Hrev_master [page 16] [Healthcare in Low-resource Settings 2014; 2:1883] Knowledge, attitude and practices on anti-tobacco measures imposed under the Cigarette and Other Tobacco Products Act among adult males in rural areas of Tamil Nadu, India Kalaivani Annadurai, Raja Danasekaran, Geetha Mani Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai, India Abstract Assessment of knowledge and attitude of adult men towards anti-tobacco measures will help us further in strengthening of regulatory activities and thereby reducing the prevalence of tobacco use. The objective of the present study was i) to assess the knowledge of men towards anti-tobacco measures imposed under Cigarette and Other Tobacco Products Act 2003 and its association with their socio-demograph- ic factors; and ii) to study the attitudes and practice of men towards anti-tobacco measures imposed under COTPA 2003. A cross-sectional study was done among 714 males aged 18 years and above in Vadagarai village of Thiruvallur district of Tamil Nadu and interviewed with pretested questionnaire. The study was done during March to September 2009. Majority of them were aware and favoring the act, i.e. 96.2% of the study population were aware of the COTPA 2003 and 95.24% were favoring the act. Most of them felt that anti-tobacco measures did not have any impact among tobacco users. Preventive steps like behavioral change com- munication, fiscal measures and further more strong enforcement of the act will be needed to decrease the prevalence further. Introduction Tobacco use is a serious public health prob- lem. Tobacco is a risk factor for six of the eight leading causes of deaths in the world.1 Every eight seconds someone, somewhere in the world, dies as a result of tobacco use. Around five million people die globally every year due to the effect of tobacco and this is likely to exceed eight million by 2030.2 The International Classification of Diseases (ICD- 10) has recognized that tobacco dependence is a disease.3 Tobacco use causes a wide range of major diseases which impact nearly every organ of the body. These include several types of cancers, coronary heart disease, cerebro- vascular disease and lung diseases.4 Research has generated scientific evidence that second- hand smoke causes the same problems as direct smoking, including cardiovascular dis- ease, lung cancer, and lung ailments such bronchitis and asthma attacks.5-8 World Health Organization (WHO) recommends five policies for controlling tobacco use: smoke-free envi- ronments; support programmes for tobacco users who wish to stop; health warnings on tobacco packs; bans on the advertising, promo- tion and sponsorship of tobacco; and higher taxation of tobacco.9 In India, tobacco con- sumption continues to grow at 2-3% per annum.10 India’s anti-tobacco legislation, first passed at the national level in 1975, was large- ly limited to health warnings and proved to be inefficient. The adoption of a WHO Framework Convention on Tobacco Control (WHO FCTC) by the World Health Assembly on 24th May 1999 was an important landmark to achieve comprehensive tobacco control worldwide.11 India was the 7th country that ratified the WHO FCTC on 5th February 2004. In 2003, The Central Government passed the Cigarettes and Other Tobacco Products Act (COTPA) applica- ble to all tobacco products.12 Maximum number of violations were recorded in Tamil Nadu and ranks first among the states. A total of 9,648 people have been fined and a whopping Rs 11,42,950 collected as fine from the south- ern state for violating the ban on smoking in public places in effect since October 2nd 2007.13 Due to the scarcity of studies regarding the awareness of COTPA, this study was done to assess the knowledge, attitude and practices of adult males towards anti-tobacco measures imposed under the act. Materials and Methods A cross sectional study was done among adult males aged 18 years and above in Vadagarai village in Thiruvallur district of Tamil Nadu. The sample size was calculated on the basis of 35% prevalence rate of smoking in rural area according to NFHS-3 survey with allow- able error 10%, sample size came to 714.14 Vadagarai HSC was chosen randomly from Naravarikuppam block Primary Health Centre. In order to get 714 men aged 18 years and above, it was decided to survey 445 households in Vadagarai subcenter, with a total of 1581 households with population of 2539 men above 18 years. The households were sampled by systematic random sampling. The sampling interval was 4 and the first household was selected randomly choosing a number