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Indian Journal of Cancer, Vol. 40, No. 1, (January - March 2003) , pp. 3-14 Special Report Tobacco use among School Personnel in Eight North-Eastern States of India Sinha DN, Gupta PC,* Pednekar MS** School of Preventive Oncology, Patna, India; *Tata Institute of Fundamental Research,
Mumbai,
India; and **Tata Memorial Centre, Mumbai, India.
Code Number: cn03001 ABSTRACT AIMS: To obtain baseline information about tobacco use prevalence, knowledge and attitude among school personnel in Eight North-eastern states of India (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura). MATERIAL AND METHODS: A sample of schools with probability proportional to the enrolment in grades 8-10. Anonymous self-administered questionnaire was used for all personnel working in the selected schools. RESULTS: The school response rate was 100% in all states except Meghalaya (96%) and Tripura (92%). Over 70% of school personals participated in the survey, the proportion of men being 56% (Meghalaya) to 83% (Assam). The prevalence of daily smoking ranged from 25.9% (Mizoram) to 12.8% (Arunachal Pradesh) and of smokeless tobacco use from 57.8% (Mizoram) to 10.7% (Assam). Daily smoking among men and women was similar in five states but not in Arunachal Pradesh (men 15.0%, women 4.0%), Nagaland (men 18.7%, 5.0%), and Tripura (men 18.6%, women 0.4%). In four states cigarette was the most prevalent form of smoking (range 41% to 55%) whereas in other four states it was bidi (range 34% to 53%). Although the number of women was small, cigarettes smoking was reported more among women than men in four states: Assam, Arunachal Pradesh, Manipur, and Nagaland. Over 50% of current smokeless tobacco users reported using betel quid in six states, except Mizoram (20%) and Sikkim (16%). CONCLUSION: Tobacco use among school personnel was high. High smoking rates reported by women were unexpected. Key Words: Personnel, Grade, Adolescents, Policy, Daily. Introduction For adolescent, school personnel form important role models. Tobacco use often starts during adolescence and school personnel can potentially influence students' tobacco use. To plan effective interventions, it is essential to have information on the extent and the type of tobacco use among school personnel, their attitudes towards tobacco control, and the existence of school health polices about tobacco.1 Tobacco use among 13-15 year old students is being studied worldwide through the Global Youth Tobacco Survey (GYTS).2 The Global School Personnel Survey (GSPS) is carried out in the same schools at the same time as GYTS. The objectives of GSPS are: (1) to obtain baseline information on tobacco use; (2) to evaluate the existence, implementation, and enforcement of tobacco control policies in schools; (3) to understand the knowledge and attitudes towards tobacco control policies; (4) to assess training and material requirements for implementing tobacco prevention and control interventions; and (5) to verify some information obtained from the GYTS. One GSPS report showed high prevalence of tobacco use in school personnel from Bihar.3 This document is the report of the GSPS from India and includes data from eight North-eastern states - Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura. A regional unified development council links the North-eastern states. This region is set apart from the rest of India by geographically difficult terrain, socio-cultural pattern, population density, high proportion of tribal population, high prevalence of tobacco use, alcohol and drug abuse. In the National Family Health Survey (NFHS-2), the prevalence of tobacco use was reported to be much higher in the North-eastern states compared to other parts of India.4 Material and Methods The study was carried out during January-March 2001. The schools were sampled with probability of selection proportional to the school enrolment size in grades 8-10 (corresponding to ages 13-15 years). At the first stage, a fixed number of schools (50 in Assam, 24 in Manipur, and 25 each in all other states) were selected with a probability proportional to enrollment size. All school personnel (including non-teaching staff) in the selected schools were eligible to participate. In India, education is a state responsibility and almost all schools were part of state educational system. GSPS was conducted using the same survey personnel who had conducted the GYTS. The questionnaire was