Applied nutritional investigation Parental tobacco use is associated with increased risk of child malnutrition in Bangladesh Cora M. Best, M.H.S. a,c , Kai Sun, Ph.D. a,b , Saskia de Pee, Ph.D. c , Martin W. Bloem, M.D. a,c , Gudrun Stallkamp, M.Sc. d , and Richard D. Semba, M.D., M.P.H. a,b, * a Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA b Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA c World Food Program, Rome, Italy d Concern Worldwide, Dublin, Ireland Abstract Objectives: We investigated the relation between parental tobacco use and malnutrition in children 5 y of age and compared expenditures on foods in households with and without tobacco use. Methods: Tobacco use, child anthropometry, and other factors were examined in a stratified, multistage cluster sample of 77 678 households from the Bangladesh Nutrition Surveillance Project (2005–2006). Main outcome measurements were stunting, underweight, and wasting, and severe stunting, severe underweight, and severe wasting. Secondary outcomes included the proportion of household expenditures spent on food. Results: The prevalence of parental tobacco use was 69.9%. Using the new World Health Organization child growth standards, prevalences of stunting, underweight, and wasting were 46.0%, 37.6%, and 12.3%, respectively. After adjusting for potential confounders, parental tobacco use was associated with an increased risk of stunting (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.12–1.21, P  0.0001), underweight (OR 1.17, 95% CI 1.12–1.22, P  0.0001), and wasting (OR 1.10, 95% CI 1.03–1.17, P = 0.004), and severe stunting (OR 1.16, 95% CI 1.10 –1.23, P  0.0001), severe underweight (OR 1.21, 95% CI 1.13–1.30, P  0.0001), and severe wasting (OR 1.14, 95% CI 0.98 –1.32, P = 0.09). Households with tobacco use spent proportionately less per capita on food items and other necessities. Conclusions: In Bangladesh parental tobacco use may exacerbate child malnutrition and divert household funds away from food and other necessities. Further studies with a stronger analytic approach are needed. These results suggest that tobacco control should be part of public health strategies aimed at decreasing child malnutrition in developing countries. © 2007 Elsevier Inc. All rights reserved. Keywords: Bangladesh; Malnutrition; Poverty; Smoking; Tobacco Introduction Cigarette smoking causes 5 million deaths worldwide annually, and it is estimated that the annual death toll from smoking will climb to 10 million deaths by 2030, with 7 million deaths in developing countries [1,2]. Cigarette smoke damages the lower respiratory tract, increases oxi- dative stress, and increases the risk of bronchitis, chronic obstructive lung disease, cancer, and death [1]. As tobacco control legislation in developed countries has exerted pres- sure on tobacco companies, these companies have gradually shifted their market from high-income to low-income coun- tries, where many people are poorly informed about the health risks of tobacco use and antismoking policy is rela- tively weak [2]. Although much research has been focused on the relation between smoking and adverse outcomes such as cancer, respiratory disease, and cardiovascular disease, the problem of smoking and its relation to malnutrition and poverty has not been well characterized [2]. Tobacco use may have adverse consequences for nutrition, health, and This work was supported in part by a Lew R. Wasserman Merit Award for Research to Prevent Blindness to Dr. Semba and by the Eye Foundation of America. * Corresponding author. Tel: +410-955-3572; fax: +410-955-0629. E-mail address: rdsemba@jhmi.edu (R. D. Semba). Nutrition 23 (2007) 731–738 www.elsevier.com/locate/nut 0899-9007/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.nut.2007.06.014