Parental health risk perceptions and preventive measures related to Children’s second-hand cigarette smoke exposure in Malaysia

This cross-sectional nationwide study conducted from October 2018 until April 2019 involved data collection from 13 states and 2 federal territories in Malaysia. Eligible participants were recruited in public areas, including shopping malls, playgrounds and food courts. The data collectors approached parents at their convenience in the abovementioned public areas during weekends. The exact time of data collection was not specified.

The study included parents with at least one child aged ≤12 years. The sample size was calculated based on an estimated smoking prevalence amongst Malaysian adults of 25% (highest estimate reported by the National Health and Morbidity Survey Report in 2015) [19]. A minimum sample size of 289 parents was required, with a precision level set at 5% and a confidence level of 95%. Twenty participants were needed from each state and federal territory.

A validated questionnaire measuring parental risk perception of SHS on their children’s health was adapted from Myers et al. [8]. The instrument had a good reliability coefficient, with a Cronbach’s alpha of 0.934 and a validated construct to quantify parents’ perceptions of their children’s exposure to SHS. Due to logistical difficulties in collecting nationwide data, the third section of the questionnaire with eight photographs was adapted. Following consultation with the author, it was felt that this adaptation did not violate the questionnaire’s validity. The photographs showed parents smoking in the presence of young children in various settings (indoors with an open window, in a closed room and outdoors) at different distances. The exact question asked was ‘Please rate the health risk to the child in the pictured situation’. The respondents were required to rate the risk level of SHS exposure to young children’s health based on a 5-point Likert scale ranging from 1 (no risk) to 5 (extremely high-risk). A questionnaire from Ratajczak et al. (2018) was adapted to assess if parents had implemented household and car smoking restriction rules as preventive measures to protect their children from SHS exposure [20]. An additional question was added as a separate section to explore whether parents had taught their children to stay away from smokers as a measure to avoid SHS exposure [18].

The questionnaire was translated into Malay via forward and backward translation. The questionnaires in English and Malay underwent content and face validation by 2 paediatricians and were pre-tested by 10 parents for each language. Both the English and Malay questionnaires were built into an online electronic form (Google Forms).

Data collectors from each state were sent instructions specifying the procedures. If both parents were present during recruitment, they were invited to participate and required to answer the questionnaire separately, which allowed each parent to respond without being influenced by the other. Both parents from the same household were allowed to participate mainly because of the issue of gender imbalance in the context of SHS exposure at home. Women may sometimes demonstrate behaviour that meets cultural social expectations, particularly in Asian countries. Some women think that it is inappropriate to interrupt the husband or father-in-law who smokes in the shared space at home despite having a negative attitude towards SHS. A qualitative review found a gender imbalance, describing women’s lack of agency in changing male family members’ smoking behaviour in the home [21, 22]. Hence, the mother’s perception may be different from the father’s even though they are from the same household. The parents who agreed to participate were required to give online informed consent and answer the questionnaire on a mobile device provided by the data collector to ensure only one entry per participant.

All statistical tests were analysed using SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Parental occupation was coded based on Standard Occupational Classification 2010 [23]. Descriptive analysis was used to summarise participants’ characteristics. Each scenario of SHS exposure was treated as equal risk based on the statement of ‘there is no risk-free level of secondhand smoke exposure; even brief exposure can be harmful to health’ [1]. An overall mean SHS risk perception index was calculated for the 8 individual SHS exposure measures. The overall mean risk perception index ranged from 1 (no risk) to 5 (extremely high risk) with higher scores representing higher parental perceived risk [8]. Simple linear regression analysis was used to identify measures potentially associated with overall mean risk perceptions (p-value < 0.05). A multivariable linear model was then estimated using backward elimination to identify statistically significant variables for a final multivariable model. Variables included in the final multivariable regression model that predicted SHS risk perception index were parental role, education level, mother’s occupation, father’s occupation, presence of an extended family member in the household who was a smoker, whether children were taught to stay away from smokers, presence of household and car rules allowing or prohibiting smoking. Assumptions were checked, no multicollinearity problems were detected and a p-value of less than 0.05 was considered statistically significant.

Most respondents (87.1%) were non-smokers. Approximately one-third (33.7%) had a tobacco cigarette smoker living in the same household (Table 1).