self-administered with no identification information collected (name, school or village/ town), maintaining complete anonymity. School personnel completed the self-administered questionnaire during the break hours, recording their responses directly on a sheet, which could subsequently be optically read by machine. All questions required answering (i.e. there was no skipping or branching pattern). The tobacco use was mainly classified in two categories: smoking and smokeless. Tobacco and tobacco products used in all Northeastern states were similar with few exceptions. Tobacco was mainly smoked in the form of cigarette and bidi (tobacco rolled in tendu leaf). Several new ways of tobacco smoking not reported from elsewhere in India were also identified. The most important among them was the hand-rolled cigarettes (rolled tobacco in special white and a thin paper manufactured in Norway), which could either be rolled by the user or even purchased from the market. Another way of smoking tobacco was through kamchung, a small curved, retort shaped pipe with a cup like end, which contains burning tobacco and a very small container of water in the middle of the pipe. Smoking of ganja (a kind of Hashish) was also common and as it was always smoked with tobacco, it has been included among tobacco smoking habits. In addition to smokeless tobacco products such as betel quid, gutka (industrially manufactured tobacco product, contains areca nut, tobacco and other ingredients), khaini, snuff, and lal dantamanjan, which are also common in different parts of India has been described elsewhere.5 Several new smokeless tobacco products were found. The most unusual was tobacco water called tuibur or hidakphu made by passing tobacco smoke through water and bottling that water. A sip of this water is kept in the mouth for few minutes and then spat out. Another one was gul, pyrolysed tobacco with some other ingredients, used as dentifrice. Data analysis was performed using SUDAAN® and the C-sample procedure in Epi-Info taking the probabilities of selection into account as well as adjustment for non-response at the school, and school personnel level. Ninety-five percent confidence intervals were calculated and used to test for significance of difference. Whenever a denominator was less than 35, the data were not included in the table. A small description of each state and its detailed results follows for each of the eight states. Assam Assam is geographically located at latitude 26.00 N and longitude 93.00 E, covering a population of 26,638,407 (13,787,799 men, 12,850,608 women) at a decadal growth rate of 18.8%. Density (per sq. km.) was 340 with a sex ratio of 932 women per 1000 men and a literacy rate of 64.3% (71.9% men, 56.0% women).6 Results All selected 50 schools participated in the survey (response rate 100%). The school personnel response rate was 78.0% (out of 1002 sampled); the reason for non-response was absence from school on the day(s) of the survey. Out of the total 782 participating school personnel 82.8% were men; 51.2% were less than 40 years old; and, 12.7% were 50 years or older. Very few were more than 60 as mandatory retirement age is 60 years. Men were somewhat younger than women. Most school personnel (85.6%) were teachers and health personnel (0.9%) were very few. (These results were not shown in the tables) Current daily smoking was reported by 22.2% (men 23.2%, women 16.9%) while current occasional smoking by 29.5% (men 32.1%, women 16.9%). Current daily smokeless tobacco use was reported by 10.7% (men 10.1%, women 13.5%) while current occasional smokeless tobacco use by 34.7% (men 34.3%, women 37.0%). Current daily smoking was twice more common than current daily smokeless tobacco use (Table 1). Among smokers, 34.4% reported bidi smoking, 29.9% manufactured cigarettes, 15.8% ganja smoking while 17.0% reported smoking in other forms mainly hand-rolled cigarettes popularly known as surot (Table 2). Ganja was smoked primarily by men. Among men, the most popular form of smokeless tobacco use was betel quid (75.5%) followed by khaini (7.9%) and gutka (7.8%). Among women, betel quid (36.3%) followed by tuibur (35.7%), gul (13.5%) and gutka (13.4%) were commonest (Table 2). Gul and tuibur was used primarily by women. Some 58.2% school personnel considered tobacco was addictive, 48.6% admitted that it had serious health consequences and 46.0% believed that environmental tobacco smoke (ETS) was harmful. Over 80% school personnel reported