The approach of smokers to the new tobacco law and the change in their behaviour

Giriş: Çalışmamızın amacı, sigara içenlerin yeni tütün yasasına yaklaşımlarını ve yasa sonrası sigara içme alışkanlıklarındaki değişimleri ve bu değişimde rol oynayan etkenleri değerlendirmektir. Materyal ve Metod: Veriler 30 soruluk anketle toplandı. Anket halen sigara içmekte olan ya da yasa sonrası sigarayı bırakmış 1509 kişiye uygulandı. Analizler için SPSS paket programı kullanıldı. Bulgular: Katılımcıların 419 (%28)’u kadın, 1090 (%72)’ı erkek olmak üzere yaş ortalaması 33.6 ± 10.5 yıldı. %80’i pasif içiciliğin sağlığa zararlı etkilerini bilmekle beraber evde ve araç içinde sigara içme oranları yüksekti. Katılımcıların 869 (%58)’u yasayı destekliyordu; 87 (%5.8) kişi yasadan sonra sigarayı bırakmış, 316 (%20.9) kişi ise azaltmıştı. Sağlık sorunları (%37.3) sigara bırakmada en sık neden iken, sigara içilen alanların kısıtlanması azaltmada en sık nedendi (%54.2). Sonuç: Yeni tütün yasasının sigara içenlere sigarayı bırakma yönünde etkili olduğunu saptadık. Bununla birlikte sigara içenlerin büyük çoğunluğu yasayı desteklemektedir. Anahtar Kelimeler: Tütün yasası, Türkiye.


INTRODUCTION
Tobacco smoking is a powerful risk factor for many diseases (1)(2)(3)(4)(5).It kills nearly 6 million people and causes hundreds of billions of dollars of economic damage worldwide each year.If current trends continue, by 2030 tobacco will kill more than 8 million people worldwide each year, with 80% of these premature deaths among people living in low and middle-income countries.Over the course of the 21 st century, tobacco use could kill a billion people or more unless urgent action is taken (6).
In March 2004 Ireland became the first country in the world to impose an outright ban on smoking in workplaces.The Irish legislation made it an offence to smoke in workplaces, which had the effect of banning smoking in pubs and restaurants (7).Following this successful example, other countries, such as Norway, Italy, Britain, Portugal and Sweden, have drafted plans to establish similar laws.
The tobacco control efforts made significant progress in recent years in Turkey.In December 2004, Turkey ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) with the Law no 5261.This law bans consumption of tobacco products in all enclosed public and private places including restaurants and business places across Turkey as of 19 July 2009.From this date on, it is illegal to smoke in coffeehouses, cafeterias, pubs, narghile-smoking places, clubs of associations and foundations, restaurants, taxis, mass transportation vehicles of highway, railway, seaway and airway (8).
In order to evaluate the effectiveness of Tobacco Control Policies, national-scale studies are needed.Questionnaire studies are one of the methods to be used for this purpose.We performed this questionnaire study for determine the reaction of individuals to the new legislation.

MATERIALS and METHODS
In our research, the questionnaire included thirty question.The first seven questions asked for personal information, the 8-13 th questions were for Fagerstrom Nicotine Dependence Scale, 14-18 th questions were for comments about the Tobacco Act and to measure the smoking habit changes after the law, 19-30 th questions were for current smoking habits.The questionnaire was prepared as total of two pages (one sheet) for easy implementation.The study's sample included 1509 persons who are current smokers or who quitted smoking after July 2009.Data were analyzed using the SPSS version 15.0.Data were expressed as mean ± SD.For comparisons of continuous variables, a Student's t test was performed.The chi-square test (or Fisher's exact test when appropriate) was used for testing differences between groups.A p value less than 0.05 was considered statistically significant.

