Prevalence, Patterns, and Predictors of Tobacco Consumption among Adolescents: An Observational Study from a Rural area of Rajasthan

Abstract

Background:

The prevalence of smoking cigarettes among adolescents in India is nearly one in 10, and almost half of them initiate tobacco use before turning 10 years old. Our study objective was to assess the prevalence of tobacco consumption and the sociodemographic factors associated with tobacco consumption among adolescents in a rural area of Rajasthan.

Materials and Methods:

This community-based, cross-sectional study was conducted for a period of 1 year from April 2021 to March 2022 in village Naila, Jaipur. All 1083 adolescents of village Naila were contacted; however, 1049 were included in the study. Multivariate logistic regression (forward likelihood model) was used to assess the strength of the association of risk factors for the consumption of tobacco.

Results:

A considerable proportion, that is, 22.4% (235/1049), of adolescents were tobacco consumers. Out of 235 consumers, 104 were smokers, 65 were consuming smokeless tobacco, and 66 were consuming both forms of tobacco. In multivariate analysis, age, sex, grade of participants, pocket money, family history of tobacco and alcohol consumption, maternal education, and per capita income were found to be significant predictors of tobacco consumption (P < 0.05).

Conclusion:

Tobacco consumption is highly common in Rajasthan’s rural adolescent population, and it begins at a very young age. Hence, corrective measures need to be initiated in an early stage of life. To reduce the impact of social norms, peer pressure, and family members who consume tobacco, the behavioral change communication activities must be strengthened.

INTRODUCTION

The tobacco epidemic is a leading cause of preventable mortality and morbidity.[1] Globally, cigarette smoking is the most popular way to consume tobacco.[2] Approximately 8 million people pass away each year from diseases linked to tobacco consumption. Around 7 million of these deaths are directly related to tobacco consumption and about 1.2 million are caused by exposure to second-hand smoke.[3] In India, about 1 million deaths occur due to tobacco consumption annually.[4] Tobacco consumption in India leaves about 150 million people in poverty.[5] Premature deaths among tobacco users cost their families in terms of income, education, and health care, further driving them into poverty.[6]

Most tobacco users start using tobacco products during childhood or adolescence and achieve adulthood levels by their late 20s. Adolescence includes the stage of life between 10 and 19 years of age.[7] Worldwide, one in 10 girls and one in five boys between the age of 13 and 15 years use tobacco products.[8] Tobacco initiation in adolescence can lead to accelerated dependence after just a few months of the first exposure, and they continue to use it for the rest of their lives due to nicotine’s presence.[9,10] According to the World Health Organization (WHO), behaviors that start in adolescence, like substance abuse, aggression, depression, dangerous driving, and sexual behavior, result in about 70% of premature deaths in adults.[11,12]

The World Bank has stated that globally, around 82,000–99,000 children and adolescents start smoking tobacco daily. Approximately half continue to smoke into adulthood, and half of the adult smokers pass away prematurely due to tobacco-linked illnesses.[13]

The prevalence of smoking cigarettes in adolescents of age 13–15 years in India is nearly 1 in 10, and almost half of them initiate tobacco use before turning 10 years old.[14] In India, a Global Youth Tobacco Survey (GYTS) was conducted in 2019; it reported that the proportion of tobacco consumers was 8.5% in 2019 and that of current tobacco users among boys and girls of 13–15 years age group was 9.6% and 7.4%, respectively, in 2019. In Rajasthan, among adolescents of 13–15 years age group, the proportion of tobacco users was 4.1% in GYTS of 2019.[15] In Rajasthan, Singh and Gupta[16] concluded that the proportion of tobacco users in the 13–18 years age group was 2.1% in boys (1.5%–2.6%) and 1.7% in girls (0.9%–2.5%).

Adolescents’ use of tobacco is influenced by a variety of factors including use of tobacco by other family members, peer pressure, family disputes, experimentation, easy availability to nicotine products, and personality factors.[17] Major predictors of smoking in adolescents are poor family income, parents with low levels of education, and single-parent households. Contrarily, it was discovered that family elements such as high level of bonding, parental punishment, and supervision were protective against smoking.[18] Most studies did not include the GYTS questionnaire to investigate tobacco consumption among adolescents. So, considering all these facts, this study was planned with the following objectives:

1. To estimate the prevalence of tobacco consumption among adolescents

2. To determine the sociodemographic factors associated with tobacco consumption and to find out the reasons for initiation of tobacco consumption

3. To develop a model predicting tobacco consumption among adolescents

MATERIALS AND METHODS

This community-based analytical cross-sectional study was carried out in village Naila, a field practice area of Rural Health Training Center (RHTC) Naila, under the Department of Community Medicine, a tertiary care facility in Jaipur. Data collection for the study was started in April 2021 after clearance from the Institutional Ethical Committee (reference 454/MC/EC/2021 dated 03/25/2021) was obtained and completed in March 2022.

