Abstract
Background and aim: Children who are exposed to tobacco smoke (ETS) are at risk for a variety of health issues. There are enough legislative provisions in Indian law to safeguard children from ETS in outdoor settings, but no such specific rules exist to shield them from exposure indoors. This study aimed to examine the trend in under-five children's exposure to indoor tobacco smoke over the course of a decade (from 2005 to 2016) in India.
Materials and methods: Data from the National Family and Health Survey (NFHS) for the years 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4) on under-five children have been taken into consideration in cross-sectional analyses of the Demographic and Health Survey on India. Based on different sociodemographic factors, the propensity of indoor ETS among Indian children has been estimated and compared using both bivariate and multivariate logistic regression models.
Results: The prevalence of indoor ETS among Indian children under the age of five has greatly risen over the past decade, rising from 4.12% to 52.70%. According to the findings, there has been a noticeable increase in every group of kids, regardless of their age, place of residence, geographic location, socioeconomic status, and literacy level of their mothers.
Conclusion: In India, the incidence of indoor ETS among children under five has risen by 13 times in the last 10 years, endangering the country. As a result, the Indian government must prepare to take legislative action to safeguard children by passing laws that forbid smoking inside.
Keywords: exposed to tobacco smoke, tobacco smoke, indian constitution, logistic regression, passive smoking
Introduction
Tobacco use has led to fiscal and human tragedy on a global scale, killing eight million people annually from preventable causes [1,2]. The majority of deaths (85%) involve direct or primary tobacco use, with the remaining 15% occurring in nonsmokers who were subjected to secondhand smoke [2]. There is no safe degree of exposure to tobacco because it has negative physical and psychological effects. This is true of all tobacco products, whether they are used first or second. Significant negative health impacts of secondhand smoke exposure include cardiovascular [3], respiratory [4], renal [5], and physiological issues [6]. Children are more susceptible to the negative effects of cigarette smoke exposure than adults because of their immature immune systems [7]. Children who are exposed to tobacco smoke (ETS) have an increased chance of developing asthma, wheezing, respiratory infections, and sudden infant death syndrome (SIDS) [8-10]. It results in pregnancy problems, mortality, morbidity, and low birth weight in pregnant women [11-13].
India's overall prevalence of tobacco use is 10.38%, and smokeless tobacco use is 21.38%, according to the Global Adult Tobacco Survey (GATS) performed in 2016-2017. The Indian legislative system and Indian government have made decisions in every area, beginning with production, dissemination, and consumption levels, which are necessary to safeguard health and healthcare quality for both main and secondhand smokers [14,15]. The Indian government has started a campaign to raise awareness of the harmful effects of tobacco smoke, which has been found to be very effective [15-17].
In order to control exposure in the outdoor environment and restrict the accessibility of any tobacco-related products, the Indian legislative system has enacted various laws both at the state as well as country levels, such as the Bihar Prohibition of Smoking Act 1954 (updated in 2020), Orissa Prohibition of Smoking Act 1961, Delhi Prohibition of Smoking and Non-smokers Health Protection Act 1996, Himachal Pradesh Prohibition of Smoking and Non-smokers Health Protection Act 1997, Rajasthan Prohibition of Smoking and Non-smokers Health Protection Act 1999, Assam Prohibition of Smoking and Non-smokers Health Protection Act 1999, West Bengal Prohibition of Smoking and Spitting and Protection of Health of Non-smokers and Minors Act, 2001, Andhra Pradesh Prohibition of Smoking Health Protection Act 2002, Tamil Nadu Prohibition of Smoking and Spitting Act 2002, Assam Students and Juvenile Smoking Act 1923, Prohibition of Smoking in Public Places Rules, 2002, etc. Many states such as Uttar Pradesh, Madhya Pradesh, Jharkhand, Chhattisgarh, Uttarakhand, and Maharashtra, have been following the guidelines of country laws of WHO Framework Convention on Tobacco Control (WHO FCTC) 2002, Cigarettes and Other Tobacco Products Act (COTPA) 2003, and WHO Framework Convention on Tobacco Control, 2015 (WHO FCPC).
