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South African Family Practice
ISSN: 2078-6190 (Print) 2078-6204 (Online) Journal homepage: https://www.tandfonline.com/loi/ojfp20
The smoking habits, attitudes towards smoking
and knowledge regarding anti-smoking legislation
of students in institutions of higher learning in the
Eastern Cape Province of South Africa
AA Awotedu, ER Jordaan, OZB Ndukwana, NO Fipaza, KO Awotedu, J
Martinez, H Foyaca-Sibat & MK Mashiyi
To cite this article: AA Awotedu, ER Jordaan, OZB Ndukwana, NO Fipaza, KO Awotedu, J
Martinez, H Foyaca-Sibat & MK Mashiyi (2006) The smoking habits, attitudes towards smoking
and knowledge regarding anti-smoking legislation of students in institutions of higher learning in
the Eastern Cape Province of South Africa, South African Family Practice, 48:9, 14-14d, DOI:
10.1080/20786204.2006.10873456
To link to this article: https://doi.org/10.1080/20786204.2006.10873456
© 2006 SAAFP. Published by Medpharm.
Published online: 15 Aug 2014.
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SA Fam Pract 2006:48(9)
14
Original Research
The smoking habits, attitudes towards smoking
and knowledge regarding anti-smoking legislation
of students in institutions of higher learning in the
Eastern Cape Province of South Africa
Awotedu AA, FMCP (Nig), FCCP, FCP (SA-PR),
Department of Internal Medicine, Walter Sisulu University, Mthatha
Jordaan ER, MSc, Biostatistics Unit, Medical Research Council of South Africa, Tygerberg
Ndukwana OZB, BACur, BACurHons (UNISA), MPH, Department of Health Promotion, Walter Sisulu University, Mthatha
Fipaza NO, BSc, MSc(Leeds), Department of Health Promotion, Walter Sisulu University, Mthatha
Awotedu KO, BSc Hon, MBBS, FMCGP (Nig), Department of Physiology, Walter Sisulu University. Mthatha
Martinez J, MD (Havana), Department of Community Medicine, Walter Sisulu University, Mthatha.
Foyaca-Sibat H, MD (Havana), Department of Internal Medicine, Walter Sisulu University , Mthatha
Mashiyi MK, MBChB; FCP (SA), Department of Internal Medicine, Walter Sisulu University , Mthatha
Correspondence to: Professor AA Awotedu, e-mail: awotedu@worldonline.co.za
Abstract
Background
The study aimed to i) investigate the smoking habits of students attending tertiary institutions of learning in
the Eastern Cape Province (ECP) and ii) determine the knowledge of the students about the health hazards of
smoking and their attitude towards current government anti-smoking legislation.
Methods
This was a questionnaire-based study involving all seven tertiary institutions of learning in the ECP, viz. the
Universities of Transkei, Fort Hare, Port Elizabeth and Rhodes University, and the Border, Eastern Cape
and Port Elizabeth technikons. A total of 1 728 students were interviewed out of a student population of
30,080. Stratified random sampling was used to select the students. Two-way tables were used to test the
independence of the variables and chi-square tests were applied. A ‘p’ value of below 5% was used as a test
of significance.
Results
A total of 1 480 students completed the questionnaires (86%). The racial classification of the respondents was
79% Black, 13% White, 7% Coloured and 2% Indian. Twenty-six per cent of the students were smokers, of
which 37% were male and 15% were female. Forty-five per cent of the Coloured students smoked, while the
figures for Whites and Blacks were 26% and 25% respectively. Seventy per cent of the students smoked less
than 10 cigarettes a day. Fifty-two per cent of the smokers said they wanted to stop smoking. Sixty-one per
cent had been influenced to start smoking by their friends and only 13% were influenced by advertisements.
Ninety-four percent agreed that smoking was dangerous to the smoker’s health, while 73% responded that
there was a relationship between mothers who smoke and low birth weight. Thirteen per cent thought the
legislation was too tough, while 30% said it was good as it was. On measures to reduce smoking, 86%
favoured restricting smoking in public places.
Conclusion
This study has demonstrated that smoking is prevalent in tertiary institutions of learning in the Eastern Cape
Province. The demographic profile of the smokers reflects the national picture. The knowledge of the harmful
effects of smoking is generally good.
