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Health Policy
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he efficacy of different models of smoke-free laws ineducing exposure to second-hand smoke: A multi-countryomparison
ark Warda,b,∗, Laura M. Curriea,c, Zubair Kabira,d, Luke Clancya
TobaccoFree Research Institute, The Digital Depot, Thomas Street, Dublin 8, IrelandSchool of Social Work and Social Policy, Trinity College Dublin 2, IrelandDivision of Population Health Science, Royal College of Surgeons in Ireland, Mercer Street Lower, Dublin 2, IrelandDepartment of Epidemiology and Public Health, University College, Cork, Ireland
r t i c l e i n f o
rticle history:eceived 1 August 2012eceived in revised form 15 February 2013ccepted 19 February 2013
Exposure to second-hand tobacco smoke is a serious public health concern and while allEU Member States have enacted some form of regulation aimed at limiting exposure, thescope of these regulations vary widely and many countries have failed to enact compre-hensive legislation creating smoke-free workplaces and indoor public places. To gauge theeffectiveness of different smoke-free models we compared fine particles from second-handsmoke in hospitality venues before and after the implementation of smoking bans in France,Greece, Ireland, Italy, Portugal, Turkey, and Scotland.
Data on PM2.5 fine particle concentration levels were recorded in 338 hospitality venuesacross these countries before and after the implementation of smoke-free legislation.Changes in mean PM2.5 concentrations during the period from pre- to post-legislation werethen compared across countries.
While a reduction in PM2.5 was observed in all countries, those who had enacted andenforced more fully comprehensive smoke-free legislation experienced the greatest reduc-
tion in second-hand tobacco smoke.
Comprehensive smoke-free laws are more effective than partial laws in reducing expo-sure to second-hand tobacco smoke. Also, any law, regardless of scope must be activelyenforced in order to have the desired impact. There is continued need for surveillance ofsmoke-free efforts in all countries.
. Introduction
Second-hand smoke (SHS), also known as Environmen-
al Tobacco Smoke (ETS), contains over 4000 chemicals,
ore than 50 carcinogens and many toxic substances [1].ncreased exposure to SHS is associated with greater risk
∗ Corresponding author at: School of Social Work and Social Policy,rinity College, Dublin 2, Ireland. Tel.: +353 1 8962718.
and there is no safe level of exposure [1,2]. Chronic expo-sure to SHS causes many of the same diseases as activesmoking, increasing the risk of lung cancer by 20–30% andof coronary heart disease by 25–30% among non-smokerswho live with smokers [3]. In addition, SHS is associatedwith respiratory diseases and exacerbates the symptomsof asthma, allergies, and chronic obstructive pulmonarydisease. Infants, young children, and pregnant women are
particularly vulnerable to the harm caused by SHS expo-sure. Within the EU25 in 2002, it was estimated that 79,449deaths were attributable to SHS exposure, with a quarter(19,242) of these deaths occurring among non-smokers [4].
All EU Member States have enacted some form of regula-tion aimed at limiting exposure to SHS, however the scopeof these regulations vary widely. Many countries havefailed to enact comprehensive legislation compliant withArticle 8 of the World Health Organisation’s FrameworkConvention for Tobacco Control (FCTC) which obligatesParties, including the EU and many of its Member States,to take effective steps to provide protection from exposureto SHS [5].
Many of the strategies proposed for evaluating the effec-tiveness of smoke-free policies [2,6,7] recommend thatlevels of exposure to SHS be monitored in order to mea-sure the anticipated reduction in environmental tobaccosmoke. This is key to evaluating smoke-free policies as ameans of protecting workers from exposure to harmfulSHS. A number of countries adhered to these proposals andhave recorded atmospheric particulate matter in varioussettings where individuals were exposed to SHS. Specif-ically, many of these studies have measured particulatematter with a diameter of approximately 2.5 micrometres(PM2.5), which has become a widely used marker of ETS[8]. Of interest for this project were measurements takenin hospitality venues, such as bars/pubs, restaurants, nightclubs/discos.
The seven countries considered in this study are clas-sified as having implemented either comprehensive orpartial smoke-free laws as defined by the EC Green Paper‘Towards a Europe free from Tobacco Smoke’ [9]. Of theseven countries included in the current study, five (France,Ireland, Italy, Scotland, and Turkey) were classified as hav-ing comprehensive smoke-free laws in place at the timePM2.5 measurements were recorded and two (Greece andPortugal) were classified as having partial laws in place.According to the criteria, France and Italy should both bedefined as having partial laws given allowances in their leg-islation for designated smoking areas in hospitality venues.However, their regulations to permit a business to desig-nate a smoking area were prohibitive making the provisionof smoking rooms impractical.
