Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: a meta-analysis

Smoke-free legislation and the incidence of paediatric respiratory infections and wheezing/asthma: interrupted time series analyses in the four UK nations

We investigated the association between introduction of smoke-free legislation in the UK (March 2006 for Scotland, April 2007 for Wales and Northern Ireland, and July 2007 for England) and the incidence of respiratory diseases among children. We extracted monthly counts of new diagnoses of wheezing/asthma and RTIs among children aged 0–12 years from all general practices in the Clinical Practice Research Datalink during 1997–2012. Interrupted time series analyses were performed using generalised additive mixed models, adjusting for underlying incidence trends, population size changes, seasonal factors, and pandemic influenza, as appropriate. 366,642 new wheezing/asthma diagnoses and 4,324,789 RTIs were observed over 9,536,003 patient-years. There was no statistically significant change in the incidence of wheezing/asthma after introduction of smoke-free legislation in England (incidence rate ratio (IRR) 0.94, 95% CI 0.81–1.09) or any other UK country (Scotland: IRR 0.99, 95% CI 0.83–1.19; Wales: IRR 1.09, 95% CI 0.89–1.35; Northern Ireland: IRR 0.96, 95% CI 0.76–1.22). Similarly no statistically significant changes in RTI incidence were demonstrated (England: IRR 0.95, 95% CI 0.86–1.06; Scotland: IRR 0.96, 95% CI 0.83–1.11; Wales: IRR 0.97, 95% CI 0.86–1.09; Northern Ireland: IRR 0.90, 95% CI 0.79–1.03). There were no demonstrable reductions in the incidence of paediatric wheezing/asthma or RTIs following introduction of smoke-free legislation in the UK.

Tobacco control policies and perinatal and child health: a systematic review and meta-analysis protocol

INTRODUCTION

Children experience considerable morbidity and mortality due to tobacco smoke exposure. Tobacco control policies may benefit child health by reducing this exposure. We aim to comprehensively assess the effects of the range of tobacco control policies advocated by the WHO on perinatal and child health.

METHODS AND ANALYSIS

We will systematically search 19 electronic literature databases (from inception) for published studies, and the WHO International Clinical Trials Registry Platform for unpublished studies. Additional work will be identified via handsearching references and citations, and through consulting an international panel of experts. No language restrictions will apply. Following Cochrane Effective Practice and Organisation of Care (EPOC) guidelines, randomised and clinical controlled trials, controlled before-and-after studies, and interrupted time series designs, are eligible. Studies of interest will assess the impact of any of the WHO-advocated tobacco control policies contained in the MPOWER acronym (except 'Monitoring tobacco use') on at least one outcome of interest among children aged 0-12 years. The primary outcomes are: perinatal mortality, preterm birth, asthma exacerbations requiring hospital attendance and respiratory infections requiring hospital attendance. Data will be extracted using customised forms and authors will be contacted to obtain missing information. Risk of bias will be assessed using EPOC criteria. Findings will be reported in narrative and tabular form. Between-study heterogeneity will be assessed clinically and statistically using I(2). If appropriate and possible, random-effects meta-analysis will be conducted for each unique combination of intervention and outcome. Subgroup analyses will be performed to assess the influence of the comprehensiveness of each policy, and to explore the impact of each policy according to socioeconomic status.

ETHICS AND DISSEMINATION

No ethical assessment is necessary as we will summarise existing studies. We will publish our findings in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

PROSPERO; CRD42015023448.

Association of Smoke-Free Laws With Lower Percentages of New and Current Smokers Among Adolescents and Young Adults: An 11-Year Longitudinal Study

IMPORTANCE

Smoke-free laws are associated with a lower prevalence of smoking.

OBJECTIVE

To quantify the effect of 100% smoke-free laws on the smoking behavior of adolescents and young adults in a longitudinal analysis.

DESIGN, SETTING, AND PARTICIPANTS

Pooled logistic regression and zero-inflated negative binomial regression analysis of participants in the National Longitudinal Survey of Youth 1997 (data from 1997 to 2007), with complete data on initiation of smoking (n = 4098) and number of days respondents reported smoking in the past 30 days (n = 3913).

EXPOSURES

Laws for 100% smoke-free workplaces, laws for 100% smoke-free bars, and state cigarette taxes.

MAIN OUTCOMES AND MEASURES

Smoking initiation (first report of smoking cigarette), current (for 30 days) smoking, and number of days respondents reported smoking in the past 30 days among current smokers.

RESULTS

Laws for 100% smoke-free workplaces, but not bars, were associated with significantly lower odds of initiating smoking (odds ratio, 0.66 [95% CI, 0.44-0.99]). Laws for 100% smoke-free bars were associated with lower odds of being a current smoker (odds ratio, 0.80 [95% CI, 0.71-0.90]) and fewer days of smoking (incidence rate ratio, 0.85 [95% CI, 0.80-0.90]) among current smokers. Taxes were associated with a lower percentage of new smokers but not current smokers among adolescents and young adults. The effect of smoke-free workplace laws on smoking initiation is equivalent to a $1.57 (in 2007 dollars) tax increase. Smoke-free bar laws are associated with lower rates of current smoking, as well as a decrease in the number of days reported smoking among current smokers.

CONCLUSIONS AND RELEVANCE

Smoke-free laws are an important tobacco control tool. They not only protect bystanders from secondhand smoke but also contribute to less smoking among adolescents and young adults.

Impact of smoke-free legislation on perinatal and infant mortality: a national quasi-experimental study

Smoke-free legislation is associated with improved early-life outcomes; however its impact on perinatal survival is unclear. We linked individual-level data with death certificates for all registered singletons births in England (1995–2011). We used interrupted time series logistic regression analysis to study changes in key adverse perinatal events following the July 2007 national, comprehensive smoke-free legislation. We studied 52,163 stillbirths and 10,238,950 live-births. Smoke-free legislation was associated with an immediate 7.8% (95%CI 3.5–11.8; p < 0.001) reduction in stillbirth, a 3.9% (95%CI 2.6–5.1; p < 0.001) reduction in low birth weight, and a 7.6% (95%CI 3.4–11.7; p = 0.001) reduction in neonatal mortality. No significant impact on SIDS was observed. Using a counterfactual scenario, we estimated that in the first four years following smoke-free legislation, 991 stillbirths, 5,470 cases of low birth weight, and 430 neonatal deaths were prevented. In conclusion, smoke-free legislation in England was associated with clinically important reductions in severe adverse perinatal outcomes.

Overview of systematic reviews on the health-related effects of government tobacco control policies

BACKGROUND

Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

METHODS

An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

RESULTS

Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

CONCLUSION

When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.

Effect of Uruguay's National 100% Smokefree Law on Emergency Visits for Bronchospasm

INTRODUCTION

Implementation of smokefree laws is followed by drops in hospital admissions for cardiovascular diseases and asthma. The impact of smokefree laws on use of non-hospital medical services has not been assessed. The purpose of this study is to evaluate the impact of Uruguay's national 100% smokefree legislation on non-hospital emergency care visits, hospitalizations for bronchospasm, and bronchodilator use.

