Massachusetts Chapter of the American College of Surgeons

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Association of State Tobacco Control Policies with Active Smoking at the Time of Intervention for Intermittent Claudication
Scott R. Levin, M.D., M.Sc.1, Summer S. Hawkins, Ph.D., M.S.2, Alik Farber, M.D., M.B.A.1, Philip P. Goodney, M.D., M.S.3, Nicholas H. Osborne, M.D., M.S.4, Tze-Woei Tan, M.D.5, Mahmoud B. Malas, M.D., M.H.S.6, Virendra I. Patel, M.D., M.P.H.7, Jeffrey J. Siracuse, M.D., M.B.A.1
1Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA 2Boston College School of Social Work, Chestnut Hill, MA 3Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, NH 4Division of Vascular and Endovascular Surgery, University of Michigan Medical Center, Ann Arbor, MI 5Division of Vascular and Endovascular Surgery, University of Arizona Medical Center, Tucson, AZ 6Division of Vascular and Endovascular Surgery, University of California San Diego Medical Center, La Jolla, CA 7Division of Vascular Surgery and Endovascular Interventions, New York Presbyterian-Columbia University Irving Medical Center, New York, NY

Background: Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies reduce smoking in the general U.S. population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC. Methods: We queried the Vascular Quality Initiative database for peripheral endovascular interventions and infrainguinal/suprainguinal bypasses for IC. We implemented difference-in-differences analysis to isolate changes in active smoking due to cigarette taxes and smoke-free workplace legislation implementation. The models controlled for age, gender, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year.
Results: Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011-2019. Across the study, active smoking at the time of intervention decreased from 48% to 40%. Every .00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% CI -10 to -1 percentage points, P=.02), representing an 11% reduction relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and Medicare recipients. The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence.
Conclusion: Cigarette tax increases are an effective strategy to reduce active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.


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