Knowledge, attitude and practice regarding various tobacco products and their effects on health and COTPA act among ≥15 years age group persons in urban field practice area of a medical college in Telangana

INTRODUCTION

Tobacco contributes to 5 million deaths per year globally. According to World Health Organization (WHO), tobacco kills more people annually than AIDS, alcohol, other addictions (drugs) and accidents put together and this figure is expected to rise to 10 million tobacco deaths annually by 2025. 500 million die prematurely due to tobacco use; most of these are children and young adults of today.¹

One-fifth of all worldwide deaths attributed to tobacco occur in India; more than 8,00,000 people die and 12 million people fall ill due to tobacco use each year.¹ By 2030 it is expected to kill more than 9 million people per year; of aged 35-69. The epidemic is increasingly affecting developing countries, where most of the world’s smokers (84% or 1billion) live. Close to half of all men in low-income countries smoke daily and this has been increasing. Many deaths and much disease could be prevented by reducing smoking prevalence.

Tobacco addiction is the most widespread addiction in the world. There are nearly 1.3 billion smokers in the world, 80% of them are in the developing countries. India has more than 300 million smokers. Tobacco use is the leading cause of death in the world. On an average, every user of tobacco loses 15 years of life. Total tobacco-attributable deaths from ischemic heart disease, cerebro-vascular disease (stroke), chronic obstructive pulmonary disease and other diseases are projected to rise from 5.4 million in 2004 to 8.3 million in 2030, almost 10% of all deaths worldwide.²

Tobacco is the only legally available consumer product which kills people when it is used entirely as intended.³ If we look at the prevalence and mortality of tobacco use in a population over time, we saw the image of a social epidemic. It is highly contagious at various times to various groups and some population groups abandon it. Social norms do not totally explain the phenomenon of tobacco use, nor do nicotine addiction, personality traits, psychological needs, genetics, history and economic structure of the community or the latitude for marketing tactics by the tobacco industry.

Several negotiations later, the World Health Assembly in May 2003 finally adopted the Framework Convention on Tobacco Control (FCTC), which has provisions for members to have comprehensive legislation to curb the tobacco epidemic.⁴ India was one of the first few countries that ratified the FCTC. The Government of India formulated “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 regarding COTPA provisions were notified. As per the act, smoking is prohibited in all public places, ban is placed on advertisements of tobacco products, and prohibition of sale of tobacco products to minors and within 100 yards of educational institutions.⁵

The implementation of this law remained largely ineffective in the initial years. The Government of India reviewed the situation and revised the law, with effect from 2^nd October 2008, making additional provisions to improve the implementation of smoke free law.⁶ Not many studies have been done on awareness and attitudes of the general public regarding Cigarettes and Other Tobacco Products Act (COTPA).

For effective implementation of tobacco control knowledge regarding the awareness, attitudes and practices of the population towards tobacco control is necessary. Hence a humble attempt was made to do this study.

Aim and objectives of the study was to assess and study KAP regarding tobacco use and COTPA, 2003 in Urban slums of Nalgonda, to study the proportion of tobacco use among individuals aged more than 15 years age group in urban field practice area of KIMS, to study the association of socio demographic factors and tobacco use among the study group, to assess the awareness towards anti- tobacco measures imposed under cigarettes and other tobacco products act 2003 and to assess the attitude towards anti- tobacco measures imposed under cigarettes and other tobacco products act 2003.

METHODS

The present study was community based cross sectional study conducted between July 2017 and August 2017. The study was conducted in urban field practice area of Kamineni Institute of Medical Sciences, Narketpally. According to pilot study done in the urban slum field practice area, awareness about among men in the age group >15 years was 47.5%. Using this prevalence, we calculated the sample size with the following formula,

n = (Zα)²pq/L²

where,

n = minimum sample size

p = prevalence in percentage

q = 100-p

L = allowable error in percentage of prevalence.

Zα = Z0.05 = 1.96 (Approximately = 2)

(Zα)² = (Z0.05)² = 4

Using the above formula and data,

p = 47.5

q = (100 –47.5) =52.5

L = 10% of p = 10% of 47.5 = 4.75

Sample size (n) = 4x47.5x52.5/4.75x4.75 = 242

Simple random sampling was done, the sample size has been rounded off to 300. Data was collected from all the persons aged more than 15 years who were residents of the study area.

Inclusion criteria

All the persons aged more than 15 years and above who give consent to participate in the study.

Exclusion criteria

Those who are not willing to participate in the study, those who could not be contacted even after three visits were excluded from the study. Pre-tested, semi structured questionnaire was used as study tool and data collection was done by face to face interview. Baseline data was collected on socio-demographic profile of the subjects, consumption of smoking, type of smoking, their knowledge, attitude and practices regarding antitobacco measures imposed under COTPA 2003.

