i An update to this article is included at the end Environmental Research 195 (2021) 110806 Contents lists available at ScienceDirect Environmental Research journal homepage: www.elsevier.com/locate/envres Secondhand smoke presence in outdoor areas in 12 European countries The TackSHS Project Investigators, Elisabet Henderson a, b, c, Alessandra Lugo d, Xiaoqiu Liu d, Xavier Continente a, b, e, Esteve Fernández f, g, h, i, Maria J. López a, b, c, e, *, Silvano Gallus d a Agència de Salut Pública de Barcelona, Barcelona, Spain b Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain c Departament de Ciències Experimentals i de la Salut (DCEXS), Universitat Pompeu Fabra, Barcelona, Spain d Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy e Sant Pau Institute of Biomedical Research (IIB Sant Pau), Barcelona, Spain f Tobacco Control Unit, Institut Català d’Oncologia, L’Hospitalet de Llobregat, Spain g Tobacco Control Research Group, Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Spain h School of Medicine and Health Sciences, Universitat de Barcelona, L’Hospitalet de Llobregat, Spain i Consortium for Biomedical Research in Respiratory Diseases (CIBERES), Madrid, Spain A R T I C L E I N F O A B S T R A C T Keywords: Introduction: Secondhand smoke (SHS) causes morbidity and mortality among non-smokers. Tobacco smoke pollution Objectives: To investigate SHS presence in outdoor areas from 12 European countries and its association with Environmental tobacco smoke country-level characteristics. Outdoor Methods: Cross-sectional study performed in 2017–2018 within the TackSHS project. We conducted a face-to-face Smoke-free policies Prevention survey on a representative sample of the population aged 15 years and older from 12 European countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain. Out of 11,902 participants, 8,562 were non-smokers. SHS presence was assessed in selected outdoor areas and defined as respondents viewing someone smoking the last time they visited each setting within the last 6 months. A ranking score for outdoor SHS presence was assigned to each country based on the SHS presence in each setting. We used Spearman’s correlation (r) and the Chi-squared tests to assess the relationship between SHS presence and country-level characteristics. Results: Except for children’s playgrounds (39.5%; 95% confidence interval, CI: 37.6%–41.3%), more than half of non-smokers reported SHS presence in outdoor areas: schools (52.0%; 95%CI: 50.2%–53.7%), stadia (57.4%; 95%CI: 55.4%–59.4%), parks (67.3%; 95%CI: 66.0%–68.5%), hospitals (67.3%; 95%CI: 65.8%–68.7%), public transport stops (69.9%; 95%CI: 68.6%–71.2%), bar/restaurant terraces (71.4%; 95%CI: 70.2%–72.6%), and beaches (72.8%; 95%CI: 71.4%–74.1%). Residents in Latvia showed the highest overall outdoor SHS presence rank, followed by Greece, and Portugal. Outdoor SHS presence was directly correlated to the country’s smoking prevalence (r = 0.64), and inversely correlated to the Tobacco Control Scale 2016 overall score (r = − 0.62), the socio-demographic index 2017 (r = − 0.56), and Gross Domestic Product per capita 2018 (r = − 0.47) (p < 0.001). Conclusions: SHS presence is high in most outdoor areas in Europe, especially in countries with higher smoking prevalence and lower tobacco control performance. To address outdoor SHS exposure, our findings require considering smoking bans along with other strategies to reduce smoking prevalence. 1. Introduction In the pediatric population, SHS exposure has been linked to asthma and other respiratory conditions (U.S. Department of Health and Human Secondhand smoke (SHS) exposure is a substantial contributor to Services, 2006). Worldwide, 1.2 million deaths were attributed to SHS preventable morbidity and mortality (Carreras et al., 2019). exposure in 2017, of which over 63,000 deaths were among children Non-smokers exposed to SHS are more likely to be diagnosed with younger than 10 years old (GBD Risk Factor Collaborators, 2018; Car­ chronic adverse health outcomes, such as lung cancer and heart disease. reras et al., 2019). In Europe, the burden of disease related to SHS * 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). https://doi.org/10.1016/j.envres.2021.110806 Received 7 October 2020; Received in revised form 9 December 2020; Accepted 22 January 2021 Available online 28 January 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/). The TackSHS Project Investigators Environmental Research 195 (2021) 110806 exposure ranged from 600 to 1,200 disability-adjusted life years of country-level differences in SHS exposure in outdoor venues across (Hänninen et al., 2014). Europe. Therefore, in this study, we describe SHS exposure in selected Advocacy and policy efforts in Europe aiming to curb SHS exposure outdoor settings in Europe and identify key country-level exposure de­ have mainly focused, if not exclusively, on indoor locations. The change terminants in outdoor areas. in the social norm governing indoor areas has stimulated the voluntary adoption of similar rules for homes (Monson and Arsenault, 2017). Yet, 2. Methods indoor smoking bans have also led smokers to identify new venues for smoking, such as outdoor areas neglected in smoke-free regulations Data were drawn from the TackSHS survey (Gallus et al., 2020; (Sureda et al., 2015). Consequently, banning or restricting smoking