The Collaborative Funding Program for Southeast Asia Tobacco Control Research

Exposure to SHS among Workers in the Restaurants in Vientiane Capital and Luang Prabang Province
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Dr. Keonakhone Houamboun, NIOPH, MOH Dr. Sengchanh Kounnavong, NIOPH, MOH

Financial support from The Rockefeller Foundation and Thai Health Promotion Foundation

Exposure to SHS among Workers in the Restaurants in Vientiane Capital and Luang Prabang Province
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Dr. Keonakhone Houamboun, NIOPH, MOH Dr. Sengchanh Kounnavong, NIOPH, MOH

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Editors Foong Kin, PhD Menchi G. Velasco

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Supported by

Southeast Asia Tobacco Control Alliance (SEATCA)
Under The Collaborative Funding Program for Tobacco Control Research

Financial support from The Rockefeller Foundation and Thai Health Foundation (ThaiHealth)

June 2009

TABLE OF CONTENTS

ACKNOWLEDGEMENTS...........................................................................................4 INTRODUCTION .........................................................................................................7 LITERATURE REVIEW ..............................................................................................9 STUDY OBJECTIVES................................................................................................17 3.1 Overall Objective ...............................................................................................17 3.2 Specific Objectives ............................................................................................17 METHODS & DATA SOURCES ...............................................................................18 4.1 Research Design.................................................................................................18 4.2 Sampling Frame .................................................................................................18 4.4 Sample Size........................................................................................................19 4.5 Respiratory symptoms in the last two months ...................................................20 4.6 Data Collection Methods ...................................................................................20

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4.7 Pre-testing of the Questionnaire.........................................................................21 4.8 Data Collection and its Quality Control.............................................................21 4.9 Data Processing and Analysis............................................................................22 4.10 Ethical Consideration.......................................................................................22 RESULTS ....................................................................................................................23 5.1 General Characteristics of Respondents in Both Groups...................................23 5.2 The Association between Work Site and the Risk of Developing Respiratory Symptoms ................................................................................................................27 5.3 Estimation of the Direct and Indirect Costs of Smoking-related Diseases Among the Workers Who Are Exposed to SHS in the Restaurants .....................................29 DISCUSSION ..............................................................................................................33 CONCLUSION AND RECOMMENDATIONS ........................................................35 REFERENCES ............................................................................................................36 ANNEXES...................................................................................................................40 A. Screening Form ..................................................................................................40 B. Data Collection Tool ..........................................................................................41

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LIST OF TABLES
Table 1: Background characteristics of respondents, restaurant workers and officers by province Table 2: Percent distribution of respondents on policy knowledge by province Table 3: Frequency distribution of respondents by occupation with past working experience Table 4: Frequency distribution of respondents exposed to secondhand smoke by places and province Table 5: Mean and Standard deviation of hours that respondents are exposed to smoking pollution Table 6: Frequency distribution of people who are smokers that the respondents had contact with Table 7: Frequency distribution of respondents in the worksites and respiratory symptoms Table 8: Frequency distribution of respondents in worksites and respiratory symptoms by province Table 9: Frequency distribution of respondents who are exposed to passive smoking by living with smokers at home and respiratory symptoms Table 10: Frequency distribution of respondents who reported having respiratory symptoms by places of smoking exposure Table 11: Frequency distribution of respondents who reported seeking care by services Table 12: Health care cost by province 23 24 25 26 26 27 28 28 29 29 30 31

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Table 13: Respiratory symptoms and health care cost by exposed and 31 non-exposed restaurants workers and officers Table 14: Respiratory symptoms and health care cost by exposed and 32 non-exposed restaurants workers and officers in two provinces

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Sithath Insisiengmay. The research team would like to thank Adventist Development and Relief Agency (ADRA Lao) for their coordination and support. Dr.ACKNOWLEDGEMENTS This study received technical support from the Southeast Asia Tobacco Control Alliance (SEATCA) under The Collaborative Funding Program for Tobacco Control Research and financial support from The Rockefeller Foundation and the Thai Health Promotion Foundation (ThaiHealth). << >> 4 . all data collectors and respondents from Vientiane and Luang Prabang provinces. This research could not be completed without the support and encouragement of Prof.

250 Kips or US$59. and cost of treatment related to health symptoms from 300 cases of workers who are exposed to SHS in the restaurants and 300 staff in smoke-free offices. in which 284. 15.001).EXECUTIVE SUMMARY The study on exposure to secondhand smoke (SHS) among non-smoking workers in the restaurants in comparison to non-smoking officers in the smoke-free offices in Vientiane capital city (VTE) and Luang Prabang Province (LPB). 11.0% in the restaurant group and 6.0% in LPB) (p<0.6. and most of them were single.3% in VTE and 38.7% in LPB) compared to the office workers (7.041). The mean number of hours that restaurant workers in Vientiane capital city were exposed to smoking pollution was higher than those in Luang Prabang province which has smoke-free areas (20 versus 2. The respondents were mostly females in the young age group (15-35 years old).5.3). had completed secondary and higher education. The collected data was entered into Epi-info 6.7) were indirect cost. The mean of total health expenditure spent on treating their illness was 319.7% reported having respiratory symptoms compared to 4. health symptoms. The study showed the strong association between exposure to secondhand smoke and respiratory symptoms including chest pain and coughing with phlegm in the morning (10. This cross-sectional study was carried out from September to October 2007 using the structured interview questionnaires to collect data on SHS exposure. among those respondents who were living with smokers.3% in VTE and 60. In addition.001) experienced such symptoms.160 Kips (US$7. The study found that most of the workers at the restaurants had been exposed to secondhand smoke on average 11.7%). << >> 1 1 US Dollar is equivalent to 8.04 dataset and analyzed using cross-tabulation and logistic regression by SPSS statistical packages version 11.001)].2) were direct cost and 66.63 hours (p<0. Lao PDR aimed to provide research-based evidences to policy-makers that would support the drive to enforce tobacco control policy under the Lao PDR Act of 2001. particularly Article 4 which is the implementation of smoke-free policy in places including restaurants.6 hours per week in comparison to those who worked in the office where smoking is prohibited [1.3% in office group (OR=2.568 LAO KIPS as of August 2008 5 .315 Kips or US$23).5% among those who were not living with smokers (p=0.620 Kips (US$33. p=0.48 hours). The exposed restaurant workers spent more (513.9) than the exposed office workers (197.612 Kips 1 (US$37. Higher rates of exposure to smoke at the work place were observed among the restaurant workers (99.

this study provides strong evidence to support a complete ban on smoking in restaurants. and other public places as mentioned in Article 4 of the tobacco control policy.The data derived from this study confirmed that public places such as restaurants are among the worksites that have high level of secondhand smoke. therefore. pubs. << >> 6 . bars. but these workplaces are least likely to be covered by laws or policies on smoking ban.

or cigar. Most recently. Culture. 7 << >> . Their findings showed that the prevalence of smoking in Laos continues to increase. mass organizations. as a community based survey with national representatives and the results showed that the prevalence of smoking is about 40%. and related organizations. the Ministry of Health (MOH) approved to develop the tobacco control policy following the national conference in Vientiane capital on 24 July 2000 which was attended by 46 participants from 12 ministries. The projects trained the teachers as educators who then train their school children about the dangers of smoking and secondhand smoke. pipe. Article 8 of the UN Framework Convention on Tobacco Control (FCTC) called for the expansion of smoke-free places at the national and other jurisdictional levels in signatory countries. thus smoking is observed in many of the above-mentioned places. To control the risk of SHS.INTRODUCTION Secondhand smoke (SHS) is a mixture of the smoke given off by the burning of a cigarette. Lao PDR. In 2000. There are more than 4. However. Many places have begun to implement the policy.800 chemicals in secondhand smoke including 69 carcinogens as well as other chemicals that are irritants. Education and Health) and in the Ministry of Foreign Affairs. The regulation on the establishment of smoke-free places is one of 9 articles of the policy which include the banning of smoking in schools. the World Health Organization (WHO) has promoted smoke-free legislations around the world by organizing the convention on tobacco control in 2003. a number of researches have been conducted recently focusing mainly on the prevalence of smoking and smoking behaviors of different target groups in different places. the National Institute of Public Health conducted a health survey as part of the World Health Survey (WHS) 2003 in Lao PDR. the enforcement of the policy is very limited. hospitals. The smoke-free policy was also adopted in government offices in the province of Luang Prabang (4 Provincial Department: Provincial Administration Office. 2005). toxicants and mutagens (Framework Convention Alliance on Tobacco Control. In Lao PDR. as well as a higher prevalence found in rural areas. and other public places. has adopted initiatives to implement smoke-free regulations in the country in accordance with Article 8 of the Framework Convention on Tobacco Control (FCTC). 6 of 17 provinces of Laos have a pilot project in about 60 schools. as a member country of the WHO. with males exceeding females. including most of the government hospitals. for example. restaurants. government offices. and the smoke exhaled from the lungs of smokers.

