Measurement of airborne nicotine, as a marker of secondhand smoke exposure, in homes with residents who smoke in 9 European countries.

OBJECTIVE: Smoke-free policies are effective in preventing secondhand smoke (SHS) exposure, but their adoption at home remains largely voluntary. This study aimed to quantify SHS exposure in homes with residents who smoke in Europe according to households' characteristics, tobacco consumption habits, and national contextual factors. METHODS: Cross-sectional study (March 2017-September 2018) based on measurements of air nicotine inside 162 homes with residents who smoke from nine European countries. We installed passive samplers for seven consecutive days to monitor nicotine concentrations. Through self-administered questionnaires, we collected sociodemographic information and the number of individuals who smoke, smoking rules, frequency, location, and quantity of tobacco use in households. Country-level factors included the overall score in the Tobacco Control Scale 2016, the smoking prevalence, and self-reported SHS exposure prevalence. Nicotine concentrations were analyzed as continuous and dichotomous variables, categorized based on the limit of quantification of 0.02 µg/m3. RESULTS: Overall, median nicotine concentration was 0.85 µg/m3 (interquartile range (IQR):0.15-4.42), and there was nicotine presence in 93% of homes. Participants reported that smoking was not permitted in approximately 20% of households, 40% had two or more residents who smoked, and in 79% residents had smoked inside during the week of sampling. We found higher nicotine concentrations in homes: with smell of tobacco smoke inside (1.45 µg/m3 IQR: 0.32-6.34), where smoking was allowed (1.60 µg/m3 IQR: 0.68-7.63), with two or more residents who smoked (2.42 µg/m3 IQR: 0.58-11.0), with more than 40 cigarettes smoked (2.92 µg/m3 IQR: 0.97-10.61), and where two or more residents smoked inside (4.02 µg/m3 IQR: 1.58-11.74). Household nicotine concentrations were significantly higher in countries with higher national smoking prevalence and self-reported SHS exposure prevalence (p < 0.05). CONCLUSIONS: SHS concentrations in homes with individuals who smoke were approximately twenty times higher in homes that allowed smoking compared to those reporting smoke-free household rules. Evidence-based interventions promoting smoke-free homes should be implemented in combination with strengthening other MPOWER measures.

Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries.

OBJECTIVE: Due to partial or poorly enforced restrictions secondhand tobacco smoke (SHS) is still present in outdoor hospitality venues in many European countries. This study aimed to assess SHS concentrations in outdoor hospitality venues across Europe and identify contextual exposure determinants. METHODS: Cross-sectional study. We measured airborne nicotine and evidence of tobacco use in terraces of bars, cafeterias, and pubs from 11 European countries in 2017-2018. Sites were selected considering area-level socioeconomic indicators and half were visited during nighttime. We noted the smell of smoke, presence of smokers, cigarette butts, ashtrays, and number of physical covers. Contextual determinants included national smoke-free policies for the hospitality sector, the Tobacco Control Scale score (2016), and the national smoking prevalence (2017-2018). We computed medians and interquartile ranges (IQR) of nicotine concentrations and used multivariate analyses to characterize the exposure determinants. RESULTS: Nicotine was present in 93.6% of the 220 sites explored. Overall concentrations were 0.85 (IQR:0.30-3.74) µg/m3 and increased during nighttime (1.45 IQR:0.65-4.79 µg/m3), in enclosed venues (2.97 IQR:0.80-5.80 µg/m3), in venues with more than two smokers (2.79 IQR:1.03-6.30 µg/m3), in venues in countries with total indoor smoking bans (1.20 IQR:0.47-4.85 µg/m3), and in venues in countries with higher smoking prevalence (1.32 IQR:0.49-5.34 µg/m3). In multivariate analyses, nicotine concentrations were also positively associated with the observed number of cigarette butts. In venues with more than two smokers, SHS levels did not significantly vary with the venues' degree of enclosure. CONCLUSIONS: Our results suggest that current restrictions in outdoor hospitality venues across Europe have a limited protective effect and justify the adoption of total smoking bans in outdoor areas of hospitality venues.

Who Smokes in Europe? Data From 12 European Countries in the TackSHS Survey (2017-2018).

