legislation and hospitalizations for acute coronary syndrome
Pell J. P., Haw S., Cobbe S., Newby D. E., Pell
A. C., Fischbacher C., McConnachie A., Pringle
S., Murdoch D., Dunn F., Oldroyd K., Macintyre P., O’Rourke B.,
of Glasgow, United Kingdom
Background. Previous studies
have suggested a reduction in the total number of hospital
admissions for acute coronary syndrome after the enactment of
legislation banning smoking in public places. However, it is unknown
whether the reduction in admissions involved nonsmokers, smokers, or
Methods. Since the end of
March 2006, smoking has been prohibited by law in all enclosed public
places throughout Scotland. We collected information prospectively on
smoking status and exposure to secondhand smoke based on
questionnaires and biochemical findings from all patients admitted
with acute coronary syndrome to nine Scottish hospitals during the
10-month period preceding the passage of the legislation and during
the same period the next year. These hospitals accounted for 64% of
admissions for acute coronary syndrome in Scotland, which has
a population of 5.1 million.
Results. Overall, the number
of admissions for acute coronary syndrome decreased from 3235 to 2684
a 17% reduction (95% confidence interval, 16 to 18) as compared
with a 4% reduction in England (which has no such legislation)
during the same period and a mean annual decrease of 3% (maximum
decrease, 9%) in Scotland during the decade preceding the study. The
reduction in the number of admissions was not due to an increase in
the number of deaths of patients with acute coronary syndrome who
were not admitted to the hospital; this latter number decreased by
6%. 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. Persons who had never smoked reported a decrease in the
weekly duration of exposure to secondhand smoke (P < 0.001 by the
chi-square test for trend) that was confirmed by a decrease in
their geometric mean concentration of serum cotinine from 0.68 to
0.56 ng per milliliter (P < 0.001 by the t-test).
Conclusions. The number of
admissions for acute coronary syndrome decreased after the
implementation of smoke-free legislation. A total of 67% of the
decrease involved nonsmokers. However, fewer admissions among smokers
also contributed to the overall reduction.
of foetal exposure to cigarette smoke after recent implementations of
smoke-free policy in Italy
Franchini M., Caruso C., Perico A., Pacifici R.,
Monleon T., Garcia-Algar O., Rossi S., Pichini S.
of Obstetrics and Gynaecology, S. M. Annunziata Hospital,
Background. We investigated
foetal exposure to cigarette smoke following maternal active and
passive smoking at the end of the pregnancy in a cohort of
mother-infant dyads after recent implementation of the Italian
smoke-free legislation and information campaigns against smoking.
Methods. Study subjects were
979 mothers and their newborns attended at one of the major Florence
hospitals between the end of 2004 and during 2005, when smoking
banning legislation in all the enclosed places of employment was
completely enforced. A structured questionnaire was completed by
mothers and cord serum cotinine was used as a biomarker of
foetal exposure to maternal smoke at the end of the pregnancy.
Results. Women (53.9%)
declared to be non-smokers not exposed to environmental tobacco smoke
(ETS), 33.5% to be exposed non-smokers, while 12.6% reported daily
smoking during pregnancy. Based on the levels of cord serum cotinine,
78.9% newborns were not exposed to ETS, 13.5% were exposed to ETS and
7.7% were exposed to active maternal smoke.
policies can be an effective strategy for reducing both first-hand
and second-hand exposure to cigarette smoke in pregnant women and
their newborns. Due to the implementation of smoke-free legislation
and information campaigns against smoking, a significant trend
towards less active smoking during pregnancy was observed in our
study cohort, as well as a minimal exposure to ETS in
non-smoking pregnant women and their newborns.
the smoke has cleared: evaluation of the impact of a new
national smoke-free law in New Zealand
Edwards R., Thomson G., Wilson N., Waa A., Bullen
C., O’Dea D., Gifford H., Glover M., Laugesen M.,
of Public Health, University of Otago, Wellington, New Zealand
Background. The New Zealand
2003 Smoke-free Environments Amendment Act (SEAA) extended existing
restrictions on smoking in office and retail workplaces by
introducing smoking bans in bars, casinos, members’ clubs,
restaurants and nearly all other workplaces from 10 December 2004.
To evaluate the implementation and outcomes of aspects
of the SEAA relating to smoke-free indoor workplaces and public
places, excluding schools and early learning centres.
