|Year : 2017 | Volume
| Issue : 1 | Page : 22-27
Status of Implementation and Opinion of Stakeholders about Antismoking Legislation in Educational Institutions of Delhi
Nandini Sharma, Sunita Dhaked, C Vankhuma, Tanu Anand, Charu Kohli, Mongjam Meghachandra Singh
Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||1-Mar-2017|
Department of Community Medicine, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Smoking is the most important cause of lung cancer and exposure to secondhand smoke (SHS) is as harmful as active smoking. The state of Delhi has been a front runner in the implementation of the Cigarettes and Other Tobacco Products Act (COTPA), 2003 to overcome this health hazard and started the “Smoke Free Delhi” initiative in 2009. Aims: The aim of this study is to assess compliance, awareness, and support for implementation of smoke-free initiative in educational institutions in Delhi. Materials and Methods: It was a cross-sectional study conducted in educational institutions of six districts of Delhi. Participants were selected by cluster sampling from the educational institutions in the selected districts. A total of 596 participants were interviewed. Data were collected using a pretested semi-structured questionnaire. Statistical Analysis Used: Data were analyzed using SPSS (version 17.0) and expressed in percentages. Differences between the proportions were observed by Chi-square test and P < 0.05 was considered as statistically significant. Results: Out of the total, 125 (21%) reported to be current smokers. A little more than three-fifth (64.8%) of the participants were aware about the COTPA, but the awareness about the organizations implementing the act was very low, being only 7 (5.6%) among smokers, and 23 (4.9%) among nonsmokers. Regarding the awareness of places designated as “Smoke Free Zones,” majority said educational institutions, followed by airport, shopping malls, and buses/trains. Most of the participants were also aware about other steps taken to prohibit smoking at public places, such as ban on sale of tobacco products to minors (80%), advertisements displaying ill effects of smoking (72.1%), and increase in the cost of tobacco products (64.6%). Conclusion: The level of awareness about antismoking legislation was high and majority support ban on smoking. However, the mechanism of implementation of the law was unclear to most.
Keywords: Cigarettes and other tobacco products, smoke-free delhi, smoking
|How to cite this article:|
Sharma N, Dhaked S, Vankhuma C, Anand T, Kohli C, Singh MM. Status of Implementation and Opinion of Stakeholders about Antismoking Legislation in Educational Institutions of Delhi. MAMC J Med Sci 2017;3:22-7
|How to cite this URL:|
Sharma N, Dhaked S, Vankhuma C, Anand T, Kohli C, Singh MM. Status of Implementation and Opinion of Stakeholders about Antismoking Legislation in Educational Institutions of Delhi. MAMC J Med Sci [serial online] 2017 [cited 2017 Aug 23];3:22-7. Available from: http://www.mamcjms.in/text.asp?2017/3/1/22/201099
| Introduction|| |
Tobacco use is a global epidemic that kills 5.4 million people annually, tragically, more than 80% of those deaths occur in the developing countries. Smoking is the most important cause of lung cancer to the extent that over 80% of lung cancers are caused by smoking. Smokeless tobacco causes oral cancer and about 90% cases in India are caused by tobacco use.
Smokers are not the only ones affected and killed by tobacco; scientific evidence has unequivocally established that exposure to secondhand smoke (SHS) is as harmful as active smoking and causes cancer, heart disease, and many other serious diseases. There is no risk-free level of contact with SHS; even brief exposure can be harmful to health. Only 100% smoke-free (SF) environment can give complete protection.
Tobacco use usually begins in adolescence, and the risk of tobacco use is highest among those who start early and continue its use for a long period. A survey of tobacco users among young people, the Global Youth Tobacco Survey-2009, revealed that nearly 15% of youth in India use tobacco.
In the wake of international efforts and growing consciousness about harmful effects of tobacco use, the Government of India enacted “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” (COTPA), in May 2003 with a view to protect public health by prohibiting smoking in public places, banning advertisements of the tobacco products, banning sale of tobacco products to minors and near educational institutions, prescribing strong health warnings including pictorial depiction on tobacco products, and regulation of tar and nicotine contents of tobacco products. The Ministry of Health and Family Welfare, Government of India also took a step toward translating the law into practice and adopted the National Tobacco Control Programme under the 11th Five Year Plan of 2007–2012.
