In Japan, since 2003, the Health Promotion Law obliges managers of public facilities to make efforts to prevent second-hand smoke, and it has achieved a certain degree of success. However, many people are likely to be exposed to second-hand smoke in these facilities. In 2005, the World Health Organization Framework Convention on Tobacco Control (FCTC) came into force, and the “Guidelines for Protection from exposure to tobacco smoke” was adopted at the Second Conference of the Parties (COP) in 2007. Article 8 of the FCTC states: “Each Party shall adopt and implement in areas of existing national jurisdiction as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or other measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.” Therefore, it is necessary to strengthen the measures against passive smoking to promote the health of people. Based on these circumstances, the Revision of a Part of the Health Promotion Act (Revised Law) was enacted in July 2018.

The revised law outlines three basic concepts: (1) eliminating unwanted second-hand smoke, (2) giving special consideration to children and patients whose health is greatly affected by it, and (3) implementing measures for each type and location of facilities.

The revised law also stipulates that smoking should be prohibited, except in certain places. Violators of this law will be urged to improve based on guidance, recommendations, and orders by the prefectural governors, etc., and fines will be imposed if they are not followed. The revised law, which had been enforced in stages according to the content of regulations, came into full force on April 1, 2020.

The revised law has unified the rules on smoking areas, which had been separated by each facility, and promoted the development of an environment in which unwanted second-hand smoke did not occur. In addition, to prevent unwanted second-hand smoke, there is an obligation to consider the surroundings when smoking. Furthermore, in addition to the regulations under the revised law, efforts will be made to raise awareness of the harmful effects of second-hand smoke and support the businesses that have established smoking rooms. Through these efforts, we expect to create an environment in which both smokers and non-smokers can respect each other and hope that this is an environment where people can spend time comfortably. We will continue to work on second-hand smoke measures.

In Japan, health effects of tobacco smoking, including second-hand smoke (SHS) exposure, are comprehensively evaluated in the report “Smoking and Health -A Report of the Evaluation Committee on Health Effects of Smoking” (so called “Tobacco White Paper”) in 2016 (Ministry of Health, Labour and Welfare). The diseases evaluated as “Level 1 (evidence is sufficient to infer a causal relationship)” to SHS exposure are lung cancer, ischemic heart diseases, and stroke in adults. The population attributable fraction of each of these diseases is 1-4% in males and 9-10% in females, corresponding to 15,000 annual deaths in Japan. For childhood, sudden infant death syndrome (SIDS) and prevalence of asthma was judged as “Level 1.” Smoking ban in public places with a penalty is effective and one of the global standards in preventing SHS exposure. Indeed, scientific evidence is sufficient on the reduction of health outcomes of adult, reproductive and childhood health after legislative measures. The world first report on the health effects of SHS exposure was produced in Japan, which led to the global social norm of banning indoor smoking after several decades. The tobacco industry’s interference, in which many scientists have also been involved, is one of the reasons why building the social system was not realize earlier.

In April 2020, the Revised Health Promotion Act and the Tokyo Metropolitan Ordinance to Prevent Exposure to Second-Hand Smoke were enacted. In Japan, 50% of restaurants and bars, with over 80% of them in Tokyo, will be asked to forbid indoor smoking. It is criticized that the Act and Ordinance are not so strict as compared to the Framework Convention on Tobacco Control (FCTC) of WHO, because those permitted to install smoking rooms inside in Japan.

About half of the member countries of the FCTC had the smoke-free legislation for restaurants and bars in December 2018. In many countries that started the smoke-free legislation for restaurants and bars before Japan, the compliance and acceptance by the general population were good. In Ireland, where smoke-free legislation was started in 2004, the compliance of restaurants and bars was 94% after six months. Irish people’s response to the legislation was big news in 2004. In Japan, according to the survey before the enforcement of the Act and Ordinance, over 70% of the general population experienced second-hand smoke at restaurants or bars, and desired to stop it. For the young generation, it was a hurdle to attend an official party at a smoking restaurant. Most of the general population welcomed the smoke-free legislation in Japan and other countries.

On the other hand, some restaurant and bar organizations opposed the legislation in Japan. According to a survey of restaurants and bars in Tokyo and Osaka, about half agreed to the legislation. Under such a situation, we summarized a “response” from restaurants and bars that had started non-smoking before the legislation. Positive aspects of non-smoking, ways to deal with smokers and new tobacco products are shown in the booklet to boost for restaurants and bars.

We have some issues such as compliance and outdoor smoking after the non-smoking legislation in Japan. In addition, the cost for the removal of smoking rooms should be considered, because the Act and Ordinance allowed their installation. At the moment, although it is a very difficult time for restaurants and bars due to COVID-19, I hope that many of them start a smoke-free environment in order to avoid severe pneumonia.

