Levels of second hand smoke in pubs and bars by deprivation and food-serving status: a cross-sectional study from North West England.

ral
ssBioMed CentBMC Public Health
Open AcceResearch article
Levels of second hand smoke in pubs and bars by deprivation and
food-serving status: a cross-sectional study from North West
England
Richard Edwards*1, Christian P Hasselholdt2, Kim Hargreaves3,
Claire Probert4, Richard Holford5, Judy Hart6, Martie Van Tongeren7 and
Adrian FR Watson2
Address: 1Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand,
2Department of Environmental & Geographical Sciences, Manchester Metropolitan University, Oxford Rd, Manchester, UK, 3East Lancashire
Public Health Network, Eagle St, Accrington, UK, 4North West ASH, Silver St, Bury, UK, 5Manchester Public Health Development Service, Victoria
Mill, Lower VickersStreet, Manchester, UK, 6Evidence for Population Health, Division of Epidemiology and Health Sciences, University of
Manchester, Oxford Rd, Manchester, UK and 7Centre for Occupational and Environmental Health, Division of Epidemiology and Health Sciences,
University of Manchester, Oxford Rd, Manchester, UK
Email: Richard Edwards* - Richard.Edwards@otago.ac.nz; Christian P Hasselholdt - houchez@hotmail.com;
Kim Hargreaves - kim_m_hargreaves@yahoo.com.au; Claire Probert - claire.probert@burypct.nhs.uk;
Richard Holford - richard.holford@northpct.manchester.nwest.nhs.uk; Judy Hart - judy.hart@manchester.ac.uk; Martie Van
Tongeren - martie.j.van-tongeren@manchester.ac.uk; Adrian FR Watson - a.watson@mmu.ac.uk
* Corresponding author
Abstract
Background: The UK government proposed introducing partial smokefree legislation for England with exemptions for
pubs and bars that do not prepare and serve food. We set out to test the hypothesis that pubs from more deprived areas
and non food-serving pubs have higher levels of particulate air pollution.
Methods: We conducted a cross sectional study in four mainly urban areas of the North West of England. We recruited
a stratified random sample of 64 pubs divided into four groups based on whether their local population was affluent or
deprived (using a UK area based deprivation measure), and whether or not they served food. The timing of air quality
monitoring stratified to ensure similar distribution of monitoring by day of the week and time of evening between groups.
We used a portable air quality monitor to collect fine particle (PM2.5) levels over a minimum of 30 minutes in areas where
smoking was allowed,, and calculated mean time-time weighted average PM2.5 levels.
Results: Mean PM2.5 was 285.5 µg/m3 (95% CI 212.7 to 358.3). Mean levels in the four groups were: affluent food-serving
pubs (n = 16) 188.1 µg/m3 (95%CI 128.1 to 248.1); affluent non food-serving (n = 16) 186.8 µg/m3 (95%CI 118.9 to 254.3);
deprived food-serving (n = 17) 399.4 µg/m3 (95%CI 177.7 to 621.2); and deprived non food-serving (n = 15) 365.7 µg/m3
(195.6 to 535.7). Levels were higher in pubs in deprived communities: mean 383.6 µg/m3 (95% CI 249.2 to 518.0) vs 187.4
µg/m3 (144.8 to 229.9); geometric mean 245.2 µg/m3 vs 151.2 µg/m3 (p = 0.03). There was little difference in particulate
levels between food and non food-serving pubs.
Conclusion: This study adds to the evidence that the UK government’s proposals for partial smokefree legislation in
England would offer the least protection to the most heavily exposed group - bar workers and customers in non food-
Published: 22 February 2006
BMC Public Health 2006, 6:42 doi:10.1186/1471-2458-6-42
Received: 25 January 2006
Accepted: 22 February 2006
This article is available from: http://www.biomedcentral.com/1471-2458/6/42
© 2006 Edwards et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6
(page number not for citation purposes)
serving pubs in deprived areas. The results suggest these proposals would work against the UK government’s stated aim
to reduce health inequalities.

