A qualitative study on attitude towards smoking, quitting and tobacco control policies among current smokers of different socio-economic status.

INTRODUCTION: Tobacco consumed as smoke and smokeless forms is an important preventable public health issue projected to be the single largest cause of mortality worldwide. The aim of the study was to qualitatively assess the attitudes towards smoking, quitting and tobacco control policies among current smokers of different socio-economic status.
MATERIALS AND METHODS: An in-depth interview for 10 current smokers and a focus group discussion comprising of 10 current smokers was conducted with a guide and moderator which was audio recorded. About 6, 8 and 6 subjects from white collar, blue collar, and black collar employee status participated in the study. Their tobacco consumption and dependence using the Fagerstrom Test for Nicotine Dependence scale (FTNDS) was assessed.
RESULTS: About 50% of the participants had low; 30% had moderate and 20% had high nicotine dependency. Most of the participants started smoking by peer influence and continued as it made them to socialize. Relapses during their quit attempt was mainly due to work stress. Participants heard about the control of tobacco act but were unsure of the features in it. They perceived that no changes will happen if government bans production and selling of tobacco products. Also anti-tobacco commercials in social media will have no use. Nicotine replacement therapy may help in quitting the habit.
CONCLUSION: The study concluded that people in low socio-economic status had high nicotine dependency with inadequate knowledge on tobacco control policies. They strongly believe that an individual's self-restrain only can succeed him in quitting the habit. Copyright:

Introduction

Tobacco remains as a single largest cause for heart diseases and stroke in India, with more than one million deaths/year.[1] India faces an enormous economic burden for treating tobacco-related diseases amounted to $907 and $285 million for smoke and smokeless tobacco respectively.[2] Control and prevention of tobacco use becomes a major public health issue in limiting morbidity and mortality.[3] The prevalence of adult current smokers and smokeless tobacco users is 24.3% and 25.9%, respectively. With increasing tobacco control measures (surveillance and monitoring, tobacco control policy, legislation, capacity building) by the Government of India, still prevention of smoking remains a major challenge.[4] Although the prevalence of tobacco users has been decreasing over last two decades, about 19% of adult males and 2% of adult females continue using tobacco currently. Evidence says that 55.4% and 49.6% of smoke and smokeless tobacco users planned to or were thinking about quitting.[5] However only <2% tobacco users have made an attempt to quit using mCessation program – Quit Tobacco For Life.[6] Though use of tobacco among the adults dropped from 35% in 2009–10 to 29% in 2016–17 still a high economic burden is posed on India.[7]

Studies have demonstrated that a brief physician-delivered intervention (as brief as three minutes) using cognitive behavioural therapy (CBT) for smoking cessation in primary care setting significantly increases patients' smoking cessation rates.[8] Smoking cessation produces immediate and substantial health benefits.[9] The nicotine replacement medications and psychotic drugs have produced reasonable results in smoking cessation among high tobacco dependence individuals.[10] Thus there is a need for population-based interventions to complement individual-based behavioural or pharmacological interventions, capacity building for smoking cessation and treatment of tobacco dependence.[11] Social support for quitting, training of health professionals and integration of smoking cessation in other health programmes are essential for successful implementation of tobacco cessation programmes.[12] Recognizing the importance of tobacco cessation, there are 19 tobacco cessation clinics (TCCs) in India with the support of the World Health Organization.[13]

The Quit Tobacco International (QTI) has embarked on a project of incorporating tobacco cessation intervention in the undergraduate medical curriculum in two countries: India and Indonesia. As part of this project in India, 15 course modules were developed, piloted, implemented and evaluated in various departments of five medical colleges in Kerala and Karnataka States.[14]

Recent study suggested that even after being diagnosed with Head and Neck Cancer, one third of the study population continued to use tobacco.[15] Thus, it becomes an integral part of health professionals to provide a structured approach to initiate smoking cessation, manage withdrawal symptoms, and provide long-term support.[16] However, these cessation programs are usually customised according to individuals. This necessitates an in-depth understanding of the perception towards smoking and quitting in bringing out a targeted behavioural change.

