1
LiCX, e al. BMJ Public Heal h 2025;3:e002903. doi:10.1136/bmjph-2025-002903
Exposu e o secondhand smoke om
ciga e es and secondhand ae osol om
obacco and nico ine p oduc s in indoo
and ou doo public spaces in he
Eu opean Union: a c oss- sec ional s udy
Cha lo e Xin Li ,1,2 Pin- Chun Wang ,1 A iadna Feliu ,1,3
An hony A La e y ,1 C is ina Ma inez ,4,5,6,7 A mando Pe uga,3,4,5
Cha is Gi alaki,2 Co nel Radu Loghin,2 Cons an ine I Va da as,8
Filippos T Filippidis 1
O iginal esea ch
To ci e: LiCX, WangP- C,
FeliuA, e al. Exposu e o
secondhand smoke om
ciga e es and secondhand
ae osol om obacco
and nico ine p oduc s in
indoo and ou doo public
spaces in he Eu opean
Union: a c oss- sec ional
s udy. BMJ Public Heal h
2025;3:e002903. doi:10.1136/
bmjph-2025-002903
►Addi ional supplemen al
ma e ial is published online only.
To iew, please isi he jou nal
online (h ps:// doi. o g/ 10. 1136/
bmjph- 2025- 002903).
Recei ed 17 Ma ch 2025
Accep ed 18 July 2025
Fo numbe ed a ilia ions see
end o a icle.
Co espondence o
D Filippos T Filippidis;
. ilippidis@ impe ial. ac. uk
© Au ho (s) (o hei
employe (s)) 2025. Re- use
pe mi ed unde CC BY.
Published by BMJ G oup.
ABSTRACT
In oduc ion In Decembe 2024, he Council o he
Eu opean Union (EU) adop ed a ecommenda ion o expand
egula ions on he use o nico ine- con aining p oduc s bo h
in indoo se ings and speci ic ou doo a eas. This s udy
aimed o examine sociodemog aphic ac o s associa ed
wi h exposu e o con en ional obacco smoke and ae osols
ac oss he EU and suppo o ele an egula ions.
Me hods We pe o med a seconda y analysis o c oss-
sec ional da a om he Special Eu oba ome e 99.3
(n=26 358, May–June 2023) ac oss 27 EU Membe
S a es (MS). We es ima ed he weigh ed p e alence o
secondhand exposu e o obacco smoke and ae osols
and suppo o bans on smoking, e- ciga e es and
hea ed obacco p oduc s in public se ings. Mul ile el
Poisson eg ession models explo ed associa ions be ween
sociodemog aphic ac o s and hese ou comes.
Resul s Exposu e o secondhand smoke and ae osols
a ied ac oss EU MS. Younge indi iduals, hose wi h highe
educa ion, li ing wi h child en, and cu en and o me obacco
and nico ine use s (p e alence a io (PR) 1.16, 1.01–1.33;
and PR 1.22, 1.05–1.41, espec i ely) we e mo e likely o
epo exposu e o bo h obacco smoke and ae osol om
eme ging p oduc s. Women (PR 1.05, 1.02–1.08; and PR 1.03,
1.02–1.05, espec i ely), hose li ing wi h child en (PR 1.05,
1.02–1.07; and PR 1.04, 1.02–1.07, espec i ely) and hose
wi h highe educa ion le els (PR 1.10, 1.04–1.15; and PR
1.10, 1.06–1.14) we e mo e likely o suppo bans, whe eas
hose wi h inancial di icul ies (PR 0.94, 0.89–0.99 and PR:
0.95, 0.91–0.99, espec i ely), as well as cu en and o me
smoke s (PR 0.61, 0.55–0.67; and PR 0.78, 0.73–0.84,
espec i ely) and eme ging p oduc use s (PR 0.84, 0.76–0.92;
and PR 0.69, 0.62–0.76, espec i ely), we e less suppo i e.
Conclusion Ou analysis ound ha bo h exposu e o
secondhand smoke and ae osol and suppo o bans
in public spaces a y subs an ially be ween popula ion
subg oups and ac oss coun ies. Ou indings can suppo
EU MS in implemen ing a ge ed in e en ions o inc ease
popula ion suppo o and implemen he ecen EU Council
ecommenda ions.
INTRODUCTION
Tobacco emains one o he mos p e en able
heal h h ea s in he Eu opean Union (EU),
esponsible o nea ly 700 000 dea hs annu-
ally.1 All o ms o obacco use a e ha m ul,
wi h no sa e le el o exposu e.2 3 This includes
WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒Public suppo o smoke- ee en i onmen s in indoo
se ings is high in he Eu opean Union (EU), bu he e a e
inequi ies in exposu e o secondhand smoke. Despi e
his, li le is known abou exposu e o secondhand
smoke om combus ible obacco and secondhand
ae osol om e- ciga e es and hea ed obacco p oduc s
in ou doo se ings ac oss he EU. Addi ionally, he e is a
lack o ex ensi e esea ch on public suppo o smoke-
ee and ae osol- ee policies in ou doo spaces in he
EU.
WHAT THIS STUDY ADDS
⇒This s udy e eals signi ican a ia ion in ou doo sec-
ondhand smoke and ae osol exposu e ac oss he EU,
wi h sociodemog aphic ac o s and obacco and nic-
o ine use in luencing exposu e le els. Public suppo
o smoke- ee and ae osol- ee policies also a ies by
coun y and socioeconomic s a us, hough he majo i y
o esponden s suppo mo e comp ehensi e and s ic -
e smoke- and ae osol- ee policies.
HOW THIS STUDY MIGHT AFFECT RESEARCH,
PRACTICE OR POLICY
⇒Following he EU’s ecen Council Recommenda ion on
smoke- and ae osol- ee en i onmen s, ou indings
emphasise he need o mo e a ge ed policies, pa ic-
ula ly o p o ec ulne able g oups. Wi h go e nmen s
now esponsible o implemen ing smoke- and ae osol-
ee legisla ion, ou s udy p o ides c ucial e idence o
encou age such ac ions ac oss he EU.
