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Tobacco Use Amongst Children in Karnataka
G. Gururaj and N. Girish
Department of Epidemiology, National Institute of Mental Health and Neurosciences, Bangalore, India
ABSTRACT
Objective. To estimate the prevalence, pattern and correlates of tobacco use amongst the 13-15 year olds in schools of
Karnataka
Methods. A three stage (area, school level and class level) cluster sample design was adopted and 80 schools from 12 districts
of the statewere selected. A total of 4,110 students participated in the study with an overall response rate of 87%.
Results. Point prevalence of tobacco use amongst 13-15 year old was 4.9%. Current tobacco use was predominantly a male
feature and use of smokeless variety predominated (transitional Karnataka (8.2%); metropolis (6.8%); rural (3.4%). One third
of current tobacco users (30.8%) purchased tobacco product in a store and one-fifth used it at home. Nearly half of the never
smokers (43% to 56.7%) were exposed to tobacco smoke outside home and 83% favored a ban on smoking in public places.
A male tobacco user was perceived to have more friends and was repotted to make them look attractive. Print media was a
predominant source of message, more so in the metropolitan region. Only one-third (31.6%) reported that the reasons of tobacco
usage amongst youth was discussed in formal school settings.
Conclusion. GYTS Karnataka has provided reliable estimates and shown the feasibility of implementing a surveillance
programme. Specific challenges for Public health that emerge from the study are increasing number of users in transitional
areas, continued media exposure, tobacco users being perceived to be popular and attractive, easy and relatively unrestricted
access, lack of systematic support within schools and social acceptance of tobacco use at home. The need of the hour is to
target and focus interventions through comprehensive programmes aimed at children, school authorities, parents and policy
makers. [Indian J Pediatr 2007; 74 (12) : 1095-1098] E-mail: guru@nimhans.kar.nic.in
Key words : Tobacco use: Public health challenges; School health education; Behavioural determinants; Transitional area
Tobacco and alcohol use among youth and children are a
part of the spectrum of adverse health behaviours leading
to acute and long term health problems. The diverse
socio-economic, cultural and political milieu
characterizing Indian states presents several challenges in
delivery of health care services and organizing preventive
programmes.12-2 While the traditional models of health
care delivery have been found to be inadequate, there is
a lack of new insight to appropriately manage the
diseases of transition represented by high risk behaviours.
With the central legislation in place for regulating trade
and commerce including advertisement of tobacco
products’, an emerging trend has been the decreasing age
of tobacco use and need to understand its
Correspondence and Reprint requests : Dr. Gururaj G. MD,
Professor and Head. Department of Epidemiology, National Institute
of Mental Health and Neurosclcnces. Bangalore - 560029. Ph: 080■26995245/Fax : 080-26562121 or 26564830
[Received February 20, 2007; Accepted June 5. 2007)
Indian Journal of Pediatrics, Volume 74—December, 2007
determinants.'"77 Overcoming the methodological
limitations of earlier individual studies, Global Youth
Tobacco Survey (GYTS) - India adopted a uniform
methodology to estimate tobacco use amongst 13-15 yr
across the States and Union territories.2 The present
report outlines salient findings from a rapidly progressive
State of India, viz.. Karnataka.
MATERIALS AND METHODS
GYTS - Karnataka (GYTS-K) estimated prevalence of
tobacco use in 13-15 yr age group in Karnataka during
2003-04 adopting a three stage (area, school level and
class level) cluster sample design: Strata 1 included
Bangalore and Mysore as metropolis, other urban
Karnataka as transitional area and Karnataka rural as
remaining areas. Probability proportional to school
enrollment size and lottery method was employed to
select school and sections in classes respectively.
Operational and logistics issues noted during the pilot
study (difficulty in comprehending the use of bubble
1095
42
G Gururaj et al
sheets as response sheets, need for use of a local language
version of the study instrument) were attended to in the
main study.
