Młodzi dorośli popierają zakaz palenia w miejscach publicznych w Polsce – badanie jakościowe

INTRODUCTION

Legislative steps taken to reduce the harmful effects of smoking

Over the past 20 years, anti-smoking policies have been introduced in many European countries as smoking bans in public places. The introduction of a comprehensive smoke-free policy can contribute to cutting the incidence of smoking among adolescents and adults as well as reducing public acceptance of smoking [1].
To provide a smoke-free environment in Poland, the Act of 15th November 2010 was introduced as an amendment to the Act of 9th November 1995 on the Protection of Public Health against the Effects of Use of Tobacco and Tobacco Products. Stricter laws against smoking in public places were implemented. The law was extended to the following smoke-free areas:
• health care entities and facilities providing health services,
• public areas in culture and recreation facilities,
• public transport and establishments serving the needs of travellers,
• public transport stops,
• public playgrounds for children.
There was a significant change as regards a smoking ban on catering and entertainment facilities. The Act still allows owners to designate special areas for smoking [2].
The main objective of those changes was to protect people from exposure to second hand smoke and reduce the percentage of smokers.
This work aims to present the opinions and views of Polish young adults regarding the institutional changes introduced in the field of smoking in public places.
There are still not many studies in the literature focusing on the opinions of respondents, but only on collecting and presenting quantitative data. The qualitative study can provide a better understanding of the specifics of the phenomenon related to the support for the introduced smoke- -free policy by respondents with different smoking statuses. During the interview, the researcher was able to find out respondents’ thoughts about the ban – whether it is considered as a barrier for smokers or as a form of protection for non-smokers’ environment. In addition, qualitative research provides a better understanding of the impact of introduced restrictions on individuals and their attitudes towards smoking. The conclusions of qualitative research can be used to develop quantitative research as well as epidemiological standards describing the problem.

Tobacco smoking epidemiology

The tobacco smoking epidemic remains one of the most important global public health problems due to its direct impact on premature death. Tobacco smoking is one of the main reasons of premature death in Poland [3], leading to about 10% of deaths globally [4-6] including 18% of deaths in high-income, 11% in middle-income and 4% in low-income countries [7]. These rates are expected to increase due to the recorded growing number of smokers in low and middle-income countries.
Smoking is a major problem in Poland despite the ban on it in public places. It is harmful, life threatening and is linked to at least 16 types of cancer while passive smoking is also carcinogenic [8].
The 2008-2013 Global Adult Tobacco Survey (GATS) conducted in 22 low and middle-income countries, shows that about 31.1% of men and 6.2% of women smoke [9]. In the 25 European Union Member States (excluding Bulgaria, Croatia, and Romania), the frequency of tobacco smoking in 20 to 64 year-olds is 37% in men and 26.9% in women [10].
The Polish edition of GATS was conducted at the turn of 2009 and 2010. The study was organised by the Centers for Disease Control and Prevention (CDC) and WHO. The Medical University of Warsaw, the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology and Pentor Research International [3, 6, 11] were responsible for its execution. The data collected shows that the percentage of smokers aged 15 years and more was 30.3% (36.9% of men and 24.4% of women) and 27% of adults used tobacco every day [10, 11]. Among men, the highest percentage of smokers (i.e. smoking every day and occasionally) was observed in the 40 to 49 year-olds (45.3%), the lowest in 15 to 19 and 60 year old and older age groups (both 23.4%). Among women, the highest percentage of smokers (37.4%) was noted in the 50-59 year old age group and the lowest (10%) in the 60 year-olds and older [3].
The Act prohibiting smoking in public places was introduced in Poland in 2010. GATS conducted before and after implementation of the Act indicate that the percentage of smokers between February 2010 and July 2012 remained at a comparable level of about 30% (2010 – 30.3%; 2011 – 29.8%; 2012 – 30.7%) [12]. In 2019 it fell to 26% [13].
Education level is one of the most significant factors increasing the risk of smoking among men and women. Studies carried out in Poland and the other European Union countries confirm that the frequency of smoking increases in those groups with a lower education level in the population [14]. Periodic analyses conducted in Poland by the Public Opinion Research Centre (CBOS) showed that the lowest percentage of smokers was noted in the university degree group, with the highest percentage of smokers recorded among the respondents with only vocational education (Figure 1) [12, 13].
Data from the quantitative survey shows an increase in the percentage of people supporting a ban on smoking in public places in Poland from 2010 to 2012. The overall number of people who strongly or rather supported the smoking ban increased from 75.6% in 2010 to 83.2% in 2011, and to 85% in 2012 (p < 0.001). Women predominated among respondents who approved of the legal regulation of smoking bans in public places at 81.4% – 2010, 89% – 2011 and 88.4% – 2012. Support among men was 69.4%, 77%, 81.3% respectively [12].
The objective of this study was to collect and present the opinions of smokers, non-smokers, and those who had quit smoking for the smoking ban in public places introduced on 15th November 2010 in the amendment to the Act of 9th November 1995 on the Protection of Public Health against the Effects of Use of Tobacco and Tobacco Products. The aim was also to gain a better understanding of the impact of the introduced restrictions on individuals and their attitudes towards smoking.

