How much progress has been made toward a smoke-free environment in the restaurants and bars of Japan? Limitations of partial bans and their enforcement.

Background: In April 2020, the revised Health Promotion Act and Tokyo Metropolitan Ordinance to prevent second-hand smoke (SHS) exposure was fully enforced. The government has provided an exemption for small-scale, existing establishments by allowing them 'unregulated' status, and it is unclear to what extent indoor smoking bans have been applied in these small bars and restaurants. In this study, we report on indoor smoking status before/after the enforcement of the current legislation both regulated and unregulated restaurants and bars.

Methods: Self-questionnaire surveys were conducted in March 2020 and 2021. We applied the questionnaire to 6,000 restaurants and bars in Tokyo, Osaka and Aomori in the first survey and to 3609 restaurants in the second survey, including those that had responded to the first survey as well as 2800 additional establishments. We calculated the proportions of indoor smoking status before/after enforcement both regulated and unregulated establishments. In addition, we calculated the national estimate of indoor smoking status in all restaurants and bars in Japan after the enforcement using a restaurant guide website and the results of this study.

Results: The responded establishments were 879 to the first (response rate: 14.7%) and 837 to the second (response rate: 23.2%). Of all the establishments, 67.0% kept "separate smoking or smoking" status, and 62.1% of unregulated establishments kept "separate smoking or smoking". Although all the regulated establishments were required to change to "no smoking" by law, 78.4% that were "separate smoking or smoking" before the enforcement did not change their indoor smoking status. The national estimate of smoking status showed that the proportion of "no smoking" would change from 54.5% to 69.4% after the enforcement. If all regulated establishments changed smoking status to "no smoking", the ideal proportion of "no smoking" would be 85.8% in Japan.

Conclusions: More unregulated restaurants and bars changed to "no smoking" than planned before the enforcement. In contrast, most of the regulated restaurants and bars continued to be "separate smoking or smoking" in non-compliance with the legislation. In order to prevent SHS exposure in all restaurants and bars, we need comprehensive legislation for indoor smoking bans in Japan.