|Year : 2019 | Volume
| Issue : 2 | Page : 157-162
Factors influencing the prevalence of tobacco use among high schoolchildren: A pilot study
G Radha1, Bobby Joseph2, HL Jayakumar3, Varadharajula Venkata Ramaiah4
1 Department of Public Health Dentistry, V. S. Dental College and Hospital, Bengaluru, Karnataka, India
2 Department of Community Medicine, St. Johns Medical College and Hospital, Bengaluru, Karnataka, India
3 Department of Public Health Dentistry, Syamala Reddy Dental College Hospital and Research Centre, Bengaluru, Karnataka, India
4 Department of Public Health Dentistry, College of Dentistry and Applied Health Sciences, Riyadh, Saudi Arabia
|Date of Submission||12-Jun-2018|
|Date of Acceptance||09-May-2019|
|Date of Web Publication||20-Jun-2019|
Dr. G Radha
Department of Public Health Dentistry, V. S. Dental College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The health risks of tobacco use are well known, but kids and teens continue to smoke and use tobacco. Many young people pick up tobacco habits every year; in fact, 90% of all adult smokers began smoking started when they were kids. Aims: The aim of this study was to estimate factors influencing the prevalence of tobacco use among 13–15-year-old high schoolchildren and to assess their knowledge, attitude, and behavior regarding tobacco use. Material and Methods: This pilot study was conducted among 210 schoolchildren selected from three schools based on convenient sampling method. The modified version of Global Youth Tobacco Questionnaire (World Health Organization) was used to measure the knowledge, attitude, and tobacco use of children. The analysis was carried out using the Statistical Package for the Social Sciences software version 17. Descriptive statistics were used for the analysis of the study variables. Chi-square and Fisher's exact tests were applied to test the association of knowledge of and attitude toward factors influencing tobacco use. The level of significance was set at 5%. Results: Of the 210 children participated in the study, 54.8% were boys and 45.2% were girls. Ever tobacco use was reported by 31.4% of children, of which, over 10% reported initiation around 8–10 years of age and 21% of them at 12–15 years of age. Among them, 32 (15.2%) children used the smoking form of tobacco (cigarette, beedi, and other unspecified forms), 27 (12.9%) used the chewing form of tobacco, and 7 (3.3%) participants used both forms. The association was found to be statistically significant with regard to the knowledge (P = 0.03) and attitude scores (P < 0.001). Conclusion: It was found that tobacco use by parents, siblings, and teachers influences the children to initiate tobacco. Knowledge about the harmful effects of tobacco use among children was poor.
Keywords: Attitude, knowledge, practice, schoolchildren, tobacco use
|How to cite this article:|
Radha G, Joseph B, Jayakumar H L, Ramaiah VV. Factors influencing the prevalence of tobacco use among high schoolchildren: A pilot study. J Indian Assoc Public Health Dent 2019;17:157-62
| Introduction|| |
The World Health Organization (WHO) estimates that approximately over 1 billion people smoke tobacco currently. Among adolescents, 12% of boys and 7% of girls smoke cigarettes. Deaths attributed to tobacco, in India, are expected to rise from 1.4% of all deaths in 1990 to 13.3% in 2020. The usage of tobacco has increased to such an extent that it has now been referred to as the “tobacco epidemic.” Recent trends indicate an earlier age of initiation among children and adolescents, thus contributing to an increasing smoking prevalence in this vulnerable group. Various studies, including some conducted in India, have revealed that most children start using tobacco as early as 8 years of age, with the median age of smoking being <15 years. The early age of initiation underscores the urgent need to intervene and protect them from falling prey to this addiction. The most common reasons cited for children to start using tobacco are peer pressure, sibling and parental tobacco habits, easy availability, pocket money given by parents, and colorful sachets that attract children.,,
An adolescent once initiated into tobacco use will continue using it lifelong, with very low quit rates. High-risk behaviors are not only more prevalent, but also result in more serious complications to adolescents than adults. Smokeless tobacco is economically priced and is easier to hide and use than the smoke product, especially in the restricted environment of schools. Furthermore, smoking may also be a “gateway” to illegal drug use such as marijuana, abusive drugs, cocaine, and heroin.
