|Year : 2018 | Volume
| Issue : 2 | Page : 128-132
Exposure to second hand smoke and its correlates in Northern State of India
Garima Bhatt1, Sonu Goel2, Suman Mor3, Rakesh Gupta4
1 PhD Scholar, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Additional Professor of Health Management, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Coordinator, Centre for Public Health, Panjab University, Chandigarh, India
4 Chief Chemical Examiner cum Deputy Director, Department of Health and Family Welfare, Government of Punjab, India
|Date of Web Publication||14-Jun-2018|
School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Second-hand smoke (SHS) has enormous adverse health impacts with grave health implications for the next generation. Section 4 of Indian legislation, Cigarettes and Other Tobacco Products Act, prohibits smoking at public places, thus protecting people from SHS. Objective: The objective of present study was to assess the exposure to SHS at home and working areas in Punjab, India. Methods: The present cross-sectional study was conducted from December 2015 to March 2016. A three-stage sampling technique was used for collecting data from three randomly selected districts representing three major regions of Punjab, India. A sample size of 510 individuals was divided equally into an urban and rural area with proportionate sampling on the basis of subsets of age groups and gender. The questionnaire based on tobacco questions for the survey, a subset of key questions from global adult tobacco survey was used. Results: At home, the odds of exposure to SHS exposure was higher (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 0.6–7.3) in urban area, females, low educational status, and nongovernment employee as compared to their counterparts. At workplace, (OR = 3.9 and 95% CI = 1.11–14.3) SHS exposure was higher in rural area, among males, primary and middle education and nongovernment or self-employed occupation. Conclusion: SHS exposure was low in Punjab, India especially in females as compared to other states of the country. The socio-economic disadvantaged groups and people with low education were more likely to experience exposure to SHS at workplace, which should be targeted to reduce tobacco consumption.
Keywords: Cigarette, global adult tobacco survey, India, other tobacco products act, second-hand smoke, tobacco
|How to cite this article:|
Bhatt G, Goel S, Mor S, Gupta R. Exposure to second hand smoke and its correlates in Northern State of India. Indian J Public Health 2018;62:128-32
|How to cite this URL:|
Bhatt G, Goel S, Mor S, Gupta R. Exposure to second hand smoke and its correlates in Northern State of India. Indian J Public Health [serial online] 2018 [cited 2021 Jan 26];62:128-32. Available from: https://www.ijph.in/text.asp?2018/62/2/128/234511
| Introduction|| |
Second-hand smoke (SHS) exposure has adverse effects on men as well as women with grave health implications for the next generation. Globally, this exposure is estimated to have caused 6 million premature deaths, which exceeds the combined death tolls of AIDS, tuberculosis, and malaria. Researchers predict that this figure will increase to 8 million by 2030, and most of these deaths are likely to be concentrated in the developing world. According to the World Bank report, exposure to SHS causes as estimated 5% of the global burden of disease, which is slightly higher than the burden from direct use of tobacco (4%). It also implicates 10.9 million loss of disability-adjusted life years which is about 0.7% of worldwide burden of diseases. The level of exposure to SHS among women and children inside homes and at public places is alarmingly high in the SouthEast Asia region. As per the global adult tobacco survey (GATS) (2009), the proportion of adults exposed to SHS ranged from 29% (India) to 53.5% (Thailand) at public places. Exposure to SHS in workplaces among men is almost two times that of women in Bangladesh, India, and Thailand. According to GATS, India (2009–2010) 43.9% of nonsmoker males and 51.3% of nonsmoker females were exposed to SHS at home whereas 28.1% of nonsmoker males and 18.9% of nonsmoker females were exposed to SHS at workplace.
The Government of India enacted “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 (COTPA)” and Smoke Act Rules (2008) to prohibit the consumption of cigarettes and other tobacco products at public places, thus protecting people from SHS. The State of Punjab in India has been a forerunner in its tobacco control efforts. Since 2010, Punjab has taken various measures and issued notifications for effective implementation of Tobacco Control Act which included authorization of competent persons to act against any person who violates the Act, constitution of state level and district level monitoring committees to monitor its implementation, involvement of stakeholders from different departments, issuing challans (monitory fines), which had led to declaration of Punjab as first large “Tobacco Smoke Free” State of India in 2015. GATS 2009–2010, Punjab reported that 32.1% of adults were exposed to SHS at home (35.3% men and 28.4% women).
