|Year : 2020 | Volume
| Issue : 3 | Page : 256-265
Pattern and correlates of tobacco use among school personnel from a rural area in Kashmir, India
Romshi Raina, Suhail Majid Jan, Aasim Farooq Shah
Department of Public Health Dentistry, Government Dental College and Hospital, Srinagar, Jammu and Kashmir, India
|Date of Submission||13-Dec-2019|
|Date of Decision||30-Dec-2019|
|Date of Acceptance||10-Oct-2020|
|Date of Web Publication||24-Oct-2020|
149-C, Wazir Bagh, Surya Vihar, Patta Bohri, Tallab Tillo, Jammu - 180 002, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Tobacco -free schools and non smoking school personnel set a positive environment for the younger genration. Aim: The aim of this study was to assess the patterns and correlates of tobacco use among school personnel in a rural area in Kashmir. Methodology: This school-based cross-sectional study was conducted from April 2018 to November 2018 in 50 government high schools. The study population comprised all the school personnel (teaching as well as nonteaching) of the selected schools. An anonymous pretested self-administered questionnaire (Global School Personnel Survey) was used for the collection of data. All data were analyzed using SPSS version 20.0 to demonstrate frequencies, cross-tabulation obtained from Chi-square tests. Multivariate analysis was done to predict factors associated with tobacco control. A significance level of < 0.05 was considered for statistical analysis. Results: Majority of the school personnel (68.3%) were smoking cigarettes on a daily basis (P < 0.001). Current bidi and hookah use was significantly higher among females than males (5.5% vs. 3.9%, P < 0.001). About 93.8% of the school health personnel strongly perceived the need for an anti-tobacco training (P = 0.151). Multivariate regression analysis predicted a positive association between the position in the school, age, and knowledge concerning harmful effects of environmental tobacco smoke (P < 0.001). School personnel with primary responsibility of teaching about health predicted a higher need for specific anti-tobacco training (P < 0.001). The smokers less strongly perceived the need for nonclassroom anti-tobacco activities (P = 0.000). Conclusions: The present study reports a high level of tobacco consumption among the school personnel and paucity of tobacco control school policies. Moreover, smokers felt a lesser need for tobacco control training among school personnel. These findings underscore the importance of support for tobacco control regulations and training in educational units.
Keywords: Adolescents, cross-sectional survey, Kashmir, school personnel, tobacco control training, tobacco use patterns
|How to cite this article:|
Raina R, Jan SM, Shah AF. Pattern and correlates of tobacco use among school personnel from a rural area in Kashmir, India. J Indian Assoc Public Health Dent 2020;18:256-65
|How to cite this URL:|
Raina R, Jan SM, Shah AF. Pattern and correlates of tobacco use among school personnel from a rural area in Kashmir, India. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2020 Nov 25];18:256-65. Available from: https://www.jiaphd.org/text.asp?2020/18/3/256/298996
| Introduction|| |
Tobacco use is the emerging public health epidemic of the 21st century. Around 80% of the world's 1.1 billion smokers live in low- and middle-income countries. Children and young people in middle- and low-income countries take up smoking between 5 and 7 times per day more than high-income countries. Data gathered from GATS 2 India (2016–2017) have indicated that the prevalence of tobacco use among persons aged 15–17 years has increased from 3.0% in GATS 1%–5.3% in GATS 2. The mean age at initiation of tobacco use has increased from 17.2 years in GATS 1 to 18.0 years in GATS 2.
To support the primordial prevention, the WHO Framework Convention on Tobacco Control (FCTC) was developed, which India was one of the foremost countries that signed the treaty in February 2004., Article 20 of the FCTC calls for the consistent monitoring of progress in reducing tobacco consumption and exposure to tobacco smoke through the Global Tobacco Surveillance System (GTSS)., The Global School Personnel Survey (GSPS) is one of the surveys used in GTSS.
School-based strategies are one of the key elements of adolescent tobacco control because school environments are established systems in which adolescent behavior can be targeted and in which social behaviors are reinforced., School personnel's daily interactions and strong influence on students potentially make them an influential group for tobacco control.
Effective school-based interventions essentially need information on the extent and the type of tobacco use among school personnel, their attitudes toward tobacco control, and the existence of school health policies about tobacco.
In India, national tobacco surveillance and training activities dedicated to tobacco control are pretty well elaborated, involving mostly big cities leaving rural population poorly covered by such initiatives. To be able to reduce the burden of tobacco, the inverse relationship between tobacco burden and tobacco control needs to be amended. In Jammu and Kashmir, no such previous research has been conducted to the best of our knowledge, and likewise, no similar studies were available from the literature search wherein the pattern and behavioral attitude toward tobacco use and enforcement of tobacco control laws in school premises were considered.