Amalia et al., 2021), a face-to-face population-based cross-sectional exclusively in indoor spaces might be insufficient to completely protect study coordinated by Mario Negri Institute (Milan, Italy) and conduct­ non-smokers from the harms of SHS exposure. We provide a supple­ ed within the framework of the TackSHS Project (Fernández et al., mentary table (Supplementary Table 3) with information on the 2020). The TackSHS survey was performed in 12 European countries: smoke-free policies in 12 European countries for a range of indoor and Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, outdoor areas and up to 2018. Poland, Portugal, Romania, and Spain. Data were collected between Outdoor areas constitute significant spaces for SHS exposure. Ac­ June 2017 and October 2018 (except Italy, where a pilot study was cording to a systematic review on SHS in open and semi-open settings, carried out November 2016) by DOXA, the Italian branch of the PM2.5 levels in most outdoor smoking areas exceeded the annual mean Worldwide Independent Network/Gallup International Association and concentration recommended by the WHO Air Quality Guidelines. The its European partners. A total of 11,902 participants were surveyed. clustering of smokers, low wind speeds, and partially enclosed areas Countries included in the TackSHS survey were selected to reflect the contributed to higher SHS outdoor concentrations (Sureda et al., 2013). variations in the geographical distribution, per capita income, smoking Available evidence has also shown SHS levels drift from outdoor areas prevalence, and tobacco control policies across Europe, and represented (in building entrances and terraces of hospitality venues) to indoor areas 79.2% of the whole European Union (EU) population aged 15 years or where smoking is already banned (Kaufman et al., 2011; López et al., older. Participants were eligible if they matched the following criteria: 2012; Sureda et al., 2012). Given these circumstances, the lack of (i) be at least 15 years old; (ii) reside in either of the 12 selected coun­ smoking bans in some outdoor areas might result in more vulnerable tries; (iii) be able to understand the TackSHS survey questionnaire groups, including children, people in deprived contexts, or people with translated to country-specific languages; and (iv) formally accept to asthma, being exposed to SHS. These groups may thus experience a participate in the study. disproportionate burden of harm from outdoor SHS exposures. The TackSHS survey was approved by local Ethics Committees in Beyond the toxic dimension of SHS exposure in outdoor areas, each of the 12 countries. All participants were informed about the several other concerns have been stated regarding tobacco use in out­ TackSHS survey through a structured information sheet and provided door settings. Smoking in outdoor public locations increases the visi­ their consent to participate in the study. The study protocol was regis­ bility of negative role models to youth, provides opportunities to smoke, tered in ClinicalTrials.gov (ID: NCT02928536). and enhances smoking normalization and social acceptability (Alesci Sampling methods have been described elsewhere (Gallus et al., et al., 2003). Moreover, outdoor areas are also the most frequent loca­ 2020). Briefly, multi-stage sampling was used in Bulgaria, Greece, Italy, tion for European adolescent smokers to smoke (Lagerweij et al., 2019). Latvia, and Romania; stratified random sampling in Germany, Ireland, Thus, the regulation of smoking in specific outdoor venues might not Poland, Portugal, and Spain, combining also quotas on sex, age, and only reduce the opportunities for young people from smoking but also social class in Ireland; cluster sampling in England, and quota method in prompt smokers to make healthier decisions (Bloch and Shopland, 2000; France. Alesci et al., 2003; Thomson et al., 2009). Last, outdoor smoke-free Participants were asked by trained interviewers about demographic policies could help reduce the pollution generated by cigarette left­ and socioeconomic characteristics, smoking habits, and other tobacco- overs, the most common form of littering (WHO, 2017; European related variables in computer-assisted personal interviewing (CAPI). Environment Agency, 2018). Non-smokers were either never smokers, those who reported not having To date, most of the studies documenting the prevalence of exposure smoked at least 100 cigarettes (also hand-rolled cigarettes) during their to SHS in European countries were based on exposures occurring in lifetime, or former smokers, those who reported having smoked at least indoor locations (Thyrian et al., 2010; Fischer and Kraemer, 2016; 100 cigarettes in their life and were not smoking by the time they Lidón-Moyano et al., 2017; Rachiotis et al., 2017). One of the studies answered the questionnaire. Current smokers were smokers who re­ looking at SHS exposure both indoors and outdoors showed that, while ported smoking at the time they participated in this survey. SHS exposure in indoor settings was nearly absent, non-smokers still The primary outcome of interest was SHS presence in the last visit to reported to be exposed in some outdoor areas after comprehensive different outdoor settings. Outdoor SHS presence was determined in smoke-free legislation (Sureda et al., 2015). Another study on a repre­ terraces of restaurants and bars, public transport stops, outdoor areas of sentative sample of children younger than 12 years in Spain reported hospitals, outdoor areas of schools, parks, children’s playgrounds, sta­ one third of the children were exposed at the outdoor school or nursery dia, and beaches by asking non-smokers: “In the last 6 months, were entrance, with a higher exposure prevalence in those households of people smoking regular cigarettes the last time you visited the following lower socioeconomic status (López et al., 2018). Support to extend sites?