Effect of the Italian smoking ban on population rates of acute coronary events

Is Cancer Overtaking Cardiovascular Diseases as the Killer Number one in Men in Tuscany?

Aims and background

For the first time in 2006, cancer became the main cause of death in men in Italy, exceeding cardiovascular disease. The aim of the study was to verify whether the overtaking of cancer male mortality occurred also in Tuscany or in some of its 12 subregional areas and whether there was a geographical trend.

Methods

Age-standardized mortality rates from the Tuscan Regional Mortality Registry, 1987–2008, were calculated for neoplasms, cardiovascular diseases, and respiratory diseases, considering the whole region and its 12 areas. Joinpoint analyses were carried out to study temporal trend.

Results

Up to 2008, the number of male deaths for neoplasms (6,786) in Tuscany did not exceed deaths from cardiovascular disease (7,065). Instead, overtaking occurred in some subregional areas from 2004 onwards. When we compared age-standardized mortality rates, cancer became the first cause of death in Tuscany from 2004 onwards (age-standardized mortality rates for cancer 236.5 per 100,000; for cardiovascular disease 227.8 per 100,000). Age-standardized mortality rates for cardiovascular disease recorded an annual 2.4% decrease until 1998, then a 3.5% decrease. Age- standardized mortality rates for all cancers recorded an annual 1.6% decrease in the whole period.

Conclusions

Our study confirmed a geographical trend in cancer overtaking as the main cause of death in males: from the more urbanized areas in northern Tuscany, where the phenomenon occurred earlier, to the southern part. Free full text available at www.tumorionline.it

The role of the non-smoker in enforcing smoke-free laws

Compliance with laws making certain environments smoke free has focused mainly on smokers' behavior, while the role of non-smokers has scarcely been investigated. Our cross-sectional study interviewed 4043 adults (2037 smokers and 2006 non-smokers) in the general population of Greece during April 2009. Non-smokers reported that they would actively work for compliance with the law. The non-smokers were older, more educated (odds ratio, OR 1.4), and were more likely to be annoyed by the smell of environmental tobacco smoke (OR 2.4) or report that it irritates their eyes (OR 1.8). Policymakers should evaluate how non-smokers could actively support smoke-free laws through reporting of violations using media campaigns that inform them of their rights, and other measures.

Change in indoor particle levels after a smoking ban in Minnesota bars and restaurants

BACKGROUND

Smoking bans in bars and restaurants have been shown to improve worker health and reduce hospital admissions for acute myocardial infarction. Several studies have also reported improved indoor air quality, although these studies generally used single visits before and after a ban for a convenience sample of venues.

PURPOSE

The primary objective of this study was to provide detailed time-of-day and day-of-week secondhand smoke-exposure data for representative bars and restaurants in Minnesota.

METHODS

This study improved on previous approaches by using a statistically representative sample of three venue types (drinking places, limited-service restaurants, and full-service restaurants), conducting repeat visits to the same venue prior to the ban, and matching the day of week and time of day for the before- and after-ban monitoring. The repeat visits included laser photometer fine particulate (PM₂.₅) concentration measurements, lit cigarette counts, and customer counts for 19 drinking places, eight limited-service restaurants, and 35 full-service restaurants in the Minneapolis/St. Paul metropolitan area. The more rigorous design of this study provides improved confidence in the findings and reduces the likelihood of systematic bias.

RESULTS

The median reduction in PM₂.₅ was greater than 95% for all three venue types. Examination of data from repeated visits shows that making only one pre-ban visit to each venue would greatly increase the range of computed percentage reductions and lower the statistical power of pre-post tests. Variations in PM₂.₅ concentrations were found based on time of day and day of week when monitoring occurred.

CONCLUSIONS

These comprehensive measurements confirm that smoking bans provide significant reductions in SHS constituents, protecting customers and workers from PM₂.₅ in bars and restaurants.

Smokefree legislation: a review of health and economic outcomes research

CONTEXT

Smokefree legislation is a powerful public health intervention. Despite progress in smokefree legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation.

EVIDENCE ACQUISITION

This paper reviews the scientific literature on health and economic outcome studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy.

EVIDENCE SYNTHESIS

There is a wealth of research showing the health benefits to entire populations when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, economic studies confirm that smokefree laws do not adversely affect business revenues or operating costs.

CONCLUSIONS

While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations.

