1 PM2.5 as a marker of exposure to tobacco smoke and other sources of 2 particulate matter in Cairo, Egypt 3
4 Christopher A. Loffredo,1 Yitao Tang,1 Mohamed Momen,2 Kepher Makambi,1 5 Ghada Nasr Radwan,3 Aisha Aboul-Foutoh2 6 7
8 1 Georgetown University, Washington DC, USA
9 2 Ain Shams University, Cairo, Egypt
10 3 Cairo University, Cairo, Egypt 11 12 13 Send correspondence to: 14 Dr. Christopher Loffedo, Georgetown University, 3970 Reservoir Rd NW, 15 Washington DC 20057, 202-687-3758 (phone) 202-687-0313 (fax), 16 [email protected] 17 18 Authors’ emails: 19 Christopher A. Loffredo [email protected] 20 Yitao Tang [email protected] 21 Mohamed Momen [email protected] 22 Kepher Makambi [email protected] 23 Ghada Nasr Radwan [email protected] 24 Aisha Aboul-Foutoh [email protected] 25 26 27 28 29
30 31 PM2.5 and waterpipe smoking in Egypt
32 ABSTRACT
33 Setting: Cairo and Giza governorates of Egypt
34 Objective: Particulate matter under 2.5 microns in diameter (PM2.5) arises
35 from diverse sources, including tobacco smoke from cigarettes and
36 waterpipes, and is recognized as a cause of acute and chronic morbidity and
37 mortality. Our study aimed to measure PM2.5 in workplaces with different
38 intensities of smoking and varying levels of smoking restrictions
39 Design: We conducted an air sampling study to measure PM2.5 levels in a
40 convenience sample of indoor and outdoor venues in 2005-6.
41 Results: 3,295 individual measurements were collected at 96 venues with a
42 calibrated SidePak instrument. Compared to indoor venues where tobacco
3 43 smoking was banned (PM2.5 levels of 72-81ug/m ), places offering waterpipes
44 to patrons of cafes (478 ug/m3) and Ramadan tents (612 ug/m3) had much
45 higher concentrations, as did venues such as public buildings with poor
46 enforcement of smoking restrictions (range: 171-704 ug/m3). Both the number
47 of waterpipe smokers and the number of cigarette smokers observed at each
48 venue contributed significantly to the overall burden of PM2.5.
49 Conclusion: Such data will support smoke-free policies and programs aimed
50 at reducing environmental tobacco exposure specifically and improving air
51 quality generally, and will provide a baseline for monitoring the impact of
52 tobacco control policies.
53 Key words: particulate matter, indoor air quality, smoking
2 PM2.5 and waterpipe smoking in Egypt
54 BACKGROUND
55 Atmospheric particulate matter with diameter <= 2.5 microns (PM2.5) is
56 generated from anthropogenic sources such as vehicle exhaust and tobacco
57 smoke and is composed of diverse compounds and elements including
58 organic matter, sulfate, ammonium, nitrate, and various metals (e.g. Cu, Cr,
59 Mn, As, Pb and Zn).1,2 The main route of human exposure results in
60 absorption into the bloodstream through the respiratory tract. Studies show
61 that variations in the level of PM2.5 in air is associated with changes in the
62 incidence of all-cause mortality3,4 and with cause-specific hospital
5 6 63 admissions, especially for cardiovascular and respiratory diseases. PM2.5 is a
64 major component of both cigarette smoke and environmental tobacco smoke
65 (ETS), both of which are associated with cancer and other chronic diseases.
66 The U.S. Environmental Protection Agency cited over 80 epidemiologic
67 studies in creating an initial particulate air pollution standard in 1997 to protect
68 public health and more recently updated the current standards to 12 μg/m3 as
3 69 the average annual level of PM2.5 exposure, with 35 μg/m as the upper limit for
70 24-hour exposure.7,8
71
72 Although PM2.5 levels have been well characterized in relation to cigarette
73 smoking, relatively little is known about the contribution of waterpipe (or
74 hookah) smoking to PM2.5, particularly in countries in North Africa and the
75 Middle East, where waterpipe smoking represents a major form of tobacco
76 use.9 Exposure to ETS from waterpipes, which are typically smoked in social
77 settings including cafes, bars, and restaurants, may be a particular concern
78 for workers in such establishments, who often have low levels of protection
3 PM2.5 and waterpipe smoking in Egypt
79 due to inadequate smoking regulations in some countries.10-16 Indeed, the
80 World Health Organization’s Framework Convention on Tobacco Control calls
81 on governments to “protect all persons from exposure to tobacco smoke,”
82 rather than just specific populations such as children or pregnant women. This
83 protection should be extended, according to Article 8, “in indoor workplaces,
84 public transport, indoor public places and…other public places.”17
85
86 Limited laboratory-based testing suggests that the levels of particulate matter
87 released from waterpipes under controlled conditions are comparable to those
88 from cigarettes; in one such experimental protocol, a waterpipe smoking
89 session of 30 minutes generated PM emissions similar in magnitude to a 90 91 single cigarette smoked for 10 minutes.18 In contrast, there is scant data
92 reporting measurements of PM2.5 under natural exposure conditions of
93 waterpipe smoking, and the contribution of such emissions to the overall
94 societal burden of PM2.5 has yet to be established. Therefore, the purpose of
95 our study was to measure PM2.5 in a sample of workplaces in Cairo, Egypt,
96 characterized by different intensities of waterpipe smoking and varying levels
97 of indoor smoking restrictions. Such data will support more effective smoke-
98 free policies and programs aimed at reducing ETS exposure and will provide
99 a baseline for monitoring the impact of tobacco control policies.
