Abstract
Background:
A ban on smoking in the workplace was introduced in Ireland on March 29, 2004. As exposure to secondhand smoke has been implicated in the development of coronary disease, this might impact the incidence of acute coronary syndromes (ACS).
Hypothesis:
The smoking ban was associated with a decreased rate of hospital admissions for ACS.
Methods:
We analyzed data collected in a registry of all patients admitted to hospital with ACS in the southwest of Ireland, catchment population 620 525, from March 2003 until March 2007.
Results:
In the year following implementation of the ban, there was a significant 12% reduction in ACS admissions (177.9 vs 205.9/100,000; 95% confidence interval [CI]: 164.0‐185.1, P = 0.002). This reduction was due to fewer events occurring among men (281.5 vs 233.5, P = 0.0011) and current smokers (408 vs 302 admissions, P < 0.0001). There was no change in the rate of admissions for ACS in the following year (174.3/100,000; 95% CI: 164.0‐185.1, P > 0.1). However, a further 13% reduction was observed between March 2006 and March 2007 (149.2; 95% CI: 139.7‐159.2). Variation in admissions with time as a continuous variable also demonstrated a reduction on implementation of the smoking ban.
Conclusions:
A national ban on smoking in public places was associated with an early significant decrease in hospital admissions for ACS, suggesting a rapid effect of banning smoking in public places on ACS. A further reduction of similar magnitude 2 years after implementation of the ban is consistent with a longer‐term effect that should be further examined in long‐term studies.
No funding was received for this study. The Coronary Heart Attack Ireland Registry (CHAIR) is funded by the Department of Health and Children, which had no role in the design, data collection, data analysis, data interpretation, writing or revising of the report. IJP is chairman of the Research Institute for a Tobacco Free Society. The other authors have no funding, financial relationships, or conflicts of interest to disclose.
Introduction
Smoking is an important global public health issue.1 It is the second leading risk factor for mortality worldwide, accounting for almost 5 million deaths annually (3.84 million in men and 1 million in women), including 848 000 due to cardiovascular disease.2 In Ireland, tobacco use is the leading cause of preventable death, with nearly 7000 people dying prematurely each year from diseases caused by tobacco smoke,3 and approximately one‐quarter of the adult Irish population are current smokers (defined as smoking ≥1 cigarettes per week).4 On March 29, 2004, the Republic of Ireland became the first country in the world to completely ban smoking in the workplace. The law covers all enclosed public spaces, and has been associated with a high level of compliance.5
Active smoking6 and, more recently, passive smoking have been established as causes of coronary heart disease.7., 8., 9., 10. Secondhand smoke has been implicated as an acute trigger for myocardial infarction,11., 12. and therefore measures that reduce exposure to tobacco smoke would be expected to decrease the burden of ACS (acute coronary syndromes). A number of previous studies have reported a decline in the incidence of ACS following the implementation of total or partial smoking bans.13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24., 25., 26., 27. However, all but 1 study used retrospectively collected, administrative or hospital discharge data,14., 15., 16., 17., 18., 19., 20., 21., 23., 24., 25., 26., 27. and many examined periods of ≤1 year after implementation.13., 15., 18., 19., 20., 21., 22., 24. In some regions, preexisting restrictions or staggered implementation of smoking bans may have masked any effect of the ban on population ACS rates.17., 18., 25., 26. The only truly prospective study thus far, and the only to prospectively collect smoking‐status data, is that of Pell et al.22 This found a significant decline in admissions for ACS to 9 hospitals in Scotland, largely driven by reductions in admissions in nonsmokers. The effect on ACS admissions in that study became more marked over the 10 months after the ban. We sought therefore to ascertain the early and late effects of the Irish smoking ban on the rate of admissions with ACS by analyzing data from a prospective register of all patients admitted with suspected ACS in a defined geographical area.
