|Year : 2016 | Volume
| Issue : 2 | Page : 322-324
Smokeless tobacco use and perceptions of risk among students in Mumbai municipal schools
ML Rose, D Chadha, TD Bhutia
Department of Research, Salaam Bombay Foundation, Mumbai, Maharashtra, India
|Date of Web Publication||6-Jan-2017|
M L Rose
Department of Research, Salaam Bombay Foundation, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Nearly 15% of youth in India use tobacco. However, few studies have explored the use, knowledge, and attitudes of smokeless tobacco use among youth. AIM: To determine the patterns of use as well as knowledge and perceptions of smokeless tobacco among youth in Mumbai attending municipal schools. Materials and Methods: A cross-sectional survey was performed among 1053 students in the 8th and 9th grades in 16 municipal schools in Mumbai to determine the knowledge and perceptions about smokeless tobacco products as well as the patterns of use. Results and Conclusions: Ever use of smokeless tobacco was reported by 47 (4.7%) students in the survey. Twenty-nine (2.9%) students reported ever using smoked tobacco. Students were more likely to identify cigarettes and bidis as tobacco products compared to smokeless tobacco products such as gutkha, mishri, and khaini. Betel nut products were used by 178 (17.9%) students. The high rate of smokeless tobacco and betel nut use coupled with low levels of knowledge about their contents and harms suggests that tobacco control programs targeting youth should ensure that these products are adequately explained and understood by students.
Keywords: Betel nut, smokeless tobacco, supari, youth
|How to cite this article:|
Rose M L, Chadha D, Bhutia T D. Smokeless tobacco use and perceptions of risk among students in Mumbai municipal schools. Indian J Cancer 2016;53:322-4
| » Introduction|| |
Tobacco use is an increasingly important factor effecting morbidity and mortality in India. Children and youth are acknowledged as the most susceptible group for tobacco use initiation. Nationally, 14.6% of youth (aged 13–15 years) report using tobacco products. The majority of youth tobacco users report using products other than cigarettes.
Only a few studies have examined smokeless tobacco use among children and youth, as well as attitudes and beliefs about smokeless tobacco in India. These studies have shown mixed results. For instance, a study of students in Noida found the ever use of smokeless tobacco to be 4.6%. A similar study conducted with youth in Delhi and Chennai found 10.8% of students reported smokeless tobacco use. A third study conducted in Chennai found students were more likely to report smoking tobacco compared to using smokeless tobacco products. Despite the large number of youth who report tobacco use, less than two-thirds report being taught about the effects of tobacco use in school.
The study reported here seeks to extend the information available on youth smokeless tobacco use as well as use of betel nut (areca or supari) products while highlighting the areas of knowledge and perception among youth for tobacco control education initiatives.
| » Materials and Methods|| |
A cross-sectional study was conducted in 16 municipal schools in Mumbai in January and February 2014. Schools were randomly selected and one classroom from the 8th to 9th grade within each school was randomly selected. All students in each selected class were invited to participate in the study. Students were surveyed to assess tobacco use (smoked and smokeless), knowledge about tobacco and betel nut products, and perceptions of risk associated with each product. Current use was defined as use of product within the 30 days preceding the survey. Schools from all areas of Mumbai were included in the survey.
The objective of the study along with the study protocol was explained to the school principal. Assent was sought from each student participating in the survey. For the assent process, the survey administrator explained the purpose of the study, the protocol for the study, and confidentiality to the student participants prior to the survey being administrated.
Analysis of data
Data were entered into Microsoft Excel following the survey. Data analysis was conducted using IBM Statistical Package for Social Sciences (Version 22). Logistic regression was used to test difference in tobacco use and awareness levels by gender, age, and the presence of tobacco control program in the selected schools.
| » Results|| |
In total, 1053 students were surveyed from 16 municipal schools in Mumbai. Fifty-seven students (5.4%) declined to participate in the study. Of the surveyed students, 586 (58.8%) students were selected from the 8th grade and 410 (41.2%) students were selected from the 9th grade. Among the study participants, 519 (52.1%) were female and 477 (47.9%) were male. The mean age of participants was 14.2 ± 1.23 years (range 10–17 years).
Differences in tobacco and betel nut product use
Overall, 56 (5.6%) of students reported ever using a tobacco product. Fifty-two (5.2%) students reported currently using any tobacco product. Smokeless tobacco was more commonly reported compared to smoked tobacco. Among study participants, 29 (2.9%) reported ever using smoked tobacco, 47 (4.7%) reported ever using smokeless tobacco, and 20 (2.0%) students reported using both. Similarly, 29 (2.9%) students reported current smoked tobacco use and 45 (4.5%) reported current smokeless tobacco use. The survey found 178 (17.9%) students had reported ever trying betel nut products and 118 (11.8%) students were current users.
Mawa was the most commonly reported form of smokeless tobacco ever used, followed by mishri, gutkha, and khaini. Current use of smokeless tobacco products followed a similar trend. Nearly, one in five students reported ever using betel nut products including supari and pan masala (17.9%, n = 178).
As seen in [Table 1], male students were more likely to report tobacco use compared to their female peers. As shown in [Table 2], male students were significantly more likely to report ever smokeless tobacco use, as well as smoked and smokeless tobacco use within the 30 days preceding the survey.
There were no statistically significant associations found between tobacco use and student grade or age.
