Smoke-Free Policies in the World’s 50 Busiest Airports

Morbidity and Mortality Weekly Report

Weekly / Vol. 66 / No. 46 November 24, 2017

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

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1283 QuickStats

Smoke-Free Policies in the World’s 50 Busiest Airports — August 2017

Michael A. Tynan

; Elizabeth Reimels JD

; Jennifer Tucker MPA

; Brian A. King PhD

Exposure to secondhand smoke from burning tobacco prod-

ucts causes premature death and disease, including coronary

heart disease, stroke, and lung cancer among nonsmoking

adults and sudden infant death syndrome, acute respiratory

infections, middle ear disease, exacerbated asthma, respiratory

symptoms, and decreased lung function in children (1,2).

The U.S. Surgeon General has concluded that there is no

risk-free level of exposure to secondhand smoke (1). Previous

CDC reports on airport smoke-free policies found that most

large-hub airports in the United States prohibit smoking (3);

however, the extent of smoke-free policies at airports globally

has not been assessed. CDC assessed smoke-free policies at the

world’s 50 busiest airports (airports with the highest number of

passengers traveling through an airport in a year) as of August

2017; approximately 2.7 billion travelers pass through these

50 airports each year (4). Among these airports, 23 (46%)

completely prohibit smoking indoors, including five of the 10

busiest airports. The remaining 27 airports continue to allow

smoking in designated smoking areas. Designated or venti-

lated smoking areas can cause involuntary secondhand smoke

exposure among nonsmoking travelers and airport employees.

Smoke-free policies at the national, city, or airport authority

levels can protect employees and travelers from secondhand

smoke inside airports.

The 50 busiest airports were identified using data from the

Airport International Council, which lists airports based on

total passenger traffic for 2016 (4). The Airport International

Council defines passenger traffic as the sum of enplaned pas-

sengers, deplaned passengers, and direct-transit passengers.

To determine the extent of smoke-free policies at each of the

50 busiest airports worldwide, CDC reviewed and analyzed

public information available on airport websites regarding

availability of designated indoor smoking rooms at airports as

of August 2017. Results were confirmed with information on

smoke-free airports maintained by Americans for Nonsmokers’

Rights Foundation* and with other Internet resources, includ-

ing information intended to assist smokers in finding places

where smoking is permitted in airports. In a limited number

of instances where airport websites contained unclear or

ambiguous statements about policies, additional information

was collected from other sources, including airport personnel

and local public health personnel.

Airports were considered to have a smoke-free policy if they

completely prohibit smoking in all indoor areas. Airports

were considered to have no smoke-free policy if they allowed

smoking in any indoor areas, including designated or venti-

lated indoor smoking areas. Designated smoking areas can

include, but are not limited to, rooms designed for smoking

tobacco; areas or rooms of restaurants or bars where smoking

is allowed; and designated areas and rooms in airline clubs

where smoking is allowed. Policy status was assessed overall

and by global region.

* http://no-smoke.org/learnmore.php?id=187.

Morbidity and Mortality Weekly Report

1266 MMWR / November 24, 2017 / Vol. 66 / No. 46 US Department of Health and Human Services/Centers for Disease Control and Prevention

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Patrick L. Remington, MD, MPH

Carlos Roig, MS, MA

William L. Roper, MD, MPH

William Schaffner, MD

Among the 50 busiest airports worldwide, 23 (46%) had a

smoke-free policy (Table 1). Among the top 10 busiest airports,

five had a smoke-free policy (Beijing Capital, Chicago’s O’Hare

International, London’s Heathrow, Los Angeles International,

and Shanghai Pudong International) and five allowed smok-

ing in certain indoor areas (Atlanta Hartsfield Jackson

International, Dubai International, Hong Kong International,

Paris’s Charles de Gaulle, and Tokyo International).

Regional differences were observed in smoke-free policy

status among the world’s 50 busiest airports (Table 2). Among

those in North America, 14 of 18 had a smoke-free policy; in

Europe, four of nine had a smoke-free policy, including airports

in Madrid, Barcelona, and London (Heathrow and Gatwick

airports); and in Asia, four of 22 had a smoke-free policy (all

four are in China, including Beijing Capital International

Airport, the world’s second busiest airport). The only airport

among the 50 busiest in Oceania is Sydney International,

which is smoke-free. None of the world’s 50 busiest airports

is located in South America or Africa.

Discussion

As of August 2017, nearly half (46%) of the 50 busiest air-

ports worldwide have a smoke-free policy. Smoke-free policies

substantially improve indoor air quality and reduce secondhand

smoke exposure among nonsmokers (1,2). The 2006 Surgeon

General’s report concluded that eliminating smoking in indoor

spaces fully protects nonsmokers from exposure to secondhand

smoke, and that separating smokers from nonsmokers, cleaning

the air, and ventilating buildings cannot eliminate exposure of

nonsmokers to secondhand smoke (1).

