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Original Article

Prevalence and Causalities of Tobacco Consumption (TC) among Adolescents: A Cross Sectional Study at Pune
DS Kelkar1, M Patwardhan2, VD Joshi2 Abstract
Background and objectives: Health risks associated with tobacco consumption (TC) are well known. The aim of this study was to assess the prevalence and causality of tobacco consumption among adolescents. Methods: A cross-sectional study was conducted with 6577 participants aged 12 to 20 years from 21 schools and colleges in Pune during year 2005/6. Data on socio demographic profile, family members tobacco habits and respondents tobacco consumption habits were collected by self-administered questionnaire. Convenience sampling method was used for data collection. Results: Complete information on age, gender and participants consumption of tobacco was available for 6119 students. This data was used for analysis. Average age of the students was 16.9 1.79 years. 51% were boys. 9% lived in the hostels. Prevalence of TC was 4.2% (256). Prevalence increased from 2.1% at <14 years to 9.8% at 18 to 20 years of age. Respondents aged <14 years spent about Rs. 110 per month on tobacco while those over 18 years of age spent about Rs.142 per month (P<0.05). Significantly (p< 0.0001) more boys (85.2%) consumed tobacco compared to girls (14.8%). Hostel residents consumed tobacco more than those not living in hostel (13% Vs 8.6%). Significantly more (p<0.0001) number of fathers and brothers of TCs consumed tobacco than non TCs. (Fathers: 53.1% Vs 29.7%), (Brothers: 5.7% Vs 1.1%). Conclusion: Tobacco consumption among adolescents in Pune is low. However to reduce it further, intervention should start prior to teenage before they form their opinion and start consuming tobacco.

obacco consumption is a major public health issue and a social problem worldwide. WHO estimates that annually 4.9 million deaths are due to tobacco (consumption).1 In India, the deaths attributed to tobacco, are expected to rise from 1.4% of all deaths in 1990 to 13.3% by 2020.2 Young populations nave experimentation frequently develops into regular smoking, which typically becomes a routine practice and turns into a strong addiction. The Global Youth Tobacco Study (GYTS) has reported that smoking is the predominant form of tobacco consumption among adolescents in developed countries while both smoking and smokeless tobacco consumption (Smokeless tobacco is unburnt tobacco which is placed into the mouth) are prevalent in developing countries.3 The same study had reported prevalence data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The smoking prevalence among adolescents ranged from 2.4% in Shandong, China to 33.9% in Kiev, Ukraine. In USA, prevalence of current frequent cigarette use among adolescents ranged from 2.1% to 14.5% and lifetime cigarette use varied from 25% to 63.4%.4 In England, for age 11 to 15 years, the percentage of smokers varied from 31% in London to 42% in North East of England.5 In India, wide inter regional variation in prevalence has been reported. Point prevalence among boys 12 to 18 year
1

Introduction

of age was 55% reported by The National Household Survey of Drug and Alcohol Abuse in India [NHSDAA, 2002].6 Point prevalence of tobacco use amongst 13-15 year old was 4.9% among 4110 school children in Karnataka.7 According to Indian Global School Personnel Survey, 2006,8 nearly 1 in 10 school students in the age group of 13 15 years ever smoked cigarette and half of ever smokers reported initiating smoking before the age of ten years. Prevalence of smoking was 2.1% and 1.7% among boys and girls respectively in Jaipur,9 12.2% and 10.2% among boys and girls respectively in Noida,10 17.8% and 7.3% in boys and girls respectively in Deralakatte in Karnataka State.11 These discrete studies point to the growing problem of TC. However age groups and definition of prevalence of tobacco use in these studies differ and hence comparison is difficult. Also, there are no countrywide surveys for adolescents indicating TC rates in India. At state level, prevalence of tobacco consumption has not yet been reported for Maharashtra. Studies indicate that prevalence of tobacco consumption increases with age. Findings of a study carried out amongst school adolescents in Kut city in Iraq showed that the percentage of students who were currently smoking increased with age: 7% in 13 -14 years old, 16% in 15 17 years old to 29% in 18 to 20 years old12. In England, the prevalence of regular smoking increased with age, from less than 0.5% of 11 year olds to 15% of 15 year olds.13 NHSDAA survey has shown that cigarette use is more common in boys than in girls.6 The study Tobacco use in Indian high-school students, has reported male predominance in smoking14 while GYTS (differences in world wide tobacco use
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Department of Oncology, 2Department of Research, Deenanath Mangeshkar Hospital and Research Centre, Erandawane, Pune 411004 Received: 25.11.2011; Revised: 24.01.2012; Re-revised: 15.03.2012; Accepted: 18.03.2012

