Section B Assessing Secondhand Smoke Exposure in Public

Section B Assessing Secondhand Smoke Exposure in Public Places 2007 Johns Hopkins Bloomberg School of Public Health

Assessment of Secondhand Tobacco Smoke Surveys and questionnaires Biomarkers in saliva, urine, hair, serum (cotinine) Indoor air concentration of tobacco constituents (nicotine) and air particulate matter (PM 2. 5) Useful for tracking the impact of clean indoor air policies and smoke-free initiatives Accurate and reliable estimate Media and policy impact 2007 Johns Hopkins Bloomberg School of Public Health 2

Secondhand Tobacco Smoke in Public Places Source: Navas-Acien, et al. (2004). 2007 Johns Hopkins Bloomberg School of Public Health 3

Smoke Free Americas Initiative Launched by PAHO in 2001 to mobilize action to create smoke-free communities, workplaces, and homes Planned activities Information dissemination Training and training tools Support for smoke-free communities Policy relevant research Images source: Smoke Free Americas. (2007). 2007 Johns Hopkins Bloomberg School of Public Health 4

Collaborative Effort Tobacco Control Program, Pan American Health Organization Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health Country collaborators Argentina UATA Brazil INCA Chile Ministry of Health Costa Rica IAFA Paraguay Ministry of Health Peru CEDRO Uruguay Local Government of Montevideo Honduras IHADFA Mexico National Institute of Public Health Panama Ministry of Health Guatemala Foundation Aldo Castañeda 2007 Johns Hopkins Bloomberg School of Public Health 5

Design and Population Cross-sectional exposure survey to measure airborne nicotine concentrations in public places of major Latin American cities (~ 100 samples/city): Secondary schools (low-middle socioeconomic status) Tertiary hospitals City government buildings Airports Restaurants (traditional and fast-food) Bars (taverns/nightclubs) Common/standardized protocol Training workshop Source: Navas-Acien, et al. (2004). 2007 Johns Hopkins Bloomberg School of Public Health 6

Air Nicotine Assessment Vapor-phase nicotine collected with a filter badge treated with sodium bisulfate (1 or 2 weeks) Collected nicotine extracted from the filter and analyzed by gas chromatography with nitrogen-selective detection Nicotine sampler Time-weighted nicotine concentration* Nicotine (µg) Air volume (m 3) = Nicotine (µg) Sampling rate (Lpm) minutes Gas-chromatograph * Method developed by Hammond SK and Leaderer BP. (1987) Image sources: Institute for Global Tobacco Control. (2007). 2007 Johns Hopkins Bloomberg School of Public Health 7

Fieldwork Country Time of Sampling Total Number of Samples % Samples Nicotine Detected Argentina November, 2002 89 100 Brazil December, 2002 90 83 Chile October, 2002 96 97 Costa Rica December, 2002 83 90 Honduras October, 2003 101 82 Mexico February, 2004 100 82 Panama November, 2003 95 46 Paraguay February, 2003 90 87 Peru July, 2002 88 97 Uruguay November, 2002 100 Source: Navas, et al. (2004). 2007 Johns Hopkins Bloomberg School of Public Health 8

Air Nicotine Concentrations (µg/m 3) in Public Places Source: adapted by CTLT from Navas-Acien, et al. (2004). 2007 Johns Hopkins Bloomberg School of Public Health 9

Air Nicotine Concentrations (µg/m 3) in Restaurants in 10 Countries* Smoking policy N Median (IQR)† No policy 54 1. 15 (0. 32– 2. 44) Smoking section 32 1. 30 (0. 43– 2. 31) Nonsmoking 20 0. 66 (0. 20– 1. 10) Smoking ban 7 0. 07 (0. 003– 0. 10) * Countries: Argentina, Brazil, Chile, Costa Rica, Paraguay, Peru, Uruguay, Honduras, Mexico and Panama † IQR: interquartile range Source: Navas-Acien, et al. (2004); Image source: New York City Department of Health and Mental Hygiene. 2007 Johns Hopkins Bloomberg School of Public Health 10

