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Casino Smoking Ban Leads to Fewer Ambulance Calls in Colorado


DALLAS — When smoking was banned from casinos in Colorado, ambulance calls to casinos in Gilpin County dropped about 20 percent, according to research reported in the American Heart Association journal Circulation.

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The drop in calls from casinos was similar to drops in ambulance calls from elsewhere two years earlier when Colorado banned smoking everywhere but casinos.

How did the smoking ban lead to a reduction in ambulance calls? Partially by eliminating exposure to secondhand smoke, said Stanton Glantz, Ph.D., the study's lead author.

"Inhaling secondhand smoke increases the chances of blood clots than can block arteries and makes it more difficult for arteries to expand properly, changes that can trigger heart attacks," said Glantz, director of the Center for Tobacco Control Research and Education and professor of medicine in the division of cardiology at the University of California, San Francisco. "The calls may also have decreased due to smokers not being able to smoke in the casinos, thus avoiding the immediate toxic effects of smoke on their blood and blood vessels and because some people quit smoking."

For this study, the first to examine the health impact of smoking bans in casinos, researchers focused on the number of ambulance calls in Gilpin County, Colorado, a tourist destination with 26 casinos — the largest concentration in the state.

Smoking was banned from public locations, including workplaces, restaurants and bars in Colorado in 2006, and ambulance calls to those locations went down 22.8 percent. Casinos, however, were exempt from the ban and their ambulance calls remained about the same.

Then, in 2008, smoking was extinguished at the casinos, too, and ambulance calls there dropped by 19.1 percent, while there was no further change at the other facilities.

The fact that there were changes only at the time the law changed in both venues is strong evidence that the law is what caused the change in ambulance calls, according to Glantz.

"Casinos are often exempted from legislation mandating smoke-free environments, putting employees and patrons at risk for heart attacks, strokes, asthma attacks and other adverse events triggered by secondhand smoke, "Glantz said. "The message to policymakers is clear: stop granting casino exemptions. They lead to a substantial number of people being sent to the hospital, often at taxpayer expense, something that is completely preventable."

As of spring 2013, 20 states have laws that require smoke-free gambling facilities, while another 28 states have state-regulated gambling but only partial or no smoke-free laws, Glantz said. These laws do not cover casinos on American Indian and Alaska native soil; only a few of those are smoke-free, he said.

"For decades the American Heart Association has strongly supported laws that require indoor public places and workplaces to be smoke-free," said Nancy Brown, CEO of the American Heart Association. "We applaud Colorado lawmakers for protecting casino workers and patrons and encourage more states and Native American tribes to follow suit."

The study did not have information on outcomes of the ambulance calls or detailed information on patients, so researchers could not differentiate events related to smoking or secondhand smoke from other emergencies.

"My advice for people with heart disease is to make your home smoke free and don't visit casinos or other venues with secondhand smoke," Glantz said.

The National Cancer Institute funded the study.

Erin Gibbs, deputy director of the Gilpin Ambulance Authority, is co-author of the study. Author disclosures are on the manuscript.


Editor's Note: Below is the UC San Francisco news release on this study.

Smoke-Free Casinos Reduce Medical Emergencies; UCSF Study First to Examine Health Impact of Casino Smoking Ban

By Elizabeth Fernandez

Commercial casinos throughout the country are often exempt from smoke-free workplace laws. Now a new study led by UC San Francisco has found that when smoking is banned in casinos, it results in considerably fewer emergency calls for ambulances.

The study is the first to examine the health impact of smoking bans in casinos.

The authors conclude that if smoke-free laws were to apply to casinos as well as other businesses, it would prevent many medical emergencies and reduce public health costs.

"Our study suggests that exempting casinos from smoke-free laws means that more people will suffer medical emergencies as a result," said lead author Stanton A. Glantz, PhD, UCSF professor of medicine and director of the Center for Tobacco Control Research and Education at UCSF.

"The research shows strong evidence of a significant drop in ambulance calls due to less secondhand smoke exposure," Glantz said. "Inhaling secondhand smoke increases the likelihood of dangers with blood clots and makes it more difficult for arteries to expand properly — changes that can trigger heart attacks. Legislative and tribal exemptions for casinos, which are all too common, are potentially putting employees and customers at risk of secondhand smoke exposure."

For decades, Glantz and his colleagues at UCSF have been pioneers in tobacco research, disclosing how the tobacco industry manipulated its products and led the public into cigarette addiction.

The latest research was published on Aug. 5 in the American Heart Association journal Circulation.

Colorado Case Study

Currently, the majority of states allow smoking in state-regulated gambling. Most tribal casinos also allow smoking.

