|Year : 2012 | Volume
| Issue : 4 | Page : 410-418
Exposure to second-hand tobacco smoke among adults in Myanmar
AA Sein1, MM Than Htike2, DN Sinha3, NN Kyaing3
1 Department of Health Planning, Ministry of Health, Myanmar
2 International Health Division, Ministry of Health, Myanmar
3 WHO Regional Office for South-East Asia, New Delhi, India
|Date of Web Publication||26-Feb-2013|
A A Sein
Department of Health Planning, Ministry of Health, Myanmar
Source of Support: WHO Regional Office for South East Asia., Conflict of Interest: None
Background: Second-hand smoke (SHS) is a threat to people's health particularly in South-East Region including Myanmar. Aim: To describe the exposure to SHS among the adult population of Myanmar. Materials and Methods: The analysis was done based on the data relating to SHS exposure from 2009 Noncommunicable Risk Factor Survey conducted in Myanmar. A total of 7,429 respondents aged 15-64 from a nationally representative household-based cross-sectional multi-stage probability sample were used. Gender-specific estimates of the proportion of adults exposed to SHS were examined across various socio-demographic characteristics. Results: The exposure to SHS was 55.6% (52% among males and 57.8% among females) at home, 63.6% (71.9% among males and 54.7% among females) in indoor places and 23.3% (38.8% among males and 13.6% among females) in public places. SHS exposure at home was more common among females. However, males were more likely to be exposed at work and public places than females. SHS exposure at home and public places decreased with age in both sexes. In these settings, SHS exposure was related to education, residence, employment status, marital status, and income level. At workplaces, it was mainly related to educational attainment and occupational status. Conclusion: Exposure was significantly high in settings having partial ban as compared with settings having a complete ban. The solution is simple and straightforward, smoke-free environments. The findings emphasize the need for continuing efforts to decrease the exposure and to increase the knowledge of its harmful effects.
Keywords: Adults, exposure, Myanmar, second-hand smoke
|How to cite this article:|
Sein A A, Than Htike M M, Sinha D N, Kyaing N N. Exposure to second-hand tobacco smoke among adults in Myanmar. Indian J Cancer 2012;49:410-8
| » Introduction|| |
Tobacco does not just harm the people who smoke - it also harms the people around them. Exposure to second-hand smoke (SHS) is a global public health problem. Involuntary exposure to SHS occurs in places where active smoking takes place. The adverse effects of SHS are both immediate and long-term and are greatly imposed on both children and adults. Exposure to SHS not only harms health but also worsens existing health problems. Most mortality and morbidity is attributable to exposure of adults to SHS and is related to cardiovascular diseases and lung cancer. The exposure of adults may occur in various places: At work, in public places, and at home. In adults, SHS increases the risk of lung cancer by 20-30% and the risk of coronary heart disease by 25-30%. ,
SHS is a major problem in countries of the South-East Asia Region as a large portion of the population smokes tobacco and the level of general awareness about the actual harmful effects of SHS is not sufficient. Exposure to SHS among the population in general, and among women and children in particular, at home, at public places, and workplaces is an issue of grave concern. Governments and different organizations have been working on various strategies such as advocacy, health promotion, and legislation to combat this source of public health threat. 
Myanmar as a signatory to the World Health Organization (WHO) framework convention on tobacco control (FCTC), has undertaken a number of initiatives towards reducing tobacco use and protecting people from the dangers of SHS over the last decades.  The National Tobacco Control Policy and Plan of Action was adopted in 2000 by the Ministry of Health and revised in 2004. The "control of smoking and consumption of tobacco product law" was enacted in May, 2006 and came into effect in May, 2007 which includes important provisions including prohibition of all forms of tobacco advertisements, designation of smoke free areas such as public places, public transport, health facilities and educational institutions, prohibition of sale of tobacco to and by minors, etc. ,,
The National Tobacco Control Programme in Myanmar has been monitoring tobacco use through Sentinel Prevalence Surveys, Global Youth Tobacco Surveys (GYTS), Global School Personnel Surveys (GSPS), and Global Health Professional Students Surveys (GHPSS). The findings indicated that exposure of students to SHS both at home and at public places were high. According to the GYTS findings, 34.1% of students aged 13-15 years reported that they were exposed to SHS from others in their homes and 46.4% of students reported they were exposed to SHS in public places.  In the surveys conducted between 2001 and 2007, exposure to SHS in their homes and in public places had not changed among youth. Data from the GHPSS showed that 68.1% of 3 rd year dental students and 54.8% of 3 rd year medical students were exposed to SHS at home and about 80% of them were exposed to SHS in public places. 
