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01.12.2016 | Research | Ausgabe 1/2016 Open Access

Tobacco Induced Diseases 1/2016

The opinions of adults about the ban on cigarette sales to minors

Zeitschrift:
Tobacco Induced Diseases > Ausgabe 1/2016
Autoren:
H. Ozcebe, N. Bilir, E. Inal, H. Unlu, E. Beser, G. Can, E. D. Evci Kiraz, P. Okyay, D. Arslantas, F. Abacigil, V. Senol, E. Turhan, S. Gokgoz, E. O. Calıkoglu, Z. Kocan
Abbreviations
FCTC
Framework Convention on Tobacco Control
GATS
Global Adult Tobacco Survey
GYTS
Global youth tobacco survey
WHO
World Health Organization

Background

Tobacco use is one of the most important public health concerns worldwide. The rapid increase in health problems associated with tobacco usage have drawn a lot of attention, and great efforts have been put in place to reduce tobacco use [ 1].
Tobacco control activities first started in developed countries, and later found their place in all countries’ agenda with the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) which was accepted at the World Health Assembly in 2003 [ 2]. FCTC points out two main groups of approaches to reduce tobacco use; the first approach is to reduce the demand for tobacco products, whereas, the second one is to reduce the supply of tobacco products, including placing ban on the sale of tobacco products to children and youth [ 3, 4]. According to several studies, increased enforcement of laws that ban tobacco sales to minors can reduce access of minors to tobacco products [ 57]. In an observational study on the impact of anti-smoking legislation in Woodridge, a suburban community of Chicago, it was found that both merchant sales and adolescent smoking behavior were reduced after the passage of the law [ 6]. According to the study, the rates of cigarette experimentation and regular use of cigarettes by adolescents were reduced by over 50% between the pre- and post-test observation periods. In addition, the reduction in cigarettes use was still apparent after 7 years [ 6]. Though previous studies suggest that the enforcement of laws banning the sale of tobacco products to the underage can lead to a reduction in tobacco use among minors, by making it harder to purchase cigarettes [ 7]. However, the effectiveness of tobacco control laws is undermined by other “social sources” of cigarettes [ 8]. For example, an intervention study done by Forster and colleagues to enact local ordinances, change retail merchants’ behavior, and promote enforcement of laws prohibiting illegal sales to minors in 14 Minnesota communities found that the prevalence of smoking among the young age groups was much less in the intervention communities as compared to other communities. In addition, they also observed that youths who reported ever smoking were very likely to cite social sources for cigarettes, though, older youth and those reporting weekly smoking also reported purchasing their own tobacco [ 5]. There are also similar studies showing that tobacco laws alone are not enough to reduce illegal sales to minors [ 810].
Public support for practices on the prevention of access to tobacco products for minors is very important if any progress is to be made. Studies have been done to this effect [ 1113]. A 1992 national telephone poll of 1200 adults residing in New York showed that approximately 83% were in favor of legislations banning tobacco advertisements targeted at teenagers in New York. In addition, three quarters of smokers also supported a ban on tobacco advertisements targeted at teenagers [ 14]. Another study shows that most of the American public do not believe that laws prohibiting the sale of tobacco to minors are adequately enforced [ 15]. In a survey conducted in the United States, it was reported that 8 out of 10 adults felt it was “very easy” or “somewhat easy” for teenagers to buy cigarettes near where they live [ 16]. Some literatures suggest that majority of adults think laws banning the sale of tobacco products to minors have not been adequately enforced [ 15, 17, 18].
Tobacco control activities first started in Turkey through the Law on Prevention of Harms of Tobacco Use in 1996 [ 19]. This Law was further amended in 2008, and played a role in making Turkey the third country in the world to be 100% smoke-free country [ 20]. The first and the amended law banned selling of tobacco products to minors less than 18 years of age [ 19, 21]. Even though there are some difficulties in the implementation of this item, Turkey has recorded important achievements in tobacco control and is the first and single country in the world implementing all six strategies of MPOWER with success [ 22]. However, tobacco use is still considered to be one of the main public health issues in Turkey, as Turkey is one of the countries with the highest tobacco usage rate in the world [ 22].
The frequency of smoking is 27.1% among older than 15 years in Turkey and about 15 million people use cigarette and other tobacco products [ 22]. According to the Global Adult Tobacco Survey (GATS), one fifth of smoker adults start using tobacco products before 15 years and more than half of adults start using tobacco products before 18 years [ 22]. This result reveals that tobacco use is quite prevalent among the young, also, a great number of smokers starts this behavior during their youth. Thus, it is very important to prevent children and the young from starting tobacco use.
The Turkish Law on the Prevention and Control of Hazards of Tobacco Products, Law No. 4207 has an article about the “prohibition of access to tobacco use for individuals who are under the age of 18 through sale and distribution” [ 19]. This is a very important law with regards to tobacco control as during tobacco control among minors, one of the focus is to prevent minors from accessing tobacco products with emphasis on advertising bans, sponsorship, promotion, brand stretching and regulations aimed at public awareness and point of sales [ 19]. This study aims to learn about the opinions and attitudes of adults with regards to minors access situations to tobacco products.

