factors affecting exhaled carbon monoxide levels in coffeehouses in the western black sea region of...

http://tih.sagepub.com/Toxicology and Industrial Health

http://tih.sagepub.com/content/27/3/195The online version of this article can be found at:

DOI: 10.1177/0748233710383888

2011 27: 195 originally published online 21 September 2010Toxicol Ind HealthTalat Bahcebasi, Hayati Kandis, Davut Baltaci and Ismail Hamdi Kara

TurkeyFactors affecting exhaled carbon monoxide levels in coffeehouses in the Western Black Sea region of

Published by:

http://www.sagepublications.com

can be found at:Toxicology and Industrial HealthAdditional services and information for

http://tih.sagepub.com/cgi/alertsEmail Alerts:

http://tih.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://tih.sagepub.com/content/27/3/195.refs.htmlCitations:

What is This?

- Sep 21, 2010 OnlineFirst Version of Record

- Mar 30, 2011Version of Record >>

at UNIVERSITY OF WINDSOR on November 15, 2014tih.sagepub.comDownloaded from at UNIVERSITY OF WINDSOR on November 15, 2014tih.sagepub.comDownloaded from

http://tih.sagepub.com/

http://tih.sagepub.com/content/27/3/195

http://www.sagepublications.com

http://tih.sagepub.com/cgi/alerts

http://tih.sagepub.com/subscriptions

http://www.sagepub.com/journalsReprints.nav

http://www.sagepub.com/journalsPermissions.nav

http://tih.sagepub.com/content/27/3/195.refs.html

http://tih.sagepub.com/content/27/3/195.full.pdf

http://tih.sagepub.com/content/early/2010/09/20/0748233710383888.full.pdf

http://online.sagepub.com/site/sphelp/vorhelp.xhtml



Factors affecting exhaled carbonmonoxide levels in coffeehouses in theWestern Black Sea region of Turkey

Talat Bahcebasi1, Hayati Kandis2, Davut Baltaci3, and_Ismail Hamdi Kara3

AbstractThe aim of this study was to evaluate indoor air quality and factors affecting expired carbon monoxide (CO)levels in a coffeehouse environment. This cross-sectional study was conducted at 16 randomly selectedcoffeehouses in Duzce, Turkey, during November 2007 to March 2008. A total of 547 people, average age46.72 + 17.03 (19–82) years, participated. The selected coffeehouses were divided into four groups: (1) smok-ing, (2) nonsmoking, (3) old-style and (iv) new-style coffeehouses. Prior to entering the coffeehouse, exhaledCO levels in smokers (mean 21.17 + 6.73 parts per million [ppm]) were significantly higher than those fornonsmokers (6.51 + 4.56 ppm; p < 0.001). Measurements taken after 2 hours in the coffeehouse also showedsignificantly higher CO concentrations for smokers (22.72 + 5.31 ppm), compared to nonsmokers (6.51 +4.56 ppm; p < 0.001). It was determined that CO levels inside coffee shops were above the WHO guidelines.Exhaled CO levels in nonsmokers are influenced by the ambient CO levels as a result of the use of cigarettes incoffeehouses in addition to the structure of coffeehouses.

KeywordsCoffeehouse, carbon monoxide, smoking, expired air, indoor air, building structure, environmental health

Introduction

Carbon monoxide (CO) has long been known to be

one of the factors polluting indoor air. The health

effects of exposure to CO are generally described

relative to carboxyhaemoglobin (COHb) levels

(Madany, 1992). The most important impact of CO

on health is its strongly binding with hemoglobin,

which leads to reduced oxygen capacity of blood.

Carbon monoxide poisoning has its most acute toxic

effects on the organs with the highest oxygen require-

ments: the heart and the brain. Thus, individuals with

ischemic heart disease are at particularly high risk

(USEPA, 1991).

In healthy subjects, endogenous production of car-

bon monoxide results in COHb levels of 0.4%–0.7%.

The COHb levels in nonsmoking general populations

are usually 0.5%–1.5%, owing to endogenous produc-

tion and environmental exposures. Nonsmokers in

certain occupational conditions (car drivers, police-

men, traffic wardens, garage and tunnel workers, fire-

men, etc.) can have long-term COHb levels of up to

5%, but heavy cigarette smokers have COHb levels

of up to 10%. In nonsmoking individuals unexposed

to environmental CO, blood COHb levels are usually

around 0.5% (Lambert, 1997). According to the World

Health Organization (WHO) guidelines determined in

2000, the acceptable maximum CO exposure levels

are 100 mg/m3 (90 ppm) for 15 minutes, 60 mg/m3 for

30 minutes, 30 mg/m3 for 1�3 hours, and 10 mg/m3 for

3�8 hours (WHO, 2000a). Individuals engaging in

heavy exercise in polluted indoor environments can

1 Medical Faculty, Public Health Department, Duzce University,Duzce, Turkey2 Medical Faculty, Emergency Medicine Department, DuzceUniversity, Duzce, Turkey3 Medical Faculty, Family Medicine Department, DuzceUniversity, Duzce, Turkey

Corresponding author:Talat Bahcebasi, Medical Faculty, Public Health Department,Duzce University, Duzce, TurkeyEmail: [email protected]

Toxicology and Industrial Health27(3) 195–204ª The Author(s) 2011Reprints and permission:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0748233710383888tih.sagepub.com

at UNIVERSITY OF WINDSOR on November 15, 2014tih.sagepub.comDownloaded from


increase their COHb levels quickly up to 10%–20%. In

indoor ice arenas, epidemic carbon monoxide poison-

ings have recently been reported (WHO, 2000b).