Currently. << >> 8 . hospitals. there is no data available concerning SHS or passive smoking and tobacco-related diseases in Laos. The study on the exposure to SHS among workers in restaurants in Vientiane Capital and Luang Prabang Province will generate strong evidences that can be used to push for the total ban on smoking in restaurants and other smoke-free places. The regulation on smoke-free places is one of 9 articles of the policy stating that smoking should be banned in schools. Data derived from this study will also be very useful for policymakers in implementing the policy concerning tobacco control in Lao PDR. restaurants and other public places.A tobacco control policy has been developed by MOH in 2001. However. governmental offices. the effort in implementing the tobacco control policy is not so strong as smoking is still permitted in many places such as restaurants and other public places and on public buses.

total cigarette consumption increased 2. (Shafey. in the United States. The WHO estimated that there were approximately 1. around 60% of the total consumption in the Region is by men and 6% by women. In the last few decades. only Japan and the Republic of Korea are experiencing decline in tobacco use prevalence. Based on the World Health Organization (WHO) estimates for 2000. 2003). with dramatic increases seen in the developing countries (those with low and middle incomes).LITERATURE REVIEW Global Trend of Tobacco Consumption and Smokers The practice of cigarette smoking is the most widespread type of tobacco consumption worldwide. The largest number of smokers in the Region is Chinese men.786 million sticks in 2000. one in three cigarettes is consumed in the Western Pacific Region. Among the five largest countries by population in the Region. For example. On the average. of which almost one billion were males. while female daily smokers in the world was about 22% of women in developed countries and around 9% of women in developing countries (Mackay & Eriksen. while the developed countries experienced a decline.3 billion people who smoke cigarettes or other products in the world in year 2003.5 times (from 141. the number of cigarettes consumed increased by about 76% from 1970 to 2000. the percentage of cigarette smokers decreased from 38% to 24% (male smoking declined from 44% to 26% and female smoking declined from 32% to 22%) and similarly in the United Kingdom. The rates of tobacco use remained high in the rest of the developing nations in the Region. Dolwick & Guindon. 2002 and Shafey. the percentage of smokers dropped from 50% to 27% (55% to 28% for male smokers and 44% to 26% for female smokers) (Mackay & Eriksen. about 35% were in the developed countries and 50% in the developing countries. Among the male smokers in the world. 2003). 2003). 2002 and Guindon & Boisclair.345 million sticks in 1970 to 363. Mackay & Eriksen. Dolwick & Guindon. 2002). Mackay and Eriksen estimated that the trend of active smoking in developed countries declined during last three decades. The International Agency for Research on Cancer also presented the prevalence of cigarette use among smokers in the world. In the South East Asia region alone. with male smokers accounting for five times more than females. << >> 9 .

0% was female. The average number of cigarettes smoked was up to 20 sticks and more among male respondents (NIOPH. and smoke that is exhaled from the lung of smokers (mainstream smoke) contain a complex mixture of gases and particles. the percentage of smokers has increased among both men and women in the last few years. A number of studies illustrated that personal direct contact with tobacco smoking could lead to a wide range of diseases.3% of respondents reported that they were currently smoking.9% was men and 20. and cigarette is the most prevalence form of tobacco consumption. The smoke that contaminates indoor spaces and outdoor environments by active smokers has often been referred to as Secondhand Smoke (SHS) or Environmental Tobacco Smoke (ETS). and they are harmful to the health of those who breathe in the tobacco smoke. 2006). Compared to other neighboring countries. Many of these substances are known to be toxic. The smoke from burning cigarettes and other type of tobacco products (sidestream smoke). 2002. The Tobacco Atlas).9%).0%). chronic lung disease such as chronic obstructive pulmonary disease (COPD) or asthma and cardiovascular disease and others (Royal College of Physicians. ammonia. arsenic. of which 78.S.Prevalence of Smoking in Lao PDR Lao PDR is classified under the Western Pacific Region by the WHO. The survey found that 40. Effects of Secondhand Smoke on Health There is a range of chemical constitutions in both sidestream and mainstream smoke. such as carbon monoxide. of Health and Human Services. The SHS 10 >> . of which the most common fatal illnesses include lung cancer. according to the Lao Health Survey. since non-smokers who are exposed to secondhand smoke also breathe in the same poisons as the active smokers. Dept. 2006). Laos has a very high proportion of adult smoking among the other nations. mercury and formaldehyde.1%).4%). Definition of Secondhand Smoke << Tobacco is consumed mainly by burning tobacco products and inhaling the smoke. which is part of the World Health Survey conducted in 2003. Myanmar (32. especially referred to as human carcinogens. they are also likely to face similar health hazards as the active smokers. and Thailand (23. Vietnam (27. 2005).7%) followed by Cambodia (37. It is a nation that has a high prevalence rate of smoking compared to its neighboring countries and some other countries in the Region (2000). Therefore. Also. which comprises around 4000 different chemicals. Lao PDR has the second highest rate of adult smoking after Mongolia (46. and the inhalation of the smoke by people who are not active smokers is commonly referred to as involuntary smoking or passive smoking (U. Moreover.4%) (Mackay & Eriksen. Malaysia (26.

and wheezing are symptoms of COPD. Also. there have been far fewer studies of passive smoking and respiratory system effects on adults compared to the number of research study on children.8 times more likely to develop asthma and wheezing than those without in utero SHS exposure (Dhala. Pinsker & Prezant. The finding of this study illustrated that exposure to SHS was an important factor that influenced the severity of COPD. 2005). indicating that a causal relation exists for COPD (Royal College of Physicians. 2006). nonetheless. children who are exposed to in utero tobacco smoke from their mothers are 1.. a longitudinal cohort study of adults in the US was conducted to explain the impact of SHS exposure on COPD health outcomes. 2006). at worst it could result to disability or mortality for the persons affected. Asthma Children can be exposed to secondhand smoke both during fetal and early postnatal life from maternal or parental smoking and exposure to SHS is a factor for asthma development. Although. The exposure to maternal smoking during in utero and after birth is a risk factor for reduced lung function development that remains a serious childhood and public health issue (Moshammer et al. (2006) indicated that mother’s smoking during pregnancy and during the first year of a child’s life was associated with an increased risk of wheezing in the child and the development of asthma at two years of age (Lannerö et al.exposure not only could lead to ill health. 2006). It was found that higher level of passive smoking exposure was associated with worse COPD severity (Eisner et al... Recently. Shortness of breath. Likewise. In the case of shortness of breath. The result of over two years of study by Lannerö et al. especially among non-smokers (University of Pittsburgh Medicine Center. coughing. there is chronic obstruction of the flow of air through the airways and out of the lungs. In both diseases. it usually gets worse during exercise. There have been a number of researches about an increased risk of COPD as shown by evidence of the damaging effects on lung function among adult non-smokers exposed to SHS. secondhand smoke is another factor that researchers identified that can be a risk factor of this disease. Respiratory System Effects Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is a chronic inflammation of the airways. Cigarette smoking is known as the most important risk factor for COPD. producing sputum (mucus). 2006). 2005). referring to chronic bronchitis and emphysema. 11 << >> .

In a study by Dhala et al.. and lung cancer (Dhala. smoke from tobacco is a carcinogen that also has been considered as a major risk factor for heart disease (US Dept. respectively in United States. 1998). 2006). 2001. Recently. has shown that exposure to cigarette smoke can significantly increase the risk of coronary heart disease mortality in non-smokers (especially. Pinsker & Prezant. focusing particularly on adults with asthma. The most important risk factor of the disease is active smoking. indicated that high level of recent SHS exposure was related to greater asthma severity and a larger prospective risk of hospital admission for asthma (Eisner et al. 2005). in 2003. 2005). Cardiovascular Effects Cardiovascular disease is the leading cause of mortality in the developed nations. Moreover. it was shown that exposure to passive smoking during childhood could lead to an increased prevalence of asthma in adult never-smokers. of Health and Human Services. carcinogenic effects (US Dept. Jee et al.000 and 158. 2005. a number of studies which investigated secondhand smoke and its relationship to cardiovascular disease... Adults who are exposed to SHS at home or in the workplace have an increased risk of around 40–60% of suffering from asthma compared to those without exposure to the smoke. and it has been estimated that millions of Americans face the risk of new or recurrent heart attack and around 700. Furthermore. Exposure to SHS also exacerbates respiratory symptoms and lung function among adults’ asthmatics (Coultas. 2000).000 persons is likely to suffer from a new or recurrent stroke each year. which evaluated the respiratory health effects of secondhand smoke. exposure to SHS is also linked to several other cancers.. of Health and Human Services. 2006) . 1999. however. there were approximately 480. Nishino et al.000 deaths due to CHD and stroke. of Health and Human Services. if people were to exposed to secondhand smoke for a long time period. which include coronary heart disease (CHD) and stroke. In addition. including reproductive system effect. there is clear evidence that they will risk facing long-term health effects. << >> 12 . For example. female non-smokers whose husbands smoke) by around 30% (Royal College of Physicians. especially among the never-smokers who have no family history of asthma (Dhala.passive smoking has been identified as a risk factor for asthma among adults. 2006). results of a cross-sectional study that examined the association between SHS exposure and pulmonary function among non-smoking adults in US. 2005). Kreuzer et al. Pinsker & Prezant. including breast nasopharyngeal and cervix cancers (US Dept.