Methods

Study design and data collection

The study was a descriptive study conducted in nine city centers of Turkey; Ankara, Aydın, Erzurum, Eskisehir, İzmir, Gümüşhane, Kayseri, Kırklareli, and Trabzon. These cities were selected by convenience from different geographic regions of the country. Thus, the study findings are not representative of the whole country.
The study was organized by the Institute of Public Health, University of Hacettepe. Faculty members from the departments of public health or public health specialist in each city coordinated field data collection. The study was funded by Hacettepe University Scientific Research Projects Coordination Unit.
The sample size was determined by accepting the prevalence as 0.50 and error as 0.05 (with 95% confidence interval). Participation in the study was voluntary and convenience sampling technique was used with the aim of reaching 400 people in each city center. Participant selection criteria included adults aged 18 years and above.
The questionnaire form was developed by the study team, based on previous literatures. The questionnaire consisting of 22 questions regarding smoking behavior of the participants, knowledge of tobacco control law, observation and reactions on tobacco sales to minors. The items in the questionnaire consisted of socio-demographic characteristics of participants (6 questions), questions on individual smoking profile (4 questions), participants opinion about smoking among minors (5 questions), knowledge about prohibition of sales of tobacco to minors (2 questions), ever witnessed tobacco sale to minors and their reactions (3 questions) and suggestion about tobacco sale to minors (2 questions). The questionnaire was initially pretested and data was collected through face to face interview.
The questionnaire was initially pretested and data was collected through face to face interview. All interviewers were trained by the local research team in each city. The interviewers comprised university graduates or final year students. The expected total number of people to be interviewed was 3600 however, the total number of people reached was 3241.
  • Variables (i) Socio-demographic variables; Socio demographic variables included age, educational status, working status and income level. Age was recorded into 18–24, 25–34, 35–44, 45–54 and 55 and above years. Educational status was recorded into literate, primary (5 years), secondary (8 years), high school (11 years), university and others. Working status was grouped into working and not working. Income level was grouped into 5 groups: income level was grouped into lowest, lower middle, middle, higher middle and highest.
  • (ii) Perception and knowledge of tobacco use and sales to minor and tobacco control law covariates; this included questions on smoking ratio in high school, sales of tobacco to minors, penalty for sales of tobacco to minors, the places providing cigarettes to minors, and minors access to cigarettes. Smoking ratio in high school was recorded into the following groups; one adolescent out of 10, 2–3 adolescents out of 10, 4–5 adolescents out of 10, and 6–7 adolescents out of 10. Sales of tobacco to minors were grouped into prohibited, allowed with their parents and not prohibited. Penalty for sales of tobacco to minors was categorized into fine, cancellation of sales certification, and imprisonment, the places providing cigarettes to minors were grouped into grocery/market, friends, vendor, and family. Minors’ access to cigarettes was grouped into very easy, not very difficult and very difficult.
  • (iii) Ever witnessed tobacco sales to minor and response against the situation variables; Respondents were asked if they witnessed any tobacco sale to minors, the sellers response to minor and the participants response against tobacco sales to minor. Ever witnessed any tobacco sales to minors was grouped into yes and no. The sellers response to minor was categorized into asking his/her ID card and not asking anything and selling tobacco product. The participant’s response against this event include the following categories; Doing nothing, warning the sellers, warning the owner, warning the child, informing the police, and talking to the other people about this event.
  • (iv) Smoking status: Smoking status was grouped into current smokers, former smokers and never smoked.