Differences in product knowledge
Students were more likely to identify cigarettes and bidis as products containing tobacco compared to smokeless products such as mishri, mawa, gutkha, and khaini. Students were most likely to identify cigarettes as a tobacco product (72.5%, n = 722), followed by bidis (61.2%, n = 610). less than half of the surveyed students were able to correctly identify mishri (42.1%, n =419), mawa (38.8%, n =386), gutkha (36.0%, n =359), and khaini (31.1%, n =310) as products with tobacco as an ingredient. Nearly, half of the students (41.5%, n = 413) surveyed believed that betel nut products such as pan masala and supari contained tobacco.
No statistically significant associations were found between knowledge of tobacco as an ingredient in products and age or gender.
Differences in perceptions of harm
While the majority of students believed that the tobacco products included in the survey were hazardous to health, striking differences were observed in attitudes about smoked and smokeless tobacco. Students were most likely to report a belief that cigarettes (81.2%, n = 803), gutkha (73.0%, n = 722), and bidis (68.8%, n = 680) were harmful to health. Students were far less likely to report believing mishri (58.4%, n = 578), khaini (54.4%, n = 538), and mawa (53.4%, n = 528) were harmful to health. More than half of the surveyed students (58.7%, n = 585) believed that betel nut products were harmful to health.
There were no statistically significant associations between knowledge that a product contained tobacco and belief that such product was hazardous to health for tobacco products. However, an association was found between belief that betel nut products contained tobacco and belief that such products were harmful to health (odds ratio: 0.316, confidence interval: 0.24–0.46, P < 0.001).
| » Discussion|| |
The results of this survey show worrying evidence about child and youth smokeless tobacco use and the use of products very similar in design to smokeless tobacco. This study found that smokeless tobacco is the predominant form of tobacco used by youth in Mumbai's municipal schools. Students were nearly 80% more likely report ever using smokeless tobacco compared to smoked tobacco.
Despite a ban on the sale, manufacture, and distribution of gutkha and scented supari products in Maharashtra, students reported using these products. At the same time, students were more likely to believe that gutkha was a tobacco harmful to health compared to other forms of smokeless tobacco. These results suggest that while students are still able to access and use gutkha in Mumbai, the ban may have promoted a belief that the product was dangerous.
Overall, students surveyed for this paper seemed unclear about the contents of smokeless tobacco and betel nut products and the harms associated with their use. Students were more likely to identify cigarettes and bidis as tobacco products that were harmful to health compared to smokeless tobacco products such as gutkha, khaini, mawa, and mishri.
Nearly, one in five students surveyed had used betel nut products at least once in their life. Betel nut products share many similarities to smokeless tobacco products. They are marketed in nearly identical ways in India, including low price, similar product packaging designs, and positioning at stores and kiosk frequented by children. In addition to being sold on its own as a mouth freshener, scented or flavored betel nut is added to many smokeless tobacco products including gutkha. For these reasons, betel nut products may be the important gateway products for smokeless tobacco use among children and youth. Given the large number of students who reported betel nut use in this survey, further investigation should be carried out to explore the links between these products more thoroughly.
A surprisingly large proportion of students felt betel nut products such as pan masala and supari contained tobacco. Students were more likely to believe betel nut products contained tobacco than they were to believe smokeless tobacco products such as gutkha, khaini, and mawa. Similarly, students were more likely to believe that betel nut products were hazardous to health than they were to report that khaini, mawa, and mishri were hazardous to health. Students who felt betel nut products were hazardous to health were significantly more likely to believe that these products were harmful to health – an association that was not seen between knowledge of product contents and attitudes about harm among tobacco products included in the study.
Given the rate of tobacco use observed in this study, it is important that policy makers should target this age group for tobacco prevention programs. These programs should ensure that children are aware of the wide range of tobacco products, particularly smokeless tobacco products, available in India. Such programs should also explicitly link the consumption of smokeless tobacco products with their health effects, including esophageal cancer and oral submucous fibrosis. Such tobacco control curricula should also devote attention to tobacco-related products, particularly betel nut products such as pan masala and supari.
A few limitations of this study should be acknowledged. First, this study relied on self-reported data collected by students. Social desirability bias may have affected students' willingness to report tobacco use in the survey. Second, since data on the students who declined to participate in the study were not collected, it is not possible to ascertain whether those students' were different in a meaningful way from students who agreed to participate.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Government of India, Ministry of Health and Family Welfare; World Health Organization, Regional Office for South-East Asia; US Department of Health and Human Services, Centers for Disease Control and Prevention. Tobacco Use among Students and Teachers: Findings from the Global Youth Tobacco Survey and Global School Personnel Survey (GSPS). Delhi: Government of India. p. 30.
Narain R, Sardana S, Gupta S, Sehgal A. Age at initiation & prevalence of tobacco use among school children in Noida, India: A cross-sectional questionnaire based survey. Indian J Med Res 2011;133:300-7.
Reddy KS, Perry CL, Stigler MH, Arora M. Differences in tobacco use among young people in urban India by sex, socioeconomic status, age, and school grade: Assessment of baseline survey data. Lancet 2006;367:589-94.
Madan Kumar PD, Poorni S, Ramachandran S. Tobacco use among school children in Chennai city, India. Indian J Cancer 2006;43:127-31.
Pankaj C. Areca nut or betel nut control is mandatory if India wants to reduce the burden of cancer especially cancer of the oral cavity. Int J Head Neck Surg 2010;1:17-20.
Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore 2004;33 4 Suppl: 31-6.
Shah SM, Merchant AT, Luby SP, Chotani RA. Addicted schoolchildren: Prevalence and characteristics of areca nut chewers among primary school children in Karachi, Pakistan. J Paediatr Child Health 2002;38:507-10.
[Table 1], [Table 2]