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  Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 49  |  Issue : 4  |  Page : 431-437
 

Intention to quit among Indian tobacco users: Findings from International Tobacco Control Policy evaluation India pilot survey


1 Healis-Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra, India
2 Department of Psychology, University of Waterloo, Ontario, Canada
3 Department of Health Behaviour, Roswell Park Cancer Institute, New York, USA

Date of Web Publication26-Feb-2013

Correspondence Address:
N S Surani
Healis-Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra
India
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Source of Support: The study was supported by the grant from Canadian Institutes of Health Research (79551)., Conflict of Interest: None


DOI: 10.4103/0019-509X.107752

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 » Abstract 

Introduction: Tobacco users face barriers not just in quitting, but also in thinking about quitting. The aim of this study was to understand factors encouraging intention to quit from the 2006 International Tobacco Control Policy (TCP) Evaluation India Pilot Study Survey. Materials and Methods: A total of 764 adult respondents from urban and rural areas of Maharashtra and Bihar were surveyed through face-to-face individual interviews, with a house-to-house approach. Dependent variable was "intention to quit tobacco." Independent variables were demographic variables, peer influence, damage perception, receiving advice to quit, and referral to cessation services by healthcare professionals and exposure to anti-tobacco messages. Logistic regression model was used with odds ratio adjusted for location, age, gender, and marital status for statistical analysis. Results: Of 493 tobacco users, 32.5% intended to quit. More numbers of users who were unaware about their friends' tobacco use intended to quit compared to those who were aware (adjusted OR = 8.06, 95% CI = 4.58-14.19). Higher numbers of users who felt tobacco has damaged their health intended to quit compared to those who did not feel that way (adjusted OR = 5.62, 95% CI = 3.53-8.96). More numbers of users exposed to anti-tobacco messages in newspapers/magazines (adjusted OR = 1.76, 95% CI = 1.02-3.03), restaurants (adjusted OR = 2.47, 95% CI = 1.37-4.46), radio (adjusted OR=4.84, 95% CI = 3.01-7.78), cinema halls (adjusted OR = 9.22, 95% CI = 5.31-15.75), and public transportation (adjusted OR = 10.58, 95% = 5.90-18.98) intended to quit compared to unexposed users. Conclusion: Anti-tobacco messages have positive influence on user's intentions to quit.


Keywords: Anti-tobacco messages, health damage, intention to quit, peer influence


How to cite this article:
Surani N S, Gupta P C, Fong T G, Pednekar M S, Quah A C, Bansal-Travers M. Intention to quit among Indian tobacco users: Findings from International Tobacco Control Policy evaluation India pilot survey. Indian J Cancer 2012;49:431-7

How to cite this URL:
Surani N S, Gupta P C, Fong T G, Pednekar M S, Quah A C, Bansal-Travers M. Intention to quit among Indian tobacco users: Findings from International Tobacco Control Policy evaluation India pilot survey. Indian J Cancer [serial online] 2012 [cited 2019 Dec 14];49:431-7. Available from: http://www.indianjcancer.com/text.asp?2012/49/4/431/107752



 » Introduction Top


Cigarette smoking is the most common form of tobacco use worldwide. However, of the South-East Asia Region countries like India have additional burden of tobacco use due to the popularity of smokeless tobacco products and numerous other smoked forms. [1]

Currently, in India, there are 274.9 million tobacco users, aged ≥15 years, of which, 43 million use tobacco occasionally. [2] There are 231.9 million daily tobacco users in India, which is almost equal to the population of Indonesia, the fourth most-populated country in the world. [2] Given this, only about half of these tobacco users have an interest in quitting tobacco. [2]

With the efforts of the global tobacco control community in creating awareness about the harmful effects of tobacco, users may understand the benefits of quitting this habit. Educational interventions in India have been found to be helpful in altering tobacco use behaviors. [3] Numerous studies show that tobacco cessation leads to considerable decrease in health risks posed by tobacco use. [4],[5] However, when it comes to actual cessation rates, the success is quite dismal, especially in low- and middle-income countries. Users face barriers not just in quitting tobacco, but also in thinking about quitting. In order to progress into the stage of taking an action to make a quit attempt, one must at least start to think about quitting. [6]

