Youth Health |
Environmental tobacco smoke in Norwegian homes, 1995 and 2001: changes in children's exposure and parents attitudes and health risk awareness
Karle E. Lund1 and Ásgeir R. Helgason2
1 National Institute of Alcohol and Drug Research, Oslo, Norway
2 Stockholm Center of Public Health, Preventive Medicine & Karolinska Institutet, Stockholm, Sweden
Correspondence: Dr Ásgeir R. Helgason, Stockholm Centre of Public Health, PO Box 17533, SE-118 91, Sweden, tel. +46 51778057, fax +46 51778075, Email: asgeir{at}ks.se
Received July 10, 2003, accepted November 5, 2003
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Abstract |
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Background: The aims of the present study were to assess changes between 1995 and 2001 in the prevalence of child exposure to environmental tobacco smoke (ETS), attitudes towards ETS among parents of small children and awareness among parents regarding the potential hazards of passive smoking to children. Method: A questionnaire, along with a stamped, addressed envelope, was sent to a stratified random sample of 1000 households in Norway containing children aged 3 years old at the time of the investigation (May 1995 and August 2001). Results: The prevalence of households containing smokers was similar in the two study periods. However, households reporting exposure of children to ETS fell from 32% in 1995 to 18% in 2001. Health-risk awareness had significantly increased in households containing smokers. In both surveys, the probability of children being exposed to ETS was positively correlated with the number of parents smoking, and inversely correlated to strength of health-risk awareness, negative attitudes towards ETS and length of household education. Conclusions: Increasing parents' awareness of the health risk of ETS exposure to children may significantly reduce children's ETS exposure.
Keywords: attitudes, children, health-risk awareness, indoor environment, parents, passive smoking, smoking, tobacco
Although Norway introduced restrictions on smoking in public places in 1989, there are no regulations for the home environment, where young children are assumed to be most exposed to environmental tobacco smoke (ETS). A nationwide study in 1995 showed that children were regularly exposed to ETS in 32% of all households containing children 3 years of age. Children were exposed in 67% of the households in which one or both parents smoked, and a substantial proportion of parents were found to be unaware of some of the established health risks of ETS exposure for their children.1 However, the 1995 survey indicated that educating parents about health risks of ETS would significantly reduce children's exposure to passive smoking.2
Consequently, the Norwegian Cancer Society has led a comprehensive information campaign since 1995 with the aim of reducing young children's ETS exposure in the home and in day care. The target population included parents, preschool personnel and other child minders. In the 1995 survey ETS exposure was found to be related to households of low socioeconomic status,1 and traditional public information strategies by means of educational programmes in the media may not get through to people whose educational levels are low.3,4 Ideally, a broad media approach should therefore be supplemented by a strategy to enhance face-to-face information in the clinical setting. Unfortunately, several studies indicate that Norwegian health professionals make little effort to motivate parents to establish a smoke-free environment for infants and toddlers.5 In the meantime, the Directorate of Health arranged communication courses in every county for health personnel, intended to help them impart non-smoking advice to parents. Furthermore, the Cancer Society developed material for general practitioners, midwifes at maternity departments and medical staff at mother-and-child clinics to use during consultations. It was hypothesized that the courses, in combination with the written material, would reduce the uneasiness reported by health personnel when raising the subject, and would enable them to talk to parents about their smoking habits.6,7
The aims of the present study were to assess changes between 1995 and 2001 in the prevalence of child exposure to ETS, attitudes towards ETS among parents of small children and awareness among parents regarding the potential hazards to children of passive smoking. The study also assessed variations in self-reported perceptions of advice on passive smoking given in the clinical setting.
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Materials and methods |
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Data collection
A questionnaire, along with a stamped, addressed envelope, was sent to a stratified random sample of 1000 households in Norway containing children aged 3 years old at the time of the investigation (May 1995 and August 2001). Addresses were extracted from the Central Office of Population Records. Permission was obtained from the Data Inspectorate. One reminder was sent out. The parent/person in charge whose birthday came first after the date on which the household received the questionnaire was instructed to answer. Parents who did not live with a partner were instructed to fill in the form themselves. The data collection was coordinated by the Norwegian Cancer Society under the supervision of the authors. The same procedures for data collection were used in 2001 and 1995. In 1995, the survey was part of a Nordic study that included households in Denmark, Finland, Iceland and Sweden. A more detailed description of methods used is presented elsewhere.1,8 In 2001, no other country took part in the survey.
