Socioeconomic Differences in Exposure to Tobacco Smoke Pollution (TSP) in Bangladeshi Households with Children: Findings from the International Tobacco Control (ITC) Bangladesh Survey
ABSTRACT This study assessed the pattern of exposure to tobacco smoke pollution (TSP; also known as, secondhand smoke) in Bangladeshi households with children and examined the variations in household smoking restrictions and perception of risk for children’s exposure to TSP by socioeconomic status. We interviewed 1,947 respondents from Bangladeshi households with children from the first wave (2009) of the International Tobacco Control (ITC) Bangladesh Survey. 43.5% of the respondents had complete smoking restrictions at home and 39.7% were very or extremely concerned about TSP risk to children’s health. Participants with lower level of education were significantly less likely to be concerned about the risk of TSP exposure to children’s health and less likely to adopt complete smoking restrictions at home. Logistic regression revealed that the predictors of concern for TSP exposure risk were educational attainment of 1 to 8 years (OR = 1.94) or 9 years or more (OR = 4.07) and being a smoker (OR = 0.24). The predictors of having complete household smoking restrictions were: urban residence (OR = 1.64), attaining education of 9 years or more (OR = 1.94), being a smoker (OR = 0.40) and being concerned about TSP exposure risk to children (OR = 3.25). The findings show that a high proportion of adults with children at home smoke tobacco at home and their perceptions of risk about TSP exposure to children’s health were low. These behaviours were more prevalent among rural smokers who were illiterate. There is a need for targeted intervention, customized for low educated public, on TSP risk to children’s health and tobacco control policy with specific focus on smoke-free home.
Article: Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries.[show abstract] [hide abstract]
ABSTRACT: Exposure to second-hand smoke is common in many countries but the magnitude of the problem worldwide is poorly described. We aimed to estimate the worldwide exposure to second-hand smoke and its burden of disease in children and adult non-smokers in 2004. The burden of disease from second-hand smoke was estimated as deaths and disability-adjusted life-years (DALYs) for children and adult non-smokers. The calculations were based on disease-specific relative risk estimates and area-specific estimates of the proportion of people exposed to second-hand smoke, by comparative risk assessment methods, with data from 192 countries during 2004. Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. This exposure was estimated to have caused 379,000 deaths from ischaemic heart disease, 165,000 from lower respiratory infections, 36,900 from asthma, and 21,400 from lung cancer. 603,000 deaths were attributable to second-hand smoke in 2004, which was about 1·0% of worldwide mortality. 47% of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men. DALYs lost because of exposure to second-hand smoke amounted to 10·9 million, which was about 0·7% of total worldwide burden of diseases in DALYs in 2004. 61% of DALYs were in children. The largest disease burdens were from lower respiratory infections in children younger than 5 years (5,939,000), ischaemic heart disease in adults (2,836,000), and asthma in adults (1,246,000) and children (651,000). These estimates of worldwide burden of disease attributable to second-hand smoke suggest that substantial health gains could be made by extending effective public health and clinical interventions to reduce passive smoking worldwide. Swedish National Board of Health and Welfare and Bloomberg Philanthropies.The Lancet 01/2011; 377(9760):139-46. · 38.28 Impact Factor
Article: Parental smoking in childhood and adult obstructive lung disease: results from the European Community Respiratory Health Survey.[show abstract] [hide abstract]