MATERIAL AND METHODS

The qualitative studies were carried out using Individual In-Depth Interviews (IDI) according to a pre-specified scenario. The interviews were conducted from February to December 2014. Qualitative methods focus on a deepener analysis of social behaviours [15] including those relating to health and its determinants [16]. These offer more detailed information for quantitative (questionnaire) methods though at the cost of the level of standardisation. The main objective of the qualitative studies is not to identify the scale of a given phenomenon, but to understand its specific nature and mutual relations [15].
The interviews were conducted by researcher in conditions favourable for the respondents. All possible distractors like noise were eliminated and quiet places were chosen. The interviews were recorded using a dictaphone and then a detailed transcription. The interviews were made anonymous for the purposes of the content analysis. The average interview time was about 40 minutes (25-60 minutes).
A literature review was conducted as part of the preparation for the study, providing the basis for the thematic scope and initial scenario outline. This, in turn, was fine-tuned in classes with students. The study scenario consisted of 5 thematic blocks divided into detailed sociodemographic, smoking, the smoking ban, the anti-smoking law and finalising questions. Those in the smoking block were adjusted to particular current smoker, those who had quit smoking and non-smoker respondent groups. All respondents provided consent to be interviewed for scientific purposes.
The group of potential respondents was selected from the researcher’s environment, through which a network of further, not directly related, contacts and a list of study participants was created. The final group of respondents consisted of those who met the study objectives. The participants were selected using a snowball sampling technique. This is a non-probability (non-random) sampling method in which the individuals selected to be studied recruit new participants [17]. In addition quota sampling was used, in which the sample size of the particular groups was taken into account, i.e. in the group of current smokers 2 women and 3 men (occasional smokers – 3, daily smokers – 2); in the group of non-smokers 3 women and 2 men; in the former smokers’ group 4 women and 1 man. The size of the studied group is typical for Individual In-Depth Interviews [18]. Sample size in the qualitative studies does not depend on principles, but rather on other factors like interview length and the difficulty of a given issue [17]. Data were collected as long as no new themes appeared or when data saturation had occurred. Initial analysis was carried out by one researcher. A second researcher verified the correctness of the analysis and data interpretation.

RESULTS

Fifteen participants from the Mazowieckie Voivodeship (Poland) took part in the study. Detailed characteristics of the study group are presented in Table I.