Although the airports in this analysis that do not have

smoke-free policies only allow smoking indoors in designated

or ventilated smoking areas, studies have documented that

secondhand smoke can transfer from designated smoking

areas into nonsmoking areas in airports, where nonsmoking

travelers and employees can be exposed (5–7). In addition to

subjecting nonsmoking travelers who pass through these areas

to involuntary secondhand smoke exposure, designated or

ventilated smoking areas can also result in involuntary exposure

of airport employees who are required to enter these areas or

work near them.

Since 2012, two of the five large-hub U.S. airports that

allowed smoking in designated indoor areas have implemented,

or are implementing, smoke-free policies. Salt Lake City

International, a large-hub U.S. airport that is not among the

world’s 50 busiest, closed its smoking rooms,

†

and Denver

International closed three of its four indoor smoking rooms,

with the final smoking room scheduled to close by 2018.

The findings in this report are subject to at least three

limitations. First, information on smoke-free policies was

based on information available on airport websites, which

could be subject to bias or be outdated. However, these data

†

http://www.sltrib.com/news/3928480-155/salt-lake-city-to-phase-out; https://

www.slcairport.com/airport-services/smoking-areas/.

https://www.flydenver.com/sites/default/files/downloads/DIAPR_130111s.pdf.

Morbidity and Mortality Weekly Report

MMWR / November 24, 2017 / Vol. 66 / No. 46 1267

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 1. Indoor smoke-free policy status of 50 busiest airports — worldwide, August 2017

Rank* Airport Jurisdiction Country

Has indoor smoke-

free policy

†

Region

1 Atlanta-Hartsfield Jackson International Atlanta United States No North America

2 Beijing Capital International Airport Beijing China Yes Asia

3 Dubai International Airport Dubai United Arab Emirates No Asia

4 Los Angeles International Airport Los Angeles United States Yes North America

5 Tokyo International Airports Tokyo Japan No Asia

6 O’Hare International Airport Chicago United States Yes North America

7 Heathrow Airport London United Kingdom Yes Europe

8 Hong Kong International Airport Hong Kong Hong Kong No Asia

9 Shanghai Pudong International Airport Shanghai China Yes Asia

10 Charles de Gaulle Airport Paris France No Europe

11 Dallas/Forth Worth International Airport Dallas/Fort Worth United States Yes North America

12 Amsterdam Airport Schiphol Amsterdam Netherlands No Europe

13 Frankfurt Airport Frankfurt Germany No Europe

14 Istanbul Ataturk Airport Istanbul Turkey No Asia

15 Guangzhou Baiyun International Airport Guangzhou China No Asia

16 John F. Kennedy International Airport New York City United States Yes North America

17 Singapore Changi Airport Changi Singapore No Asia

18 Denver International Airport Denver United States No North America

19 Seoul Incheon International Airport Incheon Republic of Korea No Asia

20 Suvarnabhumi/New Bangkok International Airport Bangkok Thailand No Asia

21 Indira Gandhi International Airport New Delhi India No Asia

22 Soekarno-Hatta International Airport Jakarta Indonesia No Asia

23 San Francisco International Airport San Francisco United States Yes North America

24 Kuala Lumpur International Airport Sepang District Malaysia No Asia

25 Madrid-Barajas Airport Madrid Spain Yes Europe

26 McCarran International Airport Las Vegas United States No North America

27 Chengdu Shuangliu International Airport Chengdu China No Asia

28 Seattle-Tacoma International Airport Seattle United States Yes North America

29 Chhatrapati Shivaji International Airport Mumbai India No Asia

30 Miami International Airport Miami United States Yes North America

31 Charlotte Douglas International Airport Charlotte United States Yes North America

32 Toronto Pearson International Airport Toronto Canada Yes North America

33 Barcelona-El Prat Airport Barcelona Spain Yes Europe

34 Phoenix Sky Harbor International Airport Phoenix United States Yes North America

35 Gatwick Airport London United Kingdom Yes Europe

36 Taiwan Taoyuan International Airport Taipei Taiwan No Asia

37 Munich Airport Munich Germany No Europe

38 Sydney International Airport Sydney Australia Yes Oceania

39 Kunming International Airport Kunming China No Asia

40 Shenzhen Bao’an International Airport Bao’an China Yes Asia

41 Orlando International Airport Orlando United States Yes North America

42 Leonardo da Vinci–Fiumicino Airport Rome Italy No Europe

43 George Bush Intercontinental Airport Houston United States Yes North America

44 Mexico City International Airport Mexico City Mexico No North America

45 Shanghai Hongqiao International Airport Shanghai China Yes Asia

46 Newark Liberty International Airport Newark United States Yes North America

47 Ninoy Aquino International Airport Manila Philippines No Asia

48 Narita International Airport Narita Japan No Asia

49 Minneapolis/St Paul International Airport Minneapolis/St Paul United States Yes North America

50 Hamad International Airport Doha Qatar No Asia

* Ranked by total 2016 passenger traffic, according to the Airports Council International.

†

Airports are considered to have a smoke-free policy if they completely prohibit smoking in all indoor areas. Airports were considered to have no smoke-free policy

if they allowed smoking in any indoor areas, including designated or ventilated indoor smoking areas.

