Support and Practice of Smoke-Free Eating Places in Sarawak, Malaysia: A Structural Path Analysis

authors:

avatar Md Mizanur Rahman ORCID 1 , * , avatar Mohd Taha Arif 2 , avatar Abdul Rahim Abdullah 2

Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
Department of Community Medicine and Public Health, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia

how to cite: Rahman M M, Arif M T, Abdullah A R. Support and Practice of Smoke-Free Eating Places in Sarawak, Malaysia: A Structural Path Analysis. J Health Rep Technol. 2022;8(3):e121427. doi: 10.5812/jhrt-121427.

Abstract

Background:

Smoke-free eating places are effective in reducing exposure to secondhand smoke (SHS). Eateries should comply with implementing smoke-free eating-places under the Control of Tobacco Products Regulations 2018 in all open-air eating-places to reduce tobacco consumption to achieve the plan of having Malaysia free of tobacco by 2045.

Objectives:

To determine the impact of perceived knowledge on tobacco control law and SHS and attitude to support and practice smoke-free eating-places.

Methods:

A total of 620 respondents participated in this cross-sectional study. The eating-places were selected randomly from 5 administrative divisions of Sarawak. Data on perceived tobacco control law, knowledge of the effects of SHS on health and environment, attitude and support towards smoke-free eating-places, and current smoke-free eating-places were collected by face-to-face interview using a structured questionnaire. A partial least squares model was developed to examine the impact of knowledge, attitude, and support towards the smoke-free eating-places with the current practice of smoke-free eating-places. WarpPLS version 7.0 was used to examine the structural path and to test the hypothesis.

Results:

The structural path analysis revealed that perceived knowledge of tobacco control law had no impact on practicing smoke-free eating-places (P > 0.05). However, the knowledge of the health and environmental effects of SHS had direct and indirect effects on attitude and support for smoke-free eating-places (P < 0.001). In addition, attitude towards smoke-free eating-places had a significant mediating effect on practicing smoke-free eating-places (P < 0.001). Besides that, supporting smoke-free eating-places had a significant direct impact on the practice of smoke-free eating-places (P < 0.001).

Conclusions:

Legislation and implementation of smoke-free eating-places along with the antismoking program and education efforts could support the cessation of tobacco use in all public places, including all eateries.

1. Background

Tobacco-free restaurant in Malaysia was implemented after the Control of Tobacco Product Regulation amendment on 24 December 2018. The new amendment in this legislation is amended in regulation two by substituting the definition of “air-conditioned eating place” with a new definition. The new meaning for “eating place” means “any premises, whether inside or outside building, where food is prepared, served or sold and included any room or area on a ship or train, or any area on the vehicle, or any area within a radius of three meters from any table or chair which is placed on preparing, serving or selling food” (1). The other amendments of regulation 11 is substituting the paragraph (d) “in any eating place or the air-conditioned shop” (1). These regulations came into effect on 1 January 2019.

In Sarawak, the implementation of smoke-free restaurants started on 1 March 2019. The State Local Government and Housing Minister informed that the Sarawak Cabinet decided to enforce this regulation on Thursday, 24 January 2019, for the health of the public. The Minister reported that the State Cabinet also agreed that the first six months from 1 March would be an educational enforcement period. The federal government’s smoking ban at all restaurants and food outlets in Peninsular Malaysia came into effect on 1 January (2). Similar to the federal law, offenders found smoking at banned places in Sarawak can be fined up to RM10,000 or jailed for a maximum of two years. Eatery owners who fail to display “No smoking” signs can be fined up to RM3,000 or jailed up to 6 months (1). The amendment of the tobacco product regulation by the Ministry of Health is a vital step to be implemented to extend the protection from the exposure of SHS besides improving the air quality and enhancing the workers’ health (3, 4). It also gives awareness to smokers to quit smoking and prevent the young generation from smoking (5, 6).

Globally, the effect of direct tobacco users is more than 7 million deaths, while the non-smoker exposed to SHS is estimated at 1.2 million (7). The harmful effect of SHS exposure has resulted in the burden of disease in children and adult non-smokers (8). Restaurants and bars have the highest SHS concentration (9, 10). In Malaysia, the prevalence of exposure to SHS in an indoor workplace is approximately 39.8%. Moreover, about 84.9% were exposed to SHS in cafes or coffee shops and 71% in restaurants. This percentage can lead to a higher incidence of SHS-related illness (11). A study from GATS Malaysia in 2011 showed that restaurant employees are more vulnerable to being exposed to SHS-related diseases (12). Therefore, this indicates that implementing policies in eating places is a precise action by the government. Various parties need to collaborate with the Ministry of Health to increase public knowledge, attitude, and support towards the success of the smoke-free policy in the eating-places.

SHS-related illness is an increasing public health burden and has a negative impact on all ages, from the womb to the tomb (12). The effects of SHS exposure cause health, environmental, and economic problems to individuals, families, and communities. This includes direct or indirect medical costs. However, there is a remarkable gap between tobacco-free restaurants’ poor practices and the support towards the policy among the community. This could be explained in several ways with one of them is that the offenders thought that protecting people from harmful exposure to SHS was an issue that the government has to tackle, or they were unaware of the punishments for breaking the Tobacco Control Act laws. It is also likely that they did not give serious thought to the potential legal ramifications of violating the smoke-free rule until they showed some kind of support (13). Another explanation may be the owner or management are concerned about the potential decline in their businesses (14, 15). The significance of this study could identify the associated factors among the respondents to support and practice a smoke-free policy in all eating places or restaurants. This could help the government to focus on incrementing supportive awareness leading to increased compliance with a smoke-free policy. This study’s main aim is to determine the impact of perceived knowledge on tobacco control law, the health and environmental effect of SHS, and attitude to support and practice smoke-free eating-places.

