The impact of a smoking ban on hospital admissions for coronary heart disease

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.

The UK BiLEVE and Mendelian randomisation: using multivariable instrumental variables to address "damned if you, damned if you don't" adjustment problems

OBJECTIVE

To explore the use of multivariable instrumental variables to resolve the "damned if you do, damned if you don't" adjustment problem created for Mendelian randomisation (MR) analysis using the smoking or lung function related phenotypes in the UK Biobank (UKB).

RESULT

"damned if you do, damned if you don't" adjustment problems occur when both adjusting and not-adjusting for a variable will induce bias in an analysis. One instance of this occurs because the genotyping chip of UKB participants differed based on lung function/smoking status. In simulations, we show that multivariable instrumental variables analyses can attenuate potential collider bias introduced by adjusting for a proposed covariate, such as the UKB genotyping chip. We then explore the effect of adjusting for genotyping chip in a multivariable MR model exploring the effect of smoking on seven medical outcomes (lung cancer, emphysema, hypertension, stroke, heart diseases, depression, and disabilities). We additionally compare our results to a traditional univariate MR analysis using genome-wide analyses summary statistics which had and had not adjusted for genotyping chip. This analysis implies that the difference in genotyping chip has introduced only a small amount of bias.

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 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.

Impact of smoke-free legislation on acute myocardial infarction and stroke mortality: Tianjin, China, 2007-2015

BACKGROUND

Smoke-free legislation is an effective way to protect the population from the harms of secondhand smoke and has been implemented in many countries. On 31 May 2012, Tianjin became one of the few cities in China to implement smoke-free legislation. We investigated the impact of smoke-free legislation on mortality due to acute myocardial infarction (AMI) and stroke in Tianjin.

METHODS

An interrupted time series design adjusting for underlying secular trends, seasonal patterns, population size changes and meteorological factors was conducted to analyse the impact of the smoke-free law on the weekly mortality due to AMI and stroke. The study period was from 1 January 2007 to 31 December 2015, with a 3.5-year postlegislation follow-up.

RESULTS

Following the implementation of the smoke-free law, there was a decline in the annual trends of AMI and stroke mortality. An incremental 16% (rate ratio (RR): 0.84; 95% CI: 0.83 to 0.85) decrease per year in AMI mortality and a 2% (RR: 0.98; 95% CI: 0.97 to 0.99) annual decrease in stroke mortality among the population aged ≥35 years in Tianjin was observed. Immediate postlegislation reductions in mortality were not statistically significant. An estimated 10 000 (22%) AMI deaths were prevented within 3.5 years of the implementation of the law.

CONCLUSION

The smoke-free law in Tianjin was associated with reductions in AMI mortality. This study reinforces the need for large-scale, effective and comprehensive smoke-free laws at the national level in China.

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.

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.

Cardiovascular disease and high blood pressure trend analyses from 2002 to 2016: after the implementation of a salt reduction strategy

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death around the world; however, many CVD events could be prevented if we focused on modification of the main risk factors. Increased salt consumption is estimated to have caused millions of deaths, mostly related to CVD, particularly stroke, which is the leading cause of death in Portugal. In our study, we aim to assess trends in the proportion of high blood pressure (HBP) in Acute Coronary Syndrome (ACS) patients as well as the trends in stroke and ACS in Portugal, especially after a set of public health initiatives were implemented to reduce salt intake.

METHODS

The monthly proportion of ACS patients presenting with previously diagnosed HBP and the monthly rate of CVD admissions into public hospitals in Portugal were calculated. CVD rates were stratified into ACS rate and stroke rates. Data were stratified by demographics variables. An interrupted time-series model was used to assess changes over time.

RESULTS

Breakpoint analysis revealed an estimated breakpoint around the year 2013 for the proportion of HBP patients, the following year there was a decreasing trend, however it was not significant. Analyses showed the trend before 2013 was increasing and started to decrease after this year. This decreased in proportion of HBP patients can be translated into a reduction of 555 people per year presenting with HBP in the ACS population. We analysed trends for ACS and stroke and tested the significance for a breakpoint in the year 2013. Although none of the remaining trends were significant for ACS crude rates and stroke crude rate, a decreasing trend was observed.

CONCLUSIONS

This research provides an indication about the impact a population-wide approach to CVD risk factors has on CVD trends themselves. Our results suggest that population-wide approaches can have an impact on the prevention and improvement of CVD control, reducing the number of CVD events, and eventually reducing premature death by CVD. As more restrictions on salt intake are being planned in Portugal in the next years, it is highly relevant to assess what is the current panorama and what further reductions we can expect.

Key Factors Inhibiting Legislative Progress Toward Smoke-Free Coverage in Appalachia

The Appalachian Region has among the highest rates of smoking and smoking-related illness in the United States. Strong smoke-free legislation could help protect nonsmoking residents from the harmful effects of secondhand smoke. However, there is a dearth of state, county, city, and subcounty smoke-free law coverage throughout Appalachia. As of July 2016, only 21% of Appalachian residents were covered by comprehensive smoke-free laws (i.e., 100% coverage for workplaces, restaurants, and bars). Only 46% of Appalachians lived in places with 100% smoke-free workplace laws, only 30% lived in places with 100% smoke-free restaurant laws, and only 29% lived in places with 100% smoke-free bar laws. Reasons for this lack of smoke-free law coverage include socioeconomic disadvantage, the historical importance of tobacco in Appalachian economies, and preemptive state legislation. By understanding the contextual issues that have inhibited smoke-free legislation, smoke-free advocates will be better prepared to lead efforts that expand smoke-free coverage in this region.