There are no data from population-based studies on the prevalence of SHS among adults in Myanmar. The issue of SHS exposure in Myanmar is pertinent because tobacco use has been socially and culturally accepted since ancient times. The chronic disease risk factor surveillance survey (STEPS) 2009 is the first nationally representative survey on the major non-communicable disease (NCD) risk factors to provide information for integrated NCD programs. , This paper summarizes and analyzes the data from a set of expanded questions from the WHO STEPS instrument to measure the exposure to SHS among the adult population of Myanmar. This paper also describes the prevalence of SHS exposure in homes, indoor work places, and other public places during the past 30 days preceding the survey and examines associated socio-demographic factors. These data are helpful for devising public health strategies to prevent SHS exposure and for providing a baseline to evaluate subsequent changes in tobacco control efforts.
| » Materials and Methods|| |
The STEPS survey 2009 in Myanmar was a nationally representative household-based cross-sectional survey, carried out in 50 townships across the country. The survey used the WHO NCD step-wise survey methodology. Further in-depth data analysis on SHS has been carried out from a subset of key questions by standard tobacco questions for surveys based on the global adult tobacco survey.  This study provided an opportunity to measure the prevalence of exposure to SHS among adults from nationally representative data. The participants included non-institutionalized men and women between the ages of 15 and 64 years. The survey used the multistage cluster-sampling method, with self-weighting sampling procedures. A total sample of 7,450 households was selected, and one eligible household member from each was selected for interview by using the Kish table method. 
Variables included in the analyses
SHS exposure and its related socio-demographic characteristics and knowledge of harm caused by SHS exposure.
Second-hand smoke exposure
SHS section of the questionnaire collected information from the adult population aged 15-64 years on exposure to tobacco smoke at home, at indoor work areas, and in other public locations such as government buildings or government offices, health care facilities, restaurants, and public transportation in the past 30 days preceding the survey. All these data were analyzed to explore the prevalence of SHS exposure.
The indicator on exposure to SHS at home is defined as the proportion of respondents who reported being exposed to smoke at home at least monthly. Exposure to SHS at work is defined as the proportion of indoor workers who were exposed to tobacco smoke in work place in the past 30 days. Indoor workers were classified as the respondents who work outside of their homes and usually work indoors or both indoors or outdoors. Exposure to SHS in public places is defined as the proportion of respondents who reported being exposed to tobacco smoke in specific public places in the past 30 days. The public places in this study included government buildings or government offices, health care facilities, restaurants, and public transportation. Respondents were also asked about the smoking rules in their home and smoking policy where they work. The analysis was carried out for prevalence of exposure to SHS in above mentioned places stratified by gender. This paper also analyzed the SHS exposure among respondents who were classified as non-smokers. Non-smokers included never smokers and former smokers who have already quitted smoking more than 1 year prior to this survey.
Relevant socio-demographic characteristics of respondents that might influence SHS exposure were included. Variables considered in the analyses are age, place of residence (urban/rural), gender (male/female), educational level, employment status, marital status, and their annual per capita income. The level of education among respondents was grouped into five categories according to their highest level of completed education: Less than primary including no formal school, primary school completed, secondary school completed, high school completed, college/university completed including post-graduate degree completed. Employed status was classified as government employee, non-government employee, self-employed, odd jobs, and unpaid work/unemployed. The last category includes non-paid, home maker, retired, and students. Regarding the socio-economic status of respondents, quintile values were calculated based on their per capita annual income: Lowest (≤1 st quintile), low (>1 st quintile - ≤2 nd quintile), middle (>2 nd quintile - ≤3 rd quintile), high (>3 rd quintile - ≤4 th quintile) and highest (>4 th quintile).
Among the respondents, 2,862 (38.5%) were male and 4,567 (61.5%) were females. Among them, 5,230 respondents (70.4%) were from the rural areas, the distribution was approximately followed the current typical urban-rural distribution of the population in Myanmar (30:70). Weighted distribution of the sample indicated that the age group of 35-44 years formed the highest proportion in both sexes (24.6%) followed by 23% in the age group 45-54 years and 21.9% in the age group 25-34 years. The youngest and oldest groups form the lowest proportion, 13.7% in the age group 15-24 years and 16.9% in the age group 55-64 years. Regarding the level of education attained by the respondents, 9.5% had no formal education, 17.4% had less than primary education, 36.4% had primary education, 18.4% had completed secondary school, 7.9% had completed high school, and 10.5% were university graduates. The highest percentage of 47.5% was self-employed followed by 33.5% unpaid where the highest percentage of women was engaged in non-paid household work. The percentage of government employee was 4.9%, non-government employee was 2.3% and 11.9% were odd jobs. About 73% of men and 67% of women were currently married. A little more than 20% of both male and female respondents were single. Only 87% of respondents gave information on their income. As per quintile values of their annual per capita income, 17.7% of the respondents belong to lowest income group, 18.8% were in low, 16.1% were in middle, 19.5% in high, and 15.2% of respondents were in highest income group.
