Household air pollution from wood-burning cookstoves and C-reactive protein among women in rural Honduras.

Household air pollution from solid fuel combustion was estimated to cause 2.31 million deaths worldwide in 2019; cardiovascular disease is a substantial contributor to the global burden. We evaluated the cross-sectional association between household air pollution (24-h gravimetric kitchen and personal particulate matter (PM2.5) and black carbon (BC)) and C-reactive protein (CRP) measured in dried blood spots among 107 women in rural Honduras using wood-burning traditional or Justa (an engineered combustion chamber) stoves. A suite of 6 additional markers of systemic injury and inflammation were considered in secondary analyses. We adjusted for potential confounders and assessed effect modification of several cardiovascular-disease risk factors. The median (25th, 75th percentiles) 24-h-average personal PM2.5 concentration was 115 µg/m3 (65,154 µg/m3) for traditional stove users and 52 µg/m3 (39, 81 µg/m3) for Justa stove users; kitchen PM2.5 and BC had similar patterns. Higher concentrations of PM2.5 and BC were associated with higher levels of CRP (e.g., a 25% increase in personal PM2.5 was associated with a 10.5% increase in CRP [95% CI: 1.2-20.6]). In secondary analyses, results were generally consistent with a null association. Evidence for effect modification between pollutant measures and four different cardiovascular risk factors (e.g., high blood pressure) was inconsistent. These results support the growing evidence linking household air pollution and cardiovascular disease.

Reduced Black Carbon Concentrations following a Three-Year Stepped-Wedge Randomized Trial of the Wood-Burning Justa Cookstove in Rural Honduras.

Introduction: Household air pollution from cooking-related biomass combustion remains a leading risk factor for global health. Black carbon (BC) is an important component of particulate matter (PM) in household air pollution. We evaluated the impact of the engineered, wood-burning Justa stove intervention on BC concentrations. Methods: We conducted a 3-year stepped-wedge randomized controlled trial with 6 repeated visits among 230 female primary cooks in rural Honduras. Participants used traditional stoves at baseline and were randomized to receive the Justa after visit 2 or after visit 4. At each visit, we measured 24-hour gravimetric personal and kitchen fine PM (PM2.5) concentrations and estimated BC mass concentrations (Sootscan Transmissometer). We conducted intent-to-treat analyses using linear mixed models with natural log-transformed 24-hour personal and kitchen BC. Results: BC concentrations were reduced for households assigned to the Justa vs. traditional stoves: e.g., personal BC geometric mean (GSD), 3.6 µg/m3 (6.4) vs. 11.5 µg/m3 (4.6), respectively. Following the intervention, we observed 53% (95% CI: 35-65%) lower geometric mean personal BC concentrations and 76% (95% CI: 66-83%) lower geometric mean kitchen BC concentrations. Conclusions: The Justa stove intervention substantially reduced BC concentrations, mitigating household air pollution and potentially benefitting human and climate health.

Visualizing Field Data Collection Procedures of Exposure and Biomarker Assessments for the Household Air Pollution Intervention Network Trial in India.

Here, we present a visual representation of standard procedures to collect population-level data on personal exposures to household air pollution (HAP) from two different study sites in a resource-constrained setting of Tamil Nadu, India. Particulate matter PM2.5 (particles smaller than 2.5 microns in aerodynamic diameter), carbon monoxide (CO), and black carbon (BC) were measured in pregnant mothers (M), other adult women (OAW), and children (C) at various times over a 4 year period. In addition, stove usage monitoring (SUMs) with data-logging thermometers and ambient measurements of air pollution were carried out. Furthermore, the feasibility of collecting biological samples (urine and dried blood spots [DBSs]) from study participants at the field sites was successfully demonstrated. Based on findings from this and earlier studies, the methods used here have enhanced the data quality and avoided issues with household air pollution and biological sample collection in resource-constrained situations. The procedures established may be a valuable educational tool and resource for researchers conducting similar air pollution and health studies in India and other low- and middle-income countries (LMICs).