BMC Public Health 2006, 6:42 http://www.biomedcentral.com/1471-2458/6/42
Background
Second hand smoke (SHS) exposure causes of a range of
serious adverse health effects in children, adults and preg-
nant women [1-3]. In the UK it is estimated that domestic
exposure to secondhand smoke causes at least 3,600
deaths annually, while workplace exposure accounts for
around 700 deaths per year
Internationally, the introduction of legislation to ensure
workplaces and other public places are smokefree is a key
current public health policy issue. In many countries and
states, such as Ireland, New York, New Zealand and Nor-
way, comprehensive smokefree legislation has been intro-
duced. In the UK, Scotland and Northern Ireland propose
to do the same. However, the UK government in its public
health White Paper Choosing Health proposed introducing
partial smokefree legislation for England with exemptions
including for pubs and bars that do not prepare and serve
food, and private members clubs [4].
A number of groups have criticised the logic of the partial
exemption of pubs and bars as studies have shown that
the highest levels of SHS exposure occur in pubs and bars
[5-7]. The policy may also maintain or even increase dif-
ferentials in ill health due to smoking as there is evidence
that pubs and bars in more deprived areas are less likely to
serve food and more likely to allow unrestricted smoking
[8,9].
We set out to test hypothesis that pubs and bars from
more deprived areas and non food-serving pubs have
higher levels of particulate air pollution.
Methods
Setting and sampling
The study was performed in four wholly or mainly urban
Local Authority areas across the north west of England –
Burnley, Bury, Blackburn with Darwen, and Manchester.
Each includes areas with relatively high levels of depriva-
tion. The sampling frame for the study was the bars and
pubs from the four study areas which had previously par-
ticipated in a survey of North West hospitality premises
[8]. We contacted pubs by letter and excluded those that
did not wish to take part from the sampling frame. We
also excluded town/city centre pubs as the area-based dep-
rivation score is less likely to be representative of the
socio-economic status of its customers. Finally, we
excluded a number of pubs from the study during the data
collection period as these were deemed to be too unsafe
by the researchers.
Pubs were allocated an area-based deprivation score
(Index of Multiple Deprivation [IMD] 2004 [10]) by map-
quintiles (IMD 1 – 5) for all Super Output Areas across the
North West. We identified four categories of pubs and
bars. Firstly, we dichotomised pubs into affluent (IMD 1–
3) and deprived (IMD 4 or 5). Secondly, we divided pubs
into those which did and did not prepare and serve food
based on their response in the earlier survey [8]. We aimed
to recruit four pubs from each of the four categories in
each study area (64 pubs in total). In order to maximise
the contrast between the groups, for each study area and
pub category we sampled randomly first from quintile 5
or 1 pubs in the sampling frame, then if necessary from
quintile 4 or 2, and finally from quintile 3, stopping once
four pubs plus 3–4 reserves were identified.
Data collection
We aimed to perform air quality measurements in four
pubs per evening, one from each category, visited in
sequence. To ensure a range of measurements we sampled
on four separate days of the week (Tuesday-Friday). Pub
occupancy may vary by day of the week and time of night.
Therefore, we included a pub from each category on every
evening and varied the order of monitoring the pubs so
that a pub from each of the four categories was monitored
once first, once second, once third and once fourth within
each of the four study areas. Occasionally, to minimise
transport time, the order of visiting pubs or choice of pubs
had to be slightly modified from this plan.
Data collection was carried out using portable air quality
monitors according to a protocol modified from one
developed for a US study [11]. Pubs were visited unan-
nounced by two or more investigators. The investigators
carried a battery operated real time aerosol monitor (TSI
SidePak AM510 Personal Aerosol Monitor – TSI, Inc., St.
Paul, USA) in a small bag. The monitor was zero cali-
brated each evening. It was fitted with a 2.5 µm impactor
to sample and record the average levels of RSP (PM2.5)
over one minute periods. The air flow rate was 1.7 l/min.
A length of Tygon™ tubing was attached to the inlet of the
SidePak, with the other end left protruding outside the
bag. The recorded measurements were downloaded to a
PC for analysis. A calibration factor of 0.32 was applied
based on calibration work with a ThermoMIE personalD-
ataRAM model pDR-1200 real-time aerosol monitor
(ThermoAndersen, Inc., Smyrna, GA, USA). This type of
monitor had been used in a previous similar study in Del-
aware and has been calibrated against standard pump-
and-filter gravimetric methods [12].
At each venue we identified the busiest room of the pub
where smoking was allowed, and selected a central area
for monitoring, away from any open external doors or
windows, kitchen areas, and not in the immediate vicinityPage 2 of 6
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ping their postcode to the Census Super Output Area.
