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Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence (2010)

Chapter:6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events

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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

6
Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events

In this chapter, the committee discusses key studies, and 11 publications from those studies, of the effects of smoking bans on acute coronary events. The articles reviewed in this chapter address two of the associations that the committee is evaluating:

  • The association between secondhand-smoke exposure and acute coronary events (Questions 2, 3, and 5, see Box 1-1).

  • The association between smoking bans and acute coronary events (Questions 4, 5, 6, 7, and 8, see Box 1-1).

Eleven publications deal with studies that looked at the effects of smoking bans in eight natural experiments: three studies in overlapping regions of Italy (Barone-Adesi et al., 2006; Cesaroni et al., 2008; Vasselli et al., 2008); one study in Pueblo, Colorado, after 18 months of followup (Bartecchi et al., 2006) and after 3 years of followup (CDC, 2009); and one study each in Helena, Montana (Sargent et al., 2004), Monroe County, Indiana (Seo and Torabi, 2007), Bowling Green, Ohio (Khuder et al., 2007), New York state (Juster et al., 2007), Saskatoon, Canada (Lemstra et al., 2008), and Scotland (Pell et al., 2008). The legislation in Bowling Green, Ohio, allowed smoking in some restaurants and bars; it called for a smoking restriction rather than a smoking ban. The studies examined changes in heart-attack rates, or acute myocardial infarctions (acute MIs) after the implementation of the bans (and one restriction) and were not designed to answer questions about the association between exposure to secondhand smoke and cardiovascular disease. Most of the studies did not measure individual exposures

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

to secondhand smoke or the smoking status of individuals; thus, they were designed to evaluate the association between smoking bans and acute MIs, not the effects of secondhand-smoke exposure. The publications on the smoking bans in Monroe County, Indiana, and Scotland, however, contain data on smoking status and results of analyses only in nonsmokers; these two studies were designed to assess the association between secondhand-smoke exposure and acute MIs.

The committee discusses the studies below, including information on the smoking bans and restriction in the different locations, available information on secondhand-smoke exposure, study designs, and study results. Publications that examine the effect of the same smoking ban are discussed together; the most comprehensive or recent publication is discussed first. The different smoking bans are discussed in order by earliest publication date. Details of the smoking bans and restriction in the different regions are presented in Table 6-1; available information on the effect of the bans on potential secondhand smoke exposure—including data on enforcement and compliance, air monitoring, and biomonitoring—is presented in Table 6-2; and details of the study designs and published results are presented in Table 6-3.

HELENA, MONTANA

Smoking Ban and Exposure Information

Helena, Montana, enacted and enforced legislation requiring smoke-free workplaces and public places for the period June 5–December 3, 2002. The legislation banned smoking in restaurants, bars, and other workplaces and protected an estimated population of 28,726 (ANRF, 2009).

One publication examined the relationship between the Helena smoking ban and acute coronary events (Sargent et al., 2004). The committee did not identify any studies reporting air monitoring or biomonitoring for potential secondhand-smoke exposure in Helena before and after the ban compared with during the ban. Regarding compliance, Sargent et al. (2004) state that “the city–county health department reported that all but two businesses complied” with the ordinance, citing a letter to the editor of the Helena Independent Review. The study provided information directly related to the association between smoking bans and acute coronary events.

Published Results on Acute Coronary Events

Sargent et al. (2004) studied the effect of the smoking-ban legislation on hospital admissions for acute MI in Helena, Montana. The study

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

TABLE 6-1 Characteristics of Smoking Bans Assessed in Key Surveillance Studies

Location

Referencesa

Effective Date

Restaurants

Bars

Workplaces

Other

Helena, Montanab

Sargent et al., 2004

6/05/2002

Gaming establishments

Italy

Barone-Adesi, 2006; Cesaroni et al., 2008; Vasselli et al., 2008

1/10/2005

Retail shops, cafés, discotheques

Pueblo, Colorado

Bartecchi et al., 2006; CDC, 2009

7/01/2003

Monroe County, Indiana

Seo and Torabi, 2007

8/01/2003

(effective 1/1/2005)

 

Bowling Green, Ohio

Khuder et al., 2007

03/2002

(except isolated bar, isolated smoking area)

Bars at owner discretion

Bowling alleys at owner discretion

New York statec

Juster et al., 2007

7/24/2003

Saskatoon, Canada

Lemstra et al., 2008

7/01/2004

 

Scotlandd

Pell et al., 2008

03/2006

a Data from cited references unless otherwise stated.

b Information on smoking-ban locations also from helenair.com (http://www.helenair.com/articles/2002/09/25/stories/helena/1a2.txt), accessed July 2009.

c A number of local smoking bans and restrictions were in place in New York state before the implementation of the statewide ban.

d Exceptions included “residential accommodation and designated room in hotels, care homes, hospices, and psychiatric units” (Haw and Gruer, 2007).

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

TABLE 6-2 Potential Secondhand-Smoke Exposure Reductions in Key Publicationsa

Location of Ban (Implementation Date)

Smoking Ban Details

Helena, Montana (June 5, 2002; rescinded December 3, 2002)

No prior ban mentioned

Legislation to require smoke-free workplaces and public places; suspended as a result of litigation after about 6 months

Smoking banned in restaurants, bars, other workplaces

Italy (January 10, 2005)

Ban on smoking in all indoor public places, including offices, retail shops, cafes, bars, restaurants, discotheques in Italy; provision for smoking rooms

Pueblo, Colorado (July 1, 2003)

Ban prohibiting smoking in workplaces, all public buildings (including restaurants, bars, bowling alleys, other business establishments) within city limits

Monroe County, Indiana (August 1, 2003; extended to bars January 1, 2005)

Ban in all restaurants, retail stores, workplaces; extended to previously exempt bars and clubs January 1, 2005

Bowling Green, Ohio (March 2002)

Ban in public places except bars, restaurants with bars if bars are isolated with separate smoking areas; bars, bowling alleys could allow smoking at owners’ discretion

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Information on Decreased Exposure or Compliance

No air monitoring, but key publication (Sargent et al., 2004) refers to newspaper letter to editor that reports that City–County Health Department reported that all but two businesses complied

No information in key publications looking at acute MI (Barone-Adesi et al., 2006; Cesaroni et al., 2008)

Survey indicated that almost 90% of surveyed population (selected locations in Italy) perceived that ban was observed in bars, restaurants; 70% in workplaces (Gallus et al., 2006)

Letter to editor presented data on nicotine vapor phase in pubs, discos in Florence before, after implementation of ban; pre-implementation median, 138.9 μg/m3 (range, 33.0–276.5 μg/m3), postimplementation median, 4.5 μg/m3 (range, 1.7–8.7 μg/m3)—decreased to average of 3.2% of the pre-ban concentrations (Gorini et al., 2005)

Fine, ultrafine particles before and after implementation in 40 establishments in Rome, urinary cotinine in nonsmoking employees (Valente et al., 2007):

Average PM2.5: decreased from 119.3 μg/m3 to 38.2 μg/m3 (p < 0.005), 43.3 μg/m3 (p < 0.01) 2–3 months, 11–12 months after implementation, respectively

Average ultrafine particles: decreased but not to as great an extent—from 76,956 particles/cm3 to 38,079 particles/cm3 (p < 0.0001), 51,692 particles/cm3 (p < 0.01) 2–3 months, 11–12 months after implementation, respectively

Average urinary cotinine: decreased from 17.8 ng/mL (95% CI, 14–21.6 ng/mL) to 5.5 ng/mL (95% CI, 3.8–7.2), 3.7 ng/mL (95% CI, 1.8–5.6 ng/mL) 2–3 months, 11–12 months after implementation, respectively

No information on decreased concentrations of SHS components, but enforcement officials strongly supported ban with strict fines and ban was implemented after vote indicating public support for it (Bartecchi et al., 2006; CDC, 2009)

No information on decreased concentrations of SHS components or compliance (Seo and Torabi, 2007)

No information on concentrations of SHS components or compliance provided in key health publication (Khuder et al., 2007)

Concentrations of SHS-related compounds (including nicotine, 3-ethenylpyridine, total RSP, RSP based on Solanesol, UVPM, FPM) in four restaurants, one smoke-free and one smoking (that is, with bar) each in Toledo, Bowling Green, Ohio; data from previous study were compared with data from average concentrations in two cities combined; analyses indicated that concentrations of SHS-related contaminants did not change after smoking restrictions, but concentrations were lower in nonsmoking restaurants than restaurants that allow smoking in separate areas (Akbar-Khanzadeh et al., 2004)

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Location of Ban (Implementation Date)

Smoking Ban Details

New York state (July 24, 2003)

New York’s Clean Indoor Air Act is 100% statewide ban on smoking in all workplaces, including restaurants, bars, gaming establishments, with limited exceptions

Statewide smoking restrictions (limiting or prohibiting smoking in some public places, such as schools, hospitals, public buildings, retail stores) had been implemented in 1989

Previously, smoking bans of various levels implemented at city or county level in some parts of state, including ban in workplaces—such as restaurants, bars—in New York City, several other large jurisdictions

State law does not pre-empt passage of local laws

Saskatoon, Canada (July 1, 2004)

Smoking ban in city of Saskatoon prohibiting smoking in any enclosed public space open to public or to which public is customarily admitted or invited; smoking also prohibited in outdoor seating areas for restaurants, licensed premises

Previously, smoking prohibited in government buildings

As of January 1, 2005, 100% smoke-free law in all public places, workplaces, including restaurants, bars, bingo halls, bowling alleys, casinos in Saskatchewan; local municipalities have right to enact smoke-free air regulations

Scotland (March 2006)

Smoking prohibited in all enclosed public places, workplaces throughout Scotland, including bars, pubs, restaurants, cafes; exceptions included residential accommodations, designated rooms in hotels, care homes, hospices, psychiatric units

Abbreviations: CI, confidence interval; FPM, fluorescent particulate matter; MI, myocardial infarction; NYATS, New York Adult Tobacco Survey; PM, particulate matter; RSP, respirable suspended particulate matter; SHS, secondhand smoke; UVPM, respirable suspended ultraviolet particulate matter.

a This table contains information on the concentration of airborne tracers or biomarkers of secondhand smoke in locations of key surveillance studies. The locations are presented in the order they are presented in the text.

