Science of the Total Environment 743 (2020) 140743 Contents lists available at ScienceDirect Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European countries Elisabet Henderson a,b,c, Xavier Continente a,c,d, Esteve Fernández e,f,g,h, Olena Tigova e,f,g,h, Nuria Cortés-Francisco a,d, Silvano Gallus i, Alessandra Lugo i, Sean Semple j, Rachel O'Donnell j, Luke Clancy k, Sheila Keogan k, Ario Ruprecht l, Alessandro Borgini l, Anna Tzortzi m, Vergina K. Vyzikidou m, Giuseppe Gorini n, Angel López-Nicolás o, Joan B. Soriano h,p, Gergana Geshanova q, Joseph Osman r, Ute Mons s, Krzysztof Przewozniak t,u,v, José Precioso w, Ramona Brad x, Maria J. López a,b,c,d,⁎, and the TackSHS project Investigators a Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023 Barcelona, Spain b Universitat Pompeu Fabra, Departament de Ciències Experimentals i de la Salut (DCEXS), Doctor Aiguader, 88, 08003 Barcelona, Spain c Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 282029 Madrid, Spain d Sant Pau Institute of Biomedical Research (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025 Barcelona, Spain e Tobacco Control Unit, Institut Català d'Oncologia, Av. Granvia de l'Hospitalet 199-203, 08908 L'Hospitalet de Llobregat, Spain f Tobacco Control Research Group, Institut d'Investigació Biomèdica de Bellvitge, Av. Granvia de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Spain g School of Medicine and Health Sciences, Universitat de Barcelona, Feixa Llarga, s/n, 08907 L'Hospitalet de Llobregat, Spain h Consortium for Biomedical Research in Respiratory Diseases (CIBERES), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 282029 Madrid, Spain i Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Department of Environmental Health Sciences, Via Mario Negri 2, 20156 Milan, Italy j Institute for Social Marketing and Health, University of Stirling, Stirling FK9 4LA, Scotland, UK k TobaccoFree Research Institute Ireland, Dublin, Ireland l Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy m George D. Behrakis Research Lab-Hellenic Cancer Society, 17 B Ipitou Street, 10557 Athens, Greece n Istituto per lo Studio, la Prevenzione e la Rete Oncologica (ISPRO), Via Cosimo il Vecchio, 2, 50139 Florence, Italy o Universidad Politécnica de Cartagena (UPCT), Plaza Cronista Isidoro Valverde, s/n, 30202 Cartagena, Spain p Hospital Universitario La Princesa (IISP), Diego de León, 62, Planta 1, 28006 Madrid, Spain q Smoke-free Life Coalition, Slivnitsa Blvd, 257, 1202 Sofia, Bulgaria r OFT Conseil, Office Français de santé et bien-être au Travail, Rue Gobert, 12, 75011 Paris, France s Cancer Prevention Unit & WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Im Neuenheimer Feld, 280, 69120 Heidelberg, Germany t Maria Sklodowska-Curie National Research Institute of Oncology, 15B Wawelska Str., 02-034, Warsaw, Poland u The Foundation Smart Health - Health in 3D, 24 Makolagwy Str., 02-811 Warsaw, Poland v Collegium Civitas, 1 Defilad Square, 00-901 Warsaw, Poland w Instituto de Educação, Universidade do Minho, 4710-057 Braga, Portugal x Healthy Romania Generation 2035 Association, Bucharest, Romania H I G H L I G H T S G R A P H I C A L A B S T R A C T • We monitored nicotine and tobacco signs in outdoor school entrances across EU. • 46% of the entrances had SHS presence, 43% had smokers, and 75% cigarette butts. • SHS exposure was higher in countries with lower scores on the TCS. • SHS exposure varied according to the national smoking prevalence and EU re- gion. • Smokers were found more frequently at school entrances in areas with lower SES. Abbreviations: SHS, secondhand smoke; SES, socioeconomic status; TCS, Tobacco Control Scale; IQR, Interquartile range; LOQ, limit of quantification; UN, United Nations. ⁎ Corresponding author at: Servei d'Avaluació i Mètodes d'Intervenció (SAMI), Agència de Salut Pública de Barcelona (ASPB), Pl. Lesseps, 1, 08023 Barcelona, Spain. E-mail address: mjlopez@aspb.cat (M.J. López). https://doi.org/10.1016/j.scitotenv.2020.140743 0048-9697/© 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 2 E. Henderson et al. / Science of the Total Environment 743 (2020) 140743 a r t i c l e i n f o a b s t r a c t Article history: Introduction: Although smoking restrictions at child-related settings are progressively being adopted, school out- Received 23 April 2020 door entrances are neglected in most smoke-free policies across Europe. Received in revised form 24 June 2020 Objectives: To describe secondhand smoke (SHS) exposure and tobacco-related signs in outdoor entrances of pri- Accepted 2 July 2020 mary schools in Europe according to area-level socioeconomic status (SES), smoke-free policy, national smoking Available online 7 July 2020 prevalence, and geographical region. Methods: In this cross-sectional study we monitored vapor-phase nicotine concentrations at 220 school outdoor Editor: Pavlos Kassomenos entrances in 11 European countries (March 2017–October 2018). To account for nicotine presence, we used the Keywords: laboratory's