Sample size: To verify the expected prevalence of 14.6%[19] of tobacco consumption in adolescents at 95% confidence level and 2.4% absolute error, a sample of 832 adolescents was calculated. After considering 20% nonrespondents, the sample size was further increased to 999. The total population of village Naila was 4784, and expecting 21%[20] proportion of adolescents, it would be nearly about 1000, hence we have included all adolescents (10–19 years) residing in village Naila of Jaipur district. A house-to-house survey was conducted before the commencement of the study with the help of Accredited Social Health Activists (ASHAs) to find out the actual number of adolescents residing in the study area. The target population (adolescents) was found to be 1083. Universal sampling was done to include all the adolescents. For adolescents of age below 18 years, verbal assent was obtained from adolescents and written informed consent was obtained from their parents, while for adolescents of 18 years and above, written informed consent was directly obtained from them to take part in the study. Adolescents who were uncooperative or on psychiatric consultation or did not give informed consent were excluded from the study. A house-to-house survey was conducted to cover all adolescents in the study area for data collection. A repeat house visit was done for 68 adolescents who were not available at the time of the first house visit. In this manner, all adolescents of village Naila were contacted. However, only 1049 eligible adolescents were included in the study (response rate 96.8%).

Study tool: WHO Global Youth Tobacco Survey (GYTS) tool[21]

WHO and the US Centers for Disease Control and Prevention (CDC) jointly developed GYTS, a global surveillance project that serves as a benchmark for consistently monitoring tobacco use among youth (both smoking and smokeless). It is a standardized, prestructured, and validated pro forma that was created by WHO in 2001. The English version of the GYTS questionnaire was translated into Hindi by experts in both languages and was pretested on 30 students in the local area. Questionnaire in both languages, Hindi and English is provided as supplementary file.

The questionnaire is self-administered and anonymous. Few more data regarding associated factors and reasons for initiating the consumption of tobacco were collected. A five-point Information, Education, and Communication (IEC) was prepared, which was approved by three senior faculties of the Community Medicine department, SMS Medical College, Jaipur, and was given to each participant to make them aware of the harmful effects of tobacco consumption.

Socioeconomic status (SES) was assessed using the modified BG Prasad’s SES scale (July 2021).[22] Tobacco use among the adolescents was evaluated according to their use of cigarettes, bidi, or smokeless tobacco products. On this basis, we divided adolescents into three categories: never, current, and former tobacco users. Adolescents were further grouped into ever and never users. The term “ever smokers” referred to combination of both current and former tobacco users. “Never tobacco users” were considered as participants who responded “No” to the question, “Have you ever tried or experimented with cigarette/bidi smoking or smokeless tobacco product (zarda with pan, khaini, gul, tobacco leaf, pan masala)?” “Current tobacco users” referred to participants who responded “Yes” to the question, “Have you ever tried or experimented with cigarette/bidi smoking or smokeless tobacco product?” and among the above who consumed tobacco in any form during the past 30 days. “Former tobacco users” were the participants who answered “Yes” to the question, “Have you ever tried or experimented with cigarette/bidi smoking or smokeless tobacco product?” and among the above who did not consume tobacco in any form during the past 30 days.

Statistical analysis

Data were collected and entered in the Microsoft Excel Sheet by the investigator himself on the same day to reduce data entry bias. Categorical data were compiled in a proportional form. Mean and standard deviation were used to summarize the continuous data. Student’s t-test was used to analyze the variance between mean and standard deviation. Normality of data was checked using Kolmogorov–Smirnov test. Non-normal continuous data was represented in the form of median and interquartile range (IQR) and analyzed using Mann–Whitney U test. Bivariate logistic regression was performed to assess the strength of the association of risk factors for the consumption of tobacco by using unadjusted odds ratio. The significance level for the inclusion of risk factors in multivariate logistic regression was kept at 90%. Forward likelihood ratio model was employed in multivariate logistic regression.

