INTRODUCTION

Smoke-free legislation has been shown to be effective and have a positive impact on the population’s health1, as people who live in countries that have smoke-free bans are less exposed to secondhand smoke (SHS), especially if they have comprehensive legislation rather than partial bans2. Moreover, smoke-free legislation could also change behaviors beyond the ban itself, such as not smoking at home3,4 and reducing smoking prevalence, mostly among women5. However, not only traditional tobacco products and SHS should be considered when talking about smoke-free environments6. The use of electronic cigarettes (e-cigarettes) or heated tobacco products (HTPs) produces aerosols containing different hazardous substances7,8 that are exhaled by users as secondhand aerosols (SHA).

There is growing evidence supporting the health harm of SHA, which contains numerous toxic and carcinogenic substances9,10, Moreover, the use of e-cigarettes and HTPs increases levels of harmful substances in the air of enclosed places-11,12,13,14. However, most of the legislations in the WHO European Region are not comprehensive enough when it comes to e-cigarettes and HTPs10. Therefore, protection against SHA should be taken into account when creating or trying to expand or enforce clean air policies8.

Another challenge is the lack of legislative solutions regarding smoke- and aerosol-free environments (SAFE). Regardless of some common regional regulation, such as the Tobacco Products Directive (TPD)15 in the European Union (EU) or, more globally, the WHO Framework Convention for Tobacco Control (FCTC)16, the level of protection offered to non-smokers varies depending on the country they live, and this is mainly a consequence of differences between clean air policies across countries2. Additionally, we must take into account that there are also differences in the terms of compliance and enforcement of these legislations17.

As acknowledged in recent global reports on the tobacco epidemic and tobacco control18,19, nations are progressively expanding smoke-free regulations to encompass outdoor spaces. Despite the decline in SHS exposure attributable to the positive impact of effective legislation, substantial exposure still persists in certain public and private settings, such as bars and restaurants, or homes and cars20.

To support further progress in protection from SHA and SHS, Work Package 8 of the Second Joint Action for Tobacco Control (JATC2) aimed to outline and disseminate best practices in order to address the upcoming challenges for smoke-free environments in Europe. For this purpose, a consultation with European experts on best practices, barriers, and opportunities to expand SAFE was designed.

This article aims to present the protocol used to identify best practices, barriers, and opportunities to protect people from exposure to SHS and SHA produced by e-cigarettes, HTPs, and other tobacco or nicotine products.

METHODOLOGICAL APPROACH

Identification and selection of experts

We applied several methods to identify and involve tobacco control experts across Europe in our consultation. First, the JATC2 employed a contact list of all partners and their affiliated authorities, institutes, or organizations working in the field of tobacco control (policymakers, regulators, researchers, tobacco inspectors, NGO activists) partners from EU Member States, as well as non-EU countries of Europe. Second, the Catalan Institute of Oncology, a WHO Collaborating Centre for Tobacco Control, provided its list of contacts, including speakers and attendees, to five editions of five ICO-WHO Symposia on tobacco control. Third, the Smoke-Free Partnership (SFP) and the European Network for Smoking and Tobacco Prevention (ENSP) were requested to provide their list of contacts, partners, and members for the JATC2 consultation. From all of these sources, we identified 110 experts from 30 European countries (27 EU Member States, Norway, Serbia, and the United Kingdom).

Inviting experts to participate in the consultation

All of the identified experts were invited by e-mail to participate in the consultation. The invitation email explained the objectives of the consultation, the instructions to complete the online questionnaire, and the links to access both Section 1 and Section 2. After accepting the invitation for the consultation, the experts were sent the online questionnaire gathering information on any type of SAFE, including both public and private environments and outdoor and enclosed places. After acceptance, the experts were sent an online questionnaire gathering information on any type of smoke-free environment, including both private and public environments, outdoor and enclosed places, and protection from tobacco smoke or exposure to aerosols from HTPs or e-cigarettes. Of the 110 invited experts, 61 (response rate of 55.4%) from 29 EU countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxemburg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden and United Kingdom of Great Britain and Northern Ireland) provided full or partial answers to the online questionnaire (Supplementary file)

Designing, programming, and testing the online questionnaire

The online questionnaire21 contained a compulsory information and consent form, as well as two other sections. Section 1, with 26 questions (nine on sociodemographic information, 9 open-ended, and 8 open questions), explored the comprehensiveness of existing smoke- and aerosol-free legislation, perceived compliance, perceived barriers, and opportunities for expansion. The first section also explored the extent of tobacco industry interference. Section 2 included 42 questions: 16 open-ended and 26 open questions, allowing national experts to provide detailed information through text or links about practices that are considered best practices on SAFE. The online questionnaire was programmed using Survey Monkey. It included multiple choice quantitative closed-questions and qualitative open-ended questions and also allowed the attachment of documents or links to some questions. Testing of the questionnaire was conducted by the WP8 partners, who, after filling it in, provided feedback about the duration, readability, and comprehensibility of the questionnaire.