limit of quantification of 0.06 μg/m3 as point threshold. We also recorded the presence of smell of Tobacco smoke pollution smoke, people smoking, cigarette butts, and ashtrays. Half of the schools were in deprived areas. We grouped Child countries according to their Tobacco Control Scale (TCS) score, smoking prevalence (2017–2018), and United Na- Smoke-free regulations tions M49 geographical region. Educational center Results: There were detectable levels of nicotine in 45.9% of the outdoor entrances, in 29.1% smell of smoke, in 43.2% people smoking, in 75.0% discarded butts, and in 14.6% ashtrays. Median nicotine concentration was below the laboratory's limit of quantification b0.06 μg/m3 (Interquartile range:b0.06–0.119). We found higher SHS levels in countries with lower TCS scores, higher national smoking prevalence, and in the Southern and East- ern European regions. People smoking were more common in schools from lower area-level SES and in countries with lower TCS scores (pb0.05). Conclusions: Smoking at school outdoor entrances is a source of SHS exposure in Europe. These findings support the extension of smoking bans with a clear perimeter to the outdoor entrances of schools. © 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction (Poulsen et al., 2002). Moreover, the existence of smoking restrictions at school influenced adolescents' support for smoke-free policies in other Secondhand tobacco smoke (SHS) exposure is a major public health public places, beyond their smoking status or their expectations to hazard. SHS has been cataloged as a human carcinogen, which is com- smoke (Lazuras et al., 2011). posed of a large number of known carcinogens, teratogens, irritants, Children's physiological characteristics (i.e., higher breathing rates, toxicants, and mutagens (IARC, 2004). Inhaling SHS has been proven immature immune and respiratory systems) increase their risk of to cause cancer, cardiovascular and respiratory disease in non- harm from environmental exposures (Öberg et al., 2010). Besides, chil- smoking adults and to increase the risk for middle ear infections and re- dren are particularly vulnerable to SHS exposure, as they lack control spiratory disorders, among others, in children (U.S. Department of over their social and physical environment (US Environmental Health and Human Services, 2006; Carreras et al., 2018). Protection Agency, 1992). Although progress has been made over Previous studies have shown that SHS exposure at outdoor locations time, SHS exposure at an early age remains an unresolved public health can be considerable and on some occasions close to the levels of indoor problem with evident social inequalities (Moore et al., 2012; Jarvis and SHS concentrations (CARB California Air Resources Board, 2005; Sureda Feyerabend, 2015; Kuntz and Lampert, 2016). Lower parental socioeco- et al., 2013). A few studies have measured SHS exposure at the outdoor nomic status (SES) has been related to higher children's SHS exposure, entrances of public buildings (Kaufman et al., 2011; Sureda et al., 2012). measured using both biomarkers (Moore et al., 2012; Jarvis and Kaufman et al. (2011) found outdoor respirable particulate matter Feyerabend, 2015; Aurrekoetxea et al., 2016) and surveys (Kuntz and (PM2.5 μm or less) concentrations to be significantly higher than back- Lampert, 2016; López et al., 2018). Moreover, parental smoking behav- ground levels when smoking took place, and PM2.5 levels to be increas- ior is more prevalent among lower SES groups (Moore et al., 2012; ing with the number of active cigarettes. Sureda et al. (2012) Aurrekoetxea et al., 2016; Kuntz and Lampert, 2016). simultaneously measured PM2.5 concentrations around outdoor en- The outdoor area at school entrances is often “on-street” or other trances and the immediate indoor halls of public administration build- public space and is thus rarely considered part of school premises in ings, libraries, educational venues, public transport buildings, and terms of smoke-free policies and rules. When enacting smoking bans healthcare centers. When smoking was present at outdoor entrances, at educational venues, these spaces are not regulated or regulation in PM2.5 levels in indoor halls were comparable to PM2.5 concentrations Europe is ambiguous, not establishing a clear perimeter where smoking outdoors, suggesting that SHS drifts from outdoor entrances to adjacent is banned. SHS levels at outdoor school entrances have never been mea- indoor spaces where smoking inside is forbidden. sured at a European level with an environmental marker and, as far as Outdoor school entrances might be as relevant as school grounds in we know, no previous study has assessed potential country-specific dif- the implementation and promotion of healthy lifestyles (Moncada et al., ferences in SHS exposure at this setting. For these reasons, we sought to 2011). Schools, and thereby, outdoor school entrances are locations describe SHS levels and tobacco-related signs in outdoor entrances