Tobacco smoking

Passive exposure to tobacco smoke

Four years after anti-smoking policy was implemented in Poland, 9 out of 10 former smokers and non-smokers declared passive exposure to smoke at work, in catering and entertainment facilities and at home. Six mentioned their own or nearest family members’ homes. Despite the smoking ban in public places, the respondents indicated passive exposure to second hand smoke. Four of them reported catering and entertainment facilities and meeting places, three the workplace and one the university.
Those respondents who mentioned work as a place of passive exposure to smoke added that this was rare. Smoking workmates endeavoured to reduce others’ exposure to smoke by not smoking in non-smokers’ immediate vicinity “I’m most exposed to smoke during work in the ambulance service. However, my workmates try to reduce our exposure to smoke and they go outside to be far away from other employees” (I2, M, 30). Moreover, smokers most often smoked outside in front of the building. This was connected with others walking through a cloud of smoke, which, according to the respondents, was not pleasant.
When exposed to second hand smoke, the respondents felt some discomfort caused by the smoke, its unpleasant smell on clothes and breathing discomofort. One person who had quit smoking did not feel any discomfort in these situations. Two out of five smokers stated that the unpleasant smell of cigarettes made them feel uncomfortable.

Smoking at social gatherings

Non-smokers participating in the study most often chose their homes or catering and entertainment facilities like restaurants, pubs, cinemas, and child-friendly places to meet their friends. Fourteen out of fifteen respondents declared that during meetings at home, people did not smoke inside. If there were smokers, they would do so on the balcony or outside: “In a private flat smokers smoke outside or on the balcony. In the pub, in turn, if there is not a place where smoking is allowed, they would go outside” (I8, M, 23).
Two respondents indicated situations in private homes when the owners allowed smoking in closed rooms: “both in winter and in summer they smoke in the kitchen but I never go in there then” (I13, W, 30); “when there are no conditions [balcony, garden] some friends allow smoking in their flats, but in a specific place, for example in the kitchen, near the extractor hood” (I14, M, 31).
Most smokers indicated houses and flats as the main meeting places. These people, however, avoided smoking inside so as not to expose children and non-smokers to second hand smoke. One of the respondents declared choosing catering and entertainment facilities as main meeting places. He can smoke in the gardens where smoking is allowed in spring and summer. He goes outside in autumn and winter.

The impact of the season on the frequency of smoking

When asked about the impact of the season on the number of cigarettes smoked, the respondents had very similar observations. Seven out of ten non-smokers stated that the season did not have any impact on the frequency of smoking for heavy smokers: “the season of the year doesn’t matter. If someone wants to smoke, they go outside. (…) For occasional smokers, the season of the year can matter and then they go outside more seldom, yet for heavy smokers the urge is stronger than the weather conditions. They just have to go outside and smoke” (I2, M, 30). According to the respondents, occasional smokers can take the weather factor into consideration. One person stated that the season was correlated with smoking, and one person claimed it was not. It just resulted in more frequent colds.
Four smoking respondents emphasised that the season has an impact on the number of smoked cigarettes or the amount of tobacco. One of the respondents smoked a pipe only in summer when there were favourable weather conditions. Another respondent suggested that “the only dependence is that in winter one leaves home less often and therefore smokes less. Because in summer you can sit outside every day (…) so you smoke more, and in winter less. Because you don’t feel like going outside” (I5, M, 36). Smoking at home and in the workplace The studied group included people smoking tobacco regularly and occasionally. Three smoked occasionally, usually in summer and outside so as not to cause discomfort to non-smokers. One of the respondents who smoked regularly declared that she usually smoked during working hours in front of the building. She smoked very seldom at home and only near the kitchen extractor hood. One of the respondents does not usually respect the rights of non-smokers and sometimes smokes in places where it is forbidden: “I smoke outside, in the rooms, there’s no European Union in my workplace. Therefore these rules [smoking ban] don’t apply. It’s normal” (I5, M, 36).

