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  Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 690-693
 

Tobacco use among high school children in Bangalore, India: A study of knowledge, attitude and practice


1 Department of Public Health Dentistry, D J College of Dental Sciences and Research, Modinagar, Ghaziabad, India
2 Department of Public Health Dentistry, Dr. Syamala Reddy Dental College, Hospital and Research Centre, Bangalore, Karnataka, India
3 Department of Public Health Dentistry, Manav Rachna Dental College, Faridabad, Haryana, India

Date of Web Publication10-Mar-2016

Correspondence Address:
Shilpi Singh
Department of Public Health Dentistry, D J College of Dental Sciences and Research, Modinagar, Ghaziabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.178413

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 » Abstract 

INTRODUCTION: Tobacco use among school children is becoming a serious problem indeveloping countries. The early age of initiation underscores the urgent need to intervene and protect this vulnerable group from becoming victims of this addiction. AIM: To assess the knowledge, attitudes, and practices about tobacco use among 13-15 year old school children of Bangalore City. MATERIALS AND METHODS: A cross-sectional study was designed and data on tobacco usage was collected from 1288 students aged 13-15 years studying in six government and private schools of Bangalore using a self-administered closed ended questionnaire. Data was analyzed using SPSS 15.0 and descriptive statistics was applied. Chi-square tests were used to determine the significant differences in the variables of interest. RESULTS: Out of 1288 children, 1281 (99.5%) children had heard about tobacco and 1162 (90.2%) students knew the harmful effects of tobacco. Only 28 (2.2%) had used tobacco products. Peer pressure was the main reason for tobacco use among children and age was not a barrier in buying tobacco products. Television (58%) was the main source of information for tobacco products followed by newspapers (26%) and movies (16%). CONCLUSION: It is encouraging to find that majority of the 13-15 year old children surveyed in the present study did not use tobacco and were aware of the health risks associated with tobacco use. This calls for the school authorities to be included in stricter implementation and monitoring of the implementation of legislation. Regular and systematic education programs catering to teachers, children, and also their parents should be undertaken.


Keywords: Attitude, knowledge, practice, schoolchildren, tobacco


How to cite this article:
Singh S, Vijayakumar N, Priyadarshini H R, Jain M. Tobacco use among high school children in Bangalore, India: A study of knowledge, attitude and practice. Indian J Cancer 2015;52:690-3

How to cite this URL:
Singh S, Vijayakumar N, Priyadarshini H R, Jain M. Tobacco use among high school children in Bangalore, India: A study of knowledge, attitude and practice. Indian J Cancer [serial online] 2015 [cited 2019 Dec 5];52:690-3. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/690/178413





 » Introduction Top


Adolescents, in today's world are increasingly exposed to changing life-styles that have very negative impact on health. Neither the parents nor the community have any clue how to deal with such situations. Addictions developed in adolescence are likely to persist into adult life.[1] One such addiction, tobacco use in children and adolescents is reaching pandemic levels. The World Bank has reported that between 82,000-99,000 children and adolescents all over the world begin smoking every day. About half of them will continue to smoke into adulthood and half of the adult smokers are expected to die prematurely due to smoking related diseases. If current smoking trends continue, tobacco will kill nearly 250 million of today's children.[2]

Considering the enormous health complications associated with tobacco use, it is of utmost importance to understand the factors leading to its use and to plan strategies to reduce its intake. This is especially relevant for developing countries like India, where tobacco use continues to be common notwithstanding the recognition of harmful consequences of its usage.[1],[3],[4] The epidemic of tobacco use is shifting from developed to developing countries, including India, where increased use is expected to result in a large disease burden in the future. In India, tobacco use is estimated to cause 800,000 deaths annually.[2],[5]

Tobacco is used in a variety of ways in India; its use has unfortunately been well recognized among the adolescents. The most susceptible time for tobacco use is during adolescence and early adulthood. Thus, tobacco addiction in a large number of adults is initiated during adolescence.[3]

