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Public Health

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Original Research

Secondhand smoke exposure of children at home

and prevalence of parental smoking following
implementation of the new tobacco control law in
Macao

Z.L. Zheng a, H.Y. Deng a, C.P. Wu a,*, W.L. Lam b, W.S. Kuok b,
W.J. Liang c, H.L. Wang a
a
Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
b
Health Bureau of Macao SAR, Macao, China
c
Guangdong Provincial Centre for Disease Control and Prevention, Guangzhou, China

article info abstract

Article history: Objective: To investigate secondhand smoke exposure (SHS) of children at home and the
Received 7 June 2016 prevalence of parental smoking after implementation of the new tobacco control law in
Received in revised form Macao. This study explored whether the smoking ban in public places in Macao has
19 September 2016 decreased the prevalence of smoking or led to increased SHS exposure of children at home.
Accepted 24 November 2016 As smokers cannot smoke in public places any more, they may smoke at home more
Available online 4 January 2017 frequently; a displacement effect of smoke-free legislation.
Study design: Cross-sectional survey.
Keywords: Methods: This study surveyed 337 fathers and 538 mothers. Questions from a subset of key
Childrens' secondhand smoke questions from the Global Adult Tobacco Survey (2nd edition) were applied to assess the
exposure SHS exposure of children and the prevalence of parental smoking since the smoking ban. A
Passive smoke classification tree analysis was used to analyse the factors increasing SHS exposure of
Environmental tobacco smoke children.
Macao Results: The prevalence of SHS exposure in children at home was 41.3%. The prevalence
New tobacco control law rates of paternal and maternal smoking were 43.7% and 3.8%, respectively. Compared with
Displacement effects of smoke-free data reported by the Health Bureau of Macao SAR in 2011, the prevalence of parental
legislation smoking and the prevalence of SHS exposure of children at home have not decreased since
the smoking ban. Analysis of the factors increasing the prevalence of SHS exposure of
children indicated that fathers with an education level below high school were more likely
to contribute to this increase, compared with fathers with a high school education or more
(48.2% vs 32.4%, respectively). In addition, fathers represented the majority of smokers at
home, accounting for 92.0% of 415 smoking parents. The prevalence of paternal smoking
(82.0%) in the group of children with SHS exposure was much higher than that in the
unexposed group (16.7%, Chi-squared test ¼ 367.199, P ¼ 0.000). The SHS exposure of
children increased consistently with the decrease in paternal education level. This was
consistent with the increasing prevalence of paternal smoking as paternal education level

* Corresponding author.
E-mail address: wuchipeng@126.com (C.P. Wu).
http://dx.doi.org/10.1016/j.puhe.2016.11.018
0033-3506/© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
58 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 5 7 e6 3

decreased. SHS exposure was most common among children whose fathers had an edu-
cation level below high school and whose mothers were aged 29 years (75.0%).
Conclusions: This study did not find any decline in the prevalence of parental smoking after
the smoking ban. These parents were more likely to smoke at home after the ban, leading
to more frequent SHS exposure for their children.
© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