ABSTRACT: Early exposure to parental smoking appears to influence the development of the airways and predispose to respiratory symptoms. A study was undertaken to determine whether the consequences of parental smoking could be traced in adulthood. Information from interviewer-led questionnaires was available for 18 922 subjects aged 20-44 years from random population samples in 37 areas participating in the European Community Respiratory Health Survey. Lung function data were available for 15,901 subjects. In men, father's smoking in childhood was associated with more respiratory symptoms (ORwheeze 1.13 (95% CI 1.00 to 1.28); never smokers: ORwheeze 1.21 (95% CI 0.96 to 1.50)) and there was a dose-dependent association between number of parents smoking and wheeze (one: OR 1.08 (95% CI 0.94 to 1.24); both: OR 1.24 (95% CI 1.05 to 1.47); ptrend = 0.010). A reduced ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) was related to father's smoking (-0.3% (95% CI -0.6 to 0)) and number of parents smoking (ptrend <0.001) among men. In women, mother's smoking was associated with more respiratory symptoms and poorer lung function (ORwheeze 1.15 (95% CI 1.01 to 1.31), never smokers: ORwheeze 1.21 (95% CI 0.98-1.51); FEV1 -24 ml (95% CI -45 to -3); FEV1/FVC ratio -0.6% (95% CI -0.9 to -0.3)). These effects were possibly accounted for by maternal smoking in pregnancy (ORwheeze 1.39 (95% CI 1.17 to 1.65); FEV1 -23 ml (95% CI -52 to 7); FEV1/FVC ratio -0.9% (95% CI -1.3 to -0.4)) as there was no association with paternal smoking among women (interaction by sex, p<0.05). These results were homogeneous across centres. Both intrauterine and environmental exposure to parental tobacco smoking was related to more respiratory symptoms and poorer lung function in adulthood in this multicultural study. The age window of particular vulnerability appeared to differ by sex, postnatal exposure being important only in men and a role for prenatal exposure being more evident in women.Thorax 04/2004; 59(4):295-302. · 6.84 Impact Factor
Article: Workplace smoking policies in the United States: results from a national survey of more than 100,000 workers.[show abstract] [hide abstract]
ABSTRACT: To determine the prevalence of smoking policies in indoor work environments as reported by a nationally representative sample of workers in the United States. Cross-sectional survey of households within the United States. All 50 state and the District of Columbia, 1992-93. Currently employed indoor workers 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey (n = 100,561). The prevalence and restrictiveness of workplace smoking policies as reported by workers currently employed in indoor workplaces in the United States. Most of the indoor workers surveyed (81.6%) reported that their place of work had an official policy that addressed smoking in the workplace; 46.0% reported that their workplace policy did not permit smoking in either the public/common areas--for example, restrooms and cafeterias--or the work areas of the workplace. The reporting of these "smoke-free" policies varied significantly by gender, age, race/ethnicity, smoking status, and occupation of the worker. Although nearly half of all indoor workers in this survey reported that they had a smoke-free policy in their workplace, significant numbers of workers, especially those in blue-collar and service occupations, reported smoke-free rates well below the national average. If implemented, the US Occupational Safety and Health Administration's proposed regulation to require worksites to be smoke-free has the potential to increase significantly the percentage of American workers covered by these policies and to eliminate most of the disparity currently found across occupational groups.Tobacco Control 02/1997; 6(3):199-206. · 3.01 Impact Factor
Int. J. Environ. Res. Public Health 2011, 8, 842-860; doi:10.3390/ijerph8030842
International Journal of
Environmental Research and
Socioeconomic Differences in Exposure to Tobacco Smoke
Pollution (TSP) in Bangladeshi Households with Children:
Findings from the International Tobacco Control (ITC)
Abu S. Abdullah 1,2,*, Sara C. Hitchman 3, Pete Driezen 4, Nigar Nargis 5, Anne C.K. Quah 3
and Geoffrey T. Fong 3,6
1 School of Public Health, Guangxi Medical University, 22 Shuangyong Road, Nanning 530021,
2 Department of Medicine (MISU), Boston University School of Medicine, 801 Massachusetts
Avenue (2nd floor), Boston, MA 02118, USA
3 Department of Psychology, University of Waterloo, 200 University Avenue West, Waterloo,
Ontario N2L3G1, Canada; E-Mails: firstname.lastname@example.org (S.C.H.);
email@example.com (A.C.K.Q.); firstname.lastname@example.org (G.T.F.)
