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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 04-March-2011, Vol 124 No 1330

A persisting secondhand smoke hazard in urban public places: results from fine particulate (PM2.5) air sampling
Nick Wilson, Richard Edwards, Rhys Parry
Abstract
Aim To assess the need for additional smokefree settings, by measuring secondhand smoke (SHS) in a range of public places in an urban setting.
Methods Measurements were made in Wellington City during the 6-year period after the implementation of legislation that made indoor areas of restaurants and bars/pubs smokefree in December 2004, and up to 20 years after the 1990 legislation making most indoor workplaces smokefree. Fine particulate levels (PM2.5) were measured with a portable real-time airborne particle monitor. We collated data from our previously published work involving random sampling, purposeful sampling and convenience sampling of a wide range of settings (in 2006) and from additional sampling of selected indoor and outdoor areas (in 2007-2008 and 2010).
Results The “outdoor” smoking areas of hospitality venues had the highest particulate levels, with a mean value of 72 µg/m3 (range of maximum values 51–284 µg/m3) (n=20 sampling periods). These levels are likely to create health hazards for some workers and patrons (i.e., when considered in relation to the WHO air quality guidelines). National survey data also indicate that these venues are the ones where SHS exposure is most frequently reported by non-smokers. Areas inside bars that were adjacent to “outdoor” smoking areas also had high levels, with a mean of 54 µg/m3 (range of maximum values: 18–239 µg/m3, for n=13 measurements).
In all other settings mean levels were lower (means: 2–22 µg/m3). These other settings included inside traditional style pubs/sports bars (n=10), bars (n=18), restaurants (n=9), cafés (n=5), inside public buildings (n=15), inside transportation settings (n=15), and various outdoor street/park settings (n=22). During the data collection in all settings made smokefree by law, there was only one occasion of a person observed smoking.
Conclusions The results suggest that compliance in pubs/bars and restaurants has remained extremely high in this city in the nearly six years since implementation of the upgraded smokefree legislation. The results also highlight additional potential health gain from extending smokefree policies to reduce SHS exposure in the “outdoor” smoking areas of hospitality venues and to reduce SHS drift from these areas to indoor areas.

Secondhand smoke (SHS) is a proven carcinogen1 and “causes disease and premature death in children and adults who do not smoke”.2 There are now at least six meta-analyses showing that exposure to SHS increases the risk of coronary heart disease (as reviewed in Sims et al3). Another supportive line of evidence is that a similar hazard, outdoor particulate air pollution, is a well established cause of adverse cardiovascular effects4 and increased mortality risk.5,6
Major reviews have found that smokefree area policies reduce exposure to SHS.7–11 Even small reductions in SHS and fine particulate levels may have large public health benefits because exposure is common and the dose-response relationship appears to be highly non-linear (i.e., relatively more hazardous at lower levels).12
A number of recent studies have also demonstrated a reduction in hospitalisations from myocardial infarction after the implementation of smoke-free public places (as reviewed in Sims et al3). A review of economic aspects of smokefree policies indicated that these were highly cost-effective, and there was evidence for large net cost savings to society.11
There is also good evidence that smokefree laws in New Zealand have been effective in reducing exposure to SHS, including for the law passed in 199013 and for the more recent revision of the law that became operational in 2004 (which included an extension to bars, pubs and all of restaurants).14–18
One study suggested possible benefits for reduced hospitalisations in Christchurch for acute myocardial infarction after the 2004 law,19 but this trend was not found in a national study.17
More recently a national survey of teachers found that 89% considered the school or early childhood centre (ECC) environment was compliant with the smokefree law “all or most of the time”.20 Only 6% of teachers indicated that their school/ECC was compliant “some or none of the time”.
Some level of compliance also appears to occur with local outdoor smokefree area policies in New Zealand. A study in Upper Hutt City found some evidence of both compliance with the ‘educational’ smokefree parks policy, but also non-compliance by some smokers.21
This study obtained observational data of park users, self-reports of interviewed smokers and accumulation of butt litter. Butt litter surveys in parks before and after smokefree parks policies were introduced also suggest reduced smoking in Opotiki22 and Rotorua.23 There is also national survey data indicating that most New Zealand smokers support new forms of smokefree laws e.g., for cars with children in them (at 97%) and for various outdoor areas.24 25
Another national survey indicated that 56% of those surveyed wanted smokefree outdoor public dining areas.26 Majority support for local smokefree park laws has also been reported (reviewed elsewhere27).
Some progress with new smokefree policies has occurred with new smokefree policies introduced at the local level. In particular there is the growing number of new smokefree settings including: parks,28 marae/cultural events,29 and grounds around tertiary education organisations (e.g., university campuses). There is also some citizen advocacy around concern for smoking in busy city streets, such as along the “Golden Mile” in central Wellington.30
Given this background, we aimed to collect new data to inform assessment of the need for additional smokefree laws in New Zealand. In particular, we aimed to measure particulate levels from SHS levels in a range of public places within an urban setting.

