Prevalence and sociodemographic correlates of second-hand smoke exposure among nonsmoking adults in district Rohtak, Haryana

ABSTRACT

Background:

Second-hand smoke (SHS) accounts for 0.9 million deaths and 24 million disability adjusted life years annually. SHS exposure has been associated to a wide range of diseases thus far, with the majority of studies focused on the link between SHS exposure and the development of cardiovascular disorders or lung cancer.

Objectives:

The objectives of the study were to estimate the prevalence of SHS exposure and identify its sociodemographic correlates among nonsmokers and also to assess knowledge and attitude toward SHS among nonsmokers in adults.

Methodology:

The study included 400 subjects where 200 each was recruited from rural and urban areas. Twenty were selected randomly using survey registers from each of the ten subcentes from rural areas. From urban areas, 66 subjects were selected randomly from three urban health posts. Data collection included information that was recorded on a predesigned, pretested semistructured interview schedule.

Results:

The prevalence of second-hand exposure at home was found to be 44% and 54% in urban and rural areas, respectively, whereas at workplaces, it was found to be 50.5% and 60.9%. It also reflected SHS exposure at home is significantly associated with study area, age category, occupation, and education, while SHS exposure at workplaces is significantly associated with occupation, education, and socioeconomic scale.

Conclusion:

The study highlights a high prevalence of second-hand smoke exposure among nonsmokers in both rural and urban areas, particularly at home and workplaces. Sociodemographic factors such as age, occupation, education, and socioeconomic status significantly influence SHS exposure. These findings underscore the need for targeted public health interventions, including awareness campaigns and policy enforcement, to reduce SHS exposure and protect nonsmokers from its harmful effects.

Introduction

Second-hand smoke (SHS), also known as environmental tobacco smoke (ETS) in the literature, is made up of side stream smoke discharged into the environment by burning cigarettes and other tobacco products in between puffs, as well as mainstream smoke exhaled by the smoker. Second-hand tobacco smoke is also referred to as ETS. Third-hand smoke occurs when tobacco smoke leaves residual nicotine and other chemicals on indoor surfaces, skin, fur, and furniture, even after the air has cleared.[1]

Side-stream smoke releases five times as much carbon monoxide and twice as much tar into the air as compared to what enters a smoker’s lungs.[2] Compared to smoke that smokers actively inhale into their lungs, SHS actually contains higher quantities of numerous carcinogens.[3] The SHS concentration is determined by the quantity of tobacco products smoked over time, the enclosed space’s volume, the ventilation rate, other processes that may remove pollutants, and individual-related features.[4] Chronic SHS exposure is estimated to be 80–90% as hazardous as chronic active smoking, with a significant dose–response connection.[5,6]

Second-hand smoke (SHS) accounts for 0.9 million deaths and 24 million disability adjusted life years (DALYs) annually. SHS exposure has been associated to a wide range of diseases thus far, with the majority of studies focused on the link between SHS exposure and the development of cardiovascular disorders or lung cancer. SHS increases the risk of heart disease and lung cancer by 25–30% and 20–30%, respectively, in people who are exposed to it.[7] Furthermore, exposure to SHS may actually encourage adolescent smokers to continue smoking and increase the likelihood of experimental smokers becoming established or become daily smokers.[8,9] Among nonsmokers, SHS exposure increases susceptibility to smoking and the likelihood of smoking initiation.[10,11] Since there is no such thing as a safe level of exposure to tobacco smoke, the World Health Organisation recommend taking appropriate precautions to protect people from SHS.[12]

Though there is general awareness among public about ill effects of SHS exposure through legislation of COTPA Act, strict implementation of various rules and penalization are not done at the ground level. In a state like Haryana, hookah usage has been seen in many houses and is used as a customary practice irrespective of their social and economic status. There are many literature studies about the prevalence of usage of hookah and other tobacco products, but studies about SHS exposure are very limited. The objectives of the study were to estimate the prevalence of SHS exposure and identify its sociodemographic correlates among nonsmokers. Also, this study assessed knowledge and attitude toward SHS among nonsmokers in adults of age 18–60 years in district Rohtak, Haryana.

