Healthcare Professionals’ Knowledge, Attitudes and Counselling Practice Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women/Children in Assiut, Egypt

Abstract

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed.

Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice.

Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

Introduction

Secondhand smoke (SHS) causes significant harm to children and adverse pregnancy outcomes [1–3]. The health care costs associated with treating health conditions due to SHS exposure are estimated to be approximately $7.1 billion in some Middle Eastern countries [4]. In Egypt, tobacco smoking is a widely accepted in homes and public places [5]. In 2018, 43.4% of males and 0.5% of females were smokers [6]. Despite, the presence of smoke-free legislations in Egypt and previous evidence linked between reductions in acute coronary event hospitalizations and implementation of smoke free legislation [7], in 2017 smoking was responsible for about 11% of disability adjusted life years (DALYs) and 17% of deaths in Egypt, and exposure to SHS was responsible for 16,000 deaths and 700,000 DALYs [8]. Low prevalence of smoking among females in Egypt is due to traditional gender roles which depict women’s smoking as disrespectful to society, and as a result there is stigma around women who smoke [9]. While only a small proportion of women are active smokers, the high rates of male smoking put non-smoking females at risk of SHS exposure.

In Egypt smoking is banned in indoor workplaces, public transport and indoor public places; however, there are no mechanisms or infrastructure to ensure enforcement of smoke-free legislation, and exposure to SHS is therefore high [10]. The prevalence of SHS exposure among women in reproductive age (15–49 years) in Egypt is estimated to be 65% [11], and about 50% of pregnant non-smoking women in Egypt are exposed daily to SHS [12] compared to 29% of non-smoking adults in European Union [13]. Pervious evidence reported significant relation between SHS exposure reductions on public places as school and in private places as cars and lower hospital admissions due to respiratory illness among children, following a comprehensive smoke-free policy [14]. In 2014, 35% of Egyptian school students (aged 13–15) were exposed to SHS at home and 55% in enclosed public places [15].

A lack of knowledge about the health risks of SHS for family members, especially children, is an important risk factor for SHS exposure [16–19]. Health care professionals (HCPs), especially nurses and midwives, are well placed to help reduce exposure to SHS in pregnant women and children. They spend a significant amount of time in contact with pregnant women and can therefore ask about their SHS exposure, advise them to prevent SHS exposure and encourage their husbands to quit smoking; this HCPs advice has been shown to be effective in previous studies [20–22].

This study aimed to explore the knowledge, attitudes and counselling practices of HCPs in maternal and child health (MCH) clinics in Egypt in relation to prevention of SHS exposure among pregnant women and children, and to identify the factors related to of their knowledge, supportive attitudes and counselling practices. We also aimed to explore barriers to the provision of counselling and the needs of HCPs in relation to improving the delivery of counselling on how to avoid SHS exposure to pregnant women and children.

Methods

A cross-sectional survey of HCPs was undertaken in Assiut city, one of the largest cities in South Egypt. An anonymous self-administered paper-based questionnaire was distributed to all 535 HCPs working in all public MCH clinics in primary or secondary health care centres in Assiut city in August 2020. The study was approved by the School of Medicine and Health Sciences Research Ethics Committee at the University of Nottingham, United Kingdom and the Research Ethics Committee in the School of Medicine at Assiut University, Egypt.

Instrument and Data Collection

A questionnaire development was guided by studies with similar research questions [23–28]. However, we did not perform a full validation procedure for the questionnaire; it was translated to Arabic by the lead researcher (ZH) then translated back into English by a second translator. It was also piloted on 15 HCPs in Egypt to determine the clarity of questions and length of time needed for questionnaire completion. The questionnaire collected data on socio-demographic and professional characteristics of HCPs, knowledge of HCPs regarding SHS exposure among pregnant women and children, barriers to the provision of counselling and perceived needs of HCPs to allow them to improve the delivery of counselling service to pregnant women and mothers to avoid SHS exposure.

