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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Secondhand tobacco smoke exposure in selected public places (PM<sub>2.5</sub> and air nicotine) and non-smoking employees (hair nicotine) in Ghana</title><author><name sortKey="Agbenyikey, Wilfred" sort="Agbenyikey, Wilfred" uniqKey="Agbenyikey W" first="Wilfred" last="Agbenyikey">Wilfred Agbenyikey</name><affiliation><nlm:aff id="aff1">Environmental Health Science Department, Yale University School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut, USA</nlm:aff></affiliation></author><author><name sortKey="Wellington, Edith" sort="Wellington, Edith" uniqKey="Wellington E" first="Edith" last="Wellington">Edith Wellington</name><affiliation><nlm:aff id="aff2">Research and Development Division, Ghana Health Service, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Gyapong, John" sort="Gyapong, John" uniqKey="Gyapong J" first="John" last="Gyapong">John Gyapong</name><affiliation><nlm:aff id="aff2">Research and Development Division, Ghana Health Service, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Travers, Mark J" sort="Travers, Mark J" uniqKey="Travers M" first="Mark J" last="Travers">Mark J. Travers</name><affiliation><nlm:aff id="aff3">Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA</nlm:aff></affiliation></author><author><name sortKey="Breysse, Patrick N" sort="Breysse, Patrick N" uniqKey="Breysse P" first="Patrick N" last="Breysse">Patrick N. Breysse</name><affiliation><nlm:aff id="aff4">Department of Environmental Health Sciences and Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</nlm:aff></affiliation></author><author><name sortKey="Mccarty, Kathleen M" sort="Mccarty, Kathleen M" uniqKey="Mccarty K" first="Kathleen M" last="Mccarty">Kathleen M. Mccarty</name><affiliation><nlm:aff id="aff1">Environmental Health Science Department, Yale University School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut, USA</nlm:aff></affiliation></author><author><name sortKey="Navas Acien, Ana" sort="Navas Acien, Ana" uniqKey="Navas Acien A" first="Ana" last="Navas-Acien">Ana Navas-Acien</name><affiliation><nlm:aff id="aff4">Department of Environmental Health Sciences and Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">20930057</idno><idno type="pmc">3045526</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045526</idno><idno type="RBID">PMC:3045526</idno><idno type="doi">10.1136/tc.2010.036012</idno><date when="2010">2010</date><idno type="wicri:Area/Pmc/Corpus">000F80</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000F80</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Secondhand tobacco smoke exposure in selected public places (PM<sub>2.5</sub> and air nicotine) and non-smoking employees (hair nicotine) in Ghana</title><author><name sortKey="Agbenyikey, Wilfred" sort="Agbenyikey, Wilfred" uniqKey="Agbenyikey W" first="Wilfred" last="Agbenyikey">Wilfred Agbenyikey</name><affiliation><nlm:aff id="aff1">Environmental Health Science Department, Yale University School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut, USA</nlm:aff></affiliation></author><author><name sortKey="Wellington, Edith" sort="Wellington, Edith" uniqKey="Wellington E" first="Edith" last="Wellington">Edith Wellington</name><affiliation><nlm:aff id="aff2">Research and Development Division, Ghana Health Service, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Gyapong, John" sort="Gyapong, John" uniqKey="Gyapong J" first="John" last="Gyapong">John Gyapong</name><affiliation><nlm:aff id="aff2">Research and Development Division, Ghana Health Service, Accra, Ghana</nlm:aff></affiliation></author><author><name sortKey="Travers, Mark J" sort="Travers, Mark J" uniqKey="Travers M" first="Mark J" last="Travers">Mark J. Travers</name><affiliation><nlm:aff id="aff3">Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA</nlm:aff></affiliation></author><author><name sortKey="Breysse, Patrick N" sort="Breysse, Patrick N" uniqKey="Breysse P" first="Patrick N" last="Breysse">Patrick N. Breysse</name><affiliation><nlm:aff id="aff4">Department of Environmental Health Sciences and Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</nlm:aff></affiliation></author><author><name sortKey="Mccarty, Kathleen M" sort="Mccarty, Kathleen M" uniqKey="Mccarty K" first="Kathleen M" last="Mccarty">Kathleen M. Mccarty</name><affiliation><nlm:aff id="aff1">Environmental Health Science Department, Yale University School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut, USA</nlm:aff></affiliation></author><author><name sortKey="Navas Acien, Ana" sort="Navas Acien, Ana" uniqKey="Navas Acien A" first="Ana" last="Navas-Acien">Ana Navas-Acien</name><affiliation><nlm:aff id="aff4">Department of Environmental Health Sciences and Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</nlm:aff></affiliation></author></analytic><series><title level="j">Tobacco Control</title><idno type="ISSN">0964-4563</idno><idno type="eISSN">1468-3318</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Secondhand tobacco smoke (SHS) exposure is a global public health problem. Ghana currently has no legislation to prevent smoking in public places. To provide data on SHS levels in hospitality venues in Ghana the authors measured (1) airborne particulate matter <2.5 μm (PM<sub>2.5</sub>) and nicotine concentrations and (2) hair nicotine concentrations in non-smoking employees. Quantifying SHS exposure will provide evidence needed to develop tobacco control legislation.