Social inequalities in secondhand smoke exposure in children in Spain

Patterns and socioeconomic differences in secondhand exposure to cigarettes, e-cigarettes, and heated tobacco products at home in Hong Kong adolescents

INTRODUCTION

Smoke or aerosols from cigarettes, e-cigarettes (ECs), or heated tobacco products (HTPs) are harmful. Yet, there is little knowledge about the specific patterns of secondhand tobacco exposure by source within household settings and the socioeconomic status (SES) differences in adolescents.

METHODS

We used territory-representative student data from a cross-sectional school-based survey in 2020-2021 to calculate the weighted prevalence of secondhand exposure to cigarettes, e-cigarettes, and HTPs in the past seven days. Parental education and perceived family affluence were used as indicators of socioeconomic status. Generalized linear mixed models were used to analyze associations.

RESULTS

Among 22039 participants, 29.8% reported any secondhand tobacco exposure (SH-Any) at home, primarily from cigarettes (27.4%), followed by e-cigarettes (4.0%) and HTPs (0.9%). Tertiary parental education level was associated with lower SH-Any exposure (Adjusted odds ratio, AOR=0.49; 95% CI: 0.45-0.53, p<0.001), fewer exposure days (β= -0.685, p<0.001), lower exposure to cigarettes (SH-CC) (AOR=0.49; 95% CI: 0.45-0.54, p<0.001) and to e-cigarettes or HTPs (SH-EC/HTP) (AOR=0.57; 95% CI: 0.45-0.71, p<0.001). 'Poor' family affluence was associated with higher exposures [AOR(SH-Any) =1.14; 95% CI: 1.06-1.22, p=0.001; β(days)=0.160, p<0.001; AOR(SH-CC) =1.15; 95% CI: 1.07-1.24, p<0.001], except for SH-EC/HTP exposure, which was higher in students in an affluent family (AOR =1.66; 95% CI: 1.25-2.21, p<0.001). Significant SES differences in SH-EC/HTP exposure were found only in groups with low parental education level. Dose-response relationships were found between lower SH-Any and SH-CC and higher SES categories (p for trend<0.001).

CONCLUSIONS

Adolescents experienced a high prevalence of tobacco smoke exposure at home, primarily from cigarettes. Higher SES was associated with lower tobacco exposure, except for SH-EC/HTP, which was higher among adolescents from affluent families. Additionally, high parental education level was protective against exposure to SH-EC/HTP. Comprehensive control measures to reduce the use of these tobacco products are needed to protect adolescents of diverse socioeconomic backgrounds.

Use of nicotine replacement therapy to reduce children's exposure to second-hand smoke in the home: a qualitative pilot study involving local community pharmacies

BACKGROUND

In Scotland, and in several other countries, most second-hand smoke exposure now occurs in low-income households, where housing constraints and sole parenting often make it harder to create a smoke-free home. This pilot study provided people who smoke with a free 12-week supply of nicotine replacement therapy through local community pharmacies to reduce smoking indoors.

METHODS

Twenty-five parents/caregivers who smoked in the home and cared for children at least weekly were recruited via Facebook during the COVID-19 pandemic. Air quality (PM2.5) was monitored in participant homes for seven days before their first pharmacy visit and 12 weeks later. Qualitative interviews (N = 14) were conducted with 13 participants who completed the study and one who withdrew part-way through. The interviews explored views/experiences of using nicotine replacement therapy to help create a smoke-free home. Another participant took part in a shorter telephone discussion at their request, with detailed notes taken by the interviewer, because of their speech disorder.

RESULTS

Three participants reported smoking outdoors only, one of whom subsequently quit smoking. Six participants reported reduced cigarette consumption by 50% in the home, four reported no (sustained) reduction and one reported increased smoking indoors. Self-reported outcomes were not always consistent with PM2.5 readings. Participants' experiences of accessing nicotine replacement therapy through community pharmacies varied. Some suggested ongoing support to use nicotine replacement products could better assist behavioural change, and that access could be streamlined by posting products to the home. Several suggested that focusing on changing home smoking behaviours using nicotine replacement therapy might facilitate a future quit attempt.

CONCLUSION

Access to free nicotine replacement therapy for temporary use indoors may support some people who smoke to reduce children's exposure to second-hand smoke. Our findings confirm the need to modify the intervention before undertaking a definitive trial to assess the effectiveness of this approach. This work is now underway.

