|Year : 2015 | Volume
| Issue : 4 | Page : 708-713
Indoor air quality due to secondhand smoke: Signals from selected hospitality locations in rural and urban areas of Bangalore and Dharwad districts in Karnataka, India
Mark J Travers1, Nayanatara S Nayak2, Vinod B Annigeri2, N Narayan Billava2
1 Department of Health Behavior, Division of Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, Buffalo, New York, USA
2 Department of Centre for Multi-Disciplinary Development Research, Dharwad, Karnataka, India
|Date of Web Publication||10-Mar-2016|
Nayanatara S Nayak
Department of Centre for Multi-Disciplinary Development Research, Dharwad, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND: Tobacco smoke has compounds that are known as human carcinogens. With every breath of secondhand smoke we inhale thousands of chemicals. The Government of India in the interest of public health has enacted the Cigarette and Other Tobacco Products Act (COTPA), 2003, which bans smoking in all the public places including hotels and restaurants. The purpose of this study was to observe and record air pollution in smoke free and smoke observed locations and thereby find out whether the owners/managers of hotels, restaurants, and bars comply with rules of COTPA. OBJECTIVES: The objectives of the study were to measure and compare the level of particulate air pollution from secondhand smoke (PM2.5) in smoking and nonsmoking venues. MATERIALS AND METHODS: The study was conducted from September 2009 to March 2010 in Karnataka, India following a nonrandom sample of 79 locations, which included restaurants, bars, cafes, hotels, and tea stalls in two districts. The concentration of PM2.5was measured using a TSI SidePak AM510 Personal Aerosol Monitor. RESULTS: In Karnataka out of the 79 hospitality locations, smoking was observed in 58% places and only 28% had displayed the required “No Smoking” signage. Places where indoor smoking was observed had high levels of air pollution with average 135 PM2.5, which were 3.1 times higher than the average 43 PM2.5in smoke-free locations and 14 times higher than the World Health Organization (WHO) target air quality guideline for PM2.5. The average PM2.5levels in different locations ranged from 11 to 417 μg/m3 and was lower in the case of apparently compliant designated smoking area (DSR). CONCLUSIONS: The patrons and the workers in the hospitality sector continue to be exposed to secondhand smoke despite the enactment of COTPA, which bans smoking in public places. This situation demands stringent measures for effective implementation of the Smoke Free Act and negative response to smoking among civil society.
Keywords: Hospitality locations, indoor air quality, noncompliance, secondhand smoke, smoke free law
|How to cite this article:|
Travers MJ, Nayak NS, Annigeri VB, Billava N N. Indoor air quality due to secondhand smoke: Signals from selected hospitality locations in rural and urban areas of Bangalore and Dharwad districts in Karnataka, India. Indian J Cancer 2015;52:708-13
|How to cite this URL:|
Travers MJ, Nayak NS, Annigeri VB, Billava N N. Indoor air quality due to secondhand smoke: Signals from selected hospitality locations in rural and urban areas of Bangalore and Dharwad districts in Karnataka, India. Indian J Cancer [serial online] 2015 [cited 2019 Dec 13];52:708-13. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/708/178447
| » Introduction|| |
Every citizen in a country has right to breathe air free of hazardous chemicals and substances. Pollutants in the atmosphere have adverse effects on human health. In addition to the harmful chemicals already present in the atmosphere due to emission from vehicles and industries, tobacco smoke adds on complex mixture of chemicals increasing one's vulnerability to ill-health. Tobacco smoke has compounds that are known as human carcinogens. Secondhand smoke is inhaling “the smoke emitted from the burning end of a cigarette or from other tobacco products usually in combination with the smoke exhaled by the smoker”. It is a dynamic complex mixture of thousands of compounds in particulate and vapour phases and cannot be measured directly as a whole. World Health Organization's (WHO's) target air quality guideline for particulate air pollution from secondhand smoke (PM2.5) is 10 µg/m 3 (annual mean) and the levels of 1-10 µg/m 3 nicotine is taken as an indicator of secondhand smoke. There is no evidence for a safe exposure level and the unit risk of cancer associated with lifetime exposure to secondhand smoke in a home where one person smokes is approximately 1 × 10-3.
