AWARENESS, ATTITUDE AND PERCEIVED BARRIERS REGARDING IMPLEMENTATION OF CIGARETTES...

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AWARENESS, ATTITUDE AND PERCEIVED BARRIERS

REGARDING IMPLEMENTATION OF CIGARETTES AND

OTHER TOBACCO PRODUCTS ACT IN GUWAHATI, ASSAM

Dr.Indrani Sharma

Dissertation submitted in partial fulfillment of the requirement for

the award of the degree of Master of Public Health

ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES (AMCHSS)

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND

TECHNOLOGY (SCTIMST)

THIRUVANANTHAPURAM

KERALA, INDIA

OCTOBER 2009

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ACKNOWLEDGEMENTS

Foremost, I would like to express my sincere gratitude to my guide Dr.K.R. Thankappan,

Professor and Head, AMCHSS for his supervision, advice and guidance throughout the

time of research and writing of this thesis. I could not have imagined having a better

advisor and mentor for my study.

This work would not have been possible without the support and encouragement of

Dr.Mala Ramanathan, Additional Professor, AMCHSS. I offer my special gratitude to her

for devoting her precious time and helping me out with the qualitative aspect of the study.

I extend my heartfelt thanks to Dr. AS Pradeepkumar for his valuable instructions and

suggestions throughout the study.

I would like to thank the entire faculty at AMCHSS: Dr. V. Raman Kutty, Dr. P. S.

Sarma, Dr. T K Sundari Ravindran, Dr K. Srinivasan, Dr. Biju Soman and Dr.Manju

R.Nair for providing their valuable suggestions to improve the study. I am also sincerely

thankful to Mr. Sundar Jayasingh, Deputy Registrar, SCTIMST for his administrative and

logistic support.

Collective and individual acknowledgements are also owed to my colleagues,all

MPH/DPH 2009 students, PhD scholars, Project staff for their help and support. Many

thanks go in particular to Dr.Tumge, Dr.Madhu and Ms.Uma for their help and constant

encouragement.

I am all grateful to the study subjects who participated or declined to participate in the

study, without whom, I would not have been able to do this piece of work.

I cannot end without thanking my family on whose constant encouragement and love I

have relied throughout my time at AMCHSS.

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Certificate

I hereby certify that the work embodied in this dissertation titled “Awareness, attitude

and perceived barriers regarding implementation of Cigarettes and Other Tobacco

Products Act in Guwahati, Assam” is a bonafide record of original research work

undertaken by Dr.Indrani Sharma, in partial fulfillment of the requirements for the award

of the degree of Master of Public Health, under my guidance and supervision.

Guide:

Dr. K R Thankappan

Professor and Head

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram, Kerala, India

October 2009

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DECLARATION

I hereby declare that this dissertation work titled „Awareness, attitude and perceived

barriers regarding implementation of Cigarettes and Other Tobacco Products Act in

Guwahati, Assam‟ is an original work of mine and it has not been submitted to any other

institution or University.

Dr. Indrani Sharma

Achutha Menon Centre for Health Science Studies (AMCHSS)

Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST)

Thiruvananthapuram

October 2009

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TABLE OF CONTENTS

ABSTRACT

CHAPTERS

Chapter 1: Review of Literature

1.1 Burden of tobacco use………………………………………………………………. 9

1.2 Tobacco use practices………………………………………………………............... 10

1.3 Health consequences of tobacco use………………………………………………… 11

1.4Awareness of the health consequences due to tobacco use…………………............... 15

1.5 Tobacco Control Efforts……………………………………………………............... 16

1.5.1 Framework Convention on Tobacco Control…………………………………. 16

1.5.2 Tobacco legislation in India…………………………………………………... 17

1.6 Impact of Tobacco control laws……………………………………………............... 19

1.6.1 In Developed Countries…………………………………………………........... 19

1.6.2 In Developing Countries………………………………………………………. 20

1.6.3 Barriers for the Implementation of the Law…………………………………… 22

1.7 Rationale for conducting the study …………………………………………….......... 23

1.8 Objectives……………………………………………………………………............. 24

Chapter 2: Methodology

2.1 Study Type………………………………………………………………...………… 25

2.2 Study Setting………………………………………………………………………… 25

2.3 Study Population…………………………………………………………………….. 25

2.4 Sample Size………………………………………………………………………….. 25

2.5 Criteria………………………………………………………………...…………….. 26

2.6 Sample Selection Procedure…………………………………………...…………….. 26

2.7 Data Collection…………………………………………...……………..…………… 28

2.8 Data storage…………………………………………………………….……...…….. 28

2.9 Data cleaning…………………………………………………………….…….…….. 29

2.10 Data Analysis and Statistical Methods………………………………….…….……. 29

2.11 Study variables………………………………………………………………..……. 30

2.12 Ethical Considerations……………………………………………………………… 36

Chapter 3: Results

3.1 Sample Characteristics………………………………………………………………. 37

3.1.1 Socio-demographic characteristics of the sample population………………… 37

3.1.2 Awareness related factors……………….……………….……………….…… 38

3.1.3 Attitude related factors……………….……………….………………….…… 44

3.1.4 Barriers for Implementation……………….……………….……………..…... 45

3.1.5 Measures for effective implementation of the Act……………….…………… 45

3.1.6 Tobacco use practices……………….……………….…………………...…... 46

3.2 Analysis of the factors related to awareness of COTPA and attitude towards it…..... 47

3.2.1 Results of bivariate analysis……………….……………….……………..…... 47

3.2.2 Multivariate Analysis (Binary logistic regression) ……………….………….. 53

3.3 Results of qualitative analysis……………….……………….……………………… 55

Chapter 4: Discussion and Conclusion

4.1 Discussion……………….……………….……………….……………….…..…...... 61

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4.2 Limitations of the study……………….……………….……………….……….…... 70

4.3 Strengths of the study……………….……………….……………….……………... 70

4.4 Conclusion……………….……………….……………….…………………...…...... 70

4.5 Recommendation and Policy implications of the study……………….…………… 71

REFERENCES………………………………………………………………………… 72

ANNEXURE

Annexure I: Cluster identification sheet………………………………………….. 80

Annexure II: Consent form for the structured interview schedule……………….. 82

Annexure III: Consent form for the in depth interviews…………………………. 85

Annexure IV: Structured interview schedule…………………………………….. 87

Annexure V: Structured guideline for the in depth interviews………………. .. 96

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LIST OF TABLES

Sample Characteristics:

3.1 Socio-demographic characteristics of the sample population...................................... 38

3.2 Awareness about tobacco related health problems and the dangers of different types

of tobacco................................................................................................................

39

3.3 Awareness of any tobacco control law in India.................................................. 40

3.4 Awareness of ban on smoking in public places.................................................. 40

3.5 Awareness about ban on sell of tobacco products to minors.............................. 41

3.6 Awareness about ban on advertisement of tobacco products............................. 41

3.7 Awareness about ban on sale of tobacco near educational institutions............... 42

3.8 Awareness about specified health warnings on tobacco packets......................... 42

3.9 Knowledge about any provision of COTPA being implemented........................ 43

3.10 Awareness scores for COTPA............................................................................. 43

3.11 Attitude towards COTPA................................................................................... 44

3.12 Barriers for Implementation............................................................................... 45

3.13 Effective implementation of the Act.......................................................................... 45

3.14 Tobacco use practices................................................................................................. 46

Results of Bivariate Analysis:

3.15 Association of socio-demographic factors with Awareness of COTPA.................... 48

3.16 Association of awareness about tobacco related health problems with awareness

of COTPA.............................................................................................................

49

3.17 Association of Tobacco use practices with awareness of COTPA............................ 49

3.18 Association of socio-demographic factors with attitude towards COTPA............... 50

3.19 Association of awareness about tobacco related health problems with attitude

towards COTPA ..................................................................................................

51

3.20 Association of awareness of COTPA with the attitude towards COTPA.................. 52

3.21 Association of Tobacco use practices with attitude towards COTPA...................... 52

Results of Multivariate Analysis (Binary Logistic Regression):

3.22 Results of multiple logistic regression for awareness of COTPA.............................. 53

3.23 Results of multiple logistic regression for attitude towards COTPA......................... 55

FIGURE

3.1 Thematic diagram of qualitative analysis..................................................................... 57

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ABSTRACT

Background: Tobacco is a major public health problem resulting in 5.4 million deaths

globally and one million deaths in India every year. The Cigarettes and Other Tobacco

Products Act (COTPA) was developed to curb this epidemic in India. However, no study

has been conducted on the awareness and attitude of the people towards the Act.

Objective: The objective of this study was to assess the awareness, attitude and their

predictors among adult population in Guwahati Municipal Corporation (GMC) towards

COTPA and to understand the perceived barriers for implementation of COTPA.

Methodology: A community-based cross-sectional survey was conducted among 300

adults (mean age 41 years, 52% men) selected by cluster sampling method from the

GMC. Information on awareness, attitude and their predictors was collected using a pre-

tested structured interview schedule. Barriers for implementation were collected using in-

depth interviews among selected implementers. Awareness was grouped into good

awareness and poor awareness based on median score. Attitude was measured using

Fishbein model. Multivariate analysis was done using SPSS to find out predictors of

awareness and attitude.

Results: Good awareness was reported by 46% (95% CI 40.4% -51.6%) and positive

attitude by 77% (CI 71.9% - 81.5%) of the population. Adults > 50 years were three times

[(Odds Ratio (OR) 3.02, CI 1.44-6.31)] and those with > 10 years of schooling were four

times (0R 3.60, CI 1.70-7.70) more likely to have good awareness of COTPA compared

to their counter parts. Those belonging to the middle socioeconomic status (SES) were

three times (0R 3.36, CI 1.13-10.01),those who reported second hand smoking harmful

were three times (0R 3.32, CI 1.45-7.62) and those with > 10 years of schooling were also

three times (OR 2.92,CI 1.01-8.45) more likely to have a positive attitude towards

COTPA compared to their counterparts. Major barriers in COTPA implementation were

lack of complete information and awareness of the Act, public opposition, cultural

acceptance of tobacco use, lack of political support and less priority given to tobacco

control.

Conclusion: Awareness towards COTPA was low in this population but attitude towards

it was good. Efforts should be made to increase the awareness focussing on younger

population, less educated, and those belonging to the low SES particularly on the health

effects of second hand smoking and the existence of the Act.

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CHAPTER 1

REVIEW OF LITERATURE

1.1 Burden of tobacco:

Global Scenario

According to the 2008 World Health Organization report on the Global Tobacco

Epidemic, currently 1.3 billion persons use tobacco in the world out of which 5.4 million

people die every year.1 Total tobacco-attributable death is projected to rise to 6.4 million

in 2015 and 8.3 million in 2030 and 80 percent of these deaths due to tobacco will be in

developing countries.2 Tobacco is projected to kill 50 percent more people in 2015 than

HIV/AIDS, and to be responsible for 10 percent of all deaths globally.2 Death toll due to

the tobacco epidemic was 100 million in the 20th

century which is projected to be one

billion during 21st century.

1 In 2000, 4·83 million premature deaths in the world were

attributable to smoking; 2·41 million in developing countries and 2·42 million in

industrialised countries,3·84 million of these deaths were in men.3 The leading causes of

death from smoking were cardiovascular diseases (1·69 million deaths), chronic

obstructive pulmonary disease (0·97 million deaths), and lung cancer (0·85 million

deaths).3

Indian Scenario:

It is estimated that fourteen million men and four million women in India are

regular tobacco users. Tobacco kills 800,000 people every year. According to the National

Family Health Survey(NFHS-3), in India over half of men (57 percent) and over one tenth

(10.8 percent) of women in the age group of 15-49 years use tobacco in some form.4

One

third of men (32.7 percent) smoke cigarettes or bidis and over one third (38.1 percent) use

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smokeless tobacco.4

Among women, almost 10 percent use smokeless tobacco, while only

1.4 per cent smokes cigarettes or bidis.4

A study on the prevalence of tobacco use among

young people in India concluded that 14.7 percent had ever used tobacco out of which

10.8 percent had chewed tobacco, 7.4 percent had smoked cigarettes 7 percent had

smoked bidis. Among the current users 3% chewed tobacco, 1.4 percent smoked

cigarettes, 1.6 percent smoked bidis.5

The India Global Youth Tobacco Survey 2006

(GYTS) has reported that 12.2 percent of students had ever smoked cigarettes (Boys =

14.7 percent, Girls = 8.9 percent), 14.0 percent currently use any tobacco product (Boys =

17.2 percent, Girls = 9.5 percent), 4.1 percent currently smoke cigarettes (Boys = 5.9

percent, Girls = 1.8 percent) and 11.8 percent currently use some other form of tobacco.6

Scenario in Assam:

In Assam percentage of men and women in the age group of 15-49 who use any

kind of tobacco is 72.4 percent and 23.2 percent respectively and percentage of men and

women of the same age group who smoke cigarette or bidi is 36.4 percent and 0.6 percent

respectively.4According to the GYTS 2006, Assam factsheet, 36 percent of students

currently use any form of tobacco; 10 percent currently smoke cigarettes and 27 percent

currently use some other form of tobacco.7 Another study on youths in Assam showed

that 25.3 percent use smokeless tobacco and smoking prevalence is 19.7 percent.8

1.2 Tobacco use practices:

Some 400 years ago when the Portuguese eventually did land on Indian shores,

they brought in tobacco. A couple of centuries later, the British introduced commercially

produced cigarettes and established tobacco production in the country.9

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Tobacco is used in various forms in India. It can be chewed, smoked or sniffed through

the nostrils. In 1997, World Health Organization (WHO) reported the prevalence of

tobacco habits in India to be, Bidis (34 percent), Cigarettes (31 percent), Chewing tobacco

(19 percent), Hookah (9 percent), Cigars-cheroots (5 percent), and Snuff (2 percent).10

The cancer patient‟s aid association of India in 2004 reported the prevalence to be

cigarettes (20 percent), bidis (40 percent) and the remaining 40 percent is consumed as

chewing tobacco, pan masala, snuff, gutkha, masheri and tobacco toothpaste. These two

set of statistics revealed the changing pattern of tobacco consumption in India.

