Introduction
Exposure to tobacco smoke remains a major contributor to adverse health outcomes in pregnant women and their children. Secondhand smoke (SHS) exposure among women who are of childbearing age in Egypt is reportedly very high, with estimates of around 60% at the home and more than 50% at work [
1‐
4]. Maternal smoking, as well as exposure to SHS, is associated with increased risks for adverse birth outcomes and maternal complications [
5]. SHS exposure carries similar risks for pregnant women compared with active smoking, [
5‐
7] and women exposed to SHS are more likely to give birth to infants with a lower birth weight, [
8,
9] reduced birth length, [
10] smaller head circumference, [
11] and stillbirth [
12]. There is no safe level of exposure to SHS for non-smokers.
While smoking among women in Egypt is relatively rare (0.5%), many men smoke (36.0%) and current rates of smoking in Egypt remain high with 41.3% of households having at least one smoker, contributing to about 24 million non-smokers being exposed to SHS [
13]. Cigarettes are the main form of combustible tobacco used in Egypt, followed by hookah (i.e., waterpipe instrument used for smoking tobacco), which is locally referred to as shisha [
14]. In rural areas, upwards of 15% of men smoke hookah [
15]. SHS exposure is more intense from smoking hookah compared with cigarettes, and the exposure to toxicants from a typical hookah tobacco smoke session can be up to 200 times that of cigarettes [
16‐
20].
To combat SHS exposure, Egypt has implemented smoke-free policies as well as complex taxation policies [
21]. Despite these rules, there is little policy enforcement. The lack of policy enforcement comes at the expense of women and children, who are usually victims of high levels of SHS exposure in Middle Eastern countries [
3,
9,
22‐
26]. Moreover, many of these policies aim only to limit smoking in public places; however, women are still vulnerable due to the high prevalence and duration of SHS exposure in their homes [
3,
26].
Knowledge regarding the impact of SHS exposure in pregnancy is lower among people with low socioeconomic status (SES) and in developing countries, especially Arab countries that exhibit higher smoking rates. Egyptian culture encompasses social norms similar to those of other Arab countries, with conservative attitudes and male-dominated family structures. Distinct gender roles in conservative cultures allow men to preside over the social practices and norms at home [
27]. Due to the presence of gender inequality at the community and interpersonal levels, it is difficult for women to negotiate to establish smoke-free homes [
28,
29]. Attitudes toward SHS exposure and knowledge about its harms is an initial step to facilitate a change in SHS avoidance behaviors, [
30] but this has been poorly studied in Egypt.
The literature from other Middle Eastern countries indicates the potential for high exposure to SHS in these countries; [
3‐
26,
31] however, the full extent of exposure to SHS and to what extent women are impacted by SHS due to the smoking behavior of their husband in the home is not reflected in current national surveys, as the majority of national surveys do not evaluate the risks of tobacco intake methods such as hookah, which is extremely popular in Egypt. This is important in order to guide tobacco control efforts in the country. Furthermore, there are no published studies that assess SHS exposure due to both cigarettes and hookah among pregnant women in Egypt. To fill these gaps, this study sought to estimate the prevalence of and factors associated with SHS exposure, and assess attitudes toward SHS among pregnant women in Cairo Metropolitan Area.
Discussion
This study is one of the first to explore SHS exposure from multiple tobacco products, including both cigarettes and hookah, among pregnant women in Egypt. Study findings show that more than half of pregnant women visiting the antenatal clinic were exposed to SHS. Consistent with the most recent national Global Adult Tobacco Survey (GATS) conducted in Egypt, [
26] the most frequent environment for SHS exposure was inside the home. Overall, many women were exposed to SHS anywhere every day for multiple hours a day. High rates of exposure were particularly common among women from rural areas. While women were aware of the risks of SHS exposure on newborns in the home, they were less aware of the harms when a mother is exposed to SHS during pregnancy. Despite the small sample size of our study, our findings were very similar to the GATS national survey regarding perceptions of tobacco use harms [
26].
Based on the results of our study, we suggest that misconceptions among pregnant women about the harms of SHS exposure highlights an important avenue for intervention to educate and empower women to reduce SHS exposure and improve pregnancy outcomes. Among the women surveyed, there was strong agreement that a woman smoking is harmful to her developing fetus and that SHS exposure was harmful to newborns. However, there was significantly less awareness of the potential harms of a pregnant woman’s SHS exposure to herself or her future child. Understanding where the gaps are can inform directed national campaign messaging to focus on SHS and how it impacts pregnancy health and prenatal development. Because of women’s heightened concern for their future children’s health, this approach may be more effective than a general message that smoking and SHS are harmful to health overall. Decreasing misconceptions about the harms of SHS is important given the high prevalence of smoking in Egypt, where about 70% of Egyptian households allow smoking in their homes and 80% of women report SHS exposure in their homes in the past month [
26]. SHS exposure is typically even higher with the use of certain tobacco products such as waterpipes (i.e., hookah), which is prevalent in Egypt and the Middle East [
18,
27,
33].