Material and Methods

After obtaining ethical clearance, this descriptive cross-sectional study was conducted in rural and urban field practice areas attached to the Department of Community Medicine, Pt. BD Sharma PGIMS, Rohtak. The study was conducted over a period of 12 months (2022–2023) from the date of commencement. Nonsmoking adults in the age group of 18–60 years who were willing to participate and residing in the study area for more than 6 months were included. Study subjects who were using any form of tobacco including smokeless tobacco and those who were severely ill or have severe mental illness were excluded from the study. Sample size was calculated taking prevalence as 51% second hand exposed in home in urban areas from Global Adult Tobacco Survey (GATS) conducted in Haryana 2016–2017[13] and taking the absolute error to be 5%. The sample size came out to be 384 subjects, rounded off to 400. The study includes 400 subjects where 200 each were recruited from rural and urban areas.

Figure 1 shows the flowchart of methodology. Community health centre (CHC) Chiri is the rural field practice area attached to the Department of Community Medicine. CHC Chiri has two primary health centre (PHC)s, namely, PHC Chiri and PHC Samargopalpur. There are 18 subcenters under CHC Chiri. Ten subcenters were selected randomly by the lottery method out of 18 subcenters under CHC Chiri. Twenty subjects were selected from each subcenter. For identifying the household in a subcenter area, the survey register of the worker was used and a list of households was prepared using simple random sampling, which were randomly generated by the computer. From the selected household, one adult was selected by simple random sampling technique after briefing about the study out of all available adults. If the selected study subject did not meet the inclusion/exclusion criteria or if the selected house was found closed, the house next to selected household was considered. In this way, a total of 200 subjects were enrolled from rural areas. Subjects were visited at their home along with multi purpose health worker-female (MPHW-F) or accredited social health activist (ASHA) workers of the areas. In urban areas, subjects were randomly enrolled from all three urban health posts, which is the urban field practice area attached to the Department of Community Medicine. Sixty-seven subjects were enrolled randomly from each of these three urban health posts till the sample size of 200 was reached in urban areas. The rest of the process was similar to that followed in the rural area.

Figure 1.

Flowchart of Methodology

A questionnaire was designed for the study which consisted of information regarding sociodemographic profiles of study subjects and information regarding SHS exposure of the study participants from the GATS, which was administered to the study subjects. It is the standardized tool and is freely available in the public domain. The questionnaire also consisted of information about knowledge and attitude toward SHS exposure which were in the form of Yes/No questions and Likert scale, respectively.

The investigator met the subject to explain the purpose of the study with patient information sheets, and a written consent was sought to seek their cooperation before the study. Help of health workers/ASHA/Anganwadi workers at the time of the interview was taken. The purpose of the study was explained in the study subject’s vernacular language in detail. The confidentiality of the information obtained was maintained. Data were collected, compiled, and entered in the MS Excel sheet. Analysis was carried out using MS Excel with appropriate statistical tests wherever applicable.

Results

From Table 1, it was seen that in urban areas, smoking was allowed in home for 44% study subjects, whereas in rural areas, smoking was allowed in home for 54% study subjects. Smoking was never allowed in home for 44% study subjects in urban areas, whereas in rural areas, smoking was never allowed in home for 28.5% study subjects.

Table 1.

Distribution of subjects according to whether smoking is allowed inside the home (n=400)

Is smoking allowed inside the home	Urban (n=200)		Rural (n=200)
	Frequency	Percentage	Frequency	Percentage
Yes	88	44	108	54
Not allowed but exceptions	24	12	35	17.5
Never allowed	88	44	57	28.5
Total	200	100	200	100

People who reported yes when they were asked if smoking was allowed inside home were considered exposed to SHS at home. Figure 2 shows that the prevalence of second-hand exposure at home was found to be 44% and 54% in urban and rural areas, respectively.

Figure 2.

Prevalence of SHS Exposure

People who reported yes when they were asked if anyone smokes in indoor areas where they work in the past 30 days were considered exposed to SHS at workplace. Figure 2 shows that the prevalence of second-hand exposure at workplace was found to be 50.5% and 60.9% in urban and rural areas, respectively.

Subjects who answered yes or not allowed but with exceptions when they were asked if smoking was allowed inside home were asked this question. Table 2 shows that in urban areas, 57.2% and 3.6% of the SHS exposed were exposed on a daily and weekly basis, respectively. On the other hand, in rural areas, it was 60.1% and 22.4%, respectively.

Table 2.

