Tobacco control policies and respiratory conditions among children presenting in primary care.

Tobacco control policies can protect child health. We hypothesised that the parallel introduction in 2008 of smoke-free restaurants and bars in the Netherlands, a tobacco tax increase and mass media campaign, would be associated with decreases in childhood wheezing/asthma, respiratory tract infections (RTIs), and otitis media with effusion (OME) presenting in primary care. We conducted an interrupted time series study using electronic medical records from the Dutch Integrated Primary Care Information database (2000-2016). We estimated step and slope changes in the incidence of each outcome with negative binomial regression analyses, adjusting for underlying time-trends, seasonality, age, sex, electronic medical record system, urbanisation, and social deprivation. Analysing 1,295,124 person-years among children aged 0-12 years, we found positive step changes immediately after the policies (incidence rate ratio (IRR): 1.07, 95% CI: 1.01-1.14 for wheezing/asthma; IRR: 1.16, 95% CI: 1.13-1.19 for RTIs; and IRR: 1.24, 95% CI: 1.14-1.36 for OME). These were followed by slope decreases for wheezing/asthma (IRR: 0.95/year, 95% CI: 0.93-0.97) and RTIs (IRR: 0.97/year, 95% CI: 0.96-0.98), but a slope increase in OME (IRR: 1.05/year, 95% CI: 1.01-1.09). We found no clear evidence of benefit of changes in tobacco control policies in the Netherlands for the outcomes of interest. Our findings need to be interpreted with caution due to substantial uncertainty in the pre-legislation outcome trends.

Public support for smoke-free private indoor and public outdoor areas in the Netherlands: A trend analysis from 2018-2022.

INTRODUCTION: In addition to smoke-free policies in indoor public and workplaces, governments increasingly implement smoke-free policies at beaches, in parks, playgrounds and private cars ('novel smoke-free policies'). An important element in the implementation of such policies is public support. In the context of the ambition of the Netherlands to reach a smoke-free generation by 2040, we investigated temporal changes in public support for novel smoke-free policies. METHODS: We analyzed annual cross-sectional questionnaires in a representative sample of the Dutch population from 2018 to 2022. Multivariable logistic regression was applied to model public support for each smoke-free policy area as a function of time (calendar year), smoking status, gender, and socioeconomic status. Interaction terms were added for time with smoking status and with socioeconomic status. RESULTS: A total of 5582 participant responses were included. Between 2018 and 2022, support increased most for smoke-free policies regarding train platforms (+16%), theme parks (+12%), beaches (+10%), and terraces (+10%). In 2022, average support was higher than 65% for all categories of smoke-free places and highest for private cars with children (91%). Regression analyses indicated significant increases in support over time within each category of smoke-free places (adjusted odds ratio, AOR between 1.09 and 1.17 per year), except smoke-free private cars with children (AOR=0.97; 95% CI: 0.89-1.05). Regardless of smoking status, support was high for places where children often go. CONCLUSIONS: Support for novel smoke-free places in the Netherlands is high and increasing, in particular for places frequented by children. This indicates the potential to implement such measures in the Netherlands.

Socio-economic inequalities in smoking and drinking in adolescence: Assessment of social network dynamics.

AIMS: We investigated whether (1) adolescents selected friends with a similar socio-economic status (SES), (2) smoking and alcohol consumption spread in networks and (3) the exclusion of non-smokers or non-drinkers differed between SES groups. DESIGN: This was a longitudinal study using stochastic actor-oriented models to analyze complete social network data over three waves. SETTING: Eight Hungarian secondary schools with socio-economically diverse classes took part. PARTICIPANTS: This study comprised 232 adolescents aged between 14 and 15 years in the first wave. MEASUREMENTS: Self-reported smoking behavior, alcohol consumption behavior and friendship ties were measured. SES was measured based upon entitlement to an income-tested regular child protection benefit. FINDINGS: Non-low-SES adolescents were most likely to form friendships with peers from their own SES group [odds ratio (OR) = 1.07, 95% confidence interval (CI) = 1.02-1.11]. Adolescents adjusted their smoking behavior (OR = 24.05, 95% CI = 1.27-454.86) but not their alcohol consumption (OR = 1.65, 95% CI = 0.62-4.39) to follow the behavior of their friends. Smokers did not differ from non-smokers in the likelihood of receiving a friendship nomination (OR = 0.98, 95% CI = 0.87-1.10), regardless of their SES. Alcohol consumers received significantly more friendship nominations than non-consumers (OR = 1.16, 95% CI = 1.01-1.33), but this association was not significantly different according to SES. CONCLUSIONS: Hungarian adolescents appear to prefer friendships within their own socio-economic status group, and smoking and alcohol consumption spread within those friendship networks. Socio-economic groups do not differ in the extent to which they encourage smoking or alcohol consumption.

