March 1, 2017

Stanton A. Glantz, PhD

The evidence keeps piling up: Smoke-free law in São Paulo linked to fewer hospitalizations and deaths due to heart attacks

Tobacco Free Kids recently distributed this summary of a new paper documenting fewer heart attacks following implementation of a smokefree law, this time in Brazil:
São Paulo, a city of more than 12 million inhabitants, was the first city in Brazil to enact a comprehensive smoke-free law. A two-part study published in Tobacco Control evaluated the impact of the law. The first phase reported the positive effects of the smoking ban on air quality, while the second phase analyzed the rates of hospitalization and deaths for heart attacks before and after the enactment of the law (2005-2010). The time-series study primarily uses hospital admission and mortality data from DATASUS, the primary public health database in Brazil, the Mortality Information System (SIM), and population and pollutant data. 
Key Findings

  • The smoke-free law resulted in an immediate reduction in hospital admissions for heart attacks.
  • Hospital admissions for heart attacks decreased 5.4 percent during the first three months after the implementation of the law.
  • In the first 17 months after implementation of the smoke-free law, Sao Paulo experienced a monthly decrease of almost 12 percent in deaths due to heart attacks.
  • This translates to 571 heart attack deaths avoided after the law was implemented.
  • Those who benefited the most from the new smoke-free law were the patrons and workers of bars, restaurants, and other establishments that were not required to be smoke-free under the previous law.

Key Messages

  • Comprehensive smoke-free laws reduce secondhand smoke exposure and improve indoor air quality.
  • Comprehensive smoke-free laws save lives and have both immediate and long-term positive public health impacts.
  • Article 8 of the WHO Framework Convention on Tobacco Control (FCTC) obligates Parties to enact and implement policies that provide comprehensive protection from secondhand smoke exposure by banning smoking in all indoor public places, workplaces and public transportation.

Full citation: Abe TMO, Scholz J, de Masi E, et al. Decrease in mortality rate and hospital admissions for acute myocardial infarction after the enactment of the smoking ban law in Sao Paulo city, Brazil. Tobacco Control. Published Online First: 28 October 2016. 
Study abstract [English only] available from:
Additional Resources:

Tobacco Control is an internationally peer-reviewed journal covering the nature and consequences of tobacco use worldwide. The journal is for health professionals and others in tobacco control and is a publication of the British Medical Journal.
Here is the abstract:
Background Smoking restriction laws have spread worldwide during the last decade. Previous studies have shown a decline in the community rates of myocardial infarction after enactment of these laws. However, data are scarce about the Latin American population. In the first phase of this study, we reported the successful implementation of the law in São Paulo city, with a decrease in carbon monoxide rates in hospitality venues.
Objective To evaluate whether the 2009 implementation of a comprehensive smoking ban law in São Paulo city was associated with a reduction in rates of mortality and hospital admissions for myocardial infarction.
Methods We performed a time-series study of monthly rates of mortality and hospital admissions for acute myocardial infarction from January 2005 to December 2010. The data were derived from DATASUS, the primary public health information system available in Brazil and from Mortality Information System (SIM). Adjustments and analyses were performed using the Autoregressive Integrated Moving Average with exogenous variables (ARIMAX) method modelled by environmental variables and atmospheric pollutants to evaluate the effect of smoking ban law in mortality and hospital admission rate. We also used Interrupted Time Series Analysis (ITSA) to make a comparison between the period pre and post smoking ban law.
Results We observed a reduction in mortality rate (−11.9% in the first 17 months after the law) and in hospital admission rate (−5.4% in the first 3 months
after the law) for myocardial infarction after the implementation of the smoking ban law.
Conclusions Hospital admissions and mortality rate for myocardial infarction were reduced in the first months after the comprehensive smoking ban law was implemented.

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