Introduction

This paper is a practical report that examines how much the smoking rate of residents can be reduced by promoting smoking measures at several events.

Efforts to reduce the smoking rate

Smoking cessation clinic covered by insurance

Since April 2006, smoking cessation treatment has been covered by health insurance [1], and from June of the same year, nicotine patches were introduced as a medicine covered by insurance. In August 2008, an oral medicine was released. These drugs are given to subjects (1) with a score of 5 or more on a test to diagnose nicotine dependence, (2) whose average number of cigarettes smoked per day × number of years smoked = 200 or more, and (3) who wish to start smoking cessation within 1 month. If a smoker agrees in writing to receive smoking treatment, the treatment will be covered by insurance. According to the JT report [2], the rate of smokers in 2008 was as high as 39.5% for males and 12.9% for females, and in Japan, where prohibitions on smoking are less frequently promoted in the social environment when compared with such prohibitions in other countries, the rate of success in smoking cessation after 9 months is <50% [3]. This is because Japanese society is one in which people are tempted to smoke. However, although the smoking rate among Hamamatsu citizens is as low as 10.2% (Fig. 1), there is a significant trend toward enacting smoking restrictions in the social environment in parallel with clinical practices at smoking cessation clinics. According to Shibuya [4], the two major determinants of adult mortality due to noninfectious diseases and disorders in Japanese are smoking and hypertension (Fig. 2); therefore, a comprehensive response to widespread smoking is desired.

Fig. 1
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Hamamatsu Municipal Smoking Rate 2016. Comparison of smoking rates: JT national average and Hamamatsu city

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Fig. 2
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Two major determinants of adult mortality from noninfectious diseases and disorders are smoking and hypertension [4]

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History of smoking in the social environment

Shizuoka Prefecture and Hamamatsu City have hosted a series of large events (Table 1) including the 2003 58th NEW!! Wakafuji National Athletic Meet (the year following the enforcement of the Health Promotion Act), the Shizuoka International Horticultural Exposition in Shizuoka Prefecture, the Hamanako Flower Expo (the year before the Framework Convention on Tobacco Control came into force), the birth of Hamamatsu as an ordinance-designated city in 2005, the Hamamatsu Mosai Culture World Exposition in 2009, and the opening of Mt. Fuji Shizuoka Airport in 2009, all of which were large, nationwide or worldwide events. Countermeasures against secondhand smoke in areas where large numbers of people gather are important and result in a reduction in smoking rates. For a long time, I felt that there was a limit to how much support I could give to people who were attempting to quit smoking, so my approach to society as a whole has varied.

Table 1 Smoking prevention events (Shizuoka—World)and 19 public forums and 10 World No-Smoking Day events were held
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Oki-jinja Shrine smoking measures

The Oki-jinja shrine was established in 705 and dedicated to the god of wind (Shinatsuhiko-kami and Shinatsuhime-kami). The autumn festival, the largest event in the Yuto area, is held on the shrine grounds and has provided opportunities for minors to start smoking.

In 2005, the federation, which hosts the festival, requested the creation of measures against passive smoking in the precincts. The request was based on the fact that at the time of the Lake Hamana exposition in 2004, the federation proposed to its secretariat the idea of limiting smoking to a public smoking area and was then chosen to organize the exposition. The 56 ha garden was smoke free except for ten smoking areas, and ~5.44 million people were able to attend the exposition smoothly. In addition, the Health Promotion Law had been promulgated during the previous fiscal year, and the prevention of passive smoking is mentioned in Article 25 of the law. The exposition and the regional festival were held in the plaza where many people can gather. There were 5.44 million people at the Hamanako Flower Expo, so I wanted to help at least 12,000 people who participated in the festival to understand the importance of smoking cessation.

As for measures against smoking, in cooperation with the Japan Federation of Community Associations, the government has expanded the size of the area covered by the ban every year.

2004: Three smoking areas were established in the precincts (smoking outside of the areas was prohibited).

2005: Smoking regulations began to be enforced on the streets in and around the shrine.

2006: Smoking was prohibited at the torii gate at the front of the shrine.

In 2007, the Medical Association, the Association of Joint Residents, and the Oki-jinja Shrine posted signs (Fig. 3) about the total nonsmoking policy in the precincts. With the permission of the Tsurugaoka Hachimangu Shrine, the same sign that had been used at that shrine in Kamakura city was introduced at the Oki-jinja Shrine. Article 25 of the Health Promotion Law (“It is bad for your health, so let's not do it.”), which stipulates the goal of preventing passive smoking, has been epoch making.