Diseases caused by SHS exposure not only incur increased direct medical costs. in the United States in 2004. 6.Economic Effects of SHS Exposure to SHS is significantly associated with increased morbidity and mortality from a wide range of diseases.150. << The study on tobacco-related socio-economic cost of stroke.10 billion due to disability and premature deaths from 3 categories of diseases caused by exposure to secondhand smoke. they also result in lost of economic value due to lost wages and fringe benefits. This is a public health problem and a considerable economic burden on both the individual and household. approximately 126 million Americans were estimated to have been 13 .720 Kips (US$790) for stoke range. For example. with the decline in smoking prevalence in the last few decades in the developed countries.081. Eriksen & Lin. In the United States. lung cancer. >> Trend in the Exposure to SHS of Non-smokers Exposure to SHS by non-smokers will depend upon the smoking prevalence (percentage of smokers) and the number of cigarettes smoked by each smoker per unit time that non-smokers are in contact with. an estimated US$3. 2005).752 million) (Behan. The mean total health care cost during hospitalization was 4. and chronic obstructive pulmonary diseases in Lao PDR revealed that the rate of tobacco smoking is significantly higher in patients suffering from the 3 diseases (62%). or 88% of the survey population from 1988-1991 and the proportion continuously declined to 80% (1991-1994). Thus. In the first phase. COPD (US$886 million).862 Kips (US$464) for lung cancer. Additionally.310 Kips (US$310) for COPD (Chu Vang et al.85 billion was spent on medical care for non-smokers who were suffering from lung cancer. nearly all non-smokers were exposed to tobacco smoke. COPD and CHD as a result of exposure to secondhand smoke. The number of people exposed to SHS decreased to 51% during 1999-2000 and further decreased to 43% in 2001-2002. It results in excess cost of morbidity and mortality.413. including direct medical costs. 2. over a period of 14 years (1988 to 2002) based on examination of the blood fluid cotinine levels over four periods of time. costs associated with disability or mortality and the opportunity costs of unpaid caregivers. They are: lung cancer (US$469 million). and CHD (US$2. and national levels. 2007). the trend showed that the number of non-smokers who are exposed to SHS has significantly decreased to approximately 70% overall. as well as the value of lost household services estimated at about US$4. the number of people exposed to SHS in these countries would have decreased as well.

D. A number of countries have responded by trying to reduce the health risks and burden of the population by restricting or prohibiting smoking in worksites and public places by imposing “smoke-free laws”.. particular the group of people who are not smokers but are subjected to SHS because of their occupation. Their respiratory and sensory symptoms were reduced and their respiratory function has also improved (Menzies et al.000 men and 108.. et al. After three months following a ban on smoking in public place. 2004). BS Smith & Blanc. and 86 million non-smoking adults aged 20 years or more (US Dept.402. 18 million non-smoking youth aged 12 to 19 years. at varying degrees. the majority of bartenders who initially were suffering from respiratory and sensory irritation symptoms have reported that these symptoms have appreciably declined.072.895.000 Chinese women aged between 35-74 years of age were current cigarette smokers. This can reduce the health risks to non-smokers. and 19. human health and the economies of a huge number of populations worldwide.000 non-smoking Chinese who experienced SHS exposure during that period (Gu.358. << >> 14 .000 women were exposed to SHS at home.exposed to SHS in 2000. Similar results were reported by the recent study by Menzies et al. al.658.372. there were 191. in China during 2000-2001 estimated that 147. there are still a huge number of non-smokers exposed to SHS. 1998).000 women were exposed to Environmental Tobacco Smoke (ETS) in their workplaces. especially those of non-smokers. It makes one wonder about the trend of exposure to SHS by people in the developing countries. where the prevalence of tobacco consumption and the percentage of smokers are the highest. 2006). in Scotland. Smoke-free Law SHS exposure affects.504. In total. a cross-sectional study of Gu et. there was a rapid improvement in the health of the bar staff. For example. however. About 8. including around 22 million children aged 3 to 11 years. Also.000 men and 55.000 Chinese men and 15. the number of non-smokers who suffers from the SHS would be enormous. As 80% of the world’s population reside in the developing countries. Positive results can been seen in California where one to two months after the establishment of a ban on smoking in bars and taverns in the state. 2006). the function of pulmonary has improved following a decreased in SHS exposure in their workplace (Eisner. Although the number of non-smoking persons who experienced inhalation of tobacco smoke appreciably dropped over a period of one decade. of Health and Human Services.

pubs.. Hence. and public places including restaurants. tend to suffer from the effects of high level of exposure to SHS. M. spend most of their time in. public places such as restaurants.Moreover. bars etc. The result of the second study showed that air nicotine was detected in all the bars where smoking was allowed. Barbeau. but they are least likely to be afforded protection from the health risk. OY. Because the home is where many people. these workplaces are least likely to be covered by laws or policies that ban smoking. (2005). worksites. The workplace is the second most important site for SHS exposure because it is a place where adults spend most of their time. nonetheless. Risk of SHS has not only been shown to be the main cause of human lung carcinogen. and bars. particularly the non-smokers. While public places such as bars and restaurants have been identified as worksites where SHS exposure is high (Edwards et al. This is particularly true of pubs and bars which are places of refuge for smokers. BS Smith & Blanc. These places contribute to personal exposures in varying degrees across different groups. Tobacco Smoking Sites and Exposure to SHS The Report of the Surgeon General in 2006 confirmed that the three main places where exposures to secondhand smoke often occur were homes. EM. the advantage of having smoke-free workplaces is that not only would it reduce health risks or hazards among people who do not smoke. an occupational mortality study found that being a waitress was the most hazardous occupation for women. malls. Furthermore. but it could also reduce cigarette consumption among smokers (Eisner. No nicotine was detected in the hair of non-smoking employees working in a smoke-free bar. According to two studies conducted by researchers at the Johns Hopkins Bloomberg School of Public Health. are also important contributors to SHS exposure for clients and staff who do not smoke.. while high levels of nicotine were detected in the hair from non-smoking employees working in bars where smoking is allowed. The harmful effects of exposure to SHS on non-smokers are clearly established. it is therefore potentially the most important place for SHS exposure especially for those who live with regular tobacco smokers. indicating that involuntary exposure to tobacco smoke occurs in Baltimore bars. the results of the first study showed that the average level of particulate matter pollution in the bars surveyed was at least 10 times higher than the Environmental Protection Agency’s (EPA) outdoor air safety levels. Although the home and workplaces are important sites where non-smokers are exposed to SHS. 1998). workers in these worksites. and this could lead to a decrease in morbidity and mortality of smokers as well as reduce the economic costs related to smoking. and being a bartender ranks among the seven most hazardous occupations (Siegel. 2006). especially children. & Osinubi. but it 15 << >> .

<< >> 16 .also increases the risk of respiratory system illness in both children of all ages and adults (American College of Chest Physicians. chest tightness. However. These symptoms are linked to exposure to SHS. SHS also results in acute and chronic respiratory ill health in non-smokers. 2006).. but they have not consistently included asthma and some other environmental factors (US Dept. A number of studies have attempted to evaluate the relationship between SHS exposure and respiratory symptoms. of Health and Human Services. The short-term respiratory effect that often occurs is respiratory symptoms. 1995). including coughing. 2006). recent studies have demonstrated that reduced SHS exposure of waitress or bartenders in their workplaces has decreased respiratory symptoms that they had previously suffered (Eisner. BS Smith & Blanc. which is an acute pulmonary effect of SHS. and difficulty in breathing. 1998 and Menzies et al. wheezing.

STUDY OBJECTIVES 3. To investigate the association between non-smoking workers in restaurants and the smoke-free offices on the risk of developing respiratory syndromes. To compare health status (respiratory syndromes) between the workers who are exposed to SHS in the restaurants and unexposed workers to SHS in smoke-free offices. To estimate the direct and indirect costs of smoking-related diseases among the workers who are exposed to SHS in the restaurants/offices • << • >> • 17 .2 Specific Objectives • To investigate the association between passive smoking at restaurants with environmental tobacco smoke exposure and the risk of developing respiratory syndromes. particularly Article 4 on the establishment of smoke-free places including restaurants 3.1 Overall Objective To provide the evidence based information on health-related issues caused by secondhand smoke to policy-makers in order to push for the adoption of the tobacco control policy of Lao PDR Act of 2001.

A total of 70 restaurants in VTE and 65 restaurants registered with Luang Prabang provincial travel authorities were in the frame for the first sampling unit.g. followed by Luang Prabang municipality. The restaurants were classified into 3 types as (1) Air-conditioned enclosed Restaurants. and (3) Open-air Restaurants. Sisattanack. the waiters or waitress should have environmental tobacco smoke (ETS) exposure 4. (2) Mixed enclosed/open air Restaurants. Chanthabury. • Workers of both sexes who have at least one year of working experience in either of the two places. Saysetha. The sampling frame was based on the following criteria: • Restaurants with more than 5 workers and that allow smoking in both VTE and LPB municipality. and Saythany. the researchers visited the restaurants. • Smoke-free offices in both VTE and LPB municipality. the research team therefore conducted a pilot survey first in Vientiane capital city by collecting a list of all available restaurants that are registered at the district travel authorities of 5 districts namely Sikhottabong. 4. After obtaining such a list.METHODS & DATA SOURCES 4. << >> 18 . • Workers at restaurants e.1 Research Design This is a cross-sectional study that was carried out using structured interview questionnaires (Face to face interview) as data collection tool among non-smoking restaurant workers and non-smoking workers in smoke-free offices.3 Sampling Method Due to the lack of information about the restaurants or offices where smoking is allowed or prohibited.2 Sampling Frame Vientiane capital city (VTE) and Luang Prabang (LPB) municipality were selected because they are popular tourist sites with many existing restaurants. A screening form (Annex 1) based on the above mentioned criteria was used to list all target population for further sampling in addition to obtaining information about personal smoking habits.

