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

Smoke-free homes, strength of smoke-free law, and children in the home

INTRODUCTION

Secondhand smoke (SHS) is a leading cause of childhood illness and premature death, especially in rural areas. The study examined the relationship of having a smoke-free home, strength of smoke-free law (SFL) in the county of residence, having one or more minor children in the home, rural/urban location, and demographics.

METHODS

An Internet-based panel survey was administered to Kentucky residents from 2007 to 2012. Sample size ranged from 400 to 513 per year; N = 2,653 total. Most were female, aged 35-54, had at least some college education, and lived in a smoke-free home. Almost half lived in a county with a comprehensive SFL; 14% lived in a county with a moderate or weak law.

RESULTS

Multivariate logistic regression revealed that the significant predictors of a smoke-free home included having education beyond high school, being a nonsmoker, living in an urban county, and having a year of participation in the survey. Controlling for smoking status and other personal characteristics, those who responded to the survey in the last 2 years of administration were more likely to have a smoke-free home compared to the reference year of 2007. Respondents living in urban counties were nearly 2 times more likely to report a smoke-free home than rural dwellers.

CONCLUSIONS

Smoke-free homes in urban areas, where SFLs may be the norm, may be more typical than in rural communities. Public awareness campaigns and education about the benefits of smoke-free homes is needed, especially in rural areas, targeting smokers, those with less education, and those with children living in the home.

Brief exposure to secondhand smoke reversibly impairs endothelial vasodilatory function

INTRODUCTION

We sought to determine the effects of brief exposures to low concentrations of tobacco secondhand smoke (SHS) on arterial flow-mediated dilation (FMD, a nitric oxide-dependent measure of vascular endothelial function), in a controlled animal model never before exposed to smoke. In humans, SHS exposure for 30 min impairs FMD. It is important to gain a better understanding of the acute effects of exposure to SHS at low concentrations and for brief periods of time.

METHODS

We measured changes in FMD in rats exposed to a range of real-world levels of SHS for durations of 30 min, 10 min, 1 min, and 4 breaths (roughly 15 s).

RESULTS

We observed a dose-response relationship between SHS particle concentration over 30 min and post-exposure impairment of FMD, which was linear through the range typically encountered in smoky restaurants and then saturated at higher concentrations. One min of exposure to SHS at moderate concentrations was sufficient to impair FMD.

CONCLUSIONS

Brief SHS exposure at real-world levels reversibly impairs FMD. Even 1 min of SHS exposure can cause reduction of endothelial function.

Biomarkers of tobacco smoke exposure and asthma severity in adults

BACKGROUND

Tobacco biomarkers including serum cotinine and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) have been used in research settings.

PURPOSE

The goal of the study was to examine the association of cotinine and NNAL with asthma outcomes in the U.S. adult population.

METHODS

A cross-sectional design was used, using data from the National Health and Nutrition Examination Survey, 2007-2008, with participants aged >20 years with self-reported asthma (N=456). Past-year asthma exacerbations and emergency room/urgent care visits for asthma were examined. Analyses were conducted in 2013.

RESULTS

Among adult asthmatics, 50.3% reported a past-year asthma attack (61.8% smokers, 46.6% nonsmokers, p=0.029). Among these, 24.7% reported a past-year emergency/urgent visit for asthma (34.7% smokers, 20.1% nonsmokers, p=0.034). Median concentrations of cotinine and creatinine-adjusted NNAL (NNAL/Cr) were significantly higher in those with a past-year asthma attack (0.43 ng/mL and 7.28 pg/mL) than in those without (0.06 ng/mL and 2.26 pg/mL), and highest in those with past-year emergency/urgent visits (0.93 ng/mL and 28.14 pg/mL). Among nonsmokers, increasing levels of log cotinine or log NNAL/Cr, adjusted for demographics, were significantly associated with past-year asthma exacerbation (log cotinine OR=1.46 [95% CI=1.1, 1.92]; log NNAL/Cr OR=1.42 [95% CI=1.07, 1.88]) and past-year emergency/urgent visit (log cotinine OR=1.95 [95% CI=1.32, 2.88]; log NNAL/Cr OR=1.58 [95% CI=1.23, 2.02]). Among smokers, increasing biomarker levels were not significantly associated with either outcome.