India has been very conscious of the harmful effects of tobacco use, disease burden and related social and economic costs of health care. At the global level, India has been a forerunner in the negotiations leading to the frame-work convention on tobacco control (FCTC), which was ratified by India in February 2004. Over the period, various administrative measures have been taken to prohibit tobacco smoking in public places and regulate the sale of tobacco products and their advertisements. For any legislation to be successful there is a need for adequate preparedness on the part of civil society, locally, and globally, with regard to awareness of the existing problem and acceptance of the necessity for such legal measures. Thus, there is a need for locally relevant community based data regarding tobacco use among children, their knowledge, attitude, and practices for designing an effective community based intervention strategy. Hence, the aim of the present study was to assess the knowledge, attitudes, and practices about tobacco use among 13-15 year old school children of Bangalore, India.


 » Materials and Methods Top


Study design and, study population

A cross-sectional questionnaire study was conducted among 13-15 year old school children from six government and private schools of Marathahalli, Bangalore which were selected based on equal probability sampling. A number of schools situated in the country are of similar nature. All the school children in the age group of 13-15 years who were present on the day of the study were included. The study population included 1288 school children whose parents gave permission for them to participate in the study.

Questionnaire

A 20-item structured, self-administered questionnaire was used for the study. Each item was a closed-ended question which was translated from English into Kannada, back translated and then both versions were checked for reliability by the test-retest method. Each item was a multiple-choice question with a single answer. There was no skippattern; no multiple response questions and all questions were required to be answered. The questions were written at a language level that should have allowed comprehension by even the youngest subjects.

The questions were grouped into categories relating to tobacco use, their knowledge about the harmfulness of tobacco, access to tobacco, attitudes towards tobacco use, cessation behavior, exposure to tobacco advertisements and attitudes towards tobacco control [Table 1]. Responses were measured based on the correct answer provided by each participant. Twenty subjects pre-tested the questionnaire to assess translation accuracy, validity, and suitable modifications were done before field administration. Reliability was assessed using Cronbach's alpha internal consistency coefficient (the value averaged 0.82).
Table 1: Questions pertaining to knowledge, attitude and practice of study participants

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Organizing the survey

Before the revised survey was administered, prior permissions were obtained from the heads of the respective institutions and parents of the school children. Ethical clearance was obtained from the institutional review board. The pre-tested questionnaire was administered after explaining the study purpose and informing that they were required to complete the entire questionnaire. Only those participants who agreed were taken into the study and written informed consent was obtained for the same. This was done to reduce drop outs due to incomplete questionnaire. No study subject was forced to complete the questionnaire.

Students were not permitted to discuss among themselves while answering the questionnaire and the survey was completed in the presence of the investigator. The identity of the study subject was not included on the questionnaire form and also the investigator was not familiar with the study subjects. The investigator clarified doubts and answered students' queries regarding the questionnaire. The questionnaire was collected back after scrutinizing for completeness and confidentiality was ensured.

Statistical analysis

Data was analyzed using the SPSS Version 15.0. Descriptive statistics included percentages, frequencies and Chi-square tests were used to find out significant mean differences (P < 0.05).


 » Results Top


A total of 1288 school children participated in the study with a response rate of 89.3%. Out of 1288 children, 602 (46.7%) were from government schools and 686 (53.3%) were from private schools. There were 371 students aged 13 years old, 315 students aged 14 years old and 602 students aged 15 years old as the study population. Equal number of boys and girls participated in the study [Table 2].
Table 2: Distribution of study subjects according to gender and school type

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Out of 1288 children, 99.5% (1281) had heard about tobacco and its products and only 0.5% (7) school children had no knowledge about tobacco and its products. The various forms of tobacco known to the children were bidi, cigarette, gutka, pan masala and zarda. Twenty eight (2.2%) schoolchildren had ever used tobacco in some form. The reason for tobacco use among tobacco users was mainly fun with friends (75%) and out of curiosity (25%) [Table 3].
Table 3: Reasons for tobacco use among tobacco users

