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Objectives: Policy responses to the COVID-19 pandemic in 2020 led to behaviour changes in the UK's population, including a sudden shift towards working from home. These changes may have affected overall exposure to fine particulate matter (PM2.5), an air pollutant and source of health harm. We report the results of a simulation model of a representative sample of the UK's population, including workers and non-workers, to estimate PM2.5 exposure before and during the pandemic. Methods: PM2.5 exposure was simulated in April and August 2017–2020 for 10,000 individuals across the UK drawn from the 2011 nationwide census. These data were combined with data from the UK's ambient PM2.5 monitoring network, time use data and data on relevant personal behaviour before and during the first stage of the pandemic (such as changes in smoking and cooking). Results: The simulated exposures were significantly different between each year. Changes in ambient PM2.5 resulted in regional and temporal variation. People living in homes where someone smoked experienced higher exposure than those in smoke-free homes, with an increase of 4 µg/m3 in PM2.5 exposure in 2020. Conclusions: Changes in PM2.5 exposure were minimal for most individuals despite the simulated increases in cooking activity. Those living in smoking homes (estimated to be around 11% of the UK population) experienced increased exposure to PM2.5 during COVID lockdown measures and this is likely to have increased mortality and morbidity among this group. Government policy should address the risk of increased exposure to second-hand smoke in the event of future COVID-19-related restrictions.

Adoption of smoke-free measures has been one of the central elements of tobacco control activity over the past 30 years. The past decade has seen an increasing number of countries and proportion of the global population covered by smoke-free policies to some extent. Despite reductions in global smoking prevalence, population growth means that the number of non-smokers exposed to the harms caused by secondhand smoke remains high. Smoke-free policy measures have been shown to be useful in protecting non-smokers from secondhand smoke, and can additionally increase cessation and reduce smoking initiation. Policies tend to be aimed primarily at enclosed public or workplace settings with very few countries attempting to control exposure in private or semiprivate spaces such as homes and cars, and, as a result, children may be benefiting less from smoke-free measures than adults. Compliance with legislation also varies by country and there is a need for education and empowerment together with guidance and changing social norms to help deliver the full benefits that smoke-free spaces can bring. Restrictions and policies on use of electronic cigarettes (e-cigarettes) in smoke-free settings require more research to determine the benefits and implications of bystanders' exposure to secondhand e-cigarette aerosol, dual use and smoking cessation.

Abstract

Objectives
Prisons in Scotland were one of the few workplaces exempt from the 2006 comprehensive smoking ban in indoor public places, excluding the prison workforce from the health benefits of smokefree workplaces. The November 2018 introduction of comprehensive restrictions on smoking in Scottish prisons aimed to protect prison staff and people in custody from the harmful impacts of second-hand smoke (SHS) exposure. This study presents SHS exposure data gathered after smokefree policy implementation and compares these with data gathered during and before policy development.


Methods
Dylos DC1700 monitors were used to measure concentrations of fine particulate matter (PM2.5) derived from SHS across Scotland's 15 prisons. Six days of fixed-site monitoring (09.00 22 May 2019 to 09.00 28 May 2019) were conducted in residential halls in each prison 6 months post-smokefree policy implementation. Prison staff task-based measurements were conducted to assess concentrations of SHS in various locations (e.g. gyms and workshops) and during specific activities (e.g. cell searches, maintenance, and meal service). Utilizing the fixed-site monitoring data, typical daily PM2.5 exposure profiles were constructed for the prison service and time-weighted average (TWA) exposure concentrations were estimated for the typical shift patterns of residential staff pre- and post-smokefree policy implementation. Staff perceptions of changes to SHS exposure were assessed using online surveys.


Results
Analysis of both fixed-site and mobile task-based PM2.5 measurements showed the smokefree policy implementation was successful in reducing SHS exposures across the Scottish prison estate. Measured PM2.5 in residential halls declined markedly; median fixed-site concentrations reduced by more than 91% compared with measures in 2016 before policy announcement. The changes in the TWA concentrations across shifts (over 90% decrease across all shifts) and task-based measurements (89% average decrease for high-exposure tasks) provide evidence that prison staff exposure to SHS has significantly reduced. Following smokefree policy implementation, the majority of staff reported no longer being exposed to SHS at work.


Conclusions
To our knowledge, this is the first comprehensive international study to objectively measure SHS levels before, during, and after implementation of a smokefree policy across a country's prison system. The findings confirm that such a policy change can be successfully implemented to eliminate occupational exposures to SHS. The results are highly relevant for other jurisdictions considering changes to prison smoking legislation.