CONCLUSIONS

In a population-based cross-sectional analysis, increased cotinine and NNAL were found to be associated with asthma exacerbation and healthcare use in nonsmokers with asthma. If these findings are confirmed in prospective studies, these biomarkers might be candidates for clinical indicators of risk of asthma.

Reduction in myocardial infarction admissions in Liverpool after the smoking ban: potential socioeconomic implications for policymaking

OBJECTIVES

To analyse the trends and trend changes in myocardial infraction (MI) and coronary heart disease (CHD) admissions, to investigate the effects of the 2007 smoke-free legislation on these trends, and to consider the policy implications of any findings.

DESIGN SETTING

Liverpool (city), UK.

PARTICIPANTS

Hospital episode statistics data on all 56 995 admissions for CHD in Liverpool between 2004 and 2012 (International Classification of Diseases codes I20-I25 coded as an admission diagnosis within the defined dates).

PRIMARY AND SECONDARY OUTCOME MEASURES

Trend gradient and change points (by trend regressions analysis) in age-standardised MI admissions in Liverpool between 2004 and 2012; by sex and by socioeconomic status. Secondary analysis on CHD admissions.

RESULTS

A significant and sustained reduction was seen in MI admissions in Liverpool beginning within 1 year of the smoking ban. Comparing 2005/2006 and 2010/2011, the age-adjusted rates for MI admissions fell by 42% (39-45%) (41.6% in men and by 42.6% in women). Trend analysis shows that this is significantly greater than the background trend of decreasing admissions. These reductions appeared consistent across all socioeconomic groups. Interestingly, admission rates for total CHD (including mild to severe angina) increased by 10% (8-12%).

CONCLUSIONS

A dramatic reduction in MI admissions in Liverpool has been observed coinciding with the smoking ban in 2007. Furthermore, the benefits were apparent across the socioeconomic spectrum. Health inequalities were not affected and may even have been reduced. The rapid effects observed with this top-down, environmental policy may further increase its value to policymakers.

Environmental determinants of smoking behaviors: The role of policy and environmental interventions in preventing smoking initiation and supporting cessation

Tobacco control strategies have contributed to substantial declines in smoking in the United States. However, smoking still remains the single largest preventable cause of disease and premature deaths in the country. Despite the continuing challenges of implementing tobacco control strategies and the pervasive influence of the tobacco industry to undermine such strategies, there are now unprecedented opportunities to prevent smoking initiation, facilitate cessation, and protect nonsmokers from secondhand smoke. In this paper, we briefly review the most recent literature discussing key strategies that have proven effective in tobacco control including regulations on sales and marketing of tobacco products, taxation, and smoke-free legislation. We focused on these three tobacco control strategies because of their potential to positively influence the environment of both minors and adults regardless of their smoking status. Although research has identified significant individual and social predictors of tobacco use, environmental influences are also important risk factors for tobacco use.

Impact of the Irish smoking ban on sales in bars using a large business-level data set from 1999 to 2007

BACKGROUND

Ireland introduced comprehensive smoke-free workplace legislation in 2004. This study evaluates the economic impact of the workplace smoking ban on the value of sales in bars.

METHODS

Data on the value of bar sales were derived from a large, nationally representative, annual business-level survey from 1999 to 2007. The economic impact of the smoking ban was evaluated according to geographical region and bar size. Analysis was based on an econometric model which controlled for background changes in population income and wealth and for investments made by the bars during this period.

RESULTS

The overall impact of the Irish smoking ban on bar sales appears to be very small. The ban was associated with an increase in sales among medium to large bars in the Border-Midland-West (more rural) region of Ireland, and a small reduction in sales among large bars in the more urban, South-East region. We failed to find any evidence of a change in bar sales in the remaining categories studied.

