Linking Global Youth Tobacco Survey 2003 and 2006 Data to Tobacco Control Policy in India
By Sinha, Dhirendra Narain Gupta, Prakash C; Reddy, K Srinath; Prasad, Vinayak M; Rahman, Khalilur; Warren, Charles W; Jones, Nathan R; Asma, Samira
ABSTRACT BACKGROUND: India made 2 important policy statements regarding tobacco control in the past decade. First, the India Tobacco Control Act (ITCA) was signed into law in 2003 with the goal to reduce tobacco consumption and protect citizens from exposure to secondhand smoke (SHS). Second, in 2005, India ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). During this same period, India conducted the Global Youth Tobacco Survey (GYTS) in 2003 and 2006 in an effort to track tobacco use among adolescents.
METHODS: The GYTS is a school-based survey of students aged 13- 15 years. Representative national estimates for India in 2003 and 2006 were used in this study.
RESULTS: In 2006, 3.8% of students currently smoked cigarettes and 11.9% currently used other tobacco products. These rates were not significantly different than those observed in 2003. Over the same period, exposure to SHS at home and in public places significantly decreased, whereas exposure to pro-tobacco ads on billboards and the ability to purchase cigarettes in a store did not change significantly.
CONCLUSIONS: The ITCA and the WHO FCTC have had mixed impacts on the tobacco control effort for adolescents in India. The positive impacts have been the reduction in exposure to SHS, both at home and in public places. The negative impacts are seen with the lack of change in pro-tobacco advertising and ability to purchase cigarettes in stores. The Government of India needs to consider new and stronger provisions of the ITCA and include strong enforcement measures.
Keywords: smoking and tobacco; international health; child and adolescent health.
Tobacco use is one of the major preventable causes of premature death and disease in the world. A disproportionate share of the global tobacco burden falls on developing countries, where 84% of 1.3 billion current smokers live.1 In an effort to strengthen the tobacco control effort in India, the Government of India passed the India Tobacco Control Act (ITCA) in 2003.2 Additionally, in 2005, the Government of India ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).3
India Tobacco Control Act
The ITCA includes many tobacco control provisions: prohibiting smoking in public places, prohibiting direct or indirect advertisement of cigarettes and other tobacco products on billboards and in all media excluding point of sale, prohibiting the sale of tobacco products to minors (less than 18 years of age), and prohibiting the sale of tobacco products within a radius of 100 yards of any educational institution. Currently, the Government of India is finalizing rules regarding placing specified health warning labels on packages of all tobacco products, including details of the nicotine and tar content.
World Health Organization Framework Convention on Tobacco Control
The WHO FCTC is the world’s first public health treaty on tobacco control. The WHO FCTC encourages countries to develop and implement action plans to include public policies, such as bans on direct and indirect tobacco advertising, tobacco tax and price increases, promoting smoke-free public places and workplaces, and placing health warning labels on tobacco packaging. The WHO FCTC also calls on countries to establish surveillance programs of “the magnitude, patterns, determinants, and consequences of tobacco consumption and exposure to tobacco smoke.”3
Global Tobacco Surveillance
In 1998, the World Health Organization (WHO), the US Centers for Disease Control and Prevention, the Canadian Public Health Association developed the Global Tobacco Surveillance System (GTSS) to assist WHO Member States in establishing continuous tobacco control surveillance and monitoring.4,5 The GTSS includes collection of data through 3 surveys: the Global Youth Tobacco Survey (GYTS) for youth, and the Global School Personnel Survey, and the Global Health Professions Student Survey for adults. The GYTS provides systematic global surveillance of youth tobacco use. Countries can use GYTS data to enhance their capacity to monitor tobacco use among youth; guide development, implementation, and evaluation of their national tobacco prevention and control program; and allow comparison of tobacco-related data at the national, regional, and global levels.
The purpose of this paper was to use data from the GYTS conducted in India in 2003 and 2006 to examine changes in different tobacco control measures, which can be used to monitor provisions of the ITCA and relevant articles in the WHO FCTC.
METHODS
Procedures
The GYTS is a school-based survey that uses a 2-stage cluster sample design to produce representative samples of students in grades associated with ages 13-15 years. The sampling frame included all schools containing any of the identified grades. At the first stage, the probability of schools selected was proportional to the number of students enrolled in the specified grades. At the second sampling stage, classes within the selected schools were randomly selected. All students in selected classes attending school the day the survey was administered were eligible to participate. Student participation was voluntary and anonymous using self-administered data collection procedures. The GYTS sample design produced representative, independent, cross-sectional estimates for each site. Data in this paper are limited to students aged 13-15 years old.
