The association of tobacco control policies and the risk of acute myocardial infarction using hospital admissions data

Association between the extension of smoke-free legislation and incident acute myocardial infarctions in Singapore from 2010 to 2019: an interrupted time-series analysis

BACKGROUND

We examined the association between smoke-free laws implemented in the outdoors and the common areas of residential apartment blocks and reported acute myocardial infarctions (AMI) in Singapore.

METHODS

We used an interrupted time-series design and seasonal autoregressive integrated moving average models to examine the effect of the smoke-free law extensions in 2013 (common areas of residential blocks, covered pedestrian linkways, overhead bridges and within 5 m of bus stops), 2016 (parks) and 2017 (educational institutions, buses and taxis) on the monthly incidence rate of AMIs per 1 000 000 population.

RESULTS

We included 133 868 AMI reports from January 2010 to December 2019. Post-2013, there was a decrease in the AMI incidence trend (β=-0.6 per month, 95%CI -1.0 to -0.29) and 2097 (95% CI 2094 to 2100) more AMIs may have occurred without the extension. There was a significant step-decline in male AMIs and a non-significant step-increase in female AMIs post-2013. Those 65 years and older experienced a greater decline to the postlegislation 2013 trend (β=-5.9, 95% CI -8.7 to -3.1) compared with those younger (β=-0.4, 95% CI -0.6 to -0.2), while an estimated 19 591 (15 711 to 23472) additional AMI cases in those 65 years and above may have occurred without the extension. We found a step-increase in monthly AMI incidence post-2016 (β=14.2, 95%CI 3.3 to 25.0).

CONCLUSION

The 2013 smoke-free law extension to residential estates and other outdoor areas were associated with a decline in AMIs and those above the age of 65 years and men appeared to be major beneficiaries. Additional epidemiological evidence is required to support the expanded smoke-free legislation to parks, educational institutions, buses and taxis.

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.

Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30-75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019

BACKGROUND

Recent estimates of hypertension in Panama remain unknown. We aim to describe the variation in prevalence and unawareness of hypertension in two Panamanian provinces using two different cross-sectional population-based studies and to investigate risk factors associated with hypertension unawareness.

METHODS

Data were derived from a sub-national study conducted in the provinces of Panama and Colon (PREFREC-2010 [2,733 participants]) and from a nationally representative study (ENSPA-2019), in which we restricted our analyses to the same provinces (4,653 participants). Individuals aged 30-75 years who had (a) self-reported history of hypertension or (b) blood pressure (BP) ≥140/90mmHg or (c) a combination or both were classified as hypertensive. Participants with BP≥140/90mmHg who denied a history of hypertension were considered unaware of the condition. Multivariable logistic regression models were used to estimate the association between risk factors and unawareness, expressed as odds ratios (OR) and 95% confidence interval (CI).

FINDINGS

In 2010, the prevalence and unawareness of hypertension in men were 51.6% (95% CI: 45.7-57.5) and 32.3% (25.4-40.1), respectively, and in women 46.0% (42.1-49.9) and 16.1% (12.6-20.4), respectively. In 2019, the prevalence and unawareness of hypertension in men were 46.5% (42.1-51.0) and 52.3% (45.9-58.6), and in women 42.1% (39.6-44.7) and 33.3% (29.8-37.0). Men (2010 and 2019), age <50 years (2010 and 2019), having no/primary education (2010), and living in a non-urban region (2019) were positively associated with hypertension unawareness, whereas obesity (2010), physical inactivity (2010), family history of hypertension (2019), and BP assessment in the year before study enrollment (2010 and 2019) were inversely associated with hypertension unawareness.

INTERPRETATION

Benefits of a decrease in the prevalence of hypertension are being undermined by an increase in hypertension unawareness. Actions should be encouraged to strengthen the implementation of the existing healthcare program for cardiovascular risk factor control.

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.