SA Fam Pract 2006;48(9):14
The full version of this article is available at: www.safpj.co.za P This article has been peer reviewed
SA Fam Pract 2006:48(9)
14
Original Research
SA Fam Pract 2006:48(9) 14 a
Introduction
Smoking, a manmade epidemic, occurs
all over the world and is accompanied
by a host of diseases that threaten the
health and shorten the life of the con-
sumer.1 The World Health Organization
(WHO) estimates that, globally, 47% of
men and 12% of women smoke, with
about 4.9 million people dying each
year as a consequence of smoking.2
This figure is expected to rise to 10 mil-
lion deaths by 2030 if the present trend
continues.2 Prevalence rates and trends
vary from country to country, often de-
pendent on the level of monitoring of
tobacco use behaviour. While the rate
of cigarette smoking is decreasing in
the developed economies, the reverse
is happening in the Third World and
in Africa in particular. Two decades
ago, cigarette smoking in Africa was
referred to as ‘the coming epidemic’.3
This ‘prophesy’ has been confirmed, as
many countries on the continent are now
in the middle of the epidemic. The situ-
ation on the continent has been charac-
terised by rising consumption and a
corresponding increasing prevalence of
tobacco-related diseases. The available
information shows that the prevalence
of smoking in African countries ranges
from 17% to 32%.4,5,6,7
There is a view that Africa was
targeted by the tobacco industries be-
cause there was little control of tobacco
advertising. Tobacco advertisements
are widespread and uncontrolled in
most African countries except Sudan
and Mozambique, where there is a total
ban on such advertising.8 Most African
governments turn a blind eye because
of the revenue generated from tobacco,
forgetting the enormous burden of
cigarette-related diseases on the health
budgets. In most African countries
where there is no control over cigarette
manufacture, the tobacco companies
manufacture low-quality cigarettes that
would not be sold in Europe and North
America.9 In their 1996 report on smok-
ing in South Africa, Reddy et al. state
that the prevalence of smoking had
increased by 1% per annum from 1992,
with the result that 34% of adult South
Africans were smoking by 1996.10 The
prevalence of smoking in South Africa
varies in the different population groups,
with rates of 49% in the Coloured popu-
lation, 37% in Whites, 28% in Indians
and 23% in Blacks.3 However, recent in-
formation suggests that the prevalence
of smo-king in South Africa is falling,
except in the Coloured community.11
The relatively low smoking prevalence
among Black South Africans as a group
and women in particular may suggest
that the tobacco industry has been
unsuccessful in penetrating these mar-
kets.11 Through its tough anti-tobacco
legislation enacted in 1995, 1999 and
2001, South Africa is at the forefront
of the global anti-cigarette smoking
campaign, with other countries on the
continent following its example. It is
expected that the aggressive stand
of government on smoking will result
in a reduction in smoking. The loss of
revenue from tobacco advertising will
eventually be balanced by the lowering
of the costs of treating smoking-related
diseases. Although there are many stud-
ies on tobacco use in South Africa, there
is little information available on smoking
in the Eastern Cape Province in general
and amongst students in particular. This
study was therefore undertaken to ad-
dress this lack of information.
Aims and objectives
The aims and objectives of this study
were:
1. To investigate the prevalence of
smoking among students attending
institutions of higher learning in the
Eastern Cape province.
2. To investigate the prevalence of to-
bacco use and the psychosocial de-
terminants of this behaviour amongst
the students.
3. To determine if there are any differ-
ences in the knowledge of the health
hazards of smoking among the stu-
dents on the basis of the institution of
learning and the course of study.
4. To determine the attitude of the
students towards government anti-
smoking legislation.
Methodology
This was a descriptive, cross-sectional
survey. The population surveyed con-
sisted of students attending four univer-
sities (the Universities of Fort Hare, Port
Elizabeth, Transkei and Rhodes Uni-
versity) and three technikons (Border,
Eastern Cape and Port Elizabeth) in the
Eastern Cape. The total population of
students in these institutions was 32 070
in 2001, when the study was conducted.
Stratified random sampling was used,
with seven strata (as mentioned above).
