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Cancer Control: Journal of the Moffitt Cancer Center logoLink to Cancer Control: Journal of the Moffitt Cancer Center
. 2024 May 12;31:10732748241255538. doi: 10.1177/10732748241255538

Communication and Social Determinants of Cancer Preventive Behaviors in Adolescents From Low Socio-Economic Backgrounds in India: A Cross-Sectional Study

Dhriti Dhawan 1,✉, Rachel McCloud 1, Ramya Pinnamaneni 2, Gaurav Arora 3, Rajashree Kadam 3, Anamika Dutt 3, Nandina Biswas-Ramchandran 3, K Viswanath 1,2
PMCID: PMC11089949  PMID: 38736171

Abstract

Purpose

Promoting cancer preventive behaviors among adolescents, especially those from lower socioeconomic backgrounds, is crucial due to the significant impact of health behaviors in adolescence on disease risk in adulthood. With India witnessing a rise in cancer incidence and mortality, adolescence becomes a pivotal stage for establishing healthy habits, emphasizing the need for early cancer prevention efforts.

Methods

This cross-sectional study used survey data from 2242 adolescents attending public schools of Mumbai, India. Multiple logistic regression was conducted to determine the associations between cancer preventive behaviors and: (1) the individual and social determinants of health, and (2) media exposure.

Findings

Merely 21.5% of the adolescents ate fruits and vegetables daily, 50% of the adolescents exercised 3 or more times a week, and 20% of the adolescents admitted having used tobacco and/or supari. Girls were found to have lower odds of exercising, as well as using tobacco and/or supari. Wealth and father’s education were positively associated with all 3 cancer preventive behaviors. Media exposure was negatively associated, with television exposure linked to reduced fruits and vegetables consumption, while movies and social media exposure were associated with increased tobacco and/or supari use.

Interpretation

Our findings suggest that individual and social determinants of health and media exposure can influence cancer preventive health behaviors in low socio-economic status (SES) adolescents. Efforts to increase awareness to promote cancer preventive behaviors among the adolescents, particularly low SES adolescents, a population more vulnerable to poor health outcomes, is critical.

Keywords: adolescent health, health communication, cancer prevention, tobacco, areca nut, well-being, physical activity, media exposure

Plain language summary

This study investigates factors that can influence cancer preventive behaviors among low socioeconomic status (SES) adolescents, focusing on dietary habits, physical activity, and avoidance of tobacco and areca nut. Our study gathered data from an underrepresented population of India, which is more vulnerable to poor health outcomes and have less access to health care. Our findings can alert public health officials, policy makers and non-governmental organizations to target this population and customize their intervention strategies to promote health and prevent cancer.

Introduction

Adolescence is associated with major changes in life, which can have a long-lasting imprint on health behaviors. 1 Adolescence is also when life’s health and disease risk trajectories are shaped, making it a critical period for solidifying health behaviors. Healthy behaviors like a good diet and regular exercise become common for some during adolescence, whereas unhealthy behaviors like substance use and a sedentary lifestyle become routine for others. 2

Background

India is home to the world’s largest adolescent population, 253 million, and a significant percentage lives in low-income households. 3 To support the country’s continued development, it is critical to ensure that such a multitude of adolescents follow optimal health behaviors and remain healthy. Realizing the potential of the country’s youth, the Government of India is also committed to support adolescent health and well-being and has introduced programs like the National Adolescent Health Program. 4

Socioeconomic status (SES) is a reliable predictor of health outcomes. 5 Individuals who spend their childhood and adulthood in a low SES environment have a higher likelihood of poor health compared to those who spend their entire lives in a high SES environment. 6 The effects of disadvantaged conditions associated with low SES, especially during adolescence, can lead to unhealthy behaviors. 7 These behaviors, in turn, can result in lifelong health impairments and can also influence adult SES.

