“Published Study Finds No Effect of Smoking Ban on Heart Attacks in Tuscany, Italy in First Year After Ban”

I was alerted to the following article on Dr. Michael Siegel’s blog earlier today by Mr. Bill Hannegan, who maintains the blog KEEP St. LOUIS FREE, and who vigorously opposes smoke-free air laws. Mr. Hannegan wrote:

Mr. Pion,

Dr. Michael Siegel, on his blog, had offered $100 to any antismoking group that posts the attached study. I don’t think anyone has taken up his challenge yet. Posting this on your blog is an easy way to pick up $100.

I checked his blog and sure enough Dr. Siegel had challenged anyone in the tobacco control movement to post this study. He asserted that “Anti-smoking groups have largely lost their scientific base and scientific integrity and they are now turning into propaganda machines which are only interested in disseminating findings that are favorable to their cause.” To back up his assertion he was offering $100 to anyone in the “anti-smoking movement” that published the results of this negative study.

I would categorize Missouri GASP as pro-smoke-free air rather than anti-smoking, but we’re more than happy to publicize peer-reviewed and reliable scientific studies which challenge accepted orthodoxy. Likewise we are not afraid to publish any studies funded by MoGASP, no matter what their results show. Below is Dr. Siegel’s blog in its entirety, together with a link to the original published paper which prompted his blog. (The paper has also been uploaded to the mogasp blog as a pdf file: Smoking_bans_&_heart_attacks_Tuscany_study_2010.)

After contacting Dr. Siegel to let him know MoGASP had accepted his challenge he wrote back:

I commend you for being willing to consider the scientific evidence, even if it is “unfavorable” to our agenda. I will highlight your action on my blog and will also make a $100 donation to Missouri GASP. I hope this will set an example for other groups and demonstrate that we can promote anti-smoking policies and retain our scientific integrity at the same time. They are not conradictory to each other.
Thanks for taking a leadership role in the movement in terms of scientific integrity.

Best regards,

Note that on November 29, 2009, the mogasp blog reproduced an article from Parade Magazine with an on-line poll “Should Smoking Be Banned Outdoors?” That post can be found by clicking the above title. The Parade Magazine article noted studies showing a dramatic reduction in heart attacks following the enactment of smoke-free air laws and up to now that has been the accepted science.

Personally, I don’t believe that this latest evidence challenges the estimates of at least 30,000 annual U.S. heart attack deaths among nonsmokers exposed to secondhand smoke, no more than it does the 3,000 lung cancer deaths attributed to the same cause.

Dr. Michael Siegel, Boston University School of Public Health


Published Study Finds No Effect of Smoking Ban on Heart Attacks in Tuscany, Italy in First Year After Ban

A peer-reviewed study published in the European Journal of Epidemiology has concluded that there was no significant effect of the smoking ban in Tuscany, Italy on heart attacks during the first year of implementation (see: Gasparrini A, Gorini G, Barchielli A. On the relationship between smoking bans and incidence of acute myocardial infarction. European Journal of Epidemiology 2009; 24:597-602).

This is the first published study to report no significant effect of a smoking ban on heart attacks.

The smoking ban in Italy went into effect on January 10, 2005. The investigators compared incident cases of acute myocardial infarction (heart attacks) among the Tuscany population (which is about 3.6 million) during the five-year period before the ban (2000-2004) with the number of cases during the first year after the ban (2005).

Monthly, age-standardized rates for acute myocardial infarction were determined for the entire study period and a Poisson regression model was used to assess the significance of any changes in heart attack incidence during 2005 compared to the baseline period. The analysis controlled for seasonality, long-term trends, and changes in the age distribution of the population.

Two models were tested: a linear model and a non-linear model. In the linear model, the authors found that the smoking ban was associated with a non-significant 5.4% reduction in the heart attack rate in 2005. In the non-linear model, the authors found that the smoking ban was associated with no effect whatsoever on heart attack rates (a non-significant 1% increase).

The article concludes: “Differently from the results published to date, this study did not find a comparable effect of the smoke-free law on the incidence of AMI [acute myocardial infarction] during the first year after the implementation of the ban. Our estimate and the related uncertainty suggest that the expected reduction is likely to be lower. … The estimate of the effect of the ban seems to be highly sensitive to the model specification and to the effects of unaccounted factors which could modify the trend of AMI incidence, such as changes in the prevalence of other risk factors or the modification of diagnostic criteria. Several arguments which are put forward to inspect the causal relation between smoking bans and AMI indicate that the plausible effects could be lower than the estimates reported so far.”

