The Patterns of Cigarette Smoking and Beliefs, Attitudes and Opinions About Smoking Among Technikon Students
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Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujdigispace.uj.ac.za (Accessed: Date). THE PATTERNS OF CIGARETTE SMOKING AND BELIEFS, ATTITUDES AND OPINIONS ABOUT SMOKING AMONG TECHNIKON STUDENTS
by
Leon Eduard Oberholster
DISSERTATION
submitted for fulfilment of the requirements for the degree
MAGISTER TECHNOLOGIAE
in
ENVIRONMENTAL HEALTH
at
TECHNIKON WITWATERSRAND
STUDY LEADER: DR JJ SCHOEMAN CO-STUDY LEADER: DR Y SALOOJEE
August 1996 • The following persons who have made valuable contributions to this.study, or assisted me in some way or another, deserve my thanks:
• Drs Johan Schoeman and Y Saloojee for their input as study leaders
• Drs Johan Schoeman, Cornelius Bakkes and Barry Frey, messrs Braam Aucamp, Erroll Blair, Koos Engelbrecht and Hanri Maarschalk for assisting in the application of the questionnaire.
• Megan Izzard, for her competent and accurate language editing.
• My wife Chrissie, for her continuous support and proof reading of the manuscript.
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(ii) SYNOPSIS
Although evidence ofthe hazards of cigarette smoking has been in existence for many decades, millions ofpeople around the world are still smoking, hundreds ofthousands of teenagers take up smoking and the tobacco companies are allowed to continue promoting their products. To the annoyance ofnon-smokers, smoking is still allowed in many public places, such as restaurants and offices.
This study serves, firstly, to provide an overview of the results of research on the dangers ofsmoking, nicotine addiction and passive smoking. Secondly, a self-comple tion questionnaire has been applied to a sample ofstudents at eight technikons in South Africa. The questionnaire was designed to investigate the prevalence of smoking among the different population groups and genders to reveal some of the pattems of smoking of students, the factors influencing students' smoking status and to test students' beliefs, opinions and attitudes regarding smoking. The third objective ofthe study is to develop a theory on cigarette smoking and to propose anti-smoking measures at technikons.
Researchers have produced conclusive proof that cigarette smoking is the cause of cancer, respiratory and heart disease and other diseases. Smoking maims and kills millions ofpeople around the world annually and threatens the health ofunbom babies and non-smokers, especially children. Tobacco companies apply the most sophistic ated promotion techniques to persuade people to smoke and teenagers and certain other sectors' of the population are targeted by these activities.
A study of nicotine addiction reveals that the need for this substance becomes as strong as any of man's basic physiological needs, such as those for food and water. This makes it very difficult, ifnot impossible, for many smokers to give up smoking. A multi-pronged strategy to combat smoking at education institutions is proposed, which includes health education and the banning of smoking on campuses.
(iii) CONTENTS
Page
SYNOPSIS (iii)
LIST OF TABLES (xviii)
LIST OF FIGURES (xxi)
Chapter 1
INTRODUCTION AND ORIENTATION
1.1 INTRODUCTION 1
1.2 HISTORY OF TOBACCO USE 2
1.3 MOnVAnON FOR THE STUDY 4
1.3.1 Smoking: a public health problem 4 1.3.2 Smoking: an avoidable problem 4 1.3.3 The extent of the problem 5
1.3.3.1 Adolescents and children take up smoking 5 1.3.3.2 Health education not effective 1.3.3.3 Conclusions 5
1.4 FORMULATION OF THE PROBLEM 6
1.4.1 Primary problem statement 6 1.4.2 Secondary problem statements 6
(iv) 1.5 AIMS OF THE STUDY 6
1.6 CONTRIBUTION OF THE STUDY 7
1.7 SOURCES AND RESEARCH METHODS 7
1.7.1 Literature study 7 1.7.2 Questionnaire 8 1.7.3 Statistical analyses 8
1.8 DEFINITION OF CONCEPTS 8
1.8.1 The concept of health 8 1.8.2 The concept of public health 9 1.8.3 Definition of smokers and ex-smokers 10 1.8.4 Conclusion 10
1.9 PROGRAMME OF STUDY 10
Chapter 2
TOBACCO PRODUCTION AND THE PHARMACOLOGY AND TOXICOLOGY OF TOBACCO SMOKE
2.1 INTRODUCTION 12
2.2 TOBACCO AND CIGARETTE PRODUCTION 12
2.2.1 The tobacco plant 12
2.2.1.1 Chemical characteristics of the tobacco leaf 13 2.2.1.2 The classification of tobacco in South Africa 14 2.2.1.3 Curing of tobacco 15
2.2.2 Cigarette production 16
2.2.2.1 The cigarette manufacturing machines 16
(v) 2.2.2.2 The tobacco companies 16
2.3 PHARMACOLOGY AND TOXICOLOGY OF TOBACCO SMOKE 17
2.3.2 Introduction 17 2.3.2 Mainstream and sidestream smoke 17 2.3.3 Principal constituents of cigarette smoke 18
2.3.3.1 Irritant substances 20 2.3.3.2 Carbon monoxide 20 2.3.3.3 Nicotine 21 2.3.3.4 Particulate matter 22 2.3.3.5 Acrolein 22 2.3.3.6 Cresol and phenols 22 2.3.3.7 Hydrocyanic acid 22 2.3.3.8 Oxides of nitrogen 23 2.3.3.9 Compounds containing nitrogen 23 2.3.3.10 Compounds containing sulphur 24 2.3.3.11 Hydrocarbons 24 2.3.3.12 Trace elements 24 2.3.3.13 Pesticides 24 2.3.3.14 Fungi and viruses 25
2.3.4 Conclusions 25
2.4 ATMOSPHERIC POLLUTION BY SMOKING 25
2.4.1 Historical 25 2.4.2 The combustion process 25
2.4.2.1 Combustion zone 26 2.4.2.2 Pyrolysis zone 26 2.4.2.3 Distillation zone 26 2.4.2.4 Filters 26
2.4.3 Exposure to carbon monoxide 27 2.4.4 Other pollutants 27
(vi) 2.5 SUMMARY 28
2.6 NOTES 28
2.6.1 Alkaloids 28 2.6.2 Isomerism 29 2.6.3 Cilia and ciliatory action 29 2.6.4 Pound and dollar values 29
Chapter 3
SMOKING AND ADDICTION, MORTALITY AND ILLNESS
3.1 INTRODUCTION 30
3.2 mSTorocALBACKGROUND 30
3.3 NICOTINE DEPENDENCE/ADDICTION 31
3.3.1 Background 31 3.3.2 Definition of addiction and dependence 32 3.3.3 Criteria for drug dependence 33 3.3.4 The addictive qualities of cigarettes 34
3.3.4.1 Regulation of nicotine in the body 34 3.3.4.2 Tolerance 35 3.3.4.3 Withdrawal 35
3.3.5 Psychological determinants of nicotine addiction 36
3.3.5.1 Anxiety, stress and smoking 36
3.3.6 Low- and high-tar nicotine cigarettes 37 3.3.7 Conclusions 38
3.4 SMOKING AND MORTALITY 39
(vii) 3.4.1 Reduction of life expectancy 39 3.4.2 Smoking-related mortality in developed countries 40
~ i 3.4.2.1 United States l i America I 40 . 3.4.3 Smoking-related mortality in South Africa 43 3.4.3.1 Discussion 43 3.4.3.2 Conclusions 44 3.5 SMOKING AND CANCER 46 3.5.1 Known cancer-producing substances (carcinogens) 47 3.5.1.1 Lung cancer 48 3.5.1.2 Oesophageal cancer 50 3.6 SMOKING AND CARDIOVASCULAR DISEASE 51 3.7 SMOKING AND RESPIRATORY DISEASES 51 3.8 SMOKING AND OTHER CAUSES OF DEATH 52 3.9 SMOKING AND ILL-HEALTH 52 3.10 WOMEN AND SMOKING 52 3.10.1 Smoking and reproductive health 53 3.10.1.1 Spontaneous abortion 53 3.10.1.2 Perinatal mortality 53 3.10.1.3 Sudden infant death syndrome (SillS) 54 3.10.2 Osteoporosis 54 3.10.3 Conclusions 54 (viii) 3.11 THE EFFECTS OF ENVIRONMENTAL TOBACCO SMOKE AND PASSIVE SMOKING 54 3.11.1 Definition of passive smoking 54 3.11.2 Biochemical markers of exposure to tobacco smoke 55 3.11.3 Passive smoking and lung cancer 55 3.11.4 Passive smoking and respiratory illness 55 3.11.5 Passive smoking, the foetus and children 56 3.11.5.1 Low birth weight 56 3.11.5.2 Intelligence 56 3.11.5.3 Childhood illnesses 56 3.11.6 Conclusions 57 3.12 SUMMARY 58 3.13 NOTES 59 3.13.1 Drug dependence and drug addiction 59 3.13.2 Respiratory morbidity among children 59 Chapter 4 ECONOMIC CONSIDERATIONS OF TOBACCO PRODUCTION AND USE 4.1 INTRODUCTION 60 4.2 TOBACCO SALES 60 4.2.1 Tobacco sales promotion 62 4.2.1.1 Impact of advertising 62 4.2.1.2 Sponsorship of sport 63 4.2.1.3 Youth and other groups targeted 65 4.2.1.4 . Discussion 66 (ix) 4.3 EcoNOMIC CONSIDERATIONS 66 4.3.1 Morbidity and mortality 67 4.3.2 Smoking and loss of productivity 67 4.3.3 Smoking and the strain on health services 68 4.3.4 Economic implications - a comparison 69 4.4 CONCLUSIONS 70 4.5 SUMMARY 71 Chapter 5 SMOKING AND YOUTH 5.1 INTRODUCTION 73 5.2 SMOKING PREYALENCE 73 5.3 SMOKING IN SOUTH AFRICA 73 5.3.1 Smoking patterns 73 5.32 Prevalence of smoking among South African youths 76 5.3.2.1 Conclusion 76 5.4 ONSET OF SMOKING 76 5.4.1 Age of onset 76 5.4.1.1 Conclusion 77 5.4.2 Motivation for taking up smoking 78 5.5 CONCLUSIONS 79 5.6 SUMMARY' 80 (x) Chapter 6 KMPIRICAL RESEARCH 6.1 INTRODUCTION 81 6.2 PLANNING OF THE RESEARCH 81 6.2.1 Empirical problem statement 82 6.2.1.1 The sub-problems 83 6.2.2 Hypotheses 84 6.3 UNITS OF ANALYSIS 86 6.3.1 The research groups 86 6.3.1.1 Definition of the research groups 86 6.3.2 The measuring instrument 87 6.3.2.1 The covering letter 87 6.3.2.2 The questionnaire 87 6.3.2.3 The measuring scale 88 6.3.3 Background data and sampling 88 6.3.3.1 Population of the research project 88 6.3.3.2 The sampling procedure 89 6.3.3.3 Sample size 90 6.3.4 The pilot studies 90 6.4 ESSENTIAL'QUALITIES OF RESEARCH 91 (xi) 6.4.1 Validity of the research project 91 6.4.1.1 Content validity 91 6.4.1.2 Empirical validity 92 6.4.1.3 Construct validity 92 6.4.2 Reliability of the measuring instrument 92 6.4.2.1 Sensitivity of the measuring instrument 94 6.4.2.2 Appropriateness of the measuring instrument 94 6.4.2.3 Practicability of the measuring instrument 95 6.4.2.4 Ethical acceptability of the measuring instrument 95 6.5 THE EMPIRICAL RESEARCH 95 6.5.1 Course of the research 95 6.5.1.1 Distribution and return of the questionnaire 95 6.5.1.2 Specific problems encountered during the investigation 96 6.5.1.3 The response rate 96 6.5.2 Data processing 96 6.6 E~IPIRICAL RESlJLTS 97 6.6.1 Profile of the respondents 97 6.6.2 Population group, gender and smoking status 97 6.6.2.1 Conclusions 98 6.6.3 Influence of family members' smoking status 98 6.6.3.1 Discussion 100 6.6.3.2 Conclusions 102 6.6.4 Smoking status of partners 105 (xii) 6.6.4.1 Conclusions 107 6.6.5 Influence of anti-smoking campaigns 107 6.6.5.1 Discussion 110 6.6.5.2 Conclusions 110 6.6.6 Beliefs about the health hazards of smoking 110 6.6.6.1 Discussion 111 6.6.6.2 Conclusions 111 6.6.7 Beliefs and attitudes about environmental smoke 113 6.6.7.1 Discussion 115 6.6.7.2 Conclusions 115 6.6.8 Influence of anti-smoking warnings 116 6.6.8.1 Discussion 116 6.6.8.2 Conclusions 117 6.6.9 Anti-smoking measures 117 6.6.9.1 Discussion 117 6.6.9.2 Conclusions 119 6.6.10 Brands of cigarettes smoked 119 6.6.11 Number of cigarettes smoked per day 119 6.6.11.1 Discussion 119 6.6.11.2 Conclusions 119 6.6.12 Age when respondents have started smoking 120 6.6.12.1 Discussion 120 6.6.12.2 Conclusions 120 (xiii) 6.6.13 Reasons for starting smoking 123 6.6.13.1 Discussion 123 6.6.13.2 Conclusions J<' ..j 124 6.6.14 Reasons why respondents continue smoking 124 6.6.14.1 Discussion 124 6.6.14.2 Conclusions 125 6.6.15 Giving up smoking 125 6.6.15.1 Discussion 128 6.6.15.2 Conclusions 128 6.6.16 Reasons for giving up smoking 129 6.6.16.1 Discussion 129 6.6.16.2 Conclusions 129 6.6.17 Testing the hypotheses 130 6.7 SUMMARY 150 Chapter 7 ANTI-SMOKING MEASURES 7.1 INTRODUCTION 154 7.1.1 Background 154 7.2 MEASURES APPLIED PRESENTLY 155 7.2.1 Government policy 155 7.2.2 Legislation 155 (xiv) 7.2.2.1 Sales of cigarettes to young people 155 7.2.2.2 Warnings on cigarette packs and advertisements 156 7.2.3 Restrictions on smoking in public places 157 7.2.4 Restrictions in airports and on planes 157 7.2.5 Legal action 158 7.2.6 Increased insurance premiums 158 7.2.7 Healtheducation 158 7.3 Planned and proposed anti-smoking measures 159 7.3.1 Classifying nicotine as a drug 159 7.3.2 Stricter legislation 159 7.3.2.1 Ban on advertising 161 7.3.2.2 Higher taxes on cigarettes 161 7.3.3 Dismantling tobacco/sport connections 162 7.3.4 The treatment of addicted smokers 163 7.4 CONCLUSIONS 163 7.5 A THEORY ON CIGARETTE SMOKING 164 7.5.1 Introduction 164 7.5.2 DefInition of concepts 164 7.5.2.1 Human needs and motives 164 7.5.2.2 Beliefs 167 7.5.2.3 Attitudes 167 7.5.2.4 Opinions 168 7.5.3 Theories on attitude change 168 7.5.3.1 The Yale attitude change approach 168 7.5.3.2 . The group dynamics approach 168 7.5.3.3 Cognitive dissonance theory 169 (xv) 7.5.3.4 Social learning theory" 170 7.5.4 Cigarette smoking and human needs 170 7.5.4.1 Starting and continuing smoking 170 7.5.4.2 Nicotine dependence 171 7.5.4.3 Conclusions 171 7.5.5. A value and belief system 172 7.5.5.1 Conclusions 173 7.6 A MODEL FOR ANTI-SMOKING MEASURES 174 7.6.1 Objectives of anti-smoking measures 174 7.6.2 The banning of smoking in and on campus facilities 174 7.6.3 Assisting smokers in their efforts to stop smoking 175 7.6.4 Marketing strategies 175 7.6.5 Student projects 175 7.6.6 Research projects 176 7.6.7 Health Education 176 7.6.7.1 Conditions for effective health education 176 7.6.7.2 Lectures, talks and work sessions, etc. 177 7.6.7.3 Debates 178 7.6.7.4 Educational media 178 7.6.8 General anti-smoking measures 178 7.6.9 Evaluation of anti-smoking measures 178 7.6.10 Value and belief system 178 7.7 SUMMARY 179 (xvi) Chapter 8 SUMl\1ARY AND CONCLUSIONS 8.1 INTRODUCTION 180 8.1.1 Motivation for the study 180 8.2 SUMMARY OF THE STUDY PROJECT 180 8.3. GENERAL CONCLUSIONS 182 8.3.1 The individual's freedom of choice to start smoking 182 8.3.2 The freedom to smoke in non-smokers' presence 182 8.3.3 The freedom of tobacco companies to advertise 183 8.3.4 The economic benefits of smoking 183 8.4 WEAKNESSES OF THE RESEARCH PROJECT 183 8.4.1 Limitations of the research project 183 8.4.2 Threats in respect of pure research 183 8.4.3 Deficiencies in research project 184 8.5 TOPICS FOR RESEARCH 184 BffiLIOGRAPHY 186 ANNEXURE A 199 ANNEXUREB 205 (xvii) LIST OF TABLES Table 2.1 Principal constituents of cigarette smoke 19 Table 3.1 Millions of deaths per year in developed countries 40 Table 3.2 Millions of smoking-related deaths in developed countries 41 Table 3.3 Category A causes of death 44 Table 3.4 Category B causes of death 44 Table 3.5 Category C causes of death 45 Table 3.6 Estimated number of smoking related deaths 46 Table 3.7 US cancer deaths attributed to tobacco consumption 47 Table 3.8 Annual lung cancer deaths in the United States . 50 Table 4.1 Total world consumption of tobacco 61 Table 4.2 Morbidity and mortality from 1 000 tons of added tobacco consumption 67 Table 4.3 Economic consequences in smoking and non-smoking societies 70 Table 5.1 Smoking status among South Africans 74 Table 5.2 Smoking prevalence in South Africa by population group 75 Table 6.1 Distribution of respondents according to population group and gender 99 Table 6.2 Influence of family members on smoking status Black smokers 101 Table 6.3 Influence of family members on smoking status Black ex-smokers 102 Table 6.4 Influence of family members on smoking status Black non-smokers 103 Table 6.5 Influence of family members on smoking status White smokers 104 Table 6.6 Influence of family members on smoking status White ex-smokers 104 Table 6.7 Influence of family members on smoking status White non-smokers 105 (xviii) Table 6.8 Smokers and partners 106 Table 6.9 Ex-smokers plus non-smokers and partners 106 Table 6.10 Smokers who have attended anti-smoking campaigns 108 Table 6.11 Ex-smokers who have attended anti-smoking campaigns 108 Table 6.12 Non-smokers who have attended anti-smoking campaigns 109 Table 6.13 Grand total of respondents who have attended anti-smoking campaigns 109 Table 6.14 Respondents who believe smoking is harmful to smokers' health 111 Table 6.15 Respondents' belief about smoking and disease 112 Table 6.16 Respondents who believe that smokers should not be allowed to smoke where and when they wish 113 Table 6.17 Respondents who believe that smoking is harmful to non-smokers 113 Table 6.18 Respondents who feel that smoking in their rooms bothers them 114 Table 6.19 Respondents who will request a smokers not to smoke in their presence on public transport 114 Table 6.20 Smokers who smoke in non-smokers' presence and smokers who will extinguish their cigarettes when asked to do so 114 Table 6.21 Respondents who have noticed warnings on cigarette packets and in the press 116 Table 6.22 Respondents who support stricter anti-smoking measures 118 Table 6.23 Number of cigarettes smoked per day 118 . Table 6.24 Age when respondents have started smoking 121 Table 6.25 Details of ages when respondents have started smoking 122 Table 6.26 Reasons why respondents have started smoking 122 Table 6.27 Reasons why respondents continue smoking 124 Table 6.28 Smokers' belief whether they can give up smoking permanently or not 126 Table 6.29 Smokers who report that they can give up permanently: Number of times tried 126 (xix) Table 6.30 Smokers who report that they cannot give up permanently: Number of times tried 127 Table 6.31 Smokers' efforts to give up smoking .~ .: Totals of ~ ~bles 6.26 and 6._lJ 127 Table 6.32 The latest attempt to give up smoking 128 Table 6.33 Ex-smokers reasons for giving up smoking 129 (xx) LIST OF FIGURES Figure 2.1 Main kinds of tobacco 14 Figure 7.1 Maslow's hierarchy of motives 166 (xxi) CHAPTER 1 INTRODUCTION AND ORIENTATION 1.1 - INTRODUCTION The use of tobacco, and specifically cigarette smoking, has become one of the most entrenched habits among many millions of people around the world. Stebbins (1990:227) quotes Rogers and Mulligan (1984): "Cigarette smoking, once a rare custom, is now a worldwide habit of staggering proportions." Many people have given up smoking, but millions around the world, especially children and young adults, are taking up the habit every day. Apart from thedebate around the dangers ofcigarette smoking, other issues regarding the habit have become hotly contested. • The question ofthe individual's 'freedom ofchoice' to take up smoking is presently being debated. Part of the discussion regarding choice revolves around the evidence that nicotine is-highly addictive to many people. • Another controversy pertains to the individual's choice to smoke wherever he/she pleases, for example, at places of work and in restaurants. The evidence that passive smoking can be detrimental to non-smokers' health has entered this debate. • The freedom of tobacco companies to ~dvertise their products in the media, on billboards, etc., is a bone of contention. This, in tum, has a bearing on the 'freedom of choice' issue. • The fact that many people start smoking at an early age, leads to strong objections from tobacco control advocates to tobacco companies' sponsoring of sport events. - 1 - Chapter 1 • The economic benefits of tobacco production versus the costs in human lives and illness, as well as other direct and indirect costs, have become a controversial topic. There exists no doubt among scientists and medical practitioners that cigarette smoking is a dangerous habit which cripples and kills many millions annually. "Cigarette smoking is now as important a cause of death as were the great epidemic diseases such as typhoid, cholera, and tuberculosis that affected previous generations in this country" (Royal College of Physicians 1971 :9). Peto and his associates calculate that approximately 3 million people in the world die annually from smoking - around 2 million in developed countries and roughly 1 million in developing countries. Should the trend continue, roughly 60 million smoking-related deaths would have occurred in developed countries during the second part of this century (Peto et al. 1992:1269 and Peto et al. 1994:Al). 1.2 mSTORY OF TOBACCO USE The use of tobacco dates back over 16 centuries. The Bible mentions a plant referred to as mandrake which was a stimulant - this may represent the first record of tobacco use (Genesis 30:14-16; Song of Solomon 7:13). During excavations in both Mexico , and Peru, tobacco seeds were discovered. A stone carving depicting a priest smoking, left by the Mayans around 400 AD, has been located by archaeologists in Palenque, in the Mexican state of Shiapas. Indications are that the Indians of Brazil may have started the habit of 'snuffing'. During his visits to America in the 15th century, Christopher Columbus found the Indians using tobacco in much the same way as today. The American Indians ascribed medicinal properties to tobacco and used it during ceremonies such as the smoking of the pipe of peace. (Davis 1987:15.) Tobacco was introduced into Europe during the 16th century: France, 1556; Portugal, 1558; Spain, 1559; and England, 1565. Jean Nicot, the French ambassador to Lisbon, after whom the genus Nicotiana was named, grew and promoted tobacco in Europe 'for its magic cure-all' (Davis 1987:15) and is reported to have sent seeds of Nicotiana tabacum to Catherine de Medicis, the queen consort and regent ofFrance. Portuguese and Spanish sailors were mainly responsible for the spread of tobacco from Europe to other parts of the world (The New Encyclopaedia Britannica 1986a:812). - 2- Chapter 1 The history of the cultivation of tobacco outside Europe is not well documented but European settlers in America started planting tobacco in the 16th century: Santo Domingo, 1531; Cuba, 1580; Brazil, 1600; Jamestown, Virginia, 1612; Maryland, 1631. "Tobacco soon became the chief commodity exchanged by the colonists for European manufactured articles" (The New Encyclopaedia Britannica 1986a:812). It is .possible that tobacco came to Africa in the 14th century when the Turks introduced it into Egypt. The Portuguese and Spaniard seafarers brought tobacco to the east coast towards East Africa in about 1560, and from there it spread through central and western Africa. Evidently the Portuguese brought tobacco directly to the Cape during the 1650s, while the first Dutch Governor at the Cape, Jan van Riebeeck, probably shipped tobacco to the settlement in 1652. Tobacco farming became established in South Africa and the early settlers used tobacco for many years as a form of currency. (Yach, McIntyre & Saloojee 1992a:272.) Up to the middle of the 19th century, men were the chief consumers of tobacco smoking pipes as well as snuffmg and chewing tobacco. The cigarette had its origin with tribes like the Aztecs who smoked a hollow reed or cane tube stuffed with tobacco. A form of 'cigarette' was smoked by other natives of Mexico, Central America and parts of South America, who crushed tobacco leaves and rolled the . shreds in maize husk or other vegetable wrappers. The conquistadors, however, brought the cigar, rather than this prototype of the cigarette, to Spain for use by the wealthy. (Royal College of Physicians 1977: 16.) During the 16th century, beggars in Seville started collecting discarded cigar butts, shredding them and rolling the tobacco into scraps of paper (Spanish papeletes), and smoking these first improvised 'cigarettes'. The Spanish referred to these poor man's smokes as cigarillos (Spanish for 'little cigars'). (The New Encyclopaedia Britannica 1986b:318.) Cigarettes gained respectability during the late 18th century and cigarette smoking spread to Portugal and Italy. Portuguese traders carried cigarettes to the Levant and Russia, while French and British troops encountered them during the Napoleonic Wars. Turkish cigarettes were introduced to another generation ofFrench and British soldiers fighting in The Crimean War. During this period cigarettes acquired popu- - 3 - Chapter 1 larity among citizens of the United States of America. (The New Encyclopaedia Britannica J986b:318.) By the end of the century, with the advent of machines producing cigarettes, and the use of milder, flue-cured tobaccos, cigarette smoking rose in popularity, and other forms of smoking declined. Since 1920, cigarettes have dominated tobacco sales (Royal College of Physicians 1977:16.) 1.3 MOTIVATION FOR THE STUDY 1.3.1 SMOKING - A PUBLIC HEALTH PROBLEM Cigarette smoking has become a public health problem of great impact. The death rate as a result of cigarette smoking has assumed epidemic proportions. Africa is presently targeted, together with other developing countries, by international tobacco companies to replace tobacco sales which are on the decrease in Europe and North America. Barnum (1993:13) argues that, if this move could be counteracted, millions of lives would be saved in the future. . Furthermore, cigarette smoking is a source of air pollution and endangers the health of not only smokers, but non-smokers as well. Smoking has become a nuisance and a source of irritation to non-smokers, for example, in offices, restaurants and other public places. 1.3.2 SMOKING - ANAVOIDABLE PROBLEM The smoking habit is largely dependent upon the addictive properties of nicotine there are no micro-organisms involved, and the spread is through example and adver tising. The enormous number of deaths and disease conditions caused by smoking could, therefore, be avoided if people would stop smoking. Dr C. Everett Koop, the then US Surgeon-General, announced in 1982: "Cigarette smoking is the chief,. single, avoidable cause of death in our society, and the most important public health issue of our time" (Taylor 1984:xvii). - 4- Chapter 1 1.3.3 THE EXTENT OF THE PROBLEM 6 I ~ i i .. Stebbins (1990:227) quotes Rogers and Mulligan (1984): "Over one billion people now smoke, consuming over five trillion cigarettes per year." "This overall level of con sumption represents 984 manufactured cigarettes for each person for the world as a whole in 1984 averaging over half a pack per day" (Chandler 1986:6, quoted by Stebbins 1990:227). Martin (1987:2) claims that, by 1984, over 4,6 trillion cigarettes were being produced annually. 1.3.3.1 Smoking patterns among adolescents and children While many adults, especially middle-aged people, give up smoking, school children, teenagers and young adults acquire the habit. Nath (1986:115) observes: "Smoking among young people, and among children, is a distressing yet very visible phenomenon not only in the more affluent areas ofthe world but in the less developed countries too." 1.3.3.2 Ineffective health education It has become apparent that, in spite of intensive health education programmes and . other anti-smoking campaigns, cigarette smoking is on the increase among certain groups in the population. It is also obvious that Africa has become one of the target regions of tobacco companies, as far as advertising and promotion of their products are concerned. Martin (1987:2) states: "The world's consumption of cigarettes continues to increase in spite of established pulmonary and cardiovascular risks and published health warnings." 1.3.3.3 Conclusions Some of the important questions which follow from these fmdings, are: • Why is health education with regard to smoking relatively ineffective? • Why is it so difficult for people to give up smoking? - 5 - Chapter 1 • Why are governments and other agencies unable to stem the tide of smoking, especially among the youth? 1.4 FORMULATION OF THE PROBLEM 1.4.1 PRIMARY PROBLEM STATEMENT • What smoking patterns and habits prevail among young people presently and what is the prevalence of smoking among the South African youth? 1.4.2 SECONDARY PROBLEM STATEMENTS • How knowledgable are adolescent smokers and non-smokers about the dangers of cigarette smoking? • Has health education regarding smoking reached a good proportion of adolescent smokers and non-smokers? • Does health education have any influence on the smoking habits of adolescents? , 1.5 AIMS OF THE STUDY The aims of the study may be summarised as follows: • To record the present state of medical and scientific knowledge of cigarette smoking and the hazards associated with smoking. • To measure the extent of cigarette smoking among technikon students. • To establish what perceptions, attitudes and opinions regarding the dangers of smoking, exist among technikon students. • To gauge the influence of certain factors, such as the smoking status of family members, upon the smoking status of technikon students. - 6- Chapter 1 • To determine the extent to which health education on smoking has reached the technikon students. • To ascertain what influence, if any, health education has had on the smoking habits and/or patterns of technikon students. • To examine the economic considerations around tobacco production and use. 1.6 CONTRIBUTION OF THE STUDY It is hoped that the fmdings of the study will be used to create an awareness among technikon students of the health hazards of cigarette smoking. The author's objective is to apply the fmdings of the study in the formulation of proposals towards health education designed to encourage and assist students in giving up smoking and to dissuade others from starting smoking. 1.7 SOURCES AND RESEARCH METHODS The study consists of a number of facets which are examined with the aid of various appropriate methods. These methods include the following: 1.7.1 LITERATURE STUDY Various aspects relating to cigarette smoking are reviewed with the aid of extensive literature studies. These include: • the history of tobacco use; • the manufacture of tobacco; • the composition of tobacco and tobacco smoke; • the health hazards of smoking and passive smoking; • tobacco advertising; - 7 - Chapter 1 • smoking among the youth; • health education regarding cigarette smoking; • economics relating to smoking. Whenever possible, use is made of primary sources. These are not, however, always available and, on occasion, secondary sources have to suffice in the absence of primary sources. 1.7.2 QUESTIONNAIRE An important part of the study consists ofa questionnaire which is applied to a sample of technikon students across South Africa. 1.7.3 STATISTICAL ANALYSES The analyses ofresults from the application of the questionnaire are discussed in detail in Chapter 6. The statistical analyses consist of the application of the Chi-square test to proportions. 1.8 DEFINITION OF THE CONCEPTS 1.8.1 THE CONCEPT OF HEALTH The notions of 'health' and 'good health' are interpreted differently by various authors and researchers. Spector (1979:687) points out that good health for a person in a particular occupation, for example a librarian, might be quite different from good health for a farmer or a steelworker. He proceeds to describe 'health' as "... the extent of an individual's continuing physical, emotional, mental, and social ability to cope with his environment". Spector (1979:687) defmes 'bad health' and 'good health' as follows: "Bad health can be defmed as the presence of disease, good health as its absence-particularly the absence ofcontinuing disease ... " The World Health Organization (WHO) adds a rider to this defmition and sees health as: "... a state of - 8 - Chapter I complete physical, mental and social well-being and not merely the absence of disease or deformity" (quoted by Stewart 1971:3). Searle (1982:1) feels that the concepts 0'£ 'health' and 'disease' are relative and variable and that the World Health Organization's defmitions of these concepts are too idealistic and absolute. Searle (1982.1) maintains that as yet no one has been able to formulate an accurate and universal description of the term 'health' and prefers Hanlon's (1974) defmition: ... health is a state of total effective physiologic and psychologic functioning: it has both a relative and an absolute meaning, varying through time and space both in the individual and the group; it is the result of the combination of many forces, intrinsic and extrinsic, inherited and contrived, individual and collective, private and public, medical, environmental and social; and it is conditioned by culture, economy, law and governments. 1.8.2 THE CONCEPT OF PUBLIC HEALTH The Third Council of the World Health Organization (Geneve 1950), accepted Winslow's (1923) defmition of Public Health (Stewart 1971:3). Smolensky (1982:2) paraphrases this defmition in an analytical fashion: , Public Health is the Science and Art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for: • the sanitation of the environment, • the control of communicable infections, • the education of the individual in personal hygiene, • the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and • the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, - 9 - Chapter 1 so organising these benefits as to enable every citizen to realise his birthright ofhealth and longevity. 1.8.3 DEFINITION OF SMOKERS AND EX-SMOKERS Yach, McIntyre & Saloojee (1992a:273) suggest the following definitions: • A smoker is a person who has been smoking at least one cigarette a day for three months . • An ex-smoker is a person who has not smoked for at least three months after having previously met the criterion for being a smoker. 1.8.4 CONCLUSION It is every individual's right to live as healthily as possible. Society has the responsibility of ensuring that this right is protected, especially with regard to the environment. This responsibility must include adequate measures to protect people, and particularly children, against the hazards of smoking, passive smoking and addiction to tobacco. 1.9 PROGRAMl\1E OF STUDY • Chapter 1 deals with a description of the problem of cigarette smoking as related to this study. The history of smoking is briefly outlined and evidence is produced that smoking has become a public health problem of great proportions and world wide impact. • In Chapter 2 certain aspects of tobacco production are discussed and the properties of the tobacco plant and cigarette smoke are examined. • Chapter 3 outlines some of the research results regarding mortality and the health hazards associated with cigarette smoking. - 10 - Chapter 1 • Chapter 4 is devoted to various economic con~i~erations regarding smoking as well as a discussion around th-..~ }~omotion of tob.. (:0 products. • Chapter 5 highlights the problem of smoking among the youth, with special reference to South Africa. • Chapter 6 represents the empirical research of the study and an analysis of the results of the questionnaire. • Chapter 7 deals with anti-smoking measures, e.g. legislation, health education and anti-smoking campaigns. A theory on smoking and a model for anti-smoking measures at technikons are developed in this chapter. • Chapter 8 summarises the research project, reviews the weaknesses of the project and mentions possibilities for further research. - 11 - CHAPTER 2 TOBACCO PRODUCTION AND THE PHARMACOLOGY AND TOXICOLOGY OF TOBACCO SMOKE 2.1 INTRODUCTION In order to understand the extent of the dangers of tobacco consumption, It IS necessary to have a brief overview of the tobacco plant and the chemical composition of tobacco smoke. This chapter provides an overview of the research results per taining to tobacco smoke and some of its effects on the human body and includes a discussion about atmospheric pollution by smoking. 2.2 TOBACCO AND CIGARETTE PRODUCTION 2.2.1 THE TOBACCO PLANT The various tobacco plants represent numerous species of the genus Nicotiana, a member of the Solanaceae family (Chollat-Traquet 1992:4). Common commercial tobacco is derived from Nicotiana tabacum which is native to South America, Mexico and the West Indies. Nicotiana rustica is a species of wild tobacco, cultivated by the Indians of eastern North America, and presently grown in Turkey, Russia, India and some European countries. The botanist and explorer Linnaeus, described these two species in 1753. The Indians of western North America used species such as Nicotiana attenuata, N. trigonophylla and N. quadrivalvis for smoking, while several ornamental flowering species are in existence. (The New Encyclopaedia Britannica 1986a:812.) The Nicotiana tabacum has been modified to resist local diseases, and sometimes to reduce the nicotine or tar-generating properties of the leaf. (Shephard 1982:29.) - 12 - Chapter 2 The common tobacco plant grows to a height of 1 to 2 metres and bears pink, sometimes carmine or white flowers. Some of the larger varieties grow leaves which may reach lengths between 60 and 90 ems with a width ofabout half the length. (The New Encyclopaedia Britannica 1986a:812.) The leaves and other cuttings from the tobacco plant are classified and graded in terms of their position on the stem. (RSA Tobacco Board 1994:10.) Commencing at the base, subdivisions include scape trash and trash lugs (used for granulated smoking); sand lugs, good lugs and best leaf (used for cigarettes); second leaf (used for chewing and wrappers); tips and green tips (used for chewing and fillers). The carbohydrate content decreases moving up the plant from the best leaf, but the nicotine and nitrogen content increase. (Shephard 1982:29.) 2.2.1.1 Chemical characteristics of the tobacco leaf The chemical characteristics oftobacco depend on the variety ofthe tobacco plant, the environment in which it is grown, the part of the plant that is cut and the method of curing. There is potential for a threefold variation in sterols, a fivefold variation in phenols, a tenfold variation in nitrates and a thirtyfold variation in alkaloid content. (Shephard 1982:29.) Environmental factors influencing the chemical composition of the leaf, include the soil texture, the availability of minerals, organic matter and water, plus appropriate conditions of light and temperature. If the soil provides little nitrogen, acetate from the tricarboxylic acid cycle is used to produce such substances as carbohydrates, fats, oils, resins and polyterpines. Oriental tobaccos, for example, are usually grown on poor soil in areas of limited rainfall. The amount of nicotine is then low, while the gum content is high. The Oriental product is commonly treated with goat or sheep manure, and this tends to give it a high chlorine content. (Shephard 1982:29.) From a health point of view, one of the most important substances found in tobacco leaves is nicotine, (see 2.6.1) an alkaloid which has many powerful actions on the nervous system. The normal content of nicotine in tobacco leaves is 1 to 3 %, al though there may be many exceptions. The nicotine content varies according to the - 13 - Chapter 2 hybrid of tobacco plant, the position of the leaf on the plant, and the region where it is grown. (Royal College of Physicians 1977:39.) 