CONCLUSIONS

The results indicate that although some bars saw positive effects and some negative, the overall impact of the smoking ban on the value of sales in bars was negligible. These findings provide further supporting evidence that comprehensive smoke-free workplace legislation does not harm hospitality businesses while having positive health effects.

Changes in hospitalization rates for acute coronary syndrome after a two-phase comprehensive smoking ban

AIMS

The impact of a comprehensive stepwise smoking ban (2007 and 2008) was assessed by analysing the hospitalization rate for acute coronary syndrome (ACS) in France, between 2003 and 2009.

METHODS AND RESULTS

Between 2003 and 2009, 867,164 hospitalizations for ACS were observed among about 23 million administrative reports. The age-and gender-standardized hospitalization rates were calculated and their variation before and after the smoking ban implementation was investigated by Poisson regression that included the ACS seasonal variations and the historical trend. The hospitalization rate decreased by 12.8% (from 269 to 235/100,000) with a significant historical trend reduction (p < 0.10(-3)) in all groups, but in young women. After adjusting for linear trend, reductions linked to the ban remained not significant in all groups: relative risk (RR) from 0.96 (95% CI 0.91-1.01) in men older than 55 years to 0.99 (95% CI 0.93-1.04) in men aged 55 years or less after the first phase, and from 0.96 (95% CI 0.89-1.04) in men older than 55 years to 1.03 (95% CI 0.94-1.12) in women older than 65 years after the second phase of the ban.

CONCLUSIONS

This study did not demonstrate a significant effect of a two-phases smoking ban on ACS hospitalization rate. A steadily decrease of this rate over the 7-year period, the past preventive measures in France leading to low levels of passive smoking, and the significant increase in active smoking during the studied period may explain this result. Our study highlights the difficulty of proving an effect of smoking bans in a country with an already low ACS incidence.

Changes in ambulance calls after implementation of a smoke-free law and its extension to casinos

BACKGROUND

Casinos are often exempted from legislation mandating smoke-free environments, potentially putting employees and patrons at risk for adverse events triggered by secondhand smoke exposure.

METHODS AND RESULTS

We used an interrupted time series analysis of ambulance calls not originating and originating from casinos in Gilpin County, Colorado, a rural Colorado county with a large casino presence, from January 2000 through December 2012 to determine whether there was a change in ambulance calls originating from casinos when a state smoke-free law was extended to include them. Initial implementation of the smoke-free law (which exempted casinos) was followed by a significant 22.8% drop in ambulance calls (incidence rate ratio, 0.772; 95% confidence interval, 0.685-0.871; P<0.001) from locations other than casinos but no significant change in calls from casinos (P>0.9). The law requiring smoke-free casinos taking effect was followed by a 19.1% (incidence rate ratio, 0.809; 95% confidence interval, 0.724-0.905; P<0.001) drop in ambulance calls from casinos but no change in calls originating outside casinos (P>0.1).

CONCLUSIONS

The observation that ambulance calls not coming from casinos dropped when the smoke-free law was initially implemented (excluding casinos) with no change in calls from casinos, followed by a comparable drop in calls originating from casinos (but not calls from elsewhere) when the law was extended to casinos, suggests that the important effects of secondhand smoke exposure occur acutely. These results also suggest that exempting casinos from smoke-free laws means that more people will suffer medical emergencies.

Israel is failing to protect its citizens from secondhand smoke: underestimating public support

Rather than clearly and unequivocally requiring 100% smokefree workplaces and public places (including restaurants, bars and other entertainment venues), Israeli law contains several elements that parallel the tobacco companies’ “accommodation” program, which is designed to maintain the social acceptability of smoking and protect industry profits. Rather than 100% smokefree workplaces, smoking is permitted in private offices despite the fact that it then wafts throughout the building. Bars and pubs are allowed to set aside a quarter of their space for smokers, as long as it is in a separate room, and this explains the dangerous levels of secondhand smoke air pollution in Israeli bars and pubs. The weaknesses in the current Israeli laws are sending Israeli citizens to the hospital for secondhand smoke-induced heart attacks, asthma and other diseases. The Israeli government needs to catch up with the rest of the developed world and enact and implement a strong smokefree law.