Coffeehouses are found widely spread in Turkey as

well as other Middle Eastern countries and these are

places where only adult men are allowed to join cof-

feehouse activities (generally above 18). It is free to

smoke in coffeehouses. In other words, these are

places where men get together, and social, cultural

and even economical relations are experienced. In

winter months, the time spent in coffeehouses espe-

cially during evening hours are much longer. The

Province of Duzce is located in the Western Black Sea

region. In Duzce, outdoor air pollution can develop

very easily due to geo-topographical structure sur-

rounded by mountains which prevent sufficient air

circulation. In Duzce, the majority of the male popu-

lation (the total population is 323,328 and 160,823 of

it are male) are older than 18, which is the legal age

for entry to the coffeehouses, and is 107,882 in total

(TSSI, 2002). In all, 734 coffeehouses are present in

Duzce, which includes 326 cities and 418 villages

(FTC, 2006). In Duzce, coffeehouses are located in

attached or detached buildings, which always have a

closed area (some have outdoor areas in summer) with

a capacity of 10 to 100 people and these are busi-

nesses run by legal permits. In almost all of the cof-

feehouses in Duzce, stoves are used as heaters;

wood, coal, hazelnut shells, and gas oil are used as

fuel. However,liquid petrol gas (LPG) is generally

used in cooking for tea and coffee (Bekler and

Simsek, 2004).

After the earthquake, not only the building materi-

als but also building style and architectural design

were completely changed. Old buildings were perme-

able for air flow, however, newer buildings are not

permeable for air flow because of design for heat and

air isolation (more important) and used materials

(quality of cement and plastic materials etc.); there-

fore, CO levels in old style coffeehouses are very low

when compared to the newer ones (Bekler and Sim-

sek, 2004; Bahcebasi et al., 2007).

The aim of this study is to measure ambient CO

levels that people are exposed to in coffeehouses and

to determine the factors influencing individual

expired CO levels during their stay in coffeehouses.

Materials and methods

This study was performed during the winter months

(November 2006�March 2007). Informed consents

were obtained from coffeehouse managers and

individuals before participating in this study.

Two forms were developed to use in the study. In

the first form, information about the coffeehouse was

recorded and in the second one, measurements and

information such as individual’s personal history,

habits, demographic characteristics, etc. were

recorded. Throughout the study, the same people and

same measuring instruments were used. Measure-

ments were repeated at least twice, in 2-minute inter-

vals. The measurement was repeated a third time

when discrepancy was seen between the initial two

measurements, and the average of the three measure-

ment were considered as the final value. Measurement

tools were calibrated on a daily basis before starting

the study. Prior to the main study, a number of pilot

experiments were completed to confirm the suitability

of the sampling and analytical procedures that had

been proposed for the main study.

Studies were carried out in 16 coffeehouses of

Duzce during the busiest hours of 19:00�23:00. The

selected coffeehouses were divided into four groups:

(i) smoking, (ii) nonsmoking, (iii) old-style and

(iv) new-style coffeehouses. Four groups were

formed based on whether smoking was allowed and

which construction materials were used in the cof-

feehouses where the studies were carried out: Group

A, built with old construction materials and smoking

not allowed; Group B, built with old construction

materials and smoking is allowed; Group C, built

with new construction materials and smoking not

allowed, Group D, built with new construction mate-

rials and smoking allowed, each group consisted of

four coffeehouses.

Male individuals who had been going to coffee-

houses continuously for at least 3 months have not

been to the coffeehouse earlier during the day of the

study, and those declared that they would stay for at

least 2 hours daily, 3�4 days in a week were included

in the study. People who went to the coffeehouse

before the study hours were not included in the study.

Individuals’ demographic features, age, educational

status, occupational group, smoking status, and alco-

hol intake were recorded.

Measurement technique

Indoor CO measurement. Indoor CO level was

measured with a portable CO meter device, Fluke

CO-220 (2009). The detector mechanism of the

device works with an electrochemical sensor and

196 Toxicology and Industrial Health 27(3)



shows the result as a ppm value. It can perform

measurements with 1 ppm resolution and + 2 ppm

accuracy within a 0�200 ppm range at 0�50�C. It has

self time of below 20 seconds and response time

under 30 seconds. By using this device, indoor CO

level was measured 70 cm far away from individual

and at height of 1.5 meter from ground, before not

measuring expired CO level of individual at once.

