Determinants of change in paternal smoking trends during pregnancy in Lebanon
Monique Chaaya, Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, P.O. BOX 11-0236, Riad El-Solh/Beirut 1107-2020, Lebanon. E-mail: firstname.lastname@example.org
For pregnant women and their fetus, secondhand smoking poses major public health effects. This study analyzes the determinants of change in smoking behavior among fathers whose partners were pregnant. The study is a secondary analysis of a nationally representative Lebanese cross-sectional survey of 1,028 households conducted in 2007. Currently smoking fathers with a child of 5 years of age or less were included. The main outcome was the change in the father's smoking behavior during his wife's last pregnancy. The study concluded that fathers who changed their smoking patterns when their wives were pregnant were significantly more educated, more likely to smoke a lesser number of cigarettes per day (OR = 96, 95% CI (0.93, 0.99)), and more knowledgeable about cigarette constitutes and its health risks (OR = 1.37, 95% CI (1.08, 1.74). Public health practitioners and health professionals are recommended to raise awareness and provide cessation programs for parents and especially fathers.
Smoking has well been established in the literature as a major public health threat. In the United States, smoking is considered the leading preventable cause of death and disability. In addition to the health risks associated with active smoking, cigarette smoking also produces secondhand smoking which is associated with other major health risks (1). Several studies demonstrated the effects of secondhand smoking during pregnancy on both the mother and fetus (2–8). Other studies focused on the profile of mothers who smoke during pregnancy or the determinants of smoking during pregnancy (9–13). According to the published literature, very little research has focused on the determinants of paternal smoking during pregnancy (4,14,15).
In the United States, the home was the major source of secondhand smoking according to the National Health and Nutrition Examination Surveys (NHANES) (16). The respondents reported that 58% of the exposure was at home and the major source of smoking at home was the spouse (16). Among women of childbearing age, 30% of those aged 20–29 years and 26% of those aged 30–39 years reported exposure to secondhand smoking. In developing countries, a survey was done in 2008 on nine developing nations to study tobacco use and secondhand smoke exposure during pregnancy. The study, covering nations in Latin America, Africa and Asia, revealed that 50% of pregnant women in Pakistan and 30% in Argentina and Brazil were frequently exposed to indoor tobacco smoke; making secondhand smoking a major violation to the ‘right to health’ of women and their fetus (17).
In Lebanon, only one study has measured practices of smoking among pregnant women and their exposure to secondhand smoking (18). In this study a stratified sample of 864 women from 23 health care centers distributed in the country were interviewed. The study revealed that 70% of the reported exposure to secondhand tobacco smoking.
Regardless of the mother's smoking status, secondhand smoking has adverse health effects on the fetus. Secondhand smoking is more harmful than active maternal smoking during pregnancy, because it contains fetal toxins in greater concentrations (3). It has been associated with preterm deliveries (2, 6). Paternal smoking in front of a non-smoking mother is considered as secondhand smoking to the mother and thus to the fetus. In several studies the adverse effects of paternal smoking have been described, specifically a decreasing trend in birthweight with an increasing number of cigarettes smoked by the father, as well as childhood leukemia, lymphomas, and malignant central nervous system tumors (2, 4–6, 15). Moreover, heavy paternal smoking increased the risk of pregnancy loss with an adjusted odds ratio of 1.81 (7).
Although paternal smoking during pregnancy poses a major public health threat on both the mother and fetus, little research has been conducted concerning paternal views of secondhand smoking during pregnancy. Only one qualitative study, conducted in South Australia, looked at the determinants of paternal smoking during pregnancy. Partners who did not stop smoking suggested that the fetus was protected inside its mother's womb and some argued that the smoke going out from the cigarette is filtered twice before reaching the fetus (once through the father's lungs and a second time through the mother's lungs). Other partners did not feel the urgency to stop smoking as long as their wives were themselves smokers (14).
Given the important gap in the literature, the present study was conducted to analyze the determinants of change in paternal smoking trends during pregnancy in Lebanon.
