Longitudinal associations of smoke-free policies and incident cardiovascular disease: CARDIA study

Stephanie L. Mayne, Rachel Widome, Allison J. Carroll, Pamela J. Schreiner, Penny Gordon-Larsen, David R. Jacobs, Kiarri N. Kershaw

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


BACKGROUND: Smoke-free legislation has been associated with lower rates of cardiovascular disease hospital admissions in ecological studies. However, prior studies lacked detailed information on individuallevel factors (eg, sociodemographic and clinical characteristics) that could potentially confound associations. Our objective was to estimate associations of smoke-free policies with incident cardiovascular disease in a longitudinal cohort after controlling for sociodemographics, cardiovascular disease risk factors, and policy covariates. METHODS: Longitudinal data from 3783 black and white adults in the CARDIA study (Coronary Artery Risk Development in Young Adults; 1995-2015) were linked to state, county, and local 100% smoke-free policies in bars, restaurants, and nonhospitality workplaces by Census tract. Extended Cox regression estimated hazard ratios (HRs) of incident cardiovascular disease associated with time-dependent smoke-free policy exposures. Models were adjusted for sociodemographic characteristics, cardiovascular disease risk factors, state cigarette tax, participantreported presence of a smoking ban at their workplace, field center, and metropolitan statistical area poverty. RESULTS: During a median follow-up of 20 years (68 332 total personyears), 172 participants had an incident cardiovascular disease event (2.5 per 1000 person-years). Over the follow-up period, 80% of participants lived in areas with smoke-free policies in restaurants, 67% in bars, and 65% in nonhospitality workplaces. In fully adjusted models, participants living in an area with a restaurant, bar, or workplace smoke-free policy had a lower risk of incident cardiovascular disease compared with those in areas without smoke-free policies (HR, 0.75, 95% confidence interval, 0.49-1.15; HR, 0.76, 95% confidence interval, 0.47-1.24; HR, 0.54, 95% confidence interval, 0.34-0.86, respectively; HR, 0.58, 95% confidence interval, 0.33-1.00 for living in an area with all 3 types of policies compared with none). The estimated preventive fraction was 25% for restaurant policies, 24% for bar policies, and 46% for workplace policies. CONCLUSIONS: Consistent with prior ecological studies, these individualbased data add to the evidence that 100% smoke-free policies are associated with lower risk of cardiovascular disease among middle-aged adults.

Original languageEnglish (US)
Pages (from-to)557-566
Number of pages10
Issue number6
StatePublished - 2018

Bibliographical note

Funding Information:
CARDIA is conducted and supported by the National Heart, Lung, and Blood Institute in collaboration with the University of Alabama at Birmingham (HH-SN268201300025C and HHSN268201300026C), Northwestern University (HH-SN268201300027C), University of Minnesota (HHSN268201300028C), Kaiser Foundation Research Institute (HHSN268201300029C), and Johns Hopkins University School of Medicine (HHSN268200900041C). CARDIA is also partially supported by the Intramural Research Program of the National Institute on Aging and an intra-agency agreement between the National Institute on Aging and National Heart, Lung, and Blood Institute (AG0005). Additional support was provided by the National Heart, Lung, and Blood Institute (R01-HL114091). This manuscript has been reviewed by CARDIA for scientific content. Research reported in this publication was also supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award T32HL069771.

Publisher Copyright:
© 2018 American Heart Association, Inc.


  • Epidemiology
  • Health policy
  • Risk factors
  • Smoking
  • cardiovascular diseases


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