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

Quasi-experimental study on the impact of local smoke-free policies on smoking among Indonesian adults: Evidence from repeated national health surveys

BACKGROUND

Smoke-free policies (SFPs) have been effective in reducing smoking prevalence, but evidence remains limited for low- and middle-income countries. Due to decentralized governance in Indonesia, SFPs are adopted in different ways in different locations. This study aims to assess the impact of local smoke-free policies (SFPs) on current smoking among Indonesian adults.

METHODS

Data from national health surveys conducted in 515 districts and 34 provinces in 2007, 2013, and 2018, involving 1,599,517 adults, were analyzed. A multilevel logistic regression analysis was performed, considering variables such as survey year, SFP adoption in 2007, SFP between 2007 and 2013, SFP between 2013 and 2018, socio-demographic factors, and district characteristics.

RESULTS

Moderate (OR:0.94, 95%CI:0.91-0.97) and strong (OR:0.95, 95%CI:0.0.92-0.98) district-level SFPs between 2013 and 2018 were associated with decreased odds of current smoking, compared to no district-level SFP adoption. Similar results were observed for moderate (OR:0.91, 95%CI:0.86-0.96) and strong (OR:0.89, 95%CI:0.85-0.94) district-level SFPs between 2007 and 2013, compared to no district-level SFP. Compared to provinces without SFPs, individuals living in provinces with moderate SFPs between 2007 and 2013 had lower odds of current smoking (OR:0.67; 95% CI:0.63-0.71), while those in districts with moderate SFPs between 2013 and 2018 had higher odds (OR: 1.08, 95% CI: 1.05-1.11).

CONCLUSIONS

Local SFPs demonstrated a potential in reducing smoking persistence in Indonesia, particularly at the district level. However, the impact of province-level SFPs differed. Tailored SFPs and district-province strategies, focusing on synchronizing the top-down SFP implementation in the Indonesia's decentralized systems, are critical for lowering smoking rates.

Assessing exposure to secondhand smoke among Iranian patients with cardiac diseases; a cross-sectional study

Introduction

Studies have linked secondhand smoke (SHS) exposure to adverse health effects. The high prevalence of heart disease necessitates the need for studies in this field. Therefore, the aim of the present study was to assess the exposure to SHS in cardiac patients.

Method

This study is a cross-sectional descriptive study. A total of 430 patients who were referred to Imam Ali Hospital in Kermanshah, Iran, in 2020 were included in the study based on predetermined inclusion and exclusion criteria. The researchers collected and recorded demographic information, disease history, and exposure to secondhand smoke (SHS) through a digital questionnaire. Bivariate analysis was conducted using a chi-square test and an independent T-test, depending on the variable scale.

Results

The results of the study showed that 237 patients were male (55.12 %) and 193 were female (44.8 %). The prevalence of exposure to secondhand smoke was 72.09 %. Notably, the highest rate of exposure to secondhand smoke was associated with 'exposure to tobacco smoke in public places' with a rate of 69.30 %. Additionally, it was observed that approximately 39.07 % of patients reported exposure to secondhand smoke in public places at least once a week.

Conclusion

The present study has found that cardiac patients frequently experience secondhand smoking exposure, with public settings being the primary location of exposure. Implementing intervention strategies and enacting laws that prohibit smoking can effectively mitigate the negative impact of SHS exposure.

Smoking Cessation Barriers among Individuals with Mental Illnesses: A Qualitative Study of Patients' and Healthcare Providers' Perspectives

In this paper we aimed to explore: (1) challenges that people with mental illnesses (MIs) describe in engaging in smoking cessation, (2) challenges that mental health providers (MHPs) perceive that people living with MIs face, and (3) how the perceived challenges are similar and/or different from both perspectives. Semi-structured interviews were used to obtain narrative data from 16 MHPs and 13 psychiatric inpatients with MIs. We identified themes purport societal, group, and individual factors may influence smoking cessation treatment engagement. The scope of the perceived challenges appeared varied in the narratives of MHPs as compared to those with MI.

Long-Term Follow-up Study of Hospitalizations for Acute Coronary Syndrome in Kobe-City and Other Districts Under the Hyogo Smoking Ban Legislation - A Nationwide Database Study

BACKGROUND

Hyogo Prefecture has managed smoking ban legislation with partial restrictions in public places (Hyogo-L) since 2013. Previous studies have reported a significant decrease in admissions for acute coronary syndrome (ACS) in Kobe-city, but not in other districts of Hyogo Prefecture in the 2 years after Hyogo-L. The aim of the present study was to define the long-term effect of Hyogo-L.Methods and Results: The JROAD-DPC dataset was used to collect information on the number of hospitalizations for ACS in Hyogo Prefecture, and in Osaka-city without smoking ban legislation, from April 2013 to March 2020. Poisson regression analysis was performed to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). ACS records of 3,101 in Kobe-city, 11,375 in areas of Hyogo Prefecture other than Kobe-city and 11,079 in Osaka-city were collected for admissions. The incidence of ACS reduced significantly over time in Kobe-city [IRR (95% CI); 0.96 (0.94-0.97)], but did not reduce in the others. The decrease in Kobe-city was observed in ACS patients without smoking, hypertension, and hyperlipidemia, but not in those with such risk factors.

CONCLUSIONS

The long-term ACS reduction or non-reduction under Hyogo-L was determined at the initial period and the same scenario continued, supporting the importance of legislation and compliance with the smoking ban. The lowering effect was remarkable in ACS patients without risk factors such as non-smoking.

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population

BACKGROUND

National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups.

METHODS

Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position.

RESULTS

Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban.

CONCLUSION

The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

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.

