Longitudinal Associations of Smoke-Free Policies and Incident Cardiovascular Disease: CARDIA Study

Evaluation of Federally Mandated Smoke-Free Housing Policy and Health Outcomes Among Adults Over the Age of 50 in Low-Income, Public Housing in New York City, 2015-2022

INTRODUCTION

Effective July 2018, the U.S. Department of Housing and Urban Development issued a rule requiring all public housing authorities to implement smoke-free housing (SFH) policies in their developments. We examined the differential impacts of SFH policy on hospitalizations for myocardial infarction (MI) and stroke among adults aged ≥50 years old living in New York City (NYC) Housing Authority (NYCHA) versus a matched-comparison population in NYC.

AIMS AND METHODS

We identified census block groups (CBGs) comprised solely of 100% NYCHA units (N = 160) and compared NYCHA CBGs to a selected subset of CBGs from all CBGs with no NYCHA units (N = 5646). We employed propensity score matching on distributions of key CBG-level sociodemographic and housing covariates. We constructed incident rates per 1000 persons by aggregating 3-month "quarterly" counts of New York State all-payer hospitalization data from October 2015 to December 2022 and dividing by the population aged ≥50 in selected CBGs, ascertained from 2016 American Community Survey 5-year estimates. We selected a difference-in-differences (DID) analytic approach to examine pre- and post-policy differences in incident hospitalizations between the intervention and matched-comparison groups.

RESULTS

Matching results indicated a balanced match for all covariates, with standardized mean differences <0.10. In DID analyses, we observed small declines in both MI (DID = -0.26, p = .02) and stroke (DID = -0.28, p = .06) hospitalization rates for NYCHA CBGs compared to non-NYCHA CBGs from pre-to post-54 months' policy.

CONCLUSIONS

SFH policies in NYC were associated with small reductions in CVD-related hospitalizations among older adults living in housing subject to the policy.

IMPLICATIONS

Housing remains a key focal setting for interventions to reduce SHS exposure and associated morbidities. Ongoing monitoring is warranted to understand the long-term impacts of SFH policies in public housing developments.

Global trends in the burden of ischemic heart disease attributable to smoking from 1990 to 2021: A systematic analysis of the Global Burden of Disease Study 2021

INTRODUCTION

Ischemic heart disease (IHD) remains a leading cause of death and disability worldwide. This study evaluates the trends in IHD burden attributable to smoking, utilizing Global Burden of Disease Study 2021 (GBD 2021) data, across 204 countries and territories from 1990 to 2021. By examining age-standardized death rates (ASDR) and disability-adjusted life years (ASRDALYs), the study provides insights into the spatiotemporal variations associated with smokingattributable IHD in different sociodemographic regions.

METHODS

Data on smoking-attributable IHD mortality and DALYs were obtained from the GBD 2021 database. This secondary analysis examined ASDR and ASRDALYs for IHD as primary outcomes, with active smoking as the primary exposure. Temporal trends were analyzed using estimated annual percentage changes (EAPCs). The burden was stratified by age, sex, and sociodemographic index (SDI) to identify disparities across regions.

RESULTS

Over the last three decades, global ASDR and ASRDALYs for smokingrelated IHD have generally declined. High-SDI regions had the largest reductions, with EAPCs of -4.31 (95% CI: -5.73 - -2.87) and -4.02 (95% CI: -5.40 - -2.62), respectively. In contrast, low-SDI regions experienced slower declines, with EAPCs of -0.54 (95% CI: -1.41-0.33) and -0.80 (95% CI: -1.52 - -0.08), respectively. Older age groups and males consistently had a higher burden across all regions. Global death rates for populations aged 15-49, 50-74, and ≥75 years were 4.31, 46.57, and 142.52 per 100000, respectively. The global ASDR for males (30.24) was 8.54 times higher than that for females (3.54). Regional disparities were most pronounced in low- and middle-income areas, particularly in Eastern Europe and Central Asia, where smoking related IHD burden remains high.

