Four-year follow-up of smoke exposure,attitudes and smoking behaviour following enactment of Finland's national smoke-free work-place law

Aims This study evaluated the possible impact of national smoke‐free work‐place legislation on employee exposure to environmental tobacco smoke (ETS), employee smoking habits and attitudes on work‐place smoking regulations. Design Repeated cross‐sectional questionnaire surveys and indoor air nicotine measurements were carried out before, and 1 and 3 years after the law had come into effect. Setting Industrial, service sector and office work‐places from the Helsinki metropolitan area, Finland. Participants A total of 880, 940 and 659 employees (response rates 70%, 75% and 75%) in eight work‐places selected from a register kept by the Uusimaa Regional Institute of Occupational Health to represent various sectors of public and private work‐places. Measurements Reported exposure to ETS, smoking habits, attitudes on smoking at work and measurements of indoor air nicotine concentration. Findings Employee exposure to ETS for at least 1 hour daily decreased steadily during the 4‐year follow‐up, from 51% in 1994 to 17% in 1995 and 12% in 1998. Respondents’ daily smoking prevalence and tobacco consumption diminished 1 year after the enforcement of legislation from 30% to 25%, and remained at 25% in the last survey 3 years later. Long‐term reduction in smoking was confined to men. Both smokers’ and non‐smokers’ attitudes shifted gradually towards favouring a total ban on smoking at work. Median indoor airborne nicotine concentrations decreased from 0.9 µg/m³ in 1994–95 to 0.1 µg/m³ in 1995–96 and 1998. Conclusions This is the first follow‐up study on a nationally implemented smoke‐free work‐place law. We found that such legislation is associated with steadily reducing ETS exposure at work, particularly at work‐places, where the voluntary smoking regulations have failed to reduce exposure. The implementation of the law also seemed to encourage smokers to accept a non‐smoking work‐place as the norm.     

Cost effectiveness of interventions to reduce relapse to smoking following smoking cessation

Aims To determine the incremental cost effectiveness of nicotine replacement therapy (NRT), bupropion and varenicline for preventing relapse to smoking when used by abstinent smokers Design setting and participants Cohort simulation and sensitivity analyses combining cost and health service data with systematic review estimates for the effectiveness of NRT, bupropion and varenicline when used by abstinent quitters to prevent their relapse to smoking. Measurements Incremental health gain in Quality Adjusted Life Years (QALYs) generated by each drug compared to ‘no intervention’. Findings Bupropion resulted in an incremental QALY increase of 0.07 with a concurrent cost saving of £68; NRT and varenicline both caused incremental QALYs increases of 0.04 at costs of £12 and £90 respectively, although varenicline findings were based on data from a single clinical trial and require cautious interpretation. Even after extensive sensitivity analyses with substantial varying of key model parameters, cost effectiveness of all drugs remained. Cost effectiveness ratios only exceeded the UK National Institute of Clinical Excellence (NICE) benchmark of £20 000 per QALY when drug treatment effects were postulated to last for no longer than 1 year; or, for NRT and varenicline, efficacy was reduced to 10% of that observed in clinical trials. Conclusions Bupropion, nicotine replacement therapy and varenicline appear cost effective at preventing relapse to smoking by smokers who are in quit attempts and have recently become abstinent; they have comparable cost effectiveness to smoking cessation interventions. Widespread use of these effective relapse prevention treatments could promote substantial health gain at an acceptable cost to health providers.     

Reduction in acute myocardial infarction hospitalization after implementation of a smoking ordinance

Background

Smoking ordinances have been associated with reduced acute myocardial infarction rates, but nearly all studies lack patient-level data.

Objective

We determined whether a smoking ordinance was associated with a reduction in hospitalizations for acute myocardial infarction, irrespective of smoking status and infarct presentation (ST elevation vs. non-ST elevation).

Methods

Detailed chart abstraction of biomarkers to confirm first acute myocardial infarction events was performed from the single community hospital serving Greeley, Colorado and adjacent zip codes, 17 months before and 31 months after implementing a public smoking ordinance. Poisson regression analysis, adjusted for population growth, was used to assess changes in mean incidence rates.

Results

A total of 706 hospitalizations were identified from July 2002 through June 2006: 482 among Greeley city residents and 224 within adjacent zip code areas. A postordinance reduction in hospitalizations was observed in Greeley (relative risk [RR] 0.73; 95% confidence interval [CI], 0.59-0.90). A smaller, nonsignificant decrease was noted in the area immediately surrounding Greeley (RR 0.83; 95% CI, 0.61-1.14). However, the comparison of relative risk reductions between Greeley and the surrounding area was not significant (P = .48). The reduction in Greeley was more pronounced among smokers (RR 0.44; 95% CI, 0.29-0.65) than nonsmokers (RR 0.86; 95% CI, 0.67-1.09) and did not differ by acute myocardial infarction presentation (P = .38).

