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Attitudes towards smoking restrictions
and tobacco advertisement bans
in Georgia
George D Bakhturidze,
1,2
Maurice B Mittelmark,
1
Leif E Aarø,
1,3
Nana T Peikrishvili
2
To cite: Bakhturidze GD,
Mittelmark MB, Aarø LE, et al.
Attitudes towards smoking
restrictions and tobacco
advertisement bans
in Georgia. BMJ Open 2013;3:
e003461. doi:10.1136/
bmjopen-2013-003461
▸Prepublication history and
additional material for this
paper is available online. To
view these files please visit
the journal online
(http://dx.doi.org/10.1136/
bmjopen-2013-003461).
Received 23 June 2013
Revised 7 October 2013
Accepted 11 October 2013
1
Department of Health
Promotion and Development,
Faculty of Psychology,
University of Bergen, Bergen,
Norway
2
Tobacco Control Research,
Framework Convention on
Tobacco Control
Implementation and
Monitoring Center in Georgia,
Tbilisi, Georgia
3
Division of Mental Health,
Norwegian Institute of Public
Health, Oslo, Norway
Correspondence to
Dr George D Bakhturidze;
iayd@yahoo.com
ABSTRACT
Objectives: This study aims to provide data on a
public level of support for restricting smoking in public
places and banning tobacco advertisements.
Design: A nationally representative multistage
sampling design, with sampling strata defined by
region (sampling quotas proportional to size) and
substrata defined by urban/rural and mountainous/
lowland settlement, within which census enumeration
districts were randomly sampled, within which
households were randomly sampled, within which a
randomly selected respondent was interviewed.
Setting: The country of Georgia, population 4.7
million, located in the Caucasus region of Eurasia.
Participants: One household member aged between
13 and 70 was selected as interviewee. In households
with more than one age-eligible person, selection was
carried out at random. Of 1588 persons selected, 14
refused to participate and interviews were conducted
with 915 women and 659 men.
Outcome measures: Respondents were interviewed
about their level of agreement with eight possible
smoking restrictions/bans, used to calculate a single
dichotomous (agree/do not agree) opinion indicator.
The level of agreement with restrictions was analysed
in bivariate and multivariate analyses by age, gender,
education, income and tobacco use status.
Results: Overall, 84.9% of respondents indicated
support for smoking restrictions and tobacco
advertisement bans. In all demographic segments,
including tobacco users, the majority of respondents
indicated agreement with restrictions, ranging from a
low of 51% in the 13–25 age group to a high of 98%
in the 56–70 age group. Logistic regression with all
demographic variables entered showed that agreement
with restrictions was higher with age, and was
significantly higher among never smokers as compared
to daily smokers.
Conclusions: Georgian public opinion is normatively
supportive of more stringent tobacco-control measures
in the form of smoking restrictions and tobacco
advertisement bans.
BACKGROUND
The WHO Framework Convention on Tobacco
Control (FCTC) emphasises the importance
of combining tobacco demand reduction
with tobacco supply restrictions. Article 8 of
the FCTC addresses the need for protection
from exposure to tobacco smoke and recog-
nises the scientific evidence that exposure to
tobacco smoke causes death, disease and dis-
ability. Article 13 calls for a comprehensive
ban on advertising, promotion and sponsor-
ship to stimulate reduction in the consump-
tion of tobacco products.
1
Evidence from countries that have carried
out well in reducing tobacco consumption
suggests that a comprehensive approach to
tobacco control should include (1) increased
tobacco prices and taxes; (2) bans on tobacco
advertising, promotion and sponsorship; (3)
no sales to minors; and (4) the conduct of
public awareness campaigns.
1–4
In addition,
clean indoor-air laws have been the focus of
many of the tobacco-control efforts in North
America, Western Europe and Australia, the
lessons of which are instructive to those draft-
ing tobacco-control policies in low-income
and middle-income countries.
5–7
Regarding tobacco advertisement and pro-
motional activities, a special concern is their
influence on adolescent behaviour.
8
Partial
bans on tobacco advertisement are not effect-
ive, and WHO analyses suggest that compre-
hensive control programmes, including
comprehensive advertising bans, are required
to reduce cigarette consumption.
59
Tobacco use in Georgia and tobacco-control
policies
Tobacco use in the former Soviet state of
Georgia has increased to alarming proportions
Strengths and limitations of this study
▪Internal consistency of attitudes towards smoking
prohibition and tobacco ad ban is very high.
▪In the period since the data of this study were
collected (2008) and in this publication, it is
possible that there have been shifts in public
opinion that might affect our conclusions.
Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461 1
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since 1990, mostly due to the transition towards market
economy and the arrival of the international tobacco
industry. In 2001, the prevalence of tobacco use among
men was 53.3% and rose to 59.8% in 2008.
10 11
Among
women, the prevalence increased from 6.3% to 14.9% in
thesameperiod(ibid).Thetobaccousetrendamong
youth is also worrying. The Global Youth Tobacco Survey
conducted in 2000–2007 estimated that 19.2% of youth
aged 13–15 years smoked cigarettes in European countries,
while the prevalence was 23.7% in Georgia.
12
Smoking restrictions in public places were implemen-
ted in Georgia in 2003, when the first Georgian Law on
Tobacco Control was enacted.
13
In 2004, changes in the
Georgian Code of Administrative Offences established
penalties for violations of tobacco-control law mea-
sures.