With this background, the aim of the present research was to assess tobacco use patterns, knowledge and attitudes toward tobacco as well as availability of tobacco control training among school personnel in a rural area in Kashmir.
| Methodology|| |
Study design and population
This school-based cross-sectional study was conducted among all school personnel (teaching as well as nonteaching staff) of schools in the rural area of Kashmir province of Jammu and Kashmir from April 2018 to November 2018. The schools were sampled with probability proportional to the school enrollment size in grades 8–10 (corresponding to ages 13–15 years). Fifty government high schools were selected with a probability proportional to enrollment size with involvement of 406 school personnel. The sample size was calculated using the below formula:
n = Sample size
Zα = Standard deviate at 95% (1.96 for 0.05 α)
e = Desired level of precision
p = Estimated proportion of the attribute (50%, as no previous data were available)
=386 + (5% of 386)
=386 + 19.3 = 405.3 ≈ 406
A 5% margin for nonresponse from the study participants was expected. Thus 5% of 386 were added to the sample size and rounded off making the sample size of the study to 406 school personnel.
All school personnel (including nonteaching staff) present on the day of the survey were eligible to participate. Written informed consent was obtained from all of the study participants. The ethical clearance for the study was obtained from the IRB of the institute (No.: Comm/Dent/GDC: 1589).
An anonymous, self-administered, pretested questionnaire adapted from GSPS consisting of 44 questions about demographics (4 items), tobacco consumption (10 items), knowledge and attitude (15 items), school policies (11 items), and school curriculum (4 items) was used to collect the data., The questionnaire was translated from the original language that is English to the local language that is Urdu for better comprehension among the study participants. The questionnaire was face validated by a committee in the medical education department, the content validity was evaluated using Aiken's V index, and its score for each item ranged between 0.8–1; the reliability was statistically evaluated using Cronbach's alpha coefficient, found to be 0.72 (acceptable internal consistency) following a pilot study conducted among 20 school personnel who were not part of the main study. The questionnaire was designed with no skip patterns to allow all respondents to answer all questions. Trained survey personnel conducted a survey generally at staff meetings or after school.
- Tobacco use prevalence among school personnel
- The existence and implementation of school policies for prohibition of tobacco use (among students and school personnel)
- Tobacco-related curriculum (percentage of school personnel who had taught students how to avoid tobacco use, had access to teaching and learning materials about tobacco, had received training to prevent youth tobacco use, or had nonclassroom programs to teach about tobacco prevention among students)
- Attitudes among school personnel regarding several tobacco issues (concern about youth tobacco use, teacher's tobacco use influences youth tobacco use, tobacco product advertising and sponsorship should be banned, and price of tobacco should be increased).
All data were analyzed using SPSS 20.0 (IBM Corp, Armonk, NY, USA) to demonstrate frequencies, cross-tabulation obtained from Chi-square tests. The association between selected variables (age, gender, position in school, responsibility for teaching about health, and smoking status) and school personnel's knowledge, concern over youth tobacco use, need for anti-tobacco training, and activities performed to educate the youth about tobacco use and its prevention was tested by the linear regression model. A significance level of 0.05 was considered for statistical analysis.
| Results|| |
A total of 406 school personnel (83% teaching staff and 17% nonteaching staff) from 50 schools participated in the survey. Among them, 55.0% were female and 45.0% were male participants. 34.3% were in the age group of 30–39 years and 60.8% were responsible for teaching about health.
Pattern of tobacco use among the study population
Among the participants, 68.3% of the school personnel were currently smoking cigarettes on a daily basis. The proportion of the current smokers was higher among the administrators/headmasters (37.1%) as compared to other school personnel (P < 0.001). Significantly more smokers were observed among males than females (14.4% vs. 7.7%). Smoking status also differed depending on the age of the respondents, with a higher proportion of smokers being observed among the 40–49 year olds (26.5%). Among the school personnel, there were significantly more never smokers among Class IV employees (79.2%).
Bidi and hookah use
Current bidi and hookah use was significantly higher among females than males (5.5% vs. 3.9%). 60–69 year olds consumed a significantly higher proportion of bidi and hookah (50.0%). The percentage of current bidi and hookah users was higher among Class IV employees (20.8%).
Only 1.1% of the study participants had experience of smokeless tobacco [Table 1].
Knowledge attitudes toward tobacco
One hundred percent of the school health service personnel agreed with the statement that second-hand smoke is harmful to health (P < 0.001). Around 82.7% of the school personnel primarily responsible for teaching about health stated that tobacco use is addictive. Similarly, significantly more teachers primarily responsible for teaching about health compared to other school personnel reported that tobacco causes lung cancer (P < 0.001).
