Assessment of Awareness Regarding Health Hazards of Plastic Chemicals and their Warning Label among a Sample Population of Varanasi City: A Cross-sectional Study.

BACKGROUND: Plastic containers are widely used to store and serve edibles. In the production of some types of plastic, chemicals such as bisphenol A (BPA) and bisphenol S (BPS) are used. These chemicals leach from the plastic containers into the edibles, get access into the biological systems, and cause a toxic impact on health. AIM: This cross-sectional survey was planned to assess the usage of food contact plastic and awareness regarding the health hazards of plastic chemicals and warning labels on plastic items among a sample population of Varanasi city.
MATERIALS AND METHODS: Data were collected by interviewing the 556 adult participants, using a prevalidated structured questionnaire. Chi-square test was used to test the association and P < 0.05 was considered as significant.
RESULTS: Most of the participants were found to be following routine practices during cooking and storage of edibles which may expose them to BPA and BPS through the gut. Although many participants were aware that plastic may contain some type of chemicals which may enter the human body and harm human health in some way, they lacked precise knowledge regarding warning label like "BPA free plastic" "plastic containing BPA" and "food grade plastic." Furthermore, none of the participants could recognize the "resin identification codes" correctly.
CONCLUSION: Most of the participants had only elementary awareness of health risk of plastic usage. A significant number of participants lacked crucial information that can help them to make healthy choices as a consumer and use safe alternatives of plastic. Copyright:

INTRODUCTION

Plastic is an indispensable part of the modern lifestyle. Plastic containers are extensively used to store, serve, and transport edibles. In production of some types of plastic, chemicals uch as bisphenol A (BPA) are used to impart valuable properties to plastic-like shatter resistance, lightweight, and heat resistance.[1] Unfortunately, this chemical leaches from the plastic containers into the edibles.[12] The leaching is greater when plastic is exposed to extremes of temperature and ph.[2] On consumption of such food items, biological systems are exposed to this chemical.[1] This is evident bythe presence of BPA in various body fluids.[3] In addition, BPA is now ubiquitous in the environment.[1] Besides the oral route being the main route of exposure, the exposure to BPA has also been reported through dermal absorption,[4] inhalation,[5] placenta,[6] and breastfeeding.[78] BPA-containing plastic has been in use for several decades and there has been frequent reporting of its toxic impact on reproductive, endocrine, immune, and other body systems.[91011] Due to this, in many countries, BPA-containing feeding bottles have been banned.[1112] In view of regulations on marketing of BPA, industrialists are progressively substituting BPA with bisphenol S (BPS) in many plastic items such as feeding bottles and thermal paper.[13] Such plastic items are often labeled as “BPA Free.”[12] Although BPS has been marketed as a benign substitute to BPA, many ill effects of BPS have been reported recently.[141516]

Although avoiding plastic totally from our day to day life, totally, is not practically possible, awareness in the masses regarding the ill impact of these chemicals on health and their warning labels (”BPA free,” “resin identification codes”) may evoke willingness in the masses to reduce usage or choose suitable of plastic items. Earlier studies have reported awareness among the general population in India regarding health hazards and environmental toxicity associated with the usage of plastic bags,[1718] but we have not come across any study assessing awareness regarding health hazards of plastic chemicals and their warning labels.

A survey-based, cross-sectional study was planned to assess the day-to-day behavior of the local population, which may enhance its exposure to plastic chemicals such as BPA and BPS. Furthermore, the prevailing level of awareness about health hazards caused by plastic chemicals and understanding of warning labels on plastic items was explored. The awareness level was defined by an arbitrary scale, as described later.

MATERIALS AND METHODS

The study was conducted for the Hindi-speaking population of Varanasi. The sample size was calculated on basis of prevalence of awareness (86.4%) of legislation regarding plastic ban as reported in an early study.[17] With 95% confidence level and 5% relative precision, the sample size was calculated to be 242. Assuming 10% nonresponse/incomplete response, the sample size was calculated to be 269.

The data were collected in a health fair held for 3 consecutive days at the Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Data were collected by interviewing the participants having age above 18 years. A total of 556 adult visitors were included in the study after obtaining their written consent. This study was of single-blind type as the identities of the participants were kept confidential. The data were collected using a prevalidated structured questionnaire. The validation of the questionnaire was done among 10 nonrandomly chosen participants, on day a of health fair. The questions were finalized after incorporating the suggestions of these ten participants and these participants were excluded from the main study.

