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CHEST

Original Research TOBACCO CESSATION AND PREVENTION

Acute Pulmonary Admissions Following Implementation of a National Workplace Smoking Ban Brian D. Kent, MBBCh; Imran Sulaiman, MBBCh; Trevor T. Nicholson, MBBCh; Stephen J. Lane, PhD, FCCP; and Edward D. Moloney, MD, FCCP

Background: The implementation of workplace smoking bans has contributed to a significant reduction in the incidence of acute coronary syndrome admissions, but their influence on adult acute pulmonary disease admissions is unclear. We sought to assess the impact of a national smoking ban on nationwide admissions of individuals of working age with acute pulmonary illness. Methods: Data relating to emergency hospital admissions of subjects aged 20 to 70 years preceding and succeeding the implementation of the Irish smoking ban were obtained from a central registry. Population, weather, pollution, and influenza data were obtained from the relevant authorities. Poisson regression analysis was used to assess adjusted risk of emergency hospital admission following implementation of the smoking ban. Results: Overall admissions with pulmonary illness decreased from 439 per 100,000 population per annum to 396 per 100,000 population per annum following the ban (unadjusted relative risk [RR], 0.91; 95% CI, 0.83-0.99; P 5 .048). This persisted following adjustment for confounding factors (adjusted RR, 0.85; 95% CI, 0.72-0.99; P 5 .04) and was most marked among younger age groups and in admissions due to asthma (adjusted RR, 0.60; 95% CI, 0.39-0.91; P 5 .016). Admissions with acute coronary syndromes (adjusted RR, 0.82; 95% CI, 0.70-0.97; P 5 .02), but not stroke (adjusted RR, 0.93; 95% CI, 0.73-1.20; P 5 .60), were also reduced. Conclusions: The implementation of a nationwide workplace smoking ban is associated with a decline in admissions with acute pulmonary disease among specific age groups and an overall reduction in asthma admissions. This may result from reduced exposure of vulnerable individuals to environmental tobacco smoke, emphasizing the potential benefit of legislation reducing second-hand smoke exposure. CHEST 2012; 142(3):673–679 Abbreviations: HIPE 5 Hospital In-Patient Enquiry; HPSC 5 Health Protection Surveillance Centre; PM2.5 5 particulate matter with an aerodynamic diameter , 2.5 mm; PM10 5 particulate matter with an aerodynamic diameter , 10 mm; RR 5 relative risk

smoking is a major cause of morbidity Cigarette and mortality worldwide, contributing to cardio-

vascular, cerebrovascular, neoplastic, and pulmonary diseases. Passive exposure of nonsmokers to second-

Manuscript received November 4, 2011; revision accepted February 2, 2012. Affiliations: From the Department of Respiratory Medicine (Drs Kent, Sulaiman, Lane, and Moloney), Adelaide and Meath Hospital; and the Department of Respiratory Medicine (Drs Kent and Nicholson), St. Vincent’s University Hospital, Dublin, Ireland. Funding/Support: Dr Kent is supported by a grant from the Health Research Board, Ireland. Correspondence to: Brian D. Kent, MBBCh, Department of Respiratory Medicine, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland; e-mail: [email protected]

hand smoke has been shown to increase cardiovascular morbidity,1 promote carcinogenesis,2 and possibly impair pulmonary function.3 Recently, there has been a significant focus on international public health strategies to combat the adverse effects of smoking, and secondhand smoke in particular. Ireland was the first country to introduce a nationwide workplace smoking ban, prohibiting smoking in all public indoor locations since March 2004, © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.11-2757

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and similar restrictions have since been introduced in several other countries. Studies of the impact of workplace smoking bans on cardiovascular outcomes have demonstrated a significant reduction in admissions with acute coronary syndromes in the aftermath of a ban.4-6 Other studies have shown improved pulmonary function and reduced systemic inflammation among bar workers following implementation of workplace smoking bans.7-10 Conversely, the available evidence would suggest that smoking bans make no significant impact on incidence of acute cerebrovascular syndromes.11 However, the potential impact of such legislation on the incidence of emergency admissions with acute pulmonary illness has not been explored to the same degree. Recent evidence would suggest smoke-free legislation leads to a reduction in pediatric asthma admissions,12 and although some data would suggest a similar effect in the overall population,13 there is a general paucity of information on the impact of such bans on working-age, adult populations, who may have the greatest exposure to secondhand smoke in the workplace. The aim of this study was to examine the potential impact of the Irish smoking ban on emergency hospital admissions with pulmonary illness, acute coronary syndromes, and acute cerebrovascular syndromes among individuals of working age. Some of these data have previously been presented in abstract form.14 Materials and Methods Diagnosis-Specific Admission Data Demographic and clinical data relating to admissions to acute hospitals in the Republic of Ireland are recorded on the Hospital In-Patient Enquiry (HIPE) database, which is maintained centrally by the Economic and Social Research Institute. Diagnostic data are recorded and classified according to the International Classification of Diseases. Prior to 2005, HIPE data were classified according to International Classification of Diseases 9th Revision, Clinical Modification, with International Classification of Diseases 10th Revision, Australian Modification, used since 2005. Data from HIPE pertaining to emergency medical admissions with acute respiratory, cardiac, and cerebrovascular disease for the years preceding (2002 and 2003) and the years succeeding (2005 and 2006) the introduction of the Irish workplace smoking ban in 2004 were obtained. The specific pulmonary admission diagnoses were exacerbations of COPD, pneumonia, lower respiratory tract infection, exacerbations of asthma, and spontaneous pneumothorax. Data were also obtained for admissions with acute coronary syndromes (myocardial infarction and unstable angina) and acute cerebrovascular syndromes (stroke and transient ischemic attack). Age- and sex-specific incidence data were also obtained. We restricted our analysis to individuals between the ages of 20 and 69 years of age, reflecting the majority of the working population.

significant economic growth in Ireland at this time, large-scale inward migration occurred during the years of interest. To derive population-adjusted incidence data, population statistics were obtained from the Irish Central Statistics Office. These were based on two national censuses performed in 2002 and 2006, with interim analyses performed by the Central Statistics Office evaluating the population in 2003 and 2005. Again, sex- and agespecific population data were also obtained. Influenza Data The Health Protection Surveillance Centre (HPSC) is Ireland’s specialist center for surveillance of disease. The HPSC has established a network of sentinel general practice clinics that report on a weekly basis the number of patients seen with influenza-like symptoms. All cases thus reported have virologic analysis performed by the Irish National Virus Reference Laboratory, allowing for robust estimation of national incidence of influenza. The HPSC publishes weekly incidence reports during the traditional influenza season from October to May. Data were obtained pertaining to influenza incidence for 2002, 2003, 2005, and 2006. Climate and Air-Quality Data Annual climate reports were obtained from the Irish Meteorological Service, describing mean monthly temperature and rainfall for the years in question. Data quantifying national mean levels of atmospheric particulate matter with an aerodynamic diameter , 10 mm and , 2.5 mm (PM10 and PM2.5, respectively) were obtained from the Irish Environmental Protection Agency and the European Environmental Agency for each of the years in question. Data Analysis Poisson log-linear regression analysis was performed. For the univariate model, with the age-specific population-adjusted admission rates for each diagnosis as the dependent variable, the independent variable was an indicator of the post-ban period. Goodness of fit was determined using the deviance statistic. Where the Poisson model was found to be inappropriate following this, a negative binomial model was used. In the multivariate model, together with smoking ban status, potential confounding variables were also included. These were: PM10, PM2.5, influenza-like illness rate, positive influenza case rate, and also seasonal temperature. For this, seasonal temperature averages for winter (November-January), spring (FebruaryApril), summer (May-July), and autumn (August-October) were investigated. All potential explanatory variables were also assessed for colinearity. A level of significance 0.05 was used for all statistical analysis. Statistical analysis was performed using the SPSS, version 18 software package (SPSS Inc).

Results Population Statistics The Irish working-age population grew by 286,000 (or 11.6%) between 2002 and 2006. The greatest increases were seen in the 20- to 29-year-old and 30- to 39-year-old age groups, and a greater increase was seen among men than women (e-Table 1).

Population Data

Influenza Incidence

Data obtained and stored by the Economic and Social Research Institute are expressed in absolute numbers. As a result of

No significant variation in peak influenza-like illness incidence was noted in presentations to sentinel

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Table 2—Adjusted Risk of Emergency Admission Following Implementation of Workplace Smoking Ban by Diagnosis Admission Diagnosis Pulmonary disease Exacerbation of COPD Asthma Pneumonia Lower respiratory tract infection Spontaneous pneumothorax Acute coronary syndromes Myocardial infarction Unstable angina Stroke Transient ischemic attack

Unadjusted RR (95% CI)

P Value

Adjusted RR (95% CI)

P Value

0.90 (0.83-0.99) 1.21 (1.01-1.44) 0.64 (0.50-0.82) 0.77 (0.64-0.93) 1.00 (0.84-1.21) 0.62 (0.33-1.15) 0.81 (0.69-0.95) 0.88 (0.70-1.10) 0.75 (0.61-0.93) 0.94 (0.74-1.20) 1.00 (0.72-1.40)

.048 .04 , .001 .007 .96 .13 .008 .27 .008 .63 1

0.85 (0.72-0.99) 1.18 (0.86-1.60) 0.60 (0.39-0.91) 0.71 (0.52-0.98) 0.83 (0.61-1.13) 0.62 (0.22-1.75) 0.82 (0.70-0.97) 0.89 (0.70-1.13) 0.77 (0.61-0.96) 0.93 (0.73-1.20) 1.00 (0.70-1.42)

.04 .3 .016 .04 .24 .36 .02 .33 .023 .6 1

Data adjusted for influenza-like illness rates, influenza cases, mean seasonal temperatures, PM10 levels, and PM2.5 levels. Referent value is presmoking ban hospital admissions. PM2.5 5 particulate matter with an aerodynamic diameter , 2.5 mm; PM10 5 particulate matter with an aerodynamic diameter , 10 mm.

worldwide. There is a substantial body of evidence evaluating the impact of such measures on incidence of acute myocardial infarction and acute coronary syndromes. Data from the United Kingdom, Italy, and the United States have all supported a role for smoking bans in the reduction of acute cardiovascular morbidity.4-6,11,15 Moreover, a recent systematic review and meta-analysis in this area found an overall risk reduction of acute myocardial infarction of 17% associated with such bans.5 Other beneficial public health effects, such as reduced incidence of preterm birth and maternal smoking, have also been reported.16

Figure 1. Pulmonary admissions by age group following implementation of smoke-free legislation. Data are expressed as relative risk of admission with 95% CI.

Less information exists regarding any impact of this legislation with regard to respiratory disease. Although improvements in lung function and reductions in systemic inflammation have been reported in bar workers following a smoking ban,7-9 along with a diminution in pediatric asthma admissions,12 it remains unclear if this translates into a reduction of healthcare use by the general adult working population. We observed a reduction in emergency admissions to Irish hospitals as a result of acute respiratory illness in the aftermath of our smoking ban. This reduction was most pronounced in younger adults and was not accounted for by changes in influenza incidence, climate, or air quality. In terms of individual pulmonary diagnoses, we observed a significant reduction in admissions due to asthma and pneumonia but not COPD. We believed that a composite diagnosis of “pulmonary disease” would best encompass emergency pulmonary admissions, as the possibility of an admission with, for example, pneumonia being misclassified as COPD could not be discounted. That no significant reductions were seen in admissions with COPD may represent an example of misclassification bias, or alternatively may demonstrate that the majority of exacerbation-prone subjects with COPD are not exposed to secondhand smoke in a workplace setting. We further observed a significant decrease in admissions of middle-aged adults with acute coronary syndromes, with an 18% reduction in emergency cardiac admissions observed. Conversely, no reduction in incidence of acute cerebrovascular syndromes was seen. A number of possible explanations exist for the observed reduction in emergency admissions with respiratory disease. It is plausible that it may be due to a reduction in the number of active smokers in the population. Smoking prevalence transiently decreased from approximately 28% of the population preceding the smoking ban to approximately 26%

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Table 2—Adjusted Risk of Emergency Admission Following Implementation of Workplace Smoking Ban by Diagnosis Admission Diagnosis Pulmonary disease Exacerbation of COPD Asthma Pneumonia Lower respiratory tract infection Spontaneous pneumothorax Acute coronary syndromes Myocardial infarction Unstable angina Stroke Transient ischemic attack

Unadjusted RR (95% CI)

P Value

Adjusted RR (95% CI)

P Value

0.90 (0.83-0.99) 1.21 (1.01-1.44) 0.64 (0.50-0.82) 0.77 (0.64-0.93) 1.00 (0.84-1.21) 0.62 (0.33-1.15) 0.81 (0.69-0.95) 0.88 (0.70-1.10) 0.75 (0.61-0.93) 0.94 (0.74-1.20) 1.00 (0.72-1.40)

.048 .04 , .001 .007 .96 .13 .008 .27 .008 .63 1

0.85 (0.72-0.99) 1.18 (0.86-1.60) 0.60 (0.39-0.91) 0.71 (0.52-0.98) 0.83 (0.61-1.13) 0.62 (0.22-1.75) 0.82 (0.70-0.97) 0.89 (0.70-1.13) 0.77 (0.61-0.96) 0.93 (0.73-1.20) 1.00 (0.70-1.42)

.04 .3 .016 .04 .24 .36 .02 .33 .023 .6 1

Data adjusted for influenza-like illness rates, influenza cases, mean seasonal temperatures, PM10 levels, and PM2.5 levels. Referent value is presmoking ban hospital admissions. PM2.5 5 particulate matter with an aerodynamic diameter , 2.5 mm; PM10 5 particulate matter with an aerodynamic diameter , 10 mm.

worldwide. There is a substantial body of evidence evaluating the impact of such measures on incidence of acute myocardial infarction and acute coronary syndromes. Data from the United Kingdom, Italy, and the United States have all supported a role for smoking bans in the reduction of acute cardiovascular morbidity.4-6,11,15 Moreover, a recent systematic review and meta-analysis in this area found an overall risk reduction of acute myocardial infarction of 17% associated with such bans.5 Other beneficial public health effects, such as reduced incidence of preterm birth and maternal smoking, have also been reported.16

Figure 1. Pulmonary admissions by age group following implementation of smoke-free legislation. Data are expressed as relative risk of admission with 95% CI.

Less information exists regarding any impact of this legislation with regard to respiratory disease. Although improvements in lung function and reductions in systemic inflammation have been reported in bar workers following a smoking ban,7-9 along with a diminution in pediatric asthma admissions,12 it remains unclear if this translates into a reduction of healthcare use by the general adult working population. We observed a reduction in emergency admissions to Irish hospitals as a result of acute respiratory illness in the aftermath of our smoking ban. This reduction was most pronounced in younger adults and was not accounted for by changes in influenza incidence, climate, or air quality. In terms of individual pulmonary diagnoses, we observed a significant reduction in admissions due to asthma and pneumonia but not COPD. We believed that a composite diagnosis of “pulmonary disease” would best encompass emergency pulmonary admissions, as the possibility of an admission with, for example, pneumonia being misclassified as COPD could not be discounted. That no significant reductions were seen in admissions with COPD may represent an example of misclassification bias, or alternatively may demonstrate that the majority of exacerbation-prone subjects with COPD are not exposed to secondhand smoke in a workplace setting. We further observed a significant decrease in admissions of middle-aged adults with acute coronary syndromes, with an 18% reduction in emergency cardiac admissions observed. Conversely, no reduction in incidence of acute cerebrovascular syndromes was seen. A number of possible explanations exist for the observed reduction in emergency admissions with respiratory disease. It is plausible that it may be due to a reduction in the number of active smokers in the population. Smoking prevalence transiently decreased from approximately 28% of the population preceding the smoking ban to approximately 26%

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Figure 2. Acute coronary syndromes by age group following implementation of smoke-free legislation. Data are expressed as relative risk of admission with 95% CI.

thereafter.17 Continuing cigarette smoking was demonstrated to contribute to accelerated decline of lung function in the Lung Health Study,18 and a follow-up analysis of this cohort found smoking cessation programs could have a significant effect on subsequent mortality.19 Similarly, smokers with asthma have poorer

Figure 3. Acute cerebrovascular admissions by age group following implementation of smoke-free legislation. Data are expressed as relative risk of admission with 95% CI.

