Second-Hand Tobacco Smoke Exposure in Open and Semi-Open Settings: A Systematic Review.

Cancer Control and Prevention Group, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL
Environmental Health Perspectives (Impact Factor: 7.98). 05/2013; 121(7). DOI: 10.1289/ehp.1205806
Source: PubMed


Background: Some countries have recently extended smoke-free policies to particular outdoor settings; however, there is controversy regarding whether this is scientifically and ethically justifiable.
Objectives: The objective of the present study was to review research on secondhand smoke (SHS) exposure in outdoor settings.
Data sources: We conducted different searches in PubMed for the period prior to September 2012. We checked the references of the identified papers, and conducted a similar search in Google Scholar.
Study selection: Our search terms included combinations of “secondhand smoke,” “environmental tobacco smoke,” “passive smoking” OR “tobacco smoke pollution” AND “outdoors” AND “PM” (particulate matter), “PM2.5” (PM with diameter ≤ 2.5 µm), “respirable suspended particles,” “particulate matter,” “nicotine,” “CO” (carbon monoxide), “cotinine,” “marker,” “biomarker” OR “airborne marker.” In total, 18 articles and reports met the inclusion criteria.
Results: Almost all studies used PM2.5 concentration as an SHS marker. Mean PM2.5 concentrations reported for outdoor smoking areas when smokers were present ranged from 8.32 to 124 µg/m3 at hospitality venues, and 4.60 to 17.80 µg/m3 at other locations. Mean PM2.5 concentrations in smoke-free indoor settings near outdoor smoking areas ranged from 4 to 120.51 µg/m3. SHS levels increased when smokers were present, and outdoor and indoor SHS levels were related. Most studies reported a positive association between SHS measures and smoker density, enclosure of outdoor locations, wind conditions, and proximity to smokers.
Conclusions: The available evidence indicates high SHS levels at some outdoor smoking areas and at adjacent smoke-free indoor areas. Further research and standardization of methodology is needed to determine whether smoke-free legislation should be extended to outdoor settings.

