102460 J Epidemiol 2015;25(7):496-504 doi:10.2188/jea.JE20150001 Health Policy News Industry Speed Bumps on Local Tobacco Control in Japan? The Case of Hyogo Keiko Yamada1,2,3, Nagisa Mori1,4, Mina Kashiwabara5, Sakiko Yasuda6, Rumi Horie7, Hiroshi Yamato8, Loic Garçon1, and Francisco Armada1 1 World Health Organization, Centre for Health Development, Kobe, Japan 2 Public Health, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan 3 Health & Welfare Department, Hyogo Prefectural Government, Kobe, Japan 4 Department of Social and Preventive Epidemiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan 5 World Health Organization, Western Pacific Regional Office, Manila, Philippines 6 Department of Global Health and Socio-epidemiology, School of Public Health, Kyoto University, Kyoto, Japan 7 Tokyo Development Learning Center, the World Bank, Tokyo, Japan 8 Department of Health Development, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan Received January 11, 2015; accepted March 28, 2015; released online July 5, 2015 Copyright © 2015 Keiko Yamada et al. This is an open access article distributed under the terms of Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ABSTRACT Background: Despite being a signatory since 2004, Japan has not yet fully implemented Article 8 of the World Health Organization’s Framework Convention on Tobacco Control regarding 100% protection against exposure to second-hand smoke (SHS). The Japanese government still recognizes designated smoking rooms (DSRs) in public space as a valid control measure. Furthermore, subnational initiatives for tobacco control in Japan are of limited effectiveness. Through an analysis of the Hyogo initiative in 2012, we identified key barriers to the achievement of a smoke-free environment. Methods: Using a descriptive case-study approach, we analyzed the smoke-free policy development process. The information was obtained from meeting minutes and other gray literature, such as public records, well as key informant interviews. Results: Hyogo Prefecture established a committee to propose measures against SHS, and most committee members agreed with establishing completely smoke-free environments. However, the hospitality sector representatives opposed regulation, and tobacco companies were allowed to make a presentation to the committee. Further, political power shifted against completely smoke-free environments in the context of upcoming local elections, which was an obvious barrier to effective regulation. Throughout the approving process, advocacy by civil society for stronger regulation was weak. Eventually, the ordinance approved by the Prefectural Assembly was even weaker than the committee proposal and included wide exemptions. Conclusions: The analysis of Hyogo’s SHS control initiative shed light on three factors that present challenges to implementing tobacco control regulations in Japan, from which other countries can also draw lessons: incomplete national legislation, the weakness of advocacy by the civil society, and the interference of the tobacco industry. Key words: smoking; tobacco smoke pollution; legislation; local government; Japan In 2000, the Ministry of Health, Labour and Welfare INTRODUCTION (MHLW) of Japan initiated a national health promotion Article 8 of the World Health Organization (WHO) movement (known as Health Japan 21), which set tobacco- Framework Convention on Tobacco Control (FCTC) related indicators focusing on the dissemination of evidenced- requests its parties to implement a 100% smoke-free policy. based information on the health impact of smoking.3 Adoption Despite being a signatory since 2004, Japan has not yet fully of the Health Promotion Act in 2002 provided a legal basis for implemented its provisions.1,2 protecting people from second-hand smoke (SHS). However, smoking in many public places remains unrestricted.4 Address for correspondence. Keiko Yamada, MD, Public Health, Department of Social Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan (e-mail: keiko-yamada@umin.org). 496 Yamada K, et al. 497 Smoke-free legislation passed at the national level is ideal conditions of Hyogo during the time of the studied initiative. for providing nationwide coverage. In its absence, many Another limitation to consider, often related to case-studies, subnational governments worldwide have adopted local is the potential bias from the researchers due to their own smoke-free policies. Subnational smoke-free intervention, subjectivity or from others involved in the process,15 although which may complement or precede national law, is this has been disregarded by Flyvberg.16 becoming a popular option for increasing numbers of local governments. RESULTS While there is no national smoke-free law in Japan, municipalities have implemented street smoking bans. By Overview and background the end of 2009, more than 100 municipalities had banned In 2000, Hyogo Prefecture launched an anti-SHS initiative, smoking on streets. However, these bans provide limited including a policy for smoking separation (separating protection from SHS only in specific outdoor zones.5,6 smoking and non-smoking areas) in all public places and An important consideration in understanding tobacco