Adherence to standard treatment guidelines among prescribers in primary healthcare facilities in the Dodoma region of Tanzania.

BACKGROUND: Tanzania's primary healthcare system suffers from a scarcity of financial and human resources that impedes its effectiveness to deliver dependable and uniform quality healthcare. Adherence to standard treatment guidelines (STG) can help provide more consistent and correct diagnoses and treatments and limit the irrational use of medicines and the negative health consequences that can occur as a result. The purpose of this study was to investigate prescribers' adherence of their diagnoses and respective treatments to national STG and to identify potential areas for planning interventions. METHODS: A cross-sectional study on prescribers' adherence to diagnosis and treatment, according to national STG, was conducted in 2012 in public primary healthcare facilities (HCF) in the Dodoma region of Tanzania. Information on 2886 patients was collected, prospectively and retrospectively, from 120 HCF across the Dodoma region using a structured questionnaire. Twenty-five broadly defined main illness groups were recorded and the nine most prevalent and relevant conditions were statistically analysed in detail. RESULTS: Diagnoses and related treatments were recorded and analysed in 2872 cases. The nine most prevalent conditions were upper respiratory tract infections (25%), malaria (18%), diarrhoea (9.9%), pneumonia (6.1%), skin problems (5.8%), gastrointestinal diagnoses (5%), urinary tract infections (4%), worm infestations (3.6%) and eye problems (2.1%). Only 1.8% of all diagnoses were non-communicable diseases. The proportion of prescribers' primary diagnoses that completely adhered to national STG was 599 (29.9%), those that partially adhered totalled 775 (38.7%), wrong medication was given in 621 cases (30.9%) and no diagnosis or medication was given in nine cases (0.5%). Sixty-one percent of all patients received an antibiotic regardless of the diagnoses. Complete adherence was highest when worms were diagnosed and lowest for diarrhoea. The proportion of cases that did not adhere to STG was highest with patients with skin problems and lowest for malaria. CONCLUSION: Prescribers' general adherence to national STG in primary HCF in the public sector in Dodoma region is sub-optimal. The reasons are multifaceted and focused attention, directed at improving prescribing and pharmacotherapy, is required with a view of improving patient care and health outcomes.

Impact of the wood-burning Justa cookstove on fine particulate matter exposure: A stepped-wedge randomized trial in rural Honduras.

TRIAL DESIGN: We evaluated the impact of a biomass stove intervention on fine particulate matter (PM2.5) concentrations using an individual-level, stepped-wedge randomized trial. METHODS: We enrolled 230 women in rural Honduran households using traditional biomass stoves and randomly allocated them to one of two study arms. The Justa stove, the study intervention, was locally-sourced, wood-burning, and included an engineered combustion chamber and chimney. At each of 6 visits over 3 years, we measured 24-hour gravimetric personal and kitchen PM2.5 concentrations. Half of the households received the intervention after Visit 2 and half after Visit 4. We conducted intent-to-treat analyses to evaluate the intervention effect using linear mixed models with log-transformed kitchen or personal PM2.5 (separately) as the dependent variable, adjusting for time. We also compared PM2.5 concentrations to World Health Organization (WHO) guidelines. RESULTS: Arms 1 and 2 each had 115 participants with 664 and 632 completed visits, respectively. Median 24-hour average personal PM2.5 exposures were 81 µg/m3 (25th-75th percentile: 50-141 µg/m3) for the traditional stove condition (n=622) and 43 µg/m3 (25th-75th percentile: 27-73 µg/m3) for the Justa stove condition (n=585). Median 24-hour average kitchen concentrations were 178 µg/m3 (25th-75th percentile: 69-440 µg/m3; n=629) and 53 µg/m3 (25th-75th percentile: 29-103 µg/m3; n=578) for the traditional and Justa stove conditions, respectively. The Justa intervention resulted in a 32% reduction in geometric mean personal PM2.5 (95% confidence interval [CI]: 20-43%) and a 56% reduction (95% CI: 46-65%) in geometric mean kitchen PM2.5. During rainy and dry seasons, 53% and 41% of participants with the Justa intervention had 24-hour average personal PM2.5 exposures below the WHO interim target-3 guideline (37.5 µg/m3), respectively. CONCLUSION: The Justa stove intervention substantially lowered personal and kitchen PM2.5 and may be a provisional solution that is feasible for Latin American communities where cleaner fuels may not be available, affordable, or acceptable for some time. Clinicaltrials.gov: NCT02658383.