14
Since May 2006, the FCTC entered into force in
Georgia,
15
following which several changes have been
made to the Georgian tobacco-control law. As of this
writing, the law prohibits tobacco smoking in educational
institutions, enclosed sports buildings, in medical and
pharmaceutical buildings and in public transport. In
working places where smoking is restricted, smoking-
allowed zones may be created.
Regarding tobacco advertisement regulation, the 1999
Georgian Law on Advertisement only bans tobacco ads
on TV and radio.
16
After entering into the FCTC,
Georgia had 5 years to achieve full implementation of a
total ban on tobacco advertisement and promotion.
However, as of this writing, the ban is still only a partial
one, with outdoor advertising and other advertising
forms (except TV and radio) still being permitted.
Despite the existing restrictions, tobacco use is ubiqui-
tous even in places where it is prohibited, due to lax
enforcement of the law. Thus Georgian tobacco-control
law requires revision to emphasise enforcement mea-
sures. This calls for policy-makers to revisit the present
structure of tobacco-control law. In this context, public
opinion about the appropriateness and acceptability of
tobacco-control measures may have an important role to
play in informing the policy-making process.
Influence of public opinion on policy-making
‘Public opinion’refers to citizen’s attitudes, perspectives
and viewpoints on policy issues that decision makers may
take into account in policy-making processes.
17
Policy-
makers are influenced by public opinion through a range
of ‘barometers’including election results, what elected
officials sense that people want, what powerful constitu-
ents have to say, how the media reflect public sentiment,
public demonstrations, public opinion polls and survey
research.
18
In democracies, a key factor that determines the
power of the public opinion’s political influence is how
close the coming election is.
19
That public policy is
responsive to public opinion is a core expectation of
democratic theory, under the principle that political
actors should be alert to changes in public opinion and
adjust their behaviour accordingly.
20
However, public
opinion influences policy even where there is no democ-
racy, through informal pressure from dissatisfied
publics.
21–25
Indeed, there is some concern that policy-makers may
pay too much attention to the public’s opinion, and that
policy researchers underestimate this source of influence
because the study of public opinion is emphasised less
than other policy determinants.
21
Worried that public
opinion has too much influence, Brooks and Manza
25
point out that the wishes and preferences of the public
are often not sufficiently informed or reflective about
the trade-offs and risks involved in policy decisions. For
complex and/or highly targeted policy issues, the public
may simply not be sufficiently informed to express
meaningful opinions.
24 26–28
Regardless, research shows
that the impact of public opinion on policy is substan-
tial, and remains strong even when the influence of
organised interests is taken into account.
29
Not only is
the broad shape of policy responsive to public
opinion
22
; but can also be the proximal cause of a
policy.
30
The relationship between public opinion and policy-
making may often operate as a self-tuning system, the
way a thermostat interacts with a machine to keep it
within operating temperature.
31 32
Public opinion sends
signals to policy-makers that can help in fine-tuning
policy, and policy sends signals to the public, which can
help shape public opinion.
Public’s support for tobacco control
Data from several countries indicate that smoking bans
in workplaces, public transport and in public spaces
such as shopping malls are widely supported by the
public.
2333–39
Significant support for tobacco control is
evident even among smokers.
33 40
An opinion poll in
New South Wales, Australia, showed that 89% supports
smoke-free policy for children’s playgrounds, 77% for
sports facilities, 72% for bars, 69% for outdoor dings, 55%
for beaches and 77% for autos carrying children.
41 42
Perhaps the highest ever levels of support for tobacco bans
were reported in a study in Lausanne, Switzerland, with
87% supporting smoking bans in public places.
43
Some studies about internal tobacco industry docu-
ments revealed a strategy using international scientific
consultants to influence public opinion on environmen-
tal tobacco smoke.
44 45
In summary, there is good evidence from Anglo-Saxon
countries that the public supports legislation restricting
the use of tobacco, and that public opinion matters in
tobacco policy-making. However, there are no similar
studies in Georgia. This prompted the present study,
which aimed to collect, analyse and disseminate data on
the Georgian public’s attitudes towards smoking restric-
tions and tobacco advertisement bans.
The precise degree to which public opinion influences
decision-making cannot be ascertained, since there is no
method to separate this source of influence from many
other sources of influence (eg, lobbying, scientific
2Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461
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evidence and Government white papers). Therefore,
this study is limited in documenting the state of public
opinion, and cannot make valid and reliable estimates
of the degree to which public opinion has affected
actual tobacco-control decision-making in Georgia.
STUDY AIM AND METHODOLOGY
Aim
This study aims to provide data from a nationally repre-
sentative sample including non-smokers, ex-smokers and
current smokers on their level of support for restricting
smoking in public places, banning tobacco advertise-
ment, and increasing penalties for violations of restric-
tions and bans.
Study design and methods
Survey data were collected in January and February 2008
in the whole country. The primary sampling units were
households and one member aged between 13 and 70
was selected for the interview. The sampling frame was
formed on the basis of the national census, covering the
non-institutionalised population. Households located at
the sampled addresses were observed. The sample size
was determined with the objective to ensure high statis-
tical reliability of the estimates of key indicators: the
95% CI should not exceed 10–15% of a key indicator
estimate. According to this criterion, the sample size was
determined to be 1655. The sampling was carried out by
using stratification and a two-stage procedure. At the
first stage, a sample of primary sampling units (enumer-
ation districts) was drawn. In accordance with the sam-
pling design, the country was divided into 10
comparatively homogenous regions. Each region was
divided into homogenous strata according to urban/
rural and mountainous/lowland settlements. Regional
sampling quotas were proportional to their size. Primary
sampling units were selected in each stratum by random
sampling (with the probability proportional to size)
from the frame of enumeration districts. At the first
stage of sampling, from 16 000 enumeration districts 94
districts were selected. At the next stage, lists of the
household addresses in the selected districts were com-
plied. Then, using systematic sampling, addresses were
selected from those lists according to the sampling
quotas.