The questionnaire was in the form of multiple-choice questions and took about 12–15 min to completely fill it. The questionnaire included the participant's sociodemographic information, questions regarding the use of food contact plastic items or their substitutes in routine practices, and questions to evaluate knowledge of the participants in regard to recognition of safe types of plastics (warning labels on food contact plastic items), types of chemicals leaching from plastics, kinds of potential health hazards associated with plastic chemicals, and precautions to reduce these risks.

Statistical analysis

The data obtained from the survey were maintained in MS Excel and were analyzed using trial version 25.0 of the Statistical Package for the Social Software (SPSS Inc., Chicago, IL, USA). Chi-square test was used to find association of sociodemographic variables with routine practices which may cause exposure of body systems to plastic chemicals and secondly with related awareness level among the participants. The significance level was set at P < 0.05 at two-tailed test.

RESULTS

Five hundred and fifty-six participants consented to participate and gave a complete response. This included both adult male and female. The age of participants ranged from 18 to 76 years [Table 1].

Table 1

Distribution of participants according to the demographic profile, expressed as absolute number (n) and percent (in bracket)

Age (years)	<25, n (%)	25-45, n (%)	>50, n (%)	Total, n (%)
Gender
Male	68 (12.2)	154 (27.7)	38 (6.8)	260 (46.76)
Female	138 (24.8)	132 (23.7)	26 (4.7)	296 (53.23)
Education
Higher Secondary School	52 (9.4)	60 (10.8)	42 (7.6)	154 (27.70)
Graduate	86 (15)	98 (17.6)	10 (1.8)	194 (34.89)
Postgraduate	68 (12.2)	110 (19.8)	12 (2.2)	190 (34.17)
Ph.D	0	18 (3.2)	0	18 (3.23)
Occupation
Student	192 (34)	54 (9.7)	0	246 (44.24)
Housewife	8 (1.4)	72 (12.9)	22 (4)	102 (18.34)
Government/private employee	0	92 (16.5)	12 (2.2)	104 (18.70)
Own business	6 (1.1)	68 (12.2)	30 (5.4)	104 (18.70)
Total, n (%)	206 (37)	286 (51)	64 (11.5)	556 (100)

Most of the participants were found to follow practices which may cause their oral exposure to plastic chemicals like BPA and BPS. 42.9% of total participants (χ2 = 8.225, P = 0.084) agreed to the use of plastic feeding bottles over substitutes for feeding infants. Among these, a significant number of users (71.2%; χ2 = 18.069, P < 0.001) were regular users, who did not use any type of feeding bottle other than that made up of plastic. A significant number (61.9%, χ2 = 5.793, P = 0.04) of participants admitted that they were not concerned about the material of toys (plastic/others) they choose for their children.

About 59.4% of participants were found to use microwaves for cooking food and heating precooked edibles and 27.3% of these admitted that they preferred plastic food containers for microwaving their edibles over containers made up of other microwave-safe materials. Interestingly, all of these microwave users did not have any information or concern about using food-grade plastic for microwaves.

Use of plastic bottles for storage of water in refrigerator water was reported by 84.9% of participants, while a statistically significant number of participants (64.4%, χ2 = 15.384, P < 0.001) agreed to use of overhead water tanks made up of plastic. In addition, use of water purifier containers with plastic body and plastic lunch box was confirmed by 73% and 62.2% of total participants. About 60.1% of participants admitted multiple times reuse of the nonrecyclable plastic bags and containers for storage of food items.

A significant number of participants (91.3%, χ2 = 14.074, P < 0.001) stated that while having tea outside their home, which is a very common practice in their day-to-day life, they prefer tea in kulhad (a traditional handle-less clay cup), considering it as a safer option for serving tea as compared to plastic cups.

Assessment of participants' level of awareness regarding the possible impact of plastic on human health revealed interesting facts. Although 84.9%, (χ2 = 3.295, P = 0.193) participants had an idea that besides being harmful to the environment, plastic is harmful to human health as well, a significant number of the participants (72.3%, χ2 = 24.100, P < 0.001) were not aware that their routine practices of cooking and storage of food and drinks in plastic containers may be exposing them to toxic plastic chemicals such as BPA and BPS on daily basis. When precisely asked, significantly less number of participants (12.6%; χ2 = 16.526, P = 0.035) were found to have an understanding of “BPA free plastic” and “food grade plastic” [Figure 1] and 20.5% of participants know about plastic leached toxic chemicals [Figure 2]. Only 3.2% of the participants could recognize the 'resin identification codes[1920] correctly [Figure 3 and Table 2].