In 2010, before the new tobacco control law was imple-

Introduction
Exposure to environmental tobacco smoke, also called
‘secondhand smoke’ (SHS) exposure, is associated with car-
diovascular disease, cancer, pulmonary diseases and many
other health problems.1 The risk of lung cancer is increased if
exposure to SHS occurs before 25 years of age.2 Children born to
women exposed to SHS during pregnancy have a higher prev-
alence of physician-diagnosed childhood asthma.3 Addition-
ally, children may be at greater risk from SHS than adults as
they have a higher breath frequency, inhale more air per body
weight, and are less able to handle serious adverse health ef-
fects due to immature liver metabolism and other clearing
mechanisms.4 As early as 2009, the World Health Organization
(WHO) estimated that there were approximately 186,000 pre-
mature deaths in children due to SHS exposure every year.5 As
the application of the WHO Framework Convention on Tobacco
Control extended to Macao,6 the Government of Macao SAR put
the ‘Regime of Tobacco Prevention and Control’ (or the so-called
‘new tobacco control law’) into practice on 1 January 2012,
following Hong Kong and many other countries or areas where
smoke-free legislation had been established.7 The smoking ban
covers public places with fuel production and suppliers, gov-
ernment institutions, indoor areas of restaurants and work-
places, hotels, shopping halls, consumer casinos (including
karaoke clubs and saunas), public entertainment places
(including parks and swimming pools), markets, museums,
cultural exhibition centres, airports and ports among others.8
Campaigns against smoking in public places have reduced
the prevalence of smoking in some parts of the world. The
prevalence of smoking decreased approximately 8 months
after the smoking ban was introduced in the state of Wash-
ington, USA.7 In the Republic of Ireland and Italy, the preva-
lence of smoking decreased by 2% and 2.9%, respectively, 1
year after implementing comprehensive smoke-free legisla-
tion.9 In Macao, however, the overall prevalence of smoking
had not decreased 6 months after implementation of the new
tobacco control law.10 As Lin and Bian reported, the preva-
lence of smoking of 16.8%, after adjusting the sex ratio, was
close to the prevalence of 16.9% reported by the Health Bureau
of Macao SAR in 2011.11 In addition, in Hong Kong, SHS
exposure of primary students grade 2 to 4 at home was re-
ported to be higher after implementation of the public smok-
ing ban, and the prevalence of parental smoking remained at
the same level as before the ban.12 Chan et al.13 declared that
smoke-free legislation in public places may lead to more
smoking at home, increasing SHS exposure of other family
members, especially children. This phenomenon is called the
‘displacement effect of smoke-free legislation’.12e14
mented in Macao, 40% of surveyed adolescents (aged 13e15
years) were reported to be exposed to SHS at home.11 The daily
smoking prevalence rates of males and females aged >14
years were 31.4% and 3.8%, respectively. The highest preva-
lence of smoking occurred in males aged 35e44 years and
females aged 25e34 years, with rates of 40.7% and 5.2%,
respectively.11 To the authors' knowledge, no study to date has
evaluated SHS exposure of children or the prevalence of
parental smoking since implementation of the new tobacco
control law. As such, the authors designed a questionnaire to
investigate the prevalence of SHS exposure of children at
home and the prevalence of parental smoking from October
2013 to March 2014 in Macao. Furthermore, a classification
tree analysis (CTA) was undertaken in an attempt to deter-
mine the factors that increase SHS exposure.15
CTA is a non-parametric statistical method typically used
to identify high-risk populations. Unlike parametric multi-
variate regression which lacks the ability to capture unspeci-
fied, complex inter-relationships across factors,16 CTA can
address these limitations by revealing unspecified inter-
relationships through an easily interpreted tree diagram.17 It
is data adaptive and can provide insight into the predictive
structure of data.18 In this study, CTA was used to unravel the
risk factors contributing to SHS exposure of children at home,
as well as the interactions potentially overlooked in logistic
regression.
Methods
Sampling method
Fathers or mothers whose children were in the first, third or
fifth grade at four primary schools in Our Lady of Fatima
Parish, Macao, were surveyed. All of the children were aged
between 6 and 14 years. Macao has a total of seven parishes,
of which Our Lady of Fatima Parish is the most densely
populated, accounting for 40% of the total population.19 The
questionnaire used for the study was self-administered. It
included demographic information and information about
SHS exposure of children at home, as well as parental
smoking habits. The questions to demarcate SHS exposure
and smokers were cited from a subset of key questions from
the Global Adult Tobacco Survey (2nd edition)20 in order to
better compare the data with related information reported
by the Health Bureau of Macao SAR. Exposure of children to
SHS at home was defined by the question, ‘How often does
anyone smoke inside your home?’, with the options of daily,
 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 5 7 e6 3 59