BACKGROUND: Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries. METHODS: Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants. RESULTS: Overall, 25.9% of participants were current smokers (31.0% of men and 21.2% of women, P < 0.001), while 16.5% were former smokers. Smoking prevalence ranged from 18.9% in Italy to 37.0% in Bulgaria. It decreased with increasing age (compared to <45, multivariable odds ratio [OR] for ≥65 year, 0.31; 95% confidence interval [CI], 0.27-0.36), level of education (OR for low vs high, 1.32; 95% CI, 1.17-1.48) and self-rated household economic level (OR for low vs high, 2.05; 95% CI, 1.74-2.42). The same patterns were found in both sexes. CONCLUSIONS: These smoking prevalence estimates represent the most up-to-date evidence in Europe. From them, it can be derived that there are more than 112 million current smokers in the EU-28. Lower socio-economic status is a major determinant of smoking habit in both sexes.

Passive exposure of non-smokers to E-Cigarette aerosols: Sensory irritation, timing and association with volatile organic compounds.

AIM: The current study examined symptoms of irritation reported by non-smokers passively exposed to e-cigarette aerosols and their timing and association with the concentrations of volatile organic compounds (VOCs) produced. METHODS: 40 healthy non-smoking adults were exposed to e-cigarette aerosols for 30 min in a 35 m3 room. Second-hand e-cigarette aerosol (SHA) was produced by an experienced e-cigarette user using a standardized topography and two resistance settings (exposure 0.5 Ohm and 1.5 Ohm), in addition to a control session (no emissions). PM2.5 and PM1.0 were continuously measured over the duration of exposure, while Volatile Organic Compounds (VOCs) were recorded at 0, 15 and 30 min (t0, t15 and t30) of exposure. Each participant completed an irritation questionnaire at t0, t15, t30 of exposure and t60 (30 min post-exposure) on ocular, nasal, throat-respiratory symptoms of irritation and general complaints. Kruskal-Wallis H test for PM comparisons, repeated measures ANOVA for VOCs and Generalized Estimating Equations for symptoms of irritation and association with VOCs were used for statistical analysis. RESULTS: 20 males and 20 females, with a mean age of 24.6 years (SD = 4.3) and exhaled CO < 7 ppm participated. PM concentrations in both experimental sessions were higher than the Control (p < 0.001). The most commonly reported symptoms were burning, dryness, sore throat, cough, breathlessness and headache. During both experimental sessions, ocular, nasal, throat-respiratory symptoms and general complaints increased significantly (p < 0.05). Ocular and nasal symptoms returned to baseline by t60 (p > 0.05) while throat-respiratory symptoms were still significantly higher at t60 (p = 0.044). VOCs were significantly associated with reported nasal and throat-respiratory symptoms in both experimental sessions (p < 0.05). CONCLUSION: A 30-min exposure to SHA provoked symptoms of sensory irritation and general complaints that lasted up to 30 min after the exposure and were positively associated with the concentrations of the VOC mixture emitted.

Exposure to secondhand aerosol from electronic cigarettes at homes: A real-life study in four European countries.

Electronic cigarette (e-cigarette) use emits potentially hazardous compounds and deteriorates indoor air quality. Home is a place where e-cigarettes may frequently be used amid its increasing prohibition in public places. This study assessed the real-life scenario of bystanders' exposure to secondhand e-cigarette aerosol (SHA) at home. A one-week observational study was conducted within the TackSHS project in four countries (Greece, Italy, Spain, and the United Kingdom) in 2019 including: 1) homes of e-cigarette users living together with a non-user/non-smoker; and 2) control homes with no smokers nor e-cigarette users. Indoor airborne nicotine, PM2.5, and PM1.0 concentrations were measured as environmental markers of SHA. Biomarkers, including nicotine and its metabolites, tobacco-specific nitrosamines, propanediol, glycerol, and metals were measured in participants' saliva and urine samples. E-cigarette use characteristics, such as e-cigarette refill liquid's nicotine concentration, e-cigarette type, place of e-cigarette use at home, and frequency of ventilation, were also collected. A total of 29 e-cigarette users' homes and 21 control homes were included. The results showed that the seven-day concentrations of airborne nicotine were quantifiable in 21 (72.4 %) out of 29 e-cigarette users' homes; overall, they were quite low (geometric mean: 0.01 µg/m3; 95 % CI: 0.01-0.02 µg/m3) and were all below the limit of quantification in control homes. Seven-day concentrations of PM2.5 and PM1.0 in e-cigarette and control homes were similar. Airborne nicotine and PM concentrations did not differ according to different e-cigarette use characteristics. Non-users residing with e-cigarette users had low but significantly higher levels of cotinine, 3'-OH-cotinine and 1,2-propanediol in saliva, and cobalt in urine than non-users living in control homes. In conclusion, e-cigarette use at home created bystanders' exposure to SHA regardless of the e-cigarette use characteristics. Further studies are warranted to assess the implications of SHA exposure for smoke-free policy.

