Introduction

Research into the adverse health effects of exposure to secondhand smoke (SHS) has consistently identified it as a public health hazard and cause of disease [1]. By the end of 2010, 28 countries had 100% comprehensive smoke-free policies, covering 11% of the world’s population [2,3]. Many countries have witnessed the successful enforcement of smoke-free policies. In Scotland, 99.4% of all premises complied with smoking bans in the first 3 months [4]. Similarly, the United Kingdom achieved 98% compliance, and Ireland achieved 94% compliance within a year [5]. High compliance rates have also been achieved in developing countries such as India, Mexico, and Uruguay [1,6,7]. Concurrently, successful implementation also leads to declines in exposure to SHS and significant health improvements among employees who work in businesses who comply with smoke-free policies. For instance, after six months’ implementation, 92% of surveyed Scottish bar staff worked in environments without SHS exposure [8]. Following the country’s implementation of smoke-free legislation in Ireland, ambient air nicotine concentrations decreased by 83%, and bar employees’ exposure to SHS plunged from 30 hours per week to zero [9].

Efforts to reduce smoking in public places have a 20-year history in Shanghai, The first "Shanghai Provisional Regulation of No-smoking in Public Places" in Shanghai came in to force in 1994. These initial regulations were amended in 1997 [10]. According to this policy, eight kinds of public places were targeted to become smoke-free but even among these settings smoking was not completely prohibited. For instance, smoking was prohibited in the commercial area of shops larger than 200 square meters. In hospitals, smoking was prohibited only in waiting rooms, diagnosis and treatment rooms, and sickrooms. In school and kindergartens, smoking was prohibited in children’s education and activity areas. Hotels and restaurants were not mentioned in these regulations. In addition to the piecemeal nature of these policies, enforcement of the regulations was not strong. Since the World Health Organization Framework Convention on Tobacco Control [11] officially took effect in China on January 9, 2006, several large Chinese cities including Beijing, Shenyang, Yinchuan, Hangzhou, Guangzhou, and Shanghai have extended their local smoking bans.

In March 2010, the Shanghai Public Places Smoking Control Legislation was passed by the Shanghai People’s Congress Standing Committee and went into effect. This was the first provincial-level legislation on tobacco control passed by the Standing Committee in China. According to this legislation, smoking is totally prohibited in 13 types of public places including medical institutions; inside and outside nurseries and kindergartens; primary and secondary schools; indoor public places for science, education, culture and art; and public transportation areas such as buses and the subway. Since the implementation of these regulations, the Shanghai government has built a management working system that is consistent across seven enforcement authorities [12]. However, the new legislation is still not a comprehensive ban. For instance, no detailed standards were provided for hotel lobbies and restaurants, and smoking zones were still permitted in these settings. In addition, there is still no mention in the policy of workplaces such as offices.

We aimed to evaluate the compliance, support, and impact of new smoke-free legislation in Shanghai after six months of implementation to inform further improvement of this policy. In addition, although evidence from research in other countries showed clear reductions in SHS exposure and improved health among employees [7,13–16], these potential benefits await confirmation in mainland China where some of the aforementioned concerns may dilute findings of decreased exposure. The importance of determining the real impact of this legislation goes beyond Shanghai’s borders. The National Government in China is planning the introduction of country-wide legislation on tobacco control [17]. Further, the experiences and lessons from Shanghai can also work as a reference for other developing countries with a high smoking prevalence.

Materials and Methods

Results

Discussion

To our knowledge, this is the first comprehensive evaluation of a provincial-level smoking control policy in mainland China. A reduction in exposure to SHS was seen half a year after the regulation was enacted. This study also confirms increasing support for a total smoking ban in the workplaces among employees. This study clearly demonstrates that the introduction of legislation in Shanghai has led to a decrease in exposure to SHS in these workplaces. These findings are consistent with those in other countries [22–25].

This study is somewhat different from other studies examining the impact of smoke-free legislation [14,26,27]. In fact, there were some pre-existing regulations in schools, kindergartens, shopping malls, and hospitals [10]. Therefore, this study is not a “none to all” comparison. In addition, the results presented in this study suggest that the implementation of this policy was not as effective as in other studies. Compared to other international studies [13–16,28,29], the results of this study showed lower compliance rates, higher proportions of exposure to SHS, and limited health effects.