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BMJ Public Heal h
no only he mos p e alen o m, ciga e e smoking, bu
also eme ging p oduc s such as e- ciga e es and hea ed
obacco p oduc s (HTPs), which ha e been g owing in
popula i y.4 Al hough hese p oduc s a e o en pe cei ed
as less ha m ul han adi ional combus ible ciga e es,
hey s ill pose signi ican heal h isks.5 Besides endan-
ge ing indi idual heal h o hose who smoke, obacco
combus ion p oduces secondhand smoke (SHS) ha
inc eases he isk o lung cance , co ona y hea disease
and o he condi ions in non- smoke s.6 While eme ging
p oduc s such as e- ciga e es and HTPs do no p oduce
smoke bu a he an ae osol, he e a e conce ns abou
hei po en ial ad e se heal h e ec s. E- ciga e e and
HTP ae osols a e composed o complex mix u es o
ha m ul subs ances, including nico ine, p opylene glycol,
ege able glyce in and ola ile o ganic compounds.7
Al hough he long- e m e ec s o secondhand ae osol
(SHA) exposu e emain unde in es iga ion, SHA expo-
su e appea s o nega i ely a ec adolescen s’ espi a o y
heal h.8
Exposu e o SHS is pe iodically measu ed by Eu o-
ba ome e su eys ac oss he EU, wi h ecen da a indi-
ca ing no able a ia ion in exposu e le els.9 O he s udies
suppo his inding, wi h one e ealing ha Hunga y,
Romania and Spain ha e s onge indoo smoking bans
and mo e comp ehensi e obacco con ol policies,
esul ing in lowe le els o exposu e compa ed wi h
Ge many and Poland.10 11 I is also well- es ablished ha
he bu den o SHS exposu e disp opo iona ely a ec s
ulne able popula ions, including child en, adolescen s
and hose wi h inancial di icul ies, exace ba ing heal h
dispa i ies ac oss he EU.12–16 The ew exis ing s udies
on SHA exposu e in indoo public spaces indica e ha
younge indi iduals, hose wi h highe educa ion and
cu en o o me e- ciga e e use s epo highe le els o
exposu e o SHA in he EU.17 Howe e , mos o he li e -
a u e ocuses on exposu e in indoo se ings and a ely
includes assessmen o exposu e o SHAl ou doo s.
In Decembe 2024, he Council o he Eu opean
Union adop ed a new Council Recommenda ion on
smoke- and ae osol- ee en i onmen s, which calls on
MS o ex end hei smoke- ee policies o key ou doo
a eas, including public playg ounds, amusemen pa ks,
swimming pools and public anspo s a ions, o ensu e
e ec i e p o ec ion o bys ande s, pa icula ly child en
and adolescen s. Mo eo e , he Council Recommenda-
ion also ad ises MS o expand all smoke- ee policies
o include eme ging p oduc s.18 As o ea ly 2025, many
EU MS ha e enac ed smoke- ee legisla ion banning
smoking in enclosed public spaces, public anspo and
wo kplaces, wi h limi ed excep ions.19 Howe e , he e ec-
i eness o hese egula ions a ies conside ably due o
inconsis en en o cemen a he na ional and egional
le els. Complex legisla ion, pa icula ly when exemp-
ions a e included, has p o en challenging o en o ce in
some EU MS, esul ing in compliance issues.19 The e o e,
o ensu e s onge p o ec ion o bys ande s, pa icula ly
o ulne able popula ions, comp ehensi e smoke- ee
egula ions wi h ew exemp ions a e ecommended.11
O e all, success ul implemen a ion and en o cemen o
such policies ely hea ily on public suppo .20 The e o e,
unde s anding he ac o s ha shape public suppo o
newly p oposed measu es is c ucial o iden i ying a ge
g oups and ailo ing s a egies.
Despi e g owing a en ion o SHS and SHA, he e is
a signi ican gap in unde s anding ou doo exposu e
le els ac oss he EU. Fu he mo e, limi ed esea ch has
examined public suppo o smoke- ee and ae osol-
ee policies in ou doo spaces, pa icula ly wi hin he
EU con ex . In ligh o he adop ion o he new Council
Recommenda ion on smoke- and ae osol- ee en i on-
men s, we used da a om he 27 EU MS collec ed in
2023 o examine he sel - epo ed exposu e o SHS and
ae osol in a ious indoo and ou doo se ings and le els
o public suppo o he p oposed ou doo smoking ban
policies, and o explo e sociodemog aphic a ia ions in
hese ou comes.
METHODS
Da a sou ce
We pe o med a seconda y analysis using da a om all
27 EU MS using Special Eu oba ome e 99.3, conduc ed
om 10 May 2023 o 5 June 2023, which included
26 358 esponden s aged ≥15 yea s, esiding in each
o he EU MS. The Eu oba ome e su ey employed a
mul is age sampling me hod: households we e sampled
using s anda d ‘ andom ou e’ p ocedu es, and one
esponden was andomly selec ed based on household
size o pa icipa e in in e iews and p o ide sel - epo ed
da a in he ele an na ional language.9 Consen o
pa icipa ion was eques ed a he beginning o each
in e iew. To ensu e he samples we e na ionally ep e-
sen a i e, he da ase s we e weigh ed o accoun o age,
sex and a ea o esidence.
