The Effect of Adult Smoking Behavior on Children's Exposure to Secondhand Smoke. An Analysis Based on Salivary Cotinine Levels Among Children in Dhaka and Karachi

Abstract

Introduction: Exposure to secondhand smoke (SHS) risks children's health. However, biomarkers are rarely used to study SHS exposure among children in low- and middle-income countries.

Aims and methods: We analyzed cross-sectional data collected between March and November 2022 for a cluster-randomized controlled trial investigating a Smoke-Free Intervention in 2769 children aged 9-15 in 74 schools (34 in Dhaka, Bangladesh, and 40 in Karachi, Pakistan). Children's saliva was tested for the concentration of cotinine-a highly sensitive and specific biomarker for SHS exposure. Based on their reports, children's homes were categorized as Nonsmoking Homes (NSH) when residents were nonsmokers; Smoke-free Homes (SFH) when residents and visitors smoked outdoors only; and Smoke-permitted Homes (SPH) when either residents or visitors smoked indoors. We compared cotinine concentrations across these home types and the two cities using a proportional odds model.

Results: Overall, 95.7% of children (92% in Dhaka; and 99.4% in Karachi) had cotinine levels between 0.1 and 12 ng/mL, indicating SHS exposure. Median cotinine levels were higher in Karachi (0.58 ng/mL, IQR 0.37 to 0.93) than in Dhaka (0.27 ng/mL, IQR 0.16 to 0.49). Median cotinine concentration was also higher among children living in SPH than those in either NSH or SFH; with absolute differences of approximately 0.1-0.3 and 0.05 ng/mL, respectively.

Conclusions: The level of SHS exposure in Dhaka and Karachi indicates widespread and unrestricted smoking. Smoking restrictions in households and enforcement of smoking bans are urgently needed.

Implications: The high levels of SHS exposure in children living in SFH suggest parental behavior to hide their smoking and/or exposure in private vehicles or public spaces. It is important to advocate for SFH and cars to protect children from SHS exposure. However, these initiatives alone may not be enough. There is a need to enforce smoking bans in enclosed public places and transportation, as well as extend these bans to playgrounds, parks, fairgrounds, and other public spaces that children frequently visit. It is essential to complement smoking restrictions with tobacco cessation advice and support in these settings.

Figure 1.

Schematic of data availability and analysis sets.

Figure 2.

(A–D) Estimated median cotinine concentrations by type of home (NSH, Smoke-free Homes or Smoke-permitted Homes), conditional on age (9–15 years), country (Bangladesh = BD or Pakistan = PK), sex (Male = M or Female = F), outside space reported at home and SHS exposure reported outside of the home. The point estimates are shown as the darker line with the shaded areas showing pointwise 95% confidence intervals. Note the variation in the range of the Y-axis across the four plots.

Figure 3.

(A–F) Estimated median cotinine concentrations by country (Bangladesh = BD or Pakistan = PK), conditional on age (9–15 years), type of home (NSH, Smoke-free Homes, or Smoke-permitted Homes), sex (Male = M or Female = F), outside space reported at home and SHS exposure reported outside of the home. The point estimates are shown as the darker line with the shaded areas showing pointwise 95% confidence intervals. Note the variation in the range of the Y-axis across the four plots.