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SMOKE-FREE POLICIES: CLEANING THE AIR WITH MONEY TO SPARE

Thursday, 27th of March 2014

SMOKE-FREE POLICIES: CLEANING THE AIR WITH MONEY TO SPARE

The Lancet, Early Online Publication, 28 March 2014

Copyright © 2014 Elsevier Ltd All rights reserved.

Sara Kalkhoran b, Stanton A Glantz a b

One reason that politicians are reluctant to invest in aggressive tobacco control policies and programmes is the perception that the costs (money and the risk of irritating tobacco companies) come now, whereas the benefits (reduced disease and medical costs) are years away. In The Lancet, Jasper Been and colleagues meta-analysis1 adds another dimension to the already strong case2 that this perception is wrong.

Drawing on 11 studies done in North America and Europe, including more than 2·5 million births and nearly 250 000 asthma exacerbations, Been and colleagues show that smoke-free workplace and public place laws were followed by immediate drops in preterm births (10·4%, 95% CI 2·0—18·8%) and childhood emergency department visits and hospital attendances (10·1%, 5·0—15·2). Although there was no significant change in low birthweight (—1·7%, −5·1 to 1·6%), there was a decline in children being very small for gestational age (5·3%, 5·2—5·4). In addition to clearing the air, smoke-free laws bring rapid health benefits and improved lives, whilst, at the same time, reducing medical costs by avoiding emergency department visits and admissions to hospitals.1

Smoke-free laws are also followed by benefits for adults, including drops in hospital admissions for cardiac disease, cerebrovascular accidents, and respiratory disease, and reduced ambulance calls.2 This fall in adverse events shows up in hospital costs: after German states enacted weak smoking restrictions in restaurants (policies that generally allowed smoking in small bars and parts of large restaurants), hospital costs for angina pectoris and acute myocardial infarction dropped by 9·6% and 20·1%, respectively, totalling €7·7 million in the first year.3 Because stronger laws are followed by bigger declines in admissions to hospital,2 political compromises like those made by German politicians to exempt some venues come with substantial health and economic costs.

Smoke-free workplace and public place laws stimulate people to make their homes smoke free voluntarily,4, 5 which reduces second-hand smoke exposure and supports quitting. This effect is particularly crucial for infants and children who have no control over their environment. Furthermore, living in a smoke-free home and the perception of being covered by a public smoke-free law are associated with smoking a decreased number of cigarettes, increased attempts to quit,6 increased use of pharmaceutical cessation aids, and increased cessation success.7

Children exposed to second-hand smoke have a 1·4 times increased odds of emergency department visits and, in children with asthma, 2·2 times greater odds of admission to hospital compared with unexposed children.8 Furthermore, children admitted to hospital for asthma with detectable cotinine (a biomarker of second-hand smoke exposure) had a 1·5 times greater odds of readmission within 1 year.9 Achievement of such substantial reductions in medical costs through smoke-free policies is a less expensive and faster solution than other present options, including individualised home-based environmental interventions that, although beneficial, can cost more than US$10 000 per patient.10 Medical expenses for asthma exceeded US$50 billion in the USA in 2007,11 and US$20 billion in Europe in 2006.12 If asthma emergency department visits and admissions to hospital decreased by even 10%, the savings in the USA and Europe together would be US$7 billion annually.

The speed of such health improvements and medical cost reductions helps to explain the rapid and huge returns on investment in aggressive tobacco control programmes. For example, between 1989 and 2008, implementation of Californias tobacco control programme cost US$2·4 billion and resulted in US$243 billion in medical cost savings, a 100 to one return on investment.13

 

Full-size image (82K) B.S.P.I/Corbis

The cigarette companies, their allies, and the groups they sponsor have long used claims of economic harm, particularly to restaurants, bars, and casinos, to oppose smoke-free laws despite consistent evidence to the contrary.2 By contrast, the rapid economic benefits that smoke-free laws and other tobacco control policies bring in terms of reduced medical costs are real. Rarely can such a simple intervention improve health and reduce medical costs so swiftly and substantially.

Indeed, the largest cost is paid by politicians who have to stand up to the tobacco companies and their lobbyists. Been and colleagues1 add to the case that it is a cost well worth paying.

We declare that we have no competing interests.

References

1 Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet 2014. published online March 28. http://dx.doi.org/10.1016/S0140-6736(14)60082-9.

2 US Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, National Center on Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

3 Sargent JD, Demidenko E, Malenka DJ, Li Z, Gohlke H, Hanewinkel R. Smoking restrictions and hospitalization for acute coronary events in Germany. Clin Res Cardiol 2012; 101: 227-235. CrossRef | PubMed

4 Cheng KW, Glantz SA, Lightwood JM. Association between smokefree laws and voluntary smokefree-home rules. Am J Prev Med 2011; 41: 566-572. CrossRef | PubMed

5 Nazar GP, Lee JT, Glantz SA, Arora M, Pearce N, Millett C. Association between being employed in a smoke-free workplace and living in a smoke-free home: evidence from 15 low and middle income countries. Prev Med 2014; 59: 47-53. CrossRef | PubMed

6 Zablocki RW, Edland SD, Myers MG, Strong DR, Hofstetter CR, Al-Delaimy WK. Smoking ban policies and their influence on smoking behaviors among current California smokers: a population-based study. Prev Med 2014; 59: 73-78. CrossRef | PubMed

7 Gilpin EA, Messer K, Pierce JP. Population effectiveness of pharmaceutical aids for smoking cessation: what is associated with increased success?. Nicotine Tob Res 2006; 8: 661-669. CrossRef | PubMed

8 Jin Y, Seiber EE, Ferketich AK. Secondhand smoke and asthma: what are the effects on healthcare utilization among children?. Prev Med 2013; 57: 125-128. CrossRef | PubMed

9 Howrylak JA, Spanier AJ, Huang B, et al. Cotinine in children admitted for asthma and readmission. Pediatrics 2014; 133: e355-e362. CrossRef | PubMed

10 Nurmagambetov TA, Barnett SB, Jacob V, et al. Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity a community guide systematic review. Am J Prev Med 2011; 41: S33-S47. CrossRef | PubMed

11 Centers for Disease Control and Prevention. Vital Signs: asthma in the US. Atlanta: United States Centers for Disease Control and Prevention, 2011. http://www.cdc.gov/vitalsigns/pdf/2011-05-vitalsigns.pdf. (accessed Jan 27, 2014).

12 Braman SS. The global burden of asthma. Chest 2006; 130: 4S-12S. CrossRef | PubMed

13 Lightwood J, Glantz SA. The effect of the California tobacco control program on smoking prevalence, cigarette consumption, and healthcare costs: 1989—2008. PLoS One 2013; 8: e47145. CrossRef | PubMed

a Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, CA 94143-1390, USA

b Department of Medicine, University of California San Francisco, San Francisco, CA, USA