How Smoke-free Laws Improve Air Quality
How Smoke-free Laws Improve
Air Quality:
A Global Study of Irish
Pubs
Feabhas ar an aer de
bharr dhlíthe chosc an tobac: Staidéar
Cuimsitheach ar Thithe Ósta na
hÉireann
United
States
Harvard School of Public Health Division of Public Health
Practice
Gregory N. Connolly, DMD, MPH
Carrie M. Carpenter, MS
Roswell Park Cancer Institute
Department of Health Behavior
Mark Travers, MS
K. Michael Cummings, PhD, MPH
Andrew Hyland, PhD
Ireland
Health Service Executive-West, Environmental Health
Department, Galway
Maurice Mulcahy, MSc
Research Institute for a Tobacco Free Society
Professor Luke Clancy, BSc, MD, FRCPI
Office of Tobacco Control
Overview
When St. Patrick, known as the patron
saint of Ireland, arrived in Ireland in the first half of the 5th
century, tobacco was not known to Ireland or the rest of Europe. It
wasn't until the middle of the 16th century that tobacco was
introduced to this part of the world. Nearly 500 years later,
smoking was banned in public places, making the air as clean as it
was when St. Patrick arrived in Ireland.
In March 2004, the Republic of Ireland
banned indoor smoking in all public spaces including restaurants
and pubs. Many said that it could not be done, smokers would simply
ignore the law and chaos and economic ruin would follow. Nearly two
years later, the critics are silent, and hundreds of communities
around the globe and nearly a dozen countries have followed
Ireland's lead by adopting smoke-free legislation as the norm.
Irish pubs can be found in nearly every
city in the world. Some are smoke-free, while others remain
smoke-filled. We conducted a study to test the air quality of Irish
pubs around the globe. Indoor air quality was assessed in 128 Irish
pubs in 15 countries, between January 21, 2004 and March 10,
2006.
Air quality was evaluated using an
aerosol monitor which measures the level of fine particle (PM2.5)
pollution in the air. Fine particle pollutants, such as those
generated from burning cigarettes, are less than 2.5 microns in
diameter. These fine particles are especially dangerous since they
can be easily inhaled deep into the lungs and result in a variety
of adverse health effects including cardiovascular disease,
respiratory morbidity, and even death.
Testing sites included 41 smoke-free
Irish pubs in the Republic of Ireland, the United States, and
Canada, and 87 smoking-permitted Irish pubs located in Armenia,
Australia, Belgium, China, England, France, Germany, Greece,
Lebanon, Northern Ireland, Poland, Romania, and the United
States.
The results of the study found that,
overall, the level of air pollution inside Irish pubs located in
smokefree cities was 93% lower than the level found in pubs in
smoke-permitted cities. Specifically, the average level of indoor
air pollution in Ireland's authentic smoke-free pubs was 91% lower
than Irish pubs in cities that allow smoking.
No doubt St. Patrick would prefer to
see those who wish to celebrate in his honor do so in a place where
workers and patrons alike can breathe fresh air free from tobacco
smoke pollution.
Introduction
Secondhand smoke (SHS) exposure remains
a major global public health concern that is entirely
preventable.1 SHS is a known human carcinogen containing
at least 250 chemicals that are known to be toxic or
carcinogenic2, and is responsible for an estimated 3,000
lung cancer deaths annually in never smokers in the U.S., as well
as over 35,000 deaths annually from coronary heart disease in never
smokers, plus respiratory infections, asthma, Sudden
Infant Death Syndrome (SIDS), and other illnesses in
children.3 SHS is a major source of respirable suspended
particles (RSPs). A specific category of RSPs, known as PM2.5 (i.e.
