Abstract
Background
Students aged 13–15 years in Grades 8–10 have been surveyed in the year 2006 and in 2009 to monitor the prevalences of smoking and smokeless tobacco use and to assess their attitudes, knowledge and behaviors towards tobacco use and its health impact.
Methods
The Global Youth Tobacco Survey is a cross sectional survey that uses a two-stage cluster sample design to get a representative sample of schools and students for the study. In India, a total of 12 086 students in the year 2006 and 11 768 in 2009 were surveyed.
Results
About 14% (13.7% in 2006 and 14.6% in 2009) of students use tobacco (smoking/smokeless tobacco). The prevalence of smoking among boys is about three times that of girls in both the surveys. The prevalence of smokeless tobacco among girls is twice that of smoking tobacco in both the surveys. In the 2009 survey comparing with the 2006, the percentage of students who initiated bidi smoking before 10 years of age is significantly higher in boys (2006: 26.0% and 2009:45.4%); the percentage of never smokers likely to initiate smoking in the following year is significantly lower in girls (2006: 16.0% and 2009: 10.8%); the percentage of students exposed to smoke from parents is significantly lower (2006: Boys-38.3%, Girls-30.7% and 2009: Boys-29.3%, Girls-22.4%); the percentage of students who reported that they were taught about the dangers of smoking during the school year is higher; and, ever smokers received help or advice to help stop smoking is significantly higher (2009: 19.5% and 2006: 4.4%). The percentage of students who saw any advertisements for tobacco, the percentage of students offered free cigarettes by a cigarette company representative or their access/availability to smoking tobacco and the changes observed in the prevalences of tobacco use among students in 2009 is not significantly different from 2006.
Conclusions
No significant difference is seen in the prevalence of tobacco use among students between the 2006 and 2009 surveys. The percentage of boys who initiated bidi smoking before age 10 is statistically higher in 2009 compared to 2006. There is a need to strengthen enforcement of policies already in place as well as focus on expansion into additional program efforts.
Introduction
Tobacco is the single largest cause of premature death. Since the first Surgeon General's Report 1 in 1964 on the health risks of tobacco use, overwhelming evidence regarding increased tobacco-attributable morbidity and mortality has been reported.
In the 20th century, tobacco caused an estimated 100 million deaths. With unchanged current tobacco smoking patterns, the number of deaths caused by tobacco use is projected to increase to 10 million per year (ie, 100 million per decade) by around the year 20302–4 with shift of burden of tobacco deaths from developed to developing countries. ie, globally 1 billion tobacco related deaths are expected to occur in the 21st century or ten times as many deaths as in the 20th century. 4 Half (ie, one in two) of those who continue the habit of tobacco smoking, whether in developed or developing countries, will be killed by tobacco; half of these deaths occur in middle age and will lose 20 years of life expectancy.4,5
Globally about 1.25 billion adults aged 15 years or older smoke daily. 6 In 2005 current tobacco smoking prevalence amounted to 26% of all adults population aged 15 years or older, 42.4% of men and 9.6% of women. 7 In high income countries 34.5% of men and 22.1% of women smoke tobacco, while in low income countries 30.7% of men and but only 4.6% of women aged 15 and over smoke tobacco. 7 Globally 10.5% of boys and 6.7% of girls at ages 13–15 years are current cigarette smokers. 8 The prevalence of current tobacco use is an important predictor of future burden of tobacco related diseases.
The Global Youth Tobacco Survey (GYTS) 9
The World Health Organization (WHO), spearheaded by the Tobacco Free Initiative (TFI), the United Nations Children's Fund (UNICEF) and the Office on Smoking and Health in the Centers for Disease Control and Prevention (OSH-CDC), have developed the Global Youth Tobacco Survey (GYTS), a standard instrument to assess smoking and smokeless tobacco prevalence and various other variables related to tobacco use in the youth aged 13–15 years in grades 8–10. GYTS data are useful to assess the tobacco situation among the youth at one point in time but repeat surveys over time (eg, every 3–5 years) will provide useful information for monitoring the tobacco situation and the impact of interventions among youth.
Objectives of the GYTS
To document and monitor the prevalences of smoking and smokeless tobacco use
To understand and assess students' attitudes, knowledge and behavior towards tobacco use and its health impact, including: cessation, second hand smoke, media and advertising, minors' access and school curriculum
The results of the GYTS conducted in India in the year 2009 are compared with the results of the GYTS conducted in the year 2006 and reported here.
Methods
Coverage
The GYTS has been conducted in all 6 administrative regions in India (Fig. 1) twice, in the first half of 2006 and from May to July 2009. The methodology used is the same in both the surveys. However, for administrative reasons, Uttaranchal and Uttar Pradesh were moved from North to Central region in the 2009 survey. All six regional GYTS data have been combined to get national estimates.