ETS can take place indoors, outdoors, or both. The amount of exposure children encounter typically varies with their age, such as when they are exposed to their mothers as fetuses [18,19]. When a child is older than three years, both indoor and outdoor environments determine the amount of exposure [20,21]. From the neonatal to infant period, this is primarily dependent on the indoor environment [22,23].
Legislative safeguards in the open air and close to smoking places have received more attention in order to protect children [24], who are more susceptible to suffering negative effects from exposure to tobacco smoke. The purpose of this study was to compare the trend (2005-2016) of indoor tobacco smoke exposure experienced by children under the age of five in India and to map the associations between regional and socioeconomic characteristics with it in order to determine whether the current Indian legislative system on protection from ETS is effective in the indoor environment as well.
Materials and methods
Secondary data from the Demographic and Health Survey (DHS) (https://dhsprogram.com/data/), which offers a nationally representative database containing data on the population, including information on the health, anthropometry, and nutritional status of chosen people, was used to perform cross-sectional studies. All living children who are five years old or younger are included in the study. Children older than five years who are deceased are excluded from the study. The National Family and Health Survey (NFHS) for the years 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4) on Indian children under five years of age have been taken into consideration in the current research.
Outcome variable
The ETS experienced by the child under-five years of age in the indoor environment depends on whether any of the family members is a smoker or any outsider tobacco smoke inside the house. Under both of the situations where a child gets in secondhand smoke in an indoor environment has been considered as exposed to tobacco smoke, and in the notation of dichotomous variable denoted as "1," if not exposed then "0."
Study parameters
Based on different demographic characterizations, it has been studied how to understand the behavioral shift in ETS among Indian children in an indoor setting. The decadal shift in the sociodemographic distribution of exposure over the periods (2005-06 and 2015-16) has been compared, presuming that the current legislative enactments are capable of protecting children from exposure.
Gender and age of the child, residence, region, religion, caste, wealth index, gender of the head of household (HH), mother's age group, education, and profession, and father's education and occupation are some of the demographic factors that have been taken into account. The mother provided the child's age, which is divided into the following five distinct subgroups: 1, 1-2, 2-3, 3-4, and 4-5 years. Depending on their location, geographic zones have been categorized as Central, Eastern, North-Eastern, Northern, Southern, and Western. Hinduism, Islam, Christianity, and other religions are divided into these four categories. There are two categories of residence - urban and country. Based on their wealth index, the family's socioeconomic standing has been divided into the following categories: poorest, poorer, middle-class, richer, and richest. Mothers' ages were voluntarily recorded, and divided into seven distinct subgroups, including 15-19, 20-24,..., and 45-49. There are four categories for a parent's educational background - no formal schooling, primary, secondary, and higher. Five groups have been used to categorize parent occupations - not working (housewife/househusband), professional, agricultural, services, and skilled and unskilled manual-related duties. Two weeks previous to the survey, mothers were questioned about whether their kids had symptoms of acute respiratory infections (ARI). ARI is described as a chest-related cough that is followed by short, rapid, or challenging breathing. Information about the birth weight (in grams) has been classified into three groups viz., <2500 g, ≥2500 g, and not weighed at birth. To estimate and contrast the propensity of indoor ETS and its associated factors among Indian children over the past 10 years, both bivariate and multivariate logistic regression models were used. For all analytical work, SAS University Edition software has been used.
