Unheard Voices: Smokers’ Support for Anti-Smoking Campaigns

Unheard Voices: Smokers’ Support for Anti-Smoking Campaigns

Mohd Haazik Mohamed, Yessy Octavia Misdi, Razima Hanim Osman, Najah Afina Mohd Harun, Wanda Kiyah George Albert

Faculty of Psychology and Social Work, Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia

DOI: https://dx.doi.org/10.47772/IJRISS.2025.9010228

Received: 06 January 2025; Accepted: 11 January 2025; Published: 14 February 2025

ABSTRACT

Tobacco use remains a significant global public health challenge, with considerable health, social, and economic consequences. In Malaysia, anti-smoking campaigns like the long-standing “Tak Nak Merokok” and the 2019 “Speak Out” campaign have raised awareness about smoking dangers, with “Speak Out” empowering non-smokers to reprimand smokers and protect themselves. However, understanding smokers’ attitudes toward these campaigns is essential for improving their effectiveness. This study aims to investigate smokers’ perception of anti-smoking campaigns that encourage people to stand up, reprimand smokers who smoke around them, and protect themselves from secondhand and thirdhand smoke, as well as the factors that influence these perceptions. Data were collected from a survey conducted by the Health Education Division, Ministry of Health Malaysia, in 2019, involving 3,453 respondents aged 18 and above, with 217 identifying as smokers. The survey examined respondents’ smoking behaviours, awareness of secondhand and thirdhand smoke, and their outrage to reprimand smokers who smoke in public places spaces. Descriptive and inferential statistical analyses were performed using IBM SPSS Statistics version 25. The results revealed significant differences in attitudes based on demographic factors and smoking behaviours. Younger respondents were more likely to support reprimanding smokers in public, while those with family members or housemates who smoked were less willing to take action. Awareness of the dangers of secondhand and thirdhand smoke significantly influenced respondents’ likelihood to reprimand smokers. Logistic regression analysis identified key predictors, with respondents who perceived secondhand smoke as harmful being six times more likely to reprimand smokers in public. These findings emphasize the importance of considering demographic and behavioural factors in the design of future anti-smoking campaigns, offering valuable insights to enhance their reach and impact in reducing smoking prevalence in Malaysia.

Keywords: Smoker’s support, anti-smoking campaigns, speak out campaign, health promotion, Malaysia

INTRODUCTION

Tobacco use remains a pressing public health issue worldwide, with significant health, social, and economic consequences. Anti-smoking campaigns have been implemented globally to address the adverse effects of active smoking, secondhand smoke, and thirdhand smoke exposure, aiming to change attitudes, reduce smoking prevalence, and ultimately promote healthier behaviours. In Malaysia, these efforts have intensified over the years, with public health authorities launching various initiatives to increase awareness of smoking dangers and associated risks. One of the most prominent anti-smoking campaigns in the country was the “Tak Nak Merokok” campaign, introduced by the Ministry of Health Malaysia in 2004, which marked the nation’s largest anti-smoking initiative at the time (Abdullah, 2004). Designed to educate the public on the negative health consequences of smoking, the campaign targeted a broad demographic, including adolescents, schoolchildren, adults, and current smokers, aiming to address smoking at multiple societal levels (Health Education Division, 2010).

Despite the implementation of such campaigns, the effectiveness of anti-smoking initiatives often hinges on understanding smokers’ attitudes and their level of support for these efforts. Studies indicate that support for anti-smoking campaigns among smokers varies based on multiple factors, including their personal smoking habits, perceived risks of smoking, demographic characteristics, and exposure to campaign messages (Thrasher et al., 2013; Hammond et al., 2004). While non-smokers often express strong support for anti-smoking efforts, smokers’ perspectives provide critical insights into the barriers to behaviours change and the factors that could enhance campaign effectiveness. For example, research has shown that smokers who perceive anti-smoking campaigns as credible and relatable are more likely to support such initiatives and consider quitting smoking (Wakefield et al., 2010). Furthermore, campaigns that incorporate emotionally resonant themes, such as the impact of smoking on loved ones, tend to elicit higher levels of engagement and support from smokers (Durkin et al., 2012).

