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The association of tobacco use in adolescents with their interpersonal surroundings and assessing tobacco vendor compliance with COPTA policies: A cross-sectional study

Open AccessPublished:March 16, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101008

      Abstract

      Introduction

      The prevalence of tobacco consumption is increasing globally and in South-east Asian countries. Despite the government's efforts in passing the laws for monitoring tobacco consumption, their effectiveness is questionable. The study's objectives are to investigate the association of tobacco use among the study participants as a function of community, interpersonal and individual factors.

      Methadology

      A conceptual framework was drawn based on Bronfenbrenner's theory of the ecology of human development, the social learning theory, and the social control theory. An observational study was conducted in 13 government and 26 private pre-university colleges in the Shimoga district of Karnataka, India. The study was conducted in two stages. First at the student level and the second at the tobacco vendor level. Ethical approval from the institutional board and informed consent from the participants were obtained. A descriptive, comparative and multivariate analysis was performed.

      Results

      Of the 726 participants, 19.6% had used tobacco at least once. The most common type being flavoured cigarettes (54.3%). The average compliance of permanent tobacco outlets was 6.1/10, while the mobile tobacco outlet scored 3.8/10. Active tobacco use was strongly associated with peer tobacco use (r = −0.439, p < 0.001), community compliance (r = −0.365, p = 0.004), family educating against tobacco use (r = −0.269, p < 0.038) and age of initiation of tobacco use (r = −0.327, p = 0.011).

      Conclusion

      Our study shows us that the issue of adolescent tobacco use is multipronged. It centres on community, interpersonal and individual factors. We need a mixed-methods approach focusing on improving compliance with COPTA laws and effective anti-tobacco education in schools and immediate interpersonal surroundings.

      Keywords

      1. Introduction

      Tobacco use is recognized as a critical public health hazard faced by both developing and developed countries. It has been estimated that globally, by the year 2030, nearly eight million deaths (annually) will be related to tobacco use. Indians use tobacco derivatives such as cigarette/beedis (tobacco flakes rolled in tendu leaves) and chewing tobacco (smokeless).
      • Raj N.
      • Sarita S.
      • Sanjay G.
      Age at initiation & prevalence of tobacco use among school children in Noida, India: a cross-sectional questionnaire based survey.
      It is associated with almost eight hundred thousand deaths annually in India, 13.3% of all the deaths in 2020.
      • Janazzo D.
      The Tobacco Epidemic in India.
      The importance of prevention of tobacco use in adolescents stems from the fact that those adolescents who don't start tobacco use during adolescence are unlikely to ever use it.
      • Preventing C.D.C.
      Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.
      Research indicates that the probability of successful tobacco cessation among adults is inversely related to the age at initiation of tobacco use.
      • Coambs R.B.
      • Li S.
      • Kozlowski L.T.
      Age interacts with heaviness of smoking in predicting success in cessation of smoking.
      ,
      • Breslau N.
      • Peterson E.L.
      Smoking cessation in young adults: age at initiation of cigarette smoking and other suspected influences.
      An early age initiation of tobacco use has been strongly linked with reduced lung function, reduced lung development and early cardiovascular damage.
      National Center for Chronic Disease Prevention and Health Promotion (US)
      Office on Smoking and Health. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General [Internet].
      It has also been linked with poorer academic performance and completion of schooling.
      • Mohan S.
      • Sankara Sarma P.
      • Thankappan K.R.
      Access to pocket money and low educational performance predict tobacco use among adolescent boys in Kerala.
      With this information in hand, it is concerning to know that studies have observed a downward shift in the age of initiation of use in tobacco products.
      • Lalithambigai G.
      • Rao A.
      • Rajesh G.
      • Ramya S.
      • Pai B.M.
      Predictors of cigarette smoking among young adults in Mangalore, India.
      ,
      • Sagarkar A.
      • Sagarkar R.
      • Shivamallappa S.
      • Arabbi K.
      A substantive review on tobacco use among school-going adolescents in India.
      Furthermore, nearly five thousand adolescents are said to initiate tobacco use every day in India, joining the four million young adults consuming tobacco.
      India has a tobacco control legislation called “Cigarettes and Other Tobacco Products Act of 2003” (COTPA) and became a party to the WHO Framework Convention on Tobacco Control on February 27, 2005
      • Copta
      THE CIGARETTES AND OTHER TOBACCO PRODUCTS (PROHIBITION OF ADVERTISEMENT AND REGULATION OF TRADE AND COMMERCE, PRODUCTION.
      with numerous amendments to the original COPTA act. Unfortunately, passing legislation has proven to be easier than its effective implementation. A large multi-centre study done in 38 Jurisdictions, looking at 20,455 public places in India found that only 51% of all the public places were compliant with COPTA policies. While the adherence to these policies were found to be 65% in Educational institutions.
      • Kumar R.
      • Goel S.
      • Harries A.D.
      • et al.
      How good is compliance with smoke-free legislation in India? Results of 38 subnational surveys.
      To understand the lack of compliance with these policies, we need to acquire a more robust understanding of the influence of the tobacco control policies on adolescent tobacco use. We did this by creating a conceptual framework revolving around Bronfenbrenner's theory of the ecology of human development, the social learning theory, and the social control theory (Fig. 1).
      • Ennett S.T.
      • Foshee V.A.
      • Bauman K.E.
      • et al.
      A Social Contextual Analysis of Youth Cigarette Smoking Development.
      In this study, we aim to assess the prevalence of tobacco use in college-going adolescents of both private and government institutes and investigate the association of tobacco use with their interpersonal surroundings. The objectives include the effects of community, interpersonal (peers and family), and individual factors on tobacco use. The study also examines tobacco vendor compliance with COPTA policies near schools and their relationship to teenage tobacco use.
      Fig. 1
      Fig. 1Conceptual framework to explain adolescent tobacco use and its moderators.