There have been a number of studies conducted thathave illustrated the positive impact of smoke-free laws onconcentrations of SHS [10–22]. In the main studies to datehave focused on individual countries, though a compari-son of reported results are suggestive of a greater impactfrom comprehensive smoke-free laws on levels of indoorETS compared to partial laws. The aim of the current studyis to compare the impact that comprehensive and par-tial models of smoke-free legislation in different Europeancountries have on exposure to SHS, particularly in the hos-pitality sector. A secondary aim is to gauge whether supportfor the notion that France and Italy have de facto compre-hensive laws is warranted.
The current study is one of the first to directly comparemeasured SHS concentrations across European countrieswith the explicit intention of gauging the relative impact ofthe various levels of smoke-free laws that have been imple-mented across these states. It is hoped that the findings
presented here will be of considerable value not only tocountries that are contemplating introducing smoke-freelaws for the first time but also to countries where less thancomprehensive laws exist and who recognise the need to
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comply with the EC regulations and Article 8 of WHO FCTCand may therefore be considering changing their laws.
2. Materials and methods
2.1. Data
The current paper draws together data from studieswhich have sought to measure the impact of smoke-freelaws on reducing exposure to SHS in hospitality venuesin six EU Member States and Turkey [10–22]. Data onPM2.5 concentrations were identified in France, Greece,Ireland, Italy, Scotland and Portugal. For each of thesecountries, local tobacco control experts who were involvedin the data collection provided the Tobacco Free ResearchInstitute (TFRI) research team with original datasets con-taining PM2.5 concentration levels as well as other detailson how the data were gathered. In the case of Turkey, localtobacco control experts were also commissioned by TFRI tomeasure PM2.5 concentrations in 12 hospitality venues inAnkara and Izmir in September 2010.
In France, Ireland, Italy, and Scotland there were twodata collection points, one before the introduction ofsmoke-free legislation and follow-up measurements takenafter implementation. There was no data on PM2.5 concen-trations available from Portugal before the implementationof their smoke-free laws. The two data points that wereavailable are from April 2009 and July 2010, both afterimplementation of smoke-free legislation.
While a study protocol and sample information sheetwas provided to the data collection team in Turkey, theother data had already been collected and this resultedin different methodological detail being available fromdifferent countries. For example, it is important to haveinformation on the number of customers smoking at thetime PM2.5 concentrations are recorded as this is of courseuseful when attempting to explain the level of SHS present.While this information is more obviously important incountries with partial smoke-free laws as it helps distin-guish between venues where smoking is permitted andthose where it is prohibited, it is equally important forcountries with comprehensive smoke-free laws to reportthis information. Table 1 provides information on the datesmoke-fee was introduced in each country; classification ofthe ban as comprehensive or partial; the date(s) of pre-bandata collection; the date(s) of post-ban data collection; thenumber and type of venues included; the sampling strat-egy employed; the type of air monitor used; the length oftime over which measurements were recorded; and thesource of data from each country. Details of the calibra-tion factor used to convert the logged nominal instrumentreadings from uncorrected milligrams per cubic metre toactual micrograms per cubic metre (�g/m3) of PM2.5 arealso shown.
Data for Ireland were collected as part of a study byGoodman et al. [13] that examined the impact of the leg-islation on both the air quality of 42 pubs in Dublin and
respiratory health effects in bar workers. Venues were rep-resentative of the different types of public houses foundin the city of Dublin having been selected to encompassa wide variety of building structures and clientele, size,
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Table 1Summary of PM2.5 measurement data collection.