1.1. Conceptual Framework and Hypothesis

The practice of tobacco-free restaurants is influenced by various factors such as their knowledge of smoke-free legislation, knowledge of the dangers of exposure to passive cigarettes, smoking status, personal characteristics, attitudes, and support towards the policy (11, 13, 16). For this study, there are several selected variables, including knowledge on tobacco control law, perceived effects of SHS on health and environment, and attitude and support towards smoke-free eating-places. The level of practice of smoke-free legislation in restaurants is the dependent variable. The theory of planned behaviors (TPB) is a theory of individual health promotion. Theory of planned behaviors framework was used in this study to understand tobacco-free policy compliance behaviors. Behavioral intentions as variables, such as knowledge of the law, are perceived on the effect on the health and environment capable of influencing attitude. Attitude is the most typical characteristic that has always been discussed in research to determine behavior patterns. The conceptualisation of perceived behavioral control as a core component of the TPB model reflects the understanding of people’s ability to regulate their behavior (17).

For the tobacco-free restaurant practices after implementing the policy, we need to identify factors that can increase the level of compliance. In line with other tobacco-related TPBs, the findings suggest that TPB is a useful tool for understanding tobacco-free policy enforcement behaviors. TBP is always used in addiction problems such as quitting tobacco use. However, the compliance patterns, a feature of addiction, are increasingly affected by social beliefs, cultural norms, and behavioral regulation. Regarding compliance with smoke-free policies, the results clearly show that the authorities’ continuous and practical enforcement assessments, perceptions of social expectations, and willingness to comply are the critical factors in understanding tobacco-free policies (Figure 1) (18).

Proposed conceptual framework of the practice of tobacco-free eating place

The potential hypothesis to be tested in this research is:

H1: Supporting tobacco-free eating places has a direct impact on the practice of tobacco-free eating places.

H2: Perceived attitude towards tobacco-free restaurants has a direct impact on supporting tobacco-free eating places.

H3 and H4: Perceived health effects of secondhand smoking directly and indirectly impacted supporting tobacco-free eating places.

H5: Perceived environmental effect of secondhand smoking has an indirect effect and mediating effect on supporting tobacco-free eating places.

H7: Knowledge of tobacco-free law has a mediating effect on practicing tobacco-free eating places.

2. Methods

2.1. The Setting, Population, and Sampling

This cross-sectional study was conducted in 5 out of 11 administrative divisions of Sarawak, in East Malaysia that is located in Borneo island. The population of Sarawak was estimated at 2.90 million in 2020, with a large ethnic diversity including Iban, Chinese, Malay, Bidayuh, Melanau, Kenyah, Kayan, Penan, and others. A multi-stage cluster sampling method was used to select the eating places. Firstly, we listed out the township areas in the district under the division. In each district, we randomly select 3 township areas. In the second stage, we listed the eating places in the selected township. In the third stage, we randomly selected 10% of the eating places. In the final stage, one respondent from each eating place was selected randomly. The inclusion criteria for the selection are a participant who worked in their respective eating place irrespective of gender and type of work. However, we did not select the customer of the same eating places. A total of 849 eating places were collected with 259 customers and 590 restaurant personnel.

2.2. Data Collection Instruments and Measurement Procedure

Data were collected by face-to-face interview using a validated structured questionnaire. The questionnaire was prepared in English followed by content analysis with support from an external expert. Then, a back-to-back translation was done using Bahasa Melayu, the local language. The questionnaire was administered in Bahasa Melayu. The instruments had several components with measurement of perceived knowledge on the tobacco-free eating place, tobacco-free policy, environmental and health effects of secondhand smoking, attitude and supporting tobacco-free eating place, and the current tobacco-free eating place.

The health effect of SHS was measured by asking agreement or disagreement with seven-point Likert scale questions. Eleven items of the five-point Likert scale questions were used to measure the perceived knowledge of tobacco-free policy or law supporting eating places. The answer options were ‘most unlikely’, ‘unlikely’, ‘neutral’, ‘likely’, and ‘most likely’. There were 8-item questions included in this domain, however, 9-item questions were used to assess the environmental effect of SHS. The answer options were ‘strongly disagree’, ‘somewhat disagree’, ‘slightly disagree’, ‘neither agree nor disagree’, ‘slightly agree’, ‘somewhat agree’, and ‘strongly agree’.

The attitude toward tobacco-free eating places was measured by asking the 15-item question with a 7-point Likert scale. The answer options were ‘strongly disagree’ to ‘strongly agree’. A higher score indicated a high attitude towards tobacco-free eating places.

The supporting tobacco-free eating place was measured by asking 6-point Likert’s scale questions in which the options are ‘completely not support’, ‘mostly not support’, ‘slightly not support’, ‘slightly support’, ‘mostly support’, and ‘completely support’. The higher score indicated more support for tobacco-free eating places.

