Clinical Research in Cardiology

, Volume 101, Issue 3, pp 227–235 | Cite as

Smoking restrictions and hospitalization for acute coronary events in Germany

  • James D. Sargent
  • Eugene Demidenko
  • David J. Malenka
  • Zhongze Li
  • Helmut Gohlke
  • Reiner Hanewinkel
Original Paper

Abstract

Aims

To study the effects of smoking restrictions in Germany on coronary syndromes and their associated costs.

Methods and results

All German states implemented laws partially restricting smoking in the public and hospitality sectors between August 2007 and July 2008. We conducted a before-and-after study to examine trends for the hospitalization rate for angina pectoris and acute myocardial infarction (AMI) for an insurance cohort of 3,700,384 individuals 30 years and older. Outcome measures were hospitalization rates for coronary syndromes, and hospitalization costs. Mean age of the cohort was 56 years, and two-thirds were female. Some 2.2 and 1.1% persons were hospitalized for angina pectoris and AMI, respectively, during the study period from January 2004 through December 2008. Law implementation was associated with a 13.3% (95% confidence interval 8.2, 18.4) decline in angina pectoris and an 8.6% (5.0, 12.2) decline in AMI after 1 year. Hospitalization costs also decreased significantly for the two conditions—9.6% (2.5, 16.6) for angina pectoris and 20.1% (16.0, 24.2) for AMI at 1 year following law implementation. Assuming the law caused the observed declines, it prevented 1,880 hospitalizations and saved 7.7 million Euros in costs for this cohort during the year following law implementation.

Conclusions

Partial smoking restrictions in Germany were followed by reductions in hospitalization for angina pectoris and AMI, declines that continued through 1 year following these laws and resulted in substantial cost savings. Strengthening the laws could further reduce morbidity and costs from acute coronary syndromes in Germany.

