Environmental Research 200 (2021) 111355 Contents lists available at ScienceDirect Environmental Research journal homepage: www.elsevier.com/locate/envres Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries Elisabet Henderson a, b, c, Xavier Continente a, c, d, Esteve Fernández e, f, g, h, Olena Tigova e, f, g, h, Nuria Cortés-Francisco a, d, Silvano Gallus i, Alessandra Lugo i, Sean Semple j, Ruaraidh Dobson j, Luke Clancy k, Sheila Keogan k, Ario Ruprecht l, Alessandro Borgini l, Anna Tzortzi m, Vergina K. Vyzikidou m, Giuseppe Gorini n, Angel López-Nicolás o, Joan B. Soriano h, p, q, r, Gergana Geshanova s, Joseph Osman t, Ute Mons u, v, Krzysztof Przewozniak w, x, y, José Precioso z, Ramona Brad aa, Maria J. López a, b, c, d, *, the TackSHS project Investigators1 a Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain b Universitat Pompeu Fabra, Departament de Ciències Experimentals i de la Salut (DCEXS), Doctor Aiguader, 88, 08003, Barcelona, Spain c Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 282029, Madrid, Spain d Sant Pau Institute of Biomedical Research (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain e Institut Català d’Oncologia, Av. Granvia de l’Hospitalet 199-203, 08908, L’Hospitalet de Llobregat, Spain f Institut d’Investigació Biomèdica de Bellvitge, Av. Granvia de l’Hospitalet 199, 08908, L’Hospitalet de Llobregat, Spain g Universitat de Barcelona, Feixa Llarga, S/n, 08907, L’Hospitalet de Llobregat, Spain h Consortium for Biomedical Research in Respiratory Diseases (CIBERES), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 282029, Madrid, Spain i Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Department of Environmental Health Sciences, Via Mario Negri 2, 20156, Milan, Italy j Institute for Social Marketing and Health, University of Stirling, Stirling FK9 4LA, Scotland, UK k TobaccoFree Research Institute Ireland, Dublin, Ireland l Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy m George D. Behrakis Research Lab, Hellenic Cancer Society, 17B Ipitou Str., Athens, 10557, Greece n Istituto per lo Studio, la Prevenzione e la Rete Oncologica (ISPRO), Via Cosimo Il Vecchio, 2, 50139, Florence, Italy o Universidad Politécnica de Cartagena (UPCT), Plaza Cronista Isidoro Valverde, S/n, 30202, Cartagena, Spain p Hospital Universitario La Princesa (IISP), Diego de León, 62, Planta 6, 28006, Madrid, Spain q Universidad Autónoma de Madrid (UAM), Ciudad Universitaria de Cantoblanco, 28049, Madrid, Spain r Instituto Carlos III (ISCIII), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 282029, Madrid, Spain s Smoke-free Life Coalition, Slivnitsa Blvd, 257, 1202, Sofia, Bulgaria t OFT Conseil, Office Français de Santé et Bien-être Au Travail, Rue Gobert, 12, 75011Paris, France u Cancer Prevention Unit & WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Im Neuenheimer Feld, 280, 69120, Heidelberg, Germany v Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50923, Cologne, Germany w Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena, 5, 02-781, Warsaw, Poland x The Foundation Smart Health - Health in 3D, Warsaw, Poland y Collegium Civitas, 1 Defilad Square, 00-901, Warsaw, Poland z Instituto de Educação, Universidade do Minho, 4710-057, Braga, Portugal aa Healthy Romania Generation 2035 Association, Bucharest, Romania A R T I C L E I N F O A B S T R A C T Keywords: Objective: Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in Tobacco-smoke pollution outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in out­ Airborne nicotine door hospitality venues across Europe and identify contextual exposure determinants. Smoke-free policies Methods: Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, Outdoor cafeterias, and pubs from 11 European countries in 2017–2018. Sites were selected considering area-level so­ Hospitality venue cioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of * Corresponding author. Servei d’Avaluació i Mètodes d’Intervenció (SAMI), Agència de Salut Pública de Barcelona (ASPB). Pl. Lesseps, 1. 08023, Barcelona, Spain. E-mail address: mjlopez@aspb.cat (M.J. López). 1 Full list of investigators in the Acknowledgements section. https://doi.org/10.1016/j.envres.2021.111355 Received 10 February 2021; Received in revised form 20 April 2021; Accepted 17 May 2021 Available online 19 May 2021 0013-9351/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). E. Henderson et al. Environmental Research 200 (2021) 111355 smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017–2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants. Results: Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30–3.74) μg/m3 and increased during nighttime (1.45 IQR:0.65–4.79 μg/m3), in enclosed venues (2.97 IQR:0.80–5.80 μg/m3), in venues with more than two smokers (2.79 IQR:1.03–6.30 μg/m3), in venues in countries with total indoor smoking bans (1.20 IQR:0.47–4.85 μg/m3), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49–5.34 μg/m3). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues’ degree of enclosure. Conclusions: Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues. 1. Introduction settings also demonstrated that SHS concentrations can be high and increase with the degree of enclosure, smoker density, and the number Tobacco use releases carcinogens, toxic agents, and pollutants con­ of active cigarettes (Stafford et al., 2010; Licht et al., 2013; Fu et al., tained in the smoke into the environment (WHO, 2017). Secondhand 2016; Sureda et al., 2013, 2018). Furthermore, biomarkers of SHS smoke (SHS) is a prevalent environmental risk factor and a known cause exposure (i.e. salivary cotinine and urinary NNAL (4-(methylni­ of lung cancer, cardiovascular and respiratory disease in non-smokers trosamino)-1-(3-pyridyl)-1-butanol)) were significantly higher in (U.S. Department of Health and Human Services, 2006). The World non-smokers after visiting outdoor hospitality areas when compared to Health Organization state only complete smoke-free environments fully visiting open-air sites free of smokers (St.Helen et al., 2012). Thus, SHS protect non-smokers from the harms of SHS exposures (WHO, 2007). exposure continues to be a significant health hazard in hospitality Indoor smoking bans in hospitality venues have helped reduce SHS venues, and total outdoor smoking bans should be adopted especially to exposure (Mulcahy et al., 2005; López et al., 2013) and improve the protect those who are occupationally exposed. respiratory health of hospitality workers (Fernández et al., 2009). Still, Some countries in Europe have restricted smoking according to the some studies have questioned if indoor bans alone are sufficient to number of physical structures delimiting each site. Greece, Ireland, entirely prevent SHS exposure inside hospitality venues, and advocate Romania, Spain, and the UK outlawed smoking in venues that are for the extension of smoke-free policies to the outdoor areas of such covered and have more than two sidewalls. In France, smoking is not establishments (Mulcahy et al., 2005; Edwards and Wilson, 2011; López permitted in covered venues where the main side or façade is closed. et al., 2012, 2013). Based on the assessment of airborne nicotine and However, while current restrictions