that there was no policy on prohibiting tobacco use, either for students (81.6%) or for school personnel (80.5%). About one-third school personnel reported classrooms teaching on short-term health consequences (34.6%) and 30.6% on long-term health consequences of tobacco use. In contrast, training among school personnel to prevent tobacco use (2.0%) and access to teaching material (8.0%) was virtually nonexistent. However 63.9% school personnel felt need for such training. (These results were not shown in the tables) Around two thirds of school personnel expressed need for a policy prohibiting tobacco use by students (64.2%) and by school personnel (62.5%). Some 53% thought that tobacco companies deliberately encourage youth to use tobacco while 35.1% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 61.7% wanted a complete ban on tobacco advertisements. Surprisingly, even though a large number of school personnel were tobacco users, 42.2% were in favor of increasing the prices of tobacco products. (These results were not shown in the tables) This study shows that cigarettes smoking was reported more by women (even though the numbers were small) than men. Tuibur and gul was more common among women where as betel quid was more common among men. Arunachal Pradesh Arunachal Pradesh is geographically located at latitude 28.00 N and longitude 95.00 E, covering a population of 1,091,117 (573,951 men, 517,166 women) at a decadal growth rate of 26.2%. Density (per sq. km.) was 13 with a sex ratio of 901 women per 1000 men and the literacy rate of 54.7% (64.1% men, 44.2% women).6 Results All selected 25 schools participated in the survey (response rate 100%). The school personnel response rate was 82.4% (533/647); the reason for non-response was absence from the school on the day(s) of the survey. Out of 533 participating school personnel, 80.9% were men; 46.1% were less than 40 years old; and, 9.0% were 50 years or older. The majority of school personnel (92.9%) were teachers and health personnel (<0.5%) were very few. (These results were not shown in the tables) Current daily smoking was reported by 12.8% (men 15.0%, women 4.0%) while current occasional smoking by 30.2% (men 30.2%, women 30.4%). Current daily smokeless tobacco use was reported by 28.2% while current occasional smokeless tobacco use by 19.9%. Current daily smokeless tobacco use was thrice more than current daily smoking (Table 3). Among smokers, 54.8% mainly smoked cigarettes, 21.4% smoked bidi, 9.8% smoked ganja and 9.1% reported smoking in other forms mainly hand-rolled cigarettes. Even though the number of women smokers were very few almost all (>85%) of them smoked cigarettes. Among men, 50.9% smoked cigarettes while 23.7% smoked bidi. Kamchung was primarily smoked by men. Among smokeless tobacco users, betel quid 70.8% was the most preferred among men (73.6%) and women (51.4%) school personnel. Khaini was mainly used by men (19.8%); while tuibur (32.6%) and snuff (15.2%) by women (Table 4). Some 53.3% school personnel considered tobacco as addictive, 60.9% admitted that it had serious health consequences and 57.0% believed that environmental tobacco smoke (ETS) was harmful. Over two-third of the school personnel replied that there was no policy on prohibiting tobacco use, either for students (68.8%) or for school personnel (66.7%). Nearly half of school personnel reported classroom teaching on short term (47.3%) and 50.9% on long-term health consequences of tobacco use. In contrast, training among school personnel to prevent tobacco use among youth was (3.5%) negligible, however 67.6% school personnel felt need for such training. (These results were not shown in the tables) The school personnel expressed need for a policy prohibiting tobacco use by students (71.3%) as well as by school personnel (60.8%). Almost two-third of the school personnel thought that tobacco companies deliberately encourage youth to use tobacco while 65.9% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 67.4% wanted a complete ban on tobacco advertisements. Surprisingly, even though majorities were tobacco users, 58.4% agreed with the need to increase prices of tobacco products. (These results were not shown in the tables) Manipur Manipur is geographically located at latitude 24.44 N and longitude 93.58 E, covering a population of 2,388,634 (1,207,338 men, 1,181,296 women) at a decadal growth rate of 30.0%. Density (per sq. km.) was 107 with a sex ratio of 978 women per 1000 men