The aim of the study was to qualitatively assess the attitudes towards smoking, quitting and tobacco control policies among current smokers of different socio-economic status attending a private dental college in Chennai.

Materials and Methods

Qualitative in-depth interviews and focus group discussions were conducted among current smokers visiting a private dental college in Chennai, Tamil Nadu. Ethical clearance was obtained from Institutional ethics committee, Saveetha University with the number SRB/SDC/PHD-1802/19/03. Approval obtained on 19/4/2019. The study population included white collar, blue collar, and black collar employees according to Friedrich in 2013.[17] A white-collar worker is a salaried professional, typically referring to general office workers and management. Blue-collar worker is a member of the working class who performs manual labour and either earns an hourly wage or is paid piece rate for the amount of work done. Black collar worker is a manual labourer in industries.

The study included current tobacco users, using tobacco for more than a year and aged 18 years and above. Former smokers and those who were not willing to participate in the study were excluded. The snowballing sampling method was used to recruit the study participants. Written informed consent was obtained from the study participants and the anonymity of the participants was maintained. The study was conducted during December 2019 in the department of Public Health Dentistry in a private room. The participants had varying levels of motivation to quit in the future. Interview was carried out until new responses or new ideas were generated. A baseline data on tobacco consumption, dependence was assessed using the Fagerstrom Test for Nicotine Dependence scale (FTNDS).

In depth interview

The study included an initial in-depth interview for 10 participants with 3 from black and white collar group and 4 participants from blue collar group. In-depth interview was conducted by a moderator along with an assistant. An interview guide was formulated so that we could probe into various aspects of smoking behaviour. The information's given by the participants were audio-recorded. The interview lasted 30 – 45 minutes for each participant.

The areas of discussion included reasons to start smoking and to continue, their perception as smokers, attitude towards non-smokers and their knowledge regarding health effects of smoking. Further probing was done to obtain details regarding their quit attempts and anti- health warnings on multimedia such as television, newspaper, or the cigarettes packets. The last part of the discussion included their knowledge and attitude towards nicotine replacement therapy (NRT) and tobacco control policies in the country.

Focus group discussion

A focus group discussion was conducted comprising 10 current smokers. The participants involved in the in-depth interview were not included for the focus group discussion. About 3 participants from black collar, 4 from blue collar and 3 from white collar group participated. Like in-depth interview, there was one moderator and one assistant. The discussion lasted for one hour and was audio-recorded. The moderator prompted the topics and the discussion continued. The areas of discussion included knowledge and attitude about cigarettes and other tobacco products act (COTPA), attitude about the situation what will happen if India closes the production of tobacco products. The discussion was healthy and each individual participated in briefing their perception.

Data analysis was done in accordance with thematic framework analysis to allow themes to be generated from the data collected. The audio recordings were transcribed to their verbatim format. The recordings were read and familiarised multiple times to generate themes. The focus group guide helped to sort the emerging keys points and the new themes to be segregated according to the responses. Initial analysis was undertaken manually, and the responses from each participant were identified and charted under the respective key points. Finally, interpretative analysis was done to group together similar points and to identify recurrent themes which enabled the various aspects of smoking behaviour among the participants of the three groups.

Results

Among the 20 participants, 6 were white collar, 8 were in blue collar and 6 were black collar employees. About 50% had low nicotine dependency; 30% had medium nicotine dependency and 20% had high nicotine dependency. Low dependency was seen among 40% and 20% of white and black collar employees respectively. Medium dependency was seen among 60% and 33.33% of white and blue collar employees. However, high nicotine dependency was observed among 80% of black collar and 66.67% of blue collar employees. The responses generated after the focus group discussion were segregated and the following themes were produced.

Reasons for start of smoking

Most of them started smoking at the age of 18 years. The main reason to start smoking was due to the influence of peers and friends. The reason was found similar in black and blue- collar employees while white collar employees had a different perception

One of the black collar employees said “I saw my friends smoking, was curious to know what it is about and how it would feel”

One of the blue-collar employee said “all my friends in my gang were using it and they asked me to use. I wanted to be included too”

White collar employee said “in college, only when a guy smokes, he was considered matured, macho and can impress girl classmates”

Reasons to continue smoking

All the participants considered smoking as a stress buster and a major way to socialise. They could divert their mind from what was troubling them.

