Smoke-Free Air Policy: Changing What s in the Air and in the Body

Transcription

1 Smoke-Free Air Policy: Changing What s in the Air and in the Body Mark J. Travers, Ph.D., M.S. Roswell Park Cancer Institute, Buffalo, NY Department of Health Behavior and Aerosol Pollution Exposure Research Laboratory (APERL)

2 Resources

3 Resources

4 Sources of Air Pollution

5 Sources of Air Pollution

6 Source: From: Ott, W., Total human exposure. Environ Sci Technol, (10): p AND Ott W. Exposure Analysis: A Receptor-Oriented Science. In: Ott WR, Steinemann AC, Wallace LA, editors. Exposure Analysis. Boca Raton: Taylor & Francis; p Conceptual Model Examining Air Pollution and Public Health Movement Source of Exposure Dose Effect Pollutants

7 The Environment Human Body Transport Reaction Desorption Individual time-activity location (m i ) over time (t j ) Type and rate of breathing Airway geometry Metabolism Elimination Individual susceptibility Microenvironmental (m i ) Concentrations over time (t j ) t 0 t 1 t 2 Exposure Boundary or Susceptible Body Surface m 1 C 10 C 11 C 12 Tobacco Smoke Emissions m 2 m 3 C 20 C 30 C 21 C 31 C 22 C 32 Concentration = Exposure E tot = c ij * t ij Dose Biologically effective dose Health Effects m 4 C 40 C 41 C 42 Volume of Space Dilution Ventilation Filtration Sorption Deposition Adapted from: Samet, J.M. and J.J. Jaakkola, The Epidemiologic Approach to Investigating Air Pollution, in Air Pollution and Health, S.T. Holgate, et al., Editors. 1999, Academic Press: London; Ryan, P.B. and W.E. Lambert, Personal Exposure to Indoor Air Pollution, in Indoor Air Pollution, J.M. Samet and J.D. Spengler, Editors. 1991, The Johns Hopkins University Press: Baltimore and London; Zartarian VG, Ott WR, Duan N. Basic Concepts and Definitions of Exposure and Dose. In: Ott WR, Steinemann AC, Wallace LA, editors. Exposure Analysis. Boca Raton: Taylor & Francis; p

8 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) Sidestream smoke mass emissions are relatively constant across types and brands of cigarettes

9 Major Components of TSP Classified by their Physicochemical Properties Major components Vapor pressure range Examples of compounds Gas-phase inorganic compounds >13 kpa CO 2, H 2 O, CO, NH 3 Very volatile organic compounds >7 to 13 kpa Formaldehyde, acrolein, 1,3-butadiene, acetylaldehyde Volatile organic compounds ~0.01 to 10 kpa Benzene, toluene, styrene, 2-butanone, phenol, pyridine, pyrrole, 3-ethenylpyridine (3- EP), N,N-nitrosodimethylamine, N- nitrosopyrrolidine Semivolatile organic compounds 10-2 to 10-8 kpa Nicotine, naphthalene, 1-methylnapthalene, 2- methylnapthalene, chrysene, flouranthene, pyrene, N-nitrosonornicotine (NNN), 4- (methylnitrosamino)-1-(3-pyridyl)-1- butanone (NNK) Particulate organic compounds <10-8 kpa Benzo[a]pyrene, benzo[b]flouranthene, benzo[k]flouranthene, solanasol Bold compounds are Group 1, known human carcinogens according to the International Agency for Research on Cancer (IARC) Italicized compounds either show evidence of human carcinogencity according to IARC, or are toxic according to the Agency for Adapted S from Daisey, J.M., Tracers for assessing S exposure to environmental tobacco smoke: what are they tracing? Environ Health S

10 Exposure Exposure is contact between an agent and a target at a contact boundary or exposure surface. Example: Contact between tobacco smoke and a person, with the exposure surface being a conceptual surface over the nose and mouth

11 Dose Amount of an agent that enters a target by crossing a contact boundary. Example: The amount of tobacco smoke that enters a person s lungs.

12 Effects Causally Associated with TSP Exposure Developmental Effects Disease burden in the U.S. Fetal Growth: Low birthweight and decrease in birthweight 24,500 Sudden Infant Death Syndrome (SIDS) 430 Pre-term delivery 71,900 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 3,400 Nasal sinus cancer Breast cancer in younger, primarily premenopausal women Cardiovascular and Hematological Effects Heart disease mortality 46,000 Acute and chronic coronary heart disease morbidity Altered vascular properties In children: 202,300 asthma episodes and 790,000 otitis media visits % risk

13 Effects with Suggestive Evidence of a Causal Association with ETS Exposure 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 Nasopharyngeal cancer All cancers adult and child

14 Source: From: Ott, W., Total human exposure. Environ Sci Technol, (10): p AND Ott W. Exposure Analysis: A Receptor-Oriented Science. In: Ott WR, Steinemann AC, Wallace LA, editors. Exposure Analysis. Boca Raton: Taylor & Francis; p How Can we Break this Chain? Movement Source of Exposure Dose Effect Pollutants

15 New York State Clean Indoor Air Amendment Effective July 24, 2003 Require indoor public places including bars and restaurants to be smoke-free

16 Of Course, Not Everyone Was Happy About the Law

17 1986 Tobacco Institute anti-truth Squad

18 1986 Tobacco Institute anti-truth Squad

19 What does the Tobacco Industry say about Indoor Smoking? John Fox (Labor Lawyer) Employees who are non-smokers do not have the right to a smoke-free environment. Gray Robertson (Sick Building Expert) Smoke is an indicator of bad ventilation. David Weeks (Indoor Air Expert) We really don t change the air quality with this kind of regulatory behavior.

