Research on Smoke-Free Research on Smoke-Free Environment in Malaysia: Environment in Malaysia:

Evidence for PolicyEvidence 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 PresentationOutline of Presentation IntroductionIntroduction

Research evidence on exposure to Research evidence on exposure to secondhand smoke secondhand smoke

Implications for policyImplications for policy

Prevalence of Passive Smoking in Malaysia

Passive SmokingPassive Smoking (defined as nonsmoker (defined as nonsmoker exposed to someone else cigarette smoke for exposed to someone else cigarette smoke for at least 15 minutes each exposure for at least at least 15 minutes each exposure for at least 3 days in last week):3 days in last week):

- 26.8% of 834 youth surveyed (13 - 17 years of - 26.8% of 834 youth surveyed (13 - 17 years of age)age)

- 21.5% of nonsmoking adults 18 years and - 21.5% of nonsmoking adults 18 years and above (n= 7,240) above (n= 7,240)

- 23.8% of adult females and 18.7% adult males- 23.8% of adult females and 18.7% adult males

Source: 3rd National Health and Morbidity Survey (Household Survey), (MOH 2008)Source: 3rd National Health and Morbidity Survey (Household Survey), (MOH 2008)

Recent Research Related to Recent Research Related to Smoke-free EnvironmentSmoke-free Environment

1. Evaluating exposure to secondhand 1. Evaluating exposure to secondhand smoke (SHS)/ tobacco smoke pollution smoke (SHS)/ tobacco smoke pollution (TSP) by measuring air quality of PM(TSP) by measuring air quality of PM2.5 2.5 (concentrate of particulate matter in the air (concentrate of particulate matter in the air smaller than 2.5 microns in diameter)smaller than 2.5 microns in diameter)

2. Risks for respiratory and sensory 2. Risks for respiratory and sensory symptoms among non-smoking restaurant symptoms among non-smoking restaurant workers exposed to secondhand smoke in workers exposed to secondhand smoke in the workplacethe workplace

Measuring Air Quality Cigarettes, cigars and pipes are major Cigarettes, cigars and pipes are major

emitters of respirable suspended emitters of respirable suspended particles (RSP) less than 2.5 microns particles (RSP) less than 2.5 microns (PM(PM2.52.5) in diameter) in diameter

RSP of this size are easily inhaled RSP of this size are easily inhaled deep into the lungs, and are associated deep into the lungs, and are associated with pulmonary and cardiovascular with pulmonary and cardiovascular disease and mortality*disease and mortality*

*US Environmental Protection Agency, Fine Particle (PM 2.5) Designations.

Why PM2.5? 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 PM2.5 exposure and 65 g/m3 as the 24-hours exposure in order to protect the public health.TSI SidePak AM510

Personal Aerosol Monitor

Study on Indoor Air Pollution in Study on Indoor Air Pollution in Different WorkplacesDifferent Workplaces

Objective

To determine exposure to tobacco smoke pollution through testing of indoor air quality in selected venues.

MethodsSampling 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

Data analysis Comparing average levels of RSP of Comparing average levels of RSP of

smoke-free venues (no smoking smoke-free venues (no smoking observed during sampling) and smoking observed during sampling) and smoking venues (smoking was observed during venues (smoking was observed during sampling)sampling)

Levels of Air Pollution in 4 Bars in Kuala Lumpur

181

46

527

32

417

37

0

100

200

300

400

500

600PM

2.5

in m

icro

gram

s pe

r cub

ic m

eter

Penang (n=50) Kuala Lumpur(n=103)

Total (n=153)

Figure 1: Average Fine Particle Air Pollution

Smoking Smoke-free

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)

165

28

680

284

35 47 38

0

100

200

300

400

500

600

Pm2.

5 in

mic

rogr

ams

per

cubi

c m

eter

Restaurant(n=9 smoking,10 smoke-free)

Bar (n=56) EntertainmentOutlets (n=20smoking, 5smoke-free)

Other (n=1smoking, 2smoke-free)

Figure 2 : Average Fine Particle Air pollution by Type of Venue in Kuala Lumpur

SmokingSmoke-free

61 71

402

129

17

0

100

200

300

400

500

600

PM2.

5 in

moc

rogr

ams

per

cubi

c m

eter

Restaurant (n=11smoking, 5 smoke-

free)

Bar (n=11) Other (n=16 smoking, 3smoke-free)

Figure 3 : Average Fine Particle Air Pollution by Type of Venue in Penang

SmokingSmoke-free

PM2.5 Standards to Protect Public Health

The U.S. Environmental Protection Agency (EPA) has set 15 g/m3 as the average annual level of PM2.5 exposure limit and 65 g/m3 as the 24-hours exposure limit in order to protect the public health.

US EPA Air Quality IndexAir Quality Air Quality

Index PM2.5

(g/m3) Health Advisory

Good 0-50 ≤15 None.

Moderate 51-100 16-40 Unusually sensitive people should consider reducing prolonged or heavy exertion.

Unhealthy forSensitive 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.

VeryUnhealthy 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.

Key Findings Venues that permit smoking have Venues that permit smoking have

significantly higher levels of tobacco significantly higher levels of tobacco smoke pollution than smoke-free venues smoke pollution than smoke-free venues

Bars/pubs/discos are the most polluted (at Bars/pubs/discos are the most polluted (at hazardous level)hazardous level)

This study demonstrates that workers and This study demonstrates that workers and patrons are exposed to harmful levels of a patrons are exposed to harmful levels of a known carcinogen and toxin. known carcinogen and toxin.

Study on risks of respiratory and sensory symptoms

among non-smoking restaurant workers exposed to secondhand

smoke in the workplace

Study Objectives To determine exposures to To determine exposures to

secondhand smoke (SHS) among non-secondhand smoke (SHS) among non-smoking restaurant workerssmoking restaurant workers

To identify presence of respiratory and To identify presence of respiratory and sensory symptoms in the last 30 days sensory symptoms in the last 30 days (short-term health effects)(short-term health effects)

To determine the association between To determine the association between SHS exposure at the workplace and SHS exposure at the workplace and reports of respiratory and sensory reports of respiratory and sensory symptomssymptoms

Methods 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

Measures 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±3.0Cafes 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) 0.69Cough 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) 0.07Any 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

Sensory SymptomsNot 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*

Adjusted Odds Ratios (OR) for Sensory Symptoms in the Last Month

* Statistically significant at p<0.05

Key Findings Key Findings 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

Key FindingsKey Findings 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.

Policy Recommendations 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.

Thank You