Awareness of harmful effects on tobacco smoking among adult male smokers in Sri Lanka: a cross sectional study

INTRODUCTION

Smoking is an important risk factor for many cancers of the body, cardiovascular and respiratory diseases, stroke, blindness, osteoporosis, and peripheral vascular disease. Globally 1.1 billion people smoke tobacco products and 6 million people lose their lives each year.¹ Majority of People smoke tobacco products to relief stressful conditions, and they have higher anxiety compare to non-smokers.² In addition, loss of productivity and health-care expenditures causes negative impact on the individual, family and society level.³ Smoking increases the risk of underdevelopment of the foetus and neonatal death as well as child mental health problems and reduces fertility in both women and men.⁴

Tobacco consumption has fallen substantially over the past 30 years in many industrialized countries as a result of increasing the awareness of the hazards of tobacco usage and the implementation of aggressive and effective tobacco control policies.⁴ In contrast, over the same time period, tobacco consumption has been increasing in the developing world.⁵ Cigarettes are the most widely consumed tobacco product among Sri Lankan smokers. In addition, Beedis, White Beedis and Black Cigars are also popular, especially among low income groups and people in rural areas. Information of the awareness of harmful effects of smoking among Sri Lankans was sparse. The aim of the present study was to determine the awareness of adverse effects on health from smoking among adult male smokers.

METHODS

A cross sectional study was conducted in Gampaha district from June to December 2017. The sample size was calculated using the equation of n=z² p (1-p)/d² where n=sample size, z=1.96; Critical value of specified confidence, at 95% confidence interval, p=Probable estimate of proportion of the prevalence percentage of tobacco smoking among males in Sri Lanka (29.9%), 6 d=5% of accepted amount of the absolute error. Minimum sample size of the study was 330. Sample is further increased to allow irresponsive participants and to compensate recording errors. A final sample size of 365 was obtained after a 10% non-response rate. Therefore, 365 adult males were recruited for this study. Preliminary visits were made by the research team to the selected area to select smoking individuals randomly with the help of the regional health officers. Males aged below 18 years, and have cognitive impairments were excluded.

Data collection

Before implementing the study, written consents were obtained from all the participants. Before implementing the study, the participants were informed of the nature of the study and those who volunteer to participate in the study were provided with an information sheet and an informed consent form. The subjects were given enough time to read and understand about the study and to further clarifications. All participants were informed that the participation was voluntary and have a right to refuse or withdraw any time from the study. After taking their consent, the subjects were recruited for the study. An interviewer administered questionnaire was used to collect the awareness of harmful effects and related diseases on smoking. The questionnaire was initially developed in English and then translated into the native languages of participants (Sinhala and Tamil).

Data collection was carried out with the support of the field research team. The research team was trained prior to the study on all aspects of data collection and their role by a behavioral psychologist. The data was collected from participants at their residencies to allow freedom for them to react. All data were kept confidentially.

Statistical analysis

All questionnaires were numbered and the data that collected were entered the MS Excel 2010. Data was analyzed descriptively and statistically with percentages and 95% confidence interval (CI) were calculated using SPSS Version 23. Continuous variables were reported as means whereas categorical variables were reported as proportions. Logistic regression was used to determine significant association between socio demographic characteristics with the awareness of harmful effects of smoking. The odds ratio (OR) with 95% CI was used and p value less than 0.05 was considered statistically significant.

Ethical consideration

Ethical approval for the study was obtained from the Ethics Review Committee, Faculty of Medicine, General Sir John Kotelawala Defence University. Permission from both Provincial Director of Health Services and the Regional Director of Health Services at Gampaha district was obtained to conduct the study in Gampaha district. After explaining the aims and objectives of the study and ensuring the confidentiality of responses, informed verbal and written consent was obtained from all participants. Tablet computer-based data entry system was used to gather the information. This made it unnecessary to make a separate data entry process and that minimized wrong entries thus improving the quality of the data. Patients were informed that any payments or financial benefits would not be given to them for participating the study. If the procedure changed, new methods would be explained to the participants and informed consent forms will be obtained again from each participant.

RESULTS

A total of 365 married male smokers (mean 43.3, SD=11.5 years) and their spouses (mean 40.2, SD=11.1 years) were participated in this study. Seventy six percent smokers were regret about starting smoking in their school time and could not stop smoking in school life. More than 90% of individuals were got to know adverse effects of smoking through printed and electronic media. In addition, majority of the study participants have seen health warnings on cigarette packages. Nearly one third of male participants stated that health warnings caused to think about quit smoking.

Among male respondents, majority were aware the tobacco is causing illnesses such as stroke (60.8%), heart attack (86.0%), peripheral vascular diseases (60.5%), lung cancer (96.2%), lung diseases (87.9%), impotence (60.3%), infertility (49.6%), birth defects (47.1%), premature births (45.8%) and respiratory diseases among children (58.4%). Majority of the female participants also were aware about tobacco causes illnesses like stroke (61.9%), heart attack (85.2%), peripheral vascular diseases (58.6%), lung cancer (93.7%), lung diseases (87.7%), impotence (65.5%), infertility (49.0%), birth defects (43.8%), and respiratory diseases among children (55.9%) (Table 1).

