INTRODUCTION

Tobacco use is one of the leading preventable causes of premature death worldwide¹. Almost 7 million deaths every year are attributed to the use of tobacco. Most of these deaths occur in low and middle income countries, which account for almost 80% of all tobacco-related deaths². The South-East Asia region mainly consist of developing countries, where tobacco use is a major public health problem. Tobacco kills nearly 1.2 million people annually in this region³.

India is the third largest tobacco producing nation and the second largest consumer of tobacco worldwide⁴. Deaths due to tobacco in India are estimated to be about 1 million, among which 0.926 million are attributed to tobacco smoking and the rest to smokeless tobacco use⁵. In India, tobacco is used in various forms ranging from smoked to smokeless tobacco. Approximately 266.8 million adults used tobacco during 2016–2017, of which 99.5 million used smoked tobacco⁶.

In spite of India’s government regulatory action towards tobacco control, tobacco use among youths and young adults is quite high, due to the industry’s creative branding and targeted marketing strategies. Other contributing factors to the epidemic are abundant tobacco production, weak enforcement of tobacco control measures, and easy accessibility and affordability of tobacco products³. Despite these challenges, India has addressed this problem significantly at various levels. At the national level, the Cigarettes and Other Tobacco Products Act (COTPA) was enacted in 2003, followed by the ratification of the World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) in 2004⁷. In addition, the government initiated tobacco control and prevention programs at the state level to support tobacco cessation efforts and capacity building⁷. The decreased prevalence of tobacco use can also be attributed to the advocacy efforts for tobacco control initiatives by civil society organizations and community along with government’s initiatives⁷.

Monitoring of the tobacco epidemic is the key to managing it effectively. The Global Adult Tobacco Survey (GATS) fills the need for standardized surveys of tobacco use, which uses a standardized protocol to ensure comparability, to track tobacco use, and evaluate tobacco control policies. These measures have been defined by the WHO FCTC⁸.

Given the current gap in the literature and WHO’s recommendation to strengthen tobacco use surveillance and monitoring among various groups^9,10, there is a need to understand the epidemiology of tobacco use patterns and predictors, and investigate whether it is a public health concern among college students in South India. Therefore, the objectives of this study were to estimate the current patterns of tobacco use among college students, to investigate the predictors of tobacco smoking among them, and to find the factors associated with an attempt to quit smoking. It is hoped that this research will provide a baseline for the national prevalence of tobacco use among college students and tobacco specific interventions in South India. It is also hoped that the results of this study can place the prevalence of tobacco use within regional and global context, so that future comparisons can be made.

METHODS

A cross-sectional study was conducted to assess tobacco use among college students aged 18–24 years and studying in Mangalore, South India. The study was carried out in 30 colleges in Mangalore from January 2016 to June 2018. Before initiating the study, official permission was obtained from the Joint Director of Education, Mangalore, and the heads of the institutions of the selected colleges. Ethical clearance was obtained from Yenepoya (Deemed to be University) Ethics Committee (YUEC) (YUEC 200/12/10/2015). Informed consent was obtained from the study participants prior to the start of the study.

RESULTS

The present study involved 2063 participants who completed the interview. Among them, 738 were males and 1325 were females. Table 1 shows the prevalence of different forms of tobacco use (smoking and smokeless). Among the 2063 participants, 4.8% (96) were current tobacco smokers; among the current tobacco smokers, 9.9% (69) were males and 2.1% (27) were females. Among them, 1.7% (35) smoked daily, and 3.1% (61) smoked occasionally. The prevalence of smokeless tobacco (SLT) use in the study population was 4.8% (96) among which 7.4% males (53) and 3.3% females (43) consumed smokeless tobacco. It was observed that among the current tobacco chewers, 2.1% (43) chewed tobacco on a daily basis and 2.6% (53) chewed tobacco occasionally in the past.