Secondhand smoke exposure in outdoor children's playgrounds in 11 European countries.

INTRODUCTION: Tobacco presence in outdoor children's playgrounds is concerning not only because it leads to secondhand smoke (SHS) exposure, but also cigarette butt pollution and tobacco normalization. OBJECTIVES: This study aimed to assess SHS exposure in children's playgrounds, according to area-level socioeconomic status (SES), smoke-free regulations, national smoking prevalence, and SHS exposure prevalence in playgrounds (2017-2018). METHODS: We monitored vapor-phase nicotine concentration and tobacco-related variables in 20 different playgrounds in 11 European countries (n = 220 measurements) from March 2017 to April 2018. Playgrounds were selected according to area-level SES. Data on the number of people smoking, and cigarette butts inside the playground and on playground surroundings (<1 m away) were recorded. Playground smoking bans, the Tobacco Control Scale (TCS) score, national smoking prevalence and SHS exposure prevalence in playgrounds were used to group countries. To determine nicotine presence, we dichotomized concentrations using the limit of quantification as a cut-off point (0.06 µg/m3). Nicotine median concentrations were compared using non-parametric tests, and nicotine presence and tobacco-related observational variables using the Chi-squared test. RESULTS: Airborne nicotine presence was found in 40.6% of the playgrounds. Median nicotine concentration was <0.06 µg/m3 (Interquartile range: <0.06-0.125) and higher median concentrations were found in more deprived neighborhoods, non-regulated playgrounds, in countries with lower overall TCS scores, higher national smoking prevalence and higher SHS exposure prevalence in playgrounds. Overall, people were smoking in 19.6% of the playgrounds. More than half of playgrounds had cigarette butts visible inside (56.6%) and in the immediate vicinity (74.4%). Presence of butts inside playgrounds was higher in sites from a low area-level SES, in countries with low TCS scores, and greater smoking prevalence and SHS exposure prevalence (p<0.05). CONCLUSIONS: There is evidence of SHS exposure in children's playgrounds across Europe. These findings confirm the need for smoking bans in playgrounds and better enforcement in those countries with smoking bans in playgrounds.

A pilot study of the Tobacco Treatment Guidelines for High-Risk Groups (TOB-G) for pregnant and postpartum women.

INTRODUCTION: Maternal smoking constitutes a significant risk to the fetus and is associated with multiple adverse pregnancy outcomes. Despite this, an estimated 6-19% of women in Europe smoke during pregnancy. We conducted a pilot study to examine the feasibility and effectiveness of the clinical practice recommendations of the 2017 Tobacco Cessation Guidelines for High-Risk Groups (TOB-G) for pregnant and postpartum women in an outpatient obstetrics setting. METHODS: The guideline recommendations were tested on a sample of 67 pregnant women recruited from obstetrics outpatient visits. Pregnant women who smoked received three behavioural counselling sessions through a combination of face-toface and telephone consultations by a midwife trained in the TOBG tobacco treatment recommendations. Smoking status was assessed at 1 month and at 6 months follow-up via self-report. RESULTS: Seventy-one per cent of pregnant smokers screened agreed to participate in the counselling intervention. Pregnant women participants (mean age, M=31.73 years, SD±6.09) smoked for an average of 12.2 (SD±6.55) years. Women reported smoking an average of 4.82 (SD±4.14) cigarettes per day with 51% reporting smoking within 30 minutes of waking, an indicator of higher levels of nicotine addiction. Rates of smoking abstinence among pregnant women undergoing the counselling intervention were 43.9% and 45.6% at the 1 month and at 6 months follow-up, respectively. Replacing those participants with missing data as smokers, the quit rates were 26.9% and 38.8% at the 1 month and 6 months follow-up, respectively. CONCLUSIONS: The counselling intervention delivered to pregnant women who smoke was feasible to implement in a manner that was consistent with the TOB-G guideline recommendations in an outpatient obstetrics setting. Future work should focus on increasing uptake of evidence-based tobacco treatment recommendations in outpatient obstetrics settings.