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Table 1 : Demographic Characteristics of Adolescents

Characteristics Age (years) < 14 14 16 16 18 >18 Gender Male Female Live in hostel Yes No Tobacco consumption Yes No No (%) 768 (12.55) 2482 (40.55) 1926 (31.64) 933 (15.25) 3119 (51) 3000 (49) 937 (8.8) 5567(91.2) 256 (4.2) 5863 (95.8)

Table 2 : Difference between tobacco consumers and tobacco non-consumers

Variable Tobacco Consumers N (%) = 256 (4.2) Tobacco nonconsumers N (%) = 5863 (95.8%) Total N (%) = P value 6119 (100)

by gender) has reported lack of gender difference in the rates of cigarette smoking.15 Children who start smoking at an early age often get influenced by parents, brothers or by friends. Researchers have looked at tobacco use among school children in Jaipur. They have reported significant influence of smoking or tobacco use in family members on its prevalence in children.7 It has been observed that tobacco addiction pattern varies with geography, age, gender, culture, race, religion, socio economic status, family background, etc. It is therefore important to study the tobacco addiction pattern in diverse regions. The aim of this study was to assess the prevalence of tobacco consumption among adolescents and assess causality of the consumption in Pune.

Methods
Principals of all Government aided and Government Board affiliated schools and junior colleges from different parts of the city were contacted. The study was explained to them by senior staff from Deenanath Mangeshkar Hospital and Research Centre (DMHRC). Institutions that agreed to participate in the survey were included. More than 90% of the schools/ colleges participated in the study providing a good representation of citys student population. A cross-sectional study using convenient sampling was conducted on students of 7th grade to 14th grade (age 14 to 20 years) from the 21instituttions: schools and junior colleges in Pune during years 2005 to 2007 after obtaining verbal approval from heads of each education institution and approval from Institutional Ethics Committee at DMHRC. (This was a crosssectional anonymous survey. No clinical parameters or personal identifiers of the participants were collected and there was no risk involved to the participants. Also this was a community survey for the benefit of public where interviews were conducted by a third party. Therefore, waiver of informed consent was obtained. Confidentiality was assured to the participants and heads of the institutions by reassuring that the data will be stored at DMHRC and will be used only for research purpose). Data on socio demographic profile, smoking habits, family members tobacco consumption, respondents tobacco consumption habits, frequency and opinion about tobacco consumption were collected by self-administered questionnaire. Logistics (getting appointments at the institution, explanation of the purpose of the study to the students, explanation of confidentiality, anonymity of the survey, data collection, data coding, and data entry) was