Distribution of subjects according to how often anyone smokes inside the home (n=255)

How often does anyone smoke inside home	Urban (n=112)		Rural (n=143)
	Frequency	Percentage	Frequency	Percentage
Daily	64	57.2	86	60.1
Weekly	4	3.6	32	22.4
Monthly	0	0	6	4.2
Less than monthly	24	21.4	16	11.2
Never	20	17.8	3	2.1
Total	112	100	143	100

The present study collected data on exposure to SHS during 30 days prior to the interview at six different categories of public places: 1) government building/Government office, 2) healthcare facility, 3) restaurant/public eating places, 4) public transportation, 5) night club/bar, and 6) university buildings. Figure 3 shows that among those who visited the public places, 45.8% of them were exposed to SHS in government offices or buildings, 18.6% of them were exposed to SHS in health care facilities, 39.8% of them were exposed to SHS in restaurants, 84% of them were exposed to SHS in night clubs/bars, 50.8% of them were exposed to SHS during public transportation, and 26.2% of them were exposed to SHS in university buildings.

Figure 3.

Distribution of subjects who reported exposure to SHS at public places

Table 3 depicts that association of second-hand exposure at home was statistically significant with study area (P < 0.05), gender (P < 0.005), age category (P < 0.05), occupation (P < 0.005), and education (P < 0.005), whereas second-hand exposure at home was not found statistically significant with socioeconomic status according to BG Prasad Scale (P > 0.05).

Table 3.

Association of second-hand exposure at home with various demographic predictors (n=400)

Demographic Predictors	Second-Hand Exposure at Home		Total	Association
	Yes	No
Study Area				χ2=4.002
Urban	88 (44%)	112 (56%)	200	df=1
Rural	108 (54%)	92 (46%)	200	P=0.045
Gender				χ2=8.424
Male	111 (43.5%)	144 (56.5%)	255	df=1
Female	85 (58.6%)	60 (41.4%)	145	P=0.004
Age categories
18-30	83 (57.6%)	61 (42.4%)	144	χ2=7.951
31-40	43 (46.2%)	50 (53.8%)	93	df=3
41-50	31 (47.7%)	34 (52.3%)	65	P=0.047
51-60	39 (39.8%)	59 (60.2%)	98
Occupation
Homemaker	81 (70.4%)	34 (29.6%)	115	χ2=98.484
Farmer	45 (73.8%)	16 (26.2%)	61	df=8
Laborer	35 (61.4%)	22 (38.6%)	57	P=0.000
Government Job	6 (30%)	14 (70%)	20
Private Job	2 (6.9%)	27 (93.1%)	29
Business	11 (22.9%)	37 (77.1%)	48
Unemployed	4 (50%)	4 (50%)	8
Student	10 (17.9%)	46 (82.1%)	56
Retired	2 (33.3%)	4 (66.7%)	6
Education
Illiterate	30 (62.5%)	18 (37.5%)	48	χ2=42.369
Primary	71 (69.6%)	31 (30.4%)	102	df=5
Middle	38 (48.7%)	40 (51.3%)	78	P=0.000
Secondary	29 (35.8%)	52 (64.2%)	81
Graduate	28 (34.1%)	54 (64.9%)	82
Postgraduate	0 (0%)	9 (100%)	9
Socio-Economic Status
Upper Class	14 (33.3%)	28 (66.7%)	42	χ2=8.787
Upper Middle	46 (45.1%)	56 (54.9%)	102	df=4
Middle	45 (48.9%)	47 (51.1%)	92	P=0.067
Lower Middle	77 (57.5%)	57 (42.5%)	134
Lower	14 (48.3%)	16 (51.7%)	30

Table 4 shows that association of second-hand exposure at workplace was statistically significant with occupation (P < 0.005), education (P < 0.005), and socioeconomic status (P < 0.005) according to BG Prasad Scale, whereas second-hand exposure at home was not found statistically significant with study area, gender, and age category (P > 0.05).

Table 4.

Association of second-hand exposure at workplace with various demographic predictors (n=400)

