Presented to the American Heart Association, November, 2011.

1. Myocardial Infarction and Sudden
Cardiac Death in Olmsted County,
Minnesota, Before and After Smoke-
Free Workplace Laws
Jon O. Ebbert, MD, MSc; Richard D. Hurt, MD; Susan A.
Weston, MS; Sheila M. McNallan, MPH; Ivana T. Croghan,
PhD; Darrell R. Schroeder, MS; Véronique L. Roger, MD, MPH
Mayo Clinic

2. Disclosures
• Consultant for GSK, maker of Nicorette™ gum
& Nicorette™ lozenge
• Received medication for clinical trialsfrom
Pfizer, maker of Chantix™
• Off-Label Use: None
• Sponsor: ClearWay

3. Whincup PH, et al. BMJ. 2004 Jul 24;329(7459):200-5.

4. California EPA Report on Environmental
Tobacco Smoke – 2006
Excess Morbidity and Mortality in USA
Pregnancy
Low birth weight infants 24,500
Pre Term Delivery 71,900
Children
Asthma Episodes 202,300
Lower Respiratory Illness 150,000-300,000
Otitis Media Office Visits 790,000
SIDS 430
Adults
Cardiac Deaths 46,000 (22,700-69,600)
Lung Cancer Deaths 3,400

5. Smoke-Free Legislation Reduces Coronary
Events
• Meta-analysis assessing smoke-free legislation
and acute coronary events
• 17 eligible studies
• 10 from North America
• 6 from Europe and 1 from Australasia
provided 35 estimates of effect size.
• Pooled RR = 0.90 (95% CI 0.86 to 0.94)

6. Goals of Project
• To evaluate the population impact of smoke-
free laws on the incidence of Myocardial
Infarction (MI) and Sudden Cardiac Death
(SCD) in Olmsted County during the 18-month
calendar period before and after
implementation of each smoke-free ordinance.

7. Olmsted County, MN
• Smoke free ordinances implemented on two
different dates
• January 1, 2002: smoke-free restaurant law
(Ordinance 1)
• October 1, 2007: all workplaces became
smoke-free (Ordinance 2)

8. Methods
• The Rochester Epidemiology Project (REP)
• Medical records linkage system
• Links and archives medical records of
virtually all persons residing in Olmsted
County, Minnesota
• Identifies patients through their outpatient
(office, urgent care, or emergency
department) and hospital contacts across all
local medical providers

9. Methods (Cont.)
• Myocardial infarction (MI)
• International Classification of Disease, Ninth
Revision code 410 (acute MI)
• Standard algorithms integrating cardiac pain,
electrocardiographic (ECG) and biomarker data
• CK & CKMB until 2000, troponin thereafter
• Sudden cardiac death
• Out-of-hospital deaths with the primary cause of
death classified as coronary heart disease on the
death certificate
• International Classification of Diseases, Ninth
Revision codes 410-414

10. Methods (Cont.)
• Medical records were abstracted at time of event
• Clinical diagnoses used for hypertension,
hyperlipidemia, diabetes, familial coronary heart
disease, and smoking status.
• Statistics:
• Age-and-sex-adjusted incidence rates of MI and
SCD were calculated for the 18 months before and
18 months after law implementation
• Events were numerators & denominators were
Olmsted County population as determined by
census data for the year 2000 and extrapolated
• Rates were standardized to the age distribution of
the 2000 US population

11. Results: Patient Characteristics
MI SCD
(N=768) (N=570*)
Age (years), mean (SD) 67.7 (15.2 77.7 (14.9)
Female, n(%) 285 (37.1) 252 (44.2)
Hypertension
n(%) 513 (66.8) 371 (72.6)
Current smoking
n(%) 469 (61.1) 270 (52.8)
Diabetes mellitus
n(%) 175 (22.8) 76 (15.0)
Body mass index (kg/m2) 173 (22.5) 127 (25.0)
Normal (<25), n(%) 208 (27.1) 203 (40.3)
Overweight (25-30), n(%) 289 (37.6) 163(32.3)
Obese (≥30), n(%) 271 (25.3) 138 (27.4)
Familial Coronary Heart Disease 61 (21.2) 62 (12.4)
n(%)
*Age and sex were obtained from the death certificates. For all other characteristics, data are missing for 52 patients
who did not provide consent for the use of their medical records for research purposes.

12. Results: Incidence Rates & Relative Risks
of MI Prior and Post Smoke-free Laws
Prior Post
N Rate per 100,000 N Rate per 100,000 Adjusted RR* (95%
(95% CI)* (95% CI) CI), P
MI
Ordinance #1 233 186.7 (162.5-210.8) 215 167.9 (145.3-190.5) 0.89 (0.74-1.08), 0.24
Ordinance #2 177 129.4 (11.02-148.5) 143 102.2 (85.3-119.0) 0.79 (0.63-0.98), 0.04
Pre-Ordinance #1 vs.
Post –Ordinance #2 233 186.7 (162.5-510.8) 143 102.2 (85.3-119.0) 0.54 (0.44-0.67), <0.01

13. Results: Incidence Rates & Relative Risks
of SCD Prior and Post Smoke-free Laws
Prior Post
N Rate per 100,000 N Rate per 100,000 Adjusted RR* (95%
(95% CI)* (95% CI) CI), P
SCD
Ordinance #1 199 152.5 (131.1-174.0) 148 112.2 (93.9-130.4) 0.72 (0.58-0.89), <0.01
Ordinance #2 111 78.0 (63.4-92.7) 112 76.6 (62.2-91.0) 0.99 (0.76-1.28,) 0.91
Pre-Ordinance #1 vs.
Post –Ordinance #2 199 152.5 (131.100-174.0) 112 76.6 (62.2-91.0) 0.50 (0.40-0.63), <0.01
*Adjusted for age and sex

14. Prevalence of self-reported high cholesterol, diabetes,
hypertension and obesity in Minnesota, 1999-2010 from
Behavioral Risk Factors Surveillance System (BRFSS)
High Cholesterol Hypertension
40 25
35
Prevalence (%)
20
Prevalence (%)
30
25 15
20
15 10
10
5
5
0 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year Year
Diabetes* Obesity (BMI ≥ 30 kg/m2)
8 30
7
25
Prevalence (%)
6 Prevalence (%)
5 20
4 15
3 10
2
1 5
0 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year Year

15. Prevalence of Self-Reported Current Smoking in
Minnesota, 1999-2010 from Behavioral Risk Factors
Surveillance System (BRFSS)
Current Smokers
25
20
Prevalence (%)
15
10
5
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year

16. Conclusions
• The implementation of smoke-free ordinances
was associated with significant decreases in MI
(46% reduction) and SCD (50% reduction)
• The magnitude is not explained by community
co-interventions or changes in known
cardiovascular risk factors.
• SHS exposure should be considered a
modifiable risk factor for MI and SCD.