Super Output Areas were categorised into deprivation
(< 1 metre) of anyone smoking (unless this were not pos-
sible). Smoke free areas or rooms were avoided. To avoid

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affecting occupants' behaviour, investigators acted as nor-
mal customers and bought a drink before moving to the
sampling area.
The bag was carried or placed on a seat or table wherever
possible to sample the ambient air. We recorded the place
of monitoring within the venue and time of entry. Record-
ing occurred for at least 30 minutes and usually lasted
about 30–35 minutes. We recorded whether or not special
events likely to affect occupancy, such as quiz nights, were
taking place.
Analysis
We calculated a time-weighted average PM2.5 level for each
venue, and the mean PM2.5 levels by the four pub types
and by deprivation and food-serving categories separately.
transformed data, and geometric means are also reported
where appropriate.
Ethics
Ethical approval was not required for this study as no
measurements were made on human subjects.
Results
Of 402 pubs in the sampling frame, 71% were in deprived
areas (IMD4-5). Only nine refused to take part. Monitor-
ing was completed in 64 pubs, 16 in each study area.
Equal numbers from each pub category were sampled on
each evening except for one night in Burnley when a food-
serving pub from a deprived area was substituted for a
non food-serving pub.
Fine particle levels by pub category on one night's monitoring, September 2005igure 1
Fine particle levels by pub category on one night's monitoring, September 2005.Page 3 of 6
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PM2.5 levels generally had a highly positively skewed dis-
tribution, so significance tests were performed using log
The mean time of starting monitoring by type of pub was
as follows: affluent food-serving 8.58 pm (range 7.15 to

BMC Public Health 2006, 6:42 http://www.biomedcentral.com/1471-2458/6/42
10.50 pm,); affluent non food-serving 9.17 pm (range
7.50 to 10.40 pm); deprived food-serving 8.55 pm (range
7.45 to 10.25 pm); deprived non food-serving 9.08 pm
(range 7.36 to 10.20 pm); and all affluent 9.08 pm (range
7.15 to 10.50 pm) and all deprived 9.01 pm (range 7.36
to 10.25 pm).
Figure 1 shows a typical plot from a single night's moni-
toring. It shows the dramatic increase in fine particle levels
seen as we moved from the external ambient air and
entered each pub. It also shows the variability in levels
between pubs with the highest levels seen on this evening
in the third pub, which was a non food-serving pub from
a deprived area.
The mean level of PM2.5 across all venues was 285.5 (95%
CI 212.7 to 358.3) µg/m3. Levels were highest on Thurs-
days (mean PM2.5 = 356.7 µg/m3) and lowest on Tuesdays
(mean PM2.5 = 187.3 µg/m3). Mean levels varied by order
of visit as follows: 287.3 µg/m3 for the first, 209.5 µg/m3
for the second, 311.6 µg/m3 for the third, and 333.4 µg/
m3 for the final visit.
Table 1 shows the mean, median and range of PM2.5 levels
by pub category. Figure 2 shows these data graphically.
The geometric mean for time weighted averages of PM2.5
were higher in pubs in deprived communities (245.2 µg/
m3, 95%CI 169.9 to 353.9 µg/m3) than in pubs in more
affluent areas (151.2 µg/m3; 95%CI 116.4 to 196.4 µg/
m3), p = 0.03. There was little difference in levels between
food and non food-serving pubs (difference in geometric
means = 2.4 µg/m3, p = 0.96).
Discussion
The English Public Health White Paper proposed to
exempt non food-serving pubs and bars from the smoke-
free legislation. This study was designed to investigate air
quality in pubs in relation to this proposal, and the degree
to which air quality varied by deprivation. This is the first
such investigation that we are aware of in the UK or else-
there was little difference between food and non food-
serving pubs. Our measurements spanned a range of days
and times, and included relatively quiet times early on in
midweek evenings. We excluded Saturday nights, when
occupancy and hence smoking levels are likely to be at
their greatest. Despite this four pubs still had extremely
high levels of PM2.5.
Fine particle levels have been used in previous studies of
air quality in the workplace, including in the hospitality
trade [11,12]. We found extremely high levels of PM2.5 in
these hospitality venues, of the same order as those found
in similar studies of 20 hospitality venues from New York
(mean 324 µg/m3), [11] and eight hospitality venues from
Delaware (mean 231 µg/m3) [12].