GYTS Questionnaire
The 2003 and 2006 India GYTS questionnaires were self- administered in classrooms, and school, class, and student anonymity was maintained throughout the GYTS process. India country-specific questionnaires included data on prevalence of cigarettes, bidis (small, filterless, handmade cigarettes rolled in a leaf which can be flavored), and smokeless tobacco use; perceptions and attitudes about tobacco; access to and availability of tobacco products; exposure to secondhand smoke (SHS); school curricula; media and advertising; and smoking cessation. The final India questionnaires were translated into local languages and back-translated into English to check for accuracy. GYTS country research coordinators conducted focus groups of students aged 13-15 years to confirm the accuracy of the translation and student understanding of the questions.
Participants
During 2000-2005, individual GYTS was performed in 28 states and administrative divisions of India: Andaman and Nicobar Islands, Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Chandigarh, Delhi, Goa, Gujarat, Haryana, Himachal Pradesh, Jammu and Kashmir, Karnataka, Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, Punjab, Rajasthan, Sikkim, Tamil Nadu, Tripura, Uttaranchal, Uttar Pradesh, and West Bengal. These states represent 93.9% of the total population of India. The school response rate was greater than 90% in all states and was 100% in 19 states. The student response rate ranged from 70% to 95%. In total, 68,077 students from 818 schools participated in the 28 surveys. The majority of states, including the most populous regions of India, finished data collection in 2003. The 28 independent state samples were designed to be representative of students in grades 8-10. For each survey, a weighting factor was applied to each student record to adjust for the probability of selection at the school and student level and nonresponse at the school, class, and student level. A final adjustment sums the weights by grade and gender to the population of school children in grades 8-10 in each state. Thus, the state samples could be combined to produce a weighted national estimate that would be representative of students in grades 8-10. For the purpose of this report, the 28 state GYTS have been combined into a national estimate to be identified as India GYTS 2003.
For the 2006 India GYTS, the same sampling procedure as in 2003 was followed except, rather than states, the samples were designed for 6 independent geographic regions. The 6 geographic regions consisted of contiguous states and were formed to save budget and time. The 6 regions were: north (consisting of Chandigarh, Delhi, Haryana, Himachal Pradesh, Jammu and Kashmir, Punjab, Rajasthan, Uttaranchal, and Uttar Pradesh), south (consisting of Andhra Pradesh, Karnataka, and Tamil Nadu), east (consisting of Bihar, Jharkhand, Orissa, and West Bengal), west (consisting of Goa, Gujarat, and Maharashtra), central (consisting of Chhattisgarh and Madhya Pradesh), and northeastern (consisting of Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura). These regions represent 99.7% of the total population of India. The overall school response rate was 96.7%, and student response rate was 82.3%. In total, 12,086 students from the 179 schools participated in the 6 regional surveys, with fieldwork completed during the first half of 2006. For each regional survey, a weighting factor was applied to each student record to adjust for the probability of selection at the school and student level and nonresponse at the school, class, and student level. A final adjustment sums the weights by grade and gender to the population of school children in grades 8-10 in each region. Thus, the region samples can be combined to produce a weighted national estimate that is representative of students in grades 8-10. For the purpose of this report, the 6 regional GYTS have been combined into a national estimate to be identified as India GYTS 2006. Data Analysis
SUDAAN, a software package for statistical analysis of correlated data, was used to compute standard errors of the estimates and produced 95% confidence intervals, which are shown as lower and upper bounds.6 Differences in proportions were considered statistically significant at the p < .05 level.
RESULTS
Prevalence
In 2006, 12.0% of students had ever smoked cigarettes, even 1 or 2 puffs (Table 1). Between 2003 and 2006, ever smoking did not change significantly overall or by sex. In 2006, among ever smokers, 36.9% initiated smoking before age 10, with girls (55.1%) significantly more likely than boys (32.1%) to initiate smoking early. Between 2003 and 2006, early initiation decreased significantly overall and for boys. In 2006, 3.8% of students currently smoked cigarettes (a current smoker was defined as a student who smoked a cigarette on at least 1 day in the month prior to the survey), with the rate for boys significantly higher than girls. Between 2003 and 2006, current cigarette smoking did not change significantly. In 2006, 11.9% of students currently used tobacco products other than cigarettes (such as bidis, chewing tobacco, applied pastes, betel quids, etc), with the rate for boys significantly higher than girls. Between 2003 and 2006, other tobacco use did not change significantly. In 2006, the prevalence of other tobacco use was significantly higher than cigarette smoking overall, for boys and girls.
