|Year : 2018 | Volume
| Issue : 2 | Page : 110-115
Prevalence of tobacco use among school-going adolescents in India: A systematic review of the literature
B Kumara Raja1, V N Kavitha Devi2
1 Department of Public Health Dentistry, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
2 Oral and Maxillo Facial Surgeon, Private Practitioner, Chennai, Tamil Nadu, India
|Date of Web Publication||17-May-2019|
B Kumara Raja
Tagore Dental College and Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Individuals who initiate tobacco use during adolescence are likely to continue the use into adulthood, and this constitutes a major risk factor for premature death. The purpose of this study was to systematically review existing literature on the prevalence of tobacco use among school-going adolescents in India. Records were searched from the various databases such as PubMed, PubMed Central, Cochrane Library, Embase, and Google Scholar for studies published from 2000 to 2018. A total of 20 studies with a total population of 50, 390 were reviewed. The prevalence of tobacco smoking among school-going adolescents ranged from 5.9% to 49%. The common risk factor for tobacco usage among school-going adolescents was found to be peer pressure. Parents' smoking behavior, family conflict, stress, and curiosity were also found to be additional risk factors. The prevalence of tobacco usage among school-going adolescents was found to be high. These findings emphasize the need for formulating strict tobacco control policies at school premises.
Keywords: Adolescence, adolescents, India, school, smoking, review, tobacco
|How to cite this article:|
Raja B K, Devi V N. Prevalence of tobacco use among school-going adolescents in India: A systematic review of the literature. Cancer Res Stat Treat 2018;1:110-5
|How to cite this URL:|
Raja B K, Devi V N. Prevalence of tobacco use among school-going adolescents in India: A systematic review of the literature. Cancer Res Stat Treat [serial online] 2018 [cited 2020 Jan 20];1:110-5. Available from: http://www.crstonline.com/text.asp?2018/1/2/110/258534
| Introduction|| |
Tobacco use is the leading single preventable cause of deaths worldwide. Each year, an estimated 7 million deaths are attributed to the use of tobacco. More than 6 million of those deaths are the result of direct tobacco use while around 890,000 are the result of nonsmokers being exposed to second-hand smoke.
Around 80% of the world's 1.1 billion smokers live in low- and middle-income countries. India is the third largest tobacco producing nation and second largest consumer of tobacco worldwide. Smoking is contributing in a major way to India's increasing burden of non-communicable diseases. If the current trends continue, tobacco will account for 13% of all deaths in India by 2020.
Children are more sensitive to tobacco advertisements than adults. The World Health Organization (WHO) had reported that tobacco use has doubled in the past four decades particularly among the youth. Adolescence is a developmental period where behavior is influenced by emotional and social functions. Studies have also reported that adolescent youth who initiate tobacco use will continue using it lifelong, with very low quit rates. This is due to the presence of nicotine which is the prime constituent of tobacco, and is a highly addictive substance which makes youths more vulnerable to becoming addicts compared with adults.
In 2016, the Center for Disease Control and Prevention estimated that upward of 4 million middle school and high school students in the United States used tobacco products. The National Epidemiological Surveys deliver key findings on the proportion of youth that is consuming tobacco. The National Youth Tobacco Surveys (NYTS) were designed to provide data on middle school and high school students' tobacco behaviors, as well as attitudes, beliefs, and exposure to pro- and anti-tobacco influences. Results from the 2011 to 2016 NYTS revealed that approximately 20.2% of high school students (grades 9–12) reported current tobacco use, which was defined as having used any tobacco product in the past 30 days.
In India, as per the Global Adult Tobacco Survey-2, there are 266.8 million tobacco users aged 15 or above. Among current users, 202.0 million are men and 64.8 million are women. About 12.2% started using tobacco daily before turning 15 years, 23.6% started when they were between 15 and 17 years, and 19.4% started tobacco use at 18–19 years.
There are several factors that increase the risk of youth smoking, and these include tobacco advertisements, promotion, easy access to tobacco products, and low prices. The early initiation of smoking habits and constant exposure to tobacco products increase the relative risk factor in the occurrence of serious acute or chronic health disorders. Moreover, chronic nicotine use in adolescence has also been shown to induce epigenetic changes that sensitize the brain to other drugs and increase the risks for future substance abuse.