The authors close by stating: “The implementation of smoking bans in public places represents a milestone in the history of public health. The relationship with a decrease of both active and passive smoke is unquestionable, with conclusive evidences on the reductions of a number of health outcomes after the enforcement. In particular, a decrease of cardiovascular events in the long run is expected, given the conclusive association with chronic SHS exposure. On the other hand, the estimate of the short-term effect of smoking bans on cardiovascular diseases is still uncertain, and the range of reduction showed by some of the studies published to date is likely to be an overestimate, not consistent with previous knowledge about the burden of cardiovascular diseases attributable to SHS. Moreover, several other factors, like changes in diagnostic criteria, have a strong influence on the trend of cardiovascular diseases, and it seems very problematic to properly control for their effects with this study design. Nonetheless, as this study has shown, the resulting bias could be substantial.”

The Rest of the Story

This study has a number of important strengths compared to the previous literature on this research question. First, it covers a large population of about 5.6 million people. The results are based on a total of 13,456 new cases of myocardial infarction. This compares with only 304 heart attacks in the Helena study.

A second advantage of this study is that the identification of heart attack cases is based on a registry (the Acute Myocardial Infarction Registry of Tuscany), which provides consistent surveillance for heart attacks occurring throughout the study period. This differs from studies such as the one in Scotland, where different methods were used to identify heart attacks occurring pre-ban and post-ban.

Perhaps the most important strength of the study is that it included a reasonable baseline period of five years, rather than just one or two years prior to the implementation of the smoking ban, which was the case in many of the previous studies.

A final strength of this study is that it considered both linear and non-linear trends in heart attacks to model the results. But it is important to note that even with a linear trend assumption, the study found no significant effect of the smoking ban and the estimated magnitude of the association was quite small (just 5.4%).

Importantly, this published study was not considered by the Institute of Medicine committee which reviewed this issue and released its report in October of last year. It was also not considered in published meta-analyses on this topic. Because of the high sample size of this study, it is likely that inclusion of this study in the previous meta-analyses would have negated their results.

While one study does not prove or disprove a hypothesis (one always needs to look at the totality of the evidence), this study is important because it is not consistent with the conclusions that have been widely disseminated by anti-smoking groups. The interesting thing to observe will be whether or not these findings are even reported by these groups.

Based on my experience in the anti-smoking movement, I am willing to bet that not a single group which previously reported the results of studies “favorable” to their cause will now report the results of this negative study. In fact, I’m so sure that no group will do this that I am putting up a $100 reward for the first group that does. I will contribute $100 to the first anti-smoking organization that previously reported the results of one of the positive studies and which now reports the results of this negative study.

I’m not worried about losing my money because as I’ve recently learned, it’s not the quality of the science or the truth that is important. It’s the favorability of the findings. Anti-smoking groups have largely lost their scientific base and scientific integrity and they are now turning into propaganda machines which are only interested in disseminating findings that are favorable to their cause. They will not share unfavorable findings because the ultimate goal is not the truth and the scientific facts, but the supporting of the agenda.

I’d love to be proven wrong. It can be done simply by emailing me the link to an anti-smoking group’s dissemination of the results of the Tuscany study. I’ll be waiting.

16 responses to ““Published Study Finds No Effect of Smoking Ban on Heart Attacks in Tuscany, Italy in First Year After Ban”

  1. harleyrider1978

    Since 1981 there have been 148 reported studies on ETS, involving spouses, children and workplace exposure. 124 of these studies showed no significant causal relationship between second hand smoke and lung cancer. Of the 24 which showed some risk, only two had a Relative Risk Factor over 3.0 and none higher. What does this mean. To put it in perspective, Robert Temple, director of drug evaluation at the Food and Drug Administration said “My basic rule is if the relative risk isn’t at least 3 or 4, forget it.” The National Cancer Institute states “Relative risks of less than 2 are considered small and are usually difficult to interpret. Such increases may be due to mere chance, statistical bias, or the effect of confounding factors that are sometimes not evident.” Dr. Kabat, IAQC epidemiologist states “An association is generally considered weak if the relative risk is under 3.0 and particularly when it is under 2.0, as is the case in the relationship of ETS and lung cancer. Therefore, you can see any concern of second hand smoke causing lung cancer is highly questionable.” Note that the Relative Risk (RR) of lung cancer for persons drinking whole milk is 2.14 and all cancers from chlorinated water ranked at 1.25. These are higher risks than the average ETS risk. If we believe second hand smoke to be a danger for lung cancer then we should also never drink milk or chlorinated water.