Individual expired CO level measurement. Individual

expired CO levels were measured using portable

Vitalograph Breath CO Carbon Monoxide Monitor

(2009). The device is a gas-specific (CO) electroche-

mical sensor; it can measure CO levels of 0�199 ppm

at 0�38�C, with a display resolution (confidence) of

1 ppm, and a measuring accuracy of + 3 ppm. The

subject should take a deep breath in, hold this for as

long as possible and then breath out slowly and stea-

dily through the mouthpiece over a period of around

20 seconds (evidence). Before the person enters into

the coffeehouse, we take the person into a resting

room, contiguous to coffeehouse, which has indoor

CO level measured as 0 with CO meter device. He

is left for 5 minutes there. We measured expired CO

level of individual in this room. After allowing the

person to the coffeehouse, twice measurements were

taken at 1-hour intervals.

Temperature measurement. Temperature measure-

ments were carried out with a digital Celsius thermo-

meter (EasyViewTM K Type Thermometer, 2009).

Measurement range was 0�1000�C with + (0.3%þ 1�C) accuracy and +0.1�C reliability.

Statistical analysis

Statistical analysis was conducted using SPSS 15.0

program. In this study, descriptive analysis of data

was conducted. In order to analyze the distribution

of parameter values, Kolmogorov Smirnov two-

sample test was used. Nonparametric tests were used

on values that were not appropriate for parametric

analysis. When comparing values from two groups,

independent samples t test was used for parametric

values and Wilcoxon two-sample test was used to

compare nonparametric values. To compare values

repeated within a group, parametric paired

samples test was used. In order to conduct variance

analysis to compare measurement from more than two

groups, parametric one-way analysis of variance

(ANOVA) was used. To analyze the effective

group, Post Hoc Multiple Comparisons Sidak

ANOVA test and nonparametric Kruskal-Wallis

ANOVA test were used. Nonparametric nepar

correlation was used to look for the relationships of

variables to one another. In the modeling conducted

to determine the effective factor, Curve Estimation

logistic model was used. p Values of <0.05 was con-

sidered to be statistically significant. Data was sum-

marized as mean + SD.

Results

Individual characteristics

There were 547 people participating in the study and

their average age was 46.72 + 17.03 (19–82) years.

Occupations of participants were as follows: 125

(22.9%) farmers; 105 (19.2%) retirees; 74 (13.5%)

workers; 67 (12.2%) unemployed; 63 (11.5%)

artisans; 48 (8.8%) officers; 36 (6.6%) students;

and 29 (5.3%) other occupations. No statistically

significant difference was found in individuals’ pre-

ferences of coffeehouse group based on their occu-

pation (p > 0.05).

A total of 334 (61.1%) of the participants went to

coffeehouses for 6�7 days per week; 286 (52.3%)

of the people who went to the coffeehouse throughout

the day have stayed there for about 2 hours and others

stayed for even longer amounts of time. Of the people

who participated in the study, 296 (54.1%) were

active smokers. A significant difference was deter-

mined between choices of coffeehouse groups based

on smoking status (w2 ¼ 110.13, p < 0.001). A signif-

icant difference was also observed in the choice of

coffeehouses of 296 smokers, based on the amount

and the duration of smoking (p ¼ .003 and p < .001).

Ambient CO levels in coffeehouse groups

In all measurements taken in the coffeehouses, ambient

CO levels were determined to be minimum 2 ppm and

maximum 31 ppm. CO levels of indoor air at the entry

to the coffeehouse were the lowest in Group A (mean

¼ 3.30 + 1.5 ppm) and the highest in Group D

(mean ¼ 15.85 + 4.42 ppm; Table 1). A statistically

significant difference was determined between all four

groups (p < 0.001). Ambient CO level measurements

taken at the first and second hour also showed a statisti-

cally significant difference between groups (p < 0.001).

In the post hoc multiple comparisons sidak ANOVA

analysis conducted to determine differences between

Bahcebasi et al. 197



the groups, the groups were found to be different from

one another at every time interval (p < 0.001).

When CO levels at initial entrance and second hour

time point were compared within groups (Table 2),

mean CO levels in both groups increased and this was

statistically significant (p < 0.001). The least amount

of increase was found in Group A (mean ¼ 1.17 +1.01 ppm) and the greatest increase was observed in

Group C (mean ¼ 2.37 + 1.73 ppm) (p < 0.001 and

p < 0.001, respectively).

Expired CO levels of individuals

Mean expired CO levels measured at entry were

found to be mean ¼ 21.17 + 6.73 ppm in smokers,

whereas it was mean ¼ 1.40 + 0.85 ppm in nonsmo-

kers. It was statistically significant (p < 0.001).

Expired CO levels measured at the second hour were

determined to be 22.72 + 5.31 ppm in smokers

and 6.51 + 4.56 ppm in nonsmokers. It was also sta-

tistically significant (p < 0.001).

>Expired CO levels of nonsmokers were found to

be higher after spending 2 hours in coffeehouse where

smoking is allowed compared to those who spent

2 hours in coffeehouses where smoking is not

allowed. Expired CO levels of nonsmokers were

found to be lower after spending 2 hours in coffee-

houses where smoking is not allowed compared to

those who spent 2 hours in coffeehouses where smok-

ing is allowed (Figure 1).

