Research on Smoke-Free Environment in Malaysia: Evidence for Policy Foong Kin, Ph.D. National Poison Centre Universiti Sains Malaysia Paper presented at the Third Malaysian Conference on Tobacco Control, 8-9 August 2009, held at UKKMMC, Cheras
Outline of Presentation
Research evidence on exposure to secondhand smoke
Implications for policy
Prevalence of Passive Smoking in Malaysia
Passive Smoking (defined as nonsmoker exposed to someone else cigarette smoke for at least 15 minutes each exposure for at least 3 days in last week):
- 26.8% of 834 youth surveyed (13 - 17 years of age)
- 21.5% of nonsmoking adults 18 years and above (n= 7,240)
- 23.8% of adult females and 18.7% adult males
Source: 3rd National Health and Morbidity Survey (Household Survey), (MOH 2008)
Recent Research Related to Smoke-free Environment
1. Evaluating exposure to secondhand smoke (SHS)/ tobacco smoke pollution (TSP) by measuring air quality of PM 2.5 (concentrate of particulate matter in the air smaller than 2.5 microns in diameter)
2. Risks for respiratory and sensory symptoms among non-smoking restaurant workers exposed to secondhand smoke in the workplace
Measuring Air Quality
Cigarettes, cigars and pipes are major emitters of respirable suspended particles (RSP) less than 2.5 microns (PM 2.5 ) in diameter
RSP of this size are easily inhaled deep into the lungs, and are associated with pulmonary and cardiovascular disease and mortality*
*US Environmental Protection Agency, Fine Particle (PM 2.5) Designations.
Why PM 2.5 ?
Very sensitive marker of SHS or Environmental Tobacco Smoke (ETS)
Can monitor and record data in real time
Relatively inexpensive equipment
- The EPA, USA has set standards of 15 g/m3 as the average annual level of PM 2.5 exposure and 65 g/m 3 as the 24-hours exposure in order to protect the public health. TSI SidePak AM510 Personal Aerosol Monitor
Study on Indoor Air Pollution in Different Workplaces
To determine exposure to tobacco smoke pollution through testing of indoor air quality in selected venues.
50 venues in Penang and 103 venues in Kuala Lumpur were selected for the study, 2006/7
Venues included air-conditioned restaurants, bars, discotheques, cafes, hotels, entertainment outlets (snooker, game centres) and other venues (internet cafes).
Sampling was discreet in order not to disturb the occupants’ normal behaviour. The monitor was generally located in a central location on a table or bar and not on the floor so that air being sampled was within the occupants’ normal breathing zone
Comparing average levels of RSP of smoke-free venues (no smoking observed during sampling) and smoking venues (smoking was observed during sampling)
Levels of Air Pollution in 4 Bars in Kuala Lumpur
Level of air pollution in smoking venues are 11 times greater than that in non-smoking venues; in Penang (4 times); KL (16.5 times)
PM 2.5 Standards to Protect Public Health
The U.S. Environmental Protection Agency (EPA) has set 15 g/m3 as the average annual level of PM 2.5 exposure limit and 65 g/m3 as the 24-hours exposure limit in order to protect the public health.
US EPA Air Quality Index Air Quality Air Quality Index PM 2.5 ( g/m 3 ) Health Advisory Good 0-50 ≤ 15 None. Moderate 51-100 16-40 Unusually sensitive people should consider reducing prolonged or heavy exertion. Unhealthy for Sensitive Groups 101-150 41-65 People with heart or lung disease, older adults, and children should reduce prolonged or heavy exertion. Unhealthy 151-200 66-150 People with heart or lung disease, older adults, and children should avoid prolonged or heavy exertion. Everyone else should reduce prolonged or heavy exertion. Very Unhealthy 201-300 151-250 People with heart or lung disease, older adults, and children should avoid all physical activity outdoors. Everyone else should avoid prolonged or heavy exertion. Hazardous ≥ 301 ≥ 251 People with heart or lung disease, older adults, and children should remain indoors and keep activity levels low. Everyone else should avoid all physical activity outdoors.
