Current Tobacco Use and Secondhand Smoke Exposure Among Women of Reproductive Age — 14 Countries, 2008–2010

Tobacco use and secondhand smoke (SHS) exposure in reproductive-aged women can cause adverse reproductive health outcomes, such as pregnancy complications, fetal growth restriction, preterm delivery, stillbirths, and infant death (1–3). Data on tobacco use and SHS exposure among reproductive-aged women in low- and middle-income countries are scarce. To examine current tobacco use and SHS exposure in women aged 15–49 years, data were analyzed from the 2008–2010 Global Adult Tobacco Survey (GATS) from 14 low- and middle-income countries: Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam. The results of this analysis indicated that, among reproductive-aged women, current tobacco smoking ranged from 0.4% in Egypt to 30.8% in Russia, current smokeless tobacco use was <1% in most countries, but common in Bangladesh (20.1%) and India (14.9%), and SHS exposure at home was common in all countries, ranging from 17.8% in Mexico to 72.3% in Vietnam. High tobacco smoking prevalence in some countries suggests that strategies promoting cessation should be a priority, whereas low prevalence in other countries suggests that strategies should focus on preventing smoking initiation. Promoting cessation and preventing initiation among both men and women would help to reduce the exposure of reproductive-aged women to SHS.

GATS is a nationally representative household survey conducted among persons aged ≥15 years using a standardized questionnaire, sample design, data collection method, and analysis protocol to obtain measures of key tobacco control indicators.* GATS was conducted once in each of the 14 countries during 2008–2010. In each country, a multistage cluster sample design was used, with households selected proportional to population size. Data were weighted to reflect the noninstitutionalized population aged ≥15 years in each country. Overall response rates ranged from 65.1% in Poland to 97.7% in Russia. For this analysis, the study sample included 91,190 female respondents ages 15–49 years, representing 35.8% of the population sample aged ≥15 years. Analyses were conducted separately for each country, with sample sizes ranging from 1,570 female reproductive-aged respondents in Uruguay to 28,482 in India. Data on current pregnancy status of the survey respondents were not collected; therefore, the number of pregnant women included in the sample of reproductive-age women is unknown. Based on total fertility rates in each of the 14 countries, ranging from 1.17 children per woman in Poland to 3.58 in the Philippines (4), the proportion of respondents pregnant when interviewed likely was low.

Prevalence and 95% confidence intervals (CIs) of current tobacco smoking,† current smokeless tobacco use,§ SHS exposure at home,¶ and SHS exposure at work** were calculated for reproductive-aged women by country. SHS exposure at home and work were included in the analysis because these locations are where the majority of women spend their time in an average day. SHS exposure at work was calculated among women who worked outside of the home and who usually worked indoors or both indoors and outdoors; this subgroup ranged from 5.4% of women in Bangladesh to 74.7% in Russia. By country, prevalence of each of the four tobacco indicators was stratified by age group (15–24, 25–34, and 35–49 years), residence (urban versus rural), and education level. When a country's overall tobacco prevalence among women of reproductive age was >3%, differences in prevalence by each characteristic were assessed with a z-test at significance level of p<0.05.

Current tobacco smoking prevalence among reproductive-aged women ranged from 0.4% in Egypt to 30.8% in Russia (Table). Prevalence of current smoking was ≤2.3% in Bangladesh, China, Egypt, India, Thailand, and Vietnam and >10% in Brazil, Poland, Russia, Turkey, Ukraine, and Uruguay.

Among countries with current smoking prevalence >3%, demographic subgroups with higher smoking prevalence varied by country (Table). In Brazil, Philippines, and Poland, for example, current smoking prevalence was significantly higher among women aged 35–49 years compared with other age groups, but in the other countries, prevalence was higher among younger women. Current smoking prevalence was significantly higher among women living in urban areas in Mexico, Poland, Russia, Turkey, and Ukraine.

Prevalence of current smokeless tobacco use in reproductive-aged women was <1% in almost all GATS countries, with the exception of Bangladesh (20.1%) and India (14.9%) (Table). For Bangladesh and India, prevalence of current smokeless tobacco use was significantly higher among women aged 35–49 years, those who lived in rural areas, and those who had "no formal education/less than primary" compared with their counterparts.