Disparities in Smokefree and Vapefree Home Rules and Smokefree Policy Attitudes Based on Housing Type and Cigarette Smoking Status, United States, 2019

This study examined variations in cigarette smoking status, home smoking and vaping rules, and attitudes toward smoking rules among U.S. adults. We analyzed data from the 2019 U.S. Census Bureau's Current Population Survey Supplements (n = 40,296 adults) and calculated weighted prevalence estimates of adult cigarette smoking based on housing type. In 2019, multi-unit housing (MUH) residents who currently smoked were predominantly residents of privately rented housing (66.9%), followed by privately owned (17.6%) and public housing (15.5%). MUH residents who currently smoked had the highest proportions of allowing smoking (26.7%) or vaping (29.1%) anywhere inside their homes and were least likely to support rules allowing smoking inside all MUH apartments or living areas. In the adjusted models, MUH residents with a current smoking status were 92% less likely to have a complete smoking ban. More than one in four MUH residents with a current smoking status allowed all smoking inside the home and supported allowing smoking inside all MUH apartment or living areas, reinforcing how MUH residents may be at higher risk of experiencing secondhand smoke or aerosol exposure, or incursions within their places of residence. Our results can inform the development, implementation, and sustainment of strategies to reduce exposures from tobacco and nicotine products in all living environments.

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.

Smoking Bans and Circulatory System Disease Mortality Reduction in Macao (China): Using GRA Models

This study evaluates the association between smoking rates and mortality from circulatory system diseases (CSD) after implementing a series of smoking bans in Macao (China). (1) Background: Macao phased in strict total smoking bans since 2012. During the past decade, smoking rates among Macao women have dropped by half. CSD mortalities in Macao also show a declining trend. (2) Method: Grey relational analysis (GRA) models were adopted to rank the importance of some key factors, such as income per capita, physician density, and smoking rates. Additionally, regressions were performed with the bootstrapping method. (3) Results: Overall, smoking rate was ranked as the most important factor affecting CSD mortality among the Macao population. It consistently remains the primary factor among Macao's female population. Each year, on average 5 CSD-caused deaths were avoided among every 100,000 women, equivalent to about 11.45% of the mean annual CSD mortality. (4) Conclusions: After the implementation of smoking bans in Macao, the decrease in smoking rate among women plays a primary role in the reduction in CSD mortality. To avoid excess CSD mortality due to smoking, Macao needs to continue to promote smoking cessation among the male population.

Healthcare Professionals' Knowledge, Attitudes and Counselling Practice Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women/Children in Assiut, Egypt

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

Smoke-free spaces: a decade of progress, a need for more?

Adoption of smoke-free measures has been one of the central elements of tobacco control activity over the past 30 years. The past decade has seen an increasing number of countries and proportion of the global population covered by smoke-free policies to some extent. Despite reductions in global smoking prevalence, population growth means that the number of non-smokers exposed to the harms caused by secondhand smoke remains high. Smoke-free policy measures have been shown to be useful in protecting non-smokers from secondhand smoke, and can additionally increase cessation and reduce smoking initiation. Policies tend to be aimed primarily at enclosed public or workplace settings with very few countries attempting to control exposure in private or semiprivate spaces such as homes and cars, and, as a result, children may be benefiting less from smoke-free measures than adults. Compliance with legislation also varies by country and there is a need for education and empowerment together with guidance and changing social norms to help deliver the full benefits that smoke-free spaces can bring. Restrictions and policies on use of electronic cigarettes (e-cigarettes) in smoke-free settings require more research to determine the benefits and implications of bystanders' exposure to secondhand e-cigarette aerosol, dual use and smoking cessation.

Secondhand smoke exposure for different education levels: findings from a large, nationally representative survey in Turkey

OBJECTIVES

The aim of this study is to determine the factors that influence individuals' exposure to tobacco smoke in Turkey according to their education level.

DESIGN

Secondary data analysis.

PARTICIPANTS

Altogether, 17 084 individuals aged 15 and over were included in this study.

SETTINGS

Data set of the Turkey Health Survey in 2019.

METHODS

Binary logistic regression analysis was used to determine the factors associated with individuals' exposure to tobacco smoke.

PRIMARY AND SECONDARY OUTCOME MEASURES

The variables age, gender, marital status, general health status, employment status, receipt of psychosocial support and tobacco use were found to be correlated with exposure to tobacco smoke.

RESULTS

The study determined that individuals who are illiterate/unschooled were exposed to tobacco smoke at a rate of 32.61%, primary school graduates at a rate of 34.32%, primary education graduates at a rate of 41.75%, high school graduates at a rate of 41.04% and university graduates at a rate of 40.34%.

CONCLUSION

As a result of the study, it is emphasised that men, young individuals, individuals with moderate and very good general health status, those who use tobacco, those who are unemployed and those who receive psychosocial support should be targeted. In addition, appropriate strategies for reducing secondhand smoke (SHS) exposure should be developed, taking into account public health strategies for increasing awareness of the adverse health effects of SHS exposure and the determinants of tobacco exposure according to the study.

Spatial clusters of daily tobacco consumption before and after a smoke-free policy implementation

This study assessed the spatial dependence of daily tobacco consumption and how it is spatially impacted by individual and neighborhood socioeconomic determinants, and tobacco consumption facilities before and after a smoke-free implementation. Individual data was obtained from the Bus Santé, a cross-sectional survey in Geneva. Spatial clusters of high and low tobacco consumption were assessed using Getis-Ord Gi*. Daily tobacco consumption was not randomly clustered in Geneva and may be impacted by tobacco consumption facilities independently of socioeconomic factors and a smoking ban. Spatial analysis should be considered to highlight the impact of smoke-free policies and guide public health interventions.

Secondhand Smoke Exposure is Associated with Prevalent Heart Failure: Longitudinal Examination of the National Health and Nutrition Examination Survey

INTRODUCTION

Serum cotinine is a sensitive and specific biomarker for tobacco exposure including second-hand smoke exposure (SHS). We sought to examine whether SHS is associated with heart failure (HF) among non-hospitalized adults.

METHODS

This analysis included 11 219 non-smokers (age 48.4 ± 20.5 years, 55.9% women, 70.5% whites) from the United States Third National Health and Nutrition Examination (NHANES) years 1988-1994. SHS was defined as serum cotinine ≥1 ng/mL. To assess dose-response, cut-points of serum cotinine ≥3 ng/mL and ≥6 ng/mL were used. Multivariable logistic regression was used to examine the association between SHS and HF. The consistency of this association was tested among subgroups stratified by race, gender, and comorbidities. NHANES years 2003-2006 were examined for longitudinal comparison.