and the literacy rate of 68.9% (77.9% men, 59.7% women).6 Results All selected 24 schools participated in the survey (response rate 100%). The school personnel response rate was 80.6% (395/490); the reason for non-response was absence from school on the day(s) of survey. Out of 395 participating school personnel 62.9% were men; 55.9% were less than 40 years old and 13.4% were 50 years or older. The majority of school personnel (90.8%) were teachers and health personnel (0.7%) were very few. (These results were not shown in the tables) The current daily smoking was reported by 20.4% (men 24.4%, women 13.9%) while current occasional smoking by 52.3% (men 55.1%, women 47.5%). The current daily smokeless tobacco use was reported by 14.2% (men 21.8%, women 1.6%) while current occasional smokeless tobacco use by 61.1% (men 53.2%, women 74.2%). Men reported more daily smokeless tobacco use than women (21.8% vs. 1.6%). Current occasional use of tobacco both in smoking as well as smokeless form was more than daily use (Table 5). Among smokers, the most popular form of smoking was bidi (33.6%) followed by, cigarette (25.2%), ganja (21.6%) and other form (14.7%) mainly hand-rolled cigarettes commonly known as Lazial. Cigarette and Kamchung were reported more among women than men. Majority of ganja smokers were men. Among smokeless tobacco users, betel quid (54.7%) was the most popular among both men and women. Prevalence of gutka use among men was high (24.1%) as compared to women (2.6%) while prevalence of khaini use among women was high (29.1%) as compared to men (8.9%). Tuibur was mainly used by women (27.5%, Table 6). Over one-third (35.2%) of the school personnel agreed that tobacco was addictive, 37.3% admitted that it had serious health consequences and 54% reported environmental tobacco smoke (ETS) was harmful. More than two third of the school personnel indicated that there was no policy on prohibiting tobacco use, either for students (75.5%) or for school personnel (66.5%). Only about one-tenth of school personnel reported classrooms teaching on short or long-term health consequences of tobacco use. Very little practical training was provided by school personnel to students towards avoiding tobacco use through communication skills (20.9%), goal setting skills (8.5%) and resisting peer pressure (11.4%). There was almost no training to prevent tobacco use by youth (3.7%) and little access to teaching material (11.8%). (These results were not shown in the tables) One third of school personnel expressed the need for a policy prohibiting tobacco use by students (33.5%) and 31.1% by school personnel, while 30.9% agreed that school personnel should set a good example by not using tobacco. Over one-third of school personnel thought that tobacco companies deliberately encourage youth to use tobacco (38.5%), and 36.7% opposed sponsorship of sports events by tobacco companies. About the same proportion (31.9%) favored complete ban on tobacco advertisements and (32.5%) increase in prices of tobacco products. (These results were not shown in the tables) The current daily plus occasional tobacco use was very high among women, both in smoking (61.4%) as well as smokeless form (75.8%). The prevalent form of smoking: cigarette and lazial (hand rolled cigarettes) were reported more among women than men. Meghalaya Meghalaya is geographically located at latitude 25.30 N and longitude 91.00 E, covering a population of 2,306,069 (1,167,840 men, 1,138,229 women) at a decadal growth rate of 29.9%. Density (per sq. km.) was 103 with a sex ratio of 975 women per 1000 men and the literacy rate of 63.3% (66.1%men, 60.4% women).6 Results Out of selected 25 schools 96.0% participated in the survey. Out of sampled 512 school personnel 87.3% participated in the survey. The non-response was due to absence from school on the day(s) of survey. Out of 447 participating school personnel, 55.7% were men; 67% were less than 40 years old; and, 5.6% were 50 years or older. Among the school personnel, 43.7% women and 16.6% men, were 29 years or younger. The majority of school personnel (83.2%) were teachers and 1.8% health personnel. (These results were not shown in the tables) The current daily smoking was reported by 23.0% (men 27.6%, women 17.3%) while current occasional smoking by 29.7% (men 42.0%, women 14.3%). The current daily smokeless tobacco use was reported by 24.9% (men 30.8%, women 17.4%) while current occasional smokeless tobacco use by 28.8% (men 