|Year : 2010 | Volume
| Issue : 3 | Page : 125-131
Impact of smoke-free law on tobacco consumption in Chandigarh: A community-based study
BS Chavan, Ajeet Sidana, Tanuja Kaushal
Department of Psychiatry, Government Medical College And Hospital, Chandigarh, India
|Date of Web Publication||8-May-2012|
B S Chavan
Department of Psychioatry, Government Medical College and Hospital, Sector-32, Chandigarh - 160 032
Background and Objectives: Tobacco use is a major public health issue today and it is expected that 650 million smokers will die prematurely due to tobacco use. On 15 July 2007, Chandigarh became the first city to go smoke-free. However, there is no data on the impact of smoke-free law. The objective of the present study was therefore to study the pattern and prevalence of tobacco use and to examine the impact of smoke-free law in Chandigarh. Materials and Methods: Total sample comprised of 3000 subjects. Socio-demographic data sheet along with initial two questions from the General questionnaire were administered on each individual. In addition, all the tobacco users underwent administration of the Fagerstrom test for nicotine dependence or the Fagerstrom test for smokeless tobacco (smokeless tobacco users). Results: There were 43.9% tobacco users in the sample of 3000 subjects. Out of these tobacco users, 357 (11.9%) were pure smokers and 370 (12.3%) were using smokeless tobacco and 590 (19.6%) used both. The mean number of cigarettes/bidis smoked per day was 14 (+8.64) and the mean age of starting smoking was 19.41 (SD + 4.5 years).73.2% of population was aware about implementation of smoke-free law and all the participants (100%) reported smoking in public places. 43.4% smokers reported thoughts of quitting nicotine. Interpretation and Conclusion: Although the prevalence of tobacco use in Chandigarh is lower than the national average but the rates are still alarming and need attention. The findings of this study will help in designing tobacco control strategies and understanding the epidemiology of tobacco related health burden.
Keywords: Chandigarh, impact of law, tobacco
|How to cite this article:|
Chavan B S, Sidana A, Kaushal T. Impact of smoke-free law on tobacco consumption in Chandigarh: A community-based study. Indian J Med Sci 2010;64:125-31
| ¤ Introduction|| |
Tobacco use is a major public health issue today and it is expected that out of 1.3 billion people who are current smokers worldwide, 650 million of them will die prematurely due to tobacco use.  Current statistics indicate that it will not be possible to reduce tobacco-related deaths over the next 30-50 years, unless adult smokers are encouraged to quit.  The estimated number of tobacco users in India among 10 years and above is around 250 million.  The prevalence of tobacco use among men in India has been reported to be high (generally exceeding 50%) from almost all parts of India, more in rural than in urban areas.  Women from most parts of India use smokeless tobacco and prevalence varies between 15% and 60%.  However, there are huge state and regional differences, National Household Survey (National Health Survey) on drug and alcohol abuse in India found the highest prevalence of tobacco use in south Bihar (94.7%) followed by UP (87.3%) and high rates in the northeastern states, similar to findings in local surveys and Global School Personnel Survey.  In Chandigarh, 17% of men and < 1% of women over 15 years are smokers.  This is lower than the national average of 33% of men and 1.4% of women. 
Although the awareness of harmful effects of tobacco use is growing among the young users but the resultant quit rate is not proportionate. In one of the surveys, 78.3%of students out of a sample of 3000 students had knowledge about ill effect of tobacco on health, but had limited awareness of the social, economic and environmental ill-effects of tobacco use.  In another recent study from Tamil Naidu, only 46% knew that smoking causes lung cancer while 32% reported that smoking causes or may exacerbate asthma, but only 10% knew that tobacco use can also cause cardiovascular diseases. 
In addition to awareness generation about the hazards of tobacco use, it has been shown that "policies establishing 'smoke-free environments' are the most effective method for reducing exposure to secondhand smoke".  Restrictions, policies, and ordinances which regulate locations where smoking is permitted are associated with decreased rates of cigarette consumption and may increase cessation rates. 