This is a commentary on http://www.ijhpr.org/content/2/1/20/.

A qualitative evaluation of 40 voluntary, smoke-free, multiunit, housing policy campaigns in California

Background

Although it is legal for multiunit housing (MUH) property owners in all 50 states to prohibit smoking on their premises, including in individual units, MUH constitutes a relatively new setting to reduce exposure to secondhand smoke via voluntary smoke-free policy. This paper examines California state-funded smoke-free MUH policy campaigns between 2004 and 2010.

Methods

A cross-case analysis of 40 state-funded smoke-free MUH policy campaigns was conducted via an examination of final evaluation reports submitted to the California Tobacco Control Program.

Results

The most effective voluntary smoke-free MUH policy campaigns typically included: (1) learning the local [MUH] context, (2) finding and using a champion, (3) partnering with like-minded organisations, (4) building relationships with stakeholders, (5) collecting and using local data and (6) making a compelling case to decision makers.

Discussions

The aforementioned steps tended to be intertwined, and successfully securing voluntary smoke-free MUH policy required a strategic but flexible plan of implementation prior to entrance into the field. Campaigns designed to enhance voluntary smoke-free MUH policy adoption should underscore the economic viability of such policies during each strategic step.

The pattern of indoor smoking restriction law transitions, 1970-2009: laws are sticky

OBJECTIVES

We examined the pattern of the passage of smoking laws across venues (government and private workplaces, restaurants, bars) and by strength (no law to 100% smoke-free).

METHODS

We conducted transition analyses of local and state smoking restrictions passed between 1970 and 2009, with data from the Americans for Nonsmokers' Rights Ordinance Database.

RESULTS

Each decade, more laws were enacted, from 18 passed in the 1970s to 3172 in the first decade of this century, when 91% of existing state laws were passed. Most laws passed took states and localities from no law to some level of smoking restriction, and most new local (77%; 5148/6648) and state (73%; 115/158) laws passed in the study period did not change strength.

CONCLUSIONS

Because these laws are "sticky"-once a law has passed, strength of the law and venues covered do not change often-policymakers and advocates should focus on passing strong laws the first time, rather than settling for less comprehensive laws with the hope of improving them in the future.

Epidemiology of acute coronary syndromes in Spain: estimation of the number of cases and trends from 2005 to 2049

Acute coronary syndromes are a leading cause of mortality, morbidity, and health care cost in Spain. The aims of this report are to estimate the number of acute coronary syndromes cases in the Spanish population in 2013 and 2021, and the trend from 2005 to 2049. We estimated the number of acute coronary syndromes cases by sex and Spanish autonomous community using data from the most updated population and hospital registries. We present the estimated number of cases with an exact 95% confidence interval, assuming that the number of cases followed a Poisson distribution. There will be 115,752 acute coronary syndromes cases in Spain in 2013 (95% confidence interval, 114,822-116,687). Within 28 days, 39,086 of these patients will die and 85,326 will be hospitalized. Non-ST segment elevation acute coronary syndromes (56%) and acute myocardial infarction (81%) will be the most common admission and discharge diagnoses, respectively. We estimate approximately 109,772 acute coronary syndromes cases in 2021 (95% confidence interval, 108,868-110,635). The trend of acute coronary syndromes cases from 2005 to 2049 will stabilize in the population aged 25 to 74 years, but increase in those older than 74 years. Due to population aging, the number of acute coronary syndrome cases will increase overall until 2049, it may stabilize in the population aged <75 years. The acute coronary syndromes case-fatality has decreased in hospitalized patients but the proportion of sudden deaths remains unchanged.

Reductions in cardiovascular, cerebrovascular, and respiratory mortality following the national irish smoking ban: interrupted time-series analysis

Background

Previous studies have shown decreases in cardiovascular mortality following the implementation of comprehensive smoking bans. It is not known whether cerebrovascular or respiratory mortality decreases post-ban. On March 29, 2004, the Republic of Ireland became the first country in the world to implement a national workplace smoking ban. The aim of this study was to assess the effect of this policy on all-cause and cause-specific, non-trauma mortality.

