Knowledge, Attitude and Practice of Tobacco use among
60 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2
MATeRIAlS ANd MeThOdOlOgy A cross sectional study was carried out in a Pimpri Chinchwad Municipal Corporation School in Pune in the year 2015 for a period of 2 months (July-August).
Total of 566 volunteer school children of 11-15 years were included in the study. Those who were absent at the time of study were excluded. Prior Permission and consent from the school authority was taken to carry out the study. The study was carried out in two stages, Stage 1: Questionnaire Administration and Stage 2: Oral Examination.
A close ended questionnaire was designed with 21 questions related to Knowledge, Attitude and Practice on tobacco consumption. The validated questionnaire was provided in both English and Marathi. Data was collected on the use of tobacco, age of initiation, smoking habits of parents and sibling, peer influence, reason of initiation of tobacco, places of tobacco consumption and purchase of tobacco. Tobacco use was classified as, ever use (use of tobacco even once) and current use.7 In the second stage, oral examination was done by trained professionals using diagnostic instruments.
Oral examination for tobacco related oral lesions like stains, attrition, gingivitis,periodontitis, tobacco pouch keratosis, smoker’s palate, leukoplakia, erythropakia and oral cancer. Data was collected into an excel sheet and descriptive analysis was done using statistical software programs (SPSS) version 20.
ReSulTS
Out of 570 students,566 students who participated in the study were females 51.41 % and 48.59 % were males. The response rate in the present study was 99.29%. Out of total participants,8.83 %were tobacco users;out of them, 16.78% of males were smokers and only 0.06% of females reported tobacco use in the form of quid placement. The mean age of initiation for tobacco use was around 11.5 yrs.
On assessing the practices of forms of tobacco use, the frequency of smoking showed 0.5% students were daily smokers, 7.2 % had habit of smoking, 4.2% were students smoked occasionally and a significant amount of students, i.e. 87.4% were non smokers (Table 1).On duration of habit analysis, 87.7% of tobacco smokers had smoked less than 6 months ago, 8.1% had smoked for over a year and only 0.4% had been smoking for about
4-8 years(Table 1).Among the students that were found positive for smoking, 88% of them smoked less than 5 cigarettes per day, 10% smoked 10-15 cigarettes and 0.4
% smoked more than 20 cigarettes on daily basis.6%
and 0.5% smoked tobacco in the forms of a cigarette and beedi respectively.1.8% of them had consumed gutka and 15.8% had tobacco along with the betel leaf (paan).
20% of students had habit of alcohol consumption (Table 1).30% of the students gave history of parental smoking.
It was found that 52.2% of them were aware that tobacco use causes dental staining. 61.9% and 50.7%
of them recognized the health hazard of lung and oral cancer respectively.48.2% of students were aware about the sale of tobacco in the vicinity of the school.
6.7 % of the students commenced smoking due to their peers. 3.2% of the smokers stated that according to them smoking raised their social standard.1.6% students attempted smoking out of curiosity.0.5% of students reported initiation due to stress.0.4% of them stated that familial environment was the reason for their tobacco use.Peer groups were found out to be the most preferred company for smoking 8.8% of students revealed that they smoke with their peers. 3% of the students stated that they preferred smoking alone.0.4% of the students claimed that they smoked with their parents. 0.9% of the smoking population said that they also smoked in the school premises. Parental smoking also influenced 38%
of the students. 70.4% students stated that they were never educated about the health hazards of tobacco.
81.2% students reported that they have been made aware about the ill-effects of tobacco abuse either by their doctors, parents or friends. 35% and 3.9% of the students claimed that they were satisfactory and poor in their academics respectively. 1.4% of tobacco users reported that they placed quid on various sites in the mouth for more than 10 minutes out of which 1.6%
consume it along with slake lime and 0.2% with betel nut leaf.The most common site of quid placement was buccal mucosa followed by labial mucosa.
In second stage, on oral examination tobacco related stains were noted as most common finding in 5.3% of students. Tobacco pouch keratosis was noted in 1.9%
and smoker’s palate and discoloration in 1.5% students.
Leukoplakia and attrition was noted in 0.8% cases. Out of the 5 cases of leukoplakia, 4 were homogeneous and 1 case was of non-homogeneous leukoplakia (Table 1).