In-house face-to-face interviews used a standard ques-
tionnaire. In households with more than one
age-eligible person available for selection, selection of
the respondent was carried out at random. About 50
interviewers and 10 regional supervisors from the
Department of Statistics of Georgia carried out this
survey. Regional supervisors controlled the selection of
addresses and the work of the interviewers. Sample
weights were calculated using π-estimation, determined
as the inverse 1/p (i) of its probability p (i) to be
selected.
10
Study outcomes/determinants
The variables considered in the present report were as
follows:
A. Demographic variables age, gender, education level
and income;
B. Smoking status (daily, occasional, ex-smoker and
never smoker);
C. Levels of agreement with the implementation of
eight tobacco smoking prohibitions and tobacco
advertisement/promotion ban, and increased penal-
ties on violations, coded ‘yes’,‘no’,‘don’t know’and
‘refuse to answer’:
1. Prohibition of smoking promotion (including offer-
ing free promotional items, such as t-shirts, free
samples, etc);
2. Prohibition of tobacco and tobacco company advertis-
ing in the printing media, on the billboards and
sponsorship;
3. Prohibition of all tobacco and tobacco company
advertising;
4. Prohibition of indoor smoking in government build-
ings/offices, schools and youth organisations;
5. Prohibition of indoor smoking in medical, educa-
tional, sport and cultural facilities;
6. Prohibition of indoor smoking private workplaces;
7. Prohibition of indoor smoking in restaurants bars
and nightclubs;
8. Increased penalties for violations of restrictions/
prohibitions.
In calculating agreement rates, the denominators
included those who refused to answer, such that the two
coded response categories were ‘agree’and ‘disagree or
no answer’. This was intended to create a conservative
bias in estimating the level of agreement with
restrictions.
Data analysis
The dimensionality of the attitudes towards the scale of
smoking prohibition and tobacco ad ban was examined
with correlation analysis and with factor analysis (princi-
pal axis factoring). The reliability (ie, internal consist-
ency) of the scale was estimated with Cronbach’sα.A
simple, additive sum score was constructed based on all
eight dichotomised attitude items. This sum score indi-
cates the degree of overall support for smoking restric-
tions and tobacco ad bans. The sum score was recoded
into a single dichotomous variable with high support for
smoking restrictions as one category (agreement with at
least 4 of the 8 restrictions) and low support as the
other. Support for smoking restrictions was analysed
against demographic variables with the χ
2
statistic.
Associations between demographic factors and smoking
status, and support for smoking prohibition and tobacco
ad bans, were also examined with bivariate as well as
multiple logistic regression analysis. SPSS V19 and V20
were used for all analyses. Analyses were also carried out
in Mplus with the weighted least squares—mean
adjusted and variance adjusted estimator, and all items
Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461 3
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were defined as categorical. The Mplus results, which
are not reported here, supported the results of the prin-
cipal components analysis that are reported here.
Ethical clearance
Signed informed consent was obtained from all partici-
pants. For participants under age 18, parents or guar-
dians confirmed, by signature, their approval of the
minor’s participation. The survey organisers took
responsibility with regard to the protection of confiden-
tiality during the collection, analysis and dissemination
of data. No respondent’s identity was recorded on the
interview forms or in any other manner.
RESULTS
Of the 1655 households selected, interviews could not
be conducted in 67 households due to no age-eligible
residents present (n=5), refusal to participate (n=13)
and no response/no one home (n=49). Interviews were
conducted with 1588 respondents (response rate of
96%). The number of study participants who were inter-
viewed but refused answer to one or more questions
about restrictions ranged from 14 to 76 (0.9–4.8%).
Fourteen respondents who had missing responses on
half or more of the eight restrictions questions were not
included in the analysis, reducing the analysis sample
size to 1574 (response rate 95%).
Intercorrelations between the smoking prohibition
and tobacco ads/promotion ban attitude items ranged
from 0.81 to 0.95. Factor analysis (principal axis factor-
ing) showed that the first unrotated factor had an eigen-
value of 6.41 while the second unrotated factor had an
eigenvalue of 0.56. This supports the assumption that
the scale is unidimensional and can be reduced to one
index, for which Cronbach’sαis 0.96. An unweighted
sum score was calculated using all eight attitude items.
The lowest level of approval was 47.5% among respon-
dents aged 13–25 for the ‘prohibition of indoor
smoking in restaurants, bars and night clubs’. The
highest level of approval was 98.2% among respondents
aged 56–70 for the ‘prohibition of indoor smoking in
medical, educational, sport and cultural facilities’. There
was a statistically significant age gradient for all eight
restrictions, with older respondents having the highest
approval rates (table 1).
No statistically significant gender differences or differ-
ences by income and educational level were observed
with regard to any of the smoking prohibition and
tobacco ad ban items.
Approval of each of the eight prohibitions ranged
from 88.6% to 98.9% among ex-smokers and never
smokers, from 73% to 82% among daily smokers and
from 47.1% to 53.9% among less-than-daily smokers
(table 1). Across all items, the average support for
smoking restrictions and tobacco advertisement bans was
84.9%. All eight smoking status gradients were statistic-
ally significant, with ex-smokers and never smokers
having the highest approval rates, and less-than-daily
smokers having the lowest approval rates. Daily smokers
had higher approval rates than occasional smokers but
lower than ex-smokers and never smokers.
