European Journal of Epidemiology

, Volume 24, Issue 10, pp 597–602 | Cite as

On the relationship between smoking bans and incidence of acute myocardial infarction

  • Antonio GasparriniEmail author
  • Giuseppe Gorini
  • Alessandro Barchielli


During the last few years several studies have reported a substantial reduction of acute myocardial infarction (AMI) in the general population few months after the enforcement of comprehensive smoking bans. We reviewed the consistency and plausibility of this association, investigating the effect of the Italian law, entered into force on January 10, 2005. We compared the AMI incidence on the first year after the ban with the period before (2000–2004) in the Tuscany population aged 30–64 years. The analysis was performed with a Poisson model of the monthly time-series, adjusting for seasonality and comparing different models with linear and non-linear long-term trends. While the model with linear time trend estimated a decrease of 5.4% (RR 0.95; 95% CI: 0.89–1.00), this effect completely disappeared once the linearity assumption was relaxed (RR 1.01; 95% CI: 0.93–1.10). The model with non-linear terms showed a significantly improved fit (P-value = 0.01). The estimate of the effect of the ban seems to be highly sensitive to the model specification and to the effects of unaccounted factors which could modify the trend of AMI incidence, such as changes in the prevalence of other risk factors or the modification of diagnostic criteria. Several arguments which are put forward to inspect the causal relation between smoking bans and AMI indicate that the plausible effects could be lower than the estimates reported so far.


Smoking ban Smoke free-law Myocardial infarction 



Acute myocardial infarction


Second-hand smoke


International classification of diseases, 9th version


Akaike information criterion



The authors are extremely grateful to Zaid Chalabi for his valuable suggestions.


