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RESEARCH PAPERS |
1 Roswell Park Cancer Institute, Department of Health Behavior, Elm and Carlton Streets, Buffalo, New York, USA
2 International Agency for Research on Cancer, Tobacco and Cancer Group, Lyon, France
Correspondence to:
Andrew Hyland, Roswell Park Cancer Institute, Department of Health Behavior, Elm and Carlton Streets, Buffalo, NY 14263, USA; andrew.hyland{at}roswellpark.org
Received 29 January 2007
Accepted 30 January 2008
 | ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Methods: The TSI SidePak AM510 Personal Aerosol Monitor was used to measure the concentration of particulate matter less than 2.5 microns in diameter (PM2.5) in 1822 bars, restaurants, retail outlets, airports and other workplaces in 32 geographically dispersed countries between 2003 and 2007.
Results: Geometric mean PM2.5 levels were highest in Syria (372 µg/m3), Romania (366 µg/m3) and Lebanon (346 µg/m3), while they were lowest in the three countries that have nationwide laws prohibiting smoking in indoor public places (Ireland at 22 µg/m3, Uruguay at 18 µg/m3 and New Zealand at 8 µg/m3). On average, the PM2.5 levels in places where smoking was observed was 8.9 times greater (95% CI 8.0 to 10) than levels in places where smoking was not observed.
Conclusions: Levels of indoor fine particle air pollution in places where smoking is observed are typically greater than levels that the World Health Organization and US Environmental Protection Agency have concluded are harmful to human health.
Partly driven by the FCTC call for greater second-hand smoke protection policies, several countries have initiatives to implement smoke-free regulations at the national or sub-national level. For example, in 2004, Ireland, Norway and New Zealand became the first countries to enact comprehensive smoke-free indoor air laws. In 2006, Uruguay became the first South American country to implement a 100% smoke-free regulation in workplaces, restaurants and bars. Other countries throughout Europe, Asia, North and South America, Africa and the Pacific have taken action to reduce exposure to second-hand smoke in workplaces and public places.6 While this is encouraging, smoking in indoor public places is still the norm in the vast majority of nations worldwide as they work toward achieving the FCTC standard.
Several studies have demonstrated that smoke-free policies are effective in decreasing SHS exposure and improve health outcomes. Farrelly et al showed a significant decrease in salivary cotinine concentrations and sensory symptoms in hospitality workers after New York State’s smoke-free law prohibited smoking in their worksites.7 Other studies found that respiratory health improved rapidly in samples of bartenders after smoke-free workplace laws were implemented in California8 and Scotland.9 Another study reported a 40% reduction in acute myocardial infarctions in patients admitted to a regional hospital during the 6 months that a local smoke-free ordinance was in effect.10
Some studies have shown that venues that permit smoking in indoor locations have particle levels approximately 10 times greater than in places where smoking is not allowed. In a longitudinal study of 22 hospitality venues in western New York state, Travers et al found a 90% reduction in the levels of particulate matter less than 2.5 microns in diameter (PM2.5) in bars and restaurants, an 84% reduction in large recreational venues such as bingo halls and bowling alleys, and even a 58% reduction in locations where only SHS from an adjacent room was observed at baseline.11 In a recent study in the UK, air quality was found to be poorest in smoky pubs that were located in economically deprived areas.12 A cross-sectional study of 53 hospitality venues in 7 major cities across the USA showed 82% less indoor air pollution in the locations subject to smoke-free air laws, even though compliance with the laws was less than 100%.13 Repace et al studied 15 hospitality venues in the state of Delaware and the city of Boston, Massachusetts before and after a state-wide prohibition of smoking in these types of venues and found that about 90% to 95% of the fine particle pollution could be attributed to tobacco smoke.14 15 Others who have examined levels of ambient air nicotine concentrations instead of particle concentrations have obtained similar results.16 While these studies are informative, they are typically small-scale studies performed in small geographic areas, and there is little research in this field in developing countries.