Data Management and Analysis

All data were entered into Microsoft Excel and then exported to STATA v.16 software for data management and analysis. Frequency distributions were used to summarise all variables. Similar to the approach used in previous studies [29–32], indices were created to summarise awareness, attitudes and practices. To summarise knowledge of HCPs, a knowledge index was constructed by adding the scores of individual items. A similar approach was used to create an attitude index. A high score on attitudes corresponded to a high level pronouncing a supportive attitude towards the prevention of smoking and SHS exposure among pregnant women and children. Similarly, a high score on practice corresponded to a high level of offering help (always or sometimes) to pregnant women/children to prevent SHS exposure among them by explaining the hazards of SHS and advising on how to avoid it. After creating scores for the three outcome measures (knowledge, supportive attitude towards prevention of SHS exposure, and counselling practice), each score was grouped into two categories, “high,” and “low” using the median of every score. As DeCoster, Iselin, and Gallucci (2009) [33] argued that dichotomization via the median split procedure or other cut-off points “makes analyses easier to conduct and interpret” especially if the underlying variable is naturally categorical, we used the median as a cut-off point to denote a “high” score for every index. The median of knowledge index was 9/12. The median for supportive attitude to prevention of SHS index was 7/10, and the median for counselling practice index was 3/5. The scores on the outcome measures were analysed separately (Supplementary Material S1).

Univariate logistic regression analysis was used to explore factors associated with high knowledge, supportive attitude and good counselling practice of HCPs on SHS exposure. The following variables were analysed: gender, age, specialty, smoking status, SHS exposure at workplace, SHS exposure at home, location of current medical practice i.e., urban/rural, years of post-graduate experience, and receiving previous training on smoking cessation service. Those variables that were statistically significant in univariate analysis at the p < 0.05 level were included in the multivariable logistic regression models using stepwise (forward) multivariable analyses to ascertain the factors associated with the three outcome variables (high knowledge, supportive attitude towards prevention of SHS exposure, and counselling practice). Odds ratios, 95% CI, and likelihood ratio test p-values for categorical exposure variables were reported. In the multivariable logistic regression model exploring good counselling practices, in addition to the variables included in univariate regression level, knowledge and supportive attitudes variables were included in the model as co-variates to explore the effect of knowledge and attitudes of HCPs on their counselling practice.

Results

Participant Demographics, Smoking Behaviours and Secondhand Smoke Exposure

Out of the 535 HCPs, 367 participated in the study with a response rate of 68.5% (Table 1). 44.7% were nurses, 20.4% were gynaecologists/obstetricians and 16.1% were paediatricians. A third were male and two-thirds served urban communities. 22% of study participants reported having received training on smoking cessation, mainly in the workplace. 12.5% of HCPs reported being smokers, 70.3% of study participants were exposed to SHS in their workplace and 51.8% in their homes (Table 1).

Knowledge of Health Care Professionals Regarding Secondhand Smoke

Most of HCPs knew that SHS exposure increases the risk of congenital anomalies (78.7), low birth weight (76.8), spontaneous abortion (70.5), preterm delivery (69.9), sudden unexpected death in infancy (64.6), and death in infancy (64.6), and stillbirth in pregnant women (63.8). They knew that SHS increases the risk of respiratory tract infection (88.6), wheeze and asthma (80.4), chances of smoking uptake in the future(75.5%), and behavioural problems among children (68.1) (Table 2). A lower proportion were aware that SHS exposure among children increases the risk of middle ear infection (53.1%) and invasive meningococcal disease (28.6%).

55.9% of study participants had high knowledge of the dangers of SHS exposure to health of pregnant women and children. Being a General Practitioner (GP) (OR 15.29, 95%CI 4.12–56.86), serving urban communities (OR 2.53, 95%CI 1.53–4.18) and being exposed to SHS at home (OR 2.36, 95%CI 1.48–3.78) were significantly associated with high knowledge (Table 3). The strongest observed association was for GPs who were more than 15 folds compared to obstetricians and gynaecologists (95%CI 4.12–56.86) to have high knowledge after adjustment for current medical practice and SHS exposure at home.