Public support for smoke-free policies in outdoor areas and (semi-)private places: a systematic review and meta-analysis.

Background: Smoke-free policies are essential to protect people against tobacco smoke exposure. To successfully implement smoke-free policies that go beyond enclosed public places and workplaces, public support is important. We undertook a comprehensive systematic review of levels and determinants of public support for indoor (semi-)private and outdoor smoke-free policies. Methods: In this systematic review and meta-analysis, six electronic databases were searched for studies (published between 1 January 2004 and 19 January 2022) reporting support for (semi-)private and outdoor smoke-free policies in representative samples of at least 400 respondents aged 16 years and above. Two reviewers independently extracted data and assessed risk of bias of individual reports using the Mixed Methods Appraisal Tool. The primary outcome was proportion support for smoke-free policies, grouped according to location covered. Three-level meta-analyses, subgroup analyses and meta-regression were performed. Findings: 14,749 records were screened, of which 107 were included; 42 had low risk of bias and 65 were at moderate risk. 99 studies were included in the meta-analyses, reporting 326 measures of support from 896,016 individuals across 33 different countries. Support was pooled for indoor private areas (e.g., private cars, homes: 73%, 95% confidence interval (CI): 66-79), indoor semi-private areas (e.g., multi-unit housing: 70%, 95% CI: 48-86), outdoor hospitality areas (e.g., café and restaurant terraces: 50%, 95% CI: 43-56), outdoor non-hospitality areas (e.g., school grounds, playgrounds, parks, beaches: 69%, 95% CI: 64-73), outdoor semi-private areas (e.g., shared gardens: 67%, 95% CI: 53-79) and outdoor private areas (e.g., private balconies: 41%, 95% CI: 18-69). Subcategories showed highest support for smoke-free cars with children (86%, 95% CI: 81-89), playgrounds (80%, 95% CI: 74-86) and school grounds (76%, 95% CI: 69-83). Non-smokers and ex-smokers were more in favour of smoke-free policies compared to smokers. Support generally increased over time, and following implementation of each smoke-free policy. Interpretation: Our findings suggested that public support for novel smoke-free policies is high, especially in places frequented by children. Governments should be reassured about public support for implementation of novel smoke-free policies. Funding: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation and Netherlands Thrombosis Foundation.

Piloting a complex intervention to promote a tobacco and alcohol-free pregnancy: the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study.

BACKGROUND: Tobacco smoking and alcohol consumption before and during pregnancy increase the risk of adverse health outcomes for mother and child. Interventions to address smoking and drinking before and during pregnancy have the potential to reduce early-life health inequalities. In the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pilot study we aimed to evaluate the acceptability, feasibility and effectiveness of a complex intervention supporting women in smoking and alcohol cessation before and during pregnancy. METHODS: From February 2019 till March 2021, we piloted the SAFER pregnancy intervention among pregnant women and women planning pregnancy in South-West Netherlands in an uncontrolled before-after study. Participants were supported in smoking and alcohol cessation via up to six group sessions and an online platform. In addition, biochemically validated cessation was rewarded with incentives (i.e. shopping vouchers) amounting up to 185 euros. We aimed to include 66 women. The primary outcome was smoking and/or alcohol cessation at 34-38 weeks of gestation (if pregnant) or after six group sessions (if not pregnant). Quantitative data were analysed using descriptive statistics. Focus group interviews among those involved in the study were conducted at the end of the study to explore their experiences. Qualitative data was analysed using thematic analysis. RESULTS: Thirty-nine women who smoked were included; no women who consumed alcohol were referred to the study. Unemployment (51%), financial problems (36%) and a smoking partner (72%) were common. Thirteen women (33%) dropped out, often due to other problems impeding smoking cessation or 'being too busy' to participate in the group sessions. Eleven women (28%) had quit smoking at the study's endpoint. The personal and positive approach was highly valued and biochemical validation was felt to be helpful. CONCLUSION: The SAFER pregnancy intervention seems appropriate for women in need of extra support for smoking cessation before and during pregnancy. Its impact on alcohol cessation could not be studied due to recruitment issues. Recruitment and prevention of early dropout need attention in further development of this intervention. TRIAL REGISTRATION: Netherlands Trial Register: NL7493. Date registered: 04/02/2019.

