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 ( http://www.oshpd.ca.gov/HQAD/Outcomes/Studies/HeartAttacks/ami_94-96/V19496.pdf )
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.
Of course, the question remains “did the 1995 California smoking ban happen to cut the death rate from AMI’s in California, instead of the hospital admission rate which was observed in Helena and Pueblo?” If so, then there could still be a benefit realized from California’s 1995 smoking ban. According to an article http://content.nejm.org/cgi/content/full/343/24/1772/F1 which appeared in the New England Journal of Medicine, titled Association of the California Tobacco Control Program with Declines in Cigarette Consumption and Mortality from Heart Disease, by Caroline M. Fichtenberg, M.S., and Stanton A. Glantz, Ph.D., which was published in December 2000 , and which claimed that the California Tobacco Control Program cut heart attack deaths among smokers, ( it didn’t) the following graph from that article clearly shows that the age-adjusted deaths due to AMI paralleled that of the USA through 1997, and the USA was mostly ban free, except for Vermont, Utah, and some localities in New York and Massasuchettes. It is important to use age-adjusted deaths for AMI because the population of California is much younger, on average than the USA (Approximately 11% of Californians are over age 65, and approximately 13% of the USA is over age 65.)
In 1991, most of California was not covered by any local bans. Measuring vertically, it is easy to conclude that the difference between age-adjusted death rate/100,000 in California does not significantly change relative to the USA after 1990, which was when bans began to take effect. It appears that between 1986 and 1990, that Californians did suffer unusually high incidences of AMI death, but that this is probably not attributable to changes in exposure to secondhand smoke because California did not have smoke-free laws during that period.
In conclusion, it does not appear that our findings, that California AMI admission data did not change in 1995 due to it’s state ban, is alternately explained by less deaths. To summarize, the relative total of the deaths and admissions is the same in California vs.USA in the years prior to, and after the 1995 smoking ban.