      2. Methodology

      The study took place in two phases. The first phase included the survey of adolescent pre-university college going students while the second phase consisted of the survey of tobacco vendors near these establishments. An outline of the study design is illustrated in Fig. 2.
      Fig. 2
      Fig. 2Flowchart Illustrating the study design.

      2.1 Study population and sampling

      2.1.1 Survey of the students

      The study was conducted among pre-university students in Shimoga, India, from April 2019 to November 2019. This study was approved by the Institutional Ethics Committee of JSS Medical College, Mysuru (Approval number: JSSMC/IEC/18/7/2018-19). A list of government and private pre-university colleges in Shimoga was obtained from the Department of Pre-University Education (DPUE). There were 39 pre-university colleges in Shimoga, of which 13 are government colleges, and the rest are private (Appendix A). These colleges cater to a population of 15,671 students. For the calculation of sample size, a prevalence of 15.1% in an identical study done in Bangalore city was taken which was 575 subjects (n =(Zα)2 × p × q⁄(d)
      • Raj N.
      • Sarita S.
      • Sanjay G.
      Age at initiation & prevalence of tobacco use among school children in Noida, India: a cross-sectional questionnaire based survey.
      ) where Z = 1.96 for α at 0.05 15.
      An additional 10% was added to account for students being absent/unwilling to participate, which produced an estimated sample size of 630. A two-stage stratified random sampling method was used to attain the calculated sample size. In the first stage, The colleges were stratified based on ownership (Government vs. Private), and computer generated random sampling was done to avoid the possibility of potential bias. A total of 16 colleges (8 Government and 8 private) were selected. It catered to 6329 students, all of whom are eligible to participate in the study. In the next stage, two classes from each of the sampled colleges were randomly selected by computer generated random sampling. This consisted of 1013 students, all of whom are eligible to participate in the study.

      2.1.2 Survey of the tobacco vendors

      The area around each Educational Institution (EI) was mapped to cover 100 yards and 300 m, respectively. The 300-m radius was based on the feasibility of the walking distance from the institution, and the 100 yards was to assess compliance with an essential provision of COTPA. Mapping of tobacco outlets was done using location details obtained from the municipal corporation. Field investigators further cross-checked this list in a randomly selected educational institution (EI) adjacent community. There were a total of 327 tobacco vendors eligible to participate in the study. The vendors manning the outlets were enrolled and interviewed after taking informed consent for participating in the study. Direct observations of the outlet for section 5, 5 and 6 of the COPTA act was done. The confidentiality and anonymity of the vendor's responses were maintained as per the norms.
      The 300-m radius of each EI is designated as an “EI-adjacent community”/community allowing us to calculate an average community level COPTA law compliance for each community.

      2.2 Outcomes, predictors and potential confounders

      The primary outcome of the study was to assess the prevalence and determinants of tobacco use in adolescent pre-university college going students. The secondary outcome is to assess tobacco compliance in an individual tobacco outlet and a community as a whole. The predictors considered were split into individual factors, interpersonal factors and community factors. Individual factors included age, sex, perception of tobacco use and knowledge of tobacco hazard. Interpersonal factors such as family and peer tobacco use, exposure to second hand smoke, school and family teachings of anti-tobacco teachings. Community factors included compliance to COPTA policies. Potential confounders considered for the study were alcohol use and recreational drug use.

      2.3 Data collection and study instruments

      Google forms, a web-based survey tool, was used to conduct the survey, which consisted of questions from the standardized Global Youth Tobacco Survey (GYTS) in English. No changes were made to the standardized questionnaire. The students were invited via email to participate in the survey. The invitation explained the study's objective and informed them about having taken the approval to survey their colleges. The survey ran for 15 days in each college, and the participants could complete the survey during any of those days. Total anonymity was assured to them.