RESULTS

18.9% (n = 2125) of participants had SHS exposure while 3.7% (n = 416) had HF. After adjusting for covariates, SHS was associated with a 35% increased odds of HF with a dose-response relationship between levels of serum cotinine and HF. This association was stronger in males than females (interaction p-value = 0.03) and those with a history of CVD versus those without (interaction p-value < 0.001). This association persisted in the NHANES 2003-2006 analysis.

CONCLUSION

There is a dose-response relationship between SHS and HF with possible effect modification by gender and prior CVD. This is a novel finding that underscores the harmful effects of passive smoking on the cardiovascular system and highlights the needs for further prohibition of smoking in public areas and a personalized risk assessment among high-risk groups, especially in regions with less-stringent public health policies.

IMPLICATIONS

This study showed a novel association between secondhand smoke exposure and prevalent heart failure among non-smokers, adding to the list of harmful cardiovascular manifestations of secondhand smoke exposure. This was more apparent in men and those with a prior history of cardiovascular disease. Heart failure is a debilitating disease process, so this finding has important policy implications in low-income countries and poor communities with less-stringent health policies because they are known to have the highest levels of exposure. Smoke-free policies targeting these regions would thus yield substantial public health benefits.

Changes in tobacco use patterns and motivation to quit related to the new smoke-free legislation in the Czech Republic

BACKGROUND

Smoke-free policy belongs to key public health instruments to promote health in populations. In 2017, new comprehensive smoke-free law prohibiting smoking in indoor public places was implemented. We aimed to measure changes in tobacco smoking patterns and changes in motivation to quit in adult smokers prior to and after the new smoke-free legislation came into force.

METHODS

We conducted a prospective cohort study prior to and post the implementation of Act No. 65/2017 Coll. Self-reported questionnaires were administered to 131 adult smokers by trained nurses in general practitioner offices in Prague. We analysed changes in cigarette consumption per day; ratio of cigarettes smoked in pub, street, work and home; and motivation to quit using regression modelling.

RESULTS

We found a statistically significant decrease in the daily consumption of cigarettes (an average of 1.7 cigarettes per day, P < 0.001, d = 0.34). Smoking in indoor public spaces decreased to almost zero, while tobacco consumption in outdoor public spaces (such as streets and squares) increased by nearly 20%. We observed statistically significant increase of motivation to quit smoking (P = 0.021, d = 0.21).

CONCLUSION

The study brings valuable indication of the desired public health impact related to key legislative change in the Czech Republic.

Support for smoke-free public places among adults in four countries in sub-Saharan Africa

INTRODUCTION

There is no known safe level of secondhand smoke exposure; yet, less than 30% of the global population is covered by comprehensive smoke-free policies as of 2016 and there are few smoke-free policies in sub-Saharan Africa (SSA). This study examines the support for smoke-free public places in SSA and delineates their correlates.

METHODS

Data collected through the Global Adult Tobacco Survey (2012-2017) were analyzed using SAS for descriptive and multivariable analyses, with a significance level set at p < .05.

RESULTS

No SSA country had comprehensive smoke-free policies, defined as a prohibition of smoking in eight public places. In the four countries whose Global Adult Tobacco Survey data were analyzed (Nigeria, Cameroon, Kenya, and Uganda), support for the prohibition of smoking in public places was over 90% in all eight public places except bars. Support for smoking prohibition in bars was 65.8%, 81.1%, 81.4%, and 91.0% in Nigeria, Cameroon, Kenya, and Uganda, respectively. Factors associated with support for smoke-free bars differed across the four countries, but in all countries, current smokers had decreased odds of support for smoke-free bars. Knowledge of secondhand smoke harm and living in smoke-free homes were associated with increased odds of support for smoke-free bars in all countries except Kenya.

CONCLUSION

The high support for smoke-free public places should inform the efforts of the public health community and policymakers in these four SSA countries toward meeting their obligations of Article 8 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

IMPLICATIONS

Much of the population in SSA is not protected by comprehensive smoke-free policies. It was found that the overwhelming majority of adults in four large countries in SSA support the prohibition of smoking in public places and that knowledge of the health dangers of smoking and exposure to secondhand smoke and home smoking rules increased support for the prohibition. High support for the prohibition of smoking in these four SSA countries suggests tobacco control proponents should advocate for comprehensive smoke-free policies.

Association between secondhand smoke exposure and hypertension: nearly as large as smoking

: Active smoking is a widely accepted risk factor for cardiovascular disease and is recognized as a major public health problem. Passive smoking, also known as secondhand smoke exposure (SHSE), is thought to have similar cardiovascular consequences and the risk has been postulated to be equivalent to that of active smoking. A major component of this risk involves the connection with chronic hypertension. There are several population-based observational studies investigating the relationship between SHSE and chronic hypertension, all of which demonstrate a positive association. Given that SHSE appears to be a risk factor for chronic hypertension, SHSE should also be a risk factor for hypertensive end-organ disease. Many studies have sought to investigate this relationship, but this has yet to be fully elucidated. In this review, we focus on the current evidence regarding the association between SHSE and hypertension as well as exploration of the links between SHSE and hypertensive end-organ damage.

Association between a comprehensive smoking ban and hospitalization for acute myocardial infarction: An observational study in the Autonomous Community of Valencia, Spain

OBJECTIVE

To assess the association between a comprehensive smoking ban and hospitalization rates for acute myocardial infarction (AMI).

METHODS

An observational study was conducted to assess changes in hospital admission rates for AMI in the Autonomous Community of Valencia, Spain (population 5 million), during the period 1995-2013. Law 28/2005 prohibited smoking in all enclosed spaces (public and private), and Law 42/2010 extended the ban to bars and restaurants as well as children's playgrounds and access areas of schools and hospitals. Data on hospital admissions were obtained from the Hospital Discharge Database (CMBD) of the Autonomous Community. Annual hospital admission rates per 100000 population for AMI (ICD-9-CM code 410) for men and women were calculated.

