Download Air Nicotine Monitoring Protocol

MONITORING SECONDHAND SMOKE EXPOSURE IN PUBLIC PLACES IN INDIA:
RESEARCH PLAN
A. BACKGROUND AND SIGNIFICANCE
Secondhand smoke (SHS), a complex mixture of gases and particles that contains many
carcinogenic and toxic compounds (1-3), results from tobacco smoking indoors. Over the last 30
years, a substantial body of evidence has accumulated demonstrating adverse effects to children
and adults from prolonged exposure to SHS. As the evidence has accumulated, comprehensive
reviews of the evidence by expert panels have been undertaken and have provided causality
judgments based on guidelines for interpreting the evidence. Evidence now supports causal
conclusions on acute and chronic adverse effects across the lifespan, including lung cancer and
coronary heart disease in adults and respiratory symptoms and delayed lung growth in children
(4).
As a result of the causal link between SHS exposure and acute and chronic health effects,
policies aimed at eliminating SHS exposure indoors will have direct benefits to public health.
Creation of smoke-free environments has been shown to reduce smoking prevalence and
frequency among employees (5) and, as part of a comprehensive tobacco control strategy, has
been shown to reduce overall smoking prevalence (6). Monitoring of secondhand smoke (SHS)
exposure in indoor environments can provide critical information to (a) document the
distribution and extent of SHS exposure in order to estimate health risk to those who are
exposed; (b) motivate policy and monitor compliance and enforcement with existing regulations;
and (c) monitor trends, compare buildings, cities, and regions, and evaluate the impacts of
policies and interventions aimed at reducing SHS in indoor air.
SHS exposure can be characterized by several approaches, including the use of
questionnaires or direct observation, personal and area air monitoring, or biomarkers.
Questionnaires are relatively easy to implement but do not provide quantitative estimates of SHS
exposure, specifically in public places where there may be many people smoking at the same
time and with differing patterns over time. Biomonitoring is a useful approach for characterizing
personal exposure to SHS, but does not provide information on the amount of exposure obtained
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from working or visiting specific locations. Additionally, biomonitoring is not always feasible
because it is potentially invasive and cultural barriers may exist. Environmental monitoring, a
non-invasive approach, is particularly useful to document and quantify the presence of SHS
exposure indoors. Specific components of SHS that can be measured in air include particulate
matter, nicotine, polycyclic aromatic hydrocarbons, carbon monoxide, acrolein, and nitrogen
dioxide. Airborne nicotine has commonly been used to monitor SHS exposure because (a) it is
specific to tobacco smoke (and can be considered a surrogate for exposure to the mixture of
chemicals found in SHS) and (b) it requires a relatively simple and inexpensive passive filter
sample.
In the proposed study, environmental measurements will be used to characterize SHS
exposure in key indoor places in India. India is the second most populous country in the world
and has a prevalence of tobacco use that has been reported to exceed 50 percent in men (7). As a
result, a large burden of disease and premature death can be attributed to tobacco use and SHS
exposure. Smoke-free initiatives, as well as enforcement of such policies, will continue to be a
critical part of comprehensive tobacco control programs to reduce SHS exposure and, ultimately,
tobacco consumption. This proposed approach will provide a baseline characterization of SHS
exposure in public workplaces in India, which will be used to promote clean indoor air policies
and programs and monitor and evaluate the progress of ongoing and future smoke-free initiatives
in India.
B. PURPOSE AND OBJECTIVES
PURPOSE
To conduct monitoring of secondhand smoke (SHS) exposure in public places across India.
OBJECTIVES

To measure levels of indoor air nicotine in public places (hospitals, schools, governmental
offices, restaurants, and bars/nightclubs) in different cities in India.