Measu es
Exposu e o secondhand smoke om con en ional obacco
p oduc s
Pa icipan s we e asked i , in he las 6 mon hs, people
we e smoking in (1) indoo public spaces whe e people
no mally do no smoke (eg, es au an s, ba s, shopping
malls, ai po s, conce halls), (2) an ou doo e ace o
a d inking o ea ing es ablishmen , (3) ou doo spaces
in ended o use by child en o adolescen s (eg, nu se y
and school cou ya ds, playg ounds), (4) ou doo e en s
(eg, open- ai conce s, spo s ma ches, ma ke s), (5)
ou doo public spaces (eg, pa ks, beaches, en ances
o public buildings) and (6) open- ai public anspo
s a ions (eg, bus, am o ain s a ions). The pe cen age
o ‘yes’ esponses o e he o al numbe o alid esponses
(‘yes’, ‘no’, ‘I ha e no isi ed in he las 6 mon hs’, and
‘don’ know’) was conside ed a p oxy o he p e alence
o exposu e o SHS.
Exposu e o secondhand ae osol om eme ging obacco p oduc s
Pa icipan s we e simila ly asked i hey had obse ed
he use o e- ciga e es o HTPs in he same six loca ions
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BMJ Public Heal h
o e he pas 6 mon hs, wi h he same esponse op ions as
abo e, and he pe cen age o ‘yes’ esponses was consid-
e ed as a p oxy o exposu e o SHA.
Suppo o obacco con ol policies
All pa icipan s we e asked, ‘Would you be in a ou o no
in a ou o any o he ollowing measu es? (1) Banning
o smoking in ou doo places whe e social dis ancing
canno be ensu ed (eg, pa ks, beaches, en ances o
public buildings); (2) Banning he use o e- ciga e es o
HTPs in en i onmen s whe e smoking is p ohibi ed’”
Responses we e ca ego ised as ei he in a ou o no in
a ou /don’ know.
Co a ia es
The su ey collec ed sel - epo ed da a on gende (male;
emale). The 57 esponses o ‘none o he abo e’, ‘non-
bina y’, ‘do no iden i y as male/ emale’ o ‘p e e no
o say’ we e conside ed missing alues due o e y low
numbe . Da a we e also collec ed on age (15–24; 25–39;
40–54; 55+ yea s), sel - epo ed communi y ype ( u al,
ie, ‘ u al a ea o illage’; and u ban, ie, ‘small o middle-
sized own’ o ‘la ge own’), age a which pa icipan s
s opped ull- ime educa ion (0–15; 16–19; 20+; s ill s ud-
ying), li ing wi h child en (no; yes), employmen s a us
(employed; unemployed; s uden s/house pe sons/
e i ed) and di icul ies paying bills a he end o he
mon h o e he pas 12 mon hs (almos ne e /ne e ;
om ime o ime/mos o he ime).
Cu en obacco smoking s a us was e alua ed using he
ques ion, ‘Rega ding smoking ciga e es, ciga s, ciga illos
o a pipe, which o he ollowing applies o you?’. Respon-
den s could selec om he ollowing op ions: ne e
smoke , cu en smoke o o me smoke . The cu en
use o e- ciga e es and HTPs was assessed h ough wo
sepa a e ques ions. The i s ques ion asked, ‘Thinking
abou he ollowing p oduc s, which o he ollowing
applies o you? E- ciga e es?’ Responden s could choose
om he ollowing op ions: ne e used, cu en ly using,
used o use bu ha e s opped o ied i only once o
wice. A simila ques ion was asked abou HTPs. The
esponses o hese wo ques ions we e ecoded and
combined in o a single a iable, which was ca ego ised
in o h ee g oups o be consis en wi h he exposu e and
policy suppo ques ions: (1) ne e used e- ciga e es o
HTPs, (2) cu en use o a leas one p oduc and (3)
o me use o a leas one p oduc (used o use bu ha e
s opped o ied only once o wice).
S a is ical analysis
We es ima ed he weigh ed p e alence o secondhand
exposu e o adi ional and eme ging p oduc s o e he
pas 6 mon hs in indoo and ou doo public spaces, as
well as he p e alence o public suppo o banning
obacco p oduc s in public spaces ac oss each EU MS.
O icial weigh s p o ided in he Eu oba ome e da ase
we e used.9 We conduc ed mul ile el Poisson eg ession
analyses o each o he ou come a iables, which allowed
o clus e ing o obse a ions wi hin coun ies. All
models we e adjus ed o gende , age, age a comple ion
o ull- ime educa ion, di icul ies in paying bills, commu-
ni y ype ( u al/u ban), employmen s a us, li ing wi h
child en, cu en smoking and cu en use o e- ciga e es
and HTPs. We also conduc ed a sensi i i y analysis, whe e
he ‘don’ know’ esponses we e excluded, o assess he
obus ness o he indings. All s a is ical analyses we e
pe o med using S a a 17, while maps we e gene a ed in
R. Obse a ions wi h missing alues we e excluded om
he analysis. As he Eu oba ome e da a is open- access
and anonymised, e hical app o al om an Ins i u ional
Re iew Boa d was no equi ed o his seconda y anal-
ysis. Consen o pa icipa ion was eques ed a he begin-
ning o each in e iew.
Pa ien and public in ol emen
The e was no in ol emen o pa ien s o he public in he
design, conduc , epo ing o dissemina ion plans o ou
esea ch.
RESULTS
Exposu e o secondhand smoke and ae osol
Sample cha ac e is ics a e shown in online supplemen al
able 1. In he EU o e all, exposu e o SHS and second-
hand e- ciga e e and HTP ae osol a ied subs an ially
ac oss se ings (online supplemen al ables 2 and 3). SHS
exposu e in indoo public spaces was epo ed by 21.5%
o pa icipan s (95% CI 20.7 o 22.4), while exposu e o
e- ciga e es and HTPs was 35.8% (34.8–36.7). Subs an-
ial a ia ion was obse ed be ween coun ies, wi h he
highes p e alence o exposu e epo ed on ou doo
public places and he lowes in indoo public spaces o
bo h adi ional and eme ging p oduc s.