However, no study has evaluated the effect of multipronged efforts by the Government of Punjab using a representative sample of adults. The objective of the present study was to assess the exposure to SHS and determine its socio-demographic correlates at home and workplace in Punjab, India.
| Materials and Methods|| |
A cross-sectional descriptive study assessing exposure to SHS was conducted in the population aged 15 years and above in three randomly selected districts of Punjab, India, from December 1, 2015 to March 31, 2016.
The state of Punjab is situated in Northwest India with a total area of 50,362 km 2 and population of 27,704,236 (Census, 2011). The state has 22 districts each under the administrative control of a District Collector. The rural area of a district is subdivided into Tehsils (n = 79), Tehsil into blocks (n = 143), and block into revenue villages (n = 12,278). The urban area comprises of Zila Parishads (n = 22), municipal committees (n = 136) and towns (n = 143). Rural area constitutes approximately 70% of the total population of a district.
Sample size and sampling design
A sample size of 510 respondents aged 15 years and above was obtained based on the prevalence of tobacco users in the state of Punjab as 12% (GATS 2009–2010), 3% absolute error, and 10% nonresponse rate. This sample was equally distributed in these selected districts with each district allocation of 170 households. The sample of a district (n = 170) was equiproportionately distributed to rural and urban areas. The sample size was further divided proportionately on the basis of population into different subsets of age group and gender.
For the selection of households, three-stage stratified sampling design was adopted. In an urban area, the primary sampling units were municipal councils, secondary sampling units were city wards and the tertiary sampling units were households. In rural area, the blocks were the primary sampling units, villages were the secondary sampling units, and households were the tertiary sampling units. Nearly 30% of blocks from all the blocks of selected districts (n = 27; n = 9) and similarly, 30% of municipal councils from all municipal councils (n = 47; n = 15) of chosen districts were selected randomly. From each block, five villages were selected randomly. Using systematic sampling, half of the selected households were randomly assigned to be “male” and half were assigned as “female”. From the male designated households, only males were interviewed, and those designated as female households only females were interviewed. Using KISH selection grid method, one individual was picked from each selected household.
Data collection and analysis
Data collection was done using a standard questionnaire based on tobacco questions for surveys, a subset of key questions from GATS. The content of questionnaire contained demographic information of respondents, smoking behavior, and exposure to SHS. The exposure to SHS is defined as exposure of nonsmoker adult to tobacco smoke at home or workplace over a period of 30 days. The questionnaire was administered by the interviewer. Throughout the survey, data quality and data management measure were applied. The prevalence rates of SHS exposure with respect to sociodemographic variables were calculated. Further, stepwise regression analysis was performed to determine the key sociodemographic factors associated with SHS exposure. Significance was determined at P < 0.05, and statistical analysis was performed in Statistical Package for Social Science (SPSS IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY, IBM Corp.) (Institute Inc.)
A written informed, voluntary consent was obtained from the study participants after ensuring anonymity and confidentiality. The study was approved by the Institute Ethical Committee of Post Graduate Institute of Medical Education and Research, Chandigarh.
| Results|| |
By design, the study participants were selected equiproportionately to gender (equal males and females) and age group. Each district was allocated with 170 households which were proportionately divided to rural and urban areas.
[Table 1] shows the demographic predictors of SHS at home and workplace. At home, the SHS exposure was higher among females (18.8%) as compared to males (10.1%), in urban area (18.6%) as compared to rural settings (12.7%). The no formal schooling education group (23.6%) and nongovernment employee occupation category (22.2%) had the maximum exposure to SHS in comparison to other subgroups in respective categories. During regression analysis, the adult population (25–44 years) had 2.2 times higher odds of being exposed to SHS to as compared to the younger population. The odds of exposure to SHS at home significantly decreased with increase in education status. In addition, the odds of exposure were two times higher (odds ratio [OR] = 2.252, 95% confidence interval [CI] =0.688-7.371) in nongovernment employee as compared to other occupation categories.
