Long-Term Effect of Smoking Ban Legislation on Hospitalization for Acute Coronary Syndrome
論文ID: CJ-23-0590
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論文ID: CJ-23-0590
The most important way to prevent cardiovascular disease (CVD) is to promote a lifelong healthy lifestyle, which includes avoiding smoking and secondhand smoke. After high systolic blood pressure, smoking is the leading risk factor for death and disability-adjusted life-years worldwide.1 Smoking increases CVD risk even at low doses (e.g., smoking <5 cigarettes daily).2 In addition, non-smokers’ exposure to secondhand smoke has been reported to increase CVD risk through atherosclerosis, platelet activation, and endothelial dysfunction.3 The effect of secondhand smoke may be nearly as great as that of active smoking despite the smaller dose delivered via passive exposure. However, a longer time since smoking cessation is associated with lower CVD risk4 and lower atherosclerotic burden.5 Furthermore, prior research suggests that the acute effects of secondhand smoke exposure are rapid and may reverse shortly after a reduction in exposure.3
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Given these findings, the only way to fully protect non-smokers from the effects of smoke is to create smoke-free spaces. Effective smoke-free policies that ban tobacco smoking in public places and workplaces are especially immediate and effective in reducing CVD.6 Smoke-free environments provide direct benefits by reducing exposure to secondhand smoke and indirect benefits by drawing further public attention to the dangers of smoking, encouraging smokers to quit, and sending important denormalization signals to deter children and young people from taking up smoking.7 For example, studies in the USA,8 Scotland,9 Italy,10 Uruguay,11 Argentina,12 and Canada8 suggest that reductions in hospital admissions due to acute myocardial infarction (heart attack) may be associated with smoking bans. However, most of those studies had limited follow-up periods (i.e., up to 3 years) after the implementation of smoke-free legislation.
In this issue of the Journal, Nakai et al13 estimate the trends in hospitalization for acute coronary syndrome (ACS) over 7 years (April 2013 to March 2020) following the 2013 implementation of smoking ban legislation in some areas (Kobe City, Hanshin area, and other areas) of Hyogo Prefecture and Osaka City based on data from the Japanese Registry of All Cardiac and Vascular Disease-Diagnosis Procedure Combination (JROAD-DPC; Figure 1). The authors observed a decreasing trend in ACS hospitalizations in Kobe City but not in other areas of Hyogo Prefecture and Osaka City (Figure 2). The difference in the trend between Kobe City and other areas may be attributable to a higher adherence to smoking ban legislation in that city than in other areas. A prior study reported that the adherence to smoking ban legislation in bars and restaurants larger than 100 m2 was 97% in Kobe City and 88% in Amagasaki City, one of the major cities in the Hanshin area.14 Similar trends were also observed for both sexes and younger (<65 years) and older (≥65 years) patients. The decreasing trend in ACS hospitalizations in Kobe City was obvious only in ACS patients who did not have coronary risk factors, including smoking, hypertension, diabetes mellitus, hyperlipidemia, or a history of ACS. A possible explanation may be that patients without coronary risk factors are relatively health-conscious and more sensitive to and compliant with smoking ban legislation than patients with coronary risk factors. The findings further highlight the effect of smoking ban legislation on the prevention of secondhand smoke exposure among non-smokers.
Overview of the study. ICD-10, International Classification of Diseases-10.
Incident rate ratio (IRR) for the number of hospitalizations for acute coronary syndrome during the study period. CI, confidence interval.
Nakai et al provide important evidence that supports the long-term effect of smoking ban legislation on the reduction of ACS hospitalizations. However, several limitations of this study warrant consideration. First, because the data from JROAD-DPC were limited to hospital-based care and were extracted using only the International Classification of Diseases-10 code, the study may not cover all cases of ACS hospitalization in the study areas. Second, the JROAD-DPC dataset did not include detailed information about smoking (e.g., the daily number of cigarettes smoked, the duration of smoking, and secondhand smoking); thus, this information was not considered in the study. Third, in contrast to the methodology used in prior studies, this study did not comprehensively assess the changes in the trends in ACS hospitalization before and after the implementation of smoking ban legislation. Finally, the authors carefully considered some variables (e.g., age, sex, and coronary risk factors) as confounders, although the findings may be partly explained by differences between Kobe City and other areas in unmeasured factors (e.g., socioeconomic factors).
We thank Anahid Pinchis, BSc, MBA, for editing a draft of this manuscript.
None.
Name of the ethics committee: N/A. Reference number: N/A.
