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Effect of smoke-free policies in military settings on tobacco smoke exposure and smoking behaviour: a systematic review
  1. Thomas Falconer Hall1 and
  2. K Siddiqi2,3
  1. 1AMS Support Unit, Army Medical Services, Camberley, UK
  2. 2Department of Health Sciences, University of York, York, UK
  3. 3Hull York Medical School, York, UK
  1. Correspondence to Thomas Falconer Hall, AMS Support Unit, Army Medical Services, Camberley, UK; tomfalconerhall{at}


Introduction Smoke-free legislation has been instrumental in reducing secondhand smoke (SHS) exposure in public places. However, the evidence of the impact of institutional smoke-free policies in settings such as healthcare and defence is weaker. Specifically, the literature on the effect of smoke-free policies in military settings has not yet been synthesised.

Methods This review aimed to identify, critically appraise and synthesise the available evidence to evaluate the effect of defence smoke-free policies on SHS exposure. Eight electronic databases (eg, EMBASE, MEDLINE) were searched from inception to June 2020. We included English-language studies on smoke-free policies introduced in a defence setting, assessing their impact on SHS exposure (primary outcome) and healthcare utilisation, smoking behaviours and defence efficiency (secondary outcomes). Risk of bias was assessed using ROBINS-I. Synthesis without meta-analysis was conducted using vote counting of direction of effect.

Results The search retrieved 4503 citations of which eight met inclusion criteria; two controlled and six uncontrolled before-and-after studies. The evidence, although low-quality, from one study indicated reduced SHS exposure following the introduction of a defence smoke-free policy. For secondary outcomes the review found mixed results, with the quit rate being the one outcome favouring smoke-free policies. The cumulative confidence of evidence is uncertain and therefore reliable conclusions cannot be drawn from these studies.

Conclusions A research gap exists for high-quality studies on the impact of defence smoke-free policies which should use comparators and, if possible, randomisation. Policy-makers should introduce institutional smoke-free policies in defence settings within an evaluative framework to generate such evidence.

  • public health
  • preventive medicine
  • occupational & industrial medicine
  • health policy

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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  • Collaborators Alexandra Macnamara.

  • Contributors TFH conducted the systematic review for his masters dissertation under the supervision of KS. TFH wrote the initial draft of this paper with revisions and additions made by KS. AM assisted with study selection, data collection and risk of bias assessment.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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