The Effect of Local Smokefree Regulations on Birth Outcomes and Prenatal Smoking

Objectives We assessed the impact of varying levels of smokefree regulations on birth outcomes and prenatal smoking. Methods We exploited variations in timing and regulation restrictiveness of West Virginia's county smokefree regulations to assess their impact on birthweight, gestational age, low birthweight, very low birthweight, preterm birth, and prenatal smoking. We conducted regression analysis using state Vital Statistics individual-level data for singletons born to West Virginia residents between 1995-2010 (N = 293,715). Results Only more comprehensive smokefree regulations were associated with statistically significant favorable effects on birth outcomes in the full sample: Comprehensive (workplace/restaurant/bar ban) demonstrated increased birthweight (29 grams, p < 0.05) and gestational age (1.64 days, p < 0.01), as well as reductions in very low birthweight (-0.4 %, p < 0.05) and preterm birth (-1.5 %, p < 0.01); Restrictive (workplace/restaurant ban) demonstrated a small decrease in very low birthweight (-0.2 %, p < 0.05). Among less restrictive regulations: Moderate (workplace ban) was associated with a 23 g (p < 0.01) decrease in birthweight; Limited (partial ban) had no effect. Comprehensive's improvements extended to most maternal groups, and were broadest among mothers 21+ years, non-smokers, and unmarried mothers. Prenatal smoking declined slightly (-1.7 %, p < 0.01) only among married women with Comprehensive. Conclusions Regulation restrictiveness is a determining factor in the impact of smokefree regulations on birth outcomes, with comprehensive smokefree regulations showing promise in improving birth outcomes. Favorable effects on birth outcomes appear to stem from reduced secondhand smoke exposure rather than reduced prenatal smoking prevalence. This study is limited by an inability to measure secondhand smoke exposure and the paucity of data on policy implementation and enforcement.

Prohibition of e-cigarettes in the US: Are prohibitions where alcohol is consumed related to lower alcohol consumption?

Recently, research has suggested negative consequences related to electronic cigarette (e-cig) use, including the increased risk for alcohol use and abuse. Previous work found that cigarette smoking ban legislation lowered overall smoking and alcohol use rates; however, researchers have not yet examined the potential effects of prohibiting e-cig use. The present study surveyed 617 individuals from a community-based online sample in the US (mean age = 33.33, SD = 10.50, 54.7 per cent female) who reported their smoking/e-cig use status, alcohol consumption, and the presence of e-cig prohibitions where they consume alcohol. E-cig prohibition was associated with a lower likelihood of being an e-cig user (OR = 0.12, p < 0.001) or dual user (use both cigarettes and e-cigs) (OR = 0.07, p < 0.001). Alcohol Use Disorder Identification Test scores (b = -1.92, p < 0.001), total drinks consumed over 14 days (b = -4.58, p = 0.002), and average drinks per drinking day (b = -0.71, p < 0.001) were all lower when e-cigs were prohibited. Findings are an initial step in this line of research and suggest important future work examining implications of e-cig prohibition recommendations and policy.

Effects of a national smoking ban on hospital admissions for cardiovascular diseases: a time-series analysis in Taiwan

On January 11, 2009, a comprehensive smoking ban was implemented in Taiwan. The aim of this study was to evaluate the effect of this ban on hospital admissions for ischemic heart disease (IHD). Trends in the country-level monthly hospital admission rates for IHD were determined and frequency compared to other conditions such as control conditions cholecystitis, bowel obstruction, and appendicitis from January 1997 (1 year before the first phase of smoke-free laws was implemented) to December 2012 (3 years after the second phase of the ban). Poisson regression with a monthly time-series model was used to determine alterations in the trend of admission rates for IHD with comparison to rates of other disorders after the ban. Hospital admissions for IHD decreased by 0.8% (incidence rate ratio [RR]: 0.992; 95% confidence interval [CI] = 0.991-0.994) and 1.1% (incidence RR: 0.989; 95% CI = 0.988-0.991) following the first (September 19, 1997 to January 10, 2009) and second (January 11, 2009 to December 31, 2012) phases of the ban, respectively, compared with those prior to the pre-ban period, the corresponding values for the control conditions were 0.6% (95% CI = 0.5%-0.7%) and 0.7% (95% CI = 0.6%-0.9%). The admission rates significantly fell for both men and women and for all examined age categories after both first and second phases of the ban. The present findings provide evidence of a significant reduction in hospital admissions for IHD in Taiwan following smoking bans.

The Effects of Smoking Bans on Self-Assessed Health: Evidence from Germany

We examine the effects of smoking bans on self-assessed health in Germany taking into account heterogeneities by smoking status, gender and age. We exploit regional variation in the dates of enactment and dates of enforcement across German federal states. Using data from the German Socio-Economic Panel, our difference-in-differences estimates show that non-smokers' health improves, whereas smokers report no or even adverse health effects in response to bans. We find statistically significant health improvements especially for non-smokers living in households with at least one smoker. Non smokers' health improvements materialise largely with the enactment of smoking bans. Copyright © 2016 John Wiley & Sons, Ltd.

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.

Policy Options to Promote Smokefree Environments for Children and Adolescents

Secondhand smoke (SHS) exposure among children is associated with a wide variety of adverse health risks, including: asthma, otitis media, respiratory infections, impaired lung growth and function, decreased exercise tolerance, cognitive impairments, behavior problems, and sudden infant death syndrome. Unfortunately, over 40% of children aged 3-11 years-15.1 million children-are currently exposed to SHS, with nearly 70% of black children in this age group being exposed. Over the past three decades, great strides have been made in establishing smokefree environments for adults, ultimately reducing their SHS exposure. Regulations have been passed at the organizational, local, and state levels that increasingly ban smoking in the workplace and public places. Children's SHS exposure patterns, however, differ from adults' exposures, with greater time spent in the home and other potentially unregulated venues (school, child care, and car). This means that children have been afforded relatively less protection from SHS by these smokefree regulations. It is imperative, therefore, to seek alternative options for promoting smokefree environments for children throughout the United States. This article explores policy options that promote smokefree environments for children and adolescents: comprehensive smokefree/tobacco-free policies covering indoor/outdoor public places, housing, private vehicles, and child care, as well as Clinical Guidelines regarding patient/family interviews on smoking, SHS, cessation, and voluntary smokefree efforts. The policy section highlights the role of child and adolescent health practitioners in promoting these policies with the hope of fostering engagement of these key stakeholders in the policy process. Note, there are a wide range of important policy and regulatory strategies aimed at reducing tobacco initiation and use among children, adolescents, and young adults; while essential in tobacco prevention and control efforts, a discussion of these strategies is beyond the scope of this article.