The most widely used markers for the presence and concentration of secondhand smoke in indoor environments are airborne nicotine and respirable suspended particulates (RSP) measured in various sizes. The results of the study by Coghlin et al., indicate that relatively simple questionnaires and diaries can be developed to assess current secondhand smoke exposure for epidemiologic studies. In their study, weekly exposure to secondhand smoke was measured in 53 nonsmoking volunteers using a passive nicotine monitor; a baseline questionnaire; and a 7-day diary and exposure episodes recorded according to location, space ventilation characteristics, number of smokers, number of hours, proximity of smokers, and intensity of secondhand smoke. Parental smoking and concentrations of ambient nicotine and urinary cotinine were observed in a study conducted using questionnaires, urinary cotinine, and a passive monitor for ambient nicotine in 48 children in Minnesota in 1989.
Studies quantifying the quality of air due to secondhand smoke have been documented in many countries including India ,,,, with limited reference to semiurban and rural areas. In a survey conducted in an Indian metropolitan city (Mumbai) to assess the impact of smoke free policies on indoor air quality indicated by the concentration of particulate matter <2.5 microns it was found that out of 88% of the venues declaring smoke free status, only 64% had implemented the law. In the above study recording of 97 PM2.5µg/m 3 was observed in nonsmoking venues, while smoking venues had an average of 363 PM2.5µg/m 3, which was worse than the average values observed at different garbage dumping grounds in Mumbai (149-169 PM2.5µg/m 3)”. Several studies have linked secondhand smoke to many diseases viz. lung cancer ,, chronic obstructive pulmonary disease, asthma, etc. So it is the responsibility of every government to provide a clean and safe environment to its citizens. The Global Adult Tobacco Survey-2010 reveals that 40% males and 16% females above the age of 15 years use tobacco in Karnataka, India and 37% of them are exposed to passive smoking at public places.
Cigarette and other tobacco products act, 2003
To protect individuals from the effects of secondhand smoke, the Indian government enacted a smoke free air law restricting smoking in public places. As per the provisions of COTPA, 2003 enacted by Government of India in 2004, smoking is banned in all public places including hotels and restaurants. Since the provisions of the Act were not enforced in entirety, detailed rules prohibiting smoking in public places were notified on 30th May 2008, which came into effect on 2nd October 2008. Hotels having room capacity of 30 or more and restaurants having seating capacity of 30 or more were permitted to allow smoking only if they can provide for separate smoking zone such that the smoke from that zone would be ventilated outside and does not permeate into nonsmoking zone. According to this law, persons responsible for respective public places are expected to comply with the law and may be fined for not enforcing smoke free activity. In the case of hospitality sector their responsibilities are laid down as follows:
Preventing and/or stopping persons from smoking inside or near entranceways or exit area of the location. Smoking can be allowed in designated smoking area (DSR) strictly meant for smoking only.
Signage on smoking restrictions or ban has to be displayed in prominent places of the location.
The authority of the location should ensure that ashtrays, matches, and lighters are not made available to the patrons in their location.
The question here was whether the owners/managers of hotels, restaurants, and bars comply with rules of COTPA? Has it made any difference to indoor smoking behavior in public places? Air quality monitoring in such places examined separately for spaces with and without smoking zones would give an answer to these questions and provide details about the extent of pollutants present in air, which could be related to tobacco.
In the background of the issues discussed above, the main purposes of this study were:
- To measure the level of PM2.5
- To compare the level of air quality in smoking and nonsmoking venues.
| » Materials and Methods|| |
The study was conducted from September 2009 to March 2010 in Karnataka following a nonrandom sample of 85 locations of which apt data was available for 79 locations. As per National Family Health Survey (2005-2006) 36% of men and 2% women in rural areas and 29% of men and 0.5% of women in urban areas in the age group 15-49 years smoke in India. But, the current focus of tobacco control advocacy in India is only in urban areas, whereas the population exposed to secondhand smoke is higher in rural areas. Large section of rural population is unaware of COTPA, 2003 as well on adverse effects of secondhand smoking. Therefore, the study intended to cover rural areas also.