None of the mothers recruited were current smokers and only one mother (0.5%) identified as a former smoker. Among fathers, 17 (28.3%) currently smoked and 14 (23.3%) were former smokers, comparatively higher than the mothers group (Table 1).

Overall, the mean score for parental risk perception was 4.11 (SD: 0.82), indicating a perception of SHS exposure as a high risk to their children’s health. A varying proportion of participants (ranging from 35.4 to 59.3%) rated most of the situations given as posing an extremely high risk of SHS exposure to the child’s health. A rating of ‘extremely high-risk’ was given most frequently by participants for a situation involving an adult smoking in the presence of a child in the kitchen (59.3%) (Photograph 3), followed by an adult smoking inside a car with the window open while a child was sitting in the rear (54.1%) (Photograph 5).

Roughly equal numbers of participants gave ‘high-risk’ (33.7%) and ‘extremely high-risk’ (35.4%) ratings for a situation demonstrating an adult smoking on a balcony with an open door while children were playing inside the house (Photograph 7). Two situations which most parents perceived as a ‘high risk’ to their children’s health involved an adult smoking in the presence of a child at a playground (42.3%) (Photograph 2) and an adult smoking some distance away from a child outdoors (34.1%) (Photograph 4). A rating of ‘no risk’ was given most frequently by the participants for Photograph 4 (8.1%) compared to the other situations (ranging from 0.8 to 2.8%) (Table 2).

About two-thirds of the parents (65.0%) had implemented rules prohibiting smoking inside their houses, and only 3.3% of the parents allowed smokers to smoke indoors with a window open. About 68.3% of parents forbade smoking inside the car when travelling with children. However, 6.9% of parents allowed smoking inside the car with a window open. Despite many parents setting rules prohibiting smoking in their homes or cars, there was no statistically significant association between the parental mean scores of SHS risk perception and their behaviour in setting smoking prohibition rules. The gender of the parents did not moderate the relationship between perceived risk and having smoking ban rules (Table 3). Most respondents (85.4%) had taught their children to stay away from cigarette smokers.

The mothers who worked in professional (β = 0.60, p = 0.012), intermediate (β = 0.37, p = 0.001), and semi-routine occupations (β = 0.61, p = 0.014), and participants who had taught their children to stay away from smokers (β = 0.42, p = 0.001) and set rule that ban smoking inside the house (β = 0.19, p = 0.040), had significantly higher scores in risk perception than the comparison groups. The participants who being a current smoker (β = − 0.93, p < 0.001), lived with smokers (β = − 0.33, p < 0.001) and those who allowed household smoking with an open window (β = − 0.55, p = 0.027) were associated with lower risk perception scores (Table 4).

Despite this study having covered every state in Malaysia, the population recruited might not adequately represent the proportion of all ethnic groups in this country, as most of the respondents were Malay (72%). Malaysia comprises a population of approximately 69% Bumiputera (Malays and indigenous people including Orang Asli, Sabah and Sarawak Bumiputera), 23% Chinese, 6.9% Indians and 1.0% other ethnic groups, as at 2018 [29]. The actual risk perception among parents could be lower, as less than 7% of the parents recruited were smokers, which is lower than the prevalence (25%) reported at the national level [19]. Hence, the findings may not accurately represent the risk perceptions of all parents in the Malaysian population. For example, relatively few women in Malaysia smoke compared to men (1.4% vs 43%, respectively) [19]. In the current study, no mothers reported smoking and only one reported being a former smoker. Therefore, the over-representation of mothers in this study might explain the lower prevalence of smokers in this study. It is possible that the prevalence of smokers was associated with parental status in this study. Thus, future studies may explore the risk perception of child exposure to SHS among Malaysian adults who do not have children.

Factors associated with lower parental risk perception of SHS exposure to child health are crucial for public health policymakers to consider when designing strategies to protect children from SHS. It is important for parents to be aware of the risk of SHS exposure amongst children to avoid adverse effects on their children’s growth and wellbeing. Public health authorities should raise awareness amongst parents by educating them about the harms of SHS exposure to their children and consider implementing rules prohibiting smoking inside houses and cars in the presence of children. For maximal effect, awareness and advocacy measures should specifically target parents who were active smokers and parents who live with an active smoker in the same household.