In a second step. all offices which had 5 staff or more were included in the sampling frame and to get 150 respondents. 90% power or 1. The respondents who smoke or ever smoked were excluded from the sampling frame to avoid bias. α = 0. 4.96. SHS was associated significantly with frequent colds. 30 restaurants from 70 restaurants were randomly selected for the first selection. 90% power. β = 0. the calculation was made using software EPI 6. OR = 2.28. Z α =1. They were also classified into 3 types as mentioned above. et al.89 (95% confidence interval) (Ho S. The sample size was determined with 95% confident interval. All these offices prohibit smoking in the workplaces. and P of exposure = 27 %. throat problems. a total of 70 restaurants were registered with the travel district authorities.All offices which were included in this study were smoke-free offices. and about 27% of presence of any respiratory symptoms.4 Sample Size The selection of the restaurants and office workers were made randomly from the list of restaurants and smoke-free offices provided by provincial/district travel authorities. Y.04 of unmatched case-control. In order to get 150 cases for the restaurant group.05. The estimated sample for each province was 150 restaurant workers and 150 office workers with a sub-total of 300 in each site and with a total of 600 in the two provinces. a total of 30 offices were randomly selected from all 90 offices in VTE and 62 offices in Luang Prabang province. visits were made to the selected restaurants and a list of staff members working in each restaurant was obtained. In VTE.1. and the presence of any respiratory symptoms with adjusted odds ratios of 1. For the Office group. Five workers from each restaurant was then selected proportional to size (PPS) using simple random sampling.β. detecting an OR of 2. All restaurants which had 5 or more staff were included in the sampling frame. << >> 19 . Based on the 95% confident interval. The same procedure was done in Luang Prabang province. Zβ =1. 2007). cough and phlegm.

>> 20 . The first was respiratory health of bar workers abbreviated IUALD reproduced with permission of Mark D.5 Measurement of Outcomes Exposure to Secondhand Smoke • By living with smokers • Time exposure in the last seven days (number of hours) • Contact with smokers (household member. University of California and the second was the questionnaire prepared for the Respiratory Disease Committee of the International Union Against Tuberculosis and Lung Disease (UNION) by Burney P et al. Eisner. co-worker. including workplace and home exposures as well as their past smoking history. customer. others) Respiratory symptoms in the last two months • • • • • Wheeze and tightness in the chest Shortness of breath Cough and phlegm from the chest Breathing difficulty Asthma 4. Thailand. we based self-reported exposure to passive smoking.6 Data Collection Methods << Structured Interview Questionnaires (Face to face interview) The 3 structured interview questionnaires were provided during the regional workshop in December 21-22. 2006. in Bangkok. The questionnaire was also designed to capture information about the characteristics of the respondent’s workplace with respect to passive smoking and secondhand smoking related to health care cost (Annex). To assess tobacco exposure.4. These questionnaires were revised accordingly to suit the objectives and situation of Lao PDR by the national research team with the technical assistance of the experts from SEATCA. (2006). Non-smoking workers from both the restaurant and office groups were asked in a standard interview on matters relating demographic and their past exposure to secondhand smoke. and the last was a standard respiratory symptom questionnaire developed by Hedley et al.

4. After the completion of the pre-testing. One supervisor was assigned to take care of data collection in each site. The training sessions included theory (2 days). as during the pilot survey it was not possible to find non-exposed restaurant workers as there were no 21 >> . Soon after the training. the questionnaire was revised accordingly. Data collection started in VTE capital city soon after the pilot from 20 August to 5 September 2007. The five-day training of 8 data collectors and 2 supervisors was conducted in mid-August 2007 with the aim to make the data collectors understand the objectives of the survey and the methodology on how to select targets for case and control groups. The pilot survey in Luang Prabang started on 25 August with the same procedure as that conducted in VTE capital city and data collection started on 10 September 2007 and was completed on the 25 September 2007.7 Pre-testing of the Questionnaire The questionnaire was developed in English and after it was finalized.8 Data Collection and its Quality Control Training of interviewers and supervisors was performed before the collection of the data.4. role play in the class (1 day) and field practice (1 day). and one day of revision of all the contents of the survey tool plus feedback from the field practice. The first group was responsible for interviewing 15 non-sampled restaurant workers and the other group was responsible for the same number of office workers. two teams with 4 enumerators were formed and each team was assigned the responsibility to collect the data in each study site. The total number of pre-testing questionnaire respondents was 30. the questionnaire was translated into Lao language and pre-testing was conducted in Vientiane capital city. Research team members then provided comments and suggestions on how to improve the quality of data collection. << Question by Question review was done in order to familiarize members of the research team with and to ensure that they understand all the questions in the questionnaire. All the data collectors have had experience in many national surveys in the past. Limitation The study could not draw on a non-exposed group of respondents from restaurants to compare with exposed non-smoking workers in the restaurants. The research team was divided into two groups of 4 persons each.

Logistic regression was performed. The objectives of the study were explained to all subjects recruited for the study who gave their verbal informed consents on a voluntary basis. the team decided to include offices that have similar environments to restaurants. The frequencies. The matching selection of both groups was non-smokers and never-smoked and worked at the current place for more than 1 year. Ministry of Health Lao PDR.9 Data Processing and Analysis All 600 questionnaire forms were checked for completeness and consistency by those 8 data collectors by exchanging them between the teams. << 4. The 95% confidence interval and the chi-square test were used to compare differences between groups and provinces. an Ethical clearance was issued and approved by the National Ethical Committee for Health Research. All entered data was then transferred to SPSS statistical package version 11. >> 22 .5 for further analysis. All questionnaire forms were completely entered one week after receiving all forms from each study site. to obtain a non-exposed group as an initial plan of this study. such as banks.10 Ethical Consideration In order to ensure that ethical aspects of the subjects were protected. mean.restaurants which prohibited clients from smoking. 4. Therefore.0 program. travel agencies. and proportions were calculated. standard deviations. Data entry set was developed by one of the team members using Epi-info 10. telecommunication offices where smoking is not allowed.

7) 111 (74.0) 23 . Most of the respondents were female (55. Most of the female respondents have secondary school and higher education.7) 100 (66.7) 101 (67.3) 117 (78.2) 251 (41.7) 4 (2.restaurant workers. 300 respondents from Luang Prabang province and 300 participants from Vientiane capital city. and officers .7) 80 (53.3) 20 (13.3) 76 (50.3) 349 (58. In each province.7) 14 (9.8) 269 (44.7) 25 (16.by province Restaurant workers VTE capital N (%) 74 (49.3) 79 (52.3) 33(22.8%).7) 43 (28.0) Officers VTE capital N (%) 61(40.7) 5(3.0) 133 (88.7) 57 (38.0) 3 (2.7) 88 (58.8%). range 15 to 55) with a high concentration in the age group 25 to 34 years old (44.0) 33 (22.0) 90 (60.7) 47 (31.8) Total number << >> Sex Male Female Age groups 15-24 25-34 35-44 45+ Marital status Single Married Educational level Primary school Secondary school College/ University 7 (4.3) 15 (10.7) 89 (59.2) 335 (55.8) 211 (35.8) 72 (12.0) 14 (2.3) 133 (88. while most of the office workers sampled were in the age group of 25-34 years old (58% and 67%).0) 72 (48. single (78% and 74%) and had secondary education (67% and 53%). More than half of the restaurant workers sampled were in the age group 15-24 years old (59% and 69% for Vientiane (VTE) and Luang Prabang (LPB).0) 87 (58.3) 49 (32.3) N (%) 265 (44.0) 104 (69.3) 13 (8.3) 35 (23.RESULTS 5.0) 78 (52.8SD.0) 39 (26.0) LPB N (%) 70(46.7) 23 (3.09 years old (±6.3) 7 (4. Table 1: Background characteristics of respondents . married (52% and 67%) and had college/university education (89% and 89%) (Table 1).1 General Characteristics of Respondents in Both Groups A total of 600 respondents were recruited for the study.2) 366 (61. a total of 150 non-smoking restaurant workers and 150 non-smoking officers from smoke-free offices were recruited.0) 27 (18.7) 2 (1.8) 245 (40.0) 0 17 (11. respectively). in the mean age of 27.7) 2 (1.3) 100 (66.0) LPB N (%) 60 (40.

5. On the question asked of all respondents with regards to policy knowledge.0% of the officers had previously worked elsewhere. (1) with air condition only. Table 2: Percent distribution of respondents on policy knowledge by province Type Province Policy knowledge Smoking not allowed inside Special place for the building smoking No (%) No (%) 138 (92. Library (NUOL).0) 10 (6.3) 61 (40. the result showed that for the restaurant group in Luang Prabang.7) 2 (1. and City Development Organization.0) 126 (84.3) 6 (4.2 Working Hours The workers in the restaurants in both provinces worked on average 54 to 56 hours per week and the officers work on average 40-42 hours per week. and the restaurants without air conditioning on.3) 87 (58. and (3) without air condition.7) 22 (14.1. Social Security Organization. with an average of 15 seats (range from 3 to 140). 92% of respondents stated that smoking was not allowed inside the building while 40. Public bank.7) 20 (13. The restaurants with air conditioning had on average 157 ± 126.0) 5.0% of the respondents in the office group in LPB and 82. Most of the restaurant workers and officers have been working in their current workplaces for more than one year. There were 3 types of restaurants surveyed.7% in VTE stated that smoking was not allowed inside the building (Table 2). (2) with and without air condition.6 SD (range from 37 up to 800). The offices selected for the office workers group included bank offices (BCEL. The number of seats in the restaurant which had room with air condition and open room without air condition was around 60. Meanwhile 84.1 Types of Workplaces The number of seats in the restaurants surveyed differed from one restaurant to another.1.7% in VTE stated that smoking was allowed inside the building.7) 2 (1.0) 124 (82. Lao-Viet Bank. Of those 113 restaurant workers who had previous 24 . Telecommunication office (ETL). Agricultural Promotion Bank).7% of the workers in the restaurants and 25. an average had 76 seats ± 60 SD (range from 28 to 150).3) << >> Restaurant LPB group VTE Office group LPB VTE Smoking allowed No (%) 2 (1. Approximately 37.