India map showing the states and union territories.
Sampling
All schools, both public and private, with Grades 8–10 have been included in the sampling frame of the survey. A two-stage cluster sample design was used to produce a representative sample of students for each region in India. At the first stage, schools were selected with probability proportional to school enrollment size in each region. Thirty schools were selected in each region with a total of 180 schools, for each survey (2006 and 2009) in India. The selected schools are a mixture of schools with girls alone, boys alone and with combination of boys and girls. At the 2nd stage, classes were randomly selected from the selected 180 schools using systematic equal probability sampling. The schools surveyed in 2009 were different from 2006 and there was no overlap of schools. All students in selected classes are eligible to participate in the survey. School and student participation in the survey is voluntary.
Data collection
The Research Coordinator was responsible for the overall management of the project and for the development of the final questionnaire. The survey used self administered questionnaire which was translated from English to various regional languages (Hindi, Oriya, Bangla, Marathi, Gujarathi, Assamese, Tamil, Telugu, Malayalam and Kannadam) and back translated into English to check for accuracy. The questionnaires had been pre-tested in the respective regions before they were administered in the schools to test for the accuracy of translation and understanding of the questions. The questionnaire contained multiple-choice questions with eight responses for each question. There are no open ended questions, no skip pattern and no multiple response questions. Students were not required to write their names on the Answer Sheet, or provide any other kind of identifying information. Students recorded their responses directly on an answer sheet with black lead pencil that could be scanned by a computer.
Training was given to all the Survey Administrators in each region for 2 days to ensure that they would follow the same survey procedures in the assigned schools. The administration of the questionnaire, documentation of the class and school participation, and the security of the Answer Sheets were the assigned responsibility of the Survey Administrators.
Statistical analysis
The school response rate is defined as: Number of participating schools/Number of selected schools and the student response rate is defined as: Number of students who completed the survey/Number of students enrolled in the class. A weighing factor was applied to each student record to adjust for non-response at the school, class and student level. The computer program SUDAAN 10 was used was used to compute weighted prevalence estimates and their standard errors that were used to calculate the 95% Confidence Intervals (CI). The differences in the estimates are considered statistically significant if the t-test P value was <0.05. The following variables were used in all the models to get corrected standard errors: sampling weight, sampling unit and stratum that consisted of schools.
Results
12 086 of the 14 691 students in the 2006 survey and 11 768 of the 14 543 students in the 2009 survey participated from the randomly selected 180 schools for each survey across India. The school response rate was 99.4% and student (in 8–10 grades) response rate was 82.3% in the 2006 survey and the corresponding percentages were 98.3 and 80.9 in the 2009 survey.
Prevalence
Prevalence–-India 2006 and 2009 (13–15 years only).
In the 2009 survey, among boys the percentage who initiated bidi smoking before 10 years of age has almost doubled compared to the 2006 survey (2006: 26.0% and 2009:45.4%) and this is statistically significant; slightly higher percentage initiated cigarette smoking (in 2009) and that is not statistically significant. Although the percentage of girls who initiated bidi smoking before 10 years of age is higher but cigarette smoking is lower in the 2009 survey, the changes are not significant. Compared to 2006, the percentage of never smokers likely to initiate smoking in the following year is lower in both the sexes in 2009 and this is statistically significant in girls but not in boys (Table 1).
The results of the GYTS in 2006 and 2009 on factors influencing tobacco use are compared in Table 2.
Factors influencing tobacco use–-India 2006 and 2009 (13–15 years only).
Protect from second hand smoke
Percentage of students exposed to smoke from one or two parents is significantly lower in both the sexes in the 2009 survey (Boys: 29.3%, Girls: 22.4%) compared to the 2006 survey (Boys: 38.3%, Girls: 30.7%). The percentage of students exposed to all or most best friends smoke is significantly higher in boys in 2009 (B: 12.0%, G: 5.9%) compared to 2006 (B: 7.4%, G: 4.4%) whereas no significant difference in the percentage exposed among girls in both the surveys. The percentage of students exposed to smoke in public places is slightly lower in both the sexes in 2009 compared to 2006 and this decrease is not significant.
School
Students were asked a series of questions about what they had been taught during the past school year concerning the harmful effects of tobacco. In the 2009 survey a significantly higher percentage of students in both the sexes reported that they were taught about the dangers of smoking during the school year (B: 63.6%, G: 63.2%) compared to the 2006 survey (B: 53.6%, G: 55.6%).