Cotinine-assessed second-hand smoke exposure and risk of cardiovascular disease in older adults

Objectives

To examine whether second-hand smoke (SHS) exposure measured by serum cotinine is associated with increased coronary heart disease (CHD) and stroke risk among contemporary older British adults.

Design

Prospective population-based study with self-reported medical history and health behaviours. Fasting blood samples were analysed for serum cotinine and cardiovascular disease (CVD) risk markers.

Setting

Primary care centres in 25 British towns in 1998–2001.

Patients

8512 60–79-year-old men and women selected from primary care registers.

Main outcome measures

Fatal and non-fatal myocardial infarction (MI; n=445) and stroke (n=386) during median 7.8-year follow-up.

Main exposure

Observational study of serum cotinine assayed from fasting blood sample using liquid chromatography tandem mass spectrometry method, and self-reported smoking history.

Results

Among 5374 non-smokers without pre-existing CVD, geometric mean cotinine was 0.15 ng/ml (IQR 0.05–0.30). Compared with non-smokers with cotinine ≤0.05 ng/ml, higher cotinine levels (0.06–0.19, 0.2–0.7 and 0.71–15.0 ng/ml) showed little association with MI; adjusted HRs were 0.92 (95% CI 0.63 to 1.35), 1.07 (0.73 to 1.55) and 1.09 (0.69 to 1.72), p(trend)=0.69. Equivalent HRs for stroke were 0.82 (0.55 to 1.23), 0.74 (0.48 to 1.13) and 0.69 (0.41 to 1.17), p(trend)=0.065. The adjustment for sociodemographic, behavioural and CVD risk factors had little effect on the results. The HR of MI for smokers (1–9 cigarettes/day) compared with non-smokers with cotinine ≤0.05 ng/ml was 2.14 (1.39 to 3.52) and 1.03 (0.52 to 2.04) for stroke.

Conclusions

In contemporary older men and women, SHS exposure (predominantly at low levels) was not related to CHD or stroke risks, but we cannot rule out the possibility of modest effects at higher exposure levels.

Epidemiology of cardiovascular diseases in women in Europe

Cardiovascular diseases, defined as diseases of the heart and circulatory system are the main cause of mortality, morbidity and hospitalisation in women all over Europe. Evaluation of descriptive epidemiology of cardiovascular disease and its risk factors in the European women cannot ignore the extraordinary changes in the economic and political profile of the continent that occurred in the past 20 years. A keynote is requested by the knowledge that the Eastern female populations currently appear to be the less protected from cardiovascular disease (CVD; both coronary heart disease (CHD) and stroke) and its risk factors and require major efforts in public health for both primary prevention and risk factors and events treatment. Another important piece of information is that the traditional geographical differences in CHD indicating an advantage of Southern European women in comparison with other European ones is less evident than in the past, owing to the levelling off regarding the differences in risk factors associated lifestyles. The figures for prevalence of epidemic risk factors, such as smoking, physical inactivity, overweight and obesity, high blood pressure and cholesterol levels indicate an urgent need to implement public health interest as well as investments on the whole spectrum of CVD manifestations in terms of risk factors and events.

Factors associated with active smoking, quitting, and secondhand smoke exposure among pregnant women in Greece

Background

Pregnant women are exposed to tobacco smoke through active smoking and contact with secondhand smoke (SHS), and these exposures have a significant impact on public health. We investigated the factors that mediate active smoking, successful quitting, and SHS exposure among pregnant women in Crete, Greece.

Methods

Using a cotinine-validated questionnaire, data were collected on active smoking and exposure to secondhand smoke from 1291 women who had successfully completed the first contact questionnaire of the prospective mother-child cohort (Rhea) in Crete during the 12th week of pregnancy.

Results

Active smoking at some time during pregnancy was reported by 36% of respondents, and 17% were current smokers at week 12 of gestation. Those less likely to quit smoking during pregnancy were those married to a smoker (OR, 1.76; P = 0.008), those who were multiparous (1.72; P = 0.011), and those with young husbands. Of the 832 (64%) nonsmokers, almost all (94%, n = 780) were exposed to SHS, with the majority exposed at home (72%) or in a public place (64%). Less educated women and younger women were exposed more often than their better educated and older peers (P < 0.001). Adjusting for potential confounders, parental level of education, age, and ethnicity were the main mediators of exposure to SHS during pregnancy.

