Abstrakta

Smoke-free 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., Borland W.

University of Glasgow, United Kingdom

e-mail: j.pell@clinmed.gla.ac.uk

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 both.

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.

Assessment 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.

Department of Obstetrics and Gynaecology, S. M. Annunziata Hospital, Florence, Italy

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.

Conclusions. Smoke-free 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.

BackgrounAfter 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., Woodward A.

Department of Public Health, University of Otago, Wellington, New Zealand

e-mail: richard.edwards@otago.ac.nz

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 economic impacts.

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 sectors.

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 tobacco epidemic.

BackgrounA new national smokefree law increased calls to a national quitline

Wilson N., Sertsou G., Edwards R., Thomson G., Grigg M., Li J.

Department of Public Health, Otago University Wellington, Wellington South, New Zealand

e-mail: nwilson@actrix.gen.nz

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.

Reduction 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.

College of Nursing, University of Kentucky, Lexington, Kentucky, USA

Background. Secondhand 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.

Smoke-free laws and adult smoking prevalence

Hahn E. J., Rayens M. K., Butler K. M., Zhang M., Durbin E., Steinke D.

University of Kentucky, College of Nursing, 760 Rose Street, Lexington, KY 40536-0232, USA

e-mail: ejhahn00@email.uky.edu

Background. To evaluate whether the adult smoking rate changed in Lexington-Fayette County, Kentucky, following the enactment of a smoke-free public places ordinance.

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 rates.

Environmental and economic evaluation of the Massachusetts Smoke-Free Workplace Law

Alpert H. R., Carpenter C. M., Travers M. J., Connolly G. N. 

Harvard School of Public Health, Division of Public Health Practice, Tobacco Research Program, Boston, USA

e-mail: ejhahn00@email.uky.edu

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.

Respiratory symptoms, pulmonary function, and markers of inflammation among bar workers before and after a legislative ban on smoking in public places

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.

Asthma and Allergy Research Group, Department of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland

e-mail: d.menzies@dundee.ac.uk

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).

Conclusions. Smoke-free 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.

Smoking bans: influence on smoking prevalence

Shields M.

Health Information and Research Division, Statistics Canada, Ottawa, Ontario, K1A 0T6

e-mail: margot.shields@statcan.ca

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.

Exposure to environmental tobacco smoke and health effects among hospitality workers in Sweden-before and after the implementation of a smoke-free law

Larsson M., BoĎthius G., Axelsson S., Montgomery S. M.

The Department of Respiratory Medicine, Orebro University Hospital, SE-70185 Orebro, Sweden

e-mail: matz.larsson@orebroll.se

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.