METHODS

The monthly number of non-hospital emergency care visits and hospitalizations for bronchospasm, as well as monthly puffs of bronchodilators (total and per person), from 3 years prior to the adoption of the 100% smokefree policy on March 1, 2006, through 5 years after the policy were assessed using interrupted time series negative binomial regression. Data analysis was conducted in 2014.

RESULTS

The incidence of non-hospital emergency visits for bronchospasm decreased by 15% (incidence rate ratio [IRR]=0.85, 95% CI=0.76, 0.94) following implementation of the law. Hospitalizations for bronchospasm did not change significantly (IRR=0.89, 95% CI=0.66, 1.21). Total monthly puffs of salbutamol and ipratropium administered in the non-hospital emergency setting decreased by 224 (95% CI=-372, -76) and 179 (95% CI=-340, -18.6), respectively, from means of 1,222 and 1,007 before the law.

CONCLUSIONS

Uruguay's 100% smokefree law was followed by fewer emergency visits for bronchospasm and less need for treatment, supporting adoption of such policies in low- and middle-income countries to reduce the disease burden and healthcare costs associated with smoking.

Policy Options to Promote Smokefree Environments for Children and Adolescents

Secondhand smoke (SHS) exposure among children is associated with a wide variety of adverse health risks, including: asthma, otitis media, respiratory infections, impaired lung growth and function, decreased exercise tolerance, cognitive impairments, behavior problems, and sudden infant death syndrome. Unfortunately, over 40% of children aged 3-11 years-15.1 million children-are currently exposed to SHS, with nearly 70% of black children in this age group being exposed. Over the past three decades, great strides have been made in establishing smokefree environments for adults, ultimately reducing their SHS exposure. Regulations have been passed at the organizational, local, and state levels that increasingly ban smoking in the workplace and public places. Children's SHS exposure patterns, however, differ from adults' exposures, with greater time spent in the home and other potentially unregulated venues (school, child care, and car). This means that children have been afforded relatively less protection from SHS by these smokefree regulations. It is imperative, therefore, to seek alternative options for promoting smokefree environments for children throughout the United States. This article explores policy options that promote smokefree environments for children and adolescents: comprehensive smokefree/tobacco-free policies covering indoor/outdoor public places, housing, private vehicles, and child care, as well as Clinical Guidelines regarding patient/family interviews on smoking, SHS, cessation, and voluntary smokefree efforts. The policy section highlights the role of child and adolescent health practitioners in promoting these policies with the hope of fostering engagement of these key stakeholders in the policy process. Note, there are a wide range of important policy and regulatory strategies aimed at reducing tobacco initiation and use among children, adolescents, and young adults; while essential in tobacco prevention and control efforts, a discussion of these strategies is beyond the scope of this article.

Smoke-free legislation and childhood hospitalisations for respiratory tract infections

Second-hand smoke exposure is a major risk factor for respiratory tract infections (RTIs). Although evidence suggests important early-life health benefits of smoke-free public environments, the impact on childhood RTIs is unclear. We investigated the association between England's smoke-free legislation and childhood RTI hospitalisations.

We used the Hospital Episode Statistics database to obtain nationwide data on hospital admissions for acute RTIs among children (<15 years of age) from 2001 to 2012. Hospitalisation counts were disaggregated by month, age group, sex and small-area level, and linked to urbanisation, region, deprivation index and corresponding population estimates. Negative binomial regression analyses were adjusted for confounders, seasonal variation, temporal autocorrelation, population-size changes and underlying incidence trends. Models allowed for sudden and gradual changes following the smoke-free legislation. We performed sensitivity and subgroup analyses, and estimated number of events prevented.

We analysed 1 651 675 hospital admissions. Introduction of smoke-free legislation was followed by an immediate reduction in RTI admissions (−3.5%, 95% CI −4.7– −2.3%), this mainly being attributable to a decrease in lower RTI admissions (−13.8%, 95% CI −15.6– −12.0%). The reductions in admissions for upper RTI were more incremental.

The introduction of national smoke-free legislation in England was associated with ∼11 000 fewer hospital admissions per year for RTIs in children.

Changes in Georgia restaurant and bar smoking policies from 2006 to 2012

Introduction

The purpose of this study is to examine the change in smoking policy status among Georgia restaurants and bars from 2006 to 2012 and to identify restaurant and bar characteristics that are associated with allowing smoking.

Methods

Data were obtained from similar cross-sectional indoor air surveys conducted in 2006 and 2012 in Georgia. Both surveys were designed to gather information about restaurant and bar smoking policies. Weighted χ² analyses were performed to identify changes in smoking policy status and other variables from 2006 to 2012. Weighted logistic regression analysis was used to test for significant associations between an establishment’s smoking policy and other characteristics.

Results

The percentage of restaurants and bars in Georgia that allowed smoking nearly doubled, from 9.1% in 2006 to 17.6% in 2012. The analyses also showed a significant increase in the percentage of establishments that allow smoking when minors are present. Having a liquor license was a significant predictor of allowing smoking.

Conclusion

The Smokefree Air Act was enacted in 2005 to protect the health and welfare of Georgia citizens, but study results suggest that policy makers should reevaluate the law and consider strengthening it to make restaurants and bars 100% smokefree without exemptions.

Exposure to parental smoking in childhood is associated with increased risk of carotid atherosclerotic plaque in adulthood: the Cardiovascular Risk in Young Finns Study

BACKGROUND

The association between passive smoking exposure in childhood and adverse cardiovascular health in adulthood is not well understood. Using a 26-year follow-up study, we examined whether childhood exposure to passive smoking was associated with carotid atherosclerotic plaque in young adults.

METHODS AND RESULTS

Participants were from the Cardiovascular Risk in Young Finns Study (n=2448). Information on childhood exposure to parental smoking was collected in 1980 and 1983. Carotid ultrasound data were collected in adulthood in 2001 or 2007. Childhood serum cotinine levels from 1980 were measured from frozen samples in 2014 (n=1578). The proportion of children with nondetectable cotinine levels was highest among households in which neither parent smoked (84%), was decreased in households in which 1 parent smoked (62%), and was lowest among households in which both parents smoked (43%). Regardless of adjustment for potential confounding and mediating variables, the relative risk of developing carotid plaque in adulthood increased among those children with 1 or both parents who smoked (relative risk, 1.7; 95% confidence interval, 1.0-2.8; P=0.04). Although children whose parents exercised good "smoking hygiene" (smoking parents whose children had nondetectable cotinine levels) had increased risk of carotid plaque compared with children with nonsmoking parents (relative risk, 1.6; 95% confidence interval, 0.6-4.0; P=0.34), children of smoking parents with poor smoking hygiene (smoking parents whose children had detectable serum cotinine levels) had substantially increased risk of plaque as adults (relative risk, 4.0; 95% confidence interval, 1.7-9.8; P=0.002).

CONCLUSIONS

Children of parents who smoke have increased risk of developing carotid atherosclerotic plaque in adulthood. However, parents who exercise good smoking hygiene can lessen their child's risk of developing plaque.

