Episodic Drives against Smoking in Public Places Executed by the Para-Security Forces and Other Agencies Empowered by the Prevailing Laws to Reduce the Incidence of Smoking in Public Places

Objectives

1. To determine the effect of Episodic Drives against Smoking in Public Places executed by different stakeholders in reducing the incidence of Smoking in Public Places

2. To determine the effectiveness of low-cost community outreach, such as tobacco cessation intervention, in the rural/urban population of the Una district.

Study design for baseline/end-line survey and study area

In this quasi-experimental study, a cross-sectional analytical design was used for the baseline and endline project survey, which was carried out in Una (urban area) and the Haroli Block (rural area) of District Una, Himachal Pradesh. The urban area was the district headquarters of Una itself, while the rural area was Haroli Block. The project was carried out in implementation research mode. The purpose of the same was to create an evidence base which can then be used for expanding the intervention to other areas. All the public places as per the definitions under the Tobacco Laws were enlisted and mapped in both implementation sites. Sixty-two public places were randomized to either the urban (21 places) or rural (41 places). The places included were government offices, markets, bus stands, railway stations, banks, etc.

Study population

Tobacco smokers in the study area were the unit of study.

Sample size

Sample size² to estimate the proportion of public place smokers was calculated using the estimated prevalence of smokers in India as 10.7%³ and assuming that 90% of the smokers smoke at public places, the sample size was calculated as follows:

Sample size formula =

Sample size was calculated based on an expected reduction in smoking in public places from 90% to 75% after intervention, with alpha=0.05, power=80%, using the formula for before-after comparisons:

n = (Z/2+Z)² × [p1(1-p1) + p2(1-p2)]/(p1-p2)²

where p1=0.9 and p2=0.75. This gave a sample size of 374, which was multiplied by design effect of 1.5 and adjusted for 10% attrition to get 620 participants.

P - Proportion of event in the population = 9.63% D - Acceptable difference from P = 3%

As per the Global Adult Tobacco Survey-II, India (2016-2017)³, the prevalence of smokers in India was 10.7%.

Sample size formula (cluster sampling): n’ = n × deff

= 3.74 × (90.0 × 10.7)/(3 × 3) × diff = 374 × 1.5 = 561 (if Deff = 1.5)

where P = proportion of smokers who smoke in public places (9.63%) and Q = 1-P (90.37%).

Considering 10% non-respondents/not at home, therefore N = n’ + 10% of n’ = 561 + 56 = 617; this was rounded off to 620.

Sampling strategy

The probability proportional to size method was used for sampling. A village was considered a cluster in the rural area. A ward was considered a cluster in the urban area.

Survey method and study tool

House-to-house visit was made in each cluster, and smokers were identified till the desired sample was reached in each cluster. A semi-quantitative questionnaire was used by trained staff, wherein information on sociodemographic variables (age, gender, education, occupation, socioeconomic status), smoking behavior (frequency, age of initiation, quit attempts, type of tobacco products), knowledge about health risks of smoking, attitudes toward quitting, indoor/ outdoor smoking practices, and family history of smoking and was done using a pre-tested interview schedule in Hindi. Knowledge was assessed using 10 questions about health risks of smoking, tobacco control laws, and dangers of secondhand smoke. Each correct answer received 1 point, for a maximum score of 10. Attitude was similarly scored on a 10-point scale based on responses to questions about willingness to quit, perceived importance of tobacco control, and beliefs about smoking in public places.

Implementation population

All the public places, as per the definitions under the Tobacco Control Laws, were enlisted and mapped in the two implementation sites. It is important to note that the intervention was community-wide, targeting all individuals in the selected public places, not just the enrolled study participants. The 620 enrolled smokers served as the assessment population for measuring outcomes, while the entire community was the implementation population. This community-wide approach reflects real-world tobacco control implementation.

Study duration

The intervention phase was conducted over a period of 1 year (August 2018 to August 2019), while the entire project including planning and analysis extended to February 2020, to achieve the outputs and effects.