The sampling units were classes in three
of the courses offered: science, arts and
commerce. A total of 1 728 students
were selected to be interviewed. A sam-
ple size of 1 728 students allowed for a
25% average smoking rate, a 10% error
rate, with 95% confidence intervals. The
questionnaires were administered and
collected at the same sitting. Confiden-
tiality was ensured by non-inclusion of
names on the forms. The questionnaire
was designed to answer the core ques-
tions enumerated in the aims and objec-
tives. The questionnaire was subjected
to a pilot survey and the final form was
adapted and refined on the basis of the
results of the pilot study.
Because some of the institutions were
merged during the study period, post-
weights were allocated for the analysis
of the sampling units. The appropriate
weights for the study design were used
to estimate the prevalence and 95%
confidence intervals given in the tables.
The University of Port Elizabeth and the
Port Elizabeth Technikon merged to be-
come the Nelson Mandela Metropolitan
University. The University of Transkei,
Border Technikon and the Eastern Cape
Technikon merged to become Walter
Sisulu University of Technology and Sci-
ence. Rhodes University and the Univer-
sity of Fort Hare remained as they were.
The Coloured and Indian students were
grouped together in this study because
the number of Indian students was too
small for analysis. Two-way tables were
used to test for the independence of any
two variables. To account for the survey
design, the F statistic was used to test
for independence and the calculated
p value can be interpreted in the usual
way, with a value below 5% being inter-
preted as a significant value.
Ethical approval was obtained from
the ethics committee of the faculty of
health sciences, University of Transkei
before the study was conducted. In-
stitutional approval was obtained from
the relevant authorities, while informed
Institution Sample number Student
population
Sampling
rate
UNITRA 408 4 200 9.7
Rhodes Uni. 167 5 300 4.7
UPE 237 5 800 3.2
Uni. Fort Hare 137 4 400 4.1
PE Tech. 219 4 650 3.1
Border Tech. 213 3 400 6.3
Eastern Cape T 99 4 320 2.3
TOTAL 1 480 32 070 4.6
Table I: Distribution of the sample of respondents by institutions
SA Fam Pract 2006:48(9)
14 b
Original Research
consent was also obtained from each
participant.
Results
Four universities and three technikons
were used in this study. The size of the
student population is indicated in Table
I. A total of 1 480 students, representing
86% of the selected sample, completed
the questionnaire.
Socio-demographic characteristics
of the respondents:
The ages of the respondents ranged
from 16 to 42 years, with 80% of the
students being between 16 and 25
years old. Fifty-two per cent of the stu-
dents were male and 48% were female.
The racial composition of the respon-
dents was 79% Black, 13% White, 7%
Coloured and 2% Asian/Indian. A total
of 92% of the students had no income
or an income below R1 000 a month.
About one-third of the respondents
were in their first academic year of
study, another third in their second
year, and the rest were in their third
year of study or above.
Smoking habits of respondents
Table II shows the smoking habits by
race and sex. A total of 26% of the
students were smokers, and 72% of
these smoked daily. More male (37%)
than female (15%) students smoked.
The racial distribution of students who
smoked showed that Coloureds stu-
dents constituted almost half (45%) of
the total smoking population, with 49%
of Coloured males and 40% of Co-
loured females reporting to be smok-
ers. The White students represented
26% of the smokers, made up of 30%
of the males and 24% of the females.
Black students who are smokers made
up 25% of the total number of smokers,
and 37% of the males and 10% of the
females in this population smoke.
Figure 1 shows the daily cigarette
consumption of the smokers: 51%
smoked one to five cigarettes daily, 19%
smoked six to 10 cigarettes daily, 16%
smoked 11 to 20 cigarettes daily, while
7% smoked more than 20 cigarettes
daily. Eighty-two per cent of the smok-
ers started smoking before entering the
tertiary institution, 9% started in the year
they entered and 9% started after their
first year.