  1. 1.
    Schmidt CW. A change in the air: smoking bans gain momentum worldwide. Environ Health Perspect. 2007;115(8):A412–5.PubMedCrossRefGoogle Scholar
  2. 2.
    IARC (International Agency for Research on Cancer). Tobacco smoke and involuntary smoking. IARC Monogr Eval Carcinog Risks Hum. Lyon: IARC; 2004. p. 1–1438.Google Scholar
  3. 3.
    NCI (National Cancer Institute). Health effects of exposure to environmental tobacco smoke: the report of the California Environmental Protection Agency. Bethesda: National Cancer Institute; 1999.Google Scholar
  4. 4.
    U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general. Atlanta: Centers for Disease Control and Prevention; 2006.Google Scholar
  5. 5.
    Barnoya J, Glantz SA. Cardiovascular effects of second hand smoke: nearly as large as smoking. Circulation. 2005;111(20):2684–98.CrossRefPubMedGoogle Scholar
  6. 6.
    Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ. 1997;315(7114):973–80.PubMedGoogle Scholar
  7. 7.
    Raupach T, Schafer K, Konstantinides S, et al. Secondhand smoke as an acute threat for the cardiovascular system: a change in paradigm. Eur Heart J. 2006;27(4):386–92.CrossRefPubMedGoogle Scholar
  8. 8.
    Howard G, Thun MJ. Why is environmental tobacco smoke more strongly associated with coronary heart disease than expected? A review of potential biases and experimental data. Environ Health Perspect. 1999;107(Suppl 6):853–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Gorini G, Moshammer H, Sbrogio L, et al. Italy and Austria before and after study: second-hand smoke exposure in hospitality premises before and after 2 years from the introduction of the Italian smoking ban. Indoor Air. 2008;18(4):328–34.CrossRefPubMedGoogle Scholar
  10. 10.
    Mulcahy M, Evans DS, Hammond SK, et al. Second hand smoke exposure and risk following the Irish smoking ban: an assessment of salivary cotinine concentrations in hotel workers and air nicotine levels in bars. Tob Control. 2005;14(6):384–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Valente P, Forastiere F, Bacosi A, et al. Exposure to fine and ultrafine particles from secondhand smoke in public places before and after the smoking ban, Italy 2005. Tob Control. 2007;16(5):312–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Repace JL, Hyde JN, Brugge D. Air pollution in Boston bars before and after a smoking ban. BMC Public Health. 2006;6:266.CrossRefPubMedGoogle Scholar
  13. 13.
    Allwright S, Paul G, Greiner B, et al. Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study. BMJ. 2005;331(7525):1117–20.CrossRefPubMedGoogle Scholar
  14. 14.
    Farrelly MC, Nonnemaker JM, Chou R, et al. Changes in hospitality workers’ exposure to second hand smoke following the implementation of New York’s smoke-free law. Tob Control. 2005;14(4):236–41.CrossRefPubMedGoogle Scholar
  15. 15.
    Bartecchi C, Alsever RN, Nevin-Woods C, et al. Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation. 2006;114(14):1490–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Khuder SA, Milz S, Jordan T, et al. The impact of a smoking ban on hospital admissions for coronary heart disease. Prev Med. 2007;45(1):3–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ. 2004;328(7446):977–80.CrossRefPubMedGoogle Scholar
  18. 18.
    Seo DC, Torabi MR. Reduced admissions for acute myocardial infarction associated with a public smoking ban: matched controlled study. J Drug Educ. 2007;37(3):217–26.CrossRefPubMedGoogle Scholar
  19. 19.
    Juster HR, Loomis BR, Hinman TM, et al. Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban. Am J Public Health. 2007;97(11):2035–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Lemstra M, Neudorf C, Opondo J. Implication of a public smoking ban. Can J Public Health. 2008;99(1):62–5.PubMedGoogle Scholar
  21. 21.
    Barone-Adesi F, Vizzini L, Merletti F, et al. Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. Eur Heart J. 2006;27(20):2468–72.CrossRefPubMedGoogle Scholar
  22. 22.
    Cesaroni G, Forastiere F, Agabiti N, et al. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation. 2008;117(9):1183–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Vasselli S, Papini P, Gaelone D, et al. Reduction incidence of myocardial infarction associated with a national legislative ban on smoking. Minerva Cardioangiol. 2008;56(2):197–203.PubMedGoogle Scholar
  24. 24.
    Pell JP, Haw S, Cobbe S, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med. 2008;359(5):482–91.CrossRefPubMedGoogle Scholar
  25. 25.
    Barchielli A, Balzi D, Pasqua A, et al. Incidence of acute myocardial infarction in Tuscany, 1997–2002: data from the Acute Myocardial Infarction Registry of Tuscany (Tosc-AMI). Epidemiol Prev. 2006;30(3):161–8.PubMedGoogle Scholar
  26. 26.
    Clayton D, Hills M. Statistical models in epidemiology. USA: Oxford University Press; 1993.Google Scholar
  27. 27.
    Dobson AJ. An introduction to generalized linear models. 3rd ed. Chapman & Hall/CRC; 2008.Google Scholar
  28. 28.
    Durrleman S, Simon R. Flexible regression models with cubic splines. Stat Med. 1989;8(5):551–61.CrossRefPubMedGoogle Scholar
  29. 29.
    Hunsberger S, Albert PS, Follmann DA, et al. Parametric and semiparametric approaches to testing for seasonal trend in serial count data. Biostatistics. 2002;3(2):289–98.CrossRefPubMedGoogle Scholar
  30. 30.
    ISTAT. Fattori di rischio e tutela della salute. Indagine Multiscopo sulle famiglie 1999–2000: Istituto Nazionale di Statistica (ISTAT); 1999.Google Scholar
  31. 31.
    Tominz R, Poropat C, Bovenzi M. Changes in PM10 and PM2.5 air levels in bars after the enforcement of the smoking ban in the Italian legislation. Epidemiol Prev. 2006;30(6):325–33.PubMedGoogle Scholar
  32. 32.
    Semple S, Creely KS, Naji A, et al. Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation. Tob Control. 2007;16(2):127–32.CrossRefPubMedGoogle Scholar
  33. 33.
    Pell JP, Simpson E, Rodger JC, et al. Impact of changing diagnostic criteria on incidence, management, and outcome of acute myocardial infarction: retrospective cohort study. BMJ. 2003;326(7381):134–5.CrossRefPubMedGoogle Scholar
  34. 34.
    Luepker RV, Apple FS, Christenson RH, et al. Case definitions for acute coronary heart disease in epidemiology and clinical research studies. Circulation. 2003;108(20):2543–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Joint European Society of Cardiology/American College of Cardiology Committee. 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. 2000;21(18):1502–13.CrossRefGoogle Scholar
  36. 36.
    Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation. 1997;96(4):1089–96.PubMedGoogle Scholar
  37. 37.
    Haw SJ, Gruer L. Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey. BMJ. 2007;335(7619):549–52.CrossRefPubMedGoogle Scholar
  38. 38.
    Richiardi L, Vizzini L, Merletti F, et al. Cardiovascular benefits of smoking regulations: the effect of decreased exposure to passive smoking. Prev Med. 2009;48(2):167–72.CrossRefPubMedGoogle Scholar
  39. 39.
    Jamrozik K. Estimate of deaths attributable to passive smoking among UK adults: database analysis. BMJ. 2005;330(7495):812–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Forastiere F, Lo Presti E, Agabiti N, et al. Health impact of exposure to environmental tobacco smoke in Italy. Epidemiol Prev. 2002;26(1):18–29.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  • Antonio Gasparrini
    • 1
    • 2
    Email author
  • Giuseppe Gorini
    • 2
  • Alessandro Barchielli
    • 3
  1. 1.Public and Environmental Health Research UnitLondon School of Hygiene and Tropical MedicineLondonUK
  2. 2.Environmental and Occupational Epidemiology UnitISPO Cancer Prevention and Research InstituteFlorenceItaly
  3. 3.Epidemiology Unit, Local Health UnitFlorenceItaly

Personalised recommendations