Secondhand Smoke Exposure and Cardiovascular Effects Making Sense of the Evidence (2010) / Chapter Skim
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6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events
6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events
Pages 125-162
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From page 125... ...
. • The association between smoking bans and acute coronary events (Questions 4, 5, 6, 7, and 8, see Box 1-1)
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From page 126... ...
The different smoking bans are discussed in order by earliest publication date. Details of the smoking bans and restriction in the different regions are presented in Table 6-1; available information on the effect of the bans on potential secondhand smoke exposure -- including data on enforcement and compliance, air monitoring, and biomonitoring -- is presented in Table 6-2; and details of the study designs and published results are presented in Table 6-3.
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From page 127... ...
, accessed July 2009. c A number of local smoking bans and restrictions were in place in New York state before the implementation of the statewide ban.
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From page 128... ...
(including restaurants, bars, bowling alleys, other business establishments) within city limits Monroe County, Indiana Ban in all restaurants, retail stores, workplaces; extended to (August 1, 2003; extended to bars previously exempt bars and clubs January 1, 2005 January 1, 2005)
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From page 129... ...
each in Toledo, Bowling Green, Ohio; data from previous study were compared with data from average concentrations in two cities combined; analyses indicated that concentrations of SHS related contaminants did not change after smoking restrictions, but concentrations were lower in nonsmoking restaurants than restaurants that allow smoking in separate areas (Akbar-Khanzadeh et al., 2004) Continued
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From page 130... ...
enclosed public space open to public or to which public is customarily admitted or invited; smoking also prohibited in outdoor seating areas for restaurants, licensed premises Previously, smoking prohibited in government buildings As of January 1, 2005, 100% smoke-free law in all public places, workplaces, including restaurants, bars, bingo halls, bowling alleys, casinos in Saskatchewan; local municipalities have right to enact smoke-free air regulations Scotland Smoking prohibited in all enclosed public places, workplaces (March 2006) throughout Scotland, including bars, pubs, restaurants, cafes; exceptions included residential accommodations, designated rooms in hotels, care homes, hospices, psychiatric units Abbreviations: CI, confidence interval; FPM, fluorescent particulate matter; MI, myocardial infarction; NYATS, New York Adult Tobacco Survey; PM, particulate matter; RSP, respirable suspended particulate matter; SHS, secondhand smoke; UVPM, respirable suspended ultraviolet particulate matter.
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From page 131... ...
In nonsmokers, geometric mean salivary cotinine concentration decreased from 2.9 ng/mL before ban to 0.7 ng/mL 2 months after and to 0.4 ng/mL 1 year after in 301 bar workers (Semple et al., 2007b) Serum cotinine concentrations in bar workers in Dundee and Perth, Scotland, decreased from 5.15 ng/mL before ban to 3.22 ng/mL 1 month after (reduction of 1.93 ng/mL; 95% CI, 1.03–2.83 ng/mL; p < 0.001)
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From page 132... ...
An advantage of the study design is that the suspension of enforcement of the smoking ban allowed a "cross-over comparison" of incidence before, during, and after the ban and the presence of a control community. Study limitations included the small population, the reliance on historical controls, and the lack of direct exposure information or information on individual smoking status.
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From page 133... ...
Those data indicate that the smoking ban resulted in a decrease in exposure to secondhand smoke. Published Results on Acute Coronary Events Three publications report on acute coronary events after implementation of the Italian smoking ban (Barone-Adesi et al., 2006; Cesaroni et
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From page 134... ...
ban compared Selection criteria: onset of symptoms with same months in study area, no recent procedure of 5 years before that could have precipitated acute ban MI, primary diagnosis of acute MI or secondary diagnosis with chemical evidence of acute MI at time of admission (cTn or creatine phosphokinase) Control population: county residents who lived outside city boundaries Italy Vasselli et al., 2008 (four regions Retrospective based Patients in public, private hospitals in Italy: Piedmont, Friuli–Venezia– on hospital with primary discharge diagnosis of Giulia, Latium, Campania)
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From page 135... ...
