INTRODUCTION

The use of tobacco products and exposure to secondhand smoke represents a significant public health concern, with adverse effects on both individual and public health. It is estimated that over 8 million deaths are attributed to direct tobacco use, and approximately 1.3 million to passive tobacco smoking among individuals who do not smoke¹. The scientific evidence unequivocally demonstrates that there is no safe level of exposure to secondhand tobacco smoke. The World Health Organization (WHO) and other leading health organizations concur that passive exposure to tobacco smoke causes a range of serious and often fatal diseases, including lung and other cancers, as well as cardiovascular and respiratory diseases. Furthermore, exposure to secondhand smoke can have adverse effects on children, including fetuses and newborns¹.

The extant literature demonstrates that adolescents who are passively exposed to tobacco smoke are more likely to experience symptoms related to respiratory tract infections, including shortness of breath, difficulty in exercising, wheezing during or after exercise, and a dry cough at night. Additionally, they are more likely to be unable to attend school due to illness, to experience difficulty in exercising, and to exhibit depressive symptoms^2,3. Adolescents residing with active smokers and exposed to passive cigarette smoke for a minimum of one hour per day are more prone to seek emergency department care². Children exposed to parental smoking are at an elevated risk for subclinical atherosclerosis⁴, death from coronary heart disease in adulthood⁵, and deteriorated bone health⁶.

Both active tobacco use and passive smoking result in an elevation of metabolic syndrome and cardiometabolic risk factors in adolescents^4,5. This phenomenon persists beyond adolescence, with adverse health consequences continuing into adulthood. Furthermore, passive exposure to tobacco smoke during adolescence increases the likelihood of subsequent active tobacco use⁷. It has been recommended that the issue of combating tobacco use in pediatric age groups and adolescents should be addressed with caution; as young athletes are commonly used as examples to follow or sources of inspiration and motivation for other population groups. They can also be used as trendsetters, hence, their health behaviors matter^8-10.

Despite its acknowledged detrimental impact on public health, active and passive tobacco smoking among adolescents persists globally. Yet, it is a preventable problem¹. In order to address the global issue of tobacco use, the WHO has developed a series of policies and strategies under the WHO Framework Convention on Tobacco Control (WHO FCTC). Türkiye ratified the WHO FCTC in 2004. Currently, Türkiye is striving to safeguard its population at the highest level through the implementation of comprehensive measures, including smoking bans in indoor areas and public transport vehicles, the display of deterrent health warnings on cigarette packages, the increases in taxes on tobacco products, and the dissemination of public awareness campaigns¹¹. These practices represent a significant advancement in the global effort to combat tobacco use. However, further action is required to prevent both active and passive tobacco consumption, particularly among specific demographic groups, including adolescents and athletes.

Limited research exists on smoking habits among licensed adolescent athletes in Türkiye^12,13. Prior studies have documented varying rates of tobacco use and passive smoke exposure among adolescents globally. For instance, a global study of youth aged 12–15 years reported a secondhand smoke exposure prevalence of 55.9%¹⁴. In Türkiye, studies have shown that 21.72% of male students aged 14–18 years were cigarette smokers¹², while another study among students aged 11–19 years revealed a smoking rate of 28.1%¹³. However, the prevalence of tobacco use among adolescent athletes, particularly those aged 13–14 years, remains understudied. The objective of this study was to assess tobacco use and passive exposure to tobacco smoke among a sample of adolescent athletes in Türkiye and to examine their characteristics and associated factors.

METHODS

RESULTS

Of the athlete respondents, 36.3% (n=73) were female, and 63.7% (n=128) male. The average respondent was aged 13.4 ± 0.5 years. There were 36.3% (n=73) primary school students and 63.7% (n=128) secondary school students aged 13–14 years. The sports branches were football (n=86; 38.8% male, 4.0% female), taekwondo (n=31; 6.0% male, 9.5% female), volleyball (n=30; 1.5% male, 13.4% female), boxing (n=15; 5.5% male, 2% female) and basketball (n=9; 3.5% male, 1.0% female). On average, the respondents weighed 55.1 ± 11.6 kg, were 164.8 ± 9.0 cm tall, and had a waist circumference of 70.6 ± 10.4 cm. The mean sports age was 3.2 ± 2.0 years. More details on the demographic characteristics of the athletes are provided in Table 1.

In terms of tobacco use prevalence, 92.0% (n=185) of the athletes never used tobacco, 7.0% (n=14) tried it, 0.5% (n=1) quit using tobacco, and 0.5% (n=1) are currently using tobacco. A total of 20.4% (n=41) of the athletes indicated that they were passively exposed to tobacco smoke. Of the remaining athletes, 9% (n=18) reported that they had secondhand exposure to tobacco smoke for ≥1 h every day, 25.3% (n=51) for <1 h every day, and 45.3% (n=91) at least once a week. When asked about frequency, 34.3% (n=69) of the respondents reported daily and 45.3% (n=91) reported at least once a week secondhand exposure to tobacco smoke (Table 2, Figure 1).