20.5%, women 39.2%). Almost equal number of current daily and occasional use of tobacco was reported (Table 7). Among smokers, 34.4% smoked cigarettes, 40.1% smoked bidi and 12.7% smoked in other forms, mainly hand-rolled cigarettes. Cigarette and bidi were common among both men and women, where as ganja was more common among men than women (Table 8). Among smokeless tobacco users, betel quid (55.4%) was by far the most popular followed by tuibur (13.1%), gul (12.0%) and khaini (9.1%). Gul and tuibur were primarily used more by women than men (Table 8). More than half of the school personnel agreed that tobacco was addictive (52.7%), 45.9% admitted that it had serious health consequences and 46.6% thought environmental tobacco smoke (ETS) to be harmful. Nearly three fourth (73.7%) of school personnel reported that there was no policy on prohibiting tobacco use either for students or for school personnel. School personnel reported classroom teaching on short-term health consequences (33.1%) and long-term health consequences (28.2%) of tobacco use. In contrast, training among school personnel regarding prevention of tobacco use and access to teaching material was low (5.8% and 14.2%). (These results were not shown in the tables) Around half of the personnel expressed need for a policy prohibiting tobacco use by students (48.5%) and somewhat less (40.7%) wanted a policy prohibiting tobacco use by school personnel. Among respondents, 43.5% thought that tobacco companies deliberately encourage youth to use tobacco while 49.7% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 46.9% wanted a complete ban on tobacco advertisements and 40.6% favored increased in prices of tobacco products. (These results were not shown in the tables) In Meghalaya the proportion of women among school personnel (44.3%) was quit high. Even though current daily smoking was almost equally prevalent among men and women, current occasional smoking was almost thrice more common among men than women. Mizoram Mizoram is geographically located at latitude 23.30 N and longitude 20.52 E, covering a population of 891,058 (459,783 men, 431,275 women) at a decadal growth rate of 29.2%. Density (per sq. km.) was 42 with a sex ratio of 938 women per 1000 men and a literacy rate of 88.5% (90.7% men, 86.1% women).6 Results All selected 25 schools and 69.9% (out of 439) school personnel participated in the survey. Among 307 participating school personnel, 73.5% were men; 54.6% were less than 40 years old; 19% were 50 years or older. The majority of school personnel (94.8%) were teachers and there were no health personnel reported in Mizoram. (These results were not shown in the tables) The current daily smoking was reported by 25.9% (men 30.8%, women 13.5%) while current occasional smoking by 50.2% (men 44.5%, women 62.7%). The current daily smokeless tobacco use was reported by 57.8% and occasional by 23.7%. Women reported significantly more current daily smokeless tobacco use than men (80.3% vs. 49.4%, Table 9). Among smokers, 45.0% reported cigarettes smoking and 52.6% bidi smoking. Cigarette and bidi were equally popular among men and women. Among smokeless tobacco users, 24.8% used gutka, 22.3% used khaini, 20.2% used betel quid, 16.4% used gul and 9.3% used snuff. Gutka and snuff were reported slightly more among women while gul was more among men (Table 10). More than five-sixth of school personnel considered tobacco as addictive (84.5%), 81.4% admitted that it had serious health consequences and 49.1% believed that environmental tobacco smoke (ETS) to be harmful. Nearly four-fifth of the school personnel indicated that there was no policy on prohibiting tobacco use, either for students (79.4%) or for school personnel (82.7%). Only one out of six school personnel reported classrooms teaching on short or long-term health consequences of tobacco use. Around one out of seven personnel reported providing practical training to the students towards avoiding tobacco use through communication skills (13.0%), 10.3% goal setting skills and 11.9% resisting peer pressure. In contrast, training among school personnel to prevent tobacco use among youth (3.6%) and access to teaching material (10.3%) was very low. However, around half of the school personnel felt need for such training. (These results were not shown in the tables) Some 49.5% expressed need for a policy prohibiting tobacco use by students and 59.3% by school personnel. Among respondents, 43.5% thought that tobacco