Levels of PM2.5 observed were much higher than seen in
heavily trafficked urban areas. For example, mean ambi-
ent PM2.5 levels in central London (Marylebone Road) in
September 2005 were 23.5 µg/m3, 24.6 µg/m3 between 7
and 12 pm. [13] In the UK, there is no air quality standard
for PM2.5, though one may be introduced soon. In the
USA, the Environmental Protection Agency (EPA) uses an
air quality standard for ambient air, one component of
which is the mean PM2.5 level over a 24 hour period [14].
Levels over 65, 150 and 250 µg/m3 are labelled by the EPA
as 'unhealthy', 'very unhealthy' and 'hazardous' respec-
tively [15]. Direct comparisons are only a rough guide as
the EPA Air Quality Index refers to time weighted averages
over a 24 hour period. However, using the EPA categorisa-
tion, air quality was unhealthy or worse in 57 out of 64
(89%) of the pubs, and was hazardous in 26 (41%). Of
the pubs with hazardous levels (> 250 µg/m3), 19 were in
deprived areas. All the pubs with very high levels – two
500–999 µg/m3and four > 1000 µg/m3 – were in deprived
areas.
A limitation of the study was the lack of information on
ventilation in the participating pubs. However, the data
represent current figures from real world settings and
Table 1: Fine particle (PM2.5) levels by pub category in µg/m3
Mean (95% CI) Median Range
Affluent food-serving pubs (n = 16) 188.1 (128.1 to 248.1) 160.3 59.3–424.4
Affluent non food pubs (n = 16) 186.6 (118.9 to 254.3) 163.7 14.9–497.4
Deprived food-serving pubs (n = 17) 399.4 (177.7 to 621.2) 329.8 54.1–1395.1
Deprived non food pubs (n = 15) 365.7 (195.6 to 535.7) 290.3 23.5–1226.6
All affluent pubs (n = 32) 187.4 (144.8 to 229.9) 161.3 14.9–497.4
All deprived pubs (n = 32) 383.6 (249.2 to 518.0) 312.4 23.5–1395.1
All food-serving pubs (n = 33) 293.6 (172.1 to 415.2) 166.7 54.1–1395.1
All non food pubs (n = 31) 277.3 (189.8 to 364.8) 216.6 14.9–1226.6Page 4 of 6
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where. We found that levels of fine particles were about
twice as high in pubs situated in more deprived areas, but
should therefore be representative of air quality experi-
enced by customers and staff across a range of UK pubs. As

BMC Public Health 2006, 6:42 http://www.biomedcentral.com/1471-2458/6/42
noted above, the lack of sampling on Saturday nights
means that we may have missed periods when air quality
is poorest. The very high levels of over 1000 µg/m3 seen in
four pubs in our sample show how poor air quality can be
in the smokiest venues.
Conclusion
In conclusion, we found high levels of fine particles in 64
pubs from across the north west of England. Air quality
was poorest in pubs situated in more deprived areas. Most
(86%) pubs in the sampling frame from the four study
areas were in IMD deprivation quintiles 3 to 5, and 71%
were in quintiles 4 or 5. The equivalent figures were 82%
and 65% respectively in North West pubs from 15 Local
Authority areas [8]. This suggests that the higher levels of
don't serve food, which will be exempt from the English
Public Health White Paper smokefree legislation, will be
concentrated in deprived areas [8]. Therefore, this study
adds to the evidence that the UK government's proposals
for partial smokefree legislation in the UK would offer the
least protection to the most heavily exposed group – bar
workers and customers in non food-serving pubs in
deprived areas. This finding, together with the evidence
that smokefree public places and workplaces are effective
policies for reducing overall smoking prevalence, [16]
suggest that the proposals for partial smokefree legislation
are contrary to the UK government's stated aim to reduce
health inequalities.
Competing interests
Box plots of fine particle levels by category of pub in µg/m3Figure 2
Box plots of fine particle levels by category of pub in µg/m3.Page 5 of 6
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SHS will be found in most pubs in the North West. Fur-
thermore, the North West survey found that pubs which
No specific funding was allocated to this study. Richard
Edwards was unpaid chair of NW ASH and Claire Probert