Age (years) Mean std 17.77 1.94 16.54 1.76 16.99 1.78 Gender Male 218 (85.2) 2901 (49.5) 3119 (51) Female 38 (14.8) 2962 (50.5) 3000 (49) Live in hostel [missing-19(0.2%)] Yes 33 (13) 504 (8.6) 937 (8.8) No 221(87) 5346 (91.4) 5567 (91.2) Knowledge about ill effects Yes 179 (70.2) 3746 (64.4) 3929 (64.8) No 21 (8.2) 950 (9.5) 971 (9.4) Not sure 55 (21.5) 1522 (26.2) 1977 (26.0) Family members consumption [missing - 28 (0.4%)] Yes 160 (63.0) 2044 (35.0) 2204 (36.2) No 94 (37.0) 3793 (65.0) 3887 (63.8) Idols consumption [missing - 49 (0.8%)] Yes 106 (42.4) 802 (13.8) 908 (15.0) No 144 (57.6) 5018 (86.2) 5162 (85.0) Your idol [missing - 90 (1.4%)] Father 115 (46.0) 3159 (54.7) 3274 (54.3) Mother 75 (30) 2071 (35.8) 2146 (35.6) Relatives 18 (7.2) 185 (3.2) 203 (3.4) Friends 14 (5.6) 152 (2.6) 166 (2.8) Neighbors 6 (2.4) 21 (0.4) 27 (0.4) Any other 22 (8.8) 191 (3.3) 213 (3.5)

< 0.0001 < 0.0001

0.016

0.162 Ns

<0.0001

<0.000

< 0.000

handled by trained staff from Deenanath Mangeshkar Hospital. A total of 6577/ 6709 students responded (response rate of 98%). We compared the findings between tobacco consumers and tobacco non-consumers (TNC). We also looked at the behaviour changes among younger and older (at every two years of increase in age) adolescents. The data was analyzed using SPSS (17.0). Statistical tests used were chi square and t test. As per Britannica Concise Encyclopedia,16 adolescence is the period of life between puberty to adulthood (roughly ages 12 20) characterized by marked physiological changes, development of sexual feelings, efforts towards the construction of identity, and a progression from concrete to abstract thoughts. For this study, tobacco consumption was defined as smoking cigarette, bidi, use of snuff, mishri and chewing tobacco more than once.

Results
Full information on age, gender and participants consumption of tobacco was available for 6119 students. This data has been analyzed. Table 1 gives the demographic characteristics of the participants. Average age was 16.9 1.79 years and 72% of the participants were between 14 to 18 years of age. There were equal number of boys and girls. Only 9% students were living in hostels. As shown in Table 2, 65% of the respondents had knowledge of the ill effects of smoking. 36% of the respondents family members consumed tobacco. Respondents idols were

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20 18 16 14 12 10 8 6 5 2 0

Table 3 : Characteristics of tobacco consumers

16.6
Variable Age at 1st consumption Reason for 1st time consumption Party Wanted relief from tension Some body compelled Had it in ignorance Other reasons Dont know How much money do you spend? (in Rs/month) Median Reasons behind regular consumption: Inducing factors Status symbol To get relaxation Cant stay without it Any other Dont know Type of tobacco Exposure (missing 90) Chewing tobacco Cigarette Gutkha Bidi Pipe Mishree Frequency of Consumption (missing 66) Chewing tobacco/Cigarette/ Gutkha/ Bidi/ Pipe/ Mishree Daily Chewing tobacco/Cigarette/ Gutkha/ Bidi/ Pipe/ Mishree- Twice a week Chewing tobacco/Cigarette/ Gutkha/ Bidi/ Pipe/ Mishree- Once a week Chewing tobacco/Cigarette/ Gutkha/ Bidi/ Pipe/ Mishree- Once a fortnight Chewing tobacco/Cigarette/ Gutkha/ Bidi/ Pipe/ Mishree- Once a month Chewing tobacco/Cigarette/ Gutkha/ Bidi/ Pipe/ Mishree- Occasional Values 15.86 2.76 N = 230 (%) 86 (37.4) 27 (11.7) 27(11.7) 36(15.7) 37(16.1) 17(7.4) N= 215 150 N= 225 (%) 14 (6.2) 60 (26.7) 32 (14.2) 96 (42.7) 23 (10.2) N = 166 (%) 23 (13.9) 104 (62.7) 17 (10.2) 4 (2.4) 8 (4.8) 10 (6.0) N = 183 (%) 81 (43) 21 (11) 11 (6) 14 (7) 47 (25) 16 (8)