“Whenever I have tension I want to smoke and relax. It gives relaxation and I would forget all the tension in association with drinking” - Black collar employee

“It's a good pass time and to socialize with friends in tea shop” - Blue collar employee

We received another dimension for the reason to continue from a white - collar employee.

“I have smoking zone in my office and major decisions were made here. Also I get chances to interact with the higher officials” - white collar employee.

Knowledge regarding health effects and COTPA

When asked about the harmful effects of tobacco on health, all the three groups said they are aware of the ill effects of tobacco and it affects lungs. White and blue-collar employees learned from books and movies, black collar employees learned from movies and advertisements. And some of the participants have had relatives who had suffered of health problems due to constant tobacco use. They were not aware of the COTPA act and its regulations, however watched anti-tobacco advertisements and heard from people that smoking in public is prohibited. They all never smoke in front of women and children but do smoke in public. Their usual place is the local tea shop where women and children won't be there.

Aspects related to quitting attempts

Everyone has attempted to quit tobacco. “whenever I feel financially low, I try to quit but relapsed because of tension”–blue collar employee

One of the blue-collar employees said “I want to quit when I get married and start a family”.

Stress was the main reason for relapse. One of the white-collar employees said that “I tried to quit for a month but I relapsed due to work pressure though had sufficient knowledge on ill-effects”

What will happen if tobacco is stopped manufacturing

We explained about Indian Tobacco Company (ITC) and its share in producing tobacco in the country. And we questioned what will happen if the country stops production and selling tobacco products

The black collar employees were so lethargic about the question and said its hypothetical “We can only talk about but the government will never stop manufacturing cigarettes”

“When government bans the cigarettes, people will go for other addictions of cheaper tobacco forms” – Blue collar employee

The white-collar employees said that “high dependent people may go for other addiction but people in officer ranks may try to quit”

Anti - tobacco commercials

We asked about the anti-tobacco commercials which are shown on television, theatres and on the tobacco packets.

The black collar employees were aware of the commercials and uncertain of the purpose of those commercials as they are run by the same government and companies which are selling them.

One of the blue-collar employee said “It doesn't affect me”

The white-collar employees said they feel guilty inside but -they couldn't quit it. One of the white-collar employee said “I convince myself that I know the limits of tobacco that will cause ill effects and I will stay in my limits”

Nicotine replacement therapy

We shared some knowledge about nicotine and its effects and how nicotine replacement therapy helps in quitting tobacco.

“We are not aware and can't afford for such things” -Black collar employee said

One of the blue-collar employees had an experience with NRT and he said that “I have tried one of NRT gums once but I don't like the taste of it and it doesn't satisfy me as cigarettes do”

White-collar employees were more aware of NRT and none of them had tried and they were ready to try with proper professional advice.

One of the participants from white-collar employees who had previous unsuccessful attempt in quitting came forward to share his story. He said that “people who are highly addicted inhales it deeply into the brain, gets high instantly and exhale via nose. People with medium dependency will exhale through mouth. “Also said the best way to quit tobacco is to divert into other things they are interested in and with high self-restrain”. Table 1 explains the results of all the three groups in different categories.