Education campaigns directed toward pregnant women alone, however, are unlikely to eliminate maternal exposure to SHS. As seen in this population, home exposure represents a significant driver of SHS exposure. Indeed, women in our study had low confidence in their ability to implement or enforce indoor smoking bans at home. As in other Middle Eastern countries that tend to have a more conservative culture and patriarchal society, women are not fully empowered in Egyptian society from a social perspective. The gender inequality within families is particularly notable. The Global Gender Gap Index (GGGI) for Egypt (0.64 points) is lower than most countries, ranking 129 out of 146 countries globally [
34]. Distinct gender roles, in which men take precedence over women in shaping the social practices at home, [
24] may lead to a perceived inability by women to ask family members not to smoke in the home [
23]. As observed in Egypt and other Middle Eastern countries, women often feel they have limited autonomy over SHS exposure in the home [
3,
9,
22‐
25]. Indeed, a primary obstacle to SHS avoidance has been cited as having men in the household who smoke [
22,
23]. Consequently, a majority of SHS smoke exposure occurs at home [
3‐
25,
35]. This is particularly apparent in more rural and lower SES populations that are often more culturally conservative and more traditional, as can be seen in this study and previous research in the region, [
9] where women in rural and low SES areas are more likely to be exposed to SHS in the home. Successful interventions promoting SHS avoidance behaviors have included a combination of improving both attitude and self-efficacy [
25,
36]. Without changes to both factors, behavior change is unlikely to occur. In this way, a woman’s knowledge about the harms of SHS does not always guarantee successful avoidance behaviors [
3,
25].
Furthermore, smoke-free homes not only protect non-smokers, but lead to smoking cessation and decreased cigarette consumption [
37]. In the present study, having a husband who smokes was strongly associated with SHS exposure. For this reason, gender-tailored campaigns are needed to educate men at the community level regarding the harms of SHS, to encourage smoking cessation, and to address gender inequality and provide women with a greater feeling of SHS avoidance self-efficacy. This may be particularly important in rural and lower SES populations [
9,
23].
Efforts to promote women’s perceived self-efficacy through women’s empowerment need to be paired with smoking cessation campaigns that are gender-sensitive and targeted at both women and men. As seen in this study, where women who smoke were more likely to be from urban areas, increased women’s empowerment, education, and liberal norms have been associated with a higher smoking prevalence among women [
38]. Therefore, as progress is made toward gender equality, specialized campaigns should be implemented to reduce the impact of empowerment on the uptake of smoking.
Pregnancy can be an important motivator for behavior change, [
39,
40] and there is a need to build tobacco use counseling capacity among clinicians (i.e., physicians and nurses) delivering care to pregnant women in Egypt. Preconception and prenatal visits may be an opportunity to promote SHS education and smoking cessation among both men and women. These are windows of opportunity, according to the “teachable moment concept,” in which both men and women are more receptive to health care providers’ advice and to behavioral change interventions that can affect the health of their future child [
3]. While few women report actually receiving tobacco counseling, [
26] for those who do, behavioral treatments during pregnancy are consistently effective in helping pregnant women quit smoking [
41,
42]. To be successful, however, health care providers need to be further trained on smoking cessation counseling and general knowledge about the importance of tobacco control. Lack of support from a health care provider has been cited as a barrier to engaging in SHS avoidance behaviors [
22]. Despite this need, many providers are not equipped to provide smoking counseling or tobacco control education, with barely half of health care providers in Egypt reporting high SHS knowledge or a supportive attitude toward preventing SHS exposure [
43].
In addition to increased education among patients and clinicians, there is a need for stricter enforcement of clean air laws. While enforcement appears to have been successful in some settings (e.g., metro system, airports) in Egypt, it is not consistently applied in workplaces and other public settings such as restaurants, placing even those with suitable SHS avoidance behaviors at high risk of exposure [
3,
25]. While there is support for smoke-free public spaces, [
44] there have been barriers to implementing non-smoking spaces, [
21,
22,
43,
45] and current policies allow for non-smoking areas within public places, which has been demonstrated to be an ineffective approach to SHS protection [
21,
46]. There needs to be a movement toward banning smoking entirely in public places, both indoors and outdoors, which not only leads to decreased SHS exposure, but has been shown to promote smoking cessation [
47‐
50].
This study had a few limitations. First, we recruited pregnant women from the largest public maternity hospital and two private obstetric clinics in Cairo to minimize selection bias and maximize the generalizability of the findings. However, the small sample size and targeted recruitment approach, as well as the data collection having occurred in 2015–2016, are likely to limit the generalizability of this data. In addition, the survey did not differentiate between potential different sources of SHS outside of the home, making the assessment of factors contributing to these exposure sources infeasible. However, understanding SHS exposure sources within the home remains important, as most nonsmoking policies are limited to public places, leaving pregnant women vulnerable to SHS exposure in their households [
3,
26]. The sample size is sufficiently large to identify potential patterns in SHS exposure in the home. We also excluded women with any reported complications in their current pregnancy, which might have masked additional SHS exposure in pregnancy. Second, this study is cross-sectional and retrospective in nature, capturing participants late in their pregnancy and therefore limiting our ability to assess the relations of potentially time-varying measures. Furthermore, most study measures were self-reported, which may lead to social-desirability bias, diminishing the detection of smoking exposure. Additional research examining these associations longitudinally and beginning at earlier stages of pregnancy—or even preconception—may reveal insights that could guide the targeting of anti-tobacco messages to women of reproductive age.
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