The European Journal of Public Health Advance Access originally published online on November 25, 2008
The European Journal of Public Health 2009 19(1):52-58; doi:10.1093/eurpub/ckn114
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Social inequalities |
Socioeconomic determinants of children's environmental tobacco smoke exposure and family's home smoking policy
Gabriele Bolte, Hermann Fromme and for the GME Study Group*Department of Environmental Health, Bavarian Health and Food Safety Authority, Oberschleissheim, Germany
Correspondence: Gabriele Bolte, Department of Environmental Health, Bavarian Health and Food Safety Authority, Veterinaerstr. 2, 85764 Oberschleissheim, Germany, tel: +49-89-31560159, fax: +49-89-31560835, e-mail: gabriele.bolte{at}lgl.bayern.de
Received July 22, 2008, accepted October 17, 2008
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Abstract |
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Background: Few studies have analysed the impact of different socioeconomic indicators on the prevalence of children's environmental tobacco smoke (ETS) exposure at several indoor environments and on family's home smoking policy. Methods: Data on 12 422 pre-school children (48% female) from two cross-sectional surveys conducted during 2004–06 in Germany were analysed. Exposure assessment was based on parental report. Independent effects of socioeconomic indicators were determined by mutually adjustment in logistic regression analyses. Results: Low parental education, unemployment, low household equivalent income, non-German nationality, single-parent family and family size were independently associated with children's ETS exposure at home and in cars. The strongest associations were observed for low parental education [at home: adjusted odds ratio (OR) 3.94; 95% confidence interval (CI) 3.46–4.49; in cars: 5.00; 3.84–6.50]. Indicators of material living conditions (relative poverty: 0.48; 0.39–0.57, parental unemployment: 0.55; 0.46–0.65), as well as single-parent family, non-German nationality and family size, but not parental education, were independently associated with ETS exposure at hospitality venues. Smoking households with low parental education, unemployment, poverty, single-parent family and non-German nationality were less likely to have the rule of exclusively smoking on the balcony or terrace. Low parental education and unemployment were negatively associated with no smoking in presence of the child in households with smoking inside the flat. Conclusion: Several dimensions of socioeconomic position have to be considered in explanations of social inequalities in children's ETS exposure and family's home smoking policy as well as in development of targeted interventions.
Keywords: children, education, income, passive smoking, single parent
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Introduction |
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There is no doubt that environmental tobacco smoke (ETS) exposure is a major health threat for children.1,2 Children's ETS exposure occurs predominantly at home with parental smoking as the main source, but other indoor environments such as cars or hospitality venues may also be of relevance.3,4 Studies from Great Britain, the United States and Norway showed a decline of children's ETS exposure during the past decades.5–7 Concomitant with smoke-free legislation in recent years in several countries, awareness about the health risks of ETS, willingness to restrict smoking to protect children, and adoption of smoke-free homes have further increased.8–11 These changes may come along with widening of social inequalities in children's ETS exposure. Previous studies on social differences in children's ETS exposure often relied on few socioeconomic indicators, predominantly parental education, and data on socioeconomic determinants of family's home smoking policy are scarce.7,12–16 However, recent studies on smoking behaviour of adults emphasized the need to take different socioeconomic indicators and thus several dimensions of socioeconomic position into account.17,18 Therefore the aim of our study was to disentangle the impact of several dimensions of socioeconomic position on the prevalence of children's ETS exposure at three indoor environments and on the family's home smoking policy during the time period 2004–06 when smoking bans at public places have not yet become effective in Germany.
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Methods |
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Study population
Two cross-sectional surveys were performed during compulsory school entrance health examinations 2004–05 and 2005–06 within the framework of the health monitoring units in Bavaria, Germany.19 In three rural and three urban regions parents of children aged 5–7 years were asked to fill in a self-administered questionnaire. Informed consent was obtained from all parents. The survey was approved by the local ethics committee. The response rate was 78% (first survey 2004–05) and 73% (second survey 2005–06), respectively. Altogether the study population comprised 12 556 children (first survey: 6350, second survey: 6206). Children with missing values for sex (N = 2) and for the main question on ETS exposure at home (N = 132) were excluded from analyses. Thus the final dataset for these analyses comprised 12 422 children.
