Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance

Impact of Total Indoor Smoking Ban on Cardiovascular Disease Hospitalizations and Mortality: The Case of Chile

INTRODUCTION

The harmful effects of first and secondhand smoking are well-established. Smoke-free laws aim at protecting nonsmokers. This study aimed to assess the impact of the 2013 total ban on indoor smoking in Chile on hospitalizations and deaths of major cardiovascular events.

AIMS AND METHODS

The logarithm of the monthly hospitalization and death rates, standardized by age for every 100 000 inhabitants, were estimated for ischemic heart disease, acute myocardial infarction, strokes, and a composite outcome of ischemic heart diseases (which includes acute myocardial infarction) and strokes. In addition, interrupted time series with synthetic control groups were used to assess changes in levels and trends after the intervention.

RESULTS

The total ban on indoor smoking caused significant reductions in death rates for the three diseases studied for age groups above 20 years old. In addition, there were substantial decreases in the post-intervention hospitalization rates for ischemic heart disease: for the 20-44 age group, the decrease was 8.7% compared to the pre-intervention period (p < .01). In comparison, such a reduction was 4% (p < .01) for the ≥65 age group. For acute myocardial infarction, the decrease was 11.5% (p < .01) for the 20-44 age group, while for stroke, it was a 1.2% (p < .01) decrease for the total population. It is estimated that the smoking ban averted 15.6% of the deaths compared with the synthetic control groups.

CONCLUSIONS

The implementation of total smoke-free environments in Chile contributed to the reduction of mortality for main cardiovascular diseases. This study provides additional evidence of causality linking the policy to health outcomes.

IMPLICATIONS

The total indoor smoking ban significantly affected age-standardized hospitalization and deaths. The number of deaths averted by this policy is estimated at approximately 4758 and 5256 for IHD and stroke, respectively, during the 2013-2017 period (15.6% fewer deaths than predicted by the synthetic control groups). The study contributes to the body of evidence that supports total indoor smoking bans.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

Healthy city: global systematic scoping review of city initiatives to improve health with policy recommendations

BACKGROUND

Global health will increasingly be determined by cities. Currently over half of the world's population, over 4 billion people, live in cities. This systematic scoping review has been conducted to understand what cities are doing to improve health and healthcare for their populations.

METHODS

We conducted a systematic search to identify literature on city-wide initiatives to improve health. The study was conducted in accordance with PRISMA and the protocol was registered with PROSPERO (CRD42020166210).

RESULTS

The search identified 42,137 original citations, yielding 1,614 papers across 227 cities meeting the inclusion criteria. The results show that the majority of initiatives were targeted at non-communicable diseases. City health departments are making an increasing contribution; however the role of mayors appears to be limited.

CONCLUSION

The collective body of evidence identified in this review, built up over the last 130 years, has hitherto been poorly documented and characterised. Cities are a meta-system with population health dictated by multiple interactions and multidirectional feedback loops. Improving health in cities requires multiple actions, by multiple actors, at every level. The authors use the term 'The Vital 5'. They are the five most important health risk factors; tobacco use; harmful alcohol use; physical-inactivity, unhealthy diet and planetary health. These 'Vital 5' are most concentrated in deprived areas and show the greatest increase in low and middle income countries. Every city should develop a comprehensive strategy and action plan to address these 'Vital 5'.

Monitoring and evaluation of the implementation of tobacco control legislation for protecting people from tobacco smoke exposure and health consequences of tobacco use. Methodical guidelines

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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.

Effectiveness of legislative actions against tobacco smoking regarding the reduction of in-hospital morbidity of angina pectoris and myocardial infarction in Russia as a whole and 10 Russian constituent entities

Russian anti-tobacco policy is aimed at reducing long-term morbidity and mortality from smoking-related diseases.

Aim. To assess the associations of tobacco control (TC) legislative measures with hospitalization rate for myocardial infarction (MI) and angina in Russia as a whole and in 10 Russian constituent entities, as well as to compare the effectiveness of anti-smoking measures in regions.