RESULTS

Adjusted hospital admission rates per 100000 population for AMI decreased markedly from 141.1 in 2005 to 119.2 in 2007, with a further reduction to 102.9 in 2013. Reductions in hospital admission were recorded in both men and women, but the downward trends were stronger in women.

CONCLUSION

The Spanish comprehensive smoking ban was associated with a marked reduction in the adjusted rate of hospital admissions due to AMI in the Autonomous Community of Valencia. This decrease in the number of persons requiring in-patient care due to AMI is important from both a health care and a societal perspective.

The impact of cigarette smoking on infarct location and in-hospital outcome following acute ST-elevation myocardial infarction

Introduction: Smoking, which is a major modifiable risk factor for coronary artery diseases, affects cardiovascular system with different mechanisms. We designed this study to investigate the association of smoking with location of ST-segment elevation myocardial infarction (STEMI), and short-term outcomes during hospitalization.

Methods: In 1017 consecutive patients with anterior/inferior STEMI, comprehensive demographic, biochemical data, as well as clinical complications and mortality rate, were recorded. Patients were allocated into two groups based on smoking status and compared regarding the location of myocardial infarction, the emergence of clinical complications and in-hospital mortality in univariate and multivariate logistic regression analysis.

Results: Among 1017 patients, 300 patients (29.5%) were smoker and 717 patients (70.5 %) were non-smoker. Smokers were significantly younger and had lower prevalence of diabetes, hyperlipidemia and hypertension. Inferior myocardial infarction was considerably more common in smokers than in non-smokers (45.7% vs. 36%, P = 0.001). Heart failure was developed more commonly in non-smokers (33.9% vs. 20%, P = 0.001). In-hospital mortality was significantly lower in smokers (6.7% vs. 17.3%, P = 0.001). After adjustment for confounding variables, smoking was independently associated with inferior myocardial infarction and lower heart failure [odds ratio: 1.44 (1.06-1.96), P = 0.01 and odds ratio: 0.61 (0.40-0.92), P = 0.02, respectively]. However, in-hospital mortality was not associated with smoking after adjustment for other factors [odds ratio: 0.69 (0.36-1.31), P = 0.2].

Conclusion: Smoking is independently associated with inferior myocardial infarction. Although smokers had lower incidence of heart failure, in-hospital mortality was not different after adjustment for other factors.

Maternal Smoking: A Life Course Blood Pressure Determinant?

Introduction

Exposure to maternal smoking early in life may affect blood pressure (BP) control mechanisms. We examined the association between maternal smoking (before conception, during pregnancy, and 4 years after delivery) and BP in preschool children.

Methods

We evaluated 4295 of Generation XXI children, recruited at birth in 2005-2006 and reevaluated at the age of 4. At birth, information was collected by face-to-face interview and additionally abstracted from clinical records. At 4-year follow-up, interviews were performed and children's BP measured. Linear regression models were fitted to estimate the association between maternal smoking and children's BP.

Results

Children of smoking mothers presented significantly higher BP levels. After adjustment for maternal education, gestational hypertensive disorders, and child's body mass index, children exposed during pregnancy to maternal smoking presented a higher systolic BP (SBP) z-score (β = 0.08, 95% confidence interval [CI] 0.04 to 0.14). In crude models, maternal smoking was associated with higher SBP z-score at every assessed period. However, after adjustment, an attenuation of the association estimates occurred (β = 0.08, 95% CI 0.03 to 0.13 before conception; β = 0.07, 95%CI 0.02 to 0.12; β = 0.04, 95%CI -0.02 to 0.10; and β = 0.06, 95%CI 0.00 to 0.13 for the first, second, and third pregnancy trimesters, respectively; and β = 0.07, 95%CI 0.02 to 0.12 for current maternal smoking). No significant association was observed for diastolic BP z-score levels.

Conclusion

Maternal smoking before, during, and after pregnancy was independently associated with systolic BP z-score in preschool children. This study provides additional evidence to the public health relevance of maternal smoking cessation programs if early cardiovascular health of children is envisaged.

Implications

Using observational longitudinal data from the birth cohort Generation XXI, this study showed that exposure to maternal smoking-before pregnancy, during pregnancy, and 4 years after delivery-was associated with a systolic BP-raising effect in children at the age of 4. The findings of this study add an important insight into the need to support maternal smoke-free environments in order to provide long-term cardiovascular benefit, starting as early as possible in life.

The limits of single-group interrupted time series analysis in assessing the impact of smoke-free laws on short-term mortality

BACKGROUND

Decreases in circulatory/respiratory morbimortality after the January-2006 Spanish partial smoke-free law have been found using designs without control groups, such as single-group interrupted time series (ITS), which are prone to biases. The aim was to reassess the law's impact on mortality using ITS designs with robustness checks.

METHODS

A comprehensive cohort of people aged ≥25 in each calendar-year of 2002-2007, living in 13 of 18 Spanish regions, was followed up between 01/2002 and 12/2007. The law included a smoking ban in indoor public and workplaces, allowing exceptions in catering, hospitality and leisure venues, and other interventions. Post-law changes in monthly coronary/respiratory mortality were estimated using segmented regression, adjusting for relevant covariates, including seasonality, extreme temperatures, influenza incidence and air pollution. The validity of results was assessed using control outcomes, hypothetical law dates, and non-equivalent control groups, analysing their results as difference-in-differences (DID) designs.

RESULTS

Significant immediate post-law decreases in coronary, respiratory and non-tobacco-related mortality were observed among people aged ≥70. A significant immediate post-law decrease in respiratory mortality (-12.7%) was also observed among people age 25-69, although this was neutralized by a subsequent upward trend before 1.5 years. More favourable post-law changes in coronary/respiratory mortality among the target (people aged 25-69) than control groups (people aged ≥70 or women aged ≥80) were not identified in DID designs. Establishing hypothetical law dates, immediate decreases began in February/March 2005 with maxima between April and July 2005.