Figure 1

Showing distribution of participants expressed as percentage, regarding information about bisphenol A free plastic or food-grade plastic, n = 556

Figure 2

Showing distribution of participants expressed as percentage, regarding information about toxic plastic chemical “Bisphenol A” n = 556

Figure 3

Showing distribution of participants expressed as percentage, regarding information about resin identification codes, n = 556

Table 2

Association of level of awareness of plastic chemicals and their warning labels with sociodemographic variables of the participants

Variables	Informed about safe resin identification code/plastic code		Informed about toxic plastic chemical BPA		Informed about “BPA Free” plastic or “food grade plastic”
	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)
Age
<25	6 (1.1)	200 (36.0)	20 (7.2)	83 (29.9)	14 (5)	89 (37.1)
25-50	12 (2.2)	274 (49.3)	36 (12.9)	122 (43.9)	19 (6.8)	158 (56.8)
>50	0	64 (11.5)	1 (0.4)	16 (5.8)	2 (0.7)	17 (6.1)
χ2, df, P	3.049, 2, 0.218		2.809, 2, 0.246		150, 2, 0.928
Gender
Male	14 (2.5)	246 (44.2)	30 (10.8)	100 (36.0)	17 (6.1)	113 (40.6)
Female	4 (0.7)	292 (52.5)	27 (9.7)	121 (43.5)	18 (6.5)	130 (46.8)
χ2, df, P	7.188, 1, 0.007*		0.992, 1, 0.319		0.053, 1, 0.819
Education
Higher Secondary School	4 (0.7)	148 (26.6)	9 (3.2)	67 (24.1)	6 (2.2)	70 (25.2)
Graduate	8 (1.4)	188 (33.8)	31 (11.2)	67 (24.1)	16 (5.8)	82 (29.5)
Postgraduate	6 (1.1)	184 (33.1)	15 (5.4)	80 (28.8)	13 (4.7)	82 (29.5)
Ph.D	0	18 (3.2)	2 (0.7)	7 (2.5)	0	9 (3.2)
χ2, df, P	1.230, 3, 0.746		12.256, 3, 0.007*		4.165, 3, 0.244
Occupation
Student	12 (2.2)	234 (42.1)	21 (7.6)	102 (36.7)	12 (4.3)	111 (39.9)
Housewife	0	102 (18.3)	12 (4.3)	39 (14.0)	7 (2.5)	44 (15.8)
Government/private employee	2 (0.4)	102 (18.3)	10 (3.6)	42 (15.1)	5 (1.8)	47 (16.9)
Own business	4 (0.7)	100 (18.0)	14 (5.0)	38 (13.7)	11 (4.0)	41 (14.7)
χ2, df, P	6.223, 3, 0.101		2.541, 3, 0.468		4.841, 3, 0.184
Total	18 (3.2)	538 (96.8)	57 (20.5)	221 (79.5)	35 (12.6)	243 (87.4)

*Statistical significance (Chi-square test; P<0.05). Number of participants is expressed as absolute number (n) and percent (bracket). BPA: Bisphenol A

Most (97.1%) of the participants agreed that saying no to plastic may have a positive impact on health and environment. Despite this, a significant number of these participants (44.2%, χ2 = 23.140, P < 0.001) admitted that they had either increased or not decreased the use of plastic in the past few years. About 48.6% of the total participants agreed to their dependency on plastic bags for shopping, while others were using use shopping bags made up of nonplastic material.

The level of awareness in participants about plastic chemicals and their health hazards was assessed by an arbitrary scale as described below. The participants were given the score of 0, 1, or 2 according to the number of correct responses to the questions. There were a total of 10 such questions. The participants not answering any of these questions correctly were given a score of “0.” The participants answering ≤ 50% of these questions correctly were given score of “1.” The participants answering more than 50% of the questions correctly were given a score “2” [Table 3]. Among the participants, 78.1% scored “1” which indicated their partial awareness of the health hazards associated with the use of plastic, plastic chemicals, and their warning labels. No statistically significant difference in awareness level was observed, based on the age, gender, education, and occupation of the participant.