In Assam „raw‟ (green), „ripe‟ (red) and „fermented‟ (underground or processed)

betel nuts known as 'tamul' are all chewed. 11

Chopped or crushed nuts at different stages

of ripening or decay are wrapped in betel leaf and are chewed with or without tobacco.

„Dhapat‟, dried tobacco leaf that may be treated with lime (calcium oxide), is added to the

betel nut in the quid with a mixture of finely cut and dried, raw or ripe betel nut known as

‘Supari’.11

Scented tobacco ‘Zarda’ is also chewed.11

Dried tobacco chewed alone in

Assam is known locally as ‘Chadha‟.11

‘Gul’ is a pyrolysed tobacco product marketed

under different brand names in small tin cans and used as a dentifrice in the eastern part of

India.11

Bidis and cigarettes are also commonly used in Assam.

1.3 Health consequences of tobacco use:

Tobacco contains more than 2,500 chemical constituents, many of which are

known human carcinogens.12

Tobacco smoking produces both mainstream smoke, which

is a combination of inhaled and exhaled smoke after taking a puff on a lit cigarette, and

side stream smoke, which is emitted from the end of the smouldering cigarette, and they

contain many of the same chemical constituents, including at least 250 chemicals known

to be toxic or carcinogenic.12

Environmental tobacco smoke (ETS) is the sum of side

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stream smoke, mainstream smoke, compounds that diffuse through the wrapper, and

exhaled mainstream smoke.12

Between 80 percent and 90 percent of all human lung

cancers are attributed to tobacco smoking.

Tobacco is the second major cause of death in the world and the fourth most

common risk factor for disease worldwide. A considerable number of research studies

have shown that tobacco use causes serious diseases because, in addition to nicotine,

tobacco contains several toxic and carcinogenic chemicals. Tobacco chewing emerged as

the strongest risk factor for oral cancer and, tobacco smoking as the strongest risk factor

for pharyngeal and oesophageal cancers in a study on the effect of tobacco on cancers in

Indian men.13

The annual incidence of oral cancer in men in India is estimated to be 10

per 100 000. Tobacco chewing has made cancer of the head and neck the number one

cancer in India. In the eastern Indian population, tobacco in both smoked and smokeless

forms is the most important risk factor for both development and prognosis of Head and

neck squamous cell carcinomas.14

Cancer of the oesophagus is the most commonly

diagnosed cancer in males in Assam, and ranks second for females. In North-East region

very high incidence of all sites of cancers in general, and tobacco related cancers in

particular have been reported. Both Mizoram and Assam states have reported very high

incidence of oesophageal cancer in both sexes. A case control study on oesophageal

cancer in Assam found that men chewing dried tobacco (chadha) had a nearly 5-fold

greater risk of oesophageal cancer compared to non-users.11

It also found dose response

relationships similar to that in the other studies.11

Among chewers of more than 20 years

duration, men had more than a 10- fold higher risk (OR = 10.6) and women a 7-fold

higher risk (OR = 7.2) relative to non-chewers.11

A study on the disease burden of adult lung cancer and ischemic heart disease

from passive tobacco smoking in China showed that passive smoking caused more than

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22,000 lung cancer deaths and approximately 33,800 Ischemic Heart Disease

deaths.15

Exposure to passive smoking is associated with an increased prevalence of

Chronic Obstructive Pulmonary Disease (COPD) and respiratory symptoms. It is

estimated that among never smokers 1.9 million excess deaths from COPD could be

attributed to passive smoking in the current population in China.16

According to the

baseline projections made in the Global Burden of Disease Study (GBDS) COPD by

2020, is expected to rise to the 3rd position as a cause of death and at 5th position as the

cause of loss of disability adjusted life years (DALYs) .17

The largest increase in the

tobacco related mortality is estimated to occur in India, China and other Asian countries.

17 An increased risk of lung cancer has been shown in wives of husbands who smoke.

Having a spouse who currently smoked was associated with an increased risk of first

stroke among never-smokers (hazard ratio=1.42, 95 percent CI=1.05, 1.93) and former

smokers (hazard ratio=1.72, 95 percent CI=1.33, 2.22).18

The results of another study in

Japan indicate the possible importance of passive or indirect smoking as one of the causal

factors of lung cancer as wives of heavy smokers were found to have a higher risk of

developing lung cancer and a dose-response relation was observed.19

A multicentric study

was conducted in both the urban and rural populations at four large centres in India, i.e.

Bangalore, Chandigarh, Delhi and Kanpur for diagnosis of COPD.20

Chronic obstructive

pulmonary disease was diagnosed in 4.1 percent of 35295 subjects, with a male to female

ratio of 1.56:1 and a smoker to non-smoker ratio of 2.65: 1.20

In a case–control study

conducted in Bangalore, it was found that current smoking of cigarettes or bidis is the

most important predictor of acute MI.21

The odds of acute MI was 3.6 in current smokers

overall and, in individuals who currently smoked 10 or more cigarettes per day, it was 6.7

compared to never-smokers.21

Among smokeless tobacco snuff use may elevate the risk

of fatal stroke, and particularly fatal ischemic stroke.21

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Environmental tobacco smoke is a risk factor for lung cancer and other respiratory

diseases. Children of parents who smoke have an increased incidence of cough,

bronchitis, ear infection and pneumonia. Children exposed to their parents cigarette

smoke have six times the number of respiratory infections. In one study 17 percent of

lung cancers among non-smokers was attributed to high levels of exposure to cigarette

smoke during childhood and adolescence.22

SHS exposure causes otitis media, or middle ear disease, a common childhood

illness that accounts for a large number of visits to physicians and, if untreated, can lead

to hearing impairment. Side stream smoking (passive smoking) increases the risk of Otitis

Media with Effusion and Recurrent Otitis Media.23

Maternal smoking during pregnancy

increases the risk of hospitalized bronchiolitis.24

Among Danish women interviewed at the time of mammography, smoking for

more than 30 years was associated with a 60 percent higher risk of breast cancer and onset

at an average of eight years earlier, when compared with non-smokers.25

Maternal

smoking was associated with statistically significant increased risk of Sudden Infant

Death Syndrome (SIDS).26

Maternal smoking is responsible for 15 percent of all preterm

births, 20-30 percent of all infants of low birth weight, and a 150 percent increase in

overall prenatal mortality.27

A case control study conducted in Tamil Nadu, India showed that TB mortality

among smokers was substantial and highly significant.28

In both urban and rural areas the

risk among smokers of dying from TB was more than four times than among non-

smokers.28

Smoking, which increases the incidence of clinical tuberculosis, is a cause of

half the male tuberculosis deaths in India, and of a quarter of all male deaths in middle

age(25-69 years).28

Another study showed that both active smoking and passive exposure

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to environmental tobacco smoke have multifaceted effects on bronchial asthma and

bronchial responsiveness.29

1.4 Awareness of the health consequences due to tobacco use:

The extent to which tobacco users understand the magnitude of these health risks

has a strong influence on their tobacco use behaviour. Those who perceive greater health

risk from tobacco use are more likely to intend to quit. In order to take effective action it

is necessary to take into account the gaps in awareness of the effects of tobacco on health.

The findings from a study in which representative samples from United States, United

Kingdom, Canada and Australia were taken and variation of knowledge about tobacco

risks was examined study indicate significant gaps in smokers‟ understanding of the risks

of smoking.30

It was reported by most of the smokers that smoking causes heart disease

and lung cancer, more than a quarter of smokers did not believe that smoking caused

stroke, and fewer than half of smokers believed that smoking causes impotence.30

Smokers‟ knowledge of toxic constituents in tobacco smoke was also unacceptably low.30

A few studies has been done in India which assessed the awareness level of the masses

on tobacco as a risk factor for various diseases. A case control study in Kolkata, India

revealed the poor awareness level regarding risk of tobacco use.31

About 20 percent of the

cases and control had no idea about the adverse effects of tobacco use and 75 percent of

the cases and controls were aware about the risk of smoking.31

Only 12 percent of the

cases and controls knew the risk of tobacco chewing.31

Maximum numbers of patients

were aware only after diagnosis of the disease (lung or laryngeal cancer) and after that

almost half of them tried to quit tobacco use.31

Another study on awareness of risks of tobacco among school children in Jaipur

showed that 99.2 percent boys and 99.5 percent girls were aware that tobacco use is

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harmful and similar proportions disliked it.32

More than 90 percent students were aware of

its importance in causing respiratory diseases and the majority of them knew of its

potential to cause general debility, heart disease, cancer, impotence, ulcer of stomach and

death,77.1 percent boys and 75.8 percent girls knew that passive smoking is bad.32

1.5 Tobacco Control Efforts:

The tobacco epidemic is devastating, but preventable. There is no less urgent an

infectious disease than that of tobacco usage in the world. Tobacco use is growing fastest

in low income countries, due to steady population growth coupled with tobacco industry

targeting, ensuring that millions of people become fatally addicted each year. The World‟s

fight against tobacco has started and public policies are implemented to galvanize action

at the global and country level against the tobacco epidemic.

1.5.1 Framework Convention on Tobacco Control

The WHO Framework Convention on Tobacco Control (FCTC), a multilateral

treaty with more than 150 parties, was the first step in the global fight against the tobacco

epidemic.1The WHO FCTC was developed in response to the globalization of the tobacco

epidemic.

The World Health Assembly of the World Health Organization (WHO) adopted

the FCTC at its 56th Session in May 2003.33

The WHO FCTC was opened for signature

for a period of one year ,from 16 June to 22 June 2003 in Geneva, and thereafter at the

United Nations Headquarters in New York, from 30 June 2003 to 29 June 2004.33

The

treaty, which is now closed for signature, has 168 Signatories, including the European

Community, which makes it the most widely embraced treaties in UN history.33

India has

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signed the FCTC on 10th Sep 2003 and the ratification was done on 5th February 2004.

The Convention entered into force on 27 February 2005 .33

1.5.2 Tobacco legislation in India

Large amount of information was provided by the Report on tobacco control in

India by Reddy KS and Gupta PC on behalf of Ministry of Health and Family Welfare,

Government of India.34

Legislation lies at the very heart of any effective tobacco control program. It

serves to institutionalize the program by providing it with a legal foundation. India has a

short history of tobacco-related legislation. The legislation dates back to 1975 when the

Tobacco Board Act was introduced to develop the tobacco industry, which facilitated

regulation of production of tobacco, fixed minimum prices and provided subsides to

tobacco growers. Again in 1975, Cigarettes Act of 1975 was passed. It was India's first

national level anti- tobacco legislation and prescribed all packages to carry the warning

"Cigarette smoking is injurious to health". Prevention and Control of Pollution Act was

introduced in 1988, which included smoking in the definition of air pollution. The Motor

Vehicles Act of 1988 made it illegal to smoke or spit in a public vehicle. The Cable

Television Networks Amendment Act of 2000 prohibited the transmission of tobacco

commercials on cable television across the country.

Indian Parliament passed the Cigarettes and Other Tobacco Products (Prohibition of

Advertisement and Regulation of Trade and Commerce, Production, Supply and

Distribution) Bill, in April 2003. This Bill became an Act on 18 May 2003. Rules were

formulated and enforced from 1 May 2004. According to this act there should be:

Ban on smoking in public places;

Ban on advertisements of tobacco products;

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Prohibition on sale of cigarettes or other tobacco products to a person below the

age of eighteen years and in particular area; and

Specified health warning labels on all tobacco products

This act covers most tobacco products like cigarettes, cigars, bidis, cheroots, pipe

tobacco, hookah tobacco, chewing tobacco, panmasala and gutkha. A first time offender

will result in a fine of rupees 200 and a second time offender will result in a much higher

fine amount and imprisonment for up to three years. Delhi was the first to impose a ban

on smoking in public. In 1996, Delhi Prohibition of Smoking and Non- Smokers Health

Protection Act was passed. This act prohibited sale of cigarettes 100 meters from the

school building and to minors. The offender was fined a sum of rupees 100. But it was

difficult to enforce this act and had little real impact, the key problem being lack of

manpower to enforce the act. In 1999, Kerala High Court came out with a judgement

prohibiting smoking in public places, including parks and highways and Goa banned

smoking in public places through anti-tobacco legislation. For the past three years, Tamil

Nadu and Andhra Pradesh have banned the marketing and sale of gutkha. Additional steps

that could be taken to curb the demand include increasing tax on all tobacco products,

control smuggling, closure of all advertising avenues and creation of an infrastructure for

enforcement of laws.

India on 2nd

October, 2008 imposed a countrywide ban on smoking in public spaces in

its fight against tobacco use. India has had laws against smoking in public places in place

for some time, but they have not been enforced strictly. The new order bars smoking in

hotels, eateries, cafes, pubs, bars, discotheques, offices, airports, railway stations, bus

stops, shopping malls and parks. People can continue to smoke in their homes and open

spaces. The Ministry of Health and Family Welfare, Government of India had mandated

that all tobacco products manufactured/packaged/imported in India on or after 31 May

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2009 have to display pictorial health warnings as specified under the Cigarettes and Other

Tobacco Products (packaging and labelling)Rules 2008.

