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Abstract
Objective The objectives of this study were to assess the prevalence of self-reported secondhand smoke exposure in cars among adults in Poland and to characterise public attitudes towards the implementation of the ban on smoking in cars with children.
Design Cross-sectional survey was carried out between 4 March 2022 and 7 March 2022 on a national sample of 1090 adult Polish residents. The questionnaire included 12 closed questions on smoking behaviours, secondhand smoke exposure as well as attitudes towards different smoke-free laws.
Participants Data were obtained from 1090 individuals, aged 18–84 years, 52.6% were females.
Results Almost every fifth respondent (17.7%) declared secondhand smoke exposure in cars in the past 30 days (31.8% of smokers and 12.0% of non-smokers; p<0.001). Lack of the implementation of smoke-free home rules (aOR 2.92, 95% CI 1.99 to 4.29; p<0.001), age 18–29 years (aOR 2.06; 95% CI 1.16 to 3.67; p=0.01), current smoking (aOR 1.99, 95% CI 1.37 to 2.90; p<0.001) as well as bad financial situation (aOR 1.60, 95% CI 1.02 to 2.48; p=0.04) were significantly associated with the higher risk of secondhand smoke exposure in cars. Out of all respondents, 84.2% supported the implementation of the ban on smoking in cars with children. Out of 12 different sociodemographic factors, only the female gender (aOR 1.94, 95% CI 1.37 to 2.74) and being non-smokers (aOR 1.70. 95% CI 1.20 to 2.41; p=0.003) were significantly associated with the higher odds of supporting the implementation of the ban on smoking in cars with children.
Conclusions This study showed high public support for the implementation of the ban on smoking in cars with children. Social support for smoke-free environments in Poland should be used by public health specialists and policy-makers to strengthen the national tobacco control act.
- PUBLIC HEALTH
- EPIDEMIOLOGY
- Health & safety
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study was carried out on a national sample of adults in Poland.
A logistic regression analyses were used to identify factors associated with public support for the implementation of the ban on smoking in cars with children.
Secondhand smoke exposure in cars was defined based on self-report, which may pose demand bias or recall bias.
Secondhand smoke exposure among children was not verified in this study.
Introduction
Secondhand smoke exposure is a well-documented risk factor for cardiovascular diseases, lung diseases as well as cancers.1 2 It is estimated that more than 1 million people every year die due to secondhand smoke exposure.3 Moreover, children exposed to secondhand smoke are at greater risk for tobacco use in adolescence.4 Exposure of unborn children to secondhand smoke may lead to birth defects, stillbirths, preterm births and infant deaths.3 Moreover, children living with smokers are at higher risk of developing lung disease (bronchiolitis, pneumonia and respiratory infection), early mortality and addiction due to nicotine effects in the brain.3 5
Secondhand smoke exposure mostly occurs in the home or workplace.3–5 Moreover, staying in selected public places (eg, bars and restaurants) may be associated with a greater risk of exposure to secondhand smoke.5 Findings from the cross-sectional surveys among adolescents and young adults also showed that a markable proportion of youth may be exposed to secondhand smoke in cars and private vehicles.6 7 Moreover, sociodemographic factors such as educational level, financial situation and individual health literacy levels may influence the risk of exposure to secondhand smoke.3–6
The WHO Framework Convention on Tobacco Control encourages the Member States to implement comprehensive smoke-free laws that protect non-smokers from secondhand smoke exposure.8 Moreover, the implementation of smoke-free laws may encourage smokers to quit as well as prevent smoking initiation among adolescents.9 10 However, countries across the world differ in the implementation of smoke-free laws, the extension of policies and places (both indoor and outdoor) where smoking is prohibited.11 12 The prevalence of secondhand smoke exposure is higher among low-income and middle-income countries.13 It is estimated that only one-third of the countries have implemented a comprehensive ban on smoking in public places.14 Organisational factors, political polarisation and the lack of social support are recognised as major barriers to the implementation of national smoke-free laws.15 16
Poland is an example of a former communist country in Central and Eastern Europe, that passes the first smoke-free law.17 18 In 1995, ban on smoking in healthcare facilities, schools and other educational facilities as well as enclosed workplaces and several public places was implemented.17 18 The implementation of smoke-free law was supported by a coalition of experts (including doctors, public health specialists and scientific societies), efforts to build political consensus as well as public debate on tobacco use and media anti-tobacco campaigns (eg, ‘Let’s Stop Smoking Together’).18 In 2010, the smoke-free law was extended to new places where smoking is prohibited, and in 2016, e-cigarette use in public places was banned.17 Over 10 years after the markable amendment of the smoke-free law in Poland (2009–2019), a substantial reduction in secondhand exposure was observed in all public venues.17 However, significant gaps in the implementation of smoke-free laws in private venues are observed.19 In 2019, only 66.1% of Poles adopted a full smoke-free home rule in their homes.19 There is a public debate on the implementation of the ban on smoking on apartment balconies. Moreover, some European countries (eg, Cyprus, France, UK) enforced the ban on smoking in private cars with minors.11 20 Out of 12 European countries participating in the TackSHS Survey (2017–2018), Poland was the country with the lowest level of public support for the implementation of the ban on smoking in cars with children.11 In 2018–2018, only 59.8% of non-smokers in Poland declared their support for the implementation of the ban on smoking in private cars with children.11
The COVID-19 pandemic has had a markable impact on public attitudes towards tobacco use.21 Between 2019 and 2022, the prevalence of daily smoking in Poland increased from 21% to 28.8%.22 At the same time, an increase in public awareness of smoking-related diseases was observed.23 Regular monitoring of public attitudes towards tobacco use, smoke-free laws and antitobacco legislation is the critical anti-tobacco measures recommended by the WHO in the MPOWER package.24 However, there is a lack of data on public attitudes towards the extension of the national smoke-free law in Poland, including private cars.