Morbidity and Mortality Weekly Report

1268 MMWR / November 24, 2017 / Vol. 66 / No. 46 US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 2. Smoke-free airports among the 50 busiest airports, by

region — worldwide, August 2017

Region*

No. (%) of airports

among 50 busiest

No. (%) of airports with

indoor smoke-free policies

†

Asia 22 (44) 4 (18)

Europe 9 (18) 4 (44)

North America 18 (36) 14 (78)

Oceania 1 (2) 1 (100)

Total 50 (100) 23 (46)

* No airports among the world’s 50 busiest were in the Africa or South

America regions.

†

Airports are considered to have a smoke-free policy if they completely prohibit

smoking in all indoor areas. Airports were considered to have no smoke-free

policy if they allowed smoking in any indoor areas, including designated or

ventilated indoor smoking areas.

were cross-checked with secondary information sources, and

questions about unclear information were resolved by con-

tacting local public health and airport personnel. Second, it

was not possible to identify the types of smoking areas that

were allowed in all airports (e.g., rooms used exclusively for

smoking, smoking sections in restaurants and bars, rooms or

areas in airline clubs, etc.), nor was it possible to ascertain

passenger or employee movement through airports, which

might or might not include use of or proximity to areas where

smoking is permitted. In addition, because it was not possible

to identify smoke-free policies in outdoor areas or areas near

exits, this information was not reported. Finally, only the 50

busiest airports were included in this study; therefore, regions

such as South America and Africa were not represented in the

study because they did not include any of these busiest airports.

However, many airports with lower passenger volume have

implemented smoke-free policies (8).

Progress has been made in protecting nonsmoking passengers

and employees from secondhand smoke in airports. A majority

of airports are smoke-free in many countries worldwide, includ-

ing Australia and New Zealand; European countries such as

Denmark, Ireland, Norway, Spain, and the United Kingdom;

South American countries such as Argentina, Brazil, Chile,

Ecuador, and Uruguay; and North American countries such

as Canada and the United States.

Smoke-free policies at the

national, city, or airport authority levels can protect employees

and travelers from secondhand smoke inside airports.

Acknowledgment

Xiao Lin, National Tobacco Control Office, China CDC.

http://no-smoke.org/pdf/Smokefree-Airport-Highlights-From-Around-the-

World.pdf.

Summary

What is already known about this topic?

There is no risk-free level of exposure to secondhand smoke.

Eliminating smoking in indoor spaces fully protects nonsmokers

from exposure to secondhand smoke. An overwhelming

majority of large-hub airports in the United States prohibit

smoking indoors.

What is added by this report?

Among the 50 busiest airports worldwide, 23 airports (46%),

including five of the 10 busiest airports, prohibit smoking in all

indoor areas. While smoke-free airports among the 50 busiest

are common in North America (14 of 18), few airports in Asia

(4 of 22) have implemented smoke-free polices.

What are the implications for public health practice?

Broader implementation of smoke-free policies at the national,

city, or airport authority levels can protect employees and

travelers of all ages from secondhand smoke inside airports.

Conict of Interest

No conflicts of interest were reported.

Office on Smoking and Health, National Center for Chronic Disease

Prevention and Health Promotion, CDC.

Corresponding author: Michael A. Tynan, [email protected], 404-498-1202.

References

1. US Department of Health and Human Services. The health consequences of

involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta,

GA: US Department of Health and Human Services, CDC; 2006. https://

www.surgeongeneral.gov/library/reports/secondhandsmoke/index.html

2. US Department of Health and Human Services. The health consequences

of smoking—50 years of progress: a report of the Surgeon General. Atlanta:

US Department of Health and Human Services, CDC, National Center

for Chronic Disease Prevention and Health Promotion, Office on Smoking

and Health, 2014. https://www.surgeongeneral.gov/library/reports/50-

years-of-progress/index.html

3. CDC. Smoking restrictions in large-hub airports—United States, 2002

and 2010. MMWR Morb Mortal Wkly Rep 2010;59:1484–7.

4. Port Authority of New York and New Jersey. Airport traffic report.

Passenger traffic: top 50 worldwide airport comparisons, 2016, table

2.1.2. New York, NY: Port Authority of New York and New Jersey; 2016.

http://www.panynj.gov/airports/pdf-traffic/ATR2016.pdf

5. Pion M, Givel MS. Airport smoking rooms don’t work. Tob Control

2004;13(Suppl 1):i37–40. https://doi.org/10.1136/tc.2003.005447

6. Lee K, Hahn EJ, Robertson HE, Whitten L, Jones LK, Zahn B. Air quality

in and around airport enclosed smoking rooms. Nicotine Tob Res

2010;12:665–8. https://doi.org/10.1093/ntr/ntq054

7. CDC. Indoor air quality at nine large-hub airports with and without

designated smoking areas—United States, October–November 2012.

MMWR Morb Mortal Wkly Rep 2012;61:948–51.

8. Stillman FA, Soong A, Kleb C, Grant A, Navas-Acien A. A review of smoking

policies in airports around the world. Tob Control 2015;24:528–31. https://

doi.org/10.1136/tobaccocontrol-2013-051364