Anti-smoking campaigns often utilize emotional resonance and demographic tailoring to effectively influence smokers’ behaviours. Emotional resonance involves crafting messages that evoke strong emotions, such as fear or empathy, to motivate behaviours change. Research has demonstrated that emotionally charged messages, particularly those inducing fear, are highly effective. For instance, a study by Peters et al. (2013) highlighted that fear appeals in anti-smoking campaigns significantly motivate smokers by reminding them of the serious health risks to themselves and their loved ones. Similarly, emotionally graphic content in anti-smoking advertisements was found to be effective across diverse racial and ethnic groups, emphasizing the universal applicability of such approaches (Durkin et al., 2012). These findings underscore the power of emotional resonance in creating impactful campaigns. In addition to emotional resonance, demographic tailoring enhances the effectiveness of anti-smoking campaigns by addressing unique cultural contexts and experiences. For example, culturally tailored campaigns targeting the LGBTQ+ community were shown to reduce smoking disparities within this demographic (Lempert & Glantz, 2019). Tailoring messages to specific populations, such as racial or ethnic minorities and individuals with low socioeconomic status, was also identified as a critical strategy in reaching vulnerable groups (Ho et al., 2020). These efforts ensure that anti-smoking messages are relatable and relevant, increasing their impact on specific audiences.

Combining emotional resonance with demographic tailoring creates a powerful approach to anti-smoking campaigns. Messages that evoke strong emotions while being culturally relevant are more likely to engage target audiences and inspire behaviours change. For instance, fear-based appeals about health risks can be more impactful when they reflect the specific concerns and values of a particular community. This integration of emotion and cultural relevance ensures that campaigns not only capture attention but also foster personal connections, ultimately increasing the likelihood of smoking cessation.

In Malaysia, limited research has been conducted on smokers’ perceptions and support for anti-smoking campaigns, despite the country’s long history of tobacco control initiatives. A seminal study conducted by Mohamed et al. (2023), was one of the earliest publications exploring the support of Malaysians for the Speak Out Campaign and their willingness to confront or reprimand smokers who smoke around them and their family members. The findings in other words highlighted the importance of addressing smokers’ unique concerns and the cultural context of smoking behaviours in shaping their attitudes toward anti-smoking efforts. Subsequent studies have emphasized the role of demographic and social factors, such as age, education level, and socioeconomic status, in influencing smokers’ attitudes and receptivity to anti-smoking messages (Lim et al., 2010; Abdullah et al., 2013). For instance, younger smokers may be more influenced by campaigns utilizing social media platforms, while older smokers might respond better to health-focused, community-based interventions (Meijer et al., 2016).

This study builds on previous research by examining smokers’ perspectives on anti-smoking campaigns and analyzing the factors that influence their support. By considering demographic and social characteristics, as well as personal smoking behaviours, this study seeks to identify specific elements that contribute to smokers’ support for anti-smoking campaigns in Malaysia. The findings aim to provide valuable insights for enhancing the design and delivery of future campaigns, fostering greater public support, and ultimately reducing smoking prevalence in the country. Given the growing global emphasis on reducing tobacco use, understanding smokers’ viewpoints is crucial for creating impactful, inclusive, and sustainable tobacco control strategies.

METHODOLOGY

The data for this study was derived from a survey conducted by the Health Education Division, Ministry of Health Malaysia, from April 18 to May 31, 2019, in conjunction with the World No Tobacco Day 2019. A total of 3,453 respondents aged 18 years and above participated in the survey, of which 217 were smokers. The survey was developed using Google Forms and disseminated nationwide through multiple platforms, including the Ministry of Health Malaysia’s MiHealth Facebook page, the Tak Nak Merokok (Say No to Smoking) Facebook page, the Kelab Doktor Muda (Young Doctors Club) Facebook page, and WhatsApp. The survey included background information and terms of participation, along with informed consent forms embedded in the questionnaire.  The questionnaire consisted primarily of closed-ended questions. Examples include: “Do you smoke?”, “Does any member of your household smoke?”, “Do they smoke inside the house?”, and “Should we reprimand smokers who smoke in public areas?” These questions offered binary responses such as “Yes” or “No.” Additionally, a question such as “Do you agree if the Ministry of Health Malaysia organizes a campaign to reprimand smokers who smoke in public areas or no-smoking zones?” provided answer choices like “Yes, I agree” or “No, I disagree.” Another question, “Are you willing to reprimand smokers who smoke around you or your family?” was also included to assess participants’ willingness to take action.  The data collected through Google Forms was extracted into Microsoft Excel and subsequently cleaned and analyzed using IBM SPSS Statistics version 25. The study employed descriptive and inferential statistical analysis, with chi-square tests conducted to assess associations. Independent variables included age, gender, occupation, smoking status, residential zone, having a family member who smokes, having family or friends who smoke indoors, knowledge of secondhand and thirdhand smoke, agreement with the Ministry of Health’s campaign (Speak Out), and agreement that smokers in public should be reprimanded. The dependent variable was the willingness to reprimand smokers who smoke around respondents or their families.  This study represents a formal online survey conducted by the Health Education Division, Ministry of Health Malaysia, in 2019. The survey was carried out prior to the launch of the “Speak Out: Express Your Right” campaign by the Ministry of Health. Furthermore, only data from participants aged 18 and above who provided consent to participate in the survey were included in the analysis, ensuring adherence to ethical research practices.