Fig. 3
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Smoking prohibited on the grounds of the Oki-jinja Shrine, built in 705. Rule prohibiting the following on the grounds of Oki-jinja Shrine, founded in 705: capturing wild birds, logging trees, leaving garbage/littering, climbing the Tamagaki, walking dogs, smoking (Article 25 of the Health Promotion A), and vehicles other than shrine-related vehicles

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2008: There was request for cooperation from street vendors in preventing passive smoking.

In the fifth year since the introduction of smoking measures, the need for measures against smoking by street vendors was pointed out. Therefore, I obtained information that Togenuki Jizoson and Kogan-ji Temple in Sugamo, Toshima Ward, Tokyo, have taken measures to prohibit smoking throughout the precincts. A town meeting was held with ten people connected to the Togenuki Jizo Temple and people connected to the neighborhood association in the area. This suggests the importance of direct negotiations with prominent street stallholders.

After returning to Hamamatsu, I contributed an article to the Shizuoka Shimbun newspaper. Then, I had a direct conversation with the president of the Seibu Merchants Association, who was the coordinator of street stallholders. The chairman of the board of directors praised the ban on smoking in all precincts surrounding the shrine and ordered the regulation of smoking during open-air sales.

Since 2014, the residentsʼ association has maintained a large smoking restriction display on the shrine grounds.

In the precincts of Yoimatsuri and Honmatsuri, many people gathered in protest, as the residents' awareness was considerably heightened by the community association’s announcement at the site: “Please refrain from smoking in the precinct” (Fig. 4).

Fig. 4
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Oki-jinja shrine, Yoimatsuri scene (Adherence to Article 25 of the Health Promotion Law)

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One teacher commented that it was an attempt to turn “a scene of temptation” into “a forum for enlightenment”.

First, smoking regulations have drastically reduced littering. Parents have also appreciated the safe and secure environment for visiting the shrine, and the number of participants at events has increased.

Smoking prevention class for sixth graders at Yuto Elementary School

This challenge started in fiscal year 1999. This is because Healthy Japan 21 [5] set “Eliminate youth smoking by 2010” as a goal. If smoking prevention education is continued for children until the age of 12, a generation of smokeless people will be raised in 11 years. By continuing this education, elementary school students in the district will be able to understand the truth about smoking. However, this education does not consist of a pharmacy course to learn how to use drugs but rather to learn how to avoid or stop using cigarettes.

Basically, I was in charge of the 1st to 14th, 16th to 18th, and the 20th education sessions, and I asked Dr Masayuki Kaji, Director of the Shizuoka City Health Center, to administer the 15th session, and Dr Yumiko Mochizuki, a counselor with the Cancer Society, to administer the 19th session. In February 2010, a piece of artwork called “Lifetime smokeless” (Fig. 5) was posted at the venue for visual appeal.

Fig. 5
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Hamamatsu Municipal Yuto Elementary School. “Lifetime smokeless” program

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At first, the school was reluctant and refused to present “Lifetime smokeless” to public elementary schools, but I was firm: “I want to separate smoking from children's health problems.” To date, more than 2800 classes of smokeless people have been raised by attending the program 21 times.

When asked about the smoking rate of parents in a smoking prevention class, every time, ~1/3 of the students raise their hands. Parents account for more than 35% of adult smokers (Fig. 6). Of course, there is therefore opportunity for passive smoking at home. In the sessions, I describe usual smoking behaviors followed by smoking-related illnesses, but I think even more interventions should be made [6] (Fig. 7). Every year concludes with me saying, “I hope you will be fine and have a reunion in 30 years.”

Fig. 6
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Japan Tobacco Inc. announced the smoking rate among adults

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Fig. 7
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History of smoking and related deaths [6]

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CDR (compact disc—recordable) for youth awareness of passive smoking prevention (make it for you tomorrow)

