Cardiovascular health and economic effects of smoke-free workplaces

doi:10.1016/j.amjmed.2004.02.029

The American Journal of Medicine

Volume 117, Issue 1, 1 July 2004, Pages 32-38

https://doi.org/10.1016/j.amjmed.2004.02.029 Get rights and content

Abstract

Purpose

Smoking is the leading controllable risk factor for heart disease. Only about 69% of U.S. indoor workers are currently covered by a smoke-free workplace policy. This analysis projects the cardiovascular health and economic effects of making all U.S. workplaces smoke free after 1 year and at steady state.

Methods

We estimated the number of U.S. indoor workers not covered by smoke-free workplace policies, and the effects of making all workplaces smoke free on smoking behavior and on the relative risks of acute myocardial infarctions and strokes. One-year and steady-state results were calculated using an exponential decline model. A Monte Carlo simulation was performed for a sensitivity analysis.

Results

The first-year effect of making all workplaces smoke free would produce about 1.3 million new quitters and prevent over 950 million cigarette packs from being smoked annually, worth about $2.3 billion in pretax sales to the tobacco industry. In 1 year, making all workplaces smoke free would prevent about 1500 myocardial infarctions and 350 strokes, and result in nearly $49 million in savings in direct medical costs. At steady state, 6250 myocardial infarctions and 1270 strokes would be prevented, and $224 million would be saved in direct medical costs annually. Reductions in passive smoking would account for 60% of effects among acute myocardial infarctions.

Conclusion

Making all U.S. workplaces smoke free would result in considerable health and economic benefits within 1 year. Reductions in passive smoking would account for a majority of these savings. Similar effects would occur with enactment of state or local smoke-free policies.

Section snippets

Estimation of the number of new nonsmokers by making all U.S. workplaces smoke free

The number of indoor workers was estimated using the 2000 Occupational Employment Statistics Survey (9). The 1999 Current Population Survey definition of an indoor worker was a person at least 15 years of age who was currently employed outside the home, but who was not self-employed, working outdoors or in a motor vehicle, traveling to different building or sites, or working in someone else's home (7). Persons who were not considered indoor workers included athletes and sports competitors (n =

Cigarette consumption effects

A total of 105.6 million individuals were indoor workers. Of these workers, 33.2 million individuals were not covered by a smoke-free workplace policy. Active smokers made up 8.6 million of the noncovered sample. The other 24.6 million subjects were considered passive smokers. Implementation of a nationwide smoke-free workplace policy would produce 1.3 million new nonsmokers (Table 3).

A national smoke-free workplace policy would annually cause quitters to forgo 564 million packs and remaining

Discussion

We found that making workplaces smoke free not only reduces worker exposure to secondhand smoke, but also contributes substantially to reducing cardiovascular disease among nonsmokers and smokers. Nonsmokers who are no longer exposed to secondhand smoke realize 60% of the benefit and smokers who quit realize 40% of the benefit. Although passive smokers have a lower risk of heart disease than do smokers, the sample at risk is nearly three times larger than the active smoking sample. In addition,

Acknowledgements

We appreciate comments by Eliseo Perez-Stable on a previous version of this manuscript.