Attitudes of Health Care Professionals Towards Smoking and Secondhand Smoke Exposure Among Pregnant Women and Children

34.9% of HCPs agreed that SHS exposure is private business and 45.5% agreed that giving advice on avoiding SHS exposure has a low chance of success (Table 2), reflecting the limited supportive attitude of HCPs towards prevention of SHS exposure among pregnant women and children.

Only 52.9% of HCPs had a supportive attitude towards the prevention of smoking and SHS exposure among pregnant women or children. Being female (OR 2.02, 95%CI 1.27–3.24), serving rural communities (OR 1.59, 95%CI 1.01–2.49), and not being exposed to SHS at home (OR 2.36, 95%CI 1.29–3.10) were significantly associated with a supportive attitude (Table 3). The strongest observed association was for those not exposed to SHS at home who were more than two folds compared to those exposed to SHS at home (OR 2.36, 95%CI 1.29–3.10) to have supportive attitude towards prevention of smoking and SHS exposure among pregnant women and children.

Counselling Practice of Health Care Professionals Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women and Children

About half of HCPs mentioned that they sometimes or always ask pregnant women/mothers with children if they are exposed to SHS (46.6%), explain the consequences of SHS on health (53.4%), explain the specific adverse health effects of SHS exposure to the foetus during pregnancy (53.4%), explain the specific adverse health effects of SHS on health of children (47.7%), and advise/encourage pregnant women/mother with children to avoid SHS exposure (58%) (Table 2).

About half of HCPs (51.8%) reported good counselling practice regarding counselling pregnant women/mothers with children about SHS exposure (Table 3). Being female (OR 1.88, 95%CI 1.15–3.07), serving a rural population (OR 2.44, 95%CI 1.51–3.96), receiving previous training on smoking cessation services (OR 2.59, 95%CI 1.45–4.61), not being exposed to SHS at home (OR 2.66, 95%CI 1.68–4.22), and having a supportive attitude (OR 5.49, 95%CI 3.38–8.90) towards prevention of SHS exposure were significantly associated with good counselling practice. The strongest observed association was for those having a supportive attitude towards the prevention of SHS exposure, who after adjusting for covariates were more than five folds compared to those do not have supportive attitude towards the prevention of SHS exposure (OR 5.49, 95%CI 3.38–8.90) to have good counselling practice.

Barriers to Provision of Counselling and Needs of Health Care Professionals to Improve the Delivery of Counselling

Lack of time or training, absence of reimbursement and unavailability of materials were the most common barriers to the provision of counselling (Table 4). Lack of time was the first barrier for most of gynaecologists/obstetricians (57.3%), paediatricians (72.9%), and GPs (67.7%). However, lack of training was the first barrier for most nurses (64%) and midwives (54.8%). The majority of HCPs (75%) suggested that it is nurses’ job to discuss SHS exposure with pregnant women/mothers with children. The majority of participants stated that they need training, standard guidelines and materials about SHS health hazards to help them improve the delivery of counselling on SHS. HCPs reported that health education sessions for pregnant women/mothers of children and smokers in their household could help them to reduce SHS exposure.

Discussion

The main findings of this study are that only about half of HCPs in Assiut city in Egypt have good risk awareness (55.9%), a supportive attitude (52.9%), and report good counselling practice (51.8%) regarding the prevention of SHS exposure among pregnant women and children. GPs and paediatricians were found to be most aware of the risks of SHS. Female HCPs were more likely to report good counselling practice. HCPs serving a rural population were most likely to have a supportive attitude for the prevention of SHS and report good counselling practice. HCPs who are not exposed to SHS at home were more likely to report good counselling practice and supportive attitude for its prevention among pregnant women and children.