Objectives: Prisons in Scotland were one of the few workplaces exempt from the 2006 comprehensive smoking ban in indoor public places, excluding the prison workforce from the health benefits of smokefree workplaces. The November 2018 introduction of comprehensive restrictions on smoking in Scottish prisons aimed to protect prison staff and people in custody from the harmful impacts of second-hand smoke (SHS) exposure. This study presents SHS exposure data gathered after smokefree policy implementation and compares these with data gathered during and before policy development. Methods: Dylos DC1700 monitors were used to measure concentrations of fine particulate matter (PM2.5) derived from SHS across Scotland's 15 prisons. Six days of fixed-site monitoring (09.00 22 May 2019 to 09.00 28 May 2019) were conducted in residential halls in each prison 6 months post-smokefree policy implementation. Prison staff task-based measurements were conducted to assess concentrations of SHS in various locations (e.g. gyms and workshops) and during specific activities (e.g. cell searches, maintenance, and meal service). Utilizing the fixed-site monitoring data, typical daily PM2.5 exposure profiles were constructed for the prison service and time-weighted average (TWA) exposure concentrations were estimated for the typical shift patterns of residential staff pre- and post-smokefree policy implementation. Staff perceptions of changes to SHS exposure were assessed using online surveys. Results: Analysis of both fixed-site and mobile task-based PM2.5 measurements showed the smokefree policy implementation was successful in reducing SHS exposures across the Scottish prison estate. Measured PM2.5 in residential halls declined markedly; median fixed-site concentrations reduced by more than 91% compared with measures in 2016 before policy announcement. The changes in the TWA concentrations across shifts (over 90% decrease across all shifts) and task-based measurements (89% average decrease for high-exposure tasks) provide evidence that prison staff exposure to SHS has significantly reduced. Following smokefree policy implementation, the majority of staff reported no longer being exposed to SHS at work. Conclusions: To our knowledge, this is the first comprehensive international study to objectively measure SHS levels before, during, and after implementation of a smokefree policy across a country's prison system. The findings confirm that such a policy change can be successfully implemented to eliminate occupational exposures to SHS. The results are highly relevant for other jurisdictions considering changes to prison smoking legislation.

Acknowledgements Ms C Briffa-Watt, Ms L Bruce, Ms J Madden, All Lanarkshire First Steps Programme workers, and all the mothers who participated in the study. Funding This work was funded by the Scottish Government Chief Scientist Office (CZH_4_983). ; Peer reviewed ; Postprint

Abstract
Second-hand tobacco smoke (SHS) is an avoidable and harmful exposure in the workplace but >25000 prison staff continue to be exposed on a daily basis in the UK and many more worldwide. SHS exposures in prisons are incompletely understood but may be considerable given the large proportion of smoking prisoners and limited ventilation. This study characterized the exposure of prison staff to SHS in all 15 prisons in Scotland using multiple methods. Exposure assessment strategies included 6-day area measurement of fine Particulate Matter (PM2.5) and airborne nicotine in each prison together with short (30-minute) measurements of PM2.5 covering a range of locations/activities. Pre- and post-shift saliva samples were also gathered from non-smoking staff and analysed for cotinine to estimate exposure. There was evidence of exposure to SHS in all prisons from the results of PM2.5 and nicotine measurements. The salivary cotinine results from a sub-sample of non-smoking workers indicated SHS exposures of similar magnitude to those provided by the 6-day area measurements of PM2.5. There was a high degree of exposure variability with some locations/activities involving exposure to SHS concentrations that were comparable to those measured in bars in Scotland prior to smoke-free legislation in 2006. The median shift exposure to SHS-PM2.5 was ~20 to 30 µg m−3 and is broadly similar to that experienced by someone living in a typical smoking home in Scotland. This is the most comprehensive assessment of prison workers' exposure to SHS in the world. The results are highly relevant to the development of smoke-free policies in prisons and should be considered when deciding on the best approach to provide prison staff with a safe and healthy working environment.

Smoke-free legislation reduced second-hand smoke (SHS) exposure in public places, and indirectly promoted private smoke-free settings. Nevertheless, a large proportion of adults is still exposed to SHS at home. The aim of this paper is to quantify the burden of disease due to home SHS exposure among adults in the 28-European Union (EU) countries for year 2017. The burdens by gender from lung cancer, chronic obstructive pulmonary disease (COPD), breast cancer, ischemic heart disease (IHD), stroke, asthma, and diabetes were estimated in an original research analysis using the comparative risk assessment method. Relative risks of death/diseases by gender for adults exposed to SHS at home compared to not exposed ones were estimated updating existing meta-analyses. Prevalence of home SHS exposure by gender was estimated using a multiple imputation procedure based on Eurobarometer surveys. Data on mortality and disability adjusted life years (DALYs) were obtained from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 526,000 DALYs (0.36% of total DALYs) and 24,000 deaths (0.46% of total deaths) were attributable to home SHS exposure in the 28-EU countries, mainly from COPD and IHD. South-Eastern EU countries showed the highest burden, with proportion of DALYs/deaths attributable to SHS exposure on total higher than 0.50%/0.70%, whereas northern EU-countries showed the lowest burden, with proportions of DALYs/deaths lower than 0.25%/0.34%. The burden from SHS exposure is still significant in EU countries. More could be done to raise awareness of the health risks associated with SHS exposure at home. ; Additional co-authors: TackSHS Project Investigators

Background: Prisons had partial exemption from the UK's 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such 'bans' have been very limited to date. Objective: The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service. Design: The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation). Setting: The study was set in Scotland's prisons. Participants: Participants were people in custody, prison staff and providers/users of prison smoking cessation services. Intervention: Comprehensive smoke-free prison rules were implemented across all of Scotland's prisons in November 2018. Main outcome measures: The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons. Data sources: The study utilised cross-sectional surveys of staff (total, n = 3522) and people in custody (total, n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups; n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits). Results: Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the 'new normal', were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the 'with smoke-free' policy period than in the 'without' policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold. Limitations: The ability to triangulate between different data sources mitigated limitations with constituent data sets. Conclusions: To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally. Future work: Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking. Study registration: This study is registered as Research Registry 4802. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.