Conclusions

A smoking ordinance was associated with a decrease in acute myocardial infarction hospitalizations of a magnitude similar to previous reports, but could not be distinguished from the adjacent geographic area. Reductions were greatest among smokers, despite previous studies suggesting that benefits accrue primarily among nonsmokers. Smoke-free policy may therefore exert a beneficial effect among smokers, who are disproportionately exposed to direct and sidestream smoke.     

Promoting smoking cessation during hospitalization for coronary artery disease

BACKGROUND: Quitting smoking is the most effective intervention to reduce mortality in patients with coronary artery disease who smoke. Guidelines for the treatment of tobacco dependency recommend that health care institutions develop plans to support the consistent and effective identification and treatment of tobacco users. The University of Ottawa Heart Institute (Ottawa, Ontario) has implemented an institutional program to identify and treat all smokers admitted to the Institute. OBJECTIVES: The objectives of the present paper are to describe core elements of this program and present data concerning its reach and effectiveness. PROGRAM DESCRIPTION: The goal of the program is to increase the number of smokers who are abstinent from smoking six months after a coronary artery disease-related hospitalization. Core elements of the program include: documentation of smoking status at hospital admission; inclusion of cessation intervention on patient care maps; individualized, bedside counselling by a nurse counsellor; the appropriate and timely use of nicotine replacement therapy; automated telephone follow-up; referral to outpatient cessation resources; and training of medical residents and nursing staff. Program reach and effectiveness were measured over a one-year period. RESULTS: Between April 2003 and March 2004, almost 1300 smokers were identified at admission, and 91% received intervention to help them quit smoking. At six-month follow-up, 44% were smoke-free. CONCLUSIONS: Hospitalization for coronary artery disease provides an important opportunity to intervene with smokers when their motivation to quit is high. An institutional approach reinforces the importance of smoking cessation in this patient population and increases the rate of smoking cessation. Posthospitalization quit rates should be a benchmark of cardiac program performance.     

Components of a smoke-free hospital program

Hospitals have the responsibility to provide leadership in the area of cigarette-smoking cessation and indoor-smoking elimination. A multidisciplinary committee of the Oregon Health Sciences University, Portland, planned and initiated a smoke-free hospital and clinic facility in 1987. The key planning steps for the patient and visitor ban included involvement of many representatives of the hospital staff, 2 months lead time for the ban, personal interviews with all inpatient smokers on the eve of the ban, and distribution of survival kits. Employees were offered free smoking cessation classes, gum with instructions in use, and a protected outdoor smoking area. The ban has been well accepted by patients and visitors. A questionnaire survey of employees at 6 months has indicated a modest reduction in personal cigarette smoking.     

Depressive symptoms and smoking cessation after hospitalization for cardiovascular disease

BACKGROUND: Although smoking cessation is essential for prevention of secondary cardiovascular disease (CVD), many smokers do not stop smoking after hospitalization. Mild depressive symptoms are common during hospitalization for CVD. We hypothesized that depressive symptoms measured during hospitalization for acute CVD would predict return to smoking after discharge from the hospital. METHODS: This was a planned secondary analysis of data from a placebo-controlled, double-blind, randomized trial of bupropion hydrochloride therapy in 245 smokers hospitalized for acute CVD. All subjects received smoking counseling in the hospital and for 12 weeks after discharge. Depressive symptoms were measured during hospitalization with the Beck Depression Inventory (BDI), and smoking cessation was biochemically validated at 2-week, 12-week, and 1-year follow-up. The effect of depressive symptoms on smoking cessation was assessed using multiple logistic regression and survival analyses. RESULTS: Twenty-two percent of smokers had moderate to severe depressive symptoms (BDI >or= 16) during hospitalization. These smokers were more likely to resume smoking by 4 weeks after discharge (P= .007; incidence rate ratio, 2.40; 95% confidence interval, 1.48-3.78) than were smokers with lower BDI scores. Smokers with low BDI scores were more likely to remain abstinent than were those with high BDI scores at 3-month follow-up (37% vs 15%; adjusted odds ratio, 3.02; 95% confidence interval, 1.28-7.09) and 1-year follow-up (27% vs 10%; adjusted odds ratio, 3.77; 95% confidence interval, 1.31-10.82). We estimate that 27% of the effect of the BDI score on smoking cessation was mediated by nicotine withdrawal symptoms. CONCLUSIONS: Moderate to severe depressive symptoms during hospitalization for acute CVD are independently associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up. The relationship was mediated in part by the stronger nicotine withdrawal symptoms experienced by smokers with higher depressive symptoms.     

