Immediate impact of smoke-free laws on indoor air quality

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Content: CME Topic
Immediate Impact of Smoke-free Laws on indoor air quality Kiyoung Lee, ScD, MPH, Ellen J. Hahn, DNS, RN, Carol Riker, MSN, RN, Sara Head, MPH, and Peggy Seithers, RN
Abstract: Smoke-free laws significantly impact indoor air quality. However, the temporal effects of these laws on indoor air pollution have not been determined. This paper assesses the temporal impact of one smoke-free law on indoor air quality. This quasi-experimental study compared the indoor air quality of nine hospitality venues and one bingo hall in Georgetown, Kentucky, before and after implementation of a 100% smoke-free workplace law. We made real-time measurements of particulate matter with 2.5 m aerodynamic diameter or smaller (PM2.5). Among the nine Georgetown hospitality venues, the average indoor PM2.5 concentration was 84 g/m3 before the law took effect. The average indoor PM2.5 concentrations in nine compliant venues significantly decreased to 18 g/m3 one week after the law took effect. Three venues having 82 g/m3 before the law had significantly lower levels from the first day the law was implemented, and the low level was maintained. Compliance with the law is critical to achieving clean indoor air. Indoor air pollution in the bingo hall was not reduced until the establishment decided to comply with the law. The smoke-free law showed immediate impact on indoor air quality. Key Words: secondhand smoke, smoke-free laws, indoor air quality, fine particles Secondhand smoke (SHS) is the third leading preventable cause of death in the US,1 and there is no safe level of exposure to SHS.2 SHS, which consists of a mixture of the smoke given off by the burning end of tobacco products (side stream smoke) and the smoke exhaled by smokers (mainstream smoke), is a major source of indoor air pollution containing a complex mixture of over 4,000 chemicals, more than 50 of which are cancer-causing agents.3,4 SHS is a cause From the College of Public Health and the College of Nursing, University of Kentucky, Lexington and WEDCO District health department, Georgetown, Kentucky. The authors have no financial disclosures to declare. Reprint requests to Dr. Kiyoung Lee, College of Public Health, 121 Wash- ington Avenue, Lexington, KY 40536-0003. Email: [email protected] Accepted February 28, 2007. Copyright © 2007 by The Southern Medical Association 0038-4348/02000/10000-0885
of cardiovascular disease,5­7 respiratory illness,8­10 and lung cancer11 among both smokers and nonsmokers. Kentucky has the highest prevalence of current cigarette smoking among adults.12 The prevalence rate in Kentucky in 2005 was 28.7%, while the median rate was 20.6% in the 50 states and the District of Columbia.12 The American Lung Association State of Tobacco Control 2006 is a report card that evaluates federal and state tobacco control laws translating each state's relative progress into a letter grade.13 Southern states (Region 4) tend to lag behind in tobacco prevention and control spending, smoke-free laws, state cigarette excise tax, and youth access laws. Six states in Region 4 (including Kentucky) had failing grades on the 2006 report card and only two states (Georgia and Florida) had "B" grades. As of January 12, 2007, there were 2,507 US municipalities with local smoke-free laws, 570 of which provide 100% smoke-free protection.14 A growing number of countries around the world are enacting smoke-free restaurant and bar legislation.15 Currently, 13 states (CA, CO, CT, DE, HI, ME, MA, NJ, NY, OH, RI, VT, and WA) and the District of Columbia have passed comprehensive smoke-free regulations that cover virtually all indoor worksites, including bars and restaurants.14 However, the southern tobacco-growing states lag behind in protecting workers from the dangers of SHS. The Georgetown, Kentucky (pop. 18,080), City Council passed a 100% smoke-free workplace and public place law in July 2005 and implemented the law on October 1, 2005. Smoke-free laws result in significant reductions in indoor air pollution. Indoor fine particle pollution levels decreased 91% after implementation of a comprehensive smokefree law in Lexington, Kentucky.16 In a cross-sectional Delaware study, 90% of the respirable suspended particle (RSP) levels in hospitality venues was found to be attributed to tobacco smoke.17 A longitudinal California study showed Key Points · A 100% smoke-free law significantly impacts indoor air quality. · Compliance with the law is critical to achieving clean indoor air.