In the present study, a total of 69.8% males were daily smokers while 30.2% were not daily smokers. Majority of the male smokers (95.3%) were aware that tobacco smoking is injurious to their health. In addition, most of participants (93.4%) were reported that passive smoking is also causes illness to themselves and others. Majority of participants obtained the awareness of adverse effect of smoking from social services and health clinics during past 12 months. More than 90% of individuals were aware of adverse effects of smoking through printed and electronic media. Majority of smokers were aware that tobacco smoking causes diseases such as stroke, heart attack, peripheral vascular diseases, lung cancer, lung diseases, impotence, infertility, birth defects, premature births and respiratory diseases among children. However, the awareness regarding cataract and blindness was low (Table 2).

Seventy six percent smokers were regret about starting smoking in their school time and could not stop smoking in school life. Nearly one third of male participants stated that health warnings caused to think about quit smoking. During past 12 months, 50.1% of participants were trying to quit smoking due to self-awareness of harmful effects and/or the influence from the family, friends or relatives.

Participants aged less than 50 years, and have more than secondary education showed higher awareness than old and low education level people. In addition, employed and high monthly income people have more awareness of harmful effects unemployed and low-income people.

Interestingly, participants who smoked tobacco products first after 18 years old, more than 10 times of smoking per week and the people having more than 10 smoking friends have more awareness of health risk of smoking compared to people who have less than 10 smoking friends and less than 10 smoking times per week (Table 3).

Multivariate logistic regression identified that number of smoking friends, number of smoking per week, monthly income and first exposure of smoking were significantly associated with the awareness of health risk of smoking (Table 4).

DISCUSSION

The majority of smokers believed that smoking causes cardiovascular disorders, lung cancer and lung illnesses caused by smoking. Tobacco is an addictive substance and response to increased prices will occur more slowly than for non-addictive goods. Tobacco smoke contains carbon monoxide (CO). It displaces oxygen from hemoglobin molecules and lead to hypoxia. The nicotine in tobacco smoke cause to increase the risk of cardiovascular disease.⁷ Gene mutations and changes of genetic and molecular materials were induced by exposure to tobacco smoke.

Majority of smokers have a good awareness about diseases. Similarly, several studies have reported that smokers were more aware health effects from smoking such as cancers and cardiovascular diseases.^5,8 However, considerable numbers of participants have no idea of the association to cataract and blindness. Awareness regarding heart disease, peripheral vascular disease and infertility was low. Similarly, several studies in South Asia reported that most of the tobacco users (>80%) were aware of the hazardous effects of tobacco.^5,9 More than 75% of smokers in South Asian countries have higher awareness regarding, cardiovascular disorders, lung cancer and lung diseases.^5,9

In Sri Lankan profile, 29.9% of male population is smokers.¹⁰ Majority of participants were aware that smoking has harmful effect to both the smokers as well as the people around them. Exposure to second-hand smoke carries a significant risk for both children and women.^11-13 Thus, non-smokers who are exposed to a smoky environment have an increased risk of lung cancer, ischemic heart disease, and asthma.¹⁴ Similarly, studies in several countries revealed that more than 80% adults agreed that active smoking and exposure to secondhand smoke causes serious illness.^15-17 No proper guidance and less approachable tobacco cessation programs on smokers were major causes for passive smoking. Therefore, smokers should be advocated about the adverse effect of passive smoking and instruct them not to smoke in front of nonsmokers.

Majority of respondents had known the adverse effects of tobacco smoking through television, radio, internet, posters, newspapers, magazines and movies. Another study in Sri Lanka reported that 87.9% of smokers in North Central region noticed anti-smoking massages during past six months through telecommunication.6 Although all of the smokers were seen the warning signs of cigarette packages, majority of them were not much considered about the meanings of those pictorial warnings.18 Therefore, government legislation of warning signs on cigarette packages (80% from the cigarette package) was not very much affected by the reduction of tobacco smoking.¹⁹

Chemical agents of cigarette smoking negatively effect on spermatogenesis thus finally reduces human fertility.^20,21 Smoking reduces estrogen level and causes menstrual irregularities and attains early menopause of women.²² The smoke adversely effects on foetus when mothers expose cigarrate smokes during pregnancy resulting premature birth, low birth weight and ectopic pregnancy.²³

Smoking cessation improves quality of life and drastically reduces the risk of cardiovascular and lung diseases as well as cancers in various organs.^24,25 Educating schoolchildren about the adverse effects of smoking can be achieved the reduction of prevalence of smoking in their adult age. In the present study, large numbers of smokers were not aware of the harmful effects of smoking in their school life. Awareness programs of adverse effects on smoking should be implemented more for school children to provide opportunities with linkages among teachers and health professionals and to encourage them to quit smoking and to maintain an optimal health.²⁶ It will helpful to reduce the prevalence of smoking among adolescence and young adults. In addition, lower socio-economic people should be educated more about the adverse effect of active and passive smoking.

In Sri Lanka, primary health care workers play a significant role in informing the public of the dangers of cigarette smoking although when designing the anti-smoking campaigns to the public it should be scientifically credible and the facts should be consisting in a more understandable manner. We suggest that all the primary health care workers take individual assessment regarding client’s smoking behavior.

CONCLUSION

The knowledge of harmful effects and disease conditions related to tobacco smoking in adult males was in a good level. Community awareness programs must be held targeting all the population in rural and urban areas and making them aware about the harmful effect and disease conditions of tobacco use. Anti-smoking campaigns must be initiated in a broad manner, specially targeting the smoking population. This will be provided a positive impact on public awareness in harmful effect and socioeconomic factors which is associated with tobacco smoking in Sri Lanka. Individual counseling might help in achieving the purpose of reducing the tobacco use.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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