The overall percentage of current smokers was 22.0%, the percentage for males being 44.8% and 7.8% for females. Nearly 76% of the current smokers were regular smokers.
Perceived risk from SHS was assessed with only one question: Whether they know or believe that breathing other people's exhaled tobacco smoke can cause serious illness in non-smokers. About 90% of respondents knew that SHS is harmful.
The differences in proportions between exposure to SHS and various socio-economic and demographic sub-groups were determined by the Chi-square test. The level of significance was set at 0.05 (95% confidence interval). All the data analysis was carried out by using SPSS for windows standard version release 11.5 statistical software.
| » Results|| |
[Table 1] shows the prevalence of SHS exposure at home. About 55% of respondents were exposed to SHS. Females were more likely to be exposed to SHS at home than males (57.8% vs. 52.0%). The prevalence of SHS exposure based on different demographic characteristics revealed that age, residence, education, employment status, marital status, and socio-economic status were all significantly related to household SHS exposure in both males and females. The SHS exposure at home was more common among respondents who were younger, less concerned about their health. Rural residents have higher level of exposure to SHS at home compared with urban residents. Higher education level showed a lower household SHS exposure. As for different occupations, government employee had the lowest reported exposure while those who did odd jobs and who were not working outside the home had the highest. The level of SHS exposure increased among respondents with lower income level. The SHS exposure was more prevalent among single men and married women. Only 19.6% of households in this study completely prohibited smoking at home [Figure 1]. Lack of smoking restrictions was significantly associated with greater SHS exposure at home. All these patterns of association were similar when looked at the levels of exposure for non-smokers only.
[Table 2] presents the prevalence of SHS exposure in indoor work place. Overall 63.6% of respondents who usually work indoor or both indoor and outdoor workplaces had been exposed to SHS. Exposure to SHS at work was higher among males (71.9%) than females (54.7%). Among non-smokers, the prevalence of SHS exposure at the work place was higher for males as well (63.9% vs. 53.4%). SHS exposure at work place did not vary by age and residence. The workers with lower education were more likely to be exposed to SHS at their work place. SHS exposure was lower among government employees especially in females. Only in one-fourth (26%) of work places prohibited smoking in indoors [Figure 2]. The relationship between smoking policy indoors and SHS exposure showed that the SHS exposure rates in the case of "smoking allowed anywhere", "smoking allowed in some indoor places" and "no-smoking policy" (87.8%, 82.4%, and 73.9%, respectively) were significantly higher than in the case of "smoking not allowed in any indoor places" (26%).
[Table 3] shows the SHS exposure among adult respondents in public places. Overall 23.3% were exposed to SHS in any of the public places in the past 30 days preceding the survey. The exposure in public places was significantly higher among males (38.8%) than females (13.6%). More adults from urban areas (29.7%) were exposed to SHS than the adults from rural areas (20.6%). Younger age groups reported higher level of exposure to SHS in public places. Exposure to SHS decreased with age but increased with the educational level, employ status, and level of income. Gender differences are observed across all the socio-economic and demographic subgroups. Similarly, looking at the level of exposure in public places separately for non-smokers, prevalence was almost three times higher among males compared with females (35.9% vs. 13.8%).
Exposure to SHS among respondents who visited specific public location in the past 30 days is shown in [Figure 3]. The prevalence of exposure to SHS differed according to setting.