Tobacco control law which states that "no person shall smoke in any public place" came into force on May 1, 2004. Chandigarh, on 15 July, 2007, became not only India's first city to go smoke free but third city in the world. Till now only places in the developed countries like California, Washington, New York, Sydney, etc. were smoke free.  Despite making smoking at public places a punishable offence by Chandigarh Administration, the citizens of Chandigarh feel that the smoking in public places is still rampant and the act is no deterrent to the smokers. On the other hand, the experts feel that without giving an opportunity to the smokers to quit with assistance from tobacco cessation clinic, the smokers are left with no choice but either to smoke in their houses or break the law. In order to escape from being caught, they might have designed new strategies to escape the eye of enforcement agencies. It is also expected that some of them might have shifted to chewable tobacco which is not banned under the act. However, there is no data on the impact of smoke-free law in City beautiful. Being the first smoke-free city in the country, the outcome of legal ban will be of national importance for planning similar ban in other parts of the country.
Therefore, the present study was planned to study the patterns and prevalence of smoking and smokeless tobacco in the general population of Chandigarh and to examine the impact of smoke-free law on tobacco consumption in Chandigarh.
| ¤ Materials and Methods|| |
Chandigarh with a population of about 11 Lacs comprises of urban, rural, and slum (resettlement colony) areas and thus for the purpose of the study, cluster sampling was used. The sample consisted of 3000 subjects of more than 15 years of age drawn from four sectors, four villages, and four slum areas in order to have representative sample. Out of these three different clusters, 1000 households from each cluster (250 households from each sector/village/colony) were shortlisted using simple randomization technique. After obtaining informed consent, the eldest person present in house at the time of visit was interviewed (above 15 years) and questioned about tobacco use. In case the person being interviewed was using tobacco in any form, the interview was continued further to obtain socio-demographic details on a semi structured Performa, to collect tobacco related information on General questionnaire, the Fagerstrom test for nicotine dependence  (administered on smokers) and the modified Fagerstrom test for smokeless tobacco  (administered on SLT users) for assessing degree of dependence. For individuals who were not tobacco user, only first two questions of General Questionnaire were asked besides socio-demographic details. Thus, only 1 subject was included in study from each household. Following data collection, scoring was done for the Fagerstrom test for nicotine dependence and the modified Fagerstrom test for smokeless tobacco. Subsequently, data was put in Microsoft Excel 2007. Appropriate parametric and non-parametric univariate statistical analyses were carried out for achieving the objectives of the study.
| ¤ Results and Discussion|| |
The present study was conducted in Chandigarh on 3000 subjects (male 2466, female 534) primarily to estimate the prevalence and patterns of tobacco use and to study the impact of smoke-free law in Chandigarh. Out of the total sample, 56.1% population was found to be tobacco-free while 43.9% of the Chandigarh population (males 42.46% and females 1.46%) was found to be consuming tobacco in one or the other form. Out of them, most of the tobacco users belonged to semi-urban locality i.e. to slum areas (41.7%) followed by urban locality (34.7%) and lowest in rural areas (23.5%). Among the users, 11.9% were Pure smokers, 12.33% were Pure SLT users, and 19.7% used both smoking and SLT form of tobacco. Among 1.46% of the females who consumed the tobacco in any form, a majority (68%) were SLT users. The mean current age of 35.93 years (SD +11.4) and the mean age of smoking initiation, 19.41 years (SD + 4.5) is similar to earlier study from Chandigarh [Table 1].  In a national cross-sectional household survey, 30% of the population 15 years or older, (47% men and 14% of women) either smoked or chewed tobacco. 
The impact of smoke-free law in Chandigarh was studied in terms of awareness about the smoke-free law, difficulty in buying cigarettes, quitting rates in last 6 months and challan for smoking at public places. Among the respondents, 73.2% of the total study sample (63.9% males and 9.1% females) were aware about the implementation of the smoke-free law in Chandigarh [Table 2]. Surprisingly, only 20.33% up to the age of 25 years were aware about the smoke-free law [Table 3]. Despite difficulty in procuring cigarettes (reported by 24.4%), only 43.4% thought of quitting. Out of the participants who thought of quitting, significantly more persons were staying with their spouses, were employed, and were staying in the nuclear families. It is possible that because of the ban on smoking in public places, there was pressure on them from their spouses, friends, and family members to quit. All the participants (100%) reported that they smoked at almost all the places which include office room, toilet, roads, lawns, corridors, and no one had objected to smoking at public places and only 2.5% reported being challaned for smoking at public places. The results show that neither the government is serious about the stringent implementation of ban on smoking nor the society has joined the campaign against smoking. Low awareness about smoke-free law among the youth, which is the age of tobacco initiation, is another limitation in the existing policy for implementation of the smoke-free law.