Using routine health information systems for well-designed health evaluations in low- and middle-income countries

Routine health information systems (RHISs) are in place in nearly every country and provide routinely collected full-coverage records on all levels of health system service delivery. However, these rich sources of data are regularly overlooked for evaluating causal effects of health programmes due to concerns regarding completeness, timeliness, representativeness and accuracy. Using Mozambique's national RHIS (Módulo Básico) as an illustrative example, we urge renewed attention to the use of RHIS data for health evaluations. Interventions to improve data quality exist and have been tested in low-and middle-income countries (LMICs). Intrinsic features of RHIS data (numerous repeated observations over extended periods of time, full coverage of health facilities, and numerous real-time indicators of service coverage and utilization) provide for very robust quasi-experimental designs, such as controlled interrupted time-series (cITS), which are not possible with intermittent community sample surveys. In addition, cITS analyses are well suited for continuously evolving development contexts in LMICs by: (1) allowing for measurement and controlling for trends and other patterns before, during and after intervention implementation; (2) facilitating the use of numerous simultaneous control groups and non-equivalent dependent variables at multiple nested levels to increase validity and strength of causal inference; and (3) allowing the integration of continuous 'effective dose received' implementation measures. With expanded use of RHIS data for the evaluation of health programmes, investments in data systems, health worker interest in and utilization of RHIS data, as well as data quality will further increase over time. Because RHIS data are ministry-owned and operated, relying upon these data will contribute to sustainable national capacity over time.

Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis

OBJECTIVE

To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with reductions in smoking related deaths.

DESIGN

Analysis of cross sectional survey data with the smoking attributable mortality, morbidity, and economic costs system; population based time series analysis.

SETTING

All state prisons in the United States.

MAIN OUTCOME MEASURES

Prevalence of smoking from cross sectional survey of inmates in state correctional facilities. Data on state prison tobacco policies from web based searches of state policies and legislation. Deaths and causes of death in US state prisons from the deaths in custody reporting program of the Bureau of Justice Statistics for 2001-11. Smoking attributable mortality and years of potential life lost was assessed from the smoking attributable mortality, morbidity, and economic costs system of the Centers for Disease Control and Prevention. Multivariate Poisson models quantified the association between bans and smoking related cancer, cardiovascular and pulmonary deaths.

RESULTS

The most common causes of deaths related to smoking among people in prison were lung cancer, ischemic heart disease, other heart disease, cerebrovascular disease, and chronic airways obstruction. The age adjusted smoking attributable mortality and years of potential life lost rates were 360 and 5149 per 100,000, respectively; these figures are higher than rates in the general US population (248 and 3501, respectively). The number of states with any smoking ban increased from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking related causes was lower during years with a ban than during years without a ban (110.4/100,000 v 128.9/100,000). Prisons that implemented smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91, 95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence interval 0.74 to 0.90).

CONCLUSIONS

Smoking contributes to substantial mortality in prison, and prison tobacco control policies are associated with reduced mortality. These findings suggest that smoking bans have health benefits for people in prison, despite the limits they impose on individual autonomy and the risks of relapse after release.

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.

A review of the evidence on smoking bans and incidence of heart disease

We update an earlier review of smoking bans and heart disease, restricting attention to admissions for acute myocardial infarction. Forty-five studies are considered. New features of our update include consideration of non-linear trends in the underlying rate, a modified trend adjustment method where there are multiple time periods post-ban, comparison of estimates based on changes in rates and numbers of cases, and comparison of effect estimates according to post-ban changes in smoking restrictiveness. Using a consistent approach to derive ban effect estimates, taking account of linear time trends and control data, the reduction in risk following a ban was estimated as 4.2% (95% confidence interval 1.8-6.5%). Excluding regional estimates where national estimates are available, and studies where trend adjustment was not possible, the estimate reduced to 2.6% (1.1-4.0%). Estimates were little affected by non-linear trend adjustment, where possible, or by basing estimates on changes in rates. Ban effect estimates tended to be greater in smaller studies, and studies with greater post-ban changes in smoking restrictiveness. Though the findings suggest a true effect of smoking bans, uncertainties remain, due to the weakness of much of the evidence, the small estimated effect, and various possibilities of bias.

The effect of a statewide smoking ordinance on acute myocardial infarction rates

BACKGROUND

Public smoking ordinances may reduce acute myocardial infarction events. Most studies assessed small communities with reported reductions as high as 40%. No reduction or smaller reductions were found in countrywide studies; less is known about the impact of statewide ordinances. We previously demonstrated identical 27% reductions in acute myocardial infarction hospitalizations in 2 Colorado communities after enactment of strict smoking ordinances. Subsequently, on July 1, 2006, a statewide ordinance went into effect. We sought to determine the impact of this legislation on acute myocardial infarction hospitalization rates.

METHODS

Hospital admissions for a primary acute myocardial infarction diagnosis were examined from 2000 to 2008. Poisson regression models were fit to the monthly events from January 1, 2000, to March 31, 2008. The final model included a quadratic trend over time, harmonic terms, and a post-ordinance effect. The model was adjusted temporally for population changes, using population estimates as an offset variable.

RESULTS

A total of 58,399 unique acute myocardial infarctions were recorded during the study period. No significant reduction in acute myocardial infarction rates was observed post-ordinance (relative risk, 1.059; 95% confidence interval, 0.993-1.131). However, a steep decline in acute myocardial infarction rates was noted from 2000 to 2005 just before enactment. There were 11 strict, local smoking ordinances in effect within Colorado before enactment of the statewide ordinance. After excluding these communities, the findings were similar (relative risk, 1.038; 95% confidence interval, 0.971-1.11).

CONCLUSIONS

Although local smoking ordinances in Colorado previously suggested a reduction in acute myocardial infarction hospitalizations, no significant impact of smoke-free legislation was demonstrated at the state level, even after accounting for preexisting ordinances.

The impact of smoke-free laws on asthma discharges: a multistate analysis

OBJECTIVES

This is the first, to my knowledge, multistate, county-level analysis of Healthcare Cost and Utilization Project state inpatient data to examine the relationship between smoke-free laws and asthma discharges.

METHODS

I used treatment and control groups to examine the effects of state and county or city smoke-free laws separately and together (2002-2009). I compared quarterly county-level discharge rates before and after the implementation of 12 state smoke-free laws, accounting for counties with preexisting county or city smoke-free laws and using the data from 5 states without state smoke-free laws as a control group. I used difference-in-differences models, controlling for year and state fixed effects, state cigarette taxes, seasonality, and numerous county-level factors.