When we examine the dichotomised sum score, it
turns out that among never smokers and ex-smokers,
high approval of restrictions was indicated by 94.2–
97.7% of respondents. Occasional smokers were less sup-
portive of restrictions than the daily smokers. These dif-
ferences in approval were statistically significant, as
shown in table 2.
There were no statistically significant differences in
the levels of support for restrictions by gender and
household income. The bivariate association between
the highest completed education and support for restric-
tions was significant. This significance is due to the dif-
ference between the level of support among those who
have college-level education (82.7%) and those who
have a university level education (87.9%).
The bivariate relationships between the attitude scale
and each of the sociodemographic/tobacco-use variables
also described with logistic regression are shown in table 2
(in the columns under bivariate logistic regression). The
associations are identical to the ones described with per-
centages above.
Results of a multiple logistic regression analysis are
shown in the last four columns of table 2. Support for
restrictive measures increased with age from the young-
est age group (13–25) to the second oldest (46–55),
with OR values similar to the bivariate ones. There were
no significant associations with gender and household
income. The overall association between the highest
completed level of education and support for restric-
tions was no longer significant, but the difference
between those with the lowest level of education (refer-
ence group) and those with college-level education
(OR=0.062) was significant at the p<0.05 level. When
compared with the daily smokers (reference group), the
occasional smokers were significantly less supportive of
restrictive measures (OR=0.63) and never smokers are
significantly more supportive (OR=5.80).
The multiple logistic regression analysis produced
results that were similar to the results of the bivariate
analyses, although some relationships became insignifi-
cant (overall association with highest completed educa-
tion and contrast between daily smokers and
ex-smokers) and one surfaced (contrast between lowest
education and college-level education).
DISCUSSION
The study sampling design and the 96% response rate
give reason for confidence in the representativeness of
the findings, and we surmise therefore that the majority
of the Georgian population supports smoking prohibi-
tions in public places and a total ban on tobacco adver-
tisement and promotion. The high level of public
support to prohibit smoking in public places and work
4Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461
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Table 1 Smoking restrictions and tobacco ads ban 1–8 by demography and smoking status (bivariate analyses); see footnote 1–8 for key to the specific content of each
restriction (n=1574)
12345678
Sum score
(dichotomy)
N
Percentage
of yes
Percentage
of yes
Percentage
of yes
Percentage
of yes
Percentage
of yes
Percentage
of yes
Percentage
of yes
Percentage
of yes
Percentage of
yes
Age—χ²,
p value
262.16, 0.000 273.01, 0.000 241.65, 0.000 360.73, 0.000 341.57, 0.000 346.34, 0.000 248.0, 0.000 323.38, 0.000 349.19, 0.000
13–25 51.0 51.7 54.0 49.4 53.2 50.6 47.5 52.1 51.3 263
26–35 74.8 75.4 77.4 75.7 76.4 76.4 72.1 75.4 77.0 305
36–45 88.3 88.6 87.1 91.6 93.4 91.3 83.5 91.9 91.9 333
46–55 92.9 94.6 93.9 98.0 98.0 98.0 92.5 97.6 98.0 294
56–70 95.5 96.0 96.3 97.6 98.2 97.6 92.9 96.8 98.2 379
Gender—χ²,
p value
0.04, 0.840 0.04, 0.840 0.17, 0.680 0.00, 0.920 0.59, 0.440 0.50, 0.480 0.15, 0.700 0.58, 0.450 0.00, 0.960
Male 81.8 83.0 82.7 84.2 86.2 83.6 78.8 85.1 84.8 659
Female 82.2 82.6 83.5 84.0 84.8 84.9 79.6 83.7 84.9 915
Education—
χ², p value
3.28, 0.350 7.00, 0.140 2.36, 0.310 2.84, 0.240 8.32, 0.160 3.73, 0.150 4.13, 0.130 4.02, 0.130 6.10, 0.050
Low 82.7 81.0 81.5 84.6 85.6 84.4 78.8 85.2 84.2 486
Middle 82.9 81.1 82.9 82.2 82.3 82.3 77.0 81.8 82.7 566
High 80.9 85.7 85.1 85.8 88.5 86.6 82.0 86.2 87.9 522
Income—χ²,
p value
4.42, 0.110 1.89, 0.590 3.30, 0.350 2.82, 0.420 2.78, 0.430 2.46, 0.480 1.46, 0.690 3.76, 0.290 2.25, 0.520
Low 81.1 82.5 83.6 85.8 86.5 85.6 77.0 84.7 85.8 452
Middle 80.2 84.0 83.8 83.8 84.7 84.5 79.8 84.7 84.9 568
High 84.9 82.1 82.6 83.4 85.6 83.6 79.3 84.1 84.5 535
Smoking
status—χ²,
p value
224.93, 0.000 239.88, 0.000 221.10, 0.000 248.66, 0.000 223.34, 0.000 267.03, 0.000 200.13, 0.000 232.89, 0.000 269.38, 0.000
Daily 77.1 78.4 79.1 79.3 82.0 79.8 73.0 80.4 80.9 445
Less than
daily
48.5 48.5 50.5 50.5 53.9 49.5 47.1 51.5 50.0 206
Ex-smoker 93.7 98.9 97.9 94.7 94.7 95.8 95.8 96.8 97.9 95
Never
smoker
91.7 91.8 91.8 93.8 94.0 94.2 88.6 93.1 94.2 828
1. Agree to prohibition of smoking promotion (including offering free promotional items, such as t-shirts, free samples, etc).