RESULTS

Sociodemographic characteristics

The sociodemographic characteristics of adolescents are presented in Table 1. In the current study, the mean age of the participants was 15.09 ± 2.73 years. Almost half (527/1049) of them were female and the rest were male. Three participants were never sent to school for studying, and two participants dropped out of school after fifth standard. Almost one-fourth (268/1049) of the participants were receiving >150 rupees as pocket money per week, and 90 (8.58%) participants received no pocket money. Majority (618, 58.9%) of the adolescents’ family members were involved in tobacco consumption, and 150 (14.3%) adolescents’ family members were involved in alcohol consumption.

Table 1.

Sociodemographic characteristics of adolescents (n=1049)

Variables	Frequency	Percentage
Age group (years)
10–13	308	29.36
14–16	365	34.8
17–19	376	35.84
Sex
Female	527	50.24
Male	522	49.76
Grade of student
Illiterate	5	0.48
7th	171	16.3
8th	125	11.92
9th	96	9.15
10th	117	11.15
11th	115	10.96
12th or higher	420	40.04
Pocket money in rupees per week
Zero	90	8.58
<20	126	12.01
20–50	196	18.68
51–80	134	12.77
81–100	155	14.78
101–150	80	7.63
>150	268	25.55
Maternal education
Illiterate	382	37.16
Up to 10th class	814	56.81
11th or higher	62	6.03
Paternal education
Illiterate	216	21.88
Up to 10th class	514	52.08
11th or higher	257	26.04
Maternal employment
Unemployed	667	64.88
Semiskilled	171	16.63
Skilled	190	18.47
Maternal employment
Unemployed	3	0.3
Semiskilled	339	34.35
Skilled	645	65.34
Type of family
Joint	584	55.67
Nuclear	465	44.33
Family history of tobacco consumption
No	431	41.09
Yes	618	58.91
Family history of alcohol consumption
No	899	85.7
Yes	150	14.3
SES status (modified B G Prasad)
I (Upper class)	48	4.58
II (Upper middle class)	180	17.16
III (Middle class)	207	19.73
IV (Lower Middle class)	471	44.9
V (Lower class)	143	13.63

SES=Socioeconomic status

Distribution of tobacco consumption

A substantial proportion, that is, 22.4% (235/1049), of adolescents did consume tobacco in smoking or smokeless form or both forms at any point in time. Also, out of 235 tobacco consumers, around half, that is, 104 (44.3%), were smokers, 65 (27.7%) participants were consuming smokeless tobacco, and 66 (28.1%) participants were consuming tobacco in both forms. There were a boy and a girl who had consumed tobacco only once out of curiosity and never thereafter, hence were not considered as ever tobacco consumers.

The mean age of initiation for smokeless tobacco was 13.21 ± 2.43 years, which was found to be significantly lower than the mean age of initiation for smoking form (14.16 ± 2.40 years) (P < 0.05). The mean age of initiation of both smoking and smokeless forms of tobacco among females (12.95 ± 2.55 and 12.34 ± 1.88, respectively) was lower than that of males (14.41 ± 2.30 and 13.56 ± 2.54 years, respectively) and this difference was statistically significant (P < 0.05) [Figure 1].

Figure 1.

Error bars of mean age of initiation for different forms of tobacco products among male and female

Reason for initiation of tobacco consumption

Out of a total of 235 tobacco consumers, around half, that is 109 (46.4%), of the participants stated peer pressure as a reason for initiation of tobacco consumption, and at least seven (3%) participants stated stress as a cause for initiation of consumption of tobacco [Figure 2].

Figure 2.

Bar chart of reasons for initiation of tobacco products (n = 235)

Predictors of tobacco consumption

Predictors of tobacco consumption are presented in Table 2. The age group of the participants was significantly associated with tobacco consumption. Participants of age 15–19 years were found to have 2.8 times higher odds of tobacco consumption compared to those of age 10–14 years (P < 0.05). Similarly, in bivariate logistic regression, sex, grade level, pocket money per week, maternal education, and alcohol and tobacco consumption were significantly associated with tobacco consumption (P < 0.05). The median per capita income of the family was significantly higher for participants who were consuming tobacco compared to nonconsumers (P < 0.05).

Table 2.

