Did the number of heart attacks really halve during a smoking ban in Helena, Montana, asks Conor O'Clery, North America Editor
On Last Chance Gulch, Helena's narrow main street, neon casino signs flash over hostelries at almost every corner. These are not Las Vegas-style emporiums, however, but mostly small pubs with a few 25-cent slot-machines placed against the walls.
The casino bars in Montana's sprawling capital in the foothills of the Rockies are in fact centres of social life like the pubs in any Irish town.
People drop in for a drink, a session on the slot-machines, a chat with the bartender and perhaps a cigarette. Smoking is part of the culture in some Helena bars, says Dennis White, proprietor of Dapper D's on North Montana Avenue, a stone-faced corner tavern with a few poker and keno machines along the wall and signs behind the bar such as "Moose Drool now on tap". He estimates that about 60 per cent of his customers smoke and three of his five employees.
The permission to smoke is quite explicit. Dapper D's and most other Helena bars carry a printed notice on the door, saying "smoking allowed on these premises".
It wasn't always so. For six months last year smoking was banned in Helena's bars, restaurants and all other businesses open to the public, under a city ordinance that went into effect on June 4th, 2002, and was backed by a 62 per cent vote of residents. Enforcement of the ordinance was suspended in December, however, because of a legal challenge.
Similar bans and occasional court actions have occurred in more than 1,600 municipalities across the US, from New York to California. What makes Helena unique, however, is a remarkable claim by two doctors at the local St Peter's Hospital, Robert Shepard MD and Richard Sargent MD, that during the six-month ban last year, the number of heart attack victims admitted to St Peter's, the only hospital in Helena, dropped by more than half. If authenticated, their findings would be the first empirical evidence that the health benefits of a smoking ban are almost immediate.
"We have the advantage of being small and isolated, so we were able to capture everything in one hospital," says Dr Sargent over coffee in his suburban home as a deer roams across snow-covered lawns outside. "It made the study easy to do. Can you imagine trying it in New York? What we did was go back to December of 1997 and find out how many heart attacks we would have per six months. Then we predicted, based on that past experience, what we would have in the six months of the ban in 2002. We predicted 56 heart attacks; we got 24."
The doctors, who are leaders of the anti-tobacco campaign in Montana, have yet formally to publish their findings, though they are under some pressure to do so by parties on both sides of the smoking debate. Their paper is out for peer review, says Sargent, who is a member of Citizens for a Healthy Helena and sits on the board of the Montana Tobacco Use Prevention Programme.
He explains the basis of their research. The two doctors checked billing statements and other records to ensure that they considered only heart attacks that occurred prior to admission, and not those occurring under surgery, and they excluded heart patients not living or working in the Helena catchment area of some 69,000 people. They checked the areas outside Helena and found no similar drop in heart attacks, Sargent says.
The Helena doctors presented their study, which was partly funded by the National Cancer Institute, to a meeting of the American College of Cardiology in Chicago in April. In it they attributed much of the sharp decline in acute myocardial infarctions to the near- elimination of the effect of second-hand smoke on blood platelets and the arteries that supply blood to the heart.
The risk of heart attack was reduced because smokers stopped or reduced smoking in a smoke-free environment, they concluded. They estimated that a half-hour exposure to second-hand smoke could make the cells in the bloodstream more sticky and therefore more likely to form blood-clots.
The findings have pitted the doctors against many of the tavern-owners in the Montana capital, an historic gold-mining town which nestles in a valley overlooked by conifer-clad hills and distant peaks. Seventy per cent of the town's cafés and restaurants already had voluntary no-smoking policies but smoking was common in the taverns, including Helena's 16 bar casinos.
"Here's what they will tell you," says Sargent of the bar-owners.
"They will say that in the first two months they had a 30 per cent drop or more in business - but the only objective finding is a 10 per cent drop in gambling tax receipts in that six months."
In any event, "profit is not a right", he adds, and should not justify smoking in public places. He also accuses the taverners of getting support from the tobacco industry, which he claims has five people lobbying the Montana legislature almost full-time and which makes contributions to the Montana Tavern Association.
In the taverns it is a different story. At Dapper D's, the proprietor has only scorn for the doctors' report.
"Out for peer review? If we can't see it, how do we know what kind of science is used?" says Dennis White. "I lost 40 to 45 per cent of gross return," he claims. "If my business didn't hurt, if my business didn't change, what's my motivation to lie to you."
He strongly denies any backing from cigarette companies for the Montana Tavern Association, of which he is first vice-president.
"We have never taken any money from big tobacco and never had any face-to-face contact with the tobacco industry," he says, as he serves a customer who is having an unsuccessful go at Dapper D's "Shake-a-Day" contest, where a customer rolls five dice on the counter hoping to pick up the kitty by getting the same five numbers. "We had the opportunity to be funded by them and and we turned it down."