CONCLUSIONS

After robustness checks, the results do not support a clear positive impact of the 2006 Spanish smoke-free law on short-term coronary/respiratory mortality. The favourable immediate changes observed pre- and post-law could derive mainly from the harvesting effect of the January-2005 cold wave. This highlights the risks of assessing the impact of health interventions using both morbimortality outcomes and designs without a control group and adequate robustness checks.

Analysis of non-compliance with smoke-free legislation in Russia

OBJECTIVES

The study examined the smokers' non-compliance rates in indoor public places in Russia and the sociodemographic factors associated with non-compliance.

METHODS

Univariate analysis and logistic regression models were performed using cross-sectional data from a representative sample of Russian adults (N = 4006).

RESULTS

27.2% of Russian smokers did not comply with smoke-free bans. Non-compliance was attributed to sociodemographic characteristics of smokers, mainly to the number of cigarettes smoked per day, regular alcohol consumption, being aged between 15 and 34 years, being in the highest income group and living in an urban area. Neither the sex, nor the family status of smokers exerted a statistically significant affiliation with non-compliance. Higher rates of non-compliance were observed in restaurants, cafes, bars and nightclubs, common domestic premises of apartment buildings and indoor workplaces. Violations on public transport, in governmental buildings, health and sport facilities, colleges and universities were less common.

CONCLUSIONS

There is a need to revise the methods of enforcement with respect to sociodemographic characteristics of smokers associated with non-compliance in public places where violations are widespread.

Tobacco Use Worldwide: Legislative Efforts to Curb Consumption

Tobacco smoking is recognized as a major preventable cause of disease worldwide and is linked to 6 million deaths annually, 30% of which are due to cancer. The negative health consequences of smoking currently represent one of the greatest global public health challenges. Additionally, secondhand smoke, which was declared carcinogenic by the International Agency for Research on Cancer in 2004, is a major source of morbidity and premature death in nonsmokers, particularly children. Negative health effects associated with exposure to secondhand smoke have been well documented and include lung cancer, cardiovascular disease, asthma, and other respiratory diseases. International and national policies to implement cost-effective strategies to curtail smoking will have a significant impact on population health and will protect nonsmokers. Effective interventions, such as smoking bans, tobacco price increases, easy access to tobacco cessation treatments, and anti-tobacco media campaigns, should continue. Reducing tobacco use would be a major step towards the goal of decreasing health disparities by 2030, as 80% of the projected tobacco-related deaths will occur in low and middle-income countries.

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.

Cardiovascular Diseases and Long-term Self-reported Exposure to Pollution: RESULTS OF A NATIONAL EPIDEMIOLOGICAL STUDY IN LEBANON

BACKGROUND

Cardiovascular diseases (CVDs) are linked to high mortality and morbidity, particularly in developing countries. Some studies have linked indoor and outdoor pollution to CVD, but results are inconsistent. Our objective was to assess this association in Lebanon, a Middle Eastern country.

METHODS

A national cross-sectional study was conducted across Lebanon. CVD prevalence, which included prevalent ischemic heart and cerebrovascular diseases, was assessed. Moreover, in addition to self-reported items of pollution exposure, we assessed potential predictors of CVD, including sociodemographic characteristics, self-reported health information, and biological measurements.

RESULTS

We assessed the dose-effect relationship of pollution items in relation with CVD. Self-reported indoor and outdoor pollution exposures were associated with CVD, with or without taking biological values into account. Moreover, we found a dose-effect relationship of exposure with risk of disease (44% increase in risk of CVD for every additional pollution exposure item), after adjustment for sociodemographic and biological characteristics.

CONCLUSION

Although additional studies would be necessary to confirm these findings, interventions should start to sensitize the population about the effect of pollution on chronic diseases and the work of reducing pollution and improving air quality should be implemented to decrease the disease burden on the population and health system.

Tobacco Use Worldwide: Legislative Efforts to Curb Consumption

Tobacco smoking is recognized as a major preventable cause of disease worldwide and is linked to 6 million deaths annually, 30% of which are due to cancer. The negative health consequences of smoking currently represent one of the greatest public health challenges. Secondhand smoke, declared carcinogenic by the International Agency for Research on Cancer in 2004, is also a major source of morbidity and premature death in nonsmokers, particularly children. Negative health effects associated with exposure to secondhand smoke have been well documented and include lung cancer, cardiovascular disease, asthma, and other respiratory diseases. International and national policies to implement cost-effective strategies to curtail smoking will have a significant impact on population health and will protect nonsmokers. Effective interventions, such as a combination of smoke-free laws, tobacco price increases, easy access to tobacco cessation treatments, and anti-tobacco media campaigns, should continue. Reducing tobacco use would be a major step towards the goal of decreasing health disparities by 2030 as 80% of the projected tobacco-related deaths will occur in low- and middle-income countries.

Tobacco Use Worldwide: Legislative Efforts to Curb Consumption

Tobacco smoking is recognized as a major preventable cause of disease worldwide and is linked to 6 million deaths annually, 30% of which are due to cancer. The negative health consequences of smoking currently represent one of the greatest public health challenges. Secondhand smoke, declared carcinogenic by the International Agency for Research on Cancer in 2004, is also a major source of morbidity and premature death in nonsmokers, particularly children. Negative health effects associated with exposure to secondhand smoke have been well documented and include lung cancer, cardiovascular disease, asthma, and other respiratory diseases. International and national policies to implement cost-effective strategies to curtail smoking will have a significant impact on population health and will protect nonsmokers. Effective interventions, such as a combination of smoke-free laws, tobacco price increases, easy access to tobacco cessation treatments, and anti-tobacco media campaigns, should continue. Reducing tobacco use would be a major step towards the goal of decreasing health disparities by 2030 as 80% of the projected tobacco-related deaths will occur in low- and middle-income countries.

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

BACKGROUND

Smoke-free legislation has been associated with lower rates of cardiovascular disease hospital admissions in ecological studies. However, prior studies lacked detailed information on individual-level factors (eg, sociodemographic and clinical characteristics) that could potentially confound associations. Our objective was to estimate associations of smoke-free policies with incident cardiovascular disease in a longitudinal cohort after controlling for sociodemographics, cardiovascular disease risk factors, and policy covariates.