Methods

A time-series epidemiologic assessment was conducted, utilizing Poisson regression to examine weekly age and gender-standardized rates for 215,878 non-trauma deaths in the Irish population, ages ≥35 years. The study period was from January 1, 2000, to December 31, 2007, with a post-ban follow-up of 3.75 years. All models were adjusted for time trend, season, influenza, and smoking prevalence.

Results

Following ban implementation, an immediate 13% decrease in all-cause mortality (RR: 0.87; 95% CI: 0.76–0.99), a 26% reduction in ischemic heart disease (IHD) (RR: 0.74; 95% CI: 0.63–0.88), a 32% reduction in stroke (RR: 0.68; 95% CI: 0.54–0.85), and a 38% reduction in chronic obstructive pulmonary disease (COPD) (RR: 0.62; 95% CI: 0.46–0.83) mortality was observed. Post-ban reductions in IHD, stroke, and COPD mortalities were seen in ages ≥65 years, but not in ages 35–64 years. COPD mortality reductions were found only in females (RR: 0.47; 95% CI: 0.32–0.70). Post-ban annual trend reductions were not detected for any smoking-related causes of death. Unadjusted estimates indicate that 3,726 (95% CI: 2,305–4,629) smoking-related deaths were likely prevented post-ban. Mortality decreases were primarily due to reductions in passive smoking.

Conclusions

The national Irish smoking ban was associated with immediate reductions in early mortality. Importantly, post-ban risk differences did not change with a longer follow-up period. This study corroborates previous evidence for cardiovascular causes, and is the first to demonstrate reductions in cerebrovascular and respiratory causes.

Strong smoke-free law coverage in the United States by race/ethnicity: 2000-2009

OBJECTIVES

We determined whether racial/ethnic disparities existed in coverage by type of 100% smoke-free private workplace, restaurant, and bar laws from 2000 to 2009.

METHODS

We combined US census population data and the American Nonsmokers' Rights Foundation US Tobacco Control Database to calculate the percentage of individuals in counties covered by each type of law by race/ethnicity from 2000 to 2009.

RESULTS

More of the US Hispanic and Asian populations were covered by 100% smoke-free restaurant and bar laws than non-Hispanic White and non-Hispanic Black populations. Asian coverage by smoke-free bars laws increased from 36% to 75%, and Hispanic coverage increased from 31% to 62%, compared with 6% to 41% for non-Hispanic Blacks and 8% to 49% for non-Hispanic Whites.

CONCLUSIONS

Hispanics and Asians benefited more from the rapid spread of smoke-free law coverage, whereas non-Hispanic Blacks benefited less. These ethnic disparities suggest a likely effect of geographic region and may provide a basis for more effective, community-based, and tailored policy-related interventions, particularly regarding areas with high concentrations of non-Hispanic Blacks.

The effect of the California tobacco control program on smoking prevalence, cigarette consumption, and healthcare costs: 1989-2008

BACKGROUND

Previous research has shown that tobacco control funding in California has reduced per capita cigarette consumption and per capita healthcare expenditures. This paper refines our earlier model by estimating the effect of California tobacco control funding on current smoking prevalence and cigarette consumption per smoker and the effect of prevalence and consumption on per capita healthcare expenditures. The results are used to calculate new estimates of the effect of the California Tobacco Program.

METHODOLOGY/PRINCIPAL FINDINGS

Using state-specific aggregate data, current smoking prevalence and cigarette consumption per smoker are modeled as functions of cumulative California and control states' per capita tobacco control funding, cigarette price, and per capita income. Per capita healthcare expenditures are modeled as a function of prevalence of current smoking, cigarette consumption per smoker, and per capita income. One additional dollar of cumulative per capita tobacco control funding is associated with reduction in current smoking prevalence of 0.0497 (SE.00347) percentage points and current smoker cigarette consumption of 1.39 (SE.132) packs per smoker per year. Reductions of one percentage point in current smoking prevalence and one pack smoked per smoker are associated with $35.4 (SE $9.85) and $3.14 (SE.786) reductions in per capita healthcare expenditure, respectively (2010 dollars), using the National Income and Product Accounts (NIPA) measure of healthcare spending.