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 61 Table 1: showing percentage of tobacco
consumption, frequency, duration and related oral lesions
Response rate to the
questionnaire Frequency Percentage Responded
Not Responded 566
4 99.29
0.7 Tobacco use
Yes 68 12.01
No 498 87.4
Type of tobacco Smoking
Cigarette smoking 36 06
Beedi smoking 03 0.5
Smokeless
Gutka 10 1.8
Tobacco with betel leaf 89 15.8 Current smoking status
Daily smoker 3 .5
Occasional smoker 24 4.2
Former smoker 41 7.2
Non smoker 498 87.4
Total 566 99.3
duration of smoking
Less than 6 months 500 87.7
6months to 1 year 46 8.1
1-4years 10 1.8
4-8years 8 1.4
More than 8 years 2 0.4
Total 566 99.3
No. of cigarettes smoked per day
Less than 5 506 88.8
5-10 57 10
10-15 1 0.2
More than 20 2 0.4
Total 566 99.3
Consumption of alcohol
along with tobacco 14 20
Oral examination
Tobacco related stains 30 5.3
Tobacco pouch keratosis 11 1.9
Smoker’s palate and
discoloration 9 1.5
Leukoplakia and
attrition 5 0.8
Few other finding of relevance was vesicle formation on buccal mucosa was noted in three cases. One student gave a positive history of reverse smoking on the same day and pinpoint bleeding spots were noted on the palate.
9.1% of tobacco users revealed that they desired to quit smoking and4.4% of them had made several attempts to quit but remain unsuccessful and prefer attending tobacco cessation programs.
dISCuSSION
The Global Youth Tobacco Survey reported that among adolescent children, smoking is the predominant form of tobacco use in the developed countries, whereas in the developing countries smokeless tobacco is equally prevalent.1 Using this background the present study was carried out among school children.
In the current study, 8.83% of the total students were users of some form of tobacco. The male prevalence was significantly higher than females for tobacco abuse.
These findings were found to be consistent with a study byMuttappallymyalil Jet al study, 8.5% of the total students were users of some form of tobacco. Among males, the prevalence observed was 15.9% and none of the female students in the study had the habit of tobacco use.1 This study supports the findings of the present study.
Out of 566 students 80 of them were ‘ever tobacco users’, hence 14.13% of students started using tobacco before the age of 11.5years. These findings are in accordance with a study conducted by Narainet alin which it was found that 31% of ever tobacco using students started using tobacco before the age of 11 years.3
In current study, 0.5% students were daily smokers, 7.2 % had tried smoking some time in their life, 4.2%
were students who smoked occasionally and a significant amount of students, i.e. 87.4% had never tried smoking.
On analysis it was determined that 87.7% of tobacco smokers had smoked less than 6 months ago, and very less percent (0.4%) had habit for more than one year.
Among the smokers majority of them had less frequency of smoking (88%).10% smoked 10-15 cigarettes per day and very less students had high frequency(0.4%) of smoking more than 20 cigarettes on daily basis. The above findings are unique to this study as frequency of smoking was not reported in the literature reviewed.
A study by Tsering et al reported that around 15%
of the responders expressed a desire to quit the habit of
62 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 substance abuse4 whereas in this study 9.1% of tobacco
users revealed that they desired to quit smoking and 4.4% of them had made several attempts to do so but were not successful.
In this study,the use of smokeless tobacco was more as compare to smoking.10.5% students had smoked tobacco in the forms of a cigarette and beedi.1.8% of them had consumed gutka and 15.8% had tobacco powder along with the betelnut leaf (paan). A study done by Narainet al has also reported 5.3% of students had ever smoked cigarette.3 Out of total tobacco consumption, 46.4% of males consumed gutka in the study conducted by Dongre et al [6] which was more than the percent (1.8%) observed in the present study. Very few (0.66%) of females had habit of gutka consumption.
Another important finding was20% of the students had habit of alcohol consumption along with the tobacco.
52.2%, 61.9% and 50.7% of students were aware that tobacco use causes dental staining, lung and oral cancer respectively.Dongreet al also noted that reasons for non-use of tobacco among students were fear of cancer and poor oral health.6 Sagarkaret al reviewed that exposure to second hand smoke in public places is high which was in accordance to this study as 30% of the students have fallen prey to passive smoking.2
In this study 48.2% of students were aware about the sale of tobacco in the vicinity of the school.
