|KIDS AND ADOLESCENTS
|Year : 2010 | Volume
| Issue : 5 | Page : 19-23
Smokeless tobacco consumption among school children
J Muttapppallymyalil1, J Sreedharan1, B Divakaran2
1 Research Division, Gulf Medical University, Ajman-UAE, United Arab Emirates
2 Department of Community Medicine, Academy of Medical Sciences, Pariyaram Medical College, P O Kannur, Kerala, India
|Date of Web Publication||9-Jul-2010|
Research Division, Gulf Medical University, Ajman-UAE
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Background : More than one-third of the tobacco consumed regionally is of smokeless form. Aims : To determine the prevalence and pattern of smokeless tobacco use among school children. Settings and Design : This cross-sectional study was conducted among children in 5 randomly selected high schools in Kannur district, Kerala, India. Materials and Methods : This cross-sectional study was conducted among 1200 children. A self-administered questionnaire was used for data collection. Statistical Analysis : PASW 17 software was used for data analysis. Results : The mean age of the students was 14.4 years with a standard deviation (SD) of 1.2 years, and 8.5% (CI, 7.1-10.2) of the participants were tobacco users. Smokeless tobacco was used by 2% (CI, 1.2-3.4) of the participants. None of the female students used tobacco products. Among the tobacco users, the mean age at the start of any tobacco use was 12.8 years with an SD of 1.1 years. The minimum age was 12 years and the maximum was 14 years. More than 50% smokeless tobacco users started their habit at the age of 12 years; 38.5% of them started at the age of 13 years and remaining at the age of 14 years. The 84.6% smokeless tobacco users were using it 2-3 times a week and 39% of them revealed that the tobacco products were purchased from shops located near the schools. Among the users, one used to keep the quid in the mouth for more than half an hour. Conclusion : The study concludes that there is a need to educate the children regarding the hazards associated with tobacco consumption.
Keywords: Age at initiation, prevalence, school children, smokeless tobacco
|How to cite this article:|
Muttapppallymyalil J, Sreedharan J, Divakaran B. Smokeless tobacco consumption among school children. Indian J Cancer 2010;47, Suppl S1:19-23
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|| |
Estimates show that in India, on existing trends, tobacco will kill 80 million males who are presently aged 0-34 years.  Different ways of tobacco consumptions are found all over the World. In India, smokeless tobacco use also is very common among both males and females. A study conducted in Kolkata, India, showed that about 38.3% of adult males were smokers and 35.7% were tobacco chewers. Among females, smoking habit prevalence was low, that is, 0.5% only. But 18.7% of females were tobacco chewers. The study also revealed that 52% of smokers were using cigarettes and 35% were using beedis for smoking.  A youth tobacco surveillance study reported that 68% of boys and 48% of girls had their first experience of tobacco before the age of 10 years. The current use of tobacco product was 57% among boys and 41% among girls.  A study by Horn et al showed that among youths, 31.8% were current tobacco smokers and 16.1% were current smokeless tobacco users. Among the students who were currently smokeless tobacco users, 63.2% were also current smokers. 
The traditional forms, such as betel quid, tobacco with lime, and tobacco tooth powder are commonly consumed in addition to the other forms of smokeless tobacco, and the use of new products is increasing. Usually men are the consumers but children, teenagers, women of reproductive age, and medical and dental students also consume the smokeless form.  The exact compositions of smokeless forms differ according to regional preferences. Smokeless tobacco forms are applied to the mandibular or labial groove for 10-15 min by most people and then they chew it slowly.  Consumption of processed areca nut products containing tobacco increases the chance of developing oral submucous fibrosis.  About 35-40%  of tobacco consumption in India is in smokeless forms. Moreover, smokeless form of tobacco use among children, adolescents, women, and also immigrants of South Asian descent, wherever they have settled, has increased. , The major factors that persist to encourage people to use smokeless form of tobacco are its low price, ease of purchase or production, and the widely held misconception that it has medicinal value for improvement in tooth ache, headache, and stomach ache.  Furthermore, in contrast to smoking, there is no taboo against using smokeless tobacco  and the government's efforts have also focused more on eliminating cigarette use than tobacco as a whole. [5,7] All these, coupled with peer pressure and belief that using smokeless tobacco is less hazardous than smoking mean that these forms continue to be used by vast numbers of people, especially children.
