|Year : 2010 | Volume
| Issue : 5 | Page : 63-68
Awareness, attitude and perceived barriers regarding implementation of the cigarettes and other tobacco products act in Assam, India
I Sharma, PS Sarma, KR Thankappan
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, India
|Date of Web Publication||9-Jul-2010|
K R Thankappan
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011
Source of Support: None, Conflict of Interest: None
Background : Tobacco use is a major public health problem in India. The Cigarettes and Other Tobacco Products Act (COTPA) was developed to curb this epidemic. Because no study has been conducted on the awareness, attitude and perceived barriers regarding the implementation of COTPA, this study was undertaken. Materials and Methods : A community-based cross-sectional survey was conducted among 300 adults (mean age 41 years, 52% men) selected by cluster sampling method from Guwahati Municipal Corporation. Information on awareness, attitude and their predictors and barriers for implementation was collected using a pretested, structured interview schedule. Multivariate analysis was done using SPSS. Results : Adults older than 50 years were 3 times (odds ratio [OR] 3.02, 95% CI 1.44-6.31) and those with more than 10 years of schooling were 4 times (OR 3.60, 95% CI 1.70-7.70) more likely to have good awareness of COTPA compared with their counter parts. Those belonging to the middle socioeconomic status (SES) were 3 times (OR 3.36, 95% CI 1.13-10.01), those who reported secondhand smoking harmful were 3 times (OR 3.32, 95% CI 1.45-7.62), and those with more than 10 years of schooling were 3 times (OR 2.92, 95% CI 1.01-8.45) more likely to have positive attitude toward COTPA compared with their counterparts. Lack of complete information and awareness of the Act, public opposition, cultural acceptance of tobacco use, lack of political support, and less priority for tobacco control were reported as barriers for COTPA implementation. Conclusion : Efforts should be made to increase the awareness of COTPA focusing on younger population, less educated, and those belonging to the low SES.
Keywords: Assam, attitude, awareness, barriers, India, tobacco products Act
|How to cite this article:|
Sharma I, Sarma P S, Thankappan K R. Awareness, attitude and perceived barriers regarding implementation of the cigarettes and other tobacco products act in Assam, India. Indian J Cancer 2010;47, Suppl S1:63-8
|How to cite this URL:|
Sharma I, Sarma P S, Thankappan K R. Awareness, attitude and perceived barriers regarding implementation of the cigarettes and other tobacco products act in Assam, India. Indian J Cancer [serial online] 2010 [cited 2020 Feb 16];47, Suppl S1:63-8. Available from: http://www.indianjcancer.com/text.asp?2010/47/5/63/63874
Publication of the supplement was supported by the funds from the 14th World Conference on Tobacco or Health, March 8-12, 2009, Mumbai. The Guest Editors, Editors, Authors and others involved with the journal did not get any financial or non-financial benefit from the sponsors.
| » Introduction|| |
Tobacco use is one of the major public health problems in the world, resulting in 5.4 million deaths every year.  Total tobacco-attributable deaths are projected to rise to 6.4 million in 2015 and 8.3 million in 2030, and 80% of these deaths will be in the developing countries. 
According to the National Family Health Survey (NFHS-3), in India, over half of men (57%) and over one tenth (10.8%) of women in the age group of 15-49 years use tobacco in some form.  Tobacco use in any form increased in India during the 7-year period between the NFHS-2 and NFHS-3, and the greatest increase in tobacco use occurred in persons between 15 and 24 years of age in the richer classes and in urban areas. 
In Assam, 72.4% men and 23.2% women in the age group of 15-49 years used some form of tobacco and 36.4% men and 0.6% women smoked cigarette or bidi.  According to the Global Youth Tobacco Survey-2006, 36% of students in Assam reported current use of some form of tobacco; 10% currently smoke cigarettes, and 26% currently use some other form of tobacco.  Scientific evidence from the past few decades has clearly established the harmful effects of passive smoking. The World Health Organization (WHO), International Agency for Research on Cancer (IARC), and the US Surgeon General have concluded that secondhand smoking is responsible for ill health in humans exposed to it. ,, After several rounds of negotiations, the World Health Assembly in May 2003 finally adopted the Framework Convention on Tobacco Control (FCTC), which the member states of WHO have to adopt. 