Statistical analysis

For the study sample characteristics, variables were reported as frequencies and percentages. Pearson chi-square tests were conducted to examine bivariate differences with smoking status where the assumption of the expected count less than 5 should not exceed 20% for variables was satisfied, if otherwise exact chi-square test was used. “Participant’s response against tobacco sales to minor” was specified as dependent variable and dichotomized into warming/informing and nothing (as reference). Additionally, independent variables which includes “age”, “educational status”, “income level”, “minors access to cigarettes” and “sales of tobacco to minors” were grouped as follows: “Age” was classified into 18–24, 25–34 and 35 and above; “educational status” was classified into secondary and below, high school and university; “income level” was classified into middle and below, and higher middle and above; “minors access to cigarettes” was classified into very easy, not very difficult and very difficult and “sales of tobacco to minors” was classified into prohibited and not prohibited, allowed with their parents. Since “smoking status” was thought the most important factor affecting the behavors, two logistic regression models were performed to identify the relationship between “participant’s response against tobacco sales to minor” and related factors for current smokers and participants who never smoked. For current smokers, logistic regression model was constructed to identify the relationship between “participant’s response against tobacco sales to minor” and the following explanatory variables; socio-demographic variables (age, educational status, income level, working status), “minors access to cigarettes” and “smoking ratio in high school”. For participants who never smoked, logistic regression model was constructed to identify the relationship between “participant’s response against tobacco sales to minor” and the following explanatory variables; socio-demographic variables (age, educational status, income level, working status), “smoking ratio in high school” and “sales of tobacco to minors”. Reference categories were shown in Tables  4 and 5. Hosmer-Lemeshow statistics was used to assess model assumption. The variables which were found as significant according to Pearson chi-square test were included into logistic regression model as independent variables. Since some participants did not answered all the questions, there were some missing observations in the dataset. While performing multiple logistic regression, list wise deletion method was used to handle with missing observations. A p-value below 0.05 was accepted as significant.

Ethics

This study was approved by Non-interventional Clinical Researches Ethics Board of Hacettepe University (GO 13/242-19).

Results

Most of the participants were smoker (39.2%) or ex-smoker (19.1%), and 41.7% of the participants was non-smoker; 16.1% of the smokers started smoking daily before the age of 15 while 42.6% started smoking between ages 15–17 (data is not given in the table).
A greater proportion of respondents (60.5%) were in the age group 25–44 years age group, approximately 61.3% of participants were high school or university graduates. A greater percentage of study participants (65.9%) were currently working. About 85.7% had middle and below income level. More than half of the participants (55.5%) who were current smokers were in the age group 18–34 years. Participants who were never smoked had mostly high school and above educational status (64.0%), whereas more than half of the participants (64.7%) who were current smokers had high school and above educational status. Most of the participants who were never smoked, smoked and quit, current smokers had middle income level (43.7, 49.0 and 43.7% respectively) (Table  1).
Table 1
Some sociodemographic characteristics of participants
Socio-demographic characteristics
Smoking Status
Total
P
Never
Smoked and quit
Current smoker
N
%
Age
n
%
n
%
n
%
     