The Health and Welfare Ministry of Shizuoka Prefecture is engaged in various health education activities. Above all, efforts have been made to prevent minors from smoking, but as part of the Fujinokuni Passive Smoking Prevention Activities Project in 2013, it was decided to make a CDR for education on smoking prevention for minors (elementary, junior high, and high school students). The CDR manufacturing committee was established, and joint preparations began between (1) the Association for Protecting Children from Tobacco, (2) the Hamamatsu City Dentists Association, (3) the Hamamatsu City Pharmacists Association, (4) the Hamamatsu City Board of Education nursing teacher, and (5) the Shizuoka Prefecture Board of Education nursing teacher. For the first meeting of the committee, we invited Professor Takafumi Hirama, who has been engaged in educational activities for 480,000 minors in Ibaraki Prefecture, to be a lecturer and to suggest points to be noted when preparing the CDRs. He also asked Masayuki Kaji, chief of the Shizuoka Health Center, to cooperate with the project. The CDR production committee met eight times and added ~40 slides from a doctor, ten from a dentist, and ten from a pharmacist. Three kinds of content from the committee were prepared at a level appropriate for high school students. In particular, recent tobacco regulations such as the Act on Prohibition of Smoking by Minors [7] Health Promotion Act [8], the Framework Convention on Tobacco Control [9], and Healthy Japan 21 [5] were incorporated.

The committee borrowed an animated movie called “Cigarettes Lazy” [10] prepared by the health promotion team in the health promotion section of the Okayama Prefectural Health and Welfare Ministry and added it to the CDR.

The goal was to make the students and students who watched the CDR fully understand the problems surrounding cigarettes. In particular, I explained the gap between smoking prevention in Japan and that in other countries and noted that it was not a problem of “likes and dislikes”. In addition, I explained to the committee from a child’s point of view how students can avoid starting smoking, refuse cigarettes, and protect their family’s health. I asked the committee to convey the message from a child's point of view.

The completed CDR was distributed to the Hamamatsu City Kosai Board of Education (covering elementary and junior high schools), western prefectural high schools, and private high schools, amounting to a total of 230 schools. The CDR was intended to be an adjunct to antismoking education, but the current level of awareness of smoking prevention is still low.

Hamamatsu Manner: From the installation to the removal of ashtrays

In September 2008, “Hamamatsu Manner ashtrays” were set up at the south and north exits of JR Hamamatsu Station. A nearby message board was designed to mimic the sound of cigarette smoke. These kinds of ashtrays, installed in both public and private areas, were created by the tobacco industry and installed throughout Japan. Once the ashtrays are installed, maintenance is the responsibility of the installing party. All local governments are suffering from smoking problems in front of train stations, which makes them look like saviors when the problem is fixed. However, unlike an ashtray in front of a convenience store, an ashtray installed in a public space requires less maintenance and cleaning and is usually used as a garbage can. I posted full-page advertisements in two local newspapers (in the Shizuoka Shimbun, “It is unreasonable to set up a manner ashtray”, and in the Chunichi Shimbun, “Ashtrays run counter to the age of nonsmoking”). Hamamatsu Manner ashtrays are not large enough to help beautify the JR Hamamatsu Station area. The mayor of Hamamatsu posted an explanation for my content in a newspaper article, but it still raised concerns among Hamamatsu city officials.

At about the same time, the mayor learned that the use of ashtrays installed by the public and private sectors along private railway lines in Itabashi Ward, Tokyo, had been forcibly suspended due to severe complaints from local residents. The health consciousness of the residents in this area was believed to be high, so the mayor suggested a new method to the Environmental Conservation Division of the Natural Resources and Environment Department in Itabashi Ward. To apply this method to Hamamatsu City, images of Hamamatsu Manner ashtrays that had already been disposed of in trash cans were made available to antismoking advocates nationwide.

It was necessary to convert such a method to Hamamatsu City. We asked antismoking activists across the country to view photos of the ashtrays that were dumped in garbage cans and give their opinions. It seems that there were objections and complaints about the installation of the ashtrays.

Hamamatsu City became an ordinance-designated city in April 2007. At the same time, the mayor posted an article titled “Smoking prohibited in front of stations in government-designated cities” to the Shizuoka Shimbun. Hamamatsu City has an ordinance for the creation of sound, Kaori and light environments (Hamamatsu City ordinance no. 144 of June 1, 2005) [11], and chapter 5 states that one priority is “maintaining a low-odor living environment. In modern society, environmental pollution caused by the smell of tobacco breaks this ordinance.

In the end, the Hamamatsu Manner ashtray at the north exit of Hamamatsu Station was removed 3 years after its installation, and the ashtray at the south exit of Hamamatsu Station was removed 8 years after its installation. Even if Hamamatsu had high tax revenue, this situation proved that the government would take little action to improve citizensʼ lives.

Smoking cessation in taxis: history of the Hamamatsu Taxi Association

In April 2006, Entetsu Taxi Japan started to ban smoking in its taxis, asserting that doing so was “essential for environmentally friendliness and passenger sales”. I wrote an article titled “The ban on smoking in some taxis is a bold decision” in a local newspaper. I received a letter from the former president of Entetsu Taxi, Kodaka. He immediately went to the head office of Entetsu Taxi to ask if the action was what the employees wanted. It was decided that there were various reasons for the ban on smoking in taxis and that an educational lecture would be held directly for the drivers. The following year (2007), the company announced “Entetsu Taxi Activities” at the World No Smoking Day event held in Nagoya.

