A Step Towards Primordial Prevention of Tobacco Use Among School Children

ABSTRACT

Objective: To assess the effectiveness of tobacco control programme among the 8th Standard students attending the Schools of Mangalore city, India.
Basic Research Design: Interventional Study
Study setting: Schools of Mangalore, India
Participants: School children
Interventions: Tobacco Control Interventions like awareness programme on ill effects of tobacco and tobacco control laws for school children
and teachers.
Main outcome measures: Knowledge and Attitude regarding tobacco pre and post-intervention.
Results: In the present study the mean age of the participants was 12.86 years and among them 61.6% were males. The study results show that there was an improvement in the knowledge of participants post intervention. Pre-intervention only 63.5% knew that both smoked and smokeless forms of tobacco were harmful to health while post-intervention it improved to 79.5%. Among the participants 80.3% of them knew that tobacco use can cause oral cancer and post-intervention 90.5% of them knew about it. There was a change in attitude post- intervention. The number of participants with an attitude to smoke, if a friend offered a cigarette decreased to 2.3% as compared to 8.4% pre-intervention. Pre-intervention 26.3% felt that smoking cigarettes makes people feel more comfortable at parties or gatherings, while post-intervention 64.8% felt that it does not make them feel comfortable.
Conclusion: There was an improvement in the knowledge and awareness students attending the Schools of Mangalore City after implementing the tobacco control training programme.
Keywords: Schools; Students; Tobacco; Knowledge; Attitude;
Key message: Health promotion programs about the ill effects of tobacco at schools will reach out to a large number of people at an influential age which might enable them to develop sustainable healthy lifestyles.

INTRODUCTION

Tobacco use is the single most preventable cause of death in the world today. Approximately 5.4 million people die in the world every year due to tobacco related diseases. More than 80% of these deaths occur in the developing countries.¹ Prevention of tobacco use is necessary for primordial prevention of tobacco related morbidity and mortality. Primordial prevention means action taken to prevent the emergence of risk factors in populations. It promotes healthier lifestyles among people.²

As per Global Youth Tobacco Survey (GYTS) 2009, 14.6% of the 13-15 year old school going children used tobacco in any form.³ A large number of children are exposed to second hand smoke.¹ In India the average age of initiation of tobacco use is 17.8 years. Children form the important focus groups for effective primordial prevention strategies as this is the period when lifestyle habits are formed.²

Schools form a logical setting for health promotion and population based primordial prevention for tobacco control.^2,4 They reach out to a large number of children and through them reach out to the school staff, families and the community as a whole. Health promotion during the most influential part of a child’s life can lead to sustainable habits and attitudes during adulthood.⁴ This population based approach would be primordial prevention for non users of tobacco which can bring about a behavior modification at the population level. The overall aim is to sensitize the young to the issue of tobacco use. For a long term impact it is necessary to direct health promotion strategies for prevention of tobacco use at the population level which should be augmented by high risk approach for tobacco cessation.²

Awareness programs in Schools will help the youth and the adolescents to acquire the knowledge, attitude and skills that are required to make informed choices and decisions and understand the consequences of tobacco use. It will empower students to contribute to the creation of tobacco-free environment in which they can learn and live. It is important to sensitize children at an early age and prevent the occurrence of this habit among the youth. School based tobacco control program is a key component of National Tobacco Control Programme.⁵ Schools has the potential to reach out to a large number of children repeatedly at an age when they are tempted to experiment with tobacco.¹

More than 80% of adult smokers begin smoking before 18 years of age.⁶ To combat this significant public health problem we need to redouble the efforts. Interventions directed towards reducing tobacco use among the youth are a critical component of these strategies.⁷

Children can be crusaders against tobacco. Tobacco prevention programs which are school based have been considered to be quite effective in reducing use of tobacco among adolescents. Such interventions have been shown to improve the knowledge about ill effects of tobacco, bring about a change in attitude about use of tobacco and in turn reduce tobacco use intentions and practices.⁸

Hence this study was conducted to assess the effectiveness of tobacco control programme among the 8th Standard students attending the Schools of Mangalore city, India to enable us to suggest possible plan of actions or strategies to improve their knowledge and attitude regarding tobacco control.

METHODOLOGY

A school based interventional program was conducted to assess the effectiveness of tobacco control programme among the 8th Standard students attending the Schools of Mangalore city, India. Ethical clearance was obtained from the Institutional Ethical committee.

Permission to conduct the intervention was obtained from the concerned authorities. Among the High Schools, 6 schools which gave permission were included in the study. Informed consent was obtained from the parents and assent from the participants before the start of the study. A total of 359 students participated in the study.

A close ended pre-tested questionnaire was used to assess the impact of the intervention on knowledge and attitude regarding tobacco among the participants.

The Tobacco control Intervention was categorized as follows

a. Anti-tobacco awareness program to school children using Audio-Visual aids and role plays. The program provided the following information on tobacco: History of tobacco, its various forms, chemicals in tobacco, statistics related to tobacco use, reasons for starting the habit, effects of tobacco on health, second hand smoke and its effects, Tobacco control laws, Role of students in tobacco control.
b. An awareness program on Tobacco control laws to teachers
c. Banners regarding Tobacco control laws pertaining to School campuses were distributed
d. Students were motivated to pledge against the use of tobacco

The intervention was conducted for a period of four months. Towards the end of the intervention, inter-school competitions were conducted among the participating schools. This further enforced the students on issues related to tobacco.