companies deliberately encourage youth to use tobacco while 49.7% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 46.9% reported that there must be a complete ban on tobacco advertisements and 40.6% agreed with the need to increase prices of tobacco products. (These results were not shown in the tables) Nagaland Nagaland is geographically located at latitude 26.0 N and longitude 94.20 E, covering a population of 1,988,636 (1,041,686 men, 946,950 women) at a decadal growth rate of 64.4%. Density (per sq. km.) was 120 with a sex ratio of 909 women per 1000 men and the literacy rate of 67.1% (71.8% men, 61.9% women).6 Results All selected 25 schools and 85.7% (out of 497 sampled) school personnel participated in the survey. Out of 426 participating school personnel, 65.6% were men; 71.7% were less than 40 years old and 8.6% were 50 years or older. Women were younger than men. Most of the school personnel (92.1%) were teachers and there were no health personnel. (These results were not shown in the tables) The current daily smoking was reported by 13.9% (men 18.7%, women 5.0%) while current occasional smoking by 28.3% (men 36.4%, women 13.1%). The current daily smokeless tobacco use was reported by 18.3% (men 18.5%, women 18.1%) while current occasional smokeless tobacco by 25.4% (men 31.3%, women 14.4%, Table 11). Among smokers, 46.3% smoked cigarettes, 26.3% smoked bidi, 11.6% smoked ganja and 9.3% reported smoking in other forms mainly surot (hand-rolled cigarettes). Even with small number of women smokers (therefore not shown in the table) cigarette smoking was more common among women. Ganja was primarily smoked by men (Table 12). Among smokeless tobacco users, betel quid (69.3%), khaini (15.9%) and gutka (8.3%) were the highly prevalent form. Betel quid was more common among women, whereas khaini was more common among men (Table 12). Some 60.5% school personnel agreed that tobacco was addictive, 67.3% admitted that it had serious health consequences while 62.5% believed that environmental tobacco smoke (ETS) was harmful. Over half of school personnel reported that there was no policy on prohibiting tobacco use, either for students (50.2%) or for school personnel (53.1%). Over one-third of personnel reported classroom teaching on short or long -term health consequence of tobacco use. Training among school personnel to prevent tobacco use by youth (13.6%) and access to teaching material (29.0%) was low. However, 66.6% favored such training to avoid tobacco. Even though tobacco use among school personnel was high, a vast majority was concerned about youth tobacco use (93.5%). (These results were not shown in the tables) Among the school personnel 71.2% wanted a policy prohibiting tobacco use by students but less proportion (58.9%) wanted a policy prohibiting tobacco use by school personnel. Some 46.4% thought that tobacco companies deliberately encourage youth to use tobacco and 59.4% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 63.1% thought that there must be a complete ban on tobacco advertisements, where as 34.9% agreed for the need to increase prices of tobacco products. (These results were not shown in the tables) Even though high prevalence of tobacco use (smoking as well as smokeless form) was reported among school personnel of Nagaland; almost all (>93%) school personnel were concerned about youth tobacco use and five out of seven wanted a policy prohibiting tobacco use by students. Sikkim Sikkim is geographically located at latitude 27.3 N and longitude 88.3 E, covering a population of 540,493 (288,217 men, 252,276 women) at a decadal growth rate of 33.0%. Density (per sq. km.) was 76 with a sex ratio of 875 women per 1000 men and the literacy rate of 69.7% (76.7% men, 61.5% women).6 Results All selected 25 schools and 75% (342/456) school personnel participated in the survey. Out of 342 participating school personnel, 80.2% were men; 68.1% were less than 40 years old and 9.9% were 50 years or older. Women were younger than men. The majority of school personnel (89.6%) were teachers and 3.4% health personnel. (These results were not shown in the tables) The current daily smoking was reported by 19.7% (men 16.1%, women 34.2%) while current occasional smoking by 30.0% more among men (men 36.4%, women 5.5%). The current daily smokeless tobacco use was reported by 17.6%, around six times more among women than men (51.9% vs. 8.9%, Table 13). Among smokers, 45.4% smoked cigarettes and 39.8% smoked bidi while 