Hypertension Researchhttps://doi.org/10.1038/s41440-020-0418-0

REVIEW ARTICLE
Review Series - Rationale and Practical Method for Lifestyle Modiﬁcation

Health advocacy for reducing smoking rates in Hamamatsu, Japan
Kazuharu Katoh1

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Received: 22 January 2020 / Revised: 24 January 2020 / Accepted: 25 January 2020
© The Japanese Society of Hypertension 2020

Abstract
Efforts to reduce smoking at the Olympics that will be hosted in Tokyo in 2020 are spreading across the country, but they are
not enough. In general, it is said that (1) smoke prevention education for minors, (2) smoking cessation support for smokers,and (3) smoking restriction in the social environment are necessary to reduce the smoking rate. Healthy Japan 21 called forachieving a numerical target for the reduction of youth smoking by 2010. The author is a principal school doctor at
Hamamatsu Municipal Yuto Elementary School and has been teaching antismoking classes to elementary school students
since 1999. In this area (Yuto District, Hamamatsu City in Shizuoka Prefecture, Japan), there is the Oki-jinja Shrine, which
was built in 705, and a large event (Oki-jinja grand festival) is held there each autumn, attracting 2500 people. Since many
people gather there, it is worthwhile to provide information about passive smoking prevention on shrine grounds. Since
1999, smoking prevention classes have been held at elementary schools, and in 2008, smoking was prohibited in the groundsof the Oki-jinja Shrine, making the festival there totally nonsmoking within the shrine grounds, among additional measurestaken against smoking. In addition, measures against smoking at large events in Shizuoka Prefecture and Hamamatsu City
have also been effective, and the smoking rate among Hamamatsu citizens has dropped to 10.2% (From Health Promotion
Division, Hamamatsu City, 2016), which is expected to extend their healthy life expectancy. To reduce the smoking rate, it isimportant not only to provide administrative support but also to engage in steady civic activities.
Keywords Smoking Passive smoking Population approach●●

Introduction
This paper is a practical report that examines how much thesmoking 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 coveredby insurance. In August 2008, an oral medicine was released.

* Kazuharu Katoh
kazuharu@jeans.ocn.ne.jp
1

Katoh Clinic, 11-7987 Ubumi, Yuto-cho, Nishi-ku,
Hamamatsu, Shizuoka, Japan

These drugs are given to subjects (1) with a score of 5 ormore on a test to diagnose nicotine dependence, (2) whose
average number of cigarettes smoked per day × number ofyears smoked = 200 or more, and (3) who wish to startsmoking cessation within 1 month. If a smoker agrees inwriting to receive smoking treatment, the treatment will becovered by insurance. According to the JT report [2], the rateof smokers in 2008 was as high as 39.5% for males and12.9% 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 whichpeople are tempted to smoke. However, although thesmoking 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 clinicalpractices at smoking cessation clinics. According to Shibuya[4], the two major determinants of adult mortality due tononinfectious diseases and disorders in Japanese are smoking
and hypertension (Fig. 2); therefore, a comprehensive
response to widespread smoking is desired.

K. KatohFig. 1 Hamamatsu Municipal
Smoking Rate 2016.
Comparison of smoking rates:
JT national average andHamamatsu city

Fig. 2 Two major determinantsof adult mortality fromnoninfectious diseases anddisorders are smoking andhypertension [4]History of smoking in the social environment
Shizuoka Prefecture and Hamamatsu City have hosted aseries 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 ordinancedesignated 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 howmuch support I could give to people who were attempting toquit smoking, so my approach to society as a whole hasvaried.
Oki-jinja Shrine smoking measures
The Oki-jinja shrine was established in 705 and dedicated to
the god of wind (Shinatsuhiko-kami and Shinatsuhimekami). 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.

Health advocacy for reducing smoking rates in Hamamatsu, Japan
Table 1 Smoking prevention
events (Shizuoka—World)and
19 public forums and 10 World
No-Smoking Day eventswere held

1999∼

Yutoh elementary school 6th graders start smoking prevention education

2003

Article 2003 (prevention of passive smoking) of the Health Promotion Act, 2558
NEW!! Wakafuji Kokutai (Held in 2003)
Ratiﬁcation of the Framework Convention on Tobacco Control in 2004 (FCTC)

2004

Lake Hamanako Flower Exhibition(International Horticultural Exposition: Paciﬁc Flora 2004)2007

Hamamatsu City Taxi Association nonsmoking lecture

2008

Measures against smoking started in the precincts of oki-jinja Shrine.

