Social, Cultural and Economic Determinants of Smokeless Tobacco use: Adolescents and Youth

Dr. Gaurang P. Nazar

Research Scientist

Public Health Foundation of India

November 28, 2017

Myriad varieties of tobacco products used in India

Provide opportunities for adolescents to experiment and continue use

Prevalence of SLT use among adolescents: GYTS India 2000-03; 2006; 2009

´  Global Youth Tobacco Survey India

•  Prevalence

•  Cessation

•  Knowledge and attitudes

•  Exposure to SHS

•  Access and availability

•  Exposure to pro- and anti- tobacco media advertising

•  Exposure to tobacco related school curriculum •  Prevalence of SLT use declined sharply between 2000-03

and 2006, particularly among boys.

•  Prevalence of SLT use didn’t change much between 2006 and 2009. (MoHFW, 2017)

14.6

9.4 9

18

10.7 11.1

7.9

7.5 6

0

2

4

6

8

10

12

14

16

18

20

2000-03 2006 2009

Perc

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National trends in prevalence of SLT use among 13-15 year school going adolescents (GYTS India)

Total

Boys

Girls

Gender differences in prevalence of SLT use among adolescents: GYTS India 2000-03; 2006; 2009

´  Across years, prevalence of tobacco use (both smoking and SLT) higher among boys vs. girls.

´  Among boys, SLT use was higher than smoking but difference in prevalence has declined over time – similar prevalence in 2009.

´  Among girls, SLT use has been higher than smoking throughout with little change in difference.

´  Decline in SLT use among boys over the years but not among girls.

10.5

4.2

9.4

3.6

11.2

3.7

18

7.9

10.7

7.5

11.1

6

0

2

4

6

8

10

12

14

16

18

20

Boys Girls Boys Girls Boys Girls

2000-03 2006 2009

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National trends in prevalence of SLT use among 13-15 year adolescents by gender (GYTS India)

Smoking

Smokeless Tobacco

(MoHFW, 2017)

Ever tobacco use trends by gender, grade, socio-economic status and age (Project MYTRI)

Sixth grade (n=6165)

Eighth grade (n=5477)

Ratio* P value

City Chennai Delhi

23.4% (20.1-26.7) 25.4% (23.4-27.4)

8.9% (6.7-11.1) 9% (5.6-12.4)

2.6:1 2.8:1

<0.0001 <0.0001

School Private Government

10.8% (5-16.6)

28.7% (26.7-30.7)

8.9% (6-11.8) 11% (9-13)

1.2:1 2.6:1

0.5426

<0.0001

Sex Girls Boys

20.1% (17.6-22.6) 29.2% (27-31.4)

6.9% (5.1-8.7)

12.1% (9.5-14.7)

2.9:1 2.4:1

<0.0001 <0.0001

Age (years) ≤ 11 12 13 ≥ 14

16.6% (14.4-18.8) 25.3% (22.8-27.7) 30.3% (26.7-33.9) 32.1% (25.9-38.3)

8.3% (3.5-13.1) 6.3% (4.4-8.2)

9.1% (7.5-10.7) 12.1% (8.0-16.2)

2.0:1 4.0:1 3.3:1 2.7:1

0.0003

<0.0001 <0.0001 <0.0001

Data in parenthesis are 95% CI. Estimates generated from mixed-effects models adjusted for (when not stratified by) city, school type, sex, age and grade* age. • Compares prevalence of tobacco in sixth grade with that in eigth grade •  Higher tobacco use prevalence in 6th vs. 8th grade, govt. (low SES) vs. private (high SES) schools, boys vs. girls and in older age groups vs. younger (in each grade)

(Reddy et al., 2006, Lancet)

Why focus on youth?