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Lee et al · Immediate Impact of Smoke-free Laws on Indoor Air Quality
an 82% decline in indoor air pollution after smoking was prohibited.18 Similarly, a cross-sectional western New York study found that average levels of RSP decreased 84% in 20 hospitality venues after a smoke-free law.19 However, no study has assessed how long it takes to demonstrate reductions in air pollution from SHS exposure after smoke-free laws are implemented. The purpose of this study was to examine the temporal effects of a smoke-free law in Georgetown, Kentucky. Methods The quasi-experimental study was conducted with nine hospitality venues (eight restaurants and one bowling alley) and one bingo hall in Georgetown, Kentucky. Purposive sampling was used to identify nine hospitality venues that allowed smoking in Georgetown before the enforcement of the smoke-free law. Air quality in three of the nine venues was measured on Days 1, 2, 3, 5 and 7 after the smoke-free law was implemented. All venues were measured one week after the law took effect. Air quality in the bingo hall was measured three times after the law at one-week, two-week, and three-month intervals. Fine particle concentrations were measured using a Sidepak monitor (TSI, Minneapolis, MN). The Sidepak measures particles based on light scattering, and an impactor for 2.5 m was attached to an inlet to remove particles greater than 2.5 m at a flow rate of 1.7 l pm. The Sidepak monitors were calibrated against a gravimetric measurement of particulate matter with 2.5 m aerodynamic diameter or smaller (PM2.5) in a series of laboratory chamber experiments. Based on the calibration experiments, the Sidepak readings were adjusted by a calibration factor of 0.295. In addition, the Sidepak was zero calibrated before each use by attaching a HEPA filter according to the manufacturer's specifications. The monitor was concealed in either a backpack or purse and set so that samples were collected continuously before
entering the venue and during the visit. A Tygon tube was connected to the monitor and the inlet of the tube was placed outside the bag to provide unobstructed access to ambient air. When inside the venue, a nonsmoking location was selected, which was as far away as possible from the direct puffs of cigarettes or cigars. In addition to air quality measurements, data on room size, number of burning cigarettes and cigars, temperature, relative humidity, air pressure at entryways, and maximum occupancy were collected. Total number of burning cigarettes/cigars in each venue was counted at the beginning, middle, and end of the sampling period. Smoking density in each location was calculated by average number of burning cigarettes per 100 m3 of the indoor volume. Results Nine Georgetown hospitality venues complied with the law. Table 1 presents indoor PM2.5 concentrations (g/m3) in the nine venues before and after the smoke-free law. Among the nine Georgetown hospitality venues, average indoor PM2.5 concentrations varied from 18 to 326 g/m3 with a mean of 84 g/m3 before the law took effect. Smoking density in the nine venues was 1.21 (1.53) bc/100 m3 ranging from 0 to 5.01, and smoking was observed in all but one location. On the seventh day after the smoke-free law was implemented, when smoking density was 0, the average indoor PM2.5 concentration in the same Georgetown locations was 18 g/m3, representing 21% of the mean before the law. In three hospitality venues, indoor air quality was significantly reduced from the first day the smoke-free law was implemented. Average indoor PM2.5 concentrations in the three venues was 82 g/m3 before the law. The levels were reduced to 41 g/m3 on Day 1 and maintained at 23, 20, 21 and 23 g/m3 on Days 2, 3, 5 and 7 after the law was implemented, respectively (Fig. 1). In the bingo hall, average PM2.5 levels did not decrease due to noncompliance with the law. Table 2 presents the
Table 1. Indoor PM2.5 concentrations (g/m3) in compliant Georgetown venues before and after the smoke-free law (effective as of October 1, 2005)
Venue
Smoking
Average
Smoking
Average
Size (m3)
Date (preban)
density (#bc/100 m3)
PM2.5 level (SD)
Date (postban)
density (#bc/100 m3)
PM2.5 level (SD)
Restaurant A
389
9/15/2005
0.45
48 (16)
10/7/2005
0
Restaurant B
446
9/15/2005
0.06
18 (2)
10/7/2005
0
Restaurant C
531
9/16/2005
0.04
35 (16)
10/7/2005
0
Restaurant D
956
9/16/2005
0.46
81 (27)
10/7/2005
0
Restaurant E
127
9/16/2005
2.67
326 (64)
10/7/2005
0
Restaurant F
32
9/16/2005
0
44 (16)
10/7/2005
0
Restaurant G
115
9/16/2005
5.01
115 (23)
10/7/2005
0
Restaurant H
78
9/16/2005
1.60
51 (33)
10/7/2005
0
Bowling Alley
2548
9/16/2005
0.09
42 (21)
10/7/2005
0
42 (10) 11 (2) 7 (1) 23 (2) 12 (1) 17 (4) 27 (10) 19 (3) 5 (1)
PM2.5, particulate matter with 2.5-m aerodynamic diameter or smaller.
