Smokefree Policies Improve Health

Exposure to secondhand smoke from burning tobacco products causes disease and premature death among nonsmokers.¹ There is no risk-free level of secondhand smoke, and even brief exposure can cause immediate harm.¹ Studies have shown that smokefree laws that prohibit smoking in public places like bars and restaurants help improve the health of workers and the general population.^1-17 Some of these improvements in health outcomes, such as reductions in hospital admissions for heart attacks, begin to be realized shortly after the laws take effect.^1–5

Scientific Reviews

Hospitality Workers’ Health

In 2009, a report by the International Agency for Research on Cancer concluded that there is sufficient evidence (the highest level of evidence under the report’s rating scale) that implementation of smokefree legislation decreases respiratory symptoms in workers.⁴

• In 2009, a report by the International Agency for Research on Cancer concluded that there is strong evidence (the second highest level of evidence under the report’s rating scale) that implementation of smokefree legislation causes a decline in heart disease morbidity.⁴
• In 2010, a report by the Institute of Medicine concluded that there is a causal relationship between smokefree laws and decreases in acute coronary events, although the report was unable to estimate the magnitude of this association.⁵
• In 2010, a Cochrane review of 12 studies found consistent evidence of a reduction in hospital admissions for cardiac events following implementation of smokefree laws.⁶
• In 2010, a meta-analysis of 17 studies of the effect of smokefree laws on acute coronary events reported a pooled estimate of relative risk of 0.90 (95% confidence interval: 0.86 to 0.94) and concluded that a large body of evidence exists supporting a reduction in acute coronary events following the implementation of smokefree laws, with the effect increasing over time.⁷
• In 2012, a random-effects meta-analysis of 45 studies of 33 smokefree laws with a median follow-up of 24 months (range: 2–57 months) found that comprehensive smokefree laws were associated with lower rates of hospital admissions or deaths for:
  • Coronary events (relative risk: 0.848)
  • Other heart disease (relative risk: 0.610)
  • Cerebrovascular accidents (relative risk: 0.840)
  • Respiratory disease (relative risk: 0.760)

The difference in risk did not change with longer follow-up. More comprehensive laws were associated with larger decreases in risk.⁸

Selected Studies: Hospitality Workers’ Health

Studies in:	Found that:	Was associated with:
Scotland (2006)9	Implementing a comprehensive national smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	Rapid (within 2 months) improvements in a number of health outcomes in nonsmoking bar workers, including: Reductions in respiratory symptoms, like coughing, wheezing, and shortness of breath Reductions in sensory symptoms, like eye and throat irritations and runny nose improvements in lung function Reductions in inflammation or swelling of airways Improved quality of life among bar employees with asthma
Ireland (2007)10	Implementing a comprehensive national smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	Improvements in the respiratory health of nonsmoking bar workers, including: Improvements in lung function Reductions in coughing and phlegm production Reductions in sensory symptoms, like eye and throat irritations

Selected Studies: Population Health—Acute Coronary Events

Studies in:	Found that:	Was associated with:
New York (2007)11	Implementing a comprehensive state smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	An 8% reduction in hospital admissions for acute myocardial infarction in 2004, the year after the state smokefree law took effect, accounting for 3,813 fewer admission and $56 million in savings on hospital costs
Scotland (2008)12	Implementing a comprehensive national smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	Improvements in the respiratory health of nonsmoking bar workers, including: A 17% reduction in hospital admissions for acute coronary syndrome, compared with a 4% reduction in England, which had no national smokefree law at this point Admissions falling by 21% among never smokers, 19% among former smokers, and 14% among smokers

Selected Studies: Population Health—Asthma

Studies in:	Found that:	Was associated with:
Scotland (2010)13	Implementing a comprehensive national smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	An average reduction of 18.2% per year in the rate of hospital admissions for asthma in children aged < 15 years relative to the rate on the date the law took effect
England (2013)14	Implementing a comprehensive national smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	Improvements in the respiratory health of nonsmoking bar workers, including: A significant immediate change of -8.9% in the emergency hospital admission rate of children aged ≤ 14 years with a principal diagnosis of asthma 6,802 fewer admissions in the first 3 years after the law took effect

Selected Studies: Population Health—Multiple Outcomes

Studies in:	Found that:	Was associated with:
Arizona (2011)15	Implementing a comprehensive state smokefree law prohibiting smoking in all indoor areas of workplaces, restaurants, and bars	Reductions in monthly hospital admissions for heart attacks, angina, stroke, and asthma in counties with no municipal or county smokefree laws predating the state law compared with counties with such laws.
United States (2012)16	Implementing state or local smokefree laws in workplaces, restaurants, and/or bars covering 50% or more of county’s population	Substantial health improvement among Medicare beneficiaries aged ≥ 65 years, including: A 20-21% decrease in hospital admission rates for acute myocardial infarctions (heart attacks) An 11% reduction in hospital admission rates for chronic obstructive pulmonary disease
United States (2012)17	Implementing comprehensive smokefree laws covering workplaces, restaurants, and bars in 387 U.S. counties between January 2000 and December 2007	A decrease in heart attack admissions among Medicare enrollees in the 12 months after the smokefree law took effect* *Note: There was a reduction in the strength of the association after pre-existing declines in cardiovascular disease were taken into account.