Presently, tobacco use is the leading preventable cause of death globally,  and it is estimated that by 2030, it would account for over 10 million annual deaths worldwide, , 70% of which will be in the developing world.  All forms of tobacco carry serious health consequences, most importantly oral and pharyngeal cancers ,,,, and other malignancies of the upper aerodigestive tract. ,, Tobacco-related cancers account for about one-third of all cancers in South Asia,  while the emerging "epidemic" of oral submucous fibrosis , has been attributed to chewing of areca nut and its mixtures. There is also evidence that smokeless tobacco is a risk factor for hypertension and dyslipidemias.  This study was conducted to determine the prevalence and pattern of smokeless tobacco use among school children.
| » Materials and Methods|| |
This cross-sectional study was conducted in the northern part of Kerala state in India in the year 2008. The participants were from Kannur district. Kannur district has a population of 24,08,956. Kannur district is one of the 14 districts in the state of Kerala. It is bound by Kasaragod district in the north, Kozhikode in the south, the Western Ghats in the east, and the Arabian Sea lies to the west.
A three-stage sample design was adopted to select the schools. In the first stage of the study, Kannur district was randomly selected among the districts in the northern part of Kerala. Line listing of higher secondary schools in Kannur district was done. Five schools were randomly selected from the list of schools in the second stage. The sampling unit in the study was class/division and total strength of students in each class varying from 30 to 40. In the third stage, classes were randomly selected from the selected schools.
Five high schools were randomly selected from the district. A total of 1200 students participated in the study. The response rate was 100% for schools and 81.4% for the students. Absence from the school on the day of study was the only cause for nonresponse. Students who were absent on the day of the study were excluded. No attempt was made to resurvey.
Informed consent was obtained from the school authorities before distributing the questionnaire. A self-administered, structured, open-ended pilot-tested questionnaire was used for data collection. The research tool included sociodemographic characteristics, type of tobacco habit, age at start, accessibility to tobacco products, reasons for using tobacco products, the use of spit tobacco, and the associated factors. Anonymity was maintained by asking them not to write their names in the questionnaire. The study was conducted over a period of 6 months.
After explaining the purpose of the study, all the students studying in the high schools were given the self-administered questionnaire. On the same day, the tool was collected back from the participants. The data were fed into an excel spread sheet and transformed to PASW 17 for statistical analysis. Descriptive analysis was done. Test of significance was done to find the association between variables, and a P value < 0.05 was considered statistically significant.
| » Results|| |
In [Table 1], the sociodemographic characteristics of the study participants are shown. A total of 1200 students studying in grade 8-12 participated in the study. With regard to the age of the participants, 31.1% were 14 years old, 28.7% have attained 13 years of age, 23.4% of them were 15 years of age, 9.8% were 16 years of age, and the remaining 7.1% were 17 years of age. In the present study, 52.5% were males and the remaining were females. The sex ratio observed was 869 girls for 1000 boys. As far as religion is concerned, 52.8% were Hindu compared with those belonging to the other 2 religions. The mean age of the students was 14.4 years with an SD of 1.2 years. Age ranged from 13 to 17 years.
The prevalence and the type of tobacco products used by the school children are shown in [Table 2]. Among the participants, 91.5% were not tobacco users, whereas 8.5% (CI, 7.1-10.2) of them were tobacco users and were either smoking and/or using smokeless tobacco. As regards gender and tobacco use, 84.1% of male students were not tobacco users, whereas 15.9% (CI, 13.3-18.9) were tobacco users. Among the male students, 1.6% (CI, 0.9-2.8) were smokers. Smokeless tobacco alone was used by 2% (CI, 1.2-3.4) of the male students and 12.3% (CI, 10.0-15.1) of them were smoking as well as using smokeless tobacco. None of the female students were using tobacco products.
Age at start of tobacco use is depicted in [Table 3]. Among the tobacco users, the mean age at the start of any tobacco use was 12.8 years with an SD of 1.1 years. The minimum age of initiation was 11 years and the maximum age was 15 years; 52.0% of the users started tobacco consumption by 12 years. The age at initiation of smokeless tobacco habit is also shown in [Table 3]. The minimum age was 12 years and the maximum was 14 years. More than 50% of the smokeless tobacco users started their habit at the age of 12 years; 38.5% of them started at the age of 13 years and the remaining at the age of 14 years.