Therefore, the objectives of this study were to assess: (1) the prevalence of self-reported secondhand smoke exposure in cars; (2) public attitudes towards the implementation of the ban on smoking in cars with children, and (3) to identify factors associated with public support for the implementation of the ban on smoking in cars with children.
Methods
Study design and sample
This cross-sectional survey was carried out between 4 March 2022 and 7 March 2022, on a national sample of 1090 adult inhabitants of Poland. Data were collected by the professional public opinion research company (Nationwide Research Panel Ariadna, Warsaw, Poland),25 on behalf of the research team, which provides the scientific context for this study. Computer-assisted web interview (CAWI) technique was used. Data collection methods were precisely described in previously published papers that are published within the same scientific project.22 23
Respondents were selected from more than 100 thousand registered and verified individuals, that actively participate in the surveys carried out by the Nationwide Research Panel Ariadna, Warsaw, Poland.25 A non-probability quota sampling technique was applied.25 The stratification model included the following variable: gender, age, size and location of the place of residence. The stratification was based on sociodemographic datasets collected and published Central Statistical Office of the Republic of Poland, Warsaw, Poland.26
Participants and public involvement
Participants in this study were not involved in the development of the design or recruitment. Results will be disseminated via publication in an open-access journal.
Measures
A self-prepared questionnaire was used.22 23 The questionnaire included 12 closed questions on tobacco use, tobacco-related diseases, secondhand smoke exposure as well as attitudes towards different smoke-free laws. Moreover, sociodemographic questions were addressed.
Self-reported secondhand smoke exposure in cars: Respondents were asked about exposure to secondhand smoke in cars, using the following question: ‘In the last 30 days, have you been exposed to secondhand smoke in a private car (your car or a car that you travel regularly)? (yes/no)’. Respondents who answered ‘yes’ were classified as those who were exposed to secondhand smoke in cars.
Public attitudes towards the implementation of the ban on smoking in cars with children: Respondents were asked about their attitudes towards the implementation of the ban on smoking in cars with children, using the question: ‘How much do you agree or disagree with the following statement: smoking in a car with children/minors under the 18 years of age should be banned by the law’, with five possible answers: ‘strongly agree’, ‘rather agree’, ‘rather disagree’, ‘strongly disagree’ or ‘do not know/difficult to tell’.
Respondents, who indicated ‘strongly agree’ or ‘rather agree’, were classified as those who support the implementation of the ban on smoking in cars with children.
Data analysis
All statistical calculations were performed using SPSS V.28 (IBM). The distribution of categorical variables was shown by frequencies and proportions. Cross-tabulations and χ2 tests were used to compare categorical variables.
Associations between personal characteristics (gender; age; marital status; having higher education; occupational status; self-reported financial situation; having children; children under 18 years in the home; the number of household members; place of residence), smoke-free home rules and smoking status with (1) secondhand smoke exposure and (2) attitude towards the implementation of the ban on smoking in cars with children were analysed using the logistic regression analyses. In univariate logistic regression analyses, all variables were considered separately. Multivariate logistic regression analyses included all the variables significantly associated with awareness of selected tobacco-related diseases in univariate models. The strength of association was measured by the OR and 95% CIs. Statistical inference was based on the criterion p<0.05.
Results
Characteristics of the study population
This study is based on the responses received from 1090 adults (52.6% females) in Poland. Among the respondents, 28.8% were smokers. Almost two-thirds of respondents (60.6%) lived in completely smoke-free homes. The sociodemographic characteristics of the study population is presented in table 1.