METHODS

Longitudinal data from 3783 black and white adults in the CARDIA study (Coronary Artery Risk Development in Young Adults; 1995-2015) were linked to state, county, and local 100% smoke-free policies in bars, restaurants, and nonhospitality workplaces by Census tract. Extended Cox regression estimated hazard ratios (HRs) of incident cardiovascular disease associated with time-dependent smoke-free policy exposures. Models were adjusted for sociodemographic characteristics, cardiovascular disease risk factors, state cigarette tax, participant-reported presence of a smoking ban at their workplace, field center, and metropolitan statistical area poverty.

RESULTS

During a median follow-up of 20 years (68 332 total person-years), 172 participants had an incident cardiovascular disease event (2.5 per 1000 person-years). Over the follow-up period, 80% of participants lived in areas with smoke-free policies in restaurants, 67% in bars, and 65% in nonhospitality workplaces. In fully adjusted models, participants living in an area with a restaurant, bar, or workplace smoke-free policy had a lower risk of incident cardiovascular disease compared with those in areas without smoke-free policies (HR, 0.75, 95% confidence interval, 0.49-1.15; HR, 0.76, 95% confidence interval, 0.47-1.24; HR, 0.54, 95% confidence interval, 0.34-0.86, respectively; HR, 0.58, 95% confidence interval, 0.33-1.00 for living in an area with all 3 types of policies compared with none). The estimated preventive fraction was 25% for restaurant policies, 24% for bar policies, and 46% for workplace policies.

CONCLUSIONS

Consistent with prior ecological studies, these individual-based data add to the evidence that 100% smoke-free policies are associated with lower risk of cardiovascular disease among middle-aged adults.

Implementation of 100% smoke-free law in Uganda: a qualitative study exploring civil society's perspective

BACKGROUND

In 2016, Uganda became one of few sub-Saharan African countries to implement comprehensive national smoke-free legislation. Since the World Health Organisation recommends Civil Society Organisation's (CSO) involvement to support compliance with smoke-free laws, we explored CSOs' perceptions of law implementation in Kampala, Uganda, and the challenges and opportunities for achieving compliance. Since hospitality workers tend to have the greatest level of exposure to second-hand smoke, we focussed on implementation in respect to hospitality venues (bars/pubs and restaurants).

METHODS

In August 2016, three months after law implementation, we invited key Kampala-based CSOs to participate in face-to-face semi-structured interviews. Interviews probed participants' perceptions about law implementation, barriers impeding compliance, opportunities to enhance compliance, and the role of CSOs in supporting law implementation. Interviews were recorded and transcribed. Qualitative content analysis was conducted using the interview transcripts.

RESULTS

Fourteen individuals, comprising mainly senior managers from CSOs, participated and reported poor compliance with the smoke-free law in hospitality venues. Respondents noted that contributing factors included low awareness of the law amongst the general public and hospitality staff, limited implementation activities due to scarce resources and lack of coordinated enforcement. Opportunities for improving compliance included capacity building for enforcement agency staff, routine monitoring, rigorous enactment of penalties, and education about the smoke-free law aimed at hospitality venue staff and the general public. Allegations of tobacco industry misinformation were said to have undermined compliance. Civil Society Organisations saw their role as supporting law implementation through education, stakeholder engagement, and evidence-based advocacy.

CONCLUSIONS

This study suggests that the process of smoke-free law implementation in Uganda has not aligned with World Health Organisation (WHO) guidelines for implementing smoke-free laws, and highlights that low-income countries may need additional support to enable them to effectively plan for policy implementation and resist industry interference.

Survey on the Status of Smoking Inside Eating Establishments in the Cities of Kobe and Amagasaki

BACKGROUND

The Hyogo Prefectural Government has been enforcing a smoking ban ordinance since April 2013. The present survey was conducted to determine the extent to which the smoking ban has been successfully implemented in eating establishments in Kobe City and Amagasaki City.Methods and Results:The Health and Welfare Department of the Hyogo Prefectural Government provided a list of eating establishments in Kobe and Amagasaki City. From these, we chose 1,300 from each city using random number generation. Responses were obtained from 310 establishments in Kobe City (response rate: 23.8%) and 297 in Amagasaki City (22.8%). Overall, 58.1% of the establishments surveyed in Kobe City were aware of the ordinance, a recognition rate significantly higher than that of Amagasaki City, where only 45.5% of eateries were aware of the ordinance (P=0.003). Of the Kobe City eateries, 31.7% had succeeded in implementing a complete ban on smoking. In Amagasaki City, the rate was significantly lower, at just 13.4% (P<0.001). A logistic regression analysis showed that coffee shops, Japanese-style taverns, bars, and eating establishments that served alcohol were the independent significant predictors of low compliance. Kobe City restaurants, women, and families were the independent significant predictors of high compliance with the complete smoking ban.

CONCLUSIONS

The rates of recognition and implementation of the complete smoking ban were significantly lower in Amagasaki City than in Kobe City. There needs to be a strong and continuous socialization campaign to promote the ordinance.

Air Pollution and Other Environmental Modulators of Cardiac Function

Cardiovascular disease (CVD) is the leading cause of death in developed regions and a worldwide health concern. Multiple external causes of CVD are well known, including obesity, diabetes, hyperlipidemia, age, and sedentary behavior. Air pollution has been linked with the development of CVD for decades, though the mechanistic characterization remains unknown. In this comprehensive review, we detail the background and epidemiology of the effects of air pollution and other environmental modulators on the heart, including both short- and long-term consequences. Then, we provide the experimental data and current hypotheses of how pollution is able to cause the CVD, and how exposure to pollutants is exacerbated in sensitive states. Published 2017. Compr Physiol 7:1479-1495, 2017.

Smokefree legislation effects on respiratory and sensory disorders: A systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis is to synthesize the available evidence in scientific papers of smokefree legislation effects on respiratory diseases and sensory and respiratory symptoms (cough, phlegm, red eyes, runny nose) among all populations.