Dapper D's customers who smoked - some of them power company employees who liked to wind down after a day on high-tension wires - remained loyal after the ban was imposed, White says, but they stayed less time in the bar. "The thing that bothered me was the short stays. During the ban they would come in between four and five o'clock and by seven or seven-thirty it would be quiet again."
White complied with the ordinance and only one or two customers defied it, saying: "If you get a ticket I'll pay it." He never did get fined. He put tables and chairs outside for smokers but they were used by passing drifters, he says.
Laura Fix was so badly hit by the ban that she almost went out of business. Her family owns Fat Boy and Charlie's, a bar, nightclub and upmarket restaurant on Custer Avenue, with a sign outside advertising "sticks, picks and libations", meaning pool cues, seafood, and drinks. They bought the licence in 1996 and had fun inviting customers to meet the real "Fat Boy", their cocker spaniel. Fix is a member of "Citizens for Clean Air and Common Sense", a group founded to oppose the smoking ban. But she is no pro-tobacco zealot.
She says she hates to think that the only thing she will ever be interviewed about by a reporter is smoking.
"I am a non-smoker," she says. "I don't like cigarettes. I don't like the way it makes my clothes smell."
The problem for Fat Boy and Charlie's was that customers who wanted to smoke after June 4th last year had only to drive 1.3 miles across the town limits, where the ordinance didn't apply, to the Valley Hub, a single-storey rural pub advertising slot-machines and $4 hamburgers. Eighty-five per cent of her regular customers, people who worked with their hands, were smokers, including social smokers, according to a survey they did at the door, and many deserted to the Valley Hub or drank at home. She took part in discussions with the Board of Health about making exceptions to the ban, she says, but in the end the city commission passed the ordinance without any exceptions.
"I can't begin to tell you how serious it was," she said. "We took out a bank loan to pay for the $350,000 licence in 1996 and have to make bank repayments of $8,000 a month. Sales fell over 50 per cent. We were going under. I couldn't pay the debt. We had to stop having live bands. We had to lay off people. The power company was going to cut us off."
She angrily rejects charges of exaggeration. "My accountants gave all the information to the state. Why would I lie? I don't want people to smoke; I have no reason to make up anything."
If the ban is re-imposed, she says, "I don't know what we will do, I'm tired of it". The fight was bruising. She was really hurt, she says, by Sargent's comparison of tavern-owners with murderers. The doctor had gone on record as saying: "It is not all right to murder for profit. It's not right to poison people for profit - and that's their argument. They . . . continue poisoning people, even when we've demonstrated an immediate effect of it."
Fix says she would not now sit in the same room as Sargent. She also indignantly denies a charge made at legislative hearings that she said what the tobacco industry told her to.
"The tobacco companies never called me or offered money in any way. It's just not true," she says.
While Fix was conscientious about the new ordinance, putting up "No Smoking" signs and taking away ash-trays, Greg Straw of the Nugget Casino on Euclid Avenue decided on defiance. He did nothing to stop smoking on his premises, a bar and restaurant which has more than a dozen poker and keno machines, nor did he put up signs. He received several violation tickets. Under the ordinance, breaches were treated only as "civil infractions", punishable with a $100 fine, as it had been decided that the revoking of a licence costing several thousand dollars would be too great a punishment.
The Nugget case came before City Judge Myron Pitch in Helena on December 5th. He threw out the citations, saying the ordinance could not be enforced because minor infractions did not qualify for a jury trial, which he said was a constitutional right. Suddenly, smoking in public places was back. The taverners won another victory in the spring when the state legislature passed House Bill 758, which exempts the 1,700 holders of gaming licenses in Montana from any local tobacco control ordinances, and Governor Judy Martz signed it into law.
The story is not over. The new law is being challenged by lawyers for the anti-tobacco lobby as unconstitutional, on the grounds that the Montana constitution guarantees citizens the right to a clean, healthful environment and that it denies a constitutional right to a specific category of workers and patrons in private businesses. The case is pending before Montana Supreme Court.
With the ban suspended for a year now, the rate of heart attacks is going up again, insists Sargent, though he is keeping the statistics for a formal update of the survey.
"I can't quote a number but I can tell you it went back up to close to the number we predicted," he says.
I asked him about criticisms of his findings by opponents of the ban and by tobacco lobbyists, who have pointed out, for example, that the American Heart Association attributes only 5 per cent of a total of 35,000 heart cases a year to second-hand smoke, and that the US Centre for Disease Control and Prevention says smoking accounts for one-fifth of heart disease deaths, meaning the Helena figures did not add up.
Governor Martz was also among those who find the numbers hard to accept, saying recently: "I don't believe that, statistically, you can create a fact, a good solid fact, in six months.
"You know, if you want to find a statistic you can find it," says Sargent. "But something changed in Helena."