Our results are consistent with other studies in Egypt and neighbouring countries which have reported that HCPs have vague or inaccurate knowledge about the risk of SHS and poor counselling practice in relation to SHS exposure [34–36]. Previous studies in Egypt reported better knowledge of the dangers of smoking and more supportive attitudes in relation to the provision of smoking cessation services among HCPs [23, 37]; however, those studies did not investigate in details the knowledge regarding the specific dangers of SHS to pregnant women and children which highlight the novelty of our study. This difference could be due to these existing studies being not specific to SHS and being performed in one university hospital and urban family medicine centers in Alexandria, as opposed to a combination of urban and rural clinics as in the present study, in which HCPs serving rural communities showed lower knowledge.

The limited awareness of the health risks of SHS may be partly due to a lack of relevant training. Only one in five participants in the current study had previous training on smoking cessation, whether during medical school, post graduate clinical training or training at the workplace and receiving this training was significantly was significantly associated with good counselling practice of HCPs with pregnant women and children regarding their SHS exposure. This figure is lower than previously reported [23, 37] possibly due to the limited training programs on smoking cessation in South Egypt governorates. In the current study, lack of training was the first barrier for most nurses and midwives to provide the SHS counselling service suggesting that improvement in training provided to nurses could help to reduce SHs exposure.

It is important to ensure that the wider environment is conducive to increased awareness and willingness to provide support on smoking cessation and prevention of SHS exposure. This includes proper enforcement of smoke-free policy enshrined in law, and other population-level interventions such as mass media campaigns to make the social norms against SHS exposure. In combination with additional training, this can improve the knowledge and attitudes of HCPs, as well as the general population, and change counselling practice of HCPs.

Although Egypt has made important strides in controlling tobacco use according to World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) report [6], SHS exposure remains extremely high (more than 70%) in public places such as restaurants, public transportation, and health care facilities [5, 38] as the smoke-free legislation is poorly enforced [10]. This is comparable with our results as 70% of HCPs reported exposure to SHS in the workplace. While efforts to support the provision of advice related to SHS is likely to help reduce SHS exposure, these are likely to be most effective if they are made in the context of effective implementation of tobacco control policies, particularly the enforcement of smoke-free legislation.

In the current study about half of HCPs agreed that giving advice on avoiding SHS exposure is unlikely to be successful; this could be because HCPs claimed that they do not have time, training, and materials to deliver this service, or due to a lack of understanding of the effect that such advice may have. One third disagreed that pregnant women/mothers with children are interested in receiving advice about reducing SHS exposure. As evidenced from previous systematic review, smoking and SHS exposure is socially accepted in many Middle Eastern countries [39]. Therefore, proper enforcement of smoke-free law is expected to contribute to changes in social norms which will facilitate changes in SHS exposure. Enforcement of smoke-free policy could make women more interested in avoiding SHS exposure and could make HCPs feel offering advice can be helpful. Thus, overall environment is conducive to HCPs giving this sort of advice.

In the present study, the main obstacles for HCPs to help pregnant women/children to avoid SHS exposure were found to be lack of time, lack of training, absence of reimbursement and unavailability of materials. Similar obstacles have been reported in other middle income countries [40]. Previous evidence suggest that providing training for HCPs encourage them to provide counselling service to pregnant women to adopt smoke-free environment [41]. Training of HCPs cannot work alone. A range of issues need to be addressed including lack of time and unavailability of materials. Additionally, ensuring that HCPs in Egypt have the time and financial resources needed to deliver this type of support is essential. Clear specification of SHS counselling service in the job description of HCPs working in public MCH clinics should be performed by the health system governors. In this study, the majority of HCPs suggested that it is nurses’ job to discuss SHS exposure with pregnant women, so there is no clear description on whose job it is to do counselling service. However, previous evidence reported that nurses and physicians are ideally placed to provide health advice to pregnant women and mothers with children to influence their SHS exposure [42]. Thus, all HCPs in public MCH clinics need training to address their view that it is solely nurses’ responsibility to discuss SHS exposure and encourage them to discuss SHS exposure with their patients.