To identify factors associated with different levels of indoor air nicotine (e.g. city, building
type, smoking restriction policies, building characteristics)
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
To establish baseline levels of SHS exposure to support more progressive smoke-free
policies and to monitor and evaluate progress towards a Smoke-Free India.
C. STUDY DESIGN
a. Study design
A cross sectional exposure survey will be conducted using area monitoring.
b. Study population
Cities: Several cities in India will be included in the monitoring study.
Buildings: The following places will be selected in each city:
-
Hospitals: Hospitals are critical places for the introduction of smoke-free workplaces and
environments in a country. The monitoring of hospitals may serve to increase public
awareness of the contradiction between smoking in health care settings and the health
goals of medical institutions. In addition, health care workers represent an important
proportion of the workforce; they belong to a range of socioeconomic status and play a
special exemplary role in society. Finally, smoke-free hospitals are a sign of respect
towards the patient and offer a good opportunity for smoking patients to consider
quitting.
-
Secondary schools: The relevance of studying SHS exposure in schools derives from the
importance of protecting children from the effects of passive smoking, responding to
parental concerns, and, in the case of adolescents, helping to prevent the initiation of
tobacco consumption. Finally, as for health care workers, educational workers represent a
large group of the workforce in any country and they also play a special role in the
society as educators and role models. Consequently, they must be one of the first
occupational groups to implement and enforce smoke-free workplaces.
-
Governmental offices: A smoke-free environment in public institutions is a prerequisite
to expand this policy to other workplaces. The public administration must lead the
initiative of protecting the individuals from the long-term effects of passive smoking at
work.
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-
Bars and restaurants: These are places where SHS exposure is generally very high, and
may thus present a considerable health risk for workers in these occupations.
c. Sampling Strategy
Several approaches may be taken for the selection of buildings for the monitoring study. The
selection of a random sample is ideal, in which all the buildings of a certain type in a city are
enumerated and randomly sampled from. In many settings, building enumeration may not be
feasible or there may be a lack of access to some locations or other logistical constraints. A
convenience sample of buildings may be used if enumeration of all buildings (e.g., restaurants
and bars) in a city is not possible. Further, there may be specific sentinel locations of interest,
such as a hospital that is particularly revered or that serves a particular segment of the
population.
D. DATA COLLECTION
The proposed study to estimate SHS exposure in India employs passive air monitoring of
public places. All monitoring of a particular building will occur over a 5 to 7 day period (5 days
for office environments). Figure 1 shows the overall timeline for passive air nicotine sampling
for a 7-day time window. More detail on the specific data to be collected over this period of time
is described below.
Figure 1. Data collection timeline for air monitoring in a building.
Day 1
Day 3 - 4
• Administer building
questionnaire
• Visit building to ensure
monitors are in place
• Retrieve air nicotine
monitors
• Place air nicotine monitors
• Fill out observations on
sampling sheet
• Fill out observations on
sampling sheet
• Fill out observations on
sampling sheet
SHS Monitoring in India
Day 7
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Building Characteristics
The characteristics of each establishment will be collected from the following sources:
Interview/Questionnaire. The responsible authority of each building will be interviewed
and information on general characteristics of the building will be collected, including the type of
ventilation systems and the smoking policy (including total smoking ban or partial smoking
restrictions).
Air Nicotine Monitoring
Secondhand smoke will be estimated by passive sampling of vaporphase nicotine using a filter badge treated with sodium bisulfate (8).
Sampling locations will be selected to represent the areas where people
frequently work or occupy. This will include the common area of the
building where people congregate and spend time, along with additional
areas where smoking may be likely to occur. For consistency, sampling
Nicotine monitor
locations within a building should be pre-specified. Table 1 describes the proposed sampling
locations for the present study, along with the number of buildings, number of samples per
location, and the sampling time.
Table 1. Number of buildings, number of monitors, location of the monitors, and the
sampling time for each of the places selected in each city in the study.
Sampling
Places (number)
Location of monitors
Number of samples1
time
Hospital (5)
ER waiting room
1
1 week
Doctor’s lounge
1
Patient floors*
2
Cafeteria**
2
subtotal: 30 (+6)
Secondary
Cafeteria**
2
1 week
schools (5)
Teachers’ lounge
1
(Mon-Fri)
Students’ bathroom (boys/girls)
2
Stairwells
1
subtotal: 30 (+5)
City government Working offices*
2
1 week
(5)
Lobby
1
(Mon-Fri)
Cafeteria**
2
Bathrooms (male/female)
2
subtotal: 35 (+6)
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Restaurants (10)
Smoking area
Non-smoking area
(or main dining room if no
restriction policy)
Entertainment
Smoking area
[Bars/Clubs] (10) Non-smoking area
(or main bar area if no restriction
policy)
Total (35)
1
1
subtotal: 20 (+4)
1 week
1
1
subtotal: 20 (+4)
1 week
135 (+25 quality control)
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10% of blank samples and 5-10% of duplicate samples for quality control purposes (in these cases the two monitors
are placed side by side). They will be randomly selected within each type of location, and the exact number of
quality control samples is shown between parentheses.
*Patient floors and working offices refer to common spaces not individual rooms or offices. Offices shared by 3 or
more people is acceptable.
**If there is a designated smoking area, place one monitor in the smoking and non-smoking area. Otherwise, place
the monitors in two different areas of the cafeteria.
Before placing the monitors, a letter containing basic information about the project must be
sent to the main responsible authority of each building. Permission to participate will be required
at all locations. A model of the letter will be provided.
The monitor will be left in place for five or seven days (Table 1), with the monitor filter
facing into the room being sampled. The following guidance should be used for placement of the
monitor in the room:

Hang the monitor in the air, 1-2 meters from the floor.

Hang monitors at least 1 meter away from an open window or a ventilation system.

Hang monitors at least 1 meter away from a potential regular smoker.

Do not hang monitors in an area where air does not circulate (i.e. “dead spots”), such as a
corner, under a shelf, or on curtains.

Ensure monitors are not too visible or accessible to avoid people tampering with them.

Some good places can be beams, nails or even plants or lamps.
Sample Sheet
The placement of the monitors within a building will be identified using a simple diagram
that also indicates the location of the windows and doors that open outdoor. The monitors should
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be clearly labeled with a permanent marking. Location, date and time of each monitor placement
will be recorded on a sampling sheet that will be completed at the time when the monitors are
installed (sample sheet will be provided). The approximate room volume in cubic meters will be
estimated by measuring the height, length and width of the room. We will inspect whether there
is a designated smoking area and the presence of “no smoking” or “smoking” signs will be
noted.
All buildings will be visited once during the monitoring period, preferably on a day and time
of maximum occupancy. During this visit the field worker will verify the correct placement of
the sampler and denote the condition of the windows and doors (open or closed), the location of
the air monitor, the functioning of ventilation systems, compliance with smoking restrictions, the
estimated occupancy of the room, and the number of smokers observed during a 15-minute
period (these data will be collected on the first and last day of sampling as well).
Once sampling is complete, the monitor will be returned to the plastic cup and be closed
securely into place. The date and time of removal must be recorded on the sample sheet. At the
end of the sampling, the coordinator will check that the labels are correct and will store the
monitors in a smoke-free place at room temperature in preparation for transportation to the
laboratory. Once all the air samples have been collected, the samples will be transported to the
Exposure Assessment Facility at the Johns Hopkins Bloomberg School of Public Health
(JHSPH) for the analysis of nicotine content.
Quality Control
For quality assurance and control purposes a fixed random sampling procedure will be used
to collect at least one blank sample for each 10 samples. In addition collection of duplicate
samples will occur for 5-10% of the total sample. The normal and duplicate monitors will be
located in the same place. The blank samples must be handled exactly the same as the rest of the
samples but will not stay in the public place, and they will be sent with the others to be analyzed.
Blanks will be used to determine blank-corrected nicotine concentrations and to calculate the
method limit of detection. Spike samples will also be analyzed by the laboratory. Field personnel
will be responsible for ensuring that samples are consistently collected according to the protocol
and are not tampered with. A detailed field work manual will be provided, along with training of
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field workers in data collection. A summary of the items needed prior to commencing fieldwork
is shown below.
Prior to fieldwork, the following items are needed:

The list of buildings for monitoring and permission from the appropriate authority (a
model of the letter will be provided).