The new research centered on Gilpin County, a rural community in the high country of Colorado that is about an hour outside Denver. A major tourist destination, the county has more than two dozen casinos in its gaming district, which occupies about 3 square miles of the county. Approximately, 6,000 people live in the county, but the researchers said that more than 40,000 people at a time are working or visiting the area.

The study tracked more than 16,600 ambulance calls from January 2000 through December 2012.

Colorado put a law into effect in 2006 requiring workplaces, restaurants, bars and other public spaces — but not casinos — to be smoke-free. Ambulance calls dropped nearly 23 percent in these places. During that timeframe, there was no significant change in calls from casinos that continued to allow smoking.

Two years later, when the smoking ban was expanded to include casinos, ambulance calls from casinos dropped nearly 20 percent while there was no further change at other locations.

The researchers say the results have important implications for clinicians and policy makers "since they show big, fast effects of eliminating secondhand smoke."

"The message to policymakers is clear: stop granting casinos exemptions," Glantz said.

The study was co-authored by Erin Gibbs, deputy director of the Gilpin Ambulance Authority in Colorado.

The study was supported by the National Cancer Institute (Grant CA-61021).

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.


Editor's Note: Below is a news release on the study from the American Legacy Foundation, a foundation formed to reduce the use of tobacco.

New Study Finds Implementation of Smoke-Free Casinos can Prevent Medical Emergencies

WASHINGTON — A new study published today in Circulation, a journal of the American Heart Association, takes a deeper look at the implementation of smoke-free laws in casinos and its impact on reported medical emergencies. Researchers from the University of California, San Francisco compared the number of medical emergencies before and after casinos implemented smoke-free regulations that were meant to protect people from the detrimental effects of secondhand smoke. They found a significant decrease in medical emergencies once those laws were implemented.

Today, only 19 states and Puerto Rico have laws making all state-regulated gambling smoke-free. Since many casinos are still exempted from legislation mandating smoke-free environments, many put their employees and patrons at risk for the acute effects of secondhand smoke exposure. In 2011, 600,000 non-smokers worldwide died from involuntary exposure to secondhand smoke and each year, in the United States, 49,400 people die from secondhand smoke-induced heart disease and lung cancer. The study examines the differences in ambulance calls originating from casinos before and after the casinos were made smoke-free and the results show a decrease in medical emergencies originating from casinos after implementing the smoke-free casino laws as well as a significant drop in medical emergencies from locations other than casinos after initial implementation of the smoke-free law.

"There is strong evidence to suggest that sheer volume of secondhand smoke that people are exposed to in casinos has an immediate and harmful impact on patrons," said lead researcher Dr. Stanton A. Glantz, Professor of Medicine at the University of California, San Francisco and Legacy Distinguished Professor of Tobacco Control.

According to the study, on July 1, 2006, the state of Colorado implemented a state law making all workplaces, restaurants, bars, and public spaces smoke-free with the exception of casinos; the law was later extended to casinos on January 1, 2008. For the study, researchers collected data on the number of ambulance calls that did not originate and did originate from casinos in Gilpin County, Colorado — a rural Colorado county with a large casino presence — for each month from January 2000 through December 2012 by the Gilpin Ambulance Authority. Gilpin County had a total of 26 casinos in March 2013 and during the study period, there were a total of 16,636 ambulance calls in total: 10,105 from casinos, and 6,531 not from casinos.

The study found that:

* After the initial implementation of the smoke-free law (that exempted casinos), there was a significant drop (22.8 percent) in ambulance calls not originating from casinos but no significant change in calls from casinos.

* After the smoke-free law was extended to casinos in 2008, there was a similar significant drop (19.1 percent) in ambulance calls from casinos but no change in calls originating outside casinos.

* In total, there was a reduction of about 180 calls per year from casinos and 175 calls per year from locations other than casinos following implementation of the two laws.

The observation that the magnitudes in reductions in ambulance calls after the implementation of the smoke-free laws were similar for smoke-free casinos as well as other smoke-free venues in general suggests an effect of acute exposure to secondhand smoke, according to the study.

"Casino owners who continue to fight smoke-free laws and continue to allow smoking in their casinos are literally gambling with the lives of their customers and employees. These are policies that can be changed and should be changed in order to save lives," said Glantz.

By applying smoke-free laws to casinos, states would reduce costs, the study suggests. While the economic aspect may serve as an incentive for passing smoke-free casino laws, research shows there is no risk-free level of exposure to tobacco smoke. Smoke-free laws can help prevent some 49,400 deaths that happen in the U.S. each year from second hand smoke related disease.

Learn more about Secondhand Smoke online.


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