Heart Attacks Decreased After Public Smoking Ban In Italy

Researchers in Rome compared acute coronary events in the city for five years preceding a public smoking ban with those occurring one year after the ban. They found an 11.2 percent reduction of acute coronary events in persons 35 to 64 years and a 7.9 percent reduction in those ages 65 to 74.

"Smoking bans in all public and workplaces result in an important reduction of acute coronary events," said Francesco Forastiere, M.D., Ph.D., co-author of the study and head of the Environmental and Occupational Epidemiology Unit, Department of Epidemiology, Rome E. Health Authority, Italy. "The smoking ban in Italy is working and having a real protective effect on population health."

The study was the first in Europe to show long-term health benefits of smoking bans in public places. It also was the first to consider in detail other factors such as temperature, air pollution, flu epidemics and time trends that affect acute coronary events such as heart attack.

The January 2005 comprehensive smoking ban in Italy included strong sanctions for smokers, businesses and workplace owners and managers. The prohibition included all indoor public places such as offices, retail shops, restaurants, pubs and discos.

Researchers compared the rate of acute coronary events from 2000 to 2004 to those occurring in 2005 after the ban was enforced.

Researchers identified acute coronary events from hospital discharge reports with a diagnosis of myocardial infarction or unstable angina and from the regional register of causes of deaths with diagnosis of out-of-hospital coronary deaths. The analysis was divided into three age groups: 35--64, 65--74 and 75--84 years. Researchers collected daily data on particulate matter in 40 public places and from four fixed monitors in residential areas together with temperature readings.

The indoor concentration of fine particles decreased significantly from a mean level of 119 ìg/m3 before the ban to 43 ìg/m3 one year after the ban.

During the period of the study there were changes in smoking habits such as:

• Frequency of smoking decreased from 34.9 percent to 30.5 percent in men and from 20.6 percent to 20.4 percent in women.
• Cigarette sales decreased 5.5 percent.
• While the ban resulted in a significant reduction in acute coronary events in the two younger age groups, the older group (aged 75-84 years) showed no reduction.
• When the researchers adjusted for time trends and all-cause hospitalization, the results remained statistically significant in the youngest group and in the 65--74 age group. This effect was only slightly reduced when the researchers compared the post-smoking ban data of 2005 to that from 2004.

"The older age group spends more time at home than in the workplace or public businesses," said Giulia Cesaroni, M.Sc., senior researcher at the Department of Epidemiology, Rome, Italy. "The smoking ban has a greater effect on those of working age and those who spend a lot of their time in public places."

Young people living in low socioeconomic areas seemed to have the greatest reduction in acute coronary events after the smoking ban, researchers reported. Those living in lower socioeconomic areas have worse health conditions with more risk factors for heart attack such as obesity, hypertension, diabetes and a higher rate of active smoking.

"This implies that a disadvantaged person has a higher probability of being surrounded by smokers at work and in public places unless a smoking ban is in place," Cesaroni said.

The researchers said the health benefits seen in this study probably result from a significant reduction in exposure to passive smoking. In addition, a smoking-free environment makes it easier for smokers to stop smoking.

"Since coronary heart disease is a leading cause of death in Italy, the reduction observed had enormous public health implications," Forastiere said. "It will be interesting to see if the effect of the ban is stable over time and if similar positive health effects can be detected in other places.

"While the trend is to implement smoking bans, there are still areas in the world such as some European countries, Asia, and America where smoking in public places is an important public health issue. Smoking bans should be extended to all possible countries and smoking bans in the workplace should be strongly enforced."

Other co-authors are: Nera Agabiti, M.D.; Pasquale Valente, M.D.; Piergiorgio Zuccaro, Ph.D.; and Carlo A. Perucci, M.D.

The Lazio Region Health Authority funded the study.