Methods

The setting for our air quality work was Wellington City, for reasons of convenience. Like the majority of New Zealand cities it has smokefree hospital grounds and some smokefree tertiary education campuses, but has not yet adopted smokefree parks policies.
The methods of our initial research in 2006 on SHS in Wellington have been detailed elsewhere.16 Our additional subsequent work (presented in this article) included the following:
  • Purposeful sampling of pubs/bars (primarily to measure the extent of SHS drift from outdoor smoking areas to the indoors);
  • Systematic measurement along the full length of Wellington City’s ‘Golden Mile’ route of major city streets (from the western end of Lambton Quay to the eastern end of Courtenay Place);
  • Purposeful sampling along the Golden Mile route in sites where smoking was common;
  • Convenience sampling of a range of other settings where smoking is illegal (e.g. enclosed transportation settings and indoor public places) and where it remains legal (e.g. parks in Wellington).
For these various approaches, details on sampling dates, times and frequencies are included in Table 1.
To guide the approach to measuring air quality work in 2010, we identified the most common sources of SHS exposure using unpublished national survey data from the “New Zealand Tobacco Use Survey 2008” from online data files.31 We selected key findings and only considered the age-standardised data.
In all the sampling we measured fine particulates (PM2.5, i.e., particles ≤ 2.5 µm in diameter) using a portable real-time airborne particle monitor (the TSI SidePak AM510 Personal Aerosol Monitor, TSI Inc, St Paul, USA). The use of the monitor followed a protocol modified from one developed for a global air quality monitoring project32 and which was adapted for other studies by some of the authors in the United Kingdom33 and New Zealand.16 The bag with the sampling equipment was carried on the investigator’s back or placed on a seat or table wherever possible to sample the ambient air close to the breathing zone.
To avoid affecting occupants’ behaviour in indoor/semi-enclosed settings, investigators behaved as normal customers (i.e., bought drinks and/or food in the pubs/restaurants).
As particulates from different pollution sources vary in size and density, a calibration factor (0.32) for SHS based on empirical validation studies with the SidePak monitor34 was applied (i.e., adjusted in the monitor’s internal settings). The monitor was zero-calibrated prior to each day of field work and was fitted with a 2.5 μm impactor with an air flow rate of 1.7 L/min. The air flow rate has previously been validated in the New Zealand setting using a pneumotachograph (Hans Rudolph 4813 pneumotachograph, Vacuumed differential pressure transducer 4500, Vacumetrics, California, USA), and was within 10% of the stated flow rate.
A length of Tygon™ tubing was attached to the inlet of the SidePak, with the other end left protruding (slightly) outside the bag carried by the investigator. In all the settings we looked for evidence of smoking behaviour (actual observable smoking, the presence of ash trays and discarded cigarette butts).
To put the data into context we also searched for information relating to legal action for breaches of the smokefree law using searches of media databases (e.g., Factiva) and we communicated with Ministry of Health staff. Ethical approval was obtained through the Category B ethics approval process of the University of Otago and the investigators were cognisant of the ethical issues involved in this type of research.35

