|Year : 2012 | Volume
| Issue : 4 | Page : 438-442
An assessment of the effectiveness of tobacco control measures on behavior changes related to tobacco use among adolescents and young adults in a district in Sri Lanka
WD De Silva1, DN Sinha2, A Kahandawaliyanag3
1 National Poison Center of Malaysia, University Sains Malaysia, Malaysia
2 Surveillance (Tobacco Control), WHO South-East Regional Office, New Delhi, India
3 Sustainable Development and Healthy Environments, WHO South-East Asia Regional Office, New Delhi, India
|Date of Web Publication||26-Feb-2013|
W D De Silva
National Poison Center of Malaysia, University Sains Malaysia
Source of Support: None, Conflict of Interest: None
Introduction: Sri Lanka became a signatory to the WHO Frame Work Convention on Tobacco Control in September 2003, and this was ratified in November 2003. With a view to reduce the use of tobacco in Sri Lanka, the National Authority on Tobacco and Alcohol Act (NATA) No. 27 of 2006 was implemented. Aim: To assess the behavior changes related to tobacco use among adolescents and young adults following exposure to tobacco control measures were implemented by NATA. Materials and Methods: A case-control study was conducted on 42 adolescent (aged 13-19 years) and 156 young adult (aged 20-39 years) men living in Anuradhapura Divisional Secretary area in Sri Lanka. Cases (current quitters) and controls (current smokers) were compared to ascertain the outcome following the exposure to tobacco control measures. A self-administered questionnaire and focus group discussions were used to ascertain the exposure status in cases and controls. Confounding was controlled by stratification and randomization. Univariate analysis was performed by Backward Stepwise (Likelihood Ratio) method. Results: Among 198 respondents, 66 (27.3% adolescents and 72.7% young adults) were quitters, while 132 smokers (18.2% adolescents and 81.8% young adults) were current smokers. Exposure to the anti-smoking media messages revealed that TV was the strongest media that motivated smokers to quit smoking. Majority (66%) of cases and control were not exposed to tobacco promotion advertisements, while 47% of the cases and 50% of the control had never seen tobacco advertisements during community events. All cases (66) as well as 89% (118) of the control had not noticed competitions or prizes sponsored by tobacco industry during last year ( P = 0.13). Conclusion: Tobacco control measures implemented by NATA had a favorable influence on behavior change related to smoking among quitters and current smokers.
Keywords: Adolescent, national authority on tobacco and alcohol, tobacco control, quitters, young adults
|How to cite this article:|
De Silva W D, Sinha D N, Kahandawaliyanag A. An assessment of the effectiveness of tobacco control measures on behavior changes related to tobacco use among adolescents and young adults in a district in Sri Lanka. Indian J Cancer 2012;49:438-42
|How to cite this URL:|
De Silva W D, Sinha D N, Kahandawaliyanag A. An assessment of the effectiveness of tobacco control measures on behavior changes related to tobacco use among adolescents and young adults in a district in Sri Lanka. Indian J Cancer [serial online] 2012 [cited 2020 Oct 25];49:438-42. Available from: https://www.indianjcancer.com/text.asp?2012/49/4/438/107753
| » Introduction|| |
Tobacco-related illnesses are the second biggest cause of deaths and disabilities from non-communicable diseases resulting in over 20,000 deaths annually in Sri Lanka.  According to the World Health Organization (WHO), the prevalence of smoking among men and women in Sri Lanka were 29.9% and 0.4%, respectively, in 2011,  as compared to 32.4% and 2.1% in 2006.  In another study, the prevalence of smoking was highest (44.6%) among 20-29 years age group, while it was15.6% in those below 20 years, and smoking was commonly associated with lower income and lower education.  The prevalence of current tobacco use among adolescents aged 13-15 years was 12.4% among males and 5.8% among females.  High particulate matter levels due to second-hand smoking in indoor public places in Sri Lanka were reported.  This kind of injurious influence occurs in home environment as about 40-59.9% youth lived in homes where they were exposed to second-hand smoke.  Sri Lanka ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003 and enacted Sri Lanka, National Authority on Tobacco and Alcohol Act (NATA) No. 27 of 2006. The National Quit line service was also established in Anuradhapura in 2010. 
