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Archivos argentinos de pediatría

Print version ISSN 0325-0075On-line version ISSN 1668-3501

Arch. argent. pediatr. vol.116 no.4 Buenos Aires Aug. 2018 


Measures stated by parents and caregivers of infants, toddlers, and preschoolers to prevent environmental tobacco smoke exposure


Sandra Ríos, B.S.a, Joselyn Concha, B.S.a and R. Mauricio Barría, M.D.b

a. Division of Neonatology, SubDepartment of Pediatrics, Hospital Base Valdivia.
b. Office for Evidence-Based Health (Oficina de Salud Basada en Evidencia, OSBE), School of Medicine, Universidad Austral de Chile. Valdivia, Chile.

E-mail address: R. Mauricio Barría, DrPH:

Funding: None.

Conflict of interest: None.

Received: 5-22-2017
Accepted: 1-8-2018



Introduction. The exposure to environmental tobacco smoke is a public health problem because of its potential risks for children.
Objective. To determine the preventive actions taken by parents and/or caregivers of infants, toddlers, and preschoolers regarding environmental tobacco smoke exposure.
Methods. Cross-sectional, analytical study in parents and caregivers of infants, toddlers, and preschoolers from Valdivia, Chile. A questionnaire on preventive measures regarding environmental tobacco smoke was administered. The questionnaire was analyzed with descriptive and association statistics using Fisher's exact test and logistic regression to calculate the odds ratios (ORs) and their corresponding 95% confidence intervals (95% CIs) as an estimation of the risk for not taking preventive measures at home.
Results. A total of 469 parents and caregivers participated. The prevalence of households with one member who smoked was 51.8%. Most of them smoked outside the house (92.2%). The most common measure taken outside the household was to avoid places where people smoked. In this setting, a significant difference was observed between men and women in relation to avoiding exposure (7.6% versus 2.2%; p= 0.040). A higher risk for not avoiding tobacco use inside or outside the housewas confirmed when a household member smoked (OR: 3.55; 95% CI: 2.05-6.14). Also, a lower risk was observed when there were two or more children in the household (OR: 0.46; 95% CI: 0.26-0.83).
Conclusions. Most parents and caregivers ask others to smoke outside and avoid places where people smoke; however, the level of prevention is lower among households with smokers.

Key words: Preschooler; Smoking; Tobacco smoke pollution.



Tobacco use is an important public health problem associated with more than seven million deaths every year; six million people are direct users and almost nine hundred thousand are non-smokers exposed to secondhand smoke.1 Worldwide, 40%, 35%, and 33% of children, women, and men who do not smoke, respectively, have been exposed to secondhand smoke; the burden of disease has shown to be unequal: children are the most affected ones in terms of disability-adjusted life years.2

The exposure of children to environmental tobacco smoke (ETS) leads mainly to adults who smoke in places where children live and play, which includes exposure to second- and thirdhand smoke.3-6 The consequences are given by the susceptibility of children to smoke toxicity and include a higher risk for sudden infant death, middle ear pathology, severe asthma, acute respiratory infection, pneumonia, and impaired lung function, as well as school absenteeism and restricted activities.7,8

Therefore, the different governments have implemented policies and interventions aimed at reducing home exposure through education campaigns for parents and at avoiding the exposure of children in public places.9 This was evidenced in Chile by the implementation of the anti-smoking law (19419 and 20660).10,11

However, in spite of these initiatives, ETS exposure still occurs in outdoor public places and it has not been possible to protect children at the place where they are most vulnerable: their home.12,13

At a local level, data are available on the prevalence of indoor tobacco use,14-16 but there is no information regarding the measures taken to prevent ETS exposure.

The objective was to determine preventive actions taken by parents and caregivers of infants, toddlers, and preschoolers from the city of Valdivia, Chile, to reduce the exposure of children to ETS.


