Alarming Trend in Under-Five Indian Children’s Exposure to Indoor Tobacco Smoke

Background and aim: Children who are exposed to tobacco smoke (ETS) are at risk for a variety of health issues. There are enough legislative provisions in Indian law to safeguard children from ETS in outdoor settings, but no such specific rules exist to shield them from exposure indoors. This study aimed to examine the trend in under-five children's exposure to indoor tobacco smoke over the course of a decade (from 2005 to 2016) in India. Materials and methods: Data from the National Family and Health Survey (NFHS) for the years 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4) on under-five children have been taken into consideration in cross-sectional analyses of the Demographic and Health Survey on India. Based on different sociodemographic factors, the propensity of indoor ETS among Indian children has been estimated and compared using both bivariate and multivariate logistic regression models. Results: The prevalence of indoor ETS among Indian children under the age of five has greatly risen over the past decade, rising from 4.12% to 52.70%. According to the findings, there has been a noticeable increase in every group of kids, regardless of their age, place of residence, geographic location, socioeconomic status, and literacy level of their mothers. Conclusion: In India, the incidence of indoor ETS among children under five has risen by 13 times in the last 10 years, endangering the country. As a result, the Indian government must prepare to take legislative action to safeguard children by passing laws that forbid smoking inside.


Introduction
Tobacco use has led to fiscal and human tragedy on a global scale, killing eight million people annually from preventable causes [1,2]. The majority of deaths (85%) involve direct or primary tobacco use, with the remaining 15% occurring in nonsmokers who were subjected to secondhand smoke [2]. There is no safe degree of exposure to tobacco because it has negative physical and psychological effects. This is true of all tobacco products, whether they are used first or second. Significant negative health impacts of secondhand smoke exposure include cardiovascular [3], respiratory [4], renal [5], and physiological issues [6]. Children are more susceptible to the negative effects of cigarette smoke exposure than adults because of their immature immune systems [7]. Children who are exposed to tobacco smoke (ETS) have an increased chance of developing asthma, wheezing, respiratory infections, and sudden infant death syndrome (SIDS) [8][9][10]. It results in pregnancy problems, mortality, morbidity, and low birth weight in pregnant women [11][12][13].
India's overall prevalence of tobacco use is 10.38%, and smokeless tobacco use is 21.38%, according to the Global Adult Tobacco Survey (GATS) performed in 2016-2017. The Indian legislative system and Indian government have made decisions in every area, beginning with production, dissemination, and consumption levels, which are necessary to safeguard health and healthcare quality for both main and secondhand smokers [14,15]. The Indian government has started a campaign to raise awareness of the harmful effects of tobacco smoke, which has been found to be very effective [15][16][17].
In order to control exposure in the outdoor environment and restrict the accessibility of any tobacco-related products, the Indian legislative system has enacted various laws both at the state as well as country levels,

Materials And Methods
Secondary data from the Demographic and Health Survey (DHS) (https://dhsprogram.com/data/), which offers a nationally representative database containing data on the population, including information on the health, anthropometry, and nutritional status of chosen people, was used to perform cross-sectional studies. All living children who are five years old or younger are included in the study. Children older than five years who are deceased are excluded from the study. The National

Outcome variable
The ETS experienced by the child under-five years of age in the indoor environment depends on whether any of the family members is a smoker or any outsider tobacco smoke inside the house. Under both of the situations where a child gets in secondhand smoke in an indoor environment has been considered as exposed to tobacco smoke, and in the notation of dichotomous variable denoted as "1," if not exposed then "0."

