Reduction in the Incidence of Acute Myocardial Infarction Associated with a Citywide Smoking Ordinance

A citywide anti-smoking ordinance in Pueblo , Colo. , resulted in a dramatic decrease in admissions to the local hospitals for heart attacks affecting the city’s residents. Why it’s important: Smoking is a demonstrated cause of heart disease in the general population, and second-hand smoke presents a significant risk to non-smokers, particularly those who work in smoky environments. Cities across the nation have banned smoking in public places. Demonstrating that such actions can directly affect the health of the population will give impetus to those actions by local governments. What’s already known: Chronic exposure to secondhand cigarette smoke is associated with an increased risk of having a heart attack. According to the American Heart Association, more than 35,000 nonsmokers die each year in the United States from coronary heart disease due to exposure to secondhand smoke. A recent Surgeon General’s report also confirms that secondhand smoke is a major risk factor for coronary heart disease and there is no safe level of exposure to secondhand smoke. The authors noted that secondhand smoke can have harmful effects on blood vessels. It can cause the cells lining the inner layer of the blood vessel (endothelial cells) to become unhealthy and less able to expand when needed. It also causes blood’s platelets to become more sticky and likely to form clots on the vessel wall. This can increase the risk of a heart attack. A study in Helena , Mont. , showed that a ban on smoking for six months in the city limits was associated with a 40 percent decrease in admissions for heart attack to the hospital. A legal challenge ended the smoking ban after six months. With that suspension of the ban, researchers lost the chance of doing longer-term research. The smoking ban in Pueblo , Colo. , gave the researchers a chance to do a longer study in a larger community, which, like Helena , is also fairly isolated. Pueblo had a higher percentage of smokers than the rest of the state – 22.6 percent versus 18.6 percent. How this study was done: All patients with heart attack received care at one of two hospitals, Parkview Medical Center or St. Mary-Corwin Medical Center. In 2003, Pueblo citizens voted in favor of a Smoke-Free Air Act within the city limits. The new law forbade smoking inside the workplace and all buildings open to the public, including restaurants, bars, bowling alleys and other places of business. The law was strongly enforced by Pueblo law enforcement. The researchers compared hospitalization rates for heart attack among residents who lived inside the Pueblo city limits, outside the Pueblo city limits and in El Paso County , a comparable area containing Colorado Springs in which there was no anti-smoking ordinance. What was found: The researchers led by Carl Bartecchi, M.D., of the University of Colorado Health Sciences Center in Denver , identified 2,794 heart attack patients in the three different locations. Of these, 855 were residents of Pueblo County . In the 18 months right after the time that the law took effect, admissions for heart attacks by residents within the city limits of Pueblo dropped 27 percent compared to the 18 months prior to the law’s passage. The rate of heart attacks did not change for residents of surrounding Pueblo County or for the comparison area of El Paso County . After the law went into effect, heart attack rates fell by 70 per 100,000 person-years in the city of Pueblo , 20 per 100,000 person-years in Pueblo County outside the city limits and 3 per 100,000 person-years in El Paso County . The researchers found that seasonal differences did not account for the lowering effect found after the anti-smoking ordinance. “You can save lives with drugs and expensive, sophisticated devices, but this single community action led to 108 fewer heart attacks in an 18-month period,” Dr, Bartecchi said in a released statement. “Each hospital admission for a heart attack costs an average of $20,000 here in Pueblo, so in addition to saving lives, non-smoking ordinances also save a lot of money.” Raymond Gibbons, M.D., American Heart Association president, said the development of atherosclerosis that leads to a heart attack usually takes 20 years. “The decline in the number of heart attack hospitalizations within the first year and a half after the non-smoking ban that was observed in this study is most likely due to a decrease in the effect of secondhand smoke as a triggering factor for heart attacks,” he said. “The ordinance will likely continue to decrease the number of heart attacks and save lives every year.” “After the Helena study, the Centers for Disease Control recommended that people at risk of coronary heart disease avoid secondhand smoke,” Dr. Bartecchi said. “This study should strengthen that recommendation. The Pueblo experience adds to mounting evidence that smoke-free indoor air laws are common-sense public health measures that save lives. These results should also encourage other municipalities to pass smoke-free ordinances.” The bottom line: Laws to ban smoking in public places reduces exposure to secondhand smoke can save lives, preventing heart attacks in the population, saving both lives and money.