1.6 Impact of Tobacco control laws:

1.6.1 In Developed Countries

A comparative study among adults in Ireland and UK showed that the Irish law

led to dramatic declines in reported smoking in all venues - workplaces (62 percent to 14

percent) compared to UK (37 percent to 34 percent), in restaurants (85 percent to 3

percent) and in UK (78 percent to 62 percent) and bars/pubs (98 percent to 5 percent) but

remained nearly unchanged in the UK (98 percent to 97 percent).35

Support for total bans

among Irish smokers increased in all venues, including workplaces (43 percent to 67

percent), restaurants (45 percent to 77 percent), and bars/pubs (13 percent to 46 percent).35

Another study in US showed that support was greater for banning smoking in fast-food

restaurants (42.5 percent to 63.0 percent) and at indoor sporting events (55.4 percent to

66.9 percent).36

People supported stronger enforcement of laws prohibiting the sale of

tobacco products to minors and measures to limit tobacco promotion in most of the

developed countries.36-39

Current smokers are less supportive of smoking policies and

tobacco control measures than former smokers.38

A study done in 4 States in US showed that 49 percent to 56 percent of current

smokers, agreed that cigarette advertising should be banned.39

In a cross sectional study

by Mc Millen RC et al in US showed that the majority of adults, both smokers and non-

smokers, supported smoking bans in a wide variety of places but compared to non

smokers, smokers had significantly lower levels of support for smoking bans in each of

the proposed public places.40

20

Another study on Australian smokers showed that 16 percent believe that tobacco

companies should be allowed to advertise/promote cigarettes as they please.41

After the Finland's national smoke-free work-place law came into force its impact on

employee exposure to ETS for at least 1 hour daily decreased steadily during the 4-year

follow-up, from 51 percent in 1994 to 17 percent in 1995 and 12 percent in 1998.42

Respondent‟s daily smoking prevalence and tobacco consumption reduced from 30

percent to 25 percent in 1 year after the enforcement of legislation.42

Both smokers' and

non-smokers' attitudes shifted gradually towards favouring a total ban on smoking at

work.42

Hyland et al showed the impact of the Scottish tobacco control law in adults in the

ITC Scotland/UK survey.43

Respondents were interviewed before the implementation of

the law and 1 year after it in Scotland and rest of UK.This evaluation found dramatic

declines in the observance of smoking ban in pubs, restaurants and workplaces in

Scotland relative to the rest of UK and support for the law was also higher post

implementation in Scotland.43

A study by Wakefield MA et al showed that the impact of tobacco control policy

like increase in cigarette costliness and exposure to tobacco control media campaigns

significantly reduced smoking prevalence.44

1.6.2 In Developing Countries

In a cross sectional study in South Africa 75 percent of participants felt that

tobacco sales to minors should be banned .45

Raising of tobacco taxes was supported by

50 percent and 68.8 percent in South Africa and China respectively if the revenues were

channelled for smoking control and health services.46,47

Banning tobacco advertising was

favoured by 61 percent and 85.7 percent in South Africa and China respectively.46,47

A

cross sectional study in China showed that 85.1 percent supported health warnings on

21

cigarette packages while another study in Russia reported that 56 percent believed

existing health warnings were inadequate.47,48

In a study to evaluate the support for smoke free policies about 1 in 2 Chinese

urban smokers and 4 in 5 non-smokers believed that second-hand smoke (SHS) causes

lung cancer.49

The majority of respondents supported comprehensive smoke free policies

in hospitals, schools, and public transport vehicles while support

for smoke free

workplaces, restaurants and bars was lower.49

Support for comprehensive smoke free

policies was positively associated with knowledge about the harm of SHS.

49

Danishevski K et al studied the public attitude towards smoking and tobacco

control policy in Russia and found that majority of the population supported the tobacco

control policies and there is chance of further strengthening of the support towards the law

with effective public education campaigns as knowledge of impact of smoking on health

was limited with significant underestimation of dangers and addictive qualities of

tobacco.48

A study by Levy DT et al on the role of tobacco control policies in reducing

smoking and deaths in a middle income nation like Thailand found that smoking

prevalence reduced by 25 percent post implementation and tax increase on cigarettes and

advertising bans had the largest impact .50

There was also reduction of the number of lives

lost to smoking.50

Rufat Nasibov reported that most of the people (82.7 percent) in Azerbaijan

believe that national tobacco control legislation should be strengthened to curb tobacco

use, but most respondents had low levels of awareness about existing national tobacco

control laws and the FCTC.51

Almost half of the respondents were in favour of a complete

ban on tobacco advertising and 58.3 percent of respondents were in favour of a complete

ban on smoking in public places.51

With regard to the current tobacco control law, the

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Danishevski%20K%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

22

study found a lack of enforcement of existing provisions; loopholes in the tobacco

advertising law which allow for widespread tobacco sponsorship activities; inadequate

health warning labels on cigarette packages and low level of international co operation in

tobacco control.51

A cross sectional survey among a representative sample of local self government

was conducted to see the knowledge attitude and barriers regarding the implementation of

tobacco control measures in Kerala.52

Effective tobacco control was reported as a very

important strategy to improve people‟s health by 95 percent of the respondents.52

Knowledge of the health hazards of smoking was very high.52

Knowledge about existing

smoking ban in public places in Kerala was maximum and ban on sale of tobacco

products within 100 meters of educational institutions was minimum.52

Over 80 percent of

respondents considered the most effective tobacco control policies to be smoking bans,

bans on sales of tobacco products to and by minors, advertisement bans, and sales of

tobacco products within 100 meters of educational institutions.52

1.6.3 Barriers for the Implementation of the Law

Participants in Focus group sessions at the annual Colleges Against Cancer

National Leadership Summit in October 2006, identified lack of administrative and staff

support, student involvement, and resources as barriers for effective implementation of

the smoke free policy.53

Case study among the enforcement officials in US reported

resource constraints and giving less priority to tobacco control issues as barriers for the

implementation of the law.54

A cross sectional study among a representative sample of local self government in

Kerala, India reported the following barriers for the implementation of the tobacco control

policies: lack of administrative support, lack of political will, lack of financial/human

23

resources and the fear of public opposition.52

Most representatives recommended

involving community members, non-governmental organisations, enforcing penalties and

involving local self government bodies representatives to effectively enforce tobacco

control policies.52

An Indian study came up with the conclusion that lack of educational campaign

about the health dangers of second hand smoke and existence of the law among masses is

the ultimate barrier for the implementation of the law.55

A study in Ontario showed that

the community has limited knowledge of the Tobacco Control Act on ban on supply of

cigarettes to anyone under the age of 19. 56

Most respondents were not aware of the

appropriate place to report a sale. 56

1.7 Rationale for conducting the study:

There is an immediate need to curb this much publicized evil of our society .The

past decade has seen a significant paradigm shift in tobacco related policies that has led to

a significant curtailing of the use of tobacco in many countries. However, nearly all of

these advances have occurred in industrialized countries. Unfortunately developing

countries' policies have lagged far behind, and tobacco consumption in these countries

continues to rise. In India and especially in Assam the extent of public support and public

opinion on the Cigarettes and Other Tobacco Products Act (COTPA) remains largely

unknown. Tobacco use in Assam and all the North Eastern States is an essential part of the

lifestyle. This cultural acceptance becomes a barrier for the effective implementation of

COTPA. No study has been done in Assam to see the awareness and attitude of the people

towards the act and their perception of the barriers for implementation of this act. There is

no clear understanding of why the law is not properly enforced and what are the obstacles

faced by the enforcement officials in implementing the law. From a public health

24

perspective, such information may be of great importance with respect to understanding

the degree to which public support and opinions may have on the successful

implementation of tobacco control policies and legislation in Assam. Therefore, this study

is designed to gather baseline information from the adult population of Guwahati, Assam

about awareness, perceived barriers of implementation and attitudes toward four key

tobacco control measures developed by COTPA: banning smoking in public places,

Prohibition on sale of cigarettes or other tobacco products to a person below the age of

eighteen years, banning tobacco advertising, and labelling cigarette packets with health

warnings. This study also aims to understand the barriers of implementation of this law by

the enforcement officials in Guwahati, Assam.

1.8 Objectives:

To assess the awareness and attitude of the adult population under Guwahati

Municipal Corporation towards Cigarette and Other Tobacco Products Act

(COTPA).

To understand the perceived barriers for the implementation of the Act among

enforcement officials.

25

CHAPTER 2

METHODOLOGY

2.1 Study Type: It was a community based cross sectional survey for the adult population

under Guwahati Municipal Corporation (GMC) and a qualitative survey for the

enforcement officials of the Act.

2.2 Study Setting: The study was conducted in 20 randomly selected wards out of 60

wards under the jurisdiction of Guwahati Municipal Corporation. The In depth interviews

were conducted in venues according to the convenience of the key informants.

2.3 Study Population: The study population consisted of selected individuals of 18 years

and above under the jurisdiction of Guwahati Municipal Corporation and enforcement

officials responsible for implementation of the four key provisions of the Act.

2.4 Sample Size: Sample size has been estimated by Epi Info version 3.3.2. According to

a study done in China 75.73 percent of survey respondents and half of those interviewed

were unaware of the FCTC and its provisions.57

As the tobacco use in Assam is similar to

China , I assumed the awareness level to be the same in Assam.

Taking 24.27 percent as prevalence of awareness, the calculated the sample size for adults

is:

n=1.962pq/D

2 Here, p=0.24

q=0.76

The anticipated proportion was assumed to be between 18.27% and 30.27% with 95%

confidence.

26

I took, D=6%

=0.06

Therefore, n (adults) = (1.96*1.96*0.24*0.76) ÷ (0.06*0.06)

=195

=200(rounding off)

As it was a cluster sampling method a „Design effect‟ of 1.5 was used to calculate the

sample size: 200*1.5=300

Estimated sample size was 300 in 20 selected clusters across Guwahati city. In each

cluster 15 adults were interviewed.

2.5 Criteria: Before proceeding to the selection of the sample the following criteria were

set forth for inclusion into the study.

• Inclusion Criterion: Adults aged 18 years and above.

• Exclusion Criterion: Minors(aged less than 18 years)

2.6 Sample Selection Procedure: The method used was a Simplified Cluster Sampling

Method which had been used previously by the Expanded Programme on Immunization

(EPI). 58, 59

a. Identifying the 20 clusters: Total adult population of Guwahati city was the sampling

frame of the study. Individuals for the study were selected using cluster sampling

technique with Probability Proportional to Size (PPS). The corporation wards and their

individual population sizes were enumerated, and the cumulative total population was

obtained by summation. To obtain a cumulative population, the population of the next

ward was added to the combined total of all populations in the preceding wards. Then the

total cumulative population was divided by 20 to get the „sampling interval‟.

27

Total population under Guwahati Municipal Corporation/20 clusters= Sampling Interval

809895/20=40495

Then a five digit random number 25271 was selected using a currency note

between 0 and 40495. The first cluster (ward) was identified as the ward where the

cumulative population was greater than or equal to the random number. Subsequently the

sampling interval (40495) was added to the random number (25271).The second cluster

was identified whose cumulative population was equal or greater than the number thus

obtained. Similarly all the 20 clusters were identified. (The cluster identification sheet is

provided in the Annexure I).

b. Selection of Households: In each cluster 15 adults were selected. All the adults in the

household were interviewed. The first household was selected randomly. A central

location in the ward was identified by spin bottle method. The direction of the first

household was randomly selected. Number of houses which exists along the line from the

central location to the edge of the ward was counted. A random number was selected

between one and the total number of houses along the line and that was the first house

visited. The second household visited was the one which was nearest to the first, i.e

whose front door was closest to the front door of the household that was just visited. The

same procedure was continued until the total sample of 15 adults in each ward was

obtained. This procedure was followed in all of the selected 20 clusters till a sample size

of 300 adults was obtained.

In the study, I interviewed 15 enforcement officials to reach the saturation level.

28

2.7 Data Collection:

The pretesting of the interview schedule was done from 18th June 2009 till 30th June

2009. The data were collected from 01st July 2009 till 31st August 2009 without

interruption. Informed consent from each participant was obtained before collecting the

data, and no other persons were employed for the same purpose (Annexure II and III).

a. Tools for data collection

Primary data were collected using a structured interview schedule (Annexure IV).

Assamese translation of the interview schedule was used for collecting the information.

The interview schedule mainly consisted of closed questions. Information pertaining to

other domains was collected under five different categories such as Socio-demographic

Characteristics, Awareness related factors, Attitude related factors, Barriers for

implementation and Tobacco use practices.

In depth interviews were conducted among the enforcement officials using a

structured guideline (Annexure V). Appointments were obtained prior to the interview.

The sample was a saturation sample. A list of all enforcement officials related to the

implementation of each act was made and among them a few was interviewed until there

was saturation of the information. Open ended questions were asked to explore

participant‟s perspective on the research questions.

2.8 Data storage:

Along with data collection the data were entered in Epidata version 3.1 and then

imported to SPSS for windows version 15.0 for analysis purpose. The hard copies of

interview schedule are stored in a locked chamber under my vigilance. The privacy and

confidentiality of the participants is being strictly maintained.

29

2.9 Data cleaning:

Manually all the data sheets were checked before data entry. If there was any

mistake it was corrected, for example Sex was coded as „female=0‟ and „male=1‟ ,but in

some survey forms it was coded as 3 which was a wrong entry, so it was checked

thoroughly and corrected before proceeding further. Computerised data cleaning was

again done after data entry and before proceeding to data analysis.

