Air Quality, Biomarker Levels, and Health Effects on Staff in Korean Restaurants and Pubs Before and After a Smoking Ban

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

Optimum Urine Cotinine and NNAL Levels to Distinguish Smokers from Non-Smokers by the Changes in Tobacco Control Policy in Korea from 2008 to 2018

INTRODUCTION

We examined the age- and sex-specific distributions of biomarkers of tobacco smoke exposure to determine the optimal cutoffs to distinguish smokers from non-smokers over the last 10 years in Korea, during which smoking prevalence and secondhand smoke (SHS) exposure declined due to changes in tobacco control policy.

METHODS

We analyzed data from the Korea National Health and Nutrition Examination Survey on creatinine-adjusted urinary cotinine (2008-2018; 33 429 adults: 15 653 males and 17 776 females) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; 2016-2018; 6337 adults: 3091 males and 3246 females). We determined the optimal cutoffs and confidence intervals (CIs) to distinguish smokers from non-smokers using receiver operator characteristic curve analysis and bootstrapping (1000 resamples).

RESULTS

The optimal cutoff values of creatinine-adjusted urine cotinine and NNAL concentration were 20.9 ng/mg (95% CI: 20.8-21.0, sensitivity: 96.6%, specificity: 93.8%) and 8.9 pg/mg (95% CI: 8.8-8.9, sensitivity: 94.0%, specificity: 94.7%), respectively, in 2016-2018. The optimal cutoffs of both biomarkers increased with age and were higher in females than in males for NNAL concentration. In both sexes, the optimal cutoff of urine cotinine continuously declined over the study period.

CONCLUSIONS

The optimal cotinine cutoff declined along with smoking prevalence and levels of SHS exposure due to enforcement of tobacco control policies, including smoke-free ordinances and tax increases. Monitoring of biomarkers of tobacco exposure appears necessary for verification of smoking status and regulatory use.

IMPLICATIONS

Our results based on nationally representative data suggest that a large decrease in the optimal cutoff value of urine cotinine to distinguish smokers from non-smokers was caused by decreases in smoking prevalence and SHS exposure following enforcement of tobacco control policies over the last 10 years. We determined the optimal cutoff values of urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), which were not previously reported in representative population in Asia, to enable more accurate estimation of exposure to tobacco smoke and proper assessment of disease risks. Gender- and age-specific differences in the optimal cutoffs require further study. Monitoring of biomarkers of tobacco smoke exposure seems necessary for verification of smoking status and regulatory use.

Relationship Between Urinary 4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanol and Lung Cancer Risk in the General Population: A Community-Based Prospective Cohort Study

No published studies have prospectively evaluated the association between urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) levels and lung cancer risk in the general population. Here, we conducted a prospective community-based cohort study in the Republic of Korea to evaluate the relationship between urinary NNAL levels and lung cancer risk using prediagnostic urine samples. This prospective cohort study was based on the Korean National Cancer Center Community Cohort. During the follow-up period, 173 primary lung cancer cases were identified. Total urinary NNAL levels were measured by liquid chromatography-tandem mass spectrometry, and data were analyzed using multivariable Cox proportional hazards regression models. The risk of lung cancer was significantly increased per unit of natural log-transformed urinary NNAL (HR, 1.27; 95% CI, 1.09-1.48), after adjusting for age, region, entry year into the cohort, education achievement, alcohol consumption status, BMI, smoking status, and urinary cotinine levels. Cox proportional-hazards models with NNAL quartiles also showed positive dose-response relationships with risk of lung cancer. A significantly increased risk of lung cancer was found in the fourth quartile of urinary NNAL levels (HR, 3.27; 95% CI, 1.37-7.79, P for trend < 0.01). After stratification with sex, the significant association remained in only men. Urinary NNAL levels are associated with the risk of lung cancer in the general population, and this association is independent from the quantification of cigarette smoking and nicotine uptake.

