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Indian Journal of Cancer, Vol. 40, No. 2, (April - June 2003) , pp. 43-59 Special Report Tobacco use among Students in the 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: cn03008 ABSTRACT OBJECTIVES: To obtain baseline information about prevalence of tobacco use among school children in eight states in the North-eastern part of India. MATERIAL AND METHODS: A two-stage probability sample of students in grades 8_10 corresponding to 13 to 15 years of age was selected in each state and surveyed through an anonymous, self-administered questionnaire. RESULTS: Among the sampled schools, the school response rate was 100% in all states except Tripura (92%) and Meghalaya (96%). Among the eligible students, over 80% participated in the survey. Among the respondents, the proportion of boys ranged between 50% to 55%. Ever tobacco users ranged from 75.3% (Mizoram) to 40.1% (Assam). Over 65% of users reported initiation at 10 years of age or earlier in all states except Mizoram (23.1%). The range of current tobacco use (any product) was 63% (Nagaland) to 36.1% (Assam). Current smokeless tobacco use ranged from 49.9% (Nagaland) to 25.3% (Assam). Mizoram reported the highest current smoking (34.5%, mainly cigarette) and Assam reported the lowest (19.7%, again mainly cigarette). Current smoking among girls (8.3% to 28.2%) was also quite high. Over half of current cigarette smokers (53.2% to 96.3%) and a high proportion of current smokeless tobacco users (38.5% to 80.8%) reported feeling like having tobacco first thing in the morning. Only about 20% of students reported having been taught in school about the dangers of tobacco use, except in Mizoram (around 50%). Tobacco use by parents and close friends was positively associated with students' current tobacco use. CONCLUSIONS: Tobacco use including smoking was very high, even among girls, in all eight states in the North-eastern part of India. Signs of tobacco dependency were already visible in these students, more among those who smoked. In general schools did not educate students about the hazards of tobacco use. Key Words: Tobacco, Adolescent, Students, Epidemiology, India. Introduction Given the current pattern of tobacco use globally, it is estimated that 250 million children and adolescents who are alive today, would die prematurely because of tobacco, most of them in developing countries.1 In India tobacco use is estimated to cause 800,000 deaths annually.2 The prevention of tobacco use in young people appears to be the single greatest opportunity for preventing non-communicable disease in the world today. In this era of globalization, youth and adolescents are adopting behavior patterns that are comparable from country to country. Tobacco companies are taking advantage of this situation. They are advertising tobacco products using mass media techniques targeting "the youth of the world". To counteract the effect of this strategy in India, as in the rest of the developing world, there is an urgent need for good, scientifically sound data about tobacco use patterns that would allow cross-country and within-country comparisons. This would permit the fulfillment of the dual objective of designing preventive strategies targeting "the global youth" while taking into consideration local peculiarities. The Tobacco Free Initiative of the World Health Organisation, in collaboration with the Office on Smoking and Health, Centers for Disease Control, USA, has undertaken the Global Youth Tobacco Survey (GYTS). This survey focuses on 13 to 15 year old school going students using standardized methodology. The survey uses a "core" questionnaire and an optional bank of questions. The objectives of this survey are to: 1) document and monitor the prevalence of tobacco use including cigarette smoking and other tobacco use; 2) understand students' attitudes, knowledge and behaviors related to tobacco use and its health impact, including cessation, and environmental tobacco smoke (ETS); 3) measure exposure to advertising and promotion of tobacco products; and, 4) assess minors' access and understand school curriculum about tobacco.3,4 This document is the first report of the GYTS from India and includes data from eight North-eastern states _ Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura. The six North-eastern states: Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and Tripura were all part of Assam, while Sikkim was a separate state. The Department of Development of North Eastern Region links these seven North-eastern states. This region is set apart from the rest of India by geographically difficult terrains, socio-cultural pattern, population density, high proportion of tribal population, high prevalence of tobacco use, alcohol and drug abuse. In the second 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.5 Material and Methods The study was carried out during January-March 2001. In the North-eastern states as in the rest of India, 13 to 15 year old students corresponded to grades 8 to 10. A two-stage cluster sample design was used to produce a representative sample of students for each state. A list of all schools having grades 8 to 10 was prepared with enrollment numbers for boys and girls in each school for every state. 