Global burden of lower respiratory infections attributable to secondhand smoke among children under 5 years of age, 2010-2019: a systematic analysis of the global burden of disease study 2019

BACKGROUND

Epidemiological trends of lower respiratory infections (LRIs) attributable to secondhand smoke (SHS) among children under 5 years since smoking bans have been increasingly applied globally remain unclear. Here, we aimed to estimate the spatiotemporal trends of the global, regional, and national burden of LRIs attributable to SHS among children under 5 years old between 2010 and 2019.

METHODS

Data on the deaths, and disability adjusted life years (DALYs) of the disease burden was retrieved from the Global Burden of Disease (GBD) 2019 for 204 countries and territories between 2010 and 2019. The rates per 100,000 population, along with 95% uncertainty intervals, as well as population-attributable fraction (PAF) was presented for each estimate.

RESULTS

In 2019, an estimated 6.94% (3.80-10.12%) of under-5 LRIs deaths were attributable to SHS globally, with an under-5 mortality rate of 7.02 per 100,000, a decrease of 5.77% since 2010. Similarly, 6.95% (3.81-10.13%) of LRIs DALYs were due to SHS among children under 5 years, with a rate in under-5s of 619.36 DALYs per 100,000, and also a 5.77% decrease since 2010. Azerbaijan, Turkmenistan, and Papua New Guinea showed the highest under-5 mortality and DALYs burden rates of LRIs attributable to SHS in 2019. In contrast, the PAF was stagnant over the past ten years and there is even a year-on-year upward trend in South Asia. Nationally, in 2019, Bosnia and Herzegovina, Armenia, and Montenegro showed the highest PAFSHS of LRIs burden among children under 5 years of age. In addition, the burden was heavier in children under 1 year of age and was significantly negatively associated with sociodemographic index.

CONCLUSIONS

SHS remains a risk factor that cannot be ignored for LRIs burden worldwide. Hence, governments and health systems should continue to take steps to reduce SHS pollution among young children to mitigate this burden.

Factors related to caregivers' risk perception of secondhand smoke exposure on children's health

INTRODUCTION

Home is one of the main places for children’s secondhand smoke (SHS) exposure. The implementation of smoke-free rules at home might be influenced by caregivers’ risk perception of SHS exposure. This study aimed to analyze factors related to caregivers’ risk perception of SHS exposure in children.

METHODS

We conducted a cross-sectional telephone survey among a representative sample of 2411 parents or legal guardians of children aged <12 years in Spain in 2016. The main study variable was caregivers’ healthrisk perception of SHS exposure on children. We investigated correlates of risk perception using multivariate Poisson regression models with robust variance.

RESULTS

Overall, 59.6% reported SHS exposure negatively affects children’s health a lot, while 34.1% that it affects quite a bit, and 5.5% and 0.8% a little bit or not at all, respectively. The factors associated with a higher caregivers’ risk perception were high education level (adjusted prevalence ratio, APR=1.11; 95% CI: 1.01–1.24), living in a non-smoking family unit (APR=1.17; 95% CI: 1.07–1.27), in a home with smoke-free rules (APR=1.34; 95% CI: 1.19–1.51), and with girls only (APR=1.14; 95% CI: 1.06–1.22).

CONCLUSIONS

Caregivers’ risk perception of SHS exposure is influenced by social determinants and smoking habits in family units. These findings support the need for interventions with a social equity perspective to reduce children’s SHS exposure.

Social Inequalities in Health Determinants in Spanish Children during the COVID-19 Lockdown

The COVID-19 lockdown was imposed in a context of notable inequalities in the distribution of the social determinants of health. It is possible that the housing conditions in which children and their families experienced the confinement, and the adoption of healthy behaviors, may have followed unequal patterns. The aim was to describe social inequalities in housing conditions and in health-related behaviors among children during the lockdown in Spain. This cross-sectional study was based on data from an online survey collecting information on the child population (3-12 years) living in Spain (n = 10,765). The outcome variables used were several housing conditions and health-related behaviors. The socioeconomic variables used were financial difficulties and parents' educational level. Crude prevalence and prevalence ratios estimated using Poisson models were calculated. During lockdown, children from families with low educational levels and financial difficulties not only tended to live in poor housing conditions, but were also exposed to negative health determinants such as noise and tobacco smoke; they took less physical exercise, had a poorer diet, spent more time in front of screens and had less social contact. A notable social gradient was found in most of the variables analyzed. The results point to the need to incorporate the perspective of equity in the adoption of policies in order to avoid the increase of pre-existing social inequalities in the context of a pandemic.

