CLINICAL RESEARCH STUDY

The Effect of a Statewide Smoking Ordinance on Acute

Myocardial Infarction Rates
Paul Basel, BS,a Becki Bucher Bartelson, PhD,b Marie Claire Le Lait, MS,b Mori J. Krantz, MDa,b,c
a
Department of Medicine, University of Colorado Health Sciences Center, Aurora; bDenver Health and the Rocky Mountain Poison and
Drug Center, Denver, Colo; cColorado Prevention Center, Community Health, Aurora.

ABSTRACT
BACKGROUND: Public smoking ordinances may reduce acute myocardial infarction events. Most studies
assessed small communities with reported reductions as high as 40%. No reduction or smaller reductions
were found in countrywide studies; less is known about the impact of statewide ordinances. We previously
demonstrated identical 27% reductions in acute myocardial infarction hospitalizations in 2 Colorado
communities after enactment of strict smoking ordinances. Subsequently, on July 1, 2006, a statewide
ordinance went into effect. We sought to determine the impact of this legislation on acute myocardial
infarction hospitalization rates.
METHODS: Hospital admissions for a primary acute myocardial infarction diagnosis were examined from
2000 to 2008. Poisson regression models were t to the monthly events from January 1, 2000, to March 31,
2008. The nal model included a quadratic trend over time, harmonic terms, and a post-ordinance effect.
The model was adjusted temporally for population changes, using population estimates as an offset
variable.
RESULTS: A total of 58,399 unique acute myocardial infarctions were recorded during the study period.
No signicant reduction in acute myocardial infarction rates was observed post-ordinance (relative risk,
1.059; 95% condence interval, 0.993-1.131). However, a steep decline in acute myocardial infarction rates
was noted from 2000 to 2005 just before enactment. There were 11 strict, local smoking ordinances in effect
within Colorado before enactment of the statewide ordinance. After excluding these communities, the
ndings were similar (relative risk, 1.038; 95% condence interval, 0.971-1.11).
CONCLUSIONS: Although local smoking ordinances in Colorado previously suggested a reduction in acute
myocardial infarction hospitalizations, no signicant impact of smoke-free legislation was demonstrated at
the state level, even after accounting for preexisting ordinances.
2014 Elsevier Inc. All rights reserved.
The American Journal of Medicine (2014) 127, 94.e1-94.e6
KEYWORDS: Acute myocardial infarction; Secondhand smoke; Smoking ordinance

Cigarette smoking is one of the most potent risk factors for

acute myocardial infarction in the United States.1 Secondhand smoke exposure results in a dose-dependent increase
in acute myocardial infarction risk among both smokers and
nonsmokers.2 The biologic basis for secondhand smoke as a
Funding: The Colorado Department of Public Health and Environment
provided $2000 to partially support the statistical analysis; they had no
input regarding implementation, design, and analysis.
Conict of Interest: None.
Authorship: All authors had access to the data and played a role in
writing this manuscript.
Requests for reprints should be addressed to Mori J. Krantz, MD, 777
Bannock St, MC 0960, Denver, CO 80204.
E-mail address: mkrantz@dhha.org
0002-9343/$ -see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjmed.2013.09.014

trigger for acute myocardial infarction has been documented

extensively. The cascade of ischemic events may be mediated through platelet aggregation and plaque destabilization
via augmentation of collagenases that degrade vulnerable
intracoronary plaques.3-5 This proposed mechanism of plaque destabilization suggests that secondhand smoke exposure may precipitously increase acute myocardial infarction
risk, which could explain the abrupt reduction in acute
myocardial infarction rates observed soon after smoking
ordinance enactment in both Colorado and Arizona.6,7
These ndings from geographically isolated communities have led to the assumption that wider adoption of
public smoking restrictions would decrease acute myocardial infarction incidence in the broader population.