      2.4 Definitions and measures

      2.4.1 Use of tobacco and different modes of consumption

      A “never user” had never used tobacco; an “ever user” was someone who had used any form of tobacco at least once, and an “active user” was someone who used tobacco within the last 30 days. Sociodemographic data collected included age, sex, and educational qualification. There were questions to determine the mode of tobacco consumption, i.e., smoking (cigarettes, beedis) or smokeless forms (betel quid chewing, gutka, snuff).

      2.5 Knowledge, beliefs, and attitude surrounding tobacco consumption

      Questions to determine social influences around tobacco consumption were based on family and their peers using the same. A positive attitude towards tobacco use was measured with questions like their perception of those who use tobacco, comfort associated with tobacco use in social gatherings, and the effect of tobacco use for the last year. Knowledge, attitude, and beliefs about tobacco use were assessed with questions such as their understanding of the harmful effects of tobacco, difficulty with quitting, exposure to anti-tobacco advertisements, family/teachers discussing the same with the participant, and their opinion of using tobacco for just one year.

      2.6 Compliance of tobacco vendors with the COPTA laws

      The variables for the tobacco vendors to test adherence to the COPTA act were laws under COPTA section 5, 5 and 6.
      Under section 6 of the COPTA act, the questions consisted of the sale of tobacco to minors, violations of law with the presence of tobacco selling outlets within 100 yards of EI, and compliance to the presence of appropriate signage outside EI, prohibiting the sale of tobacco products within 100 yards of EI and adherence to the signage requirement for the presence of display board 60 cm × 30 cm on tobacco shop displaying the warning prohibiting the sale of tobacco products to minors.
      Under section 5 of the COPTA act, the questions consisted of compliance to the presence of health warning (tobacco causes cancer or tobacco kills) on the top edge of the display boards at the point of sale, violation by exhibiting exterior hoardings advertising tobacco products measuring more than the prescribed dimensions (60 cm × 45 cm), violation by exhibiting more than two boards at one point of sale, violation by exhibiting hoardings with brand pack photo, brand name and other promotional messages, violation by the open display of tobacco products at tobacco outlets and a visit by law-enforcing authorities to the shop. Each rule was scored one if yes and 0 if no. The score ranged from 0 to 10 per tobacco outlet. An average of vendor compliance scores per EI adjacent community was considered to be the community score. A score of 10-7 was regarded as a high score while 6 to 4 was moderate compliance and 0 to 3 is low compliance.

      2.7 Statistical analysis

      Data from online survey forms were exported into Microsoft Excel 2017. EpiInfo™8.5.1 (2008) was used for calculating the frequencies. Missing data were addressed by using the case deletion approach wherein we omitted the cases with the missing data and analysed the subjects with complete data.
      • Kang H.
      The prevention and handling of the missing data.
      Continuous variables were represented as mean with standard deviation (SD) and categorical variables as a number with percentage (%). Statistical significance was assessed by Pearson's chi-square test for categorical variables and by Student's T test for continuous variables.
      Multivariable analyses using SPSS v.21 were conducted to identify independent variables associated with tobacco use. Variables presumed to be of clinical importance, such as demographic factors (such as age and sex) and interpersonal factors (such as having friends or family who use tobacco) were included in the model. Along with these, other factors with a significant association with tobacco use observed in the study were also added to the model. A two-tailed p < 0.05 was considered statistically significant.

