Smoke free policies- evaluating the effectiveness

HIGHLIGHTS
F R O M
I N T E R N A T I O N A L A G E N C Y F O R R E S E A R C H O N C A N C E R
W O R L D H E A L T H O R G A N I Z A T I O N
P R E S E N T E R
DR. RAJEEV KASHYAP
Evaluating the Effectiveness
of Smoke-free Policies

SHS exposure lasts considerably longer than
the act of smoking. No safe level of SHS
exposure has been identified.
(SHS – Second hand smoke)
2Dr.Rajeev Kashyap B.Sc.,B.D.S., M.Sc.,(DPH)U.K

A key intervention in reducing the burden
of disease attributable to tobacco use is
protecting people from exposure to second
hand tobacco smoke (SHS).

Cancer Prevention presents the evidence on the
effectiveness of measures enforced at the societal
level to eliminate tobacco smoking and tobacco
smoke from the environments where exposure
takes place.

Scientific evidence has unequivocally established
that
exposure to tobacco smoke
causes
death, disease and disability

“Adopt and implement… effective
legislative, executive,
administrative and/or other
measures, providing for protection
from exposure to tobacco smoke in
indoor workplaces, public
transport, indoor public places and,
as appropriate, other public places.”
(WHO, 2005)

164 countries have ratified the WHO
FCTC (Framework Convention on
Tobacco Control) and more are expected
to do so in the future.
As a result, countries around the world
are working towards designing,
implementing, and enforcing legal
measures aimed at creating 100%
smoke-free environments in public and
workplaces

IARC, which is part of the World Health
Organization, coordinates and conducts research
on the causes of human cancer and the mechanisms
of Carcinogenesis, and develops scientific strategies
for cancer control.

Secondhand smoke
 Non-smokers (and smokers) become exposed to SHS
when they breathe this contaminated air.
 In addition to carcinogens, SHS contains compounds
such as pyridine that produce unpleasant odors
(National Cancer Institute, 1999), and particles such as
nicotine, acrolein, and formaldehyde that cause
mucosal irritation (Lee et al., 1993).
 However, the degree to which non-smokers will notice
and respond to SHS exposure is related to the age of the
exposed person, their olfactory acuity, as well as their
annoyance threshold (U.S. Department of Health and
Human Services, 2006)
9
Dr.Rajeev Kashyap B.Sc.,B.D.S., M.Sc.,(DPH)U.K

Secondhand smoke: the problem
 SHS is defined as the smoke emitted either from the
burning end of a tobacco product or by the exhalation of
smoke-filled air by a smoker, both of which contain known
human carcinogens.
(IARC,2004)
 The ambient air in the immediate environment of a smoker
quickly becomes contaminated with carbon monoxide; large
quantities of particulate matter, as well as nitrogen oxides;
several substances recognised as human carcinogens, such as
formaldehyde, acetaldehyde, benzene, and nitrosamines; and
possible human carcinogens, such as hydroquinone and
cresol.
(IARC,2004)
10

Exposure to SHS
 Exposure to air that is not smoke free will lead to the
uptake of SHS contaminants.
 The dose of SHS contaminants that reach a target organ
determines the risk of disease to that organ in the non-
smoker, as well as the smoker.
 The amount of exposure to a non-smoker will vary with
both the concentration of SHS in the ambient air and
with the time that the individual spends in contact with
it.
 Ventilation and air cleaning have been
advocated as possible ways of reducing the
exposure of non-smokers to SHS.
11

Dose of SHS contaminants
 The dose of SHS contaminants that a non-smoker
receives varies with the number of cigarettes smoked
per unit of time in an area, and is inversely
proportional to the intensity of ventilation and the
rate of cleaning or removal of SHS components from
the air (Ott, 1999).
12

Ventilation and air cleaning
 In most homes, ventilation occurs by a natural
exchange of indoor and outdoor air.
 However, public and commercial buildings generally
have systems for ventilation and air exchange. These
heating, ventilating, and air conditioning systems
often distribute SHS throughout a building in the
process of air exchange, thereby potentially
magnifying the number of non-smokers who are
exposed to SHS.
(U.S. Department of Health and Human Services, 2006)
13