Material and methods. We analyzed data on hospitalizations of patients with angina (I20) and acute (I21) and subsequent (I22) MI, as well as chronic rheumatic heart diseases (I05-I09), for 2005-2019 in Russia as a whole and in 10 Russian constituent entities. We analyzed hospital admission rates for angina and MI to compare the periods before and after introduction of Federal TC law in 2013, adjusting for possible confounders and long-term trends. We used interrupted time-series design and Poisson regression model with calculation of rate ratio (RR) and 95% CI. Regions were compared by means of original TC law implementation scale (TCIS) developed based on the results of Russian TC policy evaluation survey in 10 Russian regions (n=11625). We analyzed the relationship between the TC law measures implementation scores and RR of hospital admissions reductions for angina and MI after the TC law by means of Spearman’s rank correlation (coefficient with 95% CI) and linear regression models. Statistical package STATA 11.2 was used.

Results. The actual trend of hospital admission rates for angina after TC law introduction demonstrates the greatest slope change from the predicted trend (without the law) (p=0,004); less, but still significant slope change for MI (p=0,049), and no slope change for chronic rheumatic heart disease (p=0,332). Results showed a 16,6% decrease in hospital admission rates for angina (RR, 0,83; 95% CI, 074-0,93) and 3,5% — for MI (RR, 0,96; 95% CI, 0,96-0,97) after the TC law introduction in RF and effects of various magnitude in the regions. Regions with higher TCIS scores, i.e. better enforcement of full TC package had greater reduction in hospital admission rates for angina (rsp=-0,627; 95% CI, -1,05−-0,199; p=0,004); with better enforcement of smoke-free policies — grater reduction in hospitalization rates for MI (rsp= -0,793 95%CI, -1,08−-0,506, p<0,001). Reduction of hospital admission rates for angina and MI correlated with the higher scores for help to quit tobacco use (rsp=-0,555; 95% CI, -1,098−-0,01, p=0,045), (rsp= -0,736; 95% CI, -1,12−-0,357, p=0,027). Also, hospital admission rates for angina and MI were associated with the changes in smoking cessation prevalence in 2013-2018 in the regions (β=-0,345; 95% CI, -0,67−-0,02 p=0,041) and smoking prevalence in 2019 (β=2,964; 95% CI, 1,28-5,92, p=0,049), respectively.

Conclusion. TC legislation can lead not only to immediate reductions in hospital admission rates for angina and MI, but also to longer-term results. These effects may be due not only to the introduction of TC law, as such, but also to the enforcement of the law, as well as the direct results of TC measures — the decrease in smoking prevalence in the population.

The Cardiovascular and Cerebrovascular Health in North China From 2006 to 2011: Results From the KaiLuan Study

Background: The American Heart Association (AHA) defined cardiovascular health in terms of four behaviors (smoking, diet, physical activity, body weight) and three factors (plasma glucose, cholesterol, blood pressure). By this definition, the prevalence of ideal cardiovascular health behaviors and factors is negatively correlated with all-cause mortality and risks of cardiovascular and cerebrovascular diseases and malignancy. We analyzed the trends in cardiovascular and cerebrovascular health behaviors and factors in the population of the KaiLuan study for 2006–2011, reported the results, and provided evidence for prevention.

Methods and Results: We calculated the prevalence of cardiovascular and cerebrovascular health behaviors and factors from KaiLuan data for 2006–2007, 2008–2009, and 2010–2011. The prevalence of ideal cardiovascular and cerebrovascular health behaviors and factors is low in the KaiLuan population.

Conclusions: The prevalence of ideal cardiovascular and cerebrovascular health behaviors and factors is low in the KaiLuan population.

Clinical Trial Registration:http://www.chictr.org/cn/proj/show.aspx?proj=1441, unique identifier: ChiCTR-TNC-11001489.

Impact of Qingdao's smoke-free legislation on hospitalizations and mortality from acute myocardial infarction and stroke: an interrupted time-series analysis

BACKGROUND AND AIMS

More than 20 cities in China have enacted local smoke-free laws that prohibit smoking in public places. Only two of these cities have examined the health impact of the law. Enacted in 2013, Qingdao's smoke free-law was stricter than most other municipal smoke-free laws because it did not allow designated smoking rooms. This study aimed to estimate the impact of Qingdao's smoke-free legislation on acute myocardial infarction (AMI) and stroke.

DESIGN, SETTING AND PARTICIPANTS

We used an interrupted time-series design adjusting for underlying secular trends, seasonal patterns and meteorological factors to estimate the impact of the smoke-free law on AMI and stroke events among permanent residents aged 35 years or older in Qingdao, China. The study period was from 1 January 2010 to 31 December 2015, with a post-ban follow-up of approximately 2.5 years.

