Role of Schools in Tobacco prevention-A Review

Introduction

Tobacco use is one of the leading preventable causes of morbidity and mortality in the world. Globally, tobacco epidemic kills 5.4 million people a year from various tobacco-related diseases. According to GATS, India (2016-17), 42.4% of men, 14.2% of women and 28.6% (266.8 million) of all adults currently use tobacco. 36.9% of children are found to initiate tobacco use before the age of 10 years¹ . Almost 4.2% of students currently smoke cigarettes, boys considerably higher than girls, while 11.9 % of students currently used other tobacco products² . Four out of every five persons who use tobacco initiate in adolescence and continue into adulthood. Tobacco use is increasing among the adolescents and is usually carried over to their adulthood³ . Another trend noticed these days among adolescents is tobacco purchase and usage been shifted to alternative products like electronic nicotine delivery systems (vaping), raising concerns due to increased public interest. E-cigarette marketing is of particular concern, because it is creating an illusion that they are safer and healthier option to conventional tobacco cigarettes, whereas their safety and their potential role in cessation is a matter of worry⁴ . Hence, it is crucial, to include e-cigarettes in tobacco prevention programs; targeting the vulnerable groups through early intervention efforts.

The Indian government passed a legislation, cigarettes and other tobacco products (prohibition of advertisement and regulation of trade and commerce, production, supply, and distribution) Act, 2003, or cigarettes and other tobacco products Act (COTPA) to prohibit and regulate tobacco use in India. The Act has various sections, the key being Section 4 (prohibition of smoking in public places), Section 5 (ban on advertisements of tobacco products), and Section 6 (prohibition of sale of tobacco products to minors and within 100 yards of educational institutions)⁵ .

Since most of the individuals who use tobacco begin before they reach adulthood, it is imperative that tobacco-prevention activities should focus on school-children and adolescents. Evidence suggests that school health programs can be an effective means of preventing tobacco use among youth. School-based programs provide an opportunity to prevent the initiation of tobacco use among adolescents and also support them in their quit effort.

Objective: The purpose of this review is to aid school personnel to plan, adopt, adapt and assess the tobacco educational programs and school policies on tobacco prevention. This guidelines are based on a synthesis of results of literature search, research and current practice in tobaccouse prevention and cessation.

Data source (Literature search strategy):

A comprehensive and substantial search strategy was developed, which included electronic databases, websites, Medline literature, searches, books, reports, previous reviews and contact with experts. The following search strategies were used, using the terms school children, tobacco control, prevalence and peer pressure. Databases searched include Pub Med, Medline, Google Scholar, and Dissertation Abstracts. Both key words and MeSH headings were used. Websites (World Health Organization, Action on Smoking and HealthUK, Action on Smoking and Health-US, National Institutes of Health, Centers for Disease Control and Prevention) were also searched using the key term - Tobacco use and role of teachers.

Prevalence of tobacco use in smoking and smokeless form among school children in India:

Prevalence of smoking Tobacco

The World Health Organization (WHO) estimates that approximately over 1 billion people smoke tobacco currently, among whom 12% of adolescent boys and 7% of adolescent girls smoke cigarettes . In 2009, global youth tobacco survey ( GYTS) found that nearly one in ten students in India ages 13 to15 years used some form of tobacco (SLT) (9.4% overall; 10.7% 8 boys; 7.5% girls). Among the main forms of tobacco, 79.2% consumed kharra and 46.4% consumed gutka. According to respondents, few adolescent boys taste tobacco by 8-10 years of age, while girls do it by 12-13 years.^2,5

Global Adult Tobacco Survey(GATS) reported that, 19.0% of men, 2.0% of women and 10.7% (99.5 million) of all adults currently smoke tobacco. 29.6% of men, 12.8% of women and 21.4% (199.4 million) of all adults currently use smokeless tobacco. 42.4% of men, 14.2% of women and 28.6% (266.8 million) of all adults currently use tobacco (smoked and/or smokeless tobacco)¹ .

Cigarettes and Other Tobacco Products Act for school tobacco programs to prevent and reduce tobacco use:

There are various laws and legislation for tobacco control in India. The Cigarettes and Other Tobacco Products Act (COTPA) which was formed in 2003, includes Prohibition of:

1. Sale of any tobacco products in an area within a radius of 100 yards of any educational institution. And a display board must be put up at the point of sale declaring that “sale of tobacco products to minors is prohibited”

2. Smoking in public places;

3. Advertisement of cigarettes and other tobacco products;

4. Sale of cigarette or other tobacco products below the age of 18 years and in a particular area; and prohibition on trade and commerce in and production, supply, and distribution of cigarettes and other tobacco products⁵ . In spite of the stringent laws against tobacco and penalty for violations, there is rampant violation of COTPA laws due to poor implementation. The only way for the proper implementation of COTPA laws would be creating awareness about the laws, and also what amounts to violations among general population^6,7,8.

Even with the presence of laws and penalty for violations, the tobacco consumption among youth is raising in India. Therefore, there is a stringent need for creating awareness on tobacco use and its ill effects among school children through health education programs in schools and colleges. School programs designed to prevent tobacco use could become one of the most effective strategies available to reduce tobacco use. Some of the school-based tobacco-use prevention strategies most likely to be effective in preventing tobacco use among adolescence include – to sensitize about short and long-term negative physiologic effects, social consequences of tobacco use and tobacco resistance and refusal skills among middle and high school children(6th -10th graders), provide specific training programme for school teachers in tobacco cessation services(Skill development\ Capacity building), following training to initiate a tobacco cessation\information center at their respective schools to educate children on the hazards of tobacco use and to cater to the needs of the children who need help in tobacco quitting, involve parents in support of school-based programs to prevent tobacco use, and to develop a no tobacco policy in the school premises for staff and students and to assess the tobacco prevention program at regular intervals⁹ .

