Indoor Air Quality and Smoking Control in Healthcare Environments in Northern China

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors:

This work investigated the particulate matter pollution and smoking behaviors in the consulting-room and ward in a hospital in northern China, highlighting the important influence of smoking activities from the medical staffs and patients. The satisfaction on smoking behavior was assessed via questionnaire surveys and some useful suggestions are given for smoking control in indoor environment at a hospital. The manuscript can be significantly improved before it is considered for being accepted. Specifically, the title did not adequately reflect the manuscript. There is lack of comprehensively summarization on the indoor air quality, in particular the particulate matter and nicotine concentrations in indoor environment in literature. The results obtained in this study need to compare with those found in previous studies. Some quantitative analyses are required on the smoking behavior in the hospital, e.g., the frequency, proportion, temporal variation. In addition, some of the sentences were not written in scientific style and the English language requires further improvement by native English speakers. The quality of the figures (in particular Figure 5 and Figure 7) is also need to further improve. Detailed revision suggestions and comments can be found from the notes and marks in the attached PDF file. Overall, major revisions are required before further assessment.

Comments for author File: Comments.pdf

Author Response

Please see the attachment。

Author Response File: Author Response.docx

Reviewer 2 Report

The reviewed work evaluates air quality indicators in different spaces of a hospital, and collects qualitative information on attitudes and opinions of professionals and users.

Providing a contamination-free environment is an outstanding public health objective, especially important in the case of vulnerable populations such as users of health services, which justifies the interest of studies such as the one reviewed.

In my opinion, the authors should clarify some aspects of their manuscript:

1) The last paragraph of the introduction should clearly state the objectives of the study. In the manuscript, this paragraph seems aimed at justifying the hospital's policies in relation to air quality, posing a priori the difficulty of prohibiting smoking in the center.

2) What procedure was followed exactly to recruit the people who responded to the questionnaire and the professional interviews? To what extent do they represent the group of patients and hospital professionals? What is the size of the population of users and professionals that these samples should represent? What biases could have been produced by the procedure used?

3) The authors take for granted the opinions of some participants in the sense of considering the use of tobacco as a form of decompression, positively assessing the maintenance of spaces where smoking is allowed, or considering the ban on smoking in the hospital "imperfect".  These considerations contradict the overwhelming evidence on the impact of environmental smoke exposure on health (regardless of whether the smoke is perceived as annoying or not), the efficacy that tobacco control policies have shown internationally, or the addictive effect of nicotine. It is very important that the authors review the content of the discussion and the conclusions based on this evidence.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

This is an interesting study of indoor air quality in a Chinese hospital. The reference to tobacco control in the title is somewhat circumstantial in that there are other indoor air pollutants besides tobacco smoke that are of concern.

The study aim is "to investigate indoor air quality in healthcare environments" and "propose solutions". Both are worthy objectives. However, I have concerns about the first aim and the second.

First, the study involves only one hospital. Its findings cannot be generalised to all 'healthcare environments'. Rephrasing the aim as 'to investigate indoor air quality in a large general hospital in Northern China' would be more accurate because the setting is relevant to the air quality issues.

Second, the solutions largely relate to strategies ostensibly for reducing the risk to patients from the second-hand and third-hand smoke of staff members who persisted in smoking in the hospital or proximate to it such that their smoke entered the building. Broader outdoor air quality issues that determine much indoor air quality are overlooked. The solutions are not aligned with best practices for smoke-free healthcare facilities, nor is there any evidence presented to support the acceptance of smoking as a de-stressing technique for staff, nor of smoking rooms as a way of tackling smoking in buildings.

The study abstract should include results with actual data presented. The conclusion that smoking should be managed, not forbidden, as noted above, does not align with good practice nor scientific evidence about the effectiveness of ventilation and smoking rooms for tackling second-hand smoke. (See for example: Repace and Lowrey 1985 New York State J of Med 85:381-3.)

The background and methods are mostly well done. There is a very long sentence that needs revision (line 102-107). There are some issues with english language that need to be attended to eg line 82 'crowds' should be 'groups'; line 92 'were good choice' should be 'were a good choice'. 

The authors used four data collection methods and these are well described. Line 153-154 states that the smoking behaviours of medical staff in offices were 'indicated' -suggest use 'found to be one of the more important contributors...'

The results are well documented and described in detail. Line 239 'month' should be 'mouth'.

The discussion highlights two main sources of indoor air pollution: outdoor air pollution, and smoking. Lines 312-325 appear to support smoking as a 'decompression' (stress-relief) strategy for busy medical staff despite this assertion being unsupported by evidence this is in fact correct. Furthermore , there is no evidence that additional ventilation methods such as smoking rooms help. Indeed, smoking rooms are not effective asd a solution and also visibly undermine smokefree messaging in the very facility that should be supporting health, including among medical staff, and supporting smokers to quit using evidence-based effective techniques (such as nicotine replacement treatment and counselling).

Line 343 'crowd' should be 'group'

The conclusion (lines 357-360) that a balance should be found between tobacco control and the satisfaction of medical staff smokers is unacceptable in healthcare settings, for the reasons I have already outlined. Smoking kills, even in small concentrations, and smoking is a cause of occupational disease, a cost to individuals, colleagues, patients and hospitals and society  - and a treatable disorder.

Line 371. Third hand smoke is incorrectly defined: it is the smoke embedded in furnishings, clothing, etc that can leach out. The smoke exhaled by smokers is second hand smoke.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

This revision responds well to the comments and is much improved on all the key areas of concern. 

Author Response

Point 1: This revision responds well to the comments and is much improved on all the key areas of concern.

Response 1: Many thanks for your comments.

 

Point 2: "English language and style are fine/minor spell check required"

Response 2: The manuscript has been revised again. Spell check is conducted, and all slips and errors are corrected.