|Ahead of print
Second-hand smoke exposure and its determinants among nonsmoking adolescents residing in slum areas of Bhubaneswar, India
Dheeraj Sharma, Ansuman Panigrahi
Department of Community Medicine, Kalinga Institute of Medical Sciences, Kalinga Institute of Industrial Technology University, Bhubaneswar, Odisha, India
|Date of Submission||28-Mar-2019|
|Date of Decision||27-Feb-2020|
|Date of Acceptance||06-Jun-2020|
|Date of Web Publication||02-Nov-2020|
Department of Community Medicine, Kalinga Institute of Medical Sciences, Kalinga Institute of Industrial Technology University, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Background: Second-hand exposure (SHS) is a significant public health problem and accounts for over 600,000 deaths among non smokers worldwide every year. The study aimed to estimate the prevalence and determinants of SHS exposure among nonsmoking adolescents residing in slum areas of Bhubaneswar, India.
Methods: Multistage cluster random sampling was used to select 259 nonsmoking adolescents from eleven slum areas. We used descriptive statistics to determine the prevalence of SHS exposure and inferential statistics using multivariable logistic regression model to identify factors associated with SHS exposure.
Results: Of the 259 adolescent participants, 67 (25.9%) were exposed to SHS inside home and 97 (37.5%) were exposed outside home. About 47.5% adolescents were exposed to anti-smoking media messages and 22.8% were unaware of the harmful effects of exposure to SHS. SHS exposure inside home was associated with smokeless tobacco use (adjusted odds ratio [aOR]: 10.64; 95% confidence interval (CI): 2.57-43.48), illiteracy of father (aOR: 5.40; 95% CI: 1.51-19.32), non-exposure to antismoking media messages (aOR: 3.53; 95% CI: 1.06-11.72), and absence of knowledge regarding harmful effects of SHS (aOR: 3.72; 95% CI: 1.15-12.05). Also, variables like male gender (aOR: 10.31; 95% CI: 4.50-23.81), smokeless tobacco use (aOR: 2.43; 95% CI: 1.05-5.65), illiteracy of father (aOR: 4.58; 95% CI: 1.23-17.14), and non-exposure to antismoking media messages (aOR: 4.04; 95% CI: 1.49-10.89) had increased SHS exposure outside home.
Conclusion: The findings underscore the urgent need to implement comprehensive smoke-free policies to reduce SHS exposure among slum adolescents.
Keywords: Nonsmoking adolescent, second-hand smoke, slum, smokeless tobacco
Key Message The prevalence of second-hand smoke exposure (SHS) among nonsmoking adolescents of slum areas in Bhubaneswar is high. Effective strategies incorporating the risk factors must be implemented to reduce SHS exposure among slum adolescents.
|How to cite this URL:|
Sharma D, Panigrahi A. Second-hand smoke exposure and its determinants among nonsmoking adolescents residing in slum areas of Bhubaneswar, India. Indian J Cancer [Epub ahead of print] [cited 2020 Nov 26]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=299717
| » Introduction|| |
Second-hand smoke (SHS) consists of the smoke that emanates from the burning end of tobacco products (sidestream smoke) as well as smoke exhaled by a smoker (mainstream smoke). SHS exposure is a significant public health problem and associated with respiratory infections, asthmatic exacerbations, mental health disorders, cardiovascular disorders, sleep disorders, cognitive dysfunction, lung cancer, and other forms of cancer.,,,, It is estimated that SHS exposure accounts for more than 6,00,000 deaths every year among nonsmokers worldwide., There is no known safe level of SHS exposure; even brief exposure can be detrimental to health. In 2003, the World Health Organization Framework convention on Tobacco Control (FCTC) article 8 has established that creation of smoke-free environment can protect nonsmokers from the harmful effects of SHS exposure. The Government of India introduced Cigarette and Other Tobacco Products Act (COTPA) in 2003, brought FCTC into force in 2005 and adopted legislations for prohibiting smoking in public places and workplaces.,
Adolescents are at a higher risk of smoking tobacco due to various factors such as peer pressure, stress, experimentation, or imitative nature. Studies have shown that smokers initiate smoking before 18 years of age. SHS exposure among nonsmoking adolescents adds further to this high-risk group in terms of ill effects as well as increased risk of initiating the use of tobacco. There is a large variation in the prevalence of SHS exposure (16.4%–85.4%) among adolescents in low and middle income countries with a mean prevalence of 55.9%. Furthermore, adolescents living in slum areas constitute a disadvantaged section of the society and are constantly exposed to poverty, illiteracy, ignorance, poor housing, and overcrowding. They live in unhygienic environment with inadequate infrastructure and are deprived of basic necessities of life such as safe drinking water and sanitation facilities.,
To our knowledge, data regarding SHS exposure among adolescents living in slums are scarce in India. With this background, the present study was undertaken to estimate the prevalence of SHS exposure and its determinants among nonsmoking adolescents living in slum areas of Bhubaneswar city.