Figure 1

Passive exposure status of the respondents overall and by gender

The rates of secondhand smoking for one hour or more every day and less than one hour every day did not significantly differ by gender (p>0.05). However, passive exposure at least once a week was found to be significantly higher in male athletes (male: 67.0% vs female: 33.0 %; p<0.05), while no exposure was also found to be significantly higher in male athletes (female: 34.1% and male: 65.9%) (p<0.05) (Table 2). As reported in Table 3, 59.2% (n=119) of the respondents reported passive exposure to tobacco smoke inside and 71.1% (n=143) outside the home in the past 7 days.

Concerning parents who smoked inside the home, 10.4% (n=21) of the respondents reported that their mothers smoked, 36.3% (n=73) reported that their fathers smoked, and 19.9% (n=40) reported that both their parents smoked. None of the parents smoked tobacco among 33.3% (n=67) of the respondents (Table 4). In terms of passive tobacco smoking, 27.9% (n=56) reported that their mothers, 49.8% (n=100) reported that their fathers and 12.5% (n=25) reported that their siblings smoked at home (Table 4). When looking at the smoking rules of the respondents’ homes, 23.4% of the respondents lived in homes where smoking was permitted, while 28.4% had a strict no-smoking policy. Yet, 38.8% of the respondents reported smoking was not permitted but could be allowed in certain circumstances.

When asked whether tobacco products should be prohibited in public spaces, 95.1% of the respondents responded affirmatively. The majority of the respondents who endorsed the proposition to ban tobacco products reported that they considered this course of action to be beneficial for human health. Among 5% of the respondents who thought otherwise, 3% believed the implementation of the ban would result in a reduction in work efficiency.

DISCUSSION

In our study assessing tobacco use among adolescent athletes aged 13–14 years in Ankara, Türkiye, we have found negligible rates of active tobacco use and high rates of passive tobacco smoking. The rate of secondhand smoking was significantly higher among males. Specifically, we have found that 34.3% of the respondents had passive exposure to tobacco smoke daily, while 45.0% had passive exposure at least once a week. The prevalence of secondhand smoke estimated in our study was lower than the 55.9% reported in a global study of youth aged 12–15 years¹⁴.

Prior studies documented that the use of tobacco by parents, particularly mothers, was found to be associated with subsequent uptake of tobacco by young adolescents¹⁴. In our study, 10.4% of the respondents had their mothers, 36.3% their fathers, and 19.9% both their parents smoking tobacco, which provides insight into the high prevalence of passive exposure within the home environment and raises concerns about the risk of smoking initiation among studied young athletes.

The results of the GYTS (Global Youth Tobacco Survey) conducted in 2016–2017 indicate that approximately 18% of adolescents aged 13–15 years were found to be current tobacco users¹. In another global study, the average prevalence of tobacco use in young adolescents aged 12–15 years was found to be 13%. The latest GYTS data on adolescents aged 13–15 years indicates a prevalence of tobacco use of 11.3% in boys and 6.1% in girls based on the consumption of at least one cigarette in the last 30 days¹⁷. A 2019 study conducted in Peru revealed that the prevalence of smoking among adolescents was 4.4% among females and 7.0% among males⁸. Furthermore, the prevalence of tobacco use has been reported to be higher in adolescents aged 14–15 years compared with those aged 12–13 years in the majority of countries¹⁴. A study conducted in Türkiye revealed that 21.72% of male students aged 14–18 years who enrolled in high schools in Amasya province were cigarette smokers in 2017¹². A study conducted in Ankara among students aged 11–19 years revealed a smoking rate of 28.1%¹³. In the present study, tobacco use was observed in only one athlete among adolescent athletes aged 13–14 years. Significantly lower prevalence of active smoking among our survey respondents could be attributed to their active engagement in sports and their young 13–14 age. Participation in sports and younger age may act as a deterrent to the uptake of tobacco products.

The lowest total scores on the Illegal Behavior Scale were observed in Art-Sports and Religious Schools¹³. The low prevalence of smoking in sports high schools, as observed in our study, indicates that engagement in sports may act as a preventive and/or reduction factor for smoking among adolescents.

In one study, the prevalence of passive smoking at home was found to be 17.4% in Mexico, 73.1% in Vietnam, 16.9% in Uruguay, and 65.8% in Bangladesh¹⁸. In another study, the prevalence of passive exposure at home was 14.0%, while the prevalence of passive exposure outside the home was 39.4%⁸. A study encompassing 15 countries, including Türkiye, demonstrated that passive exposure at home diminished as socioeconomic status increased¹⁸. Despite the implementation of smoke-free legislation, the prevalence of passive exposure both inside and outside the home remained considerable⁸. In the present study, the prevalence of passive exposure inside the home in the last 7 days was 59.2% and 71.1% outside the home. To reduce high passive exposure at home, periodic education and awareness-raising campaigns should be organized by experts in tobacco control. This can be achieved by inviting household members to primary healthcare facilities or by conducting home visits and educating them about the dangers of smoking. The education should provide information and raise awareness about quitting and combating addiction. Additionally, the number of free Tobacco Cessation Services should be increased.