</p></sec><sec><title>Method</title><p>PM<sub>2.5</sub> was measured for 30 min in 75 smoking and 13 non-smoking venues. Air nicotine concentrations were measured for 7 days in 8 smoking and 2 non-smoking venues. Additionally, 63 non-smoking employees provided hair samples for nicotine analysis.</p></sec><sec><title>Result</title><p>Compared to non-smoking venues, smoking venues had markedly elevated PM<sub>2.5</sub> (median 553 [IQR 259–1038] vs 16.0 [14.0–17.0] μg/m<sup>3</sup>) and air nicotine (1.83 [0.91–4.25] vs 0.03 [0.02–0.04] μg/m<sup>3</sup>) concentrations. Hair nicotine concentrations were also higher in non-smoking employees working in smoking venues (median 2.49 [0.46–6.84] ng/mg) compared to those working in non-smoking venues (median 0.16 [0.08–0.79] ng/mg). Hair nicotine concentrations correlated with self-reported hours of SHS exposure (r=0.35), indoor air PM<sub>2.5</sub> concentrations (r=0.47) and air nicotine concentrations (r=0.63).</p></sec><sec><title>Conclusion</title><p>SHS levels were unacceptably high in public places in Ghana where smoking is allowed, despite a relatively low-smoking prevalence in the country. This is one of the first studies to ascertain SHS and hair nicotine in Africa. Levels were comparable to those measured in American, Asian and European countries without or before smoking bans. Implementing a comprehensive smoke-free legislation that protects workers and customers from exposure to secondhand smoke is urgently needed in Ghana.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Navas Acien, A" uniqKey="Navas Acien A">A Navas-Acien</name></author><author><name sortKey="Peruga, A" uniqKey="Peruga A">A Peruga</name></author><author><name sortKey="Breysse, P" uniqKey="Breysse P">P Breysse</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nebot, M" uniqKey="Nebot M">M Nebot</name></author><author><name sortKey="Lopez, Mj" uniqKey="Lopez M">MJ Lopez</name></author><author><name sortKey="Gorini, G" uniqKey="Gorini G">G Gorini</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lopez, Mj" uniqKey="Lopez M">MJ Lopez</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Tob Control</journal-id><journal-id journal-id-type="publisher-id">tc</journal-id><journal-id journal-id-type="hwp">tobaccocontrol</journal-id><journal-title-group><journal-title>Tobacco Control</journal-title></journal-title-group><issn pub-type="ppub">0964-4563</issn><issn pub-type="epub">1468-3318</issn><publisher><publisher-name>BMJ Group</publisher-name><publisher-loc>BMA House, Tavistock Square, London, WC1H 9JR</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">20930057</article-id><article-id pub-id-type="pmc">3045526</article-id><article-id pub-id-type="publisher-id">tobaccocontrol36012</article-id><article-id pub-id-type="doi">10.1136/tc.2010.036012</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Paper</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>1506</subject></subj-group></article-categories><title-group><article-title>Secondhand tobacco smoke exposure in selected public places (PM<sub>2.5</sub> and air nicotine) and non-smoking employees (hair nicotine) in Ghana</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Agbenyikey</surname><given-names>Wilfred</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Wellington</surname><given-names>Edith</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Gyapong</surname><given-names>John</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Travers</surname><given-names>Mark J</given-names></name><xref ref-type="aff" rid="aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Breysse</surname><given-names>Patrick N</given-names></name><xref ref-type="aff" rid="aff4">4</xref></contrib><contrib contrib-type="author"><name><surname>McCarty</surname><given-names>Kathleen M</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Navas-Acien</surname><given-names>Ana</given-names></name><xref ref-type="aff" rid="aff4">4</xref><xref ref-type="aff" rid="aff5">5</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Environmental Health Science Department, Yale University School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut, USA</aff><aff id="aff2"><label>2</label>Research and Development Division, Ghana Health Service, Accra, Ghana</aff><aff id="aff3"><label>3</label>Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA</aff><aff id="aff4"><label>4</label>Department of Environmental Health Sciences and Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</aff><aff id="aff5"><label>5</label>Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA</aff><author-notes><corresp><bold>Correspondence to</bold> Ana Navas-Acien, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room W7033B, Baltimore, MD 21205, USA; <email>anavas@jhsph.edu</email></corresp></author-notes><pub-date pub-type="epub"><day>7</day><month>10</month><year>2010</year></pub-date><pub-date pub-type="ppub"><month>3</month><year>2011</year></pub-date><pub-date pub-type="pmc-release"><day>7</day><month>10</month><year>2010</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on the