Predictors of ever tobacco consumption using bivariate and multivariate logistic regression (n=1049)

Variables	Tobacco consumption		Unadjusted OR (confidence interval)	P	Adjusted OR (confidence interval)	P
	Never (n=814)	Ever (n=235)
Age group (years)a
10–14 years	340 (87.6%)	48 (12.4%)	1
15–19 years	474 (71.7%)	187 (28.3%)	2.794 (1.976–3.951)	<0.001	1.886 (1.151–3.091)	0.012
Sex
Female	466 (88.4%)	61 (11.6%)	1
Male	348 (66.7%)	174 (33.3%)	3.820 (2.765–5.276)	<0.001	3.534 (2.474–5.048)	<0.001
Grade levelb
Up to 10th class	440 (86.4%)	69 (13.6%)	1
11th or higher	373 (69.7%)	162 (30.3%)	2.77 (2.024–3.790)	<0.001	1.587 (1.013–2.487)	0.044
Pocket money (per week)c
≤80 rupees	463 (84.8%)	83 (15.2%)	1
>81 rupees	351 (69.8%)	152 (30.2%)	2.416 (1.787–3.265)	<0.001	1.825 (1.28–2.602)	0.001
Maternal educationd
Literate	531 (82.2%)	115 (17.8%)	1	<0.001
Illiterate and just illiterate	270 (70.7%)	112 (29.3%)	1.915 (1.421–2.582)		2.243 (1.588–3.169)	<0.001
Paternal educatione
Literate	604 (78.3%)	167 (21.7%)	1
Illiterate and just illiterate	165 (76.4%)	51 (23.6%)	1.118 (0.782–1.599)	0.541
Tobacco consumption in family
Absent	385 (89.3%)	46 (10.7%)	1
Present	429 (69.4%)	189 (30.6%)	3.687 (2.597–5.235)	<0.001	3.68 (2.486–5.447)	<0.001
Alcohol consumption in family
Absent	721 (80.2%)	178 (19.8%)	1
Present	93 (62%)	57 (38%)	2.483 (1.718–3.588)	<0.001	1.701 (1.09–2.654)	0.019
Type of family
Joint	462 (79.1%)	122 (20.9%)	1
Nuclear	352 (75.7%)	113 (24.3%)	1.216 (0.909–1.626)	0.188
Single-parent family
No	756 (78.3%)	210 (21.7%)	1
Yes	58 (69.9%)	25 (30.1%)	1.552 (0.948–2.541)	0.081
Per capita incomef
In rupees	2750 (2000–4857.1)	3000 (2142.9–5333.3)	-	0.009		0.004

^aAge group of the adolescents has been merged and regrouped into two categories. ^bTwo participants never went to school and three were dropouts after fifth class and were not included in the analysis. For making inference, we classified up to 10^th class and 11th or higher. ^cPocket money was divided into ≤80 rupees and >81 rupees because price of one packet is around one dollar (80 Rs). ^dMothers of 21 participants were dead, so these participants were not included in the analysis. Maternal education was grouped into illiterate and literate. ^eFathers of 62 participants were dead, so these participants were not included in the analysis. Paternal education was grouped into illiterate and literate. ^fPer capita income of a family of participants was mentioned in the median and was analyzed using the Mann–Whitney U test. OR=odds ratio

All independent variables with a significance level of 90% or more were included in multivariate regression analysis. A test of the full model was found to be statistically significant, indicating that the predictor as a set reliably differentiates between yes and no outcomes (Chi-square- 207.228, P < 0.001, degrees of freedom [df]- 8). Based on our model, the dependent variable’s explained variation ranged from 18.3% (Cox and Snell R²) to 28.2% (Negelkerke R²) [Figure 3]. In the multivariate logistic regression age group, sex, grade, pocket money per week, maternal education, family history of tobacco and alcohol consumption, and per capita income were significantly associated with tobacco consumption (P < 0.05).

Figure 3.

Forest plot for predictors of ever tobacco consumption using multivariate logistic regression

DISCUSSION

It is believed that tobacco initiation starts early in adolescence and continues for the rest of life. In our study, 22.4% of adolescents did consume tobacco in smoking or smokeless form or both forms at any point in time. Out of a total of 235 tobacco consumers, around half were smokers, 27.7% were consuming smokeless tobacco, and 28.1% were consuming both forms of tobacco. In Rajasthan, among adolescents in the age group of 13–15 years, the prevalence of tobacco users was found to be 4.1% in GYTS 2019.[15] Kumar et al.[23] reported that 16.4% of school-going children ever consumed tobacco and the proportion of ever smokers was 15.4% and of smokeless tobacco consumers was 12.5%. In a study done by Yadav and Dabar,[24] the prevalence of ever tobacco users was reported as 31.3%. In a study done by Shrivastav et al.,[25] the prevalence of tobacco consumption among school-going adolescents was reported to be 16%. This difference in the proportion of tobacco consumption may be due to different areas or different sampling methods. Bagchi et al.[26] stated the proportion of smokers in adolescents aged 15–19 years to be 29.6%. In our study, the mean age of initiation of tobacco products in a smoking form and smokeless form was 14.16 ± 2.40 and 13.21 ± 2.43 years, respectively. It showed lower age of initiation of smokeless tobacco, which may be because it is easily available, has a lower cost, and is easily hidden. Similar findings were reported by Kumar et al.,[23] where 53.3% of the students started smoking at 13 years of age and 26.4% of students started smoking at 12 years of age, and the mean age of initiation of smoking was 12.31 ± 1.7 years. Similarly, the mean age of starting consumption of tobacco in a smokeless form was 12.88 ± 2.1 years.

