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S25 2 how do we measure secondhand smoke- erika avila-tang
1. How do we Measure Secondhand Smoke Exposure?
Dr. Erika Avila Tang
Department of Epidemiology
Institute for Global Tobacco Control
2. FAMRI Expert SHSe Assessment
Goal:
To catalogue the approaches for Secondhand Smoke exposure (SHSe) assessment
Provide a set of uniform methods for future use to facilitate comparisons of findings
across studies
Comprehensive topic assessments on:
Questionnaires and self-reported methods
Biological samples
Environmental samples
Flight Attendant Medical Research Institute (FAMRI) Centers of Excellence
American Academy of Pediatrics Julius B. Richmond, Illinois, USA
Johns Hopkins University, Maryland, USA
University of California, San Francisco Bland Lane, California, USA
More than 20 researchers on SHSe assessment involved
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3. Why would we want to measure SHSe?
SHSe is a key element of tobacco control
research and implementation worldwide
To estimate the SHSe overall burden of disease
To determine the risks associated with SHSe
To assess population trends in support of and
evaluate tobacco control policies
To support and evaluate behavioral interventions
5. Self-reported methods of assessment
Questionnaires
Most commonly used
Inexpensive and feasible for large studies
Assessment of :
Current and long-term exposure
Time-activity patterns
Recall can be an issue
Diaries
Recall burden is reduced but respondent’s burden is increased
E.g. Report over the past day vs. past week/month
Higher awareness of instances of exposure
6. Accuracy: validity and reliability
Review of studies assessing the validity and/or
reliability of questions
Validation of questions against a “gold
standard”:
Air measurement
Biomarker
Reliability=repeatability
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7. Conclusions for questionnaires and self-
reported methods
Reliable responses for SHSe in their lifetime, childhood,
and current among adults.
For children, CPD from parents, in their presence, and in
places
Research on testing the accuracy of questions are still
needed
Current exposure for adults and children, including intensity and
duration of exposure
Exposure at home, in transport, and in social settings
Collaboration of FAMRI CoEs: AAP Richmond, Johns
Hopkins, and UCSF Bland Lane are testing questions in
pilot studies to continue building a set of core questions
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9. Biomarkers
Tobacco-specific biomarkers
Cotinine
Reflects recent SHSe (t1/2 16 hours (average))
Nicotine/cotinine in hair or toenails
Reflects “longer exposure”: 1 cm of hair proximal to the
scalp ≈ last month’s exposure; 1 mm ≈ last month’s
exposure
NNAL (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol)
Reflects “longer exposure” (t1/2 up to 3 weeks)
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10. Biomarker- Cotinine
Matrix Cut-off Pros Cons
Urine 50 ng/ml for higher Higher Need of facilities with
Non-invasive SHSe concentrations privacy during collection
than other Difficulty for population-
matrices based or children studies
(higher Need for creatinine
sensitivity) clearance adjustment
Collect data on renal
disease and some
prescription drugs
Blood 12 ng/ml for higher No adjustment Pregnant women have
Invasive SHSe required for increased clearance rate
hydration Difficulty for infants and
3 ng/ml for lower young children
SHSe Lower sensitivity
Saliva 14 ng/ml for higher Good for Potential issues with age,
Non-invasive SHSe multiple gender, race, oral pH, type
measurements of diet, dehydration, or
over a limited drug treatment
period of time Lower sensitivity
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11. Biomarker- Nicotine/Cotinine
Matrix Cut-off Pros Cons
Hair 0.8 ng/mg Easy to collect, ship, and Scarcity of hair in infants
Non-invasive (Women) store (room temperature ≤ 5 and adults
years) Chemical hair treatments
0.2 ng/mg Less affected by daily can reduce concentrations
(Pregnant) variability (fluctuating by 9%-30%
exposure, varying Age, gender, and race may
0.2 ng/mg metabolism, and nicotine play roles in determining
(Children) elimination) hair nicotine concentrations
Represents longer exposure
Toenails Not Easy to collect, ship, and Need for further research
Non-invasive available store (room temperature ≤ and population
20 years) concentrations
Overcomes day-to-day
exposure variability
Represents longer exposure
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12. Biomarker- NNAL
Matrix Cut-off Pros Cons
Urine Not Related to a lung carcinogen Analytical expertise
available Represents longer exposure Costly equipment
than cotinine NNAL is carcinogenic and
(urine/blood/saliva) mutagenic, special lab
handling
Further research needed
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14. Environmental measurements
Most widely used methods:
Nicotine: passive air monitor
Particulate matter (< 2.5µ (PM2.5)) monitor
Correlation between nicotine and PM when
measured in the same setting using a common
sampling period
An increase in 1 µg/m3 of nicotine concentration ≈ an
average increase of 10 µg/m3 of PM
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15. Air nicotine monitoring
Highly specific to tobacco smoke
Monitors (1-3) placed in each venue (hung from the
ceiling) for 5 to14 days
Filters are soaked in a bi-sodium sulfate solution that
captures nicotine on the filter
No expensive equipment to buy
up front and minimal operating
cost but requires lab analysis
Per sample laboratory costs
including the filter badge are
~$40-$100 USD
16. Particulate matter monitoring
Active, real-time monitor
Uses light scattering to measure particulate
matter concentrations (e.g. PM2.5)
Air quality standards makes easier
dissemination
Other causes of indoor air particles
High initial investment
~3,000 USD
Minimal operating cost
No per sample costs
Potential costs in labor for data analysis
17. Overall findings
Questionnaires are the most effective way to know if
people are exposed – but not how much they are exposed
Research on testing the accuracy of questions are still
needed
Choice of any SHSe assessment method depends on your
needs
Study’s objectives, subjects, design and setting and funding
Selection of a biomarker will dependent on:
Issues of privacy, invasiveness, and subject’s age
The length of SHSe may result in selecting hair or toenails over bio-
fluids
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18. Acknowledgements
Wael Al-Delaimy Melbourne Hovell
Benjamin Apelberg Andrew Hyland
David Ashley Sungroul Kim
Erika Avila-Tang Jonathan Klein
Neil Benowitz Neil Klepeis
Thomas Bernert Robert McMillen
Dana Best James Repace
Patrick Breysse Jonathan Samet
Michael Cummings Jonathan Winickoff
Geoffrey Fong Ana Navas-Acien
Lara Gundel Lisa Hepp
Kathie Hammond Jessica Elf
Stephen Hecht Camille Madsen
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