2.2.1.2 The classification of tobacco in South Africa Figure 2.1 illustrates the classification of tobacco according to the RSA Tobacco Board (1994:9). Figure 2.1 Classification of tobacco in South Africa (RSA Tobacco Board 1994:9) - 14 - Chapter 2 2.2.1.3 Curing of tobacco Tobacco curing involves the dehydration of the leaf, leading to the destruction of chlorophyll, together with other chemical changes, including the hydrolysis of starch to simple sugars, of proteins to amino acids and of pectins to pectic acid, uronic acid and methanol. (Shephard 1982:30.) The original method of air curing (the tobacco was left to dry in a barn or shed for several weeks), was replaced by fire curing, during which smoke from a wood fire was used, enabling the leaf to withstand sailing ship voyages. During 1825, tobacco farmers in parts of Virginia and North Carolina started using charcoal to eliminate the effect of smoke on the taste and aroma of the leaf. After the American Civil War, furnaces with metal flues were introduced for the curing of tobacco. (The New Encyclopaedia Britannica 1986a:812.) Flue-curing comprises hanging of the tobacco in a humid barn at a temperature rising from 30 to 75°C over five to seven days. Redrying takes place after several months ofbulk storage; after storage, ageing may take place for as long as two to three years, causing a further slow change in the chemical characteristics ofthe leaves. (Shephard 1982:30.) The White Burley tobacco (a light air-cured leaf), appeared around 1864 in Brown .County, Ohio, and has been highly suitable for use in manufacturing mixtures for chewing and smoking tobaccos - the popular American blended cigarette comes from the White Burley. (The New Encyclopaedia Britannica 1986a:812.) In the process of air-curing, whole plants wilt in the field, and are then stored in sheds with a regulated flow of air for 30 to 40 days. Chemical changes include hydrolysis, followed by an oxidation of sugars to acids. (Shephard 1982:30.) 'Homogenised leafcuring' was made possible by mechanisation - the various chemical changes take place in a homogenised tobacco slurry, and attempts can be made to remove undesirable constituents before the tobacco is reconstituted as a sheet. (Shephard 1982:30.) In South Africa, flue-cured tobacco is artificially cured, whilst air-cured and Burley tobacco, are cured mainly under natural climatic conditions, and oriental tobacco is cured in the sun. (RSA Tobacco Board 1994:18.) - 15 - Chapter 2 2.2.2 CIGARETTE PRODUCTION 2.2.2.1 The cigarette manufacturing machines Cigarettes were originally made by hand - either by the smoker or in factories. In the factory, it consisted ofhand rolling on a table, pasting and hand packaging. The first successful cigarette machine was manufactured by James A Bonsack, a Virginian, who was granted a United States patent in 1880 for his product. The tobacco was fed onto a continuous strip ofpaper and the cigarette was automatically formed, pasted, closed and cut to lengths by a rotating cutting knife. (The New Encyclopaedia Britannica 1986b:318.) The latest model cigarette machine is the Molins, which produces 5000 cigarettes in a minute (the Bonsack initially managed 200 cigarettes per minute). Presently, three large concerns are the major manufacturers of cigarette machines, namely, Molins, American Machine and Foundry, and Hauni-Polystrep. (Nath 1986: 158.) 2.2.2.2 The tobacco companies James 'Buck' Duke, a tobacco farmer from North Carolina, leased the Bonsack machines and produced 120 000 cigarettes a day. He undercut his rivals, who still .stuck with the hand-rolled process, and started buying them out. In 1890, Duke formed the American Tobacco Company, with an initial capital outlay of$25 million, (nearly R91 million; see 2.6.4) which signalled the beginning of the biggest tobacco enterprise in the world. (Taylor 1984:23/24.) The British imported the Bonsack machine during 1883, and the cigarette industry started taking off in Europe. (The New Encyclopaedia Britannica 1986b:319.) In 1902, the merged British tobacco companies, under the banner of Imperial Tobacco Company and the American Tobacco Company, formed the British-American Tobacco Company (BAT), with James Duke as its first chairman. This giant corporation con tinued its business until 1911, when the US Supreme Court ordered Duke to break it up in terms of the American anti-monopoly policy. (Taylor 1984:24.) Six multi-national tobacco conglomerates dominate the international trade in tobacco products presently. These six companies control 40 % of the world cigarette - 16 - Chapter 2 production and almost 85 % of the tobacco leafsold on the world market. (Barry /. ! 1991:917.) l ~ •! Dr Anton Rupert manufactured his first cigarettes in 1948, and started the Rembrandt Group in South Africa soon after - this became the country's third largest corporation, with interests in mining, textiles, brewing and tobacco. During the 1950s the Rembrandt Group expanded rapidly, by buying into the British Companies, Carreras and Rothmans. Further expansion took place in the early 1970s, when the Group's British, West German, Belgian and Dutch tobacco operations, merged to form Rothmans International, which became the world's fifth largest tobacco company, pro ducing one outof every twelve cigarettes sold in the world. (Taylor 1984:25.) In 1982, Rothmans International announced profits of £105 million (R590 million). (Taylor 1984:35.) The Tobacco Board presently recognises three cigarette manufacturers and fifteen manufacturers of other tobacco products, such as pipe tobacco and snuff, in South Africa. (RSA Tobacco Board 1994:(ii).) 2.3 PHARMACOLOGY AND TOXICOLOGY OF TOBACCO . SMOKE 2.3.1 INTRODUCTION Much progress has been made in the identification of the more than 2 500 constituents in the tobacco leaf, the more than 3 900 compounds in tobacco smoke, and the tumori genic and carcinogenic effects ofa great many ofthese products. (Hoffman & Wynder 1986:145.) Over 2 000 potentially toxic compounds have already been listed by researchers, and gas chromatograph tracing"suggests that other materials remain to be identified. (Shephard 1982: 17.) 2.3.2 MAINSTREAM AND SIDESTREAM SMOKE The burning of tobacco products leads to the formation of mainstream smoke (MS) and sidestream smoke. (55). MS smoke results when the smoker draws air through the cigarette, the smoke travels through the tobacco column and out of the mouthpiece - 17 - Chapter 2 into the smoker's mouth. If the smoker inhales smoke from his cigarette, the mainstream smoke is drawn into the lungs and part of it is exhaled again. (Hoffmann & Wynder 1986:145-146.) Sidestream smoke is emitted from the burning cone of the cigarette between 'puffs'. 'Smoulder stream' smoke emerges from the butt and from the cone between 'puffs'. (Shephard 1982:34.) When a cigarette is smoked, the atmosphere becomes contaminated by both main stream and sidestream smoke. Other small fractions include the 'glowstream' (emitted by the glowing cone during 'puffs'), the 'effusion stream', escaping along the length of the paper during 'puffs' and the 'diffusion stream', escaping through the paper between 'puffs'. (Shephard 1982:34.) Shephard (1982:35) points out that the combustion of a typical cigarette involves perhaps ten 2-second 'puffs' and 550 seconds of sidestream combustion. 2.3.3 PRINCIPAL CONSTITUENTS OF CIGARETTE SMOKE The average smoker takes nine or ten puffs over 10 minutes, to smoke an average filter tip cigarette. The smoker draws air through the burning tip of the cigarette and .aboutStl m1 of smoke enters the mouth with each puff. (Shephard 1982: 18.) The 50 m1 of smoke contains about 50 mg of material, which consists of 18 mg of solid particulate matter, and about 32 mg of gases and vaporised materials, the latter consisting of up to 5 % of the toxic gas carbon monoxide. (Royal College of Phys icians 1983:11.) Table 2.1 lists the principal constituents with observations based on 85 rom cigarettes, smoked to a 30 rom butt length. (Shephard 1982:18.) The following distinctions have been made by the US Surgeon General (1972), re garding some of the constituents of cigarette smoke and the dangers to health (Shephard 1982:18/19): • Constituents most likely to be hazardous to health: carbon monoxide, nicotine and 'tar' (the particulate residue remaining after elimination of nicotine and water). - 18 - Chapter 2 Table 2.1 Principal constituents of cigarette smoke Shephard 1982:18 Gas phase Constituent Mass Mass in effiuent composition (mg per cigarette) (per cent) (volume per cent) ., Particulate matter (including 40,6 8,6 - condensed water) Nitrogen 295,4 59,0 . 67,2 "" Oxygen 66,8 13,4 13,3 Carbon dioxide 68,1 13,6 9,8 Carbon monoxide 16,2 3,2 3,7 Hydrogen 0,7 0,1 2,2 Argon 5,0 1,0 0,8 Methane 1,3 0,3 0,5 Water vapour 5,8 1,2 - Hydrocarbons 2,5 0,5 - Carbonyls 1,9 0,4 - Hydrogen cyanide 0,3 0,1 - Other gases 1,0 0,2 - • Constituents probably hazardous to health: acrolein, cresol, hydrogen cyanide, nitric oxide, nitrogen dioxide and phenol. • Constituents possibly hazardous to health: acetaldehyde, acetone, acetonitrile, ammonia, benzene, 2,3 butadione, butylamine, carbon dioxide, crotononitrile, dimethylamine, DDT, endrin, ethylamine, formaldehyde, furfural, hydrogen sulphide; hydroquinone, methacrolein, methyl alcohol, methylamine, nickel compounds and pyridine. - 19 - Chapter 2 2.3.3.1 Irritant substances Ten or more compounds of cigarette smoke, including acrolein, are ciliostatic. These' substances inhibit the action of the cilia which line the bronchial tubes and stimulate the secretion of increased amounts of mucus in those tubes (see 2.6.3). Irritant sub stances are responsible for the immediate coughing and narrowing of the bronchial tubes, after inhalation of smoke. This interference with the self-cleansing mechanism of the lungs, may lead to infection, and seems to prolong contact between the lining of the bronchial tubes and the cancer-producing substances deposited in the lungs from the cigarette smoke. (Royal College of Physicians 1977:42.) 2.3.3.2 Carbon monoxide Incomplete combustion of tobacco leads to the formation of carbon monoxide (CO), which is present in quantities between 1 and 5 % in cigarette smoke. Carbon monoxide has an affinity, about 200 times greater than oxygen, for haemoglobin. As much as 15% of the haemoglobin of heavy smokers may, therefore, be prevented from carrying oxygen to the tissues because it is in the form of carboxyhaemoglobin. .(Olishifski 1981:480 and Royal College of Physicians 1977:43.) Habitual smokers' blood shows an increase in the total red blood cell count, which possibly represents a compensation for the presence of the carboxyhaemoglobin. This is a potentially harmful condition, since it makes the blood thicker and more likely to clot. (Royal College of Physicians 1983:36.) Studies show that the presence of carboxyhaemoglobin impairs smokers' capacity for exercise. Another complication is that pregnant women who smoke often produce babies with average birth-weight lower than that of non-smoking mothers. (Royal College of Physicians 1977:43.) Evidence exists that CO can increase the permeability of blood vessels to cholesterol, while inhalation of aircontaining 0,018% of CO causes changes in the arteries of - 20- Chapter 2 rabbits, similar to those found in coronary heart disease patients. (Royal College of Physicians 1977:43.) 2.3.3.3 Nicotine When tobacco is burnt, the alkaloid, nicotine, is transferred to the smoke where it becomes attached to minute droplets of tar. Most ofthe nicotine from the tobacco leaf is retained through the smoking process, and the smoker absorbs between 0;'1 and 0,2 mg of nicotine per puff (the average UK cigarette delivers 1,33 mg nicotine to the smoker). When the smoke is inhaled, nicotine is readily absorbed into the blood, and the concentration of nicotine in the blood rises steeply during smoking. It reaches a peak just after the last puff when the nicotine concentration may vary between 10 and 40 p.g/litre. (Royal College of Physicians 1983: 12.) The acidity or alkalinity of tobacco smoke is important to the user, because nicotine can be absorbed to an appreciable extent from acidic smoke, only if it is taken into the lungs. When the smoke is alkaline, nicotine may be absorbed from the mouth, and thus, cigar and pipe smokers can obtain nicotine without inhaling. (Royal College of Physicians 1977:39.) .It has been demonstrated that, while nicotine is the main addictive constituent in tobacco, it also serves as a precursor of the powerful carcinogen 4-(methylnitros amino)-I-(3-pyridil)-I-butanone (NNK), a nicotine-derived N-nitrosamine. (Hoffmann & Wynder 1986:155.) During the last 20 years, efforts have been made to reduce the nicotine yield of cigarettes. The fact that publication of information regarding nicotine content have become compulsory, was responsible for the most marked changes. Some cigarettes are still noted as delivering 2,5 mg of nicotine, but typical figures for 'medium' and 'light' cigarettes now range from 1,2 mg to 0,07 mg. (Shephard 1982:20/21.) The nicotine content of cigarettes, marketed in South Africa, ranges from 0,1 to 1,9 mg (author's own observations). The addictive and toxic aspects of nicotine will be discussed in detail in chapter 3. - 21 - Chapter 2 2.3.3.4 Particulate matter Wet particulate matter comprises 0,2 to 9,0% by weight of 'mainstream' smoke. It includes 'tar', nicotine, moisture and various absorbed vapours. (Shephard 1982:21.) 'Tar' describes the dry particulate matter, without the nicotine, in tobacco smoke. (US Department of Health and Human Services 1988:58.) The 'tar' contains a number of polycyclic aromatic hydrocarbons, some with known carcinogenic activity, others which are tumour initiators or co-carcinogens. (Shephard 1982:21.) In recent years, tobacco companies have yielded to pressure from governments, to market low tar cigarettes, and 'medium' and 'light' machine smoked cigarettes now produce between 12 and 35 mg of tar. (Hoffmann & Wynder 1986:145.) Shephard (1982:23) observes that large numbers of smokers still try to create a 'macho' image by smoking 'strong' cigarettes with a high output of tars. 2.3.3.5 .Acrolein Acrolein, or acrylic aldehyde (CH2:CHCHO) is a pungent gas formed by the decom position of glycerin, and is toxic to the tracheal cilia (see 2.3.3.1). The concentration of acrolein in the inhaled smoke rises with a decrease of cigarette length; typical .figures for total yield are 45 to 140 ug per cigarette. (Shephard 1982:23.) 2.3.3.6 Cresol and phenols Phenol (C6HsOH), the three isomers (see 2.6.2) of cresol (CH3C6H40H), and other phenols such as catechol, hydroquinone and resorcinol, are all constituents ofcigarette smoke that reach concentrations of concern for health. The phenols are toxic to cilia, and directly or indirectly can contribute to carcinogenic change in exposed cells. The delivery of cresol (all isomers), ranges from 0,07 to 0,1 mg per cigarette. (Shephard 1982:23/24). 2.3.3.7 Hydrocyanic acid Hydrocyanic acid (HCN), a toxic gas which blocks oxygen uptake at the cellular level, is formed from amino acids and protein. (Olishifski 1981:480 and Shephard 1982:24.) - 22- Chapter 2 There is about a threefold increase in HCN concentration in the inhaled smoke, from the first to the last 'puff. TV je is some evideLr~ too, that filters become saturated with HCN, before the cigarette is extinguished. The amount delivered to the smoker is 0,1 to O,4mg per cigarette. (Shephard 1982:24.) 2.3.3.8 Oxides of nitrogen Tobacco smoke contains various oxides of nitrogen (NOx-nitric oxide and nitrogen dioxide, along with small amounts of nitrous oxide and methyl nitrite). The main constituent of fresh smoke is nitric oxide (NO) and as this gas ages, nitrogen dioxide (NOz) is formed. Both NO and NOz are toxic in their own right but they also facili tate the formation of carcinogenic nitrosamines. The primary source of the oxides of nitrogen is nitrate. The leaf content ranges from 0 to 6 % in different varieties of tobacco, depending on the amount of chemical fertilizer that has been used. The nitric oxide content of the smoke varies from 0 to 0.6 mg per cigarette, and depending upon the extent of aging of the smoke, the NOz production is 0 to 0.01 mg per cigarette. (Shephard 1982:24.) 2.3.3.9 Compounds containing nitrogen Ammonia, primary amines (methylamine, ethylamine and butylamine) and secondary amines (dimethylamine and pyrrolidine), have all been detected in cigarette smoke in relatively small amounts. The secondary amines are of particular concern, not only in their own right, but also as potential precursors of the highly carcinogenic nitros amines. The principal alkaloid of tobacco smoke is nicotine, but small amounts of nornicotine, anabasine, anatabine and myosmine are also found. Cotinine (57 p,g per cigarette) is formed by oxidation ofnicotine - it has been suggested that this compound is carcinogenic. Many heterocyclic compounds are produced in smaller amounts. Of these, dibenzacridine and dibenzcarbazole are known to have carcinogenic properties. (Shephard 1982:25/26.) - 23 - Chapter 2 2.3.3.10 Compounds containing sulphur Hydrogen sulphide in cigarette smoke exceeds industrially permitted limits. Various other sulphur compounds have also been detected in cigarette smoke. Sulphur com pounds are known to cause respiratory damage. (Shephard 1982:27.) 2.3.3.11 Hydrocarbons Volatile hydrocarbons are derived from the waxy coating of the leaves. Benzene is the one compound in this group where the possibility of toxicity has been raised; workers exposed to benzene have an increased risk of leukaemia. The polycyclic aromatics are ofparticular concern as carcinogens. Compounds ofthis class that have been noted in smoke include derivatives of indane, indene and fluorene, methylfluoranthrenes, benz-pyrenes, benz-fluoranthrenes, indenopyrene, methylcresenes and benzanthracenes. The yield of such dangerous constituents depends primarily upon the cellulose, lignin and pectin content of the tobacco leaf with contributions from leaf lipids such as oils, waxes and resins. Some cyclic isoprenoids may be active as tumour producers. (Shephard 1982:27.) 2.3.3.12 Trace elements Mercury (1-3 ppm in the smoke from some Japanese cigarettes), is derived from the paper used in wrapper manufacture. Other trace elements that are of concern include lead (from lead arsenate sprays), nickel carbonyl (from nickel additives) 21opolonium (derived from the soil and air), 226radium (from phosphorus fertilizers), 210iead and cadmium. These are all highly toxic compounds. (Shephard 1982:28.) 2.3.3.13 Pesticides The use of various pesticides, such as DDT, arsenic and endrin, have been dis couraged and/or discontinued. However, herbicides such as metobromuron (broken down to 4-bromoaniline), toxic to humans, remain a potential problem. (Shephard 1982:28). - 24- --FW------ Chapter 2 2.3.3.14 Fungi and viruses Tobacco leaves are often contaminated by fungal products, including carcinogenic aflatoxins, and by the tobacco mosaic virus. (Shephard 1982:28.) 2.3.4 CONCLUSIONS There is no doubt that smokers are exposed to a startling array of noxious chemical and biological materials, and this is substantiated by extensive laboratory studies. (Hoffmann &Wynder 1986:161.) The concentrations ofthe inhaled compounds often substantially exceed the limits permitted for industrial exposures to the same substances. (Shephard 1982:28.) 2.4 ATMOSPHERIC POLLUTION BY SMOKING 2.4.1 HISTORICAL Ben Jonson (1573-1637) and James I of England and VI of Scotland (1566-1625), remarked on smoking as a public nuisance, while Johann Wolfgang Von Goethe (1749-1832) had the following to say: "Smokers pollute the air far and wide and .asphyxiate every respectable individual who cannot smoke in self-defence" (Shephard 1982:9). Exposure of the non-smoker to the toxic constituents of cigarette smoke, depends not only on the number ofcigarettes that have been smoked, but also on the volume of the room, the efficiency of ventilation, local obstructions to ventilation and the proximity of those who are smoking. (Shephard 1982:37.) 2.4.2 THE COMBUSTION PROCESS The four functional components of a modem cigarette are, the combustion zone, the pyrolysis zone, the distillation zone and the filter. (Shephard 1982:12.) - 25 - Chapter 2 2.4.2.1 Combustion zone The combustion zone is the red, glowing tip of the cigarette. In this zone, burning is relatively complete, the tobacco being converted to simple products such as carbon monoxide, carbon dioxide and water, with extraction of most of the oxygen. (Shephard 1982:12.) 2.4.2.2 Pyrolysis zone The pyrolysis zone lies immediately behind the glowing tip of the cigarette. Here a combination ofhigh temperature (600-1050°C), and a reducing gas rich in hydrogen, encourages both conversion of CO2 to carbon monoxide, and pyrolysis of the tobacco to a variety of noxious hydrocarbons. The hydrocarbons condense on very small nuclei emitted by the combustion zone, yielding an extremely dense smoke cloud (108 to 1010 per ml) of spherical particles, with a relatively uniform size (range from 0,2 to 1,0 1-', median 0,15 to 0,20 1-', on a number average, 0,5 to 0,6 1-', on a mass aver age). (Shephard 1982:13.) 2.4.2.3 Distillation zone The distillation zone is the region immediately adjacent to the pyrolysis zone in the cigarette. The temperature drops quite rapidly to about 40°C as it passes through the cigarette. Cooling favours the condensation of smoke constituents with a high boiling point; there is also a tendency for coagulation of the smoke particles. Nevertheless, little mechanical filtration occurs, and in the distillation zone the temperature remains high enough for 20 to 30 % of nicotine, additives such as menthol and other com pounds, such as dotriacontane, to distil into the smoke, without alteration ofchemical composition. In this segment, smoke can also diffuse through the wrapper into the room, while material inhaled by the smoker can be diluted by room air. (Shephard 1982:13.) 2.4.2.4 Filters Most modem cigarette brands are fitted with filters which are designed to trap selective particulate matter and toxic components of the gas phase. The efficiency of - 26 - Chapter 2 various filters on the market ranges from 20 to 75 %, depending on how much resistance a smoker is prepared to accept during puffing. (Shephard 1982:14.) Ramstrom (1986: 139) points out that many filter brands of cigarettes yield larger amounts of nicotine and tar, as well as larger amounts of gaseous smoke components, as compared ·to some non-filter brands. A comparison of filter brands with non filtered ones, regarding these factors are, therefore, irrelevant. Moreover, Paffenbarger and Hyde (1986:54) quote a study by Castelli et at. (1981), who reported no difference between smokers of filtered brands, and those smoking non-filtered ones, in respect of the incidence rates of coronary heart disease. The authors conclude that no evidence existed that filter cigarettes provided protection for the smokers in this study. 2.4.3 EXPOSURE TO CARBON MONOXIDE The currently permitted maximum concentrations of carbon monoxide for 8-hour exposure periods, are 50 ppm for industrial situations, and 9 ppm (USA) or 13 ppm (Canada), for the general urban environment. (Shephard 1982:37.) Smoky offices are a practical concern of many non-smokers, since the polluted atmosphere must be endured for up to eight hours per day. Worse conditions are encountered in many bars and .restaurants, particularly if the owners economise on heating or refrigeration by recirculating stale air. The employees, (bar-tenders, dancers and waitresses), are obliged to withstand such atmospheres for up to eight hours per day, while carrying out moderately heavy physical work. (Shephard 1982: 41/42.) Carbon monoxide accumulates in the body as the pigment carboxyhaemoglobin (COHb). Various studies indicate that passive smoking can increase blood carboxy haemoglobin levels, particularly when ventilation is poor. (Shephard 1982:47/48.) 2.4.4 OTHER POUUTANTS Galuskinova, 1964 (quoted by Shephard 1982:44) reports that the concentration of the known carcinogen, benz (a) pyrene, ranges from 28-144 ng-m? in a smoke-filled restaurant. Having regard to the normal environmental contamination (5-68 ng-m", - 27 - Chapter 2 depending upon season), Grimmer et al. 1977 (Shephard 1982:45) estimates that passive smoking increases the body burden of polycyclic aromatic hydrocarbons by about 20%. Dimethylnitrosamine is another potent carcinogen found in cigarette smoke, with an industrial threshold limit of zero ('contact by any route should not be permitted'), (Shephard 1982:45.) Heavy experimental smoking in an unventilated room yields con 3 centrations of 0,23 to 2,7 p.g·m- , while under 'real-life' conditions readings of 0,11 to 0,24 p.g·m-\ have been measured in the bar car of a train, and in a bar. Because the nitrosamines occur mainly in sidestream smoke, the non-smoker can inhale the mainstream equivalent of 0,5 to 30 cigarettes per day if he or she works in a smoky atmosphere. (Brunneman et al. 1977a quoted by Shephard 1982:47.)' 2.5 SUMMARY A substantial amount of research regarding the chemical composition of the tobacco leaf and tobacco smoke, and the health hazards posed by these chemicals has been performed. A survey of the literature indicates, however, that the effects of many compounds have to be investigated before the [mal word can be said about the dangers of tobacco consumption. The protagonists of smoking often point out that statistical evidence is not enough to convince them of the hazards of tobacco consumption. Laboratory proof is therefore essential; there are, however, ethical restrictions on the amount and type of laboratory experiments that can be done with humans, while the argument is used that evidence derived from laboratory animals cannot always be extrapolated to humans. 2.6 NOTES 2.6.1 ALKALOIDS An alkaloid is any class of nitrogenous, organic bases found in certain plants. An alkaloid has a strong physiological effect. Examples ofalkaloids are caffeine, cocaine, nicotine and quinine. (Hartmann-Petersen & Pigford 1984:6.) . - 28 - Chapter 2 2.6.2 ISOMERISM When two or more compounds have the same chemical formula, but different structures and properties, they are called isomers (Kerrod 1983:125.) 2.6.3 CILIA AND CILIATORYACTION Cilia are hairlike structures lining the air passages (bronchi and bronchioles). The cilia move in waves, about 12 times a second, sweeping mucus which contains bac teria and other foreign particles, from the lower passages to the throat. When cigarette smoke.or badly contaminated air is blown on the cilia, a temporary paralysis sets in and the wave motion stops. If the irritation continues over a long period of time, cilia wither and die and are not replaced. Mucus accumulates in the air passages and can only be partly removed by the 'smokers cough'. (Olishifski 1981:45 and Ratcliff 1975:85-86.) Schroder (1994:72) observes that smokers are more inclined to suffer from pulmonary diseases, partly because of the impaired clearance of dust particles from the lungs. 2.6.4 POUND AND DOllAR VALUES .The rand value is calculated according to Standard Bank's closing rates for 2 January 1996. Rl = $3,6350; Rl = £5,6217. - 29 - CHAPTER 3 SMOKING AND ADDICTION, MORTALITY AND ILLNESS 3.1 INTRODUCTION Despite ample evidence to the contrary, some people are still not convinced that smoking is dangerous and many smokers believe that they can give up smoking permanently if they wish to do so. This chapter reviews the research into the addictiveness of nicotine and the widespread illness and death resulting from tobacco smoking. 3.2 mSTORICAL BACKGROUND The possibility that tobacco might be detrimental to health has been an issue for at least two hundred years. In 1761, John Hill, a London physician and botanist, observed that nasal cancer could be a result of tobacco snuff use. (Davis 1987:15.) In 1789, a University of Cambridge scholar compiled a 63-page report on the dangers of snuffmg tobacco (Davis 1987:15), and in 1798 Dr Benjamin Rush condemned tobacco use in his book Essays (US Department of Health and Human Services 1988:9). The British Medical Journal Lancet published the opinions of 50 physicians on tobacco use during 1856-1857 and it was obvious that considerable controversy existed at the time, regarding the dangers or virtues of smoking (US Department of Health and Human Services 1988:9). The awareness that smoking and lung cancer are linked, is ascribed to Alton Ochsner, who saw a single autopsy of a man who died of lung cancer in the Washington hospital, ·where Ochsner was a medical student in 1919. He didn't see another case until 1936, and then nine more cases appeared within six months. This occurrence - 30 - Chapter 3 called for investigation and he found that all nine were men, all were heavy cigarette smokers, and all had started smoking during the First World War. Ochsner's observa tions led to epidemiological research by two groups independently: Ernst Wynder and E A Graham in the United States and Richard Doll and Austin Bradford Hill in the United Kingdom. Their fmdings were published in 1950, in the Journal of the American Medical Association (lAMA) and the British Medical Journal (BMl) respectively. (Raw, White & McNei1l1990:6-7.) In the late 1950s, a study group was appointed by the US Public Health Service, the National Cancer Society and the American Heart Association, with the mission to examine the current evidence on smoking and health. The study group came to the conclusion that "... excessive cigarette smoking is a causative factor in lung cancer" (US Department of Health and Human Services 1988:11). As soon as the conclusions about the relationship between smoking and lung cancer became clear, committees on smoking and health were set up in both countries, eventually leading to the first reports of the Royal College of Physicians of London (RCP) in 1962, and the United States Surgeon General in 1964. This was followed in 1967 by the first world conference on smoking and health in New York, set up by the American Cancer Society and fellow organisations in the United States. (Raw, White & McNeill 1990:7.) 3.3 NICOTINE DEPENDENCEIADDICTION 3.3.1 BACKGROUND Scientists have been trying to isolate the chief active substance of tobacco since as far back as the 18th century. During the early 1800s, Cerioli and Vauquelin discovered the oily essence of tobacco. It was named 'Nicotianine' after Jean Nicot who sent tobacco seeds from Portugal to the French court at the end of the 16th century (see Chapter 1). Posselt and Reimann isolated the pure form of Nicotianine in 1828 at the University ofHeidelberg and renamed it 'Nikotin'. During the 1840s, the chemical's empirical formula, CIOH14N2 , was determined and in the 1890s 'nicotine' was synthe sised. Since the late 1800s, research on the pharmacologic actions of nicotine has contributed substantially to a basic understanding of the functioning of the nervous system. Langley and Dickinson performed a classic investigation on the effects of - 31 - Chapter 3 nicotine in autonomic ganglia in 1889. This led to the theory that chemicals transmit information between neurons, and that receptors on cells respond functionally to stimulation by specific chemicals. (US Department of Health and Human Services 1988: 10.) During the 1920s and 1930s, researchers such as Armstrong-Jones (1927), Dorsey (1936) and Lewin (1931) concluded that nicotine was responsible for users' depend ence on tobacco products. Johnston (1942) came to the conclusion that "smoking tobacco is essentially a means of administering nicotine, just as smoking opium is a means of administering morphine" (US Department of Health and Human Services 1988;10). The strength and seriousness ofnicotine dependence are noted as follows by Schachter (1978:209): "Presumably nicotine or tar or some component of the act of smoking is so gratifying that despite the well-publicised dangers the smoker is unwilling to give up the habit." 3.3.2 DEFINITION OF ADDICTION AND DEPENDENCE The US Department of Health and Human Services (1988:7) uses the terms 'drug addiction' and 'drug dependence' synonymously, and defines these terms as: "the behaviour of repetitively ingesting mood-altering substances by individuals" (see 3.13.1). Berkow (1982:1413) offers the following descriptions of the terminology involving dependence: • Psychological dependence involves feelings of satisfaction and a drive to repeated or continuous administration of the drug, to produce pleasure or avoid discomfort. • Physical dependence is defined as a state of adaptation to a drug, accompanied by the development of tolerance, and manifested by a withdrawal or abstinence syndrome. - 32- Chapter 3 • Tolerance is defmed as the need to increase the dose progressively, in order to produce the effect originally achieved by smaller amounts. • A withdrawal syndrome is characterized.by unpleasant physiological changes that occur, when the drug is discontinued abruptly, or when its effect is counteracted by a specific antagonist. 3.3.3 CRITERIA FOR DRUG DEPENDENCE Concepts of drug dependence developed by expert committees of the World Health Organization, the American Psychiatric Association and the National Institute on Drug Abuse, have been applied by the US Department of Health and Human Services (1988:7) to develop the criteria for drug dependence: • Primary criteria • Highly controlled or compulsive use • Psychoactive effects • Drug-reinforced behaviour • Additional criteria • Addictive behaviour often involves: - stereotypical patterns of use - use despite harmful effects - relapse following abstinence - recurrent drug cravings • Dependence-producing drugs are often associated with: - tolerance - physical dependence - pleasant (euphoriant) effects - 33 - Chapter 3 . These criteria are applicable to all forms ofdrug abuse, including tobacco, the opiates, cocaine, etc. (US Department of Health and Human Services (1988: 11.) 3.3.4 THE ADDICTIVE QUALITIES OF CIGARETTES The criteria for drug dependence listed in 3.3.3 are applicable in identifying a drug as pharmacologically addicting. Various observations and experiments confmn that tobacco meets the criteria as a pharmacologically addicting substance. The US De partment of Health and Human Services (1988: 14) comments: "Highly controlled or compulsive drug use refers to drug-seeking and drug-taking behavior that is driven by strong, often irresistible urges. It can persist despite a desire to quit or even repeated attempts to quit." Habitual cigarette smoking has been demonstrated as being the result of behavioural and pharmacological factors that lead to highly controlled or compulsive use of cigarettes. Several surveys in the United States reveal that a large proportion (66 % in 1977 and 77 % in 1987) of smokers would like to quit smoking and that many smokers have made at least one serious attempt to give up smoking. (US Department of Health and Human Services 1988:149/150.) 3.3.4.1 Regulation of nicotine in the body When a smoker inhales cigarette smoke it reaches the small airways and alveoli where the nicotine is rapidly absorbed. Nicotine concentrations in the blood rise quickly during cigarette smoking and reach a peak during the last few puffs. (US Department of Health and Human Services 1988:29.) Nicotine accumulates in the regular smoker's body and significant levels may persist for 6-8 hours after the last cigarette has been smoked (e.g. overnight). The smoker may titrate nicotine intake in an attempt to regulate or maintain a particular level of nicotine in the body. For example, smoking behaviour may be changed to compensate for restricted availability of cigarettes by deeper puffs which may increase nicotine intake per cigarette by 300%. (US Department of Health and Human Services 1988:38-40.) Nicotine is metabolised ,in the body, mainly in the liver, but also in the kidneys and lungs. The fraction ofnicotine that is not detoxicated, is completely eliminated in the - 34- Chapter 3 urine along with the chemically altered forms.jThe rate of excretion of nicotine is rapid and increases linearly '.' .~h the dose. (Go<.:-!nan and Gilman 1958:622 quoted by Schachter 1978:215.) Schachter (1978:213-215) cites a number ofstudies on smokers' regulation ofnicotine intake (among others, Schachter 1977) and comes to the conclusion: "It does appear ... that heavy smokers do adjust [their] smoking rate so as to keep nicotine at a roughly constant level" . 3.3.4.2 Tolerance Tolerance is defmed as a "decreasing responsiveness to a drug or chemical such that larger doses are required to produce the same magnitude of effect" (US Department of Health and Human Services 1988:25). An example of tolerance is the disappear ance ofthe effects of initial exposure to tobacco, such as dizziness, nausea, vomiting, headaches, etc., with continued smoking. (US Department ofHealth and Human Ser vices 1988:45.) Tolerance to nicotine may be the result of a faster rate of nicotine metabolism, or to a decrease in the sensitivity of the tissues to nicotine. (US Department of Health and Human Services 1988:53.) The implication of tolerance is that smokers will increase their tobacco consumption and intake of nicotine over a period of time. (US Department of Health and Human Services 1988:50.) 