Keywords

Smoking ban Cardiovascular diseases Hospitalizations Costs Germany 

References

  1. 1.
    Peto R, Lopez AD, Boreham J, Thun M, Heath C (1994) Mortality from smoking in developed countries 1950–2000. Indirect estimates from national vital statistics. Oxford University Press, OxfordGoogle Scholar
  2. 2.
    Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet 364(9438):937–952PubMedCrossRefGoogle Scholar
  3. 3.
    Gohlke H, Yusuf S (2007) Quantitating loss of life by smoking a single cigarette. Clin Res Cardiol 96(7):522–523PubMedCrossRefGoogle Scholar
  4. 4.
    Sherif MA, Nienaber CA, Toelg R, Abdel-Wahab M, Geist V, Schneider S et al (2011) Impact of smoking on the outcome of patients treated with drug-eluting stents: 1-year results from the prospective multicentre German Drug-Eluting Stent Registry (DES.DE). Clin Res Cardiol 100(5):413–423PubMedCrossRefGoogle Scholar
  5. 5.
    US Department of Health and Human Services (2006) The health consequences of involuntary exposure to tobacco: a report of the Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and HealthGoogle Scholar
  6. 6.
    Glantz SA, Parmley WW (1995) Passive smoking and heart disease. Mechanisms and risk. JAMA 273(13):1047–1053PubMedCrossRefGoogle Scholar
  7. 7.
    Law MR, Morris JK, Wald NJ (1997) Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ 315(7114):973–980PubMedCrossRefGoogle Scholar
  8. 8.
    Sun YP, Zhu BQ, Sievers RE, Glantz SA, Parmley WW (1994) Metoprolol does not attenuate atherosclerosis in lipid-fed rabbits exposed to environmental tobacco smoke. Circulation 89(5):2260–2265PubMedGoogle Scholar
  9. 9.
    Zhu BQ, Sun YP, Sievers RE, Isenberg WM, Glantz SA, Parmley WW (1993) Passive smoking increases experimental atherosclerosis in cholesterol-fed rabbits. J Am Coll Cardiol 21(1):225–232PubMedCrossRefGoogle Scholar
  10. 10.
    Hutchison SJ, Sudhir K, Sievers RE, Zhu BQ, Sun YP, Chou TM et al (1999) Effects of l-arginine on atherogenesis and endothelial dysfunction due to secondhand smoke. Hypertension 34(1):44–50PubMedGoogle Scholar
  11. 11.
    Kallio K, Jokinen E, Raitakari OT, Hamalainen M, Siltala M, Volanen I et al (2007) Tobacco smoke exposure is associated with attenuated endothelial function in 11-year-old healthy children. Circulation 115(25):3205–3212PubMedCrossRefGoogle Scholar
  12. 12.
    Leone A, Balbarini A (2008) Exposure to passive smoking: a test to predict endothelial dysfunction and atherosclerotic lesions. Angiology 59(2):220–223PubMedCrossRefGoogle Scholar
  13. 13.
    Elwood PC, Renaud S, Sharp DS, Beswick AD, O’Brien JR, Yarnell JW (1991) Ischemic heart disease and platelet aggregation. The Caerphilly Collaborative Heart Disease Study. Circulation 83(1):38–44PubMedGoogle Scholar
  14. 14.
    Schmidt KG, Rasmussen JW (1984) Acute platelet activation induced by smoking. In vivo and ex vivo studies in humans. Thromb Haemost 51(2):279–282PubMedGoogle Scholar
  15. 15.
    Pope CA III, Burnett RT, Krewski D, Jerrett M, Shi Y, Calle EE et al (2009) Cardiovascular mortality and exposure to airborne fine particulate matter and cigarette smoke: shape of the exposure–response relationship. Circulation 120(11):941–948PubMedCrossRefGoogle Scholar
  16. 16.
    Centers for Disease Control and Prevention (CDC) (2009) Reduced hospitalizations for acute myocardial infarction after implementation of a smoke-free ordinance–City of Pueblo, Colorado, 2002–2006. MMWR Morb Mortal Wkly Rep 57(51):1373–1377Google Scholar
  17. 17.
    Barnoya J, Glantz SA (2006) Cardiovascular effects of second-hand smoke help explain the benefits of smoke-free legislation on heart disease burden. J Cardiovasc Nurs 21(6):457–462PubMedGoogle Scholar
  18. 18.
    Barone-Adesi F, Vizzini L, Merletti F, Richiardi L (2006) Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. Eur Heart J 27(20):2468–2472PubMedCrossRefGoogle Scholar
  19. 19.
    Bartecchi C, Alsever RN, Nevin-Woods C, Thomas WM, Estacio RO, Bartelson BB et al (2006) Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation 114(14):1490–1496PubMedCrossRefGoogle Scholar
  20. 20.
    Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci CA (2008) Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 117(9):1183–1188PubMedCrossRefGoogle Scholar
  21. 21.
    Jones SC, Travers MJ, Hahn EJ, Robertson H, Lee K, Higbee C et al (2006) Secondhand smoke and indoor public spaces in Paducah, Kentucky. J Ky Med Assoc 104(7):281–288PubMedGoogle Scholar
  22. 22.
    Juster HR, Loomis BR, Hinman TM, Farrelly MC, Hyland A, Bauer UE et al (2007) Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban. Am J Public Health 97(11):2035–2039PubMedCrossRefGoogle Scholar
  23. 23.
    Khuder SA, Milz S, Jordan T, Price J, Silvestri K, Butler P (2007) The impact of a smoking ban on hospital admissions for coronary heart disease. Prev Med 45(1):3–8PubMedCrossRefGoogle Scholar
  24. 24.
    Lemstra M, Neudorf C, Opondo J (2008) Implications of a public smoking ban. Can J Public Health 99(1):62–65PubMedGoogle Scholar
  25. 25.
    Pell JP, Haw S, Cobbe S, Newby DE, Pell AC, Fischbacher C et al (2008) Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med 359(5):482–491PubMedCrossRefGoogle Scholar
  26. 26.
    Sargent RP, Shepard RM, Glantz SA (2004) Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 328(7446):977–980PubMedCrossRefGoogle Scholar
