Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11861 Predictors of smoking exposure in non-smoking adolescents in Indonesia Julfia Aina Sari,1 Ferry Efendi,1,2 Lailatun Nimah,1 Gading Ekapuja Aurizki,1 Ronal Surya Aditia,3 Rifky Octavia Pradipta,1 Khadizah H. Abdul-Mumin4 1Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia; 3Faculty of Sport Science, Universitas Negeri Malang, Indonesia; 4Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam Abstract Exposure to secondhand smoke is one of the leading causes of death for non-smokers worldwide. The prevalence of exposure to secondhand smoke is higher among adolescents. Research on pre- dictors of secondhand smoke exposure in adolescents is still rarely conducted in Indonesia. This study aimed to analyze the predictors of exposure to secondhand smoke among non-smoking adoles- cents in Indonesia. This study used data from the Global Youth Tobacco Survey (GYTS) Indonesia 2019 with a cross-sectional design. A total of 7,594 adolescents aged 13 to 15 were selected using purposive sampling. The dependent variables were exposure to secondhand smoke at home and in public. The independent variables included age, gender, smoking parents, smoking friends, and knowledge of the dangers of secondhand smoke. Data were analyzed using STATA with inferential tests, namely chi-square and logistic regression. The prevalence of adolescents exposed to secondhand smoke at home and in public was 49.57% and 71.86%, respectively. At-home exposure was significantly associ- ated with smoking parents [AOR=3.50, 95% CI=2.97 to 4.12], smoking friends [AOR=1.50, 95% CI=1.30 to 1.73], and knowl- edge of the dangers of secondhand smoke [AOR=2.11, 95% CI=1.52 to 2.93]. Public exposure was associated with ages 13-15 [AOR=1.32, 95% CI=1.10 to 1.58] and older than 15 [AOR=1.77, 95% CI=1.39 to 2.25], male gender [AOR=1.31, 95% CI=1.11 to 1.53], smoking parents [AOR=1.58, 95% CI=1.36 to 1.84], smok- ing friends [AOR=2.16, 95% CI=1.85 to 2.53], and knowledge of secondhand smoke dangers [AOR=2.84, 95% CI=2.15 to 3.75]. Adolescents’ exposure to secondhand smoke in public spaces is higher in prevalence and has more associated factors compared to exposure at home. Exposure reductions require comprehensive actions from authorities by strictly implementing and expanding non-smoking areas covered by existing regulations. Also, family and school management should be involved in prevention efforts. Introduction The smoking epidemic is one of the biggest public health threats the world has ever faced.1 Indonesia is among the countries that have a high prevalence of smokers globally.2 Smoking causes many losses; not only is it harmful to health, but it can also worsen poverty and cause social, economic, and environmental damage.3 Exposure to secondhand smoke kills approximately 1.2 million non-smokers worldwide.4 Tobacco comprises a staggering array of 7,000 chemicals, encompassing hundreds of noxious compounds, and approximately 70 of these are known to be carcinogenic sub- stances.5 These substances can worsen health conditions, espe- cially for non-communicable diseases like heart disease, diabetes mellitus, stroke, and others.6 There is no safe level of exposure to secondhand smoke.4 The prevalence of exposure to secondhand smoke is higher among adolescents than adults.7 The World Health Organization (WHO) reported that 65,000 children die each year due to exposure to secondhand smoke.4 In Indonesia, around 96 million people are currently exposed to secondhand smoke.8 Research in Nigeria and West Africa has stated that expo- Correspondence: Ferry Efendi, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia. E-mail: ferry-e@fkp.unair.ac.id Key words: secondhand smoke, adolescent, tobacco control, smoking cessation, air pollution. Contributions: FE, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; LN, conceptualization, investigation, methodology; JAS, conceptualization, investigation, methodology; GEA, ROP, RSA, valida- tion, and writing – original draft, review and editing; KHA, methodolo- gy, visualization, resources, investigation, and writing –review and edit- ing. All the authors have read and approved the final version of the man- uscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Ethics approval and consent to participate: in August 2019, the Global Youth Tobacco Survey (GYTS) in Indonesia obtained official authoriza- tion from the National Institute of Health Research and Development, solidifying its credibility and legitimacy. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgements: the authors are thankful to the National Institute of Health Research and Development, and the Indonesian Ministry of Health for using the GYTS data. We also thank all the respondents who took part in GYTS Indonesia 2019 Received: 22 September 2023. Accepted: 27 February 2024. Early access: 7 March 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11861 doi:10.4081/hls.2024.11861 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11861] [page 415] Non -co mmerc ial us e o nly sure to secondhand smoke is associated with having parents and friends who smoke, being asked to buy cigarettes by family, and lower social class.9 In Indonesia, research related to predictors of secondhand smoke exposure among non-smoking adolescents using data analysis from the Global Youth Tobacco Survey (GYTS) has never been carried out. Globally, there are 1.2 million smokers from developing coun- tries.10 According to a survey involving adolescents aged 12-16 years from 1999-2018 in 142 countries, the prevalence of exposure to secondhand smoke everywhere was 62.9%, while at home and in public were 33.1% and 57.6%, respectively.11 In 2019, nearly 7 million students in the US were exposed to secondhand smoke at home, and 6 million were exposed in vehicles.5 In Indonesia and Pakistan, for example, more than 80% of people are exposed to secondhand smoke in restaurants.12 GYTS Indonesia 2019 reported exposure to secondhand smoke in closed public places reached 66.2%, while in open public places and at home were 67.2% and 57.3%, respectively.13 In Indonesia, regulations that limit exposure to secondhand smoke have been established, but their implementa- tion has not been optimal (Ref). The 2018 Basic Health Research in Indonesia reported that 32.4% of people were exposed to sec- ondhand smoke in a closed room.14 Many people are not aware of the dangers of passive smoking regarding smoking-attributable diseases.15 Research in Semarang showed that 42.86% of places do not put up a sign for the area. Six out of ten teenagers are exposed to secondhand smoke in public, and exposure to secondhand smoke is higher than exposure to secondhand smoke at home. There is still high exposure to secondhand smoke in Indonesia, so it is necessary to supervise the implementation of the regulations on non-smoking areas that have been made.16 The Southeast Asia Tobacco Control Alliance states that Indonesia is among the weak- est in tobacco control in Southeast Asia.17 The Indonesian govern- ment must implement best practices in tobacco control to reduce the burden of tobacco-related diseases.18 Factors reported to be associated with exposure to secondhand smoke were age, ethnicity, place of residence (rural), and current smoking.19 Gender and edu- cation of the head of the household are also associated with expo- sure to secondhand smoke at home.20 Considering the impact of exposure to secondhand smoke on the body, the lack of optimal supervision of smoke-free regula- tions, and the limited research on predictors of exposure to second- hand smoke, it is hoped that the results of this study can provide additional information regarding predictors of secondhand smoke exposure among non-smoking adolescents in Indonesia. These findings should be taken into consideration in developing policies to control secondhand smoke exposure in the country. Materials and Methods Design This study used secondary data from GYTS Indonesia 2019 with a cross-sectional design. Population and sample This study’s population was based on the GYTS survey popu- lation, totaling 9,992 adolescents. The GYTS is a national school- based survey of students in classes aged 13-15 years that uses a two-stage cluster sample design to obtain a representative sam- ple.13 The study purposively selected the sample based on the inclusion criteria of non-smoking adolescents and obtained 7,594 participants. Data collection Data can be downloaded for free at the Centers for Disease Control (CDC) website (https://www.cdc.gov/tobacco/global/ index.htm). The cleaning process involves meticulously curating the dataset by discerning and extracting relevant data points, cul- minating in the vital step of recoding variables essential for the study’s execution. Variables The dependent variable in this study was exposure to second- hand smoke at home and exposure in public. Exposure to second- hand smoke at home was determined based on the answers to the following question: “During the past 7 days, on how many days has anyone smoked inside your home, in your presence?” Adolescents were considered not exposed if the answer was “0 days”; any