Of the total 92 smokeless tobacco users, 84.6% were using it 2-3 times a week. The remaining were using it once in a week. Of them, 39% revealed that the tobacco products were purchased from shops located near the schools. Also, 31% reported that they were getting this from petty shops. Among these users, one used to keep the quid in the mouth for more than half an hour. Most of them were using smokeless tobacco products because of their novelty and the misconception that they are safe form of tobacco and also they could be consumed much less conspicuously than the smoke form of tobacco products at home, in school, and other locations.
| » Discussion|| |
The Global Youth Tobacco Survey reported that among adolescent children, smoking is the predominant form of tobacco use in the developed countries, whereas in the developing countries smokeless tobacco is equally prevalent.  In the current study, 8.5% of the total students were users of some form of tobacco. Among males, the prevalence observed was 15.9% and none of the female students in the study had the habit of tobacco use. As far as tobacco smoking is concerned, the prevalence was 1.6%, smokeless tobacco consumption was 2%, and both smoke and smokeless form was 12.3%. A study by Sinha et al observed that among students in the southern region of India in the age group of 13-5 years, the prevalence of any form of tobacco use was 8.2%. Among the males, the rate was 10.3% and among the females, the rate was 5.7%. With regard to smokeless tobacco use, the prevalence observed was 3.4% (4.5% among males and 2.0% among females).  This study supports the finding of prevalence of tobacco use among males in the present study. But a study among school children in Jaipur observed that any form of tobacco use in males was 2.06% and in females it was 1.7%. With regard to smokeless tobacco use, the same was 0.56% and 0.85%, respectively; this observation was not in accordance with the other studies , and also the present study. A study conducted in Goa reported that tobacco use among boys was 13.5% and among girls was 9.5%.  A study conducted in Mumbai by Jayant et al reported that the prevalence of tobacco use ranged from 6.9% to 22.5%  Another study conducted in Kerala observed that the prevalence of all types of tobacco use was 29% and smoking was 2%.  A study conducted in Gujarat by Makwana et al observed that the prevalence of tobacco chewing increases with age. The prevalence was 28.4% in the age group of 10-13 years, 33.6% in the age group of 14-16 years, and 36.3% in the age group of 17-19 years. The study also observed that among the users, 66.2% had the habit of only tobacco chewing, 14.6% had the habit of only smoking, and 19.2% had the habit of both smoking and tobacco chewing.  Another study conducted in Wardha reported that 68.3% boys and 12.4% girls had consumed some form of tobacco products in the last 30 days, with an overall prevalence of 39%.  A study conducted in Delhi observed that the prevalence of tobacco use was 5.4% (boys: 4.6%, girls: 0.8%).  Most of these studies support the observations made by the present study.
Regarding the age at initiation of tobacco habit, the present study observed that the mean age at start of any form of tobacco use was 12.8 years. The mean age at initiation of smokeless tobacco use also was found to be almost same, that is, 12.5 years. A study conducted in Mizoram observed that the mean age at the start of tobacco chewing and smoking was 17.2 years.  A study from Uttar Pradesh reported that the common age of experimenting with tobacco is 14-15 years.  The present study and other studies also observed that the initiation of tobacco use is usually in the teen period.
| » Conclusion|| |
The present study demonstrated that there is no restriction on the sale of tobacco to school children in the study area. All children had easy access to tobacco products from shops near the schools. More than 90% of the students were nontobacco users. They need to be protected from the users. Based on the study findings, inclusion of tobacco control activities in the school curricula is very important for laying the foundation of healthy lifestyle practices among the school children. The habits injurious to health should be nipped in the bud itself. Also, these children can act as messengers by transmitting the desired message to members of his or her family and community. Children are the readily available and reachable population group in the context of primordial prevention. The study suggests that Students Advising and Guiding Units should be started in schools to offer counseling services to the needy children and those who are addicted to this habit.