particulate matter less than 2.5 microns in diameter), are very
small particles suspended in the air which pose dangerous health
effects. In order to protect the public health, the EPA has set
limits of 15 µg/m3 as the average annual level of PM2.5
exposure and 65 µg/m3 24-hour exposure.4
Dangers of SHS exposure are highest
among restaurant and bar workers who typically have low levels of
protection provided by smoking regulations.1,5-10 The
most effective method for reducing SHS exposure in public places
are policies requiring smoke-free environments.11 The
World Health Organization (WHO) Framework Convention on Tobacco
Control (FCTC) calls on governments to "protect all persons from
exposure to tobacco smoke," rather than just specific populations
such as children or pregnant women (Guiding Principle 4.1). This
protection should be extended, according to Article 8.2, "in indoor
workplaces, public transport, indoor public places and…other public
places."12
In recent years, many U.S. states and
cities have passed laws prohibiting smoking in workplaces including
pubs and restaurants. In March of 2004, the government of Ireland
banned smoking in worksites including public houses (pubs) making
Ireland the first country to implement a nationwide policy. Given
the smoking rates in Ireland and the association between smoking
and visiting a pub, this was an historic event.
Previous studies in the U.S. have
evaluated the impact of smoking legislation by measuring the
difference in levels of RSPs between smoke-free venues and those
that permit smoking.13-16 Air quality assessment in
Irish pubs showed a dramatic reduction in the presence of RSPs
(PM10 and PM2.5) following the implementation of the smoke-free
law, with no adverse effects on business.17,18 Despite
claims that the law would not be adhered to and that it would have
a negative impact on pub business, these have not been realized.
Fong et al. reported high compliance with the Irish
law,19 and the Central Statistics Office (CSO) in
Ireland recently reported a slight increase in the volume of bar
sales between 2004 and 2005.20
Given the smoke-free policies in
Ireland, a study of air pollution in Irish pubs globally provides
an opportunity to assess the effectiveness of comprehensive
smoke-free laws. The purpose of the study was to examine indoor air
quality in a global sample of smoke-free and smoking-permitted
Irish pubs. It was hypothesized that RSP levels, an important
marker of secondhand smoke, would be significantly lower in
smoke-free Irish pubs than in those pubs that allow smoking.
Overview
Between January 21, 2004 and March 10,
2006, air quality was assessed in 128 Irish pubs in 15 countries.
The pubs were located in the Republic of Ireland, the United
States, Canada, Australia, Northern Ireland, France, Lebanon,
Belgium, Poland, Greece, Germany, China, England, Romania, and
Armenia; Testing sites were conveniently selected by tobacco
control professionals in their respective cities. Irish pubs were
defined as those that served Irish beer on tap, and had an Irish
name (e.g. Murphy's, O'Donnell's) or a visible statement that the
venue was an Irish pub (e.g. exterior or interior sign with terms
such as "Irish pub"). Testing was completed in smoking and
smoke-free pubs on all the days of the week from afternoon onwards.
Some pubs were individually-owned establishments and some were part
of local or national chain entities.
Smoke-free Irish pubs were located in 3
cities and 1 town in the Republic of Ireland, (Cork, Galway,
Dublin, Ennis), 2 cities in Canada (Toronto, Waterloo), and 9 US
cities (Appleton, Austin, Bethesda, Bloomington, Boston, Buffalo,
Hartford, Providence, New York City). Smoking-permitted pubs were
located in 13 countries and 38 cities including Armenia (Yerevan),
Australia (Sydney), Northern Ireland (Belfast, Newry), Germany
(Berlin), Greece (Athens), Lebanon (Beirut), France (Lyon, Paris),
Belgium (Brussels, Charleroi, Leige), Poland (Torun, Warsaw), China
(Beijing), Romania (Bucharest), the United States (Arlington,
Atlanta, Baltimore, Chapel Hill, Charleston, Chicago, Denver,
Durham, Galveston, Hoboken, Houston, Indianapolis, Lakewood,
Louisville, Manchester, Santa Fe, St. Paul, Philadelphia, Phoenix,
Washington, D.C.) and England (London, Manchester) (see Figure
1).
