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No smoking allowed. Mandatory and other strategies for tobacco control
  1. Manel Nebot
  1. Agency of Public Health of Barcelona, Pl Lesseps 1 Barcelona, Spain 08023;

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    Laws and regulations are essential to provide protection against involuntary smoking, as voluntary arrangements have proved to be insufficient.1 Despite the apparent consensus on this basic statement, many western countries are still lacking a systematic and coherent set of regulations on smoking in public places to reduce involuntary exposure to tobacco smoke. Furthermore, there are considerable differences between countries regarding the degree of acceptation and commitment to existing laws. Yet sometimes we seem to forget that regulations are never an end in themselves, but instruments at the service of strategic objectives. To be effective, laws have to be achievable, compliance (and violation) must be recognised, and when appropriate, there must be consequences for those who fail to keep the rules. Too often norms and regulations are seen as simple solutions to complex problems, often ending in large and complex legislative processes that, without education and enforcement, are meaningless.

    When regulations are designed to change behaviours like smoking, the role of education is crucial to bring awareness of the need for the change, to raise support, and to spread the new norms. Enforcement is also necessary, to detect and correct lack of compliance. Regulations to modify behaviours need to be widely and effectively communicated to the population, to the point that a reasonable majority understands their need and is ready to accept them. In the internet era, with an unprecedented saturation of information, it is not easy to spread health messages that are competing with so many other messages. Therefore, we must never forget that (health) education should be a key component of any health policy oriented to stimulate voluntary changes or to accept an involuntary restriction.

    Proactive enforcement is also needed for a successful policy implementation. This need is usually better perceived in the initial steps of legislative changes, or when the regulations deal with sensitive matters. Attitudes towards laws and regulations differ among societies and social groups. Some differences come from the tradition of democracy: societies with a longer history of democracy tend to accept more easily that public rules and laws are necessary, whereas those societies with a history of non-democratic governments are less prone to assume rules as they are seen as impositions. There are also cultural differences: in Europe, citizens of southern countries, where smoking in public places is more common, are more in favour of regulations and bans of smoking in public places,2 than citizens of northern countries. While this attitude reflects the perception of a true problem, it might also be reflecting a higher need for an “external” enforcement of the norm. In any case, enforcement of smoking restrictions has to be proportional to the enforcement of other regulations. We must assure that people do not smoke in places where it is not permitted, at least as strongly as we prosecute travelling without tickets on the underground or permitting the use of cell phones in the theatre. Only a balanced and proportionate enforcement will be well accepted and therefore contribute to progress.

    It has been argued that advertising bans stimulate the creative juices of cigarette marketers, thus redefining the nature of advertising and promotion.3 It seems clear that new and subtle forms of publicity will always be found, as long as there is economic revenue, even if this situation leads tobacco companies to an escalation of costs not paralleled by an increase in profits. In any case, the tobacco industry will always confront regulations trying to mobilise society under the flag of “individual rights” and “personal freedom”.

    Although, as health professionals, it is our duty to emphasise the failures and gaps regarding tobacco control, we can nevertheless emphasise that over the past 40 years there has been a progressive, though slow, advance regarding smoking in public places. After a first phase when prohibitions were based exclusively on safety (for example, gas stations and chemical industry), there came regulations oriented to protect the health of vulnerable groups, like children and the sick, currently in place in many countries. Now it is time to generalise successful—and healthy—experiences of total tobacco control in all indoor public places where people may be involuntarily exposed, and the workplace is the critical arena. However, the crucial point is to move ahead in a firm, progressive, and steady way. Recently there has been public debate over the idea of a total smoking ban.4 I personally believe that in a democratic context we must focus on regulating the use of addictive and harmful substances rather than banning them. The history of heroin over recent years and of alcohol under the Dry Law in the USA provides strong arguments. In the long run what we need is to implement progressive and firm regulations, to prove that they are feasible and effective, and that the costs and penalties invoked by tobacco lobbies (that is, economic loss, social conflicts) are not true. There are no shortcuts, but there is a way: let’s keep on it.


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