Parental smoking is highly prevalent in developing economies, which, along with using up scarce household income, exposes children to second-hand tobacco smoke leading to many health issues. Using the Pakistan Demographic and Health Survey (PDHS) 2017-18, we estimate the link between parental smoking and child malnutrition in Pakistan using height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height z-scores (WHZ). The children were ategorized into three groups. The first group was composed of children having mothers who smoke (maternal). The second group had children having fathers who smoked (paternal). Finally, the third group consisted of children who had either parent smoking (parental). The maternal, paternal, and parental prevalence of tobacco smoking was found to be 7%, 16.3%, and 21.6%, respectively, with higher rates in rural areas than urban areas. The results showed lower height-for-age z-scores (HAZ) among children exposed to smoking by parents. The association between maternal smoking and children’s HAZ scores was stronger compared to paternal or parental smoking. The study found a negative association between maternal, paternal, and parental tobacco use and HAZ, with the relation being statistically significant in rural areas. On the other hand, no significant relationship between second-hand smoke and children’s weight-for-height and weight-for-age was found. By employing the propensity score matching (PSM) method, the study found that children exposed to parental tobacco smoke had a lower HAZ score by 0.286 standard deviations. Considering that smoking also affects those around smokers, the need to take measures to discourage smoking becomes doubly important.
Tobacco consumption is one of the leading causes of premature deaths, causing more than 8 million deaths per year worldwide (WHO, 2021c). As of 2020, around 22.3% of adults aged 15 and above (36.7% males and 7.8% females) consume any form of tobacco, while 17% (28.9% males and 5.2% females) consume smoked tobacco (WHO, 2021a). Globally, 33% of men, 35% of women, and 40% of children are regularly exposed to the dangerous second-hand effects of tobacco smoke. Although second-hand smoke exposure among children has fallen over the past 15 years, children are still more exposed to second-hand smoke than adults.
Low birth weight, premature birth, shorter baby length, increased risk of fetal mortality, congenital abnormalities, and childhood obesity are linked to mothers’ exposure to second-hand smoke during pregnancy (Niu et al., 2016; Sunday & Kabir, 2019; Wahabi et al., 2013). Furthermore, children whose parents are tobacco users are at a higher risk of many health problems, including sudden infant death syndrome (SIDS), severe asthma, and ear and respiratory infections (US Department of Health and Human Services, 2006, 2010).
Stunting, wasting, and lower weight are among the health problems in children that may, directly and indirectly, be associated with parental tobacco consumption. In 2020, the global incidence of stunting and wasting was estimated to be 149.2 million and 45.4 million, respectively, while in Asia, the prevalence of stunting and wasting among children under the age of five years is estimated to be 53% and 70%, respectively (WHO, 2021b). These are linked to long-term health consequences that span all life stages. An increase in childhood morbidity and mortality, loss of physical development potential, increased risk of chronic diseases in adulthood, lower educational achievement, and diminished economic output are some of the consequences. The case against tobacco is further solidified in such instances since parental health choices pose long-term health costs to separate individuals (i.e., children) without the latter’s consent.
In Pakistan, the prevalence of tobacco (chewed and smoked) consumption among all adult men and women (aged 15 years and above) is 31.8% and 8.6%, respectively (PDHS 2017-18). The prevalence of smoked tobacco, which has a second-hand health concern as well, is 18.2% and 5.7% for all adult men and women, respectively.
The global prevalence of smoking during pregnancy was estimated to be 1.7% in 2015 by Lange et al. (2018). The highest prevalence of smoking during pregnancy was in the European region, at 8.1%, and the lowest prevalence of smoking during pregnancy was in the African region, at 0.8%. However, child mortality rates are higher in South and Southeast Asia where aggressive tobacco control policies, including those to reduce second-hand smoke exposure, are less common and smokeless tobacco use is higher, particularly among women.
In Pakistan, the prevalence of tobacco use among the mother, father, and any parent of a child is 10.1%, 31.2% and 37.3%, respectively. Smoked tobacco is consumed by 7% of mothers and 16.3% of fathers. (PDHS 2017-18)
Pakistan is a high tobacco-burden country with exposure to tobacco smoke at home being a 21%, more so for boys (22.9%) than for girls (18.2%) (WHO, 2013).
Tobacco-using households in Pakistan spend roughly 2.7% of their monthly budget on tobacco, with poor households spending 3% of their budget (Saleem and Iqbal, 2021). For poor households, it means spending scarce resources on tobacco that could be otherwise used on something beneficial for health. The PDHS shows malnutrition among children to be rampant in the country. A very high 38% of the children under the age of five years are stunted, with 17% severely stunted; 7% wasted, with 2% severely wasted; and 23% are underweight, with 8% severely underweight. (PDHS, 2019).
