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Table of Contents
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 110-115

Prevalence of tobacco use among school-going adolescents in India: A systematic review of the literature

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 Publication17-May-2019

Correspondence Address:
B Kumara Raja
Tagore Dental College and Hospital, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_16_19

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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 2022 May 24];1:110-5. Available from: https://www.crstonline.com/text.asp?2018/1/2/110/258534

  Introduction Top

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.[1] 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.[2]

Around 80% of the world's 1.1 billion smokers live in low- and middle-income countries.[2] India is the third largest tobacco producing nation and second largest consumer of tobacco worldwide.[3] 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.[4]

Children are more sensitive to tobacco advertisements than adults.[5] The World Health Organization (WHO) had reported that tobacco use has doubled in the past four decades particularly among the youth.[6] 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.[7] 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.[8]

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.[9] 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.[10] 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.[11]

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.[12]

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.[13] 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.[14] 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.[15]

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 Top

A systematic literature review was conducted with an aim to identify the studies that examined tobacco usage among school-going adolescents in India.

Search strategy

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.
Figure 1: Search strategy

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Inclusion criteria

  • 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.

Exclusion criteria

  • 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 Top

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].
Table 1: General characteristics of included studies in this review

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The sample size of the included studies ranged from 300[27] to 12,086,[26] and the cumulative sample total was 50,390. The prevalence of tobacco usage among school-going adolescents ranged between 5.9%[17] and 49%[23] [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 [28],[34] 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%[16] and 68.3%[28] whereas the prevalence of smoking among females ranged between 1.6%[16] and 32%[35] [Table 1].

  Discussion Top

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.[23] 'Ever users' were defined as anyone who had used tobacco even once in any form at any point in their lifetime.[19],[30] 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.[35],[36]

The prevalence of tobacco usage among school-going adolescents ranged between 5.9%[17] and 49%.[23] 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,[2] 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.[17] 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.[19],[20],[22],[23],[27],[30],[32],[34]

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.[7],[17],[19],[22],[24],[27],[30],[32],[33],[34] This was in accordance with the systematic review reported among Nigerian youths.[35] 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.[37] Parents' smoking behavior,[7],[16],[19] family conflict,[22] stress,[23] and curiosity [25],[27] 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 Top

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 Top

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