    • Congratulations on limiting your comment to 240 words! That is far more reasonable than some of your posts elsewhere. Regarding Dr. Kabat, he coauthored a study with Dr. Enstrom that has been heavily criticized, and rightly so as far as I can tell, for faulty science. I’ve never seen the statements you quote above before regarding the RR of lung cancer from drinking milk or chlorinated water but they are astonishing. Please provide your reference.
      However, you should be aware that because secondhand smoke (SHS) falls into the “weak risk” category doesn’t mean it can be dismissed. This is simply a scientific term differentiating it from a strong risk, such as that posed by active smoking.

      • Endothelial dysfunction can result in heart attacks for those at risk with pre-existing conditions, in higher extremes as a result of standing placing your hand over your heart and singing an energetic rendition of the national anthem. The effect can be seen consistently indoors and out.

        As Stanton Glanz has predicted on numerous occasions “Endothelial Dysfunction is important in the development of heart disease.”

        Should we be talking about a ban?

  2. Science by committee [The consensus view] has taken science to new lows. We now find ourselves in the dark ages of scientific integrity. It is not surprising that the larger studies demonstrate little change in Heart attack rates after smoking bans are imposed, or that casual exposures to second hand smoke posses little threat to anyone.

    What is surprising about this study is not found in its conclusions. The surprising information, is that anyone with an intelligence level of [Forest Gump + 1] would have believed anything else could be the case.

    Biological plausibility has been cast aside in promotion of the ridiculous, with the word science tacked on, not because we are seeing anything scientific, beyond political sciences, but because it sounds great in front of the cameras.

    A heart attack attributed to heart disease, is a condition which requires many years to evolve in a normal human of reasonably good health. The only significant factor we have ever recognized which increases the rate of heart attacks, in the short term, is stress. If the promotion of SES has left many in large populations seeing real physical effects, in reaction to a wisp of smoke, perhaps it is the promotions and not the smoke which need to be investigated, as deleterious to human health. The promotions are certainly deteriorating our respect for legitimate science and its ultimate integrity.

    • MoGASP reply: I believe there’s good evidence to associate a heart attack following exposure to SHS for an individual with a propensity for heart attacks. I also think the evidence linking SHS exposure in health nonsmokers to deaths due to lung cancer and heart attacks is well-founded, as the latest U.S. Surgeon General’s Reports have concluded, which can be found on-line here:

      • Thanks for your reply and willingness to discuss this topic. It is refreshing to experience and we should engage our opinions much more often.

        “MoGASP reply: I believe there’s good evidence to associate a heart attack following exposure to SHS for an individual with a propensity for heart attacks”

        Agreed however the entire population does not fit this narrow perspective. Endothelial dysfunction as the major flag of evidence, is a scary sounding condition however it need not be. The effect of walking into a change of temperature, running a dozen yards, or eating a big mac, produces identical biological effects.

        If we all experience these changes daily and they are not avoidable. What are you really telling the public by claiming a huge health risk exists, when promoting outdoor smoking bans, or bans in cars with children, to those who do not have an existing heart condition or children with debilitating health conditions?

        Your telling me that the moralist component of your agenda, is more important than complete disclosures and facts.

  3. Martin,
    Thanks again for your willingness to disseminate all the scientific evidence on this issue, not just that which supports the agenda which both your group and I share. I agree with you that this study is not relevant to the claims about the chronic health effects of secondhand smoke. However, I do believe that anti-smoking groups have been exaggerating the evidence about the acute cardiovascular effects (i.e., 30 minutes of exposure causes heart disease). I believe that the truth is enough to support workplace smoking bans and that we don’t need to exaggerate or distort the science. In fact, I believe that groups which are distorting the science are actually hurting, not helping the cause, because they are destroying the credibility of the tobacco control movement. Best regards,

  4. It’s nice to see some honesty for a change!
    It’s to bad the main stream media doesn’t know what HONESTY is.

    Seeing the media report on who pays for the negative ‘to fit the agenda’ studies AND the bans would be nice too. That is ‘pays for’, not who stamps their name on it.