Basel et al

Smoking Ordinance on Acute Myocardial Infarction

94.e2

Comprehensive public smoking ordinances now exist in

Data Collection
population centers worldwide. Many studies have attempted
Publically available data on acute myocardial infarction
to quantify the reduction in acute myocardial infarction risk
hospitalizations were obtained from the Colorado Hospital
associated with the elimination of secondhand smoke in
Association, an organization that gathers information
public venues. However, there have been considerable disfrom all acute care hospitals in the State. Deidentied increpancies in the magnitude of the effect of smoke-free
dividual hospitalization records for a primary diagnosis of
legislation. Initial studies exacute myocardial infarction (Inamining smoking ordinances and
ternational Classication of DisCLINICAL SIGNIFICANCE
acute myocardial infarction incieases, Ninth Revision 410.xx)
dence found unexpectedly large

A statewide smoking ordinance in
were obtained for the study period
reductions in acute myocardial
of January 1, 2000 to March 31,
Colorado did not decrease nonfatal
infarction hospitalizations in the
2008. Secondary diagnoses of
acute myocardial infarction hospitalipost-ordinance period, ranging
acute myocardial infarction were
zation rates signicantly, even after
from 11% to 40%.6,8-11 Three
excluded to enhance diagnostic
accounting for previous local smoking
meta-analyses summarize these
accuracy as previously desordinances.
data and suggest that in aggregate,
cribed.6,11 The statewide sum of
smoke-free policy results in a 17%

The utility of smoke-free policy for
acute myocardial infarction adto 19% relative risk (RR) reducmission for each calendar month
reducing the burden of ischemic cardiotion in acute myocardial infarction
in the study period was computed.
vascular
disease
remains
uncertain
incidence rates.12-14
Information about preexisting
despite known associations of secondStatewide and countrywide
local ordinances was obtained
hand smoke with acute myocardial
smoking regulations provide the
from the American Non-smokers
infarction.
opportunity to study larger popRights Foundation.22 A strict local
ulations compared with local
ordinance was dened as one
ordinances. Several countrywide
prohibiting smoking in both bars
studies have been completed, including studies in the
and restaurants and was required to have been enacted at
United States, Italy, Ireland, England, Netherlands, and
least 1 full month before the statewide ordinance was
Scotland.15-21 These studies report a lesser impact (no effect
implemented. Yearly population estimates were obtained
to a 17% reduction), suggesting that inadequate sample size
from the US Census Bureau to calculate population acute
could have led to random variation within smaller popmyocardial infarction rates per 100,000 individuals.23
ulations. Two small communities in Colorado previously
Linear interpolation of the yearly data was used to proenacted smoke-free legislation, and a RR reduction of
duce monthly population estimates.
27% in acute myocardial infarction hospitalizations was
demonstrated.6,11 In 2006, Colorado enacted a statewide
Analysis
smoking ordinance. We therefore assessed the impact of
The study was exempted by the Colorado Multiple Instithis statewide ordinance on acute myocardial infarction
tutional Review Board. Sociodemographic and clinical
hospitalizations overall and after accounting for preexisting
characteristics of the study population were tabulated, and
local ordinances.
differences between the pre- and post-ordinance cohort
were compared using the Student t test and the chi-square
test. A Poisson regression model was t to the time series
MATERIALS AND METHODS
of statewide monthly acute myocardial infarction counts
Smoke-free Ordinance
adjusted for monthly population estimates. Predictor variables included a harmonic to model the seasonal trend in
On July 1, 2006, the Colorado Clean Indoor Air Act was
primary acute myocardial infarction rates, a cubic model of
enacted. The ordinance prohibited smoking in most indoor
time to adjust for secular trends, and an indicator variable
enclosed areas open to the public, including bars, restaufor post-ordinance effect. We then evaluated the overall
rants, building common areas such as elevators and hallpopulation-adjusted acute myocardial infarction rates from
ways, and in all areas of employment that were not
2000 to 2008 and generated relative risk ratios. To deterspecically exempted. Smoking within 15 feet of the main
mine whether model estimates were biased to the null efentrance to a building also was prohibited. Outdoor patio
fect by preexisting local smoking ordinances, analyses
areas and cigar bars were excluded, but signage warning the
were performed subsequently excluding locations with a
public of possible secondhand smoke was required. The
strict smoke-free ordinance. An unadjusted P value less
ordinance included a ne of up to $200 for a rst violation
than .05 was considered to indicate statistical signicance.
within a calendar year escalating to a ne up to $500 for the
All analyses were performed in SAS version 8.0 (SAS
third and each subsequent violation within any given calInstitute Inc, Cary, NC).
endar year.21