The current practice of tobacco-free eating places was measured by asking two questions that are ‘Do you discourage anyone from smoking in the restaurant?’ and ‘Is smoking is allowed in this restaurant?’

2.3. Data Entry and Analysis

Data entry was done using Microsoft Excel with a validation check. All data were checked thoroughly and cleaned before analysis. Missing data were imputed using multiple imputations. The descriptive and exploratory data analysis was done using IBM SPSS version 27.0 (19). The descriptive analysis is presented in a table with frequencies, mean, standard deviation, minimum and maximum values.

We conducted a pilot study to determine the acceptability, feasibility, and comprehensibility of the instrument. All items of each domain remained during data collection. Cronbach alpha was assessed for the internal consistency of the items within each domain (20). However, before structural path analysis, we measured the measurement model in convergent and discriminant validity. Convergent validity is related to construct validity, which states that tests having the same or similar constructs should be highly correlated (21). For convergent validity, we examined the item loading of more than 0.5 (22), Cronbach alpha with an acceptable level of ≥ 0.60 (23), and composite reliability with an acceptable level of ≥ 0.60 (22). For discriminant validity, we examined three criteria that are viz. (1) Fornell-Larcker criterion, (2) Cross-loadings, and (3) heterotrait-monotrait (HTMT) ratio. The Fornell-Larcker criterion is the square root of the Average Variance Extracted (AVE). It should be higher than the correlation of the construct with all other constructs in the structural model (24). Table 1 shows that the diagonal values are the square root of the AVE. Off-diagonal elements are the correlations among the constructs. The diagonal elements should be larger than the off-diagonal elements. The cross-loading in each construct should be greater than the corresponding other items. The third criterion is the multitrait-multimethod matrix to assess discriminant validity in the form of heterotrait-monotrait (HTMT) ratio of correlations (25). A value that is greater than the HTMT0.85 of 0.85 (26) or HTMT0.90 of 0.90 (27) shows that the discriminant validity is not established.

Table 1. Discriminant Validity a
K_LawEnv_ResH_SHSAttitudeSupportPractice
Fornell-Larcker Criterion
K_Law0.685 b
Env_Res0.2190.851 b
H_SHS0.0880.2630.805 b
Attitude0.2170.6950.1900.869 b
Support0.1980.5910.4620.6920.747 b
practice0.1340.1530.2220.1770.3150.861 b
Cross-loading
B20.649 b0.1890.0620.1450.1210.138
B30.670 b0.098-0.0210.1520.0730.060
B40.756 b0.1700.0940.1470.1960.100
B80.746 b0.1140.0550.1220.1130.091
B90.592 b0.1780.1090.1740.1720.069
C80.2080.921 b0.2180.6320.5420.167
C90.2220.885 b0.2870.6130.5310.132
C100.1810.869 b0.2580.5340.4910.094
C110.2110.915 b0.2100.6610.5650.157
C160.1040.627 b0.1350.4900.3640.096
C10.0520.2070.842 b0.1610.3500.160
C20.1360.3700.744 b0.3610.4510.174
C30.1050.1550.834 b0.0690.3410.155
C40.0410.1780.875 b0.0940.3560.241
C50.0850.1530.661 b0.1270.2890.071
C60.0450.2270.793 b0.1700.4170.217
C70.0280.1840.864 b0.0850.3890.230
D10.1550.6210.1650.820 b0.5170.096
D40.1990.6500.0890.921 b0.5670.129
D50.1860.5890.1340.876 b0.6090.172
D60.1780.5850.1770.856 b0.6170.170
D70.2250.6720.1100.947 b0.6020.152
D80.1800.6630.1320.940 b0.5930.143
D90.1940.6620.1050.931 b0.6010.125
D100.1950.5900.1240.905 b0.6100.179
D110.2110.6640.0970.950 b0.6200.151
D120.1930.5330.2750.754 b0.6810.222
D130.1310.5160.1960.797 b0.5750.102
D140.1650.5440.2020.837 b0.5900.166
D150.2170.5030.3650.657 b0.6070.194
D160.1980.6230.1330.925 b0.5930.136
E10.1510.4610.4370.5320.788 b0.327
E20.1860.6830.2240.8690.758 b0.187
E30.1390.4910.4480.5320.806 b0.210
E40.1210.6130.2540.7400.797 b0.126
E50.0890.2830.3300.3380.737 b0.281
E60.1240.2530.3310.2680.672 b0.303
E70.1880.3670.3600.3890.755 b0.193
E80.1810.3730.3670.4550.647 b0.254
F1_R0.0620.0200.1860.0570.2250.861 b
F2_R0.1690.2440.1980.2470.3190.861 b
Hetero-Trait and Mono-Trait Ratio
Knowledge
Env_effect0.274
Health_SHS0.1460.291
Attitude0.2600.7420.206
Support0.2490.6630.5150.745
Practice0.1970.2000.2890.2250.415

Finally, a structural path analysis was done to examine the relationship between tobacco-free eating places and knowledge, attitude, and supporting tobacco-free eating places. The structural path analysis was performed using WarpPLS 7.0 stable version (28). However, the descriptive analysis was done by Statistical Package for the Social Sciences version 27 (19). A P-value of ≤ 0.05 is considered statistically significant.