workplaces. In 2004, Hyogo Prefecture adopted the Hyogo control in Japan is that the Ministry of Finance has been the SHS prevention guidelines aiming at the implementation of major shareholder in Japan Tobacco Inc. (JT), Japan’s largest an indoor smoking ban by March 2011.17 The guideline called tobacco corporation. Some scholars have highlighted this for a complete smoking ban in public spaces, as well as connection as a hindrance to tobacco control.7–10 preventing SHS exposure at home when pregnant women or In 2009, Kanagawa became the first prefecture in Japan infants are present.17 However, a survey conducted in 2008 by to pass an ordinance to restrict smoking in indoor public Hyogo Prefecture revealed that only 58.5% of government places.11 In 2010, Hyogo Prefecture established a consultative buildings were smoke-free.18 committee as a preliminary step to develop policy on smoking In February 2010, MHLW addressed an official letter to in public places and adopted a similar ordinance.12 governors and mayors encouraging the implementation of The objectives of this study were to describe and analyze policies to prevent SHS.19 Referring to WHO FCTC Article 8, the legislative process for protecting people from SHS. the letter noted the necessity of implementing 100% smoke- Through the analysis, we identified key elements that either free environments in public places, including outdoor spaces facilitate or interfere with developing national and subnational frequented by children and women. However, it recognized smoke-free laws in Japan. smoking separation as a valid measure where directors or managers of the establishments find it difficult to ban smoking completely and stated that the Japan Finance Corporation, METHODS under the Ministry of Finance, had made funds available for The study, which employed a descriptive case study introducing smoking separations.19 In 2011, the funder was approach,13 was conducted between November 2011 and changed from the Japan Finance Corporation to MHLW.20 February 2015. Information on the process between January These two policy documents—the Hyogo SHS prevention 2010 and September 2012, especially on the discussions of the guideline and the letter from the MHLW—were used by consultative committee, was collected through a review of the Governor of Hyogo to form the Hyogo Consultation gray literature (eg, meeting minutes and public records). Committee for SHS Prevention Measures in 2010.21 The Internet searches to obtain online news articles were made Director of Hyogo Prefectural Hospital was elected as its using the terms “Hyogo Prefecture ordinance on the chairperson. prevention of SHS”, “Hyogo Prefecture”, and similar terms Through committee meetings, the proposed content for the in Japanese. The decision to carry out the research was taken ordinance was prepared. The outline of the ordinance received after the approval of the ordinance, so notes taken during the public comments before the first draft of the ordinance was process did not follow a research protocol. Key informant submitted to the Prefectural Assembly by the Department of interviews were conducted with five stakeholders, including Health and Welfare (DoHW) (Figure). members of the committee and staff of the Hyogo Prefectural SHS Prevention Office. The information was analyzed to Committee meetings (June 2010 to June 2011) shed light on key factors that influenced the policy The committee comprised 15 members representing local development. As a guide to the analysis, we compared the government, academia, civil society, the media, health-care adopted ordinance with WHO’s Model ordinance14 and the providers, and the hospitality industry in and outside Hyogo development process with the recommendations in the WHO’s Prefecture. A staff member from a WHO office located in Twelve steps to a smoke-free city.14 Hyogo Prefecture was also included.22 The Governor, the No interviews were conducted with local parliament chairperson, and the DoHW selected the members. members, limiting the analysis of that part of the process. The committee held a total of nine meetings (though Generalization to other cities within and outside Japan would originally only four were planned). The DoHW and the be limited by the specific circumstantial and contextual chairperson drew up the agenda. Each meeting had seats for J Epidemiol 2015;25(7):496-504 498 Industry Speed Bumps on Local Tobacco Control in Japan? The Case of Hyogo Figure. The process of establishing the local ordinance for protects people from second-hand smoke in Hyogo Prefecture. JT, Japan Tobacco Inc.; LDP, Liberal Democratic Party. about 10 observers on a first-come, first-served basis; these At the fifth meeting (September 21, 2010), the committee were mostly taken by tobacco industry representatives. seemed to agree to include in the proposed ordinance a At the first meeting (June 2, 2010), the chairperson separation of smoking and non-smoking areas in private explained the role of the committee to propose specific business facilities. However, committee members noted the measures against SHS exposure in Hyogo Prefecture. The need to clarify to which kinds of establishment this separation main discussion was on whether or