The impact of anti-tobacco legislation on birth weight in Peru

Background

Tobacco exposure remains a significant issue for public health, especially for pregnant women. It increases the risk for premature labor, low birth weight and small for gestational age (SGA), among other effects. To reduce these risks, many countries have enacted public policies to curb tobacco exposure. Peru enacted anti-tobacco laws that forbid smoking in public places, require prevention text and images in products and publicity, along with restriction of sales to adults. We evaluated the effect of the implementation of this law on newborn outcomes: birth weight, prematurity and SGA.

Methods

This was a quasi-experimental study that utilized data from the Peruvian Live Birth Registry. Children born to mothers from urban areas were the intervention group, while children born to mothers from rural areas were considered the control group. Only singletons with information on birth weight and gestational age, born to mothers aged 12 to 49 years were included in the study. In addition, newborns with birth weights greater than + 4 standard deviations (SD) or less than - 4 SD from the gestational age-specific mean were excluded. To measure the effect of legislation on birth weight we performed a difference in differences analysis.

Results

A total of 2,029,975 births were included in the analysis. After adjusting for characteristics of the mother and the child, and contextual variables, the anti-tobacco law in Peru reduced the incidence of prematurity by 30 cases per 10,000 live births (95% CI: 19 to 42).

Conclusions

The reform had negligible effects on overall birth weights and on the incidence of SGA. This modest result suggests the need for a more aggressive fight against tobacco, prohibiting all types of advertising and promotion of tobacco products, among others measures.

Changes in urinary cotinine concentrations in non-smoking adults from the Korean National Environmental Health Survey (KoNEHS) II (2012-2014) after implementation of partial smoke-free regulations

BACKGROUND

The Korean government implemented partial smoke-free regulations in hospitality venues ≥150 m² in July 2013 and in venues ≥100 m² in February 2014. This study examined changes in urinary cotinine concentrations in the Korean non-smoking adult population, and socio-demographic subgroups thereof, between 2012 and 2014, and the relationships between urinary cotinine concentrations and socio-demographic factors in 2014.

METHODS

Data from the Korean National Environmental Health Survey II (2012-2014), a nationally representative cross-sectional study, were used. In total, 4218 non-smoking adults (≥19 years) were selected based on questionnaires and urinary cotinine concentrations. Linear trend tests of urinary cotinine over time and socio-demographic factors associated with urinary cotinine in 2014 were examined based on weighted linear regression models.

RESULTS

Overall, the covariate-adjusted least-square geometric mean concentrations of urinary cotinine were 2.95 μg/g creatinine (Cr) (95% confidence interval, CI = 2.37-3.67) in 2012, 1.54 μg/g Cr (95% CI = 1.26-1.88) in 2013, and 1.47 μg/g Cr (95% CI = 1.23-1.76) in 2014, a significant decrease during 2012-2014. Urinary cotinine concentrations decreased significantly during 2012-2014 in most socio-demographic subgroups. However, concentrations in adults who worked in hospitality venues, including restaurants, bars, cafes, fast-food franchises, and bakeries, remained unchanged. Data from 2014, when smoke-free regulations were implemented in hospitality venues ≥100 m², showed urinary cotinine concentrations were significantly higher in adults working in hospitality venues than in unemployed adults.

CONCLUSIONS

Overall, urinary cotinine concentrations of Korean non-smoking adults decreased during 2012-2014. However, implementation of partial smoke-free regulations in hospitality venues was not effective in reducing secondhand smoke exposure in workers at hospitality venues.

Biomarkers of Exposure to Secondhand and Thirdhand Tobacco Smoke: Recent Advances and Future Perspectives

Smoking is the leading preventable disease worldwide and passive smoking is estimated to be the cause of about 1.0% of worldwide mortality. The determination of tobacco smoke biomarkers in human biological matrices is key to assess the health effects related to the exposure to environmental tobacco smoke. The biomonitoring of cotinine, the main nicotine metabolite, in human biofluids-including urine, serum or saliva-has been extensively used to assess this exposure. However, the simultaneous determination of cotinine together with other tobacco biomarkers and the selection of alternative biological matrices, such as hair, skin or exhaled breath, would enable a better characterization of the kind and extent of tobacco exposure. This review aims to perform a critical analysis of the up-to-date literature focused on the simultaneous determination of multiple tobacco smoke biomarkers studied in different biological matrices, due to the exposure to secondhand smoke (SHS) and thirdhand smoke (THS). Target biomarkers included both tobacco-specific biomarkers-nicotine and tobacco specific nitrosamine biomarkers-and tobacco-related biomarkers, such as those from polycyclic aromatic hydrocarbons, volatile organic compounds, metals and carbon monoxide. To conclude, we discuss the suitability of determining multiple biomarkers through several relevant examples of SHS and THS exposure.

Factors associated with secondhand smoke incursion into the homes of non-smoking residents in a multi-unit housing complex: a cross-sectional study in Seoul, Korea

Background

In a multi-unit housing (MUH) complex, secondhand smoke (SHS) can pass from one living space to another. The aim of this study was to determine the prevalence of SHS incursion, and to establish the relationship between SHS incursion and socio-demographic and built environmental factors in MUH in Korea.

Methods

A population-based sample of 2600 residents (aged ≥19 years) living in MUH from across the city of Seoul, Korea, was obtained through a web-based selection panel. The residents completed a questionnaire detailing socio-demographic factors, smoking status, frequency of SHS incursion, and built environmental factors. The presence of a personal smoke-free home rule was determined by residents declaring that no one smoked inside the home.

Results

Of the 2600 participants, non-smoking residents who lived in homes with a personal smoke-free rule were selected for further analysis (n = 1784). In the previous 12 months, 74.7% of residents had experienced SHS incursion ≥1 times. A multivariate ordinal logistic regression analysis indicated that residents who spent more time at home, lived with children, supported the implementation of smoke-free regulations in MUH, lived in small homes, lived in homes with natural ventilation provided by opening a front door or the windows and front door, and lived in homes with more frequent natural ventilation were more likely to report SHS incursion into their homes.

Conclusions

The majority of the non-smoking residents experienced SHS incursion, even with a personal smoke-free rule in their homes. A smoke-free policy in MUH is needed to protect residents from SHS exposure when they are at home.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4774-x) contains supplementary material, which is available to authorized users.

Smokefree legislation effects on respiratory and sensory disorders: A systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis is to synthesize the available evidence in scientific papers of smokefree legislation effects on respiratory diseases and sensory and respiratory symptoms (cough, phlegm, red eyes, runny nose) among all populations.

Materials and methods

Systematic review and meta-analysis were carried out. A search between January 1995 and February 2015 was performed in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and Google Scholar databases. Inclusion criteria were: 1) original scientific studies about smokefree legislation, 2) Data before and after legislation were collected, and 3) Impact on respiratory and sensory outcomes were assessed. Paired reviewers independently carried out the screening of titles and abstracts, data extraction from full-text articles, and methodological quality assessment.

Results

A total number of 1606 papers were identified. 50 papers were selected, 26 were related to symptoms (23 concerned workers). Most outcomes presented significant decreases in the percentage of people suffering from them, especially in locations with comprehensive measures and during the immediate post-ban period (within the first six months). Four (50%) of the papers concerning pulmonary function reported some significant improvement in expiratory parameters. Significant decreases were described in 13 of the 17 papers evaluating asthma hospital admissions, and there were fewer significant reductions in chronic obstructive pulmonary disease admissions (range 1–36%) than for asthma (5–31%). Six studies regarding different respiratory diseases showed discrepant results, and four papers about mortality reported significant declines in subgroups. Low bias risk was present in 23 (46%) of the studies.

Conclusions

Smokefree legislation appears to improve respiratory and sensory symptoms at short term in workers (the overall effect being greater in comprehensive smokefree legislation in sensory symptoms) and, to a lesser degree, rates of hospitalization for asthma.

