Nighat Nisar  ( Department of Community Medicine, Baqai Medical University, Karachi. )
Majid Hafeez Qadri  ( Department of Community Medicine, Baqai Medical University, Karachi. )
Kiran Fatima  ( Department of Community Medicine, Baqai Medical University, Karachi. )
Shakeela Perveen  ( Department of Community Medicine, Baqai Medical University, Karachi. )

Objective: To determine the proportion of people consuming tobacco in various forms, level of knowledge and practices regarding various harmful effects of tobacco and passive smoking.

Methods: A cross-sectional study was conducted at Ghulam Mohammad Jokhio Goth, a small semi urban community of Gadap Town Karachi, which comprises of a population approximate 2225. About 157 people were interviewed regarding their tobacco consumption practices through a semi structured pre-tested questionnaire from June to August 2005. There were 314 households in the community and every alternate household was selected with a random start. The study subject was selected among all the adult members of 18 years age and above present at the time of interview in the household by lottery method and the questionnaire was administerd to those who were resident of GM Goth after taking consent.

Results: In our study 110 (70%) people were tobacco consumers, 47% were knowledgeable about hazards of smoking, 22% were aware about passive smoking, and 90% started consuming tobacco below 20 years of age. The most popular form of tobacco was pan 40%, cigarette 39% and hookah 19%. Eighty four percent were regular smokers. Only 13.6% took counseling, 26.3% tried to quit smoking but none of them succeeded. About 23.5% smokers suffered from cough and headache due to smoking. When age, sex, marital status, income of the household, education and knowledge about hazards of smoking was compared, age and knowledge showed significant association while other variables did not show any significant association.

Conclusion: Our study concluded that high proportion of people including men and women consume tobacco. Most of them were unaware about tobacco consumption hazards, and passive smoking (JPMA 57:186;2007).

The World Health Organization estimates that approximately 5 million people die each year worldwide from tobacco related illnesses. If current trends continue, this figure will rise to about 10 million per year by 2025.1 World wide approximately 1.3 billion people smoke cigarettes or other tobacco products, almost one billion men and 250 million women.2 Globally, tobacco use is significantly higher among men 47% and 12% among women.3 In developing countries 50% of men and 9% of women are smokers.4 In most developing countries this is partly due to cultural traditions, although the situation is changing and more women are taking up smoking in response to the marketing tactics of the tobacco industry.5 By 2030, a projected 7 million people in developing countries will be killed every year by tobacco.4

Tobacco consumption is on the rise in Pakistan. According to a study conducted in Karachi, a major city of Pakistan1, the prevalence of tobacco use was 32.7%.6 The prevalence of smoking in Karachi has not declined in the past few decades and requires attention of researchers to explore smoking related issues. The tobacco companies are competing to promote cigarette consumption while it has been increasing by 5% annually.7 A study conducted in Peshawar reported 36% and 11% smoking among males and females respectively and the most popular form was filter tipped cigarettes.8 Tobacco is also used in other forms like hubble bubble (hukkah), moist snuff used as an oral dip (Naswar), chewed with betel nut (Pan) and smoking of rolled dry leaves containing tobacco called beedi.9 This study aimed to determine the proportion of people consuming tobacco in various forms, level of knowledge and practices regarding the harmful effects of tobacco and passive smoking.

A community based cross-sectional study was conducted at Ghulam Mohammad Jokhio Goth, a semi urban community of Gadap Town Karachi, with a population of 2225, people. A house-to-house survey was conducted from June to August 2005, and 157 persons were interviewed regarding their tobacco consumption practices through a semi structured pre-tested questionnaire. There were 314 households in the community and every alternate household was included in the sample with a random start. The study subject was selected from the adult family members of 18 years age and above, present at the time of interview in the household by lottery method. The pre-tested semi-structured questionnaire was administered after taking consent. Data on tobacco consumption and other variables such as age, sex, marital status, education, employment, age at initiation of smoking, knowledge regarding harmful effects of tobacco and passive smoking and efforts taken to quit smoking were obtained. All the variables were translated into a database program, SPSS version (Statistical Package for Social Sciences) and analyzed in frequencies and cross tabulation to measure crude odds ratio with 95 percent confidence interval to identify association with smoking and other variables.

