Do Smoking Bans cause a 27 to 40% drop in admissions for myocardial infarction in hospitals?

A preliminary study
by David W. Kuneman and Michael J. McFadden

November 29, 2005

In April 2004, the British Medical Journal reported a study which found a 40% drop in hospital admissions (from 40 expected admissions to 24 actual admissions) for acute myocardial infarction (AMI) while a local smoking ban was in effect in Helena MT. Recently, a media release claimed a 27% reduction (from 399 expected admissions to 291 actual admissions for AMI) was found in Pueblo CO after its smoking ban took effect. Is this proposed effect the result of selective research, or can any jurisdiction considering a ban expect similar results?

Data on state-specific emergency room admissions for acute myocardial infarction are available at http://hcup.ahrq.gov/HCUPnet.asp This is the Healthcare Cost and Utilization Project which is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality(AHRQ). HCUP is based on statewide data collected by individual data organizations across the United States and provided to AHRQ through the HCUP partnership.

Researchers and policymakers use HCUP data to identify, track, analyze and compare hospital statistics at the national, regional and state levels. Acute myocardial infarction data are available in this system and can be used to study states with smoking bans.

However, not all states participate in HCUP. Some states which have passed smoking bans do participate, but passed their bans in 2004 and that data are not yet available. Other states, such as Utah and Vermont participate, but passed their bans before HCUP was initiated and data before and after those bans are not available. California, Florida, New York, and Oregon passed their bans while contributing data to HCUP, and therefore afford an opportunity to examine if their ER admissions for acute myocardial infarction declined similarly to Helena and Pueblo.

Florida’s smoking ban applies to most bars, and all clubs, and restaurants and took effect July, 2003. According to the HCUP database, Florida hospitals admitted 40,077 AMI patients during 2002 and 39,783 patients during 2003. Since the ban was only in effect for half of 2003, only half of the 35% decline in ER admissions for AMI predicted by the Helena study and the Pueblo press release should have occurred, which is 17%. While Florida did experience a 1% decline in these admissions, this is a far cry from the anticipated 17% drop which would have occurred if the effect were real, and well within the expected statistical variation which ordinarily occurs in such numbers.

New York State’s smoking ban also applies to bars, clubs, and restaurants and also took effect July 2003. According to the HCUP database, New York hospitals admitted 31,728 AMI patients during 2002, and 31,888 patients during 2003. Since the ban was only in effect for half of 2003, again, a 17% decline in ER admissions for AMI would have been expected which would have been a decrease of 5,394 admissions. Instead of a decrease of thousands though there was an actual increase of 160 admissions. These findings again are in direct conflict with the findings and the message of the researchers in the Helena study and Pueblo press release.

Oregon banned smoking in all restaurants which allow children effective July 2001. Smoking is still allowed in restaurants which do not allow children, and in bars and clubs not locally banned prior to July1, 2001. While this ban does not cover all establishments, some of the 35% reduction in ER admissions for AMI in Oregon hospitals should have been realized because patrons and workers in banned establishments should have been protected. According to the HCUP database, Oregon hospitals admitted 4,957 patients for AMI in 2000, admitted 4,927 in 2001, and 5,125 in 2002. Again, instead of a significant decrease in ER admissions for AMI, we find that AMI admissions actually increased by 4% in 2002, the first full year after the ban took effect.

California banned smoking in restaurants January, 1995, but HCUP data are not available for 1994 and 1995. California extended the ban to other kinds of establishments, including bars in January, 1998. According to the HCUP database, California hospitals admitted 40,608 AMI patents during 1997, and 43,044 during 1998. Again, based on the data and claims made about Helena and Pueblo, a decrease in AMI patients should have been observed, and again rather than a decrease the figures showed an increase… an increase of 2436 cases, an increase of 6% in AMI admissions after the full ban. While the simple extension of the ban to bars would not be expected to produce the 27 to 40% decrease reported in Helena/Pueblo, the extension should certainly have been expected to produce a decrease, rather than an increase in the number of California admissions for AMI if the proposed effect were real.

Although California banned smoking in restaurants January 1995, and data are not available through HCUP, California was conducting a similar in-state hospital performance study based on AMI admissions and 30-day survival rates in most public hospitals ( Read )

This study reported a grand total of 41,927 patients admitted into these hospitals for AMI during 1994, and 42,183 admitted in 1995, after the restaurant-only ban took effect. This represents almost all ER admissions for AMI in California during the two years. Again, no 30 or 40% decline in ER admissions for AMI as predicted by Helena/Pueblo actually occurred. And again, an increase, although small and nonsignificant, actually occurred.

Statistically, it is much less likely large populations will experience unusual circumstances where ER admissions for AMI decline suddenly and randomly. However, if dedicated researchers sift through enough small local jurisdictions with smoking bans, it may be possible to find a few unusual circumstances where a sharp decline in ER admissions for AMI has occurred at the same time a smoking ban took effect.

Helena and Pueblo have a combined population of approximately 200,000 people. California, Florida, New York and Oregon, which have bans, have a combined population of approximately 70,000,000 people… 350 times the population of that studied in Helena and Pueblo. The number of AMIs examined in Helena and Pueblo combine to a total of about 315, the number of AMIs examined in the combined states studied here total over 315,000, i.e. 1,000 times the number examined in the combined jurisdictions of Helena and Pueblo.