Performance of urine cotinine and hypomethylation of AHRR and F2RL3 as biomarkers for smoking exposure in a population-based cohort

There is a growing body of evidence demonstrating an association between smoking and DNA methylation. Accordingly, DNA methylation is now considered a promising biomarker of smoking exposure. We evaluated the relationship between methylation markers (AHRR and F2RL3) and urine cotinine as well as self-reported smoking status. DNA methylation levels of AHRR and F2RL3 in blood as well as urine cotinine were measured in 330 adults (46 to 87 years of age). Pyrosequencing was performed to measure DNA methylation of AHRR and F2RL3 associated with smoking exposure. The lung cancer risk associated with DNA methylation and urine cotinine was analyzed using logistic regression analysis. The AHRR and F2RL3 genes were significantly hypomethylated in current smokers compared to in individuals who have never smoked. An inverse relationship was observed between urine cotinine and methylation levels. Methylation of AHRR and F2RL3 distinguished current smokers from never-smokers with high accuracy. Logistic multivariate analysis showed that AHRR methylation is significantly associated with the risk of lung cancer (OR = 0.96, P = 0.011). Our study validated the smoking-associated DNA methylation markers reported in a Korean population-based cohort. In conclusion, DNA methylation of AHRR and F2RL3 provided accurate measures for smoking exposure. Methylation markers reflecting the long-term effect of smoking on the risk of lung cancer showed better performance in distinguishing former smokers from never-smokers.

Slowing the Titanic: China's Epic Struggle with Tobacco

China is home to a third of the world's smokers and, correspondingly, to a third of the world's cases of lung cancer. Beginning in the mid-1990s, a generation or so later than in many Western countries, the Chinese government commenced measures to control tobacco, limiting advertising, banning smoking in many public venues, and increasing taxation. At the time of this review, there are signs that these policies are having some effect, but hundreds of millions of Chinese continue to smoke and rates of diagnosis of lung cancer continue to rise. There is much work to be done and much premature death to be suffered before the epidemic is slowed to the levels reached in Australia or the United States. This article aims to provide, particularly for practicing lung cancer clinicians, a description of patterns of smoking in China, the lung cancer epidemic there, and the stimuli for and barriers to tobacco control imposed by the highly complex and unique regulatory setting of the Chinese tobacco industry. A particular challenge in developing this description has come from the variability of studies published about a huge nation that has enormous diversity in wealth, education, urbanization, and tradition. The studies vary because the data vary. Much information on lung cancer and smoking rates in China comes, for example, from studies of cohorts that may number in the millions yet represent only a small percentage of the population and sometimes only a tiny geographic area of such a vast nation. National registry data on lung cancer in China do not yet cover even a fifth of the national population. Even so, we argue that several major trends can be identified: (1) more than 50% of men smoke regularly; (2) there are more than 300 million smokers in China; (3) almost half a million new cases of lung cancer are diagnosed in China each year; (4) secondhand smoking is a significant problem in China (as elsewhere), accounting for a high proportion of lung cancer cases among women, most of whom do not smoke; (5) corrected for age and sex, lung cancer rates in the Chinese population are as least as high as in Western countries and arguably higher; and (6) a shift over time from squamous cell carcinoma (SCC) to adenocarcinoma is occurring in parallel with that noted in Western populations. Looking to the future, measures to control tobacco in China are strengthening but remain relatively weak. The reinforcement of control is hampered by the circumstance that the tobacco industry remains a powerful state-owned monopoly that participates, through its membership of key government bodies, in the processes that oversee the implementation of tobacco control. The conflict between the government's dual responsibilities for both the production and distribution of tobacco and for the implementation of tobacco control carries inherent contradictions and bias. How long the Chinese government chooses to live with these contradictions will determine how quickly the smoking of tobacco will be reduced and how soon the burden of disease that tobacco inflicts on individuals and society as a whole will be eased.