Conclusions

Active smoking and exposure to SHS are very prevalent among pregnant women in Greece. The above findings indicate the need for support of population-based educational interventions aimed at smoking cessation in both parents, as well as of the importance of establishing smoke-free environments in both private and public places.

Short term impact of smoke-free legislation in England: retrospective analysis of hospital admissions for myocardial infarction

OBJECTIVE

To measure the short term impact on hospital admissions for myocardial infarction of the introduction of smoke-free legislation in England on 1 July 2007.

DESIGN

An interrupted time series design with routinely collected hospital episode statistics data. Analysis of admissions from July 2002 to September 2008 (providing five years' data from before the legislation and 15 months' data from after) using segmented Poisson regression.

SETTING

England. Population All patients aged 18 or older living in England with an emergency admission coded with a primary diagnosis of myocardial infarction.

MAIN OUTCOME MEASURES

Weekly number of completed hospital admissions.

RESULTS

After adjustment for secular and seasonal trends and variation in population size, there was a small but significant reduction in the number of emergency admissions for myocardial infarction after the implementation of smoke-free legislation (-2.4%, 95% confidence interval -4.06% to -0.66%, P=0.007). This equates to 1200 fewer emergency admissions for myocardial infarction (1600 including readmissions) in the first year after legislation. The reduction in admissions was significant in men (3.1%, P=0.001) and women (3.8%, P=0.007) aged 60 and over, and men (3.5%, P<0.01) but not women (2.5% P=0.38) aged under 60.

CONCLUSION

This study adds to a growing body of evidence that smoke-free legislation leads to reductions in myocardial infarctions. It builds on previous work by showing that such declines are observed even when underlying reductions in admissions and potential confounders are controlled for. The considerably smaller decline in admissions observed in England compared with many other jurisdictions probably reflects aspects of the study design and the relatively low levels of exposure to secondhand smoke in England before the legislation.

Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona's comprehensive statewide smoking ban

OBJECTIVES

We examined the impact of Arizona's May 2007 comprehensive statewide smoking ban on hospital admissions for diagnoses for which there is evidence of a causal relationship with secondhand smoke (SHS) exposure (acute myocardial infarction [AMI], angina, stroke, and asthma).

METHODS

We compared monthly hospital admissions from January 2004 through May 2008 for these primary diagnoses and 4 diagnoses not associated with SHS (appendicitis, kidney stones, acute cholecystitis, and ulcers) for Arizona counties with preexisting county or municipal smoking bans and counties with no previous bans. We attributed reductions in admissions to the statewide ban if they occurred only in diagnoses associated with SHS and if they were larger in counties with no previous bans. We analyzed the data with Poisson regressions, controlling for seasonality and admissions trends. We also estimated cost savings.

RESULTS

Statistically significant reductions in hospital admissions were seen for AMI, angina, stroke, and asthma in counties with no previous bans over what was seen in counties with previous bans. No ban variable coefficients were statistically significant for diagnoses not associated with SHS.

CONCLUSIONS

Arizona's statewide smoking ban decreased hospital admissions for AMI, stroke, asthma, and angina.

Home and workplace smoking bans in Italy, Ireland, Sweden, France and the Czech Republic

The purpose of this study was to report predictors and prevalence of home and workplace smoking bans in five European countries. We conducted a population-based telephone survey of 4,977 females, ascertaining factors associated with smoking bans. Odds ratios and 95% confidence intervals were derived using unconditional logistic regression. A complete home smoking ban was reported by 59.5% of French, 63.5% of Irish, 61.3% of Italian, 74.4% of Czech and 87.0% of Swedish females. Home smoking bans were associated with younger age and being bothered by secondhand smoke, and among smokers, inversely associated with greater tobacco dependence. Among nonsmokers, bans were also related to believing smoking is harmful (OR 1.20, 95% CI 1.11-1.30) and having parents who smoke (OR 0.62, 95% CI 0.52-0.73). Workplace bans were reported by 92.6% of French, 96.5% of Irish, 77.9% of Italian, 79.1% of Czech and 88.1% of Swedish females. Workplace smoking bans were reported less often among those in technical positions (OR 0.64, 95% CI 0.50-0.82) and among skilled workers (OR 0.53, 95% CI 0.32-0.88) than among professional workers. Workplace smoking bans are in place for most workers in these countries. Having a home smoking ban was based on smoking behaviour, demographics, beliefs and personal preference.