“. Categorical response choices were: “Never visited in the last 6 smoking bans to outdoor areas has also been evaluated in some countries months”, “Yes” and “No”. Those having seen people smoking regular in Europe, finding that the majority favor banning smoking in outdoor cigarettes in any of the above-mentioned settings accounted for SHS areas. Estimates varied depending on the setting and smoking status, presence in that setting. We also checked if current smokers had smoked being the highest for children areas (i.e., playgrounds and school in these same settings by asking the following question: “In the last 6 grounds; above 80%) and hospitals/healthcare centers (above 70%) months, did you smoke a regular cigarette the last time you visited the (Gallus et al., 2012; Sureda et al., 2015; Fu et al., 2019). following sites?“. Response choices were the same as for non-smokers. Outdoor areas have been identified as a research priority in the Those having smoked regular cigarettes in a setting accounted for out­ future for tobacco control (Barnoya and Navas-Acien, 2013). Surveil­ door smoking in that setting. lance is fundamental to track progress towards eliminating SHS expo­ Out of 11,902 TackSHS survey participants, 8,562 were non-smokers sure. However, data on the magnitude and distribution of SHS exposure and 3,340 were current smokers. Among non-smokers, 13 did not pro­ in different outdoor settings is limited (IARC, 2009; Barnoya and vide information on SHS presence outdoors and were excluded from the Navas-Acien, 2013; Sureda et al., 2013). There is also a lack of evidence present analyses. Among current smokers, 14 did not provide 2 The TackSHS Project Investigators Environmental Research 195 (2021) 110806 information about smoking outdoors and were also excluded from the terms of age, sex, habitat (geographic area and/or size of municipality), analyses. and, in some countries, socioeconomic characteristics. For the overall We assessed a series of country characteristics from different sources. sample, we used an additional statistical weight, with each country The median smoking prevalence obtained in the same TackSHS survey contributing in proportion to its population aged 15 years or over based was used to create two categories (Gallus et al., 2020): <31% (Germany, on Eurostat 2017 (European Commission). We described SHS presence Ireland, Italy, Poland, England, Latvia); ≥31% (Bulgaria, France, and smoking in outdoor settings providing relative frequencies (%) and Greece, Portugal, Romania, Spain). We classified countries based on their corresponding 95% confidence intervals (CI). Spearman’s corre­ their overall score in the Tobacco Control Scale (TCS) 2016, developed lation (r) and Chi-squared tests were applied to analyze the associations to systematically monitor the implementation of tobacco control policies between SHS presence outdoors and the different country-level char­ at country-level across Europe (Joossens and Raw, 2016): ≥50 points acteristics. All analyses were performed using STATA 15. (England, France, Ireland, Italy, Poland, Portugal, Romania, Spain), <50 points (Bulgaria, Germany, Greece, Latvia). We also classified countries 3. Results into the four geographical European regions set by the United Nations M49 standard (Statistics Division, 1999): Northern (England, Ireland, Out of 8,549 non-smokers with available information on SHS pres­ Latvia), Western (France, Germany), Southern (Italy, Greece, Portugal, ence outdoors, 30.9% visited in the last 6 months children’s play­ Spain), and Eastern (Bulgaria, Poland, Romania). We grouped countries grounds, 36.0% schools, 27.3% stadia, 57.7% parks, 45.1% hospitals, into two categories according to their gross domestic product (GDP) per 53.4% public transport stops, 62.0% restaurant or bar terraces, and capita in euros, updated in 2018 (European Comission, 2018): ≥25.000€ 46.6% beaches (Supplementary Table 1A; 1 B). The corresponding es­ (England, France, Germany, Ireland, Italy, Spain), and <25.000€ timates for smokers were 31.0% for children’s playgrounds, 35.7% for (Latvia, Romania, Poland, Portugal, Greece, Bulgaria). We used the schools, 29,9% for stadia, 59.9% for parks, 44.9% for hospitals, 53.6% socio-demographic index (SDI) from 2017, built by the Global Burden of for public transport stops, 72.5% for restaurants or bar terraces, and Disease researchers, as an indicator of country-specific development 50.9% for beaches (data not shown in tables). status. This composite indicator derives from the geometric means of the Fig. 1 provides the prevalence of SHS reported by non-smokers and indices of total fertility rate under the age of 25, mean education for the prevalence of smoking reported by smokers in the eight outdoor those aged 15 and older, and