Rapid Responses to:

PAPERS: Richard P Sargent, Robert M Shepard, and Stanton A Glantz Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study BMJ 2004; 0: bmj.38055.715683.55v1 [Abstract]

Rapid Responses: Submit a response to this article

Rapid Responses published:

My cancer may have saved me from a stroke

Kathleen S Cheney   (6 April 2004)

Secondhand Misimpressions....

Michael J. McFadden   (6 April 2004)

To Kathleen S Cheney,

Craig Anctil   (7 April 2004)

Sample too small to form a conclusion

Ben Hirsch   (7 April 2004)

When results look too good to be true, they probably are

Geoffrey C Kabat   (8 April 2004)

Science Blinded by Wishfull Thinking

Henry F Mizgala   (9 April 2004)

Conclusion as given entirely reasonable

Adrian K midgley   (9 April 2004)

These dramatic findings warrant a more objective view of the study's limitations

Linda N Phillips   (14 April 2004)

The Puffing Docs.

Anil K Chawla   (24 April 2004)

skewing of statistics

linda dugiuay   (28 April 2004)

Can law really make a difference??

Sheena Surindran   (29 April 2004)

How strong is the evidence that the observed incidence is attributable to the public smoking ban

Kofi O Ofuafor, Dr A Oladipo, Herfordshire, UK   (12 May 2004)

Additional Information on Acute Myocardial Infarctions in Helena, Montana

Brad Rodu, Philip Cole   (25 May 2004)

People should not ignore our fundamental observations

Stanton A Glantz, Richard P Sargent and Robert M Shepard   (1 June 2004)

Simply Not Science

Robert Feal-Martinez   (2 June 2004)

Response to Mr. Glanz

Dave Hitt   (4 June 2004)

Unrealistic expectations can hinder efforts to expand smoke-free workplace laws

Farzad Mostashari, MD MSPH, Thomas R. Frieden, MD MPH   (9 June 2004)

Helena: 100 days

Michael J. McFadden   (17 July 2004)

Helena: 1,000 days

Michael J. McFadden   (4 December 2005)

Helena Study Independently Confirmed

Stanton A Glantz, Richard Sargent and Robert Shepherd   (24 December 2005)

More confirmation of Helena and Pueblo results

Stanton A. Glantz   (11 January 2006)

New York City Heart Attack Mortality Data Does Not Necessarily Indicate an Effect of Smoking Ban

Michael B. Siegel   (14 January 2006)

Helena Study Random Variation Confirmed

Brad Rodu, Philip Cole   (14 January 2006)

Independently Confirmed?

Michael J. McFadden   (16 January 2006)

Reduction in Secondhand Smoke Exposure Likely Overestimated

David W Kuneman   (4 March 2006)

Re: These dramatic findings warrant a more objective view of the study's limitations

Neil R Fell   (19 September 2007)

Re: Re: These dramatic findings warrant a more objective view of the study's limitations

Kevin M. Mulvina   (25 November 2007)