At that time, I interviewed a taxi driver near Nagoya Station. “How do you feel about a nonsmoking taxi?” The driver, who smoked, said, “Well, I think there are about 1 out of 100 nighttime troubles”. He misunderstood the purpose of introducing nonsmoking taxis as a “service to passengers”. The original purpose of nonsmoking taxis was to “protect drivers from passive smoking”, but this was not understood, and the limit was imposed from the top down.

In Hamamatsu, I told the Hamamatsu Taxi Association that I wanted to talk to them directly about the purpose of making taxis nonsmoking. The Hamamatsu City Taxi Association willingly agreed and held a no-smoking lecture for taxi drivers in August 2007. There were 500 visitors, and the smoking area before the opening was crowded with countless cigarette butts. At the beginning of the lecture, I showed a video of a 73-year-old man inhaling oxygen. “I regret this, after 50 years of smoking. One should never start using invisible hazardous substances”. “The purpose of introducing nonsmoking taxis is to protect the health of drivers” I said. The latter half of the meeting was held in the form of a town meeting, and there was a free and vigorous exchange of opinions within the venue. There were no cigarette butts added to the outdoor smoking area after the lecture. There are many crew members who still talk about the lecture from 2007. The lecture was made into a DVD and sent to 140 taxi companies nationwide.

Passive smoking prevention Summit in Hamamatsu

In March 2009, Kanagawa Prefecture, Japan, passed and enacted the Ordinance for the Prevention of Passive Smoking in Public Facilities [12]. The ordinance was initiated by former Kanagawa governor Shigefumi Matsuzawa, who showed unparalleled leadership. Although it did not meet the WHO criteria, it was our country's first ordinance on the prevention of secondhand smoke, attracting attention from all over Japan. I had been supporting the Passive Smoking Prevention Ordinance in Kanagawa Prefecture for 2 years before this, and I was able to invite former Governor Matsuzawa to Hamamatsu City in October 2009. A lecture titled “Passive Smoking Prevention Summit in Hamamatsu” was given and attended by 500 people at Hamamatsu Yuto Culture Center.

First, the lecture aimed to gather input from various fields about how to make the social environment nonsmoking. A Shizuoka prefectural assembly member, a staff member in charge of smoking cessation at restaurants, an executive member of the taxi division, and a member of the corporate industrial medicine division were on the stage. The speech of the deputy mayor of Hamamatsu and the speech of the deputy governor of Shizuoka were followed by a keynote speech from former governor Shigefumi Matsuzawa. It has been reported that global tobacco regulations have progressed with various intentions. Shigefumi Matsuzawa said that it is important for Kanagawa Prefecture to use its advanced capabilities to break through the crisis. He also concluded that “It is important to build a consensus above others to decide things.” In fact, prior to the enactment of the Kanagawa Ordinance for the Prevention of Passive Smoking, Governor Matsuzawa energetically negotiated with various industry groups and held frequent town meetings in the prefecture. The message that he “would like Hamamatsu to promote the enactment of the Passive Smoking Prevention Ordinance, which is an international treaty, as well as to enforce our country's belated tobacco control measures” fascinated the audience of 500. In this way, the message from the Kanagawa (nine million residents) prefectural government officials was conveyed to the Shizuoka (3.8 million residents) prefectural government officials.

Then, 1000 “Passive Smoking Prevention Summit in Hamamatsu” booklets and 450 DVDs were distributed to relevant persons.

Supporting the Tokyo Medical Associationʼs Smoking Measures

Under the leadership of Haruo Ozaki, President of the Tokyo Medical Association, measures were taken to promote smoking cessation at the Olympics in 2020. The National Stadium in Tokyo will be the main venue for the event, with more than 12,000 participants from 207 countries and regions participating, and 339 events in 33 sites are scheduled to be held. The revised Health Promotion Law [13] (though far from meeting the WHO's demands) was replaced by the Tokyo Ordinance for the Prevention of Passive Smoking [14]. A lecture meeting was held at a hotel in Hamamatsu to support this initiative. The speakers were Dr Haruo Ozaki, Chairman of the Tokyo Medical Association; Dr Keiko Sasai, Technical Director of the Tokyo Bureau of Health and Welfare; and Dr Hiroyasu Muramatsu from the Tobacco Control Committee of the Tokyo Medical Association. All of them are working toward a “world-class Olympic smoking policy”, and the Tokyo Medical Association is very serious about this goal. The cycling track and race will be held at the Izu Velodrome (Izu) for both the Olympic and Paralympic Games, and the mountain bike (Olympic only) will be held at the Izu Mountain Bike Course (Izu) in Shizuoka Prefecture. On the other hand, the Olympic bicycle road race goal and time trial and the Paralympic bicycle road race and time trial were held mainly at Fuji Speedway (Oyama-cho), and countermeasures against smoking at the venue were an urgent issue.