Cessation
In 2006, 70.3% of current smokers stated that they wanted to stop smoking now, 55.5% reported that they had tried to stop smoking in the past year but failed, and 81.8% reported that they had received help to stop smoking (Table 1). Between 2003 and 2006, there was no significant change in the desire by smokers to stop, attempts to stop, or receiving help to stop smoking.
Exposure to SHS
In 2006, 26.6% of the students reported that they were exposed to SHS from others in their home during the 7 days prior to the survey (Table 2). Between 2003 and 2006, exposure to SHS at home decreased significantly, overall and for boys and girls. In 2006, 40.3% of the students reported that they were exposed to SHS in public places during the 7 days prior to the survey. Between 2003 and 2006, exposure to SHS in public places significantly decreased, overall and for boys. In 2006, 74.0% of the students reported that they favored a ban on smoking in public places. Between 2003 and 2006, the desire to ban smoking in public places did not change significantly.
Media and Advertising
In 2006, 37.8% of the students reported that they saw “a lot” of advertisements for cigarettes on billboards during the month prior to the survey (Table 2). Between 2003 and 2006, exposure to billboard advertisements did not change significantly.
Minors’ Access and Availability
In 2006, 51.9% of current smokers reported that they usually bought their cigarettes in a store and 72.1% of them were not refused purchase because of their age (Table 2). Purchasing in a store and being refused sale of tobacco did not differ by sex. Between 2003 and 2006, the percent of current smokers who purchased their cigarettes in a store did not change significantly. In 2006, 11.2% of students reported that they had ever been offered free cigarettes by a tobacco company representative. Between 2003 and 2006, having been offered a free cigarette significantly increased overall and for boys.
DISCUSSION
Results from the 2003 and 2006 India GYTS indicate a number of serious challenges to prevent and control tobacco use in India. Prevalence of tobacco products other than cigarettes was significantly higher than cigarette smoking. India, thus, needs to ensure a broad comprehensive tobacco control strategy that includes cigarette smoking and use of other tobacco products like bidis, chewing and applied tobacco, and betel quid.7,8
The India GYTS data also showed that between 2003 and 2006, there was a significant decrease in exposure to SHS in homes and in public places. Enactment of the SHS provisions in the ITCA may have been important in this decline. However, in 2006, 40.3% of students reported being exposed to SHS in public places. Continued enforcement of the provisions in the ITCA banning smoking in public places is essential.
The ITCA prohibits advertisements of tobacco products in all media except at point of sale. Currently, cigarette advertisements on billboards other than at points of sale locations are not visible in any part of India, but large billboards are seen at point of sale in some parts of India. Nearly 4 in 10 students in 2006 reported being exposed to “a lot” of cigarette advertisement on billboards. The ITCA ban on advertising entered into force on May 1, 2004. The ITCA allows 60 x 30 cm tobacco advertisement point of sale displays, although there is evidence that these size restrictions are being ignored by the industry.2 The Government of India needs to amend the ITCA by including stricter provisions of enforcement of bans on advertising, especially at point of sale locations.
The ITCA includes a provision banning the sale of tobacco to and by minors. However, GYTS results show that about 7 in 10 adolescent smokers were not refused purchase of tobacco products because of their age. Public awareness and community empowerment campaigns need to be increased to enforce the ITCA provisions. About 1 in 10 students were offered free samples of cigarettes. The ITCA does not provide specific rules pertaining to giving free cigarettes to minors; therefore, new provisions should be developed and amended to the ITCA to eliminate this practice.
The findings in this report are subject to at least 3 limitations. First, because GYTS is limited to students, the survey is not representative of all adolescents aged 13-15 years. However, in India, the majority of persons aged 13-15 years attend regular, private, or technical schools.9 Second, these data apply only to students who were in school on the day of the survey and who completed the survey. In the 2003 GYTS, the student response rate ranged from 70% to 95%. In the 2006 GYTS, the student response rate was over 80% in each of the 6 regions. This suggests that the bias attributable to absence or nonresponse was limited. Finally, data were based on the self-report of students, who might underreport or overreport their behaviors or attitudes. The extent of this bias cannot be determined from these data; however, reliability studies in the United States have indicated good test-retest results for similar tobacco-related questions.10
CONCLUSION
Passing the ITCA and ratifying the WHO FCTC were public health milestones in India. However, findings from the India GYTS clearly show that enforcement of provisions of the ITCA is needed. GYTS data can be used to assist in the development of a National Program for Tobacco Control in India, as recommended in the WHO South-East Asia Regional Office strategy document, “Regional Strategy for Utilization of Global Youth Tobacco Survey Data.”11 Development of an effective comprehensive tobacco control program will require careful monitoring and evaluation of existing programs and the likely development of new efforts to encompass a range of population- based efforts to reduce tobacco use such as expanding the policies regarding SHS exposure; increasing the price of tobacco products through increased taxes; enforcing the ITCA regulations that ban sales, purchases, and consumption of tobacco products by underage youth; passing laws that regulate content, labeling, promotion, and advertising of tobacco products; and developing and implementing antitobacco mass media campaigns.1,12 The synergy created by India’s government passing the ITCA, ratifying the WHO FCTC, and supporting the conduct of the GYTS offers an excellent opportunity to develop, implement, and evaluate comprehensive tobacco control policies that can be most helpful to India.
