Knowledge and attitude about tobacco use among school personnel in Bangalore South-a Cross Sectional Study.

INTRODUCTION

Tobacco is one of the largest causes of premature death in world.1 More than one billion people, about one quarter of adult’s worldwide, currently smoke tobacco. Millions of people were killed due to tobacco epidemic in 20th century and by 2030, about 70% of deaths attributed to tobacco use will occur in developing countries.^2,3 Tobacco use among the adolescence usually starts during the school days and the school personnel and administration can potentially influence student’s tobacco use.⁴ One of the effective factors which have a major implication on smoking prevention among students is school smoking cessation policies.^2,3 On the other hand the awareness and enforcement of the legislation banning tobacco use in school environment seems to be a significant role for the prevention of tobacco use among young people.⁵ Teachers and administrators play an important role in shaping of student’s behavior towards smoking. One of the key elements of adolescent tobacco control is School-based tobacco control programmes because school environments are established systems in which adolescent behavior can be changed and in which social behavior are reinforced.⁵

The adequacy of studies measuring the above objectives were meager in South India hence the above study was undertaken to assess the prevalence of tobacco use among school personnel and study information on the extent of tobacco use among school personnel, their attitude toward tobacco control and the existence of tobacco control policies in school. The aim of the present study was to obtain baseline information on tobacco use among Government and Private school personnel and to understand the knowledge and attitudes towards tobacco usage among school personnel in Bangalore south.

METHODS

A cross sectional study was conducted among teaching and nonteaching staff working in government and private schools of Bangalore south region. Stratified random sampling technique was used. In the first phase stratification was done to select government and private schools. The list of schools was procured from DDPI (Deputy Director of Public Instruction) website.6 There are a total 962 government school and 357 private schools. A total of 40 government and 20 private schools were selected to obtain a total sample of 420 study participants. In the second phase simple random sampling technique was used to include schools from the strata. Government aided private schools were excluded from the study because of the non-accessibility of the schools as it was not feasible and permission for the study from schools were delayed repeatedly. The study was conducted during May- October 2017.

The sample size was calculated based on the study done by Sinha et al[4] with the prevalence of 25.7% tobacco use and using formula N=z2P(1-P)/D2

The Global School Personnel Survey (GSPS) uses two-stage stratified random sampling design.¹ School personnel participation was voluntary and kept anonymous by means of self-administered data collection method. Those who were present on the day of study were explained the study protocol and those given informed consent were eligible to participate and included in the study. Ethical clearance was obtained from the institutional ethical clearance committee (ethical clearance no- Rrdchet/04Phd/2017).

The questionnaire used for Global School Personnel Survey (GSPS) was a common tool standardized for this purpose by the Center for Disease Control and Prevention (CDC) and World Health Organization (WHO),¹ Cultural habits like betel nut chewing with tobacco and other forms of tobacco such as bidi smoking are prevalent among Indian population so pre-validated question related to these topics were added in the questionnaire¹⁸. The questionnaire was designed with no skip pattern to allow all respondents to answer all questions. The final India questionnaire were translated by a professional translator into local language (Kannada) and back translated into English to check for accuracy and pretested. The questionnaire was pilot tested among 30 school personnel to check for the validity and reliability before starting the study. Cronbach’s α derived was 0.75 which was acceptable. In the present study question regarding demographic, tobacco consumption and knowledge and attitude regarding tobacco were used and the final questionnaire consisted of 30 questions.

Statistical analysis- All data were analyzed using Statistical Package for the Social Sciences (SPSS) v.22 IBM Chicago. Chi-square test and Fisher’s Exact Test was used to demonstrate cross tabulation with confidence intervals. Significance level of 0.05 was considered for statistical analyses. ANOVA was used to compare the mean knowledge among the staff group.

Results

Majority of the age group from both the English and Kannada medium schools were 30-39 years of age 43.8%. Out of total 400 school personnel 64.6% were female and 35.4% were male. Majority of the school personnel were teachers (75.8%) followed by administrator 15.7%. Majority of the teachers acknowledged, the primary responsibility was to teach about the health. Over 97.2% of the school personnel in both English and Kannada medium had never smoked cigarette. Over 97.8% of the school personnel in which 97.2% of Kannada and 96.6% of English medium school personnel had never smoked cigarettes in school premises/property during past years (table 1)

About 87.1% of the school personnel agreed that cigarette smoking should be banned in public places. Over 92.7% of the school personnel did not smoke cigarette daily or occasionally. Most of the school personnel never chewed tobacco or snuff (92.7). Majority of the school personnel (95.5%) did not use chewing tobacco or snuff daily or occasionally. Over 94.4% of the school personnel never smoked bidis, cigars, or pipes. Majority of the (88.2%) of the school personnel think smoke from others people’s cigarettes is harmful. Over 82% of the school personnel think teacher’s tobacco use can influence the use of tobacco on youth (table 2).

Over 75.8% of the school personnel think teachers need specific regarding tobacco cessation. Majority of Kannada medium (71.9%) had advised their students to stop using tobacco as compared to English medium (44.9%) Table-3

Over 91.0% of the school personnel think school to have antismoking around the premises. About 62.4% of them think tobacco industry should not be allowed to sponsor school related extra curricular events . Over 84.3% of the school personnel think that tobacco product advertising should be completely banned. More than half of the school personnel think tobacco industry deliberately encourages youth to use tobacco. Majority of the school personnel agreed that tobacco use is addictive. More than half of the school personnel had knowledge that tobacco use will not cause malaria. About 87.1% of the school personnel had knowledge that tobacco use causes lung cancer. Over 69.7% of them had knowledge that tobacco use causes heart disease.

