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

15.10.3 Infant health

[content in development]

15.10.4 Other health outcomes

[content in development]

Recent news and research

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References

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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

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