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. At the second stage, between 1 to 5 classes were selected by systematic sampling with a random start and a fixed interval, depending upon the estimated number of classes in grades 8 to 10 in the selected school. All students in the selected classes irrespective of age were eligible to participate. For India, the core questionnaire of the GYTS was suitably expanded to include tobacco use in the form of bidi smoking and smokeless tobacco use. All questions required answering (i.e. there was no skipping or branching pattern). The questionnaire was self-administered with no identification information collected (name of student, class or school), maintaining complete anonymity. Responses were recorded on optically readable answer sheets. Tobacco use was classified as ever use (the use of tobacco even once) and current use (use of tobacco within 30 days preceding the survey). In India tobacco is used for smoking as well as smokeless use. In the North-eastern states tobacco is smoked in the form of cigarettes, bidis (tobacco rolled in a tendu leaf), in kamchungs (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 similar to hookah) and tobacco mixed with ganja (hashish). Smokeless tobacco use could include, betel quid, gutka (an industrially manufactured tobacco product, containing areca nut, tobacco and other ingredients), sada (tobacco leaf and lime mixture), tamol (fermented arecanut, prepared by fermenting raw arecanuts in underground pits or inside cow dung resulting in high level of arecoline often infected with fungus), tuibur (tobacco water made by passing tobacco smoke through water, traditionally used in the Mizo community), khaini, snuff, gul (pyrolysed tobacco with some other ingredients, used as dentifrice), tobacco toothpaste and lal dantamanjan (red tooth powder). Most of these habits are also common in other parts of India and have been described elsewhere.6 Many of these products (betel quid, gutka, sada, khaini etc.) are chewed whereas some (gul, snuff, tobacco tooth paste, red tooth powder etc.) are applied in the oral cavity. Chewing and applying were distinguished as the two different ways of using smokeless tobacco. Attitude towards tobacco use was assessed by two questions. One was whether boys who smoke/chew look more attractive or have more friends (both questions repeated for girls). Another question was whether men who smoke lack confidence, are stupid, are losers or they are successful, intelligent or macho. The question was repeated for women with the option `macho' changed to `sophisticated'. Data analysis was performed using SUDAAN and the C-sample procedure in Epi-Info taking the probabilities of selection (schools and classes) into account as well as adjustment for non-response at the school, class and students level. Ninety-five percent confidence intervals were calculated and used to test for significance of difference. A small description of each state and its detailed results are discussed separately 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).7 Results Among 50 sampled schools, the response rate was 100%. The student response rate was 86.8% based on 2508 sampled students. The non-response was due to absence on the day(s) of the survey. A total of 2177 students participated. The study represents results for a sample of 741,954 school going students of ages 13 to 15 years in Assam. Among 2177 respondents, 55% were boys and 45% girls. Ever tobacco use was reported by 40.1% (boys 46.8%, girls 32%, Table 1) with 80.3% users (boys 77%, girls 86.9%) reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 36.1%, more among boys (45.2%) than girls (25%). Current smokeless tobacco use was reported by 25.3% (boys 29.3%, girls 20.4%). Current smoking was reported by 19.7% (boys 28.6%, girls 8.9%). Current cigarette smoking (9.9% overall), like current smoking, was almost thrice more common among boys (14.6%) than girls (4.4%, Table 1). Smokeless tobacco use in the form of chewing was reported by 48.5% and applying by 18.8%. Among chewers, gutka use was the most popular (54.4%) followed by tamol and tobacco mixture (28.9%). Among appliers, 58.5% applied tobacco toothpaste, 25% red toothpowder and 16.3% gul. Among smokers, 60.1% reported cigarette smoking, and 21.9% reported smoking in multiple forms. Almost all cigarette smokers (96.3%), half of smokeless tobacco users among boys (54.3%) and one quarter of girls (24.3%) reported needing tobacco the first thing in the morning (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys or girls who used tobacco looks more attractive, girls who use tobacco have more friends, men or women who smoke is successful. Tobacco users felt that tobacco helped people to feel more comfortable at parties three times more often than never tobacco users. However, tobacco users also felt that tobacco helped in relieving toothache or in morning motion 2 to 3 times more often than never tobacco users. Never tobacco users reported that smoking helps in losing weight 2 to 6 times more often as compared to tobacco users. Tobacco use in any form (smoking or smokeless) and ETS was reported harmful more often by never tobacco users than tobacco users (Table 2). Current smoking at home was reported by 71.4%, more often by girls (91.6%) than boys (65.9%) (results not shown in the table). Parental tobacco use was reported 2 to 3 times more often by tobacco users compared to never tobacco users. Smoking by most or