20 Sometimes things could get a little heated

21 Food Service and Drinking Places Industry Most of the population patronizes this industry Almost 10 million workers in the U.S. Disproportionately young and female 21% of workers are teenagers, 66% less than 35 years old Among lowest of all occupations in terms of wages paid to full-time workers Only about 1% covered by union contracts Only ~43% of these workers are protected by smokefree air policies, compared to 75% of white-collar workers Lung cancer risks between 10% and 90% higher than general population

22 Measuring Exposure to Tobacco Smoke Pollution Cigarettes, cigars and pipes are major emitters of respirable suspended particles less than 2.5 microns (PM 2.5 ) 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 massconcentration

23 Tobacco smoke particle Particle Size 2.5µm particle Human Hair

24 Why Use PM 2.5 as a Marker of TSP? Very sensitive marker of TSP Can monitor and record data in real time Relatively inexpensive equipment Marker of the more than 4,000 chemicals in ETS E.g. 2,000:1, PM 2.5 :PAH Meaningful measure: there are PM 2.5 standards in place to protect public health The EPA has set standards of 15 μg/m 3 as the average annual level of PM 2.5 exposure and 35 μg/m 3 24-hour exposure in order to protect the public health

25 US EPA Air Quality Index Air Quality Air Quality Index PM 2.5 (µg/m 3 ) Health Advisory Good None. Moderate Unusually sensitive people should consider reducing prolonged or heavy exertion. Unhealthy for Sensitive Groups People with heart or lung disease, older adults, and children should reduce prolonged or heavy exertion. Unhealthy Very Unhealthy Hazardous People with heart or lung disease, older adults, and children should avoid prolonged or heavy exertion. Everyone else should reduce prolonged or heavy exertion. People with heart or lung disease, older adults, and children should avoid all physical activity outdoors. Everyone else should avoid prolonged or heavy exertion. People with heart or lung disease, older adults, and children should remain indoors and keep activity levels low. Everyone else should avoid all physical activity outdoors.

26 Denver June 9, 2002

27 Denver s visibility before Hayman fire

28 Hayman Fire Denver s Worst visibility in Colorado 1 day History, after Hayman June fire Worst PM 2.5 day in Denver Was 43 µg/m 3 (24-hr max) or 200 µg/m 3 (hourly max)

29 Wildland Firefighter Exposures About 600 µg/m 3 at base camp. About 1,100 µg/m 3 to 2,100 µg/m 3 during active, frontline, firefighting Sources: Materna 1992, Reinhardt 2004.

30 Specific Aim To determine in a cross-sectional study the difference in air quality as measured by fine particle concentrations: between hospitality venues with and without observed indoor smoking, and between hospitality venues with and without smoke-free air policies.

31 Cross-sectional Air Monitoring Study 609 hospitality venues visited in 63 different communities in 16 States, the District of Columbia, and Puerto Rico. Venues sampled included 1) bars, 2) restaurants, 3) restaurants with bars, and 4) large recreation venues such as bowling alleys, pool halls, bingo halls, and dance clubs. Venues were not selected randomly; they are a convenience sample from at least two different geographic areas of each community and were selected to provide a broad range of size and type of venue. Standardized protocol and training course

32 Location of Venues Sampled 609 total venues in 63 communities in 18 States (including DC and Puerto Rico)

33 Standardized protocol and training materials developed and used

34

35 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 discretely in a bag with the sampling tube protruding Testers are patrons: purchase something in each place

36 Analysis The mean PM 2.5 level is determined for each location visited The active smoker density is calculated for each venue: average number of burning cigarettes per 100 cubic meters The difference between PM 2.5 levels in places with smoking and without smoking was determined by Analysis of Variance of log-transformed values

37 San Juan, Puerto Rico, 1/28/ Fine particle air pollution (PM 2.5 in μg/m 3 ) /28/05 7:02pm Hotel Lobby Bar/Restaurant Bar/Restaurant no smoking observed Bar Elapsed Time in Minutes Bar/Restaurant Bar/Restaurant 1/30/05 1:52am

38 Philadelphia, PA April 10 th, 2004 Fine particle air pollution (PM 2.5 in μg/m 3 ) All venues are smoking venues with observed smoking in all venues VENUE 42 VENUE 43 VENUE 44 VENUE 45 VENUE 46 VENUE 47 VENUE /10 7:01pm Elapsed time in minutes 4/11 1:41am

39 New York City, NY April 17 th, All venues are smoke-free by law and no smoking was observed in an venue Fine particle air pollution (PM 2.5 in μg/m 3 ) VENUE 56 VENUE 57 VENUE 58 VENUE 59 VENUE 60 VENUE 61 VENUE /17 6:43pm Elapsed time in minutes 4/18 2:38am

40 New York City, April 17, 2004 and Philadelphia, April 10, 2004 Fine particle air pollution (PM 2.5 in μg/m 3 ) New York City Philadelphia Elapsed time in minutes

41 Boxplots of PM 2.5 Levels by Observed Smoking Smoking Observed (n=447) No Smoking Observed (n=162) PM 2.5 (micrograms per cubic meter)

