Journal of Public Health in Developing Countries
Vol. 3, No. 1, pp. 358-364
http://www.jphdc.org/
ISSN 2059-5409
Original Contribution
Open Access
Household Exposure to Second-hand Smoke in Pakistan: Can Electronic
Media Play a Role?
Muhammad Zubair Tahir
Fana Global Consultancy and Business Ltd, Birmingham, United Kingdom
Correspondence to: Muhammad Tahir, Fana Global Consultancy and Business Ltd, St Agatha’s Road,
Birmingham, B8 2TU, United Kingdom. Email: [email protected]
ARTICLE INFO
ABSTRACT
Article history:
Background: Passive smoking is associated with many diseases and plays an
important role reduced quality of life and increase in mortality. The aims of the study
were to investigate family members smoking frequency and their exposure to secondhand smoke (SHS) inside the households, and to assess the role of electronic media
in changing attitudes towards smoking inside the houses.
Received: 26 Nov 2016
Accepted: 23 Jan 2017
Published: 3 Mar 2017
Keywords:
 Demographic and
Health Survey
 Passive smoking
 Second-hand
smoke
 Electronic media
 Pakistan
Methods: The study is based on data from Pakistan Demographic and Health Survey
(PDHS), 2012-13, which is a countrywide survey of 12,943 households. The
frequency of smoking inside the houses by the family members was retrieved and
analysed with information on wealth index and access to mass media (radio and
television) within the households.
Results: The study showed that the family members smoked on daily basis inside
their houses in more than one-third of households. The richest households,
categorised according to economic indicators, had less daily exposure to SHS
(27.3%) compared to the poorest households (40.1%). The family members in
households that had access to radio had higher SHS exposure (37.7%) than the
households with access to television (35.7%). This difference, however, was not
statistically significant. Wealth index, radio and television all were associated with
frequency of household members smoking inside the house.
Conclusions: Smoking by family members in their households is an important public
health problem in Pakistan, which has so far been ignored. Appropriate guidelines
and law formulation, their implementation and behavioural change strategies by
creating awareness about risks through powerful electronic media messages and
community-based programmes can minimise exposure to SHS in households and at
public places.
Citation: Tahir MZ. Household Exposure to Second-hand Smoke in Pakistan: Can Electronic
Media Play a Role? J Public Health Dev Ctries. 2017; 3(1): 358-364.
© The Author 2017. All rights reserved, JPHDC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
358
INTRODUCTION
Passive smoking is the exposure to and
inhalation of second-hand smoke (SHS)
released from a smouldering cigarette or other
tobacco-related products like cigar, pipe, bidi.
SHS is also known as environmental tobacco
smoke (ETS) [1]. It is estimated that about 5000
non-smokers die annually from lung cancer due
to ETS contact and inhalation [2]. Asian
countries have high exposure to SHS in public
places. As a result the concentration of
particulate matter (microscopic solid and liquid
particles suspended in air having diameter of 2.5
μm or less), and inhalable coarse particles
(having diameter of more than 2.5 μm) is also
high due to lack of or non-compliance with the
smoke-free policies [3].
Regular and sustained exposure to SHS is
associated with various ailments that lead to
decreased health-related quality of life [4]. Nonsmokers exposed to SHS have effects on their
prospective
memory
which
involves
remembering future goals and activities [5].
Smoke due to the burning of tobacco products
weakens the human body’s immunity. This effect
is mediated through the decrease in serum
concentrations of immunoglobulins, lysozymes,
protective natural killer cells [6] and also
functional and structural changes in the
respiratory ciliary epithelium, lung surfactant
protein and immune cells such like neutrophils,
lymphocytes and alveolar macrophages [7].
Women and children under five years of age are
most vulnerable in the houses where there is
daily exposure to SHS.
Passive
smoking
damages
female
reproductive organs, and is particularly harmful
to the mother during pregnancy. SHS also
aggravates asthma and delays chronic infection
healing [8,9]. SHS exposure has risk to the life of
foetus as in pregnant women the exposure
increases the risk of miscarriage by 11% [10].