Materials and methods

Systematic review and meta-analysis were carried out. A search between January 1995 and February 2015 was performed in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and Google Scholar databases. Inclusion criteria were: 1) original scientific studies about smokefree legislation, 2) Data before and after legislation were collected, and 3) Impact on respiratory and sensory outcomes were assessed. Paired reviewers independently carried out the screening of titles and abstracts, data extraction from full-text articles, and methodological quality assessment.

Results

A total number of 1606 papers were identified. 50 papers were selected, 26 were related to symptoms (23 concerned workers). Most outcomes presented significant decreases in the percentage of people suffering from them, especially in locations with comprehensive measures and during the immediate post-ban period (within the first six months). Four (50%) of the papers concerning pulmonary function reported some significant improvement in expiratory parameters. Significant decreases were described in 13 of the 17 papers evaluating asthma hospital admissions, and there were fewer significant reductions in chronic obstructive pulmonary disease admissions (range 1–36%) than for asthma (5–31%). Six studies regarding different respiratory diseases showed discrepant results, and four papers about mortality reported significant declines in subgroups. Low bias risk was present in 23 (46%) of the studies.

Conclusions

Smokefree legislation appears to improve respiratory and sensory symptoms at short term in workers (the overall effect being greater in comprehensive smokefree legislation in sensory symptoms) and, to a lesser degree, rates of hospitalization for asthma.

Secondhand Smoke Exposure and Subclinical Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Few studies have evaluated the association between secondhand smoke (SHS) and subclinical cardiovascular disease among ethnically diverse populations. This study assesses the impact of SHS on inflammation and atherosclerosis (carotid intima-media thickness, coronary artery calcification, and peripheral arterial disease).

METHODS AND RESULTS

We examined 5032 nonsmoking adults aged 45 to 84 years without prior cardiovascular disease participating in the Multi-Ethnic Study of Atherosclerosis (MESA) from 2000 to 2002. SHS exposure was determined by self-report, and urinary cotinine was measured in a representative subset (n=2893). The multi-adjusted geometric mean ratios (95% CIs) for high-sensitivity C-reactive protein and interleukin-6 comparing 407 participants with SHS ≥12 h/wk versus 3035 unexposed participants were 1.13 (1.02-1.26) and 1.04 (0.98-1.11), respectively. The multi-adjusted geometric mean ratio for carotid intima-media thickness was 1.02 (0.97-1.07). Fibrinogen and coronary artery calcification were not associated with SHS. The prevalence of peripheral arterial disease (ankle-brachial index ≤0.9 or ≥1.4) was associated with detectable urinary cotinine (odds ratio, 2.10; 95% CI, 1.09-4.04) but not with self-reported SHS. Urinary cotinine was not associated with inflammation or carotid intima-media thickness.

CONCLUSIONS

Despite limited exposure assessment, this study supports the association of SHS exposure with inflammation and peripheral arterial disease.

Global tobacco prevention and control in relation to a cardiovascular health promotion and disease prevention framework: A narrative review

The purpose of this review is to emphasize the role of tobacco prevention and control in cardiovascular health (CVH) promotion and cardiovascular disease (CVD) prevention, including the importance of these endpoints for measuring the full impact of tobacco-related policies, programs, and practices. In this review, we describe an overview of tobacco control interventions that have led to substantial declines in tobacco use and the relationship between these declines with CVH and CVD. We review interventions that have had success in high-income countries (HICs) as well as those that are gaining traction in low- and middle-income countries (LMICs). We emphasize the challenges to comprehensive tobacco prevention and control strategies faced by LMICs, and highlight the special role of cardiovascular health professionals in achieving CVH promotion and CVD prevention endpoints through tobacco control. Tobacco prevention and control strategies have a strong scientific basis, yet a distinct gap remains between this evidence and implementation of tobacco control policies, particularly in LMICs. Health professionals can contribute to tobacco control efforts, especially through patient-level clinical interventions, when supported by a health care system and government that recognize and support tobacco control as a critical strategy for CVH promotion and CVD prevention. Understanding, supporting, and applying current and evolving policies, programs, and practices in tobacco prevention and control is the province of all health professionals, especially those concerned with CVH promotion and CVD prevention. A new tobacco control roadmap from the World Heart Federation provides a strong impetus to the needed interdisciplinary collaboration.

Results of a Prospective Study of Acute Coronary Syndrome Hospitalization After Enactment of a Smoking Ban in Public Places in Hyogo Prefecture - Comparison With Gifu, a Prefecture Without a Public Smoking Ban

BACKGROUND

Hyogo Prefecture is the 2nd prefecture in Japan, after Kanagawa, to enact a ban with penal code on smoking in public places, although the restriction is partial.Methods and Results:This study included consecutive patients with acute coronary syndrome (ACS) who were admitted to 33 major hospitals in the Hyogo District during the 12 months before implementation of the legislation and during the 24 months thereafter. Consecutive patients with ACS from Gifu Prefecture who were admitted to 20 major hospitals were enrolled as geographical controls. The number of ACS admissions did not change from the years 2012-2015 in both Hyogo District (1,774 in the pre-year, 1,784 in the 1st year, and 1,720 in the 2nd year) and Gifu Prefecture (1,226 in the pre-year, 1,174 in the 1st year, and 1,206 in the 2nd year). However, a clear reduction was observed in the subanalysis for Kobe City (895 in the preceding year, 830 (-7.3%) in the 1st year, and 792 (-11.5%) in the 2nd year), where adherence to the smoking ban was higher than in other Hyogo districts.

CONCLUSIONS

The primary endpoint did not show a significant change. However, the subanalysis showed a significant decrease in ACS admissions in Kobe City. These results suggest that ACS reduction may depend on the degree of adherence to a smoking ban. (Circ J 2016; 80: 2528-2532).