Statistical analysis

Data was entered into Microsoft excel sheet and various variables were coded. It was then analyzed using SPSS version 24. Data is represented as tables; proportions; pie charts. Chi-square test was done wherever appropriate, p<0.05 is taken as statistically significant.

Ethical considerations approval from Institutional ethics committee of KIMS, Narketpally has been obtained before the commencement of the study.

RESULTS

In this study, 300 subjects above age 15 yrs. were interviewed but only 293 subjects gave consent to participate. Among them, 54.3% were non-smokers and 45.7% were current smokers (Figure 1).

Among smokers, majority 35.8% belongs to 15-30 years age group, 83.6% were male, 94% were Hindus, 76.9% were married, 58.8% were living alone, 50.7% were illiterate, 75.4% were un-employed and 29.9% belongs to upper lower class of socioeconomic status according to modified B.G. Prasad classification, 2018. Majority of non-smokers, 32.1% belongs to 15-30 years age group, 25.2% were female, 92.5% were Hindus, 71.1% were married >50% belongs to nuclear and joint families, 69.8% were literate and 32.1% were employed and 34% belongs to lower middle socio-economic status. Statistically significant association was observed between smoking status and age, marital status, education, occupation and socio-economic status (Table 1).

Awareness about COTPA

Analysis of the study population showed that 58.02% were aware of the COTPA 2003, awareness regarding anti-tobacco measures showed that 80.2% knew that smoking was prohibited in public place, 49.8% knew that there was an age limit below which sale of tobacco products was banned and 63.8% knew that there is a ban on sale of tobacco products near educational institutions. Source of information were newspaper (18.23%), television (77.05%), health personnel (2.94%) and others (1.76%) (Tables 2 and 3).

Smoking and COTPA

Majority of smokers (53.7%) were aware about COTPA, 2003, while it was about 61.6% among non-smokers. Television was the major source of information about COTPA, 2003 among smokers (76.38%) while in non-smokers only 77.55%. This was followed by newspaper 15.27% among smokers and 20.4% among non-smokers (Table 2). Among smokers, 24.6% were not aware about section 4 of COTPA, 2003 act, while it was only 15.7% among non-smokers. 58.2% of smokers and 43.4% of non-smokers were not aware about section 6a and 47.8% of smokers and 26.4% of non-smokers were not aware about section 6b of COTPA, 2003. Statistically significant association was observed between knowledge about COTPA, 2003 and smoking status (Table 3). 53.7% of smokers were having negative attitude towards sections 7, 8, 9 of COTPA, while 40.3% of non-smokers were having positive attitude and this association was observed to be statistically significant (Table 4).

Majority of smokers (10.4%) have paid penalty for violating COTPA act, while 8.8% of non-smokers also have paid penalty. Out of 170 subjects who were aware about COTPA, 11.2% of smokers have paid penalty for violation of act, while it was only 7.3% among non-smokers and this association was observed to be statistically significant. When asked about changes in the habits of smoking use after implementation of COTPA, 2003, 55.3% expressed no change in their habits, while 32.4% have noticed reduction in the usage of tobacco to some extent, while 8.2% expressed that they totally quit tobacco usage after implementation of COTPA act, 2003 and this association was observed to be statistically significant (Table 5).

DISCUSSION

In the present study, prevalence of smoking was 45.7%, which was higher than study by Annadurai et al and Harris et al, this showed the depth of the problem.^7,8 According to Rani et al, tobacco usage increases with increase in age.⁹ In our study population there was a biphasic trend in smoking pattern i.e., the prevalence of smoking was 35.8% between 15-30 years, decreased to 22.4% in between 31-40 years and increased to 23.9% for those between 46-60 years of age i.e., prevalence was more among younger and older age groups. Similar biphasic trend was observed in study by Annadurai et al.⁷

Prevalence of smoking was more common in illiterates than well-educated. This report was similar to the findings from NFHS-310, Rani et al, Harris et al and Narayan et al.^8-11 In our study population there was no significant association between smoking and type of family. Smoking status was found to be significantly associated with age group, education, marital status, occupation and socio-economic status. Similar findings were observed in study by Annaduarai et al, Rao et al, and Sharma et al.^7,12,13

Awareness about COTPA

Studies done in Andhra Pradesh and Assam in India have reported awareness of COTPA as 47.5 and 45.7% respectively.^12,13 Our study analysis showed that 58.02% were aware of the COTPA 2003, which is higher than these studies but lower than study by Annadurai et al and Rakesh et al.^7,17 Awareness regarding anti-tobacco measures showed that 80.2% knew that smoking was prohibited in public place, 49.8% knew that there was an age limit below which sale of tobacco products was banned and 63.8% knew that there is a ban on sale of tobacco products near educational institutions. These findings were lower than findings from Annadurai et al study.⁷

