In considering the implications of this study, it is important to keep in mind that the sample consists of smokers. Non‐smokers have more positive attitudes to smoke‐free areas.10,31
This study is the first to examine both the prevalence of smoking bans across four different countries, and as such, our results revealed much about the psychosocial and behavioural effects of smoking bans in restaurants and bars and how these vary across the four study countries. Australia is leading the way in restricting smoking in restaurants, and Australian smokers most strongly support bans. UK smokers were the least likely to both report bans and to support them. In the USA and Canada, there was considerable within‐country variation, with California having higher reported bans and marginally higher support for total bans than Australia. Across the four countries, smoke‐free restaurants were far more prevalent than smoke‐free bars and support for smoke‐free in bars was far lower, even where bans are in place.
The most important limitation of this study is in characterising what restrictions each smoker actually was subject to. We used both self‐report and documented restrictions. Both have limitations. Getting information on jurisdictional bans below the level of state/province was not practical, so we were unable to document local ordinances where these are possible (USA and Canada). We were also not able to document proprietor‐initiated restrictions. Further, documented bans need to be considered in the light of any exemptions. Governmental restrictions should be applied evenly within the jurisdiction, although implementation may vary. However, it is common for laws to have exemption clauses, where the consequences differ by type of establishment. For example, exemption of bar areas in restaurants effectively allows smoking in parts of those establishments, sometimes in the same physical space as the restaurant seating area, whereas, under the same law, restaurants without bars will have total bans throughout the premises. Thus what can appear from a superficial appraisal of the policy as a complete ban, can be experienced by smokers (or others) as quite different requirements in different types of establishments. This means that at least some of the apparent disparity between reported and documented restrictions may represent legitimate experiences grounded in real differences, not lack of perceptiveness by the smokers.
Reported restrictions also have limitations. Individuals presumably respond to questions about the existence of rules based on a mix of what they know to be legislated and what they remember experiencing at individual venues they visit. Thus it is possible for residents of a jurisdiction with total bans in restaurants but not in bar areas to perceive that smoking is allowed in some areas of some restaurants. Some smokers reporting restrictions where we report no extensive restrictions could be either responding to local jurisdictional initiatives (in the USA and Canada) or to proprietor‐driven bans. Further, some of those reporting limited bans in areas where there are notionally extensive ones may be focusing on the exemptions, or areas of low compliance. Related to this, reports of limited restrictions can vary greatly in what is referred to: from total bans with limited exemptions to separate seating areas within the same space. Also, where bans exist, but are not complied with, smokers may think there are no real restrictions. Taken together, anything short of observation is unlikely to provide totally valid indices of what actually happens, and even here establishments with no formal restrictions may not have any smoking in them on some occasions.7
The above limitations mean that this study (like all surveys) should be used with caution in estimating the prevalence of strong and effective restrictions on smoking in either kind of venue. However, this study is likely to be valid for identifying between country diversity and for predicting support for bans and reported compliance with smoke‐free requirements. Here the results are consistent and robust, with essentially the same results found when we analysed as a function of reported restrictions, documented restrictions, or a combination of the two.
Support for smoke‐free environments is much stronger when they are mandated to occur or are experienced as being in place as was predicted. Further, where smokers have had comparable experiences (for example, restaurant bans) they are more likely to support bans in other areas, in this case bars. The cross‐sectional nature of this study means that this, of itself, cannot be used to make strong causal links. However, there is now strong evidence that support for smoke‐free policies in many kinds of venues, including workplaces and restaurants, increases following their implementation.9,26
Taken together, this strongly suggests that at least part of the stronger support for bans where they are in place is a result of the better than expected experiences of them. In other words, the majority of cigarette smokers appear able to easily adapt and eventually support smoking bans whether they occur where they work, dine out, or drink. Perceived or experienced ability to adapt is also important. Smokers who voluntarily did not smoke where there were no restrictions were more supportive of bans, and support for bans was also strongly related to compliance, at least as reported.
Support for restrictions on smoking in bars was less strong. This appears to be only partly due to lower levels of restrictions in bars. Although we found similar predictors of support, they accounted for less of the variance. Perceived or real synergistic effects of smoking and alcohol consumption32
may be important here.
The results show expected effects for the smoking‐related covariates: both the frequency of having thoughts about the harm smoking can do to others and the belief that passive smoking is harmful contributed independently as predictors of support for restrictions, while heavier smokers were more likely to be opposed to such restrictions. This pattern of results demonstrates that in addition to beliefs that passive smoking is harmful, the frequency of accessing those beliefs also contributes to the impact such beliefs may have in creating support for smoking bans. The role of the frequency of accessing such beliefs seems to be particularly important when bans are not in place. This result has implications for the design of public health campaigns designed to increase support for smoking bans.