2. Agree to prohibition of tobacco and tobacco companies advertising in the printing media, on the billboards and sponsorship.
3. Agree to prohibition of all types of tobacco products and advertisement by tobacco companies.
4. Agree to prohibition of indoor smoking in government buildings/offices, schools and youth organisations.
5. Agree to prohibition of indoor smoking in medical, educational, sport and cultural facilities.
6. Agree to prohibition of indoor smoking in private workplaces.
7. Agree to prohibition of indoor smoking in restaurants, bars and night clubs.
8. Agree to include more restrictions on smoking and increase the penalties for violations.
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sites is consistent with observations in other parts of the
world with different cultural and political contexts,
although there are exceptions. In Australia 76% of non-
smokers reported supporting a total ban, among
Chinese urban residents 81.8% supported banning
smoking in public places; in South Africa, 83% of non-
smokers and 70% of smokers; non-smokers were more
supportive in this regard in Greece than current
smokers.
46–50
Nine in 10 Hungarian respondents sup-
ported a ban on smoking in healthcare facilities and
almost 80% supported smoking restrictions in closed
and outdoor public places, work places, restaurants and
bars.
51
These prevalence rates suggest that Georgian public
opinion about tobacco control is in line with global
public opinion generally. Closer to home, nearly all
adults in two Russian studies agreed that indoor
smoking should be prohibited at healthcare facilities
(95%) and schools (99%), more than half thought
smoking should be prohibited in restaurants and cafes,
and almost a third supported a total ban of smoking in
bars and restaurants.
52 53
Public support for banning
smoking in educational and health facilities exceeded
94% and reached 67.1% for bars in Ukraine in 2009.
54
This pattern supports the validity of the present findings,
which might otherwise be suspected as resulting from a
possible ‘acquiescence’bias, in a public that not too
long ago was a part of the Soviet Union.
Yet important exceptions to the overall pattern do
exist. A survey conducted in nine former Soviet countries
during 2010–2011 observed that only 36.8% of adults sup-
ported a total ban of smoking in restaurants, bars and
cafes in Russia. In the same study, the corresponding
figure was 38.2% in Ukraine and 30% in Georgia.
55
It is
well known that the exact form of question wording in
survey research can have a significant influence on find-
ings, and this is sometimes exploited by pollsters who are
affiliated with candidates, campaigns and causes.
Question wording, however, is but one source of survey
research bias among many sources. It is beyond the scope
of this report to analyse and speculate about the large dis-
crepancy just noted. We simply note that the many esti-
mates cited in the paragraphs above are close to the
estimate we provide for Georgia.
There is a strong discord between public opinion as
documented in this study and tobacco control as
Table 2 Support for smoking restrictions and tobacco ads ban by demography
Bivariate logistic regression Multiple logistic regression
N
High
support
(%)* OR
95% CI for Exp(B)
p
Value OR
95% CI for Exp(B)
p
Value
Lower
bound
Upper
bound
Lower
bound
Upper
bound
Age 0.000 0.000
13–25 (ref) 263 51.3 1.00 1.00
26–35 305 77.0 3.18 2.22 4.56 0.000 3.54 2.24 5.60 0.000
36–45 333 91.9 10.75 6.77 17.05 0.000 11.21 6.52 19.28 0.000
46–55 294 98.0 45.51 19.57 105.82 0.000 37.93 15.60 92.20 0.000
56–70 379 98.2 50.39 22.96 110.56 0.000 37.44 15.98 87.74 0.000
Gender
Female (ref) 915 84.9 1.00 1.00
Male 659 84.8 0.99 0.75 1.31 0.960 1.32 0.90 1.95 0.154
Highest compulsory
education
0.000 0.124
Primary or secondary
school (ref)
486 84.2 1.00 1.00
Middle college 566 82.7 0.90 0.65 1.25 0.523 0.62 0.40 0.98 0.041
University,
postgraduation/
graduation degree
522 87.9 1.37 0.96 1.96 0.084 0.73 0.43 1.21 0.222
Household income 0.538 0.773
Low (ref) 452 85.8 1.00 1.00
Middle 568 84.9 0.92 0.65 1.31 0.660 0.98 0.64 1.51 0.930
High 535 84.5 0.90 0.63 1.28 0.552 1.20 0.77 1.86 0.421
Tobacco use 0.000 0.000
Daily (ref) 445 80.9 1.00 1.00
Less than daily 206 50.0 0.24 0.16 0.34 0.000 0.63 0.40 0.98 0.042
Ex-smoker 95 97.7 10.98 2.65 45.45 0.000 2.74 0.61 12.42 0.190
Never smoker 828 94.2 3.84 2.64 5.58 0.000 5.80 3.66 9.19 0.000
*Percentages from crosstabs (bivariate analyses) and results from binary multiple logistic regression. Low support is agreement with three or
fewer of eight types of smoking prohibition and tobacco ads ban. High support is agreement with four or more prohibitions.
6Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461
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practiced in Georgia today. Georgia has a partial ban on
tobacco ads. While there is evidence for the effectiveness
of total advertising bans in reducing per capita tobacco
consumption,
56
no such evidence exists for partial bans
and restrictions. Accordingly, limited bans cannot be
assumed to have important impact on consumption.