Smoking and COTPA

Among smokers 53.7% were aware of the act and most of them, i.e. 75.4% of smokers were aware about the ban on smoking in public places. In addition, 10.4% of smokers were fined for violating the ban on smoking in public places. Regarding quitting, 32.4% of them reported that their smoking habit got reduced because of the anti-tobacco measures under the act. These findings were lower than study by Annadurai et al.⁷ In countries with pictorial health warnings, such as Canada and Australia, these numbers were higher: more than 40% of Canadian smokers reported that the pictorial warnings have motivated them to quit smoking; in Australia, picture warnings have supported 62% of former smokers in their efforts to quit.¹⁴ In our study, 8.2% reported that they had totally quit smoking because of fine due to violation but majority of them, i.e. 55.3% reported that act did not have any impact on their smoking habit, which was higher than a study in Tamil Nadu.⁷

In general, there was a positive attitude towards COTPA, despite of having lower awareness regarding the same. 34.8% of them favoured use of pictorial health warnings. These findings of the present study were lower than that of other studies probably due to different study settings.^12,15,16

CONCLUSION

The study concludes that the prevalence of smoking was higher than the Indian national average. Nearly half the participants had awareness of COTPA and nearly two thirds had an overall positive attitude towards COTPA. Most of the smokers felt that anti-tobacco measures imposed under the act did not have any impact on their smoking status. Hence a concerted effort has to be made to increase the awareness of the Act amongst the vulnerable population, i.e., younger population, people from lower SES, and less educated people. The policy makers should consider newer options such as starting a help line for quitting tobacco to regulate the use of tobacco with consideration that most of the smokers were reluctant in quitting tobacco even after the implementation of various anti-tobacco measures under COTPA. Apart from these steps, counselling sessions have to be arranged for those tobacco users who are reluctant to quit. To conclude, the steps taken by the government bodies in the future should be strictly followed and it should be continuously monitored.

Limitations

The present study was a cross-sectional community based undertaken in an urban slum area, hence the findings may not be extrapolative to rural and urban populations.

Funding: No funding sources

Conflict of interest: None declared

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

REFERENCES

1. 1. Resource centre for tobacco free India; an initiative of Voluntary Health Association of India. Available at http://rctfi.org/goi_initiatives1.htm. Accessed on 22 February 2018.
2. 2. Tobacco control foundation of India, Tobacco facts. Available at http://tobaccoindia.org/ Tobacco-Facts.html. Accessed on 24 September 2017.
3. 3. Walton J, Barondess JA, Lock S. The Oxford Medical Companion. 1^st edition. USA. Oxford University Press. 1994.
4. 4. WHO Framework Convention on Tobacco Control, WHO, Geneva, Switzerland. Available at http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf. Accessed on 2 December 2017.
5. 5. The cigarettes and other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003. New Delhi, India: Government of India. 2003.
6. 6. The cigarettes and other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, Amendment Bill, 2007. New Delhi, India: Government of India, 2007.
7. 7. Annadurai K, Mani G, Dhanasekaran R. Tobacco usage among males in Rural Tamil Nadu, India: a cross-sectional study. Int J Med Stud. 2014;2(1):18-21.
8. 8. Harris M, Buerhaus P, Needleman J. Prevalence of smoking in China in 2010. N Engl J Med. 2011:364(25):2469-70.
9. 9. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross-sectional household survey. Tob Control. 2003;12(4):1-8.
10. 10. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005-06. India, 2007
11. 11. Narayan KM, Chadha RL, Hanson R, Tandon S, Shekhawat R, Fernandes J, et al. Prevalence and patterns of smoking in Delhi: cross sectional study. BMJ. 1996;312(7046):1576-9.
12. 12. Rao AR, Dudala SR, Bolla CR, Kumar BPR. Knowledge attitude and practices regarding the cigarettes and other tobacco products act (COTPA) in Khammam, Andhra Pradesh. Int J Res Health Sci. 2013;1(2):96-102.
13. 13. Sharma I, Sarma PS, Thankappan KR. Awareness, attitude and perceived barriers regarding implementation of the cigarettes and other tobacco products act in Assam, India. Ind J Cancer. 2010;47(5):63-8.
14. 14. Hammond D, Fong GT, Borland R. Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. Am J Prev Med. 2007;32:202-9.
15. 15. Danishevski K, Gilmore A, McKee M. Public attitudes towards smoking and tobacco control policy in Russia. Tob Control. 2008;17(4):276-83.
16. 16. Schumann A, John U, Thyrian JR, Ulbricht S, Hapke U, Meyer C. Attitudes towards smoking policies and tobacco control measures in relation to smoking status and smoking behaviour. Eur J Public Health. 2006;16(5):513-9.
17. 17. Kumar R, Salve H, Misra P. Determinants of tobacco use and perception, attitude about an antitobacco act in rural Haryana, North India. Int J Med Public Health. 2014;4:367-70.