not to introduce a measure would apply, and that it should be considered a prefectural ordinance. All committee members, except for the temporary measure until a 100% smoking ban is enforced. representatives of restaurant and hotel associations, supported The sixth meeting (October 18, 2010) addressed provisions introducing local ordinance. (including the transitional period and exceptions) for private The second meeting (July 14, 2010) was mainly devoted business facilities, and it was reaffirmed that separation of to the discussion of contrasting views presented by invited smoking areas was not adequate. This discussion continued speakers: a representative of the tobacco industry and a local during the seventh meeting (December 6, 2010) with a focus tobacco control advocate. Allegedly on grounds of fairness, on designated smoking rooms (DSRs). Some members felt the tobacco industry (Philip Morris [PM] and JT) were invited that it was unacceptable to use the term “DSRs” in the to express their views. JT introduced examples from other ordinance as it would jeopardize a future 100% smoking ban. countries where the hospitality industry claimed to experience The committee entered its final stage. The draft report a negative economic impact due to smoking bans.19 A repre- prepared for the Governor was shared for feedback at the sentative of a local civil society organization, Hyogo Tobacco eighth meeting on May 23, 2011 and approved in the final Free Advocacy (HTFA), stressed Japan’s needed compliance meeting on June 30, 2011. However, the members from the with the WHO FCTC and that Hyogo’s ordinance had to hospitality industry submitted a statement opposing the draft ensure completely smoke-free environments. The results of an report and a proposed ordinance. The DoHW expressed its online survey completed by 2289 Hyogo Prefecture residents concern that “the freedom of economic activities” would be in April 2010 showed high support for regulating smoking unfairly affected by a complete smoking ban.19 The DoHW (nearly 80%), even in hospitality premises (over 60%). further revised the report, and its final version was officially At the third (August 6, 2010) and fourth (September 10, released to the public on July 29, 2011. 2010) meetings, the DoHW shared the results of a survey While the committee meetings were in session, an targeting customers in hospitality venues, revealing high important political event took place: the quadrennial Hyogo support (nearly 70%) for regulating smoking in public places. Prefectural Assembly election was held on April 10, 2011. Most members agreed that Hyogo Prefecture must enforce Liberal Democratic Party (LDP) gained the majority of smoke-free environments to protect public health. seats.23 On September 2, 2011, a meeting between Hyogo J Epidemiol 2015;25(7):496-504 Yamada K, et al. 499 Table 1. Classification of targeted establishments under the Hyogo ordinance of 2012 Areas where smoking Type Conditions Types of establishment must be prohibited 1 The whole area of the property, It is prohibited to use existing smoking rooms. Educational establishments for persons under 18 including outdoor premises years of age 2 The whole area inside buildings Health-care facilities, government and municipal office buildings 3 Public spaces inside buildings It is prohibited to establish new smoking rooms; Educational establishments for persons over 18 years however, an existing smoking room may be of age, pharmacies used for the time being. 4 Public spaces inside buildings, A smoking area can be established in a part of Public transport facilities, social welfare institutions, as a general rule the public space (less than two thirds of the financial institutions, public meeting rooms, stadiums, public space) for the time being. athletic facilities, religious establishments, hotels, restaurants, hairdressing or beauty salons (>100 m2) 5 Smoking is permitted in the whole public space Hotels, restaurants, hairdressing or beauty salons for the time being. (≤100 m2), theatres, cinemas, entertainment halls Others Facilities that fall under the Act Regulating Adult Entertainment Businesses are exceptions. This Act regulates the sex industry and amusement business for adults. Tobacco shops that include a testing area are also exceptions. prefectural representatives of the LDP and the hospitality Hyogo Prefectural Assembly. Despite the criticism, the scope industry was held where the latter strongly opposed the of the draft ordinance had remained unchanged (Figure). ordinance. On December 21, 2011, the LDP submitted a The proposed ordinance was unanimously approved by 13 request at the Hyogo Prefectural Assembly to weaken the members of the Standing Committee of Health and Welfare regulation for economic reasons (Figure).26 on March 19, 2012, officially adopted by the Prefectural According to the outline of the ordinance officially Assembly on March 21, 2012,26 and disseminated widely, announced on November 8, 2011, all public places should using the media,27 internet, and promotional materials (eg, be smoke-free (Figure). Exceptionally, for the time being, posters, leaflets, and stickers) (Figure). smoking facilities for the hospitality industry were