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    • "• Australia, Canada, New Zealand, United States, Denmark, and Spain. Sureda et al. (2013) "
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    ABSTRACT: Honorable members of the National Assembly, my name is James Repace. I am a physicist. I served 19 years as a senior air policy analyst for the U.S. Environmental Protection Agency in Washington, DC. Now retired, I do consulting on indoor and outdoor air pollution from secondhand smoke. I have published 56 peer-reviewed research papers on the hazard, exposure, dose, risk, and control of secondhand smoke. I strongly support all provisions of Bill 44, including the ban on smoking on outdoor terraces of bars and restaurants, which will protect the health of both nonsmoking bar and restaurant wait staff and patrons. There is a scientific consensus that secondhand smoke poses dire risks to human health. It is a known human carcinogen. It has immediate adverse effects on the cardiovascular system and chronic exposure causes fatal heart disease. There is no known risk-free level of exposure to secondhand smoke. A high proportion of non-smokers report eye irritation, headache, nasal discomfort, coughing, sore throat, or sneezing when exposed to secondhand smoke. Even brief exposures can induce sensory irritation in healthy nonsmokers at very low levels, which increases with duration of exposure. A U.S. study of nonsmokers' body fluids demonstrated that nonsmokers exposed to secondhand smoke on the outdoor terraces of a bar and a restaurant for just 3 hours absorbed significant doses of secondhand smoke fine particles and carcinogens. I calculate from their data that the nonsmokers' fine particulate matter exposure from secondhand smoke constitutes Code Red or Very Poor Air Quality when evaluated by the 3-hour Canadian Air Quality Index. Risk assessment shows that this exposure constitutes a "significant risk of material impairment of health" by the standards of the US Occupational Safety and Health Administration. Separation of the outdoor patios into smoking and nonsmoking sections would only serve to increase the secondhand smoke exposure of the estimated 16,625 nonsmoking Quebec restaurant and bar wait staff who would serve in the smoking sections of bar and restaurant terraces. Nonsmoking sections on terraces would also fail to protect nonsmoking patrons from secondhand smoke carried by the wind from the smoking sections. The results of 13 field studies in as many countries demonstrate that fine particulate matter air pollution on outdoor terraces is overwhelmingly higher than that from heavy street traffic. A study commissioned by The Union of Bar Owners of Quebec asserts that “Air quality on open-air terraces would not be significantly affected by smokers,” by a separation of only 1.5 meters. However, this claim is contradicted by three different U.S. studies which showed that harmful levels of secondhand smoke fine particles and carcinogens from a single cigarette smoked on outdoor terraces occurred at downwind distances ranging from 4 to 7 to 13 meters. Because these secondhand smoke pollutants decline inversely with distance, smoke from multiple smokers will reach out proportionally to greater distances. Thus, the smoking section separation distance of 1.5 meters proposed by The Union of Bar Owners of Quebec must be rejected in favor of a total terrace smoking ban as proposed by Bill 44. Thank You for the opportunity to testify. My remarks are detailed in my written testimony. I would be pleased to answer any questions.
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    • "no roofing, no high walls). Sureda and colleagues (2013) also found measured levels of SHS to be generally higher where smoker density was high, smokers were nearby and where the outdoor smoking area was more enclosed. 13 Lower wind speeds are generally associated with higher PM 2.5 concentrations in urban settings. "
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    ABSTRACT: Aim: To examine levels of fine particulates of secondhand smoke (SHS) in outdoor dining/smoking areas and the adjacent indoor dining areas of restaurants to assess possible drift via open windows/doors. Method: We measured fine particulates (PM2.5 mcg/m³) with real-time aerosol monitors as a marker of SHS inside where smoking is banned and outside dining areas (which permit smoking) of eight restaurants in Wellington. We also collected related background data (e.g. number of smokers, time windows/doors were open, etc.). Results: Highest overall mean PM2.5 levels were observed in the outdoor dining areas (38 mcg/m³), followed by the adjacent indoor areas (34 mcg/m³), the outdoor ambient air (22 mcg/m³) and the indoor areas at the back of the restaurant (21 mcg/m³). We found significantly higher PM2.5 levels indoor near the entrance compared to indoor near the back of the restaurant (p=0.006) and in the outdoor smoking area compared to outdoor ambient levels (p<0.001). Importantly, we did not detect a significant difference in mean PM2.5 levels in outdoor smoking areas and adjacent indoor areas (p=0.149). Conclusion: Similar PM2.5 concentrations in the outdoor and adjacent indoor dining areas of restaurants might indicate SHS drifting through open doors/windows. This may especially be a problem when smoking patronage is high, the outdoor dining area is enclosed, and during peak summer season when restaurants generally have all doors and windows opened. Tighter restrictions around outdoor smoking at restaurants, to protect the health of both patrons and staff members, may be needed.
    The New Zealand medical journal 06/2014; 127(1396-1396):43-52.
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    • "Nevertheless, the current data suggest that assessment of second-hand smoke outdoors cannot be based solely on PM 2.5 measurements, given the limited correlation observed. Additional research on second-hand smoke exposure assessment outdoors still seems necessary (Sureda et al., 2013). Table 1 Median nicotine and PM 2.5 concentrations (and interquartile ranges), and Spearman's rank correlation coefficients between these airborne markers according to selected variables. "
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    ABSTRACT: The aim of this study was to assess the relationship between particulate matter of diameter≤2.5µm (PM2.5) and airborne nicotine concentration as markers of second-hand smoke exposure with respect to the setting studied, the intensity of exposure, and the type of environment studied (indoors or outdoors). Data are derived from two independent studies that simultaneously measured PM2.5 and nicotine concentrations in the air as airborne markers of second-hand smoke exposure in public places and workplaces, including health care centres, bars, public administration offices, educational centres, and transportation. We obtained 213 simultaneous measures of airborne nicotine and PM2.5. Nicotine in the air was measured with active samplers containing a sodium bisulphate-treated filter that was analysed by gas chromatography/mass spectrometry. PM2.5 was measured with a SidePak AM510 Personal Aerosol Monitor. We calculated Spearman's rank correlation coefficient and its 95% confidence intervals (95% CI) between both measures for overall data and stratified by setting, type of environment (indoors/outdoors), and intensity of second-hand smoke exposure (low/high, according to the global median nicotine concentration). We also fitted generalized regression models to further explore these relationships. The median airborne nicotine concentration was 1.36µg/m(3), and the median PM2.5 concentration was 32.13µg/m(3). The overall correlation between both markers was high (Spearman's rank correlation coefficient=0.709; 95% CI: 0.635-0.770). Correlations were higher indoors (Spearman's rank correlation coefficient=0.739; 95% CI: 0.666-0.798) and in environments with high second-hand smoke exposure (Spearman's rank correlation coefficient=0.733; 95% CI: 0.631-0.810). The multivariate analysis adjusted for type of environment and intensity of second-hand smoke exposure confirmed a strong relationship (7.1% increase in geometric mean PM2.5 concentration per µg/m(3) nicotine concentration), but only in indoor environments in a stratified analysis (6.7% increase; 95% CI: 4.3-9.1%). Although the overall correlation between airborne nicotine and PM2.5 is high, there is some variability regarding the type of environment and the intensity of second-hand smoke exposure. In the absence of other sources of combustion, air nicotine and PM2.5 measures can be used indoors, while PM2.5 should be used outdoors with caution.
    Environmental Research 10/2013; 127. DOI:10.1016/j.envres.2013.09.003 · 4.37 Impact Factor
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