RESULTS

I observed statistically significant reductions in asthma discharges after the implementation of county smoke-free laws but no statistically significant effect of state laws besides the effect of county laws or of state laws alone. There was also no statistically significant effect of any smoke-free law on appendicitis discharges.

CONCLUSIONS

It may be unwise to pursue state smoke-free laws where they have yet to pass; rather, efforts might be better focused at the local level, where there is evidence of a significant impact.

Smoking bans linked to lower hospitalizations for heart attacks and lung disease among medicare beneficiaries

Policies limiting exposure to cigarette smoke have been associated with reduced hospitalizations for heart attacks, but little is known about the impact of smoking bans on other health conditions and whether findings from individual communities generalize to other areas. We investigated the association between smoking bans targeting workplaces, restaurants, and bars passed throughout the United States during 1991-2008 and hospital admissions for smoking-related illnesses-acute myocardial infarction and chronic obstructive pulmonary disease-among Medicare beneficiaries age sixty-five or older. Risk-adjusted hospital admission rates for acute myocardial infarction fell 20-21 percent thirty-six months following implementation of new restaurant, bar, and workplace smoking bans. Admission rates for chronic obstructive pulmonary disease fell 11 percent where workplace smoking bans were in place and 15 percent where bar smoking bans were present. By contrast, very little effect was found for hospitalization for gastrointestinal hemorrhage and hip fracture-two conditions largely unrelated to smoking and examined as points of comparison. These findings provide further support for the public health benefits of laws that limit exposure to tobacco smoke.

Use of interrupted time-series method to evaluate the impact of cigarette excise tax increases in Pennsylvania, 2000-2009

Introduction

Scientific evidence shows that cigarette price increases can significantly reduce smoking prevalence and smoking initiation among adolescents and young adults. However, data are lacking regarding the effectiveness of increasing Pennsylvania’s cigarette tax to reduce smoking and/or adverse health effects of smoking. The objective of our study was to assess the impact of cigarette tax increases and resulting price increases on smoking prevalence, acute myocardial infarction (AMI) and asthma hospitalization rates, and sudden cardiac death (SCD) rates in Pennsylvania.

Methods

We used segmented regression analyses of interrupted time series to evaluate the level and trend changes in Pennsylvania adults’ current smoking prevalence, age-adjusted AMI and asthma hospitalization rates, age-specific asthma hospitalization rates, and age-adjusted SCD rates following 2 cigarette excise tax increases.

Results

After the first excise tax increase, no beneficial effects were noted on the outcomes of interest. The second tax increase was associated with significant declines in smoking prevalence for people aged 18 to 39, age-adjusted AMI hospitalization rates for men, age-adjusted asthma hospitalizations rates, and SCD rates among men. Overall smoking prevalence declined by 5.2% (P = .01), with a quarterly decrease of 1.4% (P = .01) for people aged 18 to 39 years. The age-adjusted AMI hospitalization rate for men showed a decline of 3.87/100,000 population (P = .04). The rate of age-adjusted asthma hospitalizations decreased by 10.05/100,000 population (P < .001), and the quarterly trend decreased by 3.21/100,000 population (P < .001). Quarterly SCD rates for men decreased by 1.34/100,000 population (P < .001).

Conclusion

An increase in the price of cigarettes to more than $4 per 20-cigarette pack was associated with a significant decrease in smoking among younger people (aged 18–39). Decreases were also seen in asthma hospitalizations and men’s age-adjusted AMI hospitalization and SCD rates. Further research and policy development regarding the effect of cigarette taxes on tobacco consumption should be cognizant of the psychological tipping points at which overall price affects smoking patterns.

Changes in smoking behaviours following a smokefree legislation in parks and on beaches: an observational study

OBJECTIVE

To examine the effect of an outdoor smokefree law in parks and on beaches on observed smoking in selected venues.

METHODS

The study involved repeated observations in selected parks and beaches in Vancouver, British Columbia, Canada. The main outcome measure was changes in observed smoking rates in selected venues from prelaw to 12 months postlaw.

RESULTS

No venue was 100% smokefree at the 12-month postlaw observation time point. There was a significant decrease in observed smoking rates in all venues from prelaw to 12-month postlaw (prelaw mean smoking rate=20.5 vs 12-month mean smoking rate=4.7, p=0.04). In stratified analysis by venue, the differences between the prelaw and 12-month smoking rates decreased significantly in parks (prelaw mean smoking rate=37.1 vs 12-month mean smoking rate=6.5, p=0.01) but not in beaches (prelaw mean smoking rate=2.9 vs 12-month mean smoking rate=1.0, p=0.1).

CONCLUSIONS

Smokefree policies in outdoor recreational venues have the potential to decrease smoking in these venues. The effectiveness of such policies may differ by the type and usage of the venue; for instance, compliance may be better in venues that are used more often and have enforcement. Future studies may further explore factors that limit and foster the enforcement of such policies in parks and beaches.

The effects of smoke-free legislation on acute myocardial infarction: a systematic review and meta-analysis

Background

Comprehensive smoke-free legislation has been implemented in many countries. The current study quantitatively examined the reduction in risk of acute myocardial infarction (MI) occurrence following the legislations and the relationship with the corresponding smoking prevalence decrease.

Methods

PubMed, EMBASE, and Google Scholar databases and bibliographies of relevant studies and reviews were searched for potential original studies published from January 1, 2004, through October 31, 2011. Meta-analysis was performed using a random effect model to estimate the overall effects of the smoking-free legislations. Meta-regression was used to investigate possible causes of heterogeneity in risk estimates.

Results

A total of 18 eligible studies with 44 estimates of effect size were used in this study. Meta-analysis produced a pooled estimate of the relative risk of 0.87 (95% confidence interval (CI): 0.84 to 0.91). There was significant heterogeneity in the risk estimates (overall I² = 96.03%, p<0.001). In meta-regression analysis, studies with greater smoking prevalence decrease produced larger relative risk (adjusted coefficient −0.027, 95% CI: -0.049 to −0.006, p=0.014).

Conclusion

Smoke-free legislations in public and work places were associated with significant reduction in acute MI risk, which might be partly attributable to reduced smoking prevalence.