Knowledge and attitudes
In the 2009 survey, compared to the 2006 survey the percentage of students (both boys and girls) who reported thinking boys who smoke had more friends is significantly lower; the percentage of students who reported thinking girls who smoke have more friends is lower but not significant; and the percentage of students who reported smoking makes boys/girls look more attractive is significantly lower.
Media and advertising
The percentage of students who saw any anti-smoking media messages, any advertisements for cigarettes or bidis on billboards and any advertisements for chew/apply/snuff tobacco during the past month in the 2009 survey is not significantly different from the 2006 survey.
Cessation
Students were asked if they wanted to stop smoking now. Among current smokers of cigarettes/bidis, both boys and girls put together, seven in ten (in 2006: 74.5% and in 2009: 73.7%) want to stop smoking now and one in twenty to twenty-five (in 2006: 4.1% and in 2009: 4.8%) always feel like having a cigarette/bidi first thing in the morning. The percentage of ever smokers, both boys and girls put together, who received help or advice to help stop smoking from a program or professionals and from family members or friends is significantly higher, in 2009 compared to 2006 (19.5% in 2009 and 4.4% in 2006).
Access
Students were asked questions regarding their access to cigarette/bidi and the availability of cigarette/bidi to them. There is no significant difference between boys and girls regarding access to or availability of cigarette/bidi. The percentage of current cigarette/bidi smokers, both boys and girls put together, who bought their cigarettes/bidis in a store without being refused purchase because of their age is higher, but not significant, in 2009 (70.1%) compared to 2006(61.8%) in both the sexes. The percentage of students, both boys and girls put together, who were offered free cigarettes by a cigarette company representative is significantly lower in 2009 (8.1%) compared to 2006 (11.2%).
Discussion
The GYTS is a school based cross-sectional survey. It was conducted among 12 086 and 11 768 students aged 13–15 years in Grades 8–10 during the survey in 2006 and in 2009, respectively. The results of these surveys are used to assess, among the students aged 13–15 years, the effect of tobacco control measures existing in India in the light of “MPOWER” 11 policies developed by the WHO.
Monitoring tobacco use
The percentage of current smokers of cigarettes or bidis is significantly higher in boys compared to girls in both the 2006 and 2009 surveys. The percentage of current users of smoking tobacco or smokeless tobacco is almost the same in boys whereas the percentage of girls who are current users of smokeless tobacco is almost double the percentage of current users of smoking tobacco.
Overall, about 14% (13.7% in 2006 and 14.6% in 2009) of students currently use tobacco (smoking &/or smokeless tobacco), about 4% currently smoke cigarettes (3.8% in 2006 and 4.4% in 2009), about 5% currently smoke bidis (4.7% in 2006 and 5.3% in 2009) and about 9% currently use smokeless tobacco (9.4% in 2006 and 9.0% in 2009) in India. The GYTS data collected during 2000–2007 from 151 12 sites showed boys had higher rates than girls in 59 sites and girls had higher rates than boys in five sites. Overall, 9.5% of students currently smoked cigarettes. The rate was highest in European region (19.2%) and lowest in Eastern Mediterranean Region (4.9%). About 10% students currently used tobacco products such as pipes, water pipes, smokeless tobacco, and bidis with the rate highest in Eastern Mediterranean Region (12.0%) and lowest in Western Pacific region (6.6%). 12
Of the ever cigarette smokers, significantly higher percentage of girls (one in two) compared to boys (one in three) initiated cigarette smoking before age 10 in 2006, whereas one in three (35%) in both the
There is no significant difference in the prevalences of smoking and smokeless tobacco use among students between 2006 and 2009 surveys. This may be as a result of conducting school awareness programs that has been piloted in 2007 and 2008 in 8 states in India and extended now to 21 states and 42 districts. The Government of India passed a national tobacco control legislation “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003”(COTPA) 13 that was enforced from May 2004. The COTPA bans sale of all tobacco products to persons under the age of 18 years and within 100 yards of all educational institutions.
Protect people from tobacco smoke
The percentage of students exposed to smoke at home from parents during 7 days preceding the survey is significantly lower and the percentage of students exposed to smoke in public places is non-significantly lower in both the sexes in 2009 compared to 2006. Public awareness on the ill effects of Second Hand Smoke (SHS) exposure should be strengthened to decrease further SHS exposure at homes and in public places. India has a law, 13 since 2003, banning smoking in all public places including health care facilities and educational facilities. The law was further strengthened in Oct 2008. The enforcement of the existing law on banning smoking in all public places needs to be strengthened further to reduce the exposure to SHS in public places. In India the “tobacco free schools policy” has been framed in June 2009 and is gradually being adopted in schools. Measures should be taken to implement this policy in all the schools effectively which will help to reduce exposure to smoke in school environment.