Tobacco advertising causes increased smoking and
increased smoking translates into poorer public
health.
56
The population segment most vulnerable to
ads are the youth, whose attitudes and intentions regard-
ing possible tobacco use and choice of products are in a
state of formation, compared with the more established
behavioural choices of adults. The vulnerability of youth
is exacerbated by targeted tobacco advertising and pro-
motions.
56–61
Given the damage to health attributable to
tobacco use and the special vulnerability of youth to
advertising, there is a public health imperative in
Georgia to fully implement the FCTC prohibitions, with
strong support from the Georgian public. Furthermore,
recent successes have the Baltic States
6
and Norway
61
in
implementing FCTC prohibitions—among a number of
other European countries—are nearby examples that
full implementation is feasible.
A counter-intuitive finding in the present study was
that occasional and young age smokers were less sup-
portive of restrictions than daily smokers. A search of
the literature to find comparable analyses was unsuccess-
ful, and we can only speculate about the reason for this
finding. It may be that occasional smokers in this study
perceived themselves to be in control of their tobacco
use, and therefore not in need of externally imposed
restrictions. They may have generalised this perception
to tobacco users in general. Nevertheless, fully half of
occasional smokers indicated support for four or more
of the restrictions. This puzzling finding does not
detract from the overall conclusion that even tobacco
users are generally in favour of restrictions.
Strengths and limitations
It seems evident from this study that supportive public
opinion makes the time ripe for renewed advocacy to
fully implement the FCTC and its smoking restrictions.
Strengths of this study that are worth noting are the
national representativeness of the sample and the high
response rate of 96%. Regarding measurement, the
internal consistency of attitudes towards smoking prohib-
ition and tobacco ads ban is very high in this study. On
the other hand, the attitude items have not been used
in previous research, and comparative studies are not
available. Whether the high internal consistency
observed in this study would be replicated in other
populations is therefore a matter for speculation that
only future research could illuminate. In the period
since the data of this study were collected and in this
publication, it is possible that there have been shifts in
public opinion that might affect our conclusions.
Regarding the study data, this report focuses just on one
issue, the state of public opinion regarding tobacco-control
measures. The survey also collected data not reported
here, such as the level of respondents’knowledge of the
harmful health effects of tobacco and their attitudes
towards tobacco tax policies. Thus, a complete picture of
the findings from the survey will only emerge after com-
pletion of more analyses and publication.
Further research
This study provides a model, a methodology and an
instrument for the assessment of national public
opinion about tobacco control. As we remarked in the
Background section, this study is essential in the
Georgian context, because no amount of public opinion
findings from other countries has as much currency
with Georgian decision-makers as findings from Georgia
have. Many low-income and middle-income countries in
Eastern Europe (mostly former Soviet Republics) are
struggling with the same negative forces for increased
tobacco consumption that are at work in Georgia. We
have described and demonstrated a method for gather-
ing good quality data on national public opinion regard-
ing tobacco control. The study’sfindings have relevance
in Georgia, while the study’s methodology has relevance
not only in Georgia, but also in other former Soviet
Republics that are facing the same tobacco-related
public health threat that Georgia faces.
Public opinion data have a special standing in public
health research. Questions about the generalisability of
findings are restricted to constituencies defined by polit-
ical boundaries. Each and every constituency, that is,
grappling with a public health problem like tobacco use,
and that wishes to document public opinion relevant in
controlling the problem, has to do so within the con-
stituency. Advocacy based on research in other constitu-
encies can always be expected to be less effective than
advocacy based on locally generated data and findings.
Conclusion/recommendation
The findings of this study show that all eight smoking
prohibition and tobacco ads/sponsorship ban have a
high level of public support in Georgia. We interpret
this as public demand for the government to enforce
the already existing smoking prohibitions and regula-
tions, to establish total prohibitions in any other public
places including restaurants/bars, and to totally ban
tobacco advertisement, direct and indirect, and to ban
tobacco promotion in any form. We have shown in our
review of literature that there is a good reason to
conduct research on public opinion, because the
public’s opinion is a factor in political decision-making.
High quality public opinion data can be gathered
using a methodology accessible to researchers in Former
Soviet Republics, where the threats to the health of
people consuming tobacco are in many cases rising.
Acknowledgements The authors express their gratitude to Hana Ross (USA),
Judith Watt (UK) and Konstantin Krasovsky (Ukraine), who assisted in the
design of the survey and helped to develop the questionnaire. The authors
Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461 7
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would like to acknowledge for the contribution to the sampling design of the
late Revaz Tsakadze (Georgian State Department of Statistics).
Contributors GDB participated in the planning and data collection phases of
the study and in formulating the study questions. He was the lead statistical
analyst and the lead writer of the article. MBM participated in formulating the
study questions, the statistical analysis and drafting of all sections the article.
LEA participated in the statistical analysis and contributed to the drafting of
the statistical parts of the article. NTP participated in the planning and data
collection phases of the study, and also edited the article.
Funding An Open Society-Georgia Foundation grant “Population survey on
tobacco economy and policy in Georgia”provided financial and technical
support to collect the study data.
Competing Interests The Eurasia Programme, administered by the Norwegian
Center for International Cooperation in Higher Education and the Norwegian
Ministry of Foreign Affairs, provided financial support for GDB in the study’s
data analysis and report writing phase.
Patient consent Obtained.
