INTRODUCTION
Smoking is widely recognized as a significant risk factor for numerous diseases, contributing substantially to global morbidity and mortality rates1. Epidemiological studies have consistently demonstrated a strong association between smoking and different health conditions, including cardiovascular diseases, respiratory conditions, and cancers2-5. The health burden of smoking extends beyond active smokers to those exposed to secondhand smoke, also known as passive smoking5,6. Secondhand smoke contains many of the same harmful chemicals inhaled by smokers, including nicotine, tar, and carbon monoxide, which pose significant health risks to non-smokers6. Children are particularly vulnerable to the effects of secondhand smoke7.
The pervasive and involuntary nature of secondhand smoke exposure underscores the importance of stringent smoke-free policies and public health interventions to protect non-smokers from these substantial health hazards. The cumulative evidence underscores the extensive health burden of smoking and passive smoking, including the use of novel tobacco products such as e-cigarettes and heated tobacco8.
To mitigate the adverse health impacts associated with tobacco use, a variety of tobacco control measures have been instituted globally. These measures are encapsulated in the MPOWER framework developed by the World Health Organization (WHO)9, which encompasses strategies such as monitoring tobacco use, protecting people from tobacco smoke, offering help to quit, warning about the dangers of tobacco, enforcing bans on tobacco advertising, promotion, and sponsorship, and raising taxes on tobacco products10. Among these strategies, legal interventions have been particularly effective in curbing tobacco use11. These legal changes are designed not only to reduce the accessibility and consumption of nicotine products but also to protect non-smokers from the detrimental effects of passive smoking.
Poland is a prominent example within Central and Eastern Europe for its proactive approach to tobacco control12. In 2010, Poland implemented a comprehensive ban on smoking in public places13, signifying a critical development in its public health policy. This legislative action was augmented in 2016 with the regulation of e-cigarettes, including a prohibition on their use in public spaces14. These measures positioned Poland at the forefront of tobacco control in the region. However, since these initial actions, no substantial legal reforms have been undertaken, except those required to comply with European Union directives, such as the ban on menthol cigarettes and regulations ensuring the quality of tobacco products12.
There is a high smoking prevalence in Poland, reaching one-quarter of the adult population15. Moreover, 5.9% of adults are daily e-cigarette users, and 4.9% use heated tobacco daily15. Poland has an ongoing public debate regarding the potential amendment of its anti-tobacco laws. The first smoking ban in public places was implemented in 1996 (in healthcare facilities, educational entities, and workplaces), significantly extending to numerous public places in 2010. In 2016, e-cigarettes and heated tobacco products were regulated and covered by a ban on their use in public places12,16. A focal point of this debate is the consideration of further tightening restrictions on smoking in public places and further increase of taxation of tobacco products. Public health experts raise concerns about the lack of a comprehensive public health strategy for tobacco control in Poland12. Moreover, compliance with the ban on smoking in public places, especially with a ban on e-cigarette use, poses a challenge16. Findings from the European Tobacco Control Scale 2021 showed that despite significant progress in tobacco control in 1996, Poland is currently lagging behind other Eastern European countries such as Slovenia, Lithuania, and Czechia17.
This study investigated public attitudes towards two foreseeable measures (a smoking ban on balconies and increased taxation) and an end-game scenario (a total ban on tobacco) in Poland. Therefore, it provides policymakers with evidence-based insights into public sentiment and preferences regarding smoking restrictions.
METHODS
Study design and sample
A nationwide cross-sectional survey was conducted during 2–4 February 2024, utilizing the computer-assisted web interviewing (CAWI) method. The survey comprised 14 closed questions regarding the usage of various nicotine-containing products. The specialized public opinion research company managed data collection, Nationwide Research Panel Ariadna, based in Warsaw, Poland, on behalf of the authors who provided the scientific framework for the study.
A non-probability quota sampling technique was utilized, incorporating a stratification model that considered gender, age, location of residence, and population size. This stratification was established using sociodemographic data from the Central Statistical Office of the Republic of Poland in Warsaw and was representative of the adult population of Poland.
To provide consistency with previous research, cigarette smoking, e-cigarette use, or heated tobacco use was based on the history of past 30-day use of these products (even once). Voluntary smoke-free home rules (total ban) were based on the question: ‘Is tobacco smoked in your home?’ (yes, without limitations; yes, in some parts; no, my home is 100% smoke-free). Sociodemographic questions and questions on smoking were based on previously published data within the same research project, “Poles’ attitudes towards smoking”15.
The Ethical Review Board approved this study at the Centre of Postgraduate Medical Education, decision number 403/2023 as of 23 August 2023. All procedures were in line with the Declaration of Helsinki.