Characteristics of the study population (n=1090)
Self-reported secondhand smoke exposure in cars
Almost every fifth respondent (17.7%) declared secondhand smoke exposure in cars in the past 30 days (table 2). The prevalence of secondhand smoke exposure decreased with the age (p<0.001). Respondents who had children more often declared secondhand smoke exposure in cars in the past 30 days, compared with those who did not have children (21.6% vs 15.9%; p=0.02). The prevalence of secondhand smoke exposure in cars was three times higher among those respondents without the complete ban on smoking in the home compared with those who implemented smoke-free home rules (30.1% vs 9.7%; p<0.001). Moreover, the prevalence of secondhand smoke exposure in cars among smokers was more than two times higher (31.8% vs 12.0%; p<0.001) than among non-smokers.
Self-reported secondhand smoke exposure in cars in the past 30 days by smoking status (n=1090)
Self-reported secondhand smoke exposure in cars by smoking status is presented in table 2.
In multivariate logistic regression analysis (table 3), younger (18–29 years) age (aOR 2.06; 95% CI 1.16 to 3.67; p=0.01), bad financial situation (aOR 1.60, 95% CI 1.02 to 2.48; p=0.04), lack of the implementation of smoke-free home rules (aOR 2.92, 95% CI 1.99 to 4.29; p<0.001) as well as current smoking (aOR 1.99, 95% CI 1.37 to 2.90; p<0.001) were significantly associated with the higher risk of secondhand smoke exposure in cars in the past 30 days (table 3).
Factors associated with self-reported secondhand smoke exposure in cars in the past 30 days (n=1090)
Public attitudes towards the implementation of the ban on smoking in cars with children
Among the respondents, 64.3% strongly agreed with the statement that smoking in cars with children/minors under 18 years of age should be prohibited, and 19.9% rather agreed with this statement (table 4). Out of all respondents, 84.2% supported (strongly agree or rather agree) the implementation of the ban on smoking in cars with children. Less than 5% of respondents declared that they strongly disagree with the statement that smoking in cars with children should be prohibited by the law. Among the respondents, 7% did not have clearly defined attitudes towards the implementation of the ban on smoking in cars with children (table 4). The percentage of respondents who supported the implementation of the ban on smoking in cars with children was significantly higher among females as well as older respondents (p<0.001). Moreover, those who had ever been married, currently unemployed respondents (passive occupational status), those who had as least one child as well as respondents who implemented a complete ban on smoking in the home more often declared support for the implementation of the ban on smoking in cars with children (p<0.05). More than 15% of smokers were against the implementation of the ban on smoking in cars with children (table 4).
Public attitudes towards the implementation of ban on smoking in cars with children (n=1090)
In multivariate logistic regression analysis (table 5), only females (aOR 1.94, 95% CI 1.37 to 2.74) and current non-smokers (aOR 1.70. 95% CI 1.20 to 2.41; p=0.003) had higher odds of supporting the implementation of the ban on smoking in cars with children (table 5).
Factors associated with the public support for the implementation of ban on smoking in cars with children (n=1090)
Discussion
This is the most up-to-date study on public attitudes towards the implementation of the ban on smoking in cars with children in Poland. Two years after the COVID-19 pandemic onset in Poland, the majority of adults (84.2%) declared support for the implementation of the ban on smoking in cars with children. Out of 12 different variables analysed in this study, only gender and smoking status were significantly associated with public attitudes towards strengthening the tobacco control act. Lack of differences by age, educational level, place of residence and financial situation points to a national consensus in understanding the need to protect children from exposure to secondhand smoke in cars, irrespective of socioeconomic variables.