Since we needed control group to show the differences between smoking and smoke free locations, in each sample area we tried to choose complying locations equal to 50% of the total sample in that location. But, this was not possible on the field, particularly in rural areas as almost 99% of the locations did not comply with smoke free law. So we included more number of villages in our sample to cover complying locations also.
The study was taken up in two districts represented by their respective head quarters (representing urban units), two block head quarters (representing semiurban units), and villages (representing rural units). Since the purpose of the study was strengthening advocacy for tobacco control, the focus was set aside from numbers with large sample size to a situation analysis of carefully chosen locations based on our understanding about noncompliance coming out from informal discussions and observations by the field investigators before initiating the survey and air quality monitoring. Informal discussions were held with the public, patrons, and next door petty shops for facilitating sample selection. Although this was not part of the planned methodology of the main study, informal discussions were held with the police and managers and patrons even after completion of the study to elicit their opinion on smoke free law, its implementation and observed violations in terms of indoor smoking, absence of 'No smoking signage' and absence of DSR in smoke observed places. The sample of 79 included restaurants, bars, cafes, hotels, and tea stalls distributed in two cities, four suburbs, and 32 villages in two purposively chosen districts viz. Bangalore and Dharwad. Bangalore being the state capital we assume that the laws are implemented effectively and there is greater awareness among the public due to exposure, publicity, and wider coverage by the media. Moreover most of the tobacco control activities viz. tobacco free school campaign, smoke free city, training programs for law enforcing personnel, etc., are concentrated in capital cities. Dharwad is a medium developed, quiet city known for education and is considered pensioners' paradise. Culturally and economically there is a marked difference between the two districts. The concentration of PM2.5 was measured using a TSI SidePak AM510 Personal Aerosol Monitor. PM2.5 is particulate matter in the air smaller than 2.5 microns in diameter. Particles of this size, which are released in significant amounts from burning cigarettes, are easily inhaled deep into the lungs, and cause a variety of adverse health effects including cardiovascular and respiratory diseases and death. Sidepak monitor measures the real-time concentrations of particles less than 2.5 µm in micrograms per cubic meter (PM2.5). The monitor was used for recoding the levels of PM2.5 during the peak hours of business. The Sidepak monitor was carried discretely in a bag and placed on the dining table with the end of the pipe attached to the monitor protruding out of the bag to enable sucking of air. The investigators took notes while munching snacks or food and filled the data schedules provided to them by observing the environment and made their presence felt as patrons in the hospitality locations. The information required to be filled in the schedules given to investigators related to number of patrons present in the hospitality location during the peak hours, number of people smoking, whether smokers smoke at the entrance or on the table, whether there exists 'no smoking signage', whether ash trays are kept on the table, does the location has closed or open kitchen, etc., Further the investigators took measurements of room dimension and height with the help of sonic measuring device, which makes it easy to collect the measurements electronically. These measurements helped to calculate the active smoker density for each venue, that is, average number of burning cigarettes per 100 cubic meters. The difference between PM2.5 levels in places with smoking and without smoking was tested using the Mann-Whitney U test.
| » Results|| |
In Karnataka out of the 79 hospitality locations visited by the study team (in Bangalore and Dharwad districts) smoking was observed in 46 (58%) places [Figure 1] and only 22 (28%) places had any of the required “no smoking” signage. Signage was visible in hotels, which strictly did not allow smoking. In many other places signage was found torn, not visible, written by hand on walls, or not according to the size specified in the act.
|Figure 1: Noncompliance to smoke free law in different settings in Bangalore district and Karnataka (in %)|
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Noncompliance to smoke free law in terms of illegal smoking is higher in suburban locations of both the districts. The knowledge about DSR in terms of its importance and its design was almost nil among the managers of hospitality locations in all the sample locations except three smoke observed locations in the capital city of Bangalore where provision was made for DSR [Figure 1]. Nearly three-fourth of the locations in both the districts did not exhibit “no smoking signage” and violated other rules of the COTPA, 2003 enacted by Government of India.