of dedicated to children, for whom attendance is compulsory. Tobacco schools in 11 European countries according to area-level SES, smoke- presence in outdoor entrances beyond the school grounds can pose di- free policy, national smoking prevalence (2017–2018), and geographi- rect and indirect health risks for children. Outdoor school entrances cal region. tend to be crowded delimited areas with high presence of children dur- ing school starting and ending hours. Although exposure periods at 2. Methods school entrances are usually transient, children might be exposed daily over the school years, facing short but cumulative exposures to 2.1. Study design SHS, as it has been suggested for this type of location (Kaufman et al., 2010, 2011). Also, children observing smoking at school entrances are This was a cross-sectional study within the Horizon 2020 funded exposed to pro-smoking cues within a learning environment, which project TackSHS (Fernández et al., 2020). We monitored vapor-phase might influence their attitudes and beliefs regarding tobacco use. For in- nicotine, as an objective and specific environmental marker of SHS ex- stance, reporting encountering teachers smoking at outdoor school pre- posure, at entrances of primary school buildings in 11 European coun- mises predicted adolescent daily smoking and heavy smoking behavior tries. We selected densely populated urban areas in Bulgaria (Sofia), E. Henderson et al. / Science of the Total Environment 743 (2020) 140743 3 France (Paris), Germany (Mannheim, Heidelberg), Greece (Aigaleo, smoke or people smoking when we noticed any of these tobacco- Alimos, Athens, Glyfada, Kifisia), Ireland (Dublin), Italy (Milano, Va- related variables in at least one of the three time points. All re- rese), Poland (Warsaw), Portugal (Braga), Romania (Bucharest), Spain searchers were trained before fieldwork by the coordinating center, (Barcelona), and the United Kingdom (Edinburgh) to conduct an envi- and guidance was provided in a sampling protocol. ronmental SHS exposure assessment. On-site nicotine levels were assessed in a convenience sample of 20 different school entrances per 2.4. Contextual variables country, a total of 220 measurements, from March 2017 to October 2018. This study was designed to evaluate SHS exposure according to Data from different sources were used to group the countries in our SES, for this reason, half of the schools visited were located in the study. According to the United Nation's geographical regions (M49) for most deprived neighborhoods (below the 20th percentile of the local Europe (United Nations, 1999), the countries were classified into four SES distribution) and the other half in the most affluent neighborhoods regions: Northern Europe, Southern Europe, Western Europe, and East- (above the 80th percentile of the local SES distribution). Neighborhood ern Europe. We also grouped countries based on their overall score in SES was established using ecological synthetic deprivation indexes in the 2016 Tobacco Control Scale (TCS), a ranking on tobacco control ac- each city (Stadt Mannheim, 2009; Caranci et al., 2010; Stadt Heidelberg, tivity across 35 European countries. The TCS is based on a scoring sys- 2011; Scottish Government, 2016; Pobal Deprivation Index, 2017; tem, with up to 100 points, that measures the adoption at a national Ribeiro et al., 2017; Ajuntament de Barcelona, 2017). When synthetic in- level of six tobacco control policies: price (30 points), smoke-free public dexes were not available, this was the case for Bulgaria, France, Greece, places (22 points), spending in public information campaigns (15 Poland, and Romania, other socio-economic indicators were used, such points), comprehensive advertising bans (13 points), health warnings as the cost of housing by square meter or the rate of poverty by district, (10 points), and cessation support (10 points) (Joossens and Raw, among others. Nicotine measurements were conducted exclusively 2016). In line with the TCS report, countries with less than half the over- when there was a minimum of five people (adults and/or children) pres- all score were allocated in one group and countries with 50 or more ent at the school entrance at the beginning of the measurement. Field- points in another. We also assessed the national smoking prevalence work took place during weekdays and before the start or after the end in each country, which was obtained from a different study conducted of school hours, in the pursuit of gathering the maximum number of peo- within the framework of the TackSHS project (Fernández et al., 2020; ple at school entrances. Gallus et al., 2020). The national smoking prevalence was estimated through a face-to-face survey in a representative sample aged 2.2. Airborne nicotine measurements 15 years and above during 2017–2018. Participants were considered smokers if they reported smoking at the time and had smoked at least We used portable samplers that specifically collected airborne nico- 100 