|TOBACCO AND CANCER: ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 3 | Page : 330-334
Public opinion about smoking and smoke free legislation in a district of North India
S Goel1, RJ Singh2, Sharma D1, Singh A1
1 School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Tobacco Control and NCD Control Programmes, The UNION, South-East Asia, New Delhi, India
|Date of Web Publication||10-Dec-2014|
School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Context: A growing number of cities, districts, counties and states across the globe are going smoke-free. While an Indian national law namely Cigarettes and Other Tobacco Products Act (COTPA) exists since 2003 and aims at protecting all the people in our country; people still smoke in public places. Aim: This study assessed knowledge and perceptions about smoking, SHS and their support for Smoke-free laws among people residing in Mohali district, Punjab. Materials and Methods: This cross-sectional study was conducted in Mohali district of Punjab, India. A sample size of 1600 people was obtained. Probability Proportional to Size technique was used for selecting the number of individuals to be interviewed from each block and also from urban and rural population. Statistical Analysis Used: We estimated proportions and tested for significant differences by residence, smoking status, literacy level and employment level by means of the chi-square statistics. Statistical software SPSS for Windows version 20 was used for analysing data . Results: The overall prevalence of current smoking among study participants was 25%. Around 96% were aware of the fact that smoking is harmful to health, 45% viewed second-hand smoke to be equally harmful as active smoking, 84.2% knew that smoking is prohibited in public places and 88.3% wanted the government to take strict actions to control the menace of public smoking. Multivariate logistic regression analysis showed that people aged 20 years and above, unemployed, urban, literate and non-smokers had significantly better perception towards harms of smoking. The knowledge about smoke free provisions of COTPA was significantly better among males, employed individuals, urban residents, and literate people. Conclusions: There was high knowledge about deleterious multi-dimensional effects of smoking among residents and a high support for implementation of COTPA. Efforts should be taken to make Mohali a "smoke-free district".
Keywords: Cigarette and other tobacco products act, public opinion, smoke-free legislation, smokers
|How to cite this article:|
Goel S, Singh R J, Sharma, Singh. Public opinion about smoking and smoke free legislation in a district of North India. Indian J Cancer 2014;51:330-4
| » Introduction|| |
Countries worldwide have enacted smoke-free laws for their citizens. ,,,,,,,, India is actively involved in combating the menace of tobacco by enacting a Control of Tobacco Products Act (COTPA) which prohibits smoking in public places, bans advertisement of tobacco products etc. 
In Northern India, Chandigarh city and District Shimla were declared as smoke-free in the year 2007 and 2010 respectively. , The state of Punjab also enacted this smoke-free act in letter and spirit with 'The Govt. of Punjab resolved to strictly implement COTPA including Smoke-free provisions in the state'. Against this background, the present study was carried out with an objective to gain insight into public perceptions about smoking and in turn about COTPA implementation in public places of district Mohali in Punjab.
| » Materials and Methods|| |
A cross-sectional study of persons aged fifteen years and above residing in Mohali district was carried out in October 2011. This district of North India has a population of 986, 147 as per census of India 2011. The questionnaire was anonymous and administered by trained researchers. It was pilot tested in respondents of similar background residing in the capital city of Punjab. Smoking behaviour was assessed by asking respondents if they smoke currently or do not smoke at all. Perception of smoking was assessed by asking respondents to indicate whether they agreed or disagreed with statements about smoking being harmful, whether it is an economic burden for a smoker, and whether it gives pleasure. In order to assess perception about smoke-free law (COTPA), respondents were asked to indicate, to the best of their knowledge whether they knew smoking is banned in public places and about the enforcing agency for this act. Their attitudes towards the law were assessed through the level of agreement with statements about the law like whether smoke-free law saves lives and whether the government should act hard to implement it effectively. The smokers and non-smokers in the study were defined as per GATS survey. 