Socioeconomic and demographic factors
Data on family structure, marital status, family size, nationality, parental education, occupation and income were collected to characterize the children's social circumstances. Parental education was defined as highest level of completed education achieved by mother or father using the categories ‘very high’ (at least undergraduate studies), ‘high’ (general qualification for university entrance but no completed study), ‘middle’ (upper secondary school certificate) and ‘low’ (lower secondary school certificate or no graduation).
Maternal and paternal occupation was assessed as part- or full-time working with at least 15 h/week, marginally employed with <15 h/week or vocational training, not in labour force (e.g. housewife), or unemployed. Parental employment status was categorized into ‘at least one parent employed’ (part- or full-time working) versus ‘both parents only marginally employed or unemployed’.
The household equivalent income was calculated by weighting the monthly household net income as disposable income after taxes and social transfers according to age and number of household members using the weighting factors of the OECD scale.20 As threshold of poverty risk, 60% of the regional median income per survey was defined. Since a significant proportion of parents refused to indicate their household net income, a separate category ‘not indicated/refused’ was used in the analyses.
ETS exposure and family's home smoking policy
Children's ETS exposure was assessed at home, in cars and at hospitality venues. Parents were asked ‘Is there smoking in the flat where your child lives?’ with the response categories ‘yes, inside the flat’, ‘yes, but exclusively on the balcony or terrace’ and ‘no’. Both response categories with ‘yes’ were combined into the category ‘ETS exposure at home’ for analysis. The reason for this was that smoking outdoors reduces but does not completely protect children from ETS exposure at home.21,22 All respondents indicating ETS exposure at home were further asked to specify the average number of cigarettes smoked daily by mother, father and other persons (e.g. older siblings, visitors) in the flat (including balcony or terrace).
Exposure to ETS in cars or at hospitality venues (e.g. restaurant, café) was assessed for the past 12 months with the response categories ‘frequently’, ‘casually’ and ‘never’. The categories ‘frequently’ and ‘casually’ were combined into the category ‘ever’ for analysis.
The family's home smoking policy was defined by household smoking rules and by smoking behaviour in the presence of the child. The person who answered the questionnaire provided the information on behalf of the household. The prevalence of a household smoking rule in terms of exclusively smoking on the balcony or terrace was calculated for all households with any smoking. The prevalence of parental strategies to reduce children's ETS exposure (no smoking in the presence of the child within the flat; intensive ventilation if smoking in the presence of the child within the flat) was calculated among all households where smoking inside the flat was allowed.
Housing conditions
Data on type of the residential house and its location with regard to main roads were collected. Crowding was defined as more than one person per room (not counting bathrooms) or <20 square metres living space per person (including kitchen and bathroom).
Statistical analyses
In case of the outcome children's ETS exposure the child was the unit of analysis, in case of the outcome family's home smoking policy it was the household, where the child lived. Bivariate and multivariate associations between socioeconomic indicators and the outcomes children's ETS exposure and family's home smoking policy, respectively, were examined using logistic regression analysis. As effect estimates, crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated. To avoid multicollinearity in multivariate analysis, correlations between socioeconomic indicators were estimated using Kendall's 
in case of ordinal variables and Cramer's V in case of nominal variables. Correlated variables with Kendall's or Cramer's V 
|0.25| were not simultaneously entered into the regression model. Thus marital status, type of residential house and crowding were excluded from multivariate analysis. Child's sex was not considered as a confounder in multivariate analysis, because it was not associated with the independent variables. A stepwise approach was used to account for the possibility that household income acted as an intermediate variable in regard to parental education and employment status.23 All statistical analyses were performed using the SAS software package version 9.1 (SAS Institute Inc., Cary, NC, USA).
