|KIDS AND ADOLESCENTS
|Year : 2010 | Volume
| Issue : 5 | Page : 14-18
Study on tobacco use and awareness among marginalized children
S Raval, S Maudgal, N More
Cancer Patient Aid Association, Mumbai, India
|Date of Web Publication||9-Jul-2010|
Cancer Patient Aid Association, Mumbai
Background : The current study entailed a survey of children from the lower socioeconomic strata of rural and urban regions of the states of Maharashtra and Assam who are vulnerable to tobacco usage. More than 1700 children were checked for precancerous lesions and 1004 were surveyed for tobacco habits and awareness. Aims: The objective of the survey was to determine and report on all the variant factors affecting the use of tobacco among the underprivileged children population. The aim of the clinical check-up was to detect precancerous lesions in the tobacco-using children at an early treatable stage. Materials and Methods : Awareness lectures and ENT camps were conducted at 12 organizations/community centers. A cross-section of children were interviewed to understand tobacco use among them. All the children were screened for precancerous lesions. Children with suspicious oral lesions were sent for further evaluation at a nearby diagnostic cancer facility. The survey was conducted by trained social workers. Results : The percentage of tobacco users in urban Mumbai was quite low at 4.8% compared with rural Kasara (36%) and Assam (76%); and 74.6% of the children were aware that tobacco use was dangerous and harmful to health. The average age of initiation was 9 years. Out of the 1004 children surveyed, 253 were tobacco users and 79% were males. Of the 1700 children screened, 23.5% presented with precancerous oral lesions. Conclusion : This study addresses the tobacco habits of a typical sample of marginalized children in India and the need for effective interventions aiming at reducing the burden of tobacco-related cancers by controlling at the point of initiation.
Keywords: India, marginalized children, oral cancer, precancerous lesions, tobacco
|How to cite this article:|
Raval S, Maudgal S, More N. Study on tobacco use and awareness among marginalized children. Indian J Cancer 2010;47:14-8
Publication of the supplement was supported by the funds from the 14th World Conference on Tobacco or Health, March 8-12, 2009, Mumbai. The Guest Editors, Editors, Authors and others involved with the journal did not get any financial or non-financial benefit from the sponsors.
| » Introduction|| |
Tobacco is the single most preventable cause of cancer and is responsible for over 800,000 deaths per year in India alone.  India faces the greatest challenge with the highest rates of oral cancer in the world due to easy availability of variant smoking and smokeless tobacco products. Recent data from the National Health Survey 2005-2006 shows that 57% of Indian men and 11% of women are tobacco consumers and that an estimated 55,000 children are initiated into tobacco use everyday  There is an increasing concern regarding the usage of tobacco among our youth who succumb to the habit due to peer pressure and lack of awareness. According to the Global Youth Tobacco Survey (GYTS), 17.5% of adolescents in India aged 13-15 years were using tobacco in some form or the other form. 
This current study encompassed a survey of children from the lower socioeconomic strata of India who are most vulnerable to tobacco usage. In collaboration with various organizations, we conducted lectures and awareness programs at various sites in Mumbai (urban) and Kasara (rural) in Maharashtra, and Guwahati (urban) and Amsong (rural) in Assam. Over 1700 children were interviewed and counseled by trained social workers and then examined by our panel of ENT surgeons on site for precancerous lesions. In this study, 1004 children were surveyed and the data collected is presented. The study analyzes the tobacco habits in the 4 above-mentioned regions in Maharashtra and Assam.
We have worked actively to identify the root cause of the growing problem of cancer in India. Oral cancer, the most common cancer today, is related to the socially accepted excessive use of tobacco in both the smoked and smokeless forms. Tobacco has been shown conclusively to be the biggest risk factor for contracting oral cancer. We identified marginalized children, such as juvenile delinquents in remand homes, street children, orphans, or deserted children in shelters and runaways living in railway stations as being at the highest risk. Because these habits start at an early age, we collaborated with organizations who work with such children to target their addiction. The objective of this study was to determine and report on all the variant factors related to the usage of tobacco among the underprivileged children population. Clinical check-up was carried out to detect and treat precancerous lesions in the tobacco-using children at an early stage.
| » Materials and Methods|| |
We approached various Non-Governmental Organizations (NGOs), Children's shelters, Remand homes, and Community welfare agencies to conduct awareness programs and camps to address the growing use of tobacco among the children they work with. ENT check-up camps were conducted at 12 different organizations/community centers mentioned in the next paragraph. On site, the camp set-up included a team of ENT surgeons, medical assistants, and camp counselors. Every child was registered and examined by an ENT surgeon and if found to be a tobacco user, counseled on site by the counselor present. On observation of any precancerous lesions, the children were sent for further evaluation at a nearby diagnostic cancer facility.