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Information on Decreased Exposure or Compliance

No information in key study (Juster et al., 2007), but authors cite NYATS study showing decrease in salivary cotinine from 0.078 ng/mL (range, 0.054–0.111 ng/mL) to 0.041 ng/mL (range, 0.036–0.047 ng/mL) in sample of New York state adults after implementation of ban (CDC, 2007)

NYATS (CDC, 2007) also asked about exposures to SHS; number of respondents reporting exposure to SHS in restaurants, bars decreased, but not significantly in workplaces, after implementation of ban:

In Restaurants: from 19.8% (95% CI, 15.6–24.1%) reporting exposure to 3.1% (95% CI, 2.0–4.2%) 9–10 months after ban

In Bars: from 52.4% (95% CI, 41.5–63.4%) reporting exposure to 13.4% (95% CI, 9.5–17.3%) 10 months after ban

In Workplaces: from 13.6% (95% CI, 8.1–19.1%) reporting exposure to 7.6% (95% CI, 5.1–10.2%) 9–10 months after ban

Hospitality venues in western New York before, after 2003 ban: average PM2.5 concentration decreased from 324 μg/m3 before implementation of ban to 25 μg/m3 after (p < 0.001) (CDC, 2004)

Juster et al. (2007) cite report by Research Triangle Institute, International (RTI International, 2004) that showed that 93% of restaurants, bars, bowling facilities were in compliance in year after implementation

Business compliance with ban measured by reviewing warnings, tickets issued by public-health inspectors to eligible businesses; of 924 eligible establishments, 914 were inspected within first 6 months of ban; of 914, only 13 had to be issued noncompliance warning (for not posting signs or not removing ashtrays); one ticket was issued on reinspection (Lemstra et al., 2008)

Self-reported survey provided information about exposure to SHS; number of people who had never smoked reporting no exposure to smoke increased (from 57 to 78%; p < 0.001); individual serum cotinine measurements taken; geometric mean in never smokers decreased from 0.68 to 0.56 ng/mL (p < 0.001) after legislation enacted; similar data seen in former smokers (Pell et al., 2008)

Before ban, PM2.5 concentrations ranged from 8 to 902 μg/m3 (average, 246 μg/m3); after implementation of ban, concentrations ranged from 6 to 104 μg/m3 (average, 20 μg/m3) (Semple et al., 2007a)

In nonsmokers, geometric mean cotinine concentration decreased by more than 39%, from 0.43 to 0.26 ng/mL after implementation of ban (p < 0.001) (Haw and Gruer, 2007)

In nonsmokers, geometric mean salivary cotinine concentration decreased from 2.9 ng/mL before ban to 0.7 ng/mL 2 months after and to 0.4 ng/mL 1 year after in 301 bar workers (Semple et al., 2007b)

Serum cotinine concentrations in bar workers in Dundee and Perth, Scotland, decreased from 5.15 ng/mL before ban to 3.22 ng/mL 1 month after (reduction of 1.93 ng/mL; 95% CI, 1.03–2.83 ng/mL; p < 0.001) and to 2.93 ng/mL 2 months after (reduction of 2.22 ng/mL; 95% CI, 1.34–3.10 ng/mL; p < 0.001) (Menzies et al., 2006)

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

population included consecutive patients admitted to St. Peter’s Community Hospital with a primary or secondary diagnosis of acute MI (International Classification of Diseases, Revision 9 [ICD-9] 410.xx) during the period December 1997–November 2003. Selection of patients to include in the study was based on a review of paper and electronic medical records and billing records for June–November (the months during which the ban was in effect in 2002) of 1998–2003. Data were included if a patient had primary or secondary acute MI, on the basis of the attending physician’s diagnosis of acute MI, the onset of symptoms occurred in the study area, and there was no recent procedure that could have precipitated the acute MI. If a patient had a secondary diagnosis of acute MI, patient information was included only if there was increased troponin I concentration or creatine phosphokinase activity at admission or within 24 h of admission and there was no recent precipitating procedure. The authors compared the number of hospital admissions during the months when the smoking ban was in effect in 2002 with the average number of admissions during the same months in the 4 years before and 1 year after the ban. A total of 304 admissions met the inclusion criteria.

The authors found a statistically significant reduction in the number of hospital admissions during the period when the smoking ban was in effect, from an average of 40 in June–November in the years before and after the ban was in place (1998–2001 and 2003) to a total of 24 admissions in the same months of 2002, when the smoking ban was in effect (16 fewer admissions; 95% confidence interval [CI], 0.3 to 31.7). The authors noted a nonsignificant increase of 5.6 additional events in hospital admissions in the unincorporated area surrounding Helena used as a control during the same study period.

An advantage of the study design is that the suspension of enforcement of the smoking ban allowed a “cross-over comparison” of incidence before, during, and after the ban and the presence of a control community. Study limitations included the small population, the reliance on historical controls, and the lack of direct exposure information or information on individual smoking status. The study did not account for the potential effect of the ban on primary smokers (for example, if smokers quit), so direct conclusions can be drawn only on the effect of the smoking ban and associated activities, not on the effect of secondhand-smoke exposure. The study also lacked controls for other cardiovascular risk factors. With regard to the outcome information, collection of data only from records of those who reached the hospital could miss some fatal cases of acute MI, and the criteria for diagnosing acute MI changed during the study period as the hospital began requiring a troponin I concentration for diagnosis. The authors did, however, conduct a regression analysis to test whether troponin I

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

concentration was an important factor in the analysis and found that it did not affect the study results.

ITALY

Smoking Ban and Exposure Information

On January 10, 2005, Italy implemented a nationwide smoking ban in all indoor public places, including offices, retail shops, cafés, bars, restaurants, and discotheques. Smoking was not banned in private houses or specifically equipped public areas (for example, the law had requirements for exempted areas, including ventilation systems that create negative pressure and a requirement for doors) (Vasselli et al., 2008).

Although no exposure data are available on the specific populations, some general compliance and monitoring data are available from before and after implementation of the ban. Gallus et al. (2006) found that of 3,114 people ages 15 years or older who were surveyed in Italy, almost 90% perceived that the ban was observed in bars, and 70% had that perception for workplaces. As reported by Gorini et al. (2005) in a letter to a journal editor, the median concentration of nicotine in the vapor phase of samples from four pubs and three discotheques in Florence decreased to an average of 3.2% of the pre-ban median: from 138.9 μg/m3 (range, 33.0–276.5 μg/m3) to 4.5 μg/m3 (range, 1.7–8.7 μg/m3). Valente et al. (2007) measured fine and ultrafine particles in 40 establishments in Rome and urinary cotinine in nonsmoking employees of the establishments before and after implementation of the ban. The average concentration of PM2.5 particles (particles smaller than 2.5 μm in aerodynamic diameter) decreased from 119.3 μg/m3 before the ban to 38.2 μg/m3 (p < 0.005) 2–3 months after implementation and to 43.3 μg/m3 (p < 0.01) 11–12 months after implementation. The average concentration of ultrafine particles also decreased but to a smaller extent, from 76,956 particles/cm3 before the ban to 38,079 particles/cm3 (p < 0.0001) and 51,692 particles/cm3 (p < 0.01) 2–3 months and 11–12 months after implementation, respectively. Urinary cotinine in the employees decreased from an average of 17.8 ng/mL (95% CI, 14–21.6 ng/mL) before the ban to 5.5 ng/mL (95% CI, 3.8–7.2 ng/mL) and 3.7 ng/mL (95% CI, 1.8–5.6 ng/mL) 2–3 months and 11–12 months after implementation, respectively. Those data indicate that the smoking ban resulted in a decrease in exposure to secondhand smoke.