3.3.4.3 Withdrawal Physical dependence on tobacco smoking leads. to an uncomfortable withdrawal syndrome when the smoker is deprived of cigarettes for long periods of time. This withdrawal syndrome is one of the important reinforcers of smoking behaviour. (US Department of Health and Human Services 1988: 197.) Heavy cigarette smokers may display withdrawal symptoms within two hours of the last tobacco use. The sense of craving seems to reach a peak within the frrst 24 hours of the last cigarette and then gradually declines over a few days to several weeks. The American Psychiatric Association (1987) states the following as diagnostic criteria for nicotine withdrawal (US Department of Health and Human Services 1988:200): . - 35 - Chapter 3 • Daily use of nicotine for several weeks at least. • Abrupt cessation of nicotine use, or reduction in the amount of nicotine use, followed within 24 hours by at least four of the following signs: • Craving for nicotine •.Irritability, frustration, or anger • Anxiety • Difficulty concentrating • Restlessness • Decreased heart rate • Increased appetite or weight gain 3.3.5 PSYCHOWGICAL DETERMINANTS OF NICOTINE ADDICTION 3.3.5.1 Anxiety, stress and smoking Numerous studies show that smokers smoke more when subjected to stress. Smokers, therefore, often cite anxiety reduction as their chief motive for smoking and nicotine dependence. (Pomerleau & Pomerleau 1990:225.) In a study by Myrsten et al. (1975), a group· of smokers was identified who were convinced that they smoked to relieve tension, while another group maintained that they smoked to alleviate boredom or increase arousal (quoted by Pomerleau & Pomerleau 1990:227). This, and subse quent studies, indicate that nicotine is able to arouse as well as sedate its subjects. The fact remains that nicotine intake is reinforced and the smoking habit, therefore, strengthened. The exact circumstances, however, under which sedation/arousal takes place, are not well understood. (Pomerleau & Pomerleau 1990:23.) In an experiment conducted by Schachter and his associates (Schachter, Silverstein, Kozlowski, Herman & Liebling 1977) urinary pH was measured before and after stress conditions. They come to the conclusion that"smoking under stress has nothing to do with psychological, sensory or manipulative needs that are presumably activated by the state of stress but is explained by the effects of stress on the rate of excretion of nicotine. The smoker under stress smokes to replenish nicotine supply, not to relieve anxiety" (Schachter 1978:219). - 36 - Chapter 3 Schachter (1978:209-213) summarises the relationship between anxiety and nicotine intake and refers to various experiments which indicate that: • Smoking does not reduce anxiety; in effect not smoking or insufficient nicotine increases anxiety for the heavy smoker. • Smoking does not make the smoker less irritable or vulnerable to annoyance; it is not smoking or insufficient nicotine that makes him more irritable. This means that the smoker smokes more during stress because ofincipient withdrawal symptoms, and not because of any psychological property ofnicotine or of the act of smoking. (Schachter 1978:218.) Schachter (1978:210/211) sums up: "Again and again ... one fmds the same pattern smoking doesn't improve the mood or calm ofthe smoker or improve his performance when compared with the non-smoker. However, not smoking or insufficient nicotine makes him considerably worse on all dimensions." 3.3.6 LOW- AND HIGH-TAR NICOTINE CIGARETTES Criticism is levelled at anti-smoking campaigns which advocate a switch to low nicotine, low-tar cigarettes. The possibility that this campaign may perversely be increasing the health hazards of smoking, has been raised by Domino (1973), Russell (1974) and others, who point out that the heavy smoker, who switches to low nicotine brands, may very well end up smoking more cigarettes and taking more and/or deeper puffs of each. The smoker will, in the process of regulating nicotine, probably absorb the same amounts of nicotine and tar and certainly get more of the combustion products, such as carbon monoxide into his body. (Broder 1990:90, Schachter 1978:208 and US Department of Health and Human Services 1988:12.) Schachter (1978:208) adds: "If this shift in level of smoking is permanent, the net effect of switching to low nicotine cigarettes should be to increase the dangers of smoking ... Furthermore, Ross (1976) found evidence that carbon monoxide, hydrogen cyanide and nitrogen oxide delivery is considerably greater in most of the popular brands of low nicotine, filter cigarettes than in high nicotine, non-filter cigarettes. (Quoted by Schachter 1978:223.) - 37 - Chapter 3 Barry (1991:918) points out that, although cigarette manufacturers in the United States go to great lengths to promote low tar and low nicotine cigarettes, the same products, sold in the developing countries, contain substantially more tar and nicotine. Some studies report cigarettes with 50 % higher tar content with sometimes twice as much nicotine. 3.3.7. CONCLUSIONS The US Surgeon General comes to the following major conclusions regarding tobacco addiction (US Department of Health and Human Services 1988:9). • Cigarettes' and other forms of tobacco are addictive. • Nicotine is the drug in tobacco that causes addiction. • The pharmacological and behavioural processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Schachter (1978:223) summarises his fmdings regarding nicotine addiction as follows: • The psychological and probably the sensory and manipulative gratifications of smoking are illusory. Serious smokers smoke to prevent withdrawal symptoms. • Smokers regulate nicotine intake. • Variations in smoking rate, which customarily have been interpreted in psychologi cal terms, seem better understood as an attempt to regulate nicotine. • Apparent exceptions to a regulatory model of smoking seem understandable in terms of withdrawal. The smoker who fails to regulate suffers withdrawal. The US Food and Drug Administration commissioner, David Kessler, asserts that cigarette producers control the level ofnicotine in their products in order to create and sustain addiction. (Farley 1994:52.) - 38 - Chapter 3 3.4 SMOKING AND MORTALITY Tobacco smoking is one of the greatest killers of our time. The world has brought many infectious diseases, such as poliomyelitis and smallpox, under control, but has largely failed so far to make an impression on the devastating effects of cigarette smoking. Peto (1994:938) insists that "smoking represents a great failure in public health: more than 40 years after the hazards were first established, cigarettes are still responsible for 30 % of deaths in middle age in Britain and the United States, and worldwide sales are increasing" . Peto (1994:937) estimates that, if present trends continue, the 3 million deaths worldwide annually as a result of smoking, will increase to 10 million in the year 2025. 3.4.1 REDUCTION OF LIFE EXPECTANCY Studies of smokers' death rates enable researchers to estimate the number of years of life which a smoker is likely to lose according to the number of cigarettes the smoker smokes each day, and to estimate the loss of expectation of life for each cigarette smoked. In Doll and Peto's study of British doctors (Doll & Peto 1976), it is estimated that: • The average loss of life expectancy of a smoker of 20 cigarettes per day is about 5 years. Many smokers, of course, do better than average and may have a normal life span, while others may die of a disease caused by smoking many years earlier than if they had not smoked. (Royal College of Physicians 1977:32-33.) • A habitual cigarette smoker's life is shortened by about 51h minutes for each cigarette smoked - which is not much less than the time he spends smoking it. (Royal College of Physicians 1977:32/33.) The Royal College ofPhysicians (1977:37) sums up: "The overall risk of early death has consistently been found to be raised in cigarette smokers, and is related to the amount smoked, the habit of inhaling, and the age of starting. Irregularities in this - 39 - Chapter 3 association between serious illness and smoking are small in contrast with its overall uniformity. " It is interesting to note that some of the ill-health and shortening of life results from other habits which are often associated with heavy smoking, such as heavy drinking and dangerous driving. The balance of the evidence, however, indicates that most of the harm to smokers is the direct consequence of the smoking habit. (Royal College of Physicians 1977:38.) 3.4.2 SMOKING-RELATED MORTALITYIN DEVELOPED COUNTRIES Roughly 2 million people are estimated to die annually from smoking-related causes in developed countries (see table 3.1) and, according to Peto's estimates (1994:937) this number may grow to 3 million in the year 2025 if drastic declines in smoking patterns in these countries do not occur soon. Table 3.2 contains estimates of the expected number of deaths from smoking in developed countries for the fifty years between 1950-2000. (Peto, et al. 1994:A.8.) Table 3.1 Millions of deaths per year from smoking in developed countries 1995 projections (peto et ale 1994:A.7) Age at Male Female Mean years death lost per death from smoking 35-69 900000 200000 22 years 70+ 600000 300000 8 years 3.4.2.1 United States of America The Royal College ofPhysicians (1977:31) summarises the impact of smoking on the life expectancy of Americans as follows: - 40 - Chapter 3 I Table 3.:/ ( Millions of smoking-related deaths in developed countries 50 years estimates: 1950 - 2000 (peto et ale 1994:A.8) Age at Male Female death 35-69 33 million 4,9 million 70+ 19 million 5,7 million ALL 50 million 10,0 million • During the first half of the twentieth century the life expectancy of both male and female Americans improved steadily. • By about 1950, the rate of improvement slackened, and towards the 1970s the improvement for men had stopped and for women had slowed down. • The difference in expectation oflife between men and women was 3,7 years at the tum of the century; it started to widen by 1920 and is now 6,3 years. • > Conclusion: American statistics indicate that a great proportion ofthe widening of the gap in life expectation between men and women can be accounted for by the much greater smoking habits of men over the 25 years preceding 1977. Various authors, such as Bartecchi, MacKenzie & Schrier (1994:907) and Stebbins (1990:228), show that mortality as a result of tobacco consumption has taken a prominent place in death causation in the United States: • During 1990 it was calculated that nearly one-fifth of all deaths, and more than a quarter of deaths between ages 35-64 years in the United States of America, were attributable to smoking. • The estimated 418690 deaths in 1990 due to tobacco use were four times as many as deaths due to alcohol use. - 41 - Chapter3 • These deaths were also well in excess of the combined deaths due to automobile accidents, hard drugs, suicide, homicide, airplane crashes and AIDS. Stebbins (1990:228) argues: "The ill effects of cigarette smoking are now widely considered collectively as the number one preventable health problem in the world ... " 3.4.2.2 The United Kingdom The pattern of smoking-related mortality in Britain is similar to that of the United States, and the Royal College ofPhysicians (1983:2) calculates conservatively that the following statistics. • Tobacco accounts for 15% to 20 % of all British deaths. • This brings the annual total number of deaths in the United Kingdom as a result of tobacco to a figure not less than 100 000. • This figure is put into the context of some hazards to which people are exposed. Among 1 000 young male adults in England and Wales who smoke cigarettes, on average: • 1 will be murdered • 6 will be killed on the roads • 250 will be killed before their time by tobacco A 4O-year survey of a group of male British doctors' smoking habits and mortality provides powerful statistical evidence of the dangers of.tobacco consumption (Doll et al. 1994:901). The researchers conclude that: • The death rate ratio for cigarette smokers compared with life-long non-smokers is threefold between ages 45-64 and twofold between ages 65-84. • The excess mortality among smokers results chiefly from diseases that can be caused by smoking, such as lung cancer and cardiovascular diseases. - 42 - Chapter 3 • About half of all regular cigarette smokers are eventually killed by conditions resulting from tobacco consumption. 3.4.3 SMOKING-RELATED MORTALITY IN SOUTH AFRICA· The Medical Research Council estimates that over 25 000 people presently die in South. Africa annually from tobacco-related causes (1 in 9 deaths). The smoking related death rate is expected to rise steeply, as economic growth will make 'regular tobacco use affordable to a much larger portion of the population. (Yach 1994c:l.) In order to gauge the extent of smoking-related mortality in South Africa, Yach and Townshend (1988:7-10) use the classification of smoking-related causes of death suggested by the World Health Organization's International Agency for Research on Cancer (lARC) (1986). The International Classification of Diseases (lCD) codes are used to define the diseases in the various categories. (1CD is the ninth revision of the International Classification ofDiseases.) Category A includes those diseases for which excess mortality in smokers is regarded as smoking-related and include the conditions listed in Table 3.3. Category B includes diseases in which excess mortality in smokers is smoking-related but confounded with other factors (e.g. alcohol) (Table 3.4). Category C represents diseases for which excess mortality in smokers may be partly or wholly smoking-related (Table 3.5). 3.4.3.1 Discussion Although the causes of death listed in tables 3.3, 3.4 and 3.5 (Categories A, B and C) are smoking-related, it is not easy to accurately calculate the number ofdeaths in these categories caused by smoking, because the numbers of smokers and non-smokers who died from these conditions are not known. - 43 - Chapter 3 Table 3.3 .CATEGORY A causes of death (Yach & Townshend 1988) JCDno Disease 162 Lung cancer 410-414 Ischaemic heart disease 415-417 Respiratory heart disease 441 Aortic aneurysm 490-496 Chronic obstructive airways disease Table 3.4 CATEGORY B causes of death (Yach & Townshend 1988) JCDno Disease Various Alcoholism 609 Cirrhosis of liver £850-£869 Poisoning £950-959 Suicide Yach estimates that about 33 % of deaths among whites, about 20 % of deaths among Asians, 10-15% of deaths among coloureds and approximately 5% of deaths among black in South Africa, are smoking-related (Yach 1994b:376). Table 3.6 presents the number ofsmoking-related deaths for 1990, calculated according to Yach's estimates. 3.4.3.2 Conclusions The following conclusions regarding smoking-related mortality in South Africa emerge from relevant literature: • The proportion of all deaths due to smoking-related diseases is particularly low among black women. (Yach 1994b:376.) This fact corresponds with a survey which shows a low smoking rate among this group. (Reddy, Meyer-Weitz & Yach 1995:5.) - 44- Chapter 3 • Lung cancer represents 24 % of all deaths from cancer in males and 16% in females. Most of these deaths are preventable by avoiding smoking. (Yach 1994b:376.) Table 3.5 CATEGORY C causes of death (Yach & Townshend 1988) ICD no Disease Cancer of: 150 oesophagus 146 oropharynx 151 stomach 155 liver 188 bladder 189 kidney 157 pancreas 180 cervix uteri 199 unspecified site Other: 011-012 Respiratory tuberculosis 480-486 Pneumonia vanous Other respiratory disease 648 Low birthweight 401 Hypertension 440 Atherosclerosis 434 Cerebral thrombosis 531 Gastric ulcer 532 Duodenal ulcer 550 Hernia • Deaths from smoking-related diseases accounted for a total of 100 856 potential years of life lost between 35-64 years of age in South Africans in 1988 - the highest proportion ofyears lost is found among white males, namely, 80545 years (34,3 %). (Yach, McIntyre & Saloojee 1992b:9.) - 45 - Chapter 3 Table 3.6 Estimated number of smoking-related deaths according to population group - 1990 Whites Blacks Asians Coloureds Totals Total deaths 33519 86060 4212 24867 148658 Percentages 33% 5% 20% 10% 12,6% Smoking-related deaths 11061 4303 842 2487 18693 (estimated) • The 12,6 % smoking-related deaths for 1990 implies that a total of approximately 22 408 people died during 1992 in South Africa as a result of these diseases. (Figures for different population groups are not available after 1991.) • . These figures do not include deaths of non-smokers (e.g. children), as a result of exposure to passive smoking. Yach and his co-workers observe that, though the contribution of smoking-related diseases to all deaths has declined among whites between 1984 and 1988, the absolute number of deaths in this group has grown. Among the black, coloured and Asian populations the proportion of deaths due to smoking-related diseases has grown. This growth translates into large increases in the absolute number of deaths. (Yach et at. 1992a:274/275.) 3.5 SMOKING AND CANCER Some of the compounds in tobacco smoke act chiefly in the mouth or the air passages where they are deposited. Others are absorbed from the mouth or lungs into the blood and may then act on tissues throughout the body. Peto (1986:24-31) contends that the appearance of lung cancerdepends on: - 46- Chapter 3 • The duration of smoking. The longer smokers have been smoking, the greater their chances are of suff.." hg from cancer.' r • The number ofcigarettes smoked. The more cigarettes smokers consume per day, the more likely they are to contract cancer. • The interaction with other substances causing lung cancer. Exposure to asbestos, ionizing radiations and urban pollution have a synergistic effect on smokers. (Schroder 1994:75.) 3.5.1 . KNOWN CANCER-PRODUCING SUBSTANCES (CARCINOGENS) The Royal College ofPhysicians (1977:40) mentions three kinds of cancer-producing substances: • Complete carcinogens, which above certain dose levels by themselves give rise to cancer in experimental animals. • Tumour initiators, which bring about the first stage of the carcinogenic process. Table 3.7 US cancer deaths attributed to tobacco consumption: 1985 (peto et ale 1992:1269) Lung cancer from (active or passive smoking) 110000 Cancers of other specified sites (e.g. mouth, oesophagus, pharynx, larynx, panc~eas, cervix, kidney, bladder) 31 000 Total cancer deaths attributed to tobacco 141 000 Percentage of total deaths attributed to tobacco (390 000) 36% Percentage of total deaths in 1985 in US (2,1 million) 7% - 47- Chapter 3 • Tumour promoters, which complete the process once it has been started but cannot themselves initiate it. Estimates show that tobacco use can be associated with at least 30 % of all cancer deaths in the United States (Davis 1987:20 quoting the 1982 Report of the US Surgeon General) (see Table 3.7). Doll and his co-workers report on the 40 year study on mortality among male British doctors and highlight the following trends (Doll, Peto, Wheatley, Gray & Sutherland 1994:903): • Smokers had a significantly higher mortality rate than non-smokers as a result of the following cancers: • upper respiratory sites (mouth, pharynx and larynx) • lung • oesophagus • pancreas • bladder • The mortality rate was particularly high among persons who smoked more than 25 cigarettes per day. • Former smokers showed a higher mortality compared with non-smokers but a significantly lower rate than smokers. 3.5.1.1 Lung cancer (a) Incidence It takes, on the average, 2-3 decades for lung cancer to develop from the time of starting smoking. (Sitas & Pacella 1994:16.) During 1988 no less than 660 500 new cases of lung cancer were reported in the world. Parkin and Sasco (1993:1) estimate that 76% of these cases (84% in men and 46% in women) can be attributed to tobacco smoking. They point out that an increase of0,5 % per annum, will have brought the number of cases of lung cancer worldwide - 48 - Chapter 3 to approximately 850000 by 1990. (Parkin & Sasco 1993:112.) This was confirmed by an estimated incidence of lung cancer in 1990 of nearly I million cases, of which about 440000 occurred in developing countries. (Yach 1994b:374.) The increase in tobacco use in the developing countries makes a dramatic increase in this iricidence likely. In South Africa the incidence of lung cancer ranks third of all cancers in males and fifth in females. Figures for 1989 show that at least 1 in 30 white males and at least 1 in 33 coloured males will develop cancer if the trends continues. (Sitas & Pacella 1994: 16.) (b) Mortality The United States of America is experiencing a drastic increase in lung cancer mortality. • The age adjusted lung cancer mortality rates for men have increased from 11 per 100 000 in 1940 to 74 per 100000 in 1987. • Lung cancer mortality rates for women have risen from 6 per 100000 in the early 1960s to 28 per 100 000 in 1987. • There is a significant correlation between time trends and gender differences in lung cancer mortality rates, and historical smoking patterns. Increases in lung cancer deaths parallel increases in cigarette consumption with a roughly 20-year lag, accounting for the latency period for the development of smoking-induced lung cancer (see 3.5.1.1(a». (Jinot 1992:4-2.) . The annual lung cancer deaths in the United States collected by Upfal, Divine and Siemiatycki (1995:62) are listed in table 3.8. A total of 3 398 deaths (2483 males and 915 females) in 1992 in South Africa, oc curred as a result of lung cancer. This represents 1,9 %ofthe total of 177 841 deaths for all population groups.for that year. (Central Statistical Service 1993.) - 49 - Chapter 3 Nath (1986:34) observes: "The lung cancer rate in South African men rose rapidly between 1949 and 1969. In those 20 years, the rate more than doubled in white men but increased fourfold in coloured men, until the incidence of lung cancer had exceeded that in white men." Table 3.8 Annual lung cancer deaths in the United States attributed to smoking (Upfal, Divine & Siemiatycki 1995:62) Total number of lung cancer deaths 146000 Lifetime lung cancer mortality rates: Current smokers 10329 Former smokers 4579 Never smokers 537 Relative risks for lung cancer deaths: Current smokers vs never smokers 19,22 . Fonner smokers vs never smokers 8,52 Prevalence: Current smokers 40,4% Former smokers 31,1 % Never smokers 28,5% Lung cancer death distribution: Current smokers 105 920 Former smokers 36 191 Never smokers 3 890 3.5.1.2 Oesophageal cancer The incidence of oesophageal cancer has increased greatly to become the commonest cancer in black males in many parts of South Africa, and has become the most common cause ofcancer deaths among blacks. In 1986 the incidence rate of oesopha geal cancer cases among urban blacks was 28,4 per 100 000 for males and 7,8 per - 50 - Chapter 3 100 000 for females. Strong evidence exists that smoking and alcohol are the major risk factors associated with this kind of cancer but that nutritional deficiencies play an important role. (Sumeruk, Segal, Te Winkel & Van der Merwe 1992:91.) 3.6 SMOKING AND CARDIOVASCULAR DISEASE Researchers have been reporting an association between cigarette smoking and coron ary heart disease since 1940. The evidence is now clear that cigarette smoking substantially increases the risk of cardiovascular disease, including stroke, sudden death, heart attack, peripheral vascular disease and aortic aneurysm. Among the dangers to the vascular system, is the damage by components of cigarette smoke, to the vascular endothelium. Endothelial injury is considered to be a.primary forerunner of atherosclerosis. (Bartecchi et al. 1994:907, 908.) Doll et al. (1994:904) found a significantly higher mortality among cigarette smokers compared with non-smokers, due to the following vascular diseases, in their study on male British doctors: • Pulmonary heart disease • Ischaemic heart disease •. Myocardial degeneration • Aortic aneurysm • Arteriosclerosis • Hypertension • Cerebral thrombosis • Subarachnoid haemorrhage • Other cerebrovascular disease 3.7 SMOKING AND RESPIRATORY DISEASES The study on male British doctors shows a significantly higher mortality among smokers compared with non-smokers, due to the following respiratory diseases (Doll et al. 1994:904): • Pulmonary tuberculosis - 51 - Chapter 3 • Chronic obstnictive lung disease • Pneumonia 3.8 SMOKING AND OTHER CAUSES OF DEATH Doll et al. (1994:905) find a significantly higher mortality among smokers compared with non-smokers, in the study on male British doctors, due to the following: • Peptic ulcer • Cirrhosis of liver • Poisoning • Suicide Further research is needed to ascertain the reasons why higher rates for poisoning and suicide are found among smokers. 3.9 SMOKING AND ILL-HEALm The Royal College of Physicians (1977:36) remarks: "Cigarette smoking not only shortens life, it may also cause prolonged ill-health. While, for example, many patients recover completely from a heart attack, there are others who remain invalids. Patients who ultimately die from chronic bronchitis or emphysema usually endure about 10 years of distressing breathlessness before they die. " 3.10 WOMEN AND SMOKING Women smokers are susceptible to the same diseases as men and an increase in mor tality among women due to cancer and cardiovascular disease is concomitant with an increased rate in smoking among females. Smoking among women was a rare occurrence before the First World War. Some thirty years later, however, their increasing consumption of cigarettes ran roughly parallel to that of men. (Royal College of Physicians 1977:16.) Women smokers are now numbering millions throughout the world and are increasing daily. (Chollat Traquet 1992:1.) - 52- Chapter 3 After the Second World War, and especially since 1950, the trend in adult cigarette consumption has been quite:" rerent in men an~ {Nomen. In women a steady upward trend continued throughout this period (1950-1976), and their average cigarette consumption more than doubled. (Royal College of Physicians 1977:16-17.) 3.10.1 SMOKING AND REPRODUCTIVE HEALTH Women who smoke are at risk of suffering from infections of the reproductive tract and are prone to infertility. Heavy smokers (more than 20 cigarettes a day) are three times more likely than non-smokers to take more than a year to conceive, with three times the risk of primary tubal infertility. Women smokers who use oral contracep tives are at greater risk of cardiovascular disease than non-smokers who use the pill. Cigarette smoking harbours particular dangers for the foetus and infants of smokers. Nicotine crosses the placenta easily and has been detected in the amniotic fluid and the umbilical cord of neonates as well as in breast milk. (US Department of Health and Human Services 1988:33.) 3.10.1.1 Spontaneous abortion Spontaneous abortion (miscarriage up to 28 weeks gestation) takes place more readily among smoking women. While abortuses of young smoking women are chromosom ally normal, evidence exists that smoking women over 30 are inclined to abort chro mosomally abnormal foetuses. (Royal College of Physicians 1992:4.) 3.10.1.2 Perinatal mortality Women who smoke are much more at risk than non-smokers with regard to preterm delivery (early delivery of less mature baby) as well as high morbidity and mortality among foetuses from 28 weeks gestation, and babies up to 7 days. The risk to infants increases for women who smoke before and during pregnancy. (Royal College of Physicians 1992:4-5 and World Health Organization 1975:56.) - 53 - Chapter 3 3.10.1.3 Sudden Infant Death Syndrome (SInS) A clear link has been established between maternal smoking and Sudden Infant Death Syndrome (SillS). (Royal College ofPhysicians 1992:6/7). Fleming (1996) completed a study which shows that babies of smokers are 61 % more likely to fall victim to SIDS than those ofnon-smokers (quoted by Highfield 1996:7). The exact mechanism of this phenomenon is still unknown and further research is needed before a defmite conclusion can be reached. (Martinez 1992:7-57.) 3.10.2 OSTEOPOROSIS Apart from the dangers mentioned above of smoking to women, there are indications that smoking carries an added risk of osteoporosis, with its associated fractures, among women. (Sasco 1993:55.) 3.10.3 CONCLUSIONS The fact that women smokers put their own health as well as that of the foetus and their children at risk makes smoking all the more threatening for a society where smoking is regarded as an acceptable habit. Kabwe (1993:52) claims: "There is enough evidence-of the dangers of tobacco use for women in developing countries to make its prevention a public health priority". 3.11 THE EFFECTS OF ENVIRONMENTAL TOBACCO SMOKE AND PASSIVE SMOKING 3.11.1 DEFINITION OF PASSIVE SMOKING The Royal College ofPhysicians (1977:27) defmes passive smoking as: "non-smokers breathing air which is full of smoke produced by smokers in their close proximity". The Royal College of Physicians (1977 :27) summarises the dangers of passive smoking as follows: In small enclosed spaces such as a railway compartment, a car or a small office, in which there are several heavy smokers, a non-smoker may in one hour inhale as much smoke as an average smoker - 54- Chapter 3 inhales from one cigarette, so that ifexposed continually in this way for 10 hours daily he might have the same risk of disease as a smoker of 10 cigarettes a day ... 3.11.2 BIOCHEMICAL MARKERS OF EXPOSURE TO TOBACCO SMOKE Epidemiological techniques that have been suggested for estimating exposure to cigarette smoke, include determinations of blood carboxyhaemoglobin (see 2.3.3.2), measurement of serum nicotine levels and estimates of thiocyanate in plasma, saliva and urine. (Shephard 1982:47.) Nicotine has the significant advantage from an epidemiological point of view, that it is unique to tobacco. If nicotine, or one of its metabolites (such as cotinine), is found in the body of a non-smoker, it provides unequivocal proof of passive exposure to tobacco smoke. (Shephard 1982:50.) Cotinine is easily and accurately measurable in saliva, blood, hair and urine and presently serves as an indicator of exposure to tobacco smoke. (Bartecchi et at. 1994:910.) 3.11.3 PASSIVE SMOKING AND LUNG CANCER It is conservatively estimated that in excess of 3 000 non-smokers die annually in the United States from lung cancer caused by environmental tobacco smoke (ETS) exposure. This figure includes exposure in public places, in offices and at home. (Brown 1992:6-31.) 3.11.4 PASSIVE SMOKING AND RESPIRATORYILLNESS Various recent studies produce evidence that passive smoking has significant effects on the respiratory health of non-smokers. Exposure to cigarette smoke seems to aggravate asthmatic symptoms in non-smoking women who are exposed to their hus bands' smoking, while a high incidence of coughing, phlegm and chest discomfort is reported by non-smokers who are exposed to passive smoking. (Martinez 1992:7-64 to 7-70.) - 55 - Chapter 3 3.11.5 PASSIVE SMOKING, THE FOETUS AND eH/WREN 3.11.5.1 Low birth weight Researchers have proved beyond all doubt that infants born to smoking mothers are of lower birth weight. Higher smoking rates lead to a greater reduction in birth weight and a reduction of 12 g for every cigarette smoked per day has been recorded. Low birth weight is associated with higher risks of death and disease in infancy and early childhood. (Royal College of Physicians 1992:2.) A number of studies show that paternal smoking may also lead to low birth weight. At this stage it is uncertain whether this is due to the mother's passive smoking during pregnancy, or as a result of direct damage to the sperm, or both. (Royal College of Physicians 1992:7.) 3.11.5.2 Intelligence Infants from smoking mothers are generally shorter with a smaller head circumfer ence. A smaller head circumference at birth is an indication of poor brain growth in utero. Studies show a strong correlation between exposure of the foetus to smoking during pregnancy and lower academic attainment later in life. (Royal College of Physicians 1992:4.) 3.11.5.3 Childhood illnesses Researchers fmd an increased morbidity in infants and children born to mothers who smoked during pregnancy. It is possible, however, that illness in children may be complicated by passive smoking in the home environment. Hospital admissions reveal that children of smoking mothers are afflicted with significantly more allergies and respiratory complaints than those ofnon-smokers. Recent studies report an association between smoking during pregnancy and childhood cancers, but have to be followed up for confirmation. (Royal College of Physicians 1992:6/7.) Researchers have provided indisputable proof that exposure of children to environ mental tobacco smoke, is a major cause of respiratory illnesses among such children. In one study It was reported that children so exposed were 3,5 times more likely to suffer from increased respiratory morbidity than non-exposed children (see 3.13.2). - 56- Chapter 3 (Bakoula et al. 1995:280.) Martinez (1992:7-50) observes that environmental expo sure to cigarette smoke is particularly harmful to children suffering from asthma and other respiratory illnesses. In a South African survey by the Medical Research Council and the Human Sciences Research. Council in 1995 it was found that 48 % of the respondents reported that at least one household member smoked. This is an indication ofan extremely high exposure ofchildren to tobacco smoke which, in tum, is already evident through high rates of low birth weight, asthma, acute respiratory infections and pneumonia. (Reddy et al. 1995:5.) Leaderer (1992:3.32) concludes: "Children have been identified as a particularly sensitive group at health risk from exposure to ETS [environmental tobacco smoke] in the residential indoor environment." 3.11.6 CONCLUSIONS In most experiments it is shown that atmospheric contamination due to cigarette smoke accumulation, becomes a health concern especially when ventilation is poor or non existent. There is need for further research on the build-up of benz (a) pyrene and dimethyl-nitrosamine; significant amounts of these very dangerous substances can apparently accumulate in places such as restaurants and public bars. (Royal College of Physicians 1983:74 and Shephard 1982:47.) The fact remains that smokers cause discomfort and annoyance to many non-smokers in eating places, offices, other places of work and on public transport facilities. (Royal College of Physicians 1983:79 and Le Grange 1994:288.) Scott Ballin, executive director of the Washington-based Coalition on Smoking or Health, declares: "I can't think of another product that, faced with the scientific evidence which is associated with tobacco, could remain a legal product on the market and almost exempt from regulation" (quoted by Farley 1994:54). Some tobacco companies are conceding that smoking is hazardous to health. Thomas Lauria, president of the Tobacco Institute in the United States, is reported to admit that studies since the 1960s have linked cigarette smoking as an important risk factor to emphysema, heart disease, lung cancer and other serious problems (quoted by Farley 1994:54). - 57 - . Chapter 3 The efforts ofthe tobacco industry are presently concentrated on convincing the public that smoking is a matter of free choice, and that the case for the hazards of passive smoking has not beenproved. As far as the latter is concerned, evidence is rapidly accumulating that environmental smoke. is harmful and could be life-threatening to non-smokers, especially to children. The 'freedom of choice' issue will be taken up in later chapters (see 4.2.1.1). 3.12 SUMMARY Tobacco consumption has been prevalent for centuries and, in spite of its dangers to human health, has become an acceptable and entrenched habit among millions of . people around the world. The fact that so many people smoke has more to do with the addictive qualities of nicotine than with any pleasure or stress reduction derived from the habit. The addictiveness of cigarettes is regarded as having the same characteristics as that of drugs such as cocaine and heroin. Cigarette smoking is responsible for about 3 million deaths annually around the world and if present trends continue a large increase in mortality as a result ofsmoking must be expected. The most important smoking-related causes ofdeath are lung cancer and ischaemic heart disease. Women are particularly vulnerable as regards exposure to smoking. They may jeopardize the health of their unborn babies and children and are often subjected to their husbands' smoke. The question of non-smokers' exposure to environmental smoke (passive smoking) has become prominent during the last decade and evidence exists that the health of non smokers is in danger through this exposure. - 58- Chapter 3 3.13 NOTES •.4 3.13.1 DRUG DEPENDENCE AND DRUG ADDICTION Certain authors prefer the term 'drug dependence' as scientifically more precise than 'drug addiction' (cf Iversen 1990:1). The US Department of Health and Human Services (1988:7) maintains, however, that the terms are scientifically equivalent. 