Secondhand Smoke Exposure in Primary School Children: A Survey in Dhaka, Bangladesh

The Effect of Adult Smoking Behavior on Children's Exposure to Secondhand Smoke. An Analysis Based on Salivary Cotinine Levels Among Children in Dhaka and Karachi

INTRODUCTION

Exposure to secondhand smoke (SHS) risks children's health. However, biomarkers are rarely used to study SHS exposure among children in low- and middle-income countries.

AIMS AND METHODS

We analyzed cross-sectional data collected between March and November 2022 for a cluster-randomized controlled trial investigating a Smoke-Free Intervention in 2769 children aged 9-15 in 74 schools (34 in Dhaka, Bangladesh, and 40 in Karachi, Pakistan). Children's saliva was tested for the concentration of cotinine-a highly sensitive and specific biomarker for SHS exposure. Based on their reports, children's homes were categorized as Nonsmoking Homes (NSH) when residents were nonsmokers; Smoke-free Homes (SFH) when residents and visitors smoked outdoors only; and Smoke-permitted Homes (SPH) when either residents or visitors smoked indoors. We compared cotinine concentrations across these home types and the two cities using a proportional odds model.

RESULTS

Overall, 95.7% of children (92% in Dhaka; and 99.4% in Karachi) had cotinine levels between 0.1 and 12 ng/mL, indicating SHS exposure. Median cotinine levels were higher in Karachi (0.58 ng/mL, IQR 0.37 to 0.93) than in Dhaka (0.27 ng/mL, IQR 0.16 to 0.49). Median cotinine concentration was also higher among children living in SPH than those in either NSH or SFH; with absolute differences of approximately 0.1-0.3 and 0.05 ng/mL, respectively.

CONCLUSIONS

The level of SHS exposure in Dhaka and Karachi indicates widespread and unrestricted smoking. Smoking restrictions in households and enforcement of smoking bans are urgently needed.

IMPLICATIONS

The high levels of SHS exposure in children living in SFH suggest parental behavior to hide their smoking and/or exposure in private vehicles or public spaces. It is important to advocate for SFH and cars to protect children from SHS exposure. However, these initiatives alone may not be enough. There is a need to enforce smoking bans in enclosed public places and transportation, as well as extend these bans to playgrounds, parks, fairgrounds, and other public spaces that children frequently visit. It is essential to complement smoking restrictions with tobacco cessation advice and support in these settings.

Second Hand Smoke Exposure among Children in Indian Homes: Findings from the Global Adult Tobacco Survey

Children are vulnerable to second hand smoke (SHS) exposure because of limited control over their indoor environment, especially at homes. This study determines the magnitude, patterns and determinants of SHS exposure in the home among children in India. Data collected under the Global Adult Tobacco Survey (GATS) data, a household survey of adults ≥15 years of age during 2016-2017 conducted in India were analyzed to estimate the proportion of children exposed to SHS in their homes. GATS estimates and national census population projections for 2020 were also used to estimate the number of children exposed to SHS in the homes. Nearly half (46.5%) of the children <15 years of age were exposed to SHS in their homes in India which extrapolates to nearly an estimated 170 million. Children living in rural households, north-east and central regions and households with an adult smoker were more likely to be exposed to SHS. SHS exposure among children in home is high in India which calls for adoption of voluntary smoke-free homes initiative and promoting cessation among smokers.

The effects of planned education given to parents on smoking in the home environment and passive exposure of children aged 0-5: A quasi-experimental pre-post intervention study from Turkey

PURPOSE

This study was carried out to determine the effects of planned education given to parents on smoking status at home and on children's passive smoking exposure.

DESIGN AND METHODS

This quasi-experimental study was conducted with the inclusion of 40 parents with at least one child between the ages of 0 and 5 and smoking in their homes, who were registered at a Family Health Center in a city center in the Central Anatolia Region of Turkey, from 1 September 2019 to 30 June 2020. The data of the study were collected using Participant Screening Form, a Personal Information Form, the Fagerstrom Test for Nicotine Dependence, a Smoking Behaviors and Precautions at Home Form, and a Measurement and Follow-up Form. The collected data were analyzed using the SPSS 23.0 package software.

