Engaging with policy makers and the media about the need for smoke-free homes: the UK perspective Sean Semple Associate Professor Institute for Social Marketing Faculty of Health Sciences and Sport University of Stirling sean.semple@stir.ac.uk

Measuring (SHS) to change public opinion and policy… Measurements of SHS in bars Measurements of SHS in cars Measurements of SHS in homes Measurements of SHS in prisons

Smoke-free legislation in Scotland 2006 The Bar Workers’ study (BHETSE) Aims To assess changes in SHS exposure in bars To determine changes in bar workers’ respiratory health Calculate economic value of health improvements Examine geographical and/or socio- demographic differences Look at changes in attitudes to smoke- free legislation and perceptions of risk from SHS

Where and when Random selection of public houses Aberdeen city Edinburgh Glasgow Small towns in Borders and Aberdeenshire Baseline, two month post-ban and 1 year post baseline Exposure assessment ‘Quiet’ time and ‘busy’ time visits 106 (53 pre and 53 post) bar visits made to 40 bars PM2.5, personal exposures in some and salivary cotinine 371 bar staff recruited Health questionnaires Lung function

A typical Saturday night out in six bars in February 2006…

The same visits on a Saturday in May 2006…

A typical Saturday shift in the pub.… February and May 2006

Exposure to SHS in bar workers Self-reported - fell from 28.5 to 0.8 h/week Exposure to PM2.5 - down by 86% Salivary cotinine Non-smokers level fell from 2.94 to 0.41 ng/ml (86%) -86% in non-smokers and -12% in smokers

Children’s exposure to SHS Smoke-free legislation in 2006 reduced children’s exposure to SHS in Scotland by about 40% However… Children with two smoking parents still had salivary cotinine levels1 similar to non- smokers who worked in smoky bars2 before smoke-free legislation Children were still being exposed to SHS at home and in the car1 About 25% report exposure to SHS at home in the last 7 days About 7% report exposure to SHS in cars in the last 7 days; other surveys suggest 17% of children ‘exposed more than once a week’. 1Akhtar et al. BMJ 2007;335:545-49 2Semple et al. Ann Occup Hyg 2007;51:571-80

Measuring SHS exposure in cars Measure air concentrations of Particulate Matter less than 2.5 mm in size (PM2.5) using a TSI Sidepak aerosol sampler Where smoking occurs we know >90% of indoor PM2.5 comes from SHS Typical outdoor 24h PM2.5 concentration in Edinburgh city centre: 5-20 mg/m3 World Health Organisation (WHO) recommends that exposure to PM2.5 should not exceed 25 mg/m3 averaged over 24 hours. 17 study recruits were asked to place a child-sized doll within a front- facing car seat in one of the rear car seats of their car during all journeys they made over a 3 day period Glasgow and East Anglia

Results- an example car journey

How widespread is smoking in the car? Observation data1 from across Scotland in 2009/10 suggested that at any given point about 3% of cars have someone actively smoking If we use x3 for journey prevalence this suggested that about 9-10% of all car journeys produce SHS exposure Location Cars with Smoking Total number of Cars Cars with smoking (%) Aberdeen 78 3200 2.44 Edinburgh 128 3786 3.38 Glasgow 107 4186 2.56 Livingston 168 4113 4.08 Total 481 15285 3.11 1Data from Andrew Apsley’s PhD thesis: “Second-hand tobacco smoke exposure in different micro-environments” University of Aberdeen.

SHS in cars Strong evidence that SHS exposure causes a wide range of health effects: early- life exposure are particularly damaging Measurements in real-life smoking car journeys show that PM2.5 levels average about 85 mg/m3; more than ten times the level measured in non-smoking cars Peak concentrations as high as 885 mg/m3 Two 20 min journeys per day equivalent to spending more than 1.5 hours each week in a smoky pub (before legislation) Smoking occurs in about 1:10 car journeys in Scotland Data from 2007 suggested perhaps 60,000 children are exposed to SHS in a car in the past 7 days

Providing measurement data drives action… Smoking in cars where a child is present prohibited by law from December 2016.