Ethics approval The Georgian Health Promotion and Education Foundation
Ethical Committee approved the study protocol.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The study data are available by emailing the
corresponding author.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/3.0/
REFERENCES
1. World Health Organization (WHO). WHO framework convention on
tobacco control. Geneva: WHO, 2005:1–16. http://www.who.int/
tobacco/framework/WHO_FCTC_english.pdf
2. Borland R, Yong H-H, Siahpush M, et al. Support for and reported
compliance with smoke-free restaurants and bars by smokers in four
countries: findings from the International Tobacco Control (ITC) Four
Country Survey. Tob Control 2006;15(Suppl III):iii34–41.
3. Brooks D, Mucci L. Support for smokefree restaurants among
Massachusetts adults, 1992–1999. Am J Public Health
2001;91:300–3.
4. Laforge GR, Velicer FW, Levesque AD, et al. Measuring support for
tobacco control policy in selected areas of six countries. Tob Control
1998;7:241–6.
5. Jha P, Chaloupka F. Tobacco control in developing countries.
WB&WHO. Oxford University Press, 2000:1–10, 215–34, 273–83,
449–63.
6. Joossens L, Raw M. Progress in tobacco control in 30 European
countries, 2005 to 2007. Swiss Cancer League, 2007:1–24.
7. Kerryn R. Report on smoke-free policies in Australia. WHO, 2004.
http://www.who.int/tobacco/research/secondhand_smoke/en/best_
practices_australia.pdf
8. National Institutes of Health (NIH). Changing adolescent smoking
prevalence. Smoking Tob Control Monogr 2001; No. 14. Bethesda,
MD., 210.
9. WHO Report on the Global Tobacco Epidemic. Enforcing bans on the
tobacco advertising, promotion and sponsorship. WHO, 2013. http://
apps.who.int/iris/bitstream/10665/85380/1/9789241505871_eng.pdf
10. Bakhturidze GB, Ross H, What J, et al.Population survey on
tobacco economy and policy in Georgia. FCTC Implementation and
Monitoring Center in Georgia 2008;4–22.
11. Gilmore A, Pomerleau J, McKee M, et al. Prevalence of smoking in
8 countries of the former Soviet Union: results from the living
conditions, lifestyles and health study. Am J Public Health
2004;94:2177–87.
12. Warren CW, Jones NR, Peruga A, et al. Global youth tobacco
surveillance, 2000–2007. MMWR Surveill Summ 2008;57
(SS01):1–21.
13. Georgian Law on Tobacco Control. Updated in 15 December 2010.
http://www.tobaccocontrollaws.org/files/live/Georgia/Georgia%20-%
20TC%20Law%202010.pdf
14. Georgian Code of Administrative Offences, due to date 23 September
2012. http://laws.codexserver.com/931.DOC
15. WHO. Parties to the WHO Framework Convention on Tobacco
Control by 2013. http://www.who.int/fctc/signatories_parties/en/index.
html
16. Georgian Law on Advertisement. due to date 23 September 2012.
http://laws.codexserver.com/183.DOC
17. Anderson JE, Buller D, Voeks J, et al.Public policymaking. Vol. 30.
Belmont, USA:Wadsworth, 2006:292–9.
18. Petry F. How policy makers view public opinion. Vol. 6. University of
Toronto Press, 2005.
19. Canes-Wrone B, Shotts KW. The conditional nature of presidential
responsiveness to public opinion. Am J Political Sci 2004;48:
690–706.
20. Burstein P. Why estimates of the impact of public opinion on public
policy are too high: empirical and theoretical implications. Vol. 84.
Oxford University Press, 2006:2273–89.
21. Burstein P. Bringing the public back in: should sociologists consider
the impact of public opinion on public policy? Vol 77. Oxford
University Press, 1998:27–62.
22. Burstein P. Public opinion, public policy, and democracy: old
expectations and new. Handbook of politics. Springer 2010:2–16.
23. Johnson M, Brace P, Arceneaux K. Public opinion and dynamic
representation in the American States: the case of environmental
attitudes. Soc Sci Q 2005;86:88–105.
24. Weakliem DL. Public opinion research and political sociology.
Research in Political Sociology 2003;12:49–80.
25. Brooks J E, Manza J. Social policy responsiveness in developed
democracies. Am Sociol Assoc 2006;71:474–94.
26. Weissberg R. Why policymakers should ignore public opinion polls.
Policy Analyses 2001;402:2–16.
27. Stein E. The politics of policies: economic and social progress in
Latin America. Washington, DC: Inter-American Development Bank,
2005:23–181.
28. Kinder D, Sears D. Public opinion and political action. Handb Soc
Psychol 1985;2:659–741.
29. Burstein P. The impact of public opinion on public policy: a review
and an agenda. Political Res Q 2003;56:29–40.
30. Page B, Shapiro R. Effects of public opinion on policy. Am Political
Sci Rev 1983;77:175–90.
31. Soroka SN, Wleizen C. Public Preferences and Public Expenditure in
the United Kingdom 2003: a study in representation and feedback.
http://degreesofdemocracy.mcgill.ca/sorokawlezienmpsa2003.pdf
32. Soroka SN, Wlezien C. Opinion representation and policy feedback:
Canada in comparative perspective. Can Political Sci Assoc
2004;37:531–59.
33. Trotter L, Mullins R. Environmental tobacco smoke: surveys of
restaurant patrons and hospitality industry personnel. Quit Eval Stud
1996;9:27–41.
34. Lam TH, Janghorbani M, Hedley AJ, et al. Public opinion on
smoke-free policies in restaurants and predicted effect on patronage
in Hong Kong. Tob Control 2002;11:195–200.