all friends was reported 5 to 9 times more often by tobacco users than never tobacco users (Table 2). Purchasing tobacco products in a store was reported by 78.1%, and almost no one (97.9%) was refused because of age (results not shown in the table). Over 90% cigarette smokers and 83% smokeless tobacco users reported exposure to environmental tobacco smoke inside as well outside their homes compared < 50% of never tobacco users. Never users favoured banning smoking in public places 10 times more often than cigarette smokers (Table 2). Among cigarette smokers, 25.7% wanted to stop smoking, whereas 19.8% had already tried to stop smoking during the past year. Classroom teaching during the past year on various aspects of tobacco use, like dangers of smoking and chewing tobacco, reasons why people of their age smoke or chew and the effect of smoking and chewing tobacco was reported by 18% to 24% of students (results not shown in the table). Almost everyone (> 90%) reported watching a lot of cigarette advertisements on TV, whereas about half reported watching advertisement on other media, like outdoor (58.2%), newspaper/magazines (45.5%) and social events (59.4%). About half of the students (44% to 52%) reported seeing gutka advertisements in different media (Figure 1). 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).7 Results The study represents results for a sample of 28,706 school going students of ages 13 to 15 years in Arunachal Pradesh. The school and students response rate was 100% (25/25) and 90.6% (2314/2555) respectively. Among 2314 respondents, 57.8% were boys and 42.2% were girls. Ever tobacco use was reported by 59.2% (64.4% boys, 52.1% girls, Table 3) with 75.3% users (boys 69%, girls 85.8%) reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 49.8% (54.2% boys, 43.9% girls). Current smokeless tobacco use was reported by 37.2% (35.0% boys, 40.2% girls), whereas smoking was reported by 22.8% (31.8% boys, 8.3% girls). Current cigarette smoking was reported by 8.6%, more among boys (13.1%) than girls (2.5%, Table 3). Smokeless tobacco use in the form of chewing was reported by 55.2% and in the form of applying by 28.8%. Among chewers, gutka use was reported to be the most popular (49.8%) followed by tamol and tobacco mixture (31%). Among appliers, 79.7% applied tobacco toothpaste, 12.3% red tooth powder and 8% gul. Among smokers, 49.8% reported mainly smoking cigarettes (>85% boys) and 31% reported smoking in multiple forms. Almost three-fourths cigarette smokers (73.2%), half of the smokeless tobacco users among boys (51.7%) and one-thirds of girls (29.8%) reported needing tobacco the first thing in the morning (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys or girls who use tobacco looks more attractive, men or women who smoke is successful. Tobacco users felt that tobacco helped people to feel more comfortable at parties 4 to 5 times more often than never tobacco user. However, tobacco users also felt that tobacco helped in relieving toothache or in morning motion 4 to 5 times more often than never tobacco users. Never tobacco users thought that smoking helped in losing weight and they also felt that tobacco habit was difficult to quit, around two times more often than tobacco users. Tobacco use in any form (smoking or smokeless) and ETS was reported harmful more often by never tobacco users than tobacco users (Table 4). Cigarette smoking at home was reported by 45.4%, more often by boys (46.9%) than girls (27.7%) (results not shown in the table). Parental tobacco use was reported twice more often by tobacco users as compared to never tobacco users. Smoking by most or all friends was reported 9 to12 times more often by tobacco users than never tobacco users (Table 4). Purchasing tobacco products in a store was reported by 65.2% of tobacco users and more than 85% were not refused purchasing because of age (not shown in the table). Tobacco users, more than 85% at home and more than 90% outside home, were exposed to environmental tobacco smoke, as compared to never users 51% at home and 66% outside there home. Never users favoured banning smoking in public places 2 to 4 times more often than tobacco users (Table 4). Among cigarette smokers, 46.5% boys and 88.0% girls wanted to stop smoking and nearly the same percentage (37.3% boys, 82.3% girls) had already tried to stop smoking during past year. Classroom teaching during past year on various aspects of tobacco use, like dangers of smoking and chewing tobacco, reasons why people of their age smoke or chew and the effect of smoking and chewing tobacco was reported by 23% to 30% of students (results not shown in the table). Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) was reported by 39% to 64% of students (Figure 2). 