RESULTS
Social and demographic features of study participants were shown at Table 1.Tobacco Law was supported and accepted largely by smokers (869-57.6%).443 of the participants (29.4%) are against the law, 197 (13.1%) were undecided.The number of men who oppose to the new law were more than women (p= 0.001) (Figure 1).
When we asked "Did you received any warning or response after the tobacco ban?", 426 (28.2%) of the participants answered positively.1207 of participants (80%) accepted that passive smoking is harmful to human health.People with at least high school education were more knowledgeable about the risks of passive smoking (91.3%).
Majority of participants smoke at home.Their number is 1171 (77.6%).When we asked which part of house they smoke; 784 people said they use open spaces such as balcony and garden.Therefore 387 (25.6%) people smoked indoors at home.932 of participants have own vehicles.577 of them (61.9%)smoked in their vehicles.365 (24%) of 1509 participants in the study, have children under the age of five.266 of them (72.9%) were smoking at home.58 (15.8%) of them were smoking in all rooms in the house.
The number of participants reduced smoking after the new law were 316.Due to the restriction of smoking area were 192 (61.1%), and this was significantly higher in comparison to other causes.The number of those who reduced smoking because of health problems were 41 (13.1%).The number of smokers who decreased smoking because of social pressures, affection from patients who died because of smoking related diseases, and fines were close to each other.Four participants decreased smoking for financial reasons, three participants for other reasons.Smokers supporting the law reduced and quitted cigarette more than the others.9.7% of smokers who opposed the law increased smoking (Figure 3).
Women reduced smoking more than men after the law (7.6%-5%).Quit rate was the highest in house wives.
The approach of smokers to the new tobacco law and the change in their behaviour

DISCUSSION
Turkey started to implement the smoke-free Air Act, as the sixth country in the world, and the third in Europe.
Our country is considered by World Health Organization's 2009 report as one of the countries that successfully applied the law (9).The Tobacco and Alcohol Market Regulatory Authority presented that, during the first four months of 2010, cigarette sales decreased 6.364 billion units (22.63%) in comparison to the same period in 2009.There are a number of studies on European countries that study the effects of the law.For example following the implementation of the Irish smoking ban a drop in cigarette sales of 7.5% has been reported in the first six months (10).In England equally as a whole, cigarette sales fell by 11% during July 2007 compared with July 2006 A survey of 1750 smokers in the U.K., immediately following the implementation of a smoking ban in 2007, found that 1% had quit, and a further 3% had intended to quit, in response to the policy measur (11).In Italy, a systematic review and meta-analysis showed that smoke-free workplaces were associated with reductions in smoking prevalence of 3.8% among employees and with 3.1% fewer cigarettes smoked per day per continuing smokers (12).In Norway, among persons aged 16-74 years in 2003 (prior to their smoking ban) there was a smoking prevalence of 27.3%.This ratio, fell to 24.5% in 2006 after the ban (13).
In our study, the tobacco law was supported and accepted largely by smokers (869-57.6%).A survey of 3114 subjects (smokers and non-smokers, 1511 men and 1603 women) during March-April 2005 in Italy showed that, 90.4% were moderately or more supported the ban in public smoke-free areas such as cafes and restaurants and 86.8% supported the total ban of smoking in all workplaces, public and private places (14).
334 (22.0%) people were using another tobacco product with cigarette.178 users of other tobacco products were Maras powder, 99 used narghile.High rate of Maras powder usage was evaluated as a situation unique to our region.Additional tobacco products usage was increased accordingly with the degree of dependence.Educational policy studies for the damage of tobacco products are focused on cigarette but other tobacco products are ignored.It is same in our study.Tobacco products other than cigarette are only harmful to users.These products should be taken under control programs.
Atilla  Although 80% of smokers knew that passive smoking is harmful to non-smokers, rate of smoking at home and in the car were very high.In this respect; the activities related passive smoking should be increased.
Smoking quit rate due to high prices was higher (6.0%), than the law punishment (3.0%).This result shows that increasing cigarette prices is more effective than fines.Indeed, people go on smoking in the house, outdoors or in personal vehicles.Increasing tobacco prices through higher taxes is the most effective intervention to reduce tobacco use and encourage smokers to quit (15).Indeed, some countries have imposed tobacco taxation rates in excess of 75% of the retail price (16).It is estimated that for each 10% increase in retail prices, consumption is reduced by about 4% in high-income countries and by about 8% in low and middle income countries.Young people and low-income smokers are two-to-three times more likely to quit or smoke less than other smokers after price increases, because these groups are the most economically sensitive to higher cigarette prices (17).
Second-hand smoke causes a wide range of diseases, including heart disease, lung cancer and other respiratory ailments (18).There is no known safe level of second-hand smoke exposure.Completely smoke-free environments are the only proven way to protect people adequately from the harmful effects of second-hand smoke.The current law, protects individuals from the harmful effects of ETS only in the public areas.The law should be extended in this direction.Preventive measures should be employed as a first line of defence, while all other measures should be regarded as secondary options.If we would like to live in a better society, and a better world, people should not suffer and lose their lives on such a scale for a reason that is easily preventable (19).

Figure 3 .
Figure 3. Smoking position after law and opinions about law (p< 0.001).

Table 1 . Demographic features.
Figure 1.Relationship between gender and opinion about tobacco law (p= 0.001).