rely on the premise that there are PM2.5 concentrations, these studies show SHS levels to be higher inside low SHS levels in outdoor spaces (Kennedy et al., 2010) available evi­ hospitality venues with outdoor smoking occurring, indicating tobacco dence shows SHS exposure outdoors can substantially increase with just smoke can migrate from outdoor settings to nearby indoor areas (Mul­ the presence of overhead covers (Cameron et al., 2010; Licht et al., 2013; cahy et al., 2005; Edwards and Wilson, 2011; López et al., 2012, 2013). Fu et al., 2016). Besides, there are other issues with these types of partial Also, Fu et al. (2016) simultaneously measured SHS levels inside and in bans. In general, the law is ambiguous in defining what should be the outside entrances of cafés and restaurants finding concentrations in considered an open space and there is often low compliance in these both spaces to be directly related. settings, particularly in cold seasons (Sureda et al., 2018). The de­ An unintended consequence of legislation to prevent smoking inside terminants of exposure to SHS in outdoor areas of hospitality venues are hospitality venues has been the relocation of tobacco consumption to unclear but may include factors such as area-level socioeconomic status, outdoor areas, also leading to a proliferation of outdoor smoking shelters season, time of the day, and number of smokers. In this study, we aimed in these settings post-ban. For instance, reported smoking outdoors to describe SHS concentrations and evidence of tobacco use in outdoor increased from 33.6% to 75.9% at cafés, bars, or pubs and from 28.9% to hospitality venues across Europe, and assess the association with 59.0% at restaurants after the French ban on smoking in the hospitality different contextual exposure determinants. sector (Kennedy et al., 2012). In the city of Barcelona, outside areas in bars and restaurants were the most common outdoor places for smokers 2. Methods to smoke following comprehensive legislation for all indoor public places (Sureda et al., 2015). Moreover, hospitality venue surroundings 2.1. Study design in the city of Madrid were the outdoor areas with the highest visibility of smokers (Valiente et al., 2020). Given that outdoor hospitality settings This study is part of the TackSHS project, developed to comprehen­ are usually on the street and visible for pedestrians, regulations sively explore the extent and impact of SHS and electronic cigarette restricting indoor smoking may have also enhanced the visibility of emissions in Europe (Fernández et al., 2020). In this cross-sectional smoking (Kennedy et al., 2010). Smoking visibility in public places is a study conducted between March 2017 and April 2018, we objectively drawback for tobacco use denormalization and has been associated with assessed SHS exposure concentrations at outdoor terraces in hospitality positive beliefs towards smoking among European adolescents (Lager­ venues that were located in large urban areas from 11 European coun­ weij et al., 2019). tries: Bulgaria, France, Germany, Greece, Ireland, Italy, Poland, With tobacco use moving to the outside sections of hospitality es­ Portugal, Romania, Spain, and the United Kingdom (UK). In each of the tablishments, SHS exposure in outdoor settings has gained more atten­ countries, we used a convenience sampling strategy to identify 20 tion. A study in eight European countries found airborne nicotine levels different sites, taking a total of 220 outdoor environmental measure­ to be significantly higher in outdoor areas of hospitality venues with ments. Venues were selected considering the neighborhoods’ socioeco­ indoor smoking restrictions, compared to those without such measures nomic status (SES), which we determined through different (López et al., 2012). The outdoor SHS levels reported in this study were socioeconomic indicators (Henderson et al., 2020a). Half the measure­ considerably higher than those found in households with residential ments were performed in more deprived neighborhoods, below the 20th smokers that allowed smoking inside (Arechavala et al., 2018). Other percentile of the SES distribution, and half in wealthier neighborhoods, research further characterizing SHS exposure at outdoor hospitality above the 80th percentile of the SES distribution. In this study, we also 2 E. Henderson et al. Environmental Research 200 (2021) 111355 intended to explore differences in SHS exposure by time of the day. Site 2.4. Contextual variables visits were arranged so that half the measurements were carried out during day hours and the other half during night hours, preferably after Contextual data were extracted from multiple sources. We grouped dinner hours. Each country specified daytime and nighttime hours and terraces into three different levels of enclosure (no roof + 0–4 walls, roof all visits were unannounced and carried out covertly to avoid bias. + 0–2 walls, roof + 3–4 walls) using the information compiled during Moreover, fieldwork was planned to avoid months with more extreme the fieldwork on the structures delimiting each site. Categories were set temperatures: no measurements were taken in any country December to after reviewing the national smoke-free policies for outdoor hospitality February and only in Bulgaria, Poland, and the UK some measurements venues during 2017–2018. Except for France, jurisdictions with regu­ were taken during July or August. Eligibility for inclusion was restricted lations allowed smoking in sites with no overhead covers, or with to the outdoor areas of bars, cafeterias, or pubs that had at least one overhead covers and up to a maximum of two sidewalls (Supplementary sidewall or overhead cover. We monitored SHS concentrations only Table 1). We further categorized sites combining data on outdoor when five or more customers (adults and/or children) were present. smoke-free regulations and the degree of enclosure. We defined three Researchers in charge of the fieldwork were previously trained and categories: venues in the highest level of enclosure (roof + 3–4 walls) equipped with a sampling protocol for additional guidance. were divided according to whether smoking was banned (regulated terraces and terraces in France with four sidewalls) or allowed (terraces 2.2. Nicotine measurements with no regulation and terraces in France with three sidewalls); a third category included all other terraces since smoking was permitted We measured vapor-phase nicotine, a tobacco-specific constituent, as regardless of the existence of national smoking regulations for outdoor an indicator for SHS exposure. Nicotine samples were collected on a 37- hospitality venues. Given the possible relocation of smoking behaviors mm diameter polystyrene cassette holding a filter coated with sodium towards the outdoor areas of hospitality venues with total indoor bisulfate. The sampling methodology we followed had been validated smoking bans, we also checked for the national indoor smoke-free prior to this study (Hammond et al., 1987). We carried nicotine samplers legislation in the hospitality sector. Germany, Italy, Poland, and connected to air pumps (Sidekick, SKC Ltd., Dorset, UK). Air pumps were Portugal allowed smoking rooms