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Title: Qiang Li, PhD on behalf of the ITC Team


1

Training Workshop Evaluating Smokefree Policies
Qiang Li, PhD on behalf of the ITC Team Mumbai,
India March 2009
2
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

3
Goals of the Workshop
  • Understand the dangers of secondhand smoke (SHS)
    (also known as tobacco smoke pollution TSP)

4
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

5
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
6
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

7
Goals of the Workshop
  • Become familiar with the conceptual model of
    evaluating smokefree policies

8
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.
9
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.

10
Goals of the Workshop
  • Understand different methods for measuring SHS
    exposure

11
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.

12
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

13
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

14
Particle Size
Human Hair
15
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)

16
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17
www.tobaccofreeair.org
18
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

19
Countries (in red) Participating in Global Air
Monitoring Study (n32)
Source Hyland A et al. Tobacco Control 2008.
20
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.

21
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22
US EPA Air Quality Index
23
(No Transcript)
24
Results by Country and Observed Smoking
25
Geometric Mean PM2.5 With and Without Smoking by
World Region
26
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
27
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.

28
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)

29
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

30
Denver
June 9, 2002
31
Denvers visibility before Hayman fire
32
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)
33
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

34
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

35
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

36
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

37
Results
38
News Conference
39
News Conference
40
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
41
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

42
Newspaper report of the PM2.5 measurement in
Liuzhou
43
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

44
AMS conducted in Latin America
MEXICO
VENEZUELA
GUATEMALA
BRAZIL
PANAMA
URUGUAY
ARGENTINA
45

Argentina Partners
Coordinators Drs Marita Pizarro Verónica Schoj
Smokefree Argentina Alliance
InterAmerican Heart Foundation Argentina
46
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

47
City of Buenos Aires (2008) SDAs
48
City of Bahia Blanca 100 Ordinance Measures pre
(2007) and post (2008)
CONFITERIA
CAFE
RESTAURANTE
CAFE
CONFITERIA
RESTAURANTE
49
City of Neuquen (2008) pre and post 100
smokefree law
PROMEDIO DE PARTICULAS RESPIRABLES µ /m³
50
Media Impact Argentina
Separating areas for smokers does not protect
nonsmokers health
51
Media Impact Argentina
The pollution cannot be separated
In favor of 100 smokefree bars
52
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
53
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
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