And yet neither the medical journals nor the media have paid any notice at all to the fact that in vastly larger populations, virtually no change in acute myocardial infarction rates after smoking bans has occurred. Statistically this larger population base makes for a far more stable statistical environment and the data from this population would provide a far sounder scientific basis for decisions about smoking bans that will affect the lives and livelihoods of millions of people.

And yet this story has been told by no one, broadcast nowhere, and heard by not a soul.

David W. Kuneman
Assistant Midwest Regional Director
The Smoker's Club, Inc.

Michael J. McFadden
Author of Dissecting Antismokers’ Brains
Mid-Atlantic Regional Director
The Smoker's Club, Inc.

The authors have no competing financial interests to declare. Mr. Kuneman’s worked for several years as a research chemist at 7-Up two decades ago (at a time when 7-Up had been formally bought by Philip Morris) and Mr. McFadden’s is the author of a book in the area of interest.

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More on the Kuneman-McFadden Study.

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New Data Show Decline in M.I. Admissions in Smoke-Free States is Lagging Behind Decline for Nation; Casts Doubt on Helena/Pueblo/Saskatoon Claims

August 23, 2006
By Michael Siegel
Data recently released by HCUPnet, a service of the Agency for Healthcare Research and Quality (AHRQ), show that there was a substantial decline (8.2%) in heart attack hospital admissions in the United States between 2003 and 2004. This followed a smaller decline of 2.8% between 2002 and 2003. Overall, the decline in heart attack admissions in the U.S. between 2002 and 2004 was 11%.

These sharp declines in heart attack admissions suggest that the conclusion of recent studies that smoking bans caused declines in heart attacks in Helena, Pueblo, and Saskatoon are highly suspect, as these studies fail to control for the fact that during the same period of time as these smoking bans went into effect, a secular change in heart attack admissions was occurring.

An analysis of heart attack trends in states that implemented smoking bans in recent years (but prior to 2004, which is the most recent year for which heart attack data are available) reveals that there is no evidence that smoking bans led to a decline in heart attack admissions in these states.

In New York, a smoking ban in all bars and restaurants was implemented in July, 2003. A similar ban in New York City had been implemented in March of that year. If smoking bans caused a drastic and immediate decline in heart attacks (40% in 6 months was claimed by the Helena study), then one would certainly expect to have seen a substantial decline in heart attack admissions in New York State in 2003 and 2004.

However, heart attack admissions in New York State dropped by only 0.5% in 2003, and by 3.2% in 2004, compared with the national declines of 2.8% and 8.2%, respectively. Overall, the decline in heart attack admissions in New York State from 2002 to 2004 was only 2.7%, compared to a 10.7% drop in the nation as a whole.

In Florida, a smoking ban in all restaurants was implemented in July, 2003. If smoking bans caused a drastic and immediate decline in heart attacks on the order of 40% (as claimed in Helena) or 27% (as claimed in Pueblo), then one would certainly expect to have seen a substantial decline in heart attack admissions in Florida in 2003 and 2004.

However, heart attack admissions in Florida dropped by only 0.7% in 2003, and by 2.0% in 2004, compared with the national declines of 2.8% and 8.2%, respectively. Overall, the decline in heart attack admissions in Florida from 2002 to 2004 was only 2.7%, compared to a 10.7% drop in the nation as a whole.

During the period 2003-2004, the precise period when smoking bans were implemented in New York and Florida, these states lagged substantially behind the rest of the nation in their observed rates of decline in heart attack admissions. Instead of seeing a 40%, or even 27% decline in heart attack admissions in these states, there was less than a 3% decline over two years, and this was in the face of a nearly 11% decline in the nation as a whole during the same period.

The Rest of the Story

Obviously, I am not concluding from this analysis that smoking bans cause heart attacks. But it is perhaps worth noting that the same methodology used by the Helena, Pueblo, and Saskatoon studies would lead to such a preposterous conclusion. This is the problem with attributing any observed changes in a health outcome to one particular change (i.e., a smoking ban) and ignoring all other possible changes that occurred, including random changes in the health outcome itself.

The problem is particularly troublesome in very small samples, such as those in Helena, Pueblo, and Saskatoon.

The bottom line is that there simply is not evidence to support the conclusions being disseminated by a large number of anti-smoking groups that smoking bans lead to dramatic decreases in heart attacks. This is an unsubstantiated health claim if I've ever heard one.

But the lack of evidence to substantiate the claim, as well as the lack of plausibility of the claim, do not appear to be stopping anti-smoking groups from making the claim, and from using this as propaganda in their efforts to promote smoking bans.

If you are going to be a credible scientist, you have to be willing to look at the data. I have done that, and I conclude that there is not evidence to support a contention that smoking bans will dramatically reduce heart attacks. If anything, the evidence suggests that this is not the case. Unfortunately, it doesn't appear to me that many anti-smoking researchers and groups are willing to even look at this evidence. Instead, they simply attack those calling this to their attention as being tobacco industry sympathists.

That is one thing I am not.

However, I am starting to sympathize with those who are getting sick and tired of seeing anti-smoking groups continue to spout propaganda that is unsupported by the science. Yes, I'm starting to feel your pain.
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Read more: Heart Attack Hospital Admissions Page 2