The impact of comprehensive tobacco control policies on cardiovascular diseases in Beijing, China

BACKGROUND AND AIMS

China has a high smoking prevalence, but lacks effective tobacco control interventions. In 2015, comprehensive policies that incorporated all six aspects of MPOWER were implemented in Beijing and were considered the strictest tobacco control policy implemented in China to date. Decreases in the prevalence of active smoking and secondhand smoke (SHS) exposure were observed thereafter. This study aimed to evaluate the impact of Beijing's 2015 tobacco control policy package on cardiovascular diseases (CVDs).

DESIGN

Interrupted time-series study.

SETTING

Beijing, China.

PARTICIPANTS

A total of 17.7 million employees enrolled in Urban Employee Basic Medical Insurance (UEBMI) between January 2013 to June 2017.

INTERVENTIONS

Beijing's 2015 comprehensive tobacco policy package, combining a complete ban on smoking in indoor public places, cessation support, more comprehensive bans on advertising, and tax rises.

MEASUREMENTS

The main outcome was hospital admissions for all CVDs and five major cause-specific CVDs, including ischaemic heart disease (IHD), heart failure (HF), heart rhythm disturbances (HRDs), stroke and other cerebrovascular diseases (CBDs). The absolute number and proportion of reductions in the number of hospital admissions after the policies are reported.

FINDINGS

A total of 419 875 hospital admissions for CVD were identified. In total, 13.4% [95% confidence interval (CI) = 11.5%, 15.3%] of hospital admissions for CVD were averted by the tobacco control policies. For major cause-specific CVDs, significant hospital admission reductions occurred for IHD (5.4%, 95% CI = 2.6%, 8.3%), stroke (21.2%, 95% CI = 17.8%, 24.6%) and other CBDs (25.9%, 95% CI = 20.8%, 31.0%), but not for HF (4.7%, 95% CI = -4.2%, 13.5%) or HRDs (4.7%, 95% CI = -2.9%, 12.3%).

CONCLUSIONS

Beijing's 2015 tobacco control policy package appears to have been associated with a more than 10% reduction in all cardiovascular hospital admissions, including a more than 20% reduction in admissions for cerebrovascular diseases.

Sin taxes and their effect on consumption, revenue generation and health improvement: a systematic literature review in Latin America

Sin or public health taxes are excise taxes imposed on the consumption of potentially harmful goods for health [sugar-sweetened beverages (SSBs), tobacco, alcohol, among others], aiming to reduce consumption, raise additional revenue and/or improve population health. This paper assesses the extent to which sin taxes (a) can reduce consumption of potentially harmful goods, (b) raise revenue for national health systems and (c) contribute to population health in Latin America. A systematic literature review was conducted on peer-reviewed and grey literature; endpoints included: impact of raising sin taxes on consumption, ability to raise revenue for health and the possibility of population health improvements. Risk of bias for each study was assessed. The synthesis of the literature on sin tax implementation showed improvements in all three endpoints across the study countries. Following the introduction of sin taxes or by simulating their potential impact, nearly all studies explicitly reported that consumption of potentially harmful goods (mainly SSBs and tobacco) declined; revenue was found to have increased in almost all countries, suggesting that there may be additional scope for further tax increase. Simulated improvements in population health have also been shown, by demonstrating a relationship between sin tax increases and reduction in prevalence of diabetes, stroke, heart attacks and associated deaths. However, sin tax effects on health would be better quantified over the long-term. Data quality and availability challenges did place some limitations on sin tax impact assessment. Sin taxes can be effective in reducing consumption of potentially harmful goods, improve population health and generate additional revenue. Promoting further research on this topic should be a priority.