When the smokers were asked what
influenced them to start smoking, 61%
attributed their current smoking habits to
influence by their friends, 13% felt they
were influenced by advertisements,
12% said it was due to boredom, 7%
Table II: Smoking habit by race and sex
Percentage of tobacco use
Blacks Whites Coloured Total
Current smokers 24.6
21.9-27.5
26.4
20.2-33.6
45.4
36.2-45.1
26.2
24.1-29.2
Female smokers 10.3
7.6-13.7
24.1
16.7-33.6
40.4
28.4-53.7
15.3
12.5-18.5
Male smokers 36.7
32.5-41.1
29.7
19.9-41.9
49.1
35.6-37.2
37.0
33.2-41.0
0
10
20
30
40
50
60
<1 cigs
1-5 cigs
6-10 cigs
11-20 cigs
20 cigs
% of
smokers
Figure 1. Daily cigarette consumption by smokers
blamed curiosity and 8% did not know.
Asked about the perceived benefits
of smoking, the response was as fol-
lows: 42% said it improved concentra-
tion, 19% said it ‘calmed their nerves’,
9% said it made them less shy, 8% felt
it made them more acceptable and 22%
did not know.
A total of 52% of the smokers wanted to
stop smoking and 57% had tried to stop
smoking. Of these, 25% had tried one
to two times, 11% had tried three times
and 17% had tried four or more times.
Knowledge of health hazards of smo-
king
The study also addressed the ques-
tion of the knowledge of the students
regarding the effects of cigarette smok-
ing. Table III shows the response of re-
spondents to questions on some of the
adverse health implications of cigarette
smoking. Ninety-four per cent of the
respondents agreed that smoking was
harmful to the smoker’s health and 58%
agreed that it was also harmful even if
the smoker did not smoke heavily. A
total of 87% of the respondents agreed
that smoking was also harmful to the
health of non-smokers. When asked if
there was proof that smoking causes
cancer and diseases of the heart and
lung, 70% gave a positive response.
Eighty-nine per cent knew that an
unborn baby’s health was affected by
the mother’s smoking, while 73% also
knew that there was a relationship
between mothers who smoke and low
birth weight.
Attitude to anti-smoking legislation
The attitude of the students towards
smoking and government legislative
Questions Percentage with positive
response
Smoke harmful to smoker’s health 93,0 (91.4-94.3)
Also harmful if you don’t smoke heavily 57.7 (54.9-60.4)
Harmful to non-smoker’s health 86.8 (84.8-88.6)
Proof that smoking causes cancer, heart,
lung disease 72.0 (69.4-74.5)
Is the unborn baby’s health affected
by the mother’s smoking? 88.9 (87.0-90.5)
Is there any relationship between mothers
who smoke and low birth weight? 73.1 (70.5-75.4)
Table III: Knowledge about the dangers of cigarette smoking
SA Fam Pract 2006:48(9) 14 c
Original Research
measures to curb smoking in public
places was also elicited. In Table IV
when the students were asked about
the government anti-smoking legisla-
tion, 13% said the current legislation
was “too harsh”, 34% said it was
“not tough enough”, 30% said it was
“good as it is”, while 23% either had
no opinion or were not aware of the
legislation. Sixty-nine per cent agreed
that increasing taxes on all tobacco
products would reduce the prevalence
of smoking. When asked if smoking
should be regulated on campus, 65%
agreed. When asked whether it was
not worthwhile to stop smoking, 71%
disagreed with the statement implying
that they agreed that it was worthwhile
to stop smoking.
Perceptions on strategies to reduc-
ing smoking
Table V refers to opinions of the stu-
dents about how to reduce smoking.
Sixty-three percent of the respondents
felt that there should be a complete
ban on advertising. Eighty-six per
cent agreed that smoking should be
restricted in public places and 87%
also agreed that smoking should be re-
stricted in the workplace. A total of 87%
said cigarette sales to children younger
than 16 should be prohibited. Eighty-
three per cent said mass campaigns
should be stepped up and 77% agreed
that there should be compulsory school
programmes on smoking and the as-
sociated dangers. A total of 47% of the
respondents agreed with all the above
1. A low female smoking rate compared
to their male counterparts has been re-
ported in other studies in Africa.13,14 The
narrowing of the gender gap amongst
the Coloured, Asian and White stu-
dents is consistent with international
experience.
The smoking rate is also higher in
the higher income group, with 42%
of those earning more than R1 000 a
month smoking compared to 23% in
the income group earning less than R1
000 a month. The lack of disposable
income, combined with rising cigarette
prices, has been noted to offset peer
pressure in smoking cessation.15 Only
57% of smokers in our survey tried to
stop smoking, which is lower than the
67% of respondents in a Cape Penin-
sula study.16
An institutional analysis showed higher
than average smoking rates at Rhodes
University and the Eastern Cape Tech-
nikon, with 32% and 37% respectively.