Results
Table 1 presents the sociodemographic variation in the prevalence of exposure to indoor tobacco smoke experienced by under-five Indian children in a decade during 2005-06 to 2015-16, based on NFHS data. A substantial increase from 4.1% to 52.7% has been observed in the prevalence of exposure to indoor tobacco smoke. Based on the sociodemographic characteristics of children and geographical characteristics, obtained results have shown that in a decade significant increment in the prevalence of exposure to indoor tobacco smoke among male children (NFHS-3: 50.09%; NFHS-4: 52.1%), children below two years of age (NFHS-3: 32.72%; NFHS-4: 38.75%), urban residents (NFHS-3: 15.1%; NFHS-4: 25.87%), in all geographical regions (NFHS-3: 65.71%; NFHS-4: 76.34%) except Eastern, all religious groups except Christian, among the middle and above economical classes (NFHS-3: 25.74%; NFHS-4: 50%). At the levels of family composition a decade-significant increment in the prevalence of exposure to indoor tobacco smoke among children has been observed among families having mothers who are in the age group of 20-29 years (NFHS-3: 52.54%; NFHS-4: 71%), literate (NFHS-3: 27.74%; NFHS-4: 66.73%), are either not working (housewife) or engaged in professionals jobs (NFHS-3: 48.63%; NFHS-4: 78.47%), fathers having secondary or higher educational qualifications (NFHS-3: 32.06%; NFHS-4: 64.76%), and are either not working or engaged in professionals or services related jobs (NFHS-3: 17.7%; NFHS-4: 33.52%).
Table 1. Sociodemographic distribution of change in prevalence of exposure to indoor tobacco smoke among under-five Indian children from 2005 to 2016.
| Variable | National family health survey-3 (2005-06) (4.1%) | National family health survey-4 (2015-16) (52.7%) | p-Value | |||
| Total (n=52,868) | Exposed (n=2,178) | Total (n=238,930) | Exposed (n=125,912) | |||
| Child | ||||||
| Sex of child | Male | 27,626 | 1,091 (50.09) | 124,487 | 65,598 (52.1) | <0.0001 |
| Child's age group | <1 year | 10,403 | 364 (16.7) | 46,103 | 24,012 (19.07) | <0.0001 |
| 1-2 years | 10,419 | 349 (16.02) | 47,837 | 24,777 (19.68) | ||
| 2-3 years | 10,383 | 439 (20.16) | 47,394 | 24,838 (19.73) | ||
| 3-4 years | 10,829 | 469 (21.54) | 49,827 | 26,659 (21.17) | ||
| 4-5 years | 10,835 | 557 (25.58) | 47,769 | 25,625 (20.35) | ||
| Demography | ||||||
| Country | India | 52,868 | 2,178 (4.12) | 238,930 | 125,912 (52.70) | <0.0001 |
| Residence | Urban | 13,665 | 329 (15.1) | 67,984 | 32,569 (25.87) | <0.0001 |
| Region | Central | 15,354 | 685 (31.45) | 63,410 | 40,608 (32.25) | <0.0001 |
| Eastern | 13,322 | 747 (34.29) | 60,758 | 29,788 (23.66) | ||
| North-Eastern | 1,998 | 190 (8.73) | 8,440 | 4,560 (3.62) | ||
| Northern | 6,915 | 278 (12.78) | 31,602 | 20,155 (16.01) | ||
| Southern | 12,761 | 187 (8.59) | 43,840 | 19,477 (15.47) | ||
| Western | 2,518 | 91 (4.16) | 30,880 | 11,325 (8.99) | ||
| Religion | Hindu | 41,284 | 1,609 (73.86) | 187,790 | 99,268 (78.84) | <0.0001 |
| Muslim | 9,085 | 476 (21.86) | 39,558 | 20,680 (16.42) | ||
| Christian | 1,058 | 58 (2.66) | 4,970 | 2,794 (2.22) | ||
| Other | 1,441 | 35 (1.62) | 6,613 | 3,170 (2.52) | ||
| Wealth quintile | Poorest | 13,200 | 1,051 (48.25) | 59,384 | 33,847 (26.88) | <0.0001 |
| Poorer | 11,671 | 567 (26.01) | 52,142 | 29,339 (23.3) | ||
| Middle | 10,492 | 306 (14.05) | 47,498 | 25,078 (19.92) | ||
| Richer | 9,684 | 196 (8.98) | 43,911 | 21,465 (17.05) | ||
| Richest | 7,821 | 59 (2.71) | 35,995 | 16,183 (12.85) | ||
| Family | ||||||
| Sex of head of household | Male | 46,949 | 1,900 (87.21) | 20,9673 | 111,582 (88.62) | 0.0395 |