CONCLUSIONS/SIGNIFICANCE

Between FY 1989 and 2008 the California Tobacco Program cost $2.4 billion and led to cumulative NIPA healthcare expenditure savings of $134 (SE $30.5) billion.

Impact of a partial smoke-free legislation on myocardial infarction incidence, mortality and case-fatality in a population-based registry: the REGICOR Study

BACKGROUND AND OBJECTIVE

Coronary heart disease (CHD) is the leading cause of death, and smoking its strongest modifiable risk factor. Our aim was to determine the impact of the Spanish 2006 partial smoke-free legislation on acute myocardial infarction (AMI) incidence, hospitalization and mortality rates, and 28-day case-fatality in Girona, Spain.

METHODS

Using a population-based registry (the REGICOR Study), we compared population incidence, hospitalization, and mortality rates, and 28-day case-fatality in the pre- and post-ban periods (2002-2005 and 2006-2008, respectively) by binomial regression analysis adjusted for confounding factors. We also analyzed the ban's impact on the outcomes of interest using the AMI definitions of the American Heart Association (AHA)/European Society of Cardiology (ESC) and the World Health Organization (WHO)-Monitoring trends and determinants in cardiovascular diseases (MONICA).

RESULTS

In the post-ban period, AMI incidence and mortality rates significantly decreased (relative risk [RR] = 0.89; 95% confidence interval [CI] = 0.81-0.97 and RR = 0.82; 95% CI = 0.71-0.94, respectively). Incidence and mortality rates decreased in both sexes, especially in women, and in people aged 65-74 years. Former and non-smokers (passive smokers) showed diminished incidence rates. Implementation of the ban was not associated with AMI case-fatality. Models tended to be more significant with the WHO-MONICA than with the AHA/ESC definition.

CONCLUSIONS

The 2006 Spanish partial smoke-free legislation was associated with a decrease in population AMI incidence and mortality, particularly in women, in people aged 65-74 years, and in passive smokers. These results clarify the association between AMI mortality and the enactment of a partial smoke-free legislation and reinforce the effectiveness of smoking regulations in preventing CHD.

A randomized, controlled community-wide intervention to reduce environmental tobacco smoke exposure

INTRODUCTION

Tobacco use in low- to middle-income countries is a major public health concern for both smokers and those exposed to environmental tobacco smoke (ETS). Egypt has made important strides in controlling tobacco use, but smoking and ETS remain highly prevalent. This randomized intervention sought to improve the target population's knowledge regarding the hazards of smoking and ETS and to change attitudes and smoking behaviors within the community and the household.

METHODS

In this 2005-2006 study in Egypt's Qalyubia governorate, trained professionals visited schools, households, mosques, and health care centers in rural villages randomly selected for the intervention to discuss the adverse effects of smoking and ETS exposure and ways to reduce one's ETS exposure. Data collected in interviewer-facilitated surveys before and after the intervention period were analyzed in pairwise comparisons with data from control villages to assess the effectiveness of the intervention in achieving its aims.

RESULTS

The intervention group showed a greater increase in understanding the dangers associated with smoking cigarettes and waterpipes and became more proactive in limiting ETS exposure by asking smokers to stop, avoiding areas with ETS, and enacting smoking bans in the home. However, the intervention had little to no impact on the number of smokers and the amount of tobacco smoked.

CONCLUSIONS

Results are consistent with previous studies showing that changing smokers' behavior can be difficult, but community-wide efforts to reduce ETS exposure through smoking bans, education, and empowering people to ask smokers to stop are effective. The method can be generalized to other settings.

The effect of tobacco control measures during a period of rising cardiovascular disease risk in India: a mathematical model of myocardial infarction and stroke

BACKGROUND

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.

METHODS AND FINDINGS

A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%-34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.

CONCLUSIONS

Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.