As of 2018, there are 62 countries around the world that have banned indoor smoking at all public places by law. In Japan, the Health Promotion Law was revised in 2018 and enforced from April 1, 2020. Government/municipal offices, hospitals, schools and universities should implement entire smoke-free premises (outdoor smoking corner/room is allowed). As for the private sectors including hospitality industry are required smoke-free policy (indoor designated smoking rooms are allowed). However, small restaurants and bars (capital of 50,000,000 yen or less, seating area of 100 m2 or less) that is 55% of all could select “smoking” as a transitional measure. Moreover, rooms where heated tobacco products can used while eating and drinking are also permitted in restaurants and bars.

The International Agency for Research on Cancer (IARC) Cancer Prevention Handbook featured 86 research papers that showed “there was no negative economic impact from the smoke-free policy ban on restaurant and bars.” In this study, we reviewed high quality papers from the IARC Cancer Prevention Handbook and a systematic review published in 2014. There was no negative economic impact from smoke-free policies based on objective measures such as taxable sales or revenue, number of jobs, number of stores by the service industry, restaurants/bars and the accommodation and entertainment industry.

We expect a complete smoke-free law that bans smoking in all public places including restaurants and bars will be established in the next revision that is planned 5 years later.

Objectives: To examine the response of the Public Health Centers (PHCs) to the revised Health Promotion Act (the smoke-free legislation) in Japan, as of July 2019, a survey was carried out.

Methods: Out of 472 PHCs, 328 self-administered questionnaires were returned by e-mail. (response rate: 69.5%)

Results: It was found that 67.8% of PHCs that are supposed to provide smoke-free environments in both indoor and outdoor places, do not have any designated smoking spaces. In 2018, 68.9% of PHCs have conducted programs to prevent the initiation of tobacco use among school children. The rate has declined compared to that of the 2008 survey where 30.2% and 60.7% of the PHCs have collected information on the implementation of a smoke-free policy and distributed the smoking cessation programs in medical facilities in 2018, respectively. These rates have declined compared to those of the 2008 survey. The rate of PHCs indicating that their public health division was responsible for promoting a smoke-free policy for public places and restaurants, was 63.4% and 47.0%, respectively. However, 9.5% of PHCs showed that they were not responsible for the public places and 30.5% have not yet determined which division was responsible for the restaurants.

Conclusions: Further investigation needs to be done to promote the response of PHCs to the revised Health Promotion Act.

The most health effects of smoking are mainly induced by primary smoking by the smoker, second-hand smoke that comes from the side stream of a cigarette and smoke breathed out by a smoker, and third-hand smoke that comes from the residual tobacco emitted from the clothes and walls in the smoking room. Particularly, there is lower awareness about third-hand smoke and it's health effects, in the world. However, some reports show that residual tobacco smoke in indoor rooms include various toxic compounds such as pyridines, furans, nicotine, tobacco-specific nitrosamines (TSNAs) etc. We need to pay attention to the health effects that third-hand smoking has for infants and young children, because they are unintentionally exposed to these compounds through indoor dust and air.

In Japan, the revised health promotion act was enforced in July 2019. Therefore, it is expected that indoor smoking opportunities will decrease significantly in the future due to the impact of this law. However, smoking is still possible in more than half of the restaurants, bars etc. It is thought that the change of conventional smoking areas to non-smoking areas cannot completely eliminate the effects of third-hand smoking due to the residual tobacco smoke. Furthermore, recently, a new type of tobacco product became very popular in the world. However, the health effects and environmental pollution caused by these products still remains unclear. Therefore, to respond to second-hand smoke and new smoking problems including third-hand smoking, it is necessary to establish high-performance analytical techniques to trace chemical components and employ the biological impact assessment method to obtain basic data and clarify the short-term and long-term effects on human health. It is also necessary that continuous epidemiological research in the field of public health be conducted.

The revised Health Promotion Law, which was fully enforced in April 2020, responds by implementing measures for each type and location of facilities to eliminate unwanted second-hand smoke. However, as a transitional measure, heated tobacco products (HTPs) are allowed to be used in smoking rooms where people can eat and drink. This is because HTPs have been in the Japanese market for a shorter time, there is insufficient scientific evidence regarding their health effects for smokers and second-hand smoke. The HTPs' vape mainstream smoke (aerosol) is generated by heating processed tobacco fillers with a portable device. HTPs suppress the generation of harmful chemical compounds generated from cigarettes because it does not involve combustion.

In the mainstream smoke (aerosol) from HTPs, including IQOS (launched in 2014), harmful chemical compounds from combustion are reduced by nearly 90%. On the other hand, there are unreduced harmful chemical substances. In particular, the number of harmful chemical compounds in the aerosol of HTPs has not been significantly reduced. Hence, the combined exposure of chemicals is continued as long as the HTP is used. Nicotine, an addictive substance, has been reported to have the same content in heated cigarettes and cigarettes. Smoking cessation caused by the continued use of heated cigarettes cannot be expected. The results of a health impact assessment of smokers using HTPs, showed that, the number of biomarkers of harmful chemical compounds was reduced by nearly 90% by switching from cigarettes to heated cigarettes, and some biomarkers were reduced by only about 50%. Based on the results of research to date, it has been confirmed that the use of HTPs reduces the exposure to harmful chemical compounds. However, it is considered that the improvement of health effects have not yet been confirmed.