Evaluation of venous thromboembolism risk following hospitalization

A better understanding of the relationship between outpatient venous thromboembolism (VTE) and prior hospitalization is needed including data regarding the utilization of inpatient pharmacologic VTE prophylaxis and its effect on outpatient venous thromboembolic risk. The primary objective was to assess the association between development of outpatient VTE and inpatient hospitalization within the previous 90 days. Additional outcome measures included describing patients who received pharmacologic anticoagulation during hospitalization and identification of factors independently associated with VTE. Case patients in this matched case–control study were diagnosed with an outpatient deep vein thrombosis or pulmonary embolus between January 2005 and December 2007 and were matched on age with up to five to patients who were seen for an outpatient health maintenance visit but had no VTE during the same time frame as their matched case. Information collected from electronic administrative databases and patient medical records included health services utilization, medication use, medical diagnoses, and patient demographic information. Of 2190 cases, 560 patients (25.6%) compared to 151 (1.4%) of 10,942 control patients were hospitalized in the previous 90 days (P < 0.001). Among hospitalized patients, 53.5% of cases and 47.0% of controls received an anticoagulant during hospitalization (P = 0.186). Factors associated with a VTE diagnosis included hospitalization for a surgical, medical, or orthopedic indication in the previous 90 days, younger age, longer hospitalization, cancer and an elevated Chronic Disease Score. Conclusions: A strong association exists between outpatient VTE diagnosis and hospitalization and gaps in pharmacologic prophylaxis utilization during hospitalization are evident.     

Passive smoking in asthmatic children: effect of a "smoke-free house" measured by urinary cotinine levels.

Environmental tobacco smoke (ETS) decreases pulmonary function and increases both airway reactivity and frequency of child asthma exacerbations. True exposure is related not only to parents smoking and to the number of cigarettes that they smoke, but also to involuntary smoking in public places. The aim of this study was to evaluate, by measuring urinary cotinine levels, the exposure to ETS in asthmatic children and the contribution of unapparent smoke exposure. Twenty asthmatic children (aged 7-12 years) were evaluated on the 1st day (TO) and after a week (T1) in a "smoke-free house." The mean level of urinary cotinine in children was 15.8 +/- 2.7 ng/mg of creatinine at TO and 4.2 +/- 0.6 ng/mg of creatinine at T1 (p < 0.0001). The urinary cotinine concentrations were higher in children living with smoking parents (21.8 +/- 3.4 ng/mg creatinine) compared with children not exposed to parental smoke (6.8 +/- 3.0 ng/mg creatinine; p = 0.017). The number of cigarettes smoked by parents correlates with the urinary cotinine levels (p = 0.005; r = 0.64). Urinary cotinine levels significantly decreased after the avoidance of ETS in children exposed to parental smoke (21.8 +/- 3.4 ng/mg at TO; 5.0 +/- 0.8 ng/mg at T1; p < 0.001) and also in children whose parents declared to be nonsmokers (6.8 +/- 1.2 ng/mg at TO; 3.0 +/- 0.8 ng/mg at T1; p = 0.006). Our data confirm the widespread indirect and undetected tobacco smoke exposure in children with chronic asthma and the relevance of an evaluation with an objective method of the exposure to second-hand smoke.     

The road to smoke-free legislation in Ireland

Aim To describe the process through which Ireland changed its policies towards smoking in work‐places and distil lessons for others implementing or extending smoke‐free laws. Design, setting, participants, measurements This analysis is informed by a review of secondary sources including a commissioned media analysis, documentary analysis and key informant interviews with policy actors who provide insight into the process of smoke‐free policy development. The policy analysis techniques used include the development of a time‐line for policy reform, stakeholder analysis, policy mapping techniques, impact analysis through use of secondary data and a review process. The policy analysis triangle, which highlights the importance of examining policy content, context, actors and processes, will be used as an analytical framework. Findings The importance of the political, economic, social and cultural context emerged clearly. The interaction of the context with the policy process both in identification of need for policy and its formulation demonstrated the opportunity for advocates to exert influence at all points of the process. The campaign to support the legislation had the following characteristics: a sustained consistent simple health message, sustained political leadership/commitment, a strong coalition between the Health Alliance, the Office of Tobacco Control and the Department of Health and Children, with cross‐party political support and trade union support. The public and the media support clearly defined the benefit of deliberate and consistent planning and organization of a communication strategy. Conclusions The Irish smoke‐free legislation was a success as a policy initiative because of timing, dedication, planning, implementation and the existence of strong leadership and a powerful convinced credible political champion