| Mother's age group | 15-19 | 3419 | 77 (3.55) | 6,710 | 3,437 (2.73) | <0.0001 |
| 20-24 | 18,660 | 479 (22) | 76,740 | 40,247 (31.96) | ||
| 25-29 | 17,746 | 665 (30.54) | 93,464 | 49,035 (38.94) | ||
| 30-34 | 8,529 | 499 (22.92) | 41,998 | 22,005 (17.48) | ||
| 35-39 | 3,348 | 294 (13.51) | 15,012 | 8,270 (6.57) | ||
| 40-44 | 947 | 135 (6.18) | 3,921 | 2,261 (1.8) | ||
| 45-49 | 220 | 28 (1.3) | 1,085 | 658 (0.52) | ||
| Mother education | No education | 25,960 | 1,574 (72.26) | 70,615 | 41,894 (33.27) | <0.0001 |
| Primary | 7,401 | 317 (14.57) | 33,232 | 19,155 (15.21) | ||
| Secondary | 16,749 | 270 (12.38) | 109,446 | 53,901 (42.81) | ||
| Higher | 2,756 | 17 (0.79) | 25,637 | 10,963 (8.71) | ||
| Father education | No education | 15,138 | 1,064 (49.13) | 7,107 | 4,330 (19.19) | <0.0001 |
| Primary | 7,812 | 391 (18.06) | 5,957 | 3,571 (15.83) | ||
| Secondary | 23,961 | 629 (29.07) | 22,423 | 11,930 (52.88) | ||
| Higher | 5,353 | 65 (2.99) | 5,827 | 2,681 (11.88) | ||
| Don't know | 484 | 16 (0.75) | 109 | 47 (0.21) | ||
| Mother's occupation | Not working | 33,363 | 1,039 (47.73) | 32,673 | 17,365 (76.92) | <0.0001 |
| Professional | 798 | 20 (0.9) | 762 | 349 (1.55) | ||
| Agricultural | 13,308 | 839 (38.51) | 4,890 | 3,065 (13.58) | ||
| Services | 1,574 | 70 (3.22) | 1,303 | 660 (2.93) | ||
| Skilled and unskilled manual | 3,814 | 210 (9.64) | 1,819 | 1,135 (5.03) | ||
| Father's occupation | Did not work | 547 | 26 (1.19) | 2,266 | 1,208 (5.36) | <0.0001 |
| Professional | 2,939 | 46 (2.13) | 3,112 | 1,397 (6.19) | ||
| Agricultural | 16,233 | 793 (36.45) | 12,216 | 6,967 (30.88) | ||
| Services | 11,044 | 313 (14.38) | 9,850 | 4,957 (21.97) | ||
| Skilled and unskilled manual | 21,989 | 997 (45.86) | 13,979 | 8,030 (35.59) | ||
| ARI in child | Yes | 4,952 | 257 (11.79) | 13,332 | 7,435 (5.90) | <0.0001 |
| Birth weight (in grams) | <2,500 | 3,961 | 102 (4.72) | 33,357 | 17,282 (13.73) | <0.0001 |
| >2,500 | 14,723 | 302 (13.88) | 155,636 | 78,886 (62.65) | ||
| Not weighed | 34,184 | 1,773 (81.40) | 49,937 | 29,745 (23.62) | ||
The decadal change in the determinants of the prevalence of exposure to indoor tobacco smoke among determinants of prevalence has been presented in Tables 2, 3 by using both bivariate and multivariate logistic regression analysis, respectively. The unadjusted analysis of bivariate logistic regression based on NFHS-3 (2005-2006) revealed that child gender, age groups 2-5 years, geographical regions Central, Eastern, and North-Eastern, all religions (highest among Muslims), all economical classes (highest among poorest followed by poorer), mothers of age-groups 25-49 years (highest among 45-49 years), both literate and illiterate mothers (highest among illiterates), working mothers (highest among agricultures), and both literate and illiterate father (highest non-educated) have significant effect on the prevalence of exposure to indoor tobacco smoke among children (Table 2). After a decade (based on NFHS-4 {2015-16}) the results revealed that children of age groups 3-5 years, all geographical regions, all religions (highest among Christian), all economical classes (highest among poorest followed by poorer), families having male head of household (HH), mothers of age-groups 20-49 years (highest among 45-49 years), both literate and illiterate mothers (highest among illiterates), both working and housewife mothers (highest among agricultures), both literate and illiterate father (highest non-educated), father working as agricultural labor or skilled and unskilled manual, have significant effect on the prevalence of exposure to indoor tobacco smoke among children.