As a supplement, Public Opinion News Co., Ltd and the author planned a special feature on smoking cessation targeting the upcoming Olympic and Paralympic Games and serialized it over a period of 37 months.

Countermeasures against smoking at small restaurants (55% of eating and drinking places are not regulated)

The revised Health Promotion Law will be enforced starting in April 2020. According to the law, minors and part-time workers are not allowed to work in smoking stores. This is because secondhand smoke has a major negative impact on children, and thus, none of the host countries of the Olympics have permitted indoor smoking. Moreover, it is unthinkable that 55% of restaurants are exempt from the regulation. This exemption clearly violates chapter 8 (Protection from exposure to tobacco smoke) of the Framework Convention on Tobacco Control (FCTC). Therefore, Japan can receive, at most, the second-lowest grade in the four levels of smoking regulations from the WHO (Table 2).

Table 2 Rating of number of nonsmoking area types
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I found out about the nonsmoking bar “Laundry Ship”, which has been open in Shinjuku Golden Gai, Tokyo for 32 years. In last spring, I went to Laundry Ship for an interview and listened to a talk about smoking cessation. I understood the significance of having only one nonsmoking bar out of 280 stores operating for 32 years.

The “Symposium on Passive Smoking in Restaurants and Accommodation Facilities in the Reiwa period” was planned for July 7, 2019.

The keynote address, titled “Toward a Zero Tobacco Society that Protects All People” was delivered by Dr Yumiko Mochizuki and Dr Masayuki Kaji, Director of the Shizuoka City Public Health Center. The “Law to Eliminate Passive Smoking (Revised Health Promotion Law)” was explained. The author also discussed “what has been done and what should not be done” and the “voice from the manager of a nonsmoking bar, the Laundry Ship”.

In addition, a restaurant manager who is currently operating a nonsmoking restaurant (offering Pufferfish dishes, coffee and Chinese dishes), delivered a passionate message, and in a video letter, the manager made the suggestion of offering “sushi, Italian, and Japanese food”.

Under the revised Health Promotion Law, if an employer, either of a smoking or a nonsmoking establishment, displays a “smoking permitted” sign outside the establishment, he or she will be exposed to secondhand smoke and will be in violation of an international treaty. I do not know why there is an international rule, so I want to approach restaurants from the bottom up, mainly in Hamamatsu.

Results

  1. (1)

    After 20 years of citizen activities, “lifetime smokeless” community festivals, smoke prevention education (elementary, junior high, and high schools), taxi industry changes, the removal of ashtrays in front of stations and wide areas in various municipalities, and increased citizen and restaurant awareness, the smoking rate among Hamamatsu citizens was decreased to 10.2% in 2016.

  2. (2)

    As ~35% of people in their 30–50 s continue to smoke, and thus, secondhand smoke in their families is a concern.

  3. (3)

    The revised Health Promotion Law does not regulate ~55% of eating and drinking places, and serious health damage is caused not only to smokers but also to employees and nonsmokers.

  4. (4)

    It is time to make recommendations from a medical perspective, taking into account tobacco tax revenue and social losses.

  5. (5)

    To change the existing framework, it would also be effective to shape public opinion through advocacy activities such as continuous lecture meetings and newspaper articles.

  6. (6)

    The principles of democracy require a combination of the principles of majority rule and minority rights.

  7. (7)

    Controlling tobacco use is important in extending healthy life expectancy rates.