There were some interesting sex and age effects. Female smokers were less likely to support bans (clearly in restaurants, marginally in bars). In restaurants, at least, this was clearest where they reported not being exposed to total bans. Support also increased with the age of the smoker in both venues. Again, for restaurants this effect was most pronounced where no bans were reported. Even after controlling for the covariates, there remained a country effect in support for restaurant bans with Australians being most supportive. This may be because of the pervasive nature of restaurant bans in Australia, or it could reflect some other unmeasured difference between Australian smokers and those from the other three countries. By contrast, when we included the measures of restaurant bans as predictors of support for bans in bars, the country effect disappeared. This is consistent with the more pervasive experience of bans in Australia being a key factor. The high level of support for bans in jurisdictions with documented bans is also consistent with this interpretation. It is possible that the pervasive bans on smoking in eating areas, even in bars, may be leading to more Australian smokers not smoking when visiting such establishments, as to smoke they would need to leave the area where they are seated. This would produce more experience of visiting bars and not smoking. However, as we did not ask about the specific activities our respondents engaged in, this remains speculative.
The findings reported here have several implications for jurisdictions contemplating banning smoking in recreational venues such as these. First, public support (including among smokers) can be strengthened by both informing the public about the adverse health effects of passive smoking and by encouraging them to continue thinking about the issue. Once bans are implemented there will be less need for public information as the bans seem to be largely self enforcing and, once smokers experience them, rapidly become accepted. Second, there is likely to be greater opposition from smokers to bans in bars than in restaurants, but even here post‐implementation opposition is likely to decline. It is not clear why support for bans in bars is less strong even where they are implemented. It could be because the experience is overall less positive for smokers than bans in restaurants, or it could be in part due to bans in restaurants still being a novelty. The latter is made less likely, in that support in California (essentially the only US jurisdiction with bans) was still at only a little over one quarter. However, the interactive adverse effects of alcohol and tobacco on health33
mean that policymakers cannot afford to make a long term exception for bars. The policy strategy of moving first on restaurants and then to bars may be politically more feasible, but such a strategy should not require separate legislation; instead, it should specify a later implementation date for bars. In the present study, we found no clear evidence of strong widespread antagonism to bans in bars where they were in place, so policymakers can implement comprehensive bans in recreational venues confident in their practicality and general acceptability.
Compliance in restaurants was generally high and unrelated to beliefs about harms of passive smoking or cigarette consumption. Compliance was reported as higher where smokers support the ban, and was less in the UK. The latter finding may be due to failure to control fully for the contribution of having documented area‐wide bans. As far as we know there are no laws mandating bans in restaurants in the UK, so any perceived bans would be those imposed by proprietors. This may explain their lower compliance levels. The high level of not smoking in the presence of partial bans in Australia, as compared to the other countries, is consistent with partial restrictions in Australia being more stringent. Many of the rooms used as restaurants in bars in Australia do not have any smoking even where there is a bar (proprietors' decisions). So patrons who use such places primarily to eat would need to move to another room to smoke, something that may often be inconvenient. Thus they may be less likely to smoke inside the establishment as compared with someone who can smoke in the same room, even though both report a partial ban. That support for bans is related to reported compliance suggests that gaining and sustaining public support for bans is a crucial aspect of trouble‐free implementation. Once implemented, bans seem to be largely self‐enforcing, but this may be dependent on smokers not forming strongly antagonistic views about them.
What this paper adds
Although between‐country variation in the prevalence of smoking bans in restaurants and bars is widely known, to date, systematic study has yet to be carried out and little is known about the psychosocial and behavioural effects of smoking bans on smokers in such venues.
Using baseline data from the International Tobacco Control Four Country Survey, the present study demonstrated that once implemented, support for and reported compliance with smoke‐free policies in restaurants and bars are high and their associates are also fairly similar across the four countries being studied. These findings provide further support and reassurances for policymakers to implement a comprehensive smoke‐free policy in restaurants and bars without fear of retribution from smokers. The similarity of associates of support and compliance across the four countries is likely to mean that intervention strategies can have a high degree of universality.
Care should be taken in generalising these findings to other countries, especially where cultural traditions are quite different or where smoking is more normative. That said, we can think of few countries with more established bar traditions than the four we have studied, so would be surprised if our findings for bars did not translate, or that there was stronger support in other countries, given a similarly informed population of smokers. For restaurants, cultural traditions are more similar, and we see no clear reasons to doubt that the broad findings would apply. Our results suggest a well educated population of smokers is likely to support bans, and once implemented, to comply. We can see no reason as to why this would not generalise.
The determinants of support for and reported compliance with smoking bans in restaurants and bars appear to be the same in the four countries we studied. Taken as a whole, this and other research strongly suggests that comprehensive smoke‐free policies, once implemented, will attract support from smokers and compliance will be high. Both are likely to be increased by educating smokers of the need for the policies.