Indian Journal of Dental Research

: 2011  |  Volume : 22  |  Issue : 2  |  Page : 195--199

Self-reported tobacco use, knowledge on tobacco legislation and tobacco hazards among adolescents in rural Kerala State

Radhakrishnan Jayakrishnan1, Seema Geetha2, Bhaskarapillai Binukumar3, Sreekumar1, Kamala Lekshmi1,  
1 Department of Community Oncology, Tobacco Cessation Centre, Regional Cancer Centre, Thiruvananthapuram, India
2 Department of Periodontics and Community Dentistry, Sree Sankara Dental College, Varkala, Thiruvananthapuram, India
3 Department of Statistics, Manipal University, Manipal, India

Correspondence Address:
Radhakrishnan Jayakrishnan
Department of Community Oncology, Tobacco Cessation Centre, Regional Cancer Centre, Thiruvananthapuram


Context: Tobacco consumption initiated during the adolescent period is a major contributor to the pathogenesis of fatal diseases in adulthood. Information on tobacco use and awareness regarding tobacco legislation and hazards among adolescents in rural Kerala is limited. Aims: To assess the prevalence of tobacco use among adolescent students in a rural district in Kerala state and to understand the extent of awareness about the prominent legislative measures against tobacco and tobacco hazards. Materials and Methods: Data on awareness regarding health hazards due to tobacco use and legislation against tobacco consumption were collected from students of 15 randomly selected high schools in an educational sub-district in Kerala, using a cross-sectional study design. Chi-square and Fisher«SQ»s exact test statistics were used for statistical analysis. Results: A total of 1473 students participated in the study, of which 79% were males (mean age 15.4 years, SD 1.5). The overall prevalence of «SQ»current tobacco users«SQ» was 8%. A significant association between age and tobacco use was noted among tobacco habitues (P<0.05). Awareness regarding legislation against smoking in public places was more in the higher age-groups (P<0.05). Females were more aware of the «SQ»smoking ban«SQ» than males (P<0.05). Our survey of the awareness regarding the hazards associated with tobacco use revealed that 41.5% of the students knew about the link between oral cancer and tobacco, with the awareness being greater among females than among males (64.3% vs 35.4%). Conclusion: The finding that tobacco consumption increases with age is a matter of concern. In addition to their clinical work, dental professionals should also educate the public on the hazards of tobacco and conduct tobacco cessation programmes for adolescent groups to control the tobacco epidemic.

How to cite this article:
Jayakrishnan R, Geetha S, Binukumar B, Sreekumar, Lekshmi K. Self-reported tobacco use, knowledge on tobacco legislation and tobacco hazards among adolescents in rural Kerala State.Indian J Dent Res 2011;22:195-199

How to cite this URL:
Jayakrishnan R, Geetha S, Binukumar B, Sreekumar, Lekshmi K. Self-reported tobacco use, knowledge on tobacco legislation and tobacco hazards among adolescents in rural Kerala State. Indian J Dent Res [serial online] 2011 [cited 2021 Sep 23 ];22:195-199
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Full Text

The increasing burden of tobacco-related diseases, particularly oral cancer, in India bears a direct association to the increase in consumption of a wide range of tobacco products. Oral cancer is the most common form of cancer in India and accounts for a major proportion of cancer-related deaths among men. [1]

According to the World Health Organization, tobacco kills more than five million people in the world, which is more than the mortality due to tuberculosis, HIV/AIDS, and malaria combined. In India, it is estimated that one million deaths occur due to tobacco every year. If left unchecked, it is projected that the mortality due to tobacco consumption will rise to 1.5 million by 2020. [2] Apart from being the second largest producer of tobacco and second leading seller in the world, India also has 185 million consumers of various tobacco products. [3] The increasing population, easy availability of cheap tobacco products, and weak enforcement of existing regulations are some of the factors that contribute to the increase in tobacco consumption.