Substantial literature is available globally (Talukder, et al., 2022; Jaakola, et al., 2021; Paraje and Valdes 2021; Islam, Rana and Mohanty, 2020; Chowdhury et al 2011; Best et al., 2007; Goncalves-Silva, at al, 2005) establishing a link between parental smoking and child health, and on the impact of smoking during pregnancy on birth weight and size. However, when it comes to Pakistan, little is known about the effects of postnatal exposure to parental smoking on the physical health of children aged five years and below. To date, limited information is available in the country to illustrate the association between parental smoking and stunting, wasting, and underweight among children exposed to second-hand smoke.
The public health crisis caused by tobacco use is multi-pronged and poses many challenges for society in Pakistan and elsewhere. In the current study, we focus on the impact of parental tobacco consumption on child malnutrition outcomes in Pakistan, as exhibited through weight-for-height, height-for-age, and weight-for-age.
2. LITERATURE REVIEW
There are three main channels through which parental tobacco use can harm child health outcomes. Firstly, tobacco consumption during pregnancy has developmental effects on the child through purely biological effects, leading to weak genetics and a higher probability of child malnutrition. Secondly, smoked tobacco creates indoor pollution, which creates respiratory problems for the household members. Thirdly, there is also a more direct economic effect, which can harm child health due to parental tobacco consumption, especially among poor households where already the scarce resources are directed to tobacco use instead of something more useful. Poor households also have the highest tobacco consumption prevalence.
As stated above, due to its addictive nature, poor households spend significant proportions of their incomes on tobacco. This leads to the reallocation of expenditures from health, education, and nutrient-rich and plant-based foods towards tobacco, as also documented by Best et al. (2007) and Efroymson et al. (2001), which can harm child health. It is well known that maternal consumption of tobacco (smoked and non-smoked) during pregnancy leads to a heightened risk of child mortality (Wu et al., 2021; Bhatta and Glantz, 2019; Pandey and Lin, 2013), especially through the increasing incidence of sudden infant death syndrome (Dietz et al., 2010), small-for-gestational-age (Fantuzzi et al., 2008) and stillbirths (Inamdar et al., 2014), child morbidities, such as long term disruption of respiratory processes and developmental lung damage (Maritz and Harding, 2011), and low gestational age and low birth weight (Gupta and Sreevidya, 2004; Dietz et al., 2010).
Smoking also increases passive smoking exposure in children and indoor air pollution, which hurts child health and the probability of smoking later in life (DiFranza et al., 2004). Goel et al. (2004)
found for an Indian sample that among non-smoking mothers, who were exposed to environmental tobacco smoke, there was a significantly higher incidence of pre-term birth (24.1% vs. 16.1%) and small-for-gestational-age babies (31.9% vs.17.2%) as compared to the unexposed mothers.
Children’s exposure to a tobacco-smoked environment also has an adverse impact on their health and increases the likelihood of adolescent smoking later in their life (DiFranza, Aligne, & Weitzman, 2004). Children’s morbidity and death are considerably increased as a result of passive cigarette smoke exposure (Hwang, Hwang, Moon, & Lee, 2012). The infants who are exposed to parental smoking have lower forced expiratory flows (Stocks & Dezateux, 2003). Likewise, the children who are exposed to indoor tobacco smoke during infancy or childhood have a greater relative risk of respiratory outcomes, with infancy exposure having the highest relative risk (Zhuge et al., 2020).
Various studies show that children who are exposed to second-hand smoke (SHS) have a weight, length, and head circumference deficit by the third month compared to children not exposed to SHS (Fenercioglu, Tamer, Karatekin, & Nuhoglu, 2009). Children born to passive smokers have a lower Kaup index increase from birth to 3 years than children born to smokers, including passive smoking (Braimoh et al., 2017). Up to the age of 4 years, SHS exposure is associated with poorer child weight status. (Robinson et al., 2016). Likewise, daily exposure to SHS among pregnant women is found to be associated with a smaller head circumference at the time of birth than the non-exposed group (Soesanti et al., 2019).
A study by Semba, et al. (2007) found child stunting and wasting to be linked to SHS exposure, whereas the child underweight was not associated with SHS exposure. Some other studies give slightly different results. For instance, smoking by parents is found to be associated with a higher incidence of moderate underweight, severe underweight, moderate stunting, wasting, severe wasting, and severe stunting in children in various studies (Chowdhury et al., 2011; Best et al., 2007; Bonu, Rani, Jha, Peters, & Nguyen, 2004).
In contrast, some studies’ findings are contrary to what is discussed above. For instance, some studies show that SHS is not linked to children being underweight, stunted, or wasted, at least not as severely as some other studies have found (Tielsch et al., 2009; Kyu, Georgiades, & Boyle, 2009). Likewise, Yang, Decker, and Kramer (2013) found no adverse developmental outcomes in children solely linked to parental smoking. They linked the observed association between parental smoking and child health as a residual confounded by genetic and environmental factors.
 These cited studies were not in any way funded by the tobacco industry and had clear disclaimers stating so. They are published in journals known for maintaining ethical values.
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