RESULTS

In the follow-ups after the planned smoking cessation training given to the parents, the carbon monoxide measurements at their homes decreased significantly throughout the four follow-ups, the number of parents who presented to the smoking cessation outpatient clinic increased, and the number of smoking parents decreased (p < 0.05).

CONCLUSIONS

It was concluded that the planned education that was given to smoker parents reduced the smoking rates of the parents, lowered the carbon monoxide values measured in their home environments, and thus, it was effective in reducing the passive exposure of their children at the ages of 0 to 5 years to cigarette smoke.

PRACTICE IMPLICATIONS

Parents who are addicted to cigarettes should be encouraged not to smoke at home, and homes should be included in closed environments where smoking is prohibited.

Children Learning About Secondhand Smoke (CLASS III): a protocol for a cluster randomised controlled trial of a school-based smoke-free intervention in Bangladesh and Pakistan

INTRODUCTION

Secondhand smoke (SHS) exposure is a major cause of premature death and disease, especially among children. Children in economically developing countries are particularly affected as smoke-free laws are typically only partially implemented and private homes and cars remain a key source of SHS exposure. Currently, firm conclusions cannot be drawn from the available evidence on the effectiveness of non-legislative interventions designed to protect children from SHS exposure. Following the success of two feasibility studies and a pilot trial, we plan to evaluate a school-based approach to protect children from SHS exposure in Bangladesh and Pakistan-countries with a strong commitment to smoke-free environments but with high levels of SHS exposure in children. We will conduct a two-arm cluster randomised controlled trial in Bangladesh and Pakistan to assess the effectiveness and cost effectiveness of a school-based smoke-free intervention (SFI) in reducing children's exposure to SHS and the frequency and severity of respiratory symptoms.

METHODS AND ANALYSIS

We plan to recruit 68 randomly selected schools from two cities-Dhaka in Bangladesh and Karachi in Pakistan. From each school, we will recruit approximately 40 students in a year (9-12 years old) with a total of 2720 children. Half of the schools will be randomly allocated to the intervention arm receiving SFI and the other half will receive usual education. Salivary cotinine concentration-a highly sensitive and specific biomarker of SHS exposure-is the primary outcome, which will be measured at month 3 post-randomisation. Secondary outcomes will include frequency and severity of respiratory symptoms, healthcare contacts, school absenteeism, smoking uptake and quality of life. Embedded economic and process evaluations will also be conducted.

ETHICS AND DISSEMINATION

The trial has received ethics approval from the Research Governance Committee at the University of York. Approvals have also been obtained from Bangladesh Medical Research Council and Pakistan Health Research Council. If SFI is found effective, we will use a variety of channels to share our findings with both academic and non-academic audiences. We will work with the education departments in Bangladesh and Pakistan and advocate for including SFI within the curriculum.

TRIAL REGISTRATION NUMBER

ISRCTN28878365.

Cigarette Smoke Exposure and Stunting Among Under-five Children in Rural and Poor Families in Indonesia

Cigarette smoke exposure in mothers and children is highly prevalent in Asia, especially among rural and poor families. Second-hand smoke exposure might affect the nutritional status of children. Despite the emerging double burden of malnutrition and the very high prevalence of smoking in Indonesia, few studies have examined the effects of parental smoking on children's nutritional status. This study aims to measure the relationship between family smoking behavior and the occurrence of stunting in children under 5 years. This cross-sectional study used a purposive sampling technique, with 221 households with children aged 0 to 59 months from poor areas in Indonesia. Exposure to cigarette smoke is assessed using The Secondhand Smoke Exposure Scale questionnaire. The outcome measured is child stunting (height-for-age Z-score). The prevalence of stunting was estimated at 145 (65.6%). Children living with smoking parents were counted for 157 (71%), and most smoking exposure comes from fathers 147 (67.4%). The predictors of stunting in children under 5 years were a smoker father with (AOR 1.8; 95% CI 1.281-4.641), both parents are smokers increasing the risk of stunting with (COR 3.591; 95% CI 1.67-3.77), being exposed of smoke for more than 3 hours a day increase the risk of stunted children (COR 2.05; 95% CI 1.214-3.629), and using traditional cigarette or kretek expand the risk of stunting (AOR 3.19; 95% CI 1.139-67.785). The findings demonstrate the negative impact of parental smoking on children's growth, reinforcing the importance of reducing smoking prevalence by imposing a smoke-free home policy in the stunting prevention strategy.

