title: Tobacco Smoke Exposure in Indoor and Outdoor Locations in Airports Across Europe and the United States: A Cross-Sectional Study.
abstract: OBJECTIVE
  Conduct a systematic evaluation of indoor and outdoor areas of selected airports, assess compliance and identify areas of improvement with smoke-free policies in airports.
  
  
  METHODS
  Cross-sectional observational study conducted at 21 airports in Europe (11) and the United States (10). Using a standardized protocol, we assessed compliance (smoking, cigarette butts, smoke smell), and the physical environment (signage, ashtrays, designated smoking rooms [DSRs], tobacco sales).
  
  
  RESULTS
  Cigarette butts (45% vs. 0%), smoke smell (67% vs. 0%), ashtrays (18% vs. 10%), and DSRs (63% vs. 30%) were observed more commonly indoors in Europe than in the United States. Poor compliance indoors was related to the presence of DSRs (OR 4.8, 95% CI 0.69, 33.8) and to cigarettes sales in pre-security areas (OR 6.0, 95% CI 0.57, 64.7), although not significantly different. Smoking was common in outdoor areas of airports in Europe and the United States (mean (SD) number of smokers 27.7 (23.6) and 6.3 (7.7), respectively, p value < .001). Around half (55%) of airports in Europe and all airports in the United States had some/partial outdoor smoking restrictions.
  
  
  CONCLUSIONS
  Exposure to secondhand smoke (SHS) remains a public health problem in major airports across Europe and in some airports in the United States, specifically related to the presence of DSRs and SHS exposure in outdoor areas. Airports must remove DSRs. Research is needed in low- and middle-income countries and on the effectiveness of outdoor smoking-restricted areas around entryways. Eliminating smoking at airports will protect millions of people from SHS exposure and promote social norms that discourage smoking.
  
  
  CONCLUSIONS
  Airports are known to allow exceptions to smoke-free policy by providing DSRs. We found that smoking still occurs in indoor areas in airports, particularly in the context of DSRs. Smoking, moreover, is widespread in outdoor areas and compliance with smoking restrictions is limited. Advancing smoke-free policy requires improvements to the physical environment of airports, including removal of DSRs and implementation of stricter outdoor smoking restrictions.
authors.affiliation: Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Frances A
authors.initials: FA
authors.lastname: Stillman
authors.affiliation: Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.|Department of Behavioral and Community Health, Center on Young Adult Health and Development, University of Maryland School of Public Health, College Park, MD.
authors.forename: Andrea
authors.initials: A
authors.lastname: Soong
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Yuanjie
authors.initials: Y
authors.lastname: Pang
authors.affiliation: Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Laura
authors.initials: L
authors.lastname: Zheng
authors.affiliation: Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz and CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.
authors.forename: Esther
authors.initials: E
authors.lastname: Garcia-Esquinas
authors.affiliation: Public Health Agency of Barcelona, Barcelona, Spain.|Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain.|Sant Pau Institute of Biomedical Research (IIB Sant Pau), Barcelona, Spain.
authors.forename: Maria Jose
authors.initials: MJ
authors.lastname: Lopez
authors.affiliation: Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.|Department of Environmental Health Sciences, Columbia University, Mailman School of Public Health, New York, NY.
authors.forename: Ana
authors.initials: A
authors.lastname: Navas-Acien
mesh_terms: D000328:Adult; D059028:Airports / Q000331:legislation & jurisprudence / Q000592:standards*; D003430:Cross-Sectional Studies; D005060:Europe / Q000453:epidemiology; D006801:Humans; D008297:Male; D061845:Smoke-Free Policy / Q000331:legislation & jurisprudence; D014028:Tobacco Smoke Pollution / Q000032:analysis / Q000331:legislation & jurisprudence / Q000517:prevention & control*; D000073869:Tobacco Smoking / Q000009:adverse effects* / Q000331:legislation & jurisprudence / Q000517:prevention & control*; D014481:United States / Q000453:epidemiology
chemical_list: D014028:Tobacco Smoke Pollution