Study parameters
Based on different demographic characterizations, it has been studied how to understand the behavioral shift in ETS among Indian children in an indoor setting. The decadal shift in the sociodemographic distribution of exposure over the periods (2005-06 and 2015-16) has been compared, presuming that the current legislative enactments are capable of protecting children from exposure.
Gender and age of the child, residence, region, religion, caste, wealth index, gender of the head of household (HH), mother's age group, education, and profession, and father's education and occupation are some of the demographic factors that have been taken into account. The mother provided the child's age, which is divided into the following five distinct subgroups: 1, 1-2, 2-3, 3-4, and 4-5 years. Depending on their location, geographic zones have been categorized as Central, Eastern, North-Eastern, Northern, Southern, and Western. Hinduism, Islam, Christianity, and other religions are divided into these four categories. There are two categories of residence -urban and country. Based on their wealth index, the family's socioeconomic standing has been divided into the following categories: poorest, poorer, middle-class, richer, and richest. Mothers' ages were voluntarily recorded, and divided into seven distinct subgroups, including 15-19, 20-24,..., and 45-49. There are four categories for a parent's educational background -no formal schooling, primary, secondary, and higher. Five groups have been used to categorize parent occupations -not working (housewife/househusband), professional, agricultural, services, and skilled and unskilled manual-related duties. Two weeks previous to the survey, mothers were questioned about whether their kids had symptoms of acute respiratory infections (ARI). ARI is described as a chest-related cough that is followed by short, rapid, or challenging breathing. Information about the birth weight (in grams) has been classified into three groups viz., <2500 g, ≥2500 g, and not weighed at birth. To estimate and contrast the propensity of indoor ETS and its associated factors among Indian children over the past 10 years, both bivariate and multivariate logistic regression models were used. For all analytical work, SAS University Edition software has been used. Table 1 presents the sociodemographic variation in the prevalence of exposure to indoor tobacco smoke experienced by under-five Indian children in a decade during 2005-06 to 2015-16, based on NFHS data. A substantial increase from 4.1% to 52.7% has been observed in the prevalence of exposure to indoor tobacco smoke. Based on the sociodemographic characteristics of children and geographical characteristics, obtained results have shown that in a decade significant increment in the prevalence of exposure to indoor tobacco smoke among male children (NFHS-3: 50.09%; NFHS-4: 52.1%), children below two years of age (NFHS-3: 32.72%; NFHS-4: 38.75%), urban residents (NFHS-3: 15.1%; NFHS-4: 25.87%), in all geographical regions (NFHS-3: 65.71%; NFHS-4: 76.34%) except Eastern, all religious groups except Christian, among the middle and above economical classes (NFHS-3: 25.74%; NFHS-4: 50%). At the levels of family composition a decadesignificant increment in the prevalence of exposure to indoor tobacco smoke among children has been observed among families having mothers who are in the age group of 20-29 years (NFHS-3: 52.54%; NFHS-4: 71%), literate (NFHS-3: 27.74%; NFHS-4: 66.73%), are either not working (housewife) or engaged in professionals jobs (NFHS-3: 48.63%; NFHS-4: 78.47%), fathers having secondary or higher educational qualifications (NFHS-3: 32.06%; NFHS-4: 64.76%), and are either not working or engaged in professionals or services related jobs (NFHS-3: 17.7%; NFHS-4: 33.52%).      State-wise decadal changes in the prevalence of exposure to indoor tobacco smoke among children have been depicted in Figure 1. In a decade significant rise in the prevalence has been observed throughout all states and most states reported more than 20% increment.

Discussion
Strict laws are needed to control the ETS and safeguard people from different health risks that can result in morbidity and mortality. The government is very worried about this problem because smoke exposure or inhalation has an impact on all forms of production and consumption. Children are severely impacted whenever they come into either direct or indirect touch with tobacco smoke. ETS has an effect on the infant from the time of conception until birth and even after. The kid may encounter this exposure in both indoor and outdoor settings. ETS can occur outdoors for a variety of reasons, but indoors it only happens because of family members or visitors who smoke inside. Taking into account the contributing factors, nations created their legal frameworks so that children's health could be safeguarded from exposure to cigarette smoke both indoors and out.
According to the results of the current research, there has been a significant rise in the prevalence of exposure to indoor tobacco smoke from 4.1% to 52.7%, which should worry both the government and policymakers. All regional areas and religious groups have seen an increase in the frequency of exposure to indoor tobacco smoke over the past 10 years. The prevalence of tobacco smoke exposure is notably high among children, regardless of the socioeconomic classes, age groups of the mothers (highest among 45-49 years), literacy of the mothers (highest among illiterates), employment of the mothers (highest among farmers), and literacy of the fathers (highest non-educated). Additionally, it was noted that when those heads of household were male, their prevalence increased decadally, whereas when they were female, they were discovered in decreasing order. The present study's limitations include the inability to link the effects of maternal and child exposure to other health parameters, such as the physiological, psychological, and cardiovascular systems, without knowledge of the quantity and duration of tobacco use indoors by family members or anyone else. In addition, more clinical research and pertinent data on mothers and children are needed in order to frame a policy to reduce associated risks and better understand the effect of ETS on child health.

Conclusions
India saw major advancements in maternal care, vaccination coverage, newborn and child mortality rates control, literacy, health services, and other areas over the course of a decade. But since then, the majority of states have seen a marked increase in the frequency of indoor tobacco smoke. Over the past 10 years, the prevalence of indoor ETS among children under the age of five has risen by 13 times in India. The increased decadal shift in indoor ETS prevalence among Indian children under five years puts the nation in peril. The Indian Government must therefore follow suit in light of this dangerous situation and prepare legislative interventions to safeguard children and their childhood by enacting laws against indoor smoking. In other developed countries, strict laws have been passed outlawing tobacco use in indoor settings, such as workplaces and public transportation.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.