RESULT

Table 1: Comparison of Age Between Respondents Who Agreed and Disagreed with Campaigns to Reprimand Smokers.

Respondents who agreed (mean age = 36.46, SD = 8.56) were significantly younger than those who disagreed (mean age = 38.58, SD = 12.35) with a p-value of 0.002.

Table 2: Characteristics of Respondents Based on Agreement or Disagreement

Table 2 outlines the characteristics of respondents based on their agreement or disagreement with campaigns to reprimand smokers. In terms of gender, among respondents who agreed, 91.5% were male, and 8.5% were female, compared to 88.7% male and 11.3% female among those who disagreed. This difference was not statistically significant (p = 0.586). Regarding employment status, the majority of respondents who agreed were government employees (48.8%), followed by private sector employees (30.5%), self-employed individuals (11.6%), unemployed (5.5%), and students (3.7%). Among those who disagreed, the largest group was also government employees (45.3%), followed by private sector employees (20.8%), self-employed individuals (22.6%), unemployed (7.5%), and students (3.8%), with no significant difference observed (p = 0.271).

When examining the presence of family members or housemates who smoke, a significantly smaller proportion of respondents who agreed (34.8%) reported having smokers in their household compared to those who disagreed (62.3%) (p< 0.001). Similarly, only 20.1% of those who agreed reported family members or housemates smoking indoors, compared to 50.9% of those who disagreed, which was also statistically significant (p < 0.001).

Awareness of secondhand and thirdhand smoke was significantly higher among those who agreed (84.1%) than those who disagreed (64.2%) (p = 0.003). Furthermore, 85.4% of respondents who agreed perceived secondhand smoke as harmful, compared to only 28.3% of those who disagreed (p < 0.001). Similarly, 76.2% of those who agreed perceived thirdhand smoke as harmful, compared to just 22.6% of those who disagreed (p < 0.001).

Lastly, 91.5% of respondents who agreed believed smokers in public should be reprimanded, compared to 24.5% of those who disagreed (p < 0.001). Moreover, a larger proportion of those who agreed (69.5%) expressed courage to reprimand smokers who smoke in public places compared to those who disagreed (35.8%) (p < 0.001). These findings highlight significant differences in attitudes, awareness, and behaviours between the two groups.

Table 3: The logistic regression analysis presented key predictors of courage to reprimand smokers who smoke in public places.

*p<0.005, **p<0.00

The logistic regression analysis presented key predictors of courage to reprimand smokers who smoke in public places. Respondents with family members or housemates who smoke were significantly less likely to reprimand smokers in public (B = -1.286, SE= 0.472, Wald = 7.415, p = 0.006). The odds ratio (Exp(B)) of 0.276 indicates that respondents with smokers in their household were about 72.4% less likely to reprimand public smokers compared to those without such individuals in their household, with a 95% confidence interval (CI) ranging from 0.110 to 0. 697.Conversely, respondents who believed that secondhand smoke is harmful were significantly more likely to reprimand smokers in public (B = 1.806, SE = 0.470, Wald = 14.753, p < 0.001). Their odds of reprimanding smokers were approximately six times higher (Exp(B) = 6.088) than those who did not perceive secondhand smoke as harmful, with a 95% CI of 2.422 to 15.304. Furthermore, respondents who agreed that smokers in public should be reprimanded were overwhelmingly more likely to take action themselves (B = 2.893, SE = 0.478, Wald = 36.633, p < 0.001). The odds ratio of 18.045 suggests that these respondents were 18 times more likely to reprimand smokers in public compared to those who disagreed, with a 95% CI ranging from 7.072 to 46.047. These findings underscore the influence of personal beliefs and household smoking behavior on individuals’ willingness to confront public smoking.