Statistical Analysis:

 Data was coded, entered and analyzed using SPSS version¹⁶. Descriptive data was obtained.

RESULTS

In the present study the mean age of the participants was 12.86 years and among them 61.6% were males and 38.4% were females.
Table 1 shows the knowledge of participants about ill effects of tobacco pre and post intervention. The study results shows that there was an improvement in the knowledge of participants post intervention. Pre-intervention only 63.5% knew that both smoked and smokeless forms of tobacco were harmful to health while post- intervention it improved to 79.5%. Pre-intervention only 33.6% knew that there were more than 4000 harmful chemicals in tobacco smoke, while it was known to 87.7% post-intervention. Only 44.6% of them knew that passive smoking is hazardous to the health of others, while post intervention it was known to 51.4% of them. Among the participants 80.3% of them knew that tobacco use can cause oral cancer and post-intervention 90.5% of them knew about it.
Table 1: Table showing knowledge about tobacco and its ill effects pre and post-intervention among the participants

Table 2 shows the attitude about tobacco use among the participants pre and post intervention. There was a change in attitude post-intervention.

The number of participants with an attitude to smoke, if a friend offered a cigarette decreased to 2.3% as compared to 8.4% pre-intervention. Pre-intervention 26.3% felt that smoking cigarettes makes people feel more comfortable at parties or gatherings, while post-intervention 64.8% felt that it does not make them feel comfortable. Among the participants 10.1% of them said that they might use tobacco when they grow up, while post- intervention only 2.6% said that they will use tobacco when they grow up.
Table 2: Table showing attitude about tobacco use pre and post- intervention among the participants

DISCUSSION

School based interventions can be an integral part of primordial prevention. Easy accessibility, peer and family influences, low price have been the important factors contributing to the use of tobacco among school children. Strategies to reduce tobacco use can be integrated to general health promotion in schools. This will strengthen their capacity and improve the health of the students, the staff, the families and the community.⁵
The WHO global school health initiative aims to encourage health promoting schools.⁵ Health education is one of the important component of health promotion and school based tobacco prevention programs are considered to be an effective strategy for tobacco control.^5,8 School based activities can have a lasting effect not only on them, but also on the later generations.
In the present study, the mean age of the study subjects was found to be 12.86 years. Only eighth standard students were included in this study. This is similar to the study done by Tahlil et al to evaluate the impact of education programs on smoking prevention where only 7th and 8th grade students were included.⁸
In the present study 6.6% of the students reported to having used tobacco in some form. According to the Global Youth Tobacco Survey (2009) in India 14.6% of the youth aged 13-15 years use tobacco.³ In a study done by Narain et al. (2011) 11.2% of the school children aged 11-19 years in Noida used tobacco in some form.⁹ In a study done by Philip et al. (2013) in Kerala among students aged 13-17 years, the prevalence of tobacco use was 9.85%.⁶ The lower prevalence of tobacco use in the present study may be attributed to the lower self reporting of tobacco use by the students, since it was a questionnaire study.
According to the Global Youth Tobacco Survey (2009) in India two thirds of the students think smoke from others is harmful to them.³ In the present study 44.6% believed that passive smoking was injurious to health before intervention while it improved to 51.4% after intervention.
In the present study there was an improvement in the knowledge and a more favorable attitude after providing the intervention similar to the study conducted by Tahlil et al. (2013) and Stigler et al.(2011) where there was an improvement in the awareness about ill effects of tobacco.^8,10 The results of the study are similar to that of the study by Sorensen G et al. (2012) where a significant improvement in the knowledge about tobacco and related legislation was seen after a school based tobacco control program was conducted.⁷
The limitation of this study was that convenience sampling was used to select the schools. Since it was a short term study the long term impact of the program on the knowledge, attitude and practices were not evaluated. The effect of the educational intervention on tobacco use could not be evaluated. Tobacco use by the students could have been under reported since it was a questionnaire based assessment and no biochemical parameter was used to confirm the same. Inspite of these limitations an improvement in the knowledge and a change in attitude was observed after the school based interventional program. Hence more such school based tobacco control programmes should be conducted, its long term impacts should be evaluated. An attempt should also be made to incorporate tobacco control activities into the school curriculum.

CONCLUSION

There was an improvement in the knowledge and awareness of 8th Standard students attending the Schools of Mangalore City after implementing the tobacco control training programme. More such school based programs should be conducted and the long term impacts of such interventions should be assessed.

RECOMMENDATIONS

The impact of the school based intervention program in the long term is a major concern. Hence “Booster” programs should be conducted at regular intervals to enhance the retention of the interventional effects.
A multi-pronged intervention involving the families, teachers and peers should be conducted which will enable to reinforce tobacco prevention strategies.

ACKNOWLEDGEMENT

We acknowledge ICMR for funding the study. We are grateful to the study participants and the school authorities for their co- operation throughout the study. We also acknowledge all our friends who were a part of the role play.

REFERENCES