In India, there is a dearth of research on determinants of quitting behavior including intention to quit, which is the first positive step that a tobacco user takes towards cessation. The objective of this paper was to understand the factors that encourage intention to quit from the 2006 International Tobacco Control Policy (TCP) Evaluation India Pilot Study Survey (referred to as TCP in India due to the presence of a tobacco company called the India Tobacco Company, also abbreviated as ITC). [7]


 » Materials and Methods Top


Data collection

The survey sample was recruited from four areas: Urban Maharashtra (Mumbai), rural Maharashtra, urban Bihar (Patna), and rural Bihar. Face-to-face individual interviews were conducted through a house-to-house survey without involving any proxy respondents. Fieldwork was completed by teams of two interviewers with a field supervisor in each area. A maximum of four respondents were interviewed from each household (two adult smokers, one adult smokeless tobacco user, and one adult non-user of tobacco). Out of these four, one respondent was a youth. Interviewers working in pairs were given assignments to obtain 20 respondents who were tobacco users (and up to ten respondents who were non-users of tobacco). In each of the four areas, five assignments made up the sample. For each assignment, the interviewer pair was given a randomly determined route to follow in order to select households to be contacted. They were instructed to call at every fourth dwelling unit or living quarters on the route. A total of 764 adult respondents (aged ≥18 years) were surveyed from the states of Maharashtra ( n = 337) and Bihar ( n = 427).

Written informed consent was obtained from all respondents at the time of recruitment. The survey was conducted in Maharashtra in Marathi and in Bihar in Hindi. All respondents were given a token of appreciation for their time.

Variables analyzed

Dependent variable

The dependent variable was "intention to quit tobacco," which was based on the question "Are you planning to quit tobacco (smoking and smokeless tobacco)?" This question had five response categories: "Within the next month," "within the next six months," "sometime in the future beyond six months," "not planning to quit and don't know/can't say." The first three response categories were re-coded as "intention to quit" and the last two categories were re-coded as "no intention to quit."

Independent variables

The independent variables were demographic variables (location, age, gender, and literacy), peer influence (having friends who use tobacco), damage perception (perception of damage caused by tobacco use), receiving advice to quit and referral to cessation services by healthcare professionals, and exposure to anti-tobacco messages via mass media.

Location (urban or rural) and gender (male or female) were categorized into dichotomous categories. The categories for literacy status were "literate," "illiterate," and "don't know/can't say." Those who had completed either primary, middle, secondary, or college education and above were classified as "literate."

To measure peer influence, the question "Of the five closest friends or acquaintances that you spend time with on a regular basis, how many of them are tobacco users (smoking and smokeless tobacco)?" was used. The response categories were: "0," "1," "2," "3," "4," "5," and "don't know/can't say." Those who responded with "0" were re-coded as "having no friends who are tobacco users," those who responded "1," "2," "3," "4," or "5" were re-coded as "having one or more friends who are tobacco users."

Damage perception was measured using the question: "To what extent, if at all, has tobacco use (smoking and smokeless tobacco) damaged your health?" The response categories of "a little" and "very much" were re-coded as "tobacco use has damaged health," "not at all" was re-coded as "tobacco use has not damaged health," and the third category was "don't know/can't say."

The advice and referral to cessation services by healthcare professionals was analyzed through the following question: "During any visit to the doctor or other health professional in the last six months, did you receive advice to quit tobacco (smoking and smokeless tobacco) or additional help or a referral to another service to help you quit?" The response categories were "yes," "no," and "don't know/can't say." This variable was analyzed only for those tobacco users who answered "yes" to the question: "Have you visited a health professional in the past six months?"

For exposure to anti-tobacco media messages, the question was "In the last six months, have you noticed advertising or information that talked about the dangers of smoking/smokeless tobacco use, or encourages quitting in any of the following places: "Television," "radio," "posters," "newspapers or magazines," "shop/store windows or inside shops/stores where you buy tobacco," "street vendors," "workplace," "public transportation vehicles or stations," "restaurants/cafeterias/tea bars," and "cigarette packs." The response categories were "yes," "no," and "don't know/can't say."