Table 3

Association of level of awareness (level of awareness has been described as awareness score 0-2) to the health hazards of plastic chemicals with sociodemographic variables of the participants

Variables	Score “0” (%)	Score “1” (%)	Score “2” (%)
Age (years)
<25	4 (0.7)	156 (28.1)	46 (8.3)
25-50	4 (0.7)	228 (41)	54 (9.7)
>50	0	50 (9)	14 (2.5)
χ2, df, P	2.292, 4, 0.682
Gender
Male	4 (0.7)	198 (35.6)	56 (10.4)
Female	4 (0.7)	236 (42.4)	56 (10.1)
χ2, df, P	1.036, 2, 0.596
Education
Higher Secondary School	4 (0.7)	124 (22.3)	24 (4.3)
Graduate	2 (0.4)	142 (25.5)	52 (9.4)
Postgraduate	2 (0.4)	154 (27.7)	34 (6.1)
Ph.D	0	14 (2.5)	4 (0.7)
χ2, df, P	9.224, 6, 0.161
Occupation
Student	6 (1.1)	194 (34.9)	46 (8.3)
Housewife	2 (0.4)	84 (15.1)	18 (3.2)
Government/private employee	0	80 (14.4)	22 (4.0)
Own business	0	76 (13.7)	28 (5.0)
χ2, df, P	8.361, 6, 0.213
Total	8 (1.4)	434 (78.1)	114 (20.5)

*Statistical significance (Chi-square test; P<0.05). Number of participants is expressed as absolute (n) and percent (bracket)

DISCUSSION

Most of the participants of our study admitted to follow routine practices of plastic containers that may cause leaching of plastic chemicals into their edibles. Plastic feeding bottles, especially when used with hot liquids, may be the foremost source of exposure to these toxic plastic chemicals to infants. Earlier studies have shown that BPA can leach from baby feeding bottles and this leaching increases with high temperature, vigorous washing with a bottle brush, and use of a dishwasher.[2122122232425] In fetus and in children up to 3 years of age, gut is immature and more susceptible to plastic chemical-induced damage.[12] The World Health Security Agency and government bodies in countries such as the USA, Europe, and Canada have banned the use of BPA-containing plastic in manufacturing of feeding bottles.[12] Due to these prohibitions, industrialists are gradually replacing BPA with BPS[26] and such feeding bottles are often labeled as “BPA free.”[12] While BPS has been promoted as a harmless substitute to BPA, many ill effects of BPS have been reported recently.[14] It has been documented that plastic items, especially the old ones, may leach some of the toxins of the bisphenol family, even at room temperature.[22728] Children have a habit of taking into their mouth their toys. Plastic toys are made up of nonfood-grade plastic.[29] It can be speculated that the chemicals such as BPA leach from these toys and after mixing with saliva get their way into the child's immature gut, followed by other body systems. This may be minimized by carefully choosing plastic-free toys for the children.

While the use of microwave has made cooking quick and convenient, most of the microwave users among the participants admitted preferred use of plastic containers over other microwave-safe containers for cooking and heating food. Some plastics, labeled as food safe, have been found to be highly toxic to aquatic animals and could pose a threat to humans.[30] Also, microwave-safe plastic containers may leach potentially toxic chemicals if heated multiple times, frequently washed, especially using a dishwasher.[30313233] The lack of knowledge about “resin identification code” and “food grade plastic” among microwave users puts them at risk of exposure to plastic chemicals.

Plastic water bottles may leach toxin chemicals into drinking water.[34] Similarly, plastic overhead water tanks are exposed directly to the sun, and especially during summers, the leaching can be further increased.[28] It has been reported that exposure to boiling water (100°C) increased the rate of BPA migration by up to 55-fold.[28] Water stored in overhead tanks is directly channeled into water purifiers, which are themselves made up of plastic.[34] These water purifiers clean the water by eliminating microbes but the removal of leached toxic chemicals if any is not claimed.[3435] Similarly, the use of plastic lunch box, reuse of the nonrecyclable plastic bags and plastic food containers, may increase the risk of oral exposure to plastic chemicals.

Most of the participants have a basic understanding that the use of plastic may have an adverse impact on their health; most of them lacked the necessary knowledge of plastic chemicals warning labels that can help them to make healthy choices as a consumer. Interestingly, most of these practices, which may expose our gut to the plastic chemicals, are avoidable. Usage of plastic containers when necessary, using only food grade plastic for storage of edibles, looking for safe resin identification code while purchasing plastic water bottles and lunch boxes, discarding the plastic items after a few washes, avoiding use of plastic containers in microwave, avoiding dishwashing the food contact plastic etc.

It was also observed that despite basic information that prevailing day-to-day practices, plastic may release harmful chemicals and may expose to ill health impact of these chemicals, the willingness for decreasing the use of plastic in routine and preferring plastic substitutes was not observed in most of the participants.

CONCLUSION

Most of the participants in our study lacked the key information about the health hazards of toxic plastic chemicals safe practices to curtail them. Similarly, the knowledge about resin identification code, which is crucial for the masses to make safe choices as a consumer was also lacking. There is a necessity for spreading the awareness in the masses through various modes of mass media by government and nongovernment organizations regarding health hazards of plastic chemicals and use of alternatives of plastic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.