Measuring for change: A multi-centre pre-post trial of an air quality feedback intervention to promote smoke-free homes.

INTRODUCTION: Second-hand smoke exposure in the home is a serious cause of ill-health for children. Behaviour change interventions have been developed to encourage parents to keep homes smoke-free. This study evaluates a novel air quality feedback intervention using remote air quality monitoring with SMS and email messaging to promote smoke-free homes among families from deprived areas. METHODS: This paper presents a pre-post study of this intervention. Using internet connected monitors developed with the Dylos DC1700, daily SMS and weekly email feedback provided for 16 days to participants recruited in four European countries. Participants were recruited based on their stage of change, in order to target those most able to achieve smoke-free homes. The primary outcome measure was median change in mean fine particulate matter (PM2.5) concentration between baseline and follow-up periods, while secondary outcome measures included change in time over the World Health Organisation (WHO) guideline limit for PM2.5 exposure over 24 h (25 µg/m3) in those periods and the number of homes where PM2.5 concentrations reduced. Telephone interviews were conducted with participants in Scotland post-intervention to explore intervention experience and perceived effectiveness. RESULTS: Of 86 homes that completed the intervention study, 57 (66%) experienced pre-post reductions in measured PM2.5. The median reduction experienced was 4.1 µg/m3 (a reduction of 19% from baseline, p = 0.008). Eight homes where concentrations were higher than the WHO guideline limit at baseline fell below that level at follow-up. In follow-up interviews, participants expressed positive views on the usefulness of air quality feedback. DISCUSSION: Household air quality monitoring with SMS and email feedback can lead to behaviour change and consequent reductions in SHS in homes, but within the context of our study few homes became totally smoke-free.

Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European countries.

INTRODUCTION: Although smoking restrictions at child-related settings are progressively being adopted, school outdoor entrances are neglected in most smoke-free policies across Europe. OBJECTIVES: To describe secondhand smoke (SHS) exposure and tobacco-related signs in outdoor entrances of primary schools in Europe according to area-level socioeconomic status (SES), smoke-free policy, national smoking prevalence, and geographical region. METHODS: In this cross-sectional study we monitored vapor-phase nicotine concentrations at 220 school outdoor entrances in 11 European countries (March 2017-October 2018). To account for nicotine presence, we used the laboratory's limit of quantification of 0.06 µg/m3 as point threshold. We also recorded the presence of smell of smoke, people smoking, cigarette butts, and ashtrays. Half of the schools were in deprived areas. We grouped countries according to their Tobacco Control Scale (TCS) score, smoking prevalence (2017-2018), and United Nations M49 geographical region. RESULTS: There were detectable levels of nicotine in 45.9% of the outdoor entrances, in 29.1% smell of smoke, in 43.2% people smoking, in 75.0% discarded butts, and in 14.6% ashtrays. Median nicotine concentration was below the laboratory's limit of quantification <0.06 µg/m3 (Interquartile range:<0.06-0.119). We found higher SHS levels in countries with lower TCS scores, higher national smoking prevalence, and in the Southern and Eastern European regions. People smoking were more common in schools from lower area-level SES and in countries with lower TCS scores (p<0.05). CONCLUSIONS: Smoking at school outdoor entrances is a source of SHS exposure in Europe. These findings support the extension of smoking bans with a clear perimeter to the outdoor entrances of schools.

Passive exposure to e-cigarette emissions: Immediate respiratory effects.