the lag distributed income per capita areas of the study. Among all outdoor settings, children’s playgrounds (Global Burden of Disease Collaborative Network, 2018). SDI values had significantly lower SHS presence (39.5%; 95% CI: 37.6%–41.3%) ranged from 0 to 1, being 1 the score indicating health outcomes are at and smoking (42.6%; 95% CI: 39.5%–45.8%); whereas, beaches had, the maximum level of development (lowest fertility rates, most years of except for terraces of bars and restaurants, significantly higher SHS schooling, and the highest income per capita). Countries in this study presence (72.8%; 95% CI: 71.4%–74.1%) and smoking (85.2%; 95% CI: were divided according to the SDI quintiles, all falling in the two highest 83.4%–86.9%). levels of development: high SDI (England, France, Germany, Greece, Outdoor SHS presence by country is shown in Fig. 2. Ireland had the Ireland, Italy, Latvia, Poland, Spain); high-middle SDI (Bulgaria, lowest and Latvia the highest prevalence of SHS presence in schools Portugal, Romania). (22.5% and 84.8%), stadia (30.4% and 91.2%), parks (45.2% and We assigned a ranking score for outdoor SHS presence to each 92.2%), public transport stops (25.1% and 93.9%), terraces of restau­ country. Based on the SHS presence in each setting, countries were rants and bars (32.4% and 93.5%), and beaches (40.9% and 95.6%). In scored from 1 (lowest) to 12 (highest). We obtained a total of eight children’s playgrounds the prevalence of SHS presence ranged between scores per country, corresponding to the eight outdoor settings in the 18.5% in Ireland and 73.5% in Greece, and in outdoor areas of hospitals study. A final score was calculated as the average of scores of the eight between 46.0% in Poland and 93.3% in Greece. Further information settings. regarding the distribution of subjects who visited each setting, and the In each country, we applied an individual weighting factor to pro­ prevalence estimates (with their corresponding 95% CI) of those who duce national representative estimates of the general population in answered witnessing people smoking regular cigarettes, overall and by Fig. 1. Prevalence (%) and corresponding 95% confidence intervals (CI) of secondhand smoke (SHS) presence reported by non-smokers and of smoking reported by smokers that visited selected outdoor areas in the last 6 months in 12 European countriesa. TackSHS survey 2017–2018. N = 11,902. Base: For each setting, the respondents who visited that setting in the last 6 months and gave valid answers. Note: Countries included in the survey are Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain. a A weighting factor is applied with each country contributing in proportion to its population aged 15 years or older. 3 The TackSHS Project Investigators Environmental Research 195 (2021) 110806 Fig. 2. Prevalence (%) and corresponding 95% confidence intervals (CI) of secondhand smoke (SHS) presence reported by non-smokers in various outdoor areas by countrya. TackSHS survey 2017–2018. N = 7507. Base: For each setting, the non-smokers who visited that setting in the last 6 months and gave valid answers. a A weighting factor is applied with each country contributing in proportion to its population aged 15 years or older. b EU: Overall secondhand smoke presence in the 12 European countries. 4 The TackSHS Project Investigators Environmental Research 195 (2021) 110806 country, are summarized in Supplementary Table 2A and Supplemen­ correlated to the smoking prevalence. tary Table 2B. In the same way, the present study provides the outdoor smoking Table 1 displays the final rank score of outdoor SHS presence for each prevalence reported by current smokers in the survey. The results ob­ country together with the TCS 2016 scores, the SDI 2017 values, the tained from smokers were close to, or even higher than, the reported GDP per capita in euros (2018), and the national smoking prevalence SHS presence prevalence in each setting. Therefore, the estimates we (2017–2018). By rank order, Ireland (average rank: 1.3), Poland show in this study are likely conservative measures of the actual SHS (average rank: 3.0) and England (average rank: 3.1) had lower overall presence in outdoor areas in Europe. SHS presence in outdoor settings. Portugal (average rank: 10.0), Greece Outdoor areas in hospitality venues and public transport stops were (average rank: 10.3) and Latvia (average rank: 11.8) had higher SHS amongst the settings with the highest SHS presence. Unlike other types presence overall. We found a strong inverse correlation between the of outdoor settings, these are delimited spaces where people gather, overall SHS presence rank score and the TCS overall score (r = − 0.62; p especially smokers in outdoor areas of bars and restaurants (Sureda < 0.001); a moderate inverse association between the rank scores and et al., 2015), and that can be partially enclosed. The well-accepted sci­ the SDI values (r = − 0.56; p < 0.001); a moderate inverse association entific consensus on the health risks of SHS exposure led to compre­ between the rank scores and the GDP per capita (r = − 0.47; p < 0.001), hensive indoor smoking bans across Europe. However, very few and a strong direct association between the rank scores and the coun­ countries have banned tobacco use in outdoor public transport stops, try’s national smoking (men and