College students’ knowledge and attitude towards new regulation on smoking ban in public places in Nepal

Introduction Tobacco epidemic is one of the biggest public health threats in the world that kills about six million people a year (1). Both active smoking and passive smoking are important risk factors for many diseases including cardiovascular diseases and cancer (2). Tobacco smoking is associated with ill health, disability and death from non-communicable diseases like cardiovascular diseases, cancer, Chronic Obstructive Pulmonary Disease (COPD) as well as communicable diseases like tuberculosis, lower respiratory tract infection, etc. (3). Smoking in public places causes non-smokers to be exposed to smoking. This act of second hand smoking is associated with increased incidence of cardiovascular diseases, lung cancers and respiratory problems (4, 5). Framework Convention on Tobacco Control (FCTC) was one of the important responses of World Health Organization (WHO) to the growing tobacco epidemic that was adopted by World Health Assembly in 2003 and came into force in 2005. FCTC calls for all countries to introduce comprehensive tobacco control policies and strategies as per WHO recommendations (6). Many signatory countries have implemented the smoke free policies so as to decrease the adverse health effects of smoking among smokers and second hand smoking among non-smokers (7-9). Government of Nepal also implemented the non-smoking policy by signing FCTC in 2003 that was ratified in 2006 (10). In 2011, Nepal approved “Tobacco product control and regulatory bill, 2010” which enforces a complete ban on smoking in public places, workplaces and public transportation. This law discourCollege students’ knowledge and attitude towards new regulation on smoking ban in public places in Nepal Open Access: Full Text Article Research Article Health Prospect: Journal of Public Health


Introduction
Tobacco epidemic is one of the biggest public health threats in the world that kills about six million people a year (1). Both active smoking and passive smoking are important risk factors for many diseases including cardiovascular diseases and cancer (2). Tobacco smoking is associated with ill health, disability and death from non-communicable diseases like cardiovascular diseases, cancer, Chronic Obstructive Pulmonary Disease (COPD) as well as communicable diseases like tuberculosis, lower respiratory tract infection, etc. (3). Smoking in public places causes non-smokers to be exposed to smoking. This act of second hand smoking is associated with increased incidence of cardiovascular diseases, lung cancers and respiratory problems (4,5). Framework Convention on Tobacco Control (FCTC) was one of the important responses of World Health Organization (WHO) to the growing tobacco epidemic that was adopted by World Health Assembly in 2003 and came into force in 2005. FCTC calls for all countries to introduce comprehensive tobacco control policies and strategies as per WHO recommendations (6). Many signatory countries have implemented the smoke free policies so as to decrease the adverse health effects of smoking among smokers and second hand smoking among non-smokers (7)(8)(9).
Government of Nepal also implemented the non-smoking policy by signing FCTC in 2003 that was ratified in 2006 (10). In 2011, Nepal approved "Tobacco product control and regulatory bill, 2010" which enforces a complete ban on smoking in public places, workplaces and public transportation. This law discour-ages sale of tobacco products to minors and pregnant women and also prohibits such sales by the unlicensed vendors. Similarly, health tax on tobacco products has been introduced and the advertisements, sponsorship and promotion in any forms has been forbidden. Moreover, the law also includes the provision of punishments and penalties to the offenders of the regulation (10). A more recent and stronger legislation (11) that came into force in 2015 requires that all tobacco packaging should strictly cover 90% of surface area with pictorial health warnings.
Adolescents are one of the key markets of tobacco companies (12). They are the most vulnerable population to initiate tobacco use and most of the adult users of tobacco begin using tobacco products during childhood or adolescence (13). In Nepal the prevalence of current cigarette use among those aged 13-15 years is 3.1% (14). Similarly, prevalence of ever smoking was 34.2% and current smoking was 17% among youths in Western Nepal (15). Thus, with the new law on tobacco that has come into effect in Nepal, there is need of assessment of knowledge and attitude of adolescents towards it.
A major factor determining the effectiveness of legislation is the level of awareness, concern and support for the legislation that restricts on smoking. The level of awareness and attitude also dictates the level of compliance with the introduced legislation (2). Studies on attitude towards various events and phenomenon are popular among social scientists as they help to predict and understand peoples' behavior (9). Researches carried out in many countries regarding the public opinion on government's efforts to ban smoking in public places have shown strong public endorsement (2,16). However, no such study has yet been documented in Nepal. Thus, assessment of college student's knowledge and attitude towards the governments' ban on smoking in public places will help the government find out the present adherence to the law and start timely the corrective measures to implement the program effectively.

Methods
A descriptive cross-sectional study was conducted in three randomly selected higher secondary schools of Kathmandu district from March to August 2013. First, a list of 56 colleges in Kathmandu district under Higher Secondary Education Board (HSEB) was obtained and 50 of them gave consent for the study. From this list, 3 colleges were randomly selected for the study. Within these colleges, the students from grade 11 and 12 were randomly included from their attendance sheet using Probability Proportionate to Size (PPS) method. The total sample size of the study was 394.
Self-administered questionnaire was used to collect data that included both open-ended and close-ended questions. The questionnaire was prepared by using variables from similar studies conducted in other countries (2,7,9,16). Participants' knowledge was measured by using variables like: awareness of current ban, source of information and awareness of penalty for those smoking in public places etc. Attitude was measured by using variables like: view towards current ban, reasons behind their view, and view towards possible preventive measures of smoking in public places etc. The questionnaire was prepared in Nepali language and pretested in a higher secondary school in Bhaktapur district. The questionnaire was translated back to English for analysis and interpretation.
Before administering the questionnaire, informed written consent was obtained from the students. The students thus selected were clearly explained the objectives of study. The questionnaire was administered to the students after a brief orientation. The participants were also asked not to mention their personal identity in the questionnaire. The study was approved by research committee, University Grants Commission (UGC), Nepal. Data was entered and analyzed using IBM SPSS Statistics 20 for windows PC. Quantitative findings were analyzed using descriptive statistics (measures of central tendency, frequency and percentage) to generate appropriate tables. Qualitative data were analyzed manually by verbatim transcription and content analysis which were presented under different themes.