SHS exposure can also increase the risk of
tuberculosis (TB) [11]. This may be one of the
reasons that TB burden is the highest in
countries where smoking and SHS exposure has
been increasing [12]. In addition, exposure to
SHS increases the risk of type 2 diabetes
mellitus [13-15], vascular inflammation, encour-
ages vasoconstriction and thrombus formation,
decreases myocardial oxygen balance, causes
atherothrombosis [16] and increases tissue
damage in heart resulting in ischemia or
myocardial infarction [17-19].
There
is
evidence
that
with
the
implementation of smoke-free legislation for
public places across the United States and
Europe, there has been a significant decline in
the emergency admissions for acute coronary
syndrome over the last 10-15 years [20]. In
Pakistan, due to the cultural norms, SHS is
generally tolerated in houses. The aims of the
study were to investigate family members
smoking frequency and their exposure to SHS
inside the households, and to assess the role of
electronic media in changing attitudes towards
smoking inside the houses.
MATERIALS AND METHODS
The study is based on data from Pakistan
Demographic and Health Survey (PDHS), 201213. The data were used with permission from the
PDHS organising committee.
Pakistan
Survey
Demographic
and
Health
The PDHS 2012-13 was conducted under the
authority of the Ministry of National Health
Services,
Regulations
and
Coordination
(NHSRC) and was implemented by National
Institute of Population Studies (NIPS), Pakistan.
Pakistan Bureau of Statistics (PBS) and Inner
City Fund (ICF) International provided technical
assistance for the survey through financial
assistance from the United States Agency for
International Development (USAID) and Government of Pakistan. The metadata was produced
by the World Bank and Development Economics
Data Group. The PDHS is part of the worldwide
Demographic and Health Survey programme,
which is designed to collect data on fertility,
family planning, and maternal and child health.
The survey was conducted in all regions of
Pakistan excluding Azad Jammu and Kashmir
(AJK), Federally Administered Tribal Area
(FATA), and restricted military and protected
areas.
A total of 20 teams, six members in each
359
team, were organised to collect data. Each team
consisted of a supervisor, a field editor, one
male interviewer, and three female interviewers.
The entire field work for the survey was carried
out from October 2012 to April 2013. Briefly, a
total of 248 urban and 252 rural clusters were
selected, out of which 14,000 households (6,944
in urban areas and 7,056 in rural areas) were
selected by systematic sampling technique. Out
of the 14,000 households, 13,464 households
were occupied and 12,943 households were
interviewed. The household response rate was
96%. A nationally representative sample of
13,558 ever-married women in all selected
households, and 3,134 ever-married men aged
15-49 in one-third of the selected households
were interviewed. This represented a response
rate of 93% of women and 79% of men. Due to
law and order situation, data collection was not
possible in Rajanpur district in Punjab and Dera
Bugti in Balochistan. In Tank district
(Balochistan) and Mastung (Balochistan), teams
had to stop their work due to threats, so two
clusters in these districts were only partially
completed.
Operational Definitions
a) Dependant Variable:
SHS in household was defined as “exposure to
smoke due to the household members smoking
inside the house”. The frequency of smoking
inside the house was categorised in five groups:
never, daily, weekly, monthly, occasionally/less
than monthly.
Data Analysis
SPSS version 21 (IBM, NY, USA) was used for
analyses. Categorical variables are presented as
frequency and percentage. The relationship
between the dependent and independent
variables was tested by regression analyses. A
p-value of <0.05 was considered to be
statistically significant.
RESULTS
Frequency
Households
of
Smoking
within
Table 1 shows that in 35.4% of households all
non-smoker family members were exposed to
SHS on daily basis. Overall, family members
smoked inside the house in about 38.5% of the
households in a month.
Table 1. Frequency of Smoking
within Households by Family
Members in Pakistan
Smoking Pattern
Number (%)
Daily
Weekly
Monthly
Less than a month
Missing
4,585 (35.4)
267 (2.1)
41 (0.3)
88 (0.7)
12 (0.1)
Total
12,943 (100)
b) Independent Variables:
Wealth index: It was based on the information
collected about household assets during the
interviews. Five categories were defined based
on the household economic indicators: (1) Very
poor, (2) Poor, (3) Middle class, (4) Rich, and (5)
Very rich. All households were stratified
according to these categories.
Mass media exposure: Households were categorised into those "Having radio", and "Having
television" at home and this option had two
alternative answers: No/Yes.