Citation: Sinha DN, Gupta PC, Reddy KS, Prasad VM, Rahman K, Warren CW, Jones NR, Asma S. Linking Global Youth Tobacco Survey 2003 and 2006 data to tobacco control policy in India. J Sch Health. 2008; 78: 368-373.
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7. Reddy KS, Gupta PC. Report on Tobacco Control in India. New Delhi, India: Ministry of Health and Family Welfare; 2005.
8. World Health Organization. Tobacco: Deadly in Any Form of Disguise. Geneva, Switzerland: World Health Organization; 2006. 9. United Nations Children’s Fund. The State of the World’s Children, 2002. New York, NY: United Nations Children’s Fund; 2002. Available at: http://www.unicef.org/sowc02/fullreport.htm. Accessed January 1, 2008.
10. Brener ND, Kann L, McMannus T, et al. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health. 2002;31:336-342.
11. World Health Organization, Regional Office for South-East Asia. Regional Strategy for Utilization of Global Youth Tobacco Survey Data. New Delhi, India: World Health Organization; 2005.
12. Ranney L, Melvin C, Lux L, et al. Tobacco Use: Prevention, Cessation, and Control. Evidence Report/Technology Assessment No. 140. (Prepared by the RTI International-University of North Carolina Evidence-Based Practice Center Under Contract No. 290-02-0016). Rockville, Md: Agency for Healthcare Research and Quality; 2006. AHRQ Publication no. 06-E015.
DHIRENDRA NARAIN SINHA, MD, PhD(a)
PRAKASH C. GUPTA, DSc(b)
K. SRINATH REDDY, MD(c)
VINAYAK M. PRASAD, MB:BS, MBA(d)
KHALILUR RAHMAN, PhD(e)
CHARLES W. WARREN, PhD(f)
NATHAN R. JONES, PhD(g)
SAMIRA ASMA, DDS(h)
a Chairman, (dhirendrasinha1@hotmail.com or sinhad@searo.who.int), School of Preventive Oncology, A/27, Anandpuri, Boring Canal Rd, Patna 800001, Bihar, India.
b Director, (pcgupta@healis.org), Healis Sekhsaria Institute of Public Health, Navi Mumbai, India.
c Head and Professor, (ksreddy@ccdcindia.org), Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India.
d Director (Public Health), (vinayak63@hotmail.com), Ministry of Health and Family Welfare, Government of India, Nirman Bhavan, New Delhi, India.
e Regional Advisor, (RAHMANK@searo.who.int), Tobacco Free Initiative, WHO South-East Asia Regional Office, New Delhi 110002, India.
f Office on Smoking and Health, (wcwl@cdc.gov), Centers for Disease Control and Prevention, 4770 Buford Hwy, NE MS K-50, Atlanta, GA 30341.
g Office on Smoking and Health, (njones@uwcc.wisc.edu), Centers for Disease Control and Prevention, 4770 Buford Hwy, NE MS K-50, Atlanta, GA 30341.
h Office on Smoking and Health, (sea5@cdc.gov), Centers for Disease Control and Prevention, 4770 Buford Hwy, NE MS K-50, Atlanta, GA 30341.
Address correspondence to: Dhirendra Narain Sinha, Chairman, (dhirendrasinha1@hotmail.com or sinhad@searo.who.int), School of Preventive Oncology, A/27, Anandpuri, Boring Canal Rd, Patna 800001, Bihar, India.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention (CDC). We sincerely thank the persons who helped in conducting India GYTS 2006 and WHO and CDC for sponsoring the project and providing technical assistance.
Copyright Blackwell Publishing Ltd. Jul 2008
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