Nov. 15, 2012 -- The CDC says 30 of the 50 biggest U.S. cities are smoke-free, with absolutely no smoking allowed in any bar, restaurant, or workplace. 
 
 And the news is even better than it looks. 
 
 Several more of these big cities at least partially ban smoking. Los Angeles and Atlanta, for example, are covered by state laws that ban much smoking but fall short of the CDC's 100% smoke-free designation. 
 
 Overall, about half of Americans are getting less secondhand smoke exposure because of state or local bans on indoor smoking. 
 
 The Fight Against Secondhand Smoke 
 
 "Communities have made tremendous progress eliminating smoking from work sites and public places," CDC Director Thomas Frieden, MD, MPH, says in a news release. 
 
 Even so, the CDC says, some 3,400 nonsmokers die each year from lung cancer and 46,000 die from heart disease caused by secondhand smoke. 
 
 "If we can protect workers and the public in the remaining 20 largest cities, 16 million people would be better protected from cancer and heart disease caused by secondhand smoke," Frieden says. 
 
 Ten of the 20 large U.S. cities that aren't covered by comprehensive smoking laws are in the South. And 10 of them are in states with laws that prevent local governments from passing anti-smoking restrictions. 
 
 On the positive side, 26 states and the District of Columbia have passed comprehensive smoke-free laws. 
 
 This marks a lot of progress. Just 12 years ago, only one large U.S. city -- San Jose, Calif. -- was covered by such a law. 
 
 The CDC's report on smoke-free laws appears in the Nov. 16 issue of Morbidity and Mortality Weekly Report. ||||| Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail. 
 
 Comprehensive Smoke-Free Laws — 50 Largest U.S. Cities, 2000 and 2012 
 
 Secondhand smoke (SHS) exposure causes heart disease and lung cancer in nonsmoking adults and several health conditions in children (1). Only completely eliminating smoking in indoor spaces fully protects nonsmokers from SHS (1). State and local laws can provide this protection in enclosed workplaces and public places by completely eliminating smoking in these settings (1). CDC considers a smoke-free law to be comprehensive if it prohibits smoking in all indoor areas of private workplaces, restaurants, and bars, with no exceptions (2). In response to growing evidence on the health effects of SHS, communities and states have increasingly adopted comprehensive smoke-free (CSF) laws in recent years (1,2). To assess trends in protecting the population from SHS exposure, CDC and the American Nonsmokers' Rights Foundation (ANRF) compared coverage by local or state CSF laws in the 50 largest U.S. cities as of December 31, 2000, and October 5, 2012. The analysis focused on smoking restrictions in the 50 largest cities because these cities represent an important indicator of nationwide trends in local and state policy and because they are home to an estimated 47 million persons, or nearly 15% of the U.S. population. The analysis found that the number of these cities covered by local and/or state CSF laws increased from one city (2%) in 2000 to 30 cities (60%) in 2012. A total of 20 cities (40%) were not covered by a CSF law at either the local or state level in 2012, although 14 of these cities had 100% smoke-free provisions in place at the local or state level in at least one of the three settings considered. The results of this analysis indicate that substantial progress has been achieved during 2000–2012 in implementing CSF laws in the 50 largest U.S. cities. However, gaps in coverage, especially in the southern United States and in states with laws that preempt local smoking restrictions, are contributing to disparities in SHS protections. 
 
 In the United States, the strongest smoking restrictions traditionally have originated at the local level (1). Local jurisdictions began to adopt CSF laws in the 1990s (1,3). The first local CSF law was implemented by Shasta County, California, in 1993 (3). The first state CSF law was enacted by Delaware in 2002 (2). As the past decade progressed, more states enacted CSF laws, often after a number of local jurisdictions in the state had implemented such laws (1–3). 
 
 Data on the 50 largest cities were obtained from the 2000 and 2010 U.S. censuses.* The data are based on the population within city limits. In 2010, the population of these cities ranged from 365,438 in Arlington, Texas, to 8,175,133 in New York, New York, with a median population of 600,690. During 2000–2010, New Orleans, Louisiana; Honolulu, Hawaii; and St. Louis, Missouri, dropped off this list, and Louisville-Jefferson County, Kentucky; Raleigh, North Carolina; and Arlington, Texas, were added to it. 
 
 Data on local smoking restrictions in effect for the 50 largest cities as of December 31, 2000, and October 5, 2012, were obtained from the U.S. Tobacco Control Laws Database† maintained by ANRF. This database categorizes various types of U.S. municipal and county laws relating to tobacco, including smoking restrictions. Laws included in the database are identified through various means, including systematic scanning of tobacco control publications, websites, and e-mail discussion lists and partnerships with the National Association of County and City Health Officials and the National Association of Local Boards of Health. Senior staff members use standardized guidelines and codebooks to abstract the laws. 
 