42 Mean PM 2.5 Concentrations by Observed Smoking Status and Type of Venue Geometric Mean PM 2.5 Concentration (μg/m 3 ) % No Observed Smoking Observed Smoking Error Bars: 95% CI s 98% 91% 89% 83% All Venues Bars (n=170) Restaurants Restaurants Large (n=609) with Bars (n=107) Recreation (n=314) Venues (n=17)

43 Geometric Mean PM 2.5 Levels by Smokefree Status and Type of Venue Geometric Mean PM 2.5 Concentration (μg/m 3 ) % % % All Venues Bars (n=170) Restaurants Restaurants Large (n=609) with Bars (n=107) Recreation (n=314) Venues (n=17) 112 Smokefree Smoking Permitted Error Bars: 95% CI s 77% 98% 181

44 Log-probability Plot of PM 2.5 in Venues With (n=447) and Without (n=162) Smoking no smoking observed smoking observed PM 2.5 (µg/m 3 ) Percentile

45 Percentile Log-probability Plot of PM 2.5 Concentrations in Venues With (n=447) and Without (n=162) Smoking, Compared to EPA Air Quality Index Smoking Observed No Smoking Observed 1000 PM 2.5 (µg/m 3 ) 100 Significant Harm Hazardous and Very Hazardous Very Unhealthy Unhealthy Unhealthy for Sensitive Groups Moderate Good

46 Annual Employee Exposures to Fine Particulate Matter in U.S. Hospitality Venues by Type of Venue and Smoking Status Percent of hospitality venues with employee exposure in this AQI or worse* Smoke-Free Smoking Permitted Restaura Restaura PM 2.5 (μg/m 3 ) Air Quality Index (AQI) Category Color Code All Venues Bars nts With Bars Restaura nts Large Rec Venues All Venues Bars nts With Bars Restaura nts Large Rec Venues Good Green Moderate Yellow Unhealthy for Orange sensitive groups Unhealthy Red Very unhealthy Violet Hazardous Maroon Very Hazardous Maroon > > 500 (Significant Harm) * The Air Quality Index is based on the 24-hr average outdoor PM 2.5 concentration while annual employee exposure assumes they are exposed to the measured PM 2.5 concentration for 8 hours per day, 250 days per year, and are exposed to background PM 2.5 levels of 11.5 μg/m 3 during non-work times. This category exists but is not part of the AQI (Personal communication from Ellsworth, T., USEPA Air Protection Division to Repace, J., Jan 24, 2005). U.S. Environmental Protection Agency, Guideline for reporting of daily air quality - Air Quality Index (AQI). 1999, USEPA Office of Air Quality Planning and Standards: Research Triangle Park, NC AND Repace, J., E. Hughes, and N. Benowitz, Exposure to second-hand smoke air pollution assessed from bar patrons' urinary cotinine. Nicotine Tob Res, (5): p

47 Other Findings Smoke-free venues were more likely to be restaurants while smoking permitted venues were likely to be bars or restaurants with bars Smoke-free venues tended to be smaller (717 m 3 versus 957 m 3 ) Smoke-free venues had fewer patrons on average (35 vs. 48), but this difference was not significant after adjusting for smoke-free status, type of venue, and size of venue The point prevalence of smoking was 11.6% in smoking-permitted venues and 0.1% in smoke-free venues

48 Average PM 2.5 level versus active smoker density in all venues Spearman rank correlation between active smoker density and PM 2.5 was 0.75 (p<0.01) 2500 y=169.4x Average PM 2.5 (µg/m 3 ) Active Smoker Density (average burning cigarettes per 100 m 3 )

49 Summary A protocol for using a novel real-time particle monitor for measuring tobacco smoke-derived fine particle air pollution was developed and implemented in a large sample (n=609) of public places in 63 communities in 18 states (including DC and Puerto Rico). In a large, cross-sectional sample of hospitality venues around the U.S., smoke-free venues had 89.3% (95% C.I. 86.6% to 93.5%) lower PM2.5 levels than venues allowing indoor smoking. Bars permitting smoking had the highest geometric mean PM2.5 levels (296 µg/m3), followed by large recreation venues (193 µg/m3), restaurants with bars (120 µg/m3), and restaurants (67 µg/m3). Compliance with smoke-free air policies or laws as measured with the protocol in this study was very high, 97.6%. Workers and patrons in hospitality venues permitting indoor smoking are routinely exposed to PM2.5 levels in excess of health standards set by the U.S. Environmental Protection Agency for outdoor air. Employees in places allowing indoor smoking were 14 times more likely than employees in smoke-free workplaces to have annual particle exposures that are at least unhealthy for sensitive groups, based on the PM2.5 levels during the sampling visits. Smoke-free venues were more likely to be restaurants without bars and tended to be smaller. A similar longitudinal study in venues before and after they went smoke-free would confirm these findings and eliminate the possibility of some unmeasured confounding accounting for these results.

50 Specific Aim To evaluate, longitudinally, the change in air quality in hospitality venues before and after the implementation of a community wide smoke-free air policy.