Measurement
Protocol
A standard measurement protocol was
used by data collectors across study sites. Establishments were
tested for a minimum of 30 minutes. The number of people inside the
venue and the number of burning cigarettes were recorded every 15
minutes during sampling. These observations were averaged over the
time inside the venue to determine the average number of people on
the premises and the average number of burning cigarettes. For most
establishments, a sonic measure (Zircon Corporation, Campbell, CA)
was used to measure room dimensions and hence the volume of each of
the venues. When using the sonic measure to calculate room
dimensions was not possible, room measurements were made through
estimation.
Figure 1. Locations of Irish
pubs sampled
A TSI
SidePak AM510 Personal Aerosol Monitor (TSI, Inc., St. Paul, MN)
was used to sample and record the levels of respirable suspended
particles (RSPs) in the air. The SidePak uses a built-in sampling
pump to draw air through the device where the particulate matter in
the air scatters the light from a laser to assess the real-time
concentration of particles smaller than 2.5μm in micrograms per
cubic meter, or PM2.5. The SidePak was calibrated against a laser
photometer, which had been previously calibrated and used in
similar studies. In addition, the SidePak was zerocalibrated prior
to each use by attaching a HEPA filter according to the
manufacturer's specifications. The equipment was set to a
one-minute log interval, which averages the previous 60 onesecond
measurements. Sampling was discreet in order not to disturb the
occupants' normal behavior. For each pub, the first and last minute
of logged data were removed because they are averaged with outdoors
and entryway air. The remaining data points were averaged to
provide an average PM2.5 concentration within the
venue.
Statistical
Analyses
The primary goal was to assess the
difference in the average levels of PM2.5 in a
cross-sectional sample of smoke-free and smoking-permitted Irish
pubs, which was assessed with the independentsamples t-test.
Descriptive statistics including the venue volume, number of
patrons, and average smoker density (i.e. number of burning
cigarettes per 100 m3) are also reported for each pub
and averaged for all pubs. The active smoker density was calculated
by dividing the average number of burning cigarettes by the volume
of the room in cubic meters (m3).
Results
Table 1 provides a summary of the data
collected in 128 Irish Pub including 25 authentic Irish pubs in the
Republic of Ireland, 14 in non-smoking US cities, and 2 in Toronto,
Canada. Eighty-seven smoking-permitted pubs were visited in 20 US
cities, and 18 cities in other countries including Armenia,
Northern Ireland, Greece, Germany, Lebanon, France, Belgium,
Poland, China, England, Romania, and Australia. It should be noted
that some cities will be subject to upcoming changes in smoking
policies in their respective cities (London, Manchester (UK),
Belfast, Newry, Hoboken, St Paul, Sydney).
The average size of the 128 pubs was
935 m3, with the smoke-free pubs being on average
smaller than smoking-permitted pubs (427 m3 vs. 1070
m3). The average number of patrons present during
sampling was 59, and consistent with their smaller size, the
smoke-free pubs had fewer people on average than the
smoking-permitted pubs (50 vs. 64).
Table 1. Summary of Each Irish
pub Visited By Country and City
*Limited ban (i.e., smoking
is banned only in stand-alone restaurants or eating establishments
that derive less than 25% of sales from alcohol)
**Statewide complete ban to be implemented spring
2006.
***Citywide complete ban to be implemented March 31,
2006, winter 2007, and summer 2008, accordingly.
****Nationwide complete ban to be implemented in
2007.
Note: This data is to be interpreted cautiously. Testing sites
were selected on a convenience basis and may not be representative
of pubs in each
locality.
As shown in Figure 2, 87 pubs allowed
smoking, and the average PM2.5 level in these pubs was 340
µg/m3 (SD = 270.4) ranging from 33 to 1320
µg/m3. The average PM2.5 level in the 41 smoke-free pubs
was 23 µg/m3 (SD = 18.0) ranging from 3 to 96
µg/m3.
The level of indoor air pollution was
93% lower in the pubs that were smoke-free compared to those where
smoking was permitted. The difference between the mean RSP levels
was statistically significant (t = -10.881, df = 88),
p<.001.
Figure 3 shows the average air
pollution levels found in Irish pubs in the Republic of Ireland
compared to those outside Ireland where smoking is permitted. The
average PM2.5 level in authentic Irish pubs was 29µg/m3.