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Effects of public policies in the prevention of cardiovascular diseases: a systematic review of global literature
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Of the studies of regulatory policies of smoking restrictions in public and workplaces (n = 56), studies showed considerable beneficial effects (n = 34), limited beneficial effects (n = 18), and no effects (n = 4). In the United States, many studies reported beneficial effects of declines in hospital admission for various CVDs47,89–98 and CVD-related morbidities and mortalities.99–102 However, many studies showed mixed effects and/or no or small effect sizes of smoking bans.
Given the growing interest worldwide in applying public policies to improve human health, we undertook a systematic review of studies investigating whether public policies targeting unhealthy products could reduce cardiovascular diseases.
This study was a systematic review of the literature.
We searched research studies published in 2000–2020 from major databases, including MEDLINE and Embase. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and narratively synthesized the studies based on vote counting and direction of the intervention effect.
Ninety-eight studies, mostly from high-income countries, met the inclusion criteria. Most studies were on public policies targeting sugar-sweetened beverages and tobacco, followed by alcohol, sugar, salt, and junk foods. Overall, many reported that several fiscal, regulatory, and educational policies generated beneficial effects of reducing the diseases. Those studies that reported no or limited effects highlighted several sociodemographic and health risk characteristics and design and implementation aspects of the policy interventions as factors limiting the policy effects; most of these are modifiable with appropriate policy interventions. For instance, low magnitude of tax, substitution with other unhealthy products, firms’ competitive response strategies, pre-existence of smoking bans, incremental enactment of smoking regulations, degree of enforcement, and various sociocultural factors minimized the effects of the policies.
The literature supports a growing consensus on the beneficial effects of public policy for improving human health. The design and implementation of public policies must address various impeding factors and incorporate appropriate remedial measures. Further research is needed from low- and middle-income countries and on whether and how multiple policy instruments work in tandem.
Secondhand smoke and CVD in low- and middle-income countries: A case for action
2012, Global Heart
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Smoke-free laws reduce SHS exposure quickly. Smoke-free laws also reduce active smoking prevalence approximately 15% among active smokers and reduce the number of cigarettes smoked daily [39,40]. After a smoke-free workplace legislation in Finland (1995), California (1998), New York (2002), the Republic of Ireland (2004), Scotland (2004), France (2007–2008), and smaller jurisdictions in Colorado, Montana, Canada, and Italy, SHS exposures were reduced dramatically within 5-year periods in workers surveyed before and after the bans [3,41].
Secondhand tobacco smoke (SHS) is an environmental toxin and an established cause of cardiovascular disease in nonsmokers. Smoke-free laws reduce SHS and its downstream cardiovascular disease, but until recently, evidence to support smoke-free law implementation in low- and middle-income country settings was limited. In 14 low- and middle-income nations surveyed by the Global Adult Tobacco Survey, active smoking prevalence in adults (⩾15 years old) was universally higher in men (range 21.6–60.2%) than in women (0.5–24.4%), and the highest burden of SHS exposure was in women (strong positive association between male/female active smoking ratio and female SHS exposure prevalence). A systematic review was conducted of MEDLINE-indexed studies of self-reported SHS exposure and cardiovascular harms in low- or middle-income nations. Eight papers reported the association of SHS with ischemic heart disease, and four reported the association of SHS with stroke. For all the studies, and almost all sources of SHS surveyed, a strong positive association between SHS and ischemic heart disease (main relative odds ratio range 1.17–2.36) and SHS and stroke (odds ratio or hazard ratio: 1.41–1.49). Prevalence of SHS exposure is high in low- and middle-income nations, especially among women. Epidemiologic evidence supports the conclusion that SHS harms are the same across low-, middle-, and high-income nations. Governments have an obligation to protect citizens from SHS exposure, enforcing smoke-free legislation and providing public education about SHS harms.
Smokefree Policies to Reduce Tobacco Use. A Systematic Review
2010, American Journal of Preventive Medicine
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Additional postulated benefits of smokefree policies include reduced workplace cleaning costs and reduced risk for fires.91 The economic review team identified five economic evaluation studies91–95 falling within the scope of the effectiveness review: one cost-effectiveness analysis, one cost–benefit analysis, and three studies that report benefits in terms of costs averted. For convenience of comparability, summary measures were adjusted to 2003 U.S. dollars using the all-item Consumer Price Index (CPI)96 or the Medical Care component of the CPI,97 depending on whether a majority of cost items could be attributed to nonmedical or medical care goods and services.
In 2001, a systematic review for the Guide to Community Preventive Services identified strong evidence of effectiveness of smoking bans and restrictions in reducing exposure to environmental (secondhand) tobacco smoke. As follow-up to that earlier review, the focus here was on the evidence on effectiveness of smokefree policies in reducing tobacco use. Smokefree policies implemented by worksites or communities prohibit smoking in workplaces and designated public areas. The conceptual approach was modified for this review; an updated search for evidence was conducted; and the available evidence was evaluated. Published articles that met quality criteria and evaluated changes in tobacco-use prevalence or cessation were included in the review. A total of 57 studies were identified in the period 1976 through June 2005 that met criteria to be candidates for review; of these, 37 met study design and quality of execution criteria to qualify for final assessment. Twenty-one studies measured absolute differences in tobacco-use prevalence with a median effect of −3.4 percentage points (interquartile interval: −6.3 to −1.4 percentage points). Eleven studies measured differences in tobacco-use cessation among tobacco users exposed to a smokefree policy compared with tobacco users not exposed to a smokefree policy. The median absolute change was an increase in cessation of 6.4 percentage points (interquartile interval: 1.3 to 7.9 percentage points). The qualifying studies provided sufficient evidence that smokefree policies reduce tobacco use among workers when implemented in worksites or by communities. Finally, a systematic economic review identified four studies that, overall, demonstrated economic benefits from a smokefree workplace policy. Additional research is needed to more fully evaluate the total economic effects of these policies.
Return on investment of Canadian tobacco control policies implemented between 2001 and 2016
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Factors Associated with Tobacco Smoking in HIV Infected Persons, Brazil: A Cross Sectional Survey
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Association between secondhand smoke exposure and hypertension: Nearly as large as smoking
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^☆: This work was supported by National Cancer Institute Grant CA-61021 and by Health Resources and Services Administration Training Grant 1D22HP00349.

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Special articleCardiovascular health and economic effects of smoke-free workplaces☆

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Estimation of the number of new nonsmokers by making all U.S. workplaces smoke free

Cigarette consumption effects

Discussion

Acknowledgements

Cigarette smoking among adults—United States, 2000

MMWR Morb Mortal Wkly Rep.

Annual smoking-attributable mortality, years of potential life lost and economic costs—United States, 1995–1999

MMWR Morb Mortal Wkly Rep.

Health Effects of Exposure to Environmental Tobacco Smokethe Report of the California Environmental Protection Agency/California Environmental Protection Agency, Office of Environmental Health Hazard Assessment

Environmental tobacco smoke and cardiovascular disease. A position paper from the Council on Cardiopulmonary and Critical Care, American Heart Association

Circulation

Passive smoking and the risk of coronary heart disease—a meta-analysis of epidemiologic studies

N Engl J Med

Effect of smokefree workplaces on smoking behavioursystematic review

BMJ

State-specific trends in smokefree worksite policy coverage. The Current Population Survey 1993 to 1999

J Occup Environ Med

Short-term economic and health benefits of smoking cessationmyocardial infarction and stroke

Circulation

Special article
Cardiovascular health and economic effects of smoke-free workplaces☆