My cancer may have saved me from a stroke 6 April 2004
Kathleen S Cheney, ex- Flight Attendant battling 2nd hand smoke damage home 30269 Send response to journal: Re: My cancer may have saved me from a stroke	16 years ago I was diagnosed with a smoker's throat cancer. The medical procedures needed to stop my already spreading cancer cost me my "always there when needed for work or fun" energy. Now I understand that it takes energy to be patient ( a real loss with a toddler), to remember, to think. Now I live in a very restricted world, constantly hording my energy for the highest priorities and living in the fear that my vulnerable house of cards will collapse if anything else happens. Last year, at a long term POW medical study that includes my husband (and in the past few years, myself,) they included a study of carotid arteries. With no symptoms, no risk factors, no reason for anyone to even look for this in me, I learned I had a clogged artery. I was sure it was just an over sensitive false test result but it turned out to be 90% clogged with plaque breaking off and being swept into my brain. After years of dealing with the carcinogen factor of 2nd hand smoke, now I am learning about what tar and nicotine and carbon monoxide does. It shouldn't be a surprise, I saw oxygen masks in my plane, gummed into place by the smoke reside. But it was really sobering when my husband showed me the New York Times Helena Montana Smoking Ban article last October (after my surgery for an artery that, according to the surgeon, "This is not a new clog. This has been there a while." Now I realize the connection between my 20 years of inhaling workplace smoke and the silently hidden time bombs going off inside me but also the immediacy of further tobacco smoke exposure damage. 2nd hand smoke not only clogs but also blocks arteries. Your study shows my local efforts to at least honestly identify smoke (a compromise when committee smokers out voted real protection) may have been what saved me from a stroke and gave me the precious time needed to identify a long undetected clogged artery BEFORE it was platelet log jammed into a stroke by more tobacco smoke exposure. Today I will bring your website address to our GA Legislature in hopes of breaking the Speaker of the House's hold on Smokefree Air legislation so desperately needed by the people on the ground not afforded the protection that today flight crews (F/A's and pilots) are required to have in our skies. Thank you for helping a very tired but not yet defeated involved citizen in my attempt to make my son's workplace options safer ones. Kathie Cheney Peachtree City, Ga 30269 Competing interests: I was part of the Miami F/A's lawsuit against the Tobacco Industry by the Rosenblatt attorneys. I submitted my medical history but that was all due to my fatigue. I have not yet decided to persue further litigation. Protecting my family from smoke in our community is my current priority. My parents smoked (which is why my oncologist said right off there was no workman's comp coverage for me) but lately I have realized that by growing up in Miami before our home had air conditioning, their smoke was rarely ever trapped indoors. We had fans going year round (to either cool us or bring in the warmer afternoon sun temps from outside.) I never told my parents that my throat cancer could have come from exposure to their smoke. It was already too late for me and for them. Watching them die the frightening and too often painfully degrading deaths from their smoke was awful enough for all of us.
Secondhand Misimpressions.... 6 April 2004
Michael J. McFadden, Writer/Activist Philadelphia, PA 19104 Send response to journal: Re: Secondhand Misimpressions....	Quite aside from several minor questions and quibbles (e.g. why the enormous difference in ratio of reviewed and included admissions for primary < 274/283> and secondary <30/71> diagnoses; why the limitation of previous six-month periods to just the most recent four <1998 - 2003>; how three patients experienced multiple admissions but only had a total of five admissions among the three; why similar changes have not been noted among the many prison populations that have experienced similar smoking bans; and why funding from a number of organizations who have declared openly their belief in pushing for smoking bans is not considered a conflicting interest) there is, aside from all that, one major and glaring problem with this study and the way it has been presented. The problem is the lack of differentiation between those patients who smoked (and presumably smoked less during the ban... at least that's what Antismoking groups usually claim to be an important effect of such bans) and those who did not. The terms "secondhand" smoke or smoking appear a total of twelve times in the paper. The overall tone of both the paper itself, statements to the press by at least two of the authors, and further statements to the press by prominent figures in the Antismoking community, all combine to give the strong impression that the study clearly found that exposure to secondhand smoke caused a very significant rise in heart attacks among Helena's nonsmoking population. In reality only one third of the recorded heart attacks occurred among life-long nonsmokers. Such differentiation is obviously of major importance, but the only mention of it in this paper occurs near the end when it is noted that making such a differentiation would have rendered the study totally meaningless due to small sample size. Am I exaggerating the extent of the deliberate misinterpretation to the public? Not at all. On April 2nd the American Heart Association paid $1,000 or more for a PRNewswire Press Release headlined in big bold print: “NEW STUDY LINKS SECONDHAND SMOKE TO HEART ATTACKS”. In that article the AHA's CEO,M. Cass Wheeler, states: “Banning smoking is the only logical response to the scientific evidence concerning the dangers of secondhand smoke." The text of the release then goes on to assert that 35,000 Americans die from coronary heart disease each year as a result of secondary smoke. Stanton Glantz, a co-author and guarantor of this study, is a mechanical engineer who has brought millions of dollars in Antismoking grant money to the University which eventually awarded him a chair as Professor of Medicine despite his lack of a medical degree. In another paid for PRNewswire Press Release on April 4th he stated, “This is not the first study to find a link between long term exposure to secondhand smoke and heart attacks. There is a mountain of evidence that this connection exists.” In that same press release his associate, the Executive Director of Americans for Nonsmokers’ Rights stated that the study validates her assertion that “The bottom line is simple. Secondhand smoke kills.” And “As the public has learned more about the health dangers associated with secondhand smoke, people have supported smokefree polices as a way to address this easily preventable cause of premature death…” Even Vivian Nathanson, head of research and ethics right here at the BMA, was quoted in an April 5th Quantum Business Media article on the study as saying “We estimate that second-hand smoke kills at least 1,000 people in the UK every year.” Dr. Sargent himself, the lead author of the study, gave an interview last Sept. 28th on CBS News. When asked about the effects of the ban on businesses he said: “It’s not alright to murder people for profit. It’s not alright to poison people for profit.” and asserted that business owners wanted “to be allowed to continue poisoning people even when we have demonstrated the immediate effect of it.” All of this shows quite clearly the intended message of this study. And that message is not at all the one that is probably true, namely that when a smoking ban is introduced in a small community that smokers smoke less and also spend more of their potential heart attack time outside of that community while eating, drinking, gambling and smoking. A final note of interest: while this paper does not include such a chart, there was a chart flashed on the screen for several seconds during that interview with Dr. Sargent. The chart clearly showed a steep drop in heart attacks during the first three months of the smoking ban: the period when it is most likely that angry Helena smokers deliberately went out of town for their fun, particularly since it was during the warm weather months. However the chart *also* showed that for the last three months of the ban, when the cold Montana winter was approaching and angry smokers got tired of boycotting the local businesses, the heart attack rate bounced back up to approximately normal levels. Not a bounce back *after* the ban ended as has often been claimed. In his email announcing the release of this article, Dr. Sargent stated, “It is somewhat unusual for a journal to early release articles. They do it with ones they consider to be of unusual interest or importance.” In this case I might think instead that it was done to gauge reactions to the study’s defects before committing it to the print version of the journal. I offer apologies to Drs. Sargent and Shepard for being so harsh in my criticism, but I feel the harshness is deserved when one considers the enormous damage this study has done to people in other states and communities where the “Helena Heart Miracle” has been held up as proof of the harm of secondary smoke in order to get extremist smoking bans through legislatures. Advancing a falsehood designed to implement social engineering goals amongst free people is never something to be taken lightly. Sincerely, Michael J. McFadden Author of "Dissecting Antismokers' Brains" http://www.Antibrains.com Competing interests: Competing interests: I am a member of several Free Choice organizations, and have written a book titled "Dissecting Antismokers' Brains." I have absolutely no financial connections with Big Tobacco, Big Hospitality, or any other player in this arena other than as a customer.
To Kathleen S Cheney, 7 April 2004