During the time spent in the coffeehouse, change in

expired CO levels in individuals was defined

as symbol of ‘D.’ Median (D) was found to be the low-

est in those who went to coffeehouses and did

not smoke in Group A (1-hour median ¼ 0.0 ppm and

2-hour median ¼ 1.0 ppm) and was found to be the

highest in those who went to coffeehouses and did

not smoke in Group D (1-hour median ¼ 10.0 ppm,

2-hour median ¼ 14.0 ppm).

In people who smoke, the change had a tendency to

decrease in those from Groups A and C. The change

was the lowest in those from Group B (1-hour

Table 2. Median change (D) in expired CO levels (ppm) according to individual smoking status, coffee house type, andstaying time

Smoking statusCoffeehouse

groups N

First hour afterentrance; D

Second hours afterentrance; D

Median RangeMinimun/maximum p Median Range

Minimum/maximum p

No; N ¼ 251 A 89 0.0 6.0 �2.0/4.0 <0.001 1.0 9.0 �4.0/5.0 <0.001B 29 5.0 8.0 2.0/10.0 8.0 6.0 4.0/10.0C 94 2.0 7.0 0.0/7.0 5.0 9.0 1.0/10.0D 39 10.0 14.0 1.0/15.0 14.0 17.0 3.0/20.0

Yes; N ¼ 296 A 40 �4.0 9.0 �9.0/0.0 <0.001 �7.0 10.0 �12.0/�.0 <0.001B 105 1.0 19.0 �3.0/16.0 2.0 25.0 �8.0/17.0C 43 �2.0 5.0 �5.0/0.0 �3.0 8.0 �8.0/0.0D 108 3.0 20.0 �4.0/16.0 5.0 26.0 �7.0/19.0

Abbreviation: CO: Carbon monoxide.

Table 1. The mean ambient CO level (ppm) measurements during the time of entry, first, and second hour according tocoffee house type

Groups

0 At the time of entry First hour Second hour

Mean + SD ANOVA Mean + SD ANOVA Mean + SD ANOVA

Group A (n ¼ 129) 3.30 + 1.45 F ¼ 512.57;p < 0.001

3.76 + 1.39 F ¼ 645.40;p < 0.001

4.47 + 1.32 F ¼ 696.34;p < 0.001Group B (n ¼ 134) 12.86 + 2.10 13.75 + 2.15 14.15 + 2.07

Group C (n ¼ 137) 7.02 + 2.62 8.12 + 2.35 9.39 + 2.35Group D (n ¼ 147) 15.85 + 4.42 16.89 + 3.98 17.63 + 3.65

Abbreviations: ANOVA: analysis of variance, CO: Carbon monoxide.




median¼ 1.0 ppm and 2-hour median¼ 2.0 ppm) and

the change was the highest in those who went to cof-

feehouses from Group A (1-hour median¼�4.0 ppm,

2-hour median¼ �7.0 ppm). (D) from nonsmoker’s

coffeehouse group were significant (1 hour; p <

0.001 and 2 hours; p < 0.001). (D) from smoker’s

coffeehouse group were also found to be

significant (1 hour; p < 0.001 and 2 hours; p < 0.001).

Expired CO level of nonsmokers during the second

hour was very strongly correlated with ambient CO

levels measured at the first and second hours, it was

also strongly correlated with the coffeehouse structure

(new style vs old style; 0 hour; r ¼ 0.90, p <

0.001, 1 hour; r2 ¼ 0.94, p < 0.001, 2 hours; r ¼0.95, p < 0.001, coffeehouse structure; r ¼ 0.69, p <

0.001). Expired CO level of smokers at the second

hour was relatively correlated with ambient CO levels

measured at entry, first, and second hours, and it was

poorly correlated with coffeehouse structure (0

hour; r ¼ 0.47, p < 0.001, 1 hour; r ¼ 0.49, p <

0.001, 2 hours; r ¼ 0.50, p < 0.001, coffeehouse struc-

ture; r ¼ 0.27, p < 0.001). A strong correlation was

observed between individual’s expired CO level during

entry and expired CO level during the first hour (r

¼ 0.75, p < 0.001; Figure 2).

Throughout the study, the amount of change (D) in

CO levels in expirium of people was analyzed indivi-

dually based on whether they were smokers or not.

The main important factor influencing change (D) in

expired individual CO level was ambient CO mea-

surement at first hour for smoker and nonsmoker sub-

jects (R ¼ 0.75, p < 0.001; R ¼ 0.86, p < 0.001,

respectively; Table 3).

Discussion

Many epidemiological and clinical studies have

shown that among factors influencing expired CO

levels, smoking habit is found to be one of the main

facto in addition to ambient (indoor air) CO level.

In measurements performed in the Turkish coffee-

houses, minimal CO level was 2 ppm and the maxi-

mum CO level was 24 ppm. In a study conducted in

Hanoi, Vietnam, whereas the mean CO value was

15.7 ppm, it was 18.6 ppm on motorbikes, 18.5 ppm

in cars, 11.5 ppm in buses, and 8.5 ppm during walk-

ing (according to WHO guidelines, acceptable mean

CO level is 10 ppm at 8 hours and 50 ppm at 30 min-

utes; Saksena et al., 2008). A study performed in

Korea revealed that indoor CO levels were as high

Figure 1. Individuals carbon monoxide (CO; parts per million [ppm]) levels at second hours according to smoking statusand type of coffeehouse.




as 90 ppm in five restaurants and 41 ppm in restaurant

1 (Baek et al., 1997). In the current study, CO level in

the measured air was found to be similar. The health

of people exposed to CO for a long time is known to

be affected negatively in the following ways: head-

aches, reduction in activity capacity, elevation in cor-

onary artery disease risk, and loss of work efficiency

(De Bruin et al., 2004; Sari et al. 2008).