Accelerating tobacco control at the national level with the Smoke-free Generation movement in the Netherlands.

The Netherlands has moved towards the forefront of tobacco control in Europe, after having implemented important tobacco control measures in 2020 and 2021, which included higher tobacco taxation, plain packaging of tobacco products, a partial point of sale tobacco display ban, smoking ban on school grounds, and other smoking restrictions. We examined the factors contributing to these successes, focussing on the network of tobacco control advocacy organisations and the process of agenda-setting. Crucial determining factors were stricter adherence to Article 5.3 FCTC, which prevents government to consult tobacco industry, and the genesis of a 'Smoke-free Generation' movement in the wider society, initiated by the three main national charities (Lung Foundation Netherlands, Dutch Heart Foundation, Dutch Cancer Society). The Smoke-free Generation concept proved to be a highly attractive unifying strategy for national en local policy makers and Dutch society. As a result, the Dutch government was able to start a process of strengthening tobacco control policy through drafting and implementing a National Prevention Agreement, which aims at a tobacco control endgame goal of less than 5% smokers in 2040. Between 2019 and 2020 smoking rates dropped from 21.7% to 20.2%. The Dutch experience can provide inspiration for countries where tobacco control is still lagging behind. It also illustrates that continued vigilance is needed, since the most recent government change was associated with a hampering of further reduction of the proportion of smokers and a temporary drop in attention to tobacco control from the central government.

Effect of comprehensive smoke-free legislation on neonatal mortality and infant mortality across 106 middle-income countries: a synthetic control study.

BACKGROUND: There are few quantitative studies into the effect of comprehensive smoke-free legislation on neonatal and infant mortality in middle-income countries. We aimed to estimate the effects of implementing comprehensive smoke-free legislation on neonatal mortality and infant mortality across all middle-income countries. METHODS: We applied the synthetic control method using 1990-2018 country-level panel data for 106 middle-income countries from the WHO, World Bank, and Penn World datasets. Outcome variables were neonatal (age 0-28 days) mortality and infant (age 0-12 months) mortality rates per 1000 livebirths per year. For each middle-income country with comprehensive smoke-free legislation, a synthetic control country was constructed from middle-income countries without comprehensive smoke-free legislation, but with similar prelegislation trends in the outcome and predictor variables. Overall legislation effect was the mean average of country-specific effects weighted by the number of livebirths. We compared the distribution of the legislation effects with that of the placebo effects to assess the likelihood that the observed effect was related to the implementation of smoke-free legislation and not merely influenced by other processes. FINDINGS: 31 (29%) of 106 middle-income countries introduced comprehensive smoke-free legislation and had outcome data for at least 3 years after the intervention. We were able to construct a synthetic control country for 18 countries for neonatal mortality and for 15 countries for infant mortality. Comprehensive smoke-free legislation was followed by a mean yearly decrease of 1·63% in neonatal mortality and a mean yearly decrease of 1·33% in infant mortality. An estimated 12 392 neonatal deaths in 18 countries and 8932 infant deaths in 15 countries were avoided over 3 years following the implementation of comprehensive smoke-free legislation. We estimated that an additional 104 063 infant deaths (including 95 850 neonatal deaths) could have been avoided over 3 years if the 72 control middle-income countries had introduced this legislation in 2015. 220 (43%) of 514 placebo effects for neonatal mortality and 112 (39%) of 289 for infant mortality were larger than the estimated aggregated legislation effect, indicating a degree of uncertainty around our estimates. Sensitivity analyses showed results that were consistent with the main analysis and suggested a dose-response association related to comprehensiveness of the legislation. INTERPRETATION: Implementing comprehensive smoke-free legislation in middle-income countries could substantially reduce preventable deaths in neonates and infants. FUNDING: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, Health Data Research UK.