51 Longitudinal Air Monitoring Study The air quality in various hospitality venues was measured before and after the implementation of a community- or state-wide smoke-free air law Venue selection and sampling protocol was the same as cross-sectional study Air sampling before and after the law was done on the same day of the week and at approximately the same time of day

52 Eight Communities Sampled State Community sampled Smoke-free Air Law Sample size Connecticut Hartford area Connecticut state-wide 9 Indiana Bloomington Bloomington city 9 Kentucky Georgetown Georgetown city 9 Massachusetts 5 towns Massachusetts state-wide 29 New Jersey 13 of New Jersey's 21 counties New Jersey state-wide 50 New York 3 Western New York counties New York state-wide 22 Washington 4 cities Washington state-wide 35 Wyoming Laramie Laramie city

53 Change in Air Quality in Western New York Bars and Restaurants After Implementation of the New York State Clean Indoor Air Law Respirable Suspended Particles (μg/m 3 of PM 2.5) %-95% Bar A Bar B Bar C -96% -91% Bar D -73% Bar E -95% Bar F -98% Bar G Mean size of venue = 365m 3 Mean pre-law active smoker density = 1.38 cigs/100m 3 Bar/Restaurant H Before Law: Average = 412 μg/m 3 After Law: Average = 27 μg/m 3-98% Bar/Restaurant I -89% Bar/Restaurant J -86% Bar/Restaurant K -84% Bar/Restaurant L Only venue with active smoking during post-law sampling -98% Bar/Restaurant M -80% -98% Restaurant N

54 Change in Air Quality in Western New York Large Recreation Venues After Implementation of the New York State Clean Indoor Air Law Respirable Suspended Particles (μg/m 3 of PM 2.5) % -76% Before Law: Average = 101 μg/m 3 After Law: Average = 18 μg/m 3 Mean size of venue = 3,530m 3 Mean pre-law active smoker density = 0.22 cigs/100m 3-64% Pool Hall Bingo Hall Bowling Bowling -70%

55 Bloomington, IN, December 10 th, Fine particle air pollution (PM 2.5 in μg/m 3 ) Pre-law VENUE 1a VENUE 2a VENUE 3a VENUE 4a VENUE 5a VENUE 6a VENUE 7a VENUE 8a /10/04 6:00pm Elapsed Time in Minutes 12/11/04 1:20am

56 Bloomington, IN, January 21 st, Fine particle air pollution (PM 2.5 in μg/m 3 ) Post-law VENUE 1b VENUE 2b VENUE 3b VENUE 4b VENUE 5b VENUE 6b VENUE 7b VENUE 8b /21/05 6:14pm Elapsed Time in Minutes 1/22/05 1:34am

57 Bloomington, IN Before and After Smoke-free Air Law Fine particle air pollution (PM 2.5 in μg/m 3 ) Pre-Law 12/10/04 Post-Law 1/21/ Elapsed Time in Minutes

58 Log-log scatter plot comparing pre and post law PM 2.5 concentrations (all venues) New Jersey Casinos (n=8) Smoke-free at baseline (n=34) Smoking allowed at baseline (n=134) 300 Post-ban PM 2.5 (µg/m 3 ) % -90% -99% Pre-ban PM 2.5 (µg/m 3 )

59 Change in Indoor Fine Particle Air Pollution after Smoke-free Air Law Implementation by Venue Type 160 Geometric Mean PM 2.5 Concentration (μg/m 3 ) All venues permitting smoking at baseline (n=134) All venues smoke-free at baseline (n=34) Casinos (not required to go smoke-free) (n=8) 80 14* 10 0 Before Smoke-free Air Law After Smoke-free Air Law * Significant change from pre- to post-law using paired-samples t test on logtransformed PM 2.5 values, 90.1% reduction (95% C.I.: 87.9% to 91.9%).

60 Type Bars Restaurants w/ Bars Restaurants Large Rec Venues Reduction 93.3% (95% C.I. 91.1% to 94.9%) 86.4% (95% C.I. 80.3% to 90.7%) 86.0% (95% C.I. 77.3% to 91.4%) 88.5% (95% C.I. 77.4% to 94.1%) Change in Indoor Fine Particle Air Pollution after Smoke-free Air Law Implementation by Venue Type 250 Geometric Mean PM 2.5 Concentration (μg/m 3 ) Bars (n=58) Restaurants with Bars (n=37) Restaurants (n=26) Large Recreation Venues (n=13) 0 Before Smoke-free Air Law After Smoke-free Air Law

61 Other Findings There was no difference in patron counts between the pre- and post-law visits Spearman rank correlation coefficient between ASD and PM 2.5 was 0.82 (p<0.01)

62 Scatter Plot of Pre-Law Mean PM 2.5 Concentration and Mean Active Smoker Density by Type of Venue 350 Mean PM2.5 Concentration (μg/m 3 ) Large rec Restaurants Rest w/ bars Bars Mean Active Smoker Density (mean burning cigarettes per 100m 3 )

63 Summary In a large, longitudinal sample of bars, restaurants, and other recreation venues from across the United States, fine particle indoor air pollution dropped 90%, on average, after the implementation of state and local smoke-free air legislation. In a control group of venues that were smoke-free at baseline, fine particle air pollution levels were low and remained unchanged after smoke-free air law implementation. Compliance with the smoke-free air legislation in this study was very high at 96.3%. Smoke-free air legislation, prohibiting smoking in indoor places, is an effective means to improve air quality and protect the public from harmful tobacco smoke pollution.

64 Specific Aim In a quasi-experimental study, to determine the change in air quality in hospitality venues and the change in biomarkers of exposure to tobacco smoke pollution in exposed nonsmokers after the implementation of a community-wide smoke-free air law. Also, to determine the correlation between airborne markers of tobacco smoke pollution and biological markers of tobacco smoke exposure in exposed nonsmokers.