Public attitudes toward selected tobacco control measures
Respondents were asked about their attitudes towards selected tobacco control measures using the following questions: 1) ‘Do you support the introduction of a smoking ban (tobacco use) on the balconies in a multi-family buildings (e.g. in an apartment block or multi-dwelling unit)?’; 2) ‘Do you support the introduction of a regular increase in the tax on tobacco products (e.g. a 10% tax increase every year)?; and 3) ‘Would you support a total ban on the production and sale of cigarettes and other tobacco products?’.
Participants were asked to declare their attitudes towards the abovementioned tobacco control measures on a 5-point Likert scale: ‘definitely yes’, ‘rather yes’, ‘rather no’, ‘definitely no’, and ‘I do not know’. For regression analyses, responses ‘definitely yes’ and ‘rather yes’ were combined into the category: participants who declare support for implementing a particular ban.
Data analysis
The data were analyzed using IBM SPSS Statistics version 29. Descriptive statistics were employed to present the distribution of categorical variables. Cross-tabulation with a chi-squared test was conducted to compare categorical variables. Regression analyses were used to examine the associations between sociodemographic characteristics and public support for: 1) a smoking ban on private balconies; 2) the introduction of a regular increase in the tax on tobacco products; and 3) a total ban on the production and sale of cigarettes and other tobacco products. Sociodemographic factors and smoking status were considered independent variables. Variables statistically significant in univariable logistic regression were included in the multivariable logistic regression. The strength of association was determined by the odds ratio (OR) and 95% confidence intervals (CI). Statistical significance was defined as p<0.05.
RESULTS
Sociodemographic characteristics of the study population
Data were collected from 1080 adults, with mean ± SD age of 48.4 ± 15.5 years. The gender distribution showed a slight majority of females at 53.0%, with the largest age group those aged ≥60 years (30.1%) followed by 30–39 years (19.5%), and 43.4% of the respondents held a university degree. The demographic characteristics of the study population are detailed in Table 1.
Table 1
Characteristics of the study population, cross-sectional survey, Poland, February 2024 (N=1080)
Attitudes toward various tobacco control measures
Support for introducing a smoking ban on private apartment balconies was 44.1% (26.0% definitely in favor, 18.1% rather in favor). Conversely, 19.0% were rather against, 21.9% definitely against, and 15.1% were undecided. Support for a regular annual tax increase on tobacco products was shown by 47.1% (28.4% definitely in favor, 18.7% rather in favor), while 15.1% were rather against, 21.4% definitely against, and 16.4% undecided. The least supported option was a total ban on the production and sale of cigarettes and other tobacco products, with 41.8% in favor (25.6% definitely yes, 16.2% rather yes), the strongest opposition with19% of the respondents rather against and 23.3% definitely against, and 15.8% undecided.
General support for studied tobacco control measures is presented in Table 2. Public attitudes towards selected tobacco control measures revealed significant sociodemographic differences (p<0.05), mostly by age, education level, smoking status, e-cigarette or heated tobacco use, as well as voluntary smoke-free policies at home (Table 3).
Table 2
Public attitudes towards selected tobacco control measures, cross-sectional survey, Poland, February 2024 (N=1080)
Table 3
Sociodemographic differences in public attitudes towards selected tobacco control measures, crosssectional survey, Poland, February 2024 (N=1080)
Factors associated with attitudes toward various tobacco control measures
A logistic regression revealed socioeconomic factors influencing public attitudes toward tobacco control measures (Table 4). Age ≥60 years (OR=2.12; 95% CI: 1.37–3.28; p<0.001), having a university degree (OR=1.37; 95% CI: 1.06–1.77; p<0.05), non-smoking status (OR=2.54; 95% CI: 1.80–3.57; p<0.001) and voluntary smoke-free home rules (OR=1.75; 95% CI: 1.29–2.36; p<0.001) were significantly associated with support for the smoking ban on the private balcony. Having a university degree (OR=1.71; 95% CI: 1.30–2.24; p<0.001), current employment or self-employment (OR=1.43; 95% CI: 1.12–1.83; p<0.01), non-smoking status (OR=4.19; 95% CI: 2.93–5.99; p<0.001), and voluntary smoke-free home rules (OR=1.93; 95% CI: 1.41-2.63; p<0.001) were significantly associated with support for the introduction of a regular increase in the tax on tobacco products. Having a university degree (OR=1.51; 95% CI: 1.17–1.96; p<0.01) and non-smoking status (OR=3.31; 95% CI: 2.33–4.71; p<0.001) were significantly associated with support for the total ban on the production and sale of cigarettes and other tobacco products (Table 4). There was no significant impact of gender, financial status, household size and composition, or place of residence, on public support of analysis of tobacco control measures.
