Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries

Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in outdoor hospitality venues across Europe and identify contextual exposure determinants. Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, cafeterias, and pubs from 11 European countries in 2017-2018. Sites were selected considering area-level socioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017-2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants. Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30-3.74) μg/m 3 and increased during nighttime (1.45 IQR:0.65-4.79 μg/m 3), in enclosed venues (2.97 IQR:0.80-5.80 μg/m 3), in venues with more than two smokers (2.79 IQR:1.03-6.30 μg/m 3), in venues in countries with total indoor smoking bans (1.20 IQR:0.47-4.85 μg/m 3), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49-5.34 μg/m 3). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues' degree of enclosure. Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues.