Laws restricting smoking in public spaces are associated with significant morbidity and mortality reductions related to respiratory and cardiovascular disease and birth outcomes, according to systematic review and meta-analysis findings published in the Journal of the American Medical Association Network Open.

Although tobacco control policies have been implemented across global communities, tobacco use remains the second leading risk factor of worldwide mortality. Investigators therefore sought to characterize associations between implementation of population-level tobacco control laws and health-related outcomes (ie, respiratory disease [RSD], cardiovascular disease [CVD], cancer, hospitalization, mortality, health care utilization, and adverse birth outcomes).

This systematic review and meta-analysis involved 144 population-based studies found in the Web of Science, Cumulated Index to Nursing and Allied Health Literature, EconLit, EMBASE, and PubMed electronic databases from inception to March 2022. Included studies focused on associations between population-level tobacco control policies and health-related outcomes without restriction on population type, age, or condition, and were all observational in design. Among these studies, 60 were included in meta-analysis and 84 were included in the narrative summary. Overall, 126 studies were rated high or moderate quality and 18 studies were rated poor quality. Half of the included studies were conducted in the US, 45 in Europe, 14 in the United Kingdom, and 13 elsewhere (mostly Latin America and Asia).

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Across all studies, 126 reported on smoke-free legislation policies, 14 reported on tax or price increases, 12 reported on multicomponent tobacco control programs, and 1 reported on a minimum age for cigarette purchases.

Investigators for the current analysis found smoke-free legislation was associated with decreased risk of all RSD events (odds ratio [OR], 0.83; 95% CI, 0.72-0.96), CVD events (OR, 0.90; 95% CI, 0.86-0.94), hospitalization due to RSD or CVD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). In all subgroup and sensitivity analyses (except low and moderate country income) these associations persisted.

Notably, the investigators also found that smoke-free legislation was associated with a 9% to 10% reduced risk for CVD events (including CVD incidence, prevalence, and mortality due to acute myocardial infarction, coronary heart disease, cerebrovascular disease, and sudden cardiac death).

Significant heterogeneity was noted between smoke-free legislation and RSD events (I2=98%), CVD events (I2=88%), and hospitalization due to RSD and CVD events (I2=97%) (all P <.001), and between smoke-free legislation and adverse birth outcomes (I2=76% to 97%; P <.01).

Meta-analysis showed tax or price increases had no clear association with adverse health outcomes, however, studies in the narrative summary showed statistically significant inverse associations between tax increases and adverse health event decreases. Additionally, reductions (non-significant) were found after implementation of smoke-free legislation in 14/18 studies for RSD, 8/16 studies for RSD-related hospitalizations, 13/17 studies for CVD events, 9/17 studies for CVD-related hospitalizations, and 10/14 studies for risk of adverse birth outcomes.

Systematic review and meta-analysis limitations include significant between-study heterogeneity as well as the use of data primarily from high-income countries in the meta-analysis, which may limit its generalizability.  

Investigators stated, “Implementation of smoke-free legislation was followed by a significant decrease in multiple adverse health outcomes.” They concluded these findings, “support the need to accelerate the uptake of laws restricting smoking in public spaces in efforts to protect people from related cardiovascular, respiratory, and birth health hazards.”


Akter S, Islam MR, Rahman MM, et al. Evaluation of population-level tobacco control interventions and health outcomes: A systematic review and meta-analysisJAMA Netw Open. Published online July 3, 2023. doi:10.1001/jamanetworkopen.2023.22341

This article originally appeared on Pulmonology Advisor