      3. Results

      3.1 Prevalence of tobacco use

      Out of 1013 participants, 726 completed the survey (response rate of 71.6%), 13.7% male and 4.1% female active tobacco users, with ever tobacco use prevalence being 19.6%.
      Responses were categorized according to private and government educational institutions (EI). Students from government EIs were slightly younger, had higher rates of active users and lower age of initiation. The preferred place of smoking were tea shops and tobacco stores, with a small number of participants using tobacco in school (Table 1). Most students preferred flavoured cigarettes and a small number used smokeless tobacco (Fig. 3A).
      Table 1Detailed prevalence and sociodemographic factors of the study population (N = 726).
      Private N = 352 (%)Government N = 374 (%)Test statistic
      Age15.59 ± 1.0514.57 ± 1.72t = 9.576; df = 725; SE = 0.107; p < 0.001.
      Age of initiation of tobacco use15.02 ± 1.8514.46 ± 1.54t = 4.442; df = 724; SE = 0.126; p < 0.001.
      Sex
      Male187 (53.13)197 (52.67)χ2 (1) = 0.014; p = 0.903
      Female165 (46.88)177 (47.33)
      Tobacco use status
      Non users271 (76.99)237 (63.37)χ2(1) = 21.128; p < 0.001
      Ever users81 (23.01)137 (36.63)
      Active users39 (11.08)67 (17.91)
      Place of tobacco use (N = 218)
      At home7 (3.21)12 (5.5)χ2(1) = 4.154; p = 0.527
      At school3 (1.38)9 (4.13)
      At friends' place13 (5.96)19 (8.72)
      At social events16 (7.34)17 (7.8)
      In public places4 (1.83)9(4.13)
      Others38 (17.43)71 (32.57)
      Frequency and quantity of tobacco consumption among youth (N = 218)
      No tobacco in 30 days42 (19.27)70 (32.11)χ2(1) = 1.381; p = 0.967
      <1 cigarette per day19 (8.72)32 (14.68)
      1 cigarette per day14 (6.42)20 (9.17)
      2 -5 cigarettes per day4 (1.83)4 (1.83)
      6 -10 cigarettes per day1 (0.46)4 (1.83)
      11 -20 cigarettes per day2 (0.92)3 (1.38)
      <20 cigarettes per day1 (0.46)2 (0.92)
      Structure of tobacco outlets
      Permanent107 (67.72%)101 (59.76%)χ2 (1) = 2.234; p = 0.134
      Mobile51 (32.28%)68 (40.24%)
      Alcohol use
      Yes64 (18.18%)81(21.65%)χ2 (1) = 1.370; p = 0.241
      No288 (81.82%)293 (78.35%)
      Recreational drug use
      Yes48 (13.63%)63 (16.84%)χ2 (1) = 1.441; p = 0.229
      No304 (86.37%)311 (83.16%)
      Note: 1A “never user” was defined as one who had never used tobacco; 2An “ever user” was someone who had used any form of tobacco at least once; 3An “active user” was someone who used tobacco within the last 30 days.
      Fig. 3
      Fig. 3A: Chart summarizing the different types of tobacco products used by study population (N = 143). Others: Hookah, e-cigarettes, bidis etc., Smokeless form: mishri, tobacco toothpowder, etc.
      Figure 3B: Access to tobacco products by the study population (N = 143).

      3.2 KAP concerning tobacco use

      All participants were aware that tobacco consumption is harmful to health and 41.74% believed that it is difficult to quit smoking. Most students confirmed they are being educated about the harmful effects of tobacco consumption, both at school and home. More than half (53.3%) of were exposed to anti-tobacco advertisements in media more than half felt it is not safe to consume tobacco for a year. The majority of participants (70.8%) expressed that they will not consume tobacco despite offered by a friend. The majority observed they have easy accessibility to tobacco and active users felt more comfortable consuming tobacco in social gatherings (Table 2).
      Table 2Knowledge, beliefs and Attitude towards tobacco consumption among students from PUC using the GHPSS questionnaire in the city of Shimoga, India in the year 2019-20 (N = 726).
      Private (N = 352)Government (N = 374)Test statistic
      Do you think cigarette smoking Is harmful to health?
      Yes352 (100)374 (100)
      No00
      Do you think it would be difficult to quit once someone has started smoking?
      Yes154 (43.75)149 (39.84)χ2(1) = 2.137; p = 0.343
      No63 (17.9)82 (21.93)
      Maybe135 (38.35)143 (38.24)
      Being taught the harmful effects of smoking in school
      Yes293 (83.24)264 (70.59)χ2(1) = 16.248; p < 0.001
      No59 (16.76)110 (29.41)
      Family discussing harmful effects of smoking
      Yes258 (73.3)247 (66.04)χ2(1) = 4.504; p = 0.033
      No94 (26.7)127 (33.96)
      Exposure to anti-tobacco media in the last 30 days
      A lot133 (37.78)101 (27.01)χ2(1) = 31.56; p < 0.001
      Few151 (42.9)236 (63.1)
      None68 (19.32)37 (9.89)
      Likelihood of you smoking after next 5 years
      Yes38 (10.8)41 (10.96)χ2(1) = 0.005; p = 0.942
      No314 (89.2)333 (89.04)
      Opinion on tobacco being safe to consume for 1 year
      Yes, it is safe33 (9.38)46 (12.3)χ2(1) = 1.834; p = 0.399
      No, it is not safe211 (59.94)211 (56.42)
      Not sure108 (30.68)117 (31.28)
      If one of your best friends offered you a cigarette, would you smoke it?
      Yes41 (11.65)56 (14.97)χ2(1) = 3.195; p = 0.202
      No260 (73.86)254 (67.91)
      Maybe51 (14.49)64 (17.11)
      Association of tobacco and comfort in social gatherings
      Less comfortable23 (6.53)22 (5.88)χ2(1) = 0.627; p = 0.730
      More comfortable226 (64.2)273 (72.99)
      No difference103 (29.26)79 (21.12)
      Do you think it would be easy or hard for you to get Tobacco products?
      Hard116 (32.95)159 (42.51)χ2(1) = 7.197; p = 0.007
      Easy236 (67.05)214 (57.22)