This paper evaluates the impact of NATA on tobacco control and smoking cessation among adolescents and young adults after 6 years of implementation in Sri Lanka. Furthermore, it assesses (i) the current tobacco control measures adopted in Anuradhapura District, (ii) the knowledge, attitudes, and practices on tobacco use and tobacco control measures among adolescents and young adults in Anuradhapura district, and (iii) the effectiveness of tobacco control and smoking cessation programs (exposure) by comparing cases (the quitters) with control (current smokers).
| » Materials and Methods|| |
In two stages, a case-control study was conducted in Anuradhapura Divisional Secretary area of the North Central Province of Sri Lanka. Stage 1 was a cross-sectional study and using its data, Stage 2, a case-control study was conducted. The study population included adolescent (13-19 years) and young adult (20-39 years) males living in Anuradhapura Divisional Secretary area in Sri Lanka.
A cross-sectional survey was conducted among 456 adolescents and young adults.
Male adolescent students aged 13-19 years were selected from six secondary schools, three from the urban (Municipal area) and three from the rural (other Grama Sewaka [GS]) areas of Anuradhapura Divisional secretary area. These schools were selected by simple random sampling method from the list of schools in the Anuradhapura Divisional Education office. Students were also selected from these schools by the same method using the class registers.
Sampling of young male adults aged 20-39 years was on simple random sampling method based on district proportions published in the District Statistical Handbook, a publication of the Department of Census and Statistics, 2011.
Male below 13 years and above 40 years of age, male adolescents of 13-19 years of age, and male young adults of 20-39 years of age temporarily residing in Anuradhapura as well as females (since female prevalence of smoking is very low) were excluded.
A structured, pre-tested, self-administered questionnaire was used for data collection. Questionnaire consisted of four parts: Socio-demographic data, smoking history and smoking behavior, trigger for smoking and awareness and view of the respondents on tobacco control policies/regulations, and questions based on knowledge, attitudes, beliefs, and practices of smoking.
Attitudes towards smoking were measured using a four point Likert Scale ranging from strongly agrees to strongly disagree. The level of addiction to nicotine was measured using Fagerstrom tolerance questionnaire. The questionnaire was in the local language. Data collected by trained enumerators under the supervision of the Principal investigator (PI). Through focus group discussions (FGDs), data was collected qualitatively.
Based on the analysis of data from the cross-sectional study, cases and controls were identified. Cases were the current quitters and controls represented the current smokers. Current smokers include both daily and non-daily or occasional smokers and those who had smoked at least once in the past 30 days. Quitters were those who had not smoked during the past 30 days. Cases and controls were compared to ascertain the outcome following the exposure to tobacco control measures.
The sample size was calculated using the Schlesselman 1982 formula for multiple controls per case. The minimum sample size required was 128 (64 cases, 64 controls). As there were 151 current smokers, we proceeded with a 1:2 unmatched case-control study. Confounding was controlled by stratification and randomization.
Data was coded, entered, cleaned, and analyzed using SPSS and STATA. Cross-sectional comparisons of each category and between urban and rural areas were carried out. Quantitative data obtained from the survey was analyzed descriptively. The frequency of each of the measured variables in cases (quitters) and controls (current smokers) was calculated. The odds ratio was calculated in both the groups and the confidence interval for each odds ratio was calculated. Qualitative data collected was transcribed and analyzed according to the main themes. Univariate analysis was performed.
Approval was obtained from the relevant institutions to conduct the study. Respondents were informed about the research objectives, methods, and responsibility of the respondents, length of the time involvement, voluntary participation, and data management. They were also ensured about the confidentiality of the responses they provide. Verbal consent was obtained from the respondents. All the respondents participated voluntarily.
| » Results|| |
Stage 1-Cross-sectional study
A total of 456 male respondents participated, of which 37% were adolescents (13-19 years) and 63% (288) were young adults (20-39 years). Among the respondents, 60.5% lived in rural areas while 39.5% lived in urban areas.
Based on the smoking history, 48% (217) were ever smokers, while 239 (52%) had never smoked. Among the ever smokers, 66 (14 %) had already discontinued smoking, while 151 (33%) were current smokers.
As revealed by Karl Fagerstrom Nicotine Tolerance score, among the 151 current smokers, low level of dependence was observed among 70% ( P < 0.001), medium level of dependence among 18% ( P = 0.14), and high level of dependence among 12% ( P = 0.14).