A sample size of 1534 individuals aged fifteen years and above was calculated assuming 50% respondents were aware about smoke-free law and harms of smoking, at 95% confidence interval (α = 0.05) and margin of error 2.5%. Three community development blocks of Mohali district were enlisted followed by listing of villages and towns in the respective blocks. Later, villages and towns were randomly selected using simple random sampling technique. Probability Proportional to Size (PPS) technique was used for selecting the number of individuals to be interviewed from each block and also from urban and rural population. Kharar Block, being the largest block (almost half of total population of Mohali District), was highly represented in the sample (n = 800); followed by Derrabassi (n = 500) and Majri (n = 234) blocks. The study subjects were selected by convenience sampling, wherein, the researcher stationed themselves at the exit points of predetermined public places (educational institutions, hotels/bars/restaurants, health care centres, government offices, transit sites) and interviewed all those who consented for the study. After explaining the objectives of the study, the researcher presented questions as per the questionnaire. After completing the questionnaire with the current respondent, the next respondent was interviewed. The respondents were ensured anonymity and confidentiality of his/her information. The average time for interviewing each participant was 20 minutes.
We estimated proportions and tested for significant differences by residence, smoking status, literacy level and employment status by means of the chi-square independence test. Differences among groups were considered statistically significant at P < 0.05 level. Logistic regression was done to adjust for common confounders like age, gender, literacy, residence and employment status. Statistical software SPSS for Windows version 20 was used for analysing data. The study was approved is by institute ethics committee.
| » Results|| |
The actual number of completed interviews was 1600. [Table 1] shows the socio-demographic characteristics of study participants. The mean age was 32.8 years; 13.8% were illiterate and 20.9% were currently not employed. The overall prevalence of current smoking among the study participants was 25.4%. There were significantly more current smokers in urban area (30.0%) as compared to rural areas (15.6%).
Nearly 65% of the participants opined smoking is not a pleasure. Significantly more non-smokers were of this opinion as compared to smokers. Almost all (96%) agreed that smoking was harmful to health. Around 45% respondents felt that exposure to second-hand smoke is equally harmful as active smoking; the statistically significant difference was found between urban and rural smokers and between smokers and non-smokers. Participants did not consider smoking as a part of the culture they belong to. Most (88.3%) of the study participants wanted government to take hard actions to control this evil. The perception about ill effects of smoking was significantly higher among urban population as compared to rural counterparts. Significantly more non-smokers viewed smoking a harmful activity as compared to smokers [Table 2].
|Table 2: Perception about smoking among residents of district Mohali, Punjab |
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Most (84%) of the study participants were aware that smoking was banned in public places. Very few (19%) knew about its enforcement agency. Nearly two third of the participants had seen people smoking in public places (violation of COTPA act). Half of them knew about the fine for violation of COTPA act. Around 77% participants perceived that effective COTPA implementation would save lives and 89% supported COTPA. A statistically significant difference in most of the parameters of perceptions regarding smoking and COTPA was observed with respect to residence, smoking status, literacy level and employment. More non-smokers were aware of the act as compared to smokers. The participants felt that enhanced display about COTPA through media, advocacy and its strict enforcement should be done for effective implementation of the act [Table 3].
|Table 3: Perception about COTPA act among residents of district Mohali, Punjab |
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Education was associated with better knowledge of the fact that smoking is harmful and is an economic burden. Higher proportion of literate study subjects were aware of the smoking ban in public places and wanted government to take hard actions to control smoking. Higher proportion of employed individuals (86%) as compared to unemployed (77%) were aware of the fact that smoking is banned in public places [Table 2] and [Table 3].
The multivariate logistic regression model showed that people aged 20 years and above, unemployed, urban, literate and non-smokers had significantly better perception towards harms of smoking. The knowledge about smoke-free law was significantly better among males, employed individuals, urban residents , and literate people [Table 4].
|Table 4: Multivariate logistic regression model for ascertaining predictors of perception towards harms of smoking and knowledge about smoke free law |
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| » Discussion|| |
Smoking prevalence in our study was 25.4% in people aged fifteen years and above. This data is not in congruence with GATS-India (2009-10) data wherein 6.9% of the adults of Punjab were reported as current smokers.  NFHS-3 survey concluded that 32% of the Indian adults were current smokers.  Gupta et al. in his study in Rajasthan found that 51% of men and 5% of women smoked tobacco.  Kutty et al. in a study in South India reported smoking prevalence rate to be 21.8%.  This relatively wide range of smoking prevalence estimates can be attributed to differences in the socioeconomic, cultivation and other factors in different locations of the studies.
In our study there were more smokers in rural area as compared to urban areas. This finding may be explained by the multivariate logistic regression model applied in the present study, where people in rural areas were less aware of the harms of smoking as compared to urban counterparts. NFHS 3 survey further affirmed that active smoking was comparatively more among people living in rural areas as compared to urban counterparts. 