Craig Anctil, political activist, writer government v5b4n7 Send response to journal: Re: To Kathleen S Cheney,	It is so unlikely that your blocked arteries were caused by second- hand smoke, the odds that you would have a better chance of winning the power-ball lottery twice in a year's time-span, purchasing only a single ticket. Me thinks maybe you have eaten a high-fat diet for a good part of your life.That was the likely causation for your health condition. It's all too easy to blame every illness on smoking, there are in fact many deciding factors and variables. In fact...diet, regular exercise or lack thereof, genetics, city living, germ viruses and a host of others not only smoking contribute greatly to ill health and it's acceleration. There are many risk factors for many diseases including cancer, heart attacks and strokes. Some people love to blame every disease known to mankind on smoking.Even if direct smoking were a proven health risk, (so far that has not been done, using objective, solid science) there is absolutely no irrefutable proof that second-hand smoke has caused even one death, world-wide. In fact the recirculated air quality in airplanes is currently poorer than when smoking was allowed years ago. Better and costly ventilation were used in those days. Now you are for the most part breathing stale air on most flights. The phantom second-hand smoke sham was devised about 18 years ago in order to promote smoking cessation among smokers who would not give up smoking for their own sake. After the U.S. surgeon general's report, on the dangers of tobacco smoking many smokers chose to give up their habit. Within the next decade and beyond, smoking rates remained fairly stable and in some cases were on the increase.Depending on the demographic area. The professional anti-smoking lobby devised a tactic to reverse this trend. Smoking itself, is not an overly healthy habit or pastime. Some people who choose to smoke have a far greater chance of developing certain diseases than others. By the same token many non-smokers are predisposed to a host of diseases even if they never smoke themselves. The anti-smoking lobby reasoned that if smokers would not quit for their own health reasons, that they might if they were led to believe that their habit was injuring or killing others. As I previously stated, it is obvious that smoking is not a healthy choice for many people. None the less, the product remains legal and it remains a personal choice. The anti-smoking advocates came up with the simple ideology that if smoking is a health risk, so then is second-hand smoke... However, in science especially where epidemiology is concerned: "It is not the poison itself that harms or kills, it is the dose of that poison.That has potential to do damage. Just how much of a danger-health risk factor does ETS play in a person's developing so-called smoking related diseases? The anti-smoking lobby is only guessing when they make absurd, hysterical estimates by saying passive smoking is from 2-5 times as unhealthy as direct smoking, itself. Scientific test studies to ETS exposure have been conducted where non -smoking hospitality industry workers wear electronic monitors that measure second-hand smoke exposure in the workplace. Studies like the Oakridge Laboratories study found that non-smokers working a 40 hour work-week would ingest the equivalent of 10-15 cigarettes per year, working in a poorly ventilated hospitality venue. In a well-ventilated hospitality industry venue, the same worker would only ingest the equivalent of 2-4 cigarettes per year, working a 40 hour work-week. Hardly a form of measurable health risk. The second-hand smoke "kills" sham was and is a methodology used to denormalize smoking in modern society. It is also a means to introduce social engineering using the promotion of public, children's and worker's health. This really is a thinly-veiled guise for imposing yet more government mandated, over-regulation on private property owners.It also is an attempt at guilting and goading smokers to quit smoking via learned-behaviour modification and social conditioning. In other words: brainwashing 101. The original intentions of the anti-smoking lobby were genuine. But that was many years ago before anti-smoking became a huge business. The professional anti-smoking lobby thrive now on spreading lies, misinformation hysteria and the promotion of hatred toward smokers. Money, not health is their true motivation. Not helping smokers to give up their habits or the promotion of healthy living or well-being. Without the "deep pockets" of big tobacco and the "blood money" that big anti-smoking garners via the rape and plunder of the "evil" tobacco industry most health organizations would not exist. Tobacco money makes the world go 'round. It's no wonder the world's governments have no plan to criminalize the product. It is too great a "cash-cow." Ironically, it is the anti-smoking lobby, health organizations and governments that are pushing for the demonization of smokers, the denormalization of smoking in society. Without big tobacco these groups would suffer huge revenue losses and they would have to seek out another "golden goose" like booze or unhealthy foods in order to make up for lost tobacco revenue or government funding. All generated by big tobacco and smoking. If second-hand smoke really were the toxic, deadly menace that the politically correct governments, anti-smoking groups and the medical community claims it to be, the product should be banned outright. Criminalized. Free smoking cessation should be provided to every smoker in the world. Everyone would be happy and healthy? This planet earth is a toxic waste-dump, a virtual cesspool of pollution.Second-hand smoke is the least of anyone's serious health concerns. The current war on smoking and anything but moral or ethical.No lie is to large far the anti-smoking, misanthropes and their ignorant, slobbering minions. If second-hand smoke is such a serious health risk and the governments wish to continue to profit heavily on it's sale, there should be ventilation safety standards, mandated by those governments instead of government imposed smoking bans within the confines of the private hospitality sector. Otherwise why not just ban the production, sales and manufacturing of all tobacco products? On one hand the governments are saying smoking is legal and smokers have a right to smoke.On the other hand, they are putting the livelihoods of hospitality business owners and workers by telling them they must enforce complete smoking bans within their own private businesses. Even though there is no solid proof that ETS is any more than a phantom, unproven health risk to anyone. Billions of dollars are wasted on anti-smoking campaigns that have little or no effect. If the war on smoking were a moral, ethical one... The governments would do the right thing. Give up their own financial addiction to tobacco tax revenues and in the U.S. tobacco settlement monies. Sadly, the whole war on smoking is nothing but a greedy, ash-grab. It is also a control, social engineering experiment. One truly has to wonder what the governments and anti-smoking groups would do if every smoker on the planet quit smoking tomorrow? The anti-smoking lobby would be out of a job and the governments would begin taxing everything and anything to make up for their financial revenue shortfall. I wonder which industry they would choose to demonize next? Next up: fast-food and big booze. These industries are true health concerns. Both products are proven killers. Is public health really the issue where the war on smoking, alcohol drinking, unhealthy eating and lack of physical fitness is concerned? The fact is the governments cannot afford to have every citizen, especially the poor living to ripe, old ages. The drain on the social-economic infrastructure would be unmanageable and devastating to the overall economy. Old healthy, people are the biggest burden on government social services next to the obese. Smokers who die early and reap less pension monies and pay insane, over- inflated for many years are very, cost effective. Why does the anti-smoking lobby have to lie? That's easy...The truth exposes and destroys their entire greedy, unsavoury agenda. One day honest, objective science shall prove that the second-hand smoke sham is one of the greatest frauds ever imposed the people of this planet. Until that day, those of us who are intelligent will have to spread the truth for the benefit of those who are too ignorant to think for themselves and who follow the anti-smoking,"Judas goat" blindly. Competing interests: Freedom of choice activist
Sample too small to form a conclusion 7 April 2004
Ben Hirsch, Research Assisstant University of Massachusetts Send response to journal: Re: Sample too small to form a conclusion	These numbers are far too small. The study surveyed at most 40 admissions across a six month, or 26 week period. So, even an increase/decrease of one per week makes a huge impact. It is also claimed that the increase of 5.6 in outside Helena admissions was insignificant, however it is a near 50% increase. Additionally, looking at the breakdown of years (Helena only), there were significantly fewer admissions during 2002 than 2003. In fact, from 1998-2002, only 2000 and 2001 had higher numbers of admissions, while 1998, 1999, and 2002 all had lower numbers. Not that I am suggesting that the smoking ban has increased the number of admissions from 2002 to 2003, simply that these numbers are so small that an individual admission can sway the numbers greatly and no one should be using such a data set to conduct any serious research. This study would have been much more viable if it had included data for more than the past five years as well. Competing interests: I work to oppose local smoking regulations.
When results look too good to be true, they probably are 8 April 2004
Geoffrey C Kabat, Epidemiologist New Rochelle, NY 10804 USA Send response to journal: Re: When results look too good to be true, they probably are	As a cancer researcher who has published extensively on the harmful effects of smoking, I am in favor of vigorous smoking bans and feel there is no justification for nonsmokers to have to breathe air polluted with tobacco smoke. However, the study by Sargent et al. claiming that the 6 -month smoking ban in Helena, Montana was associated with a drop in heart attacks must be viewed with skepticism. The authors reported that the number of heart attacks within the city of Helena dropped by 40% immediately following the initiation of the ban. They claim that this is powerful evidence for an effect of exposure to secondhand smoke on heart attacks. But if we look at their data we see just how questionable this claim is. First, the researchers only had information from hospital records on where a person lived. They did not interview the patients, so they had no information on whether their exposure to secondhand smoke changed as a result of the ban. They also did not present any information on whether smoking habits were affected by the ban. The fact that they had no information on exposure is a major deficiency. Second, the drop in heart attacks is based on very few cases: 4 per month on average during the ban compared to 7 per month before. Due to these small numbers the reported difference could easily be due to chance or to some uncontrolled factor. The number of heart attacks in the area outside Helena was even smaller. It should not be surprising that, given these small numbers, there are fluctuations of the magnitude seen in this study. Finally, the “immediate effect” and its magnitude really should make anyone stop and question the connection the authors are asserting. There are few interventions in public health that have such an immediate effect. Even if all active smokers in Helena had quit smoking for at least a year, one would not expect to see such a dramatic effect. No previous epidemiologic study or community smoking cessation program has ever shown that a reduction in smoking or exposure to secondhand smoke causes an immediate decline in heart disease incidence or mortality. A rigorous study would have involved collecting information on a population of adequate size and interviewing individuals to assess their pre-existing risk for heart disease as well as how their behavior was affected by the ban in order to make a plausible connection between the two phenomena. The attempt to make claims about the effects of smoking bans based on this very weak ecologic study raises disturbing questions about our ability to distinguish between sound science and wishful thinking. Competing interests: None declared