Women we e less likely o epo con en ional obacco
smoke exposu e in indoo public spaces (P e alence Ra io
(PR) 0.89; 95% CI 0.84 o 0.94) and a ou doo e en s
(PR: 0.95; 0.92–0.98) compa ed wi h men, bu he e we e
no gende di e ences in o he se ings ( able 1). Younge
people aged 15–39 yea s (compa ed wi h hose 55+) and
hose s ill s udying o wi h highe educa ion (compa ed
wi h hose in he lowes educa ion ca ego y) we e mo e
likely o epo exposu e o smoke om con en ional
obacco p oduc s in all se ings, al hough he e ec sizes
a ied. People li ing wi h child en we e mo e likely o
epo exposu e o obacco smoke in all ou doo se ings,
whe eas unemployed pa icipan s epo ed highe
exposu e only in indoo public spaces (PR: 1.10; 1.02–
1.20). People no wo king (s uden s, house pe sons and
e i ed) we e less likely o epo exposu e o obacco
smoke ac oss all se ings assessed.
Cu en and o me smoke s we e mo e likely o
epo obacco smoke exposu e ac oss all ou doo
se ings compa ed wi h ne e smoke s. In con as ,
he associa ion be ween cu en and o me use s
o eme ging p oduc s and exposu e o con en-
ional obacco smoke was s onges in indoo public
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BMJ Public Heal h
Table 1 Mul ile el Poisson eg ession es ima ed associa ions be ween sociodemog aphic and beha iou al ac o s and exposu e o adi ional obacco smoke in he pas
6 mon hs in EU membe s a es (n=25 219)
Va iables
In he las 6 mon hs, we e people smoking…
In indoo public
spaces
On ou doo
e aces
In ou doo spaces o
child en o adolescen s A ou doo e en s
In ou doo public
spaces
A open- ai public
anspo a ion s a ions
PR (95% CI)
Gende
Male ( e .) 1 1 1 1 1 1
Female 0.89 (0.84 o 0.94) 0.98 (0.96 o 1.00) 1.03 (0.99 o 1.08) 0.95 (0.92 o 0.98) 0.99 (0.97 o 1.01) 1.00 (0.98 o 1.02)
Age (yea s)
55+ ( e .) 1 1 1 1 1 1
15–24 1.38 (1.16 o 1.64) 1.11 (1.02 o 1.22) 1.34 (1.17 o 1.53) 1.12 (1.06 o 1.19) 1.11 (1.07 o 1.16) 1.13 (1.07 o 1.20)
25–39 1.15 (1.05 o 1.26) 1.06 (1.01 o 1.11) 1.18 (1.10 o 1.27) 1.12 (1.08 o 1.16) 1.06 (1.03 o 1.09) 1.07 (1.03 o 1.11)
40–54 1.02 (0.96 o 1.09) 1.04 (1.01 o 1.07) 1.03 (0.98 o 1.09) 1.05 (1.03 o 1.08) 1.04 (1.02 o 1.06) 1.04 (1.01 o 1.07)
Di icul y paying bills
Almos ne e /ne e ( e .) 1 1 1 1 1 1
F om ime o ime/mos o he ime 1.08 (0.98 o 1.20) 0.96 (0.92 o 1.01) 1.03 (0.97 o 1.11) 0.97 (0.92 o 1.01) 0.96 (0.91 o 1.01) 0.98 (0.93 o 1.03)
Communi y ype
Ru al ( e .) 1 1 1 1 1 1
U ban 0.98 (0.86 o 1.12) 1.02 (0.98 o 1.05) 0.99 (0.91 o 1.07) 1.00 (0.97 o 1.03) 1.02 (0.99 o 1.06) 1.03 (0.99 o 1.08)
Educa ion (age a comple ion)
0–15 yea s ( e .) 1 1 1 1 1 1
16–19 yea s 1.07 (0.94 o 1.21) 1.08 (1.03 o 1.14) 1.03 (0.93 o 1.14) 1.13 (1.07 o 1.20) 1.10 (1.05 o 1.15) 1.11 (1.05 o 1.18)
20+ yea s 1.08 (0.94 o 1.25) 1.15 (1.08 o 1.21) 1.04 (0.94 o 1.16) 1.17 (1.10 o 1.25) 1.14 (1.07 o 1.20) 1.16 (1.09 o 1.23)
S ill s udying 1.34 (1.10 o 1.62) 1.22 (1.11 o 1.35) 1.26 (1.10 o 1.45) 1.43 (1.30 o 1.57) 1.24 (1.16 o 1.32) 1.25 (1.15 o 1.35)
Li ing wi h child en
No ( e .) 1 1 1 1 1 1
Yes 1.02 (0.95 o 1.11) 1.05 (1.02 o 1.08) 1.12 (1.06 o 1.17) 1.05 (1.03 o 1.08) 1.04 (1.02 o 1.06) 1.03 (1.00 o 1.05)
Employmen s a us
Employed ( e .) 1 1 1 1 1 1
Unemployed 1.10 (1.02 o 1.20) 0.99 (0.94 o 1.04) 0.99 (0.91 o 1.07) 0.98 (0.93 o 1.04) 1.03 (0.99 o 1.07) 1.04 (1.00 o 1.09)
S uden s/house pe sons/ e i ed 0.87 (0.79 o 0.94) 0.93 (0.89 o 0.97) 0.91 (0.86 o 0.97) 0.87 (0.84 o 0.90) 0.92 (0.88 o 0.96) 0.93 (0.90 o 0.97)
Cu en smoking s a us
Ne e smoke ( e .) 1 1 1 1 1 1
Cu en smoke 1.06 (0.96 o 1.17) 1.15 (1.10 o 1.20) 1.09 (1.02 o 1.15) 1.13 (1.09 o 1.18) 1.11 (1.07 o 1.14) 1.10 (1.06 o 1.14)
Fo me smoke 1.04 (0.95 o 1.14) 1.11 (1.08 o 1.14) 1.08 (1.03 o 1.14) 1.11 (1.07 o 1.14) 1.09 (1.07 o 1.12) 1.06 (1.03 o 1.09)
Con inued
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BMJ Public Heal h
places (PR 1.16; 1.01–1.33; and PR 1.22; 1.05–1.41,
espec i ely).