The survey work was undertaken in the sampled
schools from 12 districts of the State. Twenty schools each
were randomly selected in the metropolis and other
urban area and 40 schools in rural area. A total of 4.110
students participated from amongst 4.708 on roll. The
overall response rate was 87.3% (84% to 91%). Key
reasons for non-participation were absence due to
festivals and fairs, sickness, extra-curricular activities in
schools and monsoon rains. The responses were suitably
weighted to arrive at final estimates.
RESULTS
Overall point prevalence of tobacco use among the 13 to
15 yr old was 4.9% and life-time prevalence was 5.1%.
Current tobacco use was predominantly a male feature
and was nearly four fold greater among males (M: 8% vs
F: 2.1%). Smokeless tobacco (gutkJia or patt-ntasa/a) use
was greater than smoking variety (5.9% and 4.0%.
respectively) amongst males, but similar amongst females
(1.4% and 1.3%, respectively). Proportion currently using
tobacco was greater in transitional Karnataka (10.1%)
than in the metropolis (8.3%) and was twice that of rural
(4.7%) population. Across 3 regions, use of smokeless
variety predominated and proportions were highest in
transitional Karnataka (8.2%) compared to metropolis
(6.8%) or rural (3.4%). One third of current tobacco users
(30.8%) reported that they had purchased the tobacco
product in a store. One-fifth of current users smoked
(17.2%) or chewed / applied (18.6%) tobacco at home.
The proportion of females using smokeless variety at
home was nearly double (28.2% vs 13.1%) than those
smoking at home. In the other urban Karnataka areas
42% reported smoking at home
While 46.9% were exposed to tobacco smoke outside
their home, 29.7% were exposed to tobacco smoke within
their home. Further, between the two genders and across
the three regions, nearly half of the never smokers (43%
to 56.7%) were exposed to tobacco smoke outside their
home. Eighty three percent of the never smokers favored
and recommended for a ban on smoking in public places.
Enquiries regarding perceived image of tobacco user
revealed that nearly one half of respondents (41.8 to
44.0%) reported that a male tobacco user has more friends
and nearly one third (31,0% to 37.4%) opined that tobacco
use makes boys look attractive. Two-thirds of the female
smokeless tobacco user perceived that a male tobacco
user has more friends (72.3%) and reported that tobacco
use makes boys look attractive (69.5%).
Print media was a predominant source of information
for tobacco use and the respondents also reported that
they witnessed large numbers of tobacco advertisements
on either TV or in social gatherings. There was a greater
exposure to media messages on tobacco in the metropolis
region (25.7% to 52.2%) when compared to transitional
Table I. Recollections of Media Messages Regarding Tobacco Usage by Never Users (%)
Category
Total
Bangalore-Mysore
Seen a lot of advertisement and media messages about Cigarette on
TV
36.5
33.5
52.2
Print Media
48.0
Newspapers/Magazines
28.5
31.8
41.2
41.3
Social gatherings
Seen a lot of advertisement and media messages about Bidis on
41.8
42.1
Print Media
Social Events
34.1
36.7
Seen a lot of advertisement and media messages about Gutka/Pan Masala on
TV
38.2
40.0
33.4
Print Media
37.3
25.7
Newspapers/Magazines
29.3
32.6
Social gatherings
36.7
Other Urban Karnataka
Karnataka Rural
29.2
39.4
21.3
34.0
33.3
47.8
28.3
41.3
38.4
33.5
42.2
33.9
26.9
28.5
22.8
26.8
38.2
37.8
29.7
37.1
Table 2. Hann Perception of Tobacco Use and Curricular Discussion Regarding Tobacco Use (%)
Category
Percent who think smoking Is definitely harmful to their health
Percent who think that chewlng/applying is definitely harmful to their health
Never smokers who definitely think smoke from others Is harmful to them (%)
Taught dangers of smoking (%)
Discussed tobacco and health as part of a lesson in class (%)
Taught the effects of tobacco use in class (%)
Discussed reasons why people their age smoke or chew (%)
1096
82.0
80.6
79.8
68.0
50.9
42.7
31.6
78.7
77.9
77.4
65.4
53.9
39.2
33.1
85.3
83.3
82.1
70.7
48.2
46.1
30.5
Indian Journal of Pediatrics, Volume 74—December, 2007
43
Tobacco Use Amongst Children in Karnataka
areas (21.3% to 39.4%) or even rural communities (28.3%
47.8%) (Table 1). Children had not come across many
messages on bidis in the Television, newspapers or
magazines.