Impact of a countywide smoke-free workplace law on emergency department visits for respiratory diseases: a retrospective cohort study

Background

With the goal of reducing exposure to secondhand smoke, the state of Minnesota (MN), enacted a smoke-free law (i.e., Freedom to Breathe Act) in all workplaces, restaurants, and bars in 2007. This retrospective cohort study analyzes emergency department (ED) visits in Olmsted County, MN, for chronic obstructive pulmonary disease (COPD) and asthma over a five-year period to assess changes after enactment of the smoke-free law.

Methods

We calculated the rates of ED visits in Olmsted County, MN, with a primary diagnosis of COPD and asthma in the five-year period from January 1, 2005 to December 31, 2009. Analyses were performed using segmented Poisson regression to assess whether ED visit rates declined following enactment of the smoke free law after adjusting for potential underlying temporal trends in ED visit rates during this time period.

Results

Using segmented Poisson regression analyses, a significant reduction was detected in asthma-related ED visits (RR 0.814, p < 0.001) but not for COPD-related ED visits following the enactment of the smoke-free law. The reduction in asthma related ED visits was observed in both adults (RR 0.840, p = 0.015) and children (RR 0.751, p = 0.015).

Conclusions

In Olmsted County, MN, asthma-related ED visits declined significantly after enactment of a smoke-free law. These results add to the body of literature supporting community health benefits of smoke-free policies in public environments and their potential to reduce health care costs.

Smoke-free policy implementation: theoretical and practical considerations

Secondhand smoke exposure is a major public health issue, increasing the risk of cardiovascular and respiratory diseases and cancer. Although best practices for adopting smoke-free policy are well understood, there is limited research on the effective implementation of smoke-free policy. This article presents theoretical and practical considerations for smoke-free policy implementation in three Kentucky communities guided by the Institutional Analysis and Development (IAD) Framework. Although both Danville and Lexington-Fayette County, Kentucky have comprehensive smoke-free policies, Danville had more effective implementation, as well as better outcomes. Further study is needed to understand the critical elements of smoke-free policy implementation and their association with population outcomes. The IAD is a promising model to guide the study of both policy adoption and implementation.

[WHO Framework Convention on Tobacco Control (FCTC) Article 8: protection from exposure to tobacco smoke]

It is necessary to implement 100% smoke-free environments in all indoor workplaces and indoor public places in order to protect people from exposure to second-hand tobacco smoke (SHS). Forty-four countries have already implemented comprehensive smoke-free legislations according to the Framework Convention on Tobacco Control (FCTC) Guidelines on protection from exposure to tobacco smoke. The Occupational Safety and Health Law (OSHL) was partially revised to strengthen the countermeasures against SHS in Japan in 2014. However, the revision was only minimal. Firstly, it is necessary to make efforts to implement countermeasures against SHS (their implementations are not obligatory, as required in Article 8). Secondly, the revised OSHL allowed the implementation of designated smoking rooms inside workplaces (Article 8 requires 100% smoke-free environments). Thirdly, revised OSHL does not effectively cover the small-scale entertainment industry so that workers in restaurants and pubs will not be protected from occupational SHS. We explain the importance of implementation of 100% smoke-free environments by law, using the data on leakage of smoke from designated smoking rooms, and occupational exposure to SHS among service industry workers. The decrease in the incidence of smoking-related diseases in people where a comprehensive smoke-free law is implemented is also introduced. These data and information should be widely disseminated to policy makers, media, owners of service industries, and Japanese people.

Legislative smoking bans for reducing exposure to secondhand smoke and smoking prevalence: Opportunities for Georgians

BACKGROUND

Secondhand smoke, which is also referred to as environmental tobacco smoke and passive smoke, is a known human carcinogen. Secondhand smoke also causes disease and premature death in nonsmoking adults and children.

METHODS

We summarize studies of secondhand smoke in public places before and after smoking bans, as well as studies of cardiovascular and respiratory disease before and after such bans.

RESULTS

To protect the public from the harmful effects of secondhand smoke, smoke-free legislation is an effective public health measure. Smoking bans in public places, which have been implemented in many jurisdictions across the U.S. and in other countries, have the potential to influence social norms and reduce smoking behavior.

CONCLUSIONS

Through legislative smoking bans for reducing secondhand smoke exposure and smoking prevalence, opportunities exist to protect the health of Georgians and other Americans and to reduce health care costs. These opportunities include increasing the comprehensiveness of smoking bans in public places and ensuring adequate funding to quit line services.

Attitudes towards electronic cigarettes regulation in indoor workplaces and selected public and private places: a population-based cross-sectional study

BACKGROUND

Currently, there is an intensive debate about the regulation of the use of electronic cigarettes (e-cigarettes) in indoor places. The aim of this study was to assess the attitudes toward e-cigarette use in indoor workplaces and selected public and private venues among the general population in Barcelona (Spain) in 2013-2014.

METHODS

This is a cross-sectional study of a representative sample of the population of Barcelona (n = 736). The field work was conducted between May 2013 and February 2014. We computed the prevalence and the adjusted odds ratios (OR) derived from multivariable logistic regression models.

RESULTS

The awareness of e-cigarettes was 82.3%. Forty five percent of respondents did not agree with the use of e-cigarettes in public places and 52.3% in workplaces. The proportion of disapproval of the use of e-cigarettes in indoor places was higher at 71.5% for schools and 65.8% for hospitals and health care centers; while the prevalence of disapproval of e-cigarette use in homes and cars was lower (18.0% and 32.5%, respectively). Respondents who disagreed on the use of e-cigarettes in indoor workplaces were more likely to be older (OR = 1.64 and 1.97 for groups 45-64 and ≧65 years old, respectively), those with a high educational level (OR = 1.60), and never and former smokers (OR = 2.34 and 2.16, respectively). Increased scores in the Fagerström test for cigarette dependence were also related to increased support for their use.

CONCLUSIONS

Based on this population based study, half of the general population of Barcelona does not support the use of e-cigarettes in indoor workplaces and public places, with the percentage reaching 65% for use in schools, hospitals and health care centers. Consequently, there is good societal support in Spain for the politicians and legislators to promote policies restricting e-cigarettes use in workplaces and public places, including hospitality venues.

Support for indoor bans on electronic cigarettes among current and former smokers

OBJECTIVES

Electronic cigarette (e-cigarette) use is increasing in the U.S. Although marketed as a safer alternative for cigarettes, initial evidence suggests that e-cigarettes may pose a secondhand exposure risk. The current study explored the prevalence and correlates of support for e-cigarette bans.

METHODS

A sample of 265 current/former smokers completed a cross-sectional telephone survey from June-September 2014; 45% Black, 31% White, 21% Hispanic. Items assessed support for home and workplace bans for cigarettes and e-cigarettes and associated risk perceptions.

RESULTS

Most participants were aware of e-cigarettes (99%). RESULTS demonstrated less support for complete e-cigarette bans in homes and workplaces compared to cigarettes. Support for complete e-cigarette bans was strongest among older, higher income, married respondents, and former smokers. Complete e-cigarette bans were most strongly endorsed when perceptions of addictiveness and health risks were high. While both e-cigarette lifetime and never-users strongly supported cigarette smoking bans, endorsement for e-cigarette bans varied by lifetime use and intentions to use e-cigarettes.