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before and after studies, interrupted-time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions

BACKGROUND

Few studies have examined the impact of anti-smoking legislation on respiratory or cardiovascular conditions other than acute myocardial infarction. We studied rates of hospital admission attributable to three cardiovascular conditions (acute myocardial infarction, angina, and stroke) and three respiratory conditions (asthma, chronic obstructive pulmonary disease, and pneumonia or bronchitis) after the implementation of smoking bans.

METHODS

We calculated crude rates of admission to hospital in Toronto, Ontario, from January 1996 (three years before the first phase of a smoking ban was implemented) to March 2006 (two years after the last phase was implemented. We used an autoregressive integrated moving-average (ARIMA) model to test for a relation between smoking bans and admission rates. We compared our results with similar data from two Ontario municipalities that did not have smoking bans and with conditions (acute cholecystitis, bowel obstruction and appendicitis) that are not known to be related to second-hand smoke.

RESULTS

Crude rates of admission to hospital because of cardiovascular conditions decreased by 39% (95% CI 38%-40%) and admissions because of respiratory conditions decreased by 33% (95% CI 32%-34%) during the ban period affecting restaurant settings. No consistent reductions in these rates were evident after smoking bans affecting other settings. No significant reductions were observed in control cities or for control conditions.

INTERPRETATION

Our results serve to expand the list of health outcomes that may be ameliorated by smoking bans. Further research is needed to establish the types of settings in which smoking bans are most effective. Our results lend legitimacy to efforts to further reduce public exposure to tobacco smoke.

Fine particulate matter measurements in Swiss restaurants, cafés and bars: what is the effect of spatial separation between smoking and non-smoking areas?

We performed 124 measurements of particulate matter (PM(2.5)) in 95 hospitality venues such as restaurants, bars, cafés, and a disco, which had differing smoking regulations. We evaluated the impact of spatial separation between smoking and non-smoking areas on mean PM(2.5) concentration, taking relevant characteristics of the venue, such as the type of ventilation or the presence of additional PM(2.5) sources, into account. We differentiated five smoking environments: (i) completely smoke-free location, (ii) non-smoking room spatially separated from a smoking room, (iii) non-smoking area with a smoking area located in the same room, (iv) smoking area with a non-smoking area located in the same room, and (v) smoking location which could be either a room where smoking was allowed that was spatially separated from non-smoking room or a hospitality venue without smoking restriction. In these five groups, the geometric mean PM(2.5) levels were (i) 20.4, (ii) 43.9, (iii) 71.9, (iv) 110.4, and (v) 110.3 microg/m(3), respectively. This study showed that even if non-smoking and smoking areas were spatially separated into two rooms, geometric mean PM(2.5) levels in non-smoking rooms were considerably higher than in completely smoke-free hospitality venues.

PRACTICAL IMPLICATIONS

PM(2.5) levels are considerably increased in the non-smoking area if smoking is allowed anywhere in the same location. Even locating the smoking area in another room resulted in a more than doubling of the PM(2.5) levels in the non-smoking room compared with venues where smoking was not allowed at all. In practice, spatial separation of rooms where smoking is allowed does not prevent exposure to environmental tobacco smoke in nearby non-smoking areas.

Second-hand smoke levels in Israeli bars, pubs and cafes before and after implementation of smoke-free legislation

BACKGROUND

In 2007, Israel passed a law to extend existing restrictions on smoking in public places and to strengthen enforcement. Responsibility for ensuring smoke-free indoor public places was placed on establishment owners. Bars and pubs were included in the law for the first time. This study aimed to assess changes in air quality in popular Israeli bars, pubs and cafes after the implementation of law, and to examine changes in patron numbers, percentage of smoking patrons and venue-seating sections.

METHODS

Air quality was determined by measuring respirable suspended particles (PM(2.5) μg(-3)) in 33 randomly selected venues in Jerusalem and Tel Aviv, including bars, pubs and cafes, before and after law implementation. Numbers of patrons and smoking patrons were recorded.

RESULTS

Average respirable small particles (RSP) level was 245 μg(-3) prior to implementation and 161 μg(-3) following implementation of the law, representing a decline of 34% (P = 0.0043). RSP levels decreased in bars and pubs and in cafes. Percentage of smoking patrons declined from 19% to 9% (P = 0.0036). The magnitude of the effect decreased over time (P = 0.0039). Non-smoking establishments were more common following the legislation (P = 0.0047).