´  Tobacco industry sees them as attractive new markets ´  Largely non-users

´  Influential age

´  Impressionable age ´  Experimentation ´  Lack of skills to resist

´  Other factors contributing to youth tobacco use in developing countries ´  Low levels of awareness about health effects of tobacco and misconceptions

´  High levels of poverty

´  Weak enforcement of tobacco control legislation

´  Tobacco industry has shifted focus from developed towards developing countries ´  High level of exposure to tobacco advertisements through media

´  Easy access, availability and affordability of tobacco products

´  Social acceptability of tobacco use

´  Poor enforcement of tobacco control policies in schools (especially in government schools)

(Reddy & Gupta, 2004, Shimkhada & Peabody, 2003; Beaglehole & Yach, 2003; CDC, 2009; Sinha et al., 2002; Sinha et al., 2003; Gupta et al. 2002; Patel, 1999, Arora et al, 2010)

Influence of peers and family members on tobacco use

´  Tobacco use by friends and family members is significantly and positively associated with tobacco use among adolescents.

´ A cross-sectional study with 550 adolescents (14-19 years) from Delhi: ´ Having seen brother/sister using tobacco was associated with 5 times the risk of

ever tobacco use (p<0.01). ´ Having seen a best friend using tobacco was associated with nearly 3 times the risk

of ever tobacco use (p<0.01).

´ A cross-sectional study with 1626 (10-12 years) adolescents in Patna: ´  Ever tobacco use associated with tobacco use among friends (OR 5.4, 95%CI

3.3-8.8). ´  Current tobacco use associated with:

´  tobacco use among friends (OR 4, 95%CI 2.0-8.2).

´  Parents and teachers sending them to buy tobacco for them (OR 2.1, 95%CI 1.4-4.2).

(Chaddha & Sengupta, 2002)

(Sharma et al., 2010)

(Singh et al., 2005)

Influence of school environment ´  The Central Board of Secondary Education (CBSE) requires:

´  A Tobacco Free Institution board be prominently placed on the outer boundary wall – No sale of tobacco products inside the premises or within a radius of 100 yards around the educational institution.

´  No smoking by students/teachers/other staff/visitors

´  Display board at prominent places inside the campus – “No smoking area – smoking here is an offence” as mandated by law.

´  Not uncommon to find schools across India where such guidelines do not exist or are not followed.

´  Sinha et al (2004) conducted a study in 50 State Govt and 50 Central Govt (NVs and KVs) schools with 6587 students in grades 8-10 in Bihar.

(Sinha et al., 2004)

Influence of exposure to tobacco advertising and promotion

´  Despite a ban on tobacco advertising and promotion, exposure is common in:

´  Electronic Media

´  Print Media

´  On buses/other public transport/bus stops

´  Billboards/hoardings

´  Point-of-sale

´  Movies

´  Indirect advertising and sponsorship common even for SLT

74 77.5

71.6 74.4

11.2 8.1

0

10

20

30

40

50

60

70

80

90

2006 2009

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Exposure to tobacco advertising and promotion (GYTS India)

Saw anti-tobacco messages in past 30 days

Saw pro-tobacco ads in past 30 days

Were offered free cigarettes by company representatives

(Chaturvedi, 2010)

Tobacco advertisements influence tobacco use among Indian adolescents – Project MYTRI

Being receptive to tobacco marketing and exposure to tobacco advertising are significantly associated with tobacco use among Indian adolescents

(Arora et al., 2008)

Exposure to tobacco use in movies is associated with adolescent tobacco use Association of ever tobacco use with exposure to tobacco use in movies and receptivity to tobacco promotions among Indian adolescents (n=3956)

Exposure variable

OR (95% CI)

Adjusted

Crude

Model I*

Model II †

Model III‡

Movie tobacco use First quartile Second quartile Third quartile Fourth quartile

Reference 0.8 (0.5-1.3) 1.3 (0.8-2.0) 1.9 (1.3-2.9)

Reference 1.0 (0.6-1.7) 1.5 (1.0-2.4) 2.3 (1.5-3.6)

Reference 1.0 (0.6-1.8) 1.5 (0.9-2.5) 2.1 (1.3-3.5)

