Smokers’ responses to being addressed when smoking in an outdoor voluntary smoke-free zone: An observational study 231 6 Introduction Tobacco smoking, including second-hand smoke (SHS), is responsible for an estimated eight million people prematurely dying each year and is the leading preventable cause of premature death worldwide.1, 2 Smoke-free policies are implemented to protect bystanders from SHS exposure and may help denormalise and demotivate smoking.3-6 To regulate smoking in selected outdoor areas, local and national policies are being developed and implemented. In the Netherlands, outdoor areas of educational institutions are expected to be smoke-free since August 2020.7 In anticipation of this national smoke-free regulation and in collaboration with the municipal government, an inner-city outdoor smoke-free zone was implemented on 2 September 2019 in Rotterdam. The zone encompasses a university hospital, a university of applied sciences, a high school, and the public road in between. The smoke-free zone was not regulated by law but focused on creating a smoke-free norm using clear communication and signage and via stimulating bystanders to address smokers who were smoking within the zone. Recently, we demonstrated that implementation of the smoke-free zone was followed by a 45% reduction in the number of smokers in the area.8 At the same time however, we noted that very few smokers were addressed when smoking within the smoke-free zone. Previous research showed that, although proper addressing of smokers is a key factor for successful implementation of smoke-free zones,9 many people feel uncomfortable to address smokers due to fear of negative responses.10 In this study we aimed to formally assess smokers’ responses to being addressed when smoking within the outdoor smoke-free zone. Methods Design and setting This observational field study was conducted in September 2019 at the grounds surrounding Erasmus MC, a tertiary hospital in Rotterdam, the Netherlands. The smoke-free zone encompasses the Erasmus MC, two educational institutions, and the public road in between. The zone is indicated with a blue line around it on the street and pavement and by “Smoke-free generation” banners, signs and tiles (see Supplement 1). In the first two weeks after implementation of the smoke-free zone, Erasmus MC representatives and initiators of the smoke-free zone (‘addressors’) made rounds on Erasmus MC grounds to address smokers
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