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实施无烟法律有助降低心肌梗死发生率 MI Rate Declines After Smoke-Free Laws Enacted in Olmsted County  

2012-11-05 12:26:02|  分类: 默认分类 |  标签: |举报 |字号 订阅

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内科学文献》(Archives of Internal Medicine)10月29日在线发表的一项研究显示,明尼苏达州奥姆斯特德县在公共场所和工作场所实施禁烟法律后,心肌梗死(MI)发生率降低了1/3 (Arch. Intern. Med. 2012 [doi:10.1001/2013.jamainternmed.46])。

实施无烟法律有助降低心肌梗死发生率  MI Rate Declines After Smoke-Free Laws Enacted in Olmsted County - gloryking3 - gloryking3的博客


研究者分析的数据来自罗彻斯特流行病学项目,该项目对稳健流行病学研究的追踪记录长达50年以上,并采用严格流行病学标准对所有社区MI和心脏性猝死病例进行验证。


奥姆斯特德县要求饭店从2002年1月1日起开始禁烟,要求酒吧和工作场所从2007年10月1日起开始禁烟。研究者分析了各条例实施前18个月和实施后18个月的MI和心脏性猝死发生率。


结果显示,在整个研究期间,共发生717例MI和514例心脏性猝死。校正年龄和性别的MI发生率从法律实施前的150.8/100,000人降至实施后的100.7/100,000人,降幅为34%。在此期间,心脏性猝死发生率也呈降低趋势,但不显著,降幅为17%。


研究者表示,无烟法律之所以有效,不仅是因为其可降低非吸烟者暴露于二手烟的量,还因为其可降低吸烟者的吸烟强度、提高戒烟率并从一开始就降低沾染烟草率。其他研究表明,只要暴露于二手烟30分钟就可导致冠状动脉血流速储备出现突然明显降低和导致血管损伤,抑制内皮功能。暴露于烟草还可导致HDL胆固醇水平降低、炎症标志物水平升高、血清纤维蛋白原和同型半胱氨酸水平升高、抗氧化物水平降低和胰岛素抵抗增加。


综合来看,这些结果表明,医生应支持有效的烟草控制政策,比如增加烟草税的征收、在香烟盒上印制图形标签、对工作场所实施禁烟和推广禁烟措施等。


研究者表示,尽管该研究未能确立禁烟与MI发生率降低之间的因果关系,但研究期间并无其他干预措施能够合理解释所观察到的MI发生率降低的现象。同时出现降低的唯一主要MI危险因素就是吸烟发生率,而高血压和高胆固醇血症发生率保持不变,糖尿病和肥胖发生率增加。该研究的局限性在于奥姆斯特德县的人群主要为白人,因此未来有必要在人种和种族构成更多样化的社区中开展进一步研究。


该研究获ClearWay Minnesota、美国国立心肺血液研究所及美国国立衰老研究所支持。研究者声明无经济利益冲突。


随刊述评:更多证据显示禁烟有益健康


加州大学内科的SARA KALKHORAN博士和该科烟草控制研究与教育中心的PAMELA M. LING博士表示,随着越来越多的地区实施禁烟法律,有关禁烟所带来的健康益处证据也日益增加。临床医生应努力填补现有禁烟政策的漏洞,并将禁烟的场所扩大至多单元住房、汽车、赌场、和室外场所。研究表明对多单元住房实施禁烟不仅可降低对二手烟的暴露,而且还可增加吸烟率通常较高的人群(如社会经济地位低的人群)的戒烟尝试。


KALKHORAN博士和LING博士均声明无经济利益冲突(Arch. Intern. Med. 2012 [doi10.1001/2013.jamainternmed.269])。




By: MARY ANN MOON, Cardiology News Digital Network


The rate of myocardial infarction dropped by one-third after laws prohibiting smoking in public places and workplaces were enacted in Olmsted County, Minnesota, according to a report published online Oct. 29 in Archives of Internal Medicine.


Although this epidemiologic study could not establish causality, no other interventions during the study period could plausibly explain this community-wide reduction in the MI rate. And the only major MI risk factor that declined concurrently was the prevalence of smoking; rates of hypertension and hypercholesterolemia remained steady, and rates of diabetes and obesity increased, said Dr. Richard D. Hurt of the Nicotine Dependence Center and the department of internal medicine at the Mayo Clinic in Rochester, Minn., and his associates.


Several studies have shown that smoke-free laws lead to a reduction in myocardial infarctions.


"We believe that secondhand smoke should be considered a major risk factor for MI, joining family history, hypertension, hyperlipidemia, diabetes mellitus, and low physical activity. Hence, all clinicians should ascertain secondhand smoke exposure and promote the elimination of secondhand smoke exposure as part of their lifestyle recommendations," they noted.


"All people should avoid secondhand smoke exposure as much as possible, and those with [coronary heart disease] should have no exposure to secondhand smoke," the investigators added.


Several studies have documented declines in hospital admissions for MI after the implementation of smoke-free laws, and the Institute of Medicine has concluded that there is a causal relationship between smoking bans and reductions in acute coronary events. To more closely examine the magnitude of that risk reduction, Dr. Hurt and his colleagues analyzed data from the Rochester Epidemiology Project, in which all cases of MI and sudden cardiac death in a well-defined community were validated using rigorous epidemiologic criteria. This project "has a long track record (more than 50 years) of robust epidemiologic studies," they said.


In Olmsted County, restaurants were required to be smoke free as of Jan. 1, 2002; bars and workplaces were required to follow suit on Oct. 1, 2007. The researchers examined rates of MI and sudden cardiac death during the 18 months before and the 18 months following implementation of each ordinance.


During the entire study period, there were 717 incident MIs and 514 cases of sudden cardiac death.


The age- and sex-adjusted rate of MI dropped from 150.8/100,000 people before the laws were implemented to 100.7/100,000 afterward – a 34% decline, the investigators said (Arch. Intern. Med. 2012 [doi:10.1001/2013.jamainternmed.46]).


Similarly, there was a 17% decline in the incidence of sudden cardiac death during this period, which indicates a trend but does not constitute a statistically significant reduction.


Smoke-free legislation is effective not only because it decreases the amount of secondhand smoke to which nonsmokers are exposed, but also because it reduces the intensity of smoking among smokers, increases quit rates, and reduces the rate of taking up smoking in the first place, Dr. Hurt and his associates said.


Other research has demonstrated that as little as 30 minutes of exposure to secondhand smoke causes an abrupt and dramatic decrease in coronary artery flow velocity reserves and vascular injury that inhibits endothelial function. Exposure also has been associated with low HDL cholesterol levels, increased markers of inflammation, increased serum levels of fibrinogen and homocysteine, decreased antioxidant levels, and increased insulin resistance, they wrote.


Taken together, these findings indicate that physicians should "become advocates for effective tobacco control policies, such as increased taxes, graphic labeling, smoke-free workplaces, and marketing and advertising restrictions," the researchers said.


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