4 Propel Centre for Population Health Impact, University of Waterloo, 200 University Avenue West,
Waterloo, Ontario N2L3G1, Canada; E-Mail: email@example.com
5 Department of Economics, University of Dhaka, Arts Building, Room 4057, Dhaka-1000,
Bangladesh; E-Mail: firstname.lastname@example.org
6 Ontario Institute for Cancer Research, MaRS Centre, South Tower, 101 College Street, Suite 800,
Toronto, Ontario M5G0A3, Canada
* Author to whom correspondence should be addressed; E-Mail: email@example.com;
Tel.: +86-771-5358805; Fax: 86-771-5350642.
Received: 6 February 2011; in revised form: 6 March 2011 / Accepted: 6 March 2011 /
Published: 15 March 2011
Abstract: This study assessed the pattern of exposure to tobacco smoke pollution (TSP;
also known as, secondhand smoke) in Bangladeshi households with children and examined
the variations in household smoking restrictions and perception of risk for children‘s
exposure to TSP by socioeconomic status. We interviewed 1,947 respondents from
Bangladeshi households with children from the first wave (2009) of the International
Tobacco Control (ITC) Bangladesh Survey. 43.5% of the respondents had complete
Int. J. Environ. Res. Public Health 2011, 8
smoking restrictions at home and 39.7% were very or extremely concerned about TSP risk
to children‘s health. Participants with lower level of education were significantly less likely
to be concerned about the risk of TSP exposure to children‘s health and less likely to adopt
complete smoking restrictions at home. Logistic regression revealed that the predictors of
concern for TSP exposure risk were educational attainment of 1 to 8 years (OR = 1.94)
or 9 years or more (OR = 4.07) and being a smoker (OR = 0.24). The predictors of having
complete household smoking restrictions were: urban residence (OR = 1.64), attaining
education of 9 years or more (OR = 1.94), being a smoker (OR = 0.40) and being
concerned about TSP exposure risk to children (OR = 3.25). The findings show that a high
proportion of adults with children at home smoke tobacco at home and their perceptions of
risk about TSP exposure to children‘s health were low. These behaviours were more
prevalent among rural smokers who were illiterate. There is a need for targeted
intervention, customized for low educated public, on TSP risk to children‘s health and
tobacco control policy with specific focus on smoke-free home.
Keywords: tobacco smoke pollution (TSP); second hand smoke (SHS); smoking
restrictions; children; Bangladesh
Exposure to tobacco smoke pollution (TSP), also known as ―second-hand smoke (SHS)‖ exposure
or ―passive smoking‖ is increasingly being recognized as a major public health threat. Worldwide, the
World Health Organization (WHO) estimated that 40% of children were exposed to TSP in 2004. The
estimated attributable deaths due to TSP totaled 603,000, of which 28% were estimated to be children.
Children accounted for 61% of DALYS (Disability Adjusted Life Years) lost worldwide; with the
largest disease burden due to lower respiratory tract infections in children under 5 years of age .
Chronic exposure to TSP in children is associated with an increased risk of a range of adverse
outcomes, including lower respiratory tract infections, wheezing, coughing, middle ear infections and
sudden infant death syndrome [2-4]. Furthermore, childhood TSP exposure decreases adult lung
function even in individuals who never smoked themselves . These adverse effects of TSP have
led to policies, in many countries, prohibiting smoking in a range of public settings including
workplaces , and recreational facilities . Knowledge of and attitudes towards TSP was associated
with supporting smoking restrictions in a number of studies [8-10]. Awareness of the health risks of
TSP was positively associated with support for smoke-free public places among the Chinese
adults [8,10]. Chen et al., found that awareness of the health risks of TSP was positively associated
with support for smoke-free public places among Taiwanese adults . Also, higher education was
significantly associated with the support for smoke-free public places in these studies [8,10,11].
With the widespread establishment of smoke-free workplaces and public venues, the home is
becoming the predominant source of exposure to TSP among children and non-smoking
adults. [1,2,12,13]. Hence, interest has increased in studying the pattern and practices of household
exposure to TSP [14-16]. However, the vast majority of available information concerning household
Int. J. Environ. Res. Public Health 2011, 8
exposure to TSP and measures to reduce exposure comes from studies conducted mostly in developed
or high income countries, and data from developing or low income countries is limited. Understanding
the impact of knowledge and attitudes towards TSP exposure and how this impact might vary as a
function of socioeconomic status (SES) would be useful to guide targeted policy development in low
and middle-income countries (LMICs).
