Mortality and morbidity deriving from tobacco use and exposure remain a global threat to health in the pediatric population [23]. Although smoking has decreased steadily among adults aged 18 and over in the last 50 years, the prevalence of smoking in Europe as a whole is still approximately 24%. Although public awareness of the damage to health caused by primary and secondary smoking has increased, awareness of exposure to THS, that part of the smoke remaining in the environment long after the cigarette has been extinguished, is still inadequate. Studies that commenced in 1991 under the auspices of the world’s largest cigarette manufacturer and that are still being published today have shown that even if ventilation is performed after a regular eight-hour smoking period, high concentrations of nicotine, nitrosamines, and carcinogenic substances remain in the air for 12 hours, and on carpets, curtains, clothes, and wallpaper for more than two months [24].
Although one child in five worldwide is reported to be exposed to tobacco smoke, it has been emphasized that the true figure is much higher because parents under-report smoking in the home and in their cars [25]. Cigarette smoking traditionally began as male behavior and a show of strength. However, manipulation on the part of the powerful tobacco industry also encouraged women to smoke as a supposed symbol of freedom and gender equality [26]. Smoking rates across the world are still higher among men than women [27]. Starting smoking at a young age is directly correlated with low income, low education levels, and membership of the working class [28]. In agreement with the previous literature, the prevalence of smoking in the present study was 21%, with a male/female ratio of 2.81, and exposure to smoking was observed at an approximate level of 21.1%. Higher rates of starting and quitting were determined among non-parent caregivers (grandfathers and grandmothers). We attribute this to increasing age-related health and financial limitations and regret over having smoked previously.
Lower socioeconomic status, whether in terms of income or education, has been identified as a greater risk in terms of exposure to cigarette smoke [29]. This explains the lower exposure to THS observed with the criteria of higher income, a higher level of education, and owning one’s own home. In the present study, being a university graduate was associated with 18-fold higher awareness on the subject of THS, a high-income level with four-fold higher awareness, and home ownership with three-fold greater awareness.
Homes and cars today represent the principal closed areas in which children are exposed to passive smoking. Potential areas of exposure to THS include homes where smoking takes place, apartments and houses previously inhabited by smokers, and cars in which people have smoked [11,30,31]. One in three of the patients in this study reporting that smoking did not take place anywhere in the home represents the most desirable situation in terms of exposure to THS.32 Reported rates of smoking prohibition in the home and car among smokers and non-smokers were 55.1% and 64.2% in Japan, 45.6% and 61.6% in Spain, and 83.7% and 78.1%, respectively, in the USA [33-35]. Some parents in the present study smoked in either some places in the home or everywhere in the home. A study from Israel reported that 39% of smoker parents smoked on the balcony, 34.1% anywhere in the home, and 26.8% outdoors [17]. Smoking in the home, even on the balcony, impacts on children in terms of both SHS and THS. Although parents who smoke on the balcony may think that this does not harm their children because they are not present with them, the children are still exposed to toxic pollutants that adhere to their skin, hair, and clothing. Since some components of THS can remain in clothing fibers for up to 19 months, even if smoking takes place in the open air, THS can still be deleterious to babies and children if they come into contact with contaminated clothing, by being picked up, for example [15]. Smoking when children are not present only prevents exposure to SHS, and does not prevent the harmful effects of THS.
In addition, due to the restricted area involved, smoking in cars has been shown to be potentially 23 times more harmful than smoking in the home [36]. Smoking in the car may be an indirect reflection of heavy smoking at home. A recent survey from Ireland showed that one child in seven was exposed to smoking in cars [37]. Consistent with the present study, Dai et al. reported that half of smokers in Japan also smoked in their cars [38]. We think that one factor in this is that vehicles in which nobody has smoked are more popular in terms of sales, and are sold for higher prices in Turkey.
One important finding of this study is the 8.7% level of awareness of the term THS. Awareness increased in proportion to education and income, and was lower in mothers. Higher awareness was determined among individuals who did not permit smoking in the home, but no significant association was found with smoking. We think that the most important factors in this context are the lack of attention paid to THS on the radio, television and social media, the lack of eye-catching public information broadcasts, and the limited level of knowledge of the subject among research and health professionals on the subject.
Although the majority of parents knew the term THS, they replied ‘I Agree’ to questions regarding health and persistence. Participants with higher sociodemographic findings, such as smoking and awareness of the term THS also registered higher BATHS scores. Studies have also shown higher scores among young parents [19,26,39]. No significant age difference was observed when the age groups were compared in the present study.
Children are particularly susceptible to diseases deriving from exposure to cigarette smoke due to their narrower airways, frequent exposure to respiratory diseases, the immaturity of their immune systems, and more frequent oxygen requirements [40].
Child health clinicians affect the beliefs of parents concerning the potential harm that THS can inflict on their children. Parents who are advised to quit smoking or to make their homes or cars smoke-free by a pediatrician are more likely to believe that THS is deleterious to their children’s health [41]. However, the level of awareness of the term THS among health workers in a study from Spain was only 34.8%, showing that awareness also needs to be raised among clinicians [42].
Fathers who smoked more on a daily basis (compared to mothers) are less likely to believe that THS is harmful to children.41 In the present study, too, parents who smoked were three times less likely to believe that THS is damaging to children. In contrast, effective educational messages and counseling for parents concerning THS can help promote no-smoking guidelines and acceptance of assistance for quitting.
All heath care environments must be entirely smoke-free. Bans on smoking will help protect children and the whole family against exposure to SHS and THS. It is particularly important for medically vulnerable children to visit institutions that are free of all forms of tobacco smoke contamination [41].
Limitations
This study involved a large number of participants in order to obtain sound results. However, it was performed with parents visiting our hospital’s pediatric clinic. It is limited by its single-center nature, and the findings cannot be generalized to the whole country. In addition, smoking history (active smoking and exposure to cigarettes in the home or car) and their effects on health were based on self-reports. Relying on parental self-reports may lead to bias error.