94.e3

The American Journal of Medicine, Vol 127, No 1, January 2014

RESULTS
Demographics and hospital length of stay for the population
with acute myocardial infarction are summarized in Table 1.
Primary acute myocardial infarction hospitalization counts
and rates during each year of the study period are shown
in Table 2. At the time of the last calendar year during
the study period, the state of Colorado had an overall
population of 4,939,456 individuals, and a total of 58,399
acute myocardial infarction hospitalizations were recorded.
Among the cohort of patients with acute myocardial
infarction, 63.9% were male. The mean age at hospitalization was 66.9 years. A sequential time series
constructed for acute myocardial infarction hospitalizations
both before and after implementation of the statewide
smoking ordinance is shown in Figure 1. The time series
illustrates both the raw monthly counts and the tted
(predicted) model. Evaluation of the time series plot
reveals several prominent features. First, a substantial
decline over the course of the study, more prominent
during 2000-2005, is apparent. Second, a clear seasonal
trend in raw acute myocardial infarction counts is shown
with peaks occurring in the winter months. Overall, a
nonsignicant increase in trend-adjusted acute myocardial
infarction rates was observed after enactment of the smoking ordinance (RR, 1.059; 95% condence interval [CI],
0.993-1.131).
In Colorado, a total of 11 strict local smoke free ordinances enacted before the statewide ordinance met our
prespecied criteria. Accounting for these local ordinances removed a total of 5411 patients with acute
myocardial infarction and 674,634 individuals from the
overall census population. Removal of corresponding
acute myocardial infarction counts from the numerator and
population counts from the denominator did not modify
the principal ndings signicantly (RR, 1.038; 95% CI,
0.971-1.11).
Table 1 Demographic Characteristics of Patients with Acute
Myocardial Infarction 2000-2008
Total N 58,399
Gender
Male
Female
Race
Asian
Black
Hispanic
Native American
White
Other/unknown
Age, y
Mean  SD
Length of stay, d
Median (IQR)

37,320 (63.9%)*
21,077 (36.1%)*
331
1336
3833
58
35,789
17,052

(0.6%)*
(2.3%)*
(6.6%)*
(0.1%)*
(61.3%)*
(29.2%)*

66.9  14.4

IQR interquartile range; SD standard deviation.

*Number (percentage).

3 (2, 5)

Table 2 Primary Acute Myocardial Infarction Hospitalization

Counts and Rates per 100,000 Person Years
Year

Colorado Population
Estimate

AMI Rate/100,000
Person-Years

2000
2001
2002
2003
2004
2005
2006
2007
2008

7669
7441
7457
6777
6337
6129
6235
5938
4416*

4,327,788
4,431,918
4,503,156
4,548,339
4,600,050
4,662,734
4,751,474
4,842,770
4,939,456

177.2
167.9
165.6
149.0
137.7
131.4
131.2
122.6
119.2

Smoking Ordinance enacted July 1, 2006.

AMI acute myocardial infarction.
*January to August only.
Rate projected through the end of the year.

DISCUSSION
We did not observe a signicant decrease in acute myocardial infarction hospitalization rates in Colorado after
enactment of a comprehensive statewide smoking ordinance. Even after removal of geographic regions where
preexisting smoking ordinances were under enforcement,
no statistically signicant reduction in acute myocardial
infarction hospitalizations was detectable. This contrasts
with a number of prior studies, including 2 local smoking
ordinance studies in Pueblo and Greeley, Colorado,6,11 and
adds to a growing literature that the cardioprotective effect
of smoking bans may be less than initially suggested.
A number of explanations for these ndings warrant our
consideration: First, the ability to discern an impact of
smoke-free legislation may be more difcult when evaluating data at a state level compared with assessing geographically isolated communities where ordinance strength
and enforcement and the ability to limit confounding variables such as population growth and health care delivery
systems changes are more readily accounted for. Second, we
accounted for secular trends in acute myocardial infarction
incidence, which is essential when using an observational,
pre-post time series design. By adjusting for known temporal reductions in acute myocardial infarction incidence in
the United States,24 a measurable impact of smoke-free
legislation may not be discernible. Third, robust acute
myocardial infarction reductions seen in smaller community
studies may be attenuated because larger sample sizes are
used for analysis of the cardiovascular effects of smoke-free
policy.
In support of this paradigm, one national study used
Medicare Provider Analysis and Review les and national
death records; a nonsignicant reduction in acute myocardial infarction-related (RR, 4.1; 95% CI, 9.4 to 1.3) and
all-cause (RR, 0.7, 95% CI, 2 to 0.6) mortality was
observed 1 year after smoking ordinance enactment.15
In this study, researchers evaluated all possible pairs of