Because of the ban on smoking, 24.7% of the smokers in last 6 months shifted to chewable form of tobacco which is easily available, cheap, and easy to use without being detected and there is no ban on its consumption at public places. The situation is someway similar to prohibition of alcohol in Haryana between 1996 and 1998, leading to increased consumption of alcohol due to smuggling of liquor from neighboring states.  and the state had become a helpless observer in checking smuggling in the face of highly influential people. The Commission also observed that there was no "visible circumstance" for imposing the prohibition, except the "desire of the then Chief Minister." Similarly, the Dowry Prohibition, prohibition of Private Lottery, prohibition of use narcotics and psychotropic substances etc are a failure because these bans do not have public mandate. Without public support and willingness, the ban on sale of tobacco has failed. People who never thought of quitting smoking in the last 6 months were significantly higher in terms of living alone by themselves, unemployed and from a joint family set up [Table 4].
|Table 4: Comparison between two groups: The ones who have decided to quit smoking in last 6 months and those who never thought of quitting in last 6 months on various socio-demographic variables|
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All the nicotine users in the present study underwent administration of the Fagerstrom test for nicotine dependence. The mean score for smokers was found to be 4.6 (Sd+2.4) which implies that most of the smokers are moderately dependent on nicotine. The modified Fagerstrom test for smokeless tobacco was administered on all SLT users and the mean score was found to be 4.8 (SD +2.5) implying moderate dependence in most of the SLT users [Table 5]. More than half of the tobacco consumers had a family member consuming tobacco. In the present study, we also studied the pattern of nicotine use. Most of the smokers (42.1%), consumed 1 to 10 cigarettes per day whereas more than one-fifth consumed 21 or more cigarettes per day. The mean no. of cigarettes/biddis smoker/day was found to be 14. Biddi, the low priced hand rolled form of tobacco, wrapped in the dried tendu leaf, was used by 37.7% smokers, where as 38.5% used both biddi and cigarette, 1% used cigar and similar figures have been reported earlier also. , The upper and middle class segments preferred filtered cigarettes, while the lower socio-economic groups consumed other types of tobacco product. Among the nicotine users, 32% of the users consumed chewable forms of tobacco, out of them 17.5% were females.
|Table 5: Mean and SD of Fagerstrom test for nicotine dependence and smokeless tobacco|
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The policies to control tobacco use among the youth, in addition to supply reduction, should focus on demand reduction for tobacco products by using mass media and producing more effective messages and message delivery systems to reach youth at high risk of smoking.  It has been consistently observed that youth who have the highest tobacco-use rates are among those who are least likely to be reached through school-based or other programs. Thus, these youth, often labeled "high-risk," are seen as a cornerstone for tobacco use prevention efforts . Another study looking at the impact of supply reduction of tobacco on the use of tobacco among the youth reported that reduction of commercial sale to zero did not result in significant reduction in use and the youths were able to obtain tobacco from other sources. To prevent or reduce tobacco use by youths, however, multiple supply-and demand-focused strategies are needed.  One of the limitations of our study is that only one subject was included from each household and there is a possibility that the younger population has overrepresentation in our sample. Also, there was no objective evidence to verify the information given by the participants and thus the element of misrepresentation cannot be entirely removed.
The findings of this study will help in designing tobacco control strategies and understanding the epidemiology of tobacco-related health burden. The anti-tobacco policies of India need to focus on bidis in anti-tobacco campaigns. The program activities must find ways to reach the rural and urban-slum populations. The shift to chewable tobacco might reduce the environmental hazards by cutting passive smoking, but at the individual level, the health risk continues and future government policies must think of ban/reduction in tobacco consumption in all forms.
| ¤ Acknowledgement|| |
We gratefully acknowledge the input and support of Mr. Jasvir Singh (Medical Social Worker) and Mr. Hardeep Singh (Medical Social Worker) during various stages of this study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]