Secondhand smoke exposure in outdoor children's playgrounds in 11 European countries

INTRODUCTION

Tobacco presence in outdoor children's playgrounds is concerning not only because it leads to secondhand smoke (SHS) exposure, but also cigarette butt pollution and tobacco normalization.

OBJECTIVES

This study aimed to assess SHS exposure in children's playgrounds, according to area-level socioeconomic status (SES), smoke-free regulations, national smoking prevalence, and SHS exposure prevalence in playgrounds (2017-2018).

METHODS

We monitored vapor-phase nicotine concentration and tobacco-related variables in 20 different playgrounds in 11 European countries (n = 220 measurements) from March 2017 to April 2018. Playgrounds were selected according to area-level SES. Data on the number of people smoking, and cigarette butts inside the playground and on playground surroundings (<1 m away) were recorded. Playground smoking bans, the Tobacco Control Scale (TCS) score, national smoking prevalence and SHS exposure prevalence in playgrounds were used to group countries. To determine nicotine presence, we dichotomized concentrations using the limit of quantification as a cut-off point (0.06 μg/m³). Nicotine median concentrations were compared using non-parametric tests, and nicotine presence and tobacco-related observational variables using the Chi-squared test.

RESULTS

Airborne nicotine presence was found in 40.6% of the playgrounds. Median nicotine concentration was <0.06 μg/m³ (Interquartile range: <0.06-0.125) and higher median concentrations were found in more deprived neighborhoods, non-regulated playgrounds, in countries with lower overall TCS scores, higher national smoking prevalence and higher SHS exposure prevalence in playgrounds. Overall, people were smoking in 19.6% of the playgrounds. More than half of playgrounds had cigarette butts visible inside (56.6%) and in the immediate vicinity (74.4%). Presence of butts inside playgrounds was higher in sites from a low area-level SES, in countries with low TCS scores, and greater smoking prevalence and SHS exposure prevalence (p<0.05).

CONCLUSIONS

There is evidence of SHS exposure in children's playgrounds across Europe. These findings confirm the need for smoking bans in playgrounds and better enforcement in those countries with smoking bans in playgrounds.

Social deprivation and secondhand smoke exposure among urban male residents: A nationwide study in China

INTRODUCTION

Social deprivation is a known determinant of health and related behaviors. Many studies have linked socioeconomic factors to secondhand smoke (SHS) exposure. However, no studies have examined the relationship between social deprivation and SHS exposure. This study examined whether contextual social deprivation – variously based on living in a house without a car, that was overcrowded, or had an unemployed member (s) – had an independent association with SHS exposure at both individual and regional levels among Chinese residents.

METHODS

A cross-sectional multistage sampling design was utilized to interview subjects from 6 selected cities in China. A standardized questionnaire selected sociodemographic characteristics, contextual social deprivation and SHS exposure. Multilevel logistic regression models were used to assess the association between social deprivation and SHS exposure.

RESULTS

A total of 5782 valid questionnaires were collected in this study. Among 2930 non-smokers, the SHS exposure prevalence was 21.9% (95% CI: 19.5– 24.30). Multilevel logistic regression showed a negative association between household income, regional GDP, and SHS exposure, respectively, and positive associations between contextual social deprivation and SHS exposure.

CONCLUSIONS

Findings support the central proposition that contextual social deprivation must be factored into SHS exposure messages. Our research underscores the importance of reducing health inequality in controlling SHS exposure.

Respiratory Symptoms and Urinary Cotinine Levels in Pre-school Children Exposed to Environmental Tobacco Smoke