Science Blinded by Wishfull Thinking 9 April 2004
Henry F Mizgala, Emeritus Professor of Medicine University of British Columbia 865 West 10th Avenue, Vancouver BC Canada. Send response to journal: Re: Science Blinded by Wishfull Thinking	Dear Sirs, I am truly amazed that a study of such poor quality was not only accepted for publication in a journal with the reputation of the BMJ but was accorded widespread coverage in the lay press as having actually been published as a peer reviewed article in the print version of the journal dated April 5. This is, in my opinion, gross misrepresentation designed to provide maximal public impact in furthering the biased and unscientific opinions of these authors.I have always assumed that submissions to BMJ would undergo rigorous peer review in regard to content, methodology and correctness of statistical analysis. This so called study does not even come close to meeting the basic criteria of a properly executed scientific study. As some medical statisticians would say: "Garbage in garbage out". I have to assume that in advancing the cause of our well meaning but scientifically challenged social engineers, correct scientific methodology can be replaced by wishful thinking. Competing interests: I have researched and reviewed the issue of risk factors for coronary artery disease including the risk factors of cigarette smoking and second hand smoke. I have submitted affidavits on behalf of defendants in the tobacco litigation
Conclusion as given entirely reasonable 9 April 2004
Adrian K midgley, GP Exeter EX1 2QS Send response to journal: Re: Conclusion as given entirely reasonable	There is as usual a fog around this simple and interesting study. Looking at the actual abstract, the conclusion actually presented is entirely reasonable. "Conclusions: Laws to enforce smoke-free workplaces and public places may be associated with an effect on morbidity from heart disease." They may. Bayes would tell us that this is quite likely. Competing interests: Smokers make me cough and interfere with my enjoyment of food.
These dramatic findings warrant a more objective view of the study's limitations 14 April 2004
Linda N Phillips, retired Ukiah 95482 Send response to journal: Re: These dramatic findings warrant a more objective view of the study's limitations	This study garnered enormous media attention, coinciding with the presentation of its initial results to the American College of Cardiologists last year. Those initial reports claimed heart attacks quickly fell by nearly 60% as a result of Helena's six months workplace smoking ban, and this staggering finding seemed to receive far more in the way of celebratory fanfare than it did sober-minded skepticism. In this published study, the so-called "Helena Miracle" is a bit more tempered, but even at 40%, as this drop is now described, it is difficult to fathom how 40% of all those suffering acute myocardial infarction actually fell ill due to their exposure to cigarette smoke in restaurants, bars and other holdout "smoking allowed" workplaces. Even though the number of hospital admissions appeared to decline dramatically, the arguments presented attributing this decline to workplace smoking bans are weak. And many of the arguments describing this finding as consistent in relation to other related studies appears weak as well. Others have mentioned important concerns (chiefly the relatively small numbers involved, the absence of any data regarding exposures to secondhand smoke, and the absence of any distinction based on the patients' own smoking behaviors). The authors acknowledged some of the study's weaknesses as well. However, while it appears great care was taken to distinguish patients in terms of consistency in the diagnoses and where they should be assigned (test group or comparison group) in terms of geography, the authors downplayed the complexities of smoking behavior and overplayed anticipated impacts of newly enacted smoking bans on that behavior. As a result, a finding of 40% decline in AMI admissions resulting from the workplace smoking ban is as astonishing for what it suggests about the relationship between smoking bans and smoking behavior as it is about any relationship between secondhand smoke and AMI risk. Even without legal smoking bans in place, many workplaces have their own policies against smoking. A ban would naturally result in an increase in the number of smoke-free workplaces, but surely a sizeable number of work places would have been smoke-free already. Would a work place smoking ban impact residential secondhand smoke exposures within just the first month or two? How many of those suffering myocardial infarction are exposed to secondhand smoke in the workplace? How many are actually still working at all? Wouldn't a disproportionate number be past retirement? Wouldn't the impact of workplace smoking bans on retired and other nonworking people be significantly diminished? The decline in heart attack admissions of 40% is so large that it begs the question: when a smoking ban passes, does everybody instantly stop smoking around others at home and in cars too, thus eliminating altogether the 30% expected increased risk of secondhand smoke exposure? Or is it just more unhealthy to breathe secondhand smoke when you're in a restaurant or your co-worker's cubicle than when your spouse lights up at home or in the family car? How could a reportedly expected risk of 30% from secondhand smoke be completely eliminated within just a few weeks, even days, simply by implementing a work place smoking ban? The authors' assert that the Helena findings were consistent with other published findings, but the research they cited for review point to far more modest impacts from smoking bans. It's hard not to conclude that the authors were overzealous, and it's important that this study be treated with more objectivity (maybe even incredulity) than has been the case so far, at least in terms of the media and publicity savvy anti- smoking activists. For example, the report claims "Data from California, however, could be interpreted as supporting our results. Death rates from heart disease fell faster in California than elsewhere in the United States during the California tobacco control programme, which, while including a tax increase and media campaign (including the promotion of smoke-free environments), focused on creating smoke-free workplaces and public places." The study goes on to offer another source, published in the NEJM, which reportedly "support[s] our results", (Fichtenberg, Glantz. Association of the California tobacco control program with declines in cigarette consumption and mortality from heart disease). This study is an examination of trends in tobacco consumption and heart disease mortality in California in the years 1989 through 1997, concurrent to California's aggressive new Tobacco Control Initiative. Unlike this current study, which leads one to conclude that a workplace smoking ban alone could account for a 40% drop in myocardial infarction, California targeted tobacco use not only through smoking bans, but with sharply steeper tobacco taxes and a powerful anti-smoking media campaign distributed statewide. Despite its more comprehensive anti-smoking campaign, heart attack mortality in California didn't decline by anything close to 40%. During the entire 9 years studied, the decline in the mortality rate was approximately 27%--yet most of this decline, it was acknowledged, should be attributable to other factors unrelated to California's tobacco program - factors which were pushing this mortality rate down nationwide. Although the study claimed California's rate of decline exceeded the national decline, this difference was in the area of 5 to 6 percent, and again, this was over a nine-year period, not a few short months. The authors referred to two other studies to argue "The fraction of the population covered by smoking restrictions rapidly increased as a result of [California's Tobacco Control] campaign" (refer to footnotes 14 and 15, both principal author Pierce), and they return once more to Fichtenberg's report to assert "there was a parallel reduction in deaths from heart disease." Again, those reductions in heart disease deaths were much smaller than 40%. During the period 1990 through 1993, which Pierce, et al, described as experiencing this "rapid increase" in smoking bans, heart disease death rates declined between 17 and 18 percent while nationwide, the rate declined about 13 percent. A case might be made attributing the difference of 4 or 5 % to California's tobacco initiatives, a portion of which attributable to their smoking bans, but these statistics do more to enhance suspicions about the over-hyped Helena results than they do to squelch them. Besides relying upon exaggerated implications in findings from other studies to help explain how AMIs could tumble so substantially, there are potentially significant problems resulting from the peculiar "geographical" assignations of the test and comparison cases. This is potentially significant because the test and comparison groups were assigned based on these geographical assignations, as opposed to more selective criteria focusing on the ban's impact on actual secondhand smoke exposures and/or reductions in active smoking. The authors described assigning certain patients to the test group, even though they lived outside the geographical area, as a result of information indicating these patients had spent time in the "test ban zone" some time prior to their illness. In other words, a patient might have spent as little as an hour or two total having lunch or dinner in Helena prior to their illness, and, if this fact were so indicated in their chart, they'd be assigned to the Helena test group. This study doesn't describe when these "specially assigned" patients were admitted to the hospital--whether they were evenly distributed throughout or whether they may have "clustered" toward pre-ban or post-ban--but it's important to note that the enactment of smoking bans have the potential to impact non-local customer or visitor traffic. The St. Peter's Hopsital may be been "geographically isolated", as the authors emphasized, but I believe just less than half of this "geographically isolated" community was subject to the smoking ban. There were numerous casinos in this area, some of them subject to smoking bans while others not, and it's reasonable to ask whether or not visitor traffic altered in response to the smoking ban. If so, this would not only mean that the pre and post population "pools", but also the AMI patient assignments between test and comparison group, were variables dependent on the passage of the smoke ban. In other words, it may be impossible to differentiate how much of the reduction