Health behaviors can affect physical and mental well-being, life satisfaction and overall quality of life, and have consequences for employment chances, productivity, and health care costs, thus having a large impact on society. 8 Health behaviors are also strong determinants of diseases like cancer and significant contributors to morbidity and mortality in the world.1,9 In India, more than 1.3 million new cancer cases are diagnosed each year, resulting in over 850,000 deaths from the disease annually. 10 Lung cancer is the most prevalent cancer among men, while breast cancer is the most common type of cancer among women. Among children between 0–14 years, lymphoid leukemia is the most common type of cancer. Between 2020 to 2025, cancer incidence in India is estimated to increase by 12.8%. 11

Cancer Prevention Through Health Behaviors

To achieve the long-term goal of cancer prevention, following a healthy lifestyle can significantly reduce cancer burden. 12 The American Institute of Cancer Research (AICR) recommendations for cancer prevention include eating fruits and vegetables, increasing physical activity (PA), maintaining a healthy weight, limiting alcohol, reducing tobacco use and getting routine cancer screenings. 13 Studies have found that eating the recommended quantity of fruits and vegetables can reduce the risk of cancer by half. 14 There is also a strong link between PA and cancer prevention, and individuals who perform high level of PA have an approximately 10-20% reduced risk of cancers. 15

Tobacco is the most important environmental cause of cancer in the world. 16 It causes cancer of the lungs, mouth, throat and bladder among others. 17 More than a quarter of India’s cancer burden can be attributed to tobacco-related cancers. 18 Using tobacco has substantial economic costs including health care costs for treating tobacco-caused diseases and the lost human capital due to tobacco-attributable morbidity and mortality. 19 Supari or areca nut is the fourth common addiction following tobacco, alcohol, and caffeine, particularly in South Asian communities and is carcinogenic when consumed, with or without tobacco. 20 Supari is widely accepted among all strata of society, including the vulnerable groups like women and children. 21

The landscape of health behaviors in India reflects concerning trends, including high prevalence of physical inactivity, with 72% boys and 76% girls between age 11-17 years being physically inactive. 22 Additionally, the consumption of fruits and vegetables in India is estimated to be about 150 g/day, falling short of the World Health Organization’s recommendation of 400 g/day. 23 Moreover, the National Family Health Survey from 2019-2021 found that 40% of Indians use tobacco, while approximately a fifth of 15-18-year-olds in India have used supari.24,25

Socio-Economic Status and Health Behaviors

Health behaviors are socially patterned. 1 Adolescents from low SES have a lower intake of fruits and vegetables and these disparities increase as they grow older. 26 Adolescents from low SES are less physically active and evidence suggests that inactive adolescents are more likely to become inactive adults.27,28 Socioeconomic differences in adolescent smoking also exists and adolescents from low SES are at higher risk. 29 The consequences of such behaviors can further contribute to socioeconomic inequalities.

Despite the knowledge that adolescents from low SES have poor health outcomes, programs directed specifically at them are scarce in India. This could be due to the significant gaps in the current knowledge about health behaviors of low SES adolescents in India. In our study we aim to bridge these gaps by determining the pattern of health behaviors among adolescents. We focus on the health behaviors recommended to prevent cancers (hereafter “cancer preventive behaviors”), such as eating fruits and vegetables daily, getting adequate PA, and avoiding tobacco and areca nut 1 (supari) consumption. 21

Media Exposure and Health Behaviors

Media exposure has been documented to influence health behaviors, such as through advertisements or product placements to reach their target audiences. 30 Adolescents engage with various forms of media for both entertainment and information. Traditional media sources like television and radio continue to be popular among young individuals.30,31 Nevertheless, a substantial amount of media consumption among adolescents is now transitioning to online and social media sources.30,31 In 2021, 31% of social media users in India were between 13-19 years old. However, comprehensive data on media consumption among low SES adolescents in India are currently unavailable. Our study seeks to address this gap by examining the media usage patterns of low SES adolescents.

Finally, we also establish the association between health behaviors that potentially contribute to cancer and individual and social determinants of health including age, gender, wealth, and mothers’ and fathers’ education, and communication determinants including media exposure. Understanding these associations for low SES adolescents can help design effective and targeted media campaigns to promote health. 32 Improving the health outcomes of adolescent girls and boys in India can be a game changer in leveraging their potential for India’s social, political, and economic growth.

Methods

This cross-sectional study included de-identified 2242 seventh grade students from public schools in Mumbai, India, predominantly from low SES households with limited access to financial, educational, and social resources. 33 Approval to conduct the study was obtained from the schools. The principals and teachers at the participating schools were briefed about the study aims and procedures, and parental and student consent was obtained before the survey.

Study Procedure

The students were administered a 30-minute survey on tablets in a classroom setting. The surveys were administered by the project staff in Hindi or Marathi, based on the language in which the students were literate. Prior to survey implementation, a feasibility study was conducted and reviewed by the study team with a cohort of adolescents from comparable public schools in Mumbai, India, to ascertain that the survey was tailored to their literacy levels. The surveys for this study were conducted between February-March 2020.