 Data on state smoking restrictions in effect as of December 31, 2000, and October 5, 2012, were obtained from CDC's State Tobacco Activities Tracking and Evaluation (STATE) System database.§ This database contains tobacco-related epidemiologic and economic data and information on state tobacco-related legislation. State legislation is collected quarterly from an online legal research database of state laws and is analyzed, coded, and entered into the STATE System. The STATE System contains information on state tobacco-related laws, including smoking restrictions, in effect since the fourth quarter of 1995. In addition to information on state smoking restrictions in worksites, restaurants, and bars, the STATE System contains information on state smoking restrictions in other settings, including government worksites, commercial and home-based child-care centers, multiunit housing, vehicles, hospitals, prisons, and hotels and motels. 
 
 The ANRF database tracks state smoking restrictions as well as local smoking restrictions. The STATE System and ANRF databases generally are in agreement in categorizing state smoking restrictions. However, in the few cases where these sources differ, this analysis relies on the STATE System categorization.¶ 
 
 Only one of the 50 largest U.S. cities (San Jose, California) was covered by a local CSF law as of December 31, 2000. None of these cities were covered by statewide CSF laws on this date, since no such laws had been implemented at the state level. 
 
 On October 5, 2012, 16 of the 50 largest cities (32%) were covered by a local CSF law (Table). Twenty of the 50 largest cities (40%) were covered by a state CSF law, including 14 (28%) of the cities that were not covered by a local CSF law and six (12%) of the cities that were covered by such a local law. Thus, 30 (60%) of the cities were covered by a local CSF law, a state CSF law, or both. 
 
 The remaining 20 cities were not covered by either local or state CSF laws. These cities are home to approximately 16 million residents, or 5% of the U.S. population. Although 14 of these cities have 100% smoke-free local or state provisions in place in at least one of the three settings considered in this study, the remaining six (Los Angeles, California; Oklahoma City, Oklahoma; Fresno, California; Virginia Beach, Virginia; Atlanta, Georgia; and Tulsa, Oklahoma) do not. The 20 cities that lack CSF laws are located in 10 states. Ten of these 20 cities are located in the southern United States (Florida, Georgia, North Carolina, Tennessee, Texas, and Virginia). Ten of the 20 cities are located in states (Florida, North Carolina, Oklahoma, Pennsylvania, Tennessee, and Virginia) with less than comprehensive state smoking restrictions that preempt (i.e., prohibit) local smoking restrictions that differ from state law.** Six of the 20 cities that lack CSF laws are located in California, which has substantial statewide smoking restrictions that were enacted in 1994, at an early point in the evolution of smoke-free policies, and fall short of current standards for CSF laws.†† The same is true of the local laws in place in some of these California cities. 
 
 Reported by 
 
 Maggie Hopkins, Cynthia Hallett, MPH, American Nonsmokers' Rights Foundation, Berkeley, California. Stephen Babb, MPH, Brian King, PhD, Michael Tynan, Allison MacNeil, MPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Stephen Babb, sbabb@cdc.gov, 770-488-1172. 
 
 Editorial Note 
 
 The results of this analysis indicate that substantial progress was achieved from 2000 to 2012 in expanding CSF policy coverage in the 50 largest U.S. cities. In the year 2000, only a relatively small number of communities had local CSF laws in place, and those communities were largely concentrated in a few states such as California and Massachusetts (1,3). No statewide CSF laws were in place at this time (2).This stands in marked contrast to the situation today. As a result of growing awareness of the health effects of SHS, diffusion of smoke-free policies as word spread about successful experiences with these policies, and changes in social norms, 26 states (including the District of Columbia) have implemented CSF laws to date (2).§§ Because of the same factors, many communities in other states have implemented CSF laws at the local level.¶¶ Consequently, a majority of the 50 largest U.S. cities are now covered by state or local CSF laws or both. 
 
 The first CSF laws in a state often are enacted by smaller communities (1,3). The successful implementation of smoke-free laws in smaller communities lays the groundwork for the adoption of similar laws by larger cities and, ultimately, at the state level (1–3). Regardless of whether they are implemented at the local or state level, smoke-free laws have been shown to receive high levels of public support and compliance, reduce SHS exposure, and improve health outcomes (1,4). The education and debate that accompany adoption of these laws generally result in increased public awareness of the law and its rationale (1,3,5–7). This education and debate, as well as the experience of living under the law, often lead to changes in social norms that result in increasing public support for the law (1,4,5). 
 
