Smoke-free laws and direct democracy initiatives on smoking bans in Germany: a systematic review and quantitative assessment.

backgroundGermany's 16 states regulate smoking differently within health protection principles laid down in the federal law. All state smoke-free laws in Germany have undergone at least one change since taking effect.

methodsWe systematically review federal and state laws regulating smoking, as well as petitions, popular initiatives and referenda that aimed at changing statutory smoking bans. Data generated through the systematic review were correlated with state smoking rates.

resultsThe protection from the dangers of secondhand smoke is the primary motive for smoking bans in Germany. The first smoke-free laws affecting smoking in pubs, restaurants and several other public places were introduced in 2007. In 2008, the Federal Constitutional Court of Germany ruled in a leading decision on the smoke-free laws of two states that some common smoking ban exemptions of the introduced smoke-free laws violate the basic right to freely exercise a profession and mandated revisions. All states but Bavaria and Saarland, whose smoking bans were more and less comprehensive than those judged by the constitutional court, respectively, needed to change the smoking ban exemptions to reconcile their smoke-free laws with the constitution. Direct democracy initiatives to change smoking bans were only successful in Bavaria in 2010, but a total of 15 initiatives by citizens' or interest groups attempted to influence non-smokers protection legislation through direct democratic procedures. Early ratification of a smoking ban in a federal state correlates with a higher reduction in the smoking rate from 2005 to 2009 (Spearman's ρ = 0.51, p = 0.04).

conclusionsThe federal government structure and direct democratic participation in smoke-free legislation in Germany has produced a diversity of local smoking bans and exemptions.