Association between Secondhand Smoke in Hospitality Venues and Urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol Concentrations in Non-Smoking Staff

The purpose of this study was to determine the relationship between urinary cotinine and total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) concentrations in non-smoking staff and the indoor levels of fine particles (PM_2.5) in hospitality venues that allow smoking, with respect to demographic and indoor environmental factors. We evaluated 62 hospitality venues that allowed smoking in Seoul, Korea. A real-time aerosol monitor was used to measure indoor PM_2.5 concentrations. Field technicians recorded indoor environmental characteristics. One non-smoking staff member in each hospitality venue was tested for urinary cotinine and total NNAL concentrations. Demographic characteristics were obtained from self-reported staff questionnaires. Natural-log (ln)-transformed PM_2.5 concentrations were significantly correlated with the ln-transformed cotinine (r = 0.31) and the total NNAL concentrations (r = 0.32). In multivariable regression analysis, the urinary cotinine concentrations of the staff members were significantly correlated with indoor PM_2.5 concentrations; those with the highest concentrations were more likely to be women or staff members that worked in venues with a volume <375 m³. Total NNAL concentrations were significantly correlated only with indoor PM_2.5 concentrations. Indoor PM_2.5 may be used as an indicator for urinary cotinine and total NNAL concentrations in non-smoking staff members in hospitality venues that allow smoking.

Impact of Partial and Comprehensive Smoke-Free Regulations on Indoor Air Quality in Bars

In Korea, smoke-free regulations have been gradually implemented in bars based on venue size. Smoking bans were implemented in 2013 for bars ≥150 m², in 2014 for bars ≥100 m², and in 2015 for bars of all sizes. The purpose of this study was to determine indoor fine particle (PM2.5) concentrations in bars before and after implementation of the smoke-free policies based on venue size. Indoor PM2.5 concentrations were measured with real-time aerosol monitors at four time points: (1) pre-regulation (n = 75); (2) after implementing the ban in bars ≥150 m² (n = 75); (3) after implementing the ban in bars ≥100 m² (n = 107); and (4) when all bars were smoke-free (n = 79). Our results showed that the geometric mean of the indoor PM2.5 concentrations of all bars decreased from 98.4 μg/m³ pre-regulation to 79.5, 42.9, and 26.6 μg/m³ after the ban on smoking in bars ≥150 m², ≥100 m², and all bars, respectively. Indoor PM2.5 concentrations in bars of each size decreased only after the corresponding regulations were implemented. Although smoking was not observed in Seoul bars after smoking was banned in all bars, smoking was observed in 4 of 21 bars in Changwon. Our study concludes that the greatest decrease in PM2.5 concentrations in bars was observed after the regulation covering all bars was implemented. However, despite the comprehensive ban, smoking was observed in bars in Changwon. Strict compliance with the regulations is needed to improve indoor air quality further.

Characterization of urinary cotinine in non-smoking residents in smoke-free homes in the Korean National Environmental Health Survey (KoNEHS)

BACKGROUND

The objectives of this study were to determine urinary cotinine concentrations in non-smoking residents of smoke-free homes and to establish the relationship of urinary cotinine with housing type and other socio-demographic and secondhand smoke (SHS) exposure factors.

METHODS

We used data from the Korean National Environmental Health Survey I (2009-2011). The study included 814 non-smoking adult residents living in apartments, attached, and detached housing. Residents who lived with smokers were excluded. Urinary cotinine concentration was used as a biomarker for SHS exposure. The factors associated with urinary cotinine levels in non-smoking residents were determined using multivariate regression analysis.

RESULTS

Urinary cotinine was detected in 88 % of the 814 non-smoking residents of smoke-free homes. The urinary cotinine concentrations of residents living in attached [1.18 ng/mg creatinine (Cr)] and detached housing (1.23 ng/mg Cr) were significantly higher than those of residents who lived in apartments (0.69 ng/mg Cr). Urinary cotinine concentrations were significantly higher in residents who were men, those with a household income ≤1000 USD/month, those who were former smokers with >1 year and ≤1 year of not smoking, and those who experienced SHS odor every day. In the multivariate regression analysis, housing type, sex, former smoking status, and frequency of experiencing SHS odor were associated with urinary cotinine concentrations (R (2) = 0.14).

CONCLUSIONS

The majority of non-smoking residents of smoke-free homes had detectable urinary cotinine. Housing type, sex, former smoking status, and frequency of experiencing SHS odor were predictors for urinary cotinine concentrations in the study participants.