CONCLUSION

Indoor air pollution from second-hand smoke in Israeli bars, pubs and cafes in Jerusalem and Tel Aviv declined following the implementation of law. This demonstrates that a law to extend existing restrictions and enforcement policies may help protect workers and patrons from tobacco smoke. However, RSP levels in Israeli bars and pubs, especially in Tel Aviv, remain unacceptably high. Enforced, 100% smoke-free laws are essential for complete protection.

Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond

This document details the procedures and recommendations of the Goals and Metrics Committee of the Strategic Planning Task Force of the American Heart Association, which developed the 2020 Impact Goals for the organization. The committee was charged with defining a new concept, cardiovascular health, and determining the metrics needed to monitor it over time. Ideal cardiovascular health, a concept well supported in the literature, is defined by the presence of both ideal health behaviors (nonsmoking, body mass index <25 kg/m(2), physical activity at goal levels, and pursuit of a diet consistent with current guideline recommendations) and ideal health factors (untreated total cholesterol <200 mg/dL, untreated blood pressure <120/<80 mm Hg, and fasting blood glucose <100 mg/dL). Appropriate levels for children are also provided. With the use of levels that span the entire range of the same metrics, cardiovascular health status for the whole population is defined as poor, intermediate, or ideal. These metrics will be monitored to determine the changing prevalence of cardiovascular health status and define achievement of the Impact Goal. In addition, the committee recommends goals for further reductions in cardiovascular disease and stroke mortality. Thus, the committee recommends the following Impact Goals: "By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%." These goals will require new strategic directions for the American Heart Association in its research, clinical, public health, and advocacy programs for cardiovascular health promotion and disease prevention in the next decade and beyond.

Changes in U.S. hospitalization and mortality rates following smoking bans

U.S. state and local governments have increasingly adopted restrictions on smoking in public places. This paper analyzes nationally representative databases, including the Nationwide Inpatient Sample, to compare short-term changes in mortality and hospitalization rates in smoking-restricted regions with control regions. In contrast with smaller regional studies, we find that smoking bans are not associated with statistically significant short-term declines in mortality or hospital admissions for myocardial infarction or other diseases. An analysis simulating smaller studies using subsamples reveals that large short-term increases in myocardial infarction incidence following a smoking ban are as common as the large decreases reported in the published literature.

Factors associated with total restrictions on smoking at work and at home: a study among populations in multiple US states and the US Virgin Islands

This study investigated factors associated with smoking restrictions in the workplace and at home in order to better understand the effects of workplace smoking restrictions. Data from the 2006 Behavior Risk Factor Surveillance System were analyzed. Multiple logistic regression was used to determine independent risk factors for potential smoking exposure at work and at home. The population potentially exposed at work were more likely to be young, male, low-income, Latino adults without college degrees or health insurance; they were also more likely to be a current or former smoker and be at risk for heavy drinking. Our study also investigated self-reported restrictions at home and found significant disparities between populations. We conclude that men, Latinos, and young adults are more likely to live in a home with a smoking ban, but are disproportionately exposed to risks at work, presumably against their preferences. Workplace smoking restrictions in 2006 offered unequal protection.

Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis

OBJECTIVES

A systematic review and a meta-analysis were performed to determine the association between public smoking bans and risk for hospital admission for acute myocardial infarction (AMI).

BACKGROUND

Secondhand smoke (SHS) is associated with a 30% increase in risk of AMI, which might be reduced by prohibiting smoking in work and public places.

METHODS

PubMed, EMBASE, and Google Scholar databases plus bibliographies of relevant studies and reviews were searched for peer-reviewed original articles published from January 1, 2004, through April 30, 2009, using the search terms "smoking ban" and "heart" or "myocardial infarct." Investigators supplied additional data. All published peer-reviewed original studies identified were included. Incidence rates of AMI per 100,000 person-years before and after implementation of the smoking bans and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated. Random effects meta-analyses estimated the overall effect of the smoking bans. Funnel plot and meta-regression assessed heterogeneity among studies.

RESULTS

Using 11 reports from 10 study locations, AMI risk decreased by 17% overall (IRR: 0.83, 95% CI: 0.75 to 0.92), with the greatest effect among younger individuals and nonsmokers. The IRR incrementally decreased 26% for each year of observation after ban implementation.

CONCLUSIONS

Smoking bans in public places and workplaces are significantly associated with a reduction in AMI incidence, particularly if enforced over several years.

