Impact of Japan's indoor smoke-free laws on the prevalence of smoke-free establishments
Tsukuba, Japan—To reduce the adverse health effects associated with exposure to second-hand smoke, Japan fully enforced the Revised Health Promotion Law in April 2020, introducing a nationwide indoor smoking ban in restaurants and similar hospitality establishments. However, the law includes temporary exemptions that permit pre-existing small-scale restaurants and bars to allow indoor smoking, provided that individuals under the age of 20 are not exposed.
To mitigate the potential public health impact of these exemptions, the Tokyo Metropolitan Government and Chiba City simultaneously implemented stricter passive smoking prevention ordinances designed to further promote smoke-free environments. Therefore, the research team assessed the effects of both the national legislation and local ordinances using data obtained from a major online restaurant review platform covering the period 2016-2022.
The researchers estimated that the proportion of smoke-free establishments nationwide increased by 5.7% points immediately after the enforcement of the Revised Health Promotion Law, compared with the period immediately preceding its implementation. In areas governed by the Tokyo Metropolitan Government and Chiba City, where additional passive smoking prevention ordinances were concurrently enforced, the proportion of smoke-free establishments was estimated to have increased by 13.5% points. Of this increase, 7.8% points were specifically attributable to the local ordinances. As of December 2022, the estimated proportions of smoke-free establishments were 68.3% for restaurants, 70.2% for cafés, 32.8% for izakaya (Japanese-style pubs), and 25.0% for bars.
This study demonstrates that the implementation of the national law and complementary local ordinances was associated with a modest increase in the proportion of smoke-free establishments. However, the findings also indicate that a substantial number of establishments continue to permit indoor smoking, largely because of the exemptions allowed under the current legislation. To further reduce opportunities for exposure to second-hand smoke, the researchers emphasize the importance of eliminating existing exemptions and strengthening the enforcement of current smoke-free regulations.
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This study was supported by the Health Labour Sciences Research Grants (19FA1005 and 22FA1002) from the Japanese Ministry of Health, Labour and Welfare, and a medical research grant from the Osaka Association of Adult Diseases Prevention obtained by Dr. Muraki.
Original Paper
Title of original paper:
Impact of ban and ordinances against indoor smoking on the proportion of smoke-free establishments in restaurants, izakaya, and bars in Japan: Interrupted time-series analysis of restaurant database
Journal:
Public Health
DOI:
10.1016/j.puhe.2026.106146
Correspondence
Professor MURAKI, Isao
Institute of Medicine, University of Tsukuba
Specially Appointed Assistant Professor KATAOKA, Aoi
Division of Molecular Epidemiology, Department of Future Medical Science, Kobe University
Professor ITO, Yuri
Department of Medical Statistics Research and Development Center, Osaka Medical and Pharmaceutical University
Division Chief KATANODA, Kota
Division of Population Data Science, National Cancer Center Institute for Cancer Control
Related Link
Journal
Public Health
Article Title
Impact of ban and ordinances against indoor smoking on the proportion of smoke-free establishments in restaurants, izakaya, and bars in Japan: Interrupted time-series analysis of restaurant database
Waterpipe smoking can cause carbon monoxide poisoning even after brief use, during outdoor smoking, or through indoor secondhand exposure
Tsukuba, Japan—Waterpipe tobacco smoking—also known as shisha, hookah, or narghile—is a method in which tobacco is heated with charcoal and the resulting smoke passes through water before being inhaled. Although the practice originated in the Middle East during the late Middle Ages, it poses a significant risk of carbon monoxide exposure because the charcoal used for heating produces CO through incomplete combustion. Within the jurisdiction of Tokyo's Third Fire District Headquarters, which covers three southwestern wards of Tokyo, emergency services recorded approximately one case of acute CO poisoning related to waterpipe smoking per month between January 2018 and June 2023. Most of these cases involved young individuals.
In the present study, the research team conducted a systematic review of six academic databases to identify case reports and case series describing CO poisoning associated with waterpipe smoking worldwide.
The review identified a total of 68 cases of acute CO poisoning. Among these, 41 cases involved individual active users, 23 cases occurred as clustered incidents involving multiple individuals (with up to 12 people affected simultaneously in indoor settings), and two cases each involved nonusers and employees working in waterpipe cafés. The most frequently reported symptom was syncope (53%), followed by headache (50%), lethargy (44%), nausea or vomiting (38%), and weakness (15%). Acute CO poisoning may present with diverse clinical manifestations, and additional reported symptoms included tremors, visual disturbances, and seizures.
Notably, approximately one-quarter of cases developed symptoms after individuals had already left the smoking venue. Furthermore, about one-fifth of cases occurred after less than 1 hour of waterpipe use, and another one-fifth occurred during outdoor smoking, indicating that even short-term or outdoor use does not eliminate the risk of CO poisoning. The review also identified 13 cases of polycythemia, a chronic condition characterized by persistently elevated hemoglobin levels and increased red blood cell counts. This condition results from prolonged exposure to carbon monoxide, which causes includes chronic hypoxia and stimulates compensatory erythrocytosis. Twelve of these cases involved individuals who reported daily waterpipe use.
Overall, this systematic review demonstrates that CO poisoning associated with waterpipe smoking can occur under conditions commonly perceived as low-risk, including short-duration use, outdoor smoking, or secondhand exposure in indoor environments.