India was one of the first few countries that ratified the FCTC. In addition to ratifying the FCTC, the Indian Parliament enacted the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA) on May 18, 2003. In 2004, the rules were notified for the COTPA provisions on the ban of smoking in public places, ban on advertisements of tobacco products, and prohibition of sale of tobacco products to minors and within 100 yards of educational institutions.  Specific pictorial warnings were notified in 2009.
No study has been conducted so far on the awareness, attitude, and perceived barriers regarding the implementation of the Act. Therefore, this study was undertaken.
| » Materials and Methods|| |
This study was approved by the Institutional Ethics Committee of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. Written informed consent was taken from all the participants and they were free to opt out of the study at any stage of the study.
This study was a community-based cross-sectional survey among 300 adults (men 52.3%) 18 years and older. The sample size of 300 was estimated based on an anticipated awareness level of 24% with a margin of error of 6%.  Because it was a cluster sampling, we also used a design effect of 1.5 in the calculation of the sample size. Twenty wards (clusters) were identified from the entire 60 wards under the jurisdiction of Guwahati Municipal Corporation in Assam, using the technique of probability proportional to size. From each of the selected wards, a cluster of 15 adults were selected.
Data were collected using a structured interview schedule. Information regarding age, sex, highest level of education, occupation, and marital status was obtained through self-reports. Total monthly household expenditure tertiles have been used as proxy for the socioeconomic status (SES). Individuals whose total household expenditure was Rs 6221 or less were grouped as "low SES," Rs. 6222-19,465 as "middle SES," and more than Rs. 19,465 as "high SES."
Awareness of tobacco-related health problems, perception that secondhand smoke is harmful, awareness about any tobacco control law in India, awareness of the 4 major provisions of the Act, and related information was collected.
Information regarding the barriers in the implementation of the Act, such as lack of awareness of the law, lack of administrative support, cultural acceptance of tobacco use, and measures for effective implementation of the Act was collected.
Ever use of tobacco (used tobacco anytime in the past), current tobacco use (any use of tobacco in the past 30 days), current smoking (use of any smoking tobacco in the past 30 days), current smokeless tobacco use (any form of smokeless tobacco use in the past 30 days), and anyone in the family using any kind of tobacco product (current tobacco use of any family member) was also collected.
There were 8 questions to assess the awareness level of adults toward COTPA. The questions were (1) Have you heard of any tobacco control laws in India? (2) Is there a ban on smoking in India? (3) Is there some penalty if someone violates the law? (4) Is there any age limit for prohibition of buying tobacco products in India? (5) Is there any age limit for prohibition of selling tobacco products to anyone in India? (6) Is there a ban on advertisement of tobacco products in India? (7) Is there a ban on selling tobacco products near educational institutions in India? and (8) Have you noticed health warnings on tobacco products? For every "yes" response, a score of one was allotted and the rest of the responses ("no" and "don't know") were scored zero. Thus, a minimum score of zero and a maximum score of 8 were obtained. The score was divided into 2 categories based on the median value (3.0). Score less than or equal to 3 was graded as "poor awareness" and score more than 3 was graded as " good awareness."
The "Fishbein model" was used to measure attitude toward the Act.  It is a compensatory multiattribute model of attitude. According to the model, a person's attitude toward any object is a function of his/her beliefs about the object and the implicit evaluative responses associated with those beliefs. In this study to measure the attitude toward COTPA, 2 questions were framed-one on belief strength measurement (Bi ) and the other on evaluative strength measurement (Ei ). Each question had 4 parts for the 4 provisions of the Act. Each individual provision was measured on a scale. A scale marked from 1 to 10 was used and the respondent was asked to tick any point on the scale, which he/she thought was appropriate. For belief strength, the scale ranged from strongly disbelieve to strongly believe and for evaluative strength measurement, it ranged from very ineffective to very effective. Individual attitude (A) for each Act was measured as A = Bi Χ Ei and overall AL = [SUM] Bi Χ Ei , where AL = the overall attitude toward the Act, Bi = the strength of the belief that the government should implement each provision of the Act, Ei = the evaluation of the effectiveness or ineffectiveness of each provision if it is implemented. The conceptual midpoint for the individual attitude is 30.25. So negative attitude was scored as less than 30.25 and positive attitude was 30.25 or more. Similarly, for the overall attitude the conceptual midpoint was 121, so negative attitude was scored as less than 121 and positive attitude was 121 or more.