Younge people (aged 15–39), males, hose s ill s udying
o wi h highe educa ion and hose li ing in u ban a eas
we e mo e likely o be exposed o ae osol om e- ciga e e
o HTP in he majo i y o indoo and ou doo se ings
( able 2). Simila o smoke om con en ional obacco
p oduc s, li ing wi h child en was associa ed wi h highe
exposu e o SHA in ou doo en i onmen s, whe eas
people no wo king we e less likely o epo exposu e
in all se ings assessed. Cu en and o me smoke s, as
well as cu en and o me use s o eme ging p oduc s,
we e consis en ly mo e likely o epo ha someone
used an e- ciga e e o HTP in each o he se ings in he
pas 6 mon hs.
Suppo o obacco con ol policies
A o al o 56.5% (55.5–57.5) o esponden s suppo ed
banning smoking in ou doo a eas whe e social
dis ancing canno be ensu ed ac oss he EU. Suppo
was highes in Sweden (73.4%; 69.9–76.7) and lowes in
Eas e n and some Sou he n Eu opean coun ies, such as
G eece (44.9%; 41.8–48.0), Cyp us (44.5%; 39.8–49.3)
and Bulga ia (45.6%; 42.5–48.7). Suppo o banning
e- ciga e es and HTPs in en i onmen s whe e smoking is
p ohibi ed was 65.8% (64.9–66.8) o e all, highes in he
Ne he lands (84.4%; 81.5–86.9) and lowes in Eas e n
Eu ope, wi h coun ies like Bulga ia (49.3%; 46.2–52.4)
and Romania (53.8%; 50.7–56.9) epo ing he leas
endo semen o he policy ( igu e 1).
The associa ions be ween sociodemog aphic ac o s
and suppo o bans we e e y consis en in he wo
assessed policies ( able 3). Compa ed wi h men, women
we e mo e likely o suppo ou doo smoking bans
(PR: 1.05; 1.02–1.08) and es ic ions on e- ciga e es o
HTPs in smoke- ee en i onmen s (PR: 1.03; 1.02–1.05).
Indi iduals wi h inancial di icul ies we e less likely o
suppo ou doo smoking bans (PR: 0.94, 0.89–0.99)
and e- ciga e e o HTP es ic ions (PR: 0.95, 0.91–0.99).
Those who comple ed hei educa ion a 20+yea s we e
10% mo e likely o suppo bo h ou doo smoking bans
(PR: 1.10, 1.04–1.15) and es ic ions on e- ciga e es o
HTPs (PR: 1.10, 1.06–1.14), compa ed wi h hose who
inished by age 15 o younge , while hose li ing wi h chil-
d en we e mo e likely o suppo bo h ou doo smoking
bans and es ic ions on eme ging p oduc s (PR: 1.05,
1.02–1.07 and PR: 1.04, 1.02–1.07, espec i ely), han
hose li ing wi hou child en. Cu en smoke s we e 39%
and 22% less likely o suppo ou doo smoking bans
(PR: 0.61, 0.55–0.67) and e- ciga e e o HTP es ic ions
(PR: 0.78, 0.73–0.84) ela i e o non- smoke s. Simila ly,
cu en e- ciga e e o HTP use s we e 16% less likely o
suppo ou doo smoking bans (PR: 0.84, 0.76–0.92) and
31% less likely o suppo e- ciga e e o HTP es ic ions
(PR: 0.69, 0.62–0.76) han non- use s.
In ou sensi i i y analysis, excluding ‘don’ know’
esponses (N o each ou come a iable, as p esen ed
Va iables
In he las 6 mon hs, we e people smoking…
In indoo public
spaces
On ou doo
e aces
In ou doo spaces o
child en o adolescen s A ou doo e en s
In ou doo public
spaces
A open- ai public
anspo a ion s a ions
PR (95% CI)
Cu en s a us o e- ciga e e and HTP use
Ne e used e- ciga e es o HTPs ( e .) 1 1 1 1 1 1
Cu en use o a leas one p oduc 1.16 (1.01 o 1.33) 1.03 (0.97 o 1.09) 1.02 (0.93 o 1.12) 1.04 (0.99 o 1.10) 1.01 (0.96 o 1.06) 0.97 (0.92 o 1.03)
Fo me use o a leas one p oduc 1.22 (1.05 o 1.41) 1.05 (1.00 o 1.10) 1.03 (0.94 o 1.12) 1.05 (1.00 o 1.09) 1.04 (1.00 o 1.08) 1.03 (0.99 o 1.06)
Indoo public apaces: indoo public spaces whe e people no mally do no smoke (eg, es au an s, ba s, shopping malls, ai po s, conce halls).
Ou doo e aces: ou doo e aces o a d inking o ea ing es ablishmen ?
Ou doo spaces: ou doo spaces in ended o use by child en o adolescen s (eg, nu se y and school cou ya d, playg ounds).
Ou doo e en s: ou doo e en s (eg, open- ai conce s, spo ma ches, ma ke s).
Ou doo public spaces: ou doo public spaces (eg, pa k, beach, en ance o public buildings).
Open- ai public anspo a ion s a ions: open- ai public anspo a ion s a ions (eg, bus, am o ain s a ions).
HTP, hea ed obacco p oduc ; PR, p e alence a io.