| » Methods|| |
The present cross-sectional study was carried out during the period from August 2016 to May 2017 among nonsmoking adolescents living in urban slums of Bhubaneswar, the capital city of Odisha situated in eastern part of India. An adolescent was considered as a nonsmoker, if he/she had never smoked before or during the study period. Assuming the prevalence of second-hand smoke exposure among adolescents as 44.2% and absolute precision of 7.5% at 95% confidence interval with a design effect of 1.5, the sample size was calculated as 253. An adolescent was considered to have second-hand smoke exposure if he/she had exposure to the smoke emerging from the burning end of tobacco product or the smoke exhaled by smokers during the past 7 days. Multistage cluster random sampling technique was adopted to select the study population. Bhubaneswar city is divided into three geographical zones: North, South-East, and South-West which comprise of 67 wards and 436 slums. Out of the 3 zones, North zone was randomly selected and 50% of the wards having slum areas in this zone were chosen by simple random sampling technique. From each selected ward, one slum was randomly selected and finally 11 slums were considered as study clusters among which the sample size was equally distributed. In a selected slum, a central area was chosen, and then a particular direction was randomly selected to walk towards the outer part of the slum. In the selected direction, first all the households on the left side and then the households on the right side were considered for the study. The same procedure was repeated till the required number of households in a slum was reached. If more than one study subjects were found in a household, only one was selected by simple random sampling technique. Overall, 259 adolescents aged 10–19 years living in the selected slums for at least 5 years were included in the study as study participants.
The study analyzed the data among adolescents who were currently not smoking tobacco. All the study participants (adolescents) and their parents were informed about the purpose of the study and details of methods involved in the study. The adolescents gave assent and their parents provided consent before initiation of the study. We designed a semi-structured schedule to collect all relevant information. First, we conducted a pilot study involving 15 adolescents to test the schedule and then final schedule was developed after suitable modifications. Using the self-designed, semi-structured schedule, information regarding socio-demographic characteristics such as age, gender, education status, parental education, family type, and socioeconomic status were collected. Also, information regarding smokeless tobacco use, exposure to antismoking media messages and knowledge on harmful effects of SHS among the adolescents was collected. Respondents' exposure to antismoking messages was assessed by asking the question “Have you noticed/heard antismoking messages in newspaper/magazine/television/radio/billboard/any other media?” Their knowledge on harmful effects of SHS was checked by putting questions like (a) Does SHS have harmful effects in non-smoker? and (b) If yes, what are the harmful effects? The two outcome measures were SHS exposure inside home and SHS exposure outside home. Outside home was referred to any outdoor public place (i.e., place/structure/infrastructure accessible by the public) which included shop, hotel, public transport, public park, street, building, cinema hall, health care facility, etc., To know about the SHS exposure inside the home, respondents were asked, “during the past 7 days, does any of your family member or any other person smoke in your home in your presence?” Similarly, to know about SHS exposure outside the home they were asked, “during the past 7 days, does your friend or any other person smoke in your presence in places other than your home?"