Published Results on Acute Coronary Events

Three publications report on acute coronary events after implementation of the Italian smoking ban (Barone-Adesi et al., 2006; Cesaroni et

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

TABLE 6-3 Summary of Results of Key Publications (Studies Listed by Smoking-Ban Region in Order of Publication)

Publication (Region)

Study Design and Duration

Selection of Patients

Helena, Montana

Sargent et al., 2004 (Helena, Montana)

Retrospective based on hospital records; 6 months of ban, 11 months after ban compared with same months of 5 years before ban

Patients 18 years old and older admitted to St. Peter’s Community Hospital for primary or secondary diagnosis of acute MI (ICD-9 410. xx)

Selection criteria: onset of symptoms in study area, no recent procedure that could have precipitated acute MI, primary diagnosis of acute MI or secondary diagnosis with chemical evidence of acute MI at time of admission (cTn or creatine phosphokinase)

Control population: county residents who lived outside city boundaries

Italy

Vasselli et al., 2008 (four regions in Italy: Piedmont, Friuli–Venezia–Giulia, Latium, Campania)

Retrospective based on hospital discharge registry; study period January 10–March 10, 2001–2005; compared 2 months after ban with same 2 months of 4 years before ban

Patients in public, private hospitals with primary discharge diagnosis of acute MI, 40–64 years old; hospital data from National Hospital Discharge Registry (2001, 2002, 2003), which is based on regional data, or from regional hospital discharge registries for years not previously incorporated into national registry (2004, 2005)

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Results

Statistical Analysis

Comments

Total of 304 cases met selection criteria; 24 cases in Helena during ban; 18 cases outside Helena during ban

Average monthly admissions declined from 40 to 24 (16 fewer admissions; 95% CI, 0.3–31.7) during same months in years before and after implementation of ban

Nonsignificant increase of 5.6 in number of acute MI admissions from outside Helena during same period

Mean comparisons before, after ban implementation, and between areas with Poisson distribution for counts

No information on individual smoking status; no measures of individual SHS exposure

Small population

Advantage of having data before ban, during ban, after rescinding of ban

Criteria for diagnosing acute MI changed during study period

Cases: 2001, 1,309; 2002, 1,408; 2003, 1,511; 2004, 1,589; 2005, 1,488

Total of all four regions: rates increased linearly from 2001 to 2004, decreased by 6.4% from 2004 to 2005

Regional level: rates less linear than total of all four regions; rates increased or unchanged from 2001 to 2004; rates decreased from 2004 to 2005 (significantly in Piedmont, Latium, Campania)

Total of all four regions, observed 2005 versus expected based on linear regression: risk reduction 13.1% (age-standardized risk ratio, 0.86; 95% CI, 0.83–0.92)

Significant decrease from expected numbers in 2005 in men but not women 45–49 years old but not other age ranges, all regions except Friuli–Venezia–Giulia

Comparison of age-standardized rates, subgroup comparisons for sex, age, region separately

No information on individual smoking status; no measures of individual SHS exposure

Limited study duration; looked only at effects 2 months after implementation of; population was less than 30% of Italy

Rates standardized by overall total, age, region, sex

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Publication (Region)

Study Design and Duration

Selection of Patients

Barone-Adesi, 2006 (Piedmont region, northern Italy)

Retrospective based on records from regional hospital discharge registry; 5 pre-ban months studied, ending 6 months before implementation; 6 months after implementation of ban studied, starting at beginning of ban

Hospital admissions with primary diagnosis of acute MI (ICD-9 401), hospital deaths due to acute MI

Cesaroni et al., 2008 (Rome, Italy)

Retrospective based on hospital discharge registry, death registry; January 1, 2000–December 31, 2005; followup just under 12 months after implementation

Cases identified from all hospitalizations of city residents at public, private hospitals in Rome, regional register that tracks all causes of death

Cases defined as principal diagnosis of acute MI (ICD-9-CM 410) or other acute, subacute forms of ischemic heart disease (ICD-9-CM 411), secondary diagnosis of acute MI with principal diagnosis indicating acute MI complications (for example, 427.1, paroxysmal ventricular tachycardia; 427.41, ventricular fibrillation)

Pueblo, Colorado

CDC, 2009 (Pueblo, Colorado)

Retrospective based on hospital admission data; duration 1.5 years before, 1.5 and 3.0 years after implementation of smoke-free ordinance

All patients with primary diagnosis of acute MI (ICD-9 401.xx) admitted to Parkview Medical Center or St. Mary-Corwin Medical Center January 1, 2002–June 30, 2006

Assessed number of fatal acute MIs in residents in Pueblo city limits (based on residential ZIP codes) around time smoke-free ordinance was passed

Control populations in Pueblo County but outside city limits, El Paso County

Analyzed data after implementation of smoking ban (January 2005–June 30, 2006; phase II after implementation) compared with 1.5 years before implementation (January 2002–June 2003), 0–1.5 years after implementation (July 2003–December 2004; phase I after implementation; previously analyzed in Bartecchi et al., 2006)

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Results

Statistical Analysis

Comments

922 cases before implementation of ban; 832 cases after

Comparison of age-standardized incidence rates; subgroup analysis by sex, age; linear dose–response analysis for effects of smoking

No information on individual smoking status; no measures of individual SHS exposure

No data on potential confounders collected

Rates of admission for acute MI decreased in people under 60 years old (RR, 0.89; 95% CI, 0.81–0.98) but not in those over 60 years old; decrease statistically significant in men, women under 60 years old

14,075 acute coronary events documented during study period

Age-standardized rates of annual acute coronary events decreased after implementation of ban in 35- to 64-year-olds (RR, 0.89; 95% CI, 0.85–0.93), 65- to 74-year-olds (RR, 0.92; 95% CI, 0.88–0.97) but not those over 74 years old

Age-standardized rates; Poisson regression applied to annual data with adjustment for sex, age, SES

No information on individual smoking status; no measures of individual SHS exposure

Potential confounders—such as particulate-matter air pollution, temperature, influenza epidemics, time trends, total hospitalization rates—taken into account

Data on cigarette sales in Rome, population smoking habits in Rome region included

Total of 1,559 cases for phase II: 237 in Pueblo city; 92 in Pueblo County (not in city); 1,230 in El Paso County

City of Pueblo: phase II relative to phase I, RR = 0.81 (95% CI, 0.67–0.96); phase II relative to pre-implementation, 0.59 (95% CI, 0.49–0.70)

Pueblo County: phase II relative to phase I, 1.21 (95% CI, 0.80–1.62); phase II relative to pre-implementation, 1.03 (95% CI, 0.68–1.39)

El Paso County: phase II relative to phase I, 0.99 (95% CI, 0.91–1.08); phase II relative to pre-implementation, 0.95 (95% CI, 0.87–1.03)

Chi-square test to compare rates over time

No information on individual smoking status; no measures of individual SHS exposure

Excluded secondary acute MI diagnoses, all acute MI patients transferred from outside facilities, residents with ZIP codes outside Pueblo County

Adjustment of acute MI rates for season, air pollution—but not directly for inclusion of control community (El Paso County), where air-pollution fluctuations are similar—reduced possibility of variability

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Publication (Region)

Study Design and Duration

Selection of Patients

Bartecchi et al., 2006 (Pueblo, Colorado)

Same as CDC (2009) but only after 1.5 years of followup

Same as CDC (2009) but data collected only through December 2004

Monroe County, Indiana

Seo and Torabi, 2007 (Monroe County, Indiana)

Retrospective based on records; study period August 1, 2001–May 31, 2005, that is, 22 months before enforcement and 22 months after

Primary, secondary diagnosis of acute MI (ICD-9-CM 410.xx) admitted to Bloomington Hospital, Ball Memorial Hospital; no past cardiac procedure or comorbidity that could have precipitated acute MI; chemical evidence of event onset of symptoms in study location

Delaware County selected as control county on basis of similar urban population rates, income, cancer mortality

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Results

Statistical Analysis

Comments

Total of 2,794 patients: 690 in Pueblo city; 165 in Pueblo County (not in city); 1,939 in El Paso County

Acute MI hospitalizations decreased in Pueblo city residents after ordinance (RR, 0.73; 95% CI, 0.63–0.85)

No significant changes in acute MI rates in Pueblo County residents (RR, 0.85; 95% CI, 0.63–1.16), El Paso County residents (RR, 0.97; 95% CI, 0.89–1.06)

Acute MI rate decrease in Pueblo residents compared with El Paso County (p < 0.001)

Chi-square test to compare sex differences across locale; ANOVA to test mean age equality; Tukey multiple-comparison procedure to compare age pairs; Poisson regression on monthly data to model seasonality with two harmonics

In addition to comments on CDC (2009), only 1.5 years of follow-up

Cases: Monroe County, 22; Delaware County, 34

Monroe County: significant decrease in number of nonsmoking-patient admissions for acute MI (admissions decreased from 17 to 5; 95% CI, 2.81–21.19) from period 1 (August 2001–May 2003, before smoking ban) to period 2 (August 2003–May 2005, smoking ban in effect)

Delaware County (control):

nonsignificant decrease in number of nonsmoking-patient admissions (admissions decreased from 18 to 16; 95% CI, decrease of 9.43–13.43) from period 1 to period 2

Significant difference in nonsmoking-patient admissions between two counties in period 2 (5 Monroe County, 16 Delaware County)

Comparison of counts before, after with Poisson regression

Included only nonsmoking patients; smoking status based on patient charts

No measures of individual SHS exposure

Admission charts were reviewed

Data collected on admission date, smoking status, comorbidity, whether past cardiac procedure could have precipitated acute MI, laboratory values, including troponin I concentrations or creatine phophokinase

Excluded people with history of past cardiac events, hypertension, high cholesterol

No information on age

Excluded 2 months from analysis (June 1, 2003–July 31, 2003) to control for season variation