Percentage

8.7 3.5 1.9

14-16 16-18

9.8 5.2

2.1

<14

>18

Age (Year) Boys Girls Age wise increase in tobacco consumption

Fig. 1 : Bars represent age-wise increase in tobacco consumption for boys and girls. Line represents age-wise increase in tobacco consumption for the total sample

mostly their parents (father 54% and mother 36% and 10% other like siblings, neighbours). From the total sample, 15% (908) of respondents idols consumed tobacco. Prevalence of TC Prevalence of tobacco consumption (TC) was (256) 4.2%, boys 7% (218), girls it was 1.3% (38). Prevalence increased with increase in age from 2.1% at <14 years to 9.8% at 18 to 20 years of age (line in Figure 1a). This was observed in both genders (bars in Figure 1). Difference between tobacco consumers (TC) and tobacco non consumers (TNC) (Table 2) The significant differences noted between TC and TNC were older age (p<.0001), boys > girls (p<0.0001), hostel dwellers > non hostel dwellers (p = 0.016), tobacco consumption among family members (p = 0.001) and more TC amongst idols (p = 0.034). No significant difference was noted pertaining to knowledge of ill effects of TC. Characteristics of tobacco consumers (Table 3) Mean age at the first time TC was 16 years. Median [due to very high amount reported by some respondents, we used median instead of mean] expenditure on tobacco consumption per month was higher among boys than girls. Among TCs, a little more than half smoked cigarettes, 22% chewed tobacco and remaining one forth used some other forms of tobacco preparations. 123 tobacco consumers gave reasons for consumption of tobacco for the first time in their life. 37.4% TC youth consumed tobacco for the 1 st time during party/ picnic while 11% consumed because they wanted relief from tension or somebody compelled 14%, 15% due to ignorance, and 16% mentioned due to other reasons such as peer pressure, to imitate family member and/ or favourite hero, thrill to smoke without being caught and to look mature. About 90% (225) respondents gave reasons for consumption of tobacco. One forth of the respondents consumed for relaxation, 14% could not stay without it, TC was a status symbol for a few (6%) while about 43% had other reasons such as pass time while waiting for a friend (11%), weight loss (1%), to have fun (8%), when alone (16%), to solve problems (6%), feel good (9%), personal (11%) and 39% did not mention any specific reason (not shown in the table)

10% of the respondents either just started consuming tobacco without giving a thought or they were shy and did not want to mention the reasons for consumption though they were assured confidentiality and anonymity of this survey. While we measured the frequency of consumption with the type of TC, we found that quarter chewed tobacco/ smoked cigarette/ consumed gutkha / bidi / pipe/ mishiree daily. 7% consumed tobacco twice a week and in the remaining, the frequency of consumption was few times a month. Age-wise change in TC habits of the subjects There was significant (p = 0.002) association between age at first consumption and role model. Up to 16 years of age, for 90% of respondents idols were parents and 10% were relatives, friends, neighbours and others. As they grew older (18 years of age), the percentage of parents as role model dropped to 85%. Significantly more money was spent with increasing age (Figure 2). The consumption pattern for various forms of tobacco did not change amongst different age groups. At all ages, respondents mainly consumed cigarettes. The reasons for the first time TC were significantly (p = 0.023)
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160

Expenditure per month (Rs.)