Expansion of Smoke-Free Policies: Stepping Up FCTC's Game.

The Framework Convention for Tobacco Control (FCTC) is undoubtedly the most efficient international instrument for tobacco control. Article 8 FCTC shapes many smoke-free policies worldwide and in doing so it is usually associated with smoke-free regulation in enclosed public spaces. Our paper highlights that the FCTC contains a sound foundation for smoke-free policies that stretch beyond enclosed public places, such as open public spaces and (quasi-)private spaces. We demonstrate, in particular, that such wide smoke-free regulation, which is gaining momentum around the globe, is versatile and compatible with human rights standards. As such, these expanded smoke-free policies contribute to a wider culture of smoking denormalisation that scales up FCTC's aspiration for tobacco control and subsequently to a smoke-free global society.

Pediatric patients' views regarding smoke-free hospital grounds compared to those of adults: A survey study.

INTRODUCTION: Children are important stakeholders in discussions about regulation of smoking and protection from secondhand smoke, but are rarely acknowledged as such. We explored the opinion of pediatric patients and other key stakeholders regarding the planned smoke-free zone around the Erasmus MC, a large university hospital in the Netherlands. METHODS: In 2019, we conducted a survey among pediatric patients and their parents, Erasmus MC employees, visitors, and adult patients, before implementation of the outdoor smoke-free zone, to assess their opinions on smoking and the planned smoke-free policy. Qualitative and quantitative data were collected and analyzed mostly using descriptive statistics and thematic analysis. RESULTS: In all, 91 parent-child dyads and 563 employees, visitors, patients and students filled in the questionnaires. Over 90% of children reported that they were regularly exposed to tobacco smoke, most often on the streets. Many underlined the exemplary role of healthcare providers, and 89% felt that nobody should be allowed to smoke near the hospital. Among parents, 89% were (very) positive towards the planned implementation of the smoke-free zone. In addition, 70% of adult patients, 81% of employees, 65% of visitors, 89% of students and 75% of 'others' were (very) positive about the new smoke-free policy. Smokers and former smokers generally were less positive about the policy. CONCLUSIONS: Children generally disapproved smoking around a hospital and felt that healthcare providers should be a good example concerning not smoking. The majority of adult patients, employees and visitors support a smoke-free zone surrounding the hospital, and virtually all pediatric patients and their parents do. Children should be acknowledged as important stakeholders in smoke-free policies and should be involved in planning and implementation.

Cigarette taxation and neonatal and infant mortality: A longitudinal analysis of 159 countries.

Previous studies on the associations between cigarette taxes and infant survival have all been in high-income countries and did not examine the relative benefits of different taxation levels and structures. We evaluated longitudinal associations of cigarette taxes with neonatal and infant mortality globally. We applied country-level panel regressions using 2008-2018 annual mortality and biennial WHO tobacco taxation data. Complete data was available for 159 countries. Outcomes were neonatal and infant mortality. We conducted analyses by type of taxes (i.e. specific cigarette taxes, ad valorem taxes, and other taxes, import duties and VAT) and the income group classification of countries. Covariates included scores for other WHO recommended tobacco control policies, socioeconomic, health-care, and air quality measures. Secondary analyses investigated the associations between cigarette tax and cigarette consumption. We found that a 10 percentage-point increase in total cigarette tax as a percentage of the retail price was associated with a 2.6% (95% Confidence Interval [CI]: 1.9% to 3.2%) decrease in neonatal mortality and a 1.9% (95% CI: 1.3% to 2.6%) decrease in infant mortality globally. Estimates were similar for both excise and ad valorem taxes. We estimated that 231,220 (95% CI: 152,658 to 307,655) infant deaths could have been averted in 2018 if all countries had total cigarette tax at least 75%. 99.2% of these averted deaths would have been in low- and middle-income countries (LMICs). The secondary analysis supported causal interpretation of results by finding that a 10 percentage-point increase in taxes was associated with a reduction of 94.6 (95% CI: 32.7 to 156.5) in annual cigarette consumption per capita. Although causal inference is precarious due to the quasi-experimental design, we used a robust analytical approach and focused on within-country changes. Limitations include an inability to include data on roll-your-own tobacco, other forms of tobacco use, and reliance on taxation data only for the cigarette brands most sold in each country. In line with limited existing evidence conducted in HICs, we found that raising taxes on tobacco was associated with a reduction in neonatal and infant mortality globally. Implementing recommended levels of taxation in LMICs should be a priority since this is where the lowest levels of taxation and the largest potential infant mortality benefits exist.

