Qiang Li, PhD on behalf of the ITC Team

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Training Workshop Evaluating Smokefree Policies
Qiang Li, PhD on behalf of the ITC Team Mumbai,
India March 2009
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Goals of the Workshop

• Understand the dangers of secondhand smoke (SHS)
  (also known as tobacco smoke pollution TSP)
• Become familiar with the conceptual model of
  evaluating smokefree policies
• Understand different methods for measuring SHS
  exposure
• Experience examples of how SHS exposure data has
  been used by advocates to educate policy makers
  about the dangers of SHS and the benefits of
  smokefree policies

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Goals of the Workshop

• Understand the dangers of secondhand smoke (SHS)
  (also known as tobacco smoke pollution TSP)

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Tobacco Smoke Pollution (TSP)

• Sidestream smoke (85) and exhaled mainstream
  smoke (15)
• Particulate phase of tobacco smoke contains more
  than 4,000 individual components
• TSP contains 69 carcinogens and 172 toxic
  substances
• Some compounds are emitted in levels 10 times
  higher in sidestream compared to mainstream smoke
  (e.g. polycyclic aromatic hyrdocarbons, PAH)
• Bottomline TSP is toxic

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Effects Associated with TSP Exposure

• Causal Effects
• Developmental Effects
• Fetal Growth Low birthweight and decrease in
  birthweight
• Sudden Infant Death Syndrome (SIDS)
• Pre-term delivery
• Respiratory Effects
• Acute lower respiratory tract infections in
  children (e.g. bronchitis and pneumonia)
• Asthma induction and exacerbation in children and
  adults
• Chronic respiratory symptoms in children
• Eye and nasal irritation in adults
• Middle ear infections in children
• Carcinogenic Effects
• Lung cancer
• Nasal sinus cancer
• Breast cancer in younger, primarily premenopausal
  women

• Suggestive Causal Effects
• Reproductive and Developmental Effects
• Spontaneous Abortion, Intrauterine Growth
  Retardation
• Adverse Impact on Cognition and Behavior
• Allergic Sensitization
• Decrease pulmonary function growth
• Adverse effects on fertility or fecundability
• Cardiovascular and Hematological Effects
• Elevated risk of stroke in adults
• Respiratory Effects
• Exacerbation of Cystic Fibrosis
• Chronic respiratory symptoms in adults
• Carcinogenic Effects
• Cervical Cancer
• Brain Cancer and lymphomas in children

Sources California EPA Report 2004, US Surgeon
General Report 2006
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Framework Convention on Tobacco Control

• The FCTC is the worlds first global public
  health treaty
• 162 countries representing 85.3 of the worlds
  population are Parties to this treaty
• Article 8 Protect people from exposure to
  tobacco smoke in indoor workplaces, public
  transport and indoor public places

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Goals of the Workshop

• Become familiar with the conceptual model of
  evaluating smokefree policies

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Conceptual Framework for the Evaluation of
Smokefree Policies
SHS secondhand smoke SES socio-economic status
Source IARC Handbook. Measuring Effectiveness
of Population Based Tobacco Control
Interventions. In press.
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Objectives

• In this short workshop, we will focus on SHS
  exposure measurement to answer some basic
  questions
• Why would you want to measure SHS?
• How do you measure SHS?
• Are some methods better than others?
• How have others used SHS exposure measurement to
  further their work in Article 8 adoption?
• For SHS policy evaluation, there are many other
  types of studies one might perform, for example,
  economic or direct health impact studies
• Summaries of these are described in the IARC
  Handbook 2.

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Goals of the Workshop

• Understand different methods for measuring SHS
  exposure

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SHS Exposure Assessment Questions

• Question Why would you want to measure SHS?
• Answer SHS is the disease causing agent.
  Measuring SHS is an excellent proxy for specific
  toxic compounds and overall disease risk.
• If a smokefree policy is not yet in effect,
  measuring high SHS levels is useful to educate
  the public about the dangers
• If a smokefree policy has been implemented,
  measuring SHS levels has been used to show
  dramatic reductions in exposure to identify areas
  on non-compliance.