2.4. Ethical Issues

The study was initiated after receiving ethics and administrative approval from the Faculty of Medicine and Health Sciences. Before the interview, informed consent was obtained from the participants. The participants were assured of anonymity and data confidentiality.

3. Results

3.1. Characteristics of the Respondents

The mean age of the respondents was 30.1 years with a standard deviation of 11.59 years. Two-fifths (58.1%) were female, and the rest were male. The highest percentage of the respondents were Malays (60.7%), followed by Iban (15.2%). More than half of the respondents had a secondary education (55.5%) followed by a diploma (17.2%). Two-fifths (38.6%) were married. The median family size was 5.0. At least one family member is a smoker. The median family income was MYR 1047.58, with a minimum of MYR 180 and a maximum of MYR 15000 (Table 2).

Table 2. Characteristics of the Respondents
VariablesNo. (%)Statistics
Mean ± SDMedianMinMax
Category
Owner198 (23.3)
Workers392 (46.2)
Customers259 (30.5)
Age (y)30.1 ± 11.59-12.079.0
< 20113 (13.3)
20 - 29399 (47.0)
30 - 39161 (19.0)
40 - 49101 (11.9)
≥ 5075 (8.8)
Gender
Male356 (41.9)
Female493 (58.1)
Ethnicity
Malay515 (60.7)
Chinese117 (13.8)
Iban129 (15.2)
Others (Bidayuh, Indian etc)88 (10.4)
Religion
Islam545 (64.2)
Christianity251 (29.6)
Others (Hinduism, Buddhism etc.)53 (6.2)
Level of education
Primary and below113 (13.3)
Secondary471 (55.5)
University119 (14.0)
Diploma146 (17.2)
Marital status
Married328 (38.6)
Single521 (61.4)
Family size5.72 ± 2.195.0114
1 - 235 (4.1)
3 - 4249 (29.3)
5 - 6314 (37.0)
≥ 7251 (29.6)
Number of smokers1.43 ± 1.411.008
0178 (21.0)
1309 (36.4)
2154 (18.1)
≥ 3208 (24.5)
Monthly income (MYR)1951.41 ± 1834.971047.5818015000
< 1000189 (22.3)
1000 - 1999230 (27.1)
2000 - 2999153 (18.0)
3000 - 3999115 (13.5)
4000 - 4999162 (19.1)
Food handling training
Yes361 (61.2)
No229 (38.8)

3.2. Convergent Validity and Discriminant Validity

Tables 1 and 3 illustrated the convergent and discriminant validity. Our analysis revealed that the loadings were all higher than 0.70, the composite reliabilities were higher than 0.70, and the AVE of the constructs was also higher than 0.50. Accordingly, the convergent validity of the constructs has been established (22, 29).

Table 3. Convergent Validity
Domains and ItemsLoadingαDijkstra-RCRAVEVIF
Knowledge of Tobacco-free eating place0.7140.7090.8150.4701.070
B20.649
B30.670
B40.756
B80.746
B90.592
Environmental effect of second-hand smoking 0.8990.9140.9280.7242.061
C80.921
C90.885
C100.869
C110.915
C160.627
Health effect of secondhand smoking 0.9070.9420.9270.6481.384
C10.842
C20.744
C30.834
C40.875
C50.661
C60.793
C70.864
Attitude toward the tobacco-free eating place0.9740.9750.9770.7562.266
D10.820
D40.921
D50.876
D60.856
D70.947
D80.940
D90.931
D100.905
D110.950
D120.754
D130.797
D140.837
D150.657
D160.925
Supporting tobacco-free eating place 0.8860.8950.9100.5582.619
E10.788
E20.758
E30.806
E40.797
E50.737
E60.672
E70.755
E80.647
Practising tobacco-free eating place 0.6520.7270.8520.7421.131
F1_R0.861
F2_R0.861

Regarding discriminant validity, the Fornell-Larcker criterion (24) suggests that the square root of AVE is higher than the correlation. Table 1 shows the diagonal values are the square root of the AVE. The off-diagonal values are the correlations among the constructs. According to the criterion, the diagonal values should be larger than the off-diagonal elements. The HTMT value is higher than HTMT0.85 of 0.85 (26) or HTMT0.90 value of 0.90 indicates that the discriminant validity is not established (27). Our results showed that the HTMT values are less than the cut of value. This indicated that the discriminant validity had been established. There is no multicollinearity problem among the domains. It has no overlapping items in each domain construct.

3.3. Model Fit and Quality Indices

Robust path analysis with a non-linear algorithm, which is bootstrapping resampling method was used for analysis (28). Model fitting and quality indices indicated that the average path coefficient was (APC) = 0.339, (P < 0.001), average R-squared (ARS) = .396, (P < 0.001), average adjusted R-squared (AARS) = 0.391, (P < 00.001), average block VIF (AVIF) = 1.065, and average full collinearity VIF (AFVIF) = 1.816. The standardized root mean squared residual (SRMR) was 0.098, and the standardized mean absolute residual (SMAR) was 0.075. All of the model fitting information indicated a well-fitted model.