<volume>20</volume><issue>2</issue><fpage>107</fpage><lpage>111</lpage><history><date date-type="received"><day>2</day><month>2</month><year>2010</year></date><date date-type="accepted"><day>6</day><month>8</month><year>2010</year></date></history><permissions><copyright-statement>© 2011, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.</copyright-statement><copyright-year>2011</copyright-year><license license-type="open-access"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/2.0/">http://creativecommons.org/licenses/by-nc/2.0/</ext-link> and <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/2.0/legalcode">http://creativecommons.org/licenses/by-nc/2.0/legalcode</ext-link>.</license-p></license></permissions><self-uri xlink:title="pdf" xlink:type="simple" xlink:href="tobaccocontrol36012.pdf"></self-uri><abstract><sec><title>Background</title><p>Secondhand tobacco smoke (SHS) exposure is a global public health problem. Ghana currently has no legislation to prevent smoking in public places. To provide data on SHS levels in hospitality venues in Ghana the authors measured (1) airborne particulate matter <2.5 μm (PM<sub>2.5</sub>) and nicotine concentrations and (2) hair nicotine concentrations in non-smoking employees. Quantifying SHS exposure will provide evidence needed to develop tobacco control legislation.</p></sec><sec><title>Method</title><p>PM<sub>2.5</sub> was measured for 30 min in 75 smoking and 13 non-smoking venues. Air nicotine concentrations were measured for 7 days in 8 smoking and 2 non-smoking venues. Additionally, 63 non-smoking employees provided hair samples for nicotine analysis.</p></sec><sec><title>Result</title><p>Compared to non-smoking venues, smoking venues had markedly elevated PM<sub>2.5</sub> (median 553 [IQR 259–1038] vs 16.0 [14.0–17.0] μg/m<sup>3</sup>) and air nicotine (1.83 [0.91–4.25] vs 0.03 [0.02–0.04] μg/m<sup>3</sup>) concentrations. Hair nicotine concentrations were also higher in non-smoking employees working in smoking venues (median 2.49 [0.46–6.84] ng/mg) compared to those working in non-smoking venues (median 0.16 [0.08–0.79] ng/mg). Hair nicotine concentrations correlated with self-reported hours of SHS exposure (r=0.35), indoor air PM<sub>2.5</sub> concentrations (r=0.47) and air nicotine concentrations (r=0.63).</p></sec><sec><title>Conclusion</title><p>SHS levels were unacceptably high in public places in Ghana where smoking is allowed, despite a relatively low-smoking prevalence in the country. This is one of the first studies to ascertain SHS and hair nicotine in Africa. Levels were comparable to those measured in American, Asian and European countries without or before smoking bans. Implementing a comprehensive smoke-free legislation that protects workers and customers from exposure to secondhand smoke is urgently needed in Ghana.</p></sec></abstract><kwd-group><kwd>Environmental tobacco smoke</kwd><kwd>public policy</kwd><kwd>surveillance and monitoring</kwd></kwd-group></article-meta></front><body><sec><title>Background</title><p>Exposure to secondhand tobacco smoke (SHS) is a global public health problem as recognised by environmental, occupational and public health authorities.<xref ref-type="bibr" rid="b1 b2 b3 b4">1–4</xref> Of all public places, restaurants and bars have the highest SHS concentrations,<xref ref-type="bibr" rid="b5 b6 b7 b8">5–8</xref> increasing the cardiovascular, respiratory and cancer risks among non-smoking workers and patrons.<xref ref-type="bibr" rid="b1">1</xref> <xref ref-type="bibr" rid="b9">9</xref> <xref ref-type="bibr" rid="b10">10</xref> To protect all people from the health effects of SHS, the Framework Convention on Tobacco Control (FCTC) legally binds signatory countries to implement legislations that eliminate smoking in all indoor public places and workplaces.<xref ref-type="bibr" rid="b2">2</xref> <xref ref-type="bibr" rid="b11">11</xref> Political influence of multinational tobacco companies remains a major obstacle for the implementation of smoke-free legislations in African countries.<xref ref-type="bibr" rid="b12">12</xref> Indeed, despite the large number of African countries that have ratified the FCTC (39 as of July 2009), only a few (Djibouti, Kenya, Mauritius, Niger and South Africa) have passed legislation addressing tobacco control in public places.<xref ref-type="bibr" rid="b12">12</xref> <xref ref-type="bibr" rid="b13">13</xref></p><p>Ghana ratified the FCTC in November 2004. While a draft tobacco control bill was presented in 2005, the bill has not yet been passed into law.