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标题：Hospital Admissions for Acute Myocardial Infarction, Angina, Stroke, and Asthma After Implementation of Arizona's Comprehensive Statewide Smoking Ban
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作者：Patricia M. Herman ; Michele E. Walsh
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2011
卷号：101
期号：3
页码：491-496
DOI：10.2105/AJPH.2009.179572
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined the impact of Arizona's May 2007 comprehensive statewide smoking ban on hospital admissions for diagnoses for which there is evidence of a causal relationship with secondhand smoke (SHS) exposure (acute myocardial infarction [AMI], angina, stroke, and asthma). Methods. We compared monthly hospital admissions from January 2004 through May 2008 for these primary diagnoses and 4 diagnoses not associated with SHS (appendicitis, kidney stones, acute cholecystitis, and ulcers) for Arizona counties with preexisting county or municipal smoking bans and counties with no previous bans. We attributed reductions in admissions to the statewide ban if they occurred only in diagnoses associated with SHS and if they were larger in counties with no previous bans. We analyzed the data with Poisson regressions, controlling for seasonality and admissions trends. We also estimated cost savings. Results. Statistically significant reductions in hospital admissions were seen for AMI, angina, stroke, and asthma in counties with no previous bans over what was seen in counties with previous bans. No ban variable coefficients were statistically significant for diagnoses not associated with SHS. Conclusions. Arizona's statewide smoking ban decreased hospital admissions for AMI, stroke, asthma, and angina. Evidence for a direct association between exposure to secondhand smoke (SHS) and a range of health conditions is growing. A number of studies in the United States and other countries^{1 – 10} and 2 meta-analyses^{11 , 12} have shown a decrease in the incidence of acute myocardial infarction (AMI) after the implementation of comprehensive smoking bans. Although the early studies have been criticized for methodological flaws (see, for example, Kabat¹³), later larger and more rigorous studies also have shown this reduction.^{1 , 6 , 7 , 10} Several studies have now also examined the effect of smoking bans on other health conditions. For example, Khuder et al.⁸ focused on coronary heart disease, which included angina, heart failure, atherosclerosis, and AMI. Juster et al.⁷ examined impacts on both AMI and stroke, and Pell et al.¹⁰ considered acute coronary syndrome, which includes AMI and unstable angina. A recent study of New Zealand's national smoking ban¹⁴ examined the effect on both cardiovascular and pulmonary diagnoses. The conditions included were those with “sufficient” (AMI and angina), “suggestive” (stroke and asthma), and “inadequate” (exacerbations of chronic obstructive pulmonary disease [COPD]) evidence of a causal relationship with SHS according to the 2006 US Department of Health and Human Services Surgeon General's report.¹⁵ Although this is the only published study that did not show a reduction in AMIs, possibly because there was a nationwide partial smoking ban in place for 14 years beforehand, it did demonstrate a reduction in the numbers of asthma, stroke, unstable angina, and COPD cases compared with the year before the ban. These reductions did not, however, survive a more rigorous Poisson regression. All studies mentioned previously utilized data on hospital admissions for the conditions of interest. Two other studies used survey methods to obtain data from individuals regarding their respiratory symptoms before and after smoking bans. A study by Menzies et al.¹⁶ used interviews, spirometry, and blood tests of nonsmoking bar workers 1 month before and 2 months after Scotland's national smoking ban to show significant reductions in respiratory (i.e., wheeze, shortness of breath, cough, phlegm) and sensory (i.e., red or irritated eyes, painful throat and nasal itch, runny nose, and sneeze) symptoms, serum cotinine levels, total white blood cell and neutrophil counts, and increases in forced expiratory volume in 1 second. Another study¹⁷ used telephone interviews of hospitality employees immediately before and 5 months after Norway's total ban on smoking in indoor hospitality venues. This study showed a significant reduction in all 5 respiratory symptoms measured (morning cough, daytime cough, phlegm cough, dyspnea, and wheezing). The reductions were largest in former smokers. Finally, all but 1 of the previously discussed studies measured changes in health impacts (hospital admissions or reported symptoms) before and after the implementation of a single smoking ban. By contrast, Juster et al.⁷ tracked monthly hospital admissions in New York State for AMI and stroke over a 10-year period by county, and captured the impact of the statewide ban as well as the impacts of the various county-level smoking bans that were in place previously. The authors classified the county bans as either comprehensive (smoking is prohibited in all worksites, including bars, restaurants, and other hospitality venues) or moderate (smoking is restricted in most worksites, but not in hospitality venues). They found an increased rate of reduction in hospital admissions for AMI after the various bans were implemented, but no immediate reduction—i.e., the interaction between time and ban implementation was statistically significant, but the main effect of ban implementation was not. They also found that the effect of the comprehensive county bans was twice that of the moderate bans, and that the statewide ban resulted in an 8% reduction in AMI admissions in the year after implementation over what had already been accomplished by the county bans. The authors hypothesized that they saw a smaller reduction in AMIs than that seen in earlier studies (40% in Helena, Montana,⁴ and 27% in Pueblo, Colorado¹) because of the incremental enactment of smoking bans and restrictions in New York over time. We used hospital admission data and data on previous county bans to determine whether Arizona's statewide smoking ban reduced the incidence of hospitalizations for AMI, unstable angina, acute stroke, and acute asthma in the state.