The general objective of the present study was to examine the prevalence of TSP exposure as well
as knowledge and attitudes toward TSP exposure in Bangladesh. With a population of 144.5 million,
Bangladesh is one of the world‘s most densely populated countries, with over 22 million adult
smokers . The high prevalence of smoked tobacco use among adults (23.0%; male: 44.7%,
female: 1.5%) in Bangladesh , means that a large number of children are exposed to TSP at home
and/or in other public venues. Additionally, because there are SES variations in smoking behavior in
Bangladesh , it may be that children from lower SES groups are exposed to TSP more frequently
than children from high SES groups due to variations in household smoking restrictions .
The aim of this study was to assess the pattern of exposure to TSP in Bangladeshi households and
examine the variations in household smoking restrictions and perception of risk for children‘s exposure
to TSP by SES.
The International Tobacco Control (ITC) Bangladesh Survey is a prospective cohort survey of a
nationally representative sample of smokers and non-smokers conducted in all six administrative
divisions of Bangladesh: Barisal, Chittagong, Dhaka, Khulna, Rajshahi, and Sylhet. The target
population of the ITC Bangladesh Survey consists of users and non-users of tobacco who are 15 years
or older. The ITC Bangladesh Survey, as with all ITC Surveys being conducted in 20 countries, was
designed to evaluate the psychosocial and behavioural effects of tobacco control policies in
Bangladesh as well as to understand factors that are related to the natural history of tobacco use over
time.  The ITC Bangladesh Survey was designed as a follow-up study of the 2004–05 WHO Study,
―Impact of Tobacco-related Illnesses in Bangladesh‖, which was conducted soon after Bangladesh‘s
ratification of the Framework Convention on Tobacco Control (FCTC) but before any policy action
had taken place. The ITC Bangladesh Wave 1 Survey data were collected between February and
May 2009. Survey data collected between February and May 2009 was a contribution to the ongoing
surveillance efforts among adults and youth in assessing the impact of the Tobacco Control Act, which
was enacted in 2005 and whose provisions were implemented in 2006, including, enhanced warning
labels, smoke-free legislation, and advertising and promotion restrictions.
The ITC Bangladesh Wave 1 Survey is a nationally representative probability sample of tobacco
users and non-users of tobacco selected through a multi-stage clustered sampling design (sampling
with probability proportional to population size at the levels of district, upazila/thana, village/ward).
A total of 94,485 adults age 15 and older from 31,689 households were enumerated to establish an
Int. J. Environ. Res. Public Health 2011, 8
accurate sampling frame from which survey participants would be drawn. For the national sample,
23 districts out of the 64 districts covering Bangladesh were selected, 20 of them using probability
proportional to population size. Two districts were selected purposively to include tribal populations
(Garo and Chakma) and one district was selected to cover one land port that is used for cross-border
trade of tobacco products. A total of 40 upazilas from the 23 districts, and two villages from each
upazila were selected, again with probability proportional to size. A total of 40 upazilas from
the 23 districts, and two villages from each upazila were selected, again with probability proportional
to size. Thus, a total of 80 villages/wards were selected for the national sample. In addition, six urban
slum areas within the city of Dhaka and its surrounding areas were selected to conduct the survey
among the floating and urban poor population (i.e., slum sample).
A total of 25 households per village were selected based on the SES and smoking status of
household members. Thus at the end of the census, 2,000 households had been selected from 80
villages for the cohort survey. Household members aged 15 years and older were sampled from within
a household to participate in the survey. From households with smokers, all available smokers, and one
non-smoker was randomly selected for interview. From households without smokers, we randomly
selected one non-smoker. Thus the total number of non-smoker respondents was fixed at 25, one from
each sample household. The total number of smoker respondents varied from village to village
depending on the smoking prevalence of that area and the availability of respondents for interview. For
the slum sample, the interviewers started randomly at one end of each slum area and continued
interviewing each household in a row until they met the target of the designated number of households
from that area. The households were enumerated and surveyed at the same visit. The interviewers
selected one non-smoker randomly and all smokers from each household. The stratification of
households based on housing condition was not followed for the slum sample.
