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November 12th, 2008:

Smoking Ban Tied To A Gain In Lives

Fatal heart attacks drop in Massachusetts

By Stephen Smith, Globe Staff | November 12, 2008

Nearly 600 fewer Massachusetts residents have died from heart attacks each year since legislators banned smoking in virtually all restaurants, bars, and other workplaces four years ago, according to a report to be released today that provides some of the strongest evidence yet that such laws save lives.

The study, conducted by the state Department of Public Health and the Harvard School of Public Health, shows that a steep decline in heart attack deaths started as Boston and most of its neighbors adopted bans. Enforcement of the statewide law beginning in mid-2004 coincided with a further reduction, the study found. From 2003 to 2006, heart attack deaths in Massachusetts plummeted 30 percent, significantly accelerating what had been a more modest long-term decline.

The report, obtained in advance by the Globe, found that the number of heart attacks began dropping in communities with strong antismoking laws years before the 2004 statewide law and that similar reductions were achieved in other cities and towns only after the state ban. By the end of 2006, the rate of decline in all cities and towns had nearly converged. The authors said this pattern showed that advances in treatment of heart attacks were not responsible for the smaller number of deaths.

“This is the strongest study yet done of the effect of smoking bans on heart attacks,” said Dr. Michael Siegel, a Boston University School of Public Health specialist in tobacco control who has been a critic of some antismoking laws and of previous research conducted by the state and Harvard. “You can no longer argue that these declines would have occurred simply due to medical treatment.”

The health benefits of smoking bans have long stirred controversy between advocates and opponents of workplace tobacco laws. While health officials including the US surgeon general have concluded that secondhand smoke is responsible for thousands of deaths annually from heart disease and lung cancer, the tobacco industry and some in the hospitality industry have suggested that the dangers of secondhand smoke are overstated and that there is little evidence that bans prevent deaths.

The study, scheduled to be presented this morning to the state Public Health Council, appears destined to bolster the case of Boston health authorities who have already given preliminary approval to a sweeping strengthening of their tobacco control laws. The toughened Boston regulations would quickly eliminate cigarette sales at drug stores and on college campuses and would shutter swank cigar salons and hookah bars within five years.

The Boston Public Health Commission was supposed to consider final approval of the measures tomorrow, but that vote has been postponed until December, because the board wants to review hundreds of comments that have flowed in, said Barbara Ferrer, executive director of the commission.

The state’s report should prove to critics that her agency is not acting capriciously, Ferrer said. “The Board of Health isn’t just acting because it likes to regulate. It’s acting because there’s so much evidence about the importance of reducing tobacco smoke.”

Brandon Salomon, an owner of the Back Bay stogie bar Cigar Masters, said he was unpersuaded by the state’s research, describing it as skewed science.

“The decrease in heart attacks could be the fact that people have stopped eating carbs so much and are exercising more,” Salomon said.

Much of the evidence about the damage wrought by smoking has focused on lung tumors, the leading cause of cancer deaths in the nation. But cancer takes years to develop, so smoking bans would not be expected to diminish cancer rates for a long time. An expanding body of scientific evidence shows, however, that even fleeting encounters with cigarette smoke can damage the cardiovascular system of nonsmokers.

In one California study published earlier this year, young adults who did not smoke were exposed to secondhand smoke for 30 minutes in amounts meant to mimic what happens in a restaurant or bar. The researchers discovered that even that amount of exposure damaged the lining of blood vessels and disarmed the body’s natural ability to repair such damage.

Cigarette smoke can also cause clots to form or spark a cascade of biological events that causes chunks of fat lining artery walls to shear off, which can result in a heart attack.

“You know all the press that this new study on statins got the other day?” said tobacco researcher Stanton Glantz of the University of California at San Francisco, referring to Boston researchers’ finding that anticholesterol drugs substantially reduce heart attacks and strokes even in patients with normal cholesterol levels. “This is a much bigger deal. And it’s free.”

A spokesman for the nation’s largest cigarette maker, Philip Morris USA, said the company’s website points out that public health officials have shown that secondhand smoke causes heart disease in nonsmokers.

“We agree that people should be able to avoid being around secondhand smoke, particularly in places where they must go,” said company spokesman Bill Phelps.

Led by Tom Land, director of surveillance and evaluation for the Massachusetts Tobacco Control Program, the researchers hunted for signs the reduction might be due to a factor other than tobacco laws.

They considered, for instance, whether there had been an improvement in how heart attack victims were transported to hospitals. They could find nothing that swayed them from their conclusion that there was an indisputable relationship between the smoking ban and fewer heart attack deaths.

That belief was strengthened when they looked at what happened in communities that had either no job-site smoking law before the state ban or a weak law. Heart attack deaths dropped nearly 20 percent in those cities and towns during the first 17 months of the law. In municipalities that had longstanding regulations – and, thus, had seen a steadier decline – the reduction was more modest.

By comparing communities that adopted early smoking bans with those that did not, the researchers were able to estimate that an average of 577 fewer people have died annually from heart attacks because of the law.

“People have assumed that the only benefit we will be able to measure of a smoking ban is long-term benefits,” said John Auerbach, the state public health commissioner. “This study demonstrates a real connection between smoking bans and short-term improvement in health outcomes.”