women combined) prevalence (r = and smoking in outdoor hospitality venues, when regulated, is still 0.64; p < 0.001). permitted if venues do not have overhead covers and more than two SHS presence in each outdoor setting according to different country- sidewalls. The high prevalence of SHS presence we observed in these level characteristics is shown in Table 2. Countries scoring below 50 in settings indicates current regulations might not be enough to protect the TCS 2016 had greater SHS presence in stadia (83.1%), parks hospitality workers, patrons, and bystanders. The findings in this study (71.6%), hospitals (74.0%), and beaches (79.9%) than those scoring 50 align with another recent study showing that adolescents’ visibility of or more (52.9%, 65.8%, 66.1% and 71.8%, respectively). All outdoor smoking in Europe was high at train/bus stops (83.7%), bars/clubs settings in countries with higher smoking prevalence had greater SHS (59.3%), and restaurants (55.4%) (Lagerweij et al., 2019). presence (p < 0.05). Moreover, differences in the SHS presence were We also show that nearly six out of ten non-smokers had seen people observed across geographic regions. In most settings, SHS presence es­ smoking in stadia. Exposure of stadium goers might resemble that in timates were lowest in the Northern region (p < 0.05). Countries with outdoor areas of bars, restaurants, and public transport stops. In stadia, lower GDP per capita had higher SHS presence in children’s playgrounds however, SHS exposure might be even harder to avoid since supporters (45.3%), public transport stops (74.2%), and terraces of bars and res­ are close together for relatively long periods and seats are assigned taurants (78.9%), but lower presence in outdoor areas of hospitals (Bloch and Shopland, 2000). Moreover, despite smoking being incom­ (61.8%). SHS presence in stadia (71.0%), parks (74.9%), public trans­ patible with sportive success, tobacco has been long tied to sport events, port stops (78.0%), terraces of hospitality venues (87.8%), and beaches making smoking behaviors appealing to youth. In this regard, legislation (83.8%) was more common in countries with lower development status. banning smoking in stadia have been adopted in Europe in the last years, most initiatives beyond national tobacco control regulations (Philpott 4. Discussion et al., 2016; Philpott and Viggars, 2016). SHS presence in playgrounds and schools was reported by four out of Our results suggest that many non-smokers in Europe face SHS ten non-smokers in playgrounds, and half the non-smokers in schools. In presence in the outdoor environments they frequent. Except for chil­ agreement with our results is a study that measured SHS with objective dren’s playgrounds, more than half the non-smokers who visited the environmental markers in playgrounds across Europe and found SHS other outdoor areas in the study reported witnessing people smoking. presence in almost half of the sample (Henderson et al., 2020). However, This study also unveils marked differences in outdoor SHS presence tobacco presence around youth’s learning environments might entail across European countries and geographic regions. Overall estimates more than the health effects of breathing toxic components in the air. were inversely correlated to the country’s degree of comprehensiveness Viewing teachers smoking at school grounds, including outdoor areas, of tobacco control policies, the SDI, and the GDP per capita; and directly was associated with higher odds of students’ smoking behavior (Poulsen Table 1 Outdoor SHS presence ranking and country-level characteristics. TackSHS survey 2017–2018. Country Rank scorea TCS 2016 SDI 2017 GDP per capita (€) 2018b Smoking prevalence (%) Ireland 1.3 70 0.88 66,670 19.6 Poland 3.0 50 0.84 12,950 23.6 England 3.1 81c 0.85 36,480c 19.8 Romania 4.4 56 0.78 10,510 34.0 Italy 5.5 51 0.84 29,210 18.9 Germany 5.9 37 0.87 40,340 23.7 France 6.9 64 0.86 35,100 31.0 Bulgaria 7.9 47 0.79 7980 37.0 Spain 8.3 55 0.82 25,730 31.8 Portugal 9.9 50 0.78 19,870 36.8 Greece 10.3 40 0.82 17,210 33.8 Latvia 11.8 44 0.83 15,080 28.1 Spearman correlation – − 0.6190 (p < 0.001) − 0.5626 (p < 0.001) − 0.4673 (p < 0.001) 0.6436 (p < 0.001) Note: SHS, secondhand smoke; TCS, Tobacco Control Scale; GDP, Gross Domestic Product; SDI, Socio-demographic index. Base: All non-smokers who had visited at least one setting in the last 6 months and gave valid answers. a Outdoor SHS presence ranking: Each country was scored from 1 to 12 based on their SHS presence in each setting. The country with the lowest proportion scored 1 and the country with the highest proportion 12. We obtained a total of eight scores per country, corresponding to the eight sites in the study. Countries were ranked based on an average score obtained by adding the scores in each site and dividing by the total number of sites in the study. b Eurostat database (accessed July 1, 2020). c Data correspond to the United Kingdom. 