Table 2 shows the association between tobacco smoking status and demographic characteristics. There was no significant association (p>0.05) between demographic variables, such as age and location of residence, and current tobacco smoking status. However, gender and education degree showed significant (p<0.05) association with the current tobacco smoking status. Majority of the participants who currently did not smoke tobacco were females (98.0%), aged 18 years (96.4%), from a rural area (95.7%), and pursuing a technical degree (98.3%).

Logistic regression analysis to determine factors influencing tobacco smoking showed that males have 0.20 more odds of being a smoker than females. Participants aged 21–24 years have 2.82 higher odds of being a smoker than participants aged 18 years. Participants in an urban area have 0.97 more odds of being a smoker than participants in a rural area. Health professional students have 0.74 more odds of being a smoker than undergraduate degree students (Table 3).

Table 4 shows distribution of factors associated with subjects who attempted to quit smoking in past 12 months. No significant difference was observed between the attempt to quit between a daily smoker and less than daily smoker (p=0.35). Among participants who noticed anti-cigarette information in newspapers, 78.6% attempted to quit and 21.4% did not attempt to quit. The odds of quitting the habit by a smoker were 3.9 times higher than those who had not seen any information (p=0.005). Among the participants who noticed anticigarette information on television, 71.4% made an attempt to quit smoking. The odds ratio of quitting smoking was 4.4 times more compared to subjects who did not notice any information on television (p=0.002). Among the participants, 72% attempted to quit smoking after seeing the health warnings on the cigarette packet and 7.1% of the subjects did not notice any such warnings. The odds of quitting the habit after seeing the packet were 33.3. Study participants who had noticed advertisements in stores were 2.41 times more likely to quit the habit compared to those who did not notice such advertisements (p=0.04).

Logistic regression analysis to determine the factors influencing attempt to quit by current smokers showed that noticing health warnings on the cigarette packs in the last 30 days strongly influenced individual’s interest to quit the smoking habit with odds ratio of 30.0. Noticing anti-cigarette information in newspapers or magazines had 2.7 more odds of quitting the habit by current smokers (Table 5).

DISCUSSION

Our study is one of the largest studies that have been done in college students in Southern India to determine the prevalence of both smoking and smokeless tobacco use. Despite the increase in population in India in the last decade, there is a significant relative decline in tobacco use among youth in India⁶. According to the data gathered from the GATS-2 India 2016–2017, 18% were aged 15–24 years. The total number of tobacco users in this age group was 12.4% and non-users were 87.6%. Among these, 1.8% were dual users who smoked and chewed tobacco⁶. From GATS-1 in 2009–2010 to GATS-2 in 2016–2017, the prevalence of use of any form of tobacco in those aged 15–24 years has decreased significantly by 9.7% from 22.1% to 12.4%. Compared to the 2016–2017 survey by GATS, India, the present study reported a significantly lower number of tobacco users in this age group. The scientific literature reveals low prevalence of tobacco use in this age group, and this could be because the addiction level is not high and the habit is not deep-rooted. It might also be due to underreporting¹³. A low prevalence of tobacco use was earlier reported among adolescents in studies conducted by Ibehcc et al.¹⁴ and Nwarfor et al.¹⁵, at 7.7% and 8.7%, respectively. In contrast, several studies reported high tobacco use in adolescents in Akwa Iban, South Nigeria by Abaslubong et al.¹⁶, in Navi Mumbai by Salvi et al.¹⁷, and the US National Youth Tobacco Survey by Lee et al.¹⁸.

The prevalence of all types of tobacco use was higher among males compared to females. In the present study, males had 0.2 more odds of being a smoker than females. Similar findings are reported among adolescents and adults in a study done by Sharma et al.¹⁹. The tobacco product most commonly used by both genders was cigarettes. This calls for interventions that target tobacco production and sale.