SHS exposure at home ranged from 17.8% in Mexico to 72.3% in Vietnam (Table). In Brazil, prevalence of SHS exposure at home was significantly higher among women aged 15–24 years than among older women. In Bangladesh, Brazil, China, Egypt, India, Philippines, Thailand, Turkey, and Vietnam, the prevalence of SHS exposure at home was significantly higher among women living in rural areas compared with those living in urban areas. SHS exposure at work ranged from 11.0% in Uruguay to 53.0% in Egypt. In Bangladesh, India, and Philippines, prevalence of SHS exposure at work was significantly higher among women living in rural areas, whereas in Russia, prevalence of SHS at work was higher among women living in urban areas.

Reported by

Roberta B. Caixeta, Pan American Health Organization; Rula N. Khoury, European Regional Office; Dhirendra N. Sinha, South-East Asia Regional Office; James Rarick, Western Pacific Regional Office, World Health Organization. Van Tong, Patricia Dietz, Div of Reproductive Health; Jason Hsia, Glenda Blutcher-Nelson, Lucinda England, Mikyong Shin, Samira Asma, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Van Tong, [email protected], 770-488-6309.

Editorial Note

This report examined current tobacco use and SHS exposure among women of reproductive age in 14 low- and middle-income countries during 2008–2010 using GATS data. These results indicate a wide variation by country in current tobacco smoking prevalence in reproductive-aged women. Study countries in Central and Eastern Europe and South America (Brazil, Poland, Russia, Turkey, Ukraine, and Uruguay) had the highest current tobacco smoking prevalences among reproductive-aged women. Only in Bangladesh and India was current smokeless tobacco use prevalent among women of reproductive age. In countries where tobacco use among reproductive-aged women was high, strategies are warranted to increase tobacco cessation and to prevent initiation. In countries where tobacco use was low (≤2%), preventing smoking initiation among reproductive-aged women can play an important role in maintaining low prevalence of use.

In countries where most women are nonsmokers, such as Bangladesh, China, Egypt, India, and Vietnam, prevalence of SHS exposure at home was high. The highest prevalence of exposure was in Vietnam, where nearly three in four women reported SHS exposure at home. This high prevalence of SHS exposure is largely the result of high smoking prevalence among men (5). Population-based interventions that decrease tobacco smoking and SHS exposure among men, as well as women, might play an important role in reducing overall SHS exposure. For example, studies conducted in high-income countries have shown that implementation of comprehensive national smoke-free laws have changed social norms toward avoiding SHS and have resulted in increases in the percentage of households that have adopted smoke-free rules (6).

The findings in this report are subject to at least three limitations. First, all tobacco exposure data were self-reported and might be subject to misclassification. Second, this analysis included only use of traditional tobacco products and did not assess use of novel tobacco products, such as snus†† or dissolvables, which might be appealing for young and female smokers (7). Finally, other potential locations where SHS exposure could occur, such as in public places other than work and in passenger vehicles, were not included.

Among women of reproductive age, current tobacco smoking prevalence varied by country, current smokeless tobacco use was prevalent in only two countries, and SHS exposure at home and at work was prevalent in all countries. In the sample countries, 92 million women were current tobacco users (smoked or smokeless), and approximately half of reproductive-aged women, representing 470 million women, were exposed to SHS in the home. An estimated 62 million births occur annually in these 14 study countries (4), highlighting the need to protect reproductive-aged women from the harms of tobacco and to promote their health and the well-being of their children (8). In 2010, the United Nations passed a resolution encouraging member states to implement effective tobacco control programs to protect the health of children and pregnant women.§§ Evidence-based tobacco control strategies outlined in the WHO MPOWER framework, as part of the WHO Framework Convention on Tobacco Control (an international treaty that presents a blueprint for countries to reduce both supply of and demand for tobacco),¶¶ can prevent or reduce tobacco use and SHS exposure in reproductive-aged women (9). These strategies include monitoring tobacco use and prevention policies; offering assistance to quit; protecting persons from exposure to SHS; warning about the dangers of tobacco; enforcing bans on advertising, promotion, and sponsorship; and raising prices and taxes on tobacco products.

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