if certain standards are met, but the calibrated before and after the fieldwork, allowing us to keep track of the other seven countries had total smoking bans for the indoor areas volume of air actively filtered. We set the flow rate at 3 l/min with (Supplementary Table 1). We used the Tobacco Control Scale 2016 Defender 510 M (Mesa Labs, Lakewood, CO, USA) calibrator. Air sam­ overall score (Joossens and Raw, 2016), which is a 100-point scale pling lasted up to approximately 30 min at each venue. Researchers sat measuring six tobacco control policies, to differentiate countries by their at any available table on the outdoor terrace throughout the whole tobacco control activity. Following the 2016 edition report, we classified sampling period. Nicotine samples were identified with a unique code countries with scores above or equal to 50 points in one group and paired to a form filled in during each measurement. Once the mea­ countries below 50 points in another, as done in previous studies surements ended, filters were stored and sent to the Agència de Salut (Henderson et al., 2020a, 2020b, 2021). Finally, we acquired data on the Pública de Barcelona laboratory together with blank filters. The labo­ country’s smoking prevalence from a European survey conducted as part ratory determined nicotine concentrations using gas of the TackSHS project in a representative sample aged 15 years and chromatography-mass spectrometry. In each batch, the blank filter, a older in 2017–2018 (Fernández et al., 2020; Gallus et al., 2021). The negative sample (solvent), and a fortified sample served as quality respondents were smokers if they reported smoking at the time of the control. We calculated the time-weighted average nicotine concentra­ survey and had smoked at least 100 cigarettes, including roll-your-own tion (μg/m3) dividing the mass of nicotine extracted from the filter by cigarettes. We generated two categories with the median smoking the volume of air filtered (flow rate multiplied by the duration the prevalence (31%) as the cut-off point. sampler was exposed). The laboratory had a limit of quantification (LOQ) of 0.06 μg/m3. Concentrations were dichotomized into pre­ 2.5. Statistical analyses sence/absence of nicotine using this LOQ as the cut-off point. Nicotine samples below the laboratory’s LOQ were given half this value in the statistical analyses. Concentration values were not normally 2.3. Observational data distributed. For this reason, we provide medians and their correspond­ ing interquartile ranges (IQR). We applied U-Mann Whitney or Kruskal Concurrently to monitoring nicotine levels, researchers screened for Wallis test to compare median nicotine concentrations across countries evidence of tobacco use within the outdoor areas of each hospitality and contextual variables. We report raw frequencies and percentages to venue: the smell of tobacco smoke (as subjectively assessed by the describe tobacco-related observational data, which we compared with researcher), visual evidence of people smoking, presence of cigarette the Chi-squared test. We plotted nicotine concentrations according to butts, ashtrays or similar receptacles. Data were recorded in a specific the degree of enclosure and stratifying by the number of smokers. We form at three measurement points: at the start, half-way through the also fitted a multiple regression model to analyze the relationship be­ visit (approximately 15 min), and at the end. In the analyses, there was a tween observational and contextual variables, and nicotine levels in the smell of smoke and people were smoking if applicable in at least one of outdoor areas of hospitality venues. Because of the skewed distribution, the three-time points. We also calculated the average number of smokers we used the log-transformed concentrations. The final model was tested observed in each venue in the three-time points. Subsequently, we used for normality of errors, homoscedasticity, absence of outliers, multi­ the median value of smokers (1.6 smokers) to classify venues into two collinearity, and self-correlation. The level of statistical significance was categories: those with two or fewer smokers and those with more than set at 5%. All analyses were performed with the statistical package two smokers. We considered there were cigarette butts when researchers STATA 15. noticed that one or more cigarette butts had been discarded, including those lying on the adjoining pavement and in ashtrays. The form was also used to note other relevant information: date and time of sampling, type of venue, number of sidewalls, and presence of overhead covers. 3 E. Henderson et al. Environmental Research 200 (2021) 111355 Table 1 Airborne nicotine concentration (μg/m3) and tobacco-related signs in outdoor terraces of hospitality venues by country (2017–2018). Country N Nicotine concentration (μg/m3) Nicotine presence Smell of smoke People smoking Cigarette butts Ashtrays Median (μg/m3) (IQR) % (n) % (n) % (n) % (n) % (n) Overall 220 0.85 (0.30–3.74) 93.6 (206) 82.3 (181) 92.3 (203) 74.6 (164) 87.7 (193) Bulgaria 20 0.66 (0.37–4.21) 95.0 (19) 90.0 (18) 100.0 (20) 75.0 (15) 100.0 (20) France 20 2.16 (0.64–5.05) 100.0 (20) 100.0 (20) 100.0 (20) 70.0 (14) 80.0 (16) Germany 20 0.38 (0.24–1.00) 90.0 (18) 65.0 (13) 80.0 (16) 80.0 (16) 85.0 (17) Greece 20 2.29 (1.13–3.66) 100.0 (20) 80.0 (16) 100.0 (20) 20.0 (4) 95.0 (19) Ireland 20 2.55 (0.53–6.43) 95.0 (19) 95.0 (19) 100.0 (20) 90.0 (18) 95.0 (19) Italy 20 1.36 (0.88–3.10) 95.0 (19) 90.0 (18) 100.0 (20) 100.0 (20) 90.0 (18) Poland 20 0.13 (<0.06–0.36) 70.0 (14) 70.0 (14) 70.0 (14) 65.0 (13) 80.0 (16) Portugal 20 0.31 (0.17–3.46) 95.0 (19) 90.0 (18) 95.0 (19) 80.0 (16) 80.0 (16) Romania 20 3.12 (0.88–6.69) 100.0 (20) 95.0 (19) 95.0 (19) 60.0 (12) 100.0 (20) Spain 20 0.87 (0.49–5.16) 100.0 (20) 95.0 (19) 100.0 (20) 100.0 (20) 85.0 (17) UK 20 0.25 (0.08–0.47) 90.0 (18) 35.0 (7) 75.0 (15) 80.0 (16) 75.0 (15) p-value 0.0001a 0.005b <0.0001b <0.0001b <0.0001b 0.161b Note: IQR, Interquartile Range. Limit of Quantification (LOQ): 0.06 μg/m3. a Kruskal-Wallis test. b Chi-squared test. 2.6. Ethical issues and 3 to 4 walls. Moreover, all the sites visited where smoking was already banned had people smoking (Table 3). The TackSHS project was approved by the Clinical Research Ethics According to multiple linear regression analysis, nicotine concen­ Committee of the Bellvitge University Hospital (PR341/15) and this trations at terraces significantly increased during nighttime hours β = study was approved by each country’s local Ethics Committees. The 0.49 (95%CI: 0.10–0.88), when more than two smokers were present β study protocol was registered in ClinicalTrials.gov (ID: NCT03150186). = 1.37 (95%CI: 0.98–1.77), with discarded cigarette butts β = 0.56 (95%CI: 0.09–1.02), with the highest level of enclosure (roof and 3 to 4 3. Results walls) β = 0.74 (95%CI: 0.15–1.33), in countries with indoor smoking bans β = 0.61 (95%CI: 0.14–1.08), and in countries with higher smoking Overall, SHS was present in 93.6% of the 220 venues and the median prevalence β = 0.63 (95%CI: 0.16–1.10) (Table 4). nicotine concentration was 0.85 μg/m3 (IQR: 0.30–3.74 μg/m3). Romania (3.12 μg/m3 IQR: 0.88–6.69 μg/m3), Ireland (2.55 μg/m3 