Reference 1.1 (0.6-2.0) 1.6 (0.9-2.7) 2.3 (1.3-3.9)

Receptive to tobacco promotions No Yes

Reference 3.0 (2.1-4.2)

Reference 2.8 (1.9-3.9)

Reference 2.0 (1.4-3.0)

Reference 2.0 (1.4-3.0)

*Adjusted for age, gender, school type and class. †Adjusted for demographic profiles and receptive to tobacco advertisements, family members using tobacco and friends using tobacco. ‡Adjusted for demographic profiles, social influences, academic performance, sensation seeking and authoritative parenting.

(Arora et al., 2011)

Between 2006-2008, half of top-grossing youth rated (U and U/A) Bollywood movies contained tobacco imagery. 1.91 billion tobacco impressions were delivered by 38 youth rated movies in Indian cinema halls. (Nazar et al., 2013)

Influence of disposable income on use of tobacco products ´  A strong positive association has been observed between disposable income and

SLT use among youth.

´  Oswal (2012) conducted secondary analyses using GYTS 2000-2003 data from 25 states across 4 regions in India.

´  A strong positive association between pocket money and current SLT use was observed in 18 out of 25 states studied after adjustment for close friend being a smoker, close friend being a smokeless tobacco user, parental influence, age, and gender.

´  Strongest associations were observed in:

´  Sikkim (AOR 10.75; 95% CI 7.32 – 15.78)

´  Uttaranchal (AOR 9.53; 95% CI 6.60 – 13.76) (Oswal, 2012)

Poor academic performance, disposable income and adolescent tobacco use

´  1323 boys (12-19 years) from 14 schools in Trivandrum city (Kerala) were studied to assess prevalence and correlates of tobacco use

´  Current tobacco use was:

´  3 times higher among boys securing poor (<40% marks) grade compared to those securing excellent (>80% marks) grade (OR 3.0, CI 1.4–6.6)

´  4 times higher among those who received pocket money compared to those who did not (OR 4.0, CI 2.2–7.4)

(Mohan et al., 2005)

Poverty and tobacco use

´  Tobacco use is higher among the low socioeconomic groups even among the children and adolescents.

´  A qualitative study conducted by Shelter Don Bosco (funded by Path Canada) with 400 street children (6-18 years) in Mumbai showed that

´  Average income was 29 Rs per day (80% earned less than 100 Rs per day)

´  47% chewed gutka, 39% smoked bidi and 28% smoked cigarette

´  Expenditure on gutka was 6 Rs per day (~185 Rs per month)

´  21% of average daily income was spent on tobacco (sometimes as high as 43%)

´  Expenses on other food products, clothes, etc. were lower as compared to tobacco

´  Tobacco was used as an alternative to food, as it “curbs hunger pangs and is inexpensive”

´  They started with these cheap products at young ages and moved on to other drugs, partying, prostitution etc as incomes increased

´  Illness levels were high

´  Tobacco use was a key contributor to poor SES of these children

(John and Vaite, 2003)

Influence of easy access and availability

´  SLT products are easily available and accessible to children and adolescents even around educational institutions.

´  Several youth compelled to sell these products due their poor financial situation.

´  Enforcement is a big challenge.

´  GYTS India 2009 shows:

´  47% of adolescent smokers bought the product from a store

´  56% were not refused the tobacco product because of their age

´  Measures for licensing of tobacco vendors announced by MoHFW in Sept 2017.

51.9 47

72.1

56.2

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10

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2006 2009

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Availability and access to tobacco products among 13-15 year old current smokers (GYTS

India)

Buy tobacco products in a store

Were not refused tobacco product because of their age

(Source: https://blogs.wsj.com/indiarealtime/2013/06/12/indias-battle-to-ban-chewing-tobacco/)

(Source: http://www.searo.who.int/india/tobacco/GYTS_India_report_2003-09.pdf?ua=1)

Influence of knowledge and attitudes towards tobacco use

´  Lack of knowledge about harmful consequences of tobacco use, myths/misconceptions about tobacco use, and positive attitudes towards tobacco use are still prevalent among Indian adolescents.