allowed. In hospitality establishments of over 75 m2, either more than The ordinance 1/3 of the area should be consistently non-smoking, or “non- The ordinance encompasses 25 articles that, in order to smoking hours” should be set, during which smoking is prevent the negative health impact of SHS, established partial completely banned. restrictions on smoking in public places.12 The level of Subsequently, Hyogo Prefecture opened a public restriction varies by type of establishment (Table 1). In type 1 consultation, making the content of the ordinance accessible and 2 establishments (eg, educational facilities for minors online and accepting feedback by e-mail, fax, or mail. and health-care facilities), smoking is completely prohibited. Between November 10 and December 9, 2011, 2428 public Smoking is partially allowed for type 3 and 4 facilities, comments were made by 851 citizens. Of these, 687 supported including tertiary educational institutions and hospitality the ordinance, 153 opposed it, and 11 neither supported nor premises over 100 m2. Smoking is permitted in type 5 opposed. A total of 202 people supported a 100% smoking establishments, such as hospitality facilities with an area less ban, 144 opposed the “smoking separation”, and 23 opposed than 100 m2, as well as in an additional list of places that “smoking hours”. Comments were also submitted by JT, PM, are considered exceptions (facilities regulated under the and the Hyogo Medical Association (HMA). JT suggested Act Regulating Adult Entertainment Businesses,28 such as that “DSRs provide adequate protection from SHS, and staff Japanese pinball shops, night clubs, and adult entertainment rooms are private spaces where smoking should be allowed”. shops, in addition to tobacco shops that include testing areas). PM agreed with the outline. HMA pointed out key differences The ordinance details the obligations of managers of between the committee’s proposals and the outline. For targeted establishments.12 For instance, when managers find example, in the outline, the term “smoking ban” was replaced a person smoking in their establishment, they are required to with “prevention of SHS” or the phrase “smoking separation ask the person to stop smoking or to leave. In addition, the is recommended” (Figure).24 Governor has the right to order on-site inspections. Penalties Around 150 citizens mentioned that the draft ordinance include a fine of up to 300 000 JPY (approximately 3000 represented a step backward from the committee report’s USD) on owners or managers of establishments who fail recommendations.25 On February 23, 2012, the draft to comply with the provisions, and up to 20 000 JPY ordinance prepared by the Governor was presented at the (approximately 200 USD) on individual smokers. J Epidemiol 2015;25(7):496-504 500 Industry Speed Bumps on Local Tobacco Control in Japan? The Case of Hyogo The enforcement of the ordinance on types 1–3 facilities A comparison of WHO’s model ordinance with the Hyogo commenced on April 1, 2013, a year after the adoption of the ordinance reveals additional gaps (Table 2). For instance, the ordinance, while a longer transition period was allowed for WHO model recommends explicit prohibition of smoking in establishments of types 4–5, with a starting date of March 31, workplaces and in non-enclosed or outdoor areas adjacent to 2014. The fines on facilities of types 1–3 became effective on smoke-free areas.14 Workplaces are covered by the Industrial October 1, 2013, and fines for facilities of types 4–5 became Safety and Health Law (ISHL) in Japan. Discussion of effective on September 30, 2014. The expression for the time prohibition of smoking in workplaces was avoided, since being is used in articles of the ordinance in reference to cases they are beyond the jurisdiction of the health department.32 of smoking separation, without mention of a deadline. However, the amended ISHL in 2014 promoted smoking The ordinance stipulates that Hyogo Prefecture is separation officially.33 Another of the omitted recommen- responsible for evaluating and potentially revising the dations is a system that allows the public to report violations ordinance 5 years after enforcement and for reviewing it or suspected violations for inspection. every 3 years thereafter.12 Nevertheless, several recommendations are followed, at least partially. For instance, the obligation of compliance is clear, as are penalties, regulations, and reporting; implemen- DISCUSSION tation guidelines were established with the ordinance; and The ordinance, which only established a partial smoking ban, the Hyogo ordinance does mention the harmful effects of fails to provide effective protection against SHS and to cover exposure to tobacco smoke. This is an important change in the gap between the existing national policy related to SHS comparison with ordinances on street smoking bans, which and WHO recommendations. A comparison between the had been common measures taken by local governments Hyogo prefectural experience and the WHO recommendations and which stressed littering and manners rather than health was carried out to identify potential strengths and weaknesses concerns.6 However, the ordinance states that “the right of of the