Impact of 2 Successive Smoking Bans on Hospital Admissions for Cardiovascular Diseases in Spain

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.

Effects of a Smoke-Free Policy in Xi'an, China: Impact on Hospital Admissions for Acute Ischemic Heart Disease and Stroke

Background

Smoking and secondhand smoke (SHS) exposure rates are much higher in China than in other countries. A smoke-free policy was implemented in Xi'an, a city in Shaanxi Province, China, on November 1, 2018. This study aimed to evaluate the effect of the smoke-free policy on changes in hospital admissions for acute ischemic heart disease (AIHD) and stroke in Xi'an.

Methods

All subjects had been hospitalized for AIHD or stroke from February 9, 2017 to December 25, 2019 (study period: 150 weeks) in six randomly selected public hospitals out of 36 tertiary hospitals in Xi'an. A generalized additive model developed using an interrupted time series design was used to compare immediate and annual percent changes in hospital admissions before and after policy implementation.

Results

The study included 31,400 cases (16,656 cases of AIHD and 14,744 cases of stroke) from 6 hospitals in Xi'an. Immediately after implementation of the smoke-free policy, AIHD admissions were reduced significantly (−31.66%, 95% CI: – 39.45 to −22.86%), but stroke admissions were not (−4.94%, 95% CI: −13.26 to 4.17%). The annual reduction in stroke-related admissions (−14.54%, 95% CI: −23.53 to −4.49%) and the annual increase in AIHD-related admissions (40.58%, 95% CI: 22.08 to 61.87%) were significant. Although there was no significant reduction in AIHD admissions, stroke admissions were significantly reduced by −15.73% (from 7,350 to 6,194) after implementation of the smoke-free policy in Xi'an.

Conclusion

The smoke-free policy had different effects on hospital admissions for AIHD and stroke in Xi'an. Xi'an should improve its smoke-free legislation and expand the measures to maintain or achieve additional significant health benefits. These findings can guide the formulation and implementation of regional and national smoke-free policies.