As of July 2016, only 21% of Appalachian residents were covered by comprehensive smoke-free laws (i.e., 100% coverage for workplaces, restaurants, and bars). Only 46% of Appalachians lived in places with 100% smoke-free workplace laws, only 30% lived in places with 100% smoke-free restaurant laws, and only 29% lived in places with 100% smoke-free bar laws. Reasons for this lack of smoke-free law coverage include socioeconomic disadvantage, the historical importance of tobacco in Appalachian economies, and preemptive state legislation.
New Smoke 2006 Key
Despite the well-known risks associated with secondhand smoke exposure and the success of smoke-free policies in improving health, only 60% of the US population was covered by comprehensive smoke-free laws that ban smoking in indoor areas of workplaces, restaurants, and bars as of July 2016.13 One area of the country that experiences a disproportionate burden of adverse effects from smoking is Appalachia. Using data from 2008, Ferketich et al.14 published the first quantitative assessment of smoke-free law coverage in the Appalachian region. They found that 16.6% of communities were covered by 100% smoke-free policies banning indoor smoking in workplaces, 15.1% of communities had 100% smoke-free policies for restaurants, and 10.7% of nondry communities had 100% smoke-free policies for bars, leaving residents of Appalachia at greater risk for being exposed to secondhand smoke.14
After the negative health effects of tobacco were made public in the 1950s, major manufacturers in the tobacco industry formed the Tobacco Growers Information Committee and the Tobacco Institute to partner tobacco manufacturers with tobacco growers to fight tobacco control laws and promote tobacco culture in key tobacco growing states.27 These efforts included a film called Leaf, produced in 1974, which promoted tobacco growing as an important intergenerational family tradition and provider of jobs.27 However, as demand for tobacco declined and manufacturers began producing tobacco overseas because of cheaper costs, the partnership between growers and manufacturers fell apart, and many growers stopped opposing smoke-free policies.26
Each of the 4 preemptive smoke-free policies in Appalachia is unique. Pennsylvania has statewide smoke-free coverage for all workplaces, but it permits smoking in bars, casinos, and closed areas of restaurants.34 Pennsylvania also preempts counties and municipalities from enacting stronger smoke-free laws that could extend smoke-free protections to all restaurants and bars.33 North Carolina has 100% smoke-free laws covering restaurants and bars, but it still preempts local control over smoke-free regulations that could expand coverage to all workplaces.33 There are no 100% smoke-free laws in Virginia because state law still permits smoking in ventilated areas of restaurants, exempts several types of workplaces and bars, and preempts local authorities from enacting stronger legislation.34 Tennessee also has no 100% smoke-free laws because state law permits smoking in workplaces with fewer than 5 employees, permits smoking in restaurants and bars that prohibit entrance to people younger than 21 years, and preempts local control over privately owned buildings.33,34
We thank Alex Liber for comments on a previous version of this article, Christina Mair, PhD, for help with databases for alcohol outlets and dry counties, and the Cancer Intervention and Surveillance Modeling Network Lung Group for helpful discussions surrounding smoke-free policy implementation.
U.S. Surgeon General Richard H. Carmona last week issued a report which concludes that secondhand smoke causes death and disease in children and adults and that there is no risk-free level of exposure to secondhand smoke. In addition, secondhand smoke puts children at an increased risk, specifically for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems and more severe asthma.
Answer: Secondhand smoke is an important issue for public health globally. The key message from the 2006 report is that exposure to secondhand smoke causes death and disease in children and adults. As far as we know, no level of exposure is safe, no matter how brief. However, control of secondhand smoke is possible by eliminating smoking in indoor environments. Nothing short of eliminating smoking all together will fully protect nonsmokers. Air filter systems or moving more air in and out of buildings will not suffice.
With this most recent report, we put together the background evidence for our conclusions in a retrievable, web-based data system. The concept was something I originally developed for the Minnesota Tobacco trial. When we began our work with CDC, we used the same data system as a foundation for the approximately 1,600 articles on secondhand smoke that we examined and included in our analysis. Our thought was that we wanted to allow researchers to go to the data and look at the evidence themselves, organize it and do their own meta-analyses. We also intend that the data could be updated with new evidence in the future.