Methods. Data were gathered
on public and stakeholder attitudes and support for smoke-free
policies; dissemination of information, enforcement activities and
compliance; exposure to secondhand smoke (SHS) in the workplace;
changes in health outcomes linked to SHS exposure; exposure to SHS in
homes; smoking prevalence and smoking related behaviours; and
Results. Surveys suggested
growing majority support for the SEAA and its underlying principles
among the public and bar managers. There was evidence of high
compliance in bars and pubs, where most enforcement problems were
expected. Self reported data suggested that SHS exposure in the
workplace, the primary objective of the SEAA, decreased significantly
from around 20% in 2003, to 8% in 2006. Air quality improved greatly
in hospitality venues. Reported SHS exposure in homes also reduced
significantly. There was no clear evidence of a short term
effect on health or on adult smoking prevalence, although calls to
the smoking cessation quitline increased despite reduced expenditure
on smoking cessation advertising. Available data suggested a broadly
neutral economic impact, including in the tourist and hospitality
Conclusions. The effects of
the legislation change were favourable from a public health
perspective. Areas for further investigation and possible regulation
were identified such as SHS related pollution in semi-enclosed
outdoor areas. The study adds to a growing body of literature
documenting the positive impact of comprehensive smoke-free
legislation. The scientific and public health case for introducing
comprehensive smoke-free legislation that covers all indoor public
places and workplaces is now overwhelming, and should be a public
health priority for legislators across the world as part of the
globalization of effective public health policy to control the
new national smokefree law increased calls to a national
Wilson N., Sertsou G., Edwards R., Thomson G.,
Grigg M., Li J.
of Public Health, Otago University Wellington, Wellington South, New
Background. A law making
all indoor workplaces including bars and restaurants smokefree became
operational in New Zealand in December 2004. New Zealand has
a national free-phone Quitline Service which has been
operational since 1999. Previous work has shown that the number of
calls to the Quitline are influenced by marketing of the service
through media campaigns. We set out to investigate if the smokefree
law increased calls to the Quitline.
Methods. For 24 months prior
to the law, and 12 months after the law, data were collected on: (i)
Quitline caller registrations and the issuing of nicotine replacement
therapy (NRT) vouchers by the Quitline Service; (ii) expenditure on
Quitline-related television advertising; (iii) expenditure on other
smokefree television advertising; and (iv) print media coverage of
smoking in major New Zealand newspapers. These data were inputs to
a time series analysis using a Box-Jenkins transfer
function model. This used the law change as the intervention
variable, with the response series being the monthly Quitline caller
rates and monthly first time NRT voucher issue rates.
Results. The monthly rates of
Quitline caller registrations and NRT voucher issues were observed to
increase in the months after the law change. The increase in both
these outcomes was even greater when considered in terms of per level
of Quitline advertising expenditure (though these patterns may have
partly reflected marked reductions in advertising expenditure at the
time of the law change and hence are of limited validity).In the more
robust time series analyses, the law change (intervention variable)
had a significant effect (p = 0.025) on increasing the monthly
caller registration rate in December 2004. This was after adjusting
for the possible effects of Quitline advertising expenditure, print
media coverage, and other smoking-related advertising expenditure.
Conclusions. The new national
smokefree law resulted in increased quitting-related behaviour. This
would suggest there is an extra opportunity for health agencies to
promote quitting at such times.
in asthma-related emergency department visits after implementation of
a smoke-free law
Rayens M. K., Burkhart P. V., Zhang M.,
Lee S., Moser D. K., Mannino D., Hahn E. J.
of Nursing, University of Kentucky, Lexington, Kentucky, USA
tobacco 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. Emergency department (ED) visits for asthma were
assessed before and after the implementation of smoke-free
legislation in Lexington-Fayette County, Ky.
To evaluate the effects of a smoke-free law on the
rate of ED visits for asthma.
Methods. The study included
ED visits for asthma from 4 hospitals in Lexington-Fayette County,
Ky. Age-adjusted rates of asthma ED visits were determined. Poisson
regression analysis of ED visits from January 1, 2001, to December
31, 2006 compared the ED visit rates between prelaw and postlaw,
adjusting for seasonality, secular trends over time, and differences
among demographic subgroups. The actual rates were graphed with the
Poisson curve showing the rates predicted by the model. A second
prediction curve was generated to show the projected rates in the
postlaw period if the law had not been implemented.
