15.10 Effects of smokefree legislation on health outcomes

When smokers smoke fewer cigarettes each day due to restrictions on smoking in public places, benefits are likely to accrue for smokers and non-smokers alike.

The benefits of reduced daily consumption of cigarettes are doubtful; however as outlined in Chapter 15, Section 15.9, smoking restrictions significantly dampen uptake, and do appear to contribute to increased rates of cessation among smokers. This will undoubtedly bring benefits in reductions in death and disease in both the long and the short term. The secondhand smoke issue can be considered a 'Trojan horse to its less discussed effects: the reduced morbidity and mortality likely to result in smokers from the significant reductions in smoking frequency that occur with the proliferation of smoking restrictions introduced in the name of concern for the health of non-smokers'(p417).1

While the benefits of reduced morbidity and mortality resulting from smoking restrictions in public places will be very difficult to quantify in the longer term, surprisingly large short-term benefits have already been detected for heart attacks and asthma exacerbations.

15.10.1 Cardiovascular disease

When a smoker quits, the risk of myocardial infarction falls quite quickly, by some estimates halving within four to five years and approaching that of a non-smoker over a 10- to 20-year period.2 As discussed in Chapter 4, Section 4.6, the risk of cardiovascular disease increases sharply with quite minimal exposure to secondhand smoke.3 It would therefore not be surprising to find that following the introduction of smokefree policies in particular communities, the number of acute cardiovascular episodes, such as heart attacks, decline quite quickly when additional smokers quit and when non-smokers are no longer exposed to tobacco smoke in public venues. Indeed, more than 20 studies have now reported rapid reductions in acute myocardial infarctions following passage of strong smokefree legislation that includes restrictions in public venues such as restaurants and bars.427

A meta-analysis of eight studies examining the effects of smokefree laws on acute myocardial infarction (AMI) authored by Glantz in 2008 reported a pooled estimate of an immediate 19% reduction on AMI admission rates associated with smokefree laws. Glantz stated: 'The fact that many studies from so many locations around the world provide consistent findings of a substantial drop in AMI's associated with the implementation of smokefree laws increases the confidence that we can have that smokefree policies have immediate and substantial benefits in terms of reducing acute myocardial infarctions' (p1).28 Lightwood and Glantz went on to show how closely this magnitude of decline corresponds to the decline in mortality that would be predicted by reductions in relative risk generated by epidemiological studies.29

Shortly after publication of the Glantz review, in 2009 the International Agency for Research on Cancer reviewed the 10 studies on AMI admissions published until the end of 2008 and concluded that there was 'strong evidence' that the reduction in myocardial infarction had been a direct result of the adoption of such policies.30

One of the best-designed of these studies was a prospective examination of coronary admissions in Scottish compared to English hospitals following the implementation of comprehensive smokefree legislation in Scotland. The number of admissions for acute coronary syndrome decreased in the Scottish hospitals by 17% after the implementation of smokefree legislation (compared with a 4% reduction in England, which had no similar legislative restrictions). Two-thirds of the decrease involved non-smokers. However, fewer admissions among smokers also contributed to the overall reduction. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked.15

In 2010 the Cochrane Collaboration published a systematic review31 of a total of 12 studies, including 10 that reported hospital admission rates for AMI or coronary heart disease following implementation of a ban: five in the US (Bartecchi 2006;7 Juster 2007;8 Khuder 2007;9 Sargent 2004;5 and Seo 200710); three in Italy (Barone-Aldesi 2006;6 Cesaroni 2008;11 and Vasselli 200814); one in Scotland (Pell 200815) and one in Canada (Lemstra 200813). Four studies had control groups without a ban. Admissions for AMI reduced in all 10 studies. Two further studies showed an impact on deaths from coronary heart disease (Fichtenberg 20004) and better prognosis post-acute coronary syndrome among non-smokers (Pell 200923) following smokefree legislation.

Another review published by Mackay and colleagues in 201032 included most of those covered in the Cochrane Collaboration review plus a further five studies.17 22 This review included seven studies with geographical control groups and a total of 35 statistical comparisons. This review came to a similar conclusion as the previous reviews by Glantz,28 the IARC30 and the Cochrane Collaboration31 finding that legislation has been followed with an average immediate fall of about 10% in the rate of myocardial infarctions and even greater reductions in the long term. Several studies published since these three reviews strengthen the case still further.2427

In summary, four major reviews28,3032 covering 17 studies and several recent additional studies2427 strongly support the conclusion that acute coronary events have reduced by at least 10% following the implementation of comprehensive smokefree legislation, with the benefits increasing over time from implementation.