legislation in Hyogo Prefecture. smokers” was also taken into account, thus weakening the The WHO’s recommendations were developed to provide public health argument. local governments with guidance for becoming smoke-free; Analysis of the policy development process provides they include a model ordinance and “twelve steps” (Table 2, insight into the passing of a regulation not compliant with Table 3).14 The model ordinance draws on experience from WHO FCTC. The process followed in Hyogo Prefecture was many jurisdictions and from the implementation guidelines of compared with the corresponding WHO recommended 12 the WHO FCTC Article 8. The model ordinance offers a set of steps (Table 3), most of which were not fully followed in comprehensive interventions in clear language for municipal- Hyogo Prefecture. ities to use as a starting point towards smoke-free legislation Setting up the consultative committee partially covered two (Table 3).14 The twelve steps summarize key actions necessary of the 12 steps: establishing a planning and implementation to make a city smoke-free through local legislation, based on committee and inviting the participation of civil society lessons learned from case studies of subnational smoke-free organizations. However, both the mandate and the mem- initiatives around the world (Table 2).14 In 2012, 9 of the 100 bership of the committee made it difficult to enact a 100% most populous cities, including Melbourne (Australia) and smoking ban. The mandate of the committee was restricted to Houston (United States), satisfied the WHO recommen- drafting a suggestion for the ordinance and did not include dation.29 East Asia is one of the world’s largest tobacco planning and implementing the regulation, except for issues epidemic regions,30 but Beijing adopted an ordinance in 2014 covered in the legislation itself. completely banning smoking in all indoor public spaces. The SHS Prevention Office was in charge of studying Hyogo’s draft ordinance was modified considerably from smoke-free interventions in other jurisdictions, thereby the committee recommendations. The most striking difference covering the recommendation on learning experiences of is the adoption of a partial restriction rather than a complete others. This office vigorously promoted the prevention ban as recommended. Allowing smoking separation for the of SHS through the media, in accordance with the time being could hinder future efforts to move towards a recommendation to develop and disseminate messages that complete smoking ban. Duties to post a sign indicating that promote the legislation to the public. Signs and leaflets were smoking is permitted in smoking areas were added in the draft prepared to announce and facilitate the implementation of ordinance. Another difference was an increase in the number the ordinance, and Hyogo Prefecture held an explanatory of facilities exempted from the regulation. The threshold for meeting for owners and managers of hospitality businesses, the restaurants to be covered by the regulation was increased as recommended in the tenth step. from 75 to 100 m2. Smoking restriction was only to be applied Another recommendation advises ensuring maintenance to those places with areas over 100 m2, the same regulatory of the law. The Hyogo ordinance specifies that periodic level as the Kanagawa ordinance, which allows 80% of mandatory review of the text of the ordinance is required. restaurants in Hyogo Prefecture to be exempted.31 However, monitoring of compliance, public opinion, indoor J Epidemiol 2015;25(7):496-504 Yamada K, et al. 501 Table 2. Comparison with the WHO model ordinance Key components of the model ordinance Hyogo prefecture 1. Purpose The ordinance protects the residents from the harmful (O) This ordinance mentions SHS in public places effects of exposure to tobacco smoke in workplaces adequately, (x) but it does not mention SHS in and public places. workplaces yet. 2. Rationale The Constitution guarantees the right to be healthy. (x) The ordinance does not mention the Constitution International guidelines prompt to eliminate the source and international rules directly. of smoke completely. (There is no safe level (O) It mentions that SHS causes death and serious of exposure to tobacco smoke.) disease in nonsmokers. 3. Definitions For the purposes of this ordinance, definitions such as (O/X) A list of establishments is used rather than public places, enclosed, smoke-free places etc need definitions of public enclosed places. to be applied. 4. Prohibition of smoking in Smoking is prohibited in all enclosed public places (X) No distance to any entry, window or air intake of an enclosed places and workplaces and within [a specified distance] of enclosed public place. any entry, window or air intake of an enclosed public (The ordinance prohibits smoking in public spaces but place or workplace. not in the workplace. Workplace is covered by the Industrial Safety and Health Law in Japan.) 5. Prohibition in non-enclosed Smoking is prohibited in non-enclosed, outdoor areas. (O/X) The ordinance prohibits smoking outdoor areas areas of educational facilities only. 6. Duty of compliance This sets out the specific actions and duties for which (O) This is covered. employers and businesses are responsible. 