School-based Tobacco Health Hazards Awareness Initiative in India

The COVID-19 pandemic has caused an immense burden on the healthcare system and has overwhelmed it, in addition to the non-COVID-19 disease burden. Evidence that smoking is likely to increase individual health risk and subsequently, health system burden from COVID-19, strongly advocates the need for the government to increase tobacco control efforts during the pandemic (Hopkinson et al 2021).

Tobacco Use and Increase in Risk of NCDs

Tobacco is a major risk factor for non-communicable diseases (NCDs) such as cancer, respiratory diseases, cardiovascular diseases and diabetes. Moreover, patients living with these conditions are more vulnerable to COVID-19 (WHO World No Tobacco Day 2021). Tobacco use is the single largest preventable cause of cancer worldwide. According to the International Agency for Research on Cancer (IARC) monograph, there is sufficient evidence in humans that tobacco smoking causes cancer of the lung, oral cavity, naso-, oro- and hypo-pharynx, nasal cavity, paranasal sinuses, larynx, oesophagus, stomach, pancreas, liver, kidney, ureter, urinary bladder, uterine cervix and bone marrow (myeloid leukaemia). Smokeless tobacco use was associated with cancers of the lip, oral cavity, pharynx, digestive, respiratory and intra-thoracic organs (Mishra et al 2012). The cancer burden in India is large, with 2–2.5 million cancer patients at any given time and about 0.7 million new cases diagnosed every year (Shastri et al 2016). Eight per cent of total deaths and 5% of total disability adjusted life years (DALYs) in India were due to cancer, which was double the number in 1990 (Dhillon et al 2018). An estimated 34% of cancers in the country are tobacco related which is now a major public health concern. India has among the highest rates of oral cancers in the world, due to tobacco use. Nearly 85,000 new cases of cancers of the oral cavity and pharynx in men and 34,000 cases among women are detected in India each year (Shastri et al 2016). Cancers caused by tobacco use are preventable by avoiding tobacco use. Tobacco use is also a risk factor for other NCDs (that is diseases that cannot be passed from person to person) such as diabetes, cardiovascular diseases like cardiac arrests and strokes, and respiratory diseases such as chronic obstructive pulmonary disease and asthma (WHO Non-Communicable Diseases Factsheet 2015), which are on the rise (India: Health of the Nation`s States 2017). Further, 40% of the tuberculosis burden in India may be attributed to smoking (Mishra et al 2012). 

Tobacco is used mainly in two forms—smoking (common in most countries and a lot of awareness on its hazards exists) and smokeless tobacco¹ (SLT), the most common form of tobacco use in India (Ray et al 2016). Global Adult Tobacco Survey or GATS is a global standard for systematically monitoring adult tobacco use (smoking and smokeless) and tracking key tobacco control indicators. It is a nationally representative survey using a standard methodology world over. This survey helps to document the extent of the problem and help to formulate preventive and control programmes and assess effectiveness of various preventive strategies. It assists countries to fulfil their obligations under the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) to generate comparable data within and across countries. In the second round of GATS, India in 2016–17² showed 28.6% tobacco users—10.7% smokers and 21.4% smokeless tobacco users—according to the Global Adult Tobacco Survey: India 2016–2017 Report. Though the prevalence of tobacco use in the second round of GATS in 2016–17 showed a 6% decline from the first round held in 2009–10,³ it is still alarmingly high.
 
Use of smokeless tobacco, due to increased salivation, causes the user to spit often. In these times of COVID-19 pandemic, this habit of spitting in public spaces can contribute to a hike in the spread of this disease and other respiratory infections and lung diseases causing additional health system burden.

Tobacco Use among Women

Tobacco use among women, a hitherto neglected aspect, needs special consideration. Currently, about 70 million women above 15 years of age use SLT. The relative risk of oral cancers among women SLT users is eight times higher than men and the relative risk of cardiovascular diseases two to four times higher than men. In addition, SLT use raises risk of adverse reproductive outcomes. At least 9–10 million women are engaged in tobacco-related occupations, suffering serious health consequences. Women carry their infants and children when working and take their work home. The infants and children are also exposed to tobacco flakes and other chemicals used during farming, processing and manufacture of tobacco products and are at a greater risk of being ill (Subramoney and Aghi 2016). Tobacco health hazards awareness message is not reaching a majority of women, especially the illiterate homemakers living in slum neighbourhood, manual labourers and from lower socio-economic strata of society.

Tobacco Use among Adolescents

Tobacco use is an emerging and growing threat to the health of adolescents (Singh 2007; Narain 2011; Soni Preeti 2012). The India Global Youth Tobacco Survey (GYTS)⁴ was a school-based survey of students in Classes 8, 9 and 10 conducted in 2009. Around 14.6% students were found to be currently using tobacco in any form, 4.4% smoked cigarettes and 12.5% were found to be using some other form of tobacco. This highlights the urgent need for creating awareness about tobacco’s ill effects for this age group. Presently, there is no uniform school-based preventive programme to create awareness about tobacco health hazards in our country.
 
A novel hitherto unexplored means to tackle the tobacco addiction in our country is to create awareness about tobacco ill-effects before an individual starts to use it, that is, in adolescents, who are the most vulnerable group that fall prey to tobacco use. They will be less likely to initiate tobacco use in future. By making maximum use of available resources, the most effective strategy will be a school-based tobacco hazards awareness initiative. Our National Health Policy of 2017 has mentioned addressing tobacco, alcohol and substance abuse as a priority area (MoHFW 2017a). This policy gives special emphasis to the health challenges of adolescents and long-term potential of investing in their healthcare (MoHFW 2017b).