MEASUREMENT

Outcome measures were weekly numbers of hospitalizations and deaths due to AMI/stroke.

FINDINGS

A total of 10 371 and 56 101 patients were hospitalized, with a principal discharge diagnosis of AMI and stroke, respectively; 32 196 AMI and 49 711 stroke deaths occurred during the study period. Following the smoke-free legislation, an incremental 20% [95% confidence interval (CI) = 14-26%] and 8% (95% CI = 3-13%) decrease per year was observed in AMI and stroke hospitalization rates, respectively. Neither the immediate nor gradual change in AMI nor stroke mortality rates associated with the law was statistically significant (P > 0.05). Post-hoc subgroup analyses indicated that statistically significant reductions in AMI hospitalizations were evident among both the 35-64 (18% per year, 95% CI = 12-27%) and 65-84 (20% per year, 95% CI = 12-27%) age groups. Statistically significant reductions in stroke hospitalization were only in the older subgroup (13% per year, 95% CI = 8-18%).

CONCLUSIONS

The 2013 smoke-free legislation in Qingdao, China was associated with reduction in hospitalization from acute myocardial infarction and stroke among permanent residents aged 35 years or older. There was no statistically significant reduction in mortality from acute myocardial infarctions or stroke.

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.

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.

Cardiovascular injury induced by tobacco products: assessment of risk factors and biomarkers of harm. A Tobacco Centers of Regulatory Science compilation

Although substantial evidence shows that smoking is positively and robustly associated with cardiovascular disease (CVD), the CVD risk associated with the use of new and emerging tobacco products, such as electronic cigarettes, hookah, and heat-not-burn products, remains unclear. This uncertainty stems from lack of knowledge on how the use of these products affects cardiovascular health. Cardiovascular injury associated with the use of new tobacco products could be evaluated by measuring changes in biomarkers of cardiovascular harm that are sensitive to the use of combustible cigarettes. Such cardiovascular injury could be indexed at several levels. Preclinical changes contributing to the pathogenesis of disease could be monitored by measuring changes in systemic inflammation and oxidative stress, organ-specific dysfunctions could be gauged by measuring endothelial function (flow-mediated dilation), platelet aggregation, and arterial stiffness, and organ-specific injury could be evaluated by measuring endothelial microparticles and platelet-leukocyte aggregates. Classical risk factors, such as blood pressure, circulating lipoproteins, and insulin resistance, provide robust estimates of risk, and subclinical disease progression could be followed by measuring coronary artery Ca2+ and carotid intima-media thickness. Given that several of these biomarkers are well-established predictors of major cardiovascular events, the association of these biomarkers with the use of new and emerging tobacco products could be indicative of both individual and population-level CVD risk associated with the use of these products. Differential effects of tobacco products (conventional vs. new and emerging products) on different indexes of cardiovascular injury could also provide insights into mechanisms by which they induce cardiovascular harm.

Effect of comprehensive smoke-free legislation on asthma and coronary disease trends in Spanish primary care patients

Background

To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex.

Methods

Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC).

Results

The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: -8.00%, 95% CI: -10.46; -5.47) and Navarre (AAPC: -3.66%, 95% CI: -4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia.

Conclusion

No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL.

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.

Strategies for the Prevention of Coronary Artery Disease Complications: Can We Do Better?

Billions of dollars have been spent over the past 25 years on developing new therapies for the prevention/treatment of adverse cardiac events related to atherosclerotic cardiovascular disease. Although some therapies have been lifesaving, several mega-randomized studies have shown only a <2% absolute reduction in adverse events with a large residual event rate. Is all this money well spent? Atherosclerosis develops decades before an adverse event, and the trials previously alluded to have nearly always been applied to secondary prevention, decades after disease initiation. Will earlier intervention result in a lower incidence of events? Individuals with an absence of the usual cardiac risk factors have a lifelong low incidence of events. Early initiation of strategies against the common cardiovascular risk factors in primary or primordial prevention will lower the incidence of adverse events, although many groups have not been well studied, including individuals younger than 40 years of age. New strategies are required to realize a radical reduction in events, and this article proposes new methods of prevention/treatment for coronary artery disease complications.

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.