Myocardial infarction and sudden cardiac death in Olmsted County, Minnesota, before and after smoke-free workplace laws

BACKGROUND

Reductions in admissions for myocardial infarction (MI) have been reported in locales where smoke-free workplace laws have been implemented, but no study has assessed sudden cardiac death in that setting. In 2002, a smoke-free restaurant ordinance was implemented in Olmsted County, Minnesota, and in 2007, all workplaces, including bars, became smoke free.

METHODS

To evaluate the population impact of smoke-free laws, we measured, through the Rochester Epidemiology Project, the incidence of MI and sudden cardiac death in Olmsted County during the 18-month period before and after implementation of each smoke-free ordinance. All MIs were continuously abstracted and validated, using rigorous standardized criteria relying on biomarkers, cardiac pain, and Minnesota coding of the electrocardiogram. Sudden cardiac death was defined as out-of-hospital deaths associated with coronary disease.

RESULTS

Comparing the 18 months before implementation of the smoke-free restaurant ordinance with the 18 months after implementation of the smoke-free workplace law, the incidence of MI declined by 33% (P < .001), from 150.8 to 100.7 per 100,000 population, and the incidence of sudden cardiac death declined by 17% (P = .13), from 109.1 to 92.0 per 100,000 population. During the same period, the prevalence of smoking declined and that of hypertension, diabetes mellitus, hypercholesterolemia, and obesity either remained constant or increased.

CONCLUSIONS

A substantial decline in the incidence of MI was observed after smoke-free laws were implemented, the magnitude of which is not explained by community cointerventions or changes in cardiovascular risk factors with the exception of smoking prevalence. As trends in other risk factors do not appear explanatory, smoke-free workplace laws seem to be ecologically related to these favorable trends. Secondhand smoke exposure should be considered a modifiable risk factor for MI. All people should avoid secondhand smoke to the extent possible, and people with coronary heart disease should have no exposure to secondhand smoke.

Second-hand tobacco smoke and cardiovascular disease risk: an epidemiological review

In this review, we have sought to examine the epidemiological, basic science, and public health data regarding the association between second-hand smoke (SHS) exposure and the development of coronary heart disease (CHD). SHS increases the risk of CHD by 25-30% according to multiple cohort, case-control, and meta-analytical studies. Physiologic and basic science research suggest that the mechanisms by which SHS affects the cardiovascular system are multiple and include increased thrombogenesis and low-density lipoprotein oxidation, decreased exercise tolerance, dysfunctional flow-mediated vasodilatation, and activation of inflammatory pathways with concomitant oxidative damage and impaired vascular repair. As a result, chronic exposure promotes atherogenesis and the development of cardiovascular disease, increasing the risk of having an acute coronary syndrome (ACS). With the implementation of statewide and nationwide public smoke-free legislation across the United States and Europe, respectively, over the last 10-15 years, there has been a significant and reciprocal decline in the incidence of emergency admissions for ACS by an average 17% despite persistent attempts on the part of the tobacco industry to diminish the correlation between SHS exposure and CHD. These findings underscore the importance of the effects of smoking legislation on community health.

The impact of the Cyprus comprehensive smoking ban on air quality and economic business of hospitality venues

Background

Several countries, including Cyprus, have passed smoke-free legislations in recent years. The goal of this study was to assess the indoor levels of particulate matter in hospitality venues in Cyprus before and after the implementation of the law on 1/1/2010, evaluate the role of enforcement, and examine the legislation’s effect on revenue and employment.

Methods

Several hospitality venues (n = 35) were sampled between April 2007 and January 2008, and 21 of those were re-sampled after the introduction of the smoking ban, between March and May 2010. Data on enforcement was provided by the Cyprus Police whereas data on revenue and employment within the hospitality industry of Cyprus were obtained from the Cyprus Statistical Service; comparisons were made between the corresponding figures before and after the implementation of the law.

Results

The median level of PM_2.5 associated with secondhand smoking was 161 μg/m³ pre-ban and dropped to 3 μg/m³ post-ban (98% decrease, p < 0.0001). Furthermore, in the year following the ban, the hotel turnover rate increased by 4.1% and the restaurant revenue by 6.4%; employment increased that same year by 7.2% and 1.0%, respectively.

Conclusion

Smoke free legislations, when enforced, are highly effective in improving the air quality and reducing the levels of indoor PM_2.5. Strict enforcement plays a key role in the successful implementation of smoking bans. Even in nations with high smoking prevalence comprehensive smoking laws can be effectively implemented and have no negative effect on accommodation, food, and beverage services.

Students' attitude and smoking behaviour following the implementation of a university smoke-free policy: a cross-sectional study

OBJECTIVE

In view of the high-smoking rate among university students in Lebanon and the known adverse effects of second-hand smoking, the American University of Beirut (AUB) decided to implement a non-smoking policy on campus. This study sought to examine the students' compliance and attitudes following the ban.

DESIGN

Cross-sectional study.

SETTING

A private university in Lebanon.

PARTICIPANTS

545 randomly selected students were approached. A stratified cluster sample of classes offered in the spring semester of the 2008/2009 academic year was selected. Students completed a self-administered paper and pencil survey during class time.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes were compliance with and attitudes towards the ban. Other secondary outcomes were the perception of barriers to implementation of the ban and attitudes towards tobacco control in general.

RESULTS

535 students participated in the study. Smokers were generally compliant with the ban (72.7%) and for some (20%) it led to a decrease in their smoking. Students' attitude towards the ban and the enforcement of a non-smoking policy in public places across Lebanon varied according to their smoking status whereby non-smokers possessed a more favourable attitude and strongly supported such policies compared with smokers; overall, the largest proportions of students were satisfied to a large extent with the ban and considered it justified (58.6% and 57.2%, respectively). While much smaller percentages reported that the ban would help in reducing smoking to a large extent (16.7%) or it would help smokers quit (7.4%). Perceived barriers to implementation of the non-smoking policy in AUB included the lack of compliance with and strict enforcement of the policy as well as the small number and crowdedness of the smoking areas.

CONCLUSIONS

An education campaign, smoking cessation services and strict enforcement of the policy might be necessary to boost its effect in further reducing students' cigarette use.

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

BACKGROUND

Secondhand smoke causes cardiovascular and respiratory disease. Smoke-free legislation is associated with a lower risk of hospitalization and death from these diseases.