      3.3 Access to tobacco products

      Eighty-five percent of participants observed that nobody refused to sell cigarettes to minors and nearly half of active users started tobacco use as minors (Table 3), who obtain it from a nearby shop or a street vendor, 20% borrowed cigarettes and 14% could get cigarettes from family members (Fig. 3B).
      Table 3Tobacco vendor compliance with COPTA laws (n = 327).
      A) Compliance/violations to Section 6: COTPA
      Sale of tobacco to minors6720.50%
      Violations of law with presence of tobacco selling outlets with-in 100 yards of EI11836.10%
      Compliance to presence of appropriate signage outside EI, prohibiting sale of tobacco products with in 100 yards of EI (n = 16)0
      Compliance to the signage requirement for presence of display board 60 cm × 30 cm on tobacco shop displaying the warning prohibiting sale of tobacco products to persons below 18 years6921.10%
      B) Compliance/violations to Section 5: COTPA point of sale advertisements
      Compliance to presence of health warning (tobacco causes cancer, or tobacco kills) on the top edge of the display boards at the point of sale20161.50%
      Violation by exhibiting exterior hoardings advertising tobacco products measuring more than the prescribed dimensions (60 cm × 45 cm)6720.50%
      Violation by exhibiting more than two boards at one point of sale15848.30%
      Violation by exhibiting hoardings with brand pack photo, brand name and another promotional message14845.30%
      Violation by open display of tobacco products at tobacco outlets21967.00%
      Visit by law-enforcing authorities to the shop19258.70%
      C) The number of tobacco selling outlets within 100 yards of EI (violation of COPTA 6b)N%
      Government
      EI 186.80%
      EI 297.60%
      EI 375.90%
      EI 454.20%
      EI 5108.50%
      EI 686.80%
      EI 71210.20%
      EI 865.10%
      Average8.1
      Private
      EI 975.90%
      EI 1043.40%
      EI 1197.60%
      EI 1286.80%
      EI 1332.50%
      EI 14119.30%
      EI 1586.80%
      EI 1632.50%
      Average6.6
      D) Community-level vendor compliance with COPTA laws
      Degree of complianceCommunitiesStudents
      PrivateGovt.
      High Compliance4117108
      Medium compliance7134129
      Low Compliance5101137
      Total16352374

      3.4 Tobacco vendor compliance for point-of-sale laws

      A total of 327 tobacco selling shops were reported in a 300 m radius of the 16 EI. Students had easy access to tobacco vendors with a high density of 8.1 tobacco vendors per GEI and 6.6 per PEI (Table 3C). There were 208 permanent tobacco outlets and 119 mobile outlets.
      One fifth vendors admitted tobacco sales to minors. Only 21% of vendor shops have signage displaying a ban on tobacco products to minors, and 61.5% were compliant with health warnings at the point of sale. Nearly 50% of shops violated point-of-sale laws by displaying more than two boards and having promotional messages with brand packs and names at the point of sale. A majority (67%) of vendors have an open display of tobacco products. Around 60% of shops were visited by law-enforcing authorities (Table 3B).
      The average compliance of permanent tobacco outlets was 6.1, while the mobile tobacco outlet was 3.8. A total of 16 communities were found around private and government educational institutions. The majority of communities have medium compliance. Low compliance to COPTA laws was observed in five communities. Only four communities have high compliance to COPTA laws, with 117 and 108 students from private and government educational institutions (Table 3D).

      3.5 Correlation matrix

      Active tobacco use in adolescents was strongly associated with peer tobacco use (r = −0.439, p < 0.001) and community compliance (r = −0.365, p = 0.004). There was also an association of active tobacco use with family educating against tobacco use (r = −0.269, p < 0.038) and age of initiation of tobacco use (r = −0.327, p = 0.011). At the community level, vendor compliance to the regulation is strongly correlated with the age of initiation of tobacco use among the adolescents (r = 0.284, p = 0.028) and peer tobacco use (r = −0.333, p = 0.009).

      3.6 Multivariate logistic regression analysis

      The tobacco consumption among students is greater among males (AOR = 2.18; 95% CI: 1.73–2.76), participants with one or more friends (AOR = 5.10; 95% CI:3.81–6.81) or family members (AOR = 4.34; 95% CI:3.94–4.76) using tobacco, participants with no education on the harmful effects of tobacco in schools (AOR = 2.19; 95% CI: 1.22–3.91) and from their family (AOR = 1.43; 95% CI: 1.11–1.86). Greater risk of tobacco consumption was observed among students residing in communities where vendors had low compliance towards POS laws (AOR = 3.92; 95% CI: 3.58–4.30) (Table 5).