Total of all four regions, observed 2005 versus expected based on linear regression: risk reduction 13.1% (age standardized risk ratio, 0.86; 95% CI, 0.83–0.92) Significant decrease from expected numbers in 2005 in men but not women 45–49 years old but not other age ranges, all regions except Friuli–Venezia–Giulia Continued
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From page 136... ...
Mary-Corwin Medical Center before, 1.5 and January 1, 2002–June 30, 2006 3.0 years after Assessed number of fatal acute MIs implementation in residents in Pueblo city limits of smoke-free (based on residential ZIP codes) ordinance around time smoke-free ordinance was passed Control populations in Pueblo County but outside city limits, El Paso County Analyzed data after implementation of smoking ban (January 2005–June 30, 2006; phase II after implementation)
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From page 137... ...
, 65- to 74-year-olds (RR, trends, total hospitalization 0.92; 95% CI, 0.88–0.97) but rates -- taken into account not those over 74 years old Data on cigarette sales in Rome, population smoking habits in Rome region included Total of 1,559 cases for phase II: Chi-square test to compare No information on individual 237 in Pueblo city; 92 in Pueblo rates over time smoking status; no measures of County (not in city)
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From page 138... ...
but only after 1.5 only through December 2004 years of followup Monroe County, Indiana Seo and Torabi, 2007 Retrospective based Primary, secondary diagnosis of acute (Monroe County, Indiana) on records; study MI (ICD--CM 410.xx)
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From page 139... ...
Cases: Monroe County, 22; Comparison of counts Included only nonsmoking Delaware County, 34 before, after with Poisson patients; smoking status based Monroe County: significant regression on patient charts decrease in number of No measures of individual SHS nonsmoking-patient admissions exposure for acute MI (admissions Admission charts were reviewed decreased from 17 to 5; 95% Data collected on admission date, CI, 2.81–21.19) from period smoking status, comorbidity, 1 (August 2001–May 2003, whether past cardiac procedure before smoking ban)
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From page 140... ...
New york state Juster et al., 2007 Retrospective based Monthly hospital admissions associated (New York state) on hospital with acute MI (ICD--CM discharge records; 410.0–410.99)
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From page 141... ...
Significant trend not seen in Kent No decrease seen after 6 months Annual averages over 10-year Multiple linear regression for No information on individual period: 46,000 admissions for interrupted time series to smoking status; no measures of acute MI, more than 58,000 analyze monthly age-, sex- individual SHS exposure admissions for stroke adjusted county rates Excluded restrictions applied only No change in trend line for to municipal buildings hospital admissions for acute New York County smoking MI with implementation of restrictions categorized as comprehensive or moderatea 2003 statewide ban Estimated 3,813 (8%) fewer hospital admissions for acute MI than would be expected in absence of state smoking ban in 2004 Estimated 19% decline in admissions would have been associated with the comprehensive state law if large number of jurisdictions in state had not already had ordinances Continued
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From page 142... ...
al., 2008; Vasselli et al., 2008) and provide information directly related to the association between smoking bans and acute coronary events.
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From page 143... ...
Admissions for acute Compared binary, ordinal Detailed information on smoking, coronary syndrome decreased data with chi-square test; exposure to SHS from by 17% (95% CI, 16–18%) subgroup analyses by sex, questionnaires, biochemical after implementation of age; two-sample t-test, log assays ban; greatest reduction in transformation on cotinine Self-reported smoking status admissions observed in concentrations Serum cotinine concentrations used nonsmokers to categorize smoking status, SHS exposure a Comprehensive laws prohibit smoking in all worksites, including restaurants, bars, and hospitality venues with few or no exemptions; moderate laws restrict smoking in most worksites but provide little or no protection in hospitality venues.
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From page 144... ...
and the lack of information on individual smoking status. Individual exposures to secondhand smoke were also not recorded.
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From page 145... ...
. The authors used two population registers -- the hospital discharge database and the regional mortality register -- to obtain information on the number of acute coronary events in residents of Rome in 2000–2005.