Although research on smoking among adolescents had been carried out over the past two decades, only few systematic reviews have been reported with context to Indian school-going children. Hence, this review was undertaken to review the existing literature on tobacco use among Indian school-going adolescents. These data can help to formulate and adapt control measures aimed at tobacco cessation among school-going adolescents.
| Materials and Methods|| |
A systematic literature review was conducted with an aim to identify the studies that examined tobacco usage among school-going adolescents in India.
Literature identification and selection of articles were performed through searching core databases such as PubMed, PubMed Central, EMBASE, Cochrane library, and Google Scholar; subject experts were contacted through emails and hand search of the journals was also performed [Figure 1]. The search was focused on studies examining the prevalence of tobacco usage among school children. The articles were searched using a combination of the following Medical Subject Heading (MeSH) terms: India, tobacco, smoking, adolescent, and schools. References of eligible studies were also searched for possible inclusion. Database searches were conducted independently by first author. Articles resulting from these searches and relevant references cited in those articles were also reviewed.
- The articles which were published from January 2000 to November 2018 were included
- Original research articles which reported the prevalence of tobacco usage among school-going children aged between 13 and 16 years were included
- The studies which were conducted in India and studies which assessed smoking behaviors were included
- Studies with reported the prevalence of “Ever users” were included.
- The studies which reported case reports, case series, reviews, and letter to the editor were excluded
- The studies published in languages other than English were excluded
- Articles with only abstracts were excluded
- Unpublished articles in the press and personal communications were also excluded.
| Results|| |
This systematic literature review focused on studies that investigated the prevalence of tobacco usage among Indian school-going adolescents published from January 2000 to November 2018. The preliminary search yielded 189 articles from electronic databases using the selected MeSH terms. A further eight potential articles were identified from the reference list of initially identified articles. Then, a total of 177 articles were excluded as they were not related to the main outcome of our study. Finally, a total of 20 articles were included for the final analysis [Table 1].
The sample size of the included studies ranged from 300 to 12,086, and the cumulative sample total was 50,390. The prevalence of tobacco usage among school-going adolescents ranged between 5.9% and 49% [Table 1].
About 4 (20%) studies were conducted in the southern part of Indian and 16 (80%) studies were conducted in the northern part of India. Only two studies , were conducted in more than one region, whereas other studies were city specific.
Among gender-specific studies, the prevalence of smoking among males ranged between 5.2% and 68.3% whereas the prevalence of smoking among females ranged between 1.6% and 32% [Table 1].
| Discussion|| |
The WHO has defined an 'adolescent' as a person in the 10–19 years age group. Adolescence is generally divided into three stages of development: early (10–13 years), middle (14–15 years), and late adolescence (16–19 years) stages. It is usually seen that risk-taking behaviors begin to manifest from middle adolescence onward. 'Ever users' were defined as anyone who had used tobacco even once in any form at any point in their lifetime., In this systematic literature review, the prevalence rate of adolescence tobacco usage was reported.
Most of the included studies were reported from northern part of India, reflecting the varying research productivity across geopolitical zones. Majority of the included studies included both the genders which was in contrast to previously conducted systematic reviews from other countries.,
The prevalence of tobacco usage among school-going adolescents ranged between 5.9% and 49%. These differences can be explained by the variation in the sample size of each included study, as well by the particular differences between the populations assessed. In the study by Soni and Raut, which showed the highest prevalence of tobacco usage, where it was seen that of the total sample of 600 students, 49% of students were regular users of tobacco in any form, 32% experimented with tobacco once or more in their lifetime but did not consume it regularly, and only 18% had never used tobacco in any form. In contrast, Basakhetre et al. observed that only 5.9% of the 1000 students were tobacco users. It is possible that this divergence is due to the different number of participants in each study since the second one assessed a larger sample than the first.