Lower than average rates were record-
ed for the University of Port Elizabeth
(19%) and Border Technikon (15%). It
is difficult to explain this observation,
and these differences may serve as an
area for future research.
The results of this study also show
that opinions on smoking less are
related to gender and race and, to a
lesser extent, to income. Females and
Blacks are generally more in favour of
restrictions on smoking. Students with
no income are more in favour of restric-
tions on smoking. It is worth noting that
63% of the students were in favour of a
complete ban on cigarette advertising,
while a study that was done a decade
earlier among adult South Africans
showed that 59% were in favour of such
a measure.12
The knowledge of the respondents
about the harmful effects of smoking
is generally very good, except that only
60% of them realised that any smoking,
regardless of consumption, is bad for
your health. Seventy per cent of the
students in our study associated smo-
king with cancer and heart disease,
compared with the 16% of the students
indicated in the study by Peltzer.12
However the same study also found
that 93% of the students associated
smoking with lung cancer.12
The gradual decrease in smoking
prevalence in South Africa over the
past five years is a welcome develop-
ment. In a study by Van Walbeek, it was
reported that, in South Africa, a 10% in-
crease in the real price of cigarettes de-
creases cigarette consumption by 6 to
8%.17 It has been postulated that, with
Table IV: Attitudes of respondents towards smoking
Questions Response Percentage
Not worth stopping smoking Disagree 70.6 (68.0-73.2)
Present government legislation Too harsh 13.2 (11.4-15.2)
Not tough enough 33.8 (31.2-36.5)
No opinion/not aware 22.9 (20.6-25.3)
Good as it is 30.1 (27.6-32.8)
Increase taxes on all tobacco
Products Agree 68.7 (66.0-71.3)
Regulate smoking on campus Agree 65.1 (62.4-67.7)
measures enumerated in the question-
naire on how to reduce smoking.
Discussion
The results of our study showed an
overall smoking prevalence of 26%,
which is similar to the 25.7% reported
among tertiary students in a report in
2000.11 Generally, the highest smok-
ing prevalence is among Coloureds
students when compared to other ra-
cial groups in South Africa. We found
a prevalence of 45% in the Coloured
population, which was slightly lower
than the 49% reported in 2000. The
corresponding smoking prevalence
figures from our study for the other
racial groups when compared to the
2000 report are as follows: Whites in
our study comprised 26% compared
to 37% in 2000, and Blacks in our
study comprised 25% against 22.7%
in 2000.11 However, a South African
study by Peltzer in 2001, involving
Black students at the University of the
North, found a smoking prevalence rate
of 15% in males and 1% in females.12
These figures are much lower than for
our Black students. The reason for this
difference may be that, in our study,
seven institutions with a relatively more
heterogeneous population distribution
participated, as against the single
institution with a predominantly Black
population surveyed by Peltzer. We
found slightly more males than females
smoke among the White and Coloured
students, but among the Black stu-
dents the male to female ratio was 3.5:
Table V: Opinion of respondents on how to reduce smoking
Questions Percentage with positive
response
Complete ban on advertising 62.9 (60.2-65.6)
Price increase 74.2 (71.6-76.6)
Restrict smoking in public places 85.9 (83.8-87.7)
Prohibit sale to those < 16 years 86.6 (84.5-88.4)
Restrict smoking in workplace 86.8 (84.8-88.6)
Step up mass campaign 82.5 (80.3-84.6)
Compulsory school programme 77.2 (74.7-79.5)
All seven actions 45.6 (42.8-48.4)
Six or more actions 64.2 (61.4-66.8)
SA Fam Pract 2006:48(9)
14 d
Original Research
the continued decrease in the smoking
population, smoking in South Africa
could be something of the past by the
middle of the 21st century.11 There is
no doubt that the tough anti-smoking
legislation and regular increase in the
price of tobacco products contribute to
this trend.
Acknowledgements
The authors wish to thank the South Af-
rican Medical Research Council, which
funded this study.
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