Are there health benefits associated with comprehensive smoke-free laws

INTRODUCTION

In the past few years, comprehensive smoke-free laws that prohibit smoking in all workplaces have been introduced in many jurisdictions in the US, Canada, and Europe. In this paper, we review published studies to ascertain if there is any evidence of health benefits resulting from the implementation of these laws.

METHODS

All papers relating to smoke-free legislation published in or after 2004 were considered for inclusion in this review. We used Pubmed, Google scholar, and Web of Science as the main search tools. The primary focus of the paper is on health outcomes, and thus many papers that only report exposure data are not included.

RESULTS

Studies using subjective measures of respiratory health based on questionnaire data alone consistently reported that workers experience fewer respiratory and irritant symptoms following the introduction of smoke-free laws. Some studies also found measured improvements in the lung function of workers. However, the most dramatic health outcome associated with smoke-free laws has been the reduction in myocardial infarction in the general population. This outcome has been observed in the US, Canada, and Europe, with studies reporting reductions of between 6 and 40%, post-legislation, the larger reductions being mostly from studies with smaller population groups. The evidence as to whether these smoke-free laws have helped smokers to stop smoking or to reduce tobacco consumption is less clear.

CONCLUSIONS

There is now significant body of published literature that demonstrates that smoke-free laws can lead to improvements in the health of both workers who are occupationally exposed and of the general population. There is no longer any reason why non-smokers should be exposed to SHS in any workplace. We recommend that all countries adopt national smoke-free laws that are in line with article 8 of the WHO Framework Convention on Tobacco Control that sets out recommendations for the development, implementation, and enforcement of national, comprehensive smoke-free laws.

Declines in acute myocardial infarction after smoke-free laws and individual risk attributable to secondhand smoke

BACKGROUND

The estimated effects of recent pubic and workplace smoking restriction laws suggest that they produce significant declines in community rates of heart attack. The consistency of these declines with existing estimates of the relative risk of heart attack in individuals attributable to passive smoking exposure is poorly understood. The objective is to determine the consistency of estimates of reductions in community rates of heart attacks resulting from smoking restriction laws with estimates of the relative risk of heart disease in individuals exposed to passive smoking.

METHODS AND RESULTS

Meta-analyses of existing estimates of declines in community rates were compared with a mathematical model of the relationship between individual risk and community rates. The outcome measure is the ratio of community rates of acute myocardial infarction (after divided by before implementation of a smoking restriction law). There is a significant drop in the rate of acute myocardial infarction hospital admissions associated with the implementation of strong smoke-free legislation. The primary reason for heterogeneity in results of different studies is the duration of follow-up after adoption of the law. The pooled random-effects estimate of the rate of acute myocardial infarction hospitalization 12 months after implementation of the law is 0.83 (95% confidence interval, 0.80 to 0.87), and this benefit grows with time. This drop in admissions is consistent with a range of plausible individual risk and exposure scenarios.

CONCLUSIONS

Passage of strong smoke-free legislation produces rapid and substantial benefits in terms of reduced acute myocardial infarctions, and these benefits grow with time.

Bibliography. Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 November 2007 and 31 October 2008 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

On the relationship between smoking bans and incidence of acute myocardial infarction

During the last few years several studies have reported a substantial reduction of acute myocardial infarction (AMI) in the general population few months after the enforcement of comprehensive smoking bans. We reviewed the consistency and plausibility of this association, investigating the effect of the Italian law, entered into force on January 10, 2005. We compared the AMI incidence on the first year after the ban with the period before (2000-2004) in the Tuscany population aged 30-64 years. The analysis was performed with a Poisson model of the monthly time-series, adjusting for seasonality and comparing different models with linear and non-linear long-term trends. While the model with linear time trend estimated a decrease of 5.4% (RR 0.95; 95% CI: 0.89-1.00), this effect completely disappeared once the linearity assumption was relaxed (RR 1.01; 95% CI: 0.93-1.10). The model with non-linear terms showed a significantly improved fit (P-value = 0.01). The estimate of the effect of the ban seems to be highly sensitive to the model specification and to the effects of unaccounted factors which could modify the trend of AMI incidence, such as changes in the prevalence of other risk factors or the modification of diagnostic criteria. Several arguments which are put forward to inspect the causal relation between smoking bans and AMI indicate that the plausible effects could be lower than the estimates reported so far.

