Preventing smoking uptake among adolescents - A primary prevention initiative for chronic lung disease in India

Smoking tobacco is the largest avoidable cause of lung cancer, chronic obstructive pulmonary disease and a range of other pulmonary disorders, and preventing the uptake and perpetuation of tobacco use is therefore crucial to reducing the global burden of chronic lung disease. Tobacco consumption is increasing in India, and as a large potential future market for tobacco products the country is vulnerable to aggressive marketing and promotion by the tobacco industry. This proposed project aims to identify and understand environmental factors that increase the risk of adolescents starting to smoke tobacco, with the aim of informing interventions that can reduce the number of new tobacco smokers and ultimately prevent chronic lung disease in the future. We will also investigate current attitudes to tobacco control policy implementation from stakeholders at local and national levels, to identify obstacles to more extensive implementation of anti-smoking policies. To ensure that our findings can be used to maximum effect they will be shared with all relevant stakeholders promoting public health in India; our findings are also likely to be directly relevant to smoking prevention in other low and middle-income countries.

Smoking is the largest avoidable cause of chronic lung diseases. In India, tobacco consumption is increasing, particularly among the rapidly growing young adult population. Preventing the uptake and perpetuation of smoking is therefore crucial to reducing the future burden of chronic lung disease.

This project aims to identify the main determinants of smoking uptake among adolescents in India. We will survey a population of 45,000 students in school grades 6-8 in Udupi region, ascertaining current and susceptibility to future tobacco use; and exposure to determinants including tobacco affordability and ease of access, tobacco imagery in films and music videos and in retail displays, health warnings, anti-tobacco media campaigns, smoke-free homes and schools, and potential confounders (including age, gender, family and peer smoking, self-esteem, rebelliousness, academic grades). One year later we will re-survey the cohort, now in grades 7-9, to estimate prospectively the independent effects and attributable risks of these exposures on smoking susceptibility and uptake. We will then carry out qualitative studies of perceived appropriate policy responses to our findings among national and regional policymakers, and local groups including police, community leaders, tobacco vendors, teachers, parents and adolescents.

Survey data will be analysed using descriptive statistics and logistic regression of independent effects of putative risk factors with adjustment for confounders; and the prospective data using a random effects model to allow for clustering effects at the block and school level. Qualitative data will be analysed using a framework approach. We will use our study findings, which are likely to be generalisable to other LMICs, to formulate and prioritise population and individual strategies to prevent smoking uptake in India, and to work with others to engage with policymakers and others to promote implementation.

Who will benefit from this research?

The main beneficiaries will be children and young people for whom the lifetime direct and indirect health effects, financial and opportunity costs of smoking, and the harms caused by their smoking to others in their families, peer groups and wider society, will be avoided. Intermediate beneficiaries will include national and local government officers, politicians, other policymakers and advocacy groups in India and in other LMICs, the WHO Framework Convention Alliance, and others who will use and apply our findings to reduce the uptake and prevalence of smoking among young people.

How will they benefit from this research?

Half of all regular smokers die from smoking, and every year of smoking after the age of 35 reduces life expectancy by three months; smoking also exacerbates poverty. Young people who avoid taking up smoking, or quit smoking, will therefore avoid these substantial harms, thus enjoying massive benefits in quality and quantity of life, wealth and productivity; this will also benefit their families, friends and wider society who also benefit from reduced passive smoke exposure. Wider society will benefit from avoiding the opportunity costs of tobacco use; the litter and fire risks generated by smoking; the demand on health services and loss of productivity that smoking causes, and environmental damage arising from tobacco farming. Since many of the impacts of tobacco use are rapidly reversible, benefits will accrue almost immediately after successful behaviour change.

Academic benefits arise from improved understanding of the relative importance of determinants of tobacco use in India, and insights into the design and implementation of improved population strategies and other policies to prevent smoking uptake. It is likely that these benefits will also apply in other countries at a similar stage of economic development to India.