Smoking Bans and Heart Attacks

         Pueblo, Colorado is not known for its beauty.  The former saddlery of America later gained fame as the ÒSteel City,Ó and is now better known for the Colorado State Fair and state mental hospital than as a cockpit for public health research.

         Several years ago Pueblo County decided to ban smoking in all public spaces.  Recognizing the opportunity to perform a large scale public health trial, researchers looked to see what banning smoking might do over the long haul.

         Plenty of studies have tracked smoking bans short term, but this time changes were observed for three years.  Heart attacks in local hospitals declined 27% the first year, 19% the second and third.  All told, heart attacks decreased 41% in three years. In nearby counties without smoking bans, there was no change.

Ripple Effects and Virtuous Circles

         The Pueblo researchers argued much of the decreased heart attacks resulting from by stopping second hand smoke.  The CDC figures 46,000 American non smokers die from second hand smoke each year.

         Yet other scientists quickly pointed out the Pueblo heart attack data did not include who was and was not a smoker, let alone who smoked in the past. More impressively, smoking in PuebloÕs adult population declined from 26 to 21%.

         The smoking ban had multiple effects, including decreased second hand smoke and decreased smoking prevalence. Smoking bans help make smoking uncool to youngsters.  And what about decreasing the number of the cityÕs smoky dives  Ð does that ultimately decrease drug and homicide rates?

         The beauty of public health changes is that they create virtuous circles, just as increased greenery in poor urban areas appears to save lives (see the November 28th article, ÒGreening America for Health.)  The ÒcausesÓ of such changes are numerous, and the ripple effects continue long afterward to make populations healthier.

         Dr. Thomas Chalmers would have loved all this.  The former dean of Mt. Sinai, who died in 1995, was a major supporter of clinical public health trials.  Though an important member of the scientific group that helped end smoking on US airplanes, Chalmers would have preferred a clinical trial comparing smoking and nonsmoking carriers.   Earlier he had advocated the VA test whether cardiac care units were worthwhile, adding them to only some hospitals and then seeing if mortality rates improved.

         Chalmers never got that chance.  Powerful forces prevented such obvious public health experiments. Those forces are still around.

The Coming Health Information Revolution

         The fact that American health planners rarely use the nationÕs health, as their main yardstick is simply one reason American health care is a mess.  That most developed countries have far better health indices than the US at less than half the per capita price may have as much to do with mass transit and encouraging walking than it does with rational health care organization. Still, most European health care systems beat the pants off of us in health effectiveness.

         Which is why the coming ÒInformation RevolutionÓ in American health care represents a real opportunity, rather than the expensive boondoggle it may well become.  Tens of billions will soon be spent ÒmodernizingÓ American health care, producing paperless medical offices from coast to coast.

         The real bill will probably costs hundreds of billions. Information technology companies, like Google, are already toting up future profits.  The end result is that health care IT spending may go the way of the Defense Department, where political connections determine who gets the giant contracts to build the weapons of the future,  with their ÒnormalÓ cost overruns at three or four hundred percent.

         It need not work that way.  Many national health systems exist that utilize IT well, with countries like Singapore leading the way.  Any future contracts let by the US government should look very carefully at how well our Òcustom systemsÓ stack up against others that already work.  Yes I know, America is a unique country, but human bodies are remarkably similar around the globe.

         This coming IT revolution calls out for careful, planned, clinical trials comparing different systems.  Hospitals can be compared with cross town rivals; public health results can be compared county by county, and should include far more than health care data.  The future IT health revolution will also change law enforcement, school policy, and privacy, as many Americans will discover itÕs not just their credit cards being sold over the Internet.

         Clinical public health trials are powerful tools.  They can save lots of money.  They can also save our lives.

Dr. Matthew Edlund practices sleep medicine and psychiatry in Sarasota.  His new book, Designed To Last, is available online. He can be reached at 365-4308 and via his Web site at doctoredlund.com.