Table 4
Logistic regression of factors associated with public attitudes towards selected tobacco control measures, cross-sectional survey, Poland, February 2024 (N=1080)
| Variables | Support for the smoking ban on the private balcony (definitely yes or rather yes) | Support for the introduction of a regular increase in the tax on tobacco products (definitely yes or rather yes) | Support for the total ban on the production and sale of cigarettes and other tobacco products (definitely yes or rather yes) | |||
|---|---|---|---|---|---|---|
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | |
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Gender | ||||||
| Women | 1.11 (0.87–1.41) | 1.12 (0.88–1.42) | 1.11 (0.87–1.41) | |||
| Men ® | 1 | 1 | 1 | |||
| Age (years) | ||||||
| 18–29 ® | 1 | 1 | 1 | 1 | ||
| 30–39 | 1.41 (0.91–2.19) | 1.45 (0.92–2.30) | 1.42 (0.93–2.19) | 0.82 (0.57–1.17) | ||
| 40–49 | 1.42 (0.91–2.21) | 1.60 (1.00–2.56) | 1.09 (0.71–1.68) | 1.11 (0.78–1.58) | ||
| 50–59 | 1.26 (0.81–1.97) | 1.50 (0.94–2.39) | 0.74 (0.48–1.15) | 1.41 (0.99–2.00) | ||
| ≥60 | 1.96 (1.30–2.96)** | 2.12 (1.37–3.28)*** | 0.90 (0.61–1.34) | 0.82 (0.54–1.23) | ||
| University degree | ||||||
| Yes | 1.50 (1.17–1.91)** | 1.37 (1.06–1.77)* | 2.02 (1.58–2.57)*** | 1.71 (1.30–2.24)*** | 1.66 (1.30–2.12)*** | 1.51 (1.17–1.96)** |
| No ® | 1 | 1 | 1 | 1 | 1 | 1 |
| Occupational status | ||||||
| Currently employed or self-employed | 0.88 (0.69–1.13) | 1.43 (1.12–1.83)** | 1.54 (1.17–2.03)** | 1.11 (0.87–1.42) | ||
| Pensioner/student/unemployed ® | 1 | 1 | 1 | 1 | ||
| Self-declared financial status | ||||||
| High | 1.25 (0.84–1.85) | 1.48 (0.99–2.21) | 1.36 (0.91–2.02) | |||
| Medium | 1.11 (0.77–1.61) | 1.33 (0.92–1.92) | 1.17 (0.81–1.70) | |||
| Low ® | 1 | 1 | 1 | |||
| Living alone | ||||||
| Yes | 0.87 (0.60–1.25) | 0.90 (0.62–1.29) | 0.81 (0.56–1.17) | |||
| No ® | 1 | 1 | 1 | |||
| Children in home | ||||||
| Yes | 0.92 (0.71–1.19) | 0.97 (0.75–1.26) | 1.05 (0.81–1.36) | |||
| No ® | 1 | 1 | 1 | |||
| Residence | ||||||
| Rural | 0.81 (0.55–1.21) | 0.75 (0.51–1.11) | 0.82 (0.55–1.23) | |||
| City <20000 inhabitants | 0.93 (0.57–1.50) | 0.94 (0.58–1.52) | 0.85 (0.52–1.38) | |||
| City 20000–99999 | 1.00 (0.65–1.56) | 0.83 (0.53–1.28) | 0.98 (0.63–1.52) | |||
| City 100000–499999 | 1.35 (0.86–2.11) | 0.97 (0.62–1.51) | 1.03 (0.66–1.62) | |||
| City >500000 ® | 1 | 1 | 1 | |||
| Cigarette smoking | ||||||
| Yes ® | 1 | 1 | 1 | 1 | 1 | 1 |
| No | 3.03 (2.28–4.03)*** | 2.54 (1.80–3.57)*** | 6.29 (0.46–8.59)*** | 4.19 (2.93–5.99)*** | 4.29 (3.16–5.83)*** | 3.31 (2.33–4.71)*** |
| E-cigarette or heated tobacco use | ||||||
| Yes ® | 1 | 1 | 1 | 1 | 1 | 1 |
| No | 1.56 (1.13–2.15)** | 0.69 (0.47–1.02) | 3.32 (2.34–4.70)*** | 1.49 (0.99–2.24) | 2.73 (1.92–3.88)*** | 1.45 (0.97–2.15) |
| Voluntary smoke-free home rules (total ban) | ||||||
| Yes | 2.51 (1.93–3.24)*** | 1.75 (1.29–2.36)*** | 3.86 (2.96–5.04)*** | 1.93 (1.41–2.63)*** | 2.41 (1.86–3.13)*** | 1.27 (0.94–1.73) |
| No ® | 1 | 1 | 1 | 1 | 1 | 1 |
DISCUSSION
This study provides critical insights into public support for various tobacco control measures in Poland, focusing on three policy options: a smoking ban on private balconies, a regular increase in tobacco taxation, and a total ban on tobacco sales. The findings in this study demonstrate varied public support for these measures, with nearly half of the respondents supporting each policy. A smoking ban on balconies of private apartments in multi-family buildings was supported by 44.1% of respondents, while 40.9% opposed it, and 15.1% were undecided. A regular annual 10% tax increase on tobacco products garnered 47.1% support, with 36.5% opposed and 16.4% uncertain. The least supported measure, a total ban on the production and sale of tobacco products, was favored by 41.8%, with the highest (42.3%) opposition and 15.8% undecided.