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Results |
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Socioeconomic characteristics and housing conditions of the study population
Demographic and socioeconomic characteristics of the 12 422 children are given in table 1. More children lived in rural (N = 7095) than in urban study regions (N = 5327). Most of the children had married parents with the father part- or full-time working. Only 10% were single-parent families. Almost one-third of the children lived in an apartment/high-rise building and 18% at a main road. Crowding was reported for 19% of the family's homes. Depending on the social indicator used, a proportion of 7% (households in relative poverty or both parents only marginally employed or unemployed) up to 27% (low parental education) of the children may be considered socially disadvantaged.
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Children's ETS exposure at home
Overall, 32% of children were exposed to ETS at home (table 2). Daily smoking occurred in 18% of the households. Fathers tended to smoke more often daily at home than mothers (12% versus 10%) and to smoke more cigarettes per day (>10 cigarettes per day: 6% fathers versus 4% mothers).
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Effect estimates for the association of socioeconomic determinants with children's exposure to ETS at home are given in table 3. In bivariate analysis, children living in relative poverty, having marginally or unemployed parents or with a low parental education were more likely to be exposed. Moreover, single-parent family, non-German nationality of the child, small family size and urban study region were positively associated with ETS exposure. ETS exposure was more frequent when living in an apartment/high-rise building [crude OR 2.41 (95% CI 2.22–2.61)] and experiencing crowding in the flat [crude OR 2.16 (95% CI 1.97–2.38)].
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In multivariate analysis, the ORs were attenuated, but remained statistically significant thus indicating that family structure, nationality, parental education and employment status were independently associated with children's ETS exposure at home. Additionally adjusting for household equivalent income did not substantially alter the effect estimates of the other covariates. Relative poverty was also independently associated with ETS exposure at home. Overall the strongest relationship was observed for low parental education [adjusted OR 3.94 (95% CI 3.46–4.49)].
Similar independent effects of these socioeconomic factors were observed for the outcome daily ETS exposure at home (data not shown).
Children's ETS exposure in cars
Ever ETS exposure in cars during the past 12 months was reported for 10% of the children (table 2). Low parental education, parental unemployment, low household equivalent income, single-parent family and non-German nationality were positively associated with this exposure setting (table 3). Children of families with at least two children and from urban study region were less likely to be exposed to ETS in cars. In addition, in bivariate analysis living in an apartment/high-rise building [crude OR 1.71 (95% CI 1.49–1.96)] and crowding in the flat [crude OR 1.53 (95% CI 1.30–1.79] were positively associated with ETS exposure in cars.
After mutually adjusting for the socioeconomic factors in multivariate analysis, the ORs were attenuated but remained significant. Household income was a determinant of ETS exposure in cars independently from parental education and employment status. The highest adjusted OR was for low parental education [adjusted OR 5.00 (95% CI 3.84–6.50)].
Children's ETS exposure at hospitality venues
The prevalence of children's ever ETS exposure at hospitality venues during the past 12 months was 70% (table 2). In contrast to ETS exposure at home and in cars, children in a privileged social position concerning parental employment status and household income were more likely to be exposed at hospitality venues (table 3). Non-German nationality, urban study region and large family size were negatively associated with ETS exposure in this indoor environment, living in a single-parent family was positively associated. Children living in an apartment/high-rise building [crude OR 0.44 (95% CI 0.40–0.48)] or in a crowded flat [crude OR 0.29 (95% CI 0.26–0.32)] were less likely to be exposed at hospitality venues.
These associations remained stable in multivariate analysis. Parental education had no independent effect on children's ETS exposure at hospitality venues. The strongest relationships were observed for non-German nationality of the child [adjusted OR 0.31 (95% CI 0.27–0.37)] and for living in poverty [adjusted OR 0.48 (95% CI 0.39–0.57)].