Previous studies have shown that pregnant women who do not smoke are often responsive to counselling regarding reduction of SHS exposure received from HCPs in antenatal care clinics [43, 44]. Moreover, studies have reported that counselling pregnant women not only led to reduction in their SHS exposure but also increased smoking cessation among their husbands, as well as increasing positive attitudes and practices to reduce SHS at home [43, 45]. Support from HCPs may therefore contribute to the reduction of SHS exposure in Egypt.

Strengths and Limitations

To our knowledge, this is the first study that provides detailed evidence on the knowledge, attitudes and practice of Egyptian HCPs regarding SHS exposure among pregnant women and children. This study achieved a high response rate by distributing paper questionnaires, though this meant that the study focussed on HCPs working in only one governorate. Despite this, the study included both urban and rural areas. Furthermore, Assiut is the largest city in Upper Egypt, however the results may not be generalizable because of differences in sociodemographic characteristics between Assiut and other cities in Egypt. A further limitation, particularly in relation to assessing counselling practice of HCPs, is that the study findings are based on self-report. However, the study identified clear shortcomings in counselling practice, which are unsurprising given the low levels of knowledge and supportive attitudes to SHS prevention. Another limitation of bias that could be due to that the study main respondents were non-smokers and females, however, we performed multivariable regression analysis and models were adjusted for main demographic characteristics. Although, dichotomizing a variable based on cut-offs can jeopardize model fit and lead to misleading interpretation of results, we have performed a sensitivity analysis to ensure that the median cut-off point used in this study is not leading to misinterpretations (Supplementary Material S2).

Conclusion and Recommendation

Awareness, attitudes and counselling practice of HCPs regarding the risks of SHS to pregnant women and children in Egypt should be improved. It is important to develop an environment which facilitates increased awareness of and willingness to provide support on smoking cessation and prevention of SHS exposure. This includes comprehensive enforcement of smoke-free policy and training programs for HCPs on smoking cessation which should cover SHS exposure. This could also extend to other population-level interventions such as mass media campaigns. Other barriers, such as the lack of time must also be addressed. More qualitative studies in Egypt are needed also to explore women’s views and experiences regarding their SHS exposure and the barriers to preventing this exposure among pregnant women and children.

References

• 1

  National Center for Chronic Disease Prevention and Health Promotion (US). Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, USA: Centers for Disease Control and Prevention (2014).

  • Google Scholar

• 2

  Royal College of Physicians of London. Passive Smoking and Children: A Report by the Tobacco Advisory Group. London: RCP (2010).

  • Google Scholar

• 3

  Yang IA Jenkins CR Salvi SS . Chronic Obstructive Pulmonary Disease in Never-Smokers: Risk Factors, Pathogenesis, and Implications for Prevention and Treatment. Lancet Respir Med (2022) 10:497–511. 10.1016/S2213-2600(21)00506-3

  • CrossRef
  • Google Scholar

• 4

  Koronaiou K Al-Lawati JA Sayed M Alwadey AM Alalawi EF Almutawaa K et al Economic Cost of Smoking and Secondhand Smoke Exposure in the Gulf Cooperation Council Countries. Tob Control (2021) 30(6):680–6. 10.1136/tobaccocontrol-2020-055715

  • CrossRef
  • Google Scholar

• 5

  World Health Organization. Global Adult Tobacco Survey (GATS): Egypt Country Report 2009. Geneva: World Health Organization (2010).

  • Google Scholar

• 6

  World Health Organization. WHO Report on the Global Tobacco Epidemic, Country Profile, Egypt (2019). Available from: https://www.who.int/tobacco/surveillance/policy/country_profile/egy.pdf (Accessed 11 03 2022).

  • Google Scholar

• 7

  Jones MR Barnoya J Stranges S Losonczy L Navas-Acien A . Cardiovascular Events Following Smoke-free Legislations: an Updated Systematic Review and Meta-Analysis. Curr Environ Health Rep (2014) 1(3):239–49. 10.1007/s40572-014-0020-1

  • CrossRef
  • Google Scholar

• 8

  Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington (2020). Available from: http://vizhub.healthdata.org/gbd-compare (Accessed 04 03 2022).