3.13.2 RESPIRATORYMORBIDITY AMONG CHILDREN Respiratory morbidity is divided as follows (Bakoula et al. 1995:280): Upper: rhinitis, tonsillitis, sinusitis, otitis media and laryngitis Lower: bronchitis, bronchiolitis, asthma, bronchopneumonia and pneumonia. - 59- \ CHAPTER 4 ECONOMIC CONSIDERATIONS OF TOBACCO PRODUCTION AND USE 4.1 INTRODUCTION Certain economic aspects of tobacco production and consumption are debated by tobacco producers and anti-smoking campaigners. For example, the argument, whether the economic benefits that a country derives from tobacco production can really be weighed up against the smoking-related loss of lives, needs closer attention. This chapter surveys relevant literature to comment on the economic considerations regarding tobacco production, promotion of tobacco products and tobacco consumption. 4.2 TOBACCO SALES The manufacturing and selling of cigarettes have become one of the world's most profitable industries; 4 trillion cigarettes worth over $40 billion (R145,4 billion) are sold annually. In 1980, Americans bought 630 billion cigarettes, spending nearly $20 billion (R72 billion), while British smokers bought 110 billion cigarettes in 1981. (Taylor 1984:xviii/xix.) Mathews (1995:19) quotes a prominent tobacco company which has revealed that the world demand for cigarettes has grown by an estimated 1 trillion or 25 % since 1980. Some of the reasons for this successful trade are that cigarettes are cheap to produce, addictive and they are recession proof. (Taylor 1984:xviii/xix.) The tobacco firms Philip Morris and RJR Nabisco are currently the leaders in the tobacco industry in the United States. In 1992 Philip Morris was the seventh largest industrial corporation in the US with $50 billion (R182 billion) in sales. However, this firm ranked first with regard to profits during that year, and made $4,9 billion - 60- CluJpter4 (R18 billion) which was more than any other company in the United States. This is an indication of the large profit margin of cigarette sales. (MacKenzie, Bartecchi & Schrier 1994:975.) African cigarette consumption presently comprises only 3 % of the world total, and in 1990 roughly 175 billion cigarettes were smoked in Africa, costing more than $7,12 billion (R26 billion) which is three and a half times the national budget of the Ivory Coast. (Chapman 1993:29.) The RSA Tobacco Board reveals that tobacco consumption in South Africa increased from 21,6 million kg in 1975 to 39,24 million kg in 1993. The increasing demand for cigarettes in South Africa is illustrated by the increased consumption 'of flue-cured tobacco, which jumped from 15,7 million kg in 1975 to 30,91 million kg in 1993. Consumer spending on tobacco products increased from Rl 061 million in 1982/83 to R5 662 million in 1993/94. During the same periods the amount private consumers spent on tobacco, as a percentage of total expenditure on food, liquor and tobacco, climbed from 4,86% to 7,23%. (RSA Tobacco Board 1994:21/22.) The global consumption of tobacco is summarised in Table 4.1. Table 4.1 Total world consumption of tobacco (thousands of tons - dry weight) (Barnum 1993:13) Region 1975 1985 1995 Developing countries 2300 3700 5000 Africa 100 150 200 Developed countries 2400 2300 2300 World 4700 6000 7300 Tobacco sales provide governments with one oftheir biggest and most reliable sources of revenue. In Britain the annual revenue from cigarettes amounts to £4 billion (R22,5 billion), while cigarette related diseases cost the National Health Services about £165 million (R927,5 million) a year. (Taylor 1984:xix.) The South African govern ment derived R390,6 million in excise duties on tobacco products during 1982; this - 61 - Chapter a income rose to Rl 01,2 million in 1993, while the Value Added Tax (VAT) paid on tobacco products amounted to roughly R612,5 million. (RSA Tobacco Board 1994:23/24.) 4.2.1 TOBACCO SALES PROMOTION During 1962, British tobacco manufacturers adopted a code eliminating cigarette ad vertisements which"over-emphasized the pleasures of smoking, featured conventional heroes of the young, appealed to manliness, romance or social success, or implied greater safety in any brand". The code was monitored by the manufacturers themselves and was partially adhered to for several years, but during the 1970s has more often been breached. The British Advertising Standards Authority (ASA) accepted responsibility for establishing a new and stricter code which took effect in March 1976. (Royal College of Physicians 1977:21.) The tobacco industry, in its promotion campaigns, has largely given up arguing that smoking is not dangerous. The present strategy revolves around the 'freedom of choice' issue. Thomas Lauria, president of the US Tobacco Institute, contends: "There are a certain amount of adult consumers who want to enjoy tobacco products. And like those who drink alcohol or who enjoy high-risk sports activities, it is really up to the individual adult to determine what's appropriate for their own conduct" (Farley 1994:54). 4.2.1.1 Impact of advertising The continuous and well-designed tobacco promotion campaigns ensure that an indi vidual's decision to smoke "does not occur in an ideal world of free and informed choice" (Stebbins 1990:227). This lack of choice exists despite the vast amount of scientific information regarding the health risks associated with cigarettes. Cigarettes are the most heavily promoted product in the United States, with over $2 billion (R7,3 billion) spent on cigarette advertising in 1985, a 400% increase since 1980. (Stebbins 1990:227.) MacKenzie et al. (1994:976) mention that annual expenditure on cigarette advertising grew from $500 million (R184 billion) to $3,9 billion (R14 billion) between 1975 to 1990. - 62- Chapter 4 4.2.1.2 Sponsorship of sport A ban on television advertising of cigarettes in Britain was imposed in 1965, but tobacco manufacturers managed to circumvent this ban through the sponsorship of sporting events and the abundant television coverage of such events. Although individual brands of cigarettes are not advertised directly at sport events, company names and groups of brands are still freely displayed. (Royal College of Physicians 1977:21.) The Royal College of Physicians (1992:vii) comments: "Much advertising is now subtle and indirect, centring around sporting events such as motor racing with which youngsters identify." As an example, Goldman (1992:194) reports that the amount of tobacco advertising on the BBC during 1991, at grand prix motor racing events, exceeded eight minutes an hour, which was more than the advertising allowed on independent television. Taylor (I984:99) observes that the overall business expenditure on sponsorship of sport and the arts in Britain has grown at around 20% a year throughout the 1970's - increasing from £15 million (R84,3 million) in 1973 to over £50 million (R281 million) by 1981. Approximately 90% of this amount has been directed towards sponsorship of sport and the balance on the arts. While the tobacco companies do not disclose their advertising budgets, they were undoubtedly the largest contributors. A voluntary agreement exists between the tobacco industry and the South African Broadcasting Corporation (SABC) that there will be no tobacco advertising on tele vision. A report on national tobacco expenditure intimated, however, that RI,2 million was spent during 1987 on television advertising of tobacco and associated products. SABC-TV gives ample time for the coverage of events such as the Rothman's July Handicap (horse racing), Gunston 500 (surfmg), Benson and Hedges (cricket), Lexington and Dunhill (golt), Winfield (rugby seven-a-side series) and Marlboro and Camel (motor racing). In this manner tobacco companies obtain exposure on television at a relatively low cost. (Yach, Strebel, McIntyre & Taylor 1989:410; Yach & Saloojee 1994:2.) This kind of advertising "makes a mockery of the Advertising Standards Authority provision that 'No [tobacco] advertising will depict or use, as endorsers, celebrities in the sporting or entertainment world'" (Yach & Saloojee 1994:2). - 63 - Chapter 4 The attitude towards anti-smoking sentiments is illustrated by the banning from the Rothman's.Cape-to-Rio yacht race of a Swedish skipper whose yacht is sponsored by a product which helps people give up smoking (Anon 1995b:3). Another example of discrimination against anti-smoking measures was the fining by the Australian Cricket Board (ACB) of Greg Matthews, international cricketer, for taking part in a govern ment backed anti-smoking advertisement. The ACB contended that they had to protect the interests of their sponsors. (Yach & Saloojee 1994:5.) Taylor (1984:99) reveals sponsorship as a particularly powerful method ofadvertising which is designed to: • Associate smoking with healthy, glamorous and life-enhancing activities. • Polish the corporate image of cigarette companies. • Create goodwill among the public. • Gain access by cigarette companies to prestigious and powerful people and institutions involved in sport and the arts. • . Make fmancially hard-pressedgovernments and governing bodies more dependent on the cigarette companies. • Get round the ban on advertising cigarettes on television. Taylor (1984:99) sums up: "Tobacco sponsorship is designed to change the public perception of cigarettes and the companies who make them. " Studies among military recruits reveal the following: •A graded inverse relationship between endurance performance and smoking. The more recruits smoke per day, the shorter the distance covered in a test. (Yach & Saloojee 1994:5.) - 64- Chapter 4 • Within each smoking category it is found that those who have smoked for a longer period have performed m" ! poorly than th~~l who started more recently. (Yach & Saloojee 1994:5.) • Smokers are less fit than non-smokers. Smoking army recruits were twice as likely to fail to complete basic training compared with non-smokers. (Royal College of Physicians 1992:35.) Another important fact is highlighted by various studies, namely, that a much smaller proportion of sportsmen and women are smokers compared with non-participants of sport. (Yach & Saloojee 1994:824.) The Royal College of Physicians (1992:vii) reveals the paradox:" smoking by sportsmen or women would result in a degree of unfitness incompatible with excellence in their chosen sport" . 4.2.1.3 Youth and other groups targeted The tobacco industry's strategy to target children and particularly the black and coloured market in its advertising is evidenced by an analysis of the results of recent advertising expenditure. In 1987, tobacco advertising accounted for 5,3 % (a total of R55 million) of all advertising expenditure in South Africa. Turning to specific media, however, it is found that 16 % of radio advertising, 16,3 % of billboard advertising and an staggering 56,3 % of cinema advertising came from tobacco and associated products. (Yach, Strebel, McIntyre & Taylor 1989:410.) A few tobacco companies have aggressively outstripped the general increased growth in tobacco advertising. These include Rothman's (30%), American Cigarette Company (28%), Dunhill (31 %) and Camel (63%). The first three brands are the most popular cigarettes smoked by black township youth and men. (Yach, Strebel, McIntyre & Taylor 1989:410.) The evidence compels Yach these authors to remark: It is clear that the tobacco industry, through the medium of radio, is attempting to increase both the individual market share of specific products and the total tobacco consumption rate among black listeners, who comprise the predominant consistent audience for commercial radio in South Africa. - 65 - Chapter 4 The tobacco companies deny that they encourage children to smoke. The evidence, however, conveys a different message. Cinema advertising is bombarded with tobacco promotion, which suggests that children are certainly targeted. Yach et at. (1989:410) observe: "New markets (youthand rapidly urbanising populations) have obviously been targeted to offset any potential loss of sales that may occur among the white sector of the community. " 4.2.1.4 Discussion Robinson (1993:19) directs warnings at countries in Africa ofthe intentions oftobacco companies to swamp the continent with the promotion ofcigarettes which will be high in tar and nicotine content and directed at the least economically viable segments of the populations. Indications are that Africa's 850 million inhabitants will be an important growth market for tobacco products. According to Chapman (1993: 28) the reasons advanced for this assumption are: • Africa's population is growing faster than that of any other region of the world. • The per capita consumption rate of tobacco products is generally low at present, allowing plenty of scope to rise. Hambros Equities, a London-based firm of fmancial analysts, maintains: "Southern African cigarette consumption, which is well below world averages, is likely to increase with improving economic conditions and a high growth rate in the over 16 year-old population" (quoted by Spira 1995:18). 4.3 ECONOMIC CONSIDERATIONS MacKenzie et al. (1994:975) estimates that the costs of smoking in the United States for 1985 amounted to roughly $65 billion (R250 billion) in terms of health care expenditures and lost productivity. The average life-time medical costs for a smoker in the United States is estimated to exceed those for a non-smoker by more than $6000 (R21 810). - 66- Chapter 4 4.3.1 MORBIDITY AND MORTALITY Some controversy exists regarding the economic benefits for a society, of tobacco production and consumption. Barnum (1993: 13/14) remarks that "tobacco adds very little to world welfare. There is, of course, some short-term satisfaction and added producer profits, but these benefits are dwarfed by the cost ofmorbidity and mortality caused by tobacco use". Table 4.2 depicts the estimated morbidity and premature mortality from 1 000 tons of added tobacco consumption. Table 4.2 Morbidity and mortality from 1000 tons of added tobacco consumption (Barnum 1993:14) Tobacco induced Annual Annual added disease new cases mortality Cancer 230 200 Cardiovascular 440 330 Cerebrovascular 130 50 COPD* 190 70 Total 990 650 * Chronic obstructive pulmonary disease Based on data derived from the US Surgeon General, it is estimated that one ton of tobacco consumed leads to an average of about 0,65 deaths, with an average lag of25 to 30 years. (Barnum 1993:14.) 4.3.2 SMOKING AND LOSS OF PRODUCTIVITY According to Mcintyre and Taylor (1989:432), the loss of productivity as a result of smoking can be categorised into three groups: • Illness (absenteeism) • TIl health (decreased output) • Premature death - 67 - Chapter 4 Making use of recognised formulae and data from the Department of Statistics, McIntyre and Taylor calculate that lost productivity in South Africa due to premature deaths was between R212,2 and R246,8 million in 1985. During this period the econ omy lost roughly R21,6 million while smokers were receiving treatment for smoking related diseases. (McIntyre & Taylor 1989:433.) By 1993, the estimated cost for South Africa, due to productivity losses from premature smoking-related deaths, came to a staggering R2,5 billion. (Yach 1994c:1.) The Royal College ofPhysicians (1977:36) estimates that at least fifty million working days may be lost in industry in Britain every year as a result of cigarette smoking. Smith (1972) (quoted by the Royal College of Physicians 1977:36) reports that both male and female employees who smoke more than 20 cigarettes a day lose about twice as much time from work as non-smokers. MacKenzie et al. (1994:975) conclude: "The cost to employers of workers who smoke, is considerable and reflects costs due to work absences, health care claims, benefits not related to health care, and decreased productivity. " 4.3.3 SMOKING AND THE STRAIN ON HEALTH SERVICES The Royal College of Physicians (1977:36) quotes a study by Ashford (1973) which claims the following: smokers under the age of45 years make consistently greater use of medical services, whether in the home, the surgery, the out-patient department, or in the hospital ward, compared with non-smokers of the same age group. The Royal College of Physicians (1977:36) comments: "The consequences of smoking make a large contribution to the present burden of the health service." The cost of cigarette smoking to South Africa during 1982 in terms of medical care, hospital care, absenteeism, loss of production and decreased gross national product, was calculated to be in the region ofR3 million per day. (Borkon, Baird & Siff 1983: 809.) With the increase in tobacco consumption in South Africa, this figure must be considerably higher presently. During 1986, smoking-related diseases were responsible for a direct cost of RI08,5 million for hospitalisation, with an additional amount of R20 million towards provin- - 68 - Chapter s cial outpatient departments - a total cost of between R362,3 and R396,9 million (McIntyre & Taylor 1989:433). By 1993, the direct costs of hospitalisation as a result of smoking-related causes amounted to an estimated Rl,46 billion. (Yach 1994c:1.) 4.3.4 ECONOMIC IMPLICATIONS - A COMPARISON McIntyre and Taylor (1989:432) summarise the different economic implications for smoking and non-smoking societies in Table 4.3. Barnum (1993:15) asserts that the world tobacco market produces an annual global loss of$200 billion (R727 billion). This amount is based on 1990 figures for medical costs and other indirect expenses resulting from tobacco consumption, calculated against the value for consumers and producers of tobacco. McIntyre and Taylor quote (1989:434) studies which indicate that money which ex smokers have spent previously on cigarettes is devoted to other consumption activities rather than being saved. According to them, a demand and consequent employment in other sectors of the economy will be generated, and they argue as follows: ... the costs of a 'smoking-free' society would only outweigh the benefits if the loss of satisfaction to smokers and the costs associated with increased obesity exceeded all the costs to a smoking society (excluding health care costs and the cost of cigarettes). Expressed differently, the following question can be posed: is the satisfaction which smokers derive from smoking worth the R212 million which the economy loses per annum in lost productivity plus the costs of disability grants, fire hazards, passive smokin g, etc..? McIntyre and Taylor (1989:435) conclude: "the available information, as presented in this study tends to suggest that the costs of the tobacco industry to society at present, and particularly in the future, outweigh the economic benefits". - 69 - Chapter 4 Table 4.3 Economic consequences in smoking and non-smoking societies (McIntyre & Taylor 1989:432) Smoking society Non-smoking society Health care costs of Increased pensions (due to smoking-related diseases longer life expectancy) Productivity losses due Increased health care costs to mortality and morbidity due to other causes Cost of cigarettes (output (competing cause of tobacco industry) phenomenon) and geriatric care Increased insurance Loss of excise duty premiums Dislocation costs of Disability grants changing crops, manufac- Fire hazards (property turing plants, etc. (reduced forests) employment in certain Health and other costs sectors e.g. advertising) of passive smoking Loss of 'satisfaction' to Legislation - cost of smokers implementation Costs associated with Anti-smoking campaigns increased obesity Intangible costs (e.g. pain and suffering) 4.4 CONCLUSIONS One of the dangers of tobacco promotion for the Third World countries is the temptation to give in to the claim that tobacco provides substantial funds for such nations and communities. Chapman (1993 :28) points out that this statement closes more political doors in developing countries to tobacco control policies than any other. Chapman (1993:28) adds: "The perception that tobacco ... is a fat goose that lays golden eggs for impoverished Third World economies has gone largely unchallenged. " Unfortunately, the possibility ofsmoking-related epidemics in the distant future carries - 70- Chapter 4 little weight with governments of countries with massive public health problems. (Chapman, Yach, Saloojee :t~: l;impson 1994:1~. ~ \.) Barry (1991:918) holds that arguments about the economic benefits oftobacco growth and production for less-developed countries must be examined carefully. These countries should measure whether fast foreign-exchange cash is able to offset the loss of protein-producing crops, payments made to the transnational companies in return for new forms of technology, as well as the health costs to the nation. Barry (1991:918) mentions that some researchers contend that tobacco takes the place of food crops that could feed an estimated 10 to 20 million people. Thompson quotes a recent report, Tobacco and jobs, compiled by the Centre for Health Economics at the University of York and the Society for the Study of Addiction, which examines the employment situation related to the tobacco industry. The report claims that if 40 % of smokers would give up smoking by the year 2000, the extra spending power could create up to 150 000 new jobs in Britain. This is in contrast with the claims of the tobacco industry that its productivity was essential to the United Kingdom's economy through the jobs it provides and through being a major source of tax revenue. (Thompson 1995:1360.) The fact that tobacco is highly addictive and destructive makes it similar to drugs such as heroin and cocaine. The sale and use of these drugs are prohibited and regarded as serious crimes. The conclusion is, therefore, that tobacco sales and use are maintained through a technicality which makes it 'legal' at present. Because tobacco is so addictive and widely consumed, the tobacco companies wield strong economic and political power which is not easy to break. 4.5 SUMMARY The tobacco industry has become one of the most successful businesses in the world today. Trillions of cigarettes are sold and consumed annually and the cigarette companies enjoy billions in profits. The promotion of tobacco, and cigarettes in particular, represents one of the best designed strategies in the advertising world and the amounts spent on promotion run - 71 - Chapter 4 into the billions. Tobacco advertising has as an objective, to make smoking appear desirable and acceptable. The youth, and groups who are not presently consuming much tobacco, have become the targets for a concentrated promotion campaign. When the benefits of tobacco production and consumption in a specific country are measured against the costs in terms of loss ofman hours, medical expenses, suffering through disease and smoking-related mortality, researchers conclude that the world would be better off without tobacco. - 72- CHAPTER 5 SMOKING AND YOUTH 5.1 . INTRODUCTION While many adults are giving up smoking, it is also true that hundreds of thousands ofchildren and teenagers around the world are taking up the habit daily. The fact that cigarette advertising primarily targets these age groups in their promotion campaigns must have an impact on their smoking habits (see Chapter 4). This chapter explores the smoking patterns and habits ofthe youth, especially in South Africa and serves as a preamble to the empirical research. The prevalence ofsmoking is surveyed and the reasons why young people start smoking are examined. 5.2 SMOKING PREVALENCE While smoking rates are declining in developed countries, tobacco consumption is on the increase in developing countries. (Strebel, Kuhn & Yach 1989:428.) According to Martin, Steyn and Yach (1992:241), the smoking prevalence among blacks, Asians and coloureds in South Africa has increased since 1976, while smoking is on the decrease among whites. 5.3 SMOKING IN SOUTH AFRICA 5.3.1 SMOKING PATI'ERNS The prevalence of smoking in South Africa varies greatly according to population groups, sub-groups and regions. Various surveys bring the smoking patterns of the South African population into perspective: - 73 - Chapter 5 • The percentage of coloured and Asian smokers increased significantly from 1984 to 1995 (see table 5.1). The smoking rates among whites are the same for 1984 and 1995. (Reddy et al. 1995:1,5.) • The smoking rate for persons over 16 years of age (all population groups), was 31 % in 1989-90. This means that an estimated 6,85 million adults in South Africa are regular smokers. (Yach, McIntyre & Saloojee 1992a:272/273.) This figure has risen to 34%, or approximately 7 million, South African smokers in 1995. This means that one out of every three adults in South Africa is a smoker. (Reddy et al. 1995:1, 5.) Table 5.1 Smoking status among South Africans (percentage of smokers in population groups) (Reddy, Meyer-Weitz & Yach 1995:5) Group 1984 1992 1995 Coloureds 41,4 52,0 59,0 Whites 34,9 31,0 35,0 Asians 29,0 37,0 36,0 Blacks 27,7 28,0 31,0 • The overall smoking rates for males are higher than for females, and urban dwellers smoke more than rural residents. (Yach & Townshend 1988:iv.) • The 1995 figures show significant differences in the prevalence ofsmoking between Asian men (48 %) and Asian women (8%), and between black men (53%) and black women (10%). Coloured men and women smokers match each other (58% and 59 %), while the prevalence ofsmoking among white men (43%) is higher than among white women (27%). (Reddy et al. 1995:5.) • The lowest smoking rates are found among the lowest income groups and persons with low levels of education. Smoking rates show an increase with an increase in - 74- Chapter 5 income and educational levels, to a point, after which they decline. (Yach & Townshend 1988:iv.) Table 5.2 presents the pattern in percentages of smoking in South Africa, for 1989 1990, according to population group, age and education level. (Yach, McIntyre & Saloojee 1992:273.) Table 5.2 The prevalence of smoking (percentage) in South Africa by population group : 1989-1990 (Yach, McIntyre & Saloojee 1992:273) White Black Coloured Asian Total 33,7 28,4 48,7 27,6 Age (years) 16-24 30,5 23,5 39,7 19,0 25-34 41,0 37,2 60,0 30,5 35-49 40,1 32,9 56,9 35,6 >50 24,5 17,9 35,8 24,2 Educational level Completed 6 years 29,7 35,4 53,5 29,2 Completed 12 years 35,6 30,6 45,6 26,6 Completed university 20,4 21,4 20,6 n/a* % of adult population 16,7 . 71,9 8,7 2,7 (n = 22,1 million) * Insufficient numbers Table 5.2 shows that the prevalence of smoking reaches a peak in the age group 25 to 34 years, after which it drops, (except for Asians where the peak is in the age group 35 to 49 years). Another interesting feature of the prevalence of smoking, is the drastic drop after completion of university (and probably technikon) training. - 75 - Chapter 5 5.3.2 PREVALENCE OF SMOKING AMONG SOUTH AFRICAN YOUTHS Borkon et al. (1983:809) conducted a study of the smoking habits of students at the University of Witwatersrand, and found that 22 % of the students smoked regularly (23% males and 19% females), while 17% of the respondents claimed that they were ex-smokers (18% males and 14% females). Coetzee (1980:103) fmds in his study among students of the University of Pretoria, that 24% were smokers, with a prevalence of 28,9% among males and 15,1 % among females. The proportion of female smokers is lower than that ofthe University ofWitwatersrand study, while that of males is higher. Strebel et al. (1989:428) found that 23,7% of the boys and 0,8% of the girls, in a sample of673 higher primary school children in Cape Town, were daily or occasional smokers. The prevalence ofsmoking among these children was 6,3 % for boys under 12 years and increased to 45% for boys 16 years and older. 5.3.2.1 Conclusion Although the prevalence of smoking among students is lower than that of the general population, the figures are still very high. 5.4 ONSET OF SMOKING Various studies have attempted to fmd correlations between certain factors, among others, personality characteristics and starting smoking. 5.4.1 AGE OF ONSET Bartecchi et at. (1994:910) records that an estimated 80% to 90% of smokers in the United States of America, begin smoking before the age of21, and that roughly 3000 teenagers start smoking each day. Approximately 450 British teenagers start smoking each day, and 25% of school leavers aged 15 years, are already regular smokers. (Partridge 1992:2.) In the 11-16 - 76- Chapter 5 year age range, the number of smokers among girls has caught up with that of boys. However, more young adult :. fitish females arc Ifresently smoking, than young adult males. Studies show that, most adult smokers start smoking regularly before the age of 18 years.. By the age of 11 years, one-third of all children, and by 16 years two thirds of all children, have already experimented with smoking. (Royal College of Physicians 1992:41.) Klesges & Robinson (1995:85) quote studies, conducted among African American children in the United States, which revealed the following: • Almost all initiation into the use of tobacco, takes place before high school graduation (i.e. before 18 years of age). • Between 80% and 90% of all children and adolescents, have tried smoking at least once. • Between 20 % and 40 % of all adolescents become regular smokers by the age of 18 years. • A very high proportion of children or adolescents who become regular smokers . continue to be regular smokers in adulthood. The University of Witwatersrand study indicates that 19% of the regular smokers had started smoking regularly by the age of 18 years or younger, while only 0,6% had begun at the age of 23 years or older. (Borkon et al. 1983:811.) In the study among school children, the median age of onset was 14 years. (Strebel et al. 1989:428.) 5.4.1.1 Conclusion Children experiment with, and start smoking at alarmingly early ages. This is a matter of the utmost urgency, which should be addressed by parents, educators and the government. Taylor (1993:18) observes that teenagers who start smoking at the age of 15, have a 50% (1 in 2) chance to die prematurely (before the age of 75), whereas 56% (1 in - 77 - Chapter 5 1,8) ofteenagers who become heavy smokers (more than 20 cigarettes a day), will die before the age of 75. This is in contrast with only 30% (1 in 3), of people who have never smoked. 5.4.2 MOTIVATION FOR TAKING UP SMOKING In a study among school children in the United States, a strong relationship has been demonstrated between the degree of rebelliousness, rejection of adult authority, personal dissatisfaction, and desire for peer approval in a child, and the risk ofstarting smoking. (Best et al. 1995:5-59.) For many females "smoking became a symbol of emancipation and defiance" (Kaufman 1994:629). Klesges and Robinson (1995:85/86) analysed studies on the variables involved in predicting adolescent smoking, and identified seven factors that are consistently related to early smoking: • The smoking behaviour of parents, friends and siblings, especially same-sex siblings is strongly linked to experimentation and initiation of smoking. • At-risk adolescents' perceptions of other smokers, e.g. overestimates of the , prevalence of smoking among peers, is a predictor of future smoking onset, and subsequent increases in smoking. This perception is presumably linked to a desire for popularity with peers. • The perceived instrumental value of smoking, is another predictor of smoking onset. Children are inclined to ascribe various personality characteristics to smokers, (often more positive characteristics), than to people who have never smoked. Some children believe that smoking cigarettes conveys an image of maturity, independence or toughness. • Adolescents who believe that they do not receive sufficient support from their friends or parents, and/or who have lower expectations for academic and general success, are also at an increased risk for starting smoking. Some authors believe that such adolescents have a greater need to define themselves as 'tough' or 'cool', or to assert their independence from authority. - 78- Chapter 5 • Young people who enjoy taking risks, or show rebelliousness, are more likely to start smoking. Adolescence is characterised by experimentation in many areas, and smoking may be one of them. Some researchers claim that smoking can be a way of showing rejection of parental authority, or a means of defining a deviant self image. • Some studies suggest that the pharmacological or emotional effects of smoking, may be a factor in many teenagers' decision to experiment with cigarettes. The young person's first experience with smoking sometimes produces pleasant physio logical and emotional sensations. • The potential for slimming and staying slim, is reportedly an important factor, especially among girls. Adolescents generally place a high premium on appearance and, smoking to control weight, seems to influence some youths to start smoking and to continue smoking on a regular basis. 5.5 CONCLUSIONS The results of the above studies compel Klesges and Robinson (1995:85) to conclude that, if adolescents can be kept smoke free, most of them will never start using tobacco. The Royal College of Physicians (l992:vii) comments as follows on the alternative: "once children and young people start to smoke, stopping or 'quitting' becomes extremely difficult and the likelihood is that they will continue to smoke into and throughout adult life". It is apparent that educational efforts designed to drastically reduce the number of people who start smoking, should be directed at school children. This view is echoed by Flynn et al. (1995:5-45), who maintain: "Helping young people to avoid cigarette' smoking is one of the major health education goals of our day. " - 79- Chapter 5 5.6 SUMMARY • Large numbers of children and teenagers start smoking every day and a substantial proportion of them will continue smoking. Studies show that many South African youths start smoking before the age of 18 years. • While smoking rates are decreasing slightly among South African whites, substantial increases in the prevalence of smoking among Asians and coloureds are recorded. South African blacks are steadily smoking more and more. • The reasons why young people start smoking are many and complex. Perceptions of peers who smoke and rebelliousness are among the important motives. - 80- CHAPTER 6 EMPIRICAL .RESEARCH 6.1 . INTRODUCTION For the purpose of this research, a self-completion questionnaire has been applied to a sample of 2 207 students at eight technikons in South Africa. . This chapter serves to explain the planning ofthe empirical research, the course of the investigation, the methods ofanalysis of the results ofthe questionnaire, as well as the analysis of the data derived from the questionnaires and the conclusions reached. 6.2 PLANNING OF THE RESEARCH In the previous chapters the following research results gained from the literature study were highlighted: • Tobacco consumption, especially cigarette smoking, kills and cripples millions of people in the world annually. • Large numbers of non-smokers suffer and die from smoking related diseases as a result of passive smoking. • The nicotine contained in tobacco smoke· is a highly addictive substance and stopping smoking can be very difficult. • Many give up smoking but hundreds of thousands of children and teenagers begin smoking every year. - 81 - Chapter 6 • The tobacco industry is powerful and applies the most sophisticated promotion strategies to market its products. It is presently targeting the youth in its promotion campaigns through sport sponsorship and advertising in cinemas. • Many countries, especially Third World communities, are reluctant to take adequate measures to curb tobacco sales and smoking among their citizens, because of.their dependence on the tobacco industry as a source of income. The planning of the empirical research process includes the determination of the following important features: • The objectives of the empirical investigation, which could be defined as the empirical problem statement, are listed in 6.2.1. • The particular groups involved in the investigation and units of analysis to which these groups belong are defmed in 6.3.1.1. • The instrument used in the investigation and certain elements of this instrument are discussed in 6.3.2. • ' The measuring scales of the instrument are identified in 6.3.2.3. 