Results. Adjusting for
seasonality, secular trends, and demographic characteristics, ED
visits for asthma declined 22% from prelaw to postlaw (P < 0.0001;
95% CI, 14% to 29%). The rate of decline was 24% in adults age 20
years and older (P < 0.0001), whereas the decrease among children
19 years or younger was 18% (P = 0.01).
Conclusions. Although this
study did not establish causation, the smoke-free law was associated
with fewer asthma ED visits among both children and adults, with
a more significant decline among adults.
laws and adult smoking
Hahn E. J., Rayens M. K., Butler K. M.,
Zhang M., Durbin E., Steinke D.
of Kentucky, College of Nursing, 760 Rose Street, Lexington, KY
Background. To evaluate
whether the adult smoking rate changed in Lexington-Fayette County,
Kentucky, following the enactment of a smoke-free public places
Methods. Behavioral Risk
Factor Surveillance System (BRFSS) data from 2001–2005 were used to
test whether smoking rates changed in Fayette County from the pre- to
post-law period, relative to the change in 30 Kentucky counties with
similar demographics. The sample consisted of 10,413 BRFSS
respondents: 7139 pre-law (40 months) and 3274 post-law (20 months).
Results. There was a 31.9%
decline in adult smoking in Fayette County (25.7% pre-law to 17.5%
post-law). In the group of 30 Control counties, the rate was 28.4%
pre-law and 27.6% post-law. Controlling for seasonality, time trend,
age, gender, ethnicity, education, marital status, and income, there
was a significant Time (pre- vs. post-law) by Group (Fayette vs.
Controls) interaction. There were an estimated 16,500 fewer smokers
in Fayette County during post-law compared to pre-law.
Conclusions. There was
a significant effect of smoke-free legislation on adult smoking
and economic evaluation of the Massachusetts Smoke-Free Workplace Law
Alpert H. R., Carpenter C. M., Travers M. J.,
Connolly G. N.
School of Public Health, Division of Public Health Practice, Tobacco
Research Program, Boston, USA
An environmental and economic evaluation of the
smoke-free law in Massachusetts provides a broad appreciation of
how a state-wide smoking ban affects the health of patrons and
workers as well as the industries that are commonly concerned about
the effects of smoking bans on business. The aim of this study is to
evaluate environmental and economic effects of the statewide
Massachusetts statewide Smoke-Free Workplace Law. Before and after
the smoking ban, air quality testing was conducted in a sample
(n = 27) of hospitality venues and state-wide economic changes were
assessed. Compliance, in terms of patronage was measured by
person-counts. Environmental outcomes were respirable suspended
particles (RSP) less than 2.5 microns in diameter (PM2.5). Economic
outcomes were meals tax collections, employment in the food services
and drinking places and accommodations industries. On average, levels
of respirable suspended particles (RSPs) less than 2.5 microns in
diameter (PM2.5) decreased 93% in these venues after the
Massachusetts Smoke-free Workplace Law went into effect. No
statistically significant changes were observed among the economic
indicators. This evaluation demonstrates that the state-wide
Massachusetts law has effectively improved indoor air quality in
a sample of Massachusetts venues and has not negatively affected
several economic indicators.
symptoms, pulmonary function, and markers of inflammation among bar
workers before and after a legislative ban on smoking in public
Menzies D., Nair A., Williamson P. A., Schembri S.,
Al-Khairalla M. Z., Barnes M., Fardon T. C.,
McFarlane L., Magee G. J., Lipworth B. J.
and Allergy Research Group, Department of Medicine, Ninewells
Hospital and Medical School, Dundee, Scotland
Context. Scotland prohibited
smoking in confined public places on March 26, 2006.
Background. To investigate the association of smoke-free
legislation with symptoms, pulmonary function, and markers of
inflammation of bar workers.
Design, setting, and participants. This
prospective observational study was conducted in Tayside, Scotland
from February – June 2006. One hundred five nonasthmatic and
asthmatic nonsmoking bar workers were initially enrolled, of whom 77
completed the study per protocol.
Methods. Respiratory and sensory symptoms, spirometry
measurements, serum cotinine levels, peripheral inflammatory cell
count, asthma quality-of-life scores, and exhaled nitric oxide levels
were evaluated before and after introduction of the smoking ban.