Gender plays an important role in predicting smoking. Palipudi et al.²⁰ reported a lower proportion of female smokers, while studies by Sharma et al.²¹ and Sreeramareddy et al.²² showed that there were no female smokers in their sample at all. However, these findings may not reflect data from other parts of the world. Hammond et al.²³ reported that females were more likely to smoke than males on a daily basis, although the number of smoked cigarettes was lower. Studies conducted in India by Goel et al.²⁴ and Roy et al.²⁵ show a significant rise in the trend of female smoking compared to males. This situation is always challenging for policymakers to plan youthfocused tobacco interventions. The low prevalence of smoking observed among women, compared to men, could be attributed to social stigma. According to the 1992 WHO report on women and tobacco, smoking by women is often socially unacceptable in many of the developing countries²⁶.

The findings of the current study are that the prevalence of tobacco use increases with age. A similar trend was reported in earlier studies^14,27. Participants aged 21–24 years had 2.8 higher odds of being a smoker than participants aged 18 years. The possible reasons could be a younger age of initiation, and curiosity and aggressive advertisement or promotional tactics of the industry targeting youth. Creating awareness among the younger generation, about addictions and the associated dangers of the habits, could possibly reduce addiction among new smokers including increasing the age for buying tobacco products at the point-of-sale (POS) from the existing 18 years to 21 years. This could be used as a useful strategy to curb the initiation of tobacco products²⁸. In our study, a relative reduction and a downward trend in the prevalence of smoking was observed. The prevalence rate was lower compared to studies done in Thailand and Bangladesh^29,30.

In the present study, 4.8% of the study population used smokeless tobacco. This showed a decreased trend in the prevalence of chewed tobacco compared to GATS-2 (2017) that showed 9.1% in those aged 15–24 years. Comparing smoking products, the use of SLT is much more common among the youth and adults in India, Thailand, Bangladesh and Pakistan^6,31. In India, although the prevalence of SLT use is lower, it is much higher than that of tobacco smoking⁶. Daily SLT users (2.1%) among the population of the current study are more compared to those smoking tobacco (1.7%). The pattern suggests that the use of SLT is still better accepted socially than tobacco smoking.

In our study, current smokers either smoked cigarettes or bidis, as these are the most commonly available forms of tobacco. Although smoking bidis is likely to be socially undesirable in educated circles, the likely explanation for its use could be that bidis are a relatively cheap product, which makes it affordable to college students. This trend is most commonly seen in the Southeast Asian countries^20,32.

During the 30 days preceding the present study, nearly equal proportions of males and females found anti-smoking information in a public site or channel (print, electronic media, internet, public wall, and transport). Television was the medium where the highest percentage (70.66%) of the participants noticed anti-smoking information. As a consequence of noticing the health warnings on the product/ packet, the desire to quit was relatively high. Yet they were not able to quit, may be due to absence of alternate products or professional help to motivate them to quit smoking. Such a situation in India is alarming, since there is a paucity of information and effective cessation aids such as individual therapy, reading materials, group therapies, and nicotine replacement therapies (NRTs). The findings of the present study are in line with other studies conducted by Spaulding et al.³³, Valera et al.³⁴, and Coppo et al.³⁵. Studies have suggested that the prohibition of tobacco advertising has led to tobacco companies’ formal contractual agreements regarding brand display within the film industry. The evidence is that images of tobacco use in movies of ‘bollywood’ and regional languages have increased post-implementation of the COTPA^35,36. In the present study, the odds of quitting the habit after seeing the packet were 33.35, suggesting that noticing health warnings on the cigarette packet significantly influenced the subjects. The COTPA rules post-FCTC might have had a major impact on adult smokers to quit the habit after noticing the pictorial images. The present study also showed a strong response to specific package warnings with the likelihood of quit attempts, consistent with previous studies^37,38.

CONCLUSIONS

The study results showed a low prevalence in the use of both smoked and smokeless forms of tobacco, current smoking, and tobacco chewing, among the study population in Mangalore, South India. Cigarettes were the most preferred tobacco product among the college students. Health professionals, educators and policymakers should adopt specific strategies to prevent youth from using tobacco. Generating data in this part of the country on tobacco use and developing tobacco control measures at regular intervals is essential to better understand and develop effective intervention programs for college students.

CONFLICTS OF INTEREST

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.