Effects of smoke-free air law on acute myocardial infarction hospitalization in Indianapolis and Marion County, Indiana

BACKGROUND

A comprehensive smoke-free air law was enacted on June 1, 2012 in most of Marion County, Indiana, including all of the City of Indianapolis. We evaluated changes in acute myocardial infarction (AMI) admission rates in Indianapolis and Marion County before compared to after the law.

METHODS

We collected AMI admissions from five Marion County hospitals between May 2007 and December 2014. We used Poisson regression to evaluate the overall effects of the law on monthly AMI hospitalizations, adjusting for month, seasonality, meteorology, air pollution, and hospital utilization. We tested the interactions between the law and AMI risk factors on monthly AMI admission rates to identify subpopulations for which the effects might be stronger.

RESULTS

Monthly AMI admissions declined 20% (95% CI 14-25%) in Marion County and 25% (95% CI 20-29%) in Indianapolis after the law was implemented. We observed decreases among never (21%, 95% CI 13-29%), former (28%, 95% CI 21-34%), and current smokers (26%, 95% CI 11-38%); Medicaid beneficiaries (19%, 95% CI 9-29%) and non-beneficiaries (26%, 95% CI 20-31%). We observed decreases among those with a history of diabetes (Yes: 22%, 95% CI 14-29%; No: 25%, 95% CI 18-31%), congestive heart failure (Yes: 23%, 95% CI 16-30%; No: 24%, 95% CI 17-31%), and hypertension (Yes: 23%, 95% CI 17-28%: No: 26%, 95% CI 15-36%).

CONCLUSIONS

We observed decreases in AMI admissions comparable with previous studies. We identified subpopulations who benefitted from the law, such as former and current smokers, and those without comorbidities such as congestive heart failure and hypertension.

A Nationwide Assessment of the Association of Smoking Bans and Cigarette Taxes With Hospitalizations for Acute Myocardial Infarction, Heart Failure, and Pneumonia

Multiple studies claim that public place smoking bans are associated with reductions in smoking-related hospitalization rates. No national study using complete hospitalization counts by area that accounts for contemporaneous controls including state cigarette taxes has been conducted. We examine the association between county-level smoking-related hospitalization rates and comprehensive smoking bans in 28 states from 2001 to 2008. Differences-in-differences analysis measures changes in hospitalization rates before versus after introducing bans in bars, restaurants, and workplaces, controlling for cigarette taxes, adjusting for local health and provider characteristics. Smoking bans were not associated with acute myocardial infarction or heart failure hospitalizations, but lowered pneumonia hospitalization rates for persons ages 60 to 74 years. Higher cigarette taxes were associated with lower heart failure hospitalizations for all ages and fewer pneumonia hospitalizations for adults aged 60 to 74. Previous studies may have overestimated the relation between smoking bans and hospitalizations and underestimated the effects of cigarette taxes.

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.

Air Pollution and Other Environmental Modulators of Cardiac Function

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

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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.

Longitudinal Impact of the Smoking Ban Legislation in Acute Coronary Syndrome Admissions

Background and Purpose. The association between smoking and CV has been proved; however smoking is still the first preventable cause of death in the EU. We aim to evaluate the potential impact of the smoke ban on the number of ACS events in the Portuguese population. In addition, we evaluate the longitudinal effects of the smoking ban several years after its implementation. Methods. We analyzed the admission rate for ACS before and after the ban using data from hospital admission. Monthly crude rate was computed, using the Portuguese population as the denominator. Data concerning the proportion of smokers among ACS patients were obtained from the NRACS. Interrupted time series were used to assess changes over time. Results. A decline of −5.8% was found for ACS crude rate after the smoking ban. The decreasing trend was observed even after years since the law. The effect of the ban was higher in men and for people over 65 years. The most significant reduction of ACS rate was found in Lisbon. Conclusions. Our results suggest that smoking ban is related to a decline in ACS admissions, supporting the importance of smoke legislation as a public health measure, contributing to the reduction of ACS rate.

Developing Approaches for Evaluating Smoke-Free Policies

This article describes how several tobacco control organizations identified and responded to an emerging need for technical assistance on how to evaluate smoke-free policies. The authors outline the purposes of evaluating smoke-free policies and present examples of evaluation approaches and tools. Examples are provided of how evaluation has been used to advance the adoption, implementation, and defense of smoke-free policies. Opportunities for further research are identified. Finally, the authors review lessons learned and discuss their implications for evaluating policy initiatives addressing other public health issues.