´  There has been some decline in these indicators between 2006 to 2009 GYTS but they continue to prevail.

´  There has only been slight improvement in imparting tobacco related knowledge through its inclusion in school curriculum but still there is a long way to go.

32.1

24

16.7 13.4

30.2

21.1 20.1

15.6

0

5

10

15

20

25

30

35

2006 2009

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Knowledge and attitudes towards tobacco use among 13-15 year olds (GYTS India)

Boys who smoke or chew have more friends

Girls who smoke or chew have more friends

Boys who smoke or chew are more attractive

Girls who smoke or chew are more attractive

51.2 55.9 54.5

63.3

37.1 37.8

0

10

20

30

40

50

60

70

2006 2009

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Imparting knowledge about tobacco through schools among 13-15 year olds (GYTS India)

Have been taught about the effects of tobacco use in past year

Have been taught about the dangers of tobacco smoke in past year

Have discussed reasons for tobacco smoking among people of their age in past year

(Source: http://www.searo.who.int/india/tobacco/GYTS_India_report_2003-09.pdf?ua=1)

Knowledge and attitudes of adolescents (ages 13–15) towards tobacco use (GYTS 2000–2002 conducted in 8 North-East Indian states) (percent)

(Sinha et al., 2003; MoHFW, 2017)

Psychosocial risk factors and tobacco use among adolescents – Project MYTRI Baseline findings

´  11,642 students in grades 6 and 8 in 32 schools (private and Government) of Delhi and Chennai were surveyed using a self-administered questionnaire to assess tobacco use and it correlates including psychosocial factors.

´  Intentions to use tobacco (chew and smoke), susceptibility to use tobacco, reasons to use tobacco and normative expectations about tobacco use were all positively associated with tobacco use.

´  6th graders had higher psychosocial risk factors compared with 8th graders.

(Reddy et al., 2006, Lancet)

Reasons for areca nut use

´ Social acceptability - used in social gatherings and ceremonies

´ Religious beliefs - auspicious in Hinduism and used to honour guests with betel leaf

´ Perceived health benefits - traditional ayurvedic medicine

´ Addiction - increases alertness, supress hunger, avoid boredom

´ Mouth freshner, taste, snack, to overcome boredom

´ Lack of knowledge about its potential to cause OSMF and oral cancer

´ Peer pressure and parental use

´ Easy availability

Recommendations/Research Gaps

´  A standard protocol needed for studying tobacco use in children: out of school, illiterates/less educated, employed and those living in rural settings.

´  The 2006 and 2009 GYTS provide regional estimates. Periodic state level information should also be collected.

´  Include some economic indicators in GYTS questionnaire on the lines of GATS.

´  Research to understand the relative importance of risk factors of SLT use among youth so that targeted interventions could be implemented where required.

´  School component under NTCP could strengthened and its scope be widened to engage family members and community outreach efforts should be incorporated to reach out of school students.

´  Immediate enforcement of Tobacco Free Educational Institution guidelines across all such institutions across India in accordance with COTPA sections and stringent compliance monitoring mechanisms put in place.

Recommendations/Research Gaps ´  Stringent compliance monitoring with regard to Section 5 (advertisement and

promotion) of COTPA particularly around places frequented by children and adolescents.

´  Research on the impact of indirect advertising and promotion of SLT products on tobacco use behaviour.

´  Develop, adapt, and implement context specific interventions/programmes for children belonging to low SES groups addressing SLT use.

´  Stringent monitoring of ban on sale to/by minors and proposed licensing of tobacco vendors, and education programmes for tobacco vendors.

´  How would licensing work for small make-shift type tobacco vendors or mobile vendors?

´  Research on alternative livelihood for small vendors, youth and poor workers involved in the SLT business.