Table 2. Unadjusted odds ratio of exposure to indoor tobacco smoke among Indian children under five years of age from 2005 to 2016.
| Variable | Odds ratio unadjusted (95%CI) | ||
| National family health survey-3 (2005-2006) | National family health survey-4 (2015-2016) | ||
| Sex of child (reference: male) | Female | 1.09 (1.00-1.19) | 1.00 (0.98-1.02) |
| Child's age group (reference: <1 year) | 1-2 years | 0.96 (0.82-1.11) | 0.99 (0.96-1.01) |
| 2-3 years | 1.22 (1.06-1.40) | 1.01 (0.99-1.04) | |
| 3-4 years | 1.25 (1.09-1.44) | 1.06 (1.03-1.09) | |
| 4-5 years | 1.50 (1.31-1.71) | 1.06 (1.04-1.09) | |
| Residence (reference: rural) | Urban | 0.50 (0.44-0.56) | 0.76 (0.75-0.78) |
| Region (reference: Western) | Central | 1.25 (1.00-1.57) | 3.08 (2.99-3.16) |
| Eastern | 1.59 (1.27-1.99) | 1.66 (1.61-1.71) | |
| North-Eastern | 2.82 (2.18-3.65) | 2.03 (1.93-2.13) | |
| Northern | 1.12 (0.88-1.43) | 3.04 (2.94-3.14) | |
| Southern | 0.40 (0.31-0.51) | 1.38 (1.34-1.42) | |
| Religion (reference: other) | Hindu | 1.61 (1.15-2.26) | 1.22 (1.16-1.28) |
| Muslim | 2.20 (1.56-3.11) | 1.19 (1.13-1.25) | |
| Christian | 2.30 (1.50-3.53) | 1.39 (1.29-1.50) | |
| Wealth quintile (reference: richest) | Poorest | 11.38 (8.74-14.82) | 1.62 (1.58-1.67) |
| Poorer | 6.71 (5.13-8.79) | 1.58 (1.53-1.62) | |
| Middle | 3.95 (2.99-5.23) | 1.37 (1.33-1.41) | |
| Richer | 2.71 (2.02-3.64) | 1.17 (1.14-1.20) | |
| Sex of head of household (reference: female) | Male | 0.85 (0.75-0.97) | 1.19 (1.16-1.21) |
| Mother's age group (reference: 15-19 years) | 20-24 | 1.14 (0.89-1.45) | 1.05 (1.00-1.10) |
| 25-29 | 1.69 (1.33-2.14) | 1.05 (1.00-1.10) | |
| 30-34 | 2.69 (2.11-3.43) | 1.05 (1.00-1.10) | |
| 35-39 | 4.17 (3.23-5.39) | 1.17 (1.10-1.24) | |
| 40-44 | 7.17 (5.37-9.59) | 1.30 (1.20-1.40) | |
| 45-49 | 6.39 (4.06-10.07) | 1.47 (1.29-1.67) | |
| Mother education (reference: higher) | No education | 10.22 (6.35-16.45) | 1.95 (1.90-2.01) |
| Primary | 7.10 (4.36-11.54) | 1.82 (1.76-1.88) | |
| Secondary | 2.59 (1.59-4.22) | 1.30 (1.26-1.34) | |
| Father education (reference: higher) | No education | 6.21 (4.82-8.00) | 1.95 (1.90-2.01) |
| Primary | 4.31 (3.31-5.62) | 1.82 (1.76-1.88) | |
| Secondary | 2.21 (1.71-2.86) | 1.30 (1.26-1.34) | |
| Don't know | 2.85 (1.64-4.95) | 0.89 (0.61-1.30) | |
| Mother's occupation (reference: professional) | Not working | 1.28 (0.81-2.02) | 1.30 (1.13-1.50) |
| Agricultural | 2.68 (1.70-4.22) | 1.98 (1.70-2.31) | |
| Services | 1.86 (1.12-3.09) | 1.21 (1.01-1.45) | |