Study design

The study population of 620 smokers was identified and enrolled through house-to-house surveys at baseline (July-August 2018), prior to initiating the community intervention. Baseline data was collected from these participants, followed by the intervention period, and then end line assessment of the same participants after 11 months.

Implementation of intervention

“Episodic drives against smoking” in this context refers to short-term, targeted campaigns or enforcement efforts focused on reducing smoking in public places. These drives are carried out by para-security forces (such as police or similar agencies) and other authorized groups such as civil defense, scouts, guides, NCC, and NGOs. They are empowered by existing laws to enforce smoking bans in public spaces. The “episodic” nature implies that these are not continuous, ongoing efforts, but rather periodic, concentrated actions aimed at raising awareness, deterring smoking, and enforcing regulations.

Special awareness and implementation drives were conducted in the project. These drives were conducted for 1 week each [Figure 1]. Initially, for 6 months, these drives were conducted every month. The periodicity was then brought down to every 2 months. After getting permission from the district authorities, banners were put up at public places, informing the public against smoking in public places. Audio messages were also played at various public places, informing the public not to smoke in public places. All the shops, nearby educational institutes, and healthcare facilities were inspected for any sale of tobacco products. Any person found smoking was video-taped and police fined on the spot [Figure 2].

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Figure 1:

Study flow.

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Figure 2:

Implementation plan. NCC: National cadet corps, NGOs: Non-government organizations.

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These drives were carried out by various agencies such as the scouts and guides of NCC, Civil Defense, Panchayat Members, and NGOs. One representative from among the project staff and one from the District Health Department always attended these advocacy drives. A list of such agencies in each of the implementation sites was prepared and mapped out. While the core components of the intervention were standardized across sites, minor adaptations were necessary to suit urban versus rural contexts. For example, messaging in rural areas emphasized agricultural analogies, while urban messaging focused on workplace scenarios. To account for potential inter-group variation, we conducted separate analyses for urban and rural areas rather than pooling the data. This stratification helped control for contextual differences that might influence intervention outcomes. Potential agencies were involved to execute the above drives as planned in the project. The agencies were also empowered to collect fines and video-tape the defaulters by the local and the state statutory bodies to ensure their seamless functioning. The Police Forces were also sensitized and informed about these drives, and they offered complete support to these agencies during the drives. Besides this, NGOs working in the area and school children in the selected Senior Secondary schools were also sensitized. Special sessions were organized for the members of Panchayati Raj Institutions in the rural area and for the Municipal Committee in an urban area.

The anti-smoking awareness program was developed, which addressed the individual’s perceptions of the threat posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and the factors influencing the decision to act (barriers, cues to action, and self-efficacy). The program focused on the people’s knowledge and beliefs about smoking, their perceived susceptibility to smoking initiation, their perceptions of the benefits of trying to avoid smoking, and their readiness to avoid its use. The following health education tools were used for the intervention:

1. Health talks

2. Information leaflets

3. Posters

4. Banners

5. Audio Message.

Health talks were held at different villages/public places/ Schools of the district Una. Advocacy sessions, each lasting for 3 hours, were organized involving related stakeholders. The health education sessions were attended by both the enrolled study participants (who were specifically invited) and other community members from the intervention areas. On average, each session had 30-40 attendees, with approximately 15-20 being enrolled study participants and the remainder being other community members. Each 3-hour session was designed to be highly interactive rather than didactic. After an initial 45-minute presentation, the remaining time was dedicated to group discussions, role-playing exercises demonstrating refusal skills, Q&A sessions, and testimonials from former smokers. This interactive approach was employed to maximize engagement and knowledge retention. Health talks were given by the lead researchers. The first session provided information on the following areas: An introduction to cigarette smoking; the contents of a cigarette; the effects of cigarette smoking on individual health; the health, social, economic, environmental effects of cigarette smoking; the dangers of nicotine addiction; reasons why people are prone to the use of cigarettes; erroneous perceptions regarding cigarette smoking.