CONCLUSIONS

Support for indoor e-cigarette bans is relatively low among individuals with a smoking history. Support for e-cigarette bans may change as evidence regarding their use emerges. These findings have implications for public health policy.

Heterogeneous associations between smoking and a wide range of initial presentations of cardiovascular disease in 1937360 people in England: lifetime risks and implications for risk prediction

Background It is not known how smoking affects the initial presentation of a wide range of chronic and acute cardiovascular diseases (CVDs), nor the extent to which associations are heterogeneous. We estimated the lifetime cumulative incidence of 12 CVD presentations, and examined associations with smoking and smoking cessation.

Methods Cohort study of 1.93 million people aged ≥30years, with no history of CVD, in 1997–2010. Individuals were drawn from linked electronic health records in England, covering primary care, hospitalizations, myocardial infarction (MI) registry and cause-specific mortality (the CALIBER programme).

Results During 11.6 million person-years of follow-up, 114 859 people had an initial non-fatal or fatal CVD presentation. By age 90 years, current vs never smokers’ lifetime risks varied from 0.4% vs 0.2% for subarachnoid haemorrhage (SAH), to 8.9% vs 2.6% for peripheral arterial disease (PAD). Current smoking showed no association with cardiac arrest or sudden cardiac death [hazard ratio (HR) = 1.04, 95% confidence interval (CI) 0.91–1.19).The strength of association differed markedly according to disease type: stable angina (HR = 1.08, 95% CI 1.01–1.15),transient ischaemic attack (HR = 1.41, 95% CI 1.28-1.55), unstable angina (HR = 1.54, 95% CI 1.38–1.72), intracerebral haemorrhage (HR = 1.61, 95% CI 1.37–1.89), heart failure (HR = 1.62, 95% CI 1.47–1.79), ischaemic stroke (HR = 1.90, 95% CI 1.72–2.10), MI (HR = 2.32, 95% CI 2.20–2.45), SAH (HR = 2.70, 95% CI 2.27–3.21), PAD (HR = 5.16, 95% CI 4.80–5.54) and abdominal aortic aneurysm (AAA) (HR = 5.18, 95% CI 4.61–5.82). Population-attributable fractions were lower for women than men for unheralded coronary death, ischaemic stroke, PAD and AAA. Ten years after quitting smoking, the risks of PAD, AAA (in men) and unheralded coronary death remained increased (HR = 1.36, 1.47 and 2.74, respectively).

Conclusions The heterogeneous associations of smoking with different CVD presentations suggests different underlying mechanisms and have important implications for research, clinical screening and risk prediction.

National trends in main causes of hospitalization: a multi-cohort register study of the finnish working-age population, 1976-2010

Background

The health transition theory argues that societal changes produce proportional changes in causes of disability and death. The aim of this study was to identify long-term changes in main causes of hospitalization in working-age population within a nation that has experienced considerable societal change.

Methodology

National trends in all-cause hospitalization and hospitalizations for the five main diagnostic categories were investigated in the data obtained from the Finnish Hospital Discharge Register. The seven-cohort sample covered the period from 1976 to 2010 and consisted of 3,769,356 randomly selected Finnish residents, each cohort representing 25% sample of population aged 18 to 64 years.

Principal Findings

Over the period of 35 years, the risk of hospitalization for cardiovascular diseases and respiratory diseases decreased. Hospitalization for musculoskeletal diseases increased whereas mental and behavioral hospitalizations slightly decreased. The risk of cancer hospitalization decreased marginally in men, whereas in women an upward trend was observed.

Conclusions/Significance

A considerable health transition related to hospitalizations and a shift in the utilization of health care services of working-age men and women took place in Finland between 1976 and 2010.

Associations of tobacco control policies with birth outcomes

IMPORTANCE

It is unclear whether the benefits of tobacco control policies extend to pregnant women and infants, especially among racial/ethnic minority and low socioeconomic populations that are at highest risk for adverse birth outcomes.

OBJECTIVE

To examine the associations of state cigarette taxes and the enactment of smoke-free legislation with US birth outcomes according to maternal race/ethnicity and education.

DESIGN, SETTING, AND PARTICIPANTS

Using a quasi-experimental approach, we analyzed repeated cross sections of US natality files with 16,198,654 singleton births from 28 states and Washington, DC, between 2000 and 2010. We first used probit regression to model the associations of 2 tobacco control policies with the probability that a pregnant woman smoked (yes or no). We then used linear or probit regression to estimate the associations of the policies with birth outcomes. We also examined the association of taxes with birth outcomes across maternal race/ethnicity and education.

EXPOSURES

State cigarette taxes and smoke-free restaurant legislation.

MAIN OUTCOMES AND MEASURES

Birth weight (in grams), low birth weight (<2500 g), preterm delivery (<37 weeks), small for gestational age (<10th percentile for gestational age and sex), and large for gestational age (>90th percentile for gestational age and sex).

RESULTS

White and black mothers with the least amount of education (0-11 years) had the highest prevalence of maternal smoking during pregnancy (42.4% and 20.0%, respectively) and the poorest birth outcomes, but the strongest responses to cigarette taxes. Among white mothers with a low level of education, every $1.00 increase in the cigarette tax reduced the level of smoking by 2.4 percentage points (-0.0024 [95% CI, -0.0004 to -0.0001]), and the birth weight of their infants increased by 5.41 g (95% CI, 1.92-8.89 g). Among black mothers with a low level of education, tax increases reduced smoking by 2.1 percentage points (-0.0021 [95% CI, -0.0003 to -0.0001]), and the birth weight of their infants increased by 3.98 g (95% CI, 1.91-6.04 g). Among these mothers, tax increases also reduced the risk of having low-birth-weight, preterm, and small-for-gestational-age babies, but increased the risk of having large-for-gestational-age babies. Associations were weaker among higher-educated black women and largely null among higher educated white women and other groups. We did not find evidence for an association of smoke-free restaurant legislation with birth outcomes.

CONCLUSIONS AND RELEVANCE

Increases in the cigarette tax are associated with improved health outcomes related to smoking among the highest-risk mothers and infants. Considering that US states increase cigarette taxes for reasons other than to improve birth outcomes, these findings are welcome by-products of state policies.

Hospital admissions for acute myocardial infarction before and after implementation of a comprehensive smoke-free policy in Uruguay: experience through 2010

BACKGROUND

Comprehensive smoke-free laws have been followed by drops in hospitalisations for acute myocardial infarction (AMI), including in a study with 2 years follow-up for such a law in Uruguay.

METHODS

Multiple linear and negative binomial regressions for AMI admissions (ICD-10 code 121) from 37 hospitals for 2 years before and 4 years after Uruguay implemented a 100% nationwide smoke-free law.

RESULTS

Based on 11 135 cases, there was a significant drop of -30.9 AMI admissions/month (95% CI -49.8 to -11.8, p=0.002) following implementation of the smoke-free law. The effect of the law did not increase or decrease over time following implementation (p=0.234). This drop represented a 17% drop in AMI admissions following the law (IRR=0.829, 95% CI 0.743 to 0.925, p=0.001).

