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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. ~t6~.~: ad '" flO«' ~ it. p'Z4i4e tpd. ad~it Ilea t6 a. ~~: /tn~ude~~ dat ~ ~Me e4{t4&e 01-: a. ~ dat ~ e4#U«Jt~. - Izaak Walton (1593-1683) (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 .<fJ- .f 3.4.2.2 The United Kingdom 42 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