  27. 27.
    Seo DC, Torabi MR (2007) Reduced admissions for acute myocardial infarction associated with a public smoking ban: matched controlled study. J Drug Educ 37(3):217–226PubMedCrossRefGoogle Scholar
  28. 28.
    Bonetti PO, Trachsel LD, Kuhn MU, Schulzki T, Erne P, Radovanovic D et al (2011) Incidence of acute myocardial infarction after implementation of a public smoking ban in Graubunden, Switzerland: two year follow-up. Swiss Med Wkly 141:w13206PubMedGoogle Scholar
  29. 29.
    Herman PM, Walsh ME (2011) Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona’s comprehensive statewide smoking ban. Am J Public Health 101(3):491–496PubMedCrossRefGoogle Scholar
  30. 30.
    Naiman A, Glazier RH, Moineddin R (2010) Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions. CMAJ 182(8):761–767PubMedCrossRefGoogle Scholar
  31. 31.
    Sims M, Maxwell R, Bauld L, Gilmore A (2010) Short term impact of smoke-free legislation in England: retrospective analysis of hospital admissions for myocardial infarction. BMJ 340:c2161PubMedCrossRefGoogle Scholar
  32. 32.
    Villalbi JR, Sanchez E, Benet J, Cabezas C, Castillo A, Guarga A et al (2011) The extension of smoke-free areas and acute myocardial infarction mortality: before and after study. BMJ Open 1(1):000067Google Scholar
  33. 33.
    Lightwood JM, Glantz SA (2009) Declines in acute myocardial infarction after smoke-free laws and individual risk attributable to secondhand smoke. Circulation 120(14):1373–1379PubMedCrossRefGoogle Scholar
  34. 34.
    Meyers DG, Neuberger JS, He J (2009) Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis. J Am Coll Cardiol 54(14):1249–1255PubMedCrossRefGoogle Scholar
  35. 35.
    Andersohn F, Schlattmann P, Roll S, Muller-Riemenschneider F, Binting S, Willich SN (2010) Regional variation of mortality from ischemic heart disease in Germany from 1998 to 2007. Clin Res Cardiol 99(8):511–518PubMedCrossRefGoogle Scholar
  36. 36.
    Müller S, Kraus L, Piontek D, Pabst A (2011) Changes in exposure to secondhand smoke and smoking behavior. Sucht 56(5):3–373Google Scholar
  37. 37.
    Bickel PJ (2001) Mathematical statistics, 2nd edn. Prentice-Hall, Upper Saddle River, NJGoogle Scholar
  38. 38.
    Fichtenberg CM, Glantz SA (2002) Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ 325(7357):188PubMedCrossRefGoogle Scholar
  39. 39.
    Lampert M, List SM (2010) Tabak-Zahlen und Fakten zum Konsum. In: Deutsche Hauptstelle für Suchtfragen (ed) Jahrbuch Sucht 2010. Neuland, Geesthacht, pp 48–68Google Scholar
  40. 40.
    Schuler J, Maier B, Behrens S, Thimme W (2006) Present treatment of acute myocardial infarction in patients over 75 years—data from the Berlin Myocardial Infarction Registry (BHIR). Clin Res Cardiol 95(7):360–367PubMedCrossRefGoogle Scholar
  41. 41.
    Tebbe U, Messer C, Stammwitz E, The GS, Dietl J, Bischoff KO et al (2007) Reduction of in-hospital mortality and improved secondary prevention after acute myocardial infarction. First results from the registry of secondary prevention after acute myocardial infarction (SAMI). Dtsch Med Wochenschr 132(30):1559–1566PubMedCrossRefGoogle Scholar
  42. 42.
    The Joint European Society of Cardiology/American College of Cardiology Committee (2000) Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J 21(18):1502–1513Google Scholar
  43. 43.
    Alpert JS, Thygesen K, Antman E, Bassand JP (2000) Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 36(3):959–969PubMedCrossRefGoogle Scholar
  44. 44.
    Gu YL, Voors AA, Zijlstra F, Hillege HL, Struck J, Masson S et al (2011) Comparison of the temporal release pattern of copeptin with conventional biomarkers in acute myocardial infarction. Clin Res Cardiol 100(12):1069–1076Google Scholar
  45. 45.
    Kurz K, Giannitsis E, Becker M, Hess G, Zdunek D, Katus HA (2011) Comparison of the new high sensitive cardiac troponin T with myoglobin, h-FABP and cTnT for early identification of myocardial necrosis in the acute coronary syndrome. Clin Res Cardiol 100(3):209–215PubMedCrossRefGoogle Scholar
  46. 46.
    Meiser F (2008) Effect of the modified definition of the myocardial infarct using troponin for diagnosis, therapy, and process of NSTEMI in clinical daily routine in Germany [Einfluss der geänderten Definition des Myokardinfarktes unter Berücksichtigung der Troponine auf Diagnose, Therapie und Verlauf des NSTEMI im klinischen Alltag in Deutschland]. Doctoral thesis, University of Heidelberg, HeidelbergGoogle Scholar
  47. 47.
    IOM (Institute of Medicine) (2010) Secondhand smoke exposure and cardiovascular effects: making sense of the evidence. The National Academy Press, Washington, DCGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • James D. Sargent
    • 1
  • Eugene Demidenko
    • 2
  • David J. Malenka
    • 3
  • Zhongze Li
    • 4
  • Helmut Gohlke
    • 5
  • Reiner Hanewinkel
    • 6
  1. 1.Department of PediatricsDartmouth Medical SchoolLebanonUSA
  2. 2.Department of Community & Family MedicineDartmouth Medical SchoolLebanonUSA
  3. 3.Dartmouth-Hitchcock Medical Center, CardiologyLebanonUSA
  4. 4.Biostatical Shared ServicesNorris Cotton Cancer CenterLebanonUSA
  5. 5.Herz-ZentrumBad KrozingenGermany
  6. 6.Institut für Therapie- und Gesundheitsforschung (IFT-Nord)KielGermany

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