(%) 58 (38.6) Restaurants or hotel 32 (55.3% in LPB compared to the office group.experience. at 63. 14.2) 25 (33. Much higher rates of exposure to smoke at the workplace were observed among the restaurant workers (99. There is no difference between the groups in terms of exposure to smoke at home.3) 8 (7.7% in LPB (p 0.0) 3(5. with higher rates recorded by the restaurant group at 100.0% in VTE and 95.3) Restaurants or hotel 9 (17.9) 4 (7.001). a list of questions were asked if the respondents were exposed to cigarette smoking at home.7) 55 (36.6) 31 (41. >> 25 .1) 14 (63.3% in VTE and 82.6) 78 (69. 69.1) 53 (35.0) Office group Government officers 17 (32. Table 3: Frequency distribution of respondents by occupation with past working experience VTE capital Luang Total No. at their workplaces.7% had experience working in the restaurants or hotels (Table 3).7) 75 (25. (%) Prabang No.3) Officers at private company 18 (31.7) << 5.3 Exposure to Smoke In order to determine the main places that respondents in both groups have exposures to secondhand smoke.3% in VTE and 38.1) 11 (14.6) 6 (5.3) 22 (14.2) 46 (83. The study found that most of the respondents in both groups were living with smokers. (%) No.7) Restaurant group Government officers 4 (6.1) Officers at enterprise 4 (6.7) 113 (37. and at leisure places.5) 21 (18.0% in LPB) (p<0.6) 4 (18.1.3) Officers at enterprise 6 (11.7) Officers at private company 21 (39.015). There was little difference between the groups where exposure to smoke at leisure was concerned (Table 4).9) 2 (3.3% in VTE and 60.09) 2 (9.1) 8(10.3) 2 (9.7% in LPB) compared to the office workers (7. while of the 75 office workers who had worked elsewhere before.1% of them worked in restaurants or hotels.

0) 49 (27.3) 35 (22.Table 4: Frequency distribution of respondents exposed to secondhand smoke by places and province Living with smoker No.4 Number of Hours that Respondents Spend with Smoking Pollution and Person Who Smokes The study found that restaurant workers were exposed to secondhand smoke for much longer periods than the office group with an average of 11.479 0 28 Total Restaurant 15.8) 5.0) 21 (14.6 hours per week for the restaurant group (range from 0 to 70) and 1.3) 145 (49.3) 73 (48.7) 35 (5.3) 99 (60.0) 5 (1. (%) 52 (34.3) Exposure at other public places 9 (6.78 group (n=143) Office group 1.3) Exposure at home No.63 (n=219) Total (n=512) 7.62* 70 group (n=293) Office group 2.0) 512 (85.0) 160 (53.3) 148 (49.7) 213 (35.24 16.63 hours for the office group (range from 0 to 15 hours (p<0.367 0 10 .3) 133 (47. (%)* 72 (48.0) 143 (95.001 << >> 26 .000) (Table 5).065 0 70 * p<0.0) 3 (2.3) 124 (82.657 0 70 Luang Prabang Restaurant 4. Table 5: Mean and Standard deviation of hours that respondents are exposed to smoking pollution Province Mean Std.5) Exposure at workplace No. Deviation Minimum Maximum VTE capital city Restaurant 18. (%)* 149 (99.48 (n=95) Total (n=245) 13.588 0 15 2.121 0 15 1.3) Exposure at leisure No.7) 267 (89.7) 65 (43.0) 63 (42.7) 11 (7.98 (n=124) Total (n=267) 1.892 0 11.3) 128 (42.3) 30 (10.3) 95 (63.05 group (n=150) Office group 2.35 13.0) 2 (1.3) 57 (38.7) 92 (61. (%) Restaurant group Office group VTE LPB VTE LPB Total VTE LPB Total 150 (100.1.422 0 28 2.3) 308 (51.7) 245 (81.94 3.156 0 70 20.8) 278 (46.0) 85 (28.

probably due to exposure to passive smoking at work.2 The Association between Work Site and the Risk of Developing Respiratory Symptoms Respondents in both groups were asked about respiratory symptoms including wheezing in the chest.3) Customers 24 (11. and asthma.3) 60 (42. The respiratory symptoms reported by the respondents in this study included chest pain in the morning and coughing in the morning with phlegm.4) Colleagues 22(23.6) 24 (11.5) 84 (38. The time frame was in the last two months.9) Colleagues 65 (43. while for the office group it was their colleagues and others ((friends.There were 5 cases which reported having been exposed to SHS for up to 70 hours per week (approximately 10 hours per day).4) 118 (53.7) Customers 231 (78.3) 19 (15.5) << >> 5.2) Others 35 (11.7) 65 (45.9) Others 93 (42.6. and the risk of developing respiratory symptoms (OR=2. Table 6: Frequency distribution of people who are smokers that the respondents had contact with VTE capital city Luang Prabang Total Number (%) Number (%) Number (%) * P<0. 27 . etc. in the bars.3% in the office group experienced these symptoms. people at parties. The study showed a strong association between worksites.7) 147 (98. wake up at night with short breath. It was found that customers were the main source of SHS for restaurant’s workers. coughing in the early morning or at night. and with phlegm in the morning.9) 5 (5.0% reported having such symptoms while 6.2) 96 (77.0) 69 (72.8)* 29 (19. Table 7).5) 117 (39.0) 84 (58.9)* Office group HH members 35 (36. short breath without workload.8) 49 (39.001. relatives.) (Table 6). p=0. chest pain in the morning.3) 6 (4.0) 125 (42. night clubs. Among the restaurant group 15.001 Restaurant group HH members 52 (34.

7) 39 (13. respectively (Table 8).7) No (%) 64 (10.378 0.0) 3.7% of respondents in both groups reported having respiratory symptoms.3%.3) 281 (93.355 1.3) 261 symptoms (87.3) 10 (6.580 P value 0.0) 274 symptoms (91.7) 140 (93.3% and 6.3) respiratory 1.487 Upper 4. In both provinces.7% in LPB.0) 255 (85.3) Lower 2.3) 141 (94. << >> 28 . with a higher rate recorded among those living with smokers (11.002 respiratory symptoms No 121 (80.0) The results showed that 10.0) No (%) 19 (6.571 7.041) (Table 9).5%) (p=0. a higher percentage of those in the restaurant group reported respiratory symptoms compared to the office group at 10.149 symptoms No 134 (89.0% in VTE and 19.7) 536 (89.001 The percentage of respondents having respiratory symptoms was higher among those residing in LPB compared to those in Vientiane at 13.0) 25 (8.7% and 6.Table 7: Frequency distribution of respondents in work sites and respiratory symptoms Restaurant Office Total OR 95% CI Having Respiratory symptoms No symptoms No (%) 45 (15.610 1. respectively.871 0. Table 8: Frequency distribution of respondents in work sites and respiratory symptoms by province Restaurant Office Total OR 95% CI P value VTE No (%) No (%) No (%) Lower Upper Having 16 (10.7%) than those who were not living with smokers (4.7) No (%) No (%) No (%) Lower Upper LPB Having 29 (19.166 0.0% and 8.799 4.7) 9 (6.

7) 116 (87. at the work place and at leisure was associated with having respiratory symptoms (14. Table 10: Frequency distribution of respondents who reported having respiratory symptoms by places of smoking exposure << Exposure at home Yes No P-value Exposure to smoking at work place Yes No P-value Exposure to smoking at leisure Yes No P-value Total VTE (n=300) Having Respiratory symptoms 12 (14.8) 0.7) 145 (93.0) 135 (91.1%. 29 .901 No symptoms >> 73 (85.5) 275 (91.7) 150 (87.057 15 (10.227 25 (8. 11.3 Estimation of the Direct and Indirect Costs of Smoking-related Diseases Among the Workers Who Are Exposed to SHS in the Restaurants A total of 221 respondents who had reported having the above respiratory symptoms were asked if they had sought care and if yes.2) 145 (86.2) 0. while in LPB exposure to smoke at home was associated with respiratory symptoms (Table 10).5) 0.1) 0.0) 0.8) 261 (87.3) 22 (12.8) 133 (95.0) 111 (86.3) 7 (5.8) 26 (17.Table 9: Frequency distribution of respondents exposed to passive smoking by living with smokers at home and respiratory symptoms Having respiratory symptoms Total Yes No Living Yes 60 (11.8) 22 (13.035 17 (12.3%.5) 88 No Total 64 (10.3) 142 (88.0) 5. exposure to smoke at home.920 39 (13.2) 18 (11.5) 84 (95.3) 10 (6.7) 452 (88. respectively).7) 536 (89.2) 126 (82.0) 0.1) 13 (6.3) 512 with smoker 4 (4.3) 600 P=0.0 13 (8. from where and how much they spent on health care cost related to smoking exposure.3%.035 No symptoms LPB (n=300) Having Respiratory symptoms 17 (13.9) 130 (89. 10.9) 202 (94.041 The study found that in VTE.

0% ) compared to those in the non-exposed group (0. indirect.315 Kips) (US$23. The mean health care cost related to reported respiratory symptoms was higher for restaurant workers in the exposed group at 513.9) compared to that of the office workers (197.A total of 185 respondents (84 respondents in VTE and 101 respondents in LPB) responded to this part of the survey.9) 16 (35.7) 2 (5.620 Kips (US$33.2) are direct cost such as doctor fees. Table 11: Frequency distribution of respondents who reported seeking care by services Place of seeking care Government hospital Private clinic Private pharmacy Self medication Total Restaurant group (n=94) VTE (n=45) 4 ((8.7) 5 (11.1) 3 (7.1) 4 (8.0) 1 (2. but they are not statistical significant (Table 12). The number of respondents who were exposed to smoke at any place was higher among restaurant workers (96%) compared to office workers (75%).7%).5) LPB (n=49) 3 (6.9) 3 (6.0%) compared to those who were not exposed to smoke (0. The respondents who were restaurant workers and were exposed to smoke in both VTE and LPB had more respiratory symptoms than those office workers and only those in the exposed group either restaurant workers or officers reported having to spend on health care related to respiratory symptoms (Table 14). and 66. 250 Kips (US$59.0) 0 5 (10.0) << Those who sought care at a health facility reported both their direct and indirect costs. Most participants in both restaurant and office groups had sought care at government hospitals and private pharmacies (Table 11).160 Kips (US$7. >> 30 . and total cost spending for respiratory symptoms in Luang Prabang is higher than in Vientiane capital city. and as such the former had more respiratory symptoms (14. in which 284. drug.6) LPB (n=52) 12 (23.1) 0 12 (23. as well as higher in restaurant workers than in office workers. Mean direct.7%).3). those office workers who were exposed to smoke were more likely to have respiratory symptoms (6.612 Kips (US$37. The mean of the total health expenditure spend per person for care of their illness related to respiratory symptoms was 319.9) 25 (48.2) Office group (n=91) VTE (n=39) 3 (7. Similarly.7) are indirect cost.1) 1 (1.0) (Table 13).7) 10 (25.1) 2 (5.1) 1 (2.

620 29 761.208 319.090 11 136.944 18 999.338 284. Deviation P-value Total Mean N Std.160 25 175. Deviation Luang Prabang Mean N Std.444 18 205.440 0.7) Officers Exposed to Not-exposed to smoke smoke at any at all place (n=225) 18 (6.0) (n=12) 513.09 392.571 7 38789.500 18 955.146 Total Health Expenditures 142.661 13 134497.612 31 778.585 66.250 (n=12) 2 (0.064 0.492.696 INDIRECT COST 34.Table 12: Health care cost by province DIRECT COST 108.828 Province VTE capital city Mean N Std.0) (n=18) 197.916 0.49 470.7) - >> 31 .41 78. Deviation << Table 13: Respiratory symptoms and health care cost by exposed and non-exposed restaurant workers and officers Restaurant workers Exposed to Not-exposed smoke at any to smoke at place all Respiratory symptoms Mean health care cost (Kips) (n=288) 42 (14.315 (n=75) 2 (0.

Table 14: Respiratory symptoms and health care cost by exposed and non-exposed restaurant workers and officers in two provinces Restaurant workers Vientiane LPB capital Exposed NonExposed exposed (n= 145) (n=5) (n=143) 15 (10.0) (n=8) 127.800 (n=10) 238.3) 2 (1.571 Respiratory symptoms Mean health care cost (Kips) Nonexposed (n=7) 2 (1.750 (n=4) 284.0) 27 (18.3) 10 (6.3) Nonexposed (n=26) - << >> 32 .7) (n=5) 81.250 Officers Vientiane LPB capital Exposed NonExposed exposed (n=101) (n=49) (n=124) 8 (5.

High rates of exposure to smoke at workplaces such as restaurants were observed in the restaurant group.78 hours per week compared to 20.7% in Luang Prabang compared with 98. (2005). even though the smoke-free policy has been declared and smoking indoor was not allowed since 2007. OY. (2005). particular the non-smokers. This may be because the policy is still at its infancy and. 2006). EM. EM.0% in Vientiane capital city. the study found that non-smoking restaurant workers were exposed to smoking pollution at an average of 2. M. M. a world heritage city. The cross-sectional and << >> 33 . the workers in these worksites tend to suffer adverse effects from the high level of SHS exposure. thus from the perspective of an occupational mortality study. & Osinubi. Hence. therefore. The study confirmed that those who live with smokers are 2. OY. Those who work in restaurants are likely to be exposed to secondhand smoke for long periods of time. in particular those who worked in the restaurants. but they are least likely to be afforded protection from the health risk. this study confirms that the workplace is the main place for respondents who are workers in restaurants to be exposed to SHS.DISCUSSION Most of the respondents in both restaurant and office groups were females. & Osinubi. chest pain and difficulty breathing as reported by Ho SY et al. The percentage of respondents who reported of exposure to customers' smoke was 58. some respondents still reported having been exposed to smoke at the workplace. The respiratory symptoms reported by the respondents include cough and phlegm. It has been a major SHS exposure site because it is a place where adults spend most of their time (Edwards et al.. In accordance with the report by the Surgeon General in 2006. After the implementation of a smoke-free policy in the city in Luang Prabang. and thus restaurant jobs are among the seven most hazardous occupations (Siegel.3 times more likely to have respiratory symptoms then those who live in a smoke-free environment and also confirmed that the rate of respiratory symptoms in non-smokers who worked in the SHS environment is higher than those who work in smoke-free places. Barbeau. In LPB.. Barbeau. but these workplaces are least likely to be covered by smoking laws or policies banning smoking. being a waitress was the most hazardous occupation for women (Siegel.. however.05 hours per weeks for non-smoking workers in the restaurants in Vientiane capital city. compliance among smokers is poor.

approximately US$7. frequent cough. pubs.prospective studies showed that SHS was associated significantly with frequent colds. According to the study at Baltimore by researchers at the Johns Hopkins Bloomberg School of Public Health. This cross-sectional study confirmed that exposure to SHS at work for part of the day was significantly associated with an increased risk of wheeze.4). indicating that involuntary exposure to tobacco smoke occurs in Baltimore bars. so they are at a greater risk of getting respiratory symptoms than those office workers working in a smoke-free environment as reported by Wakefield M et al. Workers at the restaurants spend more time at their workplace than the office group . Eriksen & Lin.612 Kips (US$37. throat problems. and bars to protect the health of restaurant workers as well as other office workers as stated in the Article 4 of the policy on tobacco control. and the presence of any respiratory symptoms. Exposure to SHS is a public health problem. which is significantly associated with increased morbidity and mortality from a wide range of diseases. as there was one case who had repeated respiratory symptoms. while high levels of nicotine were detected in the hair of non-smoking employees working in bars where smoking is allowed. 2000) at 319. sore eyes. air nicotine was detected in all the bars where smoking was allowed. In the United States. and sore throat and this study had provided evidence that non-smoking workers are affected by exposure to SHS at work and underlined the importance of imposing a 100% smoking ban in the restaurants. the mean health care expenditure for the treatment is relatively high compared to the overall health care expenditure at national level (NHS. who took self-treatment the first time and had to spend more for health check up (X-ray and blood test). cough and phlegm. The study found that eventhough few workers were ill and seeked care at health facilities.3) versus 175. << >> 34 .000 Kips (US$20. No nicotine was detected in the hair of non-smoking employees working in a smoke-free bar. 2005). especially in people who do not smoke as well as imposes considerable economic burden at both individual or household and national levels.96 billion in economic value was lost each year due to morbidity as a result of only 3 diseases as well as disability or premature death caused by exposure to passive smoking (Behan. The mean health care cost reported by respondents in LPB was higher than in VTE.

with higher cost spent by exposed restaurant workers (513.9) than exposed office workers (197. and bars to protect the health of non-smoking restaurant workers and office workers as stated in Article 4 of the policy on tobacco control. more cases of respiratory symptoms were reported by restaurant workers than by the office workers.041).160 Kips (US$7.CONCLUSION AND RECOMMENDATIONS The respondents were mostly females in the young age group (15-35 years old).620 Kips (US$33. Most participants in both restaurant and office groups had sought care at government hospitals and private pharmacies. << >> 35 . The study showed that there is an association between respiratory symptoms including chest pain. pubs. Higher rates of exposure to smoke at the workplace were observed among the restaurant workers (99. Ninety two percent of respondents in restaurants in Luang Prabang recognized that smoking s not allowed inside the building.63 hours (p<0.7% in LPB).315 Kips or US$23.3% in VTE and 38. at 10.3% of respondents in restaurants in VTE were aware of this ruling. respectively. coughing with phlegm in the morning and exposure to secondhand smoke. The mean total health expenditure spent to treat their illness is 319.3% in VTE and 60.7% versus 6.3). The study found that most of the workers at the restaurants were exposed to secondhand smoke on average 11.612 Kips (US$37.7% in LPB) compared to the office workers (7.5%) (p=0.0% in VTE and 95.0% in LPB).7) are indirect cost.001) by those who worked in offices where smoking was prohibited. and the majority were single. This study provides strong evidence that non-smoking workers are affected by exposure to SHS at work and underlines the importance of having a total ban on smoking in restaurant.7%) than those who are not living with smokers (4.250 Kips or US$59.2) are direct cost and 66. The percentage of respondents in both restaurant and office groups who were living with smokers was higher among the restaurant group (100. while only 1.0% in VTE and 19.3% versus 6. The results showed that 10. had completed secondary and higher education.3% in LPB) compared to the office group. more so in restaurant workers than in officer workers who were also exposed to SHS.3% in VTE and 82.7% in LPB.6 hours per week compared to 1.0).7% of respondents in both restaurant and office groups reported respiratory symptoms with a higher rate in those living with smokers (11. In both provinces. in which 284. (63.