Table 1 Con inued
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Table 2 Mul ile el Poisson eg ession es ima ed associa ions be ween sociodemog aphic and beha iou al ac o s and exposu e o eme ging obacco p oduc ae osol in
he pas 6 mon hs in EU membe s a es (n=25 219)
Va iables
In he las 6 mon hs, we e people using e- ciga e es o hea ed obacco p oduc s…
In indoo public
spaces
On ou doo
e aces
In ou doo spaces o
child en o adolescen s A ou doo e en s
In ou doo public
spaces
A open- ai public
anspo a ion s a ions
PR (95% CI)
Gende
Male ( e .) 1 1 1 1 1 1
Female 0.96 (0.93 o 0.99) 0.98 (0.95 o 1.00) 1.00 (0.97 o 1.04) 0.95 (0.93 o 0.98) 0.98 (0.96 o 1.00) 0.97 (0.95 o 0.99)
Age (yea s)
55+ ( e .) 1 1 1 1 1 1
15–24 1.40 (1.25 o 1.56) 1.21 (1.11 o 1.31) 1.36 (1.22 o 1.52) 1.20 (1.12 o 1.29) 1.17 (1.11 o 1.24) 1.18 (1.12 o 1.24)
25–39 1.30 (1.21 o 1.40) 1.12 (1.07 o 1.17) 1.22 (1.15 o 1.29) 1.16 (1.12 o 1.21) 1.10 (1.07 o 1.13) 1.12 (1.09 o 1.16)
40–54 1.15 (1.09 o 1.22) 1.09 (1.06 o 1.12) 1.09 (1.04 o 1.15) 1.11 (1.07 o 1.14) 1.08 (1.05 o 1.11) 1.09 (1.06 o 1.13)
Di icul y paying bills
Almos ne e /ne e ( e .) 1 1 1 1 1 1
F om ime o ime/mos o he ime 0.97 (0.89 o 1.05) 0.99 (0.95 o 1.03) 1.00 (0.95 o 1.07) 0.99 (0.94 o 1.04) 0.98 (0.93 o 1.02) 0.99 (0.95 o 1.03)
Communi y ype
Ru al ( e .) 1 1 1 1 1 1
U ban 1.04 (0.95 o 1.13) 1.06 (1.02 o 1.10) 1.03 (0.95 o 1.12) 1.05 (1.01 o 1.08) 1.07 (1.04 o 1.11) 1.08 (1.04 o 1.12)
Educa ion (age a comple ion)
0–15 yea s ( e .) 1 1 1 1 1 1
16–19 yea s 1.18 (1.02 o 1.36) 1.14 (1.06 o 1.22) 1.10 (0.99 o 1.22) 1.20 (1.11 o 1.30) 1.16 (1.08 o 1.24) 1.19 (1.11 o 1.27)
20+ yea s 1.26 (1.07 o 1.48) 1.21 (1.12 o 1.31) 1.16 (1.04 o 1.30) 1.26 (1.16 o 1.37) 1.22 (1.12 o 1.32) 1.24 (1.15 o 1.33)
S ill s udying 1.69 (1.37 o 2.08) 1.42 (1.27 o 1.59) 1.46 (1.25 o 1.70) 1.54 (1.36 o 1.76) 1.44 (1.30 o 1.61) 1.43 (1.30 o 1.57)
Li ing wi h child en
No ( e .) 1 1 1 1 1 1
Yes 1.04 (0.98 o 1.10) 1.06 (1.03 o 1.10) 1.11 (1.05 o 1.16) 1.05 (1.02 o 1.08) 1.06 (1.03 o 1.09) 1.04 (1.01 o 1.07)
Employmen s a us
Employed ( e .) 1 1 1 1 1 1
Unemployed 1.07 (0.99 o 1.15) 0.98 (0.93 o 1.03) 1.01 (0.94 o 1.09) 1.00 (0.95 o 1.05) 1.01 (0.96 o 1.05) 1.04 (0.99 o 1.10)
S uden s/house pe sons/ e i ed 0.81 (0.74 o 0.88) 0.85 (0.80 o 0.90) 0.84 (0.78 o 0.90) 0.82 (0.78 o 0.87) 0.85 (0.81 o 0.89) 0.87 (0.83 o 0.91)
Cu en smoking s a us
Ne e smoke ( e .) 1 1 1 1 1 1
Cu en smoke 1.27 (1.20 o 1.35) 1.17 (1.13 o 1.22) 1.20 (1.13 o 1.26) 1.14 (1.09 o 1.20) 1.14 (1.09 o 1.19) 1.14 (1.09 o 1.19)
Fo me smoke 1.22 (1.17 o 1.28) 1.16 (1.13 o 1.19) 1.15 (1.10 o 1.21) 1.15 (1.11 o 1.18) 1.13 (1.10 o 1.17) 1.11 (1.08 o 1.15)
Con inued
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BMJ Public Heal h
in online supplemen al able 4), he o e all indings
emained consis en , wi h no majo a ia ions obse ed.
DISCUSSION
This s udy highligh s he signi ican a ia ion in SHS and
SHA exposu e ac oss he EU MS. Vulne able popula-
ions, such as younge age g oups, hose socioeconomi-
cally disad an aged and cu en o o me obacco and
nico ine use s, sel - epo ed highe exposu e. While he
majo i y o EU esiden s suppo ed bans on obacco use
in public spaces, suppo was lowe among ulne able
g oups, obacco use s and hose li ing wi hou child en.
Smoke- ee legisla ion is he ounda ion o c ea ing
smoke- ee en i onmen s. Howe e , legisla ion alone is
no su icien ; smoke- ee policies mus be comp ehen-
si e and suppo ed by igo ous en o cemen o ensu e
compliance.21 This is illus a ed by he a ia ion in expo-
su e o SHS om con en ional obacco p oduc s in
indoo public places, despi e he ac ha many EU MS
ha e, in p inciple a leas , ex ensi e indoo smoking bans
in place. Legisla ion ega ding use o eme ging p oduc s
indoo s is no as consis en ac oss EU MS,22 which may
also pa ly explain he g ea e a ia ion in exposu e o
SHA indoo s. Despi e issues wi h en o cemen o smoke-
ee legisla ion, we ound ha exposu e o SHA, bu
pa icula ly o SHS, was much lowe in indoo spaces
compa ed wi h all ou doo se ings assessed in he su ey.
