Colorado State Smoking Ban: No Impact on Heart Attacks

As early as 2004, various medical journals published articles claiming that small-community smoking bans resulted in nearly immediate reductions in heart disease.  For example, the high-profile BMJ reported that hospital admissions for acute myocardial infarction (AMI) declined 40%, from 40 to 24, in Helena, Montana, after implementation of a smoke-free ordinance (here).  Circulation, the journal of the American Heart Association, reported that AMI admissions dropped 27% “within months” in Pueblo, Colorado (here). Similar reports came from Bowling Green, Ohio (here), Monroe County, Indiana (here) and beyond. 

The striking implication was: Eliminating second-hand smoke saves lives by reducing heart disease.

There were two problems with these claims.  First, the declines, based on small numbers of observations, were actually consistent with random variation (here).  Second, none of the reports accounted for the long-term downward trend in heart disease in the U.S.; they credited no-smoking intervention with the lower number of AMIs at a time when rates were declining nationwide.

In 2011, I documented that state-wide smoking bans in California, Utah, Delaware, South Dakota, New York and Florida had little or no immediate measurable effect on AMI deaths. The study, published in the Journal of Community Health (here), eliminated the “tiny-number” problem and factored in the national downward trend in AMI deaths.

I discussed these findings in my blog (here), but the work was largely ignored, until now.

Recently, researchers from three Colorado institutions reported AMI rates before and after a statewide smoking ban there; their work appears in the American Journal of Medicine (here).  (Thanks to Chris Snowdon, who also blogged about it here).

Paul Basel and colleagues found that “No significant reduction in [AMI] rates was observed” after the Colorado ban was implemented.  They also referred to our study:

“[The Rodu et al.] study compared the decline in [AMI] mortality in 6 states with smoke-free ordinances, with the average decline among 44 states unaffected by smoke-free policy.  No state with a smoke-free ordinance had a significantly lower observed [AMI] mortality compared with that expected by the nationwide secular decrease in states without the ordinance.  This emerging evidence highlights the importance of accounting for secular trends in [AMI] incidence before definitive attribution to smoke-free ordinances can be made.” 

It is comforting to see unfounded second-hand smoke claims corrected, particularly in the pages of a prestigious journal.

Gateway Claims Aimed at E-Cigarettes: Counterfeit, Déjà Vu

In their war against e-cigarettes, government officials often claim that the devices are a gateway to smoking.  CDC director Dr. Tom Frieden asserted (here) that “…many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes.”  The National Cancer Institute last March promoted (here) Dr. Stanton Glantz’s tortured analysis of youth e-cigarette use (discussed here and here).  While his data failed to support a gateway effect, his employer, the University of California San Francisco, made the claim anyway (here).     

Politicians also have a penchant for yelling “fire” about smoke-free devices.  U.S. Senator Richard Durbin and Democratic colleagues in the House and Senate issued a report in April titled “Gateway to Addiction” (here).  The term “gateway”, obviously used as an attention-grabber on the cover, appeared only once in the text -- as a nonspecific example of how e-cigarettes “could also increase public health risks” for non-smokers.

The marijuana gateway claim didn’t gain currency until the 1950s.  Back in the 1930s, Harry Anslinger, the first commissioner of the Federal Bureau of Narcotics (here) and the driving force behind the prohibitive Marijuana Tax Act of 1937, denied a gateway claim during Congressional hearings.  According to the excellent history of marijuana prohibition by Richard Bonnie and Charles Whitebread (here), Representative John Dingell asked Anslinger “whether the marihuana addict graduates into a heroin, an opium or cocaine user.”  The Commissioner replied unequivocally, “No sir; I have not heard of a case of that kind. I think it is an entirely different class. The marihuana addict does not go in that direction.”

By 1951, Anslinger changed course while testifying in favor of the Boggs Act, which increased federal penalties for narcotics and marijuana.  Endorsing marijuana’s new reputation as a treacherous gateway drug, he said: “The danger is this: Over 50 percent of those young addicts started on marijuana smoking. They started there and graduated to heroin; they took the needle when the thrill of marijuana was gone.”

So began marijuana gateway scaremongering, which Dr. James Anthony, professor of epidemiology and biostatistics at Michigan State, labels as “…‘vapors’ that emerged from a political cauldron during the middle of the 20th century when it was very difficult to find definitive and convincing evidence of harmful effects of cannabis use – over and above (1) the sometimes extremely severe consequences of criminal penalties for simple cannabis possession and use, and (2) adverse effects on mouth, nose, throat, and lung.” (abstract here)   

This should sound strikingly familiar to vapers (e-cigarette users) and tobacco harm reduction advocates.  As they did with marijuana, prohibitionists make the gateway claim against e-cigarettes in the near-total absence of “definitive and convincing evidence” of harm.

Snus Users’ Hearts Keep on Ticking, Not Fluttering

Swedish researchers from several institutions document that snus use is not associated with atrial fibrillation (commonly known as AFib), the most common heart arrhythmia (irregular timing of the heart beat) and a risk factor for stroke (abstract here). The same group previously reported that snus use conferred no significant risk for heart attack (discussed here) and stroke (here).

Led by Maria-Pia Hergens, researchers analyzed data on Swedish men who were subjects in several studies.  While snus users had no risks for Afib, smokers had a small but significantly elevated risk (Hazard ratio = 1.16, 95% confidence interval = 1.01-1.33)

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Although smokeless tobacco cannot be proven to be absolutely safe, this study adds important evidence that any cardiovascular effect is very minor.

Given the number of institutions represented by its authors, the report is an important development for tobacco harm reduction.  In contrast are the biased 1990s and 2000s studies from the Karolinska Institute.  There, a small group of KI researchers had access to the construction workers’ cohort and refused to share the data.  Instead, they manipulated the information to fabricate some health risks and amplify others in snus users, a fact which I documented in numerous blog posts (examples here, here, and here) and in letters to journal editors. 

Federal Survey Data on Tobacco: It’s Not About The Children

I have documented for several years a nonstop decline in smoking rates among American teens (here, here, here, and here  )

Rates of smoking and use of other tobacco products among teens are so low that they no longer provide a valid basis for the draconian anti-tobacco policy prescriptions favored by the FDA and CDC. 

A fresh National Survey on Drug Use and Health summary (here) confirms low tobacco use by teens.  The chart at left shows that the smoking rate continued its free-fall through 2013.  Cigar use also declined over the past decade to 2.3% in 2013, while smokeless tobacco use was flat at about 2% over the entire period.

These figures aren’t underestimates.  As I discussed previously (here), NSDUH estimates tend to be robust because they include any product use over the prior 30 days. 

 

Other NSDUH data (in the second chart) point to the population that should be targeted by the FDA and CDC – those aged 18-34.  The sharp jump in smoking prevalence from 11% at ages 16-17, to 27% at ages 18-20, underscores that the latter group is where the real problem starts. 

Anti-tobacco forces know that problematic behaviors in adults don’t stimulate support for prohibitionist policies, so they continue to inaccurately suggest the existence of a youth-tobacco crisis.