<xref ref-type="bibr" rid="b14">14</xref> Moreover, data on SHS levels in public places and workplaces remain largely unknown in Ghana and in Africa, in general. Concentrations of airborne particulate matter <2.5 μm (PM<sub>2.5</sub>) and nicotine have been used to assess SHS exposure in public places in the Americas, Asia and Europe.<xref ref-type="bibr" rid="b5 b6 b7 b8">5–8</xref> <xref ref-type="bibr" rid="b15">15</xref> <xref ref-type="bibr" rid="b16">16</xref> Biomarker concentrations among non-smokers are useful to quantify overall personal exposure,<xref ref-type="bibr" rid="b17">17</xref> with hair nicotine concentrations being widely used as a non-invasive biomarker for long-term SHS exposure.<xref ref-type="bibr" rid="b18 b19 b20 b21">18–21</xref></p><p>In this study, our goal was to provide objective data on indoor SHS exposure in restaurants, bars and other hospitality venues in Ghana by measuring airborne PM<sub>2.5</sub> and nicotine concentrations. In addition, to quantify SHS exposure among hospitality employees, hair nicotine concentrations were measured in non-smoking employees. This study can guide public health and policy interventions to protect the population of Ghana from the health consequences of exposure to tobacco smoke, as mandated by the FCTC.</p></sec><sec sec-type="methods"><title>Methods</title><sec><title>Study population</title><p>This cross-sectional assessment was conducted in Accra (the capital city) and other towns across Ghana (Akosombo, Kintampo, Kumasi, Nkawkaw, Takoradi, Tamale and Tema) between June and August 2007. The towns were selected on a convenience basis and represented different geographical and economical sectors within the country. PM<sub>2.5</sub> concentrations were measured in 88 restaurants/bars/nightclubs/casinos located in the popular entertainment districts within each city (from 1 in Akosombo and Kintampo to 60 in Accra depending on the size of the city). The venues were recruited using a door to door technique (in small cities only one venue was recruited as the field workers travelled from one city to another). In Accra and Tema (a major town near Accra), a subset were invited to participate in a further assessment of air nicotine concentrations. For airborne nicotine, the owner had to agree and ≥3 non-smoking employees had to be willing to provide a hair sample and answer a questionnaire. Among the 12 venues invited, 10 agreed to participate (response rate 83%). The study was approved by the Ghana Health Service Ethical Review Committee and Institutional Review Boards at the Johns Hopkins Bloomberg School of Public Health and Yale University.</p></sec><sec><title>Data collection</title><p>Real-time PM<sub>2.5</sub> concentrations were measured for ≥30 min (median 46 min) using TSI SidePak AM510 Personal Aerosol Monitor (TSI Inc., Shoreview, Minnesota, USA) with a 0.32 calibration factor<xref ref-type="bibr" rid="b22">22</xref> and following an established protocol.<xref ref-type="bibr" rid="b8">8</xref> The number of actively burning cigarettes (recorded every 15 min) and room dimensions (measured using a sonic measuring device) were used to calculate active smoking density (average number of burning cigarettes per 100 m<sup>3</sup>). Information on other burning sources was collected.</p><p>Vapour-phase nicotine was estimated for 7 days using passive samplers (two per venue).<xref ref-type="bibr" rid="b15">15</xref> <xref ref-type="bibr" rid="b23">23</xref> Samplers were shipped to the Johns Hopkins Bloomberg School of Public Health for the analysis of nicotine concentrations (μg/m<sup>3</sup>) using gas chromatography with nitrogen-selective detection. The detection limit (DL) was 0.003 μg/m<sup>3</sup>. One sample </p>
<p>Hair samples from non-smoking employees (n=69) were collected on the day the nicotine samplers were installed. A small hair sample (∼30–50 strands) was cut near the root from the back of the scalp and placed in a labelled sealed plastic bag. Up to 3 cm of hair from the scalp was used to evaluate SHS exposure during the most recent months. After sample preparation, nicotine was analysed using an established protocol.<xref ref-type="bibr" rid="b24">24</xref> The limit of detection was 0.02 ng/mg for a 30 mg hair sample.</p></sec><sec><title>Questionnaire</title><p>The 10 managers/owners and 69 non-smoking employees who participated in the air nicotine and hair nicotine assessment were interviewed by trained field workers. The managers/owners were asked to describe general characteristics of the venue (<xref ref-type="table" rid="tbl1">table 1</xref>). The employees were asked about sociodemographic information, smoking history and SHS exposure in different environments and opinions on smoke-free legislation. The interviews were voluntary and each participant signed informed consent.