Cross-validation of biomonitoring methods for polycyclic aromatic hydrocarbon metabolites in human urine: Results from the formative phase of the Household Air Pollution Intervention Network (HAPIN) trial in India.

The Household Air Pollution Intervention Network (HAPIN) trial is evaluating health benefits of a liquefied petroleum gas (LPG) stove intervention in biomass cook-fuel using homes (n = 3200) in four low-and middle-income countries (LMICs) that include Peru, Guatemala, Rwanda and India. Longitudinal urine samples (n = 6000) collected from enrolled pregnant women, infants and older women will be analyzed for biomarkers associated with exposure and health outcomes. We report results from cross-validation of a lower cost high-performance liquid chromatography with fluorescence detection (HPLC-FLD) method with a higher resolution liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the measurement of 1-hydroxypyrene (1PYR) and 2-naphthol (2NAP). Twenty-five split urine samples were analyzed by HPLC-FLD method at the India trial site in Chennai, India and by LC-MSMS method at the trial wide Biomarker Coordinating Center, Emory University, USA. The limits of detection (LOD) for the HPLC-FLD method were 0.02 ng/mL and 0.07 ng/mL for 2NAP and 1PYR, respectively. Bland-Altman analysis estimated a bias of 2.98 ng/ml for 2NAP (95% CI: -5.22, -0.75) and 0.09 ng/mL for 1PYR (95% CI: -0.02, 0.21) with HPLC-FLD levels being lower than LC-MSMS levels at higher concentrations. Analyses of additional urine samples (n = 119) collected during the formative phase of the HAPIN trial in India, showed 2NAP and 1PYR levels to be consistently above the limit of quantification (LOQ) and demonstrated the applicability of the method. The HPLC-FLD method can serve as a cost-effective and reliable analytical method to measure 2NAP and 1PYR in human urine in LMICs, within and beyond the HAPIN trial.

Design and Rationale of the Biomarker Center of the Household Air Pollution Intervention Network (HAPIN) Trial.

BACKGROUND: Biomarkers of exposure, susceptibility, and effect are fundamental for understanding environmental exposures, mechanistic pathways of effect, and monitoring early adverse outcomes. To date, no study has comprehensively evaluated a large suite and variety of biomarkers in household air pollution (HAP) studies in concert with exposure and outcome data. The Household Air Pollution Intervention Network (HAPIN) trial is a liquified petroleum gas (LPG) fuel/stove randomized intervention trial enrolling 800 pregnant women in each of four countries (i.e., Peru, Guatemala, Rwanda, and India). Their offspring will be followed from birth through 12 months of age to evaluate the role of pre- and postnatal exposure to HAP from biomass burning cookstoves in the control arm and LPG stoves in the intervention arm on growth and respiratory outcomes. In addition, up to 200 older adult women per site are being recruited in the same households to evaluate indicators of cardiopulmonary, metabolic, and cancer outcomes. OBJECTIVES: Here we describe the rationale and ultimate design of a comprehensive biomarker plan to enable us to explore more fully how exposure is related to disease outcome. METHODS: HAPIN enrollment and data collection began in May 2018 and will continue through August 2021. As a part of data collection, dried blood spot (DBS) and urine samples are being collected three times during pregnancy in pregnant women and older adult women. DBS are collected at birth for the child. DBS and urine samples are being collected from the older adult women and children three times throughout the child's first year of life. Exposure biomarkers that will be longitudinally measured in all participants include urinary hydroxy-polycyclic aromatic hydrocarbons, volatile organic chemical metabolites, metals/metalloids, levoglucosan, and cotinine. Biomarkers of effect, including inflammation, endothelial and oxidative stress biomarkers, lung cancer markers, and other clinically relevant measures will be analyzed in urine, DBS, or blood products from the older adult women. Similarly, genomic/epigenetic markers, microbiome, and metabolomics will be measured in older adult women samples. DISCUSSION: Our study design will yield a wealth of biomarker data to evaluate, in great detail, the link between exposures and health outcomes. In addition, our design is comprehensive and innovative by including cutting-edge measures such as metabolomics and epigenetics. https://doi.org/10.1289/EHP5751.