CONCLUSIONS

While global reductions in smoking-related IHD burden are encouraging, sustained disparities remain, particularly in low-SDI regions. Males and older populations continue to have a disproportionately higher burden, emphasizing the need for targeted interventions and sustained efforts to address these inequities.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Impact of Total Indoor Smoking Ban on Cardiovascular Disease Hospitalizations and Mortality: The Case of Chile

INTRODUCTION

The harmful effects of first and secondhand smoking are well-established. Smoke-free laws aim at protecting nonsmokers. This study aimed to assess the impact of the 2013 total ban on indoor smoking in Chile on hospitalizations and deaths of major cardiovascular events.

AIMS AND METHODS

The logarithm of the monthly hospitalization and death rates, standardized by age for every 100 000 inhabitants, were estimated for ischemic heart disease, acute myocardial infarction, strokes, and a composite outcome of ischemic heart diseases (which includes acute myocardial infarction) and strokes. In addition, interrupted time series with synthetic control groups were used to assess changes in levels and trends after the intervention.

RESULTS

The total ban on indoor smoking caused significant reductions in death rates for the three diseases studied for age groups above 20 years old. In addition, there were substantial decreases in the post-intervention hospitalization rates for ischemic heart disease: for the 20-44 age group, the decrease was 8.7% compared to the pre-intervention period (p < .01). In comparison, such a reduction was 4% (p < .01) for the ≥65 age group. For acute myocardial infarction, the decrease was 11.5% (p < .01) for the 20-44 age group, while for stroke, it was a 1.2% (p < .01) decrease for the total population. It is estimated that the smoking ban averted 15.6% of the deaths compared with the synthetic control groups.

CONCLUSIONS

The implementation of total smoke-free environments in Chile contributed to the reduction of mortality for main cardiovascular diseases. This study provides additional evidence of causality linking the policy to health outcomes.

IMPLICATIONS

The total indoor smoking ban significantly affected age-standardized hospitalization and deaths. The number of deaths averted by this policy is estimated at approximately 4758 and 5256 for IHD and stroke, respectively, during the 2013-2017 period (15.6% fewer deaths than predicted by the synthetic control groups). The study contributes to the body of evidence that supports total indoor smoking bans.

Global trends in deaths and disability-adjusted life years of diabetes attributable to second-hand smoke and the association with smoke-free policies

OBJECTIVES

The diabetic burden attributable to second-hand smoke (SHS) is a global public health challenge. We sought to explore the diabetic burden attributable to SHS by age, sex, and socioeconomic status during 1990-2019 and to evaluate the health benefit of smoke-free policies on this burden.

STUDY DESIGN

Cross-sectional study.

METHODS

The diabetic burden attributable to SHS was extracted from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 dataset. Country-level smoke-free policies were obtained from the World Health Organization Global Health Observatory. The deaths or disability-adjusted life years (DALYs) were quantified, and the average annual percentage changes were calculated. Hierarchical linear mixed models were applied to evaluate the health effects.

RESULTS

From 1990 to 2019, the absolute number of global deaths and DALYs of diabetes attributable to SHS has doubled, and the age-standardised rate has significantly increased. The disease burden was higher in females than in males and increased with increasing age. The SHS-related diabetic burden varied across regions and countries. Age-standardised death or DALY rates first increased and then decreased with increased Socio-demographic Index (SDI), peaking in the 0.60-0.70 range. In low to low-middle, and middle to high-middle SDI countries, SHS-related diabetic deaths and DALYs were significantly lower in countries with more than 3 smoke-free public places than in countries with 0-2 smoke-free public places.

CONCLUSIONS

More attention should be paid to females and the elderly, who bear a heavy SHS-related diabetic burden. Banning smoking in public places was associated with reduced burden of SHS-attributable diabetes, especially in low to middle social development countries.

Smoking and outcomes following personalized antiplatelet therapy in chronic coronary syndrome patients: A substudy from the randomized PATH-PCI trial

BACKGROUND

This is a sub-analysis of the Personalized Antithrombotic Therapy for Coronary Heart Disease after PCI (PATH-PCI) trial in China to explore the relationship between smoking and outcomes following personalized antiplatelet therapy (PAT) in chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI).

METHODS

As a single-center, prospective, randomized controlled and open-label trial, the PATH-PCI trial randomized CCS patients undergoing PCI into standard group or personalized group guided by a novel platelet function test (PFT), from December 2016 to February 2018. All patients were divided into smokers and nonsmokers according to their smoking status. Subsequently, we underwent a 180-day follow-up evaluation. The primary endpoint was the net adverse clinical events (NACE).