6.2.1 EMPIRICAL PROBLEM STATEMENT With reference to technikon students in South Africa, the empirical investigation is designed to: • determine the prevalence of smoking among students • identify some of the possible influences relevant to the smoking status of students • identify, evaluate and compare some of the attitudes, beliefs, opinions and habits about smoking among students who smoke, who have never smoked or who have given up smoking. - 82 - Chapter 6 6.2.1.1 The sub-problems : J • Sub-problem 1 is to determine the differences in the smoking status of male and female students of the various population groups. • Sub-problem 2 is to determine the possible influence of the smoking habits of family members on the prevalence of smoking among technikon students. • Sub-problem 3 is to determine whether anti-smoking campaigns have had an influence on students. • Sub-problem 4 is to determine the beliefs of technikon students regarding the hazards of cigarette smoking. • Sub-problem 5 is to determine the perceptions and reactions of students to anti smoking warnings. • Sub-problem 6 is to determine the attitudes of the students regarding certain anti smoking measures, such as the banning of tobacco advertising. • Sub-problem 7 is to determine the attitudes and beliefs of smokers regarding their own smoking habits. • Sub-problem 8 is to determine certain elements of smokers' habits, for example, number of cigarettes smoked per day, etc. • Sub-problem 9 is to determine the prevalence of previous smoking among non smokers. • Sub-problem 10 is to analyse and to interpret the collected data, in order to formulate recommendations about anti-smoking measures on technikon campuses. - 83 - Chapter 6 6.2.2 HYPOTHESES The following research and null hypotheses are formulated according to the format proposed by Bless and Kathriria (1993:121-124) and Leedy (1989:60/61). (The hypotheses refer, in each case, to technikon students in South Africa.) • Null hypothesis #1 There is no difference in the smoking status of male and female students and of students from different population groups. • Research hypothesis #1 There is a difference in the smoking status of male and female students and between the various population groups. • Null hypothesis #2 The smoking status of family members is independent of the smoking status of respondents. • Research hypothesis #2 There is a relationship between the smoking status of family members and that of the students. • Null hypothesis #3 There is no difference in the proportions of smokers, ex-smokers and non-smokers, on whom anti-smoking campaigns have had a negative influence on attitudes to smoking. - 84- Chapter 6 • Research hypothesis #3 There is a difference in the proportions of smokers, ex-smokers and non-smokers who have been influenced by anti-smoking campaigns to a negative attitude on smoking. • Null hypothesis #4 There is no difference in the proportions of smokers, ex-smokers and non-smokers, who believe that smoking is harmful to smokers' health. • Research hypothesis #4 There is a difference in the proportions of smokers, ex-smokers and non-smokers, who believe that smoking is harmful to smokers' health. • Null hypothesis #5 There is no difference in the proportions of smokers, ex-smokers and non-smokers, who believe that environmental smoke is harmful to non-smokers' health. • Research hypothesis #5 There is a difference in the proportions of smokers, ex-smokers and non-smokers, who believe that environmental smoke is harmful to non-smokers' health. • Null hypothesis #6 There is no difference in the proportions ofsmokers, ex-smokers and non-smokers, who report that they have been negatively influenced by anti-smoking warnings. • Research hypothesis #6 There is a difference in the proportions of smokers, ex-smokers and non-smokers, who report that they have been negatively influenced by anti-smoking warnings. - 85 - Chapter 6 • Null hypothesis #7 There is no difference in the proportions ofsmokers, ex-smokers and non-smokers, who support stricter anti-smoking measures. • Research hypothesis #7 There is a difference in the proportions ofsmokers, ex-smokers and non-smokers, who support stricter anti-smoking measures. 6.3 . UNITS OF ANALYSIS The specific units of analysis, relative to this research project, are represented by different groups of students which are defmed in 6.3.1.1. The empirical investigation poses as its subject the expected importance of the smoking rates among technikon students as a basis for proposed anti-smoking measures on technikon campuses in South Africa. 6.3.1 THE RESEARCH GROUPS The three distinct research groups involved in this investigation are smokers, non smokers and ex-smokers among full-time first, second and third year technikon students in South Africa. 6.3.1.1 Definition of the research groups • A smoker is defmed as a person who has been smoking at least one cigarette per day for the past three months. • A non-smoker is a person who has never smoked cigarettes on a regular basis. • An ex-smoker is a person who has been smoking at least one cigarette per day for at least three months, has given up smoking, and has not smoked a cigarette for the past three months. - 86 - Chapter 6 6.3.2 THE MEASURING INSTRUMENT The empirical research is conducted with .the aid of a questionnaire as measuring instrument. Leedy (1989:142) defends the use of the questionnaire as follows: "A common-place instrument for observing data beyond the physical reach ofthe observer is the questionnaire. " The covering letter and the questionnaire are included as Annexure A (English) and Annexure B (Afrikaans) of this dissertation, and certain important elements of the letter and the questionnaire are discussed in the following paragraphs. 6.3.2.1 The covering letter The covering letter was addressed to specific lecturing staff at eight technikons in South Africa. These staff members were requested to act as research assistants, and had been selected mainly owing to their involvement in lecturing and/or research activities in the field of environmental health at the various education institutions. The letter specified the aims and objectives of the research project, the method of sampling to be followed and prescriptions regarding the size of the sample. Each covering letter was signed by the researcher. 6.3.2.2 The questionnaire The questionnaire consists of four parts and is completed anonymously: • Questions I to 8 require biographical details of all respondents. • Questions 9 to 35 are completed by all respondents and are designed to: • test respondents' beliefs regarding the potential dangers of smoking • gain information about the smoking habits of certain family members of respondents - 87 - Chapter 6 • collect details about the attendance of anti-smoking campaigns by respondents and the influence of these campaigns • gauge the impact of anti-smoking advertisements • test respondents' attitudes regarding banning of advertisements, taxation .of cigarettes and prohibiting smoking in places where food is served and on public transport • test respondents' attitudes to the smoking of cigarettes in their presence. • Questions 36 to 45 are directed to smokers only, to gain information about their smoking habits and their efforts to give up smoking. • Questions 46 to 48 are completed by non-smokers and ex-smokers and complement the replies from questions 9 to 35. 6.3.2.3 The measuring scale Respondents are requested to reply to items in the questionnaire by recording a 'yes', 'no' or 'don't know' to most questions. A number of questions are open-ended and require respondents to reply with figures or short sentences. 6.3.3 BACKGROUND DATA AND SAMPLING The background data of the research project, the size of the sample, the population and the sampling procedure are discussed in the ensuing paragraphs. 6.3.3.1 Population of the research project The questionnaire was designed to investigate the habits, beliefs and attitudes regarding cigarette smoking among technikon students in South Africa. The investiga tion was conducted during the second semester of 1995 and the population of the research, therefore, consisted of full-time students enrolled for the second semester of 1995 at eight technikons in South Africa. - 88 - Chapter 6 6.3.3.2 The sampling procedure :' .~ Samples ofgroups of students were drawn by means of cluster sampling at each ofthe eight technikons taking part in the study. Sanders (1990:222) defines a cluster sample as "one in which the individual units are groups or clusters ofsingle items. It's always assumed that the individual items within each cluster are representative of the population". Steyn et al. (1994:32) reason that "If ... a relatively representative sample has to be drawn within a short time without incurring high costs, a cluster sample would be the answer." The research assistants drew random samples of clusters of students." A cluster of students was represented by students in a particular programme and year of study, for example, Marketing I, etc. The aim was to draw approximately 100 first, 100 second and 100 third year students from each of the respective technikons. A sufficient number of questionnaires were duplicated and presented for completion by the students in their classrooms. The main reasons for applying cluster sampling in this research are: • The large population of students at the technikons warrants the use of a sample. • Cluster sampling ensures that the random sample is representative of the various programmes offered at the technikons. Some programmes may have more female than male enrolments, while some may have larger proportions of certain population groups, than others. • The sampling procedure and application ofthe questionnaire to the students in their lecture rooms ensure a larger proportion of respondents than a questionnaire distributed among individual students. • Cluster sampling is a relatively inexpensive procedure. - 89 - Chapter 6 6.3.3.3 Sample size The details about the number ofsecond semester enrolments at the technikons had not been available during the plamiing phase of the empirical research. This information became available only after late registration had been completed and the data processing departments were preparing their statistical reports. It was decided, therefore, to request samples of 100 students each from the full-time, 1st, 2nd and 3rd year enrolments from each technikon, to ensure a sample of adequate size. The sample of 2 207 respondents represented 4,6 % (p = x/n) of roughly 47 700 technikon students. In order to ensure a risk of not more than 5 % that estimated percentages will not differ by more than 2 % from the correct values, a sample of approximately 2 400 respondents would have sufficed. (Steyn et al. 1994:397.) The sample size of this study is thus slightly less than the figure required to ensure a deviation of not more than 2 % from correct values. 6.3.4 THE PILOT STUDIES In order to ensure the validity of the measuring instrument (questionnaire), two pilot studies were performed. The first pilot study took place during April 1995 when the questionnaire was tested with a group of technikon students. Afterwards the questionnaire was discussed with these students who made contributions regarding the clarity of certain questions and the inclusion of others. The revised questionnaire was discussed with Dr Yach (Medical Research Council), Dr Saloojee (Council Against Smoking), Dr Sitas (SA Institute of Medical Research) and Dr Schoeman (the study leader of this project). Their inputs were considered and the questionnaire was revised accordingly. The second pilot study was conducted during May 1995 with a different group of students, before the questionnaire was fmalised. The respondents from the two pilot studies were excluded from the sample ofstudents drawn for the main study. - 90 - Chapter 6 6.4 ESSENTIAL QUALITIES OF RESEARCH The validity of the research project and the qualities of the measuring instrument are discussed in the paragraphs that follow. 6.4.1 VALIDITY OF THE RESEARCH PROJECT Mouton and Marais (1988:7) define research in the social sciences as a communal human activity by which a specific phenomenon is studied in the real world, by means of an objective method, in order to gain a valid understanding of that phenomenon. Nachmias and Nachmias (1976:59-64) argue that validity is concerned with the question, "Is one measuring what one thinks one is measuring?" They suggest that three basic types ofvalidity concerning research projects can be distinguished, namely, content validity, empirical validity and construct validity. 6.4.1.1 Content validity The two common kinds of content validity are face validity and sampling validity. •' Face validity refers to the investigator's subjective evaluation as to the validity of a measuring instrument (Nachmias & Nachmias 1976:59/60). The face validity of the questionnaire in this research was tested during the pilot study phase, when specialists in the field were consulted about the validity of the specific questions in the questionnaire (see 6.3.4). • Sampling validity is concerned with the question ofwhether a given population of situations or behaviour is adequately sampled by the measuring instrument (Nachmias & Nachmias 1976:60). The sampling validity of the questionnaire was tested against the opinion ofthe specialists mentioned in 6.3.4 and their suggestions for improvement were accepted. - 91 - Chapter 6 6.4.1.2 Empirical validity Empirical validity refers to the relations between the measuring instrument and the measurement results. Ifthe measuring instrument is valid, certain empirical relations between the results obtained by the instrument and other properties or variables will exist. (Nachmias & Nachmias 1976:60/61.) For the purposes of this research, the predictive validity of the measuring instrument is proved by the consistency in the replies to various items in the questionnaire, and by an agreement with the results from other researchers' studies. 6.4.1.3 Construct validity Nachmias and Nachmias (1976:62) believe that construct validity "involves relating a measuring instrument to an overall theoretical framework in order to determine whether the instrument is tied to the concepts and theoretical assumptions that are employed". The questionnaire compiled for this research was developed within the broad theoretical framework concerning beliefs, attitudes and opinions, as embodied in appropriate literature concerning these constructs and is, therefore, regarded as complying with the requirements of construct validity. 6.4.2 REliABILITYOF THE MEASURING INSTRUMENT Reliability can be defmed as "an indication of the extent to which a measure contains variable errors; that is, errors that differed from individual ... to individual during any one measuring instance, and that varied from time to time for a given individual measured twice by the same instrument" (Nachmias & Nachmias 1976:64/65). / Howard and Sharp (1983: 114) note that statistical models describe reality imperfectly at best and that testing of the reliability of a measuring instrument is crucial to the results of a research project. Mouton and Marais (1990:79/80) reason that the reliability of data or observations obtained by means ofa measuring instrument is dependent on four variables, namely, the researcher(s), the subject(s) of the research, the measuring instrument and the research context. - 92- Chapter 6 • Researcher effects With the use ofa questionnaire, the researcher remains relatively anonymous to the respondents, and researcher affiliation and researcher image do not playa role in the project. • Respondent effects A particular measuring process may distort the experimental results under the following conditions (Selltiz et al. 1959 quoted by Mouton & Marais 1988:86). • If respondents feel that they are being experimented with or tested, they may want to make a good impression. • If the method of data collection stimulates an interest the subject did not previously entertain. In this research it is possible that the 'syndrome of omniscience' and 'subject motivation' (Mouton & Marais 1988:87/88) may influence some respondents to react positively to questions on their beliefs regarding disease causation by cigarette smoking (items 18 to 24 of the questionnaire). • Effects of the measuring instrument The following possible effects on the research results, contributed by the questionnaire, deserve discussion: • 'Closed question' effects may play a role m distorting the results of the questionnaire through the absence of scaled replies. It is possible, however, that the topic itself (cigarette smoking) elicits such strong pro and anti-feelings, that scaled replies are not necessary. • 'Don't know' effects are catered for by allowing this as a reply to most questions. - 93 - Chapter6 • 'Middle position' effects are avoided by not using a scale of measurements. • 'Length-of-questionnaire' effects are addressed by keeping the questionnaire as short as possible. • 'Item sensitivity' effects are avoided by keeping questions short and to the .point. • 'Leading-question' effects are avoided by not suggesting 'desirable' answers in the items. • 'Fictitious attitude' effects are avoided by the anonymity of the respondents. • Context effects There are no discemable context effects which could have a bearing on respondents' replies. 6.4.2.1 Sensitivity of the measuring instrument In order to keep the questionnaire simple and brief, a scale of measurements is not applied. This renders the questionnaire less sensitive for degrees of strength of attitudes, and is regarded as a weakness of the measuring instrument. 6.4.2.2 Appropriateness of the measuring instrument No discernible threat exists in respect of the appropriateness of the measuring instrument. The respondents are all students at technikons and are in possession of matric or standard 10 certificates. The language used in the various items of the questionnaire is at a simple and understandable level. The latter measure was necessary to accommodate the English second language respondents. - 94- Chapter 6 6.4.2.3 Practicability of the measuringinstrument / i ·1· . " The questionnaire could be completed at any time during the second semester of 1995 and no serious problems were encountered in this regard. 6.4.2.4 Ethical acceptability of the measuring instrument The aims of the research project are explained in the covering letter (see Annexures A and B), and are clearly discernible from the various items in the questionnaire, in order to render the measuring instrument ethically acceptable. 6.5 THE EMPIRICAL RESEARCH The questionnaire was compiled and tested during the first semester, and the empirical research conducted during the second semester of 1995. One staff member at each of eight technikons was requested to act as a research assistant. 6.5.1 COURSE OF THE RESEARCH After completion of the pilot study and revision of the questionnaire, Afrikaans and English copies were posted with the covering letter to the research assistants at the technikons. No due date for the return of the completed questionnaires was stated but research assistants were requested to have the questionnaires completed during the early part of the semester. 6.5.1.1 Distribution and return of the questionnaire The research assistant obtained the student numbers in the different programmes for the second semester from the administration of his particular technikon. He made sufficient photocopies ofthe questionnaire and drew random samples ofclusters of 1st, 2nd and 3rd year students. Various study programmes at the technikons were represented by the different clusters. The completed questionnaires were posted to the researcher. - 95 - Chapter 6 6.5.1.2 Specific problems encountered during the investigation A few problems were encountered during the course of the research and some impacted seriously upon the results of the project. • A batch of completed questionnaires from a technikon got lost in the post and the research assistant had to repeat the process of applying the questionnaire. By that time, some ofthe clusters ofstudents selected were preparing for examinations and could not be found. 6.5.1.3 The response rate The response rate is determined by the number of students present in the class when the questionnaire was submitted. No reports were received from the research assistants of students who refused to complete the questionnaire. The response rate was, therefore, close to 100%. The high response rate was made possible through the use of the cluster sampling method, which allowed the research assistants to apply the questionnaire in the class rooms with all students present (except the absentees of the particular day). 6.5.2 DATA PROCESSING The completed questionnaires were coded and the items entered into the micro computer programmes QUATfRO 5.0 and STATGRAPHICS 3.01. The following statistical calculations were performed: • Totals and percentages of responses to the various items in the questionnaire were calculated. • Chi-square analyses were applied. The Chi-square analysis is used to determine whether significant differences exist between the percentages of various sets of data. (Milton & Tsokos 1983:199.) - 96- Chapter 6 6.6 EMPIRICAL RESULTS 6.6.1 PROFILE OF THE RESPONDENTS A total of 2 207 students from eight technikons in South Africa completed the questionnaire. The sample consists of 1 392 males and 805 females while 10 students did not state their gender. The students represent 36 different study programmes and 953 are in their 1st, 752 in their 2nd and 502 in their 3rd year of study. Altogether 30 different languages are represented among the respondents, of whom a total of 2 168 speak the eleven official South African languages, 2 represent two languages from other African countries and twenty-seven are speakers of other European and Eastern languages. Ten respondents did not give their home language. The students represent the four population groups in South Africa as follows: black 1274, white 641, Asian 172 and Coloured 60. Sixty respondents did not give their population groups. The average age of the respondents is 21 years, the oldest student being 48 and the youngest 17 years old. 6.6.2 POPULATION GROUP, GENDER AND SMOKING STATUS A total of 394 respondents are regular smokers, which translates into an average of 17,9% of the students at the eight technikons. aniy 96 of the respondents (4,3 %), declare themselves to be ex-smokers, while the remaining I 717 are non-smokers (77,8%), (see Table 6.1). Of the total of 1 532 non-smokers responding to the question whether they have ever smoked a cigarette, 454 (29,6%) answered affinna tively. - 97 - Chapter 6 6.6.2.1 Conclusions The prevalence of smoking among black and white males is virtually the same (21,8 % and 22,2%). These proportions correspond with the results obtained from the University of Witwatersrand study (see 5.3.2). A higher proportion of coloured and Asians males, than black and white males, are smokers. The smoking prevalence of these two groups is very close (28,6 % and 30,9%). The prevalence of smoking among white and coloured females (18,4% and 16,0%) is greater than among black and Asian females (3,6% and 2,0%). The smoking rate for white females is close to that found by the University of Witwatersrand study (see 5.3.2). The prevalence of smoking among white and black males and white and coloured females corresponds closely with that found among college graduates in the United States (22,6% and 17,1 %). (US Department ofHealth and Human Services 1988:571.) Smoking is least prevalent among black and Asian females (3,6% and 2,0%). These rates are confirmed by Reddyet at. (see 5.3.1). 6.6.3 INFLUENCE OF FAMILYMEMBERS' SMOKING STATUS One of the objectives of this study, is to assess the influence of the smoking status of certain family members on the smoking status ofthe respondents. An analysis, there fore, is made of the different permutations of fathers, mothers and older siblings who smoke or are non-smokers. The large difference in the prevalence of smoking among the females in the different population groups is a confounding factor. Furthermore, the small number of coloured and Asian females in the sample disallow a meaningful analysis. Those respondents who did not give their gender and/or population group are excluded from this analysis. The data for black and white respondents are, therefore, analysed - 98 - Chapter 6 Table 6.1 Distribution of respondents according to population group and gender SMOKERS M % F % Unknown % Total % Black 166 21,8 18 3,6 2 28,6 186 14,6 White 96 22,2 38 18,4 0 0,0 134 20,9 Asian 38 30,9 1 2,0 0 0,0 39 22,7 Coloured 10 28,6 4 16,0 0 0,0 14 23,3 Unknown 9 23,7 11 55,0 1 50,0 21 35,0 Totals 319 22,9 72 8,9 3 30,0 394 17,9 NON- SMOKERS Black 554 72,6 484 96,0 5 71,4 1043 81,9 White 312 72,1 157 75,8 1 100,0 470 73,3 Asian 81 65,9 48 98,0 0 0,0 129 75,0 Coloured 23 65,7 20 80,0 0 0,0 43 71,7 Unknown 23 60,5 8 40,0 1 50,0 32 53,3 Totals 993 71,3 717 89,1 7 70,0 1717 77,8 EX- SMOKERS Black 43 5,6 2 0,4 0 0,0 45 3,5 White 25 5,8 12 5,8 0 0,0 37 5,8 Asian 4 3,3 0 0,0 0 0,0 4 2,3 Coloured 2 5,7 1 4,0 0 0,0 3 5,0 Unknown 6 15,8 1 5,0 0 0,0 7 11,7 Totals 80 5,7 16 2,0 0 0,0 96 4,3 GRAND TOTALS Black 763 54,8 504 62,6 7 70,0 1274 57,7 White 433 31,1 207 25,7 1 10,0 641 29,0 Asian 123 8,8 49 6,1 0 0,0 172 7,8 Coloured 35 2,5 25 3,1 0 0,0 60 2,7 Unknown 38 2,7 20 2,5 2 20,0 60 2,7 Totals 1392 100,0 805 100,0 10 100,0 2207 100,0 - 99 - Chapter 6 separately (see Tables 6.2 to 6.7). The significance of some of the statistics IS determined in 6.6.17 where the hypotheses are tested. 6.6.3.1 Discussion Some important differences in proportions regarding the smoking status of family members, as shown in Tables 6.2 to 6.7, are highlighted in the ensuing paragraphs . • The smoking status of family members of black male smokers, ex-smokers and non-smokers: • A total of 69,9% of smokers report at least one older family member who smokes, compared to 62,8 % of ex-smokers and 58,3 % of non-smokers. • A total of 24,1% of smokers report a father and older sibling(s) who smoke, compared with 18,6% of ex-smokers and 12,8% of non-smokers. • The smoking status ofolder family members ofblack female smokers, ex-smokers and non-smokers: • A total of 83,3 % of smokers come from homes where at least one older family member smokes, compared with 53,9% of non-smokers. • A total of 44,5 % of smokers report their fathers as smokers, compared with 32,0% of non-smokers. • A total of 44,4% of smokers report older siblings as smokers, compared with 33,5 of non-smokers. • The smoking status of family members of white male smokers, ex-smokers and non-smokers: • A total of 89,6 % of smokers have at least one family member who smokes, compared with 84% of ex-smokers and 66,7% of non-smokers. - 100 - Chapter 6 .1 Table 6.':: ( Influence of family members on smoking status BLACK SMOKERS n = 184 Family memberls who smoke Male Female Total No % No % Father, mother and older sibling(s) 1 0,6 0 0,0 1 Father and mother 3 1,8 1 5,6 4 Father only 39 23,5 6 33,3 45 Mother only 0 0,0 0 0,0 0 Father and older sibling(s) 40 24,1 1 5,6 41 Older sibling(s) 32 19,3 6 33,3 38 Mother and older sibling(s) 1 0,6 1 5,6 2 Total families with smokers 116 69,9 15 83,3 131 Families with no smokers 50 30,1 3 16,7 53 Grand total 166 18 184 • A total of 75% of smokers report a father who smokes, compared with 72% of ex-smokers and 56,4% of non-smokers. • A total of 28% of ex-smokers report a father, mother and siblings who are all smokers, compared to 12,5 %smokers and 8,7% non-smokers. This statistic is not easy to explain. • A total of22,9 % ofsmokers have a father and one or more siblings who smoke, compared to 8,0% of ex-smokers and 9,9% of non-smokers. • The smoking status of older family members of white female smokers and non smokers: - 101 - Chapter 6 Table 6.3 Influence of family members on smoking status BLACK EX-SMOKERS n = 45 Family memberls who smoke Male Female Total No % No % Father, mother and older sibling(s) I 2,3 0,0 I Father and mother 0,0 ° 0,0 Father only °5 11,6 ° 0,0 °5 Mother only 0,0 ° 0,0 Father and older sibling(s) °8 18,6 ° 0,0 °8 Older sibling(s) 12 27,9 °1 50,0 13 Mother and older sibling(s) 1 2,3 ° 0,0 1 Total families with smokers 27 62,8 I 50,0 28 Families with no smokers 16 37,2 1 50,0 17 Grand total 43 2 45 • A significantly high proportion of smokers (94,7 %) have at least one older family member who smokes, compared to 69,4% of non-smokers. • A significantly higher proportion of smokers (44,7%) have a mother who smokes, compared to non-smokers (26,0%). 6.6.3.2 Conclusions It is evident from the data that individuals growing up in homes where certain of the family members smoke are more likely to become smokers themselves, than those living in a smoke-free home. A total of 311 smokers (78,9%), 71 ex-smokers (74,0%) and 1.051 non-smokers (61,5%) come from homes where at least one older family member smokes. This means that smoking occurs in a total of I 433 families (65,0%). - 102 - Chapter 6 It is especially the presence of a father and one or more older siblings who smoke that seems to be associated with the smoking status of smokers. While mothers who smoke do not playa significant role in the case of black smokers, it is particularly white female smokers who live in homes where the mother smokes. These conclu sions are in agreement with those submitted by Klesges and Robinson (1995) (see 5.4.2). Table 6.4 Influence of family members on smoking status BLACK NON-SMOKERS n = 1038 Family member/s who smoke Male Female Total No % No % Father, mother and older sibling(s) 10 1,8 1 0,2 11 Father and mother 4 0,7 4 0,8 8 Father only 122 22,0 93 19,2 215 Mother only 3 0,5 2 0,4 5 Father and older sibling(s) 71 12,8 57 11,8 128 Older sibling(s) 112 20,2 101 20,9 213 Mother and older sibling(s) 1 0,2 3 0,6 4 Total families with smokers 323 58,3 261 53,9 584 Families with no smokers 231 41,7 223 46,1 454 Grand total 554 484 1038 - 103 - Chapter6 Table 6.5 Influence of family members on smoking status WIllTE SMOKERS n = 134 Family memberls who smoke Male Female Total No % No % Father, mother and older sibling(s) 12 12,5 5 13,2 , 17 Father and mother 14 14,6 7 18,4 21 Father only 24 25,0 5 13,2 29 Mother only 6 6,3 4 10,5 10 Father and older sibling(s) 22 22,9 9 23,7 31 Older sibling(s) 8 8,3 5 13;2 13 Mother and older sibling(s) 0 0,0 1 2,6 1 Total families with smokers 86 89,6 36 94,7 122 Families with no smokers 10 10,4 2 5,3 12 Grand total 96 38 134 Table 6.6 Influence of family members on smoking status WIllTE EX-SMOKERS n = 37 Family memberls who smoke Male Female Total No % No % Father, mother and older sibling(s) 7 28,0 2 16,7 9 Father and mother 5 20,0 0 0,0 5 Father only 4 16,0 4 33,3 8 Mother only ·1 4,0 0 0,0 J Father and older sibling(s) 2 8,0 4 33,3 6 Older sibling(s) 2 8,0 0 0,0 2 Mother and older sibling(s) 0 0,0 0 0,0 0 Total families with smokers 21 84,0 10 83,3 31 Families with no smokers 4 16,0 2 16,7 6 Grand total 25 12 37 - 104- Chapter 6 Table 6.7 Influence of family members on smoking status WlllTE NON-SMOKERS n = 469 Family member/s who smoke Male Female Total No % No % Father, mother and older sibling(s) 27 8,7 12 7,6 39 Father and mother 49 15,7 17 10,8 66 Father only 69 22,1 41 26,1 110 Mother only 11 3,5 6 3,8 17 Father and older sibling(s) 31 9,9 17 10,8 48 Older sibling(s) 16 5,1 10 6,4 26 Mother and older sibling(s) 5 1,6 6 3,8 11 Total families with smokers 208 66,7 109 69,4 317 Families with no smokers 104 33,3 48 30,6 152 Grand total 312 157 469 6.6.4 SMOKING STATUS OF PARTNERS • , Tables 6.8 and 6.9 account for details of the smoking status of smokers and 000 and ex-smokers and their partners (girl/boy friends or husbands/wives). For the purposes of this analysis, ex-smokers are included with non-smokers. The small numbers of coloured and Asian respondents preclude analysis of their data. • Only a small proportion of black male smokers (3,1 %) have partners who smoke. This is, however, not significant as the prevalence of smoking among black females is low. Very much the same proportions of black male non smokers and ex-smokers (2,5 %) have partners who smoke. • 66,7% of the black female smokers have partners who smoke. This is significantly higher than the 22,4 %black female non-smokers who have partners who smoke. - 105 - Chapter 6 Table 6.8 Smokers and partners n = 372 Partners smoke Partners don't smoke Population F' group M % F % M % % Black 5 3,1 12 66,7 155 96,9 6 33,3 White 30 33,7 23 62,2 59 66,3 14 :n,8 Asian 1 2,9 0 0,0 34 97,1 1 100,0 Coloured 2 22,2 2 50,0 7 17,8 2 50,0 Unknown 2 22,2 7 70,0 7 17,8 3 30,0 Total 40 44 262 26 Table 6.9 Ex-smokers plus non-smokers and partners n = 1733 Partners smoke Partners don't smoke Population group M % F % M % F % Black 14 2,5 105 22.4 552 97,5 364 17,6 , White 18 5.5 42 25,6 308 94.5 122 74.4 Asian 2 2.5 10 21,3 79 97,5 37 78,7 Coloured 2 8,3 24 20,0 22 91,7 16 80,0 Unknown 2 7,4 1 11,1 25 92,6 8 88,9 Total 38 162 986 547 • A significantly greater proportion of white male smokers (66,3 %) have non smoking partners than smokers with smoking partners (33,7 %). • A significantly greater proportion of black male non-smokers (97,5 %) have non-smoking partners. It must be borne in mind, however, that not many black females smoke. - 106 - Chapter 6 • A significantly high proportion of black female non-smokers (77,6 %) have non-smoking partners, compared to 33,3 % of smokers with non-smoking part ners. • Only 5,5% of white male non-smokers have smoking partners, compared to 33,7% of male smokers with smoking partners. • A significantly high proportion of white male smokers (66,3 %) have non smokers as partners, compared to the 94,5 % of non-smokers with non-smoking partners. • A significantly high proportion ofwhite female smokers (62,2 %) have smokers as partners, compared to the 25,6% of non-smokers with smoking partners. • A very high proportion ofwhite male non-smokers (94,5 %) have non-smoking partners. • A significantly high proportion of white female non-smokers (74,4%) have non-smoking partners. 6.6.4.1 Conclusions Male smokers and non-smokers, as well as female non-smokers seem to prefer non smoking partners, while female smokers are more likely to have smokers as partners. 6.6.5 INFLUENCE OF ANTI-SMOKING CAMPAIGNS Tables 6.10 to 6.13 contain details about a total of431 smokers, ex-smokers and non smokers who have been exposed to anti-smoking campaigns or lectures at school or elsewhere. This means that only 19,5 %ofthe respondents have been exposed to these campaigns/lectures. Although the data for Asians and coloured smokers are included in the tables, the numbers are too small for meaningful analyses. The numbers of ex smokers (Table 6.11) are also too small for a meaningful analysis. - 107 - Table 6.10 Smokers who have been exposed to anti-smoking campaigns Population Number who attended Total number of Number negatively influenced group anti-smoking campaigns respondents towards smoking M % F % M F M % F % Black 25 15,1 2 11,1 166 18 9 36,0 0 0 White 30 31,3 13 34,2 96 38 9 30,0 0 0 Asian 9 23,7 0 0,0 38 I 1 11,1 0 0 Coloured 4 40,0 0 0,0 10 4 3 75,0 0 0 .... Unknown 0 0,0 0 0,0 9 11 0 0,0 0 0 Totals 68 21,3 15 20,8 319 72 22 32,4 0 0 Table 6.11 Ex-Smokers who have been exposed to anti-smoking campaigns '."\ Population Number who attended Total number of Number negatively influenced group anti-smoking campaigns respondents towards smoking M % F % M F M % F % Black 8 18,6 1 50,0 43 2 6 75,0 1 100,0 White 5 20,0 3 25,0 25 12 2 40,0 2 66,7 Asian 1 25,0 0 0,0 4 0 0 0,0 0 0,0 Coloured 1 50,0 1 100,0 2 1 1 100,0 1 100,0 Unknown 1 16,7 0 0,0 6 1 0 0,0 0 0 Totals 16 20,0 5 31,3 80 16 9 56,3 4 80,0 Table 6.12 Non-Smokers who have been exposed to anti-smoking campaigns Population Number who attended Total number of Number negatively influenced group anti-smoking campaigns respondents towards smoking M % F % M F M % F % Black 83 15,0 79 16,3 554 484 52 62,7 51 64,6 White 68 21,8 36 22,9 312 157 30 44,1 14 38,9 Asian 22 27,2 19 39,6 81 48 14 63,6 8 42,1 Coloured 4 17,4 4 20,0 23 20 1 25,0 1 25,0 Unknown 9 39,1 3 37,S 23 8 2 22,2 1 33,3 Totals 186 18,7 141 19,7 993 717 99 53,2 75 53,2 Table 6.13 Grand total of respondents who have been exposed to anti-smoking campaigns Population Number who attended Total number of Number negatively influenced group anti-smoking campaigns respondents towards smoking ·M % F % M F M % F % Black 116 15,2 82 16,3 763 504 67 57,8 52 63,4 White 103 23,8 52 25,1 433 207 41 39,8 16 30,8 Asian 32 26,0 19 38,8 123 49 15 46,9 8 42,1 Coloured 9 25,7 5 20,0 35 25 5 55,6 2 40,0 Unknown 10 26,3 3 15,0 38 20 2 20,0 1 33,3 Totals 270 19,4 161 20,0 1392 80S 130 48,1 79 49,1 Chapter 6 6.6.5.1 Discussion • The most significant statistic in this data is the proportion of white smokers (male, 31,3 % and female, 34,2 %) (see table 6.10) who have attended anti-smoking campaigns/lectures, which is considerably higher than that of any of the other categories of respondents. • Generally, a smaller proportion of smokers than non-smokers report that they have been influenced against smoking by anti-smoking campaigns/lectures than non smokers (see Tables 6.10 and 6.12). • Large proportions of black male, black female and Asian male non-smokers report that they have been influenced against smoking by these campaigns/lectures (62,7%,64,6% and 63,6%) (see Table 6.12). • A total of 48,5 % of all the respondents (smokers, ex-smokers and non-smokers) who have attended anti-smoking campaigns/lectures, report that they were influenced against smoking by them. 6.6.5.2 Conclusions From the collected data it is apparent that anti-smoking campaigns and lectures have had a reasonable impact on the respondents' attitudes towards smoking. It is to be expected that fewer smokers than non-smokers will report being influenced by anti smoking campaigns/lectures. However, a surprisingly large proportion of the male smokers in the different population groups (one third and more) report that the campaigns/lectures have influenced them negatively towards smoking. 6.6.6 BEliEFS ABOUT THE HEALTH HAZARDS OF SMOKING The respondents were tested on their beliefs regarding the hazards of smoking. Table 6.14 shows the numbers and percentages of smokers, ex-smokers and non-smokers who believe that smoking is detrimental to smokers' health. Table 6.15 gives the details of respondents' beliefs about smoking-related diseases and conditions. - UO - Chapter 6 Table 6.14 Respondents who believe smoking is harmful to smokers' health M % F % Total % Smokers 272 85,3 69 95,8. 341 87,2 Ex-smokers 72 90,0 15 93,8 87 90,6 Non-smokers 913 91,9 684 95,4 1597 93,4 Totals 1257 90,3 768 95,4 2025 92,2 6.6.6.1 .: Discussion The awareness that smoking is harmful to health and can cause various diseases and conditions is high among smokers, ex-smokers and non-smokers. In every category ofTables 6.14 and 6.15, the percentage of male smokers who have answered affrrmatively is lower than that of all the other groups. It is possible that cigarette smoking represents a status symbol to many male smokers - more so than to female smokers. These smokers probably find it difficult to admit or accept that smoking could be harmful to their health. Fewer respondents believe that smoking can cause heart disease, compared to the other diseases and conditions. Higher proportions of respondents believe that smoking can cause cancer and harm unborn babies, compared with the other diseases and conditions. 