The mean knowledge score among both English and Kannada medium school was equal with p value of 0.255 which was not statistically significant. The mean knowledge score among the age group of 30-39 years was 27.95(SD-3.82). The age group of 30-39 years had statistically significant more knowledge when compared with other age group (p-value <0.001). The mean knowledge score among the teachers was 28.31 (SD-3.726). Teachers had statistically significant more knowledge when compared with administrator and clerical staff (p <0.001) (table-4).The mean knowledge score among male participants was 29.2 and female participants were 26.37. Male participants had statically significant more knowledge when compared to females participants (p <0.001).

Discussion

Smoking continues to remain a major cause of morbidity and mortality from respiratory disorders, as well as several other diseases including cancer. It also leads to considerable economic burdens resulting from expenditures on health care.7 The school personnel play an important role for youth and public.⁴ The tobacco use by school personnel is socially not accepted. Most of tobacco users first try tobacco in their teens. The risks of tobacco use are also highest among those who start early and continue for prolonged periods. Teachers represent an important target population for tobacco control efforts, because they are role models for students, conveyors of tobacco prevention curricula, and key opinion leaders in relation to school tobacco attitude about tobacco use among school personnel.

In the present study most of the participants were in the age group of 30 to 39 years (43.8%). Majority of the respondent’s primary position in the school is teacher (75.8%). About 2.8% in the present study reported that they were smokers. According to the study conducted by Erick et al¹⁶ prevalence is relatively lower compared to results of other studies that have been carried out around the world. This prevalence is relatively lower compared to results of studies from Kingdom of Bahrain and Kenya in which prevalence of smoking among Bahrain and Kenya teachers were 7% each.[8,9] In the present study, it was found that 92.7% of the school personnel have responded that they have never smoked cigarettes which is in contrast with the study done by G. Mermer et al¹⁰ in Turkey where only 45.8% of the teachers have responded that they have never smoked and 27.8% smoked regularly.

In the present study, only 87.1% of the school personnel indicated existence of a policy prohibiting tobacco use among students and in schools which is in contrast with the study conducted by Dorota et al5 where only 70% of the school personnel indicated existence of a policy prohibiting tobacco use. Existence, awareness and enforcement of the legislation banning smoking in a school environment seems to be a significant element for the prevention of tobacco use among young people.¹¹ There should be policy restricting smoking among school teachers in the school building.¹⁷

In the present study, 88.2% think that smoke from other people’s cigarettes is harmful to them whereas in 2006 and 2009 survey the majority, about 95% of school personnel think that smoke from others is harmful to them.¹³ The harmful effect of environmental smoke is well-known such as frequent and severe asthma attack respiratory infection, ear infection and coronary heart disease .¹²

In the present study, 75.8% of the participants responded that teachers need specific training to be able to teach students how to avoid or stop using tobacco. This results of the knowledge of the school personnel regarding training can be comparable with the study conducted by Sorina et al⁷ in Romania where only 42.2% of the participants responded that teachers should be trained to teach the students on how to avoid or stop using tobacco. The School personnel have to actively interact with students while teaching them the adverse consequences of tobacco use.⁷ Therefore, training among school personnel will enhance their knowledge towards smoking hazards leading to better estimation of the problem and planning appropriate interventions to reduce smoking and adopt smoking policies at schools.¹⁴

The Government of India passed a national tobacco control legislation “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act,2003”(COTPA 2003) that was enforced from May 2004.¹³ Inspite of this act, In the present study it was found that only 84.3% have responded that the advertisement of tobacco product should be completely banned and only 64.6% of the school personnel were in favor of increasing the prices of tobacco products. This results is in contrast with the study done by Sharma et al¹⁵ in Rajasthan, India where 91.2% of the participants wanted complete ban on tobacco advertisements and 61.2% wanted to increase the price of tobacco products. Some 69.7% thought that tobacco industry deliberately encourages youth to use tobacco while only 37.6% of the participants were in favor of not allowing tobacco companies to sponsor school or extra curricula activities. This result is also in contrast with the study done by Sharma et al¹⁵ where 80.2% were in favor of not allowing tobacco companies to sponsor sports events.

In present study, most of the school personnel considered that tobacco is addictive (69.7%) and 87.1% reported that it cause serious health consequences. This is in contrast with the study done by Dhirendra et al³ where 90.7% reported that tobacco is addictive and 94.2% of the participants reported that it cause serious health consequences.

In present study the school personnel advised the implication of anti-tobacco smoking policy around the school surrounding area. Looking at the results of the present study, only 58.4% of the school personnel have ever advised a student to stop using tobacco. This indicates that the school personnel think that it is not their role to teach students about health related issues, while in fact this is their role. According to Sorensen et al¹⁴ and Gupta PC el al¹⁵ study continued implication of effective tobacco control policies along with providing tobacco cessation intervention can help in reducing tobacco use prevalence. The anti-smoking education will be more effective if it is given by parents or teachers who are in more contact with the children. Hence, there should be strict implementation of the law banning smoking in school building, school area and on school events. The limitation of the study is a self-reported study; it may affect the extrapolation of the results.

Recommendations

• Strict implementation of anti-tobacco law around the school premises.

• Training program for teacher about ill effects of tobacco and tobacco cessation.

• Banning of advertisement from Tobacco Company in school events.

We can conclude from the results of the present study that the school personnel’s knowledge and attitude towards tobacco use is more when compared to other studies and this can be implemented to fight tobacco use among school children by recommendation of the school personnel to the students by organize training sessions about the health effects of smoking in a reliable and valid theoretical framework. The school personnel should organize regular training sessions about the health effects of smoking to the school students in health institutions or at schools.