CONCLUSIONS

Adding two more years of follow-up data confirmed that Uruguay's smoke-free law was followed by a substantial and sustained reduction in AMI hospitalisations.

Tobacco control policies and their impacts. Past, present, and future

The 1964 Surgeon General's report on smoking and health concluded that "Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action." The adoption of remedial actions over the next half century produced what is arguably the most important public health triumph of that period in the United States and in other developed nations. At the heart of the remedial actions were governmental policies. By raising cigarette price, taxation is especially effective at reducing smoking, encouraging some smokers to quit and others to reduce their daily consumption, while also discouraging the initiation of smoking by children. Smoke-free workplace policies have dramatically reduced workers' exposure to the toxins in cigarette smoke, smoking, employers' costs, and the incidence of acute myocardial infarctions. Other policies have also helped diminish the toll of smoking. The successes of tobacco control notwithstanding, future progress will occur slowly unless society finds new, possibly radical "endgame" strategies to hasten the arrival of a smoke-free society.

A review of the evidence on smoking bans and incidence of heart disease

We update an earlier review of smoking bans and heart disease, restricting attention to admissions for acute myocardial infarction. Forty-five studies are considered. New features of our update include consideration of non-linear trends in the underlying rate, a modified trend adjustment method where there are multiple time periods post-ban, comparison of estimates based on changes in rates and numbers of cases, and comparison of effect estimates according to post-ban changes in smoking restrictiveness. Using a consistent approach to derive ban effect estimates, taking account of linear time trends and control data, the reduction in risk following a ban was estimated as 4.2% (95% confidence interval 1.8-6.5%). Excluding regional estimates where national estimates are available, and studies where trend adjustment was not possible, the estimate reduced to 2.6% (1.1-4.0%). Estimates were little affected by non-linear trend adjustment, where possible, or by basing estimates on changes in rates. Ban effect estimates tended to be greater in smaller studies, and studies with greater post-ban changes in smoking restrictiveness. Though the findings suggest a true effect of smoking bans, uncertainties remain, due to the weakness of much of the evidence, the small estimated effect, and various possibilities of bias.

The effect of local policy actions on mortality among homeless people: a before-after study

BACKGROUND

Homeless people have a 3-5-fold increased risk of mortality compared with general populations. After 2005, policy actions being implemented in Rotterdam, the Netherlands, have improved the living conditions of this group. This study examines the effect of policies aimed at improving living conditions on mortality risks of the homeless.

METHODS

Register-based 10-year follow-up study of homeless in Rotterdam, the Netherlands. The participants are homeless adults (aged 18+ years) who visited one or more services for homeless people in Rotterdam in 2001. The intervention of local policies after 2005 was to get homeless people into housing, increase their participation in employment and other regular daytime activities, and controlling drug and alcohol addictions. The main outcome measure is mortality rate ratios calculated using Poisson regression. Differences in mortality between the periods 2001-05 vs. 2006-10 were assessed.

RESULTS

The cohort of homeless adults in 2001 consisted of 1870 men and 260 women, with a mean age of 40.3 years. During the 10 years of follow-up, 265 persons (232 male and 33 female) died. Adjusted for age and sex, no significant difference in mortality was observed between the periods 2001-05 and 2006-10 (P = 0.9683). A different splitting in periods did not change the results.

CONCLUSION

Five years of local policy efforts improved their living conditions, but left the mortality rate of a homeless cohort unchanged. Incomplete reach of the program and long previous histories of homelessness ask for additional policies beyond the provision of housing and other services. Attention to the prevention of homelessness seems needed.

A controlled community-based trial to promote smoke-free policy in rural communities

PURPOSE

Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak tobacco control policies. The purpose was to test the effects of a stage-specific, tailored policy-focused intervention on readiness for smoke-free policy, and policy outcomes in rural underserved communities.

METHODS

A controlled community-based trial including 37 rural counties. Data were collected annually with community advocates (n = 330) and elected officials (n = 158) in 19 intervention counties and 18 comparison counties over 5 years (average response rate = 68%). Intervention communities received policy development strategies from community advisors tailored to their stage of readiness and designed to build capacity, build demand, and translate and disseminate science. Policy outcomes were tracked over 5 years.

FINDINGS

Communities receiving the stage-specific, tailored intervention had higher overall community readiness scores and better policy outcomes than the comparison counties, controlling for county-level smoking rate, population size, and education. Nearly one-third of the intervention counties adopted smoke-free laws covering restaurants, bars, and all workplaces compared to none of the comparison counties.

CONCLUSIONS

The stage-specific, tailored policy-focused intervention acted as a value-added resource to local smoke-free campaigns by promoting readiness for policy, as well as actual policy change in rural communities. Although actual policy change and percent covered by the policies were modest, these areas need additional resources and efforts to build capacity, build demand, and translate and disseminate science in order to accelerate smoke-free policy change and reduce the enormous toll from tobacco in these high-risk communities.

Epidemiology and public health policy of tobacco use and cardiovascular disorders in low- and middle-income countries

All forms of tobacco lead to an increased risk of cardiovascular disorders. During the past few decades, the number of people who consume tobacco has increased worldwide because of an overall increase in the global population. It is estimated that close to 80% of the >1.3 billion people who smoke tobacco in the world are in low- and middle-income countries. Smokeless forms of tobacco are also widely consumed in low- and middle-income countries, including chewable and snuffed forms. Lack of targeted and effective strategies to control tobacco consumption contributes to a large burden of cardiovascular disorders in low- and middle-income countries, where cardiovascular disorders have become the leading cause of morbidity and mortality. In this review, we evaluate the epidemiology of tobacco use in low- and middle-income countries and assess the public health policies needed to control tobacco use in such regions for the prevention of cardiovascular disorders and other tobacco-related morbidities and mortality.

Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis

OBJECTIVE

To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with reductions in smoking related deaths.

DESIGN

Analysis of cross sectional survey data with the smoking attributable mortality, morbidity, and economic costs system; population based time series analysis.

SETTING

All state prisons in the United States.

MAIN OUTCOME MEASURES

Prevalence of smoking from cross sectional survey of inmates in state correctional facilities. Data on state prison tobacco policies from web based searches of state policies and legislation. Deaths and causes of death in US state prisons from the deaths in custody reporting program of the Bureau of Justice Statistics for 2001-11. Smoking attributable mortality and years of potential life lost was assessed from the smoking attributable mortality, morbidity, and economic costs system of the Centers for Disease Control and Prevention. Multivariate Poisson models quantified the association between bans and smoking related cancer, cardiovascular and pulmonary deaths.

RESULTS

The most common causes of deaths related to smoking among people in prison were lung cancer, ischemic heart disease, other heart disease, cerebrovascular disease, and chronic airways obstruction. The age adjusted smoking attributable mortality and years of potential life lost rates were 360 and 5149 per 100,000, respectively; these figures are higher than rates in the general US population (248 and 3501, respectively). The number of states with any smoking ban increased from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking related causes was lower during years with a ban than during years without a ban (110.4/100,000 v 128.9/100,000). Prisons that implemented smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91, 95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence interval 0.74 to 0.90).

