Places With Smoke-Free Laws Have the Best Health Outcomes

Laws against smoking went hand in hand with population-level health outcomes across various countries, a meta-analysis found.

Implementation of smoke-free legislation was associated with a lowered risk for all cardiovascular disease (CVD; OR 0.90, 95% CI 0.86-0.94) and respiratory system disease (RSD; OR 0.83, 95% CI 0.72-0.96), reported Ryota Nakamura, PhD, of the Research Center for Health Policy and Economics at Hitotsubashi University in Tokyo, and coauthors.

Smoke-free legislation was also associated with a reduction in adverse birth outcomes (OR 0.94, 95% CI 0.92-0.96) and hospitalization as the result of CVD or RSD (OR 0.91, 95% CI 0.87-0.95), according to the meta-analysis published in JAMA Network Open.

Nakamura’s group noted that these tobacco control policies may have the power to not only potentially limit an individual’s smoking habits, but change a larger population’s exposure to second-hand smoke (SHS).

“Rapid declines in CVD conditions may be associated with decreases in exposure to SHS after the implementation of smoke-free laws. Even low doses of exposure to toxins in tobacco smoke have been found to increase the risk of CVD conditions through various channels, such as activation of blood platelets, increased arterial stiffness, and others,” the group wrote.

Evidence for a causal link between tobacco SHS exposure and RSD is less established, however, the authors said.

Their meta-analysis did not determine an association between adverse health outcomes and tobacco product pricing or tax increase policies.

Nevertheless, Kenneth Warner, PhD, of the University of Michigan School of Public Health in Ann Arbor, argued that price is the area “that’s probably best studied in terms of impact on behavior” and that “an increase in price associated with taxation affects cigarette consumption.”

Price increases and laws together are the “two most powerful” tools to decrease population-level smoking, he told MedPage Today in an interview.

In the U.S., the Family Smoking Prevention and Tobacco Control Act of 2009 bans the sale of tobacco products to minors, purchase of tobacco products through vending machines in places where children may be present, sales of cigarette packs under 20 individual cigarettes, free giveaways of cigarettes as a “sample,” and prohibits the sponsorships of tobacco product brands. The law does allow local, state, and tribal governments to play a role in the regulation of tobacco products.

The American Lung Association currently ranks states by their tobacco control policies, utilizing state tobacco prevention and cessation funding, smoke-free air laws, tobacco excise taxes, access to cessation services, and flavored tobacco product laws to evaluate each state.

For example, highly ranked Maine bans tobacco products from being sold to anyone under 21, and any person who appears to be age 30 or under must present a photo ID in order to buy. Smoking is also prohibited in enclosed public spaces and in outdoor spaces near children.

For their meta-analysis, Nakamura and colleagues included 144 studies. Half the studies were from the U.S., with 31.2% conducted in Europe, 9.7% in the U.K., and 9% listed as being conducted “elsewhere,” largely Asia and Latin America. Nearly 88% of reports were considered to be of “high or moderate quality.”

Smoke-free legislation policies were the most common population-level intervention, followed by tax or price increase policies, multicomponent tobacco control programs, and lastly, minimum age laws to purchase cigarettes.

Associations between smoke-free legislation and improved health outcomes were consistent across all subgroup analyses present in the study, other than national income level. Only countries with a higher income had reductions in negative health outcomes following tobacco control legislation.

Investigators confirmed associations between smoke-free legislation and reductions in CVD incidence, mortality, and events. Reductions in the composite of RSD mortality, symptoms, and occurrence was associated with these laws. Reductions in hospitalizations for both diseases were also associated with smoke-free legislation. Significant associations were also seen for birth outcomes and stillbirth.

Nakamura’s group cautioned that there was “significant between-study heterogeneity” among the included publications, and acknowledged that the policies included in the meta-analysis had been implemented to different degrees in different settings.

Other limitations included a lack of accounting for increased use of products like electronic cigarettes, and the fact that the majority of the countries included throughout the studies were considered high-income.