15.10.2 Effects on exacerbations of asthma

Exposure to secondhand smoke increases the risk for the development and increasing severity of asthma among adults and children. Reducing exposure to secondhand smoke decreases symptomatic exacerbations among patients with asthma in groups with occupational exposure as well as in the broader population (see Chapter 4, Sections 4.9.4 and 4.10).

Following the introduction of smokefree laws in the US state of Kentucky, emergency department visits for asthma declined by 22%. The rate of decline (adjusted for seasonal variations) was 24% in adults aged 20 years and older, whereas the decrease among children 19 years or younger was 18%.33 Asthma admissions declined in Delaware relative to the rest of the US following the introduction of legislation in that state at the end of 2002.27

In Scotland prior to the legislation being implemented in March 2006, hospital admissions for asthma were increasing at a mean rate of 5% per year. After implementation of the legislation, there was a mean reduction in the rate of admissions of 18% per year, relative to the rate on 26 March 2006. The reduction was apparent among both preschool and school-age children.34,35

Recent news and research

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1. Chapman S, Borland R, Hill D, Owen N and Woodward S. Why the tobacco industry fears the passive smoking issue. International Journal of Health Services 1990;20(3):417–27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2384286

2. International Agency for Research on Cancer. Reversal of risk after quitting smoking. Handbooks of cancer prevention, tobacco control, vol. 11. Lyon, France: IARC, 2007. Available from: http://apps.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=76&codcch=22

3. International Agency for Research on Cancer Working Group on the Evaluation of Carcinogenic Risks to Humans. Tobacco smoke and involuntary smoking. IARC monographs on the evaluation of carcinogenic risks to humans, vol. 83. Lyon, France: IARC, 2004. Available from: http://monographs.iarc.fr/ENG/Monographs/PDFs/index.php

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5. Sargent R, Shepard R and Glantz S. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. British Medical Journal (Clinical Research Ed.) 2004;328(7446):977–80. Available from: http://www.bmj.com/cgi/content/full/328/7446/977

6. Barone-Adesi F, Vizzini L, Merletti F and Richiardi L. Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. European Heart Journal 2006;27(20):2468–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16940340

7. Bartecchi C, Alsever R, Nevin-Woods C, Thomas W, Estacio R, Bartelson B, et al. Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation 2006;114(14):1490–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17000911

8. Juster H, Loomis B, Hinman T, Farrelly M, Hyland A, Bauer U, et al. Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban. American Journal of Public Health 2007;97(11):2035–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17901438

9. Khuder S, Milz S, Jordan T, Price J, Silvestri K and Butler P. The impact of a smoking ban on hospital admissions for coronary heart disease. Preventive Medicine 2007;45(1):3–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17482249

10. Seo D and Torabi M. Reduced admissions for acute myocardial infarction associated with a public smoking ban: matched controlled study. Journal of Drug Education 2007;37(3):217–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18047180

11. Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P and Perucci C. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 2008;117(9):1183–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18268149

12. Edwards R, Thomson G, Wilson N, Waa A, Bullen C, O'Dea D, et al. After the smoke has cleared: evaluation of the impact of a new national smoke-free law in New Zealand. Tobacco Control 2008;17(1):e2. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/17/1/e2

13. Lemstra M, Neudorf C and Opondo J. Implications of a public smoking ban. Canadian Journal of Public Health 2008;99(62):62–5.

14. Vasselli S, Papini P, Gaelone D, Spizzichino L, De Campora E, Gnavi R, et al. Reduction incidence of myocardial infarction associated with a national legislative ban on smoking. Minerva Cardioangiologica 2008;56(2):197–203. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18319698

15. Pell JP, Haw S, Cobbe S, Newby DE, Pell AC, Fischbacher C, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. New England Journal of Medicine 2008;359(5):482–91. Available from: http://content.nejm.org/cgi/content/full/359/5/482

16. Shetty A and Alex R. The experience of a smoke-free policy in a medium secure hospital. The Psychiatrist 2010;34:287–9. Available from: http://pb.rcpsych.org/cgi/content/full/34/7/287

17. Herman P and Walsh M. Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona's comprehensive statewide smoking ban. American Journal of Public Health 2009;101(3):491–6. Available from: http://ajph.aphapublications.org/cgi/content/abstract/101/3/491