cigarettes, including hand-rolled cigarettes. A median smoking tine. The samplers consisted of a 37-mm diameter plastic cassette con- prevalence among the 11 countries in this study was calculated. Coun- taining a filter treated with sodium bisulfate. We connected the plastic tries were grouped into two categories: those with smoking prevalence cassettes to air pumps (Sidekick, SKC Ltd., Dorset, UK) to control the vol- above/equal to the median or below the median. ume of air actively passing through the filter. The airflow rate was set at 3 l/min and air pumps were calibrated, before and after taking nicotine 2.5. Statistical analyses measurements, with calibrator Defender 510M (Mesa Labs, Lakewood, CO, USA). We took nicotine measurements for 30 min and at a maxi- Our data on nicotine concentrations were left bounded by the mum distance of three meters from the school main entryway. This laboratory's LOQ. Samples with concentrations below the LOQ of technique for outdoor airborne nicotine sampling has already been de- 0.06 μg/m3 were assigned half of this value. We provided the median scribed in the literature (Hammond et al., 1987) and used in previous and interquartile range (IQR) to describe nicotine concentration overall research (Fu et al., 2016; Sureda et al., 2018). To avoid drawing attention and by country, SES, geographical region, smoke-free policies, national and altering the behavior of those present at the setting, we kept the air smoking prevalence, and tobacco-related observational variables. Nico- pumps hidden in backpacks. To prevent filter contamination, sampler tine concentrations were compared using non-parametric Mann- assembly and filter removal were done in a tobacco-free environment. Whitney U or Kruskal Wallis tests, as appropriate. We used raw fre- Nicotine filters were analyzed in the Agència de Salut Pública de Barce- quencies and percentages to describe nicotine presence and tobacco- lona laboratory. Nicotine concentrations were determined by mass- related observational data overall and by country, SES, geographical re- spectrometry gas-chromatography. Along with the 20 filters sampled, gions, smoke-free policies, and smoking prevalence. Differences in nico- every country sent additional blank filters to determine blank- tine presence and tobacco-related observational variables were corrected nicotine concentrations. For every 20 nicotine samples, one assessed using the Chi-squared test. All analyses were performed with blank filter that had not been exposed and a fortified sample used as the statistical package Stata 15. quality control were analyzed. To quantify the time-weighted average nicotine concentration (in μg/m3), the amount of nicotine extracted 2.6. Ethical issues from each filter was divided by the volume of air sampled (estimated flow rate times the minutes the filter had been exposed). Nicotine con- The TackSHS project was approved by the Clinical Research Ethics centration was assessed as a continuous variable. To account for nico- Committee of the Bellvitge University Hospital (PR341/15) and this tine presence, we used the laboratory's limit of quantification (LOQ) of study was approved by each country's local Ethics Committees. The 0.06 μg/m3 as a reference. study protocol was registered in ClinicalTrials.gov (ID: NCT03150186). 2.3. Observational data 3. Results During sampling, a form was also filled out by researchers. We re- Table 1 displays the median airborne nicotine concentration and corded the presence of smell of tobacco smoke and ashtrays or sim- nicotine presence from 220 school outdoor entrances in 11 European ilar receptacles, and the number of people smoking and discarded countries. In total, median nicotine concentrations did not exceed the cigarette butts at school entrances (López et al., 2012a; López et al., laboratory's LOQ of 0.06 μg/m3, while nicotine presence was found in 2012b). This information was noted at a form over the course of 45.9% of the sites visited. Among countries, Romania (0.831 μg/m3 every measurement session at the beginning of sampling, after IQR: 0.262–2.464), Bulgaria (0.178 μg/m3 IQR: b0.06–0.346), Greece 15 min, and at the end (30 min). We considered there was smell of (0.118 μg/m3 IQR: 0.077–0.200) and Italy (0.068 μg/m3 IQR: 4 E. Henderson et al. / Science of the Total Environment 743 (2020) 140743 Table 1 Airborne nicotine concentration (μg/m3) in outdoor entrances of primary school buildings by country (2017–2018). TackSHS project. Country N Median (μg/m3) Min (μg/m3) Max (μg/m3) % nicotine presence (n) (IQR) All 220 b0.06 (b0.06 to 0.119) b0.06 5.197 45.9 (101) Bulgaria 20 0.178 (b0.06 to 0.346) b0.06 1.442 75.0 (15) France 20 b0.06 (b0.06 to b0.06) b0.06 0.440 20.0 (4) Germany 20 b0.06 (b0.06 to b0.06) b0.06 0.176 20.0 (4) Greece 20 0.118 (0.077 to 0.200) b0.06 0.622 80.0 (16) Ireland 20 b0.06 (b0.06 to b0.06) b0.06 1.419 20.0 (4) Italy 20 0.068 (b0.06 to 0.139) b0.06 2.125 70.0 (14) Poland 20 b0.06 (b0.06 to b0.06) b0.06 0.194 20.0 (4) Portugal 20 b0.06 (b0.06 to 0.115) b0.06 1.436 50.0 (10) Romania 20 0.831 (0.262 to 2.464) b0.06 5.197 95.0 (19) Spain 20 b0.06 (b0.06 to 0.097) b0.06 0.188 50.0 (10) UK 20 b0.06 (b0.06 to b0.06) b0.06 0.081 5.0 (1) Note: IQR, interquartile range. Limit of quantification (LOQ): 0.06 μg/m3. b0.06–0.139) had the highest median nicotine concentrations. Most b0.06–0.312), people smoking (0.083 μg/m3 IQR: b0.06–0.302), and school outdoor entrances in these countries had detectable levels of nic- discarded cigarette butts (0.063 μg/m3 IQR: b0.06–0.139). In these otine (Romania 95%, Greece 80%, Bulgaria 75%, and Italy 70%). cases, nicotine presence was also higher: smell of smoke (70.3% vs Across all countries, we noticed people smoking in slightly over 40% 35.9%); people smoking (64.2% vs. 32.0%) and discarded cigarette of the school entrances. The majority of the sites in Italy (80%) and butts (51.5% vs. 29.1%) (pb0.05). Bulgaria (70%) had people smoking. There was smell of smoke in three out of ten entrances and discarded cigarette butts in three- 4. Discussion quarters of the school entrances. We found ashtrays or other receptacles in 15% of the sites. Only in Italy more than half of the school entrances We performed for the first time SHS exposure measurements in out- had ashtrays or other receptacles (60%) (Table 2). door entrances of primary school buildings in several European coun- Table 3 provides the median nicotine concentrations and nicotine tries, where children's school attendance is mandatory. Overall, the presence in primary school outdoor entrances according to contextual median airborne nicotine levels encountered were below the factors. Nicotine levels were highest in the Eastern (0.104 μg/m3 IQR: laboratory's LOQ. Nevertheless, our results provide evidence of SHS ex- b0.06–0.625) and Southern (0.073 μg/m3 IQR: b0.06–0.126) European posure and visible smoking activities in nearly half the school outdoor regions; in countries scoring less than 50 points in the 2016 version of entrances. We found nicotine presence in a higher proportion of school the TCS (0.092 μg/m3 IQR: b0.06–0.199); and countries with higher entrances in countries with lower tobacco control activity, higher na- smoking prevalence (0.085 μg/m3 IQR: b0.06–0.251) (pb0.05). Simi- tional smoking prevalence, and in the Southern and Eastern European larly, nicotine presence was more common in the Eastern (63.3%) regions. In these cases, median nicotine concentrations were also and Southern (62.5%) European regions, in countries with lower higher. People were more frequently observed smoking at primary TCS total scores (58.3%), and countries with higher smoking preva- school entrances in lower socioeconomic contexts and in countries lence (61.7%) (pb0.05). with a lesser extent of tobacco control policies. People smoking were more often found in entrances of schools lo- Following indoor smoking bans being enacted in many jurisdictions cated in areas of lower SES (52.5%) (pb0.05). Moreover, countries with in Europe, people who smoke now do so in outdoor settings such as less than half of the score in the TCS had a greater presence of smell of buildings' doorways. These locations appear to smokers as convenient tobacco smoke (48.3%) and people smoking (58.3%) than countries spots to light up, which give shelter from weather, and where smoking with scores equal and over 50 points (21.9% and 37.5%, respectively) plays a role in socializing (Kaufman et al., 2010). Entrance areas are im- (pb0.05) (Table 4). portant elements of our built environment and, in the case of schools, Table 5 compares median nicotine concentrations and nicotine pres- are part of the children's learning environment: offering important so- ence in school outdoor entrances with and without different signs of to- cial interactions at the start and end of the school day. Earlier studies bacco consumption. We found higher nicotine concentrations in school have already identified outdoor entrances as relevant spaces in the fur- entrances when there was smell of smoke (0.113 μg/m3 IQR: therance of smoke-free environments. Evidence points toward the need for smoking bans in these settings to further denormalize smoking be- haviors and to fully comply with Article 8 in the WHO-FCTC (Kaufman et al., 2010, 2011; Moncada et al., 2011; Sureda et al., 2010, 2012). In Table 2 Tobacco-related variables in outdoor entrances of primary school buildings by country fact, outdoor entrances, which can also be partially enclosed, have (2017–2018). TackSHS project. been described as critical locations in terms of SHS exposure (Sureda et al., 2012). However, to our knowledge, no study has measured SHS Country N Smell of smoke People smoking Cigarette butts Ashtrays % (n) % (n) % (n) % (n) exposure in school main outdoor entrances, a setting with the potential to reach a large number of minors. All 220 29.1 (64) 43.2 (95) 75.0 (165) 14.6 (32) Bulgaria 20 75.0 (15) 70.0 (14) 100.0 (20) 10.0 (2) School entrances should serve as more than acoustic or