|Figure 3: Second - hand smoke exposure among adults who visited specific public places in the past 30 days|
Click here to view
| » Discussion|| |
More than half the adults were exposed to SHS in their homes. Nearly two-thirds of indoor workers were exposed to SHS in their workplaces. Overall, about one-fourth of adults were exposed to SHS in public places. The levels of SHS exposure among respondents who reported that they had visited for these specific places were high except in health care facilities. Males were more likely to be exposed to SHS in public places and the prevalence was almost three-fold higher in males than in females. This pattern was also present for SHS exposure among non-smokers in any public places. These findings could be explained by the fact that females who are housewives and unemployed are less likely to visit these public places as they spend most of their time at home. The gender-specific prevalence of SHS exposures was also observed in other studies. ,,,
The household SHS exposure rate was inversely associated with age, education level, employment status, and their income status in both sexes. It was revealed that rural population had higher level of exposure to SHS at home. Lack of home smoking bans and limited knowledge on harmful effects of SHS on non-smokers were associated with higher SHS exposure at home. The levels of SHS exposure in indoor workplaces did not vary by respondent's age, place of residence, marital status, and income level. However, it was directly associated with the smoking policy at their work places. Occupational disparities in SHS exposure was observed like other studies. A low level of exposure among females was observed in these public places. The lower level of exposure was also observed in rural population and unemployed respondents. The association between SHS exposure in public places and marital status may be explained by the fact that single persons spend more of their leisure time in places like tea shops and restaurants, where there are poor restrictions on smoking. The findings of the analysis of relationships between socio-demographic factors and SHS exposure in different settings were consistent with other studies. ,,,
Home smoking restrictions have primarily been promoted as a means of protecting non-smokers from second-hand tobacco smoke. In this study, less than one-fifth of respondents reported that smoking was not permitted in their home, which was similar to the rate in other developing countries but much lower than in developed countries. ,, Many studies have demonstrated that complete smoking restriction at home is a protective factor and an effective way to reduce household SHS exposure. The numbers of tobacco-free families are increasing in some developed countries. , One-fourth of work places completely prohibited indoor smoking and about two-thirds of indoor workers were exposed to SHS in their workplaces. Completely smoke-free environments are the only proven way to protect people adequately from the harmful effects of SHS. Smoke-free environments not only protects non-smokers they also help smokers who want to quit. , Following the WHO FCTC guidelines and MPOWER strategies, everyone should be protected from exposure to tobacco smoke; all indoor workplaces and indoor public places should be smoke-free; and that clear and enforceable legislation is necessary to protect people from exposure to tobacco smoke. ,,,,,,,,
Adoption of "The Control of Smoking and Consumption of Tobacco Products Law" in 2006, and the multi-sectoral efforts towards effective enforcement of the law, the prevalence of smoking across all ages has declined. However, being a complex issue, tobacco control faces many socio-cultural and economic challenges. Protecting people from tobacco smoke, in line with the Myanmar Tobacco Control Policy and Plan of Action, all health facilities had been established as smoke-free since 2001. Although, the national legislation prohibits smoking in public transport and in enclosed public places, it is a challenging issue to be aware of and follow the regulations accordingly. These challenges could be overcome by strengthening tobacco control efforts through the implementation of the MPOWER Policy Package. Close collaboration with WHO and other partners is essential in the struggle against tobacco epidemic.
The findings in this report have some limitations. Cross-sectional data based on information gathered by questionnaire are potentially subject to some degree of systemic errors. The prevalence results are based on self-reports. Locations of public places in this analysis included only four specific places. There was only one question for assessing the knowledge of the harm caused by SHS exposure. Currently, there is no national monitoring data on SHS exposure of adults in Myanmar for the comparison.
Despite regulations banning smoking in public places, schools, universities, health facilities, and public transport, exposure to SHS is still high at home, in indoor workplaces, and in public places. Strengthening of existing legislation on smoke-free environments is strongly recommended to reduce hazards of exposure to SHS.
The results highlight the need for strong, comprehensive SHS control measures, such as a complete ban of smoking in all workplaces and public places, as well as public health campaigns to promote home smoking bans and non-smoking norms.
| » Conclusions|| |
SHS exposure was found to be 55.6% at home, 63.6% in indoor places, and 23.3% in public places. SHS exposure at home was more common among females whereas males were more likely to get exposed to SHS at work places and at public places. SHS exposure was related to education, residence, employment status, marital status, and income level. However, more emphatic and continuing efforts are needed to better the outcome.
| » Acknowledgments|| |
Authors wish to thank the Tobacco Free Initiative Unit, World Health Organization Regional Office for South-East Asia for their support and the Chronic Disease Risk Factor Survey (STEPS) team from Ministry of Health, Myanmar for allowing their extended set of data for further analysis. The authors wish to express appreciation to the Technical Editor, Dr. Rama Murti Paluri for his valuable comments on the earlier draft of this paper.