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All the tobacco products used were in chewable form. Of the school children who used tobacco, 64.3% bought tobacco themselves while 35.7% borrowed it from others. Despite the legislation banning the sale of tobacco products to minors, age was not at all a barrier in buying tobacco products by the school children and the place of use was public places [Table 4].
Table 4: Percentage of tobacco users for different questions answered

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Sources of information about tobacco and its products included television (58%), newspapers (26%) followed by movies (16%) [Table 5]. In the present study, parents and/or siblings of 54.3% children used tobacco products and 34.8% school children reported that their father used tobacco products [Table 6].
Table 5: Source of information for anti-tobacco media messages

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Table 6: Parental use of tobacco products

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The difference among males and females was statistically not significant for any of the questions (P > 0.05). Knowledge about harmful effects of tobacco was reported by 90.5% of the participants. It is encouraging to find that 90.2% of the school children we surveyed were aware of the health risks associated with tobacco. Practice of tobacco usage was only 2.2% among the study subjects.


 » Discussion Top


The present study assessed knowledge, attitude, and practices about tobacco use among 13-15 year old adolescent children in government and private schools of Bangalore, India. This study showed that students were aware of the dangers of tobacco use which is consistent with the studies done by Jindal et al. and Al Haqwi et al.[6] In the present study, parents and/or siblings of 54.3% children used tobacco products which is a major initiating factor among children for tobacco use.[7] Parents significantly constitute a role model and tobacco use at home is indicative of the prevalent social acceptance of tobacco use and this is obviously a bad trendsetter for the children. We must continue to support legislation in developing countries that controls and contains the smoking epidemic. Especially, fruitful would seem to be measures that protect children from tobacco marketing.

Television was a predominant source of information for tobacco use followed by print media and movies. The impact of tobacco advertising on youth is a well-researched area globally. Studies conducted by Vaidya et al. and Gururaj et al. have shown that media advertisements influence the children's perception and initiation of tobacco use. These studies found that exposure to media messages regarding tobacco has a significant influence on initiators, experimenters and users, while increasing sales, and availability. Advertising and promotion of tobacco products attract children's attention, and they remember its messages. Advertising lures gullible youth and children through glamorous and deceptive promotional stunts. Advertisements project tobacco use in congenial surroundings or associate the brand name with idolized role models, legitimize the habit in young minds and project the use of tobacco as being socially acceptable.[7],[8] Recognizing the impact of tobacco advertisements and promotional activities, the FCTC (Article 13) has called upon countries to undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship to reduce the consumption of tobacco products. The Indian Act for tobacco control (Cigarettes and Other Tobacco Products Act, 2003) banned all forms of advertising of tobacco products except at the point of sale.[9]

Tobacco use in the present study was 2.2%. According to the survey conducted by Gururaj et al.,[10] 4.9% of 13-15 year old practiced tobacco use in Karnataka (Global Youth Tobacco Survey). In the present study, students practiced use of smokeless variety and smoking was not reported at all. This has considerable public health implication as it is known that people change over from the smokeless form to smoking over a period of time.[11] Furthermore, chewing of these products is considered less harmful than smoking by the initiators.[12],[13]

Peer pressure was the important reason for the initiation of tobacco use in the present study. This is consistent with the studies done by Jindal et al.[6] and Al Haqwi et al. This is a serious issue as it is very difficult to prevent the effect of this factor in adolescents, who favor living in friend circles.[14],[15] Parents know their children best. As honest communication is the basis of all good relationships, including the relationship parents share with their son or daughter, parents can positively influence their children's lives by building on the good communication they have already developed, thereby playing an important role in preventing the effect of this factor at such a vulnerable age. Parents must take an active and repeated stand against tobacco use.[9]

Students who used tobacco products indicated that they had purchased the tobacco product in a store. This point to the easy and relatively unrestricted access at vending outlets located near schools and inadequate regulation for restricting the sales to underage users. The youth start using tobacco even before they can understand its consequences, and the fact that tobacco is addictive prevents them from quitting when they become aware of its harmful effects later in life. One of the goals of any tobacco control policy should be to ensure that tobacco products are neither available by direct sale nor accessible through other sources to youth. Thus, the laxity in the implementation of the legislation (ban of sales to underage persons and ban on selling outlets within 100 yards of an educational institution) specifically calls for a multi-sector approach to tobacco control initiatives.[16],[17],[18],[19]