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).7 Results The study represents results for a sample of 78,803 school going students of ages 13 to 15 years in Manipur. The school and students response rate was 100% (24/24) and 84.3% (1743/2067) respectively. Among 1743 respondents, 53.2% were boys and 46.8% were girls. Ever tobacco use was reported by 69% (78.6% boys, 58.1% girls, Table 5) with 74.4% users reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 61.7% (boys 74.4%, girls 47.2%). Current smokeless tobacco use was reported by 46.1% (boys 51.5%, girls 40.1%), whereas smoking by 26.8% (40.8% boys, 10.7% girls). Current cigarette smoking was reported by 15.8% (24.9% boys, 5.6% girls) and was the most popular form of smoking (Table 5). Smokeless tobacco use in the form of chewing was reported by 53.2% and applying by 31.9%. Among chewers, gutka use (23.7%) was reported to be the most popular (17.9% boys, 30.2% girls) followed by tamol and tobacco mixture (18.1% overall, 28.0% boys, 6.8% girls). Among appliers, 18.3% boys and 32.6% girls applied tobacco toothpaste. Around four fifth of cigarette smokers (79.1%), three fourths of smokeless tobacco users among boys (70.3%) and one out of nine smokeless tobacco users among girls reported needing tobacco as first thing in the morning (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys who use tobacco looks more attractive, men or women who smoke is successful. Tobacco users felt that tobacco helped people to feel more comfortable at parties 3.5 times more often than never tobacco users. However, tobacco users also felt that tobacco helped in relieving toothache or in morning motion around 5 times more often than never tobacco users. Never tobacco users thought that smoking helped in losing weight 3 to 4 times more and they also thought tobacco habit was difficult to quit about twice more often than tobacco users. Tobacco use in any form (smoking or smokeless) and ETS was reported harmful more often by never tobacco users than tobacco users (Table 6). Current cigarette smoking at home was reported by 59.1%, almost twice more often by boys (64.0%) than girls (36.0%) (results not shown in the table). Parental tobacco use was reported twice more often by tobacco users as compared to never tobacco users. However, smoking by most or all friends was reported 18 to 26 times more often by tobacco users than never tobacco users (Table 6). Purchasing tobacco products in a store was reported by 84.3%, and more than 85% were not refused purchase because of age (results not shown in the table). Over 90% tobacco users were exposed to environmental tobacco smoke at home as well as outside their home, as compared <58% never tobacco users. However, never tobacco users favoured banning smoking in public places three times more often than tobacco users (Table 6). Among cigarette smokers, 21.6% wanted to stop smoking, whereas 12.0% had already tried to stop smoking during past year. Classroom teaching during past year on various aspects of tobacco use, like dangers of smoking and chewing tobacco, reasons why people of their aged smoke or chew and the effect of smoking and chewing tobacco was reported by 13% to 16% of students (results not shown in the table). Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) was reported by 36% to 69% of students (Figure 3). 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).7 Results The study represents results for a sample of 46,112 school going children of ages 13 to 15 years in Meghalaya. The school response rate was 96% (24/25) and students' response rate was 84.7% (2080/2455) respectively. One school was not surveyed due to problem with accessibility. Among 2080 respondents, 52.8% were boys and 47.2% were girls. Ever tobacco use was reported by 53.9% (boys 63.2%, girls 43.7%, Table 7) with 67.7% users reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 43.9% (54.7% boys, 32.0% girls). Current smokeless tobacco use was reported by 35.3% (43.0% boys, 26.8% girls), whereas smoking was reported by 21.4% (32.1% boys, 9.9% girls). Current cigarette smoking was reported by 11.6% (16.5% boys, 6.5% girls, Table 7). Smokeless tobacco use in the form of chewing was reported by 55.2% (62.1% boys, 47.7% girls) and applying by 22.9% (28% boys, 17.6% girls). Chewing was mainly in the form of gutka (19.4%), tamol with tobacco (9.2%, >80% boys) and tamol without tobacco (21%). Tobacco was applied by 18.2% as tobacco toothpaste and 3.9% as red toothpowder. Six out of ten cigarette smokers (60%) and over one third smokeless tobacco users (38.5%) reported needing tobacco first thing in the morning. This dependence was over four times more common among smokeless tobacco user boys (51.5%) than smokeless tobacco user girls (11.8%) although it was similar in cigarette smoking boys (62.3%) and girls (54.5%) (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys or girls who use tobacco looks more attractive, men or women who smoke is successful. Tobacco users felt that tobacco helped people to feel more comfortable at parties 3 to 4 times more often than never tobacco users. However, tobacco users also felt that tobacco helped in relieving toothache or with morning motion 4 times more often than never tobacco users (Table 8). Current cigarette smoking at home was reported by 43.0%, somewhat more by girls (50.7%) than boys (40.2%) (results not shown in the table). Parental tobacco use was reported twice more often by tobacco users as compared to never tobacco users. Smoking by most or all friends was reported 8 to 9 times more often by tobacco users than never tobacco users (Table 8). Purchasing tobacco products in a store was reported by 59.7% and 69.7% who bought tobacco products in a store were not refused purchasing because of age (results not shown in the table). Almost all tobacco users (>90%) were exposed to ETS in home as well as outside home, as compared never tobacco users (67.6% and 74% respectively). Never tobacco users favoured banning smoking in public places twice as often as cigarette smokers. Never tobacco users felt smoking (3 _ 4 times), tobacco use in smokeless form (3 _ 5 times) and environmental tobacco smoke (2 _ 4 times) to be more harmful to health as compared to tobacco users (Table 8). Among cigarette smokers, 47.2% wanted to stop smoking interestingly a higher percentage (50.1%) reported trying to stop smoking during past year. Classroom teaching during the past year on various aspects of tobacco use, like dangers of smoking and chewing tobacco, reasons why people of their aged smoke or chew and the effect of smoking and chewing tobacco was reported by 24% to 32% of students (results not shown in the table). Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) were reported by 41% to 61% students (Figure 4). 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).7 Results The study represents results for a sample of 26,112 school going students of ages 13 to 15 years in Mizoram. Among 25 sampled schools, the response rate was 100%. The student response rate was 83.6% based on 2746 sampled students. Among 2295 respondents, 50.3% were boys, and 49.7% were girls. Ever tobacco use was reported by 75.3% (78.6% boys, 72% girls, Table 9) with 23.9% users (boys 27.6%, girls 19.7%) reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 53.5% (58.4% boys, 48.7% girls). Current smokeless tobacco use was reported by 42.9% (45.7% boys, 40.1% girls), whereas current smoking by 34.5% (40.7% boys, 28.2% girls). Cigarette smoking was reported by 23.1% (32.8% boys, 13.4% girls) and was the most preferred type of smoking (Table 9). Smokeless tobacco use in the form of chewing was reported by 60.7% and applying by 25.0%. Among chewers, gutka use (20%) was reported to be the most popular followed by pan with tobacco (12.9%). Among appliers, majority preferred tobacco toothpaste (11.8%). Around half of tobacco users (53.2% cigarette smokers, 44.5% smokeless tobacco users) reported needing tobacco first thing in the morning (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys who use tobacco looks more attractive, boys or girls who use tobacco have more friends, men or women who smoke is successful. Both tobacco users (53% to 59%) as well as never users (62.2%) agreed that tobacco helped in losing weight (Table 10). Currents cigarette smoking at home was 30.4%, more often by girls (39.7%) than boys (26.6%). Parental tobacco use was reported 1.3 times more often by tobacco users as compared to never tobacco users. However, smoking by most or all friends was reported 2 to 5 times more often by tobacco users than never tobacco users (Table 10). Purchasing tobacco products in a store was reported by 61.9% and more than 70% were not refused purchasing because of age (results not shown in the table). Tobacco users, more than 82% were exposed to environmental tobacco smoke at home as well as outside their home, as compared <67% never tobacco users. Tobacco users (63% to 68%) as well as never tobacco users (64.5%) were equally in favour of banning smoking in public places as they were equally aware of the harmful effect of tobacco (Table 10). Among cigarette smokers, 85.3% wanted to stop smoking and 79.3% had already tried to stop smoking during past year. Classroom teaching during past year on various aspects of tobacco use like dangers of smoking and chewing tobacco, reasons why people of their aged smoke or chew and the effect of smoking and chewing tobacco was reported by more than 50% of students (results not shown in the table). Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) was reported by 15% to 30% of students (Figure 5). 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).7 Results The study represents results for a sample of 28,186 school going students of ages 13 to 15 years in Nagaland. For selected 25 schools, the response rate was 100%. The student response rate was 80.4% based on 2763 sampled students. Among 2221 respondents, 52.1% were boys and 47.9% were girls. Ever tobacco use was reported by 73.3% (81.1% boys, 64.8% girls, Table 11) with 65% users (58.7% boys, 74.4% girls) reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 63.0% (69.1% boys, 56.4% girls). Current smokeless tobacco use was reported by 49.9% (52.5% boys, 47.2% girls), whereas smoking by 29.6% (38.7% boys, 19.7% girls). Cigarette smoking reported by 19.4% (boys 25.7%, girls 12.9%) was the most popular form of smoking (Table 11). Smokeless tobacco use in the form of chewing was reported by 62.4% and applying by 40%. Among chewers, 28.1% reported gutka chewing, 8% reported pan with tobacco as the same percentage, tamol with tobacco. Among appliers, the dominating form was tobacco toothpaste (31.7%). Over three fourths of cigarette smokers (76.9%) and half of smokeless tobacco users (51.2%) reported needing tobacco first thing in the morning with little difference among boys and girls (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys or girls who use tobacco looks more attractive, men or women who smoke is successful. Tobacco users felt that tobacco helped people to feel more comfortable at parties three times more often than never tobacco users. Tobacco users also felt that tobacco helped in relieving toothache or in morning motion five times more often than never tobacco users. Never tobacco users felt that smoking helped in losing weight and they also felt that tobacco habit