Impaired eIF5A function causes a Mendelian disorder that is partially rescued in model systems by spermidine

The structure of proline prevents it from adopting an optimal position for rapid protein synthesis. Poly-proline-tract (PPT) associated ribosomal stalling is resolved by highly conserved eIF5A, the only protein to contain the amino acid hypusine. We show that de novo heterozygous EIF5A variants cause a disorder characterized by variable combinations of developmental delay, microcephaly, micrognathia and dysmorphism. Yeast growth assays, polysome profiling, total/hypusinated eIF5A levels and PPT-reporters studies reveal that the variants impair eIF5A function, reduce eIF5A-ribosome interactions and impair the synthesis of PPT-containing proteins. Supplementation with 1 mM spermidine partially corrects the yeast growth defects, improves the polysome profiles and restores expression of PPT reporters. In zebrafish, knockdown eif5a partly recapitulates the human phenotype that can be rescued with 1 µM spermidine supplementation. In summary, we uncover the role of eIF5A in human development and disease, demonstrate the mechanistic complexity of EIF5A-related disorder and raise possibilities for its treatment.

Association between tobacco control policies and hospital admissions for acute myocardial infarction in Thailand, 2006-2017: A time series analysis

Introduction

Studies in many countries have documented reductions of acute myocardial infarction (AMI) hospitalizations with smokefree policies. However, evidence on the association of cigarette tax with AMI events is unclear. There have been no studies of the associations between these two policies and AMI hospitalizations in Thailand.

Methods

We used negative binomial time series analyses of AMI hospitalizations (ICD-10 codes I21.0-I21.9), stratified by sex and age groups, from October 2006 to September 2017 to determine whether there was a change in AMI hospitalizations as a result of the changes in cigarette prices and the implementation of a 100% smokefree law.

Results

Cigarette price increases were associated with a significant 4.7% drop in AMI hospitalizations among adults younger than 45 (incidence rate ratio [IRR], 0.953; 95% confidence interval [CI], 0.914–0.993; p = 0.021). Implementation of the 100% smokefree law was followed by a significant 13.1% drop in AMI hospitalizations among adults younger than 45 (IRR, 0.869; 95% CI, 0.801–0.993; P = 0.001). There were not significant associations in older age groups.

Conclusions

The Thai cigarette tax policy and the smokefree law were associated with reduced AMI hospitalizations among younger adults. To improve effectiveness of the policies, taxes should be high enough to increase cigarette price above inflation rates, making cigarettes less likely to be purchased; smokefree laws should be strictly enforced.

Impact of a comprehensive tobacco control policy package on acute myocardial infarction and stroke hospital admissions in Beijing, China: interrupted time series study

OBJECTIVE

To evaluate a comprehensive tobacco control policy package on hospital admissions for acute myocardial infarction (AMI) and stroke in a global city.

DESIGN

Interrupted time series study.

SETTING

Beijing, China.

POPULATION

31 707 AMI and 128 116 stroke hospital admissions recorded by the Beijing Medical Claim Data for Employees in 17.7 million residents from January 2013 to June 2017.

INTERVENTION

The policy package including all components of MPOWER has been implemented since June 2015.

MAIN OUTCOME MEASURES

The immediate change of AMI and stroke hospital admissions and the annual change in the secular trend.

RESULTS

There was a secular increase trend for the crude hospital admission rates of AMI and stroke during the observational period. After implementation of the policy, immediate reductions were observed in the hospital admissions for both AMI (-5.4%, 95% CI -10.0% to -0.5%) and stroke (-5.6%, 95% CI -7.8% to -3.3%). In addition, the secular increase trend for stroke was slowed down by -15.3% (95% CI -16.7% to -13.9%) annually. Compared with the hypothetical scenario where the policy had not taken place, an estimated 18 137 (26.7%) stroke hospital admissions had been averted during the 25 months of postpolicy period.

CONCLUSIONS

The results indicated significant health benefits on cardiovascular morbidity after the Beijing tobacco control policy package, which highlighted the importance for a comprehensive tobacco control policy at the national level in China. Similar tobacco control policy which consists of all components of MPOWER is urgently needed in other areas, especially in settings with high tobacco consumption, to achieve greater public health gains.