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Publication (Region)

Study Design and Duration

Selection of Patients

Bowling Green, Ohio

Khuder et al., 2007 (Bowling Green, Ohio)

Retrospective based on hospital discharge records in 1999–2005; assessment from October 2002 to 39 months after ordinance went into effect (ordinance in effect in March 2002)

Admission rates for adults (over 18 years old) with primary diagnosis of coronary events (angina, heart failure, atherosclerosis, MI; ICD-9 410–413, 428); residents of Bowling Green, Ohio, and control city (Kent, Ohio)

2000 census population data used as denominator for rates

New York state

Juster et al., 2007 (New York state)

Retrospective based on hospital discharge records; estimates of admissions calculated statistically; data for January 1995–December 2004 (17 months after statewide ban)

Monthly hospital admissions associated with acute MI (ICD-9-CM 410.0–410.99), stroke (ICD-9-CM 430.00–438.99), persons 35 years old and older

Data extracted for all 62 New York counties

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Results

Statistical Analysis

Comments

3,235 acute coronary syndrome cases before ban; 2,684 after ban implementation

36/10,000 people in 2002, 22/10,000 in 2003, 19/10,000 in first half of 2005

39% decrease (95% CI, 33–45%) in 2002

47% decrease (95% CI, 41–55%) in data after 3 years

Significant decrease in trend (measure of change in series level, ω = −1.69; p = 0.04) in monthly series rates 7 months after full implementation and enforcement (November 2002)

Significant trend not seen in Kent

No decrease seen after 6 months

Age-standardized rates; rate comparison with Mantel–Haenszel chi-square tests; monthly data analyzed with ARIMA time-series analysis, change in level at 6 months after implementation

No significant difference in non-smoking-related admissions in either Bowling Green or Kent

No information on individual smoking status; no measures of individual SHS exposure

Annual averages over 10-year period: 46,000 admissions for acute MI, more than 58,000 admissions for stroke

No change in trend line for hospital admissions for acute MI with implementation of 2003 statewide ban

Estimated 3,813 (8%) fewer hospital admissions for acute MI than would be expected in absence of state smoking ban in 2004

Estimated 19% decline in admissions would have been associated with the comprehensive state law if large number of jurisdictions in state had not already had ordinances

Multiple linear regression for interrupted time series to analyze monthly age-, sex-adjusted county rates

No information on individual smoking status; no measures of individual SHS exposure

Excluded restrictions applied only to municipal buildings

New York County smoking restrictions categorized as comprehensive or moderatea

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Publication (Region)

Study Design and Duration

Selection of Patients

Saskatoon, Canada

Lemstra et al., 2008 (Saskatoon, Canada)

Retrospective based on hospital discharge records; compared first full year of public smoking ban (July 1, 2004–June 30, 2005) compared with previous 4 years (July 1, 2000–June 30, 2004)

Diagnosis of acute MI (ICD-410.xx); age-standardized incidence of acute MI per 100,000 people

Scotland

Pell et al., 2008 (Scotland)

Prospective; 10 months before (June 2005–March 2006), 10 months after (June 2006–March 2007) implementation of smoking ban

All patients admitted to nine hospitals with acute coronary syndrome (defined as detectable cTn after emergency admission for chest pain)

Abbreviations: CI, confidence interval; cTn, cardiac troponin; ICD-9-CM, International Classification of Diseases, Revision 9, Clinical Modification; MI, myocardial infarction; RR, relative risk; SES, socioeconomic status; SHS, secondhand smoke.

dal., 2008; Vasselli et al., 2008) and provide information directly related to the association between smoking bans and acute coronary events. All three publications include data on acute coronary events through 2005, but Vasselli et al. (2008) analyzed data from the largest number of regions, which included the regions analyzed in the other two publications.

Vasselli et al. (2008) compared admissions for acute MI in the 2 months (January 10–March 10, 2005) after the January 10, 2005, implementation of the ban on smoking in all indoor public places in Italy with admissions in the same 2-month periods in 2001–2004. Data were collected from the National Hospital Discharge Registry and from the regional hospital discharge registries in four Italian regions that make up 28% of the Italian population, which had data available on the relevant times and were willing

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Results

Statistical Analysis

Comments

1,689 cases of acute MI observed during 5-year study period

Age-standardized incidence of acute MI decreased from 176.1 cases/100,000 to 152.4 cases/100,000 after implementation of public smoking ban (13%; rate ratio, 0.87; 95% CI, 0.84–0.90)

Smoking prevalence decreased from 24.1 to 18.2% in Saskatoon from 2003 to 2005 (unchanged in Saskatchewan at 23.8%; smaller reduction in Canada overall from 22.9 to 21.3%)

Comparison of age-standardized incidence rates

No information on individual smoking status; no measures of individual SHS exposure

No control city; therefore, no comparative time trends assessed

Random telephone survey of 1,255 Saskatoon adult residents conducted 1 year after implementation of ban to collect information on smoking behavior and attitudes toward ban

Admissions for acute coronary syndrome decreased by 17% (95% CI, 16–18%) after implementation of ban; greatest reduction in admissions observed in nonsmokers

Compared binary, ordinal data with chi-square test; subgroup analyses by sex, age; two-sample t-test, log transformation on cotinine concentrations

Detailed information on smoking, exposure to SHS from questionnaires, biochemical assays

Self-reported smoking status

Serum cotinine concentrations used to categorize smoking status, SHS exposure

a Comprehensive laws prohibit smoking in all worksites, including restaurants, bars, and hospitality venues with few or no exemptions; moderate laws restrict smoking in most work-sites but provide little or no protection in hospitality venues.

to participate in the study: Piedmont, Friuli–Venezia–Giulia, Latium, and Campania.

The study population included residents of the four areas who were 40–64 years old and who had been admitted to a hospital in the regions during the study months for acute events that had a primary discharge diagnosis of acute MI (ICD-9 410.xx). A total of 7,305 cases of acute MI were reported in the publication over the 4-year period. Only new events were considered; specifically, events that occurred less than 28 days after a first hospital admission for acute MI were excluded. The authors stated, “The mean age was chosen because the risk of myocardial infarction is high among persons over 64 years and low among those under 40 years. The 40–64 year category represents a group with a higher probability of being employed and in good health, and thereby having a higher attribut-

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

able risk of acute MI due to passive smoke in the workplace and thus more sensitive to acute changes in exposure occurring as a result of the new law.” Admission rates and age-standardized admission rates were calculated for the same period before and after implementation of the ban by using the European standard population as the reference population. Linear regression was used to estimate expected values and rates of admission; differences between expected and observed values were analyzed overall and by sex, age, and region.

From January 10 to March 10, 2001, 2002, 2003, 2004, and 2005, totals of 1,309, 1,408, 1,511, 1,589, and 1,488 acute coronary events, respectively, occurred in the four Italian regions. The corresponding age-standardized rates are 24.7, 26.4, 28.2, 29.5, and 27.2 per 100,000 personyears, respectively. The data suggest that the absolute numbers and rates of events increased each year from 2001 through 2004 and then decreased in 2005, although the rate was higher in 2005 than 2001 and 2002. The trend of an increase from 2001 through 2004 and a decrease in 2005 is seen in men but not in women and in people 45–49 and 50–54 years old but not at other ages. The linear trend from 2001 to 2004 was not apparent in the four individual regions.

The total observed number of cases in the 2 months of 2005 (1,488) was lower than the number expected from linear regression (1,690), and this indicates a significant 13.1% decrease in the rate (standardized incidence ratio [SIR], 0.86; 95% CI, 0.83–0.92). When the data were analyzed by sex, the decrease was statistically significant in men (SIR, 0.85; 95% CI, 0.81–0.91) but not in women (SIR, 0.98; 95% CI, 0.87–1.11). With respect to age ranges, statistically significant decreases were seen in 45- to 49-year-olds (SIR, 0.77; 95% CI, 0.68–0.89) and 50- to 54-year-olds (SIR, 0.74; 95% CI, 0.67–0.85) but not in 40- to 44-year-olds (SIR, 0.98; 95% CI, 0.82–1.19), 55- to 59-year-olds (SIR, 0.92; 95% CI, 0.84–1.02), or 60- to 64-year-olds (SIR, 0.99; 95% CI, 0.88–1.06). Statistically significant decreases from the expected rate occurred in Piedmont (SIR, 0.79; 95% CI, 0.72–0.90), Latium (SIR, 0.89; 95% CI, 0.82–0.99), and Campania (SIR, 0.89; 95% CI, 0.83–0.98) but not in Friuli–Venezia–Giulia (SIR, 0.92; 95% CI, 0.78–1.13).

Limitations of the analysis include the lack of a control population (the ban was nationwide) and the lack of information on individual smoking status. Individual exposures to secondhand smoke were also not recorded. The study also has many of the other potential limitations of an observational pre–post study based on claims information as outlined for the Helena, Montana, study.

Barone-Adesi et al. (2006) published the first report on the effect of the Italian smoking ban on acute coronary events, looking at data from the Piedmont region. The Piedmont region is one of the regions reported

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

on by Vasselli et al. The authors used hospital admission records from the regional hospital discharge registry for Piedmont residents who had a primary discharge diagnosis code of acute MI (International Classification of Diseases, Revision 9, Clinical Modification [ICD-9-CM] 410) during January 2001 and June 2005 and hospital deaths due to acute MI, and they calculated age-standardized rates of admission. A total of 17,153 cases were included in the report.