was difficult to quit, twice more than tobacco users. Tobacco use in any form (smoking or smokeless) and ETS was reported harmful more often by never tobacco users than tobacco users (Table 12). Current cigarette smoking at home was reported by 50.3% (51.5% boys, 44.4% girls) (results not shown in the table). Parental tobacco use was reported twice more often by tobacco users as compared to never tobacco users and smoking by most or all friends, 5 to 7 times more often (Table 12). Purchasing cigarette in a store was reported by 62.6%, and more than 85% were not refused purchase because of age (results not shown in the table). Over 85% tobacco users were exposed to environmental tobacco smoke (ETS) at home as well as outside their home, as compared to <63% of never tobacco users. Never tobacco users favoured banning smoking in public places 2 to 3 times more often than tobacco users (Table 12). Among cigarette smokers, 48.4% (45.8% boys, 60.6% girls) wanted to stop smoking. However a higher percentage 49.6%, especially among boys (47.6% boys, 58.3% girls) had tried stopping smoking during past year. Classroom teaching during the past year on various aspects of tobacco use, like dangers of smoking and chewing tobacco, reasons why people of their aged smoke or chew and the effect of smoking and chewing tobacco, was reported by 19% to 28% of students (results not shown in the table). Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) was reported by 31% to 58% of students (Figure 6). 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).7 Results The study represents results for a sample of 15,247 school going students of ages 13 to 15 years in Sikkim. The school and students response rate for selected 25 schools was 100% and 85.4% (2236/2619) respectively. Among 2236 respondents, 55.0% were boys and 45.0% were girls. Ever tobacco use was reported by 56.4% (70.8% boys, 38.8% girls, Table 13) with 77.9% users (75.2% boys, 84.4% girls) reporting initiation at 10 years of age or earlier (results not shown in the table). The current tobacco use (any product) was reported by 54.7% (68.1% boys, 38.3% girls). Current smokeless tobacco use was reported by 37.7% (42.5% boys, 31.8% girls), whereas smoking by 23.6% (32.9% boys, 12.1% girls). Current cigarette smoking was reported by 18% (24.1% boys, 10.5% girls) (Table 13). Smokeless tobacco use in the form of chewing was reported by 48.3% and applying by 11.3%. Among chewers, tamol and tobacco mixture use was reported to be the most popular (52.3%) followed by gutka use (33.5%). Among appliers, 69.2% applied tobacco toothpaste, 21.4% red toothpowder and 9.4% tuibur. Almost all cigarette smokers (over 95%) and over 80% of smokeless tobacco users reported needing tobacco first thing in the morning (results not shown in the table). products in a store was reported by 74.1% and 84.1% who bought tobacco products in a store were not refused purchasing because of their age (results not shown in the table). Almost all tobacco users (over 94%) and only half never tobacco users (<54%) were exposed to environmental tobacco smoke at home as well as outside their home. Never tobacco users favoured banning smoking in public places 7 to 10 times more than tobacco users (Table 14). Current cigarette smoking at home was reported by 33.7% students (results not shown in the table). Parental tobacco use was reported 2.4 times more often by tobacco users as compared to never tobacco users. Smoking by most or all closest friends was reported 6 to 22 times more often by tobacco users than never tobacco users (Table 14). Purchasing of tobacco products in a store was reported by 74.1% and 84.1% who bought tobacco products in a store were not refused purchasing because of their age (results not shown in the table). Almost all tobacco users (over 94%) and only half never tobacco users (<54%) were exposed to environmental tobacco smoke at home as well as outside their home. Never tobacco users favoured banning smoking in public places 7 to 10 times more than tobacco users (Table 14). Among cigarette smokers, 27.2% (14.9% boys, 61.0% girls) wanted to stop smoking whereas 8.3% (9.3% boys, 5.6% girls) had already tried to stop smoking during past year. Classroom teaching during past year on various aspects of tobacco use, like dangers of smoking and chewing tobacco, reasons why people of their aged smoke or chew and the effect of smoking and chewing tobacco was reported by 21% to 24% of students (results not shown in the table). Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) was reported by 52% to 69% of students (Figure 7). 