Measures

To prevent cancer, the AICR suggests adopting behaviors that promote health or reduce harm. 13 In this study we focused on 3 of the recommended cancer preventive behaviors: eating fruits and vegetables, engaging in PA, and not using carcinogenic substances like tobacco and supari. The measures were developed by the study team and their validity was determined during the feasibility study.

Fruits and Vegetables

Fruits and vegetables consumption was measured using a two-item measure. Adolescents were asked about their frequency of fruits and vegetables consumption over the last 30 days. Their responses were dichotomized into “Not daily” and “Daily”.

Exercise

PA was evaluated in the form of exercise using a single-item measure. Adolescents were asked about the frequency of engaging in activities that made them sweat and breathe heavily in a typical week. Using the median split method, the responses were dichotomized into “2 times or less” and “3 times or more”. 34

Tobacco or Supari use

Using a two-item measure, we asked the adolescents if they ever used tobacco or supari in any form, with response options “Yes” or “No”.

Individual and Social Determinants of Health

Standard questions were used to measure the individual and social determinants of health (SDOH): age, gender, parents’ education, and wealth.

Although most of the public-school students in our study are from low SES households, we computed a wealth index using principal components analysis method similar to the National Family and Health Survey 4 (2015-2016). 35 The adolescents were asked to report their housing characteristics ranging from the number of rooms in their house, source of drinking water, toilet facilities and consumer goods in their household. Based on the responses, each student was given a score. Wealth quintiles were compiled by ranking each student. The distribution was divided into five quintiles, with the first quintile representing the population with the lowest wealth (poorest) and the fifth quintile representing the population with the highest wealth (richest).

Media Exposure

Exposure to different types of media, including television, movies, internet, videos on the internet, and social media, was measured using single-item measures for each type of media. The respondents were asked to report their frequency of media use in the past week. The responses were recategorized to “Not at all”, “Sometimes” (for 1-4 times), and “A lot” (for 5 or more times).

Data Analysis

Outcome measures (fruits and vegetables and exercise) were evaluated based on the frequency of these behaviors. Higher frequency of eating fruits and vegetables and exercising indicated better adherence to cancer preventive behaviors. The third outcome measure (tobacco or supari use) if positive indicated poor adherence to cancer preventive behaviors. In this study, we conducted multiple logistic regression to determine the associations between (1) cancer preventive behaviors and the SDOH, (2) cancer preventive behaviors and exposure to media. Both these models were controlled for the SDOH included in this study. The data were analyzed using R version 4.3.1 (2023-06-16). The analysis was conducted in 2023.

Ethics Approval

The study obtained ethical clearance from the Institutional Review Board of the Harvard T.H. Chan School of Public Health (Protocol # IRB19-1725) on 11th October 2019. The reporting of this study conforms to STROBE guidelines. 36

Results

Descriptive characteristics were examined to understand the study sample. (Table 1) The adolescents were 12.67 years old (SD 0.75) on average, and 53% were boys. The adolescents’ fathers reported higher formal schooling than their mothers. The adolescents had varying exposure to different types of media over the past week. The most popular media source was television and over 85% of the adolescents had at least some television exposure. Internet was the second most popular media source; 74% of the adolescents used the internet to watch videos or for any other purpose. Forty-eight percent of the adolescents used social media and 44% of the adolescents said they watched movies in the theater.

Table 1.

Demographic Characteristics and Descriptive Statistics of Individual and Social Determinants of Health, Media Exposure and Cancer Preventive Behaviors.