The goal of this study was to provide the latest scientific equipment and methods to practitioners around the world to determine second-hand smoke exposures in a wide range of geographically and economically disparate countries. Hypotheses to be examined included: (1) levels of indoor air pollution will be higher where smoking is observed compared to the facilities where no smoking is observed; (2) levels of smoke pollution will be higher in countries that have weak or non-existent clean indoor air policies compared to places that have comprehensive policies; and (3) levels of smoke pollution will be correlated with smoker density.
| METHODS |
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Selection of countries and coordination of data collection
Countries included in the study were identified first through existing contacts in individual countries with the help of the International Agency for Research on Cancer (IARC). Specific tailored venue sampling frames were developed for each country, taking into account conditions in those countries while striving to maintain comparability across countries. The types of public hospitality venues are not necessarily the same across countries. For example, a bar or pub in the USA, Canada, or Ireland is a readily identifiable establishment whose primary purpose is the sale of alcoholic beverages. The same type of establishment is much less prevalent in Syria or Pakistan, for example, where a sample of cafes serving non-alcoholic beverages was more appropriate. For this cross-country summary, locations sampled were ultimately collapsed into: (1) "bars", whose primary purpose is the sale of beverages; (2) "restaurants", whose primary purpose is the sale of food; (3) "transportation" venues, which includes airports, bus and train stations and train cars; and (4) "other" venues, which is a catch-all for those locales not falling into one of the other three categories and includes hotels, shopping malls, offices, casinos, retail outlets and schools.
This report includes data from 1822 air quality assessments conducted in 32 countries that have been divided up for analysis according to WHO world regions:17 the Americas (Argentina, Brazil, Canada, Mexico, USA, Uruguay, Venezuela), Europe (Armenia, Belgium, Faroe Islands, France, Germany, Greece, Ireland, Poland, Portugal, Romania, Spain, UK), Eastern Mediterranean and Africa (Ghana, Lebanon, Pakistan, Syria, Tunisia), and South-East Asia and Western Pacific (China, Laos, Malaysia, New Caledonia, New Zealand, Singapore, Thailand, Vietnam). The data from 25 air quality assessments conducted in Ireland as part of a separate study by an independent group of investigators were included to serve as a reference group to the data in this study.18
Training of data collection staff
Initially, training was performed via face-to-face meetings. One meeting conducted in November 2005 in Paris, France in collaboration with IARC and the French National Cancer Institute involved seven countries (Belgium, France, Germany, Poland, Spain, Cote d’Ivoire (did not ultimately participate in the study) and Egypt), while additional training was conducted in Bangkok, Thailand and Beijing, China in February 2006. Subsequently, we developed a web-based training course (http://www.tobaccofreeair.org). This training module includes step-by-step instructions on the operation of the air monitoring equipment, study protocol and data management. In addition, project staff at Roswell Park Cancer Institute provided telephone and email technical support throughout the project.
Measurement protocol
A standard measurement protocol was used by data collectors across study sites. Establishments were tested for a minimum of 30 min. The number of people inside the venue and the number of burning cigarettes were recorded every 15 min during sampling. Lebanon (n = 6), Pakistan (n = 1), Syria (n = 20) and Tunisia (n = 8) had locations with waterpipe smoking in addition to cigarette smoking. A burning waterpipe was counted as the same as a single cigarette in these instances, as a cigarette smoked for a typical duration of about 10 min will emit an amount of particles similar to a waterpipe session lasting 30 min.19 These observations were averaged over the time inside the venue to determine the average number of people on the premises and the average number of burning cigarettes and waterpipes. For most establishments, a sonic measure (Zircon Corporation, Campbell, California, USA) was used to measure room dimensions and hence the volume of each of the venues. When using the sonic measure to calculate room dimensions was not possible, room measurements were made through estimation. Some venues were large and consisted of multiple rooms. If there was a significant physical barrier between different spaces in a venue, such as a normal doorway separating two rooms, the volume and counts were measured only in the room where the aerosol monitor was located.
In each establishment, respirable suspended particles (RSP) were measured using a TSI SidePak AM510 Personal Aerosol Monitor (TSI, St. Paul, Minnesota, USA; fig 1). The SidePak uses a built-in sampling pump to draw air through the device where the particulate matter in the air scatters the light from a laser. The mass concentration of particles is not measured directly, but instead is determined by the amount of light scattering. This portable light-scattering aerosol monitor was fitted with a 2.5 µm impactor in order to measure the concentration of particulate matter with a mass-median aerodynamic diameter less than or equal to 2.5 µm. Tobacco smoke particles are almost exclusively less than 2.5 µm with a mass median diameter of 0.2 µm.1 The SidePak was used with a calibration factor setting of 0.32, suitable for second-hand smoke. This calibration factor was determined in an experiment with the SidePak collocated with another light-scattering instrument that had been previously calibrated against standard pump-and-filter gravimetric methods and used in SHS exposure studies.14 Klepeis et al found a similar SHS calibration factor for the SidePak when compared to a Piezobalance (Kanomax, Andover, New Jersey, USA), which provides direct measurements of RSP mass concentrations.20 This calibration factor has also been confirmed by another researcher who compared SidePak measurements of SHS to gravimetric measurements using a Personal Environmental Monitor (PEM for PM2.5, MSP Corporation, Shoreview, Minnesota, USA) (Kiyoung Lee, University of Kentucky College of Public Health, personal communication, 2006).