This study was based on and broadened the findings of the dissertations by researchers SR and JC as a requirement to qualify for their Bachelor of Science in Nursing of Universidad Austral de Chile. An observational, cross sectional design was selected for the study in a sample representative of the city of Valdivia, Chile, to meet the proposed objective in a timely manner. The target population was made up of parents and caregivers of infants, toddlers or preschoolers attending educational facilities in the city of Valdivia. The eligibility criteria were being older than 18 years (based on their discernment and legal competence), living in the city of Valdivia (to facilitate contact and data collection), and being the legal guardian of a child younger than 7 years enrolled in a nursery school or a day-care center that was part of the National Board of Nursery Schools (Junta Nacional de Jardines Infantiles, JUNJI) or Fundación Integra or a registered private facility, besides public schools, publicly-subsidized private schools, and private schools corresponding to the Ministry of Education that offered preschool education (pre-kindergarten and kindergarten).

A probability sample of 469 subjects based on a population of 6624 subjects enrolled in 2013 (report by Fundación Integra, the JUNJI, and the Provincial Department of Education), a prevalence of indoor cigarette smoking of 12.1%,17 a 95% confidence level, and a 3% estimation error were estimated. The sampling was done using a random and stratified technique, proportional by facility and level. This means that out of the randomly selected 21 facilities for infants and 15 facilities for preschoolers, a proportional weighted sample was obtained based on the population of these facilities. The same process was performed within each facility for every level. Potential participants were contacted during facility meetings; then, once the informed consent process was developed, the total number of participants defined by level was randomly selected. To complete the 469 subjects required, 474 individuals were invited because five refused to participate; with this, participation reached 98.9%. No differences were observed in the characteristics of those who were not included in the study and those who were.

Data were collected between April and December 2014 using a self-administered, anonymous questionnaire based on close-ended questions, which was developed based on expert opinion and pilot-tested in a sample similar to that of the study. The pilot test included 31 subjects from a facility that was not selected for participation and that shared similar characteristics with the ones included in the study. As a result, questions were restructured from open to close-ended, and answer options were included. On the basis of this, appearance and content were validated.

The following outcome measures were considered: sociodemographic aspects (age, sex, marital status, level of education, etc. of the father, mother or caregiver), smoking habit (active smoker: yes/no), smoking intensity (cigarettes/day), indoor smoking (yes/no), usual place for smoking, and actions taken to prevent ETS exposure at home. For this outcome measure, only household members who were active smokers were taken into consideration; it included the following: I) smoking outside the house; II) smoking indoors and airing the room; III) smoking in a different room, and IV) not taking any preventive measure. Measures regarding people who smoked but were not part of the household (actions taken at home in the presence of a third-party who smoked) were also assessed, including the following: I) asking them not to smoke; II) asking them to smoke outside the house, and III) allowing them to smoke sometimes. Lastly, actions or measures taken to prevent ETS exposure outside the household were assessed, including the following: I) no prevention; II) avoiding prolonged exposure (i.e., passing by a place where someone was smoking but not staying there); III) avoiding places where people smoked; IV) other.

Statistical analysis

Collected data were coded and included in data collection sheets in duplicate by two of the researchers for subsequent consistency assessment. The exploratory analysis included detecting missing or inconsistent data and the distribution characteristics of outcome measures. Data were analyzed using descriptive statistics with frequency distribution, measures of tendency and dispersion. Categorical and nominal outcome measures, such as sex, marital status, etc., were described as proportions. For quantitative outcome measures (e.g., age, intensity of cigarette smoking, etc.), mean and standard deviation (SD) or median and range were determined, based on the adjustment to normality as assessed by graphic representation (histogram) and the Kolmogorov-Smirnov test. Once the smoking habit status was established, the actions to prevent ETS were described by category (yes/no) and sociodemographic factors. Since the household was the main place of exposure, a multivariate model was developed using logistic regression to assess the effect of different outcome measures on "preventive measures taken at home regarding a third-party who smoked." To this end, this outcome measure was dichotomized into: I) did not allow smoking and II) allowed smoking (inside or outside the house). Outcome measures that showed a univariate association with the result and based on the theoretical plausibility criterion were included in the model. Crude and adjusted odds ratios (ORs), and their corresponding 95% confidence intervals (95% CIs), were estimated; a p value < 0.05 was considered statistically significant. The Stata software, v.11.1 (Stata-Corp, College Station, TX, 2009) was used for analysis.

Ethical aspects

The study was approved by the Ethics Committee of the Department of Health of Valdivia (Resolution 064, dated March 10th, 2014) and authorized by the Regional Division of Fundación Integra, the Regional Division of the JUNJI, the Department of Municipal Education Management, and the Provincial Department of Education of Valdivia.


1. General characteristics

Regarding the relationship with the child, it was observed that most participants were the mothers (72.5%); the participants' mean age (± SD) was 32.9 years ± 9.2, their mean level of education corresponded to 13.6 years ± 4.1; most had completed secondary education (50.8%) and were married (38%) (Table 1). The median number of children in the care of a parent or caregiver was 4; the mean age of children was 4.0 ± 1.5 years, ranging between 0.2 and 6 years.

Table 1. Sociodemographic characteristics of parents or caregivers (n= 469)

2. Exposure to environmental tobacco smoke

It was observed that 51.8% of households (n= 243) included at least one member who smoked. In 140 (57.6%) of these, only one member smoked. Eleven point nine percent of participants stated that they smoked in the presence of children. Among the households of smokers, 56% of fathers were tobacco users (n= 136). They smoked a mean number of 5.1 ± 4 cigarettes per day. Of these, 5.9% smoked 1-4 cigarettes inside the house on a daily basis. The mothers of 130 households (53.5%) were tobacco users. They smoked a mean number of 2.8 ± 2.6 cigarettes per day. Of these, 9.2% smoked 1-6 cigarettes inside the house on a daily basis (Table 2). Out of all smokers, 32.5% stated that they smoked at work; 5.8%, at home; 31.3%, in the street; 67.1%, in the backyard; and 0.8%, in other places.

Table 2. Characteristics of the smoking habit in households with smokers (n= 243)

3. General preventive measures

Among the households with smokers (n= 243), 92.2% smoked outside the house and 3.3% did not avoid ETS exposure indoors. Three participants (1.2%) smoked indoors and aired the room, and 3.3% smoked in a different room. Among smokers, 34.2% stated that they had never attempted quitting; 50.6%, had attempted once; and 15.2%, multiple times.

Among all respondents, most (82.7%) asked others to smoke outside, and only 3 (0.6%) allowed smoking inside the house. The analysis of sociodemographic outcome measures (Table 3) underscored that the proportion of parents and caregivers who asked others not to smoke was significantly higher in the households with two or more children than in those where there was only one child (20.6% versus 10.7%; p= 0.009). A statistically significant difference (p < 0.001) was also observed between households with and without smokers: smoking was prohibited in 25.2% of households of non-smokers but only in 8.6% of households with smokers, and even smoking indoors was allowed in 3 (1.2%) of these.

Table 3. Preventive measures taken at home regarding third-parties (n= 469)

In relation to the measures taken outside the household (Table 4), the most common one was avoiding places where people smoked; a significant difference was observed between men and women in terms of avoiding exposure (7.6% versus 2.2%; p= 0.040). No significant differences (p= 0.502) were observed between the households of smokers and non-smokers in this regard.

Table 4. Preventive measures taken outside the household (n= 469)

4. Risk for not taking preventive measures at home

The multivariate model (Table 5) to establish the factors associated with allowing smoking (inside or outside the house) showed that the main risk was the presence of a smoker in the household (adjusted OR: 3.55; 95% CI: 2.05-6.14).

Table 5. Estimation of the risk for not taking preventive measures at home

On the contrary, the presence of more than one child in the household was a protective factor (adjusted OR: 0.46; 95% CI: 0.26-0.83).


We approached ETS exposure and the preventive measures taken by the caregivers of infants, toddlers, and preschoolers of a city in the south of Chile, a scenario that had not been assessed before. Significant differences were observed in the preventive measures taken at home depending on the presence of smokers in the household. Outside the house, although measures were taken to avoid ETS exposure, some parents and caregivers did not prevent exposure, especially men.

A high prevalence of the smoking habit was observed (51.8%), but a small percentage (< 10%) of participants smoked indoors, similar to the 8.7% observed previously in the households of newborn infants in Valdivia.15 Also, in Temuco, 46.3% of mothers and female caregivers of infants, toddlers, and preschoolers smoked, and 36.8% of them did it indoors.14

At an international level, in Sweden the prevalence of smoking was 7% in households with infants;18 in Canada, it was 22% in households with children,19 and in Portugal, it was 36.7% in households with children and adolescents younger than 18 years.20 In Argentina, on their part, the prevalence of ETS exposure at home was 27.6% in the general population.21

It was established that almost all parents smoked outside the house, which is noteworthy because there was evidence that this reduced exposure to ETS resulting from indoor smoking.22,23 Regarding the measures taken towards third-parties who smoked, the most common action was asking them to smoke outside the house, as reported in Sweden, where 56% described the same action: results were positive but on a smaller scale than those found in this study.18 By contrast, in England, data reported that, in 42% of households, people smoked in the presence of children, which is much higher than the 11.9% observed in this investigation.24

This study also found a significant association between the preventive measures taken regarding ETS at home and the number of children present in the household. This was consistent with the data that demonstrated that households with children were 17% less likely to experience ETS exposure at home than those without children (OR: 0.83; 95% CI: 0.80-0.87).19

Regarding the preventive measures taken outside the household, most avoided public places where people smoked. This was consistent with a previous study conducted in Santiago, where 83.5% of participants indicated that it was pleasant to be in smoke-free places. Actually, 25.4% of smokers stated that they smoked less since the anti-tobacco law was passed.25 Consistent with this, it has been proposed that smoke-free public places appear to stimulate the adoption of smoke-free households, a strategy that has been associated with both a higher frequency of quitting attempts and their success.26 In Argentina, the regulation of advertising, promotion, and use of tobacco and the prohibition of smoking in closed public areas also led to a reduced exposure to ETS at home.21

However, some reports do not show a reduction in parental tobacco use following the implementation of regulations and restrictions. In addition, as parents do not quit smoking, their house remains the main place for smoking when smoking is restricted in public areas.27

In relation to specific interventions, some studies have reported changes in the level of particulate matter or nicotine, thus suggesting effective programs to reduce ETS at home. However, pollution persists and requires other strategies to fully protect children.28 Thus, it is necessary to combine effective actions to protect children at home, such as the following: I) encouraging parents to quit smoking; II) making interventions aimed at promoting smoke-free households; III) implementing regulatory approaches, such as smoke-free households; IV) running public health education campaigns to encourage smoke-free households beyond the extent of regulatory approaches.28 That said, there is not sufficient data to recommend one strategy over another to reduce ETS exposure in children or evidence of success in different contexts (healthy children, sick children, the community).29 Impact assessments are required accordingly for each context and region so as to establish which interventions are most cost-effective.

Finally, considering the outcome measures that were not assessed and that may interact in the relationship between exposure and preventive measures, this study did not analyze the individual characteristics of tobacco use because it centered on family use; children were younger than 7 years, which did not allow us to establish preventive measures regarding older children; lastly, some numbers may have been underestimated due to the pressure of giving a response that was socially acceptable. Such limitation should also be considered in the context of a self-reported measurement that was not biochemically validated, for example, by measuring urine cotinine levels.

In relation to the measures taken to prevent ETS exposure, this was a ground-breaking study that analyzed the actions taken by parents and caregivers in Chile, so comparisons with the findings of other studies may be different based on the sociocultural contexts where they were developed.


Most parents and caregivers ask others to smoke outside and avoid places where people smoke; however, the level of prevention is lower among households with smokers.


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