Exposure to household air pollution from biomass cookstoves and self-reported symptoms among women in rural Honduras.

Household air pollution from combustion of solid fuels is an important risk factor for morbidity and mortality, causing an estimated 2.6 million premature deaths globally in 2016. Self-reported health symptoms are a meaningful measure of quality of life, however, few studies have evaluated symptoms and quantitative measures of exposure to household air pollution. We assessed the cross-sectional association of self-reported symptoms and exposures to household air pollution among women in rural Honduras using stove type (traditional [n = 76]; cleaner-burning Justa [n = 74]) and 24-hour average personal and kitchen fine particulate matter (PM2.5) concentrations. The odds of prevalent symptoms were higher among women using traditional stoves vs Justa stoves (e.g. headache: odds ratio = 2.23; 95% confidence interval = 1.13-4.39). Associations between symptoms and measured PM2.5 were generally consistent with the null. These results add to the evidence suggesting reduced exposures and better health-related quality of life among women using cleaner-burning biomass stoves.

Kitchen concentrations of fine particulate matter and particle number concentration in households using biomass cookstoves in rural Honduras.

Cooking and heating with solid fuels results in high levels of household air pollutants, including particulate matter (PM); however, limited data exist for size fractions smaller than PM2.5 (diameter less than 2.5 µm). We collected 24-h time-resolved measurements of PM2.5 (n = 27) and particle number concentrations (PNC, average diameter 10-700 nm) (n = 44; 24 with paired PM2.5 and PNC) in homes with wood-burning traditional and Justa (i.e., with an engineered combustion chamber and chimney) cookstoves in rural Honduras. The median 24-h PM2.5 concentration (n = 27) was 79 µg/m3 (interquartile range [IQR]: 44-174 µg/m3); traditional (n = 15): 130 µg/m3 (IQR: 48-250 µg/m3); Justa (n = 12): 66 µg/m3 (IQR: 44-97 µg/m3). The median 24-h PNC (n = 44) was 8.5 × 104 particles (pt)/cm3 (IQR: 3.8 × 104-1.8 × 105 pt/cm3); traditional (n = 27): 1.3 × 105 pt/cm3 (IQR: 3.3 × 104-2.0 × 105 pt/cm3); Justa (n = 17): 6.3 × 104 pt/cm3 (IQR: 4.0 × 104-1.2 × 105 pt/cm3). The 24-h average PM2.5 and particle number concentrations were correlated for the full sample of cookstoves (n = 24, Spearman ρ: 0.83); correlations between PM2.5 and PNC were higher in traditional stove kitchens (n = 12, ρ: 0.93) than in Justa stove kitchens (n = 12, ρ: 0.67). The 24-h average concentrations of PM2.5 and PNC were also correlated with the maximum average concentrations during shorter-term averaging windows of one-, five-, 15-, and 60-min, respectively (Spearman ρ: PM2.5 [0.65, 0.85, 0.82, 0.71], PNC [0.74, 0.86, 0.88, 0.86]). Given the moderate correlations observed between 24-h PM2.5 and PNC and between 24-h and the shorter-term averaging windows within size fractions, investigators may need to consider cost-effectiveness and information gained by measuring both size fractions for the study objective. Further evaluations of other stove and fuel combinations are needed.