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Fig. 1 Immediate impact of smoke-free law on indoor PM2.5 level in Georgetown. indoor concentrations in the bingo hall. Average indoor PM2.5 concentrations in the bingo hall were 226 g/m3 before the law and 748 g/m3 two weeks after the law, as shown in Figure 2. When the levels were measured four weeks after the law, the level was 315 g/m3, indicating continuing noncompliance. The smoking density was 2.35, 2.43, and 2,51 #bc/ 100 m3 before the law, two weeks after the law, and four weeks after the law, respectively. At three months postlaw, the bingo hall complied with the law, and the air pollution level dropped to 43 g/m3. The average number of patrons observed during the monitoring period decreased from 200 patrons before the law to 124 two weeks after the law (smoking still allowed), and 114 four weeks after the law took effect (smoking still allowed). When the bingo hall decided to comply at three months postlaw, the average number of patrons returned to baseline at 200. The data from the 10 total establishments were analyzed to identify factors associated with indoor fine particle levels. Only smoking density was significantly associated with PM2.5 levels. When smoking density was classified into two groups (smoking and no smoking), the mean indoor PM2.5 levels were 199 (223) g/m3 when at least one cigarette was burned in a 100 m3-sized room. When no smoking was observed, the mean indoor PM2.5 level was 25 (13) g/m3. Discussion Before the smoke-free law took effect and when indoor smoking was allowed, the average PM2.5 levels were 84 g/m3. The levels were measured without prior notice,
and the monitors were concealed at all time periods. Field technicians tried to avoid direct contact with active smoking during the monitoring. Therefore, the measurements are likely representative of well-mixed concentrations. The prelaw level was slightly lower than the measurements in Lexington, New York, and Delaware.16,17,19 Georgetown does not have free- standing bars. While there is no federal standard for indoor air quality, the National Ambient Air Quality Standard (NAAQS) for PM2.5 is 35 g/m3 for 24 hours. Before the smoke-free laws, the average PM2.5 level was higher than the NAAQS. Indoor fine particle pollution levels had decreased 79% in the nine public venues one week after implementation of the smoke-free law in Georgetown. The reduction percentage was comparable to the reduction in other studies; that is, 91% in Lexington,16 84% in New York,19 90% in Delaware,17 and 82% in California.18 The PM2.5 level of 18 g/m3 after the smoke-free law was also similar to other studies and well below the 24-hour NAAQS of 35 g/m3, except in one venue with 42 g/m3. Biologic nicotine levels have been significantly reduced after smoke-free laws. In New York, saliva cotinine concentrations of hospitality workers decreased from 3.6 ng/mL to 0.8 ng/mL.20 In Lexington, Kentucky, the median hair nicotine level of hospitality workers decreased from 1.71 ng/mg before the smoke-free law to 0.75 ng/mg three months after implementation of the smoke-free law.21 Serum cotinine level of nonsmoking bar workers in Scotland decreased from 5.15 ng/mL before the law to 3.22 ng/mL one month afterward and then 2.93 ng/mL two months after the law took effect.22 Rapid improvement of both cardiovascular and respiratory health has been observed as a result of smoke-free laws. When a smoke-free law was implemented in Helena, Montana, the number of admissions for acute myocardial infarctions fell significantly within the first six months.23 A recent study in Pueblo, Colorado, showed a 27% decline in heart attacks within the 1Ѕ year period after implementation of a smoke-free law.24 The respiratory health of bartenders improved after the smoke-free law was enacted in San Francisco.25 Complete cessation of workplace SHS exposure improved mean FEV1 after controlling for personal smoking and recent upper Respiratory Tract Infections.