</p><table-wrap id="tbl1" position="float"><label>Table 1</label><caption><p>Characteristics of the hospitality venues by smoking status</p></caption><table frame="hsides" rules="groups"><thead><tr><td rowspan="2" colspan="1">N</td><td rowspan="1" colspan="1">Smoking venue</td><td rowspan="1" colspan="1">Non-smoking venue</td></tr><tr><td rowspan="1" colspan="1">8</td><td rowspan="1" colspan="1">2</td></tr></thead><tbody><tr><td colspan="3" rowspan="1">General characteristics</td></tr><tr><td rowspan="1" colspan="1"> No. years in business</td><td rowspan="1" colspan="1">6.7 (3.7)</td><td rowspan="1" colspan="1">7.0 (4.2)</td></tr><tr><td rowspan="1" colspan="1"> Maximum occupancy</td><td rowspan="1" colspan="1">244 (217)</td><td rowspan="1" colspan="1">338 (371)</td></tr><tr><td rowspan="1" colspan="1"> Number of employees</td><td rowspan="1" colspan="1">23 (18.1)</td><td rowspan="1" colspan="1">18 (3.5)</td></tr><tr><td rowspan="1" colspan="1"> Ventilation system</td><td rowspan="1" colspan="1">100%</td><td rowspan="1" colspan="1">100%</td></tr><tr><td rowspan="1" colspan="1"> Outdoor area</td><td rowspan="1" colspan="1">75%</td><td rowspan="1" colspan="1">50%</td></tr><tr><td rowspan="1" colspan="1"> Food served</td><td rowspan="1" colspan="1">75%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> Live music</td><td rowspan="1" colspan="1">37%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> Dancing space</td><td rowspan="1" colspan="1">50%</td><td rowspan="1" colspan="1">100%</td></tr><tr><td colspan="3" rowspan="1">Customers' characteristics</td></tr><tr><td colspan="3" rowspan="1"> Age<xref ref-type="table-fn" rid="table-fn1">*</xref></td></tr><tr><td rowspan="1" colspan="1"> <30 y</td><td rowspan="1" colspan="1">14%</td><td rowspan="1" colspan="1">100%</td></tr><tr><td rowspan="1" colspan="1"> ≥30</td><td rowspan="1" colspan="1">0%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> Mixed ages</td><td rowspan="1" colspan="1">86%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td colspan="3" rowspan="1"> Education</td></tr><tr><td rowspan="1" colspan="1"> College only</td><td rowspan="1" colspan="1">29%</td><td rowspan="1" colspan="1">100%</td></tr><tr><td rowspan="1" colspan="1"> Mixed or less than college</td><td rowspan="1" colspan="1">71%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td colspan="3" rowspan="1"> Source</td></tr><tr><td rowspan="1" colspan="1"> Tourist</td><td rowspan="1" colspan="1">29%</td><td rowspan="1" colspan="1">50%</td></tr><tr><td rowspan="1" colspan="1"> City residents and tourists</td><td rowspan="1" colspan="1">71%</td><td rowspan="1" colspan="1">50%</td></tr><tr><td colspan="3" rowspan="1">Smoking environment</td></tr><tr><td rowspan="1" colspan="1"> Cigarettes sales</td><td rowspan="1" colspan="1">78%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> Tobacco advertisement</td><td rowspan="1" colspan="1">33%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> Tobacco promotion</td><td rowspan="1" colspan="1">52%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td colspan="3" rowspan="1"> Customers smoking indoors<xref ref-type="table-fn" rid="table-fn2">†</xref></td></tr><tr><td rowspan="1" colspan="1"> 0%</td><td rowspan="1" colspan="1">0%</td><td rowspan="1" colspan="1">100%</td></tr><tr><td rowspan="1" colspan="1"> 0–74%</td><td rowspan="1" colspan="1">42%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> ≥75%</td><td rowspan="1" colspan="1">42%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td colspan="3" rowspan="1">Smoking policy</td></tr><tr><td rowspan="1" colspan="1"> Complete ban</td><td rowspan="1" colspan="1">0%</td><td rowspan="1" colspan="1">100%</td></tr><tr><td rowspan="1" colspan="1"> Separated smoking/non-smoking areas</td><td rowspan="1" colspan="1">0%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td rowspan="1" colspan="1"> Allowed without restrictions</td><td rowspan="1" colspan="1">100%</td><td rowspan="1" colspan="1">0%</td></tr><tr><td colspan="3" rowspan="1">Reasons for smoking allowed</td></tr><tr><td rowspan="1" colspan="1"> Customer preference</td><td rowspan="1" colspan="1">67%</td><td rowspan="1" colspan="1">–</td></tr><tr><td rowspan="1" colspan="1"> Customer preference and loss concern</td><td rowspan="1" colspan="1">33%</td><td rowspan="1" colspan="1">–</td></tr><tr><td colspan="3" rowspan="1">Going smoke-free voluntarily<xref ref-type="table-fn" rid="table-fn3">‡</xref></td></tr><tr><td rowspan="1" colspan="1"> Likely</td><td rowspan="1" colspan="1">0%</td><td rowspan="1" colspan="1">–</td></tr><tr><td rowspan="1" colspan="1"> Somewhat or very unlikely</td><td rowspan="1" colspan="1">86%</td><td rowspan="1" colspan="1">–</td></tr><tr><td colspan="3" rowspan="1">Secondhand smoke concentrations</td></tr><tr><td rowspan="1" colspan="1"> PM<sub>2.5</sub> μm (μg/m<sup>3</sup>)</td><td rowspan="1" colspan="1">905 (420, 1510)</td><td rowspan="1" colspan="1">26.5 (23.0, 30.0)</td></tr><tr><td rowspan="1" colspan="1"> Air nicotine (μg/m<sup>3</sup>)</td><td rowspan="1" colspan="1">1.83 (0.91, 4.25)</td><td rowspan="1" colspan="1">0.030 (0.025, 0.036)</td></tr></tbody></table><table-wrap-foot><fn><p>Data are mean (SD), percentage or median (25th, 75th percentile).</p></fn><fn id="table-fn1"><label>*</label><p>Owner/manager in two venues responded ‘Don't know/not sure’.</p></fn><fn id="table-fn2"><label>†</label><p>Owner/manager in one venue responded ‘Don't know/not sure’.