RESULTS

Regardless of smoking status, in the incidence of NACE, there was a reduction with PAT but that the reductions are not statistically significant. In the incidence of bleeding events, we found no statistically significant difference between two groups (smokers: 2.0% vs. 1.4%, HR = 1.455, 95% confidence interval [CI]: 0.595-3.559, p = .412; nonsmokers: 2.2% vs. 1.8%, HR = 1.228, 95% CI: 0.530-2.842, p = .632). In smokers, PAT reduced major adverse cardiac and cerebrovascular events (MACCE) by 48.7% (3.0% vs. 5.9%, HR = 0.513, 95% CI: 0.290-0.908, p = .022), compared with standard antiplatelet therapy (SAT). PAT also reduced the major adverse cardiovascular events (MACE) but there was no statistically difference in the reductions (p > .05). In nonsmokers, PAT reduced MACCE and MACE by 51.5% (3.3% vs. 6.7%, HR = 0.485, 95% CI: 0.277-0.849, p = .011) and 63.5% (1.8% vs. 4.9%, HR = 0.365, 95% CI: 0.178-0.752, p = .006), respectively. When testing p-values for interaction, we found there was no significant interaction of smoking status with treatment effects of PAT (pint-NACE  = .184, pint-bleeding  = .660).

CONCLUSION

Regardless of smoking, PAT reduced the MACE and MACCE, with no significant difference in bleeding. This suggests that PAT was an recommendable regimen to CCS patients after PCI, taking into consideration both ischemic and bleeding risk.

Obstructive Sleep Apnea and Smoking Increase the Risk of Cardiovascular Disease: Smoking Cessation Pharmacotherapy

Tobacco smoking has been a recognized risk factor for cardiovascular diseases (CVD). Smoking is a chronic relapsing disease and pharmacotherapy is a main component of smoking cessation. Obstructive sleep apnea (OSA) and smoking both increase the risk of CVD and are associated with significant morbidity and mortality. There are few existing data examining how pharmacological treatment, such as nicotine replacement therapy (NRT), bupropion, and varenicline, affect smokers suffering with OSA and especially their cardiovascular effects. The aim of this review was to evaluate the effects of smoking cessation pharmacotherapy on OSA with a special emphasis on the cardiovascular system. Results: Only small studies have assessed the effect of NRTs on OSA. Nicotine gum administration showed an improvement in respiratory events but with no permanent results. No specific studies were found on the effect of bupropion on OSA, and a limited number evaluated varenicline's effects on sleep and specifically OSA. Varenicline administration in smokers suffering from OSA reduced the obstructive respiratory events, especially during REM. Studies on second-line medication (nortriptyline, clonidine, cytisine) are even more limited. There are still no studies evaluating the cardiovascular effects of smoking cessation medications on OSA patients. Conclusions: Sleep disturbances are common withdrawal effects during smoking cessation but could be also attributed to pharmacotherapy. Smokers should receive personalized treatment during their quitting attempts according to their individual needs and problems, including OSA. Future studies are needed in order to evaluate the efficacy and safety of smoking cessation medications in OSA patients.

Measures of MRI Brain Biomarkers in Middle Age According to Average Modified Mediterranean Diet Scores Throughout Young and Middle Adulthood

BACKGROUND

The Mediterranean diet (MedDiet) has been linked with better cognitive function and brain integrity.

OBJECTIVE

To examine the association of modified Mediterranean diet (mMedDiet) scores from early through middle adulthood in relation to volumetric and microstructural midlife MRI brain measures. Assess the association of mMedDiet and brain measures with four cognitive domains. If variables are correlated, determine if brain measures mediate the relationship between mMedDiet and cognition.

METHODS

618 participants (mean age 25.4±3.5 at year 0) of the Coronary Artery Risk Development in Young Adults (CARDIA) study were included. Cumulative average mMedDiet scores were calculated by averaging scores from years 0, 7, and 20. MRI scans were obtained at years 25 and 30. General linear models were used to examine the association between mMedDiet and brain measures.