35. Brenner H, Born J, Novak P, et al. Smoking behavior and attitude
toward smoking regulations and passive smoking in the workplace.
A study among 974 employees in the German metal industry. Prev
Med 1997;26:138–43.
36. Anderson PA, Buller DB, Voeks JH, et al. Predictors of government
officials’support for youth tobacco control policies. J Public Health
Manag Pract 2007;13:621–9.
37. de Guia NA, Cohen JE, Ashley MJ, et al. Support for tobacco control
policies: how congruent are the attitudes of legislators and the
public? Can J Public Health 2003;94:36–40.
38. Synder A, Falba T, Busch S, et al. Are State legislatures responding
to public opinion when allocating funds for tobacco control
programs? Health Promot Pract 2004;5(Suppl 3):35S–45S.
39. Bartosch WJ, Pope GC. Local enactment of tobacco control policies
in Massachusetts. Am J Public Health 2002;92:941–3.
40. Rigotti NA, Regan S, Moran SE, et al. Students’opinion of tobacco
control policies recommended for US colleges: a national survey.
Tob Control 2003;12:251–6.
41. Walsh RA, Tzelepis F, Paul CL, et al. Environmental tobacco smoke
in homes, motor vehicles and licensed premises: community
attitudes and practices. Aust N Z J Public Health 2002;26:
536–42.
42. Walsh RA, Paul CL, Tzelepis F, et al. Is government action
out-of-step with public opinion on tobacco control? Results of New
South Wales population survey. Aust N Z J Public Health
2008;32:482–8.
43. Marques-Vidal P, Melich-Cerveira J, Paccaudet F, et al. Opinions on
tobacco control policies in Lausanne, Switzerland, 2003–2006. Prev
Med 2010;51:193–4.
8Bakhturidze GD, Mittelmark MB, Aarø LE, et al.BMJ Open 2013;3:e003461. doi:10.1136/bmjopen-2013-003461
Open Access
group.bmj.com on January 6, 2014 - Published by bmjopen.bmj.comDownloaded from
44. Muggli ME, Hurt RD, Blanke DD. Science for hire: a tobacco
industry strategy to influence public opinion on secondhand smoke.
Nicotine Tob Res 2003;5:303–14.
45. Saloojee Y, Dagli E. Tobacco industry tactics for resisting public
policy on health. Bull World Health Organ 2000;78:902–10.
46. McAllister I. Public opinion in Australia on restricting smoking in
public places. Tob Control 1995;4:30–5.
47. Perlstadt H, Holmes R. The role of public opinion polling in health
legislation. Am J Public Health 1987;77:612–14.
48. Yang Y, Li L, Yong H, et al. Regional differences in awareness of
tobacco advertising and promotion in China: findings from the ITC
China Survey. Tob Control 2010;19:117–24.
49. Reddy P, Meyer-Weitz A, Yach D. Smoking status, knowledge of
health effects and attitudes towards tobacco control in South Africa.
S Afr Med J 1996;86:1389–93.
50. Lazuras L, Rodafinos A, Panagiotakos DB, et al. Support for
smoke-free policies in a pro-smoking culture: findings from the
European survey on tobacco control attitudes and knowledge. Int J
Public Health 2009;54:403–8.
51. Paulik E, Maroti-Nagy A, Nagymajteni L, et al. Support for
population level tobacco control policies in Hungary. Cent Eur J
Public Health 2012;20:75–80.
52. Global Adult Tobacco Survey (GATS), Russian Federation. Country
Report. WHO, 2009. http://www.who.int/tobacco/surveillance/en_tfi_
gats_russian_countryreport.pdf
53. Danishevski K, Gilmore A, McKee M. Public attitudes towards smoking
and tobacco control policy in Russia. Tob Control 2008;17:276–83.
54. Global Adult Tobacco Survey (GATS), Ukraine.Country Report.
WHO, 2010. http://www.who.int/tobacco/surveillance/en_tfi_gats_
ukraine_report_2010.pdf
55. Roberts B, Stickley A, Gilmore AB, et al. Knowledge of the health
impacts of smoking and public attitudes towards tobacco control in
the former Soviet Union. Tob Control 2013;22:e12.
56. Saffer H, Chaloupka F. The effect of tobacco advertising bans on
tobacco consumption. J Health Econ 2000;19:1117–37.
57. Cornwell B. The use of Sponsorship-linked marketing by tobacco
firms: international public policy issues. J Consum Aff 1997;31:
238–54.
58. Arbogast R. A proposal to regulate the manner of tobacco
advertising. J Health Polit Policy Law 1986;11:393–422.
59. DiFranza JR, Wellman RJ, Sargent JD, et al. Tobacco promotion
and the initiation of tobacco use: assessing the evidence for
causality. Pediatrics 2006;117:e1237–48.
60. Moodie C, MacKintosh A, Brown A, et al. Tobacco marketing
awareness on youth smoking susceptibility and perceived
prevalence before and after an advertising ban. Eur J Public Health
2008;18:484–90.
61. Braverman M, Aarø L. Adolescent smoking and exposure to tobacco
marketing under a tobacco advertising ban: findings from 2
Norwegian national samples. Am J Public Health 2004;94:1230–8.
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2013 3: BMJ Open
George D Bakhturidze, Maurice B Mittelmark, Leif E Aarø, et al.
tobacco advertisement bans in Georgia
Attitudes towards smoking restrictions and
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