An overwhelming proportion felt that tobacco use is
definitely harmful to their health and 80% of never
smokers felt that smoke from others use of tobacco is
harmful to them. Despite being taught about dangers of
smoking (68%). only about one-third (31.6%) reported
that the reasons of tobacco usage amongst youth was
discussed in formal school settings (Table 2).
DISCUSSION
GYTS-Karnataka has provided a valid and representative
benchmark estimate for planning and implementing anti
tobacco policies and programmes. In addition, the study
has shown that it is possible and feasible to implement a
surveillance programme which could also evaluate the
impact of ongoing tobacco control programmes. In the
absence of a surveillance programme for noncommunicable diseases across the State, the framework
that has been developed could very well serve as sentinel
surveillance approach for risk factor surveillance of noncommunicable diseases.8
Against the national average of 17.5% (with variations
across States and regions). *•’ GYTS - Karnataka estimates
of current tobacco users amongst the 13 to 15 yr group
was 4.9% and these constitute 96% of life-time tobacco
users. Undoubtedly, these early experimenters are bound
to develop tobacco-related disorders at an early age;1"
have a greater probability of transforming themselves to
regular and addictive users: a greater likelihood of
acquiring other risk behaviours, chiefly alcohol use" and
thus over-burdening the already fragile health care
delivery system. In this vulnerable group, the
predominant use of smokeless tobacco across the three
areas and between the two sexes would accelerate the
early development of tobacco related health problems.12
14
The present study has brought to the fore specific
challenges for public health. Firstly, the emerging tobacco
use in districts, talukas and rural areas needs serious
attention of policy-makers. In the absence of concerted
efforts in these populations, the numbers are likely to
increase over a period of time. Secondly, the exposure to
media messages regarding tobacco has a significant
influence on initiators, experimenters and users, while
increasing sales and availability. ISI° In addition, those
using tobacco were perceived to be both popular and
attractive. These two complementing issues are indeed a
challenge, especially in the context of industry driven
strategies of promoting “new life styles". Research
conducted has already shown that children are targeted
Indian Journal of Pediatrics, Volume 74—December, 2007
heavily by both direct and indirect methods.'7Thirdly,
purchase of a tobacco product by one third of users points
to the easy and relatively unrestricted access at vending
outlets. The large number of outlets, many of which are
also located in the neighborhood of schools'" and their
regulation for restricting the sales to underage users is
indeed a major public health challenge. The laxity in the
implementation of the legislation (ban of sales to
underage persons and ban on selling outlet within 100
yards of an educational institution) specifically calls for a
multi-sectoral approach to tobacco control initiatives.
Fourthly, despite the greater harm perception, there was
a major lacuna in systematic support within the schools
to prevent tobacco use. “Saying No to Tobacco” requires
acquiring of life skills and changes in attitude; and not
just enhanced cognition or acquiring information.
Information transfer alone without emphasis or focus on
attitudinal changes and environmental modification will
have limited impact and is a major public health
challenge. Finally. Tobacco use at home, especially the
smokeless variety amongst females is indicative of the
prevalent social acceptance of tobacco use and would
very well turn out to be a major threat in creating tobacco
free environs.
CONCLUSIONS
There is need for targeted and focused interventions by
adopting a comprehensive approach. Anti-tobacco
programmes should make inroads into transitional towns
and rural areas. The focus in schools should be to make
them tobacco-free. The school authorities should be
included in stricter implementation and monitoring of the
implementation of legislation. Regular and systematic
education programmes catering to teachers, children and
also their parents should be undertaken. Enabling
teachers to educate the young impressionable minds
regarding life style disorders should be a cornerstone
activity in preventing the establishment of life style
disorders like tobacco and alcohol use within the
community.