2.10 Data Analysis and Statistical Methods:

Analysis was done in SPSS version 15.0. Univariate analysis was done to study

the sample characteristics (baseline characteristics of the study sample was assessed using

descriptive statistics). Bivariate analysis was done with two dependent variables -

awareness and attitude. For all the tests, p value of < 0.05 was considered for statistical

significance. For adjustment of possible interaction and confounding factors multivariate

analysis was done to arrive at a final model. The net bearing effect of different

independent variables was explained in terms of odds ratio (OR).Variables that were

significantly associated with the outcome variables in the bivariate analysis were used for

regression analysis.

For the qualitative survey 15 in-depth interviews were completed, five each with

regard to each type of legal policy response to reducing tobacco use. Since the enforcers

for the provisions of the Act with respect to selling of tobacco products to minors,

advertisement of tobacco products and specified health warnings were the same, the

responses to these three provisions were considered together. The 15 in-depth interviews

were read and coded in terms of the identified inputs required for implementing the Act –

awareness of the Act and personal use of tobacco products, the beliefs about tobacco and

30

its hazards and the possible consequences with respect to implementation of the Act. The

coding of the interviews was validated by using two independent coders, who reconciled

the variations in coding. Much of the variation was in terms of the language used to

construct the concept indicated by the code and not concept itself. A uniform coding

structure for the interviews was then derived and this was used across all the 15

interviews. The codes were then collapsed into themes that were explicit as part of the

analysis. The linkages between the various themes were identified by re-reading the

interviews to delineate the possible connections and also to validate those that were newly

identified.

2.11 Study variables:

a. Dependent variables

i. Awareness about the Cigarette and Other Tobacco Products Act (COTPA)-Level

of awareness is a dependent variable. There were eight questions to assess the awareness

level of adults towards COTPA. For every „yes‟ response a score of one was allotted and

the rest of the responses („no‟ and „don‟t know‟) were scored zero. Thus a minimum score

of zero and a maximum score of eight were obtained. The score was divided into two

categories based on the median value (3.0). Score less than or equal to three (≤3) was

graded as „poor awareness‟ and score more than three (>3) was graded as „good

awareness‟.

ii. Attitude towards COTPA-The „Fishbein model‟ was used to measure attitude

towards the act.60

It is a compensatory multiattribute model of attitude. According to the

model a person‟s attitude towards any object is a function of his beliefs about the object

and the implicit evaluative responses associated with those beliefs. In my study to

measure attitude towards COTPA two questions were framed - one on belief strength

31

measurement (Bi) and the other on evaluative strength measurement (Ei). Each question

had four parts for the four provisions of the act. Each individual provision was measured

on a scale. A scale marked from one to ten was used and the respondent was asked to tick

any point on the scale which he/she thought was appropriate. For belief strength the scale

ranged from strongly disbelieve to strongly believe and for evaluative strength

measurement it ranged from very ineffective to very effective. Individual attitude (A) for

each act was measured as A=Bi*Ei and overall AL= [SUM] Bi*Ei where AL= the overall

attitude towards the act, Bi= the strength of the belief that the government should

implement each provision of the act, Ei=the evaluation of the effectiveness or

ineffectiveness of each provision if it is implemented. The conceptual midpoint for the

individual attitude is 30.25 so negative attitude was scored as less than 30.25 (<30.25) and

positive attitude was more than equal to 30.25 (≥30.25). Similarly for the overall attitude

the conceptual midpoint was 121, so negative attitude was scored as less than 121(<121)

and positive attitude was more than or equal to 121(≥121).

b. Independent variables

Data collection was in the form of self reports for all variables. Initially some of

the predictor variables were grouped into a number of groups, for example marital status

was grouped as never married, currently married, widow/widower, divorced and

separated. But during analysis these were regrouped into two groups-married and others.

The highest percentage of people were married and very few responses were there in the

other groups so all the other groups were combined into one group and named as „others‟.

As the sample size is less we can‟t have more number of categories. Similarly for other

variables also regrouping has been done.

32

i. Socio-Demographic variables

Age: Age in completed years was recorded as reported by the participants. This

information was collected to see the relation between age and awareness about the act,

attitude towards the act and tobacco use practices. Age was grouped into three groups for

analysis purpose-18-35 years, 36-50 years and 50+ years.

Sex: The awareness and attitude might vary in both the sexes. It was assumed that tobacco

use was more in males than in females so the attitude towards the Act also might differ

accordingly.

Highest level of education: Since Awareness and attitude are likely to be determined by

education status, the highest level of educational status was collected for each of the

participant. Initially education was grouped as - no formal schooling, less than primary

school, primary school completed, secondary school completed, high school completed,

college/university completed and post graduate degree. Later on it was regrouped as „less

than equal to ten years of schooling‟ and „more than ten years of schooling‟.

Occupation: Occupation plays an important role in determining the awareness and

attitude. It is perceived that people who are employed their awareness level and attitude

towards the act is different from people who are not employed. The tobacco use practices

also vary between the employed and unemployed. Initially data on occupation was

collected using the groups-home maker/housewife, laborer/farmer/private informal,

private formal, government employee, professional, retired, student, unemployed and

others. Later on during data analysis it was regrouped into currently employed (also

included laborer/farmer/private informal, private formal, government employee and

professionals) and currently not employed (also included homemaker/housewife, retired,

student and unemployed).

33

Marital status: Data were collected to analyze its influence on awareness and attitude

about the Act, for example a woman whose spouse is using tobacco will have a different

attitude towards the Act than a woman whose spouse is not using tobacco.

Socio economic status (SES): Data were collected as total household expenditure in the

last one month. For further analysis total household expenditure tertiles have been used as

proxy for SES as „reported expenditure‟ is more reliable than reported income in

developing countries. Data were grouped into low SES (≤Rs 6221), middle SES (Rs

6222-19465) and high SES (>Rs 19465).

ii. Awareness related variables

Awareness on tobacco causing health problem: This was to assess the knowledge and

belief about tobacco causing any health problem and the association of knowledge with

awareness and attitude towards the Act.

Perception and Knowledge on tobacco associated health problems: This was to assess

the knowledge of tobacco associated health problems (cancer, heart problem, respiratory

disease, Tuberculosis, diabetes, hypertension, all of the above, any other). This factor can

also have a significant influence on tobacco use practices.

Knowledge about type of tobacco dangerous to health: This information was collected

to know which type of tobacco product according to people‟s perception is most

dangerous for health. The belief on the type of tobacco product dangerous to health would

influence the attitude of a person towards the Act.

Perception if second hand smoke is harmful: This was to assess the relation regarding

knowledge about second hand smoke being harmful with awareness and attitude towards

the Act.

Awareness about any tobacco control law in India: A person‟s awareness about

tobacco control law in India might shape his attitude towards the Act.

34

Rating for awareness about the law in India: Only respondents who were aware of any

tobacco control law in India was asked this question. Individuals were asked to rate

themselves as high, moderate or low regarding awareness of the law.

Aware of ban on smoking: This was to assess if awareness about ban on smoking had

any association with attitude towards the Act.

Awareness of the place where smoking is banned: Only respondents who were aware

of the provision ban on smoking was asked this question. The three choices given were

public places, homes and all places.

Awareness about penalty if someone violates the act: This was to assess if awareness

about the penalty had any association with attitude towards the Act.

Awareness about the penalty amount: The knowledge about the penalty amount may

influence the attitude towards the Act. Data were grouped into five groups- up to Rs 200,

Rs 500, Rs 1000, any amount and don‟t know.

Awareness about whom to complain: Data were collected using the groups-police,

person in charge of designated areas and don‟t know.

Awareness about age limit for prohibition of buying tobacco products: This was to

assess if an individual‟s attitude towards the Act is influenced by this factor.

Awareness about the age limit: Only respondents who were aware of the provision ban

on buying of tobacco by minors was asked this question .The choices were-less than 18

years and 18 years and above.

Awareness about age limit for prohibition of selling tobacco products: This was to

assess if an individual‟s attitude towards the Act is influenced by this factor.

Awareness about the age limit: Only respondents who were aware of the provision ban

on sale to minors was asked this question .The choices were-less than 18 years and 18

years and above.

35

Awareness about ban on advertisement of tobacco products and advertisement seen

in the past 30 days: This was to assess the influence of this factor on attitude towards the

Act. If a person had seen any advertisement on tobacco in the past 30 days that means the

act is not implemented and thus the person would have a negative attitude towards the act

as it is not effective.

Awareness about ban on sale of tobacco products near educational institutions: This

was to assess if awareness about ban on sale of tobacco products near educational

institutions had any association with attitude towards the Act.

Awareness about the distance within which tobacco shouldn’t be sold near

educational institutions: Only respondents who were aware of the provision ban on sale

of tobacco products near educational institutions was asked this question. Data were

collected using the groups-within 100 yards, 100 to 200 yards, more than 200 yards and

don‟t know.

Noticed health warning on tobacco products: A person who had noticed health

warnings on tobacco products is aware of the Act and also aware of the ill effects of

tobacco. This in turn can influence the attitude towards the Act.

Awareness about provisions of the act being implemented: Individuals attitude

towards the Act is greatly influenced by effective implementation of the Act. All the four

key provisions of the Act were listed.

iii. Variables related to barriers in implementation of the Act

Barriers in implementation of the Act: It is assumed that people who are aware of the

Act will also be aware of the barriers in implementation of the Act.

Measures for effective implementation of the Act: Suggested measures for effective

implementation of the Act.

36

iv. Variables related to tobacco use practices

Ever use of tobacco: If the participant had used tobacco anytime in the past he/she was

considered to have ever used tobacco.Tobacco use includes both smoke and smokeless

tobacco.

Current tobacco use: Current tobacco use was defined as any use in the past 30 days.

Smoking tobacco use: Self reported use of any form of smoking tobacco like cigarettes,

bidis and pipes.

Smokeless tobacco use: Self reported consumption of any form of chewing tobacco like

gutkha, dhapat, chada, zarda, pan masala, khaini, betel quid with tobacco and snuff were

included.

Anyone in the family using any kind of tobacco product: Self reported current tobacco

use status, of any family member was collected.

2.12 Ethical Considerations:

The study had obtained clearance from Technical Advisory Committee and

Institute Ethical Committee of Sree Chitra Tirunal Institute for Medical Sciences and

Technology, Thiruvananthapuram, Kerala prior to data collection.

The purpose of the study was explained and the interview was carried out only

after obtaining a prior informed written consent from the respondents in the household

survey. Similarly in the case of in depth interviews with the enforcement officials a

written informed consent was obtained preceding the interview. The participants had

freedom to withdraw from the study at any point of time. Confidentiality was maintained

with respect to the respondents and also regarding the information that was collected.

37

CHAPTER 3

RESULTS

The findings of the study are presented in this section.The general description of the study

population is presented first; the analysis of the factors related to the awareness about

COTPA and attitude towards it is described next under two sub sections- bivariate

analysis and multivariate analysis and the last part contains the result of the qualitative

survey.

3.1 Sample Characteristics:

A detailed depiction of the study sample has been provided in this section. The details of

the sample population will be discussed under the following titles: socio-demographic

details, awareness related factors, attitude related factors, barriers for implementation and

tobacco use practices. The overall statistics for each individual characteristic are identified

separately.

3.1.1 Socio-demographic characteristics of the sample population

The socio-demographic characteristic of the sample population is given in Table no

3.1.The mean age of the sample population was 41.07±15.17. Age range was 18 to 80

years. Two fifth of the sample population were below the age of 36 years and almost the

same proportion were above 36 years. More than half of the respondents were male.

About two third of the sample had more than ten years of schooling. More than half of the

respondents were currently employed. Three fifth of the respondents were currently

married. The mean household expenditure was 11102.08±6087. Majority of the

respondent belonged to the middle SES (three fifth).

38

Table 3.1 Socio-demographic characteristics of the sample population

VARIABLE FREQUENCY (%)

N=300

Age Group(years)

18-35

36-50

50+

122 (40.7)

108 (36.0)

70 (23.3)

Sex

Male

Female

157 (52.3)

143 (47.7)

Education

<=10 years of schooling

>10 years of schooling

101 (33.7)

199 (66.3)

Occupation

Currently Employed

Currently Not Employed

165 (55.0)

135 (45.0)

Marital status

Currently married

Others*

184 (61.3)

116 (38.7)

SES (Rs)

<=6221

6222-19465

>19465

missing

65 (21.7)

177 (59.0)

47 (15.7)

11 (3.6) * Others- never married, widow/widower, divorced and separated

Source: Primary survey, 2009 Guwahati

3.1.2 Awareness related factors

a. Awareness about tobacco related health problem and the dangers of different

types of tobacco

Awareness about tobacco related health problems and the dangers of different types of

tobacco is provided in Table 3.2.

39

Table 3.2 Awareness about tobacco related health problems and the dangers of

different types of tobacco

VARIABLES FREQUENCY (%)

Awareness of tobacco related health

problem (N=300)

hhh

problem

Health problem (N=300)

Yes 292 (97.3)

No 8 (2.7)

Health problems*

Cancer 159 (53.0)

Heart Problem 85 (28.3)

Respiratory disease 110 (36.7)

Tuberculosis 66 (22)

Diabetes 4 (1.3)

Hypertension 33 (11)

All of the above 44 (14.7)

Type of tobacco dangerous for health*

Cigarette 84 (28.0)

Bidi 69 (23.0)

Pan masala 71(23.7)

Snuff 27 (9.0)

Chada 47 (15.7)

Zarda 59 (19.7)

Khaini 23 (7.7)

All products 134 (44.7)

Awareness on harm of second hand smoke (N=300)

Yes 236 (78.7)

No 64 (21.3) * Percentage do not add to 100 because of multiple answers

Source: Primary survey 2009, Guwahati

40

b. Awareness of any tobacco control law in India

Awareness of any tobacco control law in India is given in Table 3.3.

