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ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 213-217

Risk factors for tobacco use among adolescents in Mangalore taluk: A cross-sectional urban–rural comparison


1 Department of Public Health Dentistry, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India
2 Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India

Date of Submission24-Jul-2018
Date of Acceptance21-Jul-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Dr. Rekha P Shenoy
102, Mithila Apartments, Karangalpady, Mangalore - 575 003, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_154_18

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  Abstract 


Background: Tobacco consumption is a major contributor to deaths from cancer, cardiovascular diseases, and other chronic diseases. The prevention of tobacco use among adolescents appears to be the single greatest opportunity for preventing noncommunicable diseases. Aim: The study aimed to assess the risk factors for current tobacco use among urban and rural school-going adolescents in Mangalore taluk. Materials and Methods: This cross-sectional study was conducted among 620 adolescents, and an equal number of participants were surveyed from urban and rural areas. After obtaining necessary approvals, schools were selected by stratified cluster sampling. A 10-item structured, self-administered questionnaire was used for data collection. Data were analyzed in the SPSS version 20.0 using the Chi-squared test with a significance level set at P < 0.05. Results: Current tobacco use was 12.7%. It was higher among males ( P < 0.001) and urban adolescents. Smokeless tobacco use was reported by 72.1% of current users; 68.3% of users reported starting habit in the past year. Rural boys formed a statistically significant component of frequent users ( P = 0.0024). Predominant reasons for initiation were used by family and friends/peers. Enhanced self-esteem was reported by 19.0% of users, whereas 39.2% experienced ill-effects. Desire to quit habit was expressed by 31.7% of users; 88.6% of users and 78.9% of nonusers stated that tobacco use was harmful. Conclusions: The prevalence of current tobacco use was 12.7%, and the smokeless form was predominantly used. Major influences on habit initiation were used by family and friends. While one-fifth reported enhanced self-esteem and 31.7% users wanted to quit habit. Enforcement of comprehensive tobacco control legislations is essential to protect this vulnerable population.

Keywords: Adolescents, prevalence, schools, tobacco use


How to cite this article:
Shenoy RP, Sonde L, Shenoy K P. Risk factors for tobacco use among adolescents in Mangalore taluk: A cross-sectional urban–rural comparison. J Indian Assoc Public Health Dent 2019;17:213-7

How to cite this URL:
Shenoy RP, Sonde L, Shenoy K P. Risk factors for tobacco use among adolescents in Mangalore taluk: A cross-sectional urban–rural comparison. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Oct 13];17:213-7. Available from: http://www.jiaphd.org/text.asp?2019/17/3/213/266752




  Introduction Top


Tobacco use is a major public health problem and the single largest cause of premature death, annually killing 5 million people worldwide and 0.8 million people in India.[1],[2],[3] India ranks second in the world in tobacco production and of great import from the public health perspective, ranks third in tobacco consumption.[4]

Tobacco consumption in India is a major contributor to mortality and morbidity and to one of the highest rates of oral cancer in the world. Tobacco use, in addition, is a risk factor for other cancers, cardiovascular diseases, chronic obstructive pulmonary diseases, and other chronic diseases found in humans.[3],[4] Initiation of tobacco use is rooted in adolescence and early adulthood, with a majority of adult smokers starting use before the age of 18.[2],[4],[5],[6] Of the approximately 186 million school-going adolescents worldwide, at least 34.8 million are current users of some form of tobacco.[7] Increased access to money, decreasing parental control, and the growing influence of the media are the often-quoted pro-tobacco influences contributing to increasing use among adolescents. In addition, a misconception exists in rural Indian settings that tobacco is good for oral health, and young children are often sent out to buy tobacco products for family and neighbors.[6] It is estimated that the current global pattern of tobacco use will lead to the premature deaths of 250 million children and adolescents, most of them in developing countries. In India, the World Health Organization has predicted a rise in mortality in excess of 1.5 million annually by the year 2020.[3],[4]

The prevention of tobacco use among the youth appears to be the single greatest opportunity for preventing noncommunicable disease in the world today.[3] While many tobacco control measures have been initiated in India through the Cigarettes and Other Tobacco Products Act, 2003, and multiplicities in the forms of tobacco used in India have handicapped implementation. For effective implementation of preventive strategies, it is necessary to have data on regional variations in tobacco consumption patterns across age groups in the community being targeted.