in AMI admissions was attributable to lessened secondhand smoke exposures and how much was attributable to a consequent relocation of the problem to other geographical areas where smoking was still welcomed. This study certainly isn't the first of its kind to suffer criticisms like those others have offered as well as myself, but more and more do such highly charged issues burst through the walls separating the political arena from the scientific, infecting the dialogue to such an extent that the scientific rigor is compromised in furtherance of political expediency. With encouragement from the study's authors, the media went wild with a story hinting all you had to do to reduce heart attack by 60% was to pass a city work place smoking ban. This study offers a somewhat more subdued promise--a 40% reduction in heart attack-- while at the same time suggesting that this amazing result is plausible since California, which began passing work place smoking bans a dozen years earlier, also experienced a reduction in heart attack mortality. (The authors carefully neglected to mention California's reduction was more along the lines of 5% as opposed to Helena's 40%, or its initially touted 60%.) In anticipation of any suggestion that California's results were dampened by the "smear out" effect described in this report, let me point out that California's statewide smoking ban went into effect during the period used in "support" of the findings observed in Helena, and any "smearing" would thus come out in the wash. Even after 9 years of gradual yet steady progression from isolated local bans to statewide smoking bans, California's overall decline in the heart attack rate was an insignificant blip when compared to Helena's reported heart attack decline, the majority of which was traceable to June and July 2002, just one month or two after the ban went into effect. The "Helena Miracle". First it's 60%, then 40%, which is supposedly comparable to California's 5 or 6%? This isn't science, folks. This is a very strange socio/cultural/political gamesmanship calling itself science and I hope somebody is getting it all down on paper. Examples like this are revelatory of the way science intersects with politics, business and the media today, and examining the distortions which often result from this intersection would be very enlightening. Competing interests: None declared
The Puffing Docs. 24 April 2004
Anil K Chawla, Senior Specialist in Medicine Royal Hospital, P.O.Box 1331, P.C. 111, Muscat, Oman Send response to journal: Re: The Puffing Docs.	When I tell a patient with a bronchitic cough, That smoking is bad and it should be cut. He laughs at me, "Sir, if it were that bad for health, Why so many of your tribe, the Docs would puff?" That shatters my confidence to convince the patient, I am forced to keep quiet at that moment. But strangely, when I tell a patient of heart attack pain, That smoking is the cause and it should be restrained, The answer is always, "I would never ever smoke again". On follow up you would see most indeed have refrained. Puffing a cigarette, blowing smoke rings into skies, Is pleasure and fun but only until when, The pain attached to the act is felt and clearly seen, As the most severe pain which nearly shatters all dreams. I wonder why we need a catastrophe to hit us, To wake us out of the slumber of feigned ignorance. Simply to notice the bold writing on the wall, "Evidence is strong: Smoking is the cause of it all!” In this matter, doctors, are no different from laymen, The urge and compulsion to go and smoke, is stronger than, The force of factual knowledge they pretend they possess; Devoid of a painful experience, this force fails to impress. In a corner of the hospital, away from public gaze, There is a room where the Docs light up without a faze. They have several pretexts to puff and fume: Concentration, relieve tension, constipation or stay slim. All nice reasons, but all cooked up, For, don't they pass motion, who never got hooked up? The danger they know within is very real, But heart attacks shall happen to others they feel. The real culprit, Sir, is Lady Nicotine, Its grip on the brain cells is strong and keen, The dependence is both physical and psychological, So no more than 3 % smokers per annum can quit (1). Within eight seconds of the first puff (2), Nicotine reaches the blood and the brain cells, The cells get excited and ask for more, “Cigarettes so are the most addicting products known” (1). The best way to quit, friends, is not to begin, For fun or adventure or just to stay slim (3), Prevention here, is better than cure, Educating kids can work for sure. Ban tobacco advertisements or ban public place smoke- These partial measures, would only partly work. Stop tobacco cultivation, stop its imports, We may lose tobacco revenues, but save in health care costs, We’ll save lives, health, happiness and environment the most. REFERENCES 1. Henningfield JE. Nicotine medications for smoking Cessation. N Engl J Med 1995;333:1196-1203. 2. Sylvis GL, Perry CL. Understanding and deterring Tobacco use among adolescents. Pediatr Clin North Am 1987;34:363-77. 3. Califano JA, Jr. The wrong way to stay slim [Editorial]. N Engl J Med 1995; 333:1214-6. Competing interests: None declared
skewing of statistics 28 April 2004
linda dugiuay, reatil sales home Noh 1a0 Send response to journal: Re: skewing of statistics	The skewing of the results is wrong. If there were even moderate, not substanstale contributing enviromental factors that were ignored. The fact that the thinning of ozone doesn't cause cancer,is what you are proporting. Due to the other contributing effects that are ignored, such as smog, and unethical envromental stewartship. The continued reinforcement of skewing will make the notices put out by health autorities questionable. I am already doubting "good science" due to funding, and one goal fostering. Competing interests: None declared
Can law really make a difference?? 29 April 2004
Sheena Surindran, clinical observer Kettering General Hospital, Kettering,NN16 8UZ Send response to journal: Re: Can law really make a difference??	In the study done at Helena, there seems to be a decrease in admissions in people with acute myocardial infarction during the ban implying the possible effects of smoking on the heart but what is more distressing is that inspite of most people being aware of the ill effects of smoking they petitioned for the ban to be removed....within 6 months! The effect of nicotine was a stronger driving force than the law!! Though there is a decrease in the number of admissions there are a number of factors to be considered. 1.The number of cases that were actually exposed to smoke both active and passive in both control and study. 2.Those patients with premorbid conditions - were they comparable in both? 3.Are the study numbers really representative of a much larger population? The study does offer a ray of hope that if more definite and extensive studies show significant outcomes, the reality of having a wider ban on smoking may be possible which would definitely make a difference for us nonsmokers! Competing interests: None declared
How strong is the evidence that the observed incidence is attributable to the public smoking ban 12 May 2004
Kofi O Ofuafor, senior SHO Gastroenterology Weston General Hospital, Weston Super Mare, BS23 4TQ, Dr A Oladipo, Herfordshire, UK Send response to journal: Re: How strong is the evidence that the observed incidence is attributable to the public smoking ban	We read with interest, the artcle by Glantz et al(I)on the reduced incidence of admission for myocardial infarction with public smoking ban. Evidence abound in the medical literature to support the beneficial effects on passive or secondhand smoking. The authors admit to not knowing the prevalence of smoking and consequently the extent of compliance in venues affected by the ban, this is crucial as demonstrated by Rigotti et al(2). They showed a lack of full compliance in their study, furthermore Rigotti and his co-workers noted no change in the frequency of smokers in their law restricting smoking study. The authors similarly conceded to not knowing the incidence of secondhand smokers during the study group, an omission which could at least have resulted to the observed effect. Given an incidence of thirty-three percent of never smoked at admission during the study period,the authors failed to give the incidence for similar cohort of patients in the period immediately before and after their study. We believe the size and methodology of the study by Glantz et al as admitted by the authors were furhter weaknesses of the study. It is also noteworthy, that the study failed to stratify the age group of patients admitted for myocardial infarction during the study period as this may have supported the effect of smoking ban at work place especially if the incidence reflected a pre-retirement age group who are more likely to benefit from the effects of such a law. The study data was drawn from billing records which may reflect a socioeconomic bias. In conclusion, we believe that extrapolating the ban on smoking to the observed effect,did not also allow for other confounding risk factors of myocardial infarction and it falls short of what ought to be another potent weapon for advancing the arguement for the law in other places. References: Sargeant R P, Shepard R M, Glantz S. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and sfter study.BMJ, 328977-980 Rigotti N A, Stoto M A, Bierer M F, Rosen A, Schelling T. Retail stores compliance with a city no smoking law. Am J Pub Health. 1993 Feb:83(2):227-232. Thank you Competing interests: None declared
Additional Information on Acute Myocardial Infarctions in Helena, Montana 25 May 2004