</p></fn><fn id="table-fn3"><label>‡</label><p>Owner/manager in one venue responded ‘Don't know/not sure’.</p></fn></table-wrap-foot></table-wrap></sec><sec><title>Statistical analysis</title><p>Average PM<sub>2.5</sub>, air nicotine and hair nicotine concentrations were described using the median, IQR and range stratifying by the smoking policy of the venue. Scatter plots and Spearman's correlation coefficients were used to evaluate the relationship between PM<sub>2.5</sub> and air nicotine concentrations and between hair nicotine with the following SHS measures: self-reported hours of exposure, PM<sub>2.5</sub> concentrations and air nicotine concentrations. Statistical analysis was performed using SAS 9.1 statistical software.</p></sec></sec><sec sec-type="results"><title>Results</title><sec><title>Indoor air PM<sub>2.5</sub> concentrations</title><p>Median (IQR, range) average PM<sub>2.5</sub> concentrations in 75 smoking venues (smoking observed during the sampling period) were 553 (259–1038, 3–2103) μg/m<sup>3</sup> compared to 16 (14–17, 12–30) μg/m<sup>3</sup> in 13 non-smoking venues (smoking not observed during the sampling period). Real-time PM<sub>2.5</sub> concentrations for the first five venues are shown in <xref ref-type="fig" rid="fig1">figure 1</xref>. No other visible PM<sub>2.5</sub> source was observed. Smoking venues in Accra had higher average PM<sub>2.5</sub> concentrations (median 688 μg/m<sup>3</sup>) compared to other cities (596 μg/m<sup>3</sup>). In smoking locations, mean (SD) active smoking density was 8.0 (5.0) burning cigarettes per 100 m<sup>3</sup>. Average PM<sub>2.5</sub> concentrations were positively correlated (Spearman's correlation coefficient 0.55, p<0.001) with active smoking density.</p><fig id="fig1" position="float"><label>Figure 1</label><caption><p>Real-time PM<sub>2.5</sub> concentrations in the first five venues.</p></caption><graphic xlink:href="tobaccocontrol36012fig1"></graphic></fig></sec><sec><title>Air nicotine concentrations</title><p>Air nicotine concentrations were measured in eight smoking venues (no smoking restriction) and two smoke-free venues (voluntary policy as reported by the owner/manager) (<xref ref-type="table" rid="tbl1">table 1</xref>). Median (IQR, range) air nicotine concentrations were 1.83 (0.91–4.25, 0.33–6.01) μg/m<sup>3</sup> in smoking venues compared to 0.03 (0.02–0.04, <0.003–0.04) μg/m<sup>3</sup> in smoke-free venues (p=0.012). Nicotine concentrations were borderline significantly higher in venues with dancing space (4.27 vs 1.52 μg/m<sup>3</sup>, p=0.07). Other characteristics (occupancy, number of employees, food, music or outdoor space) were not related to air nicotine concentrations. PM<sub>2.5</sub> concentrations comparing the eight smoking venues (median 905 μg/m<sup>3</sup>) to the two smoke-free venues (median 26.5 μg/m<sup>3</sup>) were also markedly different (p<0.001). Air nicotine concentrations were strongly and positively correlated with PM<sub>2.5</sub> concentrations, r=0.76, p<0.001. A 10-fold increase in air nicotine concentrations was associated with a 4.6-fold increase in PM<sub>2.5</sub> concentrations (95% CI 2.0–10.1).</p></sec><sec><title>Hair nicotine concentrations</title><p>Non-smoking employees working in smoking and non-smoking venues were of similar age, gender, education status, employment duration and shift length (data not shown). About 8% of employees were former smokers and 7% lived with a smoker; 76% supported comprehensive smoke-free laws.</p><p>Hair nicotine concentrations were markedly increased in non-smoking employees working in smoking venues (median 2.49, IQR 0.46–6.84, range 0.07–48.4 ng/mg) compared to non-smoking employees working in smoke-free venues (0.16, 0.08–0.79, undetectable-0.79 ng/mg). Hair nicotine concentrations were positively correlated with self-reported hours of SHS exposure (r=0.35), PM<sub>2.5</sub> concentrations (r=0.47) and air nicotine concentrations (r=0.63) (<xref ref-type="fig" rid="fig2">figure 2</xref>). The results were similar after excluding participants who lived with a smoker.</p><fig id="fig2" position="float"><label>Figure 2</label><caption><p>Scatter plots of the relationship of hair nicotine concentrations (ng/mg) with different measures of secondhand smoke exposure in the workplace (hours of exposure per week, air PM<sub>2.5</sub> concentrations and air nicotine concentrations). Dots correspond to hair nicotine concentrations for each non-smoking employee by employee self-reported hours of exposure (top panel), log-transformed PM<sub>2.5</sub> concentrations (left bottom panel) and log-transformed air nicotine concentrations (right bottom panel) in each venue. The line estimates the corresponding log-linear dose–response relationships.</p></caption><graphic xlink:href="tobaccocontrol36012fig2"></graphic></fig></sec></sec><sec sec-type="discussion"><title>Discussion</title><p>In this study, we found high levels of SHS exposure in bars and restaurants in Ghana. Airborne PM<sub>2.5</sub> concentrations measured over >30 min at a time of normal occupancy were approximately 35 times higher in smoking compared to non-smoking venues and strikingly higher than 25 μg/m<sup>3</sup>, the 24-h WHO outdoor air quality standard that has been adopted by Ghana as a guideline for the protection of public health.