The study was approved by the Institutional Ethics Committee of the authors' institution and all the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000.
All the data were analyzed using SPSS version 21.0 and expressed as percentages, odds ratio, and 95% confidence interval. Correlates of SHS exposure inside or outside home were independently assessed using univariable logistic regression. The variables which had P < 0.1 were included in the multivariable logistic regression analysis. To accommodate for the complex sampling design of the study, the sample data were weighted to get a true representation of the population. The base weight was computed considering the first two sampling stages, that is, while selecting the geographical zone and then selecting the wards in that zone. The collinearity between the variables was also checked. P < 0.05 was considered as statistically significant. The exact age (in years and months) of the participants was considered for this study.
| » Results|| |
[Table 1] presents the socio-demographic characteristics, and prevalence estimates of SHS exposure among nonsmoking adolescents. A total of 259 nonsmoking adolescents aged 10–19 years residing in slum areas of Bhubaneswar participated in the study. The mean age of the study participants was 14.73 years (standard deviation = 2.76, range = 10 - 18 years 11 months). More than one third (37.1%) of nonsmoking adolescents were aged >16 years, approximately half (49.4%) were female, 96 (37.1%) were school going adolescents and almost one third (32.8%) were illiterate. Of the 259 nonsmoking adolescents, about one fifth (19.7%) were consuming smokeless tobacco and almost all belonged to poor socioeconomic strata with median per capita monthly income as rupees 2000 (range, 600–6600). One quarter (25.1%) of adolescents had illiterate fathers and nearly one third (33.2%) had illiterate mothers. In almost 10% of adolescents, parents were either not alive or not staying with them. Overall, 25.9% of nonsmoking adolescents were exposed to SHS inside home and 37.5% were exposed outside home during last week. Among the study participants, 123 (47.5%) reported that they were exposed to antismoking media messages before SHS exposure during last month and 77.2% had some knowledge regarding harmful effects of SHS.
|Table 1: Socio-demographic characteristics and exposure to second-hand smoke (SHS) among nonsmoking adolescents of slum areas, Bhubaneswar (n=259)|
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Univariable and multivariable analyses showing association between socio-demographic factors and SHS exposure inside home is shown in [Table 2]. Multivariable analysis revealed that after adjusting for other variables, adolescents using smokeless tobacco (adjusted odds ratio (aOR): 10.64; confidence interval (CI): 2.57–43.48), adolescents who had illiterate fathers (aOR: 5.40; 95% CI: 1.51–19.32), those not exposed to antismoking media messages (aOR: 3.53; 95% CI: 1.06–11.72), and adolescents who had no knowledge regarding harmful effects of SHS (aOR: 3.72; 95% CI: 1.15–12.05) were exposed to SHS more at house.
|Table 2: Socio-demographic factors associated with SHS exposure inside home among nonsmoking adolescents of slum areas, Bhubaneswar (n=259)|
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[Table 3] depicts the association between socio-demographic factors and SHS exposure outside home. Adolescent boys (aOR: 10.31; 95% CI: 4.50–23.81), adolescents using smokeless tobacco (aOR: 2.43; 95% CI: 1.05–5.65), adolescents having illiterate fathers (aOR: 4.58; 95% CI: 1.23–17.14), and adolescents not exposed to antismoking media messges (aOR: 4.04; 95% CI: 1.49–10.89) had increased SHS exposure.