Methods
The Coronary Heart Attack Ireland Register (CHAIR) is a prospective, continuous registry of all patients admitted with suspected or confirmed ACS to the 8 acute hospitals in counties Cork and Kerry in the southwest of Ireland. Patients who are admitted for other reasons but who develop new ACS in hospital are not included in the register. Data, including demographics, risk factors, and diagnosis, on patients age ≥18 years are extracted prospectively from the medical records by dedicated registration officers and are entered into a central database. An ACS was diagnosed by the physician responsible for the patient's care. Troponin T or I were used in all hospitals during the study period. A current smoker was defined as a patient who smoked ≥1 cigarette a week, and a former smoker was defined as a patient who had quit smoking >6 months previously. Patients with a discharge diagnosis of ST‐elevation myocardial infarction (MI), non–ST‐elevation MI, or unstable angina were included in the analyses.
The combined population of Cork and Kerry counties in the 2006 census was 620 525, an increase of 40 169, or 6.9%, from the 2002 census.28 Acute coronary care is provided by 8 hospitals, spread throughout the region. Two hospitals have cardiac catheterization laboratories and perform percutaneous coronary interventions, and one of these offers coronary artery bypass surgery. The CHAIR registry was operational in all but one small (120 beds) hospital by early 2003. Data from this hospital were excluded. Data from another hospital (340 beds) were excluded due to incomplete data collection; therefore, the analysis was of admissions to 6 out of the 8 hospitals in the region. Data in the central database were cross‐checked with each hospital's local database to ensure internal validity. We excluded from our analysis patients transferred from hospitals outside of Cork and Kerry counties. We also excluded the small number of patients with suspected ACS transferred from other healthcare facilities, such as nursing homes, as some of these facilities lie within, and some without, Cork and Kerry counties.
To determine whether there were any changes in the number of deaths outside of hospital from MI, which are not captured by CHAIR, we compared mortality data for Cork and Kerry counties for each year of the study period.
Data analyzed were deidentified and patient consent was not sought, as data collected were for the registry, which is subject to separate ethics approval.
Statistical Analysis
The number of ACS admissions was counted for each year, with a year beginning on March 29 and ending on March 28 of the following year. The unit of analysis was an admission for ACS rather than an individual patient, so that it was possible for a person to be counted more than once. Poisson regression analyses were used to model the numbers of ACS events. The population of the region for each study year was projected from the 2002 and 2006 censuses. Crude rates were calculated as the number of ACS divided by the population for that year as estimated from the 2002 and 2006 censuses. Sensitivity analyses were undertaken by gender, smoking status, and type of ACS. To examine the effect of time as a continuous variable, the variation in total weekly admissions with a discharge diagnosis of ACS was examined using a local cubic polynomial (Figure 1). Data analyses were conducted using SAS software version 9.1 (SAS Institute, Pacific Grove, CA), and Stata 11.2 (Stata Corp, College Station, TX).
Figure 1.
Local polynomial showing weekly counts since July 2003. The shaded regions are 95% confidence intervals. The vertical line indicates the date of implementation of the smoking ban.
Results
The CHAIR database includes records on >16 000 patients, and approximately 40% of these patients have a discharge diagnosis of ACS. The patient demographics and cardiovascular risk factors for those admitted to hospital with ACS were similar for each year (Table 1). In the year prior to the introduction of the smoking ban, there were 205.9 ACS admissions per 100 000 population (Table 2). In the year following the implementation of the ban, there was a significant 12% reduction in the rate of admissions (177.9/100,000, 95% confidence interval [CI]: 164.0‐185.1; P = 0.002). There was no change in the rate of admissions for ACS in the following year (174.3/100,000; 95% CI: 164.0‐185.1, P > 0.1). However, a further 13% reduction was observed between March 2006 and March 2007 (149.2; 95% CI: 139.7‐159.2).
Table 1.