Around half of the adolescents stated peer pressure as a reason for initiation of tobacco consumption, followed by imitating influencers (26.4%), and at least 3% stated stress as a reason for initiation of tobacco consumption. These findings were in concordance with a study done by Sahasrabuddhe et al.,[27] where they reported peer pressure as the most (47%) common factor for initiation as stated by students and other reasons were curiosity (30%), stress (14%), enjoyment (4%), and siblings (5%). In a study done by Ravishankar and Nagarajappa,[28] curiosity was the most (36, 35%) common reason for initiation, closely followed by peer pressure (32, 31.4%), and 16 (15.7%) subjects tried tobacco to impress the opposite sex. Yadav et al.[24] also reported that peer pressure (140, 62.2%) was the most common reason for initiation of tobacco consumption.

There was a significant association of age with tobacco consumption. With increasing age, odds of tobacco consumption increase because risk-taking behaviors and experiments with substances increase with increasing age. The proportion of tobacco consumers was significantly higher in males compared to females. Similar results were reported in a study done by Kulkarni et al.[29] Male adolescents were more involved in smokeless tobacco consumption in South India. This may be because females are more socially restricted compared to males and most of the young people imitate and exercise what they observe in peers and elders. An increase in the proportion of adolescent tobacco users is seen with an increase in grade level, which justifies that as adolescence advances, they are more attracted to tobacco.

The mean age of initiation of both smoking and smokeless form of tobacco among females was lower than among male adolescents. Female adolescents may be imitating their mothers’ and grandmothers’ behavior of chewing tobacco during their house chores, and when we inquired, they told us that consumption of tobacco boosted their energy for the house chores.

In our study, with an increase in pocket money, there was an increase in tobacco consumption. Similar results were obtained by Kumar et al.[23] who reported that the median amount of pocket money among adolescents who ever consumed tobacco was 300 (IQR 100–900) rupees compared to 100 (IQR 50–200) rupees among nonusers. Higher pocket money increases the window for adolescents to shop for tobacco.

In our study, a parent being literate acted as a protective factor for tobacco consumption among adolescents, although paternal literacy was not a significant predictor. Similar findings were reported by Wen et al.[30] Children learn from their family members, mainly from their mothers because they spend more time with their mothers; being a more educated mother will influence children’s behavior and stop them from initiating tobacco consumption. So, mothers’ education is a protective behavior against tobacco consumption.

Almost one-third (30.1%) of the participants with single parents consumed tobacco compared to participants living with both parents (21.7%). It could be due to many reasons such as negligence toward the child, stress or depression, and lack of guidance from parents.

In our study, around one-third (30.6%) of the participants with a positive family history of tobacco consumption had consumed tobacco. A statistically significant result was also observed by Muttappallymyalil et al.,[31] who reported that father’s tobacco habit influenced the child’s tobacco-consuming behavior also reported that in the majority (64.1%) of students using tobacco products, at least one of the family members used tobacco. Narayan et al.[32] stated that consumption of tobacco products was common in adolescents whose parents were consuming tobacco. Children learn from what they observe in the elders of their families, and hence, family influences the practices of adolescents as they first encounter their family. The availability of tobacco at home makes the first experiment very easy for adolescents, as they try it out of curiosity. The habits of the family members are easily passed down to their children, which was observed in our study as well as in other studies.

Strengths and limitations

Being a community-based study, this reflects deeper understanding of the local context. This study was cross sectional in design, and hence cannot establish the temporal association. Adolescents who denied participating in the study might be dissimilar from the study population as they are likely to have higher levels of tobacco consumption, although the response rate was more than 95%. As consumption of tobacco among adolescents is not socially acceptable, there might be a chance of response bias. However, privacy and confidentiality were ensured during interview to limit the response bias.