Socio-demographic information
The mean age of respondents was 16.7 years. The age ranged from 13 to 22 years. Majority of the respondents (82.7%) followed Hindu religion. More than half (56.7%) of the respondents were residing in nuclear family (Table 1).

Knowledge and view about ban on smoking in public places
Of total 384 respondents who gave answer to the question, 79.9% said that there is ban on smoking in public place in Nepal. The most common source of information was television (72.3%) followed by friend (36.5%) and family members (33.9%). Most of the respondents (67.4%) said that they had frequently seen people smoking in public place. Similarly, 48.8% of total respondents had not heard or seen any penalty or punishment given to those people. Three quarters of respondents (74.2%) believed that this type of ban could prevent cigarette smoking in adolescents to some or more extent ( Table 2).
A total of 283 respondents (74.1%) had the view that the current ban on smoking in public place was a very good thing. Of them 149 (52.7%) gave the reason behind their view. The major reasons expressed by them are presented on the following themes: • Protects from diseases: Fifty one responses reflected the view that this type of ban will prevent tobacco and cigarette smoking and hence protect people from diseases like cancer. They also believed that it saves peoples' life, helps in making people healthy and increase their longevity. • Law is an effective strategy: Fifty responses reflected the view that strict law/legislative measure is an effective strategy to prevent smoking in public places. A common response was, "This type of law reduces the number of smokers by creating fear of penalty or punishment…......smokers will ultimately have to stop smoking in public places forcefully". • Change the attitude of prospective smokers: Twenty three responses reflected the view that this type of governments' ban changes the attitude of adolescents towards smoking.
One of the participants stated, "This type of law will discourage the non-smokers, ever smokers and current smokers to start or continue cigarette smoking". • Prevent the health of other people in public places: Out of total 18 responses within this theme, most of the participants viewed that the ban would help prevent the health of other people in public places. Interestingly, some partici-  pants quoted the term 'second hand smoking' and viewed that it could be prevented by the current law. • Other responses were, "this type of ban prevents environmental pollution"; "it helps to save money"; "it reduces crimes"; and "it helps to motivate self-control against smoking". Similarly, out of 68 respondents (17.8%) who said that the ban is somewhat good, some of the responses were; "the ban is good but smokers smoke anyway despite of strict law", "nothing is going to happen until effective measures for implementation are adopted", "it prevents air pollution", "it makes smokers cautious and careful while they think of smoking in public places".
Similarly, among the responses that were related to the view that the government's ban is not good, the major responses were; "By compelling people cannot be changed, activities should be done to make themselves aware of the effects of smoking", "To smoke or not to smoke in public places is peoples' own will", "People have the right to smoke".

Ways of preventing smoking among adolescents and youths
Two hundred and forty eight participants responded to the question asked to find out their ideas on possible ways of prevention of smoking among adolescents and youth. Among them, around 33% said, 'strict law should be made and implemented' , followed by 30.6% who said 'awareness raising activity and counseling is required' , 22.1% who said, 'cigarette production and import should be banned' . Similarly, need of family support (10.1%), ban or regulated sale of cigarette (9.2%), ban on advertisement (8.4%) were other important responses. (Table 3)

Discussion
Knowledge and attitude are important predictors for effectiveness of legislation on smoking restriction (2). In this research, 79.9% respondents knew that there is ban on smoking in public place in Nepal with television being the most common source of this knowledge. Similarly, 74.1% of respondents had the view that the current ban on smoking in public place is very goodwhich is lower compared tothe findings from Global Youth Tobacco Survey (GYTS) report 2008 which suggested that 77.5% respondents from South East Asia Region supported ban on smoking in public places (17).
Literature suggests that developing countries are lagging behind in strict implementation of such smoking regulations (18). In this study also, as high as 68% respondents were mostly found to have seen the people smoking in public places. About 49% of all respondents had not seen or heard the offenders being penalized but many respondents viewed that effective implementation would require such penalty and other additional measures like awareness raising, regulation in cigarette import, production, advertisement and sale. Global Youth Tobacco Survey on Smoke-Free Policies (SFPs) conducted among youth aged 13-15 years in 115 countries, primarily developing world found out that 77.3% of youths who participated in the study favored SFPs. The same study found that, knowledge on harmful effects of smoke was the strongest predictor of favoring SFPs (19). In the present study also, majority of respondents who believed that the current policy is good, gave the reason that cigarette smoking was harmful to health. They also viewed that this type of policy can discourage cigarette smoking among current and prospective smokers. On the other side, respondents who viewed the new regulation as bad reasoned that people had the right to smoke. They considered smoking as an individual business and this could not be changed by compelling people. These views reflect that for the effective implementation of the regulation, it also needs to win support from those who are more concerned about loss of personal freedom, excessive governmental power, use of compulsion, or the rights of smokers (20).
Different studies (7,21) have also shown that support for smoking free policies lead to reduction of cigarette consumption. Studies have shown that the legislations to ban smoking in public places have led reduction in rates of second hand smoking, reduction in cardiac related hospital admissions and improvement in some health indicators (22). However, there is not much information on the effects of smoking regulation in Nepal which can be scope of further research.

Conclusion
Majority of the respondents had good knowledge and positive attitude towards governments' new smoking regulation. About half of the respondents said that they still saw people smoking in public places. This research suggests that effective implementation of smoking regulation requires awareness raising, regulation in cigarette import, production, advertisement and sale; and penalty to those who violate the law.