Smokefree law and tobacco tax increases followed by big drops in heart attacks in Thailand

The fact that smokefree laws are followed by reductions in hospitalization for heart attacks has been well-documented (page 435) in developed countries such as the U.S. and European countries. Thailand began implementing smoking restrictions in 1992 and then repeatedly updated them to expand smokefree places. In 2010, Thailand achieved 100% smokefree public places at the highest level of FCTC Article 8 (protection of people from tobacco smoke).  

In addition, Thailand has increased its cigarette excise tax from 55% to 90% of the price the manufacturer charges distributors between 1992 and 2017.  Driven at least in part by the increasing taxes, the price of a 20-cigarette pack of the most popular Thai brand (Krongthip) increased from 35 THB (US$1.1) in 1992 to 90 THB (US$2.8) in 2017. Since consumption goes down as prices increase, one would expect that tobacco-caused heart attacks would also drop as taxes are increased.

In our new paper, “Association between tobacco control policies and hospital admissions for acute myocardial infarction in Thailand, 2006-2017: A time series analysis,” Roengrudee (“Kade”) Patanavanich and I examined the relationship between hospitalizations for heart attacks as smokefree laws were implemented and tobacco prices increased from October 2006 (before these changes) and September 2017 (after them) using a national database of hospital admissions.

The implementation of the 100% smokefree law was followed by a significant 13.1% drop in heart attack hospitalizations among men and women aged 18-44 years (incidence rate ratio [IRR] 0.869; 95% CI, 0.801–0.993; p=0.001).  

Cigarette price increases were followed by a significant 4.7% drop in heart attack hospitalizations per 10 THB increase (IRR 0.953; 95% CI, 0.914-0.993; p=0.021). Among 18-44 year olds, the point estimates were similar in men (IRR 0.948) and women (IRR 0.943), but the association was only statistically significant among men.

The fact that the effects were concentrated among younger adults is consistent with the larger literature, which shows that smoking and secondhand smoke risks are largest among younger people.

These drops in heart attacks saved the Thai people a lot of money on hospital costs. Between June 2010 and September 2017, the number of heart attack admissions in 18-44 year olds was 3,190 below what would have been predicted absent these changes (figure), accounting for a  savings of at least 137 million THB (US $4.4 million) in direct health costs, which increased to 1.52 billion THB (US $49.2 million) when including the indirect health costs.

These findings support implementation of tobacco control policies in Thailand and other low and middle income countries. Implementing smokefree legislation and raising cigarette prices through increasing cigarette taxes not only decreased secondhand smoke exposure and cigarette smoking prevalence, but also reduced smoking-caused diseases and, notably heart attack hospitalizations, and the associated costs.

The tobacco companies often make economic arguments against implementing smokefree laws and tax increases (among other demand reduction measures). This paper adds to the literature showing that the economic argument actually supports implementing strong public health policies, particularly since these medical cost savings appear so quickly.

Here is the abstract:

Introduction: Studies in many countries have documented reductions of acute myocardial infarction (AMI) hospitalizations with smokefree policies. However, evidence on the association of cigarette tax with AMI events is unclear. There have been no studies of the associations between these two policies and AMI hospitalizations in Thailand.

Methods: We used negative binomial time series analyses of AMI hospitalizations (ICD-10 codes I21.0-I21.9), stratified by sex and age groups, from October 2006 to September 2017 to determine whether there was a change in AMI hospitalizations as a result of the changes in cigarette prices and the implementation of a 100% smokefree law.

Results: Cigarette price increases were associated with a significant 4.7% drop in AMI hospitalizations among adults younger than 45 (incidence rate ratio [IRR], 0.953; 95% confidence interval [CI], 0.914-0.993; p=0.021). Implementation of the 100% smokefree law was followed by a significant 13.1% drop in AMI hospitalizations among adults younger than 45 (IRR, 0.869; 95% CI, 0.801–0.993; P=0.001). There were not significant associations in older age groups.

Conclusions: The Thai cigarette tax policy and the smokefree law were associated with  reduced AMI hospitalizations among younger adults. To improve effectiveness of the policies, taxes should be high enough to increase cigarette price above inflation rates, making cigarettes less likely to be purchased; smokefree laws should be strictly enforced.   

The full citation is: Patanavanich R, Glantz S. Association between tobacco control policies and hospital admissions for acute myocardial infarction in Thailand, 2006-2017: A time series analysis. PLoS ONE 2020; 15(12): e0242570. https://doi.org/10.1371/journal.pone.0242570. It is available for free here.

Published by Stanton Glantz

Stanton Glantz is a retired Professor of Medicine who served on the University of California San Francisco faculty for 45 years. He conducts research on tobacco and cannabis control and cardiovascular disease/

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