Study of the impact of laws regulating tobacco
consumption on the prevalence of passive
smoking in Spain
Carlos A. Jime ´nez-Ruiz1, Juan Antonio Riesco Miranda2, Richard D. Hurt3,
Angela Ramos Pinedo4, Segismundo Solano Reina5, Francisco Carrio ´n Valero6
Background: In 2005, the Spanish parliament passed the Spanish anti-smoking law. This legislation
restricted tobacco smoking in public places, including recreation venues (bars and restaurants), but
smoking was not completely prohibited in bars and restaurants. The law was enforced in January 2006.
With the objective of analysing the impact that this law has had on the general Spanish population, the
Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) designed and implemented a survey of a
representative sample of the general Spanish population on two separate occasions: in 2005 and in 2007
(12 months after the ban came into effect). Methods: Two epidemiological, observational and cross-
sectional surveys were performed among a random and representative sample of the general Spanish
population, using the Computer-Assisted Telephone Interview system. Results: In the first survey, a total
of 6533 subjects were interviewed, of whom 3907 (59.8%) were non-smokers and in the second, a total
of 3289 subjects were interviewed, of whom 2174 (65.9%) were non-smokers. The overall prevalence of
exposure to environmental tobacco smoke (ETS) decreased from 49.5% in 2005 to 37.9% in 2007 (22%
reduction). The greatest reduction in prevalence of ETS exposure was in workplaces (from 25.8% to
11%, a decrease of 58.8%). Smaller reductions occurred in the home (from 29.5% to 21.4%, a decrease
of 27%) and in recreation venues (from 37.4% to 31.8%, a decrease of 8%). Conclusions:
Implementation of the smoking ban resulted in a significant decrease in exposure to ETS.
Keywords: anti-smoking regulations, evaluation
cause of preventable death in Spain. Although specific data
are not available, it is estimated that passive smoking may be
responsible for around 3000–3500 deaths per year in Spain.1
Passive smoking causes fatal diseases, including lung cancer,
ischaemic heart disease and sudden infant death syndrome.2–4
Different health-related and non-health-related measures
have demonstrated efficacy in protecting the health of non-
smokers from environmental tobacco smoke (ETS).5The
methods shown to be most effective are banning smoking in
public places and restricting tobacco use in the workplace and
recreational venues, such as bars and restaurants.5–8
The Spanish government has ratified the World Health
Organization Framework Convention on Tobacco Control
(FCTC). This treaty stipulates that countries must take legal
action to address tobacco consumption in public places and to
protect non-smokers from ETS.
In December 2005, the Spanish parliament passed legislation
supporting the establishment of health measures to control
consumption of tobacco (law 28/2005). The principal
component of this new legislation was a total ban on tobacco
consumption in health centres, educational institutions and
assive smoking has been identified as the third leading
workplaces. It also restricted tobacco smoking in recreation
venues (bars and restaurants), but smoking was not completely
banned in these places. The law stipulated that bars and
restaurants with a surface area of 100m2or less could choose
either to become smoke-free or to allow smoking. Larger bars
and restaurants (>100m2) were required to provide separate,
designated smoking and non-smoking sections. The legislation
did not consider changes in the pricing of tobacco products.
The law came into effect in January 2006.
To analyse the impact that the new law has had on the
Pulmonology and Thoracic Surgery (SEPAR) designed and
implemented a survey in a representative sample of the general
Spanish population. The survey was carried out on two
separate occasions: in 2005, before the passing and imple-
mentation of the law, and in 2007, 12 months after the ban
came into effect. This paper presents data demonstrating the
impact the law has had on changes in the prevalence of passive
smoking in Spain.
Two epidemiological, observational and cross-sectional surveys
were conducted among a random and representative sample of
the general Spanish population using the Computer-Assisted
Telephone Interview (CATI) system. The validity of this
method of study has been documented in various Spanish
epidemiological studies.9The field work for the first survey was
undertaken in February of 2005, before the announcement of
the forthcoming law regulating smoking. The second survey
was conducted in January 2007, 12 months after implementa-
tion of the smoking ban.