The long history of tobacco use and its use among adolescents in India is well documented. It is also known that tobacco addiction among the majority of adults was initiated during their adolescence. [4],[5] The survey conducted in Tamil Nadu among school students of classes 8-10 under the Global Tobacco Survey initiative found that 7% of students reported using tobacco in some form. [6] The state of Kerala representing 3% of the total population of India is undergoing an epidemiological transition, with a decline in communicable diseases and a concurrent rise in noncommunicable diseases such as cardiovascular diseases, chronic obstructive pulmonary disease, and various forms of cancer. [7]

Tobacco use is considered a modifiable risk factor for common noncommunicable diseases. Hence, tobacco control is an important measure in the primary prevention of noncommunicable diseases and must be implemented if we are to control chronic diseases.

In Kerala, smoking and the use of snuff is predominantly a male habit, while the prevalence of chewing tobacco is more or less similar among men and women. Over the recent years there is an indication that tobacco chewing has increased among men and decreased among women. [7]

Similar to other states of India, in Kerala too adolescents are the most vulnerable section of the population exposed to tobacco use. This is mainly attributable to easy accessibility and availability, less social stigma, and weak legislation. The Cigarettes and Other Tobacco Products Act (COTPA; Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution), 2003, of the Government of India places emphasis on the ban of the sale of tobacco products to individuals below 18 years of age. Under section 6 (a) of the Act, the onus is on the seller to ensure that the buyer is not a minor, and the buyer should produce relevant age proof before being allowed to buy tobacco products. Section 6 (b) of the Act prohibits the sale of tobacco products within a radius of 100 yards of any educational institution, thus reducing the ease of access. [8] Though there have been studies on the prevalence of tobacco use in Kerala among adults, information on the tobacco use pattern among adolescents in rural Kerala is limited.

The objectives of this study were to assess the prevalence and patterns of tobacco use among high-school and higher secondary school students in a rural district in Kerala state and to assess the extent of awareness of the prominent legislative measures against tobacco and knowledge regarding the major tobacco-associated diseases.

 Materials and Methods

Study population

The study was conducted in a rural district of Central Kerala located approximately 100 kilometers north of Thiruvananthapuram the capital city of Kerala State. According to the educational system in Kerala, each district is further divided into 2-3 educational sub-districts. For this study, we randomly selected one educational sub-district. There were 69 aided and 31 government high-schools/higher secondary schools functioning in this educational district. Aided schools are those managed by private parties but receiving financial support from the Government. The educational curriculum followed in all the schools is the same. Prior permission was taken from the Directorate of Public Instructions and the concerned school officials to conduct the study. From the above schools, 15 high-schools/higher secondary schools were selected using the simple random sampling method. All the students in the randomly selected schools were invited for the study. The age-group of the study participants was 13-19 years. The participating students were stratified according to age into three groups: <15 years, 15-17 years, and ≥18 years. Approximately 60% of the study subjects were in the 15-17 year age-group.

We tried to include all students in the 13-19 year age-group for the study, but in two schools the students were preparing for their Secondary School Leaving Certificate examinations and they were therefore excluded from the study.

Data on the different modes of tobacco consumption, awareness of the hazards of tobacco use, family history of tobacco use, awareness of legislation against smoking in public places, and awareness of the restrictions on sale of tobacco products near school premises were collected using a structured pretested questionnaire prepared in the local language. This questionnaire was pretested in two selected government schools after which we made the necessary alterations to ensure that the questionnaire was simple and easy to understand and could be answered within a short period of time. However, it was not a validated questionnaire.

Besides general information on age, sex, and class, the self-administered questionnaire consisted of questions related to the type of tobacco consumption (viz. cigarette, bidi, betel quid, and/or gutka (gutka is the term generally used for a product containing mainly tobacco and arecanut along with flavoring agents and other substances; it is sold in a powdered or granulated form in sachets).