The exact location of sampling places within each building (the location for blank and
duplicate measurements will be identified by a random sampling procedure).

The monitors labeled and coded (a field work manual will be provided, which describes
the coding and labeling of monitors).

Sampling sheets to collect the information corresponding to each monitor (including the
location of the monitor, total amount of time, location characteristics, occupancy and
number of smokers in the room).

Building questionnaires to be asked of the building manager or other responsible
authority.
E. LABORATORY ANALYSIS
Time weighted average airborne nicotine will be assayed at the
Exposure Assessment Facility at JHSPH. Once in the laboratory, the
filters will be removed from the cassette, and the nicotine and bisulfate
Gas-chromatograph
will be desorbed in water. The nicotine is then extracted and
concentrated into a heptane solution, which is then injected into a gas chromatograph (see
figure), with nitrogen selection to increase the sensitivity. The airborne concentration of nicotine
will be calculated by dividing the amount of nicotine collected by each filter (µg) by the volume
of air sampled (m3). The volume of air sampled is equal to the total of sampling minutes
multiplied by the flow rate (the flow rate depends on the filter used and it remains unaltered
unless there are big temperature changes).
F. DATA ANALYSIS
Descriptive statistics (e.g., frequencies, means, medians, and interquartile ranges) will be
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used to address the main objectives of this survey, characterizing SHS exposure in a sample of
indoor environments in different cities in India. Box plots of air nicotine concentrations on a
logarithmic scale will also be produced to compare SHS exposure between building types,
building characteristics, and smoking and non-smoking areas in buildings. Regression models
will be used to identify factors associated with indoor air nicotine concentration, such as city,
building type, smoking restriction policies, and other building characteristics. Data will be
presented in a format that will be easily accessible and understandable to key stakeholders.
G. CONFIDENTIALITY
All information collected will be kept confidential and detailed information, such as names of
establishments will not be shared with outside parties. Findings will be used only for research
and public health purposes, not for legal purposes. The names of buildings will be coded and
monitors will be linked only to building type. The data collected will be presented only in
aggregate and will be used to highlight the significance of SHS exposure and the need to develop
and enforce strong smoke-free policies.
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REFERENCES:
1. US Department of Health and Human Services (USDHHS). The health consequences of
smoking - chronic obstructive lung disease. A report of the Surgeong General. Washington
DC: US Government Printing Office, 1984.
2. Jenkins RA, Guerin MR, Tomkins BA. The chemistry of environmental tobacco smoke:
composition and measurement. Washington DC: Lewis Publishers, 2000.
3. Guerin MR, Jenkins RA, Tomkins BA. The chemistry of environmental tobacco smoke:
composition and measurement. Chelsea, Michigan: Lewis Publishers, Inc., 1992.
4. U.S.Department of Health and Human Services. The Health Consequences of Involuntary
Exposure to Tobacco Smoke: A Report of the Surgeon General. 2006. U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, Coordinating
Center for Health Promotion, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health.
Ref Type: Report
5. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour:
systematic review. Br Med J 2002;325:188.
6. Decline in smoking prevalence--New York City, 2002-2006. MMWR
Morb.Mortal.Wkly.Rep 2007;56:604-8.
7. Report on Tobacco Control in India. Reddy, K. S. and Gupta, P. C. 2004. Ministry of
Health & Family Welfare, Government of India.
Ref Type: Report
8. Hammond SK, Leaderer BP. A Diffusion Monitor to Measure Exposure to Passive
Smoking. Environmental Science & Technology 1987;21:494-7.
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