within the sample interval. The next household was identified by adding the sampling interval with the first randomly chosen number and only one adult male was interviewed in each house. If there were more than one adult male in the same house, the participant was randomly cho- sen using lot system and then interviewed. A semi-structured questionnaire was used. It was translated into local language, pretested and standardized. It consisted of three parts of which Part I deals with questions related to socio-demographic profile, Part II deals with questions regarding their knowledge and atti- tude towards anti-tobacco measures imposed under COTPA 2003 and Part III deals with questions regarding their practice towards anti-tobacco measures. The interview was con- ducted in the house of the participants by the investigators themselves. Data entry was made in Excel software in codes and analysis was done by SPSS software. Levels of awareness, attitude and practices regarding COTPA were expressed in percent- age and their association with socio demo- graphic factors was tested for significance using chi-square test. Results Mean age of the sample population was 35.34±13.98 years with range of 18-85 years. Healthcare in Low-resource Settings 2014; volume 2:1883 Correspondence: Dr. Kalaivani Annadurai, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Tiruporur-Guduvancherry Main Road, Ammapettai 603108, India. Tel. +44.919500029829 - Fax: +44.27440138. E-mail: drkalaimdspm@gmail.com Key words: tobacco, COTPA, socio-demographic factors, regulatory activities. Contributions: KA, RD, data collecting and ana- lyzing; GM, manuscript writing. Conflict of interests: the authors declare no potential conflict of interests. Acknowledgements: we are thankful to those who have participated in the study. Received for publication: 15 August 2013. Revision received: 19 September 2013. Accepted for publication: 25 September 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright K. Annadurai et al., 2014 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2014; 2:1883 doi:10.4081/hls.2014.1883 No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2014; 2:1883] [page 17] Half of them were between 18-30 years. Most of them were Hindus (82.5%). Literacy rate of the sample population seems to be high (88.09%). Half of the participants were from upper lower socio economic group (49.01%) and about two third (76.05%) were unskilled, semi-skilled and skilled laborers (Table 1). Awareness about COTPA Analysis of the study population shows that 96.2% were aware of the COTPA 2003, the awareness regarding anti-tobacco measures showed that 96.2% knew that smoking was prohibited in public place and 88.0% knew that there was an age limit below which sale of tobacco products was banned. Source of infor- mation were newspaper (36.39%), television (21.83%), radio (10.77%), friends (4.37%) and a combination of all (26.64%) (Tables 2 and 3). There was a statistically significant associa- tion between the level of education and aware- ness about the act and its regulations (P<0.0001) (Table 4). Smokers and COTPA Out of 714 study population, 262 (36.7%) were smokers. Among smokers 92.4% were aware of the act and 88.5% of smokers were favoring the ban on smoking in public places. About violation of act among smokers (n=262), 8.0% were fined for smoking in pub- lic place. Regarding the effect of COTPA among smokers (n=262), 65.8% were of the opinion that the act did not change their smoking pat- tern, 33.8% told that anti-tobacco measures reduced their smoking habit and 0.4% quit totally due to this regulation. Discussion Studies done in Andhra Pradesh15 and Assam16 in India have reported awareness of COTPA as 47.5 and 45.7% respectively. Our Article Table. 1 Socio-demographic details of the participants. Age N % Occupation N % Religion N % Socio-economic status N % Education N % 18-30 357 50 Unemployed/student 39 5.46 Hindus 589 82.5 Upper (Class-I) 13 1.82 Illiterate 85 11.91 31-40 112 16.68 Unskilled/semiskilled/skilled 543 76.05 Christians 87 12.2 Upper middle (Class-II) 87 12.18 Literate 629 88.0 41-50 123 17.23 Clerk, shop-owner, farm-owner 97 13.59 Muslims 38 5.3 Lower middle (Class-III) 160 22.40 51-60 93 13.02 Semiprofessional/professional 13 1.82 Upper lower (Class-IV) 350 49.01 ≥61 29 4.06 Retired/old age dependent 22 3.08 Lower (Class-V) 104 14.56 Table 2. Age group in years, their awareness of COTPA and prohibition of smoking in public place. Age Total Aware of COTPA Aware about prohibition Aware about age (%) of smoking in public places