Through a procedure of random, stratified sampling [using
quotas for gender groups (male/female), age (<13; 13–40;
Correspondence: Carlos A. Jime ´nez-Ruiz, C/Santa Cruz del
Marcenado, 9, Madrid 28015, Spain, tel: +34 91 20529 60, fax: +34 91
204 49 72, e-mail: firstname.lastname@example.org; email@example.com
1 Unidad Especializada en Tabaquismo, Sub-direccion General de
Prevencio ´n y Promocio ´n de la Salud, Madrid, Spain
2 Servicio de Neumologı ´a, Hospital Clinico, Barcelona, Spain
3 Nicotine Dependence Centre, Mayo Clinic College of Medicine,
Rochester MN, USA
4 Servicio de Neumologı ´a, Hospital Fundacio ´n de Alcorcon,
5 Servicio de Neumologı ´a, Hospital Gregorio Maran ˜o ´n, Madrid, Spain
6 Servicio de Neumologı ´a, Hospital Clinico, Valencia, Spain
European Journal of Public Health, Vol. 18, No. 6, 622–625
? The Author 2008. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckn066 Advance Access published on 2 August 2008
41–65 and >65 years), habitat (rural <5000; urban >5000),
based on data provided by the National Institute of Statistics in
2001 regarding the composition of the Spanish population],
6800 questionnaires were completed during February 2005.
Following the same procedure, 3298 questionnaires were
completed during January 2007. With this sample size, the
accuracy of the estimation of the percentage of people who
know about the impact of passive smoking (assuming
maximum variability of 50%) at a national level is 1.2%.
Data were collected by surveyors who specialize in the
application of the CATI system and were trained in conducting
surveys in an electronic format. The incorporation of
responses into the database was performed using automated
filters and logic-based sorting routines in order to eliminate
inconsistent responses. Of the 6800 surveys performed in
February 2005, 6533 were valid after being filtered through the
database. Of the 3298 surveys performed in January 2007, 3298
were valid after being filtered through the database.
Descriptive analysis of the information was completed by
skilled personnel, using the SAS version 9.1.3 Service Pack 4
(site 0085630001) statistical programme.
Results are presented from the group of non-smokers in both
surveys. In the first survey, a total of 6533 subjects were
interviewed, of whom 3907 (59.8%) were non-smokers and in
the second,, a total of 3289 subjects were interviewed, of whom
2174 (65.9%) were non-smokers.
Socio-demographic characteristics of
The socio-demographic characteristics of non-smokers in the
2005 survey revealed that more females were non-smokers
than males, 57 vs. 43% (P<0.0001). Also, there were fewer
non-smokers in the middle age ranges, between 13 and 65
years (62.2%), than in the groups aged below 13 years (99%)
and above 65 years (77%) (P<0.0001). The percentage of non-
smokers among the urban population (84%) was higher than
that among the rural population (16%) (P=0.0049). These
characteristics did not change in the 2007 survey.
Exposure of non-smokers to ETS at home
Of the 3907 non-smoking subjects who completed the survey
in 2005, 1153 (29.5%) lived in homes where at least one
smoker resided. Of the 2174 non-smoking subjects who
completed the survey in 2007, 466 (21.4%) were exposed to
ETS at home (table 1). Given the timing of the surveys, it may
be concluded that this reduction of 27% is due in part to the
impact of the law. However, the rate of exposure to ETS was
higher among non-smokers younger than 13 years, but did not
appear to change after the law came into effect (40.9% in 2005
vs. 39.2% in 2007).
Exposure of non-smokers to ETS in schools
The data were analysed for the 1161 subjects in 2005 who
were non-smokers and enrolled in school (29.7% of the
survey sample). Of these, 207 (17.8%) recalled some degree of
exposure to ETS in school. This figure was reduced by nearly
50%, to 8.8% (46/521 non-smoking, school-enrolled survey
subjects) in 2007 (table 1).
This reduction of 49.8% in exposure to ETS may also, in
part, be due to the impact of the smoking ban.
Exposure of non-smokers to ETS in the workplace
In 2005, 337 (25.8%) of the 1308 non-smoking, employed
survey subjects were exposed to ETS in the workplace.
However, in 2007, only 73 (11%) of the 727 non-smoking,
employed survey subjects were exposed to ETS (table 1).
According to these findings, the prevalence of passive
smoking in the workplace decreased by 58% between 2005 and
2007. This reduction may also, in part, be due to the impact of
the smoking ban.
Exposure of non-smokers to ETS in recreation
In 2005, 1461 (37.4%) of the 3907 non-smoking survey
subjects confirmed that they were exposed to tobacco smoke in
bars and restaurants (table 1). Exposure to ETS in these
locations was higher in males than females (40.4 vs. 35.1%;
P<0.0001) and in those younger than 13 years compared with
those older than 13 years (42.8 vs. 18.8%; P<0.0001), but
there was no significant difference as a function of habitat.