 18–24
275
22.3
49
8.7
187
16.0
511
17.2
<0.001
 25–34
483
39.2
171
30.3
462
39.5
1116
37.6
 35–44
267
21.7
113
20.0
299
25.5
679
22.9
 45–54
138
11.2
123
21.8
145
12.4
406
13.7
 55 and over
68
5.5
109
19.3
78
6.7
255
8.6
Total
1231
565
1171
2967
100.0
Educational Status
 Literate
123
9.6
45
7.8
71
5.9
239
7.8
<0.001
 Primary (5 years)
122
9.6
97
16.7
164
13.7
383
12.5
 Secondary (8 years)
214
16.8
112
19.3
234
19.5
560
18.3
 High school (11 years)
345
27.0
160
27.6
389
32.5
894
29.3
 University
453
35.5
165
28.4
326
27.2
944
30.9
 Others (vocational school, etc.)
19
1.5
1
0.2
13
1.1
33
1.1
Total
1276
580
1197
3053
100.0
Working Status
 Working
768
61.0
375
65.4
847
71.7
1990
66.0
<0.001
 Not working
492
39.0
198
34.6
335
28.3
1025
34.0
Total
1260
573
1182
3015
100.0
Income Level
 Lowest
72
5.7
36
6.1
60
5.0
168
5.5
<0.001
 Lower middle
486
38.4
199
34.0
400
33.5
1085
35.6
 Middle
553
43.7
287
49.0
522
43.7
1362
44.7
 Higher middle
129
10.2
52
8.9
169
14.2
350
11.5
 Highest
25
2.0
12
2.0
43
3.6
80
2.6
Total
1265
586
1194
3045
100.0
Note: Some participants did not answer all the questions
All the participants believed that smoking behavior was highly prevalent among adolescents. Only 7.2% of participants believed that one out of 10 high school students were smokers, most of the participants (76.2%) believed that smoking prevalence was more than 40% among high school students. Participants who were current smokers thought that more high school students were current smoking as compared to non-smokers ( p = 0.001) (Table  2).
Table 2
The perception and knowledge of tobacco use and sales to minor and tobacco control law by smoking status
Perception and Knowledge on Tobacco Use and Sales
Smoking Status
Total
P
Never
Smoked and quit
Current smoker
N
%
The smoking ratio in high school
n
%
n
%
n
%
     
 One adolescent out of 10
88
7.1
44
7.8
80
7.0
212
7.2
0.001
 2–3 adolescents out of 10
240
19.3
90
15.9
161
14.0
491
16.6
 4–5 adolescents out of 10
456
36.7
196
34.7
385
33.5
1037
35.0
 6–7 adolescents out of 10
460
37.0
235
41.6
523
45.5
1218
41.2
Total
1244
565
1149
2958
100.0
Sales of tobacco to minors
 Prohibited
888
72.5
408
72.3
837
71.8
2133
72.2
0.700
 Allowed with their parents
120
9.8
61
10.8
107
9.2
288
9.8
 Not prohibited
216
17.6
95
16.8
221
19.0
532
18.0
Total
1224
564
1165
2953
100.0
Penalty for sales of tobacco to minors
 Fine
565
58.7
240
53.9
508
55.3
1313
56.4
0.003
 Cancellation of sales certification
256
26.6
140
31.5
310
33.8
706
30.4
 Imprisonment
142
14.7
65
14.6
100
10.9
307
13.2
Total
963
445
918
2326
100.0
Major point were cigarettes are provided to minors
 Grocery/Market
554
44.7
265
47.4
456
40.0
1275
43.4
<0.001
 Friends
524
42.3
217
38.8
454
39.8
1195
40.7
 Vendor
108
8.7
52
9.3
169
14.8
329
11.2
 Family
52
4.2
25
4.5
62
5.4
139
4.7
Total
1238
559
1141
2938
100.0
Minors access to cigarettes
 Very easy
749
59.3
350
60.3
795
66.9
1894
62.5
0.001
 Not very difficult
477
37.8
209
36.0
354
29.8
1040
34.3
 Very difficult
37
2.9
21
3.6
40
3.4
98
3.2
Total
1263
580
1189
3032
100.0
Note. Some participants did not answer all the questions
A higher percentage of the participants believed that it was prohibited to sell tobacco to minors, however, 9.8% of respondents believed that minors were allowed to buy tobacco products with their parents and 18.0% thought that there were no laws prohibiting the sale of tobacco to minors. A greater proportion of respondents believed that the penalty for sales of tobacco to minors was fine (56.4%) and a greater percentage of current smokers (55.3%) as compared to non-smokers believed so ( p = 0.003) (Table  2).
Almost half of the participants (54.6%) believed that minors accessed tobacco products from grocery/market or vendors, a greater proportion of current smokers as compared to non-smokers believed that minors accessed cigarettes from vendors (14.8 and 8.7%) (Table  2).
Only 3.2% of the participants believed that minors’ access to cigarettes was very difficult. According to smoking status, smokers (66.9%) believed that minors access to cigarettes was very easy as compared to nonsmokers (59.3%) ( p = 0.001). (Table  2).
More than half of the participants (57.1%) ever witnessed any tobacco sales to minors, current smokers reported higher percentage (63.8%) of having witnessed tobacco sales to minor as compared to nonsmokers ( p < 0.001) (Table  3).
Table 3
Ever witnessed tobacco sales to minor and response against the situation by smoking status
Experience of participants on tobacco sales
Smoking Behavior
Total
P
Never
Smoked and quit
Current smoker
N
%
 