Demographic Predictors	Second-Hand Exposure at Workplace		Total	Association
	Yes	No
Study Area				χ2=2.032
Urban	50 (50.5%)	49 (49.5%)	99	df=1
Rural	53 (60.9%)	34 (39.1%)	87	P=0.154
Age categories
18-30	51 (54.8%)	42 (45.2%)	93	χ2=0.371
31-40	25 (58.1%)	18 (41.9%)	43	df=3
41-50	13 (52%)	12 (48%)	25	P=0.946
51-60	14 (56%)	11 (44%)	25
Occupation
Farmer	26 (76.5%)	8 (23.5%)	34	χ2=59.874
Laborer	33 (94.3%)	2 (5.7%)	35	df=5
Government Job	6 (30%)	14 (70%)	20	P=0.000
Private Job	9 (30%)	21 (70%)	30
Business	17 (77.3%)	5 (22.7%)	22
Student	12 (26.7%)	33 (73.3%)	45
Education
Illiterate	15 (78.9%)	4 (21.1%)	19	χ2=17.213
Primary	30 (71.4%)	12 (28.6%)	42	df=5
Middle	22 (50%)	22 (50%)	44	P=0.004
Secondary	22 (51.2%)	21 (48.8%)	43
Graduate	14 (41.1%)	20 (58.9%)	34
Postgraduate	0 (0%)	4 (100%)	4
Socioeconomic Status			13
Upper Class	8 (61.5%)	5 (38.4%)		χ2=19.636
Upper Middle	16 (32%)	34 (68%)	50	df=4
Middle	31 (63.3%)	18 (36.7%)	49	P=0.001
Lower Middle	43 (70.5%)	18 (29.5%)	61
Lower	5 (38.5%)	8 (61.5%)	13

Table 5 depicts that 91.5% of the study participants were aware that breathing smoke from other people’s cigarette is harmful to one’s health, 79% knew SHS contains substances known to be toxic, and 69% were aware that asthmatic children living with smoker’s home are more likely to have asthma attacks. Almost half of the population were not aware SHS increases the risk of developing lung cancer and heart diseases. But the majority of the participants (80%) did not know that maternal exposure to SHS during pregnancy can cause low birthweight.

Table 5.

Distribution of the study population based on responses of knowledgerelated questions about SHS exposure (n=400)

Questions	Yes	No
Breathing smoke from other people’s cigarette is harmful to one’s health	366 (91.5%)	34 (8.5%)
Secondhand smoke contains substances known to be toxic	316 (79%)	84 (21%)
If one smokes at his home, one’s spouse has a higher risk of developing lung cancer	238 (59.5%)	162 (40.5%)
Risk of having heart diseases increases when exposed to second-hand smoke	148 (37%)	252 (63%)
Maternal exposure to second-hand smoke during pregnancy causes low birthweight	80 (20%)	320 (80%)
Asthmatic children living with smoker’s home are more likely to have asthma attacks	276 (69%)	124 (31%)

Table 6 depicts that more than 80% of the study population expressed that parents have no right to smoke around children and all cigarette advertisements should be banned, while 90% expressed their thoughts that banning smoking in public places will protect the health of nonsmokers.

Table 6.

Distribution of the study population based on responses of attituderelated questions about SHS exposure (n=400)

Questions	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree
Let visitors smoke in my house	27.5%	25.75%	14.5%	26.5%	5.5%
Parents have no right to smoke around children	5.25%	4.5%	5.5%	35.5%	49.25%
Banning smoking in public places will protect the health of nonsmokers	1%	1.5%	7.25%	39.5%	50.75%
All cigarette advertisements should be banned	1.5%	6%	8.5%	41.75%	42.25%
I do not chat with people while they are smoking	5.5%	20.75%	24.25%	28%	21.75%
I ask people to put their cigarettes out when they are talking to me	8.75%	20.75%	21%	29.5%	20%

On the other hand, when exploring the participants’ attitudes toward SHS exposure, 53.25% of the participants expressed that they will not let their “visitors” smoke in their house. However, this percentage became lower as 49.5% of participants expressed that they would ask “people” around them to put out their cigarettes and 49.75% of participants expressed that they would not chat with people while they are smoking.

Discussion

The present study was conducted to find out the prevalence of SHS exposure among nonsmokers in adults and identify various sociodemographic correlates of SHS exposure. This study assessed knowledge and attitude among study participants about SHS exposure.

The prevalence of second-hand exposure at home was found to be 44% and 54% in urban and rural areas, respectively. Similar trends were seen with GATS 2 India[13] conducted in 2016–17, where 58.1% of nonsmokers were exposed to SHS at home in Haryana, whereas among the whole of India, only 35% of the nonsmokers were exposed to SHS at home. Abdullah AS et al. (2014, Bangladesh)[14] reported that 43% of their study participants were exposed to SHS at home. In contrast to our study, in GATS 1 India[15] conducted in 2009–10, 70.2% of nonsmokers were exposed to SHS at home in Haryana. Some of the possible explanations can be the state’s consistently rising literacy rates and the public’s growing awareness of the harmful consequences of SHS. Bhatt G et al. (2018)[16] conducted a cross-sectional study in Punjab and reported only 14% of their study participants were exposed to SHS at home.