INTRODUCTION: The present work examined the effect of passive exposure to electronic-cigarette (e-cigarette) emissions on respiratory mechanics and exhaled inflammatory biomarkers. METHODS: A cross-over experimental study was conducted with 40 healthy nonsmokers, 18-35 years old with normal physical examination and spirometry, with body mass index <30 kg/m2, who were exposed to e-cigarette emissions produced by a smoker, according to a standardized protocol based on two resistance settings, 0.5 ohm and 1.5 ohm, for e-cigarette use. All participants underwent a 30-minute control (no emissions) and two experimental sessions (0.5 and 1.5 ohm exposure) in a 35 m3 room. The following Impulse Oscillometry (IOS) parameters were measured at pre and post sessions: impedance, resistance, reactance, resonant frequency (fres), frequency dependence of resistance (fdr=R5-R20), reactance area (AX), and fractional exhaled nitric oxide (FeNO). Differences between pre and post measurements were compared using t-tests and Wilcoxon signed rank tests, while analysis of variance (ANOVA) was used for comparisons between experimental sessions (registered under ClinicalTrials.gov ID: NCT03102684). RESULTS: IOS and FeNO parameters showed no significant changes during the control session. For IOS during the 1.5 ohm exposure session, fres increased significantly from 11.38 Hz at baseline to 12.16 Hz post exposure (p=0.047). FeNO decreased significantly from 24.16 ppb at baseline to 22.35 ppb post exposure in the 0.5 ohm session (p=0.006). CONCLUSIONS: A 30-minute passive exposure to e-cigarette emissions revealed immediate alterations in respiratory mechanics and exhaled biomarkers, expressed as increased fres and reduced FeNO.

Tobacco Treatment Guideline for High Risk Groups: A pilot study in patients with Chronic Obstructive Pulmonary Disease.

INTRODUCTION: Smoking cessation is a key clinical intervention for reducing progressive lung destruction and lung function deterioration in patients with Chronic Obstructive Pulmonary Disease (COPD). Specialised Tobacco Cessation Guidelines for High-risk Groups (TOB-G) were developed and published in 2017 that present evidence-based recommendations to support smoking cessation in COPD patients. The purpose of this pilot study was to examine the real world effectiveness of the TOB-G guideline recommendations among a sample of COPD patients. METHODS: A pilot study was conducted among a sample of COPD patients who smoke and were interested in quitting. Participants were recruited from inpatient and outpatient hospital admissions between October and December 2016 in Iasi, Romania. The intervention program was designed based on the recommendations of the TOB-G guidelines for COPD patients. Patients received a total of four contacts: at baseline, 1, 2, and 6 months. The primary outcome measure was biochemically validated point prevalence smoking abstinence measured at 6 months. RESULTS: Fifty patients (74% male; age mean±SD = 60.2±7.8) with diagnosed COPD took part in the pilot study. Self-reported rates of point prevalence smoking abstinence were 30.6%, 44.9% and 64.6% at the 1-, 2-, and 6-month follow-up, respectively. Carbon monoxide testing was completed with 51.6% of the sample at 6 months. The biochemically verified abstinent rate was 33.3% at the 6-month follow-up. CONCLUSIONS: This pilot testing of the TOB-G Clinical Practice Guidelines for COPD patients was associated with high rates of patient smoking abstinence, which are of clinical importance. Further research is needed to evaluate the guidelines large-scale effectiveness in clinical practice.

The TOBg Tobacco Treatment Guidelines for Adolescents: A real-world pilot study.

INTRODUCTION: We conducted a pilot study to: 1) obtain feedback from prevention practitioners in terms of their satisfaction, knowledge, and self-efficacy following exposure to the Tobacco Treatment Guidelines for Adolescents (TOBg Guidelines); and 2) examine the effectiveness of a school-based intervention based on the TOBg Guidelines on quit rates among a sample of adolescent tobacco users. METHODS: Two parallel studies were conducted. In Study 1, prevention practitioners were exposed to a 1-day training in the TOBg Guidelines with assessment occurring before, immediately after, and at 6 months following the training. In Study 2, participating adolescent smokers were exposed to a 3-session group-based smoking cessation intervention that drew on the TOBg Guidelines and was delivered by practitioners trained in Study 1. The primary outcome measure was self-reported smoking status assessed at 1 month and at 6 months following baseline. RESULTS: A total of 18 prevention practitioners and 65 adolescent tobacco users participated in the pilot study. The majority of practitioners reported high rates of satisfaction with the TOBg Guidelines and indicated that the guidelines positively influenced the manner in which they addressed tobacco use with adolescents. Prevention practitioners' self-efficacy for intervening with adolescent smokers was also significantly increased following exposure to the TOBg Guidelines and training. Among adolescents exposed to the school-based intervention, 62.5% and 23.1% had reduced smoking by 50% or more at 1 month and at 6 months follow-up, respectively. No significant change in smoking abstinence was documented. CONCLUSIONS: The TOBg Guidelines for adolescent smokers were well received by prevention practitioners and were feasible to implement in a real-world school setting.