The authors found that age-standardized rates of acute MI admission decreased significantly in people less than 60 years old after the smoking ban took effect (rate ratio, 0.89; 95% CI, 0.81–0.98); decreases were found in both women (rate ratio, 0.75; 95% CI, 0.58–0.96) and men (rate ratio, 0.91; 95% CI, 0.82–1.01). The data indicate that much of the overall result was driven by changes in women. In response to questions from the committee, the authors indicated (personal communication, F. Barone-Adesi, University of Turin, January 23, 2009) that an age cut point of 60 years was chosen in advance to obtain enough cases of acute MI in both age categories (under 60 years of age and 60 years of age or older) to allow analysis. In the publication, the authors hypothesize that the differences were seen because there was a “greater effect of the ban on the habits of younger persons.” Other studies did not stratify results the same way, which increases the differences across studies, but many of the studies were being conducted at the same time it would not always have been possible for researchers to design their study on the basis of the other studies. They also provided additional data analyses in which the age of 70 years was used as a cut point and that showed a similar modification of the effect by age. No decrease was seen before the ban (October–December 2004 versus October–December 2003) or in people at least 60 years old; the rate ratio in older women after implementation of the ban was 1.05 (95% CI, 0.97–1.14), in older men after implementation was 1.03 (95% CI, 0.96–1.11), and in older women and men combined after implementation was 1.05 (95% CI, 1.00–1.11).

Study limitations include those previously outlined in connection with the larger Vasselli et al. (2008) study.

Cesaroni et al. (2008) analyzed data on the frequency of acute coronary events in Rome after the introduction of the Italian ban on smoking in all indoor public places. Rome is part of the Latium region of Italy that was included by Vasselli et al. (2008). The authors used two population registers—the hospital discharge database and the regional mortality register—to obtain information on the number of acute coronary events in residents of Rome in 2000–2005. All discharges that had a principal diagnosis of acute MI (ICD-9-CM 410) or a secondary diagnosis of acute MI when the principal diagnosis indicated acute MI complications (for example, ICD-9-CM 427.1 for paroxysmal ventricular tachycardia, ICD-9-CM 427.41 for ventricular fibrillation, ICD-9-CM 427.42 for ventricular

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

flutter, and ICD-9-CM 427.5 for cardiac arrest) were defined as hospitalizations for acute coronary events. A total of 40,314 cases in 2000–2005 were analyzed for the publication. The period of followup after implementation of the ban was just under 12 months. Any event that occurred within 28 days of an event in the same person was not counted (was not considered to be an independent event). To try to control for confounding, the authors collected daily mean data on PM10 particles from four fixed monitors and data on cigarette sales in Rome and smoking habits based on health surveys provided by the National Institute of Statistics. The authors computed age-standardized annual rates of acute coronary events by using a Poisson regression analysis and adjusting for calendar time.

A statistically significant decrease in acute coronary events occurred after implementation of the smoking ban in 35- to 64-year-olds (relative risk [RR], 0.89; 95% CI, 0.85–0.93) and in 65- to 74-year-olds (RR, 0.92; 95% CI, 0.88–0.97). There was no such association in those over 74 years old. Data on smokers’ deaths from coronary heart disease show RRs decreasing with age (Burns, 2003). If the oldest group and the younger groups differ in lifestyle (for example, time spent in restaurants and in bars), that could influence the effect of the ban on the different age groups. It should be noted, however, that there appeared to be a decline in heart-attack rates even before the ban. The authors conducted an analysis that was adjusted for that long-term trend, and the decrease was significant even after that adjustment. The effect was greatest in lower socioeconomic categories and was statistically significant in men but not in women; however, analysis of the interactions with socioeconomic status and sex were not statistically significant. Both smoking prevalence and cigarette sales decreased during the study period.

Cesaroni et al. (2008) assessed outcomes in a period of 12 months, longer than the 2 months of Vasselli et al. (2008) and the 6 months of Barone-Adesi et al. (2006), but did not have as broad a population base (only Rome) as the analysis of data on four Italian regions by Vasselli et al. (2008). Although there was no concurrent control population, it controlled for potential confounders that included particulate matter (only PM10), an influenza epidemic, holidays, and air temperature. There was no information on individual smoking status, but the authors did use information on smoking prevalence in Rome and the RRs posed by active smoking to estimate the extent of the decrease in acute coronary events that might be attributable to smoking cessation; they estimated that less than 2% of the decrease was attributable to smoking cessation. The study included fatal and nonfatal acute MIs and a large population. The authors explained the rationale for including both primary and secondary events. Although it is good that troponin test results were used in diagnosing acute MIs, use of this method alone could result in misdiagnosing as acute MIs some

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

events that are not acute MIs inasmuch as troponin can also be increased in some systemic diseases and in nonthrombotic cardiac disease (Inbar and Shoenfeld, 2009) and small changes can occur in clinically stable populations (Eggers et al., 2009).

PUEBLO, COLORADO

Smoking Ban and Exposure Information

The city of Pueblo, Colorado, implemented a smoking ordinance, effective July 1, 2003, that prohibited smoking in workplaces and all public buildings (including restaurants, bars, bowling alleys, and other business establishments). The committee did not identify any air or biomonitoring studies in Pueblo. The ordinance was implemented after a vote that indicated public support for the ban, and Bartecchi et al. (2006) reported that “Pueblo law enforcement officials strongly supported the ordinance and imposed significant fines on violators and on facility owners who allowed smoking on their premises.”

Two publications report on acute coronary events after implementation of the smoking ban: Bartecchi et al. (2006) and Centers for Disease Control and Prevention (CDC, 2009). Both provide information directly related to the association between smoking bans and acute coronary events. The CDC study included 3 years of followup after implementation of the ban; the earlier publication reported data after 1.5 years of followup.

Published Results on Acute Coronary Events

CDC (2009) studied the effect of the citywide smoking ordinance on the incidence of acute MI–related hospitalizations in the city. The authors assessed patients who had a primary diagnosis of acute MI (ICD-9 410.xx) and were admitted to Parkview Medical Center or St. Mary-Corwin Medical Center in 2002–2004; cases were not confirmed clinically. Cases in three periods were assessed: the 1.5 years before implementation of the ban on July 1, 2003 (January 2002–June 2003); the 1.5 years after July 1, 2003 (July 2003–December 2004; phase I post-implementation data previously published in Bartecchi et al. [2006]; and the 1.5 years after that (January 2005–June 30, 2006; phase II post-implementation data). Information on admission date, primary diagnosis, sex, age, ICD code, and hospital name was collected; no information on individual smoking status was available. The authors classified patients in Pueblo County as residing either inside or outside the city limits on the basis of administrative data, including ZIP codes. To allow comparison, the authors also assessed rates of hospitalization for acute MI in a geographically isolated community, El Paso County,

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Colorado. Pueblo County and El Paso County are each served by only two hospitals.

Hospitalizations for acute MI decreased from 257/100,000 person-years in the 1.5 years before implementation to 187/100,000 and 152/100,000 person-years in phase I and phase II, respectively. Those decreases represent an RR for phase I of 0.73 (95% CI, 0.64–0.82) compared with the risk before implementation and RRs in phase II of 0.81 (95% CI, 0.67–0.96) compared with phase I and 0.59 (95% CI, 0.49–0.70) compared with the period before implementation. No significant decreases were seen in Pueblo County outside the Pueblo city limits (RR ranged from 0.85 with a 95% CI of 0.56–1.14 to 1.03 with a 95% CI of 0.68–1.39) or in El Paso County (RR ranged from 0.95 with a 95% CI of 0.87–1.03 to 0.99 with a 95% CI of 0.91–1.08). The authors also obtained data on the numbers of deaths from acute MI in Pueblo from the Health Statistics Section of the Colorado Department of Public Health and Environment. Assuming that all fatal acute MIs occurred in people who did not reach the hospital and adding those numbers to the numbers of cases based on admission data, the authors reported that the phase II RR remained statistically significant both when compared with phase I (RR, 0.82; 95% CI, 0.64–0.97) and when compared with the pre-implementation period (RR, 0.66; 95% CI, 0.55–0.77).

The CDC study (CDC, 2009) adds to the information on Colorado by extending the period looked at after implementation of the smoking ban from that published by Bartecchi et al. (2006). Bartecchi et al. (2006) evaluated acute MI hospitalization rates 1.5 years before and 1.5 years after enforcement of the smoke-free ordinance. They identified a total of 2,794 patients who had a primary diagnosis of acute MI during the period of interest: 690 who resided inside the Pueblo city limits, 165 patients outside the Pueblo city limits but in Pueblo County, and 1,939 in El Paso County. There was a significant difference in sex distribution in the patients in the three locations (p = 0.003): a higher proportion of female acute MI patients (40.9%) within the Pueblo city limits than outside the city limits (33.3%) or in El Paso County (33.7%). The results were similar to those of CDC with minor differences due to record updating. Bartecchi et al. (2006) found a decrease in acute MI hospitalizations in those residing within the Pueblo city limits after enforcement of the smoke-free ordinance, from 257 before the ban to 187 after implementation (RR, 0.73; 95% CI, 0.63–0.85). A significant decrease in acute MI hospitalizations remained after adjustment for season (RR, 0.74; 95% CI, 0.64–0.86). The authors did not find a significant decrease in residents outside the city limits (from 132 to 112; RR, 0.85; 95% CI, 0.63–1.16; adjusted RR, 0.87; 95% CI, 0.64–1.17) or in El Paso County (from 119 to 116;

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

RR, 0.97; 95% CI, 0.89–1.06; adjusted RR, 0.99; 95% CI, 0.90–1.08). There was, however, a significant difference in the reduction in acute MI hospitalization rate between those residing within the Pueblo city limits and those in El Paso County (p < 0.001).

