Tobacco control in Portugal: stagnating with partial indoor smoking bans

Teresa Leão and Henrique Barros

In Portugal, one person dies every hour due to a smoking-related disease. In 2019, 13,559 individuals died from a smoking-related illness (11.7% of total deaths for the year), with smoking attributed as the top cause of age-standardized healthy life years lost. In addition, 15% of smoking-related deaths are caused by second-hand smoke exposure. Those children exposed to second-hand smoking pre, during and post pregnancy have a higher risk of respiratory diseases, allergic sensitisation and high blood pressure. Exposure to second-hand smoking is still frequent: 7.7% of the population is exposed daily, and this occurs more frequently in leisure places (34.0%), at home (30.4%) and in the workplace (25.7%).

In 2019, Portugal ranked 20th out of 36 European countries on the tobacco control policy scale, with lower scores attributed to poor policies on tobacco price, health warnings, stop smoking support and bans on smoking in public places. Since it ratified the World Health Organization’s Framework Convention on Tobacco Control in 2005, Portugal has slowly strengthened its tobacco control policies. On August 14th 2007, new legislation (Law no. 37/2007) set maximum levels of tar, nicotine and carbon monoxide in cigarettes, introduced warning labels and implemented restrictions on tobacco use in enclosed public spaces. Smoking was banned in indoor areas of health care settings, teaching and commercial establishments, museums, theatres, hotels, restaurants, cafes and bars, among others. However, there were exemptions: smoking was allowed indoors in casinos and in cafes, restaurants and bars of less than 100 squared metres that were equipped with smoke extraction systems. In larger areas, indoor smoking areas were permitted if physically separated from the remaining spaces.

On 26th August 2015, a new legislation (Law no. 109/2015), aiming to better protect the population from second-hand smoke, was adopted. This legislation restricted smoking in restaurants and bars, allowing it only in areas with no table service. This ban would not come into force until 1st January 2021, allegedly to avoid economic losses for those who had invested in smoke extraction systems after the 2007 legislation. In 2017, another law (Law no. 63/2017) reduced the number of places where indoor smoking areas would be allowed, and stated that its characteristics would be defined in a future government decree – this decree proposal became public and was submitted for public consultation on 6th August 2021.

Representatives from the bars and clubs’ industry reacted strongly against the proposed regulations, saying that these would be impossible to implement and that it would become ‘impossible to smoke in bars and clubs’. Though some recognized that clients’ safety should be the first concern, others argued that these changes would worsen their economic situation, a situation already weakened by the COVID-19 pandemic. The proposal stated that only settings with more than 100 squared meters and 3 meters high could have smoking areas – and that the smoking areas should be less than 20% of the total floor plan. These areas should be separated from the remaining areas by automatic doors and a vestibule, and should have ventilation systems (and defined the levels of negative pressure, the concentration of PM 2.5 and PM 10, among others).

Whilst the reaction from the restaurants and bars sector was expected and civil society is sympathetic to some of the economic arguments, it is clear that the 2007 legislation did not lead to adverse economic consequences. Furthermore, international evaluations of comprehensive smoke-free laws in indoor public places such as restaurants and bars have found limited adverse economic consequences.

However, even if the new proposals are accepted, there is still a way to go. Many would argue that defining more limited indoor smoking areas simply confuses the message that smoke-free indoor policies are best for health.

The limitations of partial bans have been already extensively discussed in the literature: the adoption of bans that allow exceptions may hinder their communication and enforcement. Smoking will continue in indoor spaces – even in areas that may not entirely fulfil the characteristics defined in the legislation. Therefore, the aims of the restrictions will be undermined and individuals will still be exposed to carcinogens and smoking will continue to be a normalised behaviour. Indeed, in 2010-2011, after the 2007 ban, two-thirds of bars and clubs still allowed indoor smoking, and in 2016, 97% of adolescents that frequent cafes, bars and clubs had witnessed smoking in those places and, from those that frequent restaurants, 70.3% had seen smoking there.  For higher effectiveness, a comprehensive smoking ban should have been adopted and implemented. But now, for the current legislation to have an impact, it must be clear to decision-makers that the restrictions need to be clearly communicated and enforced. The authorities responsible for enforcement must be adequately equipped and provided with enough human resources to visit, inform, create awareness and enforce restrictions.  Finally, civil society needs to respect new restrictions through collective social responsibility to protect one another: tobacco is still one of the leading causes of loss of healthy life years..

Portugal experienced the latest peak in smoking prevalence in western Europe and has the highest smoking rates among men. Women’s smoking rates grew until recently – peaking in 2014. In 2019 and 2020 over 10% of pregnant women smoked. In the face of these data and the fact that smoking remains the top cause of premature mortality in Portugal, decision-makers must be indifferent to the tobacco industry’s lobbying efforts, and, as in the case of sugar taxation, fully assume the  responsibility for ending the tobacco epidemic in Portugal.

Teresa Leão is a Researcher at the Institute of Public Health and Assistant Professor at the Faculty of Medicine, both at the University of Porto in Portugal.

Henrique Barros is a Researcher at the Institute of Public Health and Full Professor at the Faculty of Medicine, both at the University of Porto in Portugal.

 

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