Brad Rodu, Professor of Pathology University of Alabama at Birmingham, USA 35294, Philip Cole Send response to journal: Re: Additional Information on Acute Myocardial Infarctions in Helena, Montana	Dear Sir, The report by Sargent et al. (1) is interesting, but it is premature to attribute the reduced hospital admissions for acute myocardial infarction (AMI) in Helena, Montana during the period June-November 2002 to the concurrent smoking ban in that city. The observations are consistent with random variation that occurs among groups of incidence statistics based on small numbers. The figure below presents annual mortality rates from 1979 to 2001 for myocardial infarction (ICD-9 codes 410-410.9 for 1979-1998 and ICD-10 codes 121.0-121.9 for 1999-2001), among persons age 35+ years in Lewis and Clark County, Montana, which includes Helena. These rates, expressed as the number of deaths per 100,000 persons per year, are from the National Center for Health Statistics Mortality Database (NCHS) (2), and are age standardized to the 2000 US population. While there is an overall downward trend in mortality from AMI in this county, the rates for 1980, 1988, 1992, are very low and that for the year 2000 is quite high (these years are designated by a * in the figure). The variability is most clearly illustrated by two periods: 1989-1993 and 1997-2001 (the bars for these periods are yellow). The latter period is notable because of the year 2000, in which the mortality rate was 110, about 50% higher than the mean for the other years in the period. The former period includes 1992, in which the mortality rate was 40% lower than the mean for the other years in the period. In addition, 1992 follows three years of increasing AMI mortality. In isolation, this period presents a picture very similar to that described by Sargent et al from 1998 to 2003. Our comparison of NCHS mortality data with incident hospital admissions for AMI is reasonable for several reasons. Both sets of data describe the same disease in similar populations (about 85% of the county population lives in Helena). The annual number of deaths in Helena from AMI during the period 1979-2001 (30, range 18-42) was of the same general magnitude as the number of AMI admissions reported by Sargent et al. during the six-month periods from 1998-2003 (38, range 24-50), and the intrinsic variation of the datasets appears to be very similar. It is not necessary to directly compare AMI mortality with AMI incidence to appreciate the similarity in year-to-year variation in these data from this small Montana city. Whether exposure to environmental tobacco smoke causes AMI is an important question. But it is not a question that can or should be addressed by the incident case report by Sargent et al. The relevant question is whether this report involves anything more than random variation. Brad Rodu Professor, Department of Pathology School of Medicine, University of Alabama at Birmingham, Birmingham, AL USA Email: rodu@uab.edu Philip Cole Professor Emeritus, Department of Epidemiology School of Public Health, UAB, Birmingham, AL 35294, USA Email: pcole@uab.edu References 1. Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004; 328: 977-980. 2. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis, Epidemiology, and Health Promotion (OAEHP), Compressed Mortality File (CMF) compiled from CMF 1968- 1988, Series 20, No. 2A 2000, CMF 1989-1998, Series 20, No. 2E 2003 and CMF 1999-2001, Series 20, No. 2G 2004 on CDC WONDER On-line Database. Competing interests: Competing Interest Research by the authors is supported by the Tobacco Research Fund at the University of Alabama at Birmingham, which is made possible by an unrestricted grant from the United States Smokeless Tobacco Company to UAB. The sponsor had no knowledge of this work, and thus had no scientific input or other influence with respect to this submission.
People should not ignore our fundamental observations 1 June 2004
Stanton A Glantz, Professor of Medicine University of California, San Francisco USA 94143, Richard P Sargent and Robert M Shepard Send response to journal: Re: People should not ignore our fundamental observations	Rodu and Cole are following a well-established tobacco industry strategy of trying to shift the focus away from our actual observations. Our finding is quite simple: There was a statistically significant drop in AMI hospital admissions for people in Helena while the smokefree ordinance was in effect. The AMI admissions rebounded when the ordinance was suspended. The fact that these results reached statistical significance means that they are unlikely to be due to underlying random fluctuations. There was no such drop or rebound observed in people from the surrounding region. In addition, there was no deviation from historical trends for the other 6 months of the year when the ordinance was not in effect (data not presented in the paper at the suggestion of one of the reviewers to simplify the analysis). If the results we found from inside Helena merely reflected some random fluctuation in heart disease in the region due to other factors, one would have expected to see similar changes both inside and outside Helena. That is not what we found. Rodu and Cole (and other critics) also ignore the important information on mechanisms (discussed in our paper and the accompanying commentary from the US Centers for Disease Control) that explain why such a rapid effect of clearing the air should be expected. Competing interests: None declared
Simply Not Science 2 June 2004
Robert Feal-Martinez, Motel Owner The Carpenters Arms Motel SN3 4ST Send response to journal: Re: Simply Not Science	I am not a scientist but with a basic knowledge of maths one can see from the various contributions that the study is based on a statistical blip. Added to which the methodology is codemmed by most of Sargents peers, including those in favour of smoking bans, it is odd that their latest response should still defend their conclusion. I would suggest that it was time for them to meld into the background before their professional credibilty such as it now is, is lost for ever, rather than try to defend the indefensable, junk science. Competing interests: None declared
Response to Mr. Glanz 4 June 2004
Dave Hitt, N/A Round Lake, 12151 Send response to journal: Re: Response to Mr. Glanz	Stanton, an almost identical drop occurred in Helena in 1998, and yet you and your fellow researchers ignored it completely. Why? It should be noted that the sample size is laughably small, no confounders were considered, and no attempt was made to separate the subjects into smokers, ex-smokers, and never smokers. The researchers, including yourself, had substantial competing interests (how much do you earn every year by vilifying smokers, Mr. Glanz?), and it was funded by anti-smoker money. And yet you claim no competing interests. Perhaps the most significant thing about this shoddy study is that the results haven't been documented anywhere else in the world. California has had a smoking ban for five years, and no such result has been noted. NYC has had one for two years, and no such result has been noted. New York State has had a ban for over a year, and no such result has been noted. These, or any one of a dozen other large populations where bans have bene in place would provide a much richer data set, which could yield accurate results, as opposed to this study. But the "researchers" carefully avoided any real study, instead capitalizing on this anomaly as if it proved something. Competing interests: I operate The Facts, a web site devoted to debunking junk science claims, particularly those about second hand smoke. http://www.davehitt.com/facts/
Unrealistic expectations can hinder efforts to expand smoke-free workplace laws 9 June 2004
Farzad Mostashari, MD MSPH, Assistant Commissioner New York City Department of Health and Mental Hygiene, Thomas R. Frieden, MD MPH Send response to journal: Re: Unrealistic expectations can hinder efforts to expand smoke-free workplace laws	Smoke-free workplace legislation protects workers and the public from cardiac, respiratory, and cancer risks associated with second-hand smoke (1, 2, 3, 4, 5) and facilitates cessation among smokers(6). However, unrealistic expectations can hinder efforts to expand smoke-free workplace laws. The 40% decline in acute myocardial infarctions (AMIs) associated with a smoke-free ordinance in Montana (7) is neither biologically nor epidemiologically plausible. Cigarette smoking itself is associated with an estimated 17% of ischemic cardiac deaths(8). Second-hand smoke exposure must be associated with a far lower proportion. Smoke-free air legislation can reduce, but not eliminate, exposure to second-hand smoke, which continues in homes, cars, and some public spaces. An analysis of the likely effects of smoke- free legislation (9) accounted for the fact that not all residents are exposed to second-hand smoke prior to passage of legislation, and that some exposure continues after legislation is in effect. This report more realistically predicted 120 fewer AMIs after one year for the state of Florida (population 16 million). This would translate to approximately 0.25 fewer AMIs over a 6-month period for Helena Montana (population 68,000), rather than the 16 fewer AMIs attributed to the smoking ban. Smoke-free workplaces can improve lung function of workers,(10) reduce smoking(5), and reduce risk of cardiac and respiratory disease, and of cancer. However, unreasonable expectations of early, dramatic reductions in cardiovascular morbidity and mortality will surely be disappointed. Tobacco control requires a comprehensive and multi-faceted approach, including smoke-free workplace legislation, as well as sustained funding and attention. 1 Law MR,Wald NJ. Environmental tobacco smoke and ischemic heart disease. Prog Cardiovasc Dis 2003;46:31-38. 2 He J, Vupputuri S, Allen K, Prerost MR, Hughes J, Whelton PK. Passive smoking and the risk of coronary heart disease-a meta-analysis of epidemiologic studies. N Engl J Med 1999;340:920-926. 3 Hackshaw AK, Law MR,Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 1997; 315:980-988. 4 International Agency for Research on Cancer. Monograph on the evaluation of the carcinogenic risk of chemicals to humans. Tobacco smoke and involuntary tobacco smoke. 2002. Vol 83. Lyons: International Agency for Research on Cancer, World Health Organization. 5 Radon K, Büsching K, Heinrich J, Wichmann HE, Jörres RA, Magnussen H, Nowak D. Passive smoking exposure: a risk factor for chronic bronchitis and asthma in adults? Chest 2002;122:1086-1090. 6 Fichtenberg CM, Glantz SA. Effect of smoke­free workplaces on smoking behaviour: systematic review. BMJ 2002; 2002;325:188-194. 7 Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004;328:977-980. 8 Centers for Disease Control and Prevention, Smoking-attributable mortality, morbidity, and economic costs, http://apps.nccd.cdc.gov/sammec/. 9 Ong M, Lightwood JM, Glantz SA. Health and economic impacts of the proposed Florida smokefree for health initiative (November 1, 2003). Center for Tobacco Control Research and Education. Tobacco Control Policy Making: United States. Paper FL 2002. http://repositories.cdlib.org/ctcre/tcpmus/FL2002. 10 Eisner M, Smith AK, Blanc PD. Bartenders' respiratory health after establishment of smoke-free bars and taverns. JAMA 1998; 280:1909- 1914. Competing interests: None declared
Helena: 100 days 17 July 2004