Table 2. Indoor PM2.5 concentrations (g/m3) in a bingo hall before and after the smoke-free law
Date
Smoke-free law
Average PM2.5 (SD)
Average people
Average smokers
Smoking density (#bc/100 m3)
9/16/2005
Before the law
226 (26)
200
30
2.35
10/14/2005 The law was not enforced
748 (291)
124
31
2.43
10/28/2005 The law was not enforced
315 (124)
114
32
2.51
1/28/2006
The law was enforced
43 (9)
200
0
0
PM2.5, particulate matter with 2.5-m aerodynamic diameter or smaller.
Southern Medical Journal · Volume 100, Number 9, September 2007
Peak PM2.5 (g/m3) 270 2624 908 70 887
Lee et al · Immediate Impact of Smoke-free Laws on Indoor Air Quality
surement in three venues may not be large enough to generalize. Since all of the sampled venues demonstrated significant improvement of indoor air quality from the first day, it is likely to represent the immediate impact of the law in other cities. We also measured indoor air quality only once per venue during dinner time. Since the owners were not aware that monitoring was taking place, we expect that the levels were representative.
Fig. 2 Indoor air quality in a bingo hall. Compliance and enforcement of smoke-free laws is critical to improve indoor air pollution. In Georgetown, the bingo hall did not initially comply with the law, and fine particle levels did not decrease until they complied with the law. While the bingo hall allowed smoking after the law, the number of patrons fell, but the fine particle levels increased. We observed that smoking density did not change during this time. One possible explanation is that noncompliance in the bingo hall resulted in an over-frequenting by heavier smokers, while nonsmokers did not come to the smoky bingo hall. Although only based on one observation, anecdotal evidence suggested that the number of bingo patrons returned to baseline levels after compliance with the smoke-free law. Indoor fine particles were significantly and immediately reduced on the first day of implementation of the smoke-free law. On the first day of the law, the indoor fine particle level was reduced by 50%. None of the three public venues had a level exceeding the 24-hour NAAQS of 35 g/m3 on the first day. The level was further decreased on the second day and was maintained at the low level. The findings demonstrated that a smoke-free law can make a significant and immediate improvement in indoor air quality. Smoke-free laws can protect the public from the harmful effects of SHS exposure as soon as the law is implemented. The immediate improvement of indoor air pollution supports several recent studies of improved health effects after smoke-free laws. A significant decrease in respiratory symptoms among hospitality workers in Norway was reported five months after enactment of a public smoking ban.26 When pulmonary function was examined at the beginning and end of a workshift, the cross shift decrease in lung function was larger before than after implementation of the smoking ban.27 A significant decrease in respiratory symptoms was reported 3 and 6 months after Lexington's law, and simultaneous decrease in hair nicotine was also found 3 months after the smoke-free law.21 Immediate improvement of respiratory symptoms, pulmonary function, and serum cotinine were reported only one month after the smoke-free law in Scotland.22 These findings should be interpreted with caution. Three venues was the maximum number of venues for one sampler to measure during dinner time. Also, the number was limited by the relatively small size of the city. Repeating the mea-
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15. Americans for Nonsmokers' Rights Foundation. Smoke-free Status of Restaurants and Bars Around the World, July 1, 2006. Available at: http://www.no-smoke.org/pdf/internationalbarsandrestaurants.pdf. Accessed on July 24, 2006. 16. Hahn EJ, Lee K, Okoli CTC, et al. Smoke-free laws and indoor air pollution in Lexington and Louisville. Louisville Medicine 2005;52:391­ 394. 17. Repace J. Respirable particles and carcinogens in the air of Delaware hospitality venues before and after a smoking ban. J Occup Environ Med 2004;46:887­905. 18. Ott WR, Switzer P, Robinson J. Particle concentration inside a tavern before and after prohibition of smoking. J Air Waste Manag Assoc 1996;46:1120 ­1134. 19. Travers MJ, Cummings A, Hyland A. Indoor air quality in hospitality venues before and after implementation of a clean indoor air law Western New York, 2003. Morbidity & Mortality Weekly Report 2004;53 (44):1038­1041. 20. Farrelly MC, Nonnemaker JM, Chou R, et al. Changes in hospitality workers' exposure to secondhand smoke following the implementation of New York's smoke-free law. Tob Control 2005;14:236­241. 21. Hahn EJ, Rayens MK, York N, et al. Effects of a smoke-free law on hair
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