In 2007, 692 (31.8%) of the 2174 non-smoking survey subjects
responded that they were exposed to ETS in bars and
restaurants (table 1). No significant differences were found
with respect to gender or habitat. Passive smoking was
more prevalent among subjects in the middle age group
(79.2%) than among the elderly (8.8%) or children (12%)
According to these findings, the prevalence of passive
smoking in bars and restaurants decreased from 37.4% in 2005
to 31.9% in 2007. This reduction of 14.7% was probably, in
part, due to the impact of the smoking ban.
Overall exposure of non-smokers to ETS
In the 2005 survey, 49.5% of non-smokers were exposed
to ETS, whereas in 2007, this figure was reduced to 37.9%
(table 1). If the various environments in which one can be
subjected to ETS (at home, at school, in the workplace and in
recreation venues) are taken into account, 72.3% of those
exposed to ETS in 2005 were exposed in one single
environment, compared with 66.5% in 2007. In 2005, 24.9%
of subjects were exposed to ETS in two different environments
vs. 30.4% in 2007 and 2.8% were exposed to ETS in three
different environments in 2005 vs. 2.7% in 2007. In 2005 the
overall rate of exposure to ETS was greater among subjects
older than 13 years than among subjects younger than 13 years
(32.6 vs. 12.9%; P<0.0001). In 2007 there was no significant
difference between sexes (males 48.9 vs. females 51%) but the
differences among age groups remained the same. In neither
year were there any differences with regard to habitat.
These data show that the overall prevalence of exposure of
non-smokers to ETS decreased from 49.5% in 2005 to 37.9%
Table 1 Changes in exposure to ETS between 2005 (pre-law)
and 2007 (post-law)
to ETS (%)
to ETS (%)
N, Number of subjects surveyed.
Impact of smoking ban in Spain
in 2007, a reduction of 22%. This reduction may be
considered, in part, due to the impact of the law.
The principal finding of this study showed, for the first time in
Spain, that the overall prevalence of exposure to ETS decreased
from 49.5% in 2005 to 37.9% in 2007. Given the introduction
of the smoking ban in 2006, it may be considered that the 22%
reduction in ETS exposure was a result of implementation of
the law. As expected, because the law prohibits smoking in
schools, one of the greatest reductions in prevalence of ETS
exposure due to the law was found in schools (down from
29.7% in 2005 to 8.8% in 2007, a decrease of 49.8%). This is
important because it is known that one of the results of
eliminating smoking in workplaces is a reduction in smoking
initiation among young people. There is no better workplace
to start than in schools, where children spend much of their
Given the laxity of the law, a surprisingly large reduction in
ETS exposure was noted in workplaces (down from 25.8% in
2005 to 11% in 2007, a decrease of 58.8% because of the law).
Smaller reductions in ETS exposure occurred in the home
(down from 29.5% in 2005 to 21.4% in 2007, a decrease of
27%) and in bars and restaurants (down from 37.4% in 2005
to 31.8% in 2007, a decrease of 8%) as a result of the law.
Putting legislative measures to control smoking into action
in workplaces, schools, health centres and recreation venues
and on public transport has been shown to be an effective
mechanism for reducing the prevalence of passive smoking in
various communities.4–7The Spanish law aspires eventually to
achieve a total ban on smoking in many of these public spaces:
schools, health centres, public transport and workplaces.
However, the law only established a partial ban in recreation
venues (restaurants, bars and discos). The marked decrease in
prevalence of exposure to ETS in Spanish educational
institutions and workplaces between 2005 and 2007 is, without
a doubt, due to the impact of the law. In contrast, the decline
in exposure to ETS detected in recreation venues was not
significant, due to the permissiveness of the law towards
tobacco use in these spaces.
Presumably, if the law had been more comprehensive, the
results would have been even better. Nevertheless, we believe
that a decrease in the overall prevalence of exposure to ETS
from 49.5% before the law to 37.9% one year after imple-
mentation is positive and a reason for optimism. In Italy,
legislation prohibiting tobacco consumption in any public
place was implemented in 2005. A recent study performed in
Italy 1 year after implementation of the ban found that mean
concentrations of nicotine in samples of environmental air in
the middle of work places or recreation venues and restaurants
had decreased by 95% compared with samples obtained before
the smoking ban was introduced.10
The decrease in the prevalence of exposure to ETS in the
home from 29.5% to 21.4% in our study appears slight and
probably reflects low awareness among the Spanish population
regarding the health hazards associated with ETS. In addition,
another figure that should be noted is the prevalence of
exposure to ETS in the home among children younger than 13
years, which was 40.9% in the 2005 survey and was almost
unchanged (39.2%) in 2007.
