November 7, 2016 | Houston Health Department | Office of Chronic Disease Prevention and Management
It’s been over 50 years since the publication of the landmark Surgeon General’s Report on Smoking and Health. 50 Years ago, smoking was a social norm; it was ordinary to smoke indoors and in communal areas. Smoking was commonly advertised as stylish, attractive, popular, and acceptable. The 1964 Surgeon General’s Report is the first federal report linking tobacco use to human diseases such as asthma, stomach ulcers, lung cancer and coronary heart disease. Since its publication, over 20 million people have died from tobacco caused diseases. Despite the enormous amount of mobilization to deter tobacco use, it is still the number one preventable risk factor for disease and death in the United States and in Houston.
Over the years, there have been a number of organizations, agencies and advocates working in the area of tobacco prevention and control. The City of Houston, the jurisdiction authority over the Houston geographic area, has passed and revised several smoking restrictions since the Surgeon General’s Report. Aware of the health and mortality consequences of tobacco and secondhand smoke exposure, 10 years ago the City of Houston concluded that increasing the number of smoke-free areas was necessary to protect the public’s health and exposure from secondhand smoke.
In October 2006, Houston, Texas passed Ordinance No. 2006-1054 prohibiting tobacco smoke in public areas and places of employment. This comprehensive revision edited the Ordinance No. 2002-800 which prohibited smoking from patient’s rooms in hospitals and nursing homes. Ordinance 2006-1054 took effect on September 1, 2007. Individuals could no longer smoke in enclosed public places and workplaces or within 25 feet of a building entrance and exit doors. This comprehensive smoke-free ordinance was a collaborative effort to protect Houston workers and general public from the serious health hazards of secondhand smoke.
Tobacco Prevention and Control Milestones
The passing of this monumental smoking ordinance led the way for new tobacco related policy changes to be made. The Mayor’s Go Healthy Houston Taskforce has worked to advocate for additional tobacco and smoke -free spaces throughout the city of Houston. These efforts have expanded beyond the indoor clean air ordinance and have increased access to tobacco and smoke -free places for all 2.2 million Houston residents.
Tobacco-Free Parks and Libraries
The Go Healthy Houston Taskforce worked with the Houston Department of Parks and Recreation and the Houston Public Library system to develop and adopt tobacco and smoke-free policies for all City parks and recreation facilities and library campuses. The city of Houston Ordinance No. 2014 -894 became fully effective on September 2, 2014; effectively expanding Houston’s 2006 smoke-free ordinance.
For parks, the policy helps keep recreation areas and natural spaces clean, healthy, and safe for all to enjoy. For libraries, the policy helps ensure that each library location is a safe, healthy, family-friendly and welcoming environment. Notably, the smoke-free libraries ordinance solidified the Houston Public Library system as the first large library system to implement this type of policy in the country.
Tobacco-Free Multi-Unit Public Housing Facilities
The Go Healthy Houston Taskforce worked with the Houston Housing Authority to institute an indoor smoke-free policy at the agency’s 25 multi-unit public housing facilities. Effective January 1, 2014, smoking is no longer allowed inside residence units, common areas, offices and within 25 feet from all main entryways. This policy provides agency employees and over 16,000 residents who reside in housing authority properties and their guests with a smoke-free living environment.
This is significant as a recent study by the Centers for Disease Control and Prevention confirmed that individuals who live in multi-unit housing are more likely to be exposed to secondhand smoke or to smoke compared to individuals living in single-family homes[i].
The Go Healthy Houston Taskforce worked with MD Anderson Cancer Center to form the Regional Tobacco-Free Taskforce. This unique taskforce encourages tobacco and smoke-free policies throughout the city of Houston and Harris County region. The taskforce developed a resource toolkit of best practices and guidelines for adopting smoke and/or tobacco-free policies at colleges and universities. Currently, the University of Houston and Rice University (combined student populations of over 46,000) have adopted smoke- and/or tobacco- free campus policies. In the future, the taskforce will begin working with additional sectors, including worksites, to implement tobacco-free policies.
Health Impacts of Policy
One of the major benefits of the Houston Smoke- Free Ordinance has been the health impact it has had on Houstonians. Limiting spaces and opportunities to smoke lowers the prevalence of smoking and exposure to secondhand smoke.