In the present study, the prevalence of second-hand exposure at workplace was found to be 50.5% and 60.9% in urban and rural areas, respectively. This was in accordance with GATS 2 India[13] conducted in 2016–17 where 52.9% were exposed to SHS at home in Haryana. In contrast to our study, in GATS 1 India[15] conducted in 2009–10, 42.7% were exposed to SHS at home in Haryana. Bhatt G et al.[16] (2018, Punjab) conducted a cross-sectional study in Punjab and reported only 12.1% of their study participants were exposed to SHS at workplace. In another study, Sein A et al. (2012, Myanmar)[17] conducted a cross-sectional study in Myanmar and reported 63.6% of their study participants were exposed to SHS at home. This pattern in our study may be due to an increase in smoking at workplace after the stricter enforcement of smoking ban at public places. There is also a seemingly increasing trend among offices, especially corporate offices, reasoned to have a designated smoking area within the buildings. The exposure to SHS was seen to be more in workplaces of rural areas as compared to the urban areas because of more stringent public smoking laws in urban areas than in the rural areas, especially in rural farms which do not have a comprehensive monitoring system.

In the present study, it is found out that among those who visited the public places, 45.8% of them were exposed to SHS in government offices or buildings, 18.6% of them were exposed to SHS in health care facilities, 39.8% of them were exposed to SHS in restaurants, 84% of them were exposed to SHS in night clubs/bars, 50.8% of them were exposed to SHS during public transportation, and 26.2% of them were exposed to SHS in university buildings. In contrast to our study, GATS 2 India[13] conducted in 2016–17 reported lower exposure of SHS among all adults in their survey in public places, 10.5% were exposed to SHS in Government buildings, 11.9% were exposed to SHS in health care facilities, 6% were exposed to SHS in restaurants, 25.4% were exposed to SHS during public transportation, and 1.9% were exposed to SHS in night clubs/bars in Haryana. This high prevalence of SHS exposure in the public could be due to poor implementation of the smoke-free law in our area. Poor compliance to smoke-free law has been noticed in restaurants/eateries in previous studies from India (Kumar et al. 2014; Khaiwal et al. 2016).[18,19]

From the present study, it is understood that though study participants were aware that SHS exposure is harmful and contains substances known to be toxic, the knowledge about exact ill effects caused by SHS like risk of developing lung cancer and heart diseases was really lacking. Also, knowledge about risk of pregnant women having harmful effects when exposed to SHS is alarmingly low. Regarding attitude toward SHS exposure, the participants in the present study exhibited favorable attitude toward parents having no right to smoke around children, banning of cigarette advertisements, and smoking in public places. The majority of them felt helpless in restraining visitors from smoking, and smoking was allowed at some or all parts of their homes. In a state like Haryana, this is expected to be prominent as families are often more culturally conservative and more traditional to ask visitors to put out the cigarette or shy away from a conversation when the visitor starts to smoke.

Limitations

In this study, SHS exposure was defined as a proxy measure constructed from self-reported home smoking rules and might thus not always reflect real exposure to SHS at home. Also, we could not assess the cumulative effect of SHS exposure. For example, we did not evaluate that how many years the participants were exposed to SHS.

Conclusion and Recommendations

The present study reflected high prevalence of SHS exposure at home, workplace, and public places among nonsmoking adults of District Rohtak, Haryana. It also reflected SHS exposure at home is significantly associated with study area, age category, occupation, and education, while SHS exposure at workplace is significantly associated with occupation, education, and socioeconomic scale. There is no safe amount of SHS exposure. The home is the main place many children and adults breathe in SHS. Though study participants were aware that SHS exposure is harmful and contains substances known to be toxic, the knowledge about exact ill effects caused by SHS was really lacking. Therefore, education to promote smoke-free homes can be part of campaigns implemented to build public support for smoke-free legislation, which have included messages informing smokers, particularly as parents, of the impact of SHS exposure in the home and have urged them to make their homes smoke-free. The role of the National Tobacco Control Programme is crucial here. It should be expanded in monitoring and evaluation of tobacco control activities, supplemented by periodic surveys beside the enforcement of the law at the district and state levels. There should be stronger public health education and advocacy efforts for the general public about smoke-free legislation to improve compliance and implementation of antitobacco laws.

Ethical clearance

Ethical Clearance: Obtained (BREC/22/TH/COMMM. MED.-02)

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.