Various studies have been conducted about tobacco consumption among adolescents. However, scant literature exists on comparison of tobacco use patterns among adolescents in the urban and rural schools in India. Therefore, this study was carried out to assess the prevalence of tobacco use, type of tobacco used, factors influencing use, reasons for continuation of habit, and quitting behavior among school-going adolescents in urban and rural areas of Mangalore taluk.


  Materials and Methods Top


This cross-sectional study was carried out for the duration of 3 months from July to November 2014 to assess the tobacco use behavior among adolescents enrolled in urban and rural schools in Mangalore taluk, India. Mangalore taluk is spread over an area of 834 km2 with a population density of 1048 persons/km2, and 78.9% of the population of approximately 0.9 million is urbanized.[8]

The sample size was determined based on the prevalence of tobacco use as found in an earlier study[9] and determined to be 620 (at a confidence level of 95% and power of the test at 90%). An equal number of participants (n = 310) were to be surveyed from urban and rural areas. Details of the high schools in urban and rural areas of Mangalore taluk were obtained from the office of the Block Educational Officers (BEOs) after explaining the purpose of the study and its public health significance. After obtaining permission from the University Ethics Committee (reference number YUEC/89/11/8/12) and the BEOs, schools in urban and rural areas were selected by stratified cluster sampling, with schools within clusters selected by the lottery method.

In each selected school, after obtaining the consent from school authorities and parents, high school students who fulfilled the following criteria were included in the survey: children studying from the 8th to the 10th standard, present in school on the day of the survey and assenting to participate in the survey.

The study instrument used for data collection was a 10-item structured, self-administered questionnaire with closed-ended, multiple-choice questions. It was used to collect demographic data and information on current tobacco use, form of tobacco used, duration and frequency of use, reason for initiation of the habit, effects of tobacco use on the participant, and quitting behavior (if present). It was translated into the local language (Kannada), pretested on 20 children and suitably modified before field administration. Validity was assessed by two subject experts, and reliability was assessed using the Cronbach's alpha internal consistency coefficient (averaged 0.80). The questionnaire was administered to the participants after explaining the purpose of the study. After data collection, the investigator answered students' queries regarding tobacco use and its ill-effects.

Statistical analysis

Data obtained from the questionnaire administration were analyzed using the Statistical Package for the Social Sciences version 20.0, International Business Machines Corporation (IBM), Armonk, New York, United States of America. The Chi-squared (χ2) test was used to compare the differences in proportions. The statistical significance level was set at P < 0.05. Binomial logistic regression was performed to see the effects of gender, tobacco form, duration, frequency, reason for initiation of the habit, knowledge of harm, and desire to quit on the likelihood of association in participants based on urban and rural areas.


  Results Top


An equal number of urban and rural respondents (n = 310) from three urban and three rural high schools participated in the study. They ranged in age from 13 to 17 years, and a mean age was 13.91 ± 1.17 years. Male participants (n = 357, 57.6%) numbered more than female participants (n = 263, 42.4%). Among the urban participants, there were 172 males (27.7%) and 138 females (22.3%); among the rural participants, there were 185 males (29.8%) and 125 females (20.2%).

Current tobacco use was defined as “use in the past 30 days, either daily/occasionally.” Among the study participants, 79 reported current use – an overall prevalence of 12.7%. The distribution of current users was as follows: urban males – 40.5%, urban females – 11.4%, urban overall – 51.9%, rural males – 38.0%, rural females – 10.1%, and rural overall – 48.1%. The prevalence of current tobacco use was higher among urban adolescents (13.2%) when compared to their rural counterparts (12.3%), and it was significantly higher among males ( P < 0.001).