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67 Quasi-Experimental Field Study: Policy, Exposure, and Dose Laramie, WY

68 Respirable particles: Mass concentration (PM 2.5 ) Urine: Nicotine Cotinine NNAL Non-smoking participant spends ~7 hours in a location that allows smoking. The mass concentration of respirable particles (PM 2.5 ) in the air is measured. In addition, the participant s change in urinary cotinine and NNAL before and after the visit is measured. This is repeated after the location goes smoke-free.

69 Study Population 14 participants: 8 female, 6 male Mean age 27.1 (SD = 7.3) All participants were in generally good health with no known respiratory or cardiovascular disease; women were neither pregnant nor breast feeding 3 participants were unable to do the post-law visit and were replaced. 1 participant was excluded from the analysis due to high cotinine levels (likely smoker)

70 Analysis Each participant s total PM 2.5 exposure was calculated (average PM 2.5 level during visit times the duration of visit times estimated inhalation rate of 0.75 m 3 /hr) All biomarker data below the limit of detection (LOD) was replaced with the LOD/sqrt(2) Pre- and post-visit biomarker levels were compared using paired-sample t tests for each biomarker (log-transforming variables and using non-parametric tests did not change the results) A two-way repeated-measure ANOVA was used as well. Dependent variable: NNAL, cotinine, or nicotine Independent variables: LAW, VISIT, LAW x VISIT Correlations between total PM 2.5 exposure and change in biomarkers (Pearson and Spearman)

71 Total Cotinine (ng/ml urine) Change in Total Cotinine From Venue Visit Before and After Smoke-Free Air Law * Pre- Law Post- Law * Pre-Visit (Apr 1) Post-Visit (Apr 2) Pre-Visit (Apr 22) Post-Visit (Apr 23) * Significant change from pre- to post-visit using paired-samples t test.

72 ANOVA results for Cotinine There was a significant main effect of VISIT (F(1,12) = 31.8, p < 0.001) and LAW (F(1,12) = 42.6, p < 0.001) on cotinine levels There was a significant interaction between VISIT and LAW (F(1,12) = 19.6, p = 0.001). So, the night out (VISIT) had a different effect on cotinine levels depending on whether it was pre- or post-law. The graph shows that before the law, there was a much greater increase in cotinine as a result of the visit (29.7 ng/ml) compared to the post-law visit (2.9 ng/ml). Using a simple effects analysis, we see that the night out (VISIT) had a significant positive effect on cotinine level both before the law, F(1,12) = 25.7, p < 0.001, and after the law, F(1,12) = 13.8, p =

73 Total NNAL (pmol/ml urine) Change in Total NNAL From Venue Visit Before and After Smoke-Free Air Law * Pre- Law Pre-Visit (Apr 1) Post-Visit (Apr 2) Pre-Visit (Apr 22) Post- Law.001 Post-Visit (Apr 23) * Significant change from pre- to post-visit using paired-samples t test.

74 ANOVA results for NNAL ANOVA reveals there was a significant main effect of VISIT on NNAL levels, F(1,12) = 33.2, p < 0.001, meaning that overall, the mean NNAL levels are higher after a visit compared to before a visit. There was no significant main effect of LAW on NNAL levels, indicating that the overall mean NNAL levels were the same before and after the law. There was a significant interaction between VISIT and LAW, F(1,12) = 7.60, p = So this tells us the visit had a different effect on NNAL levels depending on whether it was pre- or post-law. The graph shows that pre-law, there was an increase in NNAL levels after the visit., while post-law, there was no change in NNAL levels after the visit. Using a simple effects analysis, we see that the visit has a significant positive effect on NNAL level before the law, F(1,12) = 18.8, p = 0.001, but after the law there was no difference between pre- and post-visit NNAL levels, F(1,12) = 0.19, p=0.670.

75 Correlation Between Total TSP-PM 2.5 Exposure and Dose of Cotinine Cotinine Change (ng/ml urine) n = 26 r = 0.69 p < 0.01 y = x TSP-PM 2.5 is the concentration of tobacco smoke derived fine particles less than 2.5 microns in diameter Total TSP-PM 2.5 Exposure (mg)

76 Correlations between total particulate matter (PM 2.5 ) exposure and change in biomarkers of tobacco smoke exposure Correlation Coefficient PM exposure Δcotinine Δnicotine ΔNNAL PM exposure Pearson (r ) p < Spearman (r s ) p <0.01 < Δcotinine Pearson (r ) p <.01 <0.01 <0.01 Spearman (r s ) p <0.01 <0.01 <0.01 Δnicotine Pearson (r ) p 0.03 <0.01 <0.01 Spearman (r s ) p <0.01 <0.01 <0.01 ΔNNAL Pearson (r ) p 0.04 <0.01 <0.01 Spearman (r s ) p 0.01 <0.01 <0.01 All variables are significantly correlated

77 Strengths First study design to combine exposure, dose, and policy change in a single study. Outdoor PM 2.5 levels are minimal (~4 µg/m 3 ) in Wyoming Same participants for pre- and post-law visits (10 of 13). Helps to control for the significant interindividual variability is factors such as inhalation rate, pollutant uptake, metabolism, and excretion