REFERENCES
1.
Neufield KJ. Peters DH. Rani M, Bonn S. Brooner RK. Regular
use of alcohol and tobacco in India and its association with
age. gender, and poverty. DrugAkoh Depend 2005; 77:283-291.
2.
Reddy KS. Gupta PC. eds. Report on Tobacco Control 111 India.
Ministry of Health and Family Welfare, New Delhi.
Government of India, 2004.
3.
Anantha N. Nandakumar A, Vishwanath N. Venkatesh T,
Pallad YG, Manjunath P et al. Efficacy of an anti-tobacco
community education program in India. Cancer: Causes and
Control 1995; 6 ■ 119-129
4.
Government of India. Rules nolined under The cigarettes and
other tobacco products (prohibition of advertisement and
1097
44
G Gururaj et al
regulation of trade and commerce, production, supply and
distribution) Act 2003 (The Gazette of India No 37.
May 2003)
titled Prohibition of advertisement on sale of cigarettes and other
tobacco products around educational institutions Rules, 2004,
G S R. 561(E), Department of Health, Ministry of Health and
Family Welfare. New Delhi
5.
Stigler MH, Perry CL, Arora M. Reddy KS. Why are urban
Indian 6th graders using more tobacco than 8th graders?
Findings from Project MYTRI. Tobacco Control 2006;
15(suppl_l): i54 - i60.
6.
Singh G. Sinha DN. Sarnia PS. Thankappan KR. Use among
10-12 year old school students in Patna district, Bihar, India.
Indian Pediatrics 2005: 42: 805-810.
7 Sinha DN. Gupta PC. Pednekar MS: Tobacco use among
Students in the Eight North-Eastern States of India. Indian J
Cancer 2003. 40 : 43-50.
8. 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 Apr-Jun; 50 : 76-89.
9. Reddy KS. Arora M Tobacco use Among Children in India: A
Burgeoning Epidemic Editorial. Indian Pediatrics 2005; 42: 757-461.
10. Bonomo Y. Proimos J. ABC of adolescence: Substance misuse:
alcohol, tobacco, inhalants and other drugs. Br Med Journal
2005; 330 : 777-780 doi:10.1136/bmj.330.7494.777.
11. Gururaj G. Issac M, G Irish N, Subbakrishna DK. Final report
1098
of the study "Health behaviour surveillance with respect of mental
health'' submitted to the Ministry of Health and Family Welfare,
Government of India, New Delhi, 2004.
Gupta PC, Ray CS. Smokeless tobacco and health in India and
South Asia. Respirology 2003; 8: 419-431
13.
Gupta PC. Ray CS. Epidemiology of betel quid usage. Ann
Acad Medicine Singapore 2004; 33 (supl): 31s-36s
14.
Sinha DN. Gulka Advertisement and Smokeless Tobacco Use
by Adolescents in Sikkim, India. Indian J Comm Med 2005; 30:
18-20.
15.
Henriksen L. Ellen C. Feighory RN. Yun Wang, and Fortmann
SP. Association of Retail Tobacco Marketing With Adolescent
Smoking. Amer J Public Health 2004; 94 : 2081-2083.
16.
Sushma C. Sharang C. Pan masala advertisements are
surrogate for tobacco products. Indian J Cancer 2005; 42: 94-98.
17.
Vaidya SG. Vaidya JS, Naik UD. Sports sponsorship by
cigarette companies influences the adolescent children’s mind
and helps Initiate smoking: results of a national study in India.
J Indian Med Assoc 1999: 97 : 354-356. 359 PMID: 10638079.
18.
Bansal R, John S, Ling PM. Cigarette advertising in Mumbai.