6.6.6.2 Conclusions Respondents are generally aware of the health hazards of smoking. Fewer male smokers than ex-smokers and non-smokers believe that smoking is harmful to health, but even here the proportion of affrrmative replies is high (85,3 %). The awareness of the dangers of smoking, is generally very high among female respondents. - 111 - Chapter 6 Table 6.15 Respondent's belief about smoking and disease I Causes heart disease I M % F % T % Smokers 225 70,5 63 87,5 288 73,1 Ex-smokers 57 71,3 13 81,3 70 72,9 Non-smokers 756 76,1 575 80,2 1331 77,S Totals 1038 74,6 651 80,9 1689 76,5 Causes lung disease M % F % T % Smokers 240 75,2 57 79,2 297 76,4 Ex-smokers 69 86,3 15 93,8 84 87,5 Non-smokers 874 88,0 664 92,6 1538. 89,6 Total 1183 85,0 736 91,4 1919 87,0 Causes cancer M % F % T % Smokers 270 84,6 67 93,1 337 85.5 Ex-smokers 71 88,8 15 93,8 86 89,6 Non-smokers 908 91,4 675 94,1 1583 92,2 Total 1249 89,7 757 94,0 2006 90,9 Shortens life M % F % T % Smokers 226 70,8 60 83,3 286 72,6 Ex-smokers 64 80,0 12 75,0 76 79,2 Non-smokers 868 87,4 641 89,4 1509 87,9 Total 1158 83,2 713 88,6 1871 84,8 Harms physical performance M % F % T % Smokers 213 66,8 4~ 68,1 262 66,5 Ex-smokers 65 81,3 14 87,S 79 82,5 Non-smokers 837 84,3 580 80,9 1417 82,5 Total 1115 80,1 643 79,9 1758 79,7 Harms unborn babies M % F % T % Smokers 266 83,4 69 95,8 335 85,0 Ex-smokers 68 85,0 15 93,8 83 86,5 Non-smokers 843 84,9 658 91,8 1501 87,4 Total 1177 84,6 742 92,2 1919 87,0 - 112 - Chapter 6 6.6.7 BEUEFSANDATTlTUDESABOUTENVIRONMENTALSMOKE Respondents have been tested on their beliefs and attitudes towards environmental smoke (passive smoking). Tables 6.16 to 6.20 show the results of the questions pertaining to this aspect of smoking. Table 6.16 Respondents who believe that smokers should not be allowed to smoke where and when they wish M % F % Total % Smokers 173 54,2 38 52,8 211 53,6 Ex-smokers 61 76,3 12 75,0 73 76,0 Non-smokers 844 85,0 607 84,7 1451 84,5 Totals 1078 77,4 657 81,6 1735 78,6 Table 6.17 Respondents who believe that smoking is harmful to non-smokers M % F % Total % Smokers 246 77,1 64 88,9 310 78,7 Ex-smokers 73 91,3 13 81,3 86 89,6 Non-smokers 923 93,0 686 95,7 1609 93,7 Totals 1242 89,2 763 94,8 2005 90,8 - 113 - Chapter 6 Table 6.18. I Respondents who r ;,J that smoking .: their rooms bothers them M % F % Total % Smokers 79 24,8 18 25,0 97 24,6 Ex-smokers 46 57,5 10 62,5 56 58,3 , Non-smokers 821 82,7 622 86,8 1443 84,0 Totals 946 68,0 650 80,7 1596 72,3 Table 6.19 Respondents who will request a smoker not to smoke in their presence on public transport M % F % Total % Smokers 122 38,2 23 31,9 145 36,8 Ex-smokers 41 51,3 10 62,5 51 53,1 Non-smokers 567 57,1 405 56,5 972 56,6 Totals 730 52,4 438 54,4 1168 52,9 Table 6.20 Smokers who smoke in non-smokers' presence and smokers who will extinguish theircigarettes when asked to do so M % F % Total % Smoke in non-smokers presence 240 75,2 54 75,0 294 74,6 Will extinguish 238 74,6 61 84,7 299 75,9 - 114- Chapter 6 6.6.7.1 Discussion A large proportion of respondents feel that smokers should not be allowed to smoke where and when they wish (See Table 6.16). The percentages of males and females who hold this view are very close in each category. It is clear, however, that fewer smokers (53,6%) than ex-smokers (76,0%) and non-smokers (84,5%) agree with this attitude. Fewer ex-smokers than non-smokers, on the other hand, share this attitude. The majority of respondents believe that smoking is harmful to non-smokers (see Table 6.17). Fewer male (77,1 %) and female (78,7%) smokers than any other category share this belief. A large proportion ofnon-smokers (84,0%) feel that smoking by others in their rooms bothers them (see Table 6.18). Female non-smokers with this objection represent the highest proportion of all the categories (86,8 %). Surprisingly, a small proportion of smokers (24,6 %) share this attitude. The reason for this is not clear - some smokers may be more 'messy' than others - therefore the objection by the less messy smokers. Fewer ex-smokers (58,3 %) than non-smokers object to smoking in their rooms. Slightly more than half of the respondents (52,9 %) report that they will request a smoker not to smoke in their presence on public transport (See Table 6.19). Even some smokers (36,8 %) reply that they will make this request to other smokers. A large proportion of smokers (74,6%) report that they do smoke in the presence of non-smokers (see Table 6.20), yet about the same percentage (75,9%) will extinguish their cigarettes if requested. 6.6.7.2 Conclusions The investigation reveals that there is a general awareness among all respondents that passive smoking is harmful to non-smokers. According to the replies, a slightly larger proportion of female respondents is sensitive to the problem ofenvironmental smoke, especially when it comes to smoking in their rooms, while a larger proportion of female smokers will extinguish their cigarettes when requested. - 115 - Chapter 6 The fact that relatively few non-smokers will request smokers not to smoke in their presence on public transport facilities is an indication of the reluctance of people to confront smokers. A request like this may, of course, lead to an embarrassing situation which many people would rather avoid. 6.6.8 THE INFLUENCE OF ANTI-SMOKING WARNINGS Respondents are asked whether they have noticed the anti-smoking warnings on cigarette packets and above cigarette advertisements in magazines and newspapers and whether these warnings have influenced them negatively towards smoking. Table 6.21 represents the results of these questions in the questionnaire. Table 6.21 Respondents who have noticed anti-smoking warnings on cigarette packets and in the press, and the influence of these warnings Noticed % Negatively % warnings influenced Smokers 376 95,4 126 33,5 Ex-smokers 93 96,9 65 69,9 Non-smokers 1566 91,2 1209 77,2 Totals 2035 92,2 1400 68,8 6.6.8.1 Discussion A very large proportion of the respondents (92,2%) report that they have noticed the warnings, with slightly larger percentages of ex-smokers (96,9%) and smokers (95,4 %) than non-smokers (91,2 %). Larger proportions smokers and ex-smokers than non-smokers noticed anti-smoking warnings. Many non-smokers seldom see cigarette packets and probably take less notice of cigarette advertisements in the press that smokers and ex-smokers. A significant proportion of ex-smokers (69,9%) and non-smokers (77,2%) report that the warnings influenced them negatively towards smoking. Only about one third of - 116 - Chapter 6 smokers shared the feeling that they were negatively influenced by the warnings (33,5%). 6.6.8.2 Conclusions The warnings on cigarette packets and above cigarette advertisements are apparently successful in the sense that they are noticed by the majority of students, and are reported to have influenced many people. Even the 33,5 % ofsmokers who report an influence against smoking is a significant indication of the impact of these warnings. This finding suggests that some smokers dislike the habit of smoking but are so addicted that it is hard to give it up. 6.6.9 ANTI-SMOKING MEASURES Respondents were tested on their attitudes regarding certain stricter anti-smoking measures, namely, higher taxation of cigarettes, the banning of cigarette advertising, the banning ofsmoking in places where food is served and the prohibition of smoking on public transport facilities. Table 6.22 contains the results of respondents' replies. 6.6.9.1 Discussion Rough!y three quarters ofthe non-smokers (76,6 %) support higher taxes on cigarettes. A smaller proportion of ex-smokers (66,7 %) and less than one third of smokers (30,7%) are in favour of higher taxation. Higher taxes will obviously mean higher cigarette prices - something that most smokers will not welcome. Smaller proportions of respondents support a ban on cigarette advertising than higher taxation of cigarettes (smokers 27,7%, ex-smokers 44,8% and non-smokers 55,6%). The possible ban on smoking in places where food is served and on public transport enjoys greater support from smokers (50,3% and 56,1 %), ex-smokers (71,9% and 76,0%) and non-smokers (86,3% and 85,3%) than the previous two measures. Ban ning of smoking on public transport has a larger support from smokers and ex smokers, while a ban in places where food is served enjoys a slightly larger support among non-smokers. - 117 - Table 6.22 Respondents who support stricter anti-smoking measures Smoking Smoking banned Taxation % Advertising % banned in % on % banned eating places public transport Smokers 121 30,7 109 27,7 198 50,3 221 56,1 Ex-smokers 64 66,7 43 44,8 69 71,9 73 76,0 Non-smokers 1315 76,6 955 55,6 1482 86,3 1464 85,3 Totals 1500 68,0 1107 50,2 1749 79,2 1758 79,7 Table 6.23 Number of cigarettes smoked per day 1 • 5 % 6· 10 % 11 • 15 % 16·20 % 20+ % Male 94 31,1 117 38,7 51 16,9 29 9,6 II 3,6 Female 29 40,8 26 36,6 8 11,3 8 11,3 0 0,0 Total 123 33,0 143 38,3 59 15,8 37 9,9 11 2,9 Chapter6 6.6.9.2 Conclusions Stricter anti-smoking measures enjoy the overwhelming support of ex-smokers and especially non-smokers while a significant number ofsmokers agree with the proposed measures. However, a possible ban on the advertising of cigarettes does not carry the same weight ofapproval as the other measures. It is possible that respondents believe that advertising does not have such a great impact as is generally believed. In general, these findings agree with those ofMartin et at. (1992:241-245) and Yach and Paterson (1994:838). 6.6.10 BRANDS OF CIGARETTES SMOKED A total of 20 different brands with 39 sub-brands of cigarettes are smoked by respondents. Of the total of 394 smokers, 37 did not report their brand of cigarettes. Of the 20 brands, nine are smoked by a total of357 students (90,6 %). The strengths of the cigarettes smoked range from the lightest available (nicotine content 0, I mg and tar content 1 mg) to some of the strongest on the market (nicotine content 1,5 mg and tar content 18 mg). 6.6.11 NUMBER OF CIGAREITES SMOKED PER DAY Table 6.23 shows the average number ofcigarettes smoked by the respondents accord ing to gender. 6.6.11.1 Discussion Most respondents reported smoking 20 or fewer cigarettes (males 96,4%, females 100,0%) but a disturbing number of males (3,6%) are heavy smokers who smoke more than 20 cigarettes per day. 6.6.11.2 Conclusions There is not much difference between male and female respondents in the number of cigarettes smoked per day. A larger proportion offemale students (40,8 %) than males (31,1 %) are lighter smokers (1 to 5 cigarettes), but a larger proportion of females - 119 - Chapter 6 (11,3%) than males (9,6%) are in the 16 to ~Ocigarettes per day category. The larger proportion male smr' J:s smoke betwe,..! 6-10 cigarettes per day, while the larger proportion females smoke 1-5 cigarettes per day. None of the female respondentsreported smoking more than 20 cigarettes per day. The fact remains that students are already consuming large amounts of tobacco at this early age: 6.6.12 AGE WHEN RESPONDENTS HAVE STARTED SMOKING Table 6.24 includes details, according to gender, of the ages when respondents have started smoking. Table 6.25 allows a closer inspection of the ages 15 to 24 years. 6.6.12.1 Discussion A larger proportion of male students (19,4 %) than female students (8,5 %) start smoking at ages between 5 and 14 years. Greater proportions of males and females start smoking between the ages 15 to 19 years (68,2% and 81,7% respectively). A larger proportion of males (17,2 %) than females (7,0 %) start smoking between ages 10 to 14 years. After the age of 20 years for males and 19 years for females (Table 6.25), there is a drastic reduction in the proportion of students who start smoking. This fmding agrees with that of Klesges and Robinson (1995) (see 5.4.1). 6.6.12.2 Conclusions Male respondents tend to start smoking at earlier ages (5 to 14 years) than females. The critical age for onset of smoking for both genders lies between 15 and 19 years of age. For females the ages 15 and 16 years represent the most vulnerable.period (42,3%) and for males it is 17 and 18 years (35,4%) (see Table 6.25). It is at these ages that children are most sensitive to acceptance by, and predisposed to pressure from their peers. The likelihood of a student starting smoking after the age of 20 years of age is relatively small. For males it is 4,8 % and for females, 5,6% (Table 6.25). - 120 - Table 6.24 Age when respondents started smoking (All ages) 5-9 % 10 - 14 % 15· 19 % 20 - 24 % 24+ % Male 7 2,2 54 17,2 214 68,2 36 11,5 3 1,0 Female 1 1,4 5 7,0 58 81,7 6 8,5 1 1,4 Total 8 2,1 59 15,3 272 70,6 42 10,9 4 1,0 Chapter 6 Table 6.25 Details of ages when respondents started smoking (15 to 24) Age M % F % Total 15 34 10,8 14 19,7 48 16 38 12,1 16 22,5 54 17 51 16,2 7 9,9 58 18 60 19,1 12 16,9 72 19 31 9,9 9 12,7 40 20 24 7,6 3 4,2 27 21 6 1,9 3 4,2 9 22 5 1,6 ° 0,0 5 23 ° 0,0 ° 0,0 ° 24 1 0,3 ° 0,0 1 Total 250 79,6 64 90,1 314 Table 6.26 Reasons why respondents started smoking ~ Number % Pleasure 52 23,2 Influenced 89 39,7 Curiosity 38 17,0 Reduce tension 31 13,8 Boredom 9 4,0 Liquor 5 2,2 Total 224 - 122 - Chapter6 Although the greater proportion of respondents have started smoking at school-going age, large numbers seem to start at technikon (ages 18 to 24+) (40,4 % for males and 38,0% for females). This is the period when young adults become relatively independent of their parents and probably more easily influenced under new and strange circumstances. 6.6.13 REASONS FOR STARTING SMOKING The reasons reported by smokers for starting smoking are categorised and summarised in Table 6.26. A total of 170 respondents have not given a reason or have reported obscure reasons. 6.6.13.1 Discussion • 'Pleasure' also includes: '1 liked it', it was fun', and 'it looked cool'. Roughly one fifth (23,2 %) of those who have responded to the question claim these replies as reasons for starting smoking. • 'Influenced' also includes: 'peer pressure', 'to be with it', and 'parents smoke'. A significant 39,7% of the smokers report this as a reason for starting smoking. • 'Curiosity' also includes: 'trying out'. A total of 17% of the smokers give this as a reason. " • 'Reduce tension' also includes: 'relieve stress', and 'relaxation'. 13,8 % of the smokers report this as their reason for starting smoking. • 'Boredom' also includes: 'killing time' and 'loneliness'. Only 4% of the smokers report this as a reason. • The use of liquor is blamed by 2,2% of the smokers as a reason for starting smoking. - 123 - Chapter6 6.6.13.2 Conclusions The influence of others, especially peers, is the most significant reason why young people start smoking. Direct influence or.pressure, and the perception of others as having fun while smoking, or being able to reduce tension through smoking, or being made curious about smoking, accounted for 93,8 % of the smokers who responded to this question. 6.6.14 REASONS WHY RESPONDENTS CONTINUE SMOKING The reasons why respondents continue smoking are categorised and summarised in Table 6.27. A total of 145 respondents have not answered this question or have given obscure reasons. Table 6.27 Reasons why respondents continue smoking Number % Pleasure 85 34,1 Influenced 4 1,6 Slimming 3 1,2 Reduce tension 90 36,1 Boredom 14 5,6 Liquor 4 1,6 Dependent 49 19,7 Total 249 6.6.14.1 Discussion 'Pleasure' also includes: 'enjoyment', 'fun' and 'satisfaction'. A total of 34,1 % of the respondents use this as a reason for continuing smoking. 'Influenced' also includes: 'to satisfy others'. Only 1,6% of the respondents claim this as a reason. - 124- Chapter 6 Three respondents (1,2%) feel that smoking helps them in their efforts to 'slim'. 'Reduce tension' also includes: 'relaxation', 'relief, 'stress reduction', 'reduce frustration', ,to cope' and 'sedative'. A total of 36, 1% of the respondents use this as a reason for continuing smoking. 'Boredom' includes: 'something to do'. Only 4,6% of the respondents feel that this is the reason for continuing smoking. 'Liquor' also includes 'parties': Only 1,6% claim that this IS their reason for continuing smoking. 'Dependent' also includes: 'habit', 'addicted' and 'can't quit'. A total of 19,7% of the respondents admit to being addicted to smoking. 6.6.14.2 Conclusions A large proportion of smokers report that they derive pleasure from smoking. It is evident too that, as soon as a person has become a regular smoker, the influence of others becomes less important as a reason for smoking. An important observation is that the proportion of smokers who report that their smoking reduces tension has increased from the 13,8% as a reason for starting to 36,1 % as a reason for continuing. This tends to. confrrm the theory that smoking contributes to tension, rather than alleviates it. The number of smokers who are dependent on smoking is probably much higher than the reported 19,7%. This possibility is highlighted in 6.6.15.1. It is, however, difficult for most smokers to admit to addiction. 6.6.15 GIVING UP SMOKING An important objective of this study is to examine smokers' attempts at giving up smoking, including the number of attempts and when last an attempt has been made. It is, furthermore, necessary to investigate the relationship between smokers' belief that they are able to give up smoking, and their attempts to give up. - 125 - Table 6.28 Smokers' belief whether they can give up smoking permanently or not Yes % No % Not sure % Total Male 233 73,7 39 12,3 44 13,9 316 ~ Female 55 76,4 10 13,9 7 9,7 72 Totals 288 74,2 49 12,6 51 13,1 388 Table 6.29 Smokers who report that they can give up smoking permanently Number of times tried Never % 1-5 % 6 - 10 % Many % Total % numerous who don't know tried Male 69 29,6 100 42,9 7 3,0 38 16,3 145 62,2 Female 21 38,2 21 38,2 ° 0,0 9 16,4 30 54,5 Totals 90 31,3 121 42,0 7 2,4 47 16,3 175 60,8 Table 6.30 Smokers who report that they cannot give up permanently Number of times tried Many Total numerous who Never % 1-5 % 6 - 10 % don't know % have % tried Male 23 28,4 38 46,9 2 2,5 18 22,2 58 71,6 Female 3 18,8 11 68,8 0 0,0 2 12,5 13 81,3 Totals 26 26,8 49 50,5 2 2,1 20 20,6 71 73,2 Table 6.31 Smokers' efforts to give up smoking Totals of Tables 6.26 and 6.27 Many Total numerous who Never % 1 - 5 % 6 - 10 % don't know % have % tried Male 92 31,2 138 46,8 92 3,1 56 19,0 203 68,8 Female 24 35,8 32 47,8 0 0,0 11 16,4 43 64,2 Totals 116 32,0 170 47,0 92 2,5 67 18,5 246 68,0 Chapter 6 Table 6.32 The latest attempt to give up smoking Number % A week ago 34 15,3 A month ago 49 22,1 Six months ago 61 27,5 A year ago 52 23,4 Longer 26 11,7 Total 222 100,0 A total of 388 smokers have responded to the relevant parts of the questionnaire. Tables 6.28 to 6.32 contain the data for these particular aspects of smoking. 6.6.15.1 Discussion Table 6.28 shows that 74,2 % of the smokers who have responded to the question, maintain that they can give up smoking permanently if they wish to, while 13,I % are not sure and 12,6 % feel that they are addicted to smoking. Of the 288 smokers who feel that they can give up smoking permanently, only 90 (31,3%) report that they have never tried. A total of 175 of these smokers (60,8%) have tried to give up at least once (see Table 6.29). Table 6.30 represents the details of 97 smokers who admit that they are addicted to tobacco. Roughly one quarter of these respondents (26,8 %) indicate that they have never tried to give up smoking, while 73,2 % have tried at least once. Table 6.31 gives the totals of the efforts of smokers to give up smoking (the totals of Tables 6.29 and 6.30). This table shows that 68,0% of the smokers who have responded to the relevant questions have tried to give up smoking at least once, compared with nearly one third who claimed that they have never tried. Table 6.32 shows that 88,3 % of the respondents have made attempts at giving up smoking within the last year. 6.6.15.2 Conclusions The strength oftobacco addiction is confirmed by the number ofunsuccessful attempts of smokers to give up smoking. The data show that many smokers who believe (or - 128 - Chapter 6 say that they believe) that they can give up smoking may actually be addicted without realising it. Another important feature of giving up smoking is the fact that a large proportion of smokers have tried giving up within the last year (without success). The relatively small number ofex-smokers in the sample (96) is probably an indication of how difficult it is to give up smoking. 6.6.16 REASONS FOR GIVING UP SMOKING Table 6.33 includes the details of the reasons that ex-smokers advance for giving up smoking. Of the total of 96 ex-smokers in the study, 70 have responded to this question with acceptable replies. . Table 6.33 Ex-smokers' reasons for giving up smoking Number % Bad for health 41 58,6 Too expensive 15 21,4 Cost and health 6 8,6 Religious reasons 1 1,4 Sport 7 10,0 Total 70 6.6.16.1 Discussion A large proportion of the respondents (88,6%) claim that they have given up smoking because of health reasons and the cost involved in smoking. 6.6.16.2 Conclusions The proportion of respondents who mention the cost of cigarettes (30 %) makes it evident that this is an important reason why people give up smoking, or attempt to give up. This fact provides adequate motivation for considering the price ofcigarettes when taxation is planned. - 129 - Chapter 6 The awareness of the dangers of smoking to health is demonstrated by the fact that such a large proportion of ex-smokers cited this as a reason to give up the habit. 6.6.17 TESTING THE HYPOTH:ESES The hypotheses stated in 6.2.2 are sub-divided and tested with the aid of the chi squar.e test for 2x2 contingency tables. In each of the tests the following will apply: • The level of significance: ex = 0,05. • The degrees of freedom (dt) = 1. 2 • Criterion: The null hypothesis is rejected if X > 3,841, the value for X20,05 for (2 - 1)(2 - 1) = 1 degree of freedom. Table IV for the values of x2 in Freund and Smith (1986:511) are applied. • Hypothesis #1 Smoking prevalence according to population groups and genders • Null hypothesis #l(a) (Table 6.1) There is no real difference between the proportions of white and black male smokers. • Research hypothesis #l(a) There is a difference between the proportions of black and white male smokers. ... Decision Since X2 = 0,0278 does not exceed 3,841, the null hypothesis cannot be rejected. The proportion of white male smokers does not, therefore, differ significantly from that of black male smokers. - 130 - Chapter 6 • Null hypothesis #l(b) (Table 6.1) There is no real difference between the proportions of white and black female smokers. • Research hypothesis #1(b) There is a difference between the proportions of white and black female smokers. .6 Decision Since X2 = 44,2 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of white females than black females are smokers. • Null hypothesis #l(c) (Table 6.1) There is no real difference between the proportions of white and Asian male smokers. '. Research hypothesis #l(c) There isa difference between the proportions ofwhite and Asian male smokers. .6 Decision Since X2 = 3,98 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of Asian males than white males are smokers. The x2 is not signifi cant at Cl = 0,025. • Null hypothesis #l(d) There is no real difference between the proportions of white and Asian female smokers. - 131 - Chapter 6 • Research hypothesis #l(d) (Table 6.1) ./ ,: . j There is a difference between the proportions of white and Asian female smokers. .I. Decision Since x2 = 8,17 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of white females than Asian females are smokers. • Null hypothesis #I(e) (Table 6.1) There is no real difference between the proportions of white and coloured male smokers. • Research hypothesis #I(e) There is a difference between the proportions of white and coloured male smokers. .I. Decision Since X2 = 0,76 does not exceed 3,841, the null hypothesis cannot be rejected. The proportions of white and coloured male smokers do not, therefore, differ significantly. • Null hypothesis #I(f) (Table 6.1) There is no real difference between the proportions of white and coloured female smokers. • Research hypothesis #1(f) There is a difference between the proportions of white and coloured female smokers. - 132- Chapter 6 • Decision Since X2 = 0,08 does not exceed 3,841, the null hypothesis cannot be rejected. The proportions of white'and coloured female smokers do not, therefore, differ significantly. • .Null hypothesis #l(g) (Table 6.1) There is no real difference between the proportions of white male and white female smokers. • Research hypothesis #1(g) There is a difference between the proportions of white male and white female smokers. • Decision Since X2 = 1,23 does not exceed 3,841, the null hypothesis cannot be rejected. The proportions of white male and white female smokers do not, therefore, differ significantly. • Null hypothesis #l(h) (Table 6.1) There is no real difference between the proportions of black male and black female smokers. • Research hypothesis #l(h) There is a difference between proportions of black male and black female smokers. - 133 - Chapter 6 • Decision Since X2 = 80,9 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of black males than black females are smokers. • Conclusions The prevalence of smoking among white, black and coloured male technikon students does not differ significantly. A higher proportion of Asian males than white males are smokers. The prevalence of smoking among white and coloured female students does not differ significantly. A significantly higher proportion of white and coloured, than Asian female students, are smokers. The prevalence of smoking among white male and female students does not differ significantly. A significantly higher proportion of black and Asian male students, than their female counterparts, are smokers. The null hypothesis must be rejected. There are significant differences between the smoking prevalences of students from the different population groups and genders. • Hypothesis #2 Smoking status of family members • Null hypothesis #2(a) (Tables 6.2 and 6.4) There is no real difference in the proportion ofhomes where at least one family member smokes: black male smokers compared with black male non-smokers. - 134 - Chapter 6 • Research hypothesis #2(a) There is a difference between the proportions of homes where at least one family member smokes: black male smokers compared with black male non smokers. ... .Decision Since X2 = 7,19 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of black male smokers, than black male non-smokers, come from homes where at least one family member smokes. • Null hypothesis #2(b) (Tables 6.2 and 6.4) There is no real difference between the proportion of homes where at least one family member smokes: black female smokers compared with black female non smokers. • Research hypothesis #2(b) There is a difference between the proportions of homes where at least one family member smokes: black female smokers compared with black female non smokers. ... Decision Since X2 = 6,06 exceeds 3,841, the null hypothesis must be rejected. A higher proportion ofblack female smokers, than black female non-smokers, come from homes where at least one family member smokes. • Null hypothesis #2(c) (Tables 6.2 and 6.4) There is no real difference between the proportions offathers who smoke: black male smokers compared with black male non-smokers. - 135 - Chapter6 • Research hypothesis #2(c) There is a difference between the proportions of fathers who smoke: black male smokers compared with black male non-smokers. A Decision Since X2 = 8,48 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of black male smokers, than black male non-smokers, have fathers who smoke. • Null hypothesis #2(d) (Tables 6.2 and 6.4) There is no real difference between the proportion offathers who smoke: black female smokers compared with black female non-smokers. • Research hypothesis #2(d) There is a difference between the proportions of fathers who smoke: black female smokers compared with black female non-smokers. A Decision Since X2 = 1,22 does not exceed 3,841, the null hypothesis cannot be rejected. The proportions of black female smokers and black female non-smokers with fathers who smoke, do not differ. • Null hypothesis #2(e) (Tables 6.2 and 6.4) There is no real difference between the proportions of older siblings who smoke: black male smokers compared with black male non-smokers. - 136 - Chapter 6 • Research hypothesis #2(e) There is a difference between the proportions of older siblings who smoke: black male smokers compared with black male non-smokers . • Decision Since x2 = 5,38 exceeds 3,841, the null hypothesis must rejected. A higher proportion of black male smokers than black male non-smokers have older siblings who smoke. • Null hypothesis #2(J) (Tables 6.2 and 6.4) There is no real difference between the proportions of older sibling who smoke: black female smokers compared with black female non-smokers. • Research hypothesis #2(J) There is a difference between the proportions ofolder sibling who smoke: black female smokers compared with black female non-smokers . • Decision Since X2 = 0,93 does not exceed 3,841, the null hypothesis cannot be rejected. The proportion of black female smokers with older siblings who smoke is similar to that for black female non-smokers. • Null hypothesis #2(g) (Tables 6.5 and 6.7) There is no real difference between the proportion of homes where at least one family member smokes: white male smokers compared with white male non smokers. - 137 - Chapter 6 • Research hypothesis #2(g) There is a difference between the proportions of homes where at least one family member smokes: white male smokers compared with white male non smokers. ... .Decision Since x2 = 19,15 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of white male smokers, than white male non smokers, .come from homes where at least one family member smokes. • Null hypothesis #2(h) (Tables 6.5 and 6.7) There is no real difference between the proportions ofhomes where at least one family member smokes: white female smokers compared with white female non smokers. • Research hypothesis #2(h) (Tables 6.5 and 6.7) There is difference between the proportions of homes where at least one family member smokes: white female smokers compared with white female non smokers. ... Decision Since X2 = 10,28 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion ofwhite female smokers, than white female non smokers, come from homes where at least one family member smokes. • Null hypothesis #2(i) (Tables 6.5 and 6.7) There is no real difference between the proportions offathers who smoke: white male smokers compared with white male non-smokers. - 138 - Chapter 6 • Research hypothesis #2(i) There is a difference between the proportions of fathers who smoke: white male smokers compared with white male non-smokers. .. Decision Since x2 = 10,64 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of white male smokers, than white male non-smokers, have fathers who smoke. • Null hypothesis #2(j) (Table 6.5 and 6.7) There is no real difference between the proportions offathers who smoke: white female smokers compared with white female non-smokers. • Research hypothesis #2(j) There is a difference between the proportions of fathers who smoke: white female smokers compared with white female non-smokers. .. Decision Since X2 = 2,12 does not exceed 3,841, the null hypothesis cannot be rejected. The proportions of white female smokers and white female non-smokers with fathers who smoke do not differ significantly. • Null hypothesis #2(k) (Tables 6.5 and 6.7) There is no real difference between the proportions of mothers who smoke: white male smokers compared with white male non-smokers. - 139- Chopter6 • Research hypothesis #2(k) There is a difference between the proportions of mothers who smoke: white male smokers compared with white male non-smokers . .&. Decision Since X2 = 0,51 does not exceed 3,841, the null hypothesis cannot be rejected. The proportions of white male smokers and white male non-smokers with a mother who smokes do not differ significantly. • Null hypothesis #2(1) (Tables 6.5 and 6.7) There is no real difference in the proportion of mothers who smoke: white female smokers compared with white female non-smokers. • Research hypothesis #2(1) There is a difference in the proportions of mothers who smoke: white female smokers compared with white female non-smokers . .