Eating Any Type of Fruit or Vegetables Daily (%) Doing Physical Activity 3 or More times per week (%) Ever Used Supari or Tobacco (%)
Total, N = 2242 (%) 482 (21.5%) 1114 (50%) 446 (20%)
Individual and social determinants
Age (mean (SD)) (12.67 (.75)) 12.67 (.80) 12.69 (.76) 12.65 (.78)
Sex (%)
 Male (52.9%) 252 (21.4%) 687 (58.6%) 283 (24.1%)
 Female (47.1%) 229 (21.8%) 425 (40.4%) 161 (15.3%)
Wealth index (%)
 1 (poorest) (20%) 76 (17.2%) 188 (42.5%) 117 (26.5%)
 2 (20%) 120 (27.2%) 205 (46.6%) 88 (20.0%)
 3 (20%) 92 (20.8%) 218 (49.5%) 84 (19.0%)
 4 (20%) 96 (21.8%) 239 (54.4%) 74 (16.8%)
 5 (richest) (20%) 89 (20.1%) 250 (56.7%) 73 (16.6%)
Mother’s education (%)
 Illiterate (9.2%) 43 (21.1%) 90 (43.9%) 51 (24.9%)
 Less than primary (12.7%) 54 (19.1%) 130 (46.1%) 62 (22.1%)
 Primary (15.6%) 74 (21.3%) 168 (48.4%) 65 (18.7%)
 Secondary (26.9%) 119 (19.8%) 318 (53.2%) 121 (20.2%)
 Post-secondary (18.9%) 107 (25.4%) 237 (56.6%) 78 (18.5%)
 I don’t know (16.8%) 85 (22.7%) 168 (45.3%) 69 (18.5%)
Father’s education (%)
 Illiterate (4.2%) 13 (14.0%) 34 (36.6%) 32 (34.4%)
 Less than primary (9.2%) 44 (21.4%) 93 (45.6%) 47 (22.9%)
 Primary (11.6%) 41 (15.9%) 129 (49.8%) 55 (21.2%)
 Secondary (31.1%) 160 (23.1%) 354 (51.4%) 143 (20.7%)
 Post-secondary (25.2%) 133 (23.7%) 311 (55.5%) 87 (15.6%)
 I don’t know (18.6%) 88 (21.2%) 190 (45.9%) 78 (18.8%)
Media exposure
During the past week (seven days), how many times did you watch television? (%)
 Not at all (14.4%) 73 (23.2%) 161 (51.4%) 80 (25.6%)
 Sometimes (45.3%) 225 (22.7%) 460 (46.6%) 166 (16.8%)
 A lot (40.4%) 174 (19.7%) 466 (52.8%) 184 (20.8%)
During the past week (seven days), how many times did you watch videos on the internet (such as through YouTube)? (%)
 Not at all (26.1%) 72 (20.4%) 153 (43.3%) 61 (17.4%)
 Sometimes (44.8%) 108 (17.8%) 262 (43.3%) 111 (18.3%)
 A lot (29.1%) 97 (24.6%) 220 (56.1%) 75 (19.1%)
During the past week (seven days), how many times did you watch a movie in a theater? (%)
 Not at all (55.6%) 192 (19.3%) 479 (48.3%) 182 (18.3%)
 Sometimes (33.5%) 136 (22.7%) 304 (51.2%) 97 (16.3%)
 A lot (10.9%) 43 (22.1%) 96 (49.5%) 51 (26.4%)
During the past week (seven days), how many times did you use the internet for any purpose? (%)
 Not at all (25.9%) 74 (20.8%) 164 (46.3%) 66 (18.6%)
 Sometimes (47.7%) 143 (21.8%) 293 (44.9%) 112 (17.2%)
 A lot (26.3%) 70 (19.4%) 191 (53.2%) 75 (20.9%)
During the past week (seven days), how many times did you use social media (such as WhatsApp, facebook)? (%)
 Not at all (52%) 153 (19.9%) 358 (46.6%) 111 (14.5%)
 Sometimes (31%) 111 (24.2%) 223 (49.1%) 92 (20.1%)
 A lot (17.1%) 53 (20.9%) 129 (51.0%) 56 (22.1%)
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The descriptive characteristics were also used to examine the prevalence of cancer preventive behaviors. (Table 1) Only 21.5% of the adolescents ate fruits and vegetables daily and 50% of the adolescents exercised 3 or more times a week. A fifth of the adolescents admitted having ever used either tobacco or supari (or both). There was no significant difference in the proportion of girls (21.8%) and boys (21.4%) who ate fruits and vegetables daily. (Table 2) A greater proportion of boys (58.6%) exercised 3 or more times a week compared to girls (40.4%). Moreover, it was more common for boys to have ever used tobacco or supari (24.1%) than girls (15.3%).

Table 2.

Prevalence of Cancer Preventive Behaviors by Gender.