France Greece Ireland Italy Portugal Turkey Scotland
Date of bana February2007/January 2008
July 2009/July 2010 March 2004 January 2005 January 2008 May 2008/July2009
March 2006
Classification of ban De factocomprehensive
Partial Comprehensive De factocomprehensive
Partial Comprehensive Comprehensive
Data collection pre-ban January–December2007
February2006–January 2009
October2003–March 2004
November–December2004
April 2009 April–December2009
January–March2007
Data collection post-ban March–November2008
April 2010 October2004–March 2005
March–April 2005andNovember–December2005
July 2010 September 2010 March–May 2007
Number of venues 149 14 42 28 12 12 41Sampling strategy Unknown Convenience
(Athens,Thessaloniki,Heraklion, Larissa,Serres)
Representative(Dublin)
Random (Rome) Unknown Convenience(Ankara and Izmir)
Random(Aberdeen,Edinburgh,Borders,Aberdeenshire)
Type of venue Bars, pubs,restaurants, barcafés (Caen, Lyon,Marseille, Paris,Strassbourg)
Pubs, bars, cafes Public houses Pubs, bars,restaurants
Length of time Missing 30 min+ 3 h+ 20 min 30 min 30 min 30 minCalibration factorb 8.2 0.32 None x = (y + 21.01)/4.01
x = (y + 9.1)/2.66c0.51 0.23 0.295
Source Professor BertrandDautzenberg,Pitié-Salpêtrière,Paris, Franced
Hellenic AirMonitoring Study[22]
Goodman et al. [13] Valente et al. [21] Professor JoséAlberto GomesPrecioso,University ofMinho, Bragad
Ministry of HealthTurkey, PrimaryHealth Care generalDirectorate [23]
Semple et al.[17–19]
a France first introduced smoke-free legislation in February 2007 that banned smoking in all public places and workplaces, public transport and all educational premises, as well as all premises used to gather,train or accommodate minors. This ban was extended in January 2008 to include hospitality venues. A partial ban on smoking was introduced in Greece in July 2009 and extended in July 2010 to include allenclosed public spaces. In Turkey a partial workplace smoking ban was implemented in May 2008 and extended to include hospitality venues in July 2009.
b Calibration factor refers to the factor applied to convert the logged nominal instrument readings from uncorrected milligrams per cubic metre to actual micrograms per cubic metre (�g/m3) of PM2.5.c Based on the linear regression of PM2.5 concentrations measured with Dust Trak/manual gravimetric method (RFM), two correction equations were applied to the PM2.5 data: x = (y + 21.01)/4.01 for smoking
environments and x = (y + 9.1)/2.66 for smoke free environments [21, p. 313].d Private correspondence.
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600
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PM
2.5
France Greece Ireland Italy Portugal Scotland Turkey
Pre-ban PM2.5 Post-ban PM2.5
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demographics, socioeconomic factors, and geographiclocation [13, p. 841].
Taking a similar approach to that of Goodman andcolleagues, Semple et al. [17–19] measured changes inPM2.5 levels in bars in Scotland. Venues were randomlyselected from a database containing information on all pub-lic houses within the Aberdeen city postcodes (AB10–12,16, 23–25) and Edinburgh city postcodes (EH1–8), togetherwith pubs in small towns (<3000 population) in the Bordersand Aberdeenshire council regions [17, p. 127–128]. In total53 visits were made to 41 pubs across the two cities in theeight week period prior to implementation of the smokingban. Thirty-five of the visits were made during busy timesand the remaining 18 during quiet times. All 41 pubs werere-visited within two months of the ban.
Valente et al. [21] in Italy measured pre and post smok-ing ban PM2.5 concentrations in 40 venues (14 bars, sixfast food restaurants, eight restaurants, six video game par-lours, six pubs) in Rome. Venues were selected randomlyfrom an official list of businesses in the western part of thecity (Health District D) [21, p. 313]. Only data relating to thepubs, bars (14), pubs (6) and restaurants (8) are consideredin the following analysis.
Measurements of PM2.5 concentrations were providedfrom 132 hospitality venues (bars, pubs, restaurants,bar cafés) in five French cities (Caen, Lyon, Marseille,Paris, Strassbourg). Pre-ban measurements were recordedthroughout 2007 while post-ban PM2.5 concentrationswere recorded in March, October and November 2008.
In Portugal PM2.5 concentrations were recorded in 12hospitality venues after the implementation of partialsmoke-free legislation in April 2009 and again in July 2011.
In Turkey pre- and post-ban PM2.5 concentrations wererecorded by the Ministry of Health Turkey, Primary HealthCare general Directorate [23] in 12 pubs, bars, and restau-rants in Ankara and Izmir in three waves. A conveniencesample was employed with consideration given to localtransportation infrastructure and the size of the establish-ments.
