Reduced Hospitalizations for Acute Myocardial Infarction After Implementation of a Smoke-Free Ordinance

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a1.htm (for data and editorial comments)

Reduced Hospitalizations for Acute Myocardial Infarction After Implementation of a Smoke-Free Ordinance --- City of Pueblo, Colorado, 2002--2006

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Exposure to secondhand smoke (SHS) has immediate adverse cardiovascular effects, and prolonged exposure can cause coronary heart disease (1). Nine studies have reported that laws making indoor workplaces and public places smoke-free were associated with rapid, sizeable reductions in hospitalizations for acute myocardial infarction (AMI) (2--7). However, most studies examined hospitalizations for 1 year or less after laws were implemented; thus, whether the observed effect was sustained over time was unknown. The Pueblo Heart Study examined the impact of a municipal smoke-free ordinance in the city of Pueblo, Colorado, that took effect on July 1, 2003 (3). The rate of AMI hospitalizations for city residents decreased 27%, from 257 per 100,000 person-years during the 18 months before the ordinance's implementation to 187 during the 18 months after it (the Phase I post-implementation period).* This report extends that analysis for an additional 18 months through June 30, 2006 (the Phase II post-implementation period). The rate of AMI hospitalizations among city residents continued to decrease to 152 per 100,000 person-years, a decline of 19% and 41% from the Phase I post-implementation and pre-implementation period, respectively. No significant changes were observed in two comparison areas. These findings suggest that smoke-free policies can result in reductions in AMI hospitalizations that are sustained over a 3-year period and that these policies are important in preventing morbidity and mortality associated with heart disease. This effect likely is mediated through reduced SHS exposure among nonsmokers and reduced smoking, with the former making the larger contribution (4,6,7).
Two control sites were selected for comparison with the city of Pueblo: 1) the area of Pueblo County outside the city of Pueblo limits and 2) El Paso County, including Colorado Springs, the most populous city in this county. The city of Pueblo and Colorado Springs are located approximately 45 miles apart (Figure 1). Neither of the control sites had smoke-free laws in place before or during the study periods. Based on data from the Behavioral Risk Factor Surveillance System, the adult smoking prevalence for Pueblo County (including the city of Pueblo) and El Paso County during 2002--2003 was 25.9% (95% confidence interval [CI] = 20.2%--31.6%) and 17.4% (CI = 14.5%--20.2%), respectively. The corresponding prevalences for 2004--2005 were 20.6% (CI = 15.4%--25.8%) and 22.3% (CI = 19.3%--25.4%). Separate smoking prevalence estimates were not available for the city of Pueblo.
Persons with recognized AMIs that occur in the city of Pueblo and Pueblo County receive care at two hospitals, Parkview Medical Center and St. Mary-Corwin Medical Center, both located within the city of Pueblo. Persons with recognized AMIs that occur in El Paso County receive care at two other hospitals, Penrose Hospital and Memorial Hospital, both located in Colorado Springs. Data on AMI hospitalizations were drawn from electronic Colorado Hospital Association administrative data. These data included admission date, primary diagnosis code (based on International Classification of Diseases, Ninth Revision codes 410.0--410.9), sex, age, postal code of residence, and hospital name. No other patient-level data, including smoking status, were available. U.S. Census Bureau population data for 2006 were used as denominators in calculating AMI hospitalization rates. A more extensive description of the study's methodology has been published previously (3). AMI hospitalization rates among residents of the city of Pueblo, the area of Pueblo County outside the city of Pueblo limits, and El Paso County were compared across three periods: 0--18 months before the smoke-free law took effect (pre-implementation period), 0--18 months after this date (Phase I, post-implementation period), and 19--36 months after this date (Phase II, post-implementation period), for a total of 54 months. Rates were compared between periods using a chi-square test. Relative rates (RRs) were calculated as the ratios of AMI rates between two periods. Data presented in this report were not adjusted for seasonality because a season-adjusted analysis of Phase I versus the pre-implementation period found that the adjustment did not significantly change the findings (3).
During Phase II, AMI hospitalizations among residents of the city of Pueblo continued to decrease (Figure 2). AMI hospitalization rates differed significantly across all three periods within the city of Pueblo (p<0.001). ci =" 0.67--0.96)" href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a1.htm#tab">Table). In contrast, no significant change was observed for residents of the area of Pueblo County outside the city of Pueblo limits (139 per 100,000 person-years versus 115 per 100,000 person-years; RR = 1.21 [CI = 0.80--1.62]) or for residents of El Paso County (149 per 100,000 person-years versus 150 per 100,000 person-years; RR = 0.99 [CI = 0.91--1.08]) during the same period. The RR for AMI hospitalizations in the city of Pueblo in the Phase II post-implementation period compared with the pre-implementation period (rate = 257 per 100,000 person-years) was 0.59 (CI = 0.49--0.70). In contrast, RRs for the area of Pueblo County outside the city of Pueblo limits and for El Paso County for the same period were 1.03 (CI = 0.68--1.39) and 0.95 (CI = 0.87--1.03), respectively; the pre-implementation period rates were 135 per 100,000 person-years and 157 per 100,000 person-years, respectively. Within each site, the distribution of AMI patients by age and sex was unchanged over time.
To further examine whether the change in AMI rates could be attributed to pre-existing secular trends, AMI rates were examined for all three sites for three 18-month periods immediately preceding the pre-implementation phase. No statistically significant secular trend occurred in any of the three sites before July 1, 2003.
To ensure that the observed change in the city of Pueblo was not attributable to undercounting fatal AMIs post-implementation, the number of AMI deaths for the city of Pueblo were obtained from the Health Statistics Section of the Colorado Department of Public Health and Environment. After accounting for AMI deaths in a conservative manner (by assuming that all fatal AMIs occurred in patients who failed to reach the hospital) and adding these numbers to the hospital AMI admission data, the RR for the city of Pueblo remained statistically significant at 0.82 (CI = 0.64--0.97) from the Phase II to Phase I post-implementation periods and at 0.66 (CI = 0.55--0.77) from Phase II post-implementation to the pre-implementation period.
Reported by: RN Alsever, MD, Parkview Medical Center; WM Thomas, PhD, St. Mary-Corwin Medical Center; C Nevin-Woods, DO, R Beauvais, S Dennison, R Bueno, Pueblo City-County Health Dept; L Chang, PhD, Colorado State Univ-Pueblo; CE Bartecchi, MD, Univ of Colorado School of Medicine. S Babb, MPH, A Trosclair, MS, M Engstrom, MS, T Pechacek, PhD, R Kaufmann, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.