Assessing the knowledge, attitudes and perceptions of tobacco-associated diseases and how it is influenced by tobacco products advertisement, promotion and sponsorship while enforcing a strong and comprehensive ban in Panama: a cross-sectional study

OBJECTIVES

Assessing the knowledge, attitudes and perceptions (KAP) of tobacco-associated diseases, and how it is influenced by tobacco products' advertisement, promotion and sponsorship (TAPS) while enforcing a strong and comprehensive ban.

DESIGN

The Panamanian implementation of the Global Adult Tobacco Survey: an international standardised cross-sectional survey study.

SETTING

National Panamanian population aged between 15 years and 29 years old.

PARTICIPANTS

There were 4796 responding participants (n=905 830 in the expanded sample).

PRIMARY AND SECONDARY OUTCOMES

An index was developed using factorial analysis using TAPS and KAP variables. The primary outcomes were: (1) The national median index value. (2) The index value stratified by sex, age, occupation, income quintile and geographical areas. (3) The first and second factor loadings (FFL and SFL, respectively) for variables included in the KAP index.

RESULTS

Fifteen out of the 16 variables comprising the index were variables related to KAP and one variable was related to TAPS. The top three variables according to their FFL were 'KAP that cigarette is associated to …': (1) '… bladder cancer'. (2) '… breast cancer'. (3) '… stomach cancer'. The top three variables according to the SFL were 'KAP that cigarette is associated to …': (1)'… chronic bronchitis'. (2) '… myocardial infarction'. (3) '… lung cancer'. Illegal tobacco advertisement in posters was the only TAPS variable included in the index. The national KAP index value was 0.26. Our results show that current smokers, teens, men, people with the lowest income quintile, and those living in Guna Yala Indigenous Territory (health region with the highest smoking prevalence) had a lower median value than the national median.

CONCLUSIONS

Men, young adults and deprived youth had the lowest median KAP index. Illegal TAPS had no influence on the KAP of tobacco-associated diseases when a strong and comprehensive ban is enforced.

Effect of the comprehensive smoke-free law on time trends in smoking behaviour in primary healthcare patients in Spain: a longitudinal observational study

OBJECTIVE

This study aimed to analyse the impact of comprehensive smoke-free legislation (SFL) on the prevalence and incidence of adult smoking in primary healthcare (PHC) patients from three Spanish regions, overall and stratified by sex.

DESIGN

Longitudinal observational study conducted between 2008 and 2013.

SETTING

66 PHC teams in Catalonia, Navarre and the Balearic Islands (Spain).

PARTICIPANTS

Population over 15 years of age assigned to PHC teams.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Quarterly age-standardised prevalence of non-smoker, smoker and ex-smoker and incidence of new smoker, new ex-smoker and ex-smoker relapse rates were estimated with data retrieved from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardised prevalence and incidence rates. Trends were expressed as annual percentage change and average annual percent change.

RESULTS

The overall standardised smoker prevalence rate showed a significant downward trend (higher in men than women) and the overall standardised ex-smoker prevalence rate showed a significant increased trend (higher in women than men) in the three regions. Standardised smoker and ex-smoker prevalence rates were higher for men than women in all regions. With regard to overall trends of incidence rates, new smokers decreased significantly in Catalonia and Navarre and similarly in men and women, new ex-smokers decreased significantly and more in men in Catalonia and the Balearic Islands, and ex-smoker relapse increased in Catalonia (particularly in women) and decreased in Navarre.

CONCLUSIONS

Trends in smoking behaviour in PHC patients remain unchanged after the implementation of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the preceding partial SFL.