100
101
4 PM2.5 and waterpipe smoking in Egypt
102 METHODS
103 This study was approved by the Institutional Review Boards of the University
104 of Maryland, Ain Shams University, and the Ministry of Health in Egypt.
105 Venues sampled
106 A convenience sample of hospitality settings (waterpipe cafes, restaurants,
107 and Ramadan tents) was selected for PM2.5 monitoring between October 12,
108 2005 and January 31, 2006, in the Cairo and Giza governorates of Egypt.
109 Waterpipe cafes are establishments offering food, drinks, and waterpipes to
110 patrons, while Ramadan tents are similar places where people gather in the
111 evenings after daily fasting during the month of Ramadan. PM2.5 levels were
112 also examined during the same time period for a cross section of other public
113 places with varying degrees of indoor air restrictions: Cairo International
114 Airport, a municipal court building, a faculty office building at Ain Shams
115 University, and governmental offices (where tobacco smoking is officially
116 restricted but not well enforced); in transport vehicles such as buses and taxis
117 (where tobacco smoking is restricted but enforcement is at the driver’s
118 discretion); in the open air of the center of a semi-rural village within Giza
119 governorate; and sidewalks along major streets as well as in the center of the
120 crosswalk. A mosque and our Cairo study office (Egyptian Smoking
121 Prevention Research Initiative, or ESPRI) were also included in the air
122 sampling protocol, as they were among the only places in the regions where
123 tobacco smoking was absolutely not allowed. The hospitality settings were
124 sampled between 6 PM and 3 AM, and in all other settings the sampling was
125 carried out between 8 AM and 2 PM.
126
5 PM2.5 and waterpipe smoking in Egypt
127
128 Measurements
129 Each sampling site was tested for a minimum of 60 minutes. A TSI SidePak
130 AM510 Personal Aerosol Monitor (TSI, Inc., St. Paul, MN) was used to
131 sample and record the levels of suspended particles in the air. Sampling was
132 performed discreetly in order to avoid disturbing the occupants’ normal
133 behavior; for this reason the device was concealed within a backpack, with
134 the inlet tube protruding just far enough to allow air sampling. The SidePak
135 uses a built-in sampling pump to draw air through the device where the
136 particulate matter in the air scatters the light from a laser to assess the real-
137 time concentration of particles smaller than 2.5µm in micrograms per cubic
138 meter, or PM2.5. The SidePak was calibrated against a laser photometer, which
139 had been previously calibrated and used in similar studies. In addition, the
140 SidePak was zero-calibrated prior to each use by attaching a HEPA filter
141 according to the manufacturer’s specifications. For each indoor venue, the
142 first and last minute of data were removed from the statistical analysis
143 because they are strongly influenced by outdoor and entryway air. The
144 remaining data points were averaged to provide a mean PM2.5 concentration
145 within the venue. After air monitoring, the SidePak was immediately
146 connected to a PC, and the data were downloaded using TrakPro software
147 version 3.40. Observational data were entered into an Excel spreadsheet.
148
149 For the hospitality venues only, several additional variables were measured.
150 The number of patrons and the number of burning cigarettes and waterpipes
151 observed were recorded every 15 minutes during the visit. These
6 PM2.5 and waterpipe smoking in Egypt
152 observations were averaged over the time inside the venue to determine the
153 average number of people on the premises and the average number of
154 burning cigarettes and waterpipes. A sonic measure (Zircon Corporation,
155 Campbell, CA) was used to measure room dimensions and hence the volume
156 of each of the hospitality venues. When using the sonic measure to calculate
157 room dimensions was not possible, room measurements were made through
158 visual estimation.