Results

Exposure data (national survey)—Table 1 presents data on SHS exposure extracted from online data files for the New Zealand Tobacco Use Survey of 2008. It indicates that the most common source of self-reported exposure to SHS for New Zealand non-smokers was the “outdoor area of a restaurant or bar” (at 32% in the past month), followed by “a sports event” (28%).
The commonest exposure from an “illegal” activity was smoking “inside a restaurant bar or nightclub” but this finding is difficult to interpret since some technically “outdoor” smoking areas may often appear to actually be “indoors”. Also some respondents who were indoors may be reporting on perceived SHS that drifted in through windows or doors from outdoors. The persisting problem of workplace exposure (24% in the last month) was notable, but again this may partly reflect “legal” smoking in outdoor areas at a worksite.
This same data source also showed that exposure to SHS was sometimes higher in the more deprived population. For example, the most deprived quintile of the employed non-smoker population (using the small area deprivation measure “NZDep2006”), were more likely to be exposed to SHS at work than the least deprived quintile (36.5%, 95%CI: 31.2–41.8; versus 19.0%, 95%CI: 14.5–23.5).
Other results from the survey were that most respondents who were non-smokers agreed or strongly agreed with the statement “it bothers you if someone is smoking cigarettes within a couple of metres of you” (Māori: 61.6%, Pacific: 69.5%, Asian: 77.0% and European/Other: 70.5%). These results were consistent with the belief held by the majority of non-smokers that “smoke from other peoples cigarettes is harmful to you” (Māori: 90.2%, Pacific: 87.6%, Asian: 94.3% and European/Other: 92.9%; all for “agree” or “strongly agree” with the statement). Even a majority of current smokers held this belief about harm (Māori: 60.0%, Pacific: 57.1%, Asian: 74.2% and European/Other: 69.4%).
Air quality data (Wellington)—The results indicate a very wide range of fine particulate (PM2.5) levels in different settings (Table 2). The “outdoor” smoking areas of hospitality venues had the highest particulate levels (weighted mean value for four sampling strategies: 72 µg/m3; range of maximum values: 51–284 µg/m3; n=20 sampling periods). Areas inside bars that were adjacent to “outdoor” smoking areas also had high levels (mean: 54 µg/m3; range of maximum values: 18–239 µg/m3, for n=13 measurements).
In all other settings mean levels were lower (means: 2–22 µg/m3). These other settings included traditional style pubs/sports bars (n=10), bars (n=18), restaurants (n=8), cafés (n=5), inside public buildings (n=15), inside transportation settings (n=15), and various outdoor street/park settings (n=22). There were four groupings of settings in Table 2 (various indoor settings, transportation settings and parks) that had mean levels of ≤3 µg/m3. For the levels inside the hospitality settings (but not adjacent to the “outdoor” smoking area), the mean values obtained in the year 2006 were similar to those obtained in 2010.
Observational data—In all the different types of settings listed in Table 1, illegal smoking was only observed on one occasion. This was in hospital grounds (within four metres of the main hospital entrance) and involved just one individual smoker. Grounds in this hospital also have extensive cigarette butt litter that is at least tens of metres from the hospital grounds boundary, which also suggests some on-going level of non-compliance. In contrast, we saw no ash trays or butts in any of the other settings where smoking is illegal.

Table 1. Reported exposure to SHS in public settings for the New Zealand population in the past month (NZ Tobacco Use Survey 2008 data extracted from Ministry of Health data files31 and ordered by decreasing %)

Population and setting
Age-standardised % (95%CI)a
Comment on smoking legality
All non-smokers
In the outdoor area of a restaurant or bar
32.2 (30.0–34.4)
Legal—if the walls and roofing comply with the law.
At a sports event
27.7 (25.9–29.5)
Generally legal except for indoor settings. Some councils have smokefree sports fieldsb and stadia
Outside at a building entrance
23.4 (21.6–25.1)
Generally legal (except on some tertiary education campuses)
At a bus stop or train station
11.9 (10.6–13.2)
Bus stops legal but illegal inside train stations and on some platforms
Inside a restaurant bar or nightclub
8.5 (7.5–9.6)
Illegal
At a shopping mall
8.2 (7.2–9.3)
Illegal
On a street
3.8 (2.8–4.9)
Legal
At a park
2.6 (1.9–3.2)
Generally legal but some councils have smokefree “educative” policiesb 28
At a concert
1.2 (0.8–1.7)
Illegal if indoors. Some councils have smokefree facilities/grounds used for concerts
At a marae
0.2 (0.1–0.4)
Some marae have smokefree policies.c
Specific groups of non-smokers (comprising the denominator)
Employed—exposed at work
24.3 (22.3–26.3)d
Illegal (indoors but not usually outdoors)
Aged 15-16 years—exposed at school
17.1 (11.4–22.8)
Illegal
Māori—exposed at a marae
1.9 (0.9–3.5)
Some marae have smokefree policies.c
Notes:
a There was little variation from the non age-standardised percentages (usually under 1, and at the most 1.9 percentage points for the point estimate). Data for the 15-16 year old group was not age-standardised.
b These are rarely actual local government by-laws, but rather are “educative smokefree policies” with supporting signage.
c A marae is a meeting place registered as a reserve under the Te Ture Whenua Māori Act 1993 (“The Māori Land Act”) and each marae has a group of trustees who are responsible for the operations of the marae. Such operations will determine the extent to which a marae is a “public place”, in terms of its beneficiaries of iwi (tribes), hapū (sub-tribes) or whānau (families).
d Some of this exposure at work may arise from outdoor smoking and some may reflect the drift of smoke indoors from outside settings (i.e., a previous national survey conducted in 2006, found that 2.5% of respondents reported that although there is no smoking indoors at work, smoke comes in from the outside36).

