Jonathan M. Samet
Smoking Bans Prevent Heart Attacks
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Smoking Bans Prevent Heart Attacks
Jonathan M. Samet, MD, MS
of a city-wide smoking ordinance. The ordinance, which was
strictly enforced, prohibited smoking in all workplaces, in-
cluding bars and restaurants, and in all buildings open to the
public. The findings in Pueblo confirm a similar assessment
of the consequences of a public smoking ban in Helena,
Mont, which was the first such assessment reported.2In the
Montana study, the law was in force for 6 months before a
challenge led to a court order suspending it. Admissions for
acute myocardial infarction declined by 40% during the 6
months of the ban and then rose after it was lifted.
n this issue of Circulation, Bartecchi and colleagues1
describe a reduction in hospitalizations for acute myocar-
dial infarction in Pueblo, Colo, after the implementation
Article p 1490
Replication is critical in inferring causality.3The drop in
hospitalizations for acute myocardial infarction after the ban
in Pueblo provides clear confirmation of the results in Helena.
The new report1has several strengths. The number of
hospitalizations (855) is large, so the impact of the ban can be
precisely estimated; the statistical analysis indicates that the
findings are highly unlikely to have arisen by chance. The
design incorporated 2 comparison populations: residents of
Pueblo County outside of the city of Pueblo and residents of
El Paso County, which includes Colorado Springs. By includ-
ing these comparison populations, Bartecchi et al1were able
to account for temporal trends of a decline in hospitalizations
for acute myocardial infarction that might have mistakenly
been attributed to the ordinance. Their final regression model
estimated a decline of approximately 30% in the hospitaliza-
tion rate after the ordinance; there was no decline in El Paso
County. This beneficial effect is of sufficient magnitude to be
readily visible in their Figure 3, which plots the raw data.1
How might a smoking ban sharply reduce the rate of
hospitalizations for acute myocardial infarction? The imple-
mentation of an enforced smoking ordinance would be
followed by an immediate reduction in exposure to second-
hand smoke and also by a drop in the cigarette consumption
of active smokers.4Each of these consequences would be
expected to the reduce risk for acute myocardial infarction.
Active and passive smoking are well-documented causes
of morbidity and mortality from coronary heart disease, and
smoking cessation leads to relatively rapid reversal of some
of the excess risk associated with active smoking.3,5,6Within
a year after successful cessation, the smoking-associated risk
for coronary heart disease events drops by about 50%. Little
research has been carried out to determine the decline of risk
for coronary heart disease events after a reduction in exposure
to secondhand smoke. However, adverse effects of second-
hand smoke exposure on the clotting profile and endothelial
cell function might quickly reverse.6
There is extensive evidence showing that workplace bans
reduce employees’ exposure to secondhand smoke.6The bene-
ficial consequences of bans for indoor air quality have been
documented by tracking air levels of nicotine, which comes
solely from tobacco combustion, and cotinine, a principal
nicotine metabolite and highly specific biomarker in saliva,
urine, or blood. Enforced bans lower the nicotine concentration
to below the limit of detection, and cotinine levels also drop. For
example, Mulcahy et al7recently reported on the smoking ban in
Ireland and the impact it had on salivary cotinine concentrations
in hotel employees and on nicotine levels in bars. In the hotel
employees, the median cotinine concentration dropped from 1.6
ng/mL to 0.5 ng/mL; the median concentration of nicotine in the
bars declined from 35.5 ?g/m3to 6.0 ?g/m3. Smoking bans lead
to parallel reductions in exposure to the myriad other compo-
nents of tobacco smoke.6
Workplace smoking bans also reduce cigarette consumption
by active smokers by both reducing the number of cigarettes
smoked and promoting cessation.4,8In a meta-analysis of 26
studies, Fichtenberg and Glantz4estimated that totally smoke-
free workplaces were associated with reductions in smoking
prevalence of about 4% and in cigarettes consumed daily of
about 3.1 cigarettes per day for active smokers. The length of
time for the benefits of workplace smoking bans to take effect
after implementation has not been described.
Because of a lack of information on pre- and postordinance
patterns of active and passive smoking and the contributions of
various places, such as workplaces, public places, and homes to
secondhand smoke exposures of nonsmokers, the 30% drop in
hospitalization rate in Pueblo postordinance cannot readily be
apportioned among active and nonsmokers. In comparisons of
exposure to nonexposure to secondhand smoke at home or at
events by about 20% to 30%. Active smoking approximately
in never-smokers. Given the high proportion of passive smokers,
even the reduction in the workplace contribution to exposure
may have resulted in a detectable decline in the hospitalization
rate for acute myocardial infarction. Similarly, an immediate
reduction in the risk for acute myocardial infarction through
reduced active smoking may have plausibly contributed to the
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Johns Hopkins Bloomberg School of Public Health, Depart-
ment of Epidemiology and The Institute for Global Tobacco Control,
Correspondence to Jonathan M. Samet, MD, MS, Professor and
Chairman, Department of Epidemiology, Johns Hopkins University,
Bloomberg School of Public Health, 615 N Wolfe St, Suite W6041,
Baltimore, MD 21205. E-mail email@example.com
© 2006 American Heart Association, Inc.