thermal France 20 10.0 (2) 20.0 (4) 25.0 (5) 0.0 (0) buffer zones. In almost half the school outdoor entrances, we have Germany 20 30.0 (6) 45.0 (9) 80.0 (16) 30.0 (6) found SHS presence within three meters from the entryway. Several Greece 20 40.0 (8) 60.0 (12) 85.0 (17) 0.0 (0) studies assessing SHS exposure outside different building entrances Ireland 20 25.0 (5) 35.0 (7) 60.0 (12) 0.0 (0) (Sureda et al., 2012, 2010) but also in outdoor areas of hospitality Italy 20 55.0 (11) 80.0 (16) 80.0 (16) 60.0 (12) Poland 20 0.0 (0) 10.0 (2) 35.0 (7) 40.0 (8) venues (Wilson et al., 2011; López et al., 2012a; Fu et al., 2016) concur Portugal 20 25.0 (5) 25.0 (5) 100.0 (20) 5.0 (1) SHS concentrations outdoors migrate to adjacent indoor spaces. Most Romania 20 40.0 (8) 65.0 (13) 75.0 (15) 0.0 (0) of these indoor areas are already covered by smoke-free laws since Spain 20 10.0 (2) 35.0 (7) 100.0 (20) 0.0 (0) there is accumulated proof that SHS lingers and causes negative health UK 20 10.0 (2) 30.0 (6) 85.0 (17) 15.0 (3) effects (U.S. Department of Health and Human Services, 2006). E. Henderson et al. / Science of the Total Environment 743 (2020) 140743 5 Table 3 Airborne nicotine concentration (μg/m3) in outdoor entrances of primary school buildings by area-level socioeconomic status, Tobacco Control Scale overall score, national smoking prev- alence, and the United Nation's M49 regions (2017–2018). TackSHS project. Contextual factors N Median (μg/m3) (IQR) p-Valuea Min (μg/m3) Max (μg/m3) % nicotine presence (n) p-Valueb SES High 102 0.064 (b0.06 to 0.154) 0.195 b0.06 5.197 52.0 (53) 0.094 Low 118 b0.06 (b0.06 to 0.109) b0.06 3.361 40.7 (48) TCS overall score (2016)c ≥50 160 b0.06 (b0.06 to 0.090) 0.015 b0.06 5.197 41.3 (66) 0.024 b50 60 0.092 (b0.06 to 0.199) b0.06 1.442 58.3 (35) Smoking prevalence (2017–18)d b31% 100 b0.06 (b0.06 to 0.064) b0.0001 b0.06 2.125 27.0 (27) b0.0001 ≥31% 120 0.085 (b0.06 to 0.251) b0.06 5.197 61.7 (74) UN M49 regionse Northern 40 b0.06 (b0.06 to b0.06) 0.0001 b0.06 1.419 12.5 (5) b0.0001 Southern 80 0.073 (b0.06 to 0.126) b0.06 2.125 62.5 (50) Western 40 b0.06 (b0.06 to b0.06) b0.06 0.440 20.0 (8) Eastern 60 0.104 (b0.06 to 0.625) b0.06 5.196 63.3 (38) Note: SES, socioeconomic status; TCS, Tobacco Control Scale; UN; United Nations; IQR, Interquartile range. Limit of quantification (LOQ): 0.06 μg/m3. a Mann-Whitney U or Kruskal-Wallis test. b Chi-squared test. c TCS overall score: ≥50 (France, Italy, Ireland, Poland, Portugal, Romania, Spain, UK); b50 (Bulgaria, Germany, Greece). d Based on a European survey conducted in the TackSHS project. Smoking prevalence (median): b31% (Germany, Ireland, Italy, Poland, UK); ≥31% (Bulgaria, France, Greece, Portugal, Romania, Spain). e United Nation's regions: Northern (Ireland, UK); Southern (Greece, Italy, Portugal, Spain); Western (France, Germany); Eastern (Bulgaria, Poland, Romania). Any exposure to SHS does not come without risk (U.S. Department type of venue we were targeting (outdoor child-related settings). of Health and Human Services, 2006) and children are considered a vul- However, more than half the schools in Romania, Greece, Bulgaria, nerable population to the effects of SHS (Öberg et al., 2010). While SHS and Italy had SHS presence and, particularly in schools in Romania, exposure could be avoided in outdoor settings, there is no other way median SHS levels were comparable to those found at smokers' around entering a building than through its entrance. According to homes (Arechavala et al., 2018). our results, overall median nicotine levels at the outdoor entrances Children tend to emulate normative behaviors they observe in ev- were below the LOQ, an outcome that could be explained by the eryday situations (Pattemore, 2013). Our results show people were smoking in more than four out of ten school entrances, implying likely visibility of smoking in educational settings across Europe. Smoking Table 4 visibility in different public places has been linked to positive beliefs Tobacco-related variables in outdoor entrances of primary school buildings by area-level toward smoking (Lagerweij et al., 2019). Moreover, smoking exam- socioeconomic status, Tobacco Control Scale overall score, national smoking prevalence, and the United Nation's M49 regions (2017–2018). TackSHS project. ples in immediate social environments, such as teachers smoking on school premises (Poulsen et al., 2002; Roohafza et al., 2014; Contextual N Smell of People Cigarette Ashtrays Escario and Wilkinson, 2018), have been associated with students' factors smoke % (n) smoking % butts % (n) % (n) smoking behaviors. (n) We found a higher level of smoking visibility in school entrances SES from lower socioeconomic areas. These results suggest children in High 102 24.5 (25) 32.4 (33) 72.6 (74) 12.8 (13) Low 118 33.1 (39) 52.5 (62) 77.1 (91) 16.1 (19) more deprived contexts might be at greater risk of being exposed to en- p-Valuea 0.164 0.003 0.435 0.481 vironmental cues that convey the impression of smoking as a