 State CSF laws can extend policy protections to a broader population than local laws, thus eliminating disparities in these protections (1,6). State smoke-free laws that set a floor for local smoking restrictions, rather than a ceiling, allow local SHS protections to evolve in step with emerging scientific evidence and changing standards (5–7). 
 
 The progress in extending comprehensive SHS protections to the majority of the 50 largest U.S. cities reported in this study is a major public health achievement. This shift reflects broader progress in extending these protections across much of the United States (1,2). Nearly half of the U.S. population is protected by state or local CSF laws today, compared with <3% in 2000.*** However, the findings of this analysis indicate that important gaps remain in smoke-free policy coverage in large U.S. cities. In particular, a number of cities in the southern United States have ineffective smoking restrictions or none at all. This gap in policy coverage creates disparities in public health protections that are likely to both reflect and contribute to broader tobacco-related population disparities (1,2). 
 
 The findings also illustrate the barrier that state preemption laws pose to local SHS protections. Ten of the 20 cities in this study that lacked CSF laws in 2012 are located in states with such laws. These laws preclude local action to increase SHS protections (1,5–8) and are associated with lower worker coverage by smoke-free workplace policies and reduced support among smokers for smoke-free environments (5). Conversely, the findings illustrate that, in states that do not preempt local smoking restrictions, cities can implement comprehensive local protections in the absence of comprehensive state protections. 
 
 The findings in this report are subject to at least five limitations. First, this study reports on local and state smoking restrictions as of October 5, 2012; the information on city population size comes from April 1, 2010 U.S. Census data, which are the most recent census data based on actual population estimates (as opposed to projections). Second, the STATE System only captures information on certain types of state smoking restrictions, primarily statutes and executive orders, and does not include information on state administrative laws, regulations, or implementation guidelines. However, most state smoking restrictions are enacted through legislation. Third, this analysis does not include laws that restrict smoking in workplaces, restaurants, or bars without making the setting in question completely smoke-free. However, the U.S. Surgeon General has concluded that only completely eliminating smoking in indoor settings fully protects nonsmokers from SHS (1). Fourth, neither the ANRF U.S. Tobacco Control Laws Database nor the STATE System collects information on how local or state laws are enforced or observed in practice. However, if adequate preparation and education have occurred, local and state smoke-free laws are, in most cases, largely self-enforcing. Finally, the laws considered in this report do not cover all settings where nonsmokers are exposed to SHS. In particular, private settings such as homes and vehicles can be major sources of exposure, especially for children, and nonsmoking apartment residents who do not allow smoking in their homes can still be exposed to SHS that enters their homes from their neighbors' apartments (1,4,9). 
 
 Continued progress in protecting nonsmokers from SHS in workplaces and public places can be achieved through local or state action. In states with preemption, local action is not an option. New local CSF laws continue to be adopted in a number of states that lack state CSF laws but do not preempt local smoking restrictions. In early November 2012, North Dakota became the 27th state (including the District of Columbia) to enact a state CSF law, and the first state to do so since 2010. 
 
 References 
 
 What is already known on this topic? The number of states that implemented comprehensive state smoke-free laws prohibiting smoking in private workplaces, restaurants, and bars increased sharply, from zero states in 2000 to 26 states in 2010. What is added by this report? The number of the 50 largest U.S. cities covered by comprehensive local and/or state smoke-free laws in workplaces, restaurants, and bars increased from one city in 2000 to 30 cities in 2012; 20 cities were not covered by a comprehensive smoke-free law at either the local or state level in 2012. What are the implications for public health practice? Although substantial progress has been achieved during 2000–2012 in protecting residents of the 50 largest U.S. cities from secondhand smoke, substantial gaps in these protections remain, especially in southern states and in states with laws that preempt local smoking restrictions.
– A sign of how far anti-smoking bans have come in the last decade: In 2000, only one of the nation's 50 biggest cities—San Jose—had a comprehensive law that banned smoking in bars, restaurants, and workplaces. Today, the CDC says that figure is 30, reports WebMD. Of the remaining 20 cities, several are covered by partial bans, either of the city or state variety, but they don't meet the CDC's 100% threshold. "If we can protect workers and the public in the remaining 20 largest cities, 16 million people would be better protected from cancer and heart disease caused by secondhand smoke," says CDC chief Thomas Frieden. Ten of those cities are in the South. The full CDC report is here.