Will Switzerland follow Spain? Maybe, if you raise your voice!

Publication Date: 09.09.2012
Swiss Med Wkly. 2012;142:w13678

Nino Künzli, Joan Ramon Villalbi

Please find the affiliations for this article in the PDF.


This commentary is not about the economy but about public health policy making in an area where Switzerland can learn from Spain. With its “partial smoking ban” (implemented on May 1st, 2010), Switzerland splits the workforce into two categories: one is fully protected from passive exposure to tobacco smoke while the other is still forced to passively smoke at work. Fortunately the latter has become a minority due to general trends in the society [1] and the law prohibiting smoking at, most, work places. The minority are those working in restaurants smaller than 80 square meters, where employers can still choose to permit smoking.

When Spain adopted its law in December 2005, it successfully banned tobacco advertisement and smoking from workplaces. However, fierce resistance from interest groups and stakeholders resulted in exemptions for the recreation sector (e.g., bars, cafes, restaurants, dancehalls, discos, casinos). Most importantly restaurants less than 100 square meters were exempt from the protection of employees, very similarly to Switzerland, and larger facilities could keep smoking rooms if ventilation was provided; again just the same as the Federal law of Switzerland and the current rule in 18 of 26 Swiss counties [2]. Most Spanish hospitality facilities were smaller than 100 m2, and the vast majority of owners opted for “smoking permitted” as it is well known that patchy smoking bans, where the next-door business allows smoking, negatively affect the restaurant business whereas comprehensive country-wide bans do not [3].

Effects of the Spanish law were evaluated in several studies [4–6] confirming large decreases in the general exposure to second hand smoke, paralleled by health benefits such as unambiguous reductions in myocardial infarction hospitalisation and mortality rates [7]. The Spanish studies also documented extremely high exposure levels in the exempted facilities, where workers continued to be heavily exposed [8]. These findings stirred up the debate and the request to protect all workers from passive smoking. With the support of trade-unions, the Spanish parliament eventually amended the law. As of January 2011 all workplaces were smoke-free, with no exception. Despite forecasts of cataclysmic effects on business, the hospitality sector has been doing much better than the economy as a whole in these troubled times [9].

Unfortunately, Switzerland has not made the last step of the Spanish success story. Lobbies in the Federal parliament and the Government were able to block comprehensive bans. Fortunately, the country offers other political tools to progress, namely that counties can go for better policies, and Federal “initiatives” can be launched to bring issues to the ballots. In fact, 8 out of 26 Swiss Counties successfully adopted comprehensive smoking bans with no exemption. However, in a small country with one third of all counties having less than 100,000 inhabitants and county borders often running through adjacent towns and neighbourhoods, Switzerland faces a very confusing, small-scale patch-work of inconsistent policies.

A committee launched an initiative proposing a simple and comprehensive indoor smoking ban at all work places. Swiss voters can now resolve the odd policy situation at the ballot, scheduled for September 23rd, 2012. Apart from the success stories from Spain and many other countries, Swiss voters will indeed find local scientific evidence and arguments to fully support the proposed initiative:

Publicly funded Swiss research projects such as the SAPALDIA study gave insight into the deleterious respiratory effects of second hand tobacco smoke exposure at work places [10]. The impact of local smoking bans has been assessed in some counties where stronger rules apply. For example, despite the use of relatively simple methods, which became subject to provocative debates, studies in the county of Graubünden reported a >20% post-ban reduction in hospital admissions due to myocardial infarction [11–12]. The decline observed in the county of Geneva (Switzerland) was lower and statistically not significant [13], however, a recent systematic Cochrane review concluded that the largest public health impact of smoking bans is indeed related to the decline in hospital admissions due to coronary heart diseases [14], and the reported 20% was within the range observed in many studies [15]. A study from the Swiss county of Vaud reported that the ban resulted in improved lung function, physical well-being and respiratory symptoms among hospitality workers, including smokers [16]. Preliminary results of the COSIBAR study, a pre-post ban comparison of health indicators among a panel of gastronomy personnel, confirmed cardiovascular benefits of the ban [17]. Moreover, the study of Huss et al. showed that waiters working in non-smoking rooms are still exposed to considerably higher PM2.5 levels if smoking was allowed in an adjacent room [18]. A survey from Geneva indicated strong secular trends toward favouring smoke free work places [1] and the Cochrane review showed that the popularity of bans gets stronger support after its implementation. A Swiss risk assessment estimated the health impact from smoking in public places to reach some 32,000 hospital days and some 330 Mio Swiss francs per year [19]. Last but not least, a recent study from the Ticino County was unable to attribute sales patterns in the gastronomy business to the comprehensive smoking ban implemented in April, 2007, nullifying key arguments of lobbyist’s against the proposed act [20].

Thus, in the absence of a single rational argument in favour of the current Federal “semi-policy” or against the proposed initiative: why even bother with the ballot? Will Swiss voters, the majority being non-smokers, not simply follow common sense, scientific evidence, and economic arguments to clearly support the initiative? Is the battle over? We suggest health professionals to remain alert and to raise their voices very clearly to promote smoke free working environments! Swiss policy makers and the Federal Government were clearly against protecting all workers. A populist propaganda remains loud and aggressive, paraphrasing the public health objective as “extremist”. Are Spain, Ireland, Italy, France, the UK, Scandinavia and others “extremist” societies? Why do scientists call for science-based policies in India [21]?

Should hospitality workers in Switzerland remain deprived from health protection on the job? Should Swiss restaurant owners keep the right to cause lung cancer, chronic obstructive lung diseases or cardiovascular ailments among the workers while all other employers are now required to protect their health? As long as powerful interest groups oppose science based prevention, health professionals need to be vocal lobbyists to guarantee smoke-free work places for all workers.

Funding / potential competing interests: No financial support and no other potential conflict of interest relevant to this article were reported.


Correspondence:Professor Nino Künzli, MD, PhD, Deputy-Director; Head of Department of Epidemiology and Public Health, Swiss TPH, Socinstrasse 57, P.O. Box, CH-4002 Basel, Switzerland, nino.kuenzli[at]


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