| » References|| |
|1.||Katharine ME, Stephen RL. The millennium development goals and tobacco control. Geneva: World Health Organization; 2004. |
|2.||Urmi Sen. A Review of the Tobacco Scenario in Kolkata. Proceeding of Tobacco Research in India: Supporting efforts to reduce harm; 2002. |
|3.||Gupta PC. Youth tobacco Surveillance in Northeastern States of India, 2001. Proceeding of Tobacco Research in India. Supporting efforts to reduce harm; 2002. |
|4.||Horn KA, Gao X, Dino GA, Kamal-Bahl S. Determinants of youth tobacco use in West Virginia: A comparison of smoking and smokeless tobacco use. Am J Drug Alcohol Abuse 2000;26:125-138. [PUBMED] |
|5.||Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003;8:419-31. [PUBMED] |
|6.||Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore. 2004;33:31-6. |
|7.||Nishtar S, Ahmed A, Bhurgri Y, Mohamud KB, Zoka N, Sultan F, et al. Prevention and control of cancers: National action plan for NCD prevention, control and health promotion in Pakistan. J Pak Med Assoc 2004;54:S45-56. [PUBMED] |
|8.||Brundtland GH. Achieving worldwide tobacco control. Jama 2000;284:750-1. [PUBMED] [FULLTEXT] |
|9.||Warnakulasuriya S, Sutherland G, Scully C. Tobacco, oral cancer, and treatment of dependence. Oral Oncol 2005;41:244-60. [PUBMED] [FULLTEXT] |
|10.||John RM. Tobacco consumption patterns and its health implications in India. Health Policy 2005;71:213-22. [PUBMED] [FULLTEXT] |
|11.||World Health Organization. Addressing the Worldwide Tobacco Epidemic through Effective Evidence-Based Treatment. Expert Meeting March 1999, In: Tobacco Free Initiative. Rochester, Minnesota: WHO;2000. |
|12.||Mack TM. The new pan-Asian paan problem. Lancet 2001;357:1638-9. [PUBMED] [FULLTEXT] |
|13.||Avon SL. Oral mucosal lesions associated with use of quid. J Can Dent Assoc 2004;70:244-8. [PUBMED] [FULLTEXT] |
|14.||Merchant A, Husain SS, Hosain M, Fikree FF, Pitiphat W, Siddiqui AR, et al. Paan without tobacco: An independent risk factor for oral cancer. Int J Cancer 2000;86:128-31. [PUBMED] [FULLTEXT] |
|15.||Tobacco habits other than smoking; betel-quid and areca-nut chewing; and some related nitrosamines. IARC Working Group. Lyon, 23-30 October 1984. IARC Monogr Eval Carcinog Risk Chem Hum 1985;37:1-268. [PUBMED] |
|16.||Bhurgri Y, Faridi N, Kazi LA, Ali SK, Bhurgri H, Usman A, et al. Cancer esophagus Karachi 1995-2002: Epidemiology, risk factors and trends. J Pak Med Assoc 2004;54:345-8. [PUBMED] |
|17.||Warren CW, Riley L, Asma S, Eriksen MP, Green L, Blanton C, et al. Tobacco use by youth: A surveillance report from the Global Youth Tobacco Survey project. Bull World Health Organ 2000;78:868-76. [PUBMED] [FULLTEXT] |
|18.||Sinha DN, Gupta PC, P G. Tobacco use among students and school personnel in India. Asian Pac J Cancer Prev 2007;8:417-21. [PUBMED] |
|19.||Singh V, Gupta R. Prevalence of tobacco use and awareness of risks among school children in Jaipur. J Assoc Physicians India 2006;54:609-12. [PUBMED] |
|20.||Sinha DN, Reddy KS, Rahman K, Warren CW, Jones NR, Asma S. Linking global youth tobacco survey (GYTS) data to the WHO framework convention on tobacco control: The case for India. Indian J Public Health 2006;50:76-89. |
|21.||Vaidya SG, Vaidya NS, Naik UD. Epidemiology of tobacco habits in Goa, India. In: Gupta PC, Hamner JE, Murti PR. editors. Control of tobacco-related cancers and other diseases. Bombay: Oxford University Press; 1990. p. 25-46. |
|22.||Jayant K, Notani PN, Gulati SS, Gadre VV. Tobacco usage in school children in Bombay, India. A study of knowledge, attitude and practice. Indian J Cancer 1991;28:139-47. [PUBMED] |
|23.||George A, Varghese C, Sankaranarayanan R, Nair MK. Use of tobacco and alcoholic beverages by children and teenagers in a low-income coastal community in south India. J Cancer Educ 1994;9:111-13. [PUBMED] |
|24.||Makwana NR, Shah VR, Yadav S. A Study on Prevalence of Smoking and Tobacco Chewing among Adolescents in rural areas of Jamnagar District, Gujarat State. J Med Sci Res 2007;1:47-9. |
|25.||Dongre A, Deshmukh P, Murali N, Garg B. Tobacco consumption among adolescents in rural Wardha: Where and how tobacco control should focus its attention? Indian J Cancer 2008;45:100-6. [PUBMED] |
|26.||Singh V, Pal HR, Mehta M, Dwivedi SN, Kapil U. Pattern of tobacco use among school children in National Capital Territory (NCT). Indian J Pediatr 2007;74:1013-20. [PUBMED] |
|27.||Chaturvedi HK, Phukan RK, Zoramtharga K, Hazarika NC, Mahanta J. Tobacco use in Mizoram, India: Sociodemographic differences in pattern. Southeast Asian J Trop Med Public Health. 1998;29:66-70. |
|28.||Ravishankar TL, Nagarajappa R. Factors attributing to initiation of tobacco use in adolescent students of Moradabad, (UP) India. Indian J Dent Res 2009;20:346-9. [PUBMED] |
[Table 1], [Table 2], [Table 3]
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