Considerations

In preparation for the 2020 Tokyo Olympic and Paralympic Games, the government and the private sector are working together to develop infrastructure. The Framework Convention on Tobacco Control (FCTC) came into effect in 2004, and 181 countries have since ratified it (in Japan is 19th). The FCTC is the first multilateral international treaty in the field of public health to enter into force. The International Olympic Committee agreed in 1988 to ban smoking in Olympic venues, and in 2010, the committee began working with the World Health Organization (WHO) to aim for “tobacco-free Olympics”. In recent years, it has become customary for host cities and countries to enact laws and ordinances to prohibit allowing secondhand smoke not only in the athletic venues but also in eating and drinking places and other indoor facilities. In Beijing in 2008, London in 2012, and Rio de Janeiro in 2016, indoor smoking was banned in all eating and drinking places. Hosting the Olympics provides a golden opportunity to step up efforts to curb the health effects of tobacco. However, Japan’s revised Health Promotion Law, which will go into effect in April 2020, will raise the country’s rating by one notch from the lowest possible rating (Table 2), as more than half of the indoor restaurants will still allow smoke.

The health hazards of smoking (Fig. 2) have already been proven, and smoking and passive smoking have resulted in 150,000 deaths per year [6].

In the case of Japan, it has been difficult for the government to follow suit, given the considerable power given to specific ministries and agencies. In other words, no breakthrough has been made on this issue, but with the Olympics and Paralympics, which are attracting worldwide attention, the situation is changing. In these 100 years, dramatic public health advances have reduced the number of victims of infectious diseases and accidental accidents. However, the number of patients with cancer caused by smoking, which is an undesirable, lifestyle-induced disease, has not decreased. Primary prevention, secondary prevention, and tertiary prevention all aim to reduce the number of smokers depending on the measures taken against smoking. However, it is difficult to predict a definite development in the current situation of cigarette sales under national policy. However, medical professionals are expected to take advantage of the golden opportunity presented by the hosting of the Olympics and Paralympics.

Chapter I and Article I of the General Provisions of the Medical Practitioners Law [15] specify that “Physicians shall contribute to the improvement and promotion of public health by administering medical care and health guidance, and thereby ensure the healthy lives of the citizens.” This is a particularly complicated and bizarre regulation of smoking. As the Olympic Games will be held in Tokyo in 2020, it is essential that the regulation of smoking in Japan is equivalent to that in other host countries.

Tobacco originated in ancient times, evidence of which is carved into stone pillars at the “Temple of the Cross” in the Palenque ruins, a legacy of Mayan civilization, which flourished in the 7–8th centuries.

Solanaceous tobacco, combined with its highly dependency-inducing effects, has spread worldwide since the 16th century. It was introduced to Japan around 1543, and cultivation started during the Edo period in the 17th century. Tokugawa [16], Shogun of Japan, issued the world's first nonsmoking ordinance in 1609.

The reason for the prohibition of smoking was not only the risk of fire but also because the socially disruptive group Kabuki-mono, which roamed the streets of Kyoto, had introduced tobacco from Europe and the United States to Japan; smoking was rare at that time, so smoking was a sign of being in the group. The prohibition aimed to crack down on smoking and to prevent an increase in tobacco growers, which could affect rice production. After that, the Bakufu government issued several bans on smoking, but even after someone was imprisoned for smoking, he could return to his daily life and start smoking again. In some cases, it was suggested that people were completely dependent on drugs, which may be close to the addiction experienced by current smokers.

In the Meiji era (1868–1912), the mass production of cigarettes became possible. The number of cigarette users increased dramatically after the “Tobacco Monopoly Act” [17] was passed in order to raise funds for the Sino-Japanese War and the Russo-Japanese War.

In 1900, the Act on the Prohibition of Smoking by Minors [7] was enacted, but similar initiatives were not seen in other countries. Since then, smoking has grown rapidly around the world, and concerns have been raised about its impact on health. The most famous examples of formal expressions of concern are the “Smoking and Health” report of the Royal College of Medicine in 1962 and a similar report issued by the American Council of Surgeons of Public Health in 1964. The WHO expert committee published a report titled “Smoking and its Effects on Health” in 1975. In 1965, Japan also submitted the “Follow-Up Study on Smoking and Health” for residents 40 years of age or older living in the areas managed by six prefecture health centers nationwide, and in 1987, the Council of Public Health, Ministry of Health and Welfare submitted the “Report on Smoking and Health Problems (White Paper on Tobacco)”. On the other hand, the WHO established “World No Tobacco Day” in 1988 and has continued to promote it.