14.7% reported smoking as others mainly hand rolled cigarettes popularly known as Surot. Among men smokers, cigarette smoking (52.7%) was high as compared to bidi (29.9%) but among women almost all (>94%) were bidi smokers (Table 14). Among smokeless tobacco users, gutka was the most preferred (34.4%) followed by khaini (18.9%), betel quid (15.7%), gul (15.0%) and tuibur (12.4%). Gutka, khaini, and tuibur were mainly used by men while betel quid and gul by women (Table 14). Over half of the school personnel (52.8%) agreed that tobacco was addictive, 61.7% admitted that it had serious health consequences and 52.7% believed environmental tobacco smoke (ETS) to be harmful. There was no policy on prohibiting tobacco use for students (63.2%) as well as for school personnel (79.1%). School personnel reported some classroom teaching on short-term health consequences (48.7%) and long-term health consequences (43.0%) of tobacco use. There was little training among school personnel to prevent tobacco use by youth (4.8%) and access to teaching material (15.6%). However, 64.1% felt need for such training to be able to teach students to avoid tobacco use. Almost all (>94%) school personnel were concerned about youth tobacco use. (These results were not shown in the tables) Among the school personnel, 60.4% expressed need for a policy prohibiting tobacco use by students and 50.8% by school personnel. Some 41.6% of school personnel thought that tobacco companies deliberately encourage youth to use tobacco while 56.5% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 68.5% reported that there must be a complete ban on tobacco advertisements and 56.9% in favor of increasing prices of tobacco products. (These results were not shown in the tables) An interesting finding of the study was women reporting more daily use of smokeless tobacco (women 34.2% vs. men 16.1%). Tripura Tripura is geographically located at latitude 23.45 N and longitude 91.30 E, covering a population of 3,191,168 (1,636,138 men, 1,555,030 women) at a decadal growth rate of 15.7%. Density (per sq. km.) was 304 with a sex ratio of 950 women per 1000 men and the literacy rate of 73.7% (81.5% men, 65.4% women).6 Results Out of 25 sampled schools 23 participated in the survey (response rate 92%). From the sampled 758 school personnel 74.1% participated in the survey. Out of 562 participating school personnel, 78.2% were men; 48.6% were less than 40 years old and 20.5% were 50 years or older. Women were younger than men. The majority of school personnel (81.3%) were teachers and 0.7% health personnel. (These results were not shown in the tables) The current daily smoking was reported by 15.0% (men 18.6%, women 0.4%) while current occasional smoking by 31.5% (men 38.0%, women 8.8%). The current daily smokeless tobacco use was reported by 31.2% (men 38.3%, women 6.8%) while current occasional smokeless tobacco by 17.5% (men 17.2%, women 17.7%, Table 15). Among men smokers, 42.3% reported smoking cigarettes and 23.6% reported smoking bidi while 20.5% reported smoking as others mainly, hand-rolled cigarettes. Even though very few women reported smoking, almost all of them (>70%) smoked hand-rolled cigarette. Among smokeless tobacco users, betel quid was the most popular (54.9%) followed by gutka (21.0%) and khaini (10.7%). Betel quid was more popular among men than women (Table 16). Over half of the school personnel (55.6%) agreed that tobacco was addictive, 61.4% admitted that it had serious health consequences and 63.9% thought environmental tobacco smoke (ETS) as harmful. There was no policy on prohibiting tobacco use either for students (71.5%) or for school personnel (64.1%). Over one-third of personnel reported classroom teaching on short or long-term health consequences of tobacco use. But training among school personnel to prevent tobacco use (6.3%) and access to teaching material (25.5%) was not adequate. However 62.5% wanted specific training to be able to teach students to avoid tobacco use. (These results were not shown in the tables) Among the respondents, 66.3% expressed a need for a policy prohibiting tobacco use by students and 62.7% by school personnel. Nearly half of respondents (46.8%) thought that tobacco companies deliberately encourage youth to use tobacco while 66.8% were in favor of not allowing tobacco companies to sponsor sports events. On the other hand, 68.5% reported that there must be a complete ban on tobacco advertisements and 64.2% favored