other answer indicated exposure. Meanwhile, the questions used to determine exposure in public spaces were: “During the past 7 days, on how many days has any- one smoked in your presence inside any enclosed public place, other than your home (such as schools, malls, restaurants, shop- ping centers, theaters, cafes, health service facilities, public trans- portation, indoor sports venues)?” and “During the past 7 days, on how many days has anyone smoked in your presence at any out- door public place (such as playgrounds, curbside, building entrances, parks, beaches, sports fields)?” Adolescents were con- sidered not exposed if both questions were answered within “0 days”; any other answer to at least one question was considered exposure. This study included several independent variables, namely age, gender, smoking parents (“Do your parents smoke tobacco?”), smoking friends (“During the past 30 days, did you see anyone smoke inside the school building or outside on school property?”), and knowledge about the dangers of secondhand smoke (“Do you think smoke from other people’s cigarettes is harmful to you?”). Analysis Data analysis used were univariate and inferential analysis, namely Chi-square test and logistic regression using STATA ver- sion 15 application for Windows. Ethical approval In August 2019, the Global Youth Tobacco Survey (GYTS) in Indonesia obtained official authorization from the National Institute of Health Research and Development, solidifying its cred- ibility and legitimacy. Results Table 1 shows that the percentage of exposure to secondhand smoke at home was 49.57%, which is lower than the exposure in public (71.86%). The average age of adolescents was 13-15 years (51.29%), and 69% were girls. Approximately half of the adoles- cents had smoking friends (53.29%), and a similar proportion had smoking parents (42.07%). Almost all adolescents were aware of the dangers of secondhand smoke (96.22%). Exposure at home The results of the bivariate analysis indicated that four out of five independent variables were significantly associated with exposure at home, namely age (p=0.039), smoking parents Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 416] [Healthcare in Low-resource Settings 2024;12:11861] Non -co mmerc ial us e o nly (p<0.001), smoking friends (p<0.001), and knowledge of second- hand smoke dangers (p<0.001). Only gender was not significantly associated with at-home exposure (p=0.416) (Table 2). Meanwhile, based on the logistic regression analysis (Table 3), three independent variables could be significant predictors for exposure at home. Adolescents with smoking parents and smoking friends have 3 times (95% CI=2.97 to 4.12) and 1.5 times (95% CI=1.30 to 1.73) higher odds of getting exposed to secondhand smoke at home compared to those with non-smoking parents and friends. Also, adolescents who knew of secondhand smoke dangers had higher odds of getting exposed compared to those who did not know (95% CI=1.52 to 2.93). Exposure in the public The bivariate analysis shows that all independent variables were significantly associated with exposure to secondhand smoke in public, namely age (p<0.001), gender (p=0.033), smoking par- ents (p<0.001), smoking friends (p<0.001), and knowledge of the dangers of secondhand smoke (p<0.001; Table 2). Furthermore, the logistic regression results indicate that all sig- nificant variables could significantly predict exposure to second- hand smoke in public (Table 3). The older the adolescents, the higher the odds of getting exposed. Adolescents aged 13-15 years had 1.32 times higher odds (95% CI=1.10 to 1.58) compared to adolescents aged <13. The odds were even higher in those aged >15 (AOR=1.77; 95% CI=1.39 to 2.25). Meanwhile, male adoles- cents had 1.31 times higher odds of getting exposed to the public compared to their female counterparts. Adolescents with smoking parents had 1.58 times higher odds (95% CI=1.36 to 1.84) of pub- lic exposure. The odds were even higher for those having smoking friends (AOR=2.16; 95% CI=1.85 to 2.53). Meanwhile, adoles- cents with knowledge of the dangers of secondhand smoke had 2.84 times higher odds of secondhand smoke exposure in public (95% CI=2.15 to 3.75) compared to those without knowledge. Discussion Age is one of the predictors associated with exposure to sec- ondhand smoke in public but is not a predictor for exposure at home. This aligns with a study from Nigeria, which demonstrated that age as a predictor for secondhand smoke exposure depends on settings; it is significant outside the home but not inside the home.9 At