|Table 1: Sociodemographic predictors of exposure to second-hand smoke at home and workplace in study population|
Click here to view
At workplace, males (12.1%) were more exposed to SHS as compared to the females (0.7%). In addition, the exposure was lowest in 18–24 years old (5.0%) while 15–17 years old did not have exposure to SHS as compared to other age group categories. Besides, the exposure to SHS at workplace was higher in rural area (6.9%) as compared to an urban area (5.3%). The middle education category education (12.9%) had the highest exposure to SHS at the workplace in contrast to other categories. The retired and unemployed and homemaker categories did not show any exposure to SHS at workplace. The self-employed occupation category (16.6%) had the highest exposure to SHS analogous to other occupation categories. Furthermore, the odds of exposure to SHS were higher in primary and middle education (OR = 1.14, 1.17 and 95% CI = 0.36-3.62 and 0.31–4.32) category and three times higher in nongovernment employee and self-employed occupation (3.9, 3.1 and 95% CI = 1.11–14.3 and 1.62–9.60) as compared to other categories.
| Discussion|| |
The statewide representative survey showed an overall low prevalence of SHS exposure among the adult population of Punjab. The exposure at home was higher in urban area whereas exposure at workplace was higher in rural area. In addition, the exposure to SHS was higher among females at home whereas it was higher among males at the workplace. One of the probable reasons for decrease in overall exposure to SHS among the adult population is the impact of various measures undertaken by the Government of Punjab in effectively enforcing the legislation. Another reason could be low prevalence of smoking in the state because of prohibition of smoking in Sikh religion (dominant religion of Punjab), and its considered “sin” to smoke.
The following are the strengths of the study. First, it was the first statewide representative study conducted after GATS 2009–2010 using similar methodology. Thus, the results are comparable to GATS survey. Second, we comprehensively assessed the predictors of SHS exposure in the study. Thirdy, there was no nonresponse rate. Fourth, we strictly adhered to Strengthening the Reporting of Observational Studies in Epidemiology guidelines while reporting the results of study.
In the present study, the overall SHS exposure was higher at home (14.5%) as compared to the workplace (6.4%). The results of current study are in consonance with 2008–2010 GATS from 14 low- to middle-income countries: Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam GATS in different countries which also reports that SHS exposure at home was high ranging from 17.8% in Mexico to 72.3% in Vietnam, as compared to exposure at workplace. A review article by Mckay et al. also suggested that exposure at home (40%) was more common than exposure at work (29.9%). Further, in our study, the SHS exposure at home was higher among females (18.8%) as compared to males (10.1%). GATS 2009–2010, India which studied similar age group population also reported that 43.9% of nonsmoker males and 51.3% of nonsmoker females were exposed to SHS at home. Contrarily, GATS 2009–2010, Punjab reported that more men (35.3%) were exposed to SHS at home as compared to women (28.4%). A study done in Bangladesh reported that SHS exposure at home was higher in females than in males (48% versus 34%) which is in line with the current study findings. The results of present study are also consistent with findings in China, Korea, and Spain. Singh and Lal had stated that SHS is a gender issue as women are at a greater risk to SHS exposure. The high exposure among females is related to social norms that disapprove of smoking by women. Most women were homemakers and spent most of their time at home, which increased their risk to SHS exposure from male smokers in the household. Since the women had no replacement substitute for being at home and cannot avoid the exposure to SHS, it is a matter of concern. The lack of comprehensive smoke-free policies at home fuels the exposure. Moreover, strict implementation of regulations at home is difficult for any government. In few countries, initiation has been made to reduce smoking in the residential premises over the past few years. The housing units owned by private landlords are providing smoke-free housing units, and local governments have gone further, banning smoking in multifamily residential buildings. These strategies can help out in reducing SHS exposure in the urban housing premises whereas community-based interventions can be used in the rural areas with active involvement and participation of local government and Panchayati Raj Institutions.
In our study, the exposure to SHS at workplace was higher among the males (12.1%) as compared to the females (0.7%). GATS India 2009–2010 report stated that 28.1% of nonsmoker males and 18.9% of nonsmoker females were exposed to SHS at workplace. Further, a cross-country comparison of SHS exposure done by King et al. stated that in every country, workplace SHS exposure was greater among males than females. The underlying reason could be less engagement of women in employment outside the home. The SHS exposure at workplace was high among those who were not employed with any organization or were self-employed. At workplace protective measures are partial, inadequate, and do not provide a comprehensive smoke-free environment. Further, in our study, the exposure to SHS at workplace was more in rural areas as compared to the urban areas. An analysis of GATS report 2010 by Agrawal et al. also stated that the exposure to SHS was seen to be more in workplace of rural areas as compared to the urban area because of more stringent public smoking laws in urban areas than the rural areas, especially in rural farms which do not have a comprehensive monitoring system.