Basel et al

Smoking Ordinance on Acute Myocardial Infarction

94.e4

Figure 1 Monthly and predicted acute myocardial infarction rates per 100,000 person-years,
2000-2008. AMI acute myocardial infarction.

ordinance and nonordinance hospitals and recorded the

change in acute myocardial infarction incidence postordinance. They found that RR reductions of 10% or
greater were common, but that RR increases of 10% or
greater were equally as common; taken in aggregate, the
mean was near zero. Another study examined 74 cities
geographically distributed across the United States that
were affected by smoke-free legislation. Individual cities
showed wide variation in acute myocardial infarction incidence after ordinance enactment, with risk ratios ranging
from 36% to 54%; however, the mean risk ratio for the
74 cities was 0.97 (95% CI, 0.96-1.02).25 These analyses
support the hypothesis that small study populations may be
more likely to nd dramatic changes in acute myocardial
infarction incidence, whereas increasing the study sample
size attenuates the magnitude of the reduction. Also, review
of the studies in aggregate reveals data asymmetry that
suggests the potential for publication bias or heterogeneity not entirely explained by a random-effects metaanalysis.13,26 The presence of publication bias13 may
explain why small sample size studies have tended to report
large decreases in acute myocardial infarction incidence,
whereas relatively few small sample studies have shown no
effect.
Overall, a review of published research shows that
acute myocardial infarction RR reduction appears inversely
related to sample size. For example, small studies in Bowling
Green, Ohio, and Helena, Montana, found dramatic RR

reductions (39% and 40%, respectively) but also had

few acute myocardial infarction counts (58 acute myocardial infarctions in Bowling Green, 64 acute myocardial infarctions in Helena) and relatively small study
populations (30,052 and 68,140, respectively).8,10 Studies
in Greeley and Pueblo, Colorado, and Graubnden,
Switzerland, found less dramatic RR reductions (27%,
27%, and 22%, respectively), corresponding to somewhat
larger study populations (w86,000, 147,751, and 188,000,
respectively).6,11,27 A study performed in Christchurch,
New Zealand after a countrywide smoke-free ordinance,
found a 0% RR reduction in acute myocardial infarction
with an approximate population size of 350,000.28 Countrywide studies with larger population bases provide
concordant ndings. In England, a 2.4% RR reduction was
observed (population of 50 million).18 In Italy, a 4% RR
reduction was observed (population of 58 million).16 In
France, a 0% RR reduction was observed (population of 63
million).29 Finally, in a study examining the US Medicare
population in states with a smoke-free ordinance versus
those without, a 0% RR reduction was demonstrated
(population of 30 million).15
Given international heterogeneity in population characteristics and healthcare delivery systems, statewide studies
of acute myocardial infarction rates localized in the United
States provide larger study populations that approximate
smaller nations, yet provide samples larger than individual
cities. These studies seem to mirror the pattern of lower