7. Penalties and fines Persons violating provisions of the ordinance are (O) This is covered. subject to fixed monetary penalties. 8. Enforcement authority and The authority to enforce the provisions of the (O) The governor has the right to order an officer to inspections ordinance is defined. An inspector is also authorized. inspect. (X) The ordinance does not mention the enforcement authority. 9. Public complaints The public shall be authorized to report violations of (X) The ordinance does not mention public the ordinance to the inspection agency. They can call complaints. a telephone number to be displayed on signs and on the official web site. 10. Regulations The governor may issue regulations for the effective (O) The enforcement schedule is determined in detail implementation of the ordinance. by the supplement to the ordinance. 11. Reporting The governor shall issue and publish an annual report (O) This is covered. on compliance with the ordinance. 12. Entry into force The ordinance states the day of publication and the (O) This is covered. day of enforcement. (o) Completely complies with the WHO’s model ordinance; (x) Does not comply with the WHO’s model ordinance; (o/x) Partially complies with the WHO’s model ordinance. air quality, and economic impact were not specifically capabilities of the committee to propose an evidence-based addressed in the ordinance or the implementation guidelines. regulation following the WHO FCTC. The health effects of We found that a national survey, the Comprehensive Survey of SHS exposure have been established; the U.S. Environmental Living Conditions, is conducted every 3 years, and its results Protection Agency, the U.S. National Toxicology Program, are available for examination.34 No evidence was collected to the U.S. Surgeon General, and the International Agency for prove that Hyogo Prefecture followed other recommendations, Research on Cancer have all classified SHS as a known such as steps 4, 5, and 11 (Table 3). cancer-causing agent.35 In the committee, the hospitality sector representatives, As expected, JT opposed the use of legislative measures who opposed regulation from the beginning of the process, to prevent exposure to SHS in public spaces, arguing that were an obvious barrier to drafting and implementing “current evidence cannot prove that SHS has adverse effective regulation. Moreover, the opportunities provided health impacts”, advocating for “the coexistence of smokers to representatives of the tobacco industry to present their with nonsmokers” through separate smoking areas, and views made the committee into a forum seeking consensus emphasizing concerns about negative economic impact.21 between those arguing for evidence-based tobacco control These actions indicate that tobacco industry interference and those opposing regulations on the basis of perceived exists at the local level and uses strategies similar to those economic risks. This internal contradiction limited the reported in a national context in other countries.10,36,37 J Epidemiol 2015;25(7):496-504 502 Industry Speed Bumps on Local Tobacco Control in Japan? The Case of Hyogo Table 3. Comparison with the WHO “Twelve steps” Twelve steps Hyogo prefecture 1. Set up a planning and implementation (O) Hyogo Prefecture’s DoHW established a special committee in June 2010: Hyogo committee Prefecture Consultation Committee for Second-hand Smoke Prevention Measures. 2. Become an expert (O) Hyogo established an “SHS Prevention Office” in the Department of Health Promotion to research smoke-free interventions. 3. Involve local legislative experts (O/X) The committee did not include a person from the law field. The officers responsible for legislation attended the meetings. The legal department only checked the draft. 4. Study several potential legal scenarios (X) Legal action by the tobacco industry was not considered. 5. Recruit political champions (X) The Governor of Hyogo worked to promote the ordinance, but we did not find evidence of any promotion in the media record (the newspapers and magazines). 6. Invite the participation of civil society (O) A non-profit organization for children in Hyogo and the Hyogo Women’s Association were organizations invited to the committee. The chairperson of the committee is also the chairperson of the Tobacco Control Medical-Dental Research Network. 7. Work with evaluation and monitoring experts (O/X) The DoHW did not work with evaluation or monitoring experts, but national survey data (Comprehensive Survey of Living Conditions) are available. 8. Engage with media and communications (O) The prefecture is working aggressively with the media, and the officers of the SHS experts Prevention Office are promoting the prevention of SHS. 9. Work closely with enforcement authorities (O/X) The Governor has the right to order an officer to inspect a potential violation, but the prefecture did not work with enforcement authorities, such as the police or special inspectors, and did not design a clear protocol for inspections. The ordinance only established penalties and fines. 