In total the rate of noncompliance with respect to illegal smoking and absence of signage was found to be higher in Bangalore city and Bangalore suburban as compared to their counterparts in Dharwad district, while DSR was totally absent in smoke observed locations of Dharwad district [Figure 2].
|Figure 2: Noncompliance to smoke free law in different settings in Dharwad district and Karnataka (in %)|
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Indoor air quality measured through Sidepak monitor shows that places where indoor smoking was observed had high levels of air pollution (average level 135 µg/m 3). Levels of PM2.5 in smoking locations were 3.1 times higher than smoke free locations (average level of 43 µg/m 3) and 14 times higher than the WHO target air quality guideline for PM2.5[Figure 3]. Sixty percent of the places visited also had smoking occurring in the entranceway or other adjacent outdoor areas where patrons and workers are exposed upon entry and exit and where smoke can drift into the indoor spaces.
|Figure 3: Comparative levels of particulate air pollution from secondhand smoke(PM2.5)in smoke observed and smoke free locations in Bangalore district and Karnataka|
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In Bangalore the capital city of Karnataka the average level of PM2.5 at 143 recording was more than two times higher in locations with observed smoking than the locations without observed smoking showing the pollution level at 70 PM2.5, but lower than the values recorded in Dharwad city, which exhibited 187 PM2.5[Figure 4]. We should note that the readings for locations with observed smoking are 14 times higher than the WHO target air quality guideline for PM2.5 10 µg/m 3 (annual mean) in Bangalore city, while the similar readings were 19 times higher in Dharwad city. The average level of PM2.5 in city, semiurban and rural areas in Bangalore district is lower than the average PM2.5 in similar locations of Dharwad district. By this we cannot infer that the implementation of smoke free law is relatively better in Bangalore district although it includes capital city because as shown in [Figure 1] and [Figure 2], the rate of illegal smoking and absence of 'no smoking signage' is higher in Bangalore city and suburb. This indicates that there is long way to go in enforcing tobacco control laws in the state. If the situation in the capital city is not conducive to the law, it could be still worse in smaller cities and rural areas where general awareness about the laws is very low. However, the average PM2.5 was found to be lower in smoke observed locations of Bangalore rural (by 7%), Bangalore suburb (by 56%), and Bangalore city (by 31%) as compared to respective locations in Dharwad district. But, if we compare air quality in hospitality locations of cities with air quality of locations in villages and suburbs, there is a marked difference between them. PM2.5 was slightly lower in smoke observed locations of suburb and rural areas in both the districts as compared to PM2.5 in cities. These observations do not speak of better air quality or compliance in suburban and rural areas because it was observed during the field survey that patrons some of whom are also the smokers after taking tea or snacks come out of the location and smoke at the entrance of the tea stalls or restaurants. It is difficult for them to sit inside and smoke as the places are too small. Since we monitored air quality inside of the locations, the effects of outdoor smoking are not captured.
|Figure 4: Comparative levels of PM2.5in smoke observed and smoke free locations in Dharwad district and Karnataka|
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As shown in [Figure 1] and [Figure 2], none of the locations in the sample except three locations in Bangalore city (23%) have DSR for smokers. The three bars and restaurants having DSR have fixed exhaust fans. Sometimes the smoke goes to first floor if the bar is located in ground floor. Out of the three locations, which have DSR for smokers, only one location has apparently compliant DSR as also indicated by lower PM2.5 (49) recorded in its premises, which is lower by 192% than average PM2.5 of Karnataka state (sample locations). But, in the case of other two locations, which have DSR the PM2.5 was higher than the average for the sample location by 2 and 96%. And none of the DSRs have air quality as per the standards set by WHO for PM2.5 which is 10 µg/m 3 (annual mean). We should also note that it may be difficult to achieve this level of PM2.5 even in nonsmoking locations as there is deterioration in air quality for many other reasons. Having compliant DSRs would however reduce the level of exposure to secondhand smoke as shown by reduced PM2.5 levels in one of the locations with DSR noted above.