140 120

139.24

142.24

100 80 60 40 20 0

110.49

117.2

than girls (for 13 to 15 year old boys 14% and girls 6.34%). A GYTS report on a survey conducted in Karnataka showed the tobacco use was higher among boys (8%) as compared to girls (2.1%).7 Our study revealed similar pattern of prevalence (in 16 years age, boys 3.5%; girls 0.6%). Children are influenced by habits of family members. Results of our study were consistent with a similar study conducted from Jaipur9 which reported a significant influence of family members on use of tobacco by children. Similar finding has been reported in the ASH sheet.13 Though the prevalence of tobacco consumption is low in Pune city (4.2%), it is well known that earlier the individuals begin to smoke the higher is the risk of contracting lung cancer or experiencing a range of risk factors and health problems in adulthood;20 hence efforts are needed to discourage the use of tobacco among the young. Framework Convention on Tobacco control (FCTC) led by WHO has provided a framework to protect present and future generations from the devastating health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke.21 FCTC emphasizes prohibition of free tobacco or sale of tobacco products especially to those younger than 18 years. Increasing price of tobacco products could be an alternative since at such young age there may be limited money available to children; however more emphasis should be on prevention. Just as this period (nave age) presents an opportunity for picking up bad habits, it also presents a golden opportunity for behaviour modification. Preventing the initiation and continuation of smoking among adolescents will require interventions that address individual attitudes with respect to tobacco and will also need to present a clear picture of adolescent smoking. Interventions can be arranged in schools and at community gatherings for changing behaviours of those who were indulging in unhealthy behaviours. Limitations This is not an independent sample of schools and colleges but dependent on those who agreed to participate in the study. Thus, by using convenient sampling we may not have recruited a representative sample. The questionnaire did not include questions about their lifestyle such as how much time did they spend at home, their communication with parents, academic grades and extra curricular activities etc.

<14

14-16

16-18

>18

Age (Years)
Fig. 2 : Age-wise increase in per month expenditure on tobacco consumption

different for different age groups. Students < 14 years of age consumed due to ignorance and they were compelled to use while students between 14 to 16 years of age consumed during party time and because of other reasons. More respondents between 16 to 18 years of age consumed during party /picnic time and to get relief as compared to other age groups. Reasons for regular consumption of tobacco were not significantly different amongst different age groups.

Discussion
Within the fairly large sample population, the prevalence of tobacco consumption (in Pune) was 4.25%. Results indicated 18 to 20 years of age is more vulnerable as compared to below 18 years of age. The study has identified significant association between TC and increasing age, male gender, staying in hostel and idol influence. The cause of consumption differed in the different age groups. In the younger adolescents (< 14 year old) it was mainly due to ignorance and compulsion where as later on (by age of 16 onwards) consumption was during party/ picnic time and for relaxation. Adolescence is a period of identity forming and handling great pressures. Exposure, experience and behaviour during these formative years can influence lifelong health. Present study has attempted to identify tobacco consumption amongst school and college going students. FACT SHEET of Global Youth Tobacco Survey conducted in Delhi, India has mentioned current use of any tobacco products to be 4.5% (male 5.5% and female 3.1%).17 The research study on tobacco use among school going children in Chennai city in India found that prevalence of tobacco use was 41.1% among 1225 school children.18 In the present study of adolescents, 4.2% consumed tobacco. This figure is low compared to GYTS prevalence data reported from 21 countries except Shangdong3, NHSDAA figures,6 Karnataka,7 Noida,9 Delhi,15 Chennai18 and Deralakatte in Karnataka State.11 Prevalence of TC in Pune is higher compared to prevalence among boys and girls in Jaipur9 and in Shangdong in China.3 An investigation on tobacco use among adolescents in Gujarat showed that prevalence of tobacco use increased with age.19 The results of our study about rise in prevalence with increasing age were consistent with findings with a study conducted in Jamnagar in Gujarat18 and those from Kut city in Iraq.12 A systematic review on tobacco use among school children in India14 has shown that the prevalence is higher among boys
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Acknowledgement
We would like to thank Principals of the schools and Colleges for their support for the study. This study would not have been possible without their backing. Special thanks to all the students who volunteered their participation in this study. We are grateful to our project Advisor Dr. Usha Khire, for her valuable guidance and Dr. Anil Kharshikar for providing the help on statistical aspects. This study was sponsored by Jnana Prabodhini Samshodhan Sanstha, (JPSS) Pune.

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