Public smoking ban: Europe on the move.

Smoking, clearly, is the single most important avoidable cause of mortality and morbidity in developed countries. Adverse health effects of smoking are extensive, including lung cancer, cerebrovascular diseases, and chronic pulmonary obstructive disease. A recent report estimated that worldwide, a total of nearly five million premature deaths annually are attributable to smoking. In addition, overwhelming evidence demonstrates increased mortality and morbidity as a result of passive smoking (second-hand smoking). Smoking, therefore, cannot be accepted as a matter of personal preference anymore. It clearly is a significant health threat to everybody exposed to cigarette smoke. Legal bans, together with increased taxation, are the most effective measures to decrease overall smoking. Such bans do not only regulate smokers, but also—as a result—decrease active smoking. Perhaps, more importantly, these bans are likely to be effective in decreasing passive smoking. Barone-Adesi et al. provide another piece of evidence supporting the effectiveness of smoking regulations. The Italian Government has banned smoking in all indoor public places, including cafes, restaurants, and bars, from 10 January 2005. The authors thought of evaluating whether the introduction of the public smoking ban resulted in a short-term change of hospital admissions for acute myocardial infarction. In fact, Barone-Adesi and co-workers describe a significant reduction in the absolute number of admissions for acute myocardial infarction in patients ,60 years from February–June 2004 (before ban) to February–June 2005 (after ban). Such a reduction was not seen in the control period (October– December 2003 to October–December 2004). On the basis of these observations in a population of more than four million inhabitants, the authors suggest that the observed reduction in smoking could account for an 11% reduction in admissions for acute myocardial infarction. A reduction of passive smoking might account for most of the observed effect. Barone-Adesi et al. provide further pieces of evidence from national registries and surveys (i.e. 8.9% decline in cigarette sales, 7.6% reduction in cigarette consumption, .90% reduction in nicotine vapour phase concentration in pubs and discos) suggesting that the smoking ban in Italy did reduce overall smoking likely leading to the observed effect on myocardial infarction admissions. The implications of the study for public measures of health are important. However, this study is not without limitations. First, epidemiological studies are potentially biased by confounding factors (i.e. seasonal variations) that are difficult to assess or control. Furthermore, the size of the effect among active compared with passive smokers remains rather speculative and is not supported by hard data. It would also have been interesting to learn more about potential changes in the relative prevalence of smokers among patients with myocardial infarction. Finally, the increase in acute myocardial infarction in patients .60 years remains incompletely understood. Nevertheless, this study confirms and extends recent observations following regulatory changes in the USA. Particularly, a significant decrease in hospital admissions for acute myocardial infarction was observed in the much smaller community of Helena, Montana, USA, after smoking had been banned from public and workplaces. Smoking bans have been criticized over the past decades for numerous reasons including the loss of profits from tax on tobacco products, potential property rights of bar or restaurant owners, and obvious financial interests of the tobacco industry. The argument of the ‘victimless crime’, however, clearly and finally has to leave the discussion based on accumulating data, including the current article by Barone-Adesi et al. Historically, Pope Urban VII gave way to the world’s first known public smoking ban in 1590, as he threatened to excommunicate anyone who ‘took tobacco in the porchway of or inside a church, whether it be by chewing it, smoking it with a pipe, or sniffing it in powdered form through the nose’. Scientifically, already in 1938, Raymond Pearl reported in Science that tobacco smoke shortened life span by about 10 years in ‘heavy smokers’. The deleterious consequences of passive smoking and the beneficial effects of smoking bans are increasingly discussed in the current literature. Furthermore, a growing number of public initiatives for smoking regulation—like the General Public Awareness Initiative ‘World No Tobacco Day 2006’ of the European Society of Cardiology—are actively campaigning. As a result, an increasing number of cities, states, and countries