Table 3.3 Awareness of any tobacco control law in India


Aware of any tobacco control law in India (N=300)

Yes

No

98 (32.7)

202 (67.3)

Level of awareness (N=98)

High

Moderate

Low

27 (27.6)

50 (51.0)

21 (21.4)


c. Awareness of ban on smoking in public places

Awareness of ban on smoking in public places is given in Table 3.4

Table 3.4 Awareness of ban on smoking in public places


Awareness of smoking ban in India (N=300)

Yes

No

Don‟t know

246 (82.0)

43 (14.3)

11 (3.7)

Place of ban (N=246)

Public places

All places

145 (58.9)

101 (41.1)

Penalty for violating the act (N=246)

Yes

No

Don‟t know

140 (56.9)

57 (23.2)

49 (19.9)

Penalty amount (N=140)

Up to Rs 200 17 (12.1) Rs 500 52 (37.1) Rs 1000 27 (19.3)

Any amount 28 (20.0)

Don‟t know 16 (11.4)

Whom to complain (N=246)

Police 97 (39.4)

Person in charge of designated areas 66 (26.8)

Don‟t know 83 (33.7)


41

d. Awareness about ban on sale of tobacco products to anyone below 18 years

(minors)

Awareness about ban on sale of tobacco products to minors is given in Table 3.5.

Table 3.5 Awareness about ban on sell of tobacco products to minors


Awareness of age limit for selling of tobacco (N=300)

Yes

No

Don‟t know

68 (22.7)

168 (56.0)

64 (21.3)

Age limit (N=68)

Less than 18 years

18 years and above

65 (95.6)

3 (4.4)

Awareness of age limit for buying of tobacco products (N=300)

Yes

No

Don‟t know

68 (22.7)

172 (57.3)

60 (20.0)

Age limit(N=68)

Less than 18 years

18 years and above

65 (95.6)

3 (4.4)


e. Awareness about ban on advertisement of tobacco products

Awareness about ban on advertisement of tobacco products is given in Table 3.6.

Table 3.6 Awareness about ban on advertisement of tobacco products


Awareness on ban on advertisement (N=300)

Yes

No

Don‟t know

124 (41.3)

153 (51.0)

23 (7.7)

Advertisement seen in the last 1 month (N=300)

Yes

No

76 (25.3)

224 (74.7)


42

f. Awareness about ban on sell of tobacco near educational institutions

Awareness about ban on sale of tobacco near educational institutions is given in Table

3.7.

Table 3.7 Awareness about ban on sale of tobacco near educational institutions


Aware of ban on sale of tobacco near educational institution (N=300)

Yes

No

Don‟t know

121 (40.3)

151 (50.3)

28 (9.3)

Distance within which it shouldn’t be sold (N=121)

Within 100 yards

100 to 200 yards

More than 200 yards

Don‟t know

20 (16.5)

40 (33.1)

20 (16.5)

41 (33.9)


g. Awareness about specified health warnings on tobacco packets

Awareness about specified health warnings on tobacco packets is given in Table 3.8.

Table 3.8 Awareness about specified health warnings on tobacco packets


Health warnings on tobacco packets (N=300)

Yes

No

227 (75.7)

73 (24.3)


h. Knowledge about any provision of COTPA being implemented

Knowledge about any provision of COTPA being implemented is given in Table 3.9.

43

Table 3.9 Knowledge about any provision of COTPA being implemented


Aware of the Act being implemented (N=300)

Yes

No

Don‟t know

54 (18.0)

165 (55.0)

81 (27.0)

Aware of the provision being implemented*

Ban on smoking in public place 25 (8.3)

Ban on advertisement 9 (3.0)

Ban on sale to minors 0 (0.0)

Ban on sale near educational institution 12 (4.4)

Specified health warnings 23 (7.7)

*Percentage do not add to 100 because of multiple answers


i. Awareness score for COTPA

Awareness score for COTPA is given in Table 3.10.The mean score of awareness about

COTPA was 3.35 out of 8 (SD 1.9) with a range of minimum 0 and maximum 8. Score up

to 3 was graded as „poor awareness‟ and more than 3 was graded as „good awareness‟.

More than half of the respondents had poor awareness about COTPA.

Table 3.10 Awareness score for COTPA


Awareness about COTPA (N=300)

Poor awareness

Good awareness

163 (54.3)

137 (45.7)


44

3.1.3 Attitude related factors

Attitude related factors are given in Table 3.11.The mean score of attitude towards

COTPA was 184.83 out of 400 (SD 84.71) with a range of minimum 7 and maximum

400.

Table 3.11 Attitude towards COTPA


N=300

Attitude towards ban on smoking

Negative attitude

Positive attitude

83 (27.7)

217 (72.3)

Attitude towards ban on advertisement

Negative attitude

Positive attitude

117 (39.0)

183 (61.0)

Attitude towards prohibition on sale to minors and within 100 yards

Negative attitude

Positive attitude

49 (16.3)

251 (83.7)

Attitude towards specified health warnings

Negative attitude

Positive attitude

102 (34.0)

198 (66.0)

Overall Attitude

Negative attitude

Positive attitude

70 (23.3)

230 (76.7)


45

3.1.4 Barriers for Implementation

Barriers for Implementation are given in Table 3.12.

Table 3.12 Barriers for Implementation


Barriers (N=300)

Yes 235 (78.3)

No 65 (21.7)

Knowledge about the barriers*

Lack of awareness of the Act 102 (34.0)

Not familiar with the provisions of Act 25 (8.3)

Lack of awareness of ill effects of tobacco 22 (7.3)

Lack of complete information 17(5.7)

Lack of administrative support 34 (11.3)

Lack of financial and human resources 12 (4.0)

Fear of public opposition 36 (12.0)

Tobacco issues given less priority 42 (14.0)

Difficulty in paying fine by low SES 9 (3.0)

Cultural acceptance 61 (20.3)

Definitions are not clear 12 (4.0)

Others 6 (2.0) *Percentage do not add to 100 because of multiple answers


3.1.5 Measures for effective implementation of the Act

Measures for effective implementation of the Act are given in table 3.13.

Table 3.13 Effective implementation of the Act


Measures for effective implementation of the Act*

Involve social workers 29 (9.7)

Involve Police 51 (17.0)

Involve local self government 50 (16.7)

Penalties 27 (9.0)

Public education on health hazards 101 (33.7)

Publicizing the Act through media 131 (43.7)

Definitions should be clear cut 49 (16.3)

All of the above 26 (8.7) *Percentage do not add to 100 because of multiple answers.


46

3.1.6 Tobacco use practices

Tobacco use practices are given in Table 3.14.

Table 3.14 Tobacco use practices


Ever Used (N=300)

Yes 191 (63.7)

No 109 (36.3)

Current Use (N=300)

Yes 157 (52.3)

No 143 (47.7)

Using smoke type (N=300)

Yes 96 (32.0)

No 204 (68.0)

Using smokeless type (N=300)

Yes 88 (29.3)

No 212 (70.7)

Anyone in family use tobacco (N=300)

Yes 163 (54.3)

No 137 (45.7)


Almost three fifth (fifty eight percent) of the respondents were current users of tobacco in the age

group of 36-50 years. Two fifth of the females (forty percent) and more than three fifth males

(sixty three percent) were currently using tobacco. Seventy six percent of respondent with less

than or equal to 10 years of schooling and forty percent with more than 10 years of schooling were

currently using tobacco. More than two fifth people (forty four) who were currently not employed

and almost three fifth (fifty nine) currently employed were currently using tobacco. More than

four fifth (eighty six percent) of the respondent in the low SES were currently using tobacco.

More than fifty percent of males were currently using smoking form of tobacco compared to only

nine percent of females. Three fifth (sixty percent) of the respondent in low SES were using

smoking form of tobacco. Among females thirty six percent were using smokeless variety of

tobacco compared to twenty three percent males. More than half of the respondents (fifty five

47

percent) with less than or equal to 10 years of schooling were using smokeless variety of tobacco

and more than three fifth of the respondent (sixty two) in low SES were using the same.

3.2 Analysis of the factors related to awareness of COTPA and attitude towards it

3.2.1 Results of bivariate analysis

Simple chi square analysis was done to examine whether awareness of COTPA and

attitude towards it was influenced by any of the above mentioned factors. This analysis

was further divided as follows. The factors related to the first outcome variable-

awareness for COTPA were explored first and then those related to the second outcome

variable- attitude towards COTPA.

3.2.1.1 Results of analysis with outcome variable - Awareness of COTPA

a. Association of socio-demographic factors with Awareness of COTPA-

Association of socio-demographic factors with Awareness of COTPA is given in Table

3.15. As age increases the good awareness of COTPA increases significantly. As SES

improves the awareness about COTPA also improves.Socio-demographic factors that

were not found to be significant in the awareness scores were sex and occupation.

48

Table 3.15 Association of socio-demographic factors with Awareness of COTPA

Poor

awareness

(%)

Good

awareness

(%)

Total

χ2

P-value

Age (N=300)

18-35 years 80 (65.6) 42 (34.4) 122

0.001

36-50 years 56 (51.9) 52( 48.1) 108

50+ years 27 (38.6) 43 (61.4) 70

Marital status (N=300)

Currently

married

91 (49.5) 93 (50.5) 116

0.033

Others*

72 (62.1) 44 (37.9) 184

Education (N=300)

<=10 years of

schooling

81 (80.2) 20 (19.8) 101

< 0.001

>10 years of

schooling

82 (41.2) 117 (58.8) 199

SESa

<=6221 56 (86.2) 9 (13.8) 65

< 0.001

6222-19465 82 (46.3) 95 (53.7) 177

>19465 20 (42.6) 27 (57.4) 47

Sex (N=300)

Female

85 (59.4) 58 (40.6) 143 0.090

Male 78 (49.7) 79 (50.3) 157

Occupation (N=300)

Currently not

employed

Currently

employed

77 (57.0) 58 (43.0) 135

0.400

86 (52.1) 79 (48.0) 165

*Others- never married, widow/widower, divorced and separated

a Socio economic status


b. Association of awareness of tobacco related health problems with awareness of

COTPA

Association of awareness of tobacco related health problems with awareness of COTPA is

given in Table 3.16.Good awareness was significantly higher among those who were

aware of the harm due to second hand smoke.

49

Table 3.16 Association of awareness about tobacco related health problems with awareness

of COTPA

Poor

awareness (%)

Good

awareness (%)

Total

( N=300)

χ2

P-value

Awareness on harm of second hand smoke

No 53 (82.8) 11 (17.2) 64

< 0.001 Yes 110 (46.6) 126 (53.4) 236


c.Association of Tobacco use practices with awareness of COTPA

Association of Tobacco use practices with awareness of COTPA is given in Table 3.17

Table 3.17 Association of Tobacco use practices with awareness of COTPA

Poor

awareness (%)

Good

awareness (%)

Total

(N=300)

χ2

P-value

Ever used

No 42 (38.5) 67 (61.5) 109

< 0.001 Yes 121 (63.4) 70 (36.6) 191

Current tobacco use

No 59 (41.3) 84 (58.7) 143

< 0.001 Yes 104 (66.2) 53 (33.8) 157

Anyone in family use

No 64(46.7) 73(53.3) 137

0.015 Yes 99(60.7) 64(39.3) 163


Ever users and current users of tobacco were significantly less aware of COTPA

compared to their counterparts. Awareness of COTPA was significantly higher among

those whose family members did not use tobacco compared to those whose family

members did use tobacco.

50

3.2.1.2 Results of analysis with outcome variable-Attitude towards COTPA

a. Association of socio-demographic factors with attitude towards COTPA

Association of socio-demographic factors with attitude towards COTPA is given in Table

3.18

Table 3.18 Association of socio-demographic factors with attitude towards COTPA

Negative

Attitude(%)

Positive attitude

(%)

Total

χ2

P-value

Age (N=300)

18-35 years 36 (29.5) 86 (70.5) 122

0.008 36-50 years 27 (25.0) 81 (75.0) 108

50+ 7 (10.0) 63 (90.0) 70

Education (N=300)

<=10years of

schooling

52 (51.5) 49 (48.5) 101

< 0.001

>10years of

schooling

18 (9.0) 181 (91.0) 199

SESa

<=6221 44 (67.7) 21 (32.3) 65

< 0.001 6222-19465 19 (10.7) 158 (89.3) 177

>19465 4 (8.5) 43 (91.5) 4

Sex (N=300)

Female 32 (22.4) 111 (77.6) 143

0.709

Male 38 (24.2) 119 (75.8) 157

Marital Status (N=300)

Currently 40 (21.7) 144 (78.3) 184

married 0.411

Others* 30 (26.0) 86 (74.1) 116

Occupation Currently not 26(19.3) 109 (80.7) 135

employed 0.131

Currently 44(26.7) 121 (73.3) 165

employed

a Socio economic status

*Others- never married, widow/widower, divorced and separated


51

As age increases the attitude towards COTPA increases significantly. As SES improves

the attitude towards COTPA also improves.

Socio-demographic factors that were not found to be significant in the attitude scores

were sex, marital status and occupation.

b. Association of awareness about tobacco related health problems with attitude

towards COTPA

Association of awareness about tobacco related health problems with attitude towards

COTPA is given in Table 3.19.

Positive attitude was significantly higher among those who were aware of the harm due to

second hand smoke.