Smoking
Frequency
Residence
by
Area
of
The frequency of smoking by the area of
residence is shown in Table 2. A higher
proportion of non-smokers were exposed to SHS
on daily smoking by smoking family members in
the households based in rural areas compared
to those in the urban areas. However, the family
members in urban areas households had more
SHS exposure in a month than family members
of rural areas households.
360
Table 2. Frequency of Smoking within Households by Residence Area, Wealth
Index and Electronic Media Exposure (N = 12,943)
Characteristics
Smoking Patterns within Households by Family
Members (%)
Daily
Weekly
Monthly
Less than
a month
32.0
38.8
2.4
1.8
0.4
0.2
0.8
0.6
Very poor
Poor
40.1
37.7
1.7
2.2
0.2
0.3
0.5
1.0
Middle class
Rich
Very rich
39.7
35.3
27.3
2.3
2.2
2.0
0.3
0.3
0.4
0.6
0.4
0.9
Households with radios
37.7
Households with TVs
35.7
2.8
2.2
0.3
0.4
1.3
0.7
Areas of households
Urban
Rural
Wealth index
Electronic media exposure
Smoking Frequency by Wealth Index
Table 2 highlights the smoking prevalence
according to family’s wealth index. About 40.1%
of people smoked inside households on daily
basis in the very poor category households with
the lowest daily smoking prevalence of 27.3% iin
the very rich households. There was, however,
no remarkable difference among other
households groups based on the wealth index.
Electronic
Media
Exposure
Frequency of Smoking
and
There were 2,220 households that had access to
radios and 8,267 with access to TVs. The
households that had access to radio had 37.7%
of family members smoking on daily basis. On
the other hand, in the households that had
access to television (TV) around 35.7% of family
members smoked daily. Overall, there was a
higher prevalence of SHS exposure in
households having radios than households
having TVs (Table 2).
Impact of Mass Media and Wealth Index
on Smoking Frequency
As shown in Table 3, wealth index, and access
to TV and radio had a statistically significant
impact on smoking inside households by the
family members.
Table 3. Impact of Exposure to
Electronic Media and Wealth Index
(IVs) on Smoking Frequency within
Households (DV)
Characteristics
Wald Chi
Square
p-value
Radio
Access to radios
20.717
56.914
<0.001
<0.001
Access to TVs
180.924
<0.001
IVs - Independent variables; DV - dependant variable
361
DISCUSSION
The results show that the family members smoke
inside the house on daily basis and all nonsmoker family members are exposed to SHS in
more than one-third of the households. The
richest households, categorised according to
economic indicators, have lesser daily exposure
to SHS compared to the poorest households.
Households having radio were more exposed to
SHS than households having TV. Statistical
analysis shows that the wealth index, TV and
radio have impact on smoking frequency inside
the households.
PDHS 2012-13 shows that a household in
Pakistan is comprised of about seven persons
and a large percentage of Pakistani population
(39%) is under 15 years of age. Passive
smokers in households are in all age groups with
higher risks for the children under five years of
age. SHS is more dangerous in smaller and
closely-built houses in any area. In rural areas of
Pakistan all family members usually live in small
houses comprised of one or two bedrooms. This
study shows that the family members of 38.5%
of households were exposed to SHS. Electronic
media, especially TV can play an important role
in creating awareness and helping to decrease
smoking frequency inside the houses.
Urban areas in Pakistan are exposed to
pollution and ETS in addition to the family
members smoking inside households, thereby
further increasing the SHS levels inside the
houses. ETS is a main source of particulate
matter indoor pollution and is further augmented
with cigarette smoking inside the houses [21,22].
Tobacco smoke contains a wide range of toxic
gasses and particles which are injurious to not
only the smokers but also to those around them
[23].
There are different studies which indicate
that exposure to SHS at public places is linked to
cardiovascular and pulmonary diseases as well
as mortalities. Risks of diseases have been
minimised in countries where smoking at public
places is legally not allowed. When smokers are
allowed to smoke at public places then they are
also permitted to damage health of others. In a
study in Pakistan, it was found that among the
smokers, around 66% smokers smoke at public
places [24]. They not only increase the environ-
mental pollution but also put the wellbeing of
non-smokers at stake. This careless attitude
about others or lack of awareness and
information about health hazards needs attention
to modify this behaviour.