Stealing a march in the 21st century: accelerating progress in the 100-year war against tobacco addiction in the United States

Tobacco use in the United States has declined dramatically over the past 50 years, with the prevalence of cigarette smoking falling from about 42% of all adults to less than 20% by 2007. If this rate of decline continues, smoking could be eliminated in the United States by 2047. Framed in military parlance, we may be halfway through a 100-year war against the leading public health killer of our time. We describe factors that have contributed to progress over the last 50 years and identify policy and other initiatives that can contribute to the elimination of tobacco use in the United States.

Smoking cessation pharmacotherapy

Cigarette smoking remains an important risk factor for premature cardiovascular disease and its many complications. There are clear benefits from treating tobacco dependence on the rate of clinical outcomes. In addition to behavioral therapies, various pharmacologic strategies have been developed to help achieve this goal. First-line therapies include nicotine replacement, bupropion and varenicline, a partial nicotine antagonist. Second-line treatments include clonidine and nortriptyline. Additional treatment strategies with less proven efficacy include monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, opioid receptor antagonists, bromocriptine, anti-anxiety drugs, nicotinic receptor antagonists (e.g. mecamylamine) and glucose tablets. Various approaches under investigation include inhibitors of the hepatic P450 enzyme (e.g. methoxsalen), cannabinoid-1 receptor antagonists (e.g. rimonabant), and nicotine vaccines.

Bar Patronage after a Smoking Ban

On May 1, 2005, the city of Flagstaff, Arizona enacted a smoking ban in standalone bars. All other establishments already had smoking bans in place for at least three years. Trained observers carried air monitoring equipment and counted lit cigarettes and patrons on two weekends before and four weekends after the ban. Monthly hospitality revenues from 2003 to 2006 were also collected from the Coconino County Tax Assessor's office and analyzed for changes after the ban. Air quality improved immediately by 87% in bars, with no appreciable decrease in the total bar revenues over the next three years. All hospitality businesses experienced a general leveling off of growth after the ban, suggesting a change in more general economic factors. As an industry, hospitality was unaffected by the smoking ban, though individual establishments could have been adversely affected. The standalone bar industry revenue continued to increase after the ban. Alcohol and cigarette co-consumption was not supported.

Cardiovascular benefits of smoking regulations: The effect of decreased exposure to passive smoking

OBJECTIVES

Decreases in population rates of acute myocardial infarction (AMI) have been repeatedly seen in the first months after the introduction of regulations banning smoking in public places. By decreasing the exposure to passive smoking and its acute cardiovascular effects, smoking regulations may cause an immediate drop in AMI incidence, beginning from the initial days after their introduction. Using simulations, we quantified this expected decrease.

METHODS

Expected AMI decreases were estimated using several parameters, including prevalence of exposure to passive and active smoking, relative risks of AMI associated with active and passive smoking, decrease in exposure to passive smoking after the introduction of the regulation, and level of susceptibility of active smokers to exposure to passive smoking.

RESULTS

After evaluating several possible combinations of these parameters, we found that AMI reductions of 5-15% seem likely. For example, a scenario with a population average of 5 hours per week of overall exposure to passive smoking, a 50% reduction in this exposure after the introduction of the regulation, an acute relative risk (RR) of AMI of 4.5 in the first hour after passive smoking exposure, and similar susceptibility to passive smoking among both active and passive smokers translates into a 8.6% decrease in AMI.

CONCLUSIONS

Smoking regulations can cause immediate and relevant decreases in AMI through the prevention of exposure to passive smoking.

[Secondary prevention after myocardial infarction]

A significant reduction in cardiovascular mortality has been achieved during the last decade. New techniques and materials for early coronary intervention have contributed significantly to reduce early mortality after myocardial infarction. Secondary prevention determines further progress; it combines evidence-based medical treatment as well as lifestyle modifications. ACE inhibitors, angiotensin receptor blockers, and beta-blocker positively affect elevated blood pressure, left ventricular remodeling, and electrical stability. Statins decrease LDL and increase HDL cholesterol. Acetylsalicylic acid and clopidogrel are indicated for antiplatelet therapy. Lifestyle modifications unite a diet rich in polyunsaturated fatty acids, moderate physical activity, weight reduction, and smoking cessation.