94.e5
RR reductions than documented in citywide smoking ordinance studies. These include Delaware (4.7% decrease,
population w800,000), Massachusetts (7.4% reduction,
population w3.3 million), and New York (8% reduction, population w19 million).30-32 Our study adds to the
available statewide ordinance data; however, in the Colorado population of approximately 5 million, no statistically
signicant decrease in acute myocardial infarction incidence
was demonstrated. These data support the hypothesis that
small sample size smoking ordinance studies are more prone
to nd prominent RR reductions in acute myocardial
infarction incidence. Studies performed in Piedmont, Italy
and the entire country of Italy, offer insight into the variable
effects of a nationwide smoking ordinance as a function of
population denominator. Increasing sample size from Piedmont (4.3 million) to the entire nation (58 million) attenuated the risk reduction found from 11% to 4%.9,11 Of note,
several studies have examined a portion of a countrywide
population after a countrywide smoke-free ordinance and
demonstrated signicant reductions in acute myocardial
infarction rates. Studies in Southwest Ireland and Scotland
found 12% and 17% risk reductions, respectively.17,20
However, these results may be confounded because they
did not account for secular trends in acute myocardial
infarction incidence.
Available evidence suggests that acute myocardial
infarction incidence has been decreasing dramatically, unrelated to smoke-free ordinances.24 Data from the Centers
for Disease Control National Environmental Public Health
Tracking Network recently evaluated secular trends in 20
Network states from 2000 to 2008 using a longitudinal
linear mixed effects model.33 The authors documented a
statistically signicant overall decrease in age-adjusted
acute myocardial infarction hospitalization rates, with
most states showing more than a 20% decline during the
period. This temporal reduction in acute myocardial
infarction incidence is of a magnitude that exceeds the
reduction observed in many smoking ordinance studies.
Despite this, some analyses have not accounted for secular
trends.6,8-11,17,20,27,28,30 Findings of a reduction in acute
myocardial infarction incidence post-ordinance were no
longer statistically signicant in a number of smaller studies
when these trends in acute myocardial infarction rates were
accounted for.34 Another study compared the decline in
acute myocardial infarction mortality in 6 states with smokefree ordinances, with the average decline among 44 states
unaffected by smoke-free policy. No state with a smoke-free
ordinance had a signicantly lower observed acute myocardial infarction mortality compared with that expected by
the nationwide secular decrease in states without the ordinance.35 This emerging evidence highlights the importance
of accounting for secular trends in acute myocardial
infarction incidence before denitive attribution to smokefree ordinances can be made.
The current study adds to the literature on the cardiovascular impact of smoke-free policy. The evidence-base
now includes reports ranging from geographically isolated

The American Journal of Medicine, Vol 127, No 1, January 2014

communities to studies involving large population bases
including entire countries. Some of the heterogeneity in
outcomes may reect differences in end points and analytic
methods, sample size, and unmeasured confounding variables. In addition, changes in post-ordinance levels of
secondhand smoke exposure and variable duration of
follow-up may account for differential ndings. Overall,
available evidence suggests that the decrease in acute
myocardial infarction incidence associated with reductions
in secondhand smoke exposure may be substantially lower
than originally estimated. Although the American Heart
Association has endorsed smoke-free policy36 as a means to
improve the burden of ischemic heart disease, the scientic
evidence to support this recommendation is inconclusive
and suggests the need for further research.

Study Limitations
A number of methodological limitations of the current study
merit consideration. First, misclassication of exposure via
residential ZIP code may lead to a diminution in our ability
to discern small cardioprotective effects of the statewide
smoke-free ordinance. Inability to control for current
smoking status or confounding variables, such as changes in
smoking prevalence and health policy, may have inuenced
our results. In addition, we evaluated only nonfatal acute
myocardial infarction hospitalizations. Sudden cardiac death
from ventricular arrhythmia is often the presenting manifestation of acute myocardial infarction in the community
setting and is often fatal. This population could not be
assessed using the current hospital-based registry. Whether
out-of-hospital fatal acute myocardial infarction or sudden
cardiovascular death from life-threatening arrhythmia is
reduced by smoke-free policy requires further investigation.
Finally, it remains possible that enactment of a smoking
ordinance in a population with a high baseline smoking
prevalence, such as Scotland,20 might still exert a substantial
positive impact on the incidence of nonfatal acute myocardial infarction hospitalization.

CONCLUSIONS
At the state level, a smoke-free ordinance did not seem to
have a measurable impact on nonfatal acute myocardial
infarction incidence despite favorable effects of smoke-free
policy demonstrated within local studies. Smoke-free policy clearly provides an indoor environment devoid of
environmental tobacco smoke. Moreover, environmental
tobacco smoke exposure may exacerbate other health
problems, such as chronic obstructive pulmonary disease
and asthma. However, the present study does not denitively demonstrate a reduction in acute myocardial infarction incidence attributable to smoke-free legislation. The
possibility that smoke-free policy reduces the risk of out-ofhospital fatal cardiovascular disease events warrants further
investigation.

Basel et al

Smoking Ordinance on Acute Myocardial Infarction

ACKNOWLEDGMENTS
The authors thank Carsten Baumen from the Colorado
Department of Public Health and Environment and
Adrianna Padgett for administrative assistance.

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