<xref ref-type="bibr" rid="b25">25</xref> Air nicotine concentrations measured over a week were approximately 60 times higher in smoking versus smoke-free venues. Finally, hair nicotine concentrations were approximately 16 times higher in non-smoking employees working in smoking venues compared to non-smoking employees working in smoke-free venues.</p><p>SHS levels measured in this study were similar and sometimes higher than airborne PM<sub>2.5</sub> and nicotine concentrations measured in American, Asian and European countries without or before implementing comprehensive smoke-free legislations.<xref ref-type="bibr" rid="b5 b6 b7 b8">5–8</xref> <xref ref-type="bibr" rid="b16">16</xref> <xref ref-type="bibr" rid="b26 b27 b28 b29 b30">26–30</xref> Mean active smoking density in venues was also among the highest compared to studies conducted in other countries.<xref ref-type="bibr" rid="b27 b28 b29 b30">27–30</xref> While smoking prevalence in Ghana is relatively low,<xref ref-type="bibr" rid="b31">31</xref> these results provide objective evidence that SHS exposure is a major indoor pollutant in bars and restaurants in Ghana, posing serious health risks for patrons and employees spending time in those environments.</p><p>Ghana is currently in the process of regulating smoking in public places and workplaces. There are renewed efforts to get the draft bill presented to the cabinet and several civil society organisations are urging the government to expedite the passage of the tobacco control bill into law. However, similar to other countries in Africa, implementing smoke-free legislation remains a challenge.<xref ref-type="bibr" rid="b12">12</xref> <xref ref-type="bibr" rid="b14">14</xref> The high levels of SHS exposure measured in this study, the fact that there is no safe level of SHS,<xref ref-type="bibr" rid="b1">1</xref> <xref ref-type="bibr" rid="b10">10</xref> and recent experiences showing that incomplete smoking bans are more difficult to implement<xref ref-type="bibr" rid="b32">32</xref> <xref ref-type="bibr" rid="b33">33</xref> compared to comprehensive ones,<xref ref-type="bibr" rid="b34 b35 b36">34–36</xref> reinforce the urgent need to enact a comprehensive smoke-free legislation that protects all people, including workers, from SHS exposure in Ghana.</p><p>Previous studies assessing SHS concentrations in indoor environments have generally measured PM<sub>2.5</sub> or nicotine. In our study we measured both, confirming a strong positive relationship between PM<sub>2.5</sub> concentrations measured over >30 min and air nicotine concentrations measured over 7 days, consistent with previous US studies in homes and office buildings.<xref ref-type="bibr" rid="b37 b38 b39">37–39</xref> Because nicotine is tobacco specific, these results confirm that tobacco smoke was the most likely source of particulate matter and that randomly measuring PM<sub>2.5</sub> over a short period reflects SHS in most indoor environments. Our study also compared diverse markers of SHS (PM<sub>2.5</sub>, nicotine and self-reported hours of exposure) with hair nicotine, a biomarker of internal dose. Hair nicotine concentrations were moderately correlated with self-reported hours of exposure and with 30-min average PM<sub>2.5</sub> concentrations. The strong correlation between air and hair nicotine is consistent with the strong correlation between air nicotine and serum cotinine in chamber experiments.<xref ref-type="bibr" rid="b40">40</xref></p><p>To our knowledge this is the first study measuring hair nicotine concentrations in a population of non-smoking employees in a Sub-Saharan African country. Our results are consistent with hair nicotine concentrations measured in bar and restaurant workers before a total ban in New Zealand.<xref ref-type="bibr" rid="b18">18</xref> SHS exposure among hospitality employees is of concern given the long hours of exposure and high density of smokers in these environments. Before the implementation of smoke-free legislations in the USA, SHS exposure in non-smoking bar and restaurant employees was between 1.5 and 4.4 times higher compared to non-smokers who lived with smokers.<xref ref-type="bibr" rid="b41">41</xref></p><p>Study employees highly supported comprehensive smoke-free legislations, consistent with other countries.<xref ref-type="bibr" rid="b42">42</xref> <xref ref-type="bibr" rid="b43">43</xref> Conversely, most owners/managers indicated it was very unlikely for their establishments to go voluntarily smoke free. Among those who responded, 50% claimed customer preference and concerns over profit loss as the reasons for allowing smoking. Studies in other countries, however, have found no decline or even improvement in bar/restaurant business after the implementation of comprehensive smoke-free legislations.