Common assumptions in tobacco control that may not hold true for South-East Asia

Tobacco is a threat to public health in South-East Asia and its control should be a priority. However, many common assumptions about tobacco control may not hold true for the region and can misdirect policy. The substantial health risks associated with smokeless tobacco have been largely misunderstood and neglected. The syndemic association between tuberculosis and tobacco has also been overlooked. Similarly, less attention has been paid to address second-hand smoke exposure of pregnant women to indoor smoking (caused predominantly by men). On the other hand, our poor understanding of the diverse tobacco supply chain has been blocking progress in tobacco control. Finally, the rising popularity of electronic cigarettes has thrown new challenges; many governments, concerned for its youth, have banned such products. We argue for a nuanced approach to tobacco control in South-East Asia. We also encourage a wider debate in public health, where other established assumptions may be hampering progress.

Improving the Healthy Family Index to Prevent Stunting among Children aged 0–59 Months in Indonesia

BACKGROUND: In Indonesia, the prevalence of stunting which is still above the limit set by WHO, requires all parties to be involved in preventing stunting. To overcome this problem, the government is strengthening basic health efforts through the Healthy Indonesia Program with a Family Approach. AIM: This study aims to determine the relationship between the index of healthy families and the incidence of stunting among toddlers. MATERIALS AND METHODS: The design of this study was cross-sectional. The population in this study were all families with children aged 0–59 months who were in the working area of the Korobono Health Center. Based on the preliminary study, the number of children aged 0–59 months was 544 people. The number of sample was 202 selected by simple random sampling. Chi-square tests were used to examine the association between stunting and health family index and other related factors. RESULTS: The prevalence of stunting was 36.1%. Hypothesis test results show a relationship between the index of healthy families and the incidence of stunting (p = 0.008). CONCLUSIONS: Increasing the healthy family index can reduce the risk of stunting in the family. This research is expected to be an input for the public health center to improve the implementation and evaluation of the Healthy Indonesia Program with a Family Approach.

Secondhand Smoke Exposure in Lao People's Democratic Republic: Results From the 2015 National Adult Tobacco Survey

Objectives: Second-hand smoke (SHS) exposure causes >600,000 deaths annually worldwide, however, information regarding SHS exposure in Lao People's Democratic Republic (Lao PRD) is limited; we report SHS exposure prevalence at home, inside workplaces, and indoor public spaces in Lao PDR. Methods: Data were from the 2015 Lao National Adult Tobacco Survey, a nationally representative sample of 7,562 participants aged ≥15 years recruited through a stratified 2-stage cluster sampling approach. Results: 88.3% (83.9% of non-smokers) reported SHS exposure at home and 63.0% (54.0% of non-smokers) at workplaces. Among non-smokers, women had greater exposure at home than men (86.6 vs. 77.0%). Lower education levels were associated with exposure at home or the workplace. 99.2% reported SHS exposure at any public place; specifically for restaurants/food stores 57.7%, government offices 56.2%, public transport 31.6%, and health care facilities 11.7%. Conclusion: SHS exposure at home and workplace in Lao PDR is among the highest in South-East Asia. Comprehensive smoke-free policies at government-owned workplaces and facilities, stricter enforcement of these smoke-free policies, and strategies to encourage smoke-free environments at homes and in public places are urgently needed.

Efficacy and cost-effectiveness of a community-based smoke-free-home intervention with or without indoor-air-quality feedback in Bangladesh (MCLASS II): a three-arm, cluster-randomised, controlled trial

Background

Exposure to second-hand smoke from tobacco is a major contributor to global morbidity and mortality. We aimed to evaluate the efficacy and cost-effectiveness of a community-based smoke-free-home intervention, with or without indoor-air-quality feedback, in reducing second-hand-smoke exposure in homes in Bangladesh.