3.3.1. Practicing Tobacco-Free Eating Place

Figure 2 and Table 4 show the results for the structural equation modelling analysis. Consistent with the TPB, the supporting behavior is significantly associated with the practice of tobacco-free eating places (β = 0.315, P < 0.001) with a small effect size (ES = 0.100). This supports our H1.

Table 4. Hypothesis Testing
HypothesisRelationshipStd0. BetaStd0. ErrorESR2 ContributionQ2Decision
H1Support → Practice0.315 a0.0360.100 b0.1000.099Supported
H2Attitude → Support0.627 a0.0220.433 c0.4330.591Supported
H3Health effect of SHS → Support0.343 a0.0330.158 d0.158-Supported
H4Health effect of SHS → Attitude0.0060.0290.0010.0010.487Not supported
H5Environmental effect of SHS → Attitude0.678 a0.0260.471 c0.471Supported
H6Tobacco control → Attitude0.067 e0.0300.015 b0.015Supported

3.3.2. Supporting Tobacco-Free Eating Place

The analysis on supporting tobacco-free eating places indicates that it directly correlated with the attitude towards tobacco-free eating places (β = 0.627, P <0.001) and also with the perceived health effect of secondhand smoking (β = 0.343, P < 0.001) with moderate effect size (ES = 0.158). However, there is a mediating effect of the perceived health effect of secondhand smoking (β = 0.006, P > 0.05) to supporting tobacco-free eating places through with attitude towards the tobacco-free eating place. This supports our H2 of the direct impact of attitude to supporting tobacco-free eating places and H3 of health effect smoking to support tobacco-free eating places.

3.3.3. Attitude Towards the Tobacco-Free Eating Place

In line with the TPB, three background variables were included in the structural model, viz. perceived health effect of secondhand smoking, perceived environmental effect of secondhand smoking, and perceived knowledge of tobacco-free law and policy to attitude towards tobacco-free eating places. The analysis revealed that the perceived health effect of secondhand smoking had no impact on attitude towards tobacco-free eating places (β = 0.006, P > 0.05) hence not supporting hypothesis 4. However, the perceived environmental effect of secondhand smoking had a strong impact (β = 0.678, P < 0.001) and a weak impact of knowledge on tobacco law or policy (β = 0.067, P < 0.01) on attitude towards tobacco-free eating places, which support our hypothesis 5 and 6.

3.4. The Indirect and Total Effect

Analysis of the indirect and total effect of different parameters on practising tobacco-free eating places is illustrated in Table 5. For a straightforward interpretation of the mediation effect, the variance accounted for (VAF) was calculated. Analysis indicated that supporting and attitude towards tobacco-free eating places had a significant impact on practising tobacco-free eating places with a total effect of 0.198 (P < 0.001). According to Hair et al. (22), there was no mediation effect (VAF = 0.0). On the contrary, the perceived health effect of secondhand smoking to practice tobacco-free eating places had a significant mediating effect with a VAF value of 0.9 indicating full mediation. However, there was very little or no impact of tobacco-free law or policy on practising tobacco-free eating places. The variance accounted for indicated that there was no mediating effect (VAF = 0.0%). The environmental effect of secondhand smoking had a total effect on practising tobacco-free eating places with an effect size of 0.021 indicating a small effect having no mediating effect (VAF = 0.0%). However, the total effect of supporting tobacco-free restaurants to practice was .315 (P < 0.001) and also attitude had an impact on supporting tobacco-free eating places (E.S. = 0.617, P < 0.001) with environmental effect of secondhand smoking is mediated through attitude to support tobacco-free eating place (E.S. = 0.425, P < 0.001) with no potential effect. Data analysis indicated that knowledge of the environmental effect of secondhand smoking had a potential impact on attitude toward tobacco-free places (E.S. = 0.678, P < 0.001). The knowledge of the health effect of secondhand smoking had no impact (P > 0.05).

Table 5. Indirect and Total Effects of Tobacco-Free Eating Place
ParametersIndirectP-ValueESTotalP-ValueESVAF (%)
Attitude → Support → Practice0.1980.0010.0200.1980.0010.0350.0
Health effect of SHS → Attitude →Support → Practice0.0010.4200.0200.1090.0010.0240.9
Tobacco-free law → Attitude → Support → Practice0.0130.0200.0020.0130.0200.0020.0
Environmental effect of SHS → Attitude → Support → Practice0.1340.0010.0210.1340.0010.0210.0
Support → Practice--0.3150.0010.100-
Attitude →Support --0.6270.0010.433-
Tobacco-free law → Attitude → Support 0.0420.0140.0080.0420.0140.0080.0
Health effect of SHS → Attitude → Support 0.0040.4180.0180.3460.0010.1601.17
Environmental effect of SHS → Attitude → Support0.4250.0010.0230.4250.0010.2510.0
Tobacco-free law → Attitude--0.0670.0140.015-
Environmental effect of SHS → Attitude--0.6780.0010.471-
Health effect of SHS → Attitude--0.0060.4180.001-

Multi-group analysis revealed no statistically significant difference was found between restaurant personnel and customers in terms of knowledge of tobacco law to attitude towards tobacco-free eating places (P > 0.05), perceived health effect of secondhand smoking to supporting tobacco-free eating places (P > 0.05), and supporting tobacco-free eating place to practicing tobacco-free eating places (P > 0.05). A statistically significant difference was found between restaurant personnel and customers perceived environmental effect of secondhand smoking and attitude towards tobacco-free eating places (P < 0.05), attitude and supporting tobacco-free eating places (P < 0.01), and perceived health effect of secondhand smoking to attitude (P < 0.01) (Figure 3).