 Measurements of ambient nicotine concentrations
have confirmed that current ventilation systems are
insufficient to eliminate SHS from indoor air.
(Repace & Lowrey, 1993)
14

Need for policies to protect
non-smokers
 Unlike many indoor pollutants that cause disease, exposure to
SHS can be completely prevented by removing the source -
tobacco smoke.
 This requires public policy. Early steps have focused on
banning smoking from areas in which smokers and non-
smokers might congregate.
 An example was seen in 1970 when the World Health
Assembly banned smoking in meeting rooms (WHO, 1970).
By 1975, a number of countries had banned smoking in
hospitals and schools, public transport, libraries, theatres, and
concert halls. By the end of the 1980s, some countries had
even banned smoking in government offices.
 The first jurisdiction to mandate a smoke-free workplace was
California, where most workplaces were legislated to be
smoke-free by 1995,
15

“Smoke-free”
 Under the FCTC, “smoke-free” air
means that a non-smoker will not be
able to see, smell, or sense tobacco
smoke, nor will components of tobacco
smoke be able to be measured in the
air.
FCTC :Framework Convention for Tobacco Control
16

•A landmark event for the protection of non-smokers
from SHS occurred when WHO agreed to negotiate
and promote a Framework Convention for Tobacco
Control (FCTC).
•The first big success was that this treaty was
negotiated in 2003 and ratified by so many member
nations.
•The second success was that the WHO FCTC
developed evidence-based model language for smoke-
free legislation, which is embodied in Article 8.

Measurement of SHS
 The most common methods of measurement of SHS
exposure are :
 Self-reported questionnaires,
 Atmospheric markers, and
 Biomarkers of exposure within individuals.
18

Self-reported questionnaires
 Measuring exposure to SHS by self reported questionnaires
is a method frequently used in studies, whether the
exposure data are collected retrospectively or prospectively.
Self reported measures can be useful for determining if any
SHS exposure has taken place and for determining the
location of exposure.
(Borland et al., 1992; Matt et al., 1999)
 However, they have limitations because of respondents’
inability to accurately assess and then recall the duration
and intensity of SHS exposure, or of ventilation or air
conditioning practices in a particular environment.
(U.S. Department of Health and Human Services, 2006).
 More credibility is given to self-reported exposure in the home than to
exposure in other multiple locations
19

Individual biomarkers
 An individual’s exposure to SHS can be assessed
objectively using the same biomarkers as are used for
assessing active smoking.
 Biomarkers should be zero among people unexposed
to tobacco smoke; any detectable level indicates
exposure.
 The change in nicotine, cotinine, and NNAL (4-
Nnitrosomethylamino)- 1-(3-pyridyl)-1- butanol
(NNAL) - a potent tobacco specific carcinogen are
sensitive to even short-term exposure.
20

Atmospheric markers
 The level of SHS in an environment is commonly
measured by concentrations of either airborne
nicotine or particulate matter (PM). About 95% of
the nicotine in SHS is in the vapour phase
(Leaderer & Hammond, 1991)
 Vapour-phase nicotine in the air can be passively
collected in a sorbent tube or a filter treated with
sodium bisulphate, and then analysed by gas
chromatography.
 PM is defined as solid particles or liquid droplets
suspended in the atmosphere.
21

Particulate matter (PM) or Airborne nicotine
 PM is produced primarily from combustion processes
originating from many different indoor and outdoor
sources, including cooking and heating appliances and
combustion engines.
 The rate of deposition of PM increases with the square of
the particle diameter for particles >1 μm. (Hinds, 1982)
 Therefore, larger particles (over 5 μm in diameter) tend
to remain suspended for shorter periods, while smaller
particles (submicrometric) can remain suspended for
hours or even days.
(Institute of Medicine, 2001)
 Although PM is not a specific marker of SHS, the amount of PM
pollution generated by smoking can be extremely high in indoor
environments
22