Venues that permit smoking have significantly higher levels of tobacco smoke pollution than smoke-free venues
Bars/pubs/discos are the most polluted (at hazardous level)
This study demonstrates that workers and patrons are exposed to harmful levels of a known carcinogen and toxin.
Study on risks of respiratory and sensory symptoms among non-smoking restaurant workers exposed to secondhand smoke in the workplace
To determine exposures to secondhand smoke (SHS) among non-smoking restaurant workers
To identify presence of respiratory and sensory symptoms in the last 30 days (short-term health effects)
To determine the association between SHS exposure at the workplace and reports of respiratory and sensory symptoms
A cross-sectional study
A total of 203 non-smoking restaurant workers were recruited from 72 air-conditioned restaurants in Penang
Subjects were interviewed face-to-face using a structured questionnaire
Self-reported exposures to secondhand smoke in the workplace
Reported respiratory symptoms in the last 30 days (wheezing, shortness of breath, cough in morning or night and phlegm)
Reported sensory symptoms in the last 30 days (red or irritated eyes, running nose, sneezing, painful or scratchy throat)
Reported Smoking Policy By Type of Venue Type of Restaurant Smoking not allowed in any indoor area (%) Smoking is allowed in some indoor area (%) Smoking allowed everywhere (%) Total (%) Family restaurant (n=36) 61.1 22.2 16.7 100.0 Fast food restaurant (n=5) 100.0 - 100.0 Fine dining restaurant (n=19) 84.2 10.5 5.3 100.0 Bar/pub (n=6) 100.0 100.0 Cafes (n=6) 100.0 100.0
Reported Exposure to Secondhand Smoke in the Workplace by Type of Restaurant (% reported Yes) Type of Restaurant n % reported exposure Mean Duration of Exposure to Secondhand Smoke Per Day (in hours) Family restaurant 102 71.6 0.7 ±1.0 Fast food restaurant 57 35.1 1.0±0.8 Fine dining restaurant 56 51.8 1.7±1.3 Bar/pub 16 100.0 6.5±3.0 Cafes 14 78.6 0.8±0.6
Reported Exposure to Secondhand Smoke
60.8% (n=149) reported exposure to SHS in the workplace in the last 7 days
32% (n=78) reported exposure in home
Adjusted Odds Ratios (OR) for Respiratory Symptoms in the Last Month Respiratory Symptoms Not exposed to SHS in Workplace Exposed to SHS in Workplace p-value % OR % OR (95% CI) Wheezing or whistling in the chest 2.1 1 8.7 4.49 (0.99-20.4) 0.051 Shortness of breath 10.4 1 12.1 1.18 (0.52-2.68) 0.69 Cough during day or night 29.2 1 33.6 1.23 (0.70-2.14) 0.47 Phlegm 16.7 1 26.8 1.83 (0.96-3.51) 0.07 Any respiratory symptom 37.5 1 49.3 1.62 (0.96-2.74) 0.07 Rhinitis 4.7 1 3.1 0.654 (0.16-2.59) 0.55
Adjusted Odds Ratios (OR) for Sensory Symptoms in the Last Month * Statistically significant at p<0.05 Sensory Symptoms Not exposed to SHS in Workplace Exposed to SHS in Workplace p-value % OR % OR (95% CI) Red or irritated eyes 9.4 1 17.4 2.04 (0.91-4.57) 0.08 Running nose, sore nose or sneezing 33.3 1 41.6 1.43 (0.83-2.43) 0.19 Painful or scratchy throat 25.0 1 38.3 1.86 ( 1.05-3.28) 0.03* Any sensory symptom 46.9 1 61.7 1.83 (1.09-3.07) 0.02*
Majority of workers in the hospitality industry were exposed to SHS in the workplace on a daily basis.
Most restaurants have partial bans and did not comply with the regulation by having enclosed smoking rooms with ventilators
Bar workers were most exposed to SHS in the workplace
We found positive associations between workplace SHS exposure and the presence of respiratory symptoms.
Exposure to SHS was significantly associated with presence of sensory symptoms.
Malaysian government should legislate and implement 100% smoke-free environments.
Legislate and implement total smoking ban in restaurants and bars to protect worker and patron health.