159
160 For estimation of occupational exposure to PM2.5 in the hospitality settings, an
161 8 hour time weighted average was calculated. To derive the 8 hour time
162 weighted average from more than one sample of a shorter period, the
163 following equation was used: {(C1 x T1) + (C2 x T2) ... + (Cn x Tn)} / 8, where
164 C is the exposure level, T is the time for that exposure, and n is the last of the
165 sequential sampling periods.
166
167 Statistical analysis
168 PM2.5 measurements were log2-transformed so that their frequency distribution
169 achieved a normal distribution. We examined the differences in means of
170 PM2.5 levels in different venues by using ANOVA. Dunnett's t-test was used to
171 compare the means between venues, using the ESPRI office as the common
172 comparison venue. Duncan’s multiple range test was used to stratify venues
173 into statistically similar groupings of PM2.5 levels. The contribution of cigarettes
174 and waterpipes to each venue’s mean PM2.5 was tested by two-way ANOVA;
175 we also evaluated the interaction term between these two factors. Finally,
176 quadratic terms for cigarettes and waterpipes were introduced to account for
7 PM2.5 and waterpipe smoking in Egypt
177 any non-linear effects. SAS version 9.3 (Cary, North Carolina, USA) was used
178 for the statistical analysis.
179
180
8 PM2.5 and waterpipe smoking in Egypt
181 RESULTS
182 All venues
183 A total of 3,295 measurements were analyzed in this study (Table 1),
184 including 25 at Cairo International Airport, 42 in court buildings, 780 in cafes,
185 240 in restaurants, 449 in Ramadan tents, and 21 in a mosque, among a total
186 of 14 categories of venues. The municipal court, with air measurements taken
187 in the public waiting area and inside the court itself, had the highest mean
3 188 level of PM2.5 (704.3 µg/m ), followed by the Ramadan tents (612.5) and cafes
189 (478.4); in comparison, the smoke-free ESPRI offices and mosque had the
190 lowest levels (72 and 81, respectively). Venues where smoking is nominally
191 restricted but not well enforced, such as the airport, government offices, and
192 public transport vehicles, were intermediate in the measured PM2.5 levels.
193 Outdoor air measurements were relatively high (range 236-401 µg/m3),
194 reflecting the diverse sources of particulate matter in the urban environment.
195 The overall one-way ANOVA F-test on these log2-transformed raw readings
196 was highly significant (F=150, P<0.0001), suggesting a strong relationship
197 between the specific type of venue and PM2.5 levels. Comparing venues using
198 Dunnett's t-test showed that the mean levels of every venue except the
199 mosque were significantly higher than in the control venue (ESPRI office),
200 where a no smoking policy was strictly enforced.
201
202 Duncan’s multiple range test indicated the following groupings of venues
203 according to similarities in their PM2.5 levels (from highest to lowest
204 concentrations): (1) the court building, Ramadan tents, and cafes; (2) traffic
205 and transportation vehicles; (3) restaurants, university buildings,
9 PM2.5 and waterpipe smoking in Egypt
206 governmental offices, and sidewalks; (4) airport and ambient air; (5) the rural
207 village center; and (6) the mosque and the ESPRI office.
208
209 A two-way ANOVA model examining the impacts of cigarettes and waterpipes
210 showed that both types of tobacco smoking contributed significantly (F=88.58,
211 P<0.0001, and F=12.99, P<0.001, respectively) to the PM2.5 levels in the
212 combined group of Ramadan tents and cafes (data not shown). The quadratic
213 term for cigarette smoking improved the fit of the model to our data,
214 suggesting a non-linear acceleration in PM2.5 levels with increasing numbers of
215 cigarettes in a venue.
216
217 Hospitality settings
218 PM2.5 levels were measured in 25 hospitality settings (15 waterpipe cafes, 5
219 Ramadan tents and 5 restaurants). Tobacco smoking was observed in all of
220 them, with waterpipes predominating: the mean number of burning waterpipes
221 was 19 in the cafes and 16 in the tents, compared to an average of 8 burning
222 cigarettes in the cafes and 7 in the tents (data not shown). None of the
223 restaurants had smoking patrons present during sampling. Most of the
224 waterpipe cafes (11 of 15) were outdoor establishments and the remainder
225 were indoor establishments. All tents and restaurants were enclosed indoor
226 spaces, each with a roof and walls. No waterpipe smoking was observed in
227 the airport, court, university, and governmental buildings, although cigarette
228 smoking was observed in each of those venues. No smoking of any kind was
229 seen in the mosque or the ESPRI office.