In India, the Global Youth Tobacco Survey (GYTS) was a school-based survey of students in grades 8, 9 and 10 conducted in 2009. It showed the prevalence of the current use of any tobacco products was 14.6%. In our review, most of the included studies showed prevalence rate above the GYTS – India.,,,,,,,
Most of the studies have attempted to characterize the reason that led to tobacco usage among adolescent school-going children. Among the reviewed articles, the most common risk factor was found to be peer pressure.,,,,,,,,, This was in accordance with the systematic review reported among Nigerian youths. Thus, the influence of peer smoking is multifaceted, both the number of peers who smoke and peer approval of smoking are positively related to smoking initiation in adolescence. Parents' smoking behavior,,, family conflict, stress, and curiosity , were found to pose additional risk factors for tobacco usage among adolescents. In regard to the methodology employed, all the included studies investigated the prevalence of tobacco usage by cross-sectional method. In this context, it is vital that longitudinal studies should be carried out to investigate the relationship between the school students and tobacco usage, to identify what are the actual situations that lead to the use of tobacco.
Findings of the current review must be interpreted keeping in mind the methodology of the original studies. First, data for all included studies were collected through self-administered questionnaires. Thus, the assessment of the tobacco-use status was entirely dependent on the response given by the subjects, although false reporting was considered unlikely. In order to overcome this shortcoming, studies validating biomarkers can be included in future reviews. Secondly, we performed a review, not a meta-analysis, hence qualitative data will not be available for future evaluation.
| Conclusion|| |
The prevalence of tobacco usage among school-going adolescents was found to be high. The present review suggests a need for formulating strict tobacco control policies at school premises by announcing school environment as a tobacco-free zone, prohibiting tobacco use by school personnel in school premises, and monitoring the high-risk behaviors of adolescents in schools. Moreover, school-based interventions involving families of school children may help in controlling the risk behaviors among adolescents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017: Monitoring Tobacco Use and Prevention Policies. Geneva: World Health Organization; 2017.
Sinha DN, Palipudi KM, Gupta PC, Singhal S, Ramasundarahettige C, Jha P, et al.
Smokeless tobacco use: A meta-analysis of risk and attributable mortality estimates for India. Indian J Cancer 2014;51 Suppl 1:S73-7.
World Health Organization. Framework Convention on Tobacco Control. Geneva: World Health Organization; 2005.
Bonnie RJ, Lynch BS, editors. Growing up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, D.C: National Academies Press; 1994.
World Health Organization. The economic and Health Benefits of Tobacco Taxation. Switzerland: World Health Organization; 2015.
Thakur D, Gupta A, Thakur A, Mazta SR, Sharma D. Prevalence of cigarette smoking and its predictors among school going adolescents of North India. South Asian J Cancer 2014;3:193-5. [Full text]
Harvey J, Chadi N, Canadian Paediatric Society, Adolescent Health Committee. Preventing smoking in children and adolescents: Recommendations for practice and policy. Paediatr Child Health 2016;21:209-21.
Health, CDC's Office on Smoking and (2017-09-20). “CDC – Fact Sheet –Youth and Tobacco Use – Smoking and Tobacco Use”. Smoking & Tobacco Use; Retrieved 13 December, 2017.
Health, CDC's Office on Smoking and (2017-10-19). “CDC – National Youth Tobacco Survey (NYTS) – Smoking and Tobacco Use”. Smoking & Tobacco Use; Retrieved 13 December, 2017.
Jamal A. Tobacco use among middle and high school students – United states, 2011-2016. MMWR Morb Mortal Wkly Rep 2017;66:597-603.
Government of India. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act. Government of India; 2003.
Bewley BR, Bland JM, Harris R. Factors associated with the starting of cigarette smoking by primary school children. Br J Prev Soc Med 1974;28:37-44.
Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. J Physiol 2015;593:3397-412.
Kedar A, Gupta S, Singh KJ. Tobacco use and its determinants among 13-15 year old adolescents of two central government schools of New Delhi district. Int J Community Med Public Health 2017;4:1912-7.