Air Nicotine Concentrations (µg/m 3) in Hospitals Source: adapted by CTLT from Tobacco Atlas 2 nd Edition. (2006). 2007 Johns Hopkins Bloomberg School of Public Health 11

Air Nicotine in Public Places: Media Impact 2007 Johns Hopkins Bloomberg School of Public Health 12

Air Nicotine in Public Places: Policy Impact Uruguay - Decreto 16/03/04 - SE CONSIDERAN LAS DEPENDENCIAS SANITARIAS DEL PAÍS AMBIENTES 100% LIBRES DE HUMO DE TABACO […] CONSIDERANDO: I. que según datos de la Organización Panamericana de la Salud, del 10% al 15% de las muertes producidas por enfermedades tabaco dependientes en las Américas se producen en no fumadores como consecuencia de la exposición pasiva al humo de tabaco II. que los resultados del Estudio de Vigilancia de la Exposición al Humo de Tabaco realizado en Uruguay en centros asistenciales, liceos, oficinas públicas y otros, a instancias de la Organización Panamericana de la Salud y del Instituto para el Control Mundial del Tabaco de la Universidad Johns Hopkins de los Estados Unidos de Norteamérica (julio 2003), demostraron que en todas las áreas estudiadas existían niveles importantes de contaminación por humo de tabaco […] ATENTO: a lo dispuesto por el artículo 2°. de la Ley N° 9. 202 de 12 de enero de 1934 - Orgánica de Salud Pública EL PRESIDENTE DE LA REPÚBLICA DECRETA: Artículo 1°. - Dispónese que todas las dependencias sanitarias del país, tanto públicas como privadas, son consideradas "Ambientes 100% Libres de Humo de Tabaco” 2007 Johns Hopkins Bloomberg School of Public Health 13

Limitations and Strengths Limitations Sampling locations selected on a convenience basis Limited number of samples in each city Comparability across countries cannot be completely assured Measurements done on a continuous basis (underestimation of exposure during time of occupancy) Only public places were surveyed Strengths Multi-country approach Standardized protocol Use of a validated method to quantify exposure Data useful at different levels: institution, city, country, and regional/global level 2007 Johns Hopkins Bloomberg School of Public Health 14

Conclusions for Latin America As of 2002– 2003 Nicotine detected in most places that were surveyed (including hospitals and schools) Nicotine was high in restaurants/bars in all countries Nonsmoking sections in restaurants ineffective Indication that smoke-free policies and enforcement reduce exposure to secondhand smoke Since the time of the study Uruguay became the first country in the Americas to be smoke -free Buenos Aires passed a citywide ordinance that covers most— but not all—bars and restaurants 2007 Johns Hopkins Bloomberg School of Public Health 15

Air Nicotine Concentrations (µg/m 3) in Public Places Source: adapted by CTLT from Navas-Acien, et al. (2004). 2007 Johns Hopkins Bloomberg School of Public Health 16

Smoke-Free Countries Source: adapted by CTLT from Koh, H. K. , et al. (2007). 2007 Johns Hopkins Bloomberg School of Public Health 17

FCTC: Smoke-Free Environments Parties to the FCTC have committed themselves to protect their population from the harmful effects of tobacco smoke The most effective initiative is to completely eliminate exposure to tobacco smoke in indoor environments Protect all people in all public places 2007 Johns Hopkins Bloomberg School of Public Health 18

Summary Assess secondhand tobacco smoke in public places to: Evaluate exposure Contribute to promote and enforce smoke-free legislations “There is no risk-free level of exposure to secondhand smoke” “Eliminating smoking from indoor spaces fully protects nonsmokers from exposure to secondhand smoke” Source: U. S. Surgeon General’s Report. (2006). 2007 Johns Hopkins Bloomberg School of Public Health 19