| Skilled and unskilled manual | 2.32 (1.45-3.71) | 1.96 (1.65-2.32) | |
| Father's occupation (reference: did not work) | Professional | 0.35 (0.22-0.55) | 0.74 (0.69-0.80) |
| Agricultural | 1.11 (0.76-1.62) | 1.21 (1.16-1.25) | |
| Services | 0.63 (0.43-0.93) | 0.92 (0.89-0.96) | |
| Skilled and unskilled manual | 1.03 (0.71-1.49) | 1.23 (1.19-1.27) | |
| ARI in child (reference: no) | Yes | 1.31 (1.15-1.50) | 1.14 (1.10-1.18) |
| Birth weight (in grams) (reference: ≥2500) | <2500 | 1.27 (1.01-1.59) | 1.05 (1.02-1.07) |
| Not weighed | 2.61 (2.31-2.95) | 1.43 (1.40-1.46) | |
Table 3. Adjusted odds ratio of exposure to indoor tobacco smoke among Indian children under five years of age from 2005 to 2016.
| Variable | Odds ratio adjusted (95% CI) | ||
| National Family Health Survey-3 (2005-06) | National Family Health Survey-4 (2015-16) | ||
| Sex of child (reference: male) | Female | 0.98 (0.91-1.07) | 1.01 (0.99-1.02) |
| Child's age group (reference: <1 year) | 1-2 Years | 0.98 (0.86-1.13) | 1.03 (1.00-1.06) |
| 2-3 Years | 1.14 (1.00-1.30) | 1.03 (1.00-1.06) | |
| 3-4 Years | 1.11 (0.97-1.26) | 1.06 (1.03-1.09) | |
| 4-5 Years | 1.14 (1.00-1.30) | 1.07 (1.04-1.10) | |
| Residence (reference: rural) | Urban | 1.22 (1.10-1.36) | 1.02 (1.00-1.05) |
| Region (reference: Western) | Central | 0.87 (0.68-1.13) | 2.66 (2.57-2.76) |
| Eastern | 1.35 (1.05-1.73) | 1.24 (1.19-1.28) | |
| North-Eastern | 4.72 (3.70-6.01) | 2.39 (2.29-2.49) | |
| Northern | 1.00 (0.77-1.28) | 3.12 (3.01-3.24) | |
| Southern | 0.36 (0.27-0.49) | 1.13 (1.09-1.18) | |
| Religion (reference: other) | Hindu | 1.77 (1.43-2.18) | 1.31 (1.25-1.36) |
| Muslim | 1.75 (1.39-2.19) | 1.24 (1.19-1.30) | |
| Christian | 1.69 (1.37-2.10) | 2.67 (2.53-2.82) | |
| Wealth quintile (reference: richest) | Poorest | 3.61 (2.91-4.48) | 1.30 (1.25-1.35) |
| Poorer | 2.26 (1.84-2.78) | 1.34 (1.29-1.38) | |
| Middle | 2.31 (1.91-2.79) | 1.30 (1.25-1.34) | |
| Richer | 1.83 (1.53-2.19) | 1.19 (1.16-1.23) | |
| Sex of head of household (reference: female) | Male | 0.90 (0.79-1.02) | 1.10 (1.07-1.13) |
| Mother's age group (reference: 15-19) | 20-24 | 1.06 (0.86-1.32) | 1.06 (1.00-1.11) |
| 25-29 | 1.26 (1.02-1.56) | 1.04 (0.99-1.10) | |
| 30-34 | 1.59 (1.27-1.98) | 1.04 (0.98-1.10) | |
| 35-39 | 1.75 (1.38-2.21) | 1.07 (1.00-1.13) | |
| 40-44 | 2.31 (1.75-3.06) | 1.11 (1.03-1.20) | |
| 45-49 | 1.69 (1.09-2.61) | 1.07 (0.95-1.21) | |
| Mother education (reference: higher) | No education | 1.52 (1.15-2.01) | 1.53 (1.48-1.59) |
