www.rpped.com.br
REVISTA
PAULISTA
DE
PEDIATRIA
ORIGINAL
ARTICLE
Perception
of
parents
about
second
hand
smoke
on
the
health
of
their
children:
an
ethnographic
study
Fabiane
Alves
de
Carvalho
Ribeiro
∗,
Micaele
Kedma
Ribeiro
de
Moraes,
Joyce
Cristina
de
Morais
Caixeta,
Jullieth
Nadja
da
Silva,
Amanda
Sanches
Lima,
Samara
Lamounier
Santana
Parreira,
Viviane
Lemos
Silva
Fernandes
CentroUniversitáriodeAnápolis(UniEvangélica),Anápolis,GO,Brazil
Received21October2014;accepted10February2015 Availableonline28August2015
KEYWORDS
Pollutionfortobacco
smoke; Parents; Child
Abstract
Objective: Toanalyzetheperceptionofparentsaboutsecondhandsmokingintheirchildren’s health.
Methods: Ethnographicqualitativeandquantitativestudy.Wesought thepoint ofviewand understandingoftheparentswhowereactivesmokersinrelationtoenvironmentaltobacco smoke(ETS)andsecondhandsmoking.Mothersandfatherswhoareactivesmokersandthatlive withtheirchildrenfromsevendifferentpublicschoolsinthecityofAnápolis,MidwestBrazil, wereinterviewedinthefirstsemesterofinareservedroomintheschools.Adescriptiveand qualitativeanalysiswascarriedoutthroughtheethnography.
Results: 58parentswithanaveragetimeofsmokingof15.3yearsandanaveragequantityof cigarettessmokedperdayof2wereinterviewed.Amongthem,59%didnotknowwhatETSwas, and60%statedknowingwhatasecondhandsmokerwas.However,whenquestionedabouttheir childrenassecondhandsmokers,52%didnotconsiderthemtobe.Someparentsknewsomeof theeffectsofsecondhandsmokinginthehealthoftheirchildren.However,themajority(52%) ofthemdidnotbelievethattheirchildrenwouldsufferanyrespiratoryimpairmentordidnot knowabouttheseimpairments.
Conclusions: Childrenwereexposed toenvironmentaltobaccopollutionintheirresidenceif oneconsidersparentaldurationofsmokingandaverageofcigarettessmokedperday.Therewas alackofknowledgeoftheparentsaboutETS,secondhandsmokingandtheevilsthatcigarettes couldcauseinthehealthoftheirchildren.
©2015SociedadedePediatriadeS˜aoPaulo.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-license(https://creativecommons.org/licenses/by/4.0/).
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.rpped.2015.02.003
∗Correspondingauthor.
E-mail:fabi.acarvalho@globo.com(F.A.C.Ribeiro).
PALAVRAS-CHAVE
Poluic¸ãoporfumac¸a
detabaco;
Pais; Crianc¸a
Percepc¸ãodospaisarespeitodotabagismopassivonasaúdedeseusfilhos:um
estudoetnográfico
Resumo
Objetivo: Analisarapercepc¸ãodospaisarespeitodotabagismopassivonasaúdedeseusfilhos.
Métodos: Estudoqualiquantitativodecaráteretnográfico.Buscou-seopontodevistaeo con-hecimentodospaisfumantesativosquantoàpoluic¸ãotabagísticaambientaleaotabagismo passivo.Foramincluídosmãesepaisfumantesativosqueconviviamdiariamentecomseus fil-hosem seteescolaspúblicasdacidadedeAnápolis(GO) noprimeiro semestrede2014. Os paisforamentrevistadosemumasalareservadanasescolas.Procedeu-seàanálisedescritiva equalitativapormeiodaetnografia.
Resultados: Aamostrafoide58pais,otempomédiodetabagismode15,3anosea quanti-dademédiadecigarrosfumadospordiade;20,1.Grandeparte(59%)dospaisnãosabiaoque erapoluic¸ãotabagísticaambientale60%disseramsaberoqueeraumfumantepassivo. Con-tudo,quandoperguntadosarespeitodeconsideraremseusfilhosfumantespassivos,52%nãoos consideravam.Observou-sequealgunspaistêmconhecimentosobreainfluênciadotabagismo passivonasaúdedeseusfilhos.Contudo,amaioria(52%)delesacreditaqueseusfilhospodem nãosofrerprejuízorespiratórioounãosabemquaisprejuízosãoesses.