Limitations

Though the survey was anonymous but administered in the classroom and based on self-reports, this may have resulted in children not reporting actual tobacco use accurately. Data was applicable only to those who attended school on the day of survey administration and therefore, is not representative of all adolescents in the 13-15 year age group especially, those not attending schools. Furthermore, the small sample size of the present study cannot be the representative of the adolescent population of a country like India, hence more national surveys with a representative sample needs to be undertaken.


 » Conclusion Top


On the world tobacco map, India occupies a very special place. As the second most populous country in the world, India's share of the global burden of tobacco-induced disease and death is substantial. As the second-largest producer and consumer of tobacco in the world, the complex interplay of economic interests and public-health commitments becomes particularly prominent in the Indian context.[2] The Government of India has been actively working towards enforcing legislations to prevent young people from having any access to tobacco. Tobacco smoking in public places in the form of cigarettes, cigars, bidis or otherwise, is illegal, unconstitutional and falls within the purview of the penal provisions relating to public nuisance as contained in the Indian Penal Code. The integration of interventions for tobacco control into other health-care programs is essential to provide the widest outreach and the largest impact. At the same time, capacity for tobacco control needs to be built both at the level of the government (for policy, legislation, regulation and enforcement) and at the level of civil society (for advocacy, community mobilization, countering the tobacco industry and networking with potential partners). Smoking restrictions in the home and bans in public places allow a limited opportunity for tobacco users to use tobacco.[19] The mere existence of a school ban had no effect, but regular enforcement has to be undertaken. Schools with smoking policies have lower rates of smoking among students. Teachers who smoke make smoking seem safe and acceptable. Hence, the school policy must address both teachers and students tobacco use. It is required that school-based programs should adopt a comprehensive intervention approach and ensure that the modes of communication are suitable to the targeted group characteristics.[9]

It was encouraging to find that 99.5% of the study population had knowledge regarding tobacco and its harmful effects. Attitude of study subjects towards quitting tobacco was good. Practice of tobacco usage was 2.2% among the study subjects. Though, there are few school based anti-tobacco campaigns being undertaken by non-governmental organizations, more government efforts need to be incorporated. This also calls for the school authorities to be included in stricter implementation and monitoring of the implementation of legislation. Regular and systematic education programs catering to teachers, children and also their parents should be undertaken. Enabling teachers to educate young impressionable minds regarding life-style issues should be a cornerstone activity in preventing the establishment of unhealthy life-style behaviors within the community. However, there is an urgent need to carry out more such surveys to build a comprehensive database for future policy decisions on anti-tobacco campaigns.


 » Recommendations Top


There is a need for targeted and focused tobacco use prevention interventions by adopting a comprehensive approach. Enabling teachers to educate the students regularly regarding tobacco use should be a cornerstone activity. Non-governmental organizations may be involved in increasing awareness, providing health education in the local language catering to teachers, children and their parents and also in massive public health education campaigns. Moreover, nationally representative data on the prevalence, risk-factors and health consequences of tobacco use among adolescents are lacking, thus, representing a future public-health research priority.

 
 » References Top

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Chadda R, Sengupta S. Tobacco use by Indian adolescents. Tob Induc Dis 2002;1(2):1-9.  Back to cited text no. 1
    
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World Health Organization. Report on Tobacco Control in India. 2004. Available from: http://www.whoindia.org/SCN/Tobacco/Report/TCI-Report.htm. [Last accessed 15th July 2012].  Back to cited text no. 2
    
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Pal R, Tsering D. Tobacco use in Indian high-school students. Int J Green Pharm 2009;3:319-23.  Back to cited text no. 3
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Reddy KS, Gupta P. Report on tobacco control in india. India: India Ministry of Health and Family Welfare; 2004. p. 121-124.  Back to cited text no. 9
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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