INTRODUCTION

Tobacco smoke has been identified as a toxic mixture of chemicals that cause diseases such as lung cancer, heart diseases and other preventable serious ailments^1-3. The burden of disease from second hand smoke (SHS) is estimated to contribute 0.7% of the total disease burden deaths due to ischemic heart disease, adult asthma, and lung cancer as well as deaths due to lower respiratory infections (LRI) among children particularly in low-income countries⁴. Exposure to tobacco before birth and postnatal SHS has been linked with poor cognition in children⁵. Studies have further suggested that adolescent cognition was associated with SHS exposure during adolescence⁶. This is a result of carbon monoxide in tobacco smoke binding with hemoglobin to form carboxyhemoglobin in the blood, therefore depleting oxygen supply to the brain and resulting in adverse effects on the brain⁷. Recent research continues to confirm the harmful effects of tobacco smoke on academic performance. Students regularly exposed to tobacco smoke are more likely to report poor academic performance compared to students who are not exposed⁸. Exposure to tobacco smoke causes direct harm to non-smokers violating non-smoker’s right to health and clean air.

The threat posed by tobacco use and exposure to tobacco smoke has compelled developed countries to strengthen legislation and policy on tobacco control to protect public health. In response to increased regulation in developed countries, the tobacco industry has shifted its attention to poorer developing regions in Africa, Asia, Eastern Europe, and Latin America^9,10 and Botswana has not been spared. There is an increasing market for tobacco products targeted at young children and the youth^11-13. The World Health Organization (WHO) interprets the right to health to mean that governments must generate conditions in which everyone can be as healthy as possible. Governments, therefore, have a legal obligation to ensure that the public right to health is not deprived by the tobacco industry. This is only achievable through regulating the industry through enactment of appropriate policies and programs^14-16. While many college students smoke, little is known about their exposure to passive smoking¹⁷. Even though we have not come across studies on tertiary students’ exposure to passive smoke in Botswana, there is evidence that 78.9% of college students in Africa are exposed to passive smoking^18,19.

This study assessed the prevalence of smoking among university students, exposure to SHS and related respiratory symptoms among non-smoking students in three academic institutions in the City of Gaborone, Botswana. Further, the study assessed students’ attitudes towards tobacco control policies in their respective institutions.

METHODS

This cross-sectional study was undertaken in three academic institutions in Gaborone, Botswana, in March 2019. A total of 450 randomly selected undergraduate students from the faculties of Business, Engineering and Technology, Humanities, Health Sciences and Social Sciences were invited to take part in the study. A self-administered questionnaire was used to collect data from students in each institution. Questionnaires were anonymously answered with consent sought from participants. The study obtained ethical clearance from the Ministry of Health and Wellness Review Board, and upon attainment of ethical clearance, permission to access the three institutions was sought from the respective university management departments.

To determine the validity of each question in the study protocol, a pilot study was carried out among 40 environmental health students who were later excluded from the main study. Demographic questions such as religion, nationality, program of study and marital status were deleted from the original questionnaire to reduce the length of the questionnaire. Further, a question to assess student satisfaction with policy implementation was added to the final questionnaire.

In recognition of the increasing co-use of marijuana and tobacco including marijuana use in tobacco products or smoked marijuana mixed with smokeless tobacco^20-22, current tobacco smoking was defined in this study as those who answered yes to the question: ‘In the past 30 days, have you ever used any of tobacco products (e.g. cigarette, marijuana, etc.), even if it was just a puff?’.

To measure SHS exposure, participants were asked the question: ‘In the past 30 days, how often do you get exposed to tobacco smoke at home, in the school and other public areas such as bars, restaurants, etc.’. The responses for each question were then categorized into: never, 1–6, 7–14, 15–20 and >20 days. Respiratory symptoms experienced due to exposure to other people’s exposure to tobacco smoke were measured by asking questions: ‘Have you ever coughed or experienced flu-like symptoms after exposure to smoke from other people’s cigarettes?’, and ‘Have you ever had headaches after exposure to smoke from other people’s cigarettes?’.

We used SPSS version 27 to analyze the data. Prevalence of SHS exposure at home, school and public places as separate and combined variables were calculated. Descriptive results were expressed as frequency (n), percentage (%), and mean with standard deviation (SD). Logistic regression was used to estimate the likelihood that a student was exposed to SHS and to obtain adjusted odds ratios (AORs) of respiratory symptoms for exposure to SHS in non-smoking students exposed, and non-smoking students not exposed.

RESULTS

DISCUSSION

Increasingly, research continues to show that exposure to SHS places the public at increased risk for premature death, ill-health, and many other undesirable effects^1-3. Worldwide, over 40% of men smoke tobacco. On the other hand, approximately 44% of youths are exposed to tobacco smoke at home and 47% are reported to have at least one parent who smokes²³. This study assessed SHS exposure in three academic institutions in Botswana. Our findings revealed that 32% of students were current smokers, almost twice the national prevalence of 17.6% among adults aged ≥15 years currently using tobacco²⁴ and in studies elsewhere^25-27. Our results are, however, similar to more recent studies where the prevalence of smoking among medical students ranged from 28% in Germany to 31% in Italy²⁸. Our study also has similarities with a study carried out among university students in Jordan where current smoking was reported at 35% with more males than females smoking²⁹. Young adults elsewhere have previously been reported to smoke at rates higher than any other age group³⁰ because of the aggressive marketing tactics for tobacco products by the tobacco industry³¹.

Our findings revealed an alarmingly high prevalence of SHS exposure in the school environment compared to public places and the home environment. The findings are slightly higher than those of Wolfson et al.¹⁷ who found that 83% of students were exposed to SHS in the past seven days.

Most students believe exposure to SHS may increase their chance of developing cancer. However, a significant number of students did not know. This is a cause for concern as more students may stay around smokers therefore increasing their exposure to harmful tobacco smoke. Even more concerning is that a large proportion of students did not know SHS exposure may affect their academic performance. One study found that students exposed to SHS at home for 1–4 and 5–7 days a week were 14% and 28% more likely to report poor academic performance, respectively, compared to students who were not exposed to SHS⁸. It is crucial therefore, that academic institutions invest in awareness-raising initiatives on the harms caused by exposure to tobacco moke. It is further proven that SHS exposure during adolescence affects cognitive abilities⁶ and academic performance^8,29,32. Exposure to SHS causes direct harm to non-smokers violating non-smokers’ right to health and clean air. Almost half the students in our study reported that they were not satisfied with the enforcement of anti-smoking policies in their schools, with <20% reporting that they were very satisfied.

This study revealed that more than half of respondents would support a smoking ban especially non-smokers and females. This was similar to the findings of other studies^33,34, which concluded that non-smokers and females were the strongest supporters for a complete ban on smoking in universities. In contrast, one study found a large number of smokers in support of a smoking ban in universities³³. The variance may be due to the difference in samples, as their study sample included staff and students.

The school environment is the primary source of exposure for tertiary students followed by public areas. Students’ right to health and clean air is compromised. There is strong support for a smoke-free policy by students in line with the developing trends elsewhere^35,36. We recommend the promotion of culturally tailored programs targeting especially males and non-smokers to prevent tobacco use.

CONCLUSIONS

The high prevalence of smoking among students calls for the urgent provision of smoking cessation and treatment programs in academic institutions. The creation of smoke-free campuses as well as enforcement of such policies is urgently needed to protect the health of all students and preserve their right to health and life. The findings in our study support the creation of public initiatives to support the enforcement of smoking restriction. However, enforcement efforts must be coupled with smoking cessation programs that would promote a smoke-free environment for the benefit of the whole population.