Data analysis

Statistical analyses were conducted using SPSS version 13.0. The total number of tobacco users in this study was 497, of which, 493 responded to the question on intention to quit tobacco (smokers as well as smokeless users). The remaining four were treated as missing cases and were discarded from the analysis. At some places in [Table 1], the total may not add up to 493 because of some additional missing responses. Logistic regression was used to understand the correlation of intention to quit. In the multivariate analysis, the association of each of the four demographic variables (location, age, gender, and literacy status) with intention to quit was studied by adjusting for the remaining three variables. For each independent variable, a separate multivariate model was fitted adjusting for the four covariates: Location, age, gender, and literacy.
Table 1: Factors associated with intention to quit tobacco

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 » Results Top


Demographic characteristics

Majority of the respondents lived in rural areas (63.1%) were males (60.2%), literate (61.7%), had an income less than INR 5,000 (66.9%), and practiced the Hindu religion (97.4%). Almost three quarters of the respondents were married and unemployed. These demographic characteristics were similar across the two states of Maharashtra and Bihar [Table 2].
Table 2: Sample characteristics by state

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Tobacco use and intention to quit

The sample consisted of 497 (65.1%) tobacco users, 249 (32.6%) smokers, and 248 (32.5%) smokeless users. Also, 493 tobacco users responded to the question on intention to quit, of which, 160 (32.5%) users expressed an intention to quit.

Effect of location, age, gender, and literacy status on intention to quit

Tobacco users who were urban residents had greater intention to quit as compared to those who resided in rural areas (adjusted OR = 1.91, 95% CI = 1.22-2.97). Similarly, users who were literate, had greater intention to quit as compared to illiterate users (adjusted OR = 2.07, 95% CI = 1.27-3.38). Age and gender did not have any significant impact on intention to quit [Table 1].

Effect of peer influence, damage perception, and health professionals on intention to quit

The odds of intention to quit were higher among those users who did not know about their friends' tobacco use status as compared to those who reported they had one or more friends as users (adjusted OR = 8.06, 95% CI = 4.58-14.19). Not having friends as tobacco users did not affect intentions to quit among tobacco users in this study [Table 1]. Tobacco users who reported that tobacco use has damaged their health were found to have significantly greater intentions to quit as compared to those who felt that tobacco use has not damaged their health (adjusted OR = 5.62, 95% CI = 3.53-8.96). Advice and referral by healthcare professionals did not have a significant impact on users' intentions to quit [Table 1].

Effect of anti-tobacco media messages on intention to quit

Tobacco users who were exposed to anti-tobacco messages on radio (adjusted OR = 4.84, 95% CI = 3.01-7.78), newspapers/magazines (adjusted OR = 1.76, 95% CI = 1.02-3.03), cinema halls (adjusted OR = 9.22, 95% CI = 5.31-15.75), public transportation (adjusted OR = 10.58, 95% CI = 5.90-18.98), and restaurants (adjusted OR = 2.47, 95% CI = 1.37-4.46) had greater intention to quit compared to users who were not exposed to such messages. Tobacco users who were exposed to anti-tobacco messages on posters, in workplaces, and on cigarette packs also had greater intentions to quit as compared to those who were not exposed to such messages. However, these differences were no longer significant once we controlled for other covariates in the multivariate analysis [Table 1]. Exposure to anti-tobacco messages on television, shops, and street vendors did not have any significant impact on intentions to quit.


 » Discussion Top


The intention to quit in this study was low (33%) when compared to the Global Adult Tobacco Survey (GATS) India, in which about 50% tobacco users intended to quit. [2] The intention was also low when compared to the International Tobacco Control (ITC) Policy Evaluation Surveys of other Asian countries such as Malaysia (57.8%) and Thailand (40.2%) [8] and developed countries (64.7-81.5%), [9] but higher than intention to quit in China (23.6%). [10]

In the present study, location of residence and literacy status were important socio-demographic predictors of intention to quit. Making non-smoking a social norm may be more difficult in rural areas. [11] Smokers in rural part of England have been found to have lower intention to quit. [12] A study in the United States has shown a positive association between being educated and intention to quit. [13] However, in Thailand, higher education level did not show a strong association with having an intention to quit, whereas, in Malaysia, it was not associated with intention to quit. [14] Statistically significant predictors of smoking cessation include male gender and older age among 20 American and two Canadian communities, [15] which was not found to be associated with intention to quit in this study.

