there was no concurrent change in the rates of out-of-hospital deaths after implementation of the ban. The authors also conducted a survey of cases and a sample of the general population for secondhand-smoke exposure and smoking status, and they measured cotinine concentrations in these participants.

The study did, however, have limitations. Although it was large, it did not include all hospitals in Scotland, it did not have a clearly defined study population, and there could have been changes in the nine hospital catchment areas or a more general population influx or efflux after implementation of the ban. The study had a relatively short followup period (1 year), so the long-term effect of the ban on smokers and nonsmokers is not known. It is unclear whether the ban itself affected smoking status in the general population by changing social norms. Finally, as in all observational trials, other changes—including changes in health-care availability and in the standard of practice in cardiac care, such as new diagnostic criteria for acute MI—during the study period could have confounded the results.


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