The level of indoor air pollution was 91% lower in the Republic of
Ireland's pubs than in US and international smoking- permitted pubs
(340µg/m3).
Figure 4 shows the average air
pollution levels found in Irish pubs across world regions. The
average PM2.5 level in smoke-free Irish pubs in the U.S./Canada (14
µg/m3), and the Republic of Ireland (29
µg/m3) are significantly lower than levels in
smoking-permitted pubs in the U.S. (271 µg/m3), other
nations (China, Australia, Armenia, Lebanon) (328
µg/m3), Northern Ireland (375 µg/m3), and
Europe (504 µg/m3).
Figure 5 shows the average indoor air
pollution level in each of the 87 smoking pubs tested. Average
PM2.5 levels in smoke-free pubs and smoking pubs ranged from 3 to
96 µg/m3 and 33 to 1320 µg/m3, respectively.
While the average level in all of the smoking-permitted pubs is 15
times higher than in smoke-free pubs Figure 5 shows that many pubs
were much higher, with levels in excess of EPA standards. The EPA
annual (15µg/m3) and 24-hour (65 PM2.5 µg/m3)
exposure limits were exceeded by 100% and 95% of the
smoking-permitted pubs, respectively.
The average smoker density was much
greater in the smoking permitted pubs (n = 87) (1.69 burning
cigarettes per 100 m3) compared to the smoke-free
locations (0.00 burning cigarettes per 100 m3). No
smoking was observed in any of the pubs with smoke-free policies.
As shown in Figure 6, average PM2.5 levels were
significantly positively correlated (r = 0.43, p < 0.01) with
smoker density. Variation in amounts of ventilation (e.g. air
conditioning, open doors/windows) may influence PM2.5
levels. Testing did not control for ventilation or smoke that may
have migrated from outdoors where smokers tend to smoke.
Discussion
This study demonstrates that national
and subnational smoking policies have dramatically improved indoor
air quality in a sample of international Irish pubs. Indoor air
quality testing indicated that, on average, levels of PM2.5 in
smoke-free Irish pubs (23 µg/m3) were 93% lower compared
to smoking-permitted Irish pubs (340 µg/m3). These
findings are consistent with other US studies that have examined
changes in air quality to evaluate the impact of smoking
legislation.14-16 Studies conducted in the Republic of
Ireland have shown similar reductions in small
particles17 as well as air nicotine
concentrations.21 The absence of smokers in smoke-free
pubs indicates that workplace owners and patrons are complying with
these laws, across the world.
Other studies have directly assessed
the health effects of SHS exposure. One study found improvements in
respiratory health among bartenders after the implementation of a
statewide smoking ban,22 and another study reported
reductions in acute myocardial infarctions in patients admitted to
a hospital after the implantation of a local smoking
ban.23 An examination of SHS exposure among workers
following Ireland's comprehensive ban showed significant reductions
in air nicotine and saliva cotinine.21 Respiratory
health studies in Ireland have shown results similar to California
as well as dramatic reductions in exhaled carbon monoxide and
ambient Benzene levels post the smoking ban.24 According
to Repace et al. (2006), RSPs are correlated with biological
markers for exposure (e.g. nicotine, cotinine) which can be used to
predict adverse health outcomes.25 These results further
confirm that these laws effectively reduce SHS exposure and can
provide health benefits, worldwide.
Many US states and foreign countries
have implemented policies for smoke-free workplaces including
restaurant and pubs. The countries that currently have indoor
smoking bans that cover pubs include: Ireland, Bhutan, Malta,
Norway, Sweden, Italy, New Zealand and most recently, England
(effective 2007), Scotland (upcoming), Northern Ireland (effective
2007) and Uruguay. U.S. states with smoke-free laws in workplaces
including pubs are: California, Connecticut, Delaware, Maine,
Montana (2009), New Jersey (April, 2006), New York, Massachusetts,
Rhode Island, Utah (2009), Vermont, Washington. Washington DC and
Puerto Rico have also passed such laws. Washington DC will extend
to cover bars in January, 2007. Many U.S. communities have adopted
local smoke-free laws. As of January 2006, 28% of the US population
was covered by local or state-wide smoke-free bar laws, and almost
40% of the population was covered by any smoke-free law (i.e.
workplace, restaurant, bar).26
There are limitations to this study.