  • Google Scholar

• 9

  Khalil J Afifi R Fouad FM Hammal F Jarallah Y Mohamed M et al Women and Waterpipe Tobacco Smoking in the Eastern Mediterranean Region: Allure or Offensiveness. Women Health (2013) 53(1):100–16. 10.1080/03630242.2012.753978

  • CrossRef
  • Google Scholar

• 10

  Egyptian Ministry of Health. Core Questionnare of the Reporting Instrument of WHO FCTC (2020). Available at: https://untobaccocontrol.org/impldb/egypt/ (Accessed 10 03 2022).

  • Google Scholar

• 11

  Centers for Disease Control and Prevention. Current Tobacco Use and Secondhand Smoke Exposure Among Women of Reproductive Age--14 Countries, 2008-2010. MMWR Morb Mortal Wkly Rep (2012) 61(43):877–82.

  • Google Scholar

• 12

  Reece S Morgan C Parascandola M Siddiqi K . Secondhand Smoke Exposure during Pregnancy: a Cross-Sectional Analysis of Data from Demographic and Health Survey from 30 Low-Income and Middle-Income Countries. Tob Control (2019) 28(4):420–6. 10.1136/tobaccocontrol-2018-054288

  • CrossRef
  • Google Scholar

• 13

  Beeson D . Nuance, Complexity, and Context: Qualitative Methods in Genetic Counseling Research. J Genet Couns (1997) 6(1):21–43. 10.1023/a:1025659701805

  • CrossRef
  • Google Scholar

• 14

  Radó MK Mölenberg FJM Westenberg LEH Sheikh A Millett C Burdorf A et al Effect of Smoke-free Policies in Outdoor Areas and Private Places on Children’s Tobacco Smoke Exposure and Respiratory Health: a Systematic Review and Meta-Analysis. Lancet Public Heal (2021) 6(8):e566–78. 10.1016/S2468-2667(21)00097-9

  • CrossRef
  • Google Scholar

• 15

  Centre of disease control and prevention (CDC)Ministry of Health and Population (Egypt)World Health Organization (WHO). Global Youth Tobacco Survey, Egypt 2014. Atlanta, United States: Ministry of Health & Population (2014).

  • Google Scholar

• 16

  Yang L Tong EK Mao Z Hu T , 89. Acta Obstet Gynecol Scand (2010). p. 549–57. 10.3109/00016341003713851Exposure to Secondhand Smoke and Associated Factors Among Non-smoking Pregnant Women with Smoking Husbands in Sichuan Province

  • CrossRef
  • Google Scholar

• 17

  Passey ME Longman JM Robinson J Wiggers J Jones LL . Smoke-free Homes: what Are the Barriers, Motivators and Enablers? A Qualitative Systematic Review and Thematic Synthesis. BMJ Open (2016) 6(3):e010260. 10.1136/bmjopen-2015-010260

  • CrossRef
  • Google Scholar

• 18

  Sahebi Z Kazemi A Loripoor Parizi M . The Relationship between Husbands’ Health Belief and Environment Tobacco Smoke Exposure Among Their Pregnant Wife. J Matern Fetal Neonatal Med (2017) 30(7):830–3. 10.1080/14767058.2016.1188071

  • CrossRef
  • Google Scholar

• 19

  Wakefield M Reid Y Roberts L Mullins R Gillies P . Smoking and Smoking Cessation Among Men Whose Partners Are Pregnant: a Qualitative Study. Soc Sci Med (1998) 47(5):657–64. 10.1016/s0277-9536(98)00142-7

  • CrossRef
  • Google Scholar

• 20

  Sreedharan J Muttappallymyalil J Venkatramana M . Nurses’ Attitude and Practice in Providing Tobacco Cessation Care to Patients. J Prev Med Hyg (2010) 51(2):57–61.