home, adolescents may have difficulties avoiding exposure, regardless of their age groups. Individuals in their age group have a lower chance of confronting older members of their family, such Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 1. Results of univariate predictors of secondhand smoke exposure among adolescent non-smokers in Indonesia (n=7,594). Variable N % Exposure to secondhand smoke at home Yes 3,764 49.57 No 3,830 50.43 Exposure to secondhand smoke in the public Yes 5,457 71.86 No 2,137 28.14 Age (Years) <13 1,236 16.27 13-15 3,896 51.29 >15 2,464 32.44 Gender Female 5,240 69.00 Male 2,354 31.00 Smoking parents Yes 3,195 42.07 No 4,399 57.93 Smoking friends Yes 4,047 53.29 No 3,547 46.71 Knowledge of secondhand smoke dangers Yes 7,307 96.22 No 287 3.78 Table 2. Results of bivariate predictors of secondhand smoke exposure among non-smoker adolescents in indonesia (n=7,594). Variable Exposure to Secondhand Smoke (SHS) Predictors At home In public Yes No p X2 Yes No p X2 n % n % n % n % Age (Years) 0.039 11.42 <0.001 79.15 <13 574 7.56 662 8.72 773 10.18 463 6.10 13-15 1981 26.09 1915 25.22 2775 36.54 1121 14.76 >15 1209 15.92 1253 16.50 1909 25.14 553 7.28 Gender 0.416 1.48 0.0332 9.63 Female 1155 15.21 1199 15.79 3719 48.97 1521 20.03 Male 2609 34.36 2631 34.65 1738 22.89 616 8.11 Smoking parents <0.001 684.73 <0.001 83.24 Yes 2151 28.32 1613 21.24 2476 32.60 2981 39.25 No 1044 13.75 2786 36.69 719 9.47 1418 18.67 Smoking friends <0.001 89.74 <0.001 260.30 Yes 2215 29.17 1832 24.12 3240 42.67 807 10.63 No 1549 20.40 1998 26.31 2217 29.19 1330 17.51 Knowledge of SHS dangers <0.001 41.13 <0.001 94.13 Yes 3672 48.35 3635 47.87 5314 69.98 1993 26.24 No 92 1.21 195 2.57 143 1.88 144 1.90 [Healthcare in Low-resource Settings 2024;12:11861] [page 417] Non -co mmerc ial us e o nly as parents, older siblings, or other close relatives. The case is dif- ferent in public, where older adolescents are more at risk of getting exposed. This aligns with studies conducted in Malaysia,19,21 West Africa,22 and Kuwait.23 This is possible because older adolescents are usually given more freedom by their parents and are thus more likely to visit places where smokers are common. Also, parents usually become less protective as their children grow older. Although some studies24-26 found no significant associations between age and these factors, this should not discourage parents from being involved in monitoring their children’s behaviors while at home. Similar to age, gender was also a predictor for exposure to sec- ondhand smoke in public but not for exposure at home. This aligns with a study in Thailand, where gender was not strongly associated with exposure at home,27 and in Gambia, which shows significant associations between gender and exposure in indoor and outdoor public spaces.28 Nevertheless, studies conducted in India29 and Virginia, United States,24 found that gender was not significantly associated with exposure to secondhand smoke in any setting. Despite these contrasting findings, in general, men have higher odds of getting exposed to secondhand smoke than women.21,27-29 The similarity in the percentage of secondhand smoke exposure at home among both women and men can be attributed to the hesitan- cy of teenagers to confront individuals smoking indoors, making it challenging to evade such exposure. Conversely, men face a higher risk of encountering secondhand smoke in public spaces, possibly due to the predominant prevalence of male smokers in Indonesia, which amplifies their likelihood of being exposed to secondhand smoke. Having a smoking parent was a predictor associated with sec- ondhand smoke exposure at home and in public. The results were consistent with studies conducted in India, 29 South Korea,25,30 Africa,22,31 United States,24,32,33 Malaysia,21,34,35 Thailand,27 and Europe.36 Despite being significant in both settings, the odds of getting exposed were far higher at home for those with smoking parents. Home is where family members have close interactions, and the chance of getting exposed to smoking parents is high if adolescents live with their smoking parents; it is challenging to avoid such exposure. Moreover, for most Indonesians, asking par- ents to stop smoking is considered impolite, hindering adolescents from expressing concerns about their parents’ unhealthy behavior. Having smoking friends was also a predictor associated with all types of secondhand smoke exposure. The results correspond with studies in Africa,9,22,31,37,38 the United States,24,33 and Saudi Arabia.39 In contrast to having smoking