Convenience samples of Irish pubs and locations were used and thus,
findings may not be representative of all Irish pubs. SHS is not
the only source of indoor levels of PM2.5 and other
sources such as ambient particle concentrations, cooking, and
migration of tobacco smoke pollution from outside could contribute
to overall levels of indoor air pollution. We would expect,
however, that other sources would be present in both smoke-free and
smoking-permitted pubs and thus, differences in average
PM2.5 are largely attributable to SHS.
Conclusions
Irish pubs in the Republic of Ireland
and smoke-free "Irish pubs" elsewhere are significantly less
polluted than "Irish pubs" that permit smoking. These findings
underscore the importance of comprehensive smoke-free policies.
National and subnational policies that prohibit smoking in public
worksites, including restaurants and pubs, dramatically reduce
secondhand smoke exposure and improve the health of workers and
patrons.
Acknowledgements
Support for this study was provided in
part by grants from the Flight Attendant Medical Research Institute
and the U.S. National Cancer Institute (TTURC-P50 CA111236). In
addition support was given by the Health Service Executive- West,
PCCC, Galway, Republic of Ireland.
The authors wish to acknowledge the
following individuals with appreciation for their contribution in
making this project successful:
Chris Tholkes & Barbara Schillo,
Minnesota Partnership for Action Against Tobacco
Robyn Myszka, Minnesota Institute for Public Health
Ms Wendy Oakes, Tobacco Control Manager, The Cancer Council New
South Wales
Rhea Staniszewski and Donna Viverette, Denver, Colorado
Miranda Spitznagle, Indiana Tobacco Prevention and Cessation
(ITPC)
Natalie Linos, Stephanie Meredith Chace, Stephanie Weiss, Harvard
School of Public Health
Amy Barkely, Campaign for Tobacco Free Kids
Mike Kuntz, American Lung Association
Steve Houston, Smoke Free Louisville
Stephanie Uliana and Paul Kiser
Barbara A. Schillo, Director of Research Programs MPAAT
Krzysztof Przewozniak, Poland
Nan Savage, Frances Gannon, Richard Fitzgerald, Tony
Christie,Catherine Dunne,
Marie McCaffrey of various Environmental Health Departments in the
Republic of Ireland
Julia Valdez, American Heart Association, Director of Government
Affairs
Cheryl A. Ferguson, Albuquerque, NM
Philip Huang, Department of State Health Services, Austin,
TX
Meg Gallogly, Ben Needham, Erika Schlachter & Danny
McGoldrick, Tobacco Free Kids,
Adrian Watson, Manchester Metropolitan University
Connie Olson, Appleton, Wisconsin
Jiang Yuan, Kang Ji Ming, & Li Zhu, The International Tobacco
Control (ITC) Policy Evaluation
(Project China Team)
Geoffrey T. Fong, Taryn Sendzik, Matthew Sendzik - The
International Tobacco Control (ITC) Policy
Evaluation (Project Canada Team)
Julea Steiner, North Carolina
Justin Turner, Arizona
Dan Carrigan, Smoke Free Lowcountry Campaign
Stephannie Thacker, MPH Student, Florida International
University
Matthew J. Carpenter, Medical University of South Carolina
Department of Psychiatry
Cindy L. Carter, Medical University of South Carolina Hollings
Cancer Center
Heather Giles, Community Volunteer
Narine Movsisyan, Armenia
Ioana Munteanu and Florin Mihaltin, Romania
Sylviane Ratte and Christelle Nieraad, France
Isabelle Convié, Belgium
Paul Mowery Atlanta
Cheryl Higbee, Roswell Park Cancer Institute
*A special thanks to Carolyn
Dresler, IARC who organized international monitoring conducted
through Roswell Park Cancer Institute.
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