Smoke free policies- evaluating the effectiveness

HIGHLIGHTSF R O M

I N T E R N AT 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 RW O R L D H E A LT H O R G A N I Z AT I O N

P R E S E N T E R

DR. RAJEEV KASHYAP

Evaluating the Effectiveness

of Smoke-free Policies

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SHS exposure lasts considerably longer than the act of smoking. No safe level of SHS exposure has been identified.

(SHS – Second hand smoke)

Dr.Rajeev Kashyap B.Sc.,B.D.S., M.Sc.,(DPH)U.K

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


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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.


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Scientific evidence has unequivocally established

thatexposure to tobacco smoke causesdeath, disease and disability


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“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)


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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


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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.


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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)


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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)


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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.


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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).


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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)


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Measurements of ambient nicotine concentrations have confirmed that current ventilation systems are insufficient to eliminate SHS from indoor air.

(Repace & Lowrey, 1993)


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Need for policies to protectnon-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,


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“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


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•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.


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Measurement of SHS

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


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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


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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.


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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.


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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


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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.


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“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.


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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.Dr.Rajeev Kashyap B.Sc.,B.D.S., M.Sc.,

(DPH)U.K

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Respiratory disease

Reduction of lung function.Factor causing and exacerbating both chronic

obstructive pulmonary disease (COPD) and asthma


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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”


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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.


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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 lawPublic education to reduce second-hand

smoke exposureImplementation and adequate enforcement

of the policyDr.Rajeev Kashyap B.Sc.,B.D.S., M.Sc.,(DPH)U.K

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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.


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T OB A C C O C O N T R O LE VA LUAT I N G T H E E F F E C T I V E N E SS

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I N T E R N AT 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 LT H O R G A N I Z AT I O N

REFERENCE


Smoke free policies- evaluating the effectiveness

Education