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).7 Results The study represents results for a sample of 78,803 school going students of ages 13 to 15 years in Tripura. Among 25 sampled schools, 23 schools participated (response rate 92%, two sampled schools were not accessible), whereas from 2138 sampled students 1866 (response rate 87.3%) participated. Among 1866 respondents, 54.8% were boys and 45.2% were girls. Ever tobacco use was reported by 46.7% (boys 52.6%, girls 39.4%, Table 15) with over three fourth of them (76.6%) reporting initiation at 10 years of age or earlier (results not shown in the table). Current use of tobacco (any product) was reported by 44.4% (boys50.4%, girls 36.9%). Current smokeless tobacco use was reported by 35.1% (boys 39.7%, girls 29.4%), whereas smoking by 21.2% (boys 28.6%, girls 12.4%). Cigarette smoking was reported by 10.3% (boys 13.4%, girls 6.6%) (Table 15). Smokeless tobacco use in the form of chewing was reported by 57.5% and applying by 28.8%. Among chewers, gutka use was the most popular, reported by 21.3% followed by tamol with tobacco 10.5% (boys 17.0%, girls 2.6%) and tamol without tobacco 23.0% (boys 23.7%, girls 22.1%). Thus boys equally liked tamol with tobacco as well as without tobacco, whereas girls preferred tamol mainly without tobacco. Among appliers, majority preferred tobacco toothpaste (25.0%). Almost all cigarette smokers (over 94%), over three four of smokeless tobacco users among boys and about one fourth of smokeless tobacco users among girls reported needing tobacco as first thing in the morning (results not shown in the table). Compared to never tobacco users, tobacco users were much more positive towards tobacco use by others; such as boys or girls who use tobacco looks more attractive, men or women who smoke is successful. Tobacco users felt that tobacco helped people to feel more comfortable at parties around 5.5 times more often than never tobacco users. Tobacco users also felt that tobacco helped in relieving toothache or in morning motion 4 to 5 times more often than never tobacco users. Never tobacco users thought that smoking helped in losing weight 2.6 times more often than smokers. Also, never tobacco users felt that tobacco habit was difficult to quit 2 to 4 times more than tobacco users. Students feel that tobacco use in any form (smoking or smokeless) and ETS was harmful more often by never tobacco users than tobacco users (Table 16). Cigarette smoking at home was reported by 71.5%, more by girls (81.9%) than boys (67.3%) (results not shown in the table). Parental tobacco use was reported 2.6 times more often by tobacco users as compared to never tobacco users. Smoking by most or all friends was reported 11 to 14 times more often by tobacco users than never tobacco users (Table 16). Purchasing tobacco product in a store was reported by 79.2% (boys 89.5%, girls 53.9%) and almost no one (> 90%) was refused a purchase because of their age (results not shown in the table). Over 94% tobacco users reported that they were exposed to environmental tobacco smoke (ETS) at home as well as outside their home, whereas 66% of never tobacco users reported being exposed at home and 70% outside home. Never tobacco users favoured banning smoking in public places 2 to 7 times more often than tobacco users (Table 16). Among cigarette smokers, 32.9% wanted to quit smoking, far more girls (85.5%) than boys (11.9%) while 10.7% students had already tried to stop smoking during the past year. Classroom teaching during the past year on various aspect of tobacco use like dangers of smoking and chewing tobacco, reasons why people of their aged smoke or chew and the effect of smoking and chewing tobacco was reported by 12% to 15% of students. Watching of advertisements of various tobacco products (cigarette, gutka) on different media (TV, outdoor media, newspaper/magazines, social events) was reported by 49% to 73% of students (Figure 8). Discussion The data available on tobacco use by youth and related problems is weak, except in few developed countries. The GYTS was initiated as a means of providing baseline data on youth and tobacco for all countries. This study demonstrates that among 13 to 15 year-old schools going students in North-eastern India the current tobacco use prevalence is very high. The highest percentage of young people currently using any tobacco product in the North-eastern states of India was in Nagaland (63%) and the lowest (which is very high by any standard) in Assam (36%). Tobacco was used both in smokeless forms and for smoking in North-eastern states like in all other parts of India. The highest prevalence of smoking was reported in Mizoram (34.5%); even the lowest (Assam, 19.7%) was considerably high, higher than the global median of current cigarette smoking (13.9%), indeed current use of any tobacco product (18.7%).4 In India it is generally thought that smoking by girls is socially unacceptable and therefore they do not smoke very much but in the North-eastern states, girls reported a high smoking prevalence, ranging from 28% in Mizoram to 8.3% in Arunachal Pradesh. Unlike in other parts of India cigarette smoking was the most popular form of tobacco smoking in the Northeast. The highest current smokeless tobacco use was reported in Nagaland (49.9%), and the lowest (Assam, 25.3%) was also quite high. The current smokeless tobacco use even among girls was quite high (20.4% in Assam to 47.2% in Nagaland); in Arunachal Pradesh it was higher among girls than boys (girls 40.2% vs. boys 35.0%). Even though tobacco use by small children is thought to be not culturally acceptable in Indian society, initiation of tobacco use by 10 years of age was reported by over 65% of tobacco users in all the North-eastern states of India except Mizoram (24%). These results are along the same lines as those found in a small study in three rural areas in Gujarat, Tamilnadu and Karnataka, where one third to one half of children under the age of 10 years experimented with smoking or smokeless tobacco in some form.8 This is of concern, since the younger the children start using tobacco, the more likely are they to become addicted and die