|Year : 2014 | Volume
| Issue : 3 | Page : 176-179
Tobacco use among teenagers in Ludhiana, Punjab, India: A survey of initiation, prevalence, knowledge, and attitude
Ansu Elizabeth Saji, Ritu Jain, Amandeep Pabla
Department of Public Health Dentistry, Christian Dental College, Ludhiana, Punjab, India
|Date of Web Publication||17-Aug-2014|
Ansu Elizabeth Saji
Department of Public Health Dentistry, Christian Dental College, Ludhiana - 141 001, Punjab
Source of Support: Indian Council of Medical Research (ICMR), Conflict of Interest: None
Introduction: Tobacco use among school going children is becoming a serious public health issue in developing countries like India. According to the study conducted by S.K. Jindal in 2004, in the northern states of India, prevalence of tobacco use was lowest in Punjab because smoking is strongly against the Sikh tenets. However, a recognizable change in trends has been observed recently. Aim: To determine the prevalence of tobacco use, the age of initiation, factors leading to initiation, and the knowledge about the health hazards caused by tobacco use among adolescents in the city of Ludhiana, Punjab. Materials and Methods: A cross sectional study was conducted among 400 adolescents between the ages of 13 to 19 years in Ludhiana using a self-administered questionnaire. Result: In all, 12.75% of the students were found to be tobacco users. The age of initiation was around 15 years. Majority of the students were initiated into this habit by friends or by immediate family members. In total, 78.64% of the students reported to be aware of the harmful effects of tobacco use. Conclusion: This study demonstrated a relatively high prevalence of tobacco use among adolescents in Ludhiana, Punjab. Peer pressure was the main factor in the initiation of this habit. Strict laws need to be passed and interventions designed to reduce the use of tobacco among adolescents.
Keywords: Age of initiation, Ludhiana, prevalence, teenagers, tobacco use
|How to cite this article:|
Saji AE, Jain R, Pabla A. Tobacco use among teenagers in Ludhiana, Punjab, India: A survey of initiation, prevalence, knowledge, and attitude. CHRISMED J Health Res 2014;1:176-9
|How to cite this URL:|
Saji AE, Jain R, Pabla A. Tobacco use among teenagers in Ludhiana, Punjab, India: A survey of initiation, prevalence, knowledge, and attitude. CHRISMED J Health Res [serial online] 2014 [cited 2017 Jul 27];1:176-9. Available from: http://www.cjhr.org/text.asp?2014/1/3/176/138890
| Introduction|| |
Tobacco use is the leading preventable cause of morbidity and mortality globally. The World Health Organization (WHO) estimates 1.1 billion smokers in the world today a figure expected to rise to 1.64 billion by 2025.  India is the third largest producer and consumer of tobacco in the world.  Tobacco-related habits usually begin during adolescence, and majority of the teens who start experimenting with tobacco, continue to use it into adulthood as a result of addiction to the habit. In India alone, nearly 1 in 10 adolescents in the age group of 13-15 years have smoked cigarettes at least once, and almost half of these report initiating tobacco use before 10 years of age.  The increasing tobacco-related disease burden represents an enormous challenge to the country's impoverished public health services, which is already grappling with severe health challenges. Therefore, preventing every adolescent from initiating tobacco use is the best intervention for the promotion of the good health in a developing country like India. According to a study conducted by S.K. Jindal in 2004, in the northern states of India, the prevalence of tobacco use was lowest in Punjab because smoking is strongly against the Sikh tenets.  However a recognizable change in the trends has been observed recently. We have conducted this study to determine the prevalence of tobacco use among adolescents, the age of initiation, factors that lead to initiation, and knowledge about health hazards caused by tobacco use. The information gained from this study will be useful for identifying the most effective interventions to prevent teenagers from taking up the tobacco habit.
| Materials and Methods|| |
A cross-sectional study based on the Global Youth Tobacco Survey (GYTS)  was conducted among 400 adolescents in Ludhiana, Punjab, India. In this study, boys and girls of age group 13 to 19 years were equally included. A school- and community-based survey was carried out. In the community-based survey, 50 adolescents were randomly selected by personal house to house visits and were given a questionnaire to fill out. In the school-based survey, a list of both government and private higher secondary schools in Ludhiana were made. Out of the schools that gave the consent to participate in the study, 15 schools were selected by using a table of random numbers. Students studying in classes 8-12 were included in the study. In case of multiple sections/divisions in a class, the division was selected by using a draw of lots. All the students in the selected division were allowed to participate. A previous study conducted by Singhi et al., found the prevalence of tobacco use to be around 20% among school students.  Sample size was calculated as 400.
Anonymous self-administered questionnaire was given to students of selected classes after giving the instructions to fill in the questionnaire. The students were assured that all information would be kept confidential. This questionnaire was prepared based on the core questionnaire from Global Youth Tobacco Survey (GYTS).  A pilot study was conducted on 10% of the sample size (40 subjects). The questionnaire was checked for validity and reliability, which was found to be 0.8 (good). The questionnaire was provided in English to private school students and was translated in Punjabi for government school students. The translated version was validated before survey. Any student absent on the day of the survey was excluded from the study. Data was entered and analyzed using EPI info version 7.