RESULTS

Higher cumulative average mMedDiet scores were associated with better microstructural white matter (WM) integrity measured by fractional anisotropy (FA) at years 25 and 30 (all ptrend <0.05). Higher mMedDiet scores at year 7 were associated with higher WM FA at year 25 (β= 0.003, ptrend = 0.03). Higher mMedDiet scores at year 20 associated with higher WM FA at years 25 (β= 0.0005, ptrend = 0.002) and 30 (β= 0.0003, ptrend = 0.02). mMedDiet scores were not associated with brain volumes. Higher mMedDiet scores and WM FA were both correlated with better executive function, processing speed, and global cognition (all ptrend <0.05). WM FA did not mediate the association between mMedDiet scores and cognition.

CONCLUSIONS

mMedDiet scores may be associated with microstructural WM integrity at midlife.

Effect of a two-phase tobacco control regulation on incidence from ischemic stroke and hemorrhagic stroke, Shenzhen, China, 2007-2016

INTRODUCTION

The Shenzhen government is widely considered to be most efficiently implementing smoke-free legislation in China. We evaluated and compared the impact of Shenzhen's two-phase smoke-free regulation on the incidence rates for ischemic and hemorrhagic stroke.

METHODS

An interrupted time series design was used to capture immediate and annual incidence changes from 2007 to 2016 for both ischemic and hemorrhagic stroke due to two-phase smoke-free regulation in Shenzhen, China, by using a generalized additive model. The first phase, implemented on 9 March 2010, required five main public places to be smoke-free. In the second phase, the comprehensive law was expanded to the whole city on 1 March 2014.

RESULTS

The regulation implementation during phase I was associated with a strong immediate decline in the incidence rate of ischemic stroke (-14.2%, 95% CI: -19.6 - -8.4) and hemorrhagic stroke (-10.1%, 95% CI: -18.2 - -1.2), but without showing the annual changes (p>0.05). Following the implementation of the comprehensive law, the gradual annual effect showed a significant change in ischemic stroke, with a 6.3% (95% CI: 8.9 - -3.6) reduction. Neither the immediate nor gradual decreases in hemorrhagic stroke incidences associated with the comprehensive regulation were statistically significant during phase II (p>0.05). Subgroup analyses indicate that a much larger health effect of the regulation during phase I was greater among those aged ≥65 years than among those aged 35-64 years.

CONCLUSIONS

Shenzhen's two-phase smoke-free regulation was well implemented. Even though the regulation did not extend to the whole city, the immediate health benefits on the incidence rates of ischemic stroke and hemorrhagic stroke could be seen. However, the health benefits brought by the implementation of comprehensive smoke-free legislation were attenuated by previous smoke-free regulations in five main public places, which were more evident in hemorrhagic stroke.

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

US State Policy Contexts and Population Health

Policy Points This Perspective connects the dots between the polarization in US states' policy contexts and the divergence in population health across states. Key interlocking forces that fueled this polarization are the political investments of wealthy individuals and organizations and the nationalization of US political parties. Key policy priorities for the next decade include ensuring all Americans have opportunities for economic security, deterring behaviors that kill or injure hundreds of thousands of Americans each year, and protecting voting rights and democratic functioning.

Smoke-Free Policies and 30-Day Mortality Rates for Chronic Obstructive Pulmonary Disease

BACKGROUND

Smoke-free policies have been shown to impact 30-day readmission rates due to chronic obstructive pulmonary disease (COPD) among adults aged ≥65 years. However, little is known about the association between smokefree policies and 30-day mortality rates for COPD. Therefore, we investigated the association between comprehensive smoke-free policies and 30-day mortality rates for COPD.

METHODS

We used a cross-sectional study design and retrospectively examined risk-adjusted 30-day mortality rates for COPD across US hospitals in 1171 counties. Data were sourced from Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) Program, American Hospital Association (AHA) Annual Surveys, US Census Bureau Current Population Survey, and US Tobacco Control Laws Database from the American Nonsmokers' Rights Foundation (ANRF). Data were averaged at the county level for years 2015-2018. Hierarchical Poisson models adjusted for differences in hospital characteristics and accounted for the clustering of hospitals within a county were used.