METHODS AND RESULTS

Random-effects meta-analysis was conducted by law comprehensiveness to determine the relationship between smoke-free legislation and hospital admission or death from cardiac, cerebrovascular, and respiratory diseases. Studies were identified by using a systematic search for studies published before November 30, 2011 with the use of the Science Citation Index, Google Scholar, PubMed, and Embase and references in identified articles. Change in hospital admissions (or deaths) in the presence of a smoke-free law, duration of follow-up, and law comprehensiveness (workplaces only; workplaces and restaurants; or workplaces, restaurants, and bars) were recorded. Forty-five studies of 33 smoke-free laws with median follow-up of 24 months (range, 2-57 months) were included. Comprehensive smoke-free legislation was associated with significantly lower rates of hospital admissions (or deaths) for all 4 diagnostic groups: coronary events (relative risk, 0.848; 95% confidence interval 0.816-0.881), other heart disease (relative risk, 0.610; 95% confidence interval, 0.440-0.847), cerebrovascular accidents (relative risk, 0.840; 95% confidence interval, 0.753-0.936), and respiratory disease (relative risk, 0.760; 95% confidence interval, 0.682-0.846). The difference in risk following comprehensive smoke-free laws does not change with longer follow-up. More comprehensive laws were associated with larger changes in risk.

CONCLUSIONS

Smoke-free legislation was associated with a lower risk of smoking-related cardiac, cerebrovascular, and respiratory diseases, with more comprehensive laws associated with greater changes in risk.

Very low nicotine content cigarettes and potential consequences on cardiovascular disease

Cigarette smoking remains highly prevalent in the U.S. and contributes significantly to cardiovascular disease (CVD). Tobacco control policies, including product regulation, can reduce smoking-related harm. One approach being considered in the U.S. is for the FDA to set a low nicotine standard for cigarettes. Such a standard could result in multiple beneficial outcomes including reduced cardiovascular toxicity related to nicotine, reduced smoking intensity in current smokers, increased cessation rates, decreased development of smoking dependence in youth, and decreased passive smoke exposure. Consequently, CVD risk in the U.S. could be dramatically improved by nicotine reduction in cigarettes. Possible pathways linking nicotine reduction in cigarettes to decreased CVD risk are discussed, while potential unintended consequences that could offset expected gains are also presented. Gaps in the literature, including limited data on CVD biomarkers and long-term CVD outcomes following the use of very low nicotine cigarettes, are discussed to highlight areas for new research.

The impact of the Danish smoking ban on hospital admissions for acute myocardial infarction

BACKGROUND

Exposure to secondhand smoke is associated with an increased risk of acute myocardial infarction (AMI). The positive impact of a smoking ban on AMI hospitalization rates has been demonstrated both inside and outside Europe. A national smoking ban (SB) was implemented in Denmark on 15 August 2007.

PURPOSE

To evaluate the impact of the Danish SB on hospital admissions for AMI.

METHODS

Poisson regression models were used to analyse changes over time in AMI-admissions in Denmark. We investigated a seven year period: five years before and two years after implementation of the SB. We accounted for the variation in the population size and for seasonal trends. Potential confounders included were: gender, age and the incidence of type 2 diabetes (T2D).

RESULTS

A significant reduction in the number of AMI-admissions was found in the last three years of the study period after adjusting for the potential confounders. The significant reductions were found one year before the SB (relative rate (RR) = 0.86, 95% confidence interval (CI) 0.79-0.94), one year after the SB (RR = 0.77, 95% CI 0.71-0.85) and two years after the SB (RR = 0.77, 95% CI 0.70-0.84).

CONCLUSIONS

A significant reduction in the number of AMI-admissions was found already one year before the SB after adjustment for the incidence of T2D. The results differ from most results found in similar studies throughout the world and may be explained by the incremental enactment of SBs in Denmark and the implementation of a nation-wide ban on industrially produced trans-fatty acids in food in 2004.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Acute myocardial infarction mortality before and after state-wide smoking bans

Rapid declines in hospital admissions for acute myocardial infarction (AMI) following smoke-free ordinances have been reported in smaller communities. The AMI mortality rate among persons age 45 + years (deaths per 100,000 persons, age-standardized to the 2000 US population) in the 3 years before adoption of the smoke-free ordinance (the expected rate) was compared with the rate observed in the first full year after the ban (the target year) in six US states. Target-year declines were also compared to those in states without smoking bans. Target-year declines in AMI mortality in California (2.0%), Utah (7.7%) and Delaware (8.1%) were not significantly different from the expected declines (P = 0.16, 0.43 and 0.89, respectively). In South Dakota AMI mortality increased 8.9% in the target year (P = 0.007). Both a 9% decline in Florida and a 12% decline in New York in the 2004 target year exceeded the expected declines (P = 0.04 and P < 0.0002, respectively) but were not significantly different (P = 0.55 and 0.08, respectively) from the 9.8% decline that year in the 44 states without bans. Smoke-free ordinances provide a healthy indoor environment, but their implementation in six states had little or no immediate measurable effect on AMI mortality.

A critical review of major mortality risk factors for all-cause mortality in first-episode schizophrenia: clinical and research implications

A bibliographical search was performed to identify and evaluate the impact in first-episode schizophrenia of the major mortality risk factors as described by the World Health Organisation (2009). We found that at first diagnosis rates of diabetes were only slightly increased, although lipid abnormalities, mild hypertension and being overweight were commonly reported. Levels of drug and alcohol abuse were high, as were pre-diagnosis rates of smoking, physical inactivity and poor cardiorespiratory fitness. During the first year of antipsychotic treatment, there were significant increases in the rates of hyperglycaemia/diabetes, obesity, lipid abnormalities and hypertension, but no changes in fitness levels, smoking or drug and alcohol abuse. In chronic schizophrenia, excess cancer and cardiac deaths seem linked in part to availability and quality of care. Innate risk factors such as abnormal reelin and raised prolactin may also be important. New evidence, such as an inverse relationship between body mass index and suicide in the general population, suggests accepted wisdom may not apply to patients at high risk of ending their own lives. With current knowledge emphasis needs to be placed by early intervention services on physical fitness, smoking and other substance misuse, diabetes and hypertension, as well as focusing on weight reduction only in the obese.