      4. Discussion

      Understanding the rise in global tobacco consumption, the WHO global action plan for prevention and control of Non-Communicable diseases announced a 30% reduction in the prevalence of tobacco consumption by the year 2025 (baseline 2010).
      WHO
      Global action plan for the prevention and control of NCDs 2013-2020.
      If there is any hope of achieving these sustainable developmental goals, controlling tobacco use among adolescents is exceptionally vital. This is especially true for South-East Asian regions (SEAR), known for their high prevalence of tobacco consumption and early initiation. An effective tobacco control program can be formulated by utilizing a multipronged approach that integrates community, interpersonal and individual-level factors (Fig. 1).

      4.1 Community-level tobacco control

      Community-level control emphasizes decreased density of tobacco outlets, especially near EI, which has been demonstrated to effectively reduce adolescent tobacco use.
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      One-fourth of the tobacco vendors admitted to having sold to a minor, which is alarming. It is most likely an underestimation which is also a clear violation of COPTA section 6a policy.
      Additionally, the sale of single sticks of cigarettes is highly detrimental to the already established tobacco control strategies. The availability of single sticks leads to easy affordability of loose cigarettes and acts as an enabling factor for students and minors. Single sticks also lack written/pictorial warning, a clear violation of COPTA section 7 or effective taxation.
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      Increasing availability and consumption of single cigarettes: trends and implications for smoking cessation from the ITC Mexico Survey.
      As of September 11, 2017, most states, including the one where the study was conducted, issued orders/notifications banning the sale of loose cigarettes under section-7 of COTPA, 2003. Our study shows that this law is not being enforced as the sale of a single stick was seen in more than 80% of the vendor population.
      As per the Indian legislature, the advertisement of tobacco products is allowed at the point of sale. But they have to adhere to strict size and number limitations (as per the recent 2006 notification). Unfortunately, there remain loopholes to such laws. Tobacco brands often extend the display size by joining two boards or placing one large display on adjacent shops. This makes the COPTA section 5 regulations futile. In our study, violations of COPTA 5 laws ranged from 35% to 67%. The majority of these violations were seen in the placement of open displays of tobacco products and exhibiting more than two boards at one point of sale.
      Furthermore, compliance with the simple requirement to display a sign about the ban on tobacco sale to minors shows a clear anti-tobacco message deterring underage purchases, thereby reducing student tobacco use risk.
      • Frick R.G.
      • Klein E.G.
      • Ferketich A.K.
      • Wewers M.E.
      Tobacco advertising and sales practices in licensed retail outlets after the Food and Drug Administration regulations.
      Compliance with COPTA 5 reduces exposure to pro-tobacco messages and correlates to lower tobacco use
      • Shang C.
      • Huang J.
      • Cheng K.-W.
      • Li Q.
      • Chaloupka F.J.
      Global evidence on the association between POS advertising bans and youth smoking participation.
      An alarming one-third of the school adjacent communities showed low levels of compliance with COPTA regulations. Our study, along with similar others,
      • Banandur P.
      • Kumar M.
      • Gopalakrishna G.
      Awareness and Compliance to Anti-smoking Law in South Bengaluru, India.
      was consistent with the hypotheses that higher compliance with tobacco COPTA laws would be associated with a protective effect on tobacco use in adolescents. Moreover, our study also shows a direct relationship with higher community compliance scores having higher AOIs (Table 4).
      Table 4Correlation Matrix assessing different factors influencing adolescent tobacco use.
      Active tobacco useAOICommunity complianceFTEPeer tobacco use
      Active tobacco usePearson's r
      p-value
      95% CI Upper
      95% CI Lower
      AOIPearson's r−0.327*
      p-value0.011
      95% CI Upper−0.079
      95% CI Lower−0.536
      Community compliancePearson's r−0.365**0.284*
      p-value0.0040.028
      95% CI Upper−0.1230.502
      95% CI Lower−0.5670.033
      FTEPearson's r−0.269*0.463***0.167
      p-value0.038<.0010.203
      95% CI Upper−0.0160.6410.404
      95% CI Lower−0.490.236−0.091
      Peer tobacco usePearson's r0.439***0.029−0.333**−0.1
      p-value<.0010.8250.0090.447
      95% CI Upper0.2080.281−0.0860.158
      95% CI Lower0.623−0.23−0.541−0.345
      Note. *p < 0.05, **p < 0.01, ***p < 0.001.
      FTE=Family education against tobacco use; AOI = Age of initiation of tobacco use in adolescents.
      Table 5Multivariable Binomial Logistic regression analysing odds of tobacco consumption among students.
      95% Confidence Interval
      PredictorEstimateSEZOdds RatioLowerUpper
      Sex (Male)0.7740.2992.572.18*1.732.76
      Exposure to second-hand smoke
       Inside the home0.6620.1853.571.89*1.322.68
       Outside the home0.7270.1833.972.09*1.552.84
      Family or peer tobacco use
       Family tobacco use1.4480.2835.114.34*3.944.76
       Peer tobacco use1.5970.2855.615.10*3.816.81
      Knowledge of tobacco use harms0.6640.1743.811.82*1.023.26
      Exposure to counter marketing−0.4760.22−2.160.78*0.630.96
      School anti-tobacco use education0.8340.4142.012.19*1.223.91
      Family anti-tobacco use education0.3890.0914.251.43*1.111.86
      Type of college attended and tobacco use (Private)0.0210.0131.61.040.851.28
      Community-level vendor compliance (ref: high)
       Intermediate0.6150.1863.311.81*1.622.01
       Low0.8930.2933.053.92*3.584.30
      Note. *p < 0.05.
      Since tobacco vendor compliance plays such a critical role in hindering adolescent tobacco use, we need to design better interventions to improve adherence to point-of-sale compliance laws, which are now lacking.
      • Robertson L.
      • McGee R.
      • Marsh L.
      • Hoek J.
      A systematic review on the impact of point-of-sale tobacco promotion on smoking.
      Almost 40% of the vendors said that they had not had a visit by law-enforcing authorities to their shop. To overcome barriers, tobacco vendors may benefit from explicit instruction and training. This will help tobacco vendors understand that enforcement of the tobacco control policies would not jeopardize their business and express support to these regulations.
      • Rose S.W.
      • Emery S.L.
      • Ennett S.
      • Reyes H.L.M.
      • Scott J.C.
      • Ribisl K.M.
      Retailer opinions about and compliance with family smoking prevention and tobacco control act point of sale provisions: a survey of tobacco retailers.