In our study, 153 (51.69%) of active smokers used

10 or more cigarettes per day. Within smokers, there

was a significant difference in their coffeehouse

group preference based on the number of cigarettes

they smoked per day (w2 ¼ 20.09, p ¼ 0.003). Those

who smoked 10 cigarettes or more per day preferred

coffeehouses where smoking was allowed. A total

of 215 (72.64%) of smokers had been smoking for

10 years or more. Within smokers, there was a

significant difference in their coffeehouse group pre-

ference based on the length of time they had been

smoking (p < 0.001). As the length of smoking habit

increased, smokers tended to prefer coffeehouses

where smoking is allowed. When mean ambient

(indoor air) CO level are ranked from lowest to the

highest, at the time of entry to the coffeehouse, Group

A had mean ¼ 3.30 + 1.45 ppm, Group C had mean

¼ 7.02 + 2.62 ppm, Group B had mean ¼ 12.86 +2.10 ppm, and Group D had mean ¼ 15.85 + 4.42

ppm and the difference between them was found to

be statistically significant (p < 0.001). The mean

ambient CO level measurements taken at the first and

second hour also showed the same ranking and the

difference between groups were statistically

Table 3. Regression analyses with curve estimation logistic model of factors that affects changes (D) in amount ofindividual CO levels and smoking status

Factors

Nonsmoker Smoker

R R2Changein CO (Constant) F p R R2

Changein CO. (Constant) F p

First hour ambient CO level 0.86 0.74 0.89 0.27 711.42 <0.001 0.75 0.56 0.93 0.10 372.81 <0.001Smoking status in the

coffeehouse0.75 0.57 0.95 1.07 324.07 <0.001 0.68 0.47 0.97 0.64 256.16 <0.001

Structure of the coffeehouse 0.48 0.23 0.96 0.28 76.23 <0.001 0.30 0.09 0.98 0.24 29.90 <0.001Coffeehouse volume 0.47 0.22 0.96 0.01 70.02 <0.001 0.49 0.24 0.96 0.01 95.03 <0.001Coffeehouse temperature 0.28 0.08 0.99 0.05 20.38 <0.001 0.28 0.08 0.99 0.05 24.58 <0.001Expired CO level before entry 0.19 0.03 1.02 0.73 8.84 0.003 0.68 0.47 1.04 0.05 256.68 <0.001Air conditioning status of

coffeehouse0.17 0.03 0.99 0.97 7.56 0.006 0.18 0.03 0.99 0.89 9.88 0.002

Abbreviation: CO: carbon monoxide.

Figure 2. Strong correlations between carbon monoxide (CO levels; parts per million [ppm]) in individual expired airand indoor CO levels (ppm) at first and second hours.




significant (p < 0.001 and p < 0.001; Table 1). These

results show that ambient CO level is lower in coffee-

houses in Groups A and C where smoking is not

allowed compared to coffeehouses where smoking

is allowed in Groups B and D and that smoking could

be main reason for indoor air pollutant at coffee-

houses. Similar to our study, results from recent stud-

ies, conducted in homes in European cities, show

positive correlations between indoor and outdoor con-

centrations within some cities but not others; only

cigarette smoking was found to have a consistent

effect in elevating indoor concentrations (Ballesta

et al., 2006; Lai et al., 2006a; Lai et al., 2007b).

Moreover, when indoor ambient CO levels are

compared based on coffeehouse building properties,

old construction Group A has lower levels compared

to new construction Group C and old construction

Group B has lower levels compared to new construc-

tion Group D. Throughout the study, ambient CO lev-

els in coffeehouses showed tendency to increase. This

change was found to be statistically significant in all

groups (p < 0.001). It was found to be the greatest

in Group C (mean ¼ 2.37 + 1.73 ppm) followed by

Group D (mean ¼ 1.78 + 2.75 ppm). This situation

is thought to be due to insufficient air insulation of old

style coffeehouses, allowing air circulation from

inside to outside and from outside to inside, which

in turn decreases ambient CO levels. It is thought that

the use of sealing materials in doors, windows, etc.,

used in newly constructed coffeehouses, reduces air

permeability, and combined with insufficient

ventilation; it can lead to increased ambient CO

levels. Similarly, many other studies have also shown

that construction state of a building affects indoor air

quality. The main reasons for tighter construction are

to reduce energy costs and maintain thermal

comfort. Energy-efficiency programmes in the United

States tend to produce tighter houses, whereas con-

ventional houses are significantly leakier, with a lot

more variation (Sherman et al., 2002). The large

increases in the use of air conditioning units in North

American homes over the last two decades may have

significantly affected indoor air quality (Franklin,

2007), and the exposure and health benefits of air

conditioning of schools, homes, and vehicles could

be considerable (Chan et al., 2002; Hanninen et al.,

2005; Janssen et al., 2002). Much greater air exchange

rates may occur in homes outside Europe and

North America.