The content of the policy is crucial in setting parameters for implementation [30]. Effectiveness of smoke-free laws is greatly weakened when smoking is permitted in designated areas [31–33]. One of the important reasons that the Shanghai government did not introduce a comprehensive smoke-free policy is that the policy-makers regarded the implementation of a “Smoking control” policy as more practical and feasible in Shanghai than a total ban [34]. However, this study showed that in kindergartens and schools, the workplaces with the strictest regulations on tobacco use, the implementation of the policy was better than other public places, with more than 90% of staff in these workplaces agreeing that the legislation could be implemented most or all of the time. On the other hand, in hotels which were legislated to have only a partial smoking ban, implementation was not optimal and only 72.2% of the staff in this type of workplace agreed that the legislation could be enforced in their workplace most of time. In the current legislation, it is stated that separate rooms (smoking zones) can be established in the public areas of hotels without providing any further details or standards. The results of this study challenge the popular misunderstanding in China that a partial ban is more feasible in practice.

This study also indicated limited understanding of the current smoking legislation. About half participants did not know the details of the legislation. About half of participants in hotels and shopping malls had inaccurate knowledge of regulations for their workplace. This may be due to two reasons. First, the legislation is complicated with details about where smoking is allowed. Second, the media communication activities surrounding the legislation are insufficient. Experience from other countries shows that education and advocacy efforts increased public support for 100% smoke-free policies and decreased the social acceptability of smoking [35].

The successful implementation of smoking control legislation required compliance from smokers and supporting behaviors from nonsmokers. This study showed that 43.2% of smokers could not comply with the smoking regulation. Therefore, increasing the compliance among smokers is the first step with a possible solution being increasing the amount of the fine which is only 50 RMB (about $8) according to the current legislation. In addition, targeting the social norms of smoking and decreasing social acceptability of smoking by health advocacy is an important approach for promoting compliance with smoking restrictions in China where smoking is widely accepted [36,37]. Last but not least, the managers in workplaces should take the corresponding opportunity in educating staff and enforcing the rule. Roughly two-thirds of smokers still smoked in the designated indoor smoking zones. This reveals that designated smoke zones still existed in some workplaces despite being not allowed according to the new legislation.

On the other hand, less than half of nonsmokers would stop visitors from smoking in their workplace. The main reason included avoiding disputes with others, feeling as though they have no rights to persuade others, and concerns that smokers would not follow the advice. This partly reflects the culture of China to keep harmony and avoid disputes [38]. To change the status, training should be provided to staff on how to stop others smoking which can efficiently avoid disputes and increase the self-efficacy among the nonsmokers. The conception such as “breathing fresh air is the right if everyone” should be advocated among nonsmokers. In addition, as business places, both the hotels and shopping malls give high priority to the customers’ perceived rights to smoke. Results here indicate that managers in these workplaces felt that limiting smoking among customers may have a negative impact on business. However, many international studies have shown that hospitality sectors do not experience any negative economic effects and may even experience some positive effects after the introduction of smoke-free laws [31,39]. Such evidence in China is still necessary to dispel such doubts.

Although compliance is a challenge, this study found increasing support for a total ban for smoking after the legislation. The support rate for a total smoking ban in all workplaces increased from 75.8% to 87.3%. This is consistent with other studies which also showed increased social support and acceptability to smoke-free policies after the legislation was enacted [25,33,40]. Our study found that employees in kindergartens, schools, and hospitals had higher support rates than other groups. However, the greatest change to support rates to a total ban occurred in hotels, with no significant change occurring among working staff in hospitals. Hotels had virtually no regulations on smoking before the legislation. Therefore, employees in hotels may have experienced the greatest change over the course of the study. However, according to the current legislation, smoking was only partially banned in hotels so there is room to further push toward a smoke-free environment. Hospitals, on the other hand, had pre-existing smoking regulations before the new legislation, with a high support rate among the staff. Because working staff in hospitals have more knowledge on the harms of SHS, those who did not support the smoke-free policy in hospitals may be harder to change than other working populations.

There are several limitations in our study. First, we chose to use an anonymous questionnaire design to encourage truthful reporting among the employees. However, such methods also excluded the possibility to assess the change in individuals over time. Second, recall bias in the perception of exposure to SHS as well as in the reporting of respiratory symptoms cannot be disregarded. Although other studies have shown that self-reports are consistent with conclusions from environmental monitoring and biomarker studies [32,41], objective measurements of exposure to SHS such as cotinine level or concentration of particulate matter should be applied in the future. Third, seven worksites dropped out from T1 to T2 in this study. Worksite self-selection bias may have affected the results of this study. Last but not least, this study only assessed short-term impact; a longer term follow up survey should be conducted in the future.

Conclusion

Results of this study confirm a reduction in exposure to secondhand smoke and decreased prevalence of suffering from respiratory and sensory symptoms after the implementation of smoking control legislation in Shanghai. This study also indicates increased public support for such policies. Further efforts should be engaged in to strengthen the enforcement of current legislation and to decrease the social acceptability of smoking.

Acknowledgments

Some results presented in this paper - specifically results reported in Tables 4 and 5 and text to describe these findings have been published in the Chinese Journal of Health Education 2011 (10): 736-9.