IQR: 4. Discussion 0.53–6.43 μg/m3), Greece (2.29 μg/m3 IQR: 1.13–3.66 μg/m3), and France (2.16 μg/m3 IQR: 0.64–5.05 μg/m3) had the highest median This study shows concentrations of airborne nicotine, a marker of nicotine concentrations. We identified people smoking in more than SHS, in terraces or outdoor areas of hospitality premises in 11 European 90% of the terraces, with smokers being present at all the sites visited in countries. SHS was present in more than 90% of the outdoor areas, Bulgaria, France, Greece, Ireland, Italy, and Spain. There was smell of demonstrating exposure to SHS among non-smokers in Europe is likely tobacco smoke at around 80% of the outdoor establishments. Three- to occur in this type of setting. We found higher levels of exposure quarters of the terraces had discarded cigarette butts and at almost during nighttime, in sites with overhead covers and 3 to 4 sidewalls, nine out of ten venues ashtrays or similar receptacles were observed with more than two smokers, and with discarded cigarette butts. Also, (Table 1). there were higher concentrations of SHS in outdoor areas in countries We found significantly higher median nicotine concentrations in with total smoking bans inside hospitality venues, and among countries venues visited during nighttime hours (1.45 μg/m3 IQR: 0.56–4.79 μg/ with higher national smoking prevalence. Our findings also revealed m3), in those with two or more smokers (2.79 μg/m3 IQR: 1.03–6.30 μg/ that when more than two smokers were present SHS levels remained m3), in countries with total indoor smoking bans (1.20 μg/m3 IQR: high irrespective of the venues’ degree of enclosure, indicating current 0.47–4.85 μg/m3), and in countries with higher smoking prevalence smoke-free regulations based on the number of physical covers do not (1.32 μg/m3 IQR: 0.49–5.34 μg/m3). Compared to venues with lower provide adequate protection to customers and hospitality workers. levels of enclosure, median concentrations were significantly increased The results point to increased exposure levels during night hours. in terraces with overhead covers and 3 to 4 walls (2.97 μg/m3 IQR: This outcome is consistent with one study in Europe finding higher 0.80–5.80 μg/m3). Moreover, median concentrations were higher in outdoor nicotine concentrations in bars at night (López et al., 2012), and terraces with overhead covers and 3 to 4 walls where smoking was with two studies in New Zealand reporting higher smoking visibility in allowed (3.49 μg/m3 IQR: 1.19–6.46 μg/m3) in contrast to terraces with outside hospitality areas in the evenings (Chan et al., 2014; Pearson the same degree of enclosure but where smoking was banned (2.11 μg/ et al., 2014). In our study, however, we did not find differences in the m3 IQR: 0.58–5.62 μg/m3). Terraces with lower degrees of enclosure presence of smokers between daytime and nighttime hours. A possible where smoking was also allowed had the lowest concentrations (0.71 explanation for the finding of higher nicotine concentrations at night μg/m3 IQR: 0.25–2.67 μg/m3) (Table 2). could be a different patronage according to the time of the day. The In Fig. 1 we show median nicotine concentrations according to the purpose of smokers going to hospitality venues during nighttime might level of enclosure and stratifying by the number of smokers. In those be more related to leisure activities and, perhaps, higher levels of to­ terraces with 2 or less smokers, SHS concentrations significantly bacco consumption (Chan et al., 2014). This argument would be in line increased with the venues’ degree of enclosure (p < 0.05). In turn, when with our result on venues having more discarded cigarette butts at later more than 2 smokers were present median concentrations slightly hours. Even so, this indicator could also reflect the cigarettes smoked increased but did not significantly differ between levels of enclosure. over the whole day period or be the result of a cleaning effect, with We more often noticed people smoking in outdoor areas of venues cigarette butts being swept up once per day at the end of the shift or at with total indoor smoking bans, and smell of tobacco smoke and people the start of each day. Since health inspections are more likely performed smoking in countries with higher smoking prevalence (p < 0.05). Both during regular office hours, differences in exposure by time of the day these tobacco-related signs were also more common in venues with roofs could also be explained by a lower adherence to smoking restrictions at 4 E. Henderson et al. Environmental Research 200 (2021) 111355 Table 2 Airborne nicotine concentration (μg/m3) in outdoor terraces of hospitality venues by area-level socioeconomic status, time of the day, terrace degree of enclosure, smoke-free regulations, Tobacco Control Scale overall score, and national smoking prevalence (2017–2018). Contextual factors N Median (μg/m3) (IQR) p-valuea Min (μg/m3) Max (μg/m3) Overall 220 0.85 (0.30–3.74) <0.06 77.40 SES High 107 0.74 (0.23–2.85) <0.06 20.50 Low 113 1.00 (0.35–4.34) 0.133 <0.06 77.40 Time of the day Daytime 115 0.50 (0.19–2.57) <0.06 77.40 Nighttime 105 1.45 (0.56–4.79) 0.0001 <0.06 68.07 Number of smokers b ≤2 smokers 130 0.49 (0.16–1.13) <0.06 77.40 >2 smokers 90 2.79 (1.03–6.30) <0.0001 0.117 68.07 Degree of enclosure No roof and 0–4 walls 63 0.47 (0.14–2.32) <0.06 68.07 Roof and 0–2 walls 113 0.76 (0.29–3.69) 0.001 <0.06 77.40 Roof and 3–4 walls 44 2.97 (0.80–5.80) <0.06 31.64 Regulation site Roof and 3–4 walls banned 23 2.11 (0.58–5.62) <0.06 12.71 Roof and 3–4 walls allowed 21 3.49 (1.19–6.46) 0.001 <0.06 31.64 Others allowed 176 0.71 (0.25–2.67) <0.06 77.40 Indoor total smoking ban No 80 0.49 (0.15–2.25) <0.06 77.40 Yes 140 1.20 (0.47–4.85) 0.0003 <0.06 54.50 TCS overall scorec ≥50 points 160 0.84 (0.25–3.74) <0.06 77.40 <50 points 60 0.90 (0.37–3.32) 0.449 <0.06 68.07 Smoking prevalence (2017–18) d <31% 100 0.53 (0.12–2.15) <0.06 68.07 ≥31% 120 1.32 (0.49–5.34) <0.0001 <0.06 77.40 Note: SES, socioeconomic status; TCS, Tobacco Control Scale. a Mann-Whitney U test or Kruskal Wallis test. b Average number of smokers in the three-time periods categorized using the median value of 1.6 smokers. c TCS overall score: ≥50 (France, Italy, Ireland, Poland, Portugal, Romania, Spain, UK); <50 (Bulgaria, Germany, Greece). d Based on a European survey conducted in the TackSHS project. Smoking prevalence (median): <31% (Germany, Ireland, Italy, Poland, UK); ≥31% (Bulgaria, France, Greece, Portugal, Romania, Spain). Fig. 1. Nicotine distribution and median concentrations (μg/m3) in outdoor areas of hospitality venues according to the degree of enclosure and stratifying by the average number of smokers present in the observation. N = 220. TackSHS project 2017–2018. Note: For layout purposes, nicotine distribution is represented in a logarithmic scale. Values correspond to median nicotine concentrations in each category. a Kruskal-Wallis test. 5 E. Henderson et al. Environmental Research 200 (2021) 111355 Table 3 Tobacco-related variables in outdoor terraces of hospitality venues by area-level socioeconomic status, time of the day, terrace degree of enclosure, smoke-free regulations, Tobacco Control Scale overall score, and national smoking