5 The TackSHS Project Investigators Environmental Research 195 (2021) 110806 Table 2 Secondhand smoke (SHS) presence reported by non-smokers and contextual factors in outdoor areas. TackSHS survey 2017–2018. Characteristics Children’s Outdoor areas in Stadia Parks Outdoor areas in Public transport Restaurant/bar Beaches Playgrounds schools hospitals stops terraces %a (n)b %a (n)b %a (n)b %a (n)b %a (n)b %a (n)b %a (n)b %a (n)b TCS 2016 ≥50 points 38.6 (777) 51.4 (1162) 52.9 65.8 66.1 (2069) 69.7 (2280) 72.2 (2696) 71.8 (990) (2263) (2138) <50 points 44.5 (397) 55.0 (417) 83.1 71.6 74.0 (693)* 71.2 (1000) 68.6 (1116) 79.9 (793) (415)* (1293)* * Smoking prevalence <31% 34.1 (416) 45.3 (601) 54.6 62.3 64.1 (1256) 61.9 (1256) 59.2 (1324) 66.7 (607) (1612) (1261) ≥31% 46.2 (758)* 59.8 (978)* 60.8 74.8 71.3 (1506)* 79.1 (2024)* 85.9 (2488)* 80.8 (798)* (1944)* (1670)* Geographic area Northern 25.7 (234) 32.6 (357) 48.2 52.3 (853) 62.3 (774) 56.5 (731) 60.7 (822) 54.5 (611) (411) Western 39.6 (183) 59.8 (307) 60.1 69.3 (609) 71.0 (435) 71.4 (554) 72.4 (738) 74.5 (422) (240) Southern 49.9 (549) 60.6 (721) 66.1 75.1 72.7 (1177) 78.4 (1386) 79.0 (1765) 83.0 (563) (1376) (1474) Eastern 37.1 (208)* 42.7 (194)* 48.6 63.3 (718) 50.2 (376)* 68.1 (609)* 65.5 (487)* 58.8 (424) (191)* * * GDP per capita (€) 2018 ≥25,000 euros 38.0 (580) 52.3 (862) 56.7 66.7 68.4 (1621) 68.8 (1607) 70.2 (2104) 73.5 (782) (1814) (1677) <25,000 euros 45.3 (594)* 50.4 (717) 61.4 69.7 61.8 (1141)* 74.2 (1673)* 78.9 (1708)* 69.3 (623) (1742) (1254) Socio-demographic index 2017 High SDI 39.1 (853) 51.9 (1173) 56.5 66.6 67.6 (2157) 69.2 (2413) 70.2 (2838) 72.1 (1059) (2659) (2267) High-middle 43.3 (321) 52.4 (406) 71.0 74.9 (897) 63.1 (605) 78.0 (867)* 87.8 (974)* 83.8 (664) SDI (346)* * * Note: SHS, secondhand smoke; TCS, Tobacco Control Scale; GDP, Gross Domestic Product; SDI, sociodemographic index. Base: For each setting, all non-smokers who had visited at least one setting in the last 6 months and gave valid answers. a A weighting factor is applied with each country contributing in proportion to its population aged 15 years or over. b n: number of non-smokers having seen someone smoking. TCS: ≥ 50 points (England, France, Ireland, Italy, Poland, Portugal, Romania, Spain), <50 points (Bulgaria, Germany, Greece, Latvia). Smoking prevalence: < 31% (Germany, Ireland, Italy, Poland, England, Latvia); ≥31% (Bulgaria, France, Greece, Portugal, Romania, Spain). Geographic regions: Northern (England, Ireland, Latvia), Western (France, Germany), Southern (Greece, Italy, Portugal, Spain), Eastern (Bulgaria, Poland, Romania). GDP per capita: ≥ 25,000 (England, France, Germany, Ireland, Italy, Spain); < 25,000 (Bulgaria, Greece, Latvia, Poland, Portugal, Romania). Sociodemographic index: High SDI (England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Spain); High-middle SDI (Bulgaria, Portugal, Romania). Chi- squared test: estimates with * are statistically significant based on the 95% Confidence Intervals. et al., 2002; Escario and Wilkinson, 2018). It is important to notice that extend the smoke-free legislation to hospital campuses in several other Europeans most likely start smoking at school age. According to the countries. Eurobarometer (2017), more than half the smokers in Europe started Approximately seven in ten respondents reported that there were smoking between the ages of 15–18 years (European Comission, 2017). smokers in their last visit to parks and beaches. For many smokers, Moreover, while the trends in smoking initiation decreased among discarding cigarette leftovers is still an acceptable form of littering adults and older adolescents, the trend in early adolescents (between 11 (WHO, 2017). Based on recent data from the European Environmental and 15 years) had significantly increased after 1990 in Europe (Marcon Agency Marine Litter Watch, cigarette butts and filters were the most et al., 2018). European Commission Council Recommendations (2009) frequent pieces of litter on European beaches, making up a fifth of the already called Member States to implement smoke-free policies with debris found (European Environmental Agency, 2018). Furthermore, supporting actions to protect youth. Our results clearly evidence parties tobacco product waste is hazardous to the environment (Slaughter et al., should undertake additional preventive measures and better enforce the 2011; Wright et al., 2015; Green et al., 2019) and local governments and existing policies in child-related outdoor environments. taxpayers still bear most or all clean-up and disposal costs (WHO, 2017). Above 65% of non-smoking respondents reported SHS was present in We have also observed clear disparities in SHS presence outdoors the outdoor areas of hospitals, a setting that should play an exemplary between European countries. Over the past decades, tobacco control has role in promoting healthy lifestyle practices (Fernández and Martínez, shifted from exclusive jurisdiction of the European Member States to a 2010) and where smoking, behavior going on the opposite direction, is shared responsibility within the European Union. Subsequently, there at the very least, counterproductive. Smoking bans including the out­ has been an acceleration and harmonization in the adoption of tobacco door premises of healthcare facilities are scarce and might not be well control policies across countries. However, progress in the development enforced. Roughly half the non-smokers surveyed in Poland and Ireland of tobacco control regulations not subject to the EU diverged consider­ witnessed people smoking on hospital grounds that are already ably (Joossens and Raw, 2016) as well as the national smoking preva­ smoke-free by law. In Spain, a study evaluating the implementation