Schoolteachers have access to children and the potential to position themselves as a primary instrument for resolving a scarcely recognized public problem. School-based tobacco prevention education is a unique opportunity for tobacco control because it targets or reaches all children.,
To plan effective strategies, it is essential to have information on the profile of schoolchildren and their knowledge, attitude, and behavior toward tobacco use. Thereafter, developing effective strategies to engage in tobacco prevention, cessation, and protection activities at the primary care level is essential. The aim of this study was to estimate factors influencing the prevalence of tobacco use among 13–15-year-old high schoolchildren and to assess their knowledge, attitude, and behavior regarding tobacco use.
| Material and Methods|| |
Study design and setting
Prior to commencing of the study, ethical clearance was obtained from the institutional ethical committee with Ref No. 119/2014. Informed consent and assent forms were obtained from parents and all participants. The heads of the institutions were explained the purpose of the study to obtain the permission. This pilot study was conducted in three schools based on convenient sampling method. The selection of schools assured representation of diverse factors, namely types of schools (government, government aided, and private). The government schools included students representing social groups with low- to middle-socioeconomic status (SES). The private schools represented students from middle- to upper-SES groups. Seventy students who were in the age range of 13–15 years from each selected school and willing to participate in the study were randomly selected and were given detailed information about the study.
The inclusion criteria referred to children of 13–15 years' age group. Students suffering from both physical (any injury, shoulder shrugging/restriction in joint motion) and mental disorders were excluded from the study.
The present pilot study sample constituted of 210 children, which is 10% of the main study sample size.
The self-administered questionnaire was translated into the local language, and language validation was done. The investigator was available next to the participants to clarify any doubts during answering the questionnaire in school. The time duration for each participant in completing the questionnaire was found to, on average, between 20 and 30 min. Face and content validity of the questionnaire was done. The questionnaire was validated by subject expert committees. Aiken's index  for Content validity was undertaken by 11 experts. It was measured and ensured by standard back-translation process, literature review and expert panel opinion on a 5-point Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = neither, 4 = relevant, and 5 = very relevant). The internal consistency of the questionnaire was measured with Cronbach's alpha for the internal consistency of the questionnaire was found to be good (0.85).
Data collection and study instrument
Data were collected using the modified version of Global Youth Tobacco Questionnaire (GYTS) (WHO) which is a school-based survey of students aged 13–15 years used to gather data on the knowledge and attitude of adolescents toward tobacco use and its prevalence, role of media in tobacco advertising, access to various forms of tobacco, environmental tobacco smoke, and cessation of tobacco habits. The study questionnaire had the following four sections: (1) demographic factors; (2) knowledge about tobacco use and its prevention, cessation, and treatment. This domain consisted of 16 questions with each having three possible responses, namely “yes,” “no,” and “doesn't know;” (3) attitude toward tobacco use – it is defined as respondents' opinions about tobacco use, prevention of tobacco, favor of banning tobacco use, and sociocultural perspective toward tobacco use. This domain consisted of nine items with possible responses of “definitely yes,” “definitely no,” “probably yes,” and “probably no” for each question. The acceptable positive attitude responses by respondents were awarded by score 1 or else score 0; (4) behavior toward tobacco use – it is defined as respondents' practice of tobacco use and action taken to prevent the same. This domain consisted of 15 items assessed by “yes,” “no,” and “never” categories. Assured of confidentiality, the students participated in the survey voluntarily, and the data were collected anonymously using the self-administered questionnaire.
The analysis was carried out using the SPSS Statistics for Windows, v 17.0. (Chicago: SPSS Inc., USA) Descriptive statistics were used for the analysis of study variables. Chi-square and Fisher's exact tests were used for testing the association between knowledge, attitude, and practice regarding tobacco use. Test–retest reliability of the questionnaire was done using correlation coefficient, and the internal consistency of the questionnaires by Cronbach's alpha was good for all domains (knowledge, attitude, and practice) (r > 0.75, P < 0.001). The level of significance was fixed at 5%.
| Results|| |
A total of 210 schoolchildren in the age range of 13–15 years participated in the study, of which the study sample comprised 54.8% of boys and 45.2% of girls.