A matter of concern was that indoor air pollution in smoke observed locations in Bangalore city was found to be higher than air pollution recorded by officials of Karnataka State Pollution Control Board measured in terms of PM2.5 in traffic, commercial, and outdoor residential areas of Bangalore city.
The lowest levels of average PM2.5 within the sample was observed in smoke free locations of Dharwad suburb (28 PM2.5) and Bangalore suburb (31 PM2.5) and the highest levels of average PM2.5 within the sample was recorded in smoke observed locations of Dharwad city (187 PM2.5) and Bangalore city (143 PM2.5). PM2.5 was observed to be more than 300 in some of the bars, which serve nonvegetarian food and alcohol. Average PM2.5 levels ranged from 11 to 417 µg/m 3 with peak levels recorded even at 3,070 PM2.5 in one of the bars and restaurants. All PM2.5 differences between smoke free and smoking observed locations were found to be statistically significant (P < 0.05). Active smoker density (average number of burning cigarettes per 100 cubic meters) observed per location was found to be higher in suburb and rural areas of Bangalore district and in city and rural areas of Dharwad district. Higher smoker density can result in higher levels of secondhand smoking as there would be more number of smokers exhaling smoke within a specified space.
As discussed above hospitality locations serving liquor and nonvegetarian food showed highest levels of PM2.5. Therefore we tried to see average PM2.5 separately for bars and restaurants, tea stalls and cafes, and hotels and restaurants. The results are presented in [Table 1]. Hotels and restaurants, which generally serve vegetarian food had lowest levels of PM2.5 followed by cafe and tea stalls. Bars and restaurants serving liquor and nonvegetarian food had highest levels of PM2.5 showing higher levels in Dharwad district compared to Bangalore district. In rural Dharwad we did not get any bar and restaurant within the sample.
|Table 1: Average particulate air pollution from secondhand smoke (PM2.5) in bars and restaurants, cafe and tea stalls, and hotels and restaurants|
Click here to view
COTPA provides for DSR to protect the public from secondhand smoke. But, providing separate space for smoking is a difficult task due to limited space in already established restaurants and tea stalls. In rural areas the tea shop owners said that they feel awkward to ask a smoking person to sit apart as there is close bonding with the customers who gather at tea clubs to chat and socialize. Similar is the situation in suburbs and smaller city like Dharwad. We found all the locations in the entire sample to be without DSR, except three pubs (4% of entire sample and 7% of smoke observed places) in Bangalore, which exhibited compliance to smoke free law.
It is found that ash trays in cities and suburb are not kept on the table may be due to fear of sudden inspection by authorities. But smokers are allowed to throw stubs on the ground or table. Some restaurants provide waste paper also. In rural areas, ash trays were never demanded nor placed on table even earlier to implementation of the smoke free law. Villagers throw the buds on the floor or ground. According to this study smoking is rare in vegetarian and family restaurants in cities. But all the nonvegetarian restaurants and bars/pubs with restaurants allowed smoking. So at the prima facie there appears to be some link between smoking and the nature of food intake and consumption of alcoholic drinks.
