Tobacco use is responsible for approximately 1 in 5 deaths in the United States, or 443,000 deaths per year; exposure to secondhand smoke is estimated to cause 49,000 of these tobacco-related deaths (1). The economic cost of cigarette smoking is more than $193 billion, including $10 billion that results from secondhand smoke costs in terms of health care expenditures, illness, and death (1,2).

Adopting smoke-free policies can be a wise health and business decision. However, when a local government or legislature considers smoke-free ordinances or laws, the issue of economic impact is usually raised. Opponents claim that the ordinance will negatively affect the business of local restaurants and bars. A sizable body of evidence continues to accumulate on the economic effect of smoke-free legislation as it relates to restaurants, bars, and other hospitality venues.

A review of published economic studies found that smoke-free ordinances did not have an adverse economic effect in diverse localities such as New York City; Boston; Minneapolis/St. Paul; Lexington, Kentucky; or several cities in Texas (3-6). In Missouri, 3 studies examined the economic impact of smoke-free ordinances adopted in Maryville, Columbia, and Kansas City (7-9). The Maryville study found that the ordinance was associated with increased revenue, and the other 2 studies did not find any effect. None of these studies were published in a peer-reviewed journal.

The objective of this study was to examine whether smoke-free ordinances have any effect on sales of eating and drinking establishments using an objective measure of taxable sales revenues in 11 cities in Missouri.

Consistent with earlier studies (10-13), we conducted a multiple log-linear regression analysis, separately for each city, using SAS version 9.2 (SAS Institute, Inc, Cary, North Carolina). Cities included Ballwin, Blue Springs, Chillicothe, Columbia, Independence, Kansas City, Kirksville, Lee's Summit, Maryville, Nixa, and North Kansas City, all of which had at least 10 quarters of taxable sales data available postordinance as of and including December 2010 (Box). We did not include communities that had a smoke-free ordinance but did not have sufficient quarters of postordinance data to analyze the effect. These included Brentwood, Clayton, Creve Coeur, Fulton, Jefferson City, Kirkwood, Lake St. Louis, Liberty, St. Louis City, O'Fallon, St. Louis County, Springfield, and Warrensburg.

Overall, the smoke-free ordinance was associated with a significant increase in revenue for eating and drinking establishments in 8 of the 11 cities (Table). For the other 3 cities, we were unable to detect a significant effect of the ordinance on the taxable sales revenues. The largest relative increase in revenue was in Nixa (36.5%), followed by Maryville (18.6%) and Lee's Summit (10.4%). No significant change was identified in Ballwin, Kansas City, or Chillicothe. Ballwin is in the suburb of St. Louis County in eastern Missouri; Kansas City is a large city on the western border; Chillicothe, in northern Missouri, is the most rural city in the analysis. There is limited or no commonality among the 3 cities.

Consistent with findings of most peer-reviewed economic studies of smoke-free ordinances, we found that smoke-free ordinances had no negative effect on the local economy. Furthermore, our study showed that smoke-free ordinances were associated with increased revenue in 8 of the 11 cities we assessed. This study provides more evidence to local and state policy makers that the fear of harmful economic effects from passing and implementing smoke-free policies is unfounded.

Implementing effective policy and programs in Missouri to prevent smoking and associated health effects is essential. Smoking caused 9,362 deaths and cost more than $4.8 billion annually in Missouri during 2003-2007 (18). In 2010, the smoking prevalence among adults in Missouri was 21.1%, the 11th highest in the nation. Missouri's tobacco excise tax is 17 cents per pack, the lowest in the nation. In addition, Missouri does not have a statewide smoke-free law.

Enacting a smoke-free ordinance at the local level is a viable approach to prevent smoking and exposure to secondhand smoke. A negative effect on the revenues of eating and drinking establishments has often been cited in opposition to new smoke-free ordinances. This study uses Missouri-specific data from multiple cities to provide empirical evidence to address this concern.

This study had several limitations. First, only combined bar and restaurant taxable sales data were available, and the data were examined in aggregate. It is possible that specific establishments may have lost revenue after enactment of a smoke-free ordinance. However, the main focus of this study was to investigate the effect of ordinances on the local economies. Therefore, the aggregate data used in this study were sufficient. Second, other cost data, such as lost productivity, decreased property value, increased maintenance and replacement of equipment and furnishings, and increased costs of medical treatment of employees, were not included in this study. Previous studies concluded that smoke-free ordinances benefit the restaurant and bar business through greater worker productivity, lower cleaning costs, higher resale value, and potentially lower property and health insurance costs (19,20). Third, the effect of the ordinances on hospitalizations for smoke-related diseases was not included in this study, although the community benefits economically through decreased hospitalizations for myocardial infarction, asthma attacks, stroke, angina, chronic obstructive pulmonary disease, and lung infections (21-23).

Regardless of these limitations, our study used objective taxable sales data and controlled for confounding factors. Therefore, the conclusion of no negative effect is valid, even though we likely underestimated the positive effect of the ordinances due to aforementioned reasons. We also included all Missouri cities that had a smoke-free ordinance and a sufficient number of quarters of taxable sale data in the analysis. The finding of no negative effect was consistent in all 11 cities studied.

The number of local communities that have passed a smoke-free ordinance is growing in Missouri. As of June 2011, 42% of Missouri's population resided in communities that have smoke-free ordinances. The next logical step for public health is to strive for a statewide smoke-free workplace law. The finding of this study provides evidence for garnering support from the general public and legislators by allaying fears that smoke-free ordinances harm business.