The two studies had the same strengths and limitations. They both had pre-implementation and postimplementation information and a concurrent control group, and the authors adjusted for out-of-hospital deaths, season, and county population. The smoking rate in El Paso County, the concurrent control group, however, increased from 17.4% (95% CI, 14.5–20.2%) to 22.3% (95% CI, 19.3–25.4%), whereas the rate in Pueblo County (including the city of Pueblo) decreased from 25.9% (95% CI, 20.2–31.6%) to 20.6% (95% CI, 15.4–25.8%) (CDC, 2009). The trends in the smoking rates could affect the estimated changes in acute MI in comparisons between the two counties. The authors note that the decrease in Pueblo County was not significant but do not comment on the change in El Paso County. Data on changes in smoking rates in Pueblo city itself, the location of the ordinance, were not available. It is unknown to what extent Pueblo County residents who do not live in Pueblo city work or spend time in Pueblo city. If a substantial number of county residents spend time in the city that could affect comparisons by biasing towards the null. The authors did not confirm the definition of acute MI by verifying an ICD-9 code and did not provide retrospective results from Pueblo for trends in acute MI admissions. The studies lacked information on variant risk factors at the patient level, including changes in smoking status. The authors did not quantify exposure or adjust for air-pollutant concentrations, although they noted that the inclusion of a control county may have accounted for fluctuations in air quality. The studies did not account for confounders that could include prevention activities and pollution reduction in Pueblo or migration. The statistical model that accounted for season demonstrated a poor fit with only 1 degree of freedom.

MONROE COUNTY, INDIANA

Smoking Ban and Exposure Information

Monroe County, Indiana, implemented a ban on smoking in all restaurants, retail stores, and workplaces effective August 1, 2003; the ban was extended to bars on January 1, 2005. One publication examined the relationship between the smoking ban and acute coronary events (Seo and Torabi, 2007). The committee was unable to find any published information on decreased concentrations of secondhand-smoke components or compliance with the Monroe County ban.

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Published Results on Acute Coronary Events

Seo and Torabi (2007) used an ex post facto matched–control-group design to assess the effect of a smoking ban on admissions of nonsmoking patients for acute MI; thus, their study directly addressed the question of the association between secondhand-smoke exposure and acute coronary events. The study population included nonsmoking patients admitted to two Monroe County hospitals—Bloomington Hospital and Ball Memorial Hospital—with a primary or secondary diagnosis of acute MI.1 The authors assessed admission rates during two periods: period 1 consisted of 22 months before enforcement of the original smoking ban in Monroe County (August 2001–May 2003), and period 2 consisted of the 22 months after the beginning of enforcement (August 2003–May 2005). The authors selected Delaware County, Indiana, as the comparison county because it is geographically distant from Monroe County but similar to it in the percentage of the population living in urban areas, demographic profile, median household income, and mortality from heart disease and cancer.

The authors collected patient information from the hospitals, including admission date, smoking status, information on comorbidities, cardiac history, diagnosis, and laboratory values, such as troponin I and creatine phosphokinase concentrations. The criteria for patient selection included “1) a primary or secondary diagnosis of acute MI (ICD-9-CM codes 410.xx); 2) no past cardiac procedure that could have precipitated acute MI; 3) no comorbidity such as hypertension and high cholesterol that could have precipitated acute MI; 4) chemical evidence such as increased troponin I concentrations or creatine phosphokinase activity; and 5) onset of symptoms in the study area.” The committee noted that those exclusions would eliminate detection of any effects that secondhand smoke might have on the population predisposed to an acute MI.

The authors found a significant decline (12 fewer admissions; 95% CI, 2.81–21.19) in admissions of nonsmoking patients for acute MI from period 1 (17 admissions) to period 2 (5 admissions). In contrast, there was a nonsignificant decline (2 fewer admissions; 95% CI, −13.43 to 9.43) in admissions of nonsmoking patients in Delaware County from period 1 (18 admissions) to period 2 (16 admissions). The authors found no significant difference in nonsmoking-patient admissions during period 1 between Monroe County and Delaware County. However, there was a significant

1

The committee contacted a study author for more information on comorbidities. The author stated that cases with comorbidities were excluded to avoid attributing to secondhand-smoke exposure heart attacks that might have had other underlying causes. The authors excluded people who had systolic blood pressure above 140 mmHg and those with total cholesterol above 200 mg/dL (personal communication, Dr. Seo, Indiana University, Bloomington, February 9, 2009).

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

difference in nonsmoking-patient admissions between the counties during period 2 (5 admissions in Monroe County and 16 in Delaware County).

The study’s focus on nonsmokers strengthened its relevance for answering the question of the effect of a decrease in secondhand-smoke exposure, but exclusion of cases with comorbidities could exclude cases in which secondhand smoke triggered an event in a person predisposed to an acute MI, and it greatly reduced the sample size. Smoking status was determined on the basis of admission records, so there might have been misclassification. Most studies, however, including a review and meta-analysis of 26 published studies (Patrick et al., 1994) and more recent studies (Martinez et al., 2004; Studts et al., 2006), have demonstrated minimal or low underreporting of current smoking status, although others report that underreporting of smoking is significant in England and Poland but not in the United States (Lewis et al., 2003; West et al., 2007) or is rare but possibly increasing (Fendrich et al., 2005). A longer period of followup after implementation of the smoking ban would permit a fuller assessment of its impact on acute MI–related hospital admissions. In addition, Teo and Sorabi (2007) showed unusually small numbers of acute MI events in nonsmokers (for example, no admissions for acute MI in nonsmokers in Monroe County since January 1, 2005). With respect to the analysis, the authors compare the difference in acute MIs before and after the ban in Monroe County, and compare the number of acute MIs after the ban in Monroe County to Delaware County (a county with a similar population for which there were no significant differences in acute MIs prior to the ban in Monroe County, that did not implement a smoking ban). Both of those analyses, however, can have problems. Trends over time (for example, if the rate of acute MIs was decreasing prior to the implementation of the smoking ban) could confound the first analysis; differences between the two counties could confound the second analysis. A “differences-in-differences” analysis, which tests whether the differences between the decreases in the two counties are significant, would be a preferable analysis that would control for those potential confounders. Such an analysis is often conducted on observational data in social sciences to examine the effects of a program or policy change (Buckley and Shang, 2003).

BOWLING GREEN, OHIO

Smoking Restriction and Exposure Information

The city of Bowling Green, Ohio, implemented a clean-indoor-air ordinance in March 2002 that banned smoking in all public places in the city except bars, restaurants with bars in isolated areas, and bowling alleys. Bars and bowling alleys allowed smoking at the owners’ discretion.

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

One publication examines acute coronary events after implementation of the ordinance (Khuder et al., 2007). It provides information directly related to the question of the association between smoking bans and acute coronary events. The publication contains no information on compliance with the restrictions or on air monitoring or biomonitoring before or after the ban. Akbar-Khanzadeh et al. (2004), however, measured the concentrations of secondhand-smoke–related compounds in restaurants in Toledo and Bowling Green, Ohio, using standard methods (including nicotine, 3-ethenylpyridine, total respirable suspended particulate matter [RSP], RSP based on solanesol particles, respirable suspended ultraviolet-absorbing particulate matter, and fluorescent particulate matter). One smoke-free restaurant and one smoking restaurant (that is, with a bar) in each city were chosen. Data from a previous study were compared with data on average concentrations of the various compounds in the two cities combined. Analyses indicated that the concentrations of secondhand-smoke–related contaminants did not change after the adoption of the smoking restrictions, but the data also indicated that the concentrations of secondhand-smoke–related compounds were lower in the nonsmoking restaurants than in the restaurants that allowed smoking in separate areas.

