Elsevier

Health & Place

Volume 16, Issue 5, September 2010, Pages 961-968
Health & Place

Smoking in urban outdoor public places: Behaviour, experiences, and implications for public health

https://doi.org/10.1016/j.healthplace.2010.05.012Get rights and content

Abstract

This paper identifies factors that influence where people smoke outdoors and examines the impact of smoking on people who use outdoor public places. Direct observations of smoking at 12 outdoor public places and semi-structured interviews with 35 non-smoking and smoking adults were used to gather information in Toronto, Canada, about where people smoke, and smoking related behaviours, perspectives, and experiences. Observation and interview data show that smoking at building entrances was problematic. In total, approximately 37% of smoking observed across the sites was within 9 m of building entrances. Shelter, convenience, the social culture of smoking, visibility, and the presence of non-smokers were key factors that influenced where people smoked. Clearly defined rules for smoking at building entrances may allow users of public spaces to avoid tobacco smoke when entering and exiting. However, further research is needed regarding the effectiveness of outdoor restrictions and potential unintended consequences.

Introduction

With an increase in indoor smoking restrictions, many smokers smoke outdoors, especially at entrances to buildings. In high-density urban spaces, this has become a contentious social and health issue. Smokers who congregate outside buildings expose non-smokers who are standing nearby or entering and exiting the building to secondhand smoke. Approximately half (53%) of Canadian adults report being exposed to secondhand smoke at building entrances (Health Canada, 2008).

Exposure to secondhand smoke in outdoor environments is a public health concern because there is no safe level of exposure (US Department of Health and Human Services, 2006). Further, there is evidence that outdoor exposure can be substantial and, in some cases, as high as indoor exposure when smoking is present (Repace, 2005, California Air Resources Board, California Environmental Protection Agency, 2005, Klepeis et al., 2007, Hall et al., 2009). Recent unpublished studies have also shown that concentrations of tobacco smoke at building entrances can reach hazardous levels, with average concentrations more than twice as high as background levels (Kaufman et al., 2009, Kennedy et al., 2009). Secondhand smoke is linked to adverse health effects, including lung and nasal sinus cancer, heart disease, and breathing difficulty for people with chronic respiratory diseases or asthma (US Department of Health and Human Services, 2006, US Environmental Protection Agency, 1992), breast cancer in non-smoking premenopausal women (California Air Resources Board, California Environmental Protection Agency, 2005, Johnson, 2005), and adverse health effects specific to children and infants (California Air Resources Board, California Environmental Protection Agency, 2005, DiFranza and Lew, 1996). Short term exposure has also been found to cause immediate harm to non-smokers, particularly for those with very sensitive cardiovascular systems (US Department of Health and Human Services, 2006, Barnoya and Glantz, 2005, Sargent et al., 2004, Pechacek and Babb, 2004), and may induce short-term general respiratory irritation, eye irritation, and asthma symptoms (US Department of Health and Human Services, 2006). A recent study of secondhand smoke in restaurants and bars showed that even brief exposure (i.e., 30 min) can lead to sustained vascular injury (Heiss et al., 2008).

Further, smoking around doorways contributes to increased toxic litter, fire risk, negative role modelling and presents a poor image to outsiders and visitors (Nagle et al., 1996, Parry et al., 2000, Alesci et al., 2003). These more tangible concerns have led increasing numbers of jurisdictions to implement smoking restrictions in outdoor spaces.

Indeed, in communities and municipalities across Canada, legislated smoking restrictions have been implemented in a variety of outdoor settings, such as municipal playgrounds, outdoor sport and recreation facilities, parks and beaches, transit properties, patios, and during outdoor public events (Non-Smokers’ Rights Association, 2009). In some jurisdictions, these restrictions have included entrances to buildings. As of January 2010, most Canadian provinces and territories had outdoor smoke-free legislation that included a buffer zone prohibiting smoking around the entrances, operable windows, and air intakes of specific types of buildings (e.g., public buildings, healthcare facilities, or enclosed workplaces) (Smoking and Health Action Foundation/ Non-Smokers’ Rights Association, 2010).