Analysis was done using SPSS version 15.0 (SPSS Inc., IBM Company, Chicago, Illinois, USA). Variables significantly associated with the outcome variables in the bivariate analysis were used for multiple logistic regression analysis. A P value of less than 0.05 was considered to be statistically significant.
In addition to the quantitative survey mentioned above, 15 indepth interviews of the implementers of the Act were also done. The implementers included police officers, teachers, gazetted officers, restaurant/hotel managers, and petty shop owners selling tobacco. Information was collected on the practical challenges of implementation of the law, such as selling tobacco products to minors, banning advertisement of tobacco products, banning selling tobacco products within 100 yards of educational institutions, and so on. The 15 indepth interviews were read and coded by two independent coders. The codes were then collapsed into themes that were explicit as part of the analysis. The associations between the various themes were identified.
| » Results|| |
The sample characteristics are given in [Table 1]. The mean age of the sample population was 41.07 years (range 18-80 years). The mean household expenditure was Rs 11,102.
Information on the awareness about tobacco-related health problems is given in [Table 2]. The mean score of awareness about COTPA was 3.35 out of 8 with a range of minimum 0 and maximum 8. A vast majority of the participants (97%) were aware of some tobacco-related health problems. With regard to the awareness of individual diseases associated with tobacco use, more than half of the participants were aware of tobacco-related cancer and more than a third were aware of tobacco-related respiratory disease. Only a quarter of the participants were aware of the relationship between tobacco and heart problems. More than half of the participants had a poor awareness on COTPA.
Attitude toward COTPA is given in [Table 3]. The mean score of attitude toward COTPA based on the Fishbein model was 184.83 out of 400 with a range of 7-400. The largest proportion of the participants with a positive attitude toward COTPA was on the prohibition on sale to minors and within 100 yards of educational institutions.
Tobacco use practices of the study participants are given in [Table 4]. Forty percent females and 63% males were currently using some form of tobacco. More than 50% of males were currently smoking, whereas only 9% of females were currently smoking. Among females, 36% were using smokeless variety of tobacco compared with 23% males.
Results of multiple logistic regression analysis for awareness of COTPA is given in [Table 5]. Adults older than 50 years were 3 times (odds ratio [OR] 3.02, 95% CI 1.44-6.31) and those with more than 10 years of schooling were 4 times (OR 3.60, 95% CI 1.70-7.70) likely to have good awareness compared with their counterparts. Marital status, SES, awareness of the harmful effects of secondhand smoke, ever use of tobacco, current use of tobacco, and anyone in the family using tobacco, which were significant in bivariate analysis lost their significance in multivariate analysis.
Results of multiple logistic regression analysis for positive attitude toward COTPA are given in [Table 6]. Those with more than 10 years of schooling were 3 times (OR 2.92, 95% CI 1.01-8.45), those belonging to middle SES were 3 times (OR 3.36, 95% CI 1.13-10.01), and those who reported secondhand smoking harmful were 3 times (OR 3.32, 95% CI 1.45-7.62) more likely to have a positive attitude toward COTPA compared with their counterparts. Age, current tobacco use, ever use of tobacco, anyone in the family using tobacco, awareness of COTPA, which were significant in bivariate analysis lost their significance in multivariate analysis.
Overall 78.3% of the participants reported that there are barriers for the implementation of the Act. The most common barrier reported was the lack of awareness of the Act (34.0%). Other barriers reported were cultural acceptance of tobacco use (20.3%), tobacco issues given less priority (14.0%), fear of public opposition (12.0%), lack of administrative support (11.3%), not familiar with the provisions of the Act (8.3%), lack of awareness of the ill effects of tobacco (7.3%), lack of complete information (5.7%), lack of financial and human resources (4.0%), definitions are not clear (4.0%), and difficulty in paying fine by poor people (3.0%).