| Results|| |
Out of the 400 adolescents who participated in the survey, 206 (51.05%) were boys and 194 (48.50%) girls. The prevalence of tobacco use was 12.75% (95% Confidence Interval, CI: 9.72-16.51). Fifty-one students out of 400 surveyed were using tobacco, of which 5 were females (9.8%) and 46 males (90.2%). Most of the male students were occasional users and female students were experimental and occasional users [Figure 1]. Age of initiation was earlier in females (8) as compared to males (15). Two out of 5 females initiated tobacco use at 8 years and 10 out of 46 males initiated the habit at 15 years and 8 males initiated the habit at 18 years. Use of smokeless tobacco was more common among the girls when compared to smoking tobacco use. Thirty-one out of 46 males used cigarettes, and 4 out of 5 females used chewing tobacco [Table 1]. Out of the 400 surveyed adolescents, 349 had never tried using tobacco in any form. Of these, 206 (59.03%) students reported the awareness of negative health effects of tobacco as the reason for not using, whereas 97 (27.79%) reported a dislike for tobacco products. About 45 students (13.04%) believed that there is a negative social implication of tobacco use. Majority of the adolescents (80.39%) were initiated into this habit by friends whereas 9.80% were influenced by advertisements. The reason for starting the use of tobacco given by majority of the students was experimentation (52.94%). Among the factors that influenced tobacco use, acceptance in the peer group and boredom had the highest percentage, 41.18% and 43.14%, respectively. As shown in [Table 2], an equal percentage of students reported use by any other family member and the need to relieve tension as the reasons for tobacco use (7.48% each).
Among the 51 students who used tobacco (smoking or smokeless tobacco), 43 students (84.3%) reported the use of tobacco in immediate family member and 44 students (86.3%) reported its use among friends. Most children bought tobacco products from the stores themselves. Of the 51 students using tobacco, only 7 (13.7%) students reported the shopkeeper refusing to sell tobacco in view of their age and the remaining 44 (86.3%) were not refused and offered tobacco. Of the 400 students, only 22% agreed that adolescents who use tobacco have more friends whereas 78% disagreed; 10.3% children agreed that adolescents who use tobacco are more attractive. Majority of the students (55%) had used tobacco products in public places like parks, shopping centers, street corners, etc., whereas 21% of the students had consumed it at home and 12% at a friend's house. Only 2% children consumed tobacco in school [Figure 2]. Overall, 90.4% students said that the smoke from other people's cigarettes is harmful. The awareness was mainly about cancer (52.5%) and lung disease (22.25%).
| Discussion|| |
The present study was an attempt to identify tobacco related habits among 400 school students in Ludhiana, Punjab.
According to our study, the prevalence of tobacco use (smoking and smokeless) among adolescents was 12.75%, out of which 9.8% were females and 90.2% were males. The prevalence of tobacco users in our study was lower than that in studies conducted in Bangalore,  Gujarat,  and Chennai,  while higher than that in studies conducted in Jaipur,  Noida,  North Indian states (Haryana, Himachal Pradesh, Punjab and Union Territory of Chandigarh),  and GYTS conducted in India in 2003 and 2006.  The reason for higher prevalence in southern states could be because of tradition of using tobacco. In the past, the prevalence of tobacco use in Punjab was low as compared to other states as Punjab is Sikh predominant state and tobacco use is against the Sikh tenets, but the trends are changing now.
Most of the regular tobacco users were school dropouts. Our study found no difference in the frequency of tobacco use between government and private school students which is in contrast to the study conducted by Madan et al.,  in Chennai, where the prevalence of tobacco use was found to be more in corporation schools as compared to private schools.
The age of initiation was found to be earlier in government school students and dropouts when compared to private school students. In the study conducted by Narain et al.,  nearly 70% of boys and 80% of girls initiated the habit of tobacco before the age of 11 years. Bhojani et al.,  in their study found the age of initiation to be 14.7 years. This early initiation of the habit is because the adolescents are more prone to peer pressure and get easily influenced. The age of initiation of tobacco-related habits is important because the earlier the children start using it, the more likely they are to continue the habit and become addicts, which will place a high disease burden on the society. 
In our study, use of smokeless tobacco was common among the girls whereas majority of the males used smoking tobacco. These results are similar to those of Madan et al.,  where tobacco use was more prevalent among boys than girls, but use of smokeless tobacco was more common among girls when compared to use of smoking tobacco. In the study conducted by S.K. Jindal,  use of smokeless tobacco was less compared to smoking, and bidi was more popular than other smoking forms.
More than half of the students evaluated were aware of the negative health effects of tobacco. Our results were similar to those of Bhojani et al.,  where majority reported the awareness about the harmful effects of tobacco use (62.1%) and the rest reported a lack of interest or dislike for tobacco use (23.7%) and social reasons (10.3%).
Jindal et al.,  in their study found that between 16-46% of students were exposed to the habit of tobacco prevalent in either the parents or the friends. In the study by Madan et al.,  tobacco use by parents and friends were reported more often by tobacco users compared to never users. Our study also reported similar findings.
Majority of the tobacco users in our study purchased the products from the store as was also observed in other investigations (Madan et al.,  ).
Our study showed peer pressure to be the main initiating factor for tobacco use. We also noted a strong association between initiating tobacco use and tobacco use among immediate family or friends.
Adolescence is a critical time in one's life, and the habits and behavior formed during these years can have a long-lasting impact on the health of the individual. Due to various adverse health effects, it is very important to develop preventive strategies to reduce tobacco consumption. School-based educational programs focusing on all types of tobacco products (both smoked and smokeless) should be planned and implemented. Parental counseling is necessary to inform them about the influence of their tobacco use on their children. A system should be developed where the high-risk behaviors of adolescents are monitored and thus, initiation of the tobacco use can be prevented. These measures can help in minimizing tobacco use among school going students. Since our study was based on a smaller sample size, we recommend studies to be conducted in larger populations to better understand tobacco use and its associated factors.
| Acknowledgment|| |
We would like to that the Indian Council of Medical Research (ICMR), Government of India, New Delhi for giving us an opportunity to conduct this study under Short term Studentship 2012.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]