4. Discussion

Undoubtedly, smoking-free laws are effective for public health (30, 31) and a cost-effective tobacco control strategy (32). A smoke-free law has eliminated secondhand smoking in public places, thus significantly improving air quality (33). In this study, we developed a structural equation modeling to determine the impact of knowledge, attitude, and supporting tobacco-free eating places to practice tobacco-free eating places using the TPB. The law helps smokers to reduce tobacco-related illnesses, deaths, and healthcare costs, thus preventing smokers from receiving unintentional healthcare services (34, 35) and increasing the government’s revenue capacity (30). The smoking-free law also encourages smokers to quit smoking and helps to reduce the prevalence of smoking (36). The law also could raise public awareness regarding the dangers of tobacco smoke and help individuals to quit smoking voluntarily (37). This law maintains smoke-free homes and cars. A few empirical studies with economic indicators have shown that smoking-free policies have no adverse economic impact on businesses. In particular, a smoking-free policy is associated with increased productivity of workers and a reduction in overhead costs (such as health insurance) (38). Studies also indicated that secondhand smoking indirectly increased air pollution in all public places, restaurants, bars, pubs, and nightclubs (39). Moreover, the hospitality workers absorb a considerable amount of tobacco smoke and experience symptoms of shortness of breath. The study showed a decline in respiratory symptoms among hospital workers after restricting smoking in restaurants and bars (40). In our study, supporting tobacco-free laws strongly encourage practising tobacco-free eating places (P < 0.001). This is consistent with a previous study (41).

Our analysis revealed that increased knowledge of tobacco control laws and perceived environmental effects of tobacco smoke directly impacted attitude towards smoke-free eating places but had no impact on the perceived health effect of secondhand smoking towards attitude. However, perceived health effects of secondhand smoking had a strong effect of supporting smoke-free eating places. It is a complex phenomenon in which public attitudes are essential to facilitate smoke-free legislation or regulations by local or national governments (11). Public attitudes are likely to be impacted by how well such laws are enforced. On the other side, attitudes around smoking might link complex ways with the satisfaction of particular experiences, especially in restaurants and bars. Smokers are already addicted to tobacco, perceived knowledge of tobacco control laws had no effect on practicing smoke-free eating-places though they had to support smoke-free eating places or restaurants, even though they had sufficient knowledge of health effects (42, 43). This might be the fact of complex attitude-to-behavior pathways (44).

There were several limitations in this study. Firstly, we did not examine all forms of tobacco control strategies. Different states might have different media campaigns, interventions, and modes of implementation on tobacco control. Secondly, our study also has the limitation of recall bias, especially regarding the health risk of exposure to SHS. Thirdly, we have tried to maintain the highest level of confidentiality and privacy. Still, there might be the possibility of underreporting because the information given by the workers in the owner’s presence may not be accurate. Finally, our findings may not be generalizable because the study was conducted in only one state in Malaysia.

4.1. Conclusions

In our analysis, we concluded that supporting tobacco-free eating places is significantly associated with the practice of tobacco-free eating places. Similarly, supporting tobacco-free eating places is directly correlated with the attitude towards tobacco-free eating places, perceived health effect of secondhand smoking, and mediating effect of the perceived health effect of secondhand smoking. We found that the perceived health effect of secondhand smoking had no impact on attitude towards tobacco-free eating places. However, the perceived environmental effect of secondhand smoking had a strong impact on tobacco law or policy, while there is a weak impact of knowledge on tobacco law or policy. We suggest that effective tobacco control in Malaysia will require the full implementation of comprehensive tobacco control laws and could be supported by penalties. We also suggest a combination of strong public health education programs involving different segments of the population with the incorporation of people’s current knowledge on tobacco control policy and its implementation.

Acknowledgements

References

  • 1.

    National Cancer Society Malaysia. Control of Tobacco Product (Amendment) Regulations 2018. Kuala Lumpur, Wilayah Persekutuan Malaysia: National Cancer Society Malaysia; 2018.

  • 2.

    Wong P. Why wait to enforce ban in Sarawak?. Kuala Lumpur, Kuala Lumpur, Malaysia: The Star Online; 2019, [updated Tuesday, 01 Jan 2019]. Available from: https://www.thestar.com.my/opinion/letters/2019/01/01/letters-why-is-sarawak-holding-off-on-the-smoking-ban.

  • 3.

    Goodman P, Agnew M, McCaffrey M, Paul G, Clancy L. Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs. Am J Respir Crit Care Med. 2007;175(8):840-5. doi: 10.1164/rccm.200608-1085OC. [PubMed: 17204724].

  • 4.

    Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am J Public Health. 2005;95(6):1024-9. doi: 10.2105/AJPH.2004.048678. [PubMed: 15914828]. [PubMed Central: PMC1449303].

  • 5.

    Wakefield M, Cameron M, Inglis G, Letcher T, Durkin S. Secondhand smoke exposure and respiratory symptoms among casino, club, and office workers in Victoria, Australia. J Occup Environ Med. 2005;47(7):698-703. doi: 10.1097/01.jom.0000167285.33870.f9. [PubMed: 16010196].