The logistic regression analysis highlights key predictors of individuals’ willingness to reprimand smokers in public, offering practical implications for public health campaigns and interventions. First, the finding that individuals with family members or housemates who smoke are significantly less likely to reprimand smokers in public suggests that household smoking behaviour plays a crucial role in shaping public attitudes. Public health campaigns should address this by targeting households with smokers, emphasizing the importance of creating smoke-free environments at home and the impact of normalizing smoking within the family. Additionally, the study underscores the importance of increasing awareness about the harms of secondhand smoke. Respondents who recognized the dangers of secondhand smoke were more likely to confront public smokers, indicating that public health campaigns could be more effective by highlighting these risks. By using emotionally engaging messages or real-life stories, these campaigns could increase public understanding and inspire action. Finally, the strong correlation between the belief that smokers should be reprimanded in public and the likelihood of taking action suggests that fostering a collective sense of responsibility for maintaining smoke-free public spaces could further empower individuals to intervene. Public health initiatives could focus on promoting community norms that support active participation in upholding smoke-free environments, ultimately making the act of reprimanding smokers a more socially accepted and encouraged behavior.

DISCUSSION

In the government’s campaign to discourage smoking, smokers in particular have frequently been presented as the opponents rather than fighters. The survey in detail reveals that smokers themselves are aware of the negative consequences of smoking, and contrary to popular belief, they also support anti-smoking programs. However, their insights enhance our knowledge of the challenges faced in quitting smoking and the methods for creating a smoke-free atmosphere. The examination of the results from the previous “Tak Nak Merokok” campaign by the Malaysian Ministry of Health makes this point of view highly relevant (Global Adult Tobacco Campaign, 2011). Smokers are frequently the ones who are most aware of the negative effects smoking has on one’s health, relationships, and finances. These awareness increases whenever relating to the family members who are not smoking. This can be seen in this study that most of the smokers who have non-smoking family members support the second anti-smoking “Speak Out” campaign.

The subjective standards surrounding smoking are significantly shaped by family members who do not smoke. Smokers frequently believe that their family’s views on smoking are a reflection of what society expects of them. Family members’ disapproval of smoking might raise smokers’ support for anti-smoking programs like ‘Speak Out’ by making them feel pressured to follow social standards against smoking. This is supported by a study conducted by Rahmawati, Murti, and Prasetya (2022), which showed a high correlation between smokers’ aspirations to quit and positive subjective norms that encourage quitting smoking. Additionally, Hwang and Park (2021) highlighted the significant influence of social support especially family pressure in the smoking cessation process.

Apart from that, non-smoking family members engage in protective behaviors to lessen the harm that smoking can cause to their loved one. This was supported in a study done by Myung et. al, (2012) which showed that smokers who were banned from smoking in their house were more likely to quit smoking. Given their awareness of the possible harm their smoking habits may cause to their family’s health, smokers may be further motivated to participate in anti-smoking programs by this protective instinct. This kind of information makes smokers feel more accountable and motivates them to support anti-smoking campaigns that create healthier surroundings for their family.

Another reason smokers tend to support the anti-smoking campaign “Speak Out” launched by the Malaysian Ministry of Health is the increased awareness among smokers of the dangers of stale or secondhand smoke. Smokers and their contacts or non-smokers who are exposed to stale cigarette smoke or secondhand smoke are at high risk of getting a disease. A report shows that the diseases caused by smoking kill approximately 8 million people every year, and 1.3 million of them die due to secondhand smoke exposure (World Health Organization, 2023). This rather shocking figure has created public awareness and attention in the ill effects of both the active and passive smoking. Therefore, smokers are becoming more conscious of the effects their behaviours have on the health of people around them. In particular, the “Speak Out!” campaign seeks to create a culture that encourages people to speak out against smoking by empowering them to fight for their right to a smoke-free environment (Fong, 2019). This kind of empowerment makes smokers begin to think in a different way to avoid any possible harm they might be causing to others, specifically families and non-smokers who may want to avoid second-hand smoke.