Association between Florida's smoke-free policy and acute myocardial infarction by race: A time series analysis, 2000-2013

INTRODUCTION

Racial disparities in acute myocardial infarctions (AMIs) are increasing over time. Previous studies have shown that the implementation of smoke-free policies is associated with reduced AMI rates. The objective of this study was to determine the association between smoke-free policy and AMI hospitalization rates and smoking by race.

METHODS

Healthcare Cost and Utilization Project data from Florida from 2000-2013 were analyzed using interrupted time series analysis to determine the relationship between Florida's smoke-free restaurant and workplace laws and AMI among the total adult population (aged ≥18years), by age, race, and gender. Behavioral Risk Factor Surveillance System data from Florida from 2000 to 2010 were analyzed using logistic regression to determine the association between policy and the adult smoking prevalence.

RESULTS

After implementation of the smoke-free policy, no statistically significant associations between AMI hospitalization rates or smoking prevalence were detected in the total population. In the subgroup analysis, the policy was associated with declines in AMI hospitalization rates among non-Hispanic white adults aged 18-44years (β=-0.001 per 10,000, p-value=0.0083). No other relationships with AMI hospitalization rates and smoking prevalence were found in the subgroup analysis.

CONCLUSIONS

More comprehensive smoke-free and tobacco control policies are needed to further reduce AMI hospitalization rates, particularly among minority populations. Further research is needed to understand and address how the implementation of smoke-free policies affects secondhand smoke exposure among racial and ethnic minorities.

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.

The Impact of Smoking Bans on Smoking and Consumer Behavior: Quasi-Experimental Evidence from Switzerland

In this paper, we exploit the progressive implementation of smoking bans in public venues at the state level in Switzerland to evaluate both the direct effects on smoking and the potential unintended consequences of these legislations on consumer behaviors as measured by visiting restaurants/bars and discos ('going out'). Our results indicate that public venue smoking bans in Switzerland reduce smoking rates, but the findings do not emerge until 1 year following the ban. This pattern of results is consistent with delays in ban enforcement on the part of business owners, difficulties in changing addictive behaviors such as smoking, and/or learning on the part of smokers. We find evidence that smoking bans influence going-out behavior and there is substantial heterogeneity across venue and consumer characteristics.

Dose-response relations between second-hand smoke exposure and depressive symptoms among middle-aged women

A growing body of evidence indicates a strong association between smoking and depression. However, little is known about the possible effects of second-hand smoke (SHS) exposure on depression. This study aimed to examine the potential dose-response relation between SHS exposure and depressive symptoms among non-smoking middle-aged women. A cross-sectional survey was conducted using a stratified three-stage sampling method. Depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale with a cut-off point of 16. Self-reported SHS exposure was defined as non-smokers׳ inhalation of the smoke exhaled from smokers on at least one day a week. The multivariable logistic regression analysis was completed with adjustment for potential confounders. Among 1280 middle-aged women, 19.4% were classified as having depressive symptoms. There was a 104% increased odds of depressive symptoms corresponding to SHS exposure in general (OR=2.04, 95% CI 1.48-2.79) using no exposure as reference. There were significant positive relations between SHS exposure in general and depressive symptoms in a dose-response manner. These significant trends were observed consistently whether SHS exposure occurred in homes or workplaces. Our findings suggest that long-term and regular SHS exposure is associated with a significant, dose-dependent increase in risk of depressive symptoms.

Contributions of risk factors and medical care to cardiovascular mortality trends

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

Association Between a Ban on Smoking in a Hospital and the In-Hospital Onset of Acute Myocardial Infarction

Background

Smoking is an important cardiovascular risk. We hypothesized that a ban on smoking in a hospital could decrease the in-hospital onset of acute myocardial infarction (AMI).

Methods

Our hospital provided separate facilities for smokers and nonsmokers from 1981 to 2002. From 2002 to 2006, we began to introduce smoke-free zones throughout the entire building. During this period, smoking areas and smoking tables were abolished, until the entire hospital became a non-smoking area in 2007. We registered patients who experienced an in-hospital onset of AMI from January 2002 to June 2014. Patients with an in-hospital onset of AMI were defined as those who had AMI but were not under the care of the Departments of Cardiology or Emergency. We observed 25 patients (males/females, 16/9; average age, 70 years) with an in-hospital onset of AMI from 2002 to 2014.