In Ontario, the Smoke-free Ontario Act (SFOA, 2006) prohibits smoking within 9 m of any entrance or exit to a health care facility (e.g., hospital, psychiatric facility, nursing home, home for the aged, or independent health facility). Approximately 25 jurisdictions in Ontario have smoking restrictions that go beyond the SFOA by including smoke-free buffer zones of varying distances (2–10 m) at the entrances and exits, operable windows, and air intakes to public buildings (i.e., municipal or city owned). In a few cases, this has been extended to other types of workplaces and public places (e.g., Thunder Bay and Sioux Lookout) (Smoking and Health Action Foundation/Non-Smokers’ Rights Association, 2010). Of particular significance is the City of Woodstock, Ontario, where private businesses can enlist to have their doorways smoke-free and enforced through the municipal outdoor smoke-free bylaw, which prohibits smoking within 9 m of entrances to public facilities (Non-Smokers’ Rights Association, 2009, City of Woodstock, 2008).

Internationally, consideration and implementation of outdoor smoking bans has also emerged. For example, in Tasmania, Australia, smoking is prohibited within 3 m of a doorway to a public building (Smoking and Health Action Foundation/Non-Smokers’ Rights Association, 2010), and early in 2010, England’s health secretary announced a review of smoking legislation that may include restrictions at entrances (BBC News, 2010). Some cities have taken this even further. In Tokyo, smoking is banned on streets and crowded stations in the government and business district (BBC News, 2002) and Calabasas, California, has banned smoking on city sidewalks, parks, playgrounds, and within 20 feet of the main entrances and exits of public buildings (City of Calabasas, 2006). However, in most locations doorway restrictions are non-legislated (i.e., voluntary).

Public support for outdoor smoke-free spaces has also grown, particularly in relation to the impact on children (Thomson et al., 2009). Accompanying this growing acceptance of outdoor smoke-free spaces is a decrease in social tolerance for smoking. Disapproval of smoking can result in smoker stigmatization, which has been associated with quitting and preventing the uptake of smoking (Stuber et al., 2008). Similarly, social policies that increase the social unacceptability of smoking have been found to reduce cigarette consumption (Alamar and Glantz, 2006).

However, there are challenges implementing and enforcing restrictions in outdoor environments. First, there is limited research on smoking behaviour and exposure to secondhand smoke that is specific to outdoor environments. Second, the social and physical characteristics of indoor and outdoor environments differ. Site boundaries in outdoor environments can be ambiguous and subject to frequent change due to weather, seasonal transformation, and variation in site use. Third, attitudes and perceptions of risk about outdoor smoking may differ from indoor smoking.

To address these gaps in knowledge, this paper set out to identify factors that influence how people make decisions about where to smoke in outdoor urban environments, what influences these choices, and how choices about where to smoke impact people who use outdoor public places.

Section snippets

Methods

Observations (Zeisel, 1981) of smoking at 12 outdoor public places in downtown Toronto, Canada, and semi-structured face-to-face interviews with 35 smoking (n=18) and non-smoking (n=17) adults were used to gather data on smoking behaviours, attitudes, and experiences between 2004 and 2007. A pilot study in 2002 pre-tested and refined observation methods and was used to develop interview guides. Both studies were approved by the University of Toronto Research Ethics Board.

In this study we define

Factors that influenced where people smoked

Although each of the study sites varied considerably in physical layout, design, and frequency of smoking, the observation data show a similar pattern of smoking location across most sites. Concentrated smoking activity was located near or around the entrances and structural edges of buildings and places with overhead shelter and nooks, as well as less visible areas behind pillars, at side entrances and in alleyways (e.g., Fig. 1, Fig. 2). In total, approximately 37% (398/1081) of all observed

Discussion

Our findings show that smoking at entrances to buildings was problematic, with more than a third (37%) of the total observed smoking occurring within 9 m of entrances. Smokers were primarily drawn to these locations because they offered shelter and convenience. However, among non-smokers, the location of smoking at doorways raised concerns about secondhand smoke, challenges in finding smoke-free outdoor spaces, and cigarette litter.

From a public health perspective, smoking restrictions at

Limitations

The locations of smoking at each site were plotted by a pair of observers on individual hard copy site maps for each observation session. While there was very high agreement about the numbers of people smoking for each pair of maps, the location of smoking was approximated on the site plans in the field. Therefore, we have estimated a 1–2 m overall margin of error in the results. Drawing a 9 m radius on small scale site plans and counting observed incidences of smoking also may have contributed

Acknowledgements

This study was supported by a National Cancer Institute of Canada Research Grant funded by the Canadian Cancer Society (Grant No. 14072). Pilot work was funded by the Canadian Tobacco Control Research Initiative (Grant No. 13007). The views expressed are those of the authors and not necessarily those of the funder.

We are grateful to all the participants who shared their experiences and perspectives. We also thank the research assistants and staff who helped with various stages of the study:

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