Methods

We did a three-arm, cluster-randomised, controlled trial in Dhaka, Bangladesh, and randomly assigned (1:1:1) mosques and consenting households from their congregations to a smoke-free-home intervention plus indoor-air-quality feedback, smoke-free-home intervention only, or usual services. Households were eligible if they had at least one resident attending one of the participating mosques, at least one adult resident (age 18 years or older) who smoked cigarettes or other forms of smoked tobacco (eg, bidi, waterpipe) regularly (on at least 25 days per month), and at least one non-smoking resident of any age. The smoke-free-home intervention consisted of weekly health messages delivered within an Islamic discourse by religious leaders at mosques over 12 weeks. Indoor-air-quality feedback comprised providing households with feedback on their indoor air quality measured over 24 h. Households in the usual services group received no intervention. Masking of participants and mosque leaders was not possible. The primary outcome was the 24-h mean household airborne fine particulate matter (<2·5 microns in diameter [PM_2·5]) concentration (a marker of second-hand smoke) at 12 months after randomisation. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). This trial is registered with ISRCTN, 49975452.

Findings

Between April 11 and Aug 2, 2018, we enrolled 1801 households from 45 mosques. 640 households (35·5%) were assigned to the smoke-free-home intervention plus indoor-air-quality feedback group, 560 (31·1%) to the smoke-free-home intervention only group, and 601 (33·4%) to the usual services group. At 12 months, the adjusted mean difference in household mean 24-h PM_2·5 concentration was −1·0 μg/m³ (95% CI −12·8 to 10·9, p=0·88) for the smoke-free-home intervention plus indoor-air-quality feedback group versus the usual services group, 5·0 μg/m³ (–7·9 to 18·0, p=0·45) for the smoke-free-home intervention only group versus the usual services group, and −6·0 μg/m³ (–18·3 to 6·3, p=0·34) for the smoke-free-home intervention plus indoor-air-quality feedback group versus the smoke-free-home intervention only group. The ICER for the smoke-free-home intervention plus indoor-air-quality feedback versus usual services was US$653 per quality-adjusted life-year (QALY) gained, which was more than the upper limit of the Bangladesh willingness-to-pay threshold of $427 per QALY.

Interpretation

The smoke-free-home intervention, with or without indoor-air-quality feedback, was neither effective nor cost-effective in reducing household second-hand-smoke exposure compared with usual services. These interventions are therefore not recommended for Bangladesh.

Funding

Medical Research Council UK.

Translation

For the Bengali translation of the abstract see Supplementary Materials section.

Children Learning About Second-hand Smoke (CLASS II): a mixed methods process evaluation of a school-based intervention

BACKGROUND

Children are vulnerable to the effects of second-hand smoke exposure. Creating smoke-free homes is an effective strategy to limit exposure. We developed a smoke-free intervention (SFI) using children as a catalyst for change and teaching skills to negotiate a smoke-free home. In this paper, we present the process evaluation conducted within a pilot trial.

METHODS

This was a mixed-methods study comprising qualitative interviews and quantitative fidelity assessment of SFI delivery. Interviews in the six intervention schools were conducted with six headteachers and 12 teachers. These explored experiences of delivering the SFI, perceived impact, barriers and facilitators to success, and ideas for improvement and for scaling up. The data were analysed using framework analysis. Delivery of the SFI was observed and fidelity scores calculated.

RESULTS

The SFI was acceptable to headteachers and teachers. Fidelity scores ranged from 27/40 to 37/40. Didactic components were more fully implemented than interactive components. Time to complete the sessions, timing in the school day and school calendar were key challenges. Embedding the SFI into the curriculum was a potential solution.

CONCLUSIONS

These findings provide useful information to finalise the content and delivery and inform the scale-up of the SFI for our definitive trial, which is now underway.

TRIAL REGISTRATION

ISRCTN68690577.

Secondhand Smoking Among Children in Rural Households: A Community Based Cross-Sectional Study in Bangladesh

Objectives

This study aimed to determine the factors associated with reducing exposure to secondhand smoke among children in households of rural Bangladesh.