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observed decline as well. Neither the Helena2nor the Pueblo1
study addressed the specific contributions of reduced active and
passive smoking to the decline in hospitalization rate after
implementation of a smoking ordinance.
The report by Bartecchi et al1adds to a substantial body of
experimental and observational evidence on risks for cardiovas-
cular disease associated with passive smoking. The topic of
passive smoking and heart disease was not addressed in Surgeon
General Koop’s landmark 1986 report on involuntary smoking.9
The first epidemiological studies on this topic were published in
the mid-1980s, and many epidemiological and experimental
studies on secondhand smoke and cardiovascular disease have
been published subsequently. In contrast with the 1986 report,
several chapters of Surgeon General Carmona’s 2006 report6on
involuntary smoking address cardiovascular disease, and the
report offers the conclusion that exposure to secondhand smoke
causes coronary heart disease. The report reviews findings of
both cohort and case-control studies, as well as experimental
evidence, showing that secondhand smoke exposure adversely
affects platelet and endothelial cell functioning and produces
coronary atherosclerosis. A similar set of pathogenetic processes
has been postulated as an underlying association of air pollution
with cardiovascular disease.10
The 2006 report of the Surgeon General6and the 2005 report
of the California Environmental Protection Agency11on second-
hand smoke provide a strong scientific foundation for policies
that protect nonsmokers from inhaling secondhand smoke.
Among its overall conclusions, the Surgeon General’s report
comments on the causation of morbidity and premature mortal-
ity in children and adults exposed to secondhand smoke and the
impossibility of providing full protection without eliminating
of indoor with outdoor air, filtration, and separation of smokers
from nonsmokers, will not suffice.
The move toward protecting nonsmokers from involuntarily
inhaling secondhand smoke dates to the early 1970s. Surgeon
General Steinfeld recognized the possibility of adverse health
consequences of secondhand smoke in his 1972 report.12The
Civil Aeronautics Board required no-smoking sections on com-
mercial airline flights beginning in 1973, and in the 1970s some
states and municipalities passed laws to limit smoking. The
move toward smoke-free environments accelerated with the
1986 Surgeon General’s report and other authoritative reports
with conclusions that secondhand smoke exposure causes dis-
ease and other adverse health effects. As of July 1, 2006, there
were 474 municipalities and 11 states in the United States with
smoke-free ordinances in place and 8 smoke-free countries.13
After the publication of the new Surgeon General’s report in
June 2006, the strength of its findings motivated many commu-
nities and several states to pass smoke-free ordinances.
The findings in Helena and Pueblo indicate that the widening
coverage of the population of the United States (and of popula-
tions in other countries) by smoke-free ordinances will lower
coronary heart disease morbidity and mortality. The Framework
Convention for Tobacco Control, a global public health treaty,
has protection against exposure to secondhand smoke as a major
provision. Smoke-free ordinances should be included in any
population-level program for prevention of cardiovascular dis-
ease, and the broad community of health professionals involved
such initiatives.14Undoubtedly, there will be more reports
tracking the consequences of smoke-free ordinances for disease
risk; fortunately, there is an ever-increasing number of locations
with ordinances in force in which to make these observations.
Dr. Samet has received grant support from GlaxoSmithKline, the
American Legacy Foundation, Flight Attend Medical Research
Institute (FAMRI), and Atlantic Philanthropies. He is the recipient of
the Dr William Cahan Distinguished Professor Award from the
Flight Attendant Medical Research Institute.
1. Bartecchi C, Alsever RN, Nevin-Woods C, Thomas WM, Estacio RO,
Bartelson BB, Krantz MJ. Reduction in the incidence of acute myocardial
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2. Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions
for myocardial infarction associated with public smoking ban: before and
after study. BMJ. 2004;328:977–980.
3. US Department of Health and Human Services (USDHHS). The Health
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DC: US Government Printing Office; 2004.
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Centers for Disease Control and Prevention (CDC); 2006.
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smoke exposure and risk following the Irish smoking ban: an assessment
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ernment Printing Office; 1986.
10. Brook RD, Franklin B, Cascio W, Hong Y, Howard G, Lipsett M,
Luepker R, Mittleman M, Samet J, Smith SC Jr, Tager I, Expert Panel on
Population and Prevention Science of the American Heart Association.
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fessionals from the Expert Panel on Population and Prevention Science of
the American Heart Association. Circulation. 2004;109:2655–2671.
11. California Environmental Protection Agency (Cal EPA), Air Resources
Board. Proposed Identification of Environmental Tobacco Smoke as a
Toxic Air Contaminant. Sacramento, Calif: California Environmental
Protection Agency; 2005.
12. US Department of Health Education and Welfare (DHEW). The Health
Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga:
US Government Printing Office; 1972.
13. American Nonsmokers’ Rights Foundation. Municipalities with local
100% smokefree laws. Available at: http://www.no-smoke.org/pdf/
100ordlisttabs.pdf. Accessed September 14, 2006.
14. Barnoya J, Glantz SA. Cardiovascular effects of secondhand smoke:
nearly as large as smoking. Circulation. 2005;111:2684–2698.
KEY WORDS: Editorials ? epidemiology ? myocardial infarction ?
prevention ? smoking
SametSmoking Bans Prevent Heart Attacks
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