78 Limitations Since post-visit spot urine samples were used, the absolute biomarker values are dependent on the time of collection. Due to equipment limitations post-law exposure is based on shorter sampling time (M=44 minutes) instead of complete monitoring for the entire visit 3 participants were replaced from pre- to post-law Exposure assessment is not really a personal exposure assessment, but rather an area assessment, as there was only one Sidepak for each group

79 Summary There was a 95% reduction in tobacco smoke-derived fine particle air pollution exposure of the participants as a result of the smoke-free air law. The smoke-free air law intervention led to reductions in these participants dose of total cotinine, nicotine, and NNAL of 90%, 81%, and 92%, respectively, resulting from their visits to hospitality venues. The participants exposure to tobacco smoke pollution, measured by PM 2.5, was significantly correlated with their subsequent dose of all three tobacco smoke pollution biomarkers. There was no change in the average number of people inside the hospitality venues as a result of the smoke-free air ordinance. Compliance with the smoke-free air ordinance was high, although not 100%. There were 3 burning cigarettes observed after the law over the course of 51 hours of total observation time.

80 Source: From: Ott, W., Total human exposure. Environ Sci Technol, (10): p AND Ott W. Exposure Analysis: A Receptor-Oriented Science. In: Ott WR, Steinemann AC, Wallace LA, editors. Exposure Analysis. Boca Raton: Taylor & Francis; p Conceptual Model Examining Air Pollution and Public Health Movement Source of Exposure Dose Effect Pollutants

81 Source: Americans for Non-Smokers Rights.

82 Proportion of U.S. population exposed to SHS Cumulative number of local clean indoor air laws in the U.S Cumulative Number a Proportion exposed b Year a American Nonsmokers' Rights Foundation. Municipalities with local clean indoor air laws, cumulative number effective by year. Update July 3, b Pirkle JL, Bernert JT, Caudill SP, Sosnoff CS, Pechacek TF. Trends in the exposure of nonsmokers in the U.S. population to secondhand smoke: Environ Health Perspect 2006;114(6):853-8.

83 Source: Americans for Non-Smokers Rights.

84 Countries, States, and Provinces That Have Banned Smoking in Indoor Workplaces and Other Indoor Public Places. Source: Koh et al. New England Journal of Medicine, 2007.

85 U.S. Statewide Smokefree Workplace Laws Smokefree Offices Arizona 5,743, % California 35,893, % Colorado 4,601, % Connecticut 3,503, % Delaware 830, % District of Columbia 553, % Hawaii 1,262, % Illinois a 12,713, % Maine 1,317, % Maryland b 5,558, % Massachusetts 6,416, % Minnesota 5,100, % Montana 926, % New Hampshire 1,299, % New Jersey 8,698, % New Mexico 1,903, % New York 19,227, % Ohio 11,459, % Oregon c 3,594, % Puerto Rico 3,894, % Rhode Island 1,080, % Utah 2,389, % Vermont 621, % Washington 6,203, % Smokefree offices, restaurants and bars 144,794, % Florida 17,397, % Idaho 1,393, % Louisiana 4,515, % Nevada 2,334, % North Dakota 634, % Smokefree offices and restaurants 171,070, % Arkansas 2,752, % South Dakota 770, % Smokefree offices 174,593, % * Population of 50 U.S. States, the District of Columbia and Puerto Rico: 297,550,259 (estimate for July 1, 2004) ) a Illinois law goes into effect 1/2008 b Maryland law goes into effect 2/2008 c Oregon law goes into effect 1/2009 These smoke-free bar laws go into effect in Smokefree Restaurants Smokefree Bars Population (2004 est.) % of US Population*

86 Experimental Evaluation of TSP in Cars Eighteen smoking participants were asked to smoke a single cigarette in their own car under a variety of conditions See An Experimental Investigation of Tobacco Smoke Pollution in Cars by Sendzik, Fong, Travers and Hyland (

87 Experimental Evaluation of TSP in Cars: Methods

88 Experimental Evaluation of TSP in Cars: Results

89 RSP Levels in a Car When Smoking 1 Cigarette PM2.5 in micrograms per cubic meter Cigarette start, t=22 Cigarette finish, t=33 Windows up, engine off, no ventilation Elapsed Time (minutes) PM 2.5 measured with TSI Dustrak, calibration factor 0.32, participant 2, session 1.

90 RSP Levels in a Car When Smoking 1 Cigarette PM2.5 in micrograms per cubic meter Cigarette lit Cigarette extinguished Elapsed Time (minutes) Windows up, AC on, 30 minute drive PM 2.5 measured with TSI Sidepak, calibration factor 0.32, participant 4, session 5.

91 RSP Levels in a Car When Smoking 1 Cigarette PM2.5 in micrograms per cubic meter Cigarette start Cigarette finish Driver s window ½ way down, cigarette hanging out window when not puffing, 30 minute drive Elapsed Time (minutes) PM 2.5 measured with TSI Sidepak, calibration factor 0.32, participant 3, session 4.

92 Experimental Evaluation of TSP in Cars: Discussion Does this mean we need laws preventing people from smoking in their cars with kids?