The findings also show that smokers have the courage to reprimand other smokers for smoking around people. Reprimanding other smokers for their behaviour may initially seem contradictory, particularly when it comes to smoking in public areas. This reprimand behaviour is a way to reconcile their own smoking habits as smokers may turn to altering their dissonant beliefs (Fong et. al., 2004). Apart from that, these contradictory behaviours also can be explained based on Freud’s id, ego and superego concepts whereby the conflict of id and superego can be neutralized using psychological defence mechanisms. According to Chen et. al (2022), the superego of smokers maintains the moral standard and fights the temptation to smoke, whereas the id adheres to the hedonic principle and satisfies the desire to smoke at any costs. Therefore, critiquing others could help them feel less guilty about their own decisions and connect their behaviour with the social narrative that supports health.

Another reason for reprimanding behaviours among smokers is due to social responsibility whereby some smokers may feel obligated to protect non-smokers, especially the elderly and children, who are especially vulnerable. Nonetheless, this conduct is a reflection of a greater awareness of the negative effects of smoking, a sense of social duty, and frequently, individual battles with the habit. In addition to showing bravery, smokers who oppose careless smoking practices indirectly aid anti-smoking programs by upholding social norms that place a high value on respect for one another and public health.

While smokers’ support for anti-smoking campaigns provides valuable insights, stigma and social perception can be one of the limitations that can prevent the success of anti-smoking campaigns. Smokers are frequently stigmatised and seen as the issue rather than possible allies. They might be deterred from actively endorsing or expressing their views regarding anti-smoking programs by this cultural bias. Their contributions are sometimes disregarded or underappreciated, which restricts how inclusive these programs can be. By overcoming this limitation requires targeted strategies to reduce stigma, address addiction, and create platforms that genuinely include smokers as partners in the fight against tobacco. Only then can their unheard voices transform into powerful agents for change. For example, by focusing on open dialogue and empathy, these initiatives can shift the narrative from judgment to support, encouraging smokers to view themselves as active partners in public health efforts. Campaigns could highlight personal stories of individuals overcoming smoking, paired with accessible resources for quitting, to inspire change and reduce the social stigma that often isolates smokers. Additionally, promoting smoke-free environments as a collective benefit rather than a punitive measure ensures that smokers feel included in the movement for healthier communities. By leveraging inclusive messaging and community support, the “Speak Out” campaigns can empower smokers to contribute to broader health goals, fostering a culture of shared responsibility and mutual respect.

Therefore, suggestions for future study are empirical studies regarding the behaviours of protecting oneself from the dangers of stale cigarette smoke and the behaviours of reprimanding smokers who smoke around need to be actively conducted to ensure that Malaysians are truly ready to be agents of the anti-smoking campaign in Malaysia. The Speak Out campaign that was introduced in 2019 has received good support from Malaysians and has been recognized by the World Health Organization. This study proves that the Speak Out campaign is relevant to be carried out today and the findings of this study also emphasize the need for future studies that focus on knowledge, attitudes and practices towards second-hand and third-hand smoke among Malaysians.

CONCLUSION

This study sheds light on a perspective that is often overlooked, which is smokers who support anti-smoking initiatives. While smoking is usually stigmatized and smokers are often seen as opposing public health efforts, our findings show a different view. Many smokers, even though they face challenges in quitting, recognize the importance of creating healthier public spaces and support efforts to reduce smoking rates. Their support comes from concerns about their own health, a sense of responsibility to reduce others’ exposure to smoke, and for some, a growing desire to quit. Interestingly, smokers who back these policies don’t feel pushed aside by them; instead, they see them as necessary for improving social well-being and public health. While quitting can be tough, they view these policies as helpful in making it easier to quit by reducing triggers and creating an environment that’s less accepting of smoking. By acknowledging smokers’ viewpoints, policymakers can design campaigns that treat them as partners in public health, focusing on compassion and harm reduction rather than blame. In conclusion, including smokers as part of the solution in anti-smoking efforts can lead to a more collaborative approach, promoting a healthier society while acknowledging the difficulties of addiction. Future research could look deeper into this, especially in different demographic or cultural contexts, to shape more effective public health strategies.

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