n
%
n
%
n
%
     
Ever witnessed any tobacco sales to minors
 Yes
630
50.0
343
59.0
758
63.8
1731
57.1
<0.001
 No
631
50.0
238
41.0
430
36.2
1299
42.9
Total
1261
581
1188
3030
100.0
The seller’s response to the child
 Asking his/her identity card
76
12.0
51
14.8
80
10.6
207
12.0
0.176
 Not asking anything and selling tobacco product
557
88.0
294
85.2
677
89.4
1510
88.0
Total a
633
345
749
1727
100
The participant’s response against tobacco sales to minors
 Doing nothing
372
60.4
199
59.1
504
68.3
1075
63.6
0.002
 Warning the seller’s
98
15.9
61
18.1
84
11.4
243
14.4
 Warning the owner
33
5.4
14
4.2
22
3.0
69
4.1
 Warning the child
77
12.5
46
13.6
89
12.1
212
12.5
 Informing the police
21
3.4
3
0.9
14
1.9
38
2.2
 Talking to the other people about this event
15
2.4
14
4.2
25
3.4
54
3.2
Total a
616
337
738
1691
100.0
Note: aThe participants were witness at any tobacco sale under 18 years old
Approximately 64% of respondents who ever witnessed any tobacco sales to minors did not act when confronted with the event and current smokers made up a higher proportion of the group “doing nothing” as compared to non-smokers, however, nonsmokers had more positive response with regards to warning/informing the police or other people ( p = 0.002). Approximately 88.0% of the salesmen sold tobacco products without asking the child’s age or asking for an identity card (Table  3).
Two logistic regression models with multiple predictors were constructed to investigate relationship between participant’s response against tobacco sales to minors and related factors for current smokers and participants who never smoked. The results of logistic regression models for current smokers were given in Table  4. The results of logistic regression model showed that the model assumptions were satisfied ( p = 0.271) and the model was found to be statistically significant ( p < 0.001). Respondents who believed smoking ratio in high school was 4–5 adolescent out of 10 (aOR: 1.59; 95% CI: 1.09–2.34), were more likely to give a warning or informing the police or other people as compared to respondents whose perception on the smoking ratio among high school students was 6–7 adolescents out of 10, whereas 2–3 adolescent out of 10 (aOR: 0.74; 95% CI: 0.40–1.37) were less likely to give a warning or informing the police or other people (Table  4).
Table 4
Logistic regression results of participant’s response against tobacco sales to minor and related factors for current smokers
 
OR
P
95% CI
Constant
0.15
<0.001
 
Educational Status
 Literate/Primary/Secondary (ref)
1
   
 High School
1.52
0.054
0.99–2.33
 University
1.47
0.095
0.94–2.30
Age group
 18–24 (ref)
1
   
 25–34
0.97
0.914
0.55–1.69
 35 and above years
1.70
0.056
0.98–2.95
Income level
 Middle, lower middle,/ lowest (ref)
1
   
 Highest /higher middle
1.38
0.078
0.96–1.96
Working Status
 Not working (ref)
1
   
 Working
1.28
0.266
0.83–1.97
Minors access to cigarettes
 Very easy/Not very difficult (ref)
1
   