weekly or monthly. Children whose parents reported that

Table 1 e General information on the respondents.
the frequency of smoking at home was less than monthly or
never were classified as the unexposed group. All ques- General information n %
tionnaires were distributed to the students by teachers, Who filled out questionnaire
taken home by the students, completed by one of the stu- Father 337 38.5
dent's parents and then returned to the school by the stu- Mother 538 61.5
Paternal education level
dents. Questionnaire data were entered into an SPSS Version
Elementary school or below 157 17.9
21.0 (IBM Corp., Armonk, NY, USA) database by the Junior high school 335 38.3
investigators. High school 274 31.3
College or above 91 10.4
Statistical analysis Missing values 18 2.1
Maternal education level
Elementary school or below 96 11.0
Chi-squared analysis was used to analyse the relationships
Junior high school 401 45.8
between childrens' SHS exposure status and parental smoking
High school 296 33.8
status, and the prevalence of parental smoking and parental College or above 73 8.3
education levels, and to constitute the ratio of education Missing values 9 1.0
levels in mothers aged 29 years. Logistic regression analysis Paternal occupation
was used to analyse the relationship between age of the child Service industry worker 390 44.6
and SHS exposure status. Professional worker 93 10.6
Transportation and construction worker 155 17.7
CTA was used to identify the impact of SHS exposure on
Unemployed or self-employed 212 24.2
children who were more likely to be exposed to SHS. As
Missing values 25 2.9
declared previously, CTA is a useful analytic tool that can Maternal occupation
recognize specific childhood subgroups. Members of each Service industry worker 520 59.4
subgroup have similar features to indicate specific risk fac- Professional worker 31 3.5
tors of SHS exposure. The CTA model built with the Chi- Homemaker or self-employed 311 35.5
squared Automatic Interaction Detector growing method Missing values 13 1.5
Immigrant status of father
starts at the proportion of children exposed to SHS and
Local citizen 736 84.2
unexposed to SHS (root node, node 0). The root node is split New immigrant 109 12.4
into child nodes and parent nodes. The parent nodes are Missing values 30 3.4
further split and create the child nodes or parent nodes of Immigrant status of mother
the next level until no parent node can be created.21 The Local citizen 638 73.0
terminative rules include a maximum tree depth of three New immigrant 223 25.4
Missing values 14 1.6
levels, with minimum case numbers of parent nodes and
child nodes of 100 and 50, respectively. This splitting process
forms the final classification tree. The significant level of SHS exposure of children at home
merging and splitting is 0.05.
SPSS Version 21.0 was used for all analyses. The 875 valid questionnaires showed that 361 (41.3%) inves-
tigated children were exposed to SHS, and the remaining 514
(58.7%) children were not exposed to SHS at home. There was
Results no significant difference in the prevalence of SHS exposure
between boys (42.8%, 149/348) and girls (40.2%, 212/527) (Chi-
General information squared test ¼ 0.579, P ¼ 0.483). Logistic regression analysis
revealed that there was no significant relationship between
The teachers distributed 1016 questionnaires to the students, the age of children and their SHS exposure status (odds ratio
and 875 questionnaires were returned (response rate 86.1%). 0.970, 95% confidence interval 0.909e1.04).
The questionnaires were filled out by 337 (38.5%) fathers and
538 (61.5%) mothers. In total, 875 families were surveyed. The Parental smoking status
average ages of fathers and mothers were 42.9 (standard de-
viation [SD] 8.1) and 37.8 (SD 6.1) years, respectively. The Among parents, 382 fathers and 33 mothers were smokers
average age of the children was 8.7 (SD 2.1) years. In terms of with prevalence rates of 43.7% (382/875) and 3.8% (33/875),
education, 69.6% of fathers and 79.6% of mothers had a junior respectively. Of the 415 smokers, 382 fathers accounted for
high school or high school education; only 10.4% of fathers 92.0%. The prevalence rates of smoking in fathers aged
and 8.3% of mothers had a college education or more. Of the 35e44 years and mothers aged 25e34 years were 41.9% and
parents, 44.6% of fathers and 59.4% of mothers worked in the 4.7%, respectively. Chi-squared analysis showed that the
service industry; only 10.6% of fathers and 3.5% of mothers prevalence of paternal smoking decreased when paternal
were professional workers (including teachers, engineers and education level increased (Chi-squared test ¼ 30.300,
researchers, government officers, doctors and nurses) and P ¼ 0.000). No significant relationship was found between
12.9% of fathers and 25.9% of mothers were recent immigrants the prevalence of maternal smoking and maternal education
who had been living in Macao for less than 7 years. More de- level (Chi-squared test ¼ 3.763, P ¼ 0.288). Details are shown
tails are shown in Table 1. in Table 2.
60 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 5 7 e6 3

Table 2 e Prevalence of parental smoking by education level (%).

Education level Fathers Mothers
n Smokers (n) % N Smokers (n) %
Elementary school or below 157 86 54.8 96 7 7.3
Junior high school 335 168 50.1 401 13 3.2
High school 274 107 39.1 296 11 3.7
College or above 91 20 22.0 73 2 2.7
Not reported 18 1 5.56 9 0 0
Total 875 382 43.7 875 33 3.8
Chi-squared test 30.300 3.763
P 0.000 0.288

Missing data up to 3.1%.

Prevalence of parental smoking with regard to children
exposed and not exposed to SHS
Of 875, 361 families who reported exposure of their children to
SHS at home were classified as the SHS exposed group. The
other 514 families were in the unexposed group. In the
exposed group, the prevalence of parental smoking (82% of
fathers and 7.2% of mothers) was much higher than in the
unexposed group (16.7% of fathers and 1.4% of mothers). De-
tails are shown in Table 3.
CTA of factors increasing the prevalence of SHS exposure of
children at home
Besides parental smoking status, 12 factors that may increase
SHS exposure of children were selected as independent vari-
ables, including age (father, mother and child), parental edu-
cation level, parental occupation, parental immigrant status
(people living in Macao for <7 years were classified as new
immigrants and others were classified as local citizens),
number of children in the family, principal person who took
care of the child and marital status of parents. The SHS
exposure status of children (exposed and unexposed) was set
as the dependent variable of the CTA model. The values of
independent variables are shown in Table 4.
The CTA results, as shown in Fig. 1, indicated that the root
node (node 0) was split by paternal education level and
created two parent nodes (node 1, node 2). Node 1 represents a
subgroup of the children whose fathers had an education level
below high school. The prevalence of SHS exposure in node 1
was 48.2%, which was higher than that in node 2. The popu-
lation of this subgroup accounted for 56.2% of the total. Node 2
represents the subgroup of children whose fathers had an
education level of high school or more. The prevalence of SHS
exposure was 32.4%, and the population of this subgroup
accounted for 43.8%.
Node 1 was split again by maternal age to create additional
two child nodes (node 3, node 4). Node 3 had the highest
prevalence of SHS exposure of children (75.0%), and repre-
sented children whose fathers had an education level below
high school and whose mothers were aged 29 years. The
population in this node was quite small, accounting for 5.9%.
Node 4 represented the children whose fathers had an edu-
cation level below high school and whose mothers were aged
>29 years; the prevalence of SHS exposure was 45.0%.
Comparison of the constitute ratio of education levels
between mothers in node 3 and node 4
In node 3, the mothers were aged 29 years. Of these, 5.8% (3/
52) had an elementary school education or less, 51.9% (27/52)
had a junior high school education, 25.0% (13/52) had a high
school education, and 5.8% (3/52) had a college education or
more. The constitute ratio of their education levels was not
lower than that of the mothers in node 4 (age >29 years) (Chi-
squared test ¼ 7.500, P ¼ 0.058). Details are shown in Table 5.
Discussion
The Government of Macao SAR has taken many strict mea-
sures to support the smoking ban. For example, the fine for
smoking in a public place is 600 Macao patacas.8 Additionally,
the number of smoke-free areas has been extended. As the
number of places for smoking in public is decreasing, has the
prevalence of smoking declined in Macao? For comparison
with the population with the highest prevalence of smoking
(40.7% for males aged 35e44 years, 5.2% for females aged
25e34 years) reported by the Health Bureau of Macao SAR in
2011, this study analysed the prevalence rates of smoking
among fathers and mothers of the same age ranges. The
outcomes were 41.9% and 4.7%, respectively, which were

Table 3 e Prevalence of parental smoking in children who were exposed to or unexposed to secondhand smoke.
Parents Exposed group (n ¼ 361) Unexposed group (n ¼ 514) Total no. of smokers Chi-squared test P
No. of smokers % No. of smokers %
Fathers 296 82.0 86 16.7 382 367.199 0.000
Mothers 26 7.2 7 1.4 33 19.931 0.000
Total 322 e 93 e 415
 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 5 7 e6 3 61

Table 4 e Outline of creating and coding independent variables in the classification tree analysis model.
Independent variables Variable values
Age Fathers e
Mothers e
Children e
Education level Fathers 1 ¼ elementary school or below; 2 ¼ junior high school; 3 ¼ high school;
4 ¼ college or above
Mothers 1 ¼ elementary school or below; 2 ¼ junior high school; 3 ¼ high school;
4 ¼ college or above
Occupation Fathers 1 ¼ service industry workers; 2 ¼ professional workers; 3 ¼ transportation
and construction workers; 4 ¼ unemployed or self-employed
Mothers 1 ¼ service industry workers; 2 ¼ professional workers; 3 ¼ homemaker or
self-employed
Immigrant status Fathers 0 ¼ local citizens; 1 ¼ new immigrants
Mothers 0 ¼ local citizens; 1 ¼ new immigrants
Number of children in a family 1 ¼ one; 2 ¼ two; 3 ¼ three; 4 ¼ four or more
Principal person to take care of children 1 ¼ father and mother; 2 ¼ father; 3 ¼ mother; 4 ¼ grandparents; 5 ¼ nanny
or others
Marital status of parents 1 ¼ single-parent family; 2 ¼ two-parent family; 3 ¼ remarried family