The Hellenic Air Monitoring Study conducted in Greece(Wave 1: May 2010) by Vardavas et al. [22] measured expo-sure to SHS in hospitality in 149 venues in five regions ofGreece: two large urban centres (Athens and Thessaloniki),one city in Southern Greece (Heraklion), one in CentralGreece (Larissa) and one in Northern Greece (Serres). In theabsence of a comprehensive directory of hospitality venuesin Greece, a convenience sample approach was used basedon access and popularity [22, p. 5]. Of the venues visitedthere were 64 cafés, 58 café/bars, 20 tavernas, five inter-net cafés and two betting parlours. Venues were visited ondifferent days of the week. The authors of the Hellenic AirMonitoring Study provided the TFRI with PM2.5 measure-ments from 14 hospitality venues.
2.2. Statistical analysis
Details of the change in mean mass concentration of
PM2.5 particulate matter in each country were analysedusing PASW Statistics 18, Release Version 18.0.0 (SPSS,Inc., 2009, Chicago, IL). Due to differences in methodol-ogy, including the number of observations, venue size,
Fig. 1. Comparison of the distribution of PM2.5 concentrations before andafter implementation of smoke-free legislation in seven countries.
time of year data was collected, measurement instrumentused, it was not possible to directly compare the absolutevalues of PM2.5 concentrations. For this reason countriesare compared on the basis of the percentage change inPM2.5 concentrations. A Kolmogorov–Smirnov test con-firmed the non-normal distribution of the measurementstherefore non-parametric tests were used throughout. Thenon-parametric Wilcoxon signed rank test was used whereboth pre and post smoke-free legislation measurementswere recorded at the same venue. In the case of Italy aMann–Whitney U test was used as not all the same venueswere included for pre- and post-ban data collection. Effectsizes (r = Z/
√N) are reported throughout to demonstrate
the magnitude of the reduction in PM2.5 concentrationsand allow for greater comparability between countries. Boxplots of the distribution of pre- and post-ban PM2.5 concen-trations presented in Fig. 1 were created using Stata/SE 11.2(StataCorp, 2009).
3. Results
Fig. 1 shows the distribution of PM2.5 concentrationsmeasured before and after implementation of smoke-freelegislation in each country. In every instance there wasa clear reduction in the overall levels of SHS recordedwith a greater decrease observed among countries that hadimplemented comprehensive smoke-free laws betweenthe two data collection points. Among the five countrieswith comprehensive smoke-free laws there was an averagereduction in PM2.5 of 68.4% (min: 35%; max: 92%) whereasthe average reductions for Greece and Portugal which bothhad partial smoke-free laws at the time of measurementwere 40% and 41% respectively.
3.1. Ireland
The average pre-ban mass of particulate matter 2.5 �mor smaller was 35.5 �g/m3 (SD = 53.6). Post-ban mea-
surements showed a significant decrease [z(42) = −5.648,p < 0.001] of 84% to 5.8 �g/m3(SD = 4.6). This was a largeeffect (r = −0.62).
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.2. Scotland
While there was a lot of variation in the percentageeduction in PM2.5 in different pubs, more than half ofhe pubs visited showed a reduction greater than 90%.he overall reduction in PM2.5 was 92% with an aver-ge reduction of 86%. The reduction in PM2.5 from preM = 245.6 �g/m3, SD = 200.5) to post-ban (M = 20.5 �g/m3,D = 19.4) was significant [z(53) = −6.334, p < 0.001] andas a large effect with r = −0.61.
.3. Italy
Change in PM2.5 was assessed using the pre-ban mea-urements (November/December 2004) and the secondave of post-ban measurements (November/December
005). The second wave of post-ban data was chosen toontrol for seasonal effects and also as the one year time lags comparable to the Irish study [13]. Only half the venues
ere re-visited while the other half was substituted withthers. Significant differences were found [U(61) = 267.0,
< 0.01] between pre-ban (M = 130.0 �g/m3, SD = 170.9)nd post-ban (M = 39.4 �g/m3, SD = 29.7). This was aedium effect with r = −0.36.
.4. France
The average pre-ban PM2.5 concentration was0.5 �g/m3 (SD = 108.8). Post-ban measurements showed
significant decrease of 63% to 29.3 �g/m3 (SD = 142.5).his was a large effect with r = −0.54.
.5. Portugal
Significant differences were found [z(12) = −2.51, < 0.05] between measurements taken in April 2009M = 325.3 �g/m3, SD = 311.5) and those recorded in July011 (M = 191.8 �g/m3, SD = 214.9). This was a large effectith r = −0.51.