Conclusões: Ascrianc¸asanalisadasficavamexpostasàpoluic¸ãotabagísticaambientalno domi-cilio,oqueficouevidentepormeiodosdados,dotempodetabagismoedamédiadecigarros fumadospor dia.Entretanto,percebeu-secarência noconhecimentodospaisarespeito da poluic¸ãotabagísticaambiental,dotabagismopassivoedosmalesqueocigarropodecausarna saúdedosfilhos.
©2015SociedadedePediatriadeS˜aoPaulo.PublicadoporElsevierEditoraLtda.Esteéumartigo OpenAccesssobalicençaCCBY(https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Second-hand smokeis defined as theinhalation of smoke
fromtobaccoproductsbynonsmokerswholiveindoorswith
smokers,beingthe3rdleadingcauseofpreventabledeath
worldwide,after activesmokingandexcess drinking.The
smokeoftobaccoproductsindoorsiscalled environmental
tobaccosmoke(ETS),consistinginmorethanfourthousand
components,withmorethan40carcinogens.Accordingto
theWorld HealthOrganization (WHO), ETS becomesmore
damaging indoors,aspollutedair cancontainuptothree
timesmorenicotineandcarbonmonoxideand50timesmore
carcinogensthanthesmokethatgoesthroughthecigarette
filter,inhaledbytheactivesmoker.1---3
Data from the National Cancer Institute (INCA) (2011) pointoutthattheBrazilianUnifiedHealthSystem(SUS)and SocialSecurityannuallyspendapproximatelyR$37million ondiseasesanddeathscausedbypassivesmoking,andthat thenumberofdeathsisapproximately3000nonsmokersper year.Moreover,accordingtoINCA,theWorldHealth Orga-nization (WHO)states thateach year5 millionindividuals die due to smoking-related diseases and that smoking is themain preventable causeofmorbidity andmortality. It isestimatedthat1100individualsadaydieduetosmoking. Studiesshowthatthereareapproximately1.2billion smok-ers worldwide,with 24.6million of them in Brazil alone. WHO estimatesreportthat 40%of childrenworldwideare exposedtotobaccosmoke.4---6
Smoking affects smokers and nonsmokers and, in the long-term, resultsin deleteriouseffectsonthe bodysuch
asincreasedriskofcancerintherespiratory,digestiveand urinarytracts,pancreasandcervix,risk ofcoronaryheart diseases and stroke. Exposure to ETS is associated with several diseases. Children exposed to ETS are more fre-quently affected by middle ear infections, reduced lung function, respiratory diseases such as pneumonia, bron-chitis and asthma exacerbations. Babies exposed to ETS have a risk five-fold higher of developing sudden infant death syndrome, and have higher risk of pulmonary dis-eases in the first year of life.1,7---12 The absorption of
cigarette smoke by children living with smoking parents indoors may differ in their concentration, according to thenumber of smokersin the household andthe number of cigarettes smoked to which the child is exposed. The WHO reports that the risks caused by second-hand smok-ing to health are significant, being well established and preventable.1,13
Studiesreportparentalknowledge aboutpassive smok-ing;however,thelackofinformationisstillevidentamong thelowersocioeconomicclasses.Nevertheless,evenamong thosewhoknow about the effectsof ETS, thereare par-ents who exposetheir children to the harmful effects of ETSathome.13,14Parentsshouldunderstandthatany
Method
This is a quali-quantitative study. Authorization was
requested fromall involved schools todevelop the study.
Thestudy wasapprovedby theInstitutionalReview Board
(protocol:161,431)ofCentroUniversitáriodeAnápolisand
wascarriedoutin sevenpublic schoolsin Anapolis, Goias
state, BR. Contact with the parents was made at school
meetings, when current smokers were identified through
aprevious dialog; thus, participantswere informedabout
the study and invited to participate. Of the 356 parents
identifiedinallschools,96reportedbeingsmokers,and60
(63%)fathersor mothersagreedtoparticipateandsigned
theInformedConsent form;the sampleincluded onlyone
smoker fromeach householdor both. Afterconsent,
par-entsansweredthequestionsoftheproposedinterview.Only
fathersormotherswhowereactivesmokersandliveddaily
withtheir children aged6---12 yearswere included in the
study,totaling58parentswhosmoked.Thetwoother
par-entswereexcludedbecausetheydidnotanswerallofthe
questions in the interview. Sample size was attained by
applyingthedatasaturationcriterion.