More than 90% of the school personnel shared the opinion that smoking should be banned in public places. Sixty-four percent of the teachers reported to be very concerned about youth tobacco use, with significant gender difference (P < 0.001). Around 97.1% of the school personnel primarily responsible for teaching about health believed that tobacco use by teachers influences youth tobacco use. About 93.8% of the school health personnel were of the opinion that they need specific training related to tobacco control. Interestingly, school personnel with primary responsibility for teaching about health more strongly perceived that there is a need for anti-tobacco training (P < 0.001). 76.2% of the teachers had advised a student to quit tobacco [Table 2] and [Table 3].
|Table 2: Knowledge regarding harmful effects of tobacco among school personnel|
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School tobacco control policies
Almost 54.4% of the teachers reported that the schools had a policy prohibiting tobacco use among students (P < 0.001). It is imperative to highlight that the percentage of school personnel who indicated existence of the policy prohibiting smoking by the school staff was lower when compared to that focused on students. More than 30% of the school personnel primarily responsible for teaching about health indicated that their schools had no tobacco control policy for students. Furthermore, about 50% of the school health personnel reported that their schools did not have any tobacco control policy for school personnel. 36.4% reported that their schools enforce tobacco prohibiting policy for visitors [Table 4].
Around 51.9% of the school personnel primarily responsible for teaching about health stated that tobacco prevention is included in the school curriculum (P < 0.001). Only 25% of the school health personnel had access to tobacco control material. Merely 12.5% of the school health personnel had received anti-tobacco training. More than 80% of the school health personnel indicated that tobacco prevention was imparted in nonclassroom programs (P < 0.001) [Table 5].
Multivariate linear regression
In the multivariate linear regression model, a higher position in the school and increasing age predicted higher levels of knowledge concerning harmful effects of environmental tobacco smoke (ETS), furthermore increasing age and school personnel with primary responsibility of teaching about health predicted higher knowledge regarding tobacco use causing lung cancer (P < 0.001). Age, gender, and higher position in the school anticipated that teacher's tobacco use influences youth's tobacco use (P < 0.001). School personnel with primary responsibility of teaching about health predicted a higher need for specific anti-tobacco training, and conversely, gender and higher position in school perceived lesser need for such kind of training (P < 0.001). School personnel with primary responsibility of teaching about health were predicted to advise more students to quit (P < 0.001). The smokers less strongly perceived the need for nonclassroom activities to teach the youth about tobacco use and its prevention (P < 0.001) [Table 6].
|Table 6: Multivariate regression analysis/association between various indicators versus age, gender, position in the school, responsibility for teaching about health, and current smoking status|
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| Discussion|| |
The present study results indicate that > 60% of the school personnel currently smoke cigarettes. This rate is remarkably more than the average rate reported by Sinha and Gupta, 2004 and 2007; Sharma et al., 2004, Kaleta et al., 2017; and Farshad et al., 2012.,,,, Bidi and hookah use was significantly higher among females than males (5.5% vs. 3.9%) and among Class IV employees (20.8%). The results dismiss the myth of tobacco use as taboo among middle-class women in India. This may be attributed to several factors such as social acceptability of hookah in Kashmir and the myth that nicotine is filtered in hookah, so it is less harmful than cigarette smoking. Interestingly, smokeless tobacco use was very less when compared to the findings reported by Sinha and Gupta, 2004 and 2007; Sharma et al., 2004; and Gajalakshmi et al., 2012.,,, School personnel play an imperative role in tobacco control because of their status as role models in their communities and frequent contact with children. This potential can be limited if school personnel use tobacco, especially in the presence of students on school property.,,
Nearly all the school personnel were aware of the harmful effects of tobacco. Similar results were reported from GSPS studies conducted in other parts of India.,,,, However, this knowledge has to be supported with proper training and access to teaching and learning material about tobacco use and how to prevent its use. The experience all over the world is that anti-tobacco education is an effective means of stopping or curtailing tobacco use. The current study reported that only 12.5% of the school personnel had received anti-tobacco training and about 25% had access to the learning material, but over 93% of the school personnel expressed the need for such training. Similar results were reported from other GSPS studies.,,,, More training may enhance their knowledge toward smoking hazards, better estimation of the problem, and planning appropriate interventions to reduce smoking and enforce smoking policies at schools.,
The present-day study indicated that school personnel were highly concerned about the impact of teacher's tobacco use on youth tobacco use. Despite such high concerns about smoking in young people, lack of clear policies to cease smoking in schools was alarming. Similar results were echoed in studies conducted by Sinha et al., 2004 and 2007; Sharma et al., 2004; Kaleta et al., 2017; and Farshad et al., 2012.,,,,
Measures should be taken to implement the “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” in all schools effectively to help reduce the exposure to tobacco and second-hand smoke in school environment. It bans smoking in all public places including health-care facilities and educational facilities, and it was further strengthened in October 2008. It also has a provision for ban on tobacco sale to minors (under the age of 18 years) and within 100 yards of all educational institutions.