CONCLUSIONS

Smoking contributes to substantial mortality in prison, and prison tobacco control policies are associated with reduced mortality. These findings suggest that smoking bans have health benefits for people in prison, despite the limits they impose on individual autonomy and the risks of relapse after release.

Secondhand smoke exposure at home: assessment by biomarkers and airborne markers

OBJECTIVE

We assessed and characterized the relationship among biomarkers of secondhand smoke (SHS) exposure in non-smokers according to their exposure at home as measured by airborne markers.

METHODS

We conducted an observational study on exposure to SHS at home using airborne markers (nicotine and benzene) and biomarkers from the non-smokers living in these homes. We selected 49 non-smoking volunteers from different homes: 25 non-smokers living with at least one smoker and 24 non-smokers living in smoke-free homes. We installed two passive devices to measure nicotine and benzene concentrations in the main room of the house (i.e., the living room). One week later, the researcher returned to the volunteer's home to collect the two devices, obtain saliva and urine samples, and administer a SHS questionnaire.

RESULTS

Salivary and urinary cotinine concentrations highly correlated with air nicotine concentrations measured at the volunteers'homes (rsp=0.738 and rsp=0.679, respectively). The concentrations of airborne markers of SHS and biomarkers in non-smokers increased with increasing self-reported intensity and duration of SHS exposure at home during the previous week (p<0.05). The multivariable regression model showed a significant association with nicotine in air at home (β=0.126, p=0.002 for saliva and β=0.115, p=0.010 for urine).

CONCLUSIONS

Our findings suggest that, even in countries with comprehensive smoke-free legislation, exposure to SHS at home continues to be the main source of exposure for non-smokers who live in non-smoke-free homes. Therefore, public health policies should promote smoke-free homes.

Cardiovascular Events Following Smoke-Free Legislations: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Legislations banning smoking in indoor public places and workplaces are being implemented worldwide to protect the population from secondhand smoke exposure. Several studies have reported reductions in hospitalizations for acute coronary events following the enactment of smoke-free laws.

OBJECTIVE

We set out to conduct a systematic review and meta-analysis of epidemiologic studies examining how legislations that ban smoking in indoor public places impact the risk of acute coronary events.

METHODS

We searched MEDLINE, EMBASE, and relevant bibliographies including previous systematic reviews for studies that evaluated changes in acute coronary events, following implementation of smoke-free legislations. Studies were identified through December 2013. We pooled relative risk (RR) estimates for acute coronary events comparing post- vs. pre-legislation using inverse-variance weighted random-effects models.

RESULTS

Thirty-one studies providing estimates for 47 locations were included. The legislations were implemented between 1991 and 2010. Following the enactment of smoke-free legislations, there was a 12 % reduction in hospitalizations for acute coronary events (pooled RR: 0.88, 95 % CI: 0.85-0.90). Reductions were 14 % in locations that implemented comprehensive legislations compared to an 8 % reduction in locations that only had partial restrictions. In locations with reductions in smoking prevalence post-legislation above the mean (2.1 % reduction) there was a 14 % reduction in events compared to 10 % in locations below the mean. The RRs for acute coronary events associated with enacting smoke-free legislation were 0.87 vs. 0.89 in locations with smoking prevalence pre-legislation above and below the mean (23.1 %), and 0.87 vs. 0.89 in studies from the Americas vs. other regions.

CONCLUSION

The implementation of smoke-free legislations was related to reductions in acute coronary event hospitalizations in most populations evaluated. Benefits are greater in locations with comprehensive legislations and with greater reduction in smoking prevalence post-legislation. These cardiovascular benefits reinforce the urgent need to enact and enforce smoke-free legislations that protect all citizens around the world from exposure to tobacco smoke in public places.

Exposure to secondhand smoke and attitudes toward smoke-free workplaces among employed U.S. adults: findings from the National Adult Tobacco Survey

INTRODUCTION

This study assessed the prevalence and correlates of secondhand smoke (SHS) exposure and attitudes toward smoke-free workplaces among employed U.S. adults.

METHODS

Data came from the 2009-2010 National Adult Tobacco Survey, a landline and cellular telephone survey of adults aged ≥18 years in the United States and the District of Columbia. National and state estimates of past 7-day workplace SHS exposure and attitudes toward indoor and outdoor smoke-free workplaces were assessed among employed adults. National estimates were calculated by sex, age, race/ethnicity, education, annual household income, sexual orientation, U.S. region, and smoking status.

RESULTS

Among employed adults who did not smoke cigarettes, 20.4% reported past 7-day SHS exposure at their workplace (state range: 12.4% [Maine] to 30.8% [Nevada]). Nationally, prevalence of exposure was higher among males, those aged 18-44 years, non-Hispanic Blacks, Hispanics, and non-Hispanic American Indians/Alaska natives compared to non-Hispanic Whites, those with less education and income, those in the western United States, and those with no smoke-free workplace policy. Among all employed adults, 83.8% and 23.2% believed smoking should never be allowed in indoor and outdoor areas of workplaces, respectively.

CONCLUSIONS

One-fifth of employed U.S. adult nonsmokers are exposed to SHS in the workplace, and disparities in exposure exist across states and subpopulations. Most employed adults believe indoor areas of workplaces should be smoke free, and nearly one-quarter believe outdoor areas should be smoke free. Efforts to protect employees from SHS exposure and to educate the public about the dangers of SHS and benefits of smoke-free workplaces could be beneficial.

Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis

BACKGROUND

Smoke-free legislation has the potential to reduce the substantive disease burden associated with second-hand smoke exposure, particularly in children. We investigated the effect of smoke-free legislation on perinatal and child health.

METHODS

We searched 14 online databases from January, 1975 to May, 2013, with no language restrictions, for published studies, and the WHO International Clinical Trials Registry Platform for unpublished studies. Citations and reference lists of articles of interest were screened and an international expert panel was contacted to identify additional studies. We included studies undertaken with designs approved by the Cochrane Effective Practice and Organisation of Care that reported associations between smoking bans in workplaces, public places, or both, and one or more predefined early-life health indicator. The primary outcomes were preterm birth, low birthweight, and hospital attendances for asthma. Effect estimates were pooled with random-effects meta-analysis. This study is registered with PROSPERO, number CRD42013003522.

FINDINGS

We identified 11 eligible studies (published 2008-13), involving more than 2·5 million births and 247,168 asthma exacerbations. All studies used interrupted time-series designs. Five North American studies described local bans and six European studies described national bans. Risk of bias was high for one study, moderate for six studies, and low for four studies. Smoke-free legislation was associated with reductions in preterm birth (four studies, 1,366,862 individuals; -10·4% [95% CI -18·8 to -2·0]; p=0·016) and hospital attendances for asthma (three studies, 225,753 events: -10·1% [95% CI -15·2 to -5·0]; p=0·0001). No significant effect on low birthweight was identified (six studies, >1·9 million individuals: -1·7% [95% CI -5·1 to 1·6]; p=0·31).