normative and socially desirable behavior. In September 2015, the WHO European TCS overall score (2016)b ≥50 160 21.9 (35) 37.5 (60) 70.0 (112) 15.0 (24) Region issued a roadmap of actions to strengthen the implementation of b50 60 48.3 (29) 58.3 (35) 88.3 (53) 13.3 (8) the WHO FCTC by 2025. Among the report's guiding principles was the p-Valuea b0.0001 0.005 0.005 0.755 protection of children, and one of the three focus areas involved Smoking prevalence (2017–18)c denormalizing tobacco (WHO Regional Office for Europe, 2015). Still, b31% 100 24.0 (24) 40.0 (40) 68.0 (68) 29.0 (29) to further advance in lessening potential health inequalities, policy ac- ≥31% 120 33.3 (40) 45.8 (55) 80.8 (97) 2.5 (3) tions should target the social determinants that predispose children to p-Valuea 0.129 0.384 0.029 b0.0001 tobacco-related harms, as highlighted in the Health 2020 policy frame- UN M49 regionsd work (WHO Regional Office for Europe, 2013), the European child and Northern 40 17.5 (7) 32.5 (13) 72.5 (29) 7.5 (3) adolescent health strategy 2015–2020 (WHO Regional Office for Southern 80 32.5 (26) 50.0 (40) 91.3 (73) 16.3 (13) Europe, 2014), and several human right treaties (United Nations, Western 40 20.0 (8) 32.5 (13) 52.5 (21) 15.0 (6) 1948; United Nations, 1989; WHO Regional Office for Europe, 2017). Eastern 60 38.3 (23) 48.3 (29) 70.0 (42) 16.7 (10) p-Valuea 0.067 0.117 b0.0001 0.571 Schools located in countries with lower legislative tobacco control efforts had higher SHS exposure and considerably greater occurrence Note: SES, socioeconomic status; TCS, Tobacco Control Scale; UN, United Nations. a Chi-squared test. of people smoking at the outdoor entrances. These results align with b TCS overall score: ≥50 (France, Italy, Ireland, Poland, Portugal, Romania, Spain, the previous studies that show comprehensive smoke-free policies are ef- UK); b50 (Bulgaria, Germany, Greece). fective means to reduce SHS exposure (Hyland et al., 2009; Blanco- c Based on a European survey conducted in the TackSHS project. Smoking prevalence Marquizo et al., 2010; Filippidis et al., 2016) and decrease the social ac- (median): b31% (Germany, Ireland, Italy, Poland, the UK) ≥31% (Bulgaria, France, Greece, Portugal, Romania, Spain). ceptability of smoking (Hamilton et al., 2007). Along the same lines, d United Nation's regions: Northern (Ireland, the UK); Southern (Greece, Italy, Portugal, countries with more developed tobacco control measures have experi- Spain); Western (France, Germany); Eastern (Bulgaria, Poland, Romania). enced over the years a decrease in the prevalence of tobacco use and 6 E. Henderson et al. / Science of the Total Environment 743 (2020) 140743 Table 5 Airborne nicotine concentrations (μg/m3) and tobacco-related variables in outdoor entrances of primary school buildings in 11 European countries (2017–2018). TackSHS project. Contextual factors N Median (μg/m3) (IQR) p-Valuea Min (μg/m3) Max (μg/m3) % nicotine presence (n) p-Valueb Smell of smoke Yes 64 0.113 (b0.06 to 0.312) b0.0001 b0.06 5.197 70.3 (45) b0.0001 No 156 b0.06 (b0.06 to 0.080) b0.06 3.361 35.9 (56) People smoking Yes 95 0.083 (b0.06 to 0.302) b0.0001 b0.06 5.197 64.2 (61) b0.0001 No 125 b0.06 (b0.06 to 0.075) b0.06 3.361 32.0 (40) Cigarette butts Yes 165 0.063 (b0.06 to 0.139) 0.001 b0.06 5.197 51.5 (85) 0.004 No 55 b0.06 (b0.06 to 0.069) b0.06 3.361 29.1 (16) Ashtrays Yes 32 b0.06 (b0.06 to 0.070) 0.156 b0.06 0.735 43.8 (14) 0.791 No 188 b0.06 (b0.06 to 0.140) b0.06 5.197 46.3 (87) Note: IQR, Interquartile range. Limit of quantification (LOQ) 0.06 μg/m3. a Mann-Whitney U test. b Chi-squared test. an increase in the cessation rates (Feliu et al., 2019). Consistent with our comparability of the results among countries. Even so, we have de- findings regarding smoke-free policies, we found that countries above scribed SHS exposure at school outdoor entrances by grouping coun- the median smoking prevalence had higher SHS exposure at school out- tries into different contextual exposure determinants. Finally, we door entrances. Similar results have been documented for indoor spaces assess SHS exposure levels based on measurements taken for 30 min across Europe (Filippidis et al., 2016). at a specific point in time. Still, these measurements were conducted We found disparities in SHS exposure according to European re- in each country following the same protocol and at the beginning and gions, SHS levels being higher in the Southern and Eastern regions. To end of schooling hours, when SHS exposure at outdoor school entrances date, there is a generalized lack of smoking bans for most outdoor most likely takes place. areas in Europe (Martinez et al., 2014). Therefore, these results cannot Despite the limitations, this study is the first one to describe SHS ex- be directly explained by the smoking restrictions adopted but could re- posure in primary school outdoor entrances in Europe. We have mea- flect the differences in the extent of coverage, the level of enforcement, sured SHS levels in 11 strategically