93 You can lead a horse to water, but Politician

94 Scientific Data: Informing the Debate Over Smoke-free Air Policy Air monitoring studies generate effective media attention: newspaper, radio, TV Local data: has much greater impact on the public and policy makers Results are irrefutable and easy for a lay person to see and understand Push decision makers to face real data instead of anecdotes

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98 See next slide

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100 Air Monitoring in a Bar Receiving a Smoking Waiver 600 Air monitor was placed in the middle of the bar (non-smoking area), 15 feet from the door to the smoking room Saturday, February 28 th, 2004 PM2.5 (micrograms per cubic meter) Door to smoking room opened and left open for 4 minutes Average in non-smoking part of bar = 192 µg/m 3 Enter bar Door to smoking room opened Average in 21 smoke-free venues = 22 µg/m 3 Exit bar 0 9:15 PM 9:17 PM 9:20 PM 9:22 PM 9:25 PM 9:27 PM 9:30 PM 9:32 PM 9:35 PM 9:37 PM 9:40 PM 9:42 PM 9:45 PM 9:47 PM 9:50 PM 9:52 PM 9:55 PM 9:57 PM 10:00 PM

101 Air Monitoring in a Bar Receving a Smoking Waiver Sunday, March 7 th, PM 2.5 (micrograms per cubic meter) Average in smoking room = 2,885 µg/m 3 Fighting a forest fire= µg/m 3 Average in non-smoking part of bar = 221 µg/m 3 Average in 21 smoke-free venues = 22 µg/m 3 Enter bar Enter smoking room 0 9:00 PM 9:03 PM 9:07 PM 9:10 PM 9:14 PM 9:17 PM 9:21 PM 9:24 PM 9:28 PM 9:31 PM 9:35 PM 9:38 PM 9:42 PM 9:45 PM 9:49 PM 9:52 PM 9:56 PM 9:59 PM Exit smoking room Exit bar

102 TOBACCO SMOKE POLLUTION ON OUTDOOR PATIOS AN EXPERIMENTAL EVALUTION OF THE SMOKE-FREE ONTARIO ACT Ryan David Kennedy*, MAES, Department of Psychology, University of Waterloo Geoffrey T. Fong, PhD, Department of Psychology, University of Waterloo Andrew Hyland, PhD, Roswell Park Cancer Institute, Buffalo, New York Mark J. Travers, PhD, Roswell Park Cancer Institute, Buffalo, New York Seema Mutti, Department of Psychology, University of Waterloo

103 BACKGROUND PATIOS: From the Ontario Ministry of Health Promotion Smoking is prohibited if an outdoor patio has a roof, even where the roof partially covers the patio. A roof includes an awning, tarp, canvas sheeting or other permanent or temporary covering that is capable of excluding rain or impeding airflow, or both. A stand-alone umbrella covering a single table would not be considered a roof. However, if umbrellas are used in such a way so as to serve as a roof, an inspector may view it as such and act accordingly.

104 RESEARCH QUESTIONS Quantify how different patio structures and their configurations may affect TSP concentrations on a patio Quantify the movement of TSP to adjacent indoor areas

105 SURVEY METHODS Patio Location secured SET UP of PATIO doors Closed Scenario inside area Table F -- Inside -- 7 feet in from door -- SidePak 2 inside area 20 Feet 6.5 feet to edge of door 10.5 feet to centre of door 8 feet door area -- 4 feet of open area 20 feet to edge of patio Table A - 1RA Table B -- 1RA seated X TABLE E -- SidePak1 and Qtrak -- centre of patio (10 feet from edge, 7 feet from centre of door) X seated 14 feet seated X X seated Table C -- 1RA Table D -- 1 RA bannister is 3.5 feet high

106 PATIO ENVIRONMENT

107 SURVEY METHODS Scenarios Studied: Open Air Patio Umbrellas not touching Patio Umbrellas touching (not compliant SFOA) Awnings no tables underneath Awnings tables underneath (not compliant SFOA)

108 SURVEY METHODS Protocol followed Baseline readings (background PM 2.5 ) BURN 1 20 minutes Dispersion BURN 2 20 minutes Dispersion 8 cigarettes burning during burns all extinguished at 20 minute mark

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111 SMOKE REGIME AND SAMPLING METHODS Cigarettes were smoked using a hand-held 60mL syringe with a Cress mouthpiece attached via PVC tubing. 8 cigarettes smoked by 4 research assistants Health Canada testing protocol followed 55mL puffs drawn over 2 seconds every 30 seconds

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114 PM 2.5 READINGS and Air Quality PM 2.5 Readings (µg/m 3 ) AQI value AQI Description Ontario Ministry of Environment Air Quality Index (AQI) Health Information Very Good Sensitive populations may want to exercise caution Good Sensitive populations may want to exercise caution Moderate People with respiratory disease at some risk Poor People with respiratory disease should limit prolonged exertion; general population at some risk. >90 >=100 Very Poor Serious respiratory effects even during light physical activity; people with heart disease, the elderly and children at high risk; increased risk for general population.

115 RESULTS Open Air In each scenario studied, PM 2.5 levels were very good or good at baseline (using the Ontario Air Quality Index). All baseline PM2.5 readings were good or very good. During 12 open air tests (no structures) average readings were 41 µg/m 3 above background during the periods where cigarettes were smoked One test produced levels 59 µg/m 3 above background

116 RESULTS Open Air Date ONTARIO OPEN AIR Average PM 2.5 Trial Attributed to TSP 12-Jul Jul Jul Jul Jul Aug Aug Aug Aug Aug Aug Aug mean 41 max 59 min 25

117 ONTARIO OPEN AIR SCENARIO -- July Aerosols -- PM2.5 (micrograms/m^3) :15:00 PM 3:22:29 PM 3:29:59 PM 3:37:29 PM 3:44:59 PM 3:52:29 PM 3:59:59 PM 4:07:29 PM 4:14:59 PM 4:22:29 PM 4:29:59 PM time

118 RESULTS Umbrellas Scenarios with patio umbrellas produced the highest PM 2.5 levels, with readings in the poor range (82 µg/m 3 above background). All baseline PM2.5 readings were good or very good.