Clean Indoor Air Acts reduce the burden of adverse cardiovascular outcomes

OBJECTIVES

Second-hand smoke is associated with an increased risk of adverse health outcomes, such as acute myocardial infarction (AMI) and coronary heart disease (CHD). At present, 38 US states/territories have enacted Clean Indoor Air Acts (CIAAs). The purpose of the current study was to compare the prevalence of self-reported health outcomes on a state/territory-wide level 1 year prior to CIAA implementation and at least 1 year after CIAA implementation for each respective state/territory.

STUDY DESIGN

Pre-test, post-test study.

METHODS

Seventeen states/territories with pre- and post-CIAA data were included in the current study. All data (AMI, CHD/angina, former and current smoker rates) were collected from the Behavioral Risk Factor Surveillance System (BRFSS) in the year prior to each state/territory's respective CIAA implementation (baseline) and 2009 (most recent year with BRFSS data).

RESULTS

Between baseline and 2009, 10 states/territories (58.8%) had a significant decrease in the prevalence of CHD/angina or AMI, 11 states/territories (64.7%) had a significant decrease in the prevalence of current smokers, and three states/territories (17.7%) had a significant decrease in the prevalence of both current and former smokers. Six states/territories (35.3%) had a significant increase in the prevalence of former smokers.

CONCLUSIONS

State/territory-wide CIAAs are beneficial in reducing adverse cardiovascular health outcomes in the short term. The prevalence of AMI, CHD/angina, and former and current smokers decreased significantly following CIAA implementation. The current study adds further support for the passage and implementation of CIAAs on a state/territory-wide level. However, further studies need to be conducted to assess the long-term outcomes of CIAAs.

Smoking restrictions and hospitalization for acute coronary events in Germany

AIMS

To study the effects of smoking restrictions in Germany on coronary syndromes and their associated costs.

METHODS AND RESULTS

All German states implemented laws partially restricting smoking in the public and hospitality sectors between August 2007 and July 2008. We conducted a before-and-after study to examine trends for the hospitalization rate for angina pectoris and acute myocardial infarction (AMI) for an insurance cohort of 3,700,384 individuals 30 years and older. Outcome measures were hospitalization rates for coronary syndromes, and hospitalization costs. Mean age of the cohort was 56 years, and two-thirds were female. Some 2.2 and 1.1% persons were hospitalized for angina pectoris and AMI, respectively, during the study period from January 2004 through December 2008. Law implementation was associated with a 13.3% (95% confidence interval 8.2, 18.4) decline in angina pectoris and an 8.6% (5.0, 12.2) decline in AMI after 1 year. Hospitalization costs also decreased significantly for the two conditions-9.6% (2.5, 16.6) for angina pectoris and 20.1% (16.0, 24.2) for AMI at 1 year following law implementation. Assuming the law caused the observed declines, it prevented 1,880 hospitalizations and saved 7.7 million Euros in costs for this cohort during the year following law implementation.

CONCLUSIONS

Partial smoking restrictions in Germany were followed by reductions in hospitalization for angina pectoris and AMI, declines that continued through 1 year following these laws and resulted in substantial cost savings. Strengthening the laws could further reduce morbidity and costs from acute coronary syndromes in Germany.

Hospital admissions for acute myocardial infarction before and after implementation of a comprehensive smoke-free policy in Uruguay

BACKGROUND

Stimulated by the WHO Framework Convention on Tobacco Control, many countries in Latin America adopted comprehensive smoke-free policies. In March 2006, Uruguay became the first Latin American country to adopt 100% smoke-free national legislation, which ended smoking in all indoor public places and workplaces, including restaurants and bars. The objective of this study was to evaluate trends in hospital admissions for cardiovascular disease 2 years before and 2 years after the policy was implemented in Uruguay.

METHODS

Reports of hospital admissions for acute myocardial infarction (AMI) (International Classification of Disease-10 I21) from 37 hospitals (79% of all hospital admissions in the country), representing the period 2 years before and 2 years after the adoption of a nationwide smoke-free policy in Uruguay (between 1 March 2004 and 29 February 2008), were reviewed. A time series analysis was undertaken to compare the average monthly number of events of hospital admission for AMI before and after the smoke-free law.

RESULTS

A total of 7949 hospital admissions for AMI were identified during the 4-year study period. Two years after the smoke-free policy was enacted, hospital admissions for AMI fell by 22%. The same pattern and roughly the same magnitude of reduction in AMI admissions were observed for patients seen in public and private hospitals, men, women and people aged 40-65 years and older than 65 years.

CONCLUSIONS

The national smoke-free policy implemented in Uruguay in 2006 was associated with a significant reduction in hospital admissions for AMI.

Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States

BACKGROUND

Recently, the American Heart Association developed a set of 7 ideal health metrics that will be used to measure progress toward their 2020 goals for cardiovascular health. The objective of the present study was to examine how well these metrics predicted mortality from all causes and diseases of the circulatory system in a national sample of adults in the United States.

METHODS AND RESULTS

We used data from 7622 adults ≥20 years of age who participated in the National Health and Nutrition Examination Survey from 1999 to 2002 and whose mortality through 2006 was determined via linkage to the National Death Index. For the dietary and glycemic metrics, we used alternative measures. During a median follow-up of 5.8 years, 532 deaths (186 deaths resulting from diseases of the circulatory system) occurred. About 1.5% of participants met none of the 7 ideal cardiovascular health metrics, and 1.1% of participants met all 7 metrics. The number of ideal metrics was significantly and inversely related to mortality from all causes and diseases of the circulatory system. Compared with participants who met none of the ideal metrics, those meeting ≥5 metrics had a reduction of 78% (adjusted hazard ratio, 0.22; 95% confidence interval, 0.10-0.50) in the risk for all-cause mortality and 88% (adjusted hazard ratio, 0.12; 95% confidence interval, 0.03-0.57) in the risk for mortality from diseases of the circulatory system.

CONCLUSION

The number of ideal cardiovascular health metrics is a strong predictor of mortality from all causes and diseases of the circulatory system.