 Very difficult
3.11
0.076
0.89–10.89
Smoking ratio in high school
 6–7 adolescents out of 10 (ref)
1
   
 4–5 adolescents out of 10
1.59
0.016
1.09–2.34
 2–3 adolescents out of 10
0.74
0.344
0.40–1.37
 One adolescent out of 10
1.94
0.139
0.81–4.67
Classification Rate:71.7%; Hosmer-Lemeshow Test: p = 0.271
The results of logistic regression models for participants who never smoked were given in Table  5. The results of logistic regression model showed that the model assumptions were satisfied ( p = 0.215) and the model was found to be statistically significant ( p < 0.001). Respondents who believed smoking ratio in high school was 4–5 adolescent out of 10 (aOR: 1.71; 95% CI: 1.12–2.62), and 2–3 adolescent out of 10 (aOR: 2.25; 95% CI: 1.33–3.83) were more likely to give a warning or informing the police or other people as compared to respondents whose perception on the smoking ratio among high school students was 6–7 adolescents out of 10. Having knowledge of the prohibition of tobacco sales to minors (aOR: 2.06; 95% CI: 1.34–3.16) was associated with higher likelihood of giving a warning or informing the police or other people as compared to not having any knowledge on the prohibition of tobacco sales to minors. Participants who had highest or higher middle income level (aOR: 1.86; 95% CI: 1.28–2.72) were more likely to give a warning or informing the police or other people as compared to respondents who had middle, lower middle or lowest income level. Respondents knowing sales of tobacco products prohibited to minors (aOR: 2,06; 95% CI: 1.34–3.16) were more likely to give a warming or informing the police or other people as compared to respondents who were not working (Table  5).
Table 5
Logistic regression results of participant’s response against tobacco sales to minor and related factors for participants who never smoked
 
OR
P
95% CI
Constant
0.16
<0.001
 
Educational Status
 Literate/Primary/Secondary (ref)
1
   
 High School
0.91
0.709
0.57–1.47
 University
0.99
0.984
0.62–1.59
Age
 18–24 (ref)
1
   
 25–34
0.95
0.843
0.56–1.60
 35 and above years
0.99
0.988
0.58–1.70
Income level
 Middle, lower middle,/ lowest (ref)
1
   
 Highest /higher middle
1.86
0.001
1.28–2.72
Working Status
 Not working (ref)
1
   
 Working
1.23
0.326
0.81–1.88
Sales of tobacco to minors
 Not prohibited (ref)
1
   
 Prohibited
2.06
0.001
1.34–3.16
Smoking ratio in high school
 6–7 adolescents out of 10 (ref)
1
   
 4–5 adolescents out of 10
1.71
0.014
1.12–2.62
 2–3 adolescents out of 10
2.25
0.003
1.33–3.83
 One adolescent out of 10
2.06
0.105
0.86–4.94
Classification Rate: % 64.5; Hosmer-Lemeshow Test: p = 0.215