Cleaner Air for All
Inhaling secondhand smoke from cigarettes and similar tobacco products has immediate harmful effects on health. These immediate effects impact the cardiovascular system and can lead to stroke and coronary heart disease[ii]. Studies widely corroborate the beneficial health impact of improved air quality due to comprehensive smoke-free laws in all indoor areas[iii],[iv] The quality of indoor air in public spaces is cleaner, safer, and healthier for Houstonians due to the 2006 ordinance.
Reduction in the Prevalence of Smoking
Smoke free laws are effective due to their ability to reduce smoking prevalence, prevent smoking initiation among youth, and promote smoking cessation[v],[vi],[vii]. The State of Health in Houston/Harris County data suggests that 10 years later the ban is having an effect to help decrease the prevalence of smoking in the region.
From 2005 to 2013, the percentage of adults in Texas who were current smokers went from 20% to 15.9%, indicating a potential downward trend.[viii],[ix],[x],[xi],[xii] This trend is evident in Harris County (Houston-Baytown-Sugar Land MSA), as the percentage of adult cigarette smokers has gone from 17% in 2005 (Pre- ordinance) to 13.9% in 2013 (7 years post ordinance). This trend can partially be attributed to community based interventions, such as cessation and education. However, the impact of tobacco-free policy cannot be overlooked as it limits places and opportunities to smoke. This trend is displayed in detail in Table 1 below.
Table 1: Harris County Adult Cigarette Smokers
– The State of Health in Houston/Harris County Reports
|Adult Cigarette Smokers||2005||2007||2010||2013*|
|Healthy people Target||12||12||12.0||12.0|
|Houston-Baytown-Sugar Land MSA||17||15||15.6||13.9|
|State of Texas||20||19||15.8||15.9|
Source: TDSHS, BRFSS; The State of Health in Houston/Harris County Reports
*Note: BRFSS data collection methods have been changed from 2011 onward. See Appendix A for details.
Decrease in Tobacco Related Diseases
Smoking causes a considerably large percentage of all lung cancer deaths. Cigarette smoking single-handedly is associated with approximately 80% to 90% of lung cancers[xiii]. In 2015, there were nearly 2,000 expected total new cases of lung and bronchus cancer in Harris County alone. From 2004 to 2012, the rates of trachea, bronchus and lung cancer deaths were steadily decreasing after the 2006 smoke-free ordinance.
Table 2: Harris County Deaths from Cancer of the Trachea, Bronchus and Lung
-The State of Health in Houston/Harris County Reports
(per 100,000 population)
Source: TDSHS, Center for Health Statistic; State of Health in Houston/Harris County Reports
Improved heart and respiratory health is corroborated by studies from city and countries who have passed smoking bans such as Scotland, New York, Montana, Italy, Colorado, Indiana, Ohio, Beaumont, and Ireland[xix]
The smoke-free ordinance has been beneficial for businesses. Each year smoking costs Texas taxpayers around $17 billion annually in health care costs and productivity losses[xx]. Decreasing the prevalence of smoking related illness is vital for the economy. A study looking at Return On Investment (ROI) in Texas found that a less than 4% reduction in smoking prevalence between 2004 to 2010 resulted in 500 fewer smokers and $3.8 billion in combined healthcare expenditure savings and reduced productivity costs over 5 years[xxi]. This correlates to approximately $1 billion saved for each percentage point decline in smoking prevalence.
Despite concerns that the smoke free air ordinance would drastically harm businesses, the majority of studies show otherwise. The economic impact of the 2006 smoking ordinance on restaurant and mixed beverage sales was evaluated for Houston, Texas[xxii]. These analyses found that the smoking ordinance was not associated with negative outcomes in the first two quarters after implementation. Other studies results have shown similar smoke free laws result in either no economic effect or a positive one.[xxiii],[xxiv],[xxv]
Emerging Issues in Tobacco Control
Considerable progress has been made after the passing of the 2006 smoke-free ordinance. However, tobacco use continues to be the leading cause of preventable illness and death in the United States. This accounts for 1 of every 5 deaths, more than 480,000 deaths every year[xxvi]. The tobacco industry is evolving. There are new areas of tobacco prevention and control that must be studied and addressed.