Objective: Preschool children exposed to environmental tobacco smoke (ETS) are at risk of developing adverse respiratory health effects. The present study aimed to investigate the relationship between the effects of cigarette-smoking caregivers on respiratory symptoms and urinary cotinine (UC) levels in children. Methods: A cross-sectional study consisting of 543 children (aged between 5 and 6 years) from 5 kindergartens in central China was conducted using a structured questionnaire. We also analyzed UC levels to investigate the relationship between respiratory symptoms and ETS exposure. We further performed logistic regression analyses to establish the relationship between respiratory symptoms (coughing, rhinorrhea, and sneezing) and UC levels. Results: A total of 71 (13.08%) children had a history of hospital admission with respiratory illnesses including bronchitis and pneumonia over the last 6 months. In addition, 102 (18.78%) children presented coughing symptoms, 114 (20.99%) experienced rhinorrhea and 79 (14.55%) presented sneezing symptoms over the last 6 months. After adjusting the confounders, odds ratio (OR) indicated that the number of cigarettes smoked by a caregiver was associated with coughing (OR = 11.02; 95% CI, 3.72-33.66), rhinorrhea (OR = 41.83; 95% CI, 5.58-313.05) and sneezing (OR = 4.71; 95% CI, 1.33-16.48). Furthermore, UC levels in children with coughing, rhinorrhea and sneezing were significantly higher than in children without respiratory symptoms (P = 0.002, P < 0.001, P < 0.001, respectively). Conclusions: This study reveals that children exposed to ETS have higher levels of UC. Compared with caregiver who non-smoked live with children, smoked cigarettes were highly risk of developing respiratory illnesses in children. Notably, the higher the UC levels the greater the respiratory risk. Our results also signify that UC can be used as an indicator of ETS exposure to inform caregivers of the associated risks, and inform efforts to reduce related effects.

Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European countries

INTRODUCTION

Although smoking restrictions at child-related settings are progressively being adopted, school outdoor entrances are neglected in most smoke-free policies across Europe.

OBJECTIVES

To describe secondhand smoke (SHS) exposure and tobacco-related signs in outdoor entrances of primary schools in Europe according to area-level socioeconomic status (SES), smoke-free policy, national smoking prevalence, and geographical region.

METHODS

In this cross-sectional study we monitored vapor-phase nicotine concentrations at 220 school outdoor entrances in 11 European countries (March 2017-October 2018). To account for nicotine presence, we used the laboratory's limit of quantification of 0.06 μg/m³ as point threshold. We also recorded the presence of smell of smoke, people smoking, cigarette butts, and ashtrays. Half of the schools were in deprived areas. We grouped countries according to their Tobacco Control Scale (TCS) score, smoking prevalence (2017-2018), and United Nations M49 geographical region.

RESULTS

There were detectable levels of nicotine in 45.9% of the outdoor entrances, in 29.1% smell of smoke, in 43.2% people smoking, in 75.0% discarded butts, and in 14.6% ashtrays. Median nicotine concentration was below the laboratory's limit of quantification <0.06 μg/m³ (Interquartile range:<0.06-0.119). We found higher SHS levels in countries with lower TCS scores, higher national smoking prevalence, and in the Southern and Eastern European regions. People smoking were more common in schools from lower area-level SES and in countries with lower TCS scores (p<0.05).

CONCLUSIONS

Smoking at school outdoor entrances is a source of SHS exposure in Europe. These findings support the extension of smoking bans with a clear perimeter to the outdoor entrances of schools.

Exposure to household secondhand smoke among adolescents in Kuwait: Results from two school-based cross-sectional studies

INTRODUCTION

Detrimental effects of secondhand smoke (SHS) exposure are well established; however, data on SHS exposure among adolescents in Kuwait are lacking. Hence, this study sought to estimate the prevalence of household SHS exposure among two samples of adolescents in Kuwait and assess its variation by socioeconomic status and parental education level.

METHODS

Data from two large school-based cross-sectional studies were analyzed. Adolescents attending public middle (n=3864; aged 11–14 years) and high (n=1959; aged 14–19 years) schools throughout Kuwait were enrolled in 2016-2017, and parental self-reported household SHS exposure was ascertained. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (APRs) and 95% confidence intervals (CIs) were estimated.

RESULTS

Overall, 45.8% (1755/3836; 95% CI: 44.2–47.3%) of the enrolled middle school students and 51.6% (998/1936; 95% CI: 49.3–53.8%) of the enrolled high school students were exposed to household SHS. Among middle and high school students, the prevalence of household SHS exposure increased as maternal/paternal education level and family income decreased. Among middle school students, paternal educational attainment of middle school or less compared to bachelor’s degree or higher was associated with 1.60 times (95% CI: 1.44–1.79) higher household SHS exposure. Similarly, in the sample of middle school students, the prevalence of household SHS exposure significantly increased from 35.8% among children from families reporting the highest household income to 50.5% among children from families with the lowest reported household income (p-trend<0.001).

CONCLUSIONS

Household SHS exposure is substantially high among adolescents in Kuwait. Enrolled adolescents from families with low socioeconomic status or with low parental education level have the highest household SHS exposure. These findings highlight the need for national comprehensive tobacco control policies and increasing parental awareness of the impact of SHS exposure on children.