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From page 146... ...
, an influenza epidemic, holidays, and air temperature. There was no information on individual smoking status, but the authors did use information on smoking prevalence in Rome and the RRs posed by active smoking to estimate the extent of the decrease in acute coronary events that might be attributable to smoking cessation; they estimated that less than 2% of the decrease was attributable to smoking cessation.
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From page 147... ...
. Both provide information directly related to the association between smoking bans and acute coronary events.
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From page 148... ...
They identified a total of 2,794 patients who had a primary diagnosis of acute MI during the period of interest: 690 who resided inside the Pueblo city limits, 165 patients outside the Pueblo city limits but in Pueblo County, and 1,939 in El Paso County. There was a significant difference in sex distribution in the patients in the three locations (p = 0.003)
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From page 149... ...
One publication examined the relationship between the smoking ban and acute coronary events (Seo and Torabi, 2007)
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From page 150... ...
The study population included nonsmoking patients admitted to two Monroe County hospitals -- Bloomington Hospital and Ball Memorial Hospital -- with a primary or secondary diagnosis of acute MI.1 The authors assessed admission rates during two periods: period 1 consisted of 22 months before enforcement of the original smoking ban in Monroe County (August 2001–May 2003) , and period 2 consisted of the 22 months after the beginning of enforcement (August 2003–May 2005)
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From page 151... ...
. With respect to the analysis, the authors compare the difference in acute MIs before and after the ban in Monroe County, and compare the number of acute MIs after the ban in Monroe County to Delaware County (a county with a similar population for which there were no significant differences in acute MIs prior to the ban in Monroe County, that did not implement a smoking ban)
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From page 152... ...
. It provides information directly related to the question of the association between smoking bans and acute coronary events.
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From page 153... ...
NEW yORk STATE Smoking Ban and Exposure Information On July 24, 2003, New York implemented a statewide ban on smoking in all workplaces, including restaurants, bars, and gaming establishments. Statewide smoking restrictions implemented in 1989 had limited or prohibited smoking in particular public places, such as schools, hospitals, public buildings, and retail stores.
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From page 154... ...
. Their report provides information directly related to questions about the association between smoking bans and acute coronary events.
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From page 155... ...
However, the interaction between the law and time -- assessed by comparing the changes in the slope of the line for observed versus expected events after the ban -- indicated that the decline in monthly acute MIs associated with the countywide and statewide bans was greater than the decline expected in the absence of those bans. Moderate smoking bans reduced the monthly trend rate by an estimated average of 0.15/100,000 persons per month; the statewide comprehensive ban reduced the monthly trend rate by an estimated average of 0.32/100,000 per month.
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From page 156... ...
That study provides information directly related to questions about the association between smoking bans and acute coronary events. The authors measured business compliance with the ban by reviewing warnings and tickets issued by public-health inspectors to eligible businesses.
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From page 157... ...
The study surveyed participants on smoking status and secondhand-smoke exposure before and after the ban, and it measured serum cotinine. The correlation between self-reported duration of exposure to secondhand smoke and serum cotinine concentrations was similar before (r = 0.33, p < 0.001)
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From page 158... ...
Using a repeat, cross-sectional design, the researchers interviewed adults (ages 16–74 years) on health behaviors, smoking status, nicotine-replacement therapy use, and reported exposures to secondhand smoke before and after implementation of the ban.
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From page 159... ...
Their study had serum cotinine concentrations of patients and analyzed the data according to smoking status on the basis of those concentrations, so it directly addressed the question of the association between secondhand-smoke exposure and acute coronary events. The authors gathered information on cases from nine hospitals during the 10 months before implementation (June 2005–March 2006)
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From page 160... ...
2007. Reduced secondhand smoke exposure after implementation of a comprehensive statewide smoking ban -- New York, June 26, 2003–June 30, 2004.
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From page 161... ...
2008. Effect of the Italian smoking ban on population rates of acute coronary events.
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From page 162... ...
2008. Smoke-free legislation and hospitalizations for acute coronary syndrome.
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