Impact of a national smoking ban on hospital admission for acute coronary syndromes: a longitudinal study

BACKGROUND

A ban on smoking in the workplace was introduced in Ireland on March 29, 2004. As exposure to secondhand smoke has been implicated in the development of coronary disease, this might impact the incidence of acute coronary syndromes (ACS).

HYPOTHESIS

The smoking ban was associated with a decreased rate of hospital admissions for ACS.

METHODS

We analyzed data collected in a registry of all patients admitted to hospital with ACS in the southwest of Ireland, catchment population 620 525, from March 2003 until March 2007.

RESULTS

In the year following implementation of the ban, there was a significant 12% reduction in ACS admissions (177.9 vs 205.9/100,000; 95% confidence interval [CI]: 164.0-185.1, P = 0.002). This reduction was due to fewer events occurring among men (281.5 vs 233.5, P = 0.0011) and current smokers (408 vs 302 admissions, P < 0.0001). There was no change in the rate of admissions for ACS in the following year (174.3/100,000; 95% CI: 164.0-185.1, P > 0.1). However, a further 13% reduction was observed between March 2006 and March 2007 (149.2; 95% CI: 139.7-159.2). Variation in admissions with time as a continuous variable also demonstrated a reduction on implementation of the smoking ban.

CONCLUSIONS

A national ban on smoking in public places was associated with an early significant decrease in hospital admissions for ACS, suggesting a rapid effect of banning smoking in public places on ACS. A further reduction of similar magnitude 2 years after implementation of the ban is consistent with a longer-term effect that should be further examined in long-term studies.

The potential of smoking cessation programmes and a smoking ban in public places: Comparing gain in life expectancy and cost effectiveness

Background: Interventions aimed at reducing the number of smokers are generally believed to be cost effective. However as the cost of the interventions should be paid up front whereas the gains in life years only appear in the future – the budgetary consequences might be a barrier to implementing such interventions. Aims: The aim of the present paper was to assess the long-term cost effectiveness as well as the short-term (10 years) budget consequences of cessation programmes and a smoking ban in enclosed public places. Methods: We develop a population-based Markov model capable of analyzing both interventions and assess long-term costs effectiveness as well as short-term budgetary consequences and outcome gains. The smoking cessation programme model was based on data from the Danish National Smoking Cessation Database (SCDB), while the model of the smoking ban was based on effect estimates found in the literature. Results: On a population level the effect of a smoking ban has the largest potential compared with the effect of smoking cessation programmes. Our results suggest that smoking cessation programmes are cost saving and generate life-years, whereas the costs per life-year gained by a smoking ban are 40,645 to 64,462 DKK (100 DKK = €13.4). These results are conservative as they do not include the healthcare cost saving related to reduced passive smoking. Conclusions: Our results indicate that smoking cessation programmes and a smoking ban in enclosed public places both in the short term and the long term are cost-effective strategies compared with the status quo.

Oxidative stress and anxiety-like symptoms related to withdrawal of passive cigarette smoke in mice: beneficial effects of pecan nut shells extract, a by-product of the nut industry

The present study evaluated the role of pecan nut (Carya illinoensis) shells aqueous extract (AE) against oxidative damage induced by cigarette smoke exposure (CSE) and behavioral parameters of smoking withdrawal. Mice were passively exposed to cigarette smoke for 3 weeks (6, 10, and 14 cigarettes/day) and orally treated with AE (25 g/L). CSE induced lipid peroxidation in brain and red blood cells (RBC), increased catalase (CAT) activity in RBC, and decreased plasma ascorbic acid levels. AE prevented oxidative damage and increased antioxidant defenses of mice exposed to cigarette smoke. In addition, AE reduced the locomotor activity and anxiety symptoms induced by smoking withdrawal, and these behavioral parameters showed a positive correlation with RBC lipid peroxidation. Our results showed the beneficial effects of this by-product of the pecan industry, indicating its usefulness in smoking cessation.

Reduction in acute myocardial infarction hospitalization after implementation of a smoking ordinance

BACKGROUND

Smoking ordinances have been associated with reduced acute myocardial infarction rates, but nearly all studies lack patient-level data.

OBJECTIVE

We determined whether a smoking ordinance was associated with a reduction in hospitalizations for acute myocardial infarction, irrespective of smoking status and infarct presentation (ST elevation vs. non-ST elevation).

METHODS

Detailed chart abstraction of biomarkers to confirm first acute myocardial infarction events was performed from the single community hospital serving Greeley, Colorado and adjacent zip codes, 17 months before and 31 months after implementing a public smoking ordinance. Poisson regression analysis, adjusted for population growth, was used to assess changes in mean incidence rates.

RESULTS

A total of 706 hospitalizations were identified from July 2002 through June 2006: 482 among Greeley city residents and 224 within adjacent zip code areas. A postordinance reduction in hospitalizations was observed in Greeley (relative risk [RR] 0.73; 95% confidence interval [CI], 0.59-0.90). A smaller, nonsignificant decrease was noted in the area immediately surrounding Greeley (RR 0.83; 95% CI, 0.61-1.14). However, the comparison of relative risk reductions between Greeley and the surrounding area was not significant (P=.48). The reduction in Greeley was more pronounced among smokers (RR 0.44; 95% CI, 0.29-0.65) than nonsmokers (RR 0.86; 95% CI, 0.67-1.09) and did not differ by acute myocardial infarction presentation (P=.38).

CONCLUSIONS

A smoking ordinance was associated with a decrease in acute myocardial infarction hospitalizations of a magnitude similar to previous reports, but could not be distinguished from the adjacent geographic area. Reductions were greatest among smokers, despite previous studies suggesting that benefits accrue primarily among nonsmokers. Smoke-free policy may therefore exert a beneficial effect among smokers, who are disproportionately exposed to direct and sidestream smoke.

Towards negotiation as a framework for health promoting technology

In this paper we reflect on the findings of three empirical studies of health-related behavioural change and existing work in the technological and sociomedical domains, to critique emerging technological approaches to promoting health-related behavioural change. The critique challenges what appear to be implicit assumptions about technology's role in promoting health-related behavioural change. It prompts a consideration of whose agenda in being pursued, whose values are being encapsulated, and argues for a rethink and reorientation of technological interventions in this domain. As an alternative to the existing approach we suggest a shift in focus from behavioural change to health promotion, and offer negotiation as a potential framework for future innovations in this area.