230
10 PM2.5 and waterpipe smoking in Egypt
231 The average size of the sampled restaurants (128 m3 ) was smaller than that
232 of cafes and tents (235 m3 and 2878 m3 respectively). The average number of
233 patrons present during sampling in restaurants was 12 in comparison to an
234 average of 39 in the cafes and 42 in the Ramadan tents. The mean PM2.5
235 levels in open air waterpipe cafes was 478 µg/m3, ranging from 100 to 1313
236 (as shown in Table 1). However, the average PM2.5 level in Ramadan tents
237 was significantly higher - 613 µg/m3 ranging from 111 to 1723. The 8-hr time
238 weighted average of PM2.5 exposure level was significantly higher in Ramadan
239 tents when compared to cafes (141.6 µg/m3 versus 56.5 µg/m3, respectively).
3 240 Regarding the restaurants, the mean PM2.5 level was 213 µg/m (range: 105 to
3 241 865 µg/m ). Figure 1 shows the average levels of PM2.5 in each of the
242 selected venues.
243
244
11 PM2.5 and waterpipe smoking in Egypt
245 DISCUSSION 246 247 The results of this study demonstrate that venues that allowed tobacco
248 smoking, either explicitly (cafes and Ramadan tents) or by poor enforcement
249 of indoor smoking restrictions (courts and other governmental buildings) had
250 on average much higher PM2.5 levels compared to smoke-free venues (the
251 mosque and ESPRI office) and places where no smoking was observed
252 during the study (restaurants). Although both types of smokers were observed
253 during the sampling sessions, waterpipe smoking predominated over cigarette
254 smoking in the cafes and Ramadan tents. According to the indoor Air Quality
255 Index, which was established by the EPA, the indoor air quality as measured
7 256 by PM2.5 in these venues is considered very unhealthy. Our study also
257 suggests that PM2.5 levels were generally higher in venues in which waterpipe
258 smoking was observed compared to those in which only cigarette smoking
259 was observed, e.g. in transport vehicles and governmental offices, where it
260 would not be convenient for a smoker to bring his or her own waterpipe.
261
262 The findings of this study are generally consistent with previous studies.
263 Recent studies from the Middle East region that used comparable study
264 designs to ours have documented similarly elevated levels of one to two
265 orders of magnitude in venues such as waterpipe cafes compared to those
266 where tobacco smoking was banned.16, 19, 20 In contrast, other studies have
267 reported differences between venues that were slightly smaller than those in
268 our study. For example, recent air monitoring in seven cities in the U.S. found
269 PM2.5 to be 82% lower in smoke-free hospitality settings compared to venues
270 where smoking was permitted.21 Another study found a similar 90% decline in
12 PM2.5 and waterpipe smoking in Egypt
271 PM2.5 levels in 8 hospitality venues in Delaware after smoking was prohibited
272 there by a state law.22 One reason why our study may have observed smaller
273 differences between smoke-free and non-smoke-free sites is the larger size of
274 the sampled rooms and lower active smoker densities in our study, which
275 would tend to dilute the PM2.5 concentration. Even in municipalities in which
276 cigarette smoking in cafes, bars, and restaurants has been banned, regulatory
277 loopholes have resulted in a flourishing trend of waterpipe smoking in such
278 venues, e.g. Baltimore and New York City, where investigators have recently
279 measured unacceptably high levels of PM2.5, CO, and other pollutants
280 released from waterpipes.23,24
281
282 Several previous studies have assessed improvements in health associated
283 with indoor smoking bans. For example, one study found that respiratory
284 health improved rapidly in a sample of bartenders after a statewide smoke-
285 free workplace law was implemented in California,10 and another study
286 reported a 40% reduction in acute myocardial infarctions admitted to a
287 regional hospital during the first 6 months that a local smoke-free ordinance
288 was in effect.25 While our study did not assess health effects, it does provide a
289 robust baseline measure of PM2.5 exposure levels experienced by local
290 hospitality workers and patrons, against which future reductions in exposure
291 can be compared when their worksites become smoke-free.