| » References|| |
|1.||Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. Second-hand smoke: Assessing the burden of disease at national and local levels. WHO Environmental Burden of Disease Series, No. 18. Geneva: World Health Organization; 2010. p. 15-16. |
|2.||World Health Organization, Regional Office for South-East Asia. Effective implementation of the WHO framework convention on tobacco control through MPOWER policy package: Towards a smoke free region. TFI Newsletter 2009:2;1-8. |
|3.||World Health Organization. Measures relating to the reduction of demand for tobacco: WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. p. 8. |
|4.||The Union of Myanmar, The State Peace and Development Council. The Control of Smoking and Consumption of Tobacco Product Law. The State Peace and Development Council Law no. 5/2006. Dated 4 th May 2006. Yangon: State Peace and Development Council, 2006. |
|5.||Ministry of Health, Myanmar. Brief Profile on Tobacco Control in Myanmar. Nay Pyi Taw, Ministry of Health, 2009. |
|6.||Ministry of Health. Health in Myanmar 2011. Nay Pyi Taw: Ministry of Health, Myanmar; 2011. p. 68-70. |
|7.||WHO, Regional Office for South-East Asia. Report on Global Youth Tobacco Survey and Global School Personnel Survey 2007 in Myanmar. New Delhi: Regional Office for South-East Asia, World Health Organization. |
|8.||WHO, Regional Office for South-East Asia. Report on Global Health Professions Students′ Survey 2006 in Myanmar. New Delhi: Regional Office for South-East Asia, World Health Organization. |
|9.||Global Adult Tobacco Survey Collaboration Group. Protect: Exposure to Second hand Smoke. Tobacco Questions for Surveys: A Subset of Key Questions from the Global Adult Tobacco Survey (GATS), 2 nd ed. Atlanta, GA; Centers for Disease Control and Prevention; 2011. p. 12-13, 29-30. |
|10.||WHO, Regional Office for South-East Asia. Survey Methodology: Non-communicable Disease Risk Factor Survey, Myanmar 2009. New Delhi: World Health Organization, Regional Office for South-East Asia; 2011. p. 4-8 |
|11.||World Health Organization. Guidelines for implementation of article 8 of the who framework convention on tobacco control: Protection from exposure to tobacco smoke. WHO Framework Convention on Tobacco Control: Guidelines for Implementation. Geneva: World Health Organization; 2011. p. 19-30. |
|12.||Palipudi KM, Sinha DN, Choudhury S, Mustafa Z, Andes L, Asma S. Exposure to tobacco smoke among adults in Bangladesh. Indian J Public Health 2011;55:210-9. |
|13.||Twose J, Schiaffino A, García M, Borras JM, Fernández E. Correlates of exposure to second-hand smoke in an urban Mediterranean population. BMC Public Health 2007;7:194. |
|14.||Hughes SC, Corcos IA, Hofstetter CR, Hovell MF, Seo DC, Irvin VL, et al. Secondhand smoke exposure among nonsmoking adults in Seoul, Korea. Asian Pac J Cancer Prev 2008;9:247-52. |
|15.||Wang CP, Ma SJ, Xu XF, Wang JF, Mei CZ, Yang GH. The prevalence of household second-hand smoke exposure and its correlated factors in six counties of China. Tob Control 2009;18:121-6. |
|16.||Norman GJ, Ribisl KM, Howard-Pitney B, Howard KA, Unger JB. The relationship between home smoking bans and exposure to state tobacco control efforts and smoking behaviors. Am J Health Promot 2000;15:81-8. |
|17.||Gilpin EA, White MM, Farkas AJ, Pierce JP. Home smoking restrictions: Which smokers have them and how they are associated with smoking behavior. Nicotine Tob Res 1999;1:153-62. |
|18.||Farkas AJ, Gilpin EA, Distefan JM, Pierce JP. The effects of household and workplace smoking restrictions on quitting behaviours. Tob Control 1999;8:261-5. |
|19.||ASH fact sheets on Secondhand smoke in the home. Action on smoking and health: November 2011. Available from: http://www.ash.org.uk. [Last accessed 2012 Jul 11]. |
|20.||Centers for Disease Control and Prevention (CDC). Exposure to secondhand smoke among students aged 13-15 years: Worldwide, 2000-2007. MMWR Morb Mortal Wkly Rep 2007;56:497-500. |
|21.||Sinha DN, Singh G, Gupta PC, Pednekar M, Warrn CW, Asma S, et al. Linking India Global Health Professions Student Survey data to the World Health Organization Framework Convention on Tobacco Control. Indian J Cancer 2010;47:30-4. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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