| Primary | 1.52 (1.15-2.02) | 1.48 (1.42-1.54) | |
| Secondary | 1.33 (1.03-1.72) | 1.27 (1.23-1.31) | |
| Father education (reference: higher) | No education | 1.01 (0.82-1.24) | 0.98 (0.91-1.06) |
| Primary | 1.02 (0.82-1.26) | 1.05 (0.97-1.14) | |
| Secondary | 0.89 (0.74-1.07) | 0.98 (0.92-1.05) | |
| Don't know | 0.86 (0.55-1.35) | 0.67 (0.47-0.97) | |
| Mother's occupation (reference: professional) | Not working | 0.60 (0.45-0.80) | 0.85 (0.73-0.99) |
| Agricultural | 0.78 (0.58-1.05) | 1.12 (0.95-1.32) | |
| Services | 0.92 (0.67-1.26) | 0.96 (0.80-1.15) | |
| Skilled and unskilled manual | 0.64 (0.46-0.88) | 1.06 (0.88-1.26) | |
| Father's occupation (reference: did not work) | Professional | 0.72 (0.52-1.01) | 0.91 (0.83-1.00) |
| Agricultural | 0.78 (0.58-1.04) | 0.99 (0.94-1.05) | |
| Services | 0.72 (0.53-0.96) | 0.97 (0.91-1.03) | |
| Skilled and unskilled manual | 0.79 (0.60-1.06) | 1.12 (1.06-1.19) | |
The adjusted analysis of multivariate logistic regression based on NFHS-3 (2005-2006) has revealed that the determinants having significant effect on the prevalence of exposure to indoor tobacco smoke among children are children of age groups 2-3 and 4-5 years, urban residents, geographical regions Eastern and North-Eastern, all religions (highest among Muslims), all economical classes (highest among poorest followed by poorer), and mothers of age-groups 25-49 years (highest among 45-49 years), and both literate and illiterate mothers (highest among illiterates). The multivariate logistic regression based on NFHS-4 (2015-2016) has revealed that the determinants having significant effect on the prevalence of exposure to indoor tobacco smoke among children are children of age groups 2-5 years, urban residents, all geographical regions, all religions (highest among Muslims), all economical classes (highest among poorest followed by poorer), families having male head of household (HH), mothers of age-groups 20-24 and 35-44 years (highest among 40-44 years), and both literate and illiterate mothers (highest among illiterates).
State-wise decadal changes in the prevalence of exposure to indoor tobacco smoke among children have been depicted in Figure 1. In a decade significant rise in the prevalence has been observed throughout all states and most states reported more than 20% increment.
Figure 1. State-wise distribution of ETS during (A) 2005-2006, (B) 2015-2016, and (C) decadal differences in 2005-2015.