Smokers' responses to being addressed when smoking in an outdoor voluntary smoke-free zone: An observational study.

INTRODUCTION: Addressing smokers who smoke in a voluntary smoke-free area is vital to its successful implementation. Many people perceive barriers in addressing smokers due to fear of negative responses. Insights in actual responses are currently lacking. METHODS: This is an observational field study at the voluntary smoke-free zone surrounding the Erasmus MC and two schools in Rotterdam, the Netherlands. In the first month after implementing the zone, Erasmus MC representatives performed rounds to address smokers who were smoking inside the zone. Four people observed addressors for two weeks then they also addressed the smokers. Smokers were classified as employees, patients, students, or other. We noted whether smokers were addressed directly or indirectly, and their verbal and behavioral responses to being addressed. Differences between the responses of the groups were assessed using chi-squared tests. RESULTS: In all, 331 smokers were observed of whom 73% were addressed directly. Most verbal reactions were positive (46%) or neutral (18%). Employees were more likely to respond guiltily, whereas patients more often responded angrily than the others. After being addressed, the majority of smokers either extinguished their cigarette (41%) or left to continue smoking outside the smoke-free zone (34%). CONCLUSIONS: Most smokers showed a positive or neutral response when being addressed about smoking inside the smoke-free zone and the majority adapted their behavior to comply with the policy. These findings may help decrease barriers for those in doubt about addressing smokers that fail to comply with a smoke-free policy.

Contralateral surgical exploration during inguinal hernia repair in infants (HERNIIA trial): study protocol for a multi-centre, randomised controlled trial.

BACKGROUND: The incidence of metachronous contralateral inguinal hernia (MCIH) is high in infants with an inguinal hernia (5-30%), with the highest risk in infants aged 6 months or younger. MCIH is associated with the risk of incarceration and necessitates a second operation. This might be avoided by contralateral exploration during primary surgery. However, contralateral exploration may be unnecessary, leads to additional operating time and costs and may result in additional complications of surgery and anaesthesia. Thus, there is no consensus whether contralateral exploration should be performed routinely. METHODS: The Hernia-Exploration-oR-Not-In-Infants-Analysis (HERNIIA) study is a multicentre randomised controlled trial with an economic evaluation alongside to study the (cost-)effectiveness of contralateral exploration during unilateral hernia repair. Infants aged 6 months or younger who need to undergo primary unilateral hernia repair will be randomised to contralateral exploration or no contralateral exploration (n = 378 patients). Primary endpoint is the proportion of infants that need to undergo a second operation related to inguinal hernia within 1 year after primary repair. Secondary endpoints include (a) total duration of operation(s) (including anaesthesia time) and hospital admission(s); (b) complications of anaesthesia and surgery; and (c) participants' health-related quality of life and distress and anxiety of their families, all assessed within 1 year after primary hernia repair. Statistical testing will be performed two-sided with α = .05 and according to the intention-to-treat principle. Logistic regression analysis will be performed adjusted for centre and possible confounders. The economic evaluation will be performed from a societal perspective and all relevant costs will be measured, valued and analysed. DISCUSSION: This study evaluates the effectiveness and cost-effectiveness of contralateral surgical exploration during unilateral inguinal hernia repair in children younger than 6 months with a unilateral inguinal hernia. TRIAL REGISTRATION: ClinicalTrials.gov NCT03623893 . Registered on August 9, 2018 Netherlands Trial Register NL7194. Registered on July 24, 2018 Central Committee on Research Involving Human Subjects (CCMO) NL59817.029.18. Registered on July 3, 2018.

Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis.

BACKGROUND: Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy. METHODS: In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563. FINDINGS: We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55-0·87; 161 466 participants); heterogeneity was substantial (I2 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy. INTERPRETATION: Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health. FUNDING: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.

Impact of an Inner-City Smoke-Free Zone on Outdoor Smoking Patterns: A Before-After Study.

INTRODUCTION: On September 2, 2019, Rotterdam's first inner-city outdoor smoke-free zone encompassing the Erasmus MC, a large university hospital in the Netherlands, the Erasmiaans high school, the Rotterdam University of Applied Sciences and the public road in between, was implemented. AIMS AND METHODS: We aimed to assess spatiotemporal patterning of smoking before and after implementation of this outdoor smoke-free zone. We performed a before-after observational field study. We systematically observed the number of smokers, and their locations and characteristics over 37 days before and after implementation of the smoke-free zone. RESULTS: Before implementation of the smoke-free zone, 4098 people smoked in the area every weekday during working hours. After implementation, the daily number of smokers was 2241, a 45% reduction (p = .007). There was an increase of 432 smokers per day near and just outside the borders of the zone. At baseline, 31% of the smokers were categorized as employee, 22% as student and 3% as patient. Following implementation of the smoke-free zone, the largest decreases in smokers were observed among employees (-67%, p value .004) and patients (-70%, p value .049). Before and after implementation, 21 and 20 smokers were visibly addressed and asked to smoke elsewhere. CONCLUSIONS: Implementation of an inner-city smoke-free zone was associated with a substantial decline in the number of smokers in the zone and an overall reduction of smoking in the larger area. Further research should focus on optimizing implementation of and compliance with outdoor smoke-free zones. IMPLICATIONS: A smoke-free outdoor policy has the potential to denormalize and discourage smoking, support smokers who want to quit, and to protect people from secondhand smoke exposure. Implementation of an inner-city smoke-free zone encompassing a large tertiary hospital and two educational institutions was associated with a substantial decline in the number of smokers in the zone, as well as in the larger area. Voluntary outdoor smoke-free zones can help reduce the number of smokers in the area and protect people from secondhand smoke. There is a need to explore effectiveness of additional measures to further improve compliance.

European progress in working towards a tobacco-free generation.

Children have the right to grow up free from the hazards associated with tobacco smoking. Tobacco smoke exposure can have detrimental effects on children's health and development, from before birth and beyond. As a result of effective tobacco control policies, European smoking rates are steadily decreasing among adults, as is the proportion of adolescents taking up smoking. Substantial variation however exists between countries, both in terms of smoking rates and regarding implementation, comprehensiveness and enforcement of policies to address smoking and second-hand smoke exposure. This is important because comprehensive tobacco control policies such as smoke-free legislation and tobacco taxation have extensively been shown to carry clear health benefits for both adults and children. Additional policies such as increasing the legal age to buy tobacco, reducing the number of outlets selling tobacco, banning tobacco display and advertising at the point-of-sale, and introducing plain packaging for tobacco products can help reduce smoking initiation by youth. At societal level, health professionals can play an important role in advocating for stronger policy measures, whereas they also clearly have a duty to address smoking and tobacco smoke exposure at the patient level. This includes providing cessation advise and referring to effective cessation services.Conclusion: Framing of tobacco exposure as a child right's issue and of comprehensive tobacco control as a tool to work towards the ultimate goal of reaching a tobacco-free generation can help accelerate European progress to curb the tobacco epidemic. What is Known: • Tobacco exposure is associated with a range of adverse health effects among babies and children. • Comprehensive tobacco control policies helped bring down smoking rates in Europe and benefit child health. What is New: • Protecting the rights and health of children provides a strong starting point for tobacco control advocacy. • The tobacco-free generation concept helps policy-makers set clear goals for protecting future generations from tobacco-associated harms.