Answer: Educating families about the dangers of secondhand smoke or even implementing family smoking policies can reduce exposure in the home. At work, the majority of adults are covered by a smoking ban. In total, 14 states and more than 250 local jurisdictions have clean indoor air legislation. However, as an example, in Maryland, the health of employees of restaurants with liquor licenses and bars is being overlooked in favor of profits to owners, who are reluctant to be smoke-free. You simply cannot accommodate smokers and nonsmokers in the same area and protect nonsmokers. Restaurant and bar owners will need to voluntarily go smoke-free or local and state governments will need to pass legislation requiring them to do so.
Eleven publications deal with studies that looked at the effects of smoking bans in eight natural experiments: three studies in overlapping regions of Italy (Barone-Adesi et al., 2006; Cesaroni et al., 2008; Vasselli et al., 2008); one study in Pueblo, Colorado, after 18 months of followup (Bartecchi et al., 2006) and after 3 years of followup (CDC, 2009); and one study each in Helena, Montana (Sargent et al., 2004), Monroe County, Indiana (Seo and Torabi, 2007), Bowling Green, Ohio (Khuder et al., 2007), New York state (Juster et al., 2007), Saskatoon, Canada (Lemstra et al., 2008), and Scotland (Pell et al., 2008). The legislation in Bowling Green, Ohio, allowed smoking in some restaurants and bars; it called for a smoking restriction rather than a smoking ban. The studies examined changes in heart-attack rates, or acute myocardial infarctions (acute MIs) after the implementation of the bans (and one restriction) and were not designed to answer questions about the association between exposure to secondhand smoke and cardiovascular disease. Most of the studies did not measure individual exposures to secondhand smoke or the smoking status of individuals; thus, they were designed to evaluate the association between smoking bans and acute MIs, not the effects of secondhand-smoke exposure. The publications on the smoking bans in Monroe County, Indiana, and Scotland, however, contain data on smoking status and results of analyses only in nonsmokers; these two studies were designed to assess the association between secondhand-smoke exposure and acute MIs.
Three publications report on acute coronary events after implementation of the Italian smoking ban (Barone-Adesi et al., 2006; Cesaroni et dal., 2008; Vasselli et al., 2008) and provide information directly related to the association between smoking bans and acute coronary events. All three publications include data on acute coronary events through 2005, but Vasselli et al. (2008) analyzed data from the largest number of regions, which included the regions analyzed in the other two publications.
Barone-Adesi et al. (2006) published the first report on the effect of the Italian smoking ban on acute coronary events, looking at data from the Piedmont region. The Piedmont region is one of the regions reported on by Vasselli et al. The authors used hospital admission records from the regional hospital discharge registry for Piedmont residents who had a primary discharge diagnosis code of acute MI (International Classification of Diseases, Revision 9, Clinical Modification [ICD-9-CM] 410) during January 2001 and June 2005 and hospital deaths due to acute MI, and they calculated age-standardized rates of admission. A total of 17,153 cases were included in the report.
Cesaroni et al. (2008) assessed outcomes in a period of 12 months, longer than the 2 months of Vasselli et al. (2008) and the 6 months of Barone-Adesi et al. (2006), but did not have as broad a population base (only Rome) as the analysis of data on four Italian regions by Vasselli et al. (2008). Although there was no concurrent control population, it controlled for potential confounders that included particulate matter (only PM10), an influenza epidemic, holidays, and air temperature. There was no information on individual smoking status, but the authors did use information on smoking prevalence in Rome and the RRs posed by active smoking to estimate the extent of the decrease in acute coronary events that might be attributable to smoking cessation; they estimated that less than 2% of the decrease was attributable to smoking cessation. The study included fatal and nonfatal acute MIs and a large population. The authors explained the rationale for including both primary and secondary events. Although it is good that troponin test results were used in diagnosing acute MIs, use of this method alone could result in misdiagnosing as acute MIs some events that are not acute MIs inasmuch as troponin can also be increased in some systemic diseases and in nonthrombotic cardiac disease (Inbar and Shoenfeld, 2009) and small changes can occur in clinically stable populations (Eggers et al., 2009). 2ff7e9595c
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