Demographics and Traditional Cardiovascular Risk Factors of Patients Admitted With Acute Coronary Syndromes
| 2003–2004 | 2004–2005 | 2005–2006 | 2006–2007 | |
|---|---|---|---|---|
| Male sex, n (%) | 829 (68) | 701 (66) | 720 (68) | 608 (66) |
| Age, y (SD) | 68 (13) | 70 (12) | 68 (13) | 69 (13.6) |
| Total cholesterol, mmol/L (SD) | 5.0 (1.6) | 4.7 (1.6) | 4.7 (1.2) | 4.5 (1.3) |
| Current smokers, n (%) | 408 (34) | 302 (28) | 325 (31) | 271 (29) |
| Hypertension, n (%) | 553 (45) | 553 (52) | 558 (52) | 441 (48) |
| DM, n (%) | 203 (17) | 176 (16) | 171 (16) | 150 (16) |
| BMI (SD) | 27.1 (5.2) | 28.1 (12.4) | 27.7 (4.8) | 28.0 (8.7) |
| Family history IHD, n (%) | 396 (33) | 356 (33) | 350 (33) | 292 (31) |
| Personal history IHD, n (%) | 600 (49) | 517 (48) | 531 (50) | 431 (46) |
Abbreviations: BMI, body mass index; DM, diabetes mellitus; IHD, ischemic heart disease; SD, standard deviation.
Table 2.
Numbers and Rates Per 100 000 Population of Admissions for Acute Coronary Syndromes by Year and Discharge Diagnosis
| Year | All ACS Admissions | STEMI | NSTEMI | UA | ||||
|---|---|---|---|---|---|---|---|---|
| No. | Rate | No. | Rate | No. | Rate | No. | Rate | |
| 2003–2004 | 1216 | 205.9 | 279 | 47.2 | 586 | 99.2 | 351 | 59.4 |
| 2004–2005 | 1069 | 177.9 | 258 | 42.9 | 507 | 84.4 | 304 | 50.6 |
| 2005–2006 | 1065 | 174.3 | 267 | 43.7 | 471 | 77.1 | 327 | 53.5 |
| 2006–2007 | 927 | 149.2 | 210 | 33.8 | 463 | 74.5 | 254 | 40.9 |
Abbreviations: ACS, acute coronary syndromes; NSTEMI, non–ST‐segment elevation myocardial infarction; STEMI, ST‐segment elevation myocardial infarction; UA, unstable angina.
The reduction in admissions for ACS between 2003 to 2004 and 2004 to 2005 was due to a smaller number of cases among men (281.5 vs 233.5/100 000, P = 0.0011) and current smokers (408 vs 302 admissions, P < 0.0001), with no significant change observed among women, former smokers, and never smokers (Tables 3, 4). The second, later, reduction in ACS admissions (2005–2006 compared with the following year, 2006–2007) was due to a reduction among men (235.4 vs 195.2, P = 0.0021) and in current (325 vs 271, P = 0.0269) and never smokers (355 vs 302, P = 0.0386). Over 3 years, a reduction was seen across all categories of ACS (Table 2). The effect of time as a continuous variable was assessed using local polynomials (Figure 1).
Table 3.
Numbers and Rates Per 100 000 of Admissions for Acute Coronary Syndromes by Year and Sex
| 2003–2004 | 2004–2005 | 2005–2006 | 2006–2007 | |||||
|---|---|---|---|---|---|---|---|---|
| No. | Ratea | No. | Ratea | No. | Ratea | No. | Ratea | |
| All ACS | ||||||||
| F | 387 | 130.7 | 368 | 122.4 | 345 | 113.1 | 319 | 103.0 |
| M | 829 | 281.5 | 701 | 233.5 | 720 | 235.4 | 608 | 195.2 |
| STEMI | ||||||||
| F | 83 | 28.0 | 72 | 24.0 | 70 | 22.9 | 69 | 22.3 |
| M | 196 | 66.5 | 186 | 62.0 | 197 | 64.4 | 141 | 45.3 |
| NSTEMI | ||||||||
| F | 199 | 67.2 | 216 | 71.9 | 182 | 59.6 | 175 | 56.5 |
| M | 387 | 131.4 | 291 | 96.9 | 289 | 94.5 | 288 | 92.5 |
| UA | ||||||||
| F | 105 | 35.5 | 80 | 26.6 | 93 | 30.5 | 75 | 24.2 |
| M | 246 | 83.5 | 224 | 74.6 | 234 | 76.5 | 179 | 57.5 |
Abbreviations: ACS, acute coronary syndromes; F, female; M, male; NSTEMI, non–ST‐elevation myocardial infarction; STEMI, ST‐elevation myocardial infarction; UA, unstable angina.