18. Villalbí­a JR, Castillob A, Cleriesc M, Saltóc E, Sánchezd E, Martíneze R, et al. Acute myocardial infarction hospitalization statistics: apparent decline accompanying an increase in smoke-free areas Revista Española de Cardiologí­a 2009;62(07):812–5. Available from: http://www.revespcardiol.org/cardio_eng/ctl_servlet?_f=60&ident=13140265

19. Shetty KD, DeLeire T, White C and Bhattacharya J. Changes in US hospitalization and mortality rates following smoking bans. working paper no. 14790. Cambridge, MA: National Bureau of Economic Research, 2009. Available from: http://www.nber.org/papers/w14790

20. Sims M, Maxwell R, Bauld L and Gilmore A. Short term impact of smoke-free legislation in England: retrospective analysis of hospital admissions for myocardial infarction. British Medical Journal 2010;340:c2161. Available from: http://www.bmj.com/cgi/content/full/340/jun08_1/c2161?view=long&pmid=20530563

21. Cronin E, Kearney P and Kearney Pea. Impact of a national smoking ban on the rate of admissions to hospital with acute coronary syndromes. Poster 3506 Conference presentation. European Society of Cardiology 2007 Congress. Vienna, Austria, 2007.

22. Barnett R, Pearce J, Moon G, Elliott J and Barnett P. Assessing the effects of the introduction of the New Zealand Smokefree Environment Act 2003 on acute myocardial infarction hospital admissions in Christchurch, New Zealand. Australian and New Zealand Journal of Public Health 2009;33(6):515–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20078567

23. Pell J, Haw S, Cobbe S, Newby D, Pell A, Fischbacher C, et al. Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions among never-smokers. Heart (British Cardiac Society) 2009;95(17):1415–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684191

24. Trachsel L, Kuhn M, Reinhart W, Schulzki T and Bonetti P. Reduced incidence of acute myocardial infarction in the first year after implementation of a public smoking ban in Graubuenden, Switzerland. Swiss Medical Weekly 2010; Epub ahead of print. Available from: http://www.smw.ch/docs/PdfContent/smw-12955.pdf

25. Dove M, Dockery D, Mittleman M, Schwartz J, Sullivan E, Keithly L, et al. The impact of Massachusetts' smoke-free workplace laws on acute myocardial infarction deaths. American Journal of Public Health 2010;100(11):2206–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20864706

26. Barone-Adesi F, Gasparrini A, Vizzini L, Merletti F and Richiardi L. Effects of Italian smoking regulation on rates of hospital admission for acute coronary events: a country-wide study. PLoS One 2011;6(3):e17419. Available from: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0017419

27. Moraros J, Bird Y, Chen S, Buckingham R, Meltzer RS, Prapasiri S, et al. The impact of the 2002 Delaware Smoking Ordinance on heart attack and asthma. International Journal of Environmental Research and Public Health 2010;7(12):4169–78. Available from: http://www.mdpi.com/1660-4601/7/12/4169/pdf

28. Glantz S. Meta-analysis of the effects of smokefree laws on acute myocardial infarction: an update. Preventive Medicine 2008;47(4):452–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18602944

29. Lightwood J and Glantz S. Declines in acute myocardial infarction after smoke-free laws and individual risk attributable to secondhand smoke. Circulation 2009;120(14):1373–9. Available from: http://circ.ahajournals.org/cgi/content/full/120/14/1373

30. International Agency for Research on Cancer. Evaluating the effectiveness of smoke-free policies. Handbooks of cancer prevention, tobacco control, vol. 13. Lyon, France: IARC, 2009. Available from: http://com.iarc.fr/en/publications/pdfs-online/prev/handbook13/

31. Callinan J, Clarke A, Doherty K and Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database of Systematic Reviews 2010;4:CD005992. Available from: http://www2.cochrane.org/reviews/en/ab005992.html

32. Mackay D, Irfan M, Haw S and Pell J. Meta-analysis of the effect of comprehensive smoke-free legislation on acute coronary events. Heart 2010;96(19):1525–30. Available from: http://heart.bmj.com/content/96/19/1525.long

33. Rayens MK, Burkhart PV, Zhang M, Lee S, Moser DK, Mannino D, et al. Reduction in asthma-related emergency department visits after implementation of a smoke-free law Journal of Allergy and Clinical Immunology 2008;122(3):537–41e3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18692884

34. Mackay D, Haw S, Ayres J, Fischbacher C and Pell J. Smoke-free legislation and hospitalizations for childhood asthma. New England Journal of Medicine 2010;363(12):1139–45. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa1002861

35. Moral L. Smoke-free legislation and asthma. New England Journal of Medicine 2011;364(1):87; author reply 88–9. Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMc1011724

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