Electrochemical Dithiothreitol Assay for Large-Scale Particulate Matter Studies.

Particulate matter (PM) air pollution is associated with human morbidity and mortality. Measuring PM oxidative potential has been shown to provide a predictive measurement between PM exposure and adverse health impacts. The dithiothreitol (DTT) assay is commonly used to measure the oxidative potential of PM2.5 (PM less than 2.5 µm aerodynamic diameter). In the common, kinetic form of this assay, the decay of DTT is quantified over time (indirectly) using 5,5'-dithiobis(2-nitrobenzoic acid) (DTNB, Ellman's reagent) via UV/vis absorbance spectroscopy. The loss of DTT can also be quantified directly using electrochemical detection. The objectives of this work were (1) to evaluate the electrochemical assay, using commercially available equipment, relative to the UV/vis absorbance assay, and (2) to apply the electrochemical method to a large (>100) number of PM2.5 aerosol filter samples. Also presented here is the comparison an end-point assay to the kinetic assay, in an attempt to reduce the time, labor, and materials neccssary to quantify PM oxidative potential. The end-point, electrochemical assay gave comparable results to the UV/vis absorbance assay for PM filter sample analysis. Finally, high filter mass loadings (higher than about 0.5 µg PM per mm2 filter) lead to sub-optimal DTT assay performance, which suggests future studies should limit particle mass loadings on filters.

Study protocol for a stepped-wedge randomized cookstove intervention in rural Honduras: household air pollution and cardiometabolic health.

BACKGROUND: Growing evidence links household air pollution exposure from biomass-burning cookstoves to cardiometabolic disease risk. Few randomized controlled interventions of cookstoves (biomass or otherwise) have quantitatively characterized changes in exposure and indicators of cardiometabolic health, a growing and understudied burden in low- and middle-income countries (LMICs). Ideally, the solution is to transition households to clean cooking, such as with electric or liquefied petroleum gas stoves; however, those unable to afford or to access these options will continue to burn biomass for the foreseeable future. Wood-burning cookstove designs such as the Justa (incorporating an engineered combustion zone and chimney) have the potential to substantially reduce air pollution exposures. Previous cookstove intervention studies have been limited by stove types that did not substantially reduce exposures and/or by low cookstove adoption and sustained use, and few studies have incorporated community-engaged approaches to enhance the intervention. METHODS/DESIGN: We conducted an individual-level, stepped-wedge randomized controlled trial with the Justa cookstove intervention in rural Honduras. We enrolled 230 female primary cooks who were not pregnant, non-smoking, aged 24-59 years old, and used traditional wood-burning cookstoves at baseline. A community advisory board guided survey development and communication with participants, including recruitment and retention strategies. Over a 3-year study period, participants completed 6 study visits approximately 6 months apart. Half of the women received the Justa after visit 2 and half after visit 4. At each visit, we measured 24-h gravimetric personal and kitchen fine particulate matter (PM2.5) concentrations, qualitative and quantitative cookstove use and adoption metrics, and indicators of cardiometabolic health. The primary health endpoints were blood pressure, C-reactive protein, and glycated hemoglobin. Overall study goals are to explore barriers and enablers of new cookstove adoption and sustained use, compare health endpoints by assigned cookstove type, and explore the exposure-response associations between PM2.5 and indicators of cardiometabolic health. DISCUSSION: This trial, utilizing an economically feasible, community-vetted cookstove and evaluating endpoints relevant for the major causes of morbidity and mortality in LMICs, will provide critical information for household air pollution stakeholders globally. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02658383 , posted January 18, 2016, field work completed May 2018. Official title, "Community-Based Participatory Research: A Tool to Advance Cookstove Interventions." Principal Investigator Maggie L. Clark, Ph.D. Last update posted July 12, 2018.