CONCLUSION

Our study concluded that tobacco use is an important risk behavior among adolescents and is highly prevalent among adolescents. Every fifth adolescent in the rural setting was consuming tobacco. Smoking form of tobacco consumption was more common than smokeless form of tobacco. Peer pressure and imitation of influencers were the most common causes associated with the initiation of tobacco consumption. Age, sex, grade level, maternal education, per capita income, and history of tobacco and alcohol consumption in the family were found to be significant predictors of tobacco consumption. Hence, this study highlights the importance of an action-oriented approach early in life. To reduce the impact of social norms, peer pressure, and family members who consume tobacco, the behavioral change communication activities must be strengthened. Awareness programs should be initiated along with educating parents, teachers, and peer groups about the negative effects of tobacco consumption and their role in limiting the problem. Based on our findings, after taking permission from the Institutional Ethical Committee, we disseminated the results in schools without disclosing the identity of adolescents and organized an educational camp in the community with the collaboration of schools. Also, we informed the local administration about the local vendors’ shops selling tobacco products to adolescents.

Compliance with ethical standards

All procedures performed in the presented study involving human participants were in accordance with the ethical standards of the institutional ethical committee (reference no. 454/MC/EC/2021 dated 03/25/2021 at SMS Medical College, Jaipur).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplementary File

I.D.NO.----------

1. How old are you? ……………….

2. What is your sex? a. Male b. Female

3. In what grade/form are you?

a. 7^th b.8^th c.9^th d.10^th e.11^th f.12^th or higher

4. During an average week, how much money do you have that you can spend on yourself, however you want?

a. I usually don’t have any spending money b. Less than 20rs

c. 20-50rs d. 51-80rs e. 81-100rs

f. 101-150rs g. More than 150rs

5. Parents’ Marital status? a. Married b. Divorced C. Widowed

6. Single Parent family? a. Yes b. No

7. Maternal education? ……………

8. Paternal education? ……………

9. Maternal employment status? ……………

10. Paternal employment status? ……………

11. Does any family member consume tobacco? a. Yes b. No

If yes, then Who n What Form

12. Does any family member consume Alcohol? a. Yes b. No

If yes, then Who n What Form

13. Type of family… a. Nuclear b. Joint

14. Number of family members ……….

15. Total family income ………..

The next questions ask about your use of tobacco.

5. Have you ever tried or experimented with cigarette/bidi smoking, even one or two puffs?

a. Yes b. No (B1)

6. How old were you when you first tried a cigarette/bidi?

a. I have never tried smoking a cigarette b. 7 years old or younger

c. 8 or 9 years d. 10 or 11 years e. 12 or 13 years

f. 14 or 15 years g. 16 or 17 years h. 18 or 19 years (B2)

7. During the past 30 days, on how many days did you smoke cigarettes/bidis?

a. 0 days b. 1 or 2 days c. 3 to 5 days

d. 6 to 9 days e. 10 to 19 days f. 20 to 29 days g. All 30 days (B3)

8. Please think about the days you smoked cigarettes/bidis during the past 30 days, How many cigarettes did you usually smoke per day?

a. I did not smoke cigarettes during the past 30 days

b. Less than 1 cigarette per day c.1 cigarette per day

d. 2 to 5 cigarettes per day e. 6 to 10 cigarettes per day

f. 11 to 20 cigarettes per day g. More than 20 cigarettes per day (B4)

9. Have you ever tried or experimented with any form of smoked tobacco products other than cigarettes/ bidis (pipes, cigars, waterpipes, hookah, shisha)?

a. Yes b. No

10. During the past 30 days, did you use any form of smoked tobacco products other than cigarettes/ bidis (pipes, cigars, waterpipes, hookah, shisha)?

a. Yes b. No

11. Do you ever smoke tobacco or feel like smoking tobacco first thing in the morning?

a. I don’t smoke tobacco

b. No, I don’t smoke tobacco or feel like smoking tobacco first thing in the morning

c. Yes, I sometimes smoke tobacco or feel like smoking tobacco first thing in the morning

d. Yes, I always smoke tobacco or feel like smoking tobacco first thing in the morning

12. How soon after you smoke tobacco do you start to feel a strong desire to smoke again that is hard to ignore?

a. I don’t smoke tobacco

b. I never feel a strong desire to smoke again after smoking tobacco

c. Within 60 minutes d. 1 to 2 hours e. More than 2 hours to 4 hours

f. More than 4 hours but less than one full day g. 1 to 3 days

h. 4 days or more

13. Have you ever tried or experimented with any form of smokeless tobacco products (zarda with pan, khaini, gul, tobacco leaf, panmasala)?

a. Yes b. No

14. During the past 30 days, did you use any form of smokeless tobacco products (zarda with pan, khiani, gul, tobacco leaf, panmasala)?

a. Yes b. No

The next questions ask about your feelings toward stopping smoking.