&. Decision Since X2 = 5,08 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of white female smokers, than white female non-smokers, have mothers who smoke. • Null hypothesis #2(m) (Tables 6.5 and 6.7) There is no real difference in the proportion of homes where an older sibling smokes: white male smokers compared with white male non-smokers. - 140 - Chapter 6 • Research hypothesis #2(m) The proportion of homes where an older sibling smokes, differs: white male smokers compared with white male non-smokers. • Decision Since X2 = 11,95 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of white male smokers, than white male non smokers, have an older sibling who smokes. • Null hypothesis #2(n) (Tables 6.5 and 6.7) There is no real difference between the proportion of homes where older siblings smoke: white female smokers compared with white female non smokers. • Research hypothesis #2(n) The proportion of homes where older siblings smoke, differs: white female smokers compared with white female non-smokers. • Decision Since x2 = 7,91 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of white female smokers, than white female non smokers, have older siblings who smoke. o Conclusions The data confmn significantly higher proportions of the following groups of smokers, compared to non-smokers in the same groups: Black and white (male and female) smokers with at least one other family member who smokes. - 141 - Chapter 6 Male (white and black) smokers with fathers who smoke. Black male and white (male and female) smokers with older siblings who smoke. White female smokers with a mother who smokes. The null hypothesis must be rejected. The smoking status of certain family members have an influence on the smoking status of students. Smokers are more likely than non-smokers to come from homes where family members smoke. • Hypothesis #3 Influence of anti-smoking campaigns • Null hypothesis #3(a) (Table 6. to and 6.11) There is no real difference between the proportions of smokers and ex-smokers who have been influenced against smoking by anti-smoking campaigns. • Research hypothesis #3(a) There is a difference between the proportions of smokers and ex-smokers who have been influenced against smoking by anti-smoking campaigns. .... Decision Since X2 = 9,41 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of ex-smokers than smokers have been influenced against smoking by anti-smoking campaigns. • Null hypothesis #3(b) (Tables 6.10 and 6.12) There is no real difference in the proportions of smokers and non-smokers who have been influenced against smoking by anti-smoking campaigns. - 142 - Chapter 6 • Research hypothesis #3(b) There is a difference between the proportions ofsmokers and non-smokers who have been influenced against smoking. • Decision Since x2 = 18,92 exceeds 3,841, the null hypothesis must rejected. A significantly higher proportion of non-smokers than smokers have been influenced against smoking by anti-smoking campaigns. o Conclusions The null hypothesis is rejected. Non-smokers and ex-smokers are more likely than smokers to be influenced against smoking by anti-smoking campaigns. • Hypothesis #4 Smoking harmful to smokers' health • Null hypothesis #4(a) (Table 6.14) There is no real difference between the proportions ofsmokers and non-smokers who believe that smoking is harmful to smokers' health. • Research hypothesis #4(a) There is a difference between the proportions ofsmokers and non-smokers who believe that smoking is harmful to smokers' health. • Decision Since x2 = 17,79 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of non-smokers than smokers believe that smoking is harmful to smokers' health. - 143 - Chapter 6 o Conclusion The null hypothesis is rejected. Non-smokers are more likely than smokers to believe that smoking is harmful to smokers' health. • Hypothesis #5 Smoking harmful to non-smokers' health • Null hypothesis #5(a) (Table 6.17) There is. no real difference between the proportions of smokers and non smokers, who believe that smoking is harmful to non-smokers' health. • Research hypothesis #5(a) There is a difference between the proportions of smokers and non-smokers who believe that smoking is harmful to non-smokers' health. ... Decision Since X2 = 87,56 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of non-smokers than smokers believe that smoking is harmful to non-smokers' health. • Null hypothesis #5(b) (Table 6.17) There is no real difference between the proportions ofsmokers and ex-smokers who believe that smoking is harmful to non-smokers' health. • Research hypothesis #5(b) There is a difference between the proportions of smokers and ex-smokers who believe that smoking is harmful to non-smokers' health. - 144- Chapter 6 .... Decision Since X2 = 5,92 exceeds 3,841, the null hypothesis must be rejected. A higher proportion of ex-smokers than smokers believe that smoking is harmful to non smokers' health. •.Null hypothesis #5(c) (Table 6.16) There is no real difference between the proportions ofsmokers and non-smokers who believe that smokers should not be allowed to smoke where and when they wish. • Research hypothesis #5(c) There is a difference between the proportions of smokers and non-smokers who believe that smokers should not be allowed to smoke where and when they wish. .... Decision Since X2 = 183,37 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of non-smokers than smokers believe that smokers should not be allowed to smoke where and when they wish. • Null hypothesis #5(d) (Table 6.16) There is no real difference between the proportions of smokers and ex-smokers who believe that smokers should not be allowed to smoke where and when they wish. • Research hypothesis #5(d) There is a difference between the proportions of smokers and ex-smokers who believe that smokers should not be allowed to smoke where and when they wish. - 145 - Chapter 6 • Decision Since X2 = 16,02 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion ofex-smokers than smokers believe that smokers should not be allowed to smoke where and when they wish. o Conclusions The null hypothesis is rejected. Ex-smokers and non-smokers are more likely than smokers to believe that smoking is harmful to non-smokers' health. Ex-smokers and non-smokers are also more likely to believe that smokers should not be allowed to smoke where and when they wish. • Hypothesis #6 Influence of anti-smoking warnings on cigarette packets and above cigarette advertisements • Null hypothesis #6(a) (Table 6.21) There is no real difference between the proportions ofsmokers and non-smokers who report a negative influence towards smoking resulting from anti-smoking warnmgs. • Research hypothesis #6(a) There is a difference between the proportions of smokers and non-smokers who report a negative influence towards smoking resulting from anti-smoking warnings. • Decision Since x2 = 269,38 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of non-smokers than smokers report a negative influence towards smoking resulting from anti-smoking warnings. - 146 - Chapter 6 • Null hypothesis #6(b) (Table 6.21) There is no real difference between the proportions of smokers and ex-smokers who report a negative influence towards smoking resulting from anti-smoking warnings. •.Research hypothesis #6(b) There is a difference between the proportions of smokers and ex-smokers who report a negative influence towards smoking resulting from anti-smoking warnings. • Decision Since X2 = 40,88 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of ex-smokers than smokers report a negative influence towards smoking resulting from anti-smoking warnings. o Conclusions 'The null hypothesis is rejected. Ex-smokers and non-smokers are more likely to be negatively influenced towards smoking by anti-smoking warnings on cigarette packets and above cigarette advertisements. • Hypothesis #7 Respondents' support for stricter anti-smoking measures • Null hypothesis #7(a) (Table 6.22) There is no real difference between the proportions ofsmokers and non-smokers who support higher taxation of cigarettes. - 147 - Chapter 6 • Research hypothesis #7(a) There is a difference between the proportions of smokers and non-smokers who support higher taxation of cigarettes .. ... Decision Since X2 = 310,08 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion of non-smokers than smokers support higher taxation of cigarettes. • Null hypothesis #7(b) (Table 6.22) There is no real difference between the proportions ofsmokers and non-smokers who support the banning of cigarette advertising. • Research hypothesis #7(b) There is a difference between the proportions of smokers and non-smokers who support the banning of cigarette advertising. ... Decision Since X2 = 100,18 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion ofnon-smokers than smokers support the banning of cigarette advertising. • Null hypothesis #7(c) (Table 6.22) There is no real difference between the proportions ofsmokers and non-smokers who support the banning of smoking in places where food is served. - 148 - Chapter 6 • Research hypothesis #7(c) There is a difference between the proportions of smokers and non-smokers who support the banning of smoking in places where food is served. .. Decision Since X2 = 256,45 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion ofnon-smokers than smokers support the banning of smoking in places where food is served. • Null hypothesis #7(d) (Table 6.22) There is no real difference between the proportions ofsmokers and non-smokers who support the banning of smoking on public transport. • Research hypothesis #7(d) There is a difference between the proportions of smokers and non-smokers who support the banning of smoking on public transport. .. Decision Since X2 = 169,33 exceeds 3,841, the null hypothesis must be rejected. A significantly higher proportion ofnon-smokers than smokers support the banning of smoking on public transport. o Conclusions The null hypothesis is rejected. Non-smokers are more likely than smokers to support higher taxation of cigarettes, the banning of cigarette advertising and the banning of smoking in places where food is served and on public transport. - 149 - Chapter 6 6.7 SUMMARY This chapter comprises the empirical research of the dissertation, which is supported by a literature study of various aspects of tobacco consumption. The empirical research is planned around a need for information on the smoking habits of young adults, as well as on the beliefs, opinions and attitudes of smokers, ex smokers and non-smokers. The main objectives of the research are to discover the magnitude of smoking as a problem among .technikon students, and to reveal what smokers, ex-smokers and non smokers feel and believe about cigarette smoking. The empirical problem statement has been sub-divided into sub-problems. The null and research hypotheses have been formulated to adequately supply answers to the issues posed as problem statements. Smokers, ex-smokers and non-smokers among technikon students in South Africa are identified as the units of analysis and the research groups. The questionnaire, as measuring instrument, and the covering letter to research assistants at the various technikons are described and the measuring scale identified. The population of the research is described as first, second and third year, full-time students at eight technikons in South Africa. The sampling procedure involved the drawing of random samples from clusters of students. The clusters represent the different programmes offered at the technikons. The sample includes 2 207 students, comprising male and female students of the various population groups, smokers, ex-smokers and non-smokers, and students at different levels of study. Two pilot studies had been conducted, and the questionnaire discussed with specialists, before it was finalised. - 150 - Chapter 6 The validity of the research project is assessed in terms of content validity, empirical validity and construct validity. The researcher believes that the project complies with the requirements of recognised research validity. The various effects and threats that may impact on the effectiveness and appropriate ness of the questionnaire are examined. The conclusion is reached that the question nairesuffers from sensitivity as a result of the lack of a scale of measurements. The course of the research is described, including the distribution and return of the questionnaire. Certain problems have been encountered during the investigation, which impacted on the general effectiveness of the project. The micro computer programmes, QUATIRO 5.1 and STATGRAPHICS 3.01, are employed in the coding and analysis of the data. The analyses include the calculation of percentages and chi-square testing The investigation revealed certain aspects of cigarette smoking among technikon students in South Africa: • An estimated 17,9% of all students are smokers, only 4,3% are ex-smokers and ·77,8% do not-smoke. • The average prevalence of smoking among male students is 22,9% and this preva lence does not differ significantly among the various population groups. Relatively large proportions of white (18,4%) and coloured (16,0%) female students are smokers, while very few black (3,6%) and Asian (2,0%) females smoke. • The presence of smokers among family members has an influence on the smoking status of students. The smoking status of fathers and older siblings, and also mothers in the case of white female smokers, is a critical factor. • Non-smokers, and some groups of smokers, seem to prefer partners who do not smoke. - 151 - Chapter 6 • A total of only 19,4 % of the students have attended anti-smoking campaigns or lectures. Although the data show a certain measure of success from these campaigns, there is room for improvement. • Significant proportions of students believe that: • .Smoking is harmful to smokers' health. • Smokers should not be allowed to smoke where and when they please. • Cigarette smoke is harmful to non-smokers' health. • Anti-smoking warnings on cigarette packets and above cigarette advertisements have a reasonable degree of influence against smoking, especially on non-smokers and ex-smokers. • Significant proportions of students support stricter anti-smoking measures, such as higher taxation of cigarettes, the banning of cigarette advertising and the prohibition of smoking in places where food is served and on public transport. • . The critical ages at which students start smoking lie between 15 and 19 years of age. After 20 years of age the likelihood of starting smoking drops drastically. •A larger proportion ofstudents start smoking as a result of influence, especially by peers, than any other reason given. • Dependency is stated by many smokers as a reason why they continue to smoke, while the largest proportion report that they smoke to relieve tension and frustration. • Smokers support 39 types of cigarettes, registered under 20 different brands. The strengths of the cigarettes range from the lightest to some of the strongest on the South African market. - 152 - Chapter 6 • Although many smokers believe that they can give up smoking permanently should they wish to, a large proportion have made unsuccessful attempts to give up. • The cost of cigarettes and the possible harm to health are given as the main reasons why ex-smokers have given up smoking. - 153 - Chapter 7 CHAPTER 7 ANTI-SMOKING MEASURES 7.1 INTRODUCTION Various govemnients and anti-smoking campaigners have employed many different measures over the years to ban or curb smoking. It has become clear that the mere knowledge of the dangers of smoking is not nearly adequate to stop people from starting smoking, to persuade smokers to give up the habit, or for tobacco production to be curtailed. The purpose of this chapter is to survey the existing literature on measures and proposed measures against smoking, and to formulate a theory and proposals regarding anti-smoking measures, especially in relation to young adults. 7.1.1 BACKGROUND The use oftobacco has been controversial for a long period oftime, with strong views being expressed by protagonists of the different sides of the issue. During the 15th century severe penalties were imposed on users of tobacco. In the early 1600s, it was even a capital offense in Turkey to use tobacco. Some religious groups have for ~any years imposed bans on their members on the use of tobacco. (Davis 1987:15.) In 1604, Queen Elizabeth's successor to the throne, King James I, imposed a heavy tax on tobacco in an attempt to limit what he considered to be: A custome lothesome to the eye. hatefull to the Nose. harmefull to the braine, dangerous to the Lungs. and in the black stinking fume. thereof. neerest resembling the horrible Stigian smoke of the pit that is bottomeless (Stebbins 1990:227). - 154 - Chapter 7 7.2 l\tIEASURES APPLIED PRESENTLY 7.2.1 GOVERNMENT POLICY The National Health Plan for South Africa of the African National Congress (ANC) includes, among others, the following proposed measures with regard to smoking (African National Congress 1994; Yach, Harrison & Parry 1994:14-15): • The promotion of healthy life styles, community action for the implementation of healthy public policies, legislation, measures to reduce the consumption oftobacco and alcohol. • Additional state revenue from an increase in the excise on tobacco, which will have as a benefit a reduction in consumption. • The application of strict regulations on the advertising of tobacco and alcohol. • The increase of excise duties on tobacco. • The extension of regulations creating smoke-free zones to include public places, . work environments and government buildings. 7.2.2 LEGISLATION The South African Government has promulgated Act No. 83 of 1993 (Tobacco Products Control Act, 1993), and Government Notice No. 2063 (Regulations relating to the labelling, advertising and sale of tobacco products), which control, among others: 7.2.2.1 Sale of cigarettes to young people Tobacco products may not be sold or supplied to persons under the age of 16 years. Owners of vending machines must ensure that persons under the age of 16 years do not procure cigarettes from these machines. - 155 - Chapter 7 7.2.2.2 Warnings on cigarette packs and advertisements Tobacco advertisements and packages containing tobacco products must carry one of the nine prescribed warnings concerning the health hazards associated with smoking: • DANGER: SMOKING CAN KILL YOU • DANGER: SMOKING CAUSES CANCER • DANGER: SMOKING CAUSES HEART DISEASE • SMOKING DAMAGES YOUR LUNGS • PREGNANT? BREASTFEEDING? YOUR SMOKING CAN HARM YOUR BABY • WARNING: DON'T SMOKE NEAR CHILDREN • TOBACCO IS ADDICTIVE '. YOUR SMOKE CAN HARM THOSE AROUND YOU • CAUSES CANCER (special warning on snuff and chewing tobacco) Cigarette packets must reflect the tar and nicotine content of the particular brand in the following way: • ..... mgs tar ...., mgs nicotine as per Government agreement method Tests to determine the tar and nicotine content of cigarettes must be carried out by the South African Bureau of Standards, or other laboratory designated by the Director General of National Health and Population Development, at the expense of the manufacturer or importer of the cigarettes. - 156 - Chapter 7 . 7.2.3 RESTRICTIONS ON SMOKING IN PUBLIC PLACES In the United Kingdom, more and more non-smoking areas are being provided on public transport, places of entertaininent and restaurants. In 1976 the Institute of Professional Civil Servants passed a resolution asserting the rights of their members to have non-smoking office accommodation. Non-smoking carriages on trains are provided and the number has been increased during the past few years. By 191'1, most theatres had prohibited smoking in the auditorium, and many cinemas reserve up to half of their seats for non-smokers. (Royal College of Physicians 1977:24.) The United States Occupational Safety and Health Administration has recently pro posed a ban on almost all indoor smoking in the workplace. The US railroad company, Amtrak, declared that 82 % of its trains will be smoke free from 1994. (Farley 1994:52.) An increasing number of private companies are taking measures to restrict smoking in their establishments. In the United States the fast-food business, McDonald's, has banned smoking in I 400 oftheir restaurants. About one third of America's enclosed shopping malls were planning to ban smoking by the end of 1994. (Farley 1994:52.) Twelve 'local-authorities in South Africa have, to date, drafted regulations which prohibit smoking in public places. These include the cities of Cape Town, Bellville and Pretoria, as well as the Greater Johannesburg Transitional Metropolitan Council. 7.2.4 RESTRICTIONS IN AIRPORTS AND ON PLANES Non-smoking areas are now provided by nearly .all airlines (Royal College of Physicians 1977:24). South African Airways prohibited smoking on all domestic flights, taking effect from April 1989. Smoking is allowed on international flights with a ratio of70% non-smokers' seats to 30% smokers' seats. Inside South African airports smoking is allowed in restricted areas only. (South African Airways 1995.) - 157 - Chapter7 7.2.5 LEGAL ACTION During 1994, the United States Department ofJustice started reviewing allegations that since the early 1960s, tobacco companies have deliberately and illegally concealed information about the hazards of cigarette smoking and the addictiveness of nicotine. (McCarthy 1994:49.) In another development, the Commissioner of the US Food and Drug Administration (FDA), has continued a campaign to convince the United States Congress that tobacco companies intentionally use nicotine as an addictive drug, to ensure that smokers remain hooked on tobacco products. The Commissioner maintains that, one of the large tobacco concerns has secretly developed a superpotent tobacco hybrid in Brazil, called Y-1, with a nicotine content twice the value ofthat found in standard flue-cured tobacco. The evidence points to this company having used the hybrid tobacco to boost the nicotine content offive domestic US brands. Further evidence shows that tobacco companies have been adding ammonia to tobacco in order to increase the amount of nicotine delivered by cigarette smoke. (McCarthy 1994:49.) 7.2.6 INCREASED INSURANCE PREMIUMS In 1992 three insurance firms in the United States, owned by tobacco companies, charged smokers nearly double for term life insurance because smokers are about twice as likely as non-smokers to die at a given age. (MacKenzie, Bartecchi & Schrier 1994:975.) 7.2.7 HEALTH EDUCATION In a study to assess the effectiveness ofmass media and school intervention program mes set up to convince school children not to smoke, Flynn et at. (1995 :S-45) have developed common educational objectives based on social learning theory and related theories. The objectives determine that young people should: • have a positive view of non-smoking • have a negative view of smoking • have skills for refusing cigarettes - 158 - Chapter 7 • perceive that most people their own age do not smoke. This intervention programme operates on the principle that the school programmes provide the young people with information, skills practice and strong endorsements of non-smoking. The media interventions serve to reinforce these messages and present attractive modelling ofpeer group norms that favour a non-smoking lifestyle. Flynn et at. (1995:S-51) conclude that the successful combination of the two approaches apparently provides the children with both the motivation and the skills needed to avoid cigarette smoking. 7.3 PLANNED AND PROPOSED ANTI-SMOKING MEASURES 7.3.1 CLASSIFYING NICOTINE AS A DRUG The US Food and Drug Administration is investigating the possibility of classifying nicotine as a drug. This move could effectively remove cigarettes from the over-the counter market. (Farley 1994:52.) 7.3.2 STRICTER LEGISLATION Yach, Harrison and Parry (1994:1) point out that legislation regarding substance abuse is typically directed at: • the source of the product • its distribution • promotional advertising • the age groups who buy it • the places at which, and the means by which it is sold • the manner and quantity in which it may be used. In terms of some of the above aspects, The Royal College of Physicians (1992:1011102) proposes the following additional legislative measures: - 159 - Chapter 7 • The banning of all forms ofdirect and indirect tobacco promotion and advertising, including arts and sports sponsorship. Aspects of this proposal are discussed in more detail in 7.3.2.1. • The maintenance of a strong price disincentive on cigarettes for young people, by a regular increase of the real price of tobacco products through taxation. It is calculated .that, in tenus of disposable income, the price of a packet of cigarettes has halved in the last 30 years. (Royal College of Physicians 1992:97.) Proposals regarding additional taxation is discussed in 7.3.2.2. • The introduction of a special tax on tobacco, to fmance smoking prevention and related health research (see 7.3.2.2). • Raising the legal age for buying tobacco to 18 years. • The strict enforcement and monitoring of legislation on sales to children. • The introduction of plain packaging requirements for cigarette manufacturers. • The termination of all governmental aid for the production, manufacture and promotion of tobacco products, and the encouragement of diversification to products other than tobacco. • Legislating the banning of smoking in public places and especially in all schools, sports and leisure facilities. • Legislating for the right of people to work in a smoke-free environment. The United States Congress considers legislation to restrict smoking in buildings entered by 10 people or more each daily. This will include bars, restaurants and almost every facility which is not a private home. (Farley 1994:52.) The President ofthe United States ofAmerica has announced proposals to ban tobacco advertising and stop under-age smoking. The measures will include the banning of - 160 - Chapter 7 cigarette vending machines and severe penalties on shopkeepers who sell cigarettes to anybody under 18 years of age. (Anon 1995a:5.) 7.3.2.1 Ban on advertising Numerous public media in South Africa, such as newspapers and magazines, derive a substantial income through tobacco advertisements. The result is that these media are not free to report honestly and fully on the dangers and other implications of tobacco consumption. A ban on advertising of tobacco products could be a start to rectifying this situation. In the words of Yach, Harrison and Parry (1984:10): "The media's potential advocacy role in promoting positive health aspects and thus setting the agenda for health can be put to the common good." A total ban on tobacco promotion and advertising could have serious implications for the livelihood ofpeople, especially in respect of the publications and radio advertising industries, as well as sports sponsorship. Yach et at. (1989b:410/411) suggest that an increase of 25 % on the excise duty for cigarettes be implemented (this translates into a 5-8 % increase on a packet of cigarettes). The income from this 'Health Promotion Tax' will go into a fund that will be jointly administered by the Department of National Health and Population Development and community-based groups. The fund will help to place health promotion advertising in the same media that presently carry tobacco advertising. Sufficient revenue should be generated to offset losses to media and sports bodies. Yach (1994a:4) points out that a total advertising ban on tobacco will not cause serious economic effects, but will promote public health. He supports his view with the result of a survey of 10 popular magazines with circulations over 100 000. The survey has revealed that tobacco advertising accounts for less than 10% of the magazines' total advertising expenditure. 7.3.2.2 Higher taxes on cigarettes Townsend, Roderick and Cooper (1994:923) fmd that smokers in lower socio economic groups respond more readily to changes in the price of cigarettes than people in higher socio-economic brackets. The former groups are less responsive to - 161 - Chapter 7 health publicity than the latter and have the prevalence of smoking is highest in these groups. The authors suggest that the tax on cigarettes should be increased steadily, in order to create real price increases in cigarettes. Hopefully, this will reduce the differences in the prevalence of smoking and smoking related diseases between the socio-economic groups. Yach et at. (1989:411) and Yach (1993:161) support this view and point out that the price of cigarettes has lagged behind the overall consumer price index over the last ten years and cigarettes have, therefore, become more affordable. They propose a tax of at least 50 % of the pack price, for the taxation to have a real impact on cigarette sales. 7.3.3 DISMANTLING TOBACCO/SPORT CONNECTIONS Yach and Saloojee (1994:825) suggest the following elements of an integrated approach to tobacco control in South Africa, which could benefit sports administrators and participants, and promote the health of people generally: • A substantially increased tax, similar to that applied in Australia, should be instituted as a source of funding for the Health Promotion Foundation. The Foundation could, over a period of time, take over the funding of sports events from the tobacco companies. • A total ban on tobacco advertising and promotions, and a ban on smoking in all sport stadia, should be enforced. The International Olympic Committee seems determined to free the Olympics from tobacco sponsorship and publicity. The last few summer Olympics, and the Lillehammer winter Olympics, were declared smoke free. • The sponsorship of scientific research by tobacco companies should be dis continued. Apart from the unwillingness of the tobacco industry to accept scientific evidence about the hazards of smoking, the ethical aspects of using funds from the industry should be considered. - 162 - Chapter 7 Referring to the association between sport and tobacco promotion, Yach and Saloojee (1994:826) conclude: South African sport can ill afford to become dependent on an industry that is responsible for death, disease and disability in the country. The respectability gained by the tobacco industry in being associated with sport needs to be seen in proper context. Goldman (1992:194) remarks that the Australian government has banned all tobacco promotions, and has initiated a levy on cigarette sales, which goes to sports sponsor ship. 7.3.4 THE TREATMENT OF ADDICTED SMOKERS The United States Surgeon General stresses the fact that addiction is a major factor in determining whether a person can give up smoking and argues: "In treating the tobacco user, health professionals must address the tenacious hold that nicotine has on the body" (US Department of Health & Human Services 1988:v). A variety of be havioural intervention techniques, as well as nicotine replacement therapy, are presently available to assist smokers to give up smoking. (US Department of Health & Human Services 1988:v.) 7.4 CONCLUSIONS Farley (1994:52) maintains that"smoking is in danger of being legislated virtually out of existence-or at least shoved into the realm of behavior so socially reviled that it must be practised only in private". Martin, Steyn and Yach (1992:241) insist: "The overwhelming evidence of the role of tobacco in disease, death and disability makes it the ethical duty of governments to protect the health of their people, especially children. " Legislation against smoking must be accompanied by other measures, such as health education campaigns and support services for people who wish to give up smoking. Legislation, on its own, can hardly be expected to be effective. Nath (1986:261) supports this point of view, and remarks as follows on anti-smoking measures in the - 163 - Chapter 7 Third World: "The imposition of rules will have little impact unless supported by a change in awareness and a consequent response." Smolowe (1994:55) remarks that legislators in various countries have tried to curb tobacco consumption by designating smoking and non-smoking areas, banning or limiting cigarette advertisements, imposing heavy taxes, and issuing health warnings. With a few exceptions, such as in Singapore and Australia, however, cultural attitudes " and habits have largely nullified such efforts. 7.5 A THEORY ON CIGARETTE SMOKING The ensuing paragraphs will be devoted to the development of a theory regarding cigarette smoking in an effort to formulate proposals for anti-smoking measures. 7.5.1 INTRODUCTION It is indisputable that, although anti-smoking measures do have an influence on the smoking habits of many people, not nearly enough is being accomplished to prevent the death and crippling of millions of citizens around the world from smoking-related causes. It has become apparent from the literature and the empirical study, that the scrutiny of factors such as human needs and motives, attitudes, beliefs and opinions, and dependence (addiction), are crucial in the study of cigarette smoking as a habit. 7.5.2 DEFINITION OF CONCEPTS 7.5.2.1 Human needs and motives The human body has certain needs such as a need for food and fluids or a need for sleep. An important characteristic of the human body is that it strives to maintain a state of equilibrium, called homeostasis, in many of its internal physiological processes. This balance is essential for survival; for example, the body temperature must not rise too high or fall too low, the acidity/alkalinity of the blood must remain within certain limits, etc. The body is, therefore, constantly providing signals for us to eat, drink, sleep, avoid pain, etc. These signals are generally labelled motives some of our important motives are hunger and thirst. (Morgan et al. 1986:269-272.) - 164 - Chapter 7 Abraham Maslow (1954) postulates that people .are continuously in a motivational state, but that the nature of r. -ivation is fluctu ....ng. He argues that human beings seldom reach a state ofcomplete satisfaction, except for short periods. It follows that, as one need or desire becomes satisfied, another rises to take its place. (McCormick & lIgen 1980:264.) Maslow submits that, because of this fluctuation ofneeds and desires, human motives can be arranged in a hierarchy, starting with motives relating to man's basic physio logical needs, and including the more complex psychological motives (see Figure 7.1). (Hilgard, Atkinson & Atkinson 1979:315/316.) Maslow detailed human motives in the following manner (Hilgard et al. '1979 :316 and Morgan et al. 1986:298): • The need for self-actualization implies the need to find self-fulfilment and to realise one's potential. • Aesthetic needs include needs for symmetry, order and beauty. • Cognitive needs involve the need to know, understand and explore. • Esteem needs motivate us to achieve, to be competent and to gain approval and recognition. • Belongingness and love needs have to do with needs to affiliate with others, to be accepted and to belong. • Safety needs deal with needs to be secure and safe or to be out of danger. • Physiological needs include hunger, thirst, sleep, sex. etc. Maslow argues that the needs at one level must be at least partially satisfied, before those at the next level become important motivators for action. For example, when the basic needs for food and security are not easily met, the satisfaction of these needs - 165 - Chapter 7 Figure 7.1 Maslow's hierarchy of motives - 166 - Chapter 7 will dominate a person's mind and actions, and the higher motives will not receive a high priority, if any. (Hilgard et at. 1979:315.) 7.5.2.2 Beliefs A belief is a statement about the attributes or characteristics of an object, a person, the world, etc., that an individual thinks is true. A person may, therefore, believe that smoking is harmful, or that smoking makes him/her more acceptable toothers, etc. Such a belief may, in tum, lead to an attitude about the particular object (see 7.5.2.3). Beliefs are assessed by how likely they are to be true. (Morgan et at. 1986:382/383.) 7.5.2.3 Attitudes Rokeach (1968) defmes an attitude as "a learned orientation, or disposition, toward an object or situation which provides a tendency to respond favourably or unfavour ably to the object or situation". (Quoted by Morgan & King 1971:509.) The response to an object or situation results from an evaluation which expresses the person's attitude towards it. . These evaluations are expressed in terms of liking/ disliking, pro/anti, favouring/not favouring and positive/negative. A given attitude is often a summary of the evaluations made of different aspects of the attitude object. (Morgan et al. 1986:382/383.) Ifa person believes that smoking is harmful, that it is smelly and makes him/her less attractive, he/she may develop a negative attitude towards the habit. A smoker who believes that smoking makes him/her acceptable in a social group and makes him/her look mature may have a positive attitude towards smoking. An important property of attitudes is that they may guide behaviour (for example avoiding something) or induce a person to act. (Morgan et at. 1986:383.) A non smoker who becomes convinced about the dangers of passive smoking may request friends not to smoke in hislher presence. - 167 - Chapter 7 7.5.2.4 Opinions Zimbardo, Ebbesen and Maslach (1977:20) explain the relationship between attitudes and opinions as follows: "Attitudes are ... internal, private events whose existence we infer from our own introspection or from some form of behavioural evidence when they are expressed overtly in word or deed. A verbalized attitude is called an opinion." Therefore, a non-smoker with a negative attitude towards smo~g may express the opinion that smoking is harmful and should not be allowed in public buildings. 7.5.3 THEORIES ON ATTITUDE CHANGE Psychologists and other social scientists have made numerous attempts to understand the dynamics of attitude change and to develop acceptable theories to explain these dynamics. The more important features of some of these theories are discussed below. 7.5.3.1 The Yale attitude change approach According to the Yale attitude change approach, an attitude is "the affective or emotional reaction people have to the attitude object; it is their liking or disliking for a person, object, group of people, or symbol" (Zimbardo et al. 1977:56). The proponents of this approach believe that attitudes (the affective component) are influenced or changed by altering the opinions or beliefs (the cognitive or knowledge component) of individuals. The basic method applied to change a person's beliefs about a topic is through persuasive communication. (Zimbardo 'et al. 1977:57.) The use of lectures, supported by visual materials on the dangers of smoking, is an example of the application of this approach. 7.5.3.2 The group dynamics approach This approach recognises that individuals are social beings, with an intimate dependence on others for knowledge about the world, and even about themselves. The group dynamics approach maintain that people mainly tend to change their - 168- Chapter 7 attitudes, beliefs and perceptions, as a result of the discrepancy that exists between an individual's attitude or behaviour, and the group norm. This suggests that others do not necessarily have to persuade an individual by argument. They need only to hold a position that is different from that individual's. As long as the individual in question is aware of the discrepancy and need the acceptance, approval and recognition of the group, his/her attitude will tend to change. (Zimbardo et ale 1977:62.) For example, the banning of smoking on a campus, at the request of non-smokers, is a mode of expressing the group norm that smoking is not acceptable to the majority of students. 7.5.3.3 Cognitive dissonance theory Festinger (1967:347) argues that a person's beliefs, opinions and attitudes are normally arranged in clusters that are internally consistent. A non-smoker may, for example, believe that smoking causes disease; he has a negative attitude towards smoking and expresses the opinion that cigarette advertising should be banned. On the other hand, a person may harbour opinions and attitudes that are not consistent, for example, with hislher behaviour..A smoker may know that smoking is' harmful, yet continue to smoke - an inconsistency exists, therefore, between the smoker's belief and his/her actions. In such cases of inconsistency a person may rationalise hislher actions by stating that he/she may put on weight when giving up smoking or that hislher chances ofcontracting a disease are not serious. Ifthe person cannot, however, successfully rationalise the inconsistency, a condition ofpsychologi cal discomfort exists. Festinger (1967:347/348) calls this inconsistency a condition ofcognitive dissonance. He defmes cognitive dissonance as "an antecedent condition which leads to activity oriented towards dissonance reduction just as hunger leads to activity oriented towards hunger reduction" . Festinger (1967:348) argues that when cognitive dissonance exists in an individual, one of the following may occur: - 169 - Chapter 7 • Being psychologically uncomfortable, the person may be motivated to try and reduce the dissonance and achieve 'consonance'. For example, a smoker may make numerous efforts to give up smoking. • In addition to his/her efforts to reduce the dissonance, the person may actively' avoid situations and information which will tend to increase the dissonance. A smoker may avoid reading articles and posters on the dangers of smokin~. 