Tobacco smoking and nicotine delivery alternatives: patterns of product use and perceptions in 13 countries.

Background: Smoking tobacco products remains a significant public health problem. The Foundation for a Smoke-Free World commissioned a 13-country survey to gain a clearer understanding of the current landscape of smoking behavior and preferences across the world. Methods: Over 17,000 participants in 13 countries, representing different regions and income groups, answered questions on their smoking patterns and product use, their social context, their motivation to smoke, quit, or switch, and their perception of risks of products and substances. Rim weighting was done for each country to align responses with population demographics, and an additional 200 smokers for each country were surveyed to achieve sufficient sample size for sub-analyses of smoker data. Results: The observed prevalence of smoking ranged from an age-adjusted high of 57.5% in Lebanon to 8.4% in New Zealand among men, with lower rates for women. The majority of smokers were between 25-54 years old, had daily routines and social patterns associated with smoking, used boxed cigarettes, and rated their health more poorly compared to never smokers. Among a range of products and substances, smokers tended to give both cigarettes and nicotine the highest harm ratings. Smokers in high income countries were largely familiar with electronic nicotine delivery systems; the most commonly given reasons for using them were to cut down or quit smoking. A majority of smokers had tried to quit at least once, and while many tried without assistance, motivations, intentions, and methods for smoking cessation, including professional help, nicotine replacement therapies or medications, or electronic cigarettes, varied among countries. Conclusions: Smoking is deeply integrated in smokers' lives worldwide. Although a majority of smokers have tried to quit, and are concerned for their health, they do not seek help. Smokers lack understanding of the harmful components of smoking tobacco products and the risk profile of alternatives.

Household air pollution from biomass-burning cookstoves and metabolic syndrome, blood lipid concentrations, and waist circumference in Honduran women: A cross-sectional study.

BACKGROUND: Household air pollution from cooking with solid fuels affects nearly 3 billion people worldwide and is responsible for an estimated 2.5 million premature deaths and 77 million disability-adjusted life years annually. Investigating the effect of household air pollution on indicators of cardiometabolic disease, such as metabolic syndrome, can help clarify the pathways between this widespread exposure and cardiovascular diseases, which are increasing in low- and middle-income countries. METHODS: Our cross-sectional study of 150 women in rural Honduras (76 with traditional stoves and 74 with cleaner-burning Justa stoves) explored the effect of household air pollution exposure on cardiovascular disease risk factors. Household air pollution was measured by stove type and 24-h average kitchen and personal fine particulate matter [PM2.5] mass and black carbon concentrations. Health endpoints included non-fasting total cholesterol, high-density lipoprotein, calculated low-density lipoprotein, triglycerides, waist circumference to indicate abdominal obesity, and presence of metabolic syndrome (defined by current modified international guidelines: waist circumference ≥ 80 cm plus any two of the following: triglycerides > 200 mg/dL, HDL < 50 mg/dL, systolic blood pressure ≥ 130 mmHg, diastolic blood pressure ≥ 85 mmHg, or glycated hemoglobin > 5.6%). RESULTS: Forty percent of women met the criteria for metabolic syndrome. The prevalence ratio [PR] for metabolic syndrome (versus normal) per interquartile range increase in kitchen PM2.5 and kitchen black carbon was 1.16 (95% confidence interval [CI]: 1.01-1.34) per 312 µg/m3 increase in PM2.5, and 1.07 (95% CI: 1.03-1.12) per 73 µg/m3 increase in black carbon. There is suggestive evidence of a stronger effect in women ≥ 40 years of age compared to women < 40 (p-value for interaction = 0.12 for personal PM2.5). There was no evidence of associations between all other exposure metrics and health endpoints. CONCLUSIONS: The prevalence of metabolic syndrome among our study population was high compared to global estimates. We observed a suggestive effect between metabolic syndrome and exposure to household air pollution. These results for metabolic syndrome may be driven by specific syndrome components, such as blood pressure. Longitudinal research with repeated health and exposure measures is needed to better understand the link between household air pollution and indicators of cardiometabolic disease risk.