The limitations of the current study can be underreporting of data due to social desirability bias i.e., fear of nonadhering to social norms pertaining to tobacco products and failing to establish temporal association between variables and SHS exposure. Further, the “missed” population like institutionalized population was not taken for the survey, which may under or overestimate the prevalence. Due to small sample size and sampling period of the study, we may not be able to generalize conclusion to entire state or country. It can be explored further in large studies.
| Conclusion|| |
SHS exposure was low in Punjab, India, especially in females, as compared to other states of the country. The socioeconomic disadvantaged groups and people with low education are more likely to experience exposure to SHS at workplace. Therefore, these groups should be targeted to reduce tobacco consumption. The future strategy should focus on mix of behavioral and legislative intervention to further decline the SHS exposure and fulfill the dream of first “Tobacco Free State” of the country.
We would like to thank State Tobacco Control Cell, Punjab for its technical and financial support and PGIMER Chandigarh, which kindly contributed to our search results and provided additional advice.
Financial support and sponsorship
State Tobacco Control Cell, Punjab provided partial financial support for conduction of the study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Travers MJ, Nayak NS, Annigeri VB, Billava NN. Indoor air quality due to secondhand smoke: Signals from selected hospitality locations in rural and urban areas of Bangalore and Dharwad districts in Karnataka, India. Indian J Cancer 2015;52:708-13.
] [Full text]
Xu Z, Han H, Zhuang C, Zhang C, Zhao P, Yao Y, et al.
Tobacco use and exposure to second-hand smoke among urban residents: A Community-based investigation. Int J Environ Res Public Health 2015;12:9799-808.
Centers for Disease Control and Prevention. Current tobacco use and secondhand smoke exposure among women of reproductive age-14 countries, 2008-2010. MMWR Morb Mortal Wkly Rep 2012;61:877-82.
Oberg M, Jaakkola MS, Woodward A, Peruga A, Prüss-Ustün A. Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. Lancet 2011;377:139-46.
Singh RJ, Lal PG. Second-hand smoke: A neglected public health challenge. Indian J Public Health 2011;55:192-8.
] [Full text]
Government of India. Ministry of Health & Family Welfare. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, and Rules Framed There Under 2003. Available from: http://www.hp.gov.in/dhsrhp/COTPA%20Act-2003.pdf
. [Last accessed on 2017 Oct 31].
Government of India. Ministry of Health & Family Welfare. National Tobacco Control Programme, Report by Tobacco Control Cell Punjab. TOBACCO%20PPT%; 2018. Available from: http://www.pbhealth.gov.in/2(b).pdf
. [Last accessed on 2017 Oct 31].
WHO Report on the Global Tobacco Epidemic 2009: Implementing Smoke-Free Environments. Geneva, Switzerland; 2009. Available from: http://www.who.int/tobacco/mpower/en
. [Last accessed on 2017 Oct 31].
McKay AJ, Patel RK, Majeed A. Strategies for tobacco control in India: A systematic review. PLoS One 2015;10:e0122610.
Abdullah AS, Driezen P, Sansone G, Nargis N, Hussain GA, Quah AC, et al.
Correlates of exposure to secondhand smoke (SHS) at home among non-smoking adults in Bangladesh: Findings from the ITC Bangladesh survey. BMC Pulm Med 2014;14:117.
Gu D, Wu X, Reynolds K, Duan X, Xin X, Reynolds RF, et al.
Cigarette smoking and exposure to environmental tobacco smoke in China: The international collaborative study of cardiovascular disease in Asia. Am J Public Health 2004;94:1972-6.
Hughes SC, Corcos IA, Hofstetter CR, Hovell MF, Seo DC, Irvin VL, et al.
Secondhand smoke exposure among nonsmoking adults in Seoul, Korea. Asian Pac J Cancer Prev 2008;9:247-52.
Nebot M, López MJ, Tomás Z, Ariza C, Borrell C, Villalbí JR, et al.
Exposure to environmental tobacco smoke at work and at home: A population based survey. Tob Control 2004;13:95.
King BA, Mirza SA, Babb SD, GATS Collaborating Group. A cross-country comparison of secondhand smoke exposure among adults: Findings from the global adult tobacco survey (GATS). Tob Control 2013;22:e5.
Agrawal D, Aggarwal AK, Goel S. Women exposed to second-hand smoke more at home than at workplace: An analysis of GATS report, India, 2009-10. J Family Med Prim Care 2015;4:293-7.
] [Full text]