Results

The incidence of in-hospital AMI significantly decreased as the stages of non-smoking areas progressed (P for trend 0.010). Six of the 25 patients died after AMI. The death group showed significantly higher serum levels of peak creatine kinase and lower levels of hemoglobin. In addition, 10 of the 25 patients developed in-hospital AMI after surgery. Anti-coagulant therapy was canceled before an operation in three patients. After an operation, advanced anemia was seen in four patients. In addition, there were no differences in the patient characteristics between the smoking and non-smoking groups except for dyslipidemia.

Conclusion

The spread of a non-smoking policy significantly decreased the in-hospital onset of AMI in our hospital, which suggests that not only direct smoking but also passive smoking is important target for reducing in-hospital AMI.

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.

Trends in Cardiovascular Disease Risk Factor Prevalence and Estimated 10-Year Cardiovascular Risk Scores in a Large Untreated French Urban Population: The CARVAR 92 Study

BACKGROUND

Surveys measuring effectiveness of public awareness campaigns in reducing cardiovascular disease (CVD) incidence have yielded equivocal findings. The aim of this study was to describe cardiovascular risk factors (CVRFs) changes over the years in an untreated population-based study.

METHODS

Between 2007 and 2012, we conducted a screening campaign for CVRFs in men aged 40 to 65 yrs and women aged 50 to 70 yrs in the western suburbs of Paris. Data were complete for 20,324 participants of which 14,709 were untreated.

RESULTS

The prevalence trend over six years was statistically significant for hypertension in men from 25.9% in 2007 to 21.1% in 2012 (p=0.002) and from 23% in 2007 to 12.7% in 2012 in women (p<0.0001). The prevalence trend of tobacco smoking decreased from 38.6% to 27.7% in men (p=0.0001) and from 22.6% to 16.8% in women (p=0.113). The Framingham 10-year risk for CVD decreased from 13.3 ± 8.2 % in 2007 to 11.7 ± 9.0 % in 2012 in men and from 8.0 ± 4.1 % to 5.9 ± 3.4 % in women. The 10-year risk of fatal CVD based on the European Systematic COronary Risk Evaluation (SCORE) decreased in men and in women (p <0.0001).

CONCLUSIONS

Over a 6-year period, several CVRFs have decreased in our screening campaign, leading to decrease in the 10-year risk for CVD and the 10-year risk of fatal CVD. Cardiologists should recognize the importance of community prevention programs and communication policies, particularly tobacco control and healthier diets to decrease the CVRFs in the general population.

Support for indoor bans on electronic cigarettes among current and former smokers

OBJECTIVES

Electronic cigarette (e-cigarette) use is increasing in the U.S. Although marketed as a safer alternative for cigarettes, initial evidence suggests that e-cigarettes may pose a secondhand exposure risk. The current study explored the prevalence and correlates of support for e-cigarette bans.

METHODS

A sample of 265 current/former smokers completed a cross-sectional telephone survey from June-September 2014; 45% Black, 31% White, 21% Hispanic. Items assessed support for home and workplace bans for cigarettes and e-cigarettes and associated risk perceptions.

RESULTS

Most participants were aware of e-cigarettes (99%). RESULTS demonstrated less support for complete e-cigarette bans in homes and workplaces compared to cigarettes. Support for complete e-cigarette bans was strongest among older, higher income, married respondents, and former smokers. Complete e-cigarette bans were most strongly endorsed when perceptions of addictiveness and health risks were high. While both e-cigarette lifetime and never-users strongly supported cigarette smoking bans, endorsement for e-cigarette bans varied by lifetime use and intentions to use e-cigarettes.

CONCLUSIONS

Support for indoor e-cigarette bans is relatively low among individuals with a smoking history. Support for e-cigarette bans may change as evidence regarding their use emerges. These findings have implications for public health policy.

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.

Reduction of ST-elevation myocardial infarction in Canton Ticino (Switzerland) after smoking bans in enclosed public places--No Smoke Pub Study

BACKGROUND

Second-hand smoke increases the risk of acute myocardial infarction. Canton Ticino (CT) first introduced a smoking ban in public places in 2007. This offered the opportunity to assess the long-term impact of a smoking ban on the incidence of ST-elevation myocardial infarctions (STEMI) compared with a population where the law was not yet implemented.