Measuring personal exposure to fine particulate matter (PM2.5) among rural Honduran women: A field evaluation of the Ultrasonic Personal Aerosol Sampler (UPAS).

We measured 24-hour average personal exposure to fine particulate matter (PM2.5) among rural Honduran women using a lightweight, gravimetric monitor - the Ultrasonic Personal Aerosol Sampler (UPAS). Performance of the UPAS was compared with a commonly used gravimetric pump, cyclone, and filter sampling system. We observed strong agreement and correlation (Spearman ρ = 0.91; PM2.5 concentration range: 19-120 µg/m3) between 43 paired measures, supporting the use of the UPAS as a personal exposure monitor for household air pollution studies.

Exposure to household air pollution from biomass cookstoves and blood pressure among women in rural Honduras: A cross-sectional study.

Growing evidence links household air pollution exposure from biomass cookstoves with elevated blood pressure. We assessed cross-sectional associations of 24-hour mean concentrations of personal and kitchen fine particulate matter (PM2.5 ), black carbon (BC), and stove type with blood pressure, adjusting for confounders, among 147 women using traditional or cleaner-burning Justa stoves in Honduras. We investigated effect modification by age and body mass index. Traditional stove users had mean (standard deviation) personal and kitchen 24-hour PM2.5 concentrations of 126 µg/m3 (77) and 360 µg/m3 (374), while Justa stove users' exposures were 66 µg/m3 (38) and 137 µg/m3 (194), respectively. BC concentrations were similarly lower among Justa stove users. Adjusted mean systolic blood pressure was 2.5 mm Hg higher (95% CI, 0.7-4.3) per unit increase in natural log-transformed kitchen PM2.5 concentration; results were stronger among women of 40 years or older (5.2 mm Hg increase, 95% CI, 2.3-8.1). Adjusted odds of borderline high and high blood pressure (categorized) were also elevated (odds ratio = 1.5, 95% CI, 1.0-2.3). Some results included null values and are suggestive. Results suggest that reduced household air pollution, even when concentrations exceed air quality guidelines, may help lower cardiovascular disease risk, particularly among older subgroups.

Exposure to Household Air Pollution from Biomass Cookstoves and Levels of Fractional Exhaled Nitric Oxide (FeNO) among Honduran Women.

Household air pollution is estimated to be responsible for nearly three million premature deaths annually. Measuring fractional exhaled nitric oxide (FeNO) may improve the limited understanding of the association of household air pollution and airway inflammation. We evaluated the cross-sectional association of FeNO with exposure to household air pollution (24-h average kitchen and personal fine particulate matter and black carbon; stove type) among 139 women in rural Honduras using traditional stoves or cleaner-burning Justa stoves. We additionally evaluated interaction by age. Results were generally consistent with a null association; we did not observe a consistent pattern for interaction by age. Evidence from ambient and household air pollution regarding FeNO is inconsistent, and may be attributable to differing study populations, exposures, and FeNO measurement procedures (e.g., the flow rate used to measure FeNO).

The Relationship between Environmental Tobacco Smoke Exposure and Cardiovascular Disease and the Potential Modifying Effect of Diet in a Prospective Cohort among American Indians: The Strong Heart Study.

American Indians experience high rates of cardiovascular diseases (CVD). Environmental tobacco smoke (ETS) has been linked to CVD, possibly due to pro-inflammatory and oxidative stress pathways. We examined the relationship between self-reported exposure to ETS and fatal and nonfatal CVD incidence using Cox proportional hazards models among 1843 non-smoking American Indians participating in the Strong Heart Study. We also evaluated potential modifying effects of several dietary nutrients high in anti-inflammatory and anti-oxidant properties with ETS exposure on fatal and nonfatal CVD by creating interaction terms between ETS exposure and the dietary variable. Participants exposed to ETS had a higher hazard (hazard ratio: 1.22; 95% confidence interval, 1.03 to 1.44) for developing CVD compared to persons not exposed. Interaction analyses suggested stronger effects of ETS on CVD incidence among those consuming diets lower in vitamin E as compared to those consuming higher amounts, particularly on the additive scale. Additional research is recommended to clarify whether public health prevention strategies should simultaneously target reductions in ETS exposures and improvements in diets that may exceed the expected benefits of targeting these risk factors separately.