Rate per 100000 females and per 100000 males, respectively.
Table 4.
Number of Acute Coronary Syndromes by Year and Smoking Status
| 2003–2004, No. (%) | 2004–2005, No. (%) | 2005–2006, No. (%) | 2006–2007, No. (%) | |
|---|---|---|---|---|
| All ACS admissions | ||||
| Current | 408 (34) | 302 (28) | 325 (30) | 271 (29) |
| Former | 380 (31) | 378 (35) | 369 (35) | 327 (35) |
| Never | 402 (33) | 370 (35) | 355 (33) | 302 (33) |
| Unknown | 26 (2) | 19 (2) | 16 (1) | 27 (3) |
| STEMI | ||||
| Current | 127 (46) | 81 (31) | 110 (41) | 67 (32) |
| Former | 57 (20) | 77 (30) | 67 (25) | 63 (30) |
| Never | 89 (32) | 93 (36) | 83 (31) | 72 (34) |
| Unknown | 6 (2) | 7 (3) | 7 (3) | 8 (4) |
| NSTEMI | ||||
| Current | 196 (33) | 140 (28) | 132 (28) | 133 (29) |
| Former | 176 (30) | 172 (34) | 155 (33) | 153 (33) |
| Never | 201 (34) | 186 (37) | 177 (38) | 162 (35) |
| Unknown | 13 (2) | 9 (2) | 7 (1) | 15 (3) |
| UA | ||||
| Current | 85 (24) | 81 (27) | 83 (25) | 71 (28) |
| Former | 147 (42) | 129 (42) | 147 (45) | 111 (44) |
| Never | 112 (32) | 91 (30) | 95 (29) | 68 (27) |
| Unknown | 7 (2) | 3 (1) | 2 (1) | 4 (2) |
Abbreviations: ACS, acute coronary syndromes; NSTEMI, non–ST‐elevation myocardial infarction; STEMI, ST‐elevation myocardial infarction; UA, unstable angina.
To determine whether our results could be explained by changes in the number of coronary deaths outside of hospital, we obtained mortality data for Cork and Kerry counties from the Central Statistics Office for each year of the study period. We compared the total number of deaths, deaths from diseases of the circulatory system, deaths from ischemic heart disease, from acute MI, from other heart disease, from other diseases of the circulatory system, from ill‐defined causes, from unknown and unspecified causes, and from cause undetermined. There was no significant change in total deaths from all causes, and the number of deaths from circulatory causes declined by 6.5% over the study period.
Discussion
In this study of the effect of the introduction of a comprehensive workplace smoking ban, we found evidence of an early reduction in hospital admissions due to ACS. Other studies, although having important limitations, have reported broadly comparable results.13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24., 25., 26., 27. All have observed a reduction in admissions with ACS after implementation of public smoking bans, ranging from 7.9% to 71%, with a recent meta‐analysis (including this study in abstract form) reporting a pooled relative risk of 0.90 (95% CI: 0.86‐0.94).29 An early effect of a public smoking ban is consistent with evidence that exposure to secondhand smoke acts as an acute trigger of ACS.11., 12. Smoking bans in other countries have been shown to reduce exposure to tobacco smoke among active smokers and nonsmokers,30 and the Irish ban reduced both self‐reported exposure to secondhand smoke and salivary cotinine levels (a marker of exposure to secondhand smoke) in nonsmoking bar workers.31., 32.