The survey was conducted by trained social workers before the registration process to exclude any bias. In addition, the children when surveyed were alone without any parents or guardians in the vicinity. The study and camp was conducted for children from the age of 3-21 years. All the communities were urban areas except The Bridge, Kasara, and RBC Center, Assam. The community welfare centers included were Banyan Tree Center), Ramkrishna Shraddha Samiti, Streehitkarni, Family Health Center, Community Outreach Program, RBC Center, Lalsingh Academy, and Sparsh Charitable Trust. The NGOs included were Snehalaya and Vatsalya. Don Bosco Shelter (DBS) is a shelter and Umer Khandi is a remand home.
| » Results|| |
Of the total 1004 children surveyed, 65.6% of the children were male [Table 1]. This skewed gender difference was primarily due to certain centers, such as DBS, Snehalaya, and Vatsalya being boys-only homes. Moreover, a majority of the street and slum children were boys. Tobacco use among girls was found to be much less than tobacco use by boys. The product most commonly used by the girls was "Sweety" areca nut in the Lalsingh Academy, Assam, and masheri in the Kasara group.
Age of initiation
The earliest age at which tobacco was experimented with was 3 years. The average age at initiation was 8.80 years for both boys and girls across all the camps. A large number of children in Kasara were initiated into masheri use at a very early age. Thirty-seven percent of the children in India begin smoking before the age of 10 years, according to the GYTS, 2006.  A small number (33) actually quit tobacco a short while after their first experience.
Percentage of children who use tobacco
We found that among this study group of children from marginalized communities, tobacco use was rampant. Of the total children surveyed, 25% of the children were found to use tobacco in some form.
Of the groups studied, Assam stood out as having quite a high number of children using tobacco at 68%. This reflects tobacco use statistics by GYTS, which stated that the prevalence was the highest among male students in the Northeast (34%) and the lowest was 4.9% among female students of the western states in India.  In the northeastern states, tobacco use is seen to be socially accepted and even encouraged. The second highest group of 38% was in Kasara, a semi-tribal area with low awareness and education levels. Children used masheri (roasted tobacco) in the mistaken belief that it cleaned their teeth.
In comparison, the number of tobacco users in urban Mumbai was relatively low. The exception was the Umer Khandi Remand Home, where 28 out of 261 (11%) children used tobacco. In the other 9 facilities in Mumbai, put together, only 19 out of 892 (2%) were found to be users. We found that children who were going through some form of schooling had a higher level of awareness and did not experiment with tobacco.
Forms of tobacco used
Masheri (roasted tobacco) was commonly used by the Kasara children where the product was provided by the household matriarch as a form of dental hygiene. In Assam, the most popular form used was areca nut. In Amsong, we found areca nut trees growing in every back yard. The fruit is harvested and buried in pits where it is allowed to ferment and become a soft form of areca nut, which is not popular in other parts of India. Areca nut is offered to guests after meals as a mark of respect. In addition, a type of flavored areca nut product ("sweety supari") was found to be used rampantly by the adolescent school girls. In rural Assam, teenage boys were also addicted to sniffing glue. In Mumbai, the frequently used products were raw tobacco, pan masala/gutkha, areca nut, and cigarettes.
There is a varied connection between parents and children's tobacco addictions. In the shelter and remand homes visited, orphans and children who did not live with their families were obviously not influenced by parental use of tobacco. We have not been able to establish any pattern, which shows that the parents of tobacco users were tobacco users themselves. Parents of many of the nontobacco users are reported to be tobacco users. The children at Kasara who used masheri did have masheri-using parents. Mostly, the habit was instigated in the child by the mother or grandmother as a way to clean teeth and gums leading to its alternative name "Colgate."
Reasons for initiation
Most children tried tobacco due to curiosity or a form of emulation of their role models. Peer pressure is the most prevalent cause of experimentation in spite of being aware of the hazards of doing so. Many others associated tobacco use as a form of transcending into adulthood.
Children spent sums ranging from 0.50 to 200 rupees per day. In Amsong, areca nut was grown residentially and was ready to consume. The glue tubes cost Rs. 22 each and as many as 10 would be sniffed per day.
Source of money spent
Parents were the common source of money acquired but unaware of how the money was being used. Other children either begged, stole temple donations, sold recycled mineral water bottles at railway stations, worked in restaurants, or worked as shoe shiners to earn money.
Levels of awareness
When questioned, 74.60% of the children were aware that tobacco use was dangerous and harmful to health. Both sexes were equal in their levels of awareness. However, they did not know what the ingredients/carcinogens of tobacco were and why they were dangerous. It was noted, however, that children who attended school were more aware about tobacco hazards and even knew about the addictive ingredient, nicotine and its effects. A common misunderstanding among the children was that areca nut or supari was not dangerous at all. Areca nut is known to cause oral submucous fibrosis, which is a precursor to cancer,  and unlike smoking, it has adverse health effects in a short period of time. In recent years, areca nut seen in gutkha is a great cause for concern as it is popular among young people who are showing a rise in oral cancer cases. 