Smoking was frequently observed (and smelt by the investigators) on streets, in parks and in the smoking areas of hospitality venues. Sometimes doors connecting with the “outdoor smoking area” of such venues were left open, allowing tobacco smoke to drift inside and be smelt by the investigators.
We also noticed that some of these “outdoor” smoking areas in hospitality venues were highly enclosed e.g., with only one partially open side or with roofing that had only a narrow gap for air around the margins. Some of these settings used adjustable plastic or canvas sheeting so that the smoking area could become more or less enclosed, depending on the weather conditions. In one of these “outdoor” smoking areas workers were observed to be continuously based in this area (i.e., staffing a bar area with drink supplies).

Table 2. Results of air quality monitoring (fine particulates, PM2.5) in various settings in Wellington City in the 2006 to 2010 period (ordered by descending mean values within each category of setting)

Setting
Mean PM2.5 (µg/m3)
Minimum PM2.5 (µg/m3)
Maximum PM2.5 (µg/m3)
Mean sampling time per episode
(minutes)

[Ranges give the results arising for each sampling episode separately]
Fairly-enclosed “outdoor” smoking areas
“Outdoor” smoking areas of bars (n=2, purposeful sampling in the CBD, in June 2006)a
124
[20–104]
[146–284]
30
“Outdoor” smoking areas of bars (purposeful sample of n=7 bars in the CBD, with 13 individual measurements (1-3 per bar) in April, June & August 2007 and January 2008)
77
[7–35]
[59–801]
33
“Outdoor” smoking areas of bars/pubs/restaurants (n=4, random selection in the CBD, in May/June 2006)a
36
[7–13]
[51–189]
30
“Outdoor” smoking areas of bar (n=1, purposeful sampling in the CBD, in April 2010)
35
9
189
18
Inside–hospitality venues
Inside area of bars but adjacent to the entrance to the “outdoor” smoking area (purposeful sample of n=7 bars in the CBD, with 13 individual measurements (1-3 per bar) in April, June & August 2007 and January 2008)
54
[10–42]
[18–239]
25
Bars (n=8, random selection in the CBD, in May/June 2006)a
22
[10–20]
[22–56]
30
Restaurants (n=8, random selection in the CBD, in May/June 2006)a
14
[2–22]
[7–37]
30
Bars (n=10, purposeful sampling of more traditional style bars in the CBD, in June 2006)a
13
[2–28]
[5–94]
30
Traditional pubs and “sports bars” (n=10, purposeful sampling in the CBD and suburbs on Friday and Saturday nights in August/September 2010)
12
[2–15]
[4–57]
30
Cafés (n=5, purposeful sampling in the CBD and suburbs in August 2010)
11
[1–14]
[2–41]
30
Selected restaurant venue with a history of official investigation for non-compliance with the smokefree law (September 2010)
7
4
14
141
Inside/enclosed–other settings
Transportation settings (n=10, convenience sample including: buses (n=5), taxi, train, bus station, train station and airport; in May/June 2006)a
13
[1–13]
[3–62]
30
Other indoor settings (n=9, convenience sample including: cafés (2), offices (2), hospital, library, club, shopping centre and supermarket; in May/June 2006)a
3
[0–4]
[1–14]
30
Transportation settings (n=5, convenience sample including: buses (n=3); underground car park [4.30 to 6pm Friday night]; inside a train station and covered platforms, August/September 2010)
3
[1–3]
[6–21]
48
[28–113]
Other indoor settings (n=6, convenience sample including: hospital, libraries (n=2), shopping centre and supermarket, museum, indoor sports venue; in August 2010)a
2
[1–3]
[2–10]
30
Outdoor settings
Along the Golden Mileb route of major streets, usually with overhanging roofing (n=7, purposeful sampling at sites where smoking was more common, including the “outdoor” smoking area of a hospitality venue, March/April 2010)
11
[1–9]
[11–186]
13
[5–19]
Full length of the Golden Mileb route as a pedestrian (n=4 episodes, when: “quiet” (Sunday afternoon), “moderately busy”, and “busy”—Friday night [n=2]) (March/April 2010)
7
[1–3]
[11–68]
31
[26–34]
Various outdoor settings (n=6 purposeful and convenience samples at: parks (2), roadsides (2), a walkway and a legally smokefree walkway (Cable Car lane), in May/June 2006)a
7
[2–5]
[5–50]
30
Selected areas along the Golden Mileb route with at least one person smoking nearby (n=6, purposeful sampling and usually no overhanging roof) (March/April 2010)
5
[1–4]
[11–26]
12
[5–19]
Parks/sports grounds (n=5, including sidelines of a football match, August/September 2010)
2
[1–2]
[2–6]
30
Comparison data
Routine monitoring of PM2.5 in Auckland City air (1998 to 2001)37 (Wellington City airshed data are for PM10 only38)
Mean daily PM2.5 = 11.0 µg/m3 (range 2.1 to 37.6)
Notes:
a Previously published data.16 For these data sampling was set for determining average values at 60 second logging intervals (all the other sampling reported in this table was at 30 second logging intervals).
b Golden Mile—a selection of major streets in the Wellington CBD that runs from the western end of Lambton Quay to the eastern end of Courtenay Place. Further detail on some of these results is considered elsewhere.39
CBD—Central Business District.

