Biomarkers of Secondhand Smoke Exposure in Waterpipe Tobacco Venue Employees in Istanbul, Moscow, and Cairo

Background

Most smoke-free legislation to reduce secondhand smoke (SHS) exposure exempts waterpipe (hookah) smoking venues. Few studies have examined SHS exposure in waterpipe venues and their employees.

Methods

We surveyed 276 employees of 46 waterpipe tobacco venues in Istanbul, Moscow, and Cairo. We interviewed venue managers and employees and collected biological samples from employees to measure exhaled carbon monoxide (CO), hair nicotine, saliva cotinine, urine cotinine, urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and urine 1-hydroxypyrene glucuronide (1-OHPG). We estimated adjusted geometric mean ratios (GMR) of each SHS biomarker by employee characteristics and indoor air SHS measures.

Results

There were 73 nonsmoking employees and 203 current smokers of cigarettes or waterpipe. In nonsmokers, the median (interquartile) range concentrations of SHS biomarkers were 1.1 (0.2, 40.9) µg/g creatinine urine cotinine, 5.5 (2, 15) ng/mL saliva cotinine, 0.95 (0.36, 5.02) ng/mg hair nicotine, 1.48 (0.98, 3.97) pg/mg creatinine urine NNAL, 0.54 (0.25, 0.97) pmol/mg creatinine urine 1-OHPG, and 1.67 (1.33, 2.33) ppm exhaled CO. An 8-hour increase in work hours was associated with higher urine cotinine (GMR: 1.68, 95% CI: 1.20, 2.37) and hair nicotine (GMR: 1.22, 95% CI: 1.05, 1.43). Lighting waterpipes was associated with higher saliva cotinine (GMR: 2.83, 95% CI: 1.05, 7.62).

Conclusions

Nonsmoking employees of waterpipe tobacco venues were exposed to high levels of SHS, including measurable levels of carcinogenic biomarkers (tobacco-specific nitrosamines and PAHs).

Implications

Smoke-free regulation should be extended to waterpipe venues to protect nonsmoking employees and patrons from the adverse health effects of SHS.

Arsenic in groundwater in private wells in rural North Dakota and South Dakota: Water quality assessment for an intervention trial

Elevated exposure to arsenic disproportionately affects populations relying on private well water in the United States (US). This includes many American Indian (AI) communities where naturally occurring arsenic is often above 10 µg/L, the current US Environmental Protection Agency safety standard. The Strong Heart Water Study is a randomized controlled trial aiming to reduce arsenic exposure to private well water users in AI communities in North Dakota and South Dakota. In preparation for this intervention, 371 households were included in a community water arsenic testing program to identify households with arsenic ≥10 µg/L by inductively coupled plasma mass spectrometry (ICP-MS). Arsenic ≥10 µg/L was found in 97/371 (26.1%) households; median water arsenic concentration was 6.3 µg/L, ranging from <1-198 µg/L. Silica was identified as a water quality parameter that could impact the efficacy of arsenic removal devices to be installed. A low-range field rapid arsenic testing kit evaluated in a small number of households was found to have low accuracy; therefore, not an option for the screening of affected households in this setting. In a pilot study of the effectiveness of a point-of-use adsorptive media water filtration device for arsenic removal, all devices installed removed arsenic below 1 µg/L at both installation and 9 months post-installation. This study identified a relatively high burden of arsenic in AI study communities as well as an effective water filtration device to reduce arsenic in these communities. The long-term efficacy of a community based arsenic mitigation program in reducing arsenic exposure and preventing arsenic related disease is being tested as part of the Strong Heart Water Study.

Factors that influence attitude and enforcement of the smoke-free law in Turkey: a survey of hospitality venue owners and employees

INTRODUCTION

In 2009, Turkey extended the smoke-free legislation to hospitality venues. Compliance, however, remains low in some hospitality venues. We identified characteristics associated with knowledge of health effects that can be prevented by the smoke-free law, the attitude towards and enforcement of the law.

METHODS

In 2014, we conducted 400 interviews with hospitality venue owners and employees in 7 cities in Turkey. The venues were identified based on a random sampling strategy in a previous phase of the study.

RESULTS

Over one-third (37.3%) of hospitality owners and employees had adequate knowledge of the health effects from secondhand smoke (SHS), 71.3% had a positive attitude towards the law and 19.5% had personally enforced the law. Participants who worked 70 hours or more per week were more likely to have a positive attitude towards the law. Older individuals, women, participants working in bars/nightclubs, venue owners receiving fines for non-compliance and current smokers were less likely to have a positive attitude towards the law. Participants working in traditional coffee houses, former smokers, and participants with a high school education or greater were more likely to enforce the law. Smokers who quit or reduced smoking because of the law were more likely to enforce the law compared with those who were not influenced by the law.

CONCLUSIONS

Although the attitude towards the law was positive, interventions are needed to increase knowledge on the health effects of SHS and facilitate enforcement of the law, particularly among subgroups less likely to have a positive attitude and enforce the law.

Compliance with smoke-free legislation within public buildings: a cross-sectional study in Turkey

Objective

To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey.

Methods

Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts.

Findings

Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9–570.8 and aOR: 165.4; 95% CI: 98.0–279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3–0.8.

Conclusion

Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs.

Secondhand smoke in waterpipe tobacco venues in Istanbul, Moscow, and Cairo

OBJECTIVE

The prevalence of waterpipe tobacco smoking has risen in recent decades. Controlled studies suggest that waterpipe secondhand smoke (SHS) contains similar or greater quantities of toxicants than cigarette SHS, which causes significant morbidity and mortality. Few studies have examined SHS from waterpipe tobacco in real-world settings. The purpose of this study was to quantify SHS exposure levels and describe the characteristics of waterpipe tobacco venues.

METHODS

In 2012-2014, we conducted cross-sectional surveys of 46 waterpipe tobacco venues (9 in Istanbul, 17 in Moscow, and 20 in Cairo). We administered venue questionnaires, conducted venue observations, and sampled indoor air particulate matter (PM2.5) (N=35), carbon monoxide (CO) (N=23), particle-bound polycyclic aromatic hydrocarbons (p-PAHs) (N=31), 4-methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) (N=43), and air nicotine (N=46).

RESULTS

Venue characteristics and SHS concentrations were highly variable within and between cities. Overall, we observed a mean (standard deviation (SD)) of 5 (5) waterpipe smokers and 5 (3) cigarette smokers per venue. The overall median (25th percentile, 75th percentile) of venue mean air concentrations was 136 (82, 213) µg/m(3) for PM2.5, 3.9 (1.7, 22) ppm for CO, 68 (33, 121) ng/m(3) for p-PAHs, 1.0 (0.5, 1.9) ng/m(3) for NNK, and 5.3 (0.7, 14) µg/m(3) for nicotine. PM2.5, CO, and p-PAHs concentrations were generally higher in venues with more waterpipe smokers and cigarette smokers, although associations were not statistically significant.

CONCLUSION

High concentrations of SHS constituents known to cause health effects indicate that indoor air quality in waterpipe tobacco venues may adversely affect the health of employees and customers.