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8 Conclusions and Recommendations
Pages 201-226

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From page 201...
... . • The association between smoking bans and acute coronary events (Questions 4, 5, 6, 7, and 8)
From page 202...
... can also be used as an indicator of secondhand-smoke exposure, but because there are other sources of PM it is a less specific tracer than nicotine. The concentration of cotinine in serum, saliva, or urine is a specific indicator of integrated exposure to secondhand smoke.
From page 203...
... . Pathophysiology The pathophysiology of the induction of cardiovascular disease by cigarette-smoking and secondhand-smoke exposure is complex and undoubtedly involves multiple agents.
From page 204...
... The association comports with known associations between PM, a major constituent of secondhand smoke, and coronary heart disease. Overall, the pathophysiologic data indicate that it is biologically plausible for secondhand-smoke exposure to have cardiovascular effects, such as effects that lead to cardiovascular disease and acute myocardial infarction (MI)
From page 205...
... Although few studies have addressed the risk of coronary heart disease posed by secondhand-smoke exposure in the workplace, there is no biologically plausible reason to suppose that the effect of secondhandsmoke exposure at work or in a public building differs from the effect of exposure in the home environment. Epidemiologic studies demonstrate a dose–response relationship between chronic secondhand-smoke exposure as assessed by self-reports of exposure (He et al., 1999)
From page 206...
... examined rates of hospitalization for acute coronary events after the implementation of smoking bans and provided direct evidence of the relationship of secondhand-smoke exposure to acute coronary events by presenting results in nonsmokers. The decreases in acute MIs in the 11 studies ranged from about 6 to 47%, depending on characteristics of the study, including the method of statistical analysis.
From page 207...
... The data provide evidence that it is biologically plausible for secondhand smoke to be a potential causative trigger of acute coronary events. The risk of acute coronary events is likely to be increased if a person has preexisting heart disease.
From page 208...
... ban Barone-Adesi et al., 2006 Retrospective based on records from regional hospital (Piedmont region, northern discharge registry; 5 months before ban studied, ending Italy) 6 months before implementation; 6 months after ban studied Cesaroni et al., 2008 Retrospective based on hospital discharge registry, death (Rome, Italy)
From page 209...
... Ban prohibiting smoking in workplaces, all 41% decrease (RR, 0.59; 95% CI, 0.49–0.70) public buildings -- including restaurants, bars, bowling alleys, other business establishments -- in city limits Ban prohibiting smoking in workplaces, all 27% decrease (RR, 0.73; 95% CI, 0.63–0.85)
From page 210...
... Scotland Pell et al., 2008 Prospective study of acute coronary syndrome; 10 months (Scotland) before (June 2005–March 2006)
From page 211...
... fewer admissions in 2004 exceptions than expected if no prior smoking bans Statewide smoking restrictions (limiting had been in effect or prohibiting smoking in some public places, such as schools, hospitals, public buildings, retail stores) had been implemented in 1989 Previously, various levels of smoking bans implemented at city or county level in some parts of New York state, including ban in workplaces -- including restaurants, bars -- in New York City State law does not preempt passage of local laws Smoking ban implemented in city of 13% decrease (rate ratio, 0.87; 95% CI, Saskatoon prohibiting smoking in any 0.84–0.90)
From page 212...
... proved challenging, and the committee has not done it. Secondhand-Smoke Exposure and Acute Coronary Events Two of the epidemiologic studies reviewed by the committee that examine rates of hospitalization for acute coronary events after implementation of smoking bans provide direct evidence related to secondhand smoke exposures.
From page 213...
... The other key epidemiologic studies that looked at smoking bans provide indirect evidence of an association between secondhand-smoke exposure and acute coronary events (Barone-Adesi et al., 2006; Bartecchi et al., 2006; CDC, 2009; Cesaroni et al., 2008; Juster et al., 2007; Khuder et al., 2007; Lemstra et al., 2008; Sargent et al., 2004; Vasselli et al., 2008)
From page 214...
... Where evaluated, Data from INTERHEART Smoking bans are either present or response relationship) epidemiologic studies show study (Teo et al., 2006)
From page 215...
... Biologic plausibility or Yes, effects are consistent Yes, based on experimental Yes, in that secondhand-smoke coherence with current understanding data showing changes exposure is associated with of pathophysiology of that might be expected to cardiovascular disease. Evidence cardiovascular disease and precipitate such events indicates that smoking bans effects of secondhand-smoke decrease secondhand-smoke exposure in humans, including exposure that in chamber studies Experimental evidence Supported by in vitro and in Yes, for pathophysiologic Not directly relevant to ban vivo evidence changes related to acute coronary events Analogy Association comports Association comports Association comports with what with what is known about with what is known about is known about particulate-matter particulate-matter pollution particulate-matter pollution pollution, secondhand-smoke and cardiovascular disease and acute coronary events exposure, and coronary heart disease a Strength of association is categorized as "weak" because effect estimates are generally small, are variable, or both.
From page 216...
... The combination of experimental data on secondhand-smoke effects discussed above and exposure data that indicate that secondhand-smoke concentrations decrease substantially after implementation of a smoking ban provides evidence that it is biologically plausible for smoking bans to decrease the rate of acute MIs. The committee concludes that there is an association between smoking bans and a reduction in acute coronary events and, given the temporality and biologic plausibility of the effect, that the evidence is consistent with a causal relationship.
From page 217...
... Studies that examine whether decreases in hospital admissions for acute coronary events are transitory or sustained would also be informative. Many factors are likely to influence the effect of a smoking ban on the incidence and prevalence of acute coronary events in a population.
From page 218...
... A national database that captures all cardiovascular end points would facilitate future epidemiologic studies by allowing the tracking of trends and identification of high-risk populations at a more granular level. A large prospective cohort study could be very helpful in more accurately estimating the magnitude of the risk of cardiovascular disease and acute coronary events posed by secondhand-smoke exposure.
From page 219...
... 2. Is there sufficient evidence to support the plausibility of a causal relation between secondhand smoke exposure and acute coronary events such as acute myocardial infarction and unstable angina?
From page 220...
... With respect to how the risk might vary in the presence or absence of preexisting coronary arterial disease, it is generally assumed that acute coronary events are more likely to occur in people who have some level of preexisting disease, although that underlying disease is often subclinical. There are not enough data on the presence of pre-existing coronary arterial disease in the populations studied to assess the extent to which the absence or presence of such preexisting disease affects the cardiovascular risk posed by secondhand-smoke exposure.
From page 221...
... The key intervention studies that have evaluated the effects of indoor smoking bans consistently have shown a decreased risk of heart attack. Research has also indicated that secondhand-smoke exposure is causally related to heart attacks, that smoking bans decrease secondhand-smoke exposure, and that a relationship between secondhand-smoke exposure and acute coronary events is biologically plausible.
From page 222...
... The Saskatoon study had the advantage of comprehensive hospital records, and the Monroe County study excluded smokers. The populationbased studies of the risk of heart attack after the institution of comprehensive smoking bans were consistent in showing an association between the smoking bans and a decrease in the risk of acute coronary events, and this strengthened the committee's confidence in the existence of the association.
From page 223...
... Although some national databases and surveys include cardiovascular end points, a national database that tracks hospital admission rates and deaths from acute coronary events, similar to the SEER database for cancer, would improve epidemiologic studies. • The committee found a lack of understanding of a mechanism that leads to plaque rupture and from that to an acute coronary event and of how secondhand smoke affects that process.
From page 224...
... Such a study could be spe cifically designed for secondhand smoke or potentially could take advantage of existing cohort studies that might have data available or attainable for investigating secondhand-smoke exposure and its cardiovascular effects, such as was done with the INTERHEART study. Existing studies that could be explored to determine their utility and applicability to questions related to secondhand smoke include the Multi-Ethnic Study of Atherosclerosis (MESA)
From page 225...
... 2008. Effect of the Italian smoking ban on population rates of acute coronary events.
From page 226...
... 2007. Reduced admissions for acute myocardial infarction as sociated with a public smoking ban: Matched controlled study.


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