Decrease in mortality rate and hospital admissions for acute myocardial infarction after the enactment of the smoking ban law in São Paulo city, Brazil

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.

Towards a smoke-free world? South America became the first 100% smoke-free subregion in the Americas

Almost 20 years after the launching by the Pan American Health Organization of its “Smoke-Free Americas” initiative in 2001, in December 2020, South America became the first subregion in the Americas to accomplish 100% smoke-free environments in line with Article 8 of the World Health Organization Framework Convention on Tobacco Control (FCTC). Some of these countries adopted legal measures that are more robust than others, including in their laws specific outdoor places in the smoking ban (like Argentina and Uruguay) and/or novel nicotine and tobacco products under their scope (like Ecuador and Paraguay). The 10 countries took different paths to adopt this public health measure, either through executive or legislative measures or a combination of both. A few countries, like Argentina, Brazil, and Venezuela, started at the subnational level and then moved on to the national level, similar to the rest of the countries.

For achieving this milestone, an adequate context was crucial: the broad ratification of the FCTC and the relevance given to the human right to health, civil society efforts, commitments made by intergovernmental bodies, media and communication strategies, and the development of scientific evidence. Countries faced obstacles, including the well-known interference of the tobacco industry, which among other strategies used litigation; however, courts and judges upheld comprehensive legal measures on smoke-free environments.

The process by which South America achieved this milestone represents a role model for other subregions of the Americas and the world.

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

BACKGROUND AND AIMS

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

DESIGN

Interrupted time-series study.

SETTING

Beijing, China.

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Interrupted time series study.

SETTING

Beijing, China.

POPULATION

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Impact of public health initiatives on acute coronary syndrome fatality rates in Portugal

INTRODUCTION AND OBJECTIVE

Every year cardiovascular disease (CVD) causes 3.9 million deaths in Europe. Portugal has implemented a set of public health policies to tackle CVD mortality: a smoking ban in 2008, a salt reduction regulation in 2010 and the coronary fast-track system (FTS) for acute coronary syndrome (ACS) in 2007. Our goal in this study was to analyze the impact of these three public health policies in reducing case-fatality rates from ACS between 2000 and 2016.

METHODS

The impact of these policies on monthly ACS case-fatalities was assessed by creating individual models for each of the initiatives and implementing multiple linear regression analysis, using standard methods for interrupted time series. We also implemented segmented regression analysis to test which year showed a significant difference in the case-fatality slopes.

RESULTS

Separate modeling showed that the smoking ban (beta=-0.861, p=0.050) and the FTS (beta=-1.27, p=0.003) had an immediate impact after implementation, but did not have a significant impact on ACS trends. The salt reduction regulation did not have a significant impact. For the segmented model, we found significant differences between case-fatality trends before and after 2009, with rates before 2009 showing a steeper decrease.

CONCLUSIONS

The smoking ban and the FTS led to an immediate decrease in case-fatality rates; however, after 2009 no major decrease in case-fatality trends was found. Coronary heart disease constitutes an immense public health problem and it remains essential for decision-makers, public health authorities and the cardiology community to keep working to reduce ACS mortality rates.

The effect of smoke-free legislation on the mortality rate of acute myocardial infarction: a meta-analysis

Background

Several studies have demonstrated that smoke-free legislation is associated with a reduced risk of mortality from acute myocardial infarction (AMI). This study aimed to examine and quantify the potential effect of smoke-free legislation on AMI mortality rate in different countries.

Methods

Studies were identified using a systematic search of the scientific literature from electronic databases, including PubMed, Web of Science, ScienceDirect, Embase, Google Scholar, and China National Knowledge Infrastructure (CNKI), from their inception through September 30, 2017. A random effects model was employed to estimate the overall effects of smoke-free legislation on the AMI mortality rate. Subgroup analysis was performed to explore the possible causes of heterogeneity in risk estimates based on sex and age. The results of meta-analysis after excluding the studies with a high risk of bias were reported in this study.

Results

A total of 10 eligible studies with 16 estimates of effect size were included in this meta-analysis. Significant heterogeneity in the risk estimates was identified (overall I² = 94.6%, p < 0.001). Therefore, a random effects model was utilized to estimate the overall effect of smoke-free legislation. There was an 8% decline in AMI mortality after introducing smoke-free legislation (RR = 0.92, 95% confidence interval (CI): 0.90–0.94). The results of subgroup analyses showed that smoke-free legislation was significantly associated with lower rates of mortality for the following 5 diagnostic subgroups: smoke-free in workplaces, restaurants and bars (RR = 0.92, 95% CI: 0.90–0.95), smaller sample size (RR = 0.92, 95% CI: 0.89–0.95), study location in Europe (RR = 0.90, 95% CI: 0.85–0.94), regional study area (RR = 0.92, 95% CI: 0.89–0.94), and no previous local smoke-free legislation (RR = 0.91, 95% CI: 0.90–0.93). However, there was not much difference in AMI mortality rates after the legislation between the longer (RR = 0.92, 95% CI: 0.86–0.98) and shorter follow-up duration subgroups (RR = 0.92, 95% CI: 0.89–0.94).

Conclusion

Smoke-free legislation could significantly reduce the AMI mortality rate by 8%. The reduction in the AMI mortality rate was more significant in studies with more comprehensive laws, without prior smoke-free bans, with a smaller sample size, at the regional level, and with a location in Europe.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7408-7) contains supplementary material, which is available to authorized users.

Implementing smoke-free policies in low- and middle-income countries: A brief review and research agenda

INTRODUCTION

Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs.

METHODS

We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports.

We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies.

RESULTS

The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps.

CONCLUSIONS

We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

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.