A total number of 157 subjects were studied of whom 110 (70%) were tobacco consumers. In this group 39% were cigarette smokers, 19% hookah and 42% consumed tobacco in pan. About 89% people started tobacco consumption at the age of less than 20 years and the reasons given for starting tobacco were depression 22.7%, pleasure (12.7%) and social peer pressure (64.5%). About 83.6% consumed tobacco on a regular basis, 25% consuming tobacco 5 times a day, 31% ten times, 29% fifteen times and 14% more than 15 times daily. About 75% of people had smokers in their family. A very small number of smokers (13.6%) had taken counseling to stop smoking and about 26.3% tried to quit smoking but none of them succeeded. About 23.5% smokers suffered from cough and headache due to smoking. About 47% were knowledgeable about hazards of smoking while 53% did not know about them. Only 22% were aware about passive smoking. Among those who had knowledge, on hazards of smoking, 27.3% mentioned lung cancer, 11.4% oral cancer, 4% heart disease and 7.5% cough.

Table compares the characteristics of smokers vs. non-smokers. When age, sex, marital status, income of the household, education and knowledge about hazards of smoking was compared, age and knowledge showed a significant association.

Tobacco smoking is an important health issue in the world including Pakistan and other developing countries.10 Tobacco consumption is very common in Pakistan. The prevalence of smoking is much higher in men in various parts of the country as compared to women. We found in our study 64% of males and 36% females consume tobacco in various forms like Pan and Cigarette, which is consistent with findings of other studies. Studies done in other parts of the country have reported prevalence 36.8% among men and 9.3% among women in rural population.11 Another study conducted in low socioeconomic strata of Karachi reported a prevalence of 26% among people aged 15 years and above.12 A study conducted in Delhi, India reported smoking in 45% males and 7% females.13 In our study population 39% people smoked cigarettes whereas the National health survey of Pakistan reported 29% of men smoked cigarettes.9 Asghar and colleagues reported that 47 brands of cigarettes used in Pakistan have 87% tar 78.7% nicotine concentration above the upper range of International standards (20mg/ cigarettes for tar and 2mg/ cigarettes for nicotine).13 Approximately 90% of the lung cancer cases in men and 79% in women are attributable to cigarette smoking.14 Tobacco use increases with age and initiation of smoking usually occurs at an early age. Young people are the main source of tobacco consumption for the tobacco industry. In our study 90% of smokers started smoking before 20 years of age, which is consistent with the findings of other studies. A study from Northern area of Pakistan also reported that majority of people started smoking before 25 years of age.15 The youth surveillance reported that approximately 80% tobacco users initiate use before the age of 18 years.16 In our study the most common age group was 30-50 years of age for tobacco consumption. The National health survey findings reported similar findings that 25-44 years of age people smoke most commonly. Shah and colleagues also reported in their study conducted in Northern area of Pakistan that smoking cigarettes increased with increasing age 1.26 times per 10 years.15 People of low socioeconomic status and illiterates were more likely to smoke than high economic status and educated people. In our study majority (80%) of the people belonged to the low-income group due to which income did not show any significant association with smoking. Regarding literacy only 34% people had more than 5 years of schooling. The frequency of smoking was less in subjects with college level education compared to the illiterate group. Primary school education did not show a significant difference. This was also reported from the northern areas of Pakistan. Contrary to the findings of this study, a Turkish study reported that high level of education was strongly associated with smoking.17

Smoking related health hazards were first brought to public attention in 1964.18 But these are still underestimated even in the educated class In our study 47% of people had the knowledge on hazards of smoking. Smokers who consume more than two packs per day have lung cancer mortality rate 15-25 times higher than non smokers.19

Peer pressure is considered to be an important influence on smoking behaviour of young people.20 Our study also reported social peer influence in 64.5% of smokers. The symptoms reported included cough and 19%, headache 5%, which is consistent with the findings of National health survey of Pakistan.

In our study high proportion of people smoke and other people who reside with them share the environment as passive smokers. Passive smoking is involved in numerous diseases such as lung cancer, coronary diseases and strokes.21 Our study reported that only 22% of individual were knowledgeable about passive smoking. Knowledge about smoking hazards plays a significant role in quitting smoking and those who had not started it refrain themselves from smoking. According to our study finding only less than half of the people were knowledgeable about hazards of smoking. In our study only few people had counseling and tried to quit smoking but none of the trials were found to be successful and smoking was restarted. This showed that less efforts were made to stop smoking and counseling in this particular area where large proportion of people consume tobacco.

It has been determined that passive smoking is a risk factor for lung cancer, coronary heart disease and stroke.21 Knowledge about the adverse effects of passive smoking is scarce. In our study only 22% of the participants knew about it. Hazards of smoking are also not known to many people and in the present study less than half the subjects had this knowledge. Quitting smoking requires counseling and motivation which are not always successful. More consistent efforts are required to promote the "Anti-Smoking" campaign.

Our study concluded that high proportion of people including men and women consume tobacco. Most of them were not aware about hazards of tobacco consumption and passive smoking

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