Initial entry measurement in the study, in other

words, measurements taken when CO level in the air

was 0, showed that expired CO levels from nonsmokers

were low (mean 1.40 + 0.85 ppm), whereas the levels

were higher in smokers (mean 21.17 + 6.73 ppm).

There was a significant difference between the two

groups (p < 0.001). The last measurement taken during

the study indicated that expired CO levels of nonsmo-

kers had increased (mean 6.51 + 4.56 ppm) compared

to the initial measurement, although this increase was

limited in smokers (mean 22.72 + 5.31 ppm). Some

similar studies found that expired CO level was similar

with our results. One of those studies show that the mean

breath CO levels were 17.4 ppm for smokers an 1.8 ppm

for nonsmokers (Middleton and Morice 2000), and the

another study indicated that mean expired CO was

17.13 + 8.50 ppm for healthy smokers, 3.61 + 2.15

ppm for healthy nonsmokers, and 5.20 + 3.38 ppm for

passive smokers, conducted in Turkey (Deveci et al.

2004). In another study, Fidan and Cimrin (2007) have

reported on tobacco smoke exposure in coffeehouses in

Turkey. Their study showed that mean expired CO was

21.4+ 9.3 ppm for coffeehouse customers, 13.0+ 4.1

ppm for smokers who do not go to the coffeehouses, and

2.4 + 0.8 ppm for nonsmokers who do not go to the

coffeehouses.

As a result, it is thought that nonsmokers are more

seriously affected by ambient CO levels in coffee-

houses, thus the change (D) in expired CO levels of

the individual during the time spent in the coffee-

house is even more important. Change (D) in expired

CO levels of the smoking individuals does not

show difference based on the coffeehouse group

(Table 2). The ranking of nonsmoking individuals

based on their (D) shows similarity to the ranking

based on ambient CO level in the coffeehouse. This

finding suggests that ambient CO level in the coffee-

house affects (D) of nonsmoking individuals.

In smoking individuals, change (D) in expired CO

level in their expirium air varied depending on the

coffeehouse group they went (1 hour; p < 0.001 and

2 hours; p < 0.001). (D) of smokers who went to cof-

feehouses in Groups A and C tended to decrease,

whereas in those who went to coffeehouses in Groups

B and D, it tended to increase. It is suggested that the

reason for not seeing a decrease in (D) (in Groups A

and C coffeehouses is due to individuals not

smoking within 2 hours and low ambient CO

levels. The relative increase in (D) (of individuals

found in Groups B and D coffeehouses is suggested

to be due to individuals being less affected by ambient

CO level because of their continued smoking. Report

of Center of Disease Control does not address sources




of secondhand smoke exposure other than private-

sector worksites, restaurants, and bars. Homes are

another important source of exposure, especially for

children, who on average are exposed to higher levels

of secondhand smoke than adults (CDC, 2005;

USDHHS, 2000; Wortley et al., 2002).

While expired CO level of nonsmokers, measured

at the second hour, does not show any correlations

with expired CO level before entering the coffee-

house, expired CO level measured at the first hour

showed a very strong correlation with ambient CO

levels at the first and second hour; it also showed a

very strong correlation with the coffeehouse structure

(1 hour expirium; r ¼ 0.96, p < 0.001, 0 hour;

r¼ 0.90, p < 0.001, 1 hour; r¼ 0.94, p < 0.001, 2 hour;

r ¼ 0.95, p < 0.001, coffeehouse structure; r ¼ 0.69,

p < 0.001; Figure 2). Expired CO level of nonsmo-

kers, measured at the second hour of their stay in the

coffeehouse, showed a strong correlation with coffee-

house structure and ambient CO level. Expired CO

level of smokers, measured at the second hour,

showed a strong correlation with expired CO level

during an individual’s entry and especially expired

CO level during the first hour (r ¼ 0.75, p < 0.001);

it showed a medium correlation with ambient CO lev-

els during entry, first, and second hour; it showed a

poor correlation with coffeehouse structure (0 hour;

r ¼ 0.47, p < 0.001, 1 hour; r ¼ 0.49, p <

0.001, 2 hours; r¼ 0.50, p < 0.001, coffeehouse struc-

ture; r ¼ 0.27, p < 0.001). When compared with non-

smokers, expired CO levels of smokers were less

affected by ambient CO level. We attributed this

relationship to the fact that smokers had already

high CO levels, and thus being less affected from the

ambient CO.

Compared to smokers, expired CO levels of non-

smokers were affected by the coffeehouse group they

choose and ambient CO levels much more. Although

population-based data indicated declining second-

hand smoke exposure in the workplace over time, this

exposure has been remaining a common public health

hazard that is entirely preventable. Optimal protection

of nonsmokers and smokers requires a smoke-free

environment (CDC, 2005; USDHHS, 2000).