With response to the smoking habits among the family members, 24.3% of the participants' fathers and 15.7% of the participants' siblings smoked every day. With reference to chewing tobacco, 12.4% of participants' fathers and 0.5% of participants' mothers chewed tobacco every day [Table 1].
|Table 1: Distribution of the study participants according to general characteristics|
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The association between the knowledge and attitude of tobacco use was found to be statistically significant with regard to the general characteristics of the study participants (P < 0.05) [Table 2] and [Table 3].
|Table 2: Association of general characteristics with students' knowledge|
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Knowledge about the harmful effects of tobacco use was poor among the study population. Very few participants, i.e. 42.4%, believed that tobacco in any form is harmful to health. In response to attitude regarding tobacco usage among students, 35.7% of the study participants had a positive attitude toward tobacco use [Table 4].
|Table 4: Distribution of the study participants according to knowledge and attitude of tobacco usage|
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Out of the total study population, 10% of the students tried using tobacco around 8–10 years of age and 21% of them at 12–15 years of age. Among them, 32 (15.2%) used the smoking form of tobacco (cigarette, beedi, and other unspecified forms), 27 (12.9%) reported the use of chewing form of tobacco, and only 7 (3.3%) participants used both forms. Majority of the participants (95.2%) responded that they inculcated the practice of tobacco use by observing actors smoking when they were watching television, videos, or movies. Among tobacco chewers, 10% of participants swallow the juice and only 6.2% of the participants spit it after use. Among the smokers, 16.2% of the participants shared cigarette. Thirty-nine students (18.6%) had the practice of tobacco use at friends' places and public places, and none of the participants (66%, 31.4%) received help to quit tobacco [Table 5].
|Table 5: Distribution of the study participants' according to tobacco practices|
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| Discussion|| |
This study demonstrates that, among the 13 to 15-year-old school-going children, 66 (31.4%) had used tobacco. Varying reports have been presented on the prevalence of tobacco use among school-going students in various parts of India. In addition to this, there were seven (3.3%) students who had a habit of both smoking and chewing tobacco, which corroborates with the report of Narain et al. and Tiwari et al. This is of concern because the younger the child starts using tobacco, it is more likely that they become addict and die from tobacco-related diseases. Consequently, strategies to reduce the initiation of tobacco use need to be targeted toward younger age groups. The proportion of students aged <10 years of age initiating tobacco was lower in this study (10.0%) compared to the findings of Narain et al. and Ahmed et al.
Most schoolchildren who smoke (39%, 18.6%) reported that they smoked cigarettes outside of the school campus, i.e., at their friends' places and public places. This may influence their peers and close contacts to taking up the habit. Similar results were reported by Soni and Kumar. A substantial proportion (37.1%) of the students reported that at least one of their family members uses some tobacco products. This result was similar to the GYTS where 37.8% lived in homes where other family members smoke. In contrast, Gupta  reported that 71% of the students reported that one of their family members uses some tobacco products.
Majority of the schoolchildren did not find any difficulty in buying tobacco from shop nor none of the shopkeepers ever refused to sell tobacco in view of their age. Soni and Kumar also found similar results in their study, indicating that laws restricting access to minors were not implemented adequately. None of the schoolchildren had ever received any help neither from their schoolteachers nor from their family members to quit tobacco. The reason could be that parents and teachers may not be aware that their children are using tobacco. Therefore, close contacts, parents, teachers, and media should be primarily involved in imparting knowledge about substance use.
Similar to the study conducted by Vuolo and Staff, a strong association between the children's tobacco use and use of tobacco products by their friends was observed in this study, where 32 (15.2%) schoolchildren shared tobacco with their friends. These associations were also seen worldwide. Moreover, as adolescents are in a transitional phase, confusion can sometimes make them susceptible to taking up unfavorable habits. Majority of the tobacco users (31.4%) expressed a desire to quit the habit as it is a health issue. These views were also expressed in other studies, which revealed that all users did not want to continue the habit and they held a positive attitude toward quitting; therefore, motivation on the part of family, friends, and close ones could help the user to come out of this habit. Hence, it is important to have an effective school-based program including teachers to bring about a substantial and sustained decline in youth smoking.
Results of this study indicated that knowledge about tobacco as a risk factor for the development of oral cancer was adequate only among 42.2% of school-going children, among which only 43.3% of males and 40% of girls had adequate knowledge about tobacco as a risk factor for the development of cancer. These findings were similar to those of Mukherjee et al. and Tiwari et al. Tobacco use among children and youth can be prevented by additional activities in the classroom until school-leaving age by teachers who were trained in tobacco cessation program.
| Conclusion|| |
The results conclude that this questionnaire can be successfully adapted and validated for use in school students. Using this questionnaire, we found that knowledge regarding the hazards of tobacco usage among students was not adequate, and majority of them had negative attitude toward tobacco use. The practice of tobacco use among students was alarming. It was found from the study that tobacco use by parents, siblings, and teachers is an influencing factor among the study population.
The study would not have been possible without the cooperation of the children who volunteered to participate. The authors are also thankful to the school authorities for their permission to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]