As the study results indicate, a higher position in the school and increasing age predicted higher levels of knowledge concerning harmful effects of ETS. School personnel with primary responsibility of teaching about health predicted a higher need for specific anti-tobacco training and advised more students to quit. The smokers less strongly perceived the need for nonclassroom anti-tobacco activities. Similar results were reported by Kaleta et al., 2017.
The present study has certain limitations which may affect the interpretation of results. First, school personnel participation was voluntary; therefore, it may be subject to selection bias. Second, findings are based on self-reports from school personnel who may under- or over-report their behavior and their knowledge of school policies leading to social desirability bias. Third, our research did not assess the compliance of school tobacco control policies.
| Conclusions|| |
Despite minor limitations, the data clearly point out the extent of tobacco problem in Kashmir. The scarcity of tobacco-free schools and the high level of smoking on school grounds by school personnel reported in the research indicate how seriously school practices and staff actions undermine the educational messages and other prevention efforts to reduce the prevalence of smoking among adolescents. A public health effort targeting this influential group and setting up comprehensive smoking cessation programs is crucial for reducing the tobacco burden. It is important to consider the variations in tobacco use practices, social norms, and school personnel knowledge while planning tobacco control activities and continuous monitoring of school personnel behavior and knowledge toward smoking should be taken into account in future studies.
We would like to thank school authorities and study participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gajalakshmi CK, Jha P, Ranson K, Nguyen S. Global patterns of smoking and smoking-attributable mortality. Tobacco Control in Developing Countries. Oxford: Oxford University Press; 2000. p. 11-39.
Tata Institute of Social Sciences. Mumbai and Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey GATS 2 India; 2016-17.
World Health Organization, WHO Framework Convention on Tobacco Control. Geneva, Switzerland: WHO; 2003.
Global Tobacco Surveillance System Collaborating Group. Global tobacco surveillance system (GTSS): Purpose, production, and potential. J Sch Health 2005;75:15-24.
GTSS Collaborative Group. The global school personnel survey: A cross-country overview. Tob Control 2006;15 Suppl 2:ii20-30.
Poulsen LH, Osler M, Roberts C, Due P, Damsgaard MT, Holstein BE. Exposure to teachers smoking and adolescent smoking behaviour: Analysis of cross sectional data from Denmark. Tob Control 2002;11:246-51.
Conrad KM, Flay BR, Hill D. Why children start smoking cigarettes: Predictors of onset. Br J Addict 1992;87:1711-24.
Farshad AA, Vesali S, Azaripour H, Rahimi Z, Akbari F, Asadi-Lari M. School personnel tobacco use in Iran: Results of the global school personnel survey. Prim Health Care 2012;2:1-5.
World Health Organization. WHO Information series on school health; tobacco use prevention: An important entry point for the development of health-promoting schools. WHO: Geneva; 1998. p. 13-4.
Sinha DN, Gupta PC. Tobacco use among school personnel in Orissa. Indian J Public Health 2004;48:123-7.
] [Full text]
Sinha DN, Gupta PC, Gangadharan P. Tobacco use among students and school personnel in India. Asian Pac J Cancer Prev 2007;8:417-21.
Sharma R, Pednekar MS, Rehman AU, Gupta R. Tobacco use among school personnel in Rajasthan, India. Indian J Cancer 2004;41:162-6.
] [Full text]
Kaleta D, Polańska K, Rzeźnicki A, Stelmach W, Wojtysiak P. Tobacco use patterns, knowledge, attitudes towards tobacco and availability of tobacco control training among school personnel from a rural area in Poland. Tob Induc Dis 2017;15:3.
Gajalakshmi V, Kanimozhi CV, Sinha DN, Rahman K, Warren CW, Asma S. Global school personnel survey among 5200 school personnel in India: Comparison of the results for the years 2009 and 2006. Asian Pac J Cancer Prev 2012;13:539-43.
Darling H, Reeder AI, Williams S, McGee R. Is there a relation between school smoking policies and youth cigarette smoking knowledge and behaviors? Health Educ Res 2006;21:108-15.
Sorensen G, Gupta PC, Sinha DN, Shastri S, Kamat M, Pednekar MS, et al
. Teacher tobacco use and tobacco use prevention in two regions in India: Results of the global school personnel survey. Prev Med 2005;41:417-23.
Gupta PC, Mehta FS, Pindborg JJ, Aghi MB, Bhonsle RB, Daftary DK, et al
. Intervention study for primary prevention of oral cancer among 36 000 Indian tobacco users. Lancet 1986;1:1235-9.
Sinha DN, Roychowdhury S. Tobacco control practices in 25 schools of West Bengal. Indian J Public Health 2004;48:128-31.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]