When current users were assessed based on form of tobacco used, smokeless tobacco use was reported among 72.1% users, smoked tobacco use among 16.5% and dual-use was reported by 11.4% of participants. Dual-use was higher among rural boys. All female users reported the use of smokeless tobacco, and this finding was significantly higher when compared to boys ( P = 0.03) [Table 1].
Table 1: Distribution of study participants based on form of tobacco used

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All female respondents, 46.9% urban boys, and 43.3% rural boys reported starting use in the past 6 months. It was also found that 9.4% urban and 20.0% rural boys reported the use in the past 12 months, whereas 43.7% urban boys and 36.7% rural boys were users of tobacco for more than a year. In all, 31.7% of respondents reported tobacco use for more than a year, whereas 56.9% and 11.4% reported starting use in the past 6 months and 1 year, respectively. A significant number of rural boys started tobacco use in the past 1 year, and all female users started to use in the past 6 months ( P = 0.002).

Reported frequency of tobacco use was as follows: occasional use – by 44.3%, once daily use – by 39.2%, use between two to four times a day – by 11.4%, and use for five or more times – by 5.1% adolescents. All female respondents were once-daily users; among the boys, once daily use was seen among 25.0% urban and 20.0% rural boys, use between two to four times a day among 15.6% urban and 13.3% rural boys, tobacco use for five or more times a day among 3.1% urban and 10.0% rural boys, and occasional use among 56.3% urban and 56.7% rural boys. Rural boys formed a statistically significant component of those who were frequent users ( P = 0.0024).

The predominant reasons stated for initiation of tobacco use were used by family members (36.7%) and friends/peers (46.8%). While 5.1% were influenced by use among their teachers, 14.4% stated that they had no specific reason for starting the habit. The influence of peers was significantly higher among rural boys, while one-third of girls could quote no specific reason for the adoption of the habit ( P = 0.02) [Table 2].
Table 2: Distribution of study participants based on reason for initiation of the habit

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In response to the question on perceived effects of tobacco use, 19.0% of respondents reported enhanced self-esteem, 39.2% reported ill-effects on health, while 41.8% reported no effects. Urban boys reported experiencing more ill-effects; while all girls reported no ill-effects of use, a higher number of rural boys reported the same ( P < 0.001) [Table 3].
Table 3: Distribution of study participants based on self-reported effects of tobacco use

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The question on whether tobacco use is harmful was asked to all respondents in the study, users and nonusers alike, to which 88.6% users and 78.9% nonusers replied in the affirmative. Among users, 90.6% urban boys, 66.7% urban girls, 90.0% rural boys, and 100.0% rural girls reported tobacco use as harmful. Among nonusers, a similar response was given by 80.0% urban boys, 79.8% urban girls, 79.4% rural boys, and 76.1% rural girls. It was found that rural girls had higher knowledge about the ill-effects of tobacco use ( P = 0.016). Results of the binomial regression analysis revealed that urban students were 2.64 times more likely to know about the harm caused by the tobacco use compared to the rural students, but the result was not significant [Table 4].
Table 4: Binomial regression analysis performed with selected study variables in participants based on urban and rural areas

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Desire to quit tobacco use was expressed by 31.7% users (28.1% urban boys, 22.2% urban girls, 36.7% rural boys, and 37.5% rural girls). The desire to quit was significantly higher among rural girls in comparison to their urban counterparts ( P = 0.021). The regression analysis revealed that urban students were 1.92 times more likely to have the desire to quit compared to rural students, but again, the result was not significant [Table 4].


  Discussion Top


This study was carried out to assess the prevalence of tobacco use, type of tobacco used, factors influencing use, reasons for continuation of habit, and quitting behavior among school-going adolescents in urban and rural areas of Mangalore taluk. An equal number of urban and rural respondents from six high schools formed the study sample.