Smoking ban

Smoking in public places like restaurants, the workplace and public transport stops According to the amended Act of 9th November 1995 on the Protection of Public Health against the Effects of Use of Tobacco and Tobacco Products, owners or managers of catering and entertainment facilities can designate one smoking room that is also intended for food consumption with a proper ventilation system so that the smoke does not enter other rooms [2]. Despite that, nine out of ten non-smokers indicated a lack of smoking rooms in the workplace, schools and in catering and entertainment facilities. These people meet smokers who smoke in unmarked or non-smoking areas, which causes discomfort. “It’s obvious that there’s no such zone in hospitals, but the staff have such places in the basement” (I1, W, 32). Moreover, according to the non-smokers, smokers often break the rules and smoke in forbidden areas. “In front of my workplace there’s an unofficial smoking area. The ban is not followed. The employees shouldn’t smoke during working hours but they do so during the break” (I7, W, 29). One respondent emphasised that there were special smoking areas designated outside the building in his workplace.
Eight non-smokers and three smokers drew attention to often seeing people smoking at or near to public transport stops. Despite the smoking ban in this area, smokers break the law or walk away and smoke in close vicinity to the stop. The unpleasant smell and smoke cause discomfort for travellers. This a situation is connected with an unclear clause in the Act regarding the area of public transport stops: “I know that smoking at stops isn’t allowed but people still smoke there. In this sense, it’s not fully specified at what distance one can smoke. Where the stop starts and finishes” (I1, W, 32). For one person, smoking at stops was annoying and burdensome.
Besides, other forms of evading the smoking ban were mentioned. Four respondents indicated unofficial smoking rooms in health care units or on university premises. Two non-smokers and one smoker described their visits to catering and entertainment facilities where it was possible to smoke in most rooms. Sometimes, the owners of catering and entertainment facilities changed the proportions of smoking and non-smoking zones. The non-smoking zone was a small room in relation to the entire area of the facility: “in clubs they made micro-rooms for non-smokers, and the remaining part of the facility is for smokers” (I7, W, 29); “there are places that circumvented this act. They designated a vestibule, i.e. the area between two pairs of doors, with a table for non-smokers. Then there are automated doors with a warning that here a smoking zone begins and you enter at your own risk. Therefore, this place is entirely for smokers” (I5, M, 36).
Non-smokers emphasised that the implementation of the legislation significantly improved the situation of non-smokers in public places. Some restaurants resigned from the division into the zones for smokers and non-smokers, which was appreciated by non-smokers due to a reduced exposure to smoke. One respondent stated he had not met a facility without a non-smoking zone. ‘No smoking’ signs were introduced. Both smokers and non-smokers emphasised their satisfaction with the introduction of the smoking ban in public places, which has had a positive influence on their wellness and comfort while in places of this kind.

The respondents’ feelings regarding the changes caused by the smoking ban in public places