Methods

A cross-sectional study of 410 smokers and non-smokers, in 6 villages of Munshigonj district was conducted. Data were collected randomly using a self-administrative questionnaire. Differences between variables were assessed using Chi-square or Fisher's exact test (as appropriate). Univariate and multivariate logistic regression models were used to investigate associations. All results were presented as unadjusted and adjusted odds ratios with a 95% confidence interval. The level of statistical significance was reached when p < 0.05.

Results

A smoker in the household was determined to be a risk factor associated with exposure of other household members to secondhand smoke (p < 0.001). Higher education, strict implementation of household smoke-free rules, a higher influence of social norms and culture, as well as moderate knowledge on exposure to secondhand smoke were considered as preventive factors associated with exposure of others in the home to secondhand smoke.

Conclusion

Exposure to secondhand smoke is an extensive and preventable risk factor for children, and reducing exposure to secondhand smoke will have a largely positive effect in the community. An effective public health intervention model may reduce secondhand smoking.

Environmental Tobacco Smoke and Educational Self-Regulation and Achievement in First Grade High School Students

Environmental tobacco smoke, containing many toxic gases, suggests inevitable contact of humans with the damaging factors of cigarettes. On average, approximately 40% of children, 35% of women and 32% of men worldwide are exposed to environmental tobacco smoke. This study aims at investigating the relationship between environmental tobacco smoke in adolescents and their educational self-regulation and achievement. In this study, 770 students aged between 13 and 15 were selected and studied using the multistage sampling method. The tools used in this study consisted of four questionnaires, demographic characteristics, environmental tobacco smoke, educational self-regulation, and educational achievement. The validity and reliability of tools have been approved, and the data were analyzed using SPSS v22. The results indicated a significant inverse relationship between environmental tobacco smoke and students' educational self-regulation and achievement (p-value > 0.001). Given the relationship between exposure to environmental tobacco smoke and educational self-regulation and achievement, it is essential to keep children away from tobacco smoke. Family health and education policy-makers are recommended to design and operate fundamental schemes in order to deal with environmental tobacco smoke.

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): study protocol for a cluster randomised controlled trial of a community-based smoke-free homes intervention, with or without Indoor Air Quality feedback

BACKGROUND

Second-hand smoke (SHS) is a serious health hazard costing 890,000 lives a year globally. Women and children in many economically developing countries are worst affected as smoke-free laws are only partially implemented and homes remain a major source of SHS exposure. There is limited evidence on interventions designed to reduce SHS exposure in homes, especially in community settings. Following a successful pilot, a community-based approach to promote smoke-free homes in Bangladesh, a country with a strong commitment to smoke-free environments but with high levels of SHS exposure, will be evaluated. The study aims to assess the effectiveness and cost-effectiveness of a community-based intervention, Muslims for better Health (M4bH), with or without Indoor Air Quality (IAQ) feedback, in reducing non-smokers' exposure to SHS in the home.

METHODS/DESIGN

Based on behaviour-change theories, M4bH and IAQ feedback are designed to discourage people from smoking indoors. M4bH consists of a set of messages couched within mainstream Islamic discourse, delivered weekly by faith leaders (imams and khatibs) in mosques over 12 weeks (one message each week). The messages address key determinants of current smoking behaviours including lack of knowledge and misconceptions on specific harms associated with SHS exposure. IAQ feedback consists of personalised information on IAQ measured by a particulate matter (PM2.5) monitor within the home. Following adaptation of M4bH and IAQ feedback for the Bangladeshi context, a three-arm cluster randomised controlled trial will be conducted in Dhaka. Forty-five mosques and 1800 households, with at least one smoker and one non-smoker, will be recruited. Mosques will be randomised to: M4bH and IAQ feedback; M4bH alone; or usual services only. The primary outcome is 24-h mean household concentration of indoor fine particulate matter (PM2.5) at 12 months post randomisation. Secondary outcomes are 24-h mean household PM2.5 at 3 months post randomisation, frequency and severity of respiratory symptoms, health care service use and quality of life. A cost-effectiveness analysis and process evaluation will also be conducted.

DISCUSSION

The MCLASS II trial will test the potential of a community-based intervention to reduce second-hand smoke exposure at home and improve lung health among non-smokers in Bangladesh and beyond.

TRIAL REGISTRATION

ISRCTN, ISRCTN49975452 . Registered on 11 January 2018.