The state of Delhi has been a front runner in the implementation of COTPA and to enforce compliance of this act, Delhi government started the “Smoke Free Delhi” initiative in 2009. The rising trend of tobacco smoking among students in the country makes it imperative to provide a smoke-free environment in the campuses. The success of any public health legislation depends largely on compliance by the people. This study attempts to measure the compliance with the various provisions of the Act in the educational institutions of Delhi. Strict implementation of the law in educational institutions would be a deterrent to the initiation of smoking which occurs here. The status of the implementation of the law which would emerge from the study may result in stricter enforcement by pointing out the loopholes.
Therefore, the current study was undertaken with the objective to assess the status of implementation of antismoking legislation and its perception in educational institutions in Delhi.
| Materials and Methods|| |
Ethical clearance was obtained from the Institutional Ethical Committee of Maulana Azad Medical College. A cross-sectional study was conducted in the individuals, i.e., students, teachers, and other staff selected from educational institutions (government schools and colleges) of 6 districts of urban areas of Delhi from October 1, 2011, to November 30, 2011. A multistage cluster sampling was used to select the study participants. The district/zones with a higher population size had a proportionately higher sample size allocation.
Sample size for the opinion poll of Delhi was calculated from a community-based pilot study conducted on awareness, perception, and implementation of antitobacco legislation in Delhi by the investigators. At 95% confidence level and taking the opinion on ban of smoking for “Smoke Free policy” as 60.05% people supporting it (as calculated from pilot testing), and with a relative error of 2%, total sample size was calculated to be 2844 for the entire population of Delhi.
The sample size was thus finalized to be 4266, using design effect 1.5. The opinion poll interviewed 4270 persons whose opinion would have a bearing on the implementation of the law. Nearly, equal proportions of study participants were interviewed from educational institutions, healthcare facilities, places of entertainment, restaurant, public places, and offices while opinions of 708 people residing in slums of Delhi was taken. The sample size from educational institutions was finalized to be 596 total: 116 from schools and 480 from colleges.
Selection of educational institutions
The educational institutes of each district were listed and were classified as Government or private institutions, i.e., Government colleges/Private colleges and Government schools/Private schools.
Then, proportionate number of Government and private institutions was then selected by means of convenient sampling. A total of 116 schools and 480 colleges were then selected. More number of colleges was enrolled for the study because smoking prevalence and awareness were more significant in the college going groups.
Selection of study subjects from the educational institutions
Students aged ≥14 years, teachers, and other staff members at selected educational institutions were interviewed using a semi-structured questionnaire consisting of items on sociodemographic profile such as age, sex items pertaining to smoking behavior, perception about smoking, knowledge regarding the legal regulations on smoking, and enforcement of COTPA. The questionnaire was pretested in similar population and in a similar study area. Appropriate modifications were done afterward in language and content. Those who did not give consent or were not in a state to participate (drug intoxication, etc.,) were excluded from the study. Experts in the relevant field were also approached for their opinion about the items of the questionnaire. Six professional investigators were deployed for the purpose. The team was supervised by three senior supervisors to help and guide the survey activities. Two teams were headed by one senior resident/junior residents, scrutiny of all filled-in questionnaires were done on day-to-day basis.
Data were analyzed using SPSS (IBM Corp.) (version 17.0). Data were expressed in terms of percentages. Differences between the proportions were observed by Chi-square test, and P < 0.05 was considered statistically significant.
Permission was obtained from the concerned authorities of the institutions before conducting the study. Written consent was taken from the participants. The objective and procedure of the study were explained to the institutional authorities and the participants before the data collection. The option to opt out of the study was kept open without any clause and confidentiality was ensured at all stages.
| Results|| |
There were a total of 596 study participants who were interviewed from educational institutions of 6 districts of Delhi. Out of them, 116 study participants were interviewed from schools, and 480 from colleges. Out of 596, 455 (76.3%) were students and rest of them were teachers and other staff members, and most of them were in the age group of 19–29 years. The number of female participants was only 33 (5.54%). This was due to the fact that most government schools had only boys in the morning shift and groups of boys who aggregated in colleges were picked up. There was no refusal for interview for study from any site.