RESULTS

Our findings show a consistent association between stronger smoke-free policies and a reduction in COPD mortality. When evaluating smoke-free policy, county characteristics, and hospital characteristics individually, we found that counties with full coverage or partial coverage had a reduced incidence rate of COPD mortality compared to no coverage counties. After adjusting for the county and hospital characteristics, counties with full coverage of smoke-free policies had a reduced rate of 30-day COPD mortality (adjusted incidence rate ratio [IRR]: 0.87, 95% CI: 0.79, 0.96) compared to counties with no policy coverage.

CONCLUSION

Comprehensive smoke-free policies are associated with a reduction in 30-day mortality following hospital admission for COPD. Partial smoke-free legislation is an insufficient preventative measure. These findings have strong implications for hospital policy-makers, suggesting that policy interventions to reduce COPD-related 30-day mortality should include implementing smoke-free policies and public health policy-makers to incentivize comprehensive smokefree policies.

Effects of public policies in the prevention of cardiovascular diseases: a systematic review of global literature

OBJECTIVES

Given the growing interest worldwide in applying public policies to improve human health, we undertook a systematic review of studies investigating whether public policies targeting unhealthy products could reduce cardiovascular diseases.

STUDY DESIGN

This study was a systematic review of the literature.

METHODS

We searched research studies published in 2000-2020 from major databases, including MEDLINE and Embase. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and narratively synthesized the studies based on vote counting and direction of the intervention effect.

RESULTS

Ninety-eight studies, mostly from high-income countries, met the inclusion criteria. Most studies were on public policies targeting sugar-sweetened beverages and tobacco, followed by alcohol, sugar, salt, and junk foods. Overall, many reported that several fiscal, regulatory, and educational policies generated beneficial effects of reducing the diseases. Those studies that reported no or limited effects highlighted several sociodemographic and health risk characteristics and design and implementation aspects of the policy interventions as factors limiting the policy effects; most of these are modifiable with appropriate policy interventions. For instance, low magnitude of tax, substitution with other unhealthy products, firms' competitive response strategies, pre-existence of smoking bans, incremental enactment of smoking regulations, degree of enforcement, and various sociocultural factors minimized the effects of the policies.

CONCLUSION

The literature supports a growing consensus on the beneficial effects of public policy for improving human health. The design and implementation of public policies must address various impeding factors and incorporate appropriate remedial measures. Further research is needed from low- and middle-income countries and on whether and how multiple policy instruments work in tandem.

Pan-risk factor for a comprehensive cardiovascular health management

Cardiovascular diseases (CVDs) have become the leading cause of death in China. CVDs are mainly caused by multiple well-known modifiable risk factors that are affected by socioeconomic and environmental determinants, lifestyle and behavioral choices, and familial and genetic predispositions. With more risk factors proved to be associated with CVD occurrence, the concept "pan-risk factor" is proposed in this review to indicate all discovered and yet-to-be-discovered CVD risk factors for comprehensive primary prevention of CVD. Recognizing more factors and their roles in CVD development and progression is the first step in reducing the ever-increasing burden of CVD. This review is an overview of the pan-risk factor whose associations with CVD outcomes have been established. Along with the accumulation of scientific evidence, an increasing number of risk factors will be discovered and included in the list of pan-risk factors.

Association between Inclusion of E-Cigarettes in Statewide Comprehensive Smoke-Free Indoor Air Laws and Vaping Behaviors: Results from a Longitudinal Population Study

Several states have included e-cigarettes in their comprehensive smoke-free indoor air laws (i.e., aerosol-free policies), prohibiting the use of e-cigarettes--in addition to combustible tobacco products--in workplaces, restaurants, and bars. However, whether these policies contribute to reductions in e-cigarette use remains largely unknown. This study utilized a nationally representative longitudinal sample to examine the association between the implementation of statewide aerosol-free policies and e-cigarette use behaviors. Methods: This longitudinal retrospective study implemented a quasi-experimental design. Waves 1-4 (2013-2018) restricted-use data from adult participants (weighted N = 22,838,787; unweighted N = 8,663) in the Population Assessment of Tobacco and Health (PATH) study were analyzed. The generalized difference-in-difference approach along with weighted hurdle and multinomial logistic regressions were conducted to examine the associations between aerosol-free policies and three measures of e-cigarette use (past 30-day e-cigarette abstinence status and number of use days, and past-12-month use frequency) pre- and post-policy implementation. Results indicated there were not statistically significant differences in e-cigarette use behaviors between participants living in states with and without the aerosol-free policies (ps ranged from 0.301 to 0.831), considering pre- and post-policy implementation. Findings indicated that the effectiveness of the aerosol-free policies on e-cigarette use behaviors was not supported by longitudinal national data. States that have implemented aerosol-free policies should make pertinent efforts to enhance the awareness of these policies and to strengthen their enforcement. Future investigation into e-cigarette use in places where it is prohibited and implications with regard to effectiveness of aerosol-free policies is warranted.