Acute effect of sidestream cigarette smoke extract on vascular endothelial function

Acute exposure to passive smoking adversely affects vascular function by promoting oxidative stress and endothelial dysfunction. However, it is not known whether tobacco sidestream (SS) smoke has a greater deleterious effect on the endothelium than non-tobacco SS smoke and whether these effects are related to nicotinic endothelial stimulation. To test these hypotheses, endothelial-dependent relaxation and superoxide anion production were assessed in isolated rat aortas incubated with tobacco SS smoke, non-tobacco SS smoke, or pure nicotine. Tobacco SS smoke decreased the maximal relaxation to acetylcholine (Ach) from 79 +/- 6% to 57 +/- 7.3% (% inhibition of phenylephrine-induced plateau, P < 0.001) and increased superoxide anion production from 31 +/- 9.7 to 116 +/- 24 count/10 sec/mg (P < 0.01, lucigenin-enhanced chemiluminescence technique). The non-tobacco SS smoke extract had no significant effect on the response to Ach but increased superoxide anion production in the aortic wall to 133 +/- 2 count/10 sec/mg (P < 0.001). Furthermore, concentration-response curves to Ach and superoxide production remained unaltered with nicotine (0.001, 0.01, or 0.1 mM). In conclusion, despite similar increases in vascular wall superoxide production with tobacco and non-tobacco SS smoke, only the tobacco SS smoke extracts affected endothelium-dependent vasorelaxation. Nicotine alone does not reproduce the effects seen with tobacco SS smoke, suggesting that the acute endothelial toxicity of passive smoking cannot simply be ascribed to a nicotine-dependent mechanism.

Smoke-free legislation and hospitalizations for acute coronary syndrome

BACKGROUND

Previous studies have suggested a reduction in the total number of hospital admissions for acute coronary syndrome after the enactment of legislation banning smoking in public places. However, it is unknown whether the reduction in admissions involved nonsmokers, smokers, or both.

METHODS

Since the end of March 2006, smoking has been prohibited by law in all enclosed public places throughout Scotland. We collected information prospectively on smoking status and exposure to secondhand smoke based on questionnaires and biochemical findings from all patients admitted with acute coronary syndrome to nine Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the next year. These hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland, which has a population of 5.1 million.

RESULTS

Overall, the number of admissions for acute coronary syndrome decreased from 3235 to 2684--a 17% reduction (95% confidence interval, 16 to 18)--as compared with a 4% reduction in England (which has no such legislation) during the same period and a mean annual decrease of 3% (maximum decrease, 9%) in Scotland during the decade preceding the study. The reduction in the number of admissions was not due to an increase in the number of deaths of patients with acute coronary syndrome who were not admitted to the hospital; this latter number decreased by 6%. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke (P<0.001 by the chi-square test for trend) that was confirmed by a decrease in their geometric mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P<0.001 by the t-test).

CONCLUSIONS

The number of admissions for acute coronary syndrome decreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved nonsmokers. However, fewer admissions among smokers also contributed to the overall reduction.

Smoking: A Deadly Pleasant Habit—Is There a Way Out?

It was not until 1958 that the first major epidemiologic study demonstrated a strong correlation between smoking and cardiovascular disease. Although not providing definitive evidence that tobacco smoke was responsible for the increased coronary risk, it prompted the first anti-smoking measures by the US Surgeon General in his 1964 report. Smoking is a highly addictive (biological and psychological) habit. The severity of withdrawal symptoms that patients find distressing can be reduced by nicotine replacement therapy. Bupropion SR was the first nonnicotine medication shown to be effective for smoking cessation. Its possible mechanisms of action include blockade of neuronal reuptake of dopamine and norepinephrine and blockade of nicotinic acetylcholinergic receptors. Varenicline, a nicotine receptor partial agonist, is the most recently developed nonnicotine preparation. The odds of smoking cessation after 12 weeks of 1 mg twice-daily varenicline treatment was approximately twice that achieved with 150 mg twice-daily bupropion and nearly 4-fold greater than with placebo.

The impact of banning smoking in workplaces: what are the early effects?

Smoke-free workplace legislation reduces the exposure of both the general public and the workforce to second-hand smoke (SHS) without evidence of an increased exposure to SHS in children in the home. The reductions in exposure are linked to improved respiratory health in previously heavily exposed occupational groups such as bar, restaurant and casino staff. From some countries, there is evidence suggesting that smoking bans have led to declines in hospital admissions for myocardial infarction. There is general agreement that smoking bans, if associated with other tobacco control measures such as tax increases, together with provision of cessation supports, lead to a reduction in the numbers of cigarettes smoked and probably lower smoking rates. Most cities, regions and countries report neutral or positive economic impacts.