.6. Turkey
While there was an overall reduction in PM2.5 concen-rations of 35%, the difference between the pre-ban mea-urements (M = 153.7 �g/m3, SD = 218.2) recorded in April009 and post-ban PM2.5 concentrations (M = 99.3 �g/m3,D = 87.3) recorded 17 months later in September 2010 wasot statistically significant [z(12) = −0.941, p = 0.347].
.7. Greece
Data was collected between February 2006 andanuary 2009 which was before the implementa-ion of the partial smoke-free ban in Greece. Resultsrom Greece showed significantly higher concentra-ions of PM2.5 in the 142 venues that allowed smoking
182 �g/m3) compared to the seven that did not (6 �g/m3).ollow-up measurements were taken in April 2010. Sig-ificant differences were found [z(14) = −2.291, p < 0.05]etween pre-ban (M = 238.5 �g/m3, SD = 148.3) and
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post-ban (M = 142.6 �g/m3, SD = 150.5). This was a mediumeffect with r = −0.43.
4. Discussion
The results presented here clearly illustrate the effec-tiveness of smoke-free laws in reducing exposure to SHSin the hospitality sector benefiting not only those directlyemployed in this sector but also the patrons of thesevenues. It is equally apparent that more comprehensivelaws result in greater reductions in PM2.5 as best demon-strated in Ireland and Scotland where average reductionsin PM2.5 of 84% and 86% respectively were observed.
Findings from our analysis of the reduction in PM2.5concentrations after smoke-free legislation was introducedin France and Italy does not fully support the contentionthat both countries have de facto comprehensive laws. Ithad been suggested that due to the prohibitive nature ofthe provisions allowing for smoking rooms in certain cir-cumstances that it is equivalent to fully comprehensivelaws [5]. As expected a reduction in SHS was observed inboth countries, however the overall reduction was notablysmaller than in countries with truly comprehensive smoke-free laws similar to Ireland and Scotland and suggests somelevel of SHS persists in nominally designated non-smokingvenues in the hospitality sector. This issue deserves furtherinvestigation to understand the mechanisms at play andprovide the evidence to support countries in their effortsto protect their populations from the dangers of SHS.
It may be that owners or management who do notprovide designated smoking areas as allowed for in the leg-islation, compensate by implementing the law leniently.There may also be some ambiguity in the minds of thepublic, both smokers and non-smokers, as to where smok-ing is and is not permitted. This ambiguity may also bereflected in the action or inaction of enforcement agencies.The issue of enforcement is an essential element in the suc-cess or otherwise of smoke-free laws. In Italy for examplethere was an initial 1.5 year delay in arriving at regula-tions pertaining to the responsibilities of hospitality venueowners in enforcing the smoking ban during which timean appeal by the Italian Association of Owners of Hospital-ity Premises was upheld that resulted in responsibility forenforcement shifting from venue owners to the police [24].Initially enforcement was further hampered by the fact thatlocal health authorities were not explicitly given a role inenforcing the ban although this situation has since changedsomewhat. While these factors may have contributed tothe results in Italy being different they do not explain thepersistence of the differences and of course do not explainthe French results. At present it seems reasonable to sup-port the FCTC demand for fully comprehensive smoke-freelaws as the best way to protect people against SHS. WhenItaly and France legislated they accepted the compromisebecause it was unknown if protection would be compro-
mised and the political argument had not been fully won.Now such compromise can be seen not to work and also itcan be seen to be an expensive and unfair and unnecessaryburden on owners.
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As demonstrated in Turkey which saw a reduction of35% in mean PM2.5 readings, smoke-free laws, whethercomprehensive or otherwise only work effectively whenthey are applied rigorously. Although the poor resultsobserved may be conflated by the small number of loca-tions (n = 12) in which measurements were recordedand/or the very high pre and post-ban levels of PM2.5 inone particular venue in Ankara.
Furthermore, a study by Bogdanovica et al. [25] whichlooked at ecological factors that impact smoking preva-lence and smoke-free policy enactment across the EU,suggests that in some countries, notably those with higherlevels of corruption, governments may be willing to act tobe seen to implement measures to restrict smoking, but lessdisposed to enforce smoke-free measures. Equally in thesecountries the population may be less likely to comply withrestrictions [25]. Strong evidence for the beneficial impactof vigorous initial enforcement is provided in the longestfollow-up evaluation of its kind conducted in Scotland fiveyears after implementation of smoke-free legislation whichfound that high levels of enforcement immediately afterthe introduction of legislation have a long term effect onsmoking behaviour with compliance still high even thoughinitial inspection levels were not maintained [26]. This is amost promising finding suggestive of a long term positiveimpact of enforcement in smoking behaviour particularlythe de-normalisation of smoking indoors in hospitalityvenues.