A study conducted in China revealed that 74.8% of adolescents (aged 13–18 years) were exposed to tobacco smoke passively, with 36.6% of this group exposed both at home and in public places¹⁹. Given that 34.3% of the athletes in the present study were passively exposed to tobacco smoke daily, it is reasonable to conclude that a proportion of these young people will become active tobacco users in the future. As studies have demonstrated, passive exposure elevates the likelihood of future active tobacco use and induces tobacco sensitization^7,8,14. Furthermore, it has been documented that the likelihood of e-cigarette utilization among students is 2.25 times greater with elevated levels of passive smoking than without it¹⁹.

The findings of our study align with prior research, including a study on Peruvian adolescents that reported low active smoking rates but significant passive smoke exposure, particularly at home⁸. Similarly, a study conducted in Indonesia found that passive smokers supported stronger tobacco control measures, as 95.1% of our adolescent athletes favored prohibiting public tobacco use²⁰. Other studies have further highlighted the adverse effects of passive smoking, such as reduced lung function, impaired athletic performance, and developmental issues in adolescents^21-23. These consistent findings underscore the widespread public health concern of passive smoking across demographics, emphasizing the need for targeted interventions, stricter smoke-free policies, and awareness campaigns, particularly in residential settings, to protect adolescents from secondhand smoke and its long-term risks.

The results of studies conducted on young people indicate that there is a discrepancy in the findings related to passive smoking. The results of the GYTS, conducted in 168 countries between 1999 and 2008, indicate that 30.4% of adolescents who had never smoked were exposed to passive tobacco smoke inside the home and 44.2% outside the home. Additionally, approximately 14% of adolescents had both parents and peers who were smoking. The most significant factor influencing passive smoking was the presence of parents or peers who were smoking²⁴. A study conducted in Wuhan, China, in 2019, revealed that the prevalence of passive exposure at home, school, and public places among adolescents who had never smoked was 25.7%, 31.9%, and 48.9%, respectively. It has been demonstrated that the smoking habits of parents, peers, and teachers are significantly associated with the passive exposure of adolescents²⁵. In 2016, a study conducted in Malaysia revealed that 37.8% of school-going adolescents aged 11–19 years had been exposed to secondhand smoke at home, 51.2% outside the home, and 27.3% at school over the last seven days²⁶. A large-scale global study investigating passive exposure among adolescents conducted between 2010 and 2018, revealed a decline in the prevalence of passive exposure at home. However, the prevalence of passive exposure to tobacco smoke in public places has either increased or did not change in the majority of countries²⁷.

Our study revealed that 23.4% of athletes’ homes permitted smoking, while the rate of athletes’ homes where smoking is not allowed save for some exceptional cases was found to be 38.8%. Among the athletes, 27.9% reported that their mothers, 49.8% reported that their fathers, and 12.5% reported that their siblings smoked at home.

The findings of our study indicate that adolescents engaged in sports in Türkiye are subject to a considerable degree of passive tobacco smoke exposure. It would be remiss to ignore the possibility that these adolescents may become active tobacco users in adulthood. The observation that the smoking prevalence among individuals aged ≥15 years in Türkiye in 2022 is as high as 28.3% indicates that passive exposure during adolescence is a significant risk factor for active tobacco use in adulthood²⁸. In our study, 95.1% of the athletes responded affirmatively to the question of whether tobacco and tobacco products should be prohibited in public spaces. This indicates that adolescents are receptive to and supportive of the enactment of smoke-free legislation.

Both morbidity and mortality caused by active tobacco use and passive smoking are preventable. The implementation of smoke-free legislation has been demonstrated to markedly diminish the prevalence of smoking initiation among young people²⁹. It is of great importance to protect adolescents from passive smoking, particularly in the home and in public places, in order to prevent the initiation of smoking in this age group.

There are many types of tobacco products. Nil prevalence of active smoking in this age group does not guarantee nil prevalence of smokeless tobacco use, for example, as adolescents get older. The respondents in this study also have a high probability of using tobacco in the future as a result of sensitization to smoking. Future studies can examine trajectories of tobacco use among adolescent athletes over their lifetimes.

CONCLUSIONS

Our findings indicate that active tobacco use is minimal among adolescent athletes aged 13–14 years in Ankara, Türkiye, potentially due to their engagement in sports and younger age group. However, passive exposure to tobacco smoke is prevalent, with over half of the athletes reporting exposure both inside and outside the home. Parental smoking was also common, with nearly half of the athletes having at least one parent who smokes. These results highlight the need for further attention to reducing passive smoke exposure among this population. Additional research is needed to explore the long-term health implications of passive smoke exposure and its potential influence on future tobacco use behaviors.