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Statistical analyses
The primary goal was to assess the difference in the average levels of PM2.5 in venues that were smoke free (no smoking observed during sampling) and venues that were not (smoking was observed during sampling). All statistical analyses were performed using the log-transformed PM2.5 concentrations because these data are log-normally distributed, hence geometric means are compared. The comparison between smoking and smoke-free venues was performed within each country and pooled across all countries. A comparison was also made between the overall geometric mean concentration in the three smoke-free countries with comprehensive non-smoking policies (Ireland, New Zealand and Uruguay) and the other 29 countries. In addition, the comparison between smoking and smoke-free locations was also stratified by type of venue and world region. The four types of venues considered in this study were as outlined above. The generalised linear model (GLM in SPSS V.14.0; SPSS, Chicago, Illinois, USA) was used to test for differences in PM2.5 levels and construct 95% CIs. Multiple post-hoc pairwise comparisons were adjusted using the Bonferroni method, although the choice of adjustment method had no effect on the significance of any results. An alpha of 0.05 was used for all significance testing.
The active smoker density (ASD) was also calculated for each location sampled. This is defined as the average number of burning cigarettes and waterpipes per 100 m3. Spearman rho was used to determine the correlation between the ASD and average PM2.5 levels.
| RESULTS |
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Overall, there were 584 venues where no smoking was observed, and the geometric mean PM2.5 level in these places was 21 micrograms per cubic meter (µg/m3), ranging from 0 to 573 µg/m3. The geometric mean PM2.5 level in the 1238 venues where smoking was observed was 188 µg/m3, ranging from 1 to 3764 µg/m3. The PM2.5 concentration was 89% lower in the venues with no observed smoking compared to those where smoking was observed (95% CI 88 to 90%). This difference was slightly lower after adding country and type of venue to the model at 85.4% (95% CI 83 to 88%).
Figure 2 compares the average air pollution levels in places with and without smoking stratified by four types of location; (1) bars, (2) restaurants, (3) transportation venues and (4) other types of venue. Venues with smoking had significantly higher levels of PM2.5 compared with smoke-free places in all four types of location. Bars with smoking had the highest average levels (303 µg/m3) and were 15.4 times higher (95% CI 12.5 to 34.5) than smoke-free bars. The difference between smoking and smoke-free places was 6.2 times for restaurants (95% CI 5.3 to 7.2), 8.8 times for transportation venues (95% CI 5.4 to 14.2), and 7.0 times for other places (95% CI 5.4 to 9.0). The high PM2.5 level in bars is consistent with the high geometric mean active smoker density in these venues of 1.59, compared to 0.81 in restaurants, 0.74 in transportation venues, and 0.71 in other types of venues.
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| DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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These results are consistent with previous studies examining this topic, although this is one of the only studies to provide international comparisons and, for some countries, provides the first data on the level of indoor air pollution inside venues where smoking is permitted. The general comparability of conclusions across different types of venues and in different countries adds to the generalisability of the finding that fine particle air pollution levels are higher in venues where smoking occurs. Statistically higher particle concentrations were observed in bars and in some regions of the world; however, the main finding is that regardless of the type of venue assessed or its geographic location, the amount of smoking was a major force driving PM2.5 levels. In addition, these findings looking at differences in air quality measurements between countries where smoking is and is not permitted in indoor public venues closely mirror the changes in cotinine levels of New Zealand bar patrons, where a 90% reduction was observed.21
The results of this study stress the importance of governments prohibiting smoking in indoor public places in order to comply with Article 8 of the FCTC. In light of recent evidence indicating that SHS cannot be controlled through improved ventilation or filtration,22 23 and with no evidence that these measures can eliminate the health risk of SHS exposure, only the creation of 100% smoke-free environments is known to effectively achieve the goal of Article 8.