2009

Opening of Fujisan Shizuoka Airport
Lake Hamana Steric Gardening Exhibition (mosaic culture)

2010

Kanagawa Prefectural Ordinance on the prevention of passive smoking in public facilities wasenacted.
Passive Smoking Prevention Summit IN Hamamatsu

2012

Hyogo Prefectural Ordinance on the prevention of passive smoking enacted in 20122013

All Hamamatsu manner ashtrays were removed.
Fujinokuni Passive Smoking Prevention Project Production of CDR“To You Tomorrow” to prevent passive smoking

2015

Celebrating the no. 1 healthy life expectancy event in Hamamatsu, a government-designated city
in 20152015

Medi-message 2015 School of Medicine

2017

The Worldʼs Level Olympic Smoking Campaign I Want to Tell You

2018

Medi-message 2018 School of Medicine

2019

Symposium on the promotion of smoking cessation in restaurants

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 toorganize 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, theHealth Promotion Law had been promulgated during theprevious ﬁscal year, and the prevention of passive smoking
is mentioned in Article 25 of the law. The exposition andthe regional festival were held in the plaza where many
people can gather. There were 5.44 million people at theHamanako Flower Expo, so I wanted to help at least 12,000
people who participated in the festival to understand theimportance of smoking cessation.
As for measures against smoking, in cooperation with theJapan Federation of Community Associations, the government has expanded the size of the area covered by the banevery 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 thestreets in and around the shrine.
2006: Smoking was prohibited at the torii gate at thefront of the shrine.

Fig. 3 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 shrinerelated vehicles

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 Kamakuracity was introduced at the Oki-jinja Shrine. Article 25 of the
Health Promotion Law (“It is bad for your health, so let's

K. Katoh

not do it.”), which stipulates the goal of preventing passive
smoking, has been epoch making.
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 informationthat Togenuki Jizoson and Kogan-ji Temple in Sugamo,
Toshima Ward, Tokyo, have taken measures to prohibit
smoking throughout the precincts. A town meeting was heldwith ten people connected to the Togenuki Jizo Temple andpeople connected to the neighborhood association in thearea. 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 directconversation 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 alarge smoking restriction display on the shrine grounds.
In the precincts of Yoimatsuri and Honmatsuri, many
people gathered in protest, as the residents' awareness wasconsiderably heightened by the community association’s
announcement at the site: “Please refrain from smoking in
the precinct” (Fig. 4).
One teacher commented that it was an attempt to turn “ascene of temptation” into “a forum for enlightenment”.
First, smoking regulations have drastically reduced littering. Parents have also appreciated the safe and secureenvironment for visiting the shrine, and the number ofparticipants at events has increased.
Fig. 4 Oki-jinja shrine,
Yoimatsuri scene (Adherence to
Article 25 of the Health
Promotion Law)

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 by2010” as a goal. If smoking prevention education is continued for children until the age of 12, a generation ofsmokeless 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 orstop 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, toadminister the 15th session, and Dr Yumiko Mochizuki, acounselor with the Cancer Society, to administer the 19th
session. In February 2010, a piece of artwork called “Lifetimesmokeless” (Fig. 5) was posted at the venue for visual appeal.
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 healthproblems.” To date, more than 2800 classes of smokelesspeople have been raised by attending the program 21 times.
When asked about the smoking rate of parents in asmoking prevention class, every time, ~1/3 of the students
raise their hands. Parents account for more than 35% of adultsmokers (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.”Health advocacy for reducing smoking rates in Hamamatsu, Japan

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

Fig. 5 Hamamatsu Municipal Yuto Elementary School. “Lifetimesmokeless” program
Fig. 6 Japan Tobacco Inc.
announced the smoking rate
among adults