limit for sale of tobacco 18-30 357 (50%) 351 (98.3%) 351 (98.3%) 329 (92.16%) 31-40 112 (16.68%) 107 (95.54%) 107 (95.54%) 95 (84.82%) 41-50 123 (17.23%) 118 (95.93%) 118 (95.93%) 110 (89.43%) 51-60 93 (13.02%) 91 (97.85%) 91 (97.85%) 80 (86.02%) >61 29 (4.06%) 20 (68.96%) 20 (68.96%) 16 (55.17%) Total 714 (100%) 687 (96.2%) 687 (96.2%) 630 (88.2%) COTPA, Cigarette and Other Tobacco Products Act. Table 3. Education status and awareness of COTPA. Educational Total Awareness of COTPA Awareness about prohibition Awareness about age status (%) of smoking in public places limit for sale of tobacco N (%) P N (%) P N (%) P Illiterate 85 (11.9%) 70 (82.4%) <0.0001 70 (82.4%) <0.0001 60 (70.6%) <0.0001 Primary school 292 (40.9%) 285 (97.6%) <0.0001 285 (97.6%) <0.0001 260 (89.0%) <0.0001 Middle school 237 (33.19%) 232 (97.9%) <0.0001 232 (97.9%) <0.0001 215 (90.7%) <0.0001 High school 49 (6.86%) 49 (100.0%) <0.0001 49 (100.0%) <0.0001 44 (89.8%) <0.0001 College/diploma 51 (7.14%) 51 (100.0%) <0.0001 51 (100.0%) <0.0001 49 (96.1%) <0.0001 Total 714 (100.00%) 687 (96.2%) <0.0001 687 (96.2%) <0.0001 628 (88.0%) <0.0001 COTPA, Cigarette and Other Tobacco Products Act. Table 4. Attitude towards COTPA and anti-tobacco measures. Variable Attitude (%) Positive Negative Do not know About COTPA and its regulation 680 (95.24) 34 (4.76) - Implementation of ban on smoking in public places by government authorities 189 (26.5) 455 (63.7) 70 (9.8) Pictorial health warning 189 (26.5) 427 (59.8) 98 (13.7) COTPA, Cigarette and Other Tobacco Products Act. No n- co mm er cia l u se on ly [page 18] [Healthcare in Low-resource Settings 2014; 2:1883] study found the awareness level to be 96.2% which was far better than the above studies. Similar finding was observed in Rakesh et al. where it was found to be 88% among members of Panchayat raj institution, Haryana.17 Of the age group between 18-25 years, 97.8% were aware of the act and of prohibition of smoking in public places. 69.0% of the age group above 61 years were aware of the act and prohibition of smoking in public places. So, young people were more aware of the act than elders. Of the age group between 18-25 years, 92.0% was aware that there was age limit below which sale of tobacco products was banned. Of the age group above 61 years, 55.2% was aware of the age limit. So, young people were more aware of the age limit below which sale of tobacco products was banned. This finding was contradictory to the findings from Rao et al.15 and Sharma et al.16 where they found that the awareness of COTPA increased significantly with increasing age. Of literates, 98.1% were aware of the act and were aware of prohibition of smoking in public places. Of illiterates, 82.8% was aware of the act and were aware of prohibition of smoking in public places. Literates were more aware about the act than illiterates. Rao et al.15 and Sharma et al.16 have reported similar findings. Of literates, 90.3% and 70.6% of illiterates were aware of age limit below which sale of tobacco products was banned. Analysis shows that majority of them, i.e. 95.24% were favoring the act; this was similar to the findings from Rao et al.,15 Sharma et al.16 and American University of Armenia18 Majority of the study population, i.e. 63.7% felt that measures against smoking in public places were not followed correctly. Moreover, more than half, 59.8% felt that pictorial health warn- ing did not have any impact on smoking habit. Among smokers 92.4% were aware of the act and most of them, i.e. 88.5% of smokers were favoring the ban on smoking in public places. In addition 8.0% of smokers were fined for vio- lating the ban on smoking in public places. Regarding quitting, 33.8% of smokers report- ed that their smoking habit got reduced because of the anti-tobacco measures under the act. In countries with pictorial health warnings, such as Canada and Australia, these numbers were higher: more than 40% of Canadian smokers reported that the pictorial warnings have motivated them to quit smok- ing;19 in Australia, picture warnings have sup- ported 62% of former smokers in their efforts to quit.19 In our study, 0.4% reported that they had totally quit smoking because of fine due to violation but majority of them, i.e. 56.9% reported that act did not have any impact on their smoking habit. Conclusions Majority of the participants were aware of the act and favoring the act. But most of them felt reg- ulations under the act were not followed properly. Most of the smokers felt that anti-tobacco meas- ures imposed under the act did not have any impact