<xref ref-type="bibr" rid="b44">44</xref> <xref ref-type="bibr" rid="b45">45</xref></p><p>The study was limited by a small sample size and a non-random sampling strategy. However, several cities/towns were sampled. In Accra, moreover, several neighbourhoods were included. We could thus characterise exposure in venues that are meaningful to many people and workers in Ghana. Air nicotine measured over 7 days most likely underestimated exposure during actual working hours. For hair nicotine, chemical treatments may have reduced nicotine concentrations.<xref ref-type="bibr" rid="b21">21</xref> However, the correlation between air and hair nicotine was strong suggesting that both measures provided consistent exposure estimates. Study strengths include the use of established SHS methods, the large number of places with PM<sub>2.5</sub> measurements and the high response rate for air and hair nicotine assessment. Having PM<sub>2.5</sub> and air nicotine concentrations was an important strength as we clearly showed that SHS was the most important contributor to PM<sub>2.5</sub> in Ghana.</p><p>In conclusion, SHS exposure was markedly elevated in public places and workplaces where smoking is allowed in Ghana. This is the first study to describe levels of PM<sub>2.5</sub> and air nicotine concentrations in hospitality venues and hair nicotine concentrations in non-smoking employees in Ghana. The levels were high, similar to those found in American, Asian and European countries without smoke-free legislation. The finding of unacceptably high levels of SHS in hospitality venues and high levels of hair nicotine in non-smoking employees working in these venues provide a strong basis for implementing a comprehensive smoke-free legislation in Ghana.</p><boxed-text position="float"><caption><title>What this paper adds</title></caption><list list-type="bullet"><list-item><p>In Ghana, as in most countries in Africa, little is known about the extent of secondhand smoke (SHS) exposure in public places. This study measured particulate matter of 2.5 μm (PM<sub>2.5</sub>) and air nicotine concentrations in hospitality venues and hair nicotine concentrations in non-smoking employees in Ghana.</p></list-item><list-item><p>SHS levels were unacceptably high in public places in Ghana where smoking is allowed, comparable to those measured in American, Asian and European countries without or before smoking bans.</p></list-item><list-item><p>Implementing a comprehensive smoke-free legislation that protects workers and customers from SHS exposure in indoor public places is urgently needed in Ghana.</p></list-item></list></boxed-text></sec></body><back><ack><p>The authors thank the staff of the Research and Development Division, Ghana Health Service (GHS) and Professor Badu Akosa (Fmr. Director General of GHS) for their collaboration, the Ghana Tourist Board for their support with conducting the fieldwork, Cheryl Higbee (Department of Health Behavior, Roswell Park Cancer Institute) for support in particle analyses and Chrissy Torrey and Jie Yuan (Exposure Assessment Laboratory, Johns Hopkins Bloomberg School of Public Health) for support with conducting air and hair nicotine analyses.</p></ack><fn-group><fn fn-type="financial-disclosure"><p><bold>Funding:</bold> Funding for this project was provided by the <funding-source>Flight Attendant Medical Research Institute (FAMRI)</funding-source>; <funding-source>IDRC-Research for International Tobacco Control</funding-source>, Canada; <funding-source>Bloomberg Global Initiative, Johns Hopkins Bloomberg School of Public Health</funding-source>; and the Stolwijck Fellowship, Yale University. The authors, and not the funding sources, are responsible for the design and conduct of the study, the collection, the analysis and interpretation of the data and the preparation of the manuscript.</p></fn><fn fn-type="conflict"><p><bold>Competing interests:</bold> None.</p></fn><fn fn-type="other"><p><bold>Ethics approval:</bold> The study and consent procedures were approved by Ghana Health Service Ethical Review Committee and by Institutional Review Boards at Johns Hopkins Bloomberg School of Public Health and Yale University. Participation of subjects was voluntary and after receiving informed consent.</p></fn><fn fn-type="con"><p><bold>Contributors:</bold> Wilfred Agbenyikey, Edith Wellington and John Gyapong directed the fieldwork in Ghana. Mark J. Travers supervised all the aspects of the fieldwork, data analysis and interpretation related to PM<sub>2.5</sub> measures. Ana Navas-Acien supervised all aspects of the fieldwork, data analysis and interpretation related to air nicotine and hair nicotine measures. Wilfred Agbenyikey, Kathleen M. McCarty and Ana Navas-Acien analysed the data and drafted the initial version of the manuscript. Patrick Breysse is responsible for the air nicotine and hair laboratory analysis, quality control and assurance and interpretation of air and hair nicotine data. Wilfred Agbenyikey, Edith Wellington and John Gyapong are responsible for the interpretation and discussion of the study findings as they pertain to Ghana and the African context. 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