Schools are in a uniquely powerful position to play a major role in reducing the serious problem of tobacco use among children. Children spend almost a third of their waking time in schools, and much of the peer pressure children feel regarding whether or not to use tobacco occurs in school. Children develop the habit of tobacco abuse between the peak years of 13-14 years, with a considerable number starting even earlier. A study in India shows that five and a half thousand children are estimated to start smoking every day in India, joining the 4 million under 15-yearolds who already use tobacco regularly. Smoking and other tobacco use causes numerous and irreversible health effects^5,10. Smoking may also be a “gateway” to illegal drug use because smoking usually precedes illegal drug use; and the earlier a child experiments with tobacco, the more likely he or she is to use marijuana, cocaine, heroin and other illicit drugs. Recent reports on preventing drug abuse suggest that approaches effective in preventing tobacco use can also help prevent the use of alcohol and other drugs¹¹.

Include e-cigarettes as tobacco product-In the past few years, schools have a bigger problem than smoking and chewing tobacco as students have switched to sleek vaping devices. Electronic cigarettes (E-cigarettes), with their high nicotine content, appealing flavors (strawberry, chocolate etc.), low costs, easy and widespread availability, and discreet designs for easy concealability threaten tobacco prevention strategies⁸ . Although the number and levels of toxicants are lower in aerosol from e-cigarettes than from tobacco smoke, long term exposure to e-cigarette vapor cause nicotine dependence and increase the risk of respiratory and cardiovascular health effects.^12,13 E-cigarette marketing is of concern, since it is forming an impression that they are harmless and safer than conventional tobacco cigarettes. Hence there is an urgent need to include e-cigarettes in tobacco prevention programs, targeting the vulnerable groups through early intervention efforts via schools and social media.

School comprehensive tobacco prevention programme- Schools should provide comprehensive tobacco prevention education to prevent and reduce tobacco use among children. These programs should address all aspects of tobacco use, including the short- and long term negative health effects, social influences, acceptability and negative social consequences, peer pressure and refusal skills, and media literacy as it relates to tobacco marketing and advertising. It can be delivered in the form of didactic lectures, power point presentations, short educative films, and role plays. Students must get this training and guidance, in one form or another, throughout their school experience, with most intense instruction in middle and high school.^8,14 Schoolbased programs to prevent tobacco use also can contribute to preventing the use of illicit drugs, such as marijuana and cocaine which are often preceded by the use of tobacco or alcohol, typically sequential from use of tobacco or alcohol to use of marijuana, and from marijuana to other illicit drugs or prescription psychoactive drugs.

Tobacco cessation program-specific training for teachers - The role of teachers is pivotal in molding a child’s behavior. They can be instrumental in various capacities and their role as a counsellor to the students has been treasured. This quality of teachers can be harnessed to curb the tobacco addiction among the younger generation. This can be achieved by providing specific training in tobacco cessation services for school teachers with a motto of prevention, cessation and protection of children from tobacco use. When teachers are trained to properly deliver tobacco prevention curriculum, the success of the overall program is greatly improved¹⁵. Training should include didactic lectures, group discussions and hands on training. Teachers should be able to bring about behavior change among children towards stopping tobacco use among those who are using tobacco and help develop positive attitude towards “no tobacco use” and also prevent initiating tobacco use among children. Efforts to prevent the initiation of tobacco use among children and adolescents must be intensified. The schools also must create an environment that encourage antitobacco beliefs and behaviour among children. Following training teachers should be asked to initiate a tobacco cessation\information center at their respective schools to educate children on the hazards of tobacco use and to cater to the needs of the children who need help in tobacco quitting.

Involvement of parents or families in support of school-based tobacco cessation programs- Parental smoking is not only detrimental to the parent but also to the child. Forty percent of smokers live with a child younger than 18 years old¹⁶. Parents smoking at home regularly expose their children to second-hand smoke, which is linked to adverse health outcomes including childhood asthma, respiratory infections, and decreased lung growth in children. Also children whose parents smoked are twice as likely to begin smoking early. Smoking parents may be primarily motivated to quit tobacco for concerns related to the health consequences of their off springs and their own as well¹⁷. Programs with interactive homework assignments that educate and involve parents and other family members not only increase family discussions on this important topic but also lead to better home policies about tobacco use and even encourage adult tobacco users to try to quit9. Linking parents to school tobacco programs will produce significant health benefits for both parents and children, thus yielding high potential public health impact.

School policy on tobacco use - For schools to effectively prevent and reduce youth tobacco use among their students, they must create an environment that encourages anti-tobacco beliefs and behaviors. Schools should focus on more than just preventing children from starting tobacco use and help tobacco-using students and staff quit by providing effective cessation assistance^18,19. Schools should forbid tobacco use by students, staff and visitors on all school grounds which will send a strong, powerful and constructive tobaccofree message.

Assess the tobacco-use prevention program at regular intervals - Schools should regularly evaluate their success at implementing tobaccofree policies and programs and improvise on them. To achieve maximum effectiveness, school tobacco programs must be carefully planned and systematically implemented.

Conclusion

Tobacco use usually starts in adolescence and continues into adult life, meaning that many future victims of tobacco use are today's children. Schoolbased programs are likely to have broader and more powerful approach to tobacco prevention. This review recommends few steps for schools to effectively prevent and reduce tobacco use among their students which can have an enormous impact on the current and future health and well-being of the students.