  • Google Scholar

• 21

  Lee AH . A Pilot Intervention for Pregnant Women in Sichuan, China on Passive Smoking. Patient Educ Couns (2008) 71(3):396–401. 10.1016/j.pec.2008.03.014

  • CrossRef
  • Google Scholar

• 22

  Loke AY Lam TH . A Randomized Controlled Trial of the Simple Advice Given by Obstetricians in Guangzhou, China, to Non-smoking Pregnant Women to Help Their Husbands Quit Smoking. Patient Educ Couns (2005) 59(1):31–7. 10.1016/j.pec.2004.08.018

  • CrossRef
  • Google Scholar

• 23

  Mostafa N Momen M . Effect of Physicians’ Smoking Status on Their Knowledge, Attitude, Opinions and Practices of Smoking Cessation in a University Hospital. J Egypt Public Health Assoc (2017) 92(2):96–106. 10.21608/epx.2018.8947

  • CrossRef
  • Google Scholar

• 24

  Elmoghazy EH Mostafa NS Zaki LM Amin WA . Effect of Training and Smoking Status of Physicians on Smoking Cessation Practices in Egypt. Egypt J Chest Dis Tuberc (2018) 67(3):323. 10.4103/ejcdt.ejcdt_58_18

  • CrossRef
  • Google Scholar

• 25

  Eldein HN Mansour NM Mohamed SF . Knowledge, Attitude and Practice of Family Physicians Regarding Smoking Cessation Counseling in Family Practice Centers, Suez Canal University, Egypt. J Fam Med Prim Care (2013) 2(2):159–63. 10.4103/2249-4863.117411

  • CrossRef
  • Google Scholar

• 26

  Gould G Zeev Y Tywman L Oldmeadow C Chiu S Clarke M et al Do clinicians Ask Pregnant Women about Exposures to Tobacco and Cannabis Smoking, Second-Hand-Smoke and E-Cigarettes? an Australian National Cross-Sectional Survey. Int J Environ Res Public Health (2017) 14(12):1585. 10.3390/ijerph14121585

  • CrossRef
  • Google Scholar

• 27

  Thyrian JR Hannöver W Röske K Scherbarth S Hapke U John U . Midwives’ Attitudes to Counselling Women about Their Smoking Behaviour during Pregnancy and Postpartum. Midwifery (2006) 22(1):32–9. 10.1016/j.midw.2005.04.003

  • CrossRef
  • Google Scholar

• 28

  Fidler JA Shahab L West O Jarvis MJ McEwen A Stapleton JA et al The Smoking Toolkit Study”: a National Study of Smoking and Smoking Cessation in England. BMC Public Health (2011) 11(1):479. 10.1186/1471-2458-11-479

  • CrossRef
  • Google Scholar

• 29

  Evans KA Sims M Judge K Gilmore A . Assessing the Knowledge of the Potential Harm to Others Caused by Second-Hand Smoke and its Impact on Protective Behaviours at home. J Public Health (Bangkok) (2012) 34(2):183–94. 10.1093/pubmed/fdr104

  • CrossRef
  • Google Scholar

• 30

  Helgason AR Lund KE . Environmental Tobacco Smoke Exposure of Young Children—Attitudes and Health-Risk Awareness in the Nordic Countries. Nicotine Tob Res (2001) 3(4):341–5. 10.1080/14622200110050420

  • CrossRef
  • Google Scholar

• 31

  Hodgetts G Broers T Godwin M . Smoking Behaviour, Knowledge and Attitudes Among Family Medicine Physicians and Nurses in Bosnia and Herzegovina. BMC Fam Pract (2004) 5(1):12–7. 10.1186/1471-2296-5-12

  • CrossRef
  • Google Scholar

• 32

  Rosen L Kostjukovsky I . Parental Risk Perceptions of Child Exposure to Tobacco Smoke. BMC Public Health (2015) 15:90. 10.1186/s12889-015-1434-x

  • CrossRef
  • Google Scholar

• 33

  DeCoster J Iselin AMR Gallucci M . A Conceptual and Empirical Examination of Justifications for Dichotomization. Psychol Methods (2009) 14(4):349–66. 10.1037/a0016956