Basakhetre U, Jaiswal A, Deolia S, Sen S, Dawngliani M, Jaiswal A. Prevelance of tobacco use among school children reporting to dental hospital for treatment. J Datta Meghe Inst Med Sci Univ 2017;12:242-5. [Full text]
Arora V, Gupta N, Gupta P, Bansal M, Thakar S, Nagpal I. Cigarette smoking behavior and associated psychosocial determinants among school going adolescents in Panchkula, India. J Indian Assoc Public Health Dent 2017;15:27-31. [Full text]
Thakur SS, Sachdeva1 A, Singh H, Barwal V. Prevalence and determinants of tobacco use among school going adolescents in a Hilly DISTRICT of Himalayan Region in India. Sch J Appl Med Sci 2017;5:4074-9.
Sabnis R, Sahu K, Thakur D, Surana S, Mazhar H, Pandey S. Urban and rural disparity in tobacco use and knowledge about oral cancer among adolescents: An epidemiological survey on 12 and 15-year school going students. J Int Soc Prev Community Dent 2016;6:S226-31.
Jaisoorya TS, Beena KV, Beena M, Jose DC, Ellangovan K, Thennarasu K, et al.
Prevalence & correlates of tobacco use among adolescents in Kerala, India. Indian J Med Res 2016;144:704-11.
] [Full text]
Bagchi NN, Ganguly S, Pal S, Chatterjee S. A study on smoking and associated psychosocial factors among adolescent students in Kolkata, India. Indian J Public Health 2014;58:50-3.
] [Full text]
Soni P, Raut DK. Tobacco use among school students in national capital territory of Delhi. J Alcohol Drug Depend 2013;1:120.
Muttappallymyalil J, Divakaran B, Thomas T, Sreedharan J, Haran JC, Thanzeel M. Prevalence of tobacco use among adolescents in North Kerala, India. Asian Pac J Cancer Prev 2012;13:5371-4.
Narain R, Sardana S, Gupta S, Sehgal A. Age at initiation & prevalence of tobacco use among school children in Noida, India: A cross-sectional questionnaire based survey. Indian J Med Res 2011;133:300-7.
] [Full text]
Gajalakshmi V, Kanimozhi CV. A survey of 24,000 students aged 13-15 years in India: global youth tobacco survey 2006 and 2009. Tob Use Insights 2010;3:23-31.
Bhojani UM, Chander SJ, Devadasan N. Tobacco use and related factors among pre-university students in a college in Bangalore, India. Natl Med J India 2009;22:294-7.
Dongre A, Deshmukh P, Murali N, Garg B. Tobacco consumption among adolescents in rural Wardha: Where and how tobacco control should focus its attention? Indian J Cancer 2008;45:100-6.
] [Full text]
Singh V, Pal HR, Mehta M, Kapil U. Tobacco consumption and awareness of their health hazards amongst lower income group school children in National Capital Territory of Delhi. Indian Pediatr 2007;44:293-5.
Madan Kumar PD, Poorni S, Ramachandran S. Tobacco use among school children in Chennai city, India. Indian J Cancer 2006;43:127-31.
] [Full text]
Singh V, Gupta R. Prevalence of tobacco use and awareness of risks among school children in Jaipur. J Assoc Physicians India 2006;54:609-12.
Singh G, Sinha DN, Sarma PS, Thankappan KR. Prevalence and correlates of tobacco use among 10–12 year old school students in Patna District, Bihar, India. Indian Pediatr 2005;42:805-10.
Pednekar MS and Gupta PC. Tobacco use among school students in Goa, India. Indian J Public Health. 2004;48:147-52.
Sinha DN, Gupta PC, Pednekar MS. Tobacco use among students in the eight North-eastern states of India. Indian J Cancer 2003;40:43-59.
] [Full text]
Oyewole BK, Animasahun VJ, Chapman HJ. Tobacco use in Nigerian youth. A systematic review. PLoS one 2018;13:e0196362.
Braithewaite R, Addo J, Smeeth L, Lock K. A systematic review on tobacco smoking prevalence and description of tobacco control strategies in Sub – Saharan African countries; 2007-2014. PLoS one 2015;10:e0132401.
Nargiso JE, Becker SJ, Wolff JC, Uhl KM, Simon V, Spirito A, et al.
Psychological, peer, and family influences on smoking among an adolescent psychiatric sample. J Subst Abuse Treat 2011;42:310-8.