The smoking ban on private balconies is a targeted restriction to reduce secondhand smoke exposure in shared living environments. Such exposure is a risk factor, especially for minors18. It is also believed to be a driving factor for increased medical costs19. The complicated legal status of such spaces (private, semi-private) and the history of using them as designated go-to places for smokers, complicate the introduction of such measures20. In the current study, this measure gathered the support of 44.1% of respondents, particularly among non-smokers, older adults, and those with voluntary smoke-free home rules. The observed support level corresponds with other studies analyzed in a literature review by Boderie et al.21 who found an average support level of 41% for a smoking ban in outdoor private areas (e.g. private balconies). Higher acceptance rates among non-smokers and those with voluntary smoke-free home rules are consistent with the results of other studies that showed current smokers to be most skeptical towards any new tobacco control measures22.
The second policy option, a regular increase in tobacco taxation, is a widely recognized strategy for reducing smoking prevalence by making tobacco products less affordable23. Currently, the WHO recommends a minimum 75% tax share of the retail price of tobacco. This aligns with existing literature, which consistently demonstrates that tax increases are among the most effective tobacco control strategies, particularly in reducing smoking rates among younger and lower income populations24,25. In this study, 47.1% of respondents supported this measure. Other studies show higher support for increased taxation of tobacco products, as high as 59% in Denmark26 and over 76% in Vietnam27. However, the factors associated with this support are not consistent. In the current study, higher acceptance was associated with non-smoking, higher education, and being active in the labor market. Higher education and a non-smoking status are most often associated with higher support for tax increases26,27. At the same time, some studies show its dependence on gender26, place of residence27, or financial status28, which did not manifest in the current study. In this study, active occupational status was significantly associated with support for tobacco taxation, and this association was not observed when related to the ban on smoking on balconies or the total ban on sales. This observation requires further investigation.
The third policy option, a total ban on the sale of tobacco products, received the lowest support at 41.8%, with significant opposition. This reflects the controversial nature of such a measure, which, while potentially effective in eradicating smoking, raises concerns about feasibility and public acceptance29. Other studies have similarly found that while there is a growing interest in such bans, particularly in contexts of high smoking-related mortality, public support for this so-called endgame scenario is often lower than for other policy options. A recent study on support for a tobacco endgame strategy in 18 European countries30 revealed that acceptance levels vary between 20% and 60%, with a significant inverse trend observed with age and education level. Regarding the influence of education level, those results are contrary to the findings of the current study, where having a university degree was found to be significantly correlated with support for a total ban on the sale of tobacco products.
Findings from the EUREST-PLUS study showed that among smokers and recent quitters in Europe, 50.5% declared high support for implementing measures further to regulate tobacco products, and the majority of smokers would support a ban on tobacco products in the future if the government provided assistance to quit smoking31. Moreover, among smokers in Europe, public support for a ban on e-cigarette use in public places increased from 53.1% in 2016 to 54.6% in 2018, with the highest increase in Greece32. Data from Hungary showed that regulatory tightening of the Hungarian tobacco retail market resulted in short-term reductions in youth smoking prevalence33. Experiences from the European countries underline the need for a unified European tobacco control strategy implemented at the European Union level.
The practical implications of these findings are significant for policymakers. The relatively strong support for a smoking ban on private balconies suggests a potential area for immediate policy action, particularly in urban settings where shared living spaces are common. Additionally, the support for increased tobacco taxation suggests that this could be a politically viable and effective measure to further reduce smoking rates in Poland.
However, the mixed support for a total tobacco ban highlights the need for a more nuanced approach, possibly involving phased implementation or complementary strategies to address public concerns.
Limitations
The study is subject to several limitations. Firstly, the CAWI sampling strategy only provided representative data for the demographic structure of the adult population, excluding adolescents from the study population. Secondly, there is a potential for recall and demand biases, as all data were self-reported. Third, the non-probabilistic sampling is also a limitation of this study.
CONCLUSIONS
This study revealed that less than half of adults in Poland declare support for extensive tobacco regulations such as a smoking ban on private balconies, taxation increases, and a ban on tobacco sales. Social support for all analyzed policies was influenced primarily by education level, smoking status, and voluntary smoke-free rules at home. The significant association between voluntary smoke-free home rules and support for stricter policies indicates that individuals who already practice self-imposed smoking restrictions are more likely to endorse broader regulatory measures. Further educational activities are needed to build social support for tobacco control measures in Poland.