METHODS

We assessed the incidence of STEMI hospitalizations per 100 000 inhabitants both during 3 years before and after the ban application in CT and in Canton Basel City (CBC), where this law was not yet applied. Data were obtained from the codified hospital registry (ICD-10 codes).

RESULTS

In CT, the mean incidence of STEMI admissions during the 3 pre-ban years (123.7) was significantly higher than the incidence of admissions in each of the 3 post-ban years (92.9, 101.6 and 89.6 respectively; P <.024). Analysing population subsets, a post-ban reduction was observed among ≥65-year-old people of both sexes in each of the 3 post-ban years and in the <65-year age group during the first post-ban year (P = 0.02). Conversely, the mean incidence of STEMI hospitalizations in CBC (92.4) didn't change significantly in each of the 3 post-ban years (83.9, 83.3 and 79.5, P = NS) during the same period. However, a significant long-term reduction in STEMI admissions was observed in CBC among the male group with ≥65 years (P < 0.01).

CONCLUSION

Our work suggests a significant impact of the smoke-free policy on the number of annual STEMI. Specific population subsets (i.e. ≥65-year-old females) were particularly affected by the smoking ban, showing a significant reduction in STEMI hospitalizations.

The effect of workplace smoking bans on heart rate variability and pulse wave velocity of non-smoking hospitality workers

OBJECTIVES

To investigate the effect of a change in second-hand smoke (SHS) exposure on heart rate variability (HRV) and pulse wave velocity (PWV), this study utilized a quasi-experimental setting when a smoking ban was introduced.

METHODS

HRV, a quantitative marker of autonomic activity of the nervous system, and PWV, a marker of arterial stiffness, were measured in 55 non-smoking hospitality workers before and 3-12 months after a smoking ban and compared to a control group that did not experience an exposure change. SHS exposure was determined with a nicotine-specific badge and expressed as inhaled cigarette equivalents per day (CE/d).

RESULTS

PWV and HRV parameters significantly changed in a dose-dependent manner in the intervention group as compared to the control group. A one CE/d decrease was associated with a 2.3% (95% CI 0.2-4.4; p = 0.031) higher root mean square of successive differences (RMSSD), a 5.7% (95% CI 0.9-10.2; p = 0.02) higher high-frequency component and a 0.72% (95% CI 0.40-1.05; p < 0.001) lower PWV.

CONCLUSIONS

PWV and HRV significantly improved after introducing smoke-free workplaces indicating a decreased cardiovascular risk.

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.

Evaluation of a smoke-free law on indoor air quality and on workers' health in Portuguese restaurants

Workplace bans on smoking are interventions to reduce exposure to secondhand smoke (SHS) to try to prevent harmful health effects. The Portuguese Government on January 1, 2008, introduced the first national law banning smoking in public workplaces, including restaurants. The main aim of this study was to examine the impact of this law on indoor air quality (IAQ) in restaurants and on the respiratory and sensory health of restaurant workers. Concentrations of respirable suspended particulate matter (RSP), total volatile organic compounds (TVOC), carbon monoxide (CO), and carbon dioxide (CO2) in 10 restaurants were measured and compared before and after the ban. Benzene (C6H6) concentrations were also measured in all restaurants. Fifty-two and twenty-eight restaurant workers, respectively, answered questionnaires on exposure to SHS, and respiratory and sensory symptoms in the pre- and post-ban phases. There was a statistically significant decrease in RSP, CO, TVOC, and C6H6 concentrations after the ban. Additionally, in both phases the monitored CO2 concentrations greatly exceeded 1800 mg x m(-3), suggesting inefficient ventilation of the indoor spaces. Between pre- and post-ban phases a significant reduction in self-reported workplace SHS exposure was also observed after the enforcement of the law, as well as a significant marked reduction in dry, itching, irritated, or watery eyes, nasal problems, sore or dry throat, cough, wheeze, and headache. This study provides, in a single investigation, comparison of IAQ and respiratory health in Portugal before and after the introduction of the smoke-free law, the first data reported in the literature to our knowledge. Our findings suggest that a total workplace smoking ban results in a significant reduction in indoor air pollution and an improvement in the respiratory health of restaurant workers. These observations may have implications for policymakers and legislators currently considering the nature and extent of their smoke-free workplace legislation and could provide a useful contribution to the implementation of public health prevention programs.

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.