prevalence (2017–2018). Contextual factors N Smell of smoke People smoking Cigarette butts Ashtrays % (n) % (n) % (n) % (n) Overall 82.3 (181) 92.3 (203) 74.6 (164) 87.7 (193) SES High 107 80.4 (86) 90.7 (97) 70.1 (75) 89.7 (96) Low 113 84.1 (95) 93.8 (106) 78.8 (89) 85.8 (97) p-valuea 0.473 0.382 0.140 0.381 Time of the day Daytime 115 80.9 (93) 89.6 (103) 67.0 (77) 86.1 (99) Nighttime 105 83.8 (88) 95.2 (100) 82.9 (87) 89.5 (94) p-valuea 0.568 0.116 0.007 0.438 Degree of enclosure No roof and 0–4 walls 63 71.4 (45) 84.1 (53) 65.1 (41) 82.5 (52) Roof and 0–2 walls 113 85.0 (96) 93.8 (106) 74.3 (84) 89.4 (101) Roof and 3–4 walls 44 90.9 (40) 100.0 (44) 88.6 (39) 90.9 (40) p-valuea 0.019 0.007 0.023 0.321 Regulation site Roof and 3–4 walls banned 23 91.3 (21) 100.0 (23) 82.6 (19) 87.0 (20) Roof and 3–4 walls allowed 21 90.5 (19) 100.0 (21) 95.2 (20) 95.2 (20) Others allowed 176 80.1 (141) 90.3 (159) 71.0 (125) 86.9 (153) p-valuea 0.244 0.100 0.035 0.544 Indoor total smoking ban No 80 78.8 (63) 86.3 (69) 81.3 (65) 83.8 (67) Yes 140 84.3 (118) 95.7 (134) 70.7 (99) 90.0 (126) p-valuea 0.301 0.011 0.084 0.174 TCS overall scoreb ≥50 points 160 83.8 (134) 91.9 (147) 80.6 (129) 85.6 (137) <50 points 60 78.3 (47) 93.3 (56) 58.3 (35) 93.3 (56) p-valuea 0.349 0.718 0.001 0.121 National smoking prevalence (2017–18)c <31% 100 71.0 (71) 85.0 (85) 83.0 (83) 85.0 (85) ≥31% 120 91.7 (110) 98.3 (118) 67.5 (81) 90.0 (108) p-valuea <0.0001 <0.0001 0.009 0.260 Note: SES, socioeconomic status; TCS, Tobacco Control Scale. a Chi-squared test. b TCS overall score: ≥50 (France, Italy, Ireland, Poland, Portugal, Romania, Spain, UK); <50 (Bulgaria, Germany, Greece). c Based on a European survey conducted in the TackSHS project. Smoking prevalence (median): <31% (Germany, Ireland, Italy, Poland, UK); ≥31% (Bulgaria, France, Greece, Portugal, Romania, Spain). Table 4 Multivariable analyses of log-transformed nicotine concentrations in outdoor terraces of hospitality venues in 11 European countries (2017–2018). Bivariate model Multivariate model β (95% CI) p-value β (95% CI) p-value R2adj 0.3498 Constant − 2.46 (− 3.09, − 1.84) <0.0001 SES (ref. high) 0.38 (− 0.09, 0.84) 0.115 0.38 (− 0.01, 0.77) 0.058 Time of the day (ref. daytime) 0.86 (0.40, 1.31) <0.0001 0.49 (0.10, 0.88) 0.015 Number of smokers (ref. 2 or less smokers) 1.63 (1.21, 2.06) <0.0001 1.37 (0.98, 1.77) <0.0001 Presence of butts (ref. no presence of butts) 0.70 (0.17, 1.23) 0.010 0.56 (0.09, 1.02) 0.019 Degree of enclosure (ref. no roof and 0–4 walls) No roof and 0–2 walls 0.47 (− 0.06, 1.01) 0.082 0.24 (− 0.26, 0.74) 0.352 Roof and 3–4 walls 1.21 (0.55, 1.88) <0.0001 0.74 (0.15, 1.33) 0.015 Indoor total smoking ban (ref. no) 0.89 (0.42, 1.37) <0.0001 0.61 (0.14, 1.08) 0.011 National smoking prevalence (ref. <31%) 1.07 (0.62, 1.52) <0.0001 0.63 (0.16, 1.10) 0.009 Note: ref, reference; CI, Confidence Interval; SES, socioeconomic status. night (Peruga et al., 2020). with the smoking restrictions for outdoor hospitality areas. As expected, Nicotine concentrations substantially increased with the venue’s among the sites with the greatest level of enclosure SHS exposure was degree of enclosure of the outdoor space. Sites with overhead covers and highest in countries where smoking outdoors was permitted. Yet, to our a minimum of three sidewalls had more than twice the median con­ surprise, terraces where smoking was already banned had high con­ centrations than less enclosed venues. Earlier studies assessing SHS centrations which were comparable to the levels found in some coun­ exposure with airborne markers have reported similar results (Cameron tries before smoking was banned in indoor hospitality premises (Lopez et al., 2010; Stafford et al., 2010; Licht et al., 2013; Fu et al., 2016; et al., 2008). This generalized non-compliance was confirmed by the Sureda et al., 2018). One study even noted that the presence of overhead observed presence of smokers in all the venues we visited. Enforcement covers in outdoor hospitality premises raised average exposure levels by and compliance might be challenging based on ambiguous regulatory virtually 50% (Cameron et al., 2010). In the present analyses, we further frameworks. In the included European countries, current smoke-free evaluated SHS exposure levels combining the conditions of enclosure policies for outdoor hospitality venues leave some room for 6 E. Henderson et al. Environmental Research 200 (2021) 111355 interpretation. While smoking is banned in enclosed places (generally, Despite the continuing obligation under Article 8 of the WHO FCTC areas with overhead covers and more than two walls), the laws do not and Article 8 Guidelines to prohibit smoking in outdoor or quasi-outdoor provide a formal definition of what should be considered a sidewall or places with proof of a possible health hazard, the absence of a an overhead cover. Physical coverings might be movable, partial or comprehensive approach to smoking bans for hospitality venues is a complete structures, might have openings or windows, might be made of common trait of all countries in the study. The protracted resistance to very different materials, and might be placed at different heights. Un­ smoke-free laws in these settings contrasts with the compelling evidence clear regulations result in legal loopholes and confusion in the policy’s supporting the fact that this type of interventions not only curtail interpretation. Adopting complete smoking bans in all outdoor hospi­ tobacco-related health and economic costs (Hahn, 2010) but also do not tality areas would certainly remedy both these issues. adversely affect the hospitality industry (World Health Organization Although accumulating evidence supports the notion of higher SHS Regional Office for Europe, 2019). exposure levels in more enclosed areas (Cameron et al., 2010; Stafford Some limitations to this research should be acknowledged. We et al., 2010; Licht et al., 2013; Fu et al., 2016; Sureda et al., 2018), this selected the outdoor venues following a convenience sampling study demonstrates smoke-free policies should not depend on the degree approach. Therefore, we cannot extrapolate our results to other terraces of enclosure to limit smoking behaviors in outdoor hospitality settings. in the same city or country. The nature of our sample, however, does not In our analyses, when more than two people were smoking at the venue, hinder the study’s objective of evaluating SHS concentrations in outdoor SHS concentrations scaled-up and did not significantly vary across the hospitality venues considering different exposure determinants. Second, different stages of enclosure defined in current regulations. These results we gathered SHS information on a limited number of 20 sites per might imply that the smoking restrictions adopted in several European country. Consequently, data have been analyzed grouping the sample of countries have a limited protective effect and reinforce the need for total venues according to contextual factors. Finally, our exposure assessment outdoor smoking bans. Previous literature has shown that even brief SHS represents short 30-min measurements of airborne nicotine concentra­ exposures could impair several biological mechanisms leading