Assessing public support for extending smoke-free policies beyond enclosed public places and workplaces: protocol for a systematic review and meta-analysis 59 3 Introduction Second-hand smoke (SHS) exposure is related to 1.2 million deaths per year.1 Smoke-free environments have proven to be effective in reducing exposure to SHS and have major public health benefits.2 Previous systematic reviews reported consistent evidence for improved cardiovascular health and reduced smoking-related mortality, as well as reductions in preterm birth, severe asthma exacerbations and respiratory tract infections in children, following implementation of smoke-free legislation in indoor public places and workplaces.3-5 It has been shown that outdoor areas contribute significantly to SHS exposure, therefore the implementation of smoking-free policies in open spaces have the potential to reduce the associated burden of disease.6, 7 In 2004, Ireland was the first country in the world to implement comprehensive smoke-free legislation covering enclosed workplaces and public places, and many more countries followed its example.8 An increasing number of jurisdictions is now implementing, or considering implementing, additional smoke-free policies that go beyond regulating smoking in enclosed public places and target private and outdoor spaces, henceforth referred to as ‘novel smoke-free policies’. Novel smoke-free policies are implemented in an attempt to further improve population health via reducing SHS exposure. For example, several countries have implemented laws requiring private cars carrying children be smoke-free,9-11 smoke free hospital campuses have been implemented country wide in Spain and Ireland,12, 13 the city of New York banned smoking in all public parks, pedestrian plazas and at all beaches,14 and the US Department of Public Housing and Urban Development requires all public housing units to be smoke-free, both within resident units and in public areas.15 Public support is essential in democracies in order for policy-makers to consider implementing such novel smoke-free policies and to increase the likelihood of successful implementation,16 and accordingly the World Health Organisation (WHO) stated that “Involving civil society is central to achieving effective legislation”.5 However, public support may vary over time, as well as by population subgroups. For example, women and non-smokers tend to be more in favour of smoke-free legislation than men and current smokers.17 Several studies showed that public support for smoke-free policies increased after successful implementation and particularly so among smokers.18-20 Furthermore, public support for smoke-free policies was higher when policies covered spaces that were frequently visited by
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