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DALLAS — The number of acute coronary
events such as heart attack in adults dropped significantly after a smoking
ban in public places in Italy, researchers reported in Circulation: Journal of
the American Heart Association.
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
The indoor concentration of fine particles decreased significantly from a
mean level of 119 Î¼g/m3 before the ban to 43 Î¼g/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
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
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
“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
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.
Editors Note: The American Heart Association advocates for comprehensive
clean indoor workplace policies, as well as increases in tobacco excise taxes
and tobacco control prevention and cessation programs. The association also
strongly supports adequately funded, meaningful Food and Drug Administration
(FDA) authority over the manufacture, sale, distribution, labeling and
promotion of tobacco products.
Statements and conclusions of study authors that are published in the
American Heart Association scientific journals are solely those of the study
authors and do not necessarily reflect association policy or position. The
American Heart Association makes no representation or warranty as to their
accuracy or reliability.