Smoke free policies- evaluating the effectiveness

Evaluating the Effectiveness
of Smoke-free Policies
HIGHLIGHTS
FROM
INTERNATIONAL AGENCY FOR RESEARCH ON CANCER
WORLD HEALTH ORGANIZATION
PRESENTER

DR. RAJEEV KASHYAP

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

2

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

3

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.


4

Scientific evidence has
unequivocally established

that
exposure to tobacco smoke
causes
death, disease and
disability

5

“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

6

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

7

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.

8

Secondhand smoke
9

 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)

Secondhand smoke: the problem
10

 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)

Exposure to SHS
11

 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 nonsmoker, 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.

Dose of SHS contaminants
12

 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).


Ventilation and air cleaning
13

 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)


14

 Measurements of ambient nicotine concentrations

have confirmed that current ventilation systems are
insufficient to eliminate SHS from indoor air.
(Repace & Lowrey, 1993)


Need for policies to protect
non-smokers
15

 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 nonsmokers 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,

“Smoke-free”
16

 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

•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 for17smoke-free

Measurement of SHS
18

 The most common methods of measurement of SHS

exposure are :




Self-reported questionnaires,
Atmospheric markers, and
Biomarkers of exposure within individuals.


Self-reported questionnaires
19

 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

Individual biomarkers
20

 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 (4Nnitrosomethylamino)- 1-(3-pyridyl)-1- butanol
(NNAL) - a potent tobacco specific carcinogen are
sensitive to even short-term exposure.

Atmospheric markers
21

 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.

Particulate matter (PM) or Airborne nicotine
22

 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


Health effects of exposure to secondhand smoke
23

 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.


“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. B.Sc.,B.D.S., M.Sc.,(DPH)U.K
Dr.Rajeev Kashyap
24

Associations between active smoking and
fatal and nonfatal CHD
25

 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.

Respiratory disease
26

 Reduction of lung function.
 Factor causing and exacerbating both chronic

obstructive pulmonary disease (COPD) and asthma


Secondhand smoke (SHS) and cancer
27

 Carcinogenicity of tobacco smoke became a focus of

research in the first decades of the 20th century.
 The potential for tobacco smoke inhaled by nonsmokers 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”

Burden of disease
28

 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.

Smoke-free policies
29

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

Recommendations should be considered
30

 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.

REFERENCE
31
TOBACCO CONTROL
EVALUATING THE EFFECTIVENESS
OF SMOKE-FREE POLICIES
INTERNATIONAL AGENCY FOR RESEARCH ON
CANCER
WORLD HEALTH ORGANIZATION


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