Michael J. McFadden, Writer/Activist Independent Researcher, Philadelphia, 19104 Send response to journal: Re: Helena: 100 days	On April 5th 2004, 100 days ago, the online British Medical Journal published "Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study," a study that, according to media releases around the world, conclusively demonstrated the deadly effects of secondary smoke and the immense and immediate medical benefits that had been demonstrated once people were protected from "the deadly poison." (1) The release almost immediately generated a storm of criticism within these virtual pages as Rapid Responses containing over a dozen substantial questions and criticisms were generated within ten days.(2) Throughout the entirety of that 100 day period, only one response has been made by the authors of the study. That response was two months in coming and ignored over 90% of the questions and criticisms that had been raised while taking an Ad Hominem slap at the most recent pair of questioners by accusing them of "following a well-established tobacco industry strategy..." (3) Perhaps the most serious of all the charges made was the one that charged deliberate misrepresentation of results to the media, and the one that criticized the lack of honesty in the declarations of competing interests. In the first instance the charge of misrepresentation was clearly not directed at the Journal, but was instead aimed at the conscious presentation of the study by the authors and other supposedly responsible medical and tobacco control authorities as having directly examined and strongly condemned the cardiovascular effects of secondary smoke. As pointed out quietly by the authors themselves in the study, no attempt was made to even estimate such an effect. In the second instance however the charges were laid at the feet of both the authors who neglected, even after criticism, to openly admit their potential conflicts of economic interest; and at the feet of the Journal which seems to be ignoring the demand that such conflicts be openly exposed for proper consideration by readers and future researchers. The 14 points below represent only those raised and ignored in the first ten days; there are others that cry equally loudly for response as well. The British Medical Journal has demonstrated its courage in publishing the Helena study and opening its details to direct public examination rather than leaving them in a limbo of interpretation only through press release. It has also shown courage and responsibility in opening its pages to those around the world who have criticized not only this study, but others that were scientifically weak although serving sacrosanct political and medical goals. It needs to prove itself equally courageous in demanding that the Helena study authors responsibly respond to their critics and questioners in the true spirit of peer review and public accountability, and that they do so with a full and open admission and listing of their competing interests. Sincerely, Michael J. McFadden Author of "Dissecting Antismokers' Brains" http://www.Antibrains.com Footnotes: (1) http://bmj.bmjjournals.com/cgi/eletters/328/7446/977#55832 (2) 1)why the enormous difference in ratio of reviewed and included admissions for primary < 274/283> and secondary <30/71> diagnoses; 2)why the limitation of previous six-month periods to just the most recent four <1998 - 2003>; 3)how three patients experienced multiple admissions but only had a total of five admissions among the three; 4)why similar changes have not been noted among the many prison populations that have experienced similar smoking bans; 5)why funding from a number of organizations who have declared openly their belief in pushing for smoking bans is not considered a conflicting interest; 6)why the presentation and the bulk of discussion in the study was deliberately oriented toward secondary smoke while the formal study itself never specifically examined secondary smoke, exposures to it, or the statistical effects of the ban on nonsmokers; 7)why the initial results boasted a 60% reduction while the final showed only 40%; 8)why the finding of a 40% immediate reduction in Helena was claimed to be supported by studies showing only a 5% reduction in California over a period of years; 9)why the findings of increased hospital admissions immediately outside the Helena area were not factored into the reduction of admissions within Helena but were instead simply dismissed as non-significant; 10)what impact transient traffic or recall bias had upon the study; 11)what impact would have been made by using different criteria for determining relevant admissions; 12)what impact would have been made by using different criteria for those assigned to the different groups (e.g. by including/excluding those who were retired and unaffected stay-at-homes or those who had simply had a single dinner or lunch in Helena at the time of their event); 13)what difference in conclusion might have been forthcoming if the authors had examined three month rather than six month periods, given the clear disparity observed during the first three months of the smoking ban as opposed to the final three months; 14)what impact on the final numbers could have been attributed to the increased time at least some, and perhaps many, smokers spent outside the ban area during the course of the ban, particularly during that telling first three month period of good weather and possible resentment and what effort, if any, was made to examine such impact. (3) http://bmj.bmjjournals.com/cgi/eletters/328/7446/977#61207 Competing interests: I am a smoker and a member of several Free Choice organizations, and have written a book titled "Dissecting Antismokers' Brains." I have absolutely no financial connections with Big Tobacco, Big Hospitality, or any other player in this arena other than as a customer.
Helena: 1,000 days 4 December 2005
Michael J. McFadden, Writer/Researcher/Activist Philadelphia, PA 19104 Send response to journal: Re: Helena: 1,000 days	Well, to be truthful, it's really only Helena plus 976 days. The original press release circus started on April 1st, 2003 although the formal BMJ publication did not take place until a year later. Still, it *has* been many hundreds of days since criticisms, concerns, and questions about Helena appeared here with no more than a single, and sadly Ad Hominem flavored, response. (1) Meanwhile antismoking lobbyists have continued to push for smoking bans using the base of Helena and similar studies to frighten people and legislators about the "deadly threat" of wisps of secondary smoke with nary a mention of such criticisms and questions. Particularly disturbing is the recent study done in Pueblo, Colorado. Despite initial consultations with the Helena authors the Pueblo researchers not only neglected to incorporate data on smoking statuses but did not even gather such data! And, just as with Helena, the lack of such supporting data did not stop the researchers from making public statements such as this one by Dr. Mori Krantz: "This study further validates the argument that limiting exposure to deadly tobacco smoke can save lives." (2)(3) Why am I choosing to post this response now rather than wait the full 1,000 days? I am doing so because a related event of some significance has occurred. Three days ago Dave Kuneman and I published an expanded Helena-type study at SmokersClubInc.com and Dr. Michael Siegel has reviewed and expanded upon it in his web blog. (4)(5) In brief, when a database of figures literally 1,000 times larger than Helena was considered and analyzed, the theoretical 30 to 50% post- ban drop in heart attacks simply disappeared. It was not reduced… it was eliminated altogether. The figures and the work involved are not hidden from public view and examination but are fully open through public government records and the straightforward and simple analysis of those records. Can the same be said of the Helena data? The data for such states as New York was not yet available at the time of the Helena study, but the data for California has been readily accessible to researchers for years. It is hard to imagine that the Helena researchers never examined those figures and were simply unaware that there was a large and significant source of data that directly contradicted their conclusions. For them to have neglected even mentioning such data in their study presentation seems unfortunate to say the least. While California's figures may not be as "pure" as Helena's due to the more gradual phase in of the smoking bans there, it was certainly quite clear that there was no massive drop in heart attacks resulting from those bans. Not only did the much touted study in Helena fail to directly show anything at all about secondary smoke, it promoted conclusions based upon a very small sample while ignoring the easily available public data based upon a far larger sample. Tobacco companies have long been accused of promoting and funding selective research. Is the Antismoking Industry equally at fault? The Helena researchers were challenged in earlier responses to acknowledge the conflict of interest that stemmed from the orientation of the funding sources for much of their work. Researchers in this field have generally refused to acknowledge such conflict despite the fact that their livelihoods often depend upon consistently producing research pleasing to organizations that have an openly declared agenda of promoting such things as smoking bans. It is unlikely that the Robert Wood Johnson Foundation or the American Legacy Foundation would continue regular funding of any researcher who consistently designed and conducted research showing the relative harmlessness of secondary smoke in well-ventilated situations. Stanton Glantz and others have actively urged universities to eschew any research funded by "Big Tobacco." (6) The Enstrom/Kabat study brought forth a wave of pressure against publishing such research. (7) Perhaps it is time for Antismoking funding to be considered as being in the same boat as Big Tobacco funding. Much can be determined about a study's outcome at the stage of basic study design. More can be determined by the proper selection of data gathered and the tests and methods used to analyze it. And finally still more can be ordained by the researchers' words that surround those basic findings. In the case of Helena we saw references to secondhand smoke a full dozen times in the text of the study, despite the fact that there were no measurements of smoke levels, no measurements of exposure to smoke, and no reported analysis of heart attacks among nonsmokers. But the words and orientation of the study clearly set the stage for the cascade of public statements indicating that Helena proved the need to "protect" nonsmokers from wisps of smoke. It's closing in on 1,000 days since the original press conferences indicting secondary smoke and calling for smoking bans. That indictment was deeply and fatally flawed but the world has never been properly made aware of that fact. We now see that even the more proper claim that could have been made about Helena, that smoking bans produce an immediate and generalized drop in heart attacks, may be just as deeply and fatally flawed. The Kuneman/McFadden analysis of multi-state data, expanded and affirmed by Dr. Siegel, indicates clearly that smoking bans do not produce the predicted massive drops in heart attack rates that so many smoking bans have recently been based upon and most certainly indicates that "protecting nonsmokers from secondhand smoke" does not produce such an effect. This time the world should be invited to see the truth and the British Medical Journal should be in the forefront of ensuring that such an invitation is heard. Michael J. McFadden Author of "Dissecting Antismokers' Brains" http://pasan.TheTruthIsALie.com References: (1) http://bmj.bmjjournals.com/cgi/eletters/328/7446/977#61207 (2) http://www.helenair.com/articles/2005/11/15/helena/a02111505_01.txt (3) http://biz.yahoo.com/prnews/051114/lam013.html?.v=30 (4) http://kuneman.smokersclub.com/ (5) http://tobaccoanalysis.blogspot.com/2005/11/new-study-casts-doubt -on-claim-that.html (6) http://www.shns.com/shns/g_index2.cfm?action=detail&pk=LUNDSTROM- 02-17-05 (7) http://bmj.bmjjournals.com/cgi/eletters/326/7398/1057 Competing interests: I am a member of several Free Choice organizations, and have written a book titled "Dissecting Antismokers' Brains." I have absolutely no financial connections with Big Tobacco, Big Hospitality, or any other player in this arena other than as a customer.