For each household enumerated in the census, we have constructed a village-level household weight
which was used to construct a national level household weight. Then, for each household where an
interview was conducted, we constructed a national level household weight, consistent with the
weights for enumerated households. For each individual, an individual weight was then computed
within his/her household. The product of interview household weight and individual within-household
weight was calibrated to sum to assumed population numbers in groups defined by a combination of
geography and demographics.
2.3. Data Collection and Management
A standardized Bengali questionnaire was used for data collection. The survey was also
administered in Garo and Chakma for the tribal population. A total of 5,763 (3,107 smokers
and 2,656 non-smokers) face-to-face interviews were conducted. Of these 5,763 subjects, 1,947 adults
who reported having a child (13 years or younger) living in the household were included in the
analyses for this paper.
Data entry was done in parallel with the field-work. In order to control the quality of the data
collection process a multistage monitoring system was used including unannounced field visits to
Int. J. Environ. Res. Public Health 2011, 8
monitor interviews by the project manager and field coordinator, calling randomly picked households
to verify the information that interviewers filled in the survey form, and cross-checking of all
completed forms by field supervisors daily to ensure that they had been properly completed.
Two data analysts continuously ran routine checks on the data sets, informing the field coordinator
and project manager about any problems that might be present in data reporting and collection. In
consultation with the investigators, the project manager then decided on the best method(s) for
correcting errors and for communicating to all the field staff using a hotline mobile phone network. As
the fieldwork proceeded, the feedback gathered from the already entered data sets helped the field staff
to learn from the past omissions and improve on the data collection process.
Written consent was obtained from those who can read and write; others gave verbal consent.
Details of the measures used in this study are briefly described below. These measures have been
used in prior research studies in other international settings [10,12,20].
Demographics. Respondents‘ demographic information was collected as part of the overall survey,
including, gender, age, residence (rural, urban, slum), marital status, monthly household income, and
education. Information about the number of children 13 years old or younger in the home, and the age
of the youngest child was also collected. Household enumeration forms were completed to assess the
number of adult smokers and non-smokers aged 15 years and older present in each household. See
Table 1 for further details on variable categories used in the analyses.
Smoking Behaviour (smokers only). Respondents were asked about their smoking status, including,
type of tobacco smoked (cigarette, bidi, or, dual user), sticks smoked per day, if they had ever
attempted to quit smoking, and if they attempted to quit in the past year. Cigarette and bidi users all
reported that they smoked at least weekly at the time of surveying.
Tobacco Smoke Pollution Exposure (TSP)—Knowledge and Opinions on Restrictions. Knowledge
of the health consequences of TSP exposure was assessed, along with opinions towards smoking
restrictions. To measure knowledge of the health consequences of TSP exposure, respondents were
asked: ―Based on what you know or believe, does second hand smoking cause…?‖Respondents were
then read a list of diseases. Measures from the list included in the present study were: lung cancer in
non-smokers, and asthma in children. To measure opinions on smoking restrictions, respondents were
asked: ―For each of the following public places, please tell me if you think smoking should not be
allowed in any indoor areas, should be allowed only in some indoor areas, or no rules or restrictions?‖
The list included: hospitals, workplaces, restaurants or tea stalls, public transportation vehicles, and
schools/colleges/universities. See Table 2 for further details on variable categories used in the analyses.
Other Smoking Related Measures. Respondents were also asked, ―Out of your five closest friends,
how many of them are smokers?‖ (0 to 5). To measure knowledge of the addictive nature of tobacco,
respondents were asked: ―Please tell me whether you strongly agree, agree, neither agree nor disagree,
disagree, or disagree strongly with the following statement. The statement read: Smoking is addictive.