Discussion

Turkey is known as a country with a history of important successes in tobacco control [ 23]. The prevention of tobacco access is one the most important intervention, thus, preventing children and youth from starting tobacco. The most important stage in the prevention of accessibility is determined as increasing taxes and applications for point of sales [ 1, 2].
In this study, 3241 people were interviewed in 9 city centers. The people interviewed are mainly young adults and their educational status was higher than average level of education when compared to the general population. Most of the smoker and ex-smoker participants declared that they started daily smoking at adolescent ages. The participants in the current study are also aware of this as they believed that smoking is a very common behavior among high school students. According to GATS (2012), among ever daily smokers who were aged 18–34 years, 17.1 years was the average age daily smokers started smoking [ 22]. These findings actually support that tobacco use is accepted as a public health problem among young people.
As earlier stated, one of the most important intervention for the prevention of tobacco use among youths is the prevention of accessibility. In consonance, previous studies have shown that enforcement of laws against tobacco sales to minors is an effective strategy to maintain a barrier for accessibility of tobacco in the community [ 5, 6, 8]. WHO FCTC also has some suggestion on the enforcement of tobacco sales to minor through regulations of point of sales [ 24]. The regulation on tobacco sale to minors in Turkey is old, it had been prohibited since 1996, prison sentence was later added as a new regulation in 2008 [ 19, 21]. In this study, 72.2% of the all respondents gave the true answer with regards rule on tobacco sales to minors, there is not any difference of their knowledge on rule of sales of tobacco to minors between smokers and non-smokers. However, the result of our findings shows that prison sentence is less known (13.2%) and goes to support the fact that information about prison sentence being a part of the law has not become widespread in the community, especially among the smokers. The way of giving information about tobacco selling ban to minors is by having poster at points of sales as well as inspection of this sale points to see if they have the ban posters in the country. However, the posters have only information showing that tobacco sell is banned to children less than 18 years of age. The results of this study revealed that this intervention has been quite effective in increasing the awareness of adults about tobacco selling ban to minors, but this intervention was not effective in increasing the knowledge on pertaining prison sentence. It is worth noting that a high-level debate has been ongoing among the leaders of tobacco control in the country. Some are of the opinion that informative program about the ban of cigarette sale to children under the age of 18 can create a wrong perception as this information can encourage minors to be eager to smoke after the age of 18. Because of this high-level debate, there is not any proactive campaign carried out on sale of tobacco to youth, this is a barrier in front of the distribution of the true information widely in the country.
Literatures show that enforcement of tobacco sales ban to children decreases accessibility of minors to tobacco products [ 5, 6, 8]. In this study, 66.7% of the smokers and 59.3% of non-smokers think that accessibility of tobacco products is very easy and a larger proportion of respondents assume that individuals who are under the age of 18 can buy tobacco from markets or vendors. Vendors are mentioned by smokers more than non-smokers and ex-smokers ( p < 0,001). GYTS in Turkey also supports the results of this study, it states that 53.7% of the youth buy cigarettes from markets and 79.1% of young smokers are not refused sell [ 25]. GYTS results are in consonance with our study finding. There are also other supporting studies [ 15, 26, 27]. According to Elders, laws prohibiting the sale of tobacco to minors are not adequately enforced [ 15]. Also, Marcus and colleagues in their study found that 8 out of 10 adults believed teenagers can easily reach tobacco products “very easily” or “somewhat easily” in their neighborhood [ 16]. Enforcement of laws against tobacco sales to minors should be monitored and strengthened at groceries and vendors [ 28]. Changing retail merchants’ behavior to prevent illegal sales of tobacco to minors should be enforced and promoted [ 5]. In Turkey, even though the salesman are informed about the regulation on the sales of tobacco yearly, still children are able to access tobacco products from markets and vendors. As such, in the country, the education, information and monitoring program most especially as it concerns salesman and owners of vendors, should be reviewed and strengthened to obey the rules on sales of tobacco products to minors.
Previous studies have shown that youth can use social sources to access tobacco product [ 5, 811]. Our study findings are in consonance, the result of our study shows that adults are also aware of children accessibility of tobacco products through families and friends.
Public support in the enforcement of laws governing tobacco sales is also important if preventing the access of tobacco product to minors is to be achieved. In our study, 63.8% of the smokers, 59.0% of ex-smokers and 50.0% of non-smokers declared that they witnessed cigarette sale to minors, among all witness participants, 88.0% said the sellers’ response was not asking anything and selling the tobacco product. Also, most of the participants did not take any action, the percentage of smokers not taking any reaction was much higher than non-smokers. More ex-smokers reacting this event is than smokers and non-smokers, they would have had some health problems because of smoking in the past. In a society where there is a target of preventing the sale of cigarette to minors, the salesman have a role to play, in addition, it is expected that all other individuals in the society should be sensitive and play a role in the monitoring of sale points of tobacco. Increasing the awareness of society in terms of age restrictions with regards tobacco sales will strengthen the practicality of tobacco laws. There are ongoing debate in the USA about the drawing of age limit to 21 for tobacco sale, however, it is suggested that increasing the awareness of society and in overall, decreasing the usage of tobacco should be of paramount importance [ 12, 29]. Social sensitivity is important for the prevention of tobacco use and every individual have a responsibility in carrying out this society based program, most especially as it related to prevention of tobacco usage among children and youths.
A higher proportion of smoker respondent who believed the smoking ratio in high school was 6–7 adolescent out of 10, believed that major point were cigarettes are provided to minors were vendor and family, believed that minor access to cigarette was easy, ever witnessed tobacco sale and doing nothing against tobacco sales to minor belonged to the current smokers categories, Also, a lower proportion of respondent who believed imprisonment was the penalty for sale of tobacco to minors belonged to the current smokers category. This finding goes to show that current smokers as compared to other categories believed that tobacco use among minor is prevalent and access is easy, however as compared to other smoking categories were less aware that prison sentence was a part of the law, they also were more aware that minors can access tobacco product through social source such as the family, in addition, current smokers witnessed more sales of tobacco product to minors and did nothing. Non-smokers and highly informed people with regards to tobacco control law intervened more when they witness tobacco sales to minors. In the prevention of smoking among minors, adults should not only be role models for children but they should also warn them about the right behaviors directly. Because of this behavioral difference, two logistic model were conducted.
The results of logistic regression of participant’s response against tobacco sales to minor and related factors for current smokers showed that sociodemographic characteristics of participants did not affect the behavior of the person. Only, respondents who believed smoking ratio in high school was 4–5 adolescent out of 10 (aOR: 1.59; 95% CI: 1.09–2.34) were more likely to give a warning or informing the police or other people as compared to respondents whose perception on the smoking ratio among high school students was 6–7 adolescents out of 10. According to this results of model, we could not explain the witness smokers’ reaction to sale of cigarettes with sociodemographic factors and their knowledge on tobacco sale items of the law. It is need the psychosocial behavior theories should be studied on smokers behaviors to understand the causes under their behaviors to strengthen the response of smokers. On the other hand, smoking cessation interventions would change the behaviors of smokers when they witness tobacco sales to minors.
The results of logistic regression of non-smokers’ response against tobacco sales to minor were who are from higher educational level, higher economic status, working status and who believed smoking ratio in high school was 4–5 adolescent out of 10 and 2–3 adolescent out of 10 were more likely to give a warning or informing the police or other people as compared to the others. The people from higher socioeconomic status could take more responsibility to monitor the sale of tobacco products to minors. Information and education interventions on tobacco sale to minors would be given to the community, especially to low socioeconomic status in the community. Additional interventions aimed at individual responsibilities are needed for individual smokers about the ban of cigarette sale to children as earlier stated.