Helena Study Independently Confirmed 24 December 2005
Stanton A Glantz, Professor of Medicine University of California San Francisco, 94143, Richard Sargent and Robert Shepherd Send response to journal: Re: Helena Study Independently Confirmed	We are gratified that the results in our original paper [1], which reported a 42% (95% CI 1% to 79%) statistically significant drop in hospital admissions for acute myocardial infarctions (AMI) when Helena, Montana enacted a smokefree policy was recently confirmed by an independent group [2] that found a similar 27% (95% CI 15% to 37%) drop when Pueblo, Colorado enacted a similar law. The Pueblo study has the advantage of being a larger city, with more cases and so, yields a more precise estimate of the effect size. These two communities provide appropriate “natural laboratories” to examine the impact of these policies of heart disease because they are isolated and small enough that all people were hospitalized at the same hospitals, thus eliminating the effects of between-hospital variation. These conditions, which are necessary to be able to detect an effect, have not been present in larger jurisdictions for several reasons. For example, in California smokefree legislation was introduced predominately at the local level over a period of many years, thus “smearing out” the effect in time. (Nevertheless, the California Tobacco Control Program, which emphasized creation of smokefree policies, was associated with a substantial drop in mortality from heart disease [3].) Analysis of data from a state like New York is complicated not only by the fact that the laws were passed over a period of several years, but also by the fact that people who might work in New York could live (and be hospitalized) in other states, or vice versa. Florida also has a population of “snow birds” who come and go with the seasons; in addition, many of these people are retired and not affected by smokefree workplace legislation. It is also important to emphasize that the observed drop in AMI observed in Helena and Pueblo represents a combination of lower exposure to secondhand smoke as well as the fact that smokefree policies lead some smokers to cut down or quit [4]. Unfortunately, the collection of data on smoking histories is spotty at best, it is not possible to assess how much of the observed drop in AMI admissions is do to each of these two effects. In terms of the net public health benefit of these laws, the balance between these two effects is not important. In thinking about possible alternative explanations for the findings in our and the Pueblo study, it is important to consider all the observations: 1. In both cities there was a substantial drop in AMI admissions when the smokefree laws went into effect. 2. There was no such drop in AMI admissions from people from the surrounding area (and, in the case of the Pueblo study, a nearby city) who were not covered by the ordinance. These people went to the same hospitals and were subject to the same environmental factors (air pollution, weather, etc) as people living in Helena and Pueblo. 3. There was a rebound in AMI admissions in Helena when enforcement of the law was suspended. 4. There was no change in the underlying pattern of AMI admissions in the surrounding area when enforcement of the Helena ordinance was suspended. None of the individuals who have questioned either our or the Pueblo study have provided a plausible alternative explanation for these facts. These large drops in AMI admissions, while on first blush, were surprising, are consistent with the large and immediate effects that secondhand smoke has on blood platelets, vascular reactivity, and other determinants of cardiovascular function [5-7] . Richard Sargent, MD Robert Shepard, MD Stanton Glantz, PhD References 1. Sargent, R.P., R.M. Shepard, and S.A. Glantz, Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. Bmj, 2004. 328(7446): p. 977-80. 2. Bartecchi, C., et al. A city-wide smoking ordinance reduces the incidence of acute myocardial infarction. in American Heart Association Annual Scientific Sessions. 2005. Dallas, TX. 3. Fichtenberg, C.M. and S.A. Glantz, Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. N Engl J Med, 2000. 343(24): p. 1772-7. 4. Fichtenberg, C.M. and S.A. Glantz, Effect of smoke-free workplaces on smoking behaviour: systematic review. Bmj, 2002. 325(7357): p. 188. 5. Pechacek, T.F. and S. Babb, How acute and reversible are the cardiovascular risks of secondhand smoke? Bmj, 2004. 328(7446): p. 980-3. 6. Barnoya, J. and S.A. Glantz, Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation, 2005. 111(20): p. 2684-98. 7. Raupauch, T., et al., Secondhand smoke as an acute threat for the cardiovascular system: A change in paradigm. Eur Heart J, 2005. doi:10.1093/eurheartj/ehi601 (epub ahead of print)(i). Competing interests: None declared
More confirmation of Helena and Pueblo results 11 January 2006
Stanton A. Glantz, Professor of Medicine University of California San Francisco Send response to journal: Re: More confirmation of Helena and Pueblo results	On January 5, 2006, the Associated Press reported that the number of fatal heart attacks dropped 14 percent between 2003 and 2004 in New York City (Fewer New Yorkers dying of heart attacks; less smoking cited By David B. Carouso). This drop follows a smokefree law that went into effect on July 24, 2003. This result represents an additional independent confirmation of the conclusion that smokefree policies produce rapid and substantial reductions in heart attacks. One would expect a smaller change -- as was observed -- in New York City than in isolated places like Helena or Pueblo because not all people covered by the ordinance would be hospitalized in New York City and vice versa. In addition, there were earlier ordinances in some surrounding jurisdictions who would just work or live in New York City, which would "smear out" the effect in time. In addition, the ordinance was only in effect for half the year, which would also reduce the observed magnitude of the effect. Competing interests: None declared
New York City Heart Attack Mortality Data Does Not Necessarily Indicate an Effect of Smoking Ban 14 January 2006
Michael B. Siegel, Professor Boston University School of Public Health, Boston, MA, 02118, USA Send response to journal: Re: New York City Heart Attack Mortality Data Does Not Necessarily Indicate an Effect of Smoking Ban	It seems premature to conclude that the observed 14% decline in heart attack deaths in New York City was a change attributable to the smoking ban, implemented late in 2003. It appears that the only data upon which this claim is made is the observation that the number of heart attack deaths in New York City in 2004 (3,680) was 13.9% lower than in 2003 (4,275). Comparing these two numbers to estimate the effect of the New York City smoking ban is, in my view, questionable science. It seems to me that one could just as easily conclude that the observed 9.3% decline in drug and alcohol-related deaths in New York City between 2003 and 2004 was attributable to the smoking ban, or that the observed 9.1% increase in hypertensive heart disease deaths was due to this policy. If one looks more fully at the overall trends in heart attack mortality in New York City, it turns out that heart attack deaths in New York City have been declining for several years. In fact, between 2002 and 2003 (the smoking ban took effect late in 2003), there was a 6.3% decline in heart attack deaths in New York City. So if heart attack deaths had simply followed the pre-existing annual trend, it would have dropped by 6.3% between 2003 and 2004. And, in fact, not only had heart attack deaths been declining in New York City, but the rate of decline in heart attack deaths had accelerated during the previous three year period. The rate of decline in heart attack deaths was only 0.8% from 2000-2001, but rose to 4.5% from 2001-2002, and to 6.3% between 2002 and 2003. Based on the trend in the pre-existing observed decline in heart attack deaths in New York City, the expected decline in heart disease deaths from 2003 to 2004 was in fact 9.3%. Thus, the true decline "attributable to the smoking ban" was in fact not 13.9% as claimed, but only 4.6%. It seems obvious that this does not, in fact, provide any evidence for the plausibility of a 40% decline in heart attack admissions in Helena attributable to the smoking ban. In addition, while the claim in Helena was a 40% decline in the incidence of heart attacks due to the smoking ban, the New York City data relate to mortality. Many factors, in addition to changes in heart disease incidence, affect heart disease mortality changes, not the least of which is the treatment for heart disease, which has drastically improved in recent years. It is therefore not valid to attribute changes in heart attack deaths solely to changes in risk factors for heart disease. My concern in responding here has nothing to do with the justification for smoking bans, which I support based on the evidence for the hazards of occupational secondhand smoke exposure. My motivation in responding is that I am afraid that the credibility of tobacco control scientists and practitioners may be threatened if scientific claims are made that are not adequately justified. If true, that may well undermine our ability to advocate effectively for the policies that are needed to protect people from secondhand smoke. Competing interests: None declared
Helena Study Random Variation Confirmed 14 January 2006
Brad Rodu, Professor of Medicine and Endowed Chair, Tobacco Harm Reduction Research University of Louisville, Louisville KY, USA 40202, Philip Cole Send response to journal: Re: Helena Study Random Variation Confirmed	January 12, 2006 The Editor British Medical Journal Dear Sir, The recent submission (24 December 2005) by Sargent, Shepard and Glantz (1), suggests that the results of a study in Pueblo, Colorado (2) confirmed the findings of their previous study in Helena, Montana, discussed in this forum (3). Sargent et al. maintain that smoking bans -- in Helena in 2002, and in Pueblo in 2003 -- caused immediate declines (42% and 27% respectively) in hospital admissions for acute myocardial infarctions (AMI) in those communities. We previously presented data showing that the Helena observations are consistent with random variation because of the small number of observations on which they are based (4). The recent submission from Sargent et al. prompted us to update information for Lewis and Clark County in Montana (which includes Helena) with important data for the year of the ban (2002), and also to present similar data for Pueblo County in Colorado. The figures present annual mortality rates from 1979 to 2002 for myocardial infarction (ICD-9 codes 410-410.9 for 1979-1998 and ICD-10 codes 121.0-1