Stephen Babb

How acute and reversible are the cardiovascular risks of secondhand smoke

Could eating in a smoky restaurant precipitate an acute myocardial infarction in a non—smoker? As unlikely as this sounds, a growing body of scientific data suggests that this is possible. In this context, the results of the observational study in Helena, MT are provocative: hospital admissions for acute myocardial infarction declined by about 40% during the six months in which a comprehensive local ordinance on clean air was in effect, and rebounded after the ordinance was suspended.1 Given the small size and observational design of the study, these findings might be discounted or even disregarded altogether. However, the study focuses attention on an interesting subset of literature on secondhand smoke and its consequences. We now have a considerable amount of epidemiological literature and laboratory data on the mechanisms by which relatively small exposures to toxins in tobacco smoke seem to cause unexpectedly large increases in the risk of acute cardiovascular disease.2–7 Exposure to secondhand smoke increases the risk of fatal and non-fatal coronary heart disease in non-smokers by about 30%.2 5 8 9 Because coronary heart disease is a leading cause of death in many countries, even relatively small increases in risk from this one factor can result in a large population burden of disease attributable to exposure to tobacco smoke.10 11 While the substantial cardiovascular risks posed by active smoking are now almost universally accepted, the tobacco industry and some other observers continue to question the idea that secondhand smoke can cause cardiovascular disease and death.12–15 Notwithstanding the substantial clinical and experimental evidence regarding the adverse cardiovascular effects of exposure to secondhand smoke, some have argued that an association between low level environmental exposures and health outcomes should be more critically evaluated, particularly when the relative risk for the exposure …

Quitting Smoking Among Adults - United States, 2000-2015:

Quitting cigarette smoking benefits smokers at any age (1). Individual, group, and telephone counseling and seven Food and Drug Administration-approved medications increase quit rates (1-3). To assess progress toward the Healthy People 2020 objectives of increasing the proportion of U.S. adults who attempt to quit smoking cigarettes to ≥80.0% (TU-4.1), and increasing recent smoking cessation success to ≥8.0% (TU-5.1),* CDC assessed national estimates of cessation behaviors among adults aged ≥18 years using data from the 2000, 2005, 2010, and 2015 National Health Interview Surveys (NHIS). During 2015, 68.0% of adult smokers wanted to stop smoking, 55.4% made a past-year quit attempt, 7.4% recently quit smoking, 57.2% had been advised by a health professional to quit, and 31.2% used cessation counseling and/or medication when trying to quit. During 2000-2015, increases occurred in the proportion of smokers who reported a past-year quit attempt, recently quit smoking, were advised to quit by a health professional, and used cessation counseling and/or medication (p<0.05). Throughout this period, fewer than one third of persons used evidence-based cessation methods when trying to quit smoking. As of 2015, 59.1% of adults who had ever smoked had quit. To further increase cessation, health care providers can consistently identify smokers, advise them to quit, and offer them cessation treatments (2-4). In addition, health insurers can increase cessation by covering and promoting evidence-based cessation treatments and removing barriers to treatment access (2,4-6).

Helping smokers quit--opportunities created by the Affordable Care Act.

Several provisions of the ACA address the long-standing gap in insurance coverage for smoking cessation and thereby increase cessation rates. These provisions could help improve quality of care and achieve better health outcomes while reducing costs.

A cross-country comparison of secondhand smoke exposure among adults: findings from the Global Adult Tobacco Survey (GATS)

Objective Exposure to secondhand smoke (SHS) from burning tobacco products causes disease and premature death among non-smoking adults and children. The objective of this study was to determine the nature, extent and demographic correlates of SHS exposure among adults in low- and middle-income countries with a high burden of tobacco use. Methods Data were obtained from the Global Adult Tobacco Survey (GATS), a nationally representative household survey of individuals 15 years of age or older. Interviews were conducted during 2008–2010 in Bangladesh, Brazil, China, Egypt, India, Mexico, the Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay and Vietnam. Descriptive statistics were used to determine the prevalence and correlates of SHS exposure in homes, workplaces, government buildings, restaurants, public transportation and healthcare facilities. Results Exposure to SHS in the home ranged from 17.3% (Mexico) to 73.1% (Vietnam). Among those who work in an indoor area outside the home, SHS exposure in the workplace ranged from 16.5% (Uruguay) to 63.3% (China). Exposure to SHS ranged from 6.9% (Uruguay) to 72.7% (Egypt) in government buildings, 4.4% (Uruguay) to 88.5% (China) in restaurants, 5.4% (Uruguay) to 79.6% (Egypt) on public transportation, and 3.8% (Uruguay) to 49.2% (Egypt) in healthcare facilities. Conclusions A large proportion of adults living in low- and middle-income countries are exposed to SHS in their homes, workplaces, and other public places. Countries can enact and enforce legislation requiring 100% smoke-free public places and workplaces, and can also conduct educational initiatives to reduce SHS exposure in homes.

National and State Estimates of Secondhand Smoke Infiltration Among U.S. Multiunit Housing Residents

INTRODUCTION Multiunit housing (MUH) residents are susceptible to secondhand smoke (SHS), which can infiltrate smoke-free living units from nearby units and shared areas where smoking is permitted. This study assessed the prevalence and characteristics of MUH residency in the United States, and the extent of SHS infiltration in this environment at both the national and state levels. METHODS National and state estimates of MUH residency were obtained from the 2009 American Community Survey. Assessed MUH residency characteristics included sex, age, race/ethnicity, and poverty status. Estimates of smoke-free home rule prevalence were obtained from the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The number of MUH residents who have experienced SHS infiltration was determined by multiplying the estimated number of MUH residents with smoke-free homes by the range of self-reported SHS infiltration (44%-46.2%) from peer-reviewed studies of MUH residents. RESULTS One-quarter of U.S. residents (25.8%, 79.2 million) live in MUH (state range: 10.1% in West Virginia to 51.7% in New York). Nationally, 47.6% of MUH residents are male, 53.3% are aged 25-64 years, 48.0% are non-Hispanic White, and 24.4% live below the poverty level. Among MUH residents with smoke-free home rules (62.7 million), an estimated 27.6-28.9 million have experienced SHS infiltration (state range: 26,000-27,000 in Wyoming to 4.6-4.9 million in California). CONCLUSIONS A considerable number of Americans reside in MUH and many of these individuals experience SHS infiltration in their homes. Prohibiting smoking in MUH would help protect MUH residents from involuntary SHS exposure.

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage - United States, 2014-2015.

Medicaid enrollees have a cigarette smoking prevalence (30.4%) twice as high as that of privately insured Americans (14.7%), placing them at increased risk for smoking-related disease and death. Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)–approved medications are evidence-based, effective treatments for helping tobacco users quit. A Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of these treatments. However, a previous MMWR report indicated that, although state Medicaid coverage of cessation treatments had improved during 2008–2014, this coverage was still limited in most states. To monitor the most recent trends in state Medicaid cessation coverage, the American Lung Association collected data on coverage of, and barriers to, accessing all evidence-based cessation treatments except telephone counseling in state Medicaid programs (for a total of nine treatments) during January 31, 2014–June 30, 2015. As of June 30, 2015, all 50 states covered certain cessation treatments for at least some Medicaid enrollees. During 2014–2015, increases were observed in the number of states covering individual counseling, group counseling, and all seven FDA-approved cessation medications for all Medicaid enrollees; however, only nine states covered all nine treatments for all enrollees. Common barriers to accessing covered treatments included prior authorization requirements, limits on duration, annual limits on quit attempts, and required copayments. Previous research in both Medicaid and other populations indicates that state Medicaid programs could reduce smoking prevalence, smoking-related morbidity, and smoking-related health care costs among Medicaid enrollees by covering all evidence-based cessation treatments, removing all barriers to accessing these treatments, promoting coverage to Medicaid enrollees and health care providers, and monitoring use of covered treatments.

Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities.

INTRODUCTION Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smokings (e.g., those with lower education and incomes). METHODS Education and income are the 2 main social determinants of health that negatively impact health. However, there are other social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This article will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control. RESULTS Tobacco control policy interventions can be effective in addressing the social determinants of health in tobacco prevention and control to achieve equity and eliminate tobacco-related disparities when they are implemented consistently and equitably across all population groups. CONCLUSIONS Taking a social determinants of health approach in tobacco prevention and control will be necessary to achieve equity and eliminate tobacco-related disparities.

Exposure to Secondhand Smoke and Attitudes Toward Smoke-Free Workplaces Among Employed U.S. Adults: Findings From the National Adult Tobacco Survey

INTRODUCTION This study assessed the prevalence and correlates of secondhand smoke (SHS) exposure and attitudes toward smoke-free workplaces among employed U.S. adults. METHODS Data came from the 2009-2010 National Adult Tobacco Survey, a landline and cellular telephone survey of adults aged ≥18 years in the United States and the District of Columbia. National and state estimates of past 7-day workplace SHS exposure and attitudes toward indoor and outdoor smoke-free workplaces were assessed among employed adults. National estimates were calculated by sex, age, race/ethnicity, education, annual household income, sexual orientation, U.S. region, and smoking status. RESULTS Among employed adults who did not smoke cigarettes, 20.4% reported past 7-day SHS exposure at their workplace (state range: 12.4% [Maine] to 30.8% [Nevada]). Nationally, prevalence of exposure was higher among males, those aged 18-44 years, non-Hispanic Blacks, Hispanics, and non-Hispanic American Indians/Alaska natives compared to non-Hispanic Whites, those with less education and income, those in the western United States, and those with no smoke-free workplace policy. Among all employed adults, 83.8% and 23.2% believed smoking should never be allowed in indoor and outdoor areas of workplaces, respectively. CONCLUSIONS One-fifth of employed U.S. adult nonsmokers are exposed to SHS in the workplace, and disparities in exposure exist across states and subpopulations. Most employed adults believe indoor areas of workplaces should be smoke free, and nearly one-quarter believe outdoor areas should be smoke free. Efforts to protect employees from SHS exposure and to educate the public about the dangers of SHS and benefits of smoke-free workplaces could be beneficial.

Cost savings associated with prohibiting smoking in U.S. subsidized housing.

BACKGROUND Tobacco smoking in multiunit housing can lead to secondhand-smoke (SHS) exposure among nonsmokers, increased maintenance costs for units where smoking is permitted, and fire risks. During 2009-2010, approximately 7.1 million individuals lived in subsidized housing in the U.S., a large proportion of which were children, elderly, or disabled. PURPOSE This study calculated the annual economic costs to society that could be averted by prohibiting smoking in all U.S. subsidized housing. METHODS Estimated annual cost savings associated with SHS-related health care, renovation of units that permit smoking, and smoking-attributable fires in U.S. subsidized housing were calculated using residency estimates from the U.S. Department of Housing and Urban Development and previously reported national and state cost estimates for these indicators. When state estimates were used, a price deflator was applied to account for differential costs of living or pricing across states. Estimates were calculated overall and by cost type for all U.S. subsidized housing, as well as for public housing only. Data were obtained and analyzed between January and March 2011. RESULTS Prohibiting smoking in all U.S. subsidized housing would yield cost savings of approximately

National and State Cost Savings Associated With Prohibiting Smoking in Subsidized and Public Housing in the United States

521 million per year, including