Muttappallymyalilet al found that 39% of the students revealed that the tobacco products were purchased from the shops located near the schools.1
Reasons for initiation for tobacco consumption were assessed and it was found that peer pressure acted as a primary influence. 6.7 % of the students commenced smoking due to their peers. 3.2% of the smokers stated that according to them smoking raised their social standard.1.6% students attempted smoking out of curiosity.0.5% of students reported initiation due to stress. Similar findings were noted in a study by Dongreet al where overall 47.3% adolescents consumed tobacoo products due to peer pressure and 32.7% felt well due to its consumption.
Dongre et al noted that, in rural settings, family members and neighbors who often ask young children to get tobacco from nearby shops, local media advertisements and colourful attractive packing of
tobacco products acts as another pro tobacco influences for new children to take up tobacco habit which relates with the findings of this study in which 0.4% of student stated that familial environment was the reason for their tobacco use.6 On the other hand,77% of students in this study found the anti- smoking advertisements helpful in creating awareness.
In this study 0.9% of the smoking population said that they smoked in the school premises.Narain et al stated that low socioeconomic status of government school students may be responsible for tobacco use, as it is readily available and inexpensive.3 The knowledge imparted by the school authorities can help students avoid adverse habits, unfortunately, in the present study 70.4% students stated that they were never educated about the health hazards of tobacco and its use.
Although 81.2% students reported that they have been made aware about the ill-effects of tobacco abuse either by their doctors, parents or friends. Many studies have emphasized on the necessity of implementing tobacco awareness programme for school children.Shamimet al has discussed the significance of training to deliver effective tobacco dependence intervention programmes.5
In current study 1.4% of tobacco users reported that they placed quid on various sites in the mouth for more than 10 minutes out of which 1.6% consume it along with slake lime and 0.2% with betel nut leaf.
Muttappallymyalilet al showed that smokeless tobacco forms are applied to the mandibular or labial groove for 10-15 minutes by most people and then they chew it slowly.1
Staining was the most common finding observed in 5.3%, followed by hyperkeratosis in 1.9% and smoker’s palate and discoloration in 1.5% of students.
Very few percent of students showed leukoplakia and attrition (0.8%). Out of the 5 cases of leukoplakia, 4 were homogeneous and 1 case was of non-homogeneous leukoplakia.
Other findings in the study were about 14.13%
students were ‘ever tobacco users’. The most common site of quid placement was buccal mucosa followed by labial mucosa.Similar findings are noted by Shamim, stating that tobacco associated lesions such as oral leukoplakia and oral submucus fibrosis are the potentially malignant disorders of the oral mucosa that are seen in the young adolescent population in India.5
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 63 Being a premalignant lesion, the finding of
leukoplakia is an alarming and disturbing sign as it is most likely to undergo malignant transformation if the tobacco usage continues. The students who were positive for such lesions were counseled and referred to nearby tertiary dental hospital for further diagnosis and treatment.
CONCluSION
A disturbing aspect has been noted that despite having high awareness of tobacco abuse, the prevalence of tobacco consumption is relatively high and there is increased downward shift in the age of initiation of the same. The students of low socioeconomic status from government schools are more prone to the habit of tobacco abuse so more emphasis should be given on conducting anti-tobacco awareness programs.
ethical Clearance: Taken from Dr. D Y Patil Dental College and Hospital ethics committee
Source of Funding: Self
ReFeReNCeS
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Smokeless tobacco consumption among school children.Ind J Cancer. 2010;47(1):s19-s23.
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3(1):7-11.
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5. Shamim T. Smokeless tobacco use in pediatric population: What is role of dental surgeon in India? Lung Ind. 2012; 29(3):305-306.
6. Dongre AR, Deshmukh PR, Murali N, Garg BS.
Tobacco consumption among adolescents in rural Wardha: Where and how tobacco control should focus its attention? Ind J Cancer. 2008; 45:100-6.
7. Madan Kumar PD, Poorni S, Ramachandran S.
Tobacco use among school children in Chennai city, India. Ind J Cancer. 2006; 43: 127-31.