increased price of tobacco product. (These results were not shown in the tables) Discussion Tobacco use among school personnel of northeastern states reported in this study is very high. The highest current daily plus occasional smoking (76.1%) as well as smokeless (81.5%) tobacco use was in Mizoram where almost everybody used tobacco, while minimum in Nagaland (smoking 42.2%, smokeless 43.7%) was also very high by any global standard. The lowest current daily plus occasional smokeless tobacco use among men (44.4%) was high as compared to reported in other parts of India.3,7 Among women the current daily tobacco use variation was much more than men in both in smoking as well as smokeless form. The highest current daily plus current occasional smoking among men, was reported by Manipur (79.5%) and among women by Mizoram (76.2%). Even the lowest current daily plus occasional smoking prevalence among men (Arunachal Pradesh 45.2%) as well as among women (Tripura 9.2%) was high as compare to reported results in (Mumbai7 : 23.6% men, 0.4% women; Bihar3 : 47.4% men, 31% women; and Kerala8 : 34.8% men) other parts of India. As reported in other parts of India (Mumbai7 57%, Bihar3 36.8%) cigarette smoking was also high in the population of (between 22% - 44%) of Northeastern states of India. In almost every study reported in India, bidi or cigarette smoking was far more common among men than among women.3-5,7 This study however reveals opposite, bidi or cigarettes smoking in most of the Northeastern states, was more among women than men. This shows that bidi or cigarette smoking among women is certainly not a taboo in Northeastern states as in most other parts of India. This social change is likely to be due to several factors that have to be studied. Finding prevalence of drug use was not an objective of this study. Nevertheless a large proportion of smokers reported smoking tobacco with ganja (a kind of Hashish) in this self-administered questionnaire study. These data demonstrate high prevalence of drug use among men in North-eastern parts of India. Like many studies in India,5,7 overall betel quid was the most preferred type of smokeless tobacco use in this study as well. As reported in other parts of India, betel quid is generally preferred more by men than women,5 and the same was true in the present study in all states except Sikkim and Nagaland. Other smokeless tobacco use like gutka, gul, snuff and tuibur was reported more among women than men. Thus GSPS study findings reveal high prevalence of tobacco use, even among women in smoking as well as smokeless form. The unexpected finding of the study was women reporting a higher prevalence of smoking. Similar finding however, has been reported from Bihar school personnel.3 Over half of the school personnel reported that there was no policy on prohibiting tobacco use; either for students (50% - 82%) or for school personnel (53% - 83%) and over half of personnel expressed need for such policy for students as well as for school personnel. The findings, however, do not present a totally discouraging picture. School personnel thought tobacco was addictive, the highest reported by Mizoram (84.5%) and the lowest (35.2%) by Manipur. It was thought that tobacco causes serious health consequences (37% - 81%) and environmental tobacco smoke (46% - 64%) was harmful in almost all states of the North-eastern India. A need for tobacco control policies for students was felt by (33% - 71%) and for school personnel by (31% - 63%). School personnel thought that tobacco companies deliberately encouraged youth to use tobacco (35% - 67%) and they were strictly against allowing tobacco companies to sponsor sports events (32% - 68%). Even though over 40% of school personnel reported using tobacco in one or other form, they expressed support for increase in the price of tobacco products (32% - 64%). Over all it seems that the school personnel of north eastern India were concerned about youth and they supported formulation and implementation of tobacco control policies like tobacco control policy for students as well as for school personnel, preventing tobacco companies to sponsor sports events and increasing the price of tobacco products. Acknowledgements Authors wish to acknowledge the contribution and help from Samira Asma, Associate Director, Charles Warren, Distinguished Fellow, Office on smoking and health, CDC and Leanne Riley, TFI, WHO. References
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