patrons to smoke on the street. At
one nightclub, “Tropicana” (which had the lowest door price),
patrons were allowed to come

and go on to the street simply by asking the door stewards
(security staff) if they could go out
and then “to hope that they recognise you on your way back in”
(Female Observer Team A).
However, it was managed, there was no doubt that nightclub
patrons leaving to smoke on busy
city streets could lead to a number of problems, as illustrated by
the following field note.
The pass out system here is a bit of a farce. You collect a
wristband from the pay-in counter
which allows you in and out the club. In theory this should
work. Patrons enter club, pay,
get wristband at same time and then come and go as they please.
In reality, people pay and
Table I. Impact of the smoking ban inside individual nightclubs
Venue
% Patrons smoking
inside pre-ban
% Patrons smoking
outside post-ban
Patrons observed
flouting the ban
Xanadu 12.0 15.4 More than once
Armageddon 20.8 15.0 Once
Rapture 18.1 14.3 Once
Tropicana 11.3 4.0 Never
Chocolate 16.9 12.5 Never
Idols 10.6 27.5 Never
Sinatra’s 15.9 15.6 Never
Saturn 23.1 17.4 Never

Mean 16.1 15.8 –
206 A. J. M. Forsyth
enter the club. After about an hour decide they want a cigarette
so go back out to cash desk
to collect a band and either barge into everyone still waiting to
pay to get into the club in
first place or have to queue up with people still to come in and
then have to convince cash
desk staff that they have already paid. Chaos ensues. Once you
finally get your band and
make it outside you are sent right across the road to mingle with
beggars and parked cars. I
guess this is so the club doesn’t have to take responsibility for
all the dropped fag ends.
While outside I saw people from the club smoking who still had
their drinks with them. On
re-entering the club you have to undergo another search. When I
was going back in a male
went to go up the stairs, female steward shouted on him to come
back but he ignored her.
She looked around for male stewards for support but he was too
busy searching someone
else to even notice. Male patron therefore got back in without
being searched which I don’t
think the female steward was very happy about. (Female
Observer Team A, “Xanadu”)
The remaining three observed premises, “Armageddon,”
“Chocolate” and “Idols,” were
lucky in this respect, in that they had backcourts (yards to the
rear of these premises) which
could be converted into smoking areas. At these three

nightclubs, patrons could come and go
for a smoke as they pleased, as described in the field note
below.
About 40% were going out. Went to a wee [small] decking style
area with tables and
ashtrays fenced off at back of club. . . . saw male smoking a
joint in smoking area. (Female
Observer Team A, “Armageddon”)
The above field note also illustrates how the smoking ban has
provided a new opportunity for
patrons choosing to smoke cannabis during a night’s clubbing.
As will be seen from subse-
quent patron interviews, this was just one of many unintended
consequences of the ban, not
all of them positive, which allowing patrons to leave and then
re-enter nightclubs throughout
the night had brought about.
The environmental impact of this outdoor smoking on the
streets outside each nightclub was
measured by observers being asked to take note of how much
evidence of smoking there was in
the vicinity of the entrance–exit door of each premises as they
left at the end of the night. To this
end, the presence or absence of smoking materials (e.g.
cigarette ends) was measured on a
simple three-point scale, “none” (i.e. no evidence), “some” (i.e.
a few cigarette ends or matches
lying on the pavement) and “lots” (i.e. a large amount of
smoking-related “litter”). (Note that
on two occasions prior to the ban, this task was made difficult
by the presence of fresh snow.)
When these scores were examined, there was less difference
between observations before and

after the ban than what might have been anticipated (though this
did reach statistical signifi-
cance, Chi-square ¼ 7.77, degrees of freedom ¼ 2, p ¼ 0.020).
As can be seen from Table II,
this change was less dramatic than might have been anticipated
largely because smoking-related
“litter” was also present, and observed, before the ban came
into effect.
It is hypothesised that the presence of smoking-related “litter”
outside nightclubs prior to
the ban was because patrons also smoke while waiting in line in
the queue to pay to get into
them (i.e. a practice which was in place before the ban).
Additionally, after the ban these
queues may be able to use the new smoking boxes (outdoor
ashtrays or “ciggy bins,” Doward
& Biggs, 2007), introduced, post-ban, specifically for outdoor
smokers to use. As might be
expected, it can also be seen from Table II that the external
environmental impact was less
obvious at nightclubs that had a designated outdoor smoking
area to the rear of the premises,
though even at these smoking-related “litter” was observed at
their street entrance before and
after, presumably from queue smoking.
Smoking bans and late-night drinking premises 207
Inside the nightclubs in the sample, compliance with the ban
was almost universal.
Observers witnessed attempts to flout the ban in only three
nightclubs. In every case, this
was quickly enforced. In two nightclubs, “Armageddon” and

“Rapture,” this occurred only
“once,” and on both occasions the patron concerned was asked
to leave without causing any
further problems. In the third nightclub, “Xanadu,” this was
noted “more than once,” though
here the stewards merely pointed the offenders towards the
smoking exit. “Xanadu” was also
the only nightclub where any smoking-related “litter” was
observed after the ban (two
separate observations recorded in a similar fashion to the data
in Table II). No serving staff
were observed smoking inside any of the nightclubs before or
after the ban, and staff smoking
outside, post-ban, was observed at only three nightclubs
(“Chocolate” eight observations,
including two entertainers, “Idols” three observations and
“Xanadu” one observation).
Table III shows the scores for each of the environmental risk
factor for disorder scales
measured by “Form 1” (Graham (1999, 2000)), “smokiness,”
“ventilation,” “noise,” “move-
ment” and “crowdedness” (which might have been expected to
change), before and after the
ban. (These were scored from 0 to 9 by each observer for every
nightclub each time they
visited.) Unexpectedly, the only one of these scales that
changed significantly between these
times was “crowding” (which reduced). The decline in levels of
“smokiness” did not reach
statistical significance. This lack of difference in “smokiness”
scores, before and after the ban,
appeared because of the presence of smoke machines which
observers felt had been “turned
up” post-ban (the question in “Form 1” did not specify
“tobacco” smokiness).

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