  • CrossRef
  • Google Scholar

• 34

  Alzahrani SH . Levels and Factors of Knowledge about the Related Health Risks of Exposure to Secondhand Smoke Among Medical Students: A Cross-Sectional Study in Jeddah, Saudi Arabia. Tob Induc Dis (2020) 18:88. 10.18332/tid/128317

  • CrossRef
  • Google Scholar

• 35

  Lee SR Cho A Lee SY Cho YH Park EJ Kim YJ et al Secondhand Smoke Knowledge, Sources of Information, and Associated Factors Among Hospital Staff. PLoS One (2019) 14(1):e0210981. 10.1371/journal.pone.0210981

  • CrossRef
  • Google Scholar

• 36

  Al-Batanony A Salim EA Dawood AA Kasem E . NURSES’KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING SECONDHAND SMOKE, AN INTERVENTION STUDY. Egypt J Occup Med (2008) 32(1):117–31. 10.21608/ejom.2008.662

  • CrossRef
  • Google Scholar

• 37

  Sabra AA . Smoking Attitudes, Behaviours and Risk Perceptions Among Primary Health Care Personnel in Urban Family Medicine Centers in Alexandria. J Egypt Public Health Assoc (2007) 82(1–2):43–64.

  • Google Scholar

• 38

  Loffredo CA Radwan GN Eltahlawy EM El-Setouhy M Magder L Hussein MH . Estimates of the Prevalence of Tobacco Smoking in Egypt. Open J Epidemiol (2015) 05(02):129–35. 10.4236/ojepi.2015.52017

  • CrossRef
  • Google Scholar

• 39

  Hassanein ZM Nalbant G Langley T Murray RL Bogdanovica I Leonardi-Bee J . Experiences and Views of Parents on the Prevention of Second-Hand Smoke Exposure in Middle Eastern Countries: a Qualitative Systematic Review. JBI Evid Synth (2022) 20(8):1969–2000. 10.11124/JBIES-21-00222

  • CrossRef
  • Google Scholar

• 40

  Lund KE Helgason AR . Why Do Health Personnel Neglect to Talk about Passive Smoking with Parents of Small Children?Tidsskr Nor Laegeforen (2000) 120(14):1622–6.

  • Google Scholar

• 41

  Sarna L Bialous SA Zou XN Wang W Hong J Wells M et al Evaluation of a Web-Based Educational Programme on Changes in Frequency of Nurses’ Interventions to Help Smokers Quit and Reduce Second-Hand Smoke Exposure in China. J Adv Nurs (2016) 72(1):118–26. 10.1111/jan.12816

  • CrossRef
  • Google Scholar

• 42

  Merrill RM Madanat H Kelley AT Layton JB . Nurse and Physician Patient Counseling about Tobacco Smoking in Jordan. Promot Educ (2008) 15(3):9–14. 10.1177/1025382308095649

  • CrossRef
  • Google Scholar

• 43

  Tong VT Dietz PM Rolle IV Kennedy SM Thomas W England LJ . Clinical Interventions to Reduce Secondhand Smoke Exposure Among Pregnant Women : a Systematic Review. Tob Control (2015) 24:217–23. 10.1136/tobaccocontrol-2013-051200

  • CrossRef
  • Google Scholar

• 44

  Zhang L Hsia J Tu X Xia Y Zhang L Bi Z et al Exposure to Secondhand Tobacco Smoke and Interventions Among Pregnant Women in China: a Systematic Review. Prev Chronic Dis (2015) 12:E35. 10.5888/pcd12.140377

  • CrossRef
  • Google Scholar

• 45

  Dherani M Zehra SN Jackson C Satyanaryana V Huque R Chandra P et al Behaviour Change Interventions to Reduce Second-Hand Smoke Exposure at home in Pregnant Women–A Systematic Review and Intervention Appraisal. BMC Pregnancy Childbirth (2017) 17(1):378. 10.1186/s12884-017-1562-7

  • CrossRef
  • Google Scholar