on their smoking status. The policy mak- ers should consider newer options such as start- ing a help line for quitting tobacco to regulate the use of tobacco with consideration that most of the smokers were reluctant in quitting tobacco even after the implementation of various anti-tobacco measures under COTPA. Apart from these steps, counselling sessions have to be arranged for those tobacco users who are reluctant to quit. To conclude, the steps taken by the government bod- ies in the future should be strictly followed and it should be continuously monitored. References 1. WHO. Tobacco free initiative. Tobacco facts. Geneva, Switzerland: World Health Organization; 2013. Available from: http://www.who.int/tobacco/mpower/tobac- co_facts/en/ 2. Leung CM, Leung AK, Hon KL, Kong AY. Fighting tobacco smoking: a difficult but not impossible battle. Int J Environ Heal R 2009;6:69-83. 3. WHO. International statistical classification of diseases and related health problems. Geneva, Switzerland: World Health Organization; 2010. Available from: http://www.who.int/classifications/icd/ICD10 Volume2_en_2010.pdf 4. CDC. Smoking and tobacco use. Atlanta, GA, USA: Centers for Disease Control and Prevention; 2013. Available from: http://www. cdc.gov/tobacco/data_statistics/fact_sheets/h ealth_effects/effects_cig_smoking/ 5. US Department of Health and Human Services. The health consequences of invol- untary exposure to tobacco smoke: a report of the surgeon general. Washington, DC, USA: Department of Health and Human Services; 2006. Available from: www.surgeongeneral. gov/library/reports/secondhand-smoke-con- sumer.pdf 6. California Environmental Protection Agency. Health effects assessment for environmental tobacco smoke. Sacramento, CA, USA: California Environmental Protection Agency; 2005. Available from: www.oehha.ca. gov/air/environmental_tobacco/pdf/app3part b2005.pdf 7. IARC. Tobacco smoke and involuntary smok- ing. Lyon, France: International Agency for Research on Cancer; 2004. Available from: http://monographs. iarc.fr/ENG/ Monographs/ vol83/mono83-1.pdf 8. American Cancer Society. Cancer facts and figures 2012. Atlanta, GA, USA: American Cancer Society; 2012. Available from: http://www.cancer.org/cancer/cancercauses/t obaccocancer/secondhand-smoke 9. WHO. An international treaty for tobacco con- trol. Geneva, Switzerland: World Health Organization; 2003. Available from: http://www.who.int/features/2003/08/en/ 10. Jandoo T, Mehrotra R. Tobacco control in India: present scenario and challenges ahead. Asian Pac J Cancer P 2008;9:805-10. 11. WHO. Frame work convention on tobacco control. Guidelines for implementation. Geneva, Switzerland: World health organiza- tion; 2005. Available from: http://apps.who.int/iris/bitstream/10665/ 80510/1/9789241505185_eng.pdf?ua=1 12. Government of India. The cigarettes and other tobacco products (prohibition of adver- tisement and regulation of trade and com- merce, production, supply and distribution) Act, 2003, and rules framed there under. Available from: http://indiacode.nic.in/ful- lact1.asp?tfnm=200334 13. Tamil Nadu records highest number of smok- ing violation (2009, May 26). Hindustantimes. Available from: http://www. hindustantimes.com/India-news/NewDelhi/ Tamil-Nadu-records-highest-number-of- smoking-violation/Article1-414543.aspx 14. IIPS. National Family Health Survey (NFHS- 3) 2005-06. Mumbai, India: International Institute for Population Sciences; 2007. 15. Rao AR, Dudala SR, Bolla CR, Kumar BPR. Knowledge attitude and practices regarding the cigarettes and other tobacco products act (COTPA) in Khammam, Andhra Pradesh. Int J Res Health Sci 2013;1:96-102. 16. Sharma I, Sarma PS, Thankappan KR. Awareness, attitude and perceived barriers regarding implementation of the Cigarettes and Other Tobacco Products Act in Assam, India. Indian J Cancer 2010;47:63-8. 17. Rakesh K, Misra P. Knowledge, attitude and practice regarding anti-tobacco measures among members of panchayat raj institution in a rural area of Haryana. Indian J Publ Health 2011;55:339-40. 18. American University of Armenia. KAP Tobacco control policies in adult population in Armenia a follow- up survey. Yerevan, Armenia: American University of Armenia, Center for Health Services Research and Development; 2007. Available from: http://auachsr.com/UserFiles/File/RITC%20Fo llow%20Up%20Report_2007.pdf 19. Hammond D, Fong GT, Borland R. Text and graphic warnings on cigarette packages: findings from the international tobacco con- trol four country study. Am J Prev Med 2007;32:202-9. Article No n- co mm er cia l u se on ly