      4.2 Interpersonal influence in tobacco control

      Interpersonal influence is moderated by family, friends, and close acquaintances. A nurturing interpersonal environment where tobacco use is discouraged was found to reduce adolescent tobacco and helped negate the effects of the community tobacco environment (CTE).
      • Mistry R.
      • McCarthy W.J.
      • Yancey A.K.
      • Lu Y.
      • Patel M.
      Resilience and patterns of health risk behaviors in California adolescents.
      The key interpersonal predictor of our study was found to be tobacco use among the peers and family in both students studying in government and private EI. Peer pressure likely modifies adolescents’ behaviour as they tend to copy their peers to avoid being alienated. In a similar study, peer pressure was a stronger determinant for tobacco use than parental use or formal education.
      • Bhojani U.M.
      • Elias M.A.
      • Devadasan N.
      Adolescents' perceptions about smokers in Karnataka, India.
      Likewise, having had a parent/teacher explain the harmful effects of tobacco use was protective. We found that students from government EI were taught significantly less about the detrimental effects of tobacco use by either parents or teachers. Previous studies suggest a strong association between tobacco in family members and adolescent tobacco use
      • Preventing C.D.C.
      Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.
      but there is a paucity of data on how different parenting styles may affect adolescent tobacco use and how it interacts with the community-level tobacco environment.

      4.3 Individual factors of tobacco control

      The individual factors of tobacco control (biological/personality stream) of the conceptual framework detail personality traits and individual characteristics providing internal motivation to use tobacco or increase susceptibility to tobacco addiction. Our study found that the male gender was more susceptible to tobacco use than females. It is well established that the prevalence of tobacco consumption in males was higher than in females.
      • Rahmanian S.D.
      • Diaz P.T.
      • Wewers M.E.
      Tobacco use and cessation among women: research and treatment-related issues.
      Additionally, there is evidence that poor self-image can be a crucial factor of smoking initiation among youth.
      • McCool J.
      • Freeman B.
      • Tanielu H.
      Perceived social and media influences on tobacco use among Samoan youth.
      Almost 60% of the students in our study felt more comfortable in a social gathering, while one-third of the participants were likely to accept a cigarette if their friends offer it.
      One major challenge for new smokers is the harsh effect of cigarette smoke on the throat. In our study, more than half the study population preferred the use of flavoured cigarettes. Smoking flavoured cigarettes may help establish regular smoking among young people and reduce the likelihood of quitting.
      • Villanti A.C.
      • Collins L.K.
      • Niaura R.S.
      • Gagosian S.Y.
      • Abrams D.B.
      Menthol cigarettes and the public health standard: a systematic review.
      Menthol cigarettes are also more commonly used by less-established or ‘novice’ smokers and those experimenting with smoking.
      • Hersey J.C.
      • Ng S.W.
      • Nonnemaker J.M.
      • et al.
      Are menthol cigarettes a starter product for youth?.
      Research shows that the tobacco industry has manipulated the menthol content of cigarettes to promote smoking initiation and sustain tobacco use. Countries such as Canada, the EU, Chile, brazil have already taken steps to ban flavoured and mentholated cigarettes. Health policymakers in India should consider taking similar steps as banning menthol cigarettes can discourage sustained tobacco use among adolescents. Finally, ease of access to tobacco plays a significant role as an individual factor. More than 40% of the study population bought their tobacco from vendors, and 60% said it would be easy to get tobacco products. These influences may be associated with an upshift in the prevalence of adolescent tobacco use, lowering the age of initiation, intention to use, and ease of access.