292
293 PM2.5 measurements have been shown to correlate well with levels of ETS
26 294 from cigarette smoking. However, PM2.5 is only one aspect of overall air
295 quality. Other factors such as meteorologic variables and pollutants such as
13 PM2.5 and waterpipe smoking in Egypt
296 NO3, SO4, O3, NO2, and CO must also be taken into account.4,27 In addition,
297 the fact that we observed elevated levels of PM2.5 at indoor venues where
298 smoking is prohibited suggests that other sources, including the transport of
299 outdoor pollution due to factory emissions and vehicle exhaust,28-30 may have
300 contributed to the overall exposure burden. Biomass fuels for cooking,
301 heating, and lighting have also been reported to result in elevated particulate
302 levels.31-33
303
304 This study is subject to several limitations. The venues selected for air
305 measurements were a convenience sample and may not be representative of
306 all venues in Cairo and Giza. However, these venues were selected on the
307 basis of offering a wide range in terms of physical size, smoking restrictions,
308 indoor versus outdoor settings, and waterpipe availability. In addition, ETS is
309 not the only source of indoor particulate matter. While PM2.5 monitoring is not
310 specific for ETS, it is highly sensitive to it, as evidenced by the sharp elevation
311 in PM2.5 levels upon entering venues where smoking is present. Ambient
312 particle concentrations and traffic are additional sources of indoor particle
313 levels; however, PM2.5 levels were significantly higher in cafes and tents than
314 in outdoor air. In contrast to the instruments available at the time of the study,
315 current technology is capable of measuring smaller size particles, e.g. PM1.0 or
316 smaller, which may better reflect the exposures originating from cigarettes
317 and waterpipes.
318
14 PM2.5 and waterpipe smoking in Egypt
319 CONCLUSIONS
320 In summary, we sought to characterize levels of PM2.5 in diverse indoor and
321 outdoor venues in the Cairo metropolitan area. We took advantage of the
322 presence of waterpipe smoking in some venues to further explore the
323 contribution of this source of ETS to that of cigarette smoking, for which much
324 more information is available in the literature. The results suggest strongly
325 that waterpipe smoking can be a major contributor to both ETS and poor air
326 quality. Ongoing tobacco control efforts in such places need to address the
327 double burden of both types of tobacco smoking in planning for the
328 implementation and evaluation of strategies to reduce ETS exposure.
329
330
15 PM2.5 and waterpipe smoking in Egypt
331 COMPETING INTERESTS
332 The authors declare that they have no competing interests.
333 ACKNOWLEDGMENTS
334 The authors offer profound thanks to the late Dr. Mostafa Kamel Mohamed of
335 Ain Shams University, not only for conceiving and designing this study but
336 also for his leadership on tobacco control efforts in Egypt and the entire
337 region. This work was supported by grant number R01TW05944 from the
338 Fogarty International Center, U.S. National Institutes of Health and by grant
339 number 1000-024-388 from the program of Research for International
340 Tobacco Control of the International Development Research Centre. All of the
341 authors participated in writing the manuscript. Data collection was carried out
342 by MM; data analysis was performed by KM & YT; the fieldwork was
343 supervised by AAF; and study design was provided by CAL.
344
345 346
347
348
349
16 PM2.5 and waterpipe smoking in Egypt
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3 453 Table 1. PM2.5 levels (µg/m ) in the sampled venues in Cairo and Giza, Egypt. 454 Venue (N) Number Mean STD Median IQR Maximum Minimum of air samples Hospitality settings Restaurants (5) 240 297.9 183.9 231 216 865 105 Cafes (15) 780 478.4 225.2 444 292 1313 100 Ramadan tents (5) 449 612.6 385.7 590 531 1723 111 Public venues Airport (1) 25 171.5 41.1 178 35 240 80 University buildings (1) 16 223.0 13.4 219 28 244 207 Courts (2) 42 704.3 316.6 743 488 1297 80 Transport vehicles (8) 200 346.4 217.0 320 149 1330 72 Government offices 112 321.4 345.8 204 109 1176 76 (3) Open air venues Ambient air (22) 485 236.8 134.4 209 222 730 47 Village center (1) 93 102.5 25.0 96 27 236 68 Sidewalks (3) 92 253.2 144.1 240 145 1003 74 Crosswalks (28) 631 401.3 260.0 366 367 1399 41 Smoking-restricted venues Mosque (1) 21 81.1 7.2 80 9 96 72 ESPRI office (1) 109 72.1 9.8 70 13 106 55 455 STD=standard deviation; IQR=Intequartile range
456
21 PM2.5 and waterpipe smoking in Egypt
Figure 1. PM2.5 levels at various sampling sites in Cairo, Egypt, 2005-6
1400
1200
1000
3 800 /m
Ug 600
400
200
0
ESPRI
Café 9 Café Café 1 Café 2 Café 3 Café 4 Café 5 Café 6 Café 7 Café 8 Café
Tent 1 Tent 1 Tent 3 Tent 4 Tent 5 Tent
Airport
Café 10 Café 11 Café 12 Café 13 Café 14 Café 15 Café
Court 1 Court 2 Court
Office 1 Office 2 Office 3 Office 4 Office Mosque
22