This may sugges ha indoo bans a e e ec i e and ha ,
consequen ly, he ex ension o ou doo spaces ha has
been ecommended by he Council o he EU18 could
lead o simila esul s ou doo s, al hough epo s on use
o nico ine and obacco p oduc s in indoo and ou doo
spaces migh no always be di ec ly compa able.
The gap be ween he p e alence o exposu e in
indoo and ou doo spaces also a ies be ween coun ies,
e lec ing a ia ion in he p e alence o use bu also in
exis ing legisla ion and in social no ms a ound obacco
and nico ine use.23 Fo ins ance, in Slo enia, he esul s
e eal a signi ican dispa i y, wi h indoo smoking p e a-
lence being e y low (9.4%) compa ed wi h much highe
a es in ou doo spaces (86.8%). Howe e , ou doo
smoking in spaces o child en o adolescen s is no ably
lowe (56.1%). This disc epancy may be d i en by local
social no ms, whe e smoking indoo s is less socially
accep able o egula ed, while ou doo smoking, such as
in public spaces o ou doo ca és, may be mo e cul u ally
ole a ed. A he same ime, smoking in spaces equen ed
by child en o adolescen s is less accep ed. These esul s
sugges ha , e en in he absence o speci ic ou doo
smoking legisla ion, he cul u al shi ini ia ed by indoo
bans may ex end o ou doo spaces. This highligh s he
b oade impac o comp ehensi e smoke- ee policies,
which no only p o ec public heal h in public spaces bu
also encou age heal hie beha iou s in p i a e se ings.24
Howe e , u he esea ch is needed o be e unde s and
he unde lying easons o such disc epancies.
Va iables
In he las 6 mon hs, we e people using e- ciga e es o hea ed obacco p oduc s…
In indoo public
spaces
On ou doo
e aces
In ou doo spaces o
child en o adolescen s A ou doo e en s
In ou doo public
spaces
A open- ai public
anspo a ion s a ions
PR (95% CI)
Cu en s a us o e- ciga e e and HTP use
Ne e used e- ciga e es o HTPs ( e .) 1 1 1 1 1 1
Cu en use o a leas one p oduc 1.14 (1.03 o 1.26) 1.12 (1.04 o 1.20) 1.09 (0.99 o 1.20) 1.14 (1.08 o 1.20) 1.11 (1.06 o 1.16) 1.09 (1.03 o 1.15)
Fo me use o a leas one p oduc 1.22 (1.14 o 1.30) 1.13 (1.07 o 1.19) 1.13 (1.06 o 1.20) 1.12 (1.07 o 1.17) 1.09 (1.04 o 1.15) 1.09 (1.04 o 1.13)
Indoo public spaces: Indoo public spaces whe e people no mally do no smoke (eg, es au an s, ba s, shopping malls, ai po s, conce halls).
Ou doo e aces: ou doo e aces o a d inking o ea ing es ablishmen .
Ou doo spaces: ou doo spaces in ended o use by child en o adolescen s (eg, nu se y and school cou ya d, playg ounds).
Ou doo e en s: ou doo e en s (eg, open- ai conce s, spo ma ches, ma ke s).
Ou doo public spaces: ou doo public spaces (eg, pa k, beach, en ance o public buildings).
Open- ai public anspo a ion s a ions: open- ai public anspo a ion s a ions (eg, bus, am o ain s a ions).
HTP, hea ed obacco p oduc ; PR, p e alence a io.
Table 2 Con inued
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BMJ Public Heal h
Beyond di e ences be ween coun ies, we also ound
dispa i ies ac oss a ious sociodemog aphic cha ac e is-
ics. These dispa i ies could be explained, o some ex en ,
by he ac ha some g oups simply equen ce ain
places mo e o en, he eby inc easing hei chances o
exposu e. Fo example, indi iduals li ing wi h child en
a e mo e likely o isi ou doo spaces wi h child en and
adolescen s, such as playg ounds o amily- o ien ed ac i -
i ies, which inc eases hei exposu e o SHS o ae osol
in hese speci ic en i onmen s.25 Howe e , some people
in highly exposed g oups migh also p e e places whe e
smoking o aping is mo e common, ei he legally o
in iola ion o he legisla ion. Fo ins ance, cu en and
o me obacco use s a e mo e likely o equen smoke-
iendly en i onmen s, which leads o highe exposu e.
Resea ch in Canada suppo s his, showing ha smoke s
a e mo e likely o epo exposu e o SHS compa ed
wi h non- smoke s.26 Simila ly, young people o en ga he
in social se ings whe e hei pee s hang ou , and since
e- ciga e es and HTPs a e mo e p e alen among his age
g oup, hey become mo e exposed o SHA.27 28 A s udy
in he USA ound a simila end, wi h epo ed expo-
su e o SHA among you h inc easing alongside he ise
in you h e- ciga e e use, pa icula ly in en i onmen s like
schools.29 Al hough ou analysis could no disen angle
hese ac o s behind epo ed exposu e, i highligh s ha
subs an ial sec ions o socie y a e po en ially exposed o
SHS and SHA and, hence, i is impe a i e o p o ec hem
h ough app op ia e egula ions.
Implemen ing bans, such as hose ha a e included in
he EU Council Recommenda ion, can d as ically educe
exposu e o SHS and SHA in all se ings,18 which would
minimise hese socioeconomic inequali ies. Acco ding
o WHO Eu ope, hough,30 public suppo is c i ical o
ensu ing he success ul implemen a ion o heal h poli-
cies. Ou indings sugges ha public a i udes owa ds
bans oughly simila o hose included in he EU Council
Recommenda ion also di e ac oss popula ion subg oups
in he EU. Coun ies wi h highe smoking p e alence,
such as La ia, Belgium and G eece, end o show lowe
suppo o SHA and SHS bans, while No he n Eu opean
coun ies wi h ela i ely low smoking p e alence show
highe suppo o hese ou doo bans.9 This s udy ound
ha o me and cu en use s o con en ional obacco
and eme ging p oduc s a e less likely o suppo such
bans,31 32 likely because hese policies di ec ly a ec hei
beha iou s. Simila ly, coun ies like Finland, Sweden and
he Ne he lands, whe e he p e alence o e- ciga e e and
HTP use is lowe ,9 also show ela i ely high suppo o
ou doo bans.