India: targeting different socioeconomic groups, women, and
youth. Tobacco Control 2005; 14. 201-206. doi: 10.1136/
tc.2004.010I73.
19.
Gururaj G et al. Final project report of the Global Youth Survey
- Karnataka, accessed at http://www.searo.who.int/EN/
Section 1174/section 1462/pdfs/G YTS_Reports/G YTS_ Kama taka.
pdf. 14th April 2007.
12.
Indian Journal of Pediatrics, Volume 74—December, 2007
pHH 6RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DESSERTATION
1. Name of the candidate and the
address
2. Name of the institution
3. Course of study and subject
4. Date of admission to the course
5. Title of the topic
Dr. ADJTI VERMA
A-197 RAMPRASTHA, GHAZI AB AD,
U.P.-201011.
M. R. Ambedkar Dental College and Hospital
No. 1/36 Cline road, Cooke Town
Bangalore - 560005.
M.D.S (Public health Dentistry)
T^une, 2010
A study to assess the Impact of Health Education
Intervention on existing knowledge, attitude &
practices towards tobacco use among 15-16 years
old school children in North zone of the Bangalore
City.
6. Brief resume of intended work:
6.1. Need for Study
Tobacco use is a major public health issue. It is a major preventable cause of death & disability
worldwide. W.H.O. estimates 4.9 million deaths are annually attributed to tobacco. This figure is
expected to rise to 10 million in 2030, with 7 million of these deaths occurring in developing
countries, mainly India1.
Il is estimated that 5500 adolescents start using tobacco every day in India, joining the 4
million young people under the age of 15 who are already regularly using tobacco1. A study
showed the point prevalence of tobacco use amongst 13-15 years old school children in Karnataka
as 4.9% & life-time prevalence as 5.1% 4. Thus, the prevention of tobacco use in young people
appears as the single greatest opportunity for preventing non-communicable disease in the world
today1.
Health education is one of the primary interventions to bring about the changes in
knowledge, mould favorable attitudes which would translate to healthy practices. To educate the
young impressionable minds should be a cornerstone activity in preventing the establishment of life
style disorders like tobacco use within the community4. Hence, the study attempts to assess the
effectiveness of the health education intervention on knowledge, attitude & practice towards
tobacco use.
6.2.
Review of Literature
Crone et al2 (2003) conducted a group randomized controlled trial in 26 Dutch lower secondary
schools. A sample of 1444 students (average age 13 years) was taken in the intervention-group &
1118 students (average age 13 years) in control group. Intervention was imparted regarding
knowledge, attitude & social influence. Data was analyzed before, immediately after & one year
after the intervention. Results obtained were significant in decreasing the smoking prevalence of
intervention group while it is increased in control group.
Xinguang Chen et al3 (2006) conducted a quasi-experimental pilot trial in Beijing, China among
381 students from Grade 7,8,10 & 11 & assigned to 3 groups (intervention group T with school
p——————
I__
teachers delivering the program, intervention group R with researchers delivering the program &
comparison group C). Intervention programme (SAFT) consists of seven sessions. Data were
collected at baseline then, immediately after the intervention & finally, 6 months after the
intervention. Predicted smoking rate, Odd’s ratio & regression coefficient declined in both group T
& R as compared with group C.
Gururaj G. et al4 (2007) conducted a three stage cluster sample design including 80 schools from
12 districts to estimate the prevalence, pattern & correlates of tobacco use amongst the 13-15 years
A
old schoolchildren in schools of Karnataka. 4,110 students participated in the study with an overall
response rate of 87%. Results showed point-prevalence of tobacco use amongst 13-15 years old as
4.9% & life-time prevalence as 5.1%. Current tobacco use was predominantly a male feature &
was nearly 4-fold greater among males compared to females. Smokeless tobacco use was greater
than smoking variety (5.9% & 4% respectively) amongst males, but similar amongst female (1.4%
& 1.3% respectively).