of lence trends. National smoking prevalence among the countries in this smoke-free hospital campuses found most outdoor areas (62%) to be free study ranged from 18.9% in Italy to 37% in Bulgaria (Gallus et al., from smokers (Sureda et al., 2014). Conversely, our results point to­ 2020). Previous research has shown EU Member States with more wards a limited compliance in outdoor areas of hospitals in Spain, un­ comprehensive tobacco control policies had lower national smoking derscore the need to adopt measures to improve law adherence in all prevalence and higher relative decreases in the smoking prevalence countries where smoking is forbidden, and highlight the importance to from 2006 to 2014 (Feliu et al., 2019). In our study, rank scores on SHS 6 The TackSHS Project Investigators Environmental Research 195 (2021) 110806 presence outdoors were directly related to the countries’ smoking trained interviewers. Finally, to the best of our knowledge, this is the prevalence and inversely related to the TCS overall scores. Still, most first study to provide detailed information on outdoor SHS presence and national measures overlook SHS exposure in outdoor settings, and in the its association with contextual factors at a European level. TCS 2016 no points were based on outdoor smoking bans. In this In conclusion, the findings in this study are another proof that SHS context, the association we observe between SHS presence outdoors and exposure at several outdoor settings is not to be neglected. Our results smoking prevalence highlights the importance of implementing tobacco point to an urgent need to ban smoking or better enforce smoke-free control policies aiming directly at declining smoking prevalence. These policies outdoors at child-serving settings and hospitals, given that measures are particularly relevant in Europe, where one the highest they are frequented by the most vulnerable population. For ecological prevalence of tobacco use has been reported in adults and adolescents reasons, smoking bans should also be implemented at beaches where (WHO, 2017). By targeting a reduction in tobacco use rates SHS expo­ SHS presence was highly prevalent. SHS exposure remains a relevant sure outdoors would be better addressed. risk factor in terraces of hospitality venues, where the concentration of a Our results also suggest the adoption of more comprehensive tobacco large number of smokers in delimited spaces means exposure levels control policies might have resulted in a lower acceptability of smoking could still be very high. Therefore, a total ban for terraces should also be even in settings where smoking is not forbidden, similar to the positive enacted to fully protect non-smokers. Finally, to effectively address spillover effect also described at homes (Monson and Arsenault, 2017). outdoor SHS exposure, our results require considering not only smoking Nevertheless, this might not be the case for terraces in hospitality bans but also broader tobacco control measures targeting a decline on venues, where a displacement of tobacco consumption from indoor the prevalence of tobacco use across Europe. areas to outdoors has been previously documented (López et al., 2012). Terraces are popular spots for smoking ever since indoor smoking bans Ethics Committees at hospitality venues were enacted. Thus, SHS presence in this outdoor setting might reflect the differences in smoking prevalence among the Approvals of study protocol from Ethics Committees were obtained countries in the study. in the 12 European countries. Bulgaria (Ethics Committee of Bulgaria We found an inverse relationship between our ranking on SHS Sociological Association, 29/06/2017); England (Imperial College presence outdoors and the GDP per capita in 2018. Countries with a Research Ethics Committee, 17IC4241, 21/11/2017) France (Comité de higher standard of living, as indicated by higher GDP per capita, Protection des Personnes Ouest III, 2017-A01860-53, 9/10/2017); generally adopt more progressive legislation, such is the case of Ireland, Germany (Ethics Committee Hamburg Medical Chamber, PV 5718, 24/ the first EU country to have comprehensive legislation banning smoking 01/2018); Ireland (Dublin Institute of Technology, REC-17-40, 20/09/ in indoor settings (Fong et al., 2006). Although all European countries 2017); Greece (University of Athens, 24/01/2018); Italy (Fondazione fall in the two highest levels of development according to the GBD SDI in IRCCS Istituto Neurologico “Carlo Besta”, n. 30, 8/06/2016); Latvia 2017, we show higher outdoor SHS presence in countries with lower (Central Medical Ethics Committee of Latvia, 2/17-09-28, 28/09/2017); development status. These results are consistent with our findings on Poland (Ethics Committee of Health Care College, 1/2018, 28/06/ outdoor SHS presence and the GPD per capita, another proxy of eco­ 2018); Portugal (Institute of Education, University of Minho, SECVS nomic development. 