The second session consisted of a reinforcement of the topics discussed in the first session; an understanding of what second-hand smoke is; the dangers of second-hand smoke; the need to promote smoke-free norms; helping young people identify social influences to smoke (e.g., tobacco advertising and marketing strategies, peer influence, etc.) and how to say “No” to cigarette smoking. Each person who attended the session was also given an information leaflet at the end of the second health talk. This leaflet was designed by the lead researcher and reiterated the topics discussed during the health talks and was distributed with the help of the trained research assistants. Posters, further reinforcing anti-smoking behavior, were put at strategic locations in the district for the whole period of the study.

Follow-up and measuring the outcome

After 11 months of the intervention phase, the follow-up assessment was conducted in the same clusters and households using the knowledge, attitude, and practice questionnaire about smoking. The measurement of the project outcomes, to some extent, helped in proving the success of the model. The baseline and endline surveys were undertaken to measure a few aspects of the situation of public smoking, which was the primary measure to understand the success of the interventions. The primary indicator that was used for measuring the success was as follows: “Proportion of Smokers who report smoking in public places in District Headquarter, Una and Haroli Block.” Self-reported cessation of smoking was another measure of outcome.

Ethical consideration

Investigators were aware of the ethics in biomedical research policy of Indian Council of Medical Research (ICMR) (2017) and the declaration of Helsinki revised in 2002 and revised from time to time. Keeping this in view, consent from each of the study participants was obtained. Ethical approval was sought from the nearest institutional ethics committee of Dr. RKGMC, Hamirpur, H.P. This study received ethical approval from the Institutional Ethics Committee of Dr. Radha Krishnan Government Medical College, Hamirpur, H.P. (Approval No. HFW-H-Dr.RKGMC/Ethics/2019/800, dated January 21, 2018). Written informed consent was obtained from all participants prior to enrollment in the study.

Knowledge score

Pre-interventional knowledge scores were 4.99 ± 1.06 and 5.03 ± 1.06 in urban areas and rural areas, respectively. There was no difference in knowledge scores between the two groups (P = 0.67). Knowledge scores after intervention were 7.57 ± 0.94 and 5.70 ± 0.78 in urban areas and rural areas, respectively. There was a significant increase in knowledge about smoking in the whole study population, i.e., from 5.01 ± 1.06 to 6.63 ± 1.27 (P < 0.01) [Table 2].

Attitude score

There was no difference in the pre-interventional attitude scores in both the groups (P = 0.89). The post-interventional attitude score was significantly higher in urban areas (P < 0.01). After intervention, there was a significant increase in the overall mean attitude score in the study population (P < 0.01) [Table 3].

Smoking cessation

After intervention the overall smoking cessation rate was 13.3% in the study population. In urban area 23.5% participants left smoking as compared to 3.3% in rural area. Around 41% participants were doing indoor smoking before intervention which was significantly reduced to 26% after intervention.

Factors associated with smoking cessation

90 (14.5%) participants left smoking after intervention [Table 4]. Most of the participants who quit smoking had middle-standard education. There was no significant association between the level of education and smoking cessation. There was no significant relation between age group and proportion of smoking cessation. Most of the participants who left smoking belonged to the moderate (22.7%) and heavy smoker’s category (58.7%).

Demographic profile

The baseline profile of the study population, i.e., the smokers, demonstrated that the majority of smokers, both in rural and urban areas, were males and belonged to the 30–45-year age group. Raina et al.⁴ in their study on the urban population of Kangra, Himachal Pradesh, and Chezhian et al.,⁵ among smokers attending the outpatient department in Chennai also reported similar findings. Urban smokers were educated up to matriculation and rural smokers up to middle school education. The findings were similar to those reported by Chezhian et al.⁵ The Majority of urban smokers were semi-skilled workers, and in rural areas, they were involved in agriculture. Contrasting findings were reported by Chezhian et al. reported 49% of participants as indoor smokers in their study, which is higher compared to our baseline finding of 41% indoor smokers. Kock et al.⁶ in their review on intervention in socioeconomically disadvantaged groups, gave consistent evidence that individual-level interventions for smoking cessation are effective for smoking cessation in disadvantaged groups.