Table 1

Summary of the responses given by the participants for different categories

Area of discussion	Black collar employees	Blue collar employees	White collar employees
Reasons for start of smoking	I saw my friends smoking and I was curious to know what it is about and how it would feel	all my friends in my gang were using it	Only when a guy smokes he was considered matured in college
Reasons to continue smoking	Whenever I have tension I just want to smoke and relax	It’s a good pass time	I have smoking zone in my office and very good friendships were built based on that
Knowledge regarding health effect of smoking and COTPA	They all know about the health effects of tobacco that it affects the lungs and causes cancer. Some of them has had their relatives and known people who had suffered from cancer due to smoking. They all say they never smoke in front of women and children
Aspects related to quitting attempts	Whenever I feel financially low, I try to quit but then relapse because of tension	I want to quit when I get married and start a family	I tried to quit for a month but then when the work pressure is too much I relapse
What will happen if tobacco is stopped manufacturing?	We can only talk about this with a paper and pen but the govt will never stop manufacturing the cigarettes	When government bans the cigarettes, people will go for other addictions or some will use this and start cheaper tobacco forms	The high dependent people may go for other addiction but people who are in officer ranks like me may try to quit
Anti-tobacco commercials	I am aware of it but then why is the govt selling it?	It doesn’t affect me	Whenever I notice it, I scold myself but the I couldn’t quit

People who are highly addicted inhale it deeply into the brain and get high instantly and exhale via nose. People who medium dependent will exhale via mouth. That’s a way u can identify how addicted they are

Discussion

Qualitative research pivots in apprehending a research query as a humanistic or idealistic approach. Though quantitative approach is viewed as a reliable method which can be made objectively and propagated by other researchers, qualitative method helps to understand people's beliefs, experiences, behaviour, attitudes, and interactions.[18] Although once viewed as philosophically incongruent with experimental research, qualitative research is now being recognized for its ability to add a new dimension into interventional studies that cannot be obtained through measurement of variables alone.[19] Qualitative research gives voice to the participants in the study permitting them to share their experiences of effects of the drug of interest in a clinical trial. This can open our eyes to new aspects and help modify the design of the clinical trial.[20]

In the present study, peer pressure was the main reason the participants started smoking. A study by Sharma et al. in 2016, it was found that main reason to start smoking was due to the influence of peer groups and friends, while a few felt it created a high esteem among the others.[21] The reason to continue smoking and relapse in quit attempts in the present study was stress which was similar to statement in the previous studies.[22232425]

High nicotine dependency was seen among black and blue-collar employees. This proves the role of socioeconomic status and education in nicotine dependency. Previous research suggests that people in socioeconomically deprived neighbourhoods smoke more than those in affluent neighbourhoods, independently of individual-level socioeconomic status.[2627]

Tobacco cessation in primary care

Qualitative study is all about connecting to the psychological aspect of the participants that can play a role in the intervention. Early detection, diagnosis and treatment are important to increase the awareness of the population. Primary health centre physicians and dentists are the first contact of medicine. Easy accessibility of the oral cavity to examine renders it an ideal target for improved screening practices. Due to the modest investments of time and cost required by screening exams, primary care physicians assume a frontline role in the battle against tobacco and oral cancer.[28]

Regarding the health sector, more investment in training of health professionals from primary care to psychology, biopsies, in addition to intersectoral and multidisciplinary actions are necessary.[29] Further training is required at both undergraduate and postgraduate levels to increase awareness of tobacco usage, its associated risk factors to strengthen primary care practitioners' abilities.[30]

Conclusion

Findings of the study show that people in low socio-economic status had high nicotine dependency with inadequate knowledge on tobacco control policies. There is a need for interdisciplinary approach to prevent tobacco use that involves various disciples of medicine, with the support of government and the broader community. Dentists are one of the professionals who can detect the smoking habit by examining the oral cavity. A public health dentist, often are the primary contact of health worker for many of the low socio - economic groups. It is important for us to understand the various interventions and aspects of the nicotine intoxication and assist in cessation of the habit.

Summary

In the present study, among the 20 people participated in-depth interview and focus group discussions, 30% were white collar, 40% were blue collar and 30% included black collar employees. The results showed that 50% of the participants had low nicotine dependency; 30% had medium nicotine dependency and 20% had high nicotine dependency. During the focus group discussion and in depth interviews, most of the participants stated that they started the habit due to peer pressure and they were aware about the ill effects of tobacco use. Most of the participants relapsed from their quitting due to family or work tension. During focus group discussion, one of the participants from white collar employees who have had previous unsuccessful attempt in quitting said that “people who are highly addicted inhales it deeply into the brain, gets high instantly and exhale via nose”. People with medium dependency will exhale through mouth. All the participants were unaware of tobacco control policies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.