Table 3.19 Association of awareness about tobacco related health problems with

attitude towards COTPA

Negative

attitude (%)

Positive

attitude (%)

Total

N=300

χ2

P-value


No 41 (64.1) 23 (35.9) 64 < 0.001 Yes 29 (12.3) 207 (87.7) 236


c. Association of awareness of COTPA with the attitude towards COTPA

Association of awareness of COTPA with the attitude towards COTPA is given in table

3.20. Those who had good awareness of COTPA showed a significantly better positive

attitude towards it.

52

Table 3.20 Association of awareness of COTPA with the attitude towards COTPA

Negative

attitude (%)

Positive

attitude (%)

Total

N=300

χ2

P-value

Awareness of the Act

Poor awareness 56 (34.4) 107 (65.6) 163

< 0.001 Good awareness 14 (10.2) 123 (89.8) 137


d. Association of tobacco use practices with attitude towards COTPA

Association of tobacco use practices with attitude towards COTPA is given in Table 3.21.

Table 3.21 Association of Tobacco use practices with attitude towards COTPA

Negative

attitude (%)

Positive

attitude (%)

Total

χ2

P-value

Ever used

No 2 (1.8) 107 (98.2) 109 < 0.001

Yes 68 (35.6) 123 (64.4) 191

Current use

No 6 (4.2) 137 (95.8) 143 < 0.001

Yes 64 (40.8) 93 (59.2) 157

Anyone in family

No 19 (13.9) 118 (86.1) 137 < 0.001

Yes 51 (31.3) 112 (68.7) 163


Non users of tobacco (both ever and current) had significantly higher positive attitude

towards COTPA compared to their counterparts. Attitude towards COTPA was

significantly higher among those whose family members did not use tobacco compared to

those whose family members did use tobacco.

53

3.2.2 Multivariate Analysis (Binary logistic regression)

3.2.2.1 Results of binary logistic regression for awareness of COTPA

Results of multiple logistic regression for awareness of COTPA is given in Table 3.22.

Table 3.22 Results of multiple logistic regression for awareness of COTPA

VARIABLE ADJUSTED OR CONFIDENCE

INTERVAL

P-VALUE

Age

18-35 years 1

36-50 years 1.41 0.74-2.71 0.300

50+years 3.02 1.44-6.31 0.003

Marital status

Married 1.46 0.80-2.65 0.207

Others 1

Education

<=10years of schooling 1

> 10years of schooling 3.60 1.70-7.70 0.001


Yes 1.86 0.80-4.29 0.146

No 1

Current tobacco use

No 1.38 0.58-3.28 0.470

Yes 1

Anyone in family using tobacco

No 0.85 0.48-1.48 0.560

Yes 1

Ever used

No 0.98 0.40-2.36 0.962

Yes 1

SES

≤ Rs 6221 1

6222-19465 1.84 0.69-4.92 0.222

>19465 1.53 0.47-5.00 0.477


54

Two variables age and education were found to be significantly associated with awareness

of COTPA using this model. Older people (50+ years) were three times more likely to

have good awareness of COTPA compared to the people belonging to 18-35 years age

group. Similarly more educated people are four times more likely to have good awareness

of COTPA then less educated people.The predicted value was 70 percent for this model,

i.e. 70 percent of the variation in awareness can be explained by the independent

variables.

3.2.2.2 Results of binary logistic regression for attitude towards COTPA

Results of multiple logistic regression for attitude towards COTPA is given in Table

3.23.Three variables education, socio economic status and awareness about second hand

smoke being harmful were found to be significantly associated with attitude towards

COTPA using this model. More educated group was three times more likely to have a

positive attitude towards the Act then the less educated group. Those in the middle SES

were almost four times more likely to have a positive attitude towards COTPA than those

in the low SES. The group that believe second hand smoke is harmful were three times

more likely to have a positive attitude towards the Act then their counterparts. The

predicted value was 88.2 percent, i.e. 88 percent of the variation in attitude can be

explained by the independent variables.

55

Table 3.23 Results of multiple logistic regression for attitude towards COTPA

VARIABLE ADJUSTED OR CONFIDENCE

INTERVAL

P-VALUE

Age

18-35 years 1

36-50 years 0.80 0.33-2.00 0.609

50+years 2.56 0.71-9.23 0.149

Education

<=10years of schooling 1

> 10years of schooling 2.92 1.01-8.45 0.047

SES

≤ Rs 6221 1

6222-19465 3.36 1.13-10.01 0.030

>19465 2.70 0.56-12.84 0.213

Current tobacco use

No 3.15 0.89-11.12 0.074

Yes 1

Ever used

No 3.53 0.54-22.84 0.186

Yes 1

Anyone in family using tobacco

No 0.89 0.38-2.10 0.800

Yes 1

Awareness of COTPA

Poor awareness 1

Good awareness 1.21 0.50-2.90 0.662


Yes 3.32 1.45-7.62 0.005

No 1


3.3 Results of qualitative analysis:

There were 58 codes identified for the provision ban on smoking in public places, 49

codes for ban on advertisement of tobacco products, specified health warnings on all

tobacco products and ban on sale of tobacco to minors (the responses for this three

provisions were considered together as the enforcers were the same for all the three) and

56

42 codes for prohibition of sale of tobacco products within 100 yards of educational

institutions. The codes were then collapsed into themes that were explicit as part of the

analysis. The key themes identified were:

1. Input factors

a. Awareness of the act (both being aware and not being aware of the act)

b. Personal use of tobacco(whether or not the person used tobacco products

personally)

c. Existence/availability of official documents/rules about how to ban tobacco

d. Beliefs about the impact of prevention

2. Process factors

a. Beliefs about the Tobacco legislation

b. Beliefs about use of tobacco

c. Beliefs about tobacco related health effects

3. Outcomes

a. Action taken to reduce tobacco use at individual level

b. Action taken to reduce tobacco use at the institution level

The linkages between the various themes were identified by re-reading the interviews to

delineate the possible connections and also to validate those that were newly identified.

The identified themes and the interconnections between them are depicted in a schematic

diagram given below (Figure 3.1).

57

Figure 3.1 Thematic diagram of qualitative analysis

The Linkages:

The awareness of the Act and the personal use of tobacco by individuals who were in

charge of implementation were two of the key input factors required for action with

regard to implementation of the Act on tobacco use. These two factors shape the beliefs

about the tobacco Act, beliefs about tobacco use and belief about tobacco related health

effects. These beliefs are converted to concrete actions with regard to reducing the use of

tobacco only when regulations about the tobacco are made available to the concerned

officials and their own personal beliefs about the effectiveness of prevention strategies are

in consonance with the Act.

An enforcement official who personally uses tobacco tends to think that the Act would

not be effective and have his own beliefs and perceptions about tobacco use like for

example smokeless type of tobacco being less harmful then the smoked variety. Such a

Belief about

tobacco act

Action taken to

reduce tobacco use

at individual level

Empowered

officially to

take action Awarene

ss of Act

Belief about

tobacco use

Personal

use of

tobacco

Belief about

tobacco

related health

effects

Action taken to

reduce tobacco use

at institutional level

Beliefs

about

prevention

58

person would have diminished commitment towards implementation of the Act because

of his/her own personal habit of using tobacco products. He/she would be less likely to

implement the Act and in case if official orders are passed to bring this Act into Action

the enforcement official may not have any moral authority over others below him to

implement the Act because of his/her own personal choices vis-a-vis tobacco use.

Ban on smoking in public places:

Most of the implementers who reported that they aware of the Act were did not have

specific knowledge of the standard specifications. Most of them reported that they do not

know whom to complain to if someone violated the Act and they were even unaware of

the legal penalty if someone violates the Act. An implementer said that the Act is not well

defined for example „what is a public place‟? The implementers of the act were

themselves not aware of their responsibilities as implementers of the Act.

Another implementer felt that complaining to the authorities about the violation of the Act

is not the solution for effective implementation of the Act. There was a distinct difference

in the type of beliefs about tobacco use. This was shaped by the individual‟s current use

of tobacco products. While those who used tobacco reported being aware of tobacco

related health effects, they had ideas about use that were not accurate and related to their

own use of tobacco products – for example one of the implementers believed that chewing

tobacco was not as harmful as smoking tobacco. When asked about their beliefs about

tobacco being harmful, some thought that smoking helps them to take a break from day to

day work and relax. Other beliefs like „cigarette keeps one active‟, „Tobacco products if

used in excess causes harm‟ and „tobacco can‟t be blamed for all health problems‟

emerged from the discussion. Personal use of tobacco greatly shapes the belief about the

Act. A person who uses tobacco belief that the Act might not be effective as it is very

59

tough for him to not smoke as it has become a habit now. Most of the implementers

thoroughly relied on official notification of the Act without which they think that they are

not empowered to take any Action. The barriers reported for the proper implementation of

the Act were public opposition, lack of interest of the enforcers, no Act for smokeless

variety, lack of awareness of the Act, lack of political support, not levying penalty and

advertisement of tobacco products. People were greatly dependent on official notifications

to empower them to take action. Respondents who did not use tobacco and also belief the

Act will be effective had taken action without waiting for any official notification.

Recommendations by the implementers to overcome the barriers were - publicizing the

Act through media, increase the price of tobacco products, legislation for the smokeless

variety and levying penalty from those who violates the Act.

Ban on advertisement and specified health warnings:

The pattern of belief and attitude was same for this group of stakeholders also. Those who

used tobacco products had some beliefs regarding tobacco related health effects. They

believed that smoking type is more harmful than the smokeless type, tobacco if used

frequently and for a longer duration causes harm to the body and tobacco is not a major

cause of any disease. The perceived barriers among these groups were – the problems

experienced by implementers of tobacco legislation themselves violating the regulations,

lack of proper training of the implementers, lack of complete information about the Act,

difficulty in understanding the graphical images on the tobacco packets, health warnings

on display are in the local language and tax from tobacco contributes a major share to the

economy. Recommendations for proper implementation of the Act were- tobacco control

programs should be organised and monitored, creating awareness about the Act among

the enforcement officials, replacing the graphical images by some pictorial images, apart

60

from the local language warnings should be in Hindi and English so that most of the

people can read.

Ban on sell of tobacco within 100 yards of educational institutions:

According to one of the respondent tobacco use among people in the younger age group is

increasing because they believe that smoking makes them look smart. Peer pressure

among children and easy accessibility of tobacco products near educational institutions

also are factors increasing the use of tobacco in children. One of the respondents – a

teacher in a school who is an implementer for the ban on sale of tobacco within 100 yards

of educational institutions said that she does not know „how much is 100 yards is‟. Some

others felt that the distance mentioned in the Act was arbitrary. It was noticed that beliefs

about this law were also shaped by personal use of tobacco in part.

One of the major barriers reported were that only few selected schools had been informed

about the Act. The selection criteria used for informing schools were unknown.

Recommendations for proper implementation of the Act were- parents should oppose the

use of tobacco among children, all the schools should be informed by the government

about the Act, there should be proper monitoring by the police and the definitions of

specific issues used to define features of the law like „100 yards‟ – what does it indicate in

terms of distance; should be made clear.

61

CHAPTER 4

DISCUSSION AND CONCLUSION

4.1. Discussion:

Cigarettes and Other Tobacco Products Act (COTPA) intended to protect and

improve public health, encompasses various measures to reduce tobacco consumption.

Less awareness and negative attitude towards the Act may lead to non implementation or

poor implementation of the Act which will result in increase tobacco use in the

population.

Large segment of the population in the city is young according to census 2001.61

In

my study only 23 percent of people was in the older age group (above 50 years). Almost

48 percent of the population were females which shows similar pattern with the census

2001 data where the female population of Guwahati was reported to be 46 percent.61

More

than three fifth (66.3 percent) of the population had education of ≥ 10 years of schooling

which may be due to the urban setting where the study was done. Majority of the

population belong to the middle and high socio economic status. This also may be due to

the urban setting where the study was done.

In this study almost everyone (97 percent) was aware that tobacco causes health

problem unlike the study in Kolkata where 20 percent of the cases and control had no idea

about the adverse effects of tobacco use.31

This is a positive aspect because if people are

aware of the health problems caused by tobacco with a little more effort to implement the

Act, we can expect the population to accept the Act and support it. Peoples‟ awareness of

tobacco causing cancer and heart problem and respiratory disease was high similar to

62

some previous studies.30,52

A study in Kerala reported that among 153 former TB patients

surveyed, two thirds were current smokers at the time of TB diagnosis.61

In another study from south India, it was found that in both rural and urban areas

death rate from tuberculosis was about four times among ever smokers than in never

smokers.62

The above mentioned studies implies that tobacco is one of the major risk

factors for TB but the association between tobacco and TB has been underestimated. One

area where additional TB control efforts are needed is tobacco cessation.61

In the present

study only 22 percent were aware of tobacco causing TB. Specific education program to

create awareness about tobacco causing TB among the general population as well as

among TB patients is extremely important to bring down the prevalence of TB.

Another interesting finding in the present study was that only one percent of the

population knew that tobacco causes diabetes which is similar to the results of a previous

study in Kerala among the members of the local self government bodies.52

Similarly

another study in Kerala came up with the same finding where more than half of the

diabetic patients did not associate smoking with diabetes complications. Majority of the

current smokers reported that smoking does not influence or aggravate

diabetes. Clearly, a

lack of awareness exists regarding the linkages of tobacco use and diabetes and its

complications.63

There is a need to raise the consciousness among the diabetics about the

consequences of tobacco use. More proactive tobacco cessation

efforts should be

specifically focused on diabetes patients in India.63

A previous study showed that hypertension was most common in smokeless

tobacco users.64

Another study in Kerala showed that smoking status was an important

correlate of hypertension.65

A study among the migrant population in Delhi showed that

63

only a few of them cited tobacco as a cause of hypertension.66

In this present study only 11

percent were aware that tobacco causes hypertension.