Discussion
Strict laws are needed to control the ETS and safeguard people from different health risks that can result in morbidity and mortality. The government is very worried about this problem because smoke exposure or inhalation has an impact on all forms of production and consumption. Children are severely impacted whenever they come into either direct or indirect touch with tobacco smoke. ETS has an effect on the infant from the time of conception until birth and even after. The kid may encounter this exposure in both indoor and outdoor settings. ETS can occur outdoors for a variety of reasons, but indoors it only happens because of family members or visitors who smoke inside. Taking into account the contributing factors, nations created their legal frameworks so that children's health could be safeguarded from exposure to cigarette smoke both indoors and out.
According to the results of the current research, there has been a significant rise in the prevalence of exposure to indoor tobacco smoke from 4.1% to 52.7%, which should worry both the government and policymakers. All regional areas and religious groups have seen an increase in the frequency of exposure to indoor tobacco smoke over the past 10 years. The prevalence of tobacco smoke exposure is notably high among children, regardless of the socioeconomic classes, age groups of the mothers (highest among 45-49 years), literacy of the mothers (highest among illiterates), employment of the mothers (highest among farmers), and literacy of the fathers (highest non-educated). Additionally, it was noted that when those heads of household were male, their prevalence increased decadally, whereas when they were female, they were discovered in decreasing order.
There are only a few indoor laws in India, including COTPA 2003, the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation and Distribution) (COTP) Rules 2004, the Cable Television Networks Advertisement Act 1955, the Delhi Prohibition of Smoking and Non-smokers Health Protection Act 1996, and the West Bengal Prohibition of Smoking and Smog Act, 2001, which is made to protect non-smokers from ETS in an outdoor environment.
To restrict indoor ETS among children, some countries have enacted specific laws that prohibited tobacco smoking in indoor places, workplaces, and inside public transport, such as in England (The Health Act 2006), the United States of America (Family Smoking Prevention and Tobacco Control Act 2009), Australia (Smoke-Free Environment Act 2000, Smoke-Free Public Places Regulation 2005, and the Smoke-free Environment Regulation 2016), New South Wales (Smoke-Free Environment Act 2000), Ireland (The Public Health {Tobacco} Act 2002), Germany (The Protection of Young Protection Act, 2007), Bhutan (Tobacco Control Act of Bhutan 2010), Brazil (WHO Framework Convention on Tobacco Control {WHOFCTC}, 2006), and Spain (WHOFCTC in 2005).
The present study's limitations include the inability to link the effects of maternal and child exposure to other health parameters, such as the physiological, psychological, and cardiovascular systems, without knowledge of the quantity and duration of tobacco use indoors by family members or anyone else. In addition, more clinical research and pertinent data on mothers and children are needed in order to frame a policy to reduce associated risks and better understand the effect of ETS on child health.
Conclusions
India saw major advancements in maternal care, vaccination coverage, newborn and child mortality rates control, literacy, health services, and other areas over the course of a decade. But since then, the majority of states have seen a marked increase in the frequency of indoor tobacco smoke. Over the past 10 years, the prevalence of indoor ETS among children under the age of five has risen by 13 times in India. The increased decadal shift in indoor ETS prevalence among Indian children under five years puts the nation in peril. The Indian Government must therefore follow suit in light of this dangerous situation and prepare legislative interventions to safeguard children and their childhood by enacting laws against indoor smoking. In other developed countries, strict laws have been passed outlawing tobacco use in indoor settings, such as workplaces and public transportation.
Acknowledgments
The authors would like to express their deepest gratitude and sincerely thank the Demographic and Health Surveys (DHS) program to provide access to data for this study. The authors would like to thank all of the anonymous reviewers and editorial board for their valuable comments and suggestions to improve the quality of this study.
The authors have declared that no competing interests exist.
Human Ethics
Consent was obtained or waived by all participants in this study
Animal Ethics
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
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