Correlation Between Neutrophil to Lymphocyte Ratio and Myocardial Injury in Population Exposed to High Altitude

Objective: Myocardial injury is a severe complication in population exposed to high altitude. As a new biomarker for inflammatory response, neutrophil to lymphocyte ratio (NLR) has been widely used to predict the prognosis of various diseases. In this study, we intend to explore the risk factors for myocardial injury at high altitude and examine the relationship between NLR level and development of myocardial injury.

Methods: Consecutive patients admitted to a secondary general hospital at high altitude from June 2019 to May 2020 were selected into this retrospective study. Clinical and biochemical data were collected. According to the results of lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzymes (CK-MB), and aspartate amino transferase (AST), patients were divided into myocardial injury group and normal group.

Results: A total of 476 patients were enrolled in this study. Myocardial injury occurred in 158 patients (33.2%). We found that altitude, NLR, hemoglobin, total bilirubin, total cholesterol, and lipoprotein A in myocardial injury group were significantly higher than that in normal group (P < 0.05), while platelet count in myocardial injury group was significantly lower than that in normal group (P < 0.05). Logistic multivariate regression analysis revealed that there was an independent relationship between myocardial injury and smoke, NLR, hemoglobin (P < 0.05). By using Spearman correlation analysis, NLR was proved to have a significant positive correlation with LDH, CK, and CK-MB (P < 0.05) instead of AST. A receiver operating characteristic (ROC) curve was drawn to demonstrate that NLR could significantly predict the occurrence of myocardial injury with an area under the curve (AUC) of 0.594 (95% CI: 0.537–0.650, P < 0.05), and the level of 2.967 (sensitivity = 38.0%, specificity = 83.6%) was optimal cutoff value.

Conclusion: The incidence of myocardial injury is high in population at high altitude. Smoke, hemoglobin, and NLR are independent factors related to myocardial injury. As a convenient and efficient marker, NLR is found to be closely associated with myocardial enzymes and have a predict role in the occurrence of myocardial injury. This study will provide a theoretical basis on NLR for the early diagnosis of myocardial injury at high altitude.

Associations of tobacco retailer availability with chronic obstructive pulmonary disease related hospital outcomes, United States, 2014

There are associations between tobacco retailer density and smoking behaviors, but little is known about whether places with more tobacco retailers have more smoking-related health problems. Using cross-sectional data from 2014, we investigated the relationships between tobacco retailer density and chronic obstructive pulmonary disease (COPD) related outcomes in a sample of 1510 counties across the United States. Higher retailer density was associated with a 19% (IRR, 1.19; 95% CI, 1.12-1.27) higher COPD-related hospital discharge rate and 30% (IRR, 1.30; 95% CI 1.21-1.39) higher total COPD-related hospital costs per population. The tobacco retailer environment may be an important target for reducing smoking-related health burdens and costs.

Impact of Qingdao's smoke-free legislation on hospitalizations and mortality from acute myocardial infarction and stroke: an interrupted time-series analysis

BACKGROUND AND AIMS

More than 20 cities in China have enacted local smoke-free laws that prohibit smoking in public places. Only two of these cities have examined the health impact of the law. Enacted in 2013, Qingdao's smoke free-law was stricter than most other municipal smoke-free laws because it did not allow designated smoking rooms. This study aimed to estimate the impact of Qingdao's smoke-free legislation on acute myocardial infarction (AMI) and stroke.

DESIGN, SETTING AND PARTICIPANTS

We used an interrupted time-series design adjusting for underlying secular trends, seasonal patterns and meteorological factors to estimate the impact of the smoke-free law on AMI and stroke events among permanent residents aged 35 years or older in Qingdao, China. The study period was from 1 January 2010 to 31 December 2015, with a post-ban follow-up of approximately 2.5 years.