The managers of hospitality locations particularly in rural areas know that smoking is bad, but do not know that it should not be allowed in their tea stalls and restaurants. They are aware of the hazards of active smoking, but not the harmful effects of secondhand smoking. None of them have ever been questioned by authorities for allowing smoking in their premises. So there is no compulsion and alarm on their part to implement the smoke free rules.
| » Discussion|| |
The results of this study as presented above as well in earlier reports , indicate that in Karnataka the implementation of smoke free law is very weak. In all the areas including the capital city of Bangalore compliance to smoke free law by the hospitality sector is found to be unsatisfactory. Only 6% of the sample locations were found to be 100% compliant to the law. There is a long way to go to create awareness about smoke free law in the entire state and alert the people, government functionaries, the hospitality sector, educational institutions, etc., on the hazards of tobacco consumption. From the discussions that were carried out after the survey with regulatory authorities, it was felt that they are not serious about implementation of smoke free law as they have to attend to other crimes. General public, smokers, and customers; particularly in villages are not bothered about smoking and its effects. The hospitality sector in rural areas is unable to provide DSR as there is limited space within the locations. DSRs wherever provided (only in three locations) are not compliant with law and there is no proper understanding on the actual design among the managers/owners of hospitality locations. It would be difficult for other restaurants and tea stalls in cities and suburbs to provide for DSR as the buildings are already in congested area and the land value is very high. Provision of DSR is not a solution to the problem and cannot guarantee smoke free environment outside the DSR. Therefore, there cannot be any relaxation for smoking and complete ban in public places can only be the solution. As per the observations from the study smoking is found unabated in public places. The managers and owners of hospitality locations opine that to avoid smoking in public places there should not be permission for sale of smoking products near the public places, which practically is not possible unless government restricts the sale to specific points or locations similar to the provision of markets arranged for sale of fish, meat, crackers, etc., in most parts of India. The awareness among law enforcers about the provisions of the Act is also very low. Enforcement of smoke free regulations is weak, unplanned, and a non-priority issue to authorities. And none of the smoking observed locations had cases filed against them neither by customers nor the police for violating the Act.
Aftermath of the survey
The study comprised of basic research, surveillance, action, and advocacy. Immediately after completion of the study, press meets, capacity building, and awareness/sensitization programs were organized for the law enforcers and regulatory authorities. The results were disseminated to the association of hotels, bars, and restaurants compelling them to display signage. Workshops were organized in educational institutions. Awards were given in media seminars through the city Police Commissioner for complying hospitality locations as incentives for best practices as well to exhibit demonstration effect on other hotels/restaurants. The results of the study were accessible to public through media, which gave wider coverage of the results of the study.
| » Conclusion|| |
Who should communicate about smoke free laws to the managers and owners of public places and general public in remote places including suburbs and rural areas? Whose responsibility it is? Is it only through the media that the public should know about these rules? Has the government made enough advertisement of the rules made in the Smoke Free Act, 2003 in cities, semiurban, and rural areas? Do the enforcing officers fine for violations of the rules specified under the Act? Who else is responsible for collecting fines? Where should it be remitted? Can people smoke on the roadside? These are some of the questions for which majority of the enforcing officers and the general public does not have answers. Due to lack of awareness about the law and seriousness of the problem, the implementation of Smoke Free Act appears to be weak in the state.
The study shows that the patrons and the workers in the hospitality sector continue to be exposed to secondhand smoke despite the enactment of Indian COTPA, 2003, which bans smoking in public places and it should be noted that there is no safe level of exposure determined for secondhand smoke. The provision of DSR is a costly affair and cannot guarantee nonexposure to secondhand smoke within the same premises if people frequently move in and out of the venue. The results of the study also show PM2.5 in locations with DSR to be higher than their recorded levels in nonsmoking zones. DSR needs adequate space, proper designing, air vent for upward passing of smoke, and monitoring; which is not strictly adhered to in any of the three locations (with DSR) surveyed under the study. To provide safe and clean air to the patrons, all indoor hospitality locations should be 100% smoke free without any relaxations.
The violation of the ban should be treated on par with any other crimes in the interest of public health. The situation can improve only when authorities exhibit zero tolerance level to smoking in public places. In India the Smoke Free Law can be effectively implemented in urban and rural areas with the involvement of local self government entities viz. municipal bodies and village panchayats in planning and execution of advocacy programs for smoke free environment and support from the police department. The smoke free campaign in this connection should begin with big push and large scale coverage and be continued till the goal is reached. Only when the civil society and NGOs join hands with the government we can expect a tobacco free society.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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