CHAPTER 1

THE PROBLEM AND ITS BACKGROUND

This chapter Includes the introduction, theoretical framework, statement of the problem, scope
and limitation, conceptual framework, significance of the study, and the definition of terms
used.

Introduction
Smoking remains a significant public health concern with far-reaching consequences for
individuals, communities, and societies. As a behavior rooted in the inhalation of smoke from
burning tobacco products, smoking poses numerous health risks and contributes to a
substantial burden on healthcare systems worldwide. The exploration of smoking through
comprehensive research is crucial in understanding its multifaceted nature, identifying
underlying causes, and developing effective strategies for prevention and cessation.
This research endeavors to delve into the complexities surrounding smoking, shedding light on
various aspects that contribute to its prevalence and persistence. By examining the causes,
health effects, addictive nature, and social factors associated with smoking, this study aims to
provide valuable insights for policymakers, healthcare professionals, and individuals seeking to
address this pressing issue.
The research will begin by investigating the epidemiology and prevalence of smoking across
diverse populations and demographics, highlighting variations in smoking rates and behaviors.
Additionally, the study will analyze the well-established link between smoking and a range of
adverse health outcomes, including cancer, cardiovascular diseases, respiratory disorders, and
reduced life expectancy. Special attention will be given to the addictive properties of nicotine,
exploring its impact on the brain and the challenges faced by individuals attempting to quit
smoking.
Furthermore, this research will delve into the realm of smoking cessation, exploring various
strategies and interventions designed to help individuals overcome their addiction. By
evaluating the effectiveness of behavioral therapies, pharmacological treatments, counseling
programs, and digital health interventions, this study seeks to contribute to the development of
evidence-based approaches to support smoking cessation efforts.
Recognizing the pivotal role of policy in tobacco control, this research will also examine the
impact of legislative measures, such as taxation, advertising restrictions, and smoke-free laws,
on smoking prevalence, initiation, and cessation rates. By investigating the influence of social
and behavioral factors, including peer dynamics, social norms, marketing strategies, and the
tobacco industry, this study aims to deepen our understanding of the broader context in which
smoking behavior is shaped.
Ultimately, this comprehensive research endeavor aims to provide a holistic understanding of
smoking, uncovering the intricate web of factors that contribute to its persistence. By shedding
light on the underlying complexities, this study seeks to inform evidence-based policies,
empower healthcare professionals, and provide individuals with the knowledge and tools to
combat smoking effectively.

Through collaborative efforts, utilizing the collective wisdom of researchers, policymakers, and
practitioners, we can work towards reducing smoking prevalence, protecting individuals from
its harmful effects, and building a healthier future for generations to come.