Eating Any Type of Fruit or Vegetables Daily (%) P-value a Doing Physical Activity 3 or More times per week (%) P-value a Ever Used Supari or Tobacco (%) P-value a
Total, N = 2242 (%) 482 (21.5%) 1114 (50%) 446 (20%)
Sex (%) .853 <.001 <.001
 Male (52.9%) 252 (21.4%) 687 (58.6%) 283 (24.1%)
 Female (47.1%) 229 (21.8%) 425 (40.4%) 161 (15.3%)
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a Chi-square test.

Individual and Social Determinants of Cancer Preventive Behaviors

Our first aim was to examine the association between cancer preventive behaviors and the SDOH. Figure 1 displays model estimates from our 3 multivariable regressions testing the associations mutually adjusted for the SDOH. Across all the models, we found evidence of association between gender and exercise, and gender and tobacco or supari use-girls had lower odds of exercising 3 or more times a week [OR: .46; 95%CI: .38-.55] and ever using tobacco or supari [OR: .55; 95%CI: .44-.69] compared to boys. We also found evidence that wealth is a strong predictor of cancer preventive behaviors. Adolescents who belonged to the second wealth quintile (second lowest wealth) had higher odds of eating fruits and vegetables daily compared to adolescents from the first wealth quintile (poorest) [OR: 1.89; 95%CI: 1.36-2.64]. With increasing wealth, the odds of exercising 3 or more times a week increased and the odds of ever using tobacco or supari decreased. Mother’s education was not found to be a significant predictor of the cancer preventive behaviors. However, adolescents whose fathers had secondary [OR: 1.89; 95%CI: 1.02-3.76] or post-secondary level education [OR: 1.92; 95%CI: 1.02-3.86] had higher odds of having fruits and vegetables daily compared to adolescents whose fathers had no formal education. Adolescents whose fathers had post-secondary level education had higher odds of exercising 3 or more times a week [OR: 1.8; 95%CI: 1.09-3] compared to adolescents whose fathers had no formal education. Adolescents whose fathers had formal education had lower odds of ever using tobacco or supari compared to adolescents whose fathers had no formal education.

Figure 1.

Figure 1.

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Association between individual and social determinants of health and cancer preventive behaviors. The ORs are mutually adjusted for the individual and social determinants of health.

Media Exposure and Cancer Preventive Behaviors

Our second aim was to examine the association between cancer preventive behaviors and media exposure. Figure 2 displays model estimates from our 3 multivariable regressions models mutually adjusted for different types of media as well as the SDOH. Across the 3 models, we found mixed evidence of the associations between media exposure and cancer preventive behaviors. Adolescents who watched a lot of television had lower odds of eating fruits and vegetables daily [OR: .47; 95%CI: .25-.85] compared to adolescents with no television exposure. Media exposure was not found to be associated with exercise. Adolescents who watched a lot of movies [OR: 1.96; 95%CI: 1.04-3.63] or used social media sometimes [OR: 1.98; 95%CI: 1.27-3.1] or a lot [OR: 1.97; 95%CI: 1.1-3.49] had higher odds of ever using tobacco or supari compared to adolescents with no exposure to these media types.

Figure 2.

Figure 2.

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Association between media exposure and cancer preventive behaviors. The ORs are mutually adjusted for other media variables and the individual and social determinants of health.

Discussion

In our study with predominantly underprivileged adolescents of Mumbai, India, we first assessed the association between cancer preventive behaviors and SDOH. We identified that girls were less likely to exercise, and boys were more likely to have used tobacco or supari. Wealth was positively associated with fruits and vegetables consumption and exercise, and negatively associated with tobacco and supari use. Mother’s education was not associated with the cancer preventive behaviors. However, father’s education was associated with all 3 cancer preventive behaviors. Adolescents whose fathers had secondary or post-secondary level education were more likely to eat fruits and vegetables daily. Adolescents whose fathers had post-secondary level education were more likely to exercise 3 or more times a week. Moreover, adolescents whose fathers were educated were less likely to use tobacco or supari. Our study also suggests disadvantageous associations between media exposure and cancer preventive behaviors. Television was associated with lower fruits and vegetable consumption, whereas and movies and social media exposure were associated with higher tobacco or supari use.

Indians consume more carbohydrates and less fruits, vegetables and proteins than recommended by the EAT-Lancet commission. 37 This imbalance is more pronounced in poorer households because of low affordability of healthy foods in India. The government offers high subsidies on rice and wheat, which further incentivizes carbohydrates consumption. However, affordability might not be the only reason for low consumption of fruits and vegetables in India because even the rich do not consume the recommended amounts. 38 Consistent with the previous studies, in our study the smallest proportion of adolescents from the poorest households ate fruits and vegetables daily, and it did not drastically increase with increasing wealth.