MEASUREMENT

Outcome measures were weekly numbers of hospitalizations and deaths due to AMI/stroke.

FINDINGS

A total of 10 371 and 56 101 patients were hospitalized, with a principal discharge diagnosis of AMI and stroke, respectively; 32 196 AMI and 49 711 stroke deaths occurred during the study period. Following the smoke-free legislation, an incremental 20% [95% confidence interval (CI) = 14-26%] and 8% (95% CI = 3-13%) decrease per year was observed in AMI and stroke hospitalization rates, respectively. Neither the immediate nor gradual change in AMI nor stroke mortality rates associated with the law was statistically significant (P > 0.05). Post-hoc subgroup analyses indicated that statistically significant reductions in AMI hospitalizations were evident among both the 35-64 (18% per year, 95% CI = 12-27%) and 65-84 (20% per year, 95% CI = 12-27%) age groups. Statistically significant reductions in stroke hospitalization were only in the older subgroup (13% per year, 95% CI = 8-18%).

CONCLUSIONS

The 2013 smoke-free legislation in Qingdao, China was associated with reduction in hospitalization from acute myocardial infarction and stroke among permanent residents aged 35 years or older. There was no statistically significant reduction in mortality from acute myocardial infarctions or stroke.

County Smoke-Free Laws and Cigarette Smoking Among U.S. Adults, 1995-2015

INTRODUCTION

Tobacco use remains the leading cause of preventable death worldwide. Though research on smoke-free policies in the U.S. exists at the state or national level, there is limited evidence on such policies at the county level. This study examined the association between changes in county-level comprehensive smoke-free laws and smoking behavior among U.S. adults.

METHODS

Data were used from the 1995/1996 to the 2014/2015 Tobacco Use Supplement to the Current Population Survey, analyzed in 2019. Changes in county smoke-free law population coverage over time were used as a natural experiment. Quasi-experimental analyses were performed to examine the association between changes in county-level comprehensive smoke-free laws and smoking behavior (smoking status and number of cigarettes smoked).

RESULTS

During the study period, current smoking prevalence decreased from 21.6% to 11.9%. Specifically, the prevalence of every day smoking decreased from 17.1% to 9.1% and some days smoking decreased from 4.4% to 2.9%. The number of cigarettes smoked per day for every day smokers decreased from 18.5 to 13.6, and from 5.9 to 4.1 for those who smoked some days. Comprehensive smoke-free legislation was associated with lower odds of cigarette smoking (AOR=0.76, 95% CI=0.74, 0.79). Adults living in counties with comprehensive smoke-free policies smoked fewer cigarettes per day both for every day smokers (β= -1.55, p<0.0001) and some days smokers (β= -0.79, p<0.0001).

CONCLUSIONS

County smoke-free policies in the U.S. may have contributed significantly to the reduction in smoking prevalence as well as the reduction in the number of cigarettes smoked among continuing cigarette smokers.

Associations of Smoke-Free Policies in Restaurants, Bars, and Workplaces With Blood Pressure Changes in the CARDIA Study

Background

Smoke‐free legislation has been associated with reductions in secondhand smoke exposure and cardiovascular disease. However, it remains unknown whether smoke‐free policies are associated with reductions in blood pressure (BP).

Methods and Results

Longitudinal data from 2606 nonsmoking adult participants of the CARDIA (Coronary Artery Risk Development in Young Adults) Study (1995–2011) were linked to state, county, and local‐level 100% smoke‐free policies in bars, restaurants, and/or nonhospitality workplaces based on participants’ census tract of residence. Mixed‐effects models estimated associations of policies with BP and hypertension trajectories over 15 years of follow‐up. Fixed‐effects regression estimated associations of smoke‐free policies with within‐person changes in systolic and diastolic BP and hypertension. Models were adjusted for sociodemographic, health‐related, and policy/geographic covariates. Smoke‐free policies were associated with between‐person differences and within‐person changes in systolic BP. Participants living in areas with smoke‐free policies had lower systolic BP on average at the end of follow‐up compared with those in areas without policies (adjusted predicted mean differences [in mm Hg]: restaurant: −1.14 [95% confidence interval: −2.15, −0.12]; bar: −1.52 [−2.48, −0.57]; workplace: −1.41 [−2.32, −0.50]). Smoke‐free policies in restaurants and bars were associated with mean within‐person reductions in systolic BP of −0.85 (−1.61, −0.09) and −1.08 (−1.82, −0.34), respectively. Only restaurant policies were associated with a significant within‐person reduction in diastolic BP, of −0.58 (−1.15, −0.01).