References

1. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006 [accessed 2014 May 12].
2. Hahn EJ. Smoke-free Legislation: A Review of Health and Economic Outcomes Research. American Journal of Preventive Medicine 2010;39(6S1):S66–S76 [cited 2014 May 12].
3. Goodman PG, Haw S, Kabir Z, Clancy L. Are There Health Benefits Associated With Comprehensive Smoke-Free Laws?. International Journal of Public Health 2009; 54:367–78 [cited 2014 May 12].
4. International Agency for Research on Cancer (IARC). IARC Handbooks of Cancer Prevention, Tobacco Control, Vol. 13: Evaluating the Effectiveness of Smoke-Free Policies [PDF–2.67 MB]. Lyon, France: WHO, 2009 [accessed 2014 May 12].
5. Institute of Medicine. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington: The National Academies Press, 2010 [accessed 2014 May 12].
6. Callinan JE, Clarke A, Doherty K, and Kelleher C. Legislative Smoking Bans for Reducing Secondhand Smoke Exposure, Smoking Prevalence and Tobacco Consumption (Review) [PDF–1.11 MB]. [accessed 2014 May 12].
7. Mackay DF, Irfan MO, Haw S, Pell JP. Meta-Analysis of the Effect of Comprehensive Smoke-Free Legislation on Acute Coronary Events. Heart 2010;96:1525–30 [cited 2014 May 12].
8. Tan CE, Glantz SA. Association Between Smoke-Free Legislation and Hospitalizations for Cardiac, Cerebrovascular, and Respiratory Diseases: A Meta-Analysis. Circulation 2012;126:2177–83 [cited 2014 May 12].
9. Menzies D, Nair A, Williamson PA, Schembri S, Al-Khairalla MZH, Barnes M, et al. Respiratory Symptoms, Pulmonary Function, and Markers of Inflammation Among Bar Workers Before and After a Legislative Ban on Smoking in Public Places. Journal of the American Medical Association 2006;296(14):1742–8 [cited 2014 May 12].
10. Goodman P, Agnew M, McCaffrey M, Paul G, Clancy L. Effects of the Irish Smoking Ban on Respiratory Health of Bar Workers and Air Quality in Dublin Pubs. American Journal of Respiratory and Critical Care Medicine 2007;175(8):840–5 [cited 2014 May 12].
11. Juster HR, Loomis BR, Hinman TM, Farrelly MC, Hyland A, Bauer UE, Birkhead GS. Declines in Hospital Admissions for Acute Myocardial Infarction in New York State After Implementation of a Comprehensive Smoking Ban. American Journal of Public Health 2007;97(11):2035-39 [cited 2014 May 12].
12. Pell JP, Haw S, Cobbe S, Newby DE, Pell ACH, Fischbacher C, et al. Smoke-Free Legislation and Hospitalizations for Acute Coronary Syndrome. New England Journal of Medicine 2008;359:482–91 [cited 2014 May 12].
13. Mackay D, Haw S, Ayres JG, Fischbacher C, Pell JP. Smoke-Free Legislation and Hospitalizations for Childhood Asthma. New England Journal of Medicine 2010;363:1139–45 [cited 2014 May 12].
14. Millett C, Lee JT, Laverty AA, Glantz SA, Majeed A. Hospital Admissions for Childhood Asthma After Smoke-Free Legislation in England. Pediatrics 2013;131(2):e485–e501 [cited 2014 May 12].
15. Herman PM, Walsh ME. Hospital Admissions for Acute Myocardial Infarction, Angina, Stroke, and Asthma After Implementation of Arizona’s Comprehensive Statewide Smoking Ban. American Journal of Public Health 2011;101(3):491–-496 [cited 2014 May 12].
16. Barr CD, Diez DM, Wang Y, Dominici F, Samet JM. Comprehensive Smoking Bans and Acute Myocardial Infarction Among Medicare Enrollees in 387 US Counties: 1999–-2008. American Journal of Epidemiology 2012;176(7):642–-648 [cited 2014 May 12].
17. Vander Weg MW, Rosenthal GE, Sarrazin MV. Smoking Bans Linked to Lower Hospitalizations for Heart Attacks and Lung Disease Among Medicare Beneficiaries. Health Affairs 2012;31(12):2699–2707 [cited 2014 May 12].