Background of the study

Tobacco is one of the leading eight causes of death in the world. Tobacco is the largest agent
killing 100 million people in 20th century and it is estimated that around eight million people will
die of tobacco every year 2030 A.D. accounting for one death every three seconds. Eighty per
cent of the people among estimated eight million to die by 2030 likely will belong to the
developing countries. It is also predicted that tobacco will be one of the major causes both for
mortality as well as disability adjusted life years (DALY) in the 21st century. Most of the smokers
begin smoking by early adolescents and generally continue smoking in adult life also. Most of the
chronic adverse health effects may take three to four decades for a full manifestation. As a
result, those who continue smoking have a 50% chance of dying from tobacco-related disease,
and regular smokers have about three time’s higher death rate than non-smokers at all ages
(from young adulthood). (WHO 2008) Worldwide, tobacco consumption is not just one of the
leading causes of preventable deaths (accounting for more than seven million deaths per year or
one death every second) its global economic burden is estimated to be around 1.4 trillion US
Dollars together with lost productivity (WHO). In 2015, more than 1.1 billion people smoked
tobacco; and rate of smoking in WHO Eastern Mediterranean Region and African Regions is said
to be on the rise. Around 22% of the 15 years and old persons worldwide are reported to be
current smokers. Male generally smoked more than the female (WHO, 2015). Nicotine has been
consumed in many forms; chewing (e.g., Khaini, Paan, Gutkha), smoking (e.g., self-prepared bidi
from leaves in rural areas of Nepal, commercial bidi, filtered and non-filtered cigarettes, hookah)
and lately nicotine patches, lozenges or chewing gums as replacement therapy. Mostly, people
use as a recreational drug in the beginning and become habitual in later part of their
consumption. It is widely available throughout the country and most of them probably learn to
use it from their surroundings. From the beginning of the human history nicotine use has existed
side by side. However, its negative consequences on health began to come to notice after the
publication of medical dangers of tobacco by Benjamin Rush in 1798.
In Nepal, between 2009 and 2010 around 2491 tons of tobacco leaf were produced; and
cigarette production increased from 9970 million sticks in 2006-2007 to 11130 million sticks in
2008-2009. Prevalence of tobacco use or smoking in Nepal was reported to be 56.5% in men and
19.5% in women (NDHS, 2006). This is higher than in other countries. The 2007 survey carried
out by World Health Organization (STEPS) showed that the prevalence of smoking among adult
females in Nepal was 15%, which is one of the highest in the World Health Organization South-
East-Asia Region. Poor and illiterate sections of the society are more affected by tobacco use.
Eighty-six per cent of male smokers and 52% of female smokers smoked manufactured
cigarettes. (WHO STEPS Survey 2007). As an active participant in Global Tobacco Surveillance
System (GTSS), Nepal conducted three major studies; Global Youth Tobacco Survey in 2007
(GYTS, 2007), Global School Personnel Surveys in 2007 (GSPS, 2007), and Global Health
Professions Students’ Survey in 2006 (GHPSS, 2006). The Global Health Professions Students’
survey showed that 17.4% of dental and 23.7% of medical students were smoking cigarettes
actively. Around one third of the 434 third students surveyed from three dental and five medical
students used other tobacco products as well besides smoking. The Global Youth Tobacco Survey
was a cross-sectioned study carried out in 49 sampled secondary schools among the students
aged 13-15 years using the global standard protocol. This study reported that 5.7% of the boy's
smoked cigarettes and 1.9% of girls smoked cigarettes respectively. Besides smoking cigarettes,
15.5% used other tobacco products. Additionally, students were exposed to second-hand-smoke
at home (35.3%), in public places (47.3%) and more than half of the students asserted that
smoking should be banned from public places. The Global School Personnel Survey was
conducted in the same schools in which GYTS was conducted and this study all personnel of the
schools were eligible participants. This survey revealed that 37.7% smoked cigarettes every time
in their lives, 17.5% smoked bidi ever in their life's and 26.8% chewed tobacco every time in their
lives respectively. In Nepal, among the total population of 26.6 million there are 6.4 million
adolescents (which make up about 24% of the total population) as per census done in 2011.
People aged 15 years to 24 years are 5.3 million accounting for 20% of the total population. The
annual population growth rate was estimated around 1.4%. More than
83% of the total population lived in rural area. The average household size was 4.7. The crude
birth rate was 22.17 and the crude death rate 6.8% per thousand populations. Life expectancy at
birth was 64.1 years (64.5 years for females and 6.3 years for male). In our neighboring
countries, the age-standardized prevalence of current smoking in male (15 years and older) in
2015 is more than the world figure (22%) except in India where it is are ported to be 20.4%.
Pakistan and China have prevalence of 41.9% and 47.6%. In Nepal it is reported to be around
37.1% (WHO). Nepal is also a party to the World Health Organization Framework Convention on
Tobacco Control (WHO FCTC). In accordance to its requirement, Nepal also has adopted the
following policies: Pictorial warnings in tobacco product package, establishment of a tobacco
control and regulatory committee, prohibition of sale of tobacco to and by minors, prohibition of
smoking in public places, ban on all forms of tobacco advertisement (promotion or sponsorship)
etc. Likewise, Nepal has been trying to follow the tobacco control activities like MPOWER policy
of World Health Organization. MPOWER is a policy package to reverse the tobacco epidemic and
it stands for: Monitor tobacco use and prevention policies; Protect people from tobacco smoke;
Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco
advertising and promotion; and Raise taxes on tobacco products. (Brief Profile on Tobacco
Control in Nepal, Ministry of Health and Population, Government of Nepal) Adolescence is a
period of vulnerability to start smoking cigarettes or other recreational substances of abuse. The
term adolescence refers to individuals between ten to nineteen years of age (WHO). It is a time
of hormonal surge, more affiliation with the peers and a transitional phase from dependence to
independence. There are many kinds of changes that happen including physical, mental,
physiological or emotional. There is a growing recognition that because of a combination of
biological, psychological, and social factors adolescents face many challenges and health risks
such as unprotected sex, accidents, violence and as well as substance abuse including cigarette
smoking. According to Census of Nepal (2011), there are 6.4 million adolescents, making up
about 24% of the total population. Therefore, it is important that studies related to adolescents
should regularly happen as a need to control tobacco or other preventive aspects.

Conceptual Framework
A study has some basis on which it is done. Mostly, it is based on certain theories or theoretical
frameworks. Health related behaviors, social and organizational aspect of the study in which how
an individual, society, and health systems interact are generally based on the theoretical
framework of the Health Belief Model. Health Belief Model also can different theories under it
specific to the studied problems. A conceptual framework is usually drawn from certain theories
to suit the nature of the study in consideration. It differs from methodology in that theoretical
framework is more related to the ways of gaining knowledge whereas methodology is more
about the process of conducting the research per se. This study is partially based on the
theoretical literature provided by Flay, Petris and Hu (1999).
 Exposure(parents,
siblings, peers, Prevalence of
teachers, others) Age of initiation
smoking

Level of
dependence

Statement of the Problem

Smoking is a big problem in adolescent worldwide including Nepal. Smoking is known to
negatively affect many aspects of the health, academic performance, self- esteem, cost etc.
There are data about its prevalence in the world and few data in Nepal but published literature
from Itahari could not be found. Research findings show some consistent and some inconsistent
findings. Broadly in age ranges there is consistency, however, some of the areas of
inconsistencies are: some study points towards maternal role more (some paternal),
discrepancies in the initiation of smoking or factors cited for use, prevalence of smoking etc.
Findings from the local setting are important for planning effectively at a local level.
Furthermore, level of dependence is still not extensively discussed in the literature, and from
Nepal in these targeted students published studies could not be obtained. So, it is hoped that
this study would serve as the baseline data about the prevalence of ever-smoker and current-
smokers, the mean age of initiation of smoking, and association of exposure (at
home/school/peers) with status of smoking in public high schools of Itahari.

Hypothesis
There is no significant relationship between the demographic profile of the respondents and

the level of knowledge of the student’s smokers and its effects.

Scope and delimitation
This study will focus in student smokers to determine the knowledge of students regarding on
the effects of cigarette smoking. This was held at AMA UNIVERSITY.

Significance of the study

Students:
This research will guide the student smokers in different facts about cigarette

smoking that will help them to gain knowledge and better understand the risk of
smoking.
Family:
It will increase their awareness on the effects of cigarette smoking. By this it will
influenced their children in avoiding any smoking practices.

Community:
This study will facilitate change by making them realize the dangers of cigarette
smoking. Through methods from this study, a comprehensive community-based care
could be utilized.