The marked reduction in exposure to ETS in workplaces
that we observed may have important implications for Spanish
public health. In a recent study, Bartecchi et al.11found that a
public decree that reduced exposure to ETS was associated
with a decrease in hospitalisations due to acute myocardial
infarction in an isolated community 18 months after imple-
mentation of the decree (relative risk = 0.73, 95% confidence
interval 0.63–0.85). Another study found an important
reduction in admission rate for coronary heart disease after
the implementation of legislation banning smoking in work-
places and public places.12Following the implementation of
the smoking ban, the hospitalisation rate decreased by 39%
after 1 year and by 47% after 3 years.12Other studies have also
drawn similar conclusions.13,14Governments and healthcare
providers should therefore take note that one fairly simple and
inexpensive way of reducing myocardial infarction and other
hospital admissions for coronary heart disease is to implement
comprehensive smoking bans in workplaces and other public
Fong et al.15recently analysed the impact of the law regu-
lating tobacco consumption in Ireland by performing two
surveys, one before and one after implementation of the
smoking ban, in a group of smokers. The number of those
reported smoking in the workplace decreased from 62% before
the ban to 14% after the ban. Corresponding figures for pre-
ban vs. post-ban were 85 vs. 3% in restaurants and 98 vs. 5% in
bars and pubs. In addition, up to 83% of the smokers
questioned considered the law to be either ‘good’ or ‘very
Our figures are not as impressive as those in Ireland, but the
Irish ban was much more comprehensive than the Spanish
restrictions on smoking. In addition, the study designs were
different; our study interviewed non-smokers who explained
their perception of compliance with the law in different
settings, whereas Fong’s analysis focused on smokers who
explained their own behaviours in each of the settings studied.
Another important aspect of the study by Fong et al. is that
they found a decrease in the prevalence of tobacco consump-
tion in the home. In other words, although the Irish law did
not regulate tobacco consumption in the home, banning
smoking in public places led to a similar decrease in smoking
in the home. This did not occur in Spain and is probably a
result of the more comprehensive law in Ireland. Smokers tend
to rationalize their continued smoking just as alcoholics
rationalize their continued drinking, so it is easy to imagine
how smokers could misinterpret partial bans to mean: ‘If the
unhealthy they would implement a total ban’. A recent study
by Borland et al.16conducted in four countries (Australia,
Canada, United States and United Kingdom) found that once
a comprehensive smoking ban had been implemented in
restaurants and bars, support for and compliance with the ban
were high in all four countries. Another study compared levels
of indoor air pollution at different workplaces in 24
geographically diverse countries between November 2005 and
August 2006.17The study analysed PM2.5, which is the
concentration of particulate matter in the air smaller than
2.5mm in diameter. Particles of this size are released from
burning cigarettes and are associated with smoking-related
disorders. The study found that in Spain the mean concentra-
tion of PM2.5 was 215mg m?3, whereas in other countries with
more comprehensive anti-smoking regulations the concentra-
tions were lower: 29mgm?3in Ireland, 14mgm?3in New
Zealand and 66mg m?3in Canada.17
The two main weaknesses of our study are the lack of a
control group and that the data are based on non-smokers’
perceptions of tobacco smoking in the settings studied.
Without a control group we cannot be certain that the observed
changes in tobacco consumption were directly attributable to
the law. On the other hand, this was a large survey. However,
we do not provide objective data to evaluate exposure to
air contaminated with tobacco smoke. Another limitation
of our study is that it did not distinguish between smok-
ing in restaurants, bars or discos; our results presented
‘recreational venues’ as a single group. The cross-sectional
European Journal of Public Health
design of the study should also be considered as another Download full-text
In summary, we found reductions in exposure to ETS
in public places due to the impact of the law in Spain.
The greatest impact of the smoking ban was in workplaces and
schools, with a less notable impact in the home and recreation
Conflicts of interest: None declared.
? Anti-smoking laws are effective in reducing exposure
? It is essential to have a total ban on smoking in all
public places, otherwise anti-smoking laws lose
? Spanish anti-smoking laws did not help to diminish
exposure to ETS in recreational venues (bars and
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Received 21 January 2008, accepted 19 June 2008
Impact of smoking ban in Spain