Material and methods
Subjects selected for this analysis were part of a larger study done in 2007 on a nationally representative sample (N = 1,024) of Lebanese parents who at the time of the study had adolescent kids. The aim of the original study was to measure parents' knowledge, attitudes, and behaviors towards narghile (waterpipe) and cigarette smoking. For the undertaken analysis, fathers who, at the time of the study, were regular smokers and had a child of less than five years old were included. This was done to minimize recall bias among fathers when asked about their smoking patterns during their wife's last pregnancy. This inclusion criterion resulted in a sample of 100 fathers.
Data collection was done through face-to-face interviews with the father. All fathers gave oral consent to participate in the study. The study was approved by the Institutional Review Board at the American University of Beirut.
In addition to demographic variables such as age, educational level, working status, and household income, questions about cigarette use were asked. Those included current smoking status, age at initiation, number of daily cigarettes smoked and smoking pattern during theirs wife's last pregnancy. Answers to the latter question were categorized into ‘change in pattern of smoking’ for those who stopped, quitted or did not smoke near their wives when she was pregnant and ‘no change in pattern of smoking’ for those who did not change their smoking pattern. Moreover, knowledge about the health risks of cigarettes was assessed by questions about cigarette constitutes and associated diseases.
Educational level was grouped into three categories: less than secondary for those who completed intermediate education or below (≤ 6 years of schooling), secondary for those who had some or completed secondary education (7–11 years of schooling) and university for those who had some or completed university education (≥ 12 years of education). Household income, in Lebanese Liras, was categorized into four categories: 0–750,000 ($500), 750,000–1 million ($667), 1–3 million ($2,000) and greater than 3 million.
Mother's smoking status during pregnancy was categorized into three groups: smoked, stopped smoking, and non-smokers.
Total knowledge about health risks of cigarette smoking was assessed by summing all correct answers to the questions about the health risks of cigarette smoking and cigarette constitutes.
Summary statistics using means and standard deviations for continuous variables and frequency distributions for categorical variables were computed to describe the sample with respect to its socio-demographic background and smoking status. Demographic variables as well as variables about cigarette use and knowledge of cigarettes health risks were compared between fathers who changed their smoking pattern when their wives were pregnant and those who did not. This was done using the t-tests for continuous variables and chi-squared or Fisher's exact test for categorical variables. Variables that were significant at the bivariate level were included in a multivariate logistic regression model which also controlled for demographic variables such as age and educational level. The magnitude of association between the predictor variables and fathers' smoking pattern during pregnancy were presented using both crude and adjusted odds ratios (OR) and their corresponding 95% confidence intervals. Significance was set at the 5% level and all analyses were performed using the Statistical Package for Social Sciences (SPSS version 16, Chicago, USA).
Sample characteristics are summarized in Table 1. Fathers had an average age of 42 years. The majority of fathers had less than a secondary education (51%), however, all of them were currently working and 40% reported an income between 1 and 3 million Liras.
Table 1. Demographic characteristics of the sample (N = 100).
|Age started smoking||17.35||3.48|
|No. of cigarettes/day||34.35||15.42|
| Less than secondary||51||51.0%|
|Household income|| || |
| 750,000–1 million||34||34.3%|
| 1–3 million||39||39.4%|
| More than 3 million||7||7.1%|
|Change in husband's smoking behavior when wife is pregnant|
| No change||60||60.0%|
The average age of onset of cigarette smoking was 17 years and fathers smoked on average 34 cigarettes/day. Only 40% of the fathers changed their smoking behavior when their wives were pregnant.
Fathers who changed their pattern of cigarette smoking when their wives were pregnant had higher education, smoked less cigarettes per day and were more knowledgeable about cigarette constitutes and health risks as compared to those who did not change their smoking pattern (Table 2).