Published Results on Acute Coronary Events

Khuder at al. (2007) compared hospital admissions related to coronary heart disease (CHD; ICD-9-CM 410–414, 428) in Bowling Green, Ohio, with a matched control city, Kent, Ohio, over a 6.5-year period to assess the effect of the ordinance. The study took advantage of a natural experiment. The authors obtained hospital discharge data on residents of the two cities from all hospitals in Ohio and analyzed the primary diagnoses for admission of people at least 18 years old, using 2000 census population information as the denominator throughout the study period. The authors present annual standardized admission rates in their Table 1, in which the data for the first half of 2005 are doubled to provide numbers for the full year. Despite showing those annual rates, they used monthly time-series data for the analysis in the study, and only the available data for 2005 were used. They calculated age-standardized rates and found that CHD admission rates decreased significantly in Bowling Green after the implementation and enforcement of the smoking restrictions by 39% from 2002 (36/10,000 residents) to 2003 (22/10,000 residents) and by 47% from 2002 to the first half of 2005 (19/10,000 residents). Kent did not show any significant change in CHD admission rates, nor did admission rates for causes unrelated to smoking change significantly in either city. In addition, in November 2002, 7 months after implementation of the restrictions, the monthly admission rates for CHD in Bowling Green showed a significant

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

decline (the value of the parameter representing a change in the series level, ω, was −11.69; p = 0.04)

The results of the study have to be understood in relation to its limitations: the residents of Kent were assumed not to be affected by the restrictions, other risk factors for CHD may have affected admission rates, and smoking status and exposure to secondhand smoke were not accounted for. The study showed a peak in acute MIs in 2002, the year with which postimplementation years are being compared. The smoking ban was implemented in March 2002, but, on the basis of previous studies, the authors “postulated that at least 6 months would be needed to allow for the potential health effects from reduction in exposure to second hand smoke, reduction in smoking prevalence and smokers reducing the quantity of cigarettes smoked.” The authors therefore “waited until October 2002 before assessing the impact of the ordinance.” The sensitivity of the analysis to that choice would have been helpful to see. Annual standardized admission rates varied greatly across years, but the Autoregressive Integrated Moving Average (ARIMA) model used to analyze the data, which estimates the effect of the intervention and accounts for residual correlation, would take that variability into account. The published report provides little information on the fit of the time-series model used to measure the effect of the restrictions. As with Seo and Torabi (2007), a differences-in-differences analysis, as is often used to evaluate the effect of a program (Buckley and Shang, 2003), could have been explored, but it is not clear how it would be done with the information provided in the publication.

NEW YORK STATE

Smoking Ban and Exposure Information

On July 24, 2003, New York implemented a statewide ban on smoking in all workplaces, including restaurants, bars, and gaming establishments. Statewide smoking restrictions implemented in 1989 had limited or prohibited smoking in particular public places, such as schools, hospitals, public buildings, and retail stores. By 1995, countywide restrictions had begun to be put into place; by 2002, 75% of residents of New York state were subject to local restrictions more stringent than the statewide restrictions implemented in 1989 (Juster et al., 2007).

Juster et al. (2007) published the only report on the effect of the New York state smoking ban on acute coronary events. The authors did not measure compliance, enforcement, or markers of secondhand-smoke exposure for the report, but they cited a report by RTI International (2004) that showed that 93% of restaurants, bars, and bowling facilities were in compliance in the year after implementation. They took into consideration

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

preexisting smoking bans, and they collected information on those bans and categorized them as comprehensive (including the statewide ban and the preexisting bans in Nassau County and New York City) or moderate2 (all other county bans). Their report provides information directly related to questions about the association between smoking bans and acute coronary events.

Other data on compliance and potential secondhand-smoke exposure in New York state are available. The New York Adults Tobacco Survey showed decreases in saliva cotinine from 0.078 ng/mL (range, 0.054–0.111 ng/mL) to 0.041 ng/mL (0.036–0.047 ng/mL) in a sample of New York state adults before and after implementation of the ban, respectively (CDC, 2007). That study also surveyed participants about exposures to secondhand smoke. The number of respondents reporting exposure to secondhand smoke in restaurants and bars decreased significantly after implementation of the ban—in restaurants, from 19.8% reporting exposure (95% CI, 15.6–24.1%) before the ban to 3.1% (95% CI, 2.0–4.2%) 9–10 months after implementation; in bars, from 52.4% reporting exposure (95% CI, 41.5–63.4%) before the ban to 13.4% (95% CI, 9.5–17.3%) 9–10 months after implementation. However, those reporting exposure in the workplace did not decrease significantly3—from 13.6% reporting exposure before the ban (95% CI, 8.1–19.1%) to 7.6% (95% CI, 5.1–10.2%) 9–10 months after implementation.

CDC (2004) measured indoor-air quality in hospitality venues in western New York before and after implementation of the 2003 ban. Average PM2.5 concentration decreased from 324 μg/m3 before the ban to 25 μg/m3 after implementation (p < 0.001).

Published Results on Acute Coronary Events

Juster et al. (2007) assessed the effect of the statewide smoking ban in New York on hospital admissions for acute MI and stroke. The authors analyzed monthly hospital admissions associated with primary diagnoses of acute MI (ICD-9-CM 410.0–410.99) and stroke (ICD-9-CM 430.00–438.99) from January 1995 to December 2004 in 62 counties in New York state. They used data from a comprehensive database maintained by the New York State Department of Health and included data from all public and private hospitals in the state. The number of hospital admissions was combined with county population data to obtain a monthly rate of hospital admissions for acute MI and stroke; the data were age-adjusted to the 2000

2

The authors of the report defined a moderate ban as one that restricts smoking but provides little or no protection in hospitality venues.

3

Statistical analysis used a t test for trend.

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

New York population. Multiple linear-regression analysis was applied to monthly age-adjusted county rates for acute MI and stroke, and estimated regression coefficients were used to predict the potential reduction in hospital admissions related to comprehensive and moderate smoking bans.

During the study period, there were more than 46,000 hospital admissions per year for acute MI and more than 58,000 for stroke. Regression analysis indicated that no sudden decrease in hospital admissions for acute MI was associated with the implementation of the smoking ban in 2003. However, the interaction between the law and time—assessed by comparing the changes in the slope of the line for observed versus expected events after the ban—indicated that the decline in monthly acute MIs associated with the countywide and statewide bans was greater than the decline expected in the absence of those bans. Moderate smoking bans reduced the monthly trend rate by an estimated average of 0.15/100,000 persons per month; the statewide comprehensive ban reduced the monthly trend rate by an estimated average of 0.32/100,000 per month. The analysis indicated that there were 8% (3,813) fewer hospital admissions for acute MI in 2004 in the presence of the comprehensive statewide ban than would have been expected that year with only the previous local smoking restrictions and bans in place. Although it was not reported in Juster et al. (2007), the authors stated in response to questions from this committee that a similar analysis of mortality in 1998–2005 in New York state had similar results, although an interaction between law and time did not reach significance, with a p-value of 0.059 (personal communication, H. Juster, New York State Department of Health, Albany, January 14, 2009).

At the time of the study, some partial or full bans were in place in various locations in the state before the statewide ban (that is, there was not a “zero to all” implementation throughout the state) and would be expected to affect the magnitude of any change seen. Juster et al. (2007) estimated that if no local bans had been in place when the state ban was implemented, the effect of the state ban would have been a 19% decrease in acute MIs.

The study included some measures of exposure but did not assess individual patient-level data (including smoking status or other risk factors) or the effect of changes in smoking prevalence on hospital admissions. There was no control for repeat admissions of the same person. The considerable data aggregation in the study could mask heterogeneity and overstate statistical significance. From the data in Figure 1 of Juster et al. (2007), it appears that the effect of the ban on acute MIs and stroke was not immediate: an apparently anomalous initial drop in both observed admissions and admissions expected in the absence of the statewide ban (as predicted by the model) was followed by a separation between the observed occurrences with the statewide ban and the expected number in the absence of the ban. The committee notes, however, that whereas typically the rate of acute

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

MI is much greater than (as much as twice as high as) the rate of strokes (Lloyd-Jones et al., 2008), in this study there were more strokes than acute MIs. With respect to the analyses, this was the only study that attempted to account for previously implemented smoking bans; that is important given the large portion of the study population that was previously covered by smoking bans (New York City and several other large jurisdictions had previously implemented smoking bans). The results of the study, however, are sensitive to the assumptions used in the model and to the model choice. A sensitivity analysis showing the effect of model choice on study results might have provided more confidence in the study findings.

SASKATCHEWAN, CANADA

Smoking Ban and Exposure Information

Saskatoon, Saskatchewan, Canada, implemented a smoking ban on July 1, 2004. The ban prohibited smoking in “any enclosed public space that is open to the public or to which the public is customarily admitted or invited.” Smoking was also prohibited in outdoor seating areas of restaurants and licensed premises. Smoking had previously been prohibited in government buildings.

Lemstra et al. (2008) conducted the only study to assess whether the smoking ban had an effect on rates of acute MI and also assessed smoking prevalence and public support of the ban. That study provides information directly related to questions about the association between smoking bans and acute coronary events. The authors measured business compliance with the ban by reviewing warnings and tickets issued by public-health inspectors to eligible businesses. Of 924 eligible establishments, 914 (98.9%) were inspected within the first 6 months of the ban. Of the 914, only 13 (1.4%) had to be issued noncompliance warnings (for not posting signs or removing ashtrays); one ticket was issued on reinspection of those 13 that were issued warnings. The committee found no exposure-assessment data.

Published Results on Acute Coronary Events

Lemstra et al. (2008) obtained information on acute MI from the Strategic Health Information Planning Services. ICD-10 codes, rather than ICD-9 codes, were in use in Saskatoon beginning in 2000, so the analyses used data from July 2000 and later. The authors calculated age-standardized incidences of acute MI per 100,000 people in the first full year of the smoking ban (July 1, 2004–June 30, 2005) and in the previous 4 years (July 1, 2000–June 30, 2004). Data collected on smoking prevalence in 2003 and 2005 by Statistics Canada were used to evaluate changes in smoking pattern.