Prevalence of family's home smoking policy and its socioeconomic determinants
In smoking households, 55% of the parents (2148/3912) reported the smoking rule of exclusively smoking on the balcony or terrace. In bivariate and multivariate analyses, this rule was less likely in case of low parental education, parental unemployment, relative poverty, single-parent families, non-German nationality of the child and urban study region. There was no independent association with family size (table 4). The strongest associations were observed for low parental education [adjusted OR 0.48 (95% CI 0.38–0.61)] and relative poverty [adjusted OR 0.55 (95% CI 0.41–0.72)].
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Housing conditions were also associated with this rule: exclusively smoking on the balcony or terrace occurred less often when the family lived in an apartment/high-rise building [crude OR 0.56 (95% CI 0.49–0.63)] and when there was crowding [crude OR 0.53 (95% CI 0.46–0.62)].
In households where smoking inside the flat was allowed, parents reported as strategies to reduce children's exposure to ETS ‘no smoking in the presence of the child’ [during summer: 38% (556/1764), during winter: 35% (543/1764)] or ‘intensive ventilation if someone smokes in the presence of the child’ [during summer: 52% (762/1764), during winter: 55% (846/1764)]. In bivariate analysis, low parental education, parental unemployment, relative poverty and single-parent family were negatively associated with the strategy of not smoking in presence of the child within the flat during winter (table 4). In addition, this strategy to protect children occurred less often in crowded flats [crude OR 0.71 (95% CI 0.56–0.89)].
After mutually adjustment in multivariate analysis, independent associations remained for low parental education [adjusted OR 0.46 (95% CI 0.31–0.69)] and parental unemployment [adjusted OR 0.55 (95% CI 0.38–0.78)]. Family size, child's nationality and study region did not play a role. Household income was not an intermediate of the associations with parental education and employment status.
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Discussion |
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Socioeconomic determinants of children's ETS exposure
The basic assumption of our analysis was that socioeconomic indicators such as education, income and occupation measure different aspects of socioeconomic position and cannot be used interchangeably for description of the relationship between socioeconomic position and children's ETS exposure or family's home smoking policy.17,18,24,25 For example, education reflects knowledge and skills and influences health-related behaviour, whereas income is an indicator of the current material situation.
In accordance with this assumption, the relationship between several dimensions of socioeconomic position and the prevalence of children's ETS exposure at three indoor environments proved to be complex in our study. There were independent effects of several socioeconomic indicators on ETS exposure at home and in cars including household income, which did not mediate effects of parental education or employment status.
Our results are consistent with previous findings of a positive association of low parental education and of small dwelling size with children's exposure to ETS at home.12–15,26 We observed parental education and household equivalent income as independent determinants of children's ETS exposure at home and in cars with a stronger association of parental education. An analysis of cross-sectional data of smoking prevalence among adults in 11 European countries had also shown that educational inequalities were larger than income-related inequalities.27 Our observation of independent effects of single-parent family and parental employment status in addition to education and income on children's ETS exposure at home and in cars is in accordance with results of a survey of smoking behaviour of women in the United States.28
In contrast to children's ETS exposure at home and in cars, indicators of adverse material circumstances such as parental unemployment and relative poverty of the household were negatively associated with ETS exposure at hospitality venues in our study. Further determinants were single-parent family, family size, non-German nationality and urban study region. There was no independent effect of parental education. To our knowledge, socioeconomic determinants of children's ETS exposure at hospitality venues have not been examined before.
Socioeconomic determinants of family's smoking policy
Parents reported several strategies to reduce their children's ETS exposure at home in our study. All indicators of social disadvantage were independently and negatively associated with the household smoking rule of exclusively smoking on the balcony or terrace. Socioeconomic determinants of no smoking in the presence of the child were high parental education and parental employment.
