Passive smoking outdoors is harmful: it is time to take a step forward!| Tabaccologia

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It has been 19 years since Law No 3 of 16 January 2003 was passed to protect the health of non-smokers. The law came into force on 10 January 2005 and is known as the “Sirchia Law”. Italy, the third country in Europe after Ireland (1988) and Finland (1995), has thus introduced a ban on smoking in all enclosed places, both public and open to the public. This is a great achievement for the protection and respect of the majority of the population, the “non-smokers”, who have always suffered the behaviour (and its consequences) of a large minority: the smokers!

A paradox that has gone on for years and still continues in the Italian society.

Non-smokers cannot enjoy a coffee at an outdoor table or enjoy a meal in the outdoor area of a restaurant without being inevitably contaminated by the smoke of some other customer (Figure 1). And it is not uncommon for people to breathe in second-hand smoke from outside even if they choose to eat inside. And what about now in COVID-19 time, when everyone wants to be outside to reduce the risk of infection with SARS-CoV-2?

It is definitely time to go a step further and extend the smoking ban to the outdoors, as Kyoto did in 2007, New York in 2011, Sweden last year and Milan from 19 January 2021. In these “outposts”, outdoor smoking is banned not only in bars and restaurants, but also in streets, squares, train platforms, bus stops, parks, stadiums and public monuments, just to name a few. By approving the new Air Quality Regulation, Milan has also defined a series of actions that will make it the first Italian city to be smoke-free in 2025, as Melbourne did in 2016, thus becoming the world leader.

Why is it necessary to limit or eliminate outdoor smoking in crowded places? Because scientific evidence unequivocally demonstrates that passive smoking, even outdoors, is harmful to health: it contains a large number of carcinogenic, teratogenic, irritant, toxic and mutagenic agents; it is classified by the International Agency for Research on Cancer (IARC) as a group 1 carcinogen, i.e. carcinogenic to humans.

Cigarettes release considerable quantities of fine particles (PM) into the air on which all these substances adhere; since the smallest particles (PM2.5 and PM1) penetrate deep into the respiratory system and enter the circulatory stream directly, these substances are spread throughout the body and can cause cancer, cardiovascular and respiratory diseases in anyone who breathes them in. A study carried out by the National Institute of Tumours in Milan [1], assessing air quality in Brera (in the Centre of Milan) showed that the air was considerably more polluted in pedestrian areas with many smokers outside than in neighbouring areas with heavy traffic. As evidence of this, nicotine vapours were also found in pedestrian areas in addition to increased fine and ultrafine dust. As early as 2014, a study by Stanford University in California, published an article [2] showing that smoking a single cigarette under a bus shelter increased the concentration of fine particulate matter (PM2.5) by 16-35 times more than that produced by cars and lorries on the road.

Another study, conducted by the Sapienza University of Rome [3], showed that, in addition to traditional or rolled cigarettes, the use of new heated tobacco products (HTPs) and electronic cigarettes also causes a significant increase in PM1 levels outdoors, both in the vicinity of the smoker and of people nearby. PM1 remains higher than background levels even after the cigarette has been extinguished or the device has been used; indoor environments (where smoking is banned) are not fully protected from the contamination produced outside near doors and/or windows.

Indeed, some studies have shown that levels of exposure to second-hand smoke in outdoor areas can reach values similar to indoor concentration levels [4,5].

The National Bioethics Committee (CNB), an advisory body to the Prime Minister’s Office, has also urged the Government and Parliament to extend the smoking ban to outdoor places such as bars and restaurants, public gardens, entertainment venues, beaches, stadiums and sports grounds (all places often frequented by children and pregnant women), in order to avoid exposure to second-hand smoke and prevent serious harm.

The CNB has in fact pointed out that tobacco smoke is the main cause of avoidable death, for which too little has yet been done, since over eight million people die each year worldwide from smoking, including 1.2 million non-smokers due to passive smoking.

So, the proposal for “a law to create new smoke-free spaces and protect the health and freedom of citizens, also outdoors” is to be welcomed. This proposal was the focus of the press conference held in Rome on 10 December 2021 in the Nassirya Room of the Senate of the Republic. It was organised by Ideal - Organization for Digital Politics Association, and was attended by the Italian Society of Tabaccology (SITAB), the National Cancer Institute and the Umberto Veronesi Foundation.