All the respondents had heard about the smoking ban in public places prior to the interview. Nevertheless, none of them went into detail on it. Information on the implemented laws was drawn from the mass-media like the internet, television and radio. Some had discussed this issue with their families and friends.
The Act aroused a variety of sentiments. The respondents had different opinions on the Act, while a positive attitude towards the implemented restrictions prevailed. Six non-smokers noticed that the Act protected non-smokers from exposure to second hand smoke, which was necessary and useful “people don’t pay attention to others, they’re selfish and smoke in various places, even when it’s not allowed. If someone else doesn’t like it, why should I expose them to second hand smoke, that’s my opinion. I think it was well legimitised, but following the ban is much more difficult” (I14, M, 31). Smokers were of a similar opinion. Four respondents described the new situation as a significant improvement. There were the following statements: “the Act allows non-smokers to be in public places without a health risk” (I10, W, 33); “there should be smoke-free places in public spaces. If someone wants to smoke, they may do it in designated places, not anywhere” (I12, M, 32); “it ensures the comfort of non-smokers” (I4, M, 30); “I think that the Act is right, because when smokers could smoke anywhere in public places, non-smokers were discriminated against. Smoking is an addiction, and not everyone wants it. We have to respect people who don’t want to smoke. Besides, pregnant women and people with small children also have the right to not breathe in tar and other smells” (I3, W, 30).
One non-smoker had negative feelings about the ban. She drew attention to the possible negative impacts of the regulations on the economic situation: “in Poland, the tobacco industry is an important branch, and reducing smoking, or the sale of menthol or other flavoured cigarettes, can have a significant impact on the decrease in sales and can worsen the situation of this sector, and hence on those employed in this industry. It can also influence the economy. (…) On the other hand, there are people who suffer from lung cancer due to smoking cigarettes, and this is also some cost born by the state. And now someone has estimated the costs, and it turned out that we could bear this economic cost in the form of a decreased production of tobacco and its processing in Poland.” (I11, W, 31). Besides, she drew attention to the fact that “too many spheres of our life are precisely regulated and our freedom is limited by too many provisions. (…) It seems to me that similar results could be achieved by means of good promotion of a life not smoking cigarettes, and of respecting the rights of non-smokers. I’m not for regulating every sphere of our life by means of provisions of acts” (I11, W, 31).
In the group of smokers, only one person emphasised that the smoking ban in catering and entertainment facilities was harmful for smokers. According to this respondent, there is no need to introduce division into smoking and non-smoking zones. Owners should have the possibility to choose and decide if their facilities are for smokers or non-smokers. It would be verified by the guests, who then would make the choice. “If non-smokers liked a given facility, they would endure any smoke and come anyway” (I5, W, 36).