Measuring SHS in homes Quantifying

Smoke-free homes are much lower Smoke-free homes – 28 homes (in black) WHO guidance 25 mg/m3

Fine particles x7 higher in smoking homes >1 million minutes worth of PM2.5 measurements made in over 230 Scottish homes Median (IQR) PM2.5 concentrations in smoke-free homes (n=28) is 5.6 (2-9) mg/m3 Median PM2.5 in smoking-permitted homes (n=203) is 38 (15-91) mg/m3 62% of smoking homes have daily average concentrations that exceed the World Health Organisation PM2.5 24-hour guidance limit (25 mg/m3) 83% exceed WHO annual guidance of 10 mg/m3 WHO guidance 25 mg/m3

How long does SHS remain in the air? Analysed data from 103 homes Identified last cigarette of the day (9.30pm-3am) Time from peak (>25 mg/m3) to 50% of peak (n=130) Time from peak to WHO guidance level of 25 mg/m3 (n=115) Last cigarette of day

Almost an hour for SHS to reduce by 50%

2h 40m to reduce to WHO guidance About 1 in 4 cases it took more than five hours to reduce to WHO guidance limit

SHS remains in the air for many hours First and largest ‘real-world’ (i.e. not artificial laboratory measurements) measurements of this type Huge variability due to different types of houses, ventilation, window opening etc. Probably still some SHS even when you reach 25 micrograms/m3 – so values are under-estimates 1 in 4 homes >5 hours Scottish Government campaign www.rightoutside.org Scottish Government target of reducing by half the proportion of children exposed to SHS at home by 2020

PM2.5 time plots – HMP Grampian Clear diurnal pattern Modern prison ‘Median’ prison with values nearest the average for all 15 prisons

PM2.5 measurements WHO 24h guidance WHO annual guidance

Measuring SHS in prisons in Scotland 17/07/17  

Scottish Prison Service announce date for smoke-free prisons SPS announce that ALL Scottish prisons will be smoke-free by November 2018 Head of Scottish Prison Service says: “This report is a call to action. It is not acceptable that those in our care and those who work in our prisons should be exposed to second hand smoke.” Chairman of the Prison Officers' Association Scotland: "This survey, for the first time provides data to back up that claim and the concern that's been raised by staff throughout those years.” Minister for Justice: “Second-hand smoke poses an unacceptably high risk to the health of prisoners, staff and visitors.” Minister for Health: “I endorse this important step by SPS which will contribute towards our ambition of creating a tobacco-free generation by 2034”  

Final thoughts We can learn a lot by measuring… Measurement has played a part in driving policy change in relation to SHS in Scotland

Acknowledgments IAPAH REFRESH First Steps 2 Smoke-Free AFRESH TIPS Funded by the Irish Environmental Protection Agency Carole Garden1, Marie Coggins3, Karen S Galea2, Paul Whelan3, Hilary Cowie2, Jon G Ayres4 & Fintan Hurley2. REFRESH Funded by the Big Lottery Fund Inga Wilson1, Lynsey Mills1, Amanda Amos5, Deborah Ritchie5, April Shaw6, Rachel O’Donnell6, John Watson6, Stephen Turner1 First Steps 2 Smoke-Free Funded by the CSO, Scotland Tracy Henderson7, Lynn Adams7, Susan Lyttle7, Amanda Amos5, Rachel O’Donnell6, Stephen Turner1 & All the First Steps workers at NHS Lanarkshire AFRESH Funded by the MRC Ruaraidh Dobson1, Rachel O’Donnell1, Stephen Turner1 & Marijn De Bruin1 TIPS Funded by the NIHR Semple S1, Sweeting H8, Demou E8, Logan G28 O’Donnell R1, Hunt K8 1 University of Aberdeen 2 Institute of Occupational Medicine 3 National University of Ireland, Galway 4 University of Birmingham. 5 University of Edinburgh 6 ASH Scotland 7 NHS Lanarkshire 8 University of Glasgow