to tions on one occasion in each venue. Earlier studies report higher detrimental health effects on non-smokers (Flouris et al., 2010). smoking visibility in hospitality areas during weekends (Pearson et al., Therefore, despite smoking being restricted, SHS exposure levels might 2014). Since fieldwork was performed mostly on weekdays and SHS still represent a threat to health, especially in the case of vulnerable levels are likely greater at the end of the week, the SHS exposure in populations attending hospitality venues (Keogan et al., 2020), and for outdoor hospitality venues might have been underestimated. those who are exposed on a regular basis, such as hospitality workers. Despite the above limitations, this study includes the SHS exposure Outdoor hospitality venues in Romania, Ireland, Greece, and France assessment in hospitality venues distributed across 11 European coun­ had very high nicotine concentrations. Overall exposure levels in these tries with different cultural, geographical, economic, and tobacco con­ countries were similar to those reported in the indoor areas of 82 cafe­ trol contexts. For the environmental monitoring, we used airborne terias and restaurants in 10 European cities (Lopez et al., 2008). By the nicotine which is an objective and specific marker of SHS (Apelberg time this study took place, these countries, as well as Spain and the UK, et al., 2013). Moreover, all countries shared a common protocol had enacted total indoor smoking bans for the hospitality sector. As designed in accordance with a previously validated methodology suggested in earlier research, indoor smoke-free policies in hospitality (Hammond et al., 1987). Finally, the present analyses yield new insights venues seem to have displaced tobacco use, and thus, potential SHS regarding the main factors contributing to SHS concentrations on a set of exposures to adjacent outdoor areas (Kennedy et al., 2010; López et al., highly frequented outdoor venues. 2012; van Beek et al., 2019). Our study also showed significantly higher SHS levels and presence of smokers in the outdoor areas of venues 5. Conclusion covered by indoor smoke-free policies. Consequently, we provide further proof that indoor smoke-free policies in hospitality venues SHS exposure is still a relevant health hazard in outdoor hospitality should be accompanied by total outdoor smoking bans to be truly venues across Europe. Our results show that smoking restrictions which effective measures. draw on the degree of enclosure to forbid smoking are limited effective Unlike other outdoor settings, where nicotine concentrations were means to protect non-smokers. This study demonstrates there is a public lower in countries with higher scores in the TCS (Henderson et al., health rationale behind totally banning smoking in the outdoor areas of 2020a, 2020b, 2021), this study focusing on outdoor hospitality areas hospitality venues. Moreover, considering the social component of the did not find differences in SHS exposure levels according to the coun­ tobacco pandemic, a potential co-benefit of strong smoke-free policies in tries’ TCS total score in 2016. This discrepancy between different types outdoor hospitality areas could be the denormalization of tobacco use in of outdoor spaces might be explained by the fact that outdoor hospitality settings that are popular for smokers. premises are, apart from popular places for smoking, one of the only spaces where, under most circumstances, smoking is currently allowed Funding across all of the countries studied. We observed disparities in the SHS exposure levels by national This project has received funding from the European Union’s Hori­ smoking prevalence. In agreement with what has been found in other zon 2020 research and innovation program under grant agreement No outdoor areas (Henderson et al., 2020a, 2020b, 2021), and the indoor 681040. The work of SG was partially supported by the Italian League spaces of bars and restaurants (Filippidis et al., 2016), SHS exposure Against Cancer (LILT, Milan). EF is partly supported by Ministry of levels were higher in venues located in countries with greater national Universities and Research, Government of Catalonia (2017SGR319) and smoking prevalence. Countries with higher smoking prevalence also had by the Instituto Carlos III and co-funded by the European Regional a significantly higher presence of visual (smokers) and olfactory (smell Development Fund (FEDER) (INT16/00211 and INT17/00103), Gov­ of tobacco smoke) smoking stimuli at terraces. Outdoor hospitality areas ernment of Spain. are social venues commonly patronized by young people, and where smoking, as evidenced in bars, night clubs, and gaming venues, could be Credit author statement socially cued (Trotter et al., 2002). In this sense, smoke-free policies targeting outdoor hospitality premises might be particularly relevant to Elisabet Henderson: Formal analysis, Writing – original draft, Visu­ advance the denormalization of smoking, as well as reducing opportu­ alization. Xavier Continente: Conceptualization, Investigation, Valida­ nities to smoke, and help smokers with quit attempts (Chaiton et al., tion, Writing – review & editing. Esteve Fernández: Investigation, 2016; Satterlund et al., 2012). Writing – review & editing. Olena Tigova: Investigation, Writing – re­ view & editing. Nuria Cortés-Francisco: Investigation, Writing – review 7 E. Henderson et al. Environmental Research 200 (2021) 111355 & editing. Silvano Gallus: Investigation, Writing – review & editing. Appendix A. Supplementary data Alessandra Lugo: Investigation, Writing – review & editing. Sean Semple: Investigation, Writing – review & editing. Ruaraidh Dobson: Supplementary data to this article can be found online at https://doi. Investigation, Writing – review & editing. Luke Clancy: Investigation, org/10.1016/j.envres.2021.111355. Writing – review & editing. Sheila Keogan: Investigation, Writing – re­ view & editing. Ario Ruprecht: Investigation, Writing – review & edit­ References ing. Alessandro Borgini: Investigation, Writing – review & editing. Anna Tzortzi: Investigation, Writing – review & editing. Vergina K Vyzikidou: Apelberg, B.J., Hepp, L.M., Avila-Tang, E., Gundel, L., Hammond, S.K., Hovell, M.F., Hyland, A., Klepeis, N.E., Madsen, C.C., Navas-Acien, A., Repace, J., Samet, J.M., Investigation, Writing – review & editing. Giuseppe Gorini: Investiga­ Breysse, P.N., 2013. Environmental monitoring of secondhand smoke exposure. Tob. tion, Writing – review & editing. Angel López-Nicolás: Investigation, Control 22, 147–155. https://doi.org/10.1136/tobaccocontrol-2011-050301. Writing – review & editing. Joan B Soriano: Investigation, Writing – Arechavala, T., Continente, X., Pérez-Ríos, M., Schiaffino, A., Fernandez, E., Cortés- Francisco, N., Centrich, F., Muñoz, G., López, M.J., 2018. Second-hand smoke review & editing. Gergana Geshanova: Investigation, Writing – review & exposure in homes with children: assessment of airborne nicotine in the living room editing. Joseph Osman: Investigation, Writing – review & editing. Ute and children’s bedroom. Tob. Control 27, 399–406. https://doi.org/10.1136/ Mons: Investigation, Writing – review & editing. Krzysztof Przewozniak: tobaccocontrol-2017-053751. Cameron, M., Brennan, E., Durkin, S., Borland, R., Travers, M.J., Hyland, A., Spittal, M. Investigation, Writing – review & editing. José Precioso: Investigation, J., Wakefield, M.A., 2010. Secondhand smoke exposure (PM2.5) in outdoor dining Writing – review & editing. Ramona Brad: Investigation, Writing – re­ areas and its correlates. Tob. Control 19, 19–23. https://doi.org/10.1136/ view & editing. Maria J. López: Conceptualization, Investigation, tc.2009.030544. Chaiton, M., Diemert, L., Zhang, B., Kennedy, R.D., Cohen, J.E., Bondy, S.J., Ferrence, R., Writing – review & editing, Project administration, Funding acquisition. 