Specific educational programs should be organized on awareness of the health

hazards of tobacco mainly targeting the general population and specifically diabetic, TB

and hypertensive patients. In this study less than half of the population were aware of the

Act and this may be due to the poor awareness about the association of tobacco with

diseases.

Smokeless tobacco was considered to be either equal to or more harmful than

smoking in a study done among student health professionals.67

Another study among

medical students in Patna showed that awareness of the ill effects of smokeless tobacco

and areca nut products was much lower than knowledge about smoking.68

According to

NFHS-3 data smokeless tobacco use is very high in Assam. This may be due to the

perception of the people that smokeless variety is less harmful than the smoking variety

and also it is accepted as part of socio cultural aspect in Assam. COTPA also does not

emphasise much on smokeless variety. In the present study females are using more of

smokeless tobacco. This may be due to cultural acceptance and the greater use of

smokeless tobacco by women is associated with less stigma compared to smoking. The

socio cultural influences that encourage tobacco use must be studied carefully to control

tobacco consumption.

Bidis are perceived to be less of a risk to health than cigarettes. Bidi is no less

harmful than cigarettes.69

In the present study also cigarette was considered to be more

harmful than bidi. This may be due to lack of awareness among the population about harm

caused by bidi. Even the anti tobacco advertisements in the media carry only the message

on harmful effects of cigarettes. It grossly fails to discuss the harm associated with the

64

smoking of bidi. There is an immediate need for advertising the harmful effects of bidi.

Advertisements are the best means to raise awareness about the harm caused by bidis.

One of the main reasons why people smoke bidi is that it is cheap. Educational programs

on harm of bidi should be organised.

The awareness on harm caused by second hand smoke was quite high (79 percent)

which was contrary to other studies done in Wellington and Sydney70, 71

, but is

comparable to a study in China where half of the Chinese urban smokers and 4 in 5 non-

smokers believed that second-hand smoke (SHS) is harmful.

49 Steps should be taken to

encourage the vast majority of non smokers, to recognize their right to life and health.

People who smoke had certain specific beliefs about it. In this study few of the

enforcers believed that smoking makes them active and also helps them to relax. Another

study showed similar beliefs of people about smoking.72, 73

Only one third of the population was aware of any tobacco control law in India

similar to the study in Azerbaijan where most respondents had low levels of awareness

about existing national tobacco control laws and the FCTC.51

About 82 percent of the

adults were aware of the existing smoking ban in public places, while 41 percent knew

that tobacco advertisements in print and electronic media were banned, similar to the

study among local self government bodies in Kerala.52

Only one fifth of the population

was aware of the age limit for prohibition of sale to minors and two fifth knew about the

existing ban on sale of tobacco products within 100 yards of educational institutions

contrary to the findings of the Kerala study.52

Only about one fifth of the respondent

reported any of the provision of the Act being implemented in their area. Banning tobacco

advertising was favoured by 61 percent similar to a study done in South Africa.46

65

In this study there was good awareness about ban on smoking in public places and

specified health warnings on all tobacco products. This may be due to the recent

enforcement of both the provisions of the Act. India on 2nd

October, 2008 imposed a

countrywide ban on smoking in public places in its fight against tobacco use. India has

had laws against smoking in public places in place for some time, but they have not been

enforced strictly. The new order bars smoking in all public places. People can continue to

smoke in their homes and open spaces. For effective implementation of this provision the

enforcement officials should be notified and they should be given training so that they

understand the legal provisions. Proper monitoring and follow up is necessary for the

effective implementation of this provision. The provision should be strictly enforced and

there should be means to record offences. An example of the positive impact of ban on

smoking is the city of Chandigarh in India. Chandigarh is the first city in Southeast Asia

and India to be declared as a smoke free city from 15th

July 2007.This was possible

because the law was strictly enforced following all the norms and the Government as well

as the enforcement officials in Chandigarh considered tobacco to be a very serious issue.74

The civil society organizations were also actively involved in this. This experience can be

replicated in other parts of the country including Guwahati by stronger determination by

the public, enforcement officials, Government and civil society organizations.

After much delay and postponement The Ministry of Health and Family Welfare,

Government of India at last mandated that all tobacco products

manufactured/packaged/imported in India on or after 31 May 2009 have to display

pictorial health warnings as specified under the Cigarettes and Other Tobacco Products

(packaging and labelling) Rules 2008. It is very important to depict health warnings on

tobacco packets as studies in many countries that have already implemented show that it

66

has a positive impact on public health.75, 76

Few studies in the past showed that people

considered the graphical images on cigarette packets as uninformative and irrelevant.

They couldn‟t relate themselves with the labels.48, 77

The present study shows that to

increase the likelihood of a policy to be effective it is important to seek the perspectives of

the population before formulating and implementing polices aimed at protecting them.

The pictorial images should be designed in such a way that they can convey health risks to

the tobacco users. Pictorial warnings may be particularly important in communicating

health information to populations with lower literacy rates.

People in the study were not much aware about the ban on sale to minors and

prohibiting sale of tobacco within 100 yards of educational institutions. This could be due

to the non implementation of these provisions of the Act. It is very important to

implement these measures because this will ensure preventing early initiation into use. All

the enforcement officials including the staff of the school should be empowered to take

actions against violations. It is very important to educate the teachers and school

authorities of these legal provisions. Inspections should be conducted to check violations.

In this study only two fifth of the population was aware of the ban on

advertisement of tobacco products. Cigarette companies have developed sophisticated

campaigns targeting men, women, and children in different socioeconomic groups. Their

strategies have smartly avoided the Indian tobacco advertising ban. Understanding these

marketing strategies is critical to minimise the exploitation of loopholes in tobacco

control legislation.78

Young individuals perception and attitude about tobacco use is

influenced by watching their favourite actors who are their role model smoke on screen in

films and television. In India where people are ardent movie fans not just teenagers but

adults too are influenced by the on-screen behaviour of their favourite film star.79

In

67

January 2009, the Delhi High Court had overturned a government ban on showing

smoking scenes in films. The court said that the ban violated the fundamental right of

film-makers to freedom of speech and expression. Proper steps must be taken to

reimplement this provision so as to reduce the use of tobacco in the population.

The overall attitude of the population towards COTPA was high. This implies that

with a little more effort to implement the Act, we can expect the population to accept the

Act and support it. People supported and had a positive attitude towards stronger

enforcement of the provision prohibiting the sale of tobacco products to minors similar to

many studies done previously. 36-39, 45

Probably measures like non availability of tobacco

products near educational institutions and increasing the tax of tobacco products will

reduce the use of tobacco among youths.

As age increases the attitude towards COTPA increases significantly. This could

be because the elderly people do not want the younger generation to become addicted to

tobacco. They must have seen and experienced the harmful effects of tobacco and thus

they don‟t want the younger generation to suffer. As SES improves the attitude towards

COTPA also improves similar to the study in China.47

People who were aware of the

harm of second hand smoke were showing significant association with positive attitude.

The group that believe second hand smoke is harmful were three times more likely to

have a positive attitude towards the Act than their counterparts. Support for

comprehensive smoke free policies was positively associated with knowledge about the

harm of SHS.49

Having a good awareness about the law was significantly associated with

positive attitude. Non users of tobacco (both ever and current) had significantly higher

positive attitude towards COTPA compared to their counterparts as it is established in

many previous studies.36, 40, 47

Efforts should be made to increase the awareness focussing

68

on younger population, less educated, and those belonging to the low SES particularly on

the health effects of second hand smoking and the existence of the Act.

As age increases the good awareness of COTPA increases significantly. Older

people (50+ years) were three times more likely to have good awareness of COTPA

compared to the people belonging to 18-35 years age group .This may be due to the

exposure of the older people to anti tobacco advertisements on television or radio. Most of

the older people in this study were retired, so they stay at home and they pass their time

by watching television or listening to the radio. Anti tobacco messages are delivered in

those medias. This could be one reason why the awareness is high among them. More

than 10 years of schooling showed a significant association with good awareness. More

educated people were four times more likely to have good awareness of COTPA then less

educated people. This could be because the health warnings on the tobacco packets are

not very communicative i.e a person with less education or an uneducated person doesn‟t

understand the graphical images on the tobacco packets. The group of people who are

educated may be exposed to environment where anti tobacco legislation is implemented

thus their awareness is more. As SES improves the awareness about COTPA also

improves. We assume that in most cases low SES means less education and thus poor

awareness. Awareness of COTPA was high among the non users as compared to their

counterparts. May be the non users were not using tobacco because they knew about the

ill effects of tobacco and also was aware of the Act.

Barriers for proper implementation of the law which were reported by the

enforcement officials as well as by the adult population under GMC were -lack of

knowledge about the Act, no official notification received, tobacco issues given less

priority, cultural acceptance of tobacco, definitions are not clear cut, lack of awareness

69

about the health hazards of tobacco etc. Similar barriers were reported by a study done by

HRIDAY among the enforcement officials in 14 States and two Union Territories .80

A

few other previous studies report similar kind of barriers for the implementation of anti

tobacco legislation.52,55,56

.Therefore it implies that overcoming these barriers would help

to effectively implement the Act. The funding of Indian political parties by tobacco

companies is one of the major challenges for the implementation of the Indian Tobacco

Control Act.81

For the Act to be effectively implemented the political parties should refuse

from accepting tobacco company funds. It implies that overcoming these barriers would

help to effectively implement the Act.

Suggested recommendations by the enforcers for the proper implementation of

the Act were- publicizing the Act through media, increase the price of tobacco products,

legislation for the smokeless variety , levying penalty from those who violates the Act,

replacing the graphical images by some pictorial images, apart from the local language

warnings should be in Hindi and English , tobacco control programs should be organised

and monitored, ddefinitions should be clear cut ,creating awareness about the Act among

the enforcement officials.Similar studies among enforcement officials show similar kind

of recommendations by them.One of the major recommendations in the qualitative survey

was to increase the tax on tobacco products.83

This study shows the importance of

seeking the perspectives of the population before formulating and implementing policies

aimed at protecting them which is likely to increase effectiveness resulting in positive

outcomes.

70

4.2. Limitations of the study:

1. All the limitations of a cross sectional study.

2. The study sample frame included urban population and as such, the findings may not be

generalized to all metropolitan areas of India mainly because of socio cultural differences.

3. Because of the urban-focused study areas, the findings cannot be extrapolated to rural

populations.

4. The study excluded minors (age less than 18 years) .

4.3. Strengths of the study:

1. Single investigator conducted all interviews. This eliminated inter-observer variability.

2. This study was community based.

3. The qualitative survey has substantiated many of the findings of the quantitative

survey.

4.4. Conclusion:

In this community based study to see the awareness and attitude towards COTPA, good

awareness was reported by 46% (95% CI 40.4% -51.6%) and positive attitude by 77% (CI

71.9% - 81.5%) of the population. Adults > 50 years were three times [(Odds Ratio (OR)

3.02, CI 1.44-6.31)] more likely to have good awareness of COTPA compared to adults in

the age group of 18-35 years. Those with > 10 years of schooling were four times (0R

3.60, CI 1.70-7.70) more likely to have good awareness of COTPA compared to those

with ≤ 10 years of schooling. Those belonging to the middle socioeconomic status (SES)

were three times (0R 3.36, CI 1.13-10.01) more likely to have a positive attitude towards

COTPA compared to those belonging to low SES. Those who reported second hand

smoking harmful were three times (0R 3.32, CI 1.45-7.62) more likely to have a positive

71

attitude towards COTPA compared to those who didn‟t know that second hand smoke is

harmful. People with > 10 years of schooling were three times (OR 2.92, CI 1.01-8.45)

more likely to have a positive attitude towards COTPA compared to people with ≤ 10

years of schooling. Major barriers in implementation of COTPA were lack of complete

information and awareness of the Act, lack of awareness about the ill effects of tobacco,

public opposition, cultural acceptance of tobacco use, lack of political support, less

priority given to tobacco control and lack of proper training of the enforcers.

4.5. Recommendations and Policy implications of the study:

Efforts should be made to increase the awareness about the Act focussing on

younger population, less educated, and those belonging to the low SES.

Educational campaigns should also focus on effects of second hand smoke.

Understanding the populations‟ attitudes and behaviours before implementing

policies that will affect them will likely increase their effectiveness.

Monitoring the implementation of the Act .Violations should be reported to the

concerned authorities and followed up to check for the actions taken. .

The information about the Act should be complete and should reach the masses

through proper channel.

All the enforcement officials should be notified about the law and they should be

empowered to take actions. Proper training should be provided to the enforcement

officials.

72

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80

ANNEXURE I

CLUSTER (WARD) IDENTIFICATION BY SIMPLIFIED CLUSTER SAMPLING

METHOD

Ward.no Popn Cumulative.Popn Clusters Selection of

clusters

1 18190 18190 25271 1

2 13622 31812 1 40495

3 10258 42070 65766 2

4 12619 54689 40495

5 7318 62007 106261 3

6 9071 71078 2 40495

7 19166 90244 146756 4

8 9993 100237 40495

9 7272 107509 3 187251 5

10 8996 116505 40495

11 12331 128836 227746 6

12 33846 162682 4 40495

13 16609 179291 268241 7

14 21125 200416 5 40495

15 13535 213951 308736 8

16 16854 230805 6 40495

17 10924 241729 349231 9

18 7394 249123 40495

19 15010 264133 389726 10

20 11858 275991 7 40495

21 6572 282563 430221 11

22 15740 298303 40495

23 11029 309332 8 470716 12

24 15963 325295 40495

25 18425 343720 511211 13

26 10705 354425 9 40495

27 10725 365150 551706 14

28 9832 374982 40495

29 8465 383447 592201 15

30 7564 391011 10 40495

31 5616 396627 632696 16

32 10245 406872 40495

33 10531 417403 673191 17

34 11512 428915 40495

35 11968 440883 11 713686 18

36 14986 455869 40495

81

37 14546 470415 754181 19

38 8123 478538 12 40495

39 13257 491795 794676 20

40 3420 495215

41 20360 515575 13

42 12181 527756

43 5400 533156

44 15117 548273

45 15642 563915 14

46 23455 587370

47 7799 595169 15

48 11622 606791

49 26314 633105 16

50 10933 644038

51 25989 670027

52 6490 676517 17

53 8608 685125

54 15347 700472

55 11785 712257

56 19683 731940 18

57 16143 748083

58 22741 770824 19

59 18615 789439

60 20456 809895 20

Sampling interval = Total Cumulative population / 20 = 40495

Five digit random number between 0 and 40495 selected was 25271

First cluster was located in the ward where the cumulative population equalled or

exceeded the random number

Subsequent clusters were added by adding the sampling interval to the random

number.