Stage 2-Case-control study
Case-control study was performed among the above identified ever smokers (quitters and current smokers) in Stage 1.
Among the study sample ( n = 198) in this 1:2 unmatched case-control study, cases were the quitters ( n = 66) and control was the current smokers ( n = 132). Prevalence among 13-19 years age group was 12.1%, while it was 54.5% among 20-39 years age group.
Case-control comparison revealed a significant association between fathers smoking status ( P < 0.001) and employment ( P = 0.003) among current smokers [Table 1].
About 22% of cases (22.7%) had started smoking at the age of 14-15 years, while control (28.8%) had started at the age of 16-17 years. During the past week, among the control (current smokers), majority 58.3% (77) had smoked <10 cigarettes, while 16.7% (22) had smoked >20 on the days they had smoked.
The respondents "intention to quit" revealed that 44.7% of the controls planned to quit smoking during the next one month, 17.4% during next six months, 13.6% not during the next six months, while 11.4% did not plan to quit at all. When considering quitting attempts in the control group, 83.6% had previous quit attempts, while 16.4% had never tried to quit smoking, and 42% of the control had more than three previous quit attempts.
Among the cases, the susceptibility of smoking was very low as compared to the controls ( P < 0.001).
Exposure to tobacco control measures
Case-control comparison revealed that 95.5% of cases and 87.9% controls had noticed the anti-smoking media messages during past six months ( P < 0.001). Majority of the cases (93.9%) and controls (89.4%) were exposed to the above messages/information on TVs [OR = 0.54 (0.14-1.87) P = 0.29]as compared to radio [OR 1.22 (0.46-3.25) P = 0.66]. National Quit line service was utilized by 7.6% (5) of cases and 15.2% (20) of the controls (current smokers) in their quit attempts ( P = 0.13). Health warning on the cigarette packs had made them to think of health risks of smoking among 75.8% (50) of the cases and 88.6% (117) of the control ( P = 0.02). The opinion of 90% (54) of the cases and 91% (118) of the control was that the government should implement pictorial health warnings on cigarette packs in Sri Lanka ( P = 0.76). More than two of the three cases as well as the controls were not exposed to tobacco promotion advertisements on TV ( P = 0.82), radio ( P = 0.82), posters ( P = 0.79), billboards ( P = 0.69), and cinema ( P = 0.12). During sports events, trade fairs, or other community events, 31 (47%) of the cases and 50%(66) of the control had never seen tobacco advertisements ( P = 0.69). A total of 54 (82%) of the cases and 107 (81%) of the control strongly support the banning of sponsorship of sports and cultural activities by tobacco industry ( P = 0.89). The opinion of 74% (49) cases and 69% (92) control was that the enforcement of ban on tobacco advertising, promotion, and sponsorship was effective ( P = 0.51).
The effectiveness of banning tobacco sales to minors is believed as effective by 57.6% (38) of the cases and only 42.4% (56) of the control ( P = 0.51).
A total of 62% (41) cases and 55% (73) control responded that the enforcement on smoking ban in public places as effective ( P = 0.73).
The opinion of >92% of controls (122) as well as 88% of cases (57) was to increase the law enforcement ( P = 0.54) and to increase public awareness on smoking ban ( P = 0.22). The overall opinion among 98% of the cases and 94% of the control was smoking is bad ( P = 0.14).
Attitudes and beliefs
Positive social aspect of smoking
The control was more likely to perceive that smoking is a sign of being modern ( P = 0.003), it is acceptable for young men ( P = 0.04) and women ( P = 0.01) to smoke, and smokers have more friends ( P = 0.92).
Negative social effects
The control group (current smokers) was more likely to perceive that smoking is not disgusting ( P = 0.001) and less likely to perceive that Sri Lankan society disapproves smoking as compared to quitting ( P = 0.02).
Positive mental aspect of smoking
In relation to cases, the control (current smokers) was more likely to perceive that smoking make people relax ( P = 0.02), help to control body weight ( P < 0.001), and safe to smoke 1-2 years ( P = 0.04).
Negative appearance of smoking
The control (current smokers) was more likely to perceive that smoking does not make young people more mature as compared to cases ( P = 0.10).
Negative physical effects
The control was (current smokers) more likely to perceive that smokers do not have a harder time in sports as compared to cases ( P = 0.05).
