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.

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Int. J. Environ. Res. Public Health 2011, 8, 842-860; doi:10.3390/ijerph8030842

International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
Socioeconomic Differences in Exposure to Tobacco Smoke
Pollution (TSP) in Bangladeshi Households with Children:
Findings from the International Tobacco Control (ITC)
Bangladesh Survey
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,
Guangxi, China
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: schitchm@uwaterloo.ca (S.C.H.);
ackquah@uwaterloo.ca (A.C.K.Q.); gfong@uwaterloo.ca (G.T.F.)
4 Propel Centre for Population Health Impact, University of Waterloo, 200 University Avenue West,
Waterloo, Ontario N2L3G1, Canada; E-Mail: prdriezen@uwaterloo.ca
5 Department of Economics, University of Dhaka, Arts Building, Room 4057, Dhaka-1000,
Bangladesh; E-Mail: nigar_nargis@econdu.ac.bd
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: asm.abdullah@graduate.hku.hk;
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
OPEN ACCESS

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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

1. Introduction
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 [1].
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 [5]. These adverse effects of TSP have
led to policies, in many countries, prohibiting smoking in a range of public settings including
workplaces [6], and recreational facilities [7]. 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 [9]. 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

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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 [17]. The high prevalence of smoked tobacco use among adults (23.0%; male: 44.7%,
female: 1.5%) in Bangladesh [17], 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 [17], 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 [18].
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.
2. Methods
2.1. Setting
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. [19] 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.
2.2. Sampling
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

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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.
Sampling Weights
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

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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.
3. Measures
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.