  • 6.

    Nebot M, Lopez MJ, Gorini G, Neuberger M, Axelsson S, Pilali M, et al. Environmental tobacco smoke exposure in public places of European cities. Tob Control. 2005;14(1):60-3. doi: 10.1136/tc.2004.008581. [PubMed: 15735302]. [PubMed Central: PMC1747970].

  • 7.

    World Health Organization. Tobacco Factsheet: Leading cause of death, illness and impoverishment. Geneva, Switzerland: World Health Organization; 2021, [updated 24 May 2022]. Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco.

  • 8.

    Oberg M, Jaakkola MS, Prüss-Üstün A, Peruga A, Woodward A; World Health Organization. Global estimate of the burden of disease from second-hand smoke. Geneva, Switzerland: World Health Organization; 2010.

  • 9.

    Navas-Acien A, Peruga A, Breysse P, Zavaleta A, Blanco-Marquizo A, Pitarque R, et al. Secondhand tobacco smoke in public places in Latin America, 2002-2003. JAMA. 2004;291(22):2741-5. doi: 10.1001/jama.291.22.2741. [PubMed: 15187056].

  • 10.

    Brooks DR, Mucci LA. Support for smoke-free restaurants among Massachusetts adults, 1992-1999. Am J Public Health. 2001;91(2):300-3. doi: 10.2105/ajph.91.2.300. [PubMed: 11211644]. [PubMed Central: PMC1446536].

  • 11.

    Kuang Hock L, Hui Li L, Chien Huey T, Yuvaneswary V, Sayan P, Muhd Yusoff MF, et al. Support for smoke-free policy among Malaysian adults: findings from a population-based study. BMJ Open. 2019;9(2). e020304. doi: 10.1136/bmjopen-2017-020304. [PubMed: 30760510]. [PubMed Central: PMC6377523].

  • 12.

    Institute for Public Health. Report of the Global Adult Tobacco Survey (GATS) Malaysia, 2011. Kuala Lumpur, Malaysia: National Institute of Health; 2011.

  • 13.

    Chang SH, Delgermaa V, Mungun-Ulzii K, Erdenekhuu N, Odkhuu E, Huang SL. Support for smoke-free policy among restaurant owners and managers in Ulaanbaatar, Mongolia. Tob Control. 2009;18(6):479-84. doi: 10.1136/tc.2009.030486. [PubMed: 19797533]. [PubMed Central: PMC2778079].

  • 14.

    Hammar H. Restaurant owner perceptions of the effects of a smoking ban. Health Policy. 2004;70(2):243-54. doi: 10.1016/j.healthpol.2004.04.003. [PubMed: 15364153].

  • 15.

    Cremieux PY, Ouellette P. Actual and perceived impacts of tobacco regulation on restaurants and firms. Tob Control. 2001;10(1):33-7. doi: 10.1136/tc.10.1.33. [PubMed: 11226358]. [PubMed Central: PMC1763993].

  • 16.

    Mizanur MR, Felix B, Hayati DN, Zahri A, Yee En C. Practice of tobacco free environment among restaurant workers and owners in Kota Samarahan, Sarawak, Malaysia. Tob Induc Dis. 2018;16(1). doi: 10.18332/tid/84512.

  • 17.

    Tommasetti A, Singer P, Troisi O, Maione G. Extended Theory of Planned Behavior (ETPB): Investigating Customers’ Perception of Restaurants’ Sustainability by Testing a Structural Equation Model. Sustainability. 2018;10(7):2580. doi: 10.3390/su10072580.

  • 18.

    Record RA. Tobacco-Free Policy Compliance Behaviors among College Students: A Theory of Planned Behavior Perspective. J Health Commun. 2017;22(7):562-7. doi: 10.1080/10810730.2017.1318984. [PubMed: 28494210].

  • 19.

    IBM SPSS. IBM SPSS Statistics for Windows. Armonk, NY, USA: IBM SPSS; 2020.

  • 20.

    Khosravizadeh O, Ahadinezhad B, Shahsavari S, Ghiasvand M, Mehri M. Role of Organizational Silence in the Professional Performance of Frontline Staff in the Hospital Structure: A Path Analysis. Journal of Health Reports and Technology. 2022;In Press(In Press). doi: 10.5812/ijhls.121301.

  • 21.

    Gregory RJ. Psychological testing: History, principles, and applications. New York City, New York, United States: Pearson Education Limited; 2004.

  • 22.

    Hair JF, Hult GTM, Ringle C, Sarstedt M. A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). 2nd ed. Newbury Park, California, USA: SAGE Publications; 2017.

  • 23.

    van Griethuijsen RALF, van Eijck MW, Haste H, den Brok PJ, Skinner NC, Mansour N, et al. Global Patterns in Students’ Views of Science and Interest in Science. Research in Science Education. 2014;45(4):581-603. doi: 10.1007/s11165-014-9438-6.

  • 24.

    Fornell C, Larcker DF. Evaluating Structural Equation Models with Unobservable Variables and Measurement Error. Journal of Marketing Research. 1981;18(1). doi: 10.2307/3151312.

  • 25.