Up to now there have only been fragmentary data on the prevalence of household smoking rules and their socioeconomic determinants. In an US survey, a household smoking ban was present in 30% of households with smokers. Compared to our study, a considerable higher proportion of 62% of households with smokers indicated no smoking in the presence of children.29 A study among Hispanic women in the United States gave a prevalence of 66% of all smoking households with a household smoking ban.30 In Norway, 91% of households with 3-years olds and at least one smoking parent had established any rules to reduce indoor smoking.31 The fact that higher proportions of smoking rules were observed in other study populations speaks against an overestimation of smoking rules due to social desirability bias in our study.
In contrast to our results, single-parent households and households with low parental education were not less likely to make efforts to change smoking behaviour for the sake of children in Nordic countries.16
Limitations and strengths
One limitation of our study was that exposure assessment was solely based on parental questionnaire information. Underreporting of smoking in the home might result in exposure misclassification.32 However, the Third National Health and Nutrition Examination Survey for children aged 4–16 years showed that parental reports of the number of household smokers and the estimated number of cigarettes smoked in the home were well correlated with serum cotinine levels in the children with little variation of this association in socioeconomic subgroups.33 These results corresponded with further studies demonstrating that assessment of a child's exposure to ETS by questionnaire is valid.34–36
Information on children's ETS exposure in cars and at hospitality venues was gathered on a rather basic frequency scale, thus allowing only for the differentiation between being exposed or not during the past 12 months. More sophisticated exposure quantification for these indoor environments was not the objective of the study.
The strengths of our study were the substantial population sample of families, the diversity of the study area in terms of urban and rural regions and comprehensive data on several dimensions of socioeconomic position. Selection bias seems unlikely since a high response rate was achieved in the context of the compulsory school entrance health examination.
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Conclusions |
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ETS exposure of children at home and in cars is still an important public health issue of social inequalities, at least in Germany. At the time of our study when there was no smoking ban in force, ETS exposure at public places was nearly inescapable, but families’ material limitations seemed to reduce the chance of children's ETS exposure at hospitality venues. A major finding of our study is that though a considerable proportion of parents strived to protect their children from ETS exposure at home, family's home smoking policy differed substantially by socioeconomic position.
While parental education was the most prominent determinant of children's ETS exposure at home and in cars, other dimensions of socioeconomic position such as family structure, material circumstances and housing conditions as well have to be considered in the development of prevention strategies. Targeted interventions especially for socially disadvantaged families are needed to increase parental health risk awareness, to strengthen parents’ ability to create a smoke-free environment for their children, and to promote smoke-free homes.
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Bavarian State Ministry of the Environment, Public Health and Consumer Protection, Munich, Germany.
Conflicts of interests: None declared.
Key points
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Appendix |
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The members of GME Study Group are: Bavarian Health and Food Safety Authority, Oberschleissheim (Gabriele Bolte, Hermann Fromme, Annette Heißenhuber, Michael Mosetter, Gabriele Morlock, Christine Mitschek, Uta Nennstiel-Ratzel, Manfred Wildner); Health Authority of the District Office of Bamberg (Winfried Strauch, Wiltrud Doerk, Rosemarie Sittig, Heidi Thamm); Health Authority of the District Office of Guenzburg (Roland Schmid, Tatjana Friess-Hesse, Gudrun Winter); Health Authority of the City Ingolstadt (Elisabeth Schneider, Traudl Tontsch, Christine Gampenrieder, Margot Motzet, Gerlinde Woelk); Department of Health and Environment, City of Munich (Heidi Mayrhofer, Sylvia Kranebitter, Gertraud Rohrhirsch, Brigitte Weise); Health Authority of the District Office of Schwandorf (Maximilian Kuehnel, Kornelia Baranek, Gitte Koch-Singer); Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilian-University Munich (Ruediger von Kries, Ladan Baghi); Bavarian State Ministry of the Environment, Public Health and Consumer Protection (Bernhard Liebl).
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Acknowledgements |
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The authors thank all parents for participating in the surveys.
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*The members of the GME Study Group are listed in the Appendix.
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References |
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