This bipartisan bill, presented by Senator Giuseppe Auddino and signed by over 60 senators, was supported not only by Senators Eugenio Comincini, Mariolina Castellone and Anna Maria Bernini, but also by the Health Deputy Minister Pierpaolo Sileri and by the President of the Health Commission Annamaria Parente, who said they are determined to start the approval process of the law as soon as possible.

This bill consists of a single article with two letters to amend the Sirchia Law. In particular, the first letter concerns the extension of the smoking ban to crowded outdoor areas (appurtenances of the institutions of the educational and training system; external appurtenances of hospitals; external areas of restaurants, bars and other commercial establishments used for the administration and consumption of food and beverages; free beaches and bathing establishments; parks and playgrounds; public monuments of historical and artistic value; stadiums, arenas, sports facilities; other public places open to the public for events or shows; train waiting platforms and bus stops). The second letter states that the smoking ban also applies to heated tobacco products and electronic cigarettes. This is an important legislative proposal to increase the well-being and the health for all (including the environment) and to make existing bans effective, such as the ban on smoking in stadiums, issued in 2012 by the Ministry of the Interior to protect fans and staff from second-hand smoke, but which was never enforced due to the lack of a law that could sanction violations, as UEFA has repeatedly stressed.

Hoping that the political commitment made will actually materialise, a thought comes to mind: why create new smoke-free spaces when it would be more correct to create spaces for smokers? In other words, would it not be more logical, in light of scientific evidence, for people not to smoke anywhere outdoors except in designated smoking areas?

As will happen in Milan from 2025 and as already happens in airport areas, for example in London where smoking areas are marked by purple signs and fenced off, or in Japan. In the Japanese cities of Tokyo, Kyoto and Osaka, for example, you can only smoke in smoking zones, roadside locations equipped with ashtrays and dividing panels. They resemble our bus stops, and when crowded, you line up to smoke, taking your turn (Figure 2).

The Japanese respect the ban on smoking and only a few tourists infringe it and pay the fine (8 to 15 euros). You can’t walk down the street with a lit cigarette, you can only smoke under shelters where young and old, managers and workers meet at the same time.

And beware, the ban on smoking in the Japanese streets was enacted not only for health reasons, but also for environmental protection (cigarettes pollute the air, butts pollute the environment, ashes make it dirty), and safety (hands and arms moving with a lit cigarette can burn something or someone, especially children).

Why should Italy be content with just extending bans to certain outdoor areas?

Given that so many years have passed, and no changes have been made to the Sirchia Law, Italy as a country could now make a new and great leap forward by enacting legislation to allow smoking only in pre-defined places dedicated to smokers, as has already been done in some major cities around the world!

Figures and tables

Figure 1.Dehors tables in Milan before the ban on outdoor smoking (Municipal regulation on air quality).

Figure 2.Smoking area in Tokyo, Japan.

References

1. Ruprecht AA, De Marco C, Pozzi P, Mazza R, Munarini E, Di Paco A. Outdoor second-hand cigarette smoke significantly affects air quality. Eur Respir J. 2016; 48:918-20. DOI
2. Ott WR, Acevedo-Bolton V, Cheng KC, Jiang RT, Klepeis NE, Hildemann LM. Outdoor fine and ultrafine particle measurements at six bus stops with smoking on two California arterial highways-results of a pilot study. J Air Waste Manag Assoc. 2014; 64:47-60. DOI
3. Cammalleri V, Marotta D, Protano C, Vitali M, Villari P, Cattaruzza MS, on behalf of the Smoke-Free Department Working Group. How do combustion and non-combustion products used outdoors affect outdoor and indoor particulate matter levels? A field evaluation near the entrance of an Italian university library. Int J Environ Res Public Health. 2020; 17:5200. DOI
4. California Air Resources Board (CARB). Proposed identification of environmental tobacco smoke as a toxic air contaminant. 2005. Publisher Full Text
5. Sureda X, Fernández E, López MJ, Nebot M. Secondhand tobacco smoke exposure in open and semi-open settings: a systematic review. Environ Health Perspect. 2013; 121:766-73. DOI