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

The age-standardized incidence of acute MI decreased from 176.1 cases/100,000 people before the ban to 152.4 cases/100,000 after implementation of the ban. The 13% reduction was statistically significant (rate ratio, 0.87; 95% CI, 0.84–0.90). Smoking prevalence in Saskatoon decreased from 24.1% in 2003 to 18.2% in 2005 but was unchanged in the province of Saskatchewan.

The study contained some information available from a survey that determined changes in active smoking status (for example, a decrease in the number of people who actively smoked and a decrease in the number of cigarettes smoked by the people who continued to smoke). In addition, the study had a large sample and comprehensive data. The study accounted for changes in ICD coding for acute MI, choosing its timeframe on the basis, in part, of the coding change. The study has a number of limitations: no information on individual exposure to secondhand smoke was available, the postimplementation study period was brief, and no comparison city was available to permit assessment of trends or of any long-term decline.

SCOTLAND

Smoking Ban and Exposure Information

Scotland prohibited smoking in enclosed public places and workplaces—including bars, restaurants, and cafes—as of March 2006. As described by Haw and Gruer (2007), the exceptions included “residential accommodation and designated rooms in hotels, care homes, hospices, and psychiatric units.” Pell et al. (2008) conducted the only study that assessed the effects of that ban on acute coronary events. The study surveyed participants on smoking status and secondhand-smoke exposure before and after the ban, and it measured serum cotinine. The correlation between self-reported duration of exposure to secondhand smoke and serum cotinine concentrations was similar before (r = 0.33, p < 0.001) and after (r = 0.33, p < 0.001) the implementation of the smoking ban. The number of never-smokers who reported no exposure to smoke increased from 57% before the ban to 78% after implementation (p < 0.001) largely because of reduced exposure to smoke in pubs, bars, and clubs. The geometric mean of individual serum cotinine measurements in never-smokers decreased from 0.68 to 0.56 ng/mL (p < 0.001) after implementation. Participants identified as former smokers showed similar changes before and after implementation. Those data indicate that secondhand-smoke exposure decreased in the study population after implementation.

Other published research supports the conclusion that secondhand-smoke exposure decreased in Scotland after implementation of the ban. Semple et al. (2007a) monitored PM2.5 during 53 visits to 41 pubs in

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

Edinburgh and Aberdeen both before implementation of the ban and 2 months after implementation; particulate matter is one component of secondhand smoke. Air samples were collected for a minimum of 30 min; days of the week and times of day of sampling before and after implementation were matched. Before the ban, PM2.5 concentrations were 8–902 μg/m3; after implementation, they were 6–104 μg/m3. With the exception of one bar that had a very low PM2.5 concentration before the ban and only a slightly lower concentration after implementation, PM2.5 concentrations decreased by at least 50% in all establishments; in more than half, concentrations decreased by at least 90%. The researchers also collected information on compliance with the ban while conducting the sampling. Only 1 of the 41 pubs had evidence of smoking after implementation of the ban.

Haw and Gruer (2007) measured changes in exposure to secondhand smoke in the 14 regions of Scotland. Using a repeat, cross-sectional design, the researchers interviewed adults (ages 16–74 years) on health behaviors, smoking status, nicotine-replacement therapy use, and reported exposures to secondhand smoke before and after implementation of the ban. They also measured cotinine concentrations in saliva samples. Nonsmokers reported decreased exposure to secondhand smoke after implementation of the ban. When sex, years of education, and deprivation of residence (subjects were categorized according to how affluent or deprived their residences were) were controlled for, self-reported decreases were significant only for public places covered by the ban (including pubs, work, and public transport) and not in private homes and cars. In nonsmokers, the geometric mean cotinine concentration decreased by 39% (p < 0.001), from 0.43 ng/mL before the ban to 0.26 ng/mL after implementation. Nonsmokers not living with any smokers showed a greater reduction than nonsmokers living with at least one smoker, with a 49% reduction (95% CI, 40–56%; p < 0.001) and a 16% reduction (95% CI, −111 to 37%; p < 0.05), respectivel.

Menzies et al. (2006) measured serum cotinine concentrations in bar workers in Dundee and Perth, Scotland, and found that concentrations decreased by 1.93 ng/mL (95% CI, 1.03–2.83 ng/mL; p < 0.001), from 5.15 ng/mL before the ban to 3.22 ng/mL 1 month after implementation, and by 2.22 ng/mL (95% CI, 1.34–3.10 ng/mL; p < 0.001), to 2.93 ng/mL 2 months after implementation. They also found that respiratory symptoms had decreased and pulmonary function improved at both 1 and 2 months after implementation relative to 1 month before implementation.

Semple et al. (2007b) met with 371 people who worked in 72 bars in Aberdeen, Glasgow, Edinburgh, and small towns in two rural areas of Scotland before implementation of the ban (January–March 2006) and twice after implementation (May–July 2006 and January–March 2007). Salivary cotinine in 301 workers was assayed. The geometric mean salivary cotinine concentration in nonsmokers decreased from 2.9 ng/mL before the ban to

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

0.7 ng/mL about 2 months after implementation to 0.4 ng/mL about a year after implementation.

Pell et al. (2008) measured serum cotinine concentrations in the study that evaluated acute MI. The concentration of cotinine in serum samples validated self-reported smoking status and provided a measure of exposure to secondhand smoke; serum cotinine decreased by 38% in men and by 47% in women after implementation of the ban. For the purposes of the study, current smokers were those who reported being smokers and had serum cotinine greater than 12 ng/mL. Never-smokers reported never having smoked and had serum cotinine of no more than 12 ng/mL. Former smokers reported being former smokers and had serum cotinine of no more than 12 ng/mL.

Published Results on Acute Coronary Events

Pell et al. (2008) prospectively examined the number of hospital admissions for acute coronary syndrome before and after implementation of smoking ban. Their study had serum cotinine concentrations of patients and analyzed the data according to smoking status on the basis of those concentrations, so it directly addressed the question of the association between secondhand-smoke exposure and acute coronary events. The authors gathered information on cases from nine hospitals during the 10 months before implementation (June 2005–March 2006) and 10 months after (June 2006–March 2007). They used detection of cardiac troponin after emergency admission for chest pain to define an acute coronary syndrome; cardiac troponin is routinely measured in people who are admitted with chest pain. During the pre-implementation and postimplementation periods, there were 3,235 and 2,684 admissions for acute coronary syndrome, respectively, in the nine hospitals (the nine hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland). Pell et al. (2008) used English hospitals’ admissions for acute coronary syndrome as a concurrent control.

The number of admissions for acute coronary syndrome decreased by 17% (95% CI, 16–18%). Only a 4% reduction occurred during the same period in England, where no ban was in place. In the 10 years before implementation of the ban, a trend of a 3% mean reduction per year occurred in Scotland. Examination by smoking status showed a 14% reduction in smokers, 19% in former smokers, and 21% in those who never smoked; the data indicate that 67% of the prevented admissions were in nonsmokers.

This study was one of the few that used a prospective design to address the question of the effect of a smoking ban on acute coronary events. It has several strengths, including a large sample, laboratory confirmation of MI admissions with cardiac troponin assays, and confirmation that

Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
×

there was no concurrent change in the rates of out-of-hospital deaths after implementation of the ban. The authors also conducted a survey of cases and a sample of the general population for secondhand-smoke exposure and smoking status, and they measured cotinine concentrations in these participants.

The study did, however, have limitations. Although it was large, it did not include all hospitals in Scotland, it did not have a clearly defined study population, and there could have been changes in the nine hospital catchment areas or a more general population influx or efflux after implementation of the ban. The study had a relatively short followup period (1 year), so the long-term effect of the ban on smokers and nonsmokers is not known. It is unclear whether the ban itself affected smoking status in the general population by changing social norms. Finally, as in all observational trials, other changes—including changes in health-care availability and in the standard of practice in cardiac care, such as new diagnostic criteria for acute MI—during the study period could have confounded the results.

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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Suggested Citation:"6 Overview of Key Studies of the Effects of Smoking Bans on Acute Coronary Events." Institute of Medicine. 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/12649.
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Data suggest that exposure to secondhand smoke can result in heart disease in nonsmoking adults. Recently, progress has been made in reducing involuntary exposure to secondhand smoke through legislation banning smoking in workplaces, restaurants, and other public places. The effect of legislation to ban smoking and its effects on the cardiovascular health of nonsmoking adults, however, remains a question.

Secondhand Smoke Exposure and Cardiovascular Effects reviews available scientific literature to assess the relationship between secondhand smoke exposure and acute coronary events. The authors, experts in secondhand smoke exposure and toxicology, clinical cardiology, epidemiology, and statistics, find that there is about a 25 to 30 percent increase in the risk of coronary heart disease from exposure to secondhand smoke. Their findings agree with the 2006 Surgeon General's Report conclusion that there are increased risks of coronary heart disease morbidity and mortality among men and women exposed to secondhand smoke. However, the authors note that the evidence for determining the magnitude of the relationship between chronic secondhand smoke exposure and coronary heart disease is not very strong.

Public health professionals will rely upon Secondhand Smoke Exposure and Cardiovascular Effects for its survey of critical epidemiological studies on the effects of smoking bans and evidence of links between secondhand smoke exposure and cardiovascular events, as well as its findings and recommendations.

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