DISCUSSION

Qualitative studies have a significant impact in social and health studies. They allow us to make some interesting observations, yet this should be done with care, remembering the limitations associated with a small group of respondents. It should be emphasised, however, that precise principles determining the size of a studied sample have not been developed [17].
The data from the interviews present the opinions of smokers, non-smokers and people who had quit smoking towards exposure to second hand smoke and towards the smoking ban in public places. This study makes reference to a project executed in Poland during the legislative process, i.e. between June 2007 and August 2008, titled: “Lay meaning of health and life orientation of Polish society versus prevention and health promotion attitudes”. Qualitative methods were used there as well. The authors of the study were interested in public support for restrictions within the smoking ban in public places. The data from the interviews were divided into four groups reflecting the respondents’ attitudes towards the changes namely support, acceptance, conditional acceptance and ambivalent attitude. The respondents participating in the aforementioned study, and in the study analysed by the article authors emphasised that a significant element of the smoking ban was protection of non-smokers from passive exposure to tobacco smoke [19].
In both cases, smokers had a sense of unequal treatment and discrimination against the needs of heavy smokers who would like to use public places and smoke at the same time. Respondents participating in a similar study conducted in Scotland had the same opinions. Smokers thought they should be allowed to smoke whenever they liked [20].
In another Polish qualitative study, smokers reported that due to the existing bans on smoking in public places, they found it more difficult to comply with the rules when they are smokers and therefore make attempts to quit [21]. The researchers also found that a ban on smoking in workplaces encourages quitting by reducing in the amount of places available to smokers. In addition, people who decide to stop smoking should avoid environments where they could be exposed to second hand smoke [21].
In our study, all the respondents had a rather positive attitude and expressed their support for the smoking ban. The poll carried out by CBOS in 2019 showed that the total number of Poles who rather or definitely did not support the new regulations was 10% [13]. Contrary to the respondents surveyed in Poland between 2007-2009, who had little knowledge of the smoking ban [19], all the participants of this study had heard about the implemented ban and knew what places it concerned. None of them were interested in the specific provisions of the Act they were just following their own opinions or information they had heard. Besides, some respondents taking part in the previous study mentioned a lack of necessity to specify the provisions of the Act regarding places with the smoking ban. They claimed that most people would adjust to the social norms and respect other people’s will [19]. In this study, the respondents reported the lack of precise provisions and omission of the Act as a problems.
Participants in this study pointed out that the implementation of the new smoke-free policy had improved the situation of people exposed to second hand smoke, which is also reflected in the quantitative studies that were conducted in Poland in the same period. A study conducted in 2017 for the Chief Sanitary Inspector regarding attitudes towards smoking also clearly indicates the positive impact of the Anti-Tobacco Act on smokers’ behaviour. The percentage of people exposed to second hand smoke has fallen since the introduction of the law. The authors of the study indicate that we are most often exposed to passive smoking at public transportation stops and in public transport facilities. Almost half of the respondents (49%) declared compliance with the smoking ban in public places, 44% were of the opposite opinion, and 7% did not specify their answer unambiguously. Also, 40% of respondents declared that tobacco was smoked in their homes. Compared to 2013, there was a decrease in exposure to tobacco smoke by 5 percentage points. In the smokers’ group, 87% admitted that tobacco was smoked in their homes, while 76% of non-smokers declared they have completely non-smoking area in home [22]. Also in this study, 6 out of 15 respondents reported exposure to tobacco smoke in their home or their family’s home space.
This important issue, which is exposure to passive smoking in homes and private cars, was dealt with by an international group of researchers in the EUREST-PLUS ITC study. The situation in selected 6 European countries (Germany, Greece, Hungary, Poland, Romania, and Spain) related to the privately applicable rules on smoking in lower areas was analysed, despite the generally non-binding smoking ban. The results of the study indicated that 1/4 of smokers introduced a voluntary ban on smoking at home and 2/3 in cars in the presence of children [23].
This study is one of the first qualitative studies after the introduction of the smoke-free policy in Poland in 2010. During this research, the authors obtained valuable insights from young adults on the anti-smoking policy introduced in Poland. Respondents emphasised that smokers are most likely to leave a meeting place to use tobacco even if the meeting takes place in a private area. It was noted that smoking is seasonal, with warmer seasons favouring more frequent smoking. Participants underlined that a very important aspect of the smoke-free policy introduced is the protection of the non-smokers’ environment, which has had a significant impact on their comfort in public places. Respondents stressed that the introduction of the smoking ban in public places was much needed but that it was difficult to comply with. This is evidenced by reported smoking in underserved areas, the establishment of illegal smoking rooms and even in hospitals and other health facilities.

Limitations

Qualitative research methods were used in this study. In contrast to quantitative methods, they do not allow determining the scale of the studied phenomenon in the population. This is also the case in this study. The authors are not able to determine to what extent the presented opinions are representative of the population or how often they occur. This is a standard problem in qualitative studies. Nevertheless, it is possible to reveal respondents’ motivations, which are not available in the case of poll research. The advantage of qualitative studies is their accuracy, the possibility of precise respondent statements and in-depth understanding of a speaker’s arguments [17].

CONCLUSIONS

Most respondents support the smoking ban in public places. They expressed satisfaction with the introduction of smoke-free policy, which has had a positive impact on their wellness and comfort while in places of this kind. They also notice that it protects non-smokers from harmful effects of airborne smoke. A significant problem is smoking in catering and entertainment facilities the owners of which often bypass the law and create unofficial smoking rooms or change the proportions of smokers and non-smokers spaces. Some respondents paid attention to a lack of specifications of some issues in the Act, like the area of bus stops where smoking is an inconvenience and an undesired phenomenon.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

The study was carried out within the framework of a research project which ran from 2013 until 2014, funded by a grant statutory obtained by the Faculty of Health Sciences, Medical University of Warsaw. Grant No NZC/PM41D/13.
Badanie zrealizowano w ramach projektu naukowego prowadzonego w latach 2013–2014 finansowanego przez stypendium statutowe Wydziału Nauk o Zdrowiu WUM. Nr grantu NZC/PM41D/13.

Ethics/Etyka

The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo