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The socioeconomic gradient of secondhand smoke exposure in children: evidence from 26 low-income and middle-income countries
  1. Mohammad Hajizadeh1,
  2. Arijit Nandi2,3
  1. 1Faculty of Health Professions, School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
  2. 2Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
  3. 3Institute for Health and Social Policy, McGill University, Montreal, Quebec, Canada
  1. Correspondence to Dr Mohammad Hajizadeh, School of Health Administration, Dalhousie University, 5161 George Street, Suite 700, Halifax, NS, Canada B3J 1M7; m.hajizadeh{at}


Objective To provide the first analysis of socioeconomic inequalities in children's daily exposure to indoor smoking in households in 26 low-income and middle-income countries (LMICs).

Methods We used nationally representative household samples (n=369 654) collected through the Demographic Health Surveys between 2010 and 2014 to calculate daily exposure to secondhand smoke (ESHS) among children aged 0–5 years. The relative and absolute concentration (RC and AC) indices were used to quantify wealth-based inequalities in daily ESHS in each country and in urban and rural areas in each country. We decomposed total socioeconomic inequalities in ESHS into within-group and between-group (rural–urban) inequalities to identify the sources of wealth-based inequality in ESHS in LMICs.

Findings We observed substantial variation across countries in the prevalence of daily ESHS among children. Children's ESHS was higher in rural areas compared to urban areas in the majority of the countries. The RC and AC demonstrated that daily ESHS was concentrated among poorer children in almost all countries (RC, median=−0.179, IQR=0.186 and AC, median=−0.040, IQR=0.055). The concentration of ESHS among poorer children was greater in urban relative to rural areas. The decomposition of the overall socioeconomic inequality in daily ESHS revealed that wealth-based differences in ESHS within urban and rural areas were the main contributor to socioeconomic inequalities in most countries (median=46%, IQR=32%).

Conclusions Special attention should be given to reduce ESHS among children from rural and socioeconomically disadvantaged households as social inequalities in ESHS might contribute to social inequalities in health over the life course.

  • Low/Middle income country
  • Secondhand smoke
  • Socioeconomic status
  • Disparities

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  • Contributors MH and AN contributed to the conception and design of the study, MH performed the statistical analysis and drafted the manuscript and AN helped with drafting and revisions. MH and AN read and approved the final version of the manuscript.

  • Funding MH acknowledges funding for this research provided by the Canadian Institutes of Health Research (CIHR) fellowship award program. AN acknowledges the support of the Canada Research Chairs Program. Both authors acknowledge funding from the Canadian Institutes of Health Research Operating Grant, ‘Examining the impact of social policies on health equity’ (ROH-115209).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data underlying the findings are fully available on request from the Demographic Health Survey (DHS) program.