Evaluation of implementation, compliance and acceptance of partial smoking bans among hospitality workers before and after the Swiss Tobacco Control Act.

BACKGROUND: The World Health Organization recommends uniform comprehensive smoking bans in public places. In Switzerland, regulations differ between various areas and are mostly incomplete for hospitality venues. As ambiguous regulations offer more leeway for implementation, we evaluated the Swiss regulations with respect to their effects on implementation, acceptance and compliance among hospitality workers. METHODS: In our longitudinal study, a standardized, self-administered questionnaire was mailed to a sample of 185 hospitality workers before and 4-6 month after the smoking ban came into effect. The matched longitudinal sample comprised 71 participants (repeated response rate 38.4%). We developed a seven-item acceptance scale. Logistic regressions were performed to explore the factors associated with acceptance. RESULTS: Acceptance of smoking bans was influenced by smoking status and perceived annoyance with second-hand smoke in private. Although not statistically significant (P = 0.09), we found some indications that post-ban acceptance increased in an area with strict regulations, whereas it decreased in two areas with less stringent regulations. CONCLUSIONS: Tobacco bans in Swiss hospitality venues are still in a period of consolidation. The incomplete nature of the law may also have had a negative impact on the development of greater acceptance.

Effect of a smoking ban on respiratory health in nonsmoking hospitality workers: a prospective cohort study.

OBJECTIVE: The aim of this study was to examine the effect of a smoking ban on lung function, fractional exhaled nitric oxide, and respiratory symptoms in nonsmoking hospitality workers. METHODS: Secondhand smoke exposure at the workplace, spirometry, and fractional exhaled nitric oxide were measured in 92 nonsmoking hospitality workers before as well as twice after a smoking ban. RESULTS: At baseline, secondhand smoke-exposed hospitality workers had lung function values significantly below the population average. After the smoking ban, the covariate-adjusted odds ratio for cough was 0.59 (95% confidence interval, 0.36 to 0.93) and for chronic bronchitis 0.75 (95% confidence interval, 0.55 to 1.02) compared with the preban period. CONCLUSIONS: The below-average lung function before the smoking ban indicates chronic damages from long-term exposure. Respiratory symptoms such as cough decreased within 12 months after the ban.

The effect of workplace smoking bans on heart rate variability and pulse wave velocity of non-smoking hospitality workers.

OBJECTIVES: To investigate the effect of a change in second-hand smoke (SHS) exposure on heart rate variability (HRV) and pulse wave velocity (PWV), this study utilized a quasi-experimental setting when a smoking ban was introduced. METHODS: HRV, a quantitative marker of autonomic activity of the nervous system, and PWV, a marker of arterial stiffness, were measured in 55 non-smoking hospitality workers before and 3-12 months after a smoking ban and compared to a control group that did not experience an exposure change. SHS exposure was determined with a nicotine-specific badge and expressed as inhaled cigarette equivalents per day (CE/d). RESULTS: PWV and HRV parameters significantly changed in a dose-dependent manner in the intervention group as compared to the control group. A one CE/d decrease was associated with a 2.3% (95% CI 0.2-4.4; p = 0.031) higher root mean square of successive differences (RMSSD), a 5.7% (95% CI 0.9-10.2; p = 0.02) higher high-frequency component and a 0.72% (95% CI 0.40-1.05; p < 0.001) lower PWV. CONCLUSIONS: PWV and HRV significantly improved after introducing smoke-free workplaces indicating a decreased cardiovascular risk.