Eisner. Levels of Secondhand Smoke in Pubs and Bars by Deprivation and Food-serving Status: A Cross-sectional Study from North West England. Department of Community Medicine. (2005). Behan. MP. Pinsker. Thorax. American Thoracic Society. MD.. 1989. Eriksen. (1995). The Health Risks and Community Costs of Secondhand Smoke Exposures. (1998). DP. Thorax. SK. et al. KA. 280 (22). University of Hong Kong American College of Chest Physicians.. (2005). Dhala. Lactao. Respiratory Health Consequences of Environmental Tobacco Smoke. DJ. BS Smith. 53. MD. A statement of the joint committee on smoking and health. 6 (12) Eisner. 814-821 Eisner. & Iribarren. 1808-1811. BMC Pulmonary Medicine. 5 (1). & Prezant. 60. DB. Economic Effects of Environmental Tobacco Smoke. Edwards. Smoking and health: a physician’s responsibility. Directly Measured Secondhand Smoke Exposure and Asthma Health Outcomes. >> 36 . Canadian Thoracic Society. Passive Smoking and Risk of Adult Asthma and COPD: An Update. Asia Pacific Society of Respiratory. School of Public Health. the questionnaire prepared for the Respiratory Disease Committee of the International Union Against Tuberculosis and Lung Disease (UNION). European Respiratory Society. (2005). Hammond.. DF. G. Directly Measured Secondhand Smoke Exposure and COPD Health Outcomes. 1909-1914. International Union Against Tuberculosis and Lung Disease. 381-387. A. 139-156. Y. JAMA. R. Society of Actuaries. (1998). European Respiratory Journal . C. (2006). Bartenders’ Respiratory Health after Establishment of Smoke-free Bars and Taverns. BMC Public Health. & Blanc. K. Burney P et al. MD. (2006). Clin Occup Environ Med.REFERENCES Anthony J Hedley et al. & Lin.. Et al. << Coultas.. 6 (42).

Ann Epidemiology 2007. Kreienbrock L.S. Eisner et al .org/tobacco/publications. G..asp Hecht. BioMed Central. Environmental Tobacco Smoke and Lung Cancer: A Case-control Study in Germany. Lannero. Lao PDR. Office on Smoking and Health. World Bank. et al. Maternal Smoking During Pregnancy Increases the Risk of Recurrent Wheezing During the First Years of Life (BAMSE). 2001. (2004). & Boisclair. 7 (3). Pershagen. GA: U. Cigarette Smoking: Cancer Risks. (1999). (March. Past. M. Jöckel K-H.Framework Convention Alliance on Tobacco Control. (2006). In U. 2005. Guindon. Wickman. G.. San Francisco Ministry of Health. Respiratory health of bar workers abbreviated. Atlanta. American Journal of Public Health. Available at URL: http://www1. Gu. L. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Medicine University of California. E. the tobacco control. Geneva. SS. D. Department of Health and Human Services.S. . << Jee.E. Krauss M. Current and Future Trends in Tobacco Use. 2007. (2006).worldbank. Carcinogens. Centers for Disease Control and Prevention. 1972-1976. & Nordvall. Kreuzer M. Wichmann H-E. 2003). Respiratory Research. Cross-Sectional and Prospective Associations Between Passive Smoking and Respiratory Symptoms at the Workplace.. Vientiane capital >> 37 . Coordinating Center for Health Promotion. Ohrr. H. Cigarette Smoking and Exposure to Environmental Tobacco Smoke in China: The International Collaborative Study of Cardiovascular Disease in Asia. & Kim. SH. IS. Mark D. National Center for Chronic Disease Prevention and Health Promotion. Department of Health and Human Services. D. Ho Sai Yin et al. American Journal of Epidemiology 2000..151 (3):241–50. Effects of Husbands’ Smoking on the Incidence of Lung Cancer in Korean Women. and Mechanisms. 94 (11).17:126-131. (2006). Switzerland. Langenbecks Arch Surg. Adapted and updated with permission from the 2000 World Conference on Tobacco OR Health fact sheets.

I. 173. Tobacco control country profiles. GA: U. Department of Health and Human Services. JAMA.. Tsuji. Respiratory Symptoms. National Institute of Public Health. July. A report on passive smoking by the Tobacco Advisory Group of the Royal College of Physicians. Vientiane: National Institute of Public Health. S. S. Lao PDR.Mackay. G. 31. Nishino. (2003). Coordinating Center for Health Promotion. Nakatsuka & al. 5 (1). Second Edition. OY. and Marker of Inflammation Among Bar Workers Before and After a Legislation Ban on Smoking in Public Places. Passive Smoking at Home and Cancer Risk: A Population-based Prospective Study in Japanese Non-smoking Women. Pulmonary Function. at Work and in Public Places.S. Parental Smoking and Lung Function in Children. 1742-1748. (2001). (2005). Barbeau. Office on Smoking and Health.. 2003. Moshammer. O. Am J Respir Crit Care Med. Health Status of the People in Lao PDR (as part of the world health survey. Ministry of Health.. Siegel.who. Dolwick. Clin Occup Environ Med. The Tobacco Atlas. (2006). Vientiane capital Royal College of Physicians. National Center for Chronic Disease Prevention and Health Promotion. EM. (2006).S. 1255-1263. << >> 38 .. H. . supported by WHO). & Guindon. World Health Organization. M.. Y. Lao health survey as part of the World Health Survey (WHS) in Lao PDR. Kanemura. S. Geneva: World Health organization. & Osinubi. Komatsu. Going Smoke-free: The Medical Case for Clean Air in the Home. (2006). (2006). J.int/publications/2002/9241562099. The Impact of Tobacco Use and Secondhand Smoke on Hospitality Workers. & Eriksen. Department of Health and Human Services. (June..42. Atlanta. Tsubono. Ministry of Health of Lao PDR.pdf Menzies et al. National Institute of Public Health. 2005 Shafey. M. (2005). Centers for Disease Control and Prevention. 296 (14). 2002). Available at URL: http://whqlibdoc. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. In U. Y.. et al.E.

GA: U. updated reprint 2004. WHO. WHO Framework Convention on Tobacco Control.upmc. World Health Organization. Centers for Disease Control and Prevention. Atlanta. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.S. Office on Smoking and Health.10. 2003 University of Pittsburgh Medicine Center. Dolwick & Guindon. (2006). National Center for Chronic Disease Prevention and Health Promotion.com/Pdf/COPD.Shafey. Department of Health and Human Services. (2006). Tobacco Free Initiative. Department of Health and Human Services.S. Technical Document Number WHO/TFI/99.1999 World Health Organization 2003.pdf U. Switzerland. Available at URL: http://patienteducation. Coordinating Center for Health Promotion. 2005. << >> 39 . International Consultation on Environmental Tobacco Smoke (ETS) and Child Health: Consultation Report. COPD: Chronic Obstructive Pulmonary Disease. Geneva.

No Q2. How long have you been working 1. daily tobacco product such as cigarettes. Yes. Have you ever smoked? 1. Do you currently smoke any 1.ANNEXES A. No. Yes 2. occasionally cigars. More than one year Asking for consent to participate in the study Stop to Q2 Stop Stop to Q3 Stop next << >> 40 . Screening Form ID: __ __ __ Q1. Yes. or pipes? 3. Less than one year in this restaurant /office? 2. 2. not at all Q3.

........ 01 A2. Note for enumerators: Fill in the answers in the blank or circle the suitable answers A......... DURING THIS TIME I WOULD LIKE TO SPEAK WITH YOU... Data entry clerk name and number: B..... Result of interview: Name. Mixed enclosed/open air Restaurants 3. ___ ___ Name_________________________ ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___ Completed Refused Other (specify) 1 2 8 >> Q5........ Air conditioned enclosed Restaurants 2..B.. ALL THE INFORMATION WE OBTAINED WILL REMAIN STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL NEVER BE IDENTIFIED.......... Interviewer name and number: Q2. 03 A4. Saisetha... Supervisor name and number: Q3.-02 A3............. Luangprabang A1...... Lao PDR WE ARE FROM THE MINISTRY OF HEALTH AND PROVINCIAL HEALTH DEPARTMENT......... THE INTERVIEW WILL TAKE ABOUT 30 MINUTES..... Respondent's Socio Demographic Characteristics I would like to start by asking you some background questions before asking you questions on 41 ......... Name of Restaurant/Office Q8.. Restaurant/Office information Q7..... Type of ventialtion: Name _______________________ ___ ___ Name _______________________ ___ ___ :_________________________ Code ___ ___ 1. WE ARE WORKING ON A PROJECT CONCERN WITH SMOKING AND HEALTH........... 01 Q1.... BEGIN THE INTERVIEW...... Day/Month/Year of interview: Q4........ Chanthabury . Sisattanack. Open air Restaurants Q9........ May I start now? IF PERMISSION IS GIVEN........... Seating capacity ___ ___ ___ seats C.... I WOULD LIKE TO TALK TO YOU ABOUT THIS............. 04 B1. General Information Province: Vientiane capital city…………………………01 Luangprabang …………………………………06 District: A.................... Data editor Q6...... Vientiane capital city << B............ Sikhottabong............ Data Collection Tool Questionnaire on Exposure to Second Hand Smoke (SHS) among Workers in the Restaurants in Vientiane Capital and Luang Prabang Province.......... Luang Prabang.....