Discussion

Main findings and interpretation: This work identified relatively high particulate levels from SHS in the “outdoor smoking areas” of hospitality venues (Table 2). This setting is also the one in which non-smokers most commonly report being exposed to SHS (Table 1). These results are not surprising given what is known about SHS as a contributor to indoor PM2.5 levels from international work32 and for outdoor levels (in Canada40 and the USA41). Of note is that the New Zealand results for outdoor areas at hospitality venues were higher than those found in Australian studies in Perth/Mandurah42 and in Melbourne.43
Any level of PM2.5 is of some concern from a health perspective given “no threshold for PM has been identified below which no damage to health is observed” according to the World Health Organization (WHO).44 But here we consider our results in relation to the WHO air quality guidelines for a 24-hour mean of 25 μg/m3 (with this level being a target that if achieved would result in “significant reductions in risks for acute and chronic health effects from air pollution”44).
Considering the weighted mean result for all “outdoor” smoking areas (of 72 μg/m3 for data in the first four rows in Table 2), would suggest that this WHO guideline would be exceeded after 7.2 hours (while also considering the conservative assumption of the rest of the day having an average of only 5 μg/m3 of exposure). But if using the annual guideline level44 (a mean of 10 μg/m3), the time for this to be exceeded would only be 1.8 hours. Workers frequently serving patrons in such smoking areas may have relatively higher cumulative exposure and those frequently working overtime could have relatively higher annual exposure.
The next highest levels of particulates were found inside of bars but adjacent to the entrance to the “outdoor” smoking area. Given the evidence of far lower mean levels found for measurements in bars and restaurants from areas not adjacent to outdoor smoking areas (mean 12-22 µg/m3—see Table 2), this suggests that there is smoke drift from SHS in the outdoor smoking areas to the inside. This pattern corresponded with our observations of smelling tobacco smoke while indoors where there was an open connection with an “outdoor” smoking area. More generally the SHS drift issue was identified in a national survey conducted in 2006 where 2.5% of respondents (95%CI: 1.9%–3.1%) reported that although there is no smoking indoors at work, smoke drifts in from outdoors.36 The problem of SHS drift from outdoor to indoor areas has also been described for pubs and bars in Australia.45
The relatively low levels of particulates in many other settings and the rarity of illegal smoking being observed, are suggestive of high compliance with the smokefree law in this city. This impression is consistent with the rarity of prosecutions under the smokefree law (last reported in Wellington for a café owner with an illegal “outdoor” smoking area in 200746). This is also the pattern at the national level where there were only five additional prosecutions in the five years since the law was implemented,47 with the last two being in 200848 49 (based on media database searches in August 2010). However, Ministry of Health officials note that some additional cases have been settled out of court and one prosecution is being appealed [Personal communication, Brendon Baker, 3 September 2010].
Strengths, limitations and further research—Strengths of this work are that it covered a wide range of settings over several years post implementation of the upgraded smokefree law and used a well-established approach to measuring SHS-related particulates in air. Some of our sampling was purposefully of “more traditional” and “sports bars” and this may have maximised efficiency in terms of detecting illegal smoking (compared to a random sample that would have included more “up-market” bars that may better comply with the smokefree law and which may attract more law-abiding clients).
However, limitations of note with this work include the following:
  • Although relatively wide-ranging, our sampling strategy still had deficiencies in terms of not collecting air quality data in all of the settings listed in Table 1 (e.g., due to the inconvenience of getting to a concert). Also sampling did not occur very late at night and in the early morning when some bars remain open and it is plausible that compliance with the law declines. Also, the sampling along the Golden Mile route did not systematically measure levels in close proximity to major building entrances (where smokers sometimes congregate) or around bus stops.