Compared to users who reported that they had friends' who used tobacco, those who were unaware of their friends' tobacco use status had greater odds of having an intention to quit. Youth who reported having received offers to smoke cigarettes and who had friends who smoke were found to be less likely to quit smoking. [16] A study among US college students revealed that those students who smoked when they were with other people had lesser intention to quit. [17]

This study confirms the past evidence that users who think tobacco has damaged their health have greater intention to quit compared to those who think otherwise. People will contemplate to change their behavior if they feel threatened by the consequences of that behavior. A survey in China revealed that intention to quit was higher among those who felt that smoking had damaged their own health. [18]

A study amongst youth showed that advice by a physician is associated with a more accurate knowledge regarding tobacco related damage. [19] Evidence from developed countries shows that advice by healthcare professionals plays a crucial role not just in motivating users to give quitting a serious thought but also in increasing the probability of successful cessation. [20] However, in this study, neither advice nor referral to cessation services by healthcare professionals had any effect on users' intention to quit. This could possibly be explained by the low numbers of respondents who visited a healthcare professional.

The odds of intention to quit were the highest amongst those who are exposed to anti-tobacco messages on public transportation systems and cinema halls, followed by radio and newspapers. Anti-tobacco mass media campaigns have a positive impact on quitting behaviors, [21] especially those that employed multiple forms of media. [22] Previous research shows that assimilating more than one form of media may operate in a complementary manner to positively influence awareness of the health consequences of smoking and motivation to quit. [23] Although general exposure to media in India was associated with an increased risk of tobacco use, [24] exposure to a national mass media campaign targeted at smokeless tobacco users in India was associated with greater cessation-oriented intentions and behaviors among smokeless tobacco users. [25] Carefully designed anti-smoking campaigns screened before a movie in cinema halls in Australia have been shown to increase smokers' intentions to quit. [26] Exposure to anti-tobacco messages broadcast on All India Radio almost two decades ago in Karnataka, located in the southern part of India and Goa, in the western region, showed that one-third of the tobacco users intended to quit. [27] Given the cost effectiveness of producing radio advertisements and the widespread reach and acceptability of radio, it can be a potentially good medium to target tobacco users.

Interestingly, in this study, exposure to anti-tobacco messages in restaurants had a significant association with intention to quit. In India, smoke-free laws in restaurants, bars, and cafeterias are strictly implemented with "No Smoking" boards prominently displayed, thereby de-normalizing smoking and making tobacco use socially unacceptable. Shops and street vendors do not generally promote messages that would encourage users to think about quitting, with the exception of Australia, where point-of-sale health warnings about tobacco appear to act as a prompt to quitting. [28]

Shops and street vendors in India usually do not display any anti-tobacco messages. On the other hand, cigarette advertising posters are displayed all over the shops conveying the statutory health warning that "Tobacco causes cancer," that too in extremely small fonts.

There is considerable research about the effectiveness of health warnings on tobacco products and quitting behaviors, [29] especially pictorial warnings. [30] These warnings can act as impactful anti-tobacco messages. Indian pictorial warnings, however, have time and again been diluted to milder versions, [31] thereby making its intended effectiveness in altering tobacco use behaviors questionable. [32]

This paper is based on the data from the pilot survey focusing on two Indian states of Maharashtra and Bihar. Therefore, caution has to be exercised before generalizing the findings to the entire country. The data collected from this survey was dependent on respondent reports and may be subject to recall bias and differences in providing responses to perception related questions. Nevertheless, the data clearly points out the effectiveness of anti-tobacco messages on public transportation systems, in cinema halls, on radio, in restaurants, and in newspapers/magazines.

These findings will be further examined in the recently completed Wave 1 of the larger TCP India cohort study of 8,000 tobacco users and 2,400 non-users of tobacco from four Indian states (Maharashtra, Bihar, Madhya Pradesh, and West Bengal).


 » Acknowledgment Top


We would like to acknowledge Dr. Lalit Raute and Ms. Genevieve Sansone for their valuable suggestions as well as Dr. Namrata Puntambekar for providing statistical assistance. The study was supported by the grant from Canadian Institutes of Health Research (79551).


 » Ethical Consideration Top


The study protocol and survey materials were approved by the Office of Research Ethics at the University of Waterloo, Canada and by the Institutional Review Board at the Healis-Sekhsaria Institute for Public Health, India.

 
 » References Top

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    Tables

  [Table 1], [Table 2]

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