Smoker’s profile and smoking-related behavior
As shown in [Table 1], 125 (21.0%) reportedly smoked tobacco. Out of 125 study participants, 117 were current smokers and rest of them were past smokers. Significantly, higher percentage of smokers was from urban background as compared to rural (P < 0.001). The median duration of smoking was 4 (IQR 3–8) years. Out of the 117 current smokers, 71 (60.7%) wished to quit. Only 29 (24.8%) of them were aware about the services available for quitting smoking. A small percentage (47%) of the current smokers had tried to quit smoking in the past. The most common reason cited by them for quitting smoking was poor personal hygiene resulting due to smoking. Nearly two-fifth of the respondents reasoned, illnesses, and increased expenditure as other causes for quitting. Highest proportion (36.4%) of the respondents who had tried to quit smoking in the past were able to do so for <10 days while 25.5% were able to do so for 10–99 days.
Awareness about antismoking-related law and legislation
Out of the total, 335 (56.2%) respondents reported that they were aware of the antismoking legislation COTPA. [Table 2] depicts that awareness about COTPA, was significantly more among smokers as compared to nonsmokers. More than 95% of the smokers considered “Smoke Free Zones” as places where cigarette/bidi smoking is banned, whereas 83.6% of nonsmokers responded in a similar manner. Similarly, large proportion of both smokers and nonsmokers considered tobacco-free zones as places where both tobacco chewing and smoking were banned. Awareness about organization implementing COTPA was very low-only 5.6% among smokers and 4.9% among nonsmokers.
|Table 2: Awareness among smokers and nonsmokers about cigarettes and other tobacco products and “smoke free zones”|
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Out of the total respondents, 81.5% were aware of display of “no smoking” signage at public places as one of the steps to prohibit smoking, seventy nine percent were aware about display of pictorial warnings on cigarette packets, 73.2% were aware about ban on smoking at public places, and 60.4% were aware about existence of fine for smoking at public places. Only 25% were aware about the ban on advertisements related to tobacco and tobacco products as a measure by government to prohibit tobacco use. All the smokers (100%) were aware about the legal age for buying or selling tobacco products.
Out of total 596 respondents, 511 (85.7%) agreed that smoking is an economic burden on the family. Awareness about warning as punishment for smoking at public places among the participants was high (70.3%) as compared to the knowledge of fine/chalan as punishment (20.5%). Maximum proportion of the respondents reported that they do nothing when they see someone smoking at public place. One-fifth (20%) of the participants reported that they have seen people getting punished for smoking at public places.
Regarding the awareness of places designated as “Smoke Free Zones;” 513 (86.1%) said educational institutions followed by airport by 499 (83.7%), shopping malls by 446 (74.8%), and buses/trains reported by 443 (74.3%) study participants.
Most of the participants were also aware about other steps being taken to prohibit smoking at public places, such as ban on sale of tobacco products to minors (80%), advertisements displaying ill effects of smoking (72.1%), and increase in the cost of tobacco products (64.6%). Out of the total participants, 86.7% reported that they have seen “No smoking” signage at educational institutions and 92.4% reported seeing such signage at public places.
Opinion of smokers from educational institutions about smoking and antismoking legislations
As shown in [Table 3], the majority of the smokers (85.6%) supported ban on smoking at public places. Nearly half of the smokers said that they do not smoke when they are with nonsmokers at public places. Although 29 (23.2%) said that they do smoke when they have craving for smoking even at public places and 22 (17.6%) of them said that they manage to overcome their craving. On being probed about the smoking behavior at home, 44.8% said that they do not smoke at home.
|Table 3: Opinion of the smokers about smoking and antismoking legislation|
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| Discussion|| |
Antitobacco legislation in India dates back to 1975 with Cigarettes Act followed by a number of legislative strategies and programs but with limited success. Currently, The COTPA, 2003 was designed to curb the use of tobacco.