Completing the survey filling in and data collection

Each respondent was asked to report information on up to four best practices and to provide four specific online links for each best practice. Since the questionnaire had more than 60 questions and many of them required detailed descriptions, the process of filling it in required a median of two days (two entries) for most of the respondents. The questionnaire was structured to enable experts to pause, save, and resume completion at the precise point where it was initially suspended.

The follow-up of data collection was conducted weekly by programmed routines in Survey Monkey, including follow-up of the status of completion of questionnaires for each expert and reminders to continue with the task. The questionnaire was accessible for a duration of up to 12 weeks from its launch date on the 15 June up to the 15 August 2022.

Data handling and record keeping

All data were stored in Excel and transferred to Stata for analysis. A web-based repository with all best practices on SAFE reported was created and is currently fully functional.

Data analysis

Step 1

We assessed response rate, namely the number of answers received (total and per country; % of non-response); the number of Best Practices (BP) received per country; completeness of received questionnaires (overall %; and question-specific details) and the correctness of links and/or documents provided.

Step 2

Descriptive analyses were conducted to explore the distribution of BP topics. The quantitative variables of the practices, barriers, and opportunities and each category are presented in Tables 1 and 2.

Table 1

Quantitative variables to assess best practices on SAFE

VariablesCategories
Type of practiceInformation/awareness raising program
Policy
Action plan
Regulation/ban
Monitoring/surveillance
Service delivery approach/method
Tool/instrument
Guideline
Training
E-health – mHealth
Health in all policies
Don’t know
Phase of the practicePractice is at the first stage of implementation but not yet totally developed
Practice has been developed/adopted but not yet enforced
Practice has been implemented (enforced/promoted)
Practice has been evaluated
Practice has been registered in a best practice registering portal
Don’t know
Responsibility for the practiceMunicipality/city
Province/region
Nation
Public agency
University
Government
NGOs
Private institution
Don’t know
Duration of the practicePractice is ongoing
Practice has ended
Don’t know
Start and end date of the practice
Scope of the practiceInternational
National
Regional
Local
Funding of the practiceOwn resources
External resources – public
External resources – private excluding the tobacco or nicotine industry
External resources – private including the tobacco or nicotine industry
No funds required
Don’t know
Objectives of the practiceSmoke-free indoor settings (conventional tobacco products)
Smoke-free outdoor settings (conventional tobacco products)
Voluntary home smoking ban (conventional tobacco products)
Car smoking ban with minors or pregnant women (conventional tobacco products)
Car smoking ban also without minors or pregnant women (conventional tobacco products)
Smoking ban as an anti-COVID-19 measure
Indoor aerosol-free regulation for e-cigarettes
Outdoor aerosol-free regulation for e-cigarettes
Voluntary home aerosol ban regulation for e-cigarettes
Car vaping ban with minors or pregnant women
Car vaping ban also without minors or pregnant women
Vaping ban as an anti-COVID-19 measure
Indoor aerosol-free regulation for heated tobacco products
Outdoor aerosol-free regulation for heated tobacco products
Voluntary vaping ban regulation for heated tobacco products
Car heated tobacco product ban with minors or pregnant women
Car heated tobacco product ban also without minors or pregnant women
Ban of heated tobacco products use as an anti-COVID-19 measure
Target settingsRestaurants and bars (indoor)
Hotels (indoor)
Train stations and public transports (indoor)
Airports (indoor)
Workplace (indoor)
Schools/public education institutions/educational venues except universities (indoor)
Universities (indoor)
Cinemas/theatres (indoor)
Hospitals including outpatient clinics (indoor)
Primary health care institutions (indoor)
Institutions from social sector (indoor)
Prisons (indoor)
Cars
Home
Restaurants’ patios/terraces (outdoor)
Bus, tramway, trolley-bus stop waiting areas (outdoor)
Parks (outdoor)
Underpass (outdoor)
Stadiums and outdoor arenas (outdoor)
Beaches (outdoor)
Outdoor areas of hospitals and healthcare institutions (outdoor);
Outdoor areas of school (outdoor)
Children’s playgrounds (outdoor)
Target populationGeneral population
Gender specific groups
Age specific groups
Socioeconomic position (including educational level)
Certain levels in education system
Cultural/ethnic background
Vulnerable groups (Disability)
Vulnerable groups (Diseases)
Vulnerable groups (Prisoners)
Vulnerable groups (Sexual diversity; e.g. LGBTQ)
Vulnerable groups (Pregnant women)
Vulnerable groups (Immigrants/refugees)
Urban setting
Rural settings
Don’t know
Involvement of the target population in development; implementation or evaluation of the practiceInternational/European public health authorities
National public health authorities
Regional public health authorities
Local public health authorities
Hospital staff
Primary care center staff
Specialized physicians
General practitioners
Pharmacists
Nurses
Other health care professionals
Informal caregivers
Researchers/academics
School/kindergarten teachers
Employers/employees
Civil society
Enforcement of the practiceYes
No
Evaluation of the practiceYes, by an external partner
Yes, the evaluation was carried out internally
Not yet, the intervention is still ongoing but the evaluation is foreseen
No
Don’t know
Transferability of the practiceTransferability has not been considered
Practice has been implemented on local/regional/national level and transferability has not been considered in a systematic way
Ready for transfer, but the practice has not been transferred yet
Practice has been developed on local/regional/national level and transferability has been considered and structural, political and systematic recommendations have been presented. However, the practice has not been transferred yet
Practice has been transferred (i.e. scaled-up) within the same country/region
Practice has been scaled-up to other locations or regions or at national scale in the same country
SustainabilityPractice has institutional support and stable human resources
Practice provides training of staff in order to sustain it
A sustainability strategy has been developed
None of the above options
Table 2