2016. Exposure to smoking on patios and quitting: a population representative longitudinal cohort study. Tob. Control 25, 83–88. https://doi.org/10.1136/ Disclaimer tobaccocontrol-2014-051761. Chan, J., Burnett, T., Baillie, R., Blomfield, S., Cameron-Christie, P., Dickson, J., Fleishl, W., Ghandi, S., Gordon, K., Heo, J., Kesy, A., Kao, A.Y., Kenny, C., Knight, A., This paper reflects only the authors’ views and the European Com­ Wilson, N., Thomson, G., 2014. Smoking in outdoor areas of bars and cafés: large mission is not responsible for any use that may be made of the infor­ differences between midday and evening prevalences. Drugs: Educ. Prev. Policy 21, mation it contains. 484–488. https://doi.org/10.3109/09687637.2014.917273. Edwards, R., Wilson, N., 2011. Smoking outdoors at pubs and bars: is it a problem? An air quality study. N. Z.Med. J. 124, 27–37. Declaration of competing interest Fernández, E., Fu, M., Pascual, J.A., López, M.J., Pérez-Ríos, M., Schiaffino, A., Martínez- Sánchez, J.M., Ariza, C., Saltó, E., Nebot, M., Spanish Smoking Law Evaluation Group, 2009. Impact of the Spanish smoking law on exposure to second-hand smoke The authors declare that they have no known competing financial and respiratory health in hospitality workers: a cohort study. PloS One 4, e4244. interests or personal relationships that could have appeared to influence https://doi.org/10.1371/journal.pone.0004244. Fernández, E., López, M.J., Gallus, S., Semple, S., Clancy, L., Behrakis, P., Ruprecht, A., the work reported in this paper. Gorini, G., López-Nicolás, Á., Radu-Loghin, C., Soriano, J.B., TackSHS Project Investigators, 2020. Tackling second-hand exposure to tobacco smoke and aerosols Acknowledgements of electronic cigarettes: the TackSHS project protocol. Gac. Sanit. 34, 77–82. https:// doi.org/10.1016/j.gaceta.2019.07.002. 1 Filippidis, F.T., Agaku, I.T., Girvalaki, C., Jiménez-Ruiz, C., Ward, B., Gratziou, C., The TackSHS Project Investigators: Vardavas, C.I., Tobacco Control Committee of the European Respiratory Society, Catalan Institute of Oncology (ICO); Bellvitge Biomedical Research 2016. Relationship of secondhand smoke exposure with sociodemographic factors Institute (IDIBELL), Spain: Esteve Fernández, Yolanda Castellano, Mar­ and smoke-free legislation in the European Union. Eur. J. Public Health 26, 344–349. https://doi.org/10.1093/eurpub/ckv204. cela Fu, Montse Ballbè, Beladenta Amalia, Olena Tigova. Flouris, A.D., Vardavas, C.I., Metsios, G.S., Tsatsakis, A.M., Koutedakis, Y., 2010. Public Health Agency of Barcelona (ASPB), Spain: Maria José López, Biological evidence for the acute health effects of secondhand smoke exposure. Am. Xavier Continente, Teresa Arechavala, Elisabet Henderson. J. Physiol. Lung Cell Mol. Physiol. 298, L3–L12. https://doi.org/10.1152/ ajplung.00215.2009. Istituto di Ricerche Farmacologiche Mario Negri IRCCS (IRFMN), Fu, M., Fernández, E., Martínez-Sánchez, J.M., San Emeterio, N., Quirós, N., Sureda, X., Italy: Silvano Gallus, Alessandra Lugo, Xiaoqiu Liu, Elisa Borroni. Ballbè, M., Muñoz, G., Riccobene, A., Centrich, F., Saltó, E., López, M.J., 2016. Istituto DOXA, Worldwide Independent Network/Gallup Interna­ Second-hand smoke exposure in indoor and outdoor areas of cafés and restaurants: need for extending smoking regulation outdoors? Environ. Res. 148, 421–428. tional Association, Italy: Paolo Colombo. https://doi.org/10.1016/j.envres.2016.04.024. University of Stirling (UNISTIR), the UK: Sean Semple, Rachel Gallus, S., Lugo, A., Liu, X., Behrakis, P., Boffi, R., Bosetti, C., Carreras, G., Chatenoud, L., O’Donnell, Ruaraidh Dobson. Clancy, L., Continente, X., Dobson, R., Effertz, T., Filippidis, F.T., Fu, M., Geshanova, G., Gorini, G., Keogan, S., Ivanov, H., Lopez, M.J., Lopez-Nicolas, A., TobaccoFree Research Institute Ireland (TFRI), Ireland: Luke Clancy, Precioso, J., Przewozniak, K., Radu-Loghin, C., Ruprecht, A., Semple, S., Soriano, J. Sheila Keogan, Hannah Byrne. B., Starchenko, P., Trapero-Bertran, M., Tigova, O., Tzortzi, A.S., Vardavas, C., Hellenic Cancer Society - George D. Behrakis Research Lab (HCS), Vyzikidou, V.K., Colombo, P., Fernández, E., TackSHS Project Investigators, 2021. Greece: Panagiotis Behrakis, Anna Tzortzi, Constantine Vardavas, Ver­ Who smokes in Europe? Data from 12 European countries in the TackSHS survey (2017-2018). J. Epidemiol. 31, 145–151. https://doi.org/10.2188/jea.JE20190344. gina Konstantina Vyzikidou, Gerasimos Bakelas, George Mattiampa. Hahn, E.J., 2010. Smokefree legislation: a review of health and economic outcomes Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Italy: Rob­ research. Am. J. Prev. Med. 39 (6 Suppl. 1), S66–S76. https://doi.org/10.1016/j. erto Boffi, Ario Ruprecht, Cinzia De Marco, Alessandro Borgini, Chiara amepre.2010.08.013. Hammond, S.K., Leaderer, B.P., Roche, A.C., Schenker, M., 1987. Collection and analysis Veronese, Martina Bertoldi, Andrea Tittarelli. of nicotine as a marker for environmental tobacco smoke. Atmos. Environ. 21, Istituto per lo Studio, la Prevenzione, e la Rete Oncologica (ISPRO), 457–462. https://doi.org/10.1016/0004-6981(87)90027-8. Italy: Giuseppe Gorini, Giulia Carreras, Barbara Cortini, Simona Verdi, Henderson, E., Continente, X., Fernández, E., Tigova, O., Cortés-Francisco, N., Gallus, S., Lugo, A., Semple, S., O’Donnell, R., Clancy, L., Keogan, S., Ruprecht, A., Borgini, A., Alessio Lachi, Elisabetta Chellini. Tzortzi, A., Vyzikidou, V.K., Gorini, G., López-Nicolás, A., Soriano, J.B., Polytechnic University of Cartagena (UPCT), Spain: Ángel López Geshanova, G., Osman, J., Mons, U., Przewozniak, K., Precioso, J., Brad, R., Nicolás, Marta Trapero-Bertran, Daniel Celdrán Guerrero. López, M.J., TackSHS project Investigators, 2020a. Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European Network on Smoking and Tobacco Prevention (ENSP), European countries. Sci. Total Environ. 743, 140743. https://doi.org/10.1016/j. Belgium: Cornel Radu-Loghin, Dominick Nguyen, Polina Starchenko. scitotenv.2020.140743. Hospital Universitario La Princesa (IISP), Spain: Joan B Soriano, Henderson, E., Continente, X., Fernández, E., Tigova, O., Cortés-Francisco, N., Gallus, S., Lugo, A., Semple, S., O’Donnell, R., Clancy, L., Keogan, S., Ruprecht, A., Borgini, A., Julio Ancochea, Tamara Alonso, María Teresa Pastor, Marta Erro, Ana Tzortzi, A., Vyzikidou, V.K., Gorini, G., López-Nicolás, A., Soriano, J.B., Roca, Patricia Pérez, Elena García Castillo. Geshanova, G., Osman, J., Mons, U., Przewozniak, K., Precioso, J., Brad, R., López, M.J., TackSHS project investigators., 2020b. Secondhand smoke exposure in outdoor children’s playgrounds in 11 European countries. Environ Int Nov 20, 105775. https://doi.org/10.1016/j.envint.2020.105775. 