  • Improved sampling strategies would consider these issues and could increase the number of samples taken at each type of setting and sample systematically across seasons of the year (or at least winter versus summer). In particular, it could study further the outdoor areas of hospitals (particularly entrances) where smoking may be relatively common.
  • In some of the indoor settings the particulate levels may have been partly due to non-SHS sources. For example, such fine particulates can be produced by the cooking process50 51 and so can be measured in establishments that cook food (including some bars/pubs). Also, poorly ventilated fire places, unflued gas heaters and candles on tables may contribute fine particulates, along with the movement of outdoor air pollutants to inside settings (e.g., from vehicle exhausts). However, we observed low levels of particulates even in heavily trafficked areas, such as a busy intersection (mean=5 µg/m3, maximum=16 µg/m3 for two 30-minute samples in March/April 2010).
This suggests that road traffic is likely to be only a minor contributor to particulate levels in most of the settings we studied compared to SHS, including along the Golden Mile route. Furthermore, relative humidity levels may also have had some influence on the results but a humidity correction curve for the SidePak has not yet been developed.52
  • This study may not be completely generalisable to the rest of New Zealand. Firstly, smokers in the capital city (some of whom work for central government) may be more compliant with smokefree laws than rural New Zealanders. Nevertheless, none of the authors have ever observed smoking inside pubs or restaurants in other New Zealand cities or towns over the past six years, despite regular visits to such areas. Secondly, as Wellington has relatively high average wind speeds compared to the New Zealand average, it is also possible that the particulate levels we found in “outdoor” smoking areas, under-represent those typically found in other New Zealand towns and cities.
  • Interpreting the results of this study is also limited because of the absence of appropriate air quality standards for high but brief exposure to particulates in SHS (e.g., PM2.5 for one hour or three hours). Such exposure patterns are probably far more relevant than considering annual or 24-hour levels. Also, existing air quality standards refer to particulates which are often derived from traffic, industrial and domestic heating pollutants—the hazard profile and level at which hazard occurs may be different for particulates in SHS.
Policy implications—In our view the most efficient solution to the remaining SHS problem in New Zealand is to adopt endgame policies to the tobacco epidemic which will reduce smoking prevalence to close to zero, such as phasing out tobacco sales using a “sinking lid” on supply.53 But we recognise that lack of strong political leadership on this issue may mean that the country continues along a slower incremental path of adopting smaller and more “politically digestible” tobacco control steps.
If this approach continues, we would favour intensifying established key tobacco control interventions (for which there is scope for improvement in New Zealand54 55), and specifically considering the following additional measures:
  • Introducing additional smokefree laws to cover 50% of the seated outdoor area of hospitality venues as per various jurisdictions in North America and Australia (e.g., for Queensland “the total area of all DOSAs [designated outdoor smoking areas] must not be more than 50% of the whole outdoor liquor licensed area of the premises”56). This could be justified on grounds of protecting workers’ health and fairness to non-smokers (i.e., allowing some reasonable access to semi-smokefree outdoor seating) and is likely to have high public and political acceptability. Nevertheless, we note that from a public health perspective and occupational health perspective this would still often result in exposure of non-smokers and workers to some SHS hazard and nuisance (depending on the wind direction) and many people will consider this a sub-optimal compromise. This is especially so given that some jurisdictions internationally have adopted 100% outdoor smokefree areas at hospitality venues.57 58
  • Amending the existing smokefree law to ensure adequate barriers to air flow between any “outdoor” smoking areas and the inside of hospitality venues e.g., no connecting windows or doors left open and requiring a smokefree area adjacent to the connecting doorway. Making semi-enclosed “outdoor” smoking areas more open to wind flow would also reduce the extent to which SHS can drift to indoors.