Updating the evidence relating smoking bans to incidence of heart disease

In our latest update of the evidence on smoking bans and heart disease we summarize 59 studies. We take account of the underlying trends in incidence rates as far as possible by using control data in eight studies, and by adjustment based on observed trends in cases pre- and post-ban in 40 studies, being unable to make an adjustment in the remaining 11 studies. Overall, based on 62 independent estimates from the 59 studies, we estimate that bans reduce incidence by 5.0% (95% CI 3.2-6.8%), though this estimate reduces to 2.9% (0.01-5.6%) when we exclude regional estimates where national estimates are available, and studies where trend adjustment is not possible. For 25 of the studies, quadratic rather than linear adjustment is possible, but this hardly affects the overall estimates. Ban effects are somewhat greater when the pre-ban period studied is relatively short, and in smaller studies. We compare our findings with those in other recent reviews, one of which totally ignored underlying trends and results from control populations. We discuss reasons why we believe there is likely to be a true small effect of smoking bans, and weaknesses in the data which preclude reaching any very confident conclusion.

Distributional benefits of tobacco tax and smoke-free workplaces in China: A modeling study

Background

Tobacco taxation and smoke–free workplaces reduce smoking, tobacco–related premature deaths and associated out–of–pocket health care expenditures. We examine the distributional consequences of a price increase in tobacco products through an excise tax hike, and of an implementation of smoke–free workplaces, in China.

Methods

We use extended cost–effectiveness analysis (ECEA) to evaluate, across income quintiles of the male population (the large majority of Chinese smokers), the premature deaths averted, the change in tax revenues generated, and the financial risk protection procured (eg, poverty cases averted, defined as the number of individuals no longer facing tobacco–related out–of–pocket expenditures for disease treatment, that would otherwise impoverish them), that would follow a 75% increase in cigarette prices through substantial increments in excise tax fully passed onto consumers, and a nationwide total implementation of workplace smoking bans.

Results

A 75% increase in cigarette prices would avert about 24 million premature deaths among the current Chinese male population, with a third among the bottom income quintile, increase additional tax revenues by US$ 46 billion annually, and prevent around 9 million poverty cases, 19% of which among the bottom income quintile. Implementation of smoking bans in workplaces would avert about 12 million premature deaths, with a fifth among the bottom income quintile, decrease tax revenues by US$ 7 billion annually, and prevent around 4 million poverty cases, 12% of which among the bottom income quintile.

Conclusions

Increased excise taxes on tobacco products and workplace smoking bans can procure large health and economic benefits to the Chinese population, especially among the poor.

Lower incidence of myocardial infarction after smoke-free legislation enforcement in Chile

Objective

To evaluate the impact of a complete smoking ban in enclosed spaces on the incidence of acute myocardial infarction in Chile.

Methods

The population-based study involved residents of urban areas, where 80% of the Chilean population live, aged 20 years or older who had a myocardial infarction. Monthly myocardial infarction incidence and mortality rates at health-care facilities between January 2011 and December 2014 were derived from admission and mortality databases. Regression discontinuity methods were used to estimate the near-immediate impact on disease incidence of enforcing smoke-free legislation in March 2013. The same analysis was performed for ischaemic stroke, degenerative disc disease and colon cancer. Data on the concentration of fine respirable particulates were included in an additional analysis of myocardial infarction incidence in the Santiago metropolitan area.

Results

The enforcement of smoke-free legislation was associated with an abrupt, near-immediate decline of 0.639 cases of myocardial infarction per 100 000 adults per month (95% confidence interval, CI: 0.242 to 1.036; relative decline: 7.8%). Similar declines were observed in men and women and in people aged over and under 70 years. However, enforcement of the legislation was not associated with a significant change in the rate of ischaemic stroke, degenerative disc disease or colon cancer. The abrupt decline in myocardial infarction incidence was also observed when data on fine respirable particulates were included in an analysis for Santiago.

Conclusion

The enforcement of extensive smoke-free legislation in Chile was associated with an abrupt, near-immediate decline in the incidence of myocardial infarction.

