In this study, we found high levels of SHS exposure in bars and restaurants in Ghana. Airborne PM2.5
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/m3
, the 24-h WHO outdoor air quality standard that has been adopted by Ghana as a guideline for the protection of public health.25
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.
SHS levels measured in this study were similar and sometimes higher than airborne PM2.5
and nicotine concentrations measured in American, Asian and European countries without or before implementing comprehensive smoke-free legislations.5–8 16 26–30
Mean active smoking density in venues was also among the highest compared to studies conducted in other countries.27–30
While smoking prevalence in Ghana is relatively low,31
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.
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.12 14
The high levels of SHS exposure measured in this study, the fact that there is no safe level of SHS,1 10
and recent experiences showing that incomplete smoking bans are more difficult to implement32 33
compared to comprehensive ones,34–36
reinforce the urgent need to enact a comprehensive smoke-free legislation that protects all people, including workers, from SHS exposure in Ghana.
Previous studies assessing SHS concentrations in indoor environments have generally measured PM2.5
or nicotine. In our study we measured both, confirming a strong positive relationship between PM2.5
concentrations measured over >30 min and air nicotine concentrations measured over 7 days, consistent with previous US studies in homes and office buildings.37–39
Because nicotine is tobacco specific, these results confirm that tobacco smoke was the most likely source of particulate matter and that randomly measuring PM2.5
over a short period reflects SHS in most indoor environments. Our study also compared diverse markers of SHS (PM2.5
, 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 PM2.5
concentrations. The strong correlation between air and hair nicotine is consistent with the strong correlation between air nicotine and serum cotinine in chamber experiments.40
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.18
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.41
Study employees highly supported comprehensive smoke-free legislations, consistent with other countries.42 43
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.44 45
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.21
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 PM2.5
measurements and the high response rate for air and hair nicotine assessment. Having PM2.5
and air nicotine concentrations was an important strength as we clearly showed that SHS was the most important contributor to PM2.5
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 PM2.5 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.
What this paper adds
- 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 (PM2.5) and air nicotine concentrations in hospitality venues and hair nicotine concentrations in non-smoking employees in Ghana.
- 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.
- Implementing a comprehensive smoke-free legislation that protects workers and customers from SHS exposure in indoor public places is urgently needed in Ghana.