The interviews werecarried out according to a
proto-colthatincludeddataongender,age,durationofsmoking,
child’stime of exposure toETS, familyincome and level
ofeducation.The guidingquestionswereoutlinedforthis
researchandconsistedofthefollowing:doyouknowwhat
apassive smoker is? Do you consideryour child a passive
smoker?Doyouthinkthatyourchild,wheninthesameroom
withyouwhenyouaresmoking,mayhavesomedamageto
his/herhealth? Do youknow whattypeof damagethisis?
Wereyouawareoftheinfluenceofpassivesmokingon
respi-ratoryhealth(lungs)ofyourchild?Whatdoyouthinkmight
happen?Do you know whatenvironmental tobaccosmoke
is?Haveyou,atanypoint,beenadvisedontheinfluenceof
passivesmokingonthehealthofyourchildren?
Interviewswerecarriedoutinthefirsthalfof2014,ina
privateroom,availableatschool,startedandrecordedonly
whentheparticipantsfeltcomfortabletodoso.Attheend
oftheinterview,parentswereinstructedabout thetopic,
inordertoanswerquestionsaimingtoalertthemaboutthe
severaleffectsandharmsofETSandpassivesmokingonthe
healthoftheirchildren.
The interviews were transcribed. At this stage, the
recordedcontentwascarefullyplayedandlistenedto,with
theanswersofallparentsbeingaccuratelytranscribed,in
theformofnarrative.
Qualitativedatawereanalyzedthroughcarefulreading,
seekingtocapturethesignificantaspectsofthenarratives,
focusingonthe words or the senses. Afterextractingthe
categoriesofanalysisofthestudiedphenomenon,themost
remarkableandsimilarphrases werethen selectedto
for-mulatecategories of analysisof the ethnographicresults.
According to Rosa, Lucena and Crossetti, ethnography is
currently beingused asan important methodto enhance
factsrelatedtoindividuals’lifestyles,consideringthe
phys-ical,cultural,socialandenvironmentalaspectsandtheway
thesefactorsinfluence theirlife conditions,basedonthe
respondents.15,16Byemployingethnography,itwaspossible
tooutlineatrajectorytounderstandandinterpretthe expe-rienceof active smokers andtheir perceptions about the effectsofpassivesmokingontheirchildren’shealth.
Regardingthevariables---gender,age,durationof smok-ing,numberofcigarettessmokedaday,timeofchildren’s exposure toETS, family income and educational level of the parents, the descriptive analysis of data was carried outasmean,standarddeviationandrelativeandabsolute frequencies.
Results
The studysample consistedof58individuals,66% females
and 34%males, allactivesmokerswitha meanage of 30
years.The58adultslivedwith95children,withameanage
of9.2±1.7years,56%ofwhichwerefemales.
When parents were asked about duration of smoking,
they reported a mean time of 15.3 years. Regarding the
number of cigarettes smoked a day and duration of
chil-dren’s exposure to tobacco smoke, the mean was 20.1
cigarettes/dayandaround2.8hof exposuretoETSaday.
When analyzingtheknowledgeoftheseparentsabout the
ETS,59%saidtheyhadnoknowledgeofthesubject;
how-ever,60%ofparentsreportedknowingwhatapassivesmoker
was, while 52% said they did not consider their child a
passive smoker. The mean family income was around R$
1389.00; asfor the levelof education,45% said theyhad
finishedElementarySchool; 40%had finishedHighSchool;
8%hadattendedCollege/University,and7%wereilliterate.
The generated data based on narratives and
descrip-tions constitutedthe analysiscontent. Adetailed reading
of responses aimedtocapture the presence ofsignificant
aspectscontainedintheparticipants’statements.Themost
remarkableandsimilarphrasesamongtheparentswere
cho-senforeachquestion.
Whenasked‘‘Doyouknowwhatapassivesmokeris?’’,
mostparents,60%,saidtheydid;however,whenanalyzing
theanswers,weobservedapoorlevelofknowledgeamong
parents,asshownbythefollowinganswers:
‘‘Yes.WhenI’msmokingandyoucansmellit.’’ ‘‘Yes,whenI’msmokingandapersonisclosetome.’’ ‘‘Yes,whenyousmokewithoutprotectivefilter.’’ ‘‘Yes,peoplewhoareclosetothosewhoaresmoking.’’ ‘‘Yes,itistheindividualwhoisinthesameenvironment asthesmoker.’’
When they were asked ‘‘Do you consider your child a
passive smoker?’’ the majority of parents, 52%, saidthey
didnot.Onlytwoparentsjustifiedthereasonforthatwith
thefollowinganswers:
‘‘No,Idonotsmokenearthem.’’ ‘‘No,becauseIsmokefarfromthem.’’