    Henseler J, Ringle C, Sarstedt M. A new criterion for assessing discriminant validity in variance-based structural equation modeling. J Acad Mark Sci. 2014;43(1):115-35. doi: 10.1007/s11747-014-0403-8.

  • 26.

    Kline RB. Principles and Practice of Structural Equation Modeling, Third Edition. 7th ed. New York City, New York, USA: Guilford Publications; 2019.

  • 27.

    Gold AH, Malhotra A, Segars AH. Knowledge Management: An Organizational Capabilities Perspective. Journal of Management Information Systems. 2015;18(1):185-214. doi: 10.1080/07421222.2001.11045669.

  • 28.

    Ned K. WarpPLS user manual. 7th ed. Laredo, Texas, USA: ScriptWarp Systems; 2020.

  • 29.

    Hair JF, Howard MC, Nitzl C. Assessing measurement model quality in PLS-SEM using confirmatory composite analysis. Journal of Business Research. 2020;109:101-10. doi: 10.1016/j.jbusres.2019.11.069.

  • 30.

    Levy DT, Tam J, Kuo C, Fong GT, Chaloupka F. The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard. J Public Health Manag Pract. 2018;24(5):448-57. doi: 10.1097/PHH.0000000000000780. [PubMed: 29346189]. [PubMed Central: PMC6050159].

  • 31.

    Flor LS, Reitsma MB, Gupta V, Ng M, Gakidou E. The effects of tobacco control policies on global smoking prevalence. Nat Med. 2021;27(2):239-43. doi: 10.1038/s41591-020-01210-8. [PubMed: 33479500]. [PubMed Central: PMC7884287].

  • 32.

    Ekpu VU, Brown AK. The Economic Impact of Smoking and of Reducing Smoking Prevalence: Review of Evidence. Tob Use Insights. 2015;8:1-35. doi: 10.4137/TUI.S15628. [PubMed: 26242225]. [PubMed Central: PMC4502793].

  • 33.

    Office on Smoking and Health (US). Control of Secondhand Smoke Exposure. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA, USA: Centers for Disease Control and Prevention (US); 2006.

  • 34.

    Royal College of Physicians. Smoking and health 2021: a coming of age for tobacco control?. Regent's Park, London, England: Royal College of Physicians; 2021.

  • 35.

    West R. Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychol Health. 2017;32(8):1018-36. doi: 10.1080/08870446.2017.1325890. [PubMed: 28553727]. [PubMed Central: PMC5490618].

  • 36.

    Office on Smoking and Health (OSH). Smokefree Policies Reduce Smoking: Smokefree Policy Fact Sheets. Atlanta, GA, USA: Centers for Disease Control and Prevention; 2021. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/reduce_smoking/index.htm.

  • 37.

    Baumeister RF. Addiction, cigarette smoking, and voluntary control of action: Do cigarette smokers lose their free will? Addict Behav Rep. 2017;5:67-84. doi: 10.1016/j.abrep.2017.01.003. [PubMed: 29450229]. [PubMed Central: PMC5800589].

  • 38.

    U.S. National Cancer Institute; World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control. Bethesda, USA: Department of Health and Human Services, National Institutes of Health, National Cancer Institute and World Health Organization; 2016.

  • 39.

    Jones MR, Wipfli H, Shahrir S, Avila-Tang E, Samet JM, Breysse PN, et al. Secondhand tobacco smoke: an occupational hazard for smoking and non-smoking bar and nightclub employees. Tob Control. 2013;22(5):308-14. doi: 10.1136/tobaccocontrol-2011-050203. [PubMed: 22273689]. [PubMed Central: PMC3701027].

  • 40.

    Farrelly MC, Nonnemaker JM, Chou R, Hyland A, Peterson KK, Bauer UE. Changes in hospitality workers' exposure to secondhand smoke following the implementation of New York's smoke-free law. Tob Control. 2005;14(4):236-41. doi: 10.1136/tc.2004.008839. [PubMed: 16046685]. [PubMed Central: PMC1748080].

  • 41.

    Fong GT, Hyland A, Borland R, Hammond D, Hastings G, McNeill A, et al. Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tob Control. 2006;15 Suppl 3:iii51-8. doi: 10.1136/tc.2005.013649. [PubMed: 16754947]. [PubMed Central: PMC2593063].

  • 42.

    Alzahrani SH. Levels and factors of knowledge about the related health risks of exposure to secondhand smoke among medical students: A cross-sectional study in Jeddah, Saudi Arabia. Tob Induc Dis. 2020;18:88. doi: 10.18332/tid/128317. [PubMed: 33192222]. [PubMed Central: PMC7656739].

  • 43.

    Rohde K, Boles M, Bushore CJ, Pizacani BA, Maher JE, Peterson E. Smoking-related knowledge, attitudes, and behaviors among Alaska Native people: a population-based study. Int J Circumpolar Health. 2013;72. doi: 10.3402/ijch.v72i0.21141. [PubMed: 23984275]. [PubMed Central: PMC3753121].

  • 44.

    Ajzen I, Fishbein M. The Influence of Attitudes on Behavior. In: Albarracín D, Johnson BT, Zanna MP, editors. The handbook of attitudes. New Jersey, United States: Lawrence Erlbaum Associates Publishers; 2005. p. 173-221.

Copyright © 2022, Journal of Health Reports and Technology. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.