We tried to find out the number of 'current users' of tobacco. In our study, a current user was defined as a person who had the habit of using tobacco products at least 3 days in a week during the month in which the study was conducted or in the previous month if the study was done in the first week of a month. Awareness of health hazards related to tobacco products was assessed on the basis of responses to open-ended questions and the students were separated into four groups as follows: (a) no awareness about tobacco-related diseases (b) awareness of a tobacco-related cancer (c) awareness of more than one cancer and respiratory disease, and (d) awareness of cancer, respiratory disease, and cardiovascular disease.

Prior to distribution of questionnaires we tried to ensure that we would get the maximum information from the participants by explaining each question to them so that they understood it clearly. The questionnaire was explained by first and second authors. The students were also assured that all information given by them would be strictly confidential. To this end they were also advised not to write their names on the questionnaire. The intention was to increase the participation rate.

The study team members distributed questionnaires to all the students in the venue and the filled-in questionnaires were collected back when the time allotted for answering was over. There were no teachers or concerned authorities at the venue while the students were answering the questionnaire.

The association between the variables of interest was tested using chi-square statistics; Fisher's exact test statistics was used if the expected value of a cell was less than five. [9] All the analyses was carried out using the statistical software SPSS, version 16.0.


A total of 2100 self-administered questionnaires were distributed to the participants aged 13-19 years. We had a response rate of 70%, with 1471 students returning the filled up questionnaire. Of the study subjects 79% were males (mean age: 15.43 years, SD: 1.57 years) and 21% were females (mean age: 15.19 years, SD: 1.45 years). Female students were fewer in number because only four of the randomly selected schools admitted female students.

Among the participants, 91.4% were not tobacco or alcohol users, whereas 8% (95% CI: 6.61-9.39) of them were tobacco users and were either smoking and /or using smokeless tobacco along with or without alcohol. None of the female students reported use of tobacco in any form even occasionally. Among the tobacco users, a significant proportion of subjects (4.1%) were current users of pan masala containing gutka [Table 1]. The age-group distribution of pan masala containing gutka users points to the increase in its consumption with increase in age (P<0.05) [Table 2].{Table 1}{Table 2}

With regard to tobacco-related diseases we found that 41.5% of the students were aware of the relationship between oral cancer and tobacco, while 38% reported that they were unaware of any diseases due to tobacco. Over one-sixth of the students (16.1%) were aware that tobacco could cause more than one form of cancer and also be the cause of respiratory diseases, while the remaining 4.5% also mentioned cardiovascular diseases as being tobacco-related (P=0.016) [Table 2].

Awareness regarding prominent legislative measures against tobacco was assessed among the study subjects. We observed that more than half of the respondents (55.9%) were aware of the ban on smoking in public places. A statistically significant association was found between age and awareness on 'smoking ban'. An increase in awareness was observed with increase in age, with the awareness being maximum among those 18 years and above (P<0.05) [Table 2]. However, no significant association was found between age and awareness regarding the law prohibiting selling of tobacco products to minors.

Awareness of the health hazards due to tobacco and legislation against tobacco were also assessed among study participants based on gender. Awareness on oral cancer was significantly higher among females when compared to males (64.3% vs 35.4%) (P<0.01). Similarly, more female students were aware of the ban on smoking in public places than their male counterparts (68.5% vs 52.6%) (P<0.01) [Table 3].{Table 3}

We also looked into the association between tobacco use among family members and the student's habits. Of the respondents belonging to the non-user group, 92.7% reported that their family members were not tobacco users. The majority of the family members of tobacco habituees were also non-users, but an interesting finding was that tobacco consumption was more among family members of students who were pan masala users (5.6%) [Table 4].{Table 4}


In a study conducted by Mohan et al. among school students aged 12-19 years residing in urban areas of Kerala state, the current use of any form of tobacco was found to be 11%. [11] In this study 8% of participants used tobacco in some form or the other. Though there is a decrease in tobacco consumption in this study, the observed difference is relatively small. However, the prevalence of 'current smoking' in the former study was 8.1% and use of smokeless tobacco was 3.2%. Surprisingly, the present study reported a high prevalence of smokeless tobacco use among school students (4.1%), with current smokers being less than 1%. The reason for the striking contrast in the results of these two studies indicates that there is a changing trend in the tobacco consumption pattern, particularly in the rural areas of Kerala state.

A review article by Thankappan et al. [7] has pointed out that, historically, cigarette smoking has always been more prevalent among the upper socioeconomic classes. It is also true that the upper socioeconomic groups are more commonly found residing in urban areas, which might have influenced our study results. Another possible explanation could be the recent increase in the tax on cigarettes, which has resulted in cigarettes becoming more expensive than smokeless tobacco. Traditionally, rural communities use smokeless tobacco products, particularly through the habit of betel quid chewing (mixture of tobacco, slaked lime, arecanut, and betel leaves). The present study points to the changing trends in the consumption of tobacco products among adolescent groups, which is reflected in the relatively high prevalence of gutka use among the study participants. These tobacco products are marketed in attractive sachets to influence the youth. Reports have already drawn attention to the large number of outlets selling tobacco products near schools. [10] Though there is a law prohibiting the sale of tobacco products within 100 yards of a school, the implementation is lax in many districts. There is also a popular misconception that smokeless tobacco products are less harmful than smoking.

None of the female students in this study were tobacco users. Though tobacco chewing is common among women in Kerala, as has been reported elsewhere, this study suggests that the younger generation of females consider tobacco use as a socially unacceptable habit and a health hazard.

Awareness of the prominent legislative measures against tobacco was assessed among the study subjects. We observed that awareness among participants increased with increase in age. A survey commissioned by the Healis Sekhsaria Institute for Public Health that covered four metropolitan cities of India tried to understand the extent of public support for the legislation against smoking in public spaces and the awareness regarding health hazards due to second-hand smoking. [12] The results were encouraging. The study found that 92% of respondents were supportive of the ban on smoking in public places. Though the study sought to understand the public's response to the law, it did not try to assess the awareness regarding the ban on smoking in public places. In this study, over half of the study subjects were aware of the ban on smoking in public places, their source of information probably being newspapers, television channels, and various awareness programmes. Kerala was the second state in India (after Goa) to ban smoking in public places through a landmark judgment in the year 1999. This study was conducted in rural Kerala and the response shows that there is a relatively high level of awareness of the ban on smoking in public places. However, 87% of the study subjects were unaware of the law prohibiting selling of tobacco products to minors (below 18 years of age). There has been extensive publicity surrounding the ban on smoking in public places and this has probably overshadowed the publicity given to the law restricting the sale of tobacco to minors.

In this study, there was wide variation between male and female students with regard to awareness of tobacco hazards and the ban on smoking in public places. Female students were more knowledgeable in both these aspects when compared to male students. The possible reasons could be that female students might have enhanced their knowledge on social issues through print or electronic media or through sources like friends or families. The fact that none of the female students in the study used tobacco could have been a reflection of their knowledge on the social taboo and hazards associated with tobacco.


This study was a cross-sectional descriptive study. Tobacco use status was self-reported by the students. Some students may not have reported their use of tobacco. Also, some students who were using tobacco might have been absent from the school on the day of the survey. The study was carried out in one rural educational sub-district of Kerala state and the results cannot be extrapolated to the rest of the state.


Despite Kerala's high literacy rate there is a rise in the consumption of tobacco products, particularly among the youth, and this is a cause for concern. More measures are needed to raise awareness on legislation against tobacco and the hazards of tobacco in any form. In addition to their clinical work, dental professionals can contribute by undertaking mass education programmes and tobacco cessation programmes for adolescent groups to control the tobacco epidemic.


We would like to acknowledge Dr. K.G.Sasidharan Pillai, Director, District Cancer Center, Kozhencherry; the staff of the District Medical Office, Pathanamthitta; and the school authorities for their support in organizing and conducting the study.


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