Warn about the danger of tobacco
The 2006 and 2009 surveys show about more than 50% of the students reported that they were taught about the dangers of smoking during the school year. This shows the need to further increase the awareness about dangers of tobacco use among students; this may be achieved by strengthening the tobacco control component of the school health programme with a focus on training the teachers about the dangers of tobacco use in order to help the students avoid tobacco use. Necessary actions need be taken so that all the teachers in the school will get access to teaching materials on tobacco use and how to prevent its use among students.
Enforce ban on tobacco advertising and promotion
The percentage of students who saw any anti-smoking media messages, any advertisements for cigarettes or bidis on billboards, or any advertisements for chew/apply/snuff tobacco during the month prior to the 2009 survey is not significantly different from the 2006 survey. About 6 in 10 students in 2006 and 7 in 10 students in 2009, in both the sexes, bought their cigarettes/bidis in a store without being refused purchase because of their age. A total ban on advertisements in national TV and radio, local and international magazines and newspapers, and on billboards and outdoor advertising has been in existence in India. However, point-of-sale advertising is allowed with some restrictions on the size, contents etc; the industry has misused this provision and put up large hoardings at retail outlets. Because of this, students are exposed to advertisements at point of sale; hence strict enforcement at point of sale is required to reduce the exposure to tobacco advertisements and sale of tobacco products to minors. The fact about 1 in 10 students were offered free cigarettes by a cigarette company representative shows laws banning promotion of free distribution of tobacco products needs to be better enforced.
Cessation
The percentage of current smokers of cigarettes/bidis (73.7%) who want to stop smoking now or who always feel like having a cigarette/bidi first thing in the morning in 2009 are not significantly different from 2006. Compared to 2006, a significantly higher percentage of ever smokers received help or advice to help stop smoking from a program or professionals and from family members or friends in 2009. A school-based tobacco cessation program has to be developed help the students to quit the habit of using smoking and/or smokeless tobacco.
Conclusions
There is no significant difference in the prevalences of smoking and smokeless tobacco use among students between the 2006 and 2009 surveys. The percentage of boys who smoke tobacco (cigarettes/bidis) or chew smokeless tobacco are almost same whereas significantly higher percentage of girls chew smokeless tobacco compared to smoking tobacco (cigarettes/bidis). The percentage of boys who initiated bidi smoking before age 10 is statistically higher in 2009 compared to 2006. Three-quarters of the current smokers of cigarette &/or bidi want to stop smoking. More than two-thirds of the students saw anti-smoking media messages and pro-cigarette/bidi ads on billboards and any advertisements for chew/apply/snuff tobacco in the past 30 days from the date of survey.
Recommendations
Increased efforts are needed to raise awareness to reduce tobacco use, especially among young girls, on high priority.
Allocate more resources for public awareness campaign against SHS exposure in homes and public places. More efforts are required to strengthen enforcement of existing laws on banning smoking in public places to protect the youth from SHS.
Implement the “tobacco free schools policy” effectively in all schools.
Strict enforcement at point of sale and display of ‘no sale to minors’ boards are required. More involvement of local NGO's with the state/district authorities.
Law banning promotion of free distribution of tobacco products are in existence; however the law needs to be better enforced.
Tobacco industry tactics to influence and lure the youth need to be monitored closely.
Develop school-based tobacco cessation programs to help students to quit the tobacco habit.
Repeat the GYTS in the future to monitor tobacco use among students and to evaluate the impact and effectiveness of the WHO Framework Convention for Tobacco Control.
Authors' Contribution
VG organized and co-ordinated the survey in 2009; analysed the data and wrote the initial draft. CVK interpreted the results and contributed to the writing. Both authors read and approved the final manuscript.
Footnotes
Acknowledgements
This study was funded by the Tobacco Free Initiative, World Health Organization (WHO), SEARO, New Delhi, India and technical assistance was provided by the Office on Smoking and Health, Centers for Disease Control and Prevention (CDC), Atlanta, USA. The authors acknowledge the help provided by K Rahman and DN Sinha of WHO (SEARO), India and, CW Warren and S Asma of CDC, USA. We wish to thank Directors of schools in India and Headmasters and Headmistresses of the selected schools in the survey for giving permission to do this survey and students and school personnel for their cooperation.
This manuscript has been read and approved by all authors. This paper is unique and is not under consideration by any other publication and has not been published elsewhere. The authors and peer reviewers of this paper report no conflicts of interest. The authors confirm that they have permission to reproduce any copyrighted material.