Most of the implementers who reported that they were aware of the Act did not have knowledge of the standard specifications. Most of them reported that they do not know who to complain to if someone violated the Act and they were even unaware of the legal penalty if someone violates the Act. The implementers of the Act were themselves not aware of their responsibilities. Most of the implementers did not receive the official notification of the Act without which they think that they are not empowered to take any action. Most of the barriers reported by the study participants were also reported by the implementers. In addition, the implementers also reported public opposition for implementation, lack of interest of the implementers, lack of proper training of the implementers, difficulty in interpreting the graphical images on the tobacco packets, and the arbitrariness of the distance mentioned in the Act as other barriers.
| » Discussion|| |
This is the first study in India on awareness, attitude, and barriers regarding the implementation of COTPA. In this study, almost every participant (97%) was aware that tobacco causes at least some health problem unlike the study in Kolkata where 20% of the participants had no idea about the adverse effects of tobacco use.  Peoples' awareness of tobacco causing cancer, heart problem, and respiratory disease was similar to some previous studies. , Another interesting finding in the present study was that only 1% of the population knew that tobacco causes diabetes, which is similar to the results of a previous study in Kerala among the members of the local self-government bodies.  There is a need to increase the awareness level regarding the links between tobacco use and diabetes and related complications, particularly when India is projected to have the maximum number of diabetes patients in the world.  Several prospective studies have reported that cigarette smoking is an independent and modifiable risk factor for diabetes. ,, Awareness on the links between tobacco use and hypertension was only 11%, which was similar to a study reported from Delhi.  The awareness of the harmful effects of secondhand smoke was quite high, which was contrary to the studies from Wellington and Sydney. , Nearly half of the study population had good awareness of COTPA compared with a very low level of awareness about the existing national tobacco control laws and the FCTC in Azerbaijan. 
The overall attitude of the population toward COTPA was high. This implies that with a little more effort to implement the Act, we can expect the population to accept the Act and support it. A vast majority of the participants had a positive attitude toward prohibition on sale to minors and within 100 yards of educational institutions, which is similar to other studies done previously. ,,,,
As age increases, awareness of COTPA increases significantly. Most of the older people in this study were retired, so they stay at home and they might have more opportunities to watch television or listen to the radio, which broadcast antitobacco messages. Because the awareness level is less among less educated people, efforts should be made to increase awareness among them.
As age increases the attitude toward COTPA increases significantly. Elderly people must have seen and experienced the harmful effects of tobacco and thus they don't want the younger generation to suffer. As SES improves, the attitude toward COTPA also improves similar to the study in China.  Nonusers of tobacco (both ever and current) had significantly higher positive attitude toward COTPA compared with their counterparts as reported in many previous studies. ,, However, this significance observed in the bivariate analysis was lost in the multivariate analysis probably due to small sample size. The barriers reported in our study were similar to a few other previous studies. ,
In conclusion, nearly half of our participants had good awareness of COTPA and more than three-fourths of them had an overall positive attitude toward COTPA. However, the participants reported several barriers for effective implementation of the Act, which should be addressed at various levels. Awareness of COTPA significantly increased with age and education, and positive attitude toward COTPA was significantly associated with better education, higher SES, and better awareness of the harmful effects of secondhand smoking. Efforts should be made to increase the awareness of the Act focusing on younger population, less educated people, and people belonging to the low SES. Training of implementers on COTPA will also be useful for proper implementation of the Act.
One of the major strengths of this study was that a single investigator (IS) conducted all interviews, including the qualitative interviews. The other strength was the use of a combination of qualitative and quantitative methods for data collection.
This study had all the limitations of a cross-sectional study. Because of the urban-focused study areas, the findings may not be generalizable to rural populations.
| » Acknowledgments|| |
The authors express their thanks to the participants of this study for their cooperation in completing the study. The authors also thank Dr Mala Ramanathan, Additional Professor, Achutha Menon Centre For Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, for her contribution in the qualitative data collection and analysis.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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