Children spend a lot of their time in school and may face peer pressure in school. School based programmes can reach teenagers directly. In 1994, the Surgeon General’s report on preventing tobacco use among young people found that years of research on a wide variety of school-based programmes, demonstrated consistent success in reducing tobacco use. Since then, a University of Southern California review of more than 30 school programmes, found that they can reduce existing youth smoking by as much as 20%, while also effectively curbing the number of young people who even start.⁵ These observations reiterate the importance of school-based campaigns for both prevention of initiation of tobacco use and discontinuing its use by current users.
Most of the adolescent school education programmes developed in Western countries aim towards creating awareness on the hazards of smoking. In India, tobacco consumption predominantly in smokeless form, implies the urgent need to create awareness about these forms of tobacco also. As smokeless tobacco, such as chewing betel quid and use of “masheri” (a form of tobacco for dental cleaning), are sometimes an accepted societal norm with some women too using it, making children feel that it is acceptable. Many times, tobacco use is initiated due to lack of knowledge of the harmful effects. 

There have been very few reports of school-based tobacco hazards awareness programmes in India and even fewer evaluation reports. In one such study, Project MYTRI (Mobilising Youth for Tobacco Related Initiatives in India), the effectiveness of a two-year multi-component, school-based intervention designed to reduce tobacco use rates among adolescents in urban India was assessed. Project MYTRI was successful in reducing tobacco use, particularly cigarette smoking, among adolescents in Delhi and Chennai over time but was not successful in reducing rates of chewing tobacco use among adolescents in the schools studied (Perry et al 2009).

I was a member of the non-governmental organisation Prevent Addictions through Children’s Education in Pune, which was launched in 2011, creating awareness about health hazards of tobacco, alcohol and substance abuse. Since 2014, I have been conducting specifically tobacco ill-effects awareness programme for school students from Classes 8 to 10 in Mumbai. Initially, beginning with a special emphasis on schools located in low socio-economic areas and later expanding to include schools from all areas. An audio-visual medium is used to provide information and a “no tobacco pledge” is undertaken by students. Lastly, student queries are addressed in this programme for about 20 minutes, which is conducted in English, Marathi or Hindi, according to the students’ medium of instruction. During the programme, the children are informed about the presence of nicotine in tobacco which they must not even try even once as it can prompt them to repeated use. The students are told to engage in activities like running, skipping, walking or participate in any form of physical activity (if not contra-indicated medically), so that they are not tempted to try tobacco. Also, it is repeatedly emphasised to the students that they must always be “proud to be tobacco free” all their lives. With the help of one volunteer, till February 2020, 15,475 students both boys and girls have benefitted. Principals, teachers and students have found it very useful. 

The students will be more likely to remain “tobacco free” and they can help to spread this message among friends, family and neighbours. Adolescent students can be messengers to their family members, neighbours, relatives and friends. This can prove to be an important means to convey the anti-tobacco message to women, especially to those from rural areas, and those belonging to low socio-economic strata. Also, it is possible that parents may quit or contemplate quitting the habit at a son or daughter’s insistence. A similar observation has been made in a study from Kerala, where 34% of children reported that they positively influenced their parents and relatives to quit tobacco (Philip et al 2013).

An assessment to determine the effectiveness of this programme was undertaken. A study was undertaken to assess the change in knowledge, attitude towards tobacco among school children from two schools, one each from Pune and Mumbai. Pre-programme questionnaires were given. The programme was conducted, which included a PowerPoint presentation, a short film, the “No Tobacco Pledge” taken by students that they will remain tobacco free. After the programme, post-programme questionnaires were given. Around 97.4% students felt that this programme will help in preventing tobacco use and they will spread this message in the society. And, 82.1% of students reported that they would be “proud to remain tobacco-free for the rest of their lives” (Ghate et al 2016). 

A second study was conducted in a school in rural Maharashtra. A pre-programme questionnaire was circulated. Due to limited facilities, information about ill effects of tobacco use and why tobacco use should not be initiated was explained. A PowerPoint presentation was also used. An immediate post-programme questionnaire was given to study retention of knowledge, another questionnaire was given one month after the programme. The teachers were the main source of knowledge as was observed in the pre-programme questionnaire. Ninety percent of students reported that they had shared the tobacco ill effects knowledge with friends and family (Ghate and Raje 2018). The initial results have been promising and need consideration for systematic nationwide implementation. WHO South-East Asia region is home to nearly 90% of global SLT users as over 250 million such users live in this region (Sinha et al 2012). This can serve as a role model for other South-East Asian countries also.

The Way Ahead

In the ongoing COVID-19 pandemic, there have been uncertainties and delays regarding future academic schedules. The nature of implementation of this school-based tobacco hazards awareness initiative may change, with an emphasis on online education. A strategy to train teachers so as to implement this initiative with online tools is being worked upon. This will help to scale up the initiative and more adolescent students can benefit with a reduced expenditure involved in its implementation. Until then, the programme material is being upgraded to include information about the adverse effects of tobacco use when suffering from a COVID-19 infection and avenues to reach out to “out-of-school” adolescents are being explored.