Belief on tobacco industry
In relation to cases, the controls were more likely to perceive that cigarette companies do not lie about the danger of smoking ( P = 0.53), do not try to get young people to smoke ( P = 0.16), and do not use pretty young women for tobacco promotion ( P = 0.54).
Among the controls, 30 (22.7%) were not aware of the risk of lung cancer following the exposure to second-hand smoke as compared to 34.8% cases, while 28% of the control and 33.3% of cases were not aware of the possibility of blood clots in the brain due to smoking. A total of 27.3% cases as well as 31.3% of the control were not aware of the pregnancy-related complications following smoking.
Logistic regression analysis
The Univariate analysis identified some tobacco control measures that were significantly associated with quitting smoking (n = 66). A logistic regression analysis was carried out to identify tobacco control measures that contributed to quit smoking controlling for the effects of confounding. The regression equation correctly classified 84.8% of "Not quitting" and 53.0% of "quitting" for a total predictive efficiency of 76.3%. From 76.3%, it can initially be inferred that the logistic regression equation efficiently predicted the presence or absence of measures for tobacco control used among adolescent and young adult males in Anuradhapura District.
The sensitivity is given by 31/35 (88%) and the specificity is 116/132 (87.8%). Positive predictive value (PPV) by 35/51 (68.6%) and negative predictive value (NPV) by 116/147 (78.9%). The overall accuracy of this model to predict subjects' having quitting (with a predicted probability of 0.5 or greater) is 76.3%.
| » Discussion|| |
The prevalence of smoking any tobacco product among 13-39 years in this study was 33%. This shows a reduction by 5% as compared to 38% in 2010 by Katulanda et al.
TV was the strongest media that served advertisements or information on dangers of smoking or encouraging quitting. The Quit line service in Anuradhapura was minimally utilized for smoking cessation as the majority of the respondents were not aware of such a service. Among the current smokers and quitters, the knowledge on health risks of smoking and exposure to second-hand smoke was quite satisfactory. The current smokers as well as the quitters were well aware of the tobacco control measures implemented in Sri Lanka and they extended their support for the implementation of tobacco control measures.
Majority of the current smokers intended to quit smoking during next month and had low level of nicotine dependence, which was good indicator of successful quit attempts.
The current smokers as well as the quitters were well aware of the tobacco control measures implemented by NATA, which facilitated a favorable influence on behavior change on smoking among quitters and current smokers.
| » Conclusion|| |
Tobacco control measures implemented by the NATA had a favorable impact on motivating people to quit tobacco use. The TV was the strongest media source for information on ill-effects of tobacco use. Quitline services in Anuradhapura was least utilized as the majority of respondents were not aware of this service. It is noteworthy that the respondents were favorably inclined to quit smoking.
| » Acknowledgment|| |
We gratefully acknowledge the World Health Organization and Ministry of Health and Nutrition of Sri Lanka.
| » References|| |
|1.||Ministry of Healthcare and Nutrition, Government of Sri Lanka. Brief profile on Tobacco Control in Sri Lanka. Sri Lanka: Ministry of Healthcare and Nutrition; 2009:1-3. |
|2.||World Health Organization. WHO report on the global tobacco epidemic, 2011 Country profile: Sri Lanka, Geneva: World health organization (WHO) Press; 2011. |
|3.||WHO Report on the Global Tobacco Epidemic 2009: Appendix VII, Age-standardized prevalence estimates for WHO Member States; 2006. |
|4.||Katulanda P, Wickramasinghe K, Mahesh JG, Rathnapala A, Constantine GR, Sheriff R, et al. Prevalence and correlates of tobacco smoking in Sri Lanka. Asia Pac J Public Health 2011;23:861-9. |
|5.||Fact about WHO/CDC Global Youth Tobacco Survey (GYTS), World Health Organization; 2011. Available from: http://www.cdc.gov/tobacco/global/GYTS/results.htm. [Last accessed on ]. |
|6.||Percent of youth who live in homes where others smoke in their presence; 2003-2007. Available from: http://www.tobaccoatlas.org/downloads/maps/Chap9_Secondhand.pdf. [Last accessed on 2013 Januray 12]. |
|7.||Lee J, Lim S, Lee K, Guo X, Kamath R, Yamato H, et al. Secondhand smoke exposures in indoor public places in seven Asian countries. Int J Hyg Environ Health 2010;213:348-51. |