The WHO adopted the “Framework Convention on Tobacco Control” (FCTC) in 2003, and the same article was adopted by Japan in the following year. The aim of the FCTC is (1) monitoring tobacco use and prevention policies, (2) protecting people from passive smoking, (3) supporting smoking cessation, (4) raising awareness of the danger of smoking, (5) developing prohibition laws and regulations such as tobacco advertising and promotion activities, and (6) increasing the tobacco tax. Kanagawa Prefecture enacted the Ordinance for the Prevention of Passive Smoking 2009 [12], and Hyogo Prefecture followed suit with the Ordinance for the Prevention of Passive Smoking [18] in 2011. At the national level, the revised Health Promotion Law [13] was enacted, but the Tokyo Metropolitan Government supplemented its shortfalls with the Passive Smoking Prevention Ordinance [14]. It is due to the existence of the Tobacco Business Law [19] that other smoking countermeasures have been delayed so far. The Tobacco Business Law was implemented the year before the privatization of a tobacco industry monopoly corporation and is probably the largest public health barrier in Japan. In Japanʼs high economic growth period, from the latter half of the 1950s to the 1970s, pollution caused serious damage to residents. Again, it took time to determine the causes, and it has been 10 years since the government enacted the Air Pollution Control Law [20] (Act no. 97 of 1968) and the Water Pollution Control Act [21] (Act no. 138 of 1970). Before that, local governments of areas that had suffered extensive damage had their own regulations, but the national government was hesitant to act because of the benefits of the high economic growth period.

Every March, Kawachi [22] of Harvard University runs an educational tour of Japan for Harvard students called the “Japan Trip”. According to the report, students are impressed by the cleanliness and healthy eating habits of Japan, one of the “the healthiest countries in the world”, but are shocked to find that people can still smoke in restaurants. This is because in many countries around the world, a complete ban on indoor smoking is the norm. For Japan to remain a “healthy country” and to prevent secondhand smoke from becoming a form of pollution in modern Japan, Ichiro Kawachi says that all restaurants should prohibit smoking on their premises.

History of smoking cessation in the social environment

Fortunately, Shizuoka Prefecture and Hamamatsu City have continued to hold large events. Countermeasures against secondhand smoke in areas where large numbers of people gather are important and result in a reduction in smoking rates. For a long time, I felt that there was a limit to how much support I could give to people who are attempting to quit smoking, so my approach to society as a whole has varied.

Recently I have advocated for (1) the continuation of smoking prevention education, (2) the removal of ashtrays in public spaces, (4) smoking cessation, (5) smoking prevention lectures and meetings, (6) support for nonsmoking efforts at the Olympics, (7) smoking cessation in restaurants, and (8) information provision for smoking situations encountered in daily life.

I am always trying to come up with and implement a few plans. Though I paraphrase here, Yamamoto [23], who was a full admiral, said, “I’ll do it and let him see. I’ll tell him and let him listen. I’ll let him do it and praise him. Otherwise, he’ll not move. We need to talk, we need to listen, we need to approve, we need to nurture… and you have to be thankful for what theyʼre doing, and you have to trust them, or people will not bear fruit.”

In particular, in the case of Japan, the amount of information provided by those selling tobacco was extremely small, and even the mass media, which should have been neutral by nature, failed to convey the truth about cigarettes. In particular, it is strange that the mechanism of tobacco tax revenue and social loss [24] cannot be clarified. Originally, nicotine was classified as “poison” under the Poisonous and Deleterious Substances Control Law [25], but it was not so described in the Tobacco Business Law [19]. The Tokugawa shogunate was unable to enforce its smoking ban, despite five attempts at revision, because of people’s deep dependence on nicotine.

“For a long time, Japan has been disgraced by the world as an advanced industrial nation with only a third-world tobacco control policy. Japan is often cited as a bad example of the poor regulation of tobacco companies and the de facto unfettered behavior of people around the world working on tobacco control. It is easy to understand that the smoking rate among Japanese men is a result of this poor policy. The introduction in Japan of measures to regulate tobacco advertising and public smoking that have been in place for many developed countries for 10 years is only recent, but smoking rates are declining” Dr Simon Chapman [26] notes in his book “Tobacco as a Relic of History”, published in 2009.

It has recently been concluded that nicotine dependence is not a “preference” but an “addiction”. There are many people who pretend to be concerned taxpayers because of the public's health problems, but no one wants to quit smoking. Both smokers and nonsmokers are trapped under the ancient spell of nicotine. For example, the public strongly opposes raising the consumption and gasoline taxes, and the government has no intention of raising the tobacco tax. Rather, the government is concerned that a reduction in tobacco tax revenues will lead to lower social security funds.

Unknowingly, this has changed from a taxpayer issue to a problem for the heads or executives of local governments (the side to which the problem is confined has shifted). The concern for procuring funds for war after the Sino-Japanese and Russo-Japanese wars was prevalent even in times when there was no conflict. We should return to the base issue and acknowledge that health damage and social loss are much more important than lost revenue.