10. Develop and disseminate guidelines (O) The prefecture announced the implementation date for legislation by means of the media, a website, and promotion materials (eg, posters, leaflets, and stickers). It also held an explanatory meeting for owners and managers of hospitality businesses. Furthermore, a contest for creating a slogan was held. 11. Celebrate the implementation day (X) Hyogo has not celebrated the implementation day yet. 12. Ensure maintenance of the law (O/X) The ordinance specifies that it is mandatory to maintain the ordinance for at least 5 years after it comes into force, with reviews every 3 years thereafter. However, monitoring of compliance, public opinion, indoor air quality, and workers’ health and economic impact following implementation of the ordinance is not specified. DoHW, Department of Health and Welfare. (o) Completely complies with the WHO’s step; (x) Does not comply with the WHO’s step; (o/x) Partially complies with the WHO’s step. Several committee members involved in health professional Another interesting factor identified was the role of associations voiced their concerns and provided evidence in the national government. Hyogo Prefecture was partially support of smoking bans. Additionally, a representative of encouraged by the letter from the MHLW in 2010,19 which a tobacco control non-governmental organization participated stressed the importance of a 100% smoking ban to prevent in the committee, and public forums were organized by the SHS exposure. Nevertheless, by allowing smoking separation HMA and HTFA (in June 2011 and June 2012 for World as a valid measure and offering implementation funds, it is No Tobacco Day). No other actions advocating for stronger likely that the letter diminished the potential for 100% legislation or to counteract industry tactics were noted. smoking bans. The Ministry of Finance being the major Although representatives of civil society participated in the shareholder of JT might be a hindrance to stronger tobacco committee, they remained shy advocates for the ordinance. control at the national level. In contrast, in many other jurisdictions, civil society has Following the initiatives in Kanagawa and Hyogo played an important role at the local level in advocating for Prefectures, Osaka Prefecture in 2013 and the Tokyo tobacco control. For instance, in Almaty, Kazakhstan, the Metropolitan Area in 2014 experienced similar stalls and National Coalition for “Smoke-Free Kazakhstan” lobbied for opposition to making local smoke-free ordinances. a budget for the city’s smoke-free program and played a key role in developing legislation and providing support for the Conclusion approved program.38 In Chandigarh, India, the Burning Brain This case study revealed that Japan faces several challenges Society filed petitions against city government offices for limiting the enforcement of 100% smoke-free environments. violating the existing national smoke-free provisions and First, the national government provides weak guidance to urged the city government to begin full enforcement.39 prefectures and municipalities by allowing certain types of J Epidemiol 2015;25(7):496-504 Yamada K, et al. 503 establishment to introduce nonprotective smoking separation, 2011;102:49–55. thus hindering the potential to be 100% smoke-free. Second, 7. Levin MA. Smoke around the rising sun, an American look at the involvement of civil society in the development and tobacco regulation in Japan. Stanford Law Pol Rev. 1997;18: adoption of a law was very limited in comparison with other 99–124. 8. Feldman EA. The culture of legal change, a case study of international experiences, where such organizations were tobacco control in twenty-first century Japan. Michigan Journal closely involved in smoke-free interventions. Third, there is of International Law [Internet]. 2006 [updated 2006 February 5; strong interference by the tobacco industry, both directly and cited 2014 Dec 20]. Available from: http://scholarship.law. indirectly through the hospitality sector, which hinders efforts upenn.edu/cgi/viewcontent.cgi?article=1108&context=faculty_ to adopt effective policy. scholarship. 9. Hyogo Prefectural Government [homepage on internet]. [cited 30 Dec 2012] Available from: http://web.pref.hyogo.jp/fl/ ONLINE ONLY MATERIAL english/index.html. Abstract in Japanese. 10. Iida K, Proctor RN. Learning from Philip Morris: Japan Tobacco’s strategies regarding evidence of tobacco health harms as revealed in internal documents from the American ACKNOWLEDGMENTS tobacco industry. Lancet. 2004;363:1820–4. 11. Kashiwabara M, Armada F, Yoshimi I. Kanagawa, Japan’s We thank Drs. Hisayoshi Fujiwara (Hyogo Prefectural Tobacco Control Legislation: a Breakthrough? Asian Pac J Hospital) and Megumi Kano (WHO Kobe Centre) as well Cancer Prev. 2011;12:1909–16. as the Hyogo Prefecture for assistance with background 12. Hyogo Prefecture. The 18th Hyogo Prefecture ordinance on the information. We also appreciate the editing support of Mr. prevention of second-hand smoke (in Japanese) [Internet]. c2012 David Bramley and Mr. Sean Robert Leghorn. The authors [cited 2012 Dec 30]. Available from: http://web.pref.hyogo.jp/ also wish to thank Professors Hiroyasu Iso and Dr. Yasuhiko kf17/documents/03jourei.pdf. 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