The data from Greece also provides compelling evidence that providing separate sections for smokers and non-smokers does not protect individuals from SHS exposure. Only non-smoking sections of venues that allowed smoking were tested in Greece, and the average PM2.5 level with observed smoking (GM = 223 µg/m3) was similar to other countries. The current Greek law calls for 50% of the area of hospitality establishments to be non-smoking, but these data show that it is ineffective in markedly reducing SHS exposure.
To protect public health, the WHO has established air quality standards and an air quality guideline (AQG). The AQG is a measure for reducing the health impacts of air pollution. According to this guideline, an annual mean PM2.5 concentration of 35 µg/m3 or higher is associated with 15% higher long-term mortality risk.24 Many of the venues where data was collected for this study (764 out of 1822 venues, or 42%) had average PM2.5 levels that would result in an average annual exposure of over 35 µg/m3 solely from occupational exposure alone for a full-time employee. In all, 60% of venues with observed smoking exceeded this limit compared to only 4.5% of venues with no observed smoking. The WHO’s target air quality guidelines for PM2.5 are much lower: 10 µg/m3 annual mean and 25 µg/m3 24-h mean.
A limitation to be considered when interpreting these data is that second-hand smoke is not the only source of indoor particulate matter. Ambient particle concentrations and cooking are additional sources of indoor particle levels, although smoking is generally the largest contributor to indoor air pollution.13 The level of outdoor particles in a given country and the frequency with which venues were open to outside air impacts the magnitude of the difference in particle levels in venues with and without smoking. In the USA and Canada for example, venues were primarily closed and the only common source of particles was cigarette smoke, therefore there was a large (12- to 15-fold) difference between particle concentrations in venues with smoking compared to those without smoking. In China, however, ambient particle concentrations were much higher, partially explaining the smaller difference in particle levels (twofold) between venues with and without observed smoking. Malaysia and Singapore are close geographically but particle levels in venues with smoking in Singapore are higher than in Malaysia. This can be partially explained by the higher active smoker density in Singapore, but is also likely related to the greater ventilation and dilution of tobacco smoke in Malaysia due to the larger number of venues that were partially open to the outside. In some countries, the level of pollution in smoke-free venues was higher than in other countries. There are a few possible explanations for this discrepancy. The higher levels of indoor air pollution seen in some venues with no observed smoking could be due to other factors, such as cooking, open fireplaces and higher levels of ambient air pollution. Restaurants in Brazil frequently had open fires for cooking, contributing to higher particle levels in restaurants with no smoking compared to countries such as the USA and Canada. In some cases there may also have been residual tobacco smoke particles in the air of these locations from smoking that occurred before the data collection, or tobacco smoke particles that drifted in from adjacent outdoor areas or indoor areas that were not observed.
Restaurants, bars, transportation outlets and other types of venue that are "smoke free" are significantly less polluted than venues where smoking occurs, and this is true around the globe. Comprehensive smoke-free regulations are the most effective strategy to reduce second-hand smoke exposure. These findings underscore the importance of compliance with the FCTC Guiding Principle 4.2 to "take measures to protect all persons from exposure to tobacco smoke".
| ACKNOWLEDGMENTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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akowska, Daniel Pokrywczynski, Janina Fetlinska, Magorzata Zagroba, Pawl Polak. Portugal: Sílvia Menezes. Romania: Florin Dumitru Mihaltan, Ioana Munteanu. Singapore: Heng-Nung Koong. Spain: Maria J Lopez, Manel Nebot, Irene Gonzalez, Isabel Marta. Syria: Wasim Maziak, Fouad M Fouad. Thailand: Stephen Hamann, Naowarut Charoenca, Nipapun Kungskulniti, Sorakom Santhana, Chairat Neramit. Tunisia: Radhouane Fakhfakh, Karim Kammoun, Youssef Slama, Nourredine Achour. UK: Richard Edwards, Christian P Hasselholdt, Kim Hargreaves, Claire Probert, Richard Holford, Judy Hart, Martie Van Tongeren, Adrian F R Watson. USA: Gregory Connolly, Carrie Carpenter. Uruguay: Laura Roballo, Cecilia Caviglia, Gerardo Tucuna, Eduardo Bianco. Venezuela: Natasha Herrera, J Dennis Rada, Ana María Dmytrejchuk, José Felix Ruiz. Vietnam: Nguyen Thi Hoai An, Tran Thi Kieu Thanh Ha, Le Thi Chi Phuong. | FOOTNOTES |
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Published Online First 26 February 2008
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