Cigarette smoke contains harmful chemicals
and has adverse effects on almost every organ
in the body. There are harmful effects of passive
smoking especially on the health of children and
pregnant women. According to PDHS 2012-13,
large number of under-five children are also
exposed to SHS along with their mothers.
Passive smoking causes respiratory illness,
asthma, poor growth of children along with the
development of other chronic infections. This
study shows high prevalence of SHS in houses,
and children along with their pregnant mothers
are at great risks. Exposure to SHS is also
associated with childhood TB infection and
development of childhood tuberculosis [25,26].
Pakistan is among the seven countries in the
world where TB is spreading.
In rural settings in Pakistan, people work in
fields, help each other, and sit together in their
free time and generally smoke hukka/sheesha,
which is part of the social norm. This study
shows that the poorest households had higher
exposure to SHS than the richest, which may be
related to the less recreational activities and
more sitting and chatting time. Hence, smoking
seems to be time-killing or stress-relieving
activity in the poorest households. A study has
suggested that hukka use is related to frequency
of stressful life events [27]. Hookah/hukka
smoking is a community activity in rural areas of
Pakistan. People also have no knowledge about
its harmful effects as they think hukka smoking is
safer than cigarettes due to water in it. Even if
someone considers it harmful, he finds it difficult
to stop or avoid due to social gathering and
peer-pressure. A study reported that a majority
of 88% respondents believed hookah/hukka
smoking was harmful to their health, but 52%
had no intention of quitting it [28]. In hukka
smoking activity in houses, the non-smokers are
exposed to SHS on an ongoing basis.
The cultural norms in Pakistan have also
contributed to exposure to SHS in houses as
elders are not asked to stop smoking in houses.
Lack of information and knowledge, among
active and passive smokers, about health
362
hazards of SHS is also an important factor. Low
education rate, especially in rural areas along
with wrong beliefs about hukka smoking as a
safer activity than cigarette smoking, are all
contributing to health risks due to SHS [29].
Passive smoking seems to be a neglected
public health problem in Pakistan. Electronic
media - TV and radio - can be used to create
awareness, give information about hazards of
SHS and passive smoking. In rural areas of
Pakistan, radio is a very effective mode to
approach the communities and convey
messages. People listen to radio programmes
and discuss with each other. One radio is usually
used to listen to news and programmes by many
people from the different households when they
sit together or work in fields. Similarly, TV is also
shared by families and can be an important
source of information and a tool for change in
behaviour due to its additional visual power.
Media campaigns by television and radio
are usually used for large populations to convey
messages. Such media messages can produce
constructive changes, minimise effects of
negative beliefs and are effective in changing
health-related
behaviours
across
large
population segments. Along with these
messages community-based health promotion
programmes and policies can contribute in
behavioural change [30]. There is evidence that
tobacco control programmes that include mass
media campaigns can be effective in changing
smoking behaviour in adults and produce
positive results even up to eight years after the
campaign. The strength and duration of media
campaigns, however, does have influence on the
outcome [31]. This study shows that households
had access to radio and TV, so SHS exposure
can be minimised by proper electronic media
messages in Pakistan.
There is also a need for innovative
interventions to control exposure to SHS in
Pakistan.
An
experimental
innovative
intervention, Smoke-Free Homes (SFH), was
started in Pakistan which involved primary
school children, community opinion leaders and
health professionals. The intervention had
positive effect on the communities’ behaviour,
and possibility to influence adult smoking
behaviour and decrease SHS in households was
noted (32). An important facet is to provide
information about health hazards related to SHS
in households. Electronic media can change
parent’s attitude and health-related behaviours
which will control SHS exposure to non-smokers.
Avoiding smoking inside the homes by family
members and creating smoke-free homes can
also serve as a powerful tobacco control strategy
for adolescents as well [33].
CONCLUSIONS
Smoking by family members in their households
is an important public health problem in
Pakistan, which has so far been ignored.
Appropriate guidelines and law formulation, their
implementation
and
behavioural
change
strategies by creating awareness about risks
through powerful electronic media messages
and
community-based
programmes
can
minimise exposure to SHS in households and at
public places.
ACKNOWLEDGEMENTS
The author appreciates the support and
cooperation of Pakistan Demographic and
Health Survey (PDHS) organising committee.
CONFLICT OF INTEREST
Author has declared that no competing interests
exist.
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