parents, the odds of getting exposed were higher in public for those with smoking friends. Adolescents who associate with peers who smoke are highly sus- ceptible to secondhand smoke exposure. Furthermore, since ado- lescents frequently spend a substantial amount of time in the com- pany of their peers, avoiding such exposure becomes a challenging task. In the context of Indonesia, smoking is deeply ingrained as a societal norm, leading non-smoking adolescents to perceive sec- ondhand smoke exposure as routine. However, proactive measures to mitigate this issue involve educating both adolescent smokers and non-smokers about the hazards of secondhand smoke. By fos- tering awareness, it is anticipated that smoking adolescents will refrain from smoking in the presence of others, and non-smokers can take steps to steer clear of secondhand smoke exposure. Knowing the dangers of secondhand smoke is a predictor asso- ciated with all types of exposure to secondhand smoke. The per- centage of exposure to secondhand smoke is higher among adoles- cents who are aware of the dangers of secondhand smoke. The results of this study align with studies conducted in West Africa,9,38,40 Bangladesh,41 and India.42 However, the results of this study contrast with other studies, such as those in Medina,39 Africa,43,44 India,45,46 China,47 and Vietnam48 which stated that hav- ing knowledge was associated with reduced exposure to second- hand smoke. The results of this study indicate that almost all ado- lescents are aware of the dangers of exposure to secondhand smoke for their health, but very few take proactive action to avoid exposure to secondhand smoke as a whole. Due to this reason, there is a need for modification in providing education to avoid exposure to secondhand smoke, especially for adolescents. A good strategy is also needed to communicate the dangers of smoking to Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 3. Results of multivariate predictors of secondhand smoke exposure among non-smoker adolescents in Indonesia (n=7,594). Predictors Exposure to Secondhand Smoke At home In public AOR 95% CI p AOR 95% CI p Age (Years) <13 (ref) 1 1 1 1 13-15 1.08 0.92 to 1.26 0.311 1.32 1.10 to 1.58 0.003** >15 0.98 0.82 to 1.17 0.869 1.77 1.39 to 2.25 <0.001** Gender Female (ref) 1 1 1 1 Male 1.04 0.90 to 1.19 0.547 1.31 1.11 to 1.53 0.001** Smoking parents No (ref) 1 1 1 1 Yes 3.50 2.97 to 4.12 <0.001** 1.58 1.36 to 1.84 <0.001** Smoking friends No (ref) 1 1 1 1 Yes 1.50 1.30 to 1.73 <0.001** 2.16 1.85 to 2.53 <0.001** Knowledge of SHS dangers No (ref) 1 1 1 1 Yes 2.11 1.52 to 2.93 <0.001** 2.84 2.15 to 3.75 <0.001** SHS, Secondhand Smoke; * <0.05 ** <0.01. [page 418] [Healthcare in Low-resource Settings 2024;12:11861] Non -co mmerc ial us e o nly smokers themselves and others. Currently, social media can be considered and developed as a tool for interventions to improve behavior to avoid exposure to secondhand smoke among adoles- cents in Indonesia. Conclusions Six out of ten adolescents are exposed to secondhand smoke in public. The prevalence of exposure to secondhand smoke in ado- lescents is much higher in public than at home. Having parents and friends who smoke, as well as knowledge of the dangers of second- hand smoke and cigarettes, significantly increases exposure to sec- ondhand smoke at home and in public. It is necessary to promote health regarding predictors associated with exposure to second- hand smoke in Indonesia and enhance avoidance behavior against exposure to secondhand smoke. The government must provide oversight of smoking-free regulations and disseminate these regu- lations to the wider community. Furthermore, researchers can explore and modify additional variables related to exposure to sec- ondhand smoke using existing GYTS data. Strengths and limitations One of the key strengths of this study is its large sample size, which greatly enhances its representativeness as a national survey. With a substantial and diverse participant pool, the findings are more likely to accurately reflect the broader population’s charac- teristics, behaviors, and attitudes, thereby bolstering the study’s validity and generalizability to the entire nation. However, a limitation of this study is that it relies on secondary data from the Global Youth Tobacco Survey (GYTS) Indonesia in 2019, while this research was conducted in 2022. Differences in adolescent characteristics may arise due to the time gap, potential- ly leading to variations in the results compared to the current situ- ation. 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