7.5.3.4 Social learning theory Advocates of social learning theory claim that a continuous reciprocal interaction exists between a person's behaviour, the events occurring inside the person (thoughts, emotional reactions, expectations, etc.), and the environmental consequences of that behaviour. Most human actions lead to consequences that feed back on behaviour. This feedback will either maintain or change the probability of similar behaviour in the future. Zimbardo et al. (1977:80) sum up: "The theory assumes that the mechanism by which a person's future behaviour is changed is a form oflearning. " Social learning theory, therefore, is based on the supposition that the likelihood of a specific behaviour is determined by the consequences which are expected to follow the occurrence of that behaviour. Thus, if the consequences are positive or rewarding, the behaviour is likely to be repeated. If the consequences are negative or punishing ( for example, fear arousing), the behaviour is not likely to recur. (Zimbardo et al. 1977:80.) Continuous feedback to smokers, that smoking is not acceptable can be accomplished by administering a [me for smoking in non-smoking areas on a campus. 7.5.4 CIGAREITE SMOKING AND HUMAN NEEDS 7.5.4.1 Starting and continuing smoking Many smokers claim that they started smoking because of peer pressure or influence by others, or that they had the urge to try out smoking. These motives correspond with the belongingness and love needs (to be accepted and to belong), the esteem - 170- Chapter 7 needs (to gain others' approval), and the cogni1ve needs (to explore), in Maslow's hierarchy of needs (see 7 .5.~ /). This implies .....at, in some individuals, a very strong motivation exists to take up smoking. 7.5.4.2 ~icotine dependence The fact that the smoker develops such a dependence on nicotine that giving up smoking becomes extremely difficult, leads to the inference that, for some reason, the substance turns into a basic need for the smoker, similar to food and water. In terms of Maslow's theory, the need for nicotine takes its place among the physiological needs in smokers (see 7.5.2.1). This is confirmed by the following: • The habit is consistent and nicotine intake takes place on a daily basis in order to maintain homeostasis (see 7.5.2.1). The need for nicotine, therefore, resembles the need for food and water. • When cigarettes are not available, most other motives become secondary to the smoker's attempts to fmd nicotine gratification, and withdrawal symptoms, such as anxiety, anger, restlessness and frustration, result when the smoker's efforts are unsuccessful (see 3.3.4.3). • The need for nicotine takes precedence over the smoker's safety needs, such as the need to protect his/her health. 7.5.4.3 Conclusions The acts ofstarting and continuing smoking ar~ strongly associated with human needs. The fact that these needs are physiological, as well as psychological and social, accounts for the powerful hold that nicotine addiction has gained in many people's lives, and for the difficulty of giving up the habit. Although a large proportion of smokers are well aware of the dangers of smoking, the addiction to nicotine does not allow them to stop smoking easily and permanently. - 171 - Chapter 7 7.5.5 A VALUE AND BELIEF SYSTEM In any society, certain values and beliefs are considered as vital to the orderly existence and the survival of the society and its members. A belief system includes "all of the cognitions-ideas, knowledge, lore, superstitions, myths and legends shared by most members of the society and by the typical occupants of the various positions in the society" (Krech, Crutchfield & Ballachey 1962:349). A value is "an especially important class ofbeliefs shared by the members ofthe society ... concern ing what is desirable or 'good' or what ought to be" (Krech et at. 1962:349). The values and beliefs are encompassed in an integrated system which sociologists term the 'culture' of a particular group of people. (Rokeach 1967:374/375.) Certain norms, including the mores, folkways, rules, regulations and laws ofthe society, serve to assist in the enforcement of the cultural values .and beliefs. (Horton & Hunt 1980:61-68.) According to Cantril (1967:61-66), most members of a modem democratic society seek some value or system of beliefs, to which they can commit themselves. Among the beliefs and values, relevant to this study, are the following: .' We believe that humans have the capacity to make choices, and we value the freedom to exercise this capacity. (Cantril 1967:63/64.) For this reason humans are confronted with choices every day. Gibbs (1976:19/20) distinguishes between various kinds offreedom such as conative freedom. Conative freedom implies the capacity to act when a person is in a position to do what seems good to him, what he fmds agreeable, pleasing or worthwhile. The decision to smoke the first cigarette is, therefore, an example of conative freedom. As soon as nicotine dependence has taken root, however, and the smoker wishes to give up smoking, the choice is no longer so free. Equating freedom of choice with the capacity to execute an intention, and the power to do what one wills, it is evident that the addicted smoker no longer has this freedom. Gibbs (1976: 19) calls this 'minimum freedom requisite for action' and terms it optative freedom. - 172- Chapter 7 • Humans value security, both in its physical and psychological sense. (Cantril 1967:62.) This includes the value of being healthy and energetic in order to pursue happiness and material well-being. • Humans believe that they should be allowed to continuously seek to enlarge the range, and to enrich the quality of their satisfactions. (Cantril 1976:62/63.) With regard to eating, drinking and smoking, this value is sometimes in conflict with the value of being healthy. The importance ofscrutinising and analysingthe value and belief systems of particular groups of technikon students, before designing anti-smoking measures, becomes apparent from the above discourse. 7.5.5.1 Conclusions Individuals strive towards their goals within a framework of certain belief and value systems, and under the constraints of the society's cultural norms. The degree of freedom enjoyed by-an individual or group is a function of the extent to which the belief and value system and norms allow them to pursue their goals. Sometimes certain values in a society are in conflict with one another, or the values of one group may clash with those of other groups. A good example of this incongruence in a society is the contrast in beliefs and values of the tobacco industry compared with those of anti-smoking lobbyists, or between those of smokers and non-smokers. An individual's beliefs and values may be in conflict too - resulting in cognitive dissonance (see 7.5.3.3) The problem of 'freedom of choice' is a complex one which is often the subject of philosophical debate. One of the beliefs of modem society is that any form of freedom must be accompanied by a certain measure of responsibility. (Ewing 1951: 1991200.) This implies, for example, that when smokers invoke their freedom to smoke, they must accept responsibility for what happens to their own bodies and to people around them. The same principle applies to the tobacco industry which claims a 'legal freedom' to produce and sell their products. They must then assume responsi bility for the addiction, illness and death which result from smoking. - 173 - Chapter 7 7.6 A MODEL FOR ANTI-SMOKING MEASURES The complexities of tobacco promotion and consumption, and nicotine addiction, require a multi-pronged approach to combatting smoking on technikon campuses. It must be borne in mind that it is not only individuals' attitudes towards various aspects of smoking that should change, but most importantly, their behaviour. It is ofno use if a g.eneral negative attitude towards smoking exists but nothing is being done about it. The recommendations below are in agreement with the theories on human needs and attitude change, and developed in terms of the relevant current belief and value systems discussed in the preceding paragraphs. . 7.6.1 OBJECTIVES OF ANTI-SMOKING MEASURES The main objectives of anti-smoking measures at a technikon campus should include the following: • Non-smokers must be discouraged from experimenting with smoking. The dangers of smoking and the addictiveness of nicotine must be emphasised. • Non-smokers must be protected against environmental smoke (see 7.6.2). • Smokers must be encouraged to give up smoking and those who make attempts must be provided with adequate support. 7.6.2 THE BANNING OF SMOKING IN AND ON CAMPUS FACILITIES The administrations of technikons should ban smoking in all buildings, including offices, residences, sport and transport facilities, and during meetings. This rule should be firmly applied and adhered to. The message must be clear that smoking is no longer an acceptable habit and some form ofpunishment, such as a fme, should be imposed on offenders. During 1993, the author visited various education institutions in Canada, where smoking in buildings is strictly prohibited. - 174- Chapter 7 This measure should be preceded by a questionnaire among staff and students to test their attitude towards the banning of smoking. The fmdings of the empirical research suggest that a significant proportion of students will support such a measure (see 6.6.7.1). 7.6.3 ASSISTINGSMOKERS INTHEIR EFFORTS TOSTOP SMOKING Saloojee (1988:136) quotes McKennell and Thomas (1967) who claim that "for many smokers the question is no longer, whether to stop or not, but how to stop". The present study proves that many smokers make numerous attempts at giving up smok ing; very little support is, however, available to them. Certain techniques can be applied in efforts to overcome nicotine addiction, and these techniques should be made known to smokers. Ogle (1981), for example, proposes an anti-smoking diet which helps to counteract the craving for nicotine. In this respect, the technikon can play a role by inviting representatives from anti-smoking organisations such as the Council Against Smoking for advice. Support groups can be organised on campus to assist smokers during their attempts to give up smoking. In cases where the addiction is extreme and psychological pressures make it difficult for a smoker to give up .smoking, appropriate counselling should be accessible. 7.6.4 MARKETING STRATEGIES The tobacco industry applies the most sophisticated marketing strategies in their promotion ofcigarettes and the smoking habit. A technique to counteract these strate gies is to apply similar professional tactics to promote health, and to convince young adults not to smoke. The administrations and/or Students Affairs departments of technikons should consider employing the services of advertising agencies to assist in the design of a health promotion and anti-smoking programme. 7.6.5 STUDENT PROJECTS Students should be assisted to study smoking and the hazards of smoking. For example, a health promotion programme can be designed, as a joint study project, by environmental health and marketing students. An important objective of such a pro gramme should be to increase students' awareness ofthe addictive nature of tobacco - 175 - Chapter 7 use. Students can be employed to conduct surveys among school children, followed by anti-smoking campaigns at schools. (Pomrehn et al. 1995:93.) 7.6.6 RESEARCH PROJECTS Many aspects of smoking lend themselves to potential research. One of the technikon's objectives is to teach research skills to its students - researcI¥ng the various elements oftobacco consumption is a worthwhile project which could promote students' awareness of the hazards of smoking and possibly motivate them to participate in anti-smoking actions. 7.6.7 HEALTH EDUCATION For the purposes of this dissertation, 'health education' includes all sources of information about the effects of smoking on health. (cf Royal College of Physicians 1983:105.) 7.6.7.1 Conditions for effective health education The main objective ofhealth education is to assist in changing people's behaviour and to' reduce the prevalence of smoking. Hochbaum (1960) (quoted by Saloojee 1988), believes that five conditions are essential for health education to be effective, namely: • The target audience must be made aware that a threat exists. Smokers and non smokers must believe that smoking is harmful and addictive. • The audience must recognise the seriousness of the threat. There must be no doubt about the deaths and grave illnesses which result from smoking. • The members of the audience must see the threat as personally relevant. Smokers and non-smokers must realise that everybody is vulnerable to the dangers of smoking. - 176 - Chapter 7 • The audience must accept the value of preventive measures. They must be convinced that giving u. ',moking, and b .... .ning smoking from buildings, can prevent further harm to smokers and non-smokers. • The members of the audience must feel capable of taking the desired action. Smokers must believe that they can stop smoking ifthey try, and non-smokers must know that they will be supported in their efforts to ban smoking from buildings. A sustained programme for educating students about smoking should be designed in consultation with the student body. The goals and objectives ofthe programme should be clearly defmed. Possible topics and methods should be discussed with the students and appropriate speakers should be selected . 7.6.7.2 Lectures, talks and work sessions, etc Medical doctors and specialists (for example oncologists), other anti-smoking cam paigners, ex-smokers and sportsmen and -women and trainers, can be invited to arrange symposia, lectures, talks, panel and small group discussions, and work . sessions with students. (Fodor & Dalis 1989:67.) The Royal College of Physicians (1992:75) proposes the following as some ofthe objectives of anti-smoking campaigns: • To provide information about the short- and long-term consequences of smoking on physical fitness, health, personal expenditure, appearance, the environment, the economy and society as a whole. • To assist students to resist the social and marketing pressures to smoke, by teaching appropriate personal and social skills. • To implement different methods of communication, combining personal, group and mass media methods to reach all students, particularly high risk groups. The effective use of relevant audio-visual materials would be critical to the success of these meetings. One of the essential requirements of these lectures, talks and work sessions, is student participation and opportunities for questions. - 177 - Chapter 7 7.6.7.3 Debates Smoking allows for many possible topics for debate among students, especially those in health programmes. Debates give students the opportunity to air their views and fears, and to provide for better understanding of one another's points of view. 7.6.7..4 Educational media Books, pamphlets, posters, journal articles and video material on smoking and the latest research results relevant to smoking should be purchased regularly and displayed for use and perusal by the student body. 7.6.8 GENERAL ANTI-SMOKING MEASURES • Cigarette vending machines should not be allowed on technikon campuses. The presence of these machines provides the smoking habit with a suggestion of acceptance and legitimacy. • All sport sponsorship by tobacco companies, advertising and other promotional measures, such as handing out free cigarettes to students, should be prohibited on campuses. 7.6.9 EVALUATION OF ANTI-SMOKING MEASURES Anti-smoking measures should be evaluated regularly for their effectiveness. Short questionnaires, distributed to the audience after lectures and discussions etc., should be applied to assess students' views on the usefulness of the various efforts. 7.6.10 VALUE AND BEliEF SYSTEM It is important that anti-smoking measures are planned and performed within the value and belief system ofthe technikon students. Ifthis is not done, it will not be possible to develop a .'learned orientation ... which provides a tendency to respond '" unfavourably towards smoking' (Morgan & King 1971:539). This attitude would guide behaviour (see 7.5.2.3). - 178 - Chapter 7 7.7 SUMMARY Various measures are presently applied to combat smoking and it is the Government's policy to extend these measures in the near future. Legislation prohibits the sale of cigarettes to persons under the age of 16 years, and enforces the placing of anti smoking warnings on cigarette packets and above cigarette advertisements. Some local .authorities have promulgated regulations banning smoking in public places. A number of anti-smoking measures are proposed by campaigners, among others, the dismantling of tobacco/sport connections and higher taxes on cigarettes. A theory on smoking is submitted which links smoking with human needs in terms of Maslow's theory on the hierarchy of motives and needs. Theories on attitude change, such as the Yale theory, the group dynamics approach, cognitive dissonance theory and social learning theory, are discussed in order to design a model for anti-smoking measures on technikon campuses. The model includes, among others, health education, the banning of smoking in tech . nikon buildings and assistance to smokers who want to stop smoking, all within the value and belief system of the technikon students as a target group. - 179 - Chapter 8 CHAPTER 8 SUMMARY AND CONCLUSIONS 8.1 INTRODUCTION This final chapter is devoted to a summary and review ofthe research project and in cludes an outline of the conclusions and recommendations of the dissertation. The limitations, shortcomings and deficiencies ofthe project are discussed and the potential for further research is highlighted. 8.1.1 MOTIVATION FOR THE STUDY Hundreds of thousands of young people take up smoking each year, in spite of the widespread awareness of the dangers of smoking. Cigarette smoking has become a public health problem in terms of the resulting illness and large number of deaths, as well as the nuisance it creates for non-smokers. This study attempts to reveal smokers' and non-smokers' attitudes, beliefs and opinions regarding certain aspects of smoking, and includes a scrutiny ofnicotine addiction and the patterns of smoking of tecbnikon students. From the results of the study, a theory on smoking is developed which leads to the design of a model for anti-smoking measures at technikon campuses. 8.2 SUMMARY OF THE STUDY PROJECT Chapter 1 serves as an introduction to the study and includes a historical outline of tobacco use, the motivation for the study, the extent of the problem, the problem statements, the aims of the study, the possible contribution of the study, the sources - 180 - Chapter 8 and research methods, a definition of relevant concepts, and an outline of the programme of the study. In Chapter 2, the tobacco plant and its chemical characteristics are outlined, and tobacco and cigarette production briefly scrutinised. An important part of the chapter is devoted to the pharmacology and toxicology oftobacco smoke, which denotes some of the dangers of tobacco consumption. The problem of atmospheric pollution by .; smoking is discussed as a precursor to the study of passive smoking. Chapter 3 is devoted to the study of literature on nicotine addiction, as well as on death and illness resulting from smoking. Addiction is defmed and criteria for drug dependence stated. The roles of tolerance and withdrawal in the addiction syndrome is highlighted, and the psychological determinants of nicotine addiction is put under scrutiny. Smoking-related mortality in various countries is analysed and statistics of diseases resulting from smoking, such as cancer, and heart and respiratory disease, are shown. The effects of smoking on women, the foetus and children are summarised, and the dangers of passive smoking on non-smokers are put into perspective. . Chapter 4 outlines certain economic aspects and arguments around tobacco production and consumption. Tobacco companies spend large amounts on the promotion oftheir products, in the form of advertising, sport sponsorship, etc. The youth of all population groups, and particularly blacks and coloureds, are targeted in these marketing campaigns. The economic advantages for a country, oftobacco production, is weighed up against the economic cost and the sacrifice in terms of lives. The conclusion is that the world can no longer afford this expensive and crippling product. Chapter 5 gives a brief overview ofsmoking among young people, and shows that the smoking prevalence of the genders and population groups varies significantly. The chapter discusses factors related to the onset of smoking and shows the part that social motives play in starting smoking. This chapter is designed to serve as a preamble to Chapter 6. Chapter 6 is the empirical chapter in which the planning of the research is outlined, the problems and sub-problems are stated, and the hypotheses are defmed. A discus sion of the technical details of the empirical research and the measuring instrument is - 181 - Chapter 8 followed by a detailed report on the results of the completed questionnaires. Finally, the hypotheses are tested with the aid of the chi-square test and conclusions are formulated. In Chapter 7, existing and planned anti-smoking measures are summarised as a preamble to a theory on smoking. An attempt is made to explain the addiction to nicotine in terms of accepted psychological and sociological theory. The part that human needs and motives, as well as attitudes and opinions, play in smoking, is examined. This is followed by a discourse on attitude change, and theories about attitude change. Finally, a model for anti-smoking measures on technikon campuses in South Africa, within the framework of a belief and value system, is proposed. 8.3 GENERAL CONCLUSIONS Some of the issues raised in Chapter 1, deserve a fmal assessment (see 1.1): 8.3.1 THE INDIVIDUAL'S FREEDOM OF CHOICE TO START SMOKING It is certainly the right of an individual to experiment with smoking. The evidence is clear, however, that many smokers become so addicted to nicotine that they no longer have the freedom to choose whether they want to continue smoking or not. The Tobacco Institute's assertion, in an advertisement in The Sunday Times (10 December 1995), that adults "should have the right to decide for themselves whether or not to smoke" is refuted by this fact. 8.3.2 THE FREEDOM TO SMOKE IN NON-SMOKERS' PRESENCE The Tobacco Institute advocates on behalf of smokers that "The scientific evidence .. , does not demonstrate that exposure to ETS [environmental tobacco smoke] is a cause of disease." (Advertisement in The Sunday Times of 10 December 1995.) This is contrary to the results of a growing body of research which proves that smoking is extremely hazardous to non-smokers, especially children and unborn babies. - 182 - Chapter 8 8.3.3 THE FREEDOM OF TOBACCO COMPANIES TO ADVERTISE The tobacco industry claims the freedom to promote their products through advertising and sponsorships (for example ofsports events). The excuse is used that these promo tional activities are not designed to persuade non-smokers to smoke, but to get smokers to change to a particular brand. The fact that the youth and other vulnerable groups are targeted brings these claims in disrepute. The tobacco companies are des perately trying to replace the large numbers of adults who are currently giving up smoking. 8.3.4 THE ECONOMIC BENEFITS OF SMOKING The claim of the tobacco industry that they contribute towards the wealth of many countries is true. Tobacco can, however, be replaced by other crops and economic activities. The world can no longer afford the increasing number of deaths and diseases caused by smoking. 8.4 WEAKNESSES OF THE RESEARCH PROJECT The shortcomings ofthis research project are reviewed in tenus ofthree criteria which include the limitations of the project, the threats regarding pure research, and the deficiency of the project. 8.4.1 LIMITATIONS OF THE RESEARCH PROJECT • The relatively small number of coloured and Asian students who completed the questionnaire limit the significance of the conclusions made about these groups. 8.4.2 THREATS IN RESPECT OF PURE RESEARCH • The respondents exhibited a great variety of characteristics, for example, in tenus ofgender, population group, smokers, non-smokers and ex-smokers, year ofstudy, etc. It is, therefore, not possible to ascertain with any degree of certainty whether the sample complied with the requirements of a stratified sample. - 183 - Chapter 8 • A mistake in Question 33 of the Afrikaans version of the questionnaire rendered this question unsuitable for analysis. • Because of the absence of ameasuring scale in the questions, the strength of attitudes and opinions of the respondents cannot be determined. 8.4.3. DEFICIENCIES IN THE RESEARCH PROJECT • The questionnaire could have included the following questions: • To smokers: Why do you wish to give up smoking? • To non-smokers: What is the main reason why you do not smoke? • The question on the banning ofcigarette advertising (Question 30) could have been sub-divided into advertisement in the different media, such as radio, newspapers, etc. . 8.5 TOPICS FOR RESEARCH The potential for research around problems ofsmoking is limitless. It is a continuous ly changing scene which requires constant investigation. Yach, Steyn & Albrecht (1989:158/159) propose the following urgent questions which deserve attention: • Surveillance of the prevalence of smoking and the rate of giving up smoking in populations should be encouraged (due to increasing smoking rates among blacks and coloureds in South Africa). • Details of the incidence of smoking among primary and secondary school children of all races are required (there is a suggestion that children are taking up smoking at an ever earlier age). • The prevalence ofsmoking among schoolleavers (and drop-outs), and military ser vicemen is a way to monitor the future impact of smoking on health and would suggest appropriate targets for intervention. - 184 - ChopterS • Smokingrates among nurses and teachers should be studied (the type of counselling and advice on smoking given are strongly determined by the counsellor's own smoking habits). • Determinants of smoking such as age, race, sex, urban-rural differences, length of residence in an urban area, and social class need attention. • The attitudes, beliefs and behaviour of children with regard to smoking have been shown to be related to peer pressure, family roles and the marketing industry. 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Parow: South African Medical Research Council. ZIMBARDO, P.G., EBBESEN, E.B. & MASLACH, C. 1977. Influencing attitudes and changing behavior. 2nd edition. Reading, Massachusetts: Addison-Wesley Publishing Company. - 198 - · ANNEXURE A - 199 - QUESTIO~AIRE The content of this questionnaire is confidential - do not write your name on it 1. TechiIikon: 2. Department: 3. Course and level (e.g. Civil Engineering SI, etc): 4. Year of study (1st, 2nd, 3rd year, etc): 5. Gender (male/female): 6. Home language: 7. Population group: 8. Age: < Make a cross in the appropriate block: Yes No Don't know 9. Does or did your father smoke? 10. Does or did your mother smoke? 11. Do you have older brothers/sisters who smoke or had smoked? 12. Does your current girlfriend/boyfriend or wife/husband smoke? 13. Have you attended an anti-smoking campaign or anti-smoking lectures at school? 14. Have you attended any other anti-smoking campaigns or anti-smoking lectures? 15. If yes, did these anti-smoking campaigns or lectures influence you negatively towards smoking? 16. Do you believe that smokers have the right to smoke where and when they like? 17. Do you believe that smoking is bad for a smoker's health? 18. Do you believe that smoking can cause heart disease? 19. Do you believe that smokers can get lung illnesses easier than non- smokers? 20. Do you believe that smoking can cause cancer? 21. Do you believe that smoking can shorten a smoker's life? 22. Do you believe that smoking can harm a smoker's physical performance, e.g. in sport? 23. Do you believe that smoking could be bad for non-smokers, e.g. room mates? 24. Do you believe that smoking could be harmful to unborn babies? 25. Have you noticed the warning about the dangers of smoking on cigarette packets? 26. Ifyes, has this warning influenced you negatively towards smoking? 27. Have you noticed the warnings about the dangers of smoking above cigarette advertisements in newspapers and magazines? 28. If yes, have these warnings influenced you negatively towards smoking? PLEASE TURN OVER I IEJBI~~ 29. Do you feel that cigarettes should be heavily taxed by government? 30. Do you feel that cigarette advertising should be banned? 31. Do you feel that smoking should be prohibited in eating places? 32. Does it bother you when people smoke in your room? 33. Would you ask a smoker not to smoke in your bedroom? 34. Would you ask a smoker not to smoke in your presence on public transport? , 35. Do you feel that smoking should be prohibited in taxis, on buses and trains? ISMOKERS ONLY IEJB[;J 36. Do you smoke when non-smokers are in your presence? 37. Would you put out your cigarette when a non-smoker asks you to do so? 38. Do you believe that you could give up smoking permanently if you wish to do so? 39. Which brand of cigarette do you smoke mostly? (Please specify: e.g. Chesterfield Lights, etc.) 40. How many cigarettes do you smoke per day? 41. How old were you when you started smoking? 42. Why did you start smoking? 43. What is the main reason why you'smoke? 44. How many times have you tried to give up smoking? 45. When last have you tried to give up smoking? INON-SMOKERS AND EX-SMOKERSONLY IEJc:=J 46. Have you ever smoked cigarettes? 47. Did you smoke regularly? 48. If you were a regular smoker, why did you give up smoking? THANK YOU FOR COMPLETING TIllS QUESTIONNAIRE Annexure A RESEARCH ON CIGARETTE SMOKT1\TG AMONG STUDENTS Objectives of the study The purpose of the study is to examine the patterns of smoking as well as the knowledge, attitudes and beliefs about smoking among Technikon students. C I wish to establish whether any changes regarding smoking do take place among students from their first to second and third, etc., years of study. Support The Medical Research Council, SA Institute of Medical Research and the Council against Smoking are all interested in the progress and results of this study. Timing I will appreciate it if you could apply the questionnaire early during the second semester. Address for despatch of the completed questionnaires The completed questionnaires must please be posted to my home address (I will be on study leave): 72 Entombeni Drive AMANZIMTOTI 4126 Telephone: (031)-9033497 - 202- Annexure A Sampling Sample size I would like to receive the responses of approximately 300 students from your Technikon, viz roughly 100 first years, 100 second years and 100 third years. Method The sample must be drawn in a way that will conform with the requirements of research. In this case we are using the method of 'cluster' sampling where groups of st~dents are selected rather than individuals. The following method is recommended: • Get a list of all the programmes and levels offered during the second semester at your Technikon together with the numbers of students in each of the levels. • Distinguish between course levels which fall in the first, second and third years of study. (I wish to make a comparison between the smoking habits, etc., of first, second and third year students, etc.) • Write the following on separate pieces of paper for each level: names of programmes and levels number of students in the level in which year the level falls Example Civil Engineering S1 56 students 1st year Environmental Health S3 45 students 3rd year • Start with first year courses and put the pieces of paper in a container (such as a hat). - 203 - Annexure A Ask a colleague to draw one piece ofpaper at a time until you have roughly 100 students. Do the same for second and third year students. • Have a sufficient number of questionnaires photo copied for the number of students you have drawn into the sample. VERY IMPORTANT: Please copy the questionnaires back to-back - it is imperative that a respondent's answers are kept together. • Ask colleagues to help apply the questionnaire to the students in the sample. Please send me an invoice for the copying and mailing costs. Thank you very much for your help. Leon Oberholster - 204- ANNEXUREB - 205 - VRAELYS Die inhoud van hierdie vraelys is vertroulik - moenie u naam daarop skryf nie I. Technikon: 2. Departement: 3. Kursus en vlak: (bv Bemarking I, ens) 4. Jaar van studie (lste, 2de, 3de jaar, ens): 5. Geslag: 6. Huistaal: 7. Bevo1kingsgroep: 8. Ouderdom: Maak kruisies in die blokkies van jon keuse: Ja Nee Onseker 9. Rook u vader of bet hy gerook? 10. Rook u moeder of bet sy gerook? II. Het u ouer broers/susters wat rook of gerook het? 12. Rook u huidige nooi/kerel of eggenootleggenote? 13. Het u ooit 'n anti-rook veldtog of anti-rook lesings op skool bygewoon? 14. Het u enige ander anti-rook veldtoe of anti-rook Iesings bygewoon? 15. Indien ja, het hierdie anti-rook veldtoe of Iesings u negatief ingestel teenoor rook? 16. Glo u dat rokers die reg bet om te rook waar en wanneer hulle wil? 17. Glo u dat rook skadelik vir rokers se gesondheid is? 18. Glo u dat rook bartsiektes kan veroorsaak? 19. Glo u dat rook rokers meer vatbaar vir Iongsiektes kan maak? 20. Glo u dat rook kanker kan veroorsaak? 21. GIo u dat rook rokers se Iewe kan verkort? 22. Glo u dat rook nadelig vir rokers se fisiese prestasie kan wees, bv in 23. Glo u dat rook vir nie-rokers, bv kamermaats nadelig kan wees? 24. Glo u dat rook nadelig vir ongebore babas kan wees? 25. Het u die waarskuwing oor die gevare van rook wat or sigaretpakkies aangebring 26. Indien ja, bet die waarskuwing u negatief ingestel teenoor rook? 27. Het u die waarskuwings oor die gevare van rook wat bokant sigaretadvertensies in 28. Indien ja, het die waarskuwings u negatief ingestel teenoor rook? BLAAI ASSEBLIEF OM: I ~Ionsekerl 29. Voel u dat sigarette SWaaI. belas behoort te word deur die regering? 30. Voel u dat sigaretadvertensies verbied behoort te word? 3l. Voel u dat rook in eetplekke verbied behoort te word? 32. PIa dit u as persone in u kamer rook? 33. Sal u 'n Die-roker vra om Die in u kamer te rook Die? 34. Sal u 'n roker vra om Die in u teenwoordigheid op 'n openbare vervoermiddel te rook nie? 35. Voel u dat rook in huurmotors, op busse en treine verbied behoort te word? IROKERS VOLTOOI HIERDIE AFDELING I Ja INee[D~ 36. Rook u met nie-rokers in u teenwoordigheid? 37. Sal u 'n sigaret uitdoof wanneer 'n Die-roker u vra om dit te doen? 38. Glo u dat u rook permanent kan opgee indien u wil? 39. Watter soort sigaret rook u meestal? (Spesifiseer asseblief, bv Chesterfield Lights): 40. Hoeveel sigarette rook u per dag? 4l. Op watter ouderdom het u begin rook? 42. Om watter rede het u begin rook? 43. Wat is die grootste rede waarom u rook? 44. Hoeveel keer het u al probeer rook opgee? 45. Wanneer het u laas probeer rook opgee? NIE-ROKERS EN OUD-ROKERS VOLTOOI HIERDIE AFDELING Ja Nee 46. Het u ooit sigarette gerook? 47. Was u 'n gereelde roker? 48. Indien u 'n gereelde roker was, waarom het u rook opgegee? DANKIE DAT U IllERDIE VRAELYS VOLTOOI HET Annexure B NAVORSING OOR SIGARETROOK ONDER STUDENTE Doel van die ondersoek Die doel van die ondersoek is om patrone van rook, kennis, houdinge en gelowe oor rook onder Technikon studente te probeer bepaal. Ek wil ook graag vas stel of daar veranderinge onder studente ten opsigte van rook plaasvind vanafhulle eerste LOt derde of vierde jare aan Technikons. Ondersteuning Die Mediese Navorsingsraad, SA Instituut vir Mediese Navorsing en die Raad teen Rook stel belang in die verloop en resultate van hierdie projek. Tydsberekening Ek sal dit waardeer indien u die vraelys vroeg gedurende die tweede semester kan laat invu!. 'Adres vir versending van ingevulde vraelyste Die ingevulde vraelyste moet asseblief so gou as moontlik aan my versend word by die volgende adres (ek sal teen daardie tyd tuis wees met studieverlot). Entombeni-rylaan 72 AMANZIMTOTI 4126 - 208- Annexure B Monstememing Grootte vandie monster Ek sal graag die response van ongeveer 300 studente van u Technikon wil ontvang, dws 100 studente in die eerste jaar, 100 in die tweede jaar en 100 in die derde jaar. MetOde Die monster moet getrek word op 'n wyse wat aan die vereistes van navorsing sal voldoen. Ons maak van die 'tros'-steekproefmetode gebruik (cluster sampling) waarin die vraelys aan groepe studente voorgele word. Die volgende metode word aanbeveel: • Vra 'n lys aan van al die programme en vlakke wat gedurende die tweede semester aan u Technikon aangebied word tesame met die aantal studente in elk van die vlakke. • Onderskei tussen kursusvlakke wat gedurende die eerste jaar, tweede jaar, derde jaar, ens., v~ studie val. (Ek wil 'n vergelyking tref tussen die rookgewoontes van eerstejaars, tweedejaars, ens.) • Skryf die volgende op aparte stukkies papier: name van programme en vlakke aantal studente in die vlak in watter jaar van studie val die yak Voorbeeld Siviele Ingenieurswese S1 56 studente lste jaar - 209- Annexure B Omgewingsgesondheid 53 45 studente 3de jaar • Begin by eerste jaar programme en plaas die stukkies papier in 'n houer (soos 'n hoed) Vra 'n kollega om die stukkies papier een vir een te trek totdat U ongeveer 100 eerste jaar studente getrek het "' Doen dieselfde vir tweede en derde jaar studente • Laat genoeg afskrifte van die vraelys kopieer vir die aantal studente wat u in die steekproef getrek het. Let wel: kopieer asseblief die vraelys se twee bladsye rug aan-rug - dis baie belangrik dat 'n respondent se antwoorde bymekaar bly! • Vra kollegas om die vraelys deur die groepe wat u getrek het te laat voltooi. Stour asseblief 'n faktour vir die koste van die kopiering aan my. Baie dankie vir die hulp. Leon Oberholster - 210-