INTERPRETATION

Smoke-free legislation is associated with substantial reductions in preterm births and hospital attendance for asthma. Together with the health benefits in adults, this study provides strong support for WHO recommendations to create smoke-free environments.

FUNDING

Thrasher Fund, Lung Foundation Netherlands, International Paediatric Research Foundation, Maastricht University, Commonwealth Fund.

Fewer hospitalizations for chronic obstructive pulmonary disease in communities with smoke-free public policies

OBJECTIVES

We determined the impact of smoke-free municipal public policies on hospitalizations for chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a secondary analysis of hospital discharges with a primary diagnosis of COPD in Kentucky between July 1, 2003, and June 30, 2011 using Poisson regression. We compared the hospitalization rates of regions with and without smoke-free laws, adjusting for personal and population covariates, seasonality, secular trends over time, and geographic region.

RESULTS

Controlling for covariates such as sex, age, length of stay, race/ethnicity, education, income, and urban-rural status, among others, we found that those living in a community with a comprehensive smoke-free law or regulation were 22% less likely to experience hospitalizations for COPD than those living in a community with a moderate-weak law or no law. Those living in a community with an established law were 21% less likely to be hospitalized for COPD than those with newer laws or no laws.

CONCLUSIONS

Strong smoke-free public policies may provide protection against COPD hospitalizations, particularly after 12 months, with the potential to save lives and decrease health care costs.

Acute respiratory and cardiovascular admissions after a public smoking ban in Geneva, Switzerland

Background

Many countries have introduced legislations for public smoking bans to reduce the harmful effects of exposure to tobacco smoke. Smoking bans cause significant reductions in admissions for acute coronary syndromes but their impact on respiratory diseases is unclear. In Geneva, Switzerland, two popular votes led to a stepwise implementation of a state smoking ban in public places, with a temporary suspension. This study evaluated the effect of this smoking ban on hospitalisations for acute respiratory and cardiovascular diseases.

Methods

This before and after intervention study was conducted at the University Hospitals of Geneva, Switzerland, across 4 periods with different smoking legislations. It included 5,345 patients with a first hospitalisation for acute coronary syndrome, ischemic stroke, acute exacerbation of chronic obstructive pulmonary disease, pneumonia and acute asthma. The main outcomes were the incidence rate ratios (IRR) of admissions for each diagnosis after the final ban compared to the pre-ban period and adjusted for age, gender, season, influenza epidemic and secular trend.

Results

Hospitalisations for acute exacerbation of chronic obstructive pulmonary disease significantly decreased over the 4 periods and were lowest after the final ban (IRR = 0.54 [95%CI: 0.42–0.68]). We observed a trend in reduced admissions for acute coronary syndromes (IRR = 0.90 [95%CI: 0.80–1.00]). Admissions for ischemic stroke, asthma and pneumonia did not significantly change.

Conclusions

A legislative smoking ban was followed by a strong decrease in hospitalisations for acute exacerbation of chronic obstructive pulmonary disease and a trend for reduced admissions for acute coronary syndrome. Smoking bans are likely to be very beneficial for patients with chronic obstructive pulmonary disease.

Exposure to parental smoking in childhood or adolescence is associated with increased carotid intima-media thickness in young adults: evidence from the Cardiovascular Risk in Young Finns study and the Childhood Determinants of Adult Health Study

AIM

Recent evidence suggests that the exposure of children to their parents' smoking adversely effects endothelial function in adulthood. We investigated whether the association was also present with carotid intima-media thickness (IMT) up to 25 years later.

METHODS AND RESULTS

The study comprised participants from the Cardiovascular Risk in Young Finns Study (YFS, n = 2401) and the Childhood Determinants of Adult Health (CDAH, n = 1375) study. Exposure to parental smoking (none, one, or both) was assessed at baseline by questionnaire. B-mode ultrasound of the carotid artery determined IMT in adulthood. Linear regression on a pooled dataset accounting for the hierarchical data and potential confounders including age, sex, parental education, participant smoking, education, and adult cardiovascular risk factors was conducted. Carotid IMT in adulthood was greater in those exposed to both parents smoking than in those whose parents did not smoke [adjusted marginal means: 0.647 mm ± 0.022 (mean ± SE) vs. 0.632 mm ± 0.021, P = 0.004]. Having both parents smoke was associated with vascular age 3.3 years greater at follow-up than having neither parent smoke. The effect was independent of participant smoking at baseline and follow-up and other confounders and was uniform across categories of age, sex, adult smoking status, and cohort.

CONCLUSIONS

These results show the pervasive effect of exposure to parental smoking on children's vascular health up to 25 years later. There must be continued efforts to reduce smoking among adults to protect young people and to reduce the burden of cardiovascular disease across the population.

Effect of cardiovascular prevention strategies on incident coronary disease hospitalisation rates in Spain; an ecological time series analysis

OBJECTIVE

To assess the overall population impact of primary prevention strategies (promotion of healthy lifestyles, prevention of smoking and use of vascular risk drug therapy) of coronary disease in Spain.

DESIGN

Ecological time series analysis, 1982-2009.

SETTING

All public and private hospitals in Spain.

PARTICIPANTS

General population.

OUTCOME

Incident coronary disease hospitalisation as derived from official hospital discharge data.

METHODS

Annual hospitalisation rates were modelled according to nationwide use of statins, antihypertensive, antidiabetic and antiplatelet drugs, and prevalences of smoking, obesity and overweight. Additive generalised models and mixed Poisson regression models were used for the purpose, taking year as the random-effect variable and adjusting for age, sex, prevalence of vascular risk factors and the number of hospital beds in intensive and coronary care units.

RESULTS

Across 28 years and 671.5 million person-years of observation, there were 2 986 834 hospitalisations due to coronary disease; of these, 1 441 980 (48.28%) were classified as incident. Hospitalisation rates increased from 1982 to 1996, with an inflection point in 1997 and a subsequent 52% decrease until 2009. Prevalences of smoking, obesity, overweight and use of vascular risk drug therapy were significantly associated with hospitalisation rates (p<0.001): incidence rates ratios (95% CI) for the fourth versus the first quartile were 1.46 (1.42 to 1.50), 1.80 (1.78 to 1.83), 1.58 (1.55 to 1.60) and 0.57 (0.51 to 0.63), respectively. These variables accounted for 92% of interannual variability.

CONCLUSIONS

After decades of continuous rises, hospitalisation due to incident ischaemic heart disease has been cut by half, an achievement associated with the decline in smoking and the increase in vascular risk drug therapy. These results indicate that these two primary prevention strategies have been effective at a population level, thanks to an appropriate balance between financial and health goals, something that should be left intact despite the current economic crisis. Future strategies ought to lay special stress on excessive body weight prevention.

Association of strong smoke-free laws with dentists' advice to quit smoking, 2006-2007

OBJECTIVES

We examined the association of smoke-free laws with dentists' advice to quit smoking and referral to a quit line, among smokers who reported visiting the dentist in the past 12 months.