Guiseppe et al5 (2010) conducted a randomized controlled trial in Italy including 534 children (911 years) & 308 adolescents (14-15 years). Divided the sample into intervention & control group.
The intervention programme included (a).Health facts & the effects of smoking, (b).analysis of the
mechanism underlying initiation of smoking, (c).refusal skills training to deal with the social
pressure to smoke. A questionnaire was administered before intervention & 2 years later. Results
obtained were statistically significant. Smoking prevalence was significantly lower in. children
belonging to the intervention group.
6.3 Objectives of the Study
«
To assess the knowledge, attitude & practices of students towards tobacco use in
government & private school children.
•
To create awareness & assess the impact of short term health education intervention for a
period of 6 months.
7. Methodology
7.1. Source of Data
Among the three zones of Bangalore city (north, south, rural), North zone was selected
randomly for the purpose of the study.
7.2. Methods of Collection of Data
An Interventional Study for six months in 720 students of age 15-16 years who will be selected
by Stratified Random Sampling in the high schools of north zone of Bangalore city.
The above mentioned sample size was estimated as 720 with a-error considered at 5% &
P-error considered at 20% (80% power for a two-sided test).
A self administered questionnaire will be used to collect data regarding knowledge, attitude &
practice towards tobacco usage. A pilot study in a sample of 90 students has already been
conducted to validate the designed questionnaire.
A baseline situation analysis of knowledge, attitude & practice will be obtained using pre-test in all
the schools in a phased manner. Each school will receive two health education interventions within
a period of three months. Following the second health education, a post-evaluation would be
conducted and the results will be analyzed using appropriate statistical analysis (Descriptive and
Inferential statistics).
7.3.
Docs the study require any investigations to be conducted on patients or other
human/animals?
NO.
Has ethical clearance been obtained from your institution in case of 7.3?
7.4.
YES.
8. List of References
1)
Pal R, Tsering D. Tobacco use in Indian high-school students. International J Green
Pharmacy 2009; 3(4):319-323.
2)
Crone MR, Reijneveld SA, Willemesen MC et al. Prevention of smoking in adolescents
with lower education: a school based intervention study. J Epidemiol Community
Health 2003; 57:675-680.
3)
Chen X, Fang X, Li X et al. Stay Away from Tobacco: A pilot trial of a school-based
adolescent smoking prevention program in Beijing, China. Nicotine & .Tobacco
Research 2006; 8(2):227-237.
4)
G. Gururaj, N. Girish. Tobacco Use Amongst Children in Karnataka. Indian J Peadiatr
2007; 74(12): 1095-1098.
5)
La Torre G, Chiaradia G, Lea Monte L et al. A randomised controlled trial of a school
based intervention to prevent tobacco use among children & adolescents in Italy. J
Public Health Published online: 27 March 2010.
https://springerlink3.metapress.com/content/d017q302557xl781/resource-
secured/?target=fulltext.html&sid:=cr4ba3Yidhr3ieagdv3cew55&sh=www.springerlink.com.
6)
Campbell R, Starkey F, Holliday J el al. An informal school-based peer-led intervention
for smoking prevention in adolescent (ASSIT): a cluster randomized trial. Lancet 2008;
371(9624):1595-1602.
7)
Peery CL, Stigler MH, Arora M et al. Preventing Tobacco Use Among Young People in
India: Project MYTRL Am J Public Health 2009; 99(5):899-906.
8)
Johnson CC, Myers L, Webber LS et al. A school-based Environmental Intervention to
Reduce High School Students: The Acadian Coalition of Teens against Tobacco
(ACTT). Int J Environ Res Public Health 2009; 6:1293-1316.
9)
Hanewinkel R, Abhauer M. Fifteen-month follow-up results of a school-based life-skills
approach to smoking prevention. Health Edu Research 2004; 19(2): 125-137.
10)
Horn D, Courts FA, Robert M. Taylor RM et al. Cigarette Smoking Among High
School Students. Am J Public Health 1959; 49(11): 1497-1511.
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