Fig. 7 History of smoking andrelated deaths [6]The Health and Welfare Ministry of Shizuoka Prefecture isengaged 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 ProtectingChildren 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 notedwhen preparing the CDRs. He also asked Masayuki Kaji,K. Katohchief 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, andten from a pharmacist. Three kinds of content from thecommittee were prepared at a level appropriate for highschool 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] wereincorporated.
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 othercountries and noted that it was not a problem of “likes anddislikes”. In addition, I explained to the committee from achild’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 andjunior high schools), western prefectural high schools, andprivate 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 removalof 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 soundof cigarette smoke. These kinds of ashtrays, installed inboth public and private areas, were created by the tobacco
industry and installed throughout Japan. Once the ashtrays
are installed, maintenance is the responsibility of theinstalling party. All local governments are suffering fromsmoking 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 maintenanceand 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 ofashtrays 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 thisarea 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 ofHamamatsu 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 toview photos of the ashtrays that were dumped in garbagecans and give their opinions. It seems that there were
objections and complaints about the installation of theashtrays.
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 ingovernment-designated cities” to the Shizuoka Shimbun.
Hamamatsu City has an ordinance for the creation of sound,
Kaori and light environments (Hamamatsu City ordinanceno. 144 of June 1, 2005) [11], and chapter 5 states that onepriority is “maintaining a low-odor living environment. In
modern society, environmental pollution caused by thesmell of tobacco breaks this ordinance.
In the end, the Hamamatsu Manner ashtray at the northexit 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 thatthe 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 anarticle titled “The ban on smoking in some taxis is a bolddecision” in a local newspaper. I received a letter from theformer 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 andthat an educational lecture would be held directly for theHealth advocacy for reducing smoking rates in Hamamatsu, Japandrivers. 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?” Thedriver, 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 topassengers”. The original purpose of nonsmoking taxis was
to “protect drivers from passive smoking”, but this was notunderstood, and the limit was imposed from the top down.
In Hamamatsu, I told the Hamamatsu Taxi Associationthat 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 withcountless 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 neverstart using invisible hazardous substances”. “The purpose of
introducing nonsmoking taxis is to protect the health ofdrivers” I said. The latter half of the meeting was held in theform of a town meeting, and there was a free and vigorous
exchange of opinions within the venue. There were nocigarette butts added to the outdoor smoking area after thelecture. 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 andenacted the Ordinance for the Prevention of Passive
Smoking in Public Facilities [12]. The ordinance wasinitiated 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 incharge 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 speechof the deputy mayor of Hamamatsu and the speech of thedeputy 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 negotiatedwith 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 thisway, the message from the Kanagawa (nine million residents) prefectural government ofﬁcials was conveyed to the
Shizuoka (3.8 million residents) prefectural governmentofﬁcials.
Then, 1000 “Passive Smoking Prevention Summit inHamamatsu” booklets and 450 DVDs were distributed to
relevant persons.
Supporting the Tokyo Medical Associationʼs Smoking
Measures
Under the leadership of Haruo Ozaki, President of theTokyo 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 arescheduled 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 ofHealth 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 beheld at the Izu Velodrome (Izu) for both the Olympic andParalympic 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 roadrace and time trial were held mainly at Fuji Speedway(Oyama-cho), and countermeasures against smoking at thevenue were an urgent issue.

K. Katoh
Table 2 Rating of number ofnonsmoking area types

Number of nonsmoking areas

Number of countries

A representative country

8 types in total

55

Britain, Canada, Russia, Brazil, etc.

6–7 kinds

23

Norway, Hungary, etc.

3–5 kinds

47

Poland, Korea, and Japan

0–2 types

61

Malaysia, etc.

(WHO report on the global tabacco epidemic 2017). Eight types of places where the public gathers are: (1)medical facilities, (2) schools other than universities, (3) university, (4) administrative organ, (5) businesssites, (6) restaurants, (7) bar, and (8) public transportation

As a supplement, Public Opinion News Co., Ltd and theauthor planned a special feature on smoking cessation targeting the upcoming Olympic and Paralympic Games andserialized 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 parttime 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 theregulation. 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).
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 understoodthe 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” wasplanned 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)” wasexplained. 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 Pufferﬁshdishes, 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) 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 ofstations and wide areas in various municipalities, andincreased citizen and restaurant awareness, the smoking rate among Hamamatsu citizens was decreased to10.2% in 2016.
(2) As ~35% of people in their 30–50 s continue tosmoke, and thus, secondhand smoke in their families
is a concern.
(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) It is time to make recommendations from a medical
perspective, taking into account tobacco tax revenue
and social losses.
(5) To change the existing framework, it would also be
effective to shape public opinion through advocacy
activities such as continuous lecture meetings andnewspaper articles.
(6) The principles of democracy require a combination of
the principles of majority rule and minority rights.
(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