026/2017, 31/10/2017); Romania (Comisia de Bioetica a Medi­ For most of the outdoor settings in the survey, SHS presence was camentului si a Dispozitivelor Medicale, 7SNi, 7/6/2017); and Spain lowest in the Northern, and highest in the Southern countries in Europe. (Bellvitge University Hospital, PR149/17, 20/7/2017). These differences were especially acute in child-related settings and suggest an increased awareness of the harms of tobacco use around Declaration of competing interest children in the Northern regions of Europe. Nonetheless, these results should be interpreted with caution, since Latvia is the country with the The authors declare that they have no known competing financial highest overall rank score for outdoor SHS presence. In accord with our interests or personal relationships that could have appeared to influence previous findings, Gravely et al. (2017) evidenced marked differences in the work reported in this paper. the deployment of WHO FCTC measures targeting tobacco use reduction (e.g. Articles 6, 8, 11, 13, and 14) and smoking prevalence trends from Acknowledgements 2005 to 2015 among UN geographic regions. Notably, countries in the Northern region of Europe had achieved a high degree of implementa­ All partners and collaborators of the TackSHS project.*The TackSHS tion after the first decade of the treaty and experienced greater re­ Project Investigators:Catalan Institute of Oncology (ICO); Bellvitge ductions in smoking prevalence than other geographic regions Biomedical Research Institute (IDIBELL), Spain: Esteve Fernández, worldwide. Yolanda Castellano, Marcela Fu, Montse Ballbè, Beladenta Amalia, This study is limited by the self-reported data and the 6-months recall Olena Tigova. window, both prone to information bias. However, considering the Public Health Agency of Barcelona (ASPB), Spain: Maria José López, attendance to several outdoor areas might be subject to seasonality and Xavier Continente, Teresa Arechavala, Elisabet Henderson. weather conditions, the 6-month period of recall might prevent those Istituto di Ricerche Farmacologiche Mario Negri IRCCS (IRFMN), biases. Moreover, SHS presence in wide spaces, such as outdoor areas, Italy: Silvano Gallus, Alessandra Lugo, Xiaoqiu Liu, Elisa Borroni. might be susceptible to the respondent’s awareness of smoking. Even so, Istituto DOXA, Worldwide Independent Network/Gallup Interna­ we have assessed the main outcome of our study following a similar tional Association, Italy: Paolo Colombo. question included in the Eurobarometer (European Comission, 2017). University of Stirling (UNISTIR), the UK: Sean Semple, Rachel This study is also limited by the sampling methodology and the partic­ O’Donnell, Ruaraidh Dobson. ipant’s age ranges as they slightly differed among countries. However, TobaccoFree Research Institute Ireland (TFRI), Ireland: Luke Clancy, we have applied weighting factors in the analyses to assure the sample is Sheila Keogan, Hannah Byrne. representative of each country’s population aged 15 years or over. Hellenic Cancer Society - George D. Behrakis Research Lab (HCS), This is a multi-country study that includes a large sample size from Greece: Panagiotis Behrakis, Anna Tzortzi, Constantine Vardavas, Ver­ 12 strategically chosen European countries. Participants were selected gina Konstantina Vyzikidou, Gerasimos Bakelas, George Mattiampa. to obtain representative estimates of the adult population in each Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Italy: Rob­ country. Besides, the survey was conducted based on a standardized erto Boffi, Ario Ruprecht, Cinzia De Marco, Alessandro Borgini, Chiara protocol to ensure international comparability. 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Bioaccumulation Prevalence and determinants of current and secondhand smoking in Greece: results and biological effects of cigarette litter in marine worms. Sci. Rep. 5, 14119. https:// from the Global Adult Tobacco Survey (GATS) study. BMJ Open 7, e013150. https:// doi.org/10.1038/srep14119. doi.org/10.1136/bmjopen-2016-013150. 9 Update Environmental Research Volume 199, Issue , August 2021, Page DOI: https://doi.org/10.1016/j.envres.2021.111337 Environmental Research 199 (2021) 111337 Contents lists available at ScienceDirect Environmental Research journal homepage: www.elsevier.com/locate/envres Corrigendum to “Secondhand smoke presence in outdoor areas in 12 European countries” [Environ. Res. 195 (2021) 110806] Elisabet Henderson a, b, c, Alessandra Lugo d, Xiaoqiu Liu d, Xavier Continente a, b, e, Esteve Fernández f, g, h, i, Maria J. López a, b, c, e, *, Silvano Gallus d, The TackSHS Project Investigators a Agència de Salut Pública de Barcelona, Barcelona, Spain b Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain c Departament de Ciències Experimentals i de la Salut (DCEXS), Universitat Pompeu Fabra, Barcelona, Spain d Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy e Sant Pau Institute of Biomedical Research (IIB Sant Pau), Barcelona, Spain f Tobacco Control Unit, Institut Català d’Oncologia, L’Hospitalet de Llobregat, Spain g Tobacco Control Research Group, Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Spain h School of Medicine and Health Sciences, Universitat de Barcelona, L’Hospitalet de Llobregat, Spain i Consortium for Biomedical Research in Respiratory Diseases (CIBERES), Madrid, Spain We would like to inform there was a mistake in the order of authorship, being Elisabet Henderson the first author. DOI of original article: https://doi.org/10.1016/j.envres.2021.110806. * 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). https://doi.org/10.1016/j.envres.2021.111337 Available online 19 May 2021 0013-9351/© 2021 The Author(s). Published by Elsevier Inc. All rights reserved.