symptom control and relatively poor responses to inhaled corticosteroid treatment and are at increased risk of death compared with nonsmokers.20-22 Moreover, a reduction in exposure of individuals with chronic lung diseases to secondhand smoke may be a contributory factor. Studies evaluating the impact of a workplace smoking ban on the lung health of bar workers have shown an improvement in lung function6 and a reduction in systemic inflammatory markers.7 Furthermore, it has been shown that these improvements in lung function are associated with a reduction in air pollution in bars.9 Similarly, recent evidence suggests the introduction of smoke-free legislation may diminish rates of pediatric asthma admissions.12 Population studies suggest that secondhand smoke exposure is a major risk factor for the development of pulmonary symptoms and disease, particularly in nonsmokers.3,23 The duration of exposure to secondhand smoke appears to predict the risk of developing bronchitis, whereas there appears to be a dose-dependent increase in other pulmonary morbidity, including asthma.24,25 Clinical studies have demonstrated that passive smoking may also cause a worsening of lung function and symptoms in challenged patients with asthma,26-28 although its impact on bronchial hyperresponsiveness is less clear.29,30 Acute exposure to secondhand smoke has been reported to cause asthma death,31 whereas exposure to tobacco smoke in utero or during childhood increases asthma risk.32 Similarly, secondhand smoke exposure may lead to poorer health and increased risk of exacerbation in individuals with COPD.33 Emerging evidence is also suggestive of a role for secondhand smoke in the causation of pneumonia and tuberculosis in nonsmokers,34,35 and it also appears to have a deleterious effect on endothelial function and on cardiovascular morbidity.1 Although we attempted to reduce the impact of external variables by adjusting our analyses for influenza incidence, air pollution, and climate, we cannot exclude the possibility that unmeasured confounding variables may contribute to the reduction in emergency pulmonary admissions we observed. In particular, the substantial inward economic migration seen during the study period represents an important potential confounding factor. Unfortunately, there are few or no robust data that we are aware of objectively assessing the health or smoking status of these individuals. Similarly, although we were able to incorporate reported incidence of influenza-like illness into our analyses, the possibility of other viral respiratory illnesses influencing these results cannot be discounted, while changes in prescribing patterns of respiratory medications remain another significant potential confounding factor. Furthermore, although we chose a population that was broadly of working age, we are

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unable to confirm employment history or socioeconomic status within this group. Finally, as with any administrative data sets, the possibility of misclassification bias within the HIPE data exists, particularly in the context of a change in International Classification of Diseases-coding regimes. However, we used the broadest possible overall categorizations of disease to attempt to circumvent this latter issue and would further argue that a direct role for the smoking ban is both biologically plausible and supported by published data on the cardiovascular benefits of similar legislation in other jurisdictions. Conclusion We report a marked decline in emergency admissions to hospital with acute respiratory illness among young adults in Ireland in the period following implementation of a workplace smoking ban. Significant reductions were seen in admissions due to asthma in working-age adults. Similar improvements in acute coronary artery disease presentations were observed in older subjects, but no significant changes were seen in terms of acute cerebrovascular syndromes. These reductions were not accounted for by changes in climate, air pollution, or influenza incidence. We suggest that workplace smoking bans may yield a direct, tangible benefit in improving respiratory health. Acknowledgments Author contributions: Dr Kent: contributed to data abstraction and statistical analysis, writing of the manuscript, and reviewing and approving the manuscript prior to submission. Dr Sulaiman: contributed to data abstraction and statistical analysis, writing of the manuscript, and reviewing and approving the manuscript prior to submission. Dr Nicholson: contributed to data abstraction and statistical analysis, writing of the manuscript, and reviewing and approving the manuscript prior to submission. Dr Lane: contributed to writing of the manuscript, and reviewing and approving the manuscript prior to submission. Dr Moloney: contributed to writing of the manuscript, and reviewing and approving the manuscript prior to submission. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript. Other contributions: Admissions data were provided by Health Research and Information Division of the Economic and Social Research Institute, Ireland. Influenza incidence data were provided by the influenza team at the Health Protection Surveillance Centre. Population data were obtained from the Central Statistics Office, Ireland, climate data from the Irish Meteorological service, and pollution data from the Irish Environmental Protection Agency and the European Environmental Agency. We thank Sinead O’Hara and Eithne Sexton (Economic and Social Research Institute), and Lisa Domegan and Joan O’Donnell, MD (Health Protection Surveillance Centre) for their contributions. Additional information: The e-Figures and e-Tables can be found in the “Supplemental Materials” area of the online article.

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