Determinants of active and environmental exposure to tobacco smoke and upper reference value of urinary cotinine in not exposed individuals

The aims of this study were (1) to explore the behavioral and sociodemographic factors influencing urinary cotinine (COT-U) levels in active smokers and in environmental tobacco smoke (ETS)-exposed individuals, (2) to assess the specificity and sensitivity of the questionnaire for identifying active smokers and nonsmokers, and (3) to derive the upper reference value of COT-U in non-ETS exposed individuals. The COT-U levels of 495 adults (age range 18-69 years) who classified themselves as active smokers (29%) or as nonsmokers with (17%) or without (83%) ETS exposure were quantified by LC-MS-MS (quantification limit: 0.1µg/L, range of linearity: 0.1-4000µg/L). Median COT-U levels in these groups were 883, 1.38, and 0.39µg/L, respectively. Significant determinants of COT-U levels in active smokers were the number of cigarettes per day, type of smoking product, smoking environment, as well as time between the last cigarette and urine collection. Among ETS-exposed nonsmokers, significant determinants were living with smokers, being exposed to smoke at home, ETS exposure duration, as well as time between the last exposure and urine collection. When a 30-µg/L COT-U cut-off value was used to identify active daily smoking, the sensitivity and specificity of the questionnaire were 94% and 98%, respectively. For ETS exposure, the COT-U value of 1.78 (0.90 confidence interval 1.75-1.78) µg/L, corresponding to the 95th percentiles of the COT-U distribution in non-ETS-exposed participants, is proposed as upper reference value to identify environmental exposure.

The respiratory microbiome: an underappreciated player in the human response to inhaled pollutants?

PURPOSE

Microbial communities in or on the body (i.e., the microbiome) are highly physiologically active and influence human health. Although environmental scientists are increasingly aware of the gut microbiome, the respiratory microbiome's role in the human response to inhaled pollutants is largely unknown.

METHODS

We reviewed the literature and present mechanisms by which the microbiome might mediate or modify human responses to inhaled pollutants.

RESULTS

The respiratory microbiome has been shown to influence chronic lung disease exacerbations, and increasing evidence indicates a role in disease development. Research also suggests that the respiratory microbiome could plausibly metabolize inhaled pollutants or modulate host inflammatory responses to exposure. Because these responses depend on the microbes present, defining the composition of the resident microbiome and how microbial communities shift with exposure may help to explain variations in susceptibility to inhaled pollutants. Although more research is needed, significant measurement challenges remain for large epidemiologic studies of the respiratory microbiome.

CONCLUSIONS

The respiratory microbiome is likely an underexplored intermediate and potential cause of individual susceptibility to inhaled irritants/toxicants. Characterizing the microbiome's role in the human response to inhaled exposures could improve our understanding of the casual agents of exposure and suggest novel public health interventions.

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.

Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes: Clinical Perspectives From the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology

Cardiovascular morbidity and mortality as a result of inhaled tobacco products continues to be a global healthcare crisis, particularly in low- and middle-income nations lacking the infrastructure to develop and implement effective public health policies limiting tobacco use. Following initiation of public awareness campaigns 50 years ago in the United States, considerable success has been achieved in reducing the prevalence of cigarette smoking and exposure to secondhand smoke. However, there has been a slowing of cessation rates in the United States during recent years, possibly caused by high residual addiction or fatigue from cessation messaging. Furthermore, tobacco products have continued to evolve faster than the scientific understanding of their biological effects. This review considers selected updates on the genetics and epigenetics of smoking behavior and associated cardiovascular risk, mechanisms of atherogenesis and thrombosis, clinical effects of smoking and benefits of cessation, and potential impact of electronic cigarettes on cardiovascular health.

Denmark's Policy on Artificial Trans Fat and Cardiovascular Disease

INTRODUCTION

The consumption of trans fat is associated with cardiovascular disease (CVD). In January 2004, Denmark became the first country in the world to regulate the content of artificial trans fat in certain ingredients in food products, which nearly eliminated artificial trans fat from the Danish food supply. The goal of this study was to assess whether Denmark's trans fat policy reduced deaths caused by CVD.

METHODS

Annual mortality rates in Organisation for Economic Co-operation and Development (OECD) countries from 1990 to 2012 were used to estimate the effect of Denmark's food policy on CVD mortality rates. Synthetic control methods were employed to simulate the CVD mortality trajectory that Denmark would have witnessed in the absence of the policy and to measure the policy's impact on CVD mortality rates. Analyses were conducted in 2015.

RESULTS

Before the trans fat policy was implemented, CVD mortality rates in Denmark closely tracked those of a weighted average of other OECD countries (i.e., the synthetic control group). In the years before the policy, the annual mean was 441.5 deaths per 100,000 people in Denmark and 442.7 in the synthetic control group. In the 3 years after the policy was implemented, mortality attributable to CVD decreased on average by about 14.2 deaths per 100,000 people per year in Denmark relative to the synthetic control group.

CONCLUSIONS

Denmark's food policy, which restricted the content of artificial trans fat in certain ingredients in its food supply, has been followed by a decrease in CVD mortality rates.

Environmental tobacco smoke exposure and health disparities: 8-year longitudinal findings from a large cohort of Thai adults

BACKGROUND

In rich countries, smokers, active or passive, often belong to disadvantaged groups. Less is known of tobacco patterns in the developing world. Hence, we seek out to investigate mental and physical health consequences of smoke exposure as well as tobacco-related inequality in transitional middle-income Thailand.

METHODS

We studied a nationwide cohort of 87,151 middle-aged and older adults that we have been following for eight years (2005-2013) for emerging chronic diseases. Logistic regression was used to identify attributes associated with passive smoke exposure. Longitudinal associations between smoke exposure and wellbeing (SF-8) or psychological distress (Kessler 6) were investigated with multiple linear regression or multivariate logistic regression analysis.

RESULTS

A high proportion of cohort members, especially females, were passive smokers at home and at public transport stations; males were more exposed at workplace and recreational places. We observed a social gradient with more passive smoking in poorer people. We also observed a dose response relationship linking graded smoke exposures (current, former, passive, non-exposed) to less wellbeing and more psychological distress (p-trend < 0.001). Female smokers in general had less wellbeing and more distress.

CONCLUSION

Our findings add to current knowledge on the impact of active and passive smoking on health in a transitional economy. Promotion of smoking cessation programs both in public and at home could also potentially reduce adverse disparities in health and wellbeing in middle and lower income settings such as Thailand.