Health advocacy for reducing smoking rates in Hamamatsu, Japan

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 is19th). 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 andordinances to prohibit allowing secondhand smoke not onlyin the athletic venues but also in eating and drinking places
and other indoor facilities. In Beijing in 2008, London in2012, and Rio de Janeiro in 2016, indoor smoking wasbanned in all eating and drinking places. Hosting the
Olympics provides a golden opportunity to step up efforts tocurb 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 thelowest possible rating (Table 2), as more than half of theindoor 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, nobreakthrough has been made on this issue, but with theOlympics and Paralympics, which are attracting worldwide
attention, the situation is changing. In these 100 years,
dramatic public health advances have reduced the numberof victims of infectious diseases and accidental accidents.
However, the number of patients with cancer caused bysmoking, which is an undesirable, lifestyle-induced disease,has not decreased. Primary prevention, secondary prevention, and tertiary prevention all aim to reduce the number ofsmokers 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 takeadvantage of the golden opportunity presented by thehosting of the Olympics and Paralympics.
Chapter I and Article I of the General Provisions of theMedical Practitioners Law [15] specify that “Physicians
shall contribute to the improvement and promotion of
public health by administering medical care and healthguidance, 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 inTokyo 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 whichis 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 sincethe 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 theworld'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, hadintroduced tobacco from Europe and the United States toJapan; smoking was rare at that time, so smoking was a signof being in the group. The prohibition aimed to crack downon 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 tohis daily life and start smoking again. In some cases, it wassuggested 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 ofcigarettes became possible. The number of cigarette users
increased dramatically after the “Tobacco Monopoly Act”
[17] was passed in order to raise funds for the SinoJapanese 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” reportof the Royal College of Medicine in 1962 and a similarreport 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 Studyon Smoking and Health” for residents 40 years of age orolder living in the areas managed by six prefecture healthcenters 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 topromote it.
The WHO adopted the “Framework Convention on
Tobacco Control” (FCTC) in 2003, and the same article wasadopted 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 thedanger of smoking, (5) developing prohibition laws andK. Katohregulations 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 tothe existence of the Tobacco Business Law [19] that othersmoking 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 inJapan. In Japanʼs high economic growth period, from thelatter 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 ofJapan, 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, acomplete ban on indoor smoking is the norm. For Japan toremain 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. Countermeasuresagainst secondhand smoke in areas where large numbers ofpeople gather are important and result in a reduction insmoking rates. For a long time, I felt that there was a limit to
how much support I could give to people who areattempting to quit smoking, so my approach to society as awhole has varied.
Recently I have advocated for (1) the continuation ofsmoking 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 wasa 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 andDeleterious 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 andthe de facto unfettered behavior of people around the world
working on tobacco control. It is easy to understand that thesmoking 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 inplace 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 toa 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-Japaneseand Russo-Japanese wars was prevalent even in times when
there was no conﬂict. We should return to the base issue andacknowledge that health damage and social loss are much
more important than lost revenue.

Health advocacy for reducing smoking rates in Hamamatsu, JapanAs 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 innewspapers 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.
The promotion of tobacco control at very routine eventsis an opportunity for smokers to think about their tobaccouse. 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

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
Method model

Method name

Outline and examples of methods

Essential environmental measures

To improve our own environment
Self-help
Self-management and smokeless cigarette smoking
nonsmoking law cessation aids are used by smokers who wish to quit
smoking
ACS: IQuit kit, Smart Move
NCI: Helping Smokers Quit Kit
ALA:Freedom from Smoking
Physicians personally adapt self-help Smoking
Improvement of smoking environment in
Clinical method
SmokingPrevention Law at clinics
employees, workplaces, and clinics
cessation
counseling
IT counselingIndividual adaptation of self-help and nonsmoking laws
by doctors over the phone, etc.
Physicians personally adapt self-help, smoking
Smokingcessation, nicotine replacement, etc.
cessation
ALA: Freedom from Smoking
clinic method
DHHS: 5A’s (5Amethod)
AHCPR: Smoking Cessation Clinical Practice Guideline
Aversion
Physicians personally adapt Rapid Smoking Law
therapyat Clinic
Acupuncture
Acupuncturist personally adapts prick acupuncture suchas auricle at clinic
Individual
The surgeon personally adapts self-help smoking
hypnotherapy
cessation and hypnosis at the clinic
Group adaptation of self-help smoking cessation method Improvement of smoking environment inCollective method Collective
employees, workplaces and clinics
by surgeonssmoking
SDA: Five-day plan, breath-free-plancessation law
Smoke ender: Program with the same name
St.Joseph Mercy Hospital: Smokeless and Smoke
Stoppper Program
ACS: Fresh startCompanies, employees, doctors, etc. cooperate andWorkplaceapply educational methods and self-help smoking
smoking
cessation methods
measures
Wide area method
Self-help method