METHODS

We used the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey merged with the American Nonsmokers' Rights Foundation Local Ordinance Database of smoke-free laws. The dependent variables were advice from a dentist to quit smoking and referral to a quit line, and the independent variable of interest was 100% smoke-free law coverage. We controlled for respondent demographics and an index of state-level smoking ban attitudes (included to ensure that the effect detected was not the result of social attitudes).

RESULTS

Smoke-free law coverage was associated with dental advice to quit smoking (odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.01, 1.59; P = .041), but not with referral to a quit line (OR = 1.33; 95% CI = 0.79, 2.25; P = .283).

CONCLUSIONS

Interventions with dentists are needed to increase referrals to quit lines and other smoking cessation efforts.

The effect of workplace smoking bans on heart rate variability and pulse wave velocity of non-smoking hospitality workers

OBJECTIVES

To investigate the effect of a change in second-hand smoke (SHS) exposure on heart rate variability (HRV) and pulse wave velocity (PWV), this study utilized a quasi-experimental setting when a smoking ban was introduced.

METHODS

HRV, a quantitative marker of autonomic activity of the nervous system, and PWV, a marker of arterial stiffness, were measured in 55 non-smoking hospitality workers before and 3-12 months after a smoking ban and compared to a control group that did not experience an exposure change. SHS exposure was determined with a nicotine-specific badge and expressed as inhaled cigarette equivalents per day (CE/d).

RESULTS

PWV and HRV parameters significantly changed in a dose-dependent manner in the intervention group as compared to the control group. A one CE/d decrease was associated with a 2.3% (95% CI 0.2-4.4; p = 0.031) higher root mean square of successive differences (RMSSD), a 5.7% (95% CI 0.9-10.2; p = 0.02) higher high-frequency component and a 0.72% (95% CI 0.40-1.05; p < 0.001) lower PWV.

CONCLUSIONS

PWV and HRV significantly improved after introducing smoke-free workplaces indicating a decreased cardiovascular risk.

Association between being employed in a smoke-free workplace and living in a smoke-free home: evidence from 15 low and middle income countries

OBJECTIVE

To assess whether being employed in a smoke-free workplace is associated with living in a smoke-free home in 15 low and middle income countries (LMICs).

METHODS

Country-specific individual level analyses of cross-sectional Global Adult Tobacco Survey data (2008-2011) from 15 LMICs was conducted using multiple logistic regression. The dependent variable was living in a smoke-free home; the independent variable was being employed in a smoke-free workplace. Analyses were adjusted for age, gender, residence, region, education, occupation, current smoking, current smokeless tobacco use and number of household members. Individual country results were combined in a random effects meta-analysis.

RESULTS

In each country, the percentage of participants employed in a smoke-free workplace who reported living in a smoke-free home was higher than those employed in a workplace not smoke-free. The adjusted odds ratios (AORs) of living in a smoke-free home among participants employed in a smoke-free workplace (vs. those employed where smoking occurred) were statistically significant in 13 of the 15 countries, ranging from 1.12 [95% CI 0.79-1.58] in Uruguay to 2.29 [1.37-3.83] in China. The pooled AOR was 1.61 [1.46-1.79].

CONCLUSION

In LMICs, employment in a smoke-free workplace is associated with living in a smoke-free home. Accelerated implementation of comprehensive smoke-free policies is likely to result in substantial population health benefits in these settings.

The effect of a statewide smoking ordinance on acute myocardial infarction rates

BACKGROUND

Public smoking ordinances may reduce acute myocardial infarction events. Most studies assessed small communities with reported reductions as high as 40%. No reduction or smaller reductions were found in countrywide studies; less is known about the impact of statewide ordinances. We previously demonstrated identical 27% reductions in acute myocardial infarction hospitalizations in 2 Colorado communities after enactment of strict smoking ordinances. Subsequently, on July 1, 2006, a statewide ordinance went into effect. We sought to determine the impact of this legislation on acute myocardial infarction hospitalization rates.

METHODS

Hospital admissions for a primary acute myocardial infarction diagnosis were examined from 2000 to 2008. Poisson regression models were fit to the monthly events from January 1, 2000, to March 31, 2008. The final model included a quadratic trend over time, harmonic terms, and a post-ordinance effect. The model was adjusted temporally for population changes, using population estimates as an offset variable.

RESULTS

A total of 58,399 unique acute myocardial infarctions were recorded during the study period. No significant reduction in acute myocardial infarction rates was observed post-ordinance (relative risk, 1.059; 95% confidence interval, 0.993-1.131). However, a steep decline in acute myocardial infarction rates was noted from 2000 to 2005 just before enactment. There were 11 strict, local smoking ordinances in effect within Colorado before enactment of the statewide ordinance. After excluding these communities, the findings were similar (relative risk, 1.038; 95% confidence interval, 0.971-1.11).

CONCLUSIONS

Although local smoking ordinances in Colorado previously suggested a reduction in acute myocardial infarction hospitalizations, no significant impact of smoke-free legislation was demonstrated at the state level, even after accounting for preexisting ordinances.

The impact of smoke-free laws on asthma discharges: a multistate analysis

OBJECTIVES

This is the first, to my knowledge, multistate, county-level analysis of Healthcare Cost and Utilization Project state inpatient data to examine the relationship between smoke-free laws and asthma discharges.

METHODS

I used treatment and control groups to examine the effects of state and county or city smoke-free laws separately and together (2002-2009). I compared quarterly county-level discharge rates before and after the implementation of 12 state smoke-free laws, accounting for counties with preexisting county or city smoke-free laws and using the data from 5 states without state smoke-free laws as a control group. I used difference-in-differences models, controlling for year and state fixed effects, state cigarette taxes, seasonality, and numerous county-level factors.

RESULTS

I observed statistically significant reductions in asthma discharges after the implementation of county smoke-free laws but no statistically significant effect of state laws besides the effect of county laws or of state laws alone. There was also no statistically significant effect of any smoke-free law on appendicitis discharges.

CONCLUSIONS

It may be unwise to pursue state smoke-free laws where they have yet to pass; rather, efforts might be better focused at the local level, where there is evidence of a significant impact.

Secondhand smoke exposure among young adult sexual minority bar and nightclub patrons

OBJECTIVES

We compared exposure to secondhand smoke (SHS) and attitudes toward smoke-free bar and nightclub policies among patrons of lesbian, gay, bisexual, and transgender (LGBT) and non-LGBT bars and nightclubs.

METHODS

We conducted randomized time-location sampling surveys of young adults (aged 21-30 years) in 7 LGBT (n = 1113 patrons) and 12 non-LGBT (n = 1068 patrons) venues in Las Vegas, Nevada, in 2011, as part of a cross-sectional study of a social branding intervention to promote a tobacco-free lifestyle and environment in bars and nightclubs.

RESULTS

Compared with non-LGBT bars and nightclubs, patrons of LGBT venues had 38% higher adjusted odds of having been exposed to SHS in a bar or nightclub in the past 7 days but were no less likely to support smoke-free policies and intended to go out at least as frequently if a smoke-free bar and nightclub law was passed.

CONCLUSIONS

The policy environment in LGBT bars and nightclubs appears favorable for the enactment of smoke-free policies, which would protect patrons from SHS and promote a smoke-free social norm.