Results. For the per-protocol
analysis, the percentage of bar workers with respiratory and sensory
symptoms decreased from 79.2% (n = 61) before the smoke-free policy
to 53.2% (n = 41) (total change, -26%; 95% confidence interval [CI],
-13.8% to -38.1%; P < 0.001) and 46.8% (n = 38) (-32.5%; 95% CI,
-19.8% to -45.2%; P < 0.001) 1 and 2 months afterward. Forced
expiratory volume in the first second increased from 96.6% predicted
to 104.8% (change, 8.2%; 95% CI, 3.9% to 12.4%; P < 0.001) and
then 101.7% (change, 5.1%; 95% CI, 2.1% to 8.0%; P = 0.002), and
serum cotinine levels decreased from 5.15 ng/mL to 3.22 ng/mL
(change, -1.93 ng/mL; 95% CI, -2.83 to -1.03 ng/mL; P < 0.001) and
then 2.93 ng/mL (-2.22 ng/mL; 95% CI, -3.10 to -1.34 ng/mL; P <
0.001). The total white blood cell and neutrophil count was reduced
from 7610 to 6980 cells/microL at 2 months (-630 cells/muL; 95% CI,
-1010 to -260 cells/microL; P = 0.002) and from 4440 to 4030
cells/microL (-410 cells/microL; 95% CI, -740 to -90 cells/microL; P
= 0.03), respectively. Asthmatic bar workers also had less airway
inflammation, with a reduction in exhaled nitric oxide from 34.3
parts per billion (ppb) to 27.4 ppb 1 month after the ban (0.8-fold
change; 95% CI, 0.67 to 0.96 ppb; P = 0.04), and Juniper
quality-of-life scores increased from 80.2 to 87.5 points (7.3
points; 95% CI, 0.1 to 14.6 points; P = 0.049).
legislation was associated with significant early improvements in
symptoms, spirometry measurements, and systemic inflammation of bar
workers. Asthmatic bar workers also had reduced airway inflammation
and improved quality of life.
bans: influence on smoking prevalence
Information and Research Division, Statistics Canada, Ottawa,
Ontario, K1A 0T6
Background. This article
reports trends in smoking prevalence and smoking restrictions in
Canada since 2000, and examines associations between home and
workplace restrictions and smoking cessation.
Methods. Data are from the
Canadian Tobacco Use Monitoring Survey and the longitudinal component
of the National Population Health Survey.
Trends in smoking prevalence and smoking restrictions
were calculated. Associations between home and workplace smoking
restrictions and smoking cessation were examined in the context of
the Transtheoretical Model, which proposes that smokers go through
five distinct stages in attempting to quit. The likelihood of current
and former smokers being at specific stages was studied in relation
to smoking restrictions at home and at work. Longitudinal data were
used to determine if home and workplace smoking restrictions were
predictors of quitting over a two-year period.
Results. Since 2000,
Canadians smokers have faced a growing number of restrictions on
where they can smoke. Bans at home and at work were associated with
a reduced likelihood of being in the initial “stages of
change,” and an increased likelihood of being in the latter stages.
Smokers who reported newly smoke-free homes or workplaces were more
likely to quit over the next two years, compared with those who did
not encounter such restrictions at home or at work.
to environmental tobacco smoke and health effects among hospitality
workers in Sweden-before and after the implementation of a smoke-free
Larsson M., BoĎthius G., Axelsson S.,
Department of Respiratory Medicine, Orebro University Hospital,
SE-70185 Orebro, Sweden
Background. This study
attempted to identify changes in exposure to environmental tobacco
smoke, as well as symptoms and attitudes among hospitality workers
after the introduction of extended smoke-free workplace legislation.
Methods. A total of 37
volunteers working in bingo halls and casinos (gaming workers) and 54
bars and restaurant employees (other workers) in nine Swedish
communities participated in the study. Altogether 71 of 91 persons
(14 daily smokers and 57 nonsmokers) participated in both the preban
baseline survey and the follow-up 12 months after the ban. Exposure
to environmental tobacco smoke, smoking habits, respiratory and
sensory symptoms, and attitudes towards the ban were recorded, and
spirometry was carried out.
Results. The frequency of
reported respiratory and sensory symptoms was approximately halved
among the nonsmokers in both occupational groups after the
introduction of the ban. Initially 87% had exposure to environmental
tobacco smoke that was over the nicotine cut-off level chosen to
identify possible health risk.