Addi ionally, indi iduals li ing wi h child en we e mo e
suppo i e, likely app ecia ing he impo ance o hose
policies o hei child en’s heal h. Simila ly, indi iduals
wi h highe educa ion we e mo e likely o suppo such
policies, possibly because hey a e mo e awa e o he isks
associa ed wi h obacco use.33
O e all suppo o bans o HTP and e- ciga e e use
was highe han o bans on smoking. Howe e , his
may ha e o do wi h he wo ding o he espec i e ques-
ions. Al hough he ques ion abou smoking was explic-
i ly abou ou doo spaces, he one ega ding HTPs and
e- ciga e es men ioned en i onmen s whe e smoking is
p ohibi ed, which, a he ime o he su ey, mean mos ly
indoo spaces.
S eng hs and limi a ions
The s udy d aws on a la ge sample size ha includes all
27 cu en EU MS and employs a consis en se o su ey
ques ions. The da a a e ecen and co e exposu e o
SHA ac oss he EU, speci ically in ou doo spaces o he
i s ime, which is an issue o high policy ele ance o
EU MS. Howe e , some MS ha e ela i ely small sample
Figu e 1 Public suppo o smoking and e- ciga e e/hea ed obacco p oduc bans in public spaces ac oss 27 Eu opean
Union (EU) Membe S a es (n=26 358). HTPs, hea ed obacco p oduc s.
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BMJ Public Heal h
sizes, which migh limi he powe in subg oup anal-
yses. Fu he mo e, he eliance on sel - epo ed da a
in oduces po en ial biases, such as inconsis encies in
esponden s’ ecogni ion o obacco use equency o
s a us. Al hough in e iewe s p o ided e bal desc ip-
ions o each obacco and nico ine p oduc assessed a
he beginning o he in e iew, he absence o accompa-
nying images may ha e c ea ed some con usion. Howe e ,
his is unlikely o ha e esul ed in subs an ial misclas-
si ica ion. Addi ionally, cu en smoking was assessed
h ough a non- speci ic ques ion, which esponden s may
ha e in e p e ed in a ious ways, o example, in e ms o
Table 3 Mul ile el Poisson eg ession es ima ing associa ions be ween sociodemog aphic and beha iou al ac o s and
a i udes owa ds banning obacco p oduc s in public spaces in Eu open Union (EU) membe s a es (n=25 219)
Va iables
In a ou o a ban on smoking in ou doo
places whe e social dis ance canno be
ensu ed
In a ou o a ban on e- ciga e es o
HTPs in en i onmen s whe e smoking
is p ohibi ed
PR (95% CI)
Gende
Male ( e .) 1 1
Female 1.05 (1.02 o 1.08) 1.03 (1.02 o 1.05)
Age (yea s)
55+ ( e .) 1 1
15–24 1.03 (0.97 o 1.10) 1.00 (0.95 o 1.06)
25–39 0.97 (0.93 o 1.01) 0.99 (0.97 o 1.03)
40–54 0.99 (0.96 o 1.02) 1.00 (0.97 o 1.03)
Di icul y paying bills
Almos ne e /ne e ( e .) 1 1
F om ime o ime/mos o he ime 0.94 (0.89 o 0.99) 0.95 (0.91 o 0.99)
Communi y ype
Ru al ( e .) 1 1
U ban 1.01 (0.97 o 1.06) 1.01 (0.97 o 1.06)
Educa ion (age a comple ion)
0–15 yea s ( e .) 1 1
16–19 yea s 1.04 (1.00 o 1.08) 1.03 (0.99 o 1.07)
20+ yea s 1.10 (1.04 o 1.15) 1.10 (1.06 o 1.14)
S ill s udying 1.00 (0.93 o 1.07) 1.05 (0.99 o 1.12)
Li ing wi h child en
No ( e .) 1 1
Yes 1.05 (1.02 o 1.07) 1.04 (1.02 o 1.07)
Employmen s a us
Employed ( e .) 1 1
Unemployed 1.03 (0.96 o 1.10) 1.02 (0.98 o 1.07)
S uden s/house pe sons/ e i ed 1.08 (1.04 o 1.12) 1.04 (1.01 o 1.07)
Cu en smoking s a us
Ne e smoke ( e .) 1 1
Cu en smoke 0.61 (0.55 o 0.67) 0.78 (0.73 o 0.84)
Fo me smoke 0.92 (0.88 o 0.96) 0.99 (0.96 o 1.02)
Cu en s a us o e- ciga e e and HTP use
Ne e used e- ciga e es o HTPs ( e .) 1 1
Cu en use o a leas one p oduc 0.84 (0.76 o 0.92) 0.69 (0.62 o 0.76)
Fo me use o a leas one p oduc 0.90 (0.85 o 0.95) 0.90 (0.87 o 0.94)
Ban on smoking in ou doo places whe e social dis ance canno be ensu ed: a e you in a ou o banning smoking in ou doo places whe e social
dis ancing canno be ensu ed (eg, pa ks, beaches, en ances o public buildings)?
Ban on e- ciga e es o HTPs in en i onmen s whe e smoking is p ohibi ed: a e you in a ou o banning he use o e- ciga e es o hea ed obacco
p oduc s in en i onmen s whe e smoking is p ohibi ed?
HTP, hea ed obacco p oduc ; PR, p e alence a io.
BMJ Public Heal h: i s published as 10.1136/bmjph-2025-002903 on 31 July 2025. Downloaded om h ps://bmjpublicheal h.bmj.com on 6 No embe 2025 by gues .
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