|Table 3: Socio-demographic factors associated with SHS exposure outside home among nonsmoking adolescents of slum areas, Bhubaneswar (n=259)|
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| » Discussion|| |
The present study analyzed the SHS exposure and its correlates among nonsmoking adolescents living in slum areas. We observed that approximately one fourth and one third of adolescents were exposed to SHS inside and outside the home, respectively. It was reported that about 34% of children aged 13–15 years were exposed to SHS at home in Southeast Asian region. In a study conducted among higher secondary school students in Kerala, 23.2% of students were exposed to SHS at home and 56.3% of students at any outdoor place. Raute et al. observed in their study that 16.5% and 39.9% of students were exposed to SHS inside and outside their homes respectively. The differences in SHS exposure rates could be attributed to the variation in the methodologies adopted in the studies. By reducing the prevalence of SHS exposure, the burden of tobacco-related diseases can be prevented later in life and thereby checking the global tobacco epidemic. The WHO FCTC also stated that adoption and implementation of smoke-free policies could protect nonsmokers from the ill effects of SHS.
This study revealed that nonsmoking adolescents who were using smokeless tobacco were at increased risk of exposure at both the settings: inside the home as well as outside the home. The findings are in consistency with the results of earlier studies. This might be due to the reason that those who have already started using tobacco in other forms might ignore the harmful effects of SHS exposure as they gain confidence from their exposure to other forms of tobacco.
It was observed in our study that nonsmoking adolescents with illiterate fathers had approximately 5 times increased relative odds of exposure to SHS both inside and outside home as compared to adolescents who had literate fathers. This is supported by results of other studies. Rakesh et al. showed that the odds of exposure to SHS at home increased about 4.5 times in students having fathers with low education compared to students with fathers having higher education status. It indicates that literate fathers may have a positive influence on their kids in avoiding SHS exposure.
As shown in other study, the current study also showed that exposure to antismoking media messages were inversely associated with the probability of SHS exposure. However, in contrast to our finding Mamudu et al. identified positive relationship between exposure to antismoking media messages and exposure to SHS.
Our study identified that nonsmoking adolescents who had no knowledge about the harmful effects of SHS exposure had increased SHS exposure inside home. Similar result has been reported in earlier studies which suggest that knowledge contributes to increased effort in preventing exposure among vulnerable and socially disadvantaged populations., However, few other studies contradict this finding indicating knowledge was positively associated with the probability of SHS exposure.,,
This study revealed that males had 10.3 times higher odds of being exposed to SHS than their counterparts outside home. This is in consistency with the results of other studies, and may be due to the outgoing nature and increase work culture among males in countries like India. It is highlighted in the study that adolescents with low socioeconomic status were at an increased risk of SHS exposure outside home. This result is concurrent with the findings from other studies.,,, Although younger adolescents were more likely to have SHS exposure than the older ones, we did not find any significant association of age with SHS exposure as observed in earlier studies.,
The study has a few limitations. The study is cross-sectional in nature, and causal inferences cannot be established. We assessed the SHS exposure using self-reported questionnaire responses which is subjected to recall bias and both underreporting and overreporting might be possible. We did not use any objective measurement such as cotinine in saliva, tobacco-specific nitrosamines in urine, or nicotine level in hair which give more accurate results. Also, studies have shown that assessment of SHS exposure on the basis of tobacco biomarkers differ significantly from self-reported exposure., Future studies can be planned incorporating few more aspects such as health related events like recent illnesses in the house, type of house, ventilation etc., which could provide some more insights.
| » Conclusion|| |
In the midst of sparse research on SHS exposure in India, the study provided prevalence and determinants of SHS exposure among nonsmoking adolescents living in slum areas. The study points out that despite of government efforts, tobacco problem still exists in the community. Thus, it is important for all the stakeholders to join hands in increasing adoption and implementation of smoke-free policies in both public and private venues along with a comprehensive ban on advertisement, promotion, sale, and distribution of tobacco products in accordance with the WHO FCTC and COTPA, India. Identifying factors that contribute to nonsmoking slum adolescents' SHS exposure, including literacy status of father, smokeless tobacco use, exposure to antismoking media messages, knowledge regarding harmful effects of SHS exposure can provide guidance to the health professionals and policymakers to develop effective strategies for reducing exposure levels to SHS among nonsmoking adolescents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]