Esteve Fernández, Cristina Martínez
Spain has been heavily affected by the COVID-19 pandemic. From the first diagnosed case on January 31 this year to August 13, there were 337,334 cases, 129,009 hospitalizations and 28,605 deaths. After a growing number of daily cases of coronavirus across the country in recent weeks, Spain is going to regulate smoking in public outdoor spaces such as streets and terraces, based on the rationale that smoking can spread the virus.
Despite the Spanish tobacco control law already having a smoking ban in some outdoor areas, including schools, health care campuses and children’s playgrounds, there is only a partial ban in terraces, based on overall coverage and the number of walls. Smoking in open public places is very common in Spain, where 24% of the adult population smoke. The national regulation of smoking in outdoor places follows the initiative from the regional Government of Galicia, announced on August 13. Prompted by this announcement, several other regional governments publicly expressed they were going to implement the measure. After an express meeting of the Council of the National Health System, the Minister of Health announced a smoking ban in outdoor public places if a 2 meter distance is not possible.
The significant impact of COVID-19 and new outbreaks in several regions of the country after the 100-day lockdown (between March 15 and June 21) partly explain this measure aimed at curbing the resurgent disease. Previous campaigns from both non-governmental organizations (NGOs) and scientific societies, together with a favourable anti-smoking social climate, also triggered its adoption.
In May, the Spanish Government made the use of face masks compulsory in streets and other outdoor spaces, and in all public indoor places where physical distancing of at least 1.5 meters is not possible. This requirement expanded the requirement to wear masks for all transport and workplaces, which had already been passed as part of the lockdown. Early in June 2020, the NGO “Nofumadores.org” launched the campaign “Smoke-free terraces, right now!” through the platform change.org which has collected almost 89,000 signatures to date.
At the same time, the working group on tobacco control of the Spanish Society of Epidemiology wrote a fact sheet and launched a press release pointing out the higher risk of SARS-Cov-2 transmission due to smoking in outdoor public places, mainly because of the emission of droplets and their diffusion with smoke or other aerosols (in addition to the hand-mouth movements and manipulation of face masks, and the risk of relaxing of distancing). Following this policy brief recommendation, and statements from other scientific societies and professional associations (national committee on smoking prevention, society of public health, society of respiratory medicine, and the federation of physicians’ colleges) in early July the Ministry of Health recommended avoiding tobacco consumption in community and social settings. On July 30, the NGO “Nofumadores.org”, with 20 scientific societies, consumers organizations and health professional associations, including the European Network for Smoking and Tobacco Prevention and ASH United States, sent a manifesto to the Minister of Health requesting the urgent prohibition of smoking on terraces of hospitality premises, and all outdoor public places. These requests have been widely covered by the media and social networks.
Whilst public health and tobacco control stakeholders welcome this step forward, a real and permanent ban of smoking in terraces and outdoor spaces has not been passed. The agreement of the Council of the National Health System on tobacco or other tobacco or similar products use states that smoking in the streets or in outdoor spaces is forbidden when a minimum 2 meter distance could not be achieved. Hence, smokers are allowed to remove their face mask while smoking in outdoor places whereas non-smoking people have to wear it, since the use of masks is mandatory in public places.
The Spanish regulation of smoking in outdoor spaces is consistent with the WHO statement on tobacco use and COVID-19, the risk for inhalation exposure to coronaviruses in microscopic respiratory droplets that could likely be enhanced by smoke and aerosols exhaled by smokers or users of other electronic devices, and that outdoor smoking bans have good acceptance and support by the population. Governments in other jurisdictions should take note of the Spanish experience to contribute to curbing the COVID-19 epidemic, prevent new outbreaks and potential new waves.
Esteve Fernández, Cristina Martínez are with the WHO Collaborating Center for Tobacco Control, Catalan Institute of Oncology; Tobacco Control Research Unit, Bellvitge Biomedical Research Institute; School of Medicine and Health Sciences, University of Barcelona; CIBER Respiratory Diseases.