In 2010, Poland has passed an amendment to the national tobacco control act that has a significant impact on the reduction of secondhand smoke exposure in public venues.17 27 Between 2009 and 2019, the percentage of non-smokers exposed to secondhand smoke in the workplace decreased from 19.2% to 6.5%. Even a greater decrease in secondhand smoke exposure was observed in bars/pubs—from 39.4% in 2009 to 7.0% in 2019.17 However, despite the implementation of smoke-free rules, still, 11.7% of Poles were exposed to secondhand smoke in public transport stops and facilities and 3.0% declared exposure to secondhand smoke in public transportation vehicles.17 In this study, 17.7% of all respondents declared exposure to secondhand smoke in private cars, wherein smokers more often declared exposure to secondhand smoke than non-smokers (31.8% vs 12.0%; p<0.001). The percentage of Poles exposed to secondhand smoke in private cars indicates is higher than the percentage of Poles exposed to secondhand smoke in public venues. Moreover, in this study, the highest risk of secondhand smoke exposure was among the youngest respondents aged 18-29 years. We can hypothesise that young adults are travelling with friends or family, which may expose them to secondhand smoke. For example, the percentage of smokers is relatively high among university students,28 so travelling by car to universities can be a source of exposure to secondhand smoke if one of the passengers smokes. Moreover, a bad financial situation was also associated with a higher risk of secondhand smoke exposure in the car. Low socioeconomic status is usually associated with higher exposure to secondhand smoke, probably due to the higher prevalence of smoking and lower levels of health literacy.4–6 29 We can hypothesise that financial constraints may be the main reason for higher exposure to secondhand smoke in the car among vulnerable populations.29
In this study, we also analysed the impact of voluntary smoke-free homes on the exposure to secondhand smoke in cars as well as attitudes towards the implementation of the ban on smoking in cars with children. The home environment is one of the most common places where individuals may be exposed to secondhand smoke.1 4 5 Voluntary implementation of smoke-free home rules in private homes may also shape public attitudes towards the ban on smoking in cars. In this study. Respondents who do not have any smoke-free home rules had almost three times higher risk of secondhand smoke exposure in cars, compared with those individuals who voluntarily implemented the ban on smoking in homes. This finding underlines the importance of comprehensive smoke-free policies, that promote the implementation of the ban on smoking, also in selected private venues (eg, cars with minors or apartment balconies).20 21
In this study, the majority of Poles (84.2%) declared their support for the implementation of the ban on smoking in cars with children. We observed a markable increase in the percentage of non-smokers who support the ban on smoking in cars with minors, compared with data from 2017 to 2018, where only 59.8% of non-smokers in Poland supported the implementation of the ban on smoking in cars with children.11 We can hypothesise that the COVID-19 pandemic and the education on the transmission methods (air contaminated by droplets/aerosols) may have a positive impact on public awareness of respiratory health and the harmful effect of other respiratory hazards like air pollution.21 23 During the COVID-19 pandemic, an increase in public support for the implementation of smoke-free zones was also observed in Saudi Arabia30 and Israel.31
Out of 12 different sociodemographic factors, only the female gender and being non-smokers were significantly associated with the higher odds of supporting the implementation of the ban on smoking in cars with children. Numerous studies showed that smokers are less likely to support smoke-free laws.19 20 We can hypothesise that females are more likely to support the ban on smoking in cars with children, due to their social role and family model in Poland, where the females are mostly responsible for caregiving. Findings from this study showed that there is a nationwide consensus between sociodemographic groups on the importance of the implementation of the ban on smoking in cars with children, as there was no significant impact of sociodemographic factors on the public attitudes towards the implementation of the ban on smoking in cars with children.
The implementation of the ban on smoking in cars with children has been documented as an effective way to reduce secondhand smoke exposure among children.32 33 The age of the child that is covered by the ban differs across the European countries (under the age of 12 in France and Greece, to under the age of 16 in Cyprus).20 33 Moreover, some tobacco control researchers point out the need to implement a comprehensive ban on smoking in cars with children, which will also include electronic cigarettes.34 Ravara et al showed, that despite the strong ban support, poor enforcement may contribute to low compliance and exposure to secondhand smoke exposure in cars.35 As partial and poorly enforced ban is vulnerable to breaches, a comprehensive smoke-free policy is needed.35
This study has practical implications for public health specialists and policymakers in Poland. First of all, this study confirmed that there is high public support for the implementation of the ban on smoking in private cars with children. Second, this study showed that there is a lack of sociodemographic differences in the public attitudes towards the extension of the tobacco control acts, which will also include a ban on smoking in private vehicles. Third, this study underlines the further need to strengthen tobacco control policy in Poland, which will reduce secondhand smoke exposure in public and selected private venues.
There are several limitations of this study. The secondhand smoke exposure was based on self-reported data. Due to the cross-sectional design of this study, atmospheric and biological markers of secondhand smoke exposure in cars have not been evaluated.36 Only adult inhabitants of Poland were included in this study, so secondhand smoke exposure among minors has not been verified. Moreover, data were collected using the CAWI technique that may exclude those individuals that do not have internet access, so we cannot exclude a selection bias.
Conclusions
This study showed high public support for the implementation of the ban on smoking in cars with children. Social support for smoke-free environments in Poland should be used by public health specialists and policymakers to strengthen the tobacco control act. Despite the ban on smoking in numerous public venues in Poland, still, a markable proportion of Poles is exposed to secondhand smoke in private cars. As there is no safe level of secondhand smoke exposure, public actions are needed to provide smoke-free environments.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study protocol was approved by the Ethical Review Board at the Centre of Postgraduate Medical Education, Warsaw, Poland (approval no. 21/2022). Participants gave informed consent to participate in the study before taking part.
References
Footnotes
Twitter @MateJankowski
Contributors All authors (AO, MJ and JP) have contributed significantly to this work, have seen the contents of the manuscript and agreed to its submission. All the co-authors accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.