Apart from affordability, limited availability and awareness about healthier foods could be other reasons behind the poor quality of the Indian diet. 38 Our study found higher odds of consuming fruits and vegetables daily among adolescents whose fathers had secondary and post-secondary education, reflecting the established link between higher education and a healthier diet. 39 This association could be due to increased awareness among the educated, emphasizing the importance of knowledge in promoting fruits and vegetables consumption. To improve diets, food policies should prioritize raising awareness about the benefits of these foods and incentivizing their production for affordability and availability.

Studies also indicate low physical activity (PA) levels in India. 40 Our findings align with previous research, and additionally show that girls participate in PA less frequently than boys, likely influenced by traditional gender roles. 40 Factors like safety concerns and limited access to outdoor spaces hinder girls’ engagement in PA. 41 Policies and organizations promoting PA among adolescents should address these gender inequalities and norms, while encouraging girls to participate in sports at school can help promote PA. 42

Our findings demonstrate that SES is positively associated with PA. Compared to lower SES families, higher SES families perceive PA as important and can facilitate their children’s participation in sports. 43 In our study, adolescents whose fathers had higher education were also found to be more physically active. Previous studies have found that high parental education is related to less time spent watching television. 44 Educated parents may have higher health literacy and could be more likely to encourage their children to engage in PA during their leisure time as opposed to sedentary activities. Intervention strategies promoting PA might be more impactful if they are tailored to adolescents from low SES families and parents with lower formal schooling.

Gender differences in tobacco and supari use are well-established. In India, 39% of men and 4% of women use tobacco. 25 The Global Youth Tobacco Survey found that 15% of adolescents in India use tobacco, with 19% of boys and 8% of girls. 45 Among both adults and adolescents, males are more likely to consume supari.24,46 These differences are influenced by traditional gender roles, social power dynamics, and various physiological, cultural, and behavioral factors.

In low-and-middle-income-countries (LMICs), lower education and wealth status is associated with higher tobacco and supari consumption. 47 Our findings with adolescents are consistent with previous studies.46,48-50 Fortunately, adolescents generally have a lower dependence on nicotine because of shorter exposure histories, which makes them more likely to quit. 51 Therefore, efforts should be made to reach families with low SES and uneducated fathers to raise awareness and encourage adolescents to never smoke or quit before they get addicted.

Media influences behaviors in two ways: one, frequency of exposure and two, content in the media. 52 Our findings suggest that adolescents with high television exposure consume fruits and vegetables less frequently. Television exposes the viewers to fast food commercials and many food advertisements mislead the viewers regarding the nutritional value of their products. 53 Such marketing strategies can lead to the adolescents replacing healthy foods with falsely advertised “nutritious” foods. 54 Previous studies show that while fruits and vegetables are rarely advertised, heavily advertised unhealthy foods are overconsumed. 55 Moreover, nutrient-poor, high calorie food and beverage industries specifically target young individuals in their campaigns to normalize the consumption of their products. 30 Hence, there is a need to: one, advocate a stricter approval process to prevent food advertisements from making any false nutritional claims, and two, educate the consumers, including parents and children, about the misleading advertisements and the harmful effects of unhealthy diets that may lead to various diseases.

The Ministry of Health and Family Welfare of India regulates tobacco-related content in films and television. 56 However, our study shows that high movies exposure is linked to adolescent tobacco or supari use. This suggests that adolescents watching movies are still being exposed to tobacco related content. Evidently, our findings warrant stricter rules related to tobacco imagery in the movies to reduce adolescent exposure and discourage smoking.

Our study found that adolescents using social media were more likely to use tobacco or supari. Despite India’s tobacco advertising restrictions, a global health organization reported over 2000 social media posts indirectly promoting tobacco between January and May 2022. 57 These posts included marketing for related products, some containing supari, using the tobacco company’s brand name and trademark but with a different visual identity. This marketing was found on platforms like Facebook and Instagram. This suggests that despite regulations restricting tobacco marketing (and due to lack of marketing regulation of supari products), indirect marketing of tobacco products is undermining the efforts to reduce tobacco and supari initiation by adolescents. Policies to restrict marketing of any health harming products such as tobacco and supari should be instated. Moreover, the wide usage of social media platforms among adolescents could be leveraged to disseminate health promoting messages, especially those countering tobacco marketing.