Main goal
No smoking

No smoking
separation ofsmoking area
Smoke prevention,smoking cessation,and smoking
separation

Wide area method School smoking AHF: Know Your Body Program
prevention
education
Wide area method Local smoking
measures
Domestic
andinternationalsmokingmeasures

Implementation of smoking prevention
education curriculums by students,
teachers and doctors at each classand school
Local residents, medical professionals, the mass media, Improvement of local smoking
NPOs, etc. cooperated and applied lectures, antismoking environment
Smoking cessation in the social
campaigns, and self-help antismoking measures.
environment
Osaka Center for Cancer and Cardiovascular Disease
Prevention: Quit Smoking Contest
ACS: The Great American Smokeout
WHO: World No Tobacco Day
SHDPP: Stanford Five-City Project NCL: COMMI
Legislative and administrative bodies implement public
measures for smoke prevention, smoking cessation, andseparation of smoking areas
WHO: Framework Convention on Tobacco Control

ACS American Cancer Society, NCI National Cancer Institute, ALA American Lung Association, DHHS Department of Health and Human
Services, AHCPR Agency for Health Care Policy and Research, SDA Seventh-day Adventist Church, AHF American Health Foundation, WHO
World Health Organization, SHDPP Stanford Heart Disease Prevention Program, COMMIT Community Intervention Trial for Smoking
Cessation, ASSIST American Stop Smoking Intervention Study

K. KatohFig. 8 Hamamatsu City healthy life expectancy [29]. Ranked 1st in life
expectancy for three consecutive terms among 20 ordinancedesignated cities

low smoking rate but also because of its mild climate, long
daylight hours, and long hours spent working with theelderly.
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 amajor killer of humans, so it is the most important issue interms 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 othersubjects [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 theinclusion 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 theincidence of myocardial infarction and cerebrovasculardisorder [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 famousphrase in the 17th article of Prince Shotoku’s constitution,

there is also a warning to “discuss it thoroughly” and theadvice 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 witheveryone”. Public awareness of the detrimental effects of
tobacco is also changing from “at least smoking is to beallowed” 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 interms 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) Among the 5.5 million visitors to the exposition,
12,000 people participated in the festival.
(2) The survey covered 8.9 million residents in Kanagawa
Prefecture and 800,000 in Hamamatsu.
(3) The president of the Hamamatsu District Merchants
Association understood the countermeasures againstsmoking on the grounds of the Togenuki Jizo Temple,
which attracts eight million visitors annually.
Many countries and cities have reported the effectivenessof antismoking laws or ordinances in preventing thedevelopment of smoking-related diseases. Hamamatsu, amajor city, should follow suit. Residents would like topractice “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 toprevent passive smoking are needed, and the 2020 Tokyo
Olympic and Paralympic Games represent a watershed
opportunity to make headway in this area.
Acknowledgements I would like to express my heartfelt gratitude to
Dr Tatsuo Shimosawa (Professor of Clinical Laboratory Medicine,
Faculty of Medicine, International University of Health and Welfare),a board member of the Japanese Society of Hypertension, a speciﬁed
nonproﬁt corporation. I would like to thank all the people who gaveme this opportunity as a general practitioner. In addition, I would liketo express my gratitude to Ms Rumiko Yamashita, the head of theHijirikai, for developing the “Lifetime Smokeless” program for Yuto
Elementary School.

Compliance with ethical standards
Conﬂict of interest The author declares no conﬂict of interest.
Publisher’s note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional afﬁliations.

Health advocacy for reducing smoking rates in Hamamatsu, Japan

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