Main outcome measures
Households are the units of analysis, but of course, it is individuals that respond on behalf of households. All subjects were asked if the household had introduced any rules to limit smoking indoors in their own home (yes/no format). The respondent's and the partner's current smoking behaviour was assessed on a three category scale: ‘smoke daily’, ‘smoke occasionally’ and ‘never smoke’. Smokers (either daily or occasional) and respondents with smoking partners were asked how often they or their partners smoked in the course of a week when indoors with their children. Response options were ‘every day’, ‘several times a week’, ‘about once a week’, ‘less than once a week’ and ‘never’. Respondents were also instructed to state the number of cigarettes smoked indoors in the vicinity of their children. A child was categorized as ETS-exposed if parents/partners exposed the child at least once a week, or if the number of cigarettes smoked indoors per week in the vicinity of the child exceeded zero.
In order to assess attitudes towards children's rights to a smoke-free indoor environment and health-risk awareness, parents were asked to state the extent to which they either agreed or disagreed with the statements presented in tables 1 and 2. Four response options were offered for each statement. For the statements referring to attitudes, parents were asked whether they ‘agreed completely’, ‘tended to agree’, ‘tended to disagree’ or ‘disagreed completely’. For the statements referring to health-risk awareness, the response options comprised ‘not at all’, ‘maybe/maybe not’, ‘probably’ and ‘definitely’. For the analysis presented in table 3, an attitude index (minimum score = 6, maximum score = 24) and a health-risk awareness index (minimum score = 5, maximum score = 20) were constructed by adding the scores on the individual items. When responses were negative, coding was reversed prior to the statistical analysis. Cut-offs were fixed in order to produce an equal number of respondents (one-third) in each category. Three statements in table 2 were excluded when constructing the health-risk awareness index. Sudden infant death syndrome and cognitive difficulties were excluded because they were only used in the 2001 survey. Growing up to be shorter has been hypothesized as a potential health hazard of passive smoking, but was excluded from the index because the evidence in the medical literature is still inconclusive.9 ETS is not related to smallpox; hence, the coding was reversed when the item was included in the awareness index.
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Mean household education was calculated as the average number of years in education completed by the respondent or spouse/partner after the 9 years of compulsory schooling. For persons who did not live with a partner, mean household education was set equal to the number of years completed by the respondent her/himself. In the analysis the variable was categorized as ‘short’, ‘medium’ or ‘long’ education. Cut-offs were chosen in order to obtain an equal number of respondents (one-third) in each category.
Analysis
Descriptive results are presented as prevalence point estimates with 95% confidence intervals or means with standard deviations. Logistic regression analysis was used to calculate adjusted odds ratios controlling for covariates.10
All analyses were conducted using SPSS 11 software.
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Results |
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There were no significant differences in sample characteristics between the 1995 and 2001 surveys (table 4). Response rate (61%), female overrepresentation among respondents, mean age of respondents, proportion of single households, mean household education and distribution of smokers across education groups were practically the same in the two samples. A small increase was observed in the percentage of parents who did not smoke, but the difference was not statistically significant (table 4).
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Among parents in households containing smokers, a large and significant reduction of 17 percentage points was observed in the proportion agreeing to the statement that ‘adults have the right to smoke wherever they want in their own homes’ (table 1). Also, parents in smoke-free households were more likely to view ETS as a form of child abuse (table 1).
Households containing smokers reported higher health risk awareness in the 2001 survey on all statements except respiratory diseases (table 2). Also, a tendency to overestimate the risk was noted as the number of parents who believed that ETS affected children's growth had doubled in these households (table 2).
The prevalence of households reporting to expose children to ETS fell from 32% in 1995 to 18% in 2001 (table 3). In both surveys, reported exposure was positively correlated with the number of parents smoking, and inversely correlated to length of household education, negative attitudes towards ETS and strength of health-risk awareness (table 3).
Among households reporting to expose their children to ETS, the dose of exposure was reduced from 29 cigarettes per week in 1995 to 18 cigarettes in 2001 (table 5). Exposure intensity was highest for children living in households where both parents smoked and where health awareness was low. Household education and attitudes towards ETS appeared to be less important in 2001 compared with 1995, whereas high health-risk awareness appears to be more important (table 5).
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In the 1995 survey, 72% (n=598) of all households had imposed rules of some kind to limit family members or others from smoking indoors. This had increased to 85% (n=601) in 2001 (data not shown).
The number of smokers and ex-smokers reporting that health personnel had asked them about their smoking habits was practically the same in 1995 (30%, n=235) and in 2001 (29%, n=182) (data not shown).
In 1995, 67% (n=217) of parents who smoked believed that more than half of smokers exposed their children to ETS. In 2001, only 33% (n=167) held the same opinion (data not shown). Among parents who did not smoke, 75% (n=390) in 1995 and 50% (n=436) in 2001 believed that more than half of parents who smoke exposed their children to passive smoking (data not shown).
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Discussion |
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The results show a marked reduction in the proportion of households reporting to expose their children to ETS from 1995 to 2001. This is the case in spite of the fact that the proportion of smokers among Norwegian parents is practically unchanged. Among households that exposed children, the intensity of the exposure (number of cigarettes smoked) had fallen markedly, especially in families with high risk awareness.