selected countries, encompassing or the later implementation of comprehensive smoke-free policies in geographical, cultural, and legislative variations in Europe, accounting countries in the Southern and Eastern regions. Both the coverage and for almost 80% of the European population. Following a validated enforcement are key policy determinants in protecting non-smokers method (Hammond et al., 1987), we provide SHS exposure measure- from SHS exposure (Filippidis et al., 2016), and a higher degree might ments using airborne nicotine that, unlike PM2.5 concentrations, is an have translated into societal smoking denormalization to outdoor objective and specific marker of SHS exposure (Apelberg et al., 2013), areas devoted to children. and considering different contextual exposure determinants. School outdoor entrances have been neglected in most smoke-free The findings reported in this study raise concerns over SHS exposure policies in Europe. In Canada, Australia, or the United States several ju- in outdoor areas devoted to children. Our analyses confirm the need to risdictions already legally require outdoor areas around specific build- expand smoking bans to cover school outdoor entrances. Smoking bans ings, like educational centers, to be smoke-free within a certain in outdoor entrances should be implemented stating a clear perimeter perimeter. The State of New York outlaws smoking within 100 ft (ap- in which smoking is not allowed and forbidding the presence of ash- proximately 30 m) of the entrance, exit, and outdoor areas of schools trays or similar tobacco receptacles, which sends confusing messages. (New York Public Health Law, 2017). The Government of Québec bans While implementing smoking bans in school outdoor entrances, an smoking within 9 m outside a public place where smoking indoors is emerging source of SHS exposure, potential socioeconomic inequalities forbidden (Government of Québec, 2015). This restriction also applies in SHS exposure might be also better addressed. to the windows and air-intake ducts. A bylaw in the city of Toronto also prohibits smoking within 9 m of different buildings used by the CRediT authorship contribution statement public (Toronto City Government, 2013). In Queensland, smoking is only allowed beyond 5 m from the boundaries of different public build- Elisabet Henderson: Formal analysis, Writing - original draft, Visu- ings (Government of Queensland, 2016). In Victoria, smoking is alization. Xavier Continente: Conceptualization, Investigation, Valida- prohibited within 4 m from all public entrances to childcare centers, tion, Writing - review & editing. Esteve Fernández: Investigation, kindergartens, preschools, or schools (Government of Victoria, 2014). Writing - review & editing. Olena Tigova: Investigation, Writing - re- A four-meter ban for pedestrian access points is now in place in New view & editing. Nuria Cortés-Francisco: Investigation, Writing - review South Wales covering among other public places, childcare facilities, & editing. Silvano Gallus: Investigation, Writing - review & editing. schools, colleges, and universities (Government of New South Wales, Alessandra Lugo: Investigation, Writing - review & editing. Sean Sem- 2000). Therefore, European countries, as is the case in other jurisdic- ple: Investigation, Writing - review & editing. Rachel O'Donnell: Inves- tions, should consider banning smoking in school outdoor entrances tigation, Writing - review & editing. Luke Clancy: Investigation, Writing with a clear perimeter to further prevent children and adult non- - review & editing. Sheila Keogan: Investigation, Writing - review & smokers to be exposed to SHS. editing. Ario Ruprecht: Investigation, Writing - review & editing. This study presents some limitations. Firstly, we conducted a SHS ex- Alessandro Borgini: Investigation, Writing - review & editing. Anna posure assessment of a convenience sample of schools. The non- Tzortzi: Investigation, Writing - review & editing. Vergina K. representative nature of our sample hampers the generalizability of Vyzikidou: Investigation, Writing - review & editing. Giuseppe Gorini: our results to other school entrances in the same city and country but Investigation, Writing - review & editing. Angel López-Nicolás: Investi- does not compromise the main objective of the study of assessing nico- gation, Writing - review & editing. Joan B. Soriano: Investigation, Writ- tine concentrations. Second, this study is based on a geographically ex- ing - review & editing. Gergana Geshanova: Investigation, Writing - tended but limited number of schools per country which constrains the review & editing. Joseph Osman: Investigation, Writing - review & E. Henderson et al. / Science of the Total Environment 743 (2020) 140743 7 editing. Ute Mons: Investigation, Writing - review & editing. Krzysztof References Przewozniak: Investigation, Writing - review & editing. José Precioso: Ajuntament de Barcelona, 2017. 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