Quiénes quieren dejar fumar y su disposición a pagar por cesación en Panamá

Objetivo. Caracterizar el deseo de cesación y disposición al pago por una terapia de abandono de consumo de tabaco. Material y métodos. La fuente de los datos es la Encuesta Mundial de Tabaco en Adultos (EMTA). Se caracterizó la cesación y la disposición al pago mediante variables sociodemográficas (SOD) y socioeconómicas (SES). Se realizaron regresiones logísticas para estimar asociaciones. Resultados. El mayor deseo de cesación se observó en las mujeres, aspecto educativo, empleado no gubernamental e inactivo, zona rural, fumadores ocasionales, ingresos medios y la mayor disposición al pago, en educación, mayores de 60 años, empleado no gubernamental y cuenta propia, zona urbana, fumadores ocasionales e ingreso medio bajo. Conclusiones. Existe una alta relación entre el deseo de abandono y la disposición al pago con las variables SOD y SES. Las terapias de cesación pueden aplicarse en centros de trabajo y exigen un cambio de enfoque en la intervención.

Analysis of mortality trends due to cardiovascular diseases in Panama, 2001-2014

Objective

Cardiovascular diseases (CVDs) are still the leading cause of death worldwide despite the recent decline in mortality rates attributable to CVD in Western Europe and the Americas. The aim of this study is to investigate mortality trends due to ischaemic heart disease (IHD) and stroke in Panama from 2001 to 2014, as well as the mortality differences by sex and age groups.

Methods

Data were obtained from the National Mortality Register. The International Classification of Diseases 10th revision codes (ICD-10) I20–I25 and I60–I69 were used for IHD and stroke, respectively. Age-adjusted mortality rates were calculated using the world population of the WHO as standard. Trends were analysed using Joinpoint Regression Program and annual percentage changes (APC) were estimated.

Results

From 2010, the IHD mortality trend began to decline in the whole population of Panama (APC −4.7%, p<0.05). From 2001 to 2014, a decline in the trend for IHD mortality was observed (APC −1.7%, p<0.05) in women, but not in men. Stroke mortality showed a significant annual decline during the study period (APC −3.8%, p<0.05) and it was more pronounced in women (APC −4.5%, p<0.05) than in men (APC −3.3%, p<0.05).

Conclusions

In Panama, the mortality rates from IHD and stroke have declined in recent years. Better access to healthcare, improved treatment of acute IHD and stroke, low tobacco consumption and better control of hypertension probably account for a significant part of this mortality reduction.

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

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

High blood pressure in Panama: prevalence, sociodemographic and biologic profile, treatment, and control (STROBE)

The objective of this study is to estimate the prevalence, treatment, and control of high blood pressure, hypertension (HBP) in Panama and assess its associations with sociodemographic and biologic factors.A cross-sectional, descriptive study was conducted in Panama by administering a survey on cardiovascular risk factors to 3590 adults and measuring their blood pressure 3 times. A single-stage, probabilistic, and randomized sampling strategy with a multivariate stratification was used. The average blood pressure, confidence intervals (CIs), odds ratio (OR), and a value of P ≤ 0.05 were used for the analysis.The estimated prevalence of HBP was 29.6% (95% CI, 28.0-31.1); it was more prevalent in men than in women, OR = 1.37 (95% CI, 1.17-1.61); it increased with age and was more frequent among Afro-Panamanians (33.8%). HBP was associated with a family history of HBP with being physically inactive and a body mass index ≥25.0 kg/m or a waist circumference >90 cm in men and >88 cm in women (P < 0.001). Of those found to have HBP, 65.6% were aware of having HBP and taking medications, and of these, 47.2% had achieved control (<140/90 mm Hg).HBP is the most common cardiovascular risk factor among Panamanians and consequently an important public health problem in Panama. The health care system needs to give a high priority to HBP prevention programs and integrated care programs aimed at treating HBP, taking into consideration the changes in behavior that have been brought about by alterations in nutrition and sedentary lifestyles.

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.