When factors influencing the change (D) in expired

CO levels in nonsmokers were evaluated using regres-

sion analysis, ambient CO level (R¼ 0.86, p < 0.001),

smoking status in the coffeehouse (R ¼ 0.75,

p < 0.001), structure of the coffeehouse (R ¼ 0.48,

p < 0.001), volume of the coffeehouse (R ¼ 0.47,

p < 0.001), temperature of the coffeehouse (R ¼

0.28, p < 0.001), and expired CO before entry to cof-

feehouse (R¼ 0.19, p < 0.001) were found to be influ-

ential. In smokers, ambient CO level at the first hour

(R¼ 0.75, p < 0.001), expired CO before entry to cof-

feehouse (R ¼ 0.68, p < 0.001), smoking status in the

coffeehouse (R ¼ 0.68, p < 0.001), volume of the cof-

feehouse (R ¼ 0.49, p < 0.001), materials used in the

construction of the coffeehouse (R¼ 0.30, p < 0.001),

and the temperature of the coffeehouse (R ¼ 0.68,

p < 0.001) was determined to be influential (Table 3).

Ambient CO levels affected the ((D) of nonsmo-

kers more compared to the ((D) of smokers. While

individual expired CO level before entry affects

the (D) of smokers, it virtually did not affect

the (D) of nonsmokers. The smoking status of the cof-

feehouse affected the (D) of the nonsmokers more

compared to the (D) of smokers. While the structure

of the coffeehouse affected the (D) of the nonsmokers,

it virtually did not affect the (D) of smokers.

Nonsmokers were affected the greatest from CO,

which was considered an air pollutant in coffeehouses.

In many studies, it was shown that in addition to

smoking, people who become passive smokers by

going to coffeehouses are exposed to many illnesses

such as cardiovascular disease, cancer, etc. Cardio-

vascular diseases are the main cause of death in

Mexico City and have shown a rising trend over the

past 20 years. Various epidemiological studies have

reported an association between respirable particles

and carbon monoxide (CO), with cardiorespiratory

outcomes. These results show that for this high-risk

population, the alteration of the cardiac autonomic reg-

ulation was significantly associated with both PM2.5

and CO personal exposures (Riojas-Rodriguez et al.,

2006). Evidence provides a plausible link between

passive smoking, bronchial hyperresponsiveness, and

chronic obstructive pulmonary disease (COPD). How-

ever, limited information is available on these relation-

ships and due to the fact that levels of ETS doses

have been based on questionnaire reports, effects on

lung function may not have been observed at low expo-

sures (Coultas, 1998; Jaakkola et al., 1995; Jaakkola

and Jaakkola, 2002).

As a result, in the current study, ambient CO levels

inside coffeehouses were determined to be above the

WHO scales. Expired CO levels of nonsmokers who

went to coffeehouses were mainly affected by ambi-

ent CO levels and structure of the coffeehouses.

Expired CO levels of smokers were mostly affected

by ambient CO levels inside coffeehouses rather than

cigarette smoking. In order to provide air ventilation




in coffeehouses, while spaces left below doors and

above windows of old structures provide airflow, in

newer constructions, airflow is obstructed with con-

struction materials and ventilation system is either

insufficient or not operated. In addition to CO level

that was analyzed in this study, presence of other

accompanying air contaminants (CO2, etc.) should not

be ignored. For these reasons, cigarette consumption

should be prohibited by law in public areas such as

coffeehouses. Legal regulations should be supported

by programs that will inform the society, increase

awareness, and contribute to the acceptance of the

prohibition by the community. In addition, ambient

CO levels inside coffeehouses are affected by the

building’s physical location; thus ventilation systems

should be installed and operated properly in order to

provide clean air that meets living standards.

References

Baek SO, Kim YS, and Perry R (1997) Indoor air quality in

homes, offices and restaurants in Korean urban areas-

indoor/outdoor relationships. Atmospheric Environment

31: 529–544.

Bahcebası T, Sonmez O, Aydın S, and Mutlu E (2007)

Effect of Family Medicine Pilot Project on Health Care

in Duzce-Turkiye. Duzce: Yavuz Ofset, 2007.

Ballesta PP, Field RA, Connolly R, et al. (2006) Population

exposure to benzene: one day cross-sections in six

European cities. Atmospheric Environment 40: 3355–

3366.

Bekler A, Simsek MS (2004) Duzce Province Environmen-

tal Condition Report. Duzce, Duzce County Environ-

ment and Forest Directorship Publications.

CDC (2005) Prevention and health promotion: state

smoking restrictions for private-sector worksites, restau-

rants and bars—United States 1998 and 2004. Journal of

American Medical Association 294: 1202–1204.

Chan LY, Lau WL, Lee SC, and Chan CY (2002) Commu-

ter exposure to particulate matter in public transporta-

tion modes in Hong Kong. Atmospheric Environment

36: 3363–3373.

Coultas DB (1998) Passive smoking and risk of adult

asthma and COPD: an update. Thorax 53: 381–387.

De Bruin YB, Ninen OH, Carrer P, et al. (2004) Simulation

of working population exposures to carbon monoxide

using EXPOLIS-Milan microenvironment concentra-

tion and time-activity data. Journal of Exposure Analy-

sis and Environmental Epidemiology 14: 154–163.