8 E. Henderson et al. Environmental Research 200 (2021) 111355 Henderson, E., Lugo, A., Liu, X., Continente, X., Fernández, E., López, M.J., Gallus, S., Pearson, A.L., Nutsford, D., Thomson, G., 2014. Measuring visual exposure to smoking TackSHS project investigators., 2021 May 19. Corrigendum to “Secondhand smoke behaviours: a viewshed analysis of smoking at outdoor bars and cafés across a capital presence in outdoor areas in 12 European countries” [Environ. Res. 195 (2021) city’s downtown area. BMC Public Health 14, 300. https://doi.org/10.1186/1471- 110806]. Environ Res. 199, 111337. https://doi.org/10.1016/j. 2458-14-300. envres.2021.111337. Epub ahead of print. Erratum for: Environ Res. 2021 Apr; 195: Peruga, A., Molina, X., Delgado, I., Matute, I., Olea, A., Hirmas, M., González, C., 110806. Aguilera, X., 2020. Compliance with the smoking ban in enclosed, semiopen and Joossens, L., Raw, M., 2016. The Tobacco Control Scale 2016 in Europe. https://www. open areas of workplaces and public places in Chile. Tob Control Jul 23. https://doi. tobaccocontrolscale.org/TCS2016.pdf. org/10.1136/tobaccocontrol-2020-055632 tobaccocontrol-2020-055632. Kennedy, R.D., Behm, I., Craig, L., Thompson, M.E., Fong, G.T., Guignard, R., Beck, F., Satterlund, T.D., Lee, J.P., Moore, R.S., 2012. Changes in smoking-related norms in bars 2012. Outdoor smoking behaviour and support for outdoor smoking restrictions resulting from California’s Smoke-Free Workplace Act. J. Drug Educ. 42, 315–326. before and after France’s national smoking ban. Eur. J. Public Health 22 (Suppl. 1), https://doi.org/10.2190/DE.42.3.d. 29–34. https://doi.org/10.1093/eurpub/ckr208. Stafford, J., Daube, M., Franklin, P., 2010. Second hand smoke in alfresco areas. Health Kennedy, R.D., Elton-Marshall, T., Mutti, S., Dubray, J., Fong, G.T., 2010. Understanding Promot. J. Aust. 21, 99–105. https://doi.org/10.1071/he10099. the impact of the Smoke-Free Ontario Act on hospitality establishments’ outdoor St.Helen, G., Bernert, J.T., Hall, D.B., Sosnoff, C.S., Xia, Y., Balmes, J.R., Vena, J.E., environments: a survey of restaurants and bars. Tob. Control 19, 165–167. https:// Wang, J.S., Holland, N.T., Naeher, L.P., 2012. Exposure to secondhand smoke doi.org/10.1136/tc.2009.031872. outside of a bar and a restaurant and tobacco exposure biomarkers in nonsmokers. Keogan, S., Alonso, T., Sunday, S., Tigova, O., Fernández, E., López, M.J., Gallus, S., Environ. Health Perspect. 120, 1010–1016. https://doi.org/10.1289/ehp.1104413. Semple, S., Tzortzi, A., Boffi, R., Gorini, G., López-Nicolás, Á., Radu-Loghin, C., Sureda, X., Bilal, U., Fernández, E., Valiente, R., Escobar, F.J., Navas-Acien, A., Soriano, J.B., Clancy, L., the TackSHS Project Investigators, 2020. Lung function Franco, M., 2018. Second-hand smoke exposure in outdoor hospitality venues: changes in patients with chronic obstructive pulmonary disease (COPD) and asthma smoking visibility and assessment of airborne markers. Environ. Res. 165, 220–227. exposed to secondhand smoke in outdoor areas. J. Asthma 22, 1–7. https://doi.org/ https://doi.org/10.1016/j.envres.2018.04.024. 10.1080/02770903.2020.1766062. Sureda, X., Fernández, E., López, M.J., Nebot, M., 2013. Secondhand tobacco smoke Lagerweij, N.A., Kuipers, M.A.G., Schreuders, M., Grard, A., Mlinarić, M., Richter, M., exposure in open and semi-open settings: a systematic review. Environ. Health Leão, T., Kinnunen, J.M., Kunst, A.E., 2019. The visibility of smoking in Europe and Perspect. 121, 766–773. https://doi.org/10.1289/ehp.1205806. its relationship with youth’s positive beliefs about smoking. Int. J. Public Health 64, Sureda, X., Fernández, E., Martínez-Sánchez, J.M., Fu, M., López, M.J., Martínez, C., 1335–1344. https://doi.org/10.1007/s00038-019-01288-z. Saltó, E., 2015. Secondhand smoke in outdoor settings: smokers’ consumption, non- Licht, A.S., Hyland, A., Travers, M.J., Chapman, S., 2013. Secondhand smoke exposure smokers’ perceptions, and attitudes towards smoke-free legislation in Spain. BMJ levels in outdoor hospitality venues: a qualitative and quantitative review of the Open 5, e007554. https://doi.org/10.1136/bmjopen-2014-007554. research literature. Tob. Control 22, 172–179. https://doi.org/10.1136/ Trotter, L., Wakefield, M., Borland, R., 2002. Socially cued smoking in bars, nightclubs, tobaccocontrol-2012-050493. and gaming venues: a case for introducing smoke-free policies. Tob. Control 11, López, M.J., Fernández, E., Gorini, G., Moshammer, H., Polanska, K., Clancy, L., 300–304. https://doi.org/10.1136/tc.11.4.300. Dautzenberg, B., Delrieu, A., Invernizzi, G., Muñoz, G., Precioso, J., Ruprecht, A., U.S. Department of Health and Human Services, 2006. The Health Consequences of Stansty, P., Hanke, W., Nebot, M., 2012. Exposure to secondhand smoke in terraces Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. and other outdoor areas of hospitality venues in eight European countries. PloS One Coordinating Center for Health Promotion, National Center for Chronic Disease 7, e42130. https://doi.org/10.1371/journal.pone.0042130. Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA. López, M.J., Fernández, E., Pérez-Rios, M., Martínez-Sánchez, J.M., Schiaffino, A., https://www.ncbi.nlm.nih.gov/books/NBK44324/pdf/Bookshelf_NBK44324.pdf. Galán, I., Moncada, A., Fu, M., Montes, A., Saltó, E., Nebot, M., 2013. Impact of the Valiente, R., Escobar, F., Pearce, J., Bilal, U., Franco, M., Sureda, X., 2020. Mapping the 2011 Spanish smoking ban in hospitality venues: indoor secondhand smoke exposure visibility of smokers across a large capital city. Environ. Res. 180, 108888. https:// and influence of outdoor smoking. Nicotine Tob. Res. 15, 992–996. https://doi.org/ doi.org/10.1016/j.envres.2019.108888. 10.1093/ntr/nts218. van Beek, K.N.J., Kuipers, M.A.G., Lignac, O., Kunst, A.E., 2019. Smoking in bars in eight Lopez, M.J., Nebot, M., Albertini, M., Birkui, P., Centrich, F., Chudzikova, M., European countries in 2010 and 2016: an observational comparative study. Eur. J. Georgouli, M., Gorini, G., Moshammer, H., Mulcahy, M., Pilali, M., Serrahima, E., Public Health 29, 159–163. https://doi.org/10.1093/eurpub/cky111. Tutka, P., Fernandez, E., 2008. Secondhand smoke exposure in hospitality venues in World Health Organization, 2007. Media center. News releases 2007. https://www.who. Europe. Environ. Health Perspect. 116, 1469–1472. https://doi.org/10.1289/ int/mediacentre/news/releases/2007/pr26/en/. ehp.11374. World Health Organization, 2017. Tobacco and its Environmental Impact: an overview. Mulcahy, M., Evans, D.S., Hammond, S.K., Repace, J.L., Byrne, M., 2005. Secondhand https://www.who.int/tobacco/publications/environmental-impact-overview/en/. smoke exposure and risk following the Irish smoking ban: an assessment of salivary World Health Organization Regional Office for Europe, 2019. Tobacco Control Playbook. cotinine concentrations in hotel workers and air nicotine levels in bars. Tob. Control https://www.euro.who.int/__data/assets/pdf_file/0011/395687/Tobacco-Control-Pl 14, 384–388. https://doi.org/10.1136/tc.2005.011635. aybook-final.pdf. 9