Quantitative variables to assess barriers and opportunities for expansion of compliance with and enforcement of SAFE

VariablesResponse categories
In your country, can you identify any barriers for the expansion of smoke and aerosol-free environment policies?Yes/no
In your country, can you identify any barriers to the improvement of compliance with (or enforcement of) smoke and aerosol-free environment policies?Yes/no
In your country, to what extent do you think the tobacco or nicotine industries (and their allies) are interfering with the expansion of smoke and aerosol-free environments?No interference
Small
Moderate
Large
Very large interference
In your country, to what extent do you think the tobacco or nicotine industries (and their allies) are interfering with the enforcement of smoke and aerosol-free environments?No interference
Small
Moderate
Large
Very large interference
In your country, can you identify any opportunities for the expansion of smoke and aerosol-free environment policies?Yes/no
In your country, can you identify any opportunities for the improvement of compliance with (or enforcement of) smoke and aerosol-free environment policies?Yes/no

Ethical considerations

Informed consent was obtained by ticking affirmatively the two final questions of the first page of the online questionnaire: 1) ‘I understand and agree that the provided information is correct and may be used by the WP8 leaders for the purposes indicated’; and 2) ‘I understand and agree that my name and institution can be listed in the JATC-2 website and reports. Experts had the right to withdraw at any point of the consultation.

Conflicts of interest

All the experts were asked about potential conflicts of interest with the aim of the consultation. No experts with links to the tobacco and/or electronic cigarette industry were included in the experts’ panel.

DISCUSSION

Quantitative variables addressing best practices and allowing multiple choice responses were analyzed as a number of responses (frequencies) for each category of the variable. A number of practices and percentages were calculated for the single-choice response variables. Qualitative open-ended questions addressed best practices, and careful reading of each practice allowed the classification of the practice into groups. A series of thematic analyses were conducted using subjective coding systems by three members of Work Package 8 of the Joint Action on Tobacco Control 2. Responses were categorized thematically using the Title of the practice as a reference to group the practices into a broader group ‘type of setting’. Finally, the list and details of each practice were placed in a Web-based repository.

Qualitative open-ended questions addressing barriers and opportunities, a series of thematic analyses were conducted using subjective coding systems by three members of Work Package 8 of the Joint Action on Tobacco Control 2. Responses were first categorized thematically; however, this classification resulted in a high number of categories (n=11–15) that were difficult to overview. Therefore, as a second step, we collapsed these into broader thematic categories (n=5–6). Finally, these categories were presented in tables as numbers and percentages of the total responses, taking the total number of experts as the denominator.

Additional information on best practices was obtained by web links and PDF documents uploaded while answering the survey. We conducted best practices content analysis and summarized it in a narrative report to allow synthesis and readability of the results.

CONCLUSIONS

This protocol has been a guide for all the foreseen activities related to the identification of best practices to expand SAFE in European countries. It allowed us to systematically work on the online consultation with experts22, the report of the symposium with experts, the reports on best practices23, barriers, and opportunities for SAFE24, the web-based repository25, the weight of evidence26, and finally, the position paper for SAFE27.