Rural smokers initiated smoking at a younger age than urban smokers. Chezhian et al.,⁵ reported a lower age of initiation as compared to our baseline analysis. As per the present study, the majority were moderate smokers in both areas. More than half of indoor smokers were reported in urban areas. Chezhian et al. ⁵ reported 49% of indoor smokers, which was higher in comparison to our study’s (41%) population. Mishra et al. ⁷ reported 77% indoor users; however, the study population was female tobacco users. Before the start of the intervention, around half of both urban and rural smokers never considered quitting. Global adult tobacco survey (GATS-2) survey (2015–16) reported that 55.4% of current smokers were planning to quit.² Raina reported that around 63% of smokers thought of quitting. A family history of smoking was reported by a higher proportion of rural smokers as compared to urban smokers.⁴

Public smoking

To directly address our primary objective, we measured self-reported smoking in various public places. Overall, smoking in public places decreased from 65% at baseline to 38% post-intervention (P < 0.001). The reduction was more pronounced in urban areas (72% to 33%, P < 0.001) compared to rural areas (58% to 43%, P = 0.02). Complete smoking cessation (14.5% overall) further contributed to reduced smoking in public places.

Intervention

India’s anti-tobacco legislation was first passed at the national level in 1975, the Cigarettes Act 21; this was largely limited to statutory warning “Cigarette Smoking is Injurious to Health” to be displayed on cigarette packs and advertisements.⁸ Tobacco prevention and control policies in India have focused on awareness and behavior change too.⁹ Enforcement infrastructure in India is an essential intervention for the success of tobacco control.¹⁰ This can be reinforced by involving representatives from local self-government bodies, as they are potentially influential, and the untapped nexus between the mainstream policymakers and the public and their role in tobacco control will be advantageous.¹¹ The current project used repeated advocacy sessions involving stakeholders and health education tools at various public places.

Effect

The knowledge and attitude toward quitting smoking improved after intervention. However, the improvement was much better in urban areas as compared to rural. Reduction was higher in urban areas. This could be due to the high literacy level in urban areas. The intervention given in the current project was majorly group-based and not individual-based. Hence, the rural population was not as receptive to the education material as compared to the urban population. Kock et al.⁶ argued in their review that tailored, individual-level approaches are expected to have an important role in reducing health inequalities by addressing some of the needs specific to disadvantaged smokers.

Cessation in the current study was observed in the majority of moderate smokers and in those residing in joint families. The family members of the smokers can be counseled along with the smokers to facilitate quitting smoking.¹² The intervention delivered was of great success as it was integrated along with many other activities of social importance. While integration with developmental programs enhanced reach and sustainability, we acknowledge the potential risk of diluting anti-tobacco messaging. We mitigated this risk by ensuring that tobacco control remained the primary focus of all integrated activities, with clear anti-smoking messaging consistently emphasized. The significant improvements in knowledge, attitudes, and behavior suggest that the anti-tobacco focus was maintained despite the integration approach. Future studies should systematically assess whether integration affects message salience compared to tobacco-specific campaigns. Integration of tobacco control activities with developmental programs such as poverty alleviation, rural development schemes, women and child development, and tribal welfare programs would lead to an extensive and widespread presence of tobacco control activity at the grassroots level.^13,14 Other social media platforms (web-based) are also showing preliminary effectiveness in terms of increasing motivation or interest in quitting, and these can be used in conjunction with those used in current interventions.¹⁵ In a review by Thomas et al.,¹⁶ seven cluster-randomized controlled trial (RCTs) were included that evaluated the effect of system change interventions on cessation or system-level outcomes or both. All the studies included the provision of cessation advice by clinicians to all the identified smokers. It provided inconclusive information about the prevalence of abstinence from smoking but an improvement in the number of smokers counseled and organizational support given.

The current intervention involved the researchers, the stakeholders, and not only the clinicians. This shows a promising result for future policy decisions on interventions. It is also important that intervention activities should be delivered at frequent intervals and not as a one-time activity. To facilitate tobacco cessation, it is also important to identify the factors that would prevent smokers from quitting smoking.¹⁷