    • I don’t know about others but I’m interested in truthful studies, even if they don’t fit my expectations. That’s how science helps us make progress.

  5. Thank you for postings this article! Double-digit decreases in heart attack prevalence following the enacting of a smoking ban defies common sense. When one considers the variables involved in assessment the 17-47% decreases reported from a myriad of studies border on fantasy. When these reported decreases are distributed to the media the our society is saturated with the numbers. If a correction to the numbers is made…media demand wanes.

    I am a follower of science and truth and I thank you for restoring my faith that a Pro-Clean Air advocate seeks truth as well!

  6. Pingback: Medical News » Missouri GASP Disseminates Results of Tuscany Heart Attack/Smoking Ban Study, Wins $100 Award for Scientific Integrity

  7. harleyrider1978

    CONCLUSIONS: These results suggest that exposure to chlorination by-products in drinking water is associated with increased risk of colon cancer.

    you dont have to post this up to you

    Milk drinking, other beverage habits, and lung cancer risk.
    Mettlin C.

    Dept. of Cancer Control and Epidemiology, Roswell Park Memorial Institute, Buffalo, NY 14263.


    The reported beverage habits of 569 lung cancer patients and 569 control patients admitted to Roswell Park Memorial Institute (RPMI) were studied, 355 male cases and 214 female cases being matched to controls within strata of age and residence. Smoking history and an index of vitamin A from vegetables had significant, dose-response associations with risk. Animal fat intake as measured by an index of animal fats from meats showed elevated risks which were not significant. Three vegetables rich in vitamin A and 3 meats contributing to the animal fat index were, individually, associated with lung cancer risk. Frequency of consumption of milk, coffee, tea, soft drinks and alcoholic beverages was studied in multiple logistic regression analyses which controlled for smoking history, intake of vitamin A from vegetables and education level. Subjects reporting consumption of whole milk 3 or more times daily had a 2-fold increase in lung cancer risk compared to those who reported never drinking whole milk (RR = 2.14). The same frequency of intake of reduced-fat milk was associated with a significant protective effect (RR = .54). Significant risk variations were observed for other beverages but, with the exception of frequencies of reported diet cola and decaffeinated coffee intake, dose-response patterns were not evident.

    OBJECTIVES: This study assessed the association of drinking water source and chlorination by-product exposure with cancer incidence. METHODS: A cohort of 28,237 Iowa women reported their drinking water source. Exposure to chlorination by-products was determined from statewide water quality data. RESULTS: In comparison with women who used municipal ground-water sources, women with municipal surface water sources were at an increased risk of colon cancer and all cancers combined. A clear dose-response relation was observed between four categories of increasing chloroform levels in finished drinking water and the risk of colon cancer and all cancers combined. The relative risks were 1.00, 1.06, 1.39, and 1.68 for colon cancer and 1.00, 1.04, 1.24, and 1.25 for total cancers. No consistent association with either water source or chloroform concentration was observed for other cancer sites.

    • MoGASP reply: harleyrider1978 e-mailed this rather long comment, giving me the discretion on whether to post it or not, and I decided to post it and provide a longish reply.
      However, instead of leaving the article’s conclusion at the bottom, I instead pasted it at the top so the reader can decide for him or herself whether to bother to read the rest of it or not.
      It’s a conclusion that doesn’t seem to have anything to do directly with secondhand smoke, other than that there may be a significant health risk of colon cancer from drinking chlorinated water. That wouldn’t be entirely a surprise since chlorinated water in the U.S. also contains fluorine, which is absent from water supplies in England, for example. I understand there are health concerns about fluoridated water. It would be interesting to know how the incidence of colon cancer compares between Britain and the U.S. This may also suggest that colon cancer screening is important in the U.S. This is just speculation, however.

  8. When I read long and obviously fairly well researched (if not, necessarily, well, fairly researched) comments by people who sign with blognomens like “HarleyRider78”, I always ask myself, “Is he/she oneathem Harley ridin’ lawyers who is a shill for the tobacco industry. But I know I can always trust big tobacco to be honest in it’s dealings with the american public.

    MoGasp’s motivations may not be obvious but they don’t appear to profit driven. Big Tobacco’s, otoh, are PURELY profit driven.

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