E-cigarettes have emerged as a growing concern over the past decade. This concern is particularly due to their growing popularity among youth and limited research on health effects. While these battery-operated cigarettes do not burn tobacco, they contain nicotine and undisclosed trade chemicals for flavoring. Due to the unknown health risks, the Houston chapter of the American Lung Association advocates that the City of Houston limits access to the product along with traditional tobacco products. Currently, E-cigarettes are not included in the original or expanded smoke- free ordinance. With the significant risk for youth and young adults, this is an area that needs to be studied and responded with appropriate policy measures to protect the health and safety of Houstonians.
Raising the Minimum Smoking age
One strategy to delay the initiation of tobacco use in youth involves raising the minimum smoking age from 18 to 21 years of age. Some states and cities have settled for increasing the minimum age to 19, to prevent cigarettes from entering high schools and exposing underage students. The 21 age limit is suggested due to its potential to further decrease the likelihood that those under 21 will have access to tobacco products. This approach is innovative as current adult smokers initiated smoking in their adolescence. The literature shows that the younger you start; typically the harder it can be to quit. Among the many supporters of this policy change include the American Academy of Pediatricians, as it can help prevent smoking initiation in youth.
In summary, the 10 year anniversary of the passing of the Houston smoke- free ordinance illustrates how policy in combination with community-based resources has been successful in creating smoke-free environments, and promoting health and economic benefits for Houstonians. Despite this success, additional policy measures are still needed. The tobacco industry is modernizing their products and marketing approaches to adolescents and young adults. There are still many vulnerable Houstonian exposed to secondhand smoke in communal spaces. The Surgeon general report says that unless the current smoking rates drop, nearly 5.6 million American children alive today will die prematurely from smoking-related diseases[xxvii].
This is not a warning that can be taken lightly; fortunately the Houston’s public health and medical community are up for the challenge. With continued research and equitable policy measures, we can continue to limit the exposure of tobacco and tobacco products to protect the welfare of all Houstonians.
Appendix A: BRFSS data Information
The 2011 and onward BRFSS data reflects a change in weighting methodology (raking) and the addition of cell phone only respondents. Prior, the BRFSS data had been collected through landline phone surveys to households[xxviii]. As of result of these changes, data collected in 2011 and later cannot be directly compared to previous data and thus represents a suggested impact. The CDC predicts small increases for health-risk indicators such as tobacco use, HIV, obesity, asthma, binge drinking, and health status[xxix].
For additional information see the following sources:
- Centers for Disease Control and Prevention FAQ; LINK;
- CDC: Methodologic Changes in the Behavioral Risk Factor Surveillance System in 2011 and Potential Effects on Prevalence Estimates CDC MMWR report; CDC MMWR report
[i] CDC. (2016). Tobacco use, involuntary secondhand smoke exposure high in multiunit housing residents. American Journal of Preventive Medicine. [Accessed on October 10, 2016, Link]
[ii] U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2016 October 5 from Link]
[iii] Centers for Disease Control and Prevention. Indoor Air Quality in Hospitality Venues Before and After Implementation of a Clean Indoor Air Law—Western New York, 2003. Morbidity and Mortality Weekly Report 2004;53(44):1038–41 [Accessed on October 10, 2016 Link]
[iv] Centers for Disease Control and Prevention. Indoor Air Quality in Hospitality Venues Before and After Implementation of a Clean Indoor Air Law—Western New York, 2003. Morbidity and Mortality Weekly Report 2004;53(44):1038–41 [[Accessed on October 10, 2016 Link].
[v] International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco Control, Volume 13: Evaluating the Effectiveness of Smoke-Free Policies[PDF–2.67 MB]. Lyon, France: WHO, 2009 [accessed October 11, 2016 Link] [vi] Siegel M, Albers AB, Cheng DM, Biener L, Rigotti NA. Local Restaurant Smoking Regulations and the Adolescent Smoking Initiation Process: Results of a Multilevel Contextual Analysis Among Massachusetts Youth. Archives of Pediatric and Adolescent Medicine 2008;162(5):477–83 [accessed October 11, 2016 Link
[vii] U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006 [accessed October 11, 2016 Link] [viii] The State of Health in Houston/Harris County 2007. Harris County Healthcare Alliance, Houston, Texas
[ix] The State of Health in Houston/Harris County 2009. Harris County Healthcare Alliance, Houston, Texas
[x] The State of Health in Houston/Harris County 2012. Harris County Healthcare Alliance, Houston, Texas.
