August 5, 2013

Stanton A. Glantz, PhD


Casinos throughout the country are often exempt from smoke-free workplace laws. Now a new study led by UC San Francisco has found that when smoking is banned in casinos, it results in considerably fewer emergency calls for ambulances.
The study is the first to examine the health impact of smoking bans in casinos.
The authors conclude that if smoke-free laws were to apply to casinos as well as other businesses, it would prevent many medical emergencies and reduce public health costs.
“Our study suggests that exempting casinos from smoke-free laws means that more people will suffer medical emergencies as a result,” said lead author Stanton A. Glantz, PhD, UCSF professor of medicine and director of the Center for Tobacco Control Research and Education at UCSF.
“The research shows strong evidence of a significant drop in ambulance calls due to less secondhand smoke exposure,” Glantz said. “Inhaling secondhand smoke increases the likelihood of dangers with blood clots and makes it more difficult for arteries to expand properly – changes that can trigger heart attacks. Legislative and tribal exemptions for casinos, which are all too common, are potentially putting employees and customers at risk of secondhand smoke exposure.”   
The research was published on August 5 in the American Heart Association journal Circulation together with an accompanying editorial.
"For decades the American Heart Association has strongly supported laws that require indoor public places and workplaces to be smoke-free," said Nancy Brown, CEO of the American Heart Association. "We applaud Colorado lawmakers for protecting casino workers and patrons and encourage more states and Native  American tribes to follow suit."
Currently, the majority of states allow smoking in state-regulated gambling. Most tribal casinos also allow smoking.
The new research centered on Gilpin County, a rural community in the high country of Colorado that is about an hour outside Denver. A major tourist destination, the county has more than two dozen casinos in its gaming district, which occupies about 3 square miles of the county. Approximately, 6,000 people live in the county, but the researchers said that more than 40,000 people at a time are working or visiting the area.
The study tracked more than 16,600 ambulance calls from January 2000 through December 2012.
Colorado put a law into effect in 2006 requiring workplaces, restaurants, bars and other public spaces – but not casinos -- to be smoke-free. Ambulance calls dropped nearly 23 percent in these places. During that timeframe, there was no significant change in calls from casinos that continued to allow smoking.
Two years later, when the smoking ban was expanded to include casinos, ambulance calls from casinos dropped nearly 20 percent while there was no further change at other locations.
The researchers say the results have important implications for clinicians and policy makers “since they show big, fast effects of eliminating secondhand smoke.”
“The message to policymakers is clear: stop granting casinos exemptions,” Glantz said.
The study was co-authored by Erin Gibbs, deputy director of the Gilpin Ambulance Authority in Colorado.
The full study is available here.
The press release from the American Heart Association is available here.



Smokefree Casinos leading to smaller amounts of guests, which results in smaller amounts ambulance calls.
Correlation and causality appear often (in public health) like identical twins. Who does not know them closer, may become confused. ;)


The facts that (1) there was a change in ambulance calls not coming from casinos but no change from casinos when the law applying everywhere but casinos, combined with (2) a change of similar magnitude in casinos but not elsewhere when the law was extended to casinos strongly supports causality.


<strong;The Colorado Gaming Association posted the following response to the study on the target="_blank";<em;Denver Post</em; website:</strong;
The study presents an interesting – but totally unproven – hypothesis. The study admits it did not explore any statistical data about patients which made it “impossible to differentiate events possibly related to smoking or secondhand smoke… from events not likely to be related.” A co-author of the study, Erin Gibbs of the Gilpin County Ambulance Authority, has observed that starting in 2009, a younger crowd was drawn to the gaming towns because voters had just approved new games and expanded bet limits. Likewise, the post-2008 recession resulted in a drop in casino visitation of 17-22%. Giving credit for a drop in ambulance usage to the smoking ban is convenient; it’s just not scientifically established.
Other gaming jurisdictions should be wary in relying on this study to draw any conclusions at all.
Lois Rice, Executive Director, Colorado Gaming Association
<strong;Here is the response I posted: </strong;
The Colorado Gaming Association, mimicking the tobacco industry's longstanding practice of using out-of-context quotes, is ignoring the fundamental observation in our study that when everywhere but casinos were made smokefree there was a 20% drop in ambulance calls from everywhere but casinos AND that when casinos were required to go smokefree ambulance calls from casinos dropped 20% while not changing everywhere else.
Moreover, the 20% reduction is about the same as well-documented reductions in hospital admissions for heart attacks, strokes, asthma and other medical emergencies that have been consistent observed around the world following implementation of strong smokefree laws.
The fact that the available data did not allow us to determine how much of this drop was due to reductions in secondhand smoke and how much was due to less smoking in no way undermines the fundamental observation that ambulance calls dropped.
Stanton Glantz, PhD, Professor of Medicine, University of California San Francisco
You can read the ambulance study here: rel="nofollow";
You can read a summary of the studies on hospital admissions here:" rel="nofollow";

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