Have you. Female Q12. Others. Yes >> . where did _____________________ you work? For how long? D. Less than primary school 3. No. Never married 2. at any time in the last 2 months. at work place 3. Co-worker 3. Currently married 3. Respiratory symptom/illness of respondent F. High school (or equivalent) completed 6. Male 2. 42 1. specify _______________ E. at home 2. How many hours last week were you exposed to smoke in total (their estimate)? Q22. at any time in the last 2 months. Divorced 5. Higher education Q15. Others. How old are you? (Years) ___ ___ years Q13.1 Wheeze and tightness in the chest Q24. 1. Name of Respondent: Line No: ___ ___ ______________________________ Q11. Household member 2. specify 4. Yes. This information is confidential and will only be used for research purposes. Customer 4. Which of the following best describes the 1. Yes had wheezing or whistling in your chest? 2.<< your health. Before starting this current job. Do you live with a smoker? 1. What is your job title? __________________ Q17. Have you. Who are the smoker 1. What is the highest level of education? 1. Smoking is allowed only in some indoor area 3. No Q25. Smoking is allowed everywhere 4. Secondary school completed 5. Yes. What is your current marital status? 1. Separated 4. Smoking is not allowed in any indoor area smoking policy where you work? 2. Don’t know/unsure F. No formal schooling 2. Number of years working in ___ ___ Months restaurant/office: Q18. Cohabiting Q14. Average number of hours per week ___ ___ hours working in restaurant/office: Q 19. Widowed 6. Primary school completed 4. Smoking policy of the restaurant Q 23. not at all If no Go to Q23 ___ ___ hours Q21. Q10. Exposure to environmental tobacco smoke (ETS) Q20. College/pre-university/University completed 7. Record sex as observed 1. What is your current job? __________________ Q 16.

at any time in the last 2 months. When you are in a dusty part of the house or with animals (for example. dust. No attack of shortness of breath that came on after you stopped exercising? Q29.5 Animals. been 1. Yes Q28.3 Cough and phlegm from the chest Q31. Yes as much as 3 months per year? 2. No Q32b. Yes 2. Yes 2. I never or only rarely have trouble with my breathing 2. No day when you were not doing anything strenuous? 1. No chest first thing in the morning? Q 26. Yes 2. at any time in the last 2 months.4 Breathing Q 35. had an 2. Yes attack of shortness of breath that came on during the 2. feathers Q 36. at any time in the last 2 months. dogs. Have these kinds of symptoms appeared before or 1.2 Shortness of breath Q27. Do you have a cough like this most mornings for 1. No >> 43 . Have you. No Q33. Before F. Yes woken at night by an attack of shortness of breath? 2. Yes woken at night by an attack of coughing? 2. Have these kinds of symptoms appeared before or 1. Do you usually cough first thing in the morning? 1. at any time in the last 2 months. Which of the following statements best check only one: describes your breathing? 1. First time is this the first time? 2. No Q 36b. No Q 30. had an 1.<< woken up with a feeling of tightness in your 2. Have you. No If no go to Q 35 Q32a. Before F. Have these kinds of symptoms appeared 1. Before F. Start to feel short of breath? 1. been 1. Get a feeling of tightness in your chest? 1. Do you usually cough up phlegm from your chest 1. No Q32. cats or horses) or near feathers (including pillows and quilts) do you ever: Q 36a. No If no go to Q 35 Q33a. Yes 2. Have you. My breathing is never quite right F. Have you. First time is this the first time? 2. How many years have you had this cough? 1. Do you have phlegm like this most mornings for 1. I get repeated trouble with my breathing but it always gets completely better 3. Yes as much as 3 months per year? 2. First time before or is this the first time? 2. No Q33b. How many years have you had this phlegm? ___ ___ years Q 34. Yes first thing in the morning? 2.

F. For your last illness mentioned above.6 Asthma Q37. How long has your asthma symptoms _____ ____ months started? Q38. lodging.) 8. 0. Have you had an attack of asthma at any 1. how much did you or your household pay? [Write 0 if the service was free. Yes (including inhalers. aerosols or tablets) for 2. circle “not applicable. DK 8.2 Medicines 8. 1. Thinking about your last visit to the health facilities for your last illness mentioned above. Direct cost Q 42. DK Q. Private pharmacy 5. not have”] A. Public hospital 2. DK B. Others.1 Health care provider’s fees 44 8. If respondent did not have tests or drugs.4 Transport 8. Self medication 8. Yes 2.6 Income lost a) Salary b) others income per day Q 43. DK << >> Q 42.5 Others (Food. No care where did you seek care 1. Are you currently taking any medicines 1. Indirect cost Q 42. end the interview by thanking the respondent for his/her cooperation and go back to Q4 at the first page to record the results of interview G. how much did you or your household pay? [Write 0 if the service was free. No Q39. Drug store 6. Thinking about your last hospital stay for your last illness mentioned above. Health center 4. DK . No asthma? 40. Traditional healer 7. Have you ever had asthma? 1. Private clinic 3. Yes time in the last 2 months? 2. not have”] A. 3 Tests 8. specify_______________ Q 42. etc.1 Health care provider’s fees Q 42. if do not have any of the above mentioned symptoms. circle “not applicable. Direct cost Q 43. DK Q 42. No Q 37 a. ask the following questions 2. Tobacco related diseases management costs Q 41. 42. If respondent did not have tests or drugs. if having one of the above mentioned symptoms.

Q 43.5 Food costs Q 44.6 Income loss for care provider a) Salary ______________________ ______________________ a) Salary _______________ b) Other income b) Other income_________ Q 44. Health care cost paid by: a) Government/hospital _______________________ b) Insurance company _______________________ c) Pocket money _______________________ d) Others. please specify _______________________ Note for enumerator: End the interview by thanking the respondent for his/her cooperation and go back to Q4 at the first page to record the results of interview << >> 45 .7 Income loss for patient a) Salary a) Salary _______________ b) Other income b) Other income_________ Q 45. Indirect cost Q 44.2 Medicines Q 43. 3 Tests B.4 Total costs for traveling to hospital and back home Q 44.

MOH Dr. NIOPH.C. NIOPH. Dalaphone Sithideth. NIOPH. NIOPH. MOH 46 >> . Keonakhone Houamboun. MOH Data entry clerk Dr. Dalaphone Sithideht. Khouanchai Soundavong. MOH Dr. Vilavanh Xayaseng. processing and analysis Dr. The Research Study Team Principal Investigator: Dr. Manithong Vonglokham. Seng-aly Mr. Bounyai Mr. NIOPH. MOH Dr. NIOPH. Vilavanh Xayaseng. MOH Data management: Cleaning. Keonakhone Houamboun. Maniphanh Vongphosy. NIOPH. NIOPH. NIOPH. MOH Data collectors in Luangprabang province: << Ms. Sengchanh Kounnavong. Khouanchai Soundavong. Dalaphone Sithideth. Somchit Ms. NIOPH. NIOPH. ADRA Lao Team members: Data collectors in Vientiane capital city: Dr. Sengchanh Kounnavong. MOH Co-investigator: Dr. NIOPH. MOH Dr. MOH Dr. Sengchanh Kounnavong. MOH Report writing: Dr. MOH Co-ordination: Dr. NIOPH. Phonevilay Supervisor for Luangprabang team: Dr. NIOPH. MOH Dr. MOH Dr. NIOPH. MOH Dr. Manithong Vonglokham. Manithong Vonglokham.

to enhance local capacity through advocacy fellowship program./Fax: +662 241 0082 Website: http://www.. THAILAND Tel. About SEATCA The Southeast Asia Tobacco Control Alliance (SEATCA) works closely with key partners in ASEAN member countries to generate local evidence through research programs. it has supported member countries to ratify and implement the WHO Framework Convention on Tobacco Control (FCTC) Contact persons: Ms.com Southeast Asia Tobacco Control Alliance (SEATCA) Address: Thakolsuk Apartment Room 2B.org Ms.<< ………………………………………………………………………………………………….. Bungon Ritthiphakdee: SEATCA Director Email: bungon@seatca. By adopting a regional policy advocacy mission. Velasco: SEATCA Research Program Manager Email: menchi@seatca. Nakornchaisri Dusit.org ………………………………………………………………………………………………….org.. . menchi55@yahoo. Menchi G. and to be catalyst in policy development through regional forums and in-country networking. Bangkok 10300. 115 Thoddamri Rd.seatca.