Our study included information on smoking status and the reduction in ACS appeared to be due to an effect among current smokers and men. It is likely that the higher incidence of ACS among men and consequently increased power to detect an effect in men contributed to this finding. The results on smoking status are more difficult to explain. The effect of secondhand smoke would be expected to be more marked among nonsmokers and ex‐smokers than current smokers. In a recent Scottish study, the observed decrease in ACS was more marked in former smokers and those who had never smoked, than in current smokers.22 A similar decrease in ACS admissions among self‐reported nonsmokers was found in a small study from Indiana.18 No other study to date has included smoking status. There was an immediate reduction in the prevalence of smoking following the implementation of the ban,4 and it may be that some of the reduction in ACS among smokers is due to quitting. The later fall in admissions for ACS, of a similar magnitude (13%), was observed in both year‐by‐year comparisons and when examining time as a continuous variable (Figure 1), and is consistent with an increased effect on ACS over time. Several previous studies have been limited by brief follow‐up periods, so any late effect was not assessed. However, 3 recent meta‐analyses of studies have all reported an increased effect over time, with reductions consistent with our findings.29., 33., 34. One possible explanation for later effects is that they are due to less rapidly mediated effects on atherosclerosis severity and prevalence. Underlying secular trends in the incidence of ACS, as well as sample size, may also have contributed to our findings, and further, long‐term studies of the effects of similar smoking bans in different countries are required to precisely define the longer‐term effects on ACS rates.
There are a number of strengths to the design of our study. The Irish smoking ban is the most comprehensive national smoking ban ever implemented. This ensures that any effect on ACS is more likely to be seen than with a partial ban. The use of a prospective register of all patients admitted with suspected ACS as the data source avoided misclassification bias. The availability of information on gender and smoking status allowed us to assess the robustness of our findings among different subgroups. No other significant antismoking measures were implemented during the study period. Legislation increasing the minimum age for purchasing cigarettes was implemented in 2001, before the study period, and restricting pack sizes in 2007, after the end of the study period. There was no significant change in the configuration of acute hospital or emergency services in the region. As shown in Table 1, prevalence of traditional cardiovascular risk factors remained similar. The nationwide nature of the ban, along with Cork and Kerry counties' location on the southwest coast of Ireland, remote from neighboring jurisdictions, minimized the possibility of an effect being obscured by the movement of people in and out of the area where the smoking ban is in effect, or of people seeking healthcare in an area where the smoking ban is not in effect. The age structure of the total Irish population remained similar in the intercensal period, with the largest increase (14.0%) in the 25–44 age group.28
A limitation of this study is that we were unable to analyze data prior to 2003, as the registry was not fully operational before that year. As the registry collects data only on patients admitted to hospital, and not out‐of‐hospital deaths, we cannot be sure whether an increase in these deaths influenced our results. However, analysis of mortality data for Cork and Kerry counties, including total deaths and deaths from diseases of the circulatory system, did not reveal any evidence of an increase that could explain our results. Our data are not comparable to available data on hospital admissions for ACS in Northern Ireland, where a smoking ban was not implemented at the time. The nationwide implementation of the ban therefore precludes a control region. Data collected in the registry do not include measures of secondhand smoke exposure; therefore, we were unable to analyze the influence of this variable on our results.
Our findings, taken with other published studies,13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24., 25., 26., 27. suggest a rapid effect of banning smoking in public places on the incidence of ACS. The finding of a subsequent reduction 2 years after the implementation of the ban is consistent with an increasing effect over time, which may be due to a sustained effect on the incidence of ACS, and is deserving of further study. Given the global preeminence of cardiovascular disease as a cause of premature morbidity and mortality, population‐level interventions to prevent ACS are essential. Our results provide encouragement for legislators and public health authorities worldwide to implement similar policies as a means to reduce the burden of ACS.
Acknowledgements
The authors would like to acknowledge the work of the dedicated CHAIR registration officers in each hospital, and all staff of the CHAIR project; Dr Will Fennell for his assistance in the conception and design of the study, and for his support and encouragement; and Dr. Tony Fitzgerald for his advice on statistical analysis.
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