Health effects of exposure to secondhand smoke
 Exposure to SHS adversely affects the health of
children and adults.
 The inhalation of this mixture of irritant, toxic
particles, and gases has respiratory effects, as well as
effects on other organ systems, including causing
coronary heart disease (CHD) in adults and sudden
infant death syndrome (SIDS) in infants.
 There has been extensive research on mechanisms by
which SHS causes these adverse effects.
23

“Children exposed to second hand smoke are at increased risk for
•Sudden infant death syndrome (SIDS),
•Acute respiratory infections,
•Ear problems and
•Severe asthma.
•Smoking by parents causes respiratory symptoms and slows lung
growth in their children”
•The many adverse effects of SHS, beyond the causation of cancer,
strengthen the rationale for achieving smoke-free environments,
including not only public and workplaces, but homes, so as to ensure
that children are protected from exposure to SHS.
The epidemiological evidence and relevant research findings related to
the plausibility of causal associations of SHS with respiratory and
cardiovascular effects.

Associations between active smoking and
fatal and nonfatal CHD
 Active cigarette smoking is considered to increase the
risk of cardiovascular disease by promoting
atherosclerosis; affecting endothelial cell functioning;
increasing the tendency to thrombosis; causing spasm of
the coronary arteries, which increases the likelihood of
cardiac arrhythmias; and decreasing the oxygen-carrying
capacity of the blood.(U.S. Department of Health and Human Services, 1990).
 These same mechanisms have been considered to be
relevant to SHS exposure and risk for CHD (Barnoya & Glantz,
2005)
 Experimental studies support the relevance of these
mechanisms (U.S.Department of Health and Human Services, 2006).
 Among women exposed to SHS, a 24% increased risk of
stroke was found compared with those unexposed.
25

Respiratory disease
 Reduction of lung function.
 Factor causing and exacerbating both chronic
obstructive pulmonary disease (COPD) and asthma
26

Secondhand smoke (SHS) and cancer
 Carcinogenicity of tobacco smoke became a focus of
research in the first decades of the 20th century.
 The potential for tobacco smoke inhaled by non-
smokers to cause disease was first considered in the
US Surgeon General’s report in 1972.
 Epidemiological research addressed adverse effects
of smoking in the home on the health of children. In
1981, published reports from Japan. (Hirayama, 1981)
 IARC concluded that “passive smoking gives rise to
some risk of cancer”
27

Burden of disease
 Because of widespread exposure to SHS and the
numerous adverse consequences of exposure, the
impact on the health of children and adults is
substantial.
 Making such estimations requires assumptions
about exposure patterns and the risks of SHS-related
diseases applicable to particular populations.
 The estimates are made with the assumptions of
causal associations of SHS exposure with stroke and
chronic respiratory disease, in addition to lung
cancer and ischemic heart disease.
28

Smoke-free policies
On July 3, 2007, the 2nd Conference of the Parties
to the WHO FCTC approved unanimously the
guidelines
WHO FCTC guidelines on protection from
exposure to tobacco smoke
 100% Smoke-free environments, not smoking
rooms
 Universal protection by law
 Public education to reduce second-hand smoke
exposure
 Implementation and adequate enforcement of
the policy
29

Recommendations should be considered
 The guidelines for implementation of WHO FCTC Article
8 should be followed wherever possible, as these are
evidence-based from different approaches to tobacco
control and have been shown to have all the necessary
detail to minimise exposure of the citizenry to SHS and
its harmful consequences.
 2. Passing a policy is only one part of the process of
protecting a population from exposure to SHS; both
public education and enforcement efforts are
necessary when the smoke-free policy is implemented.
 3. The need for enforcement efforts usually decreases
after the policy becomes established, when it typically
becomes self-enforcing.
30

T O B A C C O C O N T R O L
E V A L U A T I N G T H E E F F E C T I V E N E S S
O F S M O K E - F R E E P O L I C I E S
I N T E R N A T I O N A L A G E N C Y F O R R E S E A R C H O N
C A N C E R
W O R L D H E A L T H O R G A N I Z A T I O N
REFERENCE
31

Smoke free policies- evaluating the effectiveness

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