Currently, there are many reports from the tobacco industry on the research on HTPs. It is urgently required that public health institutions and neutral researchers accumulate research reports on the health effects of the long-term use of HTPs.

Objectives: Establish and review enhanced surveillance for the G20 Summit in Osaka that allows all Osaka municipalities to share information on infectious disease events that could affect the Summit or could result from the Summit.

Methods: We selected 19 infectious diseases that could affect or result from the G20 Summit, and then we enhanced routine surveillance with supplemental surveillance in order to facilitate detection of those diseases during the Summit period (10 June – 16 July, 2019). To centralize data collection, we temporarily established the G20 Infectious Disease Information Analysis Center. Members of the Analysis Center assessed surveillance data and distributed feedback reports daily. The feedback reports included an overview of each surveillance system's data and results of the daily risk assessment. To evaluate this enhanced surveillance system, we surveyed stakeholders by questionnaire after the Summit period ended.

Results: Enhanced surveillance detected seven notable events associated with the 19 target diseases. None of these spread nor affected the G20 Summit. A total 66 people from 35 of 39 organizations responded to the questionnaire. Findings showed rapid information sharing occurred through the Analysis Center and feedback reports were considered useful.

Conclusion: Enhanced surveillance and feedback reports facilitated information sharing on infectious diseases across Osaka municipalities during the G20 Summit. This approach can be useful for similar events in the future but should be adapted to the context and needs of the event and stakeholders.

Objectives: In case that an accident occurs at a nuclear power plant etc., radioactive iodine may be released into the environment. When it is taken into the human body through breathing or food and drink, it accumulates in the thyroid gland and may cause thyroid cancer after several years to several decades due to radiation exposure. However, taking stable iodine can reduce internal thyroid exposure. In this study, it is discussed the establishment of people-centred stable iodine prophylaxis from the view point of risk-benefit analysis and interventional simulation in local areas, based on gender and age-specific thyroid cancer risk.

Methods: The number of excess thyroid cancer incidence from acute thyroid exposure to low LET ionizing radiation and the lifetime thyroid cancer risk per equivalent dose for gender and age at the time of exposure were estimated. The predicted equivalent dose of thyroid, providing at all times the net benefit of taking stable iodine, as an interventional level was calculated from a risk-benefit analysis. Furthermore, the number of thyroid cancer occurrences and the incidence of adverse events related to taking stable iodine were predicted from the interventional simulation of stable iodine prophylaxis in two virtual areas.

Results: The lifetime thyroid cancer risk per thyroid equivalent dose unit（1 Sv）was highest at 10.5 and 3.3, respectively, per 1,000 people, in female children and male children under 5 years of age at the time of exposure. The predicted equivalent dose of thyroid as an intervention level decreased with increasing severity of adverse events, and increased with decreasing the effect of risk reduction. The interventional simulations showed that the predicted number of adverse events could be higher in elderly groups albeit the low lifetime risk.

Conclusions: The stable iodine prophylaxis may be applied for the groups with a greater lifetime risk among the residents, based on the gender and age-factors , but not for all of the residents. However, there are circumstances that must be taken into consideration in local areas, such as available emergency medical system at nuclear accidents and the expectable interventional effects, and it is necessary to address them cooperatively through risk communications between local government agencies and residents. A stable iodine prophylaxis system that matches the characteristics of local areas and may be understood by the residents, namely a people-centred stable iodine prophylaxis system should be established.

Objectives: In case that a nuclear accident occurs, radioactive iodine may be released and cause thyroid cancer. In this study, the establishment of people-centred stable iodine prophylaxis was discussed.

Methods: The excess thyroid cancer incidence and the lifetime thyroid cancer risk were estimated and interventional level was calculated from a risk-benefit analysis. Furthermore, the number of thyroid cancer occurrences and the incidence of adverse events were predicted from the interventional simulation.

Results: The lifetime thyroid cancer risk per unit thyroid equivalent dose（1 Sv）was highest at 10.5 and 3.3, respectively, per 1,000 people, in female children and male children under 5 years of age. The predicted equivalent dose of thyroid as an intervention level decreased with increasing severity of adverse events, and increased with decreasing the effect of risk reduction. The interventional simulations showed that the predicted number of adverse events could be higher in elderly groups.

Conclusions: The stable iodine prophylaxis may be applied for the groups with a greater lifetime risk among the residents. However, there are circumstances that must be taken into consideration in local areas and it is necessary to address them cooperatively between local government agencies and residents.