82

ANNEXURE II

Awareness, Attitude and Perceived Barriers regarding implementation of

Cigarettes and Other Tobacco Products Act in Guwahati, Assam

RESEARCH SUBJECT INFORMATION SHEET

This study is being carried out as part of the course requirement for post-graduate studies

(Masters in Public Health) in Achutha Menon Center for Health Science Studies, Sree

Chitra Tirunal Institute for Medical Sciences, Thiruvananthapuram which I am currently

undertaking. This consent form may contain words that you do not understand. Please ask

me if any words or information is not clearly understood by you.

Purpose of the Study

Tobacco is extensively used in our society. There is a growing concern on the rise of

tobacco use and its health consequences. The past decade has seen a significant paradigm

shift in tobacco related policies that have lead to a significant curtailing of the use of

tobacco in many countries. India has also implemented the Cigarettes and Other Tobacco

Products Act but the extent to which public support and public opinion on the Act remains

largely unknown.

Therefore, this study is designed to gather baseline information from the adult population

of Guwahati, Assam about awareness, perceived barriers of implementation and attitudes

towards the key tobacco control measures under Cigarettes and Other Tobacco Products

Act. You have been chosen through a random process of selection from among the adult

population (18 years and above) in Guwahati city. A total of about 300 subjects will be

included and interviewed as part of this study.

Procedure

The survey would take approximately 20-30 minutes of your valuable time. You will be

asked a few questions regarding Cigarettes and Other Tobacco Products Act. The

collected data will be used for research purposes only.

83

Risks and Discomforts

Participation in this study imposes no risk to your health. However you would be asked

questions which you may find personal in nature.

Benefits

While there may not be any direct benefit for you from this study but from a public health

perspective, such information may prove of great importance with respect to

understanding the degree to which public support and opinions may have on the

successful adoption of tobacco control policies and legislation in Assam and to develop

better health polices to help the community as a whole.

Confidentiality

All information related to you will be kept confidential and at no stage will your identity

be revealed. A respondent identification number will be assigned to each participant that

will help in maintaining the confidentiality of the data collected. Access to this number

will be restricted to those analyzing the data only.

Contact Information

If you have any research related questions, you may contact me or the IEC member

secretary by phone or through e mail:

Voluntary Participation

Your participation in this study is purely voluntary which means you can decide whether

to participate in the study or not. If at any stage you wish to discontinue, you are free to

do so without any adverse consequences.

Dr. Indrani Sharma

Tel: 9746820355

E mail:[email protected]

Dr. Anoopkumar Thekkuveettil

Tel: 0471-2520256/7


84

Awareness, Attitude and Perceived Barriers regarding implementation of

Cigarettes and Other Tobacco Products Act in Guwahati, Assam

CONSENT FORM

I have read / been read out the information in the information sheet. The nature of the

study and my involvement has been explained and all my questions have been answered

satisfactorily. By signing this consent form, I indicate that I understand what will be

expected from me and that I am willing to participate in this study. I know that I can

withdraw at any time. I have been informed who should be contacted if the need arises.

Respondent‟s Name:

Respondent‟s Signature

Date:

Interviewer‟s Name:

Interviewer‟s Signature:

Date:

85

ANNEXURE III

Informed consent for In-depth Interviews with Enforcement Officials of

Cigarettes and Other Tobacco Products Act in Guwahati, Assam.

Serial No: …………….

I am Dr.Indrani Sharma, MPH Scholar in Sree Chitra Tirunal Institute for Medical

Sciences and Technology, Trivandrum and as a part of my course requirement I am

conducting a study on “Awareness, attitude and perceived barriers regarding

implementation of Cigarettes and Other Tobacco Products Act in Guwahati, Assam”. You

are one of the key persons for the enforcement of this Act and hence for this interview. I

am interested in your opinion about the various matters concerning the Act and the

barriers which you face for the implementation of this Act.

The interview will take less than an hour. You are free to refuse to participate in the

interview at anytime during the course of the interview/free to refuse to answer any

question at anytime. While there may not be any direct benefit for you from this study but

from a public health perspective this information will help in the successful adoption of

tobacco control policies and legislation in Assam and to develop better health polices to

help the community as a whole. The information that you give me will be treated as

strictly confidential and use only for purposes of the research.

If you agree to participate in this interview, I would also request your permission to record

this interview. Details of this interview will be transcribed and used exclusively for

research and your name and or of your department/institution will not be identified in the

transcriptions that will be used for analysis. Records and transcripts of the interviews will

be kept under safe custody and analyzed by me. After writing the report at the end of the

study, the same will be destroyed. If you are willing to be interviewed but not willing to

permit recording of the interview, I can keep notes of the interview.

Willing to record the interview Yes No

If No, are you still willing to be interviewed? Yes No

Name & Signature/thumb impression of the informant:

………………………………………………………….

Name & Signature of the Interviewer:

………………………………………………………

Date:

86

Contact Information

If you have any research related questions, you may contact me or the IEC member

secretary by phone or through E mail:

Dr. Indrani Sharma

Tel: 9746820355


Dr. Anoopkumar Thekkuveettil

Tel: 0471-2520256/7


87

ANNEXURE IV

INTERVIEW SCHEDULE Serial. no Ward. no Date of interview 09

Socio Demographic Characteristics:

S. No Questions Code label Value

1 Name(optional)

2 Age in completed years

3 Sex Male 1

Female 2

4 Highest level of education

attained

No formal schooling--------------------------1

Less than primary school------------------- 2

Primary School completed ------------------3

Secondary School completed----------------4

High school completed-----------------------5

College/University completed---------------6

Post graduate degree--------------------------7

5 Occupation Home maker/ Housewife---------------1

Labourer/Farmer/Private Informal----2

Private formal----------------------------3

Govt. Employee--------------------------4

Professional-------------------------------5

Retired-------------------------------------6

Student-------------------------------------7

Unemployed-------------------------------8

Others (please specify)-------------------9

6 Marital Status Never married 1

Currently married 2

Widow/widower 3

Divorced 4

separated 5

7 Average monthly household income(approx. in Rupees) -----------------

8 Total household expenditure in the last 1 month(approx in Rupees) ----------------

9 Number of members in the household ----------------

88

Awareness Related Factors:

S.No

Questions

Code label

Value

10 How many numbers of

cigarettes/bidis per day is

safe for a person?

Cigarettes 1

Bidis 2

Don‟t know 3

11 Do you think tobacco

products will cause health

problems?

Yes 1

No 2

12 If Yes, What are the health

problems caused by use of

tobacco products?

Heart problems 1

Cancer 2

Tuberculosis 3

Respiratory diseases 4

Diabetes 5

Hypertension 6

None of these 7

All of these 8

Others(specify) 9

-------------------

13 Which type of tobacco

product is dangerous for

health?

Cigarette 1

Bidi 2

Pan masala 3

Snuff 4

Chada 5

Zarda 6

Khaini 7

All products 8

Others(please specify) 9

------------------

14 Do you think the smoke

from other people‟s

cigarettes/bidis is

harmful to you?

Yes 1

No 2

Don‟t know 3

15 Have you heard of any

Tobacco control laws in

India?

Yes 1

No 2

If yes then go to 16 or else go to 17

89

16 How do you rate yourself

for the level of awareness

about the tobacco control

laws?

High 1

Moderate 2

Low 3

17 Is there a ban on smoking in

India?

Yes 1

No 2

Don‟t know 3


18 Where is it banned? Public Places 1

Homes 2

All places 3

19 Is there some penalty if

someone violates the law?

Yes 1

No 2

Don‟t know 3


20 What is the amount one has

to pay if he/she violates the

law?

Up to Rs 200 1

Rs 500 2

Rs 1000 3

Any amount 4

Don‟t know 5

21 To whom a complaint can

be made if someone is

found violating the law?

Police-----------------------------------1

Person in charge of designated Areas-----2

Don‟t know---------------------------- 3

22 Is there an age limit for

prohibition of buying

tobacco products in India?

Yes 1

No 2

Don‟t know 3


90

23 What is the age limit? Less then 18 years 1

18 years and above 2


24 Is there an age limit for

prohibition of selling

tobacco products to anyone

in India?

Yes 1

No 2

Don‟t know 3


25 What is the age limit? Less then 18 years 1



26 Is there a ban on

advertisement of tobacco

products in India?

Yes 1

No 2

Don‟t know 3

27 Have you seen any

advertisements of tobacco

products in the past 30

days?

Yes 1

No 2

Have‟nt noticed 3

28 Is there a ban on selling of

tobacco products near

educational institutions in

India?

Yes 1

No 2

Don‟t know 3


29 Within what distance

tobacco products should not

be sold near educational

institutions?

Within 100 yards 1

100-200 yards 2

More than 200 yards 3

Don‟t know 4

30 Have you noticed health

warnings on tobacco

products?

Yes 1

No 2

91

31 Are any of the above laws

implemented in your area?

Yes 1

No 2

Don‟t know 3


32

Which provision of the law

is implemented in your

area?

Prohibition of smoking in public

place------1

Prohibition of advertisement of

tobacco products----------------------2

Prohibition on sale of cigarettes or

other tobacco products to a person

below the age of eighteen years and

in particular area.-----3

Prohibition of selling of tobacco

products within 100 yards of an

educational institution----------------4

Specified health warnings on all

tobacco products----------------------5

Others(please specify)---------------6

-------------------

92

Attitude Related Factors:

(You can tick any point on the scale which you think is appropriate)

Belief Strength measurement-

33. Government should:

1. Impose a ban on smoking in public places

Strongly Disbelieve Strongly Believe

2. Impose a ban on the advertisement of tobacco products


3. Prohibition on sale of cigarettes or other tobacco products to a person below the age of

eighteen years and in particular area


4. Promote health warnings on all tobacco products


93

Evaluative Strength Measurement-

34. To reduce the use of tobacco among members of the community:

1. Ban on smoking in public places

Very ineffective Very effective

2. Ban on advertisement of tobacco products


3. Prohibition on sale of cigarettes or other tobacco products to a person below the age of

eighteen years and in particular area


4. Specified health warnings on all tobacco products


94

Barriers for implementation:

S.No Questions Code label Value

35 Are there any barriers

for implementation of

the law?

Yes 1

No 2

If yes go to 36 or else go to 37

36 What are the barriers? Lack of awareness of the law---------------------1

Not familiar with the provisions of the tobacco

control law--------------------------------------------

-2

Lack of awareness of the ill effects of tobacco

use------3

Lack of complete information---------------------

4

Lack of administrative support-------------------5

Lack of financial and human resources--------6

Fear of public opposition and resistance------7

Tobacco issues are given less priority in

comparison to other public policy issues------8

Difficulty in paying the fine of Rs 200 by

people with low income----------------------------

9

Cultural acceptance-------------------------------10

Definitions are not clear--------------------------11

Others(please specify)----------------------------12

---------------

37 How can the Tobacco

control law effectively

be implemented?

Involve social workers------------------------------

1

Involve police----------------------------------------

-2

Involve the members of local self government

bodies--3

Penalties for those who violate the law--------4

Public education on the health hazards of

tobacco use--5

Publicizing the existence of the law through

media and other mediums------------------------6

Definitions should be clear cut-------------------7

All of these--------------------------------------------

8

Others(please specify)-----------------------------9

--------------

95

Tobacco use practices:

S.No Questions Code label Value

38 Have you ever used any type of tobacco

products?

Yes 1

No 2

If yes then go to 39

39 Did you use any tobacco products in the

last one month?

Yes 1

No 2

If yes then go to 40

40 What type of tobacco products you use? Smoke 1

Smokeless 2

Snuff 3

Any other(please specify) 4

---------------

41 Do anyone in your family use tobacco

products?

Yes 1

No 2

96

ANNEXURE V

AWARENESS, ATTITUDE AND PERCEIVED BARRIERS REGARDING

IMPLEMENTATION OF CIGARETTES AND OTHER TOBACCO PRODUCTS

ACT IN GUWAHATI, ASSAM

Interview Guide for Enforcement Officials

Interview:

1) Do you know about the Act on--------------?(specific key provision)

2) How are you been notified about the Act?

Did you receive the circular?

3) Are you using any form of tobacco product? (type and since when)

4) According to the--------------------- Act what are you required to

do?(responsibilities)

5) What are the specifications for the------------------- Act?(specific key provision)

6) What do you think about the-------------------------- Act?

7) What affect the --------------- Act had on the community?

8) What efforts do you make to enforce these specifications of the--------------Act?

9) What are some barriers, if any, that you encountered?

10) How to overcome these barriers?(specific recommendation for improving the

situation)

11) Is there any other information about the Act that you think would be useful for me

to know?

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