Fig. 1 e Classification tree of the factors increasing the prevalence of secondhand smoke (SHS) exposure of children at home.
62 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 5 7 e6 3
Table 5 e Comparison of the constitute ratio of maternal
education levels in node 3 and node 4.
Education level 29 years >29 years Chi-squared P
of mothers old old test
n % n %
Elementary 3 5.8 79 18.0 7.500 0.058
school or below
Junior high school 27 51.9 268 60.9
High school 13 25.0 79 18.0
College or above 3 5.8 13 3.0
Not reported 6 11.5 1 0.2
Total 52 440
Missing data up to 1.4%.
similar to the values reported by the Health Bureau of Macao
before the smoking ban. Despite the fact that the study re-
spondents came from a single parish of Macao, the population
of this parish accounted for 40% of the total, and had similar
proportions for age structure, sex ratio and education levels
compared with the whole population of Macao.19 Therefore,
the study findings, to a certain extent, should reflect the
prevalence of smoking in the population of Macao as a whole,
and demonstrated that the smoking ban has not decreased
the overall prevalence of smoking.
As parents did not stop smoking, the home became the
main place to smoke when smoking was banned in most public
areas. Therefore, it was expected that there would be an
inevitable increase in SHS exposure of children in the home.
This study found that the prevalence of SHS exposure in the
home was 41.3%, which was slightly higher than the preva-
lence of SHS exposure of adolescents in the home in 2010
(40.0%).11 This also supported the possibility of a displacement
effect of smoke-free legislation. Moreover, it was deduced that
the displacement effect of smoke-free legislation would be
more likely to manifest in increased exposure frequency rather
than increased exposure prevalence.
The risk factors of SHS exposure of children at home were
analysed by CTA, and this showed that children whose fathers
had an education level below high school had a higher prev-
alence of exposure to SHS. The highest prevalence of SHS
exposure occurred when the paternal education level was
lower than high school and maternal age was 29 years.
The results also showed that the prevalence of SHS expo-
sure of children was lower among children whose fathers had
a higher level of education. The prevalence dropped sharply
among children whose fathers had a college education or
more. This was consistent with the decrease in prevalence of
paternal smoking as paternal education level increased. A
study in 2011 undertaken by the Health Bureau of Macao SAR
also reported that smoking prevalence in males was nega-
tively correlated with education level.11 The distribution of
parental smoking status was analysed, and fathers were
found to account for the majority of this smoking population
(92.0% among the 415 smokers). The prevalence of paternal
smoking was much higher in the group of children exposed to
SHS (82.0%) compared with the unexposed children (16.7%).
Therefore, it can be deduced that the prevalence of SHS
exposure of children will reduce if the prevalence of paternal
smoking decreases. The critical way to reduce the prevalence
of paternal smoking is to improve paternal education levels.
However, this would be very difficult to achieve. As such, it is
necessary to offer regular health education as well as smoking
cessation services to this group.
Regarding maternal age, it can be concluded that mothers
aged 29 years had probably given birth to a child before 22
years of age, as the average age of the target children was 8.7
(SD 2.1) years. As paternal education levels were lower than
high school, it was speculated that the young mothers also
had lower levels of education. This poor education back-
ground may be a key reason for the high prevalence of SHS
exposure of children at home. The constitute ratio of educa-
tion levels of mothers aged 29 years was compared with that
for mothers aged >29 years within the subgroup of paternal
education level lower than high school. The result showed
that the education levels of the younger mothers were not
lower than those of the mothers aged >29 years. In other
words, the high SHS exposure of children in this subgroup was
not related to maternal education level. As such, it was
deemed that there was correlation between paternal educa-
tion level and maternal age, with the highest prevalence (75%)
of SHS exposure of children whose fathers had an education
level below high school and whose mothers were aged 29
years. Young mothers may not be mature enough to keep their
children away from risk factors.
This study found no significant relationship between the
prevalence of maternal smoking and maternal education
level. However, this result may be invalid due to the small
number of female smokers in this study.
Author statements
Acknowledgements
The authors wish to thank the schools and the parents for
their cooperation in this study. In addition, the authors wish
to thank Dr. Robert R. Jacobs from the School of Public Health
& Information Sciences at the University of Louisville in USA
for suggestions and language assistance.
Ethical approval
None sought.
Funding
None declared.
Competing interests
None declared.
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