from tobacco related diseases. Consequently, strategies to reduce initiation of tobacco use need to be targeted more towards younger age groups. A major criterion for tobacco dependence is the interval within which a tobacco product is needed after getting up in the morning. In this study, around three fourths of cigarette smokers and around half of the smokeless tobacco user reported needing tobacco first thing in the morning in almost all the North-eastern states of India. The need was more common among cigarette smokers than among smokeless tobacco users. This shows that children were already developing dependency on tobacco at a very young age. Cigarette smoking at home was reported by a high proportion of youth in all the North-eastern states (30.4% to 71.5%), but interestingly it was reported more among girls than boys in Assam (91.6% vs. 65.9%), Tripura (81.9% vs. 67.3%), Meghalaya (50.7% vs. 40.2%), Sikkim (40.1% vs. 31.5%) and Mizoram (39.7% vs. 26.6%). It is not known whether this cigarette smoking was practiced in front of family members but obviously it would be known to family members and implied a tacit approval of girls' smoking by the family. Hardly any youth reported any difficulty in buying tobacco products despite their young age, indicating that laws restricting access to minors were not working. The proportion of students who wanted to give up smoking varied considerably in this study (10% to 85%). Similar variation was apparent in receiving help or advises to give up smoking (11% to 87%). The states that reported more help or advice for quitting smoking reported more interest in quitting smoking. So programmes and interventions targeting young people need to expand their focus to include both preventing initiation as well as offering youth cessation programmes. There are several recent reports, predicting an increase in oral cancer incidence in India. This prediction is based upon the observation of an increasing prevalence of oral submucous fibrosis, especially in younger individuals, caused by industrially manufactured smokeless tobacco products.9-12 The majority of tobacco chewers in the present study reported chewing gutka, confirming the countrywide trend of increasing gutka use. Gutka is one of the most highly advertised products in almost all media and it is noteworthy that tobacco users reported seeing more tobacco advertisements compared to never users. A high percentage of users showing positive attitude towards tobacco use by others seems to be an effect of tobacco advertising. Youth-targeted media advertisements and sports sponsorship influence this attitude. Sports sponsorship by tobacco companies influence the childrens' minds and helps initiate smoking in India.13, 14 In this study several factors showed a strong association with tobacco use: parental and closest friends' tobacco use; lack of knowledge on harmful effects of tobacco; positive attitude towards tobacco use by others; and viewing of tobacco advertisements. Several of these associations have been reported worldwide, for example, parental tobacco use.15 Despite high prevalence, it should be noted that four out of five young students are non-smokers and they need to be protected from tobacco smoke in homes and in public places. Perhaps little can be done about exposure at home except to educate the public on the need to restrict smoking at home for health reasons, but for preventing exposure in public places, the Supreme Court of India has already imposed ban on smoking in public places.16 This needs to be implemented vigorously, while the public need to be informed about the danger of environmental tobacco smoke. In Western settings, intervention programs have been successful, at least in delaying initiation of smoking.17-19 A comprehensive school tobacco control policy comprising a combination of tobacco-free school policies and an evidence-based curriculum linked to community-wide programs involving families, peers, and organizations with counter-marketing campaigns and community-based activities have shown success in reducing smoking in schools in USA.20 There is greater potential for school-based awareness programs in the North-eastern as well as the whole of India followed by cessation initiatives. The findings of the GYTS will enhance the capacity of countries to design, implement, and evaluate their own tobacco control and prevention programmes by following a standard format. It also offers a unique tool for improving the information base on tobacco use among young people, which will support medium-term and long-term programming and advocacy actions for youth targeted tobacco control. Acknowledgments This study was funded by the Tobacco Free Initiative, WHO, Geneva and the technical assistance was provided by the Office on Smoking and Health, CDC, Atlanta. The views expressed in the article, however, are those of the authors. We wish to thank the Government of India, Governments of respective states in the North-eastern region and the Ministries of Education, for their permission and administrative help for carrying out the survey. The Unit of the National Informatics Centre, India provided enrolment information. We are grateful to the students and school personnel who helped enthusiastically with this research. References
Copyright 2003 - Indian Journal of Cancer
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