Deveci SE, Deveci F, Acik Y, and Ozan AT (2004) The mea-

surement of exhaled carbon monoxide in healthy smokers

and non-smokers. Respiratory Medicine 98: 551–556.

EasyViewTM K Type Thermometer (2009) User’s

Guide of Extech Instruments. Available at: http://

www.extechinstruments.com/instrument/products/alpha/

manuals/EA11_UM.pdf

Fidan F, Cimrin A (2007) Tobacco smoke exposure in cof-

feehouse can be a potential threat for public health.

Turkish Respiratory Journal 8: 81–84.

Fluke CO-220 (2009) Carbon Monoxide Meter Instruction

Sheet Available at: http://assets.fluke.com/manuals/

co220___iseng0200.pdf April.

Franklin PJ (2007) Indoor air quality and the respiratory

health of children. Paediatric Respiratory Review 8:

281–286.

FTC (2006) Duzce Chamber of Tradesmen and Craftsmen

Publication. The Records of the Turkish Federation of

Tradesmen and Craftsmen.

Hanninen O, Palonen J, Tuomisto JT, et al (2005) Reduction

potential of urban PM2.5 mortality risk using modern

ventilation systems in buildings. Indoor Air 15: 246–256.

Jaakkola MS, Jaakkola JJK (2002) Effects of environmen-

tal tobacco smoke on therespiratory health of adults.

Scandinavian Journal of Work Environment and Health

28: 52–70.

Jaakkola MS, Jaakkola JJK, Becklake MR, and Ernst P

(1995) Passive smoking and evolution of lung function

in young adults. A 8-year longitudinal study. Journal

of Clinical Epidemiology 48: 317–327.

Janssen NAH, Schwartz J, Zanobetti A, and Suh HH (2002)

Air conditioning and source-specific particles as modi-

fiers of the effect of PM10 on hospital admissions for

heart and lung disease. Environmental Health Perspec-

tives 110: 43–49.

Lai HK, Bayer-Oglesby L, Colvile R, et al. (2006)

Determinants of indoor air concentrations of PM2.5,

black smoke and NO2 in six European cities (EXPOLIS

study). Atmospheric Environment 40: 1299–1313.

Lai HK, Jantunen MJ, Kunzli N, et al. (2007) Determinants

of indoor benzene in Europe. Atmospheric Environment

41: 9128–9135.

Lambert WE (1997) Combustion pollution in indoor envir-

onments. In: Bardana EJ, Montanaro A (eds) Indoor Air

Pollution and Health. New York, NY: Marcel Dekker,

1997; 83�103.

Madany IM (1992) Carboxyhemoglobin levels in blood

donors in Bahrain. Science of the Total Environment

116: 53–58.

Middleton ET, Morice AH (2000) Breath carbon monoxide

as an indication of smoking habit. Chest 117: 758–763.

Riojas-Rodriguez H, Escamilla-Cejudo JA, Gonzalez-

Hermosillo JA, et al. (2006) Personal PM2.5 and CO

exposures and heart rate variability in subjects with




known ischemic heart disease in Mexico City. J Expo

Sci Environ Epidemiol. 16: 131–137.

Saksena S, Quang TN, Nguyen T, et al. (2008) Commu-

ters exposure to particulate matter and carbon monox-

ide in Hanoi, Vietnam. Transportation Research 13:

206–211.

Sari I, Zengin S, Ozer O, Davutoglu V, Yildirim C, and

Aksoy M (2008) Chronic carbon monoxide exposure

increases electrocardiographic P-wave and QT disper-

sion inhalation. Inhalation Toxicology 20: 879–884.

Sherman MH, Matson ME (2002) Air tightness of new U S

houses: a preliminary report. Lawrence Berkeley

National Laboratory (Report No. LBNL-48671).

TSSI (2002) 2000 General Census: Social and Economic

Characteristics of Duzce Population. Ankara: Turkish

State Statistical Institute Publications.

USDHHS (2000) Reducing Tobacco Use: A Report of the

Surgeon General. Atlanta, GA: US Department of

Health and Human Services.

USEPA (1991) Air Quality Criteria for Carbon Monoxide.

Washington, DC: United States Environmental Protec-

tion Agency.

Vitalograph Breath CO (2009) Carbon Monoxide Monitor

User’s Guide of Extech Instruments. Available at: http://

www.vitalograph.com/pdf_library/manuals/breathco/

breathco_user_instructions.pdf

WHO (2000a) Addressing the Impact of Household Energy

and Indoor Air Pollution on the Health of the Poor

Implications for Policy Action and Intervention Mea-

sures. Washington, DC: World Health Organization.

WHO (2000b) Air Quality Guidelines–2nd ed. Copenhagen.

WHO Regional Office for Europe. Available at: http://

www.euro.who.int/document/aiq/5_5carbonmonoxide.

pdf

Wortley PM, Caraballo RS, Pederson LL, and Pechacek TF

(2002) Exposure to secondhand smoke in the workplace:

serum cotinine by occupation. Journal of Occupational

and Environmental Medicine 44: 503–509.




factors affecting exhaled carbon monoxide levels in coffeehouses in the western black sea region of...

Documents