      4.4 The interaction effect

      The conceptual design of our study centred around treating the issue of adolescent tobacco use as a sum effect of community, interpersonal and individual factors. This was further substantiated when we calculated a correlation matrix compiling the impact of community, family, and peer factors (Table 4).
      This further substantiates our conceptual design, which is based on three crucial behavioural theories that have been used to understand the initiation and maintenance of smoking in adolescents. They are the “Bronfenbrenner's theory of the ecology of human development,” “the social learning theory,” and “the social control theory.” The ecology of human development theory considers that youth behaviour develops within critical nested environments (family, peers, school, neighbourhood) that constantly interact with one another. Social learning theory describes the facilitating effect of a role model who uses tobacco and has on impressionable youth. Social control theory describes the constraining impact of social relationships (for example, a close bonding with the parents who discourage smoking) on the initiation of tobacco among the youth. Ennett et al. reported the importance of all these three theories with significant interaction between them and that neighbourhood of residence was also substantial.
      • Ennett S.T.
      • Foshee V.A.
      • Bauman K.E.
      • et al.
      A Social Contextual Analysis of Youth Cigarette Smoking Development.
      For tobacco control policies to be effective, we need to first understand that the problem of adolescent tobacco use is multifactorial. We need large-scale tobacco control campaigns which focus on merging community compliance enforcement with interpersonal and individual education. There are examples of such successful national campaigns. “True initiative,” a campaign done in the USA, is said to have prevented about 450,000 youths from tobacco initiation in the USA.
      • Richardson A.K.
      • Green M.
      • Xiao H.
      • Sokol N.
      • Vallone D.
      Evidence for truth®: the young adult response to a youth-focused anti-smoking media campaign.
      LMICs such as India could build on successful experiences when developing their national anti-tobacco campaigns to reduce tobacco use among adolescents.
      A summary of compliance to various COPTA policies and community level compliance from Indian studies are presented in Supplementary Table S1. Violation of Section 4 ranged from 27 to 85%, Section 5 ranged from 16 to 85%, Section 6a ranged from 39 to 73.1%, Section 6b ranged from 19 to 69%, Section 7 and 8, 7 and 8 ranged from 21.7 to 53.6%. Only one study previously evaluated community compliance and observed 27% high compliance, 49% moderate compliance and 24% low compliance. A summary of recent studies from India on adolescent tobacco smoking, their sample size, prevalence of tobacco smoking and the various determinants evaluated in each study are presented in Supplementary Table S2. The studies with the large sample sizes over 1000 were 2 studies from Kerala (n = 7350 & n = 1114), followed by Delhi (n = 4786) and Mumbai (n = 1317). The highest prevalence of adolescent smoking was observed in Chhattisgarh (25%), followed by Karnataka (20.4%). Only two studies from Delhi and Mumbai evaluated more than 5 determinants.
      We adopted a systematic approach to the selection of colleges wherein both private and government colleges were accounted for and equally represented. A major strength of the study is that we are assessing a combination of the influence of individual, interpersonal and community level factors together. Additionally we also assessed how these factors correlate and interact with each other. This gives us a better understanding of variables involved in adolescent tobacco use. Tobacco vendors were also interviewed to assess their understanding of the COPTA laws. The primary limitation was that it was a single city study and is not representative of India. Confounding factors such as stress, depression and risk-taking behaviour were not accounted for. The law enforcement agency and the school management were not interviewed, which would have given a more comprehensive view.

      5. Conclusion

      Tobacco control laws in India need improvement. It is crucial to comprehensively understand the reasons for the initiation and persistence of tobacco use among adolescents. This can only be done using a mixed-methods approach that focuses on improving compliance with COPTA laws in school-adjacent communities and on effective anti-tobacco education in schools and immediate interpersonal surroundings. Finally, implementing a complete ban on point-of-sale tobacco displays and promotion might narrow the scope for misinterpretation of laws, improve compliance and reduce youth tobacco use.

      Ethics statement

      This study was approved by the Institutional Ethics Committee of JSS Medical College, Mysuru (Approval number: JSSMC/IEC/18/7/2018-19).

      Human and animal rights

      No Animals were used for the study. All human procedures were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

      Consent for publication

      Informed consent was obtained from all participants and their institutions.

      Availability of data and material

      All data generated or analysed during this study are included in this published article and are available from the corresponding author upon reasonable request.

      Funding

      None. The study was self-funded.

      Declaration of competing interest

      The author(s) confirm that this article's content has no conflicts of interest.

      Acknowledgments

      None.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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