Conclusions

While the magnitude of associations was small at the individual level, results suggest a potential mechanism through which reductions in secondhand smoke because of smoke‐free policies may improve population‐level cardiovascular health.

See Editorial by https://10.1161/JAHA.118.011120

Nicotine induces insulin resistance via downregulation of Nrf2 in cardiomyocyte

Clinical studies have demonstrated that cigarette smoking is strongly associated with insulin resistance and heart disease. Nicotine is considered the primary toxin constituent associated with smoking. However, the distinct molecular mechanism of nicotine-induced cardiac dysfunction remains unclear. Cardiomyocytes with nicotine-induced insulin resistance are characterized by decreased glucose uptake, as measured by 2-[N-(7-Nitrobenz-2-oxa-1,3-diazol-4-yl)amino]-2-deoxy-d-glucose (2-NBDG), a fluorescent derivative of glucose, and reactive oxygen species (ROS) generation. Immunoblotting was used to evaluate the expression of nuclear factor erythroid 2-related factor 2 (Nrf2), extracellular signal-related kinase (ERK) and phosphoinositide 3-kinase (PI3K, p85, Y607). We determined the impact of nicotine on insulin resistance and Nrf2, phospho-ERK and phospho-PI3K expression in the myocardial tissue of a mouse model. Nicotine increased ROS production and depressed insulin-induced glucose uptake in cardiomyocytes. Pretreatment with N-acetyl-L-cysteine (NAC), an antioxidant, reversed nicotine-inhibited glucose uptake induced by insulin. Nicotine exposure directly inhibited Nrf2 and increased ERK phosphorylation in cardiomyocytes, which were obstructed by NAC. Further exploration of signaling cascades revealed nicotine-induced ROS involved in inhibiting PI3K/Nrf2 and activating ERK in cardiomyocytes. Moreover, the mouse model treated with nicotine showed glucose intolerance and impaired insulin tolerance accompanied by inhibited PI3K/Nrf2 and increased ERK in myocardial tissues. Thus, nicotine induces insulin resistance via the downregulation of Nrf2 activity in cardiomyocytes, which is a potential mechanism of the pharmacological effects of nicotine. This study identified potential therapeutic targets against nicotine-related cardiovascular diseases.

Necessity of Preventing Cardiovascular Disease by Smoke-Free Policies

See Article by https://10.1161/JAHA.118.009829

Tobacco use predicts poorer clinical outcomes and higher post-operative complication rates after open elbow arthrolysis

INTRODUCTION

Tobacco use is a worldwide public health problem, and has been found to be a predisposing factor for adverse functional outcomes and increased postoperative complication rates after various orthopedic operations. The purpose of this study was to determine the potential impact of tobacco use on open arthrolysis for post-traumatic elbow stiffness.

MATERIALS AND METHODS

A database search identified 145 patients with open arthrolysis performed for post-traumatic elbow stiffness; these were divided into three groups: current tobacco users (37), former users (28), and nonusers (80). All surgeries were performed using the same technique by the same doctor. General patient data, functional performance, and complications were documented and analyzed.

RESULTS

Demographic data and disease characteristics were comparable at baseline. Postoperatively, significant differences were found among the three groups in terms of range of motion (P < 0.001), Mayo Elbow Performance Score (P = 0.006), visual analog scale score for pain (P = 0.015), Dellon classification for ulnar nerve symptoms (P = 0.013), and total complication rates (P < 0.001). The current tobacco users group had the poorest clinical outcomes and highest complication rates, while no significant differences were found between former users and nonusers.

CONCLUSIONS

Current tobacco users reported increased risk of poorer clinical outcomes and higher postoperative complication rates after open arthrolysis. Former users were found to have outcomes similar to those of nonusers. This study underlines the importance of discontinuing tobacco use for patients with post-traumatic elbow stiffness who are considering open arthrolysis.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Design; Therapeutic Study.