119 RESULTS Umbrellas To touch or not to touch. UMBRELLA STUDIES Monday July 23, 2007 TEST 1 TEST 2 Ontario Quebec NOT TOUCHING TOUCHING BASELINE 7 7 BURN DISPERSION 8 7 BURN DISPERSION 8 8

120 RESULTS Umbrellas UMBRELLA STUDIES Monday July 23, 2007 TEST 3 TEST 3 QUEBEC QUEBEC Touching OUTSIDE Touching INDOORS BASELINE 7 7 BURN DISPERSION 9 17 BURN DISPERSION 11 19

121 RESULTS - Umbrellas ONTARIO UMBRELLAS (not touching) Scenario July PM2.5 (micrograms/m^3) Scenarios with umbrellas TIME 14:22:29 All baseline PM2.5 readings were good or very good. 14:29:59 14:37:29 14:44:59 14:52:29 14:59:59 15:07:29 time 15:14:59 15:22:29 15:29:59 15:37:29 15:44:59 OUTSIDE INSIDE

122 RESULTS - Awnings 4 scenarios to test this: Baseline Burn (Ontario Open Air) Awning All baseline (Smokers PM2.5 not readings under) were good or very good. Awning (Smokers not under) Doors Open Awning (Smokers under) Doors Open

123 RESULTS Awnings OUTSIDE Impact AWNING SCENARIOS Ontario Open Air Awning (compliant) PM 2.5 Attributable to TSP in micrograms/m 3 Outside 52 62

124 RESULTS Awnings OUTSIDE and INSIDE Impact PM 2.5 Attributable to TSP in AWNING SCENARIOS micrograms/m 3 OUTSIDE INSIDE Awning Compliant Doors Open Awning Non-Compliant Doors Open 63 35

125 KEY FINDINGS Open Air Scenarios can still experience elevated levels of TSP The presence of umbrellas and awnings on a patio increase the TSP There is negligible difference in levels observed when umbrellas are touching or not touching. There is negligible difference in levels observed when smokers sit under or not under an awning

126 KEY FINDINGS TSP drifts from patios to indoor areas if a doorway is open TSP in indoor areas do not dissipate as quickly as outdoor areas

127 Conceptual Framework for the Evaluation of Smokefree Policies Smokefree Policies Proximal Variables Compliance with smokefree policies Intermediate SHS exposure Distal Health of Non-smokers Incidental Outcomes Economic impact, home smoking, cessation behavior Moderators SHS awareness / attitudes, occupation, SES, Tobacco control policies SHS: secondhand smoke SES: socio-economic status Source: IARC Handbook. Measuring Effectiveness of Population Based Tobacco Control Interventions. In press.

128 On-going and Future Research TSP exposure in other microenvironments Cars Homes Outdoors Multi-unit housing (transfer) TSP exposure studies in other countries Global Air Monitoring Study n=43 and counting Further validation studies with the Sidepak Humidity effects Competing sources of pollution

129 Countries (in red) Participating in Global Air Monitoring Study (n=43)

130 Limitations of PM 2.5 as a Marker of SHS Not specific to tobacco smoke; other sources include cooking, vehicles, ambient/background levels

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132 Bangkok, Thailand, February 2006 PM2.5 level in micrograms per cubic meter Outdoors on busy Bangkok streets Elapsed time in minutes Restaurant with smoking

133 Bangkok, Thailand, February PM2.5 level in micrograms per cubic meter Outdoors on busy Bangkok streets Restaurant with smoking Pub Elapsed time in minutes Pub Pub

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135 On-going and Future Research (continued) Other novel, real-time air monitoring techniques Measuring multiple particle properties simultaneously to determine particle source Link real-time exposure assessment with real-time health or physiological effects Lifeshirt

136 Acknowledgments Andrew Hyland K. Michael Cummings Gary Giovino Cheryl Higbee Anthony Brown Craig Steger Penny Hausler Lori Jurkowski Jim Repace Wayne Ott Neil Klepeis Kiyoung Lee Marc Homer Stephen Hecht Steve Carmella Richard Edwards The hundreds of other researchers and advocates I have had the great pleasure to work with on these projects. Funding: Flight Attendant Medical Research Institute and U.S. National Cancer Institute to the Roswell Park Transdisciplinary Tobacco Use Research Center (TTURC) (P50 CA111236).

137 Final Thought To laugh often and much; to win the respect of intelligent people and the affection of children; to earn the appreciation of honest critics and endure the betrayal of false friends; to appreciate beauty; to find the best in others; to leave the world a bit better, whether by a healthy child, a garden patch or a redeemed social condition; to know even one life has breathed easier because you have lived. This is to have succeeded. This poem often mistakenly attributed to author Ralph Waldo Emerson. While the true origin of the poem is still debated, this is most likely the work of Bessie Stanley that was published in the Lincoln Sentinal on Nov. 30, 1905, in response to an essay contest on What Constitutes Success. This was the winning submission.

138 Lives Effected by TSP Exposure in the Workplace

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