As a physician, I provide support for quitting smoking, but I have always devoted myself to a wider population approach, focusing on “smoking cessation in the social environment” [27, 28] (Table 3). At the same time, to form public opinion, I have continued to publish articles in newspapers to raise the awareness of local residents. To date, my contributions have appeared in approximately 643,000 copies of the Shizuoka Shimbun “Hiroba” and ~136,000 copies of the Chunichi Shimbun “remark”; the latter newspaper has published 64 issues over the past 20 years.

Table 3 Elimination of smoking in the social environment by legislative bodies and administrative bodies for smoking prevention, smoking cessation, and separation of smoking areas in Japan and overseas WHO: Framework Convention on Tobacco Control
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The promotion of tobacco control at very routine events is an opportunity for smokers to think about their tobacco use. Hamamatsu City ranked 1st (Fig. 8) for three consecutive terms in healthy life expectancy among 20 ordinance-designated cities [29]. Some studies have suggested that Hamamatsu is healthy not only because of its low smoking rate but also because of its mild climate, long daylight hours, and long hours spent working with the elderly.

Fig. 8
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Hamamatsu City healthy life expectancy [29]. Ranked 1st in life expectancy for three consecutive terms among 20 ordinance-designated cities

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Hirayama [30] reported the relationship between passive smoking and an increase in lung cancer in 1980. Since then, the health hazards of secondhand smoke as well as smoking itself have been reported in many countries. In other words, in preventing hospitalization for heart disease, respiratory disease [31, 32], and central nervous system disease [33], the enactment of the passive smoking prevention laws is indispensable. Naturally, as shown in Fig. 2, smoking is a major killer of humans, so it is the most important issue in terms of public health for extending healthy life expectancy. Of course, smoking is also a major cause of cancers in 12 organs [34]. Higher incidences of cancer were also reported in the arteriosclerosis index for Asian subjects than for other subjects [35].

In addition, it has been pointed out that smoking causes a decline in corporate productivity (Toward the Realization of a Cigarette Abolition Society, Science Council of Japan, March 4, 20 (2008)) due to mental diseases such as depression and smoking-related diseases—in other words, smoking causes economic loss [36].

In addition, a majority of the public approved the inclusion of an image on the warning labels of cigarette packages sold in Japan, as recommended by the FCTC [37, 38].

In 2015, the city of Bibai, Hokkaido, Japan, enacted an ordinance to prevent passive smoking, which reduced the incidence of myocardial infarction and cerebrovascular disorder [39]. On the other hand, some studies by Kashima have shown that effective SVD (cerebral small vessel disease) prevention is possible by controlling hypertension, smoking and diabetes [40].

The Japanese live with the spirit of “harmony makes everything precious.” Although the saying is a famous phrase in the 17th article of Prince Shotoku’s constitution, there is also a warning to “discuss it thoroughly” and the advice that “it's best not to fight with everyone”. The fatal delay in enforcing a smoking policy in Japan is largely due to the country’s failure to provide accurate information while simultaneously neglecting the importance of “discussing it thoroughly” and “it's best not to fight with everyone”. Public awareness of the detrimental effects of tobacco is also changing from “at least smoking is to be allowed” to “everything but smoking is allowed”.

The core value of democracy is the logic of majority rule and minority rights [41]. If the annual national death toll of 15,000 smoking-related deaths is configured in terms of the population of Shizuoka Prefecture, there are 465 smoking-related deaths in the prefecture each year. Top-down and bottom-up efforts [42] that consider efficiency are important for nonsmoking promotion in the Hamamatsu district.

  1. (1)

    Among the 5.5 million visitors to the exposition, 12,000 people participated in the festival.

  2. (2)

    The survey covered 8.9 million residents in Kanagawa Prefecture and 800,000 in Hamamatsu.

  3. (3)

    The president of the Hamamatsu District Merchants Association understood the countermeasures against smoking on the grounds of the Togenuki Jizo Temple, which attracts eight million visitors annually.

Many countries and cities have reported the effectiveness of antismoking laws or ordinances in preventing the development of smoking-related diseases. Hamamatsu, a major city, should follow suit. Residents would like to practice “think globally” and “act locally” in this area, but it goes without saying that the enactment of the Hamamatsu Municipal Ordinance for the Prevention of Passive Smoking is important. Social reforms such as those that aim to prevent passive smoking are needed, and the 2020 Tokyo Olympic and Paralympic Games represent a watershed opportunity to make headway in this area.