Prevalence and willingness to quit
The 253 tobacco users across the 3 study areas were asked about their willingness and efforts made if any to quit [Table 2]. When asked if they wanted to give up the habit, a large majority (84.9%) said that they did. This high percentage further reinforces the fact that children were aware that the use of tobacco is harmful and should be stopped. On further questioning if any of them had tried to stop the habit, only 53.4% said yes.
The interest in quitting seems to also have a direct relationship to education and literacy rates.  Overall, the interest to quit was found to be quite low in the population and awareness of the disease risks was also the same.  The effort to try and stop was much harder than the actual realization that their habit needs to end. Commonly, the children said that they did not have enough incentive to stop and even if they did, they did not know how to stop. This clearly reflects the need for Tobacco Cessation clinics, Community Support Centers, and/or Big Brother Programs in the communities for these children. We plan to follow-up on remission rate and quit rates after the camps in all of these study areas.
Oral cancer, a highly avoidable disease, carries a poor prognosis if detected late and causes damaging functional and cosmetic defects.  The children were examined by experienced ENT surgeons for common oral cancer signs, such as submucous fibrosis, erythoplakia, leukoplakia, melanoplakia, and any other suspicious lesions of the buccal mucosa, glossal, and oral cavity [Table 3]. On observation of any of these signs or symptoms, the children were sent for further evaluation at a nearby diagnostic cancer facility. The further diagnostic tests included a biopsy of the lesion and Direct Light Scopy. In Mumbai, all the children were referred to the preventive oncology department at the Tata Memorial Hospital. Children who were only recommended observation and follow-up (3, 6, or 12 months) will be seen at our diagnostic centers.
Two ENT camps, Umer Khandi Remand Home and Sparsh Charitable Trust are also mentioned in [Table 3] where the children were only examined and not administered the survey. Out of the total 253 tobacco users found, 455 were sent for further investigation as referral cases.
The referral cases refer to all the children who were found to have some kind of precancerous lesion on examination and were recommended for further diagnostic oral testing. As expected, Assam had the highest number of referral cases followed by Kasara. This directly correlates to the number of tobacco users in these respective areas, and the use of areca nut in Assam and masheri in Kasara.
Overall, plakias were the commonly found precancerous lesions among the children. The Umer Khandi Remand Home showed the highest incidence of plakias and submucous fibrosis. They were thus also the most recommended for biopsy and annual follow-up by the in-house doctor.
Proudly noted was the lack of any tobacco usage and precancerous lesions found in the SH center of Lower Parel, Mumbai. On inquiry, it was found that these children were all enrolled in schools and were taught about the ill effects of tobacco in school. The number of schooling years has a direct correlation to tobacco use in a multivariable analysis with respect to both men and women. 
In all, 403 children were scheduled for follow-up out of the total 1711 children screened. This means 23.5% of the total children screened who had succumbed to the habit of tobacco presented with some kind of precancerous oral lesion at such a young age. If not checked at our camp, these lesions would have gone unnoticed for an undetermined period of time and becoming cancerous at a later stage. All the children across the regions noted for referral and follow-up will be regularly monitored by our diagnostic department so as to catch these precancer lesions before their advancement to cancer. The associated NGOs, Children's shelters, Remand homes, and Community welfare agencies were given educative materials on cancer prevention and tobacco cessation tips to follow-up in their communities and build on their own capacities. For instance, counseling is continued at the DBS and 2 tobacco-using children have been rehabilitated. At BTC, Chatrapati Shivaji Terminus, the parents were educated on how to monitor their children and seek in-house counseling for help.
| » Conclusion|| |
The results of the various aspects of tobacco use and awareness among the children of the lower socioeconomic strata of 2 representative parts of the country varied widely. The vast differences and similarities between the children and their perceptions of tobacco and its usage are enlightening. There emerged a direct correlation between the literacy and awareness levels to the tobacco habits of the adolescent population. There seemed to be an inverse relationship between education and tobacco use and a direct relationship existed between poverty and tobacco use. The cause of high tobacco consumption in the underprivileged population was multifactorial from curbing hunger, the myth of dental hygiene, ignorance of the health consequences, and a desire to fit in, to name a few. It is also noted that this population is most vulnerable to peer pressure and succumbs to the fatal health outcomes due to lack of or poor access to health care. This further highlights the need for policy changes in our laws for preventing easy accessibility of tobacco by the poor and underaged population. Unfortunately, the consumption of tobacco in any form has been increasing in recent times in both the rural and urban areas of India.
All of these findings restate the importance of addressing the disadvantaged children population and their tobacco habits. Effective interventions are required to reduce the burden of tobacco-related diseases, especially cancer for these children. The study highlights the need for more screening camps directed toward prevention of tobacco use and early detection of oral cancer among the marginalized children of India.
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[Table 1], [Table 2], [Table 3]