In developing economies of LMICs, smoking, eating a healthy diet and PA are shown to be some of the behaviors that are causes and consequences of socioeconomic inequalities. 1 Mass media and social media are critical tools in health promotion and are widely used to create awareness about disease prevention.32,52,58,59 Understanding the effect of media on health behaviors can, therefore, help develop strategic communications campaigns to encourage adolescents to adapt healthy behaviors.

Our findings should be interpreted within the study limitations. The participants of our study were from public schools in Mumbai and may not be representative of all Indian adolescents. The behaviors were self-reported and could have been under or over reported by students. Moreover, conducting the surveys in the classroom in the presence of adults and peers to gather sensitive information could have led to social desirability bias. Both tobacco and supari are cancer-causing substances but culturally tobacco and supari are seen very differently in India. While tobacco is a cultural taboo, supari is considered a relatively harmless or low-risk product. 24 Our survey did not gather alcohol consumption pattern among adolescents, which is also a well-known cancer-causing substance. 13 Future studies should also investigate the factors influencing alcohol consumption in adolescents from low socio-economic backgrounds. Our surveys also did not collect information about the type of media content the students are exposed to. Therefore, we could only make speculative assumptions based on existing literature. Despite these limitations, our study gathered data from an underrepresented population of India, which is more vulnerable to poor health outcomes and have less access to health care. Our findings can alert public health officials and non-governmental organizations to target this population and customize their intervention strategies to promote health and prevent cancer.

Next Steps

The next steps to promote cancer preventive behaviors among adolescents in India should involve deeper understanding of the content and influence of different media on these behaviors. For example, conducting further research to understand the impact of social media marketing on tobacco and supari use among adolescents and evaluating the effectiveness of health promotion campaigns would be beneficial for informing future interventions and policies. Moreover, given the significant impact of social factors, it will be crucial to explore the influence of social networks and peers in shaping these behaviors.

Conclusion

This study focuses on understanding the extent to which individual and social factors and media exposure are related to cancer preventive behaviors among adolescents in India. The differential association with media suggests that the content on different media varies, which eventually accounts for the variations. Understanding and documenting patterns of the effect of media use on cancer preventive behaviors in India, especially among underprivileged adolescents, a population that is more vulnerable to poor health outcomes, may help develop targeted strategic communication campaigns to promote cancer preventive behaviors among them.

Data Availability Statement

The data underlying this article will be shared on reasonable request to the corresponding author.*

Acknowledgments

The authors of this paper would like to thank the Salam Bombay Foundation for their crucial role in supervising the field data collection for this manuscript. We are deeply grateful for their unwavering commitment to promoting health and well-being among young individuals. Their expertise in tobacco control prevention education, especially with adolescents in public schools, significantly enriched the quality and context of our research.

Appendix.

Abbreviations

SES

Socioeconomic status

AICR

American institute of cancer research

PA

Physical activity

SDOH

Individual and social determinants of health

LMICs

Low-and-middle-income-countries

Note

1.

Areca nut or supari is a harmful substance popular among South Asian communities. It is said to be a precursor to tobacco use among adolescents.

Footnotes

Author contributions: Dr. Dhriti Dhawan conceptualized and designed the study, carried out all data analyses, drafted the initial manuscript, revised the manuscript, and critically reviewed the manuscript for important intellectual content. Dr. K. Viswanath conceptualized and designed the study, coordinated and supervised data collection, revised the manuscript, and critically reviewed the manuscript for important intellectual content. Dr. Rachel McCloud, Gaurav Arora, Rajashree Kadam, Anamika Dutt and Nandina Ramchandran coordinated and supervised data collection for the study, revised the manuscript, and critically reviewed the manuscript for important intellectual content. Dr. Ramya Pinnamaneni revised the manuscript, and critically reviewed the manuscript for important intellectual content.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the We thank the Lee Kum Sheung Center for Health and Happiness, Harvard T. H. Chan School of Public Health for providing the funding for the data collection. Dr Viswanath’s efforts were also funded by grant from Bill and Melinda Gates Foundation. The funders had no role in the study design; in the collection, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

ORCID iD

Dhriti Dhawan https://orcid.org/0000-0003-3005-7772

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