[xi] Texas Department of State Health Services. (2013). Texans and Tobacco Report. Retrieved October 9, 2016 from Link
[xii] The State of Health in Houston/Harris County 2015-2016. Harris County Healthcare Alliance, Houston, Texas
[xiii] Centers for Disease Control and Prevention. Fact Sheet. What Are the Risk Factors for Lung Cancer? Division of Cancer Prevention and Control, Centers for Disease Control and Prevention. 2016. Accessed on October 07, 2016 from: Link
[xiv] The State of Health in Houston/Harris County 2007. Harris County Healthcare Alliance, Houston, Texas
[xv] The State of Health in Houston/Harris County 2009. Harris County Healthcare Alliance, Houston, Texas
[xvi] The State of Health in Houston/Harris County 2012. Harris County Healthcare Alliance, Houston, Texas.
[xvii] Texas Department of State Health Services. (2013). Texans and Tobacco Report. Retrieved October 9, 2016 from Link
[xviii] The State of Health in Houston/Harris County 2015-2016. Harris County Healthcare Alliance, Houston, Texas
[xix] Centers for Disease Control and Prevention. Fact Sheet. Secondhand smoke protection air quality. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. 2016. Accessed on October 07, 2016 from: Link
[xx] Texas Department of State Health Services. Tobacco Prevention and Control Strategic Plan 2008-2013. 2013 Link
[xxi] David Lakey M.D. Understanding the Burden of Tobacco in Texas Texas Tobacco Summit. June 26, 2014 Texas Department of State Health Services. Accessed on October 5, 2016 from Link
[xxii] The Economic Impact of the Smoking Ordinance on Restaurant Sales and Mixed Beverage Sales in Houston, Texas. January 2009. Accessed on October 4, 2016 from: Link
[xxiii] Loomis BR, Shafer PR, van Hasselt M. The Economic Impact of Smoke-Free Laws on Restaurants and Bars in 9 States. Prev Chronic Dis 2013;10:120327. DOI: http://dx.doi.org/10.5888/pcd10.120327 Accessed from: Link
[xxiv] KPMG Peat Marwick for the American Beverage Institute, “Effects of 1998 California Smoking Ban on Bars, Taverns and Night Clubs,” 1998; InContext for the Massachusetts Restaurant Association, “Massachusetts Restaurant Association Study,” 1996; InContext for the Empire State Restaurant & Tavern Association, “Restaurant Jobs in New York City, 1993 Through First Quarter 1996, and the Restaurant Smoking Ban,” 1996. Accessed on October 4, 2016 from: Link
[xxv] Centers for Disease Control and Prevention.Impact of a Smoking Ban on Restaurant and Bar Revenues — El Paso, Texas, 2002. MMWR Report. February 27, 2004 / 53(07);150-152.Accessed on October 4, 2016 from Link
xxvi “E-cigarettes: An Emerging Public Health Challenge.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 2015. Web. 02 Nov. 2016.
[xxvi]i Centers for Disease Control and Prevention. Fact Sheet. Smoking & Tobacco UseNational Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health. 2016. Accessed on October 07, 2016 from Link
[xxvii]i U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed October 10, 2016 from: Link] Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults—United States, 2005–2014. Morbidity and Mortality Weekly Report 2015;64(44):1233–40 [accessed 2016 October 14] xxix The State of Health in Houston/Harris County 2015-2016. Harris County Healthcare Alliance, Houston, Texas. Link
xxx Centers for Disease Control and Prevention. Changes to the Behavioral Risk Factor Surveillance System: Frequently Asked Questions. 2013. Accessed from: http://www.cdc.gov/surveillancepractice/reports/brfss/brfss_faqs.html On October 31, 2016.