  • A possible alternative approach to the measure described immediately above, is to develop mandatory maximum indoor air pollutant levels for PM2.5 in hospitality venues (e.g., for one-hour, three-hours and a working day). This could be accompanied by a monitoring system for determining adherence, with fines on non-complying venues covering the monitoring costs. The Ministry of Health and District Health Boards could be the relevant agencies involved, but occupational health authorities are an alternative (given the important role of occupational health in past smokefree legislation in NZ).
This approach would mean that it could be left to the discretion of the venue management as to how to best comply with the air quality law. This approach would also help address the air pollution problem arising from smoky food premises (especially where food is cooked or heated in the dining area). However, because of the complexity of this approach, and the costs of effective implementation, we consider that complete (100%) smoking restrictions would be preferable.
Such regulatory responses would be expected to reduce the adverse health impacts of SHS to the general public and to workers but potentially also act to reduce health inequalities. This is because of the evidence for higher SHS exposure among deprived populations in New Zealand31 and because more deprived populations are more vulnerable to SHS in terms of having higher rates of chronic respiratory and cardiovascular disease.
Laws requiring major pedestrian areas on city streets to be smokefree (as proposed recently for Wellington’s Golden Mile in an “epetition”30) are harder to justify in terms of SHS exposure levels alone, based on these data. Nevertheless, such laws could be adopted on the grounds of reducing role-modelling of adult smoking behaviour (to children and youth),59 reducing nuisance to non-smokers, and for litter control reasons.
In Tasmania, both Hobart and Launceston have adopted smokefree outdoor policies for the central business districts.60 Similar arguments can apply to making the following areas smokefree: the area around bus stops, train platforms, children’s playgrounds, parks, sports grounds, and parts of beaches (with some of these already operational in parts of NZ28). Although local government could continue to introduce new smokefree laws and policies, it is ultimately more efficient if the major initiatives occur at a central government level.
Although this study did not re-assess the issue of SHS exposure in cars, we consider that this is probably the priority new smokefree law required in New Zealand (i.e., for when infants and children are in the vehicle).
Our previous work indicates extremely high levels of PM2.5 can occur inside cars (e.g. up to 3645 µg/m3 in a car with the windows closed).61 Also there are very high levels of public support for banning smoking in cars with children, including by New Zealand smokers62 and exploring such a law was recommended by the Maori Affairs Select Committee in 2010.63
But despite the likely health and other benefits, most smokefree laws are likely to be resisted by some sectors with commercial vested interests such as the tobacco industry, the hospitality sector and possibly the alcohol industry. This suggests that it is ideal if additional smokefree laws are accompanied with new mass media campaigns on the hazards of SHS and setting out the responsibility of government to protect non-smokers from this hazard.
A near zero-cost supplementary measure to such mass media campaigns is for the government to mandate for additional pictorial warnings on tobacco packaging that include messages on SHS hazards to children and other adults (e.g., as already used in some jurisdictions such as Canada64). Finally, attention by health workers could also go to responding to misuse of information on SHS by those opposed to smokefree laws, given the occurrence of this in New Zealand in the past.65
Competing interests: Although we do not consider it a competing interest, for the sake of full transparency we note that the first two authors have previously worked for health sector organisations working for tobacco control.
Author information: Nick Wilson, Associate Professor; Richard Edwards, Professor; Rhys Parry, 5th-year medical student; Department of Public Health, University of Otago, Wellington
Acknowledgements and funding: The authors thank colleagues who have assisted with the air sampling work (Anthony Maher, Anne Tucker, Jenny Näthe, and Rafed Jalali) and who have provided helpful advice: George Thomson (University of Otago) and Mark Travers (Roswell Park Cancer Institute). Some of the funding support for NW and RE during this period came from the ITC Project, funded by the Health Research Council and the funding for the SidePak came from the Wellington Medical Research Fund.
Correspondence: Dr Nick Wilson, Department of Public Health, University of Otago Wellington, PO Box 7343 Wellington South, New Zealand. Email: nick.wilson@otago.ac.nz
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