One interesting aspect of the present results is the observed relationship between risk awareness and children's ETS exposure. It has been suggested that knowledge about risk factors may not necessarily influence health-risk behaviour.11–13 Whereas this may be true when dealing with self-inflicted risks, like one's own smoking behaviour, the present results indicate that this may not be the case when it comes to exposing one's children to health risks.
The present study design does not allow for a conclusive explanation of the observed reduction in ETS exposure and increased health-risk awareness. However, the most probable explanation is a nationwide information campaign focusing on passive smoking provoked by the results of the 1995 survey. The Norwegian Cancer Society and the public health authorities initiated the campaign, which sparkled an ongoing nationwide debate on ETS. The debate resulted in laws prohibiting smoking in bars and restaurants and a proposal to make it illegal to expose children to ETS at home, as has been done in Iceland. Another possible explanation could be a change in the way health-care personnel approach and educate parents of young children regarding the hazards of ETS. However, the number of smokers and ex-smokers with whom the health personnel had spoken about smoking habits had not changed between the two surveys. Information transmitted from person to person has been demonstrated to be a good way of reaching persons in the low education bracket, who otherwise tend to be less sensitive to information in the media.3,4 As ETS exposure tends to be more frequent among low education households, the success of such a strategy would clearly be an important step forward.
All self-reported survey studies are susceptible to problems of validity.14,15 Asking parents to report ETS exposure is not an objective measure of ‘true’ exposure. However, the aim of the present study was to assess the relationship between reported exposure and other factors at two different point in time using the same assessment methods and study design. Bias owing to change in social pressure that may affect how people answer may be a problem in studies like these. However, while the norm of not exposing others to ETS could be expected to influence answers concerning own behaviour, it should not necessarily influence answers on how the respondent anticipates other parents to behave in front of their children. In the present study, the reported reduction in children's exposure to ETS corresponded with the widespread opinion that smokers in general tend to expose their children to ETS less frequently than before.
In summary, in spite of a minimal reduction in smoking prevalence, Norwegian parents reported a significant reduction in children's exposure to ETS from 1995 to 2001 and a significant change in health-risk awareness regarding potential hazards of ETS exposure to children. The observed changes must be viewed in the light of the massive nationwide information campaign and media focus on ETS during the observation period.
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References |
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1 Lund KE, Skrondal A, Vertio H, Helgason AR. Children's residential exposure to environmental tobacco smoke varies greatly between the Nordic countries. Scand J Soc Med 1998;2:115–20.
2 Helgason AR, Lund KE. Environmental tobacco smoke exposure of young children—attitudes and health-risk awareness in the Nordic countries. Nicotine Tob Res 2001;3:341–5.[CrossRef][Medline]
3 Rogers EM. Diffusion of innovations. Third edn. New York: The Free Press, 1982.
4 Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex and age: effects of price, income and health publicity. BMJ 1994;309:923–7.
5 Lund KE, Andersen M, Bakke P, et al. To what extent do public health nurses, midwives and doctors talk about passive smoking to the parents of babies and infants? Tidsskr Nor Laegeforen 2000;120:1616–21.[Medline]
6 Helgason AR, Lund KE. General practitioners' perceived barriers to smoking cessation—results from four Nordic countries. Scand J Public Health 2002;30:141–7.[CrossRef][Medline]
7 Lund KE, Helgason AR. Why do health personnel neglect to talk to parents of small children about passive smoking? Tidsskr Nor Laegeforen 2000;120:1622–6.[Medline]
8 Lund KE, Skrondal A, Vertio H, Helgason AR. To what extent do parents strive to protect their children from environmental tobacco smoke in the Nordic countries? A population-based study. Tob Control 1998;1:56–60.
9 Tobacco Free Initiative. International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. Consultation Report. Genova: WHO/NCD/TFI/99.10, 1999.
10 Hosmer DW, Lemeshow S. Applied logistic regression. New York: John Wiley & Sons, 1989.
11 Gatherer A, Parfit J, Porter E, Vessey M. Is health education effective? London: The Health Education Council, 1979.
12 Bartlett E. The contribution of school health education to community health promotion: what can we reasonably expect ? Am J Public Health 1981;71:1384–91.
13 Botvin GJ. Principles of prevention. In: Coombs RH, Ziedoni D, Editors. Handbook on drug abuse prevention: a comprehensive strategy to prevent the abuse of alcohol and other drugs. Boston: Allyn and Bacon, 1995:19–44.
14 Delfino RJ, Ernst P, Jakkola MS, et al. Questionnaire assessments of recent exposure to environmental tobacco smoke in relation to salivary cotinine. Eur Respir J 1993;6:1104–8.[Abstract]
15 Pirkle JL, Flegal KM, Bernett JT, et al. Exposure of the US population to environmental tobacco smoke. JAMA 1996;275:1233–40.[Abstract]
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