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SHS Exposure Assessment Questions

• Question How do you measure SHS?
• Answer There are several methods including
• - Observation
• - Questionnaire
• - Airborne nicotine
• - Cotinine biomarker
• - Airborne particulate matter
• This presentation will focus in detail on
  airborne particulate matter (PM) measurements

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Measuring Exposure to Tobacco Smoke Pollution

• Cigarettes, cigars and pipes are major emitters
  of respirable suspended particles less than 2.5
  microns (PM2.5) in diameter that are easily
  inhaled deep into the lungs
• TSI SidePak AM510 Personal Aerosol Monitor
  (weight 1 lb)
• This device is a real-time laser photometer with
  a built-in sampling pump that measures airborne
  particle mass-concentration

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Particle Size
Human Hair
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Why Use PM2.5 as a Marker of TSP?

• Very sensitive marker of TSP
• Can monitor and record data in real time
• Relatively cost-effective data collection
• Marker of the more than 4,000 chemicals in TSP
• E.g. 2,0001, PM2.5PAH
• Meaningful measure there are PM2.5 standards in
  place to protect public health
• The EPA has set standards of 15 µg/m3 as the
  average annual level of PM2.5 exposure and 35
  µg/m3 24-hour exposure in order to protect the
  public health
• The WHO has incremental benchmark standards (10
  annual and 25 24-hour)

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www.tobaccofreeair.org
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Protocol

• Minimum of 30 minutes spent in each venue
• Counts of people and burning cigarettes every 15
  minutes (minimum of 3 observations)
• Room dimensions determined with sonic measuring
  device or through estimation (pacing)
• Sidepak is carried discreetly in a bag with the
  sampling tube protruding
• Testers are patrons purchase something in each
  place

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Countries (in red) Participating in Global Air
Monitoring Study (n32)
Source Hyland A et al. Tobacco Control 2008.
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Hypotheses

• 1) Levels of indoor air pollution (PM2.5) will be
  higher where smoking is observed compared to
  facilities where no smoking is observed.
• 2) Levels of indoor air pollution (PM2.5) will be
  higher in countries that have weak or
  non-existent smoke-free air policies compared to
  countries that have comprehensive policies.
• 3) PM2.5 levels will be correlated with smoker
  density.

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US EPA Air Quality Index
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Results by Country and Observed Smoking
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Geometric Mean PM2.5 With and Without Smoking by
World Region
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Geometric Mean PM2.5 With and Without Smoking by
Type of Place
1.59
0.81
0.74
0.71
Active smoker density average number of burning
cigarettes per 100m3
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Summary

• Hazardous levels of indoor air pollution are
  observed in venues where smoking is permitted.
• The only countries with acceptable indoor air
  quality were those with comprehensive national
  smoke-free air policies Ireland, New Zealand,
  and Uruguay.
• Comprehensive smoke-free policies are the most
  effective strategy to reduce tobacco smoke
  pollution exposure.
• Study results have been used in countries around
  the world to inform the media, the public and
  policy makers on the need to enact strong
  smoke-free air protections and comply with the
  provisions of the FCTC.
• The Global Air Monitoring Study is an ongoing
  project with over 40 countries currently involved.

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SHS Exposure Assessment Questions

• Question Are Some Methods Better than Others?
• Answer It depends on your purpose.
• - PM measurement is relatively easy, affordable,
  a good proxy for specific toxic agents in SHS,
  and can be compared to other benchmarks but its
  solely derived from SHS particles
• - Questionnaires are often affordable and give a
  reasonable overall assessment but lack
  specificity
• - Airborne nicotine is specific to tobacco smoke
  but lab access is needed and data are not in real
  time
• - Biomarkers are good for recent exposure but
  are expensive and require more complex protocols.
• (see IARC Handbook 2 for more details on these
  methods)

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SHS Exposure Assessment Questions

• Question How have others used SHS exposure
  measurement to further their work in Article 8
  adoption?
• Answer 3 examples are given
• General comparison of PM2.5 levels indoors with
  that found outdoors under the extreme conditions
  of a raging forest fire.
• China Example
• Latin America

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Denver
June 9, 2002
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Denvers visibility before Hayman fire
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Denvers visibility 1 day after Hayman fire
Hayman Fire Worst in Colorado History, June 8
2002 Worst PM2.5 day in Denver Was
43 µg/m3 (24-hr max) or 200 µg/m3 (hourly max)
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How PM Measurement Is Being Used in China