Thedescriptiveanalysisoftheanswerstothequestions
‘‘Wereyou aware ofthe influenceof passive smokingon respiratoryhealth(lungs)ofyourchild?Whatdoyouthink mighthappen?’’showedthatsomeparentshadknowledge
about the influence ofpassive smokingonthe respiratory
healthoftheirchildren,asshownbytheanswers:
‘‘Yes,Ithink itcancause bronchitis,Idonot know,it somehowaffectsthelung.’’
‘‘Itgoesintothelung,doesn’tit?Andeventuallycauses alungproblem.’’
‘‘Yes,healthproblemsingeneral,itcanleadto respira-torydiseases.’’
‘‘Yes,youcanhavelungproblems.’’
‘‘Ithinkyouhave problems,butIdonotknow exactly whatcanhappen.’’
However,itwasobserved,inthedescriptiveanalysisthat
the majority of parents, 59%, reportednot knowing what
ETS isand, consideringthe analysisofthe answerstothe
samequestionabove,itwaspossibletoconfirmthelackof
informationonthe subject.Mosthadsimilaranswers,not
believing thattheirchildrencouldsuffersome respiratory
impairment,asdemonstratedbytheanswersbelow:
‘‘No,theyhardlystaynexttome andwhenIsmoke,I stayaway.’’
‘‘MyhusbandandItrynottosmokeneartheboys,soI thinktheywillhavenoproblems.’’
‘‘Ithinknothingwillhappentothe lungs.Ithink they mayhaveotherproblems,butnotinthelungs.’’ ‘‘IntheirlungsIdon’tthinkso,becauseitismylungthat suffers.’’
‘‘No,IthinkonlymyhusbandandIaretheoneswhowill havesomekindofproblem.’’
‘‘No,Iseeonlyincigarettespacks,butwedonotthink thatcanhappentous.’’
Whenaskedifthey,atanytime,hadbeengiven
instruc-tions about the influence of passive smoking on their
children’shealth,mostparentssaidtheyhadneverreceived
anyguidance,withthefollowingsimilaranswers:
‘‘No,Ihadneverheardofthissubject.’’ ‘‘No,nooneevertoldmeanything.’’
‘‘No,Ihadneverheardofsecond-handsmoke.’’ ‘‘No.ThisisthefirsttimeIhearsomethingaboutit.’’
Discussion
Second-handsmokeisthesecondaryexposuretocigarette
smoke or other tobaccoproducts by nonsmokerswholive
withsmokersindoors.The concernregardingtheeffectof
second-handsmokeonchildrenisonalargerscale,because
their bodily systems are still developing, especially the
immaturerespiratorysystem,whichcanbemoresensitive
tosuchexposure.1,17---19
Theenvironmentwherethechildlives,aswellasliving withadultindividuals,canexerciseinfluenceontheir devel-opment.Whenanalyzingtheresultsofthisstudyinrelation toparentalsmokingtime,weobservedameanof15.3years. Similarly, astudy thatassessedthe prevalence of respira-torysymptomsinchildrenandadolescentswith174parents pointedoutthat,regardingthedurationofsmoking,46.5% ofmothersand57.9%offathershadsmokedfor14yearsor longer.Astrongassociationwasalsodemonstratedbetween exposure tohousehold smokingand thedevelopment and increasedseverityofasthmainchildren.18---20
Asforthenumberofcigarettessmokeddaily,inthisstudy theparentssmokedonaverage20.1cigarettesaday.A lon-gitudinalstudyevaluatingtheincreasedincidenceofasthma inchildrenofsmokingmothersshowedthatchildrenwhose
motherssmokedmorethanhalfapackofcigarettesaday, especiallyinthe firsttwoyearsof life, wereabout twice aslikelytodevelop asthma,andthisfactmightbe associ-atedwiththegreatercontactbetweenmotherandchildin thisstage of childhood.21 In this study,the mean timeof
exposureof childrentopassive smokingwas2.83h a day. Vennersetal.evaluated1718childrenandadolescentsand reportedamildassociationbetweenparentalsmokingand thedeclinein lung functionof children whowerepassive smokers.22
Exposure toETS is associated with high morbidity and mortality in younger children. Children’s health is espe-cially vulnerable to the risk of such exposure, including upperandlowerrespiratory tractinfections.Astudy that evaluatedthe child’s exposure to tobacco smoke and its association with asthma development showed that oxida-tive/antioxidantbalance strongly leaned to the oxidative side in preschoolers who were passive smokers,with the developmentof acuteand chronic ear infections, asthma exacerbation,neurodevelopmental alterations, behavioral problemsanddecreasedschoolperformance.Thefree radi-calsoriginatedfromcigarettesmokeareconsideredamain causeofatherosclerosisandcancerandhave thecapacity todirectlyandindirectlyinduceoxidativestress.19,23
Astudycarriedoutwithchildrenwithasthmasymptoms showedthat 60% of the parents had less than 5 years of schooling.Aresearchthatanalyzed thedifferencesinthe prevalenceofsmokersamongsocioeconomicgroups found thatamongilliteratemenorthosewithlessthan4yearsof schooling,smokingprevalencereached 48.6%.Other stud-ieshavealsodemonstratedthathouseholdswhereparents had lower educational level had a higher occurrence of smoking.24---28
When considering family income, this study showed a mean of approximately two minimum wages. Studies considering the population stratification by income and occupation, showed increased consumption of cigarettes, twotothreetimeshigher,ingroups withworsesocialand economic status. It is important toquestion why parents withlowersocioeconomic statusarethe ones whosmoke themost.Smokingmaybearesponsetothestressand dif-ficultiesassociatedwithlivinginaneconomicallydeprived environment.29
When parentswereasked whethertheywereawareof theeffectofpassivesmokingontheirchildren’srespiratory health,themajorityansweredthattheydidnotthinktheir childrenwouldhaveanyproblems,notevenregarding respi-ratoryhealth.Otherparentsreportedtheybelievethatthe childrenmightonlyhaverespiratoryproblems,showingthat parentshavealackofinformationabouttheconsequences thatcigarette smokecan bring totheir children’shealth, oftenvictimizedbytheignoranceandneglectofadult smok-ers.Studieshaveshownthattobaccosmokegeneratesdirect andindirectimpactsonthechild’soverallhealthandsome ofthem,childrenofsmokingparents,showedfactors asso-ciatedwithlearningandlanguagedifficultiesandbehavioral problems.30 In the present study, some parents reported
tobecomeactivesmokersandacquirerespiratorydiseases, continuingthetobaccofamilycycle.31
Efforts to prevent morbidity and premature mortality dependonpreventionprograms,protectionpoliciesagainst tobacco,against tobacco exposure and effective smoking cessationprograms.Thecessationhelpstoreducethe bur-denofdiseases causedby smoking,due totheimmediate benefitsforthehealthofsmokersandpeoplewholivewith smokers. However, for many smokers, smoking cessation remainsadistantgoal.The change inbehaviormayoccur whenthemotivationforcessationisaltered,becausethere is a common ignorance about the magnitude of tobacco damage,combinedwiththetendencyofsmokersto under-estimatetheir personal risk. The strategy of approaching parentswiththepromotionofhealthofchildrenexposedto tobaccosmoke,insteadofpersonalrisk,canbeparticularly effectivewhenthesmokerbelievesthatthehealthofthe childwillhaveseveralbenefits.32,33
Parentsandteachersarerolemodelsduringchildhood. Parentswhosmoke arestrongexamplesfor theirchildren tobecomesmokers,whichwillnotonlymakethempassive smokers,butcanalsoinfluencethemtostartsmokingeven atyoung ages,causingthem severehealth problems. Itis importanttodevelopactionsthatwillleadthefamilyand theschooltocreatepreventiveactionsrelatedtotobacco consumption.
It is worth mentioning the difficulty of recruiting par-ents to voluntarilyparticipate in the study or attend the schoolmeetings,justastherewasasignificantlimitationin otherschoolstoopentheirdoorstothistypeofapproach, whicheventuallylimitedsamplesize.Asignificantweakness ofthisstudyisthefactthatitrepresentsaspecific popula-tionlimitedtoageographicalregion(sevenpublicschoolsin thecityofAnapolis,stateofGoias),ofwhichresultsdonot necessarilyapplytootherregionsofthecountry;however, itindicatestheneedformoreresearchexploringparental perception,asthe scarcity ofpublications onthe subject wasobserved.
Weconcludethatchildrenareexposedtoenvironmental tobacco smoke in the households, which was made evi-dentbythedata,durationofsmokingandmeannumberof cigarettessmokedaday.However,alack ofknowledgeon thepartofparentsregardingenvironmentaltobaccosmoke, passivesmokingandtheadverse effectsthatsmokingcan haveontheirchildren’shealthwasobserved.
Funding
Thisstudywassupportedby Fundac¸ãoNacionalde
Desen-volvimento do Ensino Superior Particular (FUNADESP) no.
3500655---IC13.01.13.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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