Study limitations

This study has some limitations. Firstly, the study finding is not representative for the whole country. Sampling of cities and the people interviewed were through convenient sampling, as such, the results should be carefully interpreted. Secondly, the average duration of questionnaire completion was approximately 3–4 min, perhaps, due to the time duration some questions were left unanswered by the participants. During data entry, some of these questions were removed and not used in this study.

Conclusions

Though adults think that tobacco use is a prevalent among minors, tobacco product sales ban is an important subject in tobacco accessibility, most especially at points of sales, unfortunately not enough is known by the adults and they do not take enough responsibility in ensuring the implementation of the tobacco control law as it pertain access to tobacco products by minors. Though Turkey has already made important accomplishments with regards to tobacco control, there is still a need for detailed studies and some interventions are needed to reduce accessibility of minors to tobacco products.

Acknowledgements

Not applicable.

Funding

This work was supported by the Hacettepe University Scientific Research Projects Coordination Unit.

Availability of data and materials

Please contact the corresponding author for data requests.

Authors’ contributions

HO and NB designed, HO supervised the study, EI and HU made statisctics analyses, HO, NB, EI and HU wrote the manuscript, the all researchers collected the data and made contributions to the interpretation of results and revised the manuscript. All authors read and approved the final version.

Competing interests

The authors declare that they have no competing interests. This study was also presented as a poster in European Public Health Conference 2015.

Consent for publication

Not applicable.

Ethics approval and consent to participate

All participants provided informed consent before participating in the survey. This study was approved by Non-interventional Clinical Researches Ethics Board of Hacettepe University (GO 13/242-19).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
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