Table 2. Unadjusted and adjusted odds ratio with 95% confidence intervals.
|No. of cigarettes/day||0.96||0.93-0.99||0.01||0.96||0.93–0.99||0.03|
|Educational level|| || || || || || |
| Less than secondary||1|| || ||1|| || |
|Knowledge score of smoking health risks||1.27||1.04-1.55||0.02||1.37||1.08–1.74||0.01|
|Mother's smoking status during pregnancy|| || || || || || |
| Smoked||1|| || ||1|| || |
| Stopped smoking||0.21||0.06-0.71||0.01||0.42||0.10–1.85||0.25|
The present study is the first to report information on the determinants of paternal cigarette smoking when the wife was pregnant in Lebanon and among the few in the literature that address this issue globally. The study showed that paternal smoking during pregnancy is a public health issue of significant magnitude as 60% of fathers did not change their behaviors when their wives were pregnant. In the present study three factors were directly associated with the change in paternal smoking during pregnancy: the father's daily consumption of number of cigarettes, his education and his knowledge of cigarette constitutes and smoking health risks.
The significant association between education and the change in paternal smoking trends is in line with findings of Grimard and Parent that the higher the fathers' education, the higher the probability of changing their smoking trends (19). As Grimard and Parent suggested, more educated people are better able to process the information related to the adverse smoking effects. However, other researchers found conflicting results and stated that smokers do underestimate their smoking and its adverse effects (20).
In the literature, knowledge about the harmful effects of smoking seemed to have an effect on maternal and paternal smoking during pregnancy (18,19). A Lebanese study among pregnant women revealed that those who quit smoking were slightly more knowledgeable about the harmful effects of smoking (18). In line with the literature we have found that the higher the knowledge score of smoking adverse effects, the more likely they were to change their smoking behaviors.
Secondhand smoking is still an unsolved main issue prevalent in Lebanon in relation to the rapid spread of cigarette and narghile (waterpipe) smoking, the growing social acceptability of smoking among the youth and women, the lack of tax regulations, the absence of banning laws, the lack of control on the trading and advertising of tobacco products and the deficiency in the knowledge of the harmful effects of smoking (11). In relation to secondhand smoking in Lebanon the problem gets much worse since laws protecting non-smokers are almost non-existent.
Developed countries have long since realized the public health risk of tobacco smoking and have made many attempts to control its spread and to reduce it. In Lebanon we still lack a lot in the process of assessing, planning, intervening and evaluating. According to Chaaya et al. and Lu et al. one of the determinants of maternal smoking during pregnancy is the partner's smoking habit (11, 13). Accordingly, focusing on the father's smoking pattern will not only help in decreasing smoking among fathers and possibly help them change their smoking patterns during their wives pregnancy, but also facilitate in the reduction of smoking among mothers too. Thus interventions targeting fathers can lead to better health for all individuals in the family: the father, the mother, and their unborn baby. This may be done by conveying information to couples about the harmful effects of smoking through health awareness programs and introducing cessation programs. Prenatal visits can be utilized, where obstetricians and gynecologists might play a greater role in reducing smoking during pregnancy, especially since many studies have concluded that health care providers are not addressing the problem well. According to a qualitative study done in England on paternal smoking during pregnancy, men reported that usually during a prenatal visit only the women are questioned about their smoking habits and it was rare that help or counseling was offered to assist the couple in quitting (14). In Lebanon only two-thirds of the women were asked about their smoking status by the health care provider and only 36% received information on the harmful effects of smoking (11).
Public policies should also be implemented. The reason behind the decreasing trends in exposure to secondhand smoking among the USA population between 1988 and 2002 lies in the implementation and enforcement of smoking restrictions and laws in public and work places (1). Lebanon is in great need of the implementation of policies that ban smoking in public places, control its trade, increase its taxes and reduce its consumption.
Self-reporting and recall bias might be the major limitations of the current study. We tried to minimize the effects of recall bias by selecting fathers who at the time of the study were current smokers and whose wives were pregnant not more than five years prior to data collection. The selected fathers did not differ from those fathers who at the time of the study were current smokers (N = 420), except for age (the latter group on average older by about four years) and household income (the latter group had larger income). The original study was also not designed for the purpose of determining paternal smoking during pregnancy and thus questions related to the knowledge of adverse health effects of secondhand smoking on the fetus were not included. Finally a small sample size might have masked the detection of small yet important differences.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.