As more countries follow the lead of Ireland andScotland in implementing comprehensive smoke-free leg-islation it is essential that there is on-going surveillance ofboth successful and failed aspects of each country’s imple-mentation, so that future developments may be informedof best practice. To this end researchers intending to moni-tor changes in exposure to SHS using PM2.5 measurementsshould adhere to a protocol such as that employed by theIMPASHS study (Evaluation of the impact of smoke-freepolicies in Member States on exposure to second-handsmoke and tobacco consumption study), which recom-mends that (1) the number, if any, of customers smokingwhile measurements are taken should be recorded; (2) theoutdoor level of PM2.5 should also be measured to providea control measure; (3) measurements should be recordedover a number of hours; and (4) follow-up measurementsshould be recorded in the same venues as the first wave ofdata collection and insofar as possible the venues shouldbe visited at the same time of day, on the same day of theweek and at the same time of year [27,28].
There are a number of methodological weaknesses inthis study that are noteworthy. Given the mix of retro-spective and prospective data included in the study it wasnot possible to ensure that a standardised measurementprotocol was adhered to in each country. This resulted ina number of differences between countries in terms ofthe measurement instrument used; sampling frame andtechnique employed; duration of data collection; and time-span between data collection points which means that the
gestation period of legislation varied. These deviations gen-erate valid questions as to the comparability of the datapresented. However, the authors are confident that theirinterpretation and presentation of results have been duly
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tempered. Lastly, in no instance is it claimed that the PM2.5concentrations reported for each country are representa-tive of the country as a whole with many of the studiesincluded, for example Ireland [13] and Italy [21], focusingon urban centres only.
5. Conclusions
Comprehensive smoke-free laws work and are essentialto protect hospitality workers and the general populationfully from the dangers of SHS. Partial smoke-free laws donot work as evidenced by their failure to reduce SHS signifi-cantly in the hospitality sector in Greece and Portugal. Morerecent developments in Greece have seen more robustsmoke-free laws put in place and these moves representan explicit acceptance that smoke-free legislation mustbe comprehensive in order to work. Any law, regardlessof scope, must be actively enforced to have the desiredimpact as clearly evidenced by the greater reductions inPM2.5 achieved in Ireland and Scotland compared to France,Italy and Turkey. The very nature of comprehensive lawsmay aid enforcement by removing ambiguity as to wheresmoking is permitted.
Disclosure statement
This project was funded by the Pfizer FoundationTobacco Control and Policy Micro-Grants programme.Support was provided throughout by the John HopkinsEvaluation Team and we especially wish to thank Asso-ciate Professor Frances Stillman and Dr. Michelle Kaufmannof the Johns Hopkins Bloomberg School of Public Healthfor their invaluable guidance throughout the term of theproject.
Acknowledgments
The project was only possible due to the generoussharing of expertise and data from a number of indi-viduals. The following, many of whom were IMPASHSpartners, were kind enough to share with us their knowl-edge of smoke-free policy and measurement data fromtheir respective countries: Professors Nazmi Bilir andHilal Özcebe, Hacetepe University, Turkey; Professor JoséAlberto Gomes Precioso, and Ms. Ana Catarina Samorinha,University of Minho, Braga, Portugal; Professor BertrandDautzenberg, Pitié-Salpêtrière, Paris, France; Dr. FrancescoForastiere, Public Health Agency of Lazio, Italy; Dr. PasqualeValente, Regional Directorate of Institutional Preventionand Territorial Health Care, Italy; Dr. Giuseppe Gorini, Cen-ter for Study and Prevention of Cancer (CSPO), Florence,Italy; Professor Pat Goodman, Dublin Institute of Technol-ogy and Ms. Marie McCaffrey, Health Service Executive,Dublin, Ireland; Dr. Manel Nebot and Dr. Maria José Lopez,Barcelona Public Health Agency, Spain; Dr. Sean Sem-
ple, University of Aberdeen, Scotland; Professor PanagiotisBehrakis, University of Athens, Greece and Harvard Schoolof Public Health; Dr. Constantine Vardavas, University ofCrete, Greece and Harvard School of Public Health.
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