While the prevalence of tobacco use among adolescents in urban and rural areas of Chhattisgarh[4] and West Bengal[10] has been evaluated earlier, and urban-rural differences in tobacco use statistics in other regions of the subcontinent have not been investigated. The strength of this study was the design and rigorous scientific method followed in sampling, which ensured the absence of selection bias.

The prevalence of current tobacco use was 12.7%. This is higher than reported in studies carried out in Tamil Nadu,[1] West Bengal,[10] and Delhi.[11] However, other investigations[3],[4],[12] have reported higher tobacco use statistics than found here. These differences may be attributed to regional variations in use across India, and local cultural factors which may play a role in promoting the habit. An earlier study carried out in this region[9] had found a 13.4% of prevalence of current use. Our findings indicate a decreased tobacco use among school-going adolescents over the past decade, which may be taken as a barometer to the effectiveness of anti-tobacco campaigns carried out in this region by both governmental and nongovernmental organizations.

Higher tobacco use among males has also been reported in studies carried out in Syria[13] and other regions in the Indian subcontinent.[2],[3],[4],[11] As found in this survey, higher use among urban adolescents has also been reported among high school students in West Bengal.[10] The same study in addition found that, in both urban and rural areas, males reported higher use than females,[10] which is also a finding of our study.

The predominant form used was smokeless tobacco, which has also been reported among students from Orissa, West Bengal, and the North-eastern states by various investigators.[12],[14],[15] In this study, smoking was more among urban boys,[4] whereas the dual habit was found more among rural boys. An earlier study conducted in Chhattisgarh found smoking to be higher among urban boys, but smokeless tobacco use was more among rural boys in contrast to this study.[4]

There are no studies in literature for urban-rural comparisons on duration and frequency of tobacco use among urban and rural adolescents. As reported in earlier investigations on adolescents in Syria[13] and in West Bengal[15] and Karnataka states,[16] friends and family were the predominant influence for initiation of the habit. It may be due to a false feeling of social acceptability among one's social circle.[1],[11],[13]

Increased self-esteem among tobacco users has also been reported by adolescents in rural Maharashtra.[6] Adolescents in South India and Delhi have stated that tobacco use increases attractiveness and helps in gaining more friends.[1],[11] While a study conducted in Bangaluru found 39% of respondents stated that smoking does not help in socializing;[17] another study conducted in rural West Bengal[15] reported 26% of adolescents stated that smoking causes no health problems which was lesser than found in this population.

That tobacco use is harmful was stated by 88.6% users and 78.9% nonusers. Similar findings were reported in studies conducted across India.[1],[2],[4],[6],[10],[15],[16],[17] In contrast, a study among Delhi school children has reported low awareness levels.[11]

The desire to quit tobacco use was present among 31.7% current users. These statistics were lesser than reported by other investigators.[1],[3],[12]

This study was limited to school-going adolescents present on the day of survey administration. Data collected were self-reported, with possibility of under- or over-reporting of behavior. Therefore, its findings are not applicable to those without access to the school system. With prior knowledge of this drawback, the authors have made a strong attempt to enhance the validity of the study through the sampling methodology used in school selection.


  Conclusions Top


The prevalence of current tobacco use was 12.7%; it was higher among urban adolescents, and it was significantly higher among males. The predominant form used was smokeless tobacco. A significant number of rural boys initiated the habit in the past 1 year, whereas all female users initiated use in the past 6 months. Rural boys formed a significant component of those who were frequent users. In both urban and rural areas, the predominant reasons for initiation of tobacco use were use by family and friends/peers. A majority of the study participants, both users and nonusers from urban and rural areas, knew that tobacco use was dangerous, but the desire to quit use was higher among the rural users.

The high prevalence of tobacco use among school-going adolescents, in spite of stringent anti-tobacco policies and educational campaigns conducted on a widespread basis, is a cause for concern and necessitates formulation of policies, not only to combat the growing menace but also to bring knowledge into practice. Given the devastating health effects, strict enforcement of tobacco policies and implementation of comprehensive tobacco control legislations are a dire necessity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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



 

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