• The current smoke free policies in China
• Several national level laws and policies regulate
  smoking in some public places
• Regulations on the Sanitary Administration of
  Public Places
• Law of the People's Republic of China on Tobacco
  Monopoly
• Law of the Peoples Republic of China on the
  Protection of Minors
• No national level laws regulate smoking in
  restaurants, bars, and workplaces
• Most of these laws are not comprehensive and
  exceptions are still allowed

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How PM Measurement Is Being Used in China

• The current smoke free policies in China
• About half of the cities in China have made local
  smoke free laws
• Most laws are just mirroring the national level
  laws and the enforcement is limited
• Restaurants, bars, and workplaces are not covered
  in most local laws
• Only few cities local laws are more stringent
  than the national laws
• Beijing
• Guangzhou

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How PM Measurement Is Being Used in China

• China ratified FCTC and the deadline to fulfill
  the countrys commitment of Article 8 in FCTC is
  2011
• New smoke free policies are being made in several
  China cities
• Beijing regulations on the scope of banning
  smoking in public places
• The new regulation restricts smoking in
  restaurants and workplaces, although its not
  comprehensive and designated smoking areas are
  still allowed
• Other cities that made new policies include
  Shenyang and Qingdao

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A PM Measurement Example in China

• The measurement was conducted in March 2008 in
  Beijing before the new policy was released
• The measurements follow the protocol mentioned
  earlier
• The PM2.5 level in 36 venues were measured
• 6 restaurants with comprehensive smoke free
  policy
• 6 restaurants with partial smoke free policy
• 6 restaurants without regulations on smoking
• 6 smoke free offices
• 6 smoky offices
• 6 bars without regulations on smoking

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Results
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News Conference
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News Conference
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Mass Media Campaign

• The news story was reported through TV,
  newspaper, the Internet, and magazines
• The Beijing government is considering making more
  stringent smoke free policies

The
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Another PM Measurement Example in China

• Liuzhou city made a very stringent smoke free
  policy in mid 1990s and the policy was very
  popular
• However, it was repealed for political reasons 1
  year after the enforcement
• Efforts are being made to make a new smoke free
  policy in Liuzhou city
• PM2.5 measurement was used for policy advocacy in
  Liuzhou

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Newspaper report of the PM2.5 measurement in
Liuzhou
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Air monitoring studiesin Latin America

• Ernesto M Sebrié, MD MPH
• Transdisciplinary Tobacco Use Research Center
• Department of Health Behavior
• Roswell Park Cancer Institute
• Buffalo, New York

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AMS conducted in Latin America
MEXICO
VENEZUELA
GUATEMALA
BRAZIL
PANAMA
URUGUAY
ARGENTINA
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Argentina Partners
Coordinators Drs Marita Pizarro Verónica Schoj
Smokefree Argentina Alliance
InterAmerican Heart Foundation Argentina
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Argentina example

• Total samples 616
• 9 provinces
• Venues bars, restaurants, discos, casinos,
  bingos, university
• Timeline (2007-09
• Pre and post to show drop in the contamination
  levels
• Post implementation to show level of compliance
• No policy to advocate for smokefree law

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City of Buenos Aires (2008) SDAs
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City of Bahia Blanca 100 Ordinance Measures pre
(2007) and post (2008)
CONFITERIA
CAFE
RESTAURANTE
CAFE
CONFITERIA
RESTAURANTE
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City of Neuquen (2008) pre and post 100
smokefree law
PROMEDIO DE PARTICULAS RESPIRABLES µ /m³
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Media Impact Argentina
Separating areas for smokers does not protect
nonsmokers health
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Media Impact Argentina
The pollution cannot be separated
In favor of 100 smokefree bars
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Clarin notas luego de la media sancion de la ley
de la provincia de Buenos Aires
BAHIA BLANCA Cumplimiento del 97 LA PLATA con
sectorizacion sin separacion estructural
Fuente FIC - R.PARK
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Things to Consider If You Want to Adopt PM
Measurement Into Your Work

• Go to www.tobaccofreeair.org for details on
  training and background info
• Contact a member of our team for info
• We have a limited number of TSI Sidepaks to loan
  to partners for short periods of time
• We can help analyze the data and produce a report
• Key contact is Mark Travers, PhD
  (mark.travers_at_roswellpark.org)
• When youre in the field
• Calibration
• TSI Sidepak operation
• Measurements and observations