These findings underscore the importance of raising awareness among waterpipe users and service providers regarding the potential hazards. In particular, when waterpipes are used indoors, appropriate safety measures are essential, including the installation of CO monitors and the implementation of adequate ventilation systems, as clustered poisoning events are frequently associated with enclosed environments.
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This study was supported by a Health and Labour Sciences Research Grant (22FA1002).
Original Paper
Title of original paper:
Behavioral and Environmental Factors of Carbon Monoxide Poisoning and Polycythemia due to Waterpipe Smoking: An Artificial Intelligence-Assisted Systematic Review of Case Reports
Journal:
JMA Journal
Correspondence
Professor MURAKI, Isao
Institute of Medicine, University of Tsukuba
Related Link
Journal
JMA Journal
Article Title
Behavioral and Environmental Factors of Carbon Monoxide Poisoning and Polycythemia due to Waterpipe Smoking: An Artificial Intelligence-Assisted Systematic Review of Case Reports
Automated intervention shows significant increase in smoking cessation behavior
Scalable intervention, which showed improved behavior among mothers. could lead to tens of thousands of smokers being able to quit and reduce secondhand smoke exposure for children
Philadelphia, March 17, 2026 – Researchers at Children’s Hospital of Philadelphia (CHOP) found that a new automated tobacco treatment system integrated into routine pediatric care helped drive a 3.9% absolute increase in smoking cessation among mothers – a population-level impact that could translate to tens of thousands of parents quitting each year and protect hundreds of thousands of children from harmful secondhand smoke exposure. The study, published today in Pediatrics, demonstrates how technology can scale preventive interventions without adding burden to clinical staff.
More than 40% of children in the U.S. are exposed to secondhand smoke, increasing their risk of respiratory infections, asthma flare-ups and premature death. Parents who quit smoking not only increase their own life expectancy but also decrease the likelihood of their children becoming smokers later in life.
While some parents who smoke may not have their own primary care health physician, they will seek primary care for their children multiple times a year. Researchers have been working implementing the Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention to address parental smoking by providing routine access to cessation resources during pediatric primary care visits.
“We've created a system that removes the traditional barriers, such as provider time, prescribing challenges, and workflow burden," said lead study author Brian Jenssen, MD, MSHP, Assistant Professor of Pediatrics at the University of Pennsylvania Perelman School of Medicine and a pediatrician at CHOP. "By automating the screening, motivation, and connection to evidence-based treatment, we're reaching parents at scale during a moment when they're already focused on their child's health.”
“Millions of parents who smoke attend pediatric visits annually, so even a small but noticeable decrease in smoking cessation can translate to tens of thousands of additional individuals who quit each year, which protects hundreds of thousands of children from secondhand smoke exposure,” said co-senior study author Alexander Fiks, MD, a pediatrician and the Director of Clinical Futures and the Possibilities Project: Innovation in Pediatric Primary Care at CHOP.
Building upon findings from a prior study, researchers conducted a retrospective study of parents whose children received care across 12 pediatric practices in a cluster-randomized trial between June 2021 and August 2024. An automated EHR-linked parent tobacco treatment system was implemented at six practices, while the other six only implemented screenings with no follow up. This study analyzed self-reported smoking cessation rates among parents who reported smoking during the study period.
This analysis included all parents who completed questionnaires during routine care, excluding parents enrolled in the trial. The team analyzed self-reported cessation rates among parents who reported smoking during the study period.
With data from more than 55,000 parents analyzed, the study found that cessation rates were 3.9% higher for those receiving care with the system compared with those who did not receive the prompts and connections to evidence-based treatments. This increase in cessation behavior was only observed in mothers who participated. Among fathers who smoked, there was no difference in smoking cessation rates. Overall, the system required no additional training for clinical staff and was implemented within existing EHR workflows, making it readily scalable to other pediatric health systems.
“Millions of parents who smoke attend pediatric visits annually, so even a small but noticeable decrease in smoking cessation can translate to tens of thousands of additional individuals who quit each year, which protects hundreds of thousands of children from secondhand smoke exposure,” Fiks said.
This study was supported by National Institutes of Health grant R01-CA245145.
Jenssen et al, “An EHR-based tobacco treatment system for parents in pediatric primary care.” Pediatrics. Online March 17, 2026. DOI: 10.1542/peds.2025- 073934.
About Children’s Hospital of Philadelphia:
A non-profit, charitable organization, Children’s Hospital of Philadelphia was founded in 1855 as the nation’s first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals, and pioneering major research initiatives, the hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country. The institution has a well-established history of providing advanced pediatric care close to home through its CHOP Care Network, which includes more than 50 primary care practices, specialty care and surgical centers, urgent care centers, and community hospital alliances throughout Pennsylvania and New Jersey. CHOP also operates the Middleman Family Pavilion and its dedicated pediatric emergency department in King of Prussia, the Behavioral Health and Crisis Center (including a 24/7 Crisis Response Center) and the Center for Advanced Behavioral Healthcare, a mental health outpatient facility. Its unique family-centered care and public service programs have brought Children’s Hospital of Philadelphia recognition as a leading advocate for children and adolescents. For more information, visit https://www.chop.edu.
Journal
PEDIATRICS
Method of Research
Data/statistical analysis
Subject of Research
People
Article Title
An EHR-based tobacco treatment system for parents in pediatric primary care
Article Publication Date
17-Mar-2026
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