Risk perceptions were widely regarded by scholars to play an important role in the initiation and maintenance of cigarette smoking. The majority of smokers in this study had a negative opinion of smoking. Similar to our finding, a study on awareness of the health risks of smoking in urban and rural areas of the two states of India observed that the majority of smokers agreed that smoking was 'not good' for their health. 
In our study, non-smokers viewed smoking as a harmful act and as an economic burden as compared to smokers. Similar to our findings, a population-based study from China about smoking concluded that current smokers were less likely than non-smokers to acknowledge the consequences of smoking.  Ma G in his study on perception of risks of smoking among Asian Americans concluded that never smokers held more negative perceptions regarding smoking compared to current smokers.  A US national telephone survey also observed that smokers underestimated their relative risk compared to non-smokers. 
We found that 96% were aware of the fact that smoking is harmful to health and 45% viewed second-hand smoke to be equally dangerous as active smoking. Nearly similar findings were reported a study done by Desai KT on tobacco smoking patterns, awareness and expenditure in the state of Gujarat, India.  After controlling for other variables, rural residents were less aware of harms of smoking as compared to urban counterparts in our study. A possible cause may be that rural residents have limited access to information, and thus they might not be aware of the harmful effects of tobacco and about smoke-free act; to the extent of urban counterparts. Further, urban respondents were more aware about the ill effects of second-hand smoke. Similar finding was observed by Yang in his study among adults in China, wherein he reported that 64.3% of respondents were aware of the consequence of second-hand smoke; also more urban participants were aware of it as compared to rural counterparts. 
Nearly 90% of respondents in our study supported smoke-free law COTPA. Around the world, countries which successfully introduced smoke-free laws have witnessed widespread public support for it. A survey carried out in Latin America showed that more than three fourth respondents supported smoke-free public places.  In Scotland, smoke-free legislation was widely supported both prior to and after implementation of the ban. 
The perception towards COTPA act in our study was significantly better among non-smokers as compared to smokers. A study done by Sharma I on awareness regarding implementation of the tobacco product law in Assam, reported that nearly half of our participants had a better awareness of COTPA and more than three-fourths of them had an overall positive attitude toward COTPA.  Nonusers of tobacco had a significantly higher positive attitude toward COTPA as compared with their counterparts. A study organized by WHO to determine the smoking habits, knowledge and attitude towards tobacco control of health professionals found that smoking study subjects have less favorable attitude towards tobacco control compared to non-smokers. 
In our study more urban residents as compared to rural counterparts supported smoke-free law. This finding could be due to the fact that urban residents were more likely to recall media messages about the act. Similar to our finding, an Australian study reported that urban dwellers were more supportive of smoke-free laws than rural dwellers.  Contrary to our finding, Rayens concluded that more rural residents than those in urban settings support a law for smoke-free public places. 
In the present study, education was significantly associated with better knowledge of the fact that smoking is harmful and is an economic burden. Higher proportion of literate study subjects were aware of the fact that smoking is banned in public places and wanted government to take hard actions to control the smoking epidemic. The results are consistent with other studies which also showed significant difference in knowledge regarding active and passive smoking with respect to education. , More employed individuals knew about that smoking is banned in public places as compared to unemployed. Employed people usually travel distances and visit several places thus accounting for more awareness about the act.
Humans learn most cultural traits by observing their peers. India's culture is about its unique qualities that have evolved and survived time. The finding from the present study that most respondents perceive smoking is not a part of our culture is a step in making this district of North India smoke-free.
The strength of the present study was the large sample size and wide representation of all public places of the study area. There were certain limitations of our study. The study was conducted in public places in Mohali district and hence, cannot be generalized to all people in Punjab. Smoking is a socially and culturally unacceptable habit; hence, people are less likely to report it which may lead to underreporting and in turn to decrease prevalence. This study used convenience sampling for selecting study subjects in public places which may lead to selection bias.
The study concluded that there was high knowledge about deleterious multi-dimensional effects of smoking among residents and a high support for implementation of COTPA. Efforts should be made to make Mohali a "smoke free district". Further, some prevention initiatives to target smoking initiation among youth and smoking cessation should be directed at rural residents.
| » Acknowledgment|| |
Authors acknowledge the technical guidance and financial support of Bloomberg Initiative To Reduce Tobacco Use and The Union South-East Asia, the regional office of International Union Against Tuberculosis and Lung Disease (The Union) for conduction of this study. The authors declare no conflict of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]