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Meta-Analysis
. 2019 Sep 18;19(1):1269.
doi: 10.1186/s12889-019-7408-7.

The effect of smoke-free legislation on the mortality rate of acute myocardial infarction: a meta-analysis

Min Gao  1 , Yanyu Li  2 , Fugang Wang  3 , Shengfa Zhang  1 , Zhiyong Qu  1 , Xia Wan  4 , Xiaohua Wang  1 , Jie Yang  5 , Donghua Tian  1 , Weijun Zhang  6
Affiliations
Meta-Analysis

The effect of smoke-free legislation on the mortality rate of acute myocardial infarction: a meta-analysis

Min Gao et al. BMC Public Health. .

Abstract

Background: Several studies have demonstrated that smoke-free legislation is associated with a reduced risk of mortality from acute myocardial infarction (AMI). This study aimed to examine and quantify the potential effect of smoke-free legislation on AMI mortality rate in different countries.

Methods: Studies were identified using a systematic search of the scientific literature from electronic databases, including PubMed, Web of Science, ScienceDirect, Embase, Google Scholar, and China National Knowledge Infrastructure (CNKI), from their inception through September 30, 2017. A random effects model was employed to estimate the overall effects of smoke-free legislation on the AMI mortality rate. Subgroup analysis was performed to explore the possible causes of heterogeneity in risk estimates based on sex and age. The results of meta-analysis after excluding the studies with a high risk of bias were reported in this study.

Results: A total of 10 eligible studies with 16 estimates of effect size were included in this meta-analysis. Significant heterogeneity in the risk estimates was identified (overall I2 = 94.6%, p < 0.001). Therefore, a random effects model was utilized to estimate the overall effect of smoke-free legislation. There was an 8% decline in AMI mortality after introducing smoke-free legislation (RR = 0.92, 95% confidence interval (CI): 0.90-0.94). The results of subgroup analyses showed that smoke-free legislation was significantly associated with lower rates of mortality for the following 5 diagnostic subgroups: smoke-free in workplaces, restaurants and bars (RR = 0.92, 95% CI: 0.90-0.95), smaller sample size (RR = 0.92, 95% CI: 0.89-0.95), study location in Europe (RR = 0.90, 95% CI: 0.85-0.94), regional study area (RR = 0.92, 95% CI: 0.89-0.94), and no previous local smoke-free legislation (RR = 0.91, 95% CI: 0.90-0.93). However, there was not much difference in AMI mortality rates after the legislation between the longer (RR = 0.92, 95% CI: 0.86-0.98) and shorter follow-up duration subgroups (RR = 0.92, 95% CI: 0.89-0.94).

Conclusion: Smoke-free legislation could significantly reduce the AMI mortality rate by 8%. The reduction in the AMI mortality rate was more significant in studies with more comprehensive laws, without prior smoke-free bans, with a smaller sample size, at the regional level, and with a location in Europe.

Keywords: Acute myocardial infarction (AMI); Meta-analysis; Smoke-free legislation; Systematic review.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA chart for study identification
Fig. 2
Fig. 2
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality
Fig. 3
Fig. 3
Funnel plot to illustrate possible publication bias
Fig. 4
Fig. 4
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by post-ban duration
Fig. 5
Fig. 5
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by comprehensiveness of a law
Fig. 6
Fig. 6
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by AMI death cases
Fig. 7
Fig. 7
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by study location
Fig. 8
Fig. 8
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by study classification
Fig. 9
Fig. 9
Forest plot of random effects meta-analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by previous ban in place. Note: studies without prior smoke-related bans were not included
Fig. 10
Fig. 10
Forest plot of sensitivity analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by gender
Fig. 11
Fig. 11
Forest plot of sensitivity analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified by age
Fig. 12
Fig. 12
Forest plot of sensitivity analysis of studies examining the effect of smoke-free legislation on AMI mortality stratified after excluding studies with high risk bias
See this image and copyright information in PMC

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