Lack of awareness about the act, cultural acceptance of tobacco use, lack of political support, and less priority for tobacco control have been reported as barriers for COTPA implementation in a study performed in the state of Assam in India.
In the current study, 21% study participants reported smoking at any point of time. This is comparable to another study conducted in Pakistan where 26.7% students also reported themselves to be smoking. This points toward the critical issue of increasing burden of smoking and its related ill effects among the youths in the future. Studies are needed to understand the factors which can promote the use of tobacco among youth, especially school children. To curb this menace, legislations are an important tool. However, implementation of the same is a major challenge as reported by the authors of a study carried out among law enforcers in 16 states and union territories. Important challenges with regard to the implementation of COTPA which they had reported in the study were lack of awareness about the law, lack of intergovernment coordination, lack of human and financial resources. Possible reasons for lack of awareness about COTPA may be limited use of mass media for awareness among community members, lack of political will, and shortage of finances for awareness campaigns. Effective implementation could be achieved by enabling the notified officers; police, medical officers, drug and food inspectors, principals/person in charge of educational institutions, and owners/person in charge of public places.In the present study, awareness about the existence of warning (70.3%) as a punishment for smoking at public places among the participants was high as compared to knowledge of fine/challan as punishment. Another study conducted among 209 youth and adult smokers and 18 cigarette vendors in Chandigarh showed that awareness about the law was around 70%. Fifty five percent vendors admitted decline in the sale while 86.1% did not have any difficulty in procuring cigarettes. Strict implementation of the law is essential to prevent smoking at public places, but the study showed that no strict fine/challan was issued even on violation.
A positive finding in the current study was that there was high receptivity for antismoking legislation among the smokers. This finding was comparable to a study carried out in the year 2011, in which a majority of the students agreed that smoking should be banned in institutional campus. The study also showed that SF campus leads to significant reduction in smoking behavior among the students. Thus, antismoking legislations are proven to be effective in reducing the burden of smoking among students.
| Conclusion and Recommendations|| |
The study concluded that awareness about antismoking initiative in Delhi was good among the students and most of them supported ban of smoking in public places. Receptivity for antismoking ban on educational institutions was also high. However, the implementation of the law on antismoking control was not adequate and the mechanism of implementation of such law was unclear to most of the participants. Antismoking laws should be promoted and strictly enforced among the educational institutions in Delhi.
The authors are grateful to all the study participants and educational institutions for their support. Authors acknowledge the financial support by the International Union against TB and Lung diseases and Delhi Govt. SF initiative for conduction of this study. The authors also express gratitude to the State Tobacco control cell of Government of NCT, Delhi.
Financial support and sponsorship
This study was supported by International Union against TB and Lung diseases and Delhi Govt. smoke-free initiative.
Conflicts of interest
There are no conflicts of interest.
| References|| |
HRIDAY. Implementation of Framework Convention on Tobacco Control: A Shadow Report 2010 in India. New Delhi: HRIDAY; 2010.
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.
Control of oral cancer in developing countries. A WHO meeting. Bull World Health Organ 1984;62:817-30.
SPSS Inc. Released 2008. SPSS Statistics for Windows. Ver. 17.0. Chicago: SPSS Inc.; 2016.
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 Suppl 1:63-8.
Rozi S, Butt ZA, Akhtar S. Correlates of cigarette smoking among male college students in Karachi, Pakistan. BMC Public Health 2007;7:312.
Kaur J, Jain DC. Tobacco control policies in India: Implementation and challenges. Indian J Public Health 2011;55:220-7.
Bhati V, Puri S, Kaur A, Mayank V. Impact of ban of smoking in first smoke free city of Chandigarh in India. Indian J Cancer 2010;47:109-210.
Seo DC, Macy JT, Torabi MR, Middlestadt SE. The effect of a smoke-free campus policy on college students’ smoking behaviors and attitudes. Prev Med 2011;53:347-52.
[Table 1], [Table 2], [Table 3]