15. Do you want to stop smoking now?

a. I have never smoked b. I don’t smoke now

c. Yes d. No (B5)

16. During the past 12 months, did you ever try to stop smoking?

a. I have never smoked b. I did not smoke during the past 12 months

c. Yes d. No (B6)

17. Do you think you would be able to stop smoking if you wanted to?

a. I have never smoked b. I don’t smoke now

c. Yes d. No

18. Have you ever received help or advice to help you stop smoking? (SELECT ONLY ONE RESPONSE)

a. I have never smoked b. Yes, from a program or professional

c. Yes, from a friend d. Yes, from a family member

e. Yes, from both programs or professionals and from friends or family members

f. No

The next questions ask about getting cigarettes.

19. The last time you smoked cigarettes/bidis during the past 30 days, how did you get them? (SELECT ONLY ONE RESPONSE)

a. I did not smoke any cigarettes during the past 30 days

b. I bought them in a store or shop c. I bought them from a street vendor d. I got them from someone else e. I got them some other way (B7)

20. During the past 30 days, did anyone refuse to sell you cigarettes because of your age?

a. I did not try to buy cigarettes during the past 30 days

b. Yes, someone refused to sell me cigarettes because of my age

c. No, my age did not keep me from buying cigarettes (B8)

21. The last time you bought cigarettes during the past 30 days, how did you buy them?

a. I did not buy cigarettes during the past 30 days b. I bought them in a pack

c. I bought individual sticks (singles) d. I bought them in a carton

e. I bought them in rolls. f. I bought tobacco and rolled my own

22. On average, how much do you think a pack of 20 cigarettes costs?

a. 20 or less than 20rs b. Range 21-50rs c. 51-75rs

d. 76-100rs e. 101-125rs f. 126-150rs g. More than 150rs

h. I don’t know

The next questions ask about messages that are against using tobacco (might include cigarettes, other smoked tobacco, and smokeless tobacco).

23. During the past 30 days, did you see or hear any anti-tobacco media messages on television, radio, internet, billboards, posters, newspapers, magazines, or movies?

a. Yes b. No

24. During the past 30 days, did you see or hear any anti-tobacco messages at sports events, fairs, concerts, or community events, or social gatherings?

a. I did not go to sports events, fairs, concerts, or community events, or social gatherings in the past 30 days b. Yes c. No

25. During the past 30 days, did you see any health warnings on cigarette/bidi packages?

a. Yes, but I didn’t think much of them

b. Yes, and they led me to think about quitting smoking or not starting smoking

c. No (B9)

26. During the past 12 months, were you taught in any of your classes about the dangers of tobacco use?

a. Yes b. No c. I don’t know

The next questions ask about advertisements or promotions for tobacco (might include cigarettes, other smoked tobacco, and smokeless tobacco).

27. During the past 30 days, did you see any people using tobacco on TV, in videos, or in movies?

a. I did not watch TV, videos, or movies in the past 30 days b. Yes

c. No

28. During the past 30 days, did you see any advertisements or promotions for tobacco products at points of sale (stores, shops, street vendors etc.)?

a. I did not visit any points of sale in the past 30 days b. Yes c. No

29. Would you ever use or wear something that has a tobacco company or tobacco product name or picture on it such as a lighter, t-shirt, hat, or sunglasses?

a. Yes b. Maybe c. No

30. Do you have something (for example, t-shirt, pen, backpack) with a tobacco product brand logo on it?

a. Yes b. No

31. Has a person working for a tobacco company ever offered you a free tobacco product?

a. Yes b. No(B10)

The next questions ask about your attitudes and beliefs about using tobacco. 32. If one of your best friends offered you a tobacco product, would you use it?

a. Definitely not b. Probably not

c. Probably yes d. Definitely yes (B11)

33. At anytime during the next 12 months do you think you will use any form of tobacco?

a. Definitely not b. Probably not

c. Probably yes d. Definitely yes

34. Once someone has started smoking tobacco, do you think it would be difficult for them to quit?

a. Definitely not b. Probably not

c. Probably yes d. Definitely yes (B12)

35. Do you think smoking tobacco helps people feel more comfortable or less comfortable at celebrations, parties, or in other social gatherings?

a. More comfortable b. Less comfortable

c. No difference whether smoking or not (B13)

36. Do you agree or disagree with the following: “I think I might enjoy smoking a cigarette.”

a. I currently smoke cigarettes b. Strongly agree

c. Agree d. Disagree e. Strongly disagree (B14)

The next questions ask about smokeless tobacco. This includes (FILL AS APPROPRIATE: chewing tobacco such as tobacco leaf, tobacco leaf and limekhaini/sada/surti, gutka, panmasala with zarda or pan; applying tobacco such as gul, gudaku, mishri/masheri/ tapkir, tuibur, tobacco tooth paste-dentobac etc.; tobacco tooth powder-lal dantmanjan, etc.; snuff such as nas and naswar).

1. How old were you when you first tried using smokeless tobacco?

a. I have never tried using smokeless tobacco b. 7 years old or younger c. 8 or 9 years old d. 10 or 11 years old e. 12 or 13 years old f. 14 or 15 years old g. 16 years old or older

2. During the past 30 days, on how many days did you use smokeless tobacco?

a. 0 days b. 1 or 2 days c. 3 to 5 days d. 6 to 9 days e. 10 to 19 days f. 20 to 29 days g. All 30 days

3. Please think about the days you used smokeless tobacco during the past 30 days. How many times did you usually use smokeless tobacco per day?

a. I did not use smokeless tobacco during the past 30 days

b. Less than once per day c. Once per day d. 2 to 5 times per day e. 6 to 10 times per day f.11 to 20 times per day g. More than 20 times per day

4. Do you ever use smokeless tobacco or feel like using smokeless tobacco first thing in the morning?

a. I don’t use smokeless tobacco

b. No, I don’t use or feel like using smokeless tobacco first thing in the morning.

c. Yes, I sometimes use or feel like using smokeless tobacco first thing in the morning

d. Yes, I always use or feel like using smokeless tobacco first thing in the morning

5. How soon after you use smokeless tobacco do you start to feel a strong desire to use it again that is hard to ignore?

a. I don’t use smokeless tobacco

b. I never feel a strong desire to use it again after using smokeless tobacco

c. Within 60 minutes d. 1 to 2 hours e. More than 2 hours to 4 hours f. More than 4 hours but less than one full day g. 1 to 3 days h. days or more

6. Do you want to stop using smokeless tobacco now?

a. I have never used smokeless tobacco

b. I don’t use smokeless tobacco now c. Yes d. No

7. During the past 12 months, did you ever try to stop using smokeless tobacco?

a. I have never used smokeless tobacco b. I did not use smokeless tobacco during the past 12 months c. Yes d. No

8. Do you think you would be able to stop using smokeless tobacco if you wanted to? a. I have never used smokeless tobacco b. I don’t use smokeless tobacco now c. Yes d. No

9. Have you ever received help or advice to help you stop using smokeless tobacco? (SELECT ONLY ONE RESPONSE)

a. I have never used smokeless tobacco

b. Yes, from a program or professional c. Yes, from a friend

d. Yes, from a family member

e. Yes, from both programs or professionals and from friends or family members

f. No

10. The last time you used smokeless tobacco during the past 30 days, how did you get it? (SELECT ONLY ONE RESPONSE)

a. I did not use smokeless tobacco during the past 30 days

b. I bought it in a store or shop c. I bought it from a street vendor

d. I got it from someone else e. I got it some other way

11. During the past 30 days, did anyone refuse to sell you smokeless tobacco because of your age?

a. I did not try to buy smokeless tobacco during the past 30 days

b. Yes, someone refused to sell me smokeless tobacco because of my age

c. No, my age did not keep me from buying smokeless tobacco

12. During the past 30 days, did you see any health warnings on smokeless tobacco packages?

a. Yes, but I didn’t think much of them

b. Yes, and they led me to think about quitting smokeless tobacco or not starting smokeless tobacco c. No

13. Has a person working for a tobacco company ever offered you free smokeless tobacco?

a. Yes b. No

14. If one of your best friends offered you smokeless tobacco, would you use it?

a. Definitely not b. Probably not

c. Probably yes d. Definitely yes

15. Once someone has started using smokeless tobacco, do you think it would